Our food supply is intermittent so our body has a specialized cell called Fat cell which stores energy and gives it back when needed during starvation. Due to the sedentary lifestyle and presence of nutritional abundance genetic system is altered, lead to increase energy stores and produce health complications.
Obesity is a state of excess adipose tissue mass. It’s either overweight or lean but muscular.so most widely method is BMI which is weight/height (kg/m2). Other methods for an obesity measurement are skin fold: thickness, underwater weighing, CT, MRI, electrical impedance.
Both man and women's BMI range from 19 to 26 kg/m2 but 30 used as a threshold value. The all-cause disease starts slowly e.g. heart disease and cancer.
BMI between 26 to 30 with high blood pressure and a pre-diabetic person should get therapeutic intervention. Abdominal fat is more significant then fats on buttocks and thighs because it will lead to diabetes, insulin resistance (pre-diabetic), blood pressure(BP), and hyperlipidemia (increase fat in the blood) hyperandrogenism in women (male characteristic in women).
Overall cases of obesity are more in women (38%) than men (34%) and worried about the rising trends in children and adolescents. The cause of obesity may vary from country to country, but contributory factors include rising income, changing food supplies, and reduced activity.
Bodyweight is regulated by both endocrine and neural components that regulate energy intake and expenditure so it is connected to each other. The major contributing factor is leptin which is released by fat cells and goes into brain for regulation.
Appetite is influenced by many hormones secreted in our body which pass a signal to the brain for hunger. Basal metabolic rate account for 70% of daily expenditure whereas active physical activity contributes 5-10%.
Energy expenditure has the following component 1.resing or basal metabolic rate (70%) 2. The energy cost of metabolizing and storing food; 3. The thermal effect of exercise; and 4. Adaptive thermogenesis (brown adipose tissue)
Adipose tissue is composed of lipid –storing adipose cells. The adipose cell secret compliment factors d and plasminogen activator inhibitor (that produce clot formation), angiotensin ( increase blood pressure), peroxisome proliferator-activated receptor y(PPARy, increase insulin sensitivity) are likely to contribute to obesity-related pathology.
Etiology of obesity
Obesity comes from multiple causes and it’s very complicated. Due to the complexity of neuroendocrine (brain chemical) and metabolic systems that regulate energy intake and expenditure. Gene is a causative factor for familial obesity although environmental factors, diet, and nutrition also contributing factors. Cultural factors are also important and composite of diet and physical activity. High fat diet and sleep deprivation are precipitating factors of obesity.Obesity has been known to be caused by mutation of different genes. Ob/ob gene, db/db gene, proopiomelanocortin (POMC), AgRP mutation lead to the reduction of leptin which is an important regulator of obesity.
Other specific syndromes are associated with obesity e.g. Cushing syndrome (increased steroid in the blood), hypothyroid (low thyroid), insulinoma (high insulin in the blood). Hypothalamic dysfunction (part of the brain) leads to altered satiety, hunger, and energy expenditure, and growth hormone suppression may be low in high nutrition supply.
Is the obese person eats more? The answer is yes, an obese person needs more energy to maintain their metabolic demand as compared to a lean person.
How much energy expenditure in obesity? There is a higher expenditure in obesity as compared with lean and another component is thermogenesis, called no exercise activity thermogenesis (NEAT) e.g. daily living, maintaining body posture.
Leptin level in obesity? Leptin is good for our body and it controls body weight.it has been shown that leptin resistance and low levels are seen in an obese person. So its research molecule for treating obesity!
Consequences of obesity:
Obesity has major adverse effects on health and mostly heart causes. Obesity and overweight together second leading causes in the United States, accounting for 300000 deaths per year. The life expectancy of the moderately obese individuals could be shortened by 2-5 years, and 20- 30-year-old male with BMI >45 may lose 13 years of life.Insulin resistance and type 2 diabetes mellitus
Increased levels of insulin and unresponsive insulin are massive features of obesity. More than 80% of a diabetic has obesity however remaining diabetic individual has multiple factors for diabetes mellitus type 2. Weight loss and exercise are the major contributors to diabetes even some degree can be effective.
Reproductive Disorders
Affect both men and women, male hypogonadism is associated with increase body fat with a pattern of females whose weight is > 160% ideal body weight. However, musculation, libido potency, and spermatogenesis (production of sperm) is an intact inmost person.
Obesity also associates with menstrual abnormalities in women, increasing androgen production. Most obese women with oligomenorrhea have the polycystic ovarian disease (PCOS) with associated anovulation (no menses), ovarian hyper androgens (increase steroid). obese women with PCOS, weight loss often restore normal menses.
Heart Disease
The study shows obesity is an independent risk factor for heart disease in men and women (including coronary disease, stroke, and congestive heart failure). Also, affect lipid profile increase low-density lipoprotein (LDL) and decrease high-density lipoprotein (HDL). Obesity also associated with hypertension (increase blood pressure(BP)) and often responsive to modest weight loss. Use a larger cuff to avoid false measurement BP.
