Nutrition pdf - د. رباح

Obesity

Clinical assessment and investigations

• Quantify the problem
• Exclude an underlying cause
• Identify complications
• Reach a management plan.

Obesity

Quantify the problem

• (BMI)

the body mass index

• (waist circumference)

abdominal obesity

Bioimpedance

• CT SCAN

• Densitometry (under water weighing)

Obesity

BMI (kg/m

)

Classification

Risk of co morbidity

18.5-24.9

Normal range

Negligible

25.0-29.9

Overweight

Mildly increased

≥ 30.0

Obese

30.0-34.9

Class I

Moderate

35.0-39.9

Class II

Severe

≥ 40.0

Class III

very severe

Obesity

3. Exclude an underlying cause

The Obesity-Focused History

 A dietary history obtained by a specialist

dietitian

 The patient's current diet and physical activity
 Drug-induced weight gain should also to be

considered

 specific symptoms of secondary causes of

obesity

Obesity

The Investigation

• Thyroid function

tests

(all patient)

• Serum cortisol

(Cushing's syndrome)

– Dexamethasone suppression test
– 24-hour urine free cortisol

• Genetic counseling

Monogenic and 'syndromic' causes (children

presenting with severe obesity)

Obesity

3.Identify complications

 Assessment of

cardiovascular risk factors

   Blood pressure
   measuring blood glucose
   serum lipid profile

• Serum

transaminases

(NASH)

Obesity

Management plan

• The Goal of Therapy

improve obesity-related comorbid conditions

reduce the risk of developing future comorbidities.

• The target

initial weight-loss goal of 10% over 6 months .

• The decision to treat depend

BMI

patient's risk status

Modalities

lifestyle management

pharmacotherapy

surgery

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Obesity

Lifestyle management

Behavioral Therapy

new dietary and physical activity behaviors.

Strategies

• maximizing physical activity (e.g. walking

rather than driving to work)

• Changes in eating behavior including

   food selection
   portion size control
   avoidance of snacking
   regular meals to encourage satiety



Obesity

Physical activity

 Exercise alone is only

moderately

effective for

weight loss

 Moderate exercise( brisk walking) 60m./5

times/week/1 year produce minimal wt loss

 Moderate intensive( treadmill walking,

bicycling)45m./5 times/week/1year produce
5kg loss

 The most important role of exercise appears to

be in the

maintenance

of the weight loss.

Obesity

Weight loss diets

In obese patients, more active intervention is

usually required to lose weight before
conversion to 'weight maintenance' advice

 low caloric diet

is the cornerstone of the

obesity treatment

 They all involve a reduction of daily total

energy intake of (

500-1000 kcal

) from the

patient's normal consumption.

 The goal is to lose

0.5 kg/week.

Obesity

 Very low calorie diets

(VLCDs)

are

recommended for short-term rapid weight
loss, producing losses of 1.5-2.5 kg/week

 Energy content should be a minimum of (

500

kcal

) in VLCD

 There is no role for

starvation diets

, which risk

profound loss of muscle mass and the
development of arrhythmias

Obesity

Total Strategies:

 choosing smaller portion sizes
 selecting leaner cuts of meat and skimmed

dairy products

 drinking water instead of caloric beverages.
 reducing fried foods and other added fats and

oils

 Eating

Low energy dense food

fruits and vegetables

 Avoid high energy dense food

high-fat foods such as pretzels, cheese, egg

yolks, potato chips, and red meat.



Obesity

Pharmacotherapy:

Indications:

 BMI

≥30 kg/m

 BMI

≥27 kg/m

with concomitant comorbidities

 Dietary and physical activity therapy

not

successful

Types:

1. Suppression of appetite via centrally active

medications

2. Second strategy is to reduce the absorption

of selective macronutrients such as fat.

3. Selective blocking of the endocannabinoid

Obesity

Centrally Acting Anorexia Medications

sibutramine (Meridia) : central serotonin and

norepinephrine reuptake inhibitor

Benefit:

loss of about 5

–9% of initial body weight at 12 month

maintain weight loss for up to 2 years.

Side effects:

headache, dry mouth, insomnia, and constipation.

dose-related increase in blood pressure and heart rate

Contraindications:

uncontrolled hypertension

congestive heart failure

symptomatic coronary heart disease

arrhythmias, or history of stroke

Obesity

Peripherally Acting Medications

• Orlistat (Xenical) is a synthetic derivative of a naturally

occurring lipostatin( lipase inhibitor)

• slowly reversible inhibitor of pancreatic, gastric lipases
• orlistat blocks the digestion and absorption of about

30% of dietary fat.

• Benefit:

• orlistat produces a weight loss of about 9–10%,

GI tract adverse effects

• flatus
• fecal urgency, oily stool
• increased defecation
• Serum concentrations of the fat-soluble may be

reduced

Obesity

Cannabinoid receptor antagonist

• Rimonabant acts in the hypothalamus to

reduce appetite

• Side effects :

• exacerbate or induce depression
• associated with a small increased risk of

suicide

Obesity

Surgery (Bariatric surgery )

 most effective

weight-loss therapy for

severe

obesity.

 produce

–35%

body weight loss that is

maintained in nearly

60%

of patients at 5

years.

 weight loss

is greater after bypass than

gastric surgery

 positive impact

on obesity-related morbidities

ass DM, HT and obstructive sleep apnea

Obesity

Indications:

 BMI

> 40 kg/m

)

 BMI

> 35 kg/m

) associated with a comorbidities.

Weight-loss surgeries

• Restrictive

 partial gastrectomy( sleeve gastroec).
 Laparoscopic gastric banding

• Restrictive-malabsorptive

Roux-en-Y gastric bypass

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