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+=======Obesity Powerpoint=======
+{{:obesity_presentation.pptx|}}
 ====== Obesity ======
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 <box 50% round right |>{{:bmi_classification_final.png}}</box|Figure 3: WHO standardized BMI categories in adults (Seidell & Halberstadt, 2015)>
-Body Mass Index (BMI)is an index of weight-for-height that is commonly used to classify weight in adults (Figure 3).The BMI was created to estimate the individual’s level of body fat and therefore assesses an individual’s risk of disease.
+Body Mass Index (BMI) is an index of weight-for-height that is commonly used to classify weight in adults (Figure 3).The BMI was created to estimate the individual’s level of body fat and therefore assesses an individual’s risk of disease.
-<box 35% round right |>{{:bmi_formula.png|}}</box|Figure 4: BMI Calculation Equation
-from http://www.heartnewslinks.com/editors-blog/body-mass-index-bmi-bad>
 BMI is measured standardly as weight in kilograms divided by the square of the height in meters (Figure 4). The values of the BMI are age and sex dependent as body composition varies between sexes and at different ages. The values are then assessed by looking at a BMI table or chart.<sup>[3]</sup>
+{{:bmi_formula.png|}}
+Figure 4: BMI Calculation Equation
+from http://www.heartnewslinks.com/editors-blog/body-mass-index-bmi-bad
 ==== BMI in children ====
-Obesity is defined differently for children and teens compared to adults due to the fact that they are still growing (Figure 5). <box 70% round right |>{{:weight_status_category.png|}}</box|Figure 5: BMI-for-Age Percentile Ranges for Children
+Obesity is defined differently for children and teens compared to adults due to the fact that they are still growing (Figure 5). BMIs for this cohort compare their height and weight against growth charts that take age and sex into account, since males and females in this cohort usually mature at different rates.
-from https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html>
-BMIs for this cohort compare their height and weight against growth charts that take age and sex into account, since males and females in this cohort usually mature at different rates.
 Their BMI is referred to as BMI-for-age percentile, meaning the child’s BMI is compared with other children of the same sex and age who participated in national surveys that were conducted from 1963-65 to 1988-94.<sup>[4]</sup>
+{{:weight_status_category.png|}}
+Figure 5: BMI-for-Age Percentile Ranges for Children
+from https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html>
 ==== BMI Limitations ====
 === Variance in Asian Populations ===
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 The secretory activity of adipocytes plays a huge role in regards to hormonal and metabolic activity that takes place. Adipose cells are increased in size and number in obese conditions, which initiate an immune response. The fat cells release pro-inflammatory adipokines that recruit macrophages to the site. Following this, Tumour Necrosis Factor- alpha (TNF-α) is released and additional immune cells are brought to the site. This constant state of inflammation causes insulin resistance. This is why diabetes is often comorbid with obesity <sup>[17]</sup>. This sequence of events is depicted in Figure 7.
-<box 45% round right |>{IMAGE}</box|Figure 7:This figure is a visual depiction of the secretory pathway and function of adipokines in conditions where excessive adipocyte buildup occurs >
+<box 35% round left |>{{:adipose_finalllll.png|}}</box|Figure 7:This figure is a visual depiction of the secretory pathway and function of adipokines in conditions where excessive adipocyte buildup occurs from http://www.the-scientist.com/images/December2012/Obese_Infograph.jpg>
 When analyzing other inflammatory factors, it is evident that increased concentrations of the adipokine Interleukin-6 (IL-6) are positively correlated with increased fat mass and BMI. Furthermore, IL-6 is increases post-exercise with increased NEFAs, thus proposing a correlation between the adipokine and lipid mobilization <sup>[16]</sup>.Monophosphate activated protein kinase (AMPK) enables the oxidation of fatty acids during muscle contraction. AMPK is regulated by the hormone adiponectin, which induces insulin-sensitivity. In individuals who are obese, the concentration of adiponectin is reduced, as individuals with symptoms of diabetes are resistant to insulin <sup>[16]</sup>.
