Obesity

Niken Puruhita

DEFINITION

Obesity

• Excessive amount of body fat

– Women with > 35% body fat

– Men with > 25% body fat

• Increased risk for health problems

• Are usually overweight, but can have healthy BMI and high % fat

• Measurements using calipers

Desirable % Body Fat

• Men: 8-25%

• Women 20-35%

Regional Distribution

• The regional distribution of body fat affects risk factors for the heart disease and type 2 diabetes

Body Fat Distribution: Gynecoid

• Lower-body obesity--Pear shape

• Encouraged by estrogen and progesterone

• Less health risk than upper-body obesity

• After menopause, upper-body obesity appears

Body Fat Distribution: Android

• Upper-body obesity--apple shape

• Associated with more heart disease, HTN, Type II Diabetes

• Abdominal fat is released right into the liver

• Encouraged by testosterone and excessive alcohol intake

• Defined as waist measurement of > 90 cm for men and >80 cm for women

Body Fat Distribution

Women

>88 cm (80cm) = Increased risk

Men

>102 cm (90cm) = Increased risk

Lean MEJ et al. Lancet; 1998; 351:853-6

Body fat distribution Apple shaped obesity

cm

WHO classification of obesity BMI = weight(kg)/height(m)2

WHO Classification BMI Risk of Death

Underweight Below 18.5 Low

Healthy weight 18.5-24.9 Average

Overweight (grade 1 obesity) 25.0-29.9 Mild increase

Obese (grade 2 obesity) 30.0-39.0 Moderate/severe

Morbid/severe obesity(grade 3) 40.0 and above Very severe

World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO,

1997 [3]

PATHOPHYSIOLOGY

Role of Brain Neurotransmitters

• Neurotransmitters govern the body’s response to starvation and dietary intake

• Decreases in serotonin and increases in neuropeptide Y are associated with an increase in carbohydrate appetite

• Neuropeptide Y increases during deprivation; may account for increase in appetite after dieting

• Cravings for sweet high-fat foods among obese and bulimic patients may involve the endorphin system

Hormonal Regulation of Body Weight

• Norepinephrine and dopamine—released by sympathetic nervous system in response to dietary intake

• Fasting and semistarvation lead to decreased levels of these neurotransmitters—more epinephrine is made and substrate is mobilized.

Hormones and Weight

• Hypothyroidism may diminish adaptive thermogenesis

• Insulin resistance may impair adaptive thermogenesis

• Leptin is secreted in proportion to percent adipose tissue and may regulate (decrease) appetite

Hunger vs. Satiety

• Satiety—postprandial state when excess food is being stored

• Hunger—postabsorptive state when stores are being mobilized

• Short-term regulation affected

Hunger vs. Satiety

• Feedback mechanism with signal from adipose mass when weight loss occurs—eating is the natural result

• Not always identified in the elderly

• This occurs mostly in young people

• Long-term regulation affected

Nature vs Nurture

• Identical twins raised apart have similar weights

• Genetics account for ~40%-70% of weight differences

• Genes affect metabolic rate, fuel use, brain chemistry, body shape

• Thrifty metabolism gene allows for more fat storage to protect against famine

Nature vs Nurture

Obesity tends to run in families

• If both parents are normal weight – 10% chance of obesity in offspring

• If one parent is obese – 40% chance

• If both parents obese – 80% chance

Is it genetics or learned eating behavior?

Nurture vs Nature

• Environmental factors influence weight

• Learned eating habits

• Activity factor (or lack of)

• Poverty and obesity

• Female obesity is rooted in childhood obesity

• Male obesity appears after age 30

Nurture vs Nature

• Overeating learned early in childhood

• Bottle vs breast

• Urging children to eat more, clean their plates

• Use of food as a reward

Nature and Nurture

• Obesity is nurture allowing nature to express itself

• Location of fat is influenced by genetics

• A child of obese parents must always be concerned about his weight

Causes of Obesity

Causes of Excessive Energy Intake

• Active: large portion sizes, frequent meals and snacks

• Passive: excessive intake of energy-dense foods containing hidden calories

• Variety of options: the greater the variety of foods offered, the greater the intake

