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Biology of

Biology of

Obesity

Obesity

dr Budi

dr

Budi Enoch

Enoch SpPD

SpPD

• • In In a a world world where where food food supplies supplies are are intermittent, intermittent,

the ability to store energy in excess of what is

the ability to store energy in excess of what is

required for immediate use is essential for

required for immediate use is essential for

survival.

survival.

• • Fat Fat cells, cells, residing residing within within widely widely distributed distributed

adipose tissue depots, are adapted to store

adipose tissue depots, are adapted to store

excess energy efficiently as triglyceride and,

excess energy efficiently as triglyceride and,

when needed, to release stored energy as free

when needed, to release stored energy as free

fatty acids for use at other sites.

fatty acids for use at other sites.

This This physiologic physiologic system, system, orchestrated orchestrated through through

endocrine endocrine and and neural neural pathways, pathways, permits permits

humans to survive starvation for as long as

humans to survive starvation for as long as

• • In In a a world world where where food food supplies supplies are are

several months.

several months.

• • However, However, in in the the presence presence of of nutritional nutritional

abundance and a sedentary lifestyle, and

abundance and a sedentary lifestyle, and

DEFINISI

DEFINISI

• •

Obesitas Obesitas adalah adalah keadaan keadaan

kelebihan kelebihan massa massa jaringan jaringan adiposa. adiposa.

• •

Obesitas Obesitas adalah adalah penyakit penyakit imbalans imbalans

kalori kalori yang yang disebabkan disebabkan oleh oleh

kelebihan kelebihan intake intake kalori kalori daripada daripada

DEFINISI DEFINISI • • Obesitas Obesitas adalah adalah keadaan keadaan kelebihan kelebihan massa massa jaringan jaringan

yang yang dikonsumsi dikonsumsi oleh oleh tubuh. tubuh.

• •

• •

• •

WHO: WHO:

BMI BMI ≥25 ≥25 adalah adalah overweight overweight

BMI BMI ≥30 ≥30 adalah adalah obesitas obesitas

WHO: World Health Organization BMI: body mass index

DEFINISI DEFINISI • • Obesitas Obesitas adalah adalah keadaan keadaan kelebihan kelebihan massa massa jaringan jaringan
DEFINISI DEFINISI • • Obesitas Obesitas adalah adalah keadaan keadaan kelebihan kelebihan massa massa jaringan jaringan

Robbins Pathologic Basis of Disease 8 th edition

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill ti

Ed

Nomogram for determining body mass index. To use this nomogram, place a ruler or other straight

Nomogram for determining body mass index. To use this nomogram, place a ruler or other straight edge between the body weight (without clothes) in kilograms or pounds located on the left-hand line and the height (without shoes) in centimeters or inches located on the right-hand line. The body mass index is read from the middle of the scale and is in metric units. (Copyright 1979, George A. Bray, MD; used with permission.)

Silhouettes and waist circumferences representing normal, <a href=overweight , and obese " id="pdf-obj-4-2" src="pdf-obj-4-2.jpg">

Silhouettes and waist circumferences representing normal, overweight, and obese

Silhouettes and waist circumferences representing normal, <a href=overweight , and obese " id="pdf-obj-4-9" src="pdf-obj-4-9.jpg">

EPIDEMIOLOG

EPIDEMIOLOG

I

EPIDEMIOLOG EPIDEMIOLOG I NHNES: National Health and Nutrition Examination Survey Departemen Kesehatan RI, 2011, Riset Kesehatanhttp " id="pdf-obj-5-10" src="pdf-obj-5-10.jpg">

NHNES: National Health and Nutrition Examination Survey

Departemen Kesehatan RI, 2011, Riset Kesehatan Dasar 2010: Laporan Nasional. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan RI, Jakarta.Ogden, C.L., dan Carroll, M.D., 2010, Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults : United States, Trands 1960-1962 Through 2007-2008, JAMA., 303(3):235–41. World Health Organization (WHO), 2008, Nutritional Status, (serial online), http

Pengeluaran energi Gen Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 Edition.

