This document provides an overview of obesity including its definition, prevalence, health consequences, assessment, treatment approaches, and guidelines. Some key points: - Obesity is defined as a BMI of 30 or higher. It affects over 60 million US adults and rates have doubled globally in the last 30 years. - It increases the risk of diseases like diabetes, heart disease, and cancer. Treatment involves diet, exercise, behavior change and sometimes medication or surgery. - The Edmonton Obesity Staging System complements BMI by assessing medical complications, functional limitations, and quality of life across 5 stages from no risk factors to end-stage disease.

1. Dr Nadia Shams
Assistant Professor
Medicine
RIHS

2. Approach to overweight and obesity –
management of adiposity and adiposopathy
Gonzalez-Campoy JM et al. Endocr Pract. 2013;19 Suppl 3:1-82.
Overweight and obesity should be
treated as any other chronic disease

3. Overview
 Definition, Prevalence & Consequences of
Obesity
 Assessment of Obesity
 Treatments for Obesity
 Edmonton obesity staging system
 AACE guidelines

4. Definition
“Obesity is an abnormal accumulation of body fat,
usually 20 percent or more over an individual's ideal
body weight.”

5. BMI
(Adapted from WHO, 1995, WHO, 2000 and WHO 2004)
BMI
UNDER WEIGHT ≤ 18.5
NORMAL 18.5 – 24.9
OVER WEIGHT 25.0 – 29.9
OBESITY GRADE I 30.0 – 34.9
OBESITY GRADE II 35.0 – 39.9
EXTREME OBESITY
GRADE III
≥ 40

6. BMI Cut off for Asians
BMI cut-off Weight status Comments
<18.5 Underweight
Being underweight also puts you at risk for
developing many health problems. Discuss with
your healthcare provider about how to reach a
healthy weight.
18.5 - 23.9 Healthy weight range
Your weight is within normal range. You can
continue to keep a healthy weight through
physical activity and healthy eating. Keep up
with the good work!
24 - 26.9 Overweight
Being overweight can put you at risk for
developing many chronic diseases. Discuss with
your healthcare professional on how to achieve
a healthy weight.
>27 Obese
Obesity increases risks for developing many
chronic diseases such as heart disease and
diabetes, and decreases overall quality of life.
Discuss with your healthcare provider about how
to achieve a healthy weight!
Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies.
Lancet 2004; 363:157-63

7. Target Waist Circumference for Asians
and Asian Americans
Men Women
Equals or less than 90cm
(35.5 in)
Equals or less than 80cm
(31.5 in)

8. Calculating BMI
• Calculate Body Mass Index (BMI)
weight (kg)
height squared (meters)
Or…
weight (pounds) x 703
height squared (inches)

9. Prevalence of Obesity
• Childhood and adolescent obesity increased from 5% to 16%
in the last 20 years
• Adulthood obesity increased from 12% to 21% in 10 years.
• 16 million US adults with BMI over 35 & 60 million US obese
adults (BMI > 30)

10. Prevalence of Obesity in Pakistan
 Prevalence of obesity (BMl>25) in 25-44 year olds in
rural areas was 9% for men and 14% for women
 in urban areas, 22% and 37% for men and women,
respectively.
 For 45-64 year olds, prevalence was 11% for men and
19% for women in rural areas and 23% and 40% in
urban areas for men and women, respectively.
(DJ Nanan. The Obesity Pandemic - Implications for Pakistan. 2002: JPMA)

11. Factors predisposing to obesity
• Genetic – familial tendency.
• Gender – women more susceptible .
• Activity – lack of physical activity.
• Psychogenic – depression .
• Social class – poorer classes.
• Alcohol – problem drinking.
• Smoking – cessation smoking.
• Prescribed drugs – tricyclic derivatives.

