Overweight and Obesity

Maru E Combate M.D,MS,FPCP,FPCCP

Overview
Definition, Prevalence & Consequences
of Obesity
Healthy Lifestyles
Assessment of Obesity
Treatments for Obesity

Definition
Obesity is an abnormal accumulation of body fat, usually
20 percent or more over an individual's ideal body weight.

Definition of Overweight & Obesity

Using BMI
ITEMS

BMI

UNDER WEIGHT

18.5

NORMAL

18.5 24.9

OVER WEIGHT

25.0 29.9

OBESITY

30.0 34.9

OBESITY

35.0 39.9

II

EXTREME OBESITY

40

III

GRADE

Calculating BMI
Calculate Body Mass Index (BMI) =

weight (kg)
height squared (meters)
Or
weight (pounds) x 703
height squared (inches)

Prevalence of Obesity
Childhood and adolescent obesity increased from 5% to 16%
in the last 20 years
Adulthood obesity increased from 12% to 21% in 10 years.
16 million US adults with BMI over 35
60 million US obese adults (BMI > 30)

Prevalence of Adult Obesity, U.S.A.

25

% adults

20
15

Texas
United States

10
5

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

From CDC website: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/prev_reg.htm

Factors predispose to obesity

Genetic familial tendency.

Sex women more susceptible .
Activity lack of physical activity.
Psychogenic emotional deprivation,
depression .
Social class poorer classes.
Alcohol problem drinking.
Smoking cessation smoking.
Prescribed drugs tricyclic derivatives.

Weight Gain: Medications

Disease

Examples

Diabetes

Insulin, sulfonylureas

Depression

Tricyclics

Seizures

Valproic acid, Tegretol

Hypertension

Clonidine, -blockers, -blockers

Hormones

Progesterone

Weight Gain: How Does It Happen?

Energy imbalance
calories consumed not equal to calories used

Over a long period of time

Due to a combination of several factors
Individual behaviors
Social interactions
Environmental factors
Genetics

Weight Gain: Energy In

3500 calories = 1 pound
100 calories extra per day
= 36,500 extra per year
= 10.4 lbs weight gain

Question: How much is 100 calories?

Answer: Not very much!

1 glass skim milk, or

1 banana, or
1 slice cheese, or
1 tablespoon butter

Evolving Pathology
More in and less out = weight gain
More out and less in = weight loss
Hypothalamus
control center for hunger and satiety

Endocrine disorder
where are the hormones?

Leptin
Protein hormone secreted by adipocytes
Levels correlate with lipid content of cells
Leptin acts on the hypothalamus to reduce
hunger and to stimulate energy expenditure

Ghrelin
Hormone secreted in the stomach
Acts on the hypothalamus to stimulate appetite
Levels peak just before meals and drop afterward

Bad News for Dieters

Leptin
Dieting decreases leptin levels
Reducing metabolism, stimulating appetite

Ghrelin
Levels in dieters are higher after weight loss
The body steps up ghrelin production in response to
weight loss
The higher the weight loss, the higher the ghrelin levels

Health Consequences of Obesity

Major cause of preventable
death
Increase in mortality from
all causes
Increase in risk for these
cancers

Endometrium
Breast
Prostate
Colon

Increase in risk of:

Hypertension
Dyslipidemia
Diabetes type 2
Coronary artery disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea & respiratory
problems

Assessment
Assess the patient's readiness and willingness to lose
weight :
Unfortunately those who are most concerned about their
weights are not necessarily those who are at the highest
health risk.
Those who are unable or unwilling to embark on a weight
reduction program, but they are willing to take steps to
avoid further weight gain or perhaps to work on other risk
factors such as cigarette smoking, and they should be
encouraged to do so.
For those not ready to act, the issue should be deferred and
brought up at the next visit

Assessment
Is he overweight? Obese?
What are his key health issues?

