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CPG Management of Obesity 2004

Clinical practice guideline for management of obesity in Malaysia

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Physiotherapy (HS244)

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Universiti Teknologi MARA

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Malaysian Endocrine & Metabolic Society

Malaysian Association for the Study of Obesity

Academy of Medicine of Malaysia

Ministry of Health Malaysia

Chairman

Professor Ikram Shah Ismail

Senior Consultant Endocrinologist and Vice President, Malaysian Association for the Study of Obesity and Malaysian Diabetes Association

Committee Members

Professor Wan Mohamed Wan Bebakar Senior Consultant Endocrinologist, Hospital Universiti Sains Malaysia and President, Malaysian Endocrine and Metabolic Society

Assoc Professor Nor Azmi Kamaruddin Consultant Endocrinologist, Hospital Universiti Kebangsaan Malaysia and Vice President, Malaysian Endocrine Metabolic Society

Dr Noor Hisham Abdullah Consultant Surgeon, Breast and Endocrine Surgery Unit, Hospital Putrajaya

Dr Fuziah Md Zain Consultant Paediatric Endocrinologist Department of Paediatrics, Hospital Putrajaya

Ms Siti Hawa Mohd Taib Dietitian, University of Malaya Medical Centre

Ms Lee Lai Fun Dietitian, University of Malaya Medical Centre

Professor Mohd Ismail Noor Head, Dept of Nutrition and Dietetics, Universiti Kebangsaan Malaysia and President, Malaysian Association for the Study of Obesity

Professor Rabindarjeet Singh Exercise Physiologist, Sports Science Unit, School of Medical Sciences, Universiti Sains Malaysia

Dr Zanariah Hussein Consultant Endocrinologist Endocrine Unit, Hospital Putrajaya

Section 1: Introduction

— Summary of Recommendations

• The BMI should be used to classify overweight and obesity and to

estimate relative risk for disease compared to normal weight

(Evidence Level B)

• The waist circumference should be used to assess abdominal fat content

(Evidence Level B).

• Based on current evidence in adults, overweight is defined as

BMI ≥23 kg/m 2 and obesity as BMI ≥27 kg/m 2 (See Table 3)

(Evidence Level C)

• Current evidence suggests that waist circumference of ≥90 cm in

men and ≥80 cm in women is associated with increased risk of

comorbidities (Evidence Level C).

• In overweight and obese individuals, weight loss is recommended to

(Evidence Level B):-

o Lower elevated blood pressure

o Lower elevated levels of total cholesterol, low-density lipoprotein

cholesterol and triglycerides

o Raise low levels of high-density lipoprotein cholesterol

o Lower elevated blood glucose levels

1. Introduction

1. Background

The global burden of overweight (Body Mass Index (BMI) ≥25 kg/m 2 ) and obesity (BMI ≥ 30.

kg/m 2 ) is estimated at more than 1 billion. There is evidence that the risk of obesity related

diseases among Asian rises from a lower BMI of 23 kg/m 2 (1). If this were adopted as a new

benchmark for overweight Asians, it would require a major revision of approaches in the Asian sub-regions, where a significant proportion of the 3 billion populations already has a mean BMI of 23 kg/m 2. In Malaysia, the National Health and Morbidity Survey 1996 reported that in adult males, 15% were overweight and 2% obese while in adult females, 17% were overweight and 5% obese (2). It was also reported that there was little difference between rural and urban populations and that there were more obese Malays and Indians as compared to Chinese.

The co-morbidities of obesity produce financial costs to the health economy of many developed countries. Similar demands in Malaysia will impose a huge burden on the human and economic resources and are liable to disturb priorities in the health care or other sectors (3). As Malaysia proceeds rapidly towards developed economy status, there is a need to develop a national strategy to tackle both dietary and activity contributors to the excess weight gain of the population (4).

This guideline recommends a multi-disciplinary approach to manage overweight and obese patients in Malaysia. The guideline was initiated by the Malaysian Association for the Study of Obesity (MASO) and the Malaysian Endocrine and Metabolic Society (MEMS).

