CASE

DISCUSSION
ON

CONTENTS
PATIENT HISTORY
WHAT IS OBESITY?
EPIDEMOLOGY
STATISTICS
ETIOLOGY
PATHO-PHYSIOLOGY
TRIGGERING FACTORS
GRADING
TYPES OF OBESITY
DIAGNOSTIC CRITERIA
COMPLICATIONS

GOAL OF TREATMENT
MANAGEMENTALLOPATHY
MANAGEMENT-YOGA
EVIDENCE BASED
MANAGEMENT
REFERENCES

PATIENT HISTORY
Name Mrs. Anusuya
Age 46 yrs
Gender Female
Address #19, Sri Sai Nivas,
Chunchugatta, Blore- 560062
Marital status Married
Occupation- House wife
4

CHIEF COMPLAINTS
Known C/o Hypothyroidism since yrs
K/c/o Epilepsy since 30yrs
C/o Increased body weight since 25
yrs
C/o Bilateral knee joint pain since15
years

HISTORY OF CHIEF
COMPLAINTS
H/C/o
Increased body weight since 25yrs, which is
gradual in onset, after taking epileptic
medication & after second delivery patient
noticed that, her body weight was rapidly
increasing.
H/K/C/o
Epilepsy attack happened after the first
deliver, there-on patient has undergone
allopathic medication for 20 yrs.
6

PAST HISTORY
P/H/O Appendicitis 8 yrs ago
P/H/O Arthroscopy 9 yrs ago
P/H/O Epilepsy 30 yrs ago
Not a C/O- HTN, DM, TB,
Br.Asthma, IHD

MEDICAL/DRUG HISTORY
Tab. Gardinol 30mg1-0-1
Tab. Misitol 200mg

(For 20 years)

1-0-1

OBG
Obstetric
History
Abortions- 1
Gravida- 3
Parity- 2
Live birth- 2

Gynaec History
Periods are regular.
28 days cycle.
5-6 days flow.
No clots.

Undergone Family
Planning- Tubectomy

PERSONAL HISTORY
Vegetarian
Good Appetite
Sound Sleep
Regular bowel Habits
Normal Micturation
No Habits

1
0

FAMILY HISTORY
Neither Father, nor Mother are Obese.
No other Contributions.

VITAL DATA
Blood Pressure- 134/72 mmHg
Pulse rate- 74 b/min
Respiratory Rate- 18 cycle/min
Weight 139 Kgs
Height 154 cms
BMI- 48.56(Obesity grade-III)

1
2

GENERAL PHYSICAL
EXAMINATION
Built Obese
Expression Clear
Appearance - Dull
Pallor Absent
Icterus Absent
Clubbing Absent
Cyanosis Absent
Edema Pitting edema
Lymphedenopathy Not palpable
1
3

SYSTEMIC EXAMINATION
GIT On Ultrasound Fatty liver has been

diagnosed.

Normal bowel sounds, Gynoid obesity.

Anthropometry measurements:
1. Hip circumference- 160cms
2. Mid-arm circumference -36cms
3. Chest circumference- 125cms
4. Abdominal girth- 129cms
5. Thigh circumference-98cms

1
4

SYSTEMIC EXAMINATION
RS NAD (NVRBS heard, No added sounds). Normal TMT
results.
CVS NAD (S1 S2 Heard Normal, No Added Sounds)
CNS NAD (Higher Mental Functions Normal, Reflexes Normal)

SYSTEMIC EXAMINATION
Locomotor NAD, Normal Gait (Occasional Multiple joint pains
only in Cold Season)
Endocrinology NAD
ENT NAD
Encumbrance- Mixed.

FINAL DIAGNOSIS

GYNOID OBESITY
GRADE- III

1
7

WHAT IS OBESITY?
Obesity is a medical condition in which excess body fat has
accumulated to the extent that it may have an adverse
effect on health, leading to reduced life expectancy and/or
increased health problems.
Body mass index (BMI), a measurement which compares weight
and height, defines people as overweight (pre-obese) when
their BMI is between 25kg/m2 and 30kg/m2, and obese
when it is greater than 30kg/m2.

