OBESITY

By Subin Solomen
DEFINITION
Obesity can be defined as increased
accumulation of adipose tissue so that body
mass index is above 30 kg/m2 ,body fat is
above 25 % for males or 30% for females,
or body weight is more than 20% above
upper limit for height
Classification of over weight and obesity by
body mass index
BMI, Kg/m2

Under weight <18.5

Normal 18.5-24.9
Overweigh 25.0-29.9
Obesity, class
1 30.0-34.9
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 11 35.0-39.9
111 >40
Types of obesity acc to size and number

• Juvenile onset obesity adult onset obesity

• According to the size and number of fat
cells, obesity can be divided into
• adult-type, where only the size of fat cells is
increased, and
• child-type, where the number of fat cells is
increased.
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 Based on etiology
• Type-1 obesity is not caused by a disease and,
in most cases, it is caused by excessive eating
habits and lack of exercise.
• Type-2 obesity accounts for less than 1% of
obesity cases and is caused by a disease;
• abnormal weight gains occur with type-2
obesity even when little is eaten.
Based on distribution of fat
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 Body Fat Distribution….

• Based on the distribution of adipose

tissue, obesity can be classified as
Android obesity and Gynoid obesity.
• Android Obesity
– abdominal obesity
– central obesity
– upper body fat
– “apple shape” obesity
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• Gynoid Obesity
– lower body obesity
– “pear shaped” obesity
• In android obesity: there is storage of fat in
the upper body-mainly in the abdomen giving
the individual an “apple” shape and a waist-
hip ratio of more than one. It is seen
predominantly in the male population.
Phenotypic classification

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 • On the basis of the topography of the adipose
tissue and its association with the variety of
metabolic characteristics, a classification of
obesity has been proposed.
Contd…
• The first type is characterized by excess total body
mass or body fat without any particular
concentration of fat (obesity type 1) the other types
have to do with excessive accumulation of fat in
some areas of the body.
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• The second is defined as excess subcutaneous fat
on the trunk (Obesity type 2) particularly in the
abdominal area and is equivalent to the so called
android or male type of fat deposition (Upper
obesity or central obesity).
• The third type is characterized by an excessive
amount of fat in the abdominal visceral area and
can be labeled abdominal visceral obesity
(Obesity type 3).

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• The last type is defined as gluteo-femoral obesity
(Obesity type4) and is observed primarily in
women (gynoid obesity or lower obesity).
BEHAVIORAL

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 PHYSIOLOGIC
SOCIAL

OBESITY RACIAL

CULTURAL
GENETIC

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 Etiology

• Genetics: Over weight/Obese-fat builds around

the body-Endomorphs
• Genetics-Leptin: naturally occurring hormone that
controls the appetite one of the cause of obesity
• When full, fat cells release the hormone leptin,
which decreases the appetite.
• If leptin production is hindered, the fat cells are
unable to signal that they are full and weight gain
occurs
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 Genes-Hormones
• Due to glandular or hormones problems
• Due to hypothyroidism, where not enough
thyroid hormone to control normal rates of
metabolism
• Sex hormones: In women, body fat levels
during adolescence, pregnancy and
menopause are determined by the balance of
sex hormones.
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 REVERSIBLE CAUSES OF
WEIGHT GAIN
Endocrine factors • Tricyclic antidepressants
• Hypothyroidism • Corticosteroids
• Hypothalamic tumours or • Sulphonylureas
injury • Sodium valproate
• Cushing's syndrome • Oestrogen-containing
• Insulinoma contraceptive pill
Drug treatments
• β-blockers
SOME REASONS FOR THE INCREASING
PREVALENCE OF OBESITY-THE
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 'OBESOGENIC' ENVIRONMENT
• Increasing energy • Decreasing energy
intake expenditure
• ↑ Portion sizes • ↑ • ↑ Car ownership
Snacking and loss of • ↓ Walking to school/work
regular meals
• ↑ Automation;
• ↑ Energy-dense food
• ↓ manual labour
(mainly fat)
• ↓ Sports in schools • ↑
• ↑ Affluence
Time spent on video games
and watching TV
Factors associated with obesity
• Lack of physical activity
• Environmental factors
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• High-fat diets
• simple carbohydrates.
• Enzyme pathways and hormones implicated in adipose
tissue metabolism Lipoprotein lipase brown adipose
tissue (BAT), leptin
• alpha adrenergic mechanisms regulate lipolysis at rest,
beta adrenergic activity controls lipolytic rate during
exercise

