obesity presentation american hospital

Obesity: a ticking time bomb

Obesity is a substantial public health crisis with prevalence increasing in an

alarming way.

The obesity rate in the UAE is double the world average, according to a disease

study report.

WHO: More than 2.1 billion people – close to 30 % of the global population – are

overweight or obese

A study by the research company McKinsey Global Institute, Overcoming Obesity:

an Initial Economic Analysis, published in November, predicts that almost half of the

world’s adult population could be overweight or obese by 2030.

However, according to a report entitled the Global Burden of Disease Study 2013, by

the University of Washington’s Institute for Health Metrics and Evaluation, more

than 66 per cent of men and 60 per cent of women in the UAE are already overweight

or obese.

The economic burden of obesity in UAE is US$6 billion [Dh22bn] annually.”

obesity is costing the world $2 trillion a year!!!!

The National UAE, report 18 February 2015

Data from the International Diabetes Federation to mark World Diabetes Day in

November 2014 showed that there were 803,900 diabetics in the UAE, about 19 per

cent of the population

Dr Mohammed Farghaly, head of insurance medical regulation at the Dubai Health

Authority, estimated that 1.8 million people could suffer from diabetes in the UAE

within a few years.

“Diabetes is considered a major health issue in our community now, and the

prevalence of diabetic people is increasing, which urges us to raise awareness about

this disease.”

People must be aware that the disease can be avoided by losing weight, doing more

exercise and eating a better diet

The National UAE, report 18 February 2015

Obesity: a ticking time bomb

What Causes Overweight and Obesity?

Lack of Energy Balance

To maintain a healthy weight, your energy IN and OUT don't have to balance

exactly every day. It's the balance over time that helps you maintain a healthy

weight.

An Inactive Lifestyle

In fact, more than 2 hours a day of regular TV viewing time has been linked to overweight and obesity.

Other reasons for not being active include: relying on cars instead of walking, fewer physical demands at work or at home because of modern technology and conveniences.

National institutes of health, National heart lung and Blood institutes

What causes overweight and obesity?

Environment

Our environment doesn't support healthy lifestyle habits; in fact, it encourages

obesity. Some reasons include:

Lack of neighborhood sidewalks.

Work schedules.

Lack of access to healthy foods.

Food advertising. People are surrounded by ads from food companies. Often

children are the targets of advertising for high-calorie, high-fat snacks and sugary

drinks. The goal of these ads is to sway people to buy these high-calorie foods, and

often they do.



Family History

Children adopt the habits of their parents. A child who has overweight parents who

eat high-calorie foods and are inactive will likely become overweight too. However,

if the family adopts healthy food and physical activity habits, the child's chance of

being overweight or obese is reduced.


Could obesity be related to genetics?

Since 2007 scientists have known that a gene named FTO was related to obesity

and people with higher Body Mass Index have been found to carry a variant of this

gene.

Now, researchers at MIT and Harvard Medical School believe they have discovered

that a faulty version of this gene causes energy from food to become stored as fat in

the body rather than be burned, contributing to obesity.

In the study, published in the New England Journal of Medicine, scientists took cell

samples from Europeans with either a healthy or faulty version of the FTO gene.

The findings showed that the faulty FTO gene ‘switched on’ two other genes –

IRX3 and IRX5 – which have been identified as the “master controllers” of

thermogenesis as they can prevent the process in which energy is turned into heat,

meaning it is instead stored as fat.

New England Journal of Medicine august 24, 2015


Health Conditions

hypothyroidism, Cushing's syndrome, and polycystic ovarian syndrome (PCOS).

Medicines

corticosteroids, antidepressants, and seizure medicines.

These medicines can slow the rate at which your body burns calories, increase your

appetite, or cause your body to hold on to extra water.

Emotional Factors

Some people eat more than usual when they're bored, angry, or stressed.

Smoking

Some people gain weight when they stop smoking. One reason is that food often

tastes and smells better after quitting smoking.

Another reason is because nicotine raises the rate at which your body burns

calories, so you burn fewer calories when you stop smoking. However, smoking is a

serious health risk, and quitting is more important than possible weight gain.



