IntroductionThe prevalence rates of overweight and obesity are increasing rapidly in both developed and developing countries. Previously, overweight and obesity were considered primarily problems of developed countries. However, due to lifestyle changes and urbanization, it is now apparent that developing countries are also faced with the same issues. Policymakers in developing countries have not paid much attention to the problem of excessive weight gain. Obesity contributes to a variety of serious chronic diseases, and thus to a large health burden. Indonesia is a large and populous country and is one of the economically fast growing nations of Asia, and has undergone rapid urbanization including a move of traditional food systems towards a modern supply chain. Recent surveys have shown that obesity rates are also increasing in Indonesia. Based on the National Basic Health Research in 2007, the prevalence of overweight and obesity, as determined by body mass index (BMI), were 8.8% and 10.3%, respectively. The cumulative prevalence of overweight and obesity was higher in females than in males (23.8% versus 13.9%). Obesity was observed to be more prevalent in urban areas. Furthermore, central obesity, as determined by waist circumference, was present in 18.8%, and was more commonly observed in females (29% versus 7.7% in males) and in urban area dwellers (23.6% versus 15.7% in rural areas). Similarly, the Indonesian Family and Life Survey (IFLS) of the Rand Institute, conducted in 1993, 1997, 2000 and 2007, showed that the mean BMI values among Indonesian adults has notably increased Indonesian women had higher BMIs than men, and the difference of BMIs between genders increased from 1993 onward. Average BMI levels were higher in urban compared to rural areas. However, the rate of increase in BMI over time among rural dwellers was higher compared to urban area residents. Data from the IFLS represented 83% of Indonesian population; a few remote areas were not included in the survey. In 2006, performed an epidemiologic study in Jakarta, the capital city of Indonesia (unpublished data). The survey included 1591 subjects aged 25 to 65 years, of which 41% were male. The prevalence of obesity and central obesity were 52% and 53%, respectively. In addition, the prevalence of obesity increased with age in both genders. There was a decreasing trend noted after the age of 60.Deep brain stimulation involves implanting a device called a neurostimulator, which delivers tiny electrical signals to specific areas of the brain. DBS is routinely used to control the symptoms of movement disorders, such as Parkinsons disease and dystonia.In DBS, slender leads tipped by a row of electrical contacts deliver mild electric pulses to the brain. The leads are connected to a compact, battery-operated pulse generator, similar to a heart pacemaker.The goal of electrical brain stimulation is to rebalance the brain's neural circuits by influencing when nerves fire and neurotransmitter chemicals are released. According to theNational Institutes of Health, deep brain stimulation is a well-tolerated procedure that is both individually programmable and reversible. However, potential risks include infection, bleeding in the brain, and an allergic reaction to the device components.Working with collaborators at Pennington Metabolic Center in Baton Rouge, La., Oh and colleagues arranged for the trial patients to undergo detailed metabolic studies over the course of three days.The patients rested comfortably in enclosed metabolic chambers where their oxygen consumption and carbon dioxide release were analyzed. Each patients normal resting metabolism was measured and tested against a range of neurostimulation settings.

