obesity toba kazemi, m.d. associate professor of cardiology director, birjand cardiovascular...

ObesityObesity

Toba Kazemi MDToba Kazemi MD

Associate Professor of Associate Professor of CardiologyCardiology

Director Birjand Director Birjand Cardiovascular Research Cardiovascular Research

CentreCentre

ObjectivesObjectives

To review definitions epidemiology To review definitions epidemiology and risk factorsand risk factors

To learn the available FDA approved To learn the available FDA approved medications and their mechanisms medications and their mechanisms of action (MOA)of action (MOA)

To learn the available bariatric To learn the available bariatric surgeries and their MOAsurgeries and their MOA

EpidemiologyEpidemiology PrevalencePrevalence

Prevalence of medically significant Prevalence of medically significant obesity is increasing worldwideobesity is increasing worldwide

Estimates of prevalence in US Estimates of prevalence in US adults gt20 years of ageadults gt20 years of age

Overweight (BMI gt25 kgm2) 64Overweight (BMI gt25 kgm2) 6410487071048707 Obesity (BMI gt30 25 kgm2) 305Obesity (BMI gt30 25 kgm2) 305 Extreme obesity (BMI gt40 25 Extreme obesity (BMI gt40 25

kgm2) 47kgm2) 47

EpidemiologyEpidemiology

Sex More common among womenSex More common among women Socioeconomic statusSocioeconomic status More common among poor populationsMore common among poor populations In industrial societies obesity is more In industrial societies obesity is more

common among poor womencommon among poor women In underdeveloped countries wealthier In underdeveloped countries wealthier

women are more often obesewomen are more often obese Age Prevalence is increasing in Age Prevalence is increasing in

childrenchildren

DefinitionDefinition

Characterized by a relative excess of Characterized by a relative excess of adipose tissue massadipose tissue mass

Body mass index (BMI) ge30 kgm2 Body mass index (BMI) ge30 kgm2 defines obesitydefines obesity

BMI = weightheight2 (in kgm2)BMI = weightheight2 (in kgm2)

Risk FactorsRisk Factors

Poor-quality dietPoor-quality diet Chronic ingestion of excess caloriesChronic ingestion of excess calories Sedentary lifestyleSedentary lifestyle Family history of obesityFamily history of obesity bullbullSmoking cessationSmoking cessation

EtiologyEtiology

Obesity has a multifactorial etiologyObesity has a multifactorial etiology Genetic influencesGenetic influences Environmental influencesEnvironmental influences Availability and high caloric composition of the Availability and high caloric composition of the

dietdiet Sedentary lifestyleSedentary lifestyle Sleep deprivationSleep deprivation Socioeconomiccultural influence Lower Socioeconomiccultural influence Lower

socioeconomic status is associated with obesity socioeconomic status is associated with obesity in the US and other developed countriesin the US and other developed countries

EtiologyEtiology Recent increase in the prevalence of obesity Recent increase in the prevalence of obesity

worldwide is largely due to lifestyle factors worldwide is largely due to lifestyle factors (changes in diet physical activity) as it has been (changes in diet physical activity) as it has been too rapid to be caused by changes in the gene pooltoo rapid to be caused by changes in the gene pool

Physiologically obesity results from an imbalance Physiologically obesity results from an imbalance between energy intake and energy expenditurebetween energy intake and energy expenditure

Increased energy intakeIncreased energy intake Decreased energy expenditureDecreased energy expenditure Combination of the 2 factorsCombination of the 2 factors

Associated Conditions with Associated Conditions with obesityobesity

DiseasesCushingrsquos syndrome DiseasesCushingrsquos syndrome ypothyroidism Insulinoma Male ypothyroidism Insulinoma Male hypogonadism Growth hormone hypogonadism Growth hormone deficiency Craniopharyngioma and deficiency Craniopharyngioma and other disorders involving the other disorders involving the hypothalamushypothalamus

Genetic syndromesGenetic syndromes

Associated conditionsAssociated conditions Type 2 diabetes mellitusUp to 80 of patients Type 2 diabetes mellitusUp to 80 of patients

with type 2 diabetes mellitus are obesewith type 2 diabetes mellitus are obese Polycystic ovarian syndrome (PCOS)Polycystic ovarian syndrome (PCOS) HypertensionHypertension HyperlipidemiaHyperlipidemia Coronary artery diseaseCoronary artery disease StrokeStroke Congestive heart failureCongestive heart failure Obstructive sleep apneaObstructive sleep apnea SteatohepatitisSteatohepatitis GallstonesGallstones

