Obesity, especially "central", "visceral",
"truncal", "android" (i.e. abdominal) is a major (AHA/NHLBI)
or sine qua non (IDF) criteria for the diagnosis of the Metabolic Syndrome.
Whilst its presence is an absolute requirement for the diagnosis of the
metabolic syndrome as per the IDF guidelines, it is only one out of five
criteria, the presence of any three of which leads to a diagnosis of the
metabolic syndrome as per the modified ATP-III guidelines.
Atherosclerosis is now considered in part to be a consequence of chronic
low-grade inflammation and this is also considered to play an important
role in leading to T2DM.\
Visceral adiposity leads to an increase in the proinflammatory and prothrombotic
state. It leads to an exacerbation of insulin resistance and drives the
progression of multiple cardiometabolic risk factors independently of
body mass index.
For a list of the Metabolic and Cardiovascular Risk Factors Associated
With Visceral Obesity, see Appendix 15a
|At the same time, generalized obesity is also
associated with many other disorders and increases to the morbidity
as well as even mortality associated with these disorders. Thus, the
management strategy has to be a decrease in all obesity, but special
attention must be paid to reducing the abdominal obesity.
Generalised obesity is best measured by estimation
of the Body Mass Index (BMI)
Body Mass Index (BMI)
Weight in Kg
BMI = -------------------------
Height in meters2
Normal: 20-23; > 23-25 = Overweight; > 25 = Obese ( for people from
the Indian subcontinent)
Care must be taken that the weight is not decreased below the lower limits,
as a BMI of 18.5 signifies low body weight.
For BMI charts, see Appendix 2a
Central or visceral obesity is best measured by the
For the method to measure the waist circumference and also the national/ethnic
specific waist measures see Appendix 1c
The management strategy has to be a decrease in all obesity, but special
attention must be paid to reducing the abdominal or visceral obesity.
Effective weight loss requires a combination of caloric restriction, physical
activity, and motivation; effective lifelong maintenance of weight loss
essentially requires a balance between caloric intake and physical activity.
Aim initially at slow reduction of 7% to 10% from
baseline weight. Even small amounts of weight loss are associated with
significant health benefits. Continue weight loss thereafter to extent
possible with goal to ultimately achieve desirable weight.
Weight loss at the rate of 1 to 2 lb/week (calorie deficit of 500 to 1,000
kcal/day) commonly occurs for up to 6 months.
After 6 months, the rate of weight loss usually declines and weight plateaus
because of a lesser energy expenditure at the lower weight and the lifestyle
prescription may need to be revised.
Experience reveals that lost weight usually will be regained unless a
weight maintenance program consisting of dietary therapy, physical activity,
and behavior therapy is continued indefinitely.
Many of these aspects have been discussed in detail in the section dealing
with diet therapy.
|PHYSICAL ACTIVITY AND EXERCISE
Increased physical activity along with regular exercise
is recommended as an important component of all lifestyle management regimens
to prevent and manage the metabolic syndrome as well as all diabetes management
Increasing physical activity assists in weight reduction, reduces insulin
resistance, has beneficial effects on metabolic risk factors; and importantly,
it reduces overall ASCVD risk beyond that provided by weight reduction
Many of these aspects have been discussed in detail in the section dealing
with exercise therapy
Lifestyle therapy should be considered before drug therapy and should
be continued during the pharmacotherapy.
Weight loss drugs may be used as part of a comprehensive weight loss program
for patients with a significantly raised BMI or significantly increased
Avoid use of drugs without accompanying lifestyle modification.
Avoid medications which are known to be associated with weight gain.
For a partial list of medications which have weight gain as a side
effect see Appendix 15b
The two drugs which are presently available and most
commonly used weight reducers are Orlistat and Sibutramine.
Characteristics of the Commonly used Antiobesity Medications
|Indicated for long-term treatment
||Blood pressure monitoring is required before and during therapy
||Patients must take a multivitamin supplement (2h before a dose).
No dose should be taken if a meal is missed or contains no fat
||Hypertension, tachycardia, dry mouth, anorexia, insomnia, constipation
||Abdominal pain, oily spotting, fecal urgency, flatulence with discharge,
fatty stools, fecal incontinence, increased defecation, increased
||Severe hypertension or poorly controlled hypertension, heart failure,
coronary artery disease, arrhythmias, or stroke
||Malabsorption syndrome and cholestasis. Use with caution in patients
with history of nephrolithiasis.
||Monoamine oxidase inhibitors, selective serotonin-reuptake inhibitors,
drugs that increase blood pressure or heart rate, ketoconazole[b]
||Fat-soluble vitamins, beta-carotene, and possibly cyclosporine
|Use with caution
||History of hypertension, seizures, narrow angle glaucoma
||History of hyperoxaluria or calcium oxalate nephrolithiasis
||Take once daily in the mornings. Have blood pressure and pulse checked
||Take one capsule t.id. with each meal. If meal is missed or contains
no fat, then dose can be skipped. Take a multivitamin daily 2 hr before
or after dose. Comply with a low-fat diet.
- None of these medications should be used in patients with a
history of anorexia nervosa or bulimia.
- Interactions do not appear to be clinically significant
Metformin was used in the past as a weight reducing
agent even in people with normal glucose levels. But its use has decreased
with the availability of sibutramine and orlistat.
With the increasing awareness of the critical role played by insulin resistance,
which leads to many disorders such as Polycystic Ovary Syndrome (PCOS),
etc., as well as being a serious risk factor for diabetes and premature
cardiovascular disease, its use especially in patients with impaired glucose
tolerance, and this is especially so in patients with a family history
of diabetes and premature cardiovascular disease.
Many trials have shown that a 20 mg dose of rimobanant,
which is used in the management of obese diabetics, can lead to an average
weight loss of approximately 6 kg over a year when accompanied with lifestyle
therapies. Importantly, it leads to a decrease in abdominal obesity and
improves cardiovascular risk factors. The most common reported side effects
include depression, anxiety, and nausea and should not be used in patients
on anti-depressives. It is NOT accepted for use by the U.S. FDA.
GLP-1 analogues have been shown to be associated
with weight loss, although the DPP-IV inhibitors are weight neutral.
The glitazones tend to increase the weight. But it
is now being increasingly realized that whilst the glitazones may slightly
increase the fat levels in the body, they very significantly decrease
the levels of central or visceral obesity. At the same time questions
have been raised about the cardiovascular safety of rosiglitazone and
it remains to be seen whether this is a class effect and applies to pioglitazone
Other drugs including sympathomimetics are now rarely used.
Although some other drugs such as bupropion and topiramate
are being "pushed" as agents to use in obesity, but are not
widely accepted as antiobesity drugs.
Phentermine by itself continues to be occasionally used.
Drugs such as fenfluramine, ephedra and phenylpropanolamine should NEVER
be used. One has to be very careful as many OTC drugs and herbal products
contain them or similar agents and can be dangerous in the long term.
Weight loss surgery is
an option in carefully selected patients with clinically severe obesity
with comorbid conditions when less invasive methods have failed and the
patient is at high risk for obesity-related morbidity and mortality.