Overview of therapy for obesity in adults

The morbidity and mortality related to being overweight or obese are known to the medical community since the time of Hippocrates over 2500 years ago. Overweight refers to a weight above the “normal” range, with normal defined on the idea of actuarial data. this is often determined by calculating the body mass index (BMI, defined because the weight in kilograms divided by height in meters squared). Overweight is defined as a BMI of 25 to 29.9 kg/m 2 ; obesity is defined as a BMI of ≥30 kg/m 2 . Severe obesity is defined as a BMI ≥40 kg/m 2 (or ≥35 kg/m 2 within the presence of comorbidities).
An overview of therapy for obesity is provided here. Information on specific therapies for obesity and health hazards related to obesity is reviewed intimately elsewhere.

CLINICAL GUIDELINES

— Several guidelines are available for the evaluation and treatment of obesity including:
• The American Gastroenterological Association (AGA) medical position statement and technical review also available on the AGA website
• American College of Physicians
• National Heart Lung and Blood Institute and therefore the North American Association for the Study of Obesity
Some of these approaches are reviewed well separately.
PREVALENCE


Adults —

Obesity could be a chronic disease that’s increasing in prevalence within the us and worldwide. the proportion of usa citizens with a BMI above 25 kg/m 2 or 30 kg/m 2 has been determined in several government surveys, beginning in 1960 the information are collected in two different ways: annual telephone surveys conducted by state Departments of Health unitedly with the Centers for Disease Control and Prevention in Atlanta, GA (the Behavioral Risk Factor closed-circuit television [BRFSS]), and direct measurement of height and weight in field surveys (National Health and Nutrition Examination surveys).
BRFSS data provides a prevalence that’s about two-thirds that of the NHANES surveys this might be because people underreport their weight, over-report their height, or both, during the phonephone surveys. Data would suggest that they are doing a touch of both. When reading the literature on prevalence of overweight within the US, it’s therefore important to spot which method has been used.
Behavioral risk factor (telephone) survey
— The subjective prevalence of obesity (obtained by self-report) within the us increased from a median of 19.8 percent in 2000 to 26.7 percent in 2009
Although the prevalence of obesity varies across states within the US by 2004 all states had over 15 percent obesity. In 2009, just about one state (Colorado) reported over 20 percent obesity while nine states reported quite 30 percent obesity
National health and nutrition examination survey (NHANES) — The measured prevalence of obesity is on top of the phonephone prevalence (35.7 percent versus 26 percent) based upon data collected for NHANES between 2009 and 2010 The NHANES-measured prevalence of obesity among patients with type 2 DM is even higher (54.8 percent measured between 1999 and 2002) The age-adjusted prevalence of sophistication 3 obesity (BMI ≥40), sometimes spoken as severe obesity, was 6.3 percent in 2009 to 2010
Although the prevalence of obesity increased substantially within the period between the 1976 to 1980 and 1999 to 2000 NHANES, it failed to significantly change in women over the ten year period from 1999 to 2008 or in men over the five year period from 2003 to 2008 Compared with 2003 to 2008, there was also no change within the prevalence of obesity in 2009 to 2010 (35.5 and 35.8 percent among adult men and girls, respectively
Canada
— In Canada, fewer than 10 percent of individuals were obese altogether nine provinces in 1985, but by 1990 only three provinces had fewer than 10 percent obese people, and by 1994 no provinces were still during this low percentage category and five had obesity rates between 15 and 19 percent ]. Between 2007 and 2009, over 27 percent of men and 23 percent of girls were obese, a gradual and distressing increase These data and people from other countries are indicative of a serious international epidemic.

Worldwide

— Mean body mass index is increasing worldwide Despite the wide selection, all data suggest that the majority populations have increased the proportion who are overweight over the past 20 years. Reported prevalence rates of obesity include 11 percent of men and 10 percent of ladies in Belgium (2002 to 2004), 23 percent of men and girls within the UK (2009), 24 percent of men and 34 percent of girls in Mexico (2006), 9 percent of men and 27 percent of ladies in Republic of South Africa (2003), and eight percent of men and 13 percent of ladies in Pakistan (1994
There appears to be a changing perception of obesity. This was illustrated in an exceedingly population survey study during which fewer overweight and obese individuals defined themselves as overweight in 2007 compared to 1999, despite a big increase within the prevalence of obesity
Children and adolescents — The prevalence of obesity has also increased among children and adolescents within the u. s. .)

