OBESITY

Prof. Ahmed M Athab

 ‫قال النبي محمد (صلى الله عليه‬
‫وآله وسلم)‬
‫*( ما مأل آدمي وعاء شرًا من بطنه‪.‬‬
‫بحسب ابن آدم لقيمات يقمن صلبه‪،‬‬
‫فإن كان والبد فاعًال‪ :‬فثلث لطعامه‪ ،‬و‬
‫ثلث لشرابه ‪ ،‬و ثلث لَنَفسه )‬
‫*(إياكم و البطنة ‪ ،‬فإنها مفسدة للبدن و‬
‫مورثة للسقم و مكسلة عن العبادة )‬
•According to Statistics on Obesity, 57% of
adult women and 66% of adult men are
overweight or obese
• More than 20% of adults in the UK, and
more than 30% in USA, are obese (i.e. body
mass index, BMI ≥ 30 kg/m
•The prevalence of obesity has increased
∼threefold within the last 20 years and
continues to rise.
Body Mass Index (BMI) is the
global method of determining
overweight/obesity

BMI = wt/ht²
(kg/m²)
 Body mass index (BMI)

Body Mass Index (BMI) can be used to

identify if an adult is a correct weight for Recommended BMI range (adults)
height.
Less than 18.5 Underweight
BMI can be calculated as follows: 18.5 to 25 Desirable or
healthy
range
25-30 Overweight
BMI = weight (kg) 30-35 Obese (Class I)
(height in m)2 35-40
Over 40
Obese (Class II)
Morbidly or severely
obese (Class III)
Obesity is defined as having a body mass index (BMI) greater than or equal to
30 kg/m2.

BMI is your weight (in kgs) divided by a square of your height (in meters).
 :People who are obese are more likely to suffer from

also risk for

gall stones;
• arthritis;
• some types of cancers, i.e. colon, breast, kidney
and stomach
Body fat distribution
• For some complications of obesity, the distribution rather
than the absolute amount of excess adipose tissue appears
to be important.
• Increased intra-abdominal fat causes 'central' ('abdominal',
'visceral', 'android' or 'apple-shaped') obesity, which
contrasts with subcutaneous fat accumulation causing
'generalised' ('gynoid' or 'pear-shaped') obesity; the former
is more common in men and is more closely associated with
type 2 diabetes, the metabolic syndrome and cardiovascular
disease
• The key difference between these depots of fat probably lies
in their vascular anatomy, with intra-abdominal fat draining
into the portal vein and thence directly to the liver. Thus
many factors which are released from adipose tissue
(including free fatty acids; 'adipokines' such as tumour
necrosis factor alpha (TNF-α), adiponectin and resistin; and
steroid hormones including cortisol) may be at higher
concentration in the liver and hence induce insulin
resistance and promote type 2 diabetes (
 % Overweight Adults – UK

70
60
50
40
Male
30 Female
20
10
0
1980 1997

Erens & Primatesta 1999

 % Obese Adults – UK

20
18
16
14
12
10 Male
8 Female
6
4
2
0
1980 1997

Erens & Primatesta 1999

 WHO classification of obesity
BMI = weight(kg)/height(m)2
WHO Classification BMI Risk of Death

Underweight Below 18.5 Low

Healthy weight 18.5-24.9 Average

Overweight (grade 1 obesity) 25.0-29.9 Mild increase

Obese (grade 2 obesity) 30.0-39.0 Moderate/severe

Morbid/severe obesity(grade 3) 40.0 and above Very severe

World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Geneva:
WHO, 1997 [3]
 Body fat distribution
Apple shaped obesity

cm
Women Men

cm (80cm) = Increased risk 88> cm (90cm) = Increased risk 102>

Lean MEJ et al. Lancet; 1998; 351:853-6

 Causes of Obesity
Accumulation of fat results from a discrepancy
between energy consumption and expenditure

Energy Energy
Intake Expenditure

,nutritional, activity levels, endocrine

genetic, drugs
 Energy balance

To maintain body weight it is necessary to balance energy

intake (from food and drink) with energy expenditure (from
.activity)

.This is called energy balance

When energy intake is higher than energy output, over time

.this will lead to weight gain (positive energy balance)

When energy intake is lower than energy output, over time

.this will lead to weight loss (negative energy balance)
• POTENTIALLY REVERSIBLE CAUSES OF WEIGHT GAIN
Endocrine factors
• Hypothyroidism
• Hypothalamic tumours or injury
• Cushing's syndrome
• Insulinoma
Drug treatments
• Tricyclic antidepressants
• Corticosteroids
• Sulphonylureas
• Sodium valproate
• Oestrogen-containing contraceptive pill
• β-blockers
Relationship Between Obesity
and Mortality

Obesity is a global
disease & according
to the world health
organization figures,
at least 2.8 million
people die each year
as a result of being
obese.
• Data from population studies, such as that in
Framingham, USA, show that for individuals aged
between 30 and 42 years, the risk of death
increases by 1% per annum for each 0.5 kg
increase in weight; for those aged 50-62, this
figure is 2%.
• The result is that obesity reduces life expectancy
by 7.1 years in men and 5.8 years in women
amongst non-smokers, and by 13.7 and 13.3
years respectively amongst smokers. Coronary
heart disease is the major cause of death but
cancer rates are also increased in the overweight,
especially colorectal cancer in males and cancer
of the gallbladder, biliary tract, breast,
endometrium and cervix in females.
• Obesity can be quantified conveniently using the body
mass index (BMI). BMI is calculated as the person's
weight in kilograms divided by the square of his or her
height in metres (kg/m2
• A simple measure which reflects the degree of
abdominal obesity is the waist circumference, measured
at the level of the umbilicus. A waist circumference of >
102 cm in men or > 88 cm in women indicates that the
risk of metabolic and cardiovascular complications of
obesity is high.
• More sophisticated measurements of body composition,
including percentage body fat estimation by
bioimpedance or dual energy X-ray absorptiometry
(DEXA) scanning, are available but of uncertain clinical
value
• The history of weight gain is most helpful in considering
underlying causes. A patient who has recently begun to
gain substantial weight for the first time or at a faster rate
than previously, and is not taking relevant drugs is more
likely to have an underlying disorder such as
hypothyroidism or Cushing's syndrome
• . A more detailed history and examination should be
performed with these conditions in mind. Coronary heart
disease is the major cause of death performed on one
occasion, and an overnight dexamethasone suppression
test or 24-hour urine free cortisol if Cushing's syndrome
is suspected. Monogenic and 'syndromic' causes of
obesity are usually only relevant in children presenting
with severe obesity
 Benefits of 10% Weight Loss
Mortality >20% fall in total mortality
>30% fall in diabetes related deaths
>40% fall in obesity related deaths
Blood pressure fall of 10mmHg systolic and
diastolic pressure

Diabetes 50% fall in fasting glucose

Lipids 10% dec. total cholesterol

15% dec. in LDL
30% dec. in triglycerides
8% inc. in HDL
?..What about this man
Treating obesity demands a multi-
faceted approach with chronic
monitoring
Decreased caloric intake .1
Increased exercise .2
Behavioral modification .3
Pharmacotherapy -/+ .4
Surgery -/+-5.5
A reasonable goal for most patients is to.6
lose 10% of body weight
 Set reasonable expectations
Gradually develop regular exercise •
Gradually develop more healthy eating •
Shoot for losing 5-10% of body weight first •
Decreased caloric intake .1
kcal/day less than usual 1000 - 500 •
Lose 1-2 lbs/week –
Women: 1000 - 1200 kcal/day total diet •
Men: 1200 - 1500 kcal/day total diet •
 Increased exercise .2
Exercise regularly •
Need to gradually work up to this –
Start with brisk walking 10-45 min, 3-5 –
days/week
Work up to 60-80 min, most or all days/week –
Aim to expend 1,000 - 2,000 kcal/week –

NHLBI, ACSM
 Conclusion

Obesity & its wide spectrum of comorbidities can be prevented

by the following measures:
•Following a calorie deficit diet.
•Limiting energy intake from total fats and sugars.
•Increasing consumption of fruit and vegetables, as well as
legumes, whole grains and nuts.
•Engaging in regular physical activity (60 minutes a day for
children and 150 minutes spread throughout the week for
adults).
Drugs
• A huge investment has been made by the
pharmaceutical industry to find drugs for obesity.
The side-effect profile has limited the use of
many earlier agents, but two drugs are currently
available and newer agents are likely to be
approved and marketed soon
• There is no role for diuretics, or for thyroxine
therapy without biochemical evidence of
hypothyroidism
1-Orlistat
• inhibits pancreatic and gastric lipases and
thereby decreases the hydrolysis of ingested
triglycerides, reducing dietary fat absorption by
∼30%. The drug is not absorbed and adverse
side-effects relate to the effect of the resultant
fat malabsorption on the gut, namely loose
stools, oily spotting, faecal urgency, flatus and
the potential for malabsorption of fat-soluble
vitamins. Orlistat is taken with each of the three
main meals of the day and the dose can be
adjusted (60-120 mg) to minimise side-effects.
 Orlistat (Xenical)
)Improves TC, LDL, TG, HbA1c, glucose •
:Side-effects mostly GI •
Oily spotting, flatus, fecal –
urgency/incontinence
2-Sibutramine
• reduces food intake through β1-adrenoceptor and
hydroxytryptamine, serotonin) receptor agonist activity in
the central nervous system. Weight loss achieved with
this agent is 3-5 kg better than placebo with 6 months'
therapy and is associated with an improvement in lipid
profile. Side-effects include dry mouth, constipation and
insomnia. Unfortunately, noradrenergic effects of the
drug can increase heart rate and blood pressure; these
effects are especially undesirable in many obese
patients, so that this agent is usually a second choice
after orlistat and cannot be used in those with
hypertension or cardiovascular disease. There is
insufficient evidence to recommend co-prescription of
orlistat and sibutramine
 Sibutramine (Meridia)
Appetite suppressant, ? thermogenic •
Proven efficacy, even at one year of tx •
Improves TC, LDL, TG, HbA1c •
:Side-effects •
,Headache, elevated BP, insomnia –
constipation, dry mouth
loss achieved with this agent is 3-5 kg better
than placebo with 6 months
Surgery
• 'Bariatric' surgery to reduce the size of the
stomach is by far the most effective long-
term treatment for obesity
• Several approaches are used and all can
be performed laparoscopically.
Summary of treatment based on
BMI and risk
BMI 25-30, no RF advise wt loss •
BMI 30-35: treat, +/- meds •
BMI 35-39.9, no RF: treat, +/- meds •
BMI 35-39.9, + RF: treat; +/- meds; •
consider surgery
BMI >= 40: treat; +/- meds; consider •
surgery
Semaglutide and liraglutide (suxanda)is in a •
class of medications known as glucagon-like
peptide-1 receptor agonists, or GLP-1 RAs.
GLP-1 is a hormone naturally released in the
gastrointestinal tract in response to nutrient
intake. It has multiple effects, including
increasing insulin release from the pancreas,
slowing down stomach emptying, and targeting
receptors in the brain that cause appetite
reduction. This results in a sensation of satiety,
or fullness, lasting much longer than possible
with natural GLP-1 hormone levels
 •
Week 1: Inject 0.6 mg subcutaneously once a
day
Week 2: Inject 1.2 mg subcutaneously once a
day
Week 3: Inject 1.8 mg subcutaneously once a
day
Week 4: Inject 2.4 mg subcutaneously once a
day
Week 5: Inject 3 mg subcutaneously once a day

MAINTENANCE dose: 3 mg subcutaneously

once a day