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Obesity Dr. Aftab Asif Associate Professor Psychiatry Dept. Fatima Jinnah Medical College,  Sir Ganga Ram Hospital Lahore
Obesity: Definition <ul><li>A condition in which excessive body fat may put a person at health risk. </li></ul><ul><li>A m...
Storage of fat  <ul><li>Fat is stored as triglycrides in adipose tissues and the distributed mainly under skin in </li></u...
Obesity measureament tools <ul><li>Ideal body wt. (IBW) </li></ul><ul><li>Body mass index (BMI) </li></ul><ul><ul><li>weig...
Obesity Classification > 40 Severely obese > 30 30 – 40 Obese 27.5 – 30 25 – 30 Over weight 18.5 – 27.5 20 – 25 Normal < 1...
<ul><li>Moderate obesity  </li></ul><ul><ul><li>Associated with increase in cell size </li></ul></ul><ul><li>Sever obesity...
 
Guide for Selecting Obesity Treatment The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obe...
Obesity Trends Among  US Adults: Obesity: BMI ≥30 kg/m 2 , or ~ ≥14 kg overweight for 163 cm person Data from CDC.  Behavi...
Causes of Obesity
Causes of Obesity <ul><li>Complex and multifactorial </li></ul><ul><ul><li>Genetic predisposition </li></ul></ul><ul><ul><...
<ul><ul><li>Economic status </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><ul><li>Cultural </li></ul></ul><u...
Genetic Predisposition
Multi-Hormonal Control of Body Weight: Role Of Fat-, Gut-, And Islet-derived Signals Adapted from Badman M.K. and Flier J....
Leptin <ul><li>Released from fat tissues  </li></ul><ul><li>Interact with  </li></ul><ul><ul><li>Hypothalamus </li></ul></...
How leptin causes obesity <ul><li>Primary decrease of leptin (low leptin) </li></ul><ul><li>Leptin receptor resistance (hi...
Insulin <ul><li>↑ Insulin    inhibit Hormone Sensitive lipase (HSL) </li></ul><ul><li>  Dec. break down of fat    ↑ bod...
Insulin  <ul><li>↑  insulin    stimulation of lipoprotien  lipase    ↑ storage of triglycrides in fat cells    ↑ total ...
Which fat depletes more abdominal or gluteal <ul><li>Abdominal  (hyperplastic adipose tissue ) </li></ul>
Which fat depletion site causes metabolic abnormalities <ul><li>Abdominal </li></ul><ul><li>Responding to hypocaloric dite...
Feeding center <ul><li>Hypothalamus </li></ul><ul><ul><li>Ventromedial hypothalamus (inhibits feeding) </li></ul></ul><ul>...
Diseases Linked to Obesity <ul><li>Diabetes </li></ul><ul><li>Coronary Heart Disease </li></ul><ul><li>High Blood Pressure...
<ul><li>Gastroesophageal reflux </li></ul><ul><li>Cancer </li></ul><ul><li>High cholesterol </li></ul><ul><li>Endocrine di...
<ul><li>Hypertrophic Cardiomyopathy </li></ul><ul><li>Infertility </li></ul><ul><li>Depression </li></ul><ul><li>Obstructi...
What About the Role of Serotonin? <ul><li>Theory that low serotonin levels leads to “carbohydrate craving” and plays a maj...
Psychological Complications of Obesity <ul><li>Emotional distress </li></ul><ul><li>Discrimination </li></ul><ul><li>Socia...
Cardiovascular Pathophysiology <ul><li>Excess body mass </li></ul><ul><ul><li>↑  metabolic demand -> ↑ CO 2 </li></ul></ul...
Volume Replacement <ul><li>Adult total body water percentage is 60% to 65%. </li></ul><ul><li>Severely obese total body wa...
Selected Medications That Can Cause Weight Gain <ul><li>Psychotropic medications </li></ul><ul><ul><li>Tricyclic antidepre...
