Obesity, prevalence, risk factors, approach to management- Dr Shahjada Selim

Dr Shahjada SelimDr Shahjada Selim Assistant ProfessorAssistant Professor

Department of EndocrinologyDepartment of EndocrinologyBangabandhu Sheikh Mujib Medical University, DhakaBangabandhu Sheikh Mujib Medical University, Dhaka

Email: Email: [email protected], [email protected]@gmail.com, [email protected]

Obesity

Obesity definition

•““Overweight or obesity is defined as Overweight or obesity is defined as abnormal or excessive fat accumulation that abnormal or excessive fat accumulation that

presents a risk to health”presents a risk to health”

http://www.who.int/en/

Weight status :

SEAR including Bangladesh

Category BMI

Under nutrition <18.5

Normal 18.5 – 22.9

Overweight 23.0 – 25.0

Obese >25.0

Obesity epidemic


Obesity epidemic

www.thelancet.com Vol 387 April 2, 2016

Country Age range Obesity prevalence

Male

Obesity prevalence

Female

U.S.A. 22-74 years 19.7% 24.7%

Germany 25-69 years 17% 19%

England 16-64 years 15% 16.5%

Kuwait 18 + 32% 44%

India 16-64 years 19.3% 25.6%

Currently the world is facing obesity epidemic

Childhood obesity in low resourced society

%

Misra A, Basit A, Vikram NK, Sharma R; Diabetes Res Clin Pract;2005

Measurement of Obesity

• Body mass index (BMI)Body mass index (BMI)• Waist CircumferenceWaist Circumference• Waist to hip ratioWaist to hip ratio• Skin fold thicknessSkin fold thickness• Body fat analyzerBody fat analyzer• Body fat to muscle ratioBody fat to muscle ratio• OthersOthers

BMI

It is a measure for human body shape It is a measure for human body shape based on an individual's mass and based on an individual's mass and

height. height.

BMI Classification

WHO, Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000:894:1-253.WHO. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004:363:157-63

Asian cutoff

Other cutoff

Overweight

Obese I Obese II Obese III

Abdominal obesity

Body fat Percentage

Based on NIH/WHO BMI Guidelines.As reported by Gallagher, et al., at NY Obesity Research Center.

Visceral Fat

http://tanita.eu/tanita-academy/understanding-your-measurements

Visceral Fat

Types of obesity

• Excess fat on the Abdomen

• Common in Men• Significant

correlation with Metabolic syndrome

• Excess fat on the things and buttocks

• Common in Women• Non Significant

correlation with Metabolic syndrome

Arch Pediatr Adolesc Med. 2009 Sep;163(9):826-31

Number of fat cell

•Number and size of fat cells appears to Number and size of fat cells appears to be an important factor in determining be an important factor in determining riskrisk for obesity. for obesity.

•Average non-obese person: Average non-obese person: 25 – 30 billion25 – 30 billion•Moderately obese: Moderately obese: 60 – 100 billion60 – 100 billion•Massively obese: Massively obese: 300 billion plus 300 billion plus

Journal of ObesityVolume 2011 (2011), Article ID 490650

Understanding energy balanceis this as simple…….

Understanding energy balanceits complex rather

NEPA: Non-exercise physical activityTEF: Thermic effect of food

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Obesity

Epigenetic

Epigenetic

Fawwad A, et al., Oral Presentation in Dow university of health sciences, 2012, Karachi - Pakistan

Genes and obesity phenotypes

Herrera & Lindgren 2010

Human Molecular Genetics, 2006, Vol. 15, Review Issue No. 2

Genetic links between obesity and associated conditions

Gene environment interactions

The complex interactions underlying polygenic obesity demonstrate that genetic, social, behavioral, and environmental factors are all capable of influencing the obese phenotype.

Unraveling the genetics of human obesity.Mutch DM, Clément K - PLoS Genet. (2006)

The risk triangle: Obesity

Genetics

Behavior Environment

Risk

Asia Pacific Journal of Clinical NutritionVolume 11, Issue Supplement s8, pages S718–S721, December 2002/

Determinants of obesity• Genetics• Epigenetics• Ethnicity• Age• Intrauterine

milieu • Birth weight• Post natal

catch up growth

• Pregnancy•

International Journal of Obesity & Related Metabolic Disorders . Dec2002 Supplement, Vol. 26, pS8. 1pInternational Journal of Obesity (2004) 28, 1247–125Rennie KL, et al. Behavioural determinants of obesity. Best Pract Res Clin Endocrinol Metab. 2005 Sep;19(3):343-58.

• Urbanization• Dietary habits• Physical activity• Concomitant Medical

illness• Medications• Mental Stress• Oxidative stress• smoking• Excessive or Lack of sleep• Others

Differential Impact of Obesity among various Ethnic group

Atherogenic Dyslipidemia

CAD Diabetes Hypertension

Whites +++ + + +

Blacks + + +++ +++

Hispanics & American Indians

+ + +++ +

Asian Indians

++++ ++++ ++++ +

Chinese + + +++ +Grundy SM. Circulation, 2002, 105 2696

NCDs risk & Asian ancestryRapid nutrition and lifestyle transitions leading to:

OthersOthers•Procoagulant Procoagulant state state •Endothelial Endothelial dysfunction.dysfunction.

International Journal of Obesity (2011) 35, 167–187;

Body phenotype•High body fat•High truncal fat•High Subcutaneous fat•High intra-abdominal fat•low muscle mass

Biochemical parameters •Hyperglycemia•Hyperinsulinemia •Dyslipidemia •Hyperleptinemia•Low levels of adiponectin •High levels of C-reactive protein

The Y-Y paradox

•The first author (figure, The first author (figure, right) has substantially right) has substantially more body fat than the more body fat than the second author (figure, second author (figure, left).left).•The image is a useful The image is a useful reminder of the reminder of the limitations of BMI as a limitations of BMI as a measure of adiposity measure of adiposity across populations.across populations.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)15269-5

Normal weight obesity

A metabolically-obese normal weight subject is a person who has normal weight and BMI, but with high body fat percentage specially visceral fat that may increase the possibility of developing the metabolic syndrome, insulin resistance, hypertension and CVDProg Cardiovasc Dis. 2014 Jan-Feb;56(4):426-33.

What causes obesity?

