obesity managment

1. OBESITY
MANAGEMENT
P R E PA R E D B Y D R . FA R I S H A K A M I
R 1 FA M I LY M E D I C I N E
S U P E R V I S E D B Y D R . H U S S E I N D U S H I
FA M I LY M E D I C I N E C O N S U L TA N T

2. OUTLINES
• MCQs
• INTRODUCTION
• MANAGEMENT
• ROLE OF FAMILY MEDICINE

3. MCQS
What is the threshold BMI for obesity?
A. 25
B. 27
C. 30
D. 35
E. 40

4. Clinical findings associated with Cushing disease
include all the following, except:
A. Weight gain
B. Menstrual irregularity
C. Depression/emotional lability
D. Excessive thirst
E. Glucose intolerance

5. Which of the following is a description of Prader–Willi
syndrome?
A. Tall, large arm span, increased risk of aortic rupture
B. Obese, hypotonic, mental retardation, hypogonadism
C. Short, obese, frontal bossing, precocious puberty
D. Normal size, mental retardation, precocious puberty
puberty

6. A 28-year-old man presents to your office to discuss
weight management. You determine his body mass
index (BMI) to be 28.2 kg/m 2. How should you classify
this patient?
A. His BMI classifies him as being underweight.
B. His BMI places him within the normal range.
C. His BMI classifies him as being overweight.
D. His BMI classifies him as obese.
E. His BMI classifies him as morbidly obese.

7. You are working with an obese patient to help him lose
weight. You are considering the use of orlistat to help the
patient with weight reduction. Which of the following is the
mechanism of action for this medication?
A. It is an appetite suppressant.
B. It blocks the uptake of both serotonin and norepinephrine in
the central nervous system.
C. It is a selective cannabinoid-1 receptor antagonist.
D. It reduces fat absorption in the GI tract.
E. It is a catecholaminergic amphetamine.

8. You are caring for an obese 30-year-old woman who would
like to consider pharmacotherapy for the treatment of her
obesity. Which of the following medications, if any,
demonstrates maintenance of weight loss once off the
medication?
A. Orlistat (Xenical)
B. Phentermine
C. Sibutramine (Meridia)
D. Rimonabant
E. None of the medications lead to maintenance of weight loss
once off the medication

9. Bariatric surgery can be considered in individuals who
have a body mass index (BMI) that exceeds
A. 20 kg/mm2
B. 30 kg/mm2
C. 35 kg/mm2
D. 40 kg/mm2
E. 45 kg/mm2

10. You are evaluating a patient whose BMI is 44 kg/m 2. You
would like the patient to consider weight-loss surgery,
specifically a Roux-en-Y gastric bypass. Which of the
following is true regarding this procedure?
A. The operative mortality rate for this procedure in the first 30
days is near 5%.
B. Complications from this procedure occur in approximately 40%
of the cases.
C. The procedure can be expected to help the patient lose up to
30% of initial body weight.
D. Nutritional deficiencies after surgery are rare.
E. This surgery is reserved for people with BMI greater than 30
kg/m 2.

11. INTRODUCTION
The medical rationale for weight loss in people with
obesity is that obesity is a disease associated with a
significant increase in mortality and many health risks,
including type 2 diabetes mellitus, hypertension,
dyslipidemia, and coronary heart disease

12. Goals of treatment — The goal of therapy is to prevent, treat, or
reverse the complications of obesity and improve quality of life
Identify candidates — Assessment of an individual's overall risk
status includes the degree of overweight , the presence of
abdominal obesity (waist circumference), and presence of CVD
risk factors (HTN,DM dyslipidemia) or other comorbidities (sleep
apnea, non-alcoholic fatty liver disease).

13. WEIGHT MANAGEMENT IN
CHILDREN

15. WEIGHT MANAGEMENT IN ADULT
Non- pharmacological
Dietary
therapy
Physical
activity
Behavior
therapy
Pharmacological
Medicatio
n
Surgery

17. TARGETS OF WEIGHT LOSS
• 5-10% weight loss is required for CVD and metabolic
risk reduction.
In patients with BMI 25-35 kg/m2
• In many individuals a greater than 15-20% weight loss
obtain a sustained improvement in comorbidity.
In patients with B MI>35 kg/m2

18. HEALTH BENEFITS OF WEIGHT
LOSS IN ADULTS
Evidence-A
• Improved lipid
profiles
Evidence-B
• Reduced
osteoarthritis-
related disability
Evidence-B
• Reduced blood
pressure

19. Evidence-B
• Improved glycemic
control
Evidence-B
• Reduction in risk of
type 2 diabetes
Evidence-B
• improved lung
function in patients
with asthma

20. NON-PHARMACOLOGICAL
Dietary interventions
Target energy deficit of 500-1000 kilo-calorie per day
(3,500 kcal/week). Attention should be given to the
dietary preferences of the individual
(National Health and Medical Research Council (NHMRC),
evidence grade A)

