1. O BESITY & I T ’ S M ANAGEMENT By : Zaid Alturki, Yazeed Almalki and Muhammed AbaAlkhail Supervised by : Dr. AlNaami

2. Contents:  Definition  Epidemiology  Etiology  Co-morbidity.  Assessment (Hx, Ex, Invest.)  Treatment.

3. D EFINITION  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.

4. E PIDEMIOLOGY  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.

6.  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.

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

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

9.  Hypothyroidism.  Cushing’s syndrome.  Polycystic ovarian syndrome.  Hypothalamic insufficiency.  pancreatic insulinoma. Medical causes:

10. Medications:  Cortisol and other glucocorticoids.  Sulfonylurea.  Antidepressants.  Antipsychotics, e.g. MAOIs, Risperidone.  Oral contraceptives.  Insulin. Psychatric causes:  Major depression.  Binge eating disorders

11. C O - 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.

12.  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.

13.  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.

14. O THERS..  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

15. T HE CLINICAL ASSESMENT OF AN OBESE S UBJECT  History.  Physical Examination.  Investigation.

16. H ISTORY

17. O BESITY 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.

18.  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 patient’s current diet.  Review of the systems.  GERD

19. Examination

20. E XAMINATION :  Vital signs.  General examination.  Thyroid.  Signs of Organo Megally. e.g. liver (liver span )  Heart and lung sounds.

21.  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  Cushing’s syndrome, Hypothyroidism.  Skin striae  Cushing’s syndrome, steroid use. Physical examination should target signs or conditions that predispose to or are complications of obesity!!

22. A SSESSMENT OF RISK STATUS  BMI.  Waist circumference.  Waist to hip ratio.  Presence of co-morbidities.  Body composition.

23. BMI BMI = weight (kg) / [ height (m) ]² BMI provides a measure based on height and weight that applies to both adult men and women.

24. BMI RangeWeight Classification Risk of Illness Less than 18.5UnderweightIncreased 18.5 – 24.9Ideal weightNormal 25 – 29.9OverweightIncreased 30 – 39.9ObeseHigh 40 – 50Morbid obeseVery high 50 Or greaterSuper obeseExtremely high

25. 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 * >40 inches (>102 cm) in men *of>35 inches (>88 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.

26. 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: *>( 0.95 )1.0 in men. *>( 0.85 )in women.

27. Investigations Why ??

28. L ABORATORY D ATA : 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.

29. T REATMENT OF OBESITY

30. T REATMENT 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.

31. N ATIONAL INSTITUTES OF HEALTH GUIDELINES FOR TREATMENT OF OVERWEIGHT AND OBESITY : Surgical Therapy Endoscpic Balloon Pharma Therapy Behavior mod. BMI range No Yes*25-26.9 No Yes* 27-29.9 NoYes 30-34.9 NoYes 35-39.9 YesYes*Yes 40 or more co morbidities present *

32. Non - Surgical Intervention

33. B EHAVIOR 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.

34. D IET :  Balanced, low-calorie diets.  Very low-calorie diets. ( No carbohydrates)  Low-fat diets.  Low-carbohydrate diets.  Midlevel diets.

35. E XERCISE :  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.

36. P HARMACOTHERAPY :  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.

37. Sibutramine * Appetite suppressant * Serotonin & norepinephrine uptake inhibition. * Side effect: Tachycardia, Hypertension & Insomnia. * weight loss  5%to 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.

38. I NTRA - GASTRIC B ALLOON

41. space-occupying volume device, Inserted endoscopically. Done under GA. The ballon filled with approximately 500cc of saline fluid. It’s an out-patient procedure. Short to medium term solution.

42. Contraindications :  A BMI< 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.

43. S URGICAL INTERVENTION

44.  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 Criteria

45. Adjustable gastric banding

46. 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.

47.  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. Advantages

48. 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.

49. Gastric bypass procedure

51.  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.

52. 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.

53. Sleeve Gastrectomy

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

56. 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.

57. 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.

58. T HANK YOU