Obesity in women by Dr. Sharda Jain presented on 17th August 14 at DMA Centenary CME


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Obesity in women by Dr. Sharda Jain presented on 17th August 14 at DMA Centenary CME

  1. 1. Obesity In Women Dr. Sharda Jain Dr. Yogesh Agarwala Dr. Jyoti Agarwal Dr. Jyoti Bhaskar
  2. 2. Obesity In Women Presented by Dr. Sharda Jain DMA Centenary CME & Celebration On 17/8/2014
  3. 3. OBJECTIVES: • PREVALENCE Of Obesity in women • Unique features in MEDICAL HISTORY * PHYSICAL EXAMINATION * ANTHROPOMETRIC MEASUREMENTS * TAILOR LAB TESTS • Brief Review of - Medical issues * Infertility * Pregnancy in Obese patient. • Management
  4. 4. Obesity is a … Emerging MENACE Largest increase has been seen in young adolescents and young women
  5. 5. OBESITY “AN EMERGING MENACE” 1. > 1 Billion overweight 2. > 300 Million – Obese 3. 26% of non pregnant women ages 20 – 39 are overweight / obese W H O
  6. 6. PREVALENCE OF OBESITY is on increase!! 1. Obese > - Doubled (BMI 27.5) 2. Morbid Obesity > Quadrupled (BMI 37.5) Super Obesity > Five fold Increase (BMI 47.5)
  7. 7. OBESITY in Women Creates OBESOGENIC ENVIRONMENT 1. Women at GREATER RISK FROM OBESITY THAN MEN all across the world 2. Rates of obesity are in women in INDIA too. 3. Women are at disproportionate risk of
  8. 8. Obesity in Men & WOMEN in Reproductive Age in India Country Male Female India 9 12 (2000) 12 16 (2009) Punjab 30 37.5 Gujrat 15 17 UP 16 12 Haryana 14 17 Women are More Prone than men
  9. 9. – ONSET: child, teen, adult, pregnancies, peri or postmenopausal, etc – RATE: rapid vs. slow – INCITING FACTORS: stress, marriage, divorce, illness, medication, abuse, travel, trauma History of Weight Gain is Important
  10. 10. “Obesity refers to an excess of Total body fat, which can be assessed by a variety of techniques.” OBESITY:
  11. 11. Obesity Class BMI Underweight < 18.5 Normal 18.5 – 24.9 Overweight 25 - 29.9 Obesity I 30 – 34.9 II 35 – 39.9 Extreme Obesity III > 40 BMI & OBESITY CLASSIFICATION – WHO Criteria
  12. 12. BMI Cutoff Weight Status Comments <18.5 UNDERWEIGHT Being underweight also puts you at risk for developing many health problems. 18.5 - 23.9 HEALTHY WEIGHT RANGE Your weight is within normal range. You can continue to keep a healthy weight through physical activity and healthy eating. Keep up with the good work! 24 - 26.9 OVERWEIGHT Being overweight can put you at risk for developing many chronic diseases >27 OBESE Obesity increases risks for developing many chronic diseases such as heart disease and diabetes, and decreases overall quality of life. BMI Cutoff for INDIAN -2.5 in each category
  13. 13. –CENTRAL OBESITY android, APPLE SHAPE – LOWER BODY OBESITY Gynecoid PEAR SHAPE FAT DISTRIBUTION Central Obesity is High Risk For Co-Morbidities / Complications
  14. 14. •Waist Circumference •> 40” in males •>35” in Females •Waist HIP Ratio –>1.0 in males –>0.8 in Females Fat Distribution Anthropometric measurements
  15. 15. Sometimes even when BMI is within Normal range, having too much fat around the abdomen (APPLE SHAPE BODY) will still put one at risk for heart disease and diabetes. Below are the target goals for waist circumference measurements. Target WAIST Circumference for Indians INDIAN WOMEN Equals or less than 80cm (31.5 in)
  16. 16. –ACANTHOSIS NIGRICANS (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM) – Dry Scaly skin – Hypothyroidism – Acne – PCOS, Cushing’s – Bruising – Cushing’s, hypothyroidism – Hyperpigmentation – Cushing’s – Xanthomas (palmer or tuberous)–hyperlipidemia – SKIN TAGS – IR/DM Physical Exam – Significant Findings in Skin
  17. 17. Body Composition Analysis Machine They all are obese
  18. 18. Wonder Why - One Always Gain Weight, Despite Dieting And Exercise or just drinking water !!! Resting Metabolic Rate
