3. OBJECTIVES:
• PREVALENCE Of Obesity in women
• Unique features in MEDICAL HISTORY
* PHYSICAL EXAMINATION
* ANTHROPOMETRIC MEASUREMENTS
* TAILOR LAB TESTS
• Brief Review of - Medical issues
* Infertility
* Pregnancy in Obese patient.
• Management
4. Obesity is a … Emerging MENACE
Largest increase has been seen in
young adolescents and young women
5. OBESITY
“AN EMERGING MENACE”
1. > 1 Billion overweight
2. > 300 Million – Obese
3. 26% of non pregnant
women ages 20 – 39 are
overweight / obese
W
H
O
6. PREVALENCE OF OBESITY
is on increase!!
1. Obese > - Doubled
(BMI 27.5)
2. Morbid Obesity > Quadrupled
(BMI 37.5)
Super Obesity > Five fold Increase
(BMI 47.5)
7. OBESITY in Women Creates
OBESOGENIC ENVIRONMENT
1. Women at GREATER RISK FROM
OBESITY THAN MEN all across the
world
2. Rates of obesity are in women in
INDIA too.
3. Women are at disproportionate risk of
8. Obesity in Men & WOMEN in
Reproductive Age in India
Country Male Female
India 9 12 (2000)
12 16 (2009)
Punjab 30 37.5
Gujrat 15 17
UP 16 12
Haryana 14 17
Women are More Prone than men
9. – ONSET: child, teen, adult,
pregnancies, peri or postmenopausal, etc
– RATE: rapid vs. slow
– INCITING FACTORS: stress, marriage, divorce,
illness, medication, abuse, travel, trauma
History of Weight Gain is Important
10. “Obesity refers to an excess of
Total body fat, which can be
assessed by a variety of
techniques.”
OBESITY:
11. Obesity Class BMI
Underweight < 18.5
Normal 18.5 – 24.9
Overweight 25 - 29.9
Obesity I 30 – 34.9
II 35 – 39.9
Extreme Obesity III > 40
BMI & OBESITY CLASSIFICATION
– WHO Criteria
12. BMI Cutoff Weight Status Comments
<18.5 UNDERWEIGHT
Being underweight also puts you at risk
for developing many health problems.
18.5 - 23.9
HEALTHY WEIGHT
RANGE
Your weight is within normal range. You can
continue to keep a healthy weight through physical
activity and healthy eating. Keep up with the good
work!
24 - 26.9 OVERWEIGHT
Being overweight can put you at risk for
developing many chronic diseases
>27 OBESE
Obesity increases risks for developing many
chronic diseases such as heart disease and
diabetes, and decreases overall quality of
life.
BMI Cutoff for INDIAN
-2.5 in each category
13. –CENTRAL OBESITY
android,
APPLE SHAPE
– LOWER BODY OBESITY
Gynecoid
PEAR SHAPE
FAT DISTRIBUTION
Central Obesity is High Risk
For Co-Morbidities /
Complications
14. •Waist Circumference
•> 40” in males
•>35” in Females
•Waist HIP Ratio
–>1.0 in males
–>0.8 in Females
Fat Distribution
Anthropometric measurements
15. Sometimes even when BMI is within
Normal range, having too much fat
around the abdomen (APPLE SHAPE BODY)
will still put one at risk for heart disease and diabetes. Below are
the target goals for waist circumference measurements.
Target WAIST Circumference
for Indians
INDIAN WOMEN
Equals or less than
80cm (31.5 in)
16. –ACANTHOSIS NIGRICANS (darkly shaded skin
in the
flexures of the neck , axilla, or groin – IR/DM)
– Dry Scaly skin – Hypothyroidism
– Acne – PCOS, Cushing’s
– Bruising – Cushing’s, hypothyroidism
– Hyperpigmentation – Cushing’s
– Xanthomas (palmer or tuberous)–hyperlipidemia
– SKIN TAGS – IR/DM
Physical Exam – Significant Findings in
Skin
18. Wonder Why - One Always Gain Weight,
Despite Dieting And Exercise
or just drinking water !!!