Calories chart
Calories chart
Calories chart
Calories chart
 
Treatment
Aim of treatment <ul><li>To achieve a modest weight loss that is also maintained long term </li></ul>
Impact of Weight Loss  1. Wing RR et al.  Arch Intern Med . 1987;147:1749-1753. 2. Mertens IL, Van Gaal LF.  Obes Res . 20...
Obesity Treatment Pyramid Diet Physical Activity Lifestyle Modification Pharmacotherapy Surgery
Guide for Selecting Obesity Treatment The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obe...
Treatment of Obesity <ul><li>Goal of treatment: 10% weight loss </li></ul><ul><li>Caloric restriction: -500 kcal/day </li>...
Diet <ul><li>Reduce fatty diets </li></ul><ul><li>Increase fiber diet </li></ul><ul><li>Take calories according to require...
Exercise <ul><li>Take 30 min. daily for physical activity </li></ul>
Benefits of Physical Activity for Health and Weight Control <ul><li>􀂄  Improves cardiovascular health, independent of weig...
Behavior Therapy <ul><li>Eating and physical activity patterns are learned behaviors and can be modified. </li></ul><ul><l...
Drug treatment in adults <ul><li>Record initial weight </li></ul><ul><li>Discuss decision to start drug treatment, choice ...
The Regulation of Prescription Weight-Loss Drugs  <ul><li>Part I  1947 to 1973 </li></ul><ul><ul><li>Approval of the amphe...
Drugs Approved by FDA for Treating Obesity 1997 Long-term Reductil / Meridia Sibutramine 1973 Short-term Tenulate Diethylp...
Anti-obesity drugs Dry mouth Increased BP Oily spotting Incontinence Long-term Long-term Use Insomnia Steatorrhea Side Eff...
SURGICAL THERAPY  <ul><ul><li>Only Recommended in  Selected Adult Patients </li></ul></ul><ul><ul><li>BMI > 40 or with Co-...
<ul><li>Liposuction </li></ul><ul><li>Abdomeno plasty  </li></ul><ul><li>Restrictive bariatric procedures </li></ul><ul><u...
Roux-en-Y GBP Current Status of Medical and Surgical Therapy for Obesity Gastroenterology Vol.120, No.3 Restrictive bariat...
Adjustable gastric banding Current Status of Medical and Surgical Therapy for Obesity Gastroenterology Vol.120, No.3 Restr...
Conclusion <ul><li>Lifestyle changes such as diet and exercise are still the mainstay of obesity management. </li></ul><ul...
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Obesity2

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  • Guide for selecting obesity treatment This table summarizes the guidelines for selecting treatment options for obesity [1]. Any effective treatment plan must consider the patient’s willingness to undergo therapy, his/her ability to comply with specific treatment approaches, access to skilled caregivers, and financial considerations. Lifestyle modification, which involves a program of appropriate diet, physical activity, and behavior therapy, should be considered for all patients with a body mass index (BMI)  25 kg/m 2 . Long-term pharmacotherapy should be considered in appropriate patients who were unable to achieve adequate weight loss after 6 months of lifestyle therapy and who have a BMI  30 kg/m 2 , or  27 kg/m 2 with concomitant obesity-related disease. Bariatric surgery may be necessary in patients with severe obesity who failed to lose weight with non-surgical therapy. Eligible surgical candidates should have a BMI  40 kg/m 2 or a BMI  35 kg/m 2 and a concomitant serious obesity-related disease. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub No 00-4084.
  • DISCUSSION Over the past 20 years, there has been a dramatic increase in obesity in the United States. In 2004, 7 states had obesity prevalence rates of 15–19 percent; 33 states had rates of 20–24 percent; and 9 states had rates of more than 25 percent (no data for one state). STUDY BACKGROUND The data shown in these maps were collected through Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with US adults. Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS as slightly different analytic methods are used.
