Obesity

DR. Mukesh Mahla

MU 4
Definition
• The morbidity and mortality associated with being overweight or
obese have been known to the medical profession since the time
of Hippocrates more than 2500 years ago.

• Overweight refers to a weight above the "normal" range

• It is determined by calculating the body mass index (BMI, defined

as the weight in kilograms divided by height in meters squared).

Term BMI

Overweight 25 to 29.9 kg/m2

Obesity ≥30 kg/m2
Severe obesity BMI ≥40 kg/m2 (or ≥35 kg/m2 in the presence of comorbidities).
Classification (WHO)
Classification BMI(kg/m²) Obesity class Disease risk

Underweight <18.5 --------------- --------------

Healthy weight 18.5-24.9 --------------- --------------

Asian(18.5-22.9)

Overweight 25.0-29.9 --------------- Increased

Indian(23-27.5)
Obesity 30.0-34.9 I High
Indian ≥ 27.5
Obesity 35.0-39.9 II Very High

Extreme obesity >40 III Extremely High

Waist circumference
• In addition to measuring BMI, measuring waist circumference in
overweight and obese adults to assess abdominal obesity is
recommended.

• Patients with abdominal obesity (also called central adiposity,

visceral, android, or male-type obesity) are at increased risk for
heart disease, diabetes, hypertension, dyslipidemia, and
nonalcoholic fatty liver disease.

Region Men (cms) Women (cms)

Global >102 >88
Indian >90 >80
• Measurement of the waist-to-hip ratio (>0.9 in women and >1 in men
is abnormal) provides no advantage over waist circumference alone
and is not currently recommended.

• The waist circumference is measured with a flexible tape placed on a

horizontal plane at the level of the iliac crest.
Waist
Circumference
Method to measure waist circumference.
Epidemiology and impact
Prevalence
• Prevalence of Abdominal Obesity as well as of Generalised
Obesity are high in India (30%).
• Generalised Obesity-135 million
Abdominal Obesity-153 million
Combined Obesity-107 million individuals.

1 in 4 adults are OBESE

 Magnitude of Problem
• Globally >1.9 billion adults are overweight out of which 650
million are obese. Childhood obesity also in increasing trend.

• Rajasthan (obesity)-
Female-14.1% [NFHS-3 -8.9%]
Male- 13.2% [NFHS-3 -6.2%]
[National family health survey-4 (2015-16)]
Thus clearly in 10 years(NFHS-3 to NFHS-4), prevalence of Obesity has doubled in
Rajasthan and also in other parts of the country.

• Increased risk of premature death (<65yrs),

• Leading causes of death -
-Ischemic heart disease
-OSA
-Diabetes mellitus
-Cancer.
Etiology -

Genetic (dysmorphic) obesities

• Autosomal recessive traits

• Autosomal dominant traits
• X-linked traits
• Chromosomal abnormalities
• Low birth weight
Social and behavioral factors

• Socioeconomic status
• Ethnicity
• Psychological factors
• Restrained eaters
• Night eating syndrome
• Binge eating

Sedentary lifestyle

• Enforced inactivity (postoperative)

• Aging
Neuroendocrine obesities

• Hypothalamic obesity
• Hypothyroidism
• Seasonal affective disorder
• Cushing's syndrome
• Polycystic ovary syndrome
• Hypogonadism
• Growth hormone deficiency
• Pseudohypoparathyroidism
Dietary obesity

• Infant feeding practices

• Progressive hyperplastic obesity
• Frequency of eating
• High-fat diets
• Overeating

Iatrogenic causes

• Drugs that cause weight gain

• Hypothalamic surgery
Drugs -
• Glucocorticoids (prednisone)
• Diabetes medications (insulin, sulfonylureas, thiazolidindiones,
meglitinides)
• First-generation antipsychotics (thioridazine)
• Second-generation antipsychotics (risperidone, olanzapine,
clozapine, quetiapine)
• Neurologic and mood stabilizing agents (carbamazepine,
gabapentin, lithium, valproate)
• Antihistamines (especially cyproheptadine)
• Antidepressants (paroxetine, citalopram, amitriptyline,
nortriptyline, imipramine, mirtazapine)
• Hormonal agents (especially progestins, eg,
medroxyprogesterone)
• Beta-blockers (especially propranolol)
• Alpha-blockers (especially terazosin)
Pathogenesis of Obesity-
Orexigenic
• NPY
• AgRP
• MCH
• CRH