Symptoms amp SignsSymptoms amp Signs BMI classificationBMI classification Overweight 25ndash299 kgm2Overweight 25ndash299 kgm2 Obesity (class I) 30ndash349 kgm2Obesity (class I) 30ndash349 kgm2 Obesity (class II) 35ndash399 kgm2Obesity (class II) 35ndash399 kgm2 Obesity (class III or morbid obesity) gt40 Obesity (class III or morbid obesity) gt40

kgm2kgm2 Regional fat distributionRegional fat distribution Abdominal obesity is defined by measurement Abdominal obesity is defined by measurement

of waist circumference gt102 cm (40 in) in of waist circumference gt102 cm (40 in) in men and gt88 cm (35 in) in womenmen and gt88 cm (35 in) in women

Differential DiagnosisDifferential Diagnosis Cushingrsquos syndromeCushingrsquos syndrome HypothyroidismHypothyroidism Male hypogonadismMale hypogonadism Growth hormone deficiency (Hypopituitarism)Growth hormone deficiency (Hypopituitarism) InsulinomaInsulinoma Craniopharyngioma and other disorders of Craniopharyngioma and other disorders of

hypothalamic hypothalamic dysfunction Hypothalamic dysfunction Hypothalamic dysfunction of systems controlling satiety hunger dysfunction of systems controlling satiety hunger and energy expenditure (due to central nervous and energy expenditure (due to central nervous system tumors rauma or inflammatory disorders) system tumors rauma or inflammatory disorders) can cause varying degrees of obesitycan cause varying degrees of obesity

Diagnostic ApproachDiagnostic Approach

Calculate body mass index and measure Calculate body mass index and measure waist circumferencewaist circumference

Determine degree and rate of acquisition Determine degree and rate of acquisition of obesityof obesity

Exclude identifiable causes of obesityExclude identifiable causes of obesity Assess comorbid conditions presence of Assess comorbid conditions presence of

CVD risk factors and absolute risk statusCVD risk factors and absolute risk status


Conditions that indicate high Conditions that indicate high absolute risk for obesity-related absolute risk for obesity-related disordersdisorders

Established coronary artery diseaseEstablished coronary artery disease Other atherosclerotic diseaseOther atherosclerotic disease Type 2 diabetes mellitusType 2 diabetes mellitus Sleep apneaSleep apnea

Diagnostic ApproachDiagnostic Approach gege3 of the following indicate high absolute 3 of the following indicate high absolute

risk for obesity related disordersrisk for obesity related disorders HypertensionHypertension Cigarette smokingCigarette smoking High low-density lipoprotein cholesterol level High low-density lipoprotein cholesterol level

(gt160 mgdL)(gt160 mgdL) Low high-density lipoprotein cholesterol level Low high-density lipoprotein cholesterol level

(lt35 mgdL)(lt35 mgdL) Impaired fasting glucoseImpaired fasting glucose Family history of early coronary artery diseaseFamily history of early coronary artery disease Age gt45 years in men and gt55 years in womenAge gt45 years in men and gt55 years in women

Laboratory TestsLaboratory Tests Fasting lipid profileFasting lipid profile Fasting plasma glucose and Fasting plasma glucose and

electrolyte measurementelectrolyte measurement Liver function testsLiver function tests Serum TSH measurementSerum TSH measurement Additional laboratory testing should Additional laboratory testing should

be performed on the basis of be performed on the basis of presentation of symptoms and risk presentation of symptoms and risk factorsfactors

Treatment ApproachTreatment Approach

Patients who meet the following Patients who meet the following criteria should be considered for criteria should be considered for treatmenttreatment

BMI gt30 mgkgBMI gt30 mgkg2 BMI 25ndash299 mgkg2 and presence of BMI 25ndash299 mgkg2 and presence of

ge2 risk factorsge2 risk factors BMI 25ndash299 mgkg2 and waist BMI 25ndash299 mgkg2 and waist

circumference gt102 cm (40 in) in circumference gt102 cm (40 in) in men or gt88 cm (35 in) in womenmen or gt88 cm (35 in) in women