OBESITY
It is a metabolic disorder that is primarily induced and
sustained by an over consumption or underutilization of
caloric substrate.
Obesity is the leading cause of HEART DISEASE, CANCER and
STROKE. The top 3 causes of death.
Obesity and lack of exercise may cause as many as 1/3 of
cancers.

OBESITY
AN OVERVIEW
Overweight and obesity are both
chronic conditions that are the
result of an energy imbalance over
a period of time.
The cause of this energy imbalance
can be due to a combination of
several different factors and
varies from one person to another.
Individual behaviors, environmental
factors, and genetics all
contribute to the complexity of
the obesity epidemic.

ENERGY IMBALANCE

WHAT IS IT?
Weight Gain
Calories Consumed >
Calories Used
Weight Loss
Calories Consumed <
Calories Used
No Weight Change
Calories Consumed =
Calories Used

Energy balance can be compared to

a scale.
An energy imbalance arises when the
number of calories consumed is
not equal to the number of
calories used by the body.
Weight gain usually involves the
combination of consuming too
many calories and not expending
enough through physical activity.

FAT CELL ENLARGEMENT

HYPERTROPHY
Enlarged fat cells produce the
clinical problems
associated with obesity, due
to the following:
The weight or mass of the extra fat.
The increased secretion of free fatty
acids and peptides from enlarged fat
cells.

OBESITY EVOLUTIONMOST OBESE!!

LIFE STYLE CHANGES BETWEEN 19722013 :

Increase in Sedentary Life style
Decrease Physical activities
Intake of calories remaining same
Increase in Fat intake
Most manual jobs have been replaced by
mechanized jobs
Transportation to school /work place
universally by use of motor car/Bus/Bicycles
Increase in hours for activities :TV viewing/

EPIDEMOLOGY
For thousands of yearsobesitywas rarely seen.

It was not until the 20th century that it became common, so

much so that in 1997 the World Health Organization(WHO)
formally recognized obesity as a global epidemic.

As of 2005 the WHO estimates that at least 400 million adults

(9.8%) are obese, with higher rates among women than men.

EPIDEMOLOGY
As of 2008, The World Health Organization claimed that 1.5 billion
adults, 20 and older, were overweight and of these over 200
million men and nearly 300 million women were obese.
The rate of obesity also increases with age at least up to 50 or
60years old.
Once considered a problem only of high-income countries, obesity
rates are rising worldwide.
These increases have been felt most dramatically in urban
settings. The only remaining region of the world where obesity
is not common is sub-Saharan Africa.

EPIDEMOLOGY- IN INDIA
Obesityhas reached epidemic proportions inIndiain the 21st
century, with morbid obesity affecting 5% of the country's
population.

In Northern India obesity was most prevalent in urban

populations (male = 5.5%, female = 12.6%), followed by the
urban slums (male = 1.9%, female = 7.2%). Obesity rates
were the lowest in rural populations (male = 1.6%, female =
3.8%).

EPIDEMOLOGY- IN INDIA
Socioeconomic class also had an effect on the rate of obesity.
Women of high socioeconomic class had rates of 10.4% as
opposed to 0.9% in women of low socioeconomic class.
With people moving into urban centres and wealth increasing,
concerns about an obesity epidemic in India are growing.

STATISTICS
58 Million Overweight; 40 Million Obese; 3 Million morbidly Obese.

Eight out of 10 over 25's Overweight.

25% completely Sedentary.

76% increase in Type II diabetes in adults 30-40 yrs old since

1990

STATISTICS
80% of Type II diabetes related to obesity.
70% of Cardiovascular disease related to obesity.
42% breast and colon cancer diagnosed among obese
individuals.
30% of gall bladder surgery related to obesity.
26% of obese people having high blood pressure .

CLASSIFICATION OF OBE
SITY
OBESITY

ANDROID-apple shape
GYNOID-pear shape
MIXED TYPE

ABDOMINAL
GENERALISED

ANDROID & GYNOID

CAUSE OF OBESITY
High intake calories food and less physical activity.
Heredity.
Sedentary life style.
Endocrine causes-like hypothyroidism, Cushing syndrome.
Psychological cause.

CAUSE OF OBESITY
Metabolic cause.
Hypothalamus syndrome-lesions in hypothalamus lead to
polyphagia & subsequently obesity.
Pregnancy-at the time of pregnancy adiposity happens &
subsequently increases.
GENETIC & MEDICATION.