Pengeluaran energi

Pengeluaran energi Gen Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 Edition.
Gen
Gen
Pengeluaran energi Gen Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 Edition.
Pengeluaran energi Gen Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 Edition.

Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 nd Edition. United Kingdom : Elsevier Limited

Faktor Endokrin Hipotiroidis Hipotiroidis me me Sindrom Sindrom cushing cushing Insulinoma Insulinoma Tumor Tumor s s
Faktor
Endokrin
Hipotiroidis
Hipotiroidis
me
me
Sindrom
Sindrom
cushing
cushing
Insulinoma
Insulinoma
Tumor
Tumor
s s atau
atau
Obat-obatan
cedera
cedera
• •
hipotalamu
hipotalamu
Olanzapine
Olanzapine

• •

Sulfonilurea,

Sulfonilurea,

thiazolidindion

thiazolidindion

• •

• •

e, insulin

e, insulin

Pizotifen

Pizotifen

Kortikosteroid

Kortikosteroid

• •

• •

Sodium

Sodium

valproat

valproat

Β-blocker

Β-blocker

Pengeluaran

Pengeluaran 99 kgkg 30 tahun Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19
Pengeluaran 99 kgkg 30 tahun Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19

99 kgkg

30 tahun
30 tahun

Kasper D.L.,

et

al. 2015.

Harrison’s Principles of

Internal Medicine, 19 th Edition. New York: McGraw-Hill

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 Edition. New York: McGraw-Hill Education.
Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 Edition. New York: McGraw-Hill Education.

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill Education.

• • A A major major regulator regulator of of these these adaptive adaptive responses responses is is

the the adipocyte-derived adipocyte-derived hormone hormone leptin, leptin, which which

acts through brain circuits (predominantly in the

acts through brain circuits (predominantly in the

hypothalamus) to influence appetite, energy

hypothalamus) to influence appetite, energy

expenditure, and neuroendocrine function

expenditure, and neuroendocrine function

Appetite Appetite is is influenced influenced by by many many factors factors that that are are

integrated by the brain, most importantly within

integrated by the brain, most importantly within

the hypothalamus.

the hypothalamus.

• • Hormonal Hormonal signals signals include include leptin, leptin, insulin, insulin,

cortisol, cortisol, and and gut gut peptides. peptides. Among Among the the latter latter is is

ghrelin, ghrelin, which which is is made made in in the the stomach stomach and and

stimulates feeding, and peptide YY (PYY) and

stimulates feeding, and peptide YY (PYY) and

cholecystokinin, which is made in the small

cholecystokinin, which is made in the small

intestine and signal to the brain through direct

intestine and signal to the brain through direct

• • A A major major regulator regulator of of these these adaptive adaptive responses responses

action on hypothalamic control centers and/or via

action on hypothalamic control centers and/or via

the vagus nerve.

the vagus nerve.

A graphic depiction of a leptin molecule

A graphic depiction of a leptin molecule

A graphic depiction of a leptin molecule
PATOFISIOLOGI PATOFISIOLOGI
PATOFISIOLOGI
PATOFISIOLOGI
PATOFISIOLOGI PATOFISIOLOGI Marschall S., et al. Netter’s Internal Medicine, 2 Edition. Saunders, Inc. 2009

Marschall S., et al. Netter’s Internal Medicine, 2 nd Edition. Saunders, Inc. 2009

Keadaa IMT n gizi (Kg/m 2 ) Kurus ≤ 18,5 Normal 18,5- 24,9 Overwei ≥ 25
Keadaa
IMT
n gizi
(Kg/m 2 )
Kurus
≤ 18,5
Normal
18,5-
24,9
Overwei
≥ 25
ght
Keadaan
IMT
Pre
gizi
25,0-
(Kg/m 2
EROPA
EROPA
obesitas
29,9
)
Obesitas Kurus
30,0-
≤ 18,5
I
34,9
Normal
18,5-
Obesitas
35,0-
22,9
II
39,9
Overweig
≥ 23
Obesitas ht
≥ 40,0
III
Pre
23,0-
obesitas
24,9
Obesitas I
25,0-
29,9
ASIA
ASIA
Obesitas II 30,0
INDONESIA INDONESIA
INDONESIA
INDONESIA
Keadaa IMT n gizi (Kg/m 2 ) Kurus ≤ 18,5 Normal 18,5- 24,9 Overwei ≥ 25

