ObesityTo define obesity we use body mass index (BMI) which used as a parameter for measuring overall risk of heart disease in obese person.

BMI = weight (Kg) / Height (m2)

If BMI < 18.5 under weight

18.5- 24.9 Normal

25- 29.9 Over weight

30- 34.9 Class I obesity

35- 39.9 Class II obesity

> 40 Class III obesity

N.B. Over weight person with large abdomen are generally worse health than equally obese people (fat distributed around their hips and limps)

CausesEating too many calories and not getting enough physical activity are the main causes of obesity, especially in combination. But many factors can contribute to obesity.

Risk factorsFactors that increase your risk of being obese include:1- Diet Regular consumption of high-calorie foods, such as fast foods, contributes to weight gain. High-fat foods are dense in calories. 2- Inactivity Sedentary people are more likely to gain weight because they don't burn calories through physical activities. 3- Psychological factors Some people overeat to cope with problems or deal with emotions, such as stress or boredom.

4- GeneticsIf one or both of your parents are obese, your chances of

being overweight are greater. Your genes may affect the amount of body fat you store and where that fat is distributed.

5- Age. As you get older, you tend to be less active. In addition, the

amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs. If you don't decrease your caloric intake as you age, you'll likely gain weight.

6- SmokingSmokers tend to gain weight after quitting. This weight gain

may be partially due to nicotine's increase (metabolic rate). Smoking also affects taste; quitting smoking makes food taste and smells better.

7- Pregnancy. During pregnancy a woman's weight necessarily increases.

8- Medications.

Corticosteroids and tricyclic antidepressants, in particular, can lead to weight gain. So can some high blood pressure and antipsychotic medications. 3- Medical problem

Uncommonly, obesity can be traced to a medical cause, such as low thyroid function, excess production of hormones by the adrenal glands (Cushing's syndrome) or other hormonal imbalances, such as polycystic ovary syndrome. A medical problem, such as arthritis, can also lead to decreased activity, which can result in weight gain.

10- Alcohol. Drinking alcohol adds calories to your diet — just one regular beer is about 150 calories. Additionally, excessive drinking can stimulate your appetite and make you less likely to control portion sizes. .

ComplicationsIf you're obese, you're more likely to develop a number of potentially serious health problems. These may include:

1- High blood pressure.

As you put on weight, you gain mostly fatty tissue. Just like other parts of the body, this tissue relies on oxygen and nutrients in your blood to survive. As demand for oxygen and nutrients increases, the amount of blood circulating through your body also increases. More blood traveling through your arteries means added pressure on your artery walls. Weight gain also typically increases the level of insulin→ retention of sodium and water, which increases blood volume. In addition, excess weight often is associated with an increase in your heart rate and a reduction in the capacity of your blood vessels to transport blood. All of these factors can increase blood pressure.

2- Diabetes. Obesity is a leading cause of type 2 diabetes. Excess fat makes your body resistant to insulin.

3-Abnormal blood fats.

A diet high in saturated fats — red meat and fried foods, for example — can lead to obesity as well as elevated levels of low-density lipoprotein ("bad") cholesterol. Obesity is also associated with low levels of high-density lipoprotein ("good") and high levels of triglycerides.

4-Coronary artery diseaseIt results from the buildup of fatty deposits in arteries that supply your heart. Over time these deposits can narrow your heart's arteries, so less blood flows to your heart. Diminished blood flow to your heart can cause chest pain (angina). Complete blockage can lead to a heart attack.

5- Stroke Obesity is associated with atherosclerosis including arteries in your brain. If a blood clot forms in a narrowed artery in your brain, it can block blood flow to an area of your brain. The result is a stroke. 6- OsteoarthritisExcess weight puts extra pressure on the joints and wears away the cartilage that protects them, resulting in joint pain and stiffness. 7- Sleep apneaThis serious condition causes a person to stop breathing for short periods during sleep and to snore heavily. The upper airway is blocked during sleep, which results in frequent awakening at night and subsequent drowsiness during the day. Most people with sleep apnea are overweight, which contributes to a large neck and narrowed airways. 8- CancerIn women, these include cancers of the breast, uterus, cervix, ovaries and gallbladder. Overweight men have a particularly higher risk of cancers of the colon, rectum and the prostate.

9- Fatty liver disease. When you're obese, fats can build up in your liver. This fatty accumulation can lead to inflammation and scarring of the liver. Such scarring can cause cirrhosis of the liver, even if you're not a heavy alcohol drinker.

10- Gallbladder disease. Because overweight people may produce more cholesterol, which can be deposited in the gallbladder, the risk of gallstones is higher in obese people. Fast weight loss — more than 3 pounds a week — also can increase the risk of gallstones.

11- Hirsutism. Aromatase enzyme in adipose tissue converts androgen to estrogen hormone but in obese person not act perfectly so increase androgen.

