Download (lead to central obesity ).

Obesity
Obesity
Definition:
It is a state of weight gain due to
excess adipose tissue in different
parts of the body due to excess
storage fat. It occurs in individuals
when body fat is very high relative
to lean body mass and is defined
by a value of body mass index
(BMI)≥30 kg/m² .
Obesity classification
I – According to Etio-pathogenic criteria
a – primary obesity :
genetics (leptin resistance) :
twin studies indicate strong correlation in
body weight & body fatness between
identical twins & it appears that heredity
plays a substantial role in the development
of obesity in this case. Family studies show
that obesity runs in families, but they do not
critically separate environmental ( watching
T.V ) from genetic factors.
B- secondary obesity
a-endocrine disorders as:
1-Cushing syndrome
(lead to central obesity ).
2-Myxoedema (hypothyroidism)
( due to diminished catabolic activity ).
3-Hyperinsulism ( insulin
resistance, D.M,
insulinoma (increased eating
due to fear of hypoglycemia )
4-male hypogonadism,
5-polycystic ovary syndrome in
women,
6-growth hormone deficiency .
b- tumors or other lesions
involving the hypothalamic areas
of appetite control .
c- excessive calories intake.
d- inactivity.
e- socioeconomic class: in the west, the
low socio-economic class person is obese,
while in the east, the high socio-economic
class person is obese.
II – According to severity criteria :
according to BMI , obesity has three
grades:
Grade I: BMI=30kg/m² - 34.9 kg/m² .
Grade II: BMI=35 kg/m² – 3909 kg/m²
Grade III: BMI ≥ 40 kg/m²
III - classification according to fat distribution ( clinical
criteria ):
1- Android (apple - shaped obesity):
is characterized by waist – hip index <0.85 in women and
<0.95 in men and the waist- height index < 0.5 .Adipose
tissue accumulation occurs predominantly in the upper
half of the body . This type of obesity is associated with
increased risk of hyper-insulinemia, diabetes mellitus,
dyslipidemia, hyper-uricemia, coronary artery disease and
hypertension . this type of obesity is hypertrophic, and
the treatment offers slightly better results and most
common in males.
2- Gynoid (pear - shaped obesity): is characterized by by
waist – hip index > 0.85 in women and >
0.95 in men and the waist- height index >0.5 . Adipose
tissue accumulation occurs predominantly in the lower
half of the body (pelvis, thigh ) . It is associated with
varicose veins and arthritis . This type of obesity is hyperplastic and resistant to treatment, is relatively benign & is
common in females.
obesity classification (continue)
VI - classification is based on number
&size of adipose cells:
1- hypertrophic obesity: many individuals,
often those with mild or moderate obesity
beginning in middle age, have an adipose
tissue with normal number of adipo-cytes
but containing large quantities of fat in
each cell.
2- hyper plastic obesity: other individuals,
often those with marked obesity & a
history dating to early childhood, have an
adipose depot made up of too many
adipo-cytes
each
containing
fat
reasonably normal in quantity.
1.
2.
3.
4.
5.
6.
7.
Genetic factor : studies on twins, adopted
children and the familial studies support the role
of genetic factors in the pathogenesis of obesity .
Age : although obesity may occur at any age, the
risk increases with age .
Sex : women generally have a higher BMI than
men .
Physiological circumstances : pregnancy, puberty,
menopause, andropause .
Socio-economic conditions : obesity affect mostly
the social groups with low economic possibilities
and low cultural level .
Sedentary life .
Psychological factors : depression, psychological
traumas .
8 – Disturbance of eating behavior :
 hyper caloric diet,
 some jobs (chefs, confectioners ),
 food preference, in particular, hyper lipidic food,
have little effect on satiety .
 Increased consumption of sweets promotes weight
gain both by caloric intake, and by hyperinsulinemia and hypoglycemia, responsible for the
increase of food intake,
 Rare and high-caloric meals can lead to the
development of obesity,
9 - Certain medicines: in the presence of genetic
predisposition, antipsychotics (chlorpromazine,
haloperidol), antidepressants (doxepin, lithium
salts), antiepileptic (carbamazepine), beta
blockers, corticosteroids, isoniazid, insulin,
sulfonylurea, may encourage the development of
obesity .
10 – Sleep deprivation
Increased
hunger
Decreased leptin
Sleep
deprivation
Increased
caloric
intake
Increase
opportunity
to eat
Obesity
Altered
thermoreg
ulation
Increased
fatigue
Reduced
energy
expenditure
 Obesity
is due to imbalance
between food intake and
energy expenditure.
 Body weight is regulated by
both endocrinal and neural
component.
A) Appetite:
 Neuronal afferent (Vagus from gut
distension)
 Hormonal signals (leptin, insulin,
cortisol and gut peptide).
 Metabolic (glucose hypoglycemic
hunger).

