Guidelines For Obesity

Management

By
Dr.Samar Hamdoun
Hello!
Dr . Samar Hamdoun
MSC PT Cairo University
Diploma of therapeutic nutrition NNI
Professional Master of clinical nutrition
Cairo university
Certified health coach ICF
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 1.
The Disease of Obesity
Let’s start with the first set of slides

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 “
Obesity is defined as a chronic, progressive,
relapsing, and treatable multi-factorial,
neurobehavioral disease, wherein an
increase in body fat promotes adipose
tissue dysfunction and abnormal fat mass
physical forces, resulting in adverse
metabolic, biomechanical, and psychosocial
health consequences.
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Top 10 Takeaway Messages: Obesity is a Disease:

1. The signs, symptoms, and pathophysiology of obesity fulfill the

definition of a disease
2. Obesity can substantially be due to inheritance (genetic,
epigenetic, and/or environmental inheritance)
3. Obesity may result in cellular and organ anatomic abnormalities
4. Obesity may result in cellular and organ functional abnormalities
5. Obesity may result in pathogenic adipocyte and/or adipose tissue
endocrine and immune dysfunctions that contribute to metabolic
disease (adiposopathy or “sick fat” disease)

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Top 10 Takeaway Messages: Obesity is a Disease:

6. Obesity may result in pathogenic physical forces from

excessive body fat, promoting stress damage to other body
tissues (“fat mass disease”)
7.Even when exacerbated by unhealthful behavior, obesity is no
less a disease than other diseases promoted by unhealthful
behavior
8.Data from 2017 – 2018 estimate that approximately 42% of
U.S. adults have obesity; 18.5% of youths have obesity
9.As with other diseases, obesity is best discussed using
“people-first” language
10.Obesity is promoted by genetic predisposition, and shares
similar pathophysiology as aging 7
Obesity is a
multifactorial disease
that requires a
multifaceted, patient-
centered, individual
approach (“one size
does not fit all”)

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 Obesity terminology
Encouraged Terms Discouraged Terms

✓ Weight • Morbidly obese

✓ Unhealthy weight • Obese
✓ Overweight • Fat
✓ Body mass index • Heaviness
✓ Excessive energy stores • Large size
✓ Affected by obesity

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 Multiple contributors to obesity may account for RCT variances
(sometimes wide variances) in individual responses based upon:

• Age
• Race
• Gender
• Genetics
• Individual physiology
• Economic status
• Nutrition
• Physical activity
• Concomitant medication

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 Obesity is a multifactorial disease:
Genetic environmental
epigenetic

neurobehavior medical

autoimmune endocrine

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Overall Management Goals
Overall Management Goals

First Second Last

Improve patient health

Improve patient Improve body weight and

Improve quality of life
health composition

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 “
Classification of Obesity

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Obesity Classification and Consequences :

1. For the general population, body mass index (BMI) > 25 kg/m2 is
considered overweight; BMI > 30 kg/m2 is considered obesity
2. BMI has limitations in assessing adiposity in individuals with increased
muscle mass, decrease in muscle mass, men versus women, different
races, and postmenopausal status .
3. For individuals, accurately determining percent body fat, android fat,
and visceral fat is a better assessment of adiposity compared to BMI
alone .
4. Central obesity is defined as waist circumference > 40 inches (102 cm)
for men and > 35 inches (88 cm) for women [> 90 cm for Asian men; >
80 cm for Asian women] .
5. Waist circumference is well-correlated with the risk of metabolic and
cardiovascular disease
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 Obesity Classification and Consequences :

6. Fat mass disease results in pathologic mechanical and physical

forces leading to adverse clinical outcomes (e.g., sleep apnea,
orthopedic problems) .

7. Sick fat disease (adiposopathy) results in pathologic endocrine and

immune responses that promote the most common metabolic diseases
encountered in clinical medical practice (e.g., diabetes mellitus, high
blood pressure, dyslipidemia) .

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 Obesity Classification and Consequences :

8.Anatomic adiposopathic changes with obesity include adipocyte hypertrophy,

adipose tissue expansion, increased energy storage in multiple fat depots and
increased fat deposition in body organs .

9.Functional adiposopathic changes with obesity include adipose hypoxia,

increased reactive oxygen species, extracellular matrix abnormalities, intra-
organelle dysfunction, neurological changes, and
immunopathic/endocrinopathic responses .

10.The degree by which adiposopathy results in metabolic disease largely

depends on the interactions and crosstalk with other body organs.

