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Overweight and Obesity. Dr Mojtaba Hashemzade Obesity surgeon. Overview. Definition, Prevalence & Consequences of Obesity Healthy Lifestyles Assessment of Obesity Treatments for Obesity. Definition. - PowerPoint PPT Presentation
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Overweight and Obesity
Dr Mojtaba Hashemzade
Obesity surgeon
Overview
Definition, Prevalence & Consequences of Obesity
Healthy Lifestyles Assessment of Obesity Treatments for Obesity
Definition
Obesity is an abnormal accumulation of body fat, usually 20 percent or more over an individual's ideal body weight.
Definition of Overweight & Obesity
Using BMI
ITEMS BMI GRADE
UNDER WEIGHT ≤ 18.5
NORMAL 18.5 – 24.9
OVER WEIGHT 25.0 – 29.9
OBESITY 30.0 – 34.9 I
OBESITY 35.0 – 39.9 II
EXTREME OBESITY ≥ 40 III
Calculating BMI
Calculate Body Mass Index (BMI) =
weight (kg)height squared (meters)
Or…
weight (pounds) x 703height squared (inches)
Prevalence of Obesity
Childhood and adolescent obesity increased from 5% to 16% in the last 20 years
Adulthood obesity increased from 12% to 21% in 10 years.
16 million US adults with BMI over 35 60 million US obese adults (BMI > 30)
Prevalence of Adult Obesity, U.S.A.
0
5
10
15
20
25
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
% a
dult
s
TexasUnited States
From CDC website: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/prev_reg.htm
Factors predispose to obesity
Genetic – familial tendency. Sex – women more susceptible . Activity – lack of physical activity. Psychogenic – emotional deprivation,
depression . Social class – poorer classes. Alcohol – problem drinking. Smoking – cessation smoking. Prescribed drugs – tricyclic derivatives.
Weight Gain: Medications
Disease Examples
Diabetes Insulin, sulfonylureas
Depression Tricyclics
Seizures Valproic acid, Tegretol
Hypertension Clonidine, α-blockers, β-blockers
Hormones Progesterone
Weight Gain: How Does It Happen?
Energy imbalance calories consumed not equal to calories used
Over a long period of time Due to a combination of several factors
Individual behaviors Social interactions Environmental factors Genetics
Weight Gain: Energy In
3500 calories = 1 pound
100 calories extra per day = 36,500 extra per year = 10.4 lbs weight gain
Question: How much is 100 calories? Answer: Not very much!
1 glass skim milk, or 1 banana, or 1 slice cheese, or 1 tablespoon butter
Evolving Pathology
More in and less out = weight gain More out and less in = weight loss Hypothalamus
control center for hunger and satiety Endocrine disorder
where are the hormones?
Leptin
Protein hormone secreted by adipocytes Levels correlate with lipid content of cells Leptin acts on the hypothalamus to reduce
hunger and to stimulate energy expenditure
Ghrelin
Hormone secreted in the stomach Acts on the hypothalamus to stimulate appetite Levels peak just before meals and drop afterward
Bad News for Dieters
Leptin Dieting decreases leptin levels Reducing metabolism, stimulating appetite
Ghrelin Levels in dieters are higher after weight loss The body steps up ghrelin production in response
to weight loss The higher the weight loss, the higher the ghrelin
levels
Health Consequences of Obesity
Major cause of preventable death
Increase in mortality from all causes
Increase in risk for these cancers Endometrium Breast Prostate Colon
Increase in risk of: Hypertension Dyslipidemia Diabetes type 2 Coronary artery disease Stroke Gallbladder disease Osteoarthritis Sleep apnea &
respiratory problems
Assessment
Assess the patient's readiness and willingness to lose weight : Unfortunately those who are most concerned about
their weights are not necessarily those who are at the highest health risk.
Those who are unable or unwilling to embark on a weight reduction program, but they are willing to take steps to avoid further weight gain or perhaps to work on other risk factors such as cigarette smoking, and they should be encouraged to do so.