Based on the results, the researchers chose a DBS setting that would have the greatest effect on raising each patients resting metabolic rate. The metabolic studies proved useful to guide optimal settings (of neurostimulation).The scientists found no negative effects of DBS on the patients' psychological or mental function.Current management on obesityDietsTheDietary Guidelines for Americans(along with My Pyramid) provides one example of a low-fat (LF) eating plan.1TheDietary Guidelinesare based on evidence that eating a LF (20-35%) diet helps manage weight, promote health, and reduce the risk of chronic disease. The guidelines include recommendations for foods to reduce (i.e., saturated and trans fat, cholesterol, sodium, added sugar, refined grains, alcohol) and foods to increase (i.e., fruits, vegetables, whole grains, low-fat dairy and protein foods, oils) in order to maximize the nutrient content and health promoting potential of the diet. Other examples of a LF diet are the DASH diet and those recommended by the American Diabetes Association2, American Heart Association3, and American Cancer Society4, as well as commercial programs like Weight Watchers.Efficacy, health effects, and sustainabilityLow-fat diets are the best studied of all dietary approaches to weight loss. Three large, multi-center, randomized studies (i.e., the PREMIER trial, Diabetes Prevention Program, and the Finnish Diabetes Prevention study) have demonstrated that greater weight loss is achieved in groups consuming LF diets compared to controls receiving standard lifestyle recommendations.5Furthermore, they suggest that consumption of a low-fat, low calorie diet, in the context of intensive group and/or individual counseling, has positive effects on comorbid conditions as long as they are followed. A more detailed description has been reported previously.More recent studies have reported similar findings. The Look Ahead Trial6was a large multicenter, randomized clinical trial that compared the effects of an intensive lifestyle intervention (ILI) to diabetes support and education (DSE) on the incidence of major cardiovascular disease (CVD) events in overweight or obese individuals with type 2 diabetes. Participants in the ILI group were assigned a calorie restricted LF diet, received frequent behavioral therapy, and extended contact. Those in the DSE group were given standard instruction on 3 occasions each year for eating a healthy diet and engaging in physical activity. Weight loss in the ILI group was significantly greater than the DSE group each year over the course of four years, with maximal weight loss occurring at 1 year, Individuals in the ILI group also displayed greater improvements in hemoglobin A1C(HbA1C), blood pressure, high density lipoprotein (HDL), and triacylglycerides (TAG) over the course of the study. Other studies prescribing LF diets with treatment phases ranging from 6 months to 12 months have reported weight losses of approximately 6-11 kg after 6 and 12 month 4-5 kg after 24-36 months, and 4.7% initial body weight at 48 months.The Woman's Health Initiative Dietary Modification trial showed that following a LF diet without instruction for calorie restriction can help to maintain weight loss slightly better than following a diet higher in fat.12Taken together, these findings suggest that a LF diet is an effective weight control strategy in the short- and long-term as long as it is followed.

Weight Loss Outcomes of Studies 6 Months or Greater in DurationAdherence to a calorie controlled diet appears to be one of the biggest barriers to the long-term success of weight loss maintenance. LF eating is not immune to poor long-term adherence. Researchers have investigated various strategies, from varying the percentage of fat in the diet to matching diets with food preferences, in an attempt to promote better long-term dietary adherence. One studycomparing weight loss and CVD risk factors in individuals consuming calorie controlled 20% or 30% fat diets showed that although both diets produced a similar amount of weight loss after 7 months, weight loss was maintained better and CVD risk factors were reduced more after 14 months in those following the 30% fat diet. It appears that intake was more restrictive in the 20% fat diet group, making it more difficult to follow over the long-term and resulting in greater weight regain. A limited number of studies have investigated the effects of matching treatment preferences with weight loss outcomes.A recent studyfound that whether individuals were randomized to their preferred LF diet or not (i.e., standard or lacto-ovo vegetarian), they lost similar amounts of weight after 6 months; however, differences in weight regain patterns emerged after 6 months. Curiously, those who were assigned their preferred diet began regaining weight sooner (i.e., 6 vs. 12 months) and regained more weight (i.e., 4.5% vs. 2.1%) at 18 months than those who were not assigned to their preferred diet. Similar findings were recently reported for both LF and low carbohydrate diets.Borradaile et al found that the group assigned their preferred diet lost less weight (-7.7 kg) than the group who did not receive their preferred diet (-9.7 kg) or who did not report a strong preference at baseline (-11.2 kg).16Given this seemingly counterintuitive finding, it may be useful for future studies to elaborate on preference (e.g., is their preference based on a preferred way of eating or on an