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 +=======Obesity Powerpoint=======
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 +{{:​obesity_presentation.pptx|}}
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 ====== Obesity ====== ====== Obesity ======
  
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 <box 50% round right |>​{{:​bmi_classification_final.png}}</​box|Figure 3: WHO standardized BMI categories in adults (Seidell & Halberstadt,​ 2015)> ​ <box 50% round right |>​{{:​bmi_classification_final.png}}</​box|Figure 3: WHO standardized BMI categories in adults (Seidell & Halberstadt,​ 2015)> ​
  
-Body Mass Index (BMI)is an index of weight-for-height that is commonly used to classify weight in adults (Figure 3).The BMI was created to estimate the individual’s level of body fat and therefore assesses an individual’s risk of disease.+Body Mass Index (BMI) is an index of weight-for-height that is commonly used to classify weight in adults (Figure 3).The BMI was created to estimate the individual’s level of body fat and therefore assesses an individual’s risk of disease.
  
 BMI is measured standardly as weight in kilograms divided by the square of the height in meters (Figure 4). The values of the BMI are age and sex dependent as body composition varies between sexes and at different ages. The values are then assessed by looking at a BMI table or chart.<​sup>​[3]</​sup>​ BMI is measured standardly as weight in kilograms divided by the square of the height in meters (Figure 4). The values of the BMI are age and sex dependent as body composition varies between sexes and at different ages. The values are then assessed by looking at a BMI table or chart.<​sup>​[3]</​sup>​
  
  
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 {{:​bmi_formula.png|}} {{:​bmi_formula.png|}}
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 Figure 4: BMI Calculation Equation ​ Figure 4: BMI Calculation Equation ​
 from http://​www.heartnewslinks.com/​editors-blog/​body-mass-index-bmi-bad from http://​www.heartnewslinks.com/​editors-blog/​body-mass-index-bmi-bad
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 ==== BMI in children ==== ==== BMI in children ====
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 Their BMI is referred to as BMI-for-age percentile, meaning the child’s BMI is compared with other children of the same sex and age who participated in national surveys that were conducted from 1963-65 to 1988-94.<​sup>​[4]</​sup>​ Their BMI is referred to as BMI-for-age percentile, meaning the child’s BMI is compared with other children of the same sex and age who participated in national surveys that were conducted from 1963-65 to 1988-94.<​sup>​[4]</​sup>​
  
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 {{:​weight_status_category.png|}} {{:​weight_status_category.png|}}
  
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 ==== BMI Limitations ==== ==== BMI Limitations ====
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 +
 === Variance in Asian Populations === === Variance in Asian Populations ===
  
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 The secretory activity of adipocytes plays a huge role in regards to hormonal and metabolic activity that takes place. Adipose cells are increased in size and number in obese conditions, which initiate an immune response. The fat cells release pro-inflammatory adipokines that recruit macrophages to the site. Following this, Tumour Necrosis Factor- alpha (TNF-α) is released and additional immune cells are brought to the site. This constant state of inflammation causes insulin resistance. This is why diabetes is often comorbid with obesity <​sup>​[17]</​sup>​. This sequence of events is depicted in Figure 7.  The secretory activity of adipocytes plays a huge role in regards to hormonal and metabolic activity that takes place. Adipose cells are increased in size and number in obese conditions, which initiate an immune response. The fat cells release pro-inflammatory adipokines that recruit macrophages to the site. Following this, Tumour Necrosis Factor- alpha (TNF-α) is released and additional immune cells are brought to the site. This constant state of inflammation causes insulin resistance. This is why diabetes is often comorbid with obesity <​sup>​[17]</​sup>​. This sequence of events is depicted in Figure 7. 
  
-<box 35% round left |>​{{:​adipose_finalllll.png|}}</​box|Figure 7:This figure is a visual depiction of the secretory pathway and function of adipokines in conditions where excessive adipocyte buildup occurs >+<box 35% round left |>​{{:​adipose_finalllll.png|}}</​box|Figure 7:This figure is a visual depiction of the secretory pathway and function of adipokines in conditions where excessive adipocyte buildup occurs ​from http://​www.the-scientist.com/​images/​December2012/​Obese_Infograph.jpg>
  
