KEYWORDS: ..비만은 단순한 의지력이나 자기관리의 문제가 아니라, 식욕조절 그리고 여러 질병을 야기할 수 있는 에너지대사가 복합적으로 결합된 문제이다. ..Epidemiology : Overweight : 33~50% in U.S. men and women 20years and older Obesity : 25% in U.S. men and women 20years and older (NHANES III, 1998~1994) Body Mass Index (by WHO, 1997) ▶ BMI = Weight(in kilograms) /Height 2 (in meters) ▶ 괄호안은 아시아인 기준 ▶ For reference populations, engaged in light to moderate physical activity, with no underlying medical condition Obesity Class BMI Underweight < 18.5 Normal 18.5~24.9(22.9) Overweight 25(23)~29.9(24.9) Obesity I 30(25)~34.9(29.9) Obesity II 35~39.9 Obesity III 40(30) Population group Age(years) Kcal per kg Kcal per day Children 1~3 102 1,300 4~6 90 1,800 7~10 70 2,000 Men 11~14 55 2,500 15~18 45 3,000 19~24 40 2,900 25~50 37 2,900 51+ 55 2,300 Women 11~14 47 2,200 (non-pregnant, 15~18 40 2,200 non-lactating) 19~24 38 2,200 25~50 36 2,200 51+ 30 1,900 Step 1 Estimate the recommended individual caloric requirement (kcal per day) by calculating the resting energy expenditure (REE) For adult men : REE=10×weight (in kg)+6.25×height (in cm)-5×age (in years)+5 For adult women : REE=10×weight (in kg)+6.25×height (in cm)-5×age (in years)-161 Step 2 REE×activity factor(AF) For light activity adult men : REE×1.6 For light activity adult women : REE×1.5 For higher activity adult men : REE×1.7 For higher activity adult women : REE×1.6 REE×AF=체중을 유지하기 위한 하루 필요 칼로리 < Physical and Psychologic Complications of Obesity> ▶ Type 2 DM ▶ Hypertension ▶ Gallbladder disease ▶ Sleep apnea and other respiratory problems ▶ Heart disease ▶ Stroke ▶ Certain types of cancer (endometrial, breast, prostate, colon) ▶ Dyslipidemia ▶ Reduced fertility ▶ Osteoarthritis ▶ Increase in all-cause mortality ▶ Emotional distress ▶ Discrimination ▶ Social stigmatization 볼드체의 병들은 비만 시 Relative risk가 3 이상으로 발생 위험이 특히 높은 질환 ..비록 처음 몸무게의 10% 정도의 체중 감량이라도 고혈압, 고지혈증, 고혈당 같은 만성질환의 위험도를 감소시킨다. 69 The Root of ambulatory care Treatment Obesity ..소아비만의 경우 BMI가 85th percentile 이상이면서 비만합병증이 있는 경우 와 BMI가 95th percentile이상인 경우엔 식이습관, 신체활동량, 유전적, 내분비 적, 정신적 요인과 관련된 비만의 원인에 대한 검사 및 치료를 고려해야 한 다. 하지만 소아비만 치료의 목적은 성인과 달리 ideal body weight를 유지하 는게 아니라 건강한 식습관과 활동량을 가지도록 유도하는데 있다. - Goals ▶ Initially, attempt to reduce body weight by approximately 10% from baseline. With success, attempt further weight loss, if indicated, through further assessment. ▶ Reduce weight at a rate of about 1 to 2 lb (0.45~0.9kg) per week for six months. ▶ Base subsequent strategies on the amount of weight lost. BMI≥25(23) or Waist circumference > 89cm(35 inches) for woman, > 102cm(40inches) for man History of BMI≥25(23)? Brief reinforcement/ education about weight management Advise to maintain weight : address other risk factors Assess risk factors for cardiovascular disease and diabetes - Cigarette smoking - Hypertension - High LDL cholesterol - Low HDL cholesterol - Impaired fasting glucose - Family history of premature coronary heart disease - Age (men≥45years ; women≥55years or postmenopausal) (1) BM ≥ 30(25) (2) BMI 25-29.9(23-24.9) and two or more risk factors (3) waist circumference ≥89cm (35inches) for woman, 102cm (40inches) for man and two or more risk factors Clinician and patient devise goals and treatment strategy for weight loss and risk factor control Progress being made : goal achieved? Assess reasons for failure to lose weight Does patient want to lose weight? Periodic weight check Maintenance counseling Dietary therapy Behavior therapy Physical activity Pharmacologic therapy Blank : levels for Asian adults No Yes No Yes No Yes No No Yes Yes Fig 1. Treatment for obesity 71 The Root of ambulatory care - Dietary therapy ▶ Encourage low-calorie diets for overweight and obese adults. ▶ As part of a low-calorie diet, fat reduction is a practical way to reduce calories. ▶ Reducing dietary fat alone without reducing total calories is not sufficient for weight loss. ▶ Reducing dietary fat along with dietary carbohydrates facilitates caloric reduction. ▶ An individually planned diet creating a deficit of 500 to 1,000kcal per day should be an integral part of any program aimed at achieving a weight loss of 1 to 2 lb per week. - Physical activity ▶ Physical activity may decrease abdominal fat, increases cardiorespiratory fitness, and may help maintain weight loss. ▶ Physical activity should be an integral