INVESTIGATION AND MANAGEMENT OF OBESITY

Dr Ogunwale O.O. MBBS LagosSnr Registrar EDM Div. LUTH

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

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

CLASSIFICATION

BMI (Kg/m2) Body Fat Percentage (%)Grade Male Female

Normal 15-20 25-30

Borderline 21-25 30-33

Obese >25 >33

Normal 18.5-24.9

Overweight 25-29.9

Grade1 Obese 30-34.9

Grade 2 35-39.9

Grade 3/Morbid ≥40

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

AIMS OF INVESTIGATION

• Confirm diagnosis & r/o differentials• Find underlying aetiology• Complications & Comorbidities

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***

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONSWC Male (in cm) Female(in cm)

WHO 102 88

IDF 94 80

Asian 90 80

Japan & China 85 80

Nigeria (Okafor et al) 97 95

INVESTIGATIONHarpenden Professional Skinfold Caliper

INVESTIGATION

INVESTIGATION

• Ultrasonography Fat thickness• Abd USS : NAFLD, Gallstones , Ovarian Cysts• Dual-energy radiographic absorptiometry

(DEXA)• Abd CT Scan (at L4/L5)• Abd MRI

INVESTIGATIONs

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

TREATMENT GUIDELINESBMI (kg/m2) Conventional

Therapy*Pharmacotherapy† Surgery‡

25.0-26.9 With CHD risk factors or obesity-related disease

No No

27.0-29.9 With CHD risk factors or obesity-related disease

With obesity-related disease

No

30.0-34.9 Yes Yes No

35.0-39.9 Yes Yes With obesity-related disease

≥40 Yes Yes Yes

NON-PHARMACOLOGICAL MGT

• Diet, Physical Activity & Behavioural Therapy• Self-monitoring of caloric intake & physical

activity• Goal setting*• Stimulus control• Non-food rewards• Relapse prevention

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

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

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.

NON-PHARMACOLOGICAL MGT

• Physical Activity• More of Aerobic Isotonic Exercise• Less of Anaerobic Isometric/ Resistance

Exercise

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)

PHARMACOLOGICAL MGT

• Lipase Inhibitors : Orlistat (B)• Sibutramine (C)• Lorcaserin (A)• Sympathomimetic Amines Phendimetrazine,

Phentermine ,Diethylpropion, Benzphetamine Mazindol (A)

• Antidiabetic agents

PHARMACOLOGICAL MGT

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

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)

SURGICAL MGT

SURGICAL MGT

SURGICAL MGT

• Vertical banded gastroplasty

SURGICAL MGT

SURGICAL MGT

• 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

BENEFITS

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

COMPLICATIONS OF Rx

• Electrolyte Disturbances : Ketosis, ↓K+

• Arrhythmias• Malabsorption• Malnutrition• Hyperuricaemia• Cholithiasis• Depression & Eating Disorders

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

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

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

THANK YOU