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Obesitas Dewasa
Sumarni
OBESITAS
Pendahuluan
 Prevalensi dewasa umur 20 tahun ke atas yang mengalami
obesitas di USA terdiri : laki-laki 33,5% dan perempuan
36,1% (Data NHCS 2011-2012 )
 Di Indonesia, data Riskesdas 2013, prevalensi obesitas
untuk laki-laki dewasa (> 18 tahun) sebanyak 19,7% dan
perempuan dewasa 32,9%.
Obesity
Health Risks
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•
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•
•
•
•
•
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Diabetes (Type 2)
Hypertension and Heart Disease
Neurologic Complications
Respiratory Disease
Orthopedic Condition
Psychosocial Disorders
Hyperlipidemia
GI Manifestations
Menstrual Disorders
WHO 2013,
Lorenzo 2007 
obesitas :
• Akumulasi
lemak lebih di
jaringan adiposa
• BB >30% dr
normal
Misnandiarly,
2007
• Tipe
hiperplastik
• Tipe hipertropik
• Tipe
hiperplastikhipertropik
Smith, 2008
• Obesitas primer
(faktor genetik,
nutrisi dan
lingkungan)
• Obesitas
sekunder (faktor
neural, faktor
endokrin, obatobatan )
Penentuan Obesitas
BB / TB  IMT
LP, TLK; Rasio
LP/Lpa;
Rasio LP/TB
(CDC 2000; WHO 2006;
Speiser 2005; Smith 2008;
Browning 2010)
BIA;
Hidrodensimetri;
DEXA; CT-Scan
MRI
(Smith 2008; Pudjadi 2000;
Marina 2008)
CLINICAL CLASSIFICATION
Anatomic Characteristics of Adipose Tissue
and Fat Distribution
1. Size and Number of Fat Cells
a. Hypertrophic obesity
b. Hypercellular obesity
2. Fat distribution
a. Measurements WHR
b. The metabolic syndr.
3. Lipomas and Lipodystrophy
a. Lipomas
b. lipodystrophy
B. Etiologic Classification
1. Neuroendocrine Obesity
b. cushing’s syndrome.
c. Hypothyroidism
d. Polycystic Ovary Syndr.
e. Growth hormone deficiency
2. Drug-Induced Weight Gain
3. Cessation of smoking
4. Sedentary Lifestyle
5. Diet : breastfeeding (↓), overeating (↑),
dietary fat intake, dietary carbohydrate
and fiber, frequency of eating, restrained
eating,Binge-eating disorder, Night-eating
syndr.
6. Psychological and Social Factors
7. Socioeconomic and Ethnic Factors
8. Genetic and Congenital Disorders
Konsep Keseimbangan Energi
Sumber : Siele P et al. Diabetes 2009;58:1482-4
Prevention of obesity
• Individual or population?
• Higher-risks group
• Those with Existing Obesity
or Weight-Related Comorbidities
Higher Risks group
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•
•
•
•
Abdominal obesity
Susceptible Ethnic Groups
Family History of Obesity and/or Diabetes
Adolescent Obesity
Obesity in Pregnancy
EBM Restriksi Asupan Kalori
Sumber : Clinical Practice Guidelines for the Management of Overweight and Obesity
Rekomendasi Terapi Obesitas
Sumber : Kaila B. Can J Gastroenterol 2008;22(1):61-7.
Rangkuman Metoda Diet Populer
(lanjutan)
Sumber : Sherer EL et al. JAAPA 2008;21(11):31-5.
Morbidity
Associated with Obesity
Individuals who are obese are at a greater risk of developing:
• Obstructive sleep
apnea
• Osteoarthritis
• Cardiovascular
disorders
• Gastrointestinal
disorders
• Metabolic disorders
• Endometrial, prostate
and breast cancers
• Complications of
pregnancy
• Menstrual irregularities
• Psychological disorders
Cardiovascular Disorders
Associated with Obesity
Obese individuals are at a greater risk of developing these cardiovascular disorders:
Hypertension
Stroke
Coronary Artery Disease
Hypertension
• Blood pressure is often increased in overweight individuals.
