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Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
Obesity
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Obesity

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  • 1. 7 July 2011, Shridhan A Patil, RCC Trivandrum
  • 2.
  • 3.  Definition : Obesity is a state of excess adipose tissue mass. (Harrison’s :17th ) Obesity is a disease of caloric imbalance that results from an excess intake of calories above their consumption by the body. (Robbins : 8th) The WHO definition is: a BMI greater than or equal to 25 is overweight a BMI greater than or equal to 30 is obesity.
  • 4. BMI/Quetlet index Classification of weight status NOT by mere weight Muscularity & height affect weight So, BMI or Quetlet index used to classify Body Mass Index (BMI)  Most widely used  BMI= Weight(kg) Height(mtr)2
  • 5. WHO Classification BMI Classification <18.5 Underweight  18.5-24.9 Normal weight  25-29.9 Overweight  30-34.9 Obesity Class I  35-39.9 Obesity Class II  40-49.9 Obesity Class III  50 and above Super Obesity
  • 6.  Values are age independent & same for both sexes. At similar BMI, fat content in women > men BMI 30 is threshold for obesity. BMI 25 - 30 medically significant & requires intervention• At a given BMI, women, on average, have more body fat.• Morbidity and mortality increase with BMI similarly for men and women• Risk at a given BMI can vary between populations.
  • 7. Other Indices  Broca’s index = Height ( cms ) – 100  Corpulance index = Actual weight / Desirable weight  Ponderal index = Height ( cms ) Cube root of body weight ( kg )  Lorentz’s formula Height ( cms ) – 100 - Height ( cms ) – 150 2(women) or 4(men)
  • 8. Other methods  Waist hip ratio - >0.9 for women - > 1 for men  Anthropometry ( skin fold thickness )  Harpenden skin calliper  < 40 mm in males, < 50 mm in females  Densitometry ( under water weighing )  CT Scan, MRI, Electric impedance
  • 9. Android=Abdominal=Central=Apple shapedGynecoid=Peripheral=Pearshaped
  • 10. “Super obese" maleA "super obese" male with a BMI of 47 kg/m2: weight 146 kg (322 lb), height 177 cm (5 ft 10 in)
  • 11. Adipocyte Hypertrophy and/or Hyperplasia
  • 12.  Endocrine Drugs Smoking cessation
  • 13. What causes obesity? Inactive advertising neighborhood
  • 14. Energy balance 3 components1. Afferent /peripheral system - Generates signals from various sites - Composed of leptin , adiponectin - by fatcells, ghrelin from stomach, peptide YY (PYY) fromileum, colon, insulin from pancreas
  • 15.  2.Arcuate nucleus in hypothalamus -Processes & integrates neurohumoral peripheral signals -Generates efferent signals -Composed of 2 subsets of first order neurons 1.POMC (pro-opiomelanocortin) & CART (cocaine and amphetamine-regulated transcripts) neurons 2.Neuropeptide Y & AgRP (agouti-related peptide) These first order neurons communicate with second order neurons
  • 16.  3. Efferent system Carries signals from second order neurons of hypothalamus to control food intake and energy expenditure
  • 17. Peripheral Signals
  • 18.  Produced by adipocytes Leptin Leptin Product of „ob‟ gene Provides signal for “energy sufficiency”. Abundant fat  Leptin - + POMC/CART secretion NPY/AgRP neurons Regulated by insulin neurons stimulated glucose metabolism Stimulates Produce Anorexic thermogenesis, activity, ene orexinergic neuropeptides- rgy expenditure neuropeptides (MSH)
  • 19.  MC4R ( Melanocortin receptor 4) mutations- more frequent, cause of 5% massive obesity No satiety(anorexinergic) signal generated Behave as if undernourished Haplo-insufficiency of brain-derived neurotrophic factor (BDNF) – component of MC4R downstream signaling in hypothalamus BDNF - A/w obesity in WAGR syndrome
  • 20. Adiponectin Produced mainly by adipocytes AdipoR1, AdipoR2 in Low levels in obesity skeletal Stimulates fatty acid oxidation muscle, liver, brain “Fat-burning molecule” + cAMP activated “Guardian angel against protein kinase obesity” ↓ fatty acid influx in liver, liver Inactivates acetyl glucose production coenzyme A ↓ Protects against Metabolic carboxylase (Key enzyme in Fatty syndrome acid synthesis)
  • 21.  Produces TNF, IL-6, IL-1, IL-18, Chemokine, Steroids Chronic sub-clinical inflammatory state (^ CRP) ?Link between lipid metabolism, nutrition, inflammationWHY is it HARD to maintain the weight loss for those wholose after dietary restriction?- Constant number of adipocytes- -Higher no. in obese
  • 22. ..
