Approach to
OBESITY
Jay-r B. Palec
Dr. Marj Ramos
Moderator
 2006 Canadian Clinical Practice
Guidelines on the Management &
Prevention of Obesity in Adults & Children
 Obesity Trea...
Then...
 Ancient Egyptians are said to consider
obesity as a disease, having been drawn
in a wall of depicted illnesses.
...
 Hippocrates, the father of medicine, was
aware of sudden deaths being more
common among obese men than lean
ones as stat...
Now...
 Obesity is now reaching epidemic
proportions in both developed and
developing countries and is affecting not
only...
 Obesity should no longer be viewed as a
cosmetic or body-image issue.
 The cause of obesity is complex and
multifactorial.
 The rapid increase in the prevalence of
obesity over the past 20 y...
In the Philippines...
 Data illustrates the upward trend in
overweight and obesity from first survey in
1987 to the most ...
 Among Filipino adults, the prevalence of
overweight (BMI 25-29.9, WHO
Classification) has jumped from 11.8% in
1987 to 2...
Clinical Scenario
 Ms. A is a 46-year-old woman who is
married with 2 children and is seen for an
initial primary care as...
 She is not taking any prescription
medications but occasionally takes an
over-the-counter NSAID’s for low back
pain. She...
 Her mother (age 72 years) has type 2
diabetes, and her father (age 75 years)
has coronary artery disease.
Physical Examination
 Appears generally well. She weighs 89 kg
and is 1.6 m tall. Blood pressure is135/85
mm Hg, heart ra...
 Her body habitus suggests a central
(abdominal) pattern of obesity.
 On further questioning, the patient states
that she has poor eating habits and
admits to frequent “snacking” on energy-
...
Initial Assessment &
Investigation
 We recommend measuring body mass
index (BMI; weight in kilograms divided by
height in metres squared) in all adults and
...
BMI
 Body mass index or BMI is a simple and
widely used method for estimating body
fat mass.
 BMI was developed in the 1...
 Calculated by dividing the subject's mass
by the square of his or her height
 BMI = kilograms
meters2
WHO Classification
Asia-Pacific Classification
 We recommend measuring waist
circumference in all adults to assess
obesity-related health risks [grade A, level
3].
2006...
Waist Circumference
Upper border of the
right iliac crest
Obesity Treatment Recommendations in the
Philippines: Perspective on their Utility and
Implementation in Clinical Practice...
Obesity Treatment Recommendations in the Philippines: Perspective on
their Utility & Implementation in Clinical Practice
Case
 Ms. A’s BMI is 34.8 kg/m2.
 Her waist circumference, at 98 cm, is high
for her sex, indicating a central
(abdomina...
Clinical & Laboratory
Assessment of Overweight and
Obese Adults
 We recommend that the clinical
evaluation of overweight and obese
adults include a history and a general
physical examin...
 We recommend measuring fasting
plasma glucose level and determining
lipid profile, including total cholesterol,
triglyce...
 Fasting blood glucose level and lipid
profile are important components in the
assessment of an overweight or obese
perso...
 We suggest additional investigations, such
as liver enzyme tests, urinalysis and sleep
studies (when appropriate), to sc...
 Assessment of liver enzymes and urinalysis
is a grade B recommendation because
obese patients may be at increased risk
o...
Obesity Treatment Recommendations in the Philippines: Perspective on
their Utility & Implementation in Clinical Practice
 We suggest that the health care
professional screen the overweight or
obese adult for eating disorders,
depression and p...
 Major depression and other mood
disorders are common in patients with
obesity; they occur in 20%–60% of women
aged 40 ye...
 Furthermore, the presence of a mood
disorder may adversely affect adherence
to weight management interventions.
Case
 Ms. A, laboratory testing reveals the following:
Fasting glucose level 6.4 mmol/L
Total cholesterol 5.75 mmol/L
LDL...
Case
 Ms. A is considered to have a mild
depressive disorder that appears to be
linked, in part, to concerns and anxiety
...
Diagnosis?
 Obese Class II
 Impaired fasting glucose
 Dyslipidemia
 Mild depressive disorder
Management
 We recommend a comprehensive
healthy lifestyle intervention for
overweight and obese people [grade A,
level 1].
