Fatty Diet Linked to Pancreatic Cancer

New research shows that people who eat a high-fat diet may be more likely to develop pancreatic cancer, especially if their dietary fat comes from animal foods, such as meat and dairy products.

That finding appears in the July 15 edition of the Journal of the National Cancer Institute.

"Our study demonstrated a positive association between dietary intake of total fat, particularly fat from animal sources," researcher Rachael Stolzenberg-Solomon, PhD, RD, tells WebMD. "The strongest associations we observed were from meat and dairy products."

Stolzenberg-Solomon, who is a nutritional epidemiologist at the National Cancer Institute, says previous studies have shown mixed results on whether dietary fat is associated with pancreatic cancer risk.

The new study included more than half a million U.S. adults. When the study started, none of them had pancreatic cancer.

Participants completed surveys about their diets over the previous year, which showed fat intake ranging from 20% to 40% of calories. People who ate a lot of fat were "regular eaters of fat from animals," Stolzenberg-Solomon said.

Participants were followed for six years, on average. During that time, 865 of the men and 472 of the women were diagnosed with pancreatic cancer.
Study's Findings

Compared to people with the lowest total fat intake, people with the highest fat intake were 23% more likely to be diagnosed with pancreatic cancer. And people with the highest intake of saturated fats were 36% more likely to be diagnosed with pancreatic cancer.

The study doesn't prove that dietary fat was responsible for that, or that meat or dairy products were particularly to blame. Observational studies like this one show associations, but they don't prove cause and effect.

Still, the findings held regardless of other risk factors for pancreatic cancer, including obesity, smoking, and history of diabetes.

"Our study is in line with the USDA [U.S. Department of Agriculture] guidelines to be prudent and limit fat intake to between 20% and 35% of total calories," says Stolzenberg-Solomon, noting that those USDA guidelines were developed to prevent other diseases.

Stolzenberg-Solomon says other studies are needed to confirm the findings.
Experts Weigh In

The American Cancer Society provided a statement about the study.

"This study is large and well designed, and provides important evidence that a diet high in animal fat may increase risk of one of the leading causes of cancer death. While further confirmatory research about animal fat and pancreatic cancer is still needed, results of this study support the American Cancer Society's recommendations to limit red meat and emphasize plant foods to help reduce risk of a variety of cancer," says Eric Jacobs, PhD, strategic director of pharmacoepidemiology at the American Cancer Society.

Pancreatic cancer researcher Donghui Li, PhD, who is a professor in the department of gastrointestinal medical oncology at the University of Texas M.D. Anderson Cancer Center, also praised the study and said it's still not clear how dietary fat may affect pancreatic cancer risk.

"The study really offers some convincing evidence for the association of dietary fats and pancreatic cancer," says Li, who was part of another team of researchers that published a study this week showing that overweight and obese young adults are more likely than their leaner peers to develop pancreatic cancer later in life.

An editorial published with the study notes that there isn't enough evidence to "confirm the importance of animal fats, per se, or even that meat is the important factor, as opposed to other dietary or lifestyle preferences associated with meat consumption."

"Nevertheless, sufficient evidence already suggests health benefits from limiting meat and saturated fat intake, and the current study provides additional support for these recommendations," write the editorialists, who included Brian Wolpin, MD, MPH, of the Dana Farber Cancer Institute in Boston.
Article source : http://www.webmd.com/

Obesity Costs U.S. $147 Billion a Year

July 27, 2009 - Obesity costs the U.S. health care system up to $147 billion a year: An extra $1,429 per year for each obese person.

It's not obesity itself that costs so much. It's the bad health that comes with it, says a new study.

"The medical costs attributable to obesity are almost entirely a result of costs generated from treating the diseases obesity promotes," lead study author Eric A. Finkelstein, PhD, director of North Carolina's RTI Public Health Economics Program, says in a news release.

Those diseases include heart disease, type 2 diabetes, cancer, and stroke.

If nobody in the U.S. were obese, we'd spend 9% less on health care. But more than a third of us are obese -- and another third of us are overweight.

That's a scary statistic. Here's a scarier one: 17% of U.S. children and teens are so overweight they're in the top 5% of body size for their age on growth charts. A less nice way to put it: these kids already are obese.

The health-related costs of obesity are rising. That's because more and more people are becoming obese, Finkelstein and colleagues calculate.

