Problem of obesity

1. Secrets of Weight Loss
• Dr. D.Gunasingh MD,DCH,
• Dean & Principal/Professor of
Pediatrics
• Arunai Medical College & Hospital
• Retd Professor of Pediatrics,
• ICH & HC
• Secretary, IAP- Tiruvannamalai
district branch

2. Prayer…
• I don’t want to view
healthy eating and
exercise as a punishment.
I want to be a good
steward of this body, so
empower me to reach for
foods that will nourish my
body and movement that
will nurture it…and to
genuinely enjoy them as
ways to bring glory to
You!

3. • Globally, more than 1.9
billion adults are
overweight and 650
million are obese.
• In India, more than 135
million individuals were
affected by obesity.

4. Definition
• The term "obesity" refers
to an excess of fat.
However, the methods
used to directly measure
body fat are not available
in daily practice. For this
reason, The body mass
index (BMI)which
provides an estimate of
body fat that is
sufficiently accurate for
clinical purposes.

5. World Health Organization.
Classification of body mass index
• Underweight – BMI <18.5 kg/m2
• Normal weight – BMI ≥18.5 to 24.9 kg/m2
• Overweight – BMI ≥25 to 29.9 kg/m2
• Obesity – BMI ≥30 kg/m2
• Obesity class I – BMI 30 to 34.9 kg/m2
• Obesity class II – BMI 35 to 39.9 kg/m2
• Obesity class III – BMI ≥40 kg/m2 (also referred to as severe,
extreme, or massive obesity)
• BMI classifications are based upon risk of cardiovascular disease.
For Asians define overweight as a BMI between 23 and 24.9 kg/m2
and obesity as a BMI >25 kg/m2.
• BMI: body mass index; NIH: National Institutes of Health; WHO:

6. Waist circumference
• ≥ 102 cm for men and
• ≥ 88 cm for women indicative of increased
cardio metabolic risk . Waist circumference
measurement is unnecessary in patients with BMI
≥35 kg/m2 as almost all individuals with this BMI
also have an abnormal waist circumference and
are already at a high risk from their adiposity.
• A waist circumference ≥31 in (80 cm) in Asian
females and ≥35 in (90 cm) in Asian males is
considered abnormal.

9. Birth to 5 years(WHO)

10. Classification in children Adolescents
• for children between 2 and 18 years of age
• Normal weight – BMI between the 5th and 85th
percentile for age and sex.
• Overweight – BMI between the 85th and 95th
percentile for age and sex.
• Obese – BMI ≥95th percentile for age and sex.
• Severe obesity –
• BMI ≥120 per cent of the 95th percentile,
• OR a BMI ≥35.
• OR approximately the 99th percentile.

11. Causes
Obesity
Genetic
drugs
metabolic
Socio
economic
environmental
psychological
hormonal

12. Environmental
• Sedentary lifestyle
• Caloric intake that is greater than needs.
• Environmental factors explain only part of
obesity risk, but are important targets for
treatment because they are potentially
modifiable

18. • Increasing trends in high glycemic index of foods.
• Sugar-containing beverages.
• Larger portion sizes for prepared foods.
• Fast food service .
• Diminishing family presence at meals.
• Decreasing structured physical activity.
• Shortened sleep duration
• Lack place for physical activity

19. • Television viewing
• Video games
• Medications
• Toxins :such as
bisphenol A (BPA).

22. Night-eating syndrome
 Consumption of at
least 25 per cent (and
usually more than 50
per cent) of daily energy
between the evening
meal and the next
morning .
 It is a well known
pattern of disturbed
eating in the obese

26. Benefits
of
weight
loss

27. Mechanism of Obesity

28. Four Types of Input to the Hypothalamus
Hypothalamus contains HUNGER and SATIETY centre
Paraventricular, Dorsomedial, and Arcuate nuclei of the
Hypothalamus also play a major role
• Neural input from the cerebral cortex
• Neural input from the limbic system
• Peptide hormones from the GI tract
• Adipocytokines from adipose tissue

30. HUNGER AND SATIETY
CENTRE
FEEDING SATIETY
CENTRE CENTRE
LATERAL NUCLEI
OF
HYPOTHALAMUS
VENTROMEDIAL
NUCLEI OF
HYOTHALAMUS
INHIBITION
FOOD INTAKE

31. Hormonal control

33. Management
• While it can be challenging
to make the lifestyle
changes needed to lose
weight and improve your
health, if you set goals and
commit to them, you can be
successful

34. Warning…
• Aware about complications …
• Low blood sugar (hypoglycemia) – if taking
certain glucose lowering medications
• Low-carb flu
• Cravings
• Lack of energy initially
• Bad breath
• Change in bowel habits
• Micro nutrient deficiency…

40. Multidisciplinary care
Family & Community Empathy
Physicians address medical issues
Dieticians help patients gradually learn to eat less
and incorporate healthier foods into
their diets.
Exercise specialists teach practical ways to integrate
physical activity into day-to-day life
Behavioural therapists
change;
help patients mentally prepare for the
process of lifestyle change and address
barriers to
Nurses can help patients feel comfortable in a
medical setting and assist in the
management of medical complications

41. Investigations

42. Low calorie diet

45. • The practice of eating to about 80 percent full.
• Eating to 80 percent full means you stop eating when
you’re just satisfied. Not still hungry, but not stuffed or
even completely full. It’s about feeling content, with a
little room left over.

