Obesity is an emerging pandemic. Obesity is the root cause of many non communicable diseases like Diabetes , Hypertension, CAD. The younger generation are affected by obesity and leading to morbidity and mortality

1. DR B.RAJASEKHAR
CONSULTANT NEPHROLOGIST
ADITYA MULTISPECIALITY HOSPITAL

2. Obesity

5. Definition
• Obesity is an abnormal growth of the adipose
tissue due to an enlargement of fat cell size
(hypertrophic obesity) or an increase in fat cell
number (hyperplasic obesity)or a combination of
both.
• Obesity is an abnormal increase in the proportion
of fat cells characterized predominantly by
adipocyte hypertrophy.

6. Table 2.0: Estimated global prevalence and numbers of people with
obesity and severe obesity in 2010, 2020, 2025 and 2030
Obesity prevalence defined by BMI 2010 2020 2025 2030
% n % n % n % n
Women
Obesity (Class I, II and III) ≥30kg/m2
14 304m 17 445m 18 512m 20 586m
Severe obesity (Class II and III) ≥35kg/m2
4 100m 6 159m 7 188m 7 219m
Severe obesity (Class III) ≥40kg/m2
1 32m 2 54m 2 65m 3 77m
Men
Obesity (Class I, II and III) ≥30kg/m2
9 207m 13 324m 14 380m 15 439m
Severe obesity (Class II and III) ≥35kg/m2
2 44m 3 79m 3 96m 4 114m
Severe obesity (Class III) ≥40kg/m2
0.5 11m 1 22m 1 28m 1 34m
All adults
Obesity (Class I, II and III) ≥30kg/m2
11 511m 15 764m 16 892m 18 1,025m
Severe obesity (Class II and III) ≥35kg/m2
3 143m 5 238m 5 284m 6 333m
Severe obesity (Class III) ≥40kg/m2
1 42m 2 77m 2 93m 2 111m

7. Table 3.0: Estimated global DALYs and deaths in
2019 attributed to high BMI, and as a proportion
of all preventable NCDs
Global DALYs Global deaths
Attributed to high
BMI
N = 160m,
equivalent to
2,070 per
100,000
N = 5m
equivalent to 64
per 100,000
Proportion of all
preventable
NCDs
21.5% 18.0%

8. Table 3.6: NCD DALYs per 100,000 that result from BMI in
the South East Asian region
Country DALYs per 100,000
population
Indonesia 2,701
Sri Lanka 2,443
Thailand 2,311
Myanmar 2,038
India 1,511
Bhutan 1,409
Nepal 1,079
Bangladesh 1,031
Maldives 964
Timor-Leste 680

9. Table 5.0: Obesity prevalence and numbers amongst children aged
5-9 years and 10-19 years in 2020 and 2030, by WHO region
Children 5-9y 2020 2020 2030 2030
% No. % No.
AFR 5% 7m 9% 16m
AMR 19% 14mm 23% 17m
EMR 12% 10m 15% 13m
EUR 13% 7m 16% 9m
SEA 6% 10m 12% 20m
WPR 18% 22m 27% 29m
World 11% 71m 15% 103m
Children 10-
19y
2020 2020 2030 2030
% No. % No.
AFR 3% 8m 6% 20m
AMR 15% 22m 19% 27m
EMR 8% 12m 13% 22m
EUR 8% 9m 11% 13m
SEA 3% 12m 8% 25m
WPR 10% 24m 18% 43m
World 7% 86m 11% 150m

10. Table 5.7: 2030 projections for child obesity (5-19 years) in
South East Asia
Country Prevalence 2030
Thailand 22%
Maldives 18%
Indonesia 14%
Sri Lanka 13%
Timor-Leste 12%
Myanmar 11%
Bhutan 10%
Bangladesh 8%
India 8%
Nepal 6%

11. Etiology
• Age
▫ Can occur at any age.
• Sex
▫ Women are more likely to gain weight than men
with the same calorie intake.
▫ Menopause contribute in weight gain.
▫ Pregnancy also contribute to the development of
obesity in women

12. • Genetic
▫ Family history
• Biologic Basis
▫ Change in regulation of eating behavior, energy
metabolism, body fat metabolism by hypothalamus.
▫ Increased circulating plasma levels of leptin, insulin,
and ghrelin, and decreased levels of peptide YY.
▫ Interaction of these hormones and peptides at the
level of the hypothalamus.
▫ Alterations of adipokines (hormones secreted by
adipocytes and cytokines)
 Decreased level of Adiponectin
 Increased level of Resistin

