In a study of Pima Indians by Knowler and colleagues, the contributions of obesity to the incidence of diabetes and parental diabetes were examined. The incidence of diabetes mellitus was determined in 3,137 Pima Indians during periodic examinations that included measurement of weight, height, and glucose tolerance. Data was adjusted for age and sex. The incidence was strongly related to body mass index, increasing steadily from 0.8 ± 0.8 cases/1000 person-years in subjects with body mass index < 20 kg/m 2 to 72.2 + 14.5 cases/1000 person-years in those with body mass index > 40 kg/m 2 (reported as rate + standard error). Obesity was strongly related to the incidence of diabetes over the entire range of BMI.
Data in the next 8 slides show results of a population-based longitudinal study by Brown and colleagues. The Australian Longitudinal Study on Women’s Health enrolled 13,431 women who participated in a baseline survey of selected indicators of health and well-being for middle-aged women, age 45-49. The study explored the associations between body mass index and selected indicators of health and well-being; surgical procedures(cholescystectomy, hysterectomy), symptoms like back pain, and number of visits to general practitioners or specialists. BMI was calculated using self-reported height and weight, corrected following the method of Waters. Hypertension shows a strong monotonic relationship with BMI. Trend curve estimates the relationship between BMI and hypertension. The percentage of reported hypertension increases with increasing body mass index. The prevalence of hypertension at different levels of BMI were 10.6%(BMI <20), 13.3% (BMI > 20 < 25), 22.8%(BMI > 30 < 40), and 61.3%(BMI>40). There was a 6-fold increase in the odds ratio of hypertension between women with BMI<20 and women with BMI >40.
Back pain is described in the study by Brown and colleagues as increasing with higher BMI. This trend curve shows the relationship between BMI and back pain. There is a 40% increase in the odds ratio of back pain between women with BMI < 20 and women with BMI > 40. Back pain is one of the most common symptoms reported by women in studies of health concerns.
The United States has constructed the new food pyramid which shows the daily exercise and weight control at its base. From there it is very straightforward and easy to understand with respect to daily helpings of a variety of foods that are recommended. This can be a good patient aid for helping patients understand these principles.
Menopause and obesity
MENOPAUSE AND OBESITY Dr. Vandana Bansal MS, D.Phil., DGO, FCGP
OBESITYObesity is a heterogeneous complex disorder ofmultiple etiologies characterized by excessiveaccumulation of body fat that threatens oraffects socioeconomic, mental or physical health Sharma 2007
Obesity: major public health problem• Universally there are 1 billion overweight adults, among whom 300 million are obese• Obesity is continuously increasing in the elderly population• Life expectancy increases – 77 years for men – 82 years for women• 25% of the population >65 years by 2030• Body fat increases with age, independently of BMI (sarcopenic obesity) Han TS et al, BritishMedical Bulletin 2011;1-28
Obesity: Definition• Obesity is defined in terms of body mass index• BMI is calculted as weight in kilograms divided by the square of the height in meters (kg/m2)• WHO Classification of obesity according to BMI• Classification BMI (kg/m2)• Underweight Less than 18.5• Normal range 18.5- 24.9• Overweight 25-29.9• Obese I 30-34.9• Obese II 35-39.9• Obese III Greater than or equal to 40.0• Abdominal obesity WC > 88 cm
Classification of ObesityObesity can be classified into two groups on the basis of body fat distribution and the waist-to-hip circumference ratio. The apple shape: The pear shape: also called “android”, also called “gynaeoid” or “abdominal” or “central” “peripheral” obesity obesity people with lower waist to hip ratios are people with high waist-to-hip "pears“ - their body fat is distributed ratios are "apples", their body fat is mainly on the lower trunk, the hips and distributed mainly on the upper thighs giving the typical ‘pear shape’. trunk, the chest and abdomen giving the typical ‘apple shape’ individuals are mostly female. individuals are mostly male associated health risks are minimal if any A waist-to-hip ratio >1.0 for men and >0.8 for women indicates an increased risk of cardio-vascular disease and diabetes mellitus
Classification of obesity Body Mass Index (BMI) The internationally accepted classification for obesity is the Quetelets Index, also called the Body Mass Index (BMI) The BMI is a measure of a person’s weight in relation to height and it is calculated as: weight divided by height squared (kg/m2)BMI = weight in kilograms = kg/m2 square of height in meters
WHO classification of obesity tion 1 Risk of co-Classification BMI (kg/m2) morbidityUnderweight Less than 18.5Normal 18.5 - 24.9 Not increasedOverweight or pre-obese 25.0 - 29.9 IncreasedObesity, further classified Increased asas: ≥30.0 follows: – Class I 30.0 - 34.9 – Moderate – Class II 35.0 - 39.9 – Severe – Class III ≥40.0 – Very severe Source: Adapted from WHO 1997
Prevalence of Obesity• The prevalence of obesity is increasing world wide and is reaching epidemic proportions• Majority of adults are becoming increasingly overweight• Approximately 20% of the adult world population is overweight• In postmenopausal women this prevalence is growing most rapidly• Postmenopausal women have an increased tendency for gaining weight• 44% of postmenopausal women are overweight, among whom 23% are obese.
