Obesity: Understanding Its Impact and Management Options

Obesity is excess fat (adipose tissue) in our body. Normal body fat values ​​are 12-20% in men and 20-30% in women. Thus, in numerical terms, we define obese subjects as those with percentages of body fat above 20% in men and 30% in women. Values ​​between 21 and 25% in men, and between 31 and 33% in women, are considered borderline (overweight).

Determining this percentage is not easy or quick to obtain, for this reason we use an index that is called the body mass index (; weight in kilograms divided by height in meters squared). To define obesity in adults (from 18 years of age), a BMI value of 30 kg / m2 or higher is accepted as a cut-off point, although values ​​higher than the 85th percentile of the population distribution have also been established. reference. BMI values ​​of 25 to 29'9 kg / m2 indicate overweight. In the child and youth population, the specific values ​​for age and sex of the 85th and 97th percentiles of the BMI, respectively, are used as criteria to define overweight and obesity, using the tables published by Cole in 2000.

How is it produced?

Obesity depends on the intake (the calories that enter our body each day through food) and the consumption or expenditure of energy that we do (due to physical activity or energy expenditure derived from the metabolic reactions that occur produced continuously in our body).

We can consider our body weight as if it were a balance with two pans; one of the dishes is the energy gain (intake) and the other is the energy loss (consumption). On each of these two dishes there are factors that add weight and others that take weight off; For example, the practice of physical exercise is a factor that takes weight off the expense plate (we lose weight), while being sedentary is a factor that adds weight to the expense plate (we gain weight); Similarly, a high calorie intake will add weight to the profit or appetizer dish, and a state of famine will make this dish weigh less.

The sum of all the factors that influence these dishes will make the scale balanced (normal weight) or unbalanced (overweight or obese at one extreme, or thin at the other extreme).

However, large (and obvious) food intakes are not necessary to gain weight; with only slight excesses of calories each day (gains not evident) but maintained for several years leads to gains of several kilos of weight.

We know that there are hormonal factors and nervous factors that regulate one of those scales on the scale, the plate of energy inputs or income, that is, appetite. For example, hormones such as leptin, which suppress appetite and increase energy expenditure. Or factors of the psychological nervous sphere, such as cultural beliefs about the cult of the body that our society has and that punishes obesity and equates thinness with harmony, beauty, prestige and success, that act by inhibiting the appetite and that will make us eat less and lose weight.

Or if we have a full stomach, substances are produced in the digestive tract, such as cholecystokinin (synthesized in the small intestine) or peptide YY (synthesized in the small intestine), which reach the brain and indicate the cessation of ingestion of more food; or on the contrary, ghrelin, synthesized in the stomach and which stimulates eating. The sugar we have in our blood, when it drops too low, causes a feeling of hunger. All these signals (hormones, psychological factors, cultural factors, nervous stimuli ...) reach a brain structure known as the hypothalamus, which is the regulating center of appetite.

Our genes can regulate all this network of signals and can help a person to be obese, but except in very few circumstances, they are not responsible for obesity. For example, the lack of leptin in hypogonadotrophic hypogonadism, a rare genetic disease that causes obesity among other alterations.

There are other more frequent and non-genetic diseases where obesity is one more element. It is the so-called secondary obesity. Examples of this obesity are certain endocrinological problems such as Cushing's syndrome (due to increased cortisol), (due to thyroid hormone deficiency), certain forms of (due to lesions of the hypothalamus that cause growth hormone deficiency), insulinote, polycystic ovary syndrome, and lesions in the hypothalamus (craniopharyngioma, trauma or infection).

In summary, primary obesity, the most common, has an unknown origin and is due to increased energy intake, decreased energy intake, or a combination of both factors. Genetic, metabolic, hormonal, nervous and environmental factors intervene in the development of this obesity. Secondary obesity has an identifiable cause and, in some cases, medically treatable, and potentially curable.

Symptoms of obesity

Obesity does not produce symptoms, except for the visual and aesthetic element. However, in the long term, it produces serious adverse effects on our health. Visually we can speak of various types of obesity, depending on where the fat is located: we speak of central obesity when fat accumulates in the abdomen and covers the different tissues and organs (heart, kidneys, liver, etc.); and peripheral obesity when fat accumulates in the buttocks, thighs and arms.

