Obesity

Professor Md. Abul kashem Khandaker

Professor of medicine, PMCH

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 Introduction
• Obesity is widely regarded as pandemic, with
potentially disastrous consequences for human
health.

• Over one-quarter of adults in the UK were obese

(i.e.BMI ≥ 30 kg/m2) in 2010.

• Moreover, almost 2/3 of the UK adult population

are overweight (BMI ≥25 kg/m2).
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• In developing countries, average national rates
of obesity are low,

• but these figures may disguise high rates of

obesity in urban communities;

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Complications of Obesity

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 Complications of Obesity
Risk factors Outcomes

1.‘Metabolic syndrome’
Type 2 diabetes Coronary heart disease
Hypertension Stroke
Hyperlipidaemia Diabetes complications

2.Liver fat accumulation Non-alcoholic steatohepatitis

Cirrhosis
3.Restricted ventilation Exertional dyspnoea
Obstructive sleep apnoea
Obesity hypoventilation syndrome
(Pickwickian syndrome)

4.Mechanical effects Urinary incontinence

of weight Osteoarthritis
Varicose veins

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Risk factors Outcomes
5.Increased peripheral • Hormone-dependent cancers
steroid interconversion (breast, uterus)
in adipose tissue • Polycystic ovarian syndrome
(infertility, hirsutism)

6.Others a.Psychological morbidity (low

self-esteem, depression)

b.Socioeconomic disadvantage (lower

income, less likely to be promoted)

c.Gallstones

d.Colorectal cancer

e.Skin infections (groin and

submammary candidiasis; Hidradentis)

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Metabolic syndrome

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Atherosclerosis

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OA

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OSA

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 Pickwickian syndrome
• Other name- obesity hypoventilation
syndrome
• Defined as the combination of-
1. obesity
2. Hypoxemia during sleep
3. Hypercapnia during the day
Resulting from hypoventilation.

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 Body fat distribution
• For some complications of obesity, the distribution
rather than the absolute amount of excess adipose tissue
appears to be important.
a. Central obesity-
 Increased intra-abdominal fat causes ‘central’ (‘abdominal’, ‘visceral’,
‘android’ or ‘apple-shaped’) obesity.
 It is more common in men and
 is more closely associated with type 2 diabetes, the metabolic syndrome
and cardiovascular disease.

b. Generalised obesity- subcutaneous fat accumulation causes ‘generalised’

(‘gynoid’or ‘pear-shaped’) obesity;

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Apple shaped vs pear shaped obesity

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 Aetiology
Some reasons for the increasing prevalence of obesity –
the ‘obesogenic’ environment
Increasing energy intake
• ↑ Portion sizes
• ↑ Snacking and loss of regular meals
• ↑ Energy-dense food (mainly fat)
• ↑ Affluence

Decreasing energy expenditure

• ↑ Car ownership
• ↓ Walking to school/work
• ↑ Automation; ↓ manual labour
• ↓ Sports in schools
• ↑ Time spent on computer games and watching TV
• ↑ central heating

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Potentially reversible causes of weight gain

Endocrine factors
• Hypothyroidism
• Cushing’s syndrome
• Insulinoma
• Hypothalamic tumours or injury

Drug treatments
• Atypical antipsychotics (e.g. olanzapine)
• Sulphonylureas, thiazolidinediones, insulin
• Pizotifen
• Corticosteroids
• Sodium valproate

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 Clinical assessment
In assessing an individual presenting with
obesity, the aims are to:

1. quantify the problem

2. exclude an underlying cause
3. identify complications
4. reach a management plan.

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 Quantifying obesity with body mass index
(weight/height2)
BMI (kg/m2) Classification* Risk of obesity comorbidity

18.5–24.9 Reference range Negligible

25.0–29.9 Overweight Mildly increased

> 30.0 Obese

30.0–34.9 Class I Moderate
35.0–39.9 Class II Severe
> 40.0 Class III Very Severe

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The Western Pacific Region Office of WHO
recommends that, amongst Asians,BMI

• > 23.0 is overweight and

• > 25.0 is obese.

