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					       OBESITY

FACING THE CHALLENGES OF
   MAN MADE EPIDEMIC


     Dr.Prasad Katulanda
          CCP 2009
Obesity - history
        • Fatness – a sign of
          health and prosperity!

        • Mild fatness would have
          been socially
          acceptable and possibly
          advantageous (face
          cold temperature and to
          withstand infections!
        Obesity - evolution
                       • Chronic positive
                         energy balance in
                         most modern
                         societies

                       • Obesity has
                         become
                         pathological
Obesity – a chronic disabling, disfiguring and
       often life threatening condition
Pathogenesis of obesity
Pathogenesis of obesity
                           Weight Maintenance




             Weight Gain                   Weight Loss




   Protein                                                     TEF


    Fat                                                  Physical Activity



Carbohydrate                                             Resting Metabolic
                                                               Rate




   TEF – thermogenic effect of food
Regulation of energy balance
Pathogenesis of obesity
            Genetics of obesity
                     Obesity is heritable


Monogenic forms of obesity     Polygenic obesity (common obesity)
     Monogenic forms of obesity
Prader–Willi syndrome
Fragile X syndrome
BBS
Cohen syndrome
Albright's
Wilson
Turner syndrome
Borjeson–Forssman–Lehmann syndrome
TrkB deficiency
Alstrom syndrome
Leptin deficiency
Leptin receptor deficiency
POMC deficiency
PC-1 deficiency
MC4R deficiency I
     Genetic markers of common
              obesity
Findings of genome wide scans (GWS)
•   FTO
•   MC4R
•   TMEM18
•   KCTD15
•   GNPDA2
•   SH2B1
•   MTCH2
•   NEGR1


Nature Genetics 41, 18 - 24 (2008)
Published online: 14 December 2008 | doi:10.1038/ng.274
Genetic markers – potential use
• Understand pathogenesis
• Pharmacogenetics
• ? Early identification of high risk
  individuals
• ? Selective interventions
            Mean BMI - trends
Frequency




                BMI
        Medical consequences of
                 obesity
                                 CHD
                                               Hypertension
          Type 2 diabetes    heart failure          DVT
          Dyslipidaemia                      Renal dysfunction

Surgical/anaesthetic                                  Osteoarthritis
   complications                                     Lower back pain


Pyschologial                Overweight                      Complicated
 problems                   and obesity                     pregnancies


                                                       Sleep apnoea
   Reproductive                                    Respiratory disorders
    disorders

                                                 Dermatological
                         Cancer of breast,        Gallstones
       NAFLD/NASH
                          colon, prostate,
                       kidney, gall bladder,
                             ovary and
                           endometrium
BMI and mortality -US
         Obesity - pandemic
• Obesity has become a worldwide
  pandemic
• Mostly a problem in industrialised
  countries
• Emerging as an epidemic in developing
  countries
• ? Impact underestimated in Asians
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
   Why measure/classify obesity?
• To identify individuals at high risk for
  morbidity and mortality
• Meaningful comparison within and
  between populations
• To identify priorities for intervention
• As a firm basis for evaluation interventions
        Measurement of obesity
• Body Mass Index (BMI)
      weight (kg)/height (m)2
• Waist circumference
• Waist-hip-ratio (WHR)
• Skin fold thickness
• DEXA
• MRI/CT
• Bioelectrical impedence
• Isotope dilution
            Classification of obesity
      WHO GLOBAL RECOMMENDATION                      PROPOSED CUT-OFF LEVELS FOR ASIANS

          BMI                   CATEGORY                     BMI                   CATEGORY

  < 16 KG/M2              SEVERE
                          UNDERWEIGHT

  16.0 – 16.9 KG/M2       UNDERWEIGHT

  17.0 – 18.49 KG/M2 MILD UNDERWEIGHT               < 18.5 KG/M2              UNDERWEIGHT

  18.5 – 24.9 KG/M2       NORMAL RANGE              18.5 – 22.9 KG/M2         NORMAL RANGE

  25.0 – 29.9 KG/M2       PRE OBESE                 ≥ 23 - 27.4 KG/M2         PRE OBESE

  30.0 – 34.9 KG/M2       OBESE CLASS I             ≥ 27.5 KG/M2              OBESE

  35.0 – 39.9 KG/M2       OBESE CLASS II

  ≥ 40 KG/M2              OBESE CLASS III

WHO (2000) OBESITY: PREVENTING AND MANAGING THE GLOBAL EPIDEMIC. REPORT OF A WHO CONSULTATION. WORLD HEALTH
ORGAN TECH REP SER, 894, I-XII, 1-253.
WHO (2004) APPROPRIATE BODY-MASS INDEX FOR ASIAN POPULATIONS AND ITS IMPLICATIONS FOR POLICY AND INTERVENTION
STRATEGIES. A REPORT OF A WHO CONSULTATION. LANCET, 363, 157-63.
                 Sri Lanka
• Middle Income country
• But high literacy, low levels of maternal and
  infant mortality
• Rapid socio-demographic change
Socio-demographic profile
Epidemiological transition
               CVD risk factors and BMI
             100



