2. Obesity: a ticking time bomb
 Obesity is a substantial public health crisis with prevalence increasing in an
alarming way.
 The obesity rate in the UAE is double the world average, according to a disease
study report.
 WHO: More than 2.1 billion people – close to 30 % of the global population – are
overweight or obese
 A study by the research company McKinsey Global Institute, Overcoming Obesity:
an Initial Economic Analysis, published in November, predicts that almost half of the
world’s adult population could be overweight or obese by 2030.
 However, according to a report entitled the Global Burden of Disease Study 2013, by
the University of Washington’s Institute for Health Metrics and Evaluation, more
than 66 per cent of men and 60 per cent of women in the UAE are already overweight
or obese.
 The economic burden of obesity in UAE is US$6 billion [Dh22bn] annually.”
 obesity is costing the world $2 trillion a year!!!!
The National UAE, report 18 February 2015

3.  Data from the International Diabetes Federation to mark World Diabetes Day in
November 2014 showed that there were 803,900 diabetics in the UAE, about 19 per
cent of the population
 Dr Mohammed Farghaly, head of insurance medical regulation at the Dubai Health
Authority, estimated that 1.8 million people could suffer from diabetes in the UAE
within a few years.
 “Diabetes is considered a major health issue in our community now, and the
prevalence of diabetic people is increasing, which urges us to raise awareness about
this disease.”
 People must be aware that the disease can be avoided by losing weight, doing more
exercise and eating a better diet
The National UAE, report 18 February 2015
Obesity: a ticking time bomb

4. What Causes Overweight and Obesity?
Lack of Energy Balance
 To maintain a healthy weight, your energy IN and OUT don't have to balance
exactly every day. It's the balance over time that helps you maintain a healthy
weight.
An Inactive Lifestyle
 In fact, more than 2 hours a day of regular TV viewing time has been linked to
overweight and obesity.
 Other reasons for not being active include: relying on cars instead of walking,
fewer physical demands at work or at home because of modern technology and
conveniences.
National institutes of health, National heart
lung and Blood institutes

5. What causes overweight and obesity?
Environment
 Our environment doesn't support healthy lifestyle habits; in fact, it encourages
obesity. Some reasons include:
 Lack of neighborhood sidewalks.
 Work schedules.
 Lack of access to healthy foods.
 Food advertising. People are surrounded by ads from food companies. Often
children are the targets of advertising for high-calorie, high-fat snacks and sugary
drinks. The goal of these ads is to sway people to buy these high-calorie foods, and
often they do.
National institutes of health, National heart
lung and Blood institutes

6. What Causes Overweight and Obesity?
Family History
 Children adopt the habits of their parents. A child who has overweight parents who
eat high-calorie foods and are inactive will likely become overweight too. However,
if the family adopts healthy food and physical activity habits, the child's chance of
being overweight or obese is reduced.
National institutes of health, National heart
lung and Blood institutes

7. Could obesity be related to genetics?
 Since 2007 scientists have known that a gene named FTO was related to obesity
and people with higher Body Mass Index have been found to carry a variant of this
gene.
 Now, researchers at MIT and Harvard Medical School believe they have discovered
that a faulty version of this gene causes energy from food to become stored as fat in
the body rather than be burned, contributing to obesity.
 In the study, published in the New England Journal of Medicine, scientists took cell
samples from Europeans with either a healthy or faulty version of the FTO gene.
 The findings showed that the faulty FTO gene ‘switched on’ two other genes –
IRX3 and IRX5 – which have been identified as the “master controllers” of
thermogenesis as they can prevent the process in which energy is turned into heat,
meaning it is instead stored as fat.
New England Journal of Medicine august
24, 2015

8. What Causes Overweight and Obesity?
Health Conditions
 hypothyroidism, Cushing's syndrome, and polycystic ovarian syndrome (PCOS).
Medicines
 corticosteroids, antidepressants, and seizure medicines.
 These medicines can slow the rate at which your body burns calories, increase your
appetite, or cause your body to hold on to extra water.
Emotional Factors
 Some people eat more than usual when they're bored, angry, or stressed.
Smoking
 Some people gain weight when they stop smoking. One reason is that food often
tastes and smells better after quitting smoking.
 Another reason is because nicotine raises the rate at which your body burns
calories, so you burn fewer calories when you stop smoking. However, smoking is a
serious health risk, and quitting is more important than possible weight gain.
National institutes of health, National heart
lung and Blood institutes