  • Selected medications that can cause weight gain Certain medications can cause weight gain and increase body fat, thereby making weight loss more difficult. This table presents a partial list of drugs and drug classes that contain medications associated with weight gain. These drugs differ in their propensity to increase body weight; some medications, such as the anticonvulsant valproic acid, can cause considerable weight gain of 15–20 kg, whereas other medications, such as the β-adrenergic receptor blocker propranolol, are associated with small and probably clinically insignificant weight gain. The mechanism responsible for medication-induced weight gain has not been carefully studied for most of these agents, but must be related to an increase in energy intake (e.g. antipsychotics and steroid hormones), a decrease in energy expenditure (e.g. β-adrenergic receptor blockers), a decrease in energy loss (e.g. decreased glucosuria from diabetes therapy), or a combination of these factors. Weight loss therapy can be facilitated by decreasing the dose or substituting the medication with another drug that has less weight gain potential, if possible. Pijl H, Meinders AE. Bodyweight changes as an adverse effect of drug treatment. Drug Safety 1996;14:329-342.
  • Impact of weight loss on risk factors Weight losses of 5%-10% have been shown to have a significant impact on several aspects of the metabolic syndrome, including well-recognized risk factors for cardiovascular disease and diabetes. For example: Wing and colleagues at Brown University evaluated the effect of modest weight loss in 114 patients with type 2 diabetes. Those who lost 5% or more of their baseline weight showed statistically significant decreases in serum HbA1c levels [4]. The Trial of Antihypertensive Interventions and Management Study found that weight losses of 5% or more produced reductions in diastolic pressure that were equivalent to those produced by a single dose of antihypertensive medication [3]. Numerous studies have shown that weight losses of 5%-10% improve total cholesterol, LDL-to-HDL ratio, and the ratio of total-to-HDL cholesterol [1]. In one study, weight reduction of just 5.8% was associated with a 16% reduction in total cholesterol, an 18% increase in HDL cholesterol, and a 12% decrease in LDL cholesterol [1]. More recently, Ditschunheit and colleagues documented significant decreases in total cholesterol, triglycerides, and VLDL in obese patients with baseline hyperlipidemia who maintained a weight loss of 7.6% [2]. Blackburn G. Ob Res 1995;3(Suppl2):211S-216S. Ditschunheit HH, et al. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr 2002;56:264-270. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: The effects of modest weight reduction. Ob Res 2000;8(3):270-278. Wing RR, et al. Long-term effects of modest weight loss in Type 2 diabetic patients. Arch Intern Med 1987;147:1749-1753.
  • Obesity treatment pyramid The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid.
  • Guide for selecting obesity treatment This table summarizes the guidelines for selecting treatment options for obesity [1]. Any effective treatment plan must consider the patient’s willingness to undergo therapy, his/her ability to comply with specific treatment approaches, access to skilled caregivers, and financial considerations. Lifestyle modification, which involves a program of appropriate diet, physical activity, and behavior therapy, should be considered for all patients with a body mass index (BMI)  25 kg/m 2 . Long-term pharmacotherapy should be considered in appropriate patients who were unable to achieve adequate weight loss after 6 months of lifestyle therapy and who have a BMI  30 kg/m 2 , or  27 kg/m 2 with concomitant obesity-related disease. Bariatric surgery may be necessary in patients with severe obesity who failed to lose weight with non-surgical therapy. Eligible surgical candidates should have a BMI  40 kg/m 2 or a BMI  35 kg/m 2 and a concomitant serious obesity-related disease. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub No 00-4084.
  • Reference – NHLBI?
