obesity

1. SUBJECT SEMINAR
APPROACH TO PATIENTS WITH OBESITY
CHAIR PERSON
Dr.SantoshVastrad
(M.D)
STUDENT
Dr.Anusha SJ

2. DEFINITION AND MEASUREMENT
Obesity is a state of excess adipose tissue mass
current practical definition of obesity is determined by an assessment of
BMI. (Obesity is >30 kg/m2)
BMI is calculated by dividing a person’s weight (in kilograms) / height (in
meters squared);
alternatively, the [weight (in pounds) *704 ] /height (in inches squared)

4. •PREVELANCE
• BMI >30 has increased from 14.5% to 35.7% - U.S
• Women – 6.6%
• Men – 3.5%
• more common among blacks and Hispanics.
• worldwide prevalence :more than doubled in less than 35 years
India

5. • Study Facts:
• World Population: 7,505,257,673
• World Obesity Population : 774,000,000

6. APPROACH TO PATIENTS WITH OBESITY

9. EVALUATION
• (1) a focused obesity-related history,
• (2) a physical examination to determine the degree and type of obesity,
• (3) assessment of comorbid conditions,
• (4) determination of fitness level, and
• (5) assessment of the patient’s readiness to adopt lifestyle changes.

10. The Obesity-Focused History
• What factors contribute to the patient’s obesity?
• How is the obesity affecting the patient’s health?
• What is the patient’s level of risk from obesity?

11. • What does the patient find difficult about managing weight?
• What are the patient’s goals and expectations?
• Is the patient motivated to begin a weight management program?
• What kind of help does the patient need?

12. Factors Affecting Body Mass Index–Related Risk
• The relationship between BMI and health risk is influenced by,
• body fat distribution,
• age,
• concomitant medical illness,
• weight gain,
• aerobic fitness, and
• ethnicity.

13. •CAUSES
• Role of genes Versus Environment
• Genetic
• Obesity is commonly seen in families, and the heritability of body weight is
similar to that for height.
• Environmental
• viruses
• sleep deprivation

14. Environment
Viruses
Human Animal
others
socioeconomic
status

15. •Drugs
• medications for diabetes (insulin, sulfonylureas, thiazolidinediones);
• steroid hormones; psychotropic agents; mood stabilizers (lithium);
• antidepressants (tricyclics, monoamine oxidase inhibitors, paroxetine,
mirtazapine);
• antiepileptic drugs (valproate, gabapentin, carbamazepine).

16. • Specific Syndromes
• Cushing’s syndrome
• Hypothyroidism
• Insulinoma
• Craniopharyngioma

19. •Body Mass Index (BMI) and Waist Circumference
• Three key anthropometric measurements are important in evaluating the
degree of obesity:
• weight,
• height, and
• waist circumference (102 in men and 88 in women).

20. •Physical Fitness
Several prospective studies have demonstrated that physical fitness, measured
by a maximal treadmill exercise test, is an important predictor of all-cause
mortality rate independent of BMI and body composition.

21. Obesity-Associated Comorbid Conditions
• symptoms, risk factors, and index of suspicion.
• fasting lipid panel
• fasting blood glucose level
• blood pressure .

25. Assessing the Patient’s Readiness to Change
• patient motivation and support,
• stressful life events,
• psychiatric status,
• time availability and constraints,
• and appropriateness of goals and expectations.

26. Readiness can be viewed as the balance of two opposing forces:
• (1) motivation, or the patient’s desire to change; and
• (2) resistance, or the patient’s resistance to change.
• A helpful method to begin a readiness assessment is to use the motivational
interviewing technique of “anchoring” the patient’s interest and confidence to
change on a numerical scale.

27. TREATMENT
• THE GOAL OF THERAPY
• The primary goals of treatment are to improve obesity-related comorbid
conditions and to reduce the risk of developing future comorbidities.
• Target: 8–10% over 6 months

28. • LIFESTYLE MANAGEMENT (3–5 kg)
• Diet Therapy
• Physical Activity
• Behavioural Therapy

29. • Mediterranean diet : low-carbohydrate, low-fat
• very low-calorie diets

30. Physical Activity Therapy
moderate intensity
vigorous-intensity
Behavioral Therapy

31. •PHARMACOTHERAPY
•INDICATIONS
•Sympathomimetic adrenergic agents
•Peripherally acting agents .