The health problems associated with obesity are:

• Alterations in blood fats, with an increase in triglycerides and a decrease in HDL cholesterol.
• cardiovascular diseases such as,,, cerebral stroke,, etc.
• Increased uric acid and
• Polycystic ovary syndrome.
• Acanthosis nigricans, which is a disorder manifested by darkening and thickening of the skin folds on the neck and elbows, and in the spaces between the fingers.
• Kidney injuries: obesity glomerulopathy.
• and pain in weight-bearing joints such as knees and hips.
• Lumbar spine pain.
• Carpal tunnel syndrome.
• and loss of menstruation in women.
• Difficulty and increased work to breathe.
• Cessation or decrease of breathing during sleep.
• Disease by
• Non-alcoholic fatty liver.
• Gallstones
• Abdominal and inguinal hernias.
• Fragility of the skin, especially in the folds, with frequent fungal infections.
• Striae gravidarum.
• Hyperpigmentation in the legs due to chronic venous stasis.
• Swollen legs
• Cellulitis.
• Cancers: in men the esophagus, rectum, pancreas, liver and; in women the gallbladder, bile ducts, endometrium, and ovaries.

All this conditions the person at a higher risk of becoming ill, worsens the quality of life and shortens life expectancy by several years. However, the type of obesity associated with the highest risk of becoming ill and dying is central obesity.

Diagnosis

The diagnosis of obesity is usually visual. But how do we scientifically measure and confirm that excess weight? There are three anthropometric data that are of the utmost importance to assess the degree of obesity: weight, height, and waist circumference or circumference. With them we elaborate the following indices:

• (BMI): is the number that comes from dividing the weight (in kg) by the height (in meters) squared. The risk of becoming ill starts from BMI values ​​equal to or greater than 25 kg / m2 (cut that defines overweight) and shoots up above 30 kg / m2 (obesity). In individuals with a BMI of up to 27 kg / m2 and who do not have other associated risk factors (arterial hypertension, diabetes mellitus, etc.), they can be considered "normal weight." Since height remains constant, variations in weight will determine variations in BMI. And, although the increase in fat (which is what defines obesity) is associated with an increase in body weight, the weight gain is not always due to obesity; weight gain may be due to increased muscle mass or increased fluid retention (edema). This we have to take into account when we assess the BMI of an individual.
• Waist circumference: It is the number (in cm) that comes from measuring the circumference of the waist (measured at the navel). With this value we will know the distribution of adipose tissue and we will detect abdominal or central fat, which is the one that is related to the appearance of diabetes mellitus, hypertension and cardiovascular diseases in the obese individual. In the Spanish population, values ​​above 94 cm (in men) and 80 cm (in women) are currently considered pathological.
• Waist-hip / thigh ratio: It is the number obtained by dividing the waist circumference (in cm) by the thigh circumference (in cm). This index had previously been used to determine the type of obesity: values ​​above 1'0 in men and 0'90 in women indicate central obesity. This index has been replaced by the waist circumference, explained in the previous point.

With a simple tape measure and a scale we can obtain these indices. However, we can resort to other methods that are more expensive and more complex and that are not usually used in routine clinical practice. For example, the techniques of to know the percentage of body fat of an individual. Body impedance analysis measures the opposition of body tissues to the passage of an electrical current (body impedance), which is primarily dependent on water and mineral content.

Lean mass is a good electrical conductor (it has low impedance), while fat acts as an insulator (it has high impedance). The body impedance measurement provides a direct estimate of total body water, lean mass, and body fat. Normal values ​​are in the order of 12 to 20% in men and 20 to 30% in women.

Other techniques are (CT) and abdominal, which allow diagnosing excess abdominal fat that accumulates around tissues and organs (and which is pathological fat): the visceral fat area / subcutaneous fat area index is used; an index greater than 0.4 defines visceral obesity. Although these techniques have their utility in research protocols.

In obesity it is also important to rule out secondary causes of it, for example thyroid malfunction or over-functioning of the adrenal glands.

Treatment of obesity

Genetic, metabolic, hormonal and environmental factors intervene in the development of obesity, the latter being the ones that we can modulate by modifying our lifestyle habits. We must not forget that the modification of lifestyle habits also modifies the alterations associated with obesity, such as high blood pressure, diabetes mellitus and others mentioned above.

The main objective of the treatment should be the reduction of weight in a prolonged period and then the maintenance of the loss achieved. A short-term goal is an initial weight loss of 10% at a rate of 225-1000 grams per week, although this should always be individualized according to each patient: in more obese patients perhaps more should be lost than in patients with less obesity . How these losses should be made is described in more detail in another chapter.

