Obesidade

M. Helena Cardoso
Instituto de Ciências Biomédicas Abel Salazar
Centro Hospitalar e Universitário do Porto
ICBAS
. 1º Inquérito Nacional de Saúde com Exame Físico (INSEF 2015): Estado de Saúde. Lisboa: INSA IP, 2016.
. 1º Inquérito Nacional de Saúde com Exame Físico
(INSEF 2015): Estado de Saúde. Lisboa: INSA IP, 2016.
Endocr Pract. 2016 Jul;22 Suppl 3:1-203
Medical Clinics of North America 102 (2018)
Endocr Pract. 2016 Jul;22 Suppl 3:1-203
Medical Clinics of North America 102 (2018)

Endocr Pract. 2016 Jul;22 Suppl 3:1-203

• Self Confidence
• Self-determination theory (SDT) argues for a social-contextual
approach to motivation by encouraging patients to have input and
choice (autonomy support) in making healthy lifestyle choices.
• 5As
• Goals (steps, 20minutes x 6 a day, Vegetables – half a plate)

Endocr Pract. 2016 Jul;22 Suppl 3:1-203

The 5 As Model For Weight Management Counseling :
Assess or Ask, Advise, Agree, Assist, Arrange
Agree
• Work with patients collaboratively to agree on a set of goals for behavior change.
• Behavior change goals should be specific, measurable, attainable, relevant, and
time-based
• Specific: Make goals clear and include specific details. “Exercise a lot” is too vague. Instead,
a patient might aim to walk more by going for a 20-minute walk after lunch 3 days per
week.
• Measurable: Define a metric (measure) that lets you know when you have been successful.
“Exercise a lot” is also not measurable. Instead, aiming for an increase of 500 steps per day
is a measurable goal.
• Attainable: Set a goal that is realistic for to achieve. Running a marathon by next week is
unrealistic for most, but aiming to walk for 20 minutes after lunch may be more achievable.
• Relevant: Create a goal that is consistent with the outcome you want to achieve.
• Time-bound: Set goals that can be completed in a specific amount of time.
Thinking through goals using this framework helps to minimize the likelihood of
unrealistic goals and helps to create a structure on how patients can achieve these
goals. Endocr Pract. 2016 Jul;22 Suppl 3:1-203
A range of target behaviors have been identified as effective for weight regulation.
Many come from the National Weight Control Registry, a two decades–old database of successful
weight losers, and other investigations of long-term weight management.
Some of the behaviors that are associated with successful weight loss and weight loss maintenance
include:

• Self-monitoring and self-weighing

• Reduced calorie intake, initially focused on low-fat diets, but more recently shown that most
dietary patterns intended to reduce caloric intake lead to near-equivalent weight loss magnitude
• Smaller and more frequent meals/snacks throughout the day
• Increased physical activity, which has some contribution to initial weight loss but has been shown
to be one of the most consistent predictors of long-term weight loss maintenance
• Eating breakfast
• More frequent at-home meals compared with restaurant and fast-food meals
• Reducing screen time
• Use of portion-controlled meals or meal substitutes
• Reducing sweetened beverage intake

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Medical Clinics of North America 102 (2018)

Endocr Pract. 2016 Jul;22 Suppl 3:1-203

Med Clin N Am 102 (2018) 107–124
Med Clin N Am 102 (2018) 107–124
MyPlate https://www.choosemyplate.gov
Medical Clinics of North America 102 (2018)
Medical Clinics of North America 102 (2018)
 Obesity and 3 Phases of Chronic Disease
Prevention and Treatment

Q1. Do the 3 phases of chronic disease prevention and treatment

Primary,
Secondary,
Tertiary
Apply to the disease of obesity?

