Lec 3

• Obesity


  Abnormal or excessive fat accumulation that presents a risk to health
• Obesity is a chronic disease that is increasing in prevalence globally
• In 2015, approximately 108 million children and 604 million adults globally were obese
• Increase in prevalence of obesity in almost all countries since 1980 and a doubling in prevalence in 70 countries
• Overweight or obese among primary school children in Trinidad and Tobago

  11% in 1999, 23% in 2009 (100% increase)
• Between 1999 and 2009, there was a 400% increase in overweight/obese children in Trinidad and Tobago
• Overweight and obesity in children in Trinidad and Tobago

  • 8.5% were overweight and 2.4% were obese (BMI)
  • Associated with higher BMI in the parents, higher reported birthweight, older age of the child's mother, smaller family size, and with higher maternal educational attainment
• Abdominal obesity in type 2 diabetic patients in Trinidad

  • 75% and 17% of female and male patients, respectively, had high Waist Circumference
  • Patients with elevated WC had significantly higher mean levels of basal insulin and insulin resistance
• Obesity and other risk factors for type 2 diabetes among school children in Trinidad

  • 15% were obese and 17% were overweight
  • Primary school children had a higher prevalence of obesity (22.9% vs 11.0%) and overweight (20.0% vs 15.6%) than secondary school children
  • The overall prevalence of Acanthosis Nigricans was 43.4%
• Normal weight obesity (NWO)

  Patients have a normal body mass index (BMI) but elevated body fat percentage

  
• The prevalence of NWO among young adults in Trinidad and Tobago was 19.9%
• Screening for overweight and obesity in adults

  • All adult patients should be screened by measuring BMI as part of routine physical examination
  • Measure waist circumference in those with BMI 25-35 kg/m2 as abdominal adiposity may not be captured in this BMI range, particularly for people of Asian descent

  
• BMI categories for ADULTS

  • Underweight - <18.5 kg/m2
  • Normal weight - ≥18.5 to 24.9 kg/m2
  • Overweight - ≥25.0 to 29.9 kg/m2
  • Obesity - ≥30 kg/m2 (Class I - 30.0 to 34.9 kg/m2, Class II - 35.0 to 39.9 kg/m2, Class III - ≥40 kg/m2)

  
• Waist Circumference Thresholds for ADULTS

  • Abdominal obesity (waist circumference greater than ≥35 in [88 cm] in women or ≥40 in [102 cm] in men)
  • A waist circumference ≥31 in (80 cm) in Asian females and ≥35 in (90 cm) in Asian males is considered abnormal
• Evaluation of obesity in adults

  1. Assessment of the etiology of the weight gain (Hx, Ex, FBS, A1C, TSH, liver enzymes, and fasting lipids)

  2. Subsequent intervention, if necessary, is based upon historical, physical, and/or laboratory results in the setting of shared decision making with the patient

  
• Etiologic classification of obesity

  • Social and behavioral factors
  • Genetic (dysmorphic) obesities
  • Iatrogenic causes
  • Dietary obesity
  • Neuroendocrine obesities
• Comorbidities of obesity


  • Cardiovascular disease
  • Sleep apnea
  • Nonalcoholic fatty liver disease
  • Symptomatic osteoarthritis
  • Type 2 diabetes
  • Hypertension
  • Dyslipidemia
  • Depression
  • Reduced QOL
  • Death
• Approach to Obesity Treatment


  • Little or no risk - Counseling on prevention of weight gain
  • Low risk - Counseling on prevention of weight gain
  • Moderate risk - Intensive, multicomponent behavioral intervention, pharmacologic therapy may also be considered
  • High risk - Intensive, multicomponent behavioral intervention, pharmacologic therapy, bariatric surgery
• Dietary therapy for obesity

  • The goal is to reduce the total number of calories consumed
  • Dietary Approaches to Stop Hypertension (DASH) or Mediterranean-style diet, rather than focusing on a specific nutrient
  • Reductions in refined carbohydrates, processed meats, and foods high in sodium and trans fat; moderation in unprocessed red meats, poultry, eggs, and milk; and high intakes of fruits, nuts
• Exercise for obesity


  • Increasing energy expenditure through physical activity is a strong predictor of weight loss maintenance
  • Physical activity should be performed for approximately 30 minutes or more, five to seven days a week
• Drugs that affect weight

  • Produce weight loss (Anticonvulsants, Antidepressants, Antipsychotics)
  • Are weight neutral (Antipsychotics)
  • Produce weight gain (Antidepressants, Antipsychotics, Diabetes medications, Glucocorticoids, Hormonal agents, Anticonvulsants, Neurologic and mood-stabilizing agents, Antihistamines, Alpha-blockers, Beta blockers)
• Candidates for drug therapy for obesity

  Individuals with a BMI ≥30 kg/m2, or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have not met weight loss goals (loss of at least 5 percent of total body weight at three to six months) with a comprehensive lifestyle intervention
• Pharmacologic Options for Obesity

  • Lorcaserin (for patients without diabetes)
  • Liraglutide (for patients with type 2 diabetes)
  • Orlistat (for those who do not respond to or tolerate treatment with lorcaserin or liraglutide)
• Dietary supplements are not recommended for obesity treatment as they may contain harmful substances
• Who to consider for Drug Treatment of Obesity