The objective of this Clinical Practice Guidelines is to assist healthcare providers to better diagnose and manage overweight and obese patients. Concern for effective clinical management of obesity has been growing internationally. This guideline is consistent with other similar guidelines and is developed with the expectation of improving the overall health care system in Malaysia.

The evidence presented in the guideline was collated from the following sources:

Systematic review of relevant published literature (up to 2004) as identified by electronic (e. - Medline) search
Reports of other relevant expert working groups as listed below: a. Obesity in Scotland – Integrating Prevention with Weight Management (SIGN) Scottish Intercollegiate Guidelines Network (5)

b. National Institutes of Health: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults – The Evidence Report (6).

c. The Asia-Pacific perspective: Redefining obesity and its treatment (7).

d. Obesity – Preventing and Managing the Global Epidemic (8).

e. AACE/ACE Position Statement on the Prevention, Diagnosis and Treatment of Obesity (9)

f. Report of a WHO Expert Consultation on appropriate BMI for Asian populations and its implications for policy and intervention strategies (10).

Treatment strategies have been graded based on the levels of evidence using the system outlined below (MOH): A. At least one meta analysis, systematic review, or randomized controlled trial, or evidence rated as good and directly applicable to the target population B. Evidence from well conducted clinical trials, directly applicable to the target population, and demonstrating overall consistency of results; or evidence extrapolated from meta analysis, systematic review, or RCT C. Evidence from expert committee reports, or opinions and/or clinical experiences of respected authorities; indicates absence of directly applicable clinical studies of good quality

This CPG is planned for a review at every five-year interval by the committee and appropriately updated if the need arises.

1. Definition of Obesity

Obesity is a complex, multifactorial condition characterized by excess body fat. It must be viewed as a chronic disorder that essentially requires perpetual care, support and follow-up. Obesity is associated with many other diseases, and it warrants recognition by health-care providers. Generally, men with >25% body fat and women with >35% body fat are considered obese.

1.2. Body Mass Index (BMI)

This is the most established and widely used measurement and is defined as:

BMI = Weight (kg)/ Height 2 (m) 2

The current WHO classification states that the cut-off points for overweight and obesity is 25 and 30 kg/m 2 respectively (8). However, it has become increasingly clear that there is a high prevalence of type 2 diabetes mellitus and cardiovascular risk factors in parts of Asia below those cut-off points. Evidence from several Asian countries are now available including Hong Kong (11), Singapore (12), China (13-15), India (16, 17), and Japan (18) to show that the risk of co-morbidities begin to rise at lower BMI values. Many Asian populations have a higher body fat percent at similar BMI, compared with Caucasian/European populations (19-22). In a recent WHO Consultation report, no attempt was made to redefine BMI cut-off points for Asian populations (10). However, this report identified further potential public health action points along the continuum of previous BMI classifications (8) (Figure 1) at which to trigger policy action, to facilitate prevention programmes and to measure the effect of intervention (10).

Fatty Liver Disease ( NAFLD), which represents a broad spectrum of hepatic pathology ranging from simple steatosis without any evidence of inflammation, to severe inflammatory activity with significant fibrosis or even cirrhosis (24). Simple steotosis rarely progress to nonalcoholic steatohepatitis (NASH), however once NASH has been established, a significant proportions of patients may develop significant fibrosis and cirrhosis.

In obese patients, routine LFT test must be done. If AST / ALT or both is abnormal, perform ultrasound of liver. Other causes of abnormal AST/ ALT must be excluded (e: Viral Hepatitis, Metabolic Liver Diseases and Autoimmune liver diseases). Once the diagnosis of possible fatty liver is made, the patients should be on long term follow up.

If Liver enzymes are persistently elevated for more than 6 months, the patients should be referred to a Hepatologist / Gastroenterologist for further evaluation and treatment.