Treatment ApproachTreatment Approach Combined therapy with a low-calorie diet Combined therapy with a low-calorie diet

increased physical activity and behavior increased physical activity and behavior therapy provide the most successful therapy provide the most successful intervention for weight loss and weight intervention for weight loss and weight maintenancemaintenance

All patients should be counseled on All patients should be counseled on lifestyle and behavioral modifications lifestyle and behavioral modifications (appropriate diet and physical activity) (appropriate diet and physical activity) and weight loss goals should be and weight loss goals should be individualizedindividualized

Treatment goals should be guided by the Treatment goals should be guided by the health risks of obesity in any given personhealth risks of obesity in any given person

Specific TreatmentsSpecific Treatments

Behavior modificationBehavior modification Dietary therapyDietary therapy ExerciseExercise PharmacotherapyPharmacotherapy

Behavior modificationBehavior modification The principles of behavior modification The principles of behavior modification

provide the underpinnings for many current provide the underpinnings for many current programs of weight reductionprograms of weight reduction

Goal of behavior modification is to modify Goal of behavior modification is to modify maladaptive behaviors including eating maladaptive behaviors including eating habits and physical activityhabits and physical activity

Patient is asked to monitor and record the Patient is asked to monitor and record the circumstances related to eating and physical circumstances related to eating and physical activityactivity

Patients may benefit from counseling offered Patients may benefit from counseling offered in a stable group setting for extended in a stable group setting for extended periods of time including after weight lossperiods of time including after weight loss

Dietary therapyDietary therapy Reduced caloric intake is the cornerstone of obesity Reduced caloric intake is the cornerstone of obesity

treatmenttreatment There is no scientific evidence to validate the utility of There is no scientific evidence to validate the utility of

specific fad dietsspecific fad diets General facts relevant to food intake and weight lossGeneral facts relevant to food intake and weight loss Deficit of 7500 kcal will produce a weight loss of ~1 kgDeficit of 7500 kcal will produce a weight loss of ~1 kg Consuming 100 kcald less for 1 year should cause a 5-kg weight lossConsuming 100 kcald less for 1 year should cause a 5-kg weight loss Consuming 1000 kcald less should cause a loss of ~1 kg per weekConsuming 1000 kcald less should cause a loss of ~1 kg per week Rate of weight loss on a given caloric intake is related to rate Rate of weight loss on a given caloric intake is related to rate

of energy expenditureof energy expenditure Obese persons have a higher metabolic rate than lean personsObese persons have a higher metabolic rate than lean persons Men have a higher metabolic rate than women (due to their greater lean Men have a higher metabolic rate than women (due to their greater lean

body mass) thus the rate of weight loss is greater among more obese body mass) thus the rate of weight loss is greater among more obese and among menand among men

With chronic caloric restriction the metabolic rate decreasesWith chronic caloric restriction the metabolic rate decreases With total starvation or diets restricted to lt 600 kcald initial weight lossWith total starvation or diets restricted to lt 600 kcald initial weight loss over the first week results predominantly from natriuresis and the loss of over the first week results predominantly from natriuresis and the loss of

fluidsfluids

ExerciseExercise Physical activity is an important component of the Physical activity is an important component of the

overall approach to weight reduction and overall approach to weight reduction and maintenancemaintenance

The effect of an exercise regimen as a sole therapy The effect of an exercise regimen as a sole therapy for obesity is not established but exercise is a for obesity is not established but exercise is a valuable means to sustain diet therapyvaluable means to sustain diet therapy

Additional benefitsAdditional benefits Improves cardiovascular tone and reduce blood Improves cardiovascular tone and reduce blood

pressure independent of weight losspressure independent of weight loss Helps reduce appetiteHelps reduce appetite Increases the likelihood of weight maintenance Increases the likelihood of weight maintenance

once targets are achievedonce targets are achieved Reduces intra-abdominal fatReduces intra-abdominal fat Reduces risk of glucose intoleranceReduces risk of glucose intolerance

ExerciseExercise Many obese persons have not exercised on a Many obese persons have not exercised on a

regular basis and may have cardiovascular regular basis and may have cardiovascular risk factorsrisk factors

Exercise should be introduced gradually under medical Exercise should be introduced gradually under medical supervision especially in the most obese patientssupervision especially in the most obese patients

