Obesity, prevalence, risk factors, approach to management- Dr Shahjada Selim

Dr Shahjada SelimDr Shahjada Selim
Assistant ProfessorAssistant Professor
Department of EndocrinologyDepartment of Endocrinology
Bangabandhu Sheikh Mujib Medical University, DhakaBangabandhu Sheikh Mujib Medical University, Dhaka
Email:Email: selimshahjada@gmail.com, info@shahjadaselim.comselimshahjada@gmail.com, info@shahjadaselim.com
Obesity

Obesity definition
•““Overweight or obesity is defined asOverweight or obesity is defined as
abnormal or excessive fat accumulation thatabnormal or excessive fat accumulation that
presents a risk to health”presents a risk to health”
http://www.who.int/en/

SEAR including Bangladesh
Category BMI
Under nutrition <18.5
Normal 18.5 – 22.9
Overweight 23.0 – 25.0
Obese >25.0

Obesity epidemic
http://www.who.int/e

Obesity epidemic
www.thelancet.com Vol 387 Apr

Country Age range Obesity
prevalence
Male
Obesity
prevalence
Female
U.S.A. 22-74 years 19.7% 24.7%
Germany 25-69 years 17% 19%
England 16-64 years 15% 16.5%
Kuwait 18 + 32% 44%
India 16-64 years 19.3% 25.6%
Currently the world is facing obesity epidemic

Childhood obesity in low resourced society
%
Misra A, Basit A, Vikram NK, Sharma R; Diabetes Res
Clin Pract;2005

Measurement of Obesity
• Body mass index (BMI)Body mass index (BMI)
• Waist CircumferenceWaist Circumference
• Waist to hip ratioWaist to hip ratio
• Skin fold thicknessSkin fold thickness
• Body fat analyzerBody fat analyzer
• Body fat to muscle ratioBody fat to muscle ratio
• OthersOthers

BMI
It is a measure for human body shapeIt is a measure for human body shape
based on an individual's mass andbased on an individual's mass and
height.height.

BMI Classification
WHO, Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000:894:1-253.
WHO. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004:363:157-63
Asian
cutoff
Other
cutoff
Overweig
ht
Obese I Obese II Obese III

Body fat Percentage
Based on NIH/WHO BMI Guidelines.
As reported by Gallagher, et al., at NY Obesity Research Center.

Visceral Fat
http://tanita.eu/tanita-academy/understanding-
your-measurements
Visceral Fat

Types of obesity
• Excess fat on the
Abdomen
• Common in Men
• Significant
correlation with
Metabolic
• Excess fat on the things
and buttocks
• Common in Women
• Non Significant
correlation with
Metabolic syndrome
Arch Pediatr Adolesc Med. 2009 Sep;163(9

Number of fat cell
•Number and size of fat cells appears toNumber and size of fat cells appears to
be an important factor in determiningbe an important factor in determining
riskrisk for obesity.for obesity.
•Average non-obese person:Average non-obese person: 25 – 30 billion25 – 30 billion
•Moderately obese:Moderately obese: 60 – 100 billion60 – 100 billion
•Massively obese:Massively obese: 300 billion plus300 billion plus
Journal of Obesity
Volume 2011 (2011), Article ID 490650

Understanding energy balance
is this as simple…….

Understanding energy balance
its complex rather
NEPA: Non-exercise physical
activity
TEF: Thermic effect of food

Obesi
ty
Epigene
tic
Epigene
tic
Fawwad A, et al., Oral Presentation in Dow university of health sciences,
2012, Karachi - Pakistan

Genes and obesity phenotypes
Herrera & Lindgren 2

Human Molecular Genetics, 2006, Vol. 15, Review Issue No. 2
Genetic links between obesity and
associated conditions

Gene environment interactions
The complex
interactions
underlying polygenic
obesity demonstrate
that genetic, social,
behavioral, and
environmental factors
are all capable of
influencing the obese
phenotype.
Unraveling the genetics of human
obesity.
Mutch DM, Clément K - PLoS
Genet. (2006)

The risk triangle: Obesity
Genetics
Behavior
Environment
Risk
Asia Pacific Journal of Clinical Nutrition
Volume 11, Issue Supplement s8, pages S718–S721

Determinants of obesity
• Genetics
• Epigenetics
• Ethnicity
• Age
• Intrauterine
milieu
• Birth weight
• Post natal catch
up growth
• Pregnancy
• International Journal of Obesity & Related Metabolic Disorders . Dec2002
Supplement, Vol. 26, pS8. 1p
International Journal of Obesity (2004) 28, 1247–125
Rennie KL, et al. Behavioural determinants of obesity. Best Pract Res Clin
Endocrinol Metab. 2005 Sep;19(3):343-58.
• Urbanization
• Dietary habits
• Physical activity
• Concomitant Medical
illness
• Medications
• Mental Stress
• Oxidative stress
• smoking
• Excessive or Lack of sleep
• Others

Differential Impact of Obesity among various
Ethnic group
Atherogenic
Dyslipidemia
CAD Diabetes Hypertension
Whites +++ + + +
Blacks + + +++ +++
Hispanics &
American
Indians
+ + +++ +
Asian
Indians
++++ ++++ ++++ +
Chinese + + +++ +
Grundy SM. Circulation, 2002, 1

NCDs risk & Asian ancestry
Rapid nutrition and lifestyle transitions leading to:
OthersOthers
•ProcoagulantProcoagulant
statestate
•EndothelialEndothelial International Journal of Obesity (2011) 3
Body phenotype
•High body fat
•High truncal fat
•High
Subcutaneous fat
•High intra-
abdominal fat
•low muscle mass
Biochemical
parameters
•Hyperglycemia
•Hyperinsulinemia
•Dyslipidemia
•Hyperleptinemia
•Low levels of
adiponectin
•High levels of C-
reactive protein

The Y-Y paradox
•The first author (figure,The first author (figure,
right) has substantiallyright) has substantially
more body fat than themore body fat than the
second author (figure,second author (figure,
left).left).
•The image is a usefulThe image is a useful
reminder of thereminder of the
limitations of BMI as alimitations of BMI as a
measure of adipositymeasure of adiposity
across populations.across populations.
http://www.thelancet.com/journals/lancet/article/PIIS0140-67

Normal weight obesity
A metabolically-obese
normal weight subject
is a person who has
normal weight and BMI,
but with high body fat
percentage specially
visceral fat that may
increase the possibility
of developing the
metabolic syndrome,
insulin resistance,
hypertension and CVDProg Cardiovasc Dis. 2014 Jan-Feb;56

Energy balance
•3 components3 components
1.1.Afferent /peripheral systemAfferent /peripheral system
• - Generates signals from various sites- Generates signals from various sites
• - Composed of leptin , adiponectin - by- Composed of leptin , adiponectin - by
fat cells, ghrelin from stomach, peptide YYfat cells, ghrelin from stomach, peptide YY
(PYY) from ileum, colon, insulin from(PYY) from ileum, colon, insulin from
pancreaspancreas

•2.Arcuate nucleus in hypothalamus2.Arcuate nucleus in hypothalamus
•-Processes & integrates neurohumoral peripheral-Processes & integrates neurohumoral peripheral
signalssignals
•-Generates efferent signals-Generates efferent signals
•-Composed of 2 subsets of first order neurons-Composed of 2 subsets of first order neurons
•1.POMC (pro-opiomelanocortin) & CART (cocaine1.POMC (pro-opiomelanocortin) & CART (cocaine
and amphetamine-regulated transcripts) neuronsand amphetamine-regulated transcripts) neurons
•2.Neuropeptide Y & AgRP (agouti-related peptide)2.Neuropeptide Y & AgRP (agouti-related peptide)
•These first order neurons communicate with secondThese first order neurons communicate with second
order neuronsorder neurons

•33. Efferent system. Efferent system
•Carries signals from second order neurons ofCarries signals from second order neurons of
hypothalamus to control food intake andhypothalamus to control food intake and
energy expenditureenergy expenditure

•Produced byProduced by adipocytesadipocytes
•Product of ‘Product of ‘obob’ gene’ gene
•Provides signal forProvides signal for “energy“energy
sufficiency”.sufficiency”.
•Abundant fatAbundant fat  LeptinLeptin
secretionsecretion
•Regulated byRegulated by insulininsulin
stimulated glucosestimulated glucose
metabolismmetabolism
•StimulatesStimulates thermogenesis,thermogenesis,
activity, energy expenditureactivity, energy expenditure

•MC4RMC4R ( Melanocortin receptor 4) mutations-( Melanocortin receptor 4) mutations-
more frequent, cause of 5% massive obesitymore frequent, cause of 5% massive obesity
•No satietyNo satiety(anorexinergic) signal generated(anorexinergic) signal generated
•BehaveBehave as if undernourishedas if undernourished
•Haplo-insufficiency of brain-derivedHaplo-insufficiency of brain-derived
neurotrophic factor (neurotrophic factor (BDNFBDNF) – component of) – component of
MC4R downstream signaling inMC4R downstream signaling in
hypothalamushypothalamus
•BDNF - A/w obesity inBDNF - A/w obesity in WAGRWAGR syndromesyndrome

•Produced mainly byProduced mainly by adipocytesadipocytes
•LowLow levels inlevels in obesityobesity
•Stimulates fatty acid oxidationStimulates fatty acid oxidation
•““Fat-burning molecule”Fat-burning molecule”
•““Guardian angel against obesity”Guardian angel against obesity”
•↓↓ fatty acid influx in liver, liverfatty acid influx in liver, liver
glucose productionglucose production
•↓↓ Protects against MetabolicProtects against Metabolic
syndromesyndrome

•Produces TNF, IL-6, IL-1, IL-18, Chemokine,Produces TNF, IL-6, IL-1, IL-18, Chemokine,
SteroidsSteroids
•Chronic sub-clinical inflammatory stateChronic sub-clinical inflammatory state (^ CRP)(^ CRP)
•?Link between lipid metabolism, nutrition,?Link between lipid metabolism, nutrition,
inflammationinflammation
•WHYWHY is it HARD to maintain the weight loss foris it HARD to maintain the weight loss for
those who lose after dietary restriction?those who lose after dietary restriction?
-Constant number of adipocytesConstant number of adipocytes
--Higher no. in obese-Higher no. in obese

•Short term meal initiators and terminatoprsShort term meal initiators and terminatoprs
•GhrelinGhrelin,, PYYPYY,, Pancreatic polypeptidePancreatic polypeptide,, IsulinIsulin,,
AmylinAmylin
•Ghrelin(stomach,arcuate nucleus)-Ghrelin(stomach,arcuate nucleus)- only orexenergiconly orexenergic
gut hormonegut hormone
•Most likely stimulates NPY/AgRP neuronsMost likely stimulates NPY/AgRP neurons
•PYYPYY ( ileum, colon)( ileum, colon)
•A/w hyperphagia , obesity inA/w hyperphagia , obesity in Prader-WilliPrader-Willi
syndromesyndrome
•AmylinAmylin(pancreatic ß cells),(pancreatic ß cells), PYYPYY – both stimulate– both stimulate
POMC/CART neuronsPOMC/CART neurons

Medical Risk of Obesity
Nature 404, 635-643 (6 Ap

Health Risks increase with Obesity
Archive of internal medicine 161:1

Obesity and Adipose tissue
Adipose tissue is an
endocrine organ that
secretes numerous
protein hormones,
including leptin,
adiponectin, resistin,
interleukin, apelin,
tumor necrosis factor
and estrogen.
http://www.shutterstock.com/pic-316924646/stock-photo-adipose-
tissue-is-an-endocrine-organ-that-secretes-numerous-protein-
hormones-including-leptin.html

California Medical Foundation Association Obesity Toolkit

Weng et al . Pediatrics;
Seven predictors
•Gender
•Birth weight
•Weight gain
•Maternal pre-pregnancy
BMI
•Paternal BMI
•Maternal smoking in
pregnancy
•Breastfeeding status
Estimating overweight risk in
childhood from predictors during
infancy

Three key modifiable factors
•Computer usage
•Breakfast consumption
•Transport mode to school
Duncan et al. BMC Public Health 201
Modifiable risk factors for overweight
and obesity in children and adolescents
from Brazil

Conclusion
• AwarenessAwareness
• Early identificationEarly identification
• Aggressive LSM & treatmentAggressive LSM & treatment
• Customized ethnic & Genetic basedCustomized ethnic & Genetic based
Prevention strategiesPrevention strategies
• Research, Policy making, legislation andResearch, Policy making, legislation and
effective Implementationeffective Implementation

WHO- Call of the DAY
• According to WHO, Obesity is one of theAccording to WHO, Obesity is one of the
most common, modifiable risk factor for allmost common, modifiable risk factor for all
the major NCDs which can be overcomethe major NCDs which can be overcome
using existing knowledge as the solutionsusing existing knowledge as the solutions
are highly cost-effective.are highly cost-effective.
• Comprehensive and integrated action atComprehensive and integrated action at
country level, led by governments, is thecountry level, led by governments, is the
means to achieve success.means to achieve success.
http://www.who.int/e

What is Successful Weight Loss?
Common definition:Common definition:
Lose at least 10% ofLose at least 10% of
starting weight andstarting weight and
keep it off at leastkeep it off at least
one year.one year.

What is the Goal of Obesity Treatment?
• Specifically, the goal of obesity treatmentSpecifically, the goal of obesity treatment
should be refocused from weight loss alone,should be refocused from weight loss alone,
which is often aimed at appearance, to weightwhich is often aimed at appearance, to weight
management, achieving the best weightmanagement, achieving the best weight
possible in the context of overall health.possible in the context of overall health. ––FTCFTC
PanelPanel,, Commercial Weight Loss Products and ProgramsCommercial Weight Loss Products and Programs
What Consumers Stand To Gain and Lose,What Consumers Stand To Gain and Lose, 19971997
http://www.ftc.gov/os/1998/03/weightlo.rpt.htm accessed 3-13-06

Who Should Consider A Weight
Management Intervention?
• Persons with a BMI of >30Persons with a BMI of >30 (>25)(>25)
• Persons with a BMI between 25- 29.99Persons with a BMI between 25- 29.99
(23-24.9)(23-24.9) OR a high-risk waistOR a high-risk waist
circumference, and two or more riskcircumference, and two or more risk
factorsfactors
• Persons who are ready to changePersons who are ready to change
NHLBI Obesity Education Initiative. The Practical Guide Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults.
NHLBI 00-4084, 2000.

Obesity-Associated Risk Factors: High
Absolute Risk
• Established coronary heart diseaseEstablished coronary heart disease
• Other atherosclerotic diseasesOther atherosclerotic diseases
• Type 2 diabetesType 2 diabetes
• Sleep apneaSleep apnea
NHLBI Obesity Education Initiative. The Practical
Guide Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. NHLBI 00-4084,
2000.

Obesity-Associated Risk Factors: 3 or
More = ↑ Risk
•HypertensionHypertension
•Cigarette smokingCigarette smoking
•High low-density lipoprotein cholesterolHigh low-density lipoprotein cholesterol
•Low high-density lipoprotein cholesterolLow high-density lipoprotein cholesterol
•Impaired fasting glucoseImpaired fasting glucose
•Family history of early cardiovascularFamily history of early cardiovascular
diseasedisease
•Age (maleAge (male ≥ 45 years, female ≥ 55 years)≥ 45 years, female ≥ 55 years)NHLBI Obesity Education Initiative. The Practical Guide Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. NHLBI 00-4084, 2000.

Other Obesity-Associated
Risk Factors
• OsteoarthritisOsteoarthritis
• GallstonesGallstones
• Stress incontinenceStress incontinence
• Gynecological abnormalitiesGynecological abnormalities
NHLBI Obesity Education Initiative. The Practical Guide to
Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults. NHLBI 00-4084, 2000.

How Much and How Fast?
• NIH guidelines recommend a weight loss of .5NIH guidelines recommend a weight loss of .5
to 1 pound/week for persons with a BMI of 27-to 1 pound/week for persons with a BMI of 27-
35 and 1-2 pounds a week for those with a35 and 1-2 pounds a week for those with a
BMI>35 kg/m2BMI>35 kg/m2
• Allow 6 months to achieve 10% weight lossAllow 6 months to achieve 10% weight loss
• After 6 months, focus should shift to weightAfter 6 months, focus should shift to weight
maintenance for 6 monthsmaintenance for 6 months
• Following this, weight loss efforts may resumeFollowing this, weight loss efforts may resume
(NIH, 1998)(NIH, 1998)

Weight Loss Goals
•Individualized goals of weight loss therapyIndividualized goals of weight loss therapy
should be to reduce body weight at anshould be to reduce body weight at an
optimal rate of 1-2 lbs per week for the firstoptimal rate of 1-2 lbs per week for the first
6 months and to achieve an initial weight6 months and to achieve an initial weight
loss goal of up to 10% from baseline.loss goal of up to 10% from baseline.
•These goals are realistic, achievable, andThese goals are realistic, achievable, and
sustainable.sustainable.
Strong, ImperativeStrong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt
Mgt Guidelines, accessed 2/07

Rates of Weight Loss Vary
• Men will lose weight faster than womenMen will lose weight faster than women
of similar size, due to higher LBM andof similar size, due to higher LBM and
RMRRMR
• A heavier person (who has higher energyA heavier person (who has higher energy
needs) will lose weight faster than aneeds) will lose weight faster than a
smaller person on the same caloricsmaller person on the same caloric
regimenregimen

Modest Weight Loss and Health:
Diabetes Prevention
•A 7% weight loss (mean 15 pounds)A 7% weight loss (mean 15 pounds)
through diet and exercise in high riskthrough diet and exercise in high risk
individuals was associated with a 58%individuals was associated with a 58%
reduction of diabetes incidence in thereduction of diabetes incidence in the
Diabetes Prevention ProgramDiabetes Prevention Program DPP ResearchDPP Research
Group. N Engl J Med. 2002 Feb 7;346(6):393-403.Group. N Engl J Med. 2002 Feb 7;346(6):393-403.
•An average 7.7 pound weight loss wasAn average 7.7 pound weight loss was
associated with a 58% reduction in diabetesassociated with a 58% reduction in diabetes
incidence in high risk individuals in theincidence in high risk individuals in the
Finnish Diabetes Prevention study.Finnish Diabetes Prevention study. FDPSFDPS
GroupGroup.. N Engl J MedN Engl J Med 344:1343–1350, 2001344:1343–1350, 2001

Hypertension
• Weight loss of as little as 4.5 kg (10 pounds)Weight loss of as little as 4.5 kg (10 pounds)
will improve or prevent hypertension in awill improve or prevent hypertension in a
large segment of overweight persons.large segment of overweight persons. SeventhSeventh
Report of the Joint National Committee on Prevention, Detection,Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7)Evaluation, and Treatment of High Blood Pressure (JNC 7)
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdfhttp://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
• Clinically significant long-term reductions inClinically significant long-term reductions in
blood pressure and reduced risk forblood pressure and reduced risk for
hypertension can be achieved with modesthypertension can be achieved with modest
weight loss and increased physical activity.weight loss and increased physical activity.
American Dietetic Association Evidence Analysis Library,American Dietetic Association Evidence Analysis Library,
Hypertension and hyperlipidemia.Hypertension and hyperlipidemia.
http://www.adaevidencelibrary.org/http://www.adaevidencelibrary.org/

Hyperlipidemia
•The ATP-III guidelines recommend a 10%The ATP-III guidelines recommend a 10%
weight loss in overweight persons withweight loss in overweight persons with
hyperlipidemia.hyperlipidemia.
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdfhttp://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf
•A weight loss ofA weight loss of ≥2.25 kg was associated with≥2.25 kg was associated with
a 40-50% reduction in cardiovascular riska 40-50% reduction in cardiovascular risk
factors in the Framingham Offspring Studyfactors in the Framingham Offspring Study
(BP, triglyceride, TC, FBS, HDL)(BP, triglyceride, TC, FBS, HDL) Karason K et al.Karason K et al.
Int J Obes Relat Metab Disord 1999;23:948-56Int J Obes Relat Metab Disord 1999;23:948-56..

Diabetes
•Calorie restriction and weight loss improvesCalorie restriction and weight loss improves
insulin sensitivity and glycemic control ininsulin sensitivity and glycemic control in
obese patients with Type 2 diabetes.obese patients with Type 2 diabetes.
•A 5% weight loss can decrease FBG, insulin,A 5% weight loss can decrease FBG, insulin,
A1C concentrations and medicationA1C concentrations and medication
requirements.requirements.
Wing RRWing RR,, Henry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J ClinHenry RR et al. J Clin Endocrinol Metab 1985;61:917-25; Kelly DE et al. J Clin
Endocrinol MEtab 1993;77:1287-93. et al. Arch Intern MedEndocrinol MEtab 1993;77:1287-93. et al. Arch Intern Med..1987;147:1749-531987;147:1749-53..

Setting Weight Management Goals
• Many severely overweight persons haveMany severely overweight persons have
unrealistic expectations in setting weightunrealistic expectations in setting weight
loss goals (Blackburn, 1998)loss goals (Blackburn, 1998)
• Even modest weight loss may produceEven modest weight loss may produce
significant improvements in healthsignificant improvements in health
• For some persons (especially those withFor some persons (especially those with
BMI of 25-29.9) weight maintenance may beBMI of 25-29.9) weight maintenance may be
a goala goal

Evaluation of Body Wt
• Body mass index (BMI) and waistBody mass index (BMI) and waist
circumference should be used to classifycircumference should be used to classify
overweight and obesity, estimate risk foroverweight and obesity, estimate risk for
disease, and to identify treatment options.disease, and to identify treatment options.
• BMI and waist circumference are highlyBMI and waist circumference are highly
correlated to obesity or fat mass and risk ofcorrelated to obesity or fat mass and risk of
other diseases (NHLBI report).other diseases (NHLBI report). Fair,Fair,
ImperativeImperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt
Guidelines, accessed 2/07

Estimation of Energy
Needs
• Estimated energy needs should be based on RMR. IfEstimated energy needs should be based on RMR. If
possible, RMR should be measured (e.g., indirectpossible, RMR should be measured (e.g., indirect
calorimetry).calorimetry).
• If RMR cannot be measured, then the Mifflin-St.If RMR cannot be measured, then the Mifflin-St.
Jeor equation usingJeor equation using actualactual weight is the mostweight is the most
accurate for estimating RMR for overweight andaccurate for estimating RMR for overweight and
obese individuals.obese individuals. Strong, ConditionalStrong, Conditional

Readiness to Change: A Brief
Assessment
• Has the individual sought weight loss onHas the individual sought weight loss on
his/her own initiative?his/her own initiative?
• What has led the patient to seek weightWhat has led the patient to seek weight
loss now?loss now?
• What are the patient’s stress level andWhat are the patient’s stress level and
mood?mood?
• Does the individual have an eatingDoes the individual have an eating
disorder?disorder?

Readiness to Change: A Brief
Assessment
• Does the individual understand theDoes the individual understand the
requirements of treatment and believerequirements of treatment and believe
that he/she can fulfill them?that he/she can fulfill them?
• How much weight does the patientHow much weight does the patient
expect to lose?expect to lose?

NIH Recommended Interventions
• Dietary therapy
• Physical activity
• Behavior therapy
• Pharmacotherapy
• Bariatric surgery

Comprehensive Wt Mgt
Program
• Weight loss and weight maintenanceWeight loss and weight maintenance
therapy should be based on atherapy should be based on a
comprehensive weight managementcomprehensive weight management
program including diet, physical activity,program including diet, physical activity,
and behavior therapy. The combinationand behavior therapy. The combination
therapy is more successful than usingtherapy is more successful than using
any one intervention alone.any one intervention alone. Strong,Strong,

Reduced Calorie Diets
•An individualized reduced calorie diet is theAn individualized reduced calorie diet is the
basis of the dietary component of abasis of the dietary component of a
comprehensive weight management program.comprehensive weight management program.
•Reducing dietary fat and/or carbohydrates is aReducing dietary fat and/or carbohydrates is a
practical way to create a caloric deficit of 500practical way to create a caloric deficit of 500
– 1000 kcals below estimated energy needs– 1000 kcals below estimated energy needs
and should result in a weight loss of 1 – 2 lbsand should result in a weight loss of 1 – 2 lbs
per week.per week. Strong, ImperativeStrong, Imperative

Balanced Energy-Restricted Diet
• Is the most widely-prescribed method ofIs the most widely-prescribed method of
weight reductionweight reduction
• Should be nutritionally adequate exceptShould be nutritionally adequate except
for energyfor energy
• Energy level varies with individual’sEnergy level varies with individual’s
size, sex, and activity, ranging from 800size, sex, and activity, ranging from 800
kcals to 1500 kcals (NIH, 1998)kcals to 1500 kcals (NIH, 1998)

• Should be relatively high in carbohydrate (50-Should be relatively high in carbohydrate (50-
55% of total kcals)55% of total kcals)
• CHO sources should be fruits, vegetables, whole grainsCHO sources should be fruits, vegetables, whole grains
• Include generous protein (15-25% of kcals) forInclude generous protein (15-25% of kcals) for
increased satiety and to assure adequate supplyincreased satiety and to assure adequate supply
• Fat < 30% of kcalsFat < 30% of kcals
• Increased fiber to improve satiety (NIH, 1998)Increased fiber to improve satiety (NIH, 1998)

• Alcohol and high-sugar foods should beAlcohol and high-sugar foods should be
limited to limit excess energylimited to limit excess energy
• Use of non-nutritive sweeteners and fatUse of non-nutritive sweeteners and fat
replacements may improve the palatabilityreplacements may improve the palatability
of the dietof the diet
• Vitamins and mineral supplements may beVitamins and mineral supplements may be
needed in programs that provide <1200needed in programs that provide <1200
kcals for women or 1800 kcals for menkcals for women or 1800 kcals for men
(NIH, 1998)(NIH, 1998)

Exchange System Diets
• Allow flexibility in makingAllow flexibility in making
food choices while limitingfood choices while limiting
total caloric intaketotal caloric intake
• Provides framework forProvides framework for
healthy balance ofhealthy balance of
nutrientsnutrients
• May be too complex orMay be too complex or
restrictive for some clientsrestrictive for some clients

Nutrition Education
• Nutrition education should be individualizedNutrition education should be individualized
and included as part of the diet component of aand included as part of the diet component of a
• Short term studies show that nutrition educationShort term studies show that nutrition education
(e.g. reading nutrition labels, recipe(e.g. reading nutrition labels, recipe
modification, cooking classes) increasesmodification, cooking classes) increases
knowledge and may lead to improved foodknowledge and may lead to improved food
choices.choices. Fair, ImperativeFair, Imperative
American Dietetic Association Evidence Analysis Library Adult
Wt Mgt Guidelines, accessed 2/07

Eating Frequency and Patterns
•Total caloric intake should be distributedTotal caloric intake should be distributed
throughout the day, with the consumption ofthroughout the day, with the consumption of
4 to 5 meals/snacks per day including4 to 5 meals/snacks per day including
breakfast.breakfast.
•Consumption of greater energy intake duringConsumption of greater energy intake during
the day may be preferable to eveningthe day may be preferable to evening
consumption.consumption. Fair, ImperativeFair, Imperative

Portion Control
• Portion control should be included asPortion control should be included as
part of a comprehensive weightpart of a comprehensive weight
management program. Portion controlmanagement program. Portion control
at meals and snacks results in reducedat meals and snacks results in reduced
energy intake and weight loss.energy intake and weight loss. Fair,Fair,

Meal Replacements
• For people who have difficulty with selfFor people who have difficulty with self
selection and/or portion control, mealselection and/or portion control, meal
replacements (e.g., liquid meals, meal bars,replacements (e.g., liquid meals, meal bars,
calorie-controlled packaged meals) may becalorie-controlled packaged meals) may be
used as part of the diet component of aused as part of the diet component of a
• Substituting one or two daily meals or snacksSubstituting one or two daily meals or snacks
with meal replacements is a successful weightwith meal replacements is a successful weight
loss and weight maintenance strategy.loss and weight maintenance strategy. Strong,Strong,
ConditionalConditional

Low Glycemic Index Diets
• A low glycemic index diet isA low glycemic index diet is notnot
recommended for weight loss or weightrecommended for weight loss or weight
maintenance as part of a comprehensivemaintenance as part of a comprehensive
weight management program, since itweight management program, since it
has not been shown to be effective inhas not been shown to be effective in
these areas.these areas. Strong, ImperativeStrong, Imperative

Lowfat Dairy Foods
• In order to meet current nutritionalIn order to meet current nutritional
recommendations, incorporate 3-4 servings ofrecommendations, incorporate 3-4 servings of
low fat dairy foods a day as part of the dietlow fat dairy foods a day as part of the diet
component of a comprehensive weightcomponent of a comprehensive weight
management program.management program.
• Research suggests that calcium intake lower thanResearch suggests that calcium intake lower than
recommended levels is associated with increasedrecommended levels is associated with increased
body weight. However, the effect of dairy and/orbody weight. However, the effect of dairy and/or
calcium at or above recommended levels oncalcium at or above recommended levels on
weight management is unclear.weight management is unclear. Fair, ImperativeFair, Imperative

Low Carbohydrate Diets
• Having patients focus on reducing carbohydratesHaving patients focus on reducing carbohydrates
rather than reducing calories and/or fat may be arather than reducing calories and/or fat may be a
short term strategy for some individuals.short term strategy for some individuals.
• Research indicates that focusing on reducingResearch indicates that focusing on reducing
carbohydrate intake (<35% of kcals fromcarbohydrate intake (<35% of kcals from
carbohydrates) results in reduced energy intake.carbohydrates) results in reduced energy intake.
• Consumption of a low-carbohydrate diet isConsumption of a low-carbohydrate diet is
associated with a greater weight and fat loss thanassociated with a greater weight and fat loss than
traditional reduced calorie diets during the first 6traditional reduced calorie diets during the first 6
months, but these differences are not significantmonths, but these differences are not significant
after 1 year.after 1 year. Fair, ConditionalFair, Conditional

Very Low Calorie Diets (VLCD)
•Diets providing 200-800 kcals/dayDiets providing 200-800 kcals/day
•Hypocaloric but relatively rich in proteinHypocaloric but relatively rich in protein
(.8-1.5 g/kg/day)(.8-1.5 g/kg/day)
•Designed to include adequate vitamins,Designed to include adequate vitamins,
minerals, electrolytes, and EFAsminerals, electrolytes, and EFAs
•Completely replace usual meal intakeCompletely replace usual meal intake
•Usually given for 12-16 weeksUsually given for 12-16 weeks
•Usually reserved for those with BMI>30; orUsually reserved for those with BMI>30; or
27-30 with risk factors27-30 with risk factors
NHLBI, 2000

Protein Sparing Modified Fast (PSMF)
• Contains 1.5 g protein/kg IBW as leanContains 1.5 g protein/kg IBW as lean
meat, fish and poultrymeat, fish and poultry
• Uses real foodUses real food
• May include low-carbohydrate vegetablesMay include low-carbohydrate vegetables
• Only fat is that present in the proteinOnly fat is that present in the protein
sourcessources
NIH NHLBI The practical guide. Identification, evaluation, and
treatment of overweight and obesity in adults. NHLBI, 2000

Commercial VLCD Liquid Diets
• Contain 33-70 g ofContain 33-70 g of
protein, 30-45 gprotein, 30-45 g
CHO, small amountCHO, small amount
of fatof fat
• Provides 400-800Provides 400-800
kcalskcals
• Patients lose 20 kgPatients lose 20 kg
in 12 to 16 weeksin 12 to 16 weeks
NIH NHLBI The practical guide.
Identification, evaluation, and treatment of
overweight and obesity in adults. NHLBI,
2000

VLCDs
• Cardiac complications a concernCardiac complications a concern
• Risks include potassium loss as well as bodyRisks include potassium loss as well as body
protein (higher in the less obese)protein (higher in the less obese)
• Requires close medical supervision andRequires close medical supervision and
monitoring of serum electrolytesmonitoring of serum electrolytes
• But VLCDs may be a moreBut VLCDs may be a more
effective method of weighteffective method of weight
loss for someloss for some
(Anderson et al Am J Clin Nutr 74;579:2001)(Anderson et al Am J Clin Nutr 74;579:2001)

Dietary Therapy: NIH Guidelines
• Very low calorie diets (VLCDs) should notVery low calorie diets (VLCDs) should not
be used routinely for weight loss therapybe used routinely for weight loss therapy
because they require special monitoringbecause they require special monitoring
and supplementationand supplementation
• LCDs may be just as effectiveLCDs may be just as effective
NIH NHLBI The practical guide. Identification, evaluation, and treatment
of overweight and obesity in adults. NHLBI, 2000

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Email:selimshajada@gmail.com,info@shahjadselim.com
Weight Reducing Diet
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Behavioral Therapy in Weight
Management

Behavioral Therapy: NIH Guidelines
• Self-monitoringSelf-monitoring
• Stress managementStress management
• Stimulus controlStimulus control
• Problem-solvingProblem-solving
• Contingency managementContingency management
• Cognitive restructuringCognitive restructuring
• Social supportSocial support

Behavior Therapy in Wt Mgt
• A comprehensive weight management programA comprehensive weight management program
should make maximum use of multiple strategies forshould make maximum use of multiple strategies for
behavior therapy (e.g. self monitoring, stressbehavior therapy (e.g. self monitoring, stress
management, stimulus control, problem solving,management, stimulus control, problem solving,
contingency management, cognitive restructuring,contingency management, cognitive restructuring,
and social support).and social support).
• Behavior therapy in addition to diet and physicalBehavior therapy in addition to diet and physical
activity leads to additional weight loss. Continuedactivity leads to additional weight loss. Continued
behavioral interventions may be necessary tobehavioral interventions may be necessary to
prevent a return to baseline weight.prevent a return to baseline weight. Strong,Strong,

Self Monitoring
• Records of place and time of food intakeRecords of place and time of food intake
• Accompanying thoughts and feelingsAccompanying thoughts and feelings
• Helps identify the physical andHelps identify the physical and
emotional settings in which eating occursemotional settings in which eating occurs
• Provides feedback on progress and putsProvides feedback on progress and puts
responsibility on the patientresponsibility on the patient

Problem Solving
• Process for defining the eating or weightProcess for defining the eating or weight
problemproblem
• Generating possible solutions; evaluatingGenerating possible solutions; evaluating
the solutions, choosing the best onethe solutions, choosing the best one
• Trialing the new behavior, evaluatingTrialing the new behavior, evaluating
outcome and generating alternativesoutcome and generating alternatives

Stimulus Control
Modification ofModification of
• The settings or the chain of events thatThe settings or the chain of events that
precede eatingprecede eating
• The kinds of foods consumedThe kinds of foods consumed
• The consequences of eatingThe consequences of eating
• Become mindful of satiety cuesBecome mindful of satiety cues
• Put fork down between bitesPut fork down between bites
• Pausing during mealsPausing during meals

Cognitive Restructuring
• Teaches patients to identify, challenge,Teaches patients to identify, challenge,
and correct negative thoughtsand correct negative thoughts
• Positive self-talkPositive self-talk

Behavior Modification
• Most effective in mildly obese (20-40%Most effective in mildly obese (20-40%
overweight)overweight)
• Patients can maintain losses of 20-25Patients can maintain losses of 20-25
poundspounds
• Longer programs more successfulLonger programs more successful
• Many patients regain the weight they lostMany patients regain the weight they lost
over timeover time

Physical Activity and Weight
Management

Role of Physical Activity in Weight
Management
Other Benefits:Other Benefits:
——Improved sense of well-beingImproved sense of well-being
——Relief of boredomRelief of boredom
——Sense of controlSense of control
——Relief from depressionRelief from depression

Physical Activity
• Physical activity should be part of aPhysical activity should be part of a
Physical activity level should be assessed andPhysical activity level should be assessed and
individualized long-term goals established toindividualized long-term goals established to
accumulate at least 30 minutes or more ofaccumulate at least 30 minutes or more of
moderate intensity physical activity on most, andmoderate intensity physical activity on most, and
preferably, all days of the week, unless medicallypreferably, all days of the week, unless medically
contraindicated.contraindicated.
• Physical activity contributes to weight loss, mayPhysical activity contributes to weight loss, may
decrease abdominal fat, and may help withdecrease abdominal fat, and may help with
maintenance of weight loss.maintenance of weight loss. Strong, ImperativeStrong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines,
accessed 2/07

Physical Activity: NIH Guidelines
• Physical activity increases energyPhysical activity increases energy
expenditure and plays an integral role inexpenditure and plays an integral role in
weight maintenanceweight maintenance
• Reduces the risk of heart disease more thanReduces the risk of heart disease more than
weight loss aloneweight loss alone
• Reduces body fat, prevents decrease inReduces body fat, prevents decrease in
muscle mass during weight lossmuscle mass during weight loss
• All adults: goal of 30 minutes or more ofAll adults: goal of 30 minutes or more of
moderate-intensity physical activity on mostmoderate-intensity physical activity on most
and preferably all days.and preferably all days.

Role of Physical Activity in Weight
Management
• Physical activity usually will not lead to aPhysical activity usually will not lead to a
greater weight loss over diet alone in a 6-greater weight loss over diet alone in a 6-
month period (NIH, 2000)month period (NIH, 2000)
• Physical activity is most helpful inPhysical activity is most helpful in
preventing weight regainpreventing weight regain
• Physical activity also is beneficial inPhysical activity also is beneficial in
reducing risk for heart disease and diabetesreducing risk for heart disease and diabetes
beyond the effect of weight lossbeyond the effect of weight loss

Role of Physical Activity in
Weight Management
• Exercise helps balance the loss of LBM andExercise helps balance the loss of LBM and
reduction in RMR caused by hypocaloricreduction in RMR caused by hypocaloric
dietsdiets
• A combination of aerobic exercise andA combination of aerobic exercise and
resistance training is recommendedresistance training is recommended
• Even when weight loss does not occur, lossEven when weight loss does not occur, loss
of body fat often doesof body fat often does
• May require 2 months to see loss of weightMay require 2 months to see loss of weight
through exercisethrough exercise

2009
How Many Calorie Am I Burning?
Activity 100 lb 150 lb 200 lb
Bicycling, 6 mph 160 240 312
Bicycling, 12 mph 270 410 534
Jogging, 7 mph 610 920 1,230
Jumping rope 500 750 1,000
Running, 5.5 mph 440 660 962
Running, 10 mph 850 1,280 1,664
Swimming, 25 yds/min 185 275 358
Swimming, 50 yds/min 325 500 650
Tennis singles 265 400 535
Walking, 2 mph 160 240 312
Walking, 3 mph 210 320 416
Walking, 4.5 mph 295 440 572
American Heart Association
Calories burned/hour of activity

2009
How Many Calories Do I Need?
• USDA’s MyPyramid site:USDA’s MyPyramid site: http://www.mypyramid.gov/http://www.mypyramid.gov/
• Determines calorie needs and calculates the servingsDetermines calorie needs and calculates the servings
needed from food groups.needed from food groups.
• The American Cancer Society (ACS) site:The American Cancer Society (ACS) site:
http://www.cancer.org/docroot/PED/content/PED_6_1x_Calorie_http://www.cancer.org/docroot/PED/content/PED_6_1x_Calorie_
• The ACS site indicates the number of calories that areThe ACS site indicates the number of calories that are
needed per day to maintain your current weight.needed per day to maintain your current weight.

2009
Before Beginning an Exercise
Program
• Are a man older than age 40 orAre a man older than age 40 or
a woman older than age 50a woman older than age 50
• Have had a heart attackHave had a heart attack
• Have a family history of heart-relatedHave a family history of heart-related
problems before age 55problems before age 55
• Have heart, lung, liver or kidney diseaseHave heart, lung, liver or kidney disease
• Feel pain in your chest, joints, or musclesFeel pain in your chest, joints, or muscles
during physical activityduring physical activity
• Have high blood pressure, high cholesterol,Have high blood pressure, high cholesterol,
diabetes, arthritis, osteoporosis, or asthmadiabetes, arthritis, osteoporosis, or asthma
• Have had joint replacement surgeryHave had joint replacement surgery
• SmokeSmoke
• Are overweight or obeseAre overweight or obese
• Tale medication to manage a chronicTale medication to manage a chronic
conditioncondition
• Have an untreated joint or muscleHave an untreated joint or muscle
injury, or persistent symptoms after ainjury, or persistent symptoms after a
joint or muscle injuryjoint or muscle injury
• Are pregnantAre pregnant
• Unsure of your health status.Unsure of your health status.
You should check with your doctor before beginning an exercise program if you:
Mayo Clinic

Health Benefits of
Physical Activity
Health benefits of physical activity. CMAJ. 2006; 174(6): 801-809.

2009
Physical Activity
Secondary Effects on Diabetes Mellitus
• Exercise helps in the managementExercise helps in the management
of diabetes.of diabetes.
• Aerobic and resistance trainingAerobic and resistance training helphelp
in the control of diabetesin the control of diabetes
CMAJ. 2006;174(6): 801-809.

2009
Physical Activity
Secondary Effects on Cancer
• Regular physical activity - important.Regular physical activity - important.
• Increased self-reported physical activity =Increased self-reported physical activity =
decreased reoccurrence of cancerdecreased reoccurrence of cancer and aand a
decreased risk of death from cancerdecreased risk of death from cancer..
• Reduced cancer-related death.Reduced cancer-related death.
CMAJ. 2006;174(6): 801-809.

2009
Physical Activity
Primary Effects on Osteoporosis
• Many studies have been conducted.Many studies have been conducted.
• According to findings,According to findings, routine physicalroutine physical
activityactivity, especially weight-bearing and, especially weight-bearing and
impact exercise,impact exercise, prevents bone lossprevents bone loss
associated with agingassociated with aging..
CMAJ. 2006;174(6): 801-809.

Pharmacological Therapy: NIH
Guidelines
• Should be used only in the context of aShould be used only in the context of a
program that includes lifestyle changesprogram that includes lifestyle changes
• If lifestyle changes do not promote weightIf lifestyle changes do not promote weight
loss after 6 months, drugs should beloss after 6 months, drugs should be
consideredconsidered
• Limited to those with BMI ≥30; or ≥27Limited to those with BMI ≥30; or ≥27
with risk factorswith risk factors

Wt Loss Medications
• FDA-approved weight loss medications may beFDA-approved weight loss medications may be
part of a comprehensive weight managementpart of a comprehensive weight management
program.program.
• Dietitians should collaborate with other membersDietitians should collaborate with other members
of the health care team regarding the use of FDA-of the health care team regarding the use of FDA-
approved weight loss medications for people whoapproved weight loss medications for people who
meet the NHLBI criteria.meet the NHLBI criteria.
• Research indicates that pharmacotherapy mayResearch indicates that pharmacotherapy may
enhance weight loss in some overweight andenhance weight loss in some overweight and
obese adults.obese adults. Strong, ImperativeStrong, Imperative
American Dietetic Association Evidence Analysis Library Adult Wt Mgt Guidelines, accessed 2/07

Catecholaminergic Drugs
• Appetite suppressantsAppetite suppressants
• Act on the brain, increasing the availability ofAct on the brain, increasing the availability of
norepinephrinenorepinephrine
• Schedule II anorexic agentsSchedule II anorexic agents
• High potential for abuseHigh potential for abuse
• Include amphetamine, phenmetrazine HClInclude amphetamine, phenmetrazine HCl
• Not recommended for weight managementNot recommended for weight management
• Schedule III agentsSchedule III agents
• Some potential for abuseSome potential for abuse
• Include benzphetamine HCl, phendimetrazineInclude benzphetamine HCl, phendimetrazine
tartratetartrate
See Table 21-5 Krause 12th
edition, p. 551

Catecholaminergic Drugs
• Schedule IV agentsSchedule IV agents
• Includes diethypropion HCl, manzindolIncludes diethypropion HCl, manzindol
HCl, phentermine HCl, phentermine resinHCl, phentermine HCl, phentermine resin
• Low potential for abuseLow potential for abuse
• Can raise blood pressure, so prescribedCan raise blood pressure, so prescribed
with caution in patients withwith caution in patients with
hypertensionhypertension

Serotonin Reuptake Inhibitors
• Includes sibutramine (Meridia)Includes sibutramine (Meridia)
• Inhibits the reuptake of serotonin andInhibits the reuptake of serotonin and
norepinephrinenorepinephrine
• Initially developed to treat depressionInitially developed to treat depression
• Use caution in hypertension, CHD,Use caution in hypertension, CHD,
arrhythmias, CHFarrhythmias, CHF

Orlistat (Xenical)
• Lipase inhibitorLipase inhibitor
• Acts directly on the gastrointestinal tract toActs directly on the gastrointestinal tract to
inhibit fat absorptioninhibit fat absorption
• Associated with reduced LDL-C and increasedAssociated with reduced LDL-C and increased
HDL; improved glycemic control, reduced bloodHDL; improved glycemic control, reduced blood
pressurepressure
• Some concern about fat soluble vitaminsSome concern about fat soluble vitamins
• Side effects: oily spotting, fecal urgency, flatusSide effects: oily spotting, fecal urgency, flatus
with dischargewith discharge

FDA Approves Reduced Dose of Orlistat
for Over the Counter
• Over the counter dose ofOver the counter dose of
orlistat, a lipase inhibitororlistat, a lipase inhibitor
• Half the dose ofHalf the dose of
prescription formprescription form
(Xenical)(Xenical)
• The only FDA-approvedThe only FDA-approved
over the counter wt mgtover the counter wt mgt
drugdrug
• Available summer 2007Available summer 2007

Serotoninergic Agents
• Increase serotonin levels in the brainIncrease serotonin levels in the brain
• Fenfluramine hydrochloride andFenfluramine hydrochloride and
dexfenfluramine HCl (Fen-Phen) weredexfenfluramine HCl (Fen-Phen) were
removed from the market in 1997 due toremoved from the market in 1997 due to
association with heart valve disease andassociation with heart valve disease and
pulmonary hypertensionpulmonary hypertension

Pharmacological Obesity Treatments
• Weight loss of about 1 lb/week can beWeight loss of about 1 lb/week can be
expectedexpected
• Most weight loss will occur within the firstMost weight loss will occur within the first
6 months of therapy6 months of therapy
• Significant weight maintenance as long asSignificant weight maintenance as long as
the drug treatment is continuedthe drug treatment is continued
• Most patients regain weight if medication isMost patients regain weight if medication is
stoppedstopped

Pharmacological Obesity Treatments
• Weight-loss medications lead to anWeight-loss medications lead to an
additional weight loss of 5 to 22 poundsadditional weight loss of 5 to 22 pounds
more than with non-drug obesitymore than with non-drug obesity
treatmentstreatments
• Two to 20 kg total loss, usually duringTwo to 20 kg total loss, usually during
first 6 months of treatmentfirst 6 months of treatment
• When drugs are discontinued, weightWhen drugs are discontinued, weight
regain occursregain occurs

EXPERIMENTAL DRUGS
• Leptin & Ghrelin
•Peptide YY
•Oxyntomodulin
•Melanocortin-4 receptor agonists

Bariatric Surgery
• Dietitians should collaborate with otherDietitians should collaborate with other
members of the health care team regarding themembers of the health care team regarding the
appropriateness of bariatric surgery for peopleappropriateness of bariatric surgery for people
who have not achieved weight loss goals withwho have not achieved weight loss goals with
less invasive weight loss methods and wholess invasive weight loss methods and who
meet the NHLBI criteria.meet the NHLBI criteria.
• Separate ADA evidence based guidelines areSeparate ADA evidence based guidelines are
being developed on nutrition care in bariatricbeing developed on nutrition care in bariatric
surgery.surgery. Strong, ImperativeStrong, Imperative

Bariatric Surgery: NIH Guidelines
• Option for well-informed and motivatedOption for well-informed and motivated
patients with clinically severe obesitypatients with clinically severe obesity
(BMI≥40 or BMI ≥35 with serious co-(BMI≥40 or BMI ≥35 with serious co-
morbid conditionsmorbid conditions

Candidates for Bariatric Surgery
• BMI of 40 or more—about 100 poundsBMI of 40 or more—about 100 pounds
overweight for men and 80 pounds foroverweight for men and 80 pounds for
womenwomen
• BMI between 35 and 39.9 and a seriousBMI between 35 and 39.9 and a serious
obesity-related health problem such as type 2obesity-related health problem such as type 2
diabetes, heart disease, or severe sleep apneadiabetes, heart disease, or severe sleep apnea
• Willingness to make associated lifestyleWillingness to make associated lifestyle
changeschanges

Bariatric Surgery Options
• RestrictiveRestrictive
• MalabsorptiveMalabsorptive
• Combination restrictive/malabsorptiveCombination restrictive/malabsorptive

Restrictive Procedures
• Adjustable gastric banding (AGB)Adjustable gastric banding (AGB) aa
hollow band made of silicone rubber ishollow band made of silicone rubber is
placed around the stomach near its upperplaced around the stomach near its upper
end, creating a small pouch and a narrowend, creating a small pouch and a narrow
passage into the rest of the stomachpassage into the rest of the stomach
• Vertical banded gastroplasty.Vertical banded gastroplasty. VBG usesVBG uses
both a band and staples to create a smallboth a band and staples to create a small
stomach pouch (not often used today)stomach pouch (not often used today)

Restrictive Surgery: Adjustable Gastric Band

Diet After Surgery
• After restrictive surgeries, patients can onlyAfter restrictive surgeries, patients can only
eat ½ cup to 1 cup of food at a timeeat ½ cup to 1 cup of food at a time
• Foods often must be soft and chewedFoods often must be soft and chewed
thoroughlythoroughly
• Patients who eat too fast or the wrongPatients who eat too fast or the wrong
kinds of food may have vomitingkinds of food may have vomiting

Restrictive Procedures: Advantages
• Don’t interfere with the normalDon’t interfere with the normal
digestive processdigestive process
• Easier to perform and generally saferEasier to perform and generally safer
than malabsorptive surgeriesthan malabsorptive surgeries
• AGB often done laparoscopicallyAGB often done laparoscopically
• Can be reversed if necessaryCan be reversed if necessary

Restrictive Procedures: Disadvantages
• Generally results in less weight lossGenerally results in less weight loss
• Patients generally lose about half of theirPatients generally lose about half of their
excess body weight in the first year afterexcess body weight in the first year after
restrictive proceduresrestrictive procedures
• Only 20% keep weight off over 10 years,Only 20% keep weight off over 10 years,
though there is evidence that AGB is morethough there is evidence that AGB is more
effective than VBGeffective than VBG

Restrictive/Malabsorptive Procedures
• Roux-en-Y gastric bypass (RGBRoux-en-Y gastric bypass (RGB) is the most) is the most
commoncommon
• The surgeon creates a small stomach pouch toThe surgeon creates a small stomach pouch to
restrict food intake. Next, a Y-shaped section ofrestrict food intake. Next, a Y-shaped section of
the small intestine is attached to the pouch tothe small intestine is attached to the pouch to
allow food to bypass the lower stomach, theallow food to bypass the lower stomach, the
duodenum and the first portion of the jejunum.duodenum and the first portion of the jejunum.
• This reduces the amount of calories andThis reduces the amount of calories and
nutrients the body absorbs.nutrients the body absorbs.

Restrictive/Malabsorptive:
Roux en Y

Restrictive/Malabsorptive
Procedures: Advantages
• Patients lose weight quickly andPatients lose weight quickly and
continue to lose 18-24 months after thecontinue to lose 18-24 months after the
procedureprocedure
• With RGB, many patients maintain aWith RGB, many patients maintain a
weight loss of 60 to 70 percent of theirweight loss of 60 to 70 percent of their
excess weight for 10 years or moreexcess weight for 10 years or more

Restrictive/Malabsorptive Procedures:
Disadvantages
• More difficult to performMore difficult to perform
• More likely to result in long-termMore likely to result in long-term
nutritional deficiencies (calcium, iron)nutritional deficiencies (calcium, iron)
• Greater risk of dumping syndromeGreater risk of dumping syndrome
• Increased likelihood of complicationsIncreased likelihood of complications
including hernia (decreased withincluding hernia (decreased with
laparoscopic procedures)laparoscopic procedures)

Weight Management—Children
• Goals: Weight maintenance or slowingGoals: Weight maintenance or slowing
of gainsof gains
• Grow into weightGrow into weight
• If severely obese, lose no more than 1If severely obese, lose no more than 1
lb monthly to reach desired adultlb monthly to reach desired adult
weight for heightweight for height

Weight Management in Children
• At risk at BMI 85% to 95%ile; obese atAt risk at BMI 85% to 95%ile; obese at
95%95%
• Review parents’ history—height,Review parents’ history—height,
weight, etc.weight, etc.
• Weight management in children is aWeight management in children is a
family affairfamily affair

Weight Management in Children
• Overweight children should try toOverweight children should try to
achieve weight maintenance or slowingachieve weight maintenance or slowing
of the rate of weight gain, not weight lossof the rate of weight gain, not weight loss
• Depends on age and degree ofDepends on age and degree of
overweightoverweight
• Once adult height is achieved, weightOnce adult height is achieved, weight
loss is necessary to improve healthloss is necessary to improve health

SUMMARY
First Line with LS 2nd
Line with LS
Easy & Cheaper Invasive & Cost is More
Convenient Inconvenient
Less effective More effective
Less Persistence More
Any Degree of Obesity Higher BMI
Less Complication More Complications
Comorbiditis Cure Rate is less Comorbiditis Cure Rate is more
Dietary moderation- less Dietary moderation- more
Less Efficient Team Work More Efficient Team Work
Short Term Improvement Long Term Improvement
Easy selection Selection by Team

Summary
• Even modest weight loss can produceEven modest weight loss can produce
improvements in overall health inimprovements in overall health in
persons who are overweight (lipids,persons who are overweight (lipids,
BG, insulin, blood pressure).BG, insulin, blood pressure).
• Most persons will need sustained, long-Most persons will need sustained, long-
term lifestyle interventions to achieveterm lifestyle interventions to achieve
significant weight loss.significant weight loss.

Obesity, prevalence, risk factors, approach to management- Dr Shahjada Selim

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