– Sensory-specific satiety: as foods are consumed they become less appealing

Low Energy Expenditure

• There is a mismatch between our thrifty metabolic genetic heritage and the sedentary lifestyle

Health Problems Associated with Excess Body Fat

• Surgical risk

• Lung (pulmonary) disease

• Sleep apnea

• HTN

• CVD

• Bone and joint disorders (gout, osteoarthritis)

• Type 2 diabetes

• Gallstones

• Cancers (breast, colon, pancreas, gallbladder)

• Infertility

• Pregnancy- difficult delivery

• Reduced agility

• Early death

NHANES III Prevalence of Hypertension* According to BMI

14,9 15,2

22,1

27,727

32,7

41,937,8

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-<27 BMI 27-<30 BMI > 30

*Defined as mean systolic blood pressure 140 mm Hg, mean diastolic 90

mm Hg, or currently taking antihypertensive medication.

Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000;8:605-619.

Per

cen

t

Obesity and Diabetes Risk

0

20

40

60

80

100

<20 20-25 25-30 30-35 35-40 >40

BMI Levels

Inci

den

ce o

f N

ew C

ase

s

per

1,0

00

Pers

on

-Yea

rs

Knowler WC et al. Am J Epidemiol 1981;113:144-156.

Weight Gain and Diabetes Risk

2,11,01,0

5,33,6

2,5

21,1

9,1

6,3

0

5

10

15

20

25

<22 22-23 24+

<5 kg 5-10 kg 11+ kg

Body Mass Index at Age 21

Rel

ati

ve

Ris

k

Weight Change Since Age 21

Adapted from Chan JM et al. Diabetes Care 1994;17:960-969.

Metabolic Syndrome Criteria* Three or more of the following abnormalities: • Waist circumference >102 cm (40 inches) in men

and > 88 cm (35 inches) in women • Serum triglycerides of at least 150 mg/dL • High density lipoprotein level <40 mg/dL in men

and <50 mg/dL in women • Blood pressure >=135/85 mm/hg • Serum glucose >=110 mg/dl • Includes 47 million US residents (27.7% of the

population

*ATP III Guidelines. National Cholesterol Education Program, 2001

Polycystic Ovary Syndrome (PCOS)

• Endocrine disorder characterized by hyperandrogenism and insulin resistance

• Associated with android obesity

• Affects 5-10% of reproductive age women

• Erratic menstrual periods, chronic anovulations resulting in multiple ovarian cysts; infertility, acne, hirsutism and alopecia

• Increased risk of heart disease, type 2 diabetes, reproductive cancers

26 -Year Incidence of Coronary Heart Disease in Men

177

255

350333366

440

0

100

200

300

400

500

600

<25 25-<30 30+

<50 years 50+ years

Inci

den

ce/1

,000

BMI Levels Adapted from Hubert HB et al. Circulation 1983;67:968-977. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

26 -Year Incidence of Coronary Heart Disease in Women

76

119

179

223268

292

0

100

200

300

400

500

<25 25-<30 30+

<50 years 50+ years

Inci

den

ce/1

,000

BMI Levels

Adapted from Hubert HB et al. Circulation 1983;67:968-977. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

Hypertension

BMI

20 25 30 35 40

Relationship between BMI and crude percentage of women reporting

medical problems, surgical procedures, symptoms, and health care utilization.

Brown WJ et al. Int J Obes 1998;22:520-528.

BMI

20 25 30 35 40

Diabetes

Brown WJ et al. Int J Obes 1998;22:520-528.

Relationship between BMI and crude percentage of women reporting

medical problems, surgical procedures, symptoms, and health care utilization.

BMI

20 25 30 35 40

Cholescystectomy

Relationship between BMI and crude percentage of women reporting

medical problems, surgical procedures, symptoms, and health care utilization.

Brown WJ et al. Int J Obes 1998;22:520-528.

BMI

20 25 30 35 40

Back Pain

Brown WJ et al. Int J Obes 1998;22:520-528.