13. • Environmental Factors
▫ Greater access to pre-packed food, fast food and soft
drinks.
▫ Increased portion size of meals
▫ Eating outside home
▫ Lack of physical exercise
▫ Low Socioeconomic status
▫ Lack of sleep
• Psychosocial Factors
▫ Tendency to overeat
▫ Social gatherings or parties
• Eating Habits
▫ Excessive calorie intake
• Alcoholism
• Smoking

14. • Drugs
▫ Corticosteroids
▫ Contraceptives
▫ Insulin
▫ Beta-adrenergic blockers
▫ Antidepressants
▫ Anti-seizure drugs
▫ Antipsychotic drugs
• Disorders
▫ Endocrine disorders
▫ Congenital anomalies
▫ Metabolic problems
▫ Chromosomal anomalies
▫ CNS disorders.

15. Pathophysiology
Long-term sedentary lifestyle and/or excessive calorie intake
Imbalance between energy expenditure & energy intake
Adipocyte hypertrophy
Increases adipocyte volume & increases lipid storage
Visceral and subcutaneous fat accumulation
Alterations of adipokines
Overweight or Obesity
Increases risk for diseases

16. Measurements of obesity
• Height-weight chart
• Body mass index (BMI)
• Waist circumference
• Waist-to-hip ratio
• Skinfold Thickness

17. • Height-weight chart:
▫ Weight 10% to 20% above ideal body weight is
overweight;
▫ 20% or more above ideal body weight is obesity.
▫ Ideal weight calculation
1. Broca’s index = Height (cms) – 100
2. Corpulence index =
This should not exceed 1.2
3. Ponderal index = Height (cm)
3
weight (kg)
4. Lorentz’s formula
= [Height (cm) – 100] – Height (cm) – 150
2(women) or 4(men)
Actual weight
Desirable weight

18. • Body mass index (BMI):
▫ Best methods for defining obesity.
▫ BMI = Weight (kg)/Height (m2)
• Below 18.5
• 18.5–24.9
• 25.0–29.9
• 30.0-34.9
• 35.0-39.9
• ≥ 40.0
Underweight
Normal
Overweight
Obese class I
Obese Class II
Obese Class III or Morbid obesity

19. • Waist circumference:
▫ ≥102 cm in men and ≥88cm in females is
associated with an increased risk of metabolic
complications.
• Waist-to-hip ratio
▫ Preferred tool to measure for overweight and
obesity when the patient is predominantly
muscular.
▫ The waist measurement is divided by the hip
measurement to calculate the ratio.
▫ WHR of <0.80 is optimal.
▫ WHR greater than 0.8 indicates greater risk for
health complications.
▫ A high WHR (> 1.0 in men and > 0.85 in women)
indicates abdominal fat accumulation.

20. • Skinfold Thickness
▫ For assessing body fat.
▫ Several varieties of callipers
are used. (E.G., Harpenden
skin callipers)
▫ Normal finding is mid triceps
+ mid biceps + sub scapular +
supra iliac = 50mm in women
or 40 mm in men.

21. Classification of obesity
1. Primary obesity and secondary obesity
2. According to BMI
3. According to body shape or fat distribution

22. • Primary obesity
▫ Due to excess calorie intake for the body's
metabolic demands.
• Secondary obesity
▫ Due to various congenital anomalies, metabolic
problems, chromosomal anomalies, or CNS
disorders.

23. • According to BMI
▫ Individuals with a BMI
• 25.0–29.9
• 30.0-34.9
• 35.0-39.9
• ≥ 40.0
Overweight
Obese class I
Obese Class II
Obese Class III or Morbid obesity
• In the view of genetic susceptibility, Union
Ministry of Health and Family Welfare of India has
scaled down the BMI to >23 kg/m2 to be classified
as overweight.

24. Health risks associated with obesity
• Increased mortality
▫ Especially associated with visceral fat
• Type 2 Diabetes
• Hypertension
• Coronary heart disease & stroke
• Metabolic syndrome
• Cancer- Colon cancer, breast cancer in
postmenopausal women, endometrial cancer
• Gallstones
• GERD
• Asthma

25. • Osteoarthritis
• Low back pain
• Reduced fertility
• Sleep apnoea (interrupted breathing during sleep)
• Liver disease
• Kidney disease
• Pregnancy complications
▫ Gestational diabetes
▫ Pre-eclampsia
▫ Foetal defects
• Obesity reduces life expectancy by an average of 3
to 10 years according to its severity.

