Transcript Obesity in Adults

Overweight and Obesity
Dr Mojtaba Hashemzade
Obesity surgeon
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
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
GRADE
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.
25
% adults
20
15
10
Texas
United States
5
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
0
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, α-blockers, β-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:


Diseases associated with obesity


Cigarette smoking; Hypertension; LDL >130; HDL
<35; fasting glucose = 110 to 125; family history of
premature CHD; men age > 45; women age > 55
Other risk factors


Gynecological problems; osteoarthritis; gallstones;
stress incontinence
Cardiovascular risk factors (3 or more = high risk)


coronary heart disease; other atherosclerotic
diseases; type 2 diabetes; sleep apnea
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
<30% of total calories
Cholesterol
<300 mg per day
Protein
<15% of total calories
Carbohydrate
>55% of total calories
Sodium Chloride <2.4 g sodium, or <6 g sodium chloride
Calcium
1000 to 1500 mg/day
Fiber
20 to 30 g/day
Weight Maintenance:
How Much Should People Eat?
 Varies widely
 Some averages, below
Males
Females
Age 20-49
2900 calories/day
Age 50-plus
2500 calories/day
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


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Many obese people live sedentary lives
Avoid injury
Early changes can be activities of daily living
 Increase intensity & duration gradually
 Long-term goal

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
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?
Gardening
5 hours
Cycling 22 miles
Running
11 miles
Walking
12 miles
Dancing 3 hours
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 Weight Loss
 These drugs are only modestly effective


2 to 10 kilogram loss
Most occurs in the first 6 months
 If patient does not lose 2 kilograms in the first
4 weeks, success is unlikely
 If the first 6 months is successful, continue
medication as long as…


It is effective in maintaining weight, and
Adverse effects are not serious
Pharmacotherapy for Weight Loss
Drug
Dose
Action
Adverse
Effects
Sibutramine 5/10,/15 mg
10 mg po qd to start.
(Merida)
Nor epinephrine,
dopamine &
serotonin
reuptake inhibitor
Increase in heart
rate & blood
pressure
120 mg
120 mg po tid before
meals
Inhibits
pancreatic lipase,
decreases fat
absorption
Decrease in
absorption of fatsoluble vitamins;
soft stools and
anal leakage
May be increased to
15 mg or decreased to
5 mg
Orlistat
(Xenical)
Weight Loss Surgery
 47,000 in 2001; 98,000 in 2003
 Types of Obesity Surgery:
 1. Restrictive Surgery - uses bands or staples to
create food intake restriction:



Vertical Banded Gastroplasty (VBG) - is a “pure”
restrictive surgery since it only involves surgically creating a
stomach pouch. VBG uses bands and staples and is the
most frequently performed procedure for obesity surgery.
Gastric Banding – involves the use of a band to create the
stomach pouch.
Laparoscopic Gastric Banding (Lap-Band), approved by
the FDA in June 2001, is a less invasive procedure in which
smaller incisions are made to apply the band. The band is
inflatable and can be adjusted over time
Weight Loss Surgery
 2. Combined Restrictive and Malabsorptive Surgery - is a
combination of restrictive surgery (stomach pouch) with bypass
(malabsorptive surgery), in which the stomach is connected to
the jejunum or ileum of the small intestine, bypassing the
duodenum.

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Roux-en-Y Gastric Bypass (RGB) - is the most commonly
performed gastric bypass procedure, and the second most
frequently performed surgery for obesity after VBG. RGB
involves a stomach pouch for food intake restriction. A direct
connection, which is Y-shaped, is made from the ileum or
jejunum to the stomach pouch for malabsorption.
Biliopancreatic Diversion (BPD) - is one of the most
complicated obesity surgery, sometimes involving the removal
of a portion of the stomach. The remaining section of the
stomach is connected to the ileum. BPD successfully
promotes weight loss, but this procedure is typically used for
persons with severe obesity who have a BMI of 50 or more
Weight Loss Surgery
 Indications

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100 pounds overweight or more
Or, BMI > 40
Or, BMI > 35 and 2 significant comorbidities
Age 18 to 60
Documented failure at nonsurgical efforts
Psychological stability
Weight Loss Surgery
 Roux-en-Y gastric bypass


Limits food intake
Alters digestion
Figure from NIDDK website
Weight Loss Surgery
 Complications of surgery
 Mortality
 <1% mortality in healthy young adults BMI < 50
 2-4% mortality in patients with disease and BMI > 60
 Operative complications
 < 10%
 Late complications are uncommon
 Incisional hernias
 Gallstones
 Vitamin B12 & iron deficiency
 Weight loss failure
 Neurologic symptoms in unusual cases
Weight Loss Surgery Outcomes
 Durable weight loss

One study followed pts for 14 years
 Average excess weight loss = 61.2%
 77% with diabetes no longer require meds

From Wald meta-analysis in JAMA 2004)
Followup
 Schedule a return visit in 2 to 4 weeks after
starting weight loss plan

Monitor treatment effectiveness & side effects
 Schedule monthly visits for first 3 months


If making favorable progress
See more frequently if monitoring medical
complications or chronic disease
 Reduce frequency of visits after 6 months
Followup
 Monitor weight, BP, pulse at each visit
 Monitor waist size intermittently
 Share progress with patient; praise efforts
 Share lab results with patient

Emphasize findings associated with weight
reduction
 Focus on medical benefits

Most weight loss doesn’t reach individual’s
‘ideal’ (cosmetic) goal
Thank You!