32. MEDICAL
1. Phentermine/Topiramate
2. Lorcaserin
3. Bupropion and naltrexone (ContraveTM)
4. Liraglutide
5. Sibutramine
6. Orlistat (XenicalTM)
Centrally acting
agents
Peripherally acting agent

33. SURGERY
INDICATIONS
• restrictive,
• restrictive malabsorptive, and
• malabsorptive

34. Restrictive surgeries.
• Prototype - Laparoscopic adjustable gastric banding
i. LAP-BAND,
ii. REALIZE band,
Malabsorptive
• laparoscopic sleeve gastrectomy,

35. Restrictive-malabsorptive bypass procedure
• Roux-en-Y gastric bypass,
• biliopancreatic diversion, and
• biliopancreatic diversion with duodenal switch

38. Harrison’s Principles of Internal Medicine

39. Case Presentation
• A 45-year-old white woman presents with difficulty losing weight
despite her diet and exercises program.
• She feels she is a setup for T2DM, which her mother developed when
she was the patient’s age.
• She states she was never very thin, but she has been gradually gaining
weight over the last 10 years.

40. • She attributes her weight gain to decreased physical activity and stress-
induced eating.
• She has lost 15 to 20lb on several occasions on various diet programs, but
she stops following the diet when she does not see continued progress and
then she regains her weight.
• The heaviest she ever weighed was 210lb.
• Her primary physician started her on amlodipine10mg o.d for her HTN this
past year, but she is otherwise in good health.

41. • GPE,
• B.P :130/85mm Hg.
• Weight : 200lb
• Height : 5’4”.
• W.C : 38’
• HC : 40”
• She did not have any striae, bruising, or significant hirsutism.
• She had a normal cervical fat pad for her weight.
• Her abdomen was obese with weight distribution more typical of an android
body shape

42. • Laboratory findings
• FPG : 105mg/dL,
• HbA1c : 5.5%.
• Total cholesterol -198mg/dL,
• HDL -39mg/dL,
• triglycerides -200mg/dL,
• LDL - 110mg/dL.
• TSH - 1.6IU/mL,
• 24-hoururine free cortisol- 50g/24 hours.
• The patient wants to know what she can do to lose weight and reduce her risk
of developing diabetes.

43. • BMI = 34.3
• Determine the appropriate risk of metabolic syndrome
WC or waist-to-hip ratio provides the measure of central obesity
• Weight management therapy one step further beyond the initial 5% to 10%,
• To set an appropriate goal for weight to reduce the risk of metabolic
syndrome, physicians must inform patients of where they stand on the
cardiovascular disease risk curve and what they need to do to reduce the risk
to where it is more comparable to someone without significant obesity .
• This is accomplished by reducing this patient’s BMI from her initial 34 down
to 27 or 28

44. • Setting the ideal body weight range as the appropriate goal is not realistic for
someone with significant obesity.
• An over aggressive goal only leads to weight management failure.
• Many weight loss attempts fail because people do not transition well from the
weight loss phase to the weight maintenance phase.
• caloric restriction and exercises to increase their energy expenditure in order
to maintain the weight loss.

45. REFERENCES
• HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 19TH EDITION.
• WILLIAM TEXTBOOK OF ENDOCRINOLOGY 13TH EDITION
• API TEXTBOOK OF MEDICINE . EDITOR-IN-CHIEF YASH PAL MUNJ
9th EDITION
• A CASE-BASED GUIDE TO CLINICAL ENDOCRINOLOGY TERRY F.
DAVIES, MD, FRCP, FACE

46. • CROSS REFERENCES
• Management of Obesity .Anoop Misra, Lokesh Khurana
• European Guidelines for Obesity Management in Adults .Volkan Yumuk
Constantine Tsigos Martin Fried et.al
• Update on Treatment Strategies for Obesity.Holly R. Wyatt
• Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the
Metabolic Syndrome for Asian Indians and Recommendations for Physical
Activity, Medical and Surgical Management A Misra*, P Chowbey**, BM
Makkar***,
• Obesity: Current Treatment andFuture Horizons.Article in Mini
Reviews in Medicinal Chemistry · January 2017
• Identification, assessment, and management of overweight and obesity:
summary of updated NICE guidance

47. THANK YOU