Obesity: its Causes and Management

Obesity is a widespread problem in our contemporary society. Modern life has made high energy food more available while we are spending less and less time to exercise and spend this energy. Obesity is a higher level of weight gain which is considered when body weight reaches 120% of our expected ideal body weight. Obesity is more widespread in women in particular at a certain stage of the woman' reproductive life, when they are pregnant. As we advance in age we tend to put on more weight as our metabolism gets slower and our energy needs get less and we spend more time in less active state. Obesity is more familiar in lower and middle social classes.

Obesity is the commonest dietary eating disorder in the world. It is commoner in lower social class. It is also commoner in middle age and in later life due to slowing of metabolism as we progress in years. Females are more likely to get obese due to hormonal changes during pregnancy and after the menopause. More than half of the middle-aged people in particular in lower social classes are obese.

Simply stated, obesity is a result of increase of food intake in excess of energy requirements of the person. However, some people who are physically inactive may increase in weight regardless of normal food intake. Others may lose weight while eating normally due to some metabolic reason which leads to excess need for energy as in the case of overactive thyroid gland. Abnormal eating habits in childhood have an effect on body weight in later life and probably due to increase in the number of fat cells in the body during the growth period.

Obese people are liable to have poor judgment about how much they have eaten. Eating is more related to external stimuli such as smell and sight of food and time of the day when it is usual to have their meal rather than internal stimuli such as hunger feeling or gastric motility. Some eat more in response to stress and emotional state as a way of comfort eating. This is a habit which may go back to childhood when food was given by parents at time of stress and as food carries the connotation of giving love.

There are certain medical disorders which may lead to obesity. Obesity is known to run in families and this is may be either related to genetics and inheritance or due to some environmental influences of the family.

How to manage obesity?

Dieting:

The usual approach to deal with obesity is calorie control. A careful sceduled diet with total calories not exceeding 1000 calories per day would achieve a weight loss of 1-2 kilograms every week. Dieting may result in irritability and a sense of depression and sadness in some people and this may be the actual cause of relapse in many cases.

Psychotherapy in the form of group psychotherapy or support groups are helpful and effective. The person's life style and circumstances may need to be examined and problems such as marital conflict or any other cause of distress leading ton overeating may need to be dealt with.

Behaviour techniques are used to overcome obesity problems. One way is self regulation and keeping a diary of food eaten and calorie content of each item. It is also important to control the environmental cues which lead to excessive eating. It is vital to change the eating habits and behaviour as these may be causal to the faulty eating behaviour. Groups as those run by Weight Watchers help to reinforce weight loss through self-reinforcement and group reinforcement. Obese people may have to cope with the usual pattern of guilt and feeling of failure as these feelings in themselves may lead to relapses.

Drugs may play a limited role as they may cause a number of side effects and they are used as the last resort . Some of these are stimulants which are derived from amphetamines, and they are used for short-term use. They are less practical for patients who are exceptionally obese.

1. Orlistat (Xenical) reduces absorption of fat in the intestine.
2. Sibutramine (Reductil or Meridia) is an anorectic or appetite suppressant, which reduces the desire to eat. Sibutramine has been withdrawn from the market in many countries due to the risks of stroke and myocardial infarction
3. Rimonabant (Acomplia) is a cannabinoid (CB1) receptor antagonist that acts centrally on the brain thus decreasing appetite and increasing body heat production and energy expenditure. It has not received approval yet.
4. Metformin (Glucophage): can reduce wieght in people with Diabetes mellitus type 2.
5. Exenatide (Byetta) is a long-acting analogue of the hormone GLP-1. GLP-1 is secreted in the intestine in response to the presence of food. GLP-1 delays gastric emptying and promotes a feeling of satiety. Byetta is currently available as a treatment for Diabetes mellitus type 2. It must be injected subcutaneously twice daily, and it causes severe nausea in some patients, especially when therapy is started.
6. Pramlintide (Symlin) is a synthetic analogue of the hormone Amylin, which in normal people is secreted by the pancreas in response to eating. Amylin delays gastric emptying and promotes a feeling of satiety. Symlin is only approved to be used along with insulin by Type 1 and Type 2 diabetics. Symlin must be injected at mealtimes.

Surgical treatment

Sometimes the last resort for management of obesity is surgical intervention. Dental splinting, truncal vagotomy, gastric bypass or partitioning and intestinal bypass are effective in massive obesity. Liposuction is also another surgical approach in immense obesity.

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