Uncontrolled Hypertension

OBSTRUCTIVE SLEEP APNOEA  (OSA)—is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort during sleep.. It is characterized by recurrent episodes of upper airway collapse during sleep.These episodes are associated with recurrent oxygen desaturations and arousals from sleep. Signs and symptoms…… NOCTURNAL SYMPTOMS :-- Snoring, usually loud, habitual, and bothersome to others Gasping and choking sensations that arouse the patient from sleep Nocturia Insomnia; restless sleep DAYTIME SYMPTOMS :-- Nonrestorative sleep… ie waking up as tired Morning headache Excessive daytime sleepiness Daytime fatigue memory and intellectual impairment Personality and mood changes Sexual dysfunction Gastroesophageal reflux Resistant Hypertension DIAGNOSIS Evaluate the upper airway in all patients, particularly in nonobese adults with symptoms consistent with OSA. Examination findings may include the following: Abnormal (increased) Mallampati score Abnormally enlarged tonsils & /or Adenoids in children Systemic arterial hypertension: Present in about 50% of cases Congestive heart failure Pulmonary hypertension Stroke Metabolic syndrome Type 2 diabetes mellitus DIAGNOSIS :- An overnight sleep study, or polysomnography, is required to diagnose OSA. MANAGEMENT of OSA Conservative therapy and prevention,...... (1)Avoid supine position during sleep or Sleeping in an upright position for markedly obese patients (2) Avoiding alcohol and other sedatives. Standard treatment option :- (1)Nasal CPAP (2)Bilevel positive airway pressure (3)Oral appliance therapy Pharmacotherapy Medications such as modafinil have been used adjunctively in the management. Surgery (1)Uvulopalatopharyngoplasty (2)Craniofacial reconstruction with advancement of tongue or maxillomandibular bones (3)Tracheostomy Most of the patients remain undiagnosed until progressed to an advanced stage.. Multiple cases of road traffic accident is reported while driving a vehicle.. We must keep the diagnosis of OSA in mind while getting cases with similar symptoms.. Epworth Sleepiness Scale is also available to assess these patients clinically.. I hope this information will be HELPFUL in your clinical practice…

SLEEP APNEA Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have Sleep apnea if you snore loudly and you feel tired even after a full night's sleep. There are two main types of Sleep apnea: Obstructive Sleep apnea, the more common form that occurs when throat muscles relax Central Sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing If you think you might have Sleep apnea, see your doctor. Treatment is necessary to avoid heart problems and other complications. SYMPTOMS The signs and symptoms of obstructive and central Sleep apneas overlap, sometimes making the type of Sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central Sleep apneas include: Excessive daytime sleepiness (hypersomnia) Loud Snoring, which is usually more prominent in obstructive Sleep apnea Episodes of breathing cessation during sleep witnessed by another person Abrupt awakenings accompanied by shortness of breath, which more likely indicates central Sleep apnea Awakening with a Dry mouth or Sore throat Morning headache Difficulty staying asleep (Insomnia) Attention problems When to see a doctor Consult a medical professional if you experience, or if your partner notices, the following: Snoring loud enough to disturb the sleep of others or yourself Shortness of breath that awakens you from sleep Intermittent pauses in your breathing during sleep Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving Many people don't think of Snoring as a sign of something potentially serious, and not everyone who has Sleep apnea snores. But be sure to talk to your doctor if you experience loud Snoring, especially Snoring that's punctuated by periods of silence. Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as Narcolepsy. CAUSES Causes of obstructive Sleep apnea Obstructive Sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils, the side walls of the throat and the tongue. When the muscles relax, your airway narrows or closes as you breathe in, and you can't get an adequate breath in. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so you can reopen your airway. This awakening is usually so brief that you don't remember it. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours. People with obstructive Sleep apnea may not be aware that their sleep was interrupted. In fact, some people with this type of Sleep apnea think they sleep well all night. Causes of central Sleep apnea Central Sleep apnea, which is much less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting to sleep or staying asleep. Like with obstructive Sleep apnea, Snoring and daytime sleepiness can occur. The most common cause of central Sleep apnea is Heart failure and, less commonly, a Stroke. People with central Sleep apnea may be more likely to remember awakening than are people with obstructive Sleep apnea. RISK FACTORS Sleep apnea can affect anyone. Even children can have Sleep apnea. But certain factors put you at increased risk: Obstructive Sleep apnea Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has Sleep apneais overweight. Thin people develop this disorder, too. Neck circumference. People with a thicker neck may have a narrower airway. A narrowed airway. You may have inherited a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway. Being male. Men are twice as likely to have Sleep apnea. However, women increase their risk if they're overweight, and their risk also appears to rise after Menopause. Being older. Sleep apnea occurs significantly more often in adults older than 60. Family history. If you have family members with Sleep apnea, you may be at increased risk. Race. In people under 35 years old, blacks are more likely to have obstructive Sleep apnea. Use of