Minimal physical activity recommendationsMinimal physical activity recommendations Adults should engage in moderate-intensity physical Adults should engage in moderate-intensity physical

activities for ge 30 minutes on ge 5 days of the week oractivities for ge 30 minutes on ge 5 days of the week or Adults should engage in vigorous-intensity physical Adults should engage in vigorous-intensity physical

activity ge 3 days per week for ge 20 minutes per activity ge 3 days per week for ge 20 minutes per occasionoccasion

PharmacotherapyPharmacotherapy May be considered as adjunctive therapy May be considered as adjunctive therapy 11 in patients with a BMI ge30 kgm2 or ge27 kgm2 in patients with a BMI ge30 kgm2 or ge27 kgm2

with other risk factorswith other risk factors

22 diseases who fail to achieve weight loss goals diseases who fail to achieve weight loss goals through nonpharmacologic approachesthrough nonpharmacologic approaches

LimitationsLimitations11 Medication-induced weight loss is not a cure despite Medication-induced weight loss is not a cure despite

modest short-term benefits from several agentsmodest short-term benefits from several agents

22 Safety and efficacy of weight loss agents beyond 2 years Safety and efficacy of weight loss agents beyond 2 years has not been establishedhas not been established

33 Rebound weight gain after the cessation of drug use is Rebound weight gain after the cessation of drug use is commoncommon

44 Most agents are associated with substantial side effects Most agents are associated with substantial side effects and some have potential for abuseand some have potential for abuse

Drugs for Drugs for obesityobesityPhenterminePhentermine

Phentermine is approved for short-term use Phentermine is approved for short-term use (lt12 weeks)(lt12 weeks)

o Mechanism of action increases the release o Mechanism of action increases the release of norepinephrine and dopamine from nerve of norepinephrine and dopamine from nerve terminals and inhibits their reuptaketerminals and inhibits their reuptake

Dosing 15 mgndash30 mgdDosing 15 mgndash30 mgd Efficacy modest (10 versus 44 kg of weight Efficacy modest (10 versus 44 kg of weight

loss over 24 weeks in a well-controlled study)loss over 24 weeks in a well-controlled study) Side effects (numerous) insomnia dry mouth Side effects (numerous) insomnia dry mouth

constipation palpitationshypertensionconstipation palpitationshypertension

Drugs for Drugs for obesityobesitySibutramineSibutramine

Sibutramine is approved for long-term useSibutramine is approved for long-term use Mechanism of action central reuptake Mechanism of action central reuptake

inhibitor of both norepinephrine and inhibitor of both norepinephrine and serotoninserotonin

Dosing 10 mgdDosing 10 mgd Efficacy Once-daily dose over 24 weeks Efficacy Once-daily dose over 24 weeks

produced a 7 weight loss and decreased produced a 7 weight loss and decreased cholesterol and triglyceride levels in a cholesterol and triglyceride levels in a double-blind placebo-controlled trialdouble-blind placebo-controlled trial

Adverse effects increases pulse by an Adverse effects increases pulse by an average of 4ndash5 beatsmin and blood average of 4ndash5 beatsmin and blood pressure by 1ndash3 mmHgpressure by 1ndash3 mmHg

Drugs for obesityDrugs for obesityOrlistatOrlistat Orlistat is approved for long-term useOrlistat is approved for long-term use Mechanism of action inhibitor of pancreatic lipase with no Mechanism of action inhibitor of pancreatic lipase with no

systemic availability causes modest weight loss due to drug-systemic availability causes modest weight loss due to drug-induced fat malabsorptioninduced fat malabsorption

DosingDosing 120 mg 3 times daily before meals taken with a 120 mg 3 times daily before meals taken with a multivitaminmultivitamin

EfficacyEfficacy 2-year randomized double-blind trial revealed modest 2-year randomized double-blind trial revealed modest weight loss) during first year andweight loss) during first year and

better maintenance of weight loss in second year compared with better maintenance of weight loss in second year compared with the placebo groupthe placebo group

Adverse effectsAdverse effects GI side effects include oily stools flatulence and fecal urgency GI side effects include oily stools flatulence and fecal urgency

these usually diminish as patients limit fat intake to avoid these usually diminish as patients limit fat intake to avoid symptomssymptoms

Absorption of fat-soluble Absorption of fat-soluble vitamins is decreasedvitamins is decreased