Energy balance

•3 components3 components1.1.Afferent /peripheral systemAfferent /peripheral system• - Generates signals from various sites- Generates signals from various sites• - Composed of leptin , adiponectin - by - Composed of leptin , adiponectin - by fat cells, ghrelin from stomach, peptide YY fat cells, ghrelin from stomach, peptide YY (PYY) from ileum, colon, insulin from (PYY) from ileum, colon, insulin from pancreaspancreas

•2.Arcuate nucleus in hypothalamus2.Arcuate nucleus in hypothalamus•-Processes & integrates neurohumoral peripheral -Processes & integrates neurohumoral peripheral signalssignals•-Generates efferent signals-Generates efferent signals•-Composed of 2 subsets of first order neurons-Composed of 2 subsets of first order neurons•1.POMC (pro-opiomelanocortin) & CART (cocaine 1.POMC (pro-opiomelanocortin) & CART (cocaine and amphetamine-regulated transcripts) neuronsand amphetamine-regulated transcripts) neurons•2.Neuropeptide Y & AgRP (agouti-related peptide)2.Neuropeptide Y & AgRP (agouti-related peptide)•These first order neurons communicate with second These first order neurons communicate with second order neuronsorder neurons

•33. Efferent system. Efferent system•Carries signals from second order neurons of Carries signals from second order neurons of hypothalamus to control food intake and hypothalamus to control food intake and energy expenditureenergy expenditure

Peripheral Signals

•Produced by Produced by adipocytesadipocytes•Product of ‘Product of ‘obob’ gene’ gene•Provides signal for Provides signal for “energy “energy sufficiency”.sufficiency”.•Abundant fat Abundant fat Leptin Leptin secretionsecretion•Regulated by Regulated by insulin insulin stimulated glucose stimulated glucose metabolismmetabolism•Stimulates Stimulates thermogenesis, thermogenesis, activity, energy expenditureactivity, energy expenditure

•MC4RMC4R ( Melanocortin receptor 4) mutations- ( Melanocortin receptor 4) mutations- more frequent, cause of 5% massive obesitymore frequent, cause of 5% massive obesity•No satietyNo satiety(anorexinergic) signal generated(anorexinergic) signal generated•Behave Behave as if undernourishedas if undernourished•Haplo-insufficiency of brain-derived Haplo-insufficiency of brain-derived neurotrophic factor (neurotrophic factor (BDNFBDNF) – component of ) – component of MC4R downstream signaling in hypothalamusMC4R downstream signaling in hypothalamus•BDNF - A/w obesity in BDNF - A/w obesity in WAGR WAGR syndromesyndrome

•Produced mainly by Produced mainly by adipocytesadipocytes•LowLow levels in levels in obesityobesity•Stimulates fatty acid oxidationStimulates fatty acid oxidation•““Fat-burning molecule”Fat-burning molecule”•““Guardian angel against obesity”Guardian angel against obesity”•↓ ↓ fatty acid influx in liver, liver fatty acid influx in liver, liver glucose productionglucose production•↓ ↓ Protects against Metabolic Protects against Metabolic syndromesyndrome

•Produces TNF, IL-6, IL-1, IL-18, Chemokine, Produces TNF, IL-6, IL-1, IL-18, Chemokine, SteroidsSteroids•Chronic sub-clinical inflammatory stateChronic sub-clinical inflammatory state (^ CRP) (^ CRP)•?Link between lipid metabolism, nutrition, ?Link between lipid metabolism, nutrition, inflammationinflammation

•WHY WHY is it HARD to maintain the weight loss for is it HARD to maintain the weight loss for those who lose after dietary restriction?those who lose after dietary restriction?-Constant number of adipocytesConstant number of adipocytes--Higher no. in obese-Higher no. in obese

..

•Short term meal initiators and terminatoprsShort term meal initiators and terminatoprs•GhrelinGhrelin, , PYYPYY, , Pancreatic polypeptidePancreatic polypeptide, , IsulinIsulin, , AmylinAmylin•Ghrelin(stomach,arcuate nucleus)- Ghrelin(stomach,arcuate nucleus)- only orexenergic only orexenergic gut hormonegut hormone•Most likely stimulates NPY/AgRP neuronsMost likely stimulates NPY/AgRP neurons•PYYPYY ( ileum, colon) ( ileum, colon)•A/w hyperphagia , obesity in A/w hyperphagia , obesity in Prader-Willi syndromePrader-Willi syndrome•AmylinAmylin(pancreatic ß cells), (pancreatic ß cells), PYYPYY – both stimulate – both stimulate POMC/CART neuronsPOMC/CART neurons

Medical Risk of Obesity

Nature 404, 635-643 (6 April 2000)

Health Risks increase with Obesity

Archive of internal medicine 161:1501,2001)

Obesity and Adipose tissue

Adipose tissue is an endocrine organ that secretes numerous protein hormones, including leptin,

adiponectin, resistin, interleukin, apelin,

tumor necrosis factor and estrogen.

http://www.shutterstock.com/pic-316924646/stock-photo-adipose-tissue-is-an-endocrine-organ-that-secretes-numerous-protein-hormones-including-leptin.html

California Medical Foundation Association Obesity Toolkit

Weng et al . Pediatrics; 2013

Seven predictors•Gender•Birth weight•Weight gain•Maternal pre-pregnancy BMI •Paternal BMI•Maternal smoking in pregnancy•Breastfeeding status

Estimating overweight risk in childhood from predictors during

infancy

Three key modifiable factors •Computer usage•Breakfast consumption•Transport mode to school

Duncan et al. BMC Public Health 2011, 11:585

Modifiable risk factors for overweight and obesity in children

and adolescents from Brazil

Conclusion

• AwarenessAwareness• Early identificationEarly identification• Aggressive LSM & treatmentAggressive LSM & treatment• Customized ethnic & Genetic based Customized ethnic & Genetic based

Prevention strategiesPrevention strategies• Research, Policy making, legislation Research, Policy making, legislation

and effective Implementationand effective Implementation

WHO- Call of the DAY

• According to WHO, Obesity is one of the According to WHO, Obesity is one of the most common, modifiable risk factor for all most common, modifiable risk factor for all the major NCDs which can be overcome the major NCDs which can be overcome using existing knowledge as the solutions using existing knowledge as the solutions are highly cost-effective. are highly cost-effective.

• Comprehensive and integrated action at Comprehensive and integrated action at country level, led by governments, is the country level, led by governments, is the means to achieve success.means to achieve success.


What is Successful Weight Loss?

Common definition: Common definition: Lose at least 10% of Lose at least 10% of starting weight and starting weight and keep it off at least keep it off at least one year. one year.

What is the Goal of Obesity Treatment?

