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Overweight and Obesity. Harvey Hsu M.D. July 9, 2007. Introduction. Obesity is a multifactorial chronic disease Involves social, behavioral, cultural, physiological, metabolic and genetic factors. Second leading cause of preventable death in the United States - PowerPoint PPT Presentation

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  • Overweight and ObesityHarvey Hsu M.D.July 9, 2007

  • Introduction

    Obesity is a multifactorial chronic diseaseInvolves social, behavioral, cultural, physiological, metabolic and genetic factors.Second leading cause of preventable death in the United StatesMore evident in some minority groups, those with lower incomes, and less education

  • Overweight and ObeseSubstantially raises risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers.Social stigmatization and discrimination

  • Body Mass Index (BMI)BMI = weight (kg)/ height (m2) or 704.5 x lb/in2Overweight is defined as a BMI of 25 to 29.9 kg/m2Obesity is a BMI of 30 kg/m2Normal is a BMI 24.9 kg/m2 to 18.5 kg/m2Underweight is
  • ObesityObesity class 1 BMI 30.0-34.9Obesity class 2BMI 35.0- 39.9Obesity class 3BMI >= 40Waist circumferenceMen > 102 cm ( > 40 in)Women > 88 cm ( > 35 in)

  • Body Mass IndexLindsay Lohan is 56 and 112 lb BMI 18.1Jennifer Lopez is 56 and 118 lb BMI 19Amare Stoudemire is 610 and 245lb BMI 25.6George Bush is 60 and 190 lb BMI 25.8Arnold Schwarzenegger 62 and 257. BMI 33Competition wt 235 BMI 30.2

  • Body Mass IndexWalter Hudson (worlds fattest man) was 1400 lbs , height 5 11 ? BMI 198Robert Wadlow (worlds tallest man) was 811 and 440 lb BMI 27.4

  • NHANES 65.7 percent of U.S. Adults are overweight or obese. (2001-2002) 33 percent are at a healthy weight Total 65.1 % overweigh or obese, 30.4% were obese, and 4.9% were extremely obese. (1999-2002)

  • NHANES

  • HypertensionAge adjusted prevalence of high blood pressure increases progressively with higher levels of BMIEach kg of weight loss decreases systolic BP by 2.5mm and diastolic 1.7 mm/Hg

  • DyslipidemiaOverweight and obesity are associated with increased cholesterol levels. Increased triglyceridesDecreased HDLIncreased LDL

  • Diabetes MellitusThe increased risk of diabetes as weight increases has been shown by prospective studiesRelative risk of diabetes increases by approximately 25% for each additional unit of BMI over 22 kg/m2

  • Coronary Heart DiseaseObservational studies have shown that overweight, obesity, and excess abdominal fat are directly related to cardiovascular risk factors, including high levels of total cholesterol, LDL-cholesterol, triglycerides, blood pressure, fibrinogen and insulin [86] , and low levels of HDL- cholesterol

  • Congestive heart failureOverweight and obesity have been identified as important and independent risk factors for congestive heart failure (CHF) in a number of studies, including the Framingham Heart Study

  • StrokeOverweight may be associated with ischemic strokeRecent prospective studies demonstrate that the risk of stroke shows a graded increase as BMI risesischemic stroke risk is 75 percent higher in women with BMI > 27, and 137 percent higher in women with a BMI > 32, compared with women having a BMI < 21

  • GallstonesRisk of gallstones increases with adult weightRisk of either gallstones or cholecystectomy is as high as 20 per 1,000 women per year when BMI is above 40, compared with 3 per 1,000 among women with BMI < 24

  • OsteoarthritisAssociation with increased weight and knee osteoarthritis is stronger in women.Every kilogram increase in weight increased the risk of developing osteoarthritis by 9 to 13%

  • Sleep ApneaObesity, particularly upper body obesity, is a risk factor for sleep apnea and has been shown to be related to its severityMost people with sleep apnea have a BMI>30Large neck girth is predictive

  • CancerColon cancerBreast CancerEndometrial cancerGallbladder canceroverweight and obesity in the United States could account for 14 percent of all deaths from cancer in men and 20 percent of those in women

  • Relative to the normal weight category (BMI 18.5 to 25), obesity (BMI >30) was associated with 111 909 excess deaths (95% confidence interval [CI], 53 754-170 064) and underweight with 33 746 excess deaths (95% CI, 15 726-51 766). Overweightwas not associated with excess mortality (-86 094 deaths; 95% CI, -161 223to -10 966). JAMA. 2005;293:1861-1867 www.jama.com

  • Natural laws of Prehistoric TimesEat when hungryEat food high in fatSleep near food supplyConserve energy

  • TreatmentDietExercisePharmacotherapySurgery

  • Diet3500 kcal is equivalent to 1 poundMultiply your body weight times 13. Add to that the number of calories you typically burn off during exercise each day. Subtract 2% of that total for each decade after the age of 30. The result is your daily caloric need.