@@ Line 150: / Line 168: @@
 A study conducted by Kazmi et al.(1996) investigated leptin concentrations in a sample of a  Rawalpindi population. There were three sampling groups—health obese, overweight and non-obese. According to the results, the mean serum leptin concentration for the obese group was 52.8 ug/mL and 6.3 ug/mL for the non-obese group. The results of this study concluded there is certainly a positive correlation between the Body Mass Index and leptin concentrations in individuals <sup>[21]</sup>.
+<box 45% round right|>{{:intake_final.png|}}</box|Figure 8: Human hormones and food intake from http://blog.naturessunshine.com/wp-content/uploads/2015/12/Control_Food_Intake.jpg>
 **Ghrelin**
-Ghrelin is an appetite-stimulating hormone predominantly secreted by the stomach when it is empty. It increases food intake and promotes fat storage. One would expect the concentration of ghrelin to be higher with obesity because it would account to increased food intake generally involved in cases of obesity. However, this is not the case. Ghrelin concentrations are actually much lower in obese individuals.To investigate the role of ghrelin in obese pathology, Tschop et al. (2001) conducted a study where the plasma ghrelin concentrations of lean and obese individuals were measured. As can be seen in the graph (Figure 2), the plasma ghrelin concentrations of obese individuals are much lower than in lean individuals.5 There seems to be a negative correlation between plasma ghrelin concentrations and fat mass.
+Ghrelin is an appetite-stimulating hormone secreted primarily by the stomach during times of low caloric intake <sup>[20]</sup>. It signals individuals to increase their food intake and promote fat storage. The concentration of ghrelin is expected to be higher with obesity, because it would account for the increased food intake in cases of obesity. However, experimental evidence shows that Ghrelin concentrations are actually much lower in obese individuals. To investigate the role of ghrelin in obese pathology, Tschop et al. (2001) conducted a study where the plasma ghrelin concentrations of lean and obese individuals were measured. The plasma ghrelin concentrations of obese individuals were much lower than in lean individuals <sup>[22]</sup>. There seemed to be a negative correlation between plasma ghrelin concentrations and fat mass.
-This could simply be because of the body’s instinctive shift for homeostasis. Since, ghrelin and leptin both have an antagonistic role, it would not be possible for there to be high concentrations of both hormones. Since, leptin concentration is high it could result in a lowering in ghrelin levels to balance the two hormones.3 The exact mechanism through which this happens is yet to be elucidated by research.
+The body’s instinctive shift for homeostasis could account for the downregulation of plasma ghrelin in obese individuals. Since ghrelin and leptin display antagonistic properties, it would not be possible for there to be high concentrations of both hormones. High leptin concentrations could account for low concentrations of ghrelin <sup>[20]</sup>. The exact mechanism through which this happens is yet to be elucidated by research.
-<box 45% round right |>{IMAGE}</box|Figure 8: >
 ==== Genetic Predisposition ====
-<style justify>
+When assessing the heritability of obesity, it has a numerical association of 0.7, which is fairly high relative to heritability in schizophrenia (0.81) and autism (0.9). In the case of rare familial obesity, gene defects occur in appetite regulation. Variants in the leptin-melanocortin pathway result in about 5% of morbid human obesity. Common polygenic obesity is characterized by the human obesity gene map. When performing a closer analysis of some of the key factors involved in obesity, Pre-B cell colony enhancing factor (PBEF1), which is secreted by lymphocytes, is expressed by adipocytes. Presently, it is referred to as Visfatin <sup>[23]</sup>.
+Due to the interconnectedness of genes, it can be difficult to address conflicting effects of similar genetic factors. Ghrelin binds to the growth hormone secretagogue receptor (GHSR), and initially, variants of GHSR were evident in common obesity and rare familial obesity. More recent studies show a negative correlation between GHSR variants and obesity. It is hypothesized that these effects could be due to obestatin, which is a hormone that regulates appetite in the opposite way that ghrelin does  <sup>[23]</sup>.
