Obesity

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

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Aim-Objectives

Aim

: At the end of this session, the participants will have knowledge on burden of obesity, its complications, and management.

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Objectives

: At the end of this session, the trainees should be able to describe Body Mass Index (BMI) in categories discuss the health risks associated with obesity. identify the components of obesity management beable to explain screening recommendations for obesity.

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Global Prevalence of Obesity in Adult Males With examples of the top 5 Countries in each Region

European Region

Croatia 31% Cyprus 27% Czech Republic 25% Albania (urban) 23% England 23%

North America

USA 31% Mexico 19% Canada (self report) 17% Guyana 14% Bahamas 14%

Eastern Mediterranean

Lebanon 36% Qatar 35% Jordan 33% Kuwait 28% Saudi Arabia 26%

% Obese 0-9.9% 10-14.9% 15-19.9% 20-24.9% 25-29.9% ≥30% Self Reported data South Central America

Panama 28% Paraguay 23% Argentina (urban) 20% Uruguay (self report) 17% Dominican Republic 16% © International Obesity TaskForce, London –January 2007

Africa

South Africa 10% Seychelles 9% Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5%

South East Asia & Pacific Region

Nauru 80% Tonga 47% Cook Island 41% French Polynesia Samoa 33%

Global Prevalence of Obesity in Adult Females With examples of the top 5 Countries in each Region

European Region

Albania 36% Malta 35% Turkey 29% Slovakia 28% Czech Republic 26%

North America

USA 33% Barbados 31% Mexico 29% St Lucia 28% Bahamas 28%

Eastern Mediterranean

Jordan 60% Qatar 45% Saudi Arabia 44% Palestine 43% Lebanon 38%

% Obese 0-9.9% 10-14.9% 15-19.9% 20-24.9% 25-29.9% ≥30% Self Reported data Africa South Central America

Seychelles 28% Panama 36% South Africa 28% Paraguay 36% Ghana 20% Peru (urban) 23% Mauritania 19% Chile (urban) 23% Dominican Republic 18% © International Obesity TaskForce, London –January 2007 Cameroon (urban) 14%

South East Asia & Pacific Region

Nauru 78% Tonga 70% Samoa 63% Niue 46% French Polynesia

Body Mass Index (BMI)

 The BMI is an easily obtained and reliable measurement for obesity and is defined as a person's weight (in kilograms) divided by the square of the person's height (in meters).

 Example: 72 kg, 166 cm person = 72 / 1.66 x 1.66

= 72 / 2.75

= 26.1

Obesity classification.

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Obesity is further divided into three separate classes, with Class III obesity being the most extreme of the three.

Obesity class

Class I Class II Class III ( Extreme Obesity )

With a BMI of: You are considered:

Below 18.5

18.5 - 24.9

25.0 - 29.9

30 or higher

Underweight

Healthy Weight

Overweight

Obese BMI (kg/m 2 )

30.0- 34.9

35.0-39.9

≥ 40.0

CDC, NHLBI

BMI (kg/m 2 ) Height (in.) 71 72 73 74 75 76 58 59 60 61 62 63 64 65 66 67 68 69 70 19 136 140 144 148 152 156 91 94 97 100 104 107 110 114 118 121 125 128 132 20 21 22 23 24 25 26 27 28 29 30 35 40 143 147 151 155 160 164 96 99 102 106 109 113 116 120 124 127 131 135 139 150 154 159 163 168 172 100 104 107 111 115 118 122 126 130 134 138 142 146 157 162 166 171 176 180 105 109 112 116 120 124 128 132 136 140 144 149 153 165 169 174 179 184 189 110 114 118 122 126 130 134 138 142 146 151 155 160 172 177 182 186 192 197 115 119 123 127 131 135 140 144 148 153 158 162 167 186 191 197 202 208 213 124 128 133 137 142 146 151 156 161 166 171 176 181 Weight (lb.) 179 184 189 194 200 205 119 124 128 132 136 141 145 150 155 159 164 169 174 193 199 204 210 216 221 129 133 138 143 147 152 157 162 167 172 177 182 188 200 206 212 218 224 230 134 138 143 148 153 158 163 168 173 178 184 189 195 208 213 219 225 232 238 138 143 148 153 158 163 169 174 179 185 190 196 202 215 221 227 233 240 246 143 148 153 158 164 169 174 180 186 191 197 203 207 250 258 265 272 279 287 167 173 179 185 191 197 204 210 216 223 230 236 243 286 294 302 311 319 328 191 198 204 211 218 225 232 240 247 255 262 270 278