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 PHYSIOLOGIC REGULATION
OF ENERGY BALANCE
Psychological Cultural

Central Control of
FactorsFactors
apetite
Increase Decrease
NPY MSH
Neural
MCH CART
AGRP GLP1
Orexim Serotonin

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AfferentsHormones
cardioresp)
Vagal Leptin
Insulin
Cortisol

Gut PeptidesMetabolites
Glucose
Ketones18
Appetite is influenced by many factors that are integrated by
the brain, most importantly within the hypothalamus
Signals that impinge on the hypothalamic center include
neural afferents, hormones, and metabolites. Vagal inputs
are particularly important, bringing information from
viscera, such as gut distention.
Hormonal signals include leptin, insulin,cortisol, and gut
peptides such as ghrelin, peptide YY (PYY), and
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 cholecystokinin, which signal to the brain through direct
action on hypothalamic control centers and/ or via the
vagus nerve.
Metabolites, including glucose, can influence appetite, as
seen by the effect of hypoglycemia to induce hunger;
• Factors will release hypothalamic peptides
which increases or decreeases the apetite
with in hypothalamus
• hypothalamic peptides includes
neuropeptide Y (NPY), Agouti-related
peptide (AgRP), melanocyte-stimulating
hormone (-MSH), melanin-
concentrating hormone (MCH
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 Pathogenisis
• Obesity is the end result of a mismatch
between energy intake and energy
expenditure, such that exceeds expenditure,
resulting in net accumulation of energy
stores in the body.

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ENERGY METABOLISM AND
OBESITY
Components of energy balance: Energy
intake, energy expenditure, and body energy
storage.

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 Energy intake
Energy intake is defined as the caloric or energy content of
food as provided by the major sources of dietary energy:
carbohydrate (4 Kcal/g), protein (4 Kcal /g), fat (9
Kcal/g), and alcohol (7Kcal /g).
. The energy that is consumed in the form of food can be
stored in the body in the form of fat (the major energy
store), glycogen (short-term energy and carbohydrate
reserves), or protein (rarely used by the body for energy
except in severe cases of starvation and other wasting
conditions,

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 ENERGY EXPENDITURE
basal metabolic rate, which is the energy expended
by the body to maintain basic physiologic
functions (e.g., heart beat, muscle contraction and
function, respiration).
it is difficult to measure the basal metabolic rate except
perhaps during sleep because energy expenditure
increases above basal level as a result of energy cost of
arousal.
resting metabolic rate is preferred
resting metabolic rate is the slightly higher energy expended
than bmr

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 Meal-induced thermogenesis
increase in energy expenditure in response to
food intake.
the energy that is expended to digest,
metabolize, and store ingested
macronutrients
thermic effect of a meal usually constitutes
approximately 10% of the caloric content of
the meal that is consumed
• Physical activity energy expenditure
frequently used to describe the increase
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 in metabolic rate that is caused by use of
skeletal muscles for any type of physical
movement.
• MINOR COMPONENTS
Energy needed for growth adaptive
thermogenesis heat production during
exposure to reduced temperatures
Energy balance
When energy intake exceeds energy
expenditure, a state of positive energy
balance occurs.