27. Diagnostic measures
• History collection
• Physical examination
▫ Full medical assessment
• Measurements of obesity
• Laboratory examination
▫ Fasting lipid profile
▫ Liver function tests
▫ Thyroid function tests
▫ Fasting glucose and haemoglobin A1c(HBA1c)

28. Management

29. Life style modifications
Nutritional Therapy
Physical activity
Behavior modification

30. Nutritional Therapy
• Calorie-Restricted Weight-Reduction Diet
▫ Low calorie diet
 800-1200 calories per day
▫ Very Low calorie diet
 Less than 800 calories per day

31. Healthy eating habits
• Limit total fat intake and shift fat consumption away
from saturated fats to unsaturated fats and
elimination of trans fats.
▫ Eat fat-free and low-fat dairy products, such as low-fat
yogurt, cheese, and milk.
▫ Avoid whole milk, whole-milk cheese, cream, butter,
and ice cream
▫ Avoid foods containing solid fats(vanaspati ghee,
coconut, and palm oils) such as deep fried fast foods
▫ Limit foods prepared with partially hydrogenated oils
(doughnuts, cookies, crackers, muffins and cakes).
▫ Limit use of ground beef, sausage, and processed meats.

32. • Increase consumption of fruits, vegetables, pulses,
whole grains, legumes and nuts
• Limit intake of sugar and salt.
• Eat regularly. Do not skip meals.
• Reduce fat intake by baking, or steaming foods.
Portion size
• Measure foods to determine the correct portion
size.
• Avoid oversized portions.
• Use a smaller plate, bowl, and glass.

33. Food weight
• Eat foods that are lower in calories and fat for a
given amount of food.
▫ For eg: replacing a full-fat food product that
weighs two ounces with a low-fat product that
weighs the same.
• Eat foods that contain a lot of water, such as
vegetables, fruits, and soups.
Fad diet
• Weight-loss plan that promises dramatic results.
• Typically, these diets are not healthy and don't
result in long-term weight loss.

34. Physical activity
• Regular physical exercise.
• To increase energy expenditure.
• Daily 30 minutes to 1 hour per day.

35. Behavior modification
• Changing behaviors or habits related to food and
physical activity is important for losing weight.
• Change the habits promoting weight gain such
as watching television for long hours.
• Self monitoring
▫ Keep a record of weight loss.
• Stimulus control
• Reward the success for meeting weight-loss
goals.

36. Pharmacotherapy
• Only as adjuncts to a nutritional therapy and
exercise program.
• Prescribed only when BMI is 28 kg/m 2 or more
with other weight related conditions or BMI 30
kg/m 2 or more.
• Two categories of drugs:
1) Appetite-suppressing drugs
2) Nutrient absorption blocking drugs

37. Appetite-suppressing drugs
Noradrenergic drugs
Serotonergic drugs
Mixed noradrenergic-serotonergic drugs
Noradrenergic drugs
• Reduce food intake by noradrenergic mechanism in
the CNS.
• Recommended only for short term use- less than 12
wks.
• Eg: phentemine, diethyipropol, phendimetrazine,
Benzpbetamine

38. Serotonergic drugs
• Act by either increase the release of serotonin or
decrease its uptake, thus reducing the
metabolism.
• Not currently used because of its adverse effects.
Mixed noradrenergic-serotonergic drugs
• Inhibits both serotonin and norepinephrine
uptake, thus decreases appetite.
• Eg: Sibutramine

39. Nutrient absorption blocking drugs
• Eg: Orlistat
• Inhibits the action of intestinal lipases, thus
block breakdown and absorption of fat in the
intestine.

40. Surgical management
• The field of obesity surgery is called bariatric
surgery
• Indications
▫ Morbid obesity.
▫ Gross obesity for 5 years
▫ Failure to reduce weight with other forms of
therapy
▫ Body weight 100% above ideal weight
▫ Presence of a high-risk condition that weight loss
would relieve.

41. Bariatric surgeries
Bariatric
surgeries
Vertical Banded
Gastroplasty
Restrictive
surgeries
Adjustable Gastric
Banding
Malabsorptive
surgeries
Biliopancreatic
Diversion
Biliopancreatic
Diversion with
Duodenal Switch
Combination of
malabsorptive
& restrictive
Roux-en-Y gastric
bypass

42. Restrictive surgeries
• Reduces the size of a stomach to 30 ml or less,
which causes the patient to feel full quicker.
1. Vertical Banded
Gastroplasty
• Involves partitioning the
stomach into a small
pouch in the upper portion
along the lesser curvature
of the stomach.
• This small pouch
drastically limits capacity.

