Obesity

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Obesity Its Management

• By Zaid Alturki , Yazeed Almalki and Muhammed
  AbaAlkhail
• Supervised by Dr. AlNaami

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Contents

• Definition
• Epidemiology
• Etiology
• Co-morbidity.
• Assessment (Hx, Ex, Invest.)
• Treatment.

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Definition

• Obesity is a medical condition in which
  excess body fat has accumulated to the extent
  that it may have an adverse effect on health.
• It is a leading preventable cause of
  death worldwide.
• This excess accumulation is the result of a
  positive energy balance where caloric intake
  exceeds caloric expenditure.
• With increasing prevalence in adults
  and children, the authorities view it as one of
  the most serious public health problems of the
  21 century.

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Epidemiology

• In  1997 the WHO formally recognized obesity as a
  global epidemic.
• WHO further study that by 2015, approximately 2.3
  billion adults will be overweight and more than
  700 million will be obese.
• At least 20 million children under the age of 5
  years are overweight globally in 2005.

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• a study done in Saudi Arabia showed that the
  prevalence of overweight among male subjects was
  29 vs. 27 among female subjects.
• While as the prevalence of obesity among female
  subjects was significantly higher than for male
  subjects (24 vs. 16)
• This value is higher than that reported in the
  UK, Australian and US populations.

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Etiology

• Energy imbalance.
• Diet ( increase Food especially Fatty diets)
  major cause of Obesity.
• Exercises (Link between physical inactivity and
  weight gain).

• Multifactorial disorder
• Genetics
• Polygenic.
• It has been long known that the tendency to gain
  weight runs in families.
• However, family members share not only genes but
  also diet and life style habits that may
  contribute to obesity.
• morbid obesity has a stronger genetic component
  than moderate level of excess overweight

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Etiology

• At an individual level, a combination of
  
  excessive caloric intake and a lack of physical
  activity. Is the major cause of obesity.

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Medical causes

• Hypothyroidism.
• Cushings syndrome.
• Polycystic ovarian syndrome.
• Hypothalamic insufficiency.
• pancreatic insulinoma.

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

• Psychatric causes
• Major depression.
• Binge eating disorders

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Co-morbidity

• Obesity is associated with more than 30 medical
  conditions, and scientific evidence has
  established a strong relationship with at least
  15 of those conditions!!
• In addition, life expectancy is shown to be
  reduced in those who are obese or overweight.

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• Diabetes (Type 2)
• Obesity complicates the management of type 2
  diabetes by increasing insulin resistance and
  glucose intolerance, which makes drug treatment
  less effective.
• Hypertension
• Cardiovascular Disease (CVD).
• Obesity increases CVD risk due to its effect
  on blood lipid levels.

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• Osteoarthritis (OA).
• Obesity is associated with the development of OA
  of the hand, hip, back and especially the knee.
• Sleep Apnea.
• Obesity, particularly upper body obesity, is the
  most significant risk factor for obstructive
  sleep apnea.

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Others..

• Cancers (breast,prostste,liver,gallbladder).
• Carpal Tunnel Syndrome (CTS).
• Chronic Venous Insufficiency (CVI) Deep Vein
  Thrombosis (DVT).
• Gout.
• abdominal hernias.
• Polycystic ovarian syndrome and infertility.
• Low back pain.
• Stroke Abdominal obesity appears to predict
  the risk of stroke in men.
• Headache

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The clinical assesment of an obese Subject

• History.
• Physical Examination.
• Investigation.

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History
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Obesity focused history

• Take a full Hx.
• Age of onset of obesity.
• The pattern of weight gain and loss since
  puberty.
• The level of activity and exercise.
• The weight of the partner and children may give
  an indication about shared dietary habits and
  lifestyle.
• Drug history and Past or present use of weight
  loss medications.
• The psychological aspects such as loneliness,
  boredom, or stress.

