Obesity

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Obesity Is

  • A disease.
  • A worldwide health concern.
  • Caused by many factors.
  • Treatable and manageable.

Obesity Is Not

  • Your fault.
  • Yours to manage alone.
  • Just about food.
  • Cured by a miracle treatment.

Body mass index (BMI)

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Body fat is hard to measure directly. So it is often measured by body mass index (BMI). BMI measures weight related to height. It is a common way to measure body fat and is one tool healthcare providers use when talking about weight.

BMI is not a percentage of body fat. BMI is only part of a diagnosis of obesity. Ask your healthcare provider for other ways of determining obesity.

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What are the health risks associated with obesity?

Obesity is not just a cosmetic consideration; it is harmful to one’s health as it is a risk factor for many conditions. In the United States, roughly 112,000 deaths per year are directly related to obesity, and most of these deaths are in patients with a BMI over 30. Patients with a BMI over 40 have a reduced life expectancy. Obesity also increases the risk of developing a number of chronic diseases, including the following:

Insulin resistance. Insulin is necessary for the transport of blood glucose (sugar) into the cells of muscle and fat (which the body uses for energy). By transporting glucose into cells, insulin keeps the blood glucose levels in the normal range. Insulin resistance(IR) is the condition whereby there is diminished effectiveness of insulin in transporting glucose (sugar) into cells. Fat cells are more insulin resistant than muscle cells; therefore, one important cause of insulin resistance is obesity. The pancreas initially responds to insulin resistance by producing more insulin. As long as the pancreas can produce enough insulin to overcome this resistance, blood glucose levels remain normal. This insulin resistance state (characterized by  normal blood glucose levels and high insulin levels) can last for years. Once the pancreas can no longer keep up with producing high levels of insulin, blood glucose levels begin to rise, resulting in type 2 diabetes, thus insulin resistance is a pre-diabetes condition.

  • Type 2 (adult-onset) diabetes. The risk of type 2 diabetes increases with the degree and duration of obesity. Type 2 diabetes is associated with central obesity; a person with central obesity has excess fat around his/her waist (apple-shaped figure).
  • High blood pressure (hypertension). Hypertension is common among obese adults. A Norwegian study showed that weight gain tended to increase blood pressure in women more significantly than in men.
  • High cholesterol (hypercholesterolemia)
  • Stroke (cerebrovascular accident or CVA
  • High cholesterol (hypercholesterolemia)
  • Congestive heart failure
  • Heart attack. A prospective study found that the risk of developing coronary artery disease increased three to four times in women who had a BMI greater than 29. A Finnish study showed that for every 1 kilogram (2.2 pounds) increase in body weight, the risk of death from coronary artery disease increased by 1%. In patients who have already had a heart attack, obesity is associated with an increased likelihood of a second heart attack
  • Congestive heart failure
  • Cancer. Obesity is a risk factor for cancer of the colonin men and women, cancer of the rectum and prostate in men, and cancer of the gallbladder and uterus in women. Obesity may also be associated with breast cancer, particularly in postmenopausal women. Fat tissue is important in the production of estrogen, and prolonged exposure to high levels of estrogen increases the risk of breast cancer.
  • Gallstones
  • Gout and gouty arthritis
  • Osteoarthritis (degenerative arthritis) of the knees, hips, and the lower back
  • Sleep apnea

CAUSES

The balance between calorie intake and energy expenditure determines a person’s weight. If a person eats more calories than he or she burns (metabolizes), the person gains weight (the body will store the excess energy as fat). If a person eats fewer calories than he or she metabolizes, he or she will lose weight. Therefore, the most common causes of obesity are overeating and physical inactivity. Ultimately, body weight is the result of genetics, metabolism, environment, behavior, and culture.