Drugs for Drugs for obesityobesityMetforminMetformin

Metformin tends to decrease body Metformin tends to decrease body weight in patients with obesity and weight in patients with obesity and type 2 diabetes mellitustype 2 diabetes mellitus

Phentermine15 Phentermine15 30 375 30 375 MGMG

Drugs for obesityDrugs for obesityleptinleptin

Recombinant leptin is highly effective in Recombinant leptin is highly effective in rare cases of leptin deficiency caused by rare cases of leptin deficiency caused by mutations of the leptin genemutations of the leptin gene

Regulates hunger and induces loss of fat Regulates hunger and induces loss of fat mass while preserving lean body massmass while preserving lean body mass

Response to leptin is limited or absent in Response to leptin is limited or absent in common obesity which is associated with common obesity which is associated with hyperleptinemia and leptin resistancehyperleptinemia and leptin resistance

SurgerySurgery

Bariatric surgeryBariatric surgery Vertical-banded gastroplastyVertical-banded gastroplasty Roux-en-Y gastric bypassRoux-en-Y gastric bypass Laparoscopic adjustable gastric Laparoscopic adjustable gastric

bandingbanding

SurgerySurgery Potential Potential benefitsbenefits

Significant sustained weight loss Significant sustained weight loss (10ndash159 kg over 1ndash5 years)(10ndash159 kg over 1ndash5 years)

Improvements in hypertension Improvements in hypertension diabetes sleep apnea congestive diabetes sleep apnea congestive heart failure angina heart failure angina hyperlipidemia and venous diseasehyperlipidemia and venous disease

SurgerySurgery Short-term Short-term complicationscomplications

Pulmonary embolusPulmonary embolus Anastomotic leakAnastomotic leak BleedingBleeding Wound infectionWound infection

SurgerySurgery Long-term Long-term complicationscomplications

Dumping syndromeDumping syndrome Stomal stenosisStomal stenosis Marginal ulcersMarginal ulcers HerniasHernias Lifelong medical monitoring after Lifelong medical monitoring after

surgery is necessarysurgery is necessary Lifelong supplementation with vitamin Lifelong supplementation with vitamin

B12 iron folate and calcium is B12 iron folate and calcium is recommendedrecommended

ObesityObesity Complications Complications Insulin resistance and type 2 diabetes Insulin resistance and type 2 diabetes

mellitusmellitus Hyperinsulinemia and insulin resistance increase with Hyperinsulinemia and insulin resistance increase with

weight gain and diminish with weight lossweight gain and diminish with weight loss Insulin resistance is more strongly linked to intra-Insulin resistance is more strongly linked to intra-

abdominal fat than to fat elsewhereabdominal fat than to fat elsewhere Despite nearly universal insulin resistance most obese Despite nearly universal insulin resistance most obese

persons do not develop diabetes however obesity is a persons do not develop diabetes however obesity is a major risk factor for diabetesmajor risk factor for diabetes

Up to 80 of patients with type 2 diabetes mellitus Up to 80 of patients with type 2 diabetes mellitus are obeseare obese

Weight loss and exercise even of modest degree are Weight loss and exercise even of modest degree are associated with increased insulin sensitivity and associated with increased insulin sensitivity and improved glucose control in diabetesimproved glucose control in diabetes

ObesityObesity Complications Complications

Reproductive disordersReproductive disorders Men Male hypogonadism Total plasma Men Male hypogonadism Total plasma

testosterone and sex hormonendashbinding globulin testosterone and sex hormonendashbinding globulin levels are often reduced Free testosterone levels are often reduced Free testosterone may be decreased Gynecomastiamay be decreased Gynecomastia

WomenMenstrual abnormalities Increased WomenMenstrual abnormalities Increased androgen production decreased SHBG level androgen production decreased SHBG level and increased peripheral conversion of and increased peripheral conversion of androgen to estrogenandrogen to estrogen

40 of women with PCOS are obese40 of women with PCOS are obese

ObesityObesity Complications Complications Cardiovascular diseaseCardiovascular disease Obesity is an independent risk factor for CVDisease Obesity is an independent risk factor for CVDisease

in men and women including coronary disease in men and women including coronary disease stroke and congestive heart failurestroke and congestive heart failure

Effect of obesity on cardiovascular mortality Effect of obesity on cardiovascular mortality in women may be seen at BMI as low as 25 in women may be seen at BMI as low as 25 kgm2kgm2

