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Obesity Associated Comorbidities

Mar 15 | 2:30 PM

Obesity is defined as abnormal or excessive fat accumulation that presents a risk to health. The evidence is overwhelming on the association of obesity to a number of medical conditions. These include: insulin resistance, glucose intolerance, diabetes mellitus, hypertension, dyslipidemia, sleep apnea, arthritis, hyperuricemia, gall bladder disease, and certain types of cancer. The independent association of obesity seems also clearly established for coronary artery disease, heart failure, cardiac arrhythmia, stroke, and menstrual irregularities. Join us live on Medflix as Dr. Poonam, a renowned Bariatric physician, Director and Founder of Laparo - Obeso Centre , gives us an informative overview to all the frequently seen risk factors.

[Music] very good evening to all of you netflix welcomes you all today uh we are here to discuss a very more important topic obesity and its associated co-morbidities i doctor simran kalman md general medicine currently working in patiala as a consulting physician today we all have gathered here to discuss on a very important topic which at present has become an alarming situation in the world as we all know obesity is a complex condition which threatens almost all age groups being in a medical profession we see hundreds of patients suffering from obesity but they are not aware of its co-morbidities so today we have our expert none other than ma'am dr poonam shah welcome you ma'am she's a founder and director she's the founder and director of la probeso center in pune mam is first bridetrick physician in india and she has more than eight years of experience with thousands of patients of obesity associated comorbidities she also has experience of more than five years as an intensivist which gives her an additional edge over others in treating various challenges of obese patients mam has been invited as a speaker in various national and international conferences she has established first support group in india known as obiso sport group now popularly known as dream slim club she also has published many research papers in many national and international journals we welcome you ma'am with this i would request dr poonam to guide us with her knowledge also over to you ma'am thank you dr for this introduction and i'm just not letting you hand over all this and this team for this opportunity to share my experience as a as obesity or a bariatric physician so without wasting any more time let me start it's a very extensive topic and um it's very difficult to cover in such a short time but let's see the who has uh defined overweight and obesity as abnormal or excessive fat accumulation that presents a risk to help so basically it is not about excess weight but excess fat percentage is something that we should remember i would like to define obesity with multiple adjectives like it is long lifelong progressive life threatening it is costly it is genetically related is multifactorial it is multi-organ is a very complex physiological disease of excess fat storage leading to multiple commodities the most important thing to remember to understand obesity that it is a very low grade inflammatory disorders which is the basic problem which gives rise to obesity so obesity as you know the word comes from the latin word obesitas which means plump or fat and the ob or the over which also means there is to eat so basically to start with only it has been assumed that obesity is something due to overeating but in 192013 it is the american medical association has ultimately classified obesity as a disease so it is not just a lifestyle disorder as it was once believed even by clinicians because as a resident i don't remember treating a patient only for obesity usually would treat him for the various metabolic disorders but never obesity as the diagnosis so even in 2014 the whs statuses said 600 million adults and 42 million children under the age of five for obese women much more than men and in india at that time 12 percent males and 16 females were obese with females much more than the males now um in on 4th of march uh 2022 the world obesity day uh who says that the worldwide obesity has nearly tripled since 1975 which is like you know just about 35 years of um uh mankind that you know so there's so much change has uh come in this and more than one billion people worldwide are obese about six fifty million adults three forty million adolescents and 39 million children are obese which is like alarming statistics the wh estimates it by 2025 which is just about three years from now 167 million people adults and children will become less healthy because they are overweight or obese coming to india the prevalence of obesity as um by a study done by venkatrav just a year ago uh the prevalence is 40.3 percent there are zonal verifications where south has the highest prevalence and east has the lowest it is higher among women more in urban people more in people who are more than 40 more in those who are educated versus the uneducated and most important it is more in those with lower physical activity than those who are vigorously active so it is one of the most serious public health problem but it is also a preventable cause of death and that is what we should remember as uh clinician so obesity is an inflammatory disease and the fat is an endocrine organ now over last so many years we all know this that the visceral adipose tissue secretes various cytokines like resistant free fatty acids the tumor necrosis factor which stimulates the uh highly sensitive c reactive protein the interleukin 6 these limit the action of the good hormone which is adiponectin which actually decreases the atherosclerosis so uh limiting action of this hormone will increase the atherogenous will decrease the insulin sensitivity this gives rise to increase in the insulin resistance increase in the insulin increase in the blood sugars the interest in the lipids itself gives rise to oxidative stress endothelial dysfunction and then what we see is various cardiovascular and other metabolic problems so this has been represented in this slide which i've taken for the from the net on the on my left is the the yellow adipose tissue with all the adipo the kinds and angiotensin and cytokines which are secreted on the right hand side is is the end result hyperglycemia dyslipidemia hyperuricemia and hypertension so obesity is multifactors that's why there is no one specific thing which will treat obesity there can be a genetic