Overweight And Obesity : Proven Health Risks, We All Should Know

Overweight and Obesity: Proven Health Risks, we all should know…

Dr Sanjiv Haribhakti of 8

Overweight and Obesity: Proven Health Risks, we all should know… What is Obesity? Overweight and obesity are defined as abnormal or excessive fat accumulation in the body that presents a risk to health. Obesity will have a negative effect on health, leading to reduced life expectancy and/or increased health problems. According to WHO, Obesity is one of the most serious public health problems of the 21st century. Obesity isn’t just a cosmetic concern. It increases risk of diseases and health problems such as heart disease, diabetes and high blood pressure.In 2013, the American Medical Association classified obesity as a disease. Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat, and/or body water. Both terms mean that a person’s weight is greater than what’s considered healthy for his or her height. Obesity occurs over time when one eats more calories than use. The balance between calories-in and calories-out differs for each person. Factors that might affect our weight include our genetic makeup, overeating, eating high-fat foods, and not being physically active. Is Obesity a new disease of the new world? Hippocrates wrote that “Corpulence is not only a disease itself, but the harbinger of others”. As early as 6th century BC, the pioneer Indian surgeon Sushruta related obesity to diabetes and heart disorders. He recommended physical work to help cure it and its side effects. Thus Obesity is prevalent since the ancient times, but has reached epidemic proportions globally in the 21st century. What are the causes for Obesity? Obesity is most commonly caused by a combination of excessive food energy intake, lack of physical activity, and genetic susceptibility, although a few cases are caused primarily by genes, endocrine disorders, medications, or psychiatric illness. In contrast, increasing rates of obesity at a societal level are felt to be due to an easily accessible and palatable diet, increased reliance on vehicles, and mechanized manufacturing. Diet and Obesity From 1971 to 2000, obesity rates in the United States increased from 14.5% to 30.9%. During the same period, an increase occurred in the average amount of food energy consumed. For women, the average increase was 335 calories per day, while for men the average increase was 168 calories per day. Most of this extra food energy came from an increase in carbohydrate consumption rather than fat consumption. The primary sources of these extra carbohydrates



are sweetened beverages, which now account for almost 25 percent of daily food energy in young adults in America. Consumption of sweetened drinks such as soft drinks, fruit drinks, iced tea, and energy and vitamin water drinks is believed to be contributing to the rising rates of obesity and to an increased risk of metabolic syndrome and type 2 diabetes. Sedentary Lifestyle and Obesity A sedentary lifestyle plays a significant role in obesity. Worldwide there has been a large shift towards less physically demanding work, and currently at least 30% of the world’s population gets insufficient exercise. This is primarily due to increasing use of mechanized transportation such as cars and two wheelers, and a greater prevalence of home help or labour saving technology in the home, such as TV, computers, remotes, cell phones etc. In children, there appears to be decline in levels of physical activity due to less walking and outdoor games. In both children and adults, there is an association between television viewing time and the risk of obesity. Genes and Obesity A faulty gene, called FTO, makes 1 in every 6 people overeat, a team of scientists from University College London reported in the Journal of Clinical Investigation (July 2013 issue). Like many other medical conditions, obesity is the result of an interplay between genetic and environmental factors. People with two copies of the FTO gene (fat mass and obesity associated gene) have been found on average to weigh 3–4 kg more and have a 1.67-fold greater risk of obesity compared with those without the risk allele. Other illnesses Medical illnesses that increase obesity risk include several rare genetic syndromes as well as some congenital or acquired conditions: hypothyroidism, Cushing’s syndrome, growth hormone deficiency, and the eating disorders: binge eating disorder and night eating syndrome. Medications Certain medications may cause weight gain or changes in body composition; these include insulin, sulfonylureas, thiazolidinediones, atypical antipsychotics, anti-depressants, steroids, certain anticonvulsants (phenytoin and valproate), pizotifen, and some forms of hormonal contraception. Social Class Among developed countries, levels of adult obesity, and percentage of teenage children who are overweight, are correlated with income inequality. In undeveloped countries the ability to afford food, high energy expenditure with physical labour, and cultural values favouring a larger body size are believed to contribute to the observed patterns. In the developing world urbanization is playing a role in increasing rate of obesity.



How is Obesity measured? BMI is usually expressed in kilograms per square metre, resulting when weight is measured in kilograms and height in metres.

BMI (kg/m2)

Classification from up to

18.5 Underweight

18.5 25.0 Normal weight

25.0 30.0 Overweight

30.0 35.0 Class I obesity

35.0 40.0 Class II obesity

40.0 Class III obesity

• BMI ≥ 35 kg/m2is severe obesity. • BMI of ≥ 35 kg/m2and experiencing obesity-related health conditions or ≥40–

44.9 kg/m2 is morbid obesity. • BMI of ≥ 45 or 50 kg/m2is super obesity.