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The Anthropometric Component of the Diagnosis of Obesity

Q2. How should the degree of adiposity be measured in the clinical setting?
• Q2.1. What is the best way to optimally screen or aggressively case-find for
overweight and obesity?
• Q2.2. What are the best anthropomorphic criteria for defining excess adiposity in
the diagnosis of overweight and obesity in the clinical setting?
• Q2.3. Does waist circumference provide information in addition to BMI to indicate
adiposity risk?
• Q2.4. Do BMI and waist circumference accurately capture adiposity risk at all levels
of BMI, ethnicities, gender, and age?

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Endocr Pract. 2016 Jul;22 Suppl 3:1-203
Co-Morbilidades Associadas à
Obesidade

Obesidade
Diabetes
Hipertensão
Dislipidemia
Apneia do Sono
Osteoartrite
Insuficiência Venosa
Hipogonadismo Masculino perguntar sempre problemas ao nível da função
sexual
Hiperandrogenismo Feminino
Co-Morbilidades Relacionadas Com o
Peso e Pressão

Peso/Pressão
Doença Articular
Degenerativa
Volume Sanguíneo
Fluxo Sanguíneo Renal
Pressão Intra-abdominal
Pressão intra-torácica (padrão restritivo)
Alterações de Decúbito
Disfunção Psico-Social
 Q4. Does BMI or other measures of adiposity convey full
information regarding the impact of excess body weight on the
patient’s health?

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 Therapeutic Benefits of Weight Loss in Patients
with Overweight or Obesity
Q5. Do patients with excess adiposity and related complications benefit more from weight loss than patients
without complications, and, if so, how much weight loss would be required?
Q5.6. Is weight loss effective to treat nonalcoholic fatty liver disease and nonalcoholic steatohepatitis? How
much weight loss would be required?
Q5.7. Is weight loss effective to treat PCOS? How much weight loss would be required?
Q5.8. ... infertility in women? How much weight loss would be required?
Q5.9. … male hypogonadism? How much weight loss would be required?
Q5.10. … obstructive sleep apnea? How much weight loss would be required?
Q5.11. … asthma/reactive airway disease? How much weight loss would be required?
Q5.12. …osteoarthritis? How much weight loss would be required?
Q5.13. …urinary stress incontinence? How much weight loss would be required?
Q5.14. …gastroesophageal reflux disease (GERD)? How much weight loss would be required?
Q5.15. … improve symptoms of depression? How much weight loss would be required?
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 Individualization of Pharmacotherapy in the Treatment of
Obesity
Q8. Are there hierarchies of drug preferences in patients with the following
disorders or characteristics?
• Q8.1. Chronic kidney disease
• Q8.2. Nephrolithiasis
• Q8.3. Hepatic impairment
• Q8.4. Hypertension
• Q8.5. Cardiovascular disease and arrhythmia
• Q8.6. Depression with or without selective serotonin reuptake inhibitors
• Q8.7. Anxiety
• Q8.8. Psychotic disorders with or without medications (lithium, atypical antipsychotics, monoamine oxidase inhibitors)
• Q8.9. Eating disorders including binge eating disorder
• Q8.10. Glaucoma
• Q8.11. Seizure disorder
• Q8.12. Pancreatitis
• Q8.13. Opioid use
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Macro-intervenções
A Cidade
Caminhos pedestres seguros e agradáveis
Vias para bicicletas
Transportes públicos – transportes individuais
Macro-intervenções
A Cidade
Áreas de lazer
Parques com actividades ao ar livre
Pavilhões gimnodesportivos
Medidas estimuladoras da actividade desportiva
Impostos e medidas fiscais que estimulem a actividade
física
Macro-intervenções
Cantinas escolares
Oferta de alimentos saudáveis
Impostos estimuladores de uma alimentação saudável
Bebedouros públicos
Regulamentar as máquinas de venda automática de
alimentos em lugares públicos, como escolas e hospitais
 Sedentarismo
Jogos de Video
Computadores Individuais
Televisão
Dependência excessiva do automóvel
Mecanização
Sedentarismo
Fast Food and Inactivity are Fueling the
Obesity Epidemic

MEDICINE 2014; 43:2

Fast Food and Inactivity are Fueling the
Obesity Epidemic

MEDICINE 2014; 43:2

 The CARDIA Study
Fast-food Habits, Eight Gain, and Insulin Resistance
15-Year Prospective Analysis.