12. Medications leading to weight gain
Disease Examples
Diabetes Insulin, sulfonylureas
Depression Tricyclics
Seizures Valproic acid, Tegretol
Hypertension Clonidine, α-blockers, β-blockers
Hormones Progesterone

13. Weight Gain: How Does It Happen?
•Calories consumed are not equal to calories
used
•Occurs over a long period of time due to
combination of several factors
• Individual behaviors
• Social interactions
• Environmental factors
• Genetics

14. Weight Gain: Energy In
3500 calories = 1 pound
• 100 calories extra per day
• = 36,500 extra per year
• = 10.4 lbs weight gain
Question: How much is 100 calories?
Answer: Not very much!
• 1 glass skim milk, or
• 1 banana, or
• 1 slice cheese, or
• 1 tablespoon butter

15. Leptin
• Protein hormone secreted by adipocytes
• Levels correlate with lipid content of cells
• Leptin acts on the hypothalamus to reduce
hunger and to stimulate energy expenditure

16. Ghrelin
• It is secreted in the stomach
• Acts on the hypothalamus to stimulate appetite
• Levels peak just before meals and drop afterward

17. Bad News for Dieters
• Leptin
• Dieting decreases the leptin levels
• Thus reducing metabolism, stimulating appetite
• Ghrelin
• Levels in dieters are higher after weight loss
• The body steps up ghrelin production in
response to weight loss
• The higher the weight loss, the higher the
ghrelin levels

18. Health Consequences of Obesity . . .

19. Health Consequences of Obesity
• Major cause of preventable
death
• Increase in mortality from
all causes
• Increased risk for these
cancers
• Endometrial carcinoma
• CA Breast
• CA Prostate
• CA Colon
• Increased risk of:
• Hypertension
• Dyslipidemia
• Diabetes Mellitus type 2
• Coronary artery disease
• CVA
• Gallbladder disease
• Osteoarthritis
• Sleep apnea & respiratory
problems

20. Assessment
• Is he/ she overweight or 0bese?
• What are the key health issues?

21. Assessment
• Measure the Body Mass Index- BMI
• Measure waist circumference
• “Apple shape” body is higher risk for DM, CVD, HTN
• Waist larger than 40 inches for men
• Waist larger than 35 inches for women

22. Assess for other risk factors
• Pre-existing high risk disease:
• coronary heart disease; Type 2 diabetes;
• sleep apnea
• Diseases associated with obesity
• Gynecological problems; osteoarthritis; gallstones; stress
incontinence
• Cardiovascular risk factors (3 or more = high risk)
• Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting
glucose = 110 to 125; family history of premature CHD; men age
> 45; women age > 55
• Presence of other risk factors
• Physical inactivity; elevated serum triglycerides
• Medications associated with obesity

23. Assess for other risk factors
Cardiovascular risk factors (3 or more = high risk)
________________________________________
•Cigarette smoking
•Hypertension; LDL >130
•HDL <35
•fasting glucose = 110 to 125
•family history of premature CHD
•men age > 45
•women age > 55

24. Treatment Approach
• A multi-faceted
approach is best
• Diet
• Physical activity
• Behavior change

25. Treatment Approach
• Initial goal: 10% weight loss
• Significantly decreases risk factors
• Rate of weight loss
• 1 to 2 pounds per week
• Reduction of caloric intake 500-1000 per day
• Slow weight loss is more stable
• Rapid weight loss is almost always followed by weight
gain
• Rapid weight loss increases risk for gallstones &
electrolyte imbalances

26. Treatment Approach
• Aim for 4 - 6 months of weight loss effort
• Most people will lose 20 to 25 pounds
• After 6 months, weight loss is more difficult
• Ghrelin & Leptin are at work!
• Changes in resting metabolic rate
• Energy requirements decrease as weight decreases
• Diet adherence wavers
• Set goals for weight maintenance for next 6
months, then reassess.

27. Dietary Therapy
• Weight reduction with dietary treatment is
recommended for virtuallyall patients with a
BMI 25-30 who have comorbidities and for all
patients over BMI 30.
• Strategies of dietary therapy include teaching
about calorie content of different foods, food
composition (fats, carbohydrates, and
proteins), reading nutrition labels, types of
foods to buy, and how to prepare foods.

28. Low-Calorie Step I Diet
• 1000 to 1200 kcal/day for women
• 1200 to 1600 kcal/day for men
• Adjust for current weight & activity
• Too hungry?
• increase kcal by 100 - 200/day
• Not losing?
• decrease kcal by 100 - 200/day

29. How Much is 1200 Calories?
• Could you stick to 1200 per day?
1 Big Mac (580)
1 SMALL Fries (210)
1 SMALL shake (430)

30. Low-Calorie Step I Diet
Nutrient Recommended intake
Calories 500 to 1000 kcal/day reduction from usual
Total fat <30% of total calories
Cholesterol <300 mg per day
Protein <15% of total calories
Carbohydrate >55% of total calories
Sodium Chloride <2.4 g sodium, or <6 g sodium chloride
Calcium 1000 to 1500 mg/day
Fiber 20 to 30 g/day