LIFETIME RISK

— The lifetime risk of developing overweight within the us is critical. Using the info from the Framingham Heart Study the calculated four-year risk of becoming overweight (BMI >25 kg/m 2 ) for men and girls at ages 30, 40, and 50 who had a standard BMI at each age was 14 to 19 percent in women and 26 to 30 percent in men. The four-year risk for developing a BMI >30 kg/m 2 if BMI was normal at baseline was 5 to 7 percent for ladies and seven to 9 percent for men. Over the longer 30-year interval, the risks were similar in men and girls, and varied somewhat with age, being lower if you were under 50 years old. The 30-year risk was one in two (50 percent) of developing overweight (BMI >25 kg/m 2 ), was one in four (25 percent) of developing a BMI >30 kg/m 2 , and 1 in 10 (10 percent) of developing a BMI >35 kg/m 2 and also the long-term (10 to 30 year) risk of becoming overweight


IMPORTANCE OF WEIGHT LOSS

— The medical rationale for weight loss in obese subjects is that obesity is related to a big increase in mortality) and plenty of health risks including type 2 diabetes, hypertension, dyslipidemia, and coronary cardiovascular disease. These risks are reviewed very well separately.
Benefits of weight loss
— insurance reports were the primary to suggest that reducing weight lowers morbidity and mortality. This notion has subsequently been supported in other studies that are reviewed thoroughly separately.
In spite of the known risks of obesity and therefore the health benefits of weight loss, clinicians are diagnosing obesity and recommending therapy in mere a minority of patients..

Maintenance of weight loss

— Achieving and maintaining weight loss is created difficult by the reduction in energy expenditure that’s induced by weight loss. In one study, as an example, maintenance of weight at 10 percent below the baseline weight in obese subjects was related to an 8 kcal/kg decrease in energy expenditure
Recidivism, which is regaining of lost weight, could be a common problem in treating obesity. Some reports suggest that subjects who change state during any treatment program might not maintain the load loss variety of strategies to assist maintain weight loss are reviewed separately..
Characteristics of these who are likely to succeed include a weight loss of over 2 kg in four weeks, frequent and regular attendance at a weight loss program, and therefore the subject’s belief that his or her weight is controlled. Behavioral interventions can also help individuals maintain their weight loss..
Exercise consistently stands out as a crucial consider maintaining weight loss after any weight reduction.
Risks of weight loss — Some studies have suggested that weight loss is also related to an increased risk of death However, these studies couldn’t distinguish intentional from unintentional weight loss. When intentional weight loss was distinguished from unintentional weight loss], intentional weight reduced mortality, whereas unintentional weight was related to increased risk of mortality.
Weight loss may increase the likelihood of cholelithiasis because the flux of cholesterol through the biliary system increases. Diets with moderate amounts of fat that trigger gallbladder contraction may reduce this risk. Similarly, therapy with a steroid (eg, ursodeoxycholic acid ) is also advisable in selected subjects, like those that are losing weight rapidly (>1 to 1.5 kg/week).
APPROACH TO THERAPY — over two-thirds of adults within the us are either trying to change state or to take care of their weight However, only 20 percent are both eating fewer calories and interesting in a minimum of 150 minutes of physical activity during leisure weekly. Thus, clinicians can play a crucial role in educating people regarding the necessity for and therefore the optimal strategies for losing weight. For initial weight loss, treatment should be geared toward decreasing food intake and, when possible, increasing energy expenditure. the previous could also be accomplished by dieting, with or without the addition of anti-obesity drugs.
All treatments of obesity entail some risk. Several groups including the Institute of drugs, The National Heart, Lung and Blood Institute together with the North American Association for the Study of Obesity, have provided guidelines to assist in making risk-benefit evaluations and choosing therapy The initial approach to the treatment of overweight or obese subjects must consider the subsequent questions:
• What are the risks of treatment?
• Is treatment appropriate?
• What is that the most appropriate treatment regimen