Keadaan

IMT

gizi

(Kg/m 2 )

Kurus

< 17,0

sekali

Kurus

17,0-

18,4

Normal

18,5-

25,0

Overweig

25,1-

ht

27,0

Obesitas

> 27,0

Departemen Kesehatan RI., 2007, Pedoman Pengukuran dan Pemeriksaan, Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan RI, Jakarta.

TIPE OBESITAS

TIPE OBESITAS

HIPPOCRATES

“sudden death is more

common in those who

are naturally fat than in

lean.”

TIPE OBESITAS TIPE OBESITAS HIPPOCRATES “sudden death is more common in those who are naturally fat
TIPE OBESITAS TIPE OBESITAS HIPPOCRATES “sudden death is more common in those who are naturally fat

BMI

yang

Lemak wanita >> pria

Lemak wanita

pria

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill Education.

OBESITAS ANDROID

OBESITAS ANDROID

OBESITAS GINOID

OBESITAS GINOID

The The distribution distribution of of adipose adipose tissue tissue in in different different anatomic anatomic

depots also has substantial implications for morbidity.

depots also has substantial implications for morbidity.

• • Specifically, Specifically, intraabdominal intraabdominal and and abdominal abdominal

subcutaneous fat have more significance than

subcutaneous fat have more significance than

subcutaneous fat present in the buttocks and lower

subcutaneous fat present in the buttocks and lower

extremities.

extremities.

• • This This distinction distinction is is most most easily easily made made clinically clinically by by

determining the waist-to-hip ratio, with a ratio >0.9 in

determining the waist-to-hip ratio, with a ratio >0.9 in

women and >1.0 in men being abnormal.

women and >1.0 in men being abnormal.

• • Many Many of of the the most most important important complications complications of of

obesity such as insulin resistance, diabetes,

obesity such as insulin resistance, diabetes,

hypertension, hyperlipidemia, and

hypertension, hyperlipidemia, and

hyperandrogenism in women, are linked more

hyperandrogenism in women, are linked more

• The The distribution distribution of of adipose adipose tissue tissue in in different different anatomic

strongly to intraabdominal and/or upper body fat

strongly to intraabdominal and/or upper body fat

than to overall adiposity.

than to overall adiposity.

Physiologic Regulation

Physiologic Regulation

of Energy Balance

of Energy Balance

Physiologic Regulation Physiologic Regulation of Energy Balance of Energy Balance
Physiologic Regulation Physiologic Regulation of Energy Balance of Energy Balance

• • Energy expenditure includes the

Energy expenditure includes the

following components:

following components:

(1) resting or basal metabolic rate;

(1) resting or basal metabolic rate;

• • (2) the energy cost of metabolizing and

(2) the energy cost of metabolizing and

storing food;

storing food;

(3) the thermic effect of exercise; and

(3) the thermic effect of exercise; and

• • (4) adaptive thermogenesis, which varies in

(4) adaptive thermogenesis, which varies in

response to long-term caloric intake (rising

response to long-term caloric intake (rising

with increased intake).

with increased intake).

Basal metabolic rate accounts for 70%

Basal metabolic rate accounts for 70%

of daily energy expenditure, whereas

of daily energy expenditure, whereas

• • Energy expenditure includes the Energy expenditure includes the following components: following components: • (1)

active physical activity contributes 5–10%.

active physical activity contributes 5–10%.

Thus, a significant component of daily

Thus, a significant component of daily

energy consumption is fixed.

energy consumption is fixed.

The Adipocyte and Adipose

The Adipocyte and Adipose

Tissue

Tissue

• • Adipose Adipose tissue tissue is is composed composed of of the the lipid-storing lipid-storing adipose adipose

cell and a stromal/vascular compartment in which cells

cell and a stromal/vascular compartment in which cells

including preadipocytes and macrophages reside.

including preadipocytes and macrophages reside.

