Obesity trts.

1. Kurdistan Board GEH Weekly J Club:
Supervisor:
Professor Dr.Mohamem Alshekhani
MBChB-CABM-FRCP-L-EBGH

2. Introduction:
 Obesity is an international public health issue affects QOL, increases
the risk of illness& raises health-care costs.
 BMI should be considered as a screening measurement rather than a
diagnostic method.
 Additional measurements include WC (or W/Ht),both strong predictors
of health risk,taking ethnicity into consideration.
 In addition to measures of central adiposity, BP, glucose, lipids (HDL/
TG) should also be measured.
 Obesity /DM management is expensive, costs rise progressively as BMI
increases & it is second only to depression in its cost.

3. Introduction:
 Obesity is multifactorial resulting from genetic, epigenetic,
physiological, behavioural,sociocultural,envir factors leading to an
imbalance between energy intake / expenditure during an extended
time period.
 Other contributors to the obesity epidemic:
 Less sleep, endocrine disruptors—some chemicals in food packaging /
foods—increased time in climate-controlled areas, cessation of
smoking, some medications, older parental age at birth, intrauterine/
intergenerational effects have been reported as.
 Obesity shortens life span& affects the function of many organs.
 Mortality results from several obesity-related diseases, including
DM,CKD, GI disease,CVDs.
 Maintaining weight loss is often difficult or unsuccessful.

4. Outline of therapy:
 lifestyle changes.
 Dietary modification.
 Increased physical activity.
 The use of medications.
 In some cases surgery.

5. Comprehensive, or multicomponent lifestyle interventions:
 Is simultaneous implementation of 3 strategies:
 Lifestyle or behavioural training, dietary change to reduce energy
intake&increase in physical activity.
 Number of behavioural sessions attended, number of meal
replacements used &weekly minutes of physical activity all
predicted weight loss at 1, 4, 8 years ,delivered in at least 14 face-
to-face (group or individual) sessions over 6 months with treatment
continuing to 1 year, the average reported weight loss would be 8
kg, translates into clinically significant improvements.
 So individuals with obesity& CVD risk factors & Co-morbidities
should be referred for lifestyle treatment.
 These commercial programmes provide on average a weight loss of
3%/year, but long-term compliance is generally poor &the
differences between named diets were not significant.

7. Diets for wt loss:
 Amount: reduction of energy by 500 kcal/day below energy
requirements or by using a dietary plan of 1200–1500 kcal/day for
women or 1500–1800 kcal/day for men (increased by a further 300
kcal/day for each sex if weight exceeds 150 kg) will accomplish the first
goal.
 Type:
 The best is low energy diets likely to be adhered by the patient&
provide health benefits.
 Mediterranean style diets were associated with a significant decrease in
bodyweight &reductions in HbA1c, fasting plasma glucose,fasting
insulin&reduce CVD risk.
 Caution needed in recommending low-glycaemic index diets for wt loss.
 Very low-calories,resulted in 4% greater short-term wt loss than
counselling, but some attenuation of effect after 6 months.

9. Physical Activity (PA):
 Gradually increasing aerobic physical activity (as brisk walking) to >150
min/week (>30 min/day, for at least 5 days/week).
 Benefits general health independent of weight loss.
 Offers additional 1–1.5kg wet loss over 1 year in addition to diet alone.
 A greater amount PA (30–45 min/day) is needed to prevent obesity for
long-term weight maintenance in those who have lost weight.
 60–90 min/day is required, but require close supervision as part of an
intensive programme.
 The type (eg, aerobic vs resistance or high intensity vs low intensity)
does not seem to affect overall weight loss, but as more intensive
activity produces similar weight loss with a reduced time commitment.
 PA is effective in short term, but the activities/benefits not sustained.

10. Adding drugs: Indications
 H/O failure to achieve clinically meaningful weight loss (>5% total BWT)
 To sustain lost weight.
 For patients who meet regulatory prescribing guidelines:
 BMI ≥27 kg/m. with one or more comorbidities.
 BMI >30 kg/m. with or without associated metabolic effect.

11. Adding drugs: Principles
 1.Effective lifestyle support should be provided.
 2.The prescriber &patient should be familiar with the drug &potential
side-effects.
 3. Unless clinically meaningful weight loss occurs after 3 - 4 months, (4–
5% in patients without & >3% with diabetes), a new treatment plan
should be implemented.
 4. No one medication is effective in every patient.

12. Individual approved Drugs: Phentermine
 A sympathomimetic drug with CV stimulatory properties.
 It has small risk of misuse potential & primary PHT.