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Body Mass Index: Increase Body
Fat (Adiposity ):
Body mass index (BMI) in kilograms per meters squared (kg/m2)*

BMI

Normal weight
over weight obese class 1. 30- obese class 2 35- Class 3 obesity
18.5-24.9
25-29.9 34.9 39.9 >40

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body Mass Index (BMI = kg/m2 or weight in
kilograms/height in meters squared)
meters squared)
Advantages
• Increased BMI generally
correlates with metabolic and
fat mass diseases in population
studies
• Commonly used
• Reasonably reproducible
• Low cost
• Adequate measure for
epidemiological studies
• Adequate screening metric for
most patients 19
body Mass Index (BMI = kg/m2 or weight in
kilograms/height in meters squared)
meters squared)
Disadvantages
• While BMI can estimate percent body fat
in populations, BMI may not always
correlate well with body composition,
metabolic disease, and fat mass diseases
in an individual patient
• Does not account for muscle mass
• May over-diagnose obesity in muscular
individuals, under-diagnose patients with
sarcopenia
• BMI cut-off points do not always
distinguish between men and women,
nor ethnic and racial considerations . 20
Obesity Medicine Association (OMA) Classification
of Percent body fat:ody
Fat

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Percent Body fat

Advantages:
• More specific assessment of body fat
• May be a reasonable longitudinal
measure, especially in patients who
may not be losing weight, but
engaged in resistance exercise
training, and thus may be losing body
fat, and increasing muscle .

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Percent Body fat
Disadvantages:
• Some measurement techniques are not always accurate, nor easily
reproducible. For example, even with proper placement and multiple
measures, skinfold calipers can vary from more accurate measures of
percent body fat by 10% or more.
• Electronic body fat measurements may be more expensive than
calipers
• The accuracy and reproducibility of electronic body fat
measurements are dependent upon the equipment and software,
technique, the expertise of the technician, and with some measures,
the condition of the patient at time of measurement (e.g., state of
hydration)
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Obesity classification: Waist circumference (WC)* :

Abdominal Obesity -
Women
Abdominal Obesity - Men
>35 inches
> 40 inches
>88centimeters
> 102 centimeters

Different WC abdominal obesity cut-off points are appropriate for different races (e.g., > 90 centimeters for
Asian men and > 80 centimeters for Asian women)

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Waist circumference

Advantages:
• Well-correlated to metabolic and
cardiovascular disease
• Individualized anatomical measure of
adipose tissue deposition, with an
increase in waist circumference
reflective of adipose tissue dysfunction
• Correlates well with total abdominal fat
• Low cost

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 Waist circumference
• Disadvantages:
• Measurement not always reproducible
• Waist circumference is not superior to BMI in
correlating to metabolic disease in patients with BMI >
35 kg/m2
• Racial/ethnic differences in the cut-off points that
correlated to an increased risk of metabolic disease
• May not correlate well with intraperitoneal (visceral)
fat, which can vary depending on gender and ethnicity
• May not correlate well with intraperitoneal (visceral
fat) in patients with prior abdominal liposuction
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Metabolic syndrome:
Patient must meet three or more of the following five risk factors

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Edmonton Obesity Staging System
STAGE 0: No apparent risk factors, no physical symptoms, functional limitations,
and/or impairment of well-being

STAGE 1: Presence of obesity-related subclinical risk factors, mild physical symptoms,

mild psychopathology, mild functional limitations, and/or mild impairment of well-being

STAGE 2: Presence of established obesity-related chronic disease, moderate

psychopathology, moderate functional limitations, and/or impairment of well-being

STAGE 3: Established end-organ damage, significant psychopathology, significant

functional limitations, and/or impairment of well-being

STAGE 4: Severe (potentially end-stage) disabilities from obesity-related chronic

diseases, severe disabling psychopathology, severe functional limitations, and/or
severe impairment of well-being
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Obesity Paradox
 “
Are some individuals who are overweight
or with obesity “paradoxically” healthy?
Do some individuals who are normal
weight, or only mildly overweight
“paradoxically” have metabolic disease?

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“Metabolic Healthy Obesity” (MHO)
Phenotype

• Patients with metabolic disease are generally less

healthy than patients with obesity and no diagnosed
metabolic disease
• Some individuals are reported to have increased body
fat, but without metabolic disease
• No standard definition exists for MHO
• With aging, 30 – 40% of patients with MHO develop
metabolic disease within 6 years
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 “Metabolic Obesity Normal Weight”
(MONW) Phenotype

• Defined as normal-weight individuals who express

metabolic diseases typically associated with an increased
in body fat
• Some individuals may express adiposopathy with
increased body fat not outside the upper range of normal
• Some individuals may have genetic or acquired
dysfunction of other body organs that result in
disharmonious physiologic interactions with adipose tissue
(“metabolic inflexibility”)

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Evaluation and
Treatment Overview:
 Obesity Evaluation :

• Useful nutrition monitoring approaches include recording food and

beverage diaries
• Body systems to be evaluated before prescribing a physical
activity program include cardiac, pulmonary, and neuro-
musculoskeletal systems, as well as body metabolic processes
(diabetes mellitus, hypertension)
• Routine laboratory assessment may include measures of glycemia
(fasting glucose levels, HbA1c), lipid levels, liver enzymes,
electrolytes, creatinine & blood urea nitrogen, thyroid stimulating
hormone, complete blood count, urine for albumin, and possibly
vitamin D

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body Composition:

1.Lean body mass is total body mass less stored

fat in adipose tissue (i.e., lean body mass = water,
mineral, protein, glycogen, essential organ fat) .

