investigation and management of obesity
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INVESTIGATION AND MANAGEMENT OF OBESITY. Dr Ogunwale O.O. MBBS Lagos Snr Registrar EDM Div. LUTH. OUTLINE. INTRODUCTION CLASSIFICATION AIMS OF INVESTIGATION INVESTIGATIONS TREATMENT GUIDELINES NON-PHARMACOLOGICAL MGT PHARMACOLOGICAL MGT SURGICAL MGT BENEFITS OF WEIGHT LOSS - PowerPoint PPT PresentationTRANSCRIPT
INVESTIGATION AND MANAGEMENT OF OBESITY
Dr Ogunwale O.O. MBBS LagosSnr Registrar EDM Div. LUTH
OUTLINE• INTRODUCTION• CLASSIFICATION• AIMS OF INVESTIGATION• INVESTIGATIONS• TREATMENT GUIDELINES • NON-PHARMACOLOGICAL MGT• PHARMACOLOGICAL MGT• SURGICAL MGT• BENEFITS OF WEIGHT LOSS• COMPLICATIONS OF TREATMENT• CONCLUSION• REFERENCES
INTRODUCTION
• Basically a clinical/anthropometric diagnosis• History & PE vital.• Underlying cause needs be investigated• Classification based on BMI • Also on Body Fat Distribution/%• Not necessarily about ↑weight. but ↑body
fat• Mgmt. is multidisciplinary
CLASSIFICATION
BMI (Kg/m2) Body Fat Percentage (%)Grade Male FemaleNormal 15-20 25-30
Borderline 21-25 30-33
Obese >25 >33
Normal 18.5-24.9
Overweight 25-29.9
Grade1 Obese 30-34.9
Grade 2 35-39.9
Grade 3/Morbid ≥40
CLASSIFICATION
• Surgical : Super Obese BMI : ≥ 50• BF% : Calculated from Deurenberg’s Equation• 1.2(BMI)+0.23(Age)-10.8(Sex)-5.4• Sex : 1 for Male, 0 for Female• Both Underweight & Overweight are assoc.
with ↑risk of dx.• Risk ↑ with ↑ Obesity
AIMS OF INVESTIGATION
• Confirm diagnosis & r/o differentials• Find underlying aetiology• Complications & Comorbidities
INVESTIGATIONS
• BMI = Wt in Kg/ (Ht)2 in m 2
• Waist Circumference• Sagittal Abdominal Diameter• Caliper-derived measurements of skin-fold
thickness*• Bioelectrical impedance analysis**• Underwater weighing***
INVESTIGATIONS
INVESTIGATIONS
INVESTIGATIONS
INVESTIGATIONSWC Male (in cm) Female(in cm)
WHO 102 88
IDF 94 80
Asian 90 80
Japan & China 85 80
Nigeria (Okafor et al) 97 95
INVESTIGATION
Harpenden Professional Skinfold Caliper
INVESTIGATION
INVESTIGATION
• Ultrasonography Fat thickness• Abd USS : NAFLD, Gallstones , Ovarian Cysts• Dual-energy radiographic absorptiometry
(DEXA)• Abd CT Scan (at L4/L5)• Abd MRI
INVESTIGATIONs
• FLP• LFT• TFT• FBG• C-peptide and Insulin Studies• Brain MRI*• Genetic studies **• GH & IGF-1 Assays.
TREATMENT GUIDELINESBMI (kg/m2) Conventional
Therapy*Pharmacotherapy† Surgery‡
25.0-26.9 With CHD risk factors or obesity-related disease
No No
27.0-29.9 With CHD risk factors or obesity-related disease
With obesity-related disease
No
30.0-34.9 Yes Yes No
35.0-39.9 Yes Yes With obesity-related disease
≥40 Yes Yes Yes
NON-PHARMACOLOGICAL MGT
• Diet, Physical Activity & Behavioural Therapy• Self-monitoring of caloric intake & physical
activity• Goal setting*• Stimulus control• Non-food rewards• Relapse prevention
NON-PHARMACOLOGICAL MGT
• Goals should be SMART• Who - Who is involved?• What - What do I want to accomplish?• Where - Identify a location• When - Establish a time frame• Which - Identify requirements and constraints• Why - Identify specific reasons for or purpose
or benefits of the goal
NON-PHARMACOLOGICAL MGT
• Weight-loss programs• 3 major phases :• Pre-inclusion screening phase*• Weight-loss phase• Maintenance phase - Can last for rest of pt's
life but ideally lasts for at least 1 yr post program completion
NON-PHARMACOLOGICAL MGT
• DIET• Low Calorie Diet :800 - 1500 kcal/day • Very Low Calorie Diet < 800 kcal/day usu. high
in protein (70 to 100 g/day) & low in fat (<15 g/day).