• Estimates suggest that control of overweight would eliminate
48%
of the hypertension in Caucasians and 28% in
African Americans.
• Overweight and hypertension interact with cardiac
function, leading to thickening of the ventricular
wall and larger heart volume, and thus to a
greater likelihood of cardiac failure.
J La State Med Soc .2005; 157 (1): S42-49.
Hypertension
Prevalence in the Overweight
35
32.7
Prevalence of HTN
30
25
27.0
27.7
Age-adjusted prevalence
of hypertension in
overweight U.S. adults
22.1
20
14.9
15.2
15
BMI < 25
BMI > 25 & < 27
BMI > 27 & <30
10
5
0
Males
Females
Adapted from:
http://www.obesityinamerica.org/trends.html
Stroke
• Normally, blood containing oxygen and
nutrients is delivered to the brain, and
carbon dioxide and cellular wastes are
removed.
• A stroke occurs when the blood supply to
part of the brain is suddenly interrupted
by a blocked vessel or when a blood
vessel in the brain bursts.
• Once their supply of oxygen and
nutrients from the blood is cut off to the
brain cells, they die.
Stroke
The symptoms of a stroke include:
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•
•
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Sudden numbness or weakness, especially on one side of the body
Sudden confusion or trouble speaking or understanding speech
Sudden trouble seeing in one or both eyes
Sudden trouble with walking, dizziness, or loss of balance or
coordination
• Sudden severe headache with no known cause
Stroke
• There are two forms of stroke: ischemic and hemorrhagic.
• Ischemic stroke occurs when an artery to the brain is blocked.
• Overweight and obesity increase the risk for ischemic stroke in men and
women.
• With increasing BMI, the risk of ischemic stroke increases progressively
and is doubled in those with a BMI greater than 30 kg/m2 when
compared to those having a BMI of less than 25 kg/m2.
• Hemorrhagic strokes occur when a blood vessel in the brain erupts.
• Overweight and obesity do not increase the risk for hemorrhagic
strokes.
NINDS
J La State Med Soc .2005; 156 (1): S42-49.
Coronary Artery Disease
• Coronary artery disease (CAD) is a type of atherosclerosis that occurs
when the arteries supplying blood to the heart muscle (coronary arteries)
become hardened and narrowed.
• This hardening and narrowing is caused by plaque buildup.
• As the plaque increases in size, the insides of the coronary arteries get
narrower, and eventually, blood flow to the heart muscle is reduced.
• This is critical because blood carries much-needed oxygen to the heart.
2009
NHLBI
Coronary Arteries
Blood Flow
• When the heart muscle
is not receiving the
amount of oxygen that
it needs, one of two
things can happen:
• Angina
• Heart Attack
Angina
This is the chest pain or discomfort that
occurs when the heart is not getting enough
blood.
Heart attack
This is what happens when a blood clot
develops at the site of the plaque in a
coronary artery.
The result is a
sudden blockage, which may block all or most
of the blood supply to the heart muscle.
Because cells in the heart muscle begin to die
when they are not receiving adequate amount
of oxygen, permanent damage to the heart
muscle can occur if blood flow is not quickly
restored.
NHLBI
Coronary Artery Disease
• Over time, CAD can weaken
the heart muscle and
contribute to:
• Heart Failure
• Arrhythmias
Heart Failure
In this condition, the heart can’t pump
blood effectively to the rest of the body.
Heart failure does not mean that the heart
has stopped nor does it mean that it is
about to. It means that the heart is failing to
pump blood the way that it should.
Arrhythmias
Arrhytmias are changes in the normal
beating rhythm of the heart. They can be
either faster or slower than normal.
Some arrhythmias can be quite serious.