Age

As you get older, you tend to lose muscle, especially if you're less active. Muscle loss can slow down the rate at which your body burns calories.

Midlife weight gain in women is mainly due to aging and lifestyle, but menopause also plays a role. Many women gain about 5 pounds during menopause and have more fat around the waist than they did before.

Pregnancy

women gain weight to support their babies’ growth and development. After giving birth, some women find it hard to lose weight.

Lack of Sleep

Sleep helps maintain a healthy balance of the hormones that make you feel hungry (ghrelin) or full (leptin). When you don't get enough sleep, your level of ghrelin goes up and your level of leptin goes down. This makes you feel hungrier than when you're well-rested.

Sleep also affects how your body reacts to insulin. Lack of sleep results in a higher than normal blood sugar level, which may increase your risk for diabetes.


Endocrine society guidelines In January, 2015, the Endocrine Society released new guidelines on the treatment of

obesity to include the following:

Diet, exercise, and behavioral modification should be included in all obesity

management approaches for body mass index (BMI) of 25 kg/m 2 or higher. Other

tools, such as pharmacotherapy for BMI of 27 kg/m 2 or higher with comorbidity or

BMI over 30 kg/m2 and bariatric surgery for BMI of 35 kg/m 2with comorbidity or

BMI over 40 kg/m 2.

Drugs may amplify adherence to behavior change and may improve physical

functioning such that increased physical activity is easier in those who cannot

exercise initially. Patients who have a history of being unable to successfully lose

and maintain weight and who meet label indications are candidates for weight loss

medications.

Tucker ME. New US obesity guidelines. Treat the weight first. Medscape Medical News. Available at http://www.medscape.com/viewarticle/838285.

Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J ClinEndocrinol Metab. 2015 Feb. 100(2):342-62

http://www.medscape.com/viewarticle/838285

Endocrine society guidelines

To promote long-term weight maintenance, the use of approved weight loss medication is suggested to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI of 30 kg/m 2 or higher or in individuals with a BMI of 27 kg/m 2 and at least one associated comorbid medical condition (hypertension, dyslipidemia, type 2 diabetes mellitus, and obstructive sleep apnea).

If a patient's response to a weight loss medication is deemed effective (weight loss of 5% or more of body weight at 3 mo) and safe, it is recommended that the medication be continued. If deemed ineffective (weight loss less than 5% at 3 mo) or if there are safety or tolerability issues at any time, it is recommended that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered.


Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2015 Feb. 100(2):342-62


Endocrine society guidelines In patients with type 2 diabetes who are overweight or obese,

antidiabetic medications that have additional actions to promote weight loss (such as glucagon-like peptide-1 [GLP-1] analogs or sodium-glucose-linked transporter-2 [SGLT-2] inhibitors) are suggested, in addition to the first-line agent for type 2 diabetes mellitus and obesity, metformin.

In obese patients with type 2 diabetes mellitus who require insulin therapy, at least one of the following is suggested: metformin, pramlintide, or GLP-1 agonists to mitigate associated weight gain due to insulin.

Angiotensin-converting enzyme (ACE) inhibitors, angiotensinreceptor blockers (ARBs), and calcium channel blockers, rather than beta-adrenergic blockers, should be considered as first-line therapy for hypertension in patients with type 2 diabetes mellitus who are obese.


Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J ClinEndocrinol Metab. 2015 Feb. 100(2):342-62


WHO classification

The most widely accepted classifications are those from the World Health

organization based on BMI:

o Grade 1 overweight (commonly and simply called overweight) - BMI of 25-29.9 kg/m 2

o Grade 2 overweight (commonly called obesity) - BMI of 30-39.9 kg/m 2

o Grade 3 overweight (commonly called severe or morbid obesity) - BMI ≥40 kg/m 2

Some authorities advocate a definition of obesity based on percentage of body fat, as follows:

o Men - Percentage of body fat greater than 25%, with 21-25% being borderline

o Women - Percentage of body fat great than 33%, with 31-33% being borderline

Obesity related comorbidities

The clinician should also determine whether the patient has had any of the

comorbidities related to obesity, including the following :

Respiratory - Obstructive sleep apnea, respiratory infections, increased incidence of

bronchial asthma, and Pickwickian syndrome (obesity hypoventilation syndrome)

