OBESITY & ITS

MANAGEMENT
By : Zaid Alturki , Yazeed Almalki and
Muhammed AbaAlkhail

Supervised by : Dr. AlNaami

:Contents
Definition
Epidemiology
Etiology
Co-morbidity.
Assessment (Hx, Ex, Invest.)
Treatment.

DEFINITION

Obesity is amedical conditionin which excessbody fathas

accumulated to the extent that it may have an adverse effect on
health.
It is a leadingpreventable cause of deathworldwide.
This excess accumulation is the result of a positive energy
balance where caloric intake exceeds caloric expenditure.
With increasingprevalencein adults andchildren, the
authorities view it as one of the most serious public
healthproblems of the 21century.

EPIDEMIOLOGY

In 1997 the WHO formally recognized obesity as a

global epidemic.
WHO further study that by 2015, approximately 2.3
billion adults will be overweight and more than 700
million will be obese.
At least 20 million children under the age of 5 years are
overweight globally in 2005.

a study done in Saudi Arabia showed that the prevalence

of overweight among male subjects was 29% vs. 27%
among female subjects.

While as the prevalence of obesity among female subjects

was significantly higher than for male subjects (24% vs.
16%)

This value is higher than that reported in the UK,

Australian and US populations.

ETIOLOGY
Multifactorial disorder
Genetics:
Polygenic.
It has been long known that
the tendency to gain weight
runs in families.
However, family members
share not only genes but
also diet and life style habits
that may contribute to
obesity.
morbid obesity has a
stronger genetic component
than moderate level of
excess overweight

Energy imbalance.
Diet ( increase Food especially
Fatty diets) major cause of Obesity.
Exercises (Link between physical
inactivity and weight gain).

ETIOLOGY

At an individual level, a combination of

excessivecaloricintake and a lack
ofphysical activity. Is the major cause of obesity.

Medical causes:

Hypothyroidism.
Cushings syndrome.
Polycystic ovarian syndrome.
Hypothalamic insufficiency.
pancreatic insulinoma.

Medications:

Cortisol and other glucocorticoids.

Sulfonylurea.
Antidepressants.
Antipsychotics, e.g. MAOIs,
Risperidone.
Oral contraceptives.
Psychatric
Insulin.

causes:
Major depression.
Binge eating disorders

CO-MORBIDITY

Obesity is associated with more than 30 medical

conditions, and scientific evidence has established a
strong relationship with at least 15 of those
conditions!!

In addition, life expectancy is shown to be reduced in

those who are obese or overweight.

Diabetes (Type 2)

Obesity complicates the management of type 2 diabetes by

increasing insulin resistance and glucose intolerance, which
makes drug treatment less effective.

Hypertension

Cardiovascular Disease (CVD).

Obesity increases CVD risk due to its effect on blood lipid

levels.

Osteoarthritis (OA).

Obesity is associated with the development of OA of the hand, hip,

back and especially the knee.

Sleep Apnea.

Obesity, particularly upper body obesity, is the most significant risk

factor for obstructive sleep apnea.

..OTHERS
Cancers (breast,prostste,liver,gallbladder).
Carpal Tunnel Syndrome (CTS).
Chronic Venous Insufficiency (CVI) & Deep Vein
Thrombosis (DVT).
Gout.
abdominal hernias.
Polycystic ovarian syndrome and infertility.
Low back pain.
Stroke
Abdominal obesity appears to predict the
risk of stroke in men.
Headache

THE CLINICAL ASSESMENT OF

AN OBESE SUBJECT
History.
Physical Examination.
Investigation.

HISTORY

OBESITY FOCUSED HISTORY

Take a full Hx.
Age of onset of obesity.
The pattern of weight gain and loss since puberty.
The level of activity and exercise.
The weight of the partner and children may give an
indication about shared dietary habits and lifestyle.
Drug history and Past or present use of weight loss
medications.
The psychological aspects such as loneliness, boredom,
or stress.

Smoking or alcohol consumption habits.

