This document provides an overview of the management of morbid obesity. It discusses the increasing prevalence of obesity worldwide and in India. Obesity is defined as a chronic disease that increases the risk of several health conditions such as diabetes, heart disease, and some cancers. Treatment involves comprehensive lifestyle changes including a reduced calorie diet, increased physical activity and behavioral therapy. Pharmacotherapy and bariatric surgery are also options for those who meet criteria. A multidisciplinary team approach is emphasized to safely and effectively treat obesity and support long-term weight loss maintenance.

1. Management of Morbid Obesity
An Overview
Dr Saurabh Kalia
MS,DNB,MCh
Consultant Surgical Gastroenterology
Narayana Multispeciality Hospital, Jaipur

2. WHO factsheet 2015
• Worldwide obesity has more than doubled since 1980.
• In 2014, more than 1.9 billion adults, 18 years and older, were
overweight. Of these over 600 million were obese.
• 39% of adults aged 18 years and over were overweight in 2014,
and 13% were obese.
• Obesity kills more people
than underweight.
• 42 million children under the
age of 5 were overweight or
obese in 2013.
• Obesity is preventable.

3. Indian scenario
• Almost 30-65% of adult urban Indians are
either overweight or obese or have abdominal
obesity
• Rajasthan - 2.6% have BMI>30 ( 20 Lac Obese)
CAB Survey 2014
• Obesity related co-morbidities at lower levels of body mass
index (BMI) and waist circumference (WC)
Obesity BMI >25 kg/m2, WC cutoff Men: 90 cm, women: 80 cm
• Asian Indians have higher percentage body fat, abdominal
adiposity at lower or similar BMI levels

4. Obesity - A Chronic Disease
• Impairs bodily function
• Characteristic Symptoms and sings
• Associated Morbidity and risk of Mortality
• Wide range of
complications
Physical effects of fat mass
Metabolic and Physiological
consequences of fat tissue
dysfunction and Insulin resistance

5. Obesity – A silent killer
• Obesity raises the risk of morbidity from
– hypertension ,dyslipidemia, type 2 diabetes mellitus
– coronaryheart disease (CHD), stroke, gallbladder disease,
– osteoarthritis,
– sleep apnea and respiratory problems,
– some cancers.
• Obesity is also associated with increased risk of all-cause and
CVD mortality.
• The biomedical, psychosocial, and economic consequences of
obesity.

6. Etiology
• The fundamental cause - energy imbalance
between calories consumed and calories
expended.
– An increased intake of energy-
dense foods that are high in fat
– an increase in physical inactivity
due to the increasingly sedentary nature of work.
• Environmental and societal changes

7. Pathophysiological mechanisms of Obesity
results in more
favorable impact on obesity-related
comorbid conditions

8. Double Burden of Disease
• In low- and middle-income countries
• Problems of infectious disease and under-nutrition,
• Obesity and overweight, particularly in urban settings.
• Children.
– Exposed to high-fat, high-sugar, high-salt, energy-
dense, micronutrient-poor foods.
– In conjunction with lower levels of physical activity,
result in sharp increases in childhood obesity

9. Healthy Diet
• Fruits, vegetables, legumes (e.g. lentils,
beans), nuts and whole grains (e.g.
unprocessed maize, millet, oats, wheat,
brown rice).
• At least 400 g (5 portions) of fruit and
vegetables a day .
• Less than 10% of total energy intake from
free sugars which is equivalent to 50g (or
around 12 level teaspoons)
• Less than 30% of total energy intake from
fats .
– Unsaturated fats are preferable to
saturated fats
– Avoid Industrial trans fats found in
processed food
• Less than 5 g of salt (equivalent to
approximately 1 teaspoon) per day and
use of iodized salt.

10. Comprehensive management of Adult
Obesity
• Guidelines, Recommendation, Algorithms
– Recognition of individuals to benefit
– Presence and Severity of Weight related complications
– Assessment of Disease severity
– Goals of obesity management
– Identification of Therapeutic options

11. Identifying Individuals
• BMI – Established index
• Metabolic Syndrome/
CV risk factors
• Waist circumference
• Obesity related
complications

12. Diagnosis of Metabolic syndrome
• The metabolic syndrome is defined as a
clustering of cardiovascular risk factors in an
individual which predisposes the person to a
greater risk of developing T2DM and CVDs

13. Checklist Obesity Related
Complications
• Metabolic Syndrome – Waist circumference, HTN, Triglycerides,
HDL-C, FBS
• Pre-diabetes, Type 2 DM
• Dyslipidemia
• Hypertension
• NAFLD
• PCOD
• OSA
• OA
• Urinary Stress incontinence
• GERD
• Disability/Immobility
• Psychological disorder
• Obesity due to genetic syndrome, Hormonal disease and Drugs

