1. WEIGHT GAIN /OBESITY By Dr. Cuong Ngo-Minh Back to Basics April 14th 2010

2. LMCC Objectives 1 To clinically assess obesity by determining body mass index, waist to hip ratio, morbidity and mortality risk To clinically assess obesity by determining body mass index, waist to hip ratio, morbidity and mortality risk To differentiate exogenous from endogenous etiologies of obesity To differentiate exogenous from endogenous etiologies of obesity To make a differential diagnosis of causes of weight gain/obesity. To make a differential diagnosis of causes of weight gain/obesity. To create an individualized plan of management with modalities of treatment of the obesity client. Discuss pros and cons of anorectic drugs and surgery treatments. Select clients appropriately for neuro-endocrine investigation/referral. To create an individualized plan of management with modalities of treatment of the obesity client. Discuss pros and cons of anorectic drugs and surgery treatments. Select clients appropriately for neuro-endocrine investigation/referral.

3. Definitions 1 Obesity: Formally define as Body Mass Index (BMI) of 30 or more. Obesity: Formally define as Body Mass Index (BMI) of 30 or more. Morbid obesity: BMI of 40 or more Overweight: BMI from 25-29.9 kg/m2 Morbid obesity: BMI of 40 or more Overweight: BMI from 25-29.9 kg/m2 BMI= Weigt (in kg)/ height in square meters (m)2. BMI= Weigt (in kg)/ height in square meters (m)2. Risk: Every increase of 5 in BMI higher than 21 is associated with a corresponding 10% increase in risk of mortality. Risk: Every increase of 5 in BMI higher than 21 is associated with a corresponding 10% increase in risk of mortality. NB. Interpret BMI and waist circumference according to ethnic background. Lower cut-off of BMI of 27 or more in Asian population. Some well-muscled individuals can have high BMI with actual low health risk. So fat distribution provides a more complete picture than BMI alone.

4. Definitions 2 Waist circumference is taken at level of anterior iliac crest. In women, high if > 88 cm (35 inches). In men, high if > 102cm (40 inches), it’s a marker for central adiposity. Associated with increased risk for diabetes type 2, dyslipidemia, hypertension, cardiovascular disease and metabolic syndrome. Waist to hip ratio: defined as high if > 0.9 in women, > 0.83 in men. Better predictor of cardiovascular event than BMI or waist circumference alone according to INTERHEART study, except in Chinese and African descent in which waist circumference is better predictor. WtoH= Circ. MID dist between lower ribs & Anterior iliac crest (waist) WtoH= Circ. MID dist between lower ribs & Anterior iliac crest (waist) Circ. at level of Ischeal Tuberosity (hip) Circ. at level of Ischeal Tuberosity (hip)

5. Etiology of Obesity 1 Weight gain : in which Energy intake EXCEEDS energy expenditure. Weight gain : in which Energy intake EXCEEDS energy expenditure. result of mismatches of energy balance Each individual is different for genetic traits, metabolic rate at rest/exercice, appetite, response to diet. Each individual is different for genetic traits, metabolic rate at rest/exercice, appetite, response to diet. 2 main etiology of obesity: exogenous and endogenous. 2 main etiology of obesity: exogenous and endogenous. 1) Exogenous : 1) Exogenous : A) Increase energy intake a1) High daily calory intake (large portions, frequent eating, high calory density, binge eating) a1) High daily calory intake (large portions, frequent eating, high calory density, binge eating) a2) Socio-economic and behavioral factors (meals as social event, eat-out, alcohol-beer) a2) Socio-economic and behavioral factors (meals as social event, eat-out, alcohol-beer) a3) Iatrogenic eg. Chronic use of Antipsychotics/antidepressant, prednisone, hormones like insulin, birth control pill a3) Iatrogenic eg. Chronic use of Antipsychotics/antidepressant, prednisone, hormones like insulin, birth control pill B) Decrease energy loss (sedentary lifestyle, smoking cessation)