  • Individuals with a BMI ≥30 kg/m2
  • Individuals with a BMI of 27 to 29.9 kg/m2 with comorbidities
  • Who have not met weight loss goals (loss of at least 5 percent of total body weight at three to six months) with a comprehensive lifestyle intervention
• Pharmacologic Options for Obesity

  • Lorcaserin (for patients without diabetes)
  • Liraglutide (for patients with type 2 diabetes)
  • Orlistat (for those who do not respond to or tolerate treatment with lorcaserin or liraglutide)
• Drug Therapies NOT Recommended for Obesity


  • Dietary supplements
  • HCG injections
  • Calcium
  • Green tea
• Dietary supplements


  • May contain sibutramine, enproporex, fluoxetine, bumetanide, furosemide, phenytoin, rimonabant, cetilistat, amphetamines, BZD, and phenolphthalein
  • High incidence of adverse effects
• Bariatric Surgery Candidates


  • Adults with a BMI ≥40 kg/m2
  • Adults with a BMI of 35- 39.9 kg/m2 with at least one serious comorbidity
  • Who have not met weight loss goals with diet, exercise, and drug therapy
• Bariatric Procedures


  • Roux-en-Y gastric bypass
  • Sleeve gastrectomy
  • Biliopancreatic Diversion with duodenal switch
• Classification of obesity in Children (2-20 years of age)

  • Overweight - BMI between the 85th and 95th percentile for age and sex
  • Obesity - BMI ≥95th percentile for age and sex
  • Severe obesity - BMI ≥120 percent of the 95th percentile values or a BMI ≥35
• Comparison of Obesity Categories for adults and children


  • Underweight - Adults: BMI <18.5, Youth: BMI <5th percentile for age
  • Normal weight - Adults: BMI 18.5-24.9, Youth: BMI ≥5th to <85th percentile
  • Overweight - Adults: BMI 25-29.9, Youth: BMI ≥85th to <95th percentile
  • Obesity - Adults: BMI ≥30, Youth: BMI ≥95th percentile
  • Severe obesity - Adults: BMI ≥35 (class II obesity), BMI ≥40 (class III obesity), Youth: BMI ≥120 percent of the 95th percentile, or a BMI ≥35 (whichever is lower), BMI ≥140 percent of the 95th percentile, or a BMI ≥40 (whichever is lower)

  
• Tracking of obesity


  • The likelihood of persistence of childhood obesity into adulthood is related to age, parental obesity, and severity of obesity
  • A substantial component of adolescent obesity is established before five years of age
• Causes of obesity in Children

  • Glycemic index of foods
  • Sugar-containing beverages
  • Larger portion sizes for prepared foods
  • Fast food service
  • Diminishing family presence at meals
  • Decreasing structured physical activity
  • Television viewing
  • Medications (eg, certain psychoactive drugs)
  • Genes
  • Endocrine disorders (<1%)
  • Hypothalamic lesions
  • Metabolic programming (mother's weight, in utero, early childhood)
• Childhood Obesity Evaluation


  • Screen ALL children for Obesity - MEASURE BMI!!
  • Assess nutrition and physical activity
  • History and Examination for etiologies and complications
  • Labs for lipids, Hba1c/FBS, LFTs
• Symptoms that may indicate potential significance in Childhood Obesity

  • Delayed development (Genetic syndrome)
  • Short stature or reduced height velocity (Genetic syndrome, Endocrinologic etiology)
  • Headaches (especially morning) (Pseudotumor cerebri)
  • Nausea/vomiting
  • Blurred or decreased vision
  • Snoring (Sleep apnea, obesity hypoventilation syndrome)
  • Daytime sleepiness
  • Nocturnal enuresis
  • Abdominal pain (Gall bladder disease, Nonalcoholic fatty liver disease)
  • Hip pain, knee pain, limp (Slipped capital femoral epiphysis (SCFE) or Blount disease (tibia vara))
  • Right upper quadrant abdominal pain (Cholelithiasis or non-alcoholic fatty liver disease)
  • Oligomenorrhea or amenorrhea (Polycystic ovary syndrome (PCOS))
  • Prader-Willi syndrome
• Childhood Obesity Treatment


  • Education for family
  • Dietary counseling
  • Physical activity - 60 mins physical activity daily
  • Adequate sleep - Preschool :10-13 hrs, teenagers: 8-10hrs
• Tips for dietary counseling in children

  • Family has little or no structure to dietary patterns
  • Child is motivated by sports and activity, but has little interest in making dietary changes
  • Family frequently eats meals away from home
  • Large portion sizes
  • Fast eating pace
  • Poor dietary quality (lack of fruits/vegetables and whole grains, consumption of whole milk, etc...)
  • Lacks nutritional knowledge (no label reading, does not make shopping list, etc...)
  • Excessive refined grains (white bread) and simple carbohydrates (sugars)
  • High-fat dairy intake
  • Skipping meals
  • Excessive snacking
  • High intake of sugar-sweetened beverages
  • Low fruit and vegetable intake
• Whole System Approaches are those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course
• Take home messages


  • Obesity is very common and on the rise!
  • Screen for obesity and its complications, even if patient doesn't 'look' obese
  • Educate and offer interventions to all overweight and obese patients