Transcript 36-Obesity

OBESITY & IT’S
MANAGEMENT
By : Zaid Alturki , Yazeed Almalki and
Muhammed AbaAlkhail
Supervised by : Dr. AlNaami
Contents:
Definition
Epidemiology
Etiology
Co-morbidity.
Assessment (Hx, Ex, Invest.)
Treatment.
DEFINITION
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Obesity is a medical condition in which excess body fat has
accumulated to the extent that it may have an adverse effect on
health.
It is a leading preventable cause of death worldwide.
This excess accumulation is the result of a positive energy balance
where caloric intake exceeds caloric expenditure.
With increasing prevalence in adults and children, the authorities
view it as one of the most serious public health problems of the
21 century.
EPIDEMIOLOGY
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In 1997 the WHO formally recognized obesity as a
global epidemic.
WHO further study that by 2015, approximately 2.3
billion adults will be overweight and more than 700
million will be obese.
At least 20 million children under the age of 5 years are
overweight globally in 2005.
a study done in Saudi Arabia showed that the prevalence
of overweight among male subjects was 29% vs. 27%
among female subjects.
While as the prevalence of obesity among female subjects
was significantly higher than for male subjects (24% vs.
16%)
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This value is higher than that reported in the UK,
Australian and US populations.
ETIOLOGY
Multifactorial disorder
 Genetics:
 Polygenic.
 It has been long known that
the tendency to gain weight
runs in families.
However, family members
share not only genes but
also diet and life style
habits that may contribute
to obesity.
 morbid obesity has a
stronger genetic component
than moderate level of
excess overweight
●Energy imbalance.
●Diet ( increase Food especially
Fatty diets) major cause of Obesity.
●Exercises (Link between physical
inactivity and weight gain).
ETIOLOGY
At an individual level, a combination of
excessive caloric intake and a lack of physical
activity. Is the major cause of obesity.
Medical causes:
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Hypothyroidism.
Cushing’s syndrome.
Polycystic ovarian syndrome.
Hypothalamic insufficiency.
pancreatic insulinoma.
Medications:
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Cortisol and other glucocorticoids.
Sulfonylurea.
Antidepressants.
Antipsychotics, e.g. MAOIs,
Risperidone.
Oral contraceptives.
Insulin.
Psychatric causes:
Major depression.
Binge eating disorders
CO-MORBIDITY
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Obesity is associated with more than 30 medical
conditions, and scientific evidence has established a
strong relationship with at least 15 of those
conditions!!
In addition, life expectancy is shown to be reduced in
those who are obese or overweight.
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Diabetes (Type 2)
Obesity complicates the management of type 2 diabetes by
increasing insulin resistance and glucose intolerance, which
makes drug treatment less effective.
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Hypertension
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Cardiovascular Disease (CVD).
Obesity increases CVD risk due to its effect on blood lipid
levels.
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Osteoarthritis (OA).
Obesity is associated with the development of OA of the hand, hip,
back and especially the knee.
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Sleep Apnea.
Obesity, particularly upper body obesity, is the most significant risk
factor for obstructive sleep apnea.
OTHERS..
Cancers (breast,prostste,liver,gallbladder).
 Carpal Tunnel Syndrome (CTS).
 Chronic Venous Insufficiency (CVI) & Deep Vein
Thrombosis (DVT).
 Gout.
 abdominal hernias.
 Polycystic ovarian syndrome and infertility.
 Low back pain.
 Stroke
Abdominal obesity appears to predict the
risk of stroke in men.
 Headache
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THE CLINICAL ASSESMENT OF AN
OBESE SUBJECT
History.
 Physical Examination.
 Investigation.
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HISTORY
OBESITY FOCUSED HISTORY
Take a full Hx.
 Age of onset of obesity.
 The pattern of weight gain and loss since puberty.
 The level of activity and exercise.
 The weight of the partner and children may give an
indication about shared dietary habits and lifestyle.
 Drug history and Past or present use of weight loss
medications.
 The psychological aspects such as loneliness, boredom,
or stress.
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Smoking or alcohol consumption habits.
 Family history is important familial predisposition
should be considered if at least one first degree relative
is also obese.
 Assess any co-morbidities that are directly or indirectly
related to obesity.
 Detailed dietary history of the patient’s current diet.
