The document discusses obesity, including its definition, prevalence, health risks, and approaches to management. It defines obesity as a BMI of 30 kg/m2 or higher. Treatment involves lifestyle changes like diet and exercise, as well as potential pharmacotherapy or bariatric surgery. Behavioral interventions focus on self-monitoring, stimulus control, and nutrition counseling. Approved prescription medications include orlistat, lorcaserin, and phentermine-topiramate, but all have potential side effects. Bariatric surgery may be considered for those with a BMI over 40 or over 35 with comorbidities.

1. พญสุภลักษณ์ ตันติทวีโชค 52226

2. Introduction
 prevalence of obesity > 30% in adults
 associated with increased risk
 cardiovascular disease
 type 2 diabetes
 cancer (i.e., liver, kidney, breast, endometrial, prostate,
and colon).
 Overweight and obesity are chronic diseases with
behavioral origins

4. Definition
 Body mass index (BMI)
 Overweight = BMI range: 25 - 29 kg/m2,
 Obesity = BMI ≥ 30 kg/m2.
Body mass index (BMI)= weight(kg)
height(m2)

6.  BMI correlates with the amount of body fat
 BMI ≠ directly measure body fat
The National Heart, Lung and Blood Institute (NHLBI)
Waist Circumference

7. The NHLBI defines abdominal obesity as:
Waist circumference
Men > 40 inch (102 cm)
Women > 35 inch (88 cm)
Measure at a level parallel to the floor
midpoint between the top of the iliac crest and the lower margin
of the last palpable rib in the mid axillary line.

10. Approach to Management
significant weight loss = 5-10%total body weight
 Behavioral Treatment
 Pharmacotherapy
 Bariatric Surgery

12. Behavioral Treatment
The goal is
 enable patients to monitoring and modifying their food
intake
 increasing their physical activity
 recognizing and controlling cues that trigger overeating
Behavioral interventions in conjunction with
dietary or drug therapy are more effective than routine
care alone

13.  The United States Preventive Services Task Force(
USPSTF) developed the stepwise framework known as
the 5 A’s
5 A’s
• Ask
• Advise
• Assess
• Assist
• Arrange

14. The 5 A’s for Evaluation and Treatment of Obesity
Assess
• Severity of obesity
 BMI
 waist circumference
 Comorbidities
• Food intake and physical activity
• Medications that affect weight or satiety
• Readiness to change behavior

16. Advise
 Diagnosis of overweight, obese, or severe obesity
 Caloric deficit needed for weight loss
 Various types of diets
 Appropriateness, cost, and effectiveness of
 meal replacements
 dietary supplements
 over-the-counter weight aids
 medications
 surgery
 Importance of self-monitoring

17. Agree
 patient is not ready
discuss at another visit
 patient is motivated and ready to change
 develop treatment plan
 set weight-loss goal at 10% from baseline
 patient can do surgery review options

18. Assist
 diet plan, physical activity guide, behaviormodification
guide
 Web resources based on patient interest or need
 method for self-monitoring (e.g., diary)
 Review food and activity diary on follow-up (reassess if
initial goal is not met)

19. Arrange
 Follow-up appointments to meet patient
needs
 Referral to registered dietitian and/or
behavioral specialist
 Referral to surgical program
 Maintenance counseling to prevent relapse or
weight regain
*helpful for patients who are ready to change

20. Motivational interviewing
 for patients who are ambivalent or hesitant about
making lifestyle changes.
 physicians ask questions that lead patients to identify
healthy choices that they want to make
 gives them an opportunity for self-examination that
may lead to the realization that they can do more to
improve their health

22. Self-Monitoring
 improved outcomes
 a key element in any successful behavioral weight-loss
program

24. Stimulus Control
help long-term maintenance.
Examples
-eating only at the dining table
-not eating while watching television
-not keeping snack foods at home;

25. Nutrition Counseling
 dietary recommendations such as
 controlling portion sizes
 increasing fruit and vegetable
 decreasing saturated fat.
 reducedcalorie diet can result in meaningful weight
loss

26.  National Heart, Lung and Blood Institute guidelines
suggest reduce caloric intake
Reduce
500 - 1,000
kcal/day
weight loss 1-2 lb
(0.45 to 0.90 kg)
/week.

27. Physical Activity
 Physicians should routinely recommend regular
physical activity to all patients, not only to those who
are overweight or obese
 The 2008 Physical Activity Guidelines for Americans
recommend
 ≥ 150 minutes of moderate-intensity aerobic activity per
week or
 ≥ 75 minutes of vigorous-intensity aerobic activity per
week
 Aerobic activity should ≥10 minutes per session and
should be spread throughout the week

28.  adults should increase their aerobic physical activity to
300 minutes of moderate-intensity or 150 minutes of
vigorous-intensity aerobic activity per week.
 Adults should also engage in muscle-strengthening
activities of moderate to high intensity that involve all
major muscle groups on two or more days per week.

29. Pharmacotherapy Prescription anti-obesity drugs can be useful adjuncts
to diet and exercise
 for obese adults who have failed to achieve weight loss
with diet and exercise.

30.  Prescription weight-loss drugs are approved for
patients who meet the following criteria:
• BMI of 30 kg/m2 or greater
• BMI of 27 kg/m2 or greater
+ an obesity-related condition
 hypertension
 type 2 diabetes
 dyslipidemia

32. Three prescription medications are currently approved
for longterm management of obesity:
 orlistat (Xenical)
 lorcaserin (Belviq)
 combination phentermine-topiramate extended release
(Qsymia).