Obesity can also contribute to gout, a joint disorder.

TreatmentThe first goal in dealing with obesity is to achieve and maintain a healthier weight . The amount of weight you need to lose to improve your health may be much less than what you feel you need to lose.

I- Dietary changes Consuming fewer calories is an important factor for successful weight loss. To lose weight and keep it off, eat moderate amounts of nutrient-rich, low-fat, low-calorie foods. Follow these fundamentals of healthy eating.

Think 'energy density.' Energy density is the number of calories in a given volume of food. Choose low-energy-dense foods, which include a lot of fresh fruits and vegetables.

Choose healthy foods. Healthy foods include vegetables, fruits, grains and lean sources of protein, including beans, fish, low-fat dairy products and lean meats.

Choose the right carbohydrates. high-fiber carbohydrates are good source rather than table sugar and other sweeteners.

Cut back on sweets.Reduce fat. Because fat has more than twice the calories of carbohydrate and protein, reducing the fat content of your diet is an important way to cut calories.

Watch portion sizes.

Count calories.

  Healthy Weight Pyramid

A- Group weight-loss programs.

B- Individual weight-loss programs.

C- Popular diets.

1- The Atkins diet

2- The Zone

3- South Beach Diet

4- Sugar Busters

5- Grapefruit diet

6- Cabbage soup diet

II- Increased physical activity (exercise).

Here are some simple ways to add more activity to your day:1- Take the stairs — not the elevator.

2- Park in the farthest spot in the parking lot.

3- Walk or bike to work or to the store.

4- Walk during your lunch hour.

5- Play with your children instead of watching them play.

6- Walk with your family after dinner.

7- Buy an exercise bike and pedal during TV shows or while talking on the phone.

Increase physical activity

1- ↑ body metabolism

2- ↓ appetite

3- Good mentality and emotionally

4- Loss of muscle mass

5- Burns calories

III- Behavior change (correct eating habits).changing your lifestyle. It involves changing your approach to eating and activity, which means changing how you think, feel and act.

Research has demonstrated that a number of tools and tips are effective in helping you change. Follow these tips for change:

1- Motivate yourself

2- Make lifestyle changes a priority

3- Have a plan

4- Set small goals

5- Surround yourself with good examples 6- Avoid food triggers

7- Keep a record

8- Focus on the positive

9- Don't give up.

IV- Medications for weight loss. Prescription weight-loss drugs aren't for people who just want to lose a few pounds for cosmetic reasons. They're for people with a BMI of 30 or higher or for those with a BMI of 27 or greater who have health problems that would likely improve with weight loss.The 1st drugs used for obesity were Amphetamin, methamphetamine, phenmetrazine which act as appetite suppressant but now not used due to abuse.Also diethylpropion which act as appetite suppressant but less abuse.Some weight-loss drugs have been pulled from the market because of health risks. Until the fall of 1997, one of the most popular prescriptions for weight loss was a combination of appetite suppressants known as fen-phen (fenfluramine and phentermine). This combination of medications helped many people lose weight. But it was pulled from the market after a study found that some people taking these combined drugs experienced heart valve damage.

The two main prescription weight-loss medications are:1- Sibutramine (Meridia10, 15 mg).Mechanism

Changes your brain chemistry, making you feel full more quickly by inhibiting reuptake of serotonin, dopamine and norepinepherineSide effects

1- Increased blood pressure 2- Headache and dry mouth

3- Constipation and insomniaContraindications

1- With MAOI2- Seizures3- Congestive heart failure

DoseOne capsule (10 mg) once daily half hour before Breakfast

2- Orlistat (Xenical 120 mg). MechanismThis drug inhibits the absorption of fat in the intestines by blocking the action of the lipase enzyme in digestive tract (Lipase breaks down dietary fat and triglycerides to free fatty acid and monoglycerides). Orlistat can prevent the absorption of up to 30 percent of dietary fat. Unabsorbed fat is eliminated in the stool which can cause diarrhea. Side effects

1- Menstrual disorder 2- Headache

3- Diarrhea and insomnia Contraindications

1- Pregnancy2- Lactating3- Cholestasis

DoseOne capsule (120 mg) three times daily before meal

N.B Orlistat decreases the absorption of certain fat-soluble vitamins — for example, vitamins A, D and E. If you're taking this drug, your doctor will recommend that you take a daily vitamin supplement to prevent potential nutrient deficiencies.

If you're among those who can benefit from weight-loss medication, you'll likely need to take it indefinitely. When drug treatment is stopped, much or all of the excess weight generally returns.

Even if you qualify for weight-loss drug therapy, the drugs might not work for you. And, if they do work, their effects tend to level off after six months of use.

