Obesity is a complicated health condition

OBESITY

Obesity is a chronic disease that is increasing in prevalence. World Health Organization has labelled Obesity as Epidemic. About 135 million Indians are obese, out of which 11 million are children. The prevalence of obesity in both men and women have doubled in the last two decades. By the year 2030, India will surpass US as far as childhood obesity is concerned. This epidemic is a time bomb for the future development of diabetes and its complications.

With all treatments available for obesity; weight loss initially slows and then it stops. This plateau effect arises when the natural mechanisms in the body come into play and stabilize weight, although at a lower level than the starting level. Stoppage of weight loss often prompts patients to think that they are cured and then they stop treatment only to regain weight later.

BODY MASS INDEX (BMI)

 

BMI

BMI is defined as weight in kilograms divided by the height in meters squared

Normal BMI is between 18 to 25 kg/m2.

BMI between 25 and 29.9 is defined as overweight

BMI higher than is classified as obese.

The waist circumference is a practical measure of central adiposity ( fat deposition), which is a more precise measure of visceral ( fat around the internal organs)fat. Waist circumference is a better predictor for risk of hypertension, dyslipidemia( high cholesterol) and metabolic syndrome as compared to BMI. Waist  circumference is measured by using a metal or non stretchable plastic tape. Measurement at the level of umbilicus ( navel)or at the mid point between lower rib and suprailiac crest are the two commonest locations for measurement. Waist circumference is a good method for following the clinical progress of weight loss

CAUSES OF OBESITY

1.Intrauterine factors: Children born to diabetic mothers and those who smoke increase their risk for increased body weight and diabetes later in life

2.Infants who are breast fed have reduced incidence of obesity in later life

3.Many drugs including drugs used for depression, blood pressure, steroids, and birth control pills are known to cause obesity

4.Diet: Large portion size of food, fat intake and use of sweetened drinks   have been implicated in causing obesity

  1. Physical inactivity: Low levels of physical activity such as watching television correlates with weight gain. Time spent in watching television corelates with percentage of overweight children and more television watched, the greater the risk of overweight and obesity.

6.Smoking: Smokers have low body weight and cessation of smoking leads to weight gain. Smoking reduces hunger and change the taste perception; smokers tend to eat less.

DISEASES ASSOCIATED WITH OBESITY

1.DIABETES: The risk of diabetes rise as BMI increases and is particularly high when BMI is more than 30kg/m2

2.CHOLESTEROL DERANGEMENTS: Patients with obesity have high levels of bad cholesterol and low levels of good cholesterol

3.HEART DISEASES: Obesity increases the risk of heart failure. An increase of BMI by 1.1kg/m2 increases the risk for major heart diseases by 6 %

4.Hypertension: Blood pressure is often increased in obese individuals. For each fall of 1mmHg in diastolic blood pressure, the risk of heart attack decreases by 2-3 %

5.KIDNEY DISEASES: Obesity may lead to increased incidence of kidney stones and kidney failure

6.GALL BLADDER DISEASE: Gall stones formation is high in obese patients , may be due to high levels of cholesterol which is more in obese individuals

  1. LIVER DISEASE: Liver becomes fatty with obesity and can lead to end stage liver disease in which patients have bleeding from mouth, jaundice, fluid in abdomen and may become unconscious. If increased fat in liver is suspected, an ultrasound of the liver is better than blood tests
  2. REFLUX DISEASE: Overweight is a contributing factor for reflux. Inflammation and cancer of esophagus (food pipe) is associated with obesity

9.CANCER: Obese men are at increased risk of cancer of large intestine and prostate and women are at increased risk of cancer of gall bladder and reproductive organs

10.ENDOCRINE EFFECTS: A variety of endocrine changes are associated with obesity including Polycystic ovarian disease (PCOD)

  1. SLEEP APNEA: In this disease the capacity of the lungs decreased and can lead to stoppage of breathing. People with apnea have increased incidence of snoring. It is seen more in men. Various factors like increased neck circumference, fat deposition in the pharynx cause sleep apnea.
  2. OSTEOARTHRITIS of knees and ankles is directly related to the trauma associated with the excessive body weight. Even non weight bearing joints can be affected due to effects of obesity on bone cartilage and bone metabolism.

13.SKIN CHANGES: Several skin changes are associated with excessive weight. Scratch marks, pigmentation in the folds of neck and knuckles occur in obese individuals

14.Psychosocial  dysfunction : Obesity is a stigma both in children and adults. Individuals are disapproved by public regarding their fatness. Overweight children have a negative self image and a significant decrease in physical and social functioning compared with normal weight children. Overweight women are at increased risk of psychological dysfunction because of increased society pressure on women to be thin.

BENEFITS OF WEIGHT LOSS

  1. Weight loss improves a persons outlook. It reduces the risk of death in obese patients who are treated
  2. Weight reduction reduces the risk of diseases that result from obesity
  3. Reduction of blood pressure is achieved by weight loss. The risk of developing diabetes is also reduced , so is better control of diabetes achieved
  4. Snoring,sleep apnea improve a large extent with weight loss.
  5. With life style modifications, quality of life improves as does the heart diseases are also controlled in a better fashion.

TREATMENT

For most therapies like diet, behavior therapy, exercise; weight loss levels off at less than 10 % of the baseline. For many patients this is a frustrating experience, because their dream weight loss would require at least loss of 30% of body weight. It is important for the patient and the physician to realize that loss of 10% body weight lessens the health risk of obesity.

Obesity left to itself will lead to number of diseases, there are two strategies (1) wait until associated diseases develop (2) treat the obesity, thus reducing the risk of developing obesity related diseases. The second approach is preferable

DIETS

To lose weight, a person must consume less calories (eat less food) than the body needs for daily activities.

LOW FAT DIET: Low fat diets are a standard strategy to help patients lose weight. With this diet, heavier individuals lose more weight than lighter weight individuals.

LOW CARBOHYDRATE DIET: The most popular diets are the low carbohydrate, high protein and high fat diet.

LOW ENERGY DENSITY DIETS: with this diet, patient fills the stomach with low fat, high fiber food reduces hungry and produce satisfaction

VERY LOW-CALORIE DIET: Very low-calorie diets (diets with an energy level below 800 kcal/day) can be used for rapid weight loss prior to major surgery. In few patients, weight rebound occurs at the end of program and thus demoralizes them to use this diet in future.

LIFESTYLE MODIFICATION:

1.Basic strategy in helping obese patients lose weight is through life style changes. Behavioral strategies include helping patients learn to monitor their eating behavior, by recording what is eaten, the setting in which it is eaten and the situations which trigger the eating.

2.Patients should be encouraged to use a defined eating plan

EXERCISE

Exercise is one strategy for balancing energy intake and expenditure. Walking expends approx. 100 kcal/mile. A deficit of 3500 (500 kcal/day) maintained for one week should result in loss of 0.45 kg.  For this reason, exercise alone has not been very effective as a primary weight loss technique. Moderate to vigorous exercise for 60 minutes/day, six days/week produces more weight loss. Use of resistance training as opposed to aerobic exercise, help retain the lean body mass.

There are two important therapies for treatment of obesity viz bariatric surgery and Endoscopic methods,which shall be discussed in the next blog

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