  • Genetics. A person is more likely to develop obesity if one or both parents are obese. Genetics also affect hormones involved in fat regulation. For example, one genetic cause of obesity is leptin deficiency. Leptin is a hormone produced in fat cells and in the placenta. Leptin controls weight by signaling the brain to eat less when body fat stores are too high. If, for some reason, the body cannot produce enough leptin or leptin cannot signal the brain to eat less, this control is lost, and obesity occurs. The role of leptin replacement as a treatment for obesity is under exploration.
  • Overeating. Overeating leads to weight gain, especially if the diet is high in fat. Foods high in fat or sugar (for example, fast food, fried food, and sweets) have high energy density (foods that have a lot of calories in a small amount of food). Epidemiologic studies have shown that diets high in fat contribute to weight gain.
  • A diet high in simple carbohydrates. The role of carbohydrates in weight gain is not clear. Carbohydrates increase blood glucose levels, which in turn stimulate insulin release by the pancreas, and insulin promotes the growth of fat tissue and can cause weight gain. Some scientists believe that simple carbohydrates (sugars, fructose, desserts, soft drinks, beer, wine, etc.) contribute to weight gain because they are more rapidly absorbed into the bloodstream than complex carbohydrates (pasta, brown rice, grains, vegetables, raw fruits, etc.) and thus cause a more pronounced insulin release after meals than complex carbohydrates. This higher insulin release, some scientists believe, contributes to weight gain.
  • Frequency of eating. The relationship between frequency of eating (how often you eat) and weight is somewhat controversial. There are many reports of overweight people eating less often than people with normal weight. Scientists have observed that people who eat small meals four or five times daily, have lower cholesterol levels and lower and/or more stable blood sugar levels than people who eat less frequently (two or three large meals daily). One possible explanation is that small frequent meals produce stable insulin levels, whereas large meals cause large spikes of insulin after meals.
  • Physical inactivity. Sedentary people burn fewer calories than people who are active. The National Health and Nutrition Examination Survey (NHANES) showed a strong correlations between physical inactivity and weight gain in both sexes.
  • Medications. Medications associated with weight gain include certain antidepressants (medications used in treating depression), anticonvulsants (medications used in controlling seizures such as carbamazepine[Tegretol, Tegretol XR , Equetro, Carbatrol] and valproate [Depacon, Depakene]), some diabetes medications (medications used in lowering blood sugar such as insulin, sulfonylureas, and thiazolidinediones), certain hormones such as oral contraceptives, and most corticosteroids such as prednisone. Some high blood pressuremedications and antihistamines cause weight gain. The reason for the weight gain with the medications differs for each medication. If this is a concern for you, you should discuss your medications with your physician rather than discontinuing the medication, as this could have serious effects.
  • Psychological factors. For some people, emotions influence eating habits. Many people eat excessively in response to emotions such as boredom, sadness, stress, or anger. While most overweight people have no more psychological disturbances than normal weight people, about 30% of the people who seek treatment for serious weight problems have difficulties with binge eating.
  • Diseases such as hypothyroidism, insulin resistance, polycystic ovary syndrome, and Cushing’s syndrome are also contributors to obesity. Some diseases, such as Prader-Willi syndrome, can lead to obesity.
  • Social issues: There is a link between social issues and obesity. Lack of money to purchase healthy foods or lack of safe places to walk or exercise can increase the risk of obesity.

What is the role of physical activity and exercise in obesity?

The National Health and Examination Survey (NHANES I) showed that people who engage in limited recreational activity were more likely to gain weight than more active people. Other studies have shown that people who engage in regular strenuous activity gain less weight than sedentary people.

Physical activity and exercise help burn calories. The amount of calories burned depends on the type, duration, and intensity of the activity. It also depends on the weight of the person. A 200-pound person will burn more calories running 1 mile than a 120-pound person, because the work of carrying those extra 80 pounds must be factored in. But exercise as a treatment for obesity is most effective when combined with a diet and weight-loss program. Exercise alone without dietary changes will have a limited effect on weight because one has to exercise a lot to simply lose 1 pound. However regular exercise is an important part of a healthy lifestyle to maintain a healthy weight for the long term. Another advantage of regular exercise as part of a weight-loss program is a greater loss of body fat versus lean muscle compared to those who diet alone.