predisposition there are behavioral factors and there are also various environmental environmental factors so there are genetics like chromosomal abnormalities medical conditions like various endocrine disorders there are various drugs and basically the lifestyle of low physical activity and a diet which is high calorie high fat high sugar and high volume so a mixture of all this can give rise to obesity so it is caused by basically a long term positive energy balance where the energy expenditure is less than the energy intake whatever the basic problem is selected medications which we use in our clinics the diabetic medications like um insulin sulfur and urease the higher solution ions than the um drugs for hiv the retroviral therapy tamoxifen which is used by the c given to the cf dispersions the steadied hormones like glucocorticoids progesterones the various psychotropic medications like site and tricyclical antidepressants and then some anti-convergence beta general so the various drugs which we've taken over long period of time with additional genetic predisposition and all other factors can also give rise to obesity which does not respond very easily diseases associated with weight gain which we see is hypothyroidism pushing syndrome the policy store in disease insulinomas genetic symptoms hypothalamic disorders as well as depression with emotional eating so this is just one example of super super obesity or morbid obesity a childhood obese investigated no cause found and by the by the time she was 35 she was totally bedded in cooling stand couldn't move she had gone up to 300 kgs but what is important is to remember that obesity can be treated even super super obesity undergoing a procedure in three months time she was 183 then a second step of the procedure and now she has maintained herself at 85 to 95 kgs metabolic improvement and most important is improvement in the quality of life so obesity is treatable and that is what we should be able to tell our patient that it is disease and it is treatable various environmental and behavior factors which we all know is about the the fast food culture the high fat high sugar high sodium options which are daily available then the wrong eating habits and the adolescent periods especially and most important thing to tell our patients is sugar is a bigger enemy than the fat itself because these drinks which have high sugar content are consumed by millions of people daily and fruits are no longer eaten they are consumed in a form where there are there is lots of sugar and of course tb time when we measure open the obesity in the opinions we should remember it is we do the body mass index the waist hip ratio the waist circumference then at sometimes we do the exam or we do a ct scan and mri but the most important measurement is a measurement of the body fat percentage in our asian settings and will come to that why do we measure the bmi which is the weight in cages divided by the height in meter square it is because as the bmi goes on increasing the mortality goes on increasing that's why it is important to measure the bmi also so why has classified obesity according to the bmi as underweight less than 18.5 normal rate between 18.5 to 24.9 overweight between 25 to 29.9 that is 5 units of bmi and then about 30 is obesity grade 1 two and three so bmi above 40 is morbid obesity and the classification of obesity according to the body fat is a body fat of 25 percent in men or 30 percent in women is said to be always this method used in japan is also applicable to india the classification according to the shape is the apple which is entered over city and the pair which is ganecoid obesity and if you see this in the in the apple obesity the central obesity is much more and therefore the waist tip ratio is more than one this is more commonly seen in men and in females it is usually the fat around the buttocks and the thighs and that is the peer-shaped obesity so even by looking at the patient you can understand who is more prone to have metabolic problems so it is the apple ship which is more dangerous to have so taking all this into consideration you can see that measurement of obesity for asians and indians has been changed since 2009 normal vmi 18 to 22.9 overweight is just two units of bmi 23 to 24.9 and any one above with a bmi more than 25 kgs per meter square is said to be obese now why is this this is a very uh very popular image which was published in 2004 in the lancet um majority of you may be knowing the person on my right is dr yajnik who's the leading most very senior debitologist of india and that is the other person is his friend from uk their bmis are saying 22.3 but we see the body fat percent it is 9.1 versus 21.2 and this is because asian indians have increased genetic susceptibility to deposit visible fat which is metabolically active and strongly related to insulin resistance and that's why the bmi cutoffs are much lower because we have genetically more fat and less muscle mass at lower bmis so another reason um why even the waste circumference more than 90 in men and more than 80 in asian women is used for diagnosis uh in the clinical setting and not 102 and 88 as it is done internationally so all this gives rise to various comorbidities which are associated with obesity right from head to toe but if you see on the on my left i've written all this it gives rise to a poor quality of life this is something as clinician you have to pay attention to and on my right you can see that various nutritional deficiencies so all these co-morbidities are associated with various nutrition deficiencies also so let us go one by one let us um at least make a list of the co-morbidities of obesity like you know basically is associated with these things so one is from head to toe if we go it is the um idiopathic intracranial hypertension depression psychological problems decrease self-esteem negative body image obstructive sleep apnea obesity hyperventilation syndrome cardiovascular disease non-alcoholic liver disease the gastroesophageal reflux gallbladder stones hypertension insulin resistance diabetes type 2 metabolic syndrome the urinary stress incontinence and polycystic organ disease seen in females the hypogonadism cancers of the uterus prostate colon etc osteoarthritis of the weight-bearing joints the varicose veins gout and various nutritional deficiencies so let's this is to us to complete but let's try to understand at least a word or two of each comorbidity so starting from the head okay let's so the this is the obesity induces secondary pseudo tumor