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Management Of Obesity In Family Practice Cme 30 May08
 

Management Of Obesity In Family Practice Cme 30 May08

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    Management Of Obesity In Family Practice Cme 30 May08 Management Of Obesity In Family Practice Cme 30 May08 Presentation Transcript

    • OBESITY IN FAMILY PRACTICE MANAGEMENT OF OBESITY IN FAMILY PRACTICE
    • DR. G. C. DHAR. MD., DTM&H FRSTM&H (UK), MCFP (CANADA)
    • IN 1998, THE WORLD HEALTH ORGANIZATION DESIGNATED OBESITY AS A GLOBAL EPIDEMIC
    • WHAT TO DO ? OBESITY EPIDEMIC!
    • SEDENTARY LIFESTYLE & EXCESSIVE EATING
    • L U X U R Y L I F E !
    • ?
    • TREATMENT OF OBESITY CONSISTS OF 2 STEPS
        • ASSESSMENT: determination of degree of obesity and overall health status.
      • MANAGEMENT: not only involves weight loss and maintenance of body weight but also to control of other risk factors.
    • WHAT IS OBESITY?
      • OBESITY IS THE ABNORMAL ACCUMULATION OF ADIPOSE TISSUE IN THE BODY, DEFINED AS BODY MASS INDEX (BMI) 30KG/M2 OR ABOVE.
    • OBESITY NOW IS NOT A PROBLEM OF HIGH INCOME COUNTRIES IT IS NOW DRAMATICALLY INCREASING IN MIDDLE AND LOW INCOME COUNTRIES
    • CURRENT SITUATION
      • IN USA 64.5% ADULT POPULATION ARE EITHER OBESE OR OVERWEIGHT.
      • IN CHINA FROM 1991 TO 2004, OBESITY INCREASED FROM 12.9% TO 27.3%.
    • IN BANGLADESH
      • Bangladesh Demographic and Health Survey, 1999-2000 Year: 2000 shows:
      • 0.7% population aged 15-49 are of BMI equal or >30kg/m2
      • 4.5% population aged 15-40 are of BMI equal or >25kg/m2
      • As of 2004, prevalence of overweight has been increased up to 9.1% in urban and 5.5% in rural population.
    • IMPORTANT FACTORS FOR BANGLADESH
      • ABUNDANCE OF FAST FOOD OUTLETS.
      • ONLY 10% CHILDREN FROM BANGLA MEDIUM AND 7% CHILDREN FROM ENGLISH MEDIUM SCHOOLS HAVE ACCESS TO SPORTS.
      • ONLY 2-3 FROM MORE THAN 40 PRIVATE UNIVERSITIES IN DHAKA HAVE PLAYING FIELDS.
    • CLASSIFICATION OF OBESITY ACCORDING TO BMI
      • +STARVATION: <15KG/M2
      • +UNDERWEIGHT: 15KG/M2 TO 18.4KG/M2
      • +NORMAL: 18.5KG/M2 TO 24.9KG/M2
      • +OVERWEIGHT: 25KG/M2 TO 29.9KG/M2
      • +OBESITY CLASS I: 30KG/M2 TO 34.9KG/M2
      • +OBESITY CLASS II: 35KG/M2 TO 39.9KG/M2
      • +MORBIDLY OBESE: 40KG/M2 OR MORE .
    • WHAT IS BMI? BODY WEIGHT IN KG DIVIDED BY HEIGHT IN METER SQUARE
    • ALTHOUGH WE DEFINE OBESITY BY BMI BMI EXACTLY DOES NOT REFLECT THE ACTUAL ADIPOSITY
    • BECAUSE
      • BMI DOES NOT DIFFERENTIATE ADIPOSE TISSUE AND LEAN TISSUE. HIGH BMI CAN BE FOUND IN MASCULAR ATHLETS WHO ARE ABSOLUTELY NOT IN METABOLIC RISK
      • BMI DOES NOT DIFFERENTIATE CENTRAL OR VISCERAL OBESITY AND PERIPHERAL OBESITY.
      • BMI DOES NOT DIFFERENTIATE GENDER
    •  
    • VISCERAL OR CENTRAL OBESITY IS RISKY MEASURED BY WAIST CIRCUMFERENCE WAIST CIRCUMFERENCE
    • HOW TO MEASURE WAIST CIRCUMFERENCE?