• • Adipose Adipose mass mass increases increases by by enlargement enlargement of of adipose adipose

cells through lipid deposition, as well as by an increase

cells through lipid deposition, as well as by an increase

in the number of adipocytes.

in the number of adipocytes.

• • Obese Obese adipose adipose tissue tissue is is also also characterized characterized by by increased increased

numbers of infiltrating macrophages.

numbers of infiltrating macrophages.

• • The The process process by by which which adipose adipose cells cells are are derived derived from from a a

mesenchymal preadipocyte involves an orchestrated

mesenchymal preadipocyte involves an orchestrated

series of differentiation steps mediated by a cascade of

series of differentiation steps mediated by a cascade of

specific transcription factors.

specific transcription factors.

One One of of the the key key transcription transcription factors factors is is peroxisome peroxisome

The Adipocyte and Adipose The Adipocyte and Adipose Tissue Tissue • • Adipose Adipose tissue tissue

proliferator-activated proliferator-activated receptor receptor (PPAR), (PPAR), a a nuclear nuclear

receptor that binds the thiazolidinedione class of

receptor that binds the thiazolidinedione class of

• • Although Although the the adipocyte adipocyte has has generally generally been been

regarded as a storage depot for fat, it is also an

regarded as a storage depot for fat, it is also an

endocrine cell that releases numerous molecules

endocrine cell that releases numerous molecules

in a regulated fashion.

in a regulated fashion.

• • These These include include the the energy energy balance–regulating balance–regulating

hormone leptin, cytokines such as tumor necrosis

hormone leptin, cytokines such as tumor necrosis

factor (TNF)- and interleukin (IL)-6, complement

factor (TNF)- and interleukin (IL)-6, complement

factors factors such such as as factor factor D D (also (also known known as as adipsin), adipsin),

prothrombotic agents such as plasminogen

prothrombotic agents such as plasminogen

activator inhibitor I, and a component of the

activator inhibitor I, and a component of the

blood pressure–regulating system,

blood pressure–regulating system,

angiotensinogen.

angiotensinogen.

Adiponectin, Adiponectin, an an abundant abundant adipose-derived adipose-derived

protein whose levels are reduced in obesity,

protein whose levels are reduced in obesity,

enhances insulin sensitivity and lipid oxidation

enhances insulin sensitivity and lipid oxidation

and it has vascular-protective effects, whereas

and it has vascular-protective effects, whereas

resistin and RBP4 whose levels are increased in

resistin and RBP4 whose levels are increased in

Role of genes versus

Role of genes versus

environment

environment

• • Obesity Obesity is is commonly commonly seen seen in in families, families, and and the the

heritability of body weight is similar to that for height.

heritability of body weight is similar to that for height.

Inheritance is usually not Mendelian, however, and it is

Inheritance is usually not Mendelian, however, and it is

difficult to distinguish the role of genes and

difficult to distinguish the role of genes and

environmental factors.

environmental factors.

• • Adoptees Adoptees more more closely closely resemble resemble their their biologic biologic than than

adoptive parents with respect to obesity, providing

adoptive parents with respect to obesity, providing

strong support for genetic influences.

strong support for genetic influences.

Whatever Whatever the the role role of of genes, genes, it it is is clear clear that that the the

environment environment plays plays a a key key role role in in obesity, obesity, as as

evidenced by the fact that famine prevents obesity in

evidenced by the fact that famine prevents obesity in

even the most obesity-prone individual.

even the most obesity-prone individual.

In In addition, addition, the the recent recent increase increase in in the the prevalence prevalence of of

Role of genes versus Role of genes versus environment environment • • Obesity Obesity is is

obesity in the United States is far too rapid to be due to

obesity in the United States is far too rapid to be due to

changes in the gene pool. Undoubtedly, genes

changes in the gene pool. Undoubtedly, genes

influence the susceptibility to obesity in response to

influence the susceptibility to obesity in response to

Specific genetic

Specific

genetic syndromes

syndromes

• • For For many many years, years, obesity obesity in in rodents rodents has has been been known known to to

be caused by a number of distinct mutations distributed

be caused by a number of distinct mutations distributed

through the genome.

through the genome.

