dr liu 1 19-2013 obesity

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OBESITY

Hongbiao (Hank) Liu MD PhD

Luna Medical Care

1-19-2013

October 08, 2009 by CRC Press - 318 PagesEditor(s):

Atif B. Awad, State University of New York, Buffalo, USA; Peter G. Bradford, State University of New York, Buffalo, USA

October 08, 2009 by CRC Press - 318 PagesEditor(s):

Atif B. Awad, State University of New York, Buffalo, USA; Peter G. Bradford, State University of New York, Buffalo, USA

• Table of Contents The Adipose Organ; Saverio Cinti and Roberto Vettor Adipose Tissue as Endocrine Organ; Kerry B. Goralski and Christopher J. Sinal Epidemiology of Obesity; Michael J. LaMonte Inflammatory and Anti-Inflammatory Mediators Secreted by Adipose Tissue; Herbert Tilg and Alexander R. Moschen Adipokines and Inflammation; Melissa E. Gove and Giamila Fantuzzi Insulin as Modulator of Adipose Inflammation; Joseph Doria and Ahmad Aljada  Growth Hormone as Modulator of Adipose Inflammation; Hong-Biao Liu  Glucocorticoids as Modulators of Adipose Inflammation; Nicholas M. Morton Prostaglandins as Mediators of Adipose Inflammation; Martha Lappas Inflammatory Actions of Adiponectin, Leptin, and Resistin; Danielle M. Stringer, Vanessa C. DeClercq, Ryan W.T. Hunt,Maria S. Baranowski, Carla G. Taylor, and Peter Zahradka Dietary Fatty Acids as Modulators of Adipose Inflammation; Maximilian Zeyda and Thomas M. Stulnig Anti-Inflammatory Properties of Plant Sterols and Phytoestrogens: Experimental and Clinical Evidence; Rgia A. Othman and Mohammed H. Moghadasian Antioxidants, Polyphenols, and Adipose Inflammation; Fereidoon Shahidi and Ying Zhong Role of Exercise and Weight Loss in Reducing Inflammation; Tongian You and Michael J. LaMonte Adipose Tissue and Anti-Inflammatory Pharmacotherapy; Peter G. Bradford and Atif B. Awad Conclusions and Future Directions; Peter G. Bradford and Atif B. Awad

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Definition• A BMI of 25.0 to 29.9 kg per m2 is

defined as overweight; a BMI of 30.0 kg per m2 or more is defined as obesity.

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Historical PerspectivePaleolithic Era > 25,000 years ago

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Obesity - How Big A Problem…

• 1.7 billion worldwide are overweight or obese

• The US has the highest percentage of obese people.

• By 2006, only four states had a prevalence of obesity less than 20%. And the numbers are growing…

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Epidemiology of Obesity• 31.3% of U.S. males

• 34.7% of U.S. females

• 30% increase in the last 10 years

• Health care costs - >$100 billion/year

• Results in 300,000 preventable deaths each year in the U.S.

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Obesity and Life Expectancy• If current rates of obesity

are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents.

Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21st Century. NEJM, 352(11):1138-

1145, 2005

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Classification of Overweight and Obesity

• BMIBMI ClassificationClassification <18.5 Underweight

– 18.5-24.9 Normal weight– 25-29.9 Overweight– 30-34.9 Obesity Class I– 35-39.9 Obesity Class II– 40-49.9 Obesity Class III– 50 and above Super Obesity

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What causes Obesity?

• Nutrient and Energy model of obesity:

Metabolism

Appetite regulation

Energy expenditure

Genetics

Behavioral and cultural factors

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Contributors to weight gain

• Socio-economic status• Smoking cessation• Hormonal• Inactivity• Psychosocial/emotions• Medications

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Nutrient and Energy Model of Obesity

Obesity results from increased intake of energy or decreased expenditure of energy, as required by the first law of thermodynamics.

Energy Energy IntakeIntake

Adipose Adipose tissuetissue

Energy Energy ExpenditureExpenditure

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Why is it so hard to lose weight?