Resting Metabolic Rate
19. • Calculation vs. Testing
• Calculating RMR: Used to determine daily
caloric needs and
effective caloric deficit
• Measuring RMR:
– Hand held devices
– Quick, non-invasive
– Easily administered
Resting Metabolic Rate
20. Laboratory tests
–Comprehensive Metabolic Panel
–CBC
–TFT
–Lipid Profile
–U/A
–Also Consider doing:
Insulin levels, HbA1c, CRP, Uric Acid,
CPK, C-Peptide, Vit-D and B12,
Reproductive hormones
Tailor – Lab Work up of Obese Patient
21. OBESITY & PSYCHOSOCIAL
HEALTH in WOMAN
1. Poor body image
2. Social stigmatisation (‘a laughing
matter’)
3. Lower education levels
4. Lower rates of marriage
5. Lower socio economic levels
22. Diagnostic criteria for various conditions are
not discussed here
Pre-Diabetes Fatty Liver
Diabetes type II Hyperlipidemia
Insulin Resistance Hypo-Thyroidism
Metabolic Syndrome Vitamin-D Deficiency
Cancer screening – Breast, Colon,
Endometrial, Ovarian etc.
RULE OUT Diagnosis:
23.
24. Obesity is The Root Cause of Some
of the Serious Diseases
Metabolic Disorders
• In Indians , types 2 diabetes and
hypertension has a close link to
obesity
• 60 million people suffered from
diabetes in 2012 and will exceed
100 million by 2030
• People with BMI >32.5kg/m have a
6-fold higher risk of diabetes
25. Obesity is The Root Cause of Some
of the Serious Disease
CARDIOVASCULAR DISEASES
– Obese women have 30% higher
risk of death , due to
circulatory system diseases than normal
weight individuals
CANCER
•Obese women showed more than 2 times higher
rate of breast cancer as compared with their
normal weight counterpart
26. Morbid Obesity : Takes Heavy
Toll on Women’s Health
7-40% of CANCER cases like breast
colon, rectum, kidney, pancreas etc
45% of Diabetes cases
25%of ischemic heart disease cases
HYPTENSION , DYSLIPIDEMIA
,ASTHMA., OSTEOARTHRITIS
GALL BLADDER DISEASE ETC.
27. IMPACT OF OBESITY ON
LONGEVITY In WOMEN
• Direct relationship between increasing
BMI and relative risk of dying
prematurely
Nurses health studyNurses health study
• In morbidly obese life expectancy is
reduced by
9 yrs in women
12 yrs in men
Framingham dataFramingham data
28. Obesity & Reproductive Health
• AMENORRHEA,
ANOVULATION ,
irregular menstrual
cycle, DUB is
increasingly
occurring with
higher body weight
29. Obesity is strongly
associated with
PCOS
central obesity,
hyperandrogenism, and
insulin resistance with
compensatory
hyperinsulinenia
Obesity & Reproductive Health
30. • SKIN
– Acanthosis nigricans (darkly shaded skin in the
flexures of the neck , axilla, or groin – IR/DM)
Physical Exam – Significant Findings
Skin tags – IR/DMAcanthosis nigricans
31. Is Obese Women at Risk of Infertility
an obese woman is about THRICE
as likely to be infertile as a
normal woman
it is seen that adolescent obesity is
associated with a threefold increased
risk
Polotsky AJ, hailper SM skurnick JH, LO JC sternfeld B, santoro N associated of adolescent
women’s health across the nation (SWAN) fertility steril 2010;93:2004- 11)
Yes
32.
33. OBESITY & ASSISTED
REPRODUCTION
1. Obesity leads to poorer prognosis
with Assisted Reproduction
2. Pregnancy Rates in ART halved
for women with BMI > 35 kg/m2
34. Obese women : not only have a lower
chance of pregnancy following
In Vitro Fertilization,
they require higher doses of
gonadotropins and
have an increased miscarriage rate
OBESITY & ASSISTED
REPRODUCTION
35. Causes of Poor Pregnancy Rate
Endometrial Factor
It is postulated that lower pregnancy rate associated
with obesity is caused by altered receptivity of
endomertium due to disturb endometrium function
Oocyte factor
Obese women using donor Oocytes eliminates
bad effect of quality of egg & however
reduced Live birth rate with increasing BMI
regardless of Oocytes source is seen.