14. Lifestyle Modification – The core

15. Elements of Comprehensive Lifestyle Intervention
• Reduced calorie diet -
– Set a caloric goal (1,200-1,500 kcal/day for women, 1,500-1,800 kcal/day for men,
adjusted for body weight)
– Specify a caloric deficit (500 or 750 kcal/ day)
– Restrict/reduce intake of certain food types (e.g., high-carbohydrate, low-fiber, or high-
fat foods) to create energy deficit
– Consider patient preferences and health status when identifying a diet
• Increased physical activity
– Aerobic activity>150 min/week for weight loss
– Resistance training to preserve lean mass
– 200-300 min/week aerobic activity to maintain weight loss
• Behavioral intervention
– Ideal
• Face-to-face sessions (14 with a trained interventionist over the first 6 months)
• Maintain efforts over 1 year
• Incorporate strategies such as goal setting and self-monitoring
– Alternatives
• Telephone or electronic counseling with a trained interventionist
– Maintenance - Continued contact (once monthly) with a trained interventionist

16. Stepwise Model for Clinical
Management

18. Dietary Modification
• Yo-Yo dieting (cycle of weight gain and loss)- serious health risks
• Low-fat diets that reduce daily energy intake by 2 to 4 MJ
– weight loss of 2 to 6 kg
– waist-circumference loss of 2 to 5 cm after one year
– more effective in maintaining weight loss than low energy diets
• Nutritionally balanced low-energy diets 4 to 5 MJ/day
– weight losses of 7 to 13 kilograms and
– significant decreases in abdominal fat after six months
– half of the weight lost is regained after one to two years

19. Success of Diet therapy
• Successful long-term weight loss is defined as a
– reduction in initial weight of 5 per cent or more
– maintenance of this loss for at least one year.
– associated with significant clinical benefits
– these changes are mostly transient.
• After one year, reduced-energy diets, low-energy diets and
very low energy diets used in isolation produce weight losses
of about 4, 7 and 4 per cent respectively.
• After three to six years, people prescribed these diets will be,
on average, 5, 3 and 6 kilograms lighter respectively

20. Losing Weight
• Calorie calculation
• To lose 1 kg/week eat 1000kcal less every day

22. Pharmacotherapy
• History of being unable to successfully lose and maintain weight
• To promote long-term weight maintenance
• To ameliorate comorbidities
• Amplify adherence to behavior changes
• May improve physical functioning and greater physical activity

23. Drugs – Side effects

24. Outcomes
• Orlistat - 2.59 kg at 6 months and 2.89 kg at 12 months
• Phentermine, diethylpropion -3.0- to 3.6-kg weight loss at 1 year
• Assess Patient's response at 3 months
• Effective response (weight loss of >5% at 3 mo) and safe
– medication be continued.
• Ineffective response or safety or tolerability issues
– medication be discontinued and
– alternative medications or
– referral for alternative treatment

25. Candidates for bariatric surgery
• BMI > 40 kg/m2
, or BMI > 35 kg/m2
with significant obesity
related comorbidities
• Acceptable operative risk
• Documented failure of nonsurgical weight loss programs
• Psychologically stable, with realistic expectations
• Well-informed and motivated patient
• Supportive family and social environment
• Absence of active alcohol or substance abuse
• Absence of uncontrolled psychotic or depressive disorder

26. Guidelines on Management of
Overweight and Obesity in adults
• Identifying patients
• Matching treatment with risk profile
• Diets for weight loss
• Lifestyle intervention counselling
• Selecting patients for Bariatric surgery
ACC/AHA Task Force on Practice Guidelines 2013

32. Bariatric Surgery
• Recommended as Adjunct to lifestyle modifications
• Produces greater weight loss and weight loss
maintenance
• Results in more favorable impact on obesity-related
comorbid conditions
• Weight loss efficacy varies depending on the type of
procedure and initial body weight.

34. Multidisciplinary Team required

35. Conclusions
• Diet, exercise, and behavioral modification -
(BMI) of 25 kg/m 2 or higher.
• Pharmacotherapy for BMI of 27 kg/m 2 or
higher with comorbidity or BMI over 30 kg/m2
• Bariatric surgery for BMI of 35 kg/m 2 with
comorbidity or BMI over 40 kg/m 2, should be
used as adjuncts to behavioral modification to
reduce food intake and increase physical
activity when this is possible.

36. Fountain of Youth
39 year old , Sleeve Gastrectomy in June 2013 – Weight 130 kg, BMI 42kg/m2
40 year old now , lost about 45 kg , BMI 27.5 kg/m2

37. New lease of life
40 year old mother of 2, operated in Oct 2013, lost 30 kg over 9 months
(from 95 kg to 65 kg ) ,Diabetes resolved

38. Thank You