Pulmonary Disease
Obesity is associated with low chest wall compliance lead to obstructive sleep apnea in which decreases oxygen in the blood and more prone to hypertension (increase blood pressure(BP)). Reducing 10 -20 kg may help in improvement in symptoms and BiPAP(ventilator) machine may get some relief.
Hepatobiliary Disease
Obesity is associated with nonalcoholic fatty liver disease (NAFLD) represent the most common cause of liver disease in the industrial field. NAFLD may progress to Nonalcoholic steatohepatitis (NASH). Obesity enhances biliary secretion lead to symptomatic gall stone. Reducing weight will make a difference.
Cancer
Obesity is associated with an increased risk of cancer. Obesity in male higher cancer mortality of esophagus, stomach, pancreas, colon, liver. Females are associated with gall bladder cancer.
Bone, Joint and Cutaneous Disease
Obesity is associated with osteoarthritis due to weight-bearing and activate inflammatory pathways. The prevalence of Gout is also increasing. Dark, thick skin folds around neck and elbow and interphalangeal joint space. Fingal and yeast are also more prone to developed.
Evolution and management of obesity
As you from above so many complications are happened due to obesity so we have to find a solution right from the root level so we ask the patient to several questions so we can manage obesity.1 focus on obesity related history
2 physical examination and determine degree of obesity
3 assessment of comorbid condition4 determination of fitness level
5 assessment of patient to readiness to adopt life style changes
Although the vast majority of cases of obesity from behavior factors that affect diet and physical activity the history may suggest secondary causes that merit further evaluation.
Body Mass Index (BMI) and Waist Circumference
Bai calculate as a weight/ height (kg/m2) or weight/ height (lb. /in28)*703. It gives body fat and the risk of other complications. Excess abdominal fat is assessed by the waist to hip ratio is independently associated with diabetes mellitus and heart disease.
Physical fitness
A study shows exercise as an important predictor for all-cause mortality rate-independent BMI.
Obesity-associated condition
Fasting lipid profile should be done with fasting glucose and blood pressure(BP) measurementIdentifying the high risk patients
American college of endocrinology have proposed obesity disease 4 stages
.
Assessing the patient’s readiness to change
Motivation and support need to reduce the weight of the patient. This can be check by question scale 1-10 whether they are interested in weight loss. 10 means confident and 0 means are frustrated.
Treatment
The goal of therapyThe primary goal is to improve obesity and comorbid conditions to reduce the risk of developing comorbidity. Therapy begins with lifestyle modification, 8-10% weight loss in 6 months is a realistic target.
LIFESTYLE MANAGEMENT
Obesity involves three basic components diet habits, physical exercise, and behavior modification.
Diet therapy
Our primary focus is on the reduction of calorie consumption. Guideline from the American heart association /American college of cardiology/ the obesity society recommended reducing 500-752 kcal/day. A diet of 1200-1500 kcal/d for women and 1500-1800 kcal/day for men. Dietary
substitution is choosing small portion size, eating more fruit and vegetables, consuming whole grain cereals, selecting leaner cut meat and skimmed dairy product, reducing consumption of fried foods, other food added fats and oil, drinking water instead of sugar-sweetened beverages.
Macronutrient composite of diet may vary with the preference. Decreasing sodium (salt) intake <2300 mg/day guidelines to specific goals is found on www.choosemyplate.gov.
Many trials showed that more effective to reduce weight is to decrease calorie intake. However, a consultation with a registered dietitian would be beneficial.
Energy density is another concept to reduce your hunger. You may add extra water or fiber in the diet to reduce its energy density.
Very low-calorie diet (VLCD) aggressive dietary therapy <800 kcal/day. It helps in comorbid conditions and failed the conventional weight loss regime.
Physical Activity Therapy
Exercise and dietary modification is the most effective behavior approach. Physical activity guidelines www.health.gov recommend that adult should engage 150 min moderate-intensity or >300 min high intensity exercise physical activity per week. Consultation with a physiologist or personal trainer may be helpful.
Behavior therapy
Reinforce to new dietary and physical activity behaviors including self – monitoring techniques (e.g. journaling, weighing, measuring food and activity) stress management stimulus control (e.g. using a smaller plate, not eating in front of a television or in-car) social support, problem-solving these techniques is time-consuming need supervision by ancillary office staff, nurse-clinician or registered dietitian.
Drugs
It is mainly used for BMI >30 and has not been successful in dietary and physical activity. There are mainly two types of medication 1.appetite suppressants 2. Fat blocker.
Surgery
Bariatric surgery can be considered for a patient BMI>40kg/m2 severe obesity and BMI >35 moderate obesity associated with a serious medical condition.
Please do not hesitate to comment, if you have any queries
Dr Manish Khokhar
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