Our AgendaOur Agenda

• Obesity as a problemObesity as a problem• CausesCauses• Diagnosis.Diagnosis.• How to deal.How to deal.

BY /Essam Adel Wahab

Associated lecturer of Internal Medicine

BY /Essam Adel Wahab

Associated lecturer of Internal Medicine

Obese elsewhere Obese elsewhere

Rise in Childhood ObesityRise in Childhood Obesity

0

5

10

15

20

25

1989 1998

OverweightObese

Bundred et al, BMJ Feb 2001

Animal problem Animal problem

Most important disease states in the world?

20201990

CommunicableDiseases

ChronicDisease

Injuries

Source: Harvard School of Public Health

Obesity Trends Among U.S. Adults (BMI > 30)Obesity Trends Among U.S. Adults (BMI > 30)BRFSS, 1991, 1995, and 2000BRFSS, 1991, 1995, and 2000

1991 1995

2000

No Data <10% 10%-14% 15-19% 20%

Global effect of Over weight

Globally WHO estimates that:• 58% of Diabetes mellitus,• 21% Ischemic heart diseases,• 4-42% of certain cancer,

Were attributable to BMI above 21 kg/m²

Prevalence of overweight and obesity

* Obesity only

Financial costs Financial costs Health problems Health problems

• £2.6 billion pa, UK (1998)£2.6 billion pa, UK (1998)• Direct Direct

– Co-morbidities, health service expend, Co-morbidities, health service expend, prescriptions,hospitals, drugsprescriptions,hospitals, drugs

• IndirectIndirect– Disability, unemployment, early retirementDisability, unemployment, early retirement– 18 million sick days, 40 000 lost years working life, 18 million sick days, 40 000 lost years working life,

obese die 9 years earlyobese die 9 years early• Intangible Intangible • Loss self esteem, relationships, painLoss self esteem, relationships, pain

The Costs of ObesityThe Costs of ObesityThe Costs of ObesityThe Costs of Obesity

Burden of Obesity

Obesity is killing around, 150.000 men and women each year.

Health Risks of Excessive FatHealth Risks of Excessive Fat

• Impaired cardiac functionImpaired cardiac function• HPN, stroke, and DVDHPN, stroke, and DVD• Type 2 diabetes (80% of these patients are Type 2 diabetes (80% of these patients are

overweight)overweight)• Renal diseaseRenal disease• Sleep apneaSleep apnea• Osteoarthritis, degenerative joint disease, goutOsteoarthritis, degenerative joint disease, gout• Endometrial, prostrate. breast, colon cancersEndometrial, prostrate. breast, colon cancers• Abnormal plasma lipid and lipoprotein levelsAbnormal plasma lipid and lipoprotein levels• Menstrual irregularitiesMenstrual irregularities• Gallbladder diseaseGallbladder disease

PhysicalPhysical Effects of Obesity Effects of Obesity

CardiovascularRespiratory disease

Gall bladder disease

Hormonal abnormalities

Hyperuricaemia and gout

Stroke

Diabetes

Osteoarthritis

Cancer

Cardiovascular Chronic RespiratoryDisease Type 2 Diabetes Cancer

chronic diseases result in percent of deaths worldwide...4

50

Association of Obesity and related diseases

Obesity

CancerGall-bladder disease

Kidney failure

Stroke

Heart failure

Hyper-tension

Type 2 diabetes

Athero-sclerosis

East

Diabetes

Hypertension

Smoking

Obesity

Dyslipidaemia

Physical Inactivity

RISK FACTORS

Diabetes 2 in 10

Hypertension 1 in 4

Smoking 1 in 3

Obesity 1 in 2

Dyslipidaemia 1 in 2

Physical Inactivity

8 in 10

Source: Hinkle et al., CDC 1997

What matters most in health care?

Lifestyle Factors

Human Biology

Environmental Factors

Medical Care

Fat bloke my arse

3… and are caused by risk factors

Tobacco Poor DietLack of Exercise

Size is every thing

Obesity is caused by what?

Rare syndromes can be identified with monogenic aetiologies ( e.g.leptin deficiency)

Polygenic conditions can be identified with obesity as part of the syndrome (Prader-Willi syndrome)

Majority of obesity is caused by an imbalance between energy consumption and energy expenditure…

Energy Expenditure

Energy Intake

Pathways to ObesityPathways to Obesity

• Fat intake (“cafeteria” diet)Fat intake (“cafeteria” diet)• Inactivity (25% get regular exercise)Inactivity (25% get regular exercise)• Metabolic issuesMetabolic issues• OvereatingOvereating• ““Thrifty genome”Thrifty genome”• Combinations of aboveCombinations of above

Or, in simple terms

…We are eating too much and doing too little exercise

Women

>88 cm (80cm) = Increased risk

Men

>102 cm (90cm) = Increased risk

Body fat distributionBody fat distributionApple shaped obesity Apple shaped obesity

cm

Waist Measurement or BMI?Waist Measurement or BMI?

