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Diagnosis of Obesity, AbdominalDiagnosis of Obesity, AbdominalObesity and the Metabolic Obesity and the Metabolic

Syndrome for Asian Indians Syndrome for Asian Indians

Recommendations for Physical Recommendations for Physical Activity, Medical and SurgicalActivity, Medical and Surgical

ManagementManagement

Presenter - Dr Ruchita Presenter - Dr Ruchita SharmaSharma

Moderator – Col P Prusty Moderator – Col P Prusty

(Review article JAPI Feb2009)(Review article JAPI Feb2009)

INTRODUCTIONINTRODUCTIONEpidemiologyEpidemiology

Indian senarioIndian senario

PrevelencePrevelence

Almost 30-65% of adult urban Indians are Almost 30-65% of adult urban Indians are either overweight or obese or have either overweight or obese or have abdominal obesity.abdominal obesity.

NCEP ATP IIINCEP ATP III Three or more of the following:Three or more of the following:

Central obesity: Waist circumference >102 cm Central obesity: Waist circumference >102 cm (M), >88 cm (F)(M), >88 cm (F)

Hypertriglyceridemia: Triglycerides > 150 Hypertriglyceridemia: Triglycerides > 150 mg/dL mg/dL

HDL cholesterol: <40 mg/dL(M) and < 50 HDL cholesterol: <40 mg/dL(M) and < 50 mg/dL(F)mg/dL(F)

Hypertension: Blood pressure > 130/85 mmHgHypertension: Blood pressure > 130/85 mmHg

Fasting plasma glucose > 100 mg/dLFasting plasma glucose > 100 mg/dL

IDF CRITERIAIDF CRITERIAWAIST CIRCUMFERENCEWAIST CIRCUMFERENCE

MenMen WomenWomen EthnicityEthnicity

94 cm 94 cm 80 cm80 cm EuropeansEuropeans

90 cm 90 cm 80 cm80 cm South Asian, South Asian, ChineseChinese

85 cm 85 cm 90 cm90 cm JapaneseJapanese

Two or more of the following:Two or more of the following:

Fasting triglycerides >150 mg/dL or specific medicationFasting triglycerides >150 mg/dL or specific medication HDL cholesterol <40 mg/dL and <50 mg/dL for men and women, HDL cholesterol <40 mg/dL and <50 mg/dL for men and women,

respectively, or specific medicationrespectively, or specific medication Blood pressure >130 systolic or >85 mm diastolic or previous Blood pressure >130 systolic or >85 mm diastolic or previous

diagnosis or specific medicationdiagnosis or specific medication Fasting plasma glucose 100 mg/dL or previously diagnosed type 2 Fasting plasma glucose 100 mg/dL or previously diagnosed type 2

diabetesdiabetes

WHO DefinitionHyperinsulinemia . fasting glucose Hyperinsulinemia . fasting glucose 110 mg/dL 110 mg/dL

AND at least 2 of the following:AND at least 2 of the following:

Abdominal obesity:Abdominal obesity:

(1) waist-to-hip ratio, men (1) waist-to-hip ratio, men 90 cm and women 90 cm and women 85 cm or BMI 85 cm or BMI 30 kg/m30 kg/m22; ; oror

(2) waist girth (2) waist girth 94 cm 94 cm

Dyslipidemia: Serum TG Dyslipidemia: Serum TG 150 mg/dL, 150 mg/dL,

HDL-C, men HDL-C, men 35 mg/dL and women 35 mg/dL and women 39 39 mg/dLmg/dL

Blood Pressure Blood Pressure 140/90 mm Hg or medication140/90 mm Hg or medication

WHY REVISION OF GUIDELINES FOR WHY REVISION OF GUIDELINES FOR

OBESITY AND METABOLIC SYNDROMEOBESITY AND METABOLIC SYNDROME

ARE NEEDED FOR ASIAN INDIANS?ARE NEEDED FOR ASIAN INDIANS?

a.a. Changing trend Changing trend

b.b. Asian Indians manifest higher risk at Asian Indians manifest higher risk at lower level of obesity and dyslipidemia lower level of obesity and dyslipidemia than in non-Asian Indian populations.than in non-Asian Indian populations.

