Surgery should be reserved for carefully selected patients who have not achieved significant weight loss with nonsurgical methods, or for patients with life-threatening obesity-related conditions who may benefit more from early surgical intervention.

1. MENOPAUSE AND OBESITY
Dr. Vandana Bansal
MS, D.Phil., DGO, FCGP

2. OBESITY
Obesity is a heterogeneous complex disorder of
multiple etiologies characterized by excessive
accumulation of body fat that threatens or
affects socioeconomic, mental or physical health
Sharma 2007

3. Obesity: major public health problem
• Universally there are 1 billion overweight adults,
among whom 300 million are obese
• Obesity is continuously increasing in the elderly
population
• Life expectancy increases
– 77 years for men
– 82 years for women
• 25% of the population >65 years by 2030
• Body fat increases with age, independently of
BMI (sarcopenic obesity)
Han TS et al, BritishMedical Bulletin 2011;1-28

4. Obesity: Definition
• Obesity is defined in terms of body mass index
• BMI is calculted as weight in kilograms divided by the square
of the height in meters (kg/m2)
• WHO Classification of obesity according to BMI
• Classification BMI (kg/m2)
• Underweight Less than 18.5
• Normal range 18.5- 24.9
• Overweight 25-29.9
• Obese I 30-34.9
• Obese II 35-39.9
• Obese III Greater than or equal to 40.0
• Abdominal obesity WC > 88 cm

5. Classification of Obesity
Obesity can be classified into two groups on the basis of body fat
distribution and the waist-to-hip circumference ratio.
The apple shape: The pear shape:
 also called “android”,  also called “gynaeoid” or
“abdominal” or “central” “peripheral” obesity
obesity
 people with lower waist to hip ratios are
 people with high waist-to-hip "pears“ - their body fat is distributed
ratios are "apples", their body fat is mainly on the lower trunk, the hips and
distributed mainly on the upper thighs giving the typical ‘pear shape’.
trunk, the chest and abdomen
giving the typical ‘apple shape’  individuals are mostly female.
 individuals are mostly male  associated health risks are minimal if
any
 A waist-to-hip ratio >1.0 for men
and >0.8 for women indicates an
increased risk of cardio-vascular
disease and diabetes mellitus

6. Classification of obesity
Body Mass Index (BMI)
The internationally accepted classification for
obesity is the Quetelet's Index, also called the Body
Mass Index (BMI)
The BMI is a measure of a person’s weight in
relation to height and it is calculated as:
weight divided by height squared (kg/m2)
BMI = weight in kilograms = kg/m2
square of height in meters

7. WHO classification of obesity
tion 1
Risk of co-
Classification BMI (kg/m2) morbidity
Underweight Less than 18.5
Normal 18.5 - 24.9 Not increased
Overweight or pre-obese 25.0 - 29.9 Increased
Obesity, further classified Increased as
as: ≥30.0 follows:
– Class I 30.0 - 34.9 – Moderate
– Class II 35.0 - 39.9 – Severe
– Class III ≥40.0 – Very severe
Source: Adapted from WHO 1997

8. Prevalence of Obesity
• The prevalence of obesity is increasing world wide
and is reaching epidemic proportions
• Majority of adults are becoming increasingly
overweight
• Approximately 20% of the adult world population is
overweight
• In postmenopausal women this prevalence is growing
most rapidly
• Postmenopausal women have an increased tendency
for gaining weight
• 44% of postmenopausal women are overweight,
among whom 23% are obese.

9. Prevalence of obesity - India
• Overweight – females – 47.5%
males - 32%
• Obese – females – 14%
males – 3%
• Abdominal adiposity – females – 35%
males – 49%
www.nutritionfoundationofindia.in

10. Measurement of obesity
Introduction 1
1. Measurements that are simple, cheap and appropriate for
routine use include:
• Waist circumference
• Hip circumference
• Waist-to-hip circumference ratio
• Body Mass Index (BMI)
• Skin fold thickness using callipers (e.g. triceps, scapular)
1. Measurements of body fat that are expensive and require
special equipment and highly trained personnel include:
• Underwater weighing
• Bioelectrical impedance
• Computerized topography

11. Postmenopausal women: higher prevalence of
obesity compared to premenopausal women

12. Menopausal changes in body
composition
• Increase weight
• Increase total body fat (%)
• Decrease lean body mass
• Increase abdominal adiposity
– Increase waist circumference
– Increase truncal fat (Dexa Scan)

13. Cause of obesity in postmenopausal
women
• Weight gain, during and after the menopause
is common
• Contributing factors
– Ethnicity
– Reduced physical activity
– Reduced lean mass
– Reduced resting metabolic rate (RMR) and
– Treatment with certain drugs e.g. steroids, insulin,
glitazones.
– Genetics

14. Slowing Metabolism
• Decreasing the number of calories a middle
age need for energy.
• The muscle mass decrease so less calories
needed.
• Muscle need more calorie than fat.

