Transcript Management_of_Obesityx

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 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 management
Indications: 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