2. Obesity and Risk Factors Dr. Mouna Dakar

3. Definition Obesity is defined as an excess accumulation of body fat This excess accumulation is the result of a positive energy balance where caloric intake exceeds caloric expenditure It is the most common nutritional disorder in industrialized countries and is becoming increasingly prevalent in developing countries due to changing lifestyles.

5. Overweight and obesity among adults Health Survey for England 2011-2013 4Patterns and trends in adult obesity Adult (aged 16+) overweight and obesity: BMI ≥ 25kg/m 2 More than 6 out of 10 men are overweight or obese (66.2%) More than 5 out of 10 women are overweight or obese (57.6%)

6. Adult BMI status by sex Health Survey for England 2011-2013 5Patterns and trends in adult obesity Adult (aged 16+) BMI thresholds: Underweight: <18.5kg/m 2 Healthy weight: 18.5 to <25kg/m 2 Overweight: 25 to <30kg/m 2 Obese: ≥30kg/m 2

7. Adult obesity prevalence by age Health Survey for England 2011-2013 6Patterns and trends in adult obesity Adult (aged 16+) obesity: BMI ≥ 30kg/m 2

8. Dietary Management for Older Subjects with Obesity http://www.learnwell.org/nutri.htm

9. Etiology Multifactorial disorders Genetics:  polygenic, each gene having a small contribution in the presence of precipitating environmental factors  It has been long known that the tendency to gain weight runs in families. However, family members share not only genes but also diet and life style habits that may contribute to obesity.  morbid obesity has a stronger genetic component than moderate level of excess overweight Energy imbalance Diet  obesity is associated with increased food consumption  Intake of excess dietary fat has been implicated as a major cause of obesity Exercises  For a decades A strong link exists between physical inactivity and weight gain

10. Cont. Diseases  Hypothyroidism, Cushing’s syndrome, pancreatic insulinoma, growth hormone deficiency, and hypothalamic insufficiency  A variety of psychosocial factors contribute to the development of obesity and to difficulty losing weight Drugs  antipsychotics (phenothiazines, butyrophenones); antidepressants and antiepileptics, (tricyclic antidepressants, lithium, valproate, carbamazepine); and insulin and some oral hypoglycemics. Whereas most of these medications contribute modestly to obesity,  the large doses of steroids sometimes used to treat autoimmune diseases can cause true obesity

12. Health Effects of Obesity Obesity is associated with more than 30 medical conditions, and scientific evidence has established a strong relationship with at least 15 of those conditions It has been established that obesity is associated with an increased prevalence of coronary artery disease, hypertension, diabetes mellitus, and other diseases. In addition, life expectancy is shown to be reduced in those who are obese or overweight.

13. Cont. Diabetes (Type 2)  As many as 90% of individuals with type 2 diabetes are reported to be overweight or obese.  Obesity has been found to be the largest environmental influence on the prevalence of diabetes in a population.  Obesity complicates the management of type 2 diabetes by increasing insulin resistance and glucose intolerance, which makes drug treatment for type 2 diabetes less effective.  A weight loss of as little as 5% can reduce high blood sugar.

14. Cont. Hypertension  Over 75% of hypertension cases are reported to be directly attributed to obesity.  Weight or BMI in association with age is the strongest indicator of blood pressure in humans.  The association between obesity and high blood pressure has been observed in virtually all societies, ages, ethnic groups, and in both genders.  The risk of developing hypertension is five to six times greater in obese adult Americans, age 20 to 45, compared to non-obese individuals of the same age.

15. Cont. Cardiovascular Disease (CVD)  Obesity increases CVD risk due to its effect on blood lipid levels.  Weight loss improves blood lipid levels by lowering triglycerides and LDL (“bad”) cholesterol and increasing HDL (“good”) cholesterol.  Weight loss of 5% to 10% can reduce total blood cholesterol.  The effects of obesity on cardiovascular health can begin in childhood, which increases the risk of developing CVD as an adult.  Overweight and obesity increase the risk of illness and death associated with coronary heart disease.  Obesity is a major risk factor for heart attack, and is now recognized as such by the American Heart Association.