              80
Percentage




              60



              40



              20



               0
                   1    2        3     4
                       BMI quartiles
                           ROC curves
                    BMI for predicting CVD risk

              1.0
                                                                     1.0

              0.8
                                                                     0.8
Sensitivity




                                                       Sensitivity
              0.6
                                                                     0.6

              0.4
                                                                     0.4

              0.2
                                                                     0.2

              0.0
                                                                     0.0
                 0.0   0.2     0.4   0.6   0.8   1.0
                                                                        0.0   0.2     0.4   0.6   0.8   1.0
                             1 - Specificity                                        1 - Specificity


                                Male                                                 Female

          AUC 0.71 (0.68 – 0.73)                                      AUC 0.71 (0.69 – 0.73)
             BMI cut off 20.7                                           BMI cut off 22.0
Prevalence and patterns of
         obesity
               Prevalence of generalised obesity


             100%
                    7.2               12.0             9.7

             80%    22.9
                                                       25.9
                                      28.6
                                                              ≥27.7
Prevalence




             60%
                                                              23-27.4
                    44.9
                                                       40.8   18.5-22.9
             40%                      37.1
                                                              <18.5

             20%
                    25.0              22.4             23.6

              0%
                    Male             Fem ale           All




                           P <0.0001 Male vs. Female
              Prevalence of generalised obesity


             100%                       7.3               9.7
                     19.1

             80%                       23.8
                                                      25.9

                                                                ≥27.7
Prevalence




                     33.8
             60%
                                                                23-27.4
                                       42.6
                                                      40.8      18.5-22.9
             40%
                     33.9
                                                                <18.5

             20%
                                       26.3           23.6
                     13.2
              0%
                    Urban              Rural              All




                            P <0.0001 – Urban vs. Rural
        Management of obesity
•   Diagnosis and classification
•   Evaluation – aetiology and effects
•   Lifestyle intervention
•   Pharmacological treatment
•   Bariatric surgery
Management of obesity
     Rationale
         Management of obesity
              Rationale
   Conditions         Out come
   Blood pressure      Fall of 10 mm systolic
                         Fall of 20 mm diastolic
   Plasma lipids         Fall of 10% total cholesterol
                         Fall of 15% LDL
                         Fall of 30% triglycerides
                         Rise of 8% HDL
   Diabetes              Fall of 50% FPG (newly diagnosed)
   Mortality             Fall of >20% total mortality
                         Fall of >30% diabetes-related
                         Fall of >40% obesity-related cancers


Benefits of 5-10% of Body weight loss (adapted from SING, 1996)
        Management of obesity
                 Clinical evaluation
•   Measurement of obesity
•   Presence of obesity related morbidity/risk
    factors
•   Family history of obesity and related
    disorders
•   Personal attitudes and perception
•   Lifestyle factors
        Management of obesity
       Clinical evaluation - Lifestyle factors
Diet
• Eating patterns
• Portion sizes
• Knowledge on food – protein, CHO, Lipids etc
Physical activity
• From childhood
• Occupational, daily living, transportation and leisure time
• Barriers to increase in physical activity
       Management of obesity
        Lifestyle intervention
In all patients with obesity
Diet
• Very important in weight reduction
• Achieve a negative calorie balance
• Prevent selective malnutrition
Physical activity
• Complementary to diet
• Helps maintenance of weight
• Additional benefits – CVD, osteoporosis, well being
      Lifestyle intervention - diet
Dietary advices
•A balance varied diet
•Encourage to drink 2-3L of water daily and discourage
calorie containing drinks (e.g. fizzy drinks)
•A variety of salads and vegetables
•Increased fruit and vegetable intake, at least 5 potions
per day
•Lower fat intake.
•Lower sugar intake
•Encourage wholemeal and non-refine carbohydrate for
main staple foods
•Limit alcohol consumption
•Limit salt intake and salty food items
•Meal replacements may be needed for selected adults
  Lifestyle intervention – physical
                activity
Advices on physical activity
•Walking very useful – easy to achieve
•Travel whenever possible by foot and aim for 30
minutes brisk walking per day
•Walk all or part of the journey to work or the shops
•If usual travel is by bus to get off a stop earlier
•Using the stairs instead of the lift
•Avoid sitting for long periods
•If you have a garden spend more time working in it
•Exercises - start gradually and increasing, when
appropriate, with some resistance training
          Lifestyle intervention
•   Involvement of other HCWs
•   Dietician/Nutritionist
•   Clinical Psychologist
•   Cognitive behaviour therapy
•   Exercise/physical activity experts -
    physical activity training
  Pharmacological management
          of obesity
                   Mechanisms of actions

• Increase satiety (fullness)
• Increase thermogenesis
• Interfere with digestion and absorption