What are the chances of treatment? — Treatments for obesity are often divided in line with the risk of side effects. Most of the currently available drugs have minor side effects that diminish with treatment; however, some serious side effects are identified that ought to preclude short-term use in subjects who wish to lose small amounts of weight (the majority of overweight people). Even with potentially dangerous drugs, chronic treatment could also be needed when the magnitude of the obesity carries larger risks, eg, a BMI above 30 kg/m 2 , or between 27 and 30 kg/m 2 with complicating factors like diabetes or hypertension
Is treatment appropriate? — The goal of therapy is to forestall the complications of obesity noted above. Both overall fatness and central adiposity should be assessed. The BMI is that the most practical thanks to evaluate the degree of excess weight and therefore the waist circumference is that the most practical measure of central adiposity. BMI is calculated as follows:
BMI = weight (in kg) ÷ square of stature (height squared, in meters)
The BMI is estimated from a table or a calculator BMI is correlated with body fat and is comparatively unaffected by height. Overweight and obesity are defined as a BMI between 25 and 29.9 kg/m 2 and ≥30 kg/m 2 , respectively.
Waist circumference is measured with a metal or plastic, nondistensible measuring device, placed round the abdomen at the umbilicus parallel to the ground with the patient standing
When estimating the cardiovascular risk related to obesity from the BMI, both regional fat distribution and comorbid conditions should be taken under consideration..
• A BMI of 20 to 25 kg/m 2 is related to little or no increased risk unless visceral fat is high, or the topic has gained over 10 kg since age 18 years.
• Subjects with a BMI of 25 to 30 kg/m 2 could also be described as having low risk, while those with a BMI of 30 to 35 kg/m 2 are at moderate risk.
• Subjects with a BMI of 35 to 40 kg/m 2 are at high risk, and people with a BMI above 40 kg/m 2 are at very high risk from their obesity.
Central adiposity
— At any given level of BMI, the chance to health is increased by more abdominal fat, dyslipidemia, hypertension, age but 40 years, male sex, and a robust case history of diabetes, hypertension, or cardiopathy. With these measures, the presence of the Metabolic Syndrome are often diagnosed. Its presence suggests increased risk for diabetes and cardiovascular disease.
Subjects within the highest risk categories should receive the foremost aggressive treatment.
Some subjects may need to melt off, whether or not they’re not “overweight.” For this group, exercise is that the first recommendation. additionally, psychotherapy techniques and a diet is also helpful.

What is the foremost appropriate treatment?

— Treatments for obesity either decrease energy intake or increase energy expenditure. those who decrease energy intake have a greater potential for causing weight loss than those who increase energy expenditure through exercise.
All of our nutrient energy comes from food and beverages; thus, we will potentially reduce nutrient intake to zero (starvation). In contrast, energy expenditure encompasses a minimum level related to the energy required to keep up vital sign, repair tissues, and maintain function of the guts and other organs. Simply staying in bed reduces energy expenditure to approximately 0.8 kcal/min (1150 kcal/day) for a normal-weight adult. High levels of physical activity can increase energy expenditure four- to eightfold.
Thus, for initial weight loss, treatment should be geared toward decreasing food intake and, when possible, increasing energy expenditure. the previous could also be accomplished by dieting, with or without the addition of anti-obesity drugs.

Behavior modification

— psychotherapy or behavior modification is one cornerstone within the treatment for obesity. These concepts are usually included in programs conducted by psychologists or other trained personnel moreover as many self-help groups

Dietary therapy — Approximately 22 to 25 kcal/kg is required to keep up one kilogram of weight in an exceedingly normal adult. Thus, the expected or calculated energy expenditure for a girl weighing 100 kg is approximately 2200 to 2500 kcal/day. The variability of ± 20 percent could make energy needs as high as 2620 to 3000 kcal/day and as low as 1860 to 2000 kcal/day.
No adult who has been studied in an exceedingly metabolic chamber has needed fewer than 1000 kcal/day for weight maintenance. Thus, even subjects who claim to be “metabolically resistant” to weight loss should turn if they suits a diet of 800 to 1200 kcal/day. If subjects claim to eat but 1200 kcal/day and yet don’t thin one can conclude they’re recording intake erroneously and suggest that they reduce by half what they claim to eat. More severe caloric restriction may well be expected to induce weight loss more quickly, but a comparison with 400 versus 800 kcal/day diet formulas showed no difference in weight loss. We thus recommend diets with >800 kcal/day.
The selection of a diet depends upon the subjects’ preferences. like any treatment recommendation, the patient’s expectations should be assessed. Many patients and a few clinicians have unrealistic expectations of the speed that individuals can thin. A loss of 5 percent or more by six months is realistic, but over that’s often seen. If weight loss is related to improvement in associated risk factors and is maintained, then therapy has been “successful” with today’s treatment programs.
If weight loss is a smaller amount than 5 percent within the first six months, something else should be tried. One option would be to use portion-controlled foods like frozen dinners or lunch entrees, and shakes or food bars that have an outlined number of calories Weight loss of quite 5 percent of initial weight is satisfactory; but one-half of subjects will lose 10 percent or more of initial weight before reaching a plateau.
The addition of dietary counseling may facilitate weight loss, particularly during the primary year.)


Exercise

— Increasing energy expenditure through physical activity has particular attractiveness in efforts at long-term maintenance of a lower weight.
Drug therapy
— Drug therapy could also be a helpful component of the treatment regimen for obese subjects; it is considered for those with a BMI greater than 30 kg/m 2 , or a BMI of 27 to 29.9 kg/m 2 if they need comorbid conditions]. The role of drug therapy has been questioned thanks to concerns about efficacy, the potential for abuse, and side effects.)