Anorexigenic
• POMC(Pro-opiomelanocortin)
• CART( Cocaine and Amphetamine Regulated Transcript)
• Alpha-MSH
• Serotonin
• GLP-1
Expert Screening Guidelines

• The AHA recommend measuring height and weight and calculating

BMI at least annually

• In overweight and obese adults, they recommend also measuring

waist circumference.
Evaluation of Obese

• Specifically, evaluation of the overweight or obese patient includes-

• History
Physical examination
Fasting glucose,HbA1c.
Thyroid-stimulating hormone (TSH)
LFTs and Lipid profile.
• Subsequent intervention, if necessary, is based upon historical,
physical, and/or laboratory results.
Comorbidities a/w Obesity

Obesity and increased central fat are associated with

increased morbidity in addition to mortality.

Diabetes mellitus
• Obesity has been a major contributor to the type 2 diabetes
epidemic where nearly 80% of those with type 2 diabetes
are considered overweight or obese in all ethnic groups.

• Insulin resistance with hyperinsulinemia is characteristic of

obesity and is present before the onset of hyperglycemia.
Dyslipidemia
• Unfavorable obesity related effects include high serum
concentrations of cholesterol, low-density lipoprotein
(LDL) cholesterol, and very-low-density lipoprotein (VLDL)
cholesterol, and triglycerides, and a reduction in serum
high-density lipoprotein (HDL)

• Central fat distribution also plays an important role in the

serum lipid abnormalities.
Cardiovascular
Hypertension —
• The risk of hypertension is greatest with upper body and
abdominal obesity.
• Individuals with BMI >30 have a 9 fold increasesed risk of high
blood pressure.

Heart disease —
• CHD,
• heart failure,
• Myocardial steatosis
• Atrial fibrillation
Stroke
Venous thrombosis — assocated with an increased risk of
deep vein thrombosis and pulmonary embolus.
Musculoskeletal

• Osteoarthritis
• Gout

Gastrointestinal

• Nonalcoholic fatty liver disease.

• Gall stones.
• Pancreatitis
• GERD and erosive esophagitis.
Genitourinary

• Chronic kidney disease

• Focal segmental glomerulosclerosis
• Kidney stones
• Urinary incontinence

Psychosocial

• Stigma of obesity — Obese subjects are often exposed to public

disapproval because of their fatness. This stigma is seen in
education, employment, and health care, among other areas.
• Depression
• Dementia
Respiratory system

• Sleep apnea is the most important respiratory problem associated with

obesity.
• The prevalence of OSA is almost double in obese compared with lean
individuals.

Skin changes

Several changes in the skin are associated with obesity.

• Stretch marks (striae).
• Acanthosis nigricans, with deepening pigmentation around the neck,
axilla knuckles, and extensor surfaces, may occur in connection with
obesity.
• Hirsutism in women
Cancer
• Excess weight is associated with an increased risk of multiple
cancer types.
• Obesity has been estimated to cause 20 percent of all cancers.
• Overweight and obesity were estimated to account for between 2
(thyroid) and 41 (endometrial) percent of these cancers.
• Overweight and Obesity accounts almost 14% deaths in men and
20% in females from cancers.

Endometrial Pancreatic Ovarian

Gallbladder Colon Breast(Postmenopausal)

Kidney Cervical Leukemia, NHL, MM

Liver Thyroid
Risk factors for comorbities a/w
obesity
≥ 3 risk factors confers a high mortality & morbidity-
• Men ≥ 45 years
• Women ≥ 55 years
• Cigarette smoking
• Family history of- premature coronary heart disease
≤ 55 years (Father)
≤65 yrs(mother)
• HDL < 35 mg/dl
• Impaired fasting glucose (110 - 125 mg/dl)
• BP ≥ (140/90 mm Hg )
• LDL ≥ 160 mg/dl
Mortality and Obesity

For every 5 kg/m2 increment in BMI above 25kg/m2-

• Mortality was on average approximately 30 percent higher

• Vascular mortality by 40%, and diabetic, renal and hepatic mortality by 60

to 120%.

• at BMI 30 to 35 median survival is reduced by 2 to 4 years

• at BMI 40 to 45 median survival is reduced by 8 to 10 years.

 Risk of disease and Obesity

Increasing BMI,even within the normal

range of BMI (21-24.9), is associated with
an increased risk of type 2 diabetes,
hypertension, coronary heart disease,
and cholelithiasis
Risk of diabetes in obesity

BMI (kg/m2) Risk of diabetes

>25 2-8 fold

>30 10-40 folds

>35 >40 fold

depending upon ethnicity, age, sex, duration and degree of adiposity.

