Obesity

Motea Al-Awlaqi, MD
Assistant professor of cardiology, Aden University
Cardiologist Consultant, Al-Gamhouria General Teaching Hospital
 Introduction
▪ Obesity is a chronic metabolic disease characterized by an increase of body fat stores
▪ It is a gateway to ill health, and has become one of the leading causes of disability and death,
affecting not only adults but also children and adolescents worldwide
▪ The number of overweight and obese people worldwide has increased over recent years, giving
rise to a global obesity epidemic
▪ Health hazards associated with obesity: HTN, heart disease, hyperlipidemia, type 2 diabetes,
stroke, osteoarthritis, liver disease, cancer, OSA, obesity hypoventilation syndrome, and
depression
▪ Obesity is associated with a significant increase in mortality
▪ Changes in lifestyle, dietary habits, physical activity and the social and cultural environment are
associated with the occurrence of obesity
▪ Therefore, prevention and control of obesity can play an important role in reducing the risk for
chronic diseases
 Definition and classification
▪ In clinical practice, the body fatness is usually estimated by Body Mass Index (BMI)
▪ BMI is calculated as measured body weight (kg) divided by measured height squared meter (m2)
▪ Patients with a BMI of 25 kg/m2 or greater are classified as being overweight
▪ Pre obesity and obesity class I, II and III (extreme obesity) are defined as a BMI of 25 kg/m2 to
29.9 kg/m2, 30 kg/m2 to 34.9 kg/m2, 35 kg/m2 to 39.9 kg/m2, and 40 kg/m2 or greater,
respectively
 Obesity related disease risk
▪ Obesity related disease risk is related to overweight
▪ obesity-related disease risk is also increased in individuals with normal weight and BMI who have
an increased waist circumference (WC): a waist circumference of more than 102 cm (40 inches) in
men and more than 88 cm (35 inches) in women
▪ Waist circumference is an indirect measurement of visceral adiposity, which is metabolically
active and responsible for the secretion of pro-inflammatory cytokines that are, in part,
responsible for the pathogenesis of insulin resistance and the metabolic syndrome
▪ Accumulation of intra-abdominal fat is associated with higher metabolic and cardiovascular
disease risk
▪ The amount of abdominal fat can be assessed by waist circumference which highly correlates with
intra-abdominal fat content
▪ The WC is measured in the horizontal plane midway in the distance of the superior iliac crest and
the lower margin of the last rib
Quantifying obesity with BMI and waist circumference for risk of
type 2 diabetes and cardiovascular disease
 Pathogenesis and etiology
▪ The etiology of obesity is multifactorial, involving a complex interaction among genetics,
hormones and the environment
Some reasons for the increasing prevalence of
obesity – the ‘obesogenic’ environment
 Pathogenesis and etiology
▪ Genetic susceptibility to obesity
- Susceptibility to obesity and its adverse consequences undoubtedly varies between individuals
- The pattern of inheritance suggests a polygenic disorder, with small contributions from a number
of different genes, together accounting for 25–70% of variation in weight
- These genes include the beta-3-adrenergic receptor gene, peroxisome-proliferator-activated
receptor gamma 2 genes, chromosome 10p, melanocortin-4 receptor gene and other genetic
polymorphisms
- Additional genetic conditions in which obesity is a feature include Prader–Willi and Lawrence–
Moon–Biedl syndrome
 Pathogenesis and etiology
▪ Multiple hormones are involved in the regulation and pathophysiology of obesity, including
Gut-related hormones, adipokines and other
The gut hormone signaling to the brain under fasted and fed states in healthy state
 Pathogenesis and etiology
Summary of the role of gut hormones on appetite regulation and other actions
Hypothalamic circuit regulating appetite and energy hemostasis
pathways to obesity
Hypothalamic circuit regulating appetite and energy hemostasis pathways to obesity
 Pathogenesis and etiology
▪ Potentially reversible causes of weight gain
 Complications of obesity
▪ Obesity has adverse effects on both mortality and morbidity
▪ It is suggested that obesity at age 40 years can reduce life expectancy by up to 7 years for non-smokers
and by 13 years for smokers
▪ Coronary heart disease is the major cause of death but cancer rates are also increased in the
overweight, especially colorectal cancer in males and cancer of the gallbladder, biliary tract, breast,
endometrium and cervix in females.
