Herpes labialis at the angle of mouth.

stomatitis is associated with cheilosis in

Angular niacin deficiency and pellagra.
o Write a short note on definition, causes, risk factors and
and treatment of obesity.
Dethined as a chronic, multi-factorial, neurobehavioural disease, wherein an fat prornotes adipose tisse
drsiunc
ton and
abnormal fat mass physical forces, resulting in adverse metabolic, increase in body psychosocial health conseGiehces.
In Asians. obesitv is measured by the parameters mentioned in the following biomechanical
box.
l and

Oriteria
Definition Reference Values
Body mass Defined as person's weight (kilogranms) " Normal-BMI18.5-23 kg/m?
ingsx BMI) divided by the square of person's Underweight-BMI <18.5 kg/m?
height (metres) Overweight-BMI 23.1-29.9 kg/m?
Ht (m)2 Class I obesity--BMI 30-34.9 kg/m²
Class II obesity-BMI 35-39.9 kg/m?
Cl¡ss IlII obesityBMI >40 kg/m²
Calculated by multiplying square of Overweight-more than 10% of ideal body weight
0eal body weight
weight for height (meters) by 22.5 " Obesity-more than 20% of ideal body
Underweightless than 20% of ideal body weight
neight males 12.5 mm
Estimated by using special calipers " Normal triceps skin-fold thickness in
Safold " Normal triceps skin-fold thickness in females
thickness Over triceps, biceps, subscapular and
16.5 mm
suprailiac regions Abdominal obesity-waist circumference >80 cm
narrowest
Waist Waist measurement at the
ribcage and top of in females and >90 crm in males
circumfer segment between
ence iliac crests Normal<0.8 in females and <0.9 in males
and hip
"Waist to hip Ratio of waist circumference
e circumference Abdominal obesity->0.8 in females and >0.9 in
(maximum measure
ratio males
ment over buttocks)

CAUSES
Secondary Obesity
Simple Obesity Hypothyroidism
Phiysical inactivity Cushing's syngrome -coshiostid
Eating habits / " Hypothalamic disorders
be a
Psychological
Symptomn
factors (overeating mayfrustration) " Diabetes mellitus
of depression, anxiety and " Pickwickian syndrome
syndrome, melano-
Genetic
Cortin
factors- -Prader-Willi
Albright's
hereditary " Laurence-Moon-Biedl syndrome
4receptordeficiency, receptor Medications--valproic acid, carbamazepine, gabapen
Osteodystrophy, leptin deficiency, leepptin
deficiency. pro-opiomelanocortin deficiency
tin, antidepressants, corticosteroids, antipsychotics,
lithium, antidiabetics (insulins, sulphonylureas, thiazoli
dinediones), clozapine, olanzapine
 Medicine Prep Manual for Undergraduates

Genetic Fectors
Mplpnncortin &Recepto Deficiency
Autemal dom1nant ot recesSIe
Mosi common known geneti detet predisposing to obesity.
eatuN
dpephag1a and ohesity carly in childhood.
Intease in hon mineral densitv ("big boned").
Aelerated l1neat growth
Leptin
ieptan as a hormonc produced bv cells of adipose tissue. It controls food intake and energy expenditure.
Teceptors expresed in speihe rogions of the hypothalamus) to activate and regulate mRNA expression of)keyIt acts on lepti
neuropeptide cg pro-opiomelanocortin (POMC).
Adetet in iept1n genc or its reccptormay produce obesity.
hypothalamig
f obes persons. some have a low level of leptin in the blood while majority have high
reSIstanK to ity ations.
leptin levels indicating
DetectivT lept1n gene or leptin receptor may be responsible for only aminority of patients
periphera
with obesity.
PraderWilli Syndrome
Occun dur to loss of function of a portion of chromosome 15; not
Hvperphag1a with short stature and obesity, hypotonia, small hands/inherited.
feet, behavioural
narrow forehcad. almond-shaped eyes and triangular disturbances, intellectual impaimer
Often with fair skin and light-coloured hair. mouth.