 When analyzing other inflammatory factors, it is evident that increased concentrations of the adipokine Interleukin-6 (IL-6) are positively correlated with increased fat mass and BMI. Furthermore,​ IL-6 is increases post-exercise with increased NEFAs, thus proposing a correlation between the adipokine and lipid mobilization <​sup>​[16]</​sup>​.Monophosphate activated protein kinase (AMPK) enables the oxidation of fatty acids during muscle contraction. AMPK is regulated by the hormone adiponectin,​ which induces insulin-sensitivity. In individuals who are obese, the concentration of adiponectin is reduced, as individuals with symptoms of diabetes are resistant to insulin <​sup>​[16]</​sup>​. ​ When analyzing other inflammatory factors, it is evident that increased concentrations of the adipokine Interleukin-6 (IL-6) are positively correlated with increased fat mass and BMI. Furthermore,​ IL-6 is increases post-exercise with increased NEFAs, thus proposing a correlation between the adipokine and lipid mobilization <​sup>​[16]</​sup>​.Monophosphate activated protein kinase (AMPK) enables the oxidation of fatty acids during muscle contraction. AMPK is regulated by the hormone adiponectin,​ which induces insulin-sensitivity. In individuals who are obese, the concentration of adiponectin is reduced, as individuals with symptoms of diabetes are resistant to insulin <​sup>​[16]</​sup>​. ​
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 The  gene map (Figure 9), includes all obesity-related genes and quantitative trait loci identified from the various lines of evidence reviewed in the paper. It is further explained and categorized into the 5 categories, where information pertaining to the mouse chromosome, mouse gene, human chromosome, human homolog, statistical analyses of variance, gene description,​ details pertaining to its role in obesity and more is provided. Areas of research pertaining to molecular genetics are expanding the scope of genetic predispositions involved in obesity <​sup>​[24]</​sup>​. ​ The  gene map (Figure 9), includes all obesity-related genes and quantitative trait loci identified from the various lines of evidence reviewed in the paper. It is further explained and categorized into the 5 categories, where information pertaining to the mouse chromosome, mouse gene, human chromosome, human homolog, statistical analyses of variance, gene description,​ details pertaining to its role in obesity and more is provided. Areas of research pertaining to molecular genetics are expanding the scope of genetic predispositions involved in obesity <​sup>​[24]</​sup>​. ​
  
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 {{:​genetics.gif}} {{:​genetics.gif}}
  
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 **Diet** **Diet**
  
-<​box ​28% round right |>​{{:​meal.png|}}</​box|Figure 10: Illustration of the ideal food plate including all food groups >+<​box ​25% round right |>​{{:​meal.png|}}</​box|Figure 10: Illustration of the ideal food plate including all food groups ​from http://​www.arthritis.org/​images/​slideshows/​ra-diet/​ra-diet-13-fill-your-plate.jpg  
 +>
 The first component of lifestyle modifications to treating obesity is undergoing dietary therapy (Figure 10). When assessing diet management in obese patients, weight reduction is highly dependent upon energy intake in comparison to energy expenditure <​sup>​[27]</​sup>​. ​ The first component of lifestyle modifications to treating obesity is undergoing dietary therapy (Figure 10). When assessing diet management in obese patients, weight reduction is highly dependent upon energy intake in comparison to energy expenditure <​sup>​[27]</​sup>​. ​
  
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 The purpose of the CBT treatment is not to eliminate a psychiatric disorder but to change eating and exercise behaviours <​sup>​[36]</​sup>​. This intervention aims to educate individuals on how to change problematic behaviours. Firstly, CBT is based on the cognitive conceptualization of the processes that lead to overeating. Specifically,​ thoughts and thinking patterns that are considered central to the problem. Secondly, CBT is focused on altering the cognitive and behavioural mechanisms that maintain the problem behaviour. Lastly, CBT uses both cognitive and behavioural techniques to maintain healthy mechanisms <​sup>​[37]</​sup>​. The diagram here shows different components that contribute to CBT.  The purpose of the CBT treatment is not to eliminate a psychiatric disorder but to change eating and exercise behaviours <​sup>​[36]</​sup>​. This intervention aims to educate individuals on how to change problematic behaviours. Firstly, CBT is based on the cognitive conceptualization of the processes that lead to overeating. Specifically,​ thoughts and thinking patterns that are considered central to the problem. Secondly, CBT is focused on altering the cognitive and behavioural mechanisms that maintain the problem behaviour. Lastly, CBT uses both cognitive and behavioural techniques to maintain healthy mechanisms <​sup>​[37]</​sup>​. The diagram here shows different components that contribute to CBT. 
  