Measurement of obesity Introduction 11. Measurements that are simple, cheap and appropriate for routine use include: • Waist circumference • Hip circumference • Waist-to-hip circumference ratio • Body Mass Index (BMI) • Skin fold thickness using callipers (e.g. triceps, scapular)1. Measurements of body fat that are expensive and require special equipment and highly trained personnel include: • Underwater weighing • Bioelectrical impedance • Computerized topography
Postmenopausal women: higher prevalence ofobesity compared to premenopausal women
Menopausal changes in body composition• Increase weight• Increase total body fat (%)• Decrease lean body mass• Increase abdominal adiposity – Increase waist circumference – Increase truncal fat (Dexa Scan)
Cause of obesity in postmenopausal women• Weight gain, during and after the menopause is common• Contributing factors – Ethnicity – Reduced physical activity – Reduced lean mass – Reduced resting metabolic rate (RMR) and – Treatment with certain drugs e.g. steroids, insulin, glitazones. – Genetics
Slowing Metabolism• Decreasing the number of calories a middle age need for energy.• The muscle mass decrease so less calories needed.• Muscle need more calorie than fat.
Overeating & Reduced Physical Activities• Increased appetite• Eating more , cause increasing fat• Less energy needed so less calorie food is used and it all change to fat around the waist• Hormonal imbalance make you tired• Less tendencies to exercise.
Mechanisms of Menopause- Related Increases in Adiposity Menopause Preferential abdominal fat Increased Hormonal changes Accumulation abdominal and of the menopause intraabdominal transition Increased fat adiposity accumulationEstrogen deficiency Altered energy metabolism Age Life-style
Obese postmenopausal women differ from the general postmenopausal women 1. Hot flushes and menopausal symptoms are more frequent 2. Increased risk of developin coronary heart disease 3. Stroke risk increase linearly with increasing BMI 4. Obesity is associated with increased risk of venous thromboembolism 5. Obese postmenopausal women are at increased risk of developing breast cancer (RR : 1.26 – 2.52) Lambroinoudaki I et al., Maturitas 2010
Adverse effects of obesity in Menopausal Women• Cardiovascular disease• Diabetes mellitus• Arthritis• Respiratory dysfunction• Urinary incontinence• Cancer (breast, endometrium, colon)• Cognitive dysfunction / dementia• Impaired quality of life Han TS et al, BritishMedical Bulletin 2011;1-28
Obesity is associated with features of the metabolic syndrome (MS)• Elevated BP (> 135 / 85 mmHg)• increased central adiposity• increased fasting blood glucose (>100mg/dL)• low HDL-cholesterol (<50mg/dL)• or elevated triglyceride levels (>150mg/dL) MS is an independent risk factor for cardiovascular disease in postmenopausal women Lin JWet al, J Clin Endocrinol Metab 2010
Obesity and Diabetes Risk 100 80Incidence of NewCases per 1,000 60Person-Years 40 20 0 <20 20-25 25-30 30-35 35-40 >40 BMI Levels Knowler WC et al. Am J Epidemiol 1981
Obesity and Hypertension 60 50 Percentage 40 30 20 10 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.Brown WJ et al. Int J Obes 1998;22:520-528.
Obesity and Back Pain 35 30 Percentage 25 20 15 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.Brown WJ et al. Int J Obes 1998;22:520-528.
Management of obesity in menopausal women• Effective management of obesity requires long-term strategies and an integrated, multi-disciplinary approach that includes community-based support for behavioural modification including diet and exercise.• Research over the last decade indicates that a 5-10% reduction in body weight is sufficient to significantly improve medical conditions associated with obesity• As always, “prevention is better than cure”. 25
Management of obesity in menopausal women• Prevention is the Key• Team work• Individualized goal of wt loss• Components: – Education & motivation – Diet modification – Behavioural/lifestyle modifications – Physical activity – Medical treatment – Surgical treatment 26
Education & Motivation• Public support for healthier lifestyles needs to be initiated• Teach early - why physical activity and healthy eating are so important.• Provide them with the knowledge and the cognitive skills to manage energy balance in the modern environment.
