1 Obesity Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

Aim-Objectives 2 Aim: At the end of this session, the participants will have knowledge on burden of obesity, its complications, and management. Objectives: At the end of this session, the trainees should be able to describe Body Mass Index (BMI) in categories discuss the health risks associated with obesity. identify the components of obesity management beable to explain screening recommendations for obesity.

Global Prevalence of Obesity in Adult Males % Obese 0-9.9% % % % % ≥30% Self Reported data North America USA 31% Mexico 19% Canada (self report) 17% Guyana 14% Bahamas 14% South Central America Panama 28% Paraguay 23% Argentina (urban) 20% Uruguay (self report) 17% Dominican Republic 16% Africa South Africa 10% Seychelles 9% Cameroon (urban) 5% Ghana 5% Tanzania (urban) 5% South East Asia & Pacific Region Nauru 80% Tonga 47% Cook Island 41% French Polynesia 36% Samoa 33% Eastern Mediterranean Lebanon 36% Qatar 35% Jordan 33% Kuwait 28% Saudi Arabia 26% European Region Croatia 31% Cyprus 27% Czech Republic 25% Albania (urban) 23% England 23% With examples of the top 5 Countries in each Region With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity TaskForce, London –January 2007

Global Prevalence of Obesity in Adult Females South East Asia & Pacific Region Nauru 78% Tonga 70% Samoa 63% Niue 46% French Polynesia 44% Africa Seychelles 28% South Africa 28% Ghana 20% Mauritania 19% Cameroon (urban) 14% South Central America Panama 36% Paraguay 36% Peru (urban) 23% Chile (urban) 23% Dominican Republic 18% North America USA 33% Barbados 31% Mexico 29% St Lucia 28% Bahamas 28% Eastern Mediterranean Jordan 60% Qatar 45% Saudi Arabia 44% Palestine 43% Lebanon 38% European Region Albania 36% Malta 35% Turkey 29% Slovakia 28% Czech Republic 26% % Obese 0-9.9% % % % % ≥30% Self Reported data With examples of the top 5 Countries in each Region With the limited data available, prevalence's are not age standardised. Self reported surveys may underestimate true prevalence. Sources and references are available from the IOTF. © International Obesity TaskForce, London –January 2007

Body Mass Index (BMI) The BMI is an easily obtained and reliable measurement for obesity and is defined as a person's weight (in kilograms) divided by the square of the person's height (in meters). Example: 72 kg, 166 cm person = 72 / 1.66 x 1.66 = 72 / 2.75 = 26.1

Obesity classification. Obesity is further divided into three separate classes, with Class III obesity being the most extreme of the three. Obesity classBMI (kg/m 2 ) Class I Class II Class III (Extreme Obesity) ≥ 40.0 With a BMI of:You are considered: Below 18.5Underweight Healthy Weight Overweight 30 or higherObese CDC, NHLBI

7 BMI (kg/m 2 ) Height (in.) Weight (lb.)

Waist circumference For men, <94cm is low, cm is high and > 102cm is very high For women, <80cm is low, 80-88cm is high and > 88cm is very high

Several serious medical conditions have been linked to obesity

History in Obese Patient A full history must include: Onset Recent weight change Occupation A dietary inventory and an analysis of the subject's activity level. Screening for depression Screening for eating disorders Previous comorbidities Explore causes of secondary obesity

Previous trial & experiences to lose weight Family history of weight problems. The patient's expectations The patient's level of motivation. Medication history. 11

Selected Medications That Can Cause Weight Gain  Psychotropic medications –Tricyclic antidepressants –Monoamine oxidase inhibitors –Specific SSRIs –Atypical antipsychotics –Lithium –Specific anticonvulsants   -adrenergic receptor blockers SSRI=selective serotonin reuptake inhibitor Diabetes medications – Insulin – Sulfonylureas – Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid hormones – Glucocorticoids – Progestational steroids

Physical examination In the clinical examination, 1. Measure anthropometric parameters,height weight, BMI 2. Waist to hip ratio. 3. Skin fold thickness Perform a standard, detailed examination skin : Look for hirsutism in women, intertriginous rashes, acanthosis nigricans, and possible contact dermatoses. CVS: BP ( appropriate calf size) Look for cardiomegaly and respiratory insufficiency. Abdomen: hepatomegaly ( fatty liver) LL +,- odema

Lack of time Lack of recognition of obesity as a chronic condition Insufficient data Lack of data Lack of patient interest Inadequate training 17 Physician Barriers to Evaluation and Treatment of Obesity

Obesity Treatment Non pharmacological Diet Physical activity Behavioral therapy pharmacological Pharmacotherapy Surgical 18

comorbid ities Waist circumference BMI classificaion Very high highlow overweight Obesity I Obesity II Obesity III General advice on healthy weight and lifestyle Diet and physical activity Diet and physical activity; consider drugs Diet and physical activity; consider drugs; consider surgery

Management General recommendations: Avoid complications such as excessive loss of lean body mass, dehydration, electrolyte imbalance, gallbladder disease and psychological distress Physicians engaging in weight loss counseling also should consider their own weight and set an example for their patients by demonstrating healthy weight management

No body is exempted from obesity. It can be you.

