ObesityDone by:

Abdulaziz S. Al-Mehlisi Fahad I. Abuguyan Wael M.Al-Subaiyel

SupervisorDr. Al-Naami

Definition:

By WHO:Overweight and obesity are defined as

abnormal or excessive fat accumulation that presents a risk to health.

A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

BMI = weight (kg) / [ height sq. (m2) ]

BMI Classification:categoryBMIRisk of Co-morbiditiesUnderweight< 18.5

Normal18.5 – 24.9AverageOverweight25.0 – 29.9Increased

Obese I30.0 – 34.9Moderate

Obese II35.0 – 39.9Severe

Obese III≥ 40Very severe

Prevalence:WHO’s latest projections indicate that globally

in 2005: An estimated 1.6 billion adults worldwide are

overweight (BMI>25) and 400 million are obese (BMI>30), and potentially as many as 20 million children are overweight.

WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese.

A study had been done in KSA and showed:The prevalence of overweight among men

was 30.7% and among women was 28.4%. While prevalence of obesity was 14.2% in

males and 23.6% in females .

Etiologies:The fundamental cause of obesity and

overweight is an energy imbalance between calories consumed on one hand, and calories expended on the other.

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Etiologies: Life style & physical inactivity. Diet & eating patterns. Smoking. Age. Sex. Race.

Cont.Medical causes: Hypothyroidism. Cushing’s syndrome. Polycystic ovarian

syndrome. Hypothalamic insufficiency.

Cont. Medications:

Cortisol and other glucocorticoids.

Sulfonylureas. Antidepressants. Antipsychotics, e.g. MAOIs,

Risperidone. Oral contraceptives. Insulin.

Cont.Familial Genetic:

Prader-Willi syndrome. Laurence-Moon-Biedl (Bardet-Biedl)

syndrome. Down syndrome . Turner syndrome. Leptin deficiency or resistance to

leptin action.

Cont.Psychatric causes:

Major depression.Binge eating disorders.

Co-morbidities: Medical:

o Type II diabetes.o Insulin resistance, hyperinsulinaemia. o Dyslipidaemia. o Hypertension.o Respiratory disease:

Sleep apnea. Hypoventilation syndrome.

Cont.o Cardiac and vascular diseases

Cerebrovascular disease. Congestive heart failure . Coronary heart disease . Thromboembolic disease.

Co-morbidities Cont.o Digestive system abnormalities

• Gall bladder disease. • Hepatic disease, fatty liver.• GERD.

o Reproductive system abnormalities: Infertility.

o Nervous system: Pseudotumor cerebri.o Musculoskeletal: Osteoarthritis, Gout.o Cancers: Breast, endometrial, cervix, ovary,

colon, gallbladder, kidney, prostate.

Co-morbidities Surgical:

o Perioperative risks: Anesthesia. Wound complications. Infections. Incisional hernias.

o Varicose veins.o DVT.o Carpal Tunnel Syndrome.o Fibroadenoma of the breast.o Uterine fibroma.o Stress urinary incontinence.

Cont.Psychological complications: e.g. Depression.Social complications.

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MEDICAL ASSESSMENT Some patients are “healthy” without any

recognized illnesses. They are unhappy, so they seek medical attention in an effort to lose weight, improve their quality of life and help their self-image.

Other patients are already being treated for one or more of the comorbid conditions arising from obesity.

The medical assessment includes a complete history, physical examination and lab investigations.

History Age of onset of obesity.The pattern of weight gain and loss since puberty. Diet and exercise habits.Smoking or alcohol consumption habits.Life events (lifestyle changes) such as beginning

or graduating college, marriage, pregnancy, illness, relationship problems, job change or a family death.

Family history:Of obesity (degree of relatives).Coronary artery disease.

Drugs history:Present and previous medications for any problem.Past or present use of weight loss medications.

Ask about Endocrine disorders such as Hypothyroidism, Cushing’s syndrome and hypothalamic Tumors or damage.

Psychological profile assessment.History of physical or mental abuse.Attention for specific condition. These

include PCOS, insulin resistance, hypothyroidism, and OSA.

