OBESITAS

Dr. Nanang Miftah F, SpPD

Bagian Endokrin dan Metabolik

FK UNLAM – RS ULIN
The cover of "The Economist", Dec. 13-19, 2003.
How is obesity measured? Introduction 1

Obesity is defined as the excessive accumulation of body fat.

There are a number of ways to measure body fat:

1. Measurements that are simple, cheap and appropriate for

routine use include:
• waist circumference
• hip circumference
• waist-to-hip circumference ratio
• Indices derived from weight and height, e.g. body mass
index
• skin fold thickness using callipers (e.g. triceps, scapular)

2. Measurements of body fat that are expensive and require

special equipment and highly trained personnel include:

• underwater weighing
• bioelectrical impedance
• computerized topography
 Etiology of obesity
• Too much food intake
• Insufficient energy output
– Not enough exercise
– Low resting metabolic rate
• Genetic predisposition
• Environment favoring weight gain
• Psychological stressors
Obesity is associated with increased risk of
co-morbid conditions:
• Hypertension • Gallbladder dz.
• Dyslipidemia • Sleep apnea
• Diabetes mellitus • Osteoarthritis
• Coronary artery dz. • Gout
• Cancers
• Cerebrovascular dz.
– Colon
– Breast
• OVERALL MORTALITY – Prostate
HIGHER! – Uterus
– Cervix
 Classification of obesity (1) –
‘apples’ and ‘pears’
The apple shape: The pear shape:

 also called “android”,  also called “gynaeoid” or

“abdominal” or “central”
obesity
 people with high waist-to-hip ratios are
"apples", their body fat is distributed
mainly on the upper trunk, the chest and
abdomen giving the typical ‘apple shape’
 individuals are mostly male
 A waist-to-hip ratio >1.0 for men and
>0.8 for women indicates an increased
risk of cardio-vascular disease and
diabetes mellitus
“peripheral” obesity
 people with lower waist to hip
ratios are "pears“ - their body fat is
distributed mainly on the lower trunk,
the hips and thighs giving the typical
‘pear shape’.
 individuals are mostly female.
 associated health risks are minimal
if any
Classification of obesity (2) –
body mass index (BMI)

The internationally accepted classification for

obesity is the Quetelet's Index, also called the Body
Mass Index (BMI)

The BMI is a measure of a person’s weight in

relation to height and it is calculated as:

weight divided by height squared (kg/m2)

BMI = weight in kilograms = kg/m2

square of height in meters
WHO classification of obesity
tion 1

Risk of co-
Classification BMI (kg/m2) morbidity
Normal 18.5 - 24.9 Not increased
Overweight or pre-obese 25.0 - 29.9 Increased
Obesity, further classified Increased as
as: 30.0 follows:
– Class I 30.0 - 34.9 – Moderate

– Class II 35.0 - 39.9 – Severe

– Class III 40.0 – Very severe

Note: Although overweight is identified by a BMI of ≥ 25.0 kg/m2, the risks

of obesity-associated diseases, such as diabetes, hypertension and
dyslipidaemia, increase from a BMI of about 21.0 kg/m2.

Source: Adapted from WHO 1997

 A weight and height chart is a useful
clinical tool to determine a person’s BMI
oduction 1

Source: Weight Control Information Network , NIH

Obesity Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

 Guide for Selecting Obesity
Treatment
BMI Category (kg/m2)

Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40

Diet,
Exercise, + + + + +
Behavior Tx

Pharmaco- With co-

therapy morbidities + + +
With co-
Surgery
morbidities
+

The Practical Guide: Identification, Evaluation, and Treatment of

Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084
 Impact of Weight Loss on Risk
Factors
~5% 5%-10%
Weight Loss Weight Loss
HbA1c 1 1