Liposuction

— Removal of fat by aspiration after injection of physiologic saline has been accustomed remove and contour subcutaneous fat. While this will end in a big reduction in fat mass and weight, it doesn’t appear to boost insulin sensitivity or risk factors for coronary heart condition. This was illustrated in an exceedingly study of 15 obese women (eight with normal glucose tolerance and 7 with type 2 diabetes) who underwent metabolic evaluation before and 10 to 12 weeks after large-volume abdominal liposuction with the subsequent results]:
• Liposuction decreased the amount of subcutaneous abdominal fatty tissue by 44 percent (9 kg) within the women with normal glucose tolerance and 28 (10.5 kg) percent in those with diabetes.
• Although waist circumference and plasma leptin concentrations were significantly decreased, no improvements in insulin sensitivity of muscle, liver, or animal tissue were seen in either group (assessed by the stimulation of glucose disposal, the suppression of glucose production, and therefore the suppression of lipolysis, using euglycemic hyperinsulinemic clamps and isotope-tracer infusions).
• Liposuction failed to alter plasma concentrations of C-reactive protein, interleukin-6, tumor necrosis factor alpha, or adiponectin and there have been no significant improvements in other risk factors for coronary heart condition including pressure, plasma glucose, lipid, or insulin concentrations..)
Thus, removal of enormous volumes of subcutaneous abdominal fat with liposuction doesn’t improve insulin sensitivity or risk factors for coronary cardiopathy in obese women with or without type 2 diabetes, suggesting that the negative energy balance induced by decreased nutritional intake and/or removal of visceral fat are necessary for achieving the metabolic benefits of weight loss.

Surgery

— Several surgical approaches (collectively remarked as “bariatric surgery”) are accustomed treat severe obesity that has not skillful the above approaches. Indications for the surgical management of morbid obesity were outlined by the National Institutes of Health (NIH) Consensus Development Panel in 1991 and still represent generally-accepted guidelines. Potentially eligible patients should: • Be well-informed and motivated • Have a BMI ≥40 kg/m 2 • Have acceptable risk for surgery • Have failed previous non-surgical weight loss The NIH also suggested that adults with a BMI ≥35 kg/m 2 who have serious comorbidities like severe diabetes, sleep disorder, or joint disease can also be candidates. In a meta-analysis, a majority of patients undergoing bariatric surgery for obesity experienced complete resolution or improvement in diabetes, hypertension, hyperlipidemia, and obstructive sleep disorder In addition, a randomized, trial found that laparoscopic adjustable gastric banding was significantly more practical than medical management at two years follow-up in patients with mild to moderate obesity (BMI 30 to 35 kg/m 2 ) This topic is discussed thoroughly elsewhere. ( Complementary therapies — variety of complementary therapies, specifically, ephedra and other dietary supplements, are used for weight loss. These are described well elsewhere. Acupuncture has also been studied for the treatment of obesity. While most studies are uncontrolled trials, results from some, but not all controlled trials have shown modest advantage of acupuncture for weight loss However, the bulk of those controlled trials are small, of short duration, and don’t include adequate placebo controls. INFORMATION FOR PATIENTS — UpToDate offers two sorts of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a few given condition. These articles are best for patients who desire a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the present topic. We encourage you to print or e-mail these topics to your patients. (You can even locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.) • Basics topics • Beyond the fundamentals topics SUMMARY and proposals • The medical rationale for weight loss in obese subjects is that obesity is related to a big increase in mortality ) and lots of health risks including type 2 diabetes, hypertension, dyslipidemia, and coronary cardiopathy. • Selection of treatment for overweight subjects is predicated upon an initial risk assessment. • All patients who are overweight (BMI ≥25 kg/m 2 ) or obese (BMI ≥30 kg/m 2 ) should receive counseling on diet, lifestyle, and goals for weight management. for people with a BMI >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have did not achieve weight loss goals through diet and exercise alone, we advise pharmacologic therapy be added to diet and exercise Detailed recommendations for pharmacotherapy are discussed separately. .) • For patients with BMI ≥40 kg/m 2 who have did not slenderize with diet, exercise, and drug therapy, we recommend bariatric surgery Individuals with BMI >35 kg/m2 with obesity-related comorbidities (hypertension, impaired glucose tolerance, DM, dyslipidemia, sleep apnea) who have failed diet, exercise, and drug therapy are potential surgical candidates, assuming that the anticipated benefits outweigh the prices, risks, and side effects of the procedure.

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