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Waist circumference

For men, <94cm is low, 94-102cm is high and > 102cm is very high For women, <80cm is low, 80-88cm is high and > 88cm is very high

Several serious medical conditions have been linked to obesity

History in Obese Patient

 A full history must include:  Onset  Recent weight change  Occupation  A dietary inventory and an analysis of the subject's activity level .

 Screening for depression  Screening for eating disorders  Previous comorbidities  Explore causes of secondary obesity

 Previous trial & experiences to lose weight  Family history of weight problems.

 The patient's expectations  The patient's level of motivation .

 Medication history.

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Selected Medications That Can Cause Weight Gain

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Psychotropic medications

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Tricyclic antidepressants

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Monoamine oxidase inhibitors

–

Specific SSRIs

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Atypical antipsychotics

–

Lithium

 –

Specific anticonvulsants



-adrenergic receptor blockers

 Diabetes medications – Insulin – Sulfonylureas – Thiazolidinediones  Highly active antiretroviral therapy  Tamoxifen  Steroid hormones – Glucocorticoids – Progestational steroids SSRI=selective serotonin reuptake inhibitor

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Physical examination

In the clinical examination, 1.

Measure anthropometric parameters ,height weight, BMI Waist to hip ratio.

2.

 3.

Skin fold thickness Perform a standard, detailed examination   skin : Look for hirsutism in women, intertriginous rashes, acanthosis nigricans, and possible contact dermatoses .

  CVS: BP ( appropriate calf size) Look for cardiomegaly and respiratory insufficiency .

 Abdomen : hepatomegaly ( fatty liver)  LL +,- odema

Physician Barriers to Evaluation and Treatment of Obesity

 Lack of time  Lack of recognition of obesity as a chronic condition  Insufficient data  Lack of data  Lack of patient interest  Inadequate training

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Obesity Treatment

 Non pharmacological  Diet  Physical activity  Behavioral therapy  pharmacological  Pharmacotherapy  Surgical

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BMI classificaion overweight Obesity I Obesity II Obesity III Waist circumference low high Very high comorbid ities General advice on healthy weight and lifestyle Diet and physical activity Diet and physical activity; consider drugs Diet and physical activity; consider drugs; consider surgery

Management

 General recommendations:  Avoid complications such as excessive loss of lean body mass, dehydration, electrolyte imbalance, gallbladder disease and psychological distress  Physicians engaging in weight loss counseling also should consider their own weight and set an example for their patients by demonstrating healthy weight management

No body is exempted from obesity . It can be you.

 Most adults regain any weight loss within five years .

 It is a life-long challenge to achieve and maintain a healthy weight since it needs a long-term commitment to lifestyle change,

Techniques of Motivational Interviewing

Support self efficacy Express empathy Explore discrepancies Avoid arguments Promote empowerment         Provide choices Reassure of expected outcomes Express acceptance and understanding Use reflective listening and expect ambivalent Let individuals explore their reasons for changing or not changing their behavior Avoid judging and labeling Change strategies if patient shows resistance Patients are a source of solutions, and since obesity is a self-managed disease, the patient is in charge and responsible of his or her own care

Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American Diabetic Association; 2002

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Techniques For Modifying Behavior

Self monitoring Stimulus control Contingency management Cognitive restructuring Stress management              Recording of target behavior and associated factors, found to be most helpful Recording diary of food, exercise Restricting environmental factors influencing inappropriate behaviors Eating at specific times Setting time and place for exercise Avoid buying food items that are difficult to control eating Rewarding appropriate behavior Short term contracts to formalize agreements Move thinking pattern from self rejection toward self acceptance Changing thinking patterns from unrealistic goals to realistic and achievable goals Learning methods to reduce stress and tension, since both are a primary predictor of relapse Relaxation techniques as diaphragmatic breathing, progressive muscle relaxation and meditation Regular exercise

Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American Diabetic Association; 2002.