-Counseling ​is one way a patient can undergo CBT. It can either be delivered on a one-on-one basis, or in a group setting of approximately 10 participants with a trained healthcare professional <​sup>​[38,​39]</​sup>​. A study conducted by Renjilian and colleagues comparing the two treatment modalities concluded that participants who were randomized to receive group-based therapy lost more weight after 26 weekly sessions compared to those who were treated individually. Specifically,​ those receiving group therapy lost about 11 kg after 26 weekly sessions, in comparison to 9 kg for those who were individually treated <​sup>​[40]</​sup>​. ​+Counselling ​is one way a patient can undergo CBT. It can either be delivered on a one-on-one basis, or in a group setting of approximately 10 participants with a trained healthcare professional <​sup>​[38,​39]</​sup>​. A study conducted by Renjilian and colleagues comparing the two treatment modalities concluded that participants who were randomized to receive group-based therapy lost more weight after 26 weekly sessions compared to those who were treated individually. Specifically,​ those receiving group therapy lost about 11 kg after 26 weekly sessions, in comparison to 9 kg for those who were individually treated <​sup>​[40]</​sup>​. ​
  
-In addition to counseling, having a support network is important. This is  especially true if the individual is undergoing drastic changes. Receiving encouragement from family, friends and health care practitioners can be very motivating during challenging times of the weight loss and maintenance programs. Furthermore,​ patients can also join support groups with other people undergoing weight loss <​sup>​[25]</​sup>​. ​+In addition to counselling, having a support network is important. This is  especially true if the individual is undergoing drastic changes. Receiving encouragement from family, friends and health care practitioners can be very motivating during challenging times of the weight loss and maintenance programs. Furthermore,​ patients can also join support groups with other people undergoing weight loss <​sup>​[25]</​sup>​. ​
  
 Family-based obesity treatment has also been proven to be a very effective and sustainable approach, especially when treating pediatric obesity. The role of this treatment is to target eating and activity change in both child and parent. Programs using this approach teach parents behavioural skills to facilitate child behaviour change and utilize family resources to improve the efficacy of childhood obesity treatments. Simultaneously treating the child and parent helps create positive relationships between them as they both aim to reach their weight loss goal together <​sup>​[41,​42]</​sup>​. ​ Family-based obesity treatment has also been proven to be a very effective and sustainable approach, especially when treating pediatric obesity. The role of this treatment is to target eating and activity change in both child and parent. Programs using this approach teach parents behavioural skills to facilitate child behaviour change and utilize family resources to improve the efficacy of childhood obesity treatments. Simultaneously treating the child and parent helps create positive relationships between them as they both aim to reach their weight loss goal together <​sup>​[41,​42]</​sup>​. ​
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 The Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that in addition to lifestyle modifications such as dietary changes, physical activity and behaviour therapy, overweight ​ individuals with BMIs greater than 27 kg/m^2 but with life threatening diseases, or obese individuals with BMIs greater than 30 kg/m^2 can undergo pharmacotherapy <​sup>​[2]</​sup>​. ​ The Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that in addition to lifestyle modifications such as dietary changes, physical activity and behaviour therapy, overweight ​ individuals with BMIs greater than 27 kg/m^2 but with life threatening diseases, or obese individuals with BMIs greater than 30 kg/m^2 can undergo pharmacotherapy <​sup>​[2]</​sup>​. ​
- 
-A meta analysis investigated 21 randomized control trials (RCT) that involved a total of 11 533 participants using either one of the two drugs: orlistat or sibutramine,​ or a placebo. These RCTs had a follow-up period of at least 1 year in obese and overweight adults. ​ 
  
 <box 35% round right |>​{{:​orlistat.jpg|}}</​box|Figure 12: Orlistat, one of the pharmacological treatments for obesity <box 35% round right |>​{{:​orlistat.jpg|}}</​box|Figure 12: Orlistat, one of the pharmacological treatments for obesity
 from https://​www.medexpress.co.uk/​javax.faces.resource/​treatments/​335x335xorlistat-120mg-pills.jpg.xhtml,​qln=img.pagespeed.ic.3lJxOPoYEm.jpg>​ from https://​www.medexpress.co.uk/​javax.faces.resource/​treatments/​335x335xorlistat-120mg-pills.jpg.xhtml,​qln=img.pagespeed.ic.3lJxOPoYEm.jpg>​
 +
 +A meta analysis investigated 21 randomized control trials (RCT) that involved a total of 11 533 participants using either one of the two drugs: orlistat or sibutramine,​ or a placebo. These RCTs had a follow-up period of at least 1 year in obese and overweight adults. ​
 +
  