SIGN & SYMPTOMS

Breathlessness
Snoring during sleep.
Excessive sleep
Drowsiness in day time
Feeling fatigue.
Difficulty in coping with change of physical activity.
Difficulty in sleeping
Snoring

SIGN & SYMPTOMS

Sleep apnea
Pain in your back or joints
Excessive sweating
Always feeling hot
Rashes or infection in folds of your skin
Feeling out of breath with minor exertion
Daytime sleepiness or fatigue
Depression

PATHO-PHYSIOLOGY

LEPTIN
Leptin is a 16 kDa protein hormone that plays a key role in
regulating energy intake and energy expenditure, including
appetite and metabolism.

It is one of the most important adipose derived hormones. The

''Ob(Lep)'' gene (Ob for obese, Lep for leptin) is located on
chromosome 7 in humans.

GHRELIN
Ghrelinis a 28 amino acid hunger-stimulating peptide
andhormonethat is produced mainly byP/D1 cellslining
thefundusof the human stomachandepsilon cellsof
thepancreas.

LEPTIN-GHRELIN
Leptin and ghrelin are considered to be complementary in their
influence on appetite.
Ghrelin produced by the stomach modulating short-term
appetitive control (i.e. to eat when the stomach is empty
and to stop when the stomach is stretched).
Leptin is produced by adipose tissue to signal fat storage
reserves in the body, and mediates long-term appetitive
controls (i.e. to eat more when fat storages are low and less
when fat storages are high).

LEPTIN-GHRELIN
Although administration of leptin may be effective in a small
subset of obese individuals who are leptin deficient, most
obese individuals are thought to be leptin resistant and
have been found to have high levels of leptin.
This resistance is thought to explain in part why
administration of leptin has not been shown to be effective
in suppressing appetite in most obese people.
While leptin and ghrelin are produced peripherally, they
control appetite through their actions on the central
nervous system.

MECHANISM

RISKS
Bone and cartilage degeneration (Osteoarthritis)
Coronary heart disease
Gallbladder disease
High blood pressure (Hypertension)
High total cholesterol, high levels of triglycerides (Dyslipidemia
Respiratory problems
Several cancers
Sleep apnea
Type 2 diabetes
Stroke

DIAGNOSTIC CRITERIA
Body mass index (BMI)
BMI

wt. in kgs

-----------------------------------(height in meter)

BMI

BMI in between 18-25 is normal.

BMI in between 25-30 is overweight.

BMI is more than 30 obesity.

BMI in between 30-35 is grade 1 obesity.

BMI in between 35-40 is grade 2 obesity.

BMI is more than 40 grade 3 / morbid

NOTE-Below 18 BMI shows the person suffering from

malnutrition.

obesity.

BMI
Class 1
BMI of 30-35

Class 2
BMI of 35-40

Class 3, Extreme obesity

BMI greater than 40

CIRCUMFERENCE RATIO
Waist circumferance
----------------------------- 1 (man) obesity
Hip circumferance
0.8(female) obesity
-waist circumferance= below the rib cage and above the
umbilical region.
-hip circumferance= max. portion covering the buttock area.

SKIN FOLD THICKNESS

Tip of scapula (skin fold) > 2.5 cm(male)

Tip of scapula (skin fold) > 2 cm(female)

The triceps muscle (skin fold) > 2 cm(male)

The triceps muscle (skin fold) > 3 cm(female)

COMPLICATIONS
Gastro-intestinal system
-gastro-oesophageal reflex
-hiatal hernia
-gall stone.
Circulatory system
-hypertention
-ischemic heart disease
-stroke/ paralysis.
- increase cholestrol.

COMPLICATIONS
Respiratory system
- breathlessness.
- asthma.

Musculoskeletal system
- osteoarthritis.
-backache.
-flat foot.
-possibility of fracture in fore arm.

COMPLICATIONS
Psychological problems
- depression.
- social isolation.
- image disorder.

COMPLICATIONS
Endocrine problem
- diabetes.
- insulin resistance (cell is covered
by fat.)
-polycystic ovarian disorder.
-menstrual disorder.

COMPLICATIONS
Other diseases like- fungal infection in skin.
- varicose veins.
- post operation hernia.

