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Overweight and Obesity Dr Mojtaba Hashemzade Obesity surgeon

Overweight and Obesity

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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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Page 1: Overweight and Obesity

Overweight and Obesity

Dr Mojtaba Hashemzade

Obesity surgeon

Page 2: Overweight and Obesity

Overview

Definition, Prevalence & Consequences of Obesity

Healthy Lifestyles Assessment of Obesity Treatments for Obesity

Page 3: Overweight and Obesity

Definition

Obesity is an abnormal accumulation of body fat, usually 20 percent or more over an individual's ideal body weight.

Page 4: Overweight and Obesity

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

Page 5: Overweight and Obesity

Calculating BMI

Calculate Body Mass Index (BMI) =

weight (kg)height squared (meters)

Or…

weight (pounds) x 703height squared (inches)

Page 6: Overweight and Obesity

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)

Page 7: Overweight and Obesity

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

Page 8: Overweight and Obesity

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.

Page 9: Overweight and Obesity

Weight Gain: Medications

Disease Examples

Diabetes Insulin, sulfonylureas

Depression Tricyclics

Seizures Valproic acid, Tegretol

Hypertension Clonidine, α-blockers, β-blockers

Hormones Progesterone

Page 10: Overweight and Obesity

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

Page 11: Overweight and Obesity

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

Page 12: Overweight and Obesity

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?

Page 13: Overweight and Obesity

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

Page 14: Overweight and Obesity

Ghrelin

Hormone secreted in the stomach Acts on the hypothalamus to stimulate appetite Levels peak just before meals and drop afterward

Page 15: Overweight and Obesity

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

Page 16: Overweight and Obesity

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

Page 17: Overweight and Obesity

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

Page 18: Overweight and Obesity

Assessment

Is he overweight? Obese? What are his key health issues?

Page 19: Overweight and Obesity

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

Page 20: Overweight and Obesity

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

Page 21: Overweight and Obesity

Treatment Approach

A multi-faceted approach is best Diet Physical activity Behavior change

“A” Recommendation

Page 22: Overweight and Obesity

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

Page 23: Overweight and Obesity

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.

Page 24: Overweight and Obesity

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.

Page 25: Overweight and Obesity

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

Page 26: Overweight and Obesity

How Much is 1200 Calories?

Could you stick to 1200 per day?

1 Big Mac (580)1 SMALL Fries (210)1 SMALL shake (430)

Page 27: Overweight and Obesity

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

Page 28: Overweight and Obesity

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

Page 29: Overweight and Obesity

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

Page 30: Overweight and Obesity

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

Page 31: Overweight and Obesity

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

Page 32: Overweight and Obesity

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

Page 33: Overweight and Obesity

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

Page 34: Overweight and Obesity

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

Page 35: Overweight and Obesity

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

Page 36: Overweight and Obesity

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

Page 37: Overweight and Obesity

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

Page 38: Overweight and Obesity

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

Page 39: Overweight and Obesity

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

Page 40: Overweight and Obesity

Weight Loss Surgery

Roux-en-Y gastric bypass Limits food intake Alters digestion

Figure from NIDDK website

Page 41: Overweight and Obesity

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

Page 42: Overweight and Obesity

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)

Page 43: Overweight and Obesity

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

Page 44: Overweight and Obesity

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

Page 45: Overweight and Obesity

Thank You!