16. Multiple cardiovascular risk factors drive adverse clinical outcomes Abdominal obesity Dyslipidaemia Hypertension Glucose intolerance Insulin resistance Increased Cardiometabolic Risk Metabolic Syndrome

17. Abdominal obesity and increased risk of CHD Waist circumference was independently associated with increased age-adjusted risk of CHD, even after adjusting for BMI and other CV risk factors 0.0 0.5 1.0 1.5 2.0 2.5 3.0 <69.8 69.8-<74.2 74.2-<79.2 79.2-<86.3 86.3-<139.7 1.27 2.06 2.31 2.44 p for trend = 0.007 Relative risk Rexrode et al 1998 Quintiles of waist circumference (cm)

18. Unmet clinical need associated with abdominal obesity Patients with abdominal obesity (high waist circumference) often present with one or more additional CV risk factors CV risk factors in a typical patient with abdominal obesity

19. Cont. Stroke  Elevated BMI is reported to increase the risk of ischemic stroke independent of other risk factors including age and systolic blood pressure.  Abdominal obesity appears to predict the risk of stroke in men.  Obesity and weight gain are risk factors for ischemic and total stroke in women.

20. Osteoarthritis (OA)  Obesity is associated with the development of OA of the hand, hip, back and especially the knee.  At a Body Mass Index (BMI) of > 25, the incidence of OA has been shown to steadily increase.  Modest weight loss of 10 to 15 pounds is likely to relieve symptoms and delay disease progression of knee OA.

21. Sleep Apnea  Obesity, particularly upper body obesity, is the most significant risk factor for obstructive sleep apnea.  There is a 12 to 30-fold higher incidence of obstructive sleep apnea among morbidly obese patients compared to the general population.  Among patients with obstructive sleep apnea, at least 60% to 70% are obese.

22. Cont. Impaired Respiratory Function Infertility Liver Disease Low Back Pain Surgical Complications Daytime Sleepiness

23. Cont. Cancers Carpal Tunnel Syndrome (CTS) Chronic Venous Insufficiency (CVI) & Deep Vein Thrombosis (DVT) Gallbladder Disease Gout abdominal hernias

24. Risk Factors for Cancers Cigarettes/Tobacco Betel Nut (lime?) Hepatitis B Obesity Hyperglycaemia Physical Activity Dietary Factors –Fat –Fibre –Meat (cooking methods) –Alcohol –Vegetables and Fruits –Omega 3 fatty acids

25. Obesity and Cancer Obesity is associated with the following types of cancer:  colon  breast (postmenopausal)  endometrium (the lining of the uterus)  kidney  gallbladder  pancreas  esophagus National Cancer Institute

26.  Obesity and physical inactivity may account for 25%-30% of cancer of the colon, breast (postmenopausal), endometrial, kidney, and esophagus  Preventing weight gain can reduce the risk of many cancers. Healthy eating and physical activity early in life can prevent overweight and obesity. National Cancer Institute Obesity and Cancer

31. HISTORY

32. History : You must take full Hx with out forgetting to ask about obesity cause(s) … ( Etiology ) -Energy imbalance -familial -Diseases -Medications

33. And ask about diseases which arising from obesity like: DM II HTN CVD OA Sleep apnea…. & Other diseases

34. All of the systems that make the body function are affected by morbid obesity

35. Cardiovascular System Digestive System Endocrine System Musculoskeletal System Nervous System Reproductive System Respiratory System Urinary System Dermatology System (Skin) Immune System

36. Examination

37. Examination: 1st impressions. Vital signs: PR RR BP and Temperature General examination. Size of thyroid size of abdominal organs e.g. liver… Heart and lung sounds.

38. Evaluation : Also you must evaluate the patient obesity by calculating BMI. BMI = weight (kg) / [ height (m) ]²

39. Although several classifications and definitions for degrees of obesity are accepted, the most widely accepted classifications are those from the World Health Organization (WHO), based on body mass index (BMI). The WHO designations are as follows: Grade 1 overweight (commonly and simply called overweight) - BMI of 25-29.9 kg/m 2 Grade 2 overweight (commonly called obesity) - BMI of 30-39.9 kg/m 2 Grade 3 overweight (commonly called severe or morbid obesity) - BMI ≥40 kg/m 2

40. Investigations

41. Laboratory Data:

42. ParameterNormal Range Blood glucose80-100 mg/dl Cholesterol< 200 mg/dl Triglycerides< 150 mg/dl HDL40 - 60 mg/dl LDL< 100 mg/dl Hemoglobin13-16 mg/dl Hematocrit36-44% TSH0.35-5.50 Cortisole5-25 am 3-16 pm µg/dl Serum iron40-140 mg/dl Uric acid(3.5-7.8) Hemoglobin A1c*4.8-6.3%

43. Additional Tests : ECG x-ray U.S

46. The “Toxic Environment” Physical Activity is… –To be avoided –Nearly unnecessary –Limited by infrastructure Brownell KD & Horgen KB. Food Fight. New York: McGraw-Hill; 2003.