Over-the-counter products. Over-the-counter (OTC) diet products promise to help you shed pounds by raising your metabolism or suppressing your appetite. Their side effects, however, can be dangerous.1- Ephedra (ma-huang) & Bitter orange. One of the most popular OTC weight-loss products has been Metabolife, an herbal dietary supplement. There are similar products, but the main ingredient is ephedra. Ephedra is used in asthma medicine. MechanismThis drug can slightly suppress your appetite.

Side effects1- High blood pressure2- Heart rate irregularities3- Heart attacks, strokes and death.4- Insomnia, nervousness, tremors and seizures

2- Bitter orangeTouted as an "ephedra substitute" but may cause health problems similar to those of ephedra.

3- Country mallow (heartleaf).

The claims say it Decreases appetite and increases the number of calories burned (Contains ephedra, which is dangerous)

4- Phenylpropanolamine (PPA).

Related to amphetamines and un safe due to higher risk of hemorrhagic stroke

5- Phenyl alanin.

Act as appetite suppressant via release of cholecystokinin → delay gastric emptying rat and give sense of satiety. Also regulate thermogenesis so help in burning of fats.

6- Green tea extract and caffeine.The claims say it increases calorie and fat metabolism, decreases appetite (not long enough to lead to significant weight loss) and act as diuretics but it can cause irritability, insomnia and high blood pressure.

Also, many caffeinated beverages are high in calories, which can contribute to unwanted weight gain.

7- Pyruvate.Pyruvate supplements seem safe, but claims of boosting metabolism and decreasing appetite

8- Conjugated linoleic acid (CLA).The claims say it Reduces body fat, decreases appetite and builds muscle.

9- Hoodia.The claims say it decreases appetite.

10- Guar gum.The claims say it Blocks the absorption of dietary fat

and increases the feeling of fullness → decreased calorie intake.Side effects

Can cause diarrhea, flatulence and other gastrointestinal problems11- Chitosan (chitocal®).

This is a dietary supplement made from chitin, a starch found in the skeleton of shrimp, crab and other shellfish Contain free NH+-C=o (amino group with positive charge) react with lipid (- ve charge) and prevent its absorption.Side effects

Can cause bloating and other gastrointestinal complaints 12- Pyridoxine (B6).

Essential for fat hydrolysis and thermogensis (Co-factor)

13- Chromium.Reduce body fat and builds muscle because it may

affect carbohydrate and fat metabolism.a- ↑ insulin receptor sensitivity → ↑ utilization of glucose b- Enhance penetration of amino acid inside muscle cell

N.B.Cause serious side effects, such as kidney damage, especially when taken in large doses

14- Garcinia Gambogia (hydroxycitric acid).Act as appetite suppressant and decrease lipogensis.

15- Fibers.It Difficult in digestion so delay gastric emptying rate

and give sense of satiety

16- Gymnema Sylvester.Contain gymnemic acid which similar to glucose →

competitive inhibition of glucose absorption on the receptor in the small intestine.

17- Lipotropic factors (lecithin).Inhibit deposition of fat and cholesterol on the cell

wall.

18- 5-hydroxytryptophan (5-HTP).The claims say it decrease body weight

19- St. John's wort.

This is an herbal medicine derived from the Hypericum perforatum plant purported to help relieve depression. It's also found in some weight-loss medications, but it hasn't been proved effective for weight loss, and it can interact with some prescription medications.

20- Herbal laxatives and diureticsThey cause you to lose water, and thus lose weight,

but not fat. They can lower your potassium levels, causing heart and muscle problems. Also, if you use laxatives too often, your bowels start depending on them.

V- Surgery for weight loss.If you've tried diet and exercise to lose weight but remain

seriously obese (a BMI of 35 or higher) and have weight-related health problems as a result, weight-loss surgery (bariatric surgery) may be the next best step.

The most common operations fall into one of two categories:

1- Stomach surgery.

2- Stomach surgery plus intestinal bypass.

Here are some of the specific operations, representing these two categories:

1- Vertical banded gastroplasty

2- Gastric bypass surgery

Liposuction: Not a weight-loss plan.

Liposuction is cosmetic surgery, not a weight-loss plan. The surgeon inserts a narrow tube under your skin through tiny incisions, and then suctions out fat cells. It's most commonly used to trim the outer thighs, abdomen or love handles. Though liposuction has improved to allow surgeons to remove some fat during the procedure, this body-shaping

procedure isn't a treatment for obesity.

What you can do to prevent or reverse weight gain?There's no magic formula for avoiding weight gain as you get older. The most effective approach to reversing weight gain after menopause includes a combination of the following:

1- Increase your physical activity

2- Reduce calories

3- Decrease dietary fat

Nicotine dependence

IntroductionNicotine produces physical and mood-altering effects in your brain that are temporarily pleasing; these effects reinforce your continued use of tobacco and nicotine dependence.

