Obesity 1

LINA FA
LO 2

• Epidemiologi, etiologi, faktor resiko, kriteria diagnosis

(anamnesis, pemeriksaan fisik, pemeriksaan penunjang),
tatalaksana, pencegahan, prognosis dan komplikasi dari Obesitas
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• Overweight and obesity are defined as abnormal or excessive fat

accumulation that may impair health.
• Body mass index (BMI) is a simple index of weight-for-height that
is commonly used to classify overweight and obesity in adults.
• It is defined as a person's weight in kilograms divided by the
square of his height in meters (kg/m2).
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• For adults, WHO defines overweight and obesity as follows:

• overweight is a BMI ≥ 25
• obesity is a BMI ≥ 30.
• BMI provides the most useful population-level measure of
overweight and obesity as it is the same for both sexes and for all
ages of adults.
• For children, age needs to be considered when defining
overweight and obesity.
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• For children under 5 years of age:

• overweight is weight-for-height > 2 standard deviations above WHO
Child Growth Standards median; and
• obesity is weight-for-height > 3 standard deviations above the WHO
Child Growth Standards median.
• Children aged between 5–19 years
• overweight is BMI-for-age > 1 standard deviation above the WHO
Growth Reference median; and
• obesity is BMI-for-age > 2 standard deviations above the WHO Growth
Reference median.
EPIDEMIOLOGY 6

• Facts about overweight and obesity

• Some recent WHO global estimates follow.
• In 2016, more than 1.9 billion adults aged 18 years and older were
overweight. Of these over 650 million adults were obese.
• In 2016, 39% of adults aged 18 years and over (39% of men and 40% of
women) were overweight.
• Overall, about 13% of the world’s adult population (11% of men and 15%
of women) were obese in 2016.
• The worldwide prevalence of obesity nearly tripled between 1975 and
2016.
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• In 2016, an estimated 41 million children under the age of 5 years

were overweight or obese.
• Once considered a high-income country problem, overweight and
obesity are now on the rise in low- and middle-income countries,
particularly in urban settings.
• In Africa, the number of overweight children under 5 has increased
by nearly 50 per cent since 2000. Nearly half of the children under
5 who were overweight or obese in 2016 lived in Asia.
• Over 340 million children and adolescents aged 5-19 were
overweight or obese in 2016.
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• While just under 1% of children and adolescents aged 5-19 were

obese in 1975, more 124 million children and adolescents (6% of
girls and 8% of boys) were obese in 2016.
• Overweight and obesity are linked to more deaths worldwide than
underweight. Globally there are more people who are obese than
underweight – this occurs in every region except parts of sub-
Saharan Africa and Asia.
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• The fundamental cause of obesity and overweight is an energy

imbalance between calories consumed and calories expended.
• Globally, there has been:
• an increased intake of energy-dense foods that are high in fat; and
• an increase in physical inactivity due to the increasingly sedentary
nature of many forms of work, changing modes of transportation,
and increasing urbanization.
• Changes in dietary and physical activity patterns are often the result
of environmental and societal changes associated with development
and lack of supportive policies in sectors such as health, agriculture,
transport, urban planning, environment, food processing,
distribution, marketing, and education.
ETIOLOGY : 10

• Multi-factorial and includes genetic, neuroendocrine, metabolic,

psychological, environmental and socio-cultural factors.
• Many co-morbid conditions like metabolic, cardiovascular,
psychological, orthopaedic, neurological, hepatic, pulmonary and
renal disorders are seen in association with childhood obesity.
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Gene mutation and obesity 13

• Single and polygenic gene mutations that occur naturally can produce
obesity in rodents like mice and rats.
• These mutations produce phenotypes of severe hyperphagia, obesity,
type 2 diabetes, defective thermogenesis, and infertility.
• The mutant gene responsible for the phenotype in Lepobmice encodes a
protein termed leptin, which is deficient in these animals3.
• Leptin deficiency has been documented in subsets of human obesity3.
• Genetic conditions known to be associated with predilection for obesity
include Prader-Willi syndrome, Bardet-Biedl syndrome, and Cohen
syndrome.
Neuroendocrinology of energy metabolism
14

• Energy metabolism is controlled by complex neuroendocrine

interactions, which influence food intake and energy expenditure.
• Leptin, almost exclusively produced by the adipose tissue is the major
hormone in this mechanism that acts centrally in the hypothalamus.
• High leptin and insulin concentrations found during feeding and weight
gain, decrease food intake and increase energy expenditure through
release of melanocortin and corticotropin-releasing hormone, among
others.
• The major peptides that stimulate feeding are orexins A and B, which
are secreted by the hypothalamus, and ghrelin, which is secreted by the
stomach3.
Fundamental phases in evolution of obesity
15

• Intrauterine growth patterns play a significant role in the evolution of

obesity by modifying fat and lean body mass, neuroendocrine appetite
control mechanisms, and pancreatic functional capacities.
• Longitudinal studies have identified a strong relationship between birth
weight and BMI attained in later life.
• Increasing birth weight was independently and linearly associated with
increasing prevalence of childhood obesity in the Avon Study12.
• The nature and duration of breastfeeding have been found to be
negatively associated with risk of obesity in later childhood17,18. A
systematic review of nine studies has concluded that breastfeeding
seems to have a small but consistent protective effect against obesity in
children.
Environmental risk factors for obesity
16