alcohol, sedatives or tranquilizers.These substances relax the muscles in your throat. Smoking. Smokers are three times more likely to have obstructive Sleep apnea than are people who've never smoked. Smoking may increase the amount of inflammation and Fluid retention in the upper airway. This risk likely drops after you quit smoking. Nasal congestion. If you have difficulty breathing through your nose — whether it's from an anatomical problem or Allergies — you're more likely to develop obstructive Sleep apnea. Central Sleep apnea Being male. Males are more likely to develop central Sleep apnea. Being older. People older than 65 years of age have a higher risk of having central Sleep apnea, especially if they also have other risk factors. Heart disorders. People with Atrial fibrillationor congestive Heart failure are more at risk of central Sleep apnea. Stroke or brain Tumor. These conditions can impair the brain's ability to regulate breathing. COMPLICATIONS Sleep apnea is considered a serious medical condition. Complications may include: High blood pressure or heart problems.Sudden drops in blood oxygen levels that occur during Sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive Sleep apnea, your risk of High blood pressure (hypertension) is greater than if you don't. The more severe your Sleep apnea, the greater the risk of high blood pressure. However, obstructive Sleep apnea increases the risk of Stroke, regardless of whether or not you have high blood pressure. If there's underlying Heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event. Studies also show that obstructive Sleep apnea is associated with increased risk of Atrial fibrillation, congestive Heart failure and other vascular diseases. In contrast, central Sleep apnea usually is the result, rather than the cause, of Heart disease. Daytime fatigue. The repeated awakenings associated with Sleep apnea make normal, restorative sleep impossible. People with Sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with Sleep apneamay do poorly in school or have behavior problems. Complications with medications and surgery. Obstructive Sleep apnea is also a concern with certain medications and general anesthesia. People with Sleep apneamay be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have Sleep apnea and how it's treated. Undiagnosed Sleep apnea is especially risky in this situation. Liver problems. People with Sleep apnea are more likely to have abnormal results on liver function tests, and their livers are more likely to show signs of scarring. Sleep-deprived partners. Loud Snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep-deprived as well. People with Sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of Depression, a need to urinate frequently at night (nocturia), and a decreased interest in sex. Children with untreated Sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD). PREPARING FOR YOUR APPOINTMENT If you or your partner suspects that you have Sleep apnea, you'll probably first see your primary care doctor. However, in some cases when you call to set up an appointment, you may be referred immediately to a sleep specialist. Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor. What you can do Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as modify your diet or keep a sleep diary. Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. Write down key personal information,including any major stresses or recent life changes. Make a list of all medications, vitamins or supplements that you're taking. Ask a family member or friend along, if possible. Someone who accompanies you may remember information that you missed or forgot. And, because your bed partner may be more aware of your symptoms than you are, it may help to have him or her along. Write down questions to ask your doctor. Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your visit. For Sleep apnea, some basic questions to ask your doctor include: What's the most likely cause of my symptoms? Are there other possible causes for my symptoms? What kinds of tests do I need? Do these tests require any special preparation? Is my condition likely temporary or long lasting? What treatments are available? What are the alternatives to the primary approach that you're suggesting? Which treatment do you think would be best for me? I have other health conditions. How can I best manage these conditions together? Should I see a specialist? Is there a generic alternative to the medicine or product you're prescribing me? Are there any brochures or other printed material that I can take home with me? What websites do you recommend? In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment. What to expect from your doctor Your doctor is likely to ask you a number of questions. Your doctor may ask: When did you begin experiencing symptoms? Have your symptoms been continuous or occasional? How severe are your symptoms? How does your partner describe your symptoms? Do you know if you stop breathing during sleep? If so, how many times a night? Is there anything that has helped your symptoms? Does anything worsen your symptoms, such as sleep position or alcohol consumption? What you can do in the meantime Try to sleep on your side. Most forms of Sleep apnea are milder when you sleep on your side. Avoid alcohol close to bedtime. Alcohol worsens obstructive and complex Sleep apnea. Avoid sedative medications. Drugs that relax you or make you sleepy can also worsen Sleep apnea. If you're drowsy, avoid driving. If you have Sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving at all. TESTS AND DIAGNOSIS Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Home sleep testing is gaining in popularity, because it's often easier for you and less expensive. Tests to detect Sleep apnea may include: Nocturnal polysomnography. During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. Home