6. Etiology of Obesity 2 2) Endogenous: A) Neuro endocrine: A) Neuro endocrine: Diabetes, Cushing disease, Polycystic ovary syndrome, Hypothroidism, Hypogonadism, Growth hormone deficiency Diabetes, Cushing disease, Polycystic ovary syndrome, Hypothroidism, Hypogonadism, Growth hormone deficiency B) Genetic B) Genetic Familial history of obesity, Familial history of obesity, Dysmophic eg Prader-Willi (congenital syndrome due to disruption with chromosome 15, clinically Hypotonia, hypogonadism, compulsive hyperphagia from 12 Mo onwards, mental retardation, associated with sleep apnea) Dysmophic eg Prader-Willi (congenital syndrome due to disruption with chromosome 15, clinically Hypotonia, hypogonadism, compulsive hyperphagia from 12 Mo onwards, mental retardation, associated with sleep apnea)

7. History for weight gain/obesity 1 Age of onset? (childhood, > 18 y.o) Progression and rate of weight gain. Reason on consultation today, How incapacitating or impact on daily life activities at work, home?. Age of onset? (childhood, > 18 y.o) Progression and rate of weight gain. Reason on consultation today, How incapacitating or impact on daily life activities at work, home?. Search for reversible cause and triggering factors (change diet, exercice pattern, life events). Past medical history (Endocrine disease like hypothyroidism, diabetes, PCO), Hypertension, dyslipidemia, metabolic syndrome, congestive heart failure, chronic renal failure, surgery (eg hypothalamic surgery), Eating disorder/boulimia, psychotic disorder/mental illness. Search for reversible cause and triggering factors (change diet, exercice pattern, life events). Past medical history (Endocrine disease like hypothyroidism, diabetes, PCO), Hypertension, dyslipidemia, metabolic syndrome, congestive heart failure, chronic renal failure, surgery (eg hypothalamic surgery), Eating disorder/boulimia, psychotic disorder/mental illness. Familial history (obesity, genetic disease, neuro-endocrine disease, psychiatric illness) Familial history (obesity, genetic disease, neuro-endocrine disease, psychiatric illness) Medications list updated (prednisone, hormones (contraceptive agents, insulin), antipsychotic, antidepressant eg remeron) Medications list updated (prednisone, hormones (contraceptive agents, insulin), antipsychotic, antidepressant eg remeron)

8. History for weight gain/obesity 2 Level of physical activity (limitation?), work type (desk job?), quality of sleep Level of physical activity (limitation?), work type (desk job?), quality of sleep Alcohol use, smoking cessation?, amount of soft drinks, Typical daily diet and desserts (change on diet) Alcohol use, smoking cessation?, amount of soft drinks, Typical daily diet and desserts (change on diet) Review of system for comorbid conditions. Intolerance to cold, fatigue (r/o hypothyroidism), polydipsia and polyuria (r/o diabetes), amenorrhea and hirsutism (r/o PCO), dyspnea/orthopnea (r/o congestive heart failure), somnolence (r/o sleep apnea). Symptoms of breast-colon-prostate cancer Review of system for comorbid conditions. Intolerance to cold, fatigue (r/o hypothyroidism), polydipsia and polyuria (r/o diabetes), amenorrhea and hirsutism (r/o PCO), dyspnea/orthopnea (r/o congestive heart failure), somnolence (r/o sleep apnea). Symptoms of breast-colon-prostate cancer Review of strategies to lose weight, what worked or not. Barriers to success Review of strategies to lose weight, what worked or not. Barriers to success

9. Physical examination for obesity/weight gain Body Mass Index= BMI = (weight in kg)/ (height in meters)2 Body Mass Index= BMI = (weight in kg)/ (height in meters)2 Vitals signs including alertness, Oxygen sat., glucocheck + weight Vitals signs including alertness, Oxygen sat., glucocheck + weight Hair and fat distribution (? Hirsutism, abdominal obesity?) Hair and fat distribution (? Hirsutism, abdominal obesity?) Head and neck: airway, cushingoid aspect?, thyroid, « buffalo hump » Head and neck: airway, cushingoid aspect?, thyroid, « buffalo hump » Chest: creps, wheezing, JVP Chest: creps, wheezing, JVP Abdomen: waist and hip circumference, ? Sign of chronic liver disease, ascites? Abdomen: waist and hip circumference, ? Sign of chronic liver disease, ascites? Genital: sign of hypogonadism Genital: sign of hypogonadism Legs: peripheral edema ? Legs: peripheral edema ? If suspicious of cancer of breast, prostate: do breast/prostate exam If suspicious of cancer of breast, prostate: do breast/prostate exam