The 5As of management

Assess
History, BMI, co-morbidities, dietary
Refer to dietician, behavior habit,
specialist, surgeon Physical activity, medication

Arrange Advise
Caloric deficit diet,
exercise ,medication,
surgery
Diet plan, physical activity,
behavior modification guide

Agree
Assist Diet plan, 10%wt.loss
Approach of Managment
• Goals of treatment
• Identify candidates
• Advice Initial treatment
- Comprehensive lifestyle intervention
- Dietary therapy
- Exercise
- Behavior modification
• Complementary and Alternative therapies
• Mind body solutions
• Ayurveda( ancient medicines)
• Herbal medicines
• Drug Therapy
• Surgery
• Risks of treatment
• Maintenance of weight loss
Goals of treatment

• Obesity is preventable.
• The primary goal of treatment are to improve obesity
related co-morbid conditions and to reduce the risk of
developing future co-morbidities.

• Information obtained from the history, physical

examination, and diagnostic tests is used for developing a
treatment plan.

• The decision of how aggressively to treat the patient and

which modalities to use is determined by the patients
risk status, expectations, and available resources.
Identify Candidates

Treatment BMI BMI BMI BMI BMI

25-26.9 27-29.9 30-34.9 35-39.9 >=40
(Indian≥30) (Indian≥35)

Diet, exercise, With co- With co-

behavioral therapy morbidities morbidities + + +

Pharmaco-therapy With co-

------- morbidities + + +

Surgery With co-

------- -------- -------- morbidities +
 Initial treatment

Comprehensive lifestyle intervention:

• A combination of diet, exercise, and behavioral modification. All
patients who would benefit from weight loss should receive
counseling on diet, exercise, and goals for weight loss.

• One example of a successful comprehensive lifestyle intervention

program is the Diabetes Prevention Program (DPP) used in the
Look AHEAD (Action for Health in Diabetes) study.
• The two major goals of the DPP lifestyle intervention were-

A minimum of 7 percent weight loss .

A minimum of 150 minutes of exercise per week.

• Several behavioral components were used to help achieve these

goals

• Using this approach, the DPP reported that lifestyle intervention was
more effective for preventing diabetes than a pharmacologic
intervention.
Diet therapy
• EXPENDITURE > INTAKE

• Reduce overall calorie consumption.

• Initiating treatment with a calorie deficit of 500–1000

kcal/day compared with the patient’s habitual diet.

• This reduction is consistent with a goal of losing~400-450

gm per week.

• The calorie deficit can be instituted through dietary

substitutions or alternatives.
Various diet plans -

• Balanced low caloric diet

• Low-fat/low calorie diet

• Moderate fat/low calorie, and low carbohydrate diet

• Mediterranean diet
• Even those obese patient who consider their obesity
resistant to all the measures will responed to low caloric
diet.

• Daily diet with restricted <800-1000 kcal/day intake had

shown to lose weight.
 Examples include :-

• Choosing smaller portion sizes.

• Eating more fruits and vegetables.

• Consuming more whole-grain cereals.

• Selecting leaner cuts of meat and skimmed dairy products.

• Reducing consumption of fried foods and other foods with

added fats and oils, and drinking water instead of sugar-
sweetened beverages.
• Science Daily (Dec. 12, 2008) — Severely obese patients
who have lost significant amounts of weight by changing
their diet and exercise habits may be as successful in
keeping the weight off long-term as those individuals
who lost weight after bariatric surgery,

International Journal of Obesity

 Food restriction
 Avoid alcohol.
 Avoid food high in sugar.
 Limit snacking between
meals.
Avoid faty and junk foods
The recommendations of diet therapy include :

• Maintaining a diet rich in whole grains, fruits, vegetables, and

dietary fiber.

• Consuming two servings (8 oz) of fish high in omega 3 fatty

acids per week.

• Decreasing sodium intake to <2.3 gm/day.

• Consuming 3 cups of milk per day.

• Limiting cholesterol intake to <300 mg/d; and keeping total

fat intake at 20–35% of daily calories and saturated fat intake
at <10% of daily calories.
• The specific calorie goal are recommended as -

• Carbohydrates - 45-65%
• Fat - 20-35%
• Protein - 10-35%

• Daily fiber intake- > 50 years men -38gm,

women -25gm,
< 50 years men -30gm,
women -21gm,
 Very Low Calorie Diet (VLCD)

The primary purpose of VLCD-

• Rapid and significant weight loss (13 to 23 kg)over
3 to 6 months.
• The proprietary formulas designed for this purpose typically
supply ≤800 kcal, 50–80 g of protein, and 100% of the
recommended daily intake for vitamins and minerals.

