Obesity & Dyslipidemia

1. Obesity & Dyslipidemia

2. Introduction: • Obesity is one of the most common disorders encountered in clinical practice and has major public health implications. Unfortunately, it is also one of the most difficult and frustrating disorders to manage successfully. • It is a complex condition, with serious social and psychological dimensions that affect virtually all age and socioeconomic groups and threatens to both developed and developing countries. • It is also one of the preventable causes of many diseases e.g : ( Coronary Heart Disease ) and death .

3. Definition: • Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. • Dyslipidemia is defined as an abnormal amount of lipids (e.g. cholesterol and/or fat) in the blood.

4. Epidemiology: • The prevalence of overweight and obesity has increased in the last few years. • In 1995, there were an estimated 200 million obese adults worldwide and another 18 million children under-5-years classified as overweight. • By the year 2000, the number of obese adults had increased to over 300 million. Children and adolescents are also involved in those changes. • Unfortunately, it is evident that obesity is a common health problem among Saudis. • Overweight and obesity in the adult Saudi population were reported in different studies.

5. Epidemiology: • Across the whole population from 1995–2000, 36.9% was overweight and 35.6% was obese. Rates were high amongst children aged 5–17, as 16.7% of boys and 19.4% of girls were overweight. • By 2006, 52% of men, 66% of women, 18% of teenagers, and 15% of preschoolers were overweight or obese. • This high prevalence of overweight and obesity is a cause of concern, as obesity is associated with several complications that increase both morbidity and mortality.

6. Classification of Obesity: • Obesity is a medical condition in which excess bodfat has accumulated to the extent that it may have an adverse effect on health. • It is defined by body mass index (BMI) and further evaluated in terms of fat distribution via the waist–hip ratio and total cardiovascular risk factors. • BMI is calculated by dividing the subject's mass by the square of his or her height • BMI = kilograms / meters2

7. Classification of Obesity:

8. Classification of Obesity: • In children, a healthy weight varies with age and sex. • Obesity in children and adolescents is defined not as an absolute number, but in relation to a historical normal group, such that obesity is a BMI greater than the 95th percentile. • The reference data on which these percentiles are based are from 1963 to 1994, and thus have not been affected by the recent increases in weight.

9. Classification of Dyslipidemia: • Dyslipidemia - abnormal cholesterol (TC, LDL-C, or HDL-C) and/or TG concentrations. • The primary form includes: chylomicronemia, hypertriglyceridemia,hypercholesterolemia, mixed hyperlipoproteinemia, dysbetalipoproteinemia,  combined hyperlipoproteinemia. • The secondary form is caused by other diseases, such as: diabetes mellitus, pancreatitis, renal disease, or hypothyroidism.

10. Classification of Dyslipidemia: • Normal values: • Total cholesterol < 5.5mmol/L • HDL – C >1.1 mmol/L • Triglycerides < 1.9 mmol/L • LDL – C < 3,4 mmol/L

11. Classification of Dyslipidemia: • There are two major ways in which dyslipidemias are classified: • Phenotype, or the presentation in the body (including the specific type of lipid that is increased) • Etiology, or the reason for the condition (genetic, or secondary to another condition.) This classification can be problematic, because most conditions involve the intersection of genetics and lifestyle issues. However, there are a few well-defined genetic conditions that are usually easy to identify.

12. Classification of Dyslipidemia:

13. Risk Factors: • Genetics. Your genes may affect the amount of body fat you store and where that fat is distributed. • Genetics play a role in how efficiently your body converts food into energy and how your body burns calories during exercise(the commonest monogenic human obesity is due to MELANOCORTIN RECEPTOR “MC4R”defeciency (HYPER INSULINEMIA T CELL FUNCTION). • Inactivity. If you're not very active, you don't burn as many calories. With a sedentary lifestyle, you can easily take in more calories every day than you burn off through exercise and normal daily activities. • Unhealthy diet and eating habits. Having a diet that's high in calories, eating fast food, skipping breakfast, consuming high-calorie drinks and eating oversized portions all contribute to weight gain.(daily requirment 3500)

14. Risk Factors: • Family lifestyle. Obesity tends to run in families. That's not just because of genetics. Family members tend to have similar eating, lifestyle and activity habits. If one or both of your parents are obese, your risk of being obese is increased. • Quitting smoking. Quitting smoking is often associated with weight gain. And for some, it can lead to a weight gain of as much as several pounds a week for several months, which can result in obesity. In the long run, however, quitting smoking is still a greater benefit to your health than continuing to smoke. • Pregnancy. During pregnancy a woman's weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.