Malignant - Association with endometrial, prostate, colon, breast, gall bladder, and

possibly lung cancer

Psychological - Social stigmatization and depression

Cardiovascular - Coronary artery disease, essential hypertension, left ventricular

hypertrophy, cardiomyopathy, accelerated atherosclerosis, and pulmonary

hypertension of obesity

Jiao L, Berrington de Gonzalez A, Hartge P, Pfeiffer RM, Park Y, Freedman DM, et al. Body mass index, effect modifiers, and risk of pancreatic cancer: a pooled study of seven prospective cohorts. Cancer Causes Control. 2010 Aug. 21(8):1305-14

Wijga AH, Scholtens S, Bemelmans WJ, de Jongste JC, Kerkhof M, Schipper M, et al. Comorbidities of obesity in school children: a cross-sectional study in the PIAMA birth cohort. BMC Public Health. 2010 Apr 9. 10:184

Li C, Ford ES, Zhao G, Croft JB, Balluz LS, Mokdad AH. Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in men and women: National Health and Nutrition Examination Survey, 2005-2006.

Oreopoulos A, Padwal R, McAlister FA, Ezekowitz J, Sharma AM, Kalantar-Zadeh K, et al. Association between obesity and health-related quality


Central nervous system (CNS) - Stroke, idiopathic intracranial hypertension, and meralgia paresthetica

Obstetric and perinatal - Pregnancy-related hypertension, fetal macrosomia, and pelvic dystocia

Surgical - Increased surgical risk and postoperative complications, including wound infection, postoperative pneumonia, deep venous thrombosis, and pulmonary embolism

Pelvic - Stress incontinence

Gastrointestinal (GI) - Gall bladder disease (cholecystitis, cholelithiasis), nonalcoholic steatohepatitis (NASH), fatty liver infiltration, and reflux esophagitis

Orthopedic - Osteoarthritis, coxa vera, slipped capital femoral epiphyses, Blount disease and Legg-Calvé-Perthes disease, and chronic lumbago

Metabolic - Type 2 diabetes mellitus, prediabetes, metabolic syndrome, and dyslipidemia

Reproductive (in women) - Anovulation, early puberty, infertility, hyperandrogenism, and polycystic ovaries

Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr. 2000 May.


Reproductive (in men) - Hypogonadotropic hypogonadism

Cutaneous - Intertrigo (bacterial and/or fungal), acanthosis nigricans, hirsutism, and

increased risk for cellulitis and carbuncles

Extremity - Venous varicosities, lower extremity venous and/or lymphatic edema

Miscellaneous - Reduced mobility and difficulty maintaining personal hygiene

Management

Treatment of obesity starts with comprehensive lifestyle management (diet,

physical activity, behavior modification).The 3 major phases of any successful

weight-loss program are as follows:

A. Preinclusion screening phase

B. Weight-loss phase

C. Maintenance phase - This can conceivably last for the rest of the patient's life but

ideally lasts for at least 1 year after the weight-loss program has been completed

Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy. Circulation. 2012 Mar 6

Medications

i. Centrally acting medications that impair dietary intake

ii. Medications that act peripherally to impair dietary absorption

iii. Medications that increase energy expenditure

Surgery

• Among the standard bariatric procedures are the following:

• Roux-en-Y gastric bypass

• Adjustable gastric banding

• Gastric sleeve surgery

• Vertical sleeve gastrectomy

• Horizontal gastroplasty

• Vertical-banded gastroplasty

• Duodenal-switch procedures

• Biliopancreatic bypass

• Biliopancreatic diversion

FDA approved medication

• The only medication approved by the US Food and Drug Administration (FDA) in UAE for long-term management of obesity is orlistat(XENICAL)

What is XENICAL?

• XENICAL therapeutic category: gastrointestinal lipase inhibitor

• Indicated in conjunction with a mildly hypo caloric diet for treatment of obese patients with a BMI ≥ 30 kg/m², or overweight patients (BMI > 28 kg/m²) with associated risk factors.