Metabolic syndrome is defined as glucose intolerance (IGT or diabetes mellitus) or insulin resistance, together with 2 or more of other components listed below (25) :-

a. Impaired glucose tolerance (IGT) or diabetes

b. Insulin resistance (under hyperinsulinaemic euglycaemic conditions, glucose uptake below lowest quartile for background populations under investigation)

c. Raised arterial pressure ≥140/90 mmHg

d. Raised plasma triglycerides ≥1/L and/or low HDL-C <0 mmol/L (men);

<1 mmol/L (women)

e. Central obesity (Waist Hip Ratio : Men >0, Women >0) and/or BMI >30 kg/m 2

f. Microalbuminuria (Urinary albumin excretion ≥ 20 μg/min or albumin creatinine ratio of

≥30 mg/g of creatinine)

Breathlessness is due to decrease in residual lung volume associated with increased abdominal pressure on the diaphragm.
Sleep apnoea, is due to increased neck circumference and fat deposits in the pharyngeal area.
Obesity is associated with eccentric ventricular hypertrophy which causes systolic and diastolic left ventricular dysfunction.
Obesity is often associated with anovulation cycles resulting in reduced fertility potential while in men it is associated with decreased testosterone level.

1. Economic cost of obesity

Overweight and obesity and the associated health problems have substantial economic consequences for the health care system. Direct health care costs includes preventive, diagnostic and treatment services while indirect costs refer to the value of salary lost by people unable to work because of illness or disability, as well as the value of future earnings lost by premature death (26).

Table 1 : Published costs of obesity

USA 1998

NZ 1996

France Netherlands 1995

Canada 1999

UK 1994

England 1999

$ 51 billion (5% ) $ 135 million (2% ) FF12 billion (2% ) DG 1 billion (4% )

3% from BMI 25 - 30 kg/m 2 $1 billion (2% ) BMI > 27 kg 2 GBP 30 million GBP 130 million - overweight GBP 15 million - obese

$ 47 billion

FF0 bilion

GBP 165 million

Direct Indirect

Figure 2 : Annual direct cost of disease in relation to BMI

Source: Ref (26)

Gallstones Hypertension CHD Type 2 diabetes

12

10

8

6

4

2

0

Annual cost (US$ billions)

BMI (kg/ m 2 )

23 - 24.

25 - 28.

≥ 29

Source: Ref (27)

Section 2: Diagnosis and Assessment of Obesity

in Adults — Summary of Recommendations

Medical evaluation of an obese patient should include :-

• Assessment of the degree of obesity

• Identification of associated health risks

• Screening for possible underlying psychological disorders such as

depression, substance abuse

• Identification of possible underlying endocrine, genetic or neurological

disorders

• Planning the appropriate weight management strategies

1. Advantages of Weight Loss

Weight loss has advantages in reducing cardiovascular risk factors and other obesity associated diseases.

Table 1 Benefits of weight loss on health risks in obesity (Evidence Level B)

Health Risk Benefits of 10 kg weight loss in a 100 kg subject

Blood Pressure
Lipids
Diabetes
Osteoarthritis
Mortality

10 mmHg reduction systolic BP
20 mmHg reduction diastolic BP N.
Weight loss also reduces the need for medication in hypertensive patients
10% reduction in Total Cholesterol
15% reduction in LDL-cholesterol
30% reduction in Triglycerides
8% increase in HDL-cholesterol
>50% reduction in risk of developing DM (Weight loss of 6 kg is associated with 58% reduction in incidence of diabetes, at 3 years in the Diabetes Prevention Programme) (28)
30-50% reduction in Fasting plasma glucose
15% reduction in HbA1c
Decrease BMI ≥2 kg/m 2 associated with more than 50% decreased risk for developing osteoarthritis (29)
20 –25% reduction all – cause mortality
30 – 40% reduction diabetes related death
40 – 50% reduction in obesity-related cancer death

(Modified from (30))

Table 2: Classification Of Overweight And Obesity By BMI, Waist Circumference And Associated Disease Risk*

Disease risk for type 2 diabetes, hypertension, and CVD. † Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

2. Assessment and Identification of patients at high risk

Obesity-associated diseases and risk factors contribute to an added risk of cardiovascular morbidity and mortality and will require aggressive intervention. Identifying these risk factors will provide an additional guide to the need and intensity of any weight-reducing intervention.

