OBESITY

1. TREATMENT OF OBESITY
• TARGETS:
The primary goals of treatment are to improve
obesity related co-morbid conditions and to
reduce the risk of developing future co-
morbidities.
Initial goals of weight loss therapy - 5-7% from
baseline.
Weight loss of 10-15% - very good response
>15% - excellent response.( BY
DRSARBABHAUM TRIPATHY)

2. Infrastructure development
Exercise and nutrition curriculum
in schools
Encourage traditional Indian
solutions (yoga)
Doctors should promote
awareness
Community endeavors to promote
exercise
Limit portion size
Limit watching tv
MULTIDISCIPLINARY
INITIATIVE
GOVERNMENT
FAMILYNGOs
SOCIETY

4. GUIDE TO SELECTION OF TREATMENT

5. LIFESTYLE MANAGEMENT
• Diet therapy
Primary focus is to reduce overall calorie
consumption.
Guidelines from the National heart, Lung and
blood Institute recommend initiative
treatment with calorie deficit of 500-1000
kcal, consistent with the goal of reducing 1-2
pounds per week.

6. Recommendations of Department of Agriculture
and Dietary guidelines (US) include:
• Diet rich in whole grains, fruit, vegetables and
dietary fibres
• consuming 2 servings of fish high in omega 3 fatty
acids per week
• Decreasing sodium intake to <2300mg/day
• Consuming 3 cups of milk
• Limiting cholesterol < 300 mg/day
• Total fat 20-35 % of daily calories
• Saturated fat < 10 %

7. Institute of medicine
recommendations:
• Carbohydrate- 45-60%
• Fat - 20-35 %
• Proteins – 10-35%
• Fibre - 38g (men), 25g (women) in age > 50
years;
30 g (men), 21g (women) in age < 50 years

8. TYPES OF DIET PLANS
• ATKINS DIET – LOW CARBOHYDRATES
CONSUMPTION AS DEVISED BY AMERICAN
CARDIOLOGIST DR.ROBERT ATKINS.
• TWO TYPES – ATKIN 20(STARTS WITH 20G
CARBOHYDRATE) AND ATKIN 40 (STARTS
WITH 40 G CARBOHYDRATES)
• 4 PHASES – INDUCTION,BALANCING,FINE
TUNING AND LIFE TIME MAINTENANCE

9. OTHER DIET PLANS
• ZONE DIET – 40 % carbohydrates ( non refined) 30 %
proteins and 30 % fats)
• MEDITERRANEAN DIET - based primarily on the eating
habits of southern European countries, with an emphasis
on plant foods, olive oil, fish, poultry, beans, and grains.
• SOUTH BEACH DIET- started by a cardiologist, Dr. Agatston,
and a nutritionist, Marie Almon. It focuses on the control of
insulin levels, and the benefits of unrefined slow
carbohydrates versus fast carbohydrates.

10. Concept of energy density
• It refers to the number of calories a food
contains per unit of weight
• Adding water or fibre to a food decreases its
energy density by increasing weight without
affecting calorie content.

11. Very low calorie diets
• Form of aggressive dietary therapy- aimed at
promoting rapid and significant (13-23kg).
• Short term weight loss over 3-6 month period
(consumption of <800 kcal/day)
• 50-80 g of protein per day
• 100 % of recommended daily intake for
vitamin and minerals

12. INDICATIONS
• well motivated individuals who are moderate
to severely obese (BMI>30) who have failed at
more conservative approaches to weight loss
• Underlying medical condition that would be
immediately improved with rapid weight loss
eg. type 2 DM, OSA

13. PHYSICAL ACTIVITY
• Most important role of exercise is in
maintenance of weight loss
• Physical activity guidelines for Americans
recommend 150 minute of moderate intensity
or 75 minute a week of vigorous intensity
aerobic physical exercise
• Performed in episodes of at least 10 minutes
and spread throughout the week

14. BEHAVIORAL THERAPY
• Cognitive behavioral therapy- to change and
re -inforce new dietary and physical activity
and behaviors eg. Self monitoring techniques,
stress management, stimulus controls, social
support, problem solving and cognitive
restructuring

15. PHARMACOTHERAPY
• Considered for patients with BMI >= 30;
BMI >= 27 if associated with co-morbidities
A) Appetite suppressants (Anorexiants)
Primarily targeted 3 mono amine receptor systems
in the hypothalamus i.e nor-adrenergic,
serotonergic and dopaminergic
A) Gastro intestinal fat blockers
Reduces absorption of selective macro nutrients

16. Centrally acting anoxeriant medication
- ventromedial
and lateral
hypothalamic
regions
Target
site

17. Drug Mechanism of action Dose Side effect
PHENTERAMINE
BENZPHETAMINE
NOR ADRENERGIC
SYMPATHOMIMETIC
VARIABLE INCREASED HEART
RATE, BP,
INSOMNIA, DRY
MOUTH,
CONSTIPATION,REST
LESSNESS,ABUSE
POTENTIAL
PHENTARAMINE –
TOPIRAMATE
NOR ADRENALINE
RELEASER AND ANTI
CONVULSANT(Y-
AMINOBUTYRIC
RECEPTORS,INHIBITIO
N OF CARBONIC
ANHYDRASE
INHIBITORS,GLUTAMA
TE ANTAGONISM)
INITIAL : 3.75 MG
PHENTERAMINE/23
MG TOPIRAMATE OD
X14 DAYS
7.5 MG /46 MG OD X
12 WEEKS
11.25 MG /69 MG OD
X 14 DAYS
DRY MOUTH ,TASTE
DISTURBANCES,PAR
EST-
HESIAS,DEPRESSION
,
ANXIETY,ELEVATED
HEART
RATE,COGNITIVE
IMPAIRMENT,INSO
MN-IA

