1

Obesity and Endocrine Disorders

Dr EM SelepeMBChB(Natal) FCA(SA)

1 Military HospitalThaba Tshwane

2

Obesity DefinitionO Excess of body fat sufficient to adversely

affect healthO BMI is used as the surrogate markerO Obesity is often defined in terms of the BMIO BMI does not take body build into

consideration and hence can be misleading in the presence of large muscle mass

O Fat distribution can be central (abdominal) or gluteo-femoral

O Central obesity has increased CVS risk factors

3

Obesity AssessmentO BMI commonly usedO Waist to hip circumference ratio (WHR)

can be used or waist circumference aloneO Using BMI Wt/Ht squared (kg/m2)O WHO classification:1. <18,5 Underweight2. 18.5 - 24.9 Healthy3. 25 – 29.9 Overweight4. 30 – 39 Obese5. >40 Morbid Obesity

4

Obesity Assessment“Cont”

O WHR (waist to hip ratio) O Male >1.0 Female >0.9O Waist circum Male> 103cm and

female >88 cmO Generally Waist < 100cm suggests

insulin resistance less likely in all sexes

5

EpidemiologyO Rapid increase in both developed

and developing countriesO Prevalence on the increase stats

from the UK:1. 1980 6% of male and 8% of female2. 2000 increase to 21% and 21.4%

respectively3. Now 55% of population is

overweight or obese

6

Clinical Problems O Psycho-social:1. Poor self esteem and image2. Depression3. WithdrawnO Medical:1. Gastro-oesophageal disease (GED)2. Secondary hypertension 3. Pulmonary hypertension4. Obstructive sleep apnoea (OSA)

7

Anaesthetic PracticeO Upper airway1. Short neck, neck circumference

(male 42cm , female 41cm)2. Fat padding3. Large face- difficulty in holding

mask4. Mallampati grades 3 to 4,

Thyromental <6cm and sternomental < 12cm distance

5. Poor mouth opening

8

Anaesthetic Practice“cont”

O Lower Airway:1. Poor lung compliance2. Increased airway resistance – chest bulk3. Higher peak airway pressures4. Pulmonary hypertension5. Decreased FRC leading to atelectasis

and hypoxia6. Increased abdominal pressure

decreasing the FRC ( Functional residual capacity )

9

Anaesthetic Practice“Cont”

O Cardio-vascular System: 1. Secondary hypertension2. LVH, LAH leading to diastolic dysfunction3. RVH from pulmonary hypertension leading

to RHF4. Prone to DVT and pulmonary

thromboembolism – worsening pulmonary HPT

5. OSA leads to hypercapnia, sympathetic over stimulation worsening pulmonary and systemic hypertension .

10

Anaesthetic practice “cont”

O GIT1. Gastric emptying- delyed,

potential full stomach2. Gastroeosophageal disease ( reflux)3. Associated disease ( hiatus hernia)4. Pressure on the splanchnic vessels

compromises liver perfusion.

11

Anaesthetic considerations

Anticipated problems:O Airway managementO Potential full stomach ( starvation

period prolonged , ulcer prophylaxis )O Positioning of patient and intravenous

accessO Co - morbid diseasesO Possible post op high care or ICU – OSAO Deep venous thrombosis prophylaxis

12

Endocrine Disorders( Metabolic Syndrome ) O Components 1. > Waist circumference2. Increased insulin resistance

( Diabetes mellitus)3. high LDL , decreased HDL4. Hypertension

13

Diabetes mellitus and Obesity

O There is increased incidence of obesity and Diabetes

O Obese patients have increased resistance to insulin.

O Type 2 diabetes is common in these population

O Commonly on oral hypoglycaemics and or insulin.

14

Diagnostic Criteria( WHO classification)

Venous plasma glucose ( mmol/l)

Normal Fasting2hrs post prandial

<6.0<7.8

diabetic Fasting2hr post prandial

>7.0>11.1

IGT(Impaired glucose tolerance)

Fasting 2hr post prandial

<7.0>7.8 – 11.1

IFG(Impaired fasting glucose)

Fasting 6.0 -6.9

15

Aims of TreatmentO Sensitize receptors

(thiazolidinediones , Biguanides )O Increases the B cells production of

insulin( sulphonylurea , Biguanides , GLP I (glucagon like peptide 1) )

O Decrease absorption (alpha1 gylcosidase inhibitors)

O Insulin replacement

16

Anaesthetic considerations

O Uncontrolled DM1. Dehydration (polyuria , polydypsia)2. Hyperosmolality (HONK)3. SepsisO Chronic DM1. Potential full stomach2. Autonomic and peripheral neuropathy3. Coronary artery diseases and HPT4. Kidney dysfunction/failure

17

Conclusion

O There is an accelerated prevalence of obesity and diabetes mellitus in South Africa and knowledge of the two entities is of essence as it is also part of metabolic syndrome.

O Airway management and the clinical dynamics of the two should be well appreciated.