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 When energy intake is lower than energy
expenditure, negative energy balance
energy-saving devices that have
resulted in a decline in physical
activity
(1) increased use of automated transport
(2) central heating and use of automated equipment
in the household,
(3) reduction in physical activity in the workplace as
a result of computers
(4) increased use of television and computers for
entertainment and leisure activities.;
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(5) use of elevators and escalators rather than stairs;
(6) poor urban planning,
EFFECT OF OBESITY ON
PHYSIOLOGIC FUNCTION
• 1. Cardiovascular system
• 2. Respiratory system
• 3. Exercise tolerance
• 4. Sleep apnea
• 5. Temperature regulation

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CARDIO VASCULAR DISEASE
1. Hypertension =associated arteriosclerosis
,arterial wall damage
• Increased blood viscosity may contribute to the
elevated arterial pressure in grossly obese persons.
Contd
2.Congestive heart failure, the calculating blood
volume is large and the relatively greater venous
return adds a load to a left ventricle which is
already burdened by high after load caused by
arterial hypertension
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• Obese patients have been found to have greater
cardiac out put; stroke volume left ventricular
filling pressure, and left ventricular eccentric
hypertrophy than normal ones
3.obesity-hypertension syndrome
(pickwickian syndrome) larger pulmonary
blood volume (pulmonary circulatory
congestion) pulmonary arterial vaso
constriction and hypertension secondary to
hypoxia
4.hyperlipidemia

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 RESPIRATION
• FRC decreased , by thoracic cavity squeeze.
• ERV DECRESED
due to Both the mass of overlying adipose tissue and an
elevated diaphragm
• The mechanical work of breathing
The intercostals muscles being forced to move the large
adipose tissue mass overlying the thorax and the
contraction diaphragm work against an enlarged and
distended abdomen.
• small airway closure, regional atelectasis

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Obesity-hypoventilation syndrome
• occurs in about 5% of severely obese
patients, it is characterized by
hypoventilation, periodic respiration,
somnolence, cyanosis, and polycythemia
• Sleep Apnea
• Caused by increased pharyngeal resistance,
decreased air way patency; both leads to air way
collapse during sleep
• Temperature regulation

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• obese persons are less tolerant of exposure to heat
or exercise in a warm and humid environment than
normal people
• In a cold environment, subcutaneous fat provides
thermal insulation
Temperature regulation
• obese persons are less tolerant of exposure to
heat or exercise in a warm and humid
environment than normal people
Because
• lower volume of skin blood flow
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• Fat person is rounder .so small surface area –
body mass ratio so less heat exchange per
unit mass
EVALUATION OF THE
OBESE PATIENT
• Chronological History of Weight Gain • Response
to Previous Weight Loss Attempts • Lifestyle,
Social ,family History .
• Psychiatric and Psychologic History
• Medication History
• determining risk categories

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• organ system approach to evaluating the obese
patient
• laboratory evaluation
• Body composition
Chronologic History of Weight Gain
• Age at onset and description of weight gain
• Weight gain initially occurs or is accelerated
coincident to smoking cessation or change
in other life events, such as marital status,
occupation, or residency.

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• The pattern of body weight should also be
noted, particularly if there has been
significant variations over time, so called
weight cycling
Response to Previous Weight Loss Attempts

• The nature, duration, and response to past

treatments should be discussed and documented. •
This information divulges the patient’s past
commitment and adherence to treatment
programs, the patient’s perceptions of how the
body functions, and what the patient’s needs are.

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 • Questions should focus on why the patient thought
he or she was (or was not) successful,
Lifestyle History
• obtain a description of the patient’s habitual diet
regarding meal and snack patterns, selection of
types of foods, frequency of intake of food groups ,
and portion sizes.
• Dietary behaviors, such where food is eaten, what
triggers eating, and whether there is binge eating,
are also important information.
• More detailed information can be obtained by
asking the patient to keep a food and activity diary
for several days to a week.
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• This exercise serves to increase the patient’s
awareness of dietary habits and forms the basis for
targeted changes.
Social History
• Any treatment plan for obesity must be
implemented in the context of the patient’s
personal and social environment.
• Descriptions of the home and work
environment regarding pressures to eat,
personal conflicts, flexibility in time and

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 structure, and potential allies are particularly
helpful
Family History
• A familial predisposition should be
considered if at least one first-degree
relative is also obese
• A positive family history is perhaps
more important to identify because it
may provide an opportunity to
implement preventive care for other at-
risk family members
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 Psychiatric and Psychologic History
• Many patients express emotional triggers
for their eating, such as loneliness,
boredom, or stress.
• Binge eating disorder, a syndrome
characterized by recurrent binge eating
described as loss of control over eating
large amounts of food rapidly, or feeling
disgusted or guilty after a binge.
• Bulimia nervosa is characterized by
recurrent binge eating along wit recurrent
purging, excessive exercise or fasting, and
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dioresp)
excessive concern about weight or shape. subin solomen