NHLBI
Coronary Artery Disease
• Obesity is associated with an increased risk for CAD.
• Abdominal fat distribution is believed to be related as well.
• Data from the Nurses Health Study illustrated that women in the lowest
BMI but highest waist-to-hip circumference ratio had a greater risk of
heart attack than
those in the highest BMI but lowest waist-tohip circumference ratio.
• Regional fat distribution appears to have a greater effect on CAD risk
than BMI alone.
2009
J La State Med Soc .2005; 156 (1): S42-49.
Gastrointestinal Disorders
Associated with Obesity
Obese individuals are at greater risk of developing these gastrointestinal disorders:
Colon Cancer
Gall stones
Colon Cancer
Findings Relating to Obesity
• Colon cancer has been shown to occur
more frequently in people who are obese
than in people who are of a healthy weight.
• An increased risk of colon cancer has been
consistently reported for men with high
BMIs.
• Women with high BMI are not at increased
risk of colon cancer.
There is evidence that abdominal obesity may be
important in colon cancer risk.
NCI
Gallbladder Disease
• Cholelithiasis is the primary hepatobiliary pathology associated with
overweight.
• Cholelithiasis is a condition characterized by the presence or formation
of gallstones in the gallbladder or bile ducts.
• Normally, a balance of bile salts, lecithin, and cholesterol keep
gallstones from forming. However, if there are abnormally high levels of
bile salts or, more commonly, cholesterol, then stones can form.
J La State Med Soc .2005; 156 (1): S42-49.
Gallstones
Findings Related to Obesity
• Obesity appears to be associated with the development of gallstones.
• More cholesterol is produced at higher body fat levels.
• Approximately 20 mg of additional cholesterol is synthesized for each
kg of extra body fat.
• High cholesterol concentrations relative to bile acids and
phospholipids in bile increase the likelihood of precipitation of
cholesterol gallstones in the gallbladder.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Gallstones
Findings Related to Obesity
• In the Nurses’ Health Study, when compared to those having a BMI of 24 or
less,
• Women with a BMI > 30 kg/m2 had a 2-fold increased risk for
symptomatic gallstones.
• Women with a BMI > 45 kg/m2 had a 7-fold increased risk for
symptomatic gallstones.
• The relative increased risk of symptomatic gallstone development with
increasing BMI appears to be less for men than for women.
J La State Med Soc .2005; 157 (1): S42-49.
Gallstones
Findings Related to Obesity
• Ironically, weight loss leads to an increased risk of
gallstones-- because of the increased flux of cholesterol
through the biliary system.
• Diets with moderate levels of fat that trigger gallbladder
contraction and subsequent emptying of the cholesterol
content may reduce the risk of gallstone formation.
• Bile acid supplementation can be used to lower ones risk
for gallstone formation.
J La State Med Soc .2005; 157 (1): S42-49.
Metabolic Disorders
Associated with Obesity
Obese individuals are at greater risk of developing these metabolic disorders:
Diabetes Mellitus
Dyslipidemia
Liver Disease
Diabetes Mellitus
• Type 2 diabetes mellitus (DM) is strongly associated with
overweight and obesity in both genders and in all ethnic
groups.
• The risk for Type 2 DM increases with the degree and
duration
of overweight in individuals.
• The risk for Type 2 DM also increases in individuals with a
more central distribution of body fat (abdominal).
J La State Med Soc .2005; 157 (1): S42-49.
Obesity and Type 2 DM
In the United States
15%
55%
30%
BMI < 25
BMI > 25 or BMI < 30
BMI > 30
Among people diagnosed
with Type 2 diabetes,
55 percent have a BMI ≥
30 (classified as obese),
30 percent have a
BMI ≥ 25 or ≤30
(classified as overweight),
and only 15 percent have
a BMI ≤ 25 (classified as
normal weight).