-</style>
+Having the ability to detect the genetic basis for obesity provides therapeutic solutions that can combat symptoms of obesity. A variety of biomarkers have been identified as factors involved in obesity. These biomarkers are used to differentiate between types of obesity, provide insight on the associated comorbid diseases, genetic susceptibility and explain the implications of the interaction between two or more factors <sup>[23]</sup>.
-===== Treatments =====
-<style justify>
+Areas of research pertaining to molecular genetics are expanding the scope of genetic predispositions involved in obesity. As of October 2005, 244 mutated genes or transgenes causing phenotypic changes in weight and adiposity are identified. The human obesity gene map indicates that 176 human obesity cases can be linked to 11 specific genes, and 50 loci pertaining to human obesity are linked to Mendelian syndromes <sup>[24]</sup>
+The  gene map (Figure 9), includes all obesity-related genes and quantitative trait loci identified from the various lines of evidence reviewed in the paper. It is further explained and categorized into the 5 categories, where information pertaining to the mouse chromosome, mouse gene, human chromosome, human homolog, statistical analyses of variance, gene description, details pertaining to its role in obesity and more is provided. Areas of research pertaining to molecular genetics are expanding the scope of genetic predispositions involved in obesity <sup>[24]</sup>.
+{{:genetics.gif}}
+Figure 9: Human obesity gene map, updated in 2005.
+From http://onlinelibrary.wiley.com.libaccess.lib.mcmaster.ca/doi/10.1038/oby.2006.71/full
+===== Treatments =====
 **Goals of Weight Loss and Management **
-When undergoing weight loss therapy, practice guidelines issued by the National Heart, Lung and Blood Institute and the North American Association for the Study of Obesity recommend an initial weight loss goal of approximately 10 percent from baseline over a period of 6 months of therapy. (christelle, 1)
+When undergoing weight loss therapy, practice guidelines issued by the National Heart, Lung and Blood Institute and the North American Association for the Study of Obesity recommend an initial weight loss goal of approximately 10% from baseline over a period of 6 months of therapy <sup>[25]</sup>.
+A weight loss of 10% has the potential to improve glycemic control, blood pressure control and lipid levels, especially in individuals with Type 2 diabetes or hypertension. Additionally, it might help to reduce symptoms from comorbidities, such as gastroesophageal reflux and osteoarthritis. If weight loss is maintained over a long period of time, adverse clinical outcomes, such as myocardial infarction, stroke and cardiovascular-related deaths, can be reduced <sup>[26]</sup>.
-Weight loss of 10% has the potential to improve glycemic control, blood pressure control and lipid levels, especially in individuals with type 2 diabetes or hypertension. Additionally, it might help to reduce symptoms from other obesity-related conditions such as gastroesophageal reflex and osteoarthritis. If weight-loss is maintained over a long period of time, adverse clinical outcomes such as myocardial infarction, stroke and cardiovascular-related deaths can be reduced (christelle, 2 )
 **Intervention**
-For best weight loss and maintenance results, it is important to indefinitely adopt the following lifestyle modifications: dietary therapy, physical activity and cognitive behaviour therapy. Typically, health care practitioners recommend their patients to adopt the lifestyle modifications for 6 months. Thereafter, clinicians assess whether they have reached the weight loss goal of 10% loss from baseline. If patients have reached a satisfactory progress upon evaluation, it is recommended that they maintain their lifestyle modifications for sustainable weight loss results. Regular monitoring is needed. In the case that patients have not reached a satisfactory progress after 6 months, health care practitioners typically recommend pharmacotherapy and/ or bariatric surgery to achieve their weight loss goal. Best results are seen when either pharmacotherapy or bariatric surgery are used in conjunction with lifestyle modifications
-{{:hiv-drug-classes.svg.png|}}
+For the optimal weight loss and health benefits, it is important to adopt lifestyle modifications, such as dietary therapy, physical activity and cognitive behaviour therapy. Typically, health care practitioners recommend their patients to pursue the lifestyle modifications for 6 months. Thereafter, clinicians assess whether they have reached the weight loss goal of 10% from baseline estimates. If patients have attained a satisfactory progression upon evaluation, it is recommended that they maintain their lifestyle modifications for sustainable weight loss results. Regular monitoring is a crucial aspect of ensuring a healthy lifestyle, as the influences of side effects must also be considered. In the case that patients have not attained their recommended weight after 6 months, health care practitioners typically recommend pharmacotherapy and/ or bariatric surgery to achieve their weight loss goal. The most conclusive results are seen when either pharmacotherapy or bariatric surgery are used in conjunction with lifestyle modifications <sup>[25]</sup>.
