OBESITY & IT’S
MANAGEMENT
:Contents
Definition
Epidemiology
Etiology
Co-morbidity.
Assessment (Hx, Ex, Invest.)
Treatment.
DEFINITION
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
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.
ETIOLOGY
Multifactorial disorder
Genetics: ●Energy imbalance.
Polygenic.
It has been long known that the ●Diet ( increase Food especially
tendency to gain weight runs in Fatty diets) major cause of Obesity.
families.
However, family members share
not only genes but also diet and ●Exercises (Link between physical
life style habits that may inactivity and weight gain).
contribute to obesity.
morbid obesity has a stronger
genetic component than
moderate level of excess
overweight
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:
Hypothyroidism.
Cushing’s syndrome.
Polycystic ovarian syndrome.
Hypothalamic insufficiency.
pancreatic insulinoma.
Medications:
Cortisol and other glucocorticoids.
Sulfonylurea.
Antidepressants.
Antipsychotics, e.g. MAOIs,
Risperidone.
Oral contraceptives.
Insulin. Psychatric
causes:
Major depression.
Binge eating disorders
SYNDROMES WITH OBESITY
GENES IN OBESITY
CO-MORBIDITY
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.
Diabetes (Type 2)
Obesity complicates the management of type 2 diabetes by increasing
insulin resistance and glucose intolerance, which makes drug treatment
less effective.
Hypertension
Cardiovascular Disease (CVD).
Obesity increases CVD risk due to its effect on blood lipid levels.
Osteoarthritis (OA).
Obesity is associated with the development of OA of the hand, hip, back and
especially the knee.
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
THE CLINICAL ASSESMENT OF
AN OBESE SUBJECT
History.
Physical Examination.
Investigation.
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.
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
:EXAMINATION
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!!
Mild hirsutism in women Poly Cystic Ovary Syndrome (PCOS ---- increase
weight because of insulin resistance).
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 .
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 Weight Risk of Illness
Classification
Less than 18.5 Underweight Increased
18.5 – 24.9 Ideal weight Normal
25 – 29.9 Overweight Increased
30 – 34.9 Obese grade1 High
35 – 39.9 Obese grade 2 Very high
>40 Obese grade 3 Extremely high
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.
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
• Biochemical profile.
●Fastingplasma glucose.
• Full blood count. ●Serum uric acid.
• Fasting lipid profile. ●Serum FT4 and TSH.
Further investigations depending on
clinical picture and risk factors
• 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 Behavior Pharma Endoscpic Surgical
range mod. Therapy Balloon Therapy
25-26.9 Yes* No No No
27-29.9 Yes* Yes* No No
30-34.9 Yes Yes Yes No
35-39.9 Yes Yes Yes No
40 or Yes Yes Yes* Yes
more
* co morbidities present
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.
:DIET
Balanced, low-calorie diets.
Very low-calorie diets. ( No carbohydrates)
Low-fat diets.
Low-carbohydrate diets.
Midlevel diets.
:EXERCISE
Patients should be screened for cardiovascular and respiratory
adequacy.
Aerobic exercise:
Is of greatest value for subjects who are obese.
Ultimate minimum goal:
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
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 .
• Sibutramine • Orlistat
*Appetite suppressant *Potent inhibitor of lipase activity
*Serotonin & norepinephrine *Side effect: Oily stools, bloating&
uptake inhibition. increase flatulence.
*Side effect: Tachycardia, *weight loss 10%.
Hypertension & Insomnia.
*weight loss 5%to 10%.
Weight Regain happens after stoppage of either of the drugs.
OTHER DRUGS
Lorcaserin selective 5ht2c receptor agonist
Phentermine with topiramate sympothamimetic
liraglutide GLP1 receptor agonist
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.
Contraindications:
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.
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 Digestive
Band slippage/ Pouch dilatation. Nausea, vomiting.
Esophageal dilatation/ dysmotility.
Erosion of the band into the gastric obstruction .
lumen. Constipation.
Port site pain & displacement.
Infection of the fluid within the band. 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.
Benefits: 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: complications:
Increase in satiety. Leakages & Infection along
Stomach functions normally. the staple line.
No dumping syndrome (the GERD.
pyloric portion of the stomach Gallstones.
is left intact).
postoperative gastric fistula.
No foreign body usage.
Simpler and less operative
time.
In summary
Obesity is imbalance in energy homeostasis .
We start the management by the life style
modificationthen 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.
THANK YOU
