MANAGEMENT OF OBESITY

Dr. ALI JAWA MD (USA), MPH (USA), FACE (USA)Diplomate American Board of Endocrinology & Diabetes

Diplomate American Board of Internal MedicineDiplomate American Board of Physician Nutrition Specialists

Assistant Professor of Endocrinology/DiabetesAllama Iqbal Medical College, Lahore

INTRODUCTION

• Overweight=weight above the "normal" range• Assessed by body mass index (BMI)• BMI = weight (kilograms) divided by height

(meters squared) BMI (kg/m2)

Normal 18-25

Overweight 25-29.9

obesity ≥30

Severe Obesity ≥40 ≥35 kg/m2 in the presence of comorbidities

GUIDELINES

• The American Gastroenterological Association (AGA)

• American College of Physicians• NHLBI• NAASO

PREVALENCE Worldwide

Increasing

10 % (men)/11 % (women) Belgium 23 % UK 8 % (men)/13 % (women) Pakistan.

IMPORTANCE OF WEIGHT LOSS

Obesity is associated with many health risks including

• Type 2 diabetes mellitus • Hypertension • Dyslipidemia • Coronary heart disease• Obstructive Sleep Apnea

Weight Loss lowers morbidity and mortality

Maintenance of weight loss

• The reduction in energy expenditure that is induced by weight loss.

• Maintenance of body weight at 10 percent below the baseline weight in obese subjects was associated with an 8 kcal/kg decrease in energy expenditure.

• Recidivism, that is regaining of lost weight

Characteristics of those who are likely to succeed in maintaining weight loss

• Weight loss of more than 2 kg in four weeks • Frequent and regular attendance at a weight

loss program• Subject's belief that his or her weight can be

controlled. • Exercise consistently

APPROACH TO THERAPY

All treatments of obesity entail some risk• What are the risks of treatment?• Is treatment appropriate?• What is the most appropriate treatment

regimen?

What are the risks of treatment?

• Most of the currently available drugs have minor side effects that diminish with treatment

Is treatment appropriate?

• The BMI is the most practical way to evaluate the overall degree of excess weight

• The waist circumference is the most practical measure of central adiposity.

BMI (kg/m2)

Normal 18-25

Overweight 25-29.9

obesity ≥30

Severe Obesity ≥40 ≥35 kg/m2 in the presence of comorbidities

What is the most appropriate treatment?

• Treatments for obesity either decrease energy intake or increase energy expenditure.

• Those that decrease energy intake have a greater potential for causing weight loss than those that increase energy expenditure through exercise.

Behavior modification

• Behavior modification or behavior therapy is one cornerstone in the treatment for obesity. These concepts are usually included in programs conducted by psychologists or other trained personnel as well as many self-help groups.

Dietary therapy

• Approximately 22 to 25 kcal/kg is required to maintain one kilogram of body weight in a normal adult.

• woman weighing 100 kg is approximately 2200 to 2500 kcal/day.

• No adult who has been studied in a metabolic chamber has needed fewer than 1000 kcal/day for weight maintenance.

Exercise

• Increasing energy expenditure through physical activity has particular attractiveness in efforts at long-term maintenance of a lower body weight.

DRUG THERAPY

IINDICATIONS• BMI greater than 30 kg/m2, or • BMI of 27 to 30 kg/m2 if they have comorbid

conditions

Orlistat is the only FDA approved anti-obesity drug

LIPOSUCTION

• Removal of fat by aspiration after injection of physiologic saline has been used to remove and contour subcutaneous fat.

• Does not appear to improve insulin sensitivity or risk factors for coronary heart disease.

BARIATRIC SURGERY Indications (NIH Consensus 1991 Panel)

• Be well-informed and motivated• Have a BMI ≥40 kg/m2• Have acceptable risk for surgery• Have failed previous non-surgical weight loss• Adults with a BMI ≥35 kg/m2 who have

serious comorbidities such as severe diabetes, sleep apnea, or joint disease

BARIATRIC SURGERY Benefits

Complete resolution or improvement in• diabetes, • hypertension, • hyperlipidemia, and • obstructive sleep apnea

Complementary therapies

• Ephedra• Acupuncture - modest benefit of acupuncture

for weight loss

TAKE HOME MESSAGE

• Overweight (BMI ≥ 27) or obese (BMI ≥ 30) counseling on diet, lifestyle, and goals for weight loss.

• Failed to achieve weight loss goals through diet and exercise pharmacologic therapy

• BMI ≥40 kg/m2 who have failed diet and exercise (with or without drug therapy) or for patients with BMI >35 kg/m2 and obesity-related co-morbidities bariatric surgery

THANK YOU