Obstetric & Gynaecology Malaysia

OBSTERIC & GYNAECOLOGY IN MALAYSIA

BMI=Body Mass Index is calculated by a woman's weight in kilograms divided by woman's height in meters squared


BMI=kg/m2 for Malaysian


Normal BMI 18-22.9kg/m2

Overweight BMI 23-27.4kg/m2

Obesity BMI > 27.5kg/m2






The medical rationale for weight loss is that obesity is a serious, chronic, and progressive disease and is associated with a significant increase in mortality and many health risks including type 2 diabetes mellitus, hypertension, dyslipidemia, coronary heart disease and cancer eg uterine, breast and colon cancer.


The benefits of weight loss include a reduction in the rate of progression from impaired glucose tolerance to diabetes, blood pressure in hypertensive patients, and lipid levels in higher risk patients. Other noncardiac benefits of weight loss include reductions in knee pain in osteoarthritis, urinary incontinence, sleep apnea, and depression, as well as improvements in quality of life, physical functioning, and mobility.

Selection of treatment for people with overweight or obesity is based upon an initial risk. All patients who would benefit from weight reduction should receive counseling on diet, exercise, and goals for weight management. Weight reduction is achieved via 70% diet and 30% exercise in most women.

Dietary Therapy

Many types of diets produce modest weight reduction. Dietary adherence is an important predictor of weight reduction, regardless of the type of diet chosen. Thus, we advise tailoring a diet that reduces energy intake below energy expenditure to individual patient preferences, rather than focusing on the macronutrient composition of the diet. Calorie counting using apps eg MyFitnessPal to track calories may educate women on food choices.

Metabolic studies have concluded that most adults will lose weight when fed <1000 kcal/day. Thus, even subjects who are concerned that they are "metabolically resistant" to weight loss will lose weight if they comply with a diet of 800 to 1200 kcal/day. More severe caloric restriction might be expected to induce weight reduction more quickly, but a comparison with 400 versus 800 kcal/day diet formulas showed no difference in weight reduction, presumably due to slowing of resting metabolic rate. Thus advisable to follow diets consisting of >800 kcal/day, to prevent muscle loss from protein breakdown.


Other dietary patterns, such as intermittent fasting (eg, 16 hour fast 6pm-10am, alternate-day fasting or time-restricted feeding) are sometimes help to promote weight reduction,  although the evidence of their efficacy is mixed, likely affected by the amount the women consumed during the non fast period. Fasting has also been found to be as effective as bariatic sugery d/t improvement of insulin resistance.


No matter which diet or dietary pattern is chosen, continued surveillance by both clinician and patient are essential for treatment success. Return visits with the clinician, dietician, or behaviorist should be scheduled at regular intervals to assess barriers, discuss next steps, and offer encouragement. If weight reduction is less than 5 % in the first six months or no 1kg weight reduction in 2-4 weeks, something else should be tried.


Exercise 

Although less potent than dietary restriction in promoting weight loss, increasing energy expenditure through physical activity is important to attenuate the loss of lean mass (eg, muscle) during active weight loss. Physical activity should be performed for approximately 30 minutes or more, 5-7 days a week, to prevent weight gain and to improve cardiovascular health. There appears to be a dose effect for physical activity and weight loss, and much greater amounts of exercise are needed to produce significant weight loss in the absence of a calorically restricted diet. A multicomponent program that includes aerobic and resistance training is preferred.


Behaviour modification

Behaviour modification is one cornerstone in the treatment for obesity. The goal is to help patients make long-term changes in their eating behavior by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating. 

These concepts are usually included in self help books eg 

  • Marisa Peer You Can Be Thin (free hypnosis session for download)
  • Jason Fung Obesity Code, Diabetic Code, The Longevity Solution & The Complete Guide to Fasting.
  • Allen Carr The Easy way for Women to Lose Weight
  • Brian Delaney & Lisa Walford The Longevity Diet
  • Dr Valter Longo The Longevity Diet
  • David Perlmutter Brain Grain
  • Joel Fuhrman Eat To Live
  • Gary Taubes Why We Get Fat
  • Prof Roy Taylor Life Without Diabetes
  • Dr Micheal Mosley The 8 week blood sugar diet.


Programs conducted by psychologists for hypnotherapy or dietician or trained coach eg Nu Skin AgeLoc TR19 or HerbaLife as well as many self-help groups eg Weight Watchers. Women may gain motivation from watching YouTube videos posted by by Dr Jason Fung or celebrity fitness Thomas DeLauer.