9. What Causes Overweight and Obesity?
Age
 As you get older, you tend to lose muscle, especially if you're less active. Muscle loss
can slow down the rate at which your body burns calories.
 Midlife weight gain in women is mainly due to aging and lifestyle, but menopause also
plays a role. Many women gain about 5 pounds during menopause and have more fat
around the waist than they did before.
Pregnancy
 women gain weight to support their babies’ growth and development. After giving birth,
some women find it hard to lose weight.
Lack of Sleep
 Sleep helps maintain a healthy balance of the hormones that make you feel hungry
(ghrelin) or full (leptin). When you don't get enough sleep, your level of ghrelin goes up
and your level of leptin goes down. This makes you feel hungrier than when you're well-
rested.
 Sleep also affects how your body reacts to insulin. Lack of sleep results in a higher than
normal blood sugar level, which may increase your risk for diabetes.
National institutes of health, National heart
lung and Blood institutes

10. Endocrine society guidelines
 In January, 2015, the Endocrine Society released new guidelines on the treatment of
obesity to include the following:
 Diet, exercise, and behavioral modification should be included in all obesity
management approaches for body mass index (BMI) of 25 kg/m 2 or higher. Other
tools, such as pharmacotherapy for BMI of 27 kg/m 2 or higher with comorbidity or
BMI over 30 kg/m2 and bariatric surgery for BMI of 35 kg/m 2with comorbidity or
BMI over 40 kg/m 2.
 Drugs may amplify adherence to behavior change and may improve physical
functioning such that increased physical activity is easier in those who cannot
exercise initially. Patients who have a history of being unable to successfully lose
and maintain weight and who meet label indications are candidates for weight loss
medications.
Tucker ME. New US obesity guidelines. Treat the weight first. Medscape Medical News. Available at
http://www.medscape.com/viewarticle/838285.
Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J Clin
Endocrinol Metab. 2015 Feb. 100(2):342-62

11. Endocrine society guidelines
 To promote long-term weight maintenance, the use of approved
weight loss medication is suggested to ameliorate comorbidities and
amplify adherence to behavior changes, which may improve
physical functioning and allow for greater physical activity in
individuals with a BMI of 30 kg/m 2 or higher or in individuals with
a BMI of 27 kg/m 2 and at least one associated comorbid medical
condition (hypertension, dyslipidemia, type 2 diabetes mellitus, and
obstructive sleep apnea).
 If a patient's response to a weight loss medication is deemed
effective (weight loss of 5% or more of body weight at 3 mo) and
safe, it is recommended that the medication be continued. If deemed
ineffective (weight loss less than 5% at 3 mo) or if there are safety
or tolerability issues at any time, it is recommended that the
medication be discontinued and alternative medications or referral
for alternative treatment approaches be considered.
Tucker ME. New US obesity guidelines. Treat the weight first. Medscape Medical News. Available at
http://www.medscape.com/viewarticle/838285.
Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J
Clin Endocrinol Metab. 2015 Feb. 100(2):342-62

12. Endocrine society guidelines
 In patients with type 2 diabetes who are overweight or obese,
antidiabetic medications that have additional actions to
promote weight loss (such as glucagon-like peptide-1 [GLP-1]
analogs or sodium-glucose-linked transporter-2 [SGLT-2]
inhibitors) are suggested, in addition to the first-line agent for
type 2 diabetes mellitus and obesity, metformin.
 In obese patients with type 2 diabetes mellitus who require
insulin therapy, at least one of the following is suggested:
metformin, pramlintide, or GLP-1 agonists to mitigate
associated weight gain due to insulin.
 Angiotensin-converting enzyme (ACE) inhibitors, angiotensin
receptor blockers (ARBs), and calcium channel blockers,
rather than beta-adrenergic blockers, should be considered as
first-line therapy for hypertension in patients with type 2
diabetes mellitus who are obese.
Tucker ME. New US obesity guidelines. Treat the weight first. Medscape Medical News. Available at
http://www.medscape.com/viewarticle/838285.
Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J Clin
Endocrinol Metab. 2015 Feb. 100(2):342-62

13. WHO classification
The most widely accepted classifications are those from the World Health
organization based on BMI:
o Grade 1 overweight (commonly and simply called overweight) - BMI of 25-
29.9 kg/m 2
o Grade 2 overweight (commonly called obesity) - BMI of 30-39.9 kg/m 2
o Grade 3 overweight (commonly called severe or morbid obesity) - BMI ≥40
kg/m 2
Some authorities advocate a definition of obesity based on percentage of body
fat, as follows:
o Men - Percentage of body fat greater than 25%, with 21-25% being
borderline
o Women - Percentage of body fat great than 33%, with 31-33% being
borderline