Physical examination

Physical examinationCreate an accessible and comfortable office

environment.Provide sturdy, armless chairs and high, firm

sofas in waiting rooms. Provide sturdy, wide examination tables that are

bolted to the floor to prevent tipping. Provide a sturdy stool or step with handles to

help patients get on the examination table. Provide extra large examination gowns. Install a split lavatory seat and provide a

specimen collector with a handle.

Use medical equipment that can accurately assess patients who are obese.

Use large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm.

Have extra long phlebotomy needles, tourniquets, and large vaginal speculae on hand.

Have a weight scale with adequate capacity (greater than 350 pounds) for obese patients

Reduce patient fears about weight.Weigh patients only when medically

appropriate. Weigh patients in a private area. Record weight without comments. Ask patients if they wish to discuss their weight

or health. Avoid using the term obesity. Your patients

may be more comfortable with terms such as "difficulties with weight" or "being overweight." You may wish to ask your patients what terms they prefer when discussing their weight.

Physical examination should target signs or conditions that predispose to or are complications of obesityMild hirsutism in women PCOS.Large neck size Sleep apnea.Thyroid tenderness or goiter Hypothyroidism.Slowed reflexes Hypothyroidism.Proximal muscle weakness Cushing’s

syndrome, Hypothyroidism.Skin striae Cushing syndrome’s, steroid

use.Dry or coarse skin and hair hypothyroidism.

Investigation Fasting glucose.CBC & Hb.Lipid profile (Total cholesterol, triglycerides,

LDL and HDL).Hormones:

TFT.Cortisol.Testosterone.

U/E.Abdominal U/S.

How would How would you you

diagnose diagnose obesity?obesity?

(1 )Body mass index (BMI).(2 )Waist circumference.

(3 )Risk factors for diseases andconditions associated with obesity.

The first step

Obesity is an excess of total body fatOverweight is an excess of body weight

Weight classification

BMI(kg/m2)

Obesity Class

Risk Of illness

Underweight 18.5 <

_Increased

Ideal weight18.5 to 24.9_Normal

Overweight25.0 to 29.9_Increased

Obesity(mild)

(moderate)30.0 to 34.935.0 to 39.9

III

High/very high

Extreme obesity(severe)

40 < IIIExtremely high

The second step Measure waist circumference.Important to note that waist circumference is

not measured at the level of the umbilicus (the “natural” waist), but at the level of the iliac crest.

To measure your patients’ waist circumference:1. Locate the upper hip bone and the top of the

right iliac crest.2. Place a measuring tape in a horizontal plane

around the abdomen at the level of the iliac crest.

3. Ensure that the tape is snug, but does not compress the skin, and is parallel to the floor.

4. Read the measurement at the end of a normal expiration of breath.

It is important to know your patients’ waist circumference because the health risks of overweight and obesity are independently associatedwith excess abdominal fat.5,6 Excess abdominal fat is clinicallydefined as a waist circumference of >40 inches (>102 cm) in men and

of>35 inches (>88 cm) in women

Population studies have shown that people with excess abdominal fat have an excess burden of impaired health and increased cardiovascular risk.

Obese individuals with excess fat deposited around the abdomen (‘appleshaped’)are more likely than those who have fat deposited on the hips and buttocks (‘pearshaped’)to develop health problems.

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 and >0.85 in women.

The Third step Review your patients’ medical, social and

family history for current and potential obesity-related symptoms and diseases.

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Treatment:Behavioral.Diet.Pharmacological treatment. Exercise.Intra-gastric balloon.Surgical treatment.

Behavioral:Identify the circumstances that trigger eating. Grocery shopping with a pre planned list.Reduce temptations (no food in sight).Do nothing else while eating (watch TV or read

magazines).Eat slowly.

Diet:Balanced, low-calorie diets :

Energy deficit ranging from 500 to 1000 kcal/day. Low fat diet. Helps losing 0.5 kg/week that lead to 10% weight loss over 6 months.

Very low-calorie diets (VLCDs): High protein diet with less fat & no carbohydrates. Energy is less than 800 kcal/day. Helps losing 1 – 1.5 kg/week.