21. DIETARY
INTERVENTIONS
• Provide advice on dietary modification appropriate to the
patient condition to achieve and maintain a hypo-caloric intake
• Patients should be advised to:
– undertake regular self-weighing
– Reduce Consumption of “fast foods”
– Reduce intake of energy-dense foods
(Scottish Intercollegiate Guidelines Network (SIGN) , evidence
grade B)

22. DIETARY INTERVENTIONS
TYPE OF DIETS
Convention
al
Balanced low-
calorie
Low-fat
Low-
carbohydrate
Mediterranean

23. Fad diet
Unusual combinations of foods or eating
sequences
Extremely popular
Short period of time

24. PHYSICAL ACTIVITY
Physical activity in adults
• The volume of physical activity should equal to
approximately 1,800-2,500 kcal/week.
• This could be achieved through 5 sessions of 45-60
min/week, or lesser amounts of vigorous physical
activity) (Evidence-B).

25. • Build up the pace of physical activity gradually over
time.
The volume of physical exercise should be
sustainable and tailored to the individual condition
(Canadian, evidence grade A)
Sedentary
individual
should start
with 10-20 min
Brisk walking
moderate
intensity activity
Encourage non-
weight-bearing
moderate
intensity
activities
Introduce
gradually
vigorous
intensity activity

26. Exercise as a single treatment
Modest reductions
in weight
compared with no
treatment
Modestly
decreased waist
circumference and
blood pressure
Difficult to lose
weight with
exercise alone

27. Exercise plus diet
Little additional
effect upon weight
loss
Important benefits
independent of
weight loss
Increases physical
functioning and
insulin sensitivity

28. Self-monitoring
of behavior and
progress
Stimulus
control
Cognitive
restructuring
Goal setting
Problem
solving
Assertiveness
training
PSYCHOLOGICAL/BEHAVIORAL
Psychological/behavioral interventions
Psychological interventions should be part of any
weight management program (SIGN, evidence grade
A)
Slowing the
rate of eating
Reinforcement
of changes
Relapse
prevention

29. 1. Goal setting  set realistic weight loss goals, such as 0.5 to
1 kg/week, or 5 to 10 percent of baseline weight within three to six
months
2. Self monitoring  use of food diaries, activity records, and
self-weighing
3. Stimulus control  gaining control over the environmental
factors that trigger eating and eliminating or modifying the
environmental factors that facilitate overeating
4. Cognitive restructuring  Adopting positive rather than
negative self-talk (for example, if one eats a piece of cake, choosing
to exercise rather than blaming oneself)
5. Problem solving  Developing strategies to manage food intake in
difficult situations such as restaurants and parties

30. 6. Assertiveness training  Learning to say "no"
7. Slowing the rate of eating Two ways to slow down eating
include concentrating on the tastes of the food and savoring what is
being eaten by chewing more slowly. Other techniques might involve
leaving the table briefly during a meal and drinking water between
bites or just prior to the meal
8. Reinforcement of changes  Reinforcing successful
outcomes and providing small tokens for success may be beneficial
9. Relapse prevention  putting plans to reduce relapse
(coping skills, social support , avoid situations that put you in higher
risk of relapse and think of consequences
10. Other methods  social support, stress reduction, increase
physical activity and nutrition education with meal planning

31. DRUG THERAPY
Indication:
1. (BMI) ≥ 30 kg/m2 without concomitant obesity-
related risk factors or diseases
2. BMI ≥ 27 kg/m2 with concomitant obesity-
related risk factors or diseases (diabetes,
hypertension or dyslipidemia)

32. FDA APPROVED DRUGS FOR LONG-TERM
WEIGHT MANAGEMENT
1. Orlistat (Xenical)
2. Liraglutide (saxenda)
3. Phentermine/topiramate (Qsymia)
4. Naltrexone/bupropion (Contrave)

33. FDA APPROVED DRUGS FOR SHORT-
TERM WEIGHT MANAGEMENT
1. Benzphetamine
2. Diethylpropion
3. Phentermine
4. Phendimetrazine

34. ORLISTAT:
Orlistat should be considered as an adjunct to life-style
interventions in the management of weight loss:
1. Patients with BMI ≥27 kg/m2 (with comorbidities)
2. BMI ≥30 kg/m2 should be considered on an individual case
basis following assessment of risk and benefit
(Evidence-A)

35. • Mechanism of action
Reversible inhibitor of gastric and pancreatic lipases
• Dose
120 mg orally 3 times daily
with each of 3 main meals containing fat,
may be taken during or up to 1 hour after meal
skip dose if meal skipped