35. Orlistat(xenical)
 was approved by the Food and Drug Administration
(FDA) in 1999.

36.  The effectiveness of orlistat has been demonstrated in several
randomized trials
 orlistat plus behavioral interventions lost 8% of baseline weight
compared with 5% in the control group after 12 to 18 months
(Bray GA. Drug therapy of obesity. www.UpToDate.com. Accessed
Jan. 15, 2013.)
 orlistat resulted in a weight loss of 6.6 lb (3 kg) more than placebo
(LeBlanc ES, O’Connor E, Whitlock EP,et al. Effectiveness of
primary care-relevant treatments for obesity in adults: A systematic
evidence review for the U.S. Preventive Services Task Force. Ann
Intern Med. 2011;15(7)5:434-447.)
 Orlistat also has beneficial effects on blood pressure, insulin
resistance, and lipid levels
(Carter R, Mouralidarane A, Ray S, et al. Recent advancements in
drug treatment of obesity. Clin Med. 2012; 12(5):456-460)

37. Mechanism:
Orlistat inactivates gastric
and pancreatic lipases
30% reducing the
absorption of fat

39.  The adverse effects of orlistat
 diarrhea,
 abdominal cramping
 fecal incontinence
 oily spotting
 rare reports of severe liver injury

40. Lorcaserin(belviq)
 a selective serotonin(5-hydroxytryptamine, or 5-
HT)subtype 2C receptor agonist
 reducing appetite and promoting satiety
 The FDA approved lorcaserin in 2012

42.  Lorcaserin’s safety and effectiveness were evaluated in
three randomized, placebo-controlled, double-blind
studies that were the basis for FDA approval.
 These trials included more than 6,000 patients and
lasted at least one year.
 The average weight loss with lorcaserin ranged from 3%
- 3.7% over placebo
 47% of participants lost at least 5% of their body weight,
compared with 23% for placebo
•Response to lorcaserin should be assessed at 12
weeks

43. Adverse effect
 fewer adverse effects than orlistat
 The most common adverse effects with lorcaserin
include headache, dizziness, fatigue, nausea, dry
mouth, and constipation

44.  Nonselective serotonergic agonists
increased risk of serotonin-associated cardiac valvular
disease
 fenfluramine
 dexfenfluramine
 Theoretically, lorcaserin should not have the same
cardiac effects .it is a selective agonist of serotonin
receptor 2C. However, there are currently few long-
term safety data

45. https://www.jci.org/articles/view/70678/figure/1

46. Serotonin Mechanisms in Heart Valve Disease
 Serotonin up-regulate transforming growth factor
(TGF)-β in mesangial cells via G-protein signal
transduction.
 characterized by
 hyperplastic valvular
 endocardial lesions

47. A, Thickened and retracted aortic
cusp (bold arrow) and deposits of
collagen tissue at base of cusp (thin
arrow) in a rat given serotonin
B, Aortic valve in control rat
C, Shortened, thickened, and
collagen-rich cusp in serotonin-
treated rat with aortic valve
insufficiency
http://circ.ahajournals.org/content/111/12/1517/F4.expansion.html

48. Phentermine-Topiramate
ER(qsymia)
 Phentermine is an appetite suppressant
 topiramate is an anticonvulsant act as an appetite
suppressant

49.  two large randomized, double-blind, placebo-
controlled trials.
(U.S. Food and Drug Administration. FDA approves weight-
management drug Qsymia.
www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/uc
m312468.htm. Accessed Feb. 14, 2013.)
 These trials included 3,700 patients treated for up to one
year.
 The average weight loss in patients taking phentermine-
topiramate ER ranged
from 6.7% (lowest dose) to 8.9% (recommended dose)
over placebo.

50.  62%of patients taking the lowest dose and 70% taking the
recommended dose lost at least 5% of their body weight,
compared with 20% of patients receiving placeb
 slightly more effective than orlistat and lorcaserin.
 effect on heart rate limit its use in patients with
cardiovascular disease.

51. adverse effects
 The most common adverse effects with phentermine-
topiramate ER include paraesthesia, dizziness,
dysgeusia, insomnia, constipation, and dry mouth
 should be discontinued gradually because abrupt
cessation of topiramate has been associated with
seizures in some patients

52. Sympathomimetics
 4 sympathomimetic agents are currently approved for
short-term use as weight-loss adjuncts:
 phentermine
 diethylpropion
 benzphetamine
 phendimetrazine.

56.  causing early satiety
 evidence is lacking about the long-term risks and
benefits
 These agents are contraindicated in patients with
coronary heart disease, hypertension, hyperthyroidism

57. Bariatric Surgery
 considered in adults who have not achieved weight
loss with dietary or other treatments
 who have a BMI ≥ 40 kg/m2 or
BMI ≥ 35 kg/m2
+ obesity-related comorbidities
-hypertension
- type 2 diabetes
- obstructive sleep apnea)

58. Bariatric Surgery categorized
 Restrictive procedures
limit the size of the stomach.
 laparoscopic adjustable gastric banding
 vertical sleeve gastrectomy
 Malabsorptive procedures
restrict the size of the stomach and involve bypassing
a portion of the small intestine.
 Roux-en-Y gastric bypass

60.  Sustained changes in diet and exercise habits are
essential following bariatric surgery

62. reference
 Copyright © 2013 American Academy of Family Physicians 11400
Tomahawk Creek Parkway Leawood, KS 66211 www.aafp.org
 http://www.asean-
endocrinejournal.org/index.php/JAFES/article/view/80/381
 http://asean-
endocrinejournal.org/index.php/JAFES/article/view/78/379
 http://gucdv1wwi8pslzdfpv7t0dk6.wpengine.netdna-
cdn.com/wp-content/uploads/2015/12/2015-OMTF-European-
Guidelines-for-Obesity-Management.pdf
 https://www.jci.org/articles/view/70678
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1850922/

63. Thank you