investigation and management of obesity dr ogunwale o.o. mbbs lagos snr registrar edm div. luth
TRANSCRIPT
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INVESTIGATION AND MANAGEMENT OF OBESITY
Dr Ogunwale O.O. MBBS LagosSnr Registrar EDM Div. LUTH
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OUTLINE• INTRODUCTION• CLASSIFICATION• AIMS OF INVESTIGATION• INVESTIGATIONS• TREATMENT GUIDELINES • NON-PHARMACOLOGICAL MGT• PHARMACOLOGICAL MGT• SURGICAL MGT• BENEFITS OF WEIGHT LOSS• COMPLICATIONS OF TREATMENT• CONCLUSION• REFERENCES
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INTRODUCTION
• Basically a clinical/anthropometric diagnosis• History & PE vital.• Underlying cause needs be investigated• Classification based on BMI • Also on Body Fat Distribution/%• Not necessarily about ↑weight. but ↑body
fat• Mgmt. is multidisciplinary
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CLASSIFICATION
BMI (Kg/m2) Body Fat Percentage (%)Grade Male Female
Normal 15-20 25-30
Borderline 21-25 30-33
Obese >25 >33
Normal 18.5-24.9
Overweight 25-29.9
Grade1 Obese 30-34.9
Grade 2 35-39.9
Grade 3/Morbid ≥40
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CLASSIFICATION
• Surgical : Super Obese BMI : ≥ 50• BF% : Calculated from Deurenberg’s Equation• 1.2(BMI)+0.23(Age)-10.8(Sex)-5.4• Sex : 1 for Male, 0 for Female• Both Underweight & Overweight are assoc.
with ↑risk of dx.• Risk ↑ with ↑ Obesity
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AIMS OF INVESTIGATION
• Confirm diagnosis & r/o differentials• Find underlying aetiology• Complications & Comorbidities
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INVESTIGATIONS
• BMI = Wt in Kg/ (Ht)2 in m 2
• Waist Circumference• Sagittal Abdominal Diameter• Caliper-derived measurements of skin-fold
thickness*• Bioelectrical impedance analysis**• Underwater weighing***
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INVESTIGATIONS
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INVESTIGATIONS
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INVESTIGATIONS
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INVESTIGATIONSWC Male (in cm) Female(in cm)
WHO 102 88
IDF 94 80
Asian 90 80
Japan & China 85 80
Nigeria (Okafor et al) 97 95
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INVESTIGATIONHarpenden Professional Skinfold Caliper
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INVESTIGATION
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INVESTIGATION
• Ultrasonography Fat thickness• Abd USS : NAFLD, Gallstones , Ovarian Cysts• Dual-energy radiographic absorptiometry
(DEXA)• Abd CT Scan (at L4/L5)• Abd MRI
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INVESTIGATIONs
• FLP• LFT• TFT• FBG• C-peptide and Insulin Studies• Brain MRI*• Genetic studies **• GH & IGF-1 Assays.
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TREATMENT GUIDELINESBMI (kg/m2) Conventional
Therapy*Pharmacotherapy† Surgery‡
25.0-26.9 With CHD risk factors or obesity-related disease
No No
27.0-29.9 With CHD risk factors or obesity-related disease
With obesity-related disease
No
30.0-34.9 Yes Yes No
35.0-39.9 Yes Yes With obesity-related disease
≥40 Yes Yes Yes
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NON-PHARMACOLOGICAL MGT
• Diet, Physical Activity & Behavioural Therapy• Self-monitoring of caloric intake & physical
activity• Goal setting*• Stimulus control• Non-food rewards• Relapse prevention
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NON-PHARMACOLOGICAL MGT
• Goals should be SMART• Who - Who is involved?• What - What do I want to accomplish?• Where - Identify a location• When - Establish a time frame• Which - Identify requirements and constraints• Why - Identify specific reasons for or purpose
or benefits of the goal
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NON-PHARMACOLOGICAL MGT
• Weight-loss programs• 3 major phases :• Pre-inclusion screening phase*• Weight-loss phase• Maintenance phase - Can last for rest of pt's
life but ideally lasts for at least 1 yr post program completion
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NON-PHARMACOLOGICAL MGT
• DIET• Low Calorie Diet :800 - 1500 kcal/day • Very Low Calorie Diet < 800 kcal/day usu. high
in protein (70-100 g/day) & low in fat (<15 g/day).