• Sub-optimal cognitive stimulation at home and poor socio-

economic status predict development of obesity23.
• Parental food choices significantly modify child food
preferences24, and degree of parental adiposity is a surrogate for
children’s fat preferences2
• Children and adolescents of poor socio-economic status tend to
consume less quantities of fruits and vegetables and to have a
higher intake of total and saturated fat26–28
Societal changes and obesity
17

• There is evidence stating that individual’s eating and physical

activity behaviours are heavily influenced by surrounding social
and physical environmental contexts both for adults and children.
• Urbanization related intake behaviours that have been shown to
promote obesity include frequent consumption of meals at fast-
food outlets31,32, consumption of oversized portions at home and
at restaurants33,34, consumption of high calorie foods, such as
high-fat, low-fiber foods35,36, and intake of sweetened
beverages37,38.
• Television viewing and other sedentary activities have also been
related to childhood obesity39,40
Obesitas idiopatik dan endogen 18

• Idiopatik (primer/ nutrisional) dan Endogen ( sekunder/non

nutrisional)
Idiopatik Endogen
> 90% kasus <10% kasus
Perawakan tinggi (> 50th persentil TB/U) Perawakan pendek (<5th persentil TB/U)
Riwayat obesitas dalam keluarga Tidak ada riwayat obesitas keluarga
Fungsi mental normal Fungsi mental retardasi
Usia tulang normal/advanced Usia tulang terlambat
Pmx fisik normal Terdapat stigmata pada pemeriksaan fisis
CO-MORBIDITIES RELATED TO OBESITY
19
Type 2 diabetes mellitus
20

• The association of obesity with type 2 diabetes in adolescents and

children is very strong and confirmed by various studies.
• Evidence entail that obesity driven type 2 diabetes might become
the most common form of newly diagnosed diabetes in adolescent
youth within 10 years55.
• Evidence is accumulating which suggests a global spread of type 2
diabetes in childhood56
Cardiovascular abnormalities
21

• Obesity significantly contributes to morbidity and mortality from

cardiovascular disease.
• Obesity may affect the heart through its influence on known risk
factors such as dyslipidaemia, hypertension, glucose intolerance,
inflammatory markers, obstructive sleep apnoea/hypoventilation,
and the prothrombotic state, as well as through yet unrecognized
mechanisms.
Treatment of obesity 22

• Dietary management, Due emphasis should be given to reduction

of eat outs, planning for healthy snacks, balanced diet, adequate
intake of fruits and vegetables, fiber content of diet and
avoidance of high calorie/high fat foods. The benefits of salt
reduction, restriction of sugar rich beverages and avoidance of
trans fatty acids from the diet are supported with strong evidence
• Physical activity enhancement,
• Restriction of sedentary behaviour,
• Pharmacotherapy; sibutramine, orlistat and metformin
• Bariatric surgery.
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• Pharmacotherapy should be reserved as a second line of

management and should be considered only when insulin
resistance, impaired glucose tolerance, hepatic steatosis,
dyslipidaemia or severe menstrual dysfunction persist inspite of
lifestyle interventions.
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• Adolescent candidates for bariatric surgery should be very

severely obese (defined by body mass index of > 40), have
attained a majority of skeletal maturity (generally > 13 yr of age
for girls and > 15 yr of age for boys), and have co-morbidities
related to obesity that might be remedied with durable weight
loss86.
• More severe elevation of BMI (>50 kg/m2) may be an indication for
surgical treatment in the presence of less severe co-morbidities.
• The bariatric procedures preferred in adolescents are Roux-en-Y
gastric bypass and adjustable gastric banding.
Komponen tatalaksana obesitas 25

Pengaturan diet
Menetapkan Aktifitas fisik
target penurunan KH (50-60%),
BB (0,5 kg/mgg) lemak (30%), 20-30 menit/hari
Protein (15-20%)

Modifikasi Keterlibatan
perilaku keluarga
PREVENTION OF OBESITY 26

• The strategies may be attempted at the individual, community or physician’s

level.
• Those at the individual level backed by consistent evidence include limiting
sugar sweetened beverages, reducing daily screen time to less than two hours,
removing television and computers from primary sleeping areas, eating
breakfast regularly, limiting eating out especially at fast food outlets,
encouraging family meals and limiting portion sizes. Engage in regular physical
activity 60 minutes a day for children and 150 minutes spread through the week
for adults.
• Community level interventions include advocacy to increase physical activity at
schools and at home through the creation of environments that support physical
activity.
• Physicians should encourage parents to be role models when it comes to healthy
diets, portion sizes, physical activity and screen time.
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• Individual responsibility can only have its full effect where people
have access to a healthy lifestyle.
• Therefore, at the societal level it is important to support
individuals in following the recommendations above, through
sustained implementation of evidence based and population based
policies that make regular physical activity and healthier dietary
choices available, affordable and easily accessible to everyone,
particularly to the poorest individuals.
• An example of such a policy is a tax on sugar sweetened
beverages.
What are common health consequences of
overweight and obesity? 28

• Raised BMI is a major risk factor for noncommunicable diseases such as:
• cardiovascular diseases (mainly heart disease and stroke), which were the leading cause
of death in 2012;
• diabetes;
• musculoskeletal disorders (especially osteoarthritis – a highly disabling degenerative
disease of the joints);
• some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder,
kidney, and colon).
• The risk for these noncommunicable diseases increases, with increases in BMI.
• Childhood obesity is associated with a higher chance of obesity, premature death and
disability in adulthood.
• But in addition to increased future risks, obese children experience breathing difficulties,
increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin
resistance and psychological effects.
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