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Obesity

Dr Othman A. Bani Yonis, MD
Assistant Professor/JUST University
American Fellowship in Family
Medicine/Women's Health.

 Obesity is a medical condition in which
excess body fat has accumulated to the
extent that it may have a negative effect
on health, leading to reduced life
expectancy and/or increased health
problems.

General information

 Obesity is defined based on body mass
index (BMI),Waist Circumference(WC)
or Waist to Hip Ratio(WHR).

BMI
◦ BMI defined as weight in kg divided by square
of height in meters: kg/m2

◦ Obesity is BMI ≥ 30.
◦ overweight defined as BMI 25-29.9 kg/m2

◦ obesity categorized into 3 classes
 class 1 obesity is BMI 30-34.9 kg/m2
 class 2 obesity is BMI 35-39.9 kg/m2
 class 3 obesity (also called severe obesity) is BMI >
40 kg/m2

0 35.BMI (kg/m2) Classification from up to 18.0 normal weight 25.0 40.0 class III obesity .5 25.0 overweight 30.0 class II obesity 40.0 class I obesity 35.5 underweight 18.0 30.

.  Better than BMI to predict cardiovascular disease and diabetes especially when BMI<35.Waist Circumference(WC)  WC is used to provide information on the distribution of body fat.

half-way between the superior iliac crest and the rib cage in the mid axillary line. WC  The waist circumference should be measured at a specific level. .

 In adult women a waist circumference of > 88cm (35 inches) is associated with substantial risk of obesity associated morbidity. 9 . WC  In adult men a waist circumference of > 102cm ( 40 inches) is associated with substantial risk of obesity associated morbidity.

This is calculated as waist measurement divided by hip measurement.  Increased health risk if waist-to-hip circumference ratio ◦ > 1 for men ◦ > 0.85 for women .Ratio(WHR)  Waist–hip ratio is the ratio of the circumference of the waist to that of the hips.Waist-Hip.

Waist Hip Ratio( WHR)  The waist can be measured at its narrowest point.  The hip is measured at its widest portion of the buttocks. .

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 In United States:  obesity in 36% of adults in United States in 2011- 2012  in England:  obesity in 24% of men and 26% of women in 2011.Epidemiology  Most common nutritional disease of western world.  Worldwide:  prevalence of overweight or obesity 36. .9% in men and 38% in women in 2013.

 In Jordan:  adult prevalence rate of obesity is 30% (2008). .

.Causes and risk factors  Primary Obesity:  most commonly attributed to increased caloric intake. decreased physical activity and genetic predisposition.

 glycemic index (GI) is a number associated with a particular type of food that indicates the food's effect on blood sugar level. an equivalent amount of pure glucose.Increased caloric intake  Increase intake of food with high glycemic index. . where 100 represents the standard. The number typically ranges between 50 and 100.

peanut. chili's . . almo nd. mushrooms. walnut. pumpkin. barley). kidney. strawberries. most vegetables. most whole intact . soy. pink.  small seeds (sunflower. black. mangos). rice.glycemic index (GI  Low :55 or less  beans (white. most sweet fruits (peaches. sesame.

basmati rice. not intact whole wheat or enriched wheat. pit bread. banana… . cranberry juice. grape juice. Medium:56-69  white sugar or sucrose. regular ice cream. unpeeled boiled potato.

white. maltodextrins.  carbohydrate consumption rather than fat consumption . most white rice corn flakes. high fructose corn syrup. pretzels. extruded breakfast cereals. bagels. sweet potato (70). white potato (83). maltose. High: 70 and above  glucose (dextrose. grape sugar).

due to increasing use of mechanized transportation and a greater prevalence of labor-saving technology.Decreased physical activity  A sedentary lifestyle plays a significant role in obesity. there is a decline in levels of physical activity due to less walking and physical education. .  About 30% of the world's population gets insufficient exercise.  In children.

 Rare syndromes with obesity:  1) Prader-willi syndrome  2) Bradet-beidl syndrome  3) Cohen syndrome  4) MOMO syndrome.Genetic predisposition  Obesity is the result of an interaction between genetic and environmental factors .  More than 41 site on the human genome have been linked to the development of obesity. .