Atherogenic lipid profile Increased LDL Atherogenic lipid profile Increased LDL Elevated VLDLTG Decreased HDLElevated VLDLTG Decreased HDL

HypertensionHypertension Increased PVR and COo Increased sympathetic Increased PVR and COo Increased sympathetic

nervous system tone Increased salt sensitivity o nervous system tone Increased salt sensitivity o Insulin-mediated salt retentionInsulin-mediated salt retention

ObesityObesity Complications Complications Pulmonary diseasePulmonary disease Reduced chest-wall complianceReduced chest-wall compliance Increased work of breathingIncreased work of breathing Increased minute ventilation due to increased Increased minute ventilation due to increased

metabolic ratemetabolic rate Decreased total lung capacity and functional Decreased total lung capacity and functional

residual capacitydarrresidual capacitydarr Severe obesity may be associated with obstructive Severe obesity may be associated with obstructive

sleep apnea and obesity hypoventilation syndromesleep apnea and obesity hypoventilation syndrome Weight loss (10ndash20 kg) can lead to substantial Weight loss (10ndash20 kg) can lead to substantial

improvementimprovement

ObesityObesity Complications Complications Nonalcoholic steatohepatitisNonalcoholic steatohepatitis Obesity is associated with excess Obesity is associated with excess

hepatic triglycerideshepatic triglycerides Occurs in about two-thirds of obese Occurs in about two-thirds of obese

peoplepeople Usually asymptomatic with mildly Usually asymptomatic with mildly

increased values on liver function testsincreased values on liver function tests Can lead to inflammation and fibrosisCan lead to inflammation and fibrosis Increased risk of cirrhosis particularly Increased risk of cirrhosis particularly

when associated with other liver when associated with other liver diseases such as hepatitis Cdiseases such as hepatitis C


GallstonesGallstones gt50 above ideal body weight is gt50 above ideal body weight is

associated with 6-fold increased associated with 6-fold increased incidence of symptomaticincidence of symptomatic

gallstonesgallstones Fasting-induced cholecystitis is a Fasting-induced cholecystitis is a

complication of extreme dietscomplication of extreme diets


CancerCancer Men cancer of Esophagus Colon Men cancer of Esophagus Colon

Rectum Pancreas Liver ProstateRectum Pancreas Liver Prostate Obesity accounts for 14 of cancer deaths Obesity accounts for 14 of cancer deaths

for men in the USfor men in the US Women cancer Gallbladder Bile duct Women cancer Gallbladder Bile duct

Breasto Endometrium Cervix Ovary Breasto Endometrium Cervix Ovary uterine cancer inuterine cancer in

Obesity accounts for 20 of cancer deaths Obesity accounts for 20 of cancer deaths in women in the USin women in the US


Bone joint and cutaneous diseaseBone joint and cutaneous disease Osteoarthritis GoutAcanthosis nigricansOsteoarthritis GoutAcanthosis nigricans Reflects the severity of underlying insulin Reflects the severity of underlying insulin

resistance and diminishes with weight resistance and diminishes with weight lossloss

Cutaneous fungal and yeast infections Cutaneous fungal and yeast infections due to friability of skin especially in skin due to friability of skin especially in skin foldsfolds

Venous stasisVenous stasis

ObesityObesity Prognosis Prognosis

MorbidityDistribution of adipose tissue has MorbidityDistribution of adipose tissue has substantial implications for morbidity substantial implications for morbidity complications are in previous slidscomplications are in previous slids

MortalityMortality rates increase with MortalityMortality rates increase with obesity particularly when obesity is obesity particularly when obesity is associated with increased intra-abdominal associated with increased intra-abdominal fatfat

Morbidly obese persons (BMI gt40 kgm2)Morbidly obese persons (BMI gt40 kgm2) 12-fold increase in mortality rate in men 25ndash34 years 12-fold increase in mortality rate in men 25ndash34 years

of ageof age 6-fold increase in mortality rate in men 35ndash45 years of 6-fold increase in mortality rate in men 35ndash45 years of

ageage

ObesityObesity Prevention Prevention

Maintain a healthy balanced dietMaintain a healthy balanced diet Exercise regularlyExercise regularly