• Specifically, the goal of obesity treatment Specifically, the goal of obesity treatment should be refocused from weight loss alone, should be refocused from weight loss alone, which is often aimed at appearance, to weight which is often aimed at appearance, to weight management, achieving the best weight management, achieving the best weight possible in the context of overall health.possible in the context of overall health. – –FTC FTC PanelPanel, , Commercial Weight Loss Products and ProgramsCommercial Weight Loss Products and ProgramsWhat Consumers Stand To Gain and Lose, What Consumers Stand To Gain and Lose, 19971997

http://www.ftc.gov/os/1998/03/weightlo.rpt.htm accessed 3-13-06

http://www.ftc.gov/os/1998/03/weightlo.rpt.htm

Who Should Consider A Weight Management Intervention?

• Persons with a BMI of >30 Persons with a BMI of >30 (>25)(>25)• Persons with a BMI between 25- 29.99 Persons with a BMI between 25- 29.99

(23-24.9)(23-24.9) OR a high-risk waist OR a high-risk waist circumference, and two or more risk circumference, and two or more risk factorsfactors

• Persons who are ready to changePersons who are ready to change

NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

Obesity-Associated Risk Factors: High Absolute Risk

• Established coronary heart diseaseEstablished coronary heart disease• Other atherosclerotic diseasesOther atherosclerotic diseases• Type 2 diabetesType 2 diabetes• Sleep apneaSleep apnea


Obesity-Associated Risk Factors: 3 or More = ↑ Risk

• HypertensionHypertension• Cigarette smokingCigarette smoking• High low-density lipoprotein cholesterolHigh low-density lipoprotein cholesterol• Low high-density lipoprotein cholesterolLow high-density lipoprotein cholesterol• Impaired fasting glucoseImpaired fasting glucose• Family history of early cardiovascular diseaseFamily history of early cardiovascular disease• Age (male Age (male ≥ 45 years, female ≥ 55 years)≥ 45 years, female ≥ 55 years)


Other Obesity-Associated Risk Factors

• OsteoarthritisOsteoarthritis• GallstonesGallstones• Stress incontinenceStress incontinence• Gynecological abnormalitiesGynecological abnormalities

NHLBI Obesity Education Initiative. The Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

How Much and How Fast?

• NIH guidelines recommend a weight loss of .5 NIH guidelines recommend a weight loss of .5 to 1 pound/week for persons with a BMI of 27-to 1 pound/week for persons with a BMI of 27-35 and 1-2 pounds a week for those with a 35 and 1-2 pounds a week for those with a BMI>35 kg/m2BMI>35 kg/m2

• Allow 6 months to achieve 10% weight lossAllow 6 months to achieve 10% weight loss• After 6 months, focus should shift to weight After 6 months, focus should shift to weight

maintenance for 6 monthsmaintenance for 6 months• Following this, weight loss efforts may resume Following this, weight loss efforts may resume

(NIH, 1998)(NIH, 1998)

Weight Loss Goals

• Individualized goals of weight loss therapy Individualized goals of weight loss therapy should be to reduce body weight at an should be to reduce body weight at an optimal rate of 1-2 lbs per week for the first 6 optimal rate of 1-2 lbs per week for the first 6 months and to achieve an initial weight loss months and to achieve an initial weight loss goal of up to 10% from baseline. goal of up to 10% from baseline.

• These goals are realistic, achievable, and These goals are realistic, achievable, and sustainable. sustainable. Strong, ImperativeStrong, Imperative

American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Rates of Weight Loss Vary

• Men will lose weight faster than women Men will lose weight faster than women of similar size, due to higher LBM and of similar size, due to higher LBM and RMRRMR

• A heavier person (who has higher energy A heavier person (who has higher energy needs) will lose weight faster than a needs) will lose weight faster than a smaller person on the same caloric smaller person on the same caloric regimenregimen

Modest Weight Loss and Health: Diabetes Prevention• A 7% weight loss (mean 15 pounds) A 7% weight loss (mean 15 pounds) through diet and exercise in high risk through diet and exercise in high risk individuals was associated with a 58% individuals was associated with a 58% reduction of diabetes incidence in the reduction of diabetes incidence in the Diabetes Prevention Program Diabetes Prevention Program DPP Research DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403. Group. N Engl J Med. 2002 Feb 7;346(6):393-403.

• An average 7.7 pound weight loss was An average 7.7 pound weight loss was associated with a 58% reduction in diabetes associated with a 58% reduction in diabetes incidence in high risk individuals in the incidence in high risk individuals in the Finnish Diabetes Prevention study. Finnish Diabetes Prevention study. FDPS FDPS GroupGroup. . N Engl J MedN Engl J Med 344:1343–1350, 2001 344:1343–1350, 2001

Modest Weight Loss and Health: Hypertension

• Weight loss of as little as 4.5 kg (10 pounds) Weight loss of as little as 4.5 kg (10 pounds) will improve or prevent hypertension in a will improve or prevent hypertension in a large segment of overweight persons. large segment of overweight persons. Seventh Seventh Report of the Joint National Committee on Prevention, Detection, Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Evaluation, and Treatment of High Blood Pressure (JNC 7) http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

• Clinically significant long-term reductions in Clinically significant long-term reductions in blood pressure and reduced risk for blood pressure and reduced risk for hypertension can be achieved with modest hypertension can be achieved with modest weight loss and increased physical activity. weight loss and increased physical activity. American Dietetic Association Evidence Analysis Library, American Dietetic Association Evidence Analysis Library, Hypertension and hyperlipidemia. Hypertension and hyperlipidemia. http://www.adaevidencelibrary.org/http://www.adaevidencelibrary.org/

http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

Modest Weight Loss and Health: Hyperlipidemia

• The ATP-III guidelines recommend a 10% The ATP-III guidelines recommend a 10% weight loss in overweight persons with weight loss in overweight persons with hyperlipidemia. hyperlipidemia. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf

• A weight loss of A weight loss of ≥2.25 kg was associated with ≥2.25 kg was associated with a 40-50% reduction in cardiovascular risk a 40-50% reduction in cardiovascular risk factors in the Framingham Offspring Study factors in the Framingham Offspring Study (BP, triglyceride, TC, FBS, HDL) (BP, triglyceride, TC, FBS, HDL) Karason K et al. Karason K et al.

Int J Obes Relat Metab Disord 1999;23:948-56Int J Obes Relat Metab Disord 1999;23:948-56..

http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf

Modest Weight Loss and Health: Diabetes

• Calorie restriction and weight loss improves Calorie restriction and weight loss improves insulin sensitivity and glycemic control in obese insulin sensitivity and glycemic control in obese patients with Type 2 diabetes. patients with Type 2 diabetes.

