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OBESITY
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Learning Objectives
 To define and classify obesity.
 To evaluate a patient presenting with obesity.
 To recognize the complications of obesity and the associated
health risks.
 To discuss the different management strategies of obesity.
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DEFINITION
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Definition
 Obesity is a chronic medical condition characterized by excess
adipose tissue.
 It is usually defined as body mass index (BMI) ≥ 30 kg/m2.
 BMI is a mathematical formula related to body fat. It is
calculated by dividing weight (in kg) by square of height (in
meters), or by using a BMI calculator .
 Obesity is categorized into :
o Class I obesity if BMI is 30-34.9kg/m2
o Class II obesity if BMI is 35-39.9kg/m2
o Class III or severe obesity if BMI>40 kg/m2.
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Etiology and Pathogenesis

 Obesity is caused by a positive energy imbalance among food
intake, food absorption and energy expenditure .
 Some underlying causes of Obesity include:
 Possible organic causes such as psychiatric disturbances,
hypothyroidism, Cushing syndrome, or insulinoma.
 Certain medications can cause or contribute to obesity such as
corticosteroids, anti-psychotics and anti-depressants.
 Some genetic syndromes such as Prader-Willi account for a small
percentage of people with obesity .
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Health Risks Associated with Obesity

 Obesity is associated with established health risks such as an
increased risk of:
o Diabetes mellitus
o Hypertension
o Cardiovascular diseases
o Osteoarthritis
o Certain types of cancer.
 The highest risk for increased mortality and morbidity is found
in the context of abdominal obesity.
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Complications
 Cardiovascular risks: Atherosclerotic disease,
thromboembolism , hypertension , heart failure , and stroke .
 Endocrine problems : diabetes mellitus, and hyperlipidemia.
 Pulmonary risks: Hypoventilation , sleep apnea syndrome, and
pulmonary hypertension.
 Musculoskeletal : Gout, and osteoarthritis .
 Gastrointestinal : gallbladder disease, and gastroesophageal
reflux.
 Higher death rates from cancer : colon, breast, prostate,
endometrium, liver and kidney.
 Psychosocial impact : poor self-esteem , discrimination, and
social isolation.
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EPIDEMIOLOGY
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Epidemiology
 Obesity is a major global health challenge .
 The worldwide prevalence of overweight or obesity is around
36% in men and 38 % in women in 2013.
 There is a substantial global increase of overweight or obesity
prevalence in 2013 compared to 1980 prevalence.
 Prevalence of overweight or obesity is higher in developed
countries.
 Predominant age : incidence rises in early 20s.
 Predominant sex : female>male.
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RISK FACTORS
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Risk Factors
 Advancing age
 Sedentary life style
 Parental obesity
 High intake of calorie-dense food
 Prolonged television viewing (>2 hours/day)
 Low socioeconomic status: increased risk of obesity with
decreased socioeconomic status in developed countries is
thought to be partly due to:
o lower consumption of healthy foods
o lack of access to sports facilities
o lower participation in sports
o lower physical activity outside work
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EVALUATION
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Medical History (1)

 Present Illness : ask about
o Prior attempts of weight loss
o Willingness to change lifestyle
o Diet and exercise practice
o Symptoms that may suggest endocrine disorders (thyroid ,
Cushing )
o Associated risk factors: diabetes mellitus, hypertension, lipid
disorders, sleep apnea.
 Medication history:
o Ask about medication use that may produce weight gain
 Past medical history (PMH):
o Ask mainly about mood disorders and psychiatric history
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Medical History (2)

• Family history:
o Ask about family history of obesity

• Social history:
o Assess current level of physical activity
o Ask about possible behavioral and biopsychosocial risk
factors for weight gain such as smoking cessation, recent
illness, and stressful events
o Ask about social support and resources
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Physical Exam
 General physical exam: determine elevated BMI and excess
adipose tissue
o Measure height and weight to calculate BMI.
o Estimate fat distribution pattern: assess abdominal obesity by
measuring waist circumference. Abdominal obesity is defined as a
waist circumference >102 cm for men and >88 cm.
 Measure blood pressure
o Measuring weight and blood pressure will help identifying risk
factors for complications such as metabolic syndrome.
 Look for signs that may suggest endocrine disorders (such as
moon face , thin skin , facial plethora suggesting Cushing ; dry ,
coarse skin , puffiness and goiter suggesting hypothyroidism) .
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Diagnostic Tests
 Tests are requested to screen for underlying physiologic causes
and for associated comorbidities or complications of obesity:
o Serum Lipid panel to screen for hyperlipidemia: total cholesterol,
low and high density lipoprotein cholesterol (LDL and HDL),
triglycerides.
o Fasting blood sugar, hemoglobin A1C or oral glucose tolerance test
to identify prediabetes, diabetes or metabolic syndrome.
o Liver function tests for non-alcoholic steatohepatitis.
o Complete blood count: polycythemia may be seen (if alveolar
hypoventilation).
o Thyroid function tests: to check for hypothyroidism.
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MANAGEMENT
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Treatment Goals
 Weight loss of 5%-15% may greatly reduce complications in
obese or overweight persons.
 The goal of therapy is to achieve and sustain long term weight
loss of at least 10% of body weight .
 Before deciding on treatment, assess the following:
o Degree of health risk (from BMI and waist circumference)
o Motivation to lose weight
o Patient–specific goals of treatment
o Need for intensive diet and exercise , as well as behavior
modification , and counseling
o Possibility of providing long term follow up
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Weight Loss Strategies