Pathophysiology Many hormones and mediators have recently been identified which regulate hunger and satiety, and play an important role in people becoming overweight or obese and in weight loss surgery. Since leptin’s discovery, ghrelin, insulin, orexin, PYY 3-36, cholecystokinin, adiponectin, as well as many other mediators have been studied. The adipokines are mediators produced by adipose tissue; their action is thought to modify many obesity-related diseases. Leptin and ghrelin are considered to be complementary in their influence on appetite, with ghrelin (hunger hormone) produced by the stomach, modulating short-term appetitive control (i.e. to eat when the stomach is empty and to stop when the stomach is stretched). Leptin is produced by adipose tissue to signal fat storage reserves in the body, and mediates long-term appetitive controls (i.e. to eat more when fat storages are low and less when fat storages are high). What are the hazards of Obesity? Obese people are more likely to develop a number of potentially serious health problems, including:



• High triglycerides and low high-density lipoprotein (HDL) cholesterol – The primary dyslipidemia related to obesity is characterized by increased triglycerides, decreased HDL levels, and abnormal LDL composition.

• Type 2 diabetes – One of the strongest risk factors for type 2 diabetes is obesity, and this is also one of the most modifiable as it can be partially controlled through diet and exercise.

• High blood pressure – There are multiple reasons why obesity causes hypertension, but it seems that excess fat tissue secretes substances that are acted on by the kidneys, resulting in hypertension.

• Metabolic syndrome — a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol.

• Heart disease – Obesity carries a penalty of an associated adverse cardiovascular risk profile. Largely as a consequence of this, it is associated with an excess occurrence of cardiovascular disease morbidity and mortality.

• Stroke – Rising obesity rates have been linked to more strokes among women aged 35 to 54.

• Cancers, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate – In 2002, approximately 41,000 new cases of cancer in the USA were thought to be due to obesity. In other words, about 3.2% of all new cancers are linked to obesity

• Breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts – Obesity has been found to be linked to sleep apnea. Also, weight reduction has been associated with comparable reductions in the severity of sleep apnea.

• Gastro-oesophageal reflux disease (GERD) and Hiatus Hernia – Patients with obesity commonly have severe heartburn and regurgitation of food due to reflux disease and hiatus hernia

• Gallbladder disease – Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is then delivered into the bile causing it to become supersaturated.

• Liver diseases, including Fatty Liver, NASH (Nonalcoholic steatohepatitis) and Liver Cirrhosis

• Gynecologic problems, such as infertility, PCOD(Polycystic ovarian disease) and irregular periods

• Erectile dysfunction and sexual health issues. • Osteoarthritis – Obesity is an important risk factor for osteoarthritis in most joints,

especially at the knee joint (the most important site for osteoarthritis). Obesity confers a nine times increased risk in knee joint osteoarthritis in women. Osteoarthritis risk is also



linked to obesity for other joints. Data suggest that metabolic and mechanical factors mediate the effects of obesity on joints.

• Skin conditions, including poor wound healing, and increased skin infections. Quality of life Obese people enjoy an overall lower quality of life. They may not be able to do things they normally enjoy as easily as they’d like, such as participating in enjoyable activities. They may avoid public places. Obese people may even encounter discrimination. Social issues Other weight-related issues that may affect quality of life include depression, disability, sexual problems, shame and guilt, social isolation and lower work achievement. Obesity can lead to social stigmatization and disadvantages in employment. Obesity and Life expectancy Obesity is one of the leading preventable causes of death worldwide. A BMI above 32 kg/m2 has been associated with a doubled mortality rate among women over a 16-year period. On average, obesity reduces life expectancy by six to seven years, a BMI of 30–35 kg/m2reduces life expectancy by two to four years, while severe obesity (BMI > 40 kg/m2) reduces life expectancy by ten years. Insurance companies realized the connection between weight and life expectancy and increased premiums for the obese. Medical management Obesity treatments have two objectives:

1. To achieve a healthy weight. 2. To maintain that healthy weight.

The good news is that even modest weight loss can improve or prevent the health problems associated with obesity. Counselling for behavioural modification Intensive behavioural counselling is recommended in those who are both obese and have other risk factors for heart disease. An active lifestyle and plenty of exercise, along with healthy eating, is the safest way to lose weight. Even modest weight loss can improve health. There is a need for a lot of support from family and friends. Many people find it hard to change their eating habits and behaviours. You may have practiced some habits for so long that you may not even know they are unhealthy, or you do them without thinking. You need to be motivated to make lifestyle changes. Make the behaviour change part of your life over the long term. Know that it takes time to make and keep a change in your lifestyle. The main treatment for obesity consists of dieting and physical exercise.



