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, Medical and Surgical Management Presenter - Dr Ruchita Sharma Moderator – Col P Prusty (Review article JAPI Feb2009)
30-65% of adult urban Indians are either overweight or obese or have abdominal obesity.
for different guidelines for Asian Indian-population need , background, and rationale for developing such guidelines
NCEP ATP III
or more of the following:
obesity: Waist circumference >102 cm (M), >88 cm (F) Triglycerides > 150 mg/dL
cholesterol: <40 mg/dL(M) and < 50 mg/dL(F) Blood pressure > 130/85 mmHg
plasma glucose > 100 mg/dL
WAIST CIRCUMFERENCE Men Women Ethnicity
94 cm 90 cm 85 cm
80 cm 80 cm 90 cm
Europeans South Asian, Chinese Japanese
Two or more of the following: Fasting triglycerides >150 mg/dL or specific medication HDL cholesterol <40 mg/dL and <50 mg/dL for men and women, respectively, or specific medication Blood pressure >130 systolic or >85 mm diastolic or previous diagnosis or specific medication Fasting plasma glucose 100 mg/dL or previously diagnosed type 2 diabetes
Hyperinsulinemia . fasting glucose AND at least 2 of the following:
≥ 110 mg/dL
(1) waist-to-hip ratio, men > 90 cm and women > 85 cm or BMI ≥ 30 kg/m2; or (2) waist girth ≥ 94 cm
Dyslipidemia: Serum TG ≥ 150 mg/dL, mg/dL HDL-C, men < 35 mg/dL and women < 39
Blood Pressure ≥ 140/90 mm Hg or medication
WHY REVISION OF GUIDELINES FOR OBESITY AND METABOLIC SYNDROME ARE NEEDED FOR ASIAN INDIANS?
Changing trend Asian Indians manifest higher risk at lower level of obesity and dyslipidemia than in non-Asian Indian populations.
WHO decision regarding guidelines for BMI for different countries In case of Indian population Benefit of lowering level of obesity
The Consensus Development Process
opinion for development for obesity guidelines The steering committee drafted document and communicated to all participants Revised consensus document was circulated among all the experts The consensus meeting held at New Delhi on 15-16th of November, 2008.
More than 100 medical experts from across the country and belonging to the various fields of medicine & surgery and representing reputed institutions, and policy making bodies participated to develop Asian Indian specific guidelines for defining and managing overweight and obesity. The steering committee prepared a draft document well in advance of the summit, which was communicated to all prospective participants for feedback and comments.
After incorporating the valid suggestions, the revised consensus document was circulated among all the experts for a second review before the consensus meeting. The consensus meeting was held at New Delhi on 15-16th of November, 2008. Experts discussed the questions as given below taking into account research and data in Asian Indians.
a.Which is/are the best measure(s) of obesity? b. What are optimum cut-offs for BMI and WC? c. What is the best definition for adults and children? d. What should be physical activity guidelines? e. What should be dietary guidelines? f. What should be guidelines for drug treatment of obesity? g. What should be guidelines for bariatric surgery?
WHICH IS /ARE THE BEST MEASURES FOR DIAGNOSIS OF OBESITY?
is defined as an excessive accumulation of fat in the body resulting in adverse effects on health of the individual. simple measures of obesity are widely used in clinical practice;
WC Waist-to-hip circumference ratio (WHR).
is the most researched measure of generalized obesity and should continue to be used using Asian Indian-specific cut-offs. Waist circumference should be used as a measure of abdominal obesity with Asian Indian specific cut-offs Both BMI and WC should be used together (with equal importance) for population- and clinic-based metabolic and cardiovascular risk stratification
WHAT ARE THE OPTIMUM CUT OFF FOR BMI & WC
Indians are more predisposed to develop insulin resistance and CVS risk factors at lower levels of BMI. CVS risk factors attributed by differences in body composition of Asian Indians
RECOMMENDED CUT OFFS OF BMI(kg/m²) W.H.O CONSENSUS STATEMENT
OVERWEIGHT 25- 29.9
WC AND WHR CUT OFFS FOR ASIAN INDIANS
obesity is as an important cardiovascular risk factor. of abdominal obesity with metabolic risk factors is stronger than generalized adiposity. surrogate measures of abdominal obesity are WC and WHR.
of cut-offs of WC (>102 cm in men and >88 cm in women) are not applicable to asian indians. Indians have higher morbidity at lower cut-off for WC than White Caucasians.
of WC Measurement
is preferred over WHR as a measure of abdominal obesity BMI and WC should be used together (with equal importance) for population- and clinic-based risk stratification
crest, at the end of normal expiration, in the fasting state, with the subject standing erect and looking straight forward and observer sitting in front of the subject. b. Based on the current evidence, WC is preferred over WHR as a measure of abdominal obesity with Asian Indian specific cut-offs.
Both BMI and WC should be used together (with equal importance) for population- and clinic-based risk stratification
Action level 1: Men: 78 cm, women: 72 cm. Person with WC above these levels should avoid gaining weight and maintain physical activity . Action level 2: Men: 90 cm, women: 80 cm. Subject with WC above this should seek medical help.
