Dr Praveen Ramachandra
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OBESITY

General Description of Obesity and its associated conditions

Obesity is a chronic condition defined by an excess amount of body fat. Body mass index (BMI) is a term used to describe and calculate a person's body weight, taking into account one's height to determine a person's obesity or general overweight/underweight condition. The BMI equals a person’s weight in kilograms divided by height in meters squared (BMI = kg/m2). For adults, a BMI of 30 or more is considered a state of obesity and a BMI greater than 40 is considered to be a state of severe obesity.

 

Obesity is more than a cosmetic concern for it is associated with a number of diseases that can harm person’s health. Obesity increases the risk of developing a number of chronic disease including: adult onset diabetes, high blood pressure, high cholesterol, heart attacks, stroke, chronic liver disease, congestive heart failure, cancer, gallstones, gout, osteoarthritis, sleep apnea and pickwickian syndrome.

The balance between calorie intake and energy expenditure determines a person’s weight. When intake of calories exceeds calories burned by the body, this net positive energy is stored as fat, resulting in weight gain and potential obesity. Likewise, when there is a net negative calorie balance this result in weight loss. The most common causes of obesity are over-eating and lack of physical activity. At present, we know that there are many factors that contribute to obesity such as, genetics, over-eating, slow metabolism, physical inactivity, medications, psychological factors and certain diseases, some of which have a genetic component.

Concern over obesity is directed not only at how much fat a person has but also where that fat is located in the body. The pattern of body fat distribution differs in men and women. Women typically collect fat in their hips and buttocks, giving their figures a pear shape. Men, on the other hand, usually collect fat around the belly, giving them more of an apple shape. Fat located in the belly or visceral cavity is considered more harmful than fat located elsewhere and is considered to be closely linked to many disease associated with obesity. The measurement used to determine body fat distribution - and by extension, risk of obesity - is called the waist-to-hip ratio. To find out a person’s waist to hip ratio, measure the waist at its narrowest point, and then measure the hips at the widest point. Divide the waist measurement by the hip measurement. Women with waist-to-hip ratios of more than 0.8 and men with waist-to-hip ratios of more than 1.0 are apples with excessive visceral fat, thus at further risk from potential complications stemming from obesity.

In a world where obesity-increasingly occurring in children and teenagers--is more prevalent than ever, the need to educate about weight management is one of the most important concerns all people should have about their health.

 

Overweight

Weight is higher than what is expected for height, but not high enough to be called obesity. BMI is between 25 and 30. Being overweight may be associated with all medical conditions which are associated with obesity.

 

·        Obesity

Defined as BMI > 30

 

·        Severe Obesity

Defined by BMI > 35

 

·        Morbid Obesity

Defined by BMI > 40 

                                                                                                                     

                                                                                                                              Fig 1: Degrees of obesity

Patient Education on Weight Management

The Department of Endocrinology Diabetes and Metabolism at the DiaPlus Clinic offers a comprehensive medical weight management program to help overweight individuals choose the best medical weight loss plan to assist them in losing weight as well as helping them live a healthier life. Weight loss and maintenance can be challenging but the plans are tailored the each person’s individual needs. Our program includes medical weight management, nutritional therapy, behavioral modification and psychological support also if needed we suggest for bariatric surgery.

Obesity is a complex, multi-factorial chronic disease involving:

·        Environmental (social and cultural): The tendency toward obesity is a result of our environment i.e. lack of physical activity along with high-calorie, low-cost foods. Home, work, school, and even the community can inhibit a healthy lifestyle.

·        Genetic: Hereditary plays a large role in determining how susceptible people are to overweight and obesity. Genes also influence how the body burns calories for energy and stores fat.

 

·        Physiologic, metabolic, behavioral (eating too many calories while not getting enough exercise) and psychological components: Behavioral changes brought on by economic development, modernization and urbanization have been linked to the rise in global obesity.

 

Environmental factors are the main cause to overweight and obesity but at the same time, they provide the greatest opportunities for prevention and treatment.

Calculating BMI

Body Mass Index (BMI) is a measurement tool used to determine excess body weight. Overweight is defined as a BMI of 25 or more, obesity is 30 or more, and severe obesity is 40 or more. 

 

Obesity Related Health Conditions

The morbidity and mortality risk from being overweight is proportional to its degree. Individuals with morbid obesity, therefore, have the highest risk for developing numerous diseases that often reduce mobility and quality of life due to their excess weight. In particular, type 2 diabetes, gallbladder disease and osteoarthritis have been found to increase concurrently with higher BMI. Premature death, a 20-year shorter life span, has also been found in individuals with morbid obesity. All of the systems that make the body function are affected by morbid obesity.


