OBESITY

BACKGROUND

Obesity has become one of the most important and growing public health problems not only in resource-rich countries and transitional economies but countries like Pakistan too where resources are limited and economic instability prevails. As the prevalence of obesity increased, so did the prevalence of the comorbidities associated with obesity. For this reason, it is imperative that health care providers identify overweight and obese children so that counseling and treatment can be provided.

The term "obesity" refers to an excess of fat. However, the methods used to directly measure body fat are not available in daily practice. For this reason, obesity usually is assessed by the relationship between weight and height (i.e. anthropometrics), which provides an estimate of body fat that is sufficiently accurate.

DISEASE OCCURRENCE IN POPULATION:

According to World Health Organization (WHO) estimates, 26 % of women and 19% of men in Pakistan are obese (Body Mass index (BMI) > 25) but only 4% of women and 1 % of men are recognized as obese using the standard criteria (BMI > 30). The prevalence of obesity is even higher in urban areas (56% in men and 67% in women) when Asian specific definition for obesity is used.

RISK FACTORS:

Many factors contributes in the development of obesity

• Genetics: Your genes may affect the amount of body fat you store, and where that fat is distributed. Genetics may also play a role in how efficiently your body converts food into energy and how your body burns calories during exercise.
• Family lifestyle: Obesity tends to run in families. If one or both of your parents are obese, your risk of being obese is increased. That's not just because of genetics. Family members tend to share similar eating and activity habits.
• Inactivity: If you're not very active, you don't burn as many calories. With a sedentary lifestyle, you can easily take in more calories every day than you burn through exercise and routine daily activities. Having medical problems, such as arthritis, can lead to decreased activity, which contributes to weight gain.
• Unhealthy diet: A diet that's high in calories, lacking in fruits and vegetables, full of fast food, and laden with high-calorie beverages and oversized portions contributes to weight gain.
• Medical problems: In some people, obesity can be traced to a medical cause, such as Prader-Willi syndrome, Cushing's syndrome and other conditions. Medical problems, such as arthritis, also can lead to decreased activity, which may result in weight gain.
• Certain medications: Some medications can lead to weight gain if you don't compensate through diet or activity. These medications include some antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids and beta blockers.
• Social and economic issues: Research has linked social and economic factors to obesity. Avoiding obesity is difficult if you don't have safe areas to exercise. Similarly, you may not have been taught healthy ways of cooking, or you may not have money to buy healthier foods.
• Age: Obesity can occur at any age, even in young children. But as you age, hormonal changes and a less active lifestyle increase your risk of obesity. In addition, the amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs, and can make it harder to keep off excess weight. If you don't consciously control what you eat and become more physically active as you age, you'll likely gain weight.
• Pregnancy: During pregnancy, a woman's weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.
• Quitting smoking: Quitting smoking is often associated with weight gain. And for some, it can lead to enough weight gain that the person becomes obese. In the long run, however, quitting smoking is still a greater benefit to your health than continuing to smoke.
• Lack of sleep: Not getting enough sleep or getting too much sleep can cause changes in hormones that increase your appetite. You may also crave foods high in calories and carbohydrates, which can contribute to weight gain.

SIGN AND SYMPTOMS:

Although several classifications and definitions for degrees of obesity are accepted, the most widely accepted classifications are those from the World Health Organization (WHO), based on body mass index (BMI). The WHO designations are as follows:

• Grade 1 overweight (commonly and simply called overweight) - BMI of 25-29.9 kg/m ²
• Grade 2 overweight (commonly called obesity) - BMI of 30-39.9 kg/m ²
• Grade 3 overweight (commonly called severe or morbid obesity) - BMI ≥40 kg/m ²

Some authorities advocate a definition of obesity based on percentage of body fat, as follows:

• Men - Percentage of body fat greater than 25%, with 21-25% being borderline
• Women - Percentage of body fat great than 33%, with 31-33% being borderline

DIAGNOSTIC TEST:

Standard laboratory studies in the evaluation of obesity should include the following:

• Fasting lipid panel
• Liver function test
• Thyroid function tests
• Fasting glucose and hemoglobin A1c (HbA1c)

TREATMENT OPTIONS:

Based on your measurements and your medical history, your doctor or nurse can determine what combination of weight loss treatments would work best for you. Treatments may include changes in lifestyle, exercise, dieting and, in some cases, weight loss medicines or weight loss surgery.

LIFESTYLE CHANGES:

Programs that help you to change your lifestyle are usually run by psychologists, nutritionists, or other professionals. The goals of lifestyle changes are to help you change your eating habits, become more active, and be more aware of how much you eat and exercise, helping you to make healthier choices.

This type of treatment can be broken down into three steps:

• The triggers that make you want to eat
• Eating
• What happens after you eat

TRIGGERS TO EAT: Determining what triggers you to eat involves figuring out what foods you eat and where and when you eat them. To figure out what triggers you to eat, keep a record for a few days of everything you eat, the places where you eat, how often you eat, and the emotions you were feeling when you eat.

