definition of obesity
Post on 15-Jan-2016
23 Views
Preview:
DESCRIPTION
TRANSCRIPT
Obesity is a chronic disease without tendency towards spontaneous recovery in which a clinical syndrome is produced by the following factors:
extrinsic: abnormal eating pattern, overproduction of food, low level of physical
exercise (urbanization, car transportation), stress, emotional disorders
intrinsic: genetic, metabolic, regulatory, degenerative
Definition of obesity
WHO. Obesity: Preventing and Managing the Global Epidemic. WHO/NUT/NCD/98.1Report of a WHO consultation on Obesity, Geneva, 1998
Prevalence od obesity in Europe (WHO MONICA study), USA and Australia
*BMI >30 kg/m2; **BMI >27.3 kg/m2 (women), >27.8 kg/m2 (men)
0
5
10
15
20
25
30
35
40
45
50
Sweden
Finland
Denmark
UK Germany
Belgium
FranceSwitzerland
RussiaLithuania
Poland
Czech Republic
Hungary
SpainItaly
Whites
Afro-Amer
WhitesMaorees
Men Women
USA** Australia*Europa*
0
20
40
60
80
100
France Italy Germany Spain UK USA
OverweightBMI 25 - 29.9
Obesity BMI 30 -39.9
Obesity BMI > 40
Predicted prevalence of obesity and overweight in the year 2010
Food intakeEnergy expenditure
Controlling factors
GeneticDiet components
PsychologicSocial, cultural
Everyday activityBasic metabolic rate
Food induced thermogenesis
ENERGY BALANCE
Obesity-related diseases
HypertensionHeart failureRespiratory diseases (SAS)
CHD, arrhythmia
Gall bladder diasease
Hormonal disturbances
Gout
Stroke
Diabetes
Osteoarhrosis
Cancer of the colon, endometrium, ovary,
prostate
Venous insufficiency
Breast cancer
Obesity is diagnosed using body mass index (BMI)
Classification BMI (kg/m2) Health hazard
Normal range 18.524.9 AvarageOverweight (Class I obesity) 25.029.9 ModerateClass II obesity 30.039.9 Serious Class III obesity (morbid) 40.0Extremely serious
World Health Organization, 1998
Weight (kg)
Height (m2)BMI =
In children
In sportmen, athletes
In pregnant and breast-feeding women
In the elderly
When BMI is not used in diagnosing obesity?
First of all, obesity is ...
Excessive accumulation of fat tissue
> 10-15% of body weight in men > 20-25% of body weight in women
Different distribution
abdominal obesity femoro-gluteal obesity
How to assess body fat distribution?
Waist circumference measurement (half the distance between lower costal margin and upper margin of iliac crest)
Hip circumference measurement (at the level of trochanter major of the femur)
Waist to hip ratio determination (WHR)
WOMEN: WHR > 0.8 - abdominal (visceral) obesity
MEN: WHR > 1.0
Waist circumference is a good indicator of visceral fat and the risk of obesity-related complications ...
WomenWomen
80 cm = increased risk1
>88 cm = health problems
MenMen
94 cm = increased risk1
>102 cm = health problems
1Lean MEJ, et al. Lancet;1998:351:853–6
cm
History taking
body weight from childhood, through puberty to adult life (studies, marriage, pregnancy, menopause); the pattern of body weight increase, circumstances of weight increase
obesity in family members (genetic factors) eating habits and behaviour in the family :
- response to stress, positive and negative emotions, - binge episodes - physical activity (enviromental factors) - alcohol, cigarettes
previous attempts to reduce body weight (success, failure, relapse)
Differential diagnosis – secondary obesity
ENDOCRINOPATHIES Cushing’s sydrome hypothyroidism PCO-S
pseudohypoparathyroidism primary hyperinsulinism hypopituitarism
CNS DEMAGEtrauma, surgery tumours, inflammation,
postpartum
Turner`s sy Down`s sy
GENETIC
Prader-Willi sy (15q11)Laurence-Moon-Biedel sy
(16q21)
DRUG-INDUCEDglucocorticoidsphenotiazinessedativaestrogensprogesterone insulinsulphonylureas
WHO IS AT RISK?All overweight and obese patients including
children and adults up to 65 years of age
HOW TO ASSESS THE RISKS?• BMI
• waist circumference (visceral body fat = independent factor of increased mortality)
• genetic risk factors • enviromental risk factors
• concomittant diseases• general health status
Physical examination - hints
Symptoms and conditions associated with obesity
- quality of life
- arterial hypertension; exercise tolerance
- other cardiovascular disease
- diabetes
- dyspnoea, snoring, morning somnolence, headache
- menstrual disturbances, uterine bleeding, infertility, impotence
- back pain, leg pain, pitting oedema
- gall stones, pyrosis
- constipation
Physical examination - hints
- RR, heart rate- dyspnoea (resting, on exertion); cyanosis; anasarca
- skin (dry, striae, acantosis nigricans, candidiasis)- body hair distribution; breast examination
- thyroid gland- lower lung borders- cardiac sillhouette
- liver- joints
- lower limbs: varicose veins
Laboratory and imaging studies
- ECG, exercise ECG
- fasting and postpradial (2 h) glucose
- triglicerides
- blood gases analysis *
- breast X-ray and US
- transvaginal US (endometrium, ovaries)
- gynaecological examination
- abdominal US, rectosigmoidoscopy *
The role of a physician in the long-term obesity management
Evaluation of indications for treatment
Setting realistic goals according to: - previous attempts of dieting and physical exercise - physical capacity assessment - social and enviromental status assessment - initial assessment of patient’s personality Evaluation of indications and contraindications for drug and surgical treatment
Professional supervision of „patients` support groups”
The aim of obesity management
Prevention of further weight gain
Risk factors reduction
Maintenance of weight reduction at least by 5 - 10%
• Fasting glucose 50%• Total cholesterol 10%• LDL-cholesterol 15%• Triglicerides 30%• Platelet aggregation • Fibrinolysis • Menstrual disturbances 30%
The benefits of modest weight reduction (-10kg)
• Overall mortality 20%• Deaths related to diabetes 30%• Deaths related to hypertension 40%
Whom to treat?