  • Drugs approved by FDA for treating obesity This table lists the medications approved by the United States Food and Drug Administration (FDA) for treatment of obesity; only sibutramine (Meridia) and orlistat (Xenical) have been approved for long-term use. All the approved medications act as anorexiants, with the exception of orlistat, which blocks the absorption of dietary fat. Anorexiants increase satiation (level of fullness, which regulates the amount of food consumed during a meal) or satiety (level of fullness after a meal, which determines frequency of eating), or both. Methamphetamine is also approved by the FDA for short-term use, but it is a DEA schedule II drug and should be avoided because of its abuse potential. Three anorexiant medications have been removed from the marketplace because of increased risks of either valvular heart disease (fenfluramine and dexfenfluramine) [1] or hemorrhagic stroke (phenylpropanolamine) [2] associated with their use. Khan MA, Herzog CA, St Peter JV, et al. The prevalence of cardiac valvular insufficiency assessed by transthoracic echocardiography in obese patients treated with appetite-suppressant drugs. N Engl J Med 1998;339:713-718. Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med 2000;343:1826-1832.
  • Two Bariatric procedures are being tried in children. The first is the Gastric Bypass as shown in this slide and the other is the Adjustable Gastric Band as shown in the next slide. Data is being accumulated to determine efficacy and safety for both of these procedures in children.
  • This shows the adjustable gastric band.
  • Transcript of "Obesity2"

    1. 1. Obesity Dr. Aftab Asif Associate Professor Psychiatry Dept. Fatima Jinnah Medical College, Sir Ganga Ram Hospital Lahore
    2. 2. Obesity: Definition <ul><li>A condition in which excessive body fat may put a person at health risk. </li></ul><ul><li>A metabolic disorder that is primarily induced and sustained by an over consumption or underutilization of caloric substrate </li></ul>
    3. 3. Storage of fat <ul><li>Fat is stored as triglycrides in adipose tissues and the distributed mainly under skin in </li></ul><ul><ul><li>Abdomen </li></ul></ul><ul><ul><li>Breast </li></ul></ul><ul><ul><li>Buttocks </li></ul></ul><ul><ul><li>Thighs </li></ul></ul>
    4. 4. Obesity measureament tools <ul><li>Ideal body wt. (IBW) </li></ul><ul><li>Body mass index (BMI) </li></ul><ul><ul><li>weight in Kg / height (m) 2 </li></ul></ul>
    5. 5. Obesity Classification > 40 Severely obese > 30 30 – 40 Obese 27.5 – 30 25 – 30 Over weight 18.5 – 27.5 20 – 25 Normal < 18.5 < 20 Under weight Research Standards (BMI)
    6. 6. <ul><li>Moderate obesity </li></ul><ul><ul><li>Associated with increase in cell size </li></ul></ul><ul><li>Sever obesity </li></ul><ul><ul><li>Associated with increase in no. of fat cells </li></ul></ul>
    7. 8. Guide for Selecting Obesity Treatment The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 BMI Category (kg/m 2 ) With co- morbidities + + 35-39.9 + + 30-34.9 + Surgery + With co- morbidities Pharmaco-therapy + + + Diet, Exercise, Behavior Tx > 40 27-29.9 25-26.9 Treatment
