Management of Obesity

• Promotion of increased physical activity and it’s maintenance on a long term, walking briskly for 30 minute each day can result in an additional weight loss of1 kg per month

• Where possible, this should be incorporated in the daily routine (e.g. walking rather than driving to work) since this is more likely to be sustained.

• Alternative exercise, e.g. swimming, may be necessary if musculoskeletal complications prevent walking.

• Changes in eating behaviour (including food selection, portion size control, avoidance of snacking, regular meals to encourage satiety, and substitution of sugar with artificial sweeteners) should be discussed.

• Support from a trained health-care professional (e.g. a dietitian) and participation in a group discussion may be helpful.

Specialist management o Indications :extreme or life threatening obesity, presence of complications and associated risk factors of obesity, failure of general management

1))DRUGS:

may be useful in the short term when incorporated in a program that includes diet counseling, behavior modification, and close medical supervision.

The classic sympathomimetic adrenergic agents (benz phetamine, phendimetrazine, diethylpropion, mazindol, and phentermine) function by stimulating norepinephrine release or by blocking its reuptake in the ventromedial and lateral hypothalamic regions, drugs related to amphetamine have addictive potential

the fenfluramine/phentermine combination caused valvular heart disease.

These drugs have serious side effect that restricts their use in medical practice

o

o Sibutramine :reduces food intake through B1 adrenoceptor and 5-HT receptor agonist activity,it increases metabolic rate via stimulation of peripheral B3 adrenocptor activity.

o Adverse effects :dry mouth ,constipation and insomnia,tachycardia and hypertension

o all patients should be monitored closely for blood pressure and pulse rate ,and evaluated within 1 month after initiating therapy.

o Contraindications to sibutramine use include uncontrolled hypertension, congestive heart failure, symptomatic coronary heart disease, arrhythmias, or history of stroke.

o Orlistat :(Xenical) is a synthetic hydrogenated derivative of a naturally occurring lipase inhibitor produced by the mold Streptomyces toxytricini.

o Orlistat is a potent, slowly reversible inhibitor of pancreatic, gastric, and carboxylester lipases and phospholipase A2, which are required for the hydrolysis of dietary fat into fatty acids and monoacylglycerols.

o The drug acts in the lumen of the stomach and small intestine by forming a covalent bond with the active site of these lipases.

o adverse effects : reported in at least 10% of orlistat-treated patients. These include flatus with discharge, fecal urgency, fatty/oily stool, and increased defecation. These side effects are generally experienced early, diminish as patients control their dietary fat intake.

o Psyllium mucilloid is helpful in controlling the orlistat-induced GI side effects when taken concomitantly with the medication.

o Serum concentrations of the fat-soluble vitamins D and E may be reduced, and vitamin supplements are recommended to prevent potential deficiencies

preconditions for drug therapy

• Only used in patients of 18-75 years age

• Only if the BMI >30 or >28 plus risk factors present

• Other weight reduction advices already started

• The patient should have lost at least 2.5 kg within the month prior to starting the drug

• drug should be stopped after 3 months unless 5% of weight lost and stopped after 6 months unless 10% of weight lost.

• The whole duration of treatment should not exceed 24 months

2))Treatment of associated depression is a problem since tricyclic antidepressant drugs increase weight gain

5HT reuptake inhibitors (fluoxitine) avoids this side effect

Bulk forming drugs (e.g methylcellulose)and diuretics should not be used

3))Thyroid hormone replacement only used in the presence of biochemical evidences of hypothyroidism

4))Very low calorie diets

•Under the supervision of experienced physician and a nutritionist

•Deaths had occured, some from documented ventricular tachycardia and fibrillation.

•Indicated for individuals of BMI >30 to induce a weight loss of 1.5-2.5 kg per week

•Should include a protein content of 50 gm and 40 gm for male and female respectively, energy contents of 500 kcal and 400 kcal for male and female respectively

•Side effects :orthostatic hypotension ,headache , diarrhea and nausea

Surgical managementIndications: for those with BMI of >40 or >35 plus risk factors or

life threatening co morbid diseases.

Hypertension, hyperlipidemia and diabetic glycemic control are markedly improved but short term post operative and long term medical complications need careful follow-up of these patients Vertical band gastroplasty and gastric bypass procedures involve creation of a similar small pouch but with drainage into a loop of jejunum rather than into the lower stomach.

Jaw wiring and the use of liquid food,but weight regain after unwiring is usual

Apronectomy is used for removal of overhanging abdominal fat Jejunoileal bypass has unacceptable mortality and morbidity thus , no longer recommended