IN 1998, THE WORLD HEALTH ORGANIZATION DESIGNATED OBESITY AS A

GLOBAL EPIDEMIC

WHAT IS OBESITY?
OBESITY IS THE ABNORMAL ACCUMULATION OF ADIPOSE TISSUE IN THE BODY, DEFINED AS BODY MASS INDEX (BMI) 30KG/M2 OR ABOVE.

OBESITY NOW IS NOT A PROBLEM OF HIGH INCOME COUNTRIES

IT IS NOW DRAMATICALLY INCREASING IN MIDDLE AND LOW INCOME COUNTRIES

BMI <18.5

Classification of Overweight and Obesity

Classification Underweight
Normal weight Overweight Obesity Class I Obesity Class II Obesity Class III Super Obesity

18.5-24.9 25-29.9 30-34.9 35-39.9 40-49.9 50 and above

WHAT IS BMI?

BODY WEIGHT IN KG DIVIDED BY HEIGHT IN METER SQUARE

ALTHOUGH WE DEFINE OBESITY BY BMI

BMI EXACTLY DOES NOT REFLECT THE ACTUAL ADIPOSITY

BECAUSE
BMI DOES NOT DIFFERENTIATE ADIPOSE TISSUE AND LEAN TISSUE. HIGH BMI CAN BE FOUND IN MUSCULAR ATHLETS BMI DOES NOT DIFFERENTIATE CENTRAL OR VISCERAL OBESITY AND PERIPHERAL OBESITY. BMI DOES NOT DIFFERENTIATE GENDER

VISCERAL OR CENTRAL OBESITY IS RISKY

WAIST CIRCUMFERENCE
MEASURED BY

HOW TO MEASURE WAIST CIRCUMFERENCE?

USE A TAPE MEASURE START AT THE TOP OF THE RIGHT ILIAC CREST, BRING IT ALL THE WAY AROUND AND LEVEL WITH THE NAVEL

MEN: <90CM AND WOMEN: <80CM

HIGHER WAIST CIRCUMFERENCE IS AN INDEPENDENT RISK FACTOR

HIGH CONTENT OF VISCERAL FAT = HIGHER METABOLIC RISK

MODERN MARKER OF OBESITY

WAIST HIP RATIO (WHR)

WHAT IS WAIST HIP RATIO?

MEASURE THE WAIST MEASURE THE WIDEST PART OF HIPS MAKE RATIO WAIST/ HIP FOR MEN WHR <0.9 FOR WOMEN WHR <0.7 WHR DIFFERENTIATE THE CENTRAL FROM PERIPHERAL OBESITY, HENCE BETTER MARKER OF OBESITY RELATED RISK.

OTHER MEASUREMENTS FOR OBESITY

BIOELECTRICAL IMPEDANCE ANALYSIS (BIA) CT SCAN MRI DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA) THESE ARE NOT ROUTINELY USED

BODY MASS INDEX(BMI) WAIST CIRCUMFERENCE

The two important screening methods of obesity accepted worldwide

CAUSES OF OBESITY
1. LIFESTYLE AND DIET 2. ENVIRONMENTAL FACTORS 3. GENETIC FACTORS 4. CERTAIN HORMONAL DISEASES 5. MEDICATIONS

1. LIFESTYLE AND DIET

MAIN REASONS FOR OBESITY IS ENERGY IMBALANCE e.g. CONSUMING MORE CALORIES THAN BODY NEEDS

2. ENVIRONMENTAL FACTORS
BIG PORTION SIZE HIGH FAT/ENERGY DENSE FOOD SOFT DRINKS SUGAR FAST FOOD SNACK FOOD

3. GENETIC FACTORS

RESEARCH SHOWS ABOUT 77% CASES IN CHILDHOOD OBESITY ARE INHERITED FROM OBESE PARENTS.

4. HORMONAL DISEASES
HYPOTHYROIDISM CUSHINGS SYNDROME

5. CERTAIN MEDICATIONS
ANTI-CONVULSANTS: Carbamazepine, Valporate CERTAIN ANTI-DIABETICS: sulfonylureas CERTAIN ANTIDEPRESSANTS ORAL CONTRACEPTIVES CORTICOSTEROIDS

WHY OBESITY IS RISKY?

VISCERAL OBESITY LEADS TO THE DEVELOPMENT OF: CARDIOVASCULAR DISEASE AND STROKE
TYPE 2 DIABETES HYPERCHOLESTEROLEMIA

OTHER COMPLICATIONS OF OBESITY

OSTEOARTHRITIS CANCER NON ALCOHOLIC FATTY LIVER DISEASE POLYCYSTIC OVARY SYNDROME (PSOS) CHOLELITHIASIS HYPERURICEMIA INFERTILITY

Medical Complications of Obesity

Pulmonary disease
abnormal function obstructive sleep apnea hypoventilation syndrome

Stroke Cataracts

Nonalcoholic fatty liver disease

steatosis steatohepatitis cirrhosis

CHD Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer

Gall bladder disease Gynecologic abnormalities

abnormal menses infertility Osteoarthritis PCOS
breast, uterus, cervix colon, esophagus, pancreas kidney, prostate

Phlebitis
venous stasis

Gout
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BEFORE GOING TO TREAT OBESITY

1.

LOOK FOR RISK FACTORS 2. GET LABORATORY TESTS

RISK FACTORS
Established coronary heart disease H/O myocardial infarction Angina pectoris (stable or unstable) H/O coronary artery surgery or angioplasty Family h/o CHD in first degree relatives Presence of atherosclerotic diseases e.g. PVD, abdominal aortic aneurysm, symptomatic carotid artery disease Pre-diabetes or T2DM Hypertension Hypercholesterolemia Sleep apnea Smoking Age: Men >45 years, women >55 years (postmenopausal)

High absolute risk for obesity related disease

Who are overweight and has three or more risk factors EXCEPT T2DM T2DM alone is defined as high absolute risk.