What can be done? The CDC last week released a list of community strategies to prevent obesity. It's a detailed blueprint of 24 strategies divided into six categories:

* Making affordable healthy foods and beverages more available
* Supporting healthy food choices
* Encouraging breastfeeding
* Encouraging kids to be more active
* Creating safe communities that support physical activity
* Encouraging communities to organize for change

"It is critical that we take effective steps to contain and reduce the enormous burden of obesity on our nation," CDC Director Thomas Frieden, MD, MPH, says in a news release.

Finkelstein and colleagues report their findings in the July 27 issue of Health Affairs. The CDC report appears in the July 24 issue of MMWR Recommendations and Reports.

Obesity Is Biggest Health Problem for Kids

Aug. 13, 2009 -- U.S. adults continue to rate obesity as the biggest health problem for children, according to a 2009 poll conducted by C.S. Mott Children's Hospital.

Although childhood obesity ranked No. 1 last year also, this is the first year it ranked at the top for whites, Hispanics, and African-Americans. Last year, Hispanics rated smoking as the top child health concern and African-Americans ranked teenage pregnancy.

Stress, which came in at No. 8, made the top 10 list for the first time this year. It ranked especially high among lower-income participants, perhaps reflecting the stresses that children face as their parents struggle in the current economy.

The complete list of children's health concerns rated as a "big problem:"

1. Childhood obesity
2. Drug abuse
3. Smoking/tobacco use
4. Bullying
5. Internet safety
6. Child abuse and neglect
7. Alcohol abuse
8. Stress
9. Not enough opportunities for physical activity
10. Teen pregnancy

The fact that stress -- and many other problems on the list -- are behavioral or psychological in nature means that families need more than just good health care; they also need “guidance from community health and educational programs that cultivate healthy, protective behaviors and offer support when health problems
arise,” poll director Matthew Davis, MD, says in a written statement. Davis is an associate professor of general pediatrics and internal medicine at the University of Michigan Medical School and an associate professor of public policy at the University of Michigan Gerald R. Ford School of Public Policy.

The nationally representative survey was conducted in May 2009 and included 2,017 randomly selected adults 18 or older. Participants were asked to rank 23 different health concerns facing children in their communities. The margin of error is plus or minus three to four percentage points.

Obesity - Causes and Management

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy. Body mass index (BMI), which compares weight and height, is used to define a person as overweight (pre-obese) when their BMI is between 25 kg/m2 and 30 kg/m2 and obese when it is greater than 30 kg/m2.

Obesity is associated with many diseases, particularly heart disease, type 2 diabetes, breathing difficulties during sleep, certain types of cancer, and osteoarthritis. Obesity is most commonly caused by a combination of excessive dietary calories, lack of physical activity, and genetic susceptibility, though a limited number of cases are due solely to genetics, medical reasons or psychiatric illness.

The primary treatment for obesity is dieting and physical exercise. If

this fails, anti-obesity drugs may be taken to reduce appetite or

inhibit fat absorption. In severe cases, surgery is performed or an

intragastric balloon is placed to reduce stomach volume and or bowel

length, leading to earlier satiation and reduced ability to absorb

nutrients from food.

Obesity is a leading preventable cause of death worldwide, with

increasing prevalence in adults and children, and authorities view it

as one of the most serious public health problems of the 21st century.

Obesity is stigmatized in the modern Western world, though it has been

perceived as a symbol of wealth and fertility at other times in

history, and still is in many parts of Africa

source : wikipedia.org

What Causes Obesity?

Obesity is considered a long-term complex disease. Many factors are

involved in determining why some people are heavier than others and how

much risk they have for developing other medical problems.
Science continues to search for answers. But until the disease is

better understood, the control of excess weight is something patients

must work at for their entire lives. That is why it is very important

to understand that all current medical interventions, including weight

loss surgery, should not be considered medical cures. Rather, they are

attempts to reduce the adverse effects of excessive weight and

alleviate the serious physical, emotional and social consequences of

the disease.
You gain weight when you consume more calories from food than your body

uses through its normal functions (basal metabolic rate [BMR]) and

physical activity. The unused calories are stored as fat. You become

obese if you consistently consume excess calories over a long period of

time. For example, eating an extra 100 calories per day can lead to a

gain of about 10 lbs (4.5 kgs) in a year. Gaining 10 pounds a year

eventually will result in a BMI of 30 or higher.
Your activity level is also important. Activity uses calories, which

helps balance the calories you get through food. If you are inactive,

it may be easier to gain weight.
However, calories alone do not explain weight gain and why some people

gain (or lose) weight more easily than others. Other factors that play

a major role in weight gain and obesity include:
Genetic or Hereditary Factors
Research has shown that in many cases a significant underlying cause of

morbid obesity is genetic - you inherit the tendency to gain weight.

