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Obesity
How do you diagnose obesity?
The degree of overweight or obesity in adults should be defined as follows.
Classification | BMI (kg/m2) |
---|---|
Healthy weight | 18.5–24.9 |
Overweight | 25–29.9 |
Obesity I | 30–34.9 |
Obesity II | 35–39.9 |
Obesity III | 40 or more |
Is measurement of waist circumference important?
Health risks of obesity are independently associated with abdominal fat measured by waist circumference. Thus, health risks are increased with increased waist circumference.
BMI classification | Waist circumference | |||
---|---|---|---|---|
low | High | Very high | ||
Men | < 94 cm | 94–102cm | >102cm | |
Women | < 80 cm | 80–88cm | >88cm | |
Overweight | No increased risk | Increased risk | High risk | |
Obesity I | Increased risk | High risk | Very high risk |
Why treat obesity?
Obesity is associated with multiple co-morbidities
What is the health risks associated with obesity?
Obesity is second only to smoking as the leading cause of preventable death in the US.
More than 110,000 deaths/year in the US are associated with obesity.
Are any tests needed before treating obesity?
No single laboratory test is indicated for all patients with obesity. The specific evaluations will depend on presentation of symptoms, risk factors, and index of suspicion.
How do you treat obesity?
Treatment of obesity consists of several therapeutic options
What are the principles of weight loss programme?
Programme that do not meet these criteria are unlikely to help people maintain a healthy weight in the long term.
Waist should be measured at the Midpoint between the lowest rib and the iliac crest (WHO) at the end of expiration
How do you decide on the level of intervention?
The level of intervention should be based as follows
BMI Classification |
Waist circumference | Comorbidities present |
||
---|---|---|---|---|
Low | High | Very high | ||
Overweight | Advice on healthy weight & life style | Diet +Physical activity | Diet +Physical activity | Diet +Physical activity: consider drugs |
Obesity I | Diet +Physical activity | Diet +Physical activity | Diet +Physical activity | Diet +Physical activity: consider drugs |
Obesity II | Diet +Physical activity: consider drugs | Diet +Physical activity: consider drugs | Diet +Physical activity: consider drugs | Diet +Physical activity: consider drugs: consider surgery |
Obesity III | Diet +Physical activity: consider drugs: consider surgery | Diet +Physical activity: consider drugs: consider surgery | Diet +Physical activity: consider drugs: consider surgery | Diet +Physical activity: consider drugs: consider surgery |
NB- Comorbidities include T2DM, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea.
Discuss life style changes?
Discuss Pharmacological interventions?
Drug treatment should be considered for patients who have not reached their target
weight loss or have reached a plateau on life style changes. Drug treatment is not
generally recommended for children younger than 12 years.
How do you decide which pharmacological intervention to use?
Sibutramine may be preferred in patients having difficulty controlling portion sizes due to hunger or not feeling full. It may also be useful in gastrointestinal conditions such as irritable bowel syndrome that would make it difficult to take orlistat.
Orlistat may be useful in patients needing additional motivation to adhere to a fat-modified diet
How long can you continue the drugs?
Discontinue if no response after 3 months (wt loss of at least 5%)
The medication may be continued if weight is lost within 6 months and is maintained after the initial weight loss phase. It can be continued as long as the patient continues to maintain weight loss and there are no significant adverse effects.
When would you recommend bariatric surgery?
Bariatric surgery is recommended as a treatment option for people with obesity if
all of the following criteria are fulfilled:
Remember
What are the principles of bariatric surgery?
Two main principles exist in combination or alone: restriction and malabsorption.
Purely restrictive operations limit the amount of solid food that can be consumed.
NB- Biliopancreatic diversion with or without duodenal switch is another restrictive plus malabsorptive surgery. This is technically demanding and rarely performed.
Discuss post-operative complications of bariatric surgery? (Steinbrook R. NEJM 2004)
Combined Gastric Restriction & Malabsorption Operative Risks: (vs. cholecystectomy)
Perioperative Mortality 1-2% vs. 0.2-0.8%
Early Complications 10% vs. 2.9%
Late Complications 20% vs. 1-2%
Early Complications (within 30 days) | Late complications |
---|---|
Mortality- 1% (in bypass surgery- 75% of all deaths are due to anastomotic leaks and 25 % are due to PE’s.) Anastomotic leak- 1.5% Pulmonary embolism- 2% Pneumonia- 1.9% Wound infection- 6% Acute gastric distension- rare |
Stomal Stenosis-3-20% (can be dilated upto 12mm with TTS balloon) Anastomotic Ulceration -3-20% Staple line disruption-1% Internal Hernia- rare Incisional Hernia- 15% Fistula-rare |
How do you monitor postoperatively?
There is a risk of nutritional deficiencies with malabsorptive operations.
Vitamin deficiencies- Thiamine, B12, folate, fat soluble vitamins, vitamin C
Minerals- Iron, calcium, zinc, selenium, copper
Deficiencies of protein and albumin could occur too.
There is lack of guidance regarding follow up and monitoring. However, it is suggested that;
FBC, urea and electrolytes, Ca, Mg, PO4, Glucose, LFTs, Ferritin, Vitamin B12, Folate, selenium, zinc, copper and fat soluble vitamins should be monitored at least 2-3 times a year
Bone mineral density should also be monitored
Lifelong supplementation of multivitamin tablets (including Lap band patients)
Ref
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