  19. 19. • Calculation vs. Testing • Calculating RMR: Used to determine daily caloric needs and effective caloric deficit • Measuring RMR: – Hand held devices – Quick, non-invasive – Easily administered Resting Metabolic Rate
  20. 20. Laboratory tests –Comprehensive Metabolic Panel –CBC –TFT –Lipid Profile –U/A –Also Consider doing: Insulin levels, HbA1c, CRP, Uric Acid, CPK, C-Peptide, Vit-D and B12, Reproductive hormones Tailor – Lab Work up of Obese Patient
  21. 21. OBESITY & PSYCHOSOCIAL HEALTH in WOMAN 1. Poor body image 2. Social stigmatisation (‘a laughing matter’) 3. Lower education levels 4. Lower rates of marriage 5. Lower socio economic levels
  22. 22. Diagnostic criteria for various conditions are not discussed here Pre-Diabetes Fatty Liver Diabetes type II Hyperlipidemia Insulin Resistance Hypo-Thyroidism Metabolic Syndrome Vitamin-D Deficiency Cancer screening – Breast, Colon, Endometrial, Ovarian etc. RULE OUT Diagnosis:
  23. 23. Obesity is The Root Cause of Some of the Serious Diseases Metabolic Disorders • In Indians , types 2 diabetes and hypertension has a close link to obesity • 60 million people suffered from diabetes in 2012 and will exceed 100 million by 2030 • People with BMI >32.5kg/m have a 6-fold higher risk of diabetes
  24. 24. Obesity is The Root Cause of Some of the Serious Disease CARDIOVASCULAR DISEASES – Obese women have 30% higher risk of death , due to circulatory system diseases than normal weight individuals CANCER •Obese women showed more than 2 times higher rate of breast cancer as compared with their normal weight counterpart
  25. 25. Morbid Obesity : Takes Heavy Toll on Women’s Health 7-40% of CANCER cases like breast colon, rectum, kidney, pancreas etc 45% of Diabetes cases 25%of ischemic heart disease cases HYPTENSION , DYSLIPIDEMIA ,ASTHMA., OSTEOARTHRITIS GALL BLADDER DISEASE ETC.
  26. 26. IMPACT OF OBESITY ON LONGEVITY In WOMEN • Direct relationship between increasing BMI and relative risk of dying prematurely Nurses health studyNurses health study • In morbidly obese life expectancy is reduced by 9 yrs in women 12 yrs in men Framingham dataFramingham data
  27. 27. Obesity & Reproductive Health • AMENORRHEA, ANOVULATION , irregular menstrual cycle, DUB is increasingly occurring with higher body weight
  28. 28. Obesity is strongly associated with PCOS central obesity, hyperandrogenism, and insulin resistance with compensatory hyperinsulinenia Obesity & Reproductive Health
  29. 29. • SKIN – Acanthosis nigricans (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM) Physical Exam – Significant Findings Skin tags – IR/DMAcanthosis nigricans
  30. 30. Is Obese Women at Risk of Infertility an obese woman is about THRICE as likely to be infertile as a normal woman it is seen that adolescent obesity is associated with a threefold increased risk Polotsky AJ, hailper SM skurnick JH, LO JC sternfeld B, santoro N associated of adolescent women’s health across the nation (SWAN) fertility steril 2010;93:2004- 11) Yes
  31. 31. OBESITY & ASSISTED REPRODUCTION 1. Obesity leads to poorer prognosis with Assisted Reproduction 2. Pregnancy Rates in ART halved for women with BMI > 35 kg/m2
  32. 32. Obese women : not only have a lower chance of pregnancy following In Vitro Fertilization, they require higher doses of gonadotropins and have an increased miscarriage rate OBESITY & ASSISTED REPRODUCTION
  33. 33. Causes of Poor Pregnancy Rate Endometrial Factor It is postulated that lower pregnancy rate associated with obesity is caused by altered receptivity of endomertium due to disturb endometrium function Oocyte factor Obese women using donor Oocytes eliminates bad effect of quality of egg & however reduced Live birth rate with increasing BMI regardless of Oocytes source is seen. LUKE B, et al. fujimoto VY the effect of maternal body mass index (BMI) and oocyte source on assisted reproductive technology(ART)pregnancy rates andobstetric outcomes. Fertile sterile 2009;92 suppl 1:s52
  34. 34. Even 5% Weight loss improves fertility outcome Impacts Fertility Outcomes
