Morbid ObesityBy Prof Dr

WALEED IBRAHIM

Obesity has been defined as excess body fat relative to lean body mass.

The most widely accepted measure of obesity is the body mass index (BMI).

BMI= Patient’s weight in kg / square of patient’s height in meters (kg/m²).

A normal BMI ranges from 18.5 to 24.9 kg/m²

Definition

BMI 25-29.9 = overweight. BMI ≥30 = obesity. BMI ≥35 = severe obesity. BMI ≥40 = morbid obesity. BMI ≥45 = super obese.

Classification

GENETIC ( rare )

A. SYNDROMES INDUCING OBESITY: Prader- Willi : Hypotonia, Hyperphagia, M R, Facial

features Laurence- Moon : Ret. Pig, M R , Sp. Pplegia,

Hypogonad Bardet-Biedl : Polydactyly, Renal failure

B. CHROMOSOMAL DEFECTS:

AETIOLOGY OF OBESITY

NUTRITIONAL : Intra-uterine, Infancy, Dietary.

PHYSICAL INACTIVITY : TV., Internet, Lifestyle, Technology.

TRAUMA :NEUROLOGICAL : Post op., Head injuries.PSYCHOLOGICAL : Stresses, Abuse….

MEDICATIONS : Steroids, Psychotropic drugs.

SOCIAL : Economic, Ethnic.

ENVIRONMENTAL

HYPOTHALAMIC-PITUITARY GONADAL : Polycystic Ovary ADRENAL : Cushing THYROID PANCREATIC : Hyperinsulinaemia

NEURO-ENDOCRINE

COMBINATION OF : OBESITY ( Esp. CENTRAL ) + 2 of : HT. DM. DYSLIPIDEMIA

METABOLIC SYNDROME

The American Heart Association and the National Heart, Lung, and Blood Institute recommend that the metabolic syndrome be identified as the presence of three or more of:

Elevated waist circumference:Men —Equal to or greater than 40 inches (102 cm)Women — Equal to or greater than 35 inches (88 cm)

Elevated triglycerides:Equal to or greater than 150 mg/dL

AHA

Reduced HDL (“good”) cholesterol:Men — Less than 40 mg/dLWomen — Less than 50 mg/dL

Elevated blood pressure:Equal to or greater than 130/85 mm Hg

FBS equal or greater than 100mg/dL

Morbidly obese patients are classified according to area of main fat mass:

Peripheral (Gynecoid) obesity: associated with degenerative joint disease and venous stasis in the lower extremities.

Central (Android) obesity: associated with the highest risk of mortality related problems due to the “Metabolic Syndrome” as well as increased intra-abdominal pressure.

Complications of obesity

Management of obesity

1. Dietary therapy2. Physical activity therapy3. Drug therapy4. Behavioural therapy

Non surgical treatment

Candidates for surgery1) BMI ≤ 40 Kg/m² or ≤ 35 Kg/m² with

significant cormobidities.2) Failure of non surgical weight loss

programs.3) Capability of tolerating surgery.4) Absence of endocrine disorders that can

cause massive obesity.5) Psychological stability with supportive

social environment.

Surgical management

6) Age less than 60 years7) Basic understanding of how obesity

surgery causes weight loss.8) Realization that surgery itself does not

guarantee weight loss9) Absence of active alcohol and drug abuse.10) Commitment to post-operative follow up.

1- Restrictive procedures:A)Vertical banded gastroplasty (VBG)

Bariatric Surgical Procedures

B) Adjustable gastric banding (AGB)

C) Sleeve Gastrectomy (SG)

2- Malabsorptive procedures :A) Roux en Y Gastric bypass(RYGBP)

B) Minigastric bypass

The aim of bariatric surgery is to induce weight loss that is sufficient to reduce obesity-related morbidities to acceptable levels.

Loss of visceral fat is associated with improved insulin sensitivity and glucose metabolism , also reduces intra-abdominal pressure and this change may result in improvement in urinary incontinence, gastroesophageal reflux, systemic hypertension, venous stasis disease, and hypoventilation.

Outcome of Bariatric Surgery

70-80% IMROVEMENT OF CO-MORBIDITIES :

- TYPE 2 DM. - HYPERTESION. - DYSLIPIDAEMIA.- HYPERURICAEMIA.- SLEEP APNOEA.- CARDIAC RISK.- CANCER RISK.- GERD.- PCOS.

QUALITY OF LIFE:- SOCIAL.- WORK.- SEXUAL.- PSYCHOLOGICAL

IT WAS FOUND THAT THESE POSITIVE CHANGES START (& PERSIST) AS EARLY AS WHEN 10% EWL OCCURS.

1 st, 3 rd,6 th, 12 th MONTH POSTOPERATIVELY, THEN ANNUALLY.

DO NOT FORGET:-ELECTROLYTES.-B. SUGAR.-RENAL FUNCTIONS.-LIVER FUNCTIONS.-TRANSFERRIN.- LIPID PROFILE.

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