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• Smoking or alcohol consumption habits.
• Family history is important familial
  predisposition should be considered if at least
  one first degree relative is also obese.
• Assess any co-morbidities that are directly or
  indirectly related to obesity.
• Detailed dietary history of the patients current
  diet.
• Review of the systems .
• GERD

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• Examination

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Examination

• Vital signs.
• General examination.
• Thyroid.
• Signs of Organo Megally. e.g. liver (liver span )
• Heart and lung sounds.

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Physical examination should target signs or
conditions that predispose to or are
complications of obesity!!

• Mild hirsutism in women ? Poly Cystic Ovary
  Syndrome (PCOS ---- increase weight because of
  insulin resistance).
• Large neck size ? Sleep apnea.
• Thyroid tenderness or goiter ? Hypothyroidism.
• Dry or coarse skin and hair ? Hypothyroidism.
• Slowed reflexes ? Hypothyroidism.
• Proximal muscle weakness ? Cushings syndrome,
  Hypothyroidism.
• Skin striae ? Cushings syndrome, steroid use.

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Assessment of risk status

• BMI.
• Waist circumference.
• Waist to hip ratio.
• Presence of co-morbidities.
• Body composition .

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BMI
BMI provides a measure based on height and weight
that applies to both adult men and women.
BMI weight (kg) / height (m) ²
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BMI Range Weight Classification Risk of Illness
Less than 18.5 Underweight Increased
18.5 24.9 Ideal weight Normal
25 29.9 Overweight Increased
30 39.9 Obese High
40 50 Morbid obese Very high
50 Or greater Super obese Extremely high
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waist circumference

• It is Important to note that waist circumference
  is measured at the level of the iliac crest.
• Excess abdominal fat is clinically defined as a
  waist circumference of
• gt40 inches (gt102 cm) in men
• ofgt35 inches (gt88 cm) in women.
• central (visceral) adiposity carry a greater
  health risk than peripheral adiposity.
• For this reason, the measurement of the waist
  circumference in centimeters can be a useful
  indicator of clinical risk, particularly for
  hypertension, diabetes, or dyslipidaemia.

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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
• gt( 0.95 )1.0 in men.
• gt( 0.85 )in women.

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• Investigations
• Why ??

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Laboratory Data

• Baseline
• Biochemical profile.
• Full blood count.
• Fasting lipid profile.
• Further investigations depending on clinical
  picture and risk factors
• 24 hour urine free cortisol.
• ECG , chest x ray and US (for gall stones).
• Respiratory function tests.
• Plasma leptin.

• Fasting plasma glucose.
• Serum uric acid.
• Serum FT4 and TSH.

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Treatment of obesity
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Treatment of obesity comes into two categories

• 1-non-surgical Rx
• Behavior modification.
• Diet and exercise.
• Pharmacotherapy.
• Intragastric Balloon.

• 2-surgical Rx
• Gastric banding.
• Gastric bypass.
• Sleeve gastrectomy.

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National institutes of health guidelines for
treatment of overweight and obesity
Surgical Therapy Endoscpic Balloon Pharma Therapy Behavior mod. BMI range
No No No Yes 25-26.9
No No Yes Yes 27-29.9
No Yes Yes Yes 30-34.9
No Yes Yes Yes 35-39.9
Yes Yes Yes Yes 40 or more
co morbidities present
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• Non - Surgical Intervention

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Behavior modification

• Identify the circumstances that trigger eating.
• Grocery shopping with a pre planned list.
• Do nothing else while eating (watch TV or read
  magazines).
• Eat slowly.
• Follow a balanced diet.

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Diet

• Balanced, low-calorie diets.
• Very low-calorie diets. ( No carbohydrates)
• Low-fat diets.
• Low-carbohydrate diets.
• Midlevel diets.

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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.

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Pharmacotherapy

• Currently tow drugs are used
• 1- Sibutramine. 2-
  Orlistat.
• Lasts for several years.
• Weight Regain happens.
• If no significant weight reduction in at least 3
  months, stop the drug .