Indication of VLCD- Severe obese, OSA, uncontrolled

T2DM, hyper triglyceridemia.
Complications -Fatigue, hair loss, dry skin, dizziness,
difficulty concentrating, pancreatitis, gall stones.
Contraindications – Pregnancy, cancer, MI, liver disease,
Stroke.
Physical activity therapy(Exercise)

• Exercise is less potent than dietry restrication.

• However exercise is cornerstone in maintaince of, achieved

weight loss.

• Patients medical conditions and age are important

considerations before registering him in any exersice program.

Moderate intensity physical activity- 150 minutes/week

(equivalent to a brisk walk)
OR
Vigorous intensity aerobic exercise- 75 minutes/week.
 Muscle strengthening activities-
-Moderate to high intensity that involve all major
muscle groups on ≥2 days per week.

Longer Physical activity-

-Moderate intensity - >300 minute/week.
eg. walking, using the stairs, doing housework
and yard work, and engaging in sports.
Behavorial therapy

• Cognitive behavioral therapy is used to help change and

reinforce new dietary and physical activity.

• Strategies include self-monitoring techniques (e.g.

journaling, weighing, and measuring food and activity).

• Stress management; stimulus control (e.g. using smaller

plates, not eating in front of the television or in the car).

• Social support.
Complimentary and alternative therapies
-
• Mindfulness is defined as a concentrated awareness of one’s
thoughts, actions, and motivations which may play an
essential role in long-term weight loss.

 Mind body Solutions – It includes

• Yoga therapy
• Qi Gong and Tai Chi therapy
• Hypnotherapy
• Acupuncture

 Ayurveda Medicines
 Herbal Medicines
1.)YOGA THERAPY INCLUDES -

• Yamas and Niyamas (moral and ethical

restraints)
• Asanas (postures)
• Pranayama (regulation of breathing)
• Pratyahara (internalization of the senses)
• Dharana (concentration)
• Dhyana (meditation) and
• Samadhi (self-realization).
2.) Qi Gong & Tai Chi Therapy-

• Originally practiced by the Chinese, Qi gong is a therapy that

combines movement, meditation, and regulation of
breathing to enhance the flow of universal energy (qi or ch’i)
through the body (a form of martial arts).

• ‘Tai Chi’ (origin in the Chinese literature) is also gaining

importance. It was originally developed both as a form of
martial arts (Tai Chi Chuan) and as a form of meditative
movement.
3.) HYPNOTHERAPY

it is a cognitive behaviour therapy for weight loss

4.) ACUPUNCTURE –

• It affects appetite, intestinal motility and metabolism as well as

emotional factors associated with obesity like stress by increasing
serotonin level.
 ACUPUNCTURE

Serotonin (Central nervous system and plasma)

Effect of 5-HT receptors of the

satiety center in the ventro-medial
nuclei of the hypothalamus

Increased tone in the smooth Enhances intestinal motility

muscle of the stomach

Suppressing appetite

WEIGHT LOSS
 AYURVEDA (ANCIENT MEDICINES)
• Use of honey
• Use of spices- Fenugreek, turmeric, mustard, ginger etc.

 HERBAL MEDICINES

• Green tea
• Contains tea polyphenols catechins, caffeine.
• Inhibits fat accumulation and fat synthesis
• Gugulipid
• Garcinia etc.
Management of obesity in the person with
diabetes
A DiRECT study on weight management for remission
of type 2 diabetes shows that-

• at 12 months , almost half of participants achieved remission

to a non-diabetic state and off antidiabetic drugs.
• Remission of type 2 diabetes is a practical target for primary
care.
Diabetes Self-Management Education and Support
(DSMES)

1.Promoting healthy eating and being active are two self

care behaviors that can help achieve weight loss, and
should be used as a first line treatment strategy for obese
patient during DSMES.
2. Diabetes educators can assist about the effect of food
on blood glucose , sources of carbohydrates, protein and
fat and appropriate meal planning
3. MNT (Medical Nutrition Therapy) provided by
registered dietitians , in combination with DSMES may
further benefit.
PHARMECOTHERAPY
Monitering of Drugs-

Weight, Vital Signs-

• After initiating pharmacotherapy, we moniter-
• Weight loss, blood sugar, BP, HR on a weekly basis for 4 weeks and
then monthly.

