Obesity is a chronic relapsing progressive disease similar to diabetes mellitus or hypertension. This impacts severely on individuals and society alike. Obesity is not a lifestyle choice caused by individual greed but rather caused by health inequalities, genetic influences and social factors. A persons health is influenced by a complex mix of health behaviors, genetic factors, lean mass, level of fitness and environmental risk. When diabetes is associated with obesity it is called diabesity. There are metabolically healthy obese individuals and metabolically unhealthy lean individuals. This is explained by the presence or absence of fat in the wrong places. Sumo wrestlers are metabolically healthy when they are wrestlers. The moment they retire and stop their exercises, visceral adiposity ( fat around liver, pancreas and in muscles) increases making them vulnerable. Visceral adiposity is what triggers insulin resistance.
White adipose tissue is a primary storage of energy and brown adipose tissue is for thermogenesis.
More than half the worlds population is affected by overweight or obesity related issues. Traditionally, one is labelled as obese if the BMI is >30. Insulin resistance is when the effect of insulin is less responsive which, in turn, leads to diabetes. Metabolic syndrome is a combination of insulin resistance, hypertension, and altered lipid regulation associated with obesity.
Body Mass index (BMI) has been used as early as 1832 and was coined by Ancal Keys. However, it was in mid 1900`s that the WHO recognized the impact of obesity. There are some limitations to relying only on BMI to quantify obesity and decide the plan of management. BMI does not accurately measure fat content or account for the sex and racial differences in muscle and fat distribution. The BMI is unreliable in muscular men and pregnant women. In those with similar BMI, the fat content is higher among women than among men.
Body weight is a sum of the muscle, bone and water weight.
Waist circumference, waist to hip ratio (WHR) or dual -energy X-Ray absorptiometry are betters measurements, but the dual-energy X-Ray is expensive and may be limited to high end centers. Skin fold thickness, underwater weighing, CT and MRI are also used to assess. Other indices such as Brocas Index, calculated by subtracting 100 from the height ( in cms); Corpulence index is calculated by dividing the actual weight by the desirable weight and Ponderal Index by dividing the height (in cm) by the cube root of the weight in kg
Effects of being obese: there is increased chances of developing heart related diseases, stroke, gout, infertility, polycystic ovary disease, diabetes, high blood pressure, gall stones, non alcoholic fatty liver disease, mechanical disorders such as knee and back related problems and obstructive sleep apnoea.
Causes of obesity: traditionally an imbalance of food intake and energy expenditure. However, some medicines such as chronic use of steroid tablets, insulin, antipsychotic medications, anti depressants such as citalopram, and amytryptaline can be the cause. Having co-existant medical conditions such as Cushings` disease, hypothyroidism, hypothalamic diseases and growth hormone deficiency in early life may be associated with obesity.
There is plenty of stigma associated with obesity and as a healthcare provider, one needs to ask permission from the patient before discussing their weight related issues. Once they approve, get a detailed history with emphasis on their daily habits, diet, triggers for eating, stress levels, sleep habits, family history, any medicines which might trigger the weight gain and co-existant diseases. Laboratory work up is essential besides other related tests and a sleep study, if indicated.
The management of obesity includes lifestyle changes– incorporating an adequate amount of physical activity- this is probably the most difficult step. These people are often self conscious and feel they are being body shamed, they feel being a misfit and lack the motivation and drive to persist. Forming a group may help them overcome such barriers. There are garment shops catering to plus size dresses. Start slow and steady and increase the duration and intensity of the activity gradually. Any movement is better than no activity at all. If the climate is harsh to exercise outdoors, they can do indoor exercises or even resort to interactive games such as X box or Play station. Sweating, smelling and itching are concerns in the beginning. Rubbing of thighs causing skin rashes or increased rashes in skin folds such as neck folds, arm pits, under the breasts, under belly or between the thighs are all possible to be treated with dusting some powder or meeting a dermatologist. Vary the exercise plans such as dancing, rucking ( walking with a weighted bag on the shoulders), walking with friends, listening to music while walking or swimming can help. Swimming does not cause bony pain and can actually help tone up the whole body besides being an excellent stress buster. Yoga, Pilates, dancing indoors, Hula Hoop, skipping, Tai Chi or spot jumping help in your journey. Walking the pet, playing with children can be an enjoyable way to help.
Dietary modifications: the social media is flooded with materials. I will just concentrate on some practical tips. There is no perfect diet. Have a balanced diet so that you do not feel hungry in between. Taking a glass of warm water before meals can help, avoiding bottled salad dressings, reduction of processed food and carbohydrates can help. Cutting down on sugar beverages, alcohol, taking clear soups, pureed vegetables, slice of an apple with peanut butter ( if not allergic to peanuts) and having home cooked food rather than food cooked outside of home really matter. Planning the meals, chewing on the food well while eating, eating off a small plate and not heaping the food onto the plates and avoid eating in front of the screen can go a long way to help. Shop smart and never when hungry. Skipping breakfast will not help and neither will late night heavy dinners. Walk after meals for some time rather than sit or lying down helps in a major way. Be wary of temptations such as free combo offers, king size, extras and so forth.
Behavioral therapy may be needed by a trained psychologist.
Medications: Medicines such as Phendimetrazine, diethylpropion and benzphetamine are used for those wishing a short term plan. Orlistat, naltrexone, bupropion, phenteramine, topiramate, and GLP 1RA drugs ( liraglutide– Victoza and Saxenda; Dulaglutide – Trulicity weekly; semaglutide– oral Rybelsus daily, weekly injectables- Wegovy, Ozempic; Tirzapetide– Mounjaro weekly are used for long term plans. There are new research molecules undergoing trials for safety. Oral semaglutide 50 mg tablet, oral amycretin, dual amylin and GLP1RA, oral ecnoglutide, oral orforglipron and Retatrutide -triple agonist injection are all being planned out pending approval. All these medicines basically help to curb hunger, improve satiety, reduce bingeing and improve metabolism.
GLP1, Amylin improve satiety, the hormone Gherlin increases hunger, the hormone dopamine controls the cravings and opoids control the pleasure associated with food. Be careful of alternative weight loss medicines that cost much lower, but no quality control is there in the manufacture and may be associated with serious adverse effects.
Stopping the medicines may be associated with a rebound weight regain and associated with gastric upset and nausea.
Caution with this medicine: Before starting a GLP 1 RA medicine( Wegovy, Ozempic or Mounjaro) please meet a healthcare provider. If there is a strong family history of Medullary Cancer of thyroid or history of medicine or alcohol induced pancreatitis, it is advisable not to be on this class of medicine. People with severe gastritis are advised not be started on this medicine. This is best avoided in those who are pregnant or breastfeeding or in children.
Papillary cancer or follicular cancer of thyroid, thyroiditis, hypothyroidism are not contra indications to start this medicine. If unsure about family history or medullary cancer of thyroid, discuss the risks with the treating doctor. Pancreatitis ( inflammation of pancreas) can be associated with gall stones. This is not a contra indication to start this medicine. If the gall bladder has been removed or if having pancreatic cysts
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