• Participants with infrequent (less than once a week)

fast-food restaurant use at baseline and follow-up
(n=203),
• Participants with frequent (more than twice a week)
visits to fast-food restaurants at baseline and follow-up
(n=87)
• gained an extra 4.5 kg of bodyweight (p=0.0054) and
had a two-fold greater increase in insulin resistance
(p=0.0083).

Pereira MA, Kartashov AI, et al

 Physical activity and the built
environment

• The proportion of children who meet physical activity (PA) guidelines

of 60  min of moderate-to-vigorous physical activity (MVPA) per day
ranged from 2.0% (Cyprus) to 14.7% (Sweden) in girls and from 9.5%
(Italy) to 34.1% (Belgium) in boys.32
• An additional 10  min per day of MVPA was related to an increased
bone stiffness.33
• Playground density and density of playgrounds and parks combined
showed positive effects on MVPA.35

Family extends the IDEFICS cohort

Ahrens, et al Int J Epidemiol 2016, 1–12
▪ Excess fuel storage in adipose tissue – could have originally represented a
Survival Advantage in previous times when food was relatively scarce and
physical activity was a natural component of everyday life.

▪ The ‘‘Thrifty Gene Hypothesis’’ suggests that we harbor genetic variants

that favor efficient food collection and fat deposition to survive periods of
famine and that, in the face of the easy availability of food, these
genes/variants are disadvantageous.

Cell 161, March 26, 2015

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Endocr Pract. 2016; Suppl 3:1-203
 WAIST CIRCUMFERENCE THRESHOLDS

Ross, R., Neeland, I.J., Yamashita, S. et al. Waist circumference as a vital sign in clinical practice: a Consensus
Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol 16, 177–189 (2020).
https://doi.org/10.1038/s41574-019-0310-7
Lewis et al Endocrine Reviews, 23(2):201-229, 2002
Fat Metabolism in IRS and Type 2 Diabetes

Lewis et al Endocrine Reviews, 23(2):201-229, 2002

Lewis et al Endocrine Reviews, 23(2):201-229, 2002
Ross, R., Neeland, I.J., Yamashita, S. et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR
Working Group on Visceral Obesity. Nat Rev Endocrinol 16, 177–189 (2020). https://doi.org/10.1038/s41574-019-0310-7
Avaliação do Risco da Pessoa Obesa
Quanta Gordura ? - IMC
Onde se localiza a gordura ? - Cintura
Factores de risco tradicionais ?
Hipertensão arterial, dislipidemia,
diabetes, tabagismo
Insulino-resistência ?
Cintura e triglicerídeos,
colesterol/HDL-colesterol ratio
Genes ? - História familiar de hipertensão,
diabetes, DV
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Ross, R., Neeland, I.J., Yamashita, S. et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR
Working Group on Visceral Obesity. Nat Rev Endocrinol 16, 177–189 (2020). https://doi.org/10.1038/s41574-019-0310-7
Gastric banding versus gastric bypass: evolution of anthropometric parameters and
related comorbidities during two years of follow-up after bariatric surgery

