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. 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. 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. 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. Obesity should no longer be viewed as a
cosmetic or body-image issue.
7.
8. 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.
9.
10. 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)
11. 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.
12. 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.
13. 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.
14. Her mother (age 72 years) has type 2
diabetes, and her father (age 75 years)
has coronary artery disease.
15. 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.
16. Her body habitus suggests a central
(abdominal) pattern of obesity.
17. On further questioning, the patient states
that she has poor eating habits and
admits to frequent “snacking” on energy-
dense, low-nutrient foods.
22. 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
23. 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
24. Calculated by dividing the subject's mass
by the square of his or her height
BMI = kilograms
meters2
27. 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
31. 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)
36. 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
37. 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
38. 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.
39. 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
40. 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.
43. 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
44. 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.
45. Furthermore, the presence of a mood
disorder may adversely affect adherence
to weight management interventions.
46. 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.
47. 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
48. Diagnosis?
Obese Class II
Impaired fasting glucose
Dyslipidemia
Mild depressive disorder
52. 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
53. 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
54. 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
55. 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
56. 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
57. Dietary and lifestyle interventions aimed
at decreasing energy intake and
increasing energy expenditure through a
balanced dietary and exercise program
58. 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
59. 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]
60.
61.
62. 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
63. 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
64. 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
65. 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
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.