2.In lean individuals, approximately 60% of body

weight is water (i.e., water is 75% weight of muscle
and body organs). In those with obesity, water
weight can be as low as 40% body weight.

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body Composition:

• Calipers can estimate percent body fat, user

dependent, are inexpensive, and perhaps
more useful for frequent longitudinal
assessments once body composition is
determined by more accurate measures
• Bioelectrical impedance is a hydration-
dependent body composition assessment
procedure; reasonable assessment of
android fat may best be achieved via a
complementary tape-measured waist
circumferenc
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Subsets of Patients with Overweight

Deranged endocrine and Abnormal and pathologic

immune responses physical forces
• Sick Fat Disease (SFD) • Fat Mass Disease (FMD)
(Adiposopathy) Biomechanical/structural:
Endocrine/metabolic: • Stress on weight-bearing joints
‒ Elevated blood glucose • Tissue compression (i.e., sleep
‒ Elevated blood pressure apnea, gastrointestinal reflux,
‒ Dyslipidemia high blood pressure, etc.)
Tissue friction (i.e., intertrigo,
‒ Other metabolic etc.)
diseases
• Immobility

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 Medical Management and Coordination

Behavioural Barriatric
Nutrition Physical activity
therapy
pharmacotherapy
surgery

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Energy Expenditure
 Energy Expenditure
1.For most individuals, resting metabolic rate (RMR) represents ~70%
of total daily energy expenditure
2. For most individuals without excess body fat, skeletal muscle, liver,
brain, heart, and digestive system each
account for ~10 - 20% of RMR (~75% of total RMR). Kidney, adipose
tissue, and remaining/residual = ~25%.

3.Non-exercise Activity Thermogenesis (NEAT) varies

among individuals, can range between 150 – 500 kcal/day (often
greater than bouts of physical exercise), and can help account for the
perception that some individuals more easily maintain a healthy body
weight despite similar caloric intake and dedicated physical exercise
4.less than 5000 steps per day is considered sedentary; >10,000
steps per day is considered active

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 physical Activity to Improve Health
Improve Health

• Adiposopathy (Sick Fat • Non-adipose Parameters

Disease) • Improve metabolic health
• Assist with weight maintenance • Improve musculoskeletal health
• Assist with weight loss • Improve cardiovascular health
• Improve body composition • Improve pulmonary health
• Improve adiposopathic • Improve neurological health
physiologic disturbances
• Improve mental health (e.g.,
• Possibly improve adipocyte improve mood, promote
function (“train” fat cells) happiness & sense of well-
• ‒ Improve insulin being, reduce stress)
sensitivity
• ‒ Increase mitochondrial • Improve sexual health
biogenesis • Improve cognitive heath
• ‒ Increase browning
(“beiging”) of fat cells
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Physical Activity Goals
[in addition to routine non-exercise activity thermogenesis (NEAT)]
Physical Activity Goals
• 5000 (minimum) to • Resistance training /
over 10,000 steps per muscle strengthening
day at least 2 times a
and/or week
• 150 to 300 minutes
or more moderate-
intensity aerobic
activity per week or
75 – 150 minutes or
more vigorous-
intensity aerobic
activity per week 47
Nutrition Therapy for Obesity
Principles of Healthful Nutrition:
Principles of Healthful Nutrition
Limit:

• Unhealthful ultra-processed foods of minimum nutritional

value such as “sweets,” “junk foods,” cakes, cookies, candy,
pies, chips, and ultra-processed meats such as bacon,
sausage, hot dogs, pastrami
• Energy-dense foods high in calories
• Energy-dense beverages: sugar-sweetened beverages, juice,
cream
• Avoid trans fats and excessive sodium
• Among sweeteners, sucrose and saccharin may increase
body weight compared to aspartame, rebaudioside A, and
sucralose
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Principles of Healthful Nutrition:
Principles
Encourage: of Healthful Nutrition
• Consumption of healthful proteins and
fats, vegetables, leafy greens, fruits,
berries, nuts, legumes, whole grains
• Complex carbohydrates over simple
sugars: Low glycemic index over high
glycemic index foods High-fiber foods
over low-fiber foods
• Many dairy products (while being mindful
of caloric content)
• Reading labels rather than marketing
claims
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 Factors related to improved health outcomes:

patient Patient
Evidence based Quantitative agreement adherence
Qualitative

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 choosing Nutrition Therapy for Obesity

• The most appropriate nutritional therapy for weight loss is one that
is safe, effective, and one to which the patient will adhere.