-//Figure 8: HIV Antiretroviral Treatment
-Retrieved from: https://upload.wikimedia.org/wikipedia/commons/thumb/d/d5/HIV-drug-classes.svg/450px-HIV-drug-classes.svg.png //
 **Diet**
+<box 25% round right |>{{:meal.png|}}</box|Figure 10: Illustration of the ideal food plate including all food groups from http://www.arthritis.org/images/slideshows/ra-diet/ra-diet-13-fill-your-plate.jpg
+>
+The first component of lifestyle modifications to treating obesity is undergoing dietary therapy (Figure 10). When assessing diet management in obese patients, weight reduction is highly dependent upon energy intake in comparison to energy expenditure <sup>[27]</sup>.
+According to a study conducted by Poirier and Despres (2001), it has been concluded that approximately 1 pound of mass can be lost within a week without any changes being made to the level of physical activity <sup>[27]</sup>. There are various types of diets that an individual can choose to pursue. Each type of diet is subjective to the patient, therefore it can produce differing results. Three diets that are typically suggested to obese patients are the low carbohydrate diet, the low-fat diet and the high protein diet.
+The low carbohydrate diet is consists of a reduced carbohydrate consumption <sup>[28]</sup>. Long-term studies  have shown that low carbohydrate diets produce significant results at the 3 and 6 month points. However, results become insignificant at about a year onwards <sup>[29]</sup>. When examining the weight reduction that high protein diets produced, the results were indifferent <sup>[29]</sup>. Patients were losing a significant amount of weight up until about a year and then the results started to decrease <sup>[29]</sup>. Studies about the low-fat diet have shown that  patients saw a significant weight reduction for about three years and then results were insignificant <sup>[30]</sup>.
+Although all three of these diets show promising results, the low carbohydrate and high protein diets show short term effects, while the low fat diet seems to display long term fat reduction. In conclusion, it is important to note that many individuals are susceptible to regaining their weight, thus a sustainable lifestyle is integral. Managing weight loss through dietary means can be difficult, however it can be made easier when incorporating physical activity into the daily routine.
 **Weight Loss Programs**
+Due to the vast technological advances of our time, there are many weight loss programs available that are highly accessible. Although there are a wide variety of programs to choose from, it is always encouraged to keep in mind that not every weight loss program will produce the same kinds of results for everyone. It is always important to consult with a family physician when trying to find a weight loss program that will have a positive effect on a personal weight reduction.
+Some examples of weight loss programs that are available for further investigation are listed below:
+__The Paleo Diet__: It works to incorporate whole foods, lean protein, veggies, fruits, nuts, and seeds and encourages to stay away from foods with sugars, dairy and grains.
+__The Vegan Diet:__ It is an ‘extreme’ vegetarian diet that works to eliminate dairy, eggs, and animal derived products, such as gelatin, honey, whey, and vitamin D3.
+__The Low Carbohydrate Diet:__ It encourages individuals to eat an unlimited amount of protein and fat, while completely eliminating carbohydrates.
+__The Ultra Low-Fat Diet:__ It consists of a diet where 10% or less calories come from fat. This diet is almost entirely made up plant based food items, with a very limited intake of animal products.
+__The Zone Diet:__ This diet encourages participants to balance each meal with one third of protein, and two thirds of fruits and veggies. A small amount of fat that comes from natural and healthy sources, such as avocado, almonds, or olive oil can also be consumed.
+__Intermediate Fasting:__ This diet challenges its participants to fast during portions of the day, while restricting the calorie intake during the times you do choose to eat. This diet is most efficient when you aren’t overeating during the times where the fast has been broken.
