Morbid Obesity

Morbid Obesity
Dr Imran Abbas
Medical Unit 2
Sheikh Zayed Hospital
Rahim Yar Khan
What is Obesity
For adults, WHO defines overweight and obesity as follows:
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What is BMI
The body mass index (BMI) is a measure that uses your height and
weight to work out if your weight is healthy.
The BMI calculation divides an adult's weight in kilograms by their
height in metres squared. For example,
   
   BMI= Weight(kg)/Height(m²)
What is morbid obesity
Class II obesity, formerly known as morbid obesity,
 
 is a complex chronic disease in which a person has a
  
body mass index (BMI)
 of 40 or higher
 
OR
 
BMI of 35 or higher and is experiencing obesity-related
  
health conditions.
Waist Circumference
Excess abdominal fat, assessed by measurement of waist
   
circumference or waist-to-hip ratio, is independently associated
 
 
 
with a higher risk for diabetes mellitus and cardiovascular disease.
Measurement of the waist circumference is a surrogate for visceral
adipose tissue 
a
nd should be performed in the horizontal plane above
the iliac 
crest
Pathological Consequences Of Obesity
Obesity has major adverse effects on health.
Obesity is associated with an increase in mortality, with a 50–100%
increased risk of death from all causes compared to normal-weight
individuals, mostly due to 
cardiovascula
r causes.
Mortality rates rise as obesity increases, particularly when obesity is
associated with increased intra abdominal fat.
Life expectancy of a moderately obese individual could be shortened
by 2–5 years, and a 20- to 30-year-old male with a BMI >45 may lose
13 years of life. It is likely that the degree to which obesity affects
particular organ systems is influenced by susceptibility genes that
vary in the population.
Obesity Related Organ Tissue Review
Cardiovaseular
Hypertension
Congestive heart failure
Cor pulmonale
Varicose veins
Pulmonary embolism
Coronary artery disease
 
Endocrine
Metabolic syndrome
Type 2 diabetes
Dyslipidemia
Polycystic ovarian syndrome
Musculoskeletal
Hyperuricemia and gout
Immobility
Osteoarthritis (knees and hips)
Low back pain
Carpal tunnel syndrome
Psychological
Depression
low self-esteem
Body image disturbance
Social stigmatization
Integument
Striae distensae
Stasis pigmentation of legs
Lymphedema
Cellulitis
Acanthosis nigricans
Acrochordon (skin tags)
Repiratory
Dyspnea
Obstructive sleep apnea
Hypoventilation syndrome OR
Pickwickian syndrome
Asthma
Gastrointestinal
Gastroesophageal Reflux  disease
Nonalcoholic fatty liver disease
Cholelithiasis
Hernias
colon cancers
Genitourinary
Urinary stress incontinence
Obesity related glomerulopathy
Hypogonadism (male)
Breast and uterine cancer
Pregnancy complications
Neurological
Stroke
Idiopathic intracranial hypertension
Meralgia paresthetica
Dementia
TREATMENT
Goals of Therapy; The decision of how aggressively to
   treat the patient and which modalities to use is determined by the
   patient’s risk status, expectations, and available resources
Setting an initial weight-loss goal of 8–10% over 6 months is a realistic
target. Treatment strategies include
1.
Lifestyle Management
2.
Pharmacotherapy
3.
Surgery
Lifestyle Management
Diet Therapy:
 Guidelines from the American Heart
Association/American College of Cardiology/The Obesity Society
recommend initiating treatment with a calorie deficit of 500–750
kcal/d compared with the patient’s habitual diet. Alternatively, a diet
of 1200–1500 kcal/d for women and 1500–1800 kcal/d for men.
For example choosing smaller portion sizes, eating more fruits and
vegetables, consuming more whole-grain cereals, selecting leaner
cuts of meat and skimmed dairy products, reducing consumption of
fried foods and other foods with added fats and oils, and drinking
water instead of sugar-sweetened beverages.
Physical Activity Therapy:
 The 2008 Physical Activity Guidelines for
Americans recommend that adults should engage in 150 min of
moderate-intensity or 75 min a week of vigorous-intensity aerobic
physical activity per week, performed in episodes of at least 10 min
and preferably spread throughout the week.
A high level of physical activity (>300 min of moderate-intensity
activity per week) is often needed to lose weight and sustain weight
loss.
Behavioral Therapy
: Cognitive behavioral therapy is used to help
change and reinforce new dietary and physical activity behaviors.
Strategies include self-monitoring techniques (e.g., journaling,
weighing, and measuring food and activity); stress management;
stimulus control (e.g., using smaller plates, not eating in front of the
television or in the car); social support; problem solving; and
cognitive restructuring to help patients develop more positive and
realistic thoughts about themselves
PHARMACOTHERAPY
Centrally acting anorexiant medications
; By increasing satiety and
decreasing hunger, these agents help patients reduce caloric intake
without a sense of deprivation.
Among anorexiant 
phentermine
 is most commonly prescribed
. The biologic effect of these agents on appetite regulation is
produced by augmentation of the neu
totransmission 
of three
monoamines: norepinephrine; serotonin (5-hydroxytryptamine [5-
HT]); and, to a lesser degree, dopamine.
Lorcaserin
 is a selective 5-HT2C receptor agonist
. It is thought to
decrease food intake through Pro-opiomelanocortin(POMC) system of
neurons
Naltrexone SR/bupropion SR 
(NB) is a combination of an opioid
antagonist and a mild reuptake inhibitor of dopamine and
norepnephrine.
GLP-1 Agonists ( liraglutide) 
, liraglutide inhibits both gastric
emptying and glucagon secretion and stimulates GLP-1 receptors in
arcuate nucleus of hypothalamus to reduce feeding.
Peripherally Acting medications
Orlistat;
 This drug is a potent, slowly reversible inhibitor of
pancreatic, gastric, and carboxylester lipases and phospholipase A2,
which are required for the hydrolysis of dietary fat into fatty acids and
monoacylglycerols.
Orlistat acts in the lumen of the stomach and small intestine by
forming a covalent bond with the active site of these lipases.
Taken at a therapeutic dose of 120 mg tid,
Blocks the digestion and absorption of ~30% of dietary fat.
Surgery
BARIATRIC SURGERY: can be considered for patients with severe
obesity (BMI, ≥40 kg/m2) or for those with moderate obesity (BMI,
≥35 kg/m2) associated with a serious medical condition.
It has been classified into three categories on the basis of anatomic
changes: restrictive, restrictive malabsorptive, and malabsorptive.
Restrictive Surgery includes
1.
Laproscopic adjustable gastric Binding
2.
Laproscopic sleeve gastrectomy
INTRALUMINAL GASTRIC BALLOONS
: Recently, the FDA approved
two gastric balloon devices for weight loss that are placed in the
stomach endoscopically.
The 
RESHAPE device 
consists of two silicone balloons attached to a
central silicone shaft, whereas the 
ORBERA
 is a single-balloon device.
Both are approved for upto 6 months of use in adults with BMI Of 30-
40kg/m².
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Morbid obesity, its definition, BMI, and the pathological consequences it has on health. Dr. Imran Abbas's medical unit at Sheikh Zayed Hospital in Rahim Yar Khan specializes in treating morbid obesity and related health conditions.


