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Management of obesity

Specialist managemento 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

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, insomnia,tachycardia and hypertension

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

o Monthly monitoring for the first 3 months is needed to ensure a good response and to detect adverse effects.

o 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.

o 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

Orlistat :(Xenical) is a synthetic hydrogenated derivative of a naturally occurring lipase inhibitor

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 bulk-forming laxatives (psyllium or methylcellulose) are 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

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

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 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

Protein–energy malnutrition

Protein–energy 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, protein–energy malnutrition is most often secondary to other diseases.

Kwashiorkor-like secondary protein–energy malnutrition occurs primarily

in association with hypermetabolic acute illnesses such as trauma, burns, and sepsis.

Marasmus-like secondary protein–energy malnutrition typically results from chronic diseases such as chronic obstructive pulmonary disease (COPD), congestive heart failure, cancer, or AIDS.

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

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.

Clinical features1. 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

11. Susceptibility to infections

• 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 septicemia2 Respiratory infections esp. bronchopneumonia3 Viral infections esp. measles and herpes simplex4 tuberculosis5 Strep and staphylococcal infections6 Helminthic infestation

Investigations In addition to calculation of BMI 1) Plasma free fatty acid increases ; Ketosis and acidosis2) Plasma glucose decreases 3) Serum albumin is normal4) Urine has fixed specific gravity, creatinine excretion is low5) Mild anemia, thrombocytopenia and leukopenia , Anaemia due to folate and iron deficiency. Eosinophilia suggests parasitic infestation.

7) ESR is normal unless there is infections8) Delayed skin sensitivity tests e.g tuberculin test is false

negative 9) ECG shows sinus bradycardia and small voltage

10) Stools should be examined for parasitic infestations.11) Chest X-ray - tuberculosis is common and is easily missed if

a chest X-ray is not performed.