Prevention not drugs the best answer to obesity in Panama

With Dr. Eric Ulloa 

Over half the adult population in Panama is obese or overweight, and that means big health problems looming in the near future.

Twenty percent of the population over 18 years of age is obese (BMI of 30 Kg/m2 or more) and about 31 percent is overweight (BMI 25 to 29.9 Kg/m2).

I have discussed in previous articles the risk factors obese people, including developing type 2 Diabetes mellitus, and Hypertension.
I also have encouraged a healthy diet and exercise (at least 150 minutes of moderate exercise per week) as a preventer of chronic diseases.
A multicenter study Diabetes Prevention Program(DPP) demonstrated that in overweight patients with pre-diabetes (blood glucose levels higher than normal but not high enough to be considered diabetic patients), millions of individuals could delay or avoid becoming diabetics, by losing weight through regular physical activity and a diet low in fat and calories (58 percent risk reduction).
In patients 60 years and older, the risk reduction was even better, at the level of 71 percent.
The importance of this study is that it showed that you do not have to lose too much weight in order to achieve a benefit.
The goal should be a weight reduction of 7-10 percent of their body weight in 6-12 months.
So, if you weight 200 pounds, and you are overweight for your height and body texture, by losing 14 to 20 pounds, you reduce your risk of becoming a diabetic patient by almost two thirds. Now that’s impressive.
For people already obese, who do not adopt a good exercise and diet program, the alternatives are not promising.
The medical treatment of obesity has not been very successful:
Medical guidelines say that if the obese patient (BMI of 30 Kg/m2 or more) does not respond to lifestyle changes he or she could be offered medical treatment.
The Food and Drug Administration recently suspended Mesura (Sibutramine) by Abbott Laboratories because of increased cardiovascular effects and stroke in some patients. It had been on the market for 13 years.
Several drugs have been suspended in the last 10 years, starting with Fen-Phen from Wyeth (a combination of fenfluramine and phentermine) which was discontinued in 1999 when it showed heart valve damages.
Rimonabant from Sanofi Aventis did not get approval three years ago, because preliminary studies showed increased risk of suicide and depression.
Just last month Lorcarserin from Arena pharmaceutical was not approved because the preliminary studies caused tumors in rats.
Qnexa from Vivus pharmaceutical (combination of Phentermine (a short term pill approved for obesity) and Topiramate (an anticonvulsant drug and also migraine prophylaxis), has had good results on clinical trials, but the FDA wants more proof that there are no birth defects and heart problems.
Contrave (a combination of naltrexone an anti-addiction drug, and bupropion an antidepressive) from Orexygen Therapeutics, will be evaluated by the FDA next month.
The only approved drug for long term use in Obesity is Xenical (Orlistat) from Roche, which has been in use since 1999, but the weight loss achieved is only a reduction of about 5 percent of body weight in one year, and the adverse effects are bothersome to some patients: flatulence, diarrhea, audible intestinal movements, sometimes juicy flatus.
Also weight loss achieved through medicines is gained back in the following weeks after discontinuing the treatment.

In extremely obese patients, with BMI of 40 Kg/m2 or more, that have not responded to lifestyle changes with or without medical treatment, bariatric surgery could be considered.
Overall 30 day mortality is less than one percent, in centers that have a high volume of patients. Factors associated with increased mortality risk are age over 65, male gender, concomitant chronic disease and super obesity BMI and low quality surgeons and hospital.
Pulmonary embolism is the main cause of early mortality.
Complications vary based upon the procedure performed, but could be as high as 40 percent. The three most common procedures done in the United States are the the Roux-en-Y gastric bypass (RYGB), the laparoscopic adjustable gastric band (LAGB), and the sleeve gastrectomy (SG). The type of procedure affects the morbidity rate.
For example, the morbidity associated with LAGB appears to be less than is seen with laparoscopic RYGB. A one-year analysis of 4756 patients from the ACS NSQIP database showed the LAGB carried a lower 30-day rate of major complications than laparoscopic RYGB (1 versus 3.3 percent), return visits to the operating room (0.9 versus 3.6 percent), and shorter postoperative stay (median 1 versus 2 days) [18].
There was no difference in the 30-day mortality between the two procedures.
Intraoperative complications include trocar injuries, splenic injuries, portal vein injury, bowel ischemia, internal hernias among others. The most common early complications include bleeding, infections, and leaks. Late complications include cholelithiasis, nutritional deficiencies, and neurologic and psychiatric complications.

So, as you can see, the best treatment is PREVENTION, and even if you cannot achieve your expected weight, just losing 14 to 25 pounds in the majority of the cases prevents or reduces the effects of chronic diseases like diabetes or hypertension.

 Dr, Ulloa is an internal specialist and advisor to Panama's Ministry of Health.