2.3. Coronary Heart Disease (CHD) equivalents

a) Established Ischaemic Heart Disease b) Other atherosclerotic diseases e. Cerebrovascular accidents, Peripheral Vascular Diseases c) Type 2 diabetes mellitus

2.3. Cardiovascular Risk Factors

a) High LDL-C (> 4 mmol/L) b) Low HDL-C (< 0 mmol/L) c) High TG (> 2 mmol/L) d) Hypertension e) Impaired Fasting Glycaemia and Impaired Glucose Tolerance f) Cigarette smoking g) Family history of premature IHD (First degree relative with onset before age 55 for males, and 65 for females)

h) Age (Male ≥ 45, Female ≥ 55 or postmenopausal)

Classification BMI (kg/ m 2 )

Risk of co-morbidities

Waist circumference

Underweight < 18.

18 - 22.

Low (but increased risk of

Increased

<90 cm (men) ≥ 90 cm (men)

Increased but acceptable

risk

Increased

<80 cm (women) ≥ 80 cm (women)

Overweight : BMI ≥ 23.

Normal range †

Pre-Obese

Obese I

Obese II

Obese III

23 - 27.

27 - 34.

35 - 39.

≥ 40

Increased

High

Very High

Extremely High

High

Very High

Extremely High

2. Assessment and identification of other related diseases

Obese patients are at increased risk for several medical conditions that require detection and appropriate management as listed:- i. Gynaecological abnormalities ii. Osteoarthritis iii. Gallstones iv. Stress incontinence

2. Assessment and identification of underlying aetiology of Obesity

Obesity results from interaction between underlying genetic predisposition and environmental factors. These factors should be identified and managed appropriately.

2.5. Social and Behavioural Factors

Positive behaviour is essential to ensure effective weight management. Long-term management will be more successful with sufficient continued support. Thus, assessment of behavioural (Refer Appendix 1) and social factors are important.
Weight gain is very common when people stop smoking. This is thought to be mediated at least in part by nicotine withdrawal.

2.5. Sedentary Lifestyle

Enforced inactivity (postoperative)
Elderly

2.5. Iatrogenic Causes

Drugs and hormones
Hypothalamic surgery

2.5. Endocrine Obesities

Hypothalamic syndrome
Hypothyroidism
Polycystic Ovarian syndrome
Cushing’s Syndrome
Acromegaly
Hypothalamic disorders
Growth hormone deficiency
Pseudohypoparathyroidism
Hypogonadism e – Klinefelter’s syndrome and Kallman’s syndrome

2.5. Genetic Obesities

Autosomal recessive traits
Autosomal dominant traits
X-linked traits
Chromosomal abnormalities

Section 3: Therapy: Overall Approach

— Summary of Recommendations

• The initial goal of weight loss therapy is to reduce body weight by

approximately 10% from baseline. Further weight loss can be attempted,

if indicated (Evidence Level B).

• Weight loss should be about 0 to 1 kg/week for a period of 6 months,

with the subsequent strategy based on the amount of weight lost

(Evidence Level B).

• People suffering from obesity should have long-term contact with, and

support from, health professionals (Evidence Level B).

Section 4: Therapy: Lifestyle Advice

— Summary of Recommendations

• A calorie deficit of 500 to 1000 kcal/day from maintenance requirement

(Low Calorie Diet) is important for weight loss and prevention of

weight regain (Evidence Level A).

• Reducing fat as part of a low calorie diet is a practical way to reduce

calories (Evidence Level A).

• Very Low Calorie Diet (200 to 800 kcal/day) may be indicated for

moderately to severely obese patients (BMI > 30 kg/m 2 ) (Evidence

Level B). It can result in quick, short-term weight losses, but medical

supervision is required (Evidence Level C).

• All weight management strategies should include education in healthy

eating habits (Evidence Level B).

• Physical activity should be an integral part of weight loss therapy and

weight maintenance because it contributes to weight loss, decreases

abdominal fat and increases cardio-respiratory fitness (Evidence Level A).

• For weight loss and weight maintenance, individuals require 45 - 60

minutes per day of moderate intensity activity or lesser amounts of

vigorous intensity activity (Evidence Level C).