MPT M'pal(

Medication History
• A thorough medication history should be taken for
uncovering possible drug-induced weight gain as
well as for interfering with weight loss.
• The commonest drug groups are the
antidepressants (tricyclics), lithium, antipsychotics
(phenothiazines, butyrophenones, atypical agents),
anticonvulsants (valproic acid and
carbamazepine), steroid hormones (cortiocosteroid
derivatives, megestrol acetate, estrogen), and
antidiabetics (insulin sulfonylureas,
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 thiazolidinediones
Lab investigation
• Serum blood glucose
• Lipid profile
• urinalysis
• complete blood cell count,
• blood chemistry

Investigations
• Ecg

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• LFT
• Sleep study
• Alveolar hypoventilation (pickwickian)
Syndrome (hypersomnolence possible right-
sided heart failure
– Do lung function tests (reduced lung
volumes),
CBC (to rule out polycythemia); blood gases
(PCO2 often elevated);
ECG(to rule out right-sided heart strain)
Cushing’s syndrome
– Screen with 24-h urine for free cortisol
• Gallstones
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 – Ultrasonography of gallbladder
• Hepatomegaly/ nonalcoholic
– Liver function tests
• Upper airway obstruction
– Sleep study
• Hypothyroidism
– Serum TSH (normal generally <5 U/ml)
Methods for measuring the
distribution of body fat
• 1)Quetelet's index
• 2) Waist/hip circumference ratio
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• The average value for men is about 0.93 (0.75 to
1.10) and for women 0.83 (0.70 to 1.00.)
• 3) Skin fold measurement
• the sum of skinfolds at abdominal,thighs, triceps,
subscaplar and suprailiac sites
1)Quetelet's index
body mass index
• Advantage
– Quick
– Inexpensive
• Disadvantage
– Misclassify mascular athletes as obese
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 – Underestimates fat in elderly
2) Waist/hip circumference ratio
• Waist circumference is the minimum
circumference between the costal margin and iliac
crest, measured in the horizontal plane, with the
subject standing.
• Hip circumference is the maximum circumference
in the horizontal plane, measured over the
buttocks.
• The ratio of the former to the latter provides an
index of the proportion of intra-abdominal fat.

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• The average value for men is about 0.93 with a
range of 0.75 to 1.10, and for women 0.83 with a
range from 0.70 to 1.00.
3)Skin fold ratio
• Individuals differ in the proportion of fat at
different subcutaneous sites, but the sum of
skinfolds at abdominal,thighs, triceps, subscaplar
and suprailiac sites yields an estimate of body fat.
• The method is inexpensive, but requires a skilled
observer, and is not applicable to very obese
people whose skin folds would not fit between the
jaws of the measuring caliper

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• not a reliable method for estimating
intraabdominal fat.
LESS COMMON
PROCEDURES
Bioelectrical impedance (accuracy is more)
Near-infrared interactance
Ultrasound assessment of fat
Imaging techniques
Neutron activation analysis
Methods for measuring total body fat

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 4) BioElectrical impedance

• Lean tissue is a good conductor of

electricity, since it contains an electrolytic
solution, whereas fat is not.
• Measurements of the impedance of the body
can be made by passing a small
highfrequency current between the hand and
foot;
• impedence will be directly related to the
level of body fat .

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 5)Near-infrared interactance
• The frequency spectrum of light reflected
from subcutaneous tissues when illuminated
by near-infrared light is modified by the
ratio of fat to lean in the underlying tissue.
• 6)Ultrasound assessment of fat
• The time for ultrasound wave transmission
through the tissues and back to the receiver
is converted to a distance score and
displayed on a light emitting diode scale

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 7)Imaging techniques
• Images of cross-sections of the body can be obtained by
computed tomography, using either X-ray or magnetic
resonance techniques. In principle the entire body can be
visualized by serial transverse scans, but this is very
expensive and time-consuming. In practice, a series of 20
transverse scans provides a very good estimate of the
amount and distribution of body fat. This is the gold
standard with which less expensive techniques for
measuring intraperitoneal fat are compared.