cerebri syndrome the increased intra optimal obesity because of the increase in abdominal the fat in the liver the momentum that is increasing the intravenous pressure there is this also increases the intrathoracic pressure as this pushes the diaphragm upward so what happens is it decreases cranial venous flow so the csf drainage is not right there is increased production of csf probably and this is another theory probably by activation of the mineralocorticoid receptors in the choroid plexus by probably the aldosterone or maybe the 11 beta hydroxy steroid in the cortisol pathway probably that enzyme activates this receptors and therefore there is more of csf formation also the adipose tissue secretes mineralocorticoids realizing factors so this is probably one more of the reasons so we just seen that higher bmi more uh risk recent moderate weight again higher will be there is obesity may be a secondary secondary increase if somebody has a pre-existent idiopathic hybrid intracranial hypertension already it is seen in mainly reproductive age group females so probably is there an effect of estrogen we don't know so these are all probable um theories which is not very high uh properly studied uh high csf leptin levels are seen so does that increase the csf production or is there some deficiency in the intracranial csf absorption whatever it is it is seen that bariatric surgery with um the post bariatric surgery because of the significant weight loss there is 97 percent uh resolution of the papilloma and 92 resolution of the symptoms which are mainly headache nausea vomiting impaired visual field pulse synchronous tinnitus simmering lights with colored centers sixth or seventh now policy papillon the mri will be normal the csf is normal but increase lumbar opening csf pressure of more than 250 and increase serum lectin and csf lifting levels coming to obesity and psychological problems well there can be depression and obesity which means the cause or the effect we don't know is more common in women there are suicidal tendencies there is emotional eating there is binge eating decreased self-esteem and self-confidence and various addictions like alcohol smoking and drugs are seen so this depression obesity cycle is like a vicious cycle obesity increases the risk of depression and depression has also been found to trigger obesity so all these problems with body image distraction and all and emotional eating habits also all this is like a vicious um cycle this is a type of facial which we see very commonly with the huge central obesity and lots of fat around the neck a double chin and you will find even during the day even while sitting in front of you if you just you know turn around to talk on the phone or something the patient will you know just fall asleep in front of you so this is obviously hyperventilation syndrome and the pathology is related to three major mechanisms obesity related changes in the respiratory system alterations in respiratory drive breathing abnormalities during stream what is most important is this is associated with cardio metabolic comorbidities at least 55 percent of patients have developed hypertension and 50 percent may develop pulmonary hypertension and the all-cause of mortality is 24 at 1.5 to 2 years if this is left untreated so this is uh this is represented in a in a diagram there you can see there is a you know collapse of the upper uh respiratory to the pharyngeal um because of the pharyngeal fat upper respiratory airways collapse so what happens especially when the patient is supine what happens is the there is less oxygen going in and even the carbon dioxide is not able to come out so there is carbon dioxide detection retention there is a hypoxia there is rem uh hypoventilation and because of the fat in the abdomen the diaphragm is pushed up the fat around the chest wall also it prevents the expansion of the lungs so there is decrease in the lung volume also so all this is responsible for the hyperventilation syndrome so decrease in the lung volumes increase work of breathing by the respiratory muscles so the their performance is performed there is reduced tidal volume that the sleep disorder breathing that we say which because of the upper obstructions sleep hypoventilation all these causes there is retention of carbon dioxide in the body and hypoxia and over time there is reduce a respect drive and this is dangerous for the patient the amount of weight loss needed to improve the osa is different from you know the the cycles of the apnea hypoapnea cycle so the the degree of weight loss to improve that and the degree of weight loss to improve the gas exchange is different but it needs significant you know for significant improvement in need significant weight loss of at least 30 percent and this significant weight loss may be can be seen in bariatric surgery and we have seen wonderful changes in the obesity hyperventilation syndrome another important association of obesity is obesity with insulin resistance this lipid and hypertension called as the deadly quartet or the metabolic syndrome which is a cluster of clinical and laboratory parameters predicting the cardiovascular risk this is diagnosis is independent of bmi uh it is the base circumference which is taken into consideration with increased triglycerides decreased hdl high bp and a high fasting bsn and even the inter-heart study says that the abdominal basic is a greater risk factor than the bmi indicating that measurement of waste to hip ratio should replace the bmi as the indicator of obesity so obesity and insulin insulin resistance and there are many factors which are responsible um various mechanisms which are used to explain how the insulin resistance um occur and but the basic is uh the the in the excess lipids in the body they bring about a microcontroller over activation so what happens is at the cellular level microcontroller over activation more atp is formed that much atp is not treated so it has its own negative feedback by it stimulates the ampk enzyme which stops the insulin from acting so what happens is there is insulin resistance the insulin is just outside the cells the glucose is not taken up so the glucose is also outside the cell so that is uh there is insulin resistance and a decrease in the insulin sensitivity and drugs like metformin and the thyroid and the diazolidine neons uh which act by uh you know the degrees by inhibiting the mitochondrial beta oxidation i said are seen to be helpful in improving the insulin resistance so that is the uh so this is what is seen there is excess insulin