  • 23.  Short term meal initiators and terminatoprs Ghrelin, PYY, Pancreatic polypeptide, Isulin, Amylin Ghrelin(stomach,arcuate nucleus)- only orexenergic gut hormone Most likely stimulates NPY/AgRP neurons PYY ( ileum, colon) A/w hyperphagia , obesity in Prader-Willi syndrome Amylin(pancreatic ß cells), PYY – both stimulate POMC/CART neurons
  • 24. recognized that :“sudden death ismorecommon in thosewho are naturallyfat than in lean.”
  • 25.  Insulin resistance & Type 2 DM – 80 % Type 2 DM are obese Circulating peptides – TNFα, IL6, RBP6, Adiponectin, Resistin have altered expression & modify the insulin action
  • 26. Cardiovascular system - Obesity  Independent risk factor for CAD, CHF Insulin Resistance  Waist – Hip ratio best predictor  Abdominal obesity ↑ Insulin associated with atherogenic lipid profile ↑ FFA  Hypertension ↑ Triglyceride
  • 27. ↑ Adipose tissue ↑ Leptin Hypothalamus- ↑MSH, ↑AgRP, ↓NPY Increased SNS activity Hypertension
  • 28. Syndrome X or Metabolic syndrome  Abdominal obesity  Insulin resistance  Hypertriglyceridemia  Low serum HDL  ↑ risk of CAD  Seen more in Indians, probably due to low levels of adiponectin
  • 29.  Male  Hypogonadism  ↓ Plasma testosterone & sex hormone binding globulin  Estrogen levels ↑  Masculization, libido, potency, spermatogenesis preserved Females –  Menstrual irregularities, oligomenorrhea  ↑ androgen production, ↓sex hormone binding globulin  PCOD – anovulation, obesity, hirsutism
  • 30.  Apnoeic pauses during sleep Hypersomnolence at both day & night Polycythemia Eventually right sided heart falure
  • 31.  Gall stones, Pancreatitis, Abdominal hernia, NAFLD Gall stones  ↑ cholesterol Enhanced billiary excretion of cholesterol  Super saturated bile  Cholelithiasis  In 50 % above ideal body wt. – 6 fold ↑ in symptomatic gall stones
  • 32.  Strongly associated with Obesity, Dyslipidemia, Type 2 DM Presents like – Steatosis & Steatohepatitis 10 – 20 % develop in to Cirrhosis
  • 33.  Stroke  ↑ Blood pressure  Type 2 DM  Elevated cholesterol levels Depression –  Sleep disturbances
  • 34. Bones, Joints, Cutaneous disorders  Osteoarthritis –  Trauma & joint malalignment,  Gout :- ↑ Prevalence  Skin –  Acanthosis nigrans,  Friability of skin, enhancing the risk of fungal & yeast infection
  • 35.  How they are related?  Both sexes affected equally with high mortality rate  In males – Ca. esophagus, colon, rectum, pancreas, liver & prostate  In females – Ca. gall bladder, bile duct, breast, endometrium, cervix, ovaries
  • 36.  Cushing‟s Syndrome –  ↑ cortisol levels  Promotes deposition of adipose tissue in peculiar distribution  Upper face – Moon Facies  Inter scapular area – Buffelow Hump  Mesenteric bed – Truncal obesity Hypothyrodism –  Wt. gain inspite of poor appetite  Mainly due to fluid retention
  • 37.  Insulinoma-  Wt. gain as a result of over eating to avoid hypoglycemic symptoms Craniopharyngioma –  Tumor arising from Ratheke‟s pouch  Pressure effect on hypothalamus - Obesity
  • 38. Management of obesity Goal is to reduce or prevent co- morbidities. Diet Therapy Physical Activity Therapy Behavioral Therapy Pharmacotherapy- Sibutramine, Orlistat, Rimonaba nt Surgery-.
  • 39. A. Laparoscopic gastric band (LAGB) B. The Roux-en-Y gastric bypass.
  • 40. C. Biliopancreatic diversion withduodenal switch. D. Biliopancreatic diversion.
  • 41.  Worldwide obesity has more than doubled since 1980. In 2008, 1.5 billion adults, 20 and older, were overweight. Of these over 200 million men and nearly 300 million women were obese. 65% of the worlds population live in countries where overweight and obesity kills more people than underweight. Nearly 43 million children under the age of five were overweight in 2010. Obesity is preventable.
  • 42. Remember me?
  • 43.  Robbins Pathologic Basis of Disease 8th edition Harrison’s Internal Medicine 17th edition WHO - Obesity and overweight http://www.who.int/mediacentre/factsheets/fs311 /en/index.html Wikipedia

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