OBESITY Dr. Gopalrao Jogdand, M.D. Ph.D. Professor & Head Department of community Medicine

OBESITY Dr. Gopalrao Jogdand, M.D. Ph.D. Professor & Head Department of community Medicine

Definition

Magnitude of the Problem

Prevalence of obesity BMI 30.0.

Currently the world is facing obesity epidemic.

Country Age range Obesity prevalenceMale

Obesity prevalenceFemale

U.S.A. 22-74 years 19.7% 24.7%

Germany 25-69 years 17% 19%

England 16-64 years 15% 16.5%

Kuwait 18 + 32% 44%

India 16-64 years 19.3% 25.6%

Classification of Overweight and Obese by Body Mass Index

BMI (kg/m2)

WHO guidelines Proposed Asia Pacific guidelines Underweight < 18.5 < 18.5

Normal 18.5-24.9 18.5-22.9

Overweight 25.0-29.9 > 23

At risk - 23-24.9

Obesity 30-34.9 (Class I) 25-29.9 (Class I)

35-39.9 (Class II) > 30 (Class II)

Extremely Obese > 40 (Class III) -

BMI = Weight (kg) [Height (m)]2

Waist-to-hip ratio

Ratio = WAIST

HIPS

TO FIND RATIOWaist: Measure atnarrowest point withstomach relaxed

Hips: Measure atfullest point

Desired RatioWomen : <0.8Men : < 1.0

Risk increases if waist circumference is >94 cm in men and >80 cm in women

Co-morbidities risk associated with different levels of BMI and suggested waist circumference in adult Asians

Classification BMI Risk of co-morbidities

Waist circumference

< 90 cm (men) > 90 cm (men)

< 80 cm (women) > 90 cm (women)

Underweight < 18.5 Low Average

Normal range 18.5-22.9 Average Increased

Overweight > 23

At risk 23-24.9 Increased Moderate

Obese I 25-29.9 Moderate Severe

Obese II > 30 Severe Very severe

Obesity – An imbalance in energy intake and energy expenditure

Proteins (20%) BMR (60-65%)

ENERGY INTAKE ENERGY EXPENDITURE

Carbohydrates (55%) Physical activity (25-30%)

Fats (25%) Thermic effectof food (10%)

Role of hypothalamus in mediation ofhunger and satiety

Thalamus

ParaventricularHO conservOxytocin rel.

2

AnteriorhypothalamicBody temp

Optic tract

ArcuateNeuroendocrine

FornixRage,Hunger

SupraopticVasopresin rel.

DorsomedialGI stimuli

PeriventricularNeuroendocrine

VentromedialSatiety

LateralhypothalamicHunger, thirst

Classification of obesity as per fat distribution

Android (or abdominal or central, males)-Collection of fat mostly in the abdomen (above the waist)

-apple-shaped

-Associated with insulin resistance and heart disease

Gynoid (below the waist, females)

• Collection of fat on hips and buttocks

•pear-shaped

-Associated with mechanical problems

Diseases and conditions forwhich obesity is a risk factor

Coronary artery disease**

Type II Diabetes Mellitus***

Hypertension**

Dyslipidemia***

Respiratory disease***

Gout**

Reflux disease

Psychological problems

Gallbladder disease***

Osteoarthritis**

Infertility*

Venous circulatory disease

Increased anaesthetic risk*

Low back pain*

Polycystic ovary disease*

Cancer* (ovarian, breast, endometrial, gallbladder, prostate, colon)

Prevalence of overweight and obesity in different income groups of Delhi (Nutrition Foundation of India Study)

Prevalence (%)

Slums Middle-Class Total

Overweight (BMI > 25)Males ND ND 19.6Females ND ND 44.5

Obesity (BMI > 30)Males 1 32.3 NDFemales 4 50 ND

Abdominal obesityMales ND 49.7 NDFemales ND 34.9 ND

ND: Not determined

http://www.nutritionfoundationin.org/NEW/OBESITY.HTM

The Five City Study

n=3257; aged 25-64 yrs

Cities: Moradabad (n=902), Trivandrum (n=760), Calcutta (n=410), Nagpur (n=405), Bombay (n=780)

Social Class BMI>27 WHR>0.85 Sedentary life style

I (n=985) 21.2% 96.9% 92.2%

II (n=790 16.4% 57.2% 71.4%

III (n=674) 8.9% 39.3% 42.3%

IV (n=602) 3.0% 11.9% 14.9%

V (n=206) 3.8% 8.7% 8.7%

Int J Cardiol 1999;69:139-147

Treatment goals

Prevention of further weight gain

Weight loss to achieve a realistic target BMI

Long-term maintenance of a lower body-weight

Diet Activity Drugs VLCD Surgery

BMI 23-25

No risk factors

DM/CHD/HT/HL

-

BMI 25 – 30

No risk factors

DM/CHD/HT/HL

(consider)

BMI > 30

No risk factors

DM/CHD/HT/HL

(in

severe)

(consider

in severe)

Approaches to obesity management

How much weight loss is significant?

A 5-10% reduction in weight (within 6 months) and

weight maintenance should be stressed in any weight

loss program and contributes significantly to

decreased morbidity

Advantages of weight loss

Weight loss of 0.5-9 kg (n=43,457) associated with 53% reduction in cancer-deaths, 44% reduction in diabetes-associated mortality and 20% reduction in total mortality

Survival increased 3-4 months for every kilogram of weight loss

Reduced hyperlipidemia, hypertension and insulin resistance

Improvement in severity of diseases Person feels ‘fit’ and mentally more active

 

Drug therapy

Appetite suppressants Adrenergic agents (e. g. amphetamine, methamphetamine,

phenylpropanol amine, phentermine) Serotonergic agents (ex.. fenfluramine, dexfenfluramine,

SSRIs like sertraline, fluoxetine)

Thermogenic agents ephedrine, caffeine

New ones Sibutramine ; Orlistat STORM: Sibutramine trial on obesity reduction and

maintenance.