outside the cells and but the pancreas doesn't know it continues to produce more insulin to decreases in glucose so hyperglycemia but there's also hyperinsulia also the insulin clearly by the liver and kidney is also decreased so that is how hyperinsulinia with insulin resistance is seen in obesity and we see all this diabetes salt retention hypertension we see increased testosterone we see the polycystic disease we see heart diseases we see the cancers of colon prostate breast we see the sympathetic system increase in the cytokine and increase in the blood pressure so all the insulin resistance causes all these actions the term obesity diabetes together is called as diabetes and it is a metabolic dysfunction that ranges from mild blood sugar imbalance to a full price type to diabetes now not all patients with insulin resistance develop type 2 diabetes but obesity is a major factor for development of type 2 diabetes and we know about this we'll just leave some slightly special interrupt can we go a bit slow people are asking to be oh okay okay okay so obesity and emia yeah thank you there is increase as we know there is increase in the ldl and the triglycerides there is decrease in the good cholesterol that is the hdl and there is a decrease this is because of decreased activity of the lipoprotein lipids so even 10 percent weight gain can cause a 12 milligram dl increase in the cholesterol and we have seen that with the treatment not only drugs but even with the weight loss uh significant weight loss there is can be improvement in this lipid image on all the effects of dyslexia can be decreased coming to obesity and the cardiovascular system so the cardiovascular system has to work as excess workload so it has to increase the blood supply to the excess fat tissue to increase there is increase in the metabolic demand there is increase in the oxygen consumption so to increase the air there is also increased uh extra cellular fluid volume increase in the venous return and cardiac output so the cardio the heart is over working now there is hypertension due to various mechanisms one is activation of the sympathetic nervous system the renal injury tension aldosterone system there is physical compression of the kidneys by fat in and around the kidneys and there is also activation of the mineralocorticoid receptors independent of aldosterone or angiotensin so um the heart is overworked there is arterial stiffening in all age groups so there is hypertension because of the inflammation that is lipotoxicity always glucose the glucotoxicity all this active uh for the uh for increasing the blood pressure so there is also a role in the atherosclerosis of the lipid and um of the leptin i mean and there is leptin resistance yeah in obesity and also there is low adiponectin therefore this protective hormone action does not happen and as we know there are increased um cytokines we know that we have seen cardiomyopathy in obese patients this is because the fat directly accumulates in the pores of the cells leading to a variety of conduction disturbances all kinds of arrhythmias can be seen atrial fibrillation in presence of left ventricular hypertension hypertrophy is poorly tolerated even q2 prolongation is seen in 10 percent of cases there is fatty infiltration of the conducting system itself there is hypercapnia as associated with the osa there is hypoxia because of the same problem there is coronary artery disease because of the atherosclerosis so there are many um contributors uh to the development of cardiomyopathy and again the left ventricular hypertrophy that we see on today goes and uh it is eccentric as well as concentric hyper hypertrophy and the causes are the hypertension as well as the increased blood volume there is fatty infiltration of the myocytes itself obesity and cardiovascular disease so this is just a summary the things that you see hypertension hyper and the dyslipidemias endothelial damage diabetes osa so it is important to do the waste tip ratio the bmi more than 29 itself causes a threefold increase in them in myocardial infarctions in obese patients so obesity and stroke is also common and in this the abdominal obesity is an independent risk factor and other factors of course is the atherosclerosis hypertension the dyslipidemias so obesity and gastrointestinal diseases now there are many gastrointestinal diseases and um we have diseases of the esophagus stomach we have gallbladder and as well as the liver so the pathophysiological disturbances in obesity include the esophageal motor disorders there will be lower esophageal spinder abnormalities giving rise to the reflux disease there is a trend towards development of hiatus hernia that also we very commonly see there is increased intraglass pressure and there is also increased gastric capacity another important thing is that alterations in the secretion of adiponectin and leptin from adipocytes is a proposed link between obesity and barrett's esophagus and esophageal adrenal carcinoma so that is very important to treat the grd of obesity and we have seen that bariatric surgery especially the roanoke gastric bypass can ameliorate the reflux disease through loss of excess weight so this is just a diagrammatic depiction of what i just said is sufficient this motility disorder is the lower esophageal sphincter disorders development of a higher dysmenia increase in the intra gastric pressure and increase in the volume and the effect of various hormones like lip increase lefting and decrease adiponectin another important thing that we commonly see is there is more incidence of gallbladder stones in those metabolically abnormal non-obvious as well as metabolically abnormal obesity patients and especially it is very common in type 2 diabetes so this is something which is very commonly seen patient coming to us will usually come with a sonography report saying that um he or she has a gallstone so it is maybe one of the reasons why the patient ends up in the obd a very important thing is the non-alcoholic fatty liver disease which is seen in obese all stages of nafld it is called as nafld they have in common the accumulation of fat in the liver cells now pathologically we have two terms the non-alcoholic fatty liver and the nash nash is non-alcoholic steroid hepatitis which progresses to fibrosis and cirrhosis and ultimately what you can see is hepatocellular carcinoma if all this is left untreated so this is how the healthy liver looks it is reddish and this is how it looks on microscopic the liver biopsy and to the eye it looks uh to the eye it looks