Most Most of of these these single-gene single-gene mutations mutations cause cause both both

hyperphagia and diminished energy expenditure,

hyperphagia and diminished energy expenditure,

suggesting a physiologic link between these two

suggesting a physiologic link between these two

parameters of energy homeostasis.

parameters of energy homeostasis.

• • Identification Identification of of the the ob ob gene gene mutation mutation in in genetically genetically

obese (ob/ob) mice represented a major breakthrough

obese (ob/ob) mice represented a major breakthrough

in the field.

in the field.

The The product product of of the the ob ob gene gene is is the the peptide peptide leptin, leptin, a a

name name derived derived from from the the Greek Greek root root leptos, leptos, meaning meaning thin. thin.

Specific genetic Specific genetic syndromes syndromes • • For For many many years, years, obesity obesity

Leptin is secreted by adipose cells and acts primarily

Leptin is secreted by adipose cells and acts primarily

through the hypothalamus. Its level of production

through the hypothalamus. Its level of production

provides an index of adipose energy stores

provides an index of adipose energy stores

High High leptin leptin levels levels decrease decrease food food intake intake and and

increase increase energy energy expenditure. expenditure. Another Another mouse mouse

mutant, db/db, which is resistant to leptin, has a

mutant, db/db, which is resistant to leptin, has a

mutation in the leptin receptor and develops a similar

mutation in the leptin receptor and develops a similar

syndrome.

syndrome.

• • Several Several families families with with morbid, morbid, early-onset early-onset obesity obesity

caused by inactivating mutations in either leptin or the

caused by inactivating mutations in either leptin or the

leptin receptor have been described.

leptin receptor have been described.

• • Obesity Obesity in in these these individuals individuals begins begins shortly shortly after after birth, birth, is is

severe, and is accompanied by neuroendocrine

severe, and is accompanied by neuroendocrine

abnormalities.

abnormalities.

• • The The most most prominent prominent of of these these is is hypogonadotropic hypogonadotropic

hypogonadism, which is reversed by leptin replacement

hypogonadism, which is reversed by leptin replacement

in the leptin-deficient subset. Central hypothyroidism

in the leptin-deficient subset. Central hypothyroidism

• • High High leptin leptin levels levels decrease decrease food food intake intake and and

and growth retardation are seen in the mouse model,

and growth retardation are seen in the mouse model,

but their occurrence in leptin-deficient humans is less

but their occurrence in leptin-deficient humans is less

clear. clear. To To date, date, there there is is no no evidence evidence that that mutations mutations in in

• • A A number number of of complex complex human human syndromes syndromes with with defined defined

inheritance inheritance are are associated associated with with obesity obesity (Table (Table 77-2). 77-2).

Although specific genes have limited definition at

Although specific genes have limited definition at

present, their identification will likely enhance our

present, their identification will likely enhance our

understanding of more common forms of human

understanding of more common forms of human

obesity.

obesity.

• • Most Most patients patients have have a a deletion deletion in in the the 15q11-13 15q11-13

chromosomal region, and reduced expression of the

chromosomal region, and reduced expression of the

signaling protein necdin may be an important cause of

signaling protein necdin may be an important cause of

defective hypothalamic neural development in this

defective hypothalamic neural development in this

disorder.

disorder.

• • At At least least 12 12 genetic genetic loci loci have have been been identified, identified, and and most most

of the encoded proteins form two multiprotein

of the encoded proteins form two multiprotein

complexes that are involved in ciliary function and

complexes that are involved in ciliary function and

• • A A number number of of complex complex human human syndromes syndromes with with

microtubule-based intracellular transport. Recent

microtubule-based intracellular transport. Recent

evidence suggests that mutations might disrupt leptin

evidence suggests that mutations might disrupt leptin

receptor trafficking in key hypothalamic neurons,

receptor trafficking in key hypothalamic neurons,

Other specific syndromes

Other specific syndromes

associated with obesity

associated with obesity

Cushing's syndrome

Cushing's syndrome

• • Hypothyroidism

Hypothyroidism

• • Insulinoma

Insulinoma

Craniopharyngioma and other disorders

Craniopharyngioma and other disorders

involving the hypothalamus

involving the hypothalamus

Other specific syndromes Other specific syndromes associated with obesity associated with obesity • Cushing's syndrome •