Relationship between BMI and crude percentage of women reporting

medical problems, surgical procedures, symptoms, and health care utilization.

Body Mass Index and Mortality Risk

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenesis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations

in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)

Weight Management

• Balancing energy intake and energy expenditure is the basis of weight management throughout life

Set Point Theory

• Body tends to preserve a given weight

• Energy expenditure increases and decreases with weight loss and gain

• Effect may be temporary, e.g. energy needs drop during calorie restriction and normalize when energy balance is achieved

Components of Energy Expenditure

• Resting energy expenditure: expressed as RMR

• Energy expended in voluntary activity

• Thermic effect of food (TEF) or diet-induced thermogenesis (DIT)

– Related to energy value of food consumed and adaptive response to overeating

– TEF may decline as day progresses (Romon, AJCN, 1993)

Resting Metabolic Rate

• Increases with increased muscle mass

• Declines with age

• Declines during restriction of energy intake (up to 15%)

• Explains 60-70% of total energy expenditure

Voluntary Energy Expenditure (activity thermogenesis)

• The most variable component of energy expenditure

• Accounts for 15-30% of total

• Most of us will require increasing voluntary energy expenditure as we age to offset declining fat free mass and RMR in order to maintain weight

Benefits of 10% Weight Loss

Mortality >20% fall in total mortality

>30% fall in diabetes related deaths

>40% fall in obesity related deaths

Blood pressure fall of 10mmHg systolic and

diastolic pressure

Diabetes 50% fall in fasting glucose

Lipids 10% dec. total cholesterol

15% dec. in LDL

30% dec. in triglycerides

8% inc. in HDL

Jung 1997

AHA Guidelines for Healthy Diets

• Protein: 15-20% of calories – not excessive (50-100g/d) – proportional to carbohydrate and fat – Protein foods should not contribute excess total fat, sat

fat or cholesterol

• Carbohydrates: ~55% of calories – Minimum of 100g/d

• Fat: ~30% of calories, <10% sat fat • Diet should provide adequate nutrients and

support dietary compliance

St. Jeor ST, etal. Circulation 104:1869-74, 2001.

A particular food or nutrient causes weight loss. Usually low in calories. May lead to protein calorie malnutrition leading to breakdown of lean muscle mass.

Right for your type

Beverly Hills

Fit for Life

Grapefruit Diet

Cabbage diet

Low calorie, generally levels of 1200 or less.

Jenny Craig

Weight Watchers

Slim Fast

Richard Simmons

Limit carbohydrates; increase protein and sometimes fat.

Atkin’s Diet

The Zone

Sugar Busters

Protein Power

Carbohydrate Addict’s diet

Description Diets

Categorization of Diets by CHO and Fat

Dean Ornish Diet <10% Fat

Pritikin Diet <15% Fat

Weight Watchers, Jenny Craig, DASH diet, Food Guide Pyramid

55-60% CHO <30% Fat

The Zone Diet 40% CHO 30% Fat

Carbohydrate Addicts Diet < 30% CHO

Atkins (20-60g CHO), Protein Power (<60g CHO), VLCD-protein sparing modified fast

< 20% CHO

Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

Atkins Diet Revolution

Strict limits on carbs enable body to burn fat. Insulin is “single most significant determinant of weight.”

Ketotic diet. Limited food choices. High in fat and saturated fat. Low in fiber, vit D, Ca, K, Mg, Mn.

Available supplements include chromium picolinate, carnitine, coenzyme Q10, fatty acids.

14 days = 53% fat/d, 23% sat fat/d

14 days = 28g/d (5%)

Ongoing = 33g/d

Maintenance = 128g/d

14 days = 125g/d (36%)

Ongoing = 161g/d (35%)

Maintenance = 110g/d (24%)

Safety??

Fat

Carbs

Protein

Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

Rap

The Zone

40:30:30 keeps insulin levels in “The Zone”.

Recommends drinking water and exercising. Recommends 200 IU vitamin E.