Assessment
Measure BMI
Measure waist circumference
Apple shape body is higher risk for DM, CVD,
HTN
Waist larger than 40 inches for men
Waist larger than 35 inches for women

Assessment
Assess for other risk factors
Existing high risk disease:
coronary heart disease; other atherosclerotic diseases; type 2
diabetes; sleep apnea

Diseases associated with obesity

Gynecological problems; osteoarthritis; gallstones; stress
incontinence

Cardiovascular risk factors (3 or more = high risk)

Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting
glucose = 110 to 125; family history of premature CHD; men
age > 45; women age > 55

Other risk factors

Physical inactivity; elevated serum triglycerides

Medications associated with obesity

Treatment Approach
A multi-faceted
approach is best
Diet
Physical activity
Behavior change

A Recommendation

Treatment Approach
Initial goal: 10% weight loss
Significantly decreases risk factors

Rate of weight loss

1 to 2 pounds per week
Reduction of caloric intake 500-1000 per day

Slow weight loss is more stable

Rapid weight loss is almost always followed by
weight gain
Rapid weight loss increases risk for gallstones &
electrolyte abnormalities

Treatment Approach
Aim for 4 - 6 months of weight loss effort
Most people will lose 20 to 25 pounds
After 6 months, weight loss is more difficult
Ghrelin & Leptin are at work!
Changes in resting metabolic rate
Energy requirements decrease as weight
decreases
Diet adherence wavers

Set goals for weight maintenance for next 6

months, then reassess.

Dietary Therapy
Weight reduction with dietary treatment is in
order for virtually all patients with a BMI 2530 who have comorbidities and for all patients
over BMI 30.
Strategies of dietary therapy include teaching
about calorie content of different foods, food
composition (fats, carbohydrates, and
proteins), reading nutrition labels, types of
foods to buy, and how to prepare foods.

Low-Calorie Step I Diet

1000 to 1200 kcal/day for
women
1200 to 1600 kcal/day for
men
Adjust for current weight
& activity
Too hungry?
increase kcal by 100
- 200/day
Not losing?
decrease kcal by
100 - 200/day

How Much is 1200 Calories?

Could you stick to 1200 per day?

1 Big Mac (580)

1 SMALL Fries (210)
1 SMALL shake (430)

Low-Calorie Step I Diet

Nutrient

Recommended intake

Calories

500 to 1000 kcal/day reduction from usual

Total fat

<30% of total calories

Cholesterol

<300 mg per day

Protein

<15% of total calories

Carbohydrate

>55% of total calories

Sodium Chloride

<2.4 g sodium, or <6 g sodium chloride

Calcium

1000 to 1500 mg/day

Fiber

20 to 30 g/day

Weight Maintenance:
How Much Should People Eat?
Varies widely
Some averages, below
Males

Females

Age 20-49

2900 calories/day

Age 50-plus

2500 calories/day

Age 20-49

2300 calories/day

Age 50-plus

1900 calories/day

Physical Activity
Physical activity should be an integral
part of weight loss
Physical activity alone is less successful
than a combined diet & exercise
program
Increased activity alone
does not decrease weight
Sustained activity does
prevent weight regain

Reduces risk for heart disease & diabetes

Physical Activity
Start slowly
Many obese people live sedentary lives
Avoid injury
Early changes can be activities of daily living

Increase intensity & duration gradually

Long-term goal
30 to 45 minutes or more of physical activity
5 or more days per week
Burn 1000+ calories per week

Recommend Physical Activity

What does it take to burn
1000 calories per week?
Gardening
5 hours

Cycling 22 miles

Running
11 miles

Walking
12 miles
Dancing 3 hours

Behavioral Strategies
Keep a journal of diet & activity
Very powerful intervention!

