​Kembara Xtra - Medicine - Obesity

​Kembara Xtra - Medicine -  Obesity  
A severe, persistent, and progressive condition that is measured in adults by their body mass index (BMI) (kg/m2), often at or above 30 kg/m2.
BMI of 25.0 to 29.9 kg/m2 indicates obesity
Three categories are used to classify obesity:
- BMI 30.0 to 34.9 kg/m2 is considered class 1 obesity. - BMI 35.0 to 39.9 kg/m2 is considered class 2 obesity.
BMI 40 kg/m2 is considered Class 3 obesity, commonly known as severe obesity.
Obesity is linked to detrimental health effects.
Obesity in the abdomen raises the danger of morbidity and mortality.
Aspects of Geriatrics
Body composition changes brought on by aging include sarcopenia, a decline in bone mineral density, and the buildup of visceral fat.

Epidemiology 
The incidence increases in the early 20s and peaks in middle-aged adults between the ages of 40 and 59.
Prevalence
68.5% of adults in the United States are either overweight or obese, and 42% of them are obese.
In the United States, 17% of children and adolescents (2 to 19 years old) are obese, while 32% are either overweight or obese.
Child Safety Considerations
The U.S. Preventive Services Task Force (USPSTF) advises referring children and adolescents aged 6 and older to comprehensive, intensive behavioral therapies and recommending obesity screening in those individuals (grade B recommendation).
Pediatrician categorization based on CDC or WHO development curves for each age and sex:
- Obesity: 85th to 94th percentile of BMI
- Class I obesity: BMI 95th percentile
- Class II severe obesity is defined as a BMI that is 120 percent of the 95th percentile or higher.
Class III: BMI between the 140th and 95th percentiles
Adolescent obesity is highly correlated with obesity in adulthood.
 Mental health and psychological problems, low self-esteem, and a lower quality of life are all linked to childhood obesity.


Pathophysiology and Etiology 
A multifactorial process that results in an imbalance between energy intake and expenditure due to genetic, environmental, behavioral, and psychosocial factors
An individual's neural signaling is changed to lower satiety after obesity has grown.
Leptin and adiponectin are peptides that are produced by adipocytes, or fat cells. Adiponectin increases insulin sensitivity, and leptin deficiency has been linked to extreme obesity.

Multiple genes are linked in obesity, and specific genotypes may account for disparities in weight loss response to dietary changes. Genetics. A minority of people with obesity have genetic diseases such Prader-Willi and Bardet-Biedl.


Risk factors include parental obesity, a sedentary lifestyle without regular exercise, eating foods high in calories and having limited access to fresh produce and cuisines, stress, and mental illness.

Basic Prevention 
Encourage frequent exercise, aiming for at least 150 minutes of moderate activity per week (for example, 30 minutes of exercise five days a week), as well as a balanced diet with sensible serving sizes.
 Steer clear of processed foods, sugar-sweetened beverages, and other high-calorie, low-nutrient foods.
Early preventive counseling, particularly for kids and teenagers

Accompanying Conditions 
HTN, hyperlipidemia, type 2 diabetes, coronary artery disease (CAD), and congestive heart failure
Osteoarthritis, Nonalcoholic Fatty Liver Disease, Anxiety Disorders, Depression, Polycystic Ovarian Syndrome, Obstructive Sleep Apnea, Polyarthritis,

Diagnosis: Life stressors, social support, and resources; dietary and exercise routines; reported readiness to modify lifestyle and prior attempts at weight loss; and

clinical assessment 
Physical activity vital sign: Determine whether the patient meets the weekly minimum requirement of 150 minutes of moderate physical activity.
Waist circumference may be more significant than BMI in determining the health hazards associated with obesity, particularly in older people (sarcopenia).
- Suggest taking measurements for patients with a BMI of 25 to 35 kg/m2.
- Take your measurement at the umbilicus level. Elevated:
 Males: >40 inches (102 cm), females: >35 inches (88 cm).
Common aberrant findings include striae, acanthosis nigricans, and a wide neck habitus.

Cushing syndrome, hypothyroidism, and an unidentified concurrent underlying psychiatric disease are all possible differential diagnoses.

Laboratory Results 
Check for underlying physiological reasons and concomitant disorders that may be present.
LFTs (nonalcoholic fatty liver disease), fasting blood glucose, hemoglobin A1C, lipid panel, thyroid function tests

Tests in the Future & Special Considerations
Obstructive sleep apnea may be associated with fatigue, which may call for additional sleep research.

Management 
Assess the following: - Patient-specific therapeutic goals and motivation to lose weight - Nutritional intake and exercise routines
The objective is to lose at least 5% of body weight and keep it off. The rate of weight reduction is curvilinear, starting out quickly before slowing till plateauing.
It is advised by the USPSTF to "encourage clinicians to promote behavioral interventions as the primary focus of the effective interventions for weight loss in adults."
Treat comorbidities associated with obesity.

Prior to beginning medication, guidelines advise at least 3 to 6 months of nonpharmacologic therapy using a thorough lifestyle intervention.
Consider medication for patients who have a history of struggling to lose weight sustainably (5% of total body weight) and achieve clinically meaningful weight loss:
- BMI 30 - BMI 27 + comorbidities (such as CAD, diabetes, sleep apnea, high blood pressure, or hyperlipidemia)
All active medication interventions are effective at reducing weight compared with placebo, according to meta-analyses of randomized trials comparing pharmaceutical therapy with placebo.
USPSTF discovered that when behavioral therapy was paired with medication, more weight was lost and was kept off over the course of 12 to 18 months.