46. Barriers
• Cravings are one of the most difficult
obstacles to overcome when trying to lose
weight.
• Cravings nearly invariably lead to high-calorie,
high-fat, high-sugar, high-sodium, low-
nutrition foods.

47. Controling the hunger
• Good sleep
• Short intermittent excise
• Reducing the stress
• Protein
• Nuts/Coconut
• Drink lot of water
• Vegetables/
• Soup/Lemon juice with
salt
• No to processed food
• Eat slowly

48. Basic principle
• What to eat?
• When to eat?
• How to eat?

49. Initial treatment
 Combination of diet, exercise, and behavioural
modification.
 All patients who would benefit from weight
loss should receive counselling on diet,
exercise, and goals for weight loss.
The behavioural modification component
facilitates adherence to diet and exercise
regimens, and includes regular self-monitoring
of food intake, physical activity, and weight.

50. First step… Stop gaining weight…

51. Dietary therapy
Tailoring a diet that reduces energy intake below
energy expenditure
• Many types of diets produce modest weight
loss.
• Balanced High protein, low-calorie, low-
fat/low-calorie, moderate-fat/low-calorie, or
low-carbohydrate diets, Mediterranean diet.
Dietary adherence is an important predictor of
weight loss, regardless of the type of diet
chosen

53. Balanced Diet
• A balanced diet should provide around 50-
60% of total calories from carbohydrates,
preferably from complex carbohydrates,
about 10-15% from proteins and 20-30%
from both visible and invisible fat.
• dietary fibre, antioxidants and
phytochemicals which bestow positive
health benefits.
• Antioxidants such as vitamins C and E,
beta-carotene, riboflavin and selenium
protect the human body from free radical
damage.
• Other phytochemicals such as
polyphenols, flavones, etc., also afford
protection against oxidant damage.
• Spices like turmeric, ginger, garlic, cumin
and cloves are rich in antioxidants.

55. Blue zone diet…

56. Eat to loose weight
• Metabolic studies using
state-of-the-art techniques
have concluded that most
adults will lose weight
when fed <1000 kcal/day.
• Thus, even subjects who
are concerned that they are
"metabolically resistant" to
weight loss will lose weight
if they comply with a diet
of 800 to 1200

57. Management
E-estimating energy expenditure
WHO Criteria
Step 1: Estimate basal metabolic rate
Men 18 to 30 years = (0.0630 x actual weight in kg + 2.8957) x 240 kcal/day
Men 31 to 60 years = (0.0484 x actual weight in kg + 3.6534) x 240 kcal/day
Women 18 to 30 years = (0.0621 x actual weight in kg + 2.0357) x 240 kcal/day
Women 31 to 60 years = (0.0342 x actual weight in kg + 3.5377) x 240 kcal/day
Step 2: Determine activity factor
Activity level Activity factor
Low (sedentary) 1.3
Intermediate (some regular exercise) 1.5
High (regular activity or demanding job) 1.7
Step 3: Estimate total energy expenditure
Total energy expenditure = Basal metabolic rate x activity factor

58. How much calorie to loose?
• Approximately 22 kcal/kg is required to maintain a
kilogram of body weight in a normal-weight
adult.
• The expected or calculated energy expenditure
for a woman weighing 100 kg is approximately
2200 kcal/day. The variability of ±20 per cent could
give energy needs as high as2620 kcal/day or as low
as 1860 kcal/day.
An average deficit of 500 kcal/day should result in an
• initial weight loss of approximately 0.5 kg/week (1
lb./week).

59. Low Calorie diet

60. The ketogenic diet
• is a very low-carb, high-
fat diet that shares many
similarities with the Atkins and
low-carb diets. It involves
drastically reducing carbohydrate
intake and replacing it with fat.
This reduction in carbs puts your
body into a metabolic state
called ketosis. ketogenic diet may
help to control hunger and may
improve fat oxidative metabolism
and therefore reduce body
weight.

62. How it works
• A satiating effect with decreased food cravings
due to the high-fat content of the diet.
• A decrease in appetite-stimulating hormones,
such ghrelin, when eating restricted amounts
of carbohydrate.
• A direct hunger-reducing role of ketone
bodies.