15. Overeating & Reduced Physical
Activities
• Increased appetite
• Eating more , cause increasing fat
• Less energy needed so less calorie food is
used and it all change to fat around the waist
• Hormonal imbalance make you tired
• Less tendencies to exercise.

16. Mechanisms of Menopause-
Related Increases in Adiposity
Menopause Preferential
abdominal fat Increased
Hormonal changes Accumulation abdominal and
of the menopause intraabdominal
transition Increased fat
adiposity
accumulation
Estrogen deficiency
Altered
energy
metabolism
Age
Life-style

17. Obese postmenopausal women differ from the
general postmenopausal women
1. Hot flushes and menopausal symptoms are more frequent
2. Increased risk of developin coronary heart disease
3. Stroke risk increase linearly with increasing BMI
4. Obesity is associated with increased risk of venous
thromboembolism
5. Obese postmenopausal women are at increased risk of
developing breast cancer (RR : 1.26 – 2.52)
Lambroinoudaki I et al., Maturitas 2010

18. Adverse effects of obesity in
Menopausal Women
• Cardiovascular disease
• Diabetes mellitus
• Arthritis
• Respiratory dysfunction
• Urinary incontinence
• Cancer (breast, endometrium, colon)
• Cognitive dysfunction / dementia
• Impaired quality of life
Han TS et al, BritishMedical Bulletin 2011;1-28

19. Cardiovascular impact of obesity in
postmenopausal women
• Blood pressure
• Lipids
• Metabolic syndrome / diabetes
• Inflammation
• Coronary artery disease
• Stroke
• Venous thromboembolism

20. Obesity is associated with features of
the metabolic syndrome (MS)
• Elevated BP (> 135 / 85 mmHg)
• increased central adiposity
• increased fasting blood glucose (>100mg/dL)
• low HDL-cholesterol (<50mg/dL)
• or elevated triglyceride levels (>150mg/dL)
MS is an independent risk factor for cardiovascular
disease in postmenopausal women
Lin JWet al, J Clin Endocrinol Metab 2010

21. Obesity and Diabetes Risk
100
80
Incidence of New
Cases per 1,000
60
Person-Years
40
20
0
<20 20-25 25-30 30-35 35-40 >40
BMI Levels
Knowler WC et al. Am J Epidemiol 1981

22. Obesity and Hypertension
60
50
Percentage
40
30
20
10
20 25 30 35 40
BMI
Relationship between BMI and crude percentage of women reporting
medical problems, surgical procedures, symptoms, and health care
utilization.
Brown WJ et al. Int J Obes 1998;22:520-528.

23. Obesity and Back Pain
35
30
Percentage
25
20
15
20 25 30 35 40
BMI
Relationship between BMI and crude percentage of women reporting
medical problems, surgical procedures, symptoms, and health care utilization.
Brown WJ et al. Int J Obes 1998;22:520-528.

25. Management of obesity in
menopausal women
• Effective management of obesity requires long-term
strategies and an integrated, multi-disciplinary approach
that includes community-based support for behavioural
modification including diet and exercise.
• Research over the last decade indicates that a 5-10%
reduction in body weight is sufficient to significantly
improve medical conditions associated with obesity
• As always, “prevention is better than cure”.
25

26. Management of obesity in
menopausal women
• Prevention is the Key
• Team work
• Individualized goal of wt loss
• Components:
– Education & motivation
– Diet modification
– Behavioural/lifestyle modifications
– Physical activity
– Medical treatment
– Surgical treatment 26

27. Guide to Selecting Treatment

28. Education & Motivation
• Public support for healthier lifestyles needs to
be initiated
• Teach early - why physical activity and healthy
eating are so important.
• Provide them with the knowledge and the
cognitive skills to manage energy balance in
the modern environment.

29. Dietary Modification
 Most common and conservative treatment -utilizes a
balanced, low calorie diet
 Diet must include more fruit and vegetables, nuts, whole
grains and exclude fatty and sugary foods
 weight-loss programs recommend diets consisting of 1,200
to 1,500 calories per day, usually in the following
proportions:
 60 percent carbohydrate
 30 percent fat
 10 percent protein
 The degree of weight loss being dependent on individuals
ability to adhere to dietary recommendations

30. Select bulky food with low caloric
density to produce sense of satiety
 Limit salt intake up to 6 g/day
• A diet high in natural sources of fiber 25-35 g
• Choose foods with lower glycemic index.
 Low fat diet- Low fat diary products-
 Vegetables and fruits everyday.