Initial Line
There are nine drugs for weight loss that the FDA has approved (5 for long-term use and 4 for short-term use).
Unless otherwise stated, the most frequent adverse effects are gastrointestinal (GI) related (nausea, vomiting, diarrhea, and abdominal discomfort).
Long-term therapy:
- Liraglutide (Victoza, Saxenda):
 GLP-1 agonist; recommended medication for diabetics and people with heart disease; may be prescribed for children as young as 12 years old.
0.6 mg subcutaneously daily for one week, followed by weekly increases to the target dose of 3 mg daily.
- Semaglutide (Rybelsus, Olympic, Wegovy):
 The FDA has approved GLP-1 agonists for both diabetes and obesity.
 Dose: 0.25 mg subcutaneously once weekly for four weeks, followed by dose increases every four weeks until the desired dose of 2.4 mg once weekly is reached.
- The most effective drug now on the market is likely phentermine/topiramate (Qsymia):
While topiramate reduces appetite by acting on GABA receptors, phentermine suppresses hunger by raising norepinephrine levels in the hypothalamus. medicine on the IV schedule.
 Dose: for 14 days, take 3.75 mg of phentermine and 23 mg of topiramate once daily. Then, titrate to 15 mg/92 mg once day.
 Negative effects include the propensity for overuse, tachycardia, mood disorders, dry mouth, and topiramate is linked to harmful effects on fetuses (oral clefts).
- Xenical (Orlistat):
 Pancreatic lipase inhibitor, FDA-approved for use in children under the age of 12, decreases intestinal fat absorption and increases excretion.
Dosage: 120 milligrams three times daily with meals high in fat.
GI side effects (cramps, flatulence, fecal incontinence, oily spotting) and a minor drop in fat-soluble vitamins (A, D, E, and K) should be taken into consideration when using this medication.
- Bupropion/naltrexone (Contrave):
Naltrexone, an opioid antagonist, prevents the actions of -endorphins to decrease appetite. Bupropion works on the adrenergic and dopaminergic receptors in the hypothalamus to decrease appetite.
Naltrexone 8 mg/bupropion 90 mg once day during the first week, increasing the dose to 16 mg/180 mg twice daily by the end of the fourth week.
 Negative effects include high blood pressure, headaches, dry mouth, and sleeplessness.
Plenity is an oral hydrogel made of cellulose and citric acid that induces a fullness sensation. taken twice daily, at least 16 ounces of water should be consumed with each dose, and it is relatively affordable.

Next Line
Older sympathomimetic medicines for short-term use (12 weeks) decrease food intake by generating early satiety. Increased heart rate, blood pressure, sleeplessness, and dry mouth are some negative effects.
- Phentermine, an IV drug on the schedule
 Dose: 15.0 to 37.5 mg twice daily or once daily, divided.
- Diethylpropion (IV drug regimen)
25 mg three to four times daily, before meals
Benzphetamine, a Schedule III drug
Start with 25 mg once daily and work your way up to a maximum dose of 50 mg three times daily.
- Phendimetrazine (drug on Schedule III).
Dosage: 17.5 to 35.0 mg taken twice or three times a day, one hour before meals.

Further Treatments 
In addition to food modification alone, physical activity results in additional weight loss of 1.0 to 1.5 kg over the course of a year. It doesn't appear that the type of exercise—aerobic versus resistance or high versus low intensity—affects overall weight reduction.
 Cognitive-behavioral treatment (CBT) - Components: (i) prescription of a moderately reduced calorie diet, (ii) program of increased physical activity, and (iii) behavioral methods to support compliance with diet and activity guidelines
- In-person, high-intensity treatment is best (around 14 sessions in six months), provided by a qualified interventionist.

Surgical Procedures
​Bariatric surgery may be recommended when previous therapies have failed, a patient has a BMI of 35 or higher plus concomitant conditions, or a BMI of 40 or higher.
 Linked to a significant reduction in diabetes, sleep apnea, depression, quality of life, discomfort, and bodily functionThe following surgical techniques may be performed: biliopancreatic diversion, Roux-en-Y gastric bypass, sleeve gastrectomy, laparoscopic adjustable gastric banding, vagal blocking therapy, and gastric aspiration (AspireAssist).

Continued Care – Address both present and future goals, as well as weight and lifestyle changes.
If after three to four months there has been no clinically significant weight loss, a new treatment strategy should be used.


Diet 
Long-term studies indicate that the optimal approach is a diet that a patient can follow and a net calorie reduction of about 500 kcal per day. Aim for 1,200 to 1,500 kcal for ladies and 1,500 to 1,800 kcal for males per day. A 500 kcal/day caloric deficit can lead to a weekly weight loss of up to 1 lb (0.45 kg).
When compared to low-calorie diets, very low-calorie diets (200 to 800 kcal/day) resulted in noticeably larger short-term weight loss but equivalent long-term weight loss; this diet must be followed under medical supervision
Mediterranean diet: primarily plant-based, rich in olive oil, nuts, legumes, whole grains, fruits, and vegetables, with frequent servings of fish and chicken Bodyweight, BMI, hemoglobin A1C, fasting glucose, and cardiovascular disease risk all decreased, according to a meta-analysis.
 A balanced-nutrient, moderate-calorie diet with an emphasis on plenty of fruits, vegetables, and fiber, often 1,200 to 1,800 calories per day; for example, the DASH diet.

Prognosis – Patients who are obese are more likely to have major health conditions than those who are of a normal weight.
Successful weight loss is correlated with patient motivation.

Complications include increased mortality rates from cancers of the colon, breast, prostate, endometrium, gallbladder, liver, and kidney. Other complications include cardiovascular disease, osteoarthritis, hypoventilation syndrome, and slipped capital femoral epiphysis (SCFE) in children.

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