18. DRUG MECHANISM OF
ACTION
DOSE SIDE EFFECT
LORCASERINE SEROTONIN 2C
AGONIST
15 TIMES
SELECTIVE1
10 MG BD HEADACHE
DIZZINESS NAUSEA
DRY MOUTH
CONSTIPATION
INSOMNIA
SIBUTRAMINE SEROTONIN
NORADRENALINE
REUPTAKE
INHIBITOR
NOT APPROVED INCREASED RISK OF
MI AND STROKE
BUPROPION AND
NALTREXONE
NORADRENALINE
DOPAMINE
REUPTAKE
INHIBITOR AND
OPIOD ANTAGONIST
1 TAB (8MG
N/90MG B)
DOSE ESCALATION
WEEKLY
MAX 32MG
N/360MG B
NAUSEA
CONSTIPATION
HEADACHE
VOMITING
DIZZINESS

19. DRUG MECHANISM OF
ACTION
DOSE SIDE EFFECT
RIMONABANT CB1 RECEPTOR
ANTAGONIST
NOT APPROVED DEPRESSION
ANXIETY
SUICIDAL
TENDENCY
LIRAGLUTIDE GLP-1 AGONIST
ACTION ON
HYPOTHALAMUS
START WITH 0.6 MG
SC F/B WEEKLY
ESCALATION TILL 3
MG DAILY
NAUSEA VOMITING
DIARRHEA
CONSTIPATION
ANOREXIA
RARELY:
PANCREATITIS
,SUICIDAL
THOUGHTS
ORLISTAT REVERSIBLE
INHIBITOR OF
GASTRIC
PANCREATIC AND
CARBOXYL ESTER
LIPASE AND PLA2
120 MG TID WITH
FAT-CONTAINING
MEAL
CRAMPS
FLATULENCE FECAL
INCONTINENCE
OILY SPOTTING FAT
SOLUBLE VITAMIN
DEFICIENCY

20. SURGICAL MANAGEMENT

21. • INDICATIONS
• THE NATIONAL INSTITUTE OF HEALTH
CRITERIA OF 1991 :
• BMI >= 40 KG/M2 ( > 37 IN INDIA,JAPI 2011)
• BMI >= 35 KG/M2 ASSOCIATED WITH SERIOUS
MEDICAL CONDITIONS ( > 32.5 IN INDIA,JAPI
2011)

22. DIABESITY : A UNIQUE INDIAN
CHALLENGE
• COMBINED PREVALENCE OF DIABETES
MELLITUS AND OBESITY WIDELY IN INDIA HAS
BEEN TERMED AS DIABESITY
• BARITRIC SURGERY HAS BEEN A PART OF
RECENT ALGORITHM TO TREAT DIABESITY

23. BARIATRIC TO METABOLIC SURGERY-
A REVOLUTION
• A PROCEDURE WHERE A ANATOMIC CHANGE
INDUCES A PHYSIOLOGICAL CHANGE IS A
METABOLIC SURGERY
• BARIATRIC PROCEDURES HAVE RESULTED IN
EUGLYCEMIA IN PATIENTS WITH TYPE 2 DM
IMMEDIATELY AND RAPIDLY IN POST
OPERATIVE PERIOD WITHOUT SIGNIFICANT
WEIGHT LOSS

24. HISTORY

25. TYPES OF BARIATRIC SURGERY
• RESTRICTIVE SURGERY – LIMIT THE AMOUNT OF FOOD
THE STOMACH CAN HOLD AND SLOW RATE OF GASTRIC
EMPTYING …EG – LAPARASCOPIC ADJUSTABLE GASTRIC
BANDING , LAPARASCOPIC SLEEVE GASTRECTOMY
• RESTRICTIVE AND MALABSORPTIVE-LIMIT ABSORPTION
OF NUTRIENTS ALSO…..EG ROUX –EN – Y , BILIO-
PANCREATIC DIVERSION WITH DUODENAL SWITCH
• MALABSORPTIVE - EG BILIO PANCREATIC DIVERSION

26. LAPARASCOPIC ADJUSTABLE GASTRIC BANDING
LAP -BAND ( APPROVED ON 2001) AND REALIZE
BAND ( APPROVED IN 2007 )

27. LAPARASCOPIC SLEEVE GASTRECTOMY

28. BILIOPANCREATIC DIVERSION WITH
DUODENAL SWITCH

29. BILIOPANCREATIC DIVERSION

30. ROUX – EN –Y
• MOST COMMONLY UNDERTAKEN AND MOST
ACCEPTED BYPASS PROCEDURE.

31. MECHANISMS
• CALORIC RESTRICTION
• MALABSORPTION
• HORMONAL ACTIONS –
• REDUCTION IN GHRELIN
• INCREASE IN INCRETINS – GLUCAGON LIKE
PEPTIDE 1 AND PYY 3-36 (BOTH INCREASED AS
FOOD REACHES ILEUM EARLY, REDUCE
APPETITE )

33. BIBLIOGRAPHY
• HARRISON’S PRINCIPLES OF INTERNAL
MEDICINE 19TH EDITION
• MEDICINE UPDATE 2016-1 VOLUME 2
• OBESITY,BY NICK TOWNSEND AND ANGELA
SCRIVEN
• THE METABOLIC SYNDROME BY CHFISTOPHER
D.BRYNE AND SARAH H.WILD
• THE WEB (FOR IMAGES AND ILLUSTRATIONS)