• Weight loss may cause hypoglycaemia in patients taking drfugs for

diabetes so self monitering blood glucose (SMBG) should be
performed.

• If patients do not lose 4 to 5 % weight after 12 weeks of

tolerated maximum dose therapy, the drug should be
tapered and discontinued.
Adverse effects-
Orlistat
• Pancreatic & gastric lipases inhibitor.

• 30% of ingested fat is unabsorbed and excreted

• Dose- 120 mg BD or TID before meals.

• FDA approval- for adults and adolescents as well as

children.
• Prescribe multivitamin to be taken at least two hours
before or after the medication(beacuse fat soluable
vitamin A,D,E,K absorption decreases, mostly vit D.
• Minimal systemic absorption.
• Low-fat diet ( 30%) required to minimize side effect.
• Advantage-
-↑Weight loss observed within 2 weeks of starting therapy
~6 kg weight loss in a year.
- ↓LDL& HDL cholesterol.
- ↓ Systolic and diastolic blood pressure.
- ↓Waist and hip circumference.
-Weight regain is also less significant.

• Side effect- flatulence, defecation increases, oily

evacuation, rectal leakage, steatorrhea.

• Contra indication- chronic malabsorption syndrome

pregnancy , nursing mothers, cholestasis.
Sibutramine-

• Serotonin and nor epinephrine re-uptake inhibitor

(SNRI).

• 6% to 8% weight loss with 10 to 15 mg/day.

• 2% weight loss with placebo.

• As of October 2010, medicine was taken off the market.

• Research showed that the medicine may raise the risk of

heart attack and stroke.
Lorcaserin
• Lorcaserin is a selective serotonin 2C(5-HT2C) receptor
agonist and is thought to aid weight loss by reducing
appetite and promoting satiety.

• Dose-10 mg BD

• Lorcaserin appears to have comparable effectiveness to

orlistat but to be slightly less effective than phentermine-
topiramate.
• Like orlistat, lorcaserin is indicated for obese patients with
at least one weight related co-morbidity such as diabetes,
hypertension, or dyslipidemia.

• Side effect-

Headache, dizziness, fatigue, nausea, upper respiratory

infections, dry mouth, and constipation.

• Contraindication- pregnancy, CrCL <30.

Phentermine-Topiramate

• Phentermine is nor epinephrine releasing agent and

topiramate is GABA receptor modulator act as an appetite
suppressant.

• Phentermine-topiramate appears to be slightly more

effective than orlistat and lorcaserin.

• However, concerns about phentermine-topiramate, effect

on heart rate limit its use in patients with cardiovascular
disease.

• Dose -15 mg/92mg OD in morning with/without food.

• Side effect-
Paraesthesia, dizziness, dysgeusia, insomnia, constipation,
and dry mouth, increase BP & HR.

• Topiramate increase risk of congenital fetal oral-cleft

formation so contraindicated in pregnancy. It also produces
renal stone.

• Contraindications-
• Pregnancy, Hyperthyroidism, Glaucoma, Renal stone
patients.
Naltrexone-Bupropion
• Naltrexone is opioid antagonist and
• Bupropion is dopamine and nor epinephrine reuptake inhibitor act as
an appetite suppressant.

• It could be prescribed for the obese smoker.

• Dose-8mg/90mg OD, dose is escalated upto 4th week (max. dose

16mg/180mg BD).

• Side effect- nausea, vomiting, constipation, headache,

insomnia, dry mouth, diarrhea, increase in BP and HR.

• Contraindication- HTN, seizure, drug/ alcohol withdrawal, long

term opioid use, pregnancy.
Liraglutide

• GLP-1 receptor agonist.

• Approved for morbid obese T2DM patients.

• Weight loss by delay gastric emptying & appetite suppression.

• Dose-0.6mg s/c, increases weekly max. up to 3mg.

• Side effect- nausea, vomiting, Increase lipase level, headache,

hypoglycemia, diarrhea, pain abdomen.

• Contraindication- Medullary thyroid cancer, MEN-2 and

pregnancy.
Symathomimetic Drugs
• Approved for short-term (up to 12 weeks) only because of
abusive potential and side effects.

• Benzphetamine
• Phendimetrazine
• Diethylpropion
• Phentermine
• Ephedrine

• Side effects-
• Increases HR and BP, insomnia, dry mouth, constipation.
Surger
y
Patient selection criteria-

-BMI > 40 or > 35 with co-morbidities.

-History of failed conservative weight loss approaches.

-No substance abuse / psychiatric disorders.