Numerous scientific studies have established that your genes play an

important role in your tendency to gain excess weight. The body weight

of adopted children shows no correlation with the body weight of their

adoptive parents who feed them and teach them how to eat. Their weight

does have an 80 percent correlation with their genetic parents whom

they have never met. Identical twins with the same genes show a much

higher similarity of body weights than do fraternal twins, who have

different genes. Certain groups of people, such as the Pima Indian

tribe in Arizona, have a very high incidence of severe obesity. They

also have significantly higher rates of diabetes and heart disease than

other ethnic groups.

We probably have a number of genes directly related to weight. Just as

some genes determine eye color or height, others affect our appetite,

our ability to feel full or satisfied, our metabolism, our fat-storing

ability, and even our natural activity levels.
Environmental Factors
Environmental and genetic factors are obviously closely intertwined. If

you have a genetic predisposition toward obesity, then the modern

lifestyle and environment that has readily available inexpensive food

high in fat and low in fruits and vegetables may lead to weight gain

and obesity. Fast food, long days sitting at a desk, and suburban

neighborhoods that require cars all magnify hereditary factors such as

metabolism and efficient fat storage. For those suffering from morbid

obesity, anything less than a total change in environment usually

results in failure to reach and maintain a healthy body weight by

nonoperative measures.
Metabolism
We used to think of weight gain or loss as only a function of calories

ingested and then burnt. Take in more calories than you burn and gain

weight; burn more calories than you ingest and lose weight. But now we

know the equation isn't that simple.

Obesity researchers now talk about a theory called the "set point" - a

sort of thermostat in the brain that makes people resistant to either

weight gain or loss. If you try to override the set point by

drastically cutting your calorie intake, your brain responds by

lowering metabolism and slowing activity. You then gain back any weight

you lost.

Health Hazards of Morbid Obesity

Severe obesity damages the body by its mechanical, metabolic and

physiological adverse effects on normal bodily function. These

"co-morbidities" affect nearly every organ in the body in some way, and

produce serious secondary illnesses, which may also be

life-threatening. The cumulative effect of these co-morbidities can

interfere with a normal and productive life and can seriously shorten

life, as well. The risk of developing these medical problems is

proportional to the degree of obesity.
Years of life lost
People who are obese do not live as long as those who are not obese and

the earlier a person become obese; the more years of life are lost. A

recent study in the Annals of Internal Medicine (Jan 2003) concluded

that obesity and overweight are associated with large decreases in life

expectancy and increases in early death.
- Forty year old female nonsmokers lost 7.1 years of life because of

obesity
- Forty year old male nonsmokers lost 5.8 years because of obesity
- Obese female smokers lost 13.3 years & obese male smokers lost 13.7

years compared with normal weight nonsmokers
People who are obese are at greater risk of death from cancer. In the

United States, compared to people of a healthy weight, people who are

Obese (BMI of 30-34.9) have a 9% (men) or 23% (women) increased risk of

death from cancer. Very obese (BMI of 35-39.9) have a 20% (men) or 32%

(women) increased risk of death from cancer.
Dysmetabolic Syndrome X
This recently recognized syndrome involving abdominal obesity, abnormal

blood fat levels, changes in insulin sensitivity and inflammation of

the arteries is associated with a markedly increased risk of heart and

blood vessel disease. It is also a precursor to the onset of Diabetes

in adults.
Heart Disease
Severely obese persons are approximately 6 times as likely to develop

heart disease as those who are normal-weighted. Heart disease is the

leading cause of death today and obese persons tend to develop it

earlier in life and it shortens their lives. Coronary disease is

pre-disposed by increased levels of blood fats and the metabolic

effects of obesity. Increased load on the heart leads to early

development of congestive heart failure. Severely obese persons are 40

times as likely to suffer sudden death, in many cases due to cardiac

rhythm disturbances.
High Blood Pressure
Essential hypertension, the progressive elevation of blood pressure, is

much more common in obese persons and leads to development of heart

disease, and damage to the blood vessels throughout the body, causing

susceptibility to strokes, kidney damage, and hardening of the

arteries. If your doctor finds you have high blood pressure, the first

thing he or she will recommend to you is weight loss (but doctors have

never been able to tell : How?
High Blood Cholesterol
Cholesterol levels are commonly elevated in the severely obese --

another factor predisposing to development of heart and blood vessel

disease. This abnormality is not just related to diet, but is an effect

of the massive imbalance in body chemistry which obesity causes.
Diabetes Mellitus
Overweight persons are 40 times as likely to develop Type-2,