Noradrenaline Serotonin

Sibutramine inhibits serotonin andnoradrenaline reuptake

STORM Study : Effect of sibutramine on weight loss

98

104102100

96949290

0 12 22 2420181614108642

Placebo

Sibutramine

Month

Weight loss Weight maintenance

Bod

ywei

ght (

kg)

Lancet 2000; 356:2119-2125

STORM Study:Mean Weight Loss at Two Years

-10.2

-4.7

-12

-10

-8

-6

-4

-2

0

Sibutramine Placebo

Mea

n W

eigh

t Los

s (K

g)

STORM Study : Proportion of patients maintaining at least 5% and 10% weight loss

100

20

40

60

80

06 12 18 24 6 12 18 24

5% responders 10% responders

SibutraminePlacebo

Lancet 2000; 356:2119-2125

Pro

po

rtio

n o

f pa

tien

ts (

%)

STORM Study:Effect on Waist Circumference and Waist/Hip Ratio

-9.2

-4.5

-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

Sibutramine Placebo

Dec

rea

se in

wai

stci

rcum

fere

nce

(cm

)

-1.2

0.8

-1.5

-1

-0.5

0

0.5

1

Sibutramine Placebo

Cha

nge

(a) Waist Circumference (b) Waist/Hip Ratio

STORM Study : Effects on lipids

50

-5-10-15-20-25

Placebo

Sibutramine

Triglycerides

% c

han

ge

00 2418126

50

-5-10-15-20-25

Placebo

Sibutramine

VLDL cholesterol

180 24126

% c

han

ge

Lancet 2000; 356:2119-2125

STORM Study : Effects on lipids (Contd.)

180 24126

25

20

15

10

5

0

HDL cholesterol

% c

ha

ng

e Sibutramine

Placebo

Month of assessment

Weight loss

Weight maintenance

Lancet 2000; 356:2119-2125

30

-6

-5

-4

-3

-2

-1

0

0 6 12 18 24

Month of Assessment

Placebo

Sibutramine

Lancet 2000; 356:2119-2125

% C

hang

e

HbA1c

.

STORM Study : Effect on Insulin and HbA1c

-30

-20

-10

0

0 6 12 18 24

Month of Assessment

Placebo

Sibutramine% C

hang

e

Insulin

STORM study: Other metabolic effects

Variable Baseline Month 6 Month 24

SIB PLAC SIB PLAC SIB PLAC

Uric acid 0.32 0.33 0.29 0.30 0.30 0.32

Glucose 5.20 5.11 5.07 5.01 5.13 5.17

Insulin 17.7 16.7 12.7 12.4 13.8 16.2

C-peptide 3.21 3.05 2.54 2.46 2.38 2.69

HbA1c 5.86 5.75 5.56 5.50 5.56 5.66

STORM study: Conclusions

Almost all patients who persist with a weight management program consisting of sibutramine, diet and exercise can achieve at least a 5% weight loss with sibutramine

Over half can lose more than 10% weight within 6 months

Weight loss was sustained in most patients continuing therapy for two years

Sibutramine vs. Dexfenfluramine

-3.2

-4.5-5-4.5

-4-3.5

-3-2.5

-2-1.5

-1-0.5

0

We

igh

t los

s (k

g)

Sibutramine 10 mg Dexfenfluramine 30 mg

n=226; 12 wks

Int J Obes 1995; 19. Suppl 2: 144

Adverse effects occurring in >5% of patients treated with Sibutramine compared with placebo

Sibutramine % Placebo %Adverse Effects Incidence (n=2068) Incidence (n=884)

Headache 30.3 18.6

Dry Mouth 17.2 4.2

Anorexia 13.0 3.5

Constipation 11.5 6.0

Insomnia 10.7 4.5

Dizziness 7.0 3.4

Nausea 5.9 2.8

Nervousness 5.2 2.9

Dyspepsia 5.0 2.6

Ann Pharmacother 1999;33:968-978

Sibutramine: Safety

Discontinuation rates: 9% with placebo and 7% with sibutramine

Has been associated with a mean increase in BP and heart rate of approximately 1-3mmHg and 4-5 beats/min

Cardiac side effects viz. hypertension, tachycardia and palpitations < 2.6% vs 0.6-0.9% in placebo group

Caution to be exercised in patients with history of hypertension and should not be given to patients with uncontrolled or poorly controlled hypertension

Not associated with cardiac valve abnormalities or primary pulmonary hypertension

STORM Study :Withdrawals due to BP increase

Dose of Sibutramine % patients who

withdrew due to

increase in BP

10 mg 1%

15 mg 2%

20 mg 3%

Lancet 2000; 356:2119-2125

Indications & Dosage

Recommended for obese patients with a BMI > 30 kg/m2 or > 27 kg/m2 in the presence of other risk factors (e.g. hypertension, diabetes, dyslipidemia)

In Indian patients, sibutramine could be considered in patients with BMI > 25 kg/m2 or those with BMI of 23 kg/m2 with co-morbid conditions

Recommended starting dose is 10 mg once daily. If there is inadequate weight loss, the dose may be titrated after

four weeks to a total of 15 mg once daily. The 5 mg dose should be reserved for patients who do not

tolerate the 10 mg dose. Surgical intervention: Measures like liposuction.

Prevention and Control

Weight reduction: Initial goal is to reduce the weight by 5-10% in 6 months period

Dietary changes: Low calorie diet is recommended, calorie intake is modeled to 1000 Kcal/day diet

Increased physical activity to burn the excess body fat.

Thank You