sorry from the phone here yeah to the eye this is how the liver looks very yellow on laparoscopy and this is how it looks microscopically so what the surgeon sees is this liver everywhere in the abdomen when the obese patients with fatty liver or nash comes to you the pathogenic mechanisms for development and progression are complex and they are multifactorial there are genetic and epigenetic factors by which for development as well as progression of the naflds dietary sugars fat adepo tissue lipolysis denova lipolysis they also contribute to the increased hepatic fat influx and accumulation in these obese patients they have increased adipo tissue mass again we know about the and the cytokines and all which is which are produced by the adipo tissue mass so i will not repeat this again and again again the insulin resistance is also contributes to the naf ld so this is just a diagrammatic representation now diagnosis of this nafld uh is presence of hepatic steroids detected during imaging methods or biopsy absence of significant alcohol consumption and absence of possible computing it allergies for hepatic sterosis and absence of concurrent chronic liver disease the way to diagnose this without a biopsy is by the ultrasonography based transient elastography which is called as a fibro scan however it is not easily available most important thing to remember is weight loss especially that significant weight loss can bring about change in the three crucial metabolic areas which influences this nafld improved glucose homeostasis improved lipid mechanism metabolism and reduced inflammatory activity so this is one important effect of bariatric surgery and which improves fibrosis in patients with nash what are the changes in the kidney obesity related glomerulopathy so this is a different term use obesity related glomerulopathy is the best known renal disease secondary to obesity what happens is increase in the body mass so there is increase in the metabolic demand and so there are some compensatory responses by the kidney also the initial compensatory changes in structure hemodynamics and metabolism occur but however when these compensatory mechanisms eventually fail the amount of renal injury which you will see depends on the amount of obesity the associated co-morbidities which affect the kidney like hypertension and diabetes etc and also the amount of nephron mass as the patient has so if the patient has a single kidney and obesity then that kidney will fail earlier then what will happen if the patient has two kidneys so there is uh to understand there is nephron hypertrophy increased tubular and glomerular functions associated with obesity intracellular extracellular accumulation of fluid and lipid components then there is glomerular hypertrophy with if you can see this uh the renal plasma flow rapf and the glomerular filtration rate both increase with obesity and this is better seen in this slide that the renal plasma flow and dominant filtration rate they both increase in obesity there is increase in the filtration fraction so then what happens is what it does it causes increased tubular salt resorption and then this vicious cycle goes on there are other contributing factors also so there is glomerular hyper filtration and increased tubular salt resumption going on in the same organ and there are various other factors which are associated with obesity including the adipose derived factors activation of this rasp that is the renin-agitation aldosterone system the activation of the renal sympathetic nervous system systemic hypertension and the they all contribute to this vicious cycle which goes on in the kidney at the particular or the nephron level now uh this is seen in mainly obviously in those with higher obesity more than 30 kgs per meter square for obesity the clinical features will be isolated protein area of unknown onset with or without a renal impairment is usually one of the first things so any obvious patients get a urine test done so look for protein urea then the patient may have associated hypertension and dyslipidemia so in this the presence of full nephrotic syndrome may not be seen and edema may not be a important part of the kidney involvement or the glomerulopathy associated with obesity but this clinical course is very stable and it is very slowly progressive protein urea and then gradually at some point the patient may end up in end stage renal disease and it is seen in about 10 to 33 percent of patients and of course there will be other contributing factor at that time for the progression and on the renal histology like an adrenal biopsy what you see is uh glomerulomegaly and focal segmenting glomerulous sclerosis so there are other obesity associated complications with renal problems like we just saw um in sleep apnea and nocturnal the hypoxemia of obesity they are associated with hypertension and loss of renal function obese patients with sleep apnea will have pulmonary hypertension and this will increase the right ventricular overload which leads to increase in the renal vein pressure and congested intravenous circulation which again activates the rash and the salt reception the non alcoholic fatty liver disease also which accompanies obesity it is seen that it is associated with increased risk and incidence and progression of the chronic kidney so all these organs they like once a patient is obeying super obese all these organs they affect each other nephrolitis is very commonly seen uric acid and calcium oxalate stones are seen in patients who um are obese urinary stress incontinence is female is again obesity related if you know there is no other cause for the urinal stress incontinence like any complicated gynecological obstacle problems if the patient is always a central obesity and has urinary stress incontinence it is because of the obesity because of the increased abdominal pressure and this patient has the to undergo a weight loss and it is found that the urinary stress incontinence um can disappear if the intra-abdominal pressure is reduced and a female should be asked this question because majority of the females will not come out with this symptom and they will not know that treating their obesity is going to relieve them of this stressful disorder coming to obesity and bone metabolism um so this is a very complicated um thing which happens basically there is decreased absorption of say fat soluble vitamin like say vitamin d decrease absorption of calcium so there is there is something that will not understood obvious patients undergo episodes of caloric restriction