Adult-Onset, diabetes (earlier called non insulin dependent). Elevation

of the blood sugar, the essential feature of diabetes, leads to damage

to tissues throughout the body: Diabetes is the leading cause of

adult-onset blindness, a major cause of kidney failure and the cause of

over one half of all amputations. Diabetics suffer severely from their

disease and once Diabetes occurs, it becomes even harder to lose

weight, because of hormone changes which cause the body to store fat

even more than before.
Sleep Apnea Syndrome
Sleep apnea - the stoppage of breathing during sleep -- is commonly

caused in the obese, by compression of the neck, closing the air

passage to the lungs. It leads to loud snoring, interspersed with

periods of complete obstruction during which no air gets in at all. The

sleeping person sounds to an observer like he is holding his breath,

but the sleeper is, himself, usually unaware that the problem is

occurring at all, or only notices that he sleeps poorly and awakens

repeatedly during the night. The health effects of this condition may

be severe, high blood pressure, cardiac rhythm disturbances and sudden

death. Affected persons awaken exhausted and often fall asleep during

the day, sometimes even at the wheel of their car, and complain of

being tired all the time. This condition really has a high mortality

rate, and is a life-threatening problem.
Obesity Hypoventilation Syndrome
This condition occurs primarily in the very severely obese -- over 350

lbs. It is characterized by episodes of drowsiness, or narcosis,

occurring during awake hours and is caused by abnormalities of

breathing and accumulation of toxic levels of carbon dioxide in the

blood. It is often associated with sleep apnea, and may be hard to

distinguish from it
Respiratory Insufficiency
Obese persons find that exercise causes them to be out of breath very

quickly and even during ordinary activities. The lungs are decreased in

size, and the chest wall is very heavy and difficult to lift. At the

same time, the demand for oxygen is greater, with any physical

activity. This condition prevents normal physical activities and

exercise, often interferes with usual daily activities, such as

shopping, yard-work or stair climbing, making even ordinary living

difficult or miserable, and it can become completely disabling.
Heartburn - Reflux Disease and Reflux Nocturnal Aspiration
Acid belongs to the stomach, which makes it to help digest food, and it

seldom causes any problem when it stays there. When it escapes into the

esophagus, through a weak or overloaded valve at the top of the

stomach, the result is called “gastro-esophageal reflux”. The real

problem is not with digestion, but with the burning of the esophagus by

the powerful stomach acid, getting to where it doesn't belong. When one

belches, the acid may bubble up into the back of the throat, causing a

fiery feeling there as well. Often this occurs at night, especially

after a large or late meal and if one is asleep when the acid

regurgitates, it may actually be inhaled, causing a searing of the

airway, and violent coughing and gasping.
This condition is dangerous, because of the possibility of pneumonia or

lung injury. The esophagus may become strictured, or scarred and

constricted, causing trouble with swallowing. Approximately 10 - 15% of

patients with even mild sporadic symptoms of heartburn will develop a

condition called Barrett's esophagus, which is a pre-malignant change

in the lining membrane of the esophagus, a cause of esophageal cancer
Asthma and Bronchitis
Obesity is associated with a higher rate of asthma, about 3 times

normal. Much of this effect is probably due to acid reflux (described

above), which can irritate a sensitive airway and provoke an asthmatic

attack. The improvement of asthma after surgery is often very dramatic,

even before much weight loss has occurred.
Gallbladder Disease
Gallbladder disease occurs several times as frequently in the obese, in

part due to repeated efforts at dieting, which predispose to this

problem. When stones form in the gallbladder, and cause abdominal pain

or jaundice, the gallbladder must be removed.
Stress Urinary Incontinence
A large heavy abdomen and relaxation of the pelvic muscles, especially

