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Obesity: A Family Doctor s Perspective

Why All the Fuss About Obesity?. Epidemic proportions in developed and developing countriesMost prevalent nutritional problem in the worldMost significant contributor to ill health and mortality. Scary Statistics

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Obesity: A Family Doctor s Perspective

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    1. Obesity: A Family Doctor’s Perspective Dr. Miriam Boillat September 7, 2007

    2. Why All the Fuss About Obesity? Epidemic proportions in developed and developing countries Most prevalent nutritional problem in the world Most significant contributor to ill health and mortality

    3. Scary Statistics… 59% of Canadian adults are overweight, 23% are obese 26% of Canadian children are overweight, 10% are obese (2% in 1980) Obese children become obese adults Environmental and cultural problem needing individual and population approaches

    4. Health Problems Related to Obesity Type 2 Diabetes Mellitus Hypertension Dyslipidemia Coronary Artery Disease Stroke Osteoarthritis Cancer (colon, breast) Obstructive Sleep Apnea Cholelithiasis

    5. How Do We Define Obesity? Body Mass Index (BMI) Weight (kg)/height (m˛) Waist circumference (cm) Provides information about the distribution of body fat Abdominal obesity carries the greatest risk

    6. Classification of Obesity by BMI Normal: 18.5-24.9 Overweight: 25-29.9 Class I Obesity: 30-34.9 Class II Obesity: 35-39.9 Class III Obesity: >40

    7. Waist circumference Men >102 cm Women >88 cm Cutoff points lower in certain populations Increased waist circumference marks increased disease risk even with normal weight

    8. Clinical Case Mrs. K. is a 46 year old married mother of two children. She complains of fatigue, intermittent low back pain and increased irritability for a few months. She is also requesting “a pill to help her lose weight”. Past medical history is unremarkable. She occasionally uses ibuprofen for back pain.

    9. Clinical Case Her mother has Type 2 diabetes mellitus and her father has coronary artery disease (first MI at the age of 54). She is an only child. Physical examination: weight 89 kg, height 1.6m

    10. What else would you like to know about her history? Works in an office (sedentary) Regular menses Feels sad, decreased energy, poor sleep, decreased libido Does not exercise (no time) Poor eating habits (frequent snacks on low-nutrient foods, large servings)

    11. What else would you like to know about her physical exam? BMI: 89kg/1.6m˛=34.8 Waist circumference 98 cm BP 135/85 Remainder of exam normal

    12. Management of Obesity Measure BMI and waist circumference Do appropriate laboratory investigations Fasting glucose & lipid profile Liver enzymes Creatinine, urine analysis TSH

    13. Management Treat depression if present Treat co-morbidities Assess readiness to change behavior Implement a lifestyle modification program

    14. Assessing Readiness to Change Behavior Pre-contemplation Contemplation Preparation Action Maintenance

    15. Lifestyle Modification: Using a Team Approach Goal: weight loss and prevention of weight regain Nutrition: Reduce intake by 500-1000 kcal/d Physical activity: 30 minutes of moderate intensity 3-5x/wk; eventually 60 minutes on most days; add endurance exercise training Cognitive behavior training

    16. Realistic weight loss targets A loss of 5-10% of body weight is beneficial 0.5-1.0 kg/wk x 6 months

    17. Canada Food Guide: A Pop Quiz! http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html

    18. Pharmacotherapy for Obesity Failure of first-line weight management therapy for 3-6 months and BMI > 30 BMI > 27 + risk factors

    19. Pharmacotherapy for Obesity Orlistat Lipase inhibitor that restricts fat absorption Side effects: abdominal cramping, flatulence, diarrhea Sibutramine Serotonin-norepinephrine re-uptake inhibitor that enhances satiety Side effects: dry mouth, dizziness and constipation

    20. Bariatric Surgery in Obese Adults Failure of first-line weight management therapy for 3-6 months and BMI > 40 BMI > 35 + risk factors Requires lifelong medical monitoring Liposuction does not alter disease risk!

    21. Prevention Strategies Support public health initiatives similar to those used for tobacco control Get involved in the community (e.g. the role of schools) Discuss the prevention of childhood obesity with pregnant mothers Promote exclusive breast feeding for 6 months Discuss nutrition and “screen time” with parents

    22. Obesity is a chronic disease… and requires a long term approach

    23. References 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children – summary: CMAJ 2007;176(8 suppl): S1-13 www.cmaj.ca/cgi/content/full/176/8/S1/DC1

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