▪ Obesity has little effect on life expectancy above 70 years of age, but the obese do spend a greater
proportion of their active life disabled
▪ The rise in obesity has been accompanied by an epidemic of type 2 diabetes and osteoarthritis,
particularly of the knee.
▪ Obesity may have profound psychological consequences, compounded by stigmatization of the obese in
many societies
Complications of obesity
 Clinical evaluation of the obese patient
▪ A comprehensive history
▪ Physical examination
▪ Laboratory assessment relevant to the patient’s obesity should be obtained
 Taking an obesity-focused history
• The first step in initiating obesity care is to take a comprehensive history that addresses issues
and concerns specific to obesity treatment
• This obesity-focused history allows the physician to develop tailored treatment recommendations
that are more consistent with the needs and goals of the individual patient
• For many patients, weight gain initially occurs with or is accelerated coincident to smoking
cessation, initiation of a medication, or change in life events such as a change in marital status,
change in occupation, or illness
• At-risk times for women include pregnancy and menopause. Stressful life events often result in a change in
eating and physical activity habits. Insight into predisposing genetic factors is obtained by taking a family
history
• it is important to ascertain whether the patient was overweight as a child or adolescent because early onset
of obesity is a predictor of severe obesity in adulthood
• A dietary and physical activity history should be assessed in all patients before counseling is initiated
• Assessment of psychological health and psychiatric history should be done routinely during the history
• Probing for conditions of disordered eating such as binge eating disorder, bulimia, or night-eating syndrome
or other psychological conditions that may impair treatment such as attention deficit disorder or post
traumatic stress disorder should be part of a comprehensive obesity history
 Physical examination of the obese patient
• According to the World Health Organization, assessment of risk status resulting from overweight
or obesity is based on the patient’s
1. BMI
2. Waist circumference
3. Existence of comorbid conditions
• Presence and impact of obesity-related diseases (diabetes, hypertension, dyslipidaemia,
cardiovascular, respiratory and joint diseases; non-alcoholic fatty liver disease (NAFLD), sleep
disorders, etc should be assessed
• Presence of acanthosis nigricans as a sign of insulin resistance should be looked for
 Laboratory examinations
The minimum data set required will include:
• Fasting blood glucose
• Serum lipid profile (total, HDL and LDL cholesterol, triglycerides)
• Uric acid
• Thyroid function (thyroid-stimulating hormone [TSH] level)
• Liver function (hepatic enzymes), liver investigation (ultrasound, biopsy) if abnormal liver function
tests suggest NAFLD or other liver pathology
• Cardiovascular assessment, if indicated
• Endocrine evaluation if Cushing’s syndrome or hypothalamic disease suspected and
• Sleep laboratory investigation for sleep apnoea
 Management
▪ Appropriate goals of weight management emphasize realistic weight loss to achieve a reduction in
health risks and should include
1. Promotion of weight loss
2. Maintenance of weight loss and
3. Prevention of weight regain
▪ Weight loss occurs by generating a negative energy balance, which is achieved by consuming fewer
calories than energy expended
▪ A physician should discuss with the Patient before deciding the initial level of intervention
1. Life style and physical activity
2. Pharmacological drugs
3. Bariatric surgery
 A guide to deciding the initial level of
intervention to discuss with the patient

L = Lifestyle intervention (diet and physical activity); D = consider drugs; S = consider

surgery. *BMI and waist circumference cut-off points are different for some ethnic
groups.
