A cause oriented approach to

obesity management

Gabriel I. Uwaifo, MD, FACP, FACE, FTOS,

Department of Endocrinology, diabetes, metabolism and weight

management,

Ochsner medical center

PRESENTATION

OBJECTIVE;

TO DISCUSS THE ROLE OF CAUSES,

COMPLICATIONS AND

ASSOCIATIONS OF OBESITY IN ITS

EFFECTIVE MANAGEMENT

Presentation outline•Detail classification and causes of

obesity.

•Detail complications and associations

of obesity

•Describe relationship between

causes, complications and

associations of obesity with

management strategies

➢Obesity is not one disease but a common final

pathway for many different diseases and thus no two

obese subjects are exactly the same making

individualized, nuanced evaluation and management

key to therapeutic success.

➢The effective management of obesity requires

careful attention to the 5 C’s

▪ The Classification of obesity (Types)

▪ The Causes of obesity (etiologic factors)

▪ The Complications/Consequences of obesity

▪ The Comorbidities/associations of obesity

Classification of Obesity• Childhood onset, adult onset,

geriatric

• Metabolically healthy vs unhealthy

• Sarcopenic vs non-sarcopenic

• Idiopathic vs secondary

• Genetic vs environmental vs

mixed

• Proportional vs dysmorphic

• Fit vs unfit

• Complicated vs uncomplicated

• Inflammatory vs noninflammatory

• Subcutaneous vs visceral

Class IV: >50 (super-obese)Class V: >60 (super-super obese))

Classification of Obesity• Stage 0: No obesity-related risk

factors

• Stage 1: Pre-clinical risk factors –

borderline HTN or DM, minor

aches or psychopathology

• Stage 2: Established obesity-

related disease – HTN, DM,

PCOS, moderate limitations ADL

• Stage 3: Established organ

damage – MI, CHF, DM comp,

significant limitations of ADL

• Stage 4: Severe disabilities – end

stage and limitations like

wheelchair use

Edmonton Obesity Staging System (EOSS)

Stage 0

Sharma AM & Kushner RF, Int J Obes 2009

Stage 1

Stage 2

Stage 3

Stage 4

co-morbidity

moderate

moderate

Obesity

Classification of ObesityWhy is obesity classification useful clinically?

• Disease prognostication

• Acuity for intervention

• Informing best intervention

strategies

• Enabling serial follow up

• Enabling objective

treatment effect evaluation

• Providing etiologic clues

• Important for clinical,

translational and basic

research phenotyping and

other research efforts.

Edmonton Staging System Can

Predict Mortality Better than BMI

Padwal R, Sharma AM et al. CMAJ 2011

Causes of Obesity

• Concepts of etiology, predisposition and

contributory factors.

• The concept of multiplicity of etiologies,

predispositions and contributors

• The concept of nature vs nuture; genetics vs

environment and the epigenetic bridge between

them

• The impact for the clinician; one size does not fit

all.

Causes of Obesity

Causes of Obesity

Causes of Obesity

Causes of Obesity

Causes of Obesity

Causes of Obesity; behavioral

considerations• Physical activity and exercise

• Sleep deprivation and sleep

disorders

• Pregnancy

• Dietary patterns

• Eating disorders

• Psychopathology

• Smoking cessation

• Sedentary activity, Screen time

• Alcohol consumption

• Substance abuse

Causes of Obesity;

endocrinopathies• Hypercortisolemia and Cushing’s

syndrome

• PCOS

• Hypoparathyroidism

• Hypopituitarism

• Hypogonadism

• GH deficiency

• Hypoglycemic syndromes

• Diabetes Mellitus

• Hypothyroidism **

• Acromegaly and gigantism

syndromes

• The chicken vs the

egg concept; cause,

consequence or both

Causes of Obesity; Genetics

• Polygenic “common”/familial obesity;

non mendelian inheritance

• FTO gene and other genetic

polymorphisms.

• Monogenic syndromes; Prader Willi

syndrome, Bardet Biedel, Leptin

deficiency syndrome, Defective leptin

syndrome, Prohormone convertase

deficiency syndrome, POMC

deficiency syndrome, Melanocortin 4

receptor (MC4) gene mutation **,

Froelichs (Adiposogential dystrophy)

syndrome etc.

Causes of Obesity;

Hypothalamic Obesity

Causes of Obesity;

Hypothalamic Obesity• Hypothalamic nuclei of greatest import for

energy balance, appetite control, hunger and

satiety modulation; nucleus tractus solitarius

(NTS), arcuate nucleus, paraventricular

nucleus, Ventromedial hypothalamic (VMH)

nucleus , lateral hypothalamus and amygdala.

