Obesity- Standard Treatment Guidelines

Introduction

Obesity is an increasingly important health problem worldwide including the developing countries. In India, obesity is emerging as an important health problem particularly in urban areas. Almost 30- 65% of adult urban Indians are either overweight or obese or have abdominal obesity. The rising prevalence overweight and obesity in India has a direct correlation with the increasing prevalence of obesity-related co-morbidities; hypertension, the metabolic syndrome, Dyslipidemia, Type 2 diabetes mellitus (T2DM), and cardiovascular disease (CVD). "obesitygenic" lifestyle of excess caloric intake and decreased physical activity, these same genes contribute to obesity and poor health. Obesity is commonly considered to be one of the most important preventable causes of premature death, second only to smoking. Therefore, this marked increase in obesity has enormous public health implications.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Obesity.

Following are the major recommendations :

Definitions and measurement of overweight and obesity

Obesity is generally defined conceptually as the condition of excess body fat. However, There is no precise definition of excess. The degree of adiposity is a continuous trait not marked by any clear division into normal and abnormal. In addition, direct measurement of body fat is difficult. Thus, for practical purposes, obesity is often defined as excess body weight rather than as excess fat. In epidemiologic studies, for both children and adults, body mass index (BMI) is used to express the degree of obesity. This index is calculated as the body weight (kg) divided by the stature ([height in Meter]2 squared) (wt/M2 ), BMI correlates well with body fat and is relatively unaffected by height.

BMI = Weight in Kg
(height in meter)2

Waist Circumference (WC) and Waist Hip Ratio (WHR) Cut-offs for Obesity

Abdominal obesity is increasingly being recognized as an important cardiovascular risk factor. The cardiovascular risk associated with abdominal obesity can be attributed to excess abdominal adipose tissue (visceral Fat), both intra-abdominal adipose tissue (IAT) and subcutaneous adipose tissue (SCAT). Common surrogate measures of abdominal obesity are Waist Circumference (WC) and Waist Hip Ratio (WHR). Waist circumference is a simple, easily obtainable anthropometric parameter, which can be assessed in the outpatient setting. Measurement of WHR is more difficult as accurate measurement of hip circumference may not always be possible since it requires difficult task especially in women in India. Further, changes in WHR may not accurately reflect the extent of obesity or changes in weight. As with BMI, the relationship of central fat to risk factors for health varies among populations as well as within them. Current classifications of obesity are based on BMI and waist circumference. The one recommended by the World Health Organization and the NHLBI is shown in Table-1. BMI has a curvilinear relationship to risk. Several levels of risk can be identified using the BMI.

Table – 1. Definitions for adults

Classification of Overweight & Obesity and risk of disease as Recommended by the WHO & NHLBI.

Asian Indians exhibit unique features of obesity; excess body fat, abdominal adiposity, increased subcutaneous and intra-abdominal fat, and deposition of fat in ectopic sites (liver, muscle, etc.). Obesity is a major driver for the widely prevalent metabolic syndrome and type 2 diabetes mellitus (T2DM). The proposed cut-offs for defining overweight and obesity by WHO are not appropriate for Asian Indians, and that Asian Indians are at risk of developing obesity related co-morbidities at lower levels of BMI and waist circumference (WC).

The currently recommended cut-offs of WC (>102 cm in men and >88 cm in women) are also not be applicable to all the populations due to heterogeneity and different relationship with cardiovascular risk. Asian Indians appear to have higher morbidity at lower cut-off for WC than do White Caucasians.

• Methodology of WC Measurement: WC should be measured using non-stretchable flexible tape in horizontal position, just above the iliac crest, at the end of normal expiration, in the fasting state, with the subject standing erect and looking straight forward and observer sitting in front of the subject.

• Both BMI and WC should be used together (with equal importance) for population- and clinic-based risk stratification.

For Japanese, a BMI of 23 or 24 kg/m2 has the same percent fat as that of a BMI of 25 in Caucasians or 28 to 29 in African-Americans. On the basis of these differences and the observations that the risk for diabetes and hypertension had doubled when the BMI was 25 kg/m2, a taskforce from the Asia-Oceania section of the International Association for the Study of Obesity has proposed an alternative table, where obesity is defined as a BMI >25 kg/m2 and high-risk waist circumference at >90 cm for men and >80 cm for women.

Hence it is also recommended for Asian Indian population.