Blood Pressure 2 2

Total Cholesterol 3 3

3
HDL Cholesterol 3
4
Triglycerides
1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753.
2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270-278.
3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S.
4. Ditschunheit HH et al. Eur J Clin Nutr. 2002;56:264-270.
Cardinal Behaviors of Successful Long-term Weight Management

• Self-monitoring:
– Diet: record food intake daily, limit certain foods or
food quantity
– Weight: check body weight >1 x/wk
• Low-calorie, low-fat diet:
– Total energy intake: 1300-1400 kcal/d
– Energy intake from fat: 20%-25%
• Eat breakfast daily
• Regular physical activity: 2500-3000 kcal/wk
(eg, walk 4 miles/d)

Klem et al. Am J Clin Nutr 1997;66:239.

McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.
 Assessing Weight Loss Readiness
• Motivation: Patient seeks weight reduction
• Stress level: Free of major life crises
• Psychiatric issues:
Free of severe depression,
substance abuse, bulimia nervosa
• Time availability:
Patient can devote 15-30 min/d to
weight control for next 26 weeks
YES NO
Patient Ready?
Initiate weight loss therapy Prevent weight gain and
explore barriers to weight
reduction
 1. Decreased caloric intake
• 500 - 1000 kcal/day less than usual
– Lose 1-2 lbs/week
• Women: 1000 - 1200 kcal/day total diet
• Men: 1200 - 1500 kcal/day total diet

National Heart, Lung, and Blood Institute. Clinical guidelines on

the identification, evaluation, and treatment of overweight
and obesity in adults: the evidence report. 1998.
 2. Increased exercise
• 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
Principles of Pharmacotherapy in
the Management of Obesity
 Regulation of Food Intake
External factors
Brain Emotions, Drugs
Food characteristics
Central Signals Lifestyle behaviors
Stimulate Inibit Environmental cues
NPY Orexin-A α-MSH CART
AGRP Dynorphin CRH/UCN NE
galanin ECS/CB1 GLP-I 5-HT

Peripheral signals Peripheral organs

Glucose
Gastrointestinal
CCK, GLP-1, tract
 Apo-A-IV
Vagal afferents
Food
Insulin
Intake
+ Ghrelin
Adipose
 Leptin tissue

+ Cortisol Adrenal glands

 Drugs Approved by FDA for Treating Obesity

Trade DEA Approved Year

Generic Name Names Schedule Use Approved

Orlistat Xenical None Long-term 1999

Sibutramine Meridia IV Long-term 1997

Diethylpropion Tenulate IV Short-term 1973

Adipex,
Phentermine IV Short-term 1973
lonamin

Bontril,
Phendimetrazine III Short-term 1961
Prelu-2

Benzphetamine Didrex III Short-term 1960

 Pharmacological therapy
• Candidates:
– BMI 27-29.9 and + risk factor
– BMI >=30
• Never use as sole therapy!!
– Poor effectiveness
– Poor long-term maintenance of wt loss
• Agents approved by FDA for long-term use
 Sibutramine (Meridia)
• Blocks reuptake of norepi and serotonin
• 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
• Cost: $80/month
 Orlistat (Xenical)
• Decreases fat absorption by inhibiting lipase in
intestine (not absorbed)
• Proven efficacy, even long-term
• Improves TC, LDL, TG, HbA1c, glucose)
• Side-effects mostly GI:
– Oily spotting, flatus, fecal urgency/incontinence
• Worse after fat ingestion; can lead to less fat eaten
– Multi-vit with A/D/E/K recommended
• Cost: $110/month
 Surgery for obesity
• For high-risk patients who have failed non-
surgical therapy
– BMI 35-39.9 w/ RF’s
– BMI >= 40
• Produces longest wt loss maintenance of all
treatment methods
• Significantly decreases mortality rate
• Techniques: vertical gastric banding, gastric
bypass
 Summary of treatment based on BMI
and risk
• BMI 25-30, no RF: advise wt loss
• BMI 27-29.9, >= 2 RF: treat, +/- meds
• 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
Thank You