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko
 

kebiasaan, riwayat

kebiasaan, riwayat

pengobatan, riwayat

pengobatan, riwayat

keluarga dan risiko

keluarga dan risiko

penyakit penyerta

penyakit penyerta

 
kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko penyakit penyerta
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko

Gula darah, kolesterol,

Gula darah, kolesterol,

LDL, HDL, fungsi ginjal

LDL, HDL, fungsi ginjal

dan fungsi hati

dan fungsi hati

Anamnesis Anamnesis
Anamnesis
Anamnesis
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko

Pemeriksaan fisik

Pemeriksaan fisik

Pemeriksaan

Pemeriksaan

 

laboratorium

laboratorium

 
   
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko
Pemeriksaan Pemeriksaan lanjutan lainnya lanjutan lainnya
Pemeriksaan
Pemeriksaan
lanjutan lainnya
lanjutan lainnya
air), USG, CT, dan MRI air), USG, CT, dan MRI Densitometry (didalam Densitometry (didalam
air), USG, CT, dan MRI
air), USG, CT, dan MRI
Densitometry (didalam
Densitometry (didalam
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko
DIAGNOSIS DIAGNOSIS kebiasaan, riwayat kebiasaan, riwayat pengobatan, riwayat pengobatan, riwayat keluarga dan risiko keluarga dan risiko

Jarang dilakukan

Jarang dilakukan

MRI: magnetic resonancing imaging, USG:

ultrasonograph, CT: commuted tomoghraphy

Antropometri

Antropometri

Antropometri Antropometri

KOMPLIKASI

KOMPLIKASI

KOMPLIKASI KOMPLIKASI Marschall S., et al. Netter’s Internal Medicine, 2 Edition. Saunders, Inc. 2009 Walker, B.R.,

Marschall S., et al. Netter’s Internal Medicine, 2 nd Edition. Saunders, Inc. 2009 Walker, B.R., et al. 2014. Davidson’s Principles and Pratice of Medicine, 22 nd Edition. United Kingdom : Elsevier Limited

K

K

O

O

M

M

P

P

L

L

I

I

K

K

A

A

S S

I I

K K O O M M P P L L I I K K A A

HDL: high density lipoprotein, LDL:

low density lipoprotein, VLDL: very low density lipoprotein

McPhee S.J and Maxine A.P., 2011,Current Medical Diagnosis & Treatment, 5 th Ed. McGraw Hill Lange.

Pathogenesis of common

Pathogenesis of common

Pathogenesis of common Pathogenesis of common obesity obesity During the <a href=Middle Ages and the Renaissance obesity was often seen as a sign of wealth, and was relatively common among the elite: The Tuscan General Alessandro del Borro , attributed to Charles Mellin, 1645 " id="pdf-obj-38-6" src="pdf-obj-38-6.jpg">

obesity

obesity

Pathogenesis of common Pathogenesis of common obesity obesity During the <a href=Middle Ages and the Renaissance obesity was often seen as a sign of wealth, and was relatively common among the elite: The Tuscan General Alessandro del Borro , attributed to Charles Mellin, 1645 " id="pdf-obj-38-12" src="pdf-obj-38-12.jpg">

During the Middle Ages and the Renaissance

obesity was often seen as a sign of wealth,

and was relatively common among the elite:

The Tuscan General Alessandro del Borro,

attributed to Charles Mellin, 1645

Obesity can result from increased energy

Obesity can result from increased energy

intake, decreased energy expenditure, or a

intake, decreased energy expenditure, or a

combination of the two.

combination of the two.