Family history is important familial predisposition
should be considered if at least one first degree relative
is also obese.
Assess any co-morbidities that are directly or indirectly
related to obesity.
Detailed dietary history of the patients current diet.
Review of the systems .
GERD

Examination

:EXAMINATION

Vital signs.
General examination.
Thyroid.
Signs of Organo Megally. e.g. liver (liver span )
Heart and lung sounds.

Physical examination should target signs or conditions

that predispose to or are complications of obesity!!

Mild hirsutism in women Poly Cystic Ovary Syndrome (PCOS ---increase weight because of insulin resistance).

Large neck size Sleep apnea.

Thyroid tenderness or goiter Hypothyroidism.
Dry or coarse skin and hair Hypothyroidism.
Slowed reflexes Hypothyroidism.
Proximal muscle weakness Cushings syndrome,
Hypothyroidism.
Skin striae Cushings syndrome, steroid use.

ASSESSMENT OF RISK STATUS

BMI.
Waist circumference.
Waist to hip ratio.
Presence of co-morbidities.
Body composition .

BMI
BMI provides a measure based on
height and weight that applies to both
adult men and women.

BMI =

weight (kg) / [ height (m) ]

BMI Range

Weight
Classification

Risk of Illness

Less than 18.5

Underweight

Increased

18.5 24.9

Ideal weight

Normal

25 29.9

Overweight

Increased

30 39.9

Obese

High

40 50

Morbid obese

Very high

50 Or greater

Super obese

Extremely high

WAIST CIRCUMFERENCE
It is Important to note that waist circumference is
measured at the level of the iliac crest.
Excess abdominal fat is clinically defined as a waist
circumference of
* >40 inches (>102 cm) in men
*of>35 inches (>88 cm) in women.
central (visceral) adiposity carry a greater health risk
than peripheral adiposity.
For this reason, the measurement of the waist
circumference in centimeters can be a useful indicator of
clinical risk, particularly for hypertension, diabetes, or
dyslipidaemia.

WAIST TO HIP RATIO (WHR)

A measurement of waist to hip ratio (WHR) is an appropriate
method of identifying patients with abdominal fat accumulation.
The waist is measured at the narrowest point and the hips are
measured at the widest point.
A high WHR is defined as:
*>( 0.95 )1.0 in men.
*>( 0.85 )in women.

Investigations
??Why

:LABORATORY DATA
Baseline

Biochemical profile.
Full blood count.
Fasting lipid profile.

Fasting plasma glucose.

Serum uric acid.
Serum FT4 and TSH.

Further investigations depending on

clinical picture and risk factors

24 hour urine free cortisol.

ECG , chest x ray and US (for gall
stones).
Respiratory function tests.
Plasma leptin.

TREATMENT OF OBESITY

TREATMENT OF OBESITY COMES

:INTO TWO CATEGORIES
1-non-surgical Rx:
Behavior modification.
Diet and exercise.
Pharmacotherapy.
Intragastric Balloon.

2-surgical Rx:
Gastric banding.
Gastric bypass.
Sleeve gastrectomy.

NATIONAL INSTITUTES OF HEALTH

GUIDELINES FOR TREATMENT OF
:OVERWEIGHT AND OBESITY
BMI
range

Behavior
mod.

Pharma
Therapy

Endoscpic Surgical
Balloon
Therapy

25-26.9

Yes*

No

No

No

27-29.9

Yes*

Yes*

No

No

30-34.9

Yes

Yes

Yes

No

35-39.9

Yes

Yes

Yes

No

40 or
more

Yes

Yes

Yes*

Yes

*co morbidities present

Non - Surgical Intervention

:BEHAVIOR MODIFICATION
Identify the circumstances that trigger eating.
Grocery shopping with a pre planned list.
Do nothing else while eating (watch TV or read
magazines).
Eat slowly.
Follow a balanced diet.

:DIET
Balanced,

low-calorie diets.
Very low-calorie diets. ( No carbohydrates)
Low-fat diets.
Low-carbohydrate diets.
Midlevel diets.

:EXERCISE

Patients should be screened for cardiovascular and

respiratory adequacy.
Aerobic exercise:
Is of greatest value for subjects who are obese.
Ultimate minimum goal:

30-60 minutes of continuous aerobic exercise 5-7 times per week to lose
weight
30-60 minutes of continuous aerobic exercise 3-5 times per week to
prevent long term weight regain.