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A waist circumference of
 > 102 cm in men or
 > 88 cm in women
indicates that the risk of metabolic and
cardiovascular complications of obesity is
high.

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 Exclusion of underlying cause
• The history of weight gain may help diagnose
underlying causes.
• A patient who has recently gained substantial
weight or has gained weight at a faster rate
than previously, and is not taking relevant
drugs,is more likely to have an underlying
disorder such as hypothyroidism or Cushing’s
syndrome.

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• All obese patients should have
 thyroid function tests performed on one
occasion, and
 an overnight dexamethasone suppression test
or 24-hour urine free cortisol if Cushing’s
syndrome is suspected.

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 Identification of complications
Assessment of the diverse complications of
obesity requires a-
 thorough history,
 examination
 screening investigations.
 Assessment of other cardiovascular risk
factors ( hypertension, DM, Dyslipidaemia)

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 Management Plan
• The health risks of obesity are largely
reversible.

• Lifestyle advice that lowers body weight and

increases physical exercise reduces the
incidence of type 2 diabetes .

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The management plan will vary according to the

• severity of the obesity and

• the associated risk factors and
• complications

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 Treatment modalities

1. Lifestyle advice
2. Weight loss diets
3. Drugs
4. Surgery

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Therapeutic options for obesity

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 Lifestyle advice

• Behavioural modification to avoid some of the

effects of the ‘obesogenic’ environment is the
cornerstone of long-term control of weight.

• Regular eating patterns and maximising

physical activity are advised.

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 Weight loss diets

• Moderate reduction in energy intake- 500 to

600 calories less than the energy expenditures
of the individual.
• Fat intake must be reduced.
• The aim of diet restriction is to reduce weight
by 1kg/ week.

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Say- NO

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 Drugs
Indication-

• BMI> 30 kg/m2 or
• BMI> 27 kg/m2 +obesity related diseases

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• only one drug, orlistat, is currently licensed
for long-term use.
• A number of other agents are in development,
so the situation could change rapidly over the
next few years.
• There is no role for diuretics, or for thyroxine
therapy without biochemical evidence of
hypothyroidism.

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 Orlistat
• Mechanism of action-Orlistat inhibits
pancreatic and gastric lipases and thereby
decreases the hydrolysis of ingested
triglycerides,
reducing dietary fat absorption by
approximately 30%.
• Dose- Orlistat is taken with each of the 3 main
meals of the day and the dose can be adjusted
(60–120 mg) to minimise side-effects.
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• Adverse effects-The drug is not absorbed and
adverse side-effects relate to the effect of the
resultant fat malabsorption on the gut, like-
1. loose stools,
2. oily spotting,
3. Faecal urgency,
4. flatus and
5. the potential for malabsorption of fat-soluble
vitamins.
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 Surgery
• ‘Bariatric’ surgery is by far the most effective
long-term treatment for obesity and is the only
anti-obesity intervention that has been
associated with reduced mortality.
• Bariatric surgery should be contemplated in
motivated patients who
 have very high risks of complications of obesity ,
 in whom extensive dietary and drug therapy has
been insufficiently effective.
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 It is usually reserved for those with

severe obesity (BMI > 40 kg/m2), or

those with a BMI > 35 kg/m2 and significant

complications, such as type 2 diabetes or
obstructive sleep apnoea.

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Types of laparoscopic bariatric surgical
procedures-
1. Gastric banding
2. Sleeve gastrectomy
3. Roux-en-Y gastric bypass
4. Duodenal switch

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Bariatric surgical procedures

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 Treatment of additional risk factors

• Obesity must not be treated in isolation and

other risk factors must be addressed, including-
1. smoking,
2. Excess alcohol consumption,
3. diabetes mellitus,
4. Hyperlipidaemia,
5. hypertension and
6. obstructive sleep apnoea.
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Thank You..
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