65. Paleo diet
• is a dietary plan based on
foods similar to what
might have been eaten
during the Palaeolithic
era, which dates from
approximately 2.5 million
to 10,000 years ago.
• A paleo diet typically
includes lean meats, fish,
fruits, vegetables, nuts
and seeds — foods that in
the past could be obtained
by hunting and gathering.

66. Paleo diet
What to eat
• Fruits
• Vegetables
• Nuts and seeds
• Lean meats, especially grass-
fed animals or wild game
• Fish, especially those rich in
omega-3 fatty acids, such as
salmon, mackerel and albacore
tuna
• Oils from fruits and nuts, such
as olive oil or walnut oil
What to avoid
• Grains, such as Rice, wheat,
oats and barley
• Legumes, such as beans,
lentils, peanuts and peas
• Dairy products
• Refined sugar
• Salt
• Potatoes
• Highly processed foods in
general
Calorie counting and portion sizes are not
emphasized.

67. Benefits of Paleo
• More weight loss
• Improved glucose tolerance
• Better blood pressure
control
• Lower triglycerides
• Better appetite
management

68. Paleo diet-How it works
 Increased satiety-- may facilitate a reduction
in energy consumption under ad libitum
dietary conditions;
 Increased thermogenesis-- which also
influences satiety and augments energy
expenditure

70. Autophagy
• A process by which a cell
breaks down and
destroys old, damaged,
or abnormal proteins and
other substances in its
cytoplasm The
breakdown products are
then recycled for
important cell functions,
especially during periods
of stress or starvation.

71. Intermittent fasting-How it works
• Metabolic Switching :
• After hours without food, the
body exhausts its sugar
stores and starts burning fat.

73. Intermittent fasting and weight loss: Systematic review.
Welton S, Minty R, O'Driscoll T, Willms H, Poirier D, Madden
S, Kelly L.Can Fam Physician. 2020 Feb;66(2):117-
125.PMID: 32060194
• Conclusion: Intermittent fasting shows
promise for the treatment of obesity. To
date, the studies have been small and of
short duration. Longer-term research is
needed to understand the sustainable role
it can play in weight loss.

74. The soccer team went nine days
without food

76. Exercise
• Although less potent than
dietary restriction in
promoting weight loss,
increasing energy
expenditure through physical
activity is a strong predictor
of weight loss maintenance.
• Physical activity should be
performed for approximately
30 minutes or more, five to
seven days a week, to
prevent weight gain and to
improve cardiovascular
health. The physical activity
should be gradually
increased over time as
tolerated.

81. Behaviour modification
• Behaviour modification or behaviour therapy is
one cornerstone in the treatment for obesity.
• The goal of behavioural therapy is to help
patients make long-term changes in their eating
behaviour by modifying and monitoring their
food intake, modifying their physical activity,
and controlling cues and stimuli in the
environment that trigger eating

82. Pharmacotherapy
• For most patients, liraglutide is preferred first-
line pharmacotherapy. If there is an
inadequate response to liraglutide or it is not
tolerated, and treatment with a different drug
is considered, we switch to orlistat, although
side effects often limit its use. Phentermine
(as a single agent) is also an effective,
inexpensive, and widely prescribed option

83. Pancreatic lipase inhibitor approved for long-term use
Orlistat 120 mg 3 times daily
with fat-containing
meals.
A reduced dose of 60
mg¶ is an option for
patients who do not
tolerate 120 mg.
Cramps, flatulence, faecal
incontinence, oily spotting,
absorption of fat-soluble
vitamins may be reduced
Combination of phentermine-topiramate approved for long-term
use
Phenterm
ine-
topiramat
e
Initial: 3.75 mg
phentermine/23 mg
topiramate once daily in
the morning for 14 days.
Dry mouth, taste disturbance,
constipation, paraesthesias,
depression, anxiety, elevated
heart rate, cognitive
disturbances, insomnia

84. Combination of bupropion-naltrexone approved for long-term use
Bupropion-
naltrexone
Week 1: 1 tablet (8 mg naltrexone/90 mg bupropion)
once daily.Week 2: 1 tablet twice daily.Week 3: 2
tablets in morning and one tablet in evening.Week
4: 2 tablets twice daily.
Maximum daily dose: 4 tablets (32 mg
naltrexone/360 mg bupropion);
Contraindicated
in patients with
uncontrolled
hypertension,
seizure disorder,
eating disorder,.
GLP-1 agonist approved for long-term use
Liraglutide
Initial: 0.6 mg subcutaneously daily.
Increase at weekly intervals (1.2, 1.8, 2.4 mg)
until recommended dose of 3 mg daily; re-
evaluate after 16 weeks.
◊
Monitor blood glucose in
diabetic patients and
adjust co-administered
sulfonylureas (eg,
reduce dose by 50
percent) and other anti-
diabetic medications as
needed to prevent
potentially severe
hypoglycemia.