Adapted from:
http://www.obesityinamerica.org/trends.html
Diabetes Mellitus
Findings Related to Obesity
• The Nurses’ Health Study demonstrated the curvilinear relationship
between increasing BMI and the risk of diabetes in women:
• Women with a BMI below 22 kg/m2 had the lowest risk of DM
• At a BMI of 35 kg/m2, the relative risk of DM increased 40-fold or 4,000%
• The Health Professionals Follow-up Study demonstrated a similar
relationship between increasing BMI and the risk of diabetes in
men:
• Men with a BMI below 24 kg/m2 had the lowest risk of DM
• At a BMI of 35 kg/m2, the relative risk of DM increased 60-fold or 6,000%
J La State Med Soc .2005; 157 (1): S42-49.
Diabetes Mellitus
Findings Relating to Weightloss
• Weight loss reduces the risk of developing
diabetes.
• In the Health Professionals Follow-up
Study, a weight loss of 5-11 kg decreased
the relative risk for developing diabetes by
nearly 50%.
• Type 2 DM was almost nonexistent with a
weight loss of more than 20 kg (44 lbs) or in
those with a BMI below 20.
J La State Med Soc .2005; 157 (1): S42-49.
Dyslipidemia
• Dyslipidemia is defined as abnormal
concentration of lipids or lipoproteins in the
blood.
• As BMI increases, there is an increased risk
for heart disease.
• This is because a positive correlation between
BMI and triglyceride (TG) levels has been
demonstrated.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Dyslipidemia
Findings Related to Obesity
• An inverse relationship between HDL cholesterol and BMI has beenHDL
noted.
• This relationship may be more important than the relationship
between BMI & TG levels.
• Low level of HDL carries more relative risk for developing heart
disease than do elevated triglyceride levels.
• Central fat distribution also plays an important role in lipid
abnormalities.
• Excessive body fat in the abdominal region leads to increased
circulating triglyceride levels.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Liver Disease
• Nonalcoholic fatty liver disease (NAFLD) is the term
given to describe a collection of liver abnormalities
that are associated with obesity.
• In a cross-sectional analysis of liver biopsies of obese
patients, it was found that the prevalence of steatosis,
steatohepatitis, and cirrhosis were approximately
75%, 20%, and 2% respectively.
J La State Med Soc .2005; 157 (1): S42-49.
Liver Disease
Fatty Liver
• Steatosis is the term for “fatty liver” and it is not
actually a disease, but rather a pathological
finding.
• Most cases of fatty liver are due to obesity.
• Other causes of fatty liver include:
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•
•
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•
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Diabetes
Certain drugs
Intestinal bypass operations
Starvation
Protein malnutrition
Alcoholism
The American Liver Foundation
Liver Disease
Fatty Liver
• A gradual weight reduction can
help to reduce the enlargement of
the liver due to fat, and it can
normalize the associated liver test
abnormalities.
• It is important to limit the amount
of alcohol consumed in the diet.
Alcohol can decrease the rate of
metabolism and secretion of fat in
the liver.
The American Liver Foundation
Importance of a Healthy Liver
The liver is the largest organ in the body and it plays a vital role
in performing many complex functions that are essential for life:
• The 300 billion cells of the liver control a process known as
metabolism. During metabolism, the liver breaks down nutrients
into usable products. These products are then delivered to the
rest of the body through the bloodstream.
• The liver also metabolizes toxins into byproducts that can be
safely eliminated.
• The liver also produces many important substances, such as:
albumin, bile, cholesterol, clotting factors, globin, and immune
factors.
Mayo Clinic
Other Disorders
Associated with Obesity
Obese individuals are at greater risk of developing these metabolic
disorders:
Obstructive sleep apnea
Osteoarthritis
Endometrial, prostate, and breast cancers
Complications of pregnancy
Menstrual irregularities
Psychological disorders
Obstructive Sleep Apnea
• Obstructive sleep apnea is caused by repetitive upper airway
obstruction during sleep a result of narrowing of the respiratory
passages.