and during this time they can undergo a various nutritional deficiency so let's see what happens to the bone metabolism so we've seen that obese patients in general often have abnormally low vitamin d levels and in our studies we have found that whether the patient is a vegetarian non-vegetarian they have low vitamin d levels a phenomenon that is thought to occur as a result of sequential of the vitamin d in the excess adipose tissue or from inadequate sunlight exposure related to both a more sedentary lifestyle as well as a tendency to cover up maybe because of modesty maybe because of the high heat or maybe because our obese patients do not go out very easily and the enzymes needed for the hydroxylations are produced in the adipose tissue these are decreased in obesity so what is important is there is effect of mechanical overloading the same joints are carrying say extra weight 50 kgs 100 kgs you don't know so there is a mechanical loading on the weight-bearing joints which gives rise to a pin then at the bone marrow level it is seen that obesity may decrease bone formation that is a osteoblastogenesis while increasing adipogenesis why because the adipocyte of the the fat cell and the osteoblasts of the bone marrow they are derived from a common multi potential mesenchymal cell so the decreased bone mass with which is seen in obese patients may be due to increased marrow adipogenesis fat in the bone marrow at the expense of the osteoblastogenesis because of this basic problem and or increase osteoclastrogenesis because of the upper regulated production of the pro-inflammatory cytokines or excessive leptin secretion or reduce adiponectin production and or reduce calcium absorption associated with the high fat intake so again this is how the bone metabolism is affected we see secondary hyperparathyroidism and with this vitamin d deficiency and this needs to be closely followed even after significant weight loss of bariatric um surgery obesity can we take the question at the end of the session please obesity and chronic kidney disease we uh just saw uh the other genito urinary disorders that we see is plasma testosterone in men and the sexual hormone binding global are reduced there is increased estrogens there is gynecomastia but the secondary sexual characters are preserved but erectile dysfunction is seen and especially those in obesity with diabetes in women increase androgen decrease shbg polycystic ovarian disease and infertility and uterine cancer and we discussed earlier so pcos is one which we see very commonly menstruating regulators androgen excess and obesity it is diagnosed by the rotating criteria and what is important to remember is their menstrual irregularities science of androgen excess insulin resistance elevated utilizing hormone levels they have a increased risk of type 2 diabetes dyslipidemia cardiovascular events as well as endometrial cancer and that's why pcos is part of the extended metabolic syndrome so other conditions with similar signs such as hydrogen secreting tumors or pushing syndrome of course we have to rule out so we all know that pcod and pregnancy there will be infertility issue there will be problematic pregnancies so and because they have a you know high risk of the metabolic syndrome also uh we skip this it is necessary to treat the pcod because they have a very high prevalence of metabolic syndrome in the general population and um especially those less than 40 years of age even the male relatives of the pcos women can have high incidence of ms and they can have diabetes before the years of 50 years independent of the body mass index also and later in life the pcos women have twice the prevalence of hypertension that's why it is important to treat i will skip this obesity and gout well hyperin uracimia is said to be part of the extended metabolic syndrome so the contributing factors are obesity renal insufficiency hyper lipidemia the insulin resistance the hypertension and other factors so all this this hyperurism give rise to gout and the patient usually comes with some sort of joint pains and sometimes we've even seen earth symptomatic but we've seen obese patients having a slightly higher level of uric acid which is very common coming to the last two three slides we saw all these various organs which are affected with uh obesity now obesity which is a continuous state of over nutrition you know people always believe they have no problem with food availability of food but it is in fact found to be a malnutrition state because it is associated with multiple nutritional deficiencies this has been studied by various especially the bariatric units world over and like we saw vitamin d and low vitamin d high pth which is secondary hyperparathyroidism vitamin b complex b12 is low in almost all patients that we see were not in any sort of big complex medications folic acid low b1 low b6 load the um iron studies show the low serum iron ferritin even the fat soluble vitamins vitamins like aek can be low though we don't do these regularly at our settings trace elements in copper selenium magnesium and the calcium etcetera can be low they can be protein deficiency so this is the most important slide that i want you to remember this is the same slide which is strong at the beginning that the co-morbidities from head to toe now this slide shows the comorbid reduction after bariatric surgery by which i mean after significant weight loss so if you see the slide closely right from head to toe every co-morbidity or every problem has some resolution after the uh significant weight loss like migraine pseudotumor cerebri dyslipidemia hyperlipidia the non-alcoholic fatty liver disease so you can see a 90 percent improvement in the steatosis metabolic syndrome result in 80 percent type 2 diabetes 83 to 86 percent see pcod can have even 100 percent resolution of the menstrual dysfunction and we have seen very good results the venous stasis disease 95 percent result gout 72 percent result depression 55 percent the obstructive sleep apnea very good results 98 percent resolution taxation the asthma is improved cardiovascular disease there is risk reduction there is reduction in the hypertension the grd has very good resolution rates stress incontinence very well resolved dna joint disease 71 to 46 percent result most important is quality of life improved in about 95 percent of patients and mortality 89 reduction in five year mortality so it is not just important to diagnose obesity but it is important to study it to investigate it and give various treatment options to the patients