      • USE A TAPE MEASURE
      • START AT THE TOP OF THE RIGHT ILIAC CREST, BRING IT ALL THE WAY AROUND AND LEVEL WITH THE NAVEL
      • TAPE SHOULD NOT BE TOO TIGHT AND MUST BE PARALLEL WITH THE FLOOR.
      • RELAX AND NOT TO HOLD BREATH.
    •  
    •  
    •  
    • NORMAL WAIST CIRCUMFERENCE
      • FOR NORTH AMERICANS:
      • MEN: <102CM AND WOMEN: <88CM
      • FOR EUROPIANS:
      • MEM: <94CM AND WOMEN: <80CM
      • FOR SOUTH ASIANS:
      • MEN: <90CM AND WOMEN: <80CM
      • FOR CHINESE:
      • MEN: <90CM AND WOMEN: <80CM
      • FOR AFRICANS:
      • MEN: <84CM AND WOMEN: <80CM
    • HIGHER WAIST CIRCUMFERENCE IS AN INDEPENDENT RISK FACTOR HIGH CONTENT OF VISCERAL FAT = HIGHER METABOLIC RISK
    •  
    •  
    • NOT ALL PATEINTS WITH ABDOMINAL OBESITY ARE IN RISK STOP!!!
    • ABDOMINAL FAT SHOULD BE DEFFERENTIATED INTO VISCERAL FAT & SUBCUTANEOUS FAT H O W ?
    • PRACTICAL TIP FOR PHYSICIAN
      • *If waist circumference exceeds limit, go for fasting triglyceride
      • *If fasting triglyceride >177mg/dl (>2.0mmol/L)
      • *Abdominal obesity is due to visceral fat which leads to triad: hyperinsulinemia, high level of small dense particles of LDL & high Apo-B and ultimately CVD & T2DM
      • *If fasting TG <177mg/dl (<2.0mmol/L), high waist is due to suncuteneous fat & patients are not in risk.
    • PERIPHERAL FAT e.g. AROUND HIP CONTAINS MORE PUFA AND MORE PHYSIOLOGIC
    • MODERN MARKER OF OBESITY WAIST HIP RATIO (WHR)
    • WHAT IS WAIST HIP RATIO?
      • MEASURE THE WAIST
      • MEASURE THE WIDEST PART OF HIPS
      • MAKE RATIO WAIST/ HIP
      • FOR MEN WHR <0.9
      • FOR WOMEN WHR <0.7
      • WHR DIFFERENTIATE THE CENTRAL FROM PERIPHERAL OBESITY, HENCE BETTER MARKER OF OBESITY RELATED RISK.
    • OTHER MEASUREMENTS FOR OBESITY
      • BIOELECTRICAL IMPEDANCE ANALYSIS (BIA)
      • CT SCAN
      • MRI
      • DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA)
      • THESE ARE NOT ROUTINELY USED
    • BODY MASS INDEX(BMI) WAIST CIRCUMFERENCE The two important screening methods of obesity accepted worldwide
    • CAUSES OF OBESITY
      • 1. LIFESTYLE AND DIET
      • 2. ENVIRONMENTAL FACTORS
      • 3. GENETIC FACTORS
      • 4. CERTAIN HORMONAL DISEASES
      • 5. MEDICATIONS
    • 1. LIFESTYLE AND DIET
      • MAIN REASONS FOR OBESITY IS “ENERGY IMBALANCE” e.g. CONSUMING MORE CALORIES THAN BODY NEEDS
    •  
    • 1. LIFESTYLE AND DIET cont’d
      • SEDENTARYLIFESTYLE.
      • ENERGY DENSE FAST FOOD CONSUMING WORLDWIDE HAS INCREASED 4 TIMES FROM 1977 TO 1995.
      • EVEN DIET SODA AND ARTIFICIAL SWEETENERS ALSO CAUSE OBESITY BY “CEPHALIC PHASE INSULIN RESPONSE”(CPIR)
    • 1. LIFESTYLE AND DIET cont’d
      • OVERALL WORLD POPULATION INCLUDING IN BANGLADESH ARE NOW VERY MUCH PRONE TO SEDENTARY LIFESTYLE.
