Obesity

1. OBESITY
DR NAILIL HANANI BINTI SUHAIMI
1ST YEAR MMED (FAMILY MEDICINE) HUSM

2. OUTLINE OF
PRESENTATION
• Definition of obesity
• Etiologies of obesity
• Obesity and related medical issues
• Management of obesity

3. DEFINITION OF OBESITY

4. OVERVIEW OF OBESITY
• Obesity is a condition in which excess body fat may put a person at health risk.
• Excess body fat results from an imbalance of energy intake and energy expenditure (total energy
expenditure includes energy expended at rest, in physical activity and for metabolism)
• Malaysia has the highest rate of obesity and overweight among Asian countries with 64% of male
and 65% of female population being either obese or overweight.
• The National Health and Morbidity Survey (NHMS) 2019 findings, meanwhile, showed that 50.1% of
adults in Malaysia were either overweight or obese — 30.4% overweight and 19.7% obese.

5. WHO CLASSIFICATION

6. BMI CLASSIFICATION FOR ASIAN

7. ETIOLOGIES OF OBESITY

8. • High fat diet
• Frequency of eating
• Infant feeding practice
dietary
• Drugs induced
Iatrogenic
• Hypothalamic obesity
• Cushing’s syndrome
• Hypothyrodism
• Hypogonadism
Neuroendocrine
Obesity in adults: Prevalence, screening, and evaluation, up to date

9. • Socioeconomic status
• ethnicity
• Binge eating
• Night eating syndrome
Social and behavioural factors
• Aging
• Enforced inactivity (postoperative)
Sedentary lifestyle
• Prader-willi syndrome
Dysmorphic obesity
Obesity in adults: Prevalence, screening, and evaluation, up to date

11. GENES FOR OBESITY ??
• ADIPOQ, FTO, Leptin receptor, MC4R
• These genes can cause increase hunger levels, increase caloric intake, reduced
satiety, reduced control over eating, increase tendency to be sendentary and
increased tendency to store fat
• Obesity can still be prevented and treated with effective nutrition, physical activity
and behavioural approach
Obesity medicine association

12. OBESITY AND RELATED
MEDICAL ISSUES
(BIOPSYCHOSOCIAL)

14. CPG obesity Malaysia,
2004

15. BIOLOGICAL
• In a meta-analysis of studies assessing the impact of body weight on CHD, there was a 29
percent increase in CHD for each five-unit increase in BMI. The risk of CHD in obese and
overweight persons is compounded by the frequent coexistence of other CHD risk factors
such as hypertension, dyslipidemia, and diabetes
• More than 80 percent of cases of type 2 diabetes can be attributed to obesity, which may
also account for many diabetes-related deaths.
• The risk of incident gout was higher in men with a body mass index (BMI) of 25 kg/m2 or
greater, and the magnitude of the association became larger with increasing BMI. Men who
had gained 13.6 kg or more had a twofold increased risk of incident gout compared with men
who maintained their weight, while weight loss greater than 4.5 kg was associated with a
reduced risk of incident gout.

16. Proposed pathophysiology of
obesity cardiomyopathy

17. • Even a modest increase in weight as an
adult is associated with an increased risk
of type 2 diabetes, hypertension, coronary
heart disease, and cholelithiasis. Panel A
shows data for women in the Nurses'
Health Study, initially 30 to 55 years of age,
who were followed for up to 18 years.
Panel B shows data for men in the Health
Professionals Follow-up Study, initially 40
to 65 years of age, who were followed for
up to 10 years.

18. • The magnitude of the effect of
behavioral weight loss on blood
pressures was examined in a systematic
review of eight trials of hypertensive
patients; the mean reduction in
systolic/diastolic blood pressure was
4.5/3.2 mmHg. However, the reduction
in blood pressure with weight loss is
dose dependent (ie, greater weight loss
produces a greater reduction in blood
pressure)

20. THINGS THAT YOU NEED TO DO WHEN YOU SEE
AN OBESE PATIENT
• Assess coronary heart disease (CHD) equivalent
DM, IHD, CVA, PVD
• Assess CHD risk factors
Dyslipidemia, HPT, IGT,IFT, smoking status, family hx of premature cardiac death, age
• Identify other related diseases
• Identify underlying cause of obesity
• Identify psychosocial issues in the patient

21. MANAGEMENT
OF OBESITY
• Non-pharmacological
• Pharmacological
• Surgical approach

22. NON-PHARMACOLOGICAL
• Motivational interviewing
• Self monitoring
• Stimulus control
• Nutrition counselling
• Physical activity