+There are a few options when trying to reduce weight loss. All of the diets that are listed above prove to have a positive impact on weight reduction. However every diet has its consequences. When the body is restricted from having certain kinds of foods, nutrients, minerals and vitamins are compromised. For example, if an individual were to go on the paleo diet, the restriction of whole grains and dairy prevents individuals from consuming certain vitamins. A family physician or a dietician would be able to provide the most representative diet plan for each individual <sup>[31]</sup>.
 **Physical Activity**
+The second component of the lifestyle modifications approach to treating obesity is to be physically active. The purpose behind weight loss and management programs is to stop future weight gain, decrease body weight and permanently maintain a lower body weight <sup>[32]</sup>. Maintaining a physically active lifestyle is known to be key to a long term weight maintenance, because it increases the energy expenditure through caloric deficit <sup>[33]</sup>. When incorporating physical activity into a daily routine with hopes of maintaining the reduction of body weight, it is important to remember that different training modalities such as walking, cycling and swimming can have a different impact on different individuals <sup>[34]</sup>.
+When involved in physical activity, many adaptive responses take place, which cause a more efficient system for oxygen transfer to muscle <sup>[32]</sup>. In addition, reduced adipose tissue mass representing an important mechanical advantage, allows better long-term work <sup>[32]</sup>. Physical training helps counteract the permissive and affluent environment that predisposes reduced-obese subjects to regain weight <sup>[32]</sup>. Many studies have recommended thirty to forty-five minutes of moderately intensive physical activity, to be done 3-5 times a week <sup>[35]</sup>. In particular, public health interventions have promoted walking as a physical activity, since it is safe, accessible and a low intense aerobic exercise that results in high fat loss <sup>[32]</sup>. Losing weight through physical activity can be very difficult, especially for obese patients and therefore, it is important to set realistic weight loss goals of about 0.5-1 pound per week, with the assistance <sup>[32]</sup>. Because it may seem like small steps are made in weight reduction while working out, it is important for patients to remain determined and persevere to reach their goals <sup>[32]</sup>. Keeping a positive attitude during this process can be very difficult and so, it is extremely important for the patient to have one-on-one interaction between the clinician or healthcare professional on a regular basis <sup>[32]</sup>.
 **Cognitive Behaviour Therapy**
-The third component of lifestyle modifications is to undergo a cognitive behaviour therapy (CBT) program to assess one’s current habits and identify factors, stresses or situations which may trigger one’s overeating habits and contribute to one’s obesity. With a CBT approach, patients suffering from obesity can get help through counseling, support groups, as well as adopting the family-based approach (christelle 1,2).
+<box 30% round right  |>{{:cbt.png}}</box|Figure 11: The three main components of Cognitive Behaviour Therapy: thought, emotion and behaviour
+from http://in8.uk.com/wp-content/uploads/2016/03/CBT-image.png>
-The purpose of the CBT treatment is not to eliminate a psychiatric disorder, but to change eating and exercise behaviours (christelle, 3). This intervention aims to teach skills to change the problematic behaviours. Firstly, CBT is based on a cognitive conceptualisation of the processes that lead to overeating. Specifically, thoughts and thinking patterns are understood as central to the problem. Secondly, CBT is focused on altering the cognitive and behavioural mechanisms that maintain the problem behaviour. Thirdly, CBT uses both cognitive and behavioural techniques to effect change in maintaining mechanisms (christelle, 4). The diagram here shows different components that contribute to CBT.
+The third component of lifestyle modifications is to undergo cognitive behaviour therapy (CBT) to assess one’s current habits and identify factors, stressors or situations that may trigger one’s overeating habits and contribute to their obesity (Figure 11). With a CBT approach, patients suffering from obesity can get help through counseling, support groups, as well as adopt the family-based approach <sup>[25,26]</sup>.