 Review of the systems .
 GERD
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Examination
EXAMINATION:
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Vital signs.
General examination.
Thyroid.
Signs of Organo Megally. e.g. liver (liver span )
Heart and lung sounds.
Physical examination should target signs or conditions
that predispose to or are complications of obesity!!
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Mild hirsutism in women  Poly Cystic Ovary Syndrome (PCOS ---increase weight because of insulin resistance).
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Large neck size  Sleep apnea.
Thyroid tenderness or goiter  Hypothyroidism.
Dry or coarse skin and hair  Hypothyroidism.
Slowed reflexes  Hypothyroidism.
Proximal muscle weakness  Cushing’s syndrome,
Hypothyroidism.
Skin striae  Cushing’s syndrome, steroid use.
ASSESSMENT OF RISK STATUS
BMI.
 Waist circumference.
 Waist to hip ratio.
 Presence of co-morbidities.
 Body composition .
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BMI
BMI provides a measure based on
height and weight that applies to both
adult men and women.
BMI =
weight (kg) / [ height (m) ]²
BMI Range
Risk of Illness
Less than 18.5
Weight
Classification
Underweight
18.5 – 24.9
Ideal weight
Normal
25 – 29.9
Overweight
Increased
30 – 39.9
Obese
High
40 – 50
Morbid obese
Very high
50 Or greater
Super obese
Extremely high
Increased
WAIST CIRCUMFERENCE
It is Important to note that waist circumference is
measured at the level of the iliac crest.
 Excess abdominal fat is clinically defined as a waist
circumference of
* >40 inches (>102 cm) in men
*of>35 inches (>88 cm) in women.
 central (visceral) adiposity carry a greater health risk
than peripheral adiposity.
For this reason, the measurement of the waist
circumference in centimeters can be a useful indicator of
clinical risk, particularly for hypertension, diabetes, or
dyslipidaemia.
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WAIST TO HIP RATIO
(WHR)
A measurement of waist to hip ratio (WHR) is an appropriate
method of identifying patients with abdominal fat accumulation.
The waist is measured at the narrowest point and the hips are
measured at the widest point.
A high WHR is defined as:
*>( 0.95 )1.0 in men.
*>( 0.85 )in women.
Investigations
Why ??
LABORATORY DATA:
Baseline
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Biochemical profile.
Full blood count.
Fasting lipid profile.
●Fasting plasma glucose.
●Serum uric acid.
●Serum FT4 and TSH.
Further investigations depending on
clinical picture and risk factors
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24 hour urine free cortisol.
ECG , chest x ray and US (for gall
stones).
Respiratory function tests.
Plasma leptin.
TREATMENT OF OBESITY
TREATMENT OF OBESITY COMES INTO TWO
CATEGORIES:
1-non-surgical Rx:
 Behavior modification.
 Diet and exercise.
 Pharmacotherapy.
 Intragastric Balloon.
2-surgical Rx:
Gastric banding.
Gastric bypass.
Sleeve gastrectomy.
NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR
TREATMENT OF OVERWEIGHT AND OBESITY:
BMI
range
Behavior
mod.
Pharma
Therapy
Endoscpic Surgical
Balloon
Therapy
25-26.9
27-29.9
30-34.9
35-39.9
40 or
more
Yes*
Yes*
Yes
Yes
Yes
No
Yes*
Yes
Yes
Yes
No
No
Yes
Yes
Yes*
* co morbidities present
No
No
No
No
Yes
Non - Surgical Intervention
BEHAVIOR MODIFICATION:
Identify the circumstances that trigger eating.
 Grocery shopping with a pre planned list.
 Do nothing else while eating (watch TV or read
magazines).
 Eat slowly.
 Follow a balanced diet.
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DIET:
Balanced, low-calorie diets.
 Very low-calorie diets. ( No carbohydrates)
 Low-fat diets.
 Low-carbohydrate diets.
 Midlevel diets.
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EXERCISE:
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Patients should be screened for cardiovascular and
respiratory adequacy.
Aerobic exercise:
Is of greatest value for subjects who are obese.
Ultimate minimum goal:
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30-60 minutes of continuous aerobic exercise 5-7 times per week to lose
weight
30-60 minutes of continuous aerobic exercise 3-5 times per week to
prevent long term weight regain.