14. Obesity related comorbidities
The clinician should also determine whether the patient has had any of the
comorbidities related to obesity, including the following :
Respiratory - Obstructive sleep apnea, respiratory infections, increased incidence of
bronchial asthma, and Pickwickian syndrome (obesity hypoventilation syndrome)
Malignant - Association with endometrial, prostate, colon, breast, gall bladder, and
possibly lung cancer
Psychological - Social stigmatization and depression
Cardiovascular - Coronary artery disease, essential hypertension, left ventricular
hypertrophy, cardiomyopathy, accelerated atherosclerosis, and pulmonary
hypertension of obesity
Jiao L, Berrington de Gonzalez A, Hartge P, Pfeiffer RM, Park Y, Freedman DM, et al. Body mass index, effect modifiers, and risk of pancreatic
cancer: a pooled study of seven prospective cohorts. Cancer Causes Control. 2010 Aug. 21(8):1305-14
Wijga AH, Scholtens S, Bemelmans WJ, de Jongste JC, Kerkhof M, Schipper M, et al. Comorbidities of obesity in school children: a cross-sectional
study in the PIAMA birth cohort. BMC Public Health. 2010 Apr 9. 10:184
Li C, Ford ES, Zhao G, Croft JB, Balluz LS, Mokdad AH. Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in
men and women: National Health and Nutrition Examination Survey, 2005-2006.

15. Obesity related comorbidities
Central nervous system (CNS) - Stroke, idiopathic intracranial hypertension, and
meralgia paresthetica
Obstetric and perinatal - Pregnancy-related hypertension, fetal macrosomia, and
pelvic dystocia
Surgical - Increased surgical risk and postoperative complications, including wound
infection, postoperative pneumonia, deep venous thrombosis, and pulmonary
embolism
Pelvic - Stress incontinence
Gastrointestinal (GI) - Gall bladder disease (cholecystitis, cholelithiasis),
nonalcoholic steatohepatitis (NASH), fatty liver infiltration, and reflux esophagitis
Orthopedic - Osteoarthritis, coxa vera, slipped capital femoral epiphyses, Blount
disease and Legg-Calvé-Perthes disease, and chronic lumbago
Metabolic - Type 2 diabetes mellitus, prediabetes, metabolic syndrome, and
dyslipidemia
Reproductive (in women) - Anovulation, early puberty, infertility,
hyperandrogenism, and polycystic ovaries
Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr. 2000
May.

16. Obesity related comorbidities
Reproductive (in men) - Hypogonadotropic hypogonadism
Cutaneous - Intertrigo (bacterial and/or fungal), acanthosis nigricans, hirsutism, and
increased risk for cellulitis and carbuncles
Extremity - Venous varicosities, lower extremity venous and/or lymphatic edema
Miscellaneous - Reduced mobility and difficulty maintaining personal hygiene

17. Management
Treatment of obesity starts with comprehensive lifestyle management (diet,
physical activity, behavior modification).The 3 major phases of any successful
weight-loss program are as follows:
A. Preinclusion screening phase
B. Weight-loss phase
C. Maintenance phase - This can conceivably last for the rest of the patient's life but
ideally lasts for at least 1 year after the weight-loss program has been completed
Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification for obesity: new developments in diet,
physical activity, and behavior therapy. Circulation. 2012 Mar 6

18. Medications
i. Centrally acting medications that impair dietary intake
ii. Medications that act peripherally to impair dietary absorption
iii. Medications that increase energy expenditure

19. Surgery
• Among the standard bariatric procedures are the following:
• Roux-en-Y gastric bypass
• Adjustable gastric banding
• Gastric sleeve surgery
• Vertical sleeve gastrectomy
• Horizontal gastroplasty
• Vertical-banded gastroplasty
• Duodenal-switch procedures
• Biliopancreatic bypass
• Biliopancreatic diversion

20. FDA approved medication
• The only medication approved by the US Food
and Drug Administration (FDA) in UAE for
long-term management of obesity is orlistat
(XENICAL)

21. What is XENICAL?
• XENICAL therapeutic category: gastrointestinal lipase inhibitor
• Indicated in conjunction with a mildly hypo caloric diet for
treatment of obese patients with a BMI ≥ 30 kg/m², or
overweight patients (BMI > 28 kg/m²) with associated risk
factors.
• It is used to loose weight and maintain weight loss
Xenical Summary of Product Characteristics