 Diet and exercise are the two primary strategies for losing
weight.
 According to the Academy of Nutrition and Dietetics (AND):
o The optimum rate of weight loss should be around 0.45-0.91
kg/week.
o The initial weight loss goal is up to 10% of body weight , but is 3%-
5% of body weight if cardiovascular risk factors are present (AND
strong recommendation).
o The caloric expenditure (including resting metabolic rate, thermic
effect of feeding, and physical activity) must exceed caloric intake
for any diet to be effective.
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Diets For Weight Loss

 Caloric intake must be lower than caloric expenditure for
any diet to be effective:
o Adults can lose around 0.5-1 kg/week by consuming 500-1000
fewer kcal/day.
o Most diets have good short-term results but limited long-term
efficacy.
o General advice to increase intake of vegetable and fruit, high
fibers and whole grains and reduce sugar-sweetened beverages
may contribute to weight loss.
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Effective Diets
 Portion control plate
 Low-fat diet
 Mediterranean diet
 Low-carbohydrate diet
 Low glycemic index diet
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Be cautious of the Very Low Calorie Diet

 The very low-calorie diet of 400-800 kcal/day is not
recommended.
 It can result in more rapid weight loss than the higher calorie
diets but is less effective in the long term.
 It has many associated complications such as:
o Dehydration
o Orthostatic hypotension
o Fatigue
o Muscle cramps
o Headache
o Relapse after interruption
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Exercise
 Exercise may help in weight loss, especially if combined with
dietary changes.
o Low amount of exercise (such as walking 30 minutes/day) seems
adequate to avoid weight gain, and longer exercise time promote
weight loss.
o Multiple short-bout exercise (10 minutes sessions,4 times per day,
5 days/week ) seem equivalent to long-bout exercise (40 minutes
session 5 days/week).
 Lifestyle physical activity: for example, brisk walking, raking
leaves, using stairs instead of elevator may be effective in
promoting weight loss.
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Behavior Therapy
 Behavior therapy and cognitive-behavioral methods can be
associated with small reduction in weight but are most
effective when combined with diet and exercise.
 General Behavioral Interventions as recommended by the
American Heart Association:
o Advise overweight and obese adults to participate in a
comprehensive lifestyle program for ≥ 6 months to support
adherence to a lower calorie diet and to increase physical activity.
o Counsel overweight and obese adults with cardiovascular risk
factors that lifestyle modifications may result in modest, sustained
weight loss of 3%-5%.
o Prescribe comprehensive intervention which is high-intensity (such
as ≥ 14 sessions over 6 months), on-site, and delivered by trained
professional in a group or individual setting.
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Patient Education- Lifestyle Changes

 The following weight loss strategies are reported significantly
more among successful attempts:
o Exercising > 30 minutes/day
o Adding physical activity to daily life
o Using fewer nonprescription diet products
o Meal planning on most days of the week
o Tracking calories
o Tracking fat
o Measuring food on the plate
o Weighing oneself daily
o Lifting weights
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Benefits of Weight Loss

 A sustained weight loss of 3%-5% may result in clinically
significant improvement in triglycerides, blood glucose,
Hba1C, and risk of diabetes mellitus type 2.
 Greater amounts of weight loss may reduce blood
pressure, improve LDH and HDL levels, reduce need for
medications to control blood pressure, blood glucose,
lipids, and further reduce triglycerides and blood
glucose.
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Barriers to Loosing Weight

 The following barriers are reported to be associated with lower
likelihood of successful weight loss:
o Lack of time
o Too tired to exercise
o Having no one to exercise with
o Finding it hard to maintain an exercise routine
o Frequent eating away from home
o Cost of diet and health foods
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Medications
 The National Institute of Health advocates that non-
pharmacologic treatment should be tried first for at least 6
months.
 Medication treatment may be then started for unsatisfactory
weight loss in persons with a:
o BMI≥30 without concomitant obesity-related risk factors or
diseases.
o BMI≥ 27 associated with co-morbidities(diabetes mellitus,
coronary artery disease, sleep apnea ,hypertension,
hyperlipidemia)
 Medications should be used in combination with diet, exercise
and behavioral therapy .
 Relapse may occur after discontinuation of the medication.
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First Line Medications – FDA Approved