 Olistat functions as a gastrointestinal lipase inhibitor and reduces fat absorption by approximately 30% (Figure 12). Patients can use it for up to two years <​sup>​[43]</​sup>​. On the other hand, sibutramine functions as a serotonin and noradrenaline reuptake inhibitor which induces weight loss through enhanced satiety and increased basal energy expenditure. Sibutramine is approved for clinical use for up to 1 year <​sup>​[44]</​sup>​. ​ Olistat functions as a gastrointestinal lipase inhibitor and reduces fat absorption by approximately 30% (Figure 12). Patients can use it for up to two years <​sup>​[43]</​sup>​. On the other hand, sibutramine functions as a serotonin and noradrenaline reuptake inhibitor which induces weight loss through enhanced satiety and increased basal energy expenditure. Sibutramine is approved for clinical use for up to 1 year <​sup>​[44]</​sup>​. ​
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 **Maintenance of weight loss** **Maintenance of weight loss**
 +
    
 Studies that assessed orlistat therapy for at least 2 years and up to 5 years showed that weight loss attained by year 1 was better maintained over the subsequent 3 years in patients who received ongoing drug therapy. Specifically,​ Davidson et al. showed that patients who had ongoing treatment of orlistat for 2 years were associated with less regain of weight loss (32%) compared with diet only therapy (63%) <​sup>​[45]</​sup>​. ​ Studies that assessed orlistat therapy for at least 2 years and up to 5 years showed that weight loss attained by year 1 was better maintained over the subsequent 3 years in patients who received ongoing drug therapy. Specifically,​ Davidson et al. showed that patients who had ongoing treatment of orlistat for 2 years were associated with less regain of weight loss (32%) compared with diet only therapy (63%) <​sup>​[45]</​sup>​. ​
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 **Bariatric Surgery** **Bariatric Surgery**
  
-<box 30% round left |>​{{:​surgical_procedures.png|}}</​box|Figure 13:  Four highly used surgical procedures used to treating obesity >+<box 30% round right |>​{{:​surgical_procedures.png|}}</​box|Figure 13:  Four highly used surgical procedures used to treating obesity ​from http://​www.cmaj.ca/​content/​suppl/​2007/​09/​04/​176.8.S1.DC1/​obesity-lau-onlineNEW.pdf> 
 Bariatric surgery is a treatment method that is considered for adult patients who have a BMI over 35kg/m^2 with severe comorbid diseases such as life-threatening cardiopulmonary problems, severe sleep apnea, or severe diabetes mellitus, or for those in the severely obese category with a BMI greater than 40 kg/m2. For teenagers, the Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that bariatric surgery be limited to an appropriately trained and experienced surgical team. After 6 months of using lifestyle modifications,​ healthcare practitioners assess the health of the patient and evaluate whether a satisfactory progress of weight loss or goal of 10% of body weight has been reached. In the case that satisfactory progress or goal has not been achieved, physicians will consider the eligibility of patients to undergo bariatric surgery. This is only considered if other nonsurgical weight loss attempts have failed. The goal of bariatric surgery is to relieve a patient suffering from obesity from his or her morbid body weight, improve their comorbidity and improve their quality of life. There are different surgical procedures (Figure 13). It is important to note that this treatment option requires lifelong medical surveillance <​sup>​[26]</​sup>​. ​ Bariatric surgery is a treatment method that is considered for adult patients who have a BMI over 35kg/m^2 with severe comorbid diseases such as life-threatening cardiopulmonary problems, severe sleep apnea, or severe diabetes mellitus, or for those in the severely obese category with a BMI greater than 40 kg/m2. For teenagers, the Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that bariatric surgery be limited to an appropriately trained and experienced surgical team. After 6 months of using lifestyle modifications,​ healthcare practitioners assess the health of the patient and evaluate whether a satisfactory progress of weight loss or goal of 10% of body weight has been reached. In the case that satisfactory progress or goal has not been achieved, physicians will consider the eligibility of patients to undergo bariatric surgery. This is only considered if other nonsurgical weight loss attempts have failed. The goal of bariatric surgery is to relieve a patient suffering from obesity from his or her morbid body weight, improve their comorbidity and improve their quality of life. There are different surgical procedures (Figure 13). It is important to note that this treatment option requires lifelong medical surveillance <​sup>​[26]</​sup>​. ​
  