• Patients having the disorder are most often overweight with
associated peripharyngeal infiltration of fat and/or increased size
of the soft palate and tongue.
American Academy of Family Physicians
Obstructive Sleep Apnea
• Common complaints are loud snoring, disrupted
sleep, and excessive daytime sleepiness.
• Individuals with sleep apnea suffer from fragmented
sleep and may develop cardiovascular abnormalities
because of the repetitive cycles of snoring, airway
collapse, and arousal.
• Because many individuals are not aware of heavy
snoring and nocturnal arousals, obstructive sleep
apnea may remain undiagnosed.
American Academy of Family Physicians
Obstructive Sleep Apnea
Findings Relating to Obesity
• Obstructive sleep apnea affects around 4% of middle-aged
adults.
• Individuals having a BMI of at least 30 are at greatest risk for
sleep apnea.
• Weight loss has been shown to improve the symptoms
relating to sleep apnea.
J La State Med Soc .2005; 157 (1): S42-49.
Osteoarthritis
• Osteoarthritis (OA) is the most common type of arthritis
• 40 million Americans currently have osteoarthritis.
• It is a degenerative disease which frequently leads to chronic
pain and disability.
• For individuals over the age of 65, it is the most disabling
disease.
• Currently, only the symptoms of OA can be treated; there is
no cure.
NSLS
Osteoarthritis
Findings Relating to Obesity
• The incidence of OA is significantly increased in overweight
individuals.
• OA that develops in the knees and ankles is probably
directly related to the trauma associated with the degree of
excess body weight.
• Osteoarthritis in other non-weight bearing joints suggests
that there must be some component of the overweight
syndrome responsible
for altering cartilage and bone
Areas of the body
metabolism, independent of the actual stresses of body
most commonly
weight on joints.
affected by OA
NSLS
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Cancer
Findings Relating to Obesity
• Overweight and obesity are associated with an
increased risk of: esophageal, gallbladder,
pancreatic, cervical, breast, uterine, renal, and
prostate cancers.
• Obesity and physical inactivity may account for 25
to 30 percent of several major cancers, including--colon, breast (postmenopausal), endometrial,
kidney, and cancer of the esophagus.
J La State Med Soc .2005; 157 (1): S42-49.
Endocrine Changes
• There are various endocrine changes associated with
overweight.
• Changes in the reproductive system are among the most
common.
• Irregular menses and frequent anovular cycles are common.
• Rates of fertility may also be reduced.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Endocrine Changes
Associated with Obesity
Common hormonal abnormalities associated with obesity
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•
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Increased cortisol production
Insulin resistance
Decreased sex hormone-binding globulin in women
Decreased progesterone levels in women
Decreased testosterone levels in men
Decreased growth hormone production
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Psychological Disorders
Associations with Obesity
• Obesity is associated with an impaired quality
of life.
• Higher BMI values are associated with greater
adverse effects.
• When compared to obese men, obese women
appear to be at a greater risk for
psychological dysfunction.
• This may be due to the societal pressure on
women to be thin.
J La State Med Soc .2005; 157 (1): S42-49.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Psychological Disorders
Weight Loss
• Intentional weight loss has been consistently
associated with improved quality of life.
• Severely obese patients who lost 43 kg through gastric
bypass demonstrated improved quality of life scores to
such an extent that their post-weight loss scores were
equal to or even better than population norms.
J La State Med Soc .2005; 157 (1): S42-49.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
Conclusion
The following conditions have been found to be associated with obesity:
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•
•
•
•
•
•
•
Diabetes mellitus
Hypertension
Gallbladder Disease
Liver Disease
Cancer
Coronary Artery Disease
Cerebrovascular disease (stroke)
Endocrine Changes
These diseases have been found to be
associated with increased metabolic
activity (secretion) of fat cells in obesity
•
•
•
Psychosocial Function
Obstructive Sleep Apnea
Osteoarthritis
These diseases have been found to be
associated with increased fat mass