Obesity, the evolving epidemic

By Quratulain Syedain, MD (Internist, New York)

Obesity refers to an excess of body fat. Obesity is defined in terms of body mass index (BMI) measured as weight in k.g. divided by height in meter square. For example a person weighs 61 k.g.(135 lbs) with height 5'8" which is 1.7 meter, so BMI is 61 / 1.7x1.7(2.89)  = 21 k.g/m2. BMI between 18.5-24.9 is healthy weight. Below 18.5 is underweight ,25-29.9 is over-weight and over 30 is obesity. Over 40 is morbid obesity.

In the current epidemic one third of Americans are over-weight and one third are obese.  In June 2013, American Medical Association has declared "obesity" a "disease" in itself implying that it’s not just a cosmetic and societal issue and not just to be blamed on gluttony (excessive eating and drinking) slothfulness (laziness) and a lack of willpower .Since it’s a disease, it requires management like other chronic (long-term) relapsing diseases like high blood pressure (hypertension) and diabetes.

Obesity has various causes like dietary, genetic, hormonal disorders, inactivity and low birth weight. In the words of Donna Ryan, MD Professor Emeritus at Pennington Biomedical Research Center Louisiana "Obesity produces myriad diseases and disorders of feeling and function" Diverse spectrum of medical conditions are associated with obesity like type 2 (non-insulin dependent or adult onset) Diabetes ,sleep apnea ,cardiovascular diseases, high blood pressure ,asthma, a number of cancers, fatty liver disease, polycystic ovary syndrome, osteoarthritis (joint inflammation and pain) and many other conditions.  It’s not just the amount of fat matters but location of fat equally matters. Fat localized to abdomen has a particularly adverse profile. In adults with a BMI of 25 to 34.9 ,a waist circumference greater than 40 inches(102cm) for  men and 35 inches(88cm)  for women is associated with greater risk of high blood pressure, type 2 diabetes, high cholesterol and heart disease. However there is ethnic variation for Asians. Like Japanese and South Asians have more total fat and visceral fat (fat in internal organs like liver) so in Asian men a value greater than 35.4 inches (90 cm) and in Asian women more than 31.5 inches (80cm) is considered abnormal.

But obesity is not just associated with these chronic medical conditions ,it also affects how patients feel and function .Obesity is associated with higher rates of depression ,infertility, impaired mobility (difficulty moving around) and urinary stress incontinence. There are a number of social problems associated with obesity .Obese people are stigmatized in societies, are less likely to marry and less likely to achieve higher educational levels. They also have lower incomes than non-obese people.

On the other hand modest weight loss in the range of 5-10% of body weight loss (regardless of original body weight) is associated with major health benefits .It improves a patient's risk of progressing to type 2 diabetes. In people who already have type 2 diabetes, modest weight loss can improve diabetes control and reduce or resolve the need for diabetes medications. It lowers blood pressure and can obliterate need of medication for high blood pressure. Besides improving symptoms of other obesity related conditions like sleep apnea, osteoarthritis, urinary stress incontinence.

 The most efficient way to lose weight is through diet rather than exercise, although moderate exercise is important during the diet period. When it comes to the diets, the Mediterranean diet is shown to be the best. A new study in the New England Journal of Medicine says that for preventing heart disease, the Mediterranean diet is the way to go .The study compared Med. diet with low-fat diet and it reported that Med. diet can lower risk for heart attack, stroke and chances of dying from these diseases by 30%.

Weight loss is slow and long-term process generally aims at loss of 1 lb. per week .Which requires energy deficit of 500 kCal/day through diet, exercise and increase physical activity. Exercise doesn't necessarily meant working out in GYM. Brisk walking 30 minutes daily suffice as optimal exercise.

Weight loss medications alone do not work .Medications are part of a diet, physical activity, and behavior modification program. There is paradigm shift in the medication management such as use of multiple medications together, at lower doses for long term not just for achieving weight loss but to sustain weight loss. Also patients need to be followed up by physician at-least monthly.

Bariatric (weight-loss) surgery is required for BMI over 40 to achieve weight   loss of  greater than 15% and is shown to cause remission of  type 2 diabetes ,hypertension and reduces chances of dying from heart disease and stroke.

With combined efforts we can curtail the epidemic of obesity.

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