43. 2. Adjustable Gastric
Banding
• Stomach size is limited by an
inflatable band placed around
the fundus of the stomach.
• Referred to as LapBand B.
• The band is connected to a
subcutaneous port and can be
inflated or deflated (by fluid
injection in the hospital) to
change the stoma size to
meet the patient's needs as
weight is lost.
• Laparoscopic procedure.

44. Malabsorptive surgeries
• Length of the small intestine is decreased, so that less
food is absorbed.
1. Biliopancreatic Diversion
• Involves removing approximately
three fourths of the stomach
• The remaining portion of the
stomach is connected to the lower
portion of the small intestine.
• Most of the calories and
nutrients are routed into the
colon.
• Nutrients pass without being
digested.

45. 2. Biliopancreatic Diversion with Duodenal
Switch
• Variation of Biliopancreatic Diversion.
• Half of the stomach is removed,
leaving a small area.
• The entire jejunum is excluded from
the rest of the GI tract.
• The duodenum is disconnected and
sealed off.
• The ileum is divided above the
ileocecal junction and the distal end of
the jejunum is anastomosed to the first
portion of the duodenum.
• The distal end of the biliopancreatic
limb is anastomosed to the ileum.

46. Combination of Restrictive & Malabsorptive
Surgery
1. Roux-en-Y gastric bypass
• Most common bariatric
surgery.
• In this procedure, the
stomach size is decreased
with a gastric pouch
anastomosis that empties
directly into the jejunum.

47. Cosmetic surgeries
• To reduce fatty tissue and skin folds.
1. Lipectomy
2. Liposuction

48. 1. Lipectomy
• Also called adipectomy.
• To remove unsightly flabby folds of adipose tissue.
• Up to 15% of the total fat cells are removed from the
breasts, abdomen, lumbar and femoral areas.
2. Liposuction
• Also called suction assisted Lipectomy.
• Liposuction is a surgical procedure that uses a
suction technique to remove fat from specific areas
of the body, such as abdomen, hips, thighs, buttocks,
arms or neck.
• A long hollow stainless steel cannula is inserted
through a small incision over the fatty tissue to be
suctioned.

49. Nursing diagnosis
• Imbalanced nutrition: more than body requirements
related to excessive intake in relationship to
metabolic needs.
• Impaired skin integrity related to alterations in
nutritional state, immobility, excess moisture
and multiple skinfolds
• Ineffective breathing pattern related to decreased
lung expansion from obesity.
• Chronic low self-esteem related to body size,
inability to lose weight.

50. Postoperative Care
• Maintain airway.
• Manage pain.
• Elevate head end at 35° to 40 angle to reduce
abdominal pressure and increase tidal flow.
• Wound care.
• ROM exercises.
• Early ambulation.
• Measures to prevent thrombophlebitis.
• Change position every 1 every to 2 hours.

51. • IV fluids and NG tube feeding.
• Breathing and coughing exercises.
• Frequent mouth and nose care.
• Frequent observation of wound for the amount
and type of drainage, condition of the sutures,
and signs of infection.
• Maintain hygienic needs, skin care.
• Maintain intake output chart.

52. Postoperative dietary management
• Immediate postoperative period (first 24 hr)
▫ Water and sugar-free clear liquids are given (30
ml every 2 hr while awake).
• At 1 day to 2 weeks postoperatively
▫ A high-protein liquid diet every 2 hours while
awake.
• At 2 to 4 weeks postoperatively
▫ A pureed diet is provided at frequent intervals.
• At 4 to 6 weeks
▫ Starts on a transition diet that includes solids, as
well as pureed foods.

53. Discharge instructions:
• Eat three meals per day (containing protein and
fiber).
• Include two protein snacks per day.
• Restrict total meal size to less than 1 cup.
• Eat slowly.
• Chew thoroughly.
• Eat only foods packed with nutrients (eg, peanut
butter, cheese, chicken, fish, beans).
• Do not eat and drink at the same time.
• Drink plenty of water, from 90 minutes after each
meal to 15 minutes before the next meal.
• Avoid liquid calories, such as alcoholic beverages,
fruit drinks, and regular soda (cola).
• Walk for at least 30 minutes per day.

56. Thank you