• Hypothalamic obesity is a location based

syndrome of multiple etiologies that can be

congenital or acquired. Onset can be in

childhood or adulthood. Trauma, tumors, mass

lesions, inflammatory states, infections (post

meningitis or post encephalitis), post surgical,

post cranial irradiation or due to increased intra

cranial pressure.

• Frequent accompaniments of obesity in this

setting include hypogonadism, menstrual

irregularity, neuropsychiatric syndromes,

temperature dysregulation, visual field defects,

unsteady gaite/ataxia, taste and/or smell

derangements, Diabetes insipidus, SIADHS,

seizures, somnolence, altered levels of

consciousness and varied endocrinopathies.

Causes of Obesity ; Hypothalamic

obesity◼ Leptin

◼ a-MSH

◼ CART

◼ GLP-1

◼ C-NTF

◼ CRH/Urocortin

◼ Neuromedin U

◼ Serotonin

◼ CCK

◼ Insulin

◼ Bombesin

◼ Calcitonin

◼ Enterostatin

◼ TRH

◼ IL-1B

◼ Neurotensin

◼ Oxytocin

◼ Vasopressin

◼ POMC

◼ Peptide Y-Y

◼ Neuropeptide Y

◼MCH

◼ AGRP

◼Orexin A, B (Hypocretin 1,3)

◼Galanin

◼ Dynomorphin

◼ Norepinephrine

◼ B-endorphin

◼Ghrelin

Anorexigenic Orexigenic

Causes of obesity; Mental

Health disorders• Depression; melancholic depression and other

syndromic unipolar depression as opposed to

bipolar disorder

• Eating disorders; Night eating disorder, Bulimia

• Seasonal affective disorder

• Schizophrenia

• Certain personality disorders

• The question of the chicken vs the egg; cause or

consequence or both.

Causes of Obesity; other factors• Socioeconomic status

• Gestational history

• Breast feeding history and infantile feeding history

• Ethnicity and racial disparities

• The microbiome and infective etiologies of obesity ***

• The role of viruses (adenovirus 36 and others in

obesity)

• The role of metabolic endotoxemia in obesity

• The role of antimicrobials in obesity.

Complications, Comorbidities

and Consequences of Obesity

Complications and consequences of obesity

Associated increased cancer

mortality risk estimated; 52%

higher in men and 62% higher in

women with obesity.

“ Other than smoking

Obesity is the single

most important and is

the most prevalent,

ubiquitous modifiable

cancer predisposition

risk factor in the

developed world today.”

Complications, Comorbidities

and Consequences of Obesity

PSYCHOSOCIAL consequences and

complications OF OBESITYMental

• Mood disorders

• Anxiety disorders

• Attention deficit disorders

• Sleep deprivation states

• Personality disorders

• Addiction and substance abuse disorders

• Psychotic disorders

• Cognitive disorders

• ** aggravation of indices of diabetes distress

• Discrimination against obese people

• 1. College admission

• 2. Employment, job advancement

• 3. Conjugal relationships

• 4. Childhood discrimination etc.

• 5. Delayed diagnosis and treatment deficits

Monetary

• Education

• Employment

• Reduced income

• Disability

• Medical insurance, life insurance etc

• Bariatric appropriate furniture, aids,

appliances

• Expenditure for weight management

programs, fees for dieticians, health

coaches, trainers, medications, devices,

surgery etc.

“ OBESITY IS THE LAST BASTION OF

SOCIALLY ACCEPTABLE BIGOTRY”

Dr Richard Atkinson; Former President of

TOS, AOA and emeritus Clinical Prof of

Bariatric medicine

Concluding remarks• Obesity is a complex syndrome that is the final common pathway of many

different chronic cardiometabolic diseases.

• Developing a rationale effective management plan for the individual patient

requires careful attention to identifying the causes, contributors,

comorbidities and complications of obesity for the individual patient.

• Given the complexity of determining the often multifactorial etiology of

obesity in patients a multidisciplinary approach to the clinical evaluation and

care of these patients is invariably a necessity.

• A comprehensive history and examination including medication inventory,

gestation and birth history, behavioral, psychosocial, dietary and weight

history can provide valuable insight to the major contributors and etiologies

of obesity in the individual patient thus guiding a rational management plan.

• No two obese patients are likely to have the same effective management

plan. These must be customized and nuanced based on cause oriented

approach.

THANK YOU VERY MUCH FOR

YOUR KIND ATTENTION

Questions???, Comments???

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