Bariatric Surgery, Causes of obesity, Treatment of Morbid Obesity, Who is considered obese?

Bariatric Surgery

Comes from the Greek words, Baros, meaning weight, and Jatreia, meaning treatment.

What’s meant by obesity?

The World Health Organization defines obesity as a condition of excessive fat accumulation in the body to the extent that health and well-being are adversely affected. If the amount of body fat exceeds the normal physiological values, then a person is obese.

The problem

One of the most significant public health challenges is in both economically developed and developing regions of the world. Obesity has become one of the most widespread health problems in the world. Prevalence of obesity in the U.S. increased from 12% to 21% between 1991 and 2001= 15 million people. Obesity is the 2^nd most common cause of death from a modifiable behavioral risk factor.

In 2016, more than 1.9 billion adults worldwide were overweight, of whom more than 650 million were obese, a number that has tripled since the 1970s. Half of the newly born children will be obese or overweight. In the United States, it’s estimated that 39.8% of the adult population is obese.

Obesity is associated with markedly reduced life expectancy, as it is a problem associated with cardiovascular disease and diabetes mellitus, thus becoming a leading cause of preventable deaths. In 2015, high body mass index contributed to 4 million deaths and 2120 million disability adjusted life years in the US.

Who is considered obese?

Weight measurement alone is not ideal for determining if the patient is obese or not; that is why the Body Mass Index concept is used.

Body Mass Index (BMI)

BMI is defined by the ratio of an individual’s height to weight [BMI = body weight (Kg) / height (m²)]. BMI = kg/m². Normal BMI ranges from 20-25. An individual is considered morbidly obese if he or she, has a BMI of 40 or more, or 35 or more and is experiencing obesity-related health conditions, such as DM & HTN. Persons with a BMI above 50 are considered Super Obese.

Super obesity should be dealt with as a special entity because of:

• They suffer much more from obesity related health problems.
• They impose a much higher risk on surgery and anesthesia.
• They need special beds, chairs, trolleys, surgical tables, and surgical instruments with extra lengths.
• They are better dealt with at dedicated institutions.

Weight guidelines:

1. Overweight: BMI more than 25 kg/n.
2. Obese: BMI 30 to 34.9 kg/m.
3. Severely obese: BMI 35 to 39.9 kg/m
4. Morbidity obese: BMI more than 40 kg/m or BMI 35 to 39.9 kg/m with associated medical problems (diabetes, high blood pressure, etc).

Apples vs. pears concept!!

• Not only, the body mass index important, but also the shape of their distribution of fat is important.
• There are apple-shaped and pear-shaped.
• Apple-shaped means that the waist circumference is more than the hip circumference.
• Pear-shaped means that the waist circumference is less than the hip circumference.
• Apple-shaped is more dangerous than the pear distribution, so we come to a more sophisticated index which we called the body adiposity index.
• In general, being more pear-shaped means you are at lower risk to chronic disease than being an apple shape, and this mainly has to do with your visceral and subcutaneous fat storage.
• Visceral fat is the fat that sits deep in our abdomen and surrounds our organs.
• Subcutaneous fat is stored under our skin and is the fat that you can feel in the skin folds.
• The visceral fat is the most dangerous and it increases our risks of type 2 diabetes, cardiovascular disease, high blood pressure, inflammation, and other diseases.

Obesity-Related Conditions

1. DM-Type 2: People who are obese become resistant to insulin, which regulates blood glucose levels, leading to Type 2 diabetes.
2. HTN/heart disease: The obese person usually gets HTN, which results in stroke and damage to the heart and kidneys.
3. Osteoarthritis of weight-bearing joints: Additional weight placed on joints, especially knees and hips, can cause rapid wear and tear, along with pain and inflammation. Similarly, the strain on bones and muscles in the back leads to disk problems, pain, and reduced mobility.
4. Sleep apnea respiratory problems: Fat deposits in the tongue and neck can block the air passages, especially in patients who sleep on their backs. This interferes with sleep, leading to daytime drowsiness and headache.
5. Gastroesophageal reflux disease (GERD) (hiatal hernia and heartburn): Excess weight weakens and overloads the gastro-esophageal junction and thus allows stomach acid to escape into the esophagus (reflux), leading to heartburn and acid indigestion. About 10-15% of patients with even mild heartburn develop Barrett’s esophagus (a pre-malignant change in the lining membrane and a cause of esophageal cancer).
6. Depression: People who are obese must deal with constant, depressing emotional challenges.
7. Infertility: Obesity affects male and female hormones, disrupting normal cycles and function, leading to difficulty or inability to conceive.
8. Urinary stress incontinence: A large, heavy abdomen relaxes the pelvic muscles, compounding the effects of childbirth. This weakens the urinary bladder sphincter, allowing leakage when coughing, sneezing, or laughing.

Causes of obesity

• Genetics.
• Behavior.
• (Examples: Excessive eating, social gathering, and sugar are part of the meals) In Egypt, an important cause is the exaggerated consumption of sugar.
• Environment (example: portion size).

Treatment of Morbid Obesity

There are several arms for the management of the obesity problem:

• Non-invasive: Exercise and medical therapy.
• Invasive, non-surgical: Intragastric balloon insertion.
• Surgical: Bariatric surgery.

1. Non-invasive Treatment:

A diet low in calories, fat, and carbohydrates. Exercise-40 minutes 5 times per week.

Behavior Modification:

• Eat at certain times of the day.
• Eat 3 sensible meals per day, and avoid snacking.
• Don’t eat in front of the TV or in a family environment.
• Try to spend as much as you can while eating.

Drugs/Prescription medications:

• Appetite suppressants.
• Antidepressants.
• Reduce fat absorption.

Disadvantages of non-invasive therapy:

• Most patients (95-97%) regain most or all of the weight that was lost within 2-5 years following diet or drug treatment.
• The average amount of weight loss is relatively small, 5-20 Kg.
• Drug therapy may be associated with severe complications.
• Very difficult for most people to maintain these programs in the long term.
• “Yo-Yo” effect of many different programs leads to significant weight fluctuations.

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