you need um it's not a one-man thing to do you need a passionate compassionate well-trained multidisciplinary team of physicians intensivist dietitians psychologists physiotherapists and bariatric coordination and you need very um so it is our job to motivate patients and uh transform their lives and improve their quality of life and as well as their lifespan thank you so much and it is very much beneficial for all of us and we have a very short take home message that it has become a serious problem which leads to serious comorbidities from head to toe but more importantly it is treatable by merely changing our lifestyle all right well put yeah so uh one question from my side uh just wanted to ask um as some of the uh dietitians suggest that you can take very low carbohydrate diet and others say you have to take very high protein diet a little bit knowledge which is more beneficial yeah so the type of diet that we give is also depends whether there is a medical weight loss or the surgical weight loss we do use a very low calorie diets with using meal replaces you cannot stop the patients what is important instead of giving the you know trying to balance a homemade diet for the initial stages we make use of meal replaces with again um high fiber content carbohydrates and literally no fat see that there is not too much gaps in the food intake and basically the liquid intake has to be very adequate for the whole day the patient should not feel as if he or she is starving and should not feel dehydrated so that is the key thing to you know give a diet to the patient and not anything extreme okay and um one more thing at what bmi we should we start with the for macro therapy and then what what what is the indication for surgery okay so if you remember the asian consensus for uh bmi related asian guidelines so indians you know just two units 24 25 they are already overweight at that stage you need to know what are the metabolic concerns what is the waste circumference after this we have to decide you know to whether to start with medical therapy or just wait and give a lifestyle changes to the patient pharmacotherapy according to the international guidelines we can start at 27 bmi right so we can start um alone does not work and there are actually okay seven eight years ago there were no drugs now we have few drugs but there is no magical pill for weight loss that is what we should be able to tell up is to motivate them to bring about all other lifestyle uh changes also somebody has asked about early stat and lorca syrian longest rule is no longer used it was it was introduced about two years ago but it had withdrawn from the market and um it was said to have good effect but yes early start is used or at least that is a drug which uh prevents fat from the food or the meal which is eaten at that time to be absorbed into the intestine so it prevents about 30 to 750 percent of the fat from being absorbed into the body right the drug is not absorbed into the body just one person of the drug goes into the body so it acts on the food which is in the intestine so what happens is the the food with the fat goes out in the stool so that is how oralist attacks so it is more not we cannot call it a weight loss drug it is more of a weight maintenance truck to bring about a change in your lifestyle so that is that is about or you stand about early start only i have many many patients in my opd which who say that we have we pass oily stools greasy stools which is very difficult in day to day life if we suggest oily steak to especially males females still can cope up with this thing so how can we prevent that yes so that is that is that drug is under again another thing which makes us understand how much fat is there in the stool in the food that they eat right because even if 50 percent is absorbed it is 50 percent coming out in the stool so it reflects the amount of fat which is there in the food that they're eating so like i said only drugs do not work you have to work on the type of diet the way it is cooked the amount of oil the amount of fat which is there so that understanding that education of the patient and the family or the one who is going to cook in that family that is very important and that is what our dietitians do they take care of the patients and the relatives and you know the diet which should be given to that patient is basically an anti-convulsion which is also used for treatment of migraines in a dose of 25 milligram and it was found to decrease the appetite so it is a central it is centrally acting and we have found we are using it for last many years and we have found it to be quite effective in decreasing the um appetite so yes to pyramid can be used though the combination of pyramid with fentanyl mind which is used outside and available outside is not available in india so we have to you know just use autopilot but yes we use it it has good effect but explain everything properly to the patient the patient will go with your prescription to the medical person and he will call up the medical person saying you don't have convergence and why are you taking this drug so just explain the patient properly it does help and um rule of sima glutathione obesity and what those should be given lyra glutathione how it should be started and tapered yes so it is given for um the obese obese with uncontrolled diabetes and it is started in small doses and gradually increased over two weeks and it gives also some nausea so the patient eats less and it does help in decreasing the sugar and and decreasing the weight and we have found it to be very uh useful and now we have the oral version because the this liraglutide taking it daily can be quite cumbersome for some patients and uncomfortable also so um but it has it has good results and now we have semaglutide which has come in the market which is the oral version of say this regulate family and we have to get see its long-term effects but the clinical trials have shown very good results but i'm uh it might precipitate hypoglycemia also so we have to take it very carefully in case of diet what i have read no not exactly it doesn't cause hypoglycemia as would be with insulin okay right so so it is a safer it is a safer drug to use definitely okay and mam these days keto diets are very famous so can we have a word about keto diet are they useful or we should avoid them because like i said when we treat obesity in our clinical settings we treat obesity as a whole and when we give them diet we don't use any extreme like kind of diets and we prefer to give them meal replaces