Pharmacologic Therapy

bull Indications (ACP 2005) ndash BMI ge 30ndash Failed TLCndash Long-term use

bull Orlistatbull Sibutramine

ndash Short-term usebull Phenterminebull Diethylpropion

Pharmacologic Therapy (cont)

bull Sibutramine (Meridia)ndash Specific inhibitor of norepinephrine and

serotonin reuptake into nerve terminals appetite suppression

ndash Dose 15mg PO dailyndash Effects

bull Decreased body weight and waist circumferencebull Decreased fasting blood glucose and HgbA1Cbull Decreased serum TG and LDLbull Increased HDL


ndash Adverse effectsbull Dry mouthbull Headachebull Insomniabull Constipation

ndash CautionsContraindicationsbull Pts with ho HTN CAD CHF arrhythmia CVAbull Pts receiving MAOI SSRIbull Pts receiving erythromycin ketoconazole


bull Orlistat (Xenical)ndash Inhibitor of pancreaticintestinal lipase

increased fecal fat lossndash Dose 120mg PO TID with mealsndash Effects

bull Weight lossbull Reduced conversion from IGT to diabetesbull Decrease in HgbA1Cbull Decreased LDL


ndash Adverse effectsbull Intestinal borborygmi and crampsbull Flatus +- dischargebull Steatorrheabull Bloatingbull Oily spottingbull Decreased absorption of fat soluble vitamins


bull Others (NOT recommended)ndash Antidepressants

bull Fluoxetine (Prozac)bull Bupropion (Wellbutrin Zyban)

ndash Antiepilepticsbull Topiramate (Topamax)

ndash Diabetes drugsbull Metformin (Glucophage)bull Exenatide (Byetta)


bull Summaryndash BMI ge 25 with comorbidities or ge 30

ndash Failed TLC

ndash Sibutramine 15mg daily if otherwise healthybull Appetite suppression

ndash Orlistat 120mg TID if comorbidities presentbull Increased fecal fat loss

Surgical Therapy

bull Goalsndash Reduce morbidity and mortalityndash Improve metabolic and organ function

bull Indications (NIH 1991)ndash Well-informed and motivatedndash BMI ge 35 with comorbidities or ge 40ndash Acceptable surgical riskndash Failed previous non-surgical weight loss

Surgical Therapy (continued)

bull Contraindicationsndash Untreated major depressionpsychosisndash Binge eating disordersndash Current drugEtOH abusendash Severe cardiac diseasendash Severe coagulopathyndash Inability to complyndash Age



ndash Improves most outcomes but there is risk

ndash RYGB is gold standardbull Restrictive and malabsorptive

ndash LapBand gaining favorbull Restrictive

Bottom Line

BMI Range

(and other risk factors)

Therapy

25-299

(with comorbidities)

Pharmacologic

30-399 Pharmacologic

35-399


Surgical

ge 40 Surgical



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Surgical Therapy


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Bottom Line

ObjectivesObjectives

To review definitions epidemiology To review definitions epidemiology and risk factorsand risk factors

To learn the available FDA approved To learn the available FDA approved medications and their mechanisms medications and their mechanisms of action (MOA)of action (MOA)

To learn the available bariatric To learn the available bariatric surgeries and their MOAsurgeries and their MOA





kgm2) 47kgm2) 47





childrenchildren







EtiologyEtiology























































fluidsfluids
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

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Slide 53

Surgical Therapy


Slide 56

Slide 57

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Bottom Line





kgm2) 47kgm2) 47





childrenchildren







EtiologyEtiology























































fluidsfluids
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

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Slide 53

Surgical Therapy


Slide 56

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Bottom Line





childrenchildren







EtiologyEtiology























































fluidsfluids
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



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Slide 50

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Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

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Bottom Line







EtiologyEtiology























































fluidsfluids
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

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Bottom Line




















































fluidsfluids
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

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Bottom Line
















































SurgerySurgery


bandingbanding



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

Slide 58

Bottom Line



























































ageage




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

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Bottom Line




























ndash Failed TLC



Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

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Bottom Line

Surgical Therapy










Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

Slide 58

Bottom Line








Bottom Line

BMI Range


Therapy

25-299


Pharmacologic


35-399


Surgical

ge 40 Surgical



Slide 49

Slide 50

Slide 51

Slide 52

Slide 53

Surgical Therapy


Slide 56

Slide 57

Slide 58

Bottom Line

obesity toba kazemi, m.d. associate professor of cardiology director, birjand cardiovascular...

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