8)Neutron activation analysis

• If a subject is irradiated with neutrons, it is possible to
induce measurable short-lived radioactivity in many
elements including O, H, N, Ca, P, Na, Cl, and Mg.
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• In principle this gives insight into changes in body
composition which do not depend on the assumed
constancy of the chemical composition of fat-free mass.
• However, the method is expensive and involves
irradiating the patient and so is not widely available
9)Methods for measuring total body fat

• The three classical methods for measuring body

fat in living subjects involving measurement of
density or water and potassium content, depend
on the assumption that body weight is the sum of
the weight of fat and the weight of a mixture of
nonfat components (called fat-free mass) which
has some constant characteristic

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 a)Whole-body density
• The density of fat in man is 0.90 g/ml, and the
fatfree mass is made of a mixture of water (0.993
g/ml), protein (1.34 g/ml), and mineral (3.00
g/ml). If it is assumed that the average density of
this mixture is 1.10 g/ml, and whole-body density
(d) is measured, then percentage body fat
(F&percnt;) is given by:
• Percent body fat =495/d -450
• this method is rated most accurate

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 b)Total body water
• If a known dose of isotopically labelled water is
given to a subject and allowed about 3 to 4 h to
equilibrate, the final concentration of labelled
water in body fluids indicates the weight of total
body water (TBW).
• Fat is anhydrous, so if the assumption is made that
the fat-free mass (FFM) contains 73 per cent
water, then it can be calculated thus:
• Fat free mass =total body water/0.73
• And body water can be obtained by subtracting the
fat-free mass from body weight.

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• The method is less accurate than measuring
density because the assumption that the fat-free
mass is 73 per cent water is invalid in people who
are very young or very old (in whom the hydration
is greater or less, respectively), oedematous, or
dehydrated.
• In very obese patients total body water
overestimates fat-free mass, and hence
underestimates fat, because adipose tissue contains
about 10 per cent extracellular water.
c)Total body potassium
• A naturally occurring long-lived radioactive
isotope, is present at very low
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 concentrations in all potassium, including
that in the human body.
• The average concentration of potassium in
the fat-free mass of men is 66mmol sol /kg,
and in women 60mmol sol/kg,
• so fat-free mass (kg) is given by TBK
(mmol)/66 in men and TBK (mmol)/60 in
women.
Pathological consequences of obesity
Cardiovascular system Respiratory system
Hypertension Dyspnea and fatigue
Congestive heart failure Obstructive sleep
Cor pulmonale apnea
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Varicose veins Hypoventilation
Pulmonary embolism (pickwickian
Coronary heart disease syndrome)

Gastrointestinal system Endocrine system

Gastroesophageal reflux disease Reduced insulin
Hepatic steatosis sensitivity
Choleslithiasis Glucose intolerance
Hernias Type II diabetes
Colon cancer mellitus
Dyslipidemia
Polycystic ovary Psycho social
syndrome
Infertility Work disability Amenorrhea
Social discrimination
Depression

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Musculoskeletal system Genitourinary
Urinary stress
Immobility
incontinence
Degenerative arthritis Hypogonadism
Low back pain Breast and uterine cancer
Integument Neurologic
Venous stasis of legs Stroke
Cellulitis Meralgia paresthetica
Diminished hygiene Idiopathic intracranial
hypertension
Management of obesity
• Diet
• Exercise
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• Behaviour modification
• Drugs
• Surgery