• A 5% weight loss can decrease FBG, insulin, A 5% weight loss can decrease FBG, insulin, A1C concentrations and medication requirements. A1C concentrations and medication requirements.

Wing RRWing RR, , Henry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin Endocrinol Henry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin Endocrinol

MEtab 1993;77:1287-93. et al. Arch Intern MedMEtab 1993;77:1287-93. et al. Arch Intern Med..1987;147:1749-531987;147:1749-53..

Setting Weight Management Goals

• Many severely overweight persons have Many severely overweight persons have unrealistic expectations in setting weight unrealistic expectations in setting weight loss goals (Blackburn, 1998)loss goals (Blackburn, 1998)

• Even modest weight loss may produce Even modest weight loss may produce significant improvements in healthsignificant improvements in health

• For some persons (especially those with For some persons (especially those with BMI of 25-29.9) weight maintenance may be BMI of 25-29.9) weight maintenance may be a goala goal

Evaluation of Body Wt

• Body mass index (BMI) and waist Body mass index (BMI) and waist circumference should be used to classify circumference should be used to classify overweight and obesity, estimate risk for overweight and obesity, estimate risk for disease, and to identify treatment options. disease, and to identify treatment options.

• BMI and waist circumference are highly BMI and waist circumference are highly correlated to obesity or fat mass and risk of correlated to obesity or fat mass and risk of other diseases (NHLBI report). other diseases (NHLBI report). Fair,Fair, ImperativeImperative


Estimation of Energy Needs• Estimated energy needs should be based on RMR. If Estimated energy needs should be based on RMR. If

possible, RMR should be measured (e.g., indirect possible, RMR should be measured (e.g., indirect calorimetry). calorimetry).

• If RMR cannot be measured, then the Mifflin-St. If RMR cannot be measured, then the Mifflin-St. Jeor equation using Jeor equation using actualactual weight is the most weight is the most accurate for estimating RMR for overweight and accurate for estimating RMR for overweight and obese individuals. obese individuals. Strong, ConditionalStrong, Conditional


Readiness to Change: A Brief Assessment

• Has the individual sought weight loss on Has the individual sought weight loss on his/her own initiative?his/her own initiative?

• What has led the patient to seek weight What has led the patient to seek weight loss now?loss now?

• What are the patient’s stress level and What are the patient’s stress level and mood? mood?

• Does the individual have an eating Does the individual have an eating disorder?disorder?

Readiness to Change: A Brief Assessment

• Does the individual understand the Does the individual understand the requirements of treatment and believe requirements of treatment and believe that he/she can fulfill them?that he/she can fulfill them?

• How much weight does the patient How much weight does the patient expect to lose? expect to lose?

NIH Recommended Interventions

• Dietary therapy• Physical activity• Behavior therapy• Pharmacotherapy• Bariatric surgery

Comprehensive Wt Mgt Program

• Weight loss and weight maintenance Weight loss and weight maintenance therapy should be based on a therapy should be based on a comprehensive weight management comprehensive weight management program including diet, physical activity, program including diet, physical activity, and behavior therapy. The combination and behavior therapy. The combination therapy is more successful than using therapy is more successful than using any one intervention alone. any one intervention alone. Strong, Strong, ImperativeImperative American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Dietary Interventions

Reduced Calorie Diets

• An individualized reduced calorie diet is the An individualized reduced calorie diet is the basis of the dietary component of a basis of the dietary component of a comprehensive weight management program. comprehensive weight management program.

• Reducing dietary fat and/or carbohydrates is a Reducing dietary fat and/or carbohydrates is a practical way to create a caloric deficit of 500 practical way to create a caloric deficit of 500 – 1000 kcals below estimated energy needs – 1000 kcals below estimated energy needs and should result in a weight loss of 1 – 2 lbs and should result in a weight loss of 1 – 2 lbs per week. per week. Strong, ImperativeStrong, ImperativeAmerican Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Balanced Energy-Restricted Diet

• Is the most widely-prescribed method of Is the most widely-prescribed method of weight reductionweight reduction

• Should be nutritionally adequate except Should be nutritionally adequate except for energyfor energy

• Energy level varies with individual’s Energy level varies with individual’s size, sex, and activity, ranging from 800 size, sex, and activity, ranging from 800 kcals to 1500 kcals (NIH, 1998)kcals to 1500 kcals (NIH, 1998)

Balanced Energy-Restricted Diet

• Should be relatively high in carbohydrate (50-Should be relatively high in carbohydrate (50-55% of total kcals)55% of total kcals)• CHO sources should be fruits, vegetables, whole grainsCHO sources should be fruits, vegetables, whole grains

• Include generous protein (15-25% of kcals) for Include generous protein (15-25% of kcals) for increased satiety and to assure adequate supplyincreased satiety and to assure adequate supply

• Fat < 30% of kcalsFat < 30% of kcals• Increased fiber to improve satiety (NIH, 1998)Increased fiber to improve satiety (NIH, 1998)

Balanced Energy-Restricted Diet• Alcohol and high-sugar foods should be Alcohol and high-sugar foods should be

limited to limit excess energylimited to limit excess energy• Use of non-nutritive sweeteners and fat Use of non-nutritive sweeteners and fat

replacements may improve the palatability replacements may improve the palatability of the dietof the diet

• Vitamins and mineral supplements may be Vitamins and mineral supplements may be needed in programs that provide <1200 needed in programs that provide <1200 kcals for women or 1800 kcals for men kcals for women or 1800 kcals for men (NIH, 1998)(NIH, 1998)

Exchange System Diets

• Allow flexibility in making Allow flexibility in making food choices while limiting food choices while limiting total caloric intaketotal caloric intake

• Provides framework for Provides framework for healthy balance of nutrientshealthy balance of nutrients

• May be too complex or May be too complex or restrictive for some clientsrestrictive for some clients

Nutrition Education• Nutrition education should be individualized Nutrition education should be individualized

and included as part of the diet component of a and included as part of the diet component of a comprehensive weight management program. comprehensive weight management program.

• Short term studies show that nutrition education Short term studies show that nutrition education (e.g. reading nutrition labels, recipe (e.g. reading nutrition labels, recipe modification, cooking classes) increases modification, cooking classes) increases knowledge and may lead to improved food knowledge and may lead to improved food choices. choices. Fair, ImperativeFair, Imperative


Eating Frequency and Patterns

• Total caloric intake should be distributed Total caloric intake should be distributed throughout the day, with the consumption of throughout the day, with the consumption of 4 to 5 meals/snacks per day including 4 to 5 meals/snacks per day including breakfast. breakfast.