    8. 9. Obesity Trends Among US Adults: Obesity: BMI ≥30 kg/m 2 , or ~ ≥14 kg overweight for 163 cm person Data from CDC. Behavioral Risk Factor Surveillance System . 1998 No Data <10% 10%–14% 15%–19% ≥20 2000 No Data <10% 10%–14% 15%–19% ≥20 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% No Data <10% 10%–14% 15%–19% 20%–24% ≥25% 2004
    9. 10. Causes of Obesity
    10. 11. Causes of Obesity <ul><li>Complex and multifactorial </li></ul><ul><ul><li>Genetic predisposition </li></ul></ul><ul><ul><li>Endocrine disorders </li></ul></ul><ul><ul><li>Socialization </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Sex </li></ul></ul><ul><ul><li>Race </li></ul></ul>
    11. 12. <ul><ul><li>Economic status </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><ul><li>Cultural </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><li>Environmental factors </li></ul></ul><ul><ul><li>Cessation of smoking </li></ul></ul>
    12. 13. Genetic Predisposition
    13. 14. Multi-Hormonal Control of Body Weight: Role Of Fat-, Gut-, And Islet-derived Signals Adapted from Badman M.K. and Flier J.S. Science 2005; 307: 1909-1914. Amylin GI tract Adipose tissue Pancreatic islets Hypothalamus Hindbrain CCK Adiponectin Insulin Amylin Leptin OXM Ghrelin GLP-1 PYY 3-36 GIP PP Resistin Visfatin Vagal afferents
    14. 15. Leptin <ul><li>Released from fat tissues </li></ul><ul><li>Interact with </li></ul><ul><ul><li>Hypothalamus </li></ul></ul><ul><ul><li>Adipose tissue </li></ul></ul><ul><li>Inhibits neuropeptide Y and Aguoti-related peptide (AGRP) in CNS </li></ul><ul><li>Binds to central melanocortin receptors </li></ul><ul><li>Decreases food intake </li></ul><ul><li>Increases energy expenditure </li></ul>
    15. 16. How leptin causes obesity <ul><li>Primary decrease of leptin (low leptin) </li></ul><ul><li>Leptin receptor resistance (high leptin) </li></ul><ul><li>So increase neuropeptide Y and AGRP  increase in food intake and low energy expenditure  sever obesity </li></ul>
    16. 17. Insulin <ul><li>↑ Insulin  inhibit Hormone Sensitive lipase (HSL) </li></ul><ul><li> Dec. break down of fat  ↑ body fat </li></ul>
    17. 18. Insulin <ul><li>↑ insulin  stimulation of lipoprotien lipase  ↑ storage of triglycrides in fat cells  ↑ total body fat </li></ul>
    18. 19. Which fat depletes more abdominal or gluteal <ul><li>Abdominal (hyperplastic adipose tissue ) </li></ul>
    19. 20. Which fat depletion site causes metabolic abnormalities <ul><li>Abdominal </li></ul><ul><li>Responding to hypocaloric dite more and cause metabolic abnormalities </li></ul>
    20. 21. Feeding center <ul><li>Hypothalamus </li></ul><ul><ul><li>Ventromedial hypothalamus (inhibits feeding) </li></ul></ul><ul><ul><li>Lateral hypothalamus (stimulates feeding) </li></ul></ul><ul><ul><ul><li>Oraxin  hyperphagia </li></ul></ul></ul><ul><ul><li>Arcuate nucleus  neuropeptide Y (increses appitite) </li></ul></ul>
    21. 22. Diseases Linked to Obesity <ul><li>Diabetes </li></ul><ul><li>Coronary Heart Disease </li></ul><ul><li>High Blood Pressure </li></ul><ul><li>Stroke </li></ul><ul><li>Arthritis </li></ul>
    22. 23. <ul><li>Gastroesophageal reflux </li></ul><ul><li>Cancer </li></ul><ul><li>High cholesterol </li></ul><ul><li>Endocrine disease </li></ul>
    23. 24. <ul><li>Hypertrophic Cardiomyopathy </li></ul><ul><li>Infertility </li></ul><ul><li>Depression </li></ul><ul><li>Obstructive sleep apnea </li></ul><ul><li>Gallstones </li></ul><ul><li>Fatty liver </li></ul><ul><li>Stress incontinence </li></ul><ul><li>Venous ulcers </li></ul><ul><li>Sudden death </li></ul>