24. PHARMACOLOGICAL
• Indications for pharmacological terapy:
 BMI ≥27.5 kg/m2
 BMI between 25 and 27.5 kg/m2, and at least two of the following conditions: •
Type 2 diabetes mellitus • Coronary heart disease • Cerebrovascular disease •
Hypertension • Hyperlipidaemia • Waist circumference >90 cm for men, >80 cm
for women
 Symptomatic complications of obesity such as severe osteoarthritis, obstructive
sleep apnoea, reflux oesophagitis, and the compartment syndrome
After reasonable 6 months trial of diet and physical activity

25. Drug Action Side effects
Orlistat Peripherally acting pancreatic lipase
inhibitor, decreases fat absorption
Loose stools, malabsorption of fat-soluble
vitamins
Phentermine Centrally acting via noradrenergic
pathways
(suppress appetite)
Increase in blood pressure, insomnia,
nervousness
Sibutramine Centrally acting via serotoninergic and
noradrenergic pathway
(enhances post ingestive satiety,
increase resting metabolic rate)
Increase in blood pressure and heart rate,
nausea, insomnia dry mouth, rhinitis,
constipation
Liraglutide glucagon-like peptide-1 receptor
agonist (increase post prandial satiety,
decrease hunger)
Nausea, vomiting,stomach discomfort
(delay gastric emptying)

26. CRITERIA OF BARIATRIC SURGERY
• Patients aged 18 or older
• morbid obesity (BMI ≥40 kg/m2 or between 35 and 40, with major weight related
comorbidities)
• Patients who have already had intensive management in specialized clinics with
interest in obesity.
• Patients who have failed to maintain weight loss after trying appropriate non-
surgical measures.
• Patients with no clinical or psychological contraindications to anaesthesia or
surgery
• Patients who understand and are committed to long term follow-up

27. COMPLICATIONS OF BARIATRIC SURGERY
• Nutrients deficiencies (vitamin b12, folate, iron)
• Dumping syndrome – rapid gastric emptying into the small intestines (nausea,
abdominal discomfort)
• Gallstones ( 47.8% developed gallstones, 95.8% during first 18 months) –
elevated bile concentration

28. STAMPEDE (SURGICAL TREATMENT AND MEDICATIONS
POTENTIALLY ERADICATE DIABETES EFFICIENTLY) TRIAL
• Eligibility criteria included an age of 20 to 60 years, a glycated hemoglobin level of more
than 7%, and a body-mass index (BMI, the weight in kilograms divided by the square the
height in meters) of 27 to 43
• three study groups; intensive medication therapy, gastric bypass or sleeve gastrectomy
• Patients were followed-up for 3 years and the primary outcome was a glycated
hemoglobin level of ≤ 6%, with or without the use of diabetes mellitus medications

29. • targeted HbA1C ≤ 6% was achieved in 5% of patients in the medical therapy
group compared to 38% of those in the gastric-bypass group and 24% of those
in the sleeve-gatsrectomy group
• The mean percentage reductions in weight from baseline were greater in
the gastric bypass group (24.5 ± 9.1%) and the sleeve-gastretcomy group
(21.1 ± 8.9%), as compared with a reduction of 4.2 ± 8.3% in the medical
group
• For baseline albuminuria, a return to normal values at 3 years occurred in
62% in the gastric bypass group, 80% in the sleeve-gastrectomy group and
25% in the medical-therapy group
• The decrease in triglyceride levels and increase in high-density lipoprotein
(HDL) cholesterol levels in the surgical groups, as compared with intensive
medical therapy, more sustained at 3 years
• significant reduction in the number of medications needed to treat
hyperlipidemia and hypertension in the surgical groups.

30. • The 10-year follow-up in the Swedish Obese Subjects (SOS) study
demonstrated that a bariatric surgery is a viable option for the treatment of severe
obesity. After 10 years, the average weight loss from baseline was 25% after
gastric bypass, 16% after vertical banded gastroplasty, and 14% after gastric
banding.
• The group that had undergone surgical intervention had lower incidence rates of
diabetes, hypertriglyceridemia, and hyperuricemia in comparison to the control
group. The most important recent finding of the Swedish Obese Subjects study is
a reduction of overall mortality by 24.6% in the surgery group versus control
subjects
• More than 10 years ago, Pories et al. demonstrated that 83% of patients with
diagnosed type 2 diabetes exhibited normal blood glucose and normal
glycosylated hemoglobin levels 7.6 years after bariatric surgery. Further, 99%
patients with impaired glucose tolerance normalized a glucose tolerance after
bariatric surgery.

31. TAKE HOME MESSAGES
• Obesity is an alarming health issues that in a rising trend worldwide.
• Obesity is not a stand alone disease. It is associated with multiple comorbidities
that will lead to increasing morbidity and mortality.
• Always rule out other treatable causes of obesity before blaming on the lifestyle
practice of a patient.
• Both non pharmacological and pharmacological approaches are crucial in
treating obesity.
• Both patient and health care providers need to work in tandem to make sure that
the treatments given are successful.

32. THANK YOU