OBESITY

OBESITY
Definitions: Abnormal growth of adipose tissue due to Increase amount - fat cell size (hypertrophied obesity ) Increase fat cell number (hyper plastic) Obesity is defined as an abnormal accumulation of body fat, usually 20% or more over an individuals ideal weight
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Definition
Obesity is a medical condition in which the natural energy reserve of an individual is expanded far beyond the usual level to the point where it causes health stress.

Definition of Over Weight and Obesity

Items Normal Over weight Obesity Obesity Obesity BMI 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 I Mild 11 Moderate 111 Severe Under weight <18.5

Factors predisposing to obesity

GENETIC--- familial tendency GENETIC-- SEX--SEX--women more susceptible Men gain wt ( 29- 35yrs ) 29Women gain wt (45-49yrs) (45(source Framingham study USA)

Factors predisposing to obesity

Eating Habits-----Habits-----Preference for eating in between meals , sweets, refined foods & fatty and fried foods

Factors predisposing to obesity

PHYSICAL INACTIVITY

Factors predisposing to obesity

PSYCOGENIC---emotional PSYCOGENIC---emotional deprivation and disturbance , depression, anxiety, frustration loneliness in childhood

Factors predisposing to obesity

SOCIAL CLASS---poor and affluent classes CLASS---poor ALCOHALISM SMOKING---cessation SMOKING---cessation of smoking DISEASES-------hypothyroidism, DISEASES-------hypothyroidism, cushing syndrome, polycystic ovary disease PRESCRIBED DRUGS---tricyclic derivatives DRUGS---tricyclic

Weight Gain:Medications
Disease Diabetes Depression seizures hypertension Insulin, sulfonylureas Tricyclics Valproicacid, Tegretol Alpha and bete blockers

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Weight Gain: How does it Happen

Energy Imbalance-------Calories consumed not Imbalance-------Calories equal to calories used over a long period of time due to a combination of several factors Individual behaviour, social and environmental behaviour, factors, genetics, decreased physical activity

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WHAT CAUSES OBESITY ?

How much extra wt could be gained / yr in a child / adult if 100 kcal/day gain = 5kg/yr Question: How much is 100 calories? Answer: Not very much 1 glass skim milk 1 banana or 1 slice of cheese or 1 table spoon butter

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WHAT CAUSES OBESITY ?

How ? 100 kcal/day 100 x 30 = 3000 kcal/month 3000 x 12 = 36000 kcal/year 7000 kcal = 1kg of fat 36000/7000 approximately adipose tissue

= 5 kg of

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ASSESSMENT OF OBESITY Appearance Apple Shape body is higher risk for DM, CHD, HTN but measurement is must

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ASSESSMENT OF OBESITY
Following measures are more important

1. Body weight and BMI

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Assessment
BMI (Quetlets index)= Weight(kg) (Quetlets Height squared(meters) or Weight(pounds)x703 Height squared(inches)
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Assessment
Ponderal index= ht (cm) cube root of wt(kg)

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Assessment
Brocca Index = height (cm)-100 (cm)if height is 160cm his ideal weight is 60 kg Lorentz,s index=height(cm)-100-ht(cm)-150 index=height(cm)-100-ht(cm)2(Women)or4(men) Corpulence index= actual weight Desirable weight
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ASSESSMENT OF OBESITY
1. Waist circumference Indicates intra abdominal fat And total body fat waist larger than 40 inches for men waist larger than 35 inches for women
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ASSESSMENT OF OBESITY
3. Waist Hip Ratio (WHR) Cut off points Male: > 1.0 Female : > 0.85 Simple Convenient Unrelated to height Closely related to BMI Indicator of abdominal fat mass and total body
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ASSESSMENT OF OBESITY
5. Skin fold thickness------Measurement of fat cells thickness------Measurement 18mm in men 32mm in women

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PREVALENCE
Most prevalent form of malnutrition (child disease ) Developed countries Developing countries. Children --- (++ 10-20 % ) 10 Adults ----( ++ 20 -40 % ) ----( Both sex ___ ++
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Prevalence in Pakistan
Prevalence of obesity (BMI > or = 25) in 25-44 25year olds in rural areas was 9% for men and 14% for women; in urban areas, prevalence was 22% and 37% for men and women, respectively. For 45-64 year olds, prevalence was 11% for 45men and 19% for women in rural areas, and 23% and 40% in urban areas for men and women, respectively Obesity prevalence was directly associated with SES, regardless of residence