alternative to their preferred way of eating).ExerciseThe following general description of fitness guidelines and exercise prescription serves as a framework for a more detailed discussion of obesity treatment exercise recommendations. Health-related physical fitness includes the following 3 components: cardiorespiratory fitness, body composition, and muscular fitness.The ACSM and the Centers for Disease Control and Prevention guidelines suggest 30 minutes or more of moderate physical activity on most, and preferably all, days of the week.Fitness training follows the fundamental physiologic principles of overload and specificity, where physiologic adaptation requires a progressive increase in exercise stimuli specific to the muscles involved and the type of exercise.n exercise prescription defines the mode, intensity, duration, and frequency of exercise activities. A broad fitness program that uses most major muscle groups transfers the training effect to vocational and recreational activites.5Components of a particular training session include the warm-up, conditioning phase, and cooldown. The 5- to 20-minute warm-up prepares muscles for more vigorous exercise and may reduce injuries. Stretching is recommended following the warm-up and is thought to reduce muscular injury. The conditioning phase involves a cardiorespiratory or resistance training session lasting 20 to 60 minutes. This is followed by a cooldown, which may attenuate postexercise hypotension, allow better dissipation of body heat, remove lactic acid, mitigate the rise in potentially arrhythmogenic catecholamines, and possibly reduce the risk of cardiac events during the recovery period.Cardiorespiratory conditioning uses large muscle groups in rhythmic dynamic activity. Examples of this mode include running, jogging, cycling, swimming, walking, and aerobic machines. Cardiorespiratory fitness is defined by aerobic capacity or by Vo2max. Training intensity is estimated based on calculations using percentages that depend on one's overall level of fitness and stage of progression within an exercise program. Various methods of determining Vo2maxand estimating the training zones are based on direct measurement or estimations of the heart rate, as heart rate and oxygen consumption per unit time (Vo2) are linearly related.Direct measurement of Vo2maxrequires special equipment and expertise. Therefore, heart rate estimations, although prone to inaccuracy, are more practical for routine use. Recommended training ranges vary from 40% or 50% to 85% of oxygen uptake reserve (Vo2reserve) or heart rate reserve or from 64% or 70% to 94% of maximum heart rate.5The Vo2reserve is the difference between Vo2maxand resting Vo2, and the heart rate reserve is the difference between maximum heart rate and resting heart rate. The lower end of these scales represents threshold values for physiologic stimulation, and the higher rates represent adapted training zones for accustomed individuals. Exercise intensity above the upper limit becomes anaerobic, does not provide additional benefit, and may induce injury or performance retrogression.The duration of exercise sessions should be 20 to 60 minutes. Debate exists concerning the value of performing exercise in shorter cumulative bouts throughout the day. The frequency of cardiorespiratory exercise sessions should be 3 to 5 days per week. Additional benefit derived by training beyond 6 days per week is minimal and is complicated by higher injury rates. Progression is a concept that describes a participant's adaptation over time, necessitating increased exercise volume stimulus, where volume is a function of intensity, frequency, and duration. Progression consists of initial, improvement, and maintenance stages. In general, intensity and duration are less in the initial stage, where one becomes accustomed to exercising and develops orthopedic tolerance. The initial phase occurs over the first 6 weeks or so of a new program. The improvement stage follows for the next 4 to 8 months and includes a gradual increase in overall exercise stimulus. Increases in duration or frequency should precede increases in intensity. Finally, a long-term maintenance stage focuses on continued participation in enjoyable and varying exercises.Resistance training is recommended as part of an overall fitness program, as such training alone does little to increase Vo2max, expends only moderate amounts of calories, and marginally affects the resting metabolic rate.The benefits of resistance training include bone density improvement and improvement in the performance of activities of daily living. Sets of 8 to 12 repetitions, the last of which results in volitional fatigue, increase muscular strength and endurance. A typical resistance training exercise prescription includes 8 to 10 separate exercises that involve major muscle groups of hips, thighs, legs, back, chest, shoulders, arms, and abdomen. One set of each exercise is deemed adequate performed on 2 or 3 nonconsecutive days per week. The value of the traditional practice of multiple sets per exercise has been disputed.5Resistance training follows a phased progression similar to cardiovascular fitness training, but the variable is increasing resistance.TreatmentMedicationsA variety of over-the-counter and prescription weight loss drugs are available. Some people find these drugs help curb their appetites. Studies show that patients on drug therapy lose around 10 percent of their excess