Indication for drug therapy: BMI ≥30 or BMI ≥27 with co morbidities
    Pharmacological management
            of obesity
                         Orlistat
•   Intestinal Lipase inhibitor – reduce dietary fat
    absorption
•   Used in conjunction with diet & exercise
•   Side effects due to fat malabsorption
•   May need fat soluble vitamin supplementation
•   Continue >12 wks only if >5% wt loss
•   Generally safe
•   HBA1C reduction in T2DM
•   Gradual reversal of weight gain after stopping
 Pharmacological management
         of obesity
                  Sibutramine
• Increase thermogenesis – noradrenalin and
  serotonin uptake inhibited
• Suppress appetite
• Used in conjunction with diet & exercise
• Recommended for 1 year
• Side effects due to catecholamine excess
• Continue if >2kg wt loss in 4 weeks (stop if <5%
  in >12 wks/ wt increase or stabilises)
• Gradual reversal of weight gain after stopping
    Pharmacological management
            of obesity
                    Rimonabant
•   Cannabinoid receptor antagonist
•   Acts centrally in interfere with food intake
•   Used in conjunction with diet & exercise
•   Recommended for 1 year
•   CNS Side effects – depression, epilepsy
•   Continue only if effective – FDA/EU Concerns
•   Gradual reversal of weight gain after stopping
Novel pharmacological agents
             (1) Ghrelin antagonism (or gastric bypass)
             (2) CCK agonism;
             (3) GLP-1 agonism (extendin 4, liraglutide,
                 DPP IV inhibitors); and
             (4) PYY agonism.
             (5) CNS drugs that may decrease appetite
                 through a variety of effects on
                 neurotransmitters, neuronal ion
                 channels, and possibly other pathways:
             (bupropion, some noradrenaline reuptake
                 inhibitors, selective 5HT receptor
                 agonists, some antiseizure drugs -
                 topiramate, zonisamide, some dopamine
                 antagonists, and CB 1 receptor
                 antagonists - rimonabant).
Surgical management of obesity
      Indications- BMI ≥40 or BMI ≥35 +co- morbidities


Principles
• Restrictive procedures
• Malabsorptive procedures
• Combinations
• Changes of hormones secreted by GIT
  also may play a role
Surgical management of obesity
• Increased use of minimally invasive
  procedures
• Excellent short term and good long term
  outcomes
• Surgical morbidity and mortality
• Dedicated multidisciplinary teams
• Lifelong follow up needed
Roux-en-Y gastric bypass
         (RGB)
Bilio-pancreatic diversion
          (BPD)
Gastric banding – LAP band
Sleeve gastrectomy
      Management of obesity
          Multidisciplinary approach
Physician – endocrinologist or physician with
 an interest in obesity
Nutritionist/dieticians
Physical activity expert
Psychologist or behaviour therapist
Bariatric surgeon
Patients family
Prevention of obesity…
Maintain ideal body weight
Prevention of obesity
          Prevention of obesity
Individual level approach
• Early identification of high risk individuals
• Start from childhood
• Benefits of healthy weight – cognitive behaviour Rx
• Difficulty of treating established obesity
• Targets for weight maintenance
• Simple lifestyle advises
• Involve family (parents/spouses)
• Role of other HCWs/professionals
       Prevention of obesity
High risk individuals
• Upper normal BMI (kids age appropriate)
• Family history of obesity
• Spouses of obese people
• Sedentary lifestyle
• Eating disorders
• Post natal women
• Weight gain
       Prevention of obesity
     Population Level Approach

•   A public health problem
•   Schools
•   Health education
•   Legislative measures
•   Building and town planning
•   Mass media
           Population approach – School
               based interventions


    Healthy eating and exercise into school curricula
    Promote physical exercise and sports at schools
                                                            
   Discourage unhealthy eating habits
   Discourage unhealthy leisure activities
   Screening for childhood obesity/ high risk categories
    and directing for health promotion clinics


                                      
                                                 

    Young Physicians’
    Forum 2004
  Population approach – physical
           activity……
Encourage exercise at schools and
 working places




    Gymnasia
    Incentives
    Time during working hours ( Breaks for
    exercise )
  Population approach – physical
              activity
Reduce using exercise sparing devices
 – Lifts, Cars



                               
  Population approach – physical
              activity
Regulation in town planning and construction
Population approach …




    Making trends by
    education and mass
    media
           Primary preventive
               strategies
                           Go back
                        to/preserve
                         traditional
                          lifestyles




Young Physicians’
Forum 2004
                 Conclusions

• Obesity is becoming a public health problem in
  Sri Lanka
• The overall prevalence of overweight and
  obesity together is 35.6%
• Awareness and preparation of the health system
  for the epidemic is needed
• Early preventive measures
• Research on surveillance, aetiology and
  culturally specific interventions
Acknowledgements
University of Colombo Dept of Clinical
Medicine

Oxford Centre for Diabetes Endocrinology
and metabolism


National Science Foundation – Sri Lanka


Diabetes Association of Sri Lanka


Diabetes Research Unit Team

				
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posted:10/3/2012
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