Requires strict proportions of protein, fat and carb (40:30:30) in all meals and snacks.

Menus not appealing to many with low vegetable portions. Low in whole grains, calc.

29% fat/d; 4% sat fat/d

135g/d (36%)

127g/d (34%)

Safety??

Fat

Carbs

Protein

St. Jeor ST, etal. Circulation 104:1869-74, 2001.

Riley RE. Clinics in Sports Mediicne. 18(3):691-701, 1999.

Rap

Protein Power

Limiting carbs (moderate fat and adequate protein) lowers insulin. Insulin causes obesity.

Rigid rules, CHO must be chosen carefully.

Low in Ca, fiber, Cu, Mn. High in fat and sat fat; low in whole grains and calcium. Recommends vitamin/mineral supplement.

Recommends exercise esp. strength training.

54% fat/d; 18% sat fat/d

20 to 56g/d (16%)

91g/d (26%)

Safety??

Fat

Carbs

Protein

Riley RE. Clinics in Sports Mediicne. 18(3):691-701, 1999.

Rap

High Protein: Effects

• Diuresis (limited to 1st week) – Mobilization of glycogen stores – cause weight

loss of ~ 1 kg

– Generation of ketones

• Reductions in caloric content

• Appetite suppression from ketosis

• No studies have demonstrated advantages of ketotic diet

Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

High protein: Metabolic Effects

• Ketosis – dehydration, constipation and kidney stones

– fatigue

– ??? alter cognitive functioning

• High Saturated Fat – Increases in LDL-C and TC

• Low Fruits, Vegetables and Grains – Deficient in micronutrients (Vitamin B, calcium, K) and

phytochemicals

• Increases in serum uric acid Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

Westman EC. Et al. Am J Med. 113(1): 30-6, 2002.

Other possible effects

• Kidney stones

• Osteoporosis

• Chronic renal insufficiency

Sugar Busters

Refined carbs cause obesity by raising blood sugar. Eliminates high glycemic index foods like white rice, potatoes, carrots, white bread and corn.

Eliminates many foods with carbs. Daily menus range from 7 to 44 g sat fat.

Discourages eating fruit with meals. Limits water because “excess fluid dilutes digestive juices.”

Low in Ca, vit D, vit E, Cu and K. Downplays need to exercise.

21% fat/d; 4% sat fat/d

114g/d (52%)

71g/d (27%)

Safety??

Fat

Carbs

Protein

Rap

South Beach Diet Phase 1: two weeks. Most should see a rapid

weight loss of between 8 – 13 pounds. Most restrictive.

Phase 2: until reach goal weight. Weight loss 1-2

pounds per week. Foods that were restricted in re-introduced into the diet.

Phase 3: for life. Restrictions: avoid highly

processed food that contains ‘bad’ carbs and ‘bad’ fats and try and stick to the food that contains the ‘good’ ones.

Structure

• Studies suggest that adding structure to dietary recommendations improves weight loss in the behavioral treatment of obesity.

• Structure reduces the effort required for adherence, and eliminates much of the decision making, temptation, and guesswork involved in making healthy food choices.

Weight Watchers

– Practical advice – Group techniques – Food variety – Moderate protein, low fat – Limits refined sugars and EtOH – Stresses activity

– Groups

– Very structured

– Weekly fees

Structured Meal Plans

• Providing patients with structured meal plans and grocery lists produced just as great a weight loss at 6 months (13.7%) as did providing them with portion-controlled servings of food (13.5%).

• The findings of this study indicate that specifying what foods and what amounts patients should eat improves weight loss, but that providing the food has no additional effect.

Protein – Sparing Modified Fast (Optifast, Medifast)

• Calorie intake usually <900/d

• Minimize loss of lean body mass by having 70-90g/d protein

• LCD = ~800 cal/d

• VLCD = <800 cal/d

• Usually liquid

• Medical supervision needed

Low Calorie Diets

• Reduce total body weight by average of 8% over 3-12 months

• Greater initial loss with VLCD

• No difference between VLCD and LCD over long term (> 1 year)

NHLBI. Clinical guidelines on the identification, evaluation and

treatment of overweight and obesity in adults. 1998.