Other benefits of exercise include

  • improved blood sugar control and increased insulin sensitivity (decreased insulin resistance),
  • reduced triglyceride levels and increased “good” HDL cholesterol levels,
  • lowered blood pressure,
  • a reduction in abdominal fat,
  • reduced risk of heart disease,
  • release of endorphins that make people feel good.

Remember, these health benefits can occur independently (with or without) achieving weight loss. Before starting an exercise program, talk to a doctor about the type and intensity of the exercise program.

TREATMENT

Medication treatment of obesity should be used only in patients who have health risks related to obesity. Medications should be used in patients with a BMI greater than 30 or in those with a BMI of greater than 27 who have other medical conditions (such as high blood pressure, diabetes, high blood cholesterol) that put them at risk for developing heart disease. Medications should not be used for cosmetic reasons.

Medications should only be used as an adjunct to diet modifications and an exercise program.

Like diet and exercise, the goal of medication treatment has to be realistic. With successful medication treatment, one can expect an initial weight loss of at least 5 pounds during the first month of treatment, and a total weight loss of 10%-15% of the initial body weight. It is also important to remember that these medications only work when they are taken. When they are discontinued, weight gain often occurs.

The first class (category) of medication used for weight controlcause symptoms that mimic the sympathetic nervous system. They cause the body to feel “under stress” or “nervous.” As a result, the major side effect of this class of medication is high blood pressure. This class of medication includes sibutramine(Meridia, which was taken off the market in the U.S. in October 2010 due to safety concerns) and phentermine (Adipex P). These medications also decrease appetite and create a sensation of fullness. Hunger and fullness (satiety) are regulated by brain chemicals called neurotransmitters. Examples of neurotransmitters include serotonin, norepinephrine, and dopamine. Anti-obesity medications that suppress appetite do so by increasing the level of these neurotransmitters at the junction (called synapse) between nerve endings in the brain.

Phentermine

Phentermine (Fastin, Adipex P) — the other half of fen/phen — suppresses appetite by causing a release of norepinephrine in the body. Phentermine alone is still available for treatment of obesity but only on a short-term basis (a few weeks). The common side effects of phentermine include headache, insomnia, irritability, and nervousness. Fenfluramine (the fen of fen/phen) and dexfenfluramine (Redux) suppress appetite mainly by increasing release of serotonin by the cells. Both fenfluramine and dexfenfluramine were withdrawn from the market in September 1997 because of association of these two medications with pulmonary hypertension (a rare but serious disease of the arteries in the lungs) and association of fen/phen with damage to the heart valves. Since the withdrawal of fenfluramine, some have suggested combining phentermine with fluoxetine (Prozac), a combination that has been referred to as phen/pro. However, no clinical trials have been conducted to confirm the safety and effectiveness of this combination. Therefore, this combination is not an accepted treatment for obesity.

Orlistat (Xenical, alli)

The next class (category) of drugs changes the metabolism of fat. Orlistat (Xenical, alli) is the only drug of this category that is U.S. FDA approved. This is a class of anti-obesity drugs called lipase inhibitors, or fat blockers. Fat from food can only be absorbed into the body after being broken up (a process called digestion) by digestive enzymes called lipases in the intestines. By inhibiting the action of lipase enzymes, orlistat prevents the intestinal absorption of fat by 30%. Drugs in this class do not affect brain chemistry. Theoretically, orlistat also should have minimal or no systemic side effects (side effects in other parts of the body) because the major locale of action is inside the gut lumen and very little of the drug is absorbed.