Aibright s Hereditary Osteodystrophy

Characierised by obesity, short stature,
soft-tissue calc1fications, hypocalcaemia,shortened fourth metacarpals and other bones of the hands and feet, dental hypoplasu
hyperphosphataemia.
RISKS ASSOCIATED WVITH OBESITY

Cardiovascular
Coronary artery disease Endocrine
hyperterision aabetes melitus
"eart failure and cor pulnonale nsulin resistance
Deep vein thrornbosis Dyslipidaemias
taricose veins Gastrointestinal and Hepatic
Pulnonary Gastro-oesophageal reflux
" Otstructive sleep Cholelithiasis
apnoea
" Pickwickian syndrorne Fátty liver
Neurological Malignancies
" Stroke " Increased risk of breast, endometrial and Colon cancers
Pseudoturnour cerebri Others
Musculoskeletal Depression
Osteoarthritis Gout
Nephrolithiasis
TREATMENT
Goals
Attempt initially to reduce weight by
success. approXimately 10% from baseline. Further iniil

Reduce weight at arate of about 0.5-1

kg/week for 6 months.
vwetight reduction is attempted
atier

Dietary Therapy
Low-Fat Diet
Encourage low-calorie diets with low fat. The
reduction is usually to the tune
of about 500
cal/day.
 CHAPTER 11 Nutritional Eactora in Digease
reducing total
alone without
have alower energy densitycaloies is not suffcient.
fat
R o a d u c i n g

diets Cather
than calories, this should lcad to a lower than
encrgyhigh-fat
caten
intake. diets and as humans respond mntlv to v o l m e of ood
low-fat

.
s also have higher fibre content and this
dicts
low-fat
may also enhance satiety.
many patients cannot maintain low-fat
Intortunatclh.
diet for a long time.

Low
Carbohydrate Diet or Atkins Diet
Ven
very
low carbohydrate diet but with normal or high saturated fats (total calories <800 kcal/day).
isc of a produce loss of weight | year.
to
Rounddicts
equivalent to that produced by alow-fat diet but there are no data beyond
These work by reducing caloric intake by removing a wide range of carbohydrate-rich foods.
cholesterol may rise by about 2-3%.
Mar induce precipitation of gout if history of gout present.
High-Protein Diet
30%.
kept low at
of the increased satiating effect of protein with reduction in carbohydrate. Fat is of hunger and
It makes use ketosis which results in
suppression

These
hiisgh-protein-low-carbohydrate diets induce fat burning and mild
promotionof satiety.
ed tendl function have a greater decline in renal function with a greater protein intake. calcium ston
risk for bone loss and
Patients with i n n p a i r e d t
with potential
increases urinary calcium excretion
High dietary protein intake
increased amount of red meat is consumed.
formation.

Increased risk of colorectal cancer if

Physical Exercise
cardiorespiratory fitness.
and increases
. It reduces abdominal fat minutes/day and 3-5 days/week.
Moderate exercise should be done for 30-45
.
Behaviour M o d i f i c a t i o n
physical exercise.
adjunct to diet and
It is a useful motivation to lose weight.
Patients often require
before using drugs.
Pharmacotherapy modification should be considered
and behaviour
physical exercise
Dietary therapy, increasedrisk:
BMI>30 kg/m². the patient has an
Drugs may be used if 27-30 kg/m² and
used if BMI is diabetes, obstructive sleep apnoea
and
Drugs may also be weightloss such as type 2
Asian ethnicity. with
-related disease
likely to improve
Overweight/obesity discontinuation.
dyslipidaemia. consider for
nonitored for safety
throughout.
by week 12 of using drugs,
ne patient should be of his/her
body weight
' If patient has not lost at least 5%

Sibutramine and
serotonin
uptake
inhibitor,

Centrally acting noradrenaline

loss of approximately 4.5 kg at l year.
Suppresses appetite. a mean weight insomnia.
provides
and cardiovascular events.
Along with modification headache
blood pressure and
Side effects lifestyle
constipation, increase
may
include dry mouth, heart rate and
in
"
Produces a dose-related
Withdrawn
increase
due to cardiovascular effects.