-Counseling is one of the ways a patient can experience CBT. It can either be delivered on a one-on-one basis, or in a group setting of approximately 10 participants with a trained healthcare professional (christelle 5, 6). A study conducted by Renjilian and colleagues comparing the two treatment modalities concluded that participants who were randomized to receive group-based therapy lost more weight after 26 weekly sessions compared to those who were treated individually. Specifically, those receiving group therapy lost about 11 kg after 26 weekly sessions, in comparison to 9 kg for those who were individually treated (christelle, 7).
+The purpose of the CBT treatment is not to eliminate a psychiatric disorder but to change eating and exercise behaviours <sup>[36]</sup>. This intervention aims to educate individuals on how to change problematic behaviours. Firstly, CBT is based on the cognitive conceptualization of the processes that lead to overeating. Specifically, thoughts and thinking patterns that are considered central to the problem. Secondly, CBT is focused on altering the cognitive and behavioural mechanisms that maintain the problem behaviour. Lastly, CBT uses both cognitive and behavioural techniques to maintain healthy mechanisms <sup>[37]</sup>. The diagram here shows different components that contribute to CBT.
+Counselling is one way a patient can undergo CBT. It can either be delivered on a one-on-one basis, or in a group setting of approximately 10 participants with a trained healthcare professional <sup>[38,39]</sup>. A study conducted by Renjilian and colleagues comparing the two treatment modalities concluded that participants who were randomized to receive group-based therapy lost more weight after 26 weekly sessions compared to those who were treated individually. Specifically, those receiving group therapy lost about 11 kg after 26 weekly sessions, in comparison to 9 kg for those who were individually treated <sup>[40]</sup>.
+In addition to counselling, having a support network is important. This is  especially true if the individual is undergoing drastic changes. Receiving encouragement from family, friends and health care practitioners can be very motivating during challenging times of the weight loss and maintenance programs. Furthermore, patients can also join support groups with other people undergoing weight loss <sup>[25]</sup>.
+Family-based obesity treatment has also been proven to be a very effective and sustainable approach, especially when treating pediatric obesity. The role of this treatment is to target eating and activity change in both child and parent. Programs using this approach teach parents behavioural skills to facilitate child behaviour change and utilize family resources to improve the efficacy of childhood obesity treatments. Simultaneously treating the child and parent helps create positive relationships between them as they both aim to reach their weight loss goal together <sup>[41,42]</sup>.
-In addition to counseling, having a support network is important, especially since the individual is undergoing drastic changes. Receiving encouragement from family, friends and health care practitioners can prove to be very motivating during challenging times of the weight loss and maintenance programs. Further, patients can also join support groups with other people undergoing weight loss (christelle, 1).
-Lastly, family-based obesity treatment has proven to be a very effective and sustainable approach, especially when treating pediatric obesity. The role of family-based behavioural pediatric obesity treatment is to target eating and activity change in both child and parent. Programs using this approach teach parents behavioural skills to facilitate child behaviour change and mobilize family resources to improve the efficacy of childhood obesity treatments. Simultaneously, treating the child and parent at the same time help to create positive relationships between them, as they both aim to reach their weight loss goal together (christelle 8, 9).
 **Pharmacotherapy**
-The Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that in addition to lifestyle modifications such as dietary changes, physical activity and behaviour therapy, overweight  individuals with BMIs greater than 27 kg/m2 but with life threatening diseases, or obese individuals with BMIs greater than 30 kg/m2 can undergo pharmacotherapy (christelle, 2).
+The Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that in addition to lifestyle modifications such as dietary changes, physical activity and behaviour therapy, overweight  individuals with BMIs greater than 27 kg/m^2 but with life threatening diseases, or obese individuals with BMIs greater than 30 kg/m^2 can undergo pharmacotherapy <sup>[2]</sup>.
+<box 35% round right |>{{:orlistat.jpg|}}</box|Figure 12: Orlistat, one of the pharmacological treatments for obesity
+from https://www.medexpress.co.uk/javax.faces.resource/treatments/335x335xorlistat-120mg-pills.jpg.xhtml,qln=img.pagespeed.ic.3lJxOPoYEm.jpg>
+A meta analysis investigated 21 randomized control trials (RCT) that involved a total of 11 533 participants using either one of the two drugs: orlistat or sibutramine, or a placebo. These RCTs had a follow-up period of at least 1 year in obese and overweight adults.