WHO decision regarding guidelines for WHO decision regarding guidelines for BMI for different countries BMI for different countries

In case of Indian populationIn case of Indian population

Benefit of lowering level of obesityBenefit of lowering level of obesity

The Consensus Development The Consensus Development ProcessProcess

Experts opinion for development for Experts opinion for development for obesity guidelinesobesity guidelines

The steering committee drafted The steering committee drafted document and communicated to all document and communicated to all participantsparticipants

Revised consensus document was Revised consensus document was circulated among all the expertscirculated among all the experts

The consensus meeting held at New The consensus meeting held at New Delhi on 15-16th of November, 2008.Delhi on 15-16th of November, 2008.

a.Which is/are the best measure(s) of obesity?a.Which is/are the best measure(s) of obesity?

b. What are optimum cut-offs for BMI and WC?b. What are optimum cut-offs for BMI and WC?

c. What is the best definition for adults and c. What is the best definition for adults and children?children?

d. What should be physical activity guidelines?d. What should be physical activity guidelines?

e. What should be dietary guidelines? e. What should be dietary guidelines?

f. What should be guidelines for drug f. What should be guidelines for drug treatment of obesity?treatment of obesity?

g. What should be guidelines for bariatric g. What should be guidelines for bariatric surgery?surgery?

WHICH IS /ARE THE BEST MEASURES WHICH IS /ARE THE BEST MEASURES FOR DIAGNOSIS OF OBESITY?FOR DIAGNOSIS OF OBESITY?

Obesity is defined as an excessive Obesity is defined as an excessive accumulation of fat in the body resulting accumulation of fat in the body resulting in adverse effects on health of the in adverse effects on health of the individual.individual.

Three simple measures of obesity are Three simple measures of obesity are widely used in clinical practice; widely used in clinical practice; BMI (Kg/meter square)BMI (Kg/meter square) WC WC Waist-to-hip circumference ratio (WHR).Waist-to-hip circumference ratio (WHR).

Consensus StatementConsensus Statement

BMI is the most researched measure of BMI is the most researched measure of generalized obesity and should continue to generalized obesity and should continue to be used using Asian Indian-specific cut-be used using Asian Indian-specific cut-offs.offs.

Waist circumference should be used as a Waist circumference should be used as a measure of abdominal obesity with Asian measure of abdominal obesity with Asian Indian specific cut-offsIndian specific cut-offs

Both BMI and WC should be used together Both BMI and WC should be used together (with equal importance) for population- (with equal importance) for population- and clinic-based metabolic and and clinic-based metabolic and cardiovascular risk stratificationcardiovascular risk stratification

WHAT ARE THE OPTIMUM CUT OFF FOR BMI & WCWHAT ARE THE OPTIMUM CUT OFF FOR BMI & WC

Asian Indians are more predisposed to Asian Indians are more predisposed to develop insulin resistance and CVS risk develop insulin resistance and CVS risk factors at lower levels of BMI.factors at lower levels of BMI.

Excess CVS risk factors attributed by Excess CVS risk factors attributed by differences in body composition of Asian differences in body composition of Asian Indians Indians

RECOMMENDED CUT OFFS OF RECOMMENDED CUT OFFS OF BMI(kg/m²)BMI(kg/m²)

W.H.OW.H.O CONSENSUS CONSENSUS STATEMENTSTATEMENT

NORMAL 18.5-NORMAL 18.5-24.924.9

18-22.918-22.9

OVERWEIGHT 25- 29.9OVERWEIGHT 25- 29.9 23- 24.923- 24.9

OBESITY > 30OBESITY > 30 > 25> 25

WC AND WHR CUT OFFS FOR ASIAN INDIANSWC AND WHR CUT OFFS FOR ASIAN INDIANS

Abdominal obesity is as an important Abdominal obesity is as an important cardiovascular risk factor.cardiovascular risk factor.

Association of abdominal obesity with Association of abdominal obesity with metabolic risk factors is stronger than metabolic risk factors is stronger than generalized adiposity.generalized adiposity.

Common surrogate measures of Common surrogate measures of abdominal obesity are WC and WHR.abdominal obesity are WC and WHR.

Recommendation of cut-offs of WC (>102 Recommendation of cut-offs of WC (>102 cm in men and >88 cm in women) are cm in men and >88 cm in women) are not applicable to asian indians. not applicable to asian indians.

Asian Indians have higher morbidity at Asian Indians have higher morbidity at lower cut-off for WC than White lower cut-off for WC than White Caucasians.Caucasians.