**Patients with type 2 diabetes on individual basis.
 Management
1. Dieting and physical exercise
- Is the main treatment for obesity that will lead to a net negative energy balance
- The initial goal is to achieve a 5% to 10% weight loss over the initial 6 months of treatment
- Caloric reductions is the most important component in achieving weight loss, whereas increased and
sustained physical activity is particularly important in maintaining the lost weight
❑ Dietary advice
- Should encourage healthy eating and emphasize the need to increase consumption of vegetables,
beans, legumes, lentils, grain, unsweetened cereals and fiber, and to substitute low-fat dairy products
and meats for high-fat alternatives
- It should also emphasize increased intake of seafood
- It is recommended to avoid foods containing added sugars and solid fats, as well as consumption of
sugary drinks and alcohol-containing beverages
❑ Physical exercise:
- Exercise alone can produce a 2% to 3% reduction in BMI, it is a more effective weight loss tool when
used in conjunction with dietary modification
- Physical activity can help in long-term weight loss maintenance
- A starting program of 30 min to 45 min of moderate exercise (e.g., brisk walking) at least three days
per week is recommended. This amount of physical activity expends approximately 150 kcal/day (500
to 1000 calories per week
 Management
❑ Physical exercise continue:
- Any form of physical activity is appropriate as long as it increases heart rate and energy expenditure
- Walking is the most common, safe and accessible mode of exercise that is prescribed
- The National Weight Control Registry recommends that individuals initially walk 4000 steps per day,
with a gradual increase to 12,000 steps per day over a period of six months
 Management
2. Pharmacotherapy:
- Antiobesity drug therapy is indicated for those individuals who cannot achieve weight loss despite an adequate
trial of lifestyle modification
- Pharmacotherapy should only be prescribed in conjunction with lifestyle modifications, and not as monotherapy
for obesity
- According to current Food and Drug Administration (FDA) guidance, pharmacotherapy is approved for patients
with a BMI >30 kg/m2 or >27 kg/m2 when complicated by obesity comorbidity
- They fall into 2 major categories: appetite suppressants or anorexiants and gastrointestinal fat blockers
- The efficacy of pharmacotherapy should be evaluated after the first 3 months. If weight loss achieved is
satisfactory (>5% weight loss in non-diabetic and >3% in diabetic patients), treatment should be continued.
Treatment should be discontinued in non-responders
Drugs used:
1. Orlistat (pancreatic and gastric lipase inhibitor)
2. lorcaserin (selective 5-HT2c receptor agonist)
3. combination phentermine and topiramate (exact mechanism of action unknown), have shown some benefit
4. Combination of Bupropion/Naltrexone (combines two centrally acting medications that had already been
approved)
5. Liraglutide is an injectable long-acting GLP-1R agonist designed to resist rapid metabolism by dipeptidyl
peptidase-IV
 Management
3. Bariatric and metabolic surgery:
- Patients with a BMI >40kg/m2 or those with a BMI >35 kg/m2 who have associated high-risk co-
morbid conditions such as cardiopulmonary disease or type 2 diabetes mellitus could be considered
surgical candidate
- Surgical weight loss can be achieved by restrictive, malabsorptive or combination procedures
▪ Roux-en-Y gastric bypass surgery -restrictive and malabsorptive
▪ Vertical banded gastroplasty is a purely restrictive procedure
▪ Laparoscopic adjustable gastric banding- purely restrictive procedure
 Management
4. Treatment of co-morbidities
▪ Active treatment of obesity-related co-morbidities should be integral part of the comprehensive
management of the obese patients
▪ Appropriate management of obesity complications in addition to weight management should include:
1. Management of dyslipidaemia
2. Optimizing glycaemic control in type 2 diabetics
3. Normalizing blood pressure in hypertension
4. Management of pulmonary disorders
5. Attention to pain control and mobility needs in osteoarthritis
6. Management of psychosocial disturbances, including affective disorders, eating disorders, low self-
esteem and body image disturbance