Avoid obesity 👫 in your children 💑

In the population under 14 years of age, obesity has doubled in the last decade, from 8% in boys and 5% in girls, to 17% and 12% respectively, in 2000.
Obesity is a chronic disease with negative health consequences.
There is a clear and direct association between the degree of obesity and morbidity and mortality (4).
This relationship is established by an increase in mortality due to cardiovascular diseases, some types of cancer, lung diseases and others. Although arterial hypertension, type 2 diabetes mellitus and dyslipidemia can be biological effects of obesity (especially in the central or abdominal type) and, therefore, important contributors to the increase in cardiovascular mortality (5), when the value is isolated of obesity, through a multivariate analysis, its relationship with mortality is attenuated but not eliminated (6). We must not forget the psychosocial problems that are also associated with obesity such as the unsightly image, discrimination and social rejection, the difficulty of relationship and, in some cases, the limitation of mobility, work capacity or leisure.


Childhood obesity is especially important because many obese children will continue to be so when they become adults.
In several countries the economic cost of obesity has been estimated. The calculation includes not only the cost of treating obesity itself, but also the proportion corresponding to the diseases attributable to it. In Spain, in 1999 the Delphi Prospective Study was published: «Social and economic costs of Obesity and its associated pathologies» in which the estimated annual global cost was estimated at 6.9% of total health expenditure. To this figure should be added the particular expense made by 80% of obese people trying to lose weight.

TREATMENT

The ideal treatment of obesity is prevention. Priority should be given to public health measures, such as the development of information campaigns regarding food in general, and about healthy eating habits in particular, and promoting and facilitating the development of physical exercise at different levels of activity.


The goal of treatment is to reduce body fat by inducing, obviously, a negative energy balance. The intake reduction should be individually designed to allow normal activities.
A deficit of 500 to 1000 kcal per day can cause obese adults to lose around 500 to 1000 mg per week (7). This represents diets that contribute 1000 to 1500 kcal / day.
Severe energy restrictions, with very low calorie diets, achieve weight losses more quickly but do not increase the success rate in maintaining long-term lost weight.

The combination of physical exercise and caloric restriction is more effective than either of them separately. Although the addition of exercise to the diet slightly increases weight loss in the early stages, it seems that it is the component of the treatment that most promotes the maintenance of weight reduction over time (7,8). Behavior modification plays an important role in the treatment of obesity. It is intended to help the obese to change their attitude towards food and their eating habits and physical activity, as well as combat the consequences that occur after a dietary transgression (7).

Psychological or psychiatric support may be necessary when there are significant personality disorders or relevant anxiety-depressive conditions. Drugs are another therapeutic weapon for the treatment of obesity. As it is the central theme of this review, it will be described in detail later. Unfortunately, although almost all obese people lose weight relatively quickly in the short term, it is rare for this loss to remain over time.

The vast majority are gaining weight slowly but inexorably, until recovering from the situation prior to treatment or in some cases, overcoming it. There are powerful factors that are not well understood that tend to induce the recovery of lost weight. In any case, the main problem is not the body weight itself, but the morbidity associated with metabolic complications and these can improve substantially, even after a moderate loss of weight (9). Therefore, it is not necessary to set the goal of achieving desirable or normal weight because it is unrealistic in the long term. By combining diet and exercise with behavioral treatments, losses of 5% to 10% of the weight can be achieved over a period of 4 to 6 months.

Surgical treatment, such as restrictive and / or malabsortive techniques, can cause long-term weight loss, but should only be reserved for selected patients who meet a range of conditions and with a BMI of 35-40 or higher, if they have complications. of risk associated with obesity; and, of course, that non-surgical treatments have repeatedly failed.

PHARMACOTHERAPY

As already described, the treatment of obesity is discouraging, 95% recover their weight in the long term, so research is aimed at finding effective treatments that can be maintained chronically. Pharmacological treatment should be used as a support for dietary and exercise, but should never be used as the only treatment, it requires a strict indication and medical supervision, the possibility of its prescription can be considered in obese people with a BMI of 30 kg / m2 or more, in those who have failed diet, exercise and behavioral changes, or in those with a BMI of 27 or more if important morbidity factors such as diabetes, hypertension, dyslipidemia, etc. are associated, despite other treatments.

The drugs that are and have been used in the treatment of obesity are classified into the following groups according to their mechanism of action: anorexizing drugs, which decrease appetite or increase satiety, those that decrease the absorption of nutrients and those that increase energy expenditure. To these must be added numerous substances that are currently under investigation in different clinical phases.

• Noradrenergic ANOREXIGENS These are drugs that act centrally on the reuptake of neurotransmitters, increasing their bioavailability and producing a decrease or suppression of appetite. In the 50s and 60s amphetamines were used indiscriminately, later with the development of behavioral and dietary treatments it was thought that these drugs offered few additional benefits. During the next 20 years its use was dramatically reduced. In fact, between 1993 and 1996 the Food and Drug Administration (FDA) did not approve any new drugs to treat obesity. At present, amphetamines (amphetamine, methamphetamine and fenmetracine) are banned due to their potential for abuse and addiction.


Subsequently, other adrenergic drugs were developed from biochemical modifications in the structure of amphetamines that decreased their central action and their power of addiction without completely eliminating it. These include phentermine, diethylpropion, phendimetracine, benzfetamine, phenylpropanolamine, fenproporex, clobenzorex and mazindole. The structure of the latter is unrelated to amphetamines but has a similar activity, activating β adrenergic and / or dopamine receptors except phenylpropanolamine which is an adrenergic α. Phentermine has been most commonly used in combination with fenfluramine, withdrawing from the market when this combination is associated with valvulopathies and pulmonary hypertension (10). With individual use of phentermine, valvulopathies have not been described, but pulmonary hypertension has been described (1 l). Phenylpropanolamine has also been recently recalled by being associated with hemorrhagic infarctions in women (12). Very few studies have been published with fenproporex and clobenzorex, and some cases of subarachnoid hemorrhage have been described with its use (13). Other side effects of noradrenergic drugs include nervousness, anxiety, insomnia, dry mouth, sweating, nausea, constipation, euphoria, palpitations and high blood pressure. Studies on efficacy and safety of all the drugs described include a maximum of 6 months of treatment and show moderate, although significant, differences of 2 to 10 kg of weight loss, compared to placebo. However, in view of the described side effects, some of them serious, their commercialization has been prohibited.
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