associated with the effects of childbirth, may cause the valve on the

urinary bladder to be weakened, leading to leakage of urine with

coughing, sneezing, or laughing. This condition is strongly associated

with being overweight, and is usually relieved by weight loss.
Degenerative Disease of Lumbo-Sacral Spine
The entire weight of the upper body falls on the base of the spine and

overweight causes it to wear out, or to fail. The consequence may be

accelerated arthritis of the spine, or "slipped disk", when the

cartilage between the vertebrae squeezes out. Either of these

conditions can cause irritation or compression of the nerve roots and

lead to sciatica -- a dull, intense pain down the outside of the leg.
Degenerative Arthritis of Weight-Bearing Joints
The hips, knees, ankles and feet have to bear most of the weight of the

body. These joints tend to wear out more quickly, or to develop

degenerative arthritis much earlier and more frequently, than in the

normal-weighted person. Eventually, joint replacement surgery may be

needed to relieve the severe pain. Unfortunately, the obese person

faces a disadvantage there too -- joint replacement has much poorer

results in the obese and complications are more likely. Many orthopedic

surgeons refuse to perform the surgery in severely overweight patients
Venous Stasis Disease
The veins of the lower legs carry blood back to the heart. They are

equipped with an elaborate system of delicate one-way valves, to allow

them to carry blood "uphill". The pressure of a large abdomen may

increase the load on these valves, eventually causing damage or

destruction. The blood pressure in the lower legs then increases,

causing swelling, thickening of the skin, and sometimes ulceration of

the skin. Blood clots also can form in the legs, further damaging the

veins, and can also break free and float into the lungs -- called a

Pulmonary Embolism -- a serious or even fatal event.
Emotional / Psychological Illness
Seriously overweight persons face constant challenges to their

emotions: repeated failure with dieting, disapproval from family and

friends, sneers and remarks from strangers. They often experience

discrimination at work, and cannot enjoy theatre seats, or a ride in a

bus or airliner. The severely overweight person takes challenges even

in small routine acts like that others cannot fathom. Many may be on

starvation diet but friends and relatives scrutinize their eating

habits – convinced that that are sneaking food. They cannot perform

simple things ; walking up stairs or tying shoes is a major ordeal.

Stereotypes of obese people – such as that they are lazy – may result

in lower self esteem and poor body image. There is no wonder that

anxiety and depression might accompany years of suffering from the

effects of a genetic condition -- one which skinny people all believe

should be controlled easily by will power.
Social Effects
Severely obese persons suffer inability to qualify for many types of

employment, and discrimination in employment opportunities, as well.

They tend to have higher rates of unemployment, Ignorant persons often

make rude and disparaging comments, and there is a general societal

belief that obesity is a consequence of a lack of self-discipline, or

moral weakness. Many severely obese persons find it preferable to avoid

social interactions or public places, choosing to limit their own

freedom, rather than suffer embarrassment.

obesity and fitness market in India

Obesity is increasingly posing itself as a grave problem in India, just

as in many developed countries such as the US and UK. Though India’s

obesity level is less as compared to the US and UK, at approximately

8%, against over 25% in US and 15% in Europe, the problem can soon

reach that magnitude if not adequately addressed.

The Union health ministry last year slimmed down the Body Mass Index

(BMI) to 23 kg/m2 as against 25 kg/m2 globally. BMI is the body weight

of an individual measured in proportion to his height. The primary

reason to lower BMI levels was to fight the danger of India becoming a

diabetes hub by 2050.

According to experts, obesity is more of an urban phenomenon with a

prevalence of at least 30-50% general obesity levels and 40-70%

abdominal obesity. Indian women are more prone to abdominal obesity as

opposed to men. The obesity levels are half or even lesser than these

in rural areas, says Dr Anoop Mishra, director of diabetology, obesity

and metabolism department, Fortis Group.

Dr Mishra asserts that a lower BMI guideline is necessary for Indians

living anywhere in the world. “Indians are more prone to Type 2

diabetes, hypertension and heart disease. We are developing diseases at

lower BMI too, so it was absolutely necessary to revise these in India.

We have also revised exercise guidelines to 60 minutes, all 7 days of

the week. But a lot more still needs to be done. The government needs

to launch a major programme to counter the obesity issue. Otherwise

there will soon be a diabetic factory in India.”