sleep tests. In some cases, your doctor may provide you with simplified tests to be used at home to diagnose Sleep apnea. These tests usually involve measuring your heart rate, blood oxygen level, airflow and breathing patterns. If you have Sleep apnea, the test results will show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may be able to prescribe a therapy without further testing. Portable monitoring devices don't detect all cases of Sleep apnea, so your doctor may still recommend polysomnography even if your initial results are normal. If you have obstructive Sleep apnea, your doctor may refer you to an ear, nose and throat doctor (otolaryngologist) to rule out any blockage in your nose or throat. An evaluation by a heart doctor (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central Sleep apnea. TREATMENTS AND DRUGS For milder cases of Sleep apnea, your doctor may recommend only lifestyle changes, such as losing weight or quitting smoking. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary. Treatments for obstructive Sleep apnea may include: Therapies Continuous positive airway pressure (CPAP). If you have moderate to severe Sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and Snoring. Although CPAP is the most common and reliable method of treating Sleep apnea, some people find it cumbersome or uncomfortable. Many people give up on CPAP, but with some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that's comfortable. Some people benefit from also using a humidifier along with their CPAP system. Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still Snoring despite treatment or begin Snoring again. If your weight changes, the pressure settings may need to be adjusted. Adjustable airway pressure devices. If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping. For example, units that supply bilevel positive airway pressure (BPAP) are available. These provide more pressure when you inhale and less when you exhale. Expiratory positive airway pressure (EPAP).This is the most recent treatment approved by the Food and Drug Administration (FDA). These small, single-use devices are placed over each nostril before you go to sleep. The device is a valve that allows air to move freely in, but when you exhale, air must go through small holes in the valve. This increases pressure in the airway and keeps it open. The device helped reduce Snoring and daytime sleepiness when compared to a sham device. And, it may be an option for some who can't tolerate CPAP. Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more reliably effective than oral appliances, but oral appliances may be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve Snoring and mild obstructive Sleep apnea. A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms. Surgery Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for those few people with certain jaw structure problems, it's a good first option. The goal of surgery for Sleep apnea is to enlarge the airway through your nose or throat that may be vibrating and causing you to snore or that may be blocking your upper air passages and causing Sleep apnea. Surgical options may include: Tissue removal. During this procedure, which is called uvulopalatopharyngoplasty (UPPP), your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing Snoring. However, it may be less successful in treating Sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic. Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) isn't a recommended treatment for Sleep apnea. Radiofrequency energy (radiofrequency ablation) may be an option for people who can't tolerate CPAP or oral appliances. Jaw repositioning. In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure, which is known as maxillomandibular advancement, may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success. Implants. Plastic rods are surgically implanted into the soft palate while you're under local anesthetic. This procedure may be an option for those with Snoring or milder Sleep apnea who can't tolerate CPAP. Creating a new air passageway (tracheostomy). You may need this form of surgery if other treatments have failed and you have severe, life-threatening Sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat. Other types of surgery may help reduce Snoringand contribute to the treatment of Sleep apnea by clearing or enlarging air passages: Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum) Surgery to remove enlarged tonsils or adenoids Treatments for central and complex Sleep apneamay include: Therapies Treatment for associated medical problems.Possible causes of central Sleep apneainclude heart or neuromuscular disorders, and treating those conditions may help. For example, optimizing therapy for Heart failuremay eliminate central Sleep apnea. Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central Sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs. Continuous positive airway pressure (CPAP). This method, also used in obstructive Sleep apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. CPAP may eliminate Snoring and prevent Sleep apnea. As with obstructive Sleep apnea, it's important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made. Bilevel positive airway pressure (BPAP).Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, BPAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to assist the weak breathing pattern of central Sleep apnea. Some BPAP devices can be set to automatically deliver a breath if the device detects you haven't taken one after so many seconds. Adaptive servo-ventilation (ASV). This more recently approved airflow device learns your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing. ASV appears to be more successful than other forms of positive airway pressure at treating central Sleep apnea in some people. Along with these treatments, you may read or hear about different treatments for Sleep apnea, such as implants. Although a number of medical devices and procedures have received Food and Drug Administration clearance, there's limited published research regarding how useful they are, and they aren't generally recommended as sole therapies. LIFESTYLE AND HOME REMEDIES In many cases, self-care may be the most appropriate way for you to deal with obstructive Sleep apnea and possibly central Sleep apnea. Try these tips: Lose excess weight. Even a slight loss in excess weight may help relieve constriction of your throat. Sleep apnea may be cured in some cases by a return to a healthy weight. If you don't already have a weight-loss program, talk to your doctor about the best course of action for weight loss. Exercise. Getting 30 minutes of moderate activity, such as a brisk walk, most days of the week may help ease obstructive Sleep apnea symptoms. Avoid alcohol and certain medications such as tranquilizers and sleeping pills. These relax the muscles in the back of your throat, interfering with breathing. Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top. Keep your nasal passages open at night.Use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using any nasal decongestants or antihistamines because these medications are generally recommended only for short-term use. Stop smoking, if you're a smoker. Smoking worsens obstructive Sleep apnea. ALTERNATIVE MEDICINE Most alternative medicines for Sleep apnea haven't been well studied. Acupuncture has shown some benefit in studies, but it still needs more study. Although it may be used in conjunction with standard treatments, acupuncture should not replace them. Talk to your doctor about any alternative treatment approaches you're considering. Some of the most common homeopathic medicines for Sleep Apnea are- Arsenicum Album: Arsenicum album is often prescribed for individuals who have breathing difficulties at night and is considered for people with a fearful, tense and agitated response to illness.  Lachesis: Lachesis is a remedy prescribed for conditions that worsen at night. This medicine is designed for people who are typically fearful and anxious, but also prone to jealousy and excessive talking.  Sulphur: By reputation, sulphur is a commonly prescribed homeopathic remedy, especially for nighttime congestion and sweating. Homeopathic sulphur combats a wheezy cough and congested head, both of which are suffered in sleep apnea.  Spongia Tosta: This remedy for croup may help congestive sleep apnea sufferers as it treats respiratory symptoms that worsen when lying down. 

B M I n O B E S I T Y BMI is commonly used to diagnose overweight and obesity, often in conjunction with measurement of waist circumference. Leading guidelines, such as those produced by the American Association for Clinical Endocrinology (AACE),the UK National Institute for Health and Care Excellence (NICE),[2] and the European Association for the Study of Obesity (EASO),consider a BMI of 30 kg/m2 to be the threshold for obesity, and describe 3 classes of obesity, rising in severity from low-risk/class 1 (between 30.0 and 34.9 kg/m2), through moderate-risk/class 2 (between 35.0 and 39.9 kg/m2), to high-risk/class 3 (≥40.0 kg/m2). Lower BMI thresholds may be recommended for black African, African-Caribbean, and Asian (particularly South Asian) populations in order to trigger action to reduce the risk for comorbid conditions. For example, in the NICE guidelines, a BMI of 23.0 kg/m2 in these groups indicates increased risk for type 2 diabetes mellitus (T2DM), and 27.5 kg/m2 indicates a high risk. Obesity is a global epidemic and its prevalence more than doubled between 1980 and 2014. In 2014, more than 1.9 billion adults (≥18 years), which is 39% of all adults, had overweight. More than 600 million had obesity, representing 13% of all adults. The fundamental cause of obesity and overweight is an imbalance between calories consumed and expended. Changes in dietary and physical-activity patterns worldwide have led to the increase in obesity and overweight.Obesity is a serious chronic condition that is associated with multiple comorbidities and decreased life expectancy.An increase in BMI increases a person's risk for cardiovascular disease (CVD), and obesity is an independent risk factor for CVD.It also increases the risk for T2DM; fatty liver disease; musculoskeletal disorders, in particular osteoarthritis; and some cancers, including breast, colon, kidney, and pancreatic cancer.Higher BMIs are also associated with cognitive/mood disorders, obstructive sleep apnea, gallstones, and gastroesophageal reflux. Classes 2 and 3 obesity are associated with significantly higher all-cause mortality than class 1 obesity and normal weight.Other factors, such as waist circumference, also contribute to the increased risk for obesity-related disease. As well as fat accumulation, fat distribution is related to obesity-related mortality and morbidity. Central obesity, also known as the apple shape, confers a higher risk than general obesity for several chronic diseases.In recent years, there has been a broadening of focus from BMI alone, so that the management of obesity-related comorbidities is also a priority  Physical-activity counseling is an integral part of obesity management, but would not be effective on its own. EASO guidelines recommend that pharmacological therapy is considered in patients who are overweight or who have class 1 obesity if they also have comorbidities.  