      • SPENDING MUCH TIME IN FRONT OF COMPUTER, TELEVISIONS
      • DREADFUL EXAMPLE. SAMOA, A POLYNESIAN ISLAND COUNTRY. AMERICAN GRANT AND FAST FOOD OUTLETS (INTRODUCED IN 2000) HAVE LEAD TO OBESITY PREVALENCE 75%.
      • FOR SAME REASON, HIGHEST PREVALENCE OF OBESITY IN MICRONESIAN COUNTRY NAURU WHERE OBESITY BEING 84.7% IN MALE AND 92% IN FEMALE.
    •  
    • 2. ENVIRONMENTAL FACTORS
      • BIG PORTION SIZE
      • HIGH FAT/ENERGY DENSE FOOD
      • HIGH GLYCEMIC INDEX OF FOOD
      • SOFT DRINKS
      • SUGAR
      • FAST FOOD
      • SNACK FOOD
      • LOW CALCIUM
    • 3. GENETIC FACTORS
      • RESEARCH SHOWS ABOUT 77% CASES IN CHILDHOOD OBESITY ARE INHERITED FROM OBESE PARENTS.
      • CERTAIN GENETIC DISEASES:
      • Prader Willi Syndrome (7 genes in chromosome 15 are missing or unexpressed)
      • Bardet-Biedle Syndrome (defect in chromosome 16)
    • 4. HORMONAL DISEASES
      • HYPOTHYROIDISM
      • CUSHING’S SYNDROME
      • RECENT SMOKING CESSATION (nicotine suppress appetite)
    • 5. CERTAIN MEDICATIONS
      • ANTI-CONVULSANTS: Carbamazepine, Valporate
      • CERTAIN ANTI-DIABETICS: sulfonylureas, TZDs
      • CERTAIN ANTIDEPRESSANTS
      • ORAL CONTRACEPTIVES
      • CORTICOSTEROIDS
      • ANTI-HISTAMINES
    • CHILDHOOD OBESITY DO YOU KNOW?
      • More obese children proportional to more T2DM in future adults.
      • Many obese children even at 5-6 years of age found to be hypertensive and with high cholesterol.
      • Sleep apnea, in obese children can lead to problem with learning and memory.
      • Obese children have a high incidence of liver disease and asthma.
      • Obese children have 70% chance of becoming obese in adults.
    • CHILDHOOD OBESITY FOR CHILDREN FROM 2-20 YEARS, BMI MEASUREMENT IS DIFFERENT FROM THOSE OF ADULTS
    • CHILDHOOD OBESITY
    • HOW TO MEASURE CHILD HOOD OBESITY?
    • BMI FOR CHILDREN AGE AND GENDER SPECIFIC
    • OBTAIN ACCURATE WEIGHT & HEIGHT MEASUREMENT
    • CALCULATE BMI IN THE SAME WAY AS ADULT
    • BMI NUMBER IS PLOTTED ON THE BMI-FOR-AGE GROWTH CHART TO OBTAIN PERCENTILE RANKING. DIFFERENT CHART FOR BOYS AND GIRLS
    •  
    •  
    • CLASSIFICATION OF CHILDHOOD OBESITY
      • UNDERWEIGHT: BMI-for-age <5 th . percentile.
      • HEALTHY: BMI-for-age 5 th . to 85 th . percentile.
      • RISK FOR OVERWEIGHT: 85 th . to <95 th . percentile.
      • OVERWEIGHT: Equal or >95 th . percentile.
    • WHY OBESITY IS RISKY?