Sharp words there. But hips don’t lie. According to a National Family

Health Survey-3(NFHS) survey in 2005-06, the problem has been

particularly observed in older women, women living in urban areas, well

educated women and women in households falling in the highest wealth

quintile and Sikhs. The survey found that obesity is particularly

prevalent for both men and women in Delhi, Kerala, and Punjab. The

percentage of women who are overweight or obese is highest in Punjab

(30%), followed by Kerala (28%) and Delhi (26%). It’s no wonder then

that the anti-obesity market has become a huge opportunity area which

brands want to tap it. Expanding waistlines now mean big bottomlines

for companies too.

Digest this: The present market size for the anti-obesity market in the

country is estimated as being over Rs 1,800 cr, according to leading

management consulting organisation Technopak Advisors. This overall

market—comprising fitness centres/gymnasiums, slimming services, food

supplements and ayurveda treatments—is projected to grow at a rate of

13% CAGR through 2010.

Fitness and diet centres, FMCG companies, apparel brands and even fast

food joints are all cashing in on the keep fit mantra. The Indian

healthcare market, comprising healthcare delivery, pharma and medical

technology, is estimated at a huge $34 billion and growing at 15%

annually, according to the Technopak analysis

http://economictimes.indiatimes.com/Features

Obesity Treatment

Medical Care

Theoretically, any therapeutic interventions in the child with obesity must achieve control of weight gain and reduction in body mass index (BMI) safely and effectively and should prevent the long-term complications of obesity in childhood and adulthood. First, manage any acute or chronic complications of obesity and request psychiatric assistance for unusual eating disorders or severe depression. Devise a care plan that emphasizes long-term diet and exercise, family support, and the avoidance of dramatic swings in body weight. A team approach to therapy, involving the efforts of nurse educators, nutritionists, exercise physiologists, and counselors, is likely to prove most effective. Avoid a punitive approach and reward positive behaviors.

Any intervention is likely to fail if it does not involve the active participation and support of family members. The child at hand may be only one of many family members who have obesity, and successful treatment often requires a change in the entire family's approach to eating. In selected cases, family therapy may be highly beneficial.

Recognize that a loss of 5-20% of total body weight can reduce many of the health risks associated with obesity in adults; however, whether modest weight loss or moderate reductions in BMI can improve outcomes in pediatric patients or reduce the long-term risks of obesity in adulthood is not known. Because dramatic reductions in BMI are difficult to achieve and sustain in children and adolescents as well as adults, initiating counseling and therapy may be prudent with realistic goals that emphasize gradual reductions in body fat and BMI and maintenance of weight loss rather than a rapid return to ideal body weight. Reductions in body weight are accompanied by equivalent reductions in energy expenditure. Consequently, maintenance of a given weight in a patient with obesity necessitates a lower energy intake than maintenance of an equivalent weight in a patient who has never been obese.

A recent review concluded that, although no one treatment program can be conclusively recommended, combined behavioral lifestyle interventions produce a significant reduction in weight. Although orlistat and sibutramine may be used as adjuncts to lifestyle interventions, they must be carefully considered.4

Smoking tobacco reduces appetite and is used by many adults and some teenagers to prevent or limit weight gain. The deleterious consequences of smoking clearly outweigh the benefits achieved by weight control, and all children and adolescents should be urged never to smoke. Measures to prevent excessive weight gain should be undertaken in obese adolescents who discontinue smoking.

General measures

Exercise and physical activity: Physicians and parents should encourage children to participate in vigorous physical activity throughout adolescence and young adulthood and to limit time spent watching television and videos and playing computer games. Even regular walking for 20-30 minutes per day can facilitate weight control. Exercise reduces weight accretion through increases in energy expenditure and has favorable effects on cardiovascular status, decreases body fat and total cholesterol levels, increases lean body mass and high-density lipoprotein (HDL) levels, and improves psychological well-being. Controlled trials have demonstrated that lifestyle exercise programs, in association with dietary restrictions, provide long-term weight control in children and adolescents.
Nutritional counseling and reduced fat diet
An energy-restricted balanced diet, in association with patient and parent education, behavioral modification, and exercise can limit weight gain in many pediatric patients who have mild or moderate obesity. Programs that modify family patterns of eating are most likely to be successful. Reductions in total and saturated fat may be particularly useful in adolescents who consume large quantities of high fat, snack, and packaged fast foods, including french fries, pizza, chips, and crackers.
The average diet for children and adolescents in the United States contains approximately 35% fat. Reducing fat intake to 30% of total energy is recommended by the World Health Organization (WHO); however, little evidence, epidemiological or experimental, supports the idea that a reduced-fat but otherwise unlimited diet suffices for substantial weight reduction in obese individuals. A reduced-fat diet may be more useful for primary or secondary prevention of weight gain in individuals with previous obesity individuals, particularly in those with a familial susceptibility.