Maintenance

• After losing 10% of their weight or more with 6 months of treatment, patients typically regain approximately one half of that weight within 1 year and return to their baseline weight within 5 years if they receive no further treatment

Calorie Deficit Needed For Weight Loss

• A calorie deficit of no more than 500 kcal/day.

• This can be achievable through the combination of diet + exercise.

• An example of how to create a calorie deficit of 500 kcal/day through diet + exercise would be: eating 250 kcal less per day, along with burning 250 calories through exercise

2009 ACS

Calorie Deficit Needed For Weight Loss

• Eating 250 kcal less per

day:

• Switch from soft drinks to

water

• Reduce portion sizes

• burning 250 calories through

exercise:

• Walk for 30 minutes

• Swimming 25 yards

• Bicycling for 30 minutes

2009

A caloric deficit of 500 can be done by:

Exercise + Dieting Calorie Deficit

• Initially physical activity, in combination with dieting, is an

important component of weight loss.

• However, after around 6 months, physical activity will not

lead to substantially greater weight losses when

combined with dieting.

• The benefit of sustained physical activity thereafter is

mainly through its role in the prevention of weight gain.

• In addition, it has a benefit in reducing cardiovascular

and diabetes risks beyond that produced by weight gain

alone.

2009

NHLBI

Goals for Weight Loss And Management

• The initial goal of weight loss therapy is to reduce body weight by

approximately 10 percent from baseline. Once this goal is

achieved, then further weight loss can be attempted, if

necessary.

• A reasonable time line for a 10 percent reduction in body weight

is 6 months.

• Experience reveals that lost weight is usually regained unless a

weight maintenance program, consisting of diet therapy, physical

activity and behavior therapy, is continued indefinitely.

2009 NHLBI

Goals for Weight Loss And Management

• For overweight individuals with BMIs in the typical range of 27

to 35 kg/m2, a decrease of 300 to 500 kcal/day will result in

weight losses of about ½ to 1 lb per week.

• A 10 percent weight loss could be achieved within 6 months.

• For more severely obese individuals (BMI > 35), deficits of up

to 500 to 1,000 kcal/day will lead to weight losses of about 1

to 2 lb per week.

• A 10 percent weight loss could be achieved within 6 months.

2009 NHLBI

Goals for Weight Loss And Management

• After 6 months of weight loss treatment, the individual should

be assessed.

• If no further weight loss is needed, then the current weight

should be maintained.

• Sustained physical activity is particularly important in the

prevention of weight regain.

• If further weight loss is desired, another attempt at weight

reduction can be made.

2009

Evidence-based Strategies to Increase Physical Activity

The Guide to Community Preventive Services, MMWR 2001

• Creating or Improving Access to Places for Physical Activity

• Providing Social Support in Community Settings • Community-wide Campaigns to Promote Physical

Activity

• Point-of-Decision Prompts that Encourage People to Use the Stairs

• Health Behavior Change Programs Adapted for Individual Needs

• Child-specific information to parents regarding their child’s body mass index percentile

Physical Activity

• Contributes to weight loss.

• Helpful for the prevention of

overweight and obesity.

• Helps maintain weight loss.

2009 CDC

Physical Activity

– Occupational work

• Carpentry, construction, waiting tables, farming

– Household chores

• Washing floors or windows, gardening, or yard work

– Leisure time activities

• Walking, skating, biking, swimming, playing Frisbee, dancing, softball, tennis, football, aerobics

2009 CDC

Physical Activity

• Physical activity decreases the risk for:

– Colon cancer

– Diabetes

– High blood pressure

• Physical activity also helps to:

– Control weight

– Contribute to healthy bones, muscles, and joints

– Reduce falls among the elderly

– Relieve the pain of arthritis.

2009

Regular physical activity is good for overall health.

CDC

How Much Physical Activity a Day?

