Transcript Document

Obesity
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Aim-Objectives
•
Aim: At the end of this session, the participants will have
knowledge on burden of obesity, its complications, and
management.
•
Objectives: At the end of this session, the trainees should be
able to
•
describe Body Mass Index (BMI) in categories
•
discuss the health risks associated with obesity.
•
identify the components of obesity management
•
beable to explain screening recommendations for obesity.
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Global Prevalence of Obesity in Adult Males
With examples of the top 5 Countries in each
Region
European Region
Croatia 31%
Cyprus 27%
Czech Republic 25%
Albania (urban) 23%
England 23%
Eastern
Mediterranean
Lebanon 36%
North America
Qatar 35%
USA 31%
Jordan 33%
Mexico 19%
Kuwait 28%
Canada (self report) 17%
Saudi Arabia 26%
Guyana 14%
Bahamas 14%
Africa
% Obese
0-9.9%
10-14.9%
South Central America
Panama 28%
15-19.9%
Paraguay 23%
20-24.9%
Argentina (urban) 20%
25-29.9%
Uruguay (self report) 17%
≥30%
Self Reported data
South Africa 10%
Seychelles 9%
Cameroon (urban) 5%
Ghana 5%
Tanzania (urban) 5%
With the limited data available, prevalence's are not age standardised. Self reported surveys may
underestimate true prevalence.
Sources
and references
Dominican
Republic
16% are available from the IOTF.
© International Obesity TaskForce, London –January 2007
South East Asi
Pacific Region
Nauru 80%
Tonga 47%
Cook Island 41%
French Polynesia
Global Prevalence of Obesity in Adult Females
With examples of the top 5 Countries in each Region
European Region
Albania 36%
Malta 35%
Turkey 29%
Slovakia 28%
Czech Republic 26%
North America
USA 33%
Eastern
Mediterranean
Jordan 60%
Qatar 45%
Barbados 31%
Saudi Arabia 44%
Mexico 29%
Palestine 43%
St Lucia 28%
Lebanon 38%
Bahamas 28%
Africa
% Obese
South Central America
Seychelles 28%
Panama 36%
South Africa 28%
15-19.9%
Paraguay 36%
Ghana 20%
20-24.9%
Peru (urban) 23%
Mauritania 19%
25-29.9%
Chile (urban) 23%
Cameroon (urban) 14%
0-9.9%
10-14.9%
≥30%
Self Reported data
With the limited data available, prevalence's are not age standardised. Self reported surveys may
underestimate true prevalence.
Sources
and references
Dominican
Republic
18% are available from the IOTF.
© International Obesity TaskForce, London –January 2007
South East Asi
Pacific Region
Nauru 78%
Tonga 70%
Samoa 63%
Niue 46%
Body Mass Index (BMI)
 The BMI is an easily obtained and reliable
measurement for obesity and is defined as a
person's weight (in kilograms) divided by the
square of the person's height (in meters).
 Example: 72 kg, 166 cm person
= 72 / 1.66 x 1.66
= 72 / 2.75
= 26.1
Obesity classification.
•
Obesity is further divided
into three separate classes,
with Class III obesity being
the most extreme of the three.
Obesity class
BMI (kg/m2)
Class I
30.0- 34.9
Class II
35.0-39.9
Class III
≥ 40.0
(Extreme Obesity)
With a BMI of:
You are considered:
Below 18.5
Underweight
18.5 - 24.9
Healthy Weight
25.0 - 29.9
Overweight
30 or higher
Obese
CDC, NHLBI
BMI
(kg/m2
)
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20
21
22
23
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Height
(in.)
25
26
27
28
29
30
35
40
Weight (lb.)
58
91
96
100
105
110
115
119
124
129
134
138
143
167
191
59
94
99
104
109
114
119
124
128
133
138
143
148
173
198
60
97
102
107
112
118
123
128
133
138
143
148
153
179
204
61
100
106
111
116
122
127
132
137
143
148
153
158
185
211
62
104
109
115
120
126
131
136
142
147
153
158
164
191
218
63
107
113
118
124
130
135
141
146
152
158
163
169
197
225
64
110
116
122
128
134
140
145
151
157
163
169
174
204
232
65
114
120
126
132
138
144
150
156
162
168
174
180
210
240
66
118
124
130
136
142
148
155
161
167
173
179
186
216
247
67
121
127
134
140
146
153
159
166
172
178
185
191
223
255
68
125
131
138
144
151
158
164
171
177
184
190
197
230
262
69
128
135
142
149
155
162
169
176
182
189
196
203
236
270
70
132
139
146
153
160
167
174
181
188
195
202
207
243
278
71
136
143
150
157
165
172
179
186
193
200
208
215
250
286
72
140
147
154
162
169
177
184
191
199
206
213
221
258
294
73
144
151
159
166
174
182
189
197
204
212
219
227
265
302
74
148
155
163
171
179
186
194
202
210
218
225
233
272
311
75
152
160
168
176
184
192
200
208
216
224
232
240
279
319
76
156
164
172
180
189
197
205
213
221
230
238
246
287
328
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Waist circumference
For men,
<94cm is low,
94-102cm is high
and > 102cm is very high
For women,
<80cm is low,
80-88cm is high
and > 88cm is very high
Several serious medical conditions have been
linked to obesity
History in Obese Patient
 A full history must include:

Onset

Recent weight change

Occupation
 A dietary inventory and an analysis of the subject's




activity level .
Screening for depression
Screening for eating disorders
Previous comorbidities
Explore causes of secondary obesity
 Previous trial & experiences to lose weight
 Family history of weight problems.
 The patient's expectations
 The patient's level of motivation .
 Medication history.
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Selected Medications That Can Cause Weight Gain
 Psychotropic medications

Diabetes medications
– Tricyclic antidepressants
– Insulin
– Monoamine oxidase inhibitors
– Sulfonylureas
– Specific SSRIs
– Thiazolidinediones
– Atypical antipsychotics

Highly active antiretroviral
therapy

Tamoxifen

Steroid hormones
– Lithium
– Specific anticonvulsants
 -adrenergic receptor blockers
– Glucocorticoids
– Progestational steroids
SSRI=selective serotonin reuptake inhibitor
Physical examination
 In the clinical examination,
1.
Measure anthropometric parameters ,height weight,
BMI
2.
Waist to hip ratio.
3.
Skin fold thickness
 Perform a standard, detailed examination
 skin :

Look for hirsutism in women, intertriginous rashes, acanthosis
nigricans, and possible contact dermatoses .
 CVS: BP ( appropriate calf size)

Look for cardiomegaly and respiratory insufficiency .
 Abdomen: hepatomegaly ( fatty liver)
 LL +,- odema
Physician Barriers to Evaluation and
Treatment of Obesity
 Lack of time
 Lack of recognition of obesity as a chronic condition
 Insufficient data
 Lack of data
 Lack of patient interest
 Inadequate training
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Obesity Treatment
 Non pharmacological
 Diet
 Physical activity
 Behavioral therapy
 pharmacological
 Pharmacotherapy
 Surgical
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BMI
classificaion
Waist circumference
low
high
comorbid
Very high ities
overweight
Obesity I
Obesity II
Obesity III
General advice on healthy weight and lifestyle
Diet and physical activity
Diet and physical activity; consider drugs
Diet and physical activity; consider drugs; consider surgery
Management
 General recommendations:
 Avoid complications such as excessive loss of lean
body mass, dehydration, electrolyte imbalance,
gallbladder disease and psychological distress
 Physicians engaging in weight loss counseling also
should consider their own weight and set an example
for their patients by demonstrating healthy weight
management
No body is exempted from obesity . It can be you.
 Most adults regain any weight loss within five years .
 It is a life-long challenge to achieve and maintain a
healthy weight since it needs a long-term commitment
to lifestyle change,
Techniques of Motivational Interviewing
Support self efficacy
Express empathy
Explore discrepancies
Avoid arguments
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Promote
empowerment
Provide choices
Reassure of expected outcomes
Express acceptance and understanding
Use reflective listening and expect
ambivalent
Let individuals explore their reasons for
changing or not changing their behavior
Avoid judging and labeling
Change strategies if patient shows
resistance
Patients are a source of solutions, and
since obesity is a self-managed disease,
the patient is in charge and responsible of
his or her own care
Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American
Diabetic Association; 2002
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Techniques For Modifying Behavior

Self monitoring

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Stimulus control
Contingency management
Cognitive restructuring