Intensive intervention

Anecdotal evidence suggests that children with severe obesity may develop major psychiatric disorders (eg, suicide attempts, manic depression, other depressive disorders) that require hospitalization or long-term medication. Whether most of these psychiatric disorders predate, cause, or result from the obesity or its treatment is unclear. Like adults, children who enter obesity treatment programs may be at particularly high risk for the development of psychopathology.
Treatment of the psychiatric conditions may complicate or exacerbate problems associated with weight control because numerous antidepressant medications, particularly tricyclics, stimulate appetite and weight gain. Offer patients who have obesity psychological support and refer these patients for psychiatric evaluation and care if evidence of psychopathology or dysfunction is present. As noted above, any therapeutic intervention in the child or adolescent with obesity is unlikely to succeed without the understanding, approval, and active participation of family members. Family therapy is effective in patients resistant to other therapeutic interventions, particularly those with parents who have obesity.
Very controlled–energy diets
A protein-sparing modified fast can achieve rapid weight loss in an inpatient or outpatient setting and has been successfully used by numerous investigators in children and adolescents with obesity. For example, a year-long study of 73 pediatric patients aged 7-17 years showed significant reductions in the percent overweight, total body fat (TBF), BMI, total and low-density lipoprotein cholesterol, triglycerides, and fasting serum insulin with no change in fat-free mass. Unfortunately, this study and many others combined the diet with behavior modification and a vigorous exercise program; thus, assessing the effects of the diet itself is impossible.
In general, very controlled–energy diets are hampered by high dropout rates and, in adults, have been associated with losses in lean weight, gallstone formation, cardiac arrhythmias, and sudden death. Moreover, some studies suggest that regain of weight after severe dieting may lead to overshoot, with excess weight deposited as a higher percentage of body fat. Concerns have been raised regarding the long-term cardiovascular risks of such weight cycling in adults, but the potential hazards of dramatic or cyclical weight changes in children and adolescents are unknown.
More important, the long-term effects of very controlled–energy diets on adolescent growth and development and subsequent reproductive function, musculoskeletal development, and intermediary metabolism remain poorly understood. Because of these uncertainties and the difficulties inherent in maintaining severe caloric restriction, the very controlled–energy diets cannot be recommended for the vast majority of children and adolescents with obesity.

Surgical Care

Various bariatric surgical procedures have been used in adults and some adolescents (in most centers, patients >15 y) with a BMI of more than 40 or weight exceeding 100% of ideal body weight (IBW).

The most common procedures involve gastric restriction. In the vertical-banded gastroplasty (VBG), a pouch of 15-mL to 30-mL capacity is constructed, greatly reducing the amount of food that can be eaten at any time. In the gastric bypass, a larger pouch that empties into the jejunum is created. As a result, nutrients bypass the duodenum and most of the stomach, which often creates a dumping syndrome. Overall effectiveness is good with significant weight loss, reduction in obesity complications, and increased life expectancy; however, mortality rate of the procedure is 1% in adults, and complications include encephalopathy, nephrolithiasis, cholelithiasis, protein-losing enteropathy, and other nutritional deficiencies.

Accordingly, laparoscopic placement of an adjustable gastric band (LAGB) has recently supplanted the VBG, both because of its relative safety and because of its reversibility. Use of the LAGB involves placing a collar with an internal, saline-filled balloon around the upper stomach, 1-2 cm below the esophagogastric junction. This creates a 30-mL upper gastric pouch that can be modified by injecting a small amount of saline into a subcutaneous port linked to the balloon. Recent data suggest that the LAGB is associated with superior outcomes to those observed following VBG, and its low complication rate and reversibility make LAGB a viable alternative treatment for the adolescent patient. Nevertheless, the LAGB, or any surgical approach, should be considered only in the most severe cases of adolescent obesity that are resistant to all other forms of therapy.