Methodology of WC MeasurementMethodology of WC Measurement

WC is preferred over WHR as a measure WC is preferred over WHR as a measure of abdominal obesityof abdominal obesity

Both BMI and WC should be used Both BMI and WC should be used together (with equal importance) for together (with equal importance) for population- and clinic-based risk population- and clinic-based risk stratificationstratification

Action PlanAction Plan

Action level 1: Action level 1: Men: 78 cm, women: 72 cm. Men: 78 cm, women: 72 cm. Person with WC above these levels Person with WC above these levels should avoid gaining weight and should avoid gaining weight and maintain physical activity .maintain physical activity .

Action level 2: Action level 2: Men: 90 cm, women: 80 cm. Subject Men: 90 cm, women: 80 cm. Subject with WC above this should seek with WC above this should seek medical help.medical help.

WHAT IS THE BEST DEFINITION FOR WHAT IS THE BEST DEFINITION FOR METABOLIC SYNDROME IN ADULT?METABOLIC SYNDROME IN ADULT?

The metabolic syndrome is defined as a The metabolic syndrome is defined as a clustering of cardiovascular risk factors in clustering of cardiovascular risk factors in an individual which predisposes the an individual which predisposes the person to a greater risk of developing person to a greater risk of developing T2DM and CVDs.T2DM and CVDs.


Modification of IDF definition which includesModification of IDF definition which includes

Abdominal obesity [Asian indian cut-offs of WC, Abdominal obesity [Asian indian cut-offs of WC, and WC as a nonobligatory criterion]and WC as a nonobligatory criterion]

High triglyceridesHigh triglycerides Low-HDLLow-HDL Dysglycemia (impaired fasting glucose/impaired Dysglycemia (impaired fasting glucose/impaired

glucose tolerance)glucose tolerance) And hypertension should be used. And hypertension should be used.

Three out of the five criteria have to be Three out of the five criteria have to be abnormal for diagnosing the metabolic abnormal for diagnosing the metabolic syndrome.syndrome.

Physical Activity Guidelines for Physical Activity Guidelines for Obesity and Metabolic Obesity and Metabolic

Syndrome Syndrome

Physical activity is defined as any Physical activity is defined as any activity leading to calorie activity leading to calorie consumption. consumption.

It reduces risk for cardiovascular It reduces risk for cardiovascular diseases, diabetes and other diseases, diabetes and other disabilities associated with obesity.disabilities associated with obesity.


Physical inactivity should be avoided as Physical inactivity should be avoided as far as possiblefar as possible

Pre-participation medical consultation is Pre-participation medical consultation is recommended for those with chronic recommended for those with chronic conditions or those who are symptomaticconditions or those who are symptomatic

Inactive people should start slow Inactive people should start slow Brisk walking is preferred initial mode of Brisk walking is preferred initial mode of

exercise.exercise. Total of 60 minutes of physical activity is Total of 60 minutes of physical activity is

recommended every day recommended every day

Consensus Statement (cont..)Consensus Statement (cont..) Physical activity can be accumulated Physical activity can be accumulated

throughout the day in blocks as short as 10 throughout the day in blocks as short as 10 minutes. minutes.

There is a dose-response relationship There is a dose-response relationship

between physical activity and health. between physical activity and health. Physical activity must be individualized on the Physical activity must be individualized on the

basis of person’s abilities and comorbidities.basis of person’s abilities and comorbidities. Dynamic yoga should be encouraged.Dynamic yoga should be encouraged.

Children should undertake at least 60 min of Children should undertake at least 60 min of outdoor physical activity.outdoor physical activity.

PHARMACOLOGICAL TREATMENT PHARMACOLOGICAL TREATMENT OF OBESITYOF OBESITY

The consensus group agreed that anti-The consensus group agreed that anti-obesity drugs should be used only in obesity drugs should be used only in conjunction with diet and lifestyle conjunction with diet and lifestyle modifications as a part of comprehensive modifications as a part of comprehensive weight loss program. weight loss program.

Pharmacotherapy should be monitored on Pharmacotherapy should be monitored on an ongoing basis for efficacy as well as an ongoing basis for efficacy as well as safety.safety.

International Guidelines for International Guidelines for drug treatment of obesitydrug treatment of obesity

BMI above 27 kg/m2 with risk factors BMI above 27 kg/m2 with risk factors or or

co-morbidities likeT2DM, co-morbidities likeT2DM, hypertension, dyslipidemia.hypertension, dyslipidemia.

* BMI above 30 kg/m2 without * BMI above 30 kg/m2 without comorbidity. comorbidity.

Consensus Statement for Asian IndiansConsensus Statement for Asian Indians

BMI above 25 kg/ m2 with co-morbidityBMI above 25 kg/ m2 with co-morbidity

BMI above 27 kg/m2 without co-BMI above 27 kg/m2 without co-morbidity. morbidity.