Thus, identifying the etiology of obesity

Thus, identifying the etiology of obesity

should involve measurements of both

should involve measurements of both

parameters. However, it is difficult to perform

parameters. However, it is difficult to perform

direct and accurate measurements of energy

direct and accurate measurements of energy

intake in free-living individuals; and the

intake in free-living individuals; and the

obese, in particular, often underreport intake.

obese, in particular, often underreport intake.

Measurements of chronic energy expenditure

Measurements of chronic energy expenditure

are possible using doubly labeled water or

are possible using doubly labeled water or

metabolic chamber/rooms. In subjects at

metabolic chamber/rooms. In subjects at

• Obesity can result from increased energy • Obesity can result from increased energy intake, decreased

stable weight and body composition, energy

stable weight and body composition, energy

intake equals expenditure.

intake equals expenditure.

• • There There is is continued continued interest interest in in the the concept concept of of a a

body weight "set point." This idea is supported by

body weight "set point." This idea is supported by

physiologic mechanisms centered around a

physiologic mechanisms centered around a

sensing system in adipose tissue that reflects fat

sensing system in adipose tissue that reflects fat

stores stores and and a a receptor, receptor, or or "adipostat," "adipostat," that that is is in in

the hypothalamic centers.

the hypothalamic centers.

• • When When fat fat stores stores are are depleted, depleted, the the adipostat adipostat signal signal

is low, and the hypothalamus responds by

is low, and the hypothalamus responds by

stimulating hunger and decreasing energy

stimulating hunger and decreasing energy

expenditure to conserve energy.

expenditure to conserve energy.

• • Conversely, Conversely, when when fat fat stores stores are are abundant, abundant, the the

signal is increased, and the hypothalamus

signal is increased, and the hypothalamus

responds by decreasing hunger and increasing

responds by decreasing hunger and increasing

energy expenditure.

energy expenditure.

• • There There is is continued continued interest interest in in the the concept concept

The The recent recent discovery discovery of of the the ob ob gene, gene, and and its its

product product leptin, leptin, and and the the db db gene, gene, whose whose product product is is

the leptin receptor, provides important elements

the leptin receptor, provides important elements

What is the status of food intake in

What is the status of food intake in

obesity? (Do the obese eat more than

obesity? (Do the obese eat more than

the lean?)

the lean?)

• • This This question question has has stimulated stimulated much much debate, debate, due due in in

part to the methodologic difficulties inherent in

part to the methodologic difficulties inherent in

determining food intake.

determining food intake.

• • Many Many obese obese individuals individuals believe believe that that they they eat eat

small quantities of food, and this claim has often

small quantities of food, and this claim has often

been supported by the results of food intake

been supported by the results of food intake

questionnaires.

questionnaires.

• • However, However, it it is is now now established established that that average average

energy expenditure increases as individuals get

energy expenditure increases as individuals get

more obese, due primarily to the fact that

more obese, due primarily to the fact that

metabolically active lean tissue mass increases

metabolically active lean tissue mass increases

with obesity.

with obesity.

What is the status of food intake in What is the status of food intake in

Given Given the the laws laws of of thermodynamics, thermodynamics, the the obese obese

person must therefore eat more than the average

person must therefore eat more than the average

lean person to maintain their increased weight.

lean person to maintain their increased weight

TATALAKSANA

TATALAKSANA

Target ↓BB 10% dalam 6 bulan

• •

.
.

Tujuan mengobati dan mencegah

komorbid/penyakit terkait obesitas

Seagresif apa? Modalitas?

TATALAKSANA TATALAKSANA Target  ↓BB 10% dalam 6 bulan • • . Tujuan  mengobati dan
TATALAKSANA TATALAKSANA Target  ↓BB 10% dalam 6 bulan • • . Tujuan  mengobati dan

BB: berat badan, BMI:

body mass index

Weight Reduction

Weight

Reduction

Exercise
Exercise

High fiber & low saturated fat

Drugs (sibutramine, Orlistat)

Gastric bypass surgery

- BMI >30

Weight Reduction Weight Reduction Exercise High fiber & low saturated fat Drugs (sibutramine, Orlistat) Gastric bypass

- Morbid obesity

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 Edition. New York: McGraw-Hill Ed
Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 Edition. New York: McGraw-Hill Ed