cholesterol and fat-Soluble

absorption of dietary triglycerides,
Orlistat lipases in
the gut,
reducing

Binds to intestinal and pancreatic

insulin sensitivity.
vitamins. meals. cholesterol levels, free fatty acids, HbAlc and pain that can
Dose 120 mg three times day with LDL faecal incontinence, bloating and abdominal
per cholesterol,
flatulence,

Produces favourable changes in

total diarrhoea,

deficiency. Daily fat-soluble vitamin supplementation is

urgency,
Side effects faecal
include oily stools,
be minimised by a low-fat diet. vitamin D, E and
B-carotene

Fat the risk

of
malabsorption
Tecommended that should
increases

be taken
between
meals.
 Melirinn Prop Manual for Undergraduates

Rrmenhant
inda ahnnhinod receptor (B1 bloking dn1g that has both central and peripheral actions to reduce
riatee metahol tator sh as increasing adiponctin and reducing circulating free fatty acids weipht and
rte eftets inchde nareca. diarrhoca. anxicty and depression (including increased suicidal risk) weig
orepri
At: matvating setonin veptor in the brain which results in increased satiety and
decreased hunger.
auton: xhoud he taken in paticnts who arc taking serotonergic
dahet natents hvpogvacmia may occur.
medications. This can lead to
serotonin
atr efnt include headache. fatiguc, nausca, dry mouth, dizziness
and constipation. syndrome. In
Phenterming Topiramate
Tonrattatt Ncontraindicated in pregnancy;
edaton and then every month to ensure hence, it is recommended that pregnancy testing is done
that patients are not
The ombinat1on worsens
depression and suicidal ideation; it canpregnant while taking the
also cause mood disorders, medication.
before starting the
Oters anxiety and insomnia.
Four svmpathomimetic agents are approved for short-term
pend1metrazine. These agents produce use. These are
patients with coronary heart disease, a modest weight loss benefit by phentermine, diethylpropion,
causing early satiety. These are benzphetamine and
Aragiutiar subcutarneously, starting hypertension and hyperthyroidism, and
vpogivcaemia. with 0.6 mg/day and in patients with a
gradually increased to 3.0 mg/day, history of contraindicated i
drug abuse
altrexone-bupropion combination can produce may be used. It can produee
sdexamíetamine dimesylate may be used to 5-10% weight loss.
Fuoxetunt mav be used treat binge-eating
to treat bulimia
nervosa. disorder.
Bariatric Surgery
Lisetul in patients
sáenttfiabie medical, with BMI >40 kg/m² when
physical or psychosocial other methods have failed, and
Peroperative mortality
Various options include: varies problems assoCiated with
from 0.05 to 0.5%% in patients with
their obesity. BMI >35 kg/m' who
Jaw wiring (rarely depending on the method used. have
Jejunoileal shunt: done).
Producessignificant long-term adverse
Cirrhosis and events such as
protein-calorie malnutrition.
Rarely done presently. dehydration, electrolvte
Gastroplasty or vertical
Gastric bypass by sleeve gastrectomny. imbalance, calcium oxalate
renal s
retrocolic
Laparoscopic adjustable
Involves laparoscopicgastric gastrojejunostomy
banding (Roux-en-Y gastric bypass).
pouch that fills
a feeling of
placement of an(LAGB):
quickly and empties inflatable silicone
The balloon not being hungry.
of 1the band
slowly. This induces a band at the very
ontrol of how tight the is connected to a sense of satiety top of the stomach gastric
Safest, least invasive band is and, subcutaneous access after consuming leaving a small
and most therefore, port. smaller amounts of and
food
Liposuction: how This
effective procedure. much food can allows adding
Results in a be or
removing fluid to the systet
for coronary significant
heart reduction in fat consumed.
discase. mass and weight;
however, it does not
improve insulin sensitivity or risk
factors