Obesity Done by: Supervisor Abdulaziz S. Al-Mehlisi Fahad I. Abuguyan Wael M.Al-Subaiyel Supervisor Dr. Al-Naami

Definition: By WHO: Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight. BMI = weight (kg) / [ height sq. (m2) ]

Risk of Co-morbidities BMI Classification: Risk of Co-morbidities BMI category < 18.5 Underweight Average 18.5 – 24.9 Normal Increased 25.0 – 29.9 Overweight Moderate 30.0 – 34.9 Obese I Severe 35.0 – 39.9 Obese II Very severe ≥ 40 Obese III

Prevalence: WHO’s latest projections indicate that globally in 2005: An estimated 1.6 billion adults worldwide are overweight (BMI>25) and 400 million are obese (BMI>30), and potentially as many as 20 million children are overweight. WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese.

A study had been done in KSA and showed: The prevalence of overweight among men was 30.7% and among women was 28.4%. While prevalence of obesity was 14.2% in males and 23.6% in females .

Etiologies: The fundamental cause of obesity and overweight is an energy imbalance between calories consumed on one hand, and calories expended on the other. Burning Intake

Etiologies: Life style & physical inactivity. Diet & eating patterns. Smoking. Age. Sex. Race.

Cont. Medical causes: Hypothyroidism. Cushing’s syndrome. Polycystic ovarian syndrome. Hypothalamic insufficiency.

Cont. Medications: Cortisol and other glucocorticoids. Sulfonylureas. Antidepressants. Antipsychotics, e.g. MAOIs, Risperidone. Oral contraceptives. Insulin.

Cont. Familial Genetic: Prader-Willi syndrome. Laurence-Moon-Biedl (Bardet-Biedl) syndrome. Down syndrome . Turner syndrome. Leptin deficiency or resistance to leptin action.

Cont. Psychatric causes: Major depression. Binge eating disorders.

Co-morbidities: Medical: Type II diabetes. Insulin resistance, hyperinsulinaemia. Dyslipidaemia. Hypertension. Respiratory disease: Sleep apnea. Hypoventilation syndrome.

Cont. Cardiac and vascular diseases Cerebrovascular disease. Congestive heart failure . Coronary heart disease . Thromboembolic disease.

Co-morbidities Cont. Digestive system abnormalities Gall bladder disease. Hepatic disease, fatty liver. GERD. Reproductive system abnormalities: Infertility. Nervous system: Pseudotumor cerebri. Musculoskeletal: Osteoarthritis, Gout. Cancers: Breast, endometrial, cervix, ovary, colon, gallbladder, kidney, prostate.

Co-morbidities Surgical: Perioperative risks: Varicose veins. DVT. Anesthesia. Wound complications. Infections. Incisional hernias. Varicose veins. DVT. Carpal Tunnel Syndrome. Fibroadenoma of the breast. Uterine fibroma. Stress urinary incontinence.

Cont. Psychological complications: e.g. Depression. Social complications.

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MEDICAL ASSESSMENT Some patients are “healthy” without any recognized illnesses. They are unhappy, so they seek medical attention in an effort to lose weight, improve their quality of life and help their self-image. Other patients are already being treated for one or more of the comorbid conditions arising from obesity. The medical assessment includes a complete history, physical examination and lab investigations.

History Age of onset of obesity. The pattern of weight gain and loss since puberty. Diet and exercise habits. Smoking or alcohol consumption habits. Life events (lifestyle changes) such as beginning or graduating college, marriage, pregnancy, illness, relationship problems, job change or a family death. Family history: Of obesity (degree of relatives). Coronary artery disease. Drugs history: Present and previous medications for any problem. Past or present use of weight loss medications.

Ask about Endocrine disorders such as Hypothyroidism, Cushing’s syndrome and hypothalamic Tumors or damage. Psychological profile assessment. History of physical or mental abuse. Attention for specific condition. These include PCOS, insulin resistance, hypothyroidism, and OSA.