3. Benefits of Frequent Contact

Frequency of treatment contacts and the longer weight loss is maintained are major determinants of successful weight control. Regular consultations (initially weekly to biweekly; subsequently monthly) for at least 1 year are recommended. These visits should include physician and other members of the multi-disciplinary teams. It is important to provide supportive environment by the following:

Education of lifestyle modification (diet, physical activity and behaviour therapy)
Increasing the number of visits
Reviewing food and activity logs
Monitoring exercise regimes
Monitoring diet structure and use of portion-controlled foods.

If a long-term approach is taken, a successful outcome is more likely.

4. Therapy: Lifestyle Advice

4. Dietary Therapy

The goal of the treatment of obesity is to achieve weight loss through a decrease in calories consumed and an increase in energy expended.

4.1. Low Calorie Diet

Low Calorie Diet (LCD) provides a calorie deficit of 500 to 1000 kcal/d from maintenance requirement and is important for weight loss and prevention of weight regain. LCDs reduce total body weight (average of 8-10% over 6 months) and waist circumference. Weight loss usually consists of about 75% fat (mainly abdominal fat) and 25% lean tissue (33). Mean weight loss of up to 11kg, and a concomitant reduction in waist circumference of 1 to 9 may be achieved after 6 to 12 months (34, 35). Evidence Level A.

A moderate reduction in caloric intake, which is individually designed to achieve a slow, but progressive weight loss is recommended. The rate of weight loss is directly related to the difference between the patient’s energy intake and energy requirements is wide variability because sex, age and genetic factors influence energy requirements:

- Men lose more weight than females of similar height because they have more lean body mass and therefore higher energy expenditure.

- Older patients of either sex have lower lean body mass and physical activity; metabolic rate declines by approximately 2 percent per decade. Therefore they lose weight slower than younger subjects.

To estimate energy requirement for weight reduction and weight maintenance, a simplified formula as in Table 4 may be used.

Table 4: Quick Formula for calculating calorie requirements for weight reduction and weight maintenance***

Refer to Appendix 3 for details of activity status.

Weight for calculation: Use current body weight for all except in the obese (BMI > 27 kg/m 2 ) and underweight (BMI < 18 kg/m 2 ), calculate using acceptable weight instead i. BMI 22 kg/m 2.

In general, LCDs containing 1,000 to 1,200 kcal/day should be selected for most women; a diet between 1,200 kcal/day and 1,500 kcal/day should be chosen for men and may be appropriate for women who weigh 75 kg or more, or who exercise regularly. If the patient is unable to lose weight on 1,500 kcal/day diet, a 1,200 kcal/day diet may be tried. (Please refer Appendix 2 for sample diets and 3 for food exchanges list.) Care should be taken to ensure that all of the recommended dietary allowances are met. The composition of the diet should be modified to minimise other cardiovascular risk factors such as hypercholesterolaemia and hypertension (37).

4.1. Lower-Fat Diet

Lower-fat diets provide 25 to 30% of calories from fat. They produce weight loss primarily by decreasing caloric intake. However, lower-fat diets with total caloric reduction produce greater weight loss compared with lower-fat diet alone (38). Evidence Level A

4.1. Very Low-Calorie Diet (VLCD)

VLCD (200 to 800 kcal/day) (39) is often in a form of liquid nutritional supplement and results in the most rapid weight loss. It is appropriate only when the patient faces a major health risk and the physician has determined that such a diet can be used safely. Patients treated under medical supervision using a very-low-calorie diet (400 to 800 kcal/d) lose approximately 20 kg in 12 to 16 weeks and maintain one half to two thirds of this loss in the following year (40) Evidence Level B. VLCDs are not usually recommended for weight loss therapy because:- - It results in nutritional inadequacies unless it is supplemented with vitamins and minerals. - It is not sustainable over long period - It increases serum uric acid concentrations - It results in muscle breakdown and protein loss Contraindications to VLCD

Recent myocardial infarction
Cardiac conduction disorder
History of cerebrovascular, renal or hepatic disease
Type 1 diabetes mellitus
Major psychiatric disorders
Gallbladder disease VLCD may be indicated for moderately to severely obese patients (BMI > 30 kg/m 2 ) who are highly motivated but have failed with more conservative methods, or in patients with a BMI of 27 to 30 kg/m 2 who have medical conditions that might respond to rapid weight loss (41) Evidence Level C.

