Assessment of weight loss and treatment

Assessment of weight loss and treatment

1. Indications of assessment .
2. Following are the indication for assessment of weight loss . When the patient has
3. 5% weight loss in one month
4. 10% weight loss in six months
5. Body mass index <21
6. Change in fit of clothing
7. Change in appetite, smell, or taste
8. Abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia

Assessment of people with weight loss.
Those with significant weight loss usually manifest , four cardinal manifestation.They are given below
Loss of appetite,
Loss of muscle mass
Cachexia (combines weight loss, loss of muscle and adipose tissue,loss of appetite, and weakness),
Dehydration.
Detailed history and physical examination  including dental evaluation is very important .Other things to be done as part of assessment are
Cancer screening, Mini-Mental State Examination, Mini-Nutritional Assessment, ,Assessment Questionnaire, Observation of eating,  Activities of daily living , Instrumental activities of daily
Living.
Almost all patients with malignancy and more than 90% of those with weight loss due to a reason will have atleast one laboratory abnormality.

Tests to be done are
Laboratory tests

1. Complete blood count
2. Comprehensive electrolyte and metabolic panel,
3. including liver and kidney  function tests
4. Thyroid function tests
5. Erythrocyte sedimentation rate
6. C-reactive protein
7. Ferritin
8. HIV testing, if indicated in high risk persons
9. Radiology
10. Chest x-ray
11. Abdominal ultrasound (USG)

Treatment
1.First thing tobe done is to identification and treatment of  the underlying cause.
2.Certain causes are treatable which include metabolic, psychiatric, infectious, or other systemic disorders .That will help to restore the weight.
3.Drugs causing nausea and loss of appetite should be changed.
4.Nutritional supplementation , high-energy drinks,supplements should be taken between meals
5.In some patients  antidepressant mirtazapine results in a significant increase in body weight,

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Complications of obesity

Complications of obesity

Obesity is a risk factor for many disease.It increases the morbidity and mortality.Obesity has both physical and psychosocial aspect.There is 10 TO 12 fold increase in mortality in obese people in the age group of  25 to35 years compared to non obese.Weight reduction reduce the mortality and is strongly advised.Medical complications of obesity are many and well known. Complications are more in those who gain weight rapidly than slowly over long time.

The risk for heart disease and diabetes are more in those with abdominal obesity . This is assessed clinically by measuring waist circumference.

In men

Normal measurement is up to  94 cm

Complications are increased at more than  102 cm.

In women

Normal waist circumferences in women are: 80 cm,

Increased risk   80-88 cm,

substantially increased risk  88 cm.

The social complications may be painful.It will start from the school ,affect job opportunities and social status

CO-MORBIDTY

1. Type ii diabetes
2. Hypertension
3. Dyslipidaemia
4. Obstructive sleep apnoea
5. Venous stasis syndromes
6. Osteorthritis
7. Greater risk of breast,colon cancer
8. Greater risk of cardiac  & cerebral vascular events
9. Chronic obesity hypoventilation (pickwickian)
10. Pseudotumor cerebri
11. Poor Q.O.L.
12. Herniae
13. Cholecystitis
14. Difficulty in detecting physical findings

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Drugs used for treatment of obesity

Drugs may be used in the short term that is up to 3 months for obesity treatment as an adjunct to the dietary regimen, but they are not substitute for strict dieting.

Indication for anti obesity drugs.

Adjuvant treatment with drugs are indicated  in

1.Patients with a BMI >30 kg/m 2.

2.Patients with BMI >27 kg/m 2 with concomitant obesity related diseases.

3.Patients with BMI >27 kg/m 2 who do not get satisfactory weight reduction with dietary and physical activity therapy.

Significance of lifestyle program with drugs. 

Patients should be engaged in a lifestyle program when an antiobesity drug is prescribed. The life style program will provides them the strategies and skills which are needed to use these antiobesity drug efficiently because this support increases total weight loss.

Targets of drug therapy for obesity.

Suppression of appetite via centrally active drugs which alter monoamine neurotransmitters is the most thoroughly explored treatment.

A second strategy is to decrease the absorption of selective macronutrients from the gut such a fat.

Type of antiobesity drugs.

Centrally acting drugs

They are appetite-suppressing drugs, or anorexiants, affect satiety and hunger.

Satiety is the absence of hunger after eating.

Hunger is a sensation which initiates eating.

