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