part of weight loss therapy and weight maintenance. ▶ Initially, encourage moderate levels of activity for 30 to 40minutes per day, three to five days per week. ▶ Set a long term goal to accumulate at least 30minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. Treatment Treatment < 운동 종목별 소모 열량 > 운동종목 Kcal/hr/kg 체중 체중 체중 체중 체중 체중 55kg(kcal/hr) 65kg(kcal/hr) 75kg(kcal/hr) 85kg(kcal/hr) 95kg(kcal/hr) 105kg(kcal/hr) 탁구 4.18 230 272 313 355 397 439 걷기(5km/h) 4.80 264 312 360 408 456 504 배구 4.84 266 315 363 411 460 508 골프 5.06 278 329 380 430 481 531 속보 5.28 290 343 396 449 502 554 배드민턴 5.72 315 372 429 486 543 601 스케이트 5.72 315 372 429 486 543 601 스키 5.72 315 372 429 486 543 601 자전거타기 5.94 327 386 446 505 564 624 테니스 6.38 351 415 479 542 606 670 등산 7.26 399 472 545 617 690 762 수영 7.70 424 501 578 655 732 809 축구 8.14 448 529 611 692 773 855 농구 8.28 455 538 621 704 787 869 조깅(9km/h) 9.24 508 601 693 786 878 970 스쿼시 12.72 700 827 954 1081 1208 1336 treatments treatments Obesity - Behavior therapy ▶ Behavior therapy is a useful adjunct to diet and physical activity. ▶ Assess patient motivation and readiness to implement the weight management plan and take steps to motivate patient for treatment. ▶ Behavior strategies to promote diet and exercise should be used routinely, as they are helpful in achieving weight loss and maintenance. - Pharmacotherapy 약물치료는 BMI가 30(아시안25)이상 이거나 BMI가 27이상 이면서 고혈압, 고지혈증, 관상동 맥질환, 제2형 당뇨, 수면 무호흡증 같은 비만관련 질환이 있을 때만 사용을 고려한다. ▶ Lifestyle therapy should be considered before drug therapy. ▶ Avoid use of drugs without accompanying lifestyle modification. ▶ Assess drug efficacy and safety continually. ▶ Discontinue use if the drug is ineffective in weight loss or weight maintenance, or if there are serious adverse effects. 1. Reductil.. 10mg, 15mg 1T qd for less than 2years : 식사와 관계없이 아침에 복용하며, 4주간 2kg 미만 감량일 땐 15mg으로 증량 Adverse effects: Increased blood pressure and heart rate, insomnia, dry mouth, constipation Contraindication : Poorly controlled hypertension, Coronary artery disease, Heart failure, Arrhythmias, Stroke 2. Xenical.. 120mg 1T tid for less than 2years : 지방함유 식사와 함께 또는 식사 1시간 이내 Adverse effect : Oily spotting, flatus with discharge, fecal urgency or incontinence, oily stool, increased defecation, decreased fat-soluble vitamine absorption Contraindication : Chronic malabsorption syndrome, cholestasis, known hypersensitivity to orlistat or its components. ..Reductil.. - Sibutramine : norepinephrine and serotonin reuptake inhibitor, early satiety ..Xenical.. - Orlistat : inhibited gastric and pancreatic lipase, decreased fat absorption ▶ Sibutramine사용시 최대효과는 투여 후 6개월이 지나서 나타나며, 투약을 지속할 경우 그 효 73 The Root of ambulatory care 과는 1년 이상 지속되는 것으로 보고되고 있다. < Complications of weight loss > ▶ Biliary complications : 급격한 체중감량은 담석과 당낭염의 발생위험을 증가시키며, 이는 low and high fat diets 양쪽 모두에서 관찰된다. Ursodeoxycholic acid의 보충이 질병예 방에 효과가 있다고 알려져 있으나 아직 근거는 부족한 실정이다. ▶ Ketosis : 불충분한 탄수화물 섭취는 혈중 Ketone body수치를 올릴 수 있다. 신장손상이 나 신장결석형성에 관한 관련여부는 아직 논란 중에 있다. ▶ Dietary deficiencies : 엄격한 칼로리 제한은 체내 필요한 비타민, 미네랄, 필수 지방산 또 는 단백질의 결핍을 야기할 수 있으며, 이 상태가 지속되면 단백질-칼로리 영양실조, 비타 민 결핍 및 골다공증 등이 올 수 있다. ▶ Cosmetic issues : 특히 급격한 체중감소시 피부에 striae가 생길 수 있다. ▶ Psychiatric changes : 완만한 또는 급격한 body habitus의 변화는 가족, 친구 또는 직장 동료와의 관계뿐만 아니라 자기 자신의 body image에도 영향을 미칠 수 있다. 이런 변화 는 항상 긍정적인 것만은 아니며, 때로는 심각한 정서적 고민거리가 될 수 있다. 참고 문헌 James M. Lyznicki, M.S., M.P.H., Donald C. Young, M.D., Joseph A. Riggs, M.D., Ronald M. Davis, M.D. : Obesity : Assessment and Management in Primary Care. A Journal of Am erican Family Physician 2001;63:2185-2196 Supawan Buranapin, M.D., Caroline M.Apovian M.D. : Obesity, in Conn’s Current Therapy 2004, Robert E.Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 629-635 National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults-the evidience report. Obe Res 1998;6(suppl 2) : 51S-209S[Published erratum appears in Obes Res 1998:6:464] Radhika R. Hariharan, M.D., MRCP(UK), Brian C. Reed, M.D., & Sarah R. Edmonson, M.D. : Obesity, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D.,L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 522-530 Jae-Hyoung Cho, Ji-Hyeon Ju, Jeoung-Won Jang : Overweight, in Clinical Road Map of Internal Medicine. Seoul, Panmun Book, 2005, P 166 김병성 : 고혈압 및 비만의 운동처방 가이드라인. 대한가정의학회지 2004 ; 25(11): 469-473