31. Weight Maintenance:
How Much Should People Eat?
• Varies widely
• Some averages, below
Males Age 20-49 2900 calories/day
Age 50-plus 2500 calories/day
Females Age 20-49 2300 calories/day
Age 50-plus 1900 calories/day

32. Physical Activity
• Physical activity should be an integral part of
weight loss
• Physical activity alone is less successful than a
combined diet & exercise program
• Increased activity alone
does not decrease weight
• Sustained activity does
prevent weight regain
• risk for heart disease & diabetes

33. Physical Activity
• Start slowly
• Many obese people live sedentary lives
• Avoid injury
• Early changes can be activities of daily living
• Increase intensity & duration gradually
• Long-term goal
• 30 to 45 minutes or more of physical activity
• 5 or more days per week
• Burn 1000+ calories per week

34. Recommended Physical Activity
• What does it take to burn
1000 calories per week?
Running
11 miles
Walking
12 miles
Dancing 3 hours
Gardening
5 hours
Cycling 22 miles

35. Behavioral Strategies
• Keep a journal of diet & activity
• Very powerful intervention!
• Set specific goals re: behaviors
• Eating
• Activity
• Related behaviors
• Track improvement
• Weigh & measure on a regular basis

36. Cognitive Strategies
• Focus on the goals
• Plan meals & activity
• Develop reminder systems
• Anticipate temptations & plan resistance
• Reward yourself
• Limit quantities, but do not deprive yourself
• Have confidence in your ability to succeed
• Do positive self-talk

37. Pharmacotherapy
for Weight Loss
_______________________

38. Pharmacotherapy for Weight Loss
• Adjunct to diet & physical activity
• BMI ≥ 30 Or, BMI ≥ 27 with other risk factors
• Should not be used for cosmetic weight loss
• Only for risk reduction
• Use only when 6-month trial of diet &
physical activity fails to achieve weight loss

39. Pharmacotherapy for Weight Loss
• These drugs are only modestly effective
• 2 to 10 kilogram loss
• Most occurs in the first 6 months
• If patient does not lose 2 kilograms in the first 4
weeks, success is unlikely
• If the first 6 months is successful, continue
medication as long as…
• It is effective in maintaining weight, and
• Adverse effects are not serious

40. Xenical (orlistat) product information. South San Francisco, CA: Genentech USA, Inc; December 2013.
Belviq (lorcaserin) product information. Woodcliff Lake, NJ: Eisai Inc; August 2012.
Qsymia (phentermine and topiramate extended-release) product information. Mountain View, CA: Vivus, Inc; September 2013
9

42. Weight Loss Surgery
• 47,000 in 2001; 98,000 in 2003
• Types of Obesity Surgery:
• 1. Restrictive Surgery - uses bands or staples to
create food intake restriction:
• Vertical Banded Gastroplasty (VBG)
• Gastric Banding
• Laparoscopic Gastric Banding (Lap-Band),

43. Weight Loss Surgery
• 2. Combined Restrictive and Malabsorptive Surgery
-is a combination of restrictive surgery (stomach pouch)
with bypass (malabsorptive surgery), in which the
stomach is connected to the jejunum or ileum of the
small intestine, bypassing the duodenum.
• Roux-en-Y Gastric Bypass (RGB)
• Biliopancreatic Diversion (BPD) -

44. Weight Loss Surgery
 Indications
100 pounds overweight or more
Or, BMI > 40
Or, BMI > 35 and 2 significant comorbidities
Age 18 to 60
Documented failure at nonsurgical efforts
Psychological stability

45. Weight Loss Surgery
• Roux-en-Y gastric bypass
• Limits food intake
• Alters digestion

46. Weight Loss Surgery
• Complications of surgery
• Mortality
• <1% mortality in healthy young adults BMI < 50
• 2-4% mortality in patients with disease and BMI > 60
• Operative complications
• < 10%
• Late complications are uncommon
• Incisional hernias
• Gallstones
• Vitamin B12 & iron deficiency
• Weight loss failure
• Neurologic symptoms in unusual cases

47. Weight Loss Surgery Outcomes
• Durable weight loss
• One study followed pts for 14 years
• Average excess weight loss = 61.2%
• 77% with diabetes no longer require
meds
• From Wald meta-analysis in JAMA 2004)