Set specific goals re: behaviors

Eating
Activity
Related behaviors

Track improvement
Weigh & measure on a regular basis

Cognitive Strategies

Focus on the goals

Plan meals & activity
Develop reminder systems
Anticipate temptations & plan resistance
Reward yourself
Limit quantities, but do not deprive yourself
Have confidence in your ability to succeed
Do positive self-talk

Pharmacotherapy for Weight Loss

Adjunct to diet & physical activity

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 & physical

activity fails to achieve weight loss

Pharmacotherapy for Weight Loss

These drugs are only modestly effective
2 to 10 kilogram loss
Most occurs in the first 6 months

If patient does not lose 2 kilograms in the first

4 weeks, success is unlikely
If the first 6 months is successful, continue
medication as long as
It is effective in maintaining weight, and
Adverse effects are not serious

Pharmacotherapy for Weight

Loss
Drug

Dose

Action

Adverse
Effects

Sibutramine 5/10,/15 mg
10 mg po qd to start.
(Merida)

Nor epinephrine,
dopamine &
serotonin
reuptake inhibitor

Increase in heart
rate & blood
pressure

120 mg
120 mg po tid before
meals

Inhibits
pancreatic lipase,
decreases fat
absorption

Decrease in
absorption of fatsoluble vitamins;
soft stools and
anal leakage

May be increased to
15 mg or decreased to
5 mg

Orlistat
(Xenical)

Weight Loss Surgery

47,000 in 2001; 98,000 in 2003
Types of Obesity Surgery:
1. Restrictive Surgery - uses bands or staples to create food
intake restriction:
Vertical Banded Gastroplasty (VBG) - is a pure restrictive surgery
since it only involves surgically creating a stomach pouch. VBG uses
bands and staples and is the most frequently performed procedure for
obesity surgery.
Gastric Banding involves the use of a band to create the stomach
pouch.
Laparoscopic Gastric Banding (Lap-Band), approved by the FDA in
June 2001, is a less invasive procedure in which smaller incisions are
made to apply the band. The band is inflatable and can be adjusted

over time

Weight Loss Surgery

2. Combined Restrictive and Malabsorptive Surgery - is a combination of
restrictive surgery (stomach pouch) with bypass (malabsorptive surgery),
in which the stomach is connected to the jejunum or ileum of the small
intestine, bypassing the duodenum.
Roux-en-Y Gastric Bypass (RGB) - is the most commonly performed gastric
bypass procedure, and the second most frequently performed surgery for
obesity after VBG. RGB involves a stomach pouch for food intake
restriction. A direct connection, which is Y-shaped, is made from the ileum
or jejunum to the stomach pouch for malabsorption.
Biliopancreatic Diversion (BPD) - is one of the most complicated obesity
surgery, sometimes involving the removal of a portion of the stomach. The
remaining section of the stomach is connected to the ileum. BPD successfully
promotes weight loss, but this procedure is typically used for persons with
severe obesity who have a BMI of 50 or more

Weight Loss Surgery

Indications
100 pounds overweight or more
Or, BMI > 40
Or, BMI > 35 and 2 significant comorbidities
Age 18 to 60
Documented failure at nonsurgical efforts
Psychological stability

Weight Loss Surgery

Roux-en-Y gastric bypass
Limits food intake
Alters digestion

Figure from NIDDK website

Weight Loss Surgery

Complications of surgery
Mortality
<1% mortality in healthy young adults BMI < 50
2-4% mortality in patients with disease and BMI > 60
Operative complications
< 10%

Late complications are uncommon

Incisional hernias
Gallstones
Vitamin B12 & iron deficiency
Weight loss failure
Neurologic symptoms in unusual cases

Weight Loss Surgery Outcomes

Durable weight loss
One study followed pts for 14 years

Average excess weight loss = 61.2%

77% with diabetes no longer require meds
From Wald meta-analysis in JAMA 2004)

Followup
Schedule a return visit in 2 to 4 weeks after
starting weight loss plan
Monitor treatment effectiveness & side effects

Schedule monthly visits for first 3 months

If making favorable progress
See more frequently if monitoring medical
complications or chronic disease

Reduce frequency of visits after 6 months

Followup

Monitor weight, BP, pulse at each visit

Monitor waist size intermittently
Share progress with patient; praise efforts
Share lab results with patient
Emphasize findings associated with weight
reduction

Focus on medical benefits

Most weight loss doesnt reach individuals
ideal (cosmetic) goal

Thank You!