Changes in lifestyle

The change in diet includes a reduction in total calorie consumption. The measures go through avoiding a sedentary lifestyle, doing it regularly, correcting eating mistakes and doing one. Your doctor and nutritionist will tell you what steps to take and how to develop them.

Regarding food, there are some considerations that are important to highlight. Thus, it is important to know that alcohol is a non-negligible source of calories and that light foods also contain calories. Very restrictive diets should be avoided, since although they can condition significant weight losses, these losses are also of lean mass, entail the restriction or lack of certain nutrients and are not well accepted in the medium and long term. And what it is about is to change our eating pattern and maintain this change throughout life. The use of dietary fiber before meals can be helpful to decrease appetite by producing a satiating effect; We can take some nuts or fruits prepared with guar gum before we start eating.

Physical exercise should be of moderate intensity and daily, lasting half an hour a day. Activities such as walking up the stairs instead of using the elevator, walking to the next metro or bus stop and getting off one stop earlier, walking with a group of friends, cycling, etc. are recommended.

These changes must be supported by a change in the patient's behavior. This means that it is easy to start to change your diet and start doing some physical activity, but you quickly lose interest and return to the previous pattern of sedentary lifestyle and unbalanced eating. For this, it should be recommended to use self-monitoring techniques (such as, for example, keeping a diary, weighing and measuring food and physical activity carried out), stimulus control (such as not eating, watching TV or traveling, using dishes of dimensions smaller); improve lack of self-esteem and perception of one's own body.

It must be borne in mind that the achievement of results, that is, losing weight and maintaining the loss, is a slow process that should not despair the person and that often must include the participation of the doctor, the nurse and the a nutritionist

Changes in lifestyle cause a modest decrease (3 to 5 kg) in weight. For this reason, in some cases the use of drugs or even bariatric surgery will be necessary.

Pharmacotherapy

Drug treatments should be considered as complementary therapy to lifestyle changes in individuals with a BMI greater than 30 kg / m2 at entry and also in those individuals in whom lifestyle changes to lose weight have been ineffective. However, drugs should add to lifestyle modifications and should not replace them.

There are two types of drugs to treat obesity that your doctor may use: sibutramine, which acts on the central nervous system, and decreases appetite; and orlistat, a drug that prevents the absorption of fats in the digestive tract.

Bariatric surgery and non-surgical techniques

Weight reduction surgery should be considered in severely obese individuals (those with a BMI greater than 40 kg / m2) or in individuals with moderate obesity (BMI between 35 and 40 kg / m2) but who have some other medical problem serious.

that is achieved with these techniques is due to the decrease in caloric intake (it limits the amount of food that the stomach can retain, thus sending satiety signals to the hypothalamus with small intakes). With some surgeries the absorption of macronutrients is also prevented (that is, being causes a controlled malabsorption). With these methods, an average total loss of 30 to 35% of body weight is usually obtained, which is maintained in more than half of the patients at five years.

The intragastric balloon is not properly a surgery. It consists of the endoscopic placement of a balloon filled with saline or air in the stomach, with which the stomach is filled with less food and the feeling of satiety appears earlier. Average losses of 15-20 kg can be achieved over a 6-month period, although long-term results are not available on whether these weight losses are sustained.

Conclusions.

Excess weight usually indicates the presence of a greater amount of fat in the body. Obesity is not just a cosmetic issue, it is also a serious medical problem. Fat, especially that which accumulates in the abdomen, is associated with a high risk of suffering from diabetes mellitus, high blood pressure, cardiovascular diseases, respiratory diseases and more, and of dying from it. We must make every effort to reduce weight, with the help of a nutritionist and a doctor, and with drugs and surgery when necessary. For more information about this Program and about MAPFRE health insurance.

Precautionary measures

To maintain weight within normal limits, we must ensure that we have a balanced energy balance, that is, the calories we eat and those we expend must be approximately the same. This must be achieved with food and physical activity.

On the other hand, prevention measures must begin in childhood and must be carried out within the family and continued in schools.

• Genetic, metabolic, hormonal and environmental factors (or lifestyle) intervene in the development of obesity, the latter being the ones that we can modify.
• Obesity does not produce symptoms, except for the visual and aesthetic element. However, in the long term, it produces serious adverse effects on our health: hypertension, diabetes, cancer, infertility ...
• The main objective of the treatment should be the reduction of weight in a prolonged period and then the maintenance of the loss achieved.

Internal Medicine specialist