The cut-offs for WC for initiating The cut-offs for WC for initiating pharmacotherapy was unanimously agreed pharmacotherapy was unanimously agreed upon as a WC measurement 10 cms more upon as a WC measurement 10 cms more than the upper limit of gender specific than the upper limit of gender specific normal value for adult Asian Indians.normal value for adult Asian Indians.

Sibutramine is the drug of choice unless Sibutramine is the drug of choice unless contraindicated. contraindicated.

Orlistat should be used as a second line Orlistat should be used as a second line drug because of adverse effects, lesser drug because of adverse effects, lesser ability to induce weightloss, and higher ability to induce weightloss, and higher cost.cost.

SURGICAL TREATMENT OF SURGICAL TREATMENT OF OBESITYOBESITY

It involves modification of the digestive It involves modification of the digestive system system

-By either decreasing the gastric volume -By either decreasing the gastric volume (restriction). (restriction).

- Altering the path of the food bolus - Altering the path of the food bolus causing an element of malabsorption.causing an element of malabsorption.

These alterations effect appropriate These alterations effect appropriate changes in eating behavior and aid changes in eating behavior and aid lifestyle modifications to help weight loss.lifestyle modifications to help weight loss.

International Guidelines for surgical treatment International Guidelines for surgical treatment of obesityof obesity :- :-

* BMI above 35 kg/m2 with risk factors or * BMI above 35 kg/m2 with risk factors or co- co- morbiditieslikeT2DM,hypertension,dyslipidemmorbiditieslikeT2DM,hypertension,dyslipidemia.ia.

* BMI above 40 kg/m2 without comorbidity. * BMI above 40 kg/m2 without comorbidity.

Consensus Statement for Asian Indians: TheConsensus Statement for Asian Indians: The

*BMI above 32.5 kg/ m2 with co-morbidity*BMI above 32.5 kg/ m2 with co-morbidity

*BMI above 37.5 kg/m2 without co-*BMI above 37.5 kg/m2 without co-morbidity. morbidity.

The Surgical Options for Weight Loss The Surgical Options for Weight Loss Surgery: Surgery:

1.1. Restrictive Procedures: Adjustable Restrictive Procedures: Adjustable gastric banding (LAGB) & sleeve gastric banding (LAGB) & sleeve gastrectomy.gastrectomy.

2.2. Combined Procedures: Roux-en-Y Combined Procedures: Roux-en-Y Gastric Bypass (RYGBP).Gastric Bypass (RYGBP).

3.3. Malabsorptive Procedures: Bilio-Malabsorptive Procedures: Bilio-pancreatic diversions (BPD).pancreatic diversions (BPD).

Each surgical procedure has its Each surgical procedure has its advantages and disadvantages as advantages and disadvantages as regards weight loss, resolution of surgical regards weight loss, resolution of surgical co-morbidities, peri-operative morbidity co-morbidities, peri-operative morbidity and mortality and long-term sequelae.and mortality and long-term sequelae.

Malabsorptive procedures showing better Malabsorptive procedures showing better results compared to purely restrictive results compared to purely restrictive procedures such as gastric banding.procedures such as gastric banding.

Complications of obesityComplications of obesity Coronary heart diseaseCoronary heart disease Type 2 diabetesType 2 diabetes Cancers (endometrial, breast, and colon)Cancers (endometrial, breast, and colon) Hypertension (high blood pressure)Hypertension (high blood pressure) Dyslipidemia (for example, high total cholesterol Dyslipidemia (for example, high total cholesterol

or high levels of triglycerides)or high levels of triglycerides) StrokeStroke Liver and Gallbladder diseaseLiver and Gallbladder disease Sleep apnea and respiratory problemsSleep apnea and respiratory problems Osteoarthritis (a degeneration of cartilage and its Osteoarthritis (a degeneration of cartilage and its

underlying bone within a joint)underlying bone within a joint) Gynecological problems (abnormal menses, Gynecological problems (abnormal menses,

infertility)infertility)

Advantages of obesityAdvantages of obesity

Low risk of anemia,osteoporosisLow risk of anemia,osteoporosisLow risk of depression,suicidal Low risk of depression,suicidal

tendencytendencyBetter outcome in Haemodialysis and Better outcome in Haemodialysis and

heart transplant.heart transplant.More survival in HIVMore survival in HIV In pregnancyIn pregnancy

THANK YOUTHANK YOU

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