OBESITY REVIEWED
Obesity has become a global health concern in a very short space of time. It is pandemic
sweeping the whole world, perhaps with the exception of Sub-Saharan Africa. Changing trends
in diet as well as reduced physical labour, thanks to several devices to reduce human effort, in
addition to stress have made this a disease of the masses, from a disease of the classes.
Often called a disease of prosperity, obesity has made silent inroads into the population.
Surprisingly, the adverse effects of obesity are commoner in the population of the developing
world, rather than the developed. Not surprisingly, the WHO has stated that obesity is the
world`s primary nutritional disease, rather than malnutrition.
Body Mass Index is a better measure for obesity than weight alone. BMI is measured as weight
of the individual in kilograms divided by the height in meters squared.
Causes of Obesity
Although the causes of obesity are myriad, the chief causes are as follows:
1) Increased food intake
2) Reduced physical activity
3) Genetic susceptibility.
In addition, certain endocrine disorders like Cushing`s syndrome and hypothyroidism and certain
medications like the antiepileptics phenytoin and valproate and hormonal contraceptives also
have a role to play.
Classification
Obesity is classified on the basis of the BMI of the individual. A BMI upto 25 is considered
normal. A BMI of 25 to 30 is classified as overweight and 30 and above as obese. Obesity is
further classified as class 1, 2 and 3. BMI from 30 to 34.9 is class 1, from 35 to 39.9 class 2 and
40 and above as class 3.
Class 3 obesity is again graded into severe, morbid and super obesity.
Obesity, in addition to having psychological, aesthetic and social drawbacks, is associated with
increased incidence of several serious medical conditions. The chief ones may be listed as
follows:
1) Cardio-vascular: increased incidence of angina and myocardial infarction, deep vein
thrombosis and dyslipidemias.
2) Neurological: increased incidence of stroke, migraines and multiple sclerosis.
3) Increased incidence of cancer of the breast, ovaries, liver, prostate, colon, rectum, stomach
and pancreas.
4) Gynaecological: Polycystic ovarian disease, infertility and increased incidence of intra-uterine
foetal death.
5) Gastro-intestinal: GERD and cholelithiasis.
6) Renal: increased incidence of chronic renal failure.
7) Musculoskeletal: osteoarthritis and chronic back pain.
8) Metabolic: there is a definite increase in the incidence of type2 diabetes mellitus among the
obese, mainly due to development of insulin resistance. In addition, there is a poorer control of
blood sugar levels in the obese diabetics than in those who are not.
Management of Obesity
Though there have been several strides in obesity management, diet control and regular exercise
remain the gold standards in the early management, unless precluded by certain factors like a
genetic predisposition. In addition, there are certain drugs available, but they are known to have
detrimental effects on the gastro-intestinal tract and the kidneys on long term use.
Surgical Management
In case of grade III obesity, surgical management is advised. In grade I and II obesity, if it is
associated with co-morbid conditions as osteoarthritis, surgical intervention is indicated. Recent
innovations have opened up a whole range of procedures for the morbidly obese, the exclusive
realm of obesity or bariatric surgery. These procedures are advised for those refractory cases, in
whom diet control and exercise have had little or no effect and those who have attendant
complications like type 2 diabetes mellitus
Western norms advise obesity surgery for those patients with a BMI more than 35, buthas been
advised in those with a BMI more than 32 with associated uncontrolled type 2 diabetes.
The surgical procedures for obesity maybe classified as follows:
1) Predominantly malabsorptive procedures: As the name suggests, these procedures involve
bypassing large portions of the gastrointestinal tract, so that there is reduced absorption of
nutrients. These are found to be highly effective controlling diabetes. The most popular is
biliopancreatic diversion.
However, there are quite a few attendant complications with this procedure—since it involves
multiple suture lines, it carries higher risk of infections and higher incidence of incisional hernia.
Also the malabsorption causes anemia and osteopenia and the patient has to take multiple
supplementary medication lifelong to combat this for the rest of his/her life.
2) Restrictive procedures: These procedures involve reducing the size of the stomach so that it
can accommodate only a small amount of food, effectively reducing the food intake. The
different methods are
1) Vertical banded gastrectomy: the size of the stomach is reduced by sialistic bands around the
stomach. The chief drawback is the persistent presence of a foreign body in the abdomen.
Besides, some procedures need repeated fitting of such bands as the stomach shrinks in size.
2) Laparoscopic removal of a portion of the stomach: Sleeve gastrectomy: In this, a portion of
the stomach along the greater curvature is removed either after suturing it or stapling it, thus
converting the stomach into a banana shaped or sleeve shaped organ.
3) Gastric plication: The sleeve is merely formed by suturing the stomach, without removal of
the sutured portion. However, this method is still being reviewed.
4) Gastric Bypass: This includes the Roux-en-Y gastric bypass or a sleeve gastrectomy with a
duodenal switch.
These procedures also have complications like gastric dumping syndrome, bloating and
dehydration. In addition, the patients need counselling and training for regulating their food
intake.
Conclusion
With obesity increasing rapidly, it is more important than ever to inculcate healthy dietary habits
right from childhood, in addition to an exercise regimen. However, recent surgical advances
offer hope of normalcy to those sufferers whose life is laid waste by an ever expanding waist
line.
-By Dr Sameer Rege, Associate Professor, Seth GS Medical College & KEM Hospital, Parel,
Mumbai.