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  1. Morbid Obesity Dr Imran Abbas Medical Unit 2 Sheikh Zayed Hospital Rahim Yar Khan

  2. What is Obesity For adults, WHO defines overweight and obesity as follows: Overweight is a BMI equal to or greater than 25 and Obesity is a BMI equal to or greater than 30.

  3. What is BMI The body mass index (BMI) is a measure that uses your height and weight to work out if your weight is healthy. The BMI calculation divides an adult's weight in kilograms by their height in metres squared. For example, BMI= Weight(kg)/Height(m )

  4. What is morbid obesity Class II obesity, formerly known as morbid obesity, is a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher OR BMI of 35 or higher and is experiencing obesity-related health conditions.

  5. Waist Circumference Excess abdominal fat, assessed by measurement of waist circumference or waist-to-hip ratio, is independently associated with a higher risk for diabetes mellitus and cardiovascular disease. Measurement of the waist circumference is a surrogate for visceral adipose tissue and should be performed in the horizontal plane above the iliac crest

  6. Pathological Consequences Of Obesity Obesity has major adverse effects on health. Obesity is associated with an increase in mortality, with a 50 100% increased risk of death from all causes compared to normal-weight individuals, mostly due to cardiovascular causes. Mortality rates rise as obesity increases, particularly when obesity is associated with increased intra abdominal fat. Life expectancy of a moderately obese individual could be shortened by 2 5 years, and a 20- to 30-year-old male with a BMI >45 may lose 13 years of life. It is likely that the degree to which obesity affects particular organ systems is influenced by susceptibility genes that vary in the population.

