Overweight and Obesity

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Overweight and Obesity

• Dr Mojtaba Hashemzade
• Obesity surgeon

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Overview

• Definition, Prevalence Consequences of Obesity
• Healthy Lifestyles
• Assessment of Obesity
• Treatments for Obesity

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Definition

• Obesity is an abnormal accumulation of body fat,
  usually 20 percent or more over an individual's
  ideal body weight.

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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
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Calculating BMI

• Calculate Body Mass Index (BMI)
• weight (kg)
• height squared (meters)
• Or
• weight (pounds) x 703
• height squared (inches)

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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 gt 30)

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Prevalence of Adult Obesity, U.S.A.
From CDC website http//www.cdc.gov/nccdphp/dnpa
/obesity/trend/prev_reg.htm
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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.

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Weight Gain Medications
Disease Examples
Diabetes Insulin, sulfonylureas
Depression Tricyclics
Seizures Valproic acid, Tegretol
Hypertension Clonidine, a-blockers, ß-blockers
Hormones Progesterone
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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

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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

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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?

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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

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Ghrelin

• Hormone secreted in the stomach
• Acts on the hypothalamus to stimulate appetite
• Levels peak just before meals and drop afterward

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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

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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

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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

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Assessment

• Is he overweight? Obese?
• What are his key health issues?

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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

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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 gt130 HDL
  lt35 fasting glucose 110 to 125 family history
  of premature CHD men age gt 45 women age gt 55
• Other risk factors
• Physical inactivity elevated serum triglycerides
• Medications associated with obesity

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Treatment Approach

• A multi-faceted approach is best
• Diet
• Physical activity
• Behavior change
• A Recommendation

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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

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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.

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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.

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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

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How Much is 1200 Calories?

• Could you stick to 1200 per day?

1 Big Mac (580) 1 SMALL Fries (210) 1 SMALL shake
(430)
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Low-Calorie Step I Diet
Nutrient Recommended intake
Calories 500 to 1000 kcal/day reduction from usual
Total fat lt30 of total calories
Cholesterol lt300 mg per day
Protein lt15 of total calories
Carbohydrate gt55 of total calories
Sodium Chloride lt2.4 g sodium, or lt6 g sodium chloride
Calcium 1000 to 1500 mg/day
Fiber 20 to 30 g/day
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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
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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

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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

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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
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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

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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

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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

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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

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Pharmacotherapy for Weight Loss
Drug Dose Action Adverse Effects
Sibutramine (Merida) 5/10,/15 mg 10 mg po qd to start. May be increased to 15 mg or decreased to 5 mg Nor epinephrine, dopamine serotonin reuptake inhibitor Increase in heart rate blood pressure
Orlistat (Xenical) 120 mg 120 mg po tid before meals Inhibits pancreatic lipase, decreases fat absorption Decrease in absorption of fat-soluble vitamins soft stools and anal leakage
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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

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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.
• 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

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Weight Loss Surgery

• Indications
• 100 pounds overweight or more
• Or, BMI gt 40
• Or, BMI gt 35 and 2 significant comorbidities
• Age 18 to 60
• Documented failure at nonsurgical efforts
• Psychological stability

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Weight Loss Surgery

• Roux-en-Y gastric bypass
• Limits food intake
• Alters digestion

Figure from NIDDK website
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Weight Loss Surgery

• Complications of surgery
• Mortality
• lt1 mortality in healthy young adults BMI lt 50
• 2-4 mortality in patients with disease and BMI gt
  60
• Operative complications
• lt 10
• Late complications are uncommon
• Incisional hernias
• Gallstones
• Vitamin B12 iron deficiency
• Weight loss failure
• Neurologic symptoms in unusual cases

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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)

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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

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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 doesnt reach individuals
  ideal (cosmetic) goal

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Thank You!