10. Investigations and management for weight gain Investigation are done to confirm or infirm hypothesis of diagnosis Investigation are done to confirm or infirm hypothesis of diagnosis Fasting glucose (r/o diabetes), TSH (r/o hypothyroidism), Lipid profile, Creatinine and electrolytes, LH and FSH if suspect PCO, plasma cortisol and dexamethasone test if suspect Cushing syndrome, Fasting glucose (r/o diabetes), TSH (r/o hypothyroidism), Lipid profile, Creatinine and electrolytes, LH and FSH if suspect PCO, plasma cortisol and dexamethasone test if suspect Cushing syndrome, Overnight saturation test +/- Sleep study r/o sleep apnea Overnight saturation test +/- Sleep study r/o sleep apnea Food and exercice dairy Refer to dietician Refer multidisciplinary team (re: Civic weight management clinic) Refer to specialists re:endocrinologist appropriately for investigations and treatment of suspected condition.

11. Goal of care for obesity/weigth gain Reduce mortality: by ↓ cardiovascular risk. Remember: BM1 increase 5 (eg from 25 to 30) increase 10% mortality Reduce mortality: by ↓ cardiovascular risk. Remember: BM1 increase 5 (eg from 25 to 30) increase 10% mortality Reduce morbidity : ↓ blood pressure, improves lipid profile, ↓ insulin resistance, improves level of function and mobility/fitness to exercise. Reduce morbidity : ↓ blood pressure, improves lipid profile, ↓ insulin resistance, improves level of function and mobility/fitness to exercise. Realistic goals according readiness for change (Polchaska stages, eg Contemplative stage). Ask client the impact of excess weight in their life with personal goals (eg. Able to play soccer with grand-son) Realistic goals according readiness for change (Polchaska stages, eg Contemplative stage). Ask client the impact of excess weight in their life with personal goals (eg. Able to play soccer with grand-son) Use Self-management strategies with action plan. Use Self-management strategies with action plan. A) Improve grocery choice to reduce calories B) Improve food preparation (less frying) C) Progressive exercice plan with routine (eg pedometer 5000 steps, walk 30 min after meals). D) Chart weekly weight (same scale). Agree on realistic goals.

12. Goal of care for obesity/weigth gain Benefit with interdisciplinary team for behavior change. Dietician for healthy nutrition, calory targets, counselling at grocery. Physiotherapist for Exertion (eg set example for children). Group therapy: motivation by peers (eg Weight Watchers). Significant health benefit even with moderate weight loss, waist circumference loss. Arrange regular follow-up. Anorectic drugs (orlistat =Xenical, sibutramine= Meridia) are add-on therapy. Limited benefit. Not OBD coverage, expensive, GI side effects: oily loose stools, gaz. Anorectic drugs (orlistat =Xenical, sibutramine= Meridia) are add-on therapy. Limited benefit. Not OBD coverage, expensive, GI side effects: oily loose stools, gaz. Bariatic surgery as last resort when BMI 40 (or BMI of 35 with HTN, CHF, DB, OSA), significant impairment of IADLs/function and failure of all other interventions. Access to it is limited. Bariatic surgery as last resort when BMI 40 (or BMI of 35 with HTN, CHF, DB, OSA), significant impairment of IADLs/function and failure of all other interventions. Access to it is limited.

13. Ressources 1)Essentials of Family Medicine, 4th edition by Sloane and al. Lippincott Williams & Wilkins, pp 783-801 2) Problem-Oriented Medical Diagnosis, 6th edition by Friedman, A Little Brown spiral manual, pp 367-370 3) Practice Based Learning program from McMaster University, Module on Obesity in Adults, Vol 14 (2), February 2006 4) 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children (summary), CMAJ 2007; 176 (8 suppl): S1-13