Consultations

Consultations with the following specialists may be indicated:

Nutritionist
Exercise physiologist
Psychiatrist
Pulmonary (sleep) medicine specialist
Orthopedist
Gastroenterologist

Medication

Medications approved for long-term obesity management in adult patients in the United States include sibutramine (Meridia),5,6 a selective serotonin norepinephrine reuptake inhibitor, and orlistat (Alli, Xenical), a pancreatic lipase inhibitor. Sibutramine may be classified as an anorectic drug, whereas orlistat's mechanism of action involves induction of lipid maldigestion. Although each of these medications significantly increases weight loss when compared with placebo, in long-term studies, the anorectic agents have also been shown to maintain effectiveness only in conjunction with an appropriate diet and exercise program.

Indeed, these drugs mediate only modest effects on total body weight, with long-term weight losses amounting to 2-10 kg in adults with obesity. Furthermore, responses of individuals to drug therapy widely vary. Most weight loss is achieved within the first 6 months of treatment, followed either by weight stabilization or by a slight regain of lost weight. Discontinuation of drug therapy is usually accompanied by rebound weight gain and loss of the selective advantage over placebo, unless significant lifestyle modifications have been achieved. Other older anorectic agents approved in the United States include benzphetamine (Didrex), diethylpropion, phendimetrazine (Bontril), and phentermine (Ionamin).

Rimonabant (Acomplia), an anorectic agent with specific cannabinoid receptor inhibition, was recently denied approval by the US Food and Drug Administration (FDA). The approval was unanimously rejected by the FDA's Endocrinologic and Metabolic Drugs Advisory Committee in June 2007. The FDA committee said that more detailed long-term safety information with larger patient numbers was needed with regard to neurological and psychiatric side effects that have been associated with the drug, including seizures, depression, anxiety, insomnia, aggressiveness, and suicidal thoughts. Rimonabant was approved in several European countries in 2006. Rimonabant is approved for sale in 42 countries and is marketed for obesity with associated cardiovascular risk in 20 countries.

All of these weight loss drugs are associated with significant side effects that often limit their use. With orlistat, resulting nausea, bloating, and discomfort from steatorrhea are common, although these symptoms tend to decrease with long-term use. Sibutramine may cause dry mouth, insomnia, nervousness, diaphoresis, hypertension, nausea, and constipation. Tolerance to most adverse effects is achieved within 2 weeks of continuous treatment. Contraindications to the use of noradrenergic agents include angina and other forms of atherosclerotic disease, cardiac arrhythmias, hyperthyroidism, and/or the concomitant use of monoamine oxidase inhibitors (MAOIs). Several adrenergic drugs have either been withdrawn from the market in the United States (eg, phenylpropanolamine, mazindol) or are banned by the FDA (eg, ephedrine alkaloids ephedra, Ma Huang) as the consequence of potentially fatal cardiovascular effects.

Two previously and widely used agents, the serotoninergic drugs fenfluramine and dexfenfluramine, were recently withdrawn from the commercial market because of their association with valvular heart disease and primary pulmonary hypertension. These drugs were also associated with drowsiness, insomnia, tremor, and short-term memory loss. High doses of fenfluramine and dexfenfluramine are neurotoxic in rats and monkeys, raising concerns about the long-term use of other serotoninergic preparations (eg, fluoxetine) in children.

Pediatric experience with the use of weight loss drugs is beginning to emerge. One multicenter, randomized trial of orlistat in obese adolescents demonstrated weight stabilization and reduced body fat in the orlistat group, whereas significant weight gain was observed in patients receiving placebo.7 However, a second study failed to demonstrate any significant benefit from orlistat treatment.8 Regarding the use of anorectic agents, a 12-month, randomized placebo-controlled trial of sibutramine in 498 adolescents demonstrated a significant, drug-associated reduction in BMI (sibutramine vs placebo = -8.2% vs -0.8%, P <0.001), without any observed cardiodynamic effects.5

Despite some of these promising findings, anorectic drugs should never be routinely used for the prevention or treatment of obesity in childhood or adolescence. Clearly, these agents must be absolutely proscribed for prepubertal children until carefully controlled clinical studies are performed to assess their safety and efficacy. Administration of anorectic drugs may be considered in the postpubertal adolescent, but only after the patient has failed to respond to vigorous attempts to modify behavior, diet, and family interactions. Unless prohibited by a specific investigational protocol, all adolescents who are prescribed anorectic agents should receive concurrent nutritional and family counseling and should implement a plan of regular exercise and physical activity

Articls Source : http://emedicine.medscape.com/article/985333-treatment