    24. 25. What About the Role of Serotonin? <ul><li>Theory that low serotonin levels leads to “carbohydrate craving” and plays a major role in the development of obesity. </li></ul>
    25. 26. Psychological Complications of Obesity <ul><li>Emotional distress </li></ul><ul><li>Discrimination </li></ul><ul><li>Social stigmatization </li></ul>
    26. 27. Cardiovascular Pathophysiology <ul><li>Excess body mass </li></ul><ul><ul><li>↑ metabolic demand -> ↑ CO 2 </li></ul></ul><ul><ul><ul><li>↑ workload </li></ul></ul></ul><ul><ul><ul><li>LVH (left ventricular hypertrophy) </li></ul></ul></ul><ul><ul><ul><li>↑ pulmonary blood flow </li></ul></ul></ul><ul><ul><li>Pulmonary HTN -> cor pulmonale -> right heart failure </li></ul></ul>
    27. 28. Volume Replacement <ul><li>Adult total body water percentage is 60% to 65%. </li></ul><ul><li>Severely obese total body water is 40%. </li></ul><ul><li>Estimated blood volume in obese patient is 45 to 55 mL/kg </li></ul><ul><ul><li>70 mL/kg for the non-obese </li></ul></ul>
    28. 29. Selected Medications That Can Cause Weight Gain <ul><li>Psychotropic medications </li></ul><ul><ul><li>Tricyclic antidepressants </li></ul></ul><ul><ul><li>Monoamine oxidase inhibitors </li></ul></ul><ul><ul><li>Specific SSRIs </li></ul></ul><ul><ul><li>Atypical antipsychotics </li></ul></ul><ul><ul><li>Lithium </li></ul></ul><ul><ul><li>Specific anticonvulsants </li></ul></ul><ul><li> -adrenergic receptor blockers </li></ul>SSRI=selective serotonin reuptake inhibitor <ul><li>Diabetes medications </li></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><li>Sulfonylureas ( glipizide / glucotrol ) </li></ul></ul><ul><ul><li>Thiazolidinediones ( pioglitazone ) </li></ul></ul><ul><li>Tamoxifen (anti-estrogen) </li></ul><ul><li>Steroid hormones </li></ul><ul><ul><li>Glucocorticoids </li></ul></ul>
    29. 30. Calories chart
    30. 31. Calories chart
    31. 32. Calories chart
    32. 33. Calories chart
    33. 35. Treatment
    34. 36. Aim of treatment <ul><li>To achieve a modest weight loss that is also maintained long term </li></ul>
    35. 37. Impact of Weight Loss 1. Wing RR et al. Arch Intern Med . 1987;147:1749-1753. 2. Mertens IL, Van Gaal LF. Obes Res . 2000;8:270-278. 3. Blackburn G. Obes Res . 1995;3 (Suppl 2):211S-216S. 4. Ditschunheit HH et al. Eur J Clin Nutr . 2002;56:264-270. 1 2 3 3 1 2 3 3 4 Triglycerides HDL Cholesterol Total Cholesterol Blood Pressure HbA1c 5%-10% Weight Loss ~5% Weight Loss
    36. 38. Obesity Treatment Pyramid Diet Physical Activity Lifestyle Modification Pharmacotherapy Surgery
    37. 39. Guide for Selecting Obesity Treatment The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 BMI Category (kg/m 2 ) With co- morbidities + + 35-39.9 + + 30-34.9 + Surgery + With co- morbidities Pharmaco-therapy + + + Diet, Exercise, Behavior Tx > 40 27-29.9 25-26.9 Treatment
    38. 40. Treatment of Obesity <ul><li>Goal of treatment: 10% weight loss </li></ul><ul><li>Caloric restriction: -500 kcal/day </li></ul><ul><li>Moderate physical activity </li></ul><ul><ul><li>30 minutes daily </li></ul></ul><ul><li>Behavioral modification </li></ul><ul><li>Drug therapy </li></ul>National Institutes of Health. Obes Res. 1998; 6 (suppl 2): 51S–209S.