For those not ready to act, the issue should be deferred and brought up at the next visit
Assessment
Is he overweight? Obese? What are his key health issues?
Assessment
Measure BMI Measure waist circumference
“Apple shape” body is higher risk for DM, CVD, HTN
Waist larger than 40 inches for men Waist larger than 35 inches for women
Assessment
Assess for other risk factors Existing high risk disease:
coronary heart disease; other atherosclerotic diseases; type 2 diabetes; sleep apnea
Diseases associated with obesity Gynecological problems; osteoarthritis; gallstones;
stress incontinence Cardiovascular risk factors (3 or more = high risk)
Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting glucose = 110 to 125; family history of premature CHD; men age > 45; women age > 55
Other risk factors Physical inactivity; elevated serum triglycerides
Medications associated with obesity
Treatment Approach
A multi-faceted approach is best Diet Physical activity Behavior change
“A” Recommendation
Treatment Approach
Initial goal: 10% weight loss Significantly decreases risk factors
Rate of weight loss 1 to 2 pounds per week Reduction of caloric intake 500-1000 per day
Slow weight loss is more stable Rapid weight loss is almost always followed by
weight gain Rapid weight loss increases risk for gallstones
& electrolyte abnormalities
Treatment Approach
Aim for 4 - 6 months of weight loss effort Most people will lose 20 to 25 pounds After 6 months, weight loss is more difficult
Ghrelin & Leptin are at work! Changes in resting metabolic rate Energy requirements decrease as weight
decreases Diet adherence wavers
Set goals for weight maintenance for next 6 months, then reassess.
Dietary Therapy
Weight reduction with dietary treatment is in order for virtually all patients with a BMI 25-30 who have comorbidities and for all patients over BMI 30.
Strategies of dietary therapy include teaching about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods.
Low-Calorie Step I Diet
1000 to 1200 kcal/day for women
1200 to 1600 kcal/day for men
Adjust for current weight & activity Too hungry?
increase kcal by 100 - 200/day
Not losing? decrease kcal by
100 - 200/day
How Much is 1200 Calories?
Could you stick to 1200 per day?
1 Big Mac (580)1 SMALL Fries (210)1 SMALL shake (430)
Low-Calorie Step I Diet
Nutrient Recommended intake
Calories 500 to 1000 kcal/day reduction from usual
Total fat <30% of total calories
Cholesterol <300 mg per day
Protein <15% of total calories
Carbohydrate >55% of total calories
Sodium Chloride <2.4 g sodium, or <6 g sodium chloride
Calcium 1000 to 1500 mg/day
Fiber 20 to 30 g/day
Weight Maintenance: How Much Should People Eat? Varies widely Some averages, below
Males Age 20-49 2900 calories/day
Age 50-plus 2500 calories/day
Females Age 20-49 2300 calories/day
Age 50-plus 1900 calories/day
Physical Activity
Physical activity should be an integral part of weight loss
Physical activity alone is less successful than a combined diet & exercise program Increased activity alone
does not decrease weight Sustained activity does
prevent weight regain Reduces risk for heart disease & diabetes
Physical Activity
Start slowly Many obese people live sedentary lives Avoid injury Early changes can be activities of daily living
Increase intensity & duration gradually Long-term goal
30 to 45 minutes or more of physical activity 5 or more days per week Burn 1000+ calories per week
Recommend Physical Activity
What does it take to burn
1000 calories per week?
Running 11 miles
Walking 12 miles
Dancing 3 hours
Gardening 5 hours
Cycling 22 miles
Behavioral Strategies
Keep a journal of diet & activity Very powerful intervention!