Baseline GB (n=51) RYGB (n=58) p

Age (years±SD) 48,4±10,6 45,2±9,2 ns
min-max 20,8-68,4 29,3-64,9 -
Female(n/%) 43/84,3 50/86,2 ns
Male (n/%) 8/15,7 8/13,8 ns
Body weight (Kg±SD) 122±22,5 120,9±15,2 ns
min-max. 96,0-222,0 93,5-156,0 -
BMI (Kg/m2±SD) 47,0±7,8 45,9±5,7 ns
min-max. 35,0-75,9 35,4-60,9 -
Weight excess (Kg±SD) 66,3±20,7 64,1±14,1 ns
min-max. 40,0-159,0 41,0-101,0 -
BMI excess (Kg/m2±SD) 22,0±7,8 20,9±5,7 ns
min-max. 10,0-50,9 10,4-35,9 -
Patients with DM (n/%) 12/23,5 20/34,5 ns
Number of diabetic medications: - - -
1 7/58,3 9/45 -
2 3 /25 4/20 -
≥3 0 3/15 -
Insulin users (n/%) 2/16,7 4/20 -
Patients with dyslipidemia (n/%) 14/27,5 27/46,6 ns
Patients with HT (n/%) 36/70,6 36/62,1 ns
Cardoso H et al European Congress of Endocrinology 2013
Gastric banding versus gastric bypass: evolution of anthropometric parameters and
related comorbidities during two years of follow-up after bariatric surgery

*p<0,01

GB p RYGB p p
COMORBIDITIES n/total (GB n/total (BGYR (GB vs
(% remission) T0-T2) (% remission) T0-T2) BGYR T2)

DM remission 9/12 (75%) <0,05 13/20 (65%) <0,01 ns

HT remission 22/36 (61,1%) <0,01 22/36 (61,1%) <0,01 ns
dyslipidemia remission 9/14 (64,3%) <0,05 23/27 (85,2%) <0,01 ns

Cardoso H et al European Congress of Endocrinology 2013

 Gastric banding versus gastric bypass
Patient with DM remission loose significantly more weight in GB group

DM Remitted
DM Non Remitted

p<0,01 p<0,01 ns ns

%EWL %EBMI lost %EWL %EBMI lost

Gastric banding RYGBP
Two Years of Follow-up
Model for mechanisms of T2DM remission after BS

Bose et al OBES SURG (2009) 19:217–229

Mechanisms of early improvement in glycaemic control after
Roux-en-Y gastric bypass
Acute effects (days to weeks)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of early improvement in glycaemic control after
Roux-en-Y gastric bypass
Acute effects (days to weeks)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of early improvement in glycaemic control after
Roux-en-Y gastric bypass
Acute effects (days to weeks)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of early improvement in glycaemic control after
Roux-en-Y gastric bypass
Acute effects (days to weeks)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of sustained improvement in glycaemic control after
Roux-en-Y gastric bypass
Long-term effects (months to years)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of sustained improvement in glycaemic control after
Roux-en-Y gastric bypass
Long-term effects (months to years)

Dirksen et al Diabetologia (2012) 55:1890–1901

Mechanisms of sustained improvement in glycaemic control after
Roux-en-Y gastric bypass
Long-term effects (months to years)

Dirksen et al Diabetologia (2012) 55:1890–1901

Type 2 Diabetes
Etiology and reversibility

Taylor R Diabetes Care, 36:1047-55, 2013

Locos de Controlo
• Locus de controlo externo:
Os doentes que crêem estar à mercê do
destino ou de qualquer outra força exterior
tendem a apresentar pior adesão ao tratamento e
pior controlo metabólico

Ryan 1997
 Locos de Controlo
•Locus de controlo interno.
Os doentes que crêem que são responsáveis
pela sua saúde , tendem a apresentar uma
melhor adesão ao tratmento e melhor controlo
metabólico.
Ryan 1997
 Patient
Empowerment
TRATAMENTO DA OBESIDADE

Desculpabilizar

Responsabilizar
Relação médico
doente
SIM NÃO
Empatia Confronto
Compreensão Autoritarismo
Disponibilidade Enfado
Ética individual
um desafio quotidiano...

São os pequenos passos individuais

do Homem que fazem os grandes
passos para a humanidade ...
...e não o contrário.
Uma Vida com Saúde
Central Obesity Index
• WHR = waist (cm) / hip (cm)
• WHtR = waist (cm) / height (cm)
• CI = waist (m) / 0.109 × weight kg / height(m)
• AVI = 2 × waist2 (cm) 2 + 0.7 × waist (cm) − hip (cm) 2 /1000

CI – Conicity índex; AVI - abdominal volume index

.