15. Risk Factors: • Lack of sleep. Not getting enough sleep at night can cause changes in hormones that increase your appetite. You may also crave foods high in calories and carbohydrates, which can contribute to weight gain. • Certain medications. Some medications can lead to weight gain if you don't compensate through diet or activity. These medications include some antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids and beta blockers. • Age. Obesity can occur at any age, even in young children. But as you age, hormonal changes and a less active lifestyle increase your risk of obesity. In addition, the amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs and can make it harder to keep off excess weight. If you don't control what you eat as you age, you'll likely gain weight.

16. Risk Factors: • Social and economic issues. Certain social and economic issues may be linked to obesity. You may not have safe areas to exercise, you may not have been taught healthy ways of cooking, or you may not have money to buy healthier foods. In addition, the people you spend time with may influence your weight — you're more likely to become obese if you have obese friends or relatives. • Medical problems. Obesity can rarely be traced to a medical cause, such as Prader-Willi syndrome, Cushing's syndrome, polycystic ovary syndrome, and other diseases and conditions. Some medical problems, such as arthritis, can lead to decreased activity, which may result in weight gain. A low metabolism is unlikely to cause obesity, as is having low thyroid function.

17. Complications: • Type 2 diabetes • The abnormalities in lipid and glucose metabolism appear to be related to fat distribution and to total body weight, and this is why obese patients have a higher rate of diabetes mellitus insulin resistance.

18. Complications: • High blood pressure: • Indicators for risk of hypertension include obesity, abdominal obesity and weight gain. • Obesity increases heart disease risk by increasing LDL-cholesterol levels (bad cholesterol) and reducing HDL-cholesterol levels (good cholesterol). • This produces atherosclerosis (hardening of the heart arteries), which can cause myocardial infarction (heart attacks)

19. Complications: • Metabolic syndrome — • acombination of high blood sugar, high blood pressure, high triglycerides and high cholesterol.

20. Complications: • Atheroscelorosis and Heart disease: • Your body needs cholesterol to function properly. • However, high cholesterol can cause health problems. • It can cause a condition called atherosclerosis, the effects of which include coronary heart disease, angina, and stroke. • Although the causes of increased cholesterol are often unknown, risk factors include diet, weight, and heredity. • If lifestyle changes alone are not enough, medication may be necessary to lower cholesterol.

21. Complications: • Stroke: • High blood pressure is the leading cause of stroke and death rates due to stroke are nearly 45%. • Having excess weight or being physically inactive can both lead to high blood pressure, so help to minimize your risk of stroke by maintaining a healthy weight through eating well and being regularly physically· • Individuals who are obese have a greater chance of suffering from sleep disordered breathing, known as sleep apnea.6 Those with sleep apnea have a greater risk of high blood pressure, irregular heart rhythms, and stroke. • Diabetes is an individual risk factor for stroke. Help decrease your risk of diabetes and stroke by maintaining a healthy weight by eating well and being physically active

22. Complications: • Gallbladder disease: • Gallbladder disease is a multifactorial process involved with host and environmental factors. • Obesity is considered one of the most important risk factor associated with gallstone disease and is very important mainly due its increased prevalence worldwide. • Several changes in cholesterol metabolism tend to increase gallbladder cholesterol secretion in conjunction with motility disturbances

23. Complications: • Nonalcoholic fatty liver disease: • Nonalcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver diseases ranging from the most common, fatty liver (accumulation of fat in the liver, also known as steatosis), to Nonalcoholic steatohepatitis (NASH, fat in the liver causing liver inflammation), to cirrhosis (irreversible, advanced scarring of the liver as a result of chronic inflammation of the liver). • All of the stages of Nonalcoholic fatty liver disease are now believed to be due to insulin resistance, a condition closely associated with obesity. • In fact, the BMI correlates with the degree of liver damage, that is, the greater the BMI the greater the liver damage

24. Complications: • Osteoarthritis. • Sleep apnea. • Gynecologic problems, such as infertility and irregular period. • Cancer, including cancer of the uterus, cervix, ovaries, breast, colon, rectum and prostate. • PSYCHOSOCIAL PROBLEMS.