:PHARMACOTHERAPY

Currently tow drugs are used:

1- Sibutramine.

2- Orlistat.

Lasts for several years.

Weight Regain happens.
If no significant weight reduction in at least 3 months,
stop the drug .

 Sibutramine
*Appetite suppressant
*Serotonin & norepinephrine
uptake inhibition.
*Side effect: Tachycardia,
Hypertension & Insomnia.
*weight loss 5%to 10%.

Orlistat
*Potent inhibitor of lipase activity
*Side effect: Oily stools, bloating&
increase flatulence.
*weight loss 10%.

Weight Regain happens after stoppage of either of the drugs.

INTRA-GASTRIC BALLOON

space-occupying volume device, Inserted endoscopically.

Done under GA.

The ballon filled with approximately 500cc of saline

fluid.

Its an out-patient procedure.

Short to medium term solution.

Contraindications:

A BMI< 30 .

Subjects with inflammatory disease of the GI tract.

Alcoholics or drug addicts.

Presence of large hiatal hernia.

Previous open abdominal surgery or bowel surgery.

Complications:
Severe nausea.
Dehydration.
Balloon deflation.
Migration.
Erosion.
Obstruction.

SURGICAL INTERVENTION

Criteria
Cause

of obesity is non medical.

Age below 60 years.
BMI above 40, or 35 with co morbedites.
Conservative treatment has been tried.
The patient is cooperative.
Subject must be psychologically stable and wiling to follow
postoperative diet instruction

Adjustable gastric banding

Reducing the stomach volume

by creating a small pouch at
the top of the stomach using a
band.
Holds approximately 110 to
220g.
Pouch fills quickly and sends
total stomach satiety signals
to the Brain.

Results In
The Subject is less hungry
most of the time.
Early satiety for longer
periods.
Consumption of smaller
portions.

Advantages
50%

to 60% weight loss with exercise add 10

more %.
Reduction of related co morbidities.
Fully reversible.
No cutting or stapling of the stomach.
Quick recovery, Short hospital stay.
Adjustable without further surgery.
No malabsorption issues.
Fewer life-threatening complications.

Band & port specific

Band slippage/ Pouch dilatation.
Esophageal dilatation/ dysmotility.
Erosion of the band into the gastric
lumen.
Port site pain & displacement.
Infection of the fluid within the band.

Digestive
Nausea, vomiting.
obstruction .
Constipation.
Dysphagia.
Diarrhoea.

Gastric bypass procedure

Its A Combination of
restrictive &
malabsorptive operations.
The most common
performed bariatric
procedure in the United
States.
Functions by creating a
small proximal gastric
pouch with
gastrojejunostomy.

Benefits:

Complications:
Anastomotic leakage
Rapid weight loss.
&stricture.
60% to 70% loss of excess body
Dumping syndrome.
weight.
Nutritional deficiencies. ( B12
10% more by exercise.
,EDAK )
Gallstones
Complications of
abdominal Surgery.

Sleeve Gastrectomy

The stomach is reduced to about 15% of its original size, by

removing a large portion of the stomach, following the major
curve.
The open edges are then attached together (often with
surgical staples) to form a sleeve or tube with a banana shape.
The procedure permanently reduces the size of the
stomach.
The procedure is performed laparoscopically and is not
reversible.

Advantages:
Increase in satiety.
Stomach functions
normally.
No dumping syndrome
(the pyloric portion of the
stomach is left intact).
No foreign body usage.
Simpler and less operative
time.

complications:
Leakages & Infection along
the staple line.
GERD.
Gallstones.
postoperative gastric fistula.

In summary

Obesity is imbalance in energy homeostasis .

We start the management by the life style
modificationthen medications then
surgery
roux-en-Y gastric bypass is the best surgical
treatment for morbidly obese patients
Leak is the commonest early complication in
gastric bypass
In choosing the best surgical technique we have
to put in mind the patients life style, so in a
chocoholic we never do banding
If we decide to do a surgery for morbid obese pt,
pt have to loss wt first then undergo surgery, to
do this, gastric balloon and after loss wt go to
surgery.

THANK YOU