Classification of Obesity as Recommended by the Asia - Pacific Task force –

Risk of co morbidities with waist circumference< 80 cm (women)> 80 cm (women) Weight categoryBMI< 90 cm (men)> 90 cm (men)Underweight <18.5LowAverageHealthy weight18.5-22.9AverageIncreasedOverweight> 23At Risk23 – 24.9IncreasedModerateObesity class I25 – 29.9ModerateSevereObesity class II> 30SevereVery Severe

Classification of Obesity as per fat distribution

Obesity can also be classified based on the regional distribution of the fat

Android (or abdominal or central, males) - Collection of fat mostly in the abdomen (above the waist)

• Apple-shaped

• Associated with insulin resistance and CAD

Gyneoid (below the waist, females) - Collection of fat on hips and buttocks

• Pear-shaped


• Associated with mechanical problem

Definitions of Obesity for children and adolescents

In children with 2-19 years old BMI : > 85th to 95th percentile for that age – Possible risk of overweight and should undergo further evaluation.

BMI : > 95th percentile for that age – Overweight

In the United States, the 2000 CDC BMI for age growth charts are recommended for screening of individuals who are overweight and those who are at risk for overweight.

No BMI for age reference exist for children younger than 2 years. Nor are there any consistent recommendations for the definition of overweight in this age group.

• Overweight
  
  
  
  • BMI between 85^th to 94^th percentile for age and sex
  
  
  
  


• Obese
  
  
  
  • BMI ≥95^th percentile for age and sex -or- BMI ≥30 kg/m²
  
  
  
  


• Severe obesity
  
  
  
  • ≥99^th percentile (equivalent to BMI of 30-32 kg/m² for 10-12y.o. -or- ≥34 kg/m² for 14-16y.o.)
  
  
  
  

• Weight for length is used in the under 2-yr age group

For the evaluation of obesity in Indian children IAP growth charts are used. At present, IAP suggests to use WHO growth charts and Growth charts by Agrawal DK. IAP expect to come out with its own new growth charts. Till the time IAP comes out with IAP Charts, it is suggested to use WHO growth charts, which can be accessed at http://www.who.int/childgrowth/standards/chart_catalogue/en/index.htmlHowever with secular trends growth charts often change & periodic revision of Growth charts done should be accepted.

Obesity is associated with various organ System Dysfunction & they are

Cardiovascular

Hypertension, Coronary artery disease, Congestive heart failure, Cor pulmonale, Varicose veins, Pulmonary embolism.

Musculoskeletal

Hyperuricemia and gout, Immobility-Osteoarthritis (knees and hips), Low back pain

Psychologic

Depression, low self-esteem, Body image disturbance, Social stigmatization

Respiratory

Dyspnea, Obstructive sleep apnea, Hypoventilation syndrome, Pickwickian syndrome, Asthma

Gastrointestinal

Gastroesophageal reflux disease (GERD), Nonalcoholic fatty liver disease (NAFLD), Cholelithiasis, Hernia, Colon cancer

Genitourinary

Urinary stress incontinence, Obesity-related glomerulopathy, Hypogonadism (male), Breast and uterine cancer, Pregnancy complications

Neurological

Stroke, Idiopathic intracranial hypertension, Meralgia paresthetica

Integument

Striae (stretch marks), Stasis pigmentation of legs Lymphedema, Cellulitis, Intertrigo, carbuncles, Acanthosis nigricans, skin tags, Hirsutism in patients with PCOS.

Endocrine

Metabolic syndrome, Type 2 diabetes, Dyslipidemia, PCOS, Hyperandrogenemia, menstrual disorders, Amenorrhea, infertility.

There two ways by which endocrine system is affected in Obesity.

Note: Hypothyroidism is not the cause of significant obesity. Weight gain in hypothyroidism is due to fluid retention & is usually not more than 2-5 kg.

Obesity and Obstructive Sleep Apnea

Obesity is the most powerful risk factor for obstructive sleep apnea (OSA). Several pathophysiologic mechanisms relates obesity to the development of OSA These mechanisms include anatomic and functional obstruction of the pharyngeal airway. Sleep deprivation, daytime somnolence and metabolic dysregulation may also contribute to obesity in the setting of OSA. Although history and physical examination may help predict OSA in obese individuals, polysomnography is the gold standard for making the diagnosis of OSA and assessing effects of therapy. Weight loss is an important strategy for treating OSA. However, the cornerstone of current management is continuous positive airway pressure.

Clinical Evaluation

Basic evaluation in clinics is measurement of Height, Weight, BMI, Waist Circumference. Detection of acanthosis nigricans or skin tags should suggest significant insulin resistance. A number of physical features of an obese individual may help identify a specific cause for the individual's problem. Features of the hypothalamic syndrome, Cushing's syndrome, Polycystic ovarian disease (Which is a common in younger women) should be looked for. Among the various genetic diseases that produce obesity, Prader-Willi is the most common. It includes hypotonia, mental retardation, and sexual immaturity, and can usually be recognized clinically. Bardet-Biedl syndrome, with its polydactyly and retinal disease, is distinctive. Obesity and red hair in a child might suggest a defect in the processing of POMe.