Physical examination

Physical examination Create an accessible and comfortable office environment. Provide sturdy, armless chairs and high, firm sofas in waiting rooms. Provide sturdy, wide examination tables that are bolted to the floor to prevent tipping. Provide a sturdy stool or step with handles to help patients get on the examination table. Provide extra large examination gowns. Install a split lavatory seat and provide a specimen collector with a handle.

Use medical equipment that can accurately assess patients who are obese. Use large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm. Have extra long phlebotomy needles, tourniquets, and large vaginal speculae on hand. Have a weight scale with adequate capacity (greater than 350 pounds) for obese patients

Reduce patient fears about weight. Weigh patients only when medically appropriate. Weigh patients in a private area. Record weight without comments. Ask patients if they wish to discuss their weight or health. Avoid using the term obesity. Your patients may be more comfortable with terms such as "difficulties with weight" or "being overweight." You may wish to ask your patients what terms they prefer when discussing their weight.

Physical examination should target signs or conditions that predispose to or are complications of obesity Mild hirsutism in women PCOS. Large neck size Sleep apnea. Thyroid tenderness or goiter Hypothyroidism. Slowed reflexes Hypothyroidism. Proximal muscle weakness Cushing’s syndrome, Hypothyroidism. Skin striae Cushing syndrome’s, steroid use. Dry or coarse skin and hair hypothyroidism.

Investigation Fasting glucose. CBC & Hb. Lipid profile (Total cholesterol, triglycerides, LDL and HDL). Hormones: TFT. Cortisol. Testosterone. U/E. Abdominal U/S.

How would you diagnose obesity?

Diagnosis of obesity and evaluation of health status through three key measures (1) Body mass index (BMI). (2) Waist circumference. (3) Risk factors for diseases and conditions associated with obesity.

The first step Determine your patients’ BMI using weight and height measurement BMI provides a measure of total body fat based on height and weight that applies to both adult men and women BMI is calculated as weight in kilograms (kg) divided by the square of height in meters (m2). BMI = weight (kg) height squared (m2)

Risk Of illness Obesity Class BMI (kg/m2) Weight classification Increased _ 18.5 < Underweight Normal 18.5 to 24.9 Ideal weight 25.0 to 29.9 Overweight High/very high I II 30.0 to 34.9 35.0 to 39.9 (mild) (moderate) Extremely high III 40 > Extreme obesity (severe) Obesity is an excess of total body fat Overweight is an excess of body weight

The second step Measure waist circumference. Important to note that waist circumference is not measured at the level of the umbilicus (the “natural” waist), but at the level of the iliac crest.

To measure your patients’ waist circumference: 1 To measure your patients’ waist circumference: 1. Locate the upper hip bone and the top of the right iliac crest. 2. Place a measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. 3. Ensure that the tape is snug, but does not compress the skin, and is parallel to the floor. 4. Read the measurement at the end of a normal expiration of breath.

It is important to know your patients’ waist circumference because the health risks of overweight and obesity are independently associatedwith excess abdominal fat.5,6 Excess abdominal fat is clinicallydefined as a waist circumference of >40 inches (>102 cm) in men and of>35 inches (>88 cm) in women Population studies have shown that people with excess abdominal fat have an excess burden of impaired health and increased cardiovascular risk.

Obese individuals with excess fat deposited around the abdomen (‘appleshaped’) are more likely than those who have fat deposited on the hips and buttocks (‘pearshaped’) to develop health problems.

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 and >0.85 in women.

The Third step Review your patients’ medical, social and family history for current and potential obesity-related symptoms and diseases.

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Treatment: Behavioral. Diet. Pharmacological treatment. Exercise. Intra-gastric balloon. Surgical treatment.

Behavioral: Identify the circumstances that trigger eating. Grocery shopping with a pre planned list. Reduce temptations (no food in sight). Do nothing else while eating (watch TV or read magazines). Eat slowly.