  7. Obesity Related Organ Tissue Review Cardiovaseular Hypertension Congestive heart failure Cor pulmonale Varicose veins Pulmonary embolism Coronary artery disease Endocrine Metabolic syndrome Type 2 diabetes Dyslipidemia Polycystic ovarian syndrome

  8. Musculoskeletal Hyperuricemia and gout Immobility Osteoarthritis (knees and hips) Low back pain Carpal tunnel syndrome Psychological Depression low self-esteem Body image disturbance Social stigmatization

  9. Integument Striae distensae Stasis pigmentation of legs Lymphedema Cellulitis Acanthosis nigricans Acrochordon (skin tags)

  10. Repiratory Dyspnea Obstructive sleep apnea Hypoventilation syndrome OR Pickwickian syndrome Asthma Gastrointestinal Gastroesophageal Reflux disease Nonalcoholic fatty liver disease Cholelithiasis Hernias colon cancers

  11. Genitourinary Urinary stress incontinence Obesity related glomerulopathy Hypogonadism (male) Breast and uterine cancer Pregnancy complications Neurological Stroke Idiopathic intracranial hypertension Meralgia paresthetica Dementia

  12. TREATMENT Goals of Therapy; The decision of how aggressively to treat the patient and which modalities to use is determined by the patient s risk status, expectations, and available resources Setting an initial weight-loss goal of 8 10% over 6 months is a realistic target. Treatment strategies include 1. Lifestyle Management 2. Pharmacotherapy 3. Surgery

  13. Lifestyle Management Diet Therapy: Guidelines from the American Heart Association/American College of Cardiology/The Obesity Society recommend initiating treatment with a calorie deficit of 500 750 kcal/d compared with the patient s habitual diet. Alternatively, a diet of 1200 1500 kcal/d for women and 1500 1800 kcal/d for men. For example choosing smaller portion sizes, eating more fruits and vegetables, consuming more whole-grain cereals, selecting leaner cuts of meat and skimmed dairy products, reducing consumption of fried foods and other foods with added fats and oils, and drinking water instead of sugar-sweetened beverages.

  14. Physical Activity Therapy: The 2008 Physical Activity Guidelines for Americans recommend that adults should engage in 150 min of moderate-intensity or 75 min a week of vigorous-intensity aerobic physical activity per week, performed in episodes of at least 10 min and preferably spread throughout the week. A high level of physical activity (>300 min of moderate-intensity activity per week) is often needed to lose weight and sustain weight loss.

  15. Behavioral Therapy: Cognitive behavioral therapy is used to help change and reinforce new dietary and physical activity behaviors. Strategies include self-monitoring techniques (e.g., journaling, weighing, and measuring food and activity); stress management; stimulus control (e.g., using smaller plates, not eating in front of the television or in the car); social support; problem solving; and cognitive restructuring to help patients develop more positive and realistic thoughts about themselves

  16. PHARMACOTHERAPY Centrally acting anorexiant medications; By increasing satiety and decreasing hunger, these agents help patients reduce caloric intake without a sense of deprivation. Among anorexiant phentermine is most commonly prescribed . The biologic effect of these agents on appetite regulation is produced by augmentation of the neutotransmission of three monoamines: norepinephrine; serotonin (5-hydroxytryptamine [5- HT]); and, to a lesser degree, dopamine.

  17. Lorcaserin is a selective 5-HT2C receptor agonist. It is thought to decrease food intake through Pro-opiomelanocortin(POMC) system of neurons Naltrexone SR/bupropion SR (NB) is a combination of an opioid antagonist and a mild reuptake inhibitor of dopamine and norepnephrine.

  18. GLP-1 Agonists ( liraglutide) , liraglutide inhibits both gastric emptying and glucagon secretion and stimulates GLP-1 receptors in arcuate nucleus of hypothalamus to reduce feeding.

  19. Peripherally Acting medications Orlistat; This drug is a potent, slowly reversible inhibitor of pancreatic, gastric, and carboxylester lipases and phospholipase A2, which are required for the hydrolysis of dietary fat into fatty acids and monoacylglycerols. Orlistat acts in the lumen of the stomach and small intestine by forming a covalent bond with the active site of these lipases. Taken at a therapeutic dose of 120 mg tid, Blocks the digestion and absorption of ~30% of dietary fat.

  20. Surgery BARIATRIC SURGERY: can be considered for patients with severe obesity (BMI, 40 kg/m2) or for those with moderate obesity (BMI, 35 kg/m2) associated with a serious medical condition. It has been classified into three categories on the basis of anatomic changes: restrictive, restrictive malabsorptive, and malabsorptive. Restrictive Surgery includes 1. Laproscopic adjustable gastric Binding 2. Laproscopic sleeve gastrectomy

  21. INTRALUMINAL GASTRIC BALLOONS: Recently, the FDA approved two gastric balloon devices for weight loss that are placed in the stomach endoscopically. The RESHAPE device consists of two silicone balloons attached to a central silicone shaft, whereas the ORBERA is a single-balloon device. Both are approved for upto 6 months of use in adults with BMI Of 30- 40kg/m .

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