WHO criteria for Over weight and Obesity

• Overweight = BMI of 25-29 Kg/ m²

• Obesity = BMI of 30 kg/ m²

WHOWHO

“ “Obesity cannot be prevented or Obesity cannot be prevented or managed solely by governments (or managed solely by governments (or health professionals). health professionals). The food industry, The food industry, international agencies, the media, international agencies, the media, communities and individuals need to communities and individuals need to work togetherwork together so that the environment so that the environment is less conducive to weight gain”is less conducive to weight gain”

Excuses• Governments: “Food is the responsibility of

the individual” • Doctors: “Diabetes is a disease, but obesity is

compatible with a long and happy life”• Scientists: “Obesity is genetic”• Rich individuals: “I only eat lettuce”• Poor individuals: “The best value meal I can

find is fast food”

Nonsense!

Nonsense!Nonsens

e! Nonsense!

True!

Food is advertised,

and marketed.

Choices depend on availability

Governments have a

responsibility for food standards

and labelling

Los Angeles 25Los Angeles 25thth Nov Nov 20032003

What we needWhat we need

• Health educationHealth education• Role of media.Role of media.• Public organization.Public organization.• Role of health providers.Role of health providers.• Role of person.Role of person.

The Plane The Plane

• Food Restriction.Food Restriction.• Behavior Modification.Behavior Modification.• Exercise.Exercise.• Last options – Surgery, drugs.Last options – Surgery, drugs.

Success in weight management?Success in weight management?

Starting Starting weightweight

TimeTime

Natural course of weight gain

Natural course of weight gain

Increasing Increasing successsuccess

Body Body weight weight

(kg)(kg)

Weight loss Weight loss phasephase

Weight maintenance phase

yearsyearsmonthsmonths

Who is responsible for policy response to Obesity?

Heads of state: Not in focus

Health ministries: Inadequate capacity and budget

WHO: Has tried for 48 years

Academic health centres: Not a priority

International donors: Only for HIV/AIDS (tobacco)

Private-public partnerships: All on infectious diseases

Global NGOs: No support

Media: Little

Pharmaceutical industry: Major contribution??????????????????????

Multiple stakeholder interventions can be effective

• Cigarette smokingCigarette smoking– high taxationhigh taxation– Advertising banAdvertising ban– Prevention of smoking in public placesPrevention of smoking in public places– Health campaigns to stop smokingHealth campaigns to stop smoking– Transport smoking bansTransport smoking bans– Campaign groupsCampaign groups– Health warnings on packetsHealth warnings on packets

Raising community awareness (Eat Raising community awareness (Eat less – Walk more):less – Walk more):

• Since obesity is the major risk factor, not Since obesity is the major risk factor, not only for diabetes, but also for hypertension only for diabetes, but also for hypertension and cardiovascular diseases, it is essential and cardiovascular diseases, it is essential to create awareness in the community to create awareness in the community about obesity, the risk factors involved and about obesity, the risk factors involved and the importance of a healthy lifestyle, the importance of a healthy lifestyle, including intake of fewer calories and including intake of fewer calories and more physical activity.more physical activity.

NEGLECTING NEGLECTING OVERWEIGHT-OVERWEIGHT-

OBESITYOBESITY

IS IS A disasterA disaster

“All segments of the society mustunite across the world to providea global obesity

NO MATTER HOW FAR YOU HAVE GONE ON NO MATTER HOW FAR YOU HAVE GONE ON THE WRONG ROAD,THE WRONG ROAD, JUST TURN BACKJUST TURN BACK

TURKISH PROVERBTURKISH PROVERB

سمعت رسول الله صلى الله سمعت رسول الله صلى الله ::صالح بن يحيى بن المقدام صالح بن يحيى بن المقدام عن عن •

عليه وسلم يقول : ( ما مأل آدمي وعاًءU شراU من بطن، حسبك يا عليه وسلم يقول : ( ما مأل آدمي وعاًءU شراU من بطن، حسبك يا

ابن آدم لقيمات يقمن صلبك ، فإن كان ال بد ، فثلث طعام ، ابن آدم لقيمات يقمن صلبك ، فإن كان ال بد ، فثلث طعام ،

صدق رسول اللهصدق رسول الله ..وثلث شراب ، وثلث نفسوثلث شراب ، وثلث نفس