obesity
OBESITY
Obesity is having an excessive amount of body fat in relation to lean body mass that may impair health.
The primary cause is an energy imbalance between calories consumed and expended.
Treatment goals include to lose 5-10% of body weight or 0.5-1 kg (1-2 lb)/week for 6 months and regain of <3 kg in 2 years and sustained reduction of waist circumference of at least 4 cm.
Strategies are aiming for realistic goals and a multidisciplinary approach that is a combination of dietary change, physical activity and behavioral modification.

Surgical Intervention

Bariatric Surgery

  • Most effective method to reduce and maintain weight in severely obese patients
  • Associated with average weight losses of between 16-35% of up to 8 years depending on type of surgical procedure
  • Based on long-term data, surgery has been shown to reduce overall mortality over a 15-year period compared to conservative medical treatment
  • May fail in up to 35% of patients after 5 years in patients with BMI >35
  • According to the 2016 American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) guidelines, it is indicated in patients with BMI ≥40 or BMI 35-39.9 with comorbidities in whom weight loss through surgery is expected to improve the disorder (eg diabetes mellitus and other metabolic disorders, cardiovascular disease, severe joint disease, and obesity-related severe psychological disorders)
  • Indicated also in patients who are determined to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve target outcome
  • The International Federation for the Surgery of Obesity and Metabolic Disorders - Asia Pacific Chapter (IFSO-APC) consensus statements in 2011 recommend bariatric surgery in the following Asian patients with:
    • BMI ≥35 with or without comorbidities
    • BMI ≥30 inadequately controlled by lifestyle changes or medical therapy for the treatment of type 2 diabetes mellitus or metabolic syndrome
    • BMI ≥27.5 as non-primary treatment alternative for inadequately controlled type 2 diabetes mellitus or metabolic syndrome
  • Contraindications:
    • Current alcohol abuse
    • Unstable psychological conditions
    • Esophageal dysmotility, inflammatory bowel disease, chronic pancreatitis, bile duct pathology
    • Portal hypertension, active malignancy
    • Regular use of NSAIDs or corticosteroids
    • History of gastric cancer
    • Vegetarians
  • Medical follow-up at 1, 3, 6 and 12 months, then annually is advised
  • Laparoscopic technique is the first treatment of choice
  • Complications may include dumping syndrome, hypoglycemia, malnutrition, regain of weight, or revisional surgery
  • Long-term mineral and multivitamin supplementation is recommended post-surgery
  • Restrictive Procedure
    • Limits intake of food by creating small gastric pouch causing feeling of fullness
    • Estimated weight loss of 30% in 1 year
    • Eg vertical sleeve gastrectomy, laparoscopic adjustable gastric band, intragastric balloon (IGB)
  • Malabsorptive Procedure
    • Limits absorption of macronutrients
    • Eg biliopancreatic diversion, duodenal switch, gastric bypass
    • Gastric bypass is the gold standard in bariatric surgical operation as it produced massive weight loss in obese patients
      • Roux-en-Y gastric bypass combines both restrictive and malabsorptive techniques
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