Treatment guidelines recommend that the first stage in managing patients with obesity is to assess their views of their weight and the diagnosis, as well as the possible reasons for weight gain. Failure to engage patients and to convince them of the benefits of lifestyle interventions aimed at weight loss is likely to result in the lifestyle interventions being less effective. Therefore, this is an important first step. Eating patterns and physical-activity levels should be explored, as well any beliefs about diet, exercise, and weight gain that may be unhelpful to the patient. The physician should find out if the patient has already tried to lose weight and how successful these efforts were. They should assess the patient's confidence and willingness to engage in a weight-loss program. The health and other risks of obesity should be explained, as well as the benefits of weight loss and increasing physical-activity levels. The physician should be aware that a patient's feelings about obesity and other health problems, such as surprise or denial, may reduce their willingness or ability to change. For this reason, it may help to stress that obesity is a clinical condition with specific implications for health, rather than something that focuses on how a patient looks. It has reported a divergence in the perception of obesity between people with obesity and the clinicians treating them. For example, 65% of people with obesity consider obesity to be primarily a lifestyle disease and 44% think it is possible to have obesity and be healthy, compared with 88% and 4%, respectively, for clinicians. Barriers can be motivational, such as lack of willpower, emotional/personal, such as eating habits, or practical/systemic, such as medication costs or lack of support services. A comprehensive lifestyle intervention is a fundamental part of the management of obesity. This consists of lifestyle/behavioral training, a dietary calorie-reduction plan, and increased physical activity.When developing a weight-loss plan for a patient, the main requirement is that total energy intake is less than total energy expenditure.This will help address the imbalance of energy regulation that characterizes obesity. Obesity develops when the body's weight and energy regulatory mechanisms do not work properly, leading to an elevated body fat "set point," ie, the amount of fat the body wants to retain. The energy intake behavior of an individual is determined by whether he or she is at, above, or below the set point. Diets with a daily deficit of 600 kcal, leading to a 5% to 10% reduction in current body weight over 6 months, are considered to be realistic and have proven health benefits.Lower-calorie diets with an intake of 800 to 1600 kcal/day can be considered, but they are less nutritionally complete. Very low-calorie diets (<800 kcal/day) should not be routinely used to manage obesity. Evidence from systematic reviews suggests that, although initial weight loss is more rapid with very low-calorie diets, weight change after 1 year is not very different from comprehensive approaches. Physical activity is part of a comprehensive lifestyle intervention. Although it may have only modest effects on weight loss, it will bring other benefits, such as a reduction in the risk for T2DM and CVD.Physical activity also helps to preserve fat-free mass during weight loss and promote weight maintenance. People who have had obesity but have lost weight may need to do 60 to 90 minutes of activity per day to avoid regaining weight. Weight loss is difficult to achieve for most patients with obesity because a desire to restrict caloric intake is counteracted by biological responses to weight loss. The reduction in energy expenditure and increase in appetite that occur after weight loss are associated with changes in several hormones. Some of the hormonal changes result in altered physiology that leads to weight gain, whereas other changes lead to improvements in hormonal systems as the patient gets closer to a healthy weight.  Weight-loss medications aim to reinforce the patient's efforts to change eating behaviors and produce an energy deficit.Most promote weight loss through their effects on appetite -- increasing satiety and decreasing hunger. It is possible that satiety signaling and inhibitory control are weaker in people who are prone to obesity. Many treatment guidelines recommend that weight-loss medication is considered for patients with a BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 if they also have 1 or more comorbidities and a history of failure to lose weight.The inclusion of comorbidities in the criteria reinforces the benefits of weight loss for people with obesity-related disease. ORLISTAT Unlike most weight-loss medications, orlistat is a reversible gastric and pancreatic lipase inhibitor that blocks absorption of 30% of ingested fat from a 30% fat diet when taken at the recommended dosage (120 mg 3 times per day). It is approved for use in adults and adolescents, is considered one of the safest drugs in its category, and is available in most countries around the world. However, it has well-documented GI adverse events, such as fecal leakage, which limit its popularity. NALTREXONE/BUPROPION This is a sustained-release combination of an opioid receptor antagonist (naltrexone) and a noradrenaline reuptake inhibitor (bupropion). Naltrexone has a minimal weight-loss effect on its own,but it acts synergistically with bupropion to stimulate central melanocortin pathways and antagonize inhibitory feedback loops that limit weight reduction. This leads to improved energy expenditure and a reduction in appetite.The maximum total daily dose is 32 mg naltrexone/360 mg bupropion.Naltrexone/bupropion is associated with increased BP, so it should be avoided in patients whose hypertension is not controlled, and BP should be monitored in the initial phase of therapy. The most common adverse events are nausea, headache, vomiting, anxiety, and insomnia. The risk for GI events can be minimized by gradual titration. Other anti obesity drug is Liraglutide but this and Naltrexone are not available n approved in India by FDA .Only Bupropion is available but at present is used in smoking cessation n in depression.