• It is used to loose weight and maintain weight loss

Xenical Summary of Product Characteristics

Mode of Action of XENICAL

• Xenical binds to the lipase enzyme in the stomach and intestine and inhibits its action

• Prevents the absorption of dietary fat by 30%

• Undigested fat is eliminated in the faeces.

Xenical US Prescribing Information

Acts Non Systemically


Contraindications:

- Hypersensitivity to the active substance or to any of the excipients.

- Chronic malabsorption syndrome.

- Cholestasis

- Breast-feeding

Dosage and Administration:

Recommended dose of XENICAL is one capsule, 3 daily taken with water immediately before or with each main meal or up to 1 hour after the meal

If a meal is missed or contains no fat, the dose should be skipped.

Orlistat may reduce absorption of some fat-soluble vitamins (A, D, E, K) and beta carotene. Administer a multivitamin supplement containing fat-soluble vitamins orally daily, 2 hours before or 1 hour after a meal

In order to ensure adequate vitamins intake, patients following a diet should be advised to have a diet rich in fruits or vegetables.

Xenical capsules should be stored below 250C.


If tolerability is an issue!

At the full dose of 120 mg 3 times daily, XENICAL is frequently associated with

such adverse GI events as flatulence, oily stool, diarrhea, and stool incontinence.

Frequently, these adverse events result from the common misconception that

because orlistat blocks fat absorption, people can consume more fat. It is important

to advise patients to reduce total fat intake while on orlistat to reduce the frequency

and severity of adverse events.

XENICAL Drugs interactions

If patient receiving cyclosporine, administer cyclosporine 3 hr after orlistat

For patients receiving levothyroxine, administer orlistat 4 hr apart

In particular, patients on warfarin need closer monitoring because of the potential

for malabsorption of vitamin K.

Efficacy of XENICAL:

Xenical can reduce 5% to 10% of the body weight when accompanied with lifestyle

modification.

Studies have also shown its efficacy among the adolescent age group (12-16 years)

with no major safety issues (except common GI adverse events).

1. Xenical Summary of Product Characteristics

2. Chanoine JP et al. Effect of Orlistat on weight and body composition in obese adolescents. JAMA. 2005;293:2873-2883

Eat less fat

Reduce meal portion size

Increase physical activity

Xenical + lifestyle modification resulted in statistically superior weight loss both in short and long term

-10.6

-6.2 -5.8

-3

-12

-10

-8

-6

-4

-2

0

1 year 4 years

Xenical +diet

Placebo +diet

LSM

wei

ght

loss

(kg

)

LSM: lean squares mean

p<0.001 p<0.001

Torgerson JS, et al. Diabetes Care 2004; 27(1):155–61.

XENDOS study

Xenical plus diet produces significantly more weight loss than diet alone in obese diabetic patients

49

2318

9

0

10

20

30

40

50

≥ 5% Weight Loss ≥ 10% Weight Loss

Xenical 120mgtid (n=139)

Placebo

Percentage of patients with type II diabetes mellitus who had lost ≥5% and ≥ 10 % of initial body weight at 1 year

% o

f Pa

tien

ts

p<0.001 p=0.017

Hollander et al. Diabetes Care 1998;21; 1288-1294

Better management of obese type II diabetes

Xenical reduces Total Cholesterol and LDL-C levels

-11.9

-4

-17.6

-7.6

-20

-15

-10

-5

0

Total Cholesterol LDL cholesterol

Xenical +diet

Placebo +diet

Mea

n C

han

ge (

%)

p<0.001 p<0.001

Muls E et al .Int J Obes Relat Metab Disor 2001;25(11): 1713-21

Safety Profile:

Because the drug is not systemically absorbed, most adverse effects are limited to

the gastrointestinal tract.

Most commonly reported adverse events are GI symptoms : fatty and oily stools

Generally mild, transient side effects and decrease with time.

GI events linked to high fat intake.


Take home message!

Xenical can be used to loose weight in patients with risk factors such as type 2 DM, hypertension and hyperlipidemia.

It can be used to maintain weight loss.

Xenical has a well characterized safety profile.

We are sitting on a ticking time bomb, our world is ready to ignite!! Let us ignite it with awareness and save our patients.

Prepared by: Heba Abou DiabClinical pharmacistMarketing specialist

obesity presentation american hospital

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