1. Dr. Jaber Amin Manasia
5th year medical student
Presented to
Dr. Panayiota Vryonidou Al- Louzi
Dr. Jaber Manasia
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2. Define obesity
Describe health consequences of obesity
Evaluation & Management
Obesity in adults
Obesity in children
Obesity in elderly
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3. An excessive amount of body fat, which increases the
risk of medical illness and premature death.
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4. Worldwide obesity has nearly doubled since 1980.
In 2008, more than 1.4 billion adults, 20 and older,
were overweight. Of these over 200 million men and
nearly 300 million women were obese.
35% of adults aged 20 and over were overweight in
2008, and 11% were obese.
65% of the world's population live in countries where
overweight and obesity kills more people than
underweight.
More than 40 million children under the age of five
were overweight in 2011.
Obesity is preventable.
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5. In Jordan , 64% of both men and women are
overweight.
30% of Jordanians are obese.
WHO website
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6. WHO Classification
BMI
Risk of Death
Underweight
Below 18.5
Low
Healthy weight
18.5-24.9
Average
Overweight (grade 1 obesity) 25.0-29.9
Mild increase
Obese (grade 2 obesity)
Moderate/severe
30.0-39.0
Morbid/severe obesity(grade 40.0 and above Very severe
3)
World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO,
[1997 [3

7. • BMI provides the most useful population-level
measure of overweight and obesity as it is the same
for both sexes and for all ages of adults. However, it
should be considered a rough guide because it may
not correspond to the same degree of fatness in
different individuals.
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8. Abdominal obesity
•also known as belly fat or clinically as central obesity, is
excessive abdominal fat around the stomach and abdomen.
•There is a strong correlation between
central obesity and cardiovascular disease.
•Abdominal obesity has been linked to Alzheimer's Disease
as well as other metabolic and vascular diseases.
•Visceral and central abdominal fat and waist circumference
show a strong association with type 2 diabetes.
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9. Women
cm
cm (80cm) = Increased risk 88<
Men
cm (90cm) = Increased risk 102<
Lean MEJ et al. Lancet; 1998; 351:853-6

10. Abdominal obesity, given as
waist circumference*†
Men
Women
Triglycerides
HDL cholesterol
Men
Women
Blood pressure
>102 cm (>40 in)
>88 cm (>35 in)
≥150 mg/dL
<40 mg/dL
<50 mg/dL
≥130/≥85 mm Hg
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11. The fundamental cause of obesity and overweight is an energy
imbalance between calories consumed and calories expended. Globally,
there has been:
an increased intake of energy-dense foods that are high in
fat; and
an increase in physical inactivity due to the increasingly
sedentary nature of many forms of work, changing modes of
transportation, and increasing urbanization.
Changes in dietary and physical activity patterns are often the result of
environmental and societal changes associated with development and
lack of supportive policies in sectors such as health, agriculture,
transport, urban planning, environment, food processing, distribution,
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marketing and education.
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12. Raised BMI is a major risk factor for noncommunicable
diseases such as:
cardiovascular diseases (mainly heart disease and
stroke), which were the leading cause of death in 2008;
diabetes;
musculoskeletal disorders (especially osteoarthritis - a
highly disabling degenerative disease of the joints);
some cancers (endometrial, breast, and colon).
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13. Dr. Jaber Manasia
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14. Common presenting problems include type 2 diabetes
mellitus, hypertension, musculoskeletal complaints
(particularly back, knee, hip, or foot pain), and
breathing difficulties.
It is important to identify the excess weight or obesity
as a problem, even if that is not the presenting
complaint.
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15. Dr. Jaber Manasia
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16. Physical Examination :
To rule out signs of secondary causes of obesity:
o Cushing syndrome
o hypothyroidism or
o other pituitary abnormalities.
Measurement of the waist circumference is also
important as noted above.
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17. Many treatment modalities are available to foster
weight loss.
it is crucial to remember to set goals with the patient.
The best practice is to prevent overweight and obesity
from occurring by instilling in patients the healthy
habits of good nutrition and avoiding a sedentary
lifestyle.
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18. There are critical periods in life when weight gain is
more likely, these include after childbirth and
menopause, so if patients can learn to anticipate these
changes, it is possible that they can institute
appropriate lifestyle changes to prevent weight gain.
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19. The following modalities are used in the treatment of
obesity :
Counseling and behavioral interventions
Medication
Surgery
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20. The National Heart, Lung, and Blood Institute
(NHLBI) practice guideline suggests an initial
weight loss of 10% of body weight among 6
months ; however, this may not always be
practical or achievable . and even a 10-lb weight
loss may ameliorate related conditions, such as
hypertension and elevated blood glucose.
