Pi Sunyer, 2009

Principle of Obesity Management

WHO guideline • Diet, exercise, and behavioral

modification should be included in all obesity management approaches for body mass index (BMI) of 25 kg/m2 or higher.

• Pharmacotherapy for BMI of 27 kg/m2 or higher with comorbidity or BMI over 30 kg/m2.

• Bariatric surgery for BMI of 35 kg/m2 with comorbidity or BMI over 40 kg/m2, should be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible.

BODY MASS INDEKS

Height Measurement

The purpose of weight loss program

• Aesthetic

• Personal demand

• Comfort

• Disease risk control

• Disease therapy

Dietary Intake Analysis

• Quantitative:

– 24 h recall.

– Repeated 24 h recall.

• Qualitative:

– Food frequency Questionnaire (FFQ)

• Mix:

– Semiquantitative FFQ

– Dietary History

Dietary Intake Analysis

Time Foods and beverages

Serving size

How prepared Where Comments

Next Steps ... Analyse Food composition content and weight:

– Ukuran rumah tangga. – Berat/volume makanan.

Analyze: Software/Nutrisurvey Program Manual Analysis:

– Analyse based on Indonesian food compositionn table, or

– Resep dasar makanan Indonesia, or

– Analyze food processing (convert to another software food analysis based on food processing)

– Observation to local cafe/food street, or

– Analyze nutrition fact from labelled food

Simple Steps

– Dietary recall. • Quantity.

• Frequency

• Main course/between meal

• Energy density

– Weekday & weekend habit.

– Monitoring and Evaluation: Food diary.

Reduce step by step

Another Diagnosis Tool: Body Composition Analysis

Laboratory and Clinical Assessment

• Laboratory assessment:

– Based on underlying disease.

– Renal function

– Liver function

– Blood glucose

– Lipid profile

– Hematology

• Clinical asessment:

– Underlying disease.

– Disease risk

– Disease complication

– Nutrient deficient

– Drug interaction

• Another:

– Physical activity

– Food alergy/intolerance

– Religion.

– Culture

– Another environment limitation

Nutritional Intervention

• Dietary intervention: – Regular dietary intake:

• Breakfast/Lunch/Dinner • Low calorie Between

meal snack

– Adequate protein intake – Low fat food sources – Adequate micronutrient

food sources – Increase fiber intake – Adequate non-caloric

drink. Go slow

Specific Nutrient

• Antiinflamation effect: – Balance energy and protein.

– Minimize saturated fatty acid.

– Functional food: • Vitamin A,C,E.

• Polyphenol: green tea, fruit, vegetable.

– Minimize food processing

– Low Glycemic index

– Synbiotic

– Micronutrient supplementation.

Physical Activity for Weight Management: More than this WHO recommendation:

• Increase physical activity: – Frequency : more than 3x/week – Intensity : low to moderate – Duration : 30 – 60 minutes

Medication: Site of Action of Pharmacotherapy

Contraindications: • Pregnancy, breast-feeding • Unstable cardiac disease • Uncontrollled hypertension (SBP > 180 Hg, DBP>110 mmHg) • Unstable severe systemic illness • History of anorexia nervosa • Active severe psychiatric disorder • Other drug therapy, if incompatible

(e.g. monoamine oxidase inhibitors, antimigraine, drug, adrenergic agents, drugs with arrhythmia potential) Cautions : • Presence of any severe systemic illness • History of severe psychiatric disorder • Other drug therapy • Close angel glaucoma • Age < 18 years or > 65 years

Caution of Antiobesity Drugs

Orlistat promotes weight loss by decreasing the absorption of fat from the gastrointestinal tract. On average, 120 mg of orlistat taken three times per day will decrease fat absorption by 30% . Effect on insulin sensitivity and blood glucose

Phentermine and diethylpropion is a sympathomimetic anorexogenic agent. Phentermine’s main side effects are related to its sympathomimetic properties, including elevation in blood pressure and pulse, insomnia, constipation and dry mouth Metformin as peripherally acting anti diabetes drug that enhances insulin sensitivity and has been associated with weight losses of 5-10% of initial body weight.

Medication

Alpha cyclodextrin: Binds with dietary fat and inhibits its absorption, helps manage weight /prevent weight gain when combined with a healthy diet and exercise

Lorcaserin: a selective serotonin receptor agonist treatment for obesity for adults with a BMI ≥ 30 kg/m2 or with a BMI ≥ 27 kg/m2.

Reduces appetite by binding to the 5-HT2C receptors on anorexigenic pro-opiomalocortin (POMC) neurons in the hypothalamus

Liraglutide: GLP-1 receptor agonist that has been used for type 2 diabetes in doses up to 1.8 mg. In a short-term study (5 weeks) involving obese individuals without diabetes demonstrated that liraglutide 3.0 mg/day suppressed acute food intake, subjective hunger, and delayed gastric emptying

Medication

As general popular diets could be based on:

Calorie content (low calorie diet, very low calorie diet).

Nutrient content (various composition of protein, lipid and carbohydrate)

Any unclassified methods that required scientific analysis.

People are interested in popular diets because:

Easy to use, comfort, without medical supervision and many succesfull testimonial from public figure.

CASE STUDY

• 52 year old man:

– Obese grade 2

– WC: 110 cm.

– Vital sign: in normal limit.

– Laboratory result: in normal limit

– Sedentary activity.

Case Study

• 40 year old woman

– Obese grade 1

– WC: 100 cm

– Vital sign: in normal limit

– Laboratory result: in normal limit

– As housewife