85. Benzphetamine
Initial: 25 mg once daily; may titrate
up to 25 to 50 mg one to 3 times
daily.
Applies to all sympathomimetic agents:
Due to their side effects and potential for
abuse, we suggest not prescribing
sympathomimetics for weight loss.
If prescribed, limit to short-term (≤12 weeks)
use.
Adverse effects include increase in heart rate,
blood pressure, insomnia, dry mouth,
constipation, nervousness.
Abuse potential due to amphetamine-like
effects.
May counteract effect of blood pressure
medications.
Avoid in patients with heart disease, poorly
controlled hypertension, pulmonary
hypertension, or history of addiction or drug
abuse.
Contraindicated in patients with a history of
CVD, hyperthyroidism, glaucoma, MAO
inhibitor-therapy, agitated states, pregnancy,
or breast feeding.
Maximum dose: 50 mg 3 times daily.
Diethylpropion
Immediate release: 25 mg 3 times
daily before meals.
Controlled release: 75 mg every
morning.
Phentermine
Immediate release: 15 to 37.5 mg
daily or divided twice daily.
Orally disintegrating tablet (ODT): 15
to 37.5 mg once daily in the
morning.
Phendimetrazine
Immediate release: 17.5 to 35 mg 2
or 3 times daily, 1 hour before
meals.
Maximum dose: 70 mg 3 times daily.
Sustained release: 105 mg daily in
the morning.

86. Devices
• There are several types of devices approved
for use in the treatment of obesity.
• The use of one of these devices may be
considered for use in those patients in whom
medications are ineffective or not tolerated,
for those patients who are unable or unwilling
to undergo bariatric surgery, or as a bridging
therapy prior to bariatric surgery.

87. Laparoscopic adjustable gastric
banding
• The system is used for weight loss
in severe obesity in those who
have been obese for at
• least five years and for whom
nonsurgical weight loss methods
have not been successful.
• They must be willing to make
major changes in their eating
habits and lifestyle. Patients must
• have a BMI of >40 kg/m , BMI >35
kg/m with one or more weight-
related complications, or
• be at least 100 pounds over their
estimated ideal weight. LAGB is
discussed in detail
• elsewhere.

88. Electrical stimulation (vagal blockade)
systems –
• These systems deliver
small electrical pulses to
block transmission of nerve
signals in the vagus nerve

89. Intragastric balloon systems –
• With these techniques,
saline filled balloons are
placed in
• the stomach to take up
space and produce a
sensation of satiety.

90. Gastric emptying (aspiration) systems
• – A surgically placed
gastrostomy tube is used
to
• drain a portion of the
stomach contents after
every meal, decreasing
the calories absorbed

91. Hydrogels –
• Considered medical
devices, hydrogels are
orally administered
products, taken
• twice daily before
meals, which expand in
the stomach and
intestines to create a
sensation of
• satiety.

92. THERAPIES NOT RECOMMENDED
• Liposuction
• Weight loss from
liposuction appears to be
of a short term nature
with little long term
effect.[2] After a few
months fat typically
returns and
redistributes.[2] Liposuctio
n does not
help obesity related
metabolic disorders
like insulin resistance.

93. Dietary supplements –not
recommended
Acupuncture

95. Anant Ambani shocks world with
drastic 108kg weight loss

97. MAINTENANCE OF WEIGHT LOSS
 Frequent self weighing,
 Larger initial weight loss (> 2
kg in four weeks),
 Frequent and regular
attendance at a weight loss
program,
 Belief that their weight can
be controlled,
 Consumption of a reduced
calorie(eg, 1400 kcal/day)
low-calorie diet, regular
physical activity, and
participation in a lifestyle
intervention program

98. Follow up
No matter which diet or dietary pattern is chosen,
continued surveillance by both clinician and
patient are essential for treatment success.
 Return visits with the clinician, dietician, or
behaviourist should be scheduled at regular
intervals to assess barriers, discuss next steps, and
offer encouragement.
If weight loss is less than 5 per cent in the first six
months, something else should
be tried.

99. Message
• Never go to any
parties/restaurant
• Never eat processed
food/junk food
• Start looking into label on
the food
• Avoid going to super market
• Never eat in front of
media/reading .Eat only in
the dining table
• Early to sleep…early to wake
up
• Never forced feed

100. Message
• Buy lot of vegetable/fruits.
Avoid fruits/tuber with high
calories
• Avoid fried/baked items
completely. Eat low energy-
density food.
• Eat based on your hungry.
Eat slowly .Use small plates
• Today is right day. Get up
start walking .Never sit
continuously for more than
20-30 minutes

101. Secrets
• Accept the reality. You
are having chronic
disease that has no cure
but with your
cooperation it can be
easily managed.
• The diet restriction &
exercise should be
followed life long. You
will have healthy happy
life.

102. Thank you!!!