Daniel Eshetu

IntroductionWeight is generally stable

Food intake = Energy expenditure

Coordinated control of the hypothalamus

“Feeding” center

“Satiety” center

Food intake

Availability of food

Attractiveness of food

Emotional factors

Introduction (Cont’d)

Energy expenditure

Basal metabolism – 50%

Physical activity – 40 - 50%

Voluntary change in weight – not worrisome

Involuntary change in weight – may indicate disease

Weight Gain

Mechanisms of weight gainExcess muscle – exercise

Excess fat – food intake > energy

expenditure

Excess water – fluid retention,

over hydration

Nature vs NartureGenes

Fuel homeostasis

Energy expenditure

Hunger/satiety

EnvironmentPhysical inactivity

Food

Scio cultural factors

Intrauterine programming

Environment Increased intake

Increased portion sizes

energy dense foods

High glycaemic index foods

Soft drinks

Added sugar

Easy access to foods

Marketing

Decreased expenditure

Reduced exercise

Increased automation

Vehicles

Sedentary schools

Sedentary workplace

Elevators/Escalators

TV/Computer

Other causes of Weight GainAging – slowed metabolism

Pregnancy

Endocrine & Other Medical Disorders

Cushing’s Syndrome

Hypothyroidism

Polycystic ovary syndrome

Hypogonadism

Some inherited diseases/genetic syndromes

Causes of Weight Gain (Cont’d) Drugs

Corticosteroids

Lithium

Tranquilizers

Antidepressants

Emotional factors

Anxiety

Depression

Guilt

Lifestyle Factors

Overeating

Physical inactivity

Classification of BMI (in Kg/m2)Underweight --BMI <18.5

Normal weight -- BMI ≥18.5 to 24.9

Overweight — BMI ≥25.0 to 29.9

Obesity — BMI ≥30

Obesity Class I — BMI of 30.0 to 34.9

Obesity Class II — BMI of 35.0 to 39.9

Obesity Class III — BMI ≥40

Prevalence of overweight, 2008

Source:WHO

Prevalence of CVD risk factors in A.A

Risk FactorPrevalence (%)

Males Females

Overweight 20 38

Obese 2 10

Low level of Total Physical Activity

17 31

High BP (> 140/90 mmHg)

32 29

Fikru et al., BMC Cardiovascular Disorders 2009, 9:39

Pear Shaped Fatness in WomenExcess Fat Deposited

Hips

Buttocks

Thighs

Apple Type Fatness in MalesExcess Fat Deposited

Abdomen (Beer Bellies)

Health Risks of ObesityIncreased Morbidity

Type 2 Diabetes

Hypertension

Dyslipidemia

Coronary Heart Disease

Stroke

Health Risks of Obesity (Cont’d)• Increased Morbidity

Cancer (endometrial, breast, colon)

Poor Quality of Life

Psychosocial Dysfunction

Sleep Apnea

Osteoarthritis

Increased Mortality

Work upHistory

Amount of gained weight

Duration of weight gain

Recent changes in diet or appetite

Rate of weight gain

Rapid weight gain – fluid retention

Work up (Cont’d)

History

Alcohol & Drugs Intake

Exercise Habit

Psychosocial Problems

Any other symptoms

Examination

Height, weight, BMI, waist cm

Neck size, BP, PR

Features of Insulin resistance

Goitre

Liver edge

Oedema

Laboratory tests

Glucose studies, lipids, renal & liver function

Sleep studies

Abdominal US, Echo

Secondary causes

Genetic cause/suspicion of?

Waist CircumferenceMales – 102 (94) cm

Females – 88 (80) cm

WEIGHT LOSS

IntroductionAlways ask about weight change

Change of 5% over 6 months is significant

Relative change is also important

Significant weight loss – marker of serious illness

Persistence & periodic evaluation to identify the cause - important

Mechanisms of weight loss

Increased energy expenditure

Increased energy loss

Decreased food intake

Causes of weight lossI. Involuntary with increased appetite

A. Increased energy expenditure

Hyperthyroidism

Pheochromocytoma

Extensive exercise

B. Increased energy loss

Diabetes Mellitus

Malabsorption syndromesChronic pancreatitis

Ulcerative colitis

Chrohn’s disease

Celiac sprue

Causes of weight loss (Cont’d)

II. Involuntary with decreased appetiteA. Medical disorders

CancerInfections: HIV, TB, Endocarditis, lung abscess, hepatitis, chronic helminthinfectionChronic illnesses

CHF, CLD, COPD, CKD

Endocrine diseasesAdrenal insufficiencyHypercalcemia

GI DiseasesPUDStricturesDysphagiaDiabetic gasteroparesisCompressive massInfiltrating cancer

Hyperemesis gravidarum

B. Psychiatric DisordersDepression

C. Chronic drug useAlcoholMetforminAnti cancersART

Causes of weight loss (Cont’d)

III. Voluntary Weight Loss

• Diet and exercise

• Treatment of Obesity

• Anorexia Nervosa, Bulimia

Evaluation

• Ask About Appetite

• Food Intake

• Weight History

• Maximum Weight

• Usual Weight

• Current Weight

• Patients Underestimate/Overestimate

• Ask Family Members

Evaluation (cont’d)

• Voluntary or Involuntary

• Duration, rapidity & amount of Weight Loss

• Nutritional Status

Evaluation (cont’d)

General AppearanceVital SignsHEENT :

Hair ChangesPallorMouth changes

GLANDS : Lymph NodesThyroid

Evaluation (cont’d)

RESPIRATORY SYSTEM : CoughDyspneaChest Findings

CVS :DyspneaOrthopneaOedemaCardiac Findings

Evaluation (cont’d)• GIS : Vomiting – Gastric Outlet Obstruction

DiarrheaMalabsorptionChronic Liver DiseaseOrganomegaly

• GUS : PolyuriaChronic Renal Failure

• CNS : ParaplegiaMalignancyMotor Neurone Disease

DIAGNOSTIC WORK UP

FIRST PHASE TESTS – For Every Patient

• CBC/ESR

• Urinalysis

• Blood Chemistry Tests

• Fasting blood sugar

• Calcium

• Urea & Creatinine – Chronic renal failure

• Liver function tests – Chronic liver disease

• Electrolytes

FIRST PHASE TESTS – For Every Patient (Cont’d)

• TSH – Thyrotoxicosis

• HIV test

• Chest x- ray

• Stool for occult blood

SECOND PHASE TESTS

• CT scans – Abdomen, chest, brain

• Mammography

• Parathyroid hormone level (if calcium level is elevated)

• Endoscopy

• Colonoscopy

SECOND PHASE TESTS (Cont’d)

• Blood Cultures

• 72 h stool fat

• Bone marrow biopsy

• Vitamin B12 level

• MRI of the spine

ConclusionGain & Loss in weight are important clinical problems

Involuntary change is a marker of serious underlying disease

Always ask about appetite

Obesity is a serious world wide problem with increased morbidity & mortality

Persistence and periodic evaluation is important to reach at the underlying cause for weight loss

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