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subin solomen MPT M'pal( 58cardioresp)
 Management of obesity
• Dietary approaches
• Optimal diet composition lower fat diet is
coupled with total energy reduction
• Energy density :refers to the energy in a
given weight of food
Tips for lowering energy density
of the diet
• Increase intake of high water content fruits ,
vegetables and soups
Add fruit to break fast cereal
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 Fresh fruit for snacks
Green salad with lunch or dinner
Start with soup
• Limit intake of dry foods
• Reduce intake of dietary fat
Choose lean meat inclusion of fiber diet,
complex carbohydrates
Type of diet
• Ketogenic diet
This diet includes minimal carbohydrate with
a high protein and fat diet
• High protein diet: Inclusion of more of protein
diet.effects is suppression of appetite
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• Starvation diet
Adequate carbohydrates are not given,
glycogen storage depots in muscle and liver are
reduced to low levels
Behavioral treatment
• The behavioral treatment of obesity refers to a
set of principles and techniques designed to help
overweight individuals reverse the above
described maladaptive eating and activity habits.
• goal : to help obese patients identify and
modify eating, activity, and thinking habits that
contribute to their excess weight.
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• Stand while on the telephone
• Get off the bus a stop early
• Take the long way around
• Choose outdoor activities
• Make several trips up the stairs
• Park further away from entrancess

Physiologic effects of
exercise
• Increased daily energy expenditure
• Relatively decreased appetite
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• Increased or preserved muscle mass
• Reduced body fatness-(aided by dietary
restriction)
• Increased functional capacity
• Increased fat oxidation
Decreased plasma insulin concentration
Increased tissue sensitivity to insulin, skeletal muscle
Decreased serum triglyceride concentration
Decreased heart rate both at rest and during submaximal
exercise
Decreased systolic blood pressure
Increased stroke volume
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Decreased peripheral vascular resistance
Decreased cardiac work, submaximal exercise
Increased flexibility
Better motor coordination

Psychological effects
Reduced fatigue on the job, recreational
activities
Increased self-satisfaction and acceptance
Improved self-perception, image
Improved social interactions
Improved self-esteem and confidence
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 Exercise prescription
Light activity Moderate activity Strenuous activity
(1.5 MET) (4MET) (6MET)
Light house work Cycling 5.5mph Vigorous dancing
Strolling 1.0mph Walking Cycling
golf Rowing 2.5mph Sawing
Swimming .25 mph Walking 5 mph
Walking 5 mph
Aquatic exercises Hill climbing

Potential Hazards of Exercise for

Obese Persons
Precipitation of angina pectoris or myocardial
infarction
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 Excessive rise in blood pressure-isometric exercise
• Aggravation of degenerative arthritis and other
joint Problem,Liagamentous injuries
• Injury from falling
• Excessive sweating,
Hypohydration and reduced circulating blood
volume to The skin
• Heat stroke or heat exhaustion Lower extremity
edema
Pharmacological treatment
• Indications for pharmacologic treatment for
obesity
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• BMI>27 kg/m2
• One or more complications or conditions that
are likely o improve with Weight loss
• Previous failure of conservative treatment with diet
and exercise
• Drugs used to treat obesity
• Noradrenergic agents,seratoninergic agents

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 Orlistat
• inhibits pancreatic and gastric lipases and
thereby decreases the hydrolysis of ingested

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 triglycerides, reducing dietary fat absorption
by 30%.
• adverse side-effects relate to the effect of
the resultant fat malabsorption on the gut,
namely loose stools, oily spotting, faecal
urgency, flatus and the potential for
malabsorption of fat-soluble vitamins
Sibutramine
• reduces food intake through β1-adrenoceptor
and 5-hydroxytryptamine, serotonin) receptor
agonist activity in the central nervous system.
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• Side-effects include dry mouth, constipation
and insomnia.
• noradrenergic effects of the drug can increase
heart rate and blood pressure; these effects are
especially undesirable in many obese patients
Surgeries
• Bariatic surgeries
• Disadvantages such as pouch and distal
oesophageal dilatation, persistent vomiting,
'dumping' and micronutrient deficiencies,
particularly of folate, vitamin B12 and iron,
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• Cosmetic surgeries – liposuction
Surgical procedures
• Approach operations
• Global absorption jejunoilleal bypass or
small bowel bypasss
Gastroplasty
Gastric stapling
Gastric binding
• Combined gastric roux –en –y
restriction and Damping gastric bypass
physiology

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 References
• 1. Davidson. Text book of medicine.
• 2. Oxford. Text book of medicine.
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