1. OBESITY Fighting the Battle of the Bulge

2. Overview  Energy  Definition of obesity  Etiology/pathogenesis  Obesity/health hazards  Evaluation of the obese patient  Why is it so difficult to maintain weight loss?  Treatment

3. A 50 year old patient has gained 60 pounds since the age of 30. What has been the daily average excess calorie intake in excess of average calories used? A 50 year old patient has gained 60 pounds since the age of 30. What has been the daily average excess calorie intake in excess of average calories used? A. 30 B.100 C.150 D.250 E.500

4. Energy Expenditure Resting metabolic rate70% Thermic effect of food15% Physical Activity15%

5. Caloric intake equals caloric expenditure Weight stable Caloric intake greater than caloric expenditure Weight gain Caloric intake less than caloric expenditure Weight loss

6. Definition of Obesity  Body Mass Index (BMI) of 30 or more in adults  BMI = weight in kilograms/height squared in meters  Children BMI 95 th percentile or above for age and sex

8. Etiology  Prenatal influences  Breast feeding  Women (pregnancy, menopause)  Men (sedentary lifestyle)  Sleep deprivation  Cessation of smoking  Diet  Medications  Socioeconomic

9. Medications  Antipsychotics  Antidepressants  Antiepileptics  Diabetic  Beta–blockers  Glucocorticoids

10. Genetics  Prader-Willi (Chromosome 15 q 11-13)  Several other single gene mutations have been identified  FTO gene (fat mass and obesity associated) Chromosome 16  Genes encoding the melanocortin -4 receptor (MC4R)  ? “thrift” gene

11. Health Hazards  Hypertension  Dyslipidemia  Cardiovascular disease  “Metabolic syndrome”

12. Cancer (Men)  Liver  Stomach  Pancreas  Esophagus  Rectum  Gallbladder  Multiple Myeloma

13. Cancer (Women)  Uterus  Kidney  Cervix  Pancreas  Esophagus  Gallbladder  Breast  Liver  Ovary  Colon  Rectum

14. Other Risks Related to Metabolic Effects  Gastrointestinal  Kidney  Endocrine/infertility

15. Other Risks Related to Increased Body Mass  Bone and joint disease  Pulmonary disease  Social stigmatization

16. Evaluation  BMI  Waist circumference  Waist : hip ratio  Blood pressure  Lipid panel  Glucose

17. Why is it so difficult to lose weight and maintain weight loss?

18. Answer: Our bodies defend our current weight and this makes both weight loss and maintenance of weight loss difficult.

19. Treatment  Diet  Physical exercise  Behavioral modification

20. When These Fail  Pharmacologic therapy  Bariatric surgery

21. Diet  Diet composition is less important than total calories consumed!!!

22. Diets  Low-carbohydrate diets  Low-fat diets  Low-energy dense diets  Portion controlled/very low-calorie diets  Commercial weight-loss programs  Alternative/natural/herbal diets

23. Behavioral Modifications  Setting realistic goals  Self-monitoring  Control of stimuli that activates eating  Slowing down the eating process  Social support

24. Exercise  May benefit glycemic control  Beneficial effects on cholesterol  Beneficial effects on blood pressure  Good modality in weight maintenance and as a component of weight loss

25. Pharmacologic  Sibutramine  Orlistat

26. Surgical (Bariatric)  Generally reserved for BMI of 40 or above  May consider with BMI of 35 and comorbidities

27. Types  Restrictive  Malabsorptive

28. Summary  Caloric intake that exceeds caloric expenditure results in weight gain!!!