PHARMACOTHERAPY:
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Currently tow drugs are used:
1- Sibutramine.
2- Orlistat.
Lasts for several years.
 Weight Regain happens.
 If no significant weight reduction in at least 3 months,
stop the drug .
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• Sibutramine
*Appetite suppressant
*Serotonin & norepinephrine
uptake inhibition.
*Side effect: Tachycardia,
Hypertension & Insomnia.
*weight loss 5%to 10%.
• Orlistat
*Potent inhibitor of lipase activity
*Side effect: Oily stools, bloating&
increase flatulence.
*weight loss 10%.
Weight Regain happens after stoppage of either of the drugs.
INTRA-GASTRIC BALLOON
space-occupying volume device, Inserted
endoscopically.
 Done under GA.
 The ballon filled with approximately 500cc of saline
fluid.
 It’s an out-patient procedure.
 Short to medium term solution.
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Contraindications:
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A BMI< 30 .
Subjects with inflammatory disease of the GI tract.
Alcoholics or drug addicts.
Presence of large hiatal hernia.
Previous open abdominal surgery or bowel surgery.
Complications:
Severe nausea.
Dehydration.
Balloon deflation.
Migration.
Erosion.
Obstruction.
SURGICAL INTERVENTION
Criteria
 Cause
of obesity is non medical.
 Age below 60 years.
 BMI above 40, or 35 with co morbedites.
 Conservative treatment has been tried.
 The patient is cooperative.
Subject must be psychologically stable and wiling to follow
postoperative diet instruction
Adjustable gastric banding
Reducing the stomach
volume by creating a small
pouch at the top of the
stomach using a band.
 Holds approximately 110 to
220g.
 Pouch fills quickly and sends
total stomach satiety signals
to the Brain.
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Results In
 The Subject is less hungry
most of the time.
 Early satiety for longer
periods.
 Consumption of smaller
portions.
Advantages
 50%
to 60% weight loss with exercise add 10
more %.
 Reduction of related co morbidities.
 Fully reversible.
 No cutting or stapling of the stomach.
 Quick recovery, Short hospital stay.
 Adjustable without further surgery.
 No malabsorption issues.
 Fewer life-threatening complications.
Band & port specific
Band slippage/ Pouch dilatation.
Esophageal dilatation/ dysmotility.
Erosion of the band into the gastric
lumen.
Port site pain & displacement.
Infection of the fluid within the band.
Digestive
 Nausea, vomiting.
 obstruction .
 Constipation.
 Dysphagia.
 Diarrhoea.
Gastric bypass procedure
Its A Combination of
restrictive &
malabsorptive operations.
 The most common
performed bariatric
procedure in the United
States.
 Functions by creating a
small proximal gastric
pouch with
gastrojejunostomy.
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Benefits:
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Complications:
Rapid weight loss.
 Anastomotic leakage
60% to 70% loss of excess body
&stricture.
weight.
Dumping syndrome.
10% more by exercise.
Nutritional deficiencies. ( B12
,EDAK )
Gallstones
Complications of
abdominal Surgery.
Sleeve Gastrectomy
The stomach is reduced to about 15% of its original size, by
removing a large portion of the stomach, following the major
curve.
 The open edges are then attached together (often with
surgical staples) to form a sleeve or tube with a banana shape.
The procedure permanently reduces the size of the
stomach.
The procedure is performed laparoscopically and is not
reversible.
Advantages:
 Increase in satiety.
 Stomach functions
normally.
 No dumping syndrome
(the pyloric portion of the
stomach is left intact).
 No foreign body usage.
 Simpler and less operative
time.
complications:
 Leakages & Infection along
the staple line.
 GERD.
 Gallstones.
 postoperative gastric fistula.
In summary
Obesity is imbalance in energy homeostasis .
 We start the management by the life style
modificationthen medications then
surgery
 roux-en-Y gastric bypass is the best surgical
treatment for morbidly obese patients
 Leak is the commonest early complication in
gastric bypass
 In choosing the best surgical technique we have
to put in mind the patients life style, so in a
chocoholic we never do banding
 If we decide to do a surgery for morbid obese pt,
pt have to loss wt first then undergo surgery, to
do this, gastric balloon and after loss wt go to
surgery.
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THANK YOU