BrainBrain

NPYAGRPgalanin

Orexin-Adynorphin

StimulateStimulateα-MSHCRH/UCNGLP-I

CARTNE5-HT

InibitInibit

Central SignalsCentral Signals

Glucose

CCK, GLP-1,Apo-A-IVVagal afferents

Insulin

Ghrelin

Leptin

Cortisol

Peripheral signalsPeripheral signals Peripheral organsPeripheral organs

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Gastrointestinaltract

Adiposetissue

FoodIntake

Adrenal glands

External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

BrainBrain

NPYAGRPgalanin

Orexin-Adynorphin

StimulateStimulateα-MSHCRH/UCNGLP-I

CARTNE5-HT

InibitInibit

Central SignalsCentral Signals

Glucose

CCK, GLP-1,Apo-A-IVVagal afferents

Insulin

Ghrelin

Leptin

Cortisol

Peripheral signalsPeripheral signals Peripheral organsPeripheral organs

+

+

+

+

Gastrointestinaltract

Adiposetissue

FoodIntake

Adrenal glands

External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

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Leptin

• Protein hormone produced by fat cells.

• Experiment: Leptin deficient mice: Hyperphasic Insulin resistant Infertile

Leptin administration reversed all the symptoms.

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Medical Complications of Obesity

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Gall bladder disease

Gynecologic abnormalitiesabnormal mensesinfertilityPCOS

Osteoarthritis

Gout

Phlebitisvenous stasis

Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate

Severe pancreatitis

CHD Diabetes Dyslipidemia Hypertension

Cataracts

Stroke

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Consequences of Obesity

Hippocrates

recognized that :

“sudden death is more

common in those who

are naturally fat than

in lean.”

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Treating Obesity

• Measure height and weight (BMI)• Calculate waist circumference• Assess comorbidities• What labs does the patient need?

• Is the patient ready and motivated enough to loose weight?

• Which diet should you recommend?• Discuss a physical activity goal

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Weight Loss Strategies

• Diet therapy

• Increased Physical Activity

• Pharmacotherapy

• Behavioral Therapy

• Surgery

• Any combination of the above

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Rate Of Weight Loss

• A realistic goal is from 5% to 15% from baseline in 6 months of obesity treatment.

• Weight should be lost at the rate of 1-2 lbs per week, based on the caloric deficit between 500-1000 Kcal/day.

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Dieting

• Dieting is highly ineffective - 95% long term failure rate

• Often results in higher weight than before the diet

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Principles Of Dieting

• Women should consume atleast 1200 kcal/day, men 1500 kcal/day.

• Select a diet that has: >75g/day proteins (15% of total calories) > 55% total calories from carbs▪ Fat should contribute 30% or less of total caloriesAtleast 3 meals/day.High fiber (20-30g/day), fruits and vegetables.Supplement the diet with multivitamis and minerals.Avoid sugar containing beverages and fat spreads.

What about all the diets that are out there?

• Weight Watchers ($13 registration fee, $15 weekly fee)

• Jenny Craig (consultation $200-370, $65 meals/week)

• Tops Club ($20/week)

• Nutrisystem.com ($50/week)

• Atkins Diet

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Medications

A) Serotonin Nor-epinephrine Reuptake Inhibitor: reduces food intake.

Sibutramine: initial dose 10mg/day, max 20mg/day.

B) Orlistat: Lipase inhibitor. Alters metabolism, dec absorption of dietary fat. 120mg PO TID

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Surgery

• Roux-en-Y gastric bypass.

• Lap band procedure

Criteria: a) BMI > 40 or >35 with 2 comorbidities.

b) Failure of non surgical methods

c) Presence of 2 or more medical conditions that would benefit with weight loss.

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Obesity warning on London buses

The United Kingdom Branch of the International Size Acceptance Association is encouraging the public to contact World Cancer Research Fund UK to voice their concerns about this discriminating ad campaign.

ICD 9 Codes

• Obesity: 278

• Morbid Obesity: 278.01

• Overweight: 278.02

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Questions??