weight, and that the weight loss plateaus after six to eight months. As patients stop taking the medication, weight gain usually occurs.Weight loss drugs, approved by the U.S. Food and Drug Administration (FDA) for treating obesity, include:1. Beta-methyl-phenylethylamine (Fastin) This is a stimulant that increases fat metabolism.1. Orlistat (Xenical) This drug works by blocking about 30 percent of dietary fat from being absorbed. Alli is a lower-dose, over-the-counter formula of the same medication.1. Phentermine Phentermine, an appetite suppressant, has been available for many years. It is half of the "fen-phen" combination that remains available for use. The use of phentermine alone has not been associated with the adverse health effects of the fenfluramine-phentermine combination.1. Sibutramine (Meridia) This is an appetite suppressant approved for long-term use.Medications are an important part of the morbid obesity treatment process but weight-loss drugs can have serious side effects. We recommend that you visit a certified health care professional who can prescribe appropriate medications. Before insurance companies will reimburse you for weight-loss surgery, you must follow a well-documented treatment plan that typically includes medications.SurgeryMany people ,who are morbidly obese and who have been unsuccessful in losing and keeping off the weight, opt for bariatric or weight-loss surgery.Bariatric surgery, which involves sealing off most of the stomach to reduce the quantity of food you can consume, can be an effective means for morbidly obese people to lose weight and maintain that weight loss.To be considered for weight-loss surgery, you must meet at least one of the following qualifications:1. Be more than 100 pounds over your ideal, recommended body weight.1. Have a body mass index (BMI) of 40 or higher (20 to 25 is considered a normal). BMI is a number based on both your height and weight. Surgery may be considered with a BMI as low as 35 if your doctor determines that there's a medical need for weight reduction and surgery appears to be the only way to accomplish the targeted weight loss. To qualify for surgery, you must complete a medical and psychological pre-evaluation process, and show how that you are committed to long-term, follow-up care after surgery. Most surgeons require that you demonstrate serious motivation and a clear understanding of the extensive dietary, exercise and medical guidelines that must be followed for the remainder of your life.The UCSF Bariatric Surgery Center has performed surgical weight loss procedures since 1996. Various procedures involve different risks and advantages. During your initial consultation, your surgeon will discuss in detail the different options available to you, along with their associated risks and advantages.The most common bariatric surgeries are "restrictive" procedures that reduce the size of the stomach and limit the calories you can consume.Neurosurgery and weight modulationAnatomy and animal studiesThe rationale for a clinical application of VMH-DBS to treat morbid obesity and severe eating disorders is based on an extensive literature demonstrating the regulation of food intake and satiety by the hypothalamus, and the modulation of those functions by hypothalamic electrical stimulation.Consideration of a low frequency VMH-DBS clinical trial can be advanced upon demonstration of its efficacy and safety in preclinical studies in which aspects of the clinical procedures have been modeled. The primary goals of this research were to adapt human neurosurgical methods and DBS instrumentation for use in a large animal obesity model and then evaluate the effects of VMH-DBS on weight modulation and behavior. Our results showed that in the Gttingen minipig under conditions of extra calorie intake, the continuous delivery of low frequency (50 Hz) DBS in the ventral hypothalamus region was associated with a lower weight gain compared to that in animals not receiving DBS.Prior Electrical Stimulation Studies in RodentsIn the early 1960's , it was recognized that electrical stimulation in the range of 60 Hz of the VMH region of the rat suppressed feeding in animals that were fasted for as long as 5 days. In later studies, VMH stimulation at 5060 Hz resulted in inhibition of feeding, reduced food intake, and/or reduced weight gain. Increases in lipolysis were also observed which were attributed to activation of sympathetic pathways to adipose tissues insofar as sympathetic denervation impaired or abolished the electrical stimulation response. Increases in metabolic rate and modulation of energy expenditure were also characterized for this 5060 Hz range of electrical stimulation. Those results suggested a double effect of electrical stimulation on energy balance. First, it favored a lipolytic effect by the utilization of body fat stored in adipose tissue and that resulted in an anorexigenic effect as characterized by a reduction in food ingestion as a de-novo energy source. Collectively, these studies have been invaluable for defining regional effects of hypothalamic electrical stimulation, albeit with the caveat that most studies were short term (days to weeks) and were conducted in non-obese animals.DBS Applications in the HypothalamusDBS represents the clinical counterpart of electrical stimulation as used in animal studies. Generally, DBS applications in humans are classified bimodally by frequency range - either high (100185 Hz) or low (