Most adults regain any weight loss within five years. It is a life-long challenge to achieve and maintain a healthy weight since it needs a long-term commitment to lifestyle change,

Techniques of Motivational Interviewing 23 Support self efficacy  Provide choices  Reassure of expected outcomes Express empathy  Express acceptance and understanding  Use reflective listening and expect ambivalent Explore discrepancies  Let individuals explore their reasons for changing or not changing their behavior Avoid arguments  Avoid judging and labeling  Change strategies if patient shows resistance Promote empowerment  Patients are a source of solutions, and since obesity is a self-managed disease, the patient is in charge and responsible of his or her own care Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American Diabetic Association; 2002

Techniques For Modifying Behavior 24 Self monitoring  Recording of target behavior and associated factors, found to be most helpful  Recording diary of food, exercise Stimulus control  Restricting environmental factors influencing inappropriate behaviors  Eating at specific times  Setting time and place for exercise  Avoid buying food items that are difficult to control eating Contingency management  Rewarding appropriate behavior  Short term contracts to formalize agreements Cognitive restructuring  Move thinking pattern from self rejection toward self acceptance  Changing thinking patterns from unrealistic goals to realistic and achievable goals Stress management  Learning methods to reduce stress and tension, since both are a primary predictor of relapse  Relaxation techniques as diaphragmatic breathing, progressive muscle relaxation and meditation  Regular exercise Adapted and modified from Marion J, Diane R, Arlene M. Implementing Group & Individual Medical Nutrition Therapy for Diabetes. American Diabetic Association; 2002.

A reasonable goal for weight-loss in the setting of a medical treatment program is approximately kg/wk

Dietary therapy Very low-calorie diets (VLCDs) are best used in an established, comprehensive program. VLCDs involve reducing caloric intake to 800 kcal/d or less. When used in optimal settings, they can achieve weight loss of kg/wk, with a total loss of as much as 20 kg over 12 weeks. Unless a long-term maintenance calorie-deficit program is developed and adhered, to recidivism after the diet is stopped is rapid. Most subjects quickly regain all the weight they lose and often gain more.

Calorie needs calculation Men BMR = 66 + (13.7 x W) + (5 x H) - (6.8 x Age) Women BMR = (9.6 x W) + (1.8 x H) - (4.7 x Age) Total daily calorie needs Sedentary - none or very little exercise: BMR X 1.2 Light activity for average of 2 days/week: BMR X Moderate activity level exercising 4 days/week: BMR X 1.5 High activity levels more than 6 days/week: BMR X 1.7 Higher activity levels: up to 2 x BMR 27 BMR=Basal Metabolic Rate (Harris Benedict calculation)

Example 30 year old 80 kg, 168 cm woman Basal Metabolic Rate (BMR)= (9.6 x 80) + (1.8 x 168) - (4.7 x 30) BMR = 1594 calories If light activity: 1594 x calories 28

Recommended Average Daily Energy Men Age (year) Kcal\day 11 to 14 2, to 18 3, to 24 2, to 50 2, ,300 Women (non-pregnant, non-lactating ) 11 to 14 2, to 18 2, to 24 2, to 50 2, ,900 Adapted from National Research Council

Physical activity Aerobic isotonic exercise is of the greatest value for subjects who are obese. The ultimate minimum goal should be to achieve minutes of continuous aerobic exercise 5-7 times per week. People who have been obese and have lost weight should be advised they may need to do min of activity\day to avoid regaining weight

Pharmacological Therapy Pharmacotherapy is limited to use in patients with a BMI of 30 or more and no accompanying obesity- related risk factors or diseases, or patients with a BMI of 27 or more with accompanying obesity-related risk factors or diseases patient who have not reached their target weight loss or have reached a plateau on dietary. activity and behavioral change alone.

Pharmacotherapy Major groups Centraly acting Impair deitry Intake (sibutramine) Act peripherally to impair absorption (orlistat) Increase energy Expenditure (Mazindol, Phentermine)

Indications for Medication NICE 2001/ABPI MEDICINES COMPENDIUM 2002/2005

Surgery may be considered for Patient with BMI 40 or more BMI 35 – 40 with other risk factors All appropriate non-surgical measures have been tried but failed. As 1 st line option ( instead of lifestyle interventions or drug treatment) for adults with a BMI of>50. Types of surgery: Gastric banding. Gastric bypass. Vertical banded gastroplasty.

Referral  The underlying causes need to be assessed.  The person has complex disease state and can ’ t be managed in primary care  Conventional treatment has failed.  Drug therapy is considered for a person with a BMI>35kg\m 2  Surgery is being considered.

NHLBI Practical Guide. Oct 2000 Figure 2, pg 13 Algorithm for the treatment of obesity

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