Dietary Modification Most common and conservative treatment -utilizes a balanced, low calorie diet Diet must include more fruit and vegetables, nuts, whole grains and exclude fatty and sugary foods weight-loss programs recommend diets consisting of 1,200 to 1,500 calories per day, usually in the following proportions: 60 percent carbohydrate 30 percent fat 10 percent protein The degree of weight loss being dependent on individuals ability to adhere to dietary recommendations
Select bulky food with low caloric density to produce sense of satiety Limit salt intake up to 6 g/day• A diet high in natural sources of fiber 25-35 g• Choose foods with lower glycemic index. Low fat diet- Low fat diary products- Vegetables and fruits everyday.
Ensure adequate protein intake to avoid loss of muscle mass Lean mass Body weight preservation stabilization after completion of the diet program Bopp et al., J. Am.Diet. Assoc. 2008
Balanced Diet Low in Saturated Fat White rice, white bread, Red meat and potatoes, pasta and Butter sweets Use Sparingly Use Sparingly Dairy, 1 to 2 ServingsMultiple Vitamins, ForMultiple Vitamins, For Fish, poultry and eggs Alcohol in Alcohol in 0 to 2 servingsMostMost moderation moderation Nuts and Legumes Unless Unless 1 to 3 servings Contraindicated Contraindicated Vegetables, In Abundance Fruit, 2 to 3 Servings Whole Grain Foods, At Most Meals Plant Oils, At Most Meals Daily exercise and weight control From Willett WC, Stampfer MJ. Sci Am. 2003;288:64-71.
Behavioural/Lifestyle modifications Many eating and exercise habits combine to promote weight gain. Keeping a food diary that records times, places, activities, and emotions may be linked to periods of overeating or inactivity will reveal areas needing modification Lifestyle modification is best achieved when the affected individual is motivated, enthusiastic and supported to achieve set goals Avoid eating while on their feet, watching TV or playing games. Eat home cooked meals rather than fast foods Walk rather than use cars, escalators, lifts. Reduce TV hours, and use of energy saving devices
Physical activityRegular exercise is the single best predictor for achieving long-term weight controlExercise prevent weight increase after completion of the diet program Consensus: Minimum of 30 min/day At least 2.5 h/week
Physical activityIndependently of weight loss regular exercise improves:• Triglycerides• LDL-c and HDL-c• Waist girth• Blood pressure• Blood sugar levels in diabetics and• Other obesity-related complications
Yoga and Weight Gain• Yoga can prevent weight gain andreduce unwanted fat diposition in middleage.• Yoga at least 30 minutes per day.
Medical TreatmentWhen do we prescribe medical treatment?When patients are unable to achieve weight targetdespite their best effort with diet and exercise
Pharmacotherapy Anti-obesity drugs be used only in individuals with a BMI>30kg/m2, in whom at least 3 months of managed care (supervised diet, exercise, and behaviour modification) fails to lead to significant reduction in weight • Orlistat • Sibutramine • Rimonabant • Metformin ?? Use of these drugs requires strict regular monitoring and must be discontinued if weight loss is <5% after 12 weeks of use or weight gain recurs while on the drugs Gradual reversal of weight loss is known to occur on stopping pharmacotherapy
PharmacotherapyOrlistat:•The only approved medical treatment of obesity•Inhibits the absorption of fat from the intestine by inhibitingpancreatic lipases•Orlistat prevents the absorption of up to 30% of dietary fat•Useful for those with a high intake of fat•3-4% additional weight reductionSibutramine:•Appetite suppression by blocking the re- uptake ofnorepinephrine and serotonin in nerve terminals• Should be avoided in those with hypertension, coronaryartery disease, congestive heart failure
PharmacotherapyRimonabant:• Endocannabinoid receptor antagonist• Used as an adjunct to diet and exercise for thetreatment of obese patients (BMI 30 kg/m2)• Rimonabant is contraindicated in patients on antidepressants or with history of anxiety or depression• Nausea, vomiting and mood disorders may limit its use
PharmacotherapyMetformin:• Insulin sensitizer used in the treatment of overweight /obese diabetics and PCOS women• In these populations metformin use is associated with amild weight decreasing effect•This is not sufficient to qualify as a primary treatmentfor weight loss• Metformin is not licensed for weight loss•Should be used as an adjunct in type2 diabetic patients
Surgical TreatmentBariatric surgery Surgery may be a weight-loss option for patients with a BMI of ≥ 40 kg/m2 or those with BMI ≥ 35kg/m2 & having serious medical complications. Two accepted surgical procedures : Gastroplasty Gastric bypass Both reduces the stomach to a small pouch that markedly limits the amount of food consumption Studies show that there is weight loss of 25 to 30% over the first year post operatively Longterm monitoring is needed and surgery is not without attendant operative risks.