Diet: Balanced, low-calorie diets : Very low-calorie diets (VLCDs): Energy deficit ranging from 500 to 1000 kcal/day. Low fat diet. Helps losing 0.5 kg/week that lead to 10% weight loss over 6 months. Very low-calorie diets (VLCDs): High protein diet with less fat & no carbohydrates. Energy is less than 800 kcal/day. Helps losing 1 – 1.5 kg/week. Low-fat diets. Low-carbohydrate diets. Midlevel diets (e.g. Zone diet in which the 3 major macronutrients [fat, carbohydrate, protein] are eaten in similar proportions of 30-40%)

Exercise: 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. Benefits: Helps build muscle mass. Increases metabolic activity of the whole-body mass. Reduces body-fat proportions. Decreases the amount of compensatory muscle mass loss that is typical in the setting of weight loss.

Pharmacological: Lasts for several years. Weight will increase again after cessation of the drugs in most cases. If no significant weight reduction in at least 3 months, stop the drug (5% of baseline weight).

:Orlistat Lipase inhibitor. LDL cholesterol reduction. It’s effects and side effects increase with higher fat content in the food. The ONLY FDA approved drug to decrease food absorption. Common adverse effects(>1/10 users): Fatty or oily stools. Faecal urgency. Oily faecal spotting.

:Sibutramine Centrally acting appetite suppressant. Serotonin & norepinephrine uptake inhibitor Common adverse effects: Insomnia. Nausea. Dry. Constipation. Not recommended for patients with CVS diseases. Long term 5% to 10% weight loss.

:Intra-gastric Balloon Short to medium term solution. Inserted endoscopically. Complications: Balloon deflation Migration Erosion Obstruction

Bariatric Surgery: Methods: Restrictive diseases: AGB (Adjustable gastric banding). VBG (Vertical banded gastroplasty). Sleeve gastrectomy. Malabsorptive procedures: Roux-en-Y gastric bypass (RGB). Biliopancreatic diversion (BPD).

Criteria: Age below 60 years. BMI at least 35-40 kg/m2 An efficient conservative treatment strategy has been tried. The patient is cooperative. There’s no abuse of alcohol or drugs.

American Society for Bariatric Surgery (ASBS) guidelines: A BMI of 40 or greater (MORBID OBESITY) or A BMI of 35 or greater with “significant co-morbidities” AND Can show that dietary attempts at weight control have been ineffective

Contraindications: Untreated glandular diseases: Hypothyroidism Inflammatory diseases of the gastrointestinal tract: ulcers, esophagitis, Crohn’s disease. poor surgical candidates in general: severe cardiopulmonary diseases. Dependency on alcohol or drugs. People with learning disabilities or emotionally unstable people.

Post-operative Instructions : 1st 4 wks: liquid diet 2nd 4 wks: soft diet Gradual return to normal diet Eat slowly, small amounts at a time Avoid eating sugary food

Adjustable Gastric Banding (LAP-Band):

Benefits: 50% to 60% loss of excess body weight. Performed in an outpatient setting. Exercise adds 10% more of loss. Reduce obesity and related comorbidities. Lower mortality rate: Only 1 in 2000 versus 1 in 200 for Roux-en-Y gastric bypass surgery. Fully reversible. No cutting or stapling of the stomach. Short hospital stay. Quick recovery. Adjustable without further surgery. No malabsorption issues. Fewer life-threatening complications.

Complications: Band- and port- specific: Band slippage/ Pouch dilatation. Esophageal dilatation/ dysmotility. Erosion of the band into the gastric lumen. Port site pain. Port displacement. Infection of the fluid within the band.

Digestive Nausea, vomiting. GER. Stoma obstruction . Constipation. Dysphagia. Diarrhoea.

Body as a whole Abdominal pain Asthenia Infection Fever Hernia Pain Chest pain Incisional infection

Roux-en-Y Gastric Bypass: Most commonly employed gastric bypass technique. Least likely to result in nutritional difficulties.

Benefits: Rapid weight loss. 60% to 70% loss of excess body weight. Exercise adds 10% more of loss.

Complications: Anastomotic leakage. Anastomotic stricture. Dumping syndrome. Nutritional deficincies. Gallstones: due to rapid loss of weight. Complications of abdominal surgery: Infection, hernia, obstruction… etc.

Vertical Banded Gastroplasty

Biliopancreatic Diversion

BPD with Duodenal Switch

Sleeve Gastrectomy

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