      • VISCERAL OBESITY LEADS TO THE DEVELOPMENT OF:
      • CARDIOVASCULAR DISEASE AND STROKE
      • TYPE 2 DIABETES
      • HYPERCHOLESTEROLEMIA
    • OTHER COMPLICATIONS OF OBESITY
      • OSTEOARTHRITIS
      • CANCER
      • NON ALCOHOLIC FATTY LIVER DISEASE
      • POLYCYSTIC OVARY SYNDROME (PSOS)
      • CHOLELITHIASIS
      • HYPERURICEMIA
      • INFERTILITY
    • KEY PATHOPHYSIOLOGICAL MECHANISMS FOR THE DEVELOPEMENT OF OBESITY RELATED DISEASES
    • ENDOTHELIAL DYSFUNCTION ATHEROSCLEROSIS INFLAMMATION
    • INCREASED ABDOMINAL OBESITY
      • INCREASES PLASMA FREE FATTY ACID LEVEL
      • SECRETS ADIPOCYTOKINES (SPECIAL CYTOKINES) RELEASED BY ADIPOCYTES
    • INCREASED LEVEL OF FREE FATTY ACIDS
      • PREVENT INSULIN MEDIATED GLUCOSE ENTRY INTO CELL MITOCHONDIRA IN SKELETAL MUSCLE AND LIVER CAUSING INSULIN RESISTANCE.
      • INCREASE VLDL & TG AND REDUCE HDL
    • FAT IS NO MORE AN INERT ORGAN
      • ADIPOSE TISSUE NOW PROVED TO BE A VERY ACTIVE ENDOCRINE ORGAN.
      • AS ENDOCRINE ORGAN ADIPOSE TOSSUE SECRETS ADIPOCYTOKINES .
    • ADIPOCYTOKINES OR ADIPOKINES
      • MORE THAN 50 ADIPOKINES ARE
      • LISTED
    • IMPORTANT ADIPOKINES
      • TNF-ALPHA
      • INTERLUKIN-6 (IL-6)
      • LEPTIN
      • C-REACTIVE PROTEIN (CRP)
      • ANGIOTENSIN
      • PLASMINOGEN ACTIVATOR INHIBITOR-1 (PAI-1)
      • RESISTIN
      • ADIPONECTIN
    • TNF-ALPHA Generally together with IL1 & IL6, increases the synthesis of C Reactive Protein
    • INTERLUKIN-6 (IL-6) Increases C reactive Protein
    • LEPTIN
      • Leptin in normal person by acting on hypothalamus, reduces appetite.
      • In obese and patients with T2DM leptin level is found much higher but these types of patients become resistant to usual leptin function.
    • C-Reactive Protein (CRP) Number one inflammatory marker
    • ANGIOTENSIN
      • Recent work suggests that angiotensin II has significant pro-inflammatory action on endothelium.
      • This is the reason why RAS blockers have anti-atherosclerotic activity due to reduced vascular inflammation.
    • PLASMINOGEN ACTIVATOR INHIBITOR 1 (PAI-1)
      • Plasma level of PAI-1 strongly correlate with BMI and has strong pro-inflammatory function.
      • Ref: Circulation. 2005;111:1938-1945.)
    • RESISTIN Plays both in inflammation and insulin resistance
    • ADIPONECTIN
      • Adiponectin is found in large amount in healthy individuals and markedly reduced in obese and type 2 diabetics.
      • All adipokines except adiponectin are pro-inflammatory
      • Only adiponectin is anti-inflammatory and inversely proportional to visceral obesity
    • WHY INFLAMMATION IS SO IMPORTANT?
    • ACUTE INFLAMMATION
      • It is the first line defense of the body to any infection or healing any injury
    • CHRONIC INFLAMMATION
      • High blood pressure, hypercholesterolemia, smoking and obesity causes release of large amount of pro-inflammatory adipokines, which ultimately produce “Acute Phase Proteins”
      • These are C-reactive protein, serum amyloid A and fibrinogen.
      • CRP, the most important inflammatory marker for clinical diagnosis.
    • WHAT CRP DOES?
      • CRP disturbs normal biology of the endothelium, the inner most wall of blood vessels and cause injury in to endothelium.
      • Endothelial injury stimulate production of more inflammatory markers which attract monocytes those go into the arterial wall and transform into macrophages.
      • Macrophage engulf cholesterol from blood and transform into foam cells, the earliest stage for the formation of plaques.
      • Plaques become larger, more inflammatory markers cause rupture of the plaques.
      • Plaques come into contact with platelets and clotting factors causing heart attack and stroke.
    •  
    • INFLAMMATION AND T2DM
      • Research shows that women having high level of IL-6 are in 2 folds increased risk of developing of T2DM.