Activity Status# Overweight & Obese* (BMI > 23 kg/ m 2 )

Normal Weight (BMI** 18 – 22 kg/ m 2 )

Sedentary 20 - 25 kcal/kg 30 kcal/kg Moderate activity 25 - 30 kcal/kg 35 kcal/kg Marked activity 30 – 35 kcal/kg 40 kcal/kg

Adapted from (36)

Section 5: Pharmacotherapy and Surgical Therapy

— Summary of Recommendations

• Pharmacotherapy can be a useful adjunct to lifestyle changes to induce

weight loss in some patients with a BMI greater than 27 kg/m 2 and

in patients with a BMI greater than 25 kg/m 2 with co-morbidities

(Evidence Level A).

• Drugs should be used only under careful medical supervision and in the

context of a long-term treatment strategy (Evidence Level A).

• Surgery is an option in selected patients with morbid obesity (BMI ≥

40 kg/m 2 or between 35 and 40, with major weight related comorbidities)

when less invasive methods have failed and the patient is at high risk for

obesity associated morbidity or mortality (Evidence Level B).

Self-monitoring is an essential component of a lifestyle change program and patients should be encouraged to keep daily records of physical activity, food intake and problems.
Portion control to gauge size portions eaten.
Stimulus control to identify and avoid environmental cues associated with unhealthful eating and sedentary lifestyle e. snacking while watching television.
Contingency management includes the use of rewards for positive lifestyle changes.
Stress management , which include meditation, relaxation techniques and regular physical activity to cope with stress.
Cognitive-behavioural strategies to change a patient’s attitudes and beliefs about unrealistic expectations and body image.
Weight loss support groups to reduce uncertainty about self-worth. Helps to sustain weight loss behaviour.

No single method of behaviour therapy appears superior to any other in its effect on weight loss; rather, multiple strategies appears to work best and those interventions with the greatest intensity appears to be associated with the greatest weight loss. Long-term follow-up of patients on behaviour therapy show weight regain to baseline in most patients in the absence of continued behavioural intervention.

5. Therapy: Pharmacotherapy and Surgical Therapy

5. Pharmacotherapy

Pharmacotherapy may be considered in addition to diet, exercise and behaviour modification. The decision to initiate drug therapy in overweight subjects should be made only after a careful evaluation of risks and benefits. It should be part of a long-term management strategy for obesity. A patient may require drug therapy:-

- to aid compliance with dietary restriction

to augment diet-related weight loss
to achieve weight maintenance after satisfactory weight loss.

The risks to a patient from continuing obesity need to be balanced against the risks from therapy, and doctors need to be aware of possible side-effects.

5.1. Indications for Pharmacotherapy

Pharmacotherapy must not be used simply for cosmetic purposes or when weight loss can be achieved and maintained without it. Overweight subjects should only receive anti-obesity drugs if they have had a reasonable trial of diet and exercise for 6 months and have:

BMI between 25 and 27 kg/m 2 , and at least two of the following conditions:

- Type 2 diabetes mellitus

Coronary heart disease
Cerebrovascular disease
Hypertension
Hyperlipidaemia
Waist circumference >90 cm for men, >80 cm for women

2. BMI ≥27 kg/m 2.

Symptomatic complications of obesity such as severe osteoarthritis, obstructive sleep apnoea, reflux oesophagitis, and the compartment syndrome.

5.1. Goals of Pharmacotherapy

The goal of therapy must be realistic. Therapy is considered effective if weight loss exceeds 2 kg during the first month of therapy and decreases more than 5% by 3 to 6 months, with no weight regain. Therapy must be reviewed after a month of initiation to assess response and compliance.

5.1. Types of anti-obesity drugs

Anti-obesity drugs can be classified into two groups, those acting on the:

- Gastrointestinal system to reduce fat absorption

Central nervous system to suppress appetite.