Set specific goals re: behaviors Eating Activity Related behaviors
Track improvement Weigh & measure on a regular basis
Cognitive Strategies
Focus on the goals Plan meals & activity Develop reminder systems Anticipate temptations & plan resistance Reward yourself Limit quantities, but do not deprive yourself Have confidence in your ability to succeed Do positive self-talk
Pharmacotherapy for Weight Loss
Adjunct to diet & physical activity BMI ≥ 30 Or, BMI ≥ 27 with other risk factors Should not be used for cosmetic weight loss
Only for risk reduction Use only when 6-month trial of diet & physical
activity fails to achieve weight loss
Pharmacotherapy for Weight Loss
These drugs are only modestly effective 2 to 10 kilogram loss Most occurs in the first 6 months
If patient does not lose 2 kilograms in the first 4 weeks, success is unlikely
If the first 6 months is successful, continue medication as long as… It is effective in maintaining weight, and Adverse effects are not serious
Pharmacotherapy for Weight Loss
Drug Dose Action Adverse Effects
Sibutramine
(Merida)
5/10,/15 mg
10 mg po qd to start. May be increased to 15 mg or decreased to 5 mg
Nor epinephrine, dopamine & serotonin reuptake inhibitor
Increase in heart rate & blood pressure
Orlistat
(Xenical)
120 mg
120 mg po tid before meals
Inhibits pancreatic lipase, decreases fat absorption
Decrease in absorption of fat-soluble vitamins; soft stools and anal leakage
Weight Loss Surgery
47,000 in 2001; 98,000 in 2003 Types of Obesity Surgery: 1. Restrictive Surgery - uses bands or staples to
create food intake restriction: Vertical Banded Gastroplasty (VBG) - is a “pure” restrictive
surgery since it only involves surgically creating a stomach pouch. VBG uses bands and staples and is the most frequently performed procedure for obesity surgery.
Gastric Banding – involves the use of a band to create the stomach pouch.
Laparoscopic Gastric Banding (Lap-Band), approved by the FDA in June 2001, is a less invasive procedure in which smaller incisions are made to apply the band. The band is inflatable and
can be adjusted over time
Weight Loss Surgery
2. Combined Restrictive and Malabsorptive Surgery - is a combination of restrictive surgery (stomach pouch) with bypass (malabsorptive surgery), in which the stomach is connected to the jejunum or ileum of the small intestine, bypassing the duodenum. Roux-en-Y Gastric Bypass (RGB) - is the most commonly
performed gastric bypass procedure, and the second most frequently performed surgery for obesity after VBG. RGB involves a stomach pouch for food intake restriction. A direct connection, which is Y-shaped, is made from the ileum or jejunum to the stomach pouch for malabsorption.
Biliopancreatic Diversion (BPD) - is one of the most complicated obesity surgery, sometimes involving the removal of a portion of the stomach. The remaining section of the stomach is connected to the ileum. BPD successfully promotes weight loss, but this procedure is typically used for persons with severe obesity who
have a BMI of 50 or more
Weight Loss Surgery
Indications 100 pounds overweight or more Or, BMI > 40 Or, BMI > 35 and 2 significant comorbidities Age 18 to 60 Documented failure at nonsurgical efforts Psychological stability
Weight Loss Surgery
Roux-en-Y gastric bypass Limits food intake Alters digestion
Figure from NIDDK website
Weight Loss Surgery
Complications of surgery Mortality
<1% mortality in healthy young adults BMI < 50 2-4% mortality in patients with disease and BMI > 60
Operative complications < 10%
Late complications are uncommon Incisional hernias Gallstones Vitamin B12 & iron deficiency Weight loss failure Neurologic symptoms in unusual cases
Weight Loss Surgery Outcomes
Durable weight loss One study followed pts for 14 years
Average excess weight loss = 61.2% 77% with diabetes no longer require meds
From Wald meta-analysis in JAMA 2004)
Followup
Schedule a return visit in 2 to 4 weeks after starting weight loss plan Monitor treatment effectiveness & side effects
Schedule monthly visits for first 3 months If making favorable progress See more frequently if monitoring medical
complications or chronic disease Reduce frequency of visits after 6 months
Followup
Monitor weight, BP, pulse at each visit Monitor waist size intermittently Share progress with patient; praise efforts Share lab results with patient
Emphasize findings associated with weight reduction
Focus on medical benefits Most weight loss doesn’t reach individual’s
‘ideal’ (cosmetic) goal
Thank You!