OBESITYOBESITY

Fighting the Battle of the BulgeFighting the Battle of the Bulge

OverviewOverview

EnergyEnergy Definition of obesityDefinition of obesity Etiology/pathogenesisEtiology/pathogenesis Obesity/health hazardsObesity/health hazards Evaluation of the obese patientEvaluation of the obese patient Why is it so difficult to maintain weight loss?Why is it so difficult to maintain weight loss? TreatmentTreatment

A 50 year old patient has gained 60 pounds since A 50 year old patient has gained 60 pounds since the age of 30. What has been the daily average the age of 30. What has been the daily average excess calorie intake in excess of average calories excess calorie intake in excess of average calories used?used?

A.A. 30 30

B.B. 100100

C.C. 150150

D.D. 250250

E.E. 500500

Energy ExpenditureEnergy Expenditure

Resting metabolic rateResting metabolic rate70%70%

Thermic effect of foodThermic effect of food 15%15%

Physical ActivityPhysical Activity 15%15%

Caloric intake equals caloric expenditureCaloric intake equals caloric expenditure Weight stableWeight stable

Caloric intake greater than caloric expenditureCaloric intake greater than caloric expenditure Weight gainWeight gain

Caloric intake less than caloric expenditureCaloric intake less than caloric expenditure Weight lossWeight loss

Definition of ObesityDefinition of Obesity

Body Mass Index (BMI) of 30 or more in Body Mass Index (BMI) of 30 or more in adultsadults

BMI = weight in kilograms/height squared in BMI = weight in kilograms/height squared in metersmeters

Children BMI 95Children BMI 95thth percentile or above for percentile or above for age and sexage and sex

EtiologyEtiology

Prenatal influencesPrenatal influences Breast feedingBreast feeding Women (pregnancy, menopause)Women (pregnancy, menopause) Men (sedentary lifestyle)Men (sedentary lifestyle) Sleep deprivationSleep deprivation Cessation of smokingCessation of smoking DietDiet MedicationsMedications SocioeconomicSocioeconomic

MedicationsMedications

AntipsychoticsAntipsychotics AntidepressantsAntidepressants AntiepilepticsAntiepileptics DiabeticDiabetic Beta–blockersBeta–blockers GlucocorticoidsGlucocorticoids

GeneticsGenetics

Prader-Willi (Chromosome 15 Prader-Willi (Chromosome 15 qq11-13)11-13)

Several other single gene mutations have Several other single gene mutations have been identifiedbeen identified

FTO gene (fat mass and obesity associated) FTO gene (fat mass and obesity associated) Chromosome 16Chromosome 16

Genes encoding the melanocortin -4 Genes encoding the melanocortin -4 receptor (MC4R)receptor (MC4R)

? “thrift” gene? “thrift” gene

Health HazardsHealth Hazards

HypertensionHypertension DyslipidemiaDyslipidemia Cardiovascular diseaseCardiovascular disease ““Metabolic syndrome”Metabolic syndrome”

Cancer (Men)Cancer (Men)

LiverLiver StomachStomach PancreasPancreas EsophagusEsophagus RectumRectum GallbladderGallbladder Multiple MyelomaMultiple Myeloma

Cancer (Women)Cancer (Women)

UterusUterus KidneyKidney CervixCervix PancreasPancreas EsophagusEsophagus GallbladderGallbladder BreastBreast LiverLiver OvaryOvary ColonColon RectumRectum

Other Risks Related to Metabolic Other Risks Related to Metabolic EffectsEffects

GastrointestinalGastrointestinal KidneyKidney Endocrine/infertilityEndocrine/infertility

Other Risks Related to Increased Other Risks Related to Increased Body MassBody Mass

Bone and joint diseaseBone and joint disease Pulmonary diseasePulmonary disease Social stigmatizationSocial stigmatization

EvaluationEvaluation

BMIBMI Waist circumferenceWaist circumference Waist : hip ratioWaist : hip ratio Blood pressureBlood pressure Lipid panelLipid panel GlucoseGlucose

Why is it so difficult to lose weight and Why is it so difficult to lose weight and maintain weight loss?maintain weight loss?

Answer: Answer:

Our bodies defend our current weight and Our bodies defend our current weight and this makes both weight loss and this makes both weight loss and maintenance of weight loss difficult.maintenance of weight loss difficult.

TreatmentTreatment

DietDiet Physical exercisePhysical exercise Behavioral modificationBehavioral modification

When These FailWhen These Fail

Pharmacologic therapyPharmacologic therapy Bariatric surgeryBariatric surgery

DietDiet

Diet composition is less important than total Diet composition is less important than total calories consumed!!!calories consumed!!!

DietsDiets

Low-carbohydrate dietsLow-carbohydrate diets Low-fat dietsLow-fat diets Low-energy dense dietsLow-energy dense diets Portion controlled/very low-calorie dietsPortion controlled/very low-calorie diets Commercial weight-loss programsCommercial weight-loss programs Alternative/natural/herbal dietsAlternative/natural/herbal diets

Behavioral ModificationsBehavioral Modifications

Setting realistic goalsSetting realistic goals Self-monitoringSelf-monitoring Control of stimuli that activates eatingControl of stimuli that activates eating Slowing down the eating processSlowing down the eating process Social supportSocial support

ExerciseExercise

May benefit glycemic controlMay benefit glycemic control Beneficial effects on cholesterolBeneficial effects on cholesterol Beneficial effects on blood pressureBeneficial effects on blood pressure Good modality in weight maintenance and Good modality in weight maintenance and

as a component of weight lossas a component of weight loss

PharmacologicPharmacologic

SibutramineSibutramine OrlistatOrlistat

Surgical (Bariatric)Surgical (Bariatric)

Generally reserved for BMI of 40 or aboveGenerally reserved for BMI of 40 or above May consider with BMI of 35 and May consider with BMI of 35 and

comorbiditiescomorbidities

TypesTypes

RestrictiveRestrictive MalabsorptiveMalabsorptive

SummarySummary

Caloric intake that exceeds caloric Caloric intake that exceeds caloric expenditure results in weight gain!!!expenditure results in weight gain!!!