COMPLICATION(LIVER DISEASE)

Nonalcoholic fatty liver

disease (NAFLD) is the term
given to describe a
collection of liver
abnormalities that are
associated with obesity.

COMPLICATIONS
DIAGRAM

GOAL OF TREATMENT
Prevent further increasing weight.
Reducing the existing weight.
Take care of any other risky factor / complication.

MANAGEMENT
Diet.
Exercise.
Behaviour therapy.
Medication.
Surgery.
YOGA THERAPY

DIET
:
-Normal person 2500-3000 kcal.
-obese person 1000-1500 kcal.

Low calorie diet

Note:- so the management of diet should be

made depending upon the amount of
calories.

DIET DIVIDED SMALL MEALS

Bulky foods.
Fibre food.
Plenty of boiled
green vegtables.
Avoid-sweets,
ice creams,fatty foods,etc.

EXERCISE

EXERCISE
It is useful as a supplement to dieting unless there is a medical
contraindication.
Loosening exercise.
Jogging.
Jumping.
All these exercise burns the energy which is deposited in the
body in the form of fat.

BEHAVIOR THERAPY
Councelling to the patients.
Encouraging their work.etc.

MEDICATION
It is given to patient who is having- BMI more than 30.
- BMI is 28 or more after diet control &
exercise.

MEDICATION
medicine

Group-1
Reduce apetite

Group-2
Prevent absorption
Of fat in intestine.

MEDICATION
Phenyl ethal amine derivatives.
Fenfluramine.
Mazindol.
NOTE:- These medicines cause a lot of side effects likelethargy, diarrhoea, depression. And are also
contraindicated in some specific patients.

SURGERY
It is given to patient-BMI is more than 40.
-There is no effect of diet, exercise, &
medicine.
Jejuno-ileal bypass.
Gastric plication.
Jaw wiring.
Bariatric surgery.

MANAGEMENT BY -IAYT
Yogic management according to panchkosha.
- Annamaya kosha.
- pranamaya kosha.
- manomaya kosha.
- Vijnanmaya kosha.
- Anandmaya kosha.

ANNAMAYA KOSHA
Diet.
Loosening exercise.
Asana- dynamic asanas.
Kriya- vaman dhouti & laghu sankha
prakshalana.
NOTE:- 2 kcal/ min energy burn in asana.

PRANAMAYA KOSHA
Surya anuloma-viloma
pranayama

27 round4 times/day

Pranic energetic technique (PET) twice a

day

MANOMAYA KOSHA
Mastery over the mind to reduce & control the diet.
Satisfaction through hypothallamus.
Om-meditation.
Cyclic meditation.

VIJNANAMAYA KOSA
Bhajan.
Sweet meditation i.e zero state of mind.

ANANDMAYA KOSA
Tunning with nature.
Karma yoga.
Yogic games.

EVIDENCE BASED YOGA

THERAPY
Research paper-1
Research paper-2, 3, 4, 5.

World Health Organization (2000).

Technical report series 894: "Obesity: preventing an
d managing the global epidemic."
(PDF), Geneva: World Health Organization.
ISBN 92-4-120894-5.
^

abcdefgh

National Heart, Lung, and Blood Institute.

Clinical Guidelines on the Identification, Evaluation
, and Treatment of Overweight and Obesity in Adults
. International Medical Publishing, Inc.
ISBN 1-58808-002-1.

abcdeNational Institute for Health and Clinical Excellence

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.
Clinical guideline 43: Obesity: the prevention, iden
tification, assessment and management of overweight
and obesity in adults and children
. London, 2006.

^ aHaslam DW, James WP (2005). "Obesity". Lancet 366

(9492): 1197209. doi:10.1016/S01406736(05)67483-1. PMID 16198769.

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^ "Bariatric Surgery". USC Center for Colorectal and Pelvic
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^ Emedicine|http://www.emedicine.com/med/TOPIC1653.HTM

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U.S. Preventive Services Task Force Evidence Syntheses (2000). HSTAT:

Guide to Clinical Preventive Services, 3rd Edition: Recommendations and
Systematic Evidence Reviews, Guide to Community Preventive Services.
ISBN url=
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.section.36199 .

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Budaj A, Pais P, Varigos J, Lisheng L, INTERHEART Study Investigators.
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ANY QUESTIONS??

THANK YOU!