25. Complications: • Quality of lifeWhen you're obese, your overall quality of life may be lower, too. You may not be able to do things you'd normally enjoy as easily as you'd like. You may have trouble participating in family activities. You may avoid public places. You may even encounter discrimination. • Other weight-related issues that may affect your quality of life include: • Depression • Disability • Physical discomfort • Sexual problems • Shame • Social isolationearly-onset.

26. Management of Obesity

27. Management: • Non pharmacological treatment : 1-Explanation the risk factor , the causes , and the plan. 2-Dietry counseling (evidence A). 3-Weight loss program .(reduction calories intake by 500-1000) per day.(evidence A) 4-Excersise 45-60 min per day for at least 5 days a week .(evidence B) 5- Agree on target weight reduction .(evidence B) 6-Behavioral therapy and motivation .

28. Management: • Pharmacological : • Depend upon the BMI: 1-if BMI<30 with no comorbidity , life style change is adequate. 2- if BMI >30 with risk factor or without then the drugs are helpful. 3-if BMI>40 drugs are indicated.

29. Management: • What drug should be given ? • Orlistat (Xenical ) inhibit the lipase enzyme. • Side effects :1-flautance 2- fecal incontinance.

30. Management of Dyslipidemia

31. Management: • A-Non pharmacological treatment: • Explanation of the risk factor of lipid disorders e.g effect on Heart . • Dietry counseling . • Weight loss program .(reduction calories intake by 500-1000) per day. • Excersise 45-60 min per day for at least 5 days a week . • Agree on target weight reduction . • Behavioral therapy and motivation .

32. Management: • B-pharmacological: • Guidline for treatment : • We depend on level of: • 1-LDL • 2-TG • 3-HDL • 4-Risk factors and CHD. • 5- Other health problems .

33. Management: • B-pharmacological: • Indication for treatment : 1-If patient has DM or CHD with(LDL<100 mg/dl). 2-If patient has > CHD risk factor (LDL <130 mg/dl). 3-If patient has <2 CHD risk factor (LDL <160 mg/dl). 4-If LDL >190 mg/dl after diet therapy 3-6 months in healthy people.

34. Management: • B-pharmacological: • Indication for treatment : 1-If patient has DM or CHD with(LDL<100 mg/dl). 2-If patient has > CHD risk factor (LDL <130 mg/dl). 3-If patient has <2 CHD risk factor (LDL <160 mg/dl). 4-If LDL >190 mg/dl after diet therapy 3-6 months in healthy people. • Target of TG <150 mg/dl • Check LFT and RFT before statin .

35. Management: • B-pharmacological: • 1. Statins: Fluvastatin, Simvastatin, Atorvastatin, Rosuvastatin (in order of potency): • They inhibit the rate-limiting enzyme in cholesterol synthesis (HMG CoA-reductase, HMG for hydroxy-methyl-glutaryl).

36. Management: • B-pharmacological: • 2. Fibrates: Fenofibrate and Gemfibrozil: • Agonists of nuclear receptor PPARα (peroxisomeproliferator-activated receptor α) expressed in several types of cells such as hepatocytes, skeletal muscle fibres and macrophages .

37. Management: • B-pharmacological: • 3. Niacin (nicotinic acid, vitamin B3): • Niacin is the most effective agent for increasing HDL - the "good"cholesterol. It also reduces LDL and TG concentration. • Niacin is usually co-administered with a statin (statins decrease LDL – the "bad" cholesterol) • niacin inhibits lipase activity in the adipocytes.

38. Management: • B-pharmacological: • 4. Inhibitors of bile acid absorbtion: Cholestyramine, Colesevelam and Colestipol • These are cationic (positively charged) compounds that bind negatively charged bile acids, forming non-absorbable complexes that are excreted in the stool.

39. Management: • B-pharmacological: • 5.Inhibitors of cholesterol absorbtion: plant sterols and Ezetimibe • By reducing the absorbtion of dietary and biliary cholesterol in the intestine, these agents decrease the cholesterol content of chylomicrons

40. Management: • B-pharmacological: • Omega-3 fatty acids • Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA) also known as "fish oils" may be effective in reducing plasma TGs. They are used as food supplements together with lipid-lowering drugs for patients whose plasma TG level is higher than 500mg/dL.

41. THE END… Thanks……….