MANAGEMENT OF OBESITY

Glucose Pyruvate Glycerol Amino Acids Pyruvate Glycerol Glycerol Acetyl CoA Acetyl CoA Acetyl CoA Fatty Acids Fatty Acids Fatty Acids Stored Fat Stored Fat Stored Fat

BMI (Body Mass Index BMI) BMI= ( )/ ( 2 ) (kg/m 2 ) 108kg 1.8m BMI=108/(1.8x1.8)=33.3(kg/m 2 )

WHO (1) BMI25 (kg/m 2 ) (2) BMI 23.0-24.9 24.9 (kg/m 2 ) (3) BMI 18.5-22.9 (kg/m 2 )

25 * - 8285 20 1993-1996 Prevalence (%) 15 10 5 Men Women 24.8% 25.5% 4!! 0 25-30 >30 (BMI)

) ( )

3( ) 2-3 1-2 -WHO, IOTF & IASO

10 Relative Risk 7.5 2.5 5 Diabetes BP Dyslipidaemia NASH 0 <23 23 25 30 BMI

12.6 42.4 100.0 4520 100.0 2616 100.0 1904 8.9 404 4.6 121 14.9 283 >27 16.2 731 8.0 208 27.5 523 24-27 17.5 793 11.7 306 25.6 487 22-24 44.6 2016 56.1 1467 28.8 549 18-22 12.7 576 19.6 514 3.3 62 <18 BMI(kg/m 2 ) 2003-BMI

CMO 2004 100 7717 100 3393 100 4324 3.2 250 1.5 151 2.3 99 >30 6.7 517 11.1 377 3.2 140 27-30 16.3 1257 26.3 894 8.4 363 24-27 18 1392 24.9 845 12.6 547 22-24 39.6 3055 27.9 947 48.7 2108 18.5-22 16.1 1246 5.3 179 24.7 1067 <18.5 % % % BMI

OBESITY : - : Framingham Study - x2 fold Nurses Health Study - x3.3 Swedish Women s Study - x3.7

OBESITY: DAILY CALORIE INTAKE -800-1500 kcal/day AIM FOR O.5 KG WT LOSS/WEEK INVOLVES:

OBESITY: ENERGY INTAKE <800 kcal/day HIGH PROTEIN LOW CHO MINUIMUM 400 kcal/day & 40 gm protein eg casein, egg, soy USEFUL SHORT-TERM, 3kg/wk loss NEEDS SUPERVISION!

OBESITY: MAXIMUM WT LOSS -15% body wt INITIALLY loss of Na+ & H2O - especially LOW CHO DIET LOSS OF LEAN BODY MASS - prevent with 40-50 gm protein/day MOST EFFECTIVE AGE >40 years & BMI <35kg/m 2

OBESITY: SHORT-TERM RESULTS IMPRESSIVE - up to 1 kg/wk with total 10-15 kg LONG-TERM RESULTS RARELY SUCCESSFUL Bjorvell & Rossner (1985) - 4 year study, women: 11.5 kg loss; men: 18.4 kg Binnie (1977) - 10 year study: NO loss Hughes & Stock (1990) - 2 year study of Commercial Slimming Clubs: WT GAIN!

OBESITY: MOST WIDELY USED, incorporated into slimming clubs, etc COMBINED WITH DIET Rx - sustained wt loss over 3.3 yrs (Holden et al, 1992) COMBINED WITH DRUG Rx -only useful short term (Stunkard, 1980) INTENSIVE COUNSELLING NEEDED, TRAINED PERSONNEL,PERSEVERENCE

OBESITY: AS MONOTHERAPY: average wt loss 0.5 kg./week, up to 14 kg in 6 months (Wadden & Stunkard, 1986) PLUS INTENSIVE DIET Rx, etc: - up to 30.9 kg in 1 year - attrition rate low (Bjorvell & Rosner, 1985)

OBESITY: EXERCISE PRODUES FAT LOSS - rarely >5% body wt APPETITE SHORT TERM LONG TERM UNKNOWN some studies show increased appetite & food intake (Woo et al 1982, Blair 1981)

OBESITY: EXERCISE OTHER BENEFITS INCLUDE: HDL cardiovascular fitness NEED 20-30 MINS CONSTANT EXERCISE TO LOSE approx 1000 kcals in order to lose weight NOT USEFUL IN: severely obese, elderly, arthritic, etc

Anti-Obesity Drugs Only consider if: BMI 30 3/12 of diet, exercise and behaviour modification fails May be appropriate with BMI 27 if Risk factors present Permitted by drug company

Anti-Obesity Drugs NEVER use as sole method of treatment Monitor regularly Discontinue if: Weight loss <5% after 12/52 Weight regain Combination therapy contraindicated

Orlistat (Xenical) Lipase inhibitor Reduces absorption of dietary fat Used with reduced calorie diet Only licensed for 2 years use Severe side effects May consider vitamin supplementation May gain weight once stopped

FDA approved

Surgery Consider as a last resort if Behavioural/dietary modification failed BMI >40 Mortality high Procedures Vertical banded gastroplasty Gastric bypass Lap-band procedures

Criteria for surgery >18y Morbid obesity Already had intensive management Failed to maintain weight loss No clinical / psychological C/I Understand, committed to long term follow up

OBESITY: OVERALL STRATEGY DEPENDS ON: age severity medical problems previous attempts patient commitment

OBESITY: MANAGEMENT STRATEGY MILD OBESITY - diet, exercise & behaviour or group therapy MODERATE OBESITY - ADD short term anorectics, VLCD, individualised psychotherapy GROSS OBESITY - CONSIDER gastroplasty

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Case I Question I Question II 1. 2. 3. Question III

PLAN PLAN PLAN DO DO DO CHECK CHECK CHECK ACT ACT ACT P D A C Cycle1 Cycle1 Cycle1

PLAN PLAN PLAN DO DO DO CHECK CHECK CHECK ACT ACT ACT P D A C Cycle2 Cycle2 Cycle2

Case II Question I Question II 1. 2. 3. Question III

PLAN Cycle1 DO DO P D ACT A C CHECK

PLAN PLAN PLAN DO DO DO CHECK CHECK CHECK ACT ACT ACT P D A C Cycle2 Cycle2 Cycle2