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PROBLEMS / HAZARDS ASSOCIATES WITH OBESITY

Increased Mortality Sudden death (when more than 20 % over weight )(related to hypertension ,CHD, renal disease ) and Lowered life expectancy

Increased morbidity

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PROBLEMS / HAZARDS ASSOCIATES WITH OBESITY

Obesity is Suicide Associated as risk factors for Hypertension DM Gall bladder disease Varicose vein Abdominal hernia O. arthritis of large joints Psychological stress Excess risk with surgery Lowered fertility
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Health Consequences of Obesity

Greatly Increased NIDDM Gall bladder disease Dyslipidaemia Insulin resistance Breathlessness and sleep apnea Moderately increased CHD Hypertension Osteoarhritis Hyperuricaemia and gout Slightly increased Cancer(breast,endometrial, colon Polycystic ovary disease Impaired fertility Low back pain Increased risk of anaesthesia

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Prevention and Control

Health Education and multifaceted approach focused on Diet, Physical activity, Behaviour change Appetite depressing drugs Weight loss surgery

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Prevention and Control

Goals
Prevention of weight gain
Promotion of weight maintenance PUBLIC HEALTH PROGRAMS Management of co-morbidities co Promotion of weight loss
INDIVIDUAL TREATMENT PROGRAMS

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PREVENTION & CONTROL OF OBESITY

a Dietary changes Strategies include teaching about the calorie content of different foods, food composition(fats, carbohydrates and proteins),reading food labels, types of food to buy and how to prepare food
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Low calorie step 1 Diet

10001000-1200 kcal / day for women 1200 -1600 kcal/day for men Adjust for current weight and activity Too hungry? increase kcal by 100-200 /day 100 Not losing? decrease kcal by 100-200/day 10031

Low calorie step 1 Diet

Nutrient Calorie Total fat Cholestrol Protein Carbohydrates Sodium chloride Calcium Fibre Recommended intake 500-1000kcal/day reduction from usual <30% of total calories <300 mg /day <15% of total calories >55% of total calories <2.4 g sodium,or < 6 gm sodium chloride 1000-1500 mg/day 20-30 g/day

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PREVENTION & CONTROL OF OBESITY

b Increase physical activity

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PREVENTION & CONTROL OF OBESITY

Physical activity should be an integral part of weight loss and prevention Physical activity alone is not successful than a combined diet and exercise program Regular and appropriate physical activity exercise should be adopted

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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 and duration gradually long term goal 30-45 min or more of physical activity 305 or more days per week should be targeted
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Recommended Physical Activity

What does it take to burn calories in different activities /hr? running 12km/hr--12km/hr--750kcal walking 4km/hr----160 4km/hr----160 gardening 300kcal/hr cycling 15km/hr----15km/hr-----360kcal
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Behavioral strategies
Keep a journal of diet and activity Set specific goals eating activity Track improvement weigh and measure on regular basis

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Pharmacotherapy for weight loss

Adjunct to diet and physical activity when 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 and physical activity fails to achieve weight loss

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Pharmacotherapy for weight loss

Drug Sibutramine (Merida) Dose 5/10/15 mg 10 mg qd to start. May be increased o 15 mg decreased to 5 mg 120 mg 120 mg tid before meals Action Nor epinephrine ,dopamine and serotonin reuptake inhibitror Inhabits panreatic lipase,decrease fat absorption Adverse Effects Increase in heart rate and blood pressure

Orlistat (Xenical)

Decrease in absorption of fat soluble vitamins,soft stools and anal leakage

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Weight loss surgery

Restrictive procedures - These make your stomach smaller , significantly reducing the food intake Malabsorptive procedures - Parts of the digestive system, especially the first part of the small intestine (duodenum) or the mid-section mid(jejunum), are bypassed. This procedure is generally more effective than restrictive procedures.
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Treatment
Indications 100 pounds over weight or more Or,BMI> 40 Or,BMI> Or,BMI>35 and 2 significant comorbidities Or,BMI>35

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Effects of 10% weight loss

Mortality
20% decrease in overall 30% decrease in diabetes related deaths 40% decrease in cancer related deaths

Blood pressure
10 mm Hg decrease

Lipids 15% decrease in cholesterol Decreases in other lipids

Better control Less medications

Diabetes

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Reality
Assessment
Anthropometry BMI waist Risks BP glucose, insulin lipids heart disease sleep apnoea
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Reality
Management 1. general advice 2. activity 3. eating 4. Program 5. Drugs Sibutramine 6. VLCDs 7. Surgery
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 Thank you

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