POLYCYSTIC OVARIAN SYNDROME Signs and symptoms The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following: ■ Hirsutism ■ Infertility ■ Obesity and metabolic syndrome ■ Diabetes ■ Obstructive sleep apnea Diagnosis On examination, findings in women with PCOS may include the following: ■ Virilizing signs ■ Acanthosis nigricans ■ Hypertension ■ Enlarged ovaries: May or may not be present; evaluate for an ovarian mass. Testing Baseline screening laboratory studies for women suspected of having PCOS may include the following: ■ Thyroid function tests [4] (eg, TSH, free thyroxine) -■ Serum prolactin level [4] ■ Total and free testosterone levels ■ Free androgen index [4] ■ Serum hCG level ■ Cosyntropin stimulation test ■ Serum 17-hydroxyprogesterone (17-OHPG) level ■ Urinary free cortisol (UFC) and creatinine levels ■ Low-dose dexamethasone suppression test ■ Serum insulin-like growth factor (IGF)–1 level Other tests used in the evaluation of PCOS include the following: ■ Androstenedione level ■ FSH and LH levels ■ GnRH stimulation testing ■ Glucose level ■ Insulin level ■ Lipid panel Imaging tests The following imaging studies may be used in the evaluation of PCOS: ■ Ovarian ultrasonography, preferably using transvaginal approach ■ Pelvic CT scan or MRI to visualize the adrenals and ovaries Management Lifestyle modifications are considered first-line treatment for women with PCOS. Such changes include the following ... ■ Diet ■ Exercise ■ Weight loss Pharmacotherapy Pharmacologic treatments are reserved for so-called metabolic derangements, such as anovulation, hirsutism, and menstrual irregularities. First-line medical therapy usually consists of an oral contraceptive to induce regular menses. If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. First-line treatment for ovulation induction when fertility is desired are letrozole or clomiphene citrate. ■ Medications used in the management of PCOS include the following: ■ Oral contraceptive agents (eg, ethinyl estradiol, medroxyprogesterone) ■《Antiandrogens (eg, spironolactone, leuprolide, finasteride) ■ Hypoglycemic agents (eg, metformin, insulin) ■ Selective estrogen receptor modulators (eg, clomiphene citrate) ■ Topical hair-removal agents (eg, eflornithine) ■ Topical acne agents (eg, benzoyl peroxide, tretinoin topical cream (0.02–0.1%)/gel (0.01–0.1%)/solution (0.05%), adapalene topical cream (0.1%)/gel (0.1%, 0.3%)/solution (0.1%), erythromycin topical 2%, clindamycin topical 1%, sodium sulfacetamide topical 10%) Surgery Surgical management of PCOS is aimed mainly at restoring ovulation. Various laparoscopic methods include the following: ■ Electrocautery ■ Laser drilling ■ Multiple biopsy

A obese female with history of day time sleepiness presented with sudden onset breathlessness, cough with expectoration and drowsiness since 2 days....She is having no history of any comorbidity or drug intake....Vitals - BP- 150/90 PR- 108/min spO2- 82% ....comment on the approach to this patient