2006 Can...
 We recommend an energy-reduced diet
and regular physical activity as the first
treatment option for overweight and
obese...
 We recommend diet and exercise
therapy for overweight and obese people
with risk factors for type 2 diabetes [grade
A, l...
Lifestyle Intervention
 We recommend comprehensive lifestyle
interventions (combining behaviour
modification techniques, ...
Dietary Intervention
 We suggest a high-protein or a low-fat
diet as a reasonable short-term (6–12
months) treatment opti...
 Dietary and lifestyle interventions aimed
at decreasing energy intake and
increasing energy expenditure through a
balanc...
Physical Activity
 We suggest physical activity (30 minutes a
day of moderate intensity, increasing,
when appropriate, to...
 Endurance exercise training may reduce
the risk of cardiovascular morbidity in
healthy postmenopausal women, and we
sugg...
Pharmacotherapy
 We suggest the addition of a selected
pharmacologic agent for overweight or
obese adults with type 2 dia...
 We suggest the addition of a selected
pharmacologic agent for appropriate
overweight or obese adults, who are not
attain...
Bariatric Surgery
 We suggest that adults with clinically
severe obesity (BMI ≥ 40 kg/m2 or ≥ 35
kg/m2 with severe comorb...
Alternative Therapy
 There is insufficient evidence to
recommend in favour of or against the
use of herbal remedies, diet...
Obesity Treatment Recommendations in the Philippines: Perspective on
their Utility & Implementation in Clinical Practice
Obesity Treatment Recommendations in the Philippines: Perspective on
their Utility & Implementation in Clinical Practice
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
Approach to Obesity
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Approach to Obesity

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  • Obesity is now reaching epidemic proportions in both developed and developing countries and is affectingnot only adults but also children and adolescents. Over the last 20 years, obesity has become the most prevalentnutritional problem in the world, eclipsing undernutrition and infectious disease as the most significant contributor to ill health and mortality. It is a key risk factor for many chronic and non-communicable diseases.
  • There is compelling evidence that overweight people are at increased risk of a variety of healthproblems, including type 2 diabetes, hypertension, dyslipidemia, coronary artery disease, stroke, osteoarthritis andcertain forms of cancers.
  • With progressive improvements in the standard of living in developed and developing countries, overnutrition and sedentary lifestyle have supplanted physical labour and regular physical activity, which has resulted in positive energy balance and overweight.
  • Perhaps one of the most compelling evidence recently is the independent film, Super Size Me. Released in 2004, written, produced and directed by American independent filmmaker, Martin Spurlock in an exploration of the prevalence of obesity in the USA. He documented 30 days of his life in an experiment of eating only McDonald's food with completely no exercise. He began the project as healthy and lean but ended up overweight.
  • I the assessment of BMI, we have 2 classifications.
  • Early recognition of such disorders may permit dietary and lifestyle changes that will mitigate the risk of disease development and progression.
  • Major depression and other mood disorders are common in patients with obesity; they occur in 20%–60% ofwomen aged 40 years or older with a BMI > 30 kg/m2, the group into which Mrs. A falls.
  • Screening for such disorders in appropriate individuals is a grade B recommendation. Treatment of a major depressive disorder should be undertaken in concert with any planned weight management intervention, because some pharmacologic weight-loss treatments must be avoided in patients who are taking antidepressantmedications.
  • The use of a multidisciplinary, lifestyle-based intervention for the management of obese individualsis a grade A recommendation. Furthermore, discussion of the weight management program before its initiationamong members of the health care team and the patient to establish management goals and review potential barriers to achieving these goals is a grade B recommendation.
  • Lifestyle intervention plays a big role
  • Approach to Obesity

    1. 1. Approach to OBESITY Jay-r B. Palec Dr. Marj Ramos Moderator
    2. 2.  2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children  Obesity Treatment Recommendations in the Philippines: Perspective on their Utility & Implementation in Clinical Practice
    3. 3. Then...  Ancient Egyptians are said to consider obesity as a disease, having been drawn in a wall of depicted illnesses.  Ancient China have also been aware of obesity and the dangers that come with it. They have always been a believer of prevention as a key to longevity.