Orlistat
 Acts as a lipase inhibitor and decreases the absorption of
dietary fat .
 Usually prescribed at the dose of 120 mg orally 3 times/day
with fat containing meals.
 Dose is to be omitted if meal is skipped or does not contain fat.
 Fat-soluble vitamin supplements are prescribed but should not
be taken within 2 hours of taking Orlistat.
 The side effects are mainly gastro-intestinal : cramps , flatus,
fecal incontinence. These side effects may be reduced by
increasing dietary fibers and decreasing dietary fat .
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Second Line Medications- FDA Approved (1)

Lorcaserin
 The addition of Lorcaserin to diet and exercise counseling
may increase weight loss in adults.
 It is usually given at the dose of 10 mg orally twice daily.
 It should be discontinued if patient fails to lose 5% weight
after 12 weeks of use.
 It works as a serotonin agonist and should be avoided
with other serotonergic drugs.
 It is contraindicated in pregnancy.
 It should be avoided if Creatinine Clearance <30
ml/minute.
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Second Line Medications- FDA Approved (2)

Phentermine monotherapy
 Acts as anorexiant , central nervous system stimulant, and
sympathomimetic.
 It is approved as a short-term adjunct and not for long term use .
 Tolerance to the anorectic effect usually develops within few weeks.
 Discontinue the medication if patient develops tolerance or no
response after 4 weeks.
 It should not be used in combination with SSRI antidepressants or
MAOIs .
 It is contraindicated in presence of cardiovascular disease ,
hyperthyroidism, pregnancy and history of substance abuse .
 Available in the following forms:
o Capsule/tablet : 15-37.5 mg daily given in 1-2 divided doses .
o Oral disintegrating tablet (ODT):15-37.5 mg daily every morning.
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Second Line Medications- FDA Approved (3)

 Phentermine plus extended-release Topiramate Combination:
it is contraindicated in pregnancy.
 Diethylpropion : 25 mg before meals three times daily .To be
discontinued if no response after 4 weeks . Contraindicated in
severe hypertension, hyperthyroidism, and history of substance
abuse .
 Naltrexone/Bupropion extended release combination:
approved for adults with obesity or overweight adults with ≥ 1
weight related condition such as hypertension, diabetes
mellitus type 2, or dyslipidemia.
 Liraglutide: a GLP-1 agonist recently approved for obesity
treatment. To be discontinued if patient is unable to lose more
than 4% weight after 16 weeks.
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Other Medications
 Other medications have some efficacy for weight loss, but they
are not FDA approved for this indication. These include:
o Metformin
o Zonisamide
o Bupropion
o Topiramate

 Antiobesity medications withdrawn from market include:

o Phentermine/fenfluramine
o Dexfenfluramine
o Rimonabant
o Sibutramine
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Bariatric Surgeries
 They are part of a continuum of treatment of morbidly obese
patients; they do not replace diet and behavior modification.
 They offer the most effective long-term weight loss treatment
of morbidly obese patients.
 They may result in a loss greater than 20% body weight, which
may be maintained largely for 10 years.
 They require a complex preoperative evaluation and a skilled
follow-up.
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Indications for Surgery

 Body Mass Index (BMI) ≥ 40 kg/m2 (Class 3 obesity) without
coexisting medical problems and without excessive surgical
risk.
 BMI ≥ 35 kg/m2 (Class 2 obesity) and ≥ 1 of severe obesity-
related comorbidities. The aim is weight control and improved
biochemical markers of cardiovascular disease risk.
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Types of Bariatric Surgeries

 Malabsorptive procedures:
o Roux-en-Y gastric bypass
o Bilio-pancreatic diversion with or without duodenal switch
 Restrictive procedures:
o Adjustable gastric banding
o Vertical banded gastroplasty
o Sleeve gastrectomy
 Bariatric surgeries can be conducted as open or laparoscopic
surgeries.
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Effectiveness of Bariatric Surgeries

 Comparing the 4 procedures (except sleeve) with each other , it
is not known which one is the most effective or least harmful.
 It is not known whether sleeve gastrectomy is effective.
 Operative and postoperative complications are common :
o On average, 0.28% of patients die within 30 days of surgery.
o Mortality may be as high as 2% in certain high risk
populations.
 Bariatric surgery may reduce long-term mortality compared
with no surgery.
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Liposuction
 It is not a treatment for obesity.
 Its purpose is esthetic since it is used as means of reshaping
body by removing localized fat deposits.
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Follow Up
 Long term routine follow up of patients may:
o Prevent relapse after weight loss.
o Prevent further weight gain.
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References
1. David Delaet & al. Obesity in Adults-Clinical evidence
Handbook. Am Fam Physician 2010 Oct 15 ;82(8): 974-975.
2. Dynamed (Internet) available from
http://www.ebscohot.com/DynaMed
3. Fleming & al. Global, regional and national prevalence of
overweight and obesity in children and adults during 1980-
2013 . Lancet 2014 Aug 30; (384(9945):746
4. 5-minutes Clinical Consult-Obesity. Lexicomp 2015