The U.S. Food and Drug Administration approved orlistat capsules, branded as alli, as an over-the-counter (OTC) treatment for overweight adults in February 2007. The drug had previously been approved in 1999 as a prescription weight loss aid, whose brand name is Xenical. The OTC preparation has a lower dosage than prescription Xenical.

Orlistat is recommended only for people 18 years of age and over in combination with a diet and exercise regimen. People who have difficulties with the absorption of food or who are not overweight should not take orlistat. Overweight is defined by the U.S. National Institutes of Health as having a body mass index (BMI) of 27 or greater.

Orlistat can be taken up to three times a day, with each fat-containing meal. The drug may be taken during the meal or up to one hour after the meal. If the meal is missed or is very low in fat content, the medications should not be taken.

The most common side effects of orlistat are changes in bowel habits. These include gas, the urgent need to have a bowel movement, oily bowel movements, oily discharge or spotting with bowel movements, an increased frequency of bowel movements, and the inability to control bowel movements. Women may also notice irregularities in the menstrual cyclewhile taking orlistat. Side effects are most common in the first few weeks after beginning to take orlistat. In some people, the side effects persist for as long as they are taking the drug.

People with diabetes, thyroid conditions, who have received an organ transplant, or who are taking prescription medications that affect blood clotting should check with their physician before using OTC orlistat (alli), since drug interactions with certain medications are possible.

A long-term decrease in fat absorption can cause deficiency of fat-soluble vitamins (such as vitamins A, D, E, K). Therefore, patients on orlistat should receive adequate vitamin supplementation.

Lorcaserin (Belviq)

In June 2012, the FDA approved Belviq (lorcaserin hydrochloride) as a weight-loss medication. The medication works by controlling appetite (via serotonin activation). According to the FDA data, nearly half the patients using the medication lost at least 5% of their starting weight, which is more than double that lost by patients in the control group. This was only true for patients without type 2 diabetes.

The medication is approved for patients who are obese (BMI >30) or overweight (BMQ >27) with one weight-related health issue. The predominant side effects were headache and dizziness, as well as fatigue. In patients with diabetes, low blood sugar was also a concern when taking Belviq.

Topiramate (Qsymia)

Qsymia is the newest medication approved for weight loss. It is a combination of phentermine and extended-release topiramate. As with the other medications, it is only approved for patients who are obese (BMI >30) or overweight (BMQ >27) with one weight-related health issue. According to the FDA data, a statistically significant greater proportion of the patients taking Qsymia achieved 5% and 10% weight loss. All patients in the study were also encouraged to eat a well-balanced, reduced-calorie diet.

It is important to note that Qsymia can lead to birth defects, and it is important for women to know that they are not pregnant before starting the medication. Other possible serious side effects include increased heart rate, eye problems(glaucoma), and suicidal thoughts. In patients with diabetes, low blood sugar was also a concern when taking Qsymia.

Naltrexone (Contrave)

This is a combination drug of naltrexone (an opioid antagonist) and bupropion HCL (an antidepressant medication that is an inhibitor of the reuptake of dopamine and norepinephrine). The main side effects observed with this medication are nausea, constipation, and headaches. The medication is contraindicated in patients with uncontrolled hypertension or a history of seizures.

The medication is approved as an adjunct to dietary changes and increased physical activity in adults with an initial BMI of 30 or greater or 27 or greater with at least one comorbidity.

Liraglutide (Saxenda)

Saxenda was approved in late 2014 as a weight-loss drug in combination with physical activity and diet modifications. It is a once-a-day injection (not a pill) that mimics a hormone related to digestion and appetite control (GLP-1) that is used in the management of type 2 diabetes. It activates areas of the brain involved in appetite regulation.

Saxenda has been linked to thyroid tumors in rats and mice as well as pancreatitis in humans.

The medication is approved as an adjunct to dietary changes and increased physical activity in adults with an initial BMI of 30 or greater or 27 or greater with at least one comorbidity.

2 thoughts on “Obesity

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