    4. 4.  Hippocrates, the father of medicine, was aware of sudden deaths being more common among obese men than lean ones as stated in his writings.
    5. 5. Now...  Obesity is now reaching epidemic proportions in both developed and developing countries and is affecting not only adults but also children and adolescents.
    6. 6.  Obesity should no longer be viewed as a cosmetic or body-image issue.
    7. 7.  The cause of obesity is complex and multifactorial.  The rapid increase in the prevalence of obesity over the past 20 years is a result of environmental and cultural influences rather than genetic factors.
    8. 8. In the Philippines...  Data illustrates the upward trend in overweight and obesity from first survey in 1987 to the most recent and fifth survey in 2008. -National Nutrition & Health Survey (NNHeS)
    9. 9.  Among Filipino adults, the prevalence of overweight (BMI 25-29.9, WHO Classification) has jumped from 11.8% in 1987 to 21.4% in 2008.
    10. 10. Clinical Scenario  Ms. A is a 46-year-old woman who is married with 2 children and is seen for an initial primary care assessment. She has experienced some “weariness and increased irritability” in recent months but otherwise has been in good health. Her menses are regular, and she does not have any climacteric symptoms.
    11. 11.  She is not taking any prescription medications but occasionally takes an over-the-counter NSAID’s for low back pain. She is a former smoker who works in a sedentary occupation and does not exercise regularly.
    12. 12.  Her mother (age 72 years) has type 2 diabetes, and her father (age 75 years) has coronary artery disease.
    13. 13. Physical Examination  Appears generally well. She weighs 89 kg and is 1.6 m tall. Blood pressure is135/85 mm Hg, heart rate is 72 beats/min, chest is clear to auscultation and percussion, heart sounds are normal, no abdominal organomegaly is palpable, and there are no musculoskeletal or skin abnormalities.
    14. 14.  Her body habitus suggests a central (abdominal) pattern of obesity.
    15. 15.  On further questioning, the patient states that she has poor eating habits and admits to frequent “snacking” on energy- dense, low-nutrient foods.
    16. 16. Initial Assessment & Investigation
    17. 17.  We recommend measuring body mass index (BMI; weight in kilograms divided by height in metres squared) in all adults and in all children and adolescent. [grade A, level 3] 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    18. 18. BMI  Body mass index or BMI is a simple and widely used method for estimating body fat mass.  BMI was developed in the 19th century by the Belgian statistician and anthropometrist Adolphe Quetelet
    19. 19.  Calculated by dividing the subject's mass by the square of his or her height  BMI = kilograms meters2
    20. 20. WHO Classification
    21. 21. Asia-Pacific Classification
    22. 22.  We recommend measuring waist circumference in all adults to assess obesity-related health risks [grade A, level 3]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    23. 23. Waist Circumference
    24. 24. Upper border of the right iliac crest
    25. 25. Obesity Treatment Recommendations in the Philippines: Perspective on their Utility and Implementation in Clinical Practice Gabriel V. Jasul, Jr. and Rosa Allyn G. Sy for the Philippine Association for the Study of Overweight and Obesity (PASOO)
    26. 26. Obesity Treatment Recommendations in the Philippines: Perspective on their Utility & Implementation in Clinical Practice
    27. 27. Case  Ms. A’s BMI is 34.8 kg/m2.  Her waist circumference, at 98 cm, is high for her sex, indicating a central (abdominal) pattern of obesity
    28. 28. Clinical & Laboratory Assessment of Overweight and Obese Adults
    29. 29.  We recommend that the clinical evaluation of overweight and obese adults include a history and a general physical examination to exclude secondary (endocrine or syndrome- related) causes of obesity and obesity- related health risks and complications [grade A, level 3]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    30. 30.  We recommend measuring fasting plasma glucose level and determining lipid profile, including total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and ratio of total cholesterol to HDL cholesterol, as screening tests in overweight and obese adults [grade A, level 3) 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    31. 31.  Fasting blood glucose level and lipid profile are important components in the assessment of an overweight or obese person (grade A recommendation ) because patients with obesity are at high risk of pre-diabetes, type 2 diabetes and dyslipidemia.