Laboratory Evaluation

Common laboratory tests which should be done as a part of the obesity evaluation are - Plasma Glucose (Fasting & Post glucose or postprandial), Plasma Lipids, Thyroid Functions, serum uric acid, Liver function tests, Prostate-Specific Antigen in Males, Ultrasound of the Gall Bladder. Other tests like overnight dexamethasone suppression test, serum gonadotropins, etc may be done depending on the patients clinical profile. (Serum insulin has no role in the evaluation of obesity in day today practice except in suspected cases of Insulinoma which is very rare.)

Management of Obesity

Obesity prevalence has increased markedly over the past few decades. The obesity pandemic has huge implications for public health and our society.

There are many Health benefits of moderate weight loss (5-1 0% of present body weight)

Reduction in Death - 20% overall, 30% diabetes-related & 40% cancer- related

deaths

Blood pressure Reduction - 10 mmHg decrease

Improvement in Lipids - 15 % decrease in cholesterol & improvement in other lipids

Improvement in Glycemic control in patients with Diabetes.

Hence weight loss program should be achieved by following principles

• Lifestyle Modification – Diet control, Exercise, & Behavioural Modification.

• Pharmacotherapy


• Surgery

Lifestyle Modification

Principles of weight loss

• Decrease total energy intake (TEl), Maintain a balanced deficit diet

• Increase physical activity (Adjust energy balance to prevent weight regain) appropriate for that age.

• Behavior modification;


• Maintenance program - monitoring and long term follow-up.

While managing obesity we should remember certain facts that

• Do not recommend Rapid weight loss (i.e. >5-10% weight loss in 6 months), it should be slow so that maintainance becomes easy. Rapid weight loss is associated with rebound weight gain which sometimes can be more than initial weight.

• We should have realistic expectations of 5-10% weight loss in 1 year.


• Passive exercise, Heat or Vibration therapy, etc should not be recommended.

Obesity management programs

The therapies and degree of intensity of any weight loss program should be based on an assessment of the degree of adiposity (anthropometry) and the presence or absence of medical risk factors. Mild to moderate uncomplicated overweight and obesity may require advice with a specific eating and physical activity program. Greater degrees of obesity and risk, or the presence of disease, require more intensive lifestyle interventions, the use of pharmacotherapy, or surgery & treatment of basic cause of Obesity if any. Any weight management program must provide a weight maintenance component. Regular and long-term follow-up visits and interventions are part of the management of Obesity.

Diet intervention

Although energy (calorie) restriction produces good weight loss, some individuals may find this irksome and impossible to maintain. It is the total calorie intake which decides patients weight rather than the type of food. However for some patients, a low-fat eating plan may prove effective. Such plans may be maintained for several years. Greater losses may be obtained by additionally reducing energy intake. Men may also need to reduce energy intake by limiting their alcohol intake. There is no long term difference between low calorie diet (LCD) & Very low calorie Diet (VLCD).

Physical activity /exercise program

Emphasis should be placed on increasing total daily activity to between 60 and 90 min each day. Although exercise and fitness are important, the initial emphasis should be on increasing the activities of daily living, in particular more walking. A formal written exercise prescription has been shown to increase effectiveness in general practice. Giving patients the opportunity to use or purchase a pedometer and then setting the number of steps they need do in a day may prove an effective method of increasing activity. For patients with arthritis or other disabilities, hydrotherapy (exercising in water) may be a way of initiating movement and this type of activity can assist weight loss. Patient can do any type of exercise which is suitable for his/her age & associated comorbid condition.

Behavior modification

This therapy is important and central to any weight loss program. There are many components to behavior modification, but one simple is the use of a food and exercise diary. This allows habit recognition and changes accordingly. All subjects, but most particularly those who are overweight or obese, under-report food intake and over report the activity they undertake. A diary provides an important starting point for discussion and suggests possible interventions. Additional behavioral therapies include discussion about habits, change and alternative ways of approaching situations. Other techniques involve stress management, improving self-esteem and, occasionally, more spe-cific counseling or psychiatric intervention.

Such a lifestyle program should involve a team of health professionals (dietitians, physiotherapists, nurses, psychologists). Good results and satisfaction are usually obtained by the involvement of multidisciplinary teams. Some commercial groups use conventional therapy (e.g. Weight Watchers or programs used in some gyms), whereas others rely on alternative or natural therapies and still others use magic treatments that sound plausible but which really have neither have any scientific basis nor effectiveness. Examples of the magic type of therapy would be total-body wrapping, some herbal and bulking agents. Few have been tested rigorously and very are costly, but the very existence of such program and therapies shows that many individuals desire to lose weight but need to be guided into the correct approach and provided with effective therapy.