48. Followup
• Schedule a return visit in 2 to 4 weeks after
starting weight loss plan
• Monitor treatment effectiveness & side effects
• Schedule monthly visits for first 3 months
• If making favorable progress
• See more frequently if monitoring medical
complications or chronic disease
• Reduce frequency of visits after 6 months

49. Followup
• Monitor weight, BP, pulse at each visit
• Monitor waist size intermittently
• Share progress with patient; praise efforts
• Share lab results with patient
• Emphasize findings associated with weight reduction
• Focus on medical benefits
• Most weight loss doesn’t reach individual’s ‘ideal’ (cosmetic)
goal

50. EDMONTON OBESITY STAGING SYSTEM
 Anthropometric measures alone are not a
good reflection of the severity or extent of
obesity-related comorbidities.
 Sharma and Kushner have suggested a
clinical staging system to complement the
BMI when describing the severity of obesity.
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

51. The Edmonton Obesity Staging System is
used together with BMI class for
management of obesity.
____________________________________

52. Edmonton Obesity Staging System (EOSS)
Stage 0
(Sharma AM & Kushner RF, Int J Obes 2009)
Stage 1
Stage 2
Stage 3
Stage 4
Medical
MentalFunctional
absent
absent
absent
pre-clinical
risk
factors
m
ild
m
ild
co-morbidity
moderate
moderate
end-organ
dam
age
severe
severe
end-stage
end-stage
end-stage
Obesity

53. STAGE - 0
 Patient has no apparent obesity-related
risk factors (e.g., blood pressure, serum
lipids, fasting glucose, etc. within normal
range)
 no physical symptoms, no
psychopathology, no functional limitations
or impairment of well-being.
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

54. STAGE - 1
 Patient has one or more obesity-related sub-clinical
risk factors (e.g., elevated blood pressure, impaired
fasting glucose, elevated liver enzymes, etc.)
 mild physical symptoms (e.g., dyspnea on moderate
exertion, occasional aches and pains, fatigue, etc.)
 mild psychopathology, mild functional limitations
and/or mild impairment of well-being.
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

55. STAGE - 2
 Patient has one or more established
obesity-related chronic diseases requiring
medical treatment (e.g., hypertension, type
2 diabetes, sleep apnea, osteoarthritis,
reflux disease, polycystic ovary syndrome,
anxiety disorder, etc.)
 moderate functional limitations and/or
moderate impairment of well-being.
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

56. STAGE - 3
 Patient has clinically significant end-organ
damage.
 such as myocardial infarction, heart failure,
diabetic complications, incapacitating
osteoarthritis, significant psychopathology,
significant functional limitations and/or
significant impairment of well-being.
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

57. STAGE - 4
 Patient has severe (potentially end-stage)
disabilities from obesity-related chronic
diseases, severe disabling
psychopathology, severe functional
limitations and/or severe impairment of
well-being .
(http://www.drsharma.ca/clinical-assessment-edmonton-obesity-staging-system)

58. EOSS Predicts Mortality in NHANES III
(Padwal R, Sharma AM et al. CMAJ 2011

59. EOSS Predicts Mortality at Every Level of BMI
NHANES III
(Padwal R, Sharma AM et al. CMAJ 2011)
Overweight

61. Association Between EOSS and Mortality Risk in
Aerobics Center Longitudinal Study (n = 29 533)
Kuk JL, et al. Appl. Physiol. Nutr. Metab. 2011;36: 570

62. EOSS Case 1
24 year-old physically active female,
BMI of 32 Kg/m2
no demonstrable risk factors, no functional
limitations, or mental health issues
Class I, Stage 0 Obesity
- Focus on prevention of further weight gain
- Health benefits of more aggressive obesity
treatment likely marginal
Sharma AM & Kushner RF, Int J Obes 2009

63. EOSS Case 2
32 year-old male
BMI of 36 Kg/m2
hypertension, sleep apnea, depression
Class 2, Stage 2 Obesity
- Clear benefits of obesity treatment
Sharma AM & Kushner RF, Int J Obes 2009

64. EOSS Case 3
63 year-old male
BMI of 54 Kg/m2
disabling osteoarthritis (wheel chair)
severe hypoventilation, fibromyalgia,
generalized anxiety disorder
Class 3, Stage 4 Obesity
Aggressive obesity treatment unless deemed
palliative
Sharma AM & Kushner RF, Int J Obes 2009

69. Thank You!
2014
1990