    32. 32.  We suggest additional investigations, such as liver enzyme tests, urinalysis and sleep studies (when appropriate), to screen for and exclude other common obesity related health problems [grade B, level 3]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    33. 33.  Assessment of liver enzymes and urinalysis is a grade B recommendation because obese patients may be at increased risk of liver disease (nonalcoholic steatohepatitis) and impaired renal function.
    34. 34. Obesity Treatment Recommendations in the Philippines: Perspective on their Utility & Implementation in Clinical Practice
    35. 35.  We suggest that the health care professional screen the overweight or obese adult for eating disorders, depression and psychiatric disorders, as appropriate [grade B, level 3]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    36. 36.  Major depression and other mood disorders are common in patients with obesity; they occur in 20%–60% of women aged 40 years or older with a BMI > 30 kg/m2.
    37. 37.  Furthermore, the presence of a mood disorder may adversely affect adherence to weight management interventions.
    38. 38. Case  Ms. A, laboratory testing reveals the following: Fasting glucose level 6.4 mmol/L Total cholesterol 5.75 mmol/L LDL cholesterol 3.59 mmol/L HDL cholesterol 1.26 mmol/L Triglycerides 1.98 mmol/L Total HDL: cholesterol ration 4.56 Liver enzyme levels and normal urinalysis results.
    39. 39. Case  Ms. A is considered to have a mild depressive disorder that appears to be linked, in part, to concerns and anxiety about her body image
    40. 40. Diagnosis?  Obese Class II  Impaired fasting glucose  Dyslipidemia  Mild depressive disorder
    41. 41. Management
    42. 42.  We recommend a comprehensive healthy lifestyle intervention for overweight and obese people [grade A, level 1]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    43. 43.  We recommend an energy-reduced diet and regular physical activity as the first treatment option for overweight and obese adults to achieve clinically important weight loss and reduce obesity- related symptoms [grade A, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    44. 44.  We recommend diet and exercise therapy for overweight and obese people with risk factors for type 2 diabetes [grade A, level 1] and cardiovascular disease [grade A, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    45. 45. Lifestyle Intervention  We recommend comprehensive lifestyle interventions (combining behaviour modification techniques, cognitive behavioural therapy, activity enhancement and dietary counselling) for all obese adults [grade A, level 1]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    46. 46. Dietary Intervention  We suggest a high-protein or a low-fat diet as a reasonable short-term (6–12 months) treatment option for obese adults as part of a weight-loss program [grade B, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    47. 47.  Dietary and lifestyle interventions aimed at decreasing energy intake and increasing energy expenditure through a balanced dietary and exercise program
    48. 48. Physical Activity  We suggest physical activity (30 minutes a day of moderate intensity, increasing, when appropriate, to 60 minutes a day) as part of an overall weight-loss program [grade B, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    49. 49.  Endurance exercise training may reduce the risk of cardiovascular morbidity in healthy postmenopausal women, and we suggest its use for adults with an increased BMI [grade B, level 2]
    50. 50. Pharmacotherapy  We suggest the addition of a selected pharmacologic agent for overweight or obese adults with type 2 diabetes, impaired glucose tolerance or risk factors for type 2 diabetes, who are not attaining or who are unable to maintain clinically important weight loss with dietary and exercise therapy, to improve glycemic control and reduce their risk of type 2 diabetes [grade B,level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    51. 51.  We suggest the addition of a selected pharmacologic agent for appropriate overweight or obese adults, who are not attaining or who are unable to maintain clinically important weight loss with dietary and exercise therapy, to assist in reducing obesity-related symptoms[grade B, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    52. 52. Bariatric Surgery  We suggest that adults with clinically severe obesity (BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 with severe comorbid disease) may be considered for bariatric surgery when lifestyle intervention is inadequate to achieve healthy weight goals [grade B, level 2]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    53. 53. Alternative Therapy  There is insufficient evidence to recommend in favour of or against the use of herbal remedies, dietary supplements or homeopathy for weight management in the obese person [grade C, level 4]. 2006 Canadian Clinical Practice Guidelines on the Management & Prevention of Obesity in Adults & Children
    54. 54. Obesity Treatment Recommendations in the Philippines: Perspective on their Utility & Implementation in Clinical Practice
    55. 55. Obesity Treatment Recommendations in the Philippines: Perspective on their Utility & Implementation in Clinical Practice
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