    39. 41. Diet <ul><li>Reduce fatty diets </li></ul><ul><li>Increase fiber diet </li></ul><ul><li>Take calories according to requirements </li></ul><ul><li>(1000 to 1500 Kcal) </li></ul><ul><li>Stop bing eating </li></ul>
    40. 42. Exercise <ul><li>Take 30 min. daily for physical activity </li></ul>
    41. 43. Benefits of Physical Activity for Health and Weight Control <ul><li>􀂄 Improves cardiovascular health, independent of weight loss </li></ul><ul><li>􀂄 Improves mood and energy level </li></ul><ul><li>􀂄 Increase weight loss compared with diet alone </li></ul><ul><li>􀂄 Spares loss of fat-free mass during weight loss </li></ul>
    42. 44. Behavior Therapy <ul><li>Eating and physical activity patterns are learned behaviors and can be modified. </li></ul><ul><li>􀂄 Behavior Modification Techniques </li></ul><ul><ul><li>􀂄 Self Monitoring </li></ul></ul><ul><ul><li>􀂄 Stimulus Control </li></ul></ul><ul><ul><li>􀂄 Behavioral Contracting </li></ul></ul><ul><ul><li>􀂄 Cognitive Restructuring </li></ul></ul><ul><ul><li>􀂄 Stress Management </li></ul></ul><ul><ul><li>􀂄 Relapse Prevention </li></ul></ul><ul><ul><li>􀂄 Social Support </li></ul></ul><ul><li>Hyder et al Behavior Modification in the treatment of Obesity: Practical Approaches for Family Physicians Clinics in Family Practice June 2002;2 </li></ul>
    43. 45. Drug treatment in adults <ul><li>Record initial weight </li></ul><ul><li>Discuss decision to start drug treatment, choice potential benefit and limitations, adverse effect and monitoring requirement with patient </li></ul><ul><li>Review regularly to monitor compliance, effectiveness, adverse effect </li></ul><ul><li>Reinforce lifestyle advice </li></ul>
    44. 46. The Regulation of Prescription Weight-Loss Drugs <ul><li>Part I 1947 to 1973 </li></ul><ul><ul><li>Approval of the amphetamines and the amphetamine congeners </li></ul></ul><ul><li>Part II 1974 to 1995 </li></ul><ul><ul><li>Short-term treatment </li></ul></ul><ul><li>Part III 1996 to present </li></ul><ul><ul><li>Long-term treatment </li></ul></ul>
    45. 47. Drugs Approved by FDA for Treating Obesity 1997 Long-term Reductil / Meridia Sibutramine 1973 Short-term Tenulate Diethylpropion 1973 Short-term Adipex, lonamin Phentermine 1961 Short-term Bontril, Prelu-2 Phendimetrazine 1960 1999 Year Approved Short-term Long-term Approved Use Didrex Benzphetamine Xenical Orlistat Trade Names Generic Name
    46. 48. Anti-obesity drugs Dry mouth Increased BP Oily spotting Incontinence Long-term Long-term Use Insomnia Steatorrhea Side Effects 5-15 mg OD 120 mg TID Dosing CNS monoamine reuptake inhibitor GI lipase inhibitor Mechanism of action Obesity Obesity Primary indication Reductil / trim fast Xenical Brand name Sibutramine Orlistat Drug name
    47. 49. SURGICAL THERAPY <ul><ul><li>Only Recommended in Selected Adult Patients </li></ul></ul><ul><ul><li>BMI > 40 or with Co-morbid Conditions </li></ul></ul>
    48. 50. <ul><li>Liposuction </li></ul><ul><li>Abdomeno plasty </li></ul><ul><li>Restrictive bariatric procedures </li></ul><ul><ul><li>Banding </li></ul></ul><ul><ul><li>Stapling </li></ul></ul>
    49. 51. Roux-en-Y GBP Current Status of Medical and Surgical Therapy for Obesity Gastroenterology Vol.120, No.3 Restrictive bariatric procedures
    50. 52. Adjustable gastric banding Current Status of Medical and Surgical Therapy for Obesity Gastroenterology Vol.120, No.3 Restrictive bariatric procedures
    51. 53. Conclusion <ul><li>Lifestyle changes such as diet and exercise are still the mainstay of obesity management. </li></ul><ul><li>Aim of treatment should be modest weight loss maintained in the long term </li></ul><ul><li>Add anti-obesity drugs only if above fails </li></ul><ul><li>Consider the risk vs. benefit of prescribing these drugs. </li></ul>
    52. 54. Thank you
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