+Olistat functions as a gastrointestinal lipase inhibitor and reduces fat absorption by approximately 30% (Figure 12). Patients can use it for up to two years <sup>[43]</sup>. On the other hand, sibutramine functions as a serotonin and noradrenaline reuptake inhibitor which induces weight loss through enhanced satiety and increased basal energy expenditure. Sibutramine is approved for clinical use for up to 1 year <sup>[44]</sup>.
+Pharmacotherapy trials comparing the effect of combined dietary and pharmacotherapy treatment to dietary treatment alone, showed that patients who received treatment underwent a greater weight loss compared to those who only had a reduced-energy diet. This was when orlistat or sibutramine was combined with a reduced-energy diet. More specifically, the long term weight loss for those receiving combined therapy of dietary and pharmacotherapy was about 6 to 7 kg, compared to about 2 to 3 kg for those who received dietary therapy only <sup>[26]</sup>.
-A meta analysis investigated 21 randomized control trials (RCT) that involved a total of 11 533 participants using either one of the two drugs: orlistat or sibutramine, or a placebo. These RCTs had a follow-up period of at least 1 year in obese and overweight adults. Olistat functions as a gastrointestinal lipase inhibitor and reduces fat absorption by approximately 30%. Patients can use it for up to two years (christelle, 10). On the other hand, sibutramine functions as a serotonin and noradrenaline reuptake inhibitor which induces weight loss through enhanced satiety and increased basal energy expenditure. Sibutramine is approved for clinical use for up to 1 year (christelle 11).
-Table 14 shows the results from pharmacotherapy trials, which compared the effect of having combined dietary and pharmacotherapy treatment, to dietary treatment only. Patients who received treatment with orlistat or sibutramine, when combined with a reduced-energy diet, underwent a greater weight loss, compared to those who only had a reduced-energy diet. More specifically, the long term weight loss for those receiving combined therapy of dietary and pharmacotherapy was about 6 to 7 kg, compared to about  2 to 3 kg for those who received dietary therapy only (christelle, 2).
 **Maintenance of weight loss**
-Studies which assessed orlistat therapy for at least 2 years and up to 5 years showed that weight loss attained by year 1 was better maintained over the subsequent 3 years in patients who received ongoing drug therapy. Specifically, Davidson et al. showed that patients who had ongoing treatment of orlistat for 2 years were associated with less regain of weight loss (32%) compared with diet only therapy (63%) (christelle 12).
+Studies that assessed orlistat therapy for at least 2 years and up to 5 years showed that weight loss attained by year 1 was better maintained over the subsequent 3 years in patients who received ongoing drug therapy. Specifically, Davidson et al. showed that patients who had ongoing treatment of orlistat for 2 years were associated with less regain of weight loss (32%) compared with diet only therapy (63%) <sup>[45]</sup>.
+In addition, a 2-year study conducted by James et al., showed that 43% of patients who received 6 months of weight loss induction using diet-only therapy, followed by sibutramine-diet therapy had better maintained 80% or more of weight loss, compared to only 16% in the diet-only group who received diet-placebo therapy <sup>[46]</sup>. This shows that combined therapy is more effective than diet-only group.
-In addition, a 2-year study conducted by James et al., showed that 43% of patients who received 6 months of weight loss induction using diet-only therapy, followed by sibutramine-diet therapy had better maintained 80% or more of weight loss, compared to only 16% in the diet-only group who received diet-placebo therapy (christelle 13). This shows that combined therapy is more effective than diet only group.