5.1.3. Drugs acting on the gastrointestinal system

1. Orlistat Orlistat is the only non-systemically acting drug available for the long-term treatment of obesity. It is a pancreatic lipase inhibitor which produces a dose-dependent reduction in dietary fat absorption by about 30%. In the 2-year European Study, patients treated with orlistat showed a reduction of 10% in weight compared to 6% in the placebo group at the end of one year. Weight loss at one year varied from 5 to 6% of initial body weight in the placebo group and 8 to 10% in the orlistat group. In diabetic patients, orlistat resulted in 6% reduction in weight compared with 4% in placebo after one year (45). - Other beneficial effects :- - Improves certain serum lipid values more than can be explained by weight reduction alone (46-48). (Probably related to fecal fat loss) - Improvements in glycaemic control and blood pressure have also been noted with orlistat (45). These changes may result from decreases in body weight alone. - Orlistat plus lifestyle changes resulted in greater reduction in the incidence of type 2 diabetes among obese subjects with impaired glucose tolerance (IGT) (49). - Side effects: Orlistat is generally well-tolerated. Known side effects are intestinal borborygmi and cramps, flatus, fecal incontinence, oily spotting, and flatus with discharge (45). These are usually mild and subside after the first several weeks of treatment provided fat intake is reduced. Absorption of vitamins A and E is reduced in some patients receiving orlistat. It is advisable to take multi-vitamin supplement at least 2 hours before or after the dose of orlistat.

5.1.3. Drugs acting on the central nervous system

1. Sibutramine Sibutramine specifically inhibits serotonin and noradrenaline re-uptake without affecting their release. It enhances post-ingestive satiety and increases resting metabolic rate. Sibutramine typically induces weight loss of 5-8% compared with 1-4% in placebo treated groups. In a randomised, double-blind trial to assess the usefulness of sibutramine in maintaining substantial weight loss over 2 years, 43% of treated subjects maintained their reduced weight, compared with 16% in the placebo group (50). - Other benefits: Sibutramine induced weight loss is associated with improvements in - Hyperlipidaemia and hyperuricaemia (51)

Glycaemic control in type 2 diabetic patients (52)

Table 5 : Drugs used in the treatment of obesity

Pulmonary artery hypertension• Existing heart valve abnormalities or heart murmu

Moderate to severe arterial hypertension; cerebrovascular disease• Severe cardiac disease including arrhythmias, advanced arteriosclerosis• Known hypersensitivity to sympathomimetic drugs• Hyperthyroidism• Agitated states or a history of psychiatric illne

sses

including anorexia nervosa and depression• Glaucoma• History of drug/alcohol abuse or dependence; concomitant treatment with MAOIs or within 14 days following their administration

Drug

Action

Adverse effects

Dosage

Contraindication

Orlistat

Loose stools,malabsorption of fat-soluble vitamins

120 mg 3 times/day with each main mealcontaining fat (during or up to 1 hour after the meal); omit doseif meal is missed orcontains no fat

Chronic malabsorption syndrome• Cholestasis

Peripherally acting pancreatic lipase inhibitor, decreases fat absorption

Sibutramine

Centrally acting viaserotoninergic and noradrenergicpathways, not recommended forthose with severe hepatic disease

Increase in blood pressure and heart rate, nausea,insomnia dry mouth, rhinitis, constipation

Initial: 10 mg once daily; after 4 weeks may titrate up to 15 mg once daily as needed and tolerated

Subjects receiving a monoamine oxidase inhibitor or selective serotonin reuptake inhibitor• Concomitant use with drugs metabolized by the cytochrome P450 enzyme system (isozyme CYP3A4) e.-erythromycin and ketoconazole• Uncontrolled hypertension

Phentermine

Centrally acting via noradrenergic pathways

Increase in bloodpressure, insomnia,nervousness

8 mg 3 times/day 30 minutes before meals or food or 15-30 mg/day before breakfast or 10-14hours before retiring to bed

Table 5 : Other Drugs that Favour Weight Loss

Drug

Action

Adverse effects

Dosage

Contraindication

Fluoxetine (Prozac)

Anxiety, drowsinessinsomnia,nervousness

20 mg/day in the morning; may increase after severalweeks by 20 mg/dayincrements;maximum: 60mg/day

Hypersensitivity to fluoxetine• Concomitant treatment with MAOIs (selective MAOI eg - selegiline and RIMA eg – moclobemide) including within 14 days of discontinuation treatment with MAOI or RIMA, and 5 weeks of discontinuation treatment with fluoxetine.

