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  1. 1. OBESITY 1
  2. 2. Definition• A BMI of 25.0 to 29.9 kg per m2 is defined as overweight; a BMI of 30.0 kg per m2 or more is defined as obesity. 2
  3. 3. Historical PerspectivePaleolithic Era > 25,000 years ago 3
  4. 4. Obesity - How Big A Problem…• 1.7 billion worldwide are overweight or obese• The US has the highest percentage of obese people.• By 2006, only four states had a prevalence of obesity less than 20%. And the numbers are growing… 4
  5. 5. Epidemiology of Obesity• 31.3% of U.S. males• 34.7% of U.S. females• 30% increase in the last 10 years• Health care costs - >$100 billion/year• Results in 300,000 preventable deaths each year in the U.S. 5
  6. 6. Obesity and Life Expectancy• If current rates of obesity are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents.Olshansky SJ, et al. A Potential Decline in Life Expectancyin the United States in the 21st Century. NEJM, 352(11):1138- 1145, 2005 6
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  9. 9. Classification of Overweight and Obesity• BMI Classification <18.5 Underweight – 18.5-24.9 Normal weight – 25-29.9 Overweight – 30-34.9 Obesity Class I – 35-39.9 Obesity Class II – 40-49.9 Obesity Class III – 50 and aboveSuper Obesity 9
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  11. 11. What causes Obesity?• Nutrient and Energy model of obesity: Metabolism Appetite regulation Energy expenditureGeneticsBehavioral and cultural factors 11
  12. 12. Contributors to weight gain• Socio-economic status• Smoking cessation• Hormonal• Inactivity• Psychosocial/emotions• Medications 12
  13. 13. Nutrient and Energy Model of ObesityObesity results from increased intake of energy or decreased expenditure of energy, as required by the first law of thermodynamics. Energy Energy Intake Expenditure Adipose tissue 13
  14. 14. Why is it so hard to lose weight? External factors Brain Emotions Food characteristics Central Signals Lifestyle behaviors Stimulate Inibit Environmental cues NPY Orexin-A α-MSH CART AGRP dynorphin CRH/UCN NE galanin GLP-I 5-HTPeripheral signals Peripheral organs Glucose Gastrointestinal CCK, GLP-1, tract− Apo-A-IV Vagal afferents Food Insulin Intake+ Ghrelin Adipose− Leptin tissue+ Cortisol Adrenal glands 14
  15. 15. Leptin• Protein hormone produced by fat cells.• Experiment: Leptin deficient mice: Hyperphasic Insulin resistant Infertile Leptin administration reversed all the symptoms. 15
  16. 16. Medical Complications of ObesityPulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome Stroke Cataracts CHDNonalcoholic fatty liver disease Diabetessteatosis Dyslipidemiasteatohepatitis Hypertensioncirrhosis Severe pancreatitis Gall bladder disease Cancer Gynecologic abnormalities breast, uterus, cervix abnormal menses colon, esophagus, pancreas kidney, prostate infertility Osteoarthritis PCOS Phlebitis venous stasis Gout 16
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  18. 18. Consequences of ObesityHippocratesrecognized that :“sudden death is more common in those who are naturally fat than in lean.” 18
  19. 19. Treating Obesity• Measure height and weight (BMI)• Calculate waist circumference• Assess comorbidities• What labs does the patient need?• Is the patient ready and motivated enough to loose weight?• Which diet should you recommend?• Discuss a physical activity goal 19
  20. 20. Weight Loss Strategies• Diet therapy• Increased Physical Activity• Pharmacotherapy• Behavioral Therapy• Surgery• Any combination of the above 20
  21. 21. Rate Of Weight Loss• A realistic goal is from 5% to 15% from baseline in 6 months of obesity treatment.• Weight should be lost at the rate of 1-2 lbs per week, based on the caloric deficit between 500-1000 Kcal/day. 21
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  23. 23. Dieting• Dieting is highly ineffective - 95% long term failure rate• Often results in higher weight than before the diet 23
  24. 24. Principles Of Dieting• Women should consume atleast 1200 kcal/day, men 1500 kcal/day.• Select a diet that has: >75g/day proteins (15% of total calories) > 55% total calories from carbs▪ Fat should contribute 30% or less of total caloriesAtleast 3 meals/day.High fiber (20-30g/day), fruits and vegetables.Supplement the diet with multivitamis and minerals.Avoid sugar containing beverages and fat spreads. 24
  25. 25. What about all the diets that are out there?• Weight Watchers ($13 registration fee, $15 weekly fee)• Jenny Craig (consultation $200-370, $65 meals/week)• Tops Club ($20/week)• ($50/week)• Atkins Diet 25
  26. 26. MedicationsA) Serotonin Nor-epinephrine Reuptake Inhibitor: reduces food intake. Sibutramine: initial dose 10mg/day, max 20mg/day.B) Orlistat: Lipase inhibitor. Alters metabolism, dec absorption of dietary fat. 120mg PO TID 27
  27. 27. Surgery• Roux-en-Y gastric bypass.• Lap band procedureCriteria: a) BMI > 40 or >35 with 2 comorbidities. b) Failure of non surgical methods c) Presence of 2 or more medical conditions that would benefit with weight loss. 29
  28. 28. Obesity warning on London busesThe United Kingdom Branch of the International Size Acceptance Associationis encouraging the public to contact World Cancer Research Fund UK tovoice their concerns about this discriminating ad campaign. 32
  29. 29. ICD 9 Codes• Obesity: 278• Morbid Obesity: 278.01• Overweight: 278.02 33
  30. 30. Questions??