LABORATORY TESTS
Serum electrolytes Liver Function tests (LFT) Complete blood count (CBC) Lipid profile Thyroid function tests ECG

TREATMENT OF OBESITY
Non-pharmacological

Pharmacological

Surgical

GOAL FOR OBESITY TREATMENT

1. Achieve and maintain

healthier weight 2. Risk factor management

WHAT IS THE AIM OF HEALTHIER WEIGHT?

Aim to reduce 10% of the body weight during next 6 months. Once achieved, patient enters in to the phase of weight maintenance and long term monitoring. Monitoring is important because study shows, 80% may go back to their previous weight.

NON-PHARMACOLOGICAL TREATMENT
Dietary change

Physical activity

Behavior modification

DIETARY CHANGE

1. DIETARY CHANGE TARGET LOW CALORIE DIET

Calorie intake must be reduced by 5001000kcal/day from the baseline The above are called low calorie diet (LCD) If patient feels hungry, 100-200kcal/day can be increased.

Very low calorie diet (VLCD) is <888kcal/day

TARGET: LOW CALORIE DIET

CAUTION! Must not be less than 800kcal/day

WHAT HAPPENS WHEN CALORIES REDUCED

BELOW MAINTENANCE?

EAT
More fruits, vegetables, whole grain Limit sugar and other refined carbohydrate Limit food containing large amount of saturated and trans fat Consume backed, grilled, or roasted meat instead of fried. Limit soft drinks Total daily diet should be divided in to 4 to 5 meals per day.

2. PHYSICAL ACTIVITY
Walking, dancing, gardening, team or individual sports, cycling, rowing, rope jumping, jogging. Reducing sedentary activities e.g. watching TV, computer, games. Most attractive: Walking.

PHYSICAL ACTIVITY SHOULD BE STARTED GRADUALLY.

walking 10min/day-3days in a week, increase gradually up to 45min/day-7days/week

3. BEHAVIOR MODIFICATIONS
Family Physician together with family members and friends and if possible with psychologist should modify the behaviors responsible for obesity: These are: practice self monitoring, stress management, stimulus control, contingency management, cognitive restructuring

PHARMACOLOGICAL TREATMENT IS INDICATED IF

BMI is equal or >30 AND Non-pharmacological approach can not achieve goal maximum in six months e.g. reduction of 10% body weight.

Non-pharmacological treatment should be continued

together with pharmacological agents

TWO DRUGS CURRENTLY APPROVED BY FDA

SIBUTRAMINE ORLISTAT

SIBUTRAMINE
FDA approval in November 1997. Centrally acting serotonine-norepinephrinereuptake inhibitor (SNRI). Centrally acting anorexiant or appetite suppressant. Doses: start with 5mg in the morning. Maximum 15mg/day with or without food Should not be used in patients with HTN, CHD, CHF, arrythmia or stroke. Should not be used in patients aged 16 or less.

ORLISTAT
FDA approval in April 1999. Pancreatic lipase inhibitor Inhibit absorption of dietary fat up to 30% Doses: 120mg three times a day with meal. As orlistst reduce absorption of fat soluble vitamins and beta carotene , patient should get the above vitamins, to be taken 2 hrs before or after the dose of orlistat. Study does not support use of orlistat in patients less than 12 years of age.

THESE ARE FOR LONG TERM USE

If weight reduction is not achieved 2kg in 4 weeks, drug should be discontinued

SURGICAL TREATMENT OF OBESITY

If BMI is equal or more than 40 If BMI is equal or more than 35 plus any additional risk factor. no response to lifestyle and drug treatment. Liposuction is no more popular for its complications and long term side effects. Bariatric surgery 2 types of surgery are proven to be effective

BARIATRIC SURGERY 1
Banded gastroplasty to restrict gastric volume Vertical banded gastroplasy (VBG)

BARIATRIC SURGERY 2
Rous-en-Y gastric bypass. (RYGB) In addition to limiting food intake, it alter digestion

Contraindications to Treatment of overweight & obesity Active cancer Eating disorders e.g. anorexia nervosa and bulimia. Pregnancy. Any severe illness or terminal illness

PRACTICAL TIPS FOR FAMILY PHYSICIANS

Patient Measure height, weight, waist & find BMI. BMI equal or >25 OR Waist >102cm(M) OR >88cm(F) For us: >90cm(M) or >80cm(F) Assess risk factors. Assess causes. Get laboratory tests. Go for treatment options: Goal: 10% wt. loss in 6 months.

DOCTORS! WHERE WE STAND?

WITH OBESITY?

Guidelines in Army as per AO 9/2011

10% over IBW, evaluate to find weight due to obesity /increase muscle mass/bone thickness. BMI ,WHR,Bl.sug,lipid profile,thyroid,ECG. If due to muscle mass/thick bones, i.e. WHR 0.9 or less, BMI <25,no metabolic ,ECG abnormality, P1

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DISPOSAL OF OBESE OFFICERS

In writing to reduce weight in 12 weeks if so AFMSF-3 to complete. If fails, placed in P2(T-24) Obese after six months,P2. IF P2 for 3 yr place in P3 No employment restriction

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If IBW>20%,overweight due to obesity no metabolic abnormality ,ECG normal ,placed in P2(T-24)

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Conclusion
Lifestyle changes such as diet and exercise are still the mainstay of obesity management. Aim of treatment should be modest weight loss maintained in the long term Add anti-obesity drugs only if above fails Consider the risk vs. benefit of prescribing these drugs.