• Consumption of greater energy intake during Consumption of greater energy intake during the day may be preferable to evening the day may be preferable to evening consumption. consumption. Fair, ImperativeFair, Imperative


Portion Control

• Portion control should be included as Portion control should be included as part of a comprehensive weight part of a comprehensive weight management program. Portion control management program. Portion control at meals and snacks results in reduced at meals and snacks results in reduced energy intake and weight loss. energy intake and weight loss. Fair, Fair, ImperativeImperative


Meal Replacements

• For people who have difficulty with self For people who have difficulty with self selection and/or portion control, meal selection and/or portion control, meal replacements (e.g., liquid meals, meal bars, replacements (e.g., liquid meals, meal bars, calorie-controlled packaged meals) may be calorie-controlled packaged meals) may be used as part of the diet component of a used as part of the diet component of a comprehensive weight management program. comprehensive weight management program.

• Substituting one or two daily meals or snacks Substituting one or two daily meals or snacks with meal replacements is a successful weight with meal replacements is a successful weight loss and weight maintenance strategy. loss and weight maintenance strategy. Strong, Strong, ConditionalConditional


Low Glycemic Index Diets

• A low glycemic index diet is A low glycemic index diet is notnot recommended for weight loss or weight recommended for weight loss or weight maintenance as part of a comprehensive maintenance as part of a comprehensive weight management program, since it weight management program, since it has not been shown to be effective in has not been shown to be effective in these areas. these areas. Strong, ImperativeStrong, Imperative


Lowfat Dairy Foods

• In order to meet current nutritional In order to meet current nutritional recommendations, incorporate 3-4 servings of recommendations, incorporate 3-4 servings of low fat dairy foods a day as part of the diet low fat dairy foods a day as part of the diet component of a comprehensive weight component of a comprehensive weight management program. management program.

• Research suggests that calcium intake lower than Research suggests that calcium intake lower than recommended levels is associated with increased recommended levels is associated with increased body weight. However, the effect of dairy and/or body weight. However, the effect of dairy and/or calcium at or above recommended levels on calcium at or above recommended levels on weight management is unclear. weight management is unclear. Fair, ImperativeFair, Imperative


Low Carbohydrate Diets• Having patients focus on reducing carbohydrates Having patients focus on reducing carbohydrates

rather than reducing calories and/or fat may be a rather than reducing calories and/or fat may be a short term strategy for some individuals. short term strategy for some individuals.

• Research indicates that focusing on reducing Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from carbohydrate intake (<35% of kcals from carbohydrates) results in reduced energy intake. carbohydrates) results in reduced energy intake.

• Consumption of a low-carbohydrate diet is Consumption of a low-carbohydrate diet is associated with a greater weight and fat loss than associated with a greater weight and fat loss than traditional reduced calorie diets during the first 6 traditional reduced calorie diets during the first 6 months, but these differences are not significant months, but these differences are not significant after 1 year. after 1 year. Fair, ConditionalFair, Conditional


Very Low Calorie Diets (VLCD)• Diets providing 200-800 kcals/dayDiets providing 200-800 kcals/day• Hypocaloric but relatively rich in protein (.8-1.5 Hypocaloric but relatively rich in protein (.8-1.5

g/kg/day)g/kg/day)• Designed to include adequate vitamins, minerals, Designed to include adequate vitamins, minerals,

electrolytes, and EFAselectrolytes, and EFAs• Completely replace usual meal intakeCompletely replace usual meal intake• Usually given for 12-16 weeksUsually given for 12-16 weeks• Usually reserved for those with BMI>30; or 27-30 Usually reserved for those with BMI>30; or 27-30

with risk factorswith risk factors

NHLBI, 2000

Protein Sparing Modified Fast (PSMF)

• Contains 1.5 g protein/kg IBW as lean Contains 1.5 g protein/kg IBW as lean meat, fish and poultrymeat, fish and poultry

• Uses real foodUses real food• May include low-carbohydrate vegetablesMay include low-carbohydrate vegetables• Only fat is that present in the protein Only fat is that present in the protein

sourcessources

NIH NHLBI The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NHLBI, 2000

Commercial VLCD Liquid Diets• Contain 33-70 g of Contain 33-70 g of

protein, 30-45 g protein, 30-45 g CHO, small amount CHO, small amount of fatof fat

• Provides 400-800 Provides 400-800 kcalskcals

• Patients lose 20 kg Patients lose 20 kg in 12 to 16 weeksin 12 to 16 weeks


VLCDs

• Cardiac complications a concernCardiac complications a concern• Risks include potassium loss as well as body Risks include potassium loss as well as body

protein (higher in the less obese)protein (higher in the less obese)• Requires close medical supervision and Requires close medical supervision and

monitoring of serum electrolytesmonitoring of serum electrolytes• But VLCDs may be a more But VLCDs may be a more effective method of weighteffective method of weight loss for someloss for some (Anderson et al Am J Clin Nutr 74;579:2001)(Anderson et al Am J Clin Nutr 74;579:2001)

Dietary Therapy: NIH Guidelines

• Very low calorie diets (VLCDs) should not Very low calorie diets (VLCDs) should not be used routinely for weight loss therapy be used routinely for weight loss therapy because they require special monitoring because they require special monitoring and supplementationand supplementation

• LCDs may be just as effectiveLCDs may be just as effective


Email: [email protected],[email protected]

Weight Reducing Diet









Behavioral Therapy in Weight Management

Behavioral Therapy: NIH Guidelines• Self-monitoringSelf-monitoring• Stress managementStress management• Stimulus controlStimulus control• Problem-solvingProblem-solving• Contingency managementContingency management• Cognitive restructuringCognitive restructuring• Social supportSocial support

Behavior Therapy in Wt Mgt• A comprehensive weight management program A comprehensive weight management program

should make maximum use of multiple strategies for should make maximum use of multiple strategies for behavior therapy (e.g. self monitoring, stress behavior therapy (e.g. self monitoring, stress management, stimulus control, problem solving, management, stimulus control, problem solving, contingency management, cognitive restructuring, contingency management, cognitive restructuring, and social support). and social support).