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill Ed

ti

PERUBAHAN GAYA HIDUP

PERUBAHAN GAYA HIDUP

Diet lain:  Diet rendah karbohidrat tinggi protein  efektif  Self monitoring (membaca BMI, faktor
Diet lain:
 Diet rendah karbohidrat
tinggi protein  efektif
 Self monitoring (membaca
BMI, faktor risiko
jurnal, menimbang berat
Physical Activity Guidelines
kardiovaskular. Namun
efektivitas 1 tahun sama.
for Americans  150 menit
badan secara berkala,
 aktivitas intensitas sedang
menghitung jumlah
Very low calorie diets
atau 75 menit aktivitas fisik
(VLCDs)  800 kkal
makanan dan aktivitas
fisik)
energi, 50-80 gram protein,
aerobik berat per minggu
 dan 100% vitamin dan
dilakukan dengan durasi
Manajemen stress
 mineral.
Kontrol stimulus
minimal 10 menit per episode
secara teratur.
(menggunakan piring yang
Indikasi: BMI >30, gagal
diet konvensional, memiliki
lebih kecil, tidak makan
saat nonton atau
kondisi medis yang dapat
segera membaik dengan
berkendara)
 penurunan berat badan
Dukungan sosial
 cepat (DM tipe 2 yang tidak
Problem solving
 terkontrol),
Cognitive restructuring
untuk membantu pasien
hipertrigliseridemia,
obstructive sleep apnea,
mengembangkan pikiran

FARMAKOTERAPI

FARMAKOTERAPI

FARMAKOTERAPI FARMAKOTERAPI Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 Edition. New York:

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill Education. McPhee S.J and Maxine A.P., 2011,Current Medical Diagnosis & Treatment, 5 th Ed. McGraw Hill Lange. Apovian CM; Louis JA; Daniel HB; Marie EM, 2015, Pharmacological Management of Obesity: An Endocrine

PEMBEDAHAN PEMBEDAHAN
PEMBEDAHAN
PEMBEDAHAN

Penelitian metaanalisis pembedahan dapat mengurangi berat

badan sebanyak 30-35% pada pasien obesitas berat.

Berat badan terkontrol pada 60% pasien selama 5 tahun.

Penurunan berat badan lebih besar pada prosedur restriktif-

malabsorptif.

Mortalitas <1%

Restriktif

PEMBEDAHAN PEMBEDAHAN  Penelitian metaanalisis  pembedahan dapat mengurangi berat badan sebanyak 30-35% pada pasien obesitas

Kasper D.L., et al. 2015. Harrison’s Principles of Internal Medicine, 19 th Edition. New York: McGraw-Hill Education.

Pathologic Consequences of

Pathologic Consequences of

Obesity

Obesity

• • Obesity Obesity has has major major adverse adverse effects effects on on health. health.

• • Obesity Obesity is is associated associated with with an an increase increase in in mortality, mortality,

with a 50–100% increased risk of death from all causes

with a 50–100% increased risk of death from all causes

compared to normal-weight individuals, mostly due to

compared to normal-weight individuals, mostly due to

cardiovascular causes.

cardiovascular causes.

• • Obesity Obesity and and overweight overweight together together are are the the second second

leading leading cause cause of of preventable preventable death death in in the the United United

States, accounting for 300,000 deaths per year.

States, accounting for 300,000 deaths per year.

Mortality Mortality rates rates rise rise as as obesity obesity increases, increases, particularly particularly

when obesity is associated with increased

when obesity is associated with increased

intraabdominal fat (see above).

intraabdominal fat (see above).

• • Life Life expectancy expectancy of of a a moderately moderately obese obese individual individual could could

Pathologic Consequences of Pathologic Consequences of Obesity Obesity • • Obesity Obesity has has major major

be shortened by 2–5 years, and a 20- to 30-year-old

be shortened by 2–5 years, and a 20- to 30-year-old

male with a BMI >45 may lose 13 years of life.

male with a BMI >45 may lose 13 years of life.

• •
• •
.
.

thanks bro

thanks bro