First, obesity is a chronic disease that is increasing in prevalence. Second, the cause of obesity is unknown and the cure is unlikely. Thus simply providing relief becomes the aim of the treatment. Third, obesity and visceral fat, even when they are not markedly elevated, increase health risks. Fourth, obesity is a stigmatised condition in which the overweight subject is frequently viewed as responsible for the condition.

Fifth, weight regain is common in obesity. Sixth, drugs and other treatments for obesity do not work; when appetite reducing drugs are discontinued, patients regain weight, in keeping with the concept that drugs do not cure obesity but only relieve its symptoms.

Most successful programs employ a multidisciplinary approach to weight loss, with hypocaloric diets, behaviour modification to change eating behaviour, aerobic exercise and social support. Emphasis must be on maintenance of weight loss.

Diets:

The person should be put in negative energy balance ideally 500-100 calories less than their recommended dietary allowance (RDA). An ideal reduction of 0.5-1 kg per week is approved. Once this target is fixed, progress should be checked once a month. Usually 3 kgs are lost in the first month largely due to utilisation of carbohydrate store and water. Reducing diets should provide adequate amounts of proteins, vitamins and minerals.

Controlling food intake is easier if the use of alcoholic beverages is reduced or eliminated, particularly since alcohol tends to blunt the ability to maintain other dietary controls. Increasing the frequency of eating is also a useful strategy. People who eat breakfast have a lower risk of developing obesity than individuals who do not. Ingestion of frequent small meals with relatively high carbohydrate and high fibre content is a way of decreasing fat intake and providing continued gastrointestinal fill.

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Exercise:

Fat people are usually less active than thin people. Their claim that they eat less than average may in fact be true if they expend less energy due to sedentary habits and lack of exercise. Self-consciousness prevents them from taking part in any sports. Even if they do participate, they are relatively less active on the field.

Exercise results in greater weight loss than that achieved by diet alone. Overweight women and men who are more active have lower rate of morbidity and mortality than the sedentary and unfit. Aerobic exercise enhances cardiovascular fitness, increases the potential for oxidation of fatty acids by muscle and prevents gross bone loss by providing stresses that strengthen trabecular bone (that which forms part of the bone marrow)

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Medications:

There has been no new drug approved for obesity by the food and drug administration since 1972. The appetite reducing drugs – amphetamine, diethylpropion, and phenmetrazine – are not safe.

Fenfluramine is the only drug currently approved for obesity in the U.S. This drug reduces hunger, enhance satiety, and increases energy expenditure.

The use of fenfluramine – phenteramine combinations is associated with development of valvular heart disease and fenfluramines, alone or in combination with other anorectic agents (an agent that reduce the appetite), can cause pulmonary hypertension. Consequently the only justifiable medical use of anorectic drugs is in seriously obese patients who have obesity related diseases such as coronary heart disease, diabetes mellitus, hypertension and/or hyperlipidemia. Full disclosure of risks and benefits, must be provided: patients must be monitored regularly with physical examinations and when, appropriate, echocardiography.

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Surgery:

Most popular are the vertical-banded (Mason) gastroplasty, in which a smaller stomach pouch is created, and gastric bypass procedures. Although both gastric procedures result in weight loss, studies tend to favour gastric bypass procedures. Complications are common and include wound dehiscence, peritonitis, nausea and vomiting, vitamin deficiencies and hair loss. When all necessary reversals, revisions and patients lost to follow up are considered, failure rates approach 50%. Nonetheless, loss is well- documented in, patients available for follow-up.

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