• Behavior therapy in addition to diet and physical Behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent behavioral interventions may be necessary to prevent a return to baseline weight. a return to baseline weight. Strong, ImperativeStrong, Imperative


Self Monitoring

• Records of place and time of food intakeRecords of place and time of food intake• Accompanying thoughts and feelingsAccompanying thoughts and feelings• Helps identify the physical and Helps identify the physical and

emotional settings in which eating occursemotional settings in which eating occurs• Provides feedback on progress and puts Provides feedback on progress and puts

responsibility on the patientresponsibility on the patient

Problem Solving

• Process for defining the eating or weight Process for defining the eating or weight problemproblem

• Generating possible solutions; evaluating Generating possible solutions; evaluating the solutions, choosing the best onethe solutions, choosing the best one

• Trialing the new behavior, evaluating Trialing the new behavior, evaluating outcome and generating alternativesoutcome and generating alternatives

Stimulus ControlModification ofModification of• The settings or the chain of events that The settings or the chain of events that

precede eatingprecede eating• The kinds of foods consumedThe kinds of foods consumed• The consequences of eatingThe consequences of eating

• Become mindful of satiety cuesBecome mindful of satiety cues• Put fork down between bitesPut fork down between bites• Pausing during mealsPausing during meals

Cognitive Restructuring

• Teaches patients to identify, challenge, Teaches patients to identify, challenge, and correct negative thoughtsand correct negative thoughts

• Positive self-talkPositive self-talk

Behavior Modification

• Most effective in mildly obese (20-40% Most effective in mildly obese (20-40% overweight)overweight)

• Patients can maintain losses of 20-25 Patients can maintain losses of 20-25 poundspounds

• Longer programs more successfulLonger programs more successful• Many patients regain the weight they lost Many patients regain the weight they lost

over timeover time


Physical Activity and Weight Management

Role of Physical Activity in Weight Management

Other Benefits: Other Benefits:

——Improved sense of well-beingImproved sense of well-being

——Relief of boredomRelief of boredom

——Sense of controlSense of control

——Relief from depressionRelief from depression

Physical Activity• Physical activity should be part of a Physical activity should be part of a

comprehensive weight management program. comprehensive weight management program. Physical activity level should be assessed and Physical activity level should be assessed and individualized long-term goals established to individualized long-term goals established to accumulate at least 30 minutes or more of accumulate at least 30 minutes or more of moderate intensity physical activity on most, and moderate intensity physical activity on most, and preferably, all days of the week, unless medically preferably, all days of the week, unless medically contraindicated. contraindicated.

• Physical activity contributes to weight loss, may Physical activity contributes to weight loss, may decrease abdominal fat, and may help with decrease abdominal fat, and may help with maintenance of weight loss. maintenance of weight loss. Strong, ImperativeStrong, Imperative


Physical Activity: NIH Guidelines• Physical activity increases energy Physical activity increases energy

expenditure and plays an integral role in expenditure and plays an integral role in weight maintenanceweight maintenance

• Reduces the risk of heart disease more than Reduces the risk of heart disease more than weight loss aloneweight loss alone

• Reduces body fat, prevents decrease in Reduces body fat, prevents decrease in muscle mass during weight lossmuscle mass during weight loss

• All adults: goal of 30 minutes or more of All adults: goal of 30 minutes or more of moderate-intensity physical activity on most moderate-intensity physical activity on most and preferably all days.and preferably all days.



• Physical activity usually will not lead to a Physical activity usually will not lead to a greater weight loss over diet alone in a 6-greater weight loss over diet alone in a 6-month period (NIH, 2000)month period (NIH, 2000)

• Physical activity is most helpful in Physical activity is most helpful in preventing weight regainpreventing weight regain

• Physical activity also is beneficial in Physical activity also is beneficial in reducing risk for heart disease and diabetes reducing risk for heart disease and diabetes beyond the effect of weight lossbeyond the effect of weight loss


• Exercise helps balance the loss of LBM and Exercise helps balance the loss of LBM and reduction in RMR caused by hypocaloric reduction in RMR caused by hypocaloric dietsdiets

• A combination of aerobic exercise and A combination of aerobic exercise and resistance training is recommendedresistance training is recommended

• Even when weight loss does not occur, loss Even when weight loss does not occur, loss of body fat often doesof body fat often does

• May require 2 months to see loss of weight May require 2 months to see loss of weight through exercisethrough exercise

2009

How Many Calorie Am I Burning?

Activity 100 lb 150 lb 200 lbBicycling, 6 mph 160 240 312

Bicycling, 12 mph 270 410 534

Jogging, 7 mph 610 920 1,230

Jumping rope 500 750 1,000

Running, 5.5 mph 440 660 962

Running, 10 mph 850 1,280 1,664

Swimming, 25 yds/min 185 275 358

Swimming, 50 yds/min 325 500 650

Tennis singles 265 400 535

Walking, 2 mph 160 240 312

Walking, 3 mph 210 320 416

Walking, 4.5 mph 295 440 572

American Heart Association

Calories burned/hour of activity

2009

How Many Calories Do I Need?

• USDA’s MyPyramid site: USDA’s MyPyramid site: http://www.mypyramid.gov/ • Determines calorie needs and calculates the servings Determines calorie needs and calculates the servings

needed from food groups.needed from food groups.• The American Cancer Society (ACS) site: The American Cancer Society (ACS) site:

http://www.cancer.org/docroot/PED/content/PED_6_1x_Calorie_Calculator.asp

• The ACS site indicates the number of calories that are The ACS site indicates the number of calories that are needed per day to maintain your current weight. needed per day to maintain your current weight.

http://www.mypyramid.gov/



2009

Before Beginning an Exercise Program

• Are a man older than age 40 or Are a man older than age 40 or a woman older than age 50 a woman older than age 50

• Have had a heart attackHave had a heart attack• Have a family history of heart-related Have a family history of heart-related

problems before age 55problems before age 55• Have heart, lung, liver or kidney diseaseHave heart, lung, liver or kidney disease• Feel pain in your chest, joints, or muscles Feel pain in your chest, joints, or muscles

during physical activityduring physical activity• Have high blood pressure, high cholesterol, Have high blood pressure, high cholesterol,

diabetes, arthritis, osteoporosis, or asthmadiabetes, arthritis, osteoporosis, or asthma

• Have had joint replacement surgeryHave had joint replacement surgery• SmokeSmoke• Are overweight or obeseAre overweight or obese• Tale medication to manage a chronic Tale medication to manage a chronic

conditioncondition• Have an untreated joint or muscle Have an untreated joint or muscle

injury, or persistent symptoms after a injury, or persistent symptoms after a joint or muscle injuryjoint or muscle injury

• Are pregnantAre pregnant• Unsure of your health status.Unsure of your health status.

You should check with your doctor before beginning an exercise program if you:

Mayo Clinic

Health Benefits of Physical Activity

Health benefits of physical activity. CMAJ. 2006; 174(6): 801-809.