22. Mode of Action of XENICAL
• Xenical binds to the lipase enzyme in the stomach and
intestine and inhibits its action
• Prevents the absorption of dietary fat by 30%
• Undigested fat is eliminated in the faeces.
Xenical US Prescribing Information

23. Acts Non Systemically
Xenical Summary of Product Characteristics

24. Contraindications:
- Hypersensitivity to the active substance or to
any of the excipients.
- Chronic malabsorption syndrome.
- Cholestasis
- Breast-feeding

25. Dosage and Administration:
Recommended dose of XENICAL is one capsule, 3  daily taken with water
immediately before or with each main meal or up to 1 hour after the meal
If a meal is missed or contains no fat, the dose should be skipped.
Orlistat may reduce absorption of some fat-soluble vitamins (A, D, E, K) and
beta carotene. Administer a multivitamin supplement containing fat-soluble
vitamins orally daily, 2 hours before or 1 hour after a meal
In order to ensure adequate vitamins intake, patients following a diet should
be advised to have a diet rich in fruits or vegetables.
Xenical capsules should be stored below 250C.
Xenical Summary of Product Characteristics

26. If tolerability is an issue!
At the full dose of 120 mg 3 times daily, XENICAL is frequently associated with
such adverse GI events as flatulence, oily stool, diarrhea, and stool incontinence.
Frequently, these adverse events result from the common misconception that
because orlistat blocks fat absorption, people can consume more fat. It is important
to advise patients to reduce total fat intake while on orlistat to reduce the frequency
and severity of adverse events.

27. XENICAL Drugs interactions
If patient receiving cyclosporine, administer cyclosporine 3 hr after orlistat
For patients receiving levothyroxine, administer orlistat 4 hr apart
In particular, patients on warfarin need closer monitoring because of the potential
for malabsorption of vitamin K.

28. Efficacy of XENICAL:
Xenical can reduce 5% to 10% of the body weight when accompanied with lifestyle
modification.
Studies have also shown its efficacy among the adolescent age group (12-16 years)
with no major safety issues (except common GI adverse events).
1. Xenical Summary of Product Characteristics
2. Chanoine JP et al. Effect of Orlistat on weight and body composition in obese adolescents. JAMA. 2005;293:2873-2883

29. Eat less fat

30. Reduce meal portion size

31. Increase physical activity

33. Xenical + lifestyle modification resulted in statistically superior
weight loss both in short and long term
-10.6
-6.2 -5.8
-3
-12
-10
-8
-6
-4
-2
0
1 year 4 years
Xenical +diet
Placebo +diet
LSMweightloss(kg)
LSM: lean squares mean
p<0.001 p<0.001
Torgerson JS, et al. Diabetes Care 2004; 27(1):155–61.
XENDOS study

34. Xenical plus diet produces significantly more weight loss than
diet alone in obese diabetic patients
49
23
18
9
0
10
20
30
40
50
≥ 5% Weight Loss ≥ 10% Weight Loss
Xenical 120mg
tid (n=139)
Placebo
Percentage of patients with type II diabetes mellitus who had lost ≥5%
and ≥ 10 % of initial body weight at 1 year
%ofPatients
p<0.001 p=0.017
Hollander et al. Diabetes Care 1998;21; 1288-1294
Better management of
obese type II diabetes

35. Xenical reduces Total Cholesterol and LDL-C
levels
-11.9
-4
-17.6
-7.6
-20
-15
-10
-5
0
Total Cholesterol LDL cholesterol
Xenical +diet
Placebo +diet
MeanChange(%)
p<0.001 p<0.001
Muls E et al .Int J Obes Relat Metab Disor 2001;25(11): 1713-21

36. Safety Profile:
 Because the drug is not systemically absorbed, most adverse effects are limited to
the gastrointestinal tract.
 Most commonly reported adverse events are GI symptoms : fatty and oily stools
 Generally mild, transient side effects and decrease with time.
 GI events linked to high fat intake.
Xenical Summary of Product Characteristics

37. Take home message!
 Xenical can be used to loose weight in patients with risk factors such as type 2
DM, hypertension and hyperlipidemia.
 It can be used to maintain weight loss.
 Xenical has a well characterized safety profile.

38. We are sitting on a ticking time bomb, our
world is ready to ignite!! Let us ignite it with
awareness and save our patients.

39. Prepared by: Heba Abou Diab
Clinical pharmacist
Marketing specialist