• Usu. Taken As Liquid Formula, Nutritional Bars• Conventional Food : mostly lean meat, fish -
known as protein-sparing modified fasts.
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NON-PHARMACOLOGICAL MGT
• Physical Activity• More of Aerobic Isotonic Exercise• Less of Anaerobic Isometric/ Resistance
Exercise
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PHARMACOLOGICAL MGT
• Centrally acting medications that impair dietary intake (A)
• Medications that act peripherally to impair dietary absorption(B)
• Medications that increase energy expenditure (C)
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PHARMACOLOGICAL MGT
• Lipase Inhibitors : Orlistat (B)• Sibutramine (C)• Lorcaserin (A)• Sympathomimetic Amines Phendimetrazine,
Phentermine ,Diethylpropion, Benzphetamine Mazindol (A)
• Antidiabetic agents
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PHARMACOLOGICAL MGT
• Of the drugs the following are FDA-approved:• Lorcaserin (Belviq)• Phentermine/topiramate (Qsymia)• Orlistat (Xenical) • Sibutramine no longer approved
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SURGICAL MGT
• BARIATIC SURGERY• Roux-en-Y gastric bypass (B)• Adjustable gastric banding (R)• Gastric sleeve surgery (R)• Vertical sleeve gastrectomy (R)• Horizontal (Silastic ring) gastroplasty (R)• Vertical banded gastroplasty (R)• Duodenal-switch procedures(B)• Biliopancreatic diversion (B)
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SURGICAL MGT
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SURGICAL MGT
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SURGICAL MGT
• Vertical banded gastroplasty
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SURGICAL MGT
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SURGICAL MGT
• Morbid Obesity• When Conventional Rx & Drug Rx Fail• Benefits : Improved Obstructive sleep apnea• Type 2 DM, Hypertension, CCF, Asthma,
Dyslipidaemia• Peripheral oedema, Respiratory insufficiency• Esophagitis, Pseudotumor cerebri, OA, VTE• Operative risk• Urinary incontinence
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BENEFITS
• Improved Glycaemic Control• BP Control• Dyslipidaemia Control• ↓ CV Risk• Improved Pulm. Fx• Improved Reproductive & Urinary Fx
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COMPLICATIONS OF Rx
• Electrolyte Disturbances : Ketosis, ↓K+
• Arrhythmias• Malabsorption• Malnutrition• Hyperuricaemia• Cholithiasis• Depression & Eating Disorders
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CONCLUSION
• Obesity is basically a clinical diagnosis• More about body fat than weight• Hx & PE very important to evaluate co-
morbidities and Cx• Management primarily non-pharmacological• Multidisciplinary• Benefits of Rx include ↓CV Risk, ↑Pulm. Fx
and regression of co-morbidities
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REFERENCES• Klein S, Fabbrini E, Romijnin JA Obesity in Melmed S, Polonsky KS,
Larsen PR, Kronenberg HM (eds.), Williams Textbook of Endocrinology, 12th ed. Saunders, 2011. ch 36 pp 1605- 1625
• Hamdy O, Citkowitz E, Uwaifo GI, Oral EA Obesity http://emedicine.medscape.com/article/123702. Updated : Nov 25, 2013
• de Souza NC, de Oliveira EP Sagittal abdominal diameter shows better correlation with cardiovascular risk factors than waist circumference and BMI Journal of Diabetes & Metabolic Disorders 2013 12:41
• http://www.topendsports.com/testing/skinfold-sites.htm Accessed Dec 4,2013
• http://www.ebay.com/itm/Harpenden-Professional-Skinfold-Caliper-/320795435670 Accessed Dec 4, 2013
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REFERENCES• http://www.fitnessgram.net/protocols/skinfolds.pdf Accessed Dec 6 ,2013• Sagittal Diameter http://www.myhealthywaist.org/evaluating-cmr/clinical-
tools/sagittal-diameter/page/2/print.html. Accessed Dec 6, 2013• http://www.topendsports.com/testing/tests/underwater.htm Accessed Dec.
5,2013• http://www.topendsports.com/testing/siri-equation.htm Accessed Dec. 5,
2013• http://www.myhealthywaist.org/evaluating-cmr/clinical-tools/sagittal-
diameter/page/2/print.html Accessed Dec. 6,2013• WHO Technical Report Series. Diet, nutrition and the prevention of chronic
diseases http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf Accessed Dec. 6, 2013
• http://www.nlm.nih.gov/medlineplus/ency/article/007199.htm. Updated 6/4/2012
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THANK YOU