 Some medical illnesses can increase the risk of obesity such as:  Endocrine:  hypothyroidism. . growth hormone deficiency.  Eating disorders like binge eating and night eating syndrome. Cushing syndrome.Secondary Obesity  <1 % of obesity.  Associated with psychiatric disorders.

 these include:  insulin .Medications Certain medication may cause weight gain or changes in the body composition. atypical antipsychotic . sulfonylureas . antidepressant . certain anticonvulsant ( phenytoin and valproate )and OCP. . steroids .

Conditions associated with obesity  Obesity in childhood may predict adulthood obesity. .  Infants at highest end of distribution for weight or body mass index or who grow rapidly during infancy are at increased risk of subsequent obesity.

Conditions associated with obesity  Increased rate of obesity associated with sedentary behaviors. i phones). .  Rates of obesity increasing proportionally to time spent on media (TV. computers.

 childhood physical abuse associated with increased BMI scores in adulthood.  High alcohol consumption. .Other factors  Fast-food consumption frequency strongly associated with obesity.

.Other factors ◦ Depressive symptoms in childhood and adolescence associated with overweight in later life. ◦ lower intelligence quotient (IQ) at age 11 years associated with obesity at age 42 years.

Other factors parental obesity excess weight in adolescence lower parental educational attainment lower self-esteem .

coronary heart disease. stroke. heart failure. atrial fibrillation and venous thromboembolism .Complications  obesity associated with increased risk of overall mortality.  obesity associated with increased risk for cardiovascular disease including sudden death.

 increasing BMI associated with increased risk of many cancers in men and women  obesity in middle age associated with increased risk for dementia .Complications  obesity and lack of physical activity independently associated with increased risk for diabetes mellitus type 2.

Complications  obesity associated with increased risk for gastroesophageal reflux symptoms. gallstones. labor induction. and liver disease  pregnancy-related complications include increased risks for pregnancy-induced hypertension. cesarean delivery and wound infection. fetal and neonatal mortality. and congenital anomalies . antepartum venous thromboembolism. cholecystectomy.

More complications ◦ increased risk for chronic kidney disease ◦ increased risk for kidney stones ◦ increased risk for hot flashes ◦ lower efficacy of oral contraceptives ◦ lower specificity of screening mammography .

More complications ◦ Increased risk for obstructive sleep apnea. lumbar disc degeneration. total hip replacement and knee osteoarthritis ◦ infertility associated with male obesity . ◦ obesity associated with dyspnea and asthma ◦ orthopedic complications may include increased risk for low back pain.

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History and physical  History:  Chief complaint (CC):  History of present illness (HPI):  Medication history:  Past medical history (PMH): .

exercise and lifestyle. sleep apnea  Family history (FH):  often positive family history  Social history (SH): Eating habits. binging . hyperlipidemia. media exposure. asthma. diabetes. anxiety. Ask about associated complications of obesity such as hypertension. depression.

. even without sleep apnea  dyspnea at rest can occur with obesity in otherwise healthy person. Review of systems (ROS):  daytime sleepiness associated with obesity.

Physical:  General appearance  Blood pressure  Height.  In the skin examination. weight and BMI  WC and WHR.  Neck circumference is predictive of a risk of sleep apnea. include a search for hirsutism in women. acanthosis nigricans. intertriginous rashes. and possible contact dermatoses. ..  Cardiac and respiratory evaluation.

Diagnosis  obesity defined as body mass index (BMI) ≥ 30 kg/m2.  High WC or Waist Hip Ratio .

 Testing overview:  Tests that may be useful for identifying complications of obesity ◦ Lipid profile including  total cholesterol  high-density lipoprotein (HDL) cholesterol  triglycerides ◦ Fasting blood glucose. . ◦ Thyroid-stimulating hormone (TSH).

Treatment methods depend on degree of obesity . any weight –loss programs require change in eating and increased physical activity.Management The goal is to have a healthy weight.associated co morbidities and patient willingness to loos weight .

Management  weight loss of 5%-15% may greatly reduce complications in obese or overweight persons.  Diet and exercise are primary strategies for losing weight .

