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Management of obesity

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• Specialist management
• Indications extreme or life threatening
  obesity, presence of
• complications and associated risk factors of
  obesity, failure of general
• management
• 1) Drugs
• The classic sympathomimetic adrenergic agents
  (benz phetamine, 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

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• Sibutramine reduces food intake through B1
  adrenoceptor and 5-HT receptor agonist
  activity,it increases metabolic rate via
  stimulation of peripheral B3 adrenocptor
  activity.
• Adverse effects dry mouth ,constipation,
  insomnia,tachycardia and hypertension
• Contraindications to sibutramine use include
  uncontrolled hypertension, congestive heart
  failure, symptomatic coronary heart disease,
  arrhythmias, or history of stroke.
• Monthly monitoring for the first 3 months is
  needed to ensure a good response and to detect
  adverse effects.
• All patients should be monitored closely for
  blood pressure and pulse rate .A minority of
  patients will have hypertension and tachycardia
  that contraindicate the use of the medication.
• Failure to lose weight during the first 1 to 2
  months is a strong indicator of drug treatment
  failure and should also prompt the physician to
  discontinue sibutramine

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• Orlistat (Xenical) is a synthetic hydrogenated
  derivative of a naturally occurring lipase
  inhibitor
• 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.
• The drug acts in the lumen of the stomach and
  small intestine by forming a covalent bond with
  the active site of these lipases.
• 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.
• bulk-forming laxatives (psyllium or
  methylcellulose) are helpful in controlling the
  orlistat-induced GI side effects when taken
  concomitantly with the medication.
• Serum concentrations of the fat-soluble vitamins
  D and E may be reduced, and vitamin supplements
  are recommended to prevent potential deficiencies

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• preconditions for drug
  therapy
• Only used in patients of 18-75 years age
• Only if the BMI gt30 or gt28 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

• Treatment of associated depression is a problem
  since tricyclic antidepressant drugs increase
  weight gain ,5HT reuptake inhibitors (fluoxitine)
  avoids this side effect
• Thyroid hormone replacement only used in the
  presence of biochemical evidences of
  hypothyroidism

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• 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 gt30 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

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Surgical management

• Indications for those with BMI of gt40 or gt35
  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 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

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• Proteinenergy malnutrition

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• Proteinenergy malnutrition
• occurs as a result of a relative or absolute
  deficiency of energy and protein.
• It may be primary, due to inadequate food
  intake,
• or secondary, as a result of other illness.
• For most developing nations.
• In children, starvation (protein-energy
  malnutrition, PEM) is manifest as the syndromes
  of kwashiorkor (malnutrition with oedema) and
  marasmus (malnutrition with marked
  muscle-wasting).
• In industrialized societies, proteinenergy
  malnutrition is most often secondary to other
  diseases.
• Kwashiorkor-like secondary proteinenergy
  malnutrition occurs primarily in association with
  hypermetabolic acute illnesses such as trauma,
  burns, and sepsis.
• Marasmus-like secondary proteinenergy
  malnutrition typically results from chronic
  diseases such as chronic obstructive pulmonary
  disease (COPD), congestive heart failure, cancer,
  or AIDS.

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In adults

• The predominant form of PEM is under nutrition
  results from a sustained negative energy balance.
• Etiology
• Insufficient food supply
• Persistent regurgitation or vomiting
• Anorexia
• Malabsorption
• Increased energy requirement e.g. thyrotoxicosis
• Increased calorie loss e.g. glucosuria in
  diabetes mellitus
• Under nutrition often leads to vitamin
  deficiency esp. thiamin ,folate and vit C.
• Diarrhea is also seen in these patients
  leading to loss of sodium ,potassium and
  magnesium

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• Pathophysiology
• In the first 24 hours following low dietary
  intake, the body relies for energy on the
  breakdown of hepatic glycogen to glucose, then
  gluconeogenesis to maintain glucose levels.
• The majority of protein breakdown takes place in
  muscle releasing amino acids (used for
  gluconeogenesis), with eventual loss of muscle
  bulk.
• Lipolysis, The stored triglyceride is hydrolysed
  by lipase to glycerol (used for gluconeogenesis),
  and to non-esterified fatty acids that can be
  used directly as a fuel or oxidized in the liver
  to ketone bodies.

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Clinical features

1. Loss of weight
2. Thirsty ,weakness, nocturia ,amenorrhea
   ,impotence and craving for food
3. Lax ,pale ,dry skin ,loss of turgor and
   occasionally pigmented patches
4. Hair thinning , cold and cyanosed extremities ,
   pressure sore
5. Muscle wasting and Loss of subcutaneous fat
6. Odema even in the absence of hypo albuminemia
7. Slow pulse , low blood pressure and small heart
8. Distended abdomen with diarrhea
9. Diminished tendon jerk
10. Apathy , loss of initiatives , depression
    introversion

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• The most common cause of death in famine is
  infections and the usual signs of infection may
  not appear
• All organs atrophy except the brain
• Old people are more vulnerable to death

1 Gasteroenteritis and gram negative septicemia
2 Respiratory infections esp. bronchopneumonia
3 Viral infections esp. measles and herpes simplex
4 tuberculosis
5 Strep and staphylococcal infections
6 Helminthic infestation
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Investigations

• In addition to calculation of BMI
• Plasma free fatty acid increases Ketosis and
  acidosis
• Plasma glucose decreases
• Serum albumin is normal
• Urine has fixed specific gravity, creatinine
  excretion is low
• Mild anemia, thrombocytopenia and leukopenia ,
  
• Anaemia due to folate and iron
  deficiency.
• Eosinophilia suggests parasitic
  infestation.
• ESR is normal unless there is infections
• Delayed skin sensitivity tests e.g tuberculin
  test is false negative
• ECG shows sinus bradycardia and small voltage
• Stools should be examined for parasitic
  infestations.
• Chest X-ray - tuberculosis is common and is
  easily missed if a chest X-ray is not performed.