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 A reasonable goal for weight-loss in the setting of a medical treatment program is approximately 0.9-1.5 kg/wk

Dietary therapy

     Very low-calorie diets (VLCDs) are best used in an established, comprehensive program.

VLCDs involve reducing caloric intake to 800 kcal/d or less.

When used in optimal settings, they can achieve weight loss of 1.5-2.5 kg/wk, with a total loss of as much as 20 kg over 12 weeks. Unless a long-term maintenance calorie-deficit program is developed and adhered, to recidivism after the diet is stopped is rapid.

Most subjects quickly regain all the weight they lose and often gain more.

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Calorie needs calculation

Men  BMR = 66 + (13.7 x W) + (5 x H) - (6.8 x Age)  Women  BMR = 665 + (9.6 x W) + (1.8 x H) - (4.7 x Age)  Total daily calorie needs  Sedentary - none or very little exercise: BMR X 1.2

 Light activity for average of 2 days/week: BMR X 1.375

 Moderate activity level exercising 4 days/week: BMR X 1.5

 High activity levels more than 6 days/week: BMR X 1.7

 Higher activity levels: up to 2 x BMR BMR=Basal Metabolic Rate (Harris Benedict calculation)

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Example

 30 year old 80 kg, 168 cm woman  Basal Metabolic Rate (BMR)= 665 + (9.6 x 80) + (1.8 x 168) - (4.7 x 30)  BMR = 1594 calories  If light activity:  1594 x 1.375

 2191.75 calories

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Recommended Average Daily Energy

Men Age (year) Kcal\day

11 to 14 2,500 15 to 18 19 to 24 2,900 25 to 50 3,000 2,900 51+

Women (non-pregnant, non-lactating )

11 to 14 2,300 2,200 15 to 18 19 to 24 2,200 2,200 25 to 50 2,200 51+ 1,900 Adapted from National Research Council

Physical activity

 Aerobic isotonic exercise is of the greatest value for subjects who are obese.  The ultimate minimum goal should be to achieve 30-60 minutes of continuous aerobic exercise 5-7 times per week .

 People who have been obese and have lost weight should be advised they may need to do 60-90 min of activity\day to avoid regaining weight

Pharmacological Therapy

 Pharmacotherapy is limited to use in patients with  a BMI of 30 or more and no accompanying obesity related risk factors or diseases,  or patients with a BMI of 27 or more with accompanying obesity-related risk factors or diseases  patient who have not reached their target weight loss or have reached a plateau on dietary. activity and behavioral change alone.

Pharmacotherapy

Major groups Centraly acting Impair deitry Intake (sibutramine) Act peripherally to impair absorption (orlistat) Increase energy Expenditure (Mazindol, Phentermine)

Indications for Medication

NICE 2001/ABPI MEDICINES COMPENDIUM 2002/2005

Surgery may be considered for

 Patient with BMI 40 or more  BMI 35 – 40 with other risk factors  All appropriate non-surgical measures have been tried but failed.

 As 1 st line option ( instead of lifestyle interventions or drug treatment) for adults with a BMI of>50.

 Types of surgery:  Gastric banding.  Gastric bypass.  Vertical banded gastroplasty.

Referral

     The underlying causes need to be assessed.

The person has complex disease state and can ’ t be managed in primary care Conventional treatment has failed.

Drug therapy is considered for a person with a BMI>35kg\m 2 Surgery is being considered.

Algorithm for the treatment of obesity

NHLBI Practical Guide. Oct 2000 Figure 2, pg 13 http://www.naaso.org/information/practicalguide.asp

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