000 fewer kilocalories/day.45-0.91 kg/week) by consuming 500-1.Management-Diet  Caloric expenditure must exceed caloric intake for any diet to be effective ◦ adults can lose 1-2 lbs/week (0. .

.Management-Diet  Most diets have good short-term results but limited long-term efficacy (patients typically lose 5% of body weight over first 6 months. then return to initial weight by 12-24 months)  low-fat diet appears effective for weight loss .

Management-Diet  low-carbohydrate diets ◦ low-carbohydrate. ◦ Mediterranean diet or low-carbohydrate diet each appear more effective for modest long-term weight loss than low-fat diet . ◦ low-carbohydrate diets appear to reduce weight more than low-fat diets at 6 months but not at 12 months . . high-protein diets associated with more weight loss than diets with same energy intake.

whole-grain foods associated with weight loss. ◦ increased intake of high-fiber.Management-Diet  commercial weight loss diets appear modestly effective but evidence for comparative efficacy is inconsistent . . ◦ energy-restricted diet containing fish or fish oil may further reduce weight compared to energy-restricted diet alone for overweight and moderately obese men ◦ reduction of sugar-sweetened beverage intake associated with weight loss .  specific foods and food types ◦ dietary advice to increase vegetable and fruit intake may contribute to weight loss .

◦ low amount of exercise (walking 30 minutes/day) appears adequate to avoid weight gain and higher amounts promote weight loss.Management-Exercise  exercise may promote weight loss. especially when combined with dietary change . ◦ regular exercise (brisk walking) slightly reduces body weight and body fat in postmenopausal women . . ◦ multiple short-bout exercise (four 10-minute sessions/day 5 days/week) might be equivalent to long-bout exercise (40 minute session 5 days/week.

-Increase daily activity. loss.Management-Exercise -Exercise at least 150 min a week. . (200 to 300 min a week for significant Wt.

Behavioral interventions  advise overweight and obese adults to participate in a comprehensive lifestyle programs to support adherence to a lower calorie diet and to increase physical activity .

Medication along with diet . increase BP . loss haven’t worked. .other methods of wt. Recommend if: 1.exercise and behaviour change. 2.BMI is 30 or greater 3. sleep apnea.BMI is >= 27 and have medical complication of obesity such DM .

approval in adult and children above 12 y old. Unabsorbed fat is eliminated in the stool.or 8 to 10 percent of initial body weight .Medications (FDA approved) Orlistat: primary function is preventing the absorption of fats from the human diet by acting as a lipase inhibitor. -average weight loss is approximately 5.3 kg per year. .

Those could minimize as reduce fat in diet multivitamin indicated to prevent nutritional deficiencies .bowel urgency And gas.Side Effects: frequent bowel movement .

 Appetite suppressant  After one year.8 kg) ◦ phentermine monotherapy Amphetamine congener.  approved as adjunct to exercise. anorexigenic agent. behavioral modification and caloric restriction in short-term management (a few weeks) of exogenous obesity  should not be used in combination with either selective serotonin reuptake inhibitor (SSRI) antidepressants or monoamine oxidase inhibitors (MAOIs) .8 pounds (5. the mean weight loss is approximately 12.◦ Lorcaserin:  Lorcaserin is a selective 5-HT2C receptor agonist.

◦ Phentermine plus extended- release topiramate combination: appetite suppressant.2 kg/year ◦ Diethylpropion: ◦ Phendimetrazine. appetite suppressant. average weight loss 10. average weight loss 8. ◦ Naltrexone/buproprion extended release combination.7 kg/year .

exenatide (GLP-1 agonist).Others.  non-prescription weight loss medications and supplements not recommended. but insufficient evidence to support use of metformin in overweight or obese adults without diabetes mellitus or polycystic ovary syndrome.8 kg/year  Zonisamide. not FDA approved  Metformin may be associated with small amount of weight loss .  average weight loss 2.Topiramate  Fluoxetine. Bupropion. .

Any condition where risk of the excess weight is greater than the risk of surgery. Indications: 1.Obesity related co morbid condition like DM. HTN .Obese people with BMI 40 or greater who instituted but failed exercise and diet 2. IFG or obstructive sleep apnea 3. .E) Bariatric surgery (gastric by pass surgery ).