These agents increase the satiety and decrease hunger, thus help to reduce the intake of calories without a feeling of deprivation of food.

Example of centrally acting drug is sibutramine (Meridia).

Peripherally acting drugs 

Example of peripherally acting drugs is Orlistat.

It is a lipase inhibitor, inhibit the hydrolysis of dietary fat the essential step required for their absorption. Thus Orlistat blocks the digestion and absorption of 30% of dietary fat and help to achieve weight loss. Weight regain will occurs once the drug is stopped. Studies have shown that Orlistat produces a weight loss of about 9 - 10% at the end of one year. Orlistat has minimal gut absorption so it is devoid of systemic side effects. Tolerability to Orlistat is related to the malabsorption of dietary fat and passage of fat in the feces. About 10 percentage of people treated with  this drug experience gut side effect. They are flatus with discharge, fecal urgency, increased defecation and oily stool. These side effects of Orlistat is seen early in the course of treatment. The side effect can be reduced if the patient controls the dietary fat intake.Psyllium mucilloid if taken along with orlistat will helps to reduce the gut side effects. There is decreased concentration of fat-soluble vitamins D, E and ß-carotene is seen in patients treated with Orlistat.Vitamin supplements are necessary to prevent deficiency disease.

The Endocannabinoid System 

Rimonabant is the first selective cannabinoid CB 1 receptor antagonist, used for treatment of obesity. This drug antagonizes the orexigenic effect of endocannabinoid system and suppresses appetite. Rimonabant is a weight-loss agent which shows improvement in waist circumference and reduce the heart problems. However increased risk of certain side effect such as seizures, depression, aggressiveness and suicidal thoughts anxiety, insomnia are seen. Even though the drug was available in 56 countries in 2008, European Medicines Agency (EMEA) has officially withdrawn this drug in January 2009, due to increased side effect compared to its benefits.

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What is Dyspepsia or indigestion ? What are its causes?

A common complaint in clinical practice. Term dyspepsia indicate, pain or discomfort in the upper abdomen which can be acute ,chronic or recurrent. Patients with dyspepsia also complain of heartburn, that if present indicate underlying gastroesophageal reflux disease. Patients usually use the term indigestion to describe any problems related to food. It seen in 80% of population.

Characteristic associated symptoms are population.

• Upper abdominal fullness,

• Early satiety

• Burning,

• Bloating,

• Belching,

• Nausea,

• Retching,

Alarm features in dyspepsia.

• Weight loss

• Anaemia

• Persistent Vomiting

• Vomiting of blood  ,passage of blood in stool

• Difficulty in swallowing

• Palpable abdominal mass

• Constant or severe pain

If any of the alarming symptoms are present detailed evaluation is required. Detailed evaluation is also needed in people presenting with new onset dyspepsia at the age more than 55 and young people if not responding to treatment.

Causes of indigestion or dyspepsia

Indigestion directly related to food Drug Intolerance.

Sudden self limited indigestion can occur with overeating ,quick eating ,high fat food intake, eating during stressful circumstances, excessive alcohol or coffee intake.

Drug Intolerance - Commn drugs ivolved are aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, digoxin, iron, antibiotics (metronidazole, macrolides), diabetes drugs (metformin, alpha-glucosidase inhibitors, , donepezil, rivastigmine, and opioids

Gut  Dysfunction

Peptic ulcer disease (5–15% ). Gastroesophageal reflux disease ( 20% ). Gastric cancer ( 1% ). Helicobacter pylori Infection.are seen

Other Conditions

Diabetes, thyroid disease, kidney disease, heart attack, pregnancy, intra-abdominal cancers, Pancreatic Disease, Disease of the gall bladder and bile duct may be seen.

Functional Dyspepsia

Most common cause of chronic indigestion is functional dyspepsia. Upto two third of patients have no significant cause for their indigestion. Tt is difficult to treat although it is benign.

Recent employment changes, physical and sexual abuse, marital disharmony, depression, anxiety, depression, and fear of serious disease all may lead to development of symptoms. Functional dyspepsia is often seen in young people anxiety and depression or on psychiatric drugs .

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Bariatric surgery for Obesity

Bariatric surgery is the surgical method of weight reduction. Following are the facts that should be known.
Justification - Difficulty of the condition should be greater than that of the surgery.
Aim - Is not  cosmetic, but reduce the complications of  obesity.
Surgery provides effective long lasting weight loss in morbidly obese patients.
Obesity surgery is of low priority and of doubtful value.
Obesity is the fault of the patient. Ignorance surrounding this prejudice is astounding.