• Usu. Taken As Liquid Formula, Nutritional Bars• Conventional Food : mostly lean meat, fish -
known as protein-sparing modified fasts.
NON-PHARMACOLOGICAL MGT
• Physical Activity• More of Aerobic Isotonic Exercise*• Less of Anaerobic Isometric/ Resistance
Exercise**
PHARMACOLOGICAL MGT
• Centrally acting medications that impair dietary intake (A)
• Medications that act peripherally to impair dietary absorption(B)
• Medications that increase energy expenditure (C)
PHARMACOLOGICAL MGT
• Lipase Inhibitors : Orlistat (B)• Sibutramine (C)• Lorcaserin (A)• Sympathomimetic Amines Phendimetrazine,
Phentermine ,Diethylpropion, Benzphetamine Mazindol (A)
• Antidiabetic agents
PHARMACOLOGICAL MGT
• Of the drugs the following are FDA-approved:• Lorcaserin (Belviq)• Phentermine/topiramate (Qsymia)• Orlistat (Xenical) • Sibutramine no longer approved
SURGICAL MGT• BARIATIC SURGERY• Roux-en-Y gastric bypass (M)• Adjustable gastric banding (R)• Gastric sleeve surgery (R)• Vertical sleeve gastrectomy (R)• Horizontal (Silastic ring) gastroplasty (R)• Vertical banded gastroplasty (R)• Duodenal-switch procedures(B)• Biliopancreatic bypass (B)• Biliopancreatic diversion (B)
SURGICAL MGT
• Morbid Obesity• When Conventional Rx & Drug Rx Fail• Benefits : Improved Obstructive sleep apnea• Type 2 DM, Hypertension, CCF, Asthma,
Dyslipidaemia• Peripheral oedema, Respiratory insufficiency• Esophagitis, Pseudotumor cerebri, OA, VTE• Operative risk• Urinary incontinence
BENEFITS
• Improved Glycaemic Control• BP Control• Dyslipidaemia Control• ↓ CV Risk• Improved Pulm. Fx• Improved Reproductive & Urinary Fx
COMPLICATIONS OF Rx
• Electrolyte Disturbances : Ketosis, ↓K+
• Arrhythmias• Malabsorption• Malnutrition• Hyperuricaemia• Cholithiasis• Depression & Eating Disorders
CONCLUSION
• Obesity is basically a clinical diagnosis• More about body fat than weight• Hx & PE very important to evaluate co-
morbidities and Cx• Management primarily non-pharmacological• Multidisciplinary• Benefits of Rx include ↓CV Risk, ↑Pulm. Fx
and regression of co-morbidities
REFERENCES• Klein S, Fabbrini E, Romijnin JA Obesity in Melmed S, Polonsky KS,
Larsen PR, Kronenberg HM (eds.), Williams Textbook of Endocrinology, 12th ed. Saunders, 2011. ch 36 pp 1605- 1625
• Hamdy O, Citkowitz E, Uwaifo GI, Oral EA Obesity http://emedicine.medscape.com/article/123702. Updated : Nov 25, 2013
• de Souza NC, de Oliveira EP Sagittal abdominal diameter shows better correlation with cardiovascular risk factors than waist circumference and BMI Journal of Diabetes & Metabolic Disorders 2013 12:41
• http://www.topendsports.com/testing/skinfold-sites.htm Accessed Dec 4,2013
• http://www.ebay.com/itm/Harpenden-Professional-Skinfold-Caliper-/320795435670 Accessed Dec 4, 2013
REFERENCES• http://www.fitnessgram.net/protocols/skinfolds.pdf Accessed Dec 6 ,2013• Sagittal Diameter http://www.myhealthywaist.org/evaluating-cmr/clinical-
tools/sagittal-diameter/page/2/print.html. Accessed Dec 6, 2013• http://www.topendsports.com/testing/tests/underwater.htm Accessed
Dec. 5,2013• http://www.topendsports.com/testing/siri-equation.htm Accessed Dec. 5,
2013• http://www.myhealthywaist.org/evaluating-cmr/clinical-tools/sagittal-
diameter/page/2/print.html Accessed Dec. 6,2013• WHO Technical Report Series. Diet, nutrition and the prevention of
chronic diseases http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf Accessed Dec. 6, 2013
THANK YOU