Diet Diet programs may produce weight loss over the short term, but maintaining this weight loss is frequently difficult and often requires making exercise and a lower food energy diet a permanent part of a person’s lifestyle. All types of low-carbohydrate and low-fat diets appear equally beneficial. The heart disease and diabetes risks associated with different diets also appear to be similar. Success rates of long-term weight loss maintenance with lifestyle changes are low, ranging from 2–20%. When dieting, the main goal should be to learn new, healthy ways of eating and make them a part of the daily routine. Work with your health care provider and dietician to set realistic, safe daily calorie counts that help you lose weight while staying healthy. Remember that if you drop weight slowly and steadily, you are more likely to keep them off. Your dietician can teach you about healthy food choices, healthy snacks, reading nutrition labels, new ways to prepare food, portion sizes and sweetened drinks. Extreme diets (fewer than 1,100 calories per day) are not thought to be safe or to work very well. These types of diets often do not contain enough vitamins and minerals. Most people who lose weight this way return to overeating and become obese again. Learn ways to manage stress, rather than snacking. Examples may be meditation, yoga, or exercise. If you are depressed or stressed a lot, talk to your health care provider. WHO Diet Recommendations to combat obesity :

• achieve energy balance and a healthy weight • limit energy intake from total fats and shift fat consumption away from saturated fats to

unsaturated fats and towards the elimination of trans-fatty acids • increase consumption of fruits and vegetables, and legumes, whole grains and nuts • limit the intake of free sugars • limit salt (sodium) consumption from all sources and ensure that salt is iodized

Physical activity The more you move your body the more calories you burn. To lose a kilogram of fat you need to burn 8,000 calories (1 pound of fat = 3,500 calories). Walking briskly is a good way to start increasing your physical activity if you are obese. Combining increased physical activity with a good diet will significantly increase your chances of losing weight successfully and permanently! Try to find activities which you can fit into your daily routine. Anything that becomes part of our daily life, weaved into our existing lifestyle, is more likely to become a long-term habit. If you use an elevator, try getting off one or two floors before your destination and walking the rest. One could try the same when driving your car or taking any form of public transport – get off earlier and walk that bit more. If any of your regular shops are within walking distance, try leaving the car at home.



Medications Two medications, Orlistat and Sibutramine are currently available in India, and have evidence for long term use. Orlistat interferes with fat absorption, whereas Sibutramine is an appetite suppressant. Weight loss with Orlistat and Sibutramine is modest, an average of 2.9 kg at 1 to 4 years. Its use is associated with high rates of gastrointestinal side effects such as diarrhoeas and concerns have been raised about negative effects on the kidneys. Sibutramine is known to get difficulties with getting pregnant in young females. Overall, these medications are not very effective, need to be taken for lifetime and have significant side effects. Thus they should be used for selected patients under medical supervision. Weight loss Surgery Weight loss surgery (WLS) is also known as Bariatric Surgery. It comes from the Greek work baros, which means weight. The most effective treatment for obesity is bariatric surgery. Surgery for severe obesity is associated with long-term weight loss, improvement in obesity related conditions, and decreased overall mortality. There are two types of bariatric surgeries:

• Restrictive procedures –These make the stomach smaller. The surgeon may use a gastric band or staples known as gastric sleeve operation, which is currently an effective and popular operation in selected people. After the operation, the hunger comes down significantly due to reduction of the hunger hormone (Ghrelin), and the patient cannot consume more than about one cup of food during each sitting, significantly reducing his/her food intake. Over time, some patients’ stomach may stretch and they are gradually able to consumer larger quantities.

• Malabsorptive procedures –Parts of the digestive system, especially the first part of the small intestine (duodenum) or the mid-section (jejunum), are bypassed, called the laparoscopic gastric bypass surgery, which also reduce the size of the stomach. This procedure is generally more effective than restrictive procedures. However, the patient has a higher risk of experiencing vitamin/mineral deficiencies because overall absorption is reduced, and thus need lifelong supplementation of Iron, Vitamin B12 and Calcium.

Bariatric (weight-loss) surgery can significantly reduce the risk of certain diseases in people with severe obesity. These risks include Arthritis, Diabetes, Heart disease, High blood pressure, Sleep apnea, some cancers and Stroke. Surgery alone is not the answer for weight loss. It can train a person to eat less, but they still have to do much of the work. They must be committed to diet and exercise after surgery to achieve a long term remission of weight.



Endoscopic options Endoscopic options such as balloon placement and other newer options are under evaluation. Endoscopic balloon currently can be retained for 6 months and is associated with modest weight loss in the range of 5 – 10 kg over 6 months. This may be useful in elderly patients who are at a high risk for surgery, in selected young patients, and in patients who are going for bariatric surgery, to reduce their risks for surgery. Childhood Obesity Obesity in children and adolescents is defined as a BMI greater than the 95th percentile. Childhood obesity is one of the most serious public health challenges of the 21st century, as it has reached epidemic proportions in the 21st century, with rising rates in both the developed and developing world. Changing diet and decreasing physical activity are believed to be the two most important causes for the recent increase in the incidence of child obesity. Because childhood obesity often persists into adulthood and is associated with numerous chronic illnesses, children who are obese are often tested for hypertension, diabetes, hyperlipidemia, and fatty liver. Treatments used in children are primarily lifestyle interventions and behavioural techniques, although efforts to increase activity in children have had little success.

Overweight And Obesity : Proven Health Risks, We All Should Know

Healthcare

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