Efficacy of surgery
• Involves description of weight loss following the procedures
• Target weight loss: 50% of excess weight
• The good effects noted are
     Reduction of various metabolic parameters
     Long term control of diabetes
     Loss of Lt ventricular mass
     Improvement of functioning of heart.
Selecting for surgery
• Multidisciplinary team will select suitable patient for surgery.
• Pre operative  briefing of situation is given
• BMI should be  >> 40Kg/m2        
• BMI >>35 with risk factors  
• Age between   18-55 years        
• Minimum duration of 5 years of obesity    
• Failed conservative treatment  
• No alcoholism/ Psychosis
• Those who agree for life long follow-up
Bariatric surgery procedures
Those that produce malabsorption that produce reduction of food intake.
• Jejuno ileal bypass
• Bpd
• Gastric bypass
• Vbg

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Why obesity lead to osteoarthritis ?

Obesity or overweight is a common problem in community. It will lead to a variety of health problem. One of the important health problem in obese individual is osteoarthritis. Three to six times body weight is transmitted across the knee during single-leg stance. Any increase in weight may be multiplied by this factor to reveal the excess force across the knee in overweight persons during walking. Obesity’s effect on the development and progression of disease is mediated mostly through the increased loading in weight-bearing joints that occurs in overweight persons. 

1. Obesity is closely associated with knee osteoarthritis,  in those who have body weight more than 50 per cent above their ideal body weight when compared to those people with ideal body weight. The risk is more in women than men Risk ratio is of  9.0 for women and  4.5 for men.

2. One of the interesting factor noticed is that obesity does not seem to be  a strong risk factor for  hip osteoarthritis, compared to knee osteoarthritis.

3. At the knee joint, obesity is a predisposing factor for development of disease than it follows knee osteoarthritis.

4. In some people osteoarthritis at knee may or may not be associated with symptoms, but it produce radiographic change.

5. Once the obese people develop knee osteoarthritis the painful knee also lead to sedentary lifestyle. The same thing happens with obesity.

6. For a given damage to knee joint obesity increases the pain. Obesity also increases the severity of disease.

7. Malalignment (varus/valgus knee alignment) increases the risk for osteoarthritis.

There are  two types of limb malalignment in knee joint in the frontal plane,
  1.Varus deformity in which the stress is placed across the medial compartment of the knee joint.
  2.Valgus deformity which places excess stress across the lateral compartment of the knee.

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Why obesity predispose to heart attack?

Obesity is an important risk factor for heart attack, because it contribute a number of other factors that predispose to heart attack. Obesity is measured in terms of BMI or body mass index. That is body weight divided by height squared. There are 3 levels of obesity.

1. Level 1 - More than 30

2. Level 2 - More than 34.9 less than 40

3. Level 3 - More than 40

Morbid  obesity means more than 50% of ideal body weight.

The risk of heart attack attributed to obesity is very high if the body mass index is more than 40.

Obesity is associated with 

1. Increased calories in the diet.

2. High fat intake.

3. High saturated fat intake.

4. Physical inactivity.

Heart attack risk factors that are influenced by obesity are given below.

1. Metabolic syndrome and insulin resistance.

2. Diabetes mellitus.

3. Hypertension.

4. Increased triglycerides.

5. Low HDL cholesterol.

6. Increased fibrinogen.

7. Increased C-reactive protein.

8. Alteration in blood vessel wall function leading to clot formation.

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Look at your belly and assess the health risk

Abdominal (belly) obesity is a very common problem in males and females. Main cause of it is intake of fatty and sweet foods and lack of exercise. After 30 years abdominal obesity is very common in men. Obese person with increased abdominal circumference has high risk for disease than an obese person without increased abdominal circumference. It is not only the weight but also where it is concentrated is also important in assessment of disease risk.

Why it is important?

Abdominal obesity is considered to be one of the early indicator of heart attack and diabetes mellitus in the future.

How will you measure abdominal circumference?

Take a tape ,hold it at the level of umbilicus,then take the measurement circumferentially.

Abdominal circumference in males 

Below 94 cm -Healthy

94 to102 cm - Moderate risk

More than 102 cm - High risk

Abdominal circumference in females

Below 80 cm - Healthy

80 to 88 cm - Moderate risk

More than 88 cm  -High risk. 