2009

Physical ActivitySecondary Effects on Diabetes

Mellitus• Exercise helps in the management Exercise helps in the management

of diabetes.of diabetes.

• Aerobic and resistance trainingAerobic and resistance training help help in the control of diabetes in the control of diabetes

CMAJ. 2006;174(6): 801-809.

2009

Physical ActivitySecondary Effects on Cancer

• Regular physical activity - important.Regular physical activity - important. • Increased self-reported physical activity = Increased self-reported physical activity =

decreased reoccurrence of cancerdecreased reoccurrence of cancer and a and a decreased risk of death from cancerdecreased risk of death from cancer..

• Reduced cancer-related death.Reduced cancer-related death.

CMAJ. 2006;174(6): 801-809.

2009

Physical ActivityPrimary Effects on Osteoporosis

• Many studies have been conducted.Many studies have been conducted.

• According to findings, According to findings, routine physical routine physical activityactivity, especially weight-bearing and , especially weight-bearing and impact exercise, impact exercise, prevents bone loss prevents bone loss associated with agingassociated with aging. .

CMAJ. 2006;174(6): 801-809.

Weight Loss Medications

Pharmacological Therapy: NIH Guidelines

• Should be used only in the context of a Should be used only in the context of a program that includes lifestyle changesprogram that includes lifestyle changes

• If lifestyle changes do not promote weight If lifestyle changes do not promote weight loss after 6 months, drugs should be loss after 6 months, drugs should be consideredconsidered

• Limited to those with BMI ≥30; or ≥27 Limited to those with BMI ≥30; or ≥27 with risk factorswith risk factors


Wt Loss Medications• FDA-approved weight loss medications may be part FDA-approved weight loss medications may be part

of a comprehensive weight management program. of a comprehensive weight management program. • Dietitians should collaborate with other members of Dietitians should collaborate with other members of

the health care team regarding the use of FDA-the health care team regarding the use of FDA-approved weight loss medications for people who approved weight loss medications for people who meet the NHLBI criteria. meet the NHLBI criteria.

• Research indicates that pharmacotherapy may Research indicates that pharmacotherapy may enhance weight loss in some overweight and obese enhance weight loss in some overweight and obese adults. adults. Strong, ImperativeStrong, Imperative


Catecholaminergic Drugs• Appetite suppressantsAppetite suppressants• Act on the brain, increasing the availability of Act on the brain, increasing the availability of

norepinephrinenorepinephrine• Schedule II anorexic agentsSchedule II anorexic agents

• High potential for abuseHigh potential for abuse• Include amphetamine, phenmetrazine HClInclude amphetamine, phenmetrazine HCl• Not recommended for weight managementNot recommended for weight management

• Schedule III agentsSchedule III agents• Some potential for abuseSome potential for abuse• Include benzphetamine HCl, phendimetrazine Include benzphetamine HCl, phendimetrazine

tartratetartrateSee Table 21-5 Krause 12th edition, p. 551

Catecholaminergic Drugs• Schedule IV agentsSchedule IV agents

• Includes diethypropion HCl, manzindol Includes diethypropion HCl, manzindol HCl, phentermine HCl, phentermine HCl, phentermine HCl, phentermine resinresin

• Low potential for abuseLow potential for abuse• Can raise blood pressure, so prescribed Can raise blood pressure, so prescribed

with caution in patients with with caution in patients with hypertensionhypertension


Serotonin Reuptake Inhibitors

• Includes sibutramine (Meridia)Includes sibutramine (Meridia)• Inhibits the reuptake of serotonin and Inhibits the reuptake of serotonin and

norepinephrinenorepinephrine• Initially developed to treat depressionInitially developed to treat depression• Use caution in hypertension, CHD, Use caution in hypertension, CHD,

arrhythmias, CHFarrhythmias, CHF


Orlistat (Xenical)• Lipase inhibitorLipase inhibitor• Acts directly on the gastrointestinal tract to Acts directly on the gastrointestinal tract to

inhibit fat absorptioninhibit fat absorption• Associated with reduced LDL-C and increased Associated with reduced LDL-C and increased

HDL; improved glycemic control, reduced blood HDL; improved glycemic control, reduced blood pressurepressure

• Some concern about fat soluble vitaminsSome concern about fat soluble vitamins• Side effects: oily spotting, fecal urgency, flatus Side effects: oily spotting, fecal urgency, flatus

with dischargewith discharge


FDA Approves Reduced Dose of Orlistat for Over the Counter

• Over the counter dose of Over the counter dose of orlistat, a lipase inhibitororlistat, a lipase inhibitor

• Half the dose of Half the dose of prescription form prescription form (Xenical)(Xenical)

• The only FDA-approved The only FDA-approved over the counter wt mgt over the counter wt mgt drugdrug

• Available summer 2007Available summer 2007

Serotoninergic Agents

• Increase serotonin levels in the brainIncrease serotonin levels in the brain• Fenfluramine hydrochloride and Fenfluramine hydrochloride and

dexfenfluramine HCl (Fen-Phen) were dexfenfluramine HCl (Fen-Phen) were removed from the market in 1997 due to removed from the market in 1997 due to association with heart valve disease and association with heart valve disease and pulmonary hypertensionpulmonary hypertension

Pharmacological Obesity Treatments

• Weight loss of about 1 lb/week can be Weight loss of about 1 lb/week can be expectedexpected

• Most weight loss will occur within the first Most weight loss will occur within the first 6 months of therapy6 months of therapy

• Significant weight maintenance as long as Significant weight maintenance as long as the drug treatment is continuedthe drug treatment is continued

• Most patients regain weight if medication is Most patients regain weight if medication is stoppedstopped

Pharmacological Obesity Treatments

• Weight-loss medications lead to an Weight-loss medications lead to an additional weight loss of 5 to 22 pounds additional weight loss of 5 to 22 pounds more than with non-drug obesity more than with non-drug obesity treatments treatments

• Two to 20 kg total loss, usually during Two to 20 kg total loss, usually during first 6 months of treatmentfirst 6 months of treatment

• When drugs are discontinued, weight When drugs are discontinued, weight regain occursregain occurs

EXPERIMENTAL DRUGS

• Leptin & Ghrelin

•Peptide YY

•Oxyntomodulin

•Melanocortin-4 receptor agonists

SURGERY in OBESITY

Bariatric Surgery• Dietitians should collaborate with other Dietitians should collaborate with other

members of the health care team regarding the members of the health care team regarding the appropriateness of bariatric surgery for people appropriateness of bariatric surgery for people who have not achieved weight loss goals with who have not achieved weight loss goals with less invasive weight loss methods and who less invasive weight loss methods and who meet the NHLBI criteria. meet the NHLBI criteria.