      • If both IL-6 and CRP are increased, risk goes to 6 folds.
      • Ref: Brigham and Women's Hospital in Boston
    • HOW TO MANAGE?
    • BEFORE GOING TO TREAT OBESITY
      • LOOK FOR RISK FACTORS
      • GET LABORATORY TESTS
    • RISK FACTORS
      • Established coronary heart disease
      • H/O myocardial infarction
      • Angina pectoris (stable or unstable)
      • H/O coronary artery surgery or angioplasty
      • Family h/o CHD in first degree relatives
      • Presence of atherosclerotic diseases e.g. PVD, abdominal aortic aneurysm, symptomatic carotid artery disease
      • Pre-diabetes or T2DM
      • Hypertension
      • Hypercholesterolemia
      • Sleep apnea
      • Smoking
      • Age: Men >45 years, women >55 years (postmenopausal)
    • High absolute risk for obesity related disease
      • Who are overweight
      • and has three or
      • more risk factors
      • EXCEPT
      • T2DM
      • T2DM alone is defined
      • as high absolute risk.
    • LABORATORY TESTS
      • Serum electrolytes
      • Liver Function tests (LFT)
      • Complete blood count (CBC)
      • Lipid profile
      • Thyroid function tests
      • ECG
    • TREATMENT OF OBESITY
      • Non-pharmacological
      • Pharmacological
      • Surgical
    • GOAL FOR OBESITY TREATMENT
      • Achieve and maintain healthier weight
      • Risk factor management
    • WHAT IS THE AIM OF HEALTHIER WEIGHT?
      • Aim to reduce 10% of the body weight during next 6 months.
      • 1-2 pounds loss of body weight per week is the safest way.
      • Once achieved, patient enters in to the phase of weight maintenance and long term monitoring.
      • Monitoring is important because study shows, 80% may go back to their previous weight.
    • NON-PHARMACOLOGICAL TREATMENT
      • Dietary change
      • Physical activity
      • Behavior modification
    • DIETARY CHANGE
    • 1. DIETARY CHANGE TARGET LOW CALORIE DIET
      • Calorie intake must be reduced by 500-1000kcal/day from the baseline.
      • For women calorie intake should be 1000 to 1200kcal/day
      • For men 1200-1600kcal/day
      • The above are called low calorie diet (LCD)
      • If patient feels hungry, 100-200kcal/day can be increased.
      • Very low calorie diet (VLCD) is <888kcal/day
      • may be used for short period of time under the guidance of a specialist.
    • TARGET: LOW CALORIE DIET CAUTION! Must not be less than 800kcal/day
    • WHAT HAPPENS WHEN CALORIES REDUCED BELOW MAINTENANCE?
    • RECENT INSTITUTE OF MEDICINE (IOM) GUIDELINES ACCEPTABLE MACRONUTRIENT DISTRIBUTION RANGE (MDR)
    • WHAT IS MDR?
    • TIGHT RESTRICTION
      • For Protein
      • Tight control of protein can cause undue loss of lean tissue.
      • For Fat
      • Intake of <20% of total calorie from fat can cause low level of HDL-C.
      • For Carbohydrate
      • < 120gm of carbohydrate per day can cause ketosis and associated hyperuricemia, dehydration & electrolyte imbalance.
    • EAT
      • More fruits, vegetables, whole grain
      • Limit sugar and other refined carbohydrate
      • Limit food containing large amount of saturated and trans fat
      • Consume backed, grilled, or roasted meat instead of fried.
      • Limit soft drinks
      • Total daily diet should be divided in to 4 to 5 meals per day.
    • EXAMPLE OF LCD
      • Calorie: reduction 500-1000kcal/day
      • Total fat: <30% of total calories
      • Saturated fat: 8-10% of total calories
      • Monounsaturated fatty acids: up to 15% of total calories
      • Polyunsaturated fatty acids: up to 10% of total calories
      • Cholesterol: <300mg/day
      • Protein: 15% of total calories
      • Carbohydrate: 55% of total calories
      • Table salt: approx. 6gm/day
      • Calcium: 1000-1500mg/day
      • Fiber: 20-30gm/day
    • E G G I N O B E S I T Y
    • EGG
      • One medium sized egg contains 78 Kcal, contribute approx. 4% of the average daily energy requirement.