EATING: You can change your eating habits by breaking the chain of events between the trigger for eating and eating itself. There are many ways to do this. For instance, you can:

• Limit where you eat to a few places (e.g. dining room)
• Restrict the number of utensils (e.g. only a fork) used for eating
• Drink a sip of water between each bite
• Chew your food a certain number of times
• Get up and stop eating every few minutes

The types of foods we eat on a regular basis are related to whether we gain or lose weight over time. Whole grains, fruits, vegetables, nuts, and yogurt are associated with lower weight over four years, as contrasted with weight gain seen when eating french fried potatoes or chips, sugar-sweetened beverages, and red or processed meats.

WEIGHT LOSS MEDICINE:

Taking a weight loss medicine may be helpful when used in combination with diet, exercise, and lifestyle changes. Weight loss medicines work by reducing your appetite or by changing the way you digest food.

Weight loss medicines may be recommended for people who have not been able to lose weight with diet and exercise who have a:

• Body mass index (BMI) of 30 or more
• BMI between 27 and 29.9 and have other medical problems, such as diabetes, high cholesterol, or high blood pressure, and who have failed to achieve weight loss goals through diet and exercise alone.

Some of the weight loss medicines are described below

ORLISTAT: Orlistat is a medicine that reduces the amount of fat your body absorbs from the foods you eat. The recommended dose of the prescription version is 1 capsule three times per day, taken with a meal; you can skip a dose if you skip a meal or if the meal contains no fat.

Side effects occur in 10 to 15 percent of people and may include stomach cramps, gas, diarrhea, leakage of stool, or oily stools. These problems are more likely when you take orlistat with a high-fat meal

LORCASERIN: is a medicine that reduces appetite and thereby reduces body weight in men and women. Lorcaserin appears to have similar efficacy as orlistat. After one year, the mean weight loss is approximately 12.8 pounds compared with 6.4 pounds in the placebo group. Adverse effects of lorcaserin included headache, upper respiratory infections, nasopharyngitis, dizziness, and nausea, occurring in 18, 14.8, 13.4, 8, and 7.5 percent of patients, respectively.

LIRAGLUTIDE: Liraglutide at 3.0 mg/day is approved by the US Food and Drug Administration (FDA) for weight loss. It can be used at a lower dose to treat diabetes. Patients without diabetes taking the highest doses of liraglutide for approximately six months lost 7.4 percent of their initial body weight (16 pounds [7.2 kg]), compared with 4.3 percent (9 pounds [4.1 kg]) in patients taking orlistat. Adverse effects of liraglutide include nausea (37 to 47 percent), vomiting (12 to 14 percent), diarrhea, low blood sugar, and loss of appetite. Serious but less common side effects include pancreatitis, gallbladder disease, renal impairment, and suicidal thoughts.

SURGERY:

Bariatric surgery (from the Greek words "baros," meaning "weight," and "iatrikos," meaning "medicine") is the term for a surgery that is done to help you lose weight.

Weight loss surgery is recommended only for people with one of the following:

• Severe obesity (body mass index above 40) who have not responded to diet, exercise, or weight loss medicines
• Body mass index above 35 with a serious medical problem related to obesity (including diabetes, severe joint pain, or sleep apnea) that would improve with weight loss
• Body mass index above 30 with specific conditions, including a certain type of diabetes or a combination of diseases like high blood pressure, sleep apnea, high cholesterol, and diabetes (also known as “metabolic syndrome”)

PRECAUTIONS:

BECOME MORE ACTIVE: Many types of physical activity can help, including walking. You can start with a few minutes a day and add more as you get stronger.

IMPROVE YOUR DIET: No single diet turns out to be better than any other. It is healthy to have regular meal times and smaller portions, and not to skip meals. Avoid sweets and processed snack foods, and instead eat more vegetables and fruits.

QUIT SMOKING: (if you smoke)

LIMIT ALCOHOL: Drink no more than 1 drink a day if you are woman, and no more than 2 drinks a day if you are a man.

REFERENCES:

• Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 2001; 286:2845.
• Ogden CL, Carroll MD, Lawman HG, et al. Trends in Obesity Prevalence among Children and Adolescents in the United States, 1988-1994 Through 2013-2014. JAMA 2016; 315:2292.
• Dietz WH, Robinson TN. Clinical practice. Overweight children and adolescents. N Engl J Med 2005; 352:2100.
• WHO/IASO/ITO.Asia Pacific Perspective: Redefing obesity and its treatment   World Health Organization, Western Pacific  Region;2000.
• American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Obesity Expert Panel, 2013. Expert Panel Report: Guidelines (2013) for the management of overweight and obesity in adults. Obesity (Silver Spring) 2014; 22 Suppl 2:S41.
• Mozaffarian D, Hao T, Rimm EB, et al. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011; 364:2392.
• Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015; 100:342.