Additional goals should include the maintenance
of weight loss over time, and prevention of further
weight gain.
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21. Modification of other cardiovascular risk factors,
such as smoking, hypertension, elevated
cholesterol, and physical inactivity, and
recognition and treatment of diabetes deserve
equal emphasis in the management of overweight
or obese patients.
Note that as patients quit smoking, they are likely
to gain weight, so anticipatory guidance about
this is essential.
Patients should not expect to be able to quit
smoking and lose weight at the same time.
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22. Dr. Jaber Manasia
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23. Dr. Jaber Manasia
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24. A healthy eating plan gives your body the nutrients it
needs every day. It has enough calories for good
health, but not so many that you gain weight.
A healthy eating plan is low in saturated fat, trans fat,
cholesterol, sodium (salt), and added sugar. Following
a healthy eating plan will lower your risk for heart
disease and other conditions.
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25. Healthy foods include:
Fat-free and low-fat dairy products, such as low-fat yogurt,
cheese, and milk.
Protein foods, such as lean meat, fish, poultry without
skin, beans, and peas.
Whole-grain foods, such as whole-wheat bread, oatmeal,
and brown rice. Other grain foods include pasta, cereal,
bagels, bread, tortillas, couscous, and crackers.
Fruits, which can be fresh, canned, frozen, or dried.
Vegetables, which can be fresh, canned (without salt),
frozen, or dried.
Canola and olive oils, and soft margarines made from
these oils, are heart healthy. However, you should use
them in small amounts because they're high in calories.
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27. Dr. Jaber Manasia
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28. Weight-loss medicines approved by the Food and
Drug Administration (FDA) might be an option for
some people.
If you're not successful at losing 1 pound a week after
6 months of using lifestyle changes, medicines may
help. You should only use medicines as part of a
program that includes diet, physical activity, and
behavioral changes.
Weight-loss medicines might be suitable for adults
who are obese (a BMI of 30 or greater). People who
have BMIs of 27 or greater, and who are at risk for
heart disease and other health conditions, also may
benefit from weight-loss medicines.
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29. Sibutramine (Meridia®)
As of October 2010, the weight-loss medicine
sibutramine (Meridia®) was taken off the market in the
United States. Research showed that the medicine
may raise the risk of heart attack and stroke.
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30. Table 18.11 Drugs Commonly Used for Weight Loss
Drug
Sibutramine
(Meridia)
Dose
FDA Approval Action
Adverse Effects
5, 10, 15 mg 10 mg orally Long-term use Norepinephrine Increase in heart rate and
daily to start, may be (controlled
, dopamine,
blood pressure; drug
increased to 15 mg or substance C- and serotonin interactions with CNS active
decreased to 5 mg
IV)
reuptake
drugs, including MAOIs and
inhibitor
seratonergic medications
Orlistat
120 mg
Long-term use Inhibits
Decrease in absorption of
(Xenical)
120 mg orally three
pancreatic
fat-soluble vitamins; soft
times daily before fatlipase,
stools and anal leakage
containing meals
decreases fat
absorption
Phentermine 8, 15, 18.75, 30, 37.5 mg Short-term use Appetite
Abuse, hypertension,
(Adipex-P,
8 mg three times daily (controlled
suppressant
tachycardia, restlessness,
Fastin, Oby30 minutes before
substance Cinsomnia
trim, Pro-fast, meals, or 15–37.5 mg
IV)
Zantryl)
daily before breakfast
Dietylpropion
(Tenuate,
Tenuate
Dospan,
generic
available)
25 mg, 75 mg SR
25 mg three times
daily, 1 hour before
meals, or 75 mg SR
once daily in the
midmorning
Short-term use Appetite
(controlled
suppressant
substance CIV)
Pulmonary hypertension,
arrhythmias, psychosis, dry
mouth, restlessness
CNS, central nervous system; FDA, US Food and Drug Administration; MAOIs, monoamine oxidase
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inhibitors.
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31. A recent meta-analysis demonstrated that such
medications can lead to a weight loss of about 5 kg
after 1 year, with little evidence for long-term
sustained weight loss.
A general guideline is that if a patient taking a weight
loss medication has not lost at least 2 kg after 4
weeks, the medication should be discontinued
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32. Surgical procedures for weight loss should be reserved
for patients in whom medical weight loss treatment
has failed, and who are suffering from complications
of extreme obesity.
Bariatric surgery can be considered an option for
patients with :
• BMI >= 40 kg/m2
• BMI >= 35 kg/m2, if cardiovascular risk factors are
present.
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33. Available procedures include :
• placing a restrictive band around the stomach to
reduce the capacity (gastric banding).
• ligating off part of the stomach (gastroplasty)
• bypassing the stomach altogether (gastric bypass).