  • DietCalculate total required caloriesHave patient record all mealsBehavior therapyVLCDs produce greater initial weight loss than LCDs. However, the long-term (> 1 year) weight loss is not different from that of the LCD

  • ExerciseOne additional pound of fat burns 2 kcal/dayOne additional pound of muscle burns 75 kcal/dMaintains lean body mass and metabolismThe combination of a reduced calorie diet and increased physical activity produces greater weight loss than diet alone or physical activity alone

  • PharmacotherapyDexfenfluramine/fenfluraminePhentermineSibutramine (Meridia)Orlistat (Xenical)

  • Dexfenfluramine/fenfluramineSerotonin reuptake inhibitor/serotonin releaserAdverse Effects:Valvular heart disease Primary pulmonary hypertensionNeurotoxicity

  • PhentermineA sympathomimetic amineCNS stimulationElevation of blood pressure

  • Sibutramine (Meridia)Norepinephrine, dopamine, and serotinin reuptake inhibitorAdverse Effect- increase in heart rate and blood pressure, BP 1-3 mm/Hg HR 4-5 b/minUse in BMI>30Or in BMI >27 with risk factors

  • Orlistat (Xenical)Inhibits pancreatic lipase, decreases fat absorptionAdverse effectsDecrease in absorption of fat soluble viatminsSoft stools and anal leakagePossible link to breast cancer

  • Orlistat (alli)

  • OtherEphedrine, caffeine, fluoxetine, wellbutrin have been used for weight loss but not FDA approved.Zonisamide (Topamax)Recombinant Variant of Ciliary Neurotrophic Factor (CNTF)SR141716 (Rimonabant)

  • Antiobesity drugs in pipelineRimonabant(Acomplia) Cannabinoid receptor antagonistAxokine Nerve growth factor agonistAC137/Pramlintide Delays gastric emptyingAOD9604 Increases lipolysis, decreases lipogenesis, and raises resting energy expenditureADP356 Selective 5-HT2C receptor antagonistGT 389-255 Gastrointestinal lipase inhibitor conjugated to fat-binding polymer

  • Zonisamide (Topamax)16 week randomized, double-blind, placebo-controlled trial with optional single-blind extension for 16 more weeksAt 16 weeks: 5.9kg (6.0%) vs 0.4kg (1.0%)At 36 weeks: 9.2kg (9.4%) vs 1.5kg (1.8%)

  • Recombinant Variant of Ciliary Neurotrophic Factor (CNTF)12 week double-blind, randomized, parallel group, dose-ranging, multicenter clinical trial Placebo: 0.1kg rhvCNTF 0.3 mcg/kg: -1.5kg rhvCNTF 1.0 mcg/kg: -4.1kg rhvCNTF 2.0 mcg/kg: -3.4kg

  • Acomplia (rimonabant)

    62.5 percent of patients treated for the full two years with the higher dose of Acomplia lost more than 5 percent of their body weight compared to 36.7 percent of those on the low dose of Acomplia and 33.2 percent of patients in the control group. 32.8 percent of patients treated for the full two years with the higher dose of Acomplia lost more than 10 percent of their body weight compared to 20 percent of patients on the low dose of Acomplia and 16.4 percent of patients in the control group

  • Axotine

  • SurgeryGastrointestinal surgery (gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y]) can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI >40 or 35, who have comorbid conditions and acceptable operative risks

  • Gastric Bypass Laparoscopic Adjustable Gastric Band

  • Gastric Bypass Vertical Banded Gastroplasty

  • Gastric Bypass Roux-en-Y

  • Gastric Bypass Surgery Complications: 14-Year FollowupSurgical Complications Number of Patients % of PatientsVitamin B12 deficiency23939.9Readmit for various reasons22938.2Incisional hernia14323.9Depression14223.7Staple line failure 9015.0Gastritis 7913.2Cholecystitis 6811.4Anastomotic problems 59 9.8Dehydration, malnutrition 35 5.8Dilated pouch 19 3.2Data derived from source (Pories et al.) and modified based on personal communication.Source: Pories WJ, Swanson MS, MacDonald KG Jr, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339-350; discussion 350-352.

  • Gastric Bypass Surgery Weight LossBariatric Surgery, A Systematic Review and Meta-analysis JAMA October 13, 2004

  • Gastric Bypass Surgery BenefitsBariatric Surgery, A Systematic Review and Meta-analysis JAMA October 13, 2004Diabetes: resolution in 76.8%, improvement 86%Cholesterol: total chol -33LDL -29 Triglycerides -79.65Hypertension: 61.7% resolved, improvement 78.5%Obstructive Sleep Apnea: 85.7% resolved

  • Low Carbohydrate DietsNEJM - the group on the low-carbohydrate diet had lost significantly more weight than the group on the conventional diet at 3 months (P=0.001) and 6 months (P=0.02), but the difference in weight loss was not statistically significant at 12 months (P=0.26)

  • Low Carbohydrate DietsJournal of Clinical Endocrinology and Met

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