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How will you detect obesity?

Obesity is a risk factor for many disease. Simply it means overweight. But there are special method to detect obesity. These measurements will give you an accurate level of overweight and risk of developing disease. It is a good practice to record the weight periodically. Comparison of the previous weight help to detect early weight gain.

1. B.M.I.(Body mass index) / Quetelet’s index.
Most commonly used method is BMI which is expressed as weight/height 2 (in kg/m2 ),weight measured in kilograms and height measured in meter (without shoes). This gives an objective method of patients weight and help the patient realize the need for weight reduction.It is independent of height.
2.Anthropometry (skinfold thickness),
3. Densitometry (underwater weighing),
4. CT or MRI,
5. Electrical impedance.

Classification of Weight Status and Risk of Disease

Obesity is defined as  BMI of 30kg/m2, that is  is 20% above the upper end of the acceptable range of weights for height. overweight”, indicate BMI range 25-29.9.

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Metabolic syndrome... Who is at risk?

Metabolic syndrome increases the risk of diabetes and insulin resistance. Prevalence of the metabolic syndrome is increasing worldwide. Incidence increases with age. Highest  incidence of metabolic syndrome is seen in native Americans. About 60 percentage of females and 45 percentage of men between 40 to 49 age group are affected. Rising prevalence of obesity also increases the metabolic syndrome.

Following are the risk factors of metabolic syndrome.

1. Overweight and obesity.

2. Sedentary lifestyle.

3. Aging.

4. Diabetes.

5. Coronary heart disease.

6. Lipodystrophy.

Overweight and obesity.

Obesity increases the waist circumference and the risk for metabolic syndrome. But people who are of normal weight can also develop insulin resistance and this syndrome.

Sedentary lifestyle.

It is a predictor of heart disease and related mortality. Sedentary lifestyle is associated with increased risk of central obesity, high triglycerides, low HDL (High dencity lipoprotein) cholesterol, high blood pressure and blood sugar. It has two fold increase incidence in those who watch television or computer more than 4 hours, compared to those who watch it less than 1 hour.

Age

As the age advances the risk of metabolic syndrome is increasing, this tendency is seen worldwide. It is seen in 44 percentage of males more than 50 yrs in USA. Incidence is more common in females.

Diabetes mellitus

There is increased incidence of diabetes and insulin resistance in people with metabolic syndrome. This inturn will increase the risk for heart disease.

Heart disease

People with metabolic syndrome have increased incidence of heart disease. This can be reduced by lifestyle and dietary changes and weight reduction.

Lipodystrophy

Both congenital and acquired is associated with metabolic syndrome.

Related Links

How will you identify that you have metabolic syndrome.

Obesity a rising problem 

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Obesity a rising problem

Obesity is a chronic metabolic disorder with excessive fat deposition in the body .WHO defines obesity as body mass index more than  30 kg/m². Incidence of obesity is increasing worldwide, also in developing countries. As the people get older they accumulate more fat. Obesity indicate an excess fat storage, and looking at the undressed patient it can be easily identified. The term  overweight (rather than obese) indicate individuals with BMI between 25 and 30. It is medically significant and worthy of therapeutic intervention, especially in persons with  risk factors such as hypertension and glucose intolerance.

The distribution of adipose tissue in the body is important and has implications for morbidity. Intra-abdominal and abdominal subcutaneous fat have more significance compared to subcutaneous fat in the buttocks and lower extremities. This is clinically  detected  by the waist-to-hip ratio, with a ratio > 0.9 in women and >1.0 in men being abnormal. This may be because intra-abdominal adipocytes are more lipolytically active than those from other sites. 

Incidence of obesity is increasing  because of the following 

1. Increased availability of energy rich drinks and foods.
2. Increase in labour-saving devices (e.g. lifts and remote controls).
3. Increase in passive transport(cars as opposed to walking)

Obesity can be simple obesity or it can be associated with other conditions. Most  patients have simple obesity, Even when it is associated with other conditions, excess calories consumed in the diet  than expenditure through exercise and body functions, is the main cause of obesity.

Energy balance

1. 1 kg body weight gained has energy of approx 7000 kcal.
2. 10 kg weight gain over 5 years -70000/5*365=_ _38 kcal/day.
3. This is a daily error of energy balance of _1.5%.
4. OR 10 minutes’ walk.
5. OR one square (1/8) of a 2oz milk chocolate bar.
6. OR half a digestive biscuit.

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