Obesity

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Obesity

• Done by
• Abdulaziz S. Al-Mehlisi
• Fahad I. Abuguyan
• Wael M.Al-Subaiyel
• Supervisor
• Dr. Al-Naami

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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)

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BMI Classification
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Prevalence

• WHOs latest projections indicate that globally
  in 2005
• An estimated 1.6 billion adults worldwide are
  overweight (BMI25) and 400 million are obese
  (BMI30), 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.

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• 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 .

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Etiologies

• The fundamental cause of obesity and overweight
  is an energy imbalance between calories consumed
  on one hand, and calories expended on the other.

Burning
Intake
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Etiologies

• Life style physical inactivity.
• Diet eating patterns.
• Smoking.
• Age.
• Sex.
• Race.

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Cont.

• Medical causes
• Hypothyroidism.
• Cushings syndrome.
• Polycystic ovarian syndrome.
• Hypothalamic insufficiency.

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Cont.

• Medications
• Cortisol and other glucocorticoids.
• Sulfonylureas.
• Antidepressants.
• Antipsychotics, e.g. MAOIs, Risperidone.
• Oral contraceptives.
• Insulin.

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Cont.

• Familial
• Genetic
• Prader-Willi syndrome.
• Laurence-Moon-Biedl (Bardet-Biedl) syndrome.
• Down syndrome .
• Turner syndrome.
• Leptin deficiency or resistance to leptin
  action.

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Cont.

• Psychatric causes
• Major depression.
• Binge eating disorders.

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Co-morbidities

• Medical
• Type II diabetes.
• Insulin resistance, hyperinsulinaemia.
• Dyslipidaemia.
• Hypertension.
• Respiratory disease
• Sleep apnea.
• Hypoventilation syndrome.

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Cont.

• Cardiac and vascular diseases
• Cerebrovascular disease.
• Congestive heart failure .
• Coronary heart disease .
• Thromboembolic disease.

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Co-morbidities Cont.

• Digestive system abnormalities
• Gall bladder disease.
• Hepatic disease, fatty liver.
• GERD.
• Reproductive system abnormalities Infertility.
• Nervous system Pseudotumor cerebri.
• Musculoskeletal Osteoarthritis, Gout.
• Cancers Breast, endometrial, cervix, ovary,
  colon, gallbladder, kidney, prostate.

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Co-morbidities

• Surgical
• Perioperative risks
• Anesthesia.
• Wound complications.
• Infections.
• Incisional hernias.
• Varicose veins.
• DVT.
• Carpal Tunnel Syndrome.
• Fibroadenoma of the breast.
• Uterine fibroma.
• Stress urinary incontinence.

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Cont.

• Psychological complications e.g. Depression.
• Social complications.

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• THANK YOU

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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.

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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.

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• Ask about Endocrine disorders such as
  Hypothyroidism, Cushings 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.

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Physical examination
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Physical examination

• Create 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.

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• 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

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• 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.

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• Physical examination should target signs or
  conditions that predispose to or are
  complications of obesity
• Mild hirsutism in women PCOS.
• Large neck size Sleep apnea.
• Thyroid tenderness or goiter
  Hypothyroidism.
• Slowed reflexes Hypothyroidism.
• Proximal muscle weakness Cushings
  syndrome, Hypothyroidism.
• Skin striae Cushing syndromes,
  steroid use.
• Dry or coarse skin and hair
  hypothyroidism.

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Investigation

• Fasting glucose.
• CBC Hb.
• Lipid profile (Total cholesterol, triglycerides,
  LDL and HDL).
• Hormones
• TFT.
• Cortisol.
• Testosterone.
• U/E.
• Abdominal U/S.

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• How would you diagnose obesity?

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Diagnosis of obesity and evaluation of health
statusthrough three key measures

• (1) Body mass index (BMI).
• (2) Waist circumference.
• (3) Risk factors for diseases and
• conditions associated with obesity.

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The first step

• Determine your patients BMI using weight and
  height measurement
• BMI provides a measure of total body fat based on
  height and weight that applies to both adult men
  and women
• BMI is calculated as weight in kilograms (kg)
  divided by the square of height in meters (m2).
• BMI weight (kg)
• height squared (m2)

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

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• 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.

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• 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
• of35 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.

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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.
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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.

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The Third step

• Review your patients medical, social and family
  history for current and potential obesity-related
  symptoms and diseases.

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THANK YOU
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Treatment

• Behavioral.
• Diet.
• Pharmacological treatment.
• Exercise.
• Intra-gastric balloon.
• Surgical treatment.

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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.

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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)

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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.

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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).

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Orlistat

• Lipase inhibitor.
• LDL cholesterol reduction.
• Its 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.

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Sibutramine

• Centrally acting appetite suppressant.
• Serotonin norepinephrine uptake inhibitor
• Common adverse effects
• Insomnia.
• Nausea.
• Dry.
• Constipation.
• Not recommended for patients with CVS diseases.
• Long term 5 to 10 weight loss.

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Intra-gastric Balloon

• Short to medium term solution.
• Inserted endoscopically.
• Complications
• Balloon deflation
• Migration
• Erosion
• Obstruction

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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).

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• Criteria
• Age below 60 years.
• BMI at least 35-40 kg/m2
• An efficient conservative treatment strategy has
  been tried.
• The patient is cooperative.
• Theres no abuse of alcohol or drugs.

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• 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

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• Contraindications
• Untreated glandular diseases Hypothyroidism
• Inflammatory diseases of the gastrointestinal
  tract ulcers, esophagitis, Crohns disease.
• poor surgical candidates in general severe
  cardiopulmonary diseases.
• Dependency on alcohol or drugs.
• People with learning disabilities or emotionally
  unstable people.

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• Post-operative Instructions
• 1st 4 wks liquid diet
• 2nd 4 wks soft diet
• Gradual return to normal diet
• Eat slowly, small amounts at a time
• Avoid eating sugary food

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Adjustable Gastric Banding (LAP-Band)
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• 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.

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• 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.

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• Digestive
• Nausea, vomiting.
• GER.
• Stoma obstruction .
• Constipation.
• Dysphagia.
• Diarrhoea.

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• Body as a whole
• Abdominal pain
• Asthenia
• Infection
• Fever
• Hernia
• Pain
• Chest pain
• Incisional infection

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Roux-en-Y Gastric Bypass

• Most commonly employed gastric bypass technique.
• Least likely to result in nutritional
  difficulties.

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

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

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Vertical Banded Gastroplasty
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Biliopancreatic Diversion
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BPD with Duodenal Switch
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Sleeve Gastrectomy
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Thank you