Obesity is a major preventable public health problem worldwide. Thanks to the advances in technology, our daily routine become easier and our comfort levels have increased leading to reduced physical activity. Availability of high calorie refined foods and soft drinks increased our daily calorie intake. End result of these life style changes is obesity. Technology has side effects!
WHAT IS OBESITY?
Body fat percentage greater than 25% in males and 35 % in females indicates obesity. Most commonly used parameter to define obesity is BMI (Body Mass Index). It is calculated using body weight and height
BMI = Body weight in kilograms/ square of height in meters = kg/ m2.
Indian BMI categories are different! Indians have more fat and less muscle compared to foreigners with same height and weight. So Indians are at risk of developing several medical problems at lower BMI. So Indian BMI categories have been changed.
Check your BMI now. You may have excess weight! Body mass index (BMI) ≥ 25 kg/m2 indicates obesity in India. Cut off limits for overweight and obesity are 23 and 25 kg/m2 in Indians. In western countries these limits are 25 and 30kg/m2respectively. BMI alone is not sufficient to define obesity. Classification based on BMI alone, wrongly categorize all muscular individuals, including Hollywood and Bollywood hunks, as obese! So other parameters, like waist circumference and waist to hip ratio, are used to define obesity in addition to BMI. These are better predictors of obesity than BMI in Indians.
Waist circumference (WC) >80 cm in females and >90 cm in males is considered as obesity in Indians. Waist circumference is not equal to your pant size! Belly protrudes above the pant. Waist circumference is the measurement at the maximum protrusion of your belly. Don’t pull your belly inside while measuring your waist circumference!
Another parameter is waist to hip ratio (WHR). This is the ratio of maximum circumference at waist and maximum circumference at hip. WHR > 0.8 in females and > 0.9 in males indicates obesity in Indians. In central obesity, main area of fat accumulation is in the tummy. This is very common in India and more dangerous than generalized obesity.
TECHNOLOGY GIVES YOU COMFORT. FAT COMES FREE OF COST WITH IT.
Excess eating and reduced physical activity lead to obesity in 90% of individuals. Lifestyle changes, influenced by advances in technology, are responsible for this. Effect of our genes adds fuel to this problem. In remaining 10% endocrine problems, medications etc., are responsible. People suffering from excess weight problem come to me saying that they eat less but gain a lot of weight. In fact even this less intake is more for them. In these individuals certain percentage of intake is converted into fat due to the effect of multiple factors.
Energy for all our activities comes from diet. “Calorie” is the unit to measure energy. One gram of carbohydrates contains 4 Calories. One gram of fat (oil) contains 9 Calories. Those who indulge in heavy physical activity need approximately 3500 Calories of energy per day. Those who lead sedentary life style need approximately 2000 Calories of energy per day.
What happens to the diet we take? Food reaches stomach through a long tube (esophagus). Stomach capacity and our appetite decide how much we can eat at any given point of time. Stomach acts like a grinder and breaks the food into small pieces. Ghrelin is an appetite stimulating hormone. 80% of this hormone is produced from the upper part (fundus) of the stomach. When stomach is empty, this hormone increases and makes us feel hungry. When stomach is full, this hormone comes down leading to satiety.
Figure – Gastrointestinal tract + Hepatopancreticobiliary system
E – Esophagus; S – Stomach; D – Duodenum; J – Jejunum; I – Ileum; A – Appendix; C – Caecum; AC – Ascending Colon; TC – Transverse Colon; DC – Descending Colon; SC – Sigmoid Colon; R – Rectum; L – Liver; GB – Gall Bladder; P – Pancreas
From stomach food reaches the small intestine. Most of the digestion of food and absorption of Calories, vitamins and minerals occur in the proximal part of the small intestine. In the last part of intestine, appetite suppressing hormone, GLP 1 (Glucagon Like Peptide 1) is produced. Several other hormones and factors are involved in energy consumption and expenditure. These include peptide YY, amylin, leptin, gut micro-organisms etc. Body converts excess consumed energy into fat and stores it for future use. Purpose of fat is to provide energy when needed. This requirement comes mainly with physical activity. And our physical activity is almost zero because of advances in technology. Now you don’t need to move even an inch to get your works done. Laptops, internet, remotes, mobiles, cars with auto transmission, showers, bath tubs, escalators, lifts – all are responsible for fat accumulation. As the need to burn fat never comes, it goes on accumulating.
SET POINT FOR FAT STORAGE CONTROLS FAT STORES
You don’t need to take too many calories to gain excess weight. For example if you are taking 2090 Calories instead of 2000 per day, daily additional intake is only 90 Calories. But this additional intake adds 10 grams of fat every day, 300 grams of fat in a month, 3.65 kg in a year and 36.5 kg in 10 years! This means just consuming 90 Calories excess energy per day can lead to 36.5 kg weight gain in 10 years.
Some individuals will not gain weight in spite of eating more. And others gain a lot of weight in spite of eating less. Why is this difference? Every individual has a set point for fat storage. This set point tightly regulates the total amount of fat to be stored in the body, regardless of the amount of food intake. Obese individuals have higher fat set point, so more fat is deposited in them.
Why obese individuals have higher set point? All obese people are not born with high fat set points. Set point is generally normal at the time of birth. But because of the unhealthy food habits and life style, it gradually increases over a period of several years. Chemicals in refined, processed foods increase this set point. Once increases it doesn’t come down. As long as fat set point is at higher level, no matter what you do, fat stores are maintained at that level and the effects of weight loss attempts will be temporary.
Food items with empty Calories just provide additional energy but don’t carry any nutritional value. Unhealthy foods like biscuits, chocolates, cookies, candies, sweets, cakes, ice creams, pizzas, burgers, chips, fries, soft drinks provide lot of empty Calories and also increase fat set point.
OBESITY IS NOT JUST A COSMETIC PROBLEM. IT IS A DISEASE.
Obesity can lead to more than 65 types of diseases. Obese individuals are at increased risk of developing type 2 diabetes and hypertension. Obesity and type 2 diabetes go hand in hand, so both together are called Diabesity. Blood cholesterol levels are usually higher in obese. This leads to fat accumulation in their blood vessels increasing risk of heart attack and stroke. Obesity leads to joint pains and osteoarthritis as joints bare excess weight. Obstructive sleep apnea with narrowing or blockage of air way during sleep is common in obese. This leads to snoring, lack of sleep, frequent awakening, frequent urination at night and excessive day time sleepiness. Obese individuals easily become tired and breathless even with limited physