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INVESTIGATION AND MANAGEMENT OF OBESITY

INVESTIGATION AND MANAGEMENT OF OBESITY. Dr Ogunwale O.O. MBBS Lagos Snr Registrar EDM Div. LUTH. OUTLINE. INTRODUCTION CLASSIFICATION AIMS OF INVESTIGATION INVESTIGATIONS TREATMENT GUIDELINES NON-PHARMACOLOGICAL MGT PHARMACOLOGICAL MGT SURGICAL MGT BENEFITS OF WEIGHT LOSS

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INVESTIGATION AND MANAGEMENT OF OBESITY

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  1. INVESTIGATION AND MANAGEMENT OF OBESITY Dr Ogunwale O.O. MBBS Lagos Snr Registrar EDM Div. LUTH

  2. OUTLINE • INTRODUCTION • CLASSIFICATION • AIMS OF INVESTIGATION • INVESTIGATIONS • TREATMENT GUIDELINES • NON-PHARMACOLOGICAL MGT • PHARMACOLOGICAL MGT • SURGICAL MGT • BENEFITS OF WEIGHT LOSS • COMPLICATIONS OF TREATMENT • CONCLUSION • REFERENCES

  3. INTRODUCTION • Basically a clinical/anthropometric diagnosis • History & PE vital. • Underlying cause needs be investigated • Classification based on BMI • Also on Body Fat Distribution/% • Not necessarily about ↑weight. but ↑body fat • Mgmt. is multidisciplinary

  4. CLASSIFICATION BMI (Kg/m2) Body Fat Percentage (%)

  5. CLASSIFICATION • Surgical : Super Obese BMI : ≥ 50 • BF% : Calculated from Deurenberg’s Equation • 1.2(BMI)+0.23(Age)-10.8(Sex)-5.4 • Sex : 1 for Male, 0 for Female • Both Underweight & Overweight are assoc. with ↑risk of dx. • Risk ↑ with ↑ Obesity

  6. AIMS OF INVESTIGATION • Confirm diagnosis & r/o differentials • Find underlying aetiology • Complications & Comorbidities

  7. INVESTIGATIONS • BMI = Wt in Kg/ (Ht)2 in m 2 • Waist Circumference • Sagittal Abdominal Diameter • Caliper-derived measurements of skin-fold thickness* • Bioelectrical impedance analysis** • Underwater weighing***

  8. INVESTIGATIONS

  9. INVESTIGATIONS

  10. INVESTIGATIONS

  11. INVESTIGATIONS

  12. INVESTIGATION Harpenden Professional Skinfold Caliper

  13. INVESTIGATION

  14. INVESTIGATION • Ultrasonography Fat thickness • Abd USS : NAFLD, Gallstones , Ovarian Cysts • Dual-energy radiographic absorptiometry (DEXA) • Abd CT Scan (at L4/L5) • Abd MRI

  15. INVESTIGATIONs • FLP • LFT • TFT • FBG • C-peptide and Insulin Studies • Brain MRI* • Genetic studies ** • GH & IGF-1 Assays.

  16. TREATMENT GUIDELINES

  17. NON-PHARMACOLOGICAL MGT • Diet, Physical Activity & Behavioural Therapy • Self-monitoring of caloric intake & physical activity • Goal setting* • Stimulus control • Non-food rewards • Relapse prevention

  18. NON-PHARMACOLOGICAL MGT • Goals should be SMART • Who - Who is involved? • What - What do I want to accomplish? • Where - Identify a location • When - Establish a time frame • Which - Identify requirements and constraints • Why - Identify specific reasons for or purpose or benefits of the goal

  19. NON-PHARMACOLOGICAL MGT • Weight-loss programs • 3 major phases : • Pre-inclusion screening phase* • Weight-loss phase • Maintenance phase - Can last for rest of pt'slife but ideally lasts for at least 1 yr post program completion

  20. NON-PHARMACOLOGICAL MGT • DIET • Low Calorie Diet :800 - 1500 kcal/day • Very Low Calorie Diet <800 kcal/day usu. high in protein (70-100 g/day) &low in fat (<15 g/day). • Usu. Taken As Liquid Formula, Nutritional Bars • Conventional Food : mostly lean meat, fish - known as protein-sparing modified fasts.

  21. NON-PHARMACOLOGICAL MGT • Physical Activity • More of Aerobic Isotonic Exercise • Less of Anaerobic Isometric/ Resistance Exercise

  22. PHARMACOLOGICAL MGT • Centrally acting medications that impair dietary intake (A) • Medications that act peripherally to impair dietary absorption(B) • Medications that increase energy expenditure (C)

  23. PHARMACOLOGICAL MGT • Lipase Inhibitors : Orlistat (B) • Sibutramine (C) • Lorcaserin(A) • Sympathomimetic Amines Phendimetrazine, Phentermine ,Diethylpropion, BenzphetamineMazindol(A) • Antidiabetic agents

  24. PHARMACOLOGICAL MGT • Of the drugs the following are FDA-approved: • Lorcaserin (Belviq) • Phentermine/topiramate (Qsymia) • Orlistat (Xenical) • Sibutramine no longer approved

  25. SURGICAL MGT • BARIATIC SURGERY • Roux-en-Y gastric bypass (B) • Adjustable gastric banding (R) • Gastric sleeve surgery (R) • Vertical sleeve gastrectomy (R) • Horizontal (Silastic ring) gastroplasty (R) • Vertical banded gastroplasty (R) • Duodenal-switch procedures(B) • Biliopancreaticdiversion (B)

  26. SURGICAL MGT

  27. SURGICAL MGT

  28. SURGICAL MGT • Vertical banded gastroplasty

  29. SURGICAL MGT

  30. SURGICAL MGT • Morbid Obesity • When Conventional Rx & Drug Rx Fail • Benefits : Improved Obstructive sleep apnea • Type 2 DM, Hypertension, CCF, Asthma, Dyslipidaemia • Peripheral oedema, Respiratory insufficiency • Esophagitis, Pseudotumorcerebri, OA, VTE • Operative risk • Urinary incontinence

  31. BENEFITS • Improved Glycaemic Control • BP Control • Dyslipidaemia Control • ↓ CV Risk • Improved Pulm. Fx • Improved Reproductive & Urinary Fx

  32. COMPLICATIONS OF Rx • Electrolyte Disturbances : Ketosis, ↓K+ • Arrhythmias • Malabsorption • Malnutrition • Hyperuricaemia • Cholithiasis • Depression & Eating Disorders

  33. CONCLUSION • Obesity is basically a clinical diagnosis • More about body fat than weight • Hx & PE very important to evaluate co-morbidities and Cx • Management primarily non-pharmacological • Multidisciplinary • Benefits of Rx include ↓CV Risk, ↑Pulm. Fx and regression of co-morbidities

  34. REFERENCES • Klein S, Fabbrini E, Romijnin JA Obesity in Melmed S, Polonsky KS, Larsen PR, Kronenberg HM (eds.), Williams Textbook of Endocrinology, 12th ed. Saunders, 2011. ch 36 pp 1605- 1625 • Hamdy O, Citkowitz E, Uwaifo GI, Oral EA Obesity http://emedicine.medscape.com/article/123702. Updated : Nov 25, 2013 • de Souza NC, de Oliveira EP Sagittal abdominal diameter shows better correlation with cardiovascular risk factors than waist circumference and BMI Journal of Diabetes & Metabolic Disorders 2013 12:41 • http://www.topendsports.com/testing/skinfold-sites.htm Accessed Dec 4,2013 • http://www.ebay.com/itm/Harpenden-Professional-Skinfold-Caliper-/320795435670 Accessed Dec 4, 2013

  35. REFERENCES • http://www.fitnessgram.net/protocols/skinfolds.pdf Accessed Dec 6 ,2013 • Sagittal Diameter http://www.myhealthywaist.org/evaluating-cmr/clinical-tools/sagittal-diameter/page/2/print.html. Accessed Dec 6, 2013 • http://www.topendsports.com/testing/tests/underwater.htm Accessed Dec. 5,2013 • http://www.topendsports.com/testing/siri-equation.htm Accessed Dec. 5, 2013 • http://www.myhealthywaist.org/evaluating-cmr/clinical-tools/sagittal-diameter/page/2/print.html Accessed Dec. 6,2013 • WHO Technical Report Series. Diet, nutrition and the prevention of chronic diseases http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf Accessed Dec. 6, 2013 • http://www.nlm.nih.gov/medlineplus/ency/article/007199.htm. Updated 6/4/2012

  36. THANK YOU

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