1. INVESTIGATION AND MANAGEMENT OF OBESITY Dr Ogunwale O.O. MBBS Lagos Snr Registrar EDM Div. LUTH

2. OUTLINE INTRODUCTION CLASSIFICATION AIMS OF INVESTIGATION INVESTIGATIONS TREATMENT GUIDELINES NON-PHARMACOLOGICAL MGT PHARMACOLOGICAL MGT SURGICAL MGT BENEFITS OF WEIGHT LOSS COMPLICATIONS OF TREATMENT CONCLUSION REFERENCES

3. INTRODUCTION Basically a clinical/anthropometric diagnosis History & PE vital. Underlying cause needs be investigated Classification based on BMI Also on Body Fat Distribution/% Not necessarily about ↑weight. but ↑body fat Mgmt. is multidisciplinary

4. CLASSIFICATION BMI (Kg/m 2 )Body Fat Percentage (%) GradeMaleFemale Normal15-2025-30 Borderline21-2530-33 Obese>25>33 Normal18.5-24.9 Overweight25-29.9 Grade1 Obese30-34.9 Grade 235-39.9 Grade 3/Morbid≥40

5. CLASSIFICATION Surgical : Super Obese BMI : ≥ 50 BF% : Calculated from Deurenberg’s Equation 1.2(BMI)+0.23(Age)-10.8(Sex)-5.4 Sex : 1 for Male, 0 for Female Both Underweight & Overweight are assoc. with ↑risk of dx. Risk ↑ with ↑ Obesity

6. AIMS OF INVESTIGATION Confirm diagnosis & r/o differentials Find underlying aetiology Complications & Comorbidities

7. INVESTIGATIONS BMI = Wt in Kg/ (Ht) 2 in m 2 Waist Circumference Sagittal Abdominal Diameter Caliper-derived measurements of skin-fold thickness* Bioelectrical impedance analysis** Underwater weighing***

8. INVESTIGATIONS

11. WCMale (in cm)Female(in cm) WHO10288 IDF9480 Asian9080 Japan & China8580 Nigeria (Okafor et al)9795

12. INVESTIGATION Harpenden Professional Skinfold Caliper

13. INVESTIGATION

14. Ultrasonography Fat thickness Abd USS : NAFLD, Gallstones, Ovarian Cysts Dual-energy radiographic absorptiometry (DEXA) Abd CT Scan (at L4/L5) Abd MRI

15. INVESTIGATIONs FLP LFT TFT FBG C-peptide and Insulin Studies Brain MRI* Genetic studies ** GH & IGF-1 Assays.

16. TREATMENT GUIDELINES BMI (kg/m2)Conventional Therapy* Pharmacotherapy†Surgery‡ 25.0-26.9With CHD risk factors or obesity- related disease No 27.0-29.9With CHD risk factors or obesity- related disease With obesity- related disease No 30.0-34.9Yes No 35.0-39.9Yes With obesity- related disease ≥40Yes

17. NON-PHARMACOLOGICAL MGT Diet, Physical Activity & Behavioural Therapy Self-monitoring of caloric intake & physical activity Goal setting* Stimulus control Non-food rewards Relapse prevention

18. NON-PHARMACOLOGICAL MGT Goals should be SMART Who - Who is involved? What - What do I want to accomplish? Where - Identify a location When - Establish a time frame Which - Identify requirements and constraints Why - Identify specific reasons for or purpose or benefits of the goal

19. NON-PHARMACOLOGICAL MGT Weight-loss programs 3 major phases : Pre-inclusion screening phase* Weight-loss phase Maintenance phase - Can last for rest of pt's life but ideally lasts for at least 1 yr post program completion

20. NON-PHARMACOLOGICAL MGT DIET Low Calorie Diet :800 - 1500 kcal/day Very Low Calorie Diet < 800 kcal/day usu. high in protein (70-100 g/day) & low in fat (<15 g/day). Usu. Taken As Liquid Formula, Nutritional Bars Conventional Food : mostly lean meat, fish - known as protein-sparing modified fasts.