The 2005 Dietary Guidelines for Americans recommend the following for adults:

2009

To reduce the risk of chronic diseases in adulthood:

Engage in at least 30 minutes of moderate-intensity physical activity,

above usual activity, at work or home on most days of the week.

To help manage weight and prevent gradual, unhealthy weight gain in adulthood:

Engage in approximately 60 minutes of moderate- to vigorous-intensity activity

on most days of the week while not exceeding caloric intake requirements.

To sustain weight loss in adulthood:

Participate in at least 60 to 90 minutes of daily moderate- to vigorous-intensity

physical activity while not exceeding caloric intake requirements. (Some may need

to contact their healthcare provider before participating in this level of activity.)

Dietary Guidelines for Americans

How Much Physical Activity a Day?

• Any activity helps.

• Moderate physical activity brings

health benefits.

• Make it personal.

• Start slowly (10 minute walk/day).

2009

How Many Calorie Am I Burning?

Activity 100 lb 150 lb 200 lb

Bicycling, 6 mph 160 240 312

Bicycling, 12 mph 270 410 534

Jogging, 7 mph 610 920 1,230

Jumping rope 500 750 1,000

Running, 5.5 mph 440 660 962

Running, 10 mph 850 1,280 1,664

Swimming, 25 yds/min 185 275 358

Swimming, 50 yds/min 325 500 650

Tennis singles 265 400 535

Walking, 2 mph 160 240 312

Walking, 3 mph 210 320 416

Walking, 4.5 mph 295 440 572

2009 American Heart Association

Calories burned/hour of activity

How Many Calories Do I Need?

• To maintain – use current weight.

• To lose - use the average healthy weight

recommended for defined height.

2009 ACS

Calculating Ideal Body Weight

2009

A 5’9 man’s ideal body weight would be:

First 5’0 = 106 lb standard weight for men

Plus 9 additional inches 9 (6 lbs)= 54 lbs

106 + 54= 160 pounds (± 10%)= 144 to 176

144 to 176 pounds is this man’s idea weight

A 5’4 woman’s ideal body weight would be:

First 5’0= 100 lb standard weight for women

Plus 4 additional inches 4(5 lbs)= 20

100 + 20= 120 pounds (± 10%)= 108 to 132

108 to 132 pounds is this woman’s ideal weight

For men:

Use 106 pounds of body

weight for the first 5 feet of

their height. Add 6 pounds for

each additional inch.

For women:

Use 100 pounds of body

weight for the first 5 feet of

their height. Add 5 pounds for

each additional inch.

Before Beginning an Exercise Program

• A man older than age 40 or

a woman older than age 50

• Have had a heart attack

• Have a family history of heart-related

problems before age 55

• Have heart, lung, liver or kidney disease

• Feel pain in your chest, joints, or muscles

during physical activity

• Have high blood pressure, high cholesterol,

diabetes, arthritis, osteoporosis, or asthma

• Have had joint replacement surgery

• Smoke

• Are overweight or obese

• Take medication to manage a chronic

condition

• Have an untreated joint or muscle

injury, or persistent symptoms after a

joint or muscle injury

• pregnant

• Unsure of health status.

2009

Precaution for an exercise program if:

Mayo Clinic

Physical Activity Primary Effects on Diabetes Mellitus

• Aerobic and resistance types of exercise

decrease the incidence of type 2

diabetes.

• A modest weight loss through diet and

exercise reduces the incidence of

diabetes.

2009 CMAJ. 2006;174(6): 801-809.

Physical Activity Secondary Effects on Diabetes Mellitus

• Exercise helps in the management

of diabetes.

• Aerobic and resistance training help

in the control of diabetes

2009 CMAJ. 2006;174(6): 801-809.

Physical Activity Primary Effects on Cancer

• Routine activity reduces the incidence

cancers.

• Activity results in a 30-40% reduction in

the relative risk of colon cancer and breast

cancer.

2009

Moderate physical activity is believed to exhibit a greater protective

effect than activities of less intensity.

CMAJ. 2006;174(6): 801-809.

Physical Activity Secondary Effects on Cancer

• Regular physical activity - important.