Maintenance program, Monitoring and longer term follow-up

This is an essential part of any weight loss program but the most neglected part. Follow-up programe are essential and very effective.

Patients involved in an obesity treatment program require the following monitoring of weight (ideally monthly, no greater than bimonthly); monitoring of pulse rate and blood pressure;

monitoring of obesity-related risks and diseases (e.g. dyslipidemia, type 2 diabetes).

Drug therapy

The decision to give pharmacotherapy for obesity is made from clinical judgment-based on the requirement of the each individual patient in terms of potential benefits balanced against potential risks. BMI between 25 and 30 with comorbid conditions is the definite indication to start pharmacotherapy along with lifestyle intervention.

The various drugs which have been used for obesity are :
1.Appetite suppressants
a.Adrenergic agents (e.g. amphetamine, methamphetamine phenylpropanolamine, Phentermin)
2.Serotonergic agents (e.g. fenfluramine desfenfluramine, SSRIs like setoraline, fluoxetine)
3.Thermogenc agents - Ephedrine, caffeine
4.New ones
a.Serotonin and Noradrenaline reuptake Inhibitor - Sibutramine;
b.Intestinal Lipase inhibitors - Orlistat
c.The CB1 blocker - Rimonabant,

Among all these drugs currently only Orlistat is approved drug for the medical management of obesity. All other drugs are either not approved or banned for their use in obesity. Orlistat is an intestinal lipase inhibitor. It irreversibly inhibits the action of gastric and pancreatic lipases which are required to hydrolyse dietary fat before absorption. Unabsorbed triglycerides and cholesterol are excreted in faeces. It can cause Weight loss of 5-8.5 % at the end of 1 yr.

Side effects include steatorrhoea, flatus, fecal incontinence and oily spotting. Absorption of fat soluble vitamins may be lowered with orlistat. Hence vitamin supplementation is recommended. The maximum effect of orlistat is achieved at a dose of 120 mg thrice daily with every fatty meal. In patients with Fat restricted diet this drug is of no use.

There is no good scientific evidence for the alternative therapies.

Surgical Treatment of Obesity – Overview

Gastrointestinal surgery is the most effective approach for inducing major weight loss in extremely obese patients. Bariatric surgery has evolved over the last half century as a treatment option for patients suffering from morbid obesity. It involves modification of the digestive system by either decreasing the gastric volume (restrictive) or altering the path of the food bolus causing an element of malabsorption (Malabsorptive). These alterations effect appropriate changes in eating behavior and aid lifestyle modifications to help weight loss.

Indications for Bariatric Surgery -

• Patients with a BMI 40 kg/m² or more without any comorbid condition.


• Patients with a BMI of 35.0 to 39.9 kg/m² (with comorbidiry) and one or more severe medical complications of obesity (e.g., hypertension, heart failure, Type 2 Diabetes Mellitus, sleep apnea).

• Additional eligibility criteria are the inability to maintain weight loss with conventional therapy, acceptable operative risks,

The Surgical Options for Weight loss Surgery

Restrictive Procedures

• Laparoscopic adjustable gastric banding (LAGB)

• Sleeve gastrectomy

Combined Procedures

• Roux-en-Y gastric bypass (RYGBP)

Malabsorptive Procedures

• Bilio-pancreatic diversions (BPD)

• Bilio-pancrearic diversion with duodenal switch (BPD-DS)

Experimental Procedures

• Duodeno-jejunal bypass


• Ileal interposition


• Implantable pulse generators

Over the years, minimally invasive surgery has evolved from general laparoscopic surgery to advanced laparoscopic surgery. Given the advantage of laparoscopy with other general surgery procedures, it was a logical step to attempt these complex bariatric procedures using minimally invasive approach. Laparoscopic BPD-DS has higher complication rate compared to gastric bypass or banding and a mortality rate as high as 5%.

Bariatric Surgery Outcomes - Weight Loss
Bariatric surgery is currently the most effective method to treat severe obesity. The amount of excess weight loss (EWL) varies according to procedure. Long term data is now emerging that shows maintenance of weight loss 5-15 years after modern bariatric procedures. This sustained weight loss has a major impact on individual patient health and longevity.

Approach to Obesity management

Prevention:

With Limited options of drug treatment prevention becomes an important step. Prevention should start from Childhood so that we can prevent future health hazards. Balanced diet & regular Aerobic physical activity is must for everyone & should be educated since childhood.

Guidelines by The Ministry of Health and Family Welfare :

Dr Sailesh Lodha
Fortis Escorts Jaipur