Release of various
Hypothalamic peptides
Leptin is a hormone released from
adipose cells.
 It acts primary through the
hypothalamus.

Leptin level =
food intake and
EE
THIN PERSON
In obese person Leptin may be high=
Leptin resistance
 Psychological and culture factors also
affects appetite.

Management of obesity:
I- history taking:
His or her job
*was the wt gain over a short or long period of time. (
when does obesity occur? during childhood or during
adulthood .
*when did person start to complain of obesity.
*the appetite.
*Dietary history: include( a-number of meals per day bfood record and c-food frequency).
*type of snakes
*smoking habit
alcohol intake
*psychological & social stress.
*current drug therapy that affect the wt.
(antidepressant drugs)
*risk factors such as angina, MI, stroke
*history of chronic diseases
*family history of obesity, eating behavior
History
Ask about accompanying symptoms which
are suspected to cause of secondary obesity
 Headache + a partial loss of vision…..
Pituitary tumor.
 Fatigability, easy bruising, purple striations
of skin…. ?Cushing
 Intolerance to cold, lethargy and slow
speech….Hypothyroidism
 Episodes of hunger, sweating and
palpitation… ?Insulinoma
 Past medical History: DM, HTN, thyroid,
depression, anxiety.
 Family History DM, hyper-lipidemia…

Examination
BMI IS The most widely used method to assess
obesity .
Weight in Kg / Height in M²
Because BMI does not give indications on the
distribution of adipose tissue in the body, the latter
is assessed by measurement of some
anthropometric parameters :
1. Waist circumference, it is correlated with
abdominal fat mass. As waist circumference is
greater, the higher the risk of cardiovascular
morbidity and mortality is. Values of waist
circumference greater than 94 cm in men and 80
cm in women .
2. Waist-hip index represents the ratio of abdominal
girth and pelvic girth .
3. Waist-height index represents the ratio of waist
circumference and height (normal=0.5)
Waist circumference ,waist-hip ratio have
been proposed as measures of risk of
obesity associated morbidity .
WHO waist circumference cut-offs
and risk of associated metabolic
complications .
MEN
≥94 CM
≥ 102 CM
WOMEN
≥ 80CM
≥ 88 CM
4-Mid-Upper arm circumference (MUAC) :
Midpoint between acromion process of
scapula & olecranon process of ulna .
MUAC can be used to provide
information about growth deficit . It
give an indication similar to that given
weight for age .
WHO cut off point for child :
Malnutrition >12.5 cm
Borderline 12.5 – 13.5 cm
head circumference.
5- Skin fold thickness measurements:
Most of the body fat is stored
subcutaneously . The thickness of skin
folds at specific sites is measured by
calibers & can be used to estimate total
subcutaneous fat .
The most commonly used sites are :
(sub-scapular, supra-iliac, biceps &
triceps).
Treatment:
1- if we identify a specific cause(s),
we treat it accordingly. Treatment of
endocrinal disorders
2- life-style modification : life style
approaches offer a combination of
treatment strategies that focus on all
aspects of wt loss(e.g. regular diet,
increase physical activity). By it the
individuals make gradual changes in
diet & physical activity with the use of
behavioral strategies.
a- regular Diet : is to follow a balanced mildly
hypo caloric diet. An important consideration for
any change in diet is that
individuals make slow changes over the course
of time.
Foods to be avoid in obesity:
1. All fried foods.
2. Monosaccharide's.
3. All sweet foods.
4. All dried foods like dates& figs.
5. Nuts.
6. Whole milk.
7. Ice-cream.
8. Cackes & chocolate.
9. Evaporated & densed milk
10.Sausage & lemon.
11.Boiled or packed foods.
b- Physical activity: exercise increase resting
metabolic rate, when exercise intake after
meals the thermal effect of meal may be
increase.
c- Behavior modification: are used to
encourage
positive change in diet & activity levels. The
most commonly used behavioral strategies
are:
self-monitoring, goal setting, stimulus control,
problem solving & cognitive restructuring.
3- psychological support (mental and social health
promotion): the obese person should not be
blamed for his obesity but should be supported&
encouraged from his doctor, family & friends to
continue exercise & modify his eating behaviors.
4- appetite suppressant : the national institute for
health & clinical excellence in UK recommended
pharmacotherapy, in conjunction with lifestyle
modification, for obese individuals (i.e. BMI of
30kg/m2) & for over-weight persons with BMI
greater than 27kg/m2 accompanied by at least one
co morbidity.
5- surgery: (used in morbid obesity) surgical
techniques involve either creating a small
bowel to produce a mal-absorption of ingested
calories, or creating a smaller stomach.