Patients with BMI > 30 kg/m2
who agreed to be treated
with metabolic and genetic risk factors
with obesity-related conditions
with obesity-related social and psychological problems
Physiological ageing process favours fat accumulation
In patients aged > 65 years no significant relationship between obesity and increased mortality was shown
Gynoid obesity is not associated with serious metabolic consequences
Excessive calorie intake may be a way of „coping with life”
What should be remembered?
Contraindications for obesity treatment
Absolute : - terminal diseases
Temporary: - pregnancy, breast-feeding - unstable clinical status - psychiatric disorders
Relative: - age > 65 years, - gall stones
Diet Physical activity
Behavioural modification (lifestyle, eating pattern)
Social and psychological support Drugs
Surgery
Obesity management current concepts
Daily calorie requirement and actual calorie intake
24-h energy expenditure ~ 25 kcal/kg b.w.
Energy requirement = body weight x 25 kcal/24 h
What is an average calorie intake during last 7 days??
How to calculate daily calorie intake to reduce body weight
by 0.5 - 1.0 kg/week ...
METHOD EXAMPLE 1 EXAMPLE 2
Weight, sex, age 100 kg, 45 yrs., M 80 kg, 45 yrs., F
Daily energy requirement 2500 kcal 2000 kcal
Deduct 600 kcalor 30%
1900 kcal1625 kcal
1400 kcal1400 kcal
Even little physical activity is better than no physical activity ...
causes additional energy expenditure
increases exercise capacity
prevents FFM during dieting
increases postprandial thermogenesis
increases sympathetic activity
prevents BMR reduction after weight loss
prevents „rebound phenomenon”
improves mood, fights stress
Physical activity leads to weight reduction but it is a slow process!
The obese are not capable of intensive exercise due to diminished physical capacity.
Lack of time and lack of approval for intensive exercise prevent the increase in physical activity.
Typical recommendation (NHLB Institute, Betehesda): 45 min briskly walking daily for 6 days a week.
What should be remembered ?
Diet and behavioural modification may not be sufficient!
Diet alone75% of patients – weight regain after 1 year
Diet and behavioural modification71% of patients – weight regain after 2 years
Dieta and behavioural modiication + increased physical activity
58% of patients – weight regain after po 2 years
Safer DJ. South Med J. 1991;84:1470–1474.
Indications for drug treatment
failure of diet modification and increased physical activity
BMI > 30 kg/m2
BMI < 30 kg/m2 + 1 complication of obesity
Currently approved obesity drugs
sibutramine (Meridia - Abbott): centrally-acting drug; inhibitor of synaptic serotonin and norepinephrine re-uptake
orlistat (Xenical - Roche): pancreatic lipase inhibitor; reduces fat absorption by 30%
Royal College of Physicians, 1998
START
No reduction by 10%
3 months
INCREASE > 3 kg
Pharmacology
Check-up every month
CONTINUEfor 12 months
SUCCESS
DRUG WITHDRAWAL
NO SUCCESS
FURTHER TREATMENTaccording to expected benefit and obtained results
DietBehavioural modification
Physical activity
Indications for surgical treatment
BMI > 40 kg/m2
BMI 35 - 40 kg/m2 depending on the threat to life
(National Health Institute of USA, 1991)
Vertical gastric banding (VGB)
Gastric by-pass operation
Factors influencing the outcome of obesity treatment
patient’s personality motivation for treatment, satisfaction from treatment,
realistic and individual goals results of previous treatment attempts
class of obesity the degree of health hazard, presence of obesity-related
conditions
top related