  35. 35. Complications of Obesity during Pregnancy: independent risk factor • Miscarriages • Risk of medical and surgical complications * Gestational HTN, Pre-Eclampsia, Eclampsia * Gestational Diabetes * Fetal Macrosomia * Higher rate of C-Sections and operative deliveries, infection and PPH, wound related complications •Premature deliveries • PROM • IUGR, Intra-uterine fetal death
  36. 36. Weight Gain in Pregnancy - Pre-pregnancy BMI of <20 and target weight gain as 0.23 – 0.5 kg per week during 2nd and 3rd trimesters. –If BMI is more than 26, weight gain target is 0.14- 0.32 per week in 2nd and 3rd trimesters Pregnancy is time to gain weight not lose weight. In 1990, USA published recommendations:
  37. 37. Pregnancy in obese patients Specific consideration • Labor & delivery –Obesity is should not change course of labor & delivery –C-section rates are slightly higher in these patients
  38. 38. Management in General • Obese patients are advised to lose weight which may be accomplished by one or a combination of following methods - – Diet – Diet & Exercise – Anti-obesity Medicines – BARIATRIC SURGERY
  39. 39. Management of Obesity in general 1st LINE OF MANAGEMENT : Lifestyle changes like modification of diet , physical activity and daily habits 2nd line of Management : introduction of pharmacotherapy for patients with BMI above 24 with co – morbidities and BMI above 27.5 with no co- morbidity BARIATRIC SURGERY : may be an option for treatment of morbid obesity (BMI > 32.5) when diet and exercise do not work 1 2 3
  40. 40. Treatment Modalities For Infertility in Obesity Life – Style & Nutrition Changes • Diet • Exercise • Psychological Counseling Surgical Intervention • Bariatric surgery ART • IUI • IVF • ICSI Pharmacological intervention Appetite suppressant, Weight Loss Drugs (Orlistat) Drugs Increase sucidal tendency
  41. 41. Word of Wisdom Prior to ART therapy Weight loss should be the fist – line treatment even 5% weight loss improves fertility outcome. • Dietary weight loss, Regular physical exercise , elimination of tabacco of alcohol consumption behavior modification and stress management may be of benefit ESHRE human reproduction 2010;25:578-83
  42. 42. Pre-Pregnancy Counseling • With mal-absorption - decreased folate level may cause neural tube defects • With crash dieting - there can be nutritional deficiencies • Provide supplements & consult with nutritionist
  43. 43. Pre - Pregnancy counseling after Bariatric surgery When ever possible, pregnancy should be delayed TILL WEIGHT LOSS STABILIZES for 12- 24 months, use active contraception
  44. 44. Nutrient Supplements After Bariatric Sx (In Non-Pregnant) Supplement Dose per day Multivit 1-2 Calcium Citrate 1200-2000 mg Vit-D 400-800 IU Folic Acid 400 ug Elemental Iron 40-65 mg Vit-B12 350 ug orally or 1000 ug IM/month
  45. 45. LAP Adjustable Gastric Banding Given - up procedure in India SLEEVE Gastrectomy & Gastric Bypass surgery are the only alternative & done routinely Safety of surgery in India – in good hands as safe as Lap. Cholecystectomy Bariatric Surgery A serious approach to serious problem
  46. 46. • Labor & delivery –Hx of Bariatric surgery should not change course of labor & delivery –C-section rates are slightly higher in these patients –At C- delivery, be aware of intra abdominal adhesions Pregnancy after Bariatric Sx: Specific consideration
  47. 47. Summary • There is need of SUPER SPECIALTY in gynae seeing the Increasing prevalence of obesity in women • Gynaecologists should be familiar with common types of - Medical Issues - Impact of infertility - Special ART management - Role of bariatric surgeries • Post Bariatric surgery pregnancies are generally safe. • Gynaecologist should have knowledge of nutrients’ deficiencies and - Nutrition management. - Drug Therapy
  48. 48. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com & Thank You