13. Individual approved Drugs: Orlistat
 A pancreatic lipase inhibitor that blocks absorption of 30% of ingested
fat when eating a 30% fat diet.
 It reduces the development of DM in prediabetes.
 Others: Lorcaserin, phentermine/topiramate (ER),naltrexone sustained
release (SR)/bupropion SR, liraglutide 3.0 mg.

14. Individual approved Drugs: Lorcaserin
 A specific serotonin 2c receptor agonist remarkable for its tolerability&
low of adverse events including valvulopathy.
 It should not be used with MAOIs because of the risk of serotonin
syndrome.
 Caution when used with SSRIs, SNERIs.

15. Individual approved Drugs: Phentermine/topiramate ER
 Uses lower doses of both drugs (7.5 mg phentermine / 46 mg of
topiramate with > weight loss than other available medications.
 Topiramate is associated with fetal toxic effcts (oral clefts)&pregnancy
test before initiation of therapy&monthly thereafter.
 The most common side-effects include paraesthesias, dizziness,
dysgeusia, insomnia, constipation, dry mouth.
 A rare side-effect of topiramate is acute myopia with glaucoma &
contraindicated in glaucoma.
 It is contraindicated in hyperthyroidism &within 14 days of treatment
with MAOIs.
 Other rare potential adverse risks include kidney stones(topiramate) &
increased heart rate (phentermine).

16. Individual approved Drugs: Naltrexone SR/bupropion SR
 Bupropion is a mild reuptake inhibitor of dopamine / norepinephrine.
has minimum effect on weight loss on its own.
 Naltrexone is thought to block the inhibitory effcts of opioid receptors
activated by the β-endorphin released in the hypothalamus that
stimulates feeding, allowing the inhibitory effects of α-melanocyte
stimulating hormone to reduce food intake.
 Naltrexone SR/bupropion SR can increase BP, only prescribed to patients
with controlled hypertension &BP should be monitored in the early
weeks of therapy.

17. Individual approved Drugs: Liraglutide
 GLP-1 with extended circulating half-life.
 It is used for management of T2DM up to 1.8 mg, given by injection.
 It is now approved chronic weight management at a dose of 3.0 mg.
 Nausea is principal S/E, so slow dose escalation over 5 weeks is needed.
 There is significant increase in HR, but BP tends to fall.
 Should not be prescribed in patients with family or personal history of
medullary thyroid cancer or multiple endocrine neoplasia.
 Acute pancreatitis, gall bladder disease, hypoglycaemia in diabetics are
safety issues that require managing if they occur.

18. Targets for anti-obesity drugs

20. Endoluminal bariatric treatments:
 Traditional bariatric surgical procedures generally are safe/effective,
but patient acceptance, the risk of minor &sometimes serious
complications, costs, insurance coverage have limited the application
of these techniques to the treatment of a minority of patients.
 Endoluminal techniques represent newer approaches to wet loss that
can be used independently or with traditional medical&surgical
treatments for obesity, with varying degrees of success.
 The less invasiveness will increase the appeal across a broader
representation of patients, increasing the number of obese patients
who choose an intervention over medical management & possibly
resulting in a greater total loss of excess body weight across a
population; reducing costs involved in treating the complications of
weight-related comorbidities.
 Acceptance of endoluminal bariatric procedures&devices will hinge on
proving safety, efficacy&value.

27. Endoluminal bariatrics:Importnce
 Will have favorable risk profiles compared with traditional bariatric
surgical procedures & may virtually eliminate certain surgical risks such
as wound infection/hernia.
 Endoluminal interventions may induce less physiological stress &less
physiological impact compared with surgical intervention are
anticipated to expand the number patients who will be treated, which
would reduce, possibly dramatically, the cost of caring for patients with
obesity-related comorbidities.
 Current endoluminal interventions do not result in weight loss&
comorbidity resolution rates that approach the efficacy of surgical
procedures,but the associated risk reduction has led to their
introduction into clinical practice, enhancing the offerings available to
patients over a broader range of invasiveness, efficacy& risk so that
 interventions can be more finely tuned to patient needs.

28. Surgery:
 Surgery is a treatment option for severe obesity, particularly with
advent of lower risk laparoscopic procedures.
 A 24% reduction in mortality was reported, mainly because of the
reduced risk of MI ,cancer (in women), T2DM,sleep apnoea were also
improved& QOL.
 Particularly striking & rapid improvements in glucose control seen in
T2DM,especially after gastric bypass, suggesting that part of the
metabolic improvement is independent of weight loss&medical
treatment for T2DM consistently show greater improvements in glucose
control & other risk factors in the surgical group.
 Patients / clinicians considering referral for bariatric surgery should be
 made fully aware of the risks / benefits& provision of a detailed
education session,attendance at patient support groups, detailed
lifestyle advice &psychological support both before& after surgery.

30. Thank you