• Separate ADA evidence based guidelines are Separate ADA evidence based guidelines are being developed on nutrition care in bariatric being developed on nutrition care in bariatric surgery. surgery. Strong, ImperativeStrong, Imperative


Bariatric Surgery: NIH Guidelines

• Option for well-informed and motivated Option for well-informed and motivated patients with clinically severe obesity patients with clinically severe obesity (BMI≥40 or BMI ≥35 with serious co-(BMI≥40 or BMI ≥35 with serious co-morbid conditionsmorbid conditions


Candidates for Bariatric Surgery

• BMI of 40 or more—about 100 pounds BMI of 40 or more—about 100 pounds overweight for men and 80 pounds for women overweight for men and 80 pounds for women

• BMI between 35 and 39.9 and a serious BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apneadiabetes, heart disease, or severe sleep apnea

• Willingness to make associated lifestyle Willingness to make associated lifestyle changes changes

Bariatric Surgery Options

• RestrictiveRestrictive• MalabsorptiveMalabsorptive• Combination restrictive/malabsorptiveCombination restrictive/malabsorptive

Restrictive Procedures• Adjustable gastric banding (AGB)Adjustable gastric banding (AGB) a a

hollow band made of silicone rubber is hollow band made of silicone rubber is placed around the stomach near its upper placed around the stomach near its upper end, creating a small pouch and a narrow end, creating a small pouch and a narrow passage into the rest of the stomach passage into the rest of the stomach

• Vertical banded gastroplasty.Vertical banded gastroplasty. VBG uses VBG uses both a band and staples to create a small both a band and staples to create a small stomach pouch (not often used today)stomach pouch (not often used today)

Restrictive Surgery: Adjustable Gastric Band

Diet After Surgery

• After restrictive surgeries, patients can only After restrictive surgeries, patients can only eat ½ cup to 1 cup of food at a timeeat ½ cup to 1 cup of food at a time

• Foods often must be soft and chewed Foods often must be soft and chewed thoroughlythoroughly

• Patients who eat too fast or the wrong Patients who eat too fast or the wrong kinds of food may have vomitingkinds of food may have vomiting

Restrictive Procedures: Advantages

• Don’t interfere with the normal Don’t interfere with the normal digestive processdigestive process

• Easier to perform and generally safer Easier to perform and generally safer than malabsorptive surgeriesthan malabsorptive surgeries

• AGB often done laparoscopicallyAGB often done laparoscopically• Can be reversed if necessaryCan be reversed if necessary

Restrictive Procedures: Disadvantages

• Generally results in less weight lossGenerally results in less weight loss• Patients generally lose about half of their Patients generally lose about half of their

excess body weight in the first year after excess body weight in the first year after restrictive procedures restrictive procedures

• Only 20% keep weight off over 10 years, Only 20% keep weight off over 10 years, though there is evidence that AGB is more though there is evidence that AGB is more effective than VBGeffective than VBG

Restrictive/Malabsorptive Procedures

• Roux-en-Y gastric bypass (RGBRoux-en-Y gastric bypass (RGB) is the most ) is the most commoncommon

• The surgeon creates a small stomach pouch to The surgeon creates a small stomach pouch to restrict food intake. Next, a Y-shaped section of restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to the small intestine is attached to the pouch to allow food to bypass the lower stomach, the allow food to bypass the lower stomach, the duodenum and the first portion of the jejunum. duodenum and the first portion of the jejunum.

• This reduces the amount of calories and This reduces the amount of calories and nutrients the body absorbs. nutrients the body absorbs.

Restrictive/Malabsorptive: Roux en Y

Restrictive/Malabsorptive Procedures: Advantages

• Patients lose weight quickly and Patients lose weight quickly and continue to lose 18-24 months after the continue to lose 18-24 months after the procedureprocedure

• With RGB, many patients maintain a With RGB, many patients maintain a weight loss of 60 to 70 percent of their weight loss of 60 to 70 percent of their excess weight for 10 years or more excess weight for 10 years or more

Restrictive/Malabsorptive Procedures: Disadvantages

• More difficult to performMore difficult to perform• More likely to result in long-term More likely to result in long-term

nutritional deficiencies (calcium, iron)nutritional deficiencies (calcium, iron)• Greater risk of dumping syndromeGreater risk of dumping syndrome• Increased likelihood of complications Increased likelihood of complications

including hernia (decreased with including hernia (decreased with laparoscopic procedures)laparoscopic procedures)

Weight Management—Children

• Goals: Weight maintenance or slowing Goals: Weight maintenance or slowing of gainsof gains

• Grow into weightGrow into weight• If severely obese, lose no more than 1 If severely obese, lose no more than 1

lb monthly to reach desired adult lb monthly to reach desired adult weight for heightweight for height

Weight Management in Children

• At risk at BMI 85% to 95%ile; obese at At risk at BMI 85% to 95%ile; obese at 95%95%

• Review parents’ history—height, Review parents’ history—height, weight, etc.weight, etc.

• Weight management in children is a Weight management in children is a family affairfamily affair

Weight Management in Children

• Overweight children should try to Overweight children should try to achieve weight maintenance or slowing achieve weight maintenance or slowing of the rate of weight gain, not weight lossof the rate of weight gain, not weight loss

• Depends on age and degree of Depends on age and degree of overweightoverweight

• Once adult height is achieved, weight Once adult height is achieved, weight loss is necessary to improve healthloss is necessary to improve health

SUMMARYFirst Line with LS 2nd Line with LS Easy & Cheaper Invasive & Cost is More

Convenient Inconvenient

Less effective More effectiveLess Persistence More

Any Degree of Obesity Higher BMI

Less Complication More ComplicationsComorbiditis Cure Rate is less Comorbiditis Cure Rate is moreDietary moderation- less Dietary moderation- more

Less Efficient Team Work More Efficient Team Work

Short Term Improvement Long Term ImprovementEasy selection Selection by Team

Summary• Even modest weight loss can produce Even modest weight loss can produce

improvements in overall health in improvements in overall health in persons who are overweight (lipids, persons who are overweight (lipids, BG, insulin, blood pressure).BG, insulin, blood pressure).

• Most persons will need sustained, long-Most persons will need sustained, long-term lifestyle interventions to achieve term lifestyle interventions to achieve significant weight loss.significant weight loss.

Prevention is Better

THANKS TO ALL

Health & Medicine

Obesity, prevalence, risk factors, approach to management- Dr Shahjada Selim