Anti-depressant,appetitesuppressant and a selective serotonin re-uptake inhibitor specifically approved forweight loss

Metformin

This may be usefulin managing obesity in the Type 2 diabeticpatient, although efficacy is notproved or licensedfor obesity

Nausea, flatulence,bloating, diarrhoea,lactic acidosis (rare)

500 – 1000mg 2-3times/day with meals

Hypersensitivity to metformin HCl or any excipien

Patients with diabetic ketoacidosis, diabetic pre-coma; renal failure or renal dysfunction (eg

.

serum creatinine levels >

μmol/L in males and

>

μmol/L in females)

Acute conditions with the potential to alter rena

function eg – dehydration, severe infection, sho

ck,

intravascular administration of iodinated contra

agents.• Acute or chronic disease which may cause tissue hypoxia eg - cardiac or respiratory failure, rec

ent

myocardial infarction, shock, hepatic insufficie

ncy,

acute alcohol intoxication, alcoholism• Lactation

5. Surgery for Weight Loss

Surgery is an option for weight reduction for some patients with severe and resistant morbid obesity. It should be reserved for patients with severe obesity, in whom efforts at other therapy have failed, and who are suffering from serious complications of obesity. Surgical approaches can result in substantial weight loss i. - from 50 kg to as much as 100 kg over a period of 6 months to 1 year. Compared to other interventions available, surgery has produced the longest period of sustained weight loss. In a recent retrospective study, obese patients with Type 2 diabetes who underwent surgery had a decrease in mortality rate for each year of follow up (59). Assessing both peri-operative risk and long-term complications is important and requires assessing the risk/benefit ratio in each case. A multidisciplinary team should follow patients opting for surgical intervention.

5.2. Criteria for Surgical Therapy (60)

Patients aged 18 or older with morbid obesity (BMI ≥40 kg/m 2 or between 35 and 40, with major weight related comorbidities)
Patients who have already had intensive management in specialized clinics with interest in obesity.
Patients who have failed to maintain weight loss after trying appropriate non-surgical measures.
Patients with no clinical or psychological contraindications to anaesthesia or surgery
Patients who understand and are committed to long term follow-up.

5.2. Surgical Techniques in Current Use

The aim of surgery is to modify the gastrointestinal tract to reduce net food intake. Commonly used surgical interventions in Malaysia include gastric partitioning (Vertical gastric banding) and gastric bypass (Roux-en-Y). Another procedure is the biliopancreatic bypass procedure, which involves transection of the stomach and anastomosis of the proximal part with a segment of ileum. This operation results in malabsorption, but avoids the complications of a blind loop associated with earlier intestinal bypass procedures (61). (See Appendix 5). Another gastric restriction procedure is laparoscopic insertion of a gastric ring with an inflatable pouch placed subcutaneously (62). The degree of gastric constriction can be increased or decreased by changing the volume in the subcutaneous reservoir that leads to the ring encircling the stomach. The United States Food and Drug Administration has approved the use of one system (Lap-Band Adjustable Gastric Banding System, Cio-Enterics Corp, Carpinteria, CA) for use in severely obese patients.

Liposuction is not a treatment for generalised obesity, but may be used for unsightly local collections of fat.

5.2. Complications of Surgical Therapy

Potential nutrient deficiencies e. vitamin B 12 , folate, and iron.
Gastrointestinal symptoms such as “ dumping syndrome” or gallstones.
Postoperative mood changes or presurgical depression symptoms may not be improved by the achieved weight loss. Complications related to specific surgical techniques are shown in Table 5. Lifelong medical and nutrition surveillance after surgical therapy should include monitoring of indices of inadequate nutrition and modification of any preoperative disorders.

Table 5: Complications of Gastric Reduction Surgery

Complications Gastric bypass, percent

Gastroplasty, percent

Death <1 <

Technical / metabolic 7 7

Anemia 3

Stenosis 4

Weight loss

(percent initial weight)

30 to 25 20 to 25

Surgical Failure

(20 percent weight loss)

5 20

Surgical revision needed 5 10

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