21. NON-PHARMACOLOGICAL MGT Physical Activity More of Aerobic Isotonic Exercise Less of Anaerobic Isometric/ Resistance Exercise

22. PHARMACOLOGICAL MGT Centrally acting medications that impair dietary intake (A) Medications that act peripherally to impair dietary absorption(B) Medications that increase energy expenditure (C)

23. PHARMACOLOGICAL MGT Lipase Inhibitors : Orlistat (B) Sibutramine (C) Lorcaserin (A) Sympathomimetic Amines Phendimetrazine, Phentermine,Diethylpropion, Benzphetamine Mazindol (A) Antidiabetic agents

24. PHARMACOLOGICAL MGT Of the drugs the following are FDA-approved: Lorcaserin (Belviq) Phentermine/topiramate (Qsymia) Orlistat (Xenical) Sibutramine no longer approved

25. SURGICAL MGT BARIATIC SURGERY Roux-en-Y gastric bypass (B) Adjustable gastric banding (R) Gastric sleeve surgery (R) Vertical sleeve gastrectomy (R) Horizontal (Silastic ring) gastroplasty (R) Vertical banded gastroplasty (R) Duodenal-switch procedures(B) Biliopancreatic diversion (B)

26. SURGICAL MGT

28. Vertical banded gastroplasty

29. SURGICAL MGT

30. Morbid Obesity When Conventional Rx & Drug Rx Fail Benefits : Improved Obstructive sleep apnea Type 2 DM, Hypertension, CCF, Asthma, Dyslipidaemia Peripheral oedema, Respiratory insufficiency Esophagitis, Pseudotumor cerebri, OA, VTE Operative risk Urinary incontinence

31. BENEFITS Improved Glycaemic Control BP Control Dyslipidaemia Control ↓ CV Risk Improved Pulm. Fx Improved Reproductive & Urinary Fx

32. COMPLICATIONS OF Rx Electrolyte Disturbances : Ketosis, ↓K + Arrhythmias Malabsorption Malnutrition Hyperuricaemia Cholithiasis Depression & Eating Disorders

33. CONCLUSION Obesity is basically a clinical diagnosis More about body fat than weight Hx & PE very important to evaluate co- morbidities and Cx Management primarily non-pharmacological Multidisciplinary Benefits of Rx include ↓CV Risk, ↑Pulm. Fx and regression of co-morbidities

34. REFERENCES Klein S, Fabbrini E, Romijnin JA Obesity in Melmed S, Polonsky KS, Larsen PR, Kronenberg HM (eds.), Williams Textbook of Endocrinology, 12th ed. Saunders, 2011. ch 36 pp 1605- 1625 Hamdy O, Citkowitz E, Uwaifo GI, Oral EA Obesity http://emedicine.medscape.com/article/123702. Updated : Nov 25, 2013 de Souza NC, de Oliveira EP Sagittal abdominal diameter shows better correlation with cardiovascular risk factors than waist circumference and BMI Journal of Diabetes & Metabolic Disorders 2013 12:41 http://www.topendsports.com/testing/skinfold-sites.htm Accessed Dec 4,2013 http://www.ebay.com/itm/Harpenden-Professional-Skinfold- Caliper-/320795435670 Accessed Dec 4, 2013

35. REFERENCES http://www.fitnessgram.net/protocols/skinfolds.pdf Accessed Dec 6,2013 Sagittal Diameter http://www.myhealthywaist.org/evaluating-cmr/clinical- tools/sagittal-diameter/page/2/print.html. Accessed Dec 6, 2013 http://www.topendsports.com/testing/tests/underwater.htm Accessed Dec. 5,2013 http://www.topendsports.com/testing/siri-equation.htm Accessed Dec. 5, 2013 http://www.myhealthywaist.org/evaluating-cmr/clinical-tools/sagittal- diameter/page/2/print.html Accessed Dec. 6,2013 WHO Technical Report Series. Diet, nutrition and the prevention of chronic diseases http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf Accessed Dec. 6, 2013 http://www.nlm.nih.gov/medlineplus/ency/article/007199.htm. Updated 6/4/2012

36. THANK YOU