Obesity
Obesity: Excerpt from Professional Guide to Diseases (Eighth Edition)
Obesity is an excess of body fat, generally 20% above ideal body weight. The prognosis for correction of obesity is poor: Fewer than 30% of patients succeed in losing 20 lb (9 kg), and only half of these maintain the loss over a prolonged period.
Causes and incidence
Obesity results from excessive calorie intake and inadequate expenditure of energy. Theories to explain this condition include hypothalamic dysfunction of hunger and satiety centers, genetic predisposition, abnormal absorption of nutrients, and impaired action of GI and growth hormones and of hormonal regulators such as insulin. An inverse relationship between socioeconomic status and the prevalence of obesity has been documented, especially in women. Obesity in parents increases the probability of obesity in children, from genetic or environmental factors, such as activity levels and learned patterns of eating. Psychological factors, such as stress or emotional eating, may also contribute to obesity. Rates of obesity are climbing, and the percentage of children and adolescents who are obese has doubled in the last 20 years.
Diagnosis
Observation and comparison of height and weight to a standard table indicate obesity. Measurement of the thickness of subcutaneous fat folds with calipers provides an approximation of total body fat. Although this measurement is reliable and isn’t subject to daily fluctuations, it has little meaning for the patient in monitoring subsequent weight loss. Obesity may lead to serious complications, such as respiratory difficulties, hypertension, cardiovascular disease, diabetes mellitus, renal disease, gallbladder disease, psychosocial difficulties, and premature death.
Treatment
Successful management of obesity must decrease the patient’s daily calorie intake while increasing his activity level. Effective treatment must be based on a balanced, low-calorie diet that eliminates foods high in fat or sugar. Lifelong maintenance of these improved eating and exercise patterns is necessary to achieve long-term benefits.
The popular low-carbohydrate diets offer no long-term advantage; rapid early weight reduction is due to loss of water, not fat. These and other crash or fad diets have the overwhelming drawback that they don’t teach the patient long-term modification of eating patterns and often lead to the “yo-yo syndrome” — episodes of repeated weight loss followed by weight gain. This can be more detrimental than the obesity itself because of the severe stress it can place on the body.
Total fasting is an effective method of rapid weight reduction but requires close monitoring and supervision to minimize risks of ketonemia, electrolyte imbalance, hypotension, and loss of lean body mass. Prolonged fasting and very-low-calorie diets have been associated with sudden death, possibly resulting from cardiac arrhythmias caused by electrolyte abnormalities. These methods also neglect patient re-education, which is necessary for long-term weight maintenance.
Treatment may also include hypnosis and behavior modification techniques, which promote fundamental changes in eating habits and activity patterns. In addition, psychotherapy may be beneficial for some patients, because weight reduction may lead to depression or even psychosis. Antidepressants are also helpful in weight loss.
Amphetamines and amphetamine congeners have been used to enhance compliance with a prescribed diet by temporarily suppressing the appetite and creating a feeling of well-being. However, because their value in long-term weight control is questionable, and they have significant potential for dependence and abuse, their use is generally avoided. If these drugs are used at all, they should be prescribed only for short-term therapy and should be monitored carefully.
The drug combination known as fen-phen (fenfluramine and phentermine) had been touted as an effective method of suppressing appetite. However, after researchers linked the drug combination to potentially fatal heart valve disease, fenfluramine was withdrawn from the market in September 1997. Phentermine wasn’t withdrawn but physicians are no longer allowed to combine the two drugs.
As a last resort, morbid obesity, which is indicated by body weight that’s 50% to 100% higher than ideal, body weight that’s 100 pounds higher than ideal, or a body mass index greater than 39, may be treated surgically with a variety of restrictive procedures. The two most popular bariatric surgeries are vertical banded gastroplasty and gastric bypass surgery. These procedures decrease the volume of food that the stomach can hold or bypass the stomach, with the goal of producing satiety with small intake. Bypassing the stomach also induces diarrhea when concentrated sweets are ingested. These techniques cause fewer complications than jejunoileal bypass, which induces a permanent malabsorption syndrome. Extended liquid diets are necessary adjuncts to surgery. Psychological counseling is also recommended.
Special considerations
❑ Obtain an accurate diet history to identify the patient’s eating patterns and the importance of food to his lifestyle. Ask the patient to keep a careful record of what, where, and when he eats to help identify situations that normally provoke overeating.
❑ Explain the prescribed diet carefully, and encourage compliance to improve health status.
❑ To increase calorie expenditure, promote increased physical activity, including an exercise program. Recommend varying activity levels according to the patient’s general condition and cardiovascular status.
❑ Watch carefully for signs of dependence or abuse if the patient is taking appetite-suppressing drugs; also watch for adverse effects, such as insomnia, excitability, dry mouth, and GI disturbances.
❑ Teach the grossly obese patient the importance of good skin care to prevent breakdown in moist skin folds. Recommend the regular use of powder to keep skin dry.
❑ To help prevent obesity in children, teach parents to avoid overfeeding their infants and to familiarize themselves with actual nutritional needs and optimum growth rates. Discourage parents from using food to reward or console their children, from emphasizing the importance of “clean plates,” and from allowing eating to prevent hunger rather than to satisfy it.
❑ Encourage physical activity and exercise, especially in children and young adults, to establish lifelong patterns. Suggest low-calorie snacks such as raw vegetables.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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