·        Type 2 diabetes

·        Gallbladder disease and gallstones

·        Liver disease

·        Osteoarthritis, a disease in which the joints deteriorate. This is possibly the result of excess weight on the joints.

·        Gout, another disease affecting the joints

·        Pulmonary (breathing) problems, including sleep apnea in which a person can stop breathing for a short time during sleep

·        Reproductive problems in women, including menstrual irregularities and infertility

·        Gastro-esophageal reflux/heartburn

·        Hypertension

·        Heart Disease

·        Depression

·        Psychological disorders/social impairments

·        Urinary Stress Incontinence

·        Obesity is also linked to higher rates of certain types of cancer. Obese men are more likely than non-obese men to die from cancer of the colon, rectum, or prostate. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix, or ovaries


                                                                                                

                                                                                                                         Fig 2: Obesity related health risks


Weight Management - Special Procedures & Treatments

It is important to realize that obesity is a chronic condition much like diabetes and high blood pressure. Therefore, there are no quick fix treatment strategies. Many strategies that aim for rapid weight loss usually result in rapid weight regain. More than 95% of the people lose weight but, regain the weight within five years. Treatment strategies are not aimed at achieving ideal body weight, but instead at reducing obesity and the hazards that attend it. We know that even modest weight reduction can have great health benefits including: lowered blood pressure, reduced blood cholesterol levels, reduced risk of diabetes or improvement in diabetes control, decreased chance of stroke, heart disease and overall mortality. In summary, the goal in treatment of obesity is to achieve and maintain a “healthier weight”.

Treatment strategies for treating obesity include:

·        dietary modification performed by a trained nutritionist,

·        institution of an exercise regimen under the direction of a exercise physiologist

·        treatment of psychological conditions predisposing to weight gain, and institution of preventive measures to lower cardiovascular risk in subjects with     obesity

·        medication

·        surgery


                                                                                                   

                                                                                                       Fig 3: Strategies for obesity management

Exercise

Recent studies have shown that a sedentary lifestyle was a large contributor to obesity, despite dietary modifications. Physical activity and exercise helps burn calories, build muscle, burn fat, preserve weight loss, and include other health benefits such as:

·        improve blood sugar control

·        increase insulin sensitivity

·        reduce cholesterol levels

·        lower blood pressure

·        reduce abdominal fat

·        reduce risk for heart disease

Many of these health benefits can occur independently (with or without) achieving weight loss. Before starting an exercise program, talk to doctor about the type and intensity of the exercise program. However, general exercise recommendations include 30 minutes of moderate exercise 5-7 days of the week, preferably daily. Exercise should start slowly and progress gradually to avoid injury, excessive soreness or fatigue.

Diet

The first goal of dieting is to stop further weight gain. The next goal is to establish realistic weight loss goals. While the ideal weight is a BMI of 20-25, this is difficult to achieve for many people with obesity and morbid obesity. Rather a goal is set to lose 10% to 15% of baseline weight. Even modest weight reduction translates into substantial health benefits. General diet guidelines for achieving and maintaining a healthy weight include:

·        eating more nutritious foods that have low energy density

·        eating less energy dense foods

·        educating yourself in reading food labels, estimating calories and serving sizes

Carbohydrate restricted diets have been shown to result in rapid weight loss within 2 weeks largely due to reduced intake of calories rather than effects on appetite, satiety, or fluid shifts.

Medication

Medication treatment of obesity should be used only in patients who have health risks related to obesity. Medications should be used in patients with a BMI greater than 30 or in those with a BMI of greater than 27 who have other medical conditions (such as high blood pressure, diabetes, high blood cholesterol) that put them at risk for developing heart disease. Medications should not be used for cosmetic reasons. One class of medication used for weight control effects the sympathetic nervous system. These medications also decrease appetite and create a sensation of fullness by affecting neurotransmitters in the brain. Another class of drugs changes the metabolism of fat. However, one should contact a DiaPlus Clinic Endocrinologists to discuss the appropriateness of drugs for the treatment of obesity.

Surgery

The National Institute of Health consensus has suggested the following guidelines for patients considering obesity surgery:

·        Patients with a BMI of greater than 40.

·        Patients with a BMI of greater than 35 who have serious medical problems such as sleep apnea, that would improve with weight loss.