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 As seen in figure 14, there are different approaches to treating obesity. First, it is important to set a weight loss goal to reduce body weight by approximately 10% from baseline during the first six months of treatment. Healthcare practitioners typically recommend their patients to first undergo lifestyle modifications:​ proper nutrition, physical fitness, and cognitive behaviour therapy. After six months of treatment, healthcare practitioners will assess the patient’s progress and determine whether satisfactory progress or weight loss goal has been reached. In the case that it has been reached, the patient would be closely monitored on a regular basis to make sure that their weight is maintained. In the event that satisfactory progress is not attained, physicians will assess the patient’s eligibility to either undergo pharmacotherapy or bariatric surgery. Physicians typically opt for bariatric treatment in the event that nonsurgical treatments have failed. It is important to note that best weight loss and maintenance results are achieved when pharmacotherapy or bariatric treatment is used in conjunction with lifestyle modifications. ​ As seen in figure 14, there are different approaches to treating obesity. First, it is important to set a weight loss goal to reduce body weight by approximately 10% from baseline during the first six months of treatment. Healthcare practitioners typically recommend their patients to first undergo lifestyle modifications:​ proper nutrition, physical fitness, and cognitive behaviour therapy. After six months of treatment, healthcare practitioners will assess the patient’s progress and determine whether satisfactory progress or weight loss goal has been reached. In the case that it has been reached, the patient would be closely monitored on a regular basis to make sure that their weight is maintained. In the event that satisfactory progress is not attained, physicians will assess the patient’s eligibility to either undergo pharmacotherapy or bariatric surgery. Physicians typically opt for bariatric treatment in the event that nonsurgical treatments have failed. It is important to note that best weight loss and maintenance results are achieved when pharmacotherapy or bariatric treatment is used in conjunction with lifestyle modifications. ​
  
-<style float-right>​ +{{:flowchart_final.png|}}
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 Figure 14: A holistic approach to treating obesity. Figure 14: A holistic approach to treating obesity.
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 ===== References ===== ===== References =====
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 1.      Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., & Margono, C. et al. (2014). Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013:​ a systematic analysis for the Global Burden of Disease Study 2013.The Lancet, 384(9945), 766-781. http://​dx.doi.org/​10.1016/​s0140-6736(14)60460-8 1.      Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., & Margono, C. et al. (2014). Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013:​ a systematic analysis for the Global Burden of Disease Study 2013.The Lancet, 384(9945), 766-781. http://​dx.doi.org/​10.1016/​s0140-6736(14)60460-8
-2.  Seidell, J. & Halberstadt,​ J. (2015). The Global Burden + 
-of Obesity and the Challenges of Prevention. Annals Of Nutrition And Metabolism, 66(2), 7-12. http://​dx.doi.org/​10.1159/​000375143+2.  Seidell, J. & Halberstadt,​ J. (2015). The Global Burden of Obesity and the Challenges of Prevention. Annals Of Nutrition And Metabolism, 66(2), 7-12. http://​dx.doi.org/​10.1159/​000375143 
 3.      WHO: Global Database on Body Mass Index. (2017). Apps.who.int. Retrieved 1 February 2017, from http://​apps.who.int/​bmi/​index.jsp?​introPage=intro_3.html 3.      WHO: Global Database on Body Mass Index. (2017). Apps.who.int. Retrieved 1 February 2017, from http://​apps.who.int/​bmi/​index.jsp?​introPage=intro_3.html
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 4.      Child & Teen BMI | Healthy Weight | CDC. (2017). Centers for Disease Control and Prevention. Retrieved 1 February 2017, from https://​www.cdc.gov/​healthyweight/​assessing/​bmi/​childrens_bmi/​about_childrens_bmi.html 4.      Child & Teen BMI | Healthy Weight | CDC. (2017). Centers for Disease Control and Prevention. Retrieved 1 February 2017, from https://​www.cdc.gov/​healthyweight/​assessing/​bmi/​childrens_bmi/​about_childrens_bmi.html
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 10.  Weaver, J. (2008). Classical Endocrine Diseases Causing Obesity. Obesity And Metabolism, 212-228. http://​dx.doi.org/​10.1159/​000115367 10.  Weaver, J. (2008). Classical Endocrine Diseases Causing Obesity. Obesity And Metabolism, 212-228. http://​dx.doi.org/​10.1159/​000115367
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-15.   Why Is Sleep Important? - NHLBI, NIH. (2017). National Heart, Lung and Blood Institute. + 
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