Nicotine increases the release of a brain chemical called dopamine, which makes you feel good. Getting that dopamine boost is part of the addiction process.

Your degree of addiction depends in part on how much you smoke and how long you've smoked.

Signs and symptoms

1- You can't stop smoking.

2-You experience strong withdrawals ymptoms when you try to stop. (anxiety, irritability, restlessness, difficulty concentrating, headache, drowsiness, stomach upset, even constipation or diarrhea).

3- You keep smoking despite health problems.

4- You give up social or recreational activities in order to smoke.

ComplicationsLungs. Smoking is the cause of most cases of lung cancer.

Smoking is also the primary cause of other lung problems, such as emphysema and chronic bronchitis.

Heart and circulatory system. Smoking increases your risk of dying from cardiovascular disease, including heart attack and stroke. Smokers have a higher risk of stroke that nonsmokers do; the more you smoke, the higher your risk.

Cancer. Smoking is a major cause of cancer of the esophagus, larynx, throat (pharynx) and mouth and contributes to cancer of the bladder, pancreas, liver, kidney, cervix, stomach, colon and rectum, and some leukemias.

Appearance. The chemicals in tobacco smoke can dry and irritate your skin, as well as promote wrinkles. Smoking also yellows your teeth, fingers and fingernails.

Fertility. Smoking increases the risk of infertility and miscarriage in women and the risk of impotence and infertility in men.

Pregnancy and newborn complications. Mothers who smoke while pregnant increase the risk of low birth weight, preterm delivery and impaired lung

function in their newborns.

Cold, flu and other illnesses.

Smokers are more prone to illnesses, such as colds, flu or bronchitis, than nonsmokers are.

Senses.

Smoking deadens your senses of taste and smell, so food isn't as appetizing as it once was.

TreatmentThe benefits of quitting

Lung function normally declines with age. Smoking worsens that decline. Quitting smoking won't undo permanent damage, but it will slow the decline.

Just 20 minutes after your last cigarette, your heart rate goes down.

Twelve hours later, the carbon monoxide levels in your blood return to normal.

Your lung function improves and your circulation starts to get better between two weeks and three months after your last cigarette.

Between one and nine months after quitting, your risk of infections drops and coughing and shortness of breath decrease.

After one year, the risk of coronary artery disease drops by half.

After five to 15 years, your stroke risk will be the same as that of a nonsmoker.

Methods of quitting are numerous

A- Nicotine replacement therapy

1- Nicotine patch (Nicoderm CQ, Nicotrol, Habitrol, others).

The nicotine patch provides a steady release of nicotine.

Dose

Patches must be replaced every 24 hours for 8 week or longer.

Pros:

The patch is easy to use and provides a steady release of nicotine. It's available without a prescription and in various doses (15mg step-1), (10 mg step2) and (5mg step three). This flexibility allows you to manage your withdrawal symptoms and cravings, as well as to taper the amount of nicotine you receive gradually.

Cons:

You can't quickly adjust the amount of nicotine in the patch in response to cravings. The patch may cause itching and irritation where it's applied. Other side effects may include headache, dizziness, upset stomach and blurred vision. Occasionally, patches may cause sleep disturbances and vivid, colorful dreams. Removing the patch at night may help.

2- Nicotine gum (Nicorette, others).

This is a gum-like resin that delivers nicotine to your blood through the lining of your mouth. It's available in a 2-milligram dose for regular smokers and a 4-milligram dose for heavy smokers.

Dose

The maximum number of pieces a day is 20, though you'll probably chew less. Nicotine gum is recommended for 12 week, with a maximum of 24 week.

Side effects

1- Leukoplakia 2- Gum ulcer

Leukoplakia appears as thick, white patches on your gums or on the insides of your cheeks.

2- Gum ulcer

3- Nicotine lozenge (Commit).

This is a tablet that dissolves in your mouth and, like nicotine gum, delivers nicotine through the lining of your mouth. The lozenges are also available in 2- and 4-milligram doses.

Dose

one lozenge / 2hr for six weeks, then gradually increasing the intervals between lozenges over the next six weeks.

These nicotine replacement products are available by prescription in the form of nasal inhalation and nasal spray

These nicotine replacement products are available by prescription

B-Non-nicotine medicationMedications that don't contain nicotine include:

Antidepressants. The antidepressant drug bupropion increases the level of dopamine, the chemical that's also boosted by nicotine, in your brain. As with many medications, bupropion (Zyban) has side effects, including sleep disturbance and dry mouth. If you have a history of seizures or serious head trauma, such as a skull fracture, don't use this drug. Another antidepressant that may help is nortriptyline (Aventyl, Pamelor).

Varenicline (Chantix).

This medication acts on the brain's nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Potential side effects include headache, nausea, an altered sense of taste and strange dreams.