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