Table 2'1' Classification of weight by BMI in adult Europids WHO 1998

1
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2
How is Obesity Measured in Adults?

• Body Mass Index (BMI)
• measure of weight in relation to height
• weight (kg) / height (m) 2

National Health Examination Survey in Thailand
(1991) for gt 20 years old - 16.7 had BMI
25-30 - 4.0 had BMI gt30


3
Classification of weight by BMI in adult
Europids (WHO 1998)
4
Proposed classification of weight by BMI in
adult Asians
Health risk associated with obesity occur at a
lower BMI in Asian Population.
5
Co-morbidities risk associated with different
levels of BMI and suggested waist circumference
in adult Asians
6
Health risks associated with obesity (WHO 1998)
7
Components of metabolic syndrome
8
Etiology of OBESITY
1. Genetics 2. Environment
9
Energy Balance
Energy input
Energy output
Basal metabolic Thermogenesis Physical
activity Exercise
10
Cumulative Effect of Small Daily Errors in Energy
Balance on Body Fat Mass
Change in body fat (lb/year)
1 million
Energy intake (kcal/y)
12
8
4
0
0
Energy expenditure(kcal/y)

1 million
Excess intake ( total) Excess intake (kcal/d)
0 0.5 1 5
12 kcal/d 25
kcal/d 125 kcal/d
11
Other causes of obesity

• Monogenic gene defects leptin gene or
  leptin receptor mutation
• Polygenic gene defects
• Hypothalamic obesity
• Hormonal obesity
• Medication antidepressant, antipsychotic,
  glucocorticoid, antihistamine

12
Long-term goals for obesity therapy
13
Modest Weight Reduction Improves Health

• 5-10 loss of initial body weight IMPROVES
• Hypertension1
• Lipid abnormalities2
• Glycemic control3
• REDUCES
• Cardiac events, CVD-related mortality, and
  all-cause mortality4
• Diabetes-associated mortality5
• Risk of developing type 2 diabetes6

1. Tuck ML, et al. N Engl J Med.
1981304930-933. 2. Dattilo AM,
Kris-Etherton PM. Am J Clin Nutr.
199256320-328. 3. Wing R, et al. Diabetes Care.
198710563-566. 4. Singh
RB, et al. BMJ. 19923041015-1019. 5.
Williamson DF, et al. Am J Epidemiol.
19951411128-1141. 6. DPP Res Group. N Engl
J Med. 2002346393-403.
14
Ttreatment options for difference levels of BMI
and other risk factors in Asian populations
Waist circumference gt 90 cm (men), gt 80 cm
(women)

Specific therapies relating
to the risk factor or condition, (DM,CHD,HT, HL)
may be necessary
NOTE If two or more diseases
present eg. Hypertension, then an anti-obesity
drug may be used.
15
Procedure to be followed for managing obesity
in the Asia-Pacific region
16
Treatment Options
DIET and lifestyle modification Physical
Activity Pharmacotherapy Surgery
17
Calories Count
Energy Expenditure
Energy Intake
To lose weight, energy intake must be reduced

• One pound (0.5 kg) of body fat 3500 kcal
• To lose 0.5 kg / week
• Decrease caloric intake by 500 kcal / day
• To lose 1 kg / week
• Decrease caloric intake by 1000 kcal / day

18

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23

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24

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25

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26

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27
Dietary change

• 1. Low-calorie diets (LCDs)
• - reduce intake by 500-1000 kcal/day to produce
  0.5-1 kg/week.
• - Diets low in Sat fat, fat intake lt 30 of
  total calories, low in simple sugar, sufficient
  protein and high in fruits and vegetables.

28
Dietary change

• 2. Very-low-calorie diets (VLCDs)
• - 250-800 kcal/day
• - For rapid improvement of sleep apnea, BG
  level, BP and psychological jump start or
  preparation for bariatric surgery
• - Require intensive medical monitoring, vitamin
  and mineral supplement.
• - Protein sparing modified fast, liquid meal
  replacement

29
Treatment Options
Diet PHYSICAL ACTIVITY Pharmacotherapy Surgery
30
A Sound Exercise Approach

• Regular, prolonged, low intensity
• Work up to one hour per day
• Short bouts add up are beneficial1
• Increase activities of daily living

Walking and vigorous activity provide similar
risk reduction for CV events 2

• Jakicic Int J Obesity 1995, 19,893901
• N Engl J Med 2002 347 (10)716-725, Sept 2002

31
Physical Activity

• Promote weight loss
• Preserve lean body mass
• Improve metabolic parameters insulin, glucose,
  and lipid
• Improve mood, quality of life and body
  composition
• Decrease risk of diseases
• Regular exercise is the best predictor of
  successful weight maintenance
• Initiate slowly, increase gradually to goal
  150-200 min/wk

32
Treatment Options
Diet Physical Activity PHARMACOTHERAPY Surgery
33
Adjunctive Pharmacotherapy

• When to consider
• BMI gt 25 or gt 23 with co-morbidities
• Lifestyle alone is not a sufficient treatment
  tool
• Current anti-obesity medications
• Sibutramine serotonin and norepinephrine
  reuptake inhibitor
• Orlistat gastric and pancreatic lipase
  inhibitor
• Phentermine norepinephrine releasing agent

Approved for long term use
34
Weight loss drugs and their side effects
35
Successful Strategies to Control Obesity Include
Pharmacotherapy
Pharmacotherapy Behavior Change Reduced
Calorie Diet
Pharmacotherapy Behavior Modification
Pharmacotherapy
0
-5
(5.2)
Weight Change at 6 Months
-10
(11.5)
-15
(17.1)
-20
Sibutramine
Wadden TA et al. Arch Intern Med., Jan 22, 01,
Vol 161 218
36
Treatment Options
Diet Physical Activity Pharmacotherapy SURGERY
37
Current Surgical Procedures
Gold Standard
Roux-en-Y Gastric Bypass
Vertical Banded Gastroplasty
Adjustable Gastric Banding
50-60 of initial weight (weight loss at 5 years)
48-74 of initial weight (weight loss at 5 years)
36 of excess weight (weight loss at 3 years)1
Maximum weight loss occurs 10-24 months post-op

• http//www.fda.gov/cdrh/pdf/p000008.html

38
Surgery Eligibility Criteria

• BMIgt30 with co-morbidities or severe obesity
• 16 - 55 years old
• Acceptable operative risks
• Failed non-surgical weight-loss attempts
• Realistic expectations
• Motivated
• No history of psychiatric disorders
• Understands procedure and implications
• Commitment to life-long behavioral changes
• Supportive family environment
• Commitment to long-term follow-up

39
Improvement in Comorbidities After Bariatric
Surgery

• No Signs/Symptoms Improved ( of patients) (
  of patients)
• Asthma 95 100
• Diabetes 90-95 100
• Dyslipidemia 70 85
• Heart failure 60 90
• Hypertension 60-65 90
• Sleep apnea 100 100

Surgery is the most effective treatment of severe
obesity

• Kral JG. International Textbook of Obesity. New
  York John Wiley and Sons 2001.
• Mun EC, Blackburn GL, Matthews JB.
  Gastroenterology. 2001120669-681.