 **Bariatric Surgery**
-Bariatric surgery is the treatment method that is considered for adult patients who have a BMI over 35kg/m2 with severe comorbid diseases such as life-threatening cardiopulmonary problems, severe sleep apnea, severe diabetes mellitus, or those in the severely obese category with a BMI greater than 40 kg/m2. As for teenagers, the Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that bariatric surgery to be limited to an appropriately trained and experienced surgical team. After 6 months of using lifestyle modifications, healthcare practitioners assess the health of the patient and evaluate whether a satisfactory progress of weight loss or goal of 10% of body weight has been reached. In the case that satisfactory progress or goal has not been achieved, physicians will consider the eligibility of patients to undergo bariatric surgery. This is only considered if other nonsurgical weight loss attempts have failed. The goal of bariatric surgery is to relieve a patient suffering from obesity from his or her morbid body weight, improve their comorbidity and improve their quality of life. There are different surgical procedures as shown in the diagram. It is important to note that this treatment option requires lifelong medical surveillance(christelle,2).
+<box 30% round right |>{{:surgical_procedures.png|}}</box|Figure 13:  Four highly used surgical procedures used to treating obesity from http://www.cmaj.ca/content/suppl/2007/09/04/176.8.S1.DC1/obesity-lau-onlineNEW.pdf>
-A study on obese Swedish patients investigated the conventional, nonsurgical management with surgery for morbid obesity in 2004 found that surgical management is more efficacious than medical management. Patients who received surgical treatment produced greater weight loss, improved lifestyle and dramatic improvement of comorbid disease. At 10 years of follow-up, the surgical cohort showed that they maintained a weight loss greater than 16.1% of their original body weight. In contrast, those who received the conventional, nonsurgical management had a weight gain of 1.6%. This 16.3% weight difference demonstrates the effectiveness and maintenance of surgical procedures (christelle, 14)
+Bariatric surgery is a treatment method that is considered for adult patients who have a BMI over 35kg/m^2 with severe comorbid diseases such as life-threatening cardiopulmonary problems, severe sleep apnea, or severe diabetes mellitus, or for those in the severely obese category with a BMI greater than 40 kg/m2. For teenagers, the Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommends that bariatric surgery be limited to an appropriately trained and experienced surgical team. After 6 months of using lifestyle modifications, healthcare practitioners assess the health of the patient and evaluate whether a satisfactory progress of weight loss or goal of 10% of body weight has been reached. In the case that satisfactory progress or goal has not been achieved, physicians will consider the eligibility of patients to undergo bariatric surgery. This is only considered if other nonsurgical weight loss attempts have failed. The goal of bariatric surgery is to relieve a patient suffering from obesity from his or her morbid body weight, improve their comorbidity and improve their quality of life. There are different surgical procedures (Figure 13). It is important to note that this treatment option requires lifelong medical surveillance <sup>[26]</sup>.
+A study on obese Swedish patients investigated the conventional, nonsurgical management with surgery for morbid obesity in 2004 found that surgical management is more efficacious than medical management. Patients who received surgical treatment produced greater weight loss, improved lifestyle and dramatic improvement of comorbid disease. At 10 years of follow-up, the surgical cohort showed that they maintained a weight loss greater than 16.1% of their original body weight. In contrast, those who received the conventional, nonsurgical management had a weight gain of 1.6%. This 16.3% weight difference demonstrates the effectiveness and maintenance of surgical procedures <sup>[47]</sup>.
+**Summary of Treatment Options**
+As seen in figure 14, there are different approaches to treating obesity. First, it is important to set a weight loss goal to reduce body weight by approximately 10% from baseline during the first six months of treatment. Healthcare practitioners typically recommend their patients to first undergo lifestyle modifications: proper nutrition, physical fitness, and cognitive behaviour therapy. After six months of treatment, healthcare practitioners will assess the patient’s progress and determine whether satisfactory progress or weight loss goal has been reached. In the case that it has been reached, the patient would be closely monitored on a regular basis to make sure that their weight is maintained. In the event that satisfactory progress is not attained, physicians will assess the patient’s eligibility to either undergo pharmacotherapy or bariatric surgery. Physicians typically opt for bariatric treatment in the event that nonsurgical treatments have failed. It is important to note that best weight loss and maintenance results are achieved when pharmacotherapy or bariatric treatment is used in conjunction with lifestyle modifications.
+{{:flowchart_final.png|}}
+Figure 14: A holistic approach to treating obesity.
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