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• SibutramineAppetite suppressantSerotonin
  norepinephrine uptake inhibition.Side effect
  Tachycardia, Hypertension Insomnia.
• weight loss? 5to 10.

• Orlistat
• Potent inhibitor of lipase activity
• Side effect Oily stools, bloating increase
  flatulence.
• weight loss ?10.

Weight Regain happens after stoppage of either of
the drugs.
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Intra-gastric Balloon
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• space-occupying volume device, Inserted
  endoscopically.
• Done under GA.
• The ballon filled with approximately 500cc of
  saline fluid. 
• Its an out-patient procedure.
• Short to medium term solution.

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•  Contraindications
• A BMIlt 30 .
• Subjects with inflammatory disease of the GI
  tract.
• Alcoholics or drug addicts.
• Presence of large hiatal hernia.
• Previous open abdominal surgery or bowel
  surgery.

• Complications
• Severe nausea.
• Dehydration.
• Balloon deflation.
• Migration.
• Erosion.
• Obstruction.

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Surgical intervention
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Criteria

• Cause of obesity is non medical.
• Age below 60 years.
• BMI above 40, or 35 with co morbedites.
• Conservative treatment has been tried.
• The patient is cooperative.
• Subject must be psychologically stable and wiling
  to follow postoperative diet instruction

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Adjustable gastric banding
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• Reducing the stomach volume by creating a small
  pouch at the top of the stomach using a band.
• Holds approximately 110 to 220g.
• Pouch fills quickly and sends total stomach
  satiety signals to the Brain.
• Results In
• The Subject is less hungry most of the time.
• Early satiety for longer periods.
• Consumption of smaller portions.

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Advantages

• 50 to 60 weight loss with exercise add 10 more
  .
• Reduction of related co morbidities.
• Fully reversible.
• No cutting or stapling of the stomach.
• Quick recovery, Short hospital stay.
• Adjustable without further surgery.
• No malabsorption issues.
• Fewer life-threatening complications.

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complication

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

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

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• Gastric bypass procedure

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• Its A Combination of restrictive malabsorptive
  operations.
• The most common performed bariatric procedure in
  the United States.
• Functions by creating a small proximal gastric
  pouch with gastrojejunostomy.

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• Benefits
• Rapid weight loss.
• 60 to 70 loss of excess body weight.
• 10 more by exercise.

• Complications
• Anastomotic leakage stricture.
• Dumping syndrome.
• Nutritional deficiencies. ( B12 ,EDAK )
• Gallstones
• Complications of abdominal Surgery.

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Sleeve Gastrectomy
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• The stomach is reduced to about 15 of its
  original size, by removing a large portion of the
  stomach, following the major curve.
• The open edges are then attached together (often
  with surgical staples) to form a sleeve or tube
  with a banana shape.
• The procedure permanently reduces the size of the
  stomach.
• The procedure is performed laparoscopically and
  is not reversible.

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• Advantages
• Increase in satiety.
• Stomach functions normally.
• No dumping syndrome (the pyloric portion of the
  stomach is left intact).
• No foreign body usage.
• Simpler and less operative time.

• complications
• Leakages Infection along the staple line.
• GERD.
• Gallstones.
• postoperative gastric fistula.

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• In summary
• Obesity is imbalance in energy homeostasis .
• We start the management by the life style
  modification??then medications?? then surgery
• roux-en-Y gastric bypass is the best surgical
  treatment for morbidly obese patients
• Leak is the commonest early complication in
  gastric bypass
• In choosing the best surgical technique we have
  to put in mind the patients life style, so in a
  chocoholic we never do banding
• If we decide to do a surgery for morbid obese pt,
  pt have to loss wt first then undergo surgery, to
  do this, gastric balloon and after loss wt? go to
  surgery.

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Thank you