31. Ensure adequate protein intake to
avoid loss of muscle mass
Lean mass Body weight
preservation stabilization after
completion of the diet
program
Bopp et al., J. Am.Diet. Assoc. 2008

32. Balanced Diet Low in Saturated Fat
White rice, white bread,
Red meat and potatoes, pasta and
Butter sweets
Use Sparingly Use Sparingly
Dairy,
1 to 2 Servings
Multiple Vitamins, For
Multiple Vitamins, For Fish, poultry and eggs Alcohol in
Alcohol in
0 to 2 servings
Most
Most moderation
moderation
Nuts and Legumes Unless
Unless
1 to 3 servings Contraindicated
Contraindicated
Vegetables, In Abundance
Fruit, 2 to 3 Servings
Whole Grain Foods, At Most Meals
Plant Oils, At Most Meals
Daily exercise and weight control
From Willett WC, Stampfer MJ. Sci Am. 2003;288:64-71.

33. Behavioural/Lifestyle modifications
 Many eating and exercise habits combine to promote weight
gain.
 Keeping a food diary that records times, places, activities, and
emotions may be linked to periods of overeating or inactivity
will reveal areas needing modification
 Lifestyle modification is best achieved when the affected
individual is motivated, enthusiastic and supported to achieve
set goals
 Avoid eating while on their feet, watching TV or playing
games. Eat home cooked meals rather than fast foods
 Walk rather than use cars, escalators, lifts. Reduce TV hours,
and use of energy saving devices

34. Physical activity
Regular exercise is the
single best predictor for
achieving long-term
weight control
Exercise prevent weight
increase after completion
of the diet program
 Consensus:
 Minimum of 30 min/day
 At least 2.5 h/week

35. Physical activity
Independently of weight loss regular exercise
improves:
• Triglycerides
• LDL-c and HDL-c
• Waist girth
• Blood pressure
• Blood sugar levels in diabetics and
• Other obesity-related complications

36. Yoga and Weight Gain
• Yoga can prevent weight gain and
reduce unwanted fat diposition in middle
age.
• Yoga at least 30 minutes per day.

37. Medical Treatment
When do we prescribe medical treatment?
When patients are unable to achieve weight target
despite their best effort with diet and exercise

38. Pharmacotherapy
 Anti-obesity drugs be used only in individuals with a BMI>30kg/m2,
in whom at least 3 months of managed care (supervised diet,
exercise, and behaviour modification) fails to lead to significant
reduction in weight
• Orlistat
• Sibutramine
• Rimonabant
• Metformin ??
 Use of these drugs requires strict regular monitoring and must be
discontinued if weight loss is <5% after 12 weeks of use or weight
gain recurs while on the drugs
 Gradual reversal of weight loss is known to occur on stopping
pharmacotherapy

39. Pharmacotherapy
Orlistat:
•The only approved medical treatment of obesity
•Inhibits the absorption of fat from the intestine by inhibiting
pancreatic lipases
•Orlistat prevents the absorption of up to 30% of dietary fat
•Useful for those with a high intake of fat
•3-4% additional weight reduction
Sibutramine:
•Appetite suppression by blocking the re- uptake of
norepinephrine and serotonin in nerve terminals
• Should be avoided in those with hypertension, coronary
artery disease, congestive heart failure

40. Pharmacotherapy
Rimonabant:
• Endocannabinoid receptor antagonist
• Used as an adjunct to diet and exercise for the
treatment of obese patients (BMI 30 kg/m2)
• Rimonabant is contraindicated in patients on
antidepressants or with history of anxiety or depression
• Nausea, vomiting and mood disorders may limit its use

41. Pharmacotherapy
Metformin:
• Insulin sensitizer used in the treatment of overweight /
obese diabetics and PCOS women
• In these populations metformin use is associated with a
mild weight decreasing effect
•This is not sufficient to qualify as a primary treatment
for weight loss
• Metformin is not licensed for weight loss
•Should be used as an adjunct in type2 diabetic patients

42. Surgical Treatment
Bariatric surgery
 Surgery may be a weight-loss option for patients with a BMI
of ≥ 40 kg/m2 or those with BMI ≥ 35kg/m2 & having serious
medical complications.
 Two accepted surgical procedures :
 Gastroplasty
 Gastric bypass
 Both reduces the stomach to a small pouch that markedly
limits the amount of food consumption
 Studies show that there is weight loss of 25 to 30% over the
first year post operatively
 Longterm monitoring is needed and surgery is not without
attendant operative risks.