36. Gastrointestinal side effects common
• flatus with discharge (40%),
• oily spotting (33%),
• fecal urgency (30%)
• fecal incontinence (12%)
Caution :
• Take a daily multivitamin containing fat-soluble vitamins at
at least 2 hours before or after orlistat dose.
• Contraindicated during pregnancy

37. LIRAGLUTIDE
Glucagon-like peptide-1 receptor agonist
Dose:
0.6 mg/d increased in weekly interval to 3 mg/d
Administered subcutaneously and leads to weight loss
when used for diabetes
CI:
• Personal or family history of medullary thyroid ca
• MEN type 2 syndrome

38. RANDOMIZED CLINICAL
TRIALS WAS
PUBLISHED IN 11/2022
• Conclusion (Semaglutide effect on
weight loss is much greater than in a
trial of liraglutide in adolescents).
• These findings suggest that
subcutaneous semaglutide may
become an important option for
treatment of obesity and/or type 2
diabetes in adolescents, pending
regulatory approvals.

39. PHENTERMINE/TOPIRAMATE
Combination sympathomimetic and antiepileptic
Dose:
3.75 mg/23 mg per day for 14 days
Escalates to a maximum of 15 mg/92 mg/d
d/c if 5% weight loss is not achieved in the first 12 weeks of use
at the maximum dose
S.E:
• Constipation , dizziness and dry mouth

40. NALTREXONE/BUPROPION
Combination opioid antagonist and antidepressant.
Dose:
 single 8-mg/90-mg dose then titrated from one tablet per day to
two tablets two times per day over four weeks
CI:
• uncontrolled hypertension or seizure disorder and long-term
opioid abuse

41. METFORMIN
• It is not FDA Approved.
• In one trial of patients with obesity and the metabolic
syndrome, patients receiving metformin lost
significantly more weight (1 to 2 kg) than the placebo
group
• It would appear to be a very useful choice for
overweight individuals at high risk for diabetes.

42. GREEN TEA
• In a 2012 meta-analysis
of trials comparing green
tea preparations with a
control in overweight
adults or adults with
obesity, green tea did
not significantly affect
weight loss or
maintenance of weight
loss

43. CALCIUM
• Some epidemiological studies suggested that Calcium
supplementation might be associated with weight loss.
• RCT of 100 pre- and postmenopausal women with obesity
undergoing a weight reduction program (with or without
calcium supplementation 1000 mg/day).
Reported no significant effect of calcium on body fat or
weight loss.
• Subsequent larger trials confirmed a lack of effect of
calcium supplementation on weight

44. LIPOSUCTION
• Result in a significant reduction in fat mass and weight.
• It does not appear to improve insulin sensitivity or risk
factors for coronary heart disease.
• a study of 15 obese women (eight with normal glucose
tolerance and seven with type 2 diabetes) who underwent
metabolic evaluation before and 10 to 12 weeks after
large-volume abdominal liposuction with the following
results:
– removal of large volumes of subcutaneous abdominal
adipose tissue with liposuction does not improve insulin
sensitivity or risk factors for coronary heart disease in obese
women with or without type 2 diabetes

45. BARIATRIC SURGERY
Candidates for a bariatric surgical procedure:
1. Adults with a BMI ≥40 kg/m2 without comorbid illness
2. Adults with a BMI 35.0 to 39.9 kg/m2 with at least one
serious comorbidity
3. Adults with BMI between 30.0 to 34.9 kg/m2 AND one
of the following comorbid conditions (Uncontrolled DM
and or metabolic syndrome)

46. • Bariatric surgery is more effective than diet,
behavioral modifications, and pharmacotherapy in
the management of obesity, and it leads to
improvement in numerous obesity-related
comorbidities.
1. Roux-en-Y Gastric bypass
2. Sleeve gastrectomy
3. Gastric banding

49. • The most weight loss occurs with gastric bypass, followed by
sleeve gastrectomy and gastric banding
• Bariatric surgery is relatively safe, with an overall 30-day
mortality rate of 0.08%, a complication rate of 17%, and a
reoperation rate of 7%
• Bariatric procedures have been proven effective in reducing
many obesity-related conditions
• Expected weight loss can range from 37% to 79% of excess
weight at 2 years after surgery depending on the procedure.
Patients must commit to lifelong adherence to dietary
supplementation and monitoring of vitamin levels, because
nutritional deficiencies are common.

50. ROLE OF FAMILY PHYSICIAN
• Health education
• Promotion of diet and exercise (counselling)
• Screening & prevention
• Evaluation of weight and obese
• Excluding other causes
• Management
• Refer when needed

51. WHEN TO REFER
• The underlying causes of overweight and obesity need to
be assessed
• Children with serious obesity related morbidity
• The person has complex disease states and/or needs that
cannot be managed adequately in either primary or
secondary care
• Dietitian referral
• Surgery is being considered (Bariatric)

55. Thanks