      • Protein-12.5%
      • Fat- 11.2% (17% PUFA, 32% saturated & 44% MUFA)
      • Carbohydrate-trace
      • Minerals: Iodine, Phosphorus, Zinc, Calcium, Selenium
      • Vitamins: Most of the recognized vitamins except Vit-C.
    • EGG cont’d
      • Over 30 years of prospective epidemiological surveys of CHD risk have consistently found no independent relationship between dietary cholesterol or egg consumption and CHD risk.
      • American studies found that by eating two eggs for breakfast, overweight and obese women ate less at subsequent meals and lost more weight than those eating a bagel-based breakfast . It is due to high “satiety index” (150%) of egg.
    • EGG cont’d REFERENCES
      • McNamara DJ (2000) Dietary cholesterol and atherosclerosis. Biochimica et Biophysica Acta 1529: 310-20.
      • Lee A and Griffin B (2006) Dietary cholesterol, eggs and coronary heart disease risk in perspective. British Nutrition Foundation ‘Nutrition Bulletin’ Volume 31 Number 1 pp21 – 27.
      • Dhurandhar, NV (2007) Eggs for breakfast help promote weight loss. Presented at Experimental Biology 2007. Astrup A, Buemann B, Flint A, Raben A. Low fat diets and energy balance: how does the evidence
    • 2. PHYSICAL ACTIVITY
      • Walking, dancing, gardening, team or individual sports, cycling, rowing, rope jumping, jogging.
      • Reducing sedentary activities e.g. watching TV, computer, games.
      • Most attractive: Walking. light walking-24min/mile, moderate-15min/mile & high/jog-10min/mile.
    • PHYSICAL ACTIVITY SHOULD BE STARTED GRADUALLY. walking 10min/day-3days in a week, increase gradually up to 45min/day-7days/week
    • ACSM's Guidelines for Exercise Testing and Prescription -- Sixth Edition, page 26 Virtually all sedentary individuals can begin a moderate exercise program safely.
    • 3. BEHAVIOR MODIFICATIONS
      • Family Physician together with family members and friends and if possible with psychologist should modify the behaviors responsible for obesity:
      • These are:
      • practice self monitoring, stress management, stimulus control, contingency management, cognitive restructuring
    • PHARMACOLOGICAL TREATMENT IS INDICATED IF
      • BMI is equal or >30
      • AND
      • Non-pharmacological approach can not achieve goal maximum in six months e.g. reduction of 10% body weight.
    • Non-pharmacological treatment should be continued together with pharmacological agents
    • TWO DRUGS CURRENTLY APPROVED BY FDA SIBUTRAMINE ORLISTAT
    • SIBUTRAMINE
      • FDA approval in November 1997.
      • Centrally acting serotonine-norepinephrine-reuptake inhibitor (SNRI).
      • Centrally acting anorexiant or appetite suppressant.
      • Doses: start with 5mg in the morning. Maximum 15mg/day with or without food
      • Should not be used in patients with HTN, CHD, CHF, arrythmia or stroke.
      • Should not be used in patients aged 16 or less.
    • ORLISTAT
      • FDA approval in April 1999.
      • Pancreatic lipase inhibitor
      • Inhibit absorption of dietary fat up to 30%
      • Doses: 120mg three times a day with meal.
      • As orlistst reduce absorption of fat soluble vitamins and beta carotene , patient should get the above vitamins, to be taken 2 hrs before or after the dose of orlistat.
      • Study does not support use of orlistat in patients less than 12 years of age.
    • THESE ARE FOR LONG TERM USE If weight reduction is not achieved 2kg in 4 weeks, drug should be discontinued
    • NEWER PHARMACOLOGICAL AGENT Endocannabinoid (ECS) receptor blocker
    • RIMONABANT
      • Endocannabinoids, releasing from the cell membrane acting on ECS receptors CB1, induce appetite.
      • In obese and T2DM patients, these are found in large amount.
      • Rimonabant, first ECS blocker are in use in 30 countries of the world.
      • Not yet approved by FDA
      • Although Rimonabant has some psychiatric side effects, research in on the way to find safer agents.