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Stress management

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Recording of target behavior and associated
factors, found to be most helpful
Recording diary of food, exercise
Restricting environmental factors influencing
inappropriate behaviors
Eating at specific times
Setting time and place for exercise
Avoid buying food items that are difficult to
control eating
Rewarding appropriate behavior
Short term contracts to formalize agreements
Move thinking pattern from self rejection toward
self acceptance
Changing thinking patterns from unrealistic goals
to realistic and achievable goals
Learning methods to reduce stress and tension,
since both are a primary predictor of relapse
Relaxation techniques as diaphragmatic
breathing, progressive muscle relaxation and
meditation
Regular exercise
Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American
Diabetic Association; 2002.
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 A reasonable goal for weight-loss in the setting
of a medical treatment program is
approximately 0.9-1.5 kg/wk
Dietary therapy
 Very low-calorie diets (VLCDs) are best used in an




established, comprehensive program.
VLCDs involve reducing caloric intake to 800 kcal/d or
less.
When used in optimal settings, they can achieve weight
loss of 1.5-2.5 kg/wk, with a total loss of as much as 20 kg
over 12 weeks.
Unless a long-term maintenance calorie-deficit program is
developed and adhered, to recidivism after the diet is
stopped is rapid.
Most subjects quickly regain all the weight they lose and
often gain more.
Calorie needs calculation
 Men
 BMR = 66 + (13.7 x W) + (5 x H) - (6.8 x Age)
 Women
 BMR = 665 + (9.6 x W) + (1.8 x H) - (4.7 x Age)
 Total daily calorie needs
 Sedentary - none or very little exercise: BMR X 1.2
 Light activity for average of 2 days/week: BMR X 1.375
 Moderate activity level exercising 4 days/week: BMR X 1.5
 High activity levels more than 6 days/week: BMR X 1.7
 Higher activity levels: up to 2 x BMR
BMR=Basal Metabolic Rate (Harris Benedict calculation)
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Example
 30 year old 80 kg, 168 cm woman
 Basal Metabolic Rate (BMR)=
665 + (9.6 x 80) + (1.8 x 168) - (4.7 x 30)
 BMR = 1594 calories
 If light activity:
 1594 x 1.375
 2191.75 calories
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Recommended Average Daily Energy
Men Age (year)
Kcal\day
11 to 14
2,500
15 to 18
3,000
19 to 24
2,900
25 to 50
2,900
51+
2,300
Women (non-pregnant, non-lactating )
11 to 14
2,200
15 to 18
2,200
19 to 24
2,200
25 to 50
2,200
51+
1,900
Adapted from National Research Council
Physical activity
 Aerobic isotonic exercise is of the greatest value for
subjects who are obese.
 The ultimate minimum goal should be to achieve 30-60
minutes of continuous aerobic exercise 5-7 times per week .
 People who have been obese and have lost weight should
be advised they may need to do 60-90 min of activity\day
to avoid regaining weight
Pharmacological Therapy
 Pharmacotherapy is limited to use in patients with
 a BMI of 30 or more and no accompanying obesity-
related risk factors or diseases,
 or patients with a BMI of 27 or more with accompanying
obesity-related risk factors or diseases
 patient who have not reached their target weight loss or
have reached a plateau on dietary. activity and
behavioral change alone.
Pharmacotherapy
Major groups
Centraly acting
Impair deitry
Intake
(sibutramine)
Act peripherally
to impair absorption
(orlistat)
Increase energy
Expenditure
(Mazindol,
Phentermine)
Indications for Medication
NICE 2001/ABPI MEDICINES COMPENDIUM 2002/2005
Surgery may be considered for
 Patient with BMI 40 or more
 BMI 35 – 40 with other risk factors
 All appropriate non-surgical measures have been
tried but failed.
 As 1st line option ( instead of lifestyle interventions
or drug treatment) for adults with a BMI of>50.
 Types of surgery:
 Gastric banding.
 Gastric bypass.
 Vertical banded gastroplasty.
Referral
 The underlying causes need to be assessed.
 The person has complex disease state and can’t
be managed in primary care
 Conventional treatment has failed.
 Drug therapy is considered for a person with a
BMI>35kg\m2
 Surgery is being considered.
Algorithm for the treatment of obesity
NHLBI Practical Guide. Oct 2000 Figure 2, pg 13 http://www.naaso.org/information/practicalguide.asp
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