CONTRAINDICATION FOR SURGERY

• Active substance abuser.

• Non compliance of patient.

• Patient with severe psychological disorder.

• Non ambulatory status.

Bariatric surgical techniques

Restrictive procedures –
• Reduce the storage capacity of the stomach and as a result early satiety
arises, leading to a decreased caloric intake.
-LAP band
-Vertical banded gastroplasty (VBG)
-Sleeve gastrectomy (SG)
Malabsorptive procedures –
• Induce decreased absorption of nutrients by shortening the functional
length of the small intestine.
-Gastric bypass surgery.
Combination-
• Roux-en-Y gastric bypass(RYGB)
Gastric Lap Band

• An inflatable silicone device

placed around the top portion of
the stomach.

• Reduces the amount of food

consumed.

• Weight loss-36-40%, lower risk,

reversible.

• Consequences - infection, slip,

erosion.
Vertical Banded Gastroplasty

• Formation of small proximal gastric Staple

pouch. Line

• Restricts amount of food without Pouc

bypassing the gut. h
Ban
• Delays gastric emptying. d

• Creates feeling of early satiety. Fundus

• Simpler to perform.

• Less procedural complications.

Sleeve Gastrectomy

• Stomach is reduced to 25% of its

original size by surgical resection of
a large portion of the stomach
along the greater curvature.

• Weight loss 40-70%, irreversible.

• Risk &consequences-
-Leak, Nausea,
-Hyper salivation,
-Feeling of obstruction.
Gastric Bypass Surgery

Staple
• Formation of 20-30 ml proximal
Line
gastric pouch.
Pouch Fundus
• Delays gastric emptying &
interferes with absorption
of nutrients, high risk.
Jejunum

• Weight loss- 70-80%, irreversible

• May induce dumping syndrome

after high carbohydrate meal.
• Bariatric surgery medical complications are:-

-Short term- Wound infection, abdominal hernia

pneumonia, heart attack, pulmonary embolism, strictures,
gallstone, hair loss, fistula & leak.

-Long term-Anemia, vitamins & mineral deficiency.

-Some of the dreaded neurological complications are:-

Axonal polyneuropathy,
Wernicke’s encephalopathy,
Optic neuritis,
Radiculitis,
Meralgia parasthetica .
Endoscopic intragastric baloon

• Inflated silicon balloon is left in the

stomach for six months.

• Patient feels full sooner while

eating.

• Weight loss of about 30%

• Low risk of complications

• Side effect- nausea, vomiting and

gastric discomfort in first few weeks.
 Weight loss maintainence

Phase I Phase II
(Weight Loss) (Weight-Loss Maintenance)
When stop treatment,
the disease comes back!
Weight

3-6 months Indefinitely

QUESTIONS
1 . What is the BMI cut off to define obesity?
A) >20
B) >40
C) >30
D) >25
2 .Which of the following anti-diabetic drug can also be
used as anti-obesity medication?
A) Glimiperide
B) Linagliptin
C) Liraglutide
D) None of the above
3.Why was sibutramine taken off the market?
A) Lung carcinoma
B) Heart attack and stroke
C) Erectile dysfunction
D) All of the above
4.Which adipose tissue derived protein decreases in
obesity?
A) Adiponectin
B) RBP4
C) Resistin
D) All of the above
5.Obesity is due to mutation of following protei?
A) Leptin receptor
B) AgRP
C) NPY
D)Orexin
6. Above 25 kg/m2 BMI for increase in every 5 kg/m2 BMI
mortality increases by ?
A) 20%
B) 25%%
C) 30%
D) 35%
7. Warfarin dose adjustment should be done along with
which antiobesity drug ?
1. Sibutramine
2. Orlistat
3. Lorcaserin
4. Phentaramine
8.Dumping syndrome occurs after following bariatric
surgery?
• A) sleeve gastrectomy
• B) Gastric bypass surgery
• C) Endoscopic intragastric balloon therapy
• D) All of the above
9.)If Obesity is associated with comorbid conditions,
pharmacotherapy is used at BMI ?
A) Above 23
• B) Above 25
• C) Above 27
• D) Above 30
10.Obesity is associated with all of the following except?
A) Osteoarthritis
B) Gall stone
C) Pancreatitis
D) None
 Take home message
• Obesity is an emerging epidemic for the whole
world

• Obesity itself along with its comorbities is on the

rise

• Lifestyle management, Diet, Exercise are the initial

approach in controlling obesity rather then
medical and surgical approach.
THANK YOU