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Overweight and Obesity Lecture

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  • 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 We

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