    • SURGICAL TREATMENT OF OBESITY
      • If BMI is equal or more than 40
      • If BMI is equal or more than 35 plus any additional risk factor.
      • no response to lifestyle and drug treatment.
      • Liposuction is no more popular for its complications and long term side effects.
      • Bariatric surgery
      • 2 types of surgery are proven to be effective
    • BARIATRIC SURGERY 1
      • Banded gastroplasty to
      • restrict gastric volume
      • Vertical banded gastroplasy
      • (VBG)
    • BARIATRIC SURGERY 2
      • Rous-en-Y gastric
      • bypass. (RYGB)
      • In addition to limiting
      • food intake, it alter
      • digestion
    • Contraindications to Treatment of overweight & obesity
      • Active cancer
      • Eating disorders e.g. anorexia nervosa and bulimia.
      • Pregnancy.
      • Any severe illness or terminal illness
    • PRACTICAL TIPS FOR FAMILY PHYSICIANS
      • Patient
      • Measure height, weight, waist & find BMI.
      • BMI equal or >25 OR Waist >102cm(M) OR >88cm(F)
      • For us: >90cm(M) or >80cm(F)
      • Assess risk factors.
      • Assess causes.
      • Get laboratory tests.
      • Go for treatment options:
      • Goal: 10% wt. loss in 6 months.
    • MANAGEMENT OPTION I
      • BMI 25-34.9 OR
      • WAIST: >102cm (M) & >88cm(F) for North America.
      • For Bangladeshi, >90cm(M) & >80cm(F)
      • START:
      • NON-PHARMACOLOGICAL TREATMENT
      • DIET CHANGE
      • PHYSICAL ACTIVITY
      • BEHAVIOR MODIFICATION
    • MANAGEMENT OPTION II
      • 10% weight lose not achieved in 6 months
      • Along with non-pharmacological, start
      • PHARMACOLOGICAL TREATMENT
      • Orlistat
      • Sibutramine
      • If 2kg weight loss not achieved in 4 weeks, change the drug.
    • MANAGEMENT OPTION III
      • BMI 35 or more plus 2 or more risk factors OR BMI 40 or more
      • Start both non-pharmacological & pharmacological approaches simultaneously.
      • If not reached goal e.g. 10% weight reduction in 6 months:
      • REFER TO SPECIALIZED CENTER FOR
      • FURTHER
      • ASSESSMENT OR POSSIBLE BARIATRIC
      • SURGERY
      • Vertical banded gastroplasty or Gastric bypass
    • PRACTICAL TIPS FOR CHILDHOOD OBESITY
      • Identify child’s risk by assessing family history, birth weight, socioeconomic, cultural and environmental factors.
      • Calculate & plot BMI once in a year for all children.
      • Promote breastfeeding
      • Encourage parents for healthy food habits: whole grain, low fat dairy food, fruits and vegetables.
      • Promote physical activity, playing both at home and school.
    • PRACTICAL TIPS FOR CHILDHOOD OBESITY-con’d
      • Recommend limitation of watching television and video games not more than 2 hrs/day
      • Recognize and monitor changes in obesity-associated risk factors: hypertension, dyslipidemia, hyperinsulinemia, Impaired glucose tolerance, and symptoms of obstructive sleep apnea syndrome.
    • DOCTORS! WHERE WE STAND? WITH OBESITY?
    •  
    • NO!!
    • NO!!
    • NO!!
    • NO!
    • N O !
    • Y E S !
    • YES!!
    • YES!!
    • YES!!
    • YES!
    • BE ACTIVE KEEP HEALTHY
    • References:
      • European Heart Journal 2003 24(16):1531-1537
      • Tanaka K, Kodama H, Sasazuki S, et al. Obesity, body fat distribution and coronary atherosclerosis among Japanese men & women Int J Obes Relat Metab Disord . 2001;25:191–197
      • ( Circulation. 2004;110:2246-2252.) © 2004 American Heart Association, Inc
      • By Christine Gorman and Alice Park Time Magazine, Feb. 23, 2004
      • NEJM Volume 352:1685-1695 April 21 2005 Number 16
      • Arteriosclerosis, Thrombosis, and Vascular Biology. 2002;22:1257.)
    • T H A N K Y O U!