• Encourage foods that result in a negative caloric balance

to achieve and maintain a healthy weight

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 choosing Nutrition Therapy for Obesity

❖ Consider the following:

_ Eating behaviors, and meal patterns

– Cultural background, traditions, and food availability
– Time constraints and financial issues
– Nutritional knowledge and cooking skills
– Medical conditions potentially affected by nutritional plan
•

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 choosing Nutrition Therapy for Obesity

• Nutritional approaches for weight loss typically focus on the

caloric manipulation of the three macronutrients:
carbohydrate, fat, or protein

• Very low-calorie diets contain less than 800 kcal/day and

require close medical supervision for safety reasons

• Low calorie diets range from 1200-1800 kcal/day (1200-

1500 for women, 1500-1800 for men)

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choosing Nutrition Therapy for Obesity

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Dietary Patterns :
• Mediterranean diet
• Therapeutic lifestyle diet
• DASH (Dietary Approaches to Stop Hypertension)
• Ketogenic (modified Atkins) diet
• Ornish diet
• Paleo diet
• Vegetarian or vegan diet
• Intermittent fasting / time restricted eating
• Commercial diet programs
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Motivational Interviewing
Techniques: 5A’s of Obesity
Management
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New technology for
weight management
 Technology and social media

• Applications
• Interactive Technology
• Websites
• Social Media

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Anti-obesity Medications
FDA-approved Anti-obesity Medication
Indications:
– Patients with obesity (e.g., BMI > 30kg/m2)*

– Patients with overweight (e.g., BMI > 27kg/m2) with

presence of increased adiposopathic complications (e.g.,
type 2 diabetes mellitus, hypertension, dyslipidemia)*

– Anti-obesity medications are contraindicated in

patients hypersensitive to the drugs

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 FDA-approved Anti-obesity Medication
principles:
anti-obesity medications promote variable weight loss
over variable duration in patients with overweight or
obesity
– Patients have an average of around 5 – 10% weight
loss, with greater weight loss in hyper-responders, and
less than 5% weight
loss (or even weight gain) in hypo-responders
– If no clinical improvement (e.g., at least 3 - 5% loss of
baseline body weight) after 12-16 weeks with one anti-
obesity medication,
then consider alternative anti-obesity medication or
increasing anti-obesity medication dose (if applicable)**
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FDA approved anti obesity medications:
Orlistat
Gastrointestinal lipase inhibitor that impairs digestion of
dietary fat. Lower doses are approved over-the-counter.
Some patients may lose about 5% of body weigh

Liraglutide
Glucagon-like peptide-1 receptor agonist that is an
injectable drug. At lower doses (1.8 mg per day), liraglutide
is indicated to lower blood sugar among patients with type
2 diabetes mellitus. Liraglutide 3.0 mg per day is approved
for treatment of obesity. Some patients may lose 5 – 10%
of body weight, especially with the liraglutide higher dose

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Bariatric surgeries

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Potential Bariatric Surgery Candidate

• BMI > 35 with one or more AHC

• BMI > 40 with or without AHC
• BMI 30-34.9 with one or more AHC:
Mounting evidence supports surgical
intervention as a treatment option in this
group

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Nutritional Principles Following Bariatric
Surgery
• Nutritional advice will depend upon type of bariatric
procedure
• Initially three to five small meals a day, with
decrease in meal number as portion sizes increase
• Chew small bites of food thoroughly
• Avoid consuming liquids during meals, delay for at
least 30 minutes after meals
• Protein: At least 60 grams/day, optimally 1.2 to 1.5
grams/kg/day of lean mass – avoid excessive calorie
intake
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Nutritional Principles Following Bariatric
Surgery
• Avoid concentrated sweets to minimize dumping (i.e., procedures
such as gastric by-pass) and to reduce caloric intake
• High-quality multivitamins are routinely recommended after
bariatric procedures, irrespective of deficiencies, which are often
recommended to be chewable or liquid
• Other routine supplements often include:
• – Vitamin B12 500 μg/d tablet or sublingual, or 1000 μg/mo
IM
• – Iron at least 27 mg of elemental iron daily, given with at
least 500 mg vitamin C
• – Calcium citrate 1200 mg/d, preferably with vitamin D3
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1000000
Mabrouk
Whoa! aren’t you proud?

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Thanks!
Any questions?
You can find me at:
@username
[email protected]

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