LUKE B, et al. fujimoto VY the effect of maternal body mass index (BMI) and
oocyte source on assisted reproductive technology(ART)pregnancy rates
andobstetric outcomes. Fertile sterile 2009;92 suppl 1:s52
36. Even 5% Weight loss improves
fertility outcome
Impacts Fertility Outcomes
37. Complications of Obesity during Pregnancy:
independent risk factor
• Miscarriages
• Risk of medical and surgical complications
* Gestational HTN, Pre-Eclampsia, Eclampsia
* Gestational Diabetes
* Fetal Macrosomia
* Higher rate of C-Sections and operative deliveries,
infection and PPH, wound related complications
•Premature deliveries
• PROM
• IUGR, Intra-uterine fetal death
38. Weight Gain in Pregnancy
- Pre-pregnancy BMI of <20 and
target weight gain as 0.23 – 0.5
kg per week during 2nd
and 3rd
trimesters.
–If BMI is more than 26,
weight gain target is 0.14-
0.32 per week in 2nd
and 3rd
trimesters
Pregnancy is time to gain weight not
lose weight. In 1990, USA
published recommendations:
39. Pregnancy in obese patients
Specific consideration
• Labor & delivery
–Obesity is should not
change course of labor &
delivery
–C-section rates are slightly
higher in these patients
40. Management in General
• Obese patients are advised to lose
weight which may
be accomplished by one or a
combination of following
methods -
– Diet
– Diet & Exercise
– Anti-obesity Medicines
– BARIATRIC SURGERY
41. Management of Obesity
in general
1st
LINE OF MANAGEMENT : Lifestyle changes like
modification of diet , physical activity and daily habits
2nd
line of Management : introduction of pharmacotherapy
for patients with BMI above 24 with co – morbidities and
BMI above 27.5 with no co- morbidity
BARIATRIC SURGERY : may be an option for treatment
of morbid obesity (BMI > 32.5) when diet and exercise
do not work
1
2
3
42. Treatment Modalities
For Infertility in Obesity
Life – Style &
Nutrition
Changes
• Diet
• Exercise
• Psychological
Counseling
Surgical
Intervention
• Bariatric
surgery
ART
• IUI
• IVF
• ICSI
Pharmacological intervention
Appetite suppressant, Weight Loss Drugs (Orlistat)
Drugs Increase sucidal tendency
43. Word of Wisdom
Prior to ART therapy
Weight loss should be the fist – line
treatment even 5% weight loss improves
fertility outcome.
• Dietary weight loss, Regular physical
exercise , elimination of tabacco of alcohol
consumption behavior modification and
stress management may be of benefit
ESHRE human reproduction 2010;25:578-83
44. Pre-Pregnancy Counseling
• With mal-absorption - decreased folate level
may cause neural tube defects
• With crash dieting - there can be nutritional
deficiencies
• Provide supplements & consult with
nutritionist
45. Pre - Pregnancy
counseling
after Bariatric surgery
When ever possible, pregnancy should be
delayed TILL WEIGHT LOSS STABILIZES for 12-
24 months, use active contraception
46. Nutrient Supplements After
Bariatric Sx
(In Non-Pregnant)
Supplement Dose per day
Multivit 1-2
Calcium Citrate 1200-2000 mg
Vit-D 400-800 IU
Folic Acid 400 ug
Elemental Iron 40-65 mg
Vit-B12 350 ug orally or 1000 ug IM/month
47. LAP Adjustable Gastric Banding
Given - up procedure in India
SLEEVE Gastrectomy &
Gastric Bypass surgery
are the only alternative &
done routinely
Safety of surgery in India –
in good hands as safe as Lap. Cholecystectomy
Bariatric Surgery
A serious approach to serious problem
48. • Labor & delivery
–Hx of Bariatric surgery should
not change course of labor &
delivery
–C-section rates are slightly
higher in these patients
–At C- delivery, be aware of
intra abdominal adhesions
Pregnancy after Bariatric Sx:
Specific consideration
49. Summary
• There is need of SUPER SPECIALTY in gynae seeing
the Increasing prevalence of obesity in women
• Gynaecologists should be familiar with common types
of - Medical Issues
- Impact of infertility
- Special ART management
- Role of bariatric surgeries
• Post Bariatric surgery pregnancies are generally safe.
• Gynaecologist should have knowledge of nutrients’
deficiencies and - Nutrition management.
- Drug Therapy
50. ADDRESS
11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
CONTACT US
9650588339, 011-22414049,
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
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