• Increased self-reported physical activity = decreased reoccurrence of cancer and a decreased risk of death from cancer.

• Reduced cancer-related death.

2009 CMAJ. 2006;174(6): 801-809.

Physical Activity Primary Effects on Osteoporosis

• Many studies have been conducted.

• According to findings, routine physical activity, especially weight-bearing and impact exercise, prevents bone loss associated with aging.

2009 CMAJ. 2006;174(6): 801-809.

Physical Activity Secondary Effects on Osteoporosis

• Regular physical activity can

lead to stronger bones.

• Bone responds to physical

stress at any age; even in the

elderly.

2009 CMAJ. 2006;174(6): 801-809.

Osteoporosis

Pharmacotherapy

NHLBI: • “FDA-approved pharmacotherapy can be

helpful adjunct for treatment of obesity in some patients.”

• Consider if lifestyle changes do not promote weight loss after 6 months

• Net average loss attributable to drugs 2 to 10 kg usually within first 6 months

NHLBI. Identification, evaluation and treatment of overweight and obesity in adults. October 2000.

NHLBI:

Limit drugs to BMI > 30 or BMI >27 w/concomitant risk factors or disease

Discontinue if patient does not lose 2 kg in first 4 weeks

F/U visits include weight & BP check, pulse, lab tests, discuss side effects and answer questions 2 - 4 weeks Monthly for 3 months q 3 months for 1st year

NHLBI. Identification, evaluation and treatment of overweight and obesity in adults. October 2000.

Haddock CK et al. Intl J of Obesity. 26:252-273, 2002.

Obesity Drugs • Appetite suppressants

– Noradrenergic (Schedule IV)

• Phentermine (Adipex, Fastin) • Diethylpropion (Tenuate)

– Noradrenergic (Schedule III)

• Benzphetamine (Didrex) • Phendimetrazine (Bontril)

– Serotonergic • Fenfluramine, dexfenfluramine

– Mixed Noradrenergic & Serotonergic • Sibutramine (Meridia)

• Nutrient absorption reducers – Lipase inhibitor

• Orlistat (Xenical)

Sibutramine

• Contraindicated: CAD, CHF, cardiac arrhythmias or stroke

• Side Effects: hypertension, arrhythmia, tachycardia

• pulse and BP should be checked before treatment and every 2 weeks in the 1st 3 months and every 1-3 months thereafter

Fernstrom MH. Postgraduate Med. June 2001, 10-18.

Bray GA. Nutrition. 16(10):953-60, 2000.

Carek PJ, Dickerson LM. Drugs. 57(6):883-904, 1999.

Wooltorton E. CMAJ. 166(10):1307-08, 2002.

Side Effects

• Common – Headache – Dry mouth – Constipation – Insomnia

• Stop treatment in patients who experience: – an increase in heart rate of 10 beats/min – an increase in either SBP or DBP of >10 mmHg

in 2 consecutive visits

Orlistat

• Lipase inhibitor that reduces fat absorption by ~30% resulting in reduction in energy intake

• Inhibits digestion of dietary triglycerides, decreases absorption of cholesterol and lipid-soluble vitamins

Fernstrom MH. Postgraduate Med. June 2001, 10-18.

Bray GA. Nutrition. 16(10):953-60, 2000.

Carek PJ, Dickerson LM. Drugs. 57(6):883-904, 1999.

Side Effects • GI side effects due to inhibition of fat

absorption

– pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

• Multivitamin recommended because of reduction in absorption of fat soluble vitamins (esp. A & E)

Summary: Meta-analysis

• Placebo subtracted weight losses for single drugs never exceeded 4.0 kg

• No drug or class of drug exhibits clear superiority

• Increasing length of drug treatment does not lead to more weight loss

Haddock CK, et al. Int J Obesity. 26:262-73, 2002.

Surgery

2001 47,000

2002 63,000

2003 98,000

NIH Criteria:

• Well informed and motivated patient

• BMI>40 or

• BMI>35 with co-morbidities

Mortality: 1-2%

Effectiveness: >50% excess weight loss at 14 years