Action level 1: Men: 78 cm, women: 72 cm. Person with WC above these levels should avoid gaining weight and maintain physical activity to avoid cardiovascular risk factor.
b. Action level 2: Men: 90 cm, women: 80 cm. Subject with WC above this should seek medical help.
WHAT IS THE BEST DEFINITION FOR METABOLIC SYNDROME IN ADULT?
metabolic syndrome is defined as a clustering of cardiovascular risk factors in an individual which predisposes the person to a greater risk of developing T2DM and CVDs.
of IDF definition which includes
obesity [Asian indian cut-offs of WC, and WC as a nonobligatory criterion] High triglycerides Low-HDL Dysglycemia (impaired fasting glucose/impaired glucose tolerance) And hypertension should be used.
Three out of the five criteria have to be abnormal for diagnosing the metabolic syndrome.
-low-HDL, - dysglycemia (impaired fasting glucose/impaired glucose tolerance) - and hypertension should be used. Three out of the five criteria have to be abnormal for diagnosing the metabolic syndrome..
Physical Activity Guidelines for Obesity and Metabolic Syndrome
activity is defined as any activity leading to calorie consumption. reduces risk for cardiovascular diseases, diabetes and other disabilities associated with obesity.
Physical inactivity should be avoided as far as possible Pre-participation medical consultation is recommended for those with chronic conditions or those who are symptomatic Inactive people should start slow Brisk walking is preferred initial mode of exercise. Total of 60 minutes of physical activity is recommended every day
Consensus Statement (cont..)
activity can be accumulated throughout the day in blocks as short as 10 minutes. is a dose-response relationship between physical activity and health. activity must be individualized on the basis of person’s abilities and comorbidities. yoga should be encouraged.
should undertake at least 60 min of outdoor physical activity.
Physical Activity Guidelines for Obesity and the Metabolic Syndrome Physical activity is defined as any activity leading to calorie consumption. It reduces risk for cardiovascular diseases, diabetes and other disabilities associated with obesity. Consensus Statement a. Physical inactivity should be avoided as far as possible b. Pre-participation medical consultation is recommended for those with chronic conditions or those who are symptomatic
c. Inactive people should start slow . d. Brisk walking (walking at an intensity wherein an individual finds speaking difficult but not impossible) is preferred initial mode of exercise. e. In general, a total of 60 minutes of physical activity is recommended every day, this includes aerobic activity, workrelated activity and muscle strengthening Activity.
f. Physical activity can be accumulated throughout the day in blocks as short as 10 minutes. g. There is a dose-response relationship between physical activity and health. h. Physical activity must be individualized on the basis of person’s abilities and comorbidities. i. Dynamic yoga should be enccouraged.
PHARMACOLOGICAL TREATMENT OF OBESITY
consensus group agreed that antiobesity drugs should be used only in conjunction with diet and lifestyle modifications as a part of comprehensive weight loss program. should be monitored on an ongoing basis for efficacy as well as safety.
International Guidelines for drug treatment of obesity
BMI above 27 kg/m2 with risk factors or co-morbidities likeT2DM, hypertension, dyslipidemia. * BMI above 30 kg/m2 without comorbidity.
Consensus Statement for Asian Indians BMI above 25 kg/ m2 with co-morbidity BMI above 27 kg/m2 without comorbidity.
cut-offs for WC for initiating pharmacotherapy was unanimously agreed upon as a WC measurement 10 cms more than the upper limit of gender specific normal value for adult Asian Indians. is the drug of choice unless contraindicated. should be used as a second line drug because of adverse effects, lesser ability to induce weightloss, and higher cost.
involves modification of the digestive system -By either decreasing the gastric volume (restriction). - Altering the path of the food bolus causing an element of malabsorption. alterations effect appropriate changes in eating behavior and aid lifestyle modifications to help weight loss.
SURGICAL TREATMENT OF OBESITY
International Guidelines for surgical treatment of obesity :* BMI above 35 kg/m2 with risk factors or comorbiditieslikeT2DM,hypertension,dyslipidemia. * BMI above 40 kg/m2 without comorbidity. Consensus Statement for Asian Indians: The *BMI above 32.5 kg/ m2 with co-morbidity *BMI above 37.5 kg/m2 without co-morbidity.
The Surgical Options for Weight Loss Surgery: Restrictive Procedures: Adjustable gastric banding (LAGB) & sleeve gastrectomy. Combined Procedures: Roux-en-Y Gastric Bypass (RYGBP). Malabsorptive Procedures: Biliopancreatic diversions (BPD).
surgical procedure has its advantages and disadvantages as regards weight loss, resolution of surgical co-morbidities, peri-operative morbidity and mortality and long-term sequelae.
procedures showing better results compared to purely restrictive procedures such as gastric banding.
Complications of obesity
Coronary heart disease Type 2 diabetes Cancers (endometrial, breast, and colon) Hypertension (high blood pressure) Dyslipidemia (for example, high total cholesterol or high levels of triglycerides) Stroke Liver and Gallbladder disease Sleep apnea and respiratory problems Osteoarthritis (a degeneration of cartilage and its underlying bone within a joint) Gynecological problems (abnormal menses, infertility)
Advantages of obesity
risk of anemia,osteoporosis Low risk of depression,suicidal tendency Better outcome in Haemodialysis and heart transplant. More survival in HIV In pregnancy