Gastric bypass has been shown to be more effective
than gastric banding for weight loss and requires
fewer surgeries for revision, but has more side effects.
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35. Also known as insulin resistance syndrome or
“Syndrome X.”
characterized by abdominal obesity, dyslipidemia,
elevated blood pressure, and impaired fasting glucose.
Represents a compilation of traits associated with
insulin resistance and an ↑ risk of type 2 DM.
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36. Guidelines from the 2001 National Cholesterol
Education Program (Adult Treatment Panel [ATP] III)
suggest that the clinical identification of the
metabolic syndrome should be based upon the
presence of any three of the following traits:
Abdominal obesity (waist circumference > 102 cm in
men, > 88 cm in women).
TG ≥ 150 mg/dL.
HDL < 40 mg/dL in men and < 50 mg/dL in women.
BP ≥ 130/85.
Fasting glucose ≥ 110 mg/dL.
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37. TREATMENT :
Directed toward preventing the development of type
2 DM and coronary vascular disease. Includes lifestyle
modifications (diet, weight loss, exercise) and even
treatment of insulin resistance with medications.
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38. Through the last decades, the average weights of
children have increased.
In 2011, more than 40 million children under the age
of five were overweight.
According to NHANES 2009–2010, about 1 in 6
American children ages 2–19 are obese. The survey
also suggests that overweight and obesity are having a
greater effect on minority groups, including Blacks
and Hispanics.
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39. The definition of overweight and obesity in children is
based on comparison to children of the same age and
sex as follows:
BMI-for-Age Percentile
Less than 5th percentile
5th percentile to less than the 85th percentile
85th percentile to less than the 95th percentile
95th percentile or greater
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Underweight
Healthy weight
Overweight
Obese
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42. The United States Preventive Services Task Force
(USPSTF) recommends that clinicians screen children
age 6–18 years for overweight and obesity and offer
them comprehensive behavioral intervention to
improve weight status.
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43. Appropiate, weight specific questions include
those about diet, activity level, and hours of
television viewing, breast versus formula feeding
as an infant, as well as presence of family history
of obesity, and conditions frequently comorbid
with obesity, such as type 2 diabetes,
hypertension, and lipid disorders.
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44. There is a long-standing body of evidence
supporting the theory that consumption of sweet
drinks (fruit juices and soft drinks) is associated
with overweight in children. However, a recent
publication on the study called Project Eating
Among Teens (Project EAT) did not show any
association between sugar-sweetened beverages,
juice consumption, and weight gain among
teenagers over a 5-year period.
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45. measurement of waist circumference is not helpful in
screening or diagnosis.
look for secondary causes of obesity (for example,
purple striae may suggest hypercortisolism)
Fasting lipidglucose profiles in presence of family hx.
In a child with normal growth in stature, it is unlikely
that overweight or obesity is caused by an underlying
metabolic or genetic form of overweight .
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46. Overweight children with the highest risk for adverse
health outcome include those with current weight
related comorbidities, high risk of developing weightrelated comorbidities in the future, or significant
negative psychosocial ramifications of their
overweight status.
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48. It is important to note that when older
adults lose weight, a relatively high percentage of
the weight lost is lean body mass.
The BMR decreases with age, and this may lead to
weight gain despite consistency in diet and exercise
patterns. In spite of this, the trend is for weight to
decrease in older age.
Peak weights for men occur on average at 55 years of
age and for women at 65 years.
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49. Generally, its similar to adult guidelines,which
consider water intake, increased calcium, and
selected vitamin supplements.
The study also recommended weight loss, the
improved dietary content and physical activity
seemed as important as caloric reduction.
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50.  Should not compromise nutritional status, meet nutritional
requirements, and contribute to a healthy, sustained declined in
weight
 Should result in small changes and focus on reduction in fat
intake
 Increase HDL, decrease cholesterol, and triglycerides
 Better functioning in patients with OA
 Decrease glucose intolerance
 Should not be a low carbohydrate diet, protein liquid diet, or a
high fat diet

51.  Weight loss programs for older adults should focus on
maintaining adequate intake of essential nutrients, while
reducing caloric intake by controlling dietary fat intake
 The DASH (Dietary Approaches to Stop Hypertension) diet is an
option for older adults
 Rich in fruits/vegetables
 High in lean meats, poultry, and fish
 Low fat diary products
 Whole-grain breads and cereals
 At least six 8-oz glasses of fluid
 Older adults are encouraged to seek help of nutrition
professionals such as registered dietitians for advice on how to
modify their diets

52. http://www.nhlbi.nih.gov
http://www.ncbi.nlm.nih.gov
http://www.who.int
Essential of Family Medicine 2012
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