Overweight and Obesity

Maru E Combate M.D,MS,FPCP,FPCCP

Overview

Definition, Prevalence & Consequences of Obesity

Healthy Lifestyles

Assessment of Obesity

Treatments for Obesity

Definition

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

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

Calculating BMI

Calculate Body Mass Index (BMI) =

weight (kg) height squared (meters)

Or

weight (pounds) x 703

height squared (inches)

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)

Prevalence of Adult Obesity, U.S.A.

0

5

10

15

20

251991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

% a

du

lts

Texas

United States

From CDC website: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/prev_reg.htm

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.

Weight Gain: Medications

Disease Examples

Diabetes Insulin, sulfonylureas

Depression Tricyclics

Seizures Valproic acid, Tegretol

Hypertension Clonidine, -blockers, -blockers

Hormones Progesterone

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

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

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?

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

Ghrelin

Hormone secreted in the stomach

Acts on the hypothalamus to stimulate appetite

Levels peak just before meals and drop afterward

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

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

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

Assessment

Is he overweight? Obese?

What are his key health issues?

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

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 45; women age > 55

Other risk factors Physical inactivity; elevated serum triglycerides

Medications associated with obesity

Treatment Approach

A multi-faceted approach is best

Diet

Physical activity

Behavior change

A Recommendation

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

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.

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.

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

How Much is 1200 Calories?

Could you stick to 1200 per day?

1 Big Mac (580)

1 SMALL Fries (210)

1 SMALL shake (430)

Low-Calorie Step I Diet

Nutrient Recommended intake

Calories 500 to 1000 kcal/day reduction from usual

Total fat

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

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

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

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

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

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

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

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

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

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

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

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

Weight Loss Surgery

Roux-en-Y gastric bypass

Limits food intake

Alters digestion

Figure from NIDDK website

Weight Loss Surgery

Complications of surgery Mortality

60

Operative complications

< 10%

Late complications are uncommon Incisional hernias

Gallstones

Vitamin B12 & iron deficiency

Weight loss failure

Neurologic symptoms in unusual cases

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)

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

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 doesnt reach individuals ideal (cosmetic) goal

Thank You!