Drug Treatment

Candidates for pharmacologic therapy include adults with a BMI greater than 30 kg/m2, or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have not met weight loss goals (loss of at least 5 % of total body weight at 3 to 6 months) with a comprehensive lifestyle intervention. The decision to initiate drug therapy should be individualized and made after a careful evaluation of the risks and benefits of all treatment options Treatments for obesity can be divided according to the risk of side effects. 


Recent anti-obesity drugs, should be used with doctor’s supervision with a reduced calorie diet and increased physical activity as they have minor side effects that diminish with treatment.

  • Saxenda® (liraglutide) injection 3 mg is an injectable (RM 2000 for 4 weeks).
  • Trulicity (Dulaglutide) 1.5mg/0.5ml injection 0.75 mg sc once a week for 4 week (RM 800 for 4 weeks)
  • Ozempic® (semaglutide) injection is a once-weekly non insulin medicine


Metformin, an insulin sensitizer that acts by reducing insulin resistance and decrease the hepatic production of sugar. The effect of metformin are reached within 1 to 3 hours of taking immediate-release metformin and 4 to 8 hours with extended-release formulation. Some women especially those with polycystic ovarian syndrome may reap the benefit of weight reduction with its action of reducing insulin resistance.  Side effect of metformin are physical weakness (asthenia), flatulence, diarrhea, low vitamin B12, nausea, dizziness, bloating, abdominal distension, heartburn.


Duramine containing Phentermine  is an appetite suppressant that works by directly affecting the area of the brain that controls your appetite making you feel less hungry. It can cause depression in some women. 


Xenical (Orlistat) is in a class of medications called lipase inhibitors. It works by preventing some of the fat in foods eaten from being absorbed in the intestines. This unabsorbed fat is then removed from the body in the stool, which can cause the unpleasant fecal leak in some women. 


Although oral Thyroxine that helps to increase metabolism, is not licensed for weight reduction, some women with history of constipation with her Free Thyroxine (FT4)  below 12pmol/L, may consider it under medical supervision. Side effect of Thyroxine use are rapid heartbeat, feeling hot when others do not, increased sweating, tremors, weight loss, more frequent bowel movements, nervousness, irritability or reduction in menstrual flow.


Significant weight loss (achieved via any modality) may increase the likelihood of cholelithiasis because the flux of cholesterol through the biliary system increases. Diets with moderate amounts of fat that trigger gallbladder contraction may reduce this risk. Similarly, therapy with a bile acid (eg, ursodeoxycholic acid) may be advisable in selected subjects, such as those who are losing weight rapidly (>1 to 1.5 kg/week).


MAINTENANCE OF WEIGHT Reduction

Recidivism, the regaining of lost weight, is a common problem in treating people with obesity.


Characteristics of those who are likely to succeed in maintaining weight loss include frequent self-weighing eg daily, a larger initial weight reduction (> 1 kg in four weeks), accountability-photo, apps, frequent and regular attendance at a weight loss program, a belief that their weight can be controlled, consumption of a reduced calorie (eg, 1200 kcal/day) un-processed food diet, regular physical activity, and participation in a lifestyle intervention program.

Lifestyle modification eg diet and exercise remain the foundation of long-term weight management plan. However, strategies that assume the effective treatment of obesity is only a matter of an individual's "willpower" may lead to repeated failure due to the body's tendency to revert to its set point.

Supervised medical fasting or bariatric surgery, which may alter the body's adipose tissue set point, and extended use of anti-obesity pharmacologic therapy may help address these underlying physiologic changes.


How do you screen for diabetes?

A reliable way of testing blood sugar is HbA1c (a blood test of 3 month sugar control), which do not required fasting for the blood test.

If your HbA1c is more than 6.5%, you are likely have diabetes. If your HbA1c is more than 5.9%, you are likely to have impaired sugar metabolism. If your HbA1c is more than 5.5%, yearly HbA1c advised.

If FBS (fasting blood sugar) >7mmol/L~ diabetes. If FBS >5.5 you are likely to have impaired sugar metabolism


How do you screen for thyroid?

Thyroid gland situated in front of the neck plays an important role in Metabolism regulation. You will need to be tested for Thyroid Function which includes  FT4 with normal range of 7.5-21pmol/L.