Low-fat diets.Low-carbohydrate diets.Midlevel diets (e.g. Zone diet in which the 3 major

macronutrients [fat, carbohydrate, protein] are eaten in similar proportions of 30-40%)

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.

Benefits:Helps build muscle mass.Increases metabolic activity of the whole-body mass.Reduces body-fat proportions.Decreases the amount of compensatory muscle mass

loss that is typical in the setting of weight loss.

Pharmacological:Lasts for several years.Weight will increase again after cessation of the

drugs in most cases.If no significant weight reduction in at least 3

months, stop the drug )5% of baseline weight(.

:OrlistatLipase inhibitor.LDL cholesterol reduction.It’s effects and side effects increase with higher fat

content in the food.The ONLY FDA approved drug to decrease food

absorption.Common adverse effects(>1/10 users):

Fatty or oily stools.Faecal urgency.Oily faecal spotting.

:SibutramineCentrally acting appetite suppressant.Serotonin & norepinephrine uptake inhibitorCommon adverse effects:

Insomnia.Nausea.Dry.Constipation.

Not recommended for patients with CVS diseases.Long term 5% to 10% weight loss.

:Intra-gastric BalloonShort to medium term solution.Inserted endoscopically.Complications:

Balloon deflationMigrationErosionObstruction

Bariatric Surgery:Methods:

Restrictive diseases: AGB (Adjustable gastric banding). VBG (Vertical banded gastroplasty). Sleeve gastrectomy.

Malabsorptive procedures: Roux-en-Y gastric bypass (RGB). Biliopancreatic diversion (BPD).

Criteria:Age below 60 years.BMI at least 35-40 kg/m2An efficient conservative treatment strategy has been tried.The patient is cooperative. There’s no abuse of alcohol or drugs.

American Society for Bariatric Surgery (ASBS) guidelines: A BMI of 40 or greater (MORBID OBESITY) or A BMI of 35 or greater with “significant co-morbidities”

AND Can show that dietary attempts at weight control have been

ineffective

Contraindications: Untreated glandular diseases: HypothyroidismInflammatory diseases of the gastrointestinal

tract: ulcers, esophagitis, Crohn’s disease.poor surgical candidates in general: severe

cardiopulmonary diseases.Dependency on alcohol or drugs. People with learning disabilities or emotionally

unstable people.

Post-operative Instructions :1st 4 wks: liquid diet2nd 4 wks: soft dietGradual return to normal dietEat slowly, small amounts at a timeAvoid eating sugary food

Adjustable Gastric Banding (LAP-Band):

Benefits:50% to 60% loss of excess body weight. Performed in an outpatient setting.Exercise adds 10% more of loss.Reduce obesity and related comorbidities.Lower mortality rate: Only 1 in 2000 versus 1 in 200 for Roux-en-Y

gastric bypass surgery.Fully reversible.No cutting or stapling of the stomach.Short hospital stay.Quick recovery.Adjustable without further surgery.No malabsorption issues.Fewer life-threatening complications.

Complications:Band- and port- specific:

Band slippage/ Pouch dilatation. Esophageal dilatation/ dysmotility. Erosion of the band into the gastric lumen. Port site pain. Port displacement. Infection of the fluid within the band.

DigestiveNausea, vomiting.GER.Stoma obstruction .Constipation.Dysphagia. Diarrhoea.

Body as a wholeAbdominal pain Asthenia Infection Fever Hernia Pain Chest pain Incisional infection

Roux-en-Y Gastric Bypass:Most commonly employed gastric bypass technique.Least likely to result in nutritional difficulties.

Benefits:Rapid weight loss.60% to 70% loss of excess body weight.Exercise adds 10% more of loss.

Complications: Anastomotic leakage.Anastomotic stricture. Dumping syndrome.Nutritional deficincies.Gallstones: due to rapid loss of weight.Complications of abdominal surgery: Infection,

hernia, obstruction… etc.

Vertical Banded Gastroplasty

Biliopancreatic Diversion

BPD with Duodenal Switch

Sleeve Gastrectomy