instead of experimenting with and patients when they come to us usually come with all possible diet you know they have already tried many things and then they come to us but no we don't go in for keto diets keto diet works in our preparation of the patient for surgery but not as a weight loss [Music] any words about liposuction if you can give a little bit so liposuction is removal of the fat sucking away of the fat in some problematic areas for somebody who is not you know very obese but has fat deposit in certain areas say the thighs or the upper arms or even our weight loss we would say at the end of one year all the other fat is gone but there are some resistant areas where even um good body toning has not given a proper shape then we make use of liposuction so it is it is not a permanent procedure and basically it is not going to change on metabolism it is taken as a cosmetic procedure so it is not for super obese that is a wrong thing to do yes any any role of metformin in obesity now weight loss yeah see metformin is more of a new weight loss neutral drug but we do start for newly diagnosed many people who come to us when we do their complete profiling we find that they have either pre-diabetes diabetes and if then for them we do start forming small doses we see the effect how it is working and yes it is so it is used and one last question ma'am someone has asked that what those of vitamin d supplementation should be given is it either the same dose or we should give it for extended time well it is you should have a baseline vitamin d level first thing secondly you put the patient on a weight loss program whether it's medical weight loss or undergoing a surgical weight loss after two to three months you should check the vitamin d levels again i know it is it is one of the most expensive investigations but you have a baseline level and you have a level after giving say if you give injectable uh or acute all injection of vitamin d or you give oral daily so problem in obesity is you are not sure about the oral absorption of vitamin d and that's how we prefer to give them an injectable vitamin d but it should be followed up it should be investigated so you should repeat the thing the level after three months and see what is the status hello hello yes uh yeah i am dietitian amrita uh i just wanted to ask like for weight loss why do we ask to avoid fruits like banana chico sita full because even they have high fiber content like in soluble fibers they have soluble fibers but irrespective of that why do we ask to avoid it yeah well we can say avoid or we may give them in restricted quantities it also some of these foods are high level of potassium if you're not sure of their kidney function we try to avoid fruits which will you know high in potassium then we we need to restrict the amount of sugars coming from fruits so in no weight loss diet we give them ample amounts of fruit we always give them a restricted amount of food so that is one reason why we never allow them to eat a one complete banana as at a time when they are you know as part of their meal [Music] so that's why we restrict uh foods from that point of view okay and uh does colitis has anything to do with the central obesity like incontinence i can talk about this no no not exactly incontinence of school but yes irritable bowel disease is known in obese patients i didn't get much into it but it is it is known it is seen and again it is multi-factor we don't know but there shouldn't be any incontinence unless there is loosening of you know of the pelvic floor so that etiological difference will be an anatomical this thing but those motions and you know having um continue some gi problem is part of the irritable bowl syndrome so that is known but not incontinence because i have been experiencing this colitis problem like before long dong i was just 40 kgs i have maintained that for long long years but i suddenly i started getting that problem like from last two to three years so traveling is a problem for me so in that case what can i do now my weight is uh it is 49 48.8 it should be 42 idle body weight so if you go to see my bmi that is on the normal range 22.9 but still i don't have so that is a problem how do i go about it and i have bad sugar cravings my diet is very poor but yes sugar content is what i have more sugar craving so how do i go about it so this is probably not related to your body fat or to any obesity it may be a independent irritable bowl syndrome that you have so it is it is not related to body fat percentage or you know you understand what i am trying to say so it may be an independent problem which needs some evaluation and all your i don't know about your nutritional you know your whole nutritional parameters you should see whether that is why is the sphincter loose do you have urinary incontinence also or only stool in components so that all those factors are important so urinary incontinence is also one problem it's like it becomes very difficult for me to even hold the uterine for a long time this is like since four to five years having so you said your bmi is normal so you do not have any central obesity which will cause so much of incontinence okay but uh i find my stomach is little you know little it has started bulging out so i want to get rid of that also i want to reduce that there is no fat there is some sort of a anatomical problem also it may be because of some of the malnutrition and deficiencies okay any other questions we have [Music] you need to see us that we can guide you properly [Music] yeah so i think ma'am we are over with the questions there are no more questions left thank you ma'am once again for sharing such a vast knowledge with us there is someone okay so ma'am basically i've got so much knowledge from you i've asked so many questions which were marked in my book since long and i couldn't ask my professors to tell me the answers because i'm so afraid so these were the questions which i could ask very easily so thank you so much thank you so much thank you everybody thank you dr poonam it has indeed been an enlightening session we're grateful for your time thank you ma'am thank you dr simran thank you so much thank you for the opportunity

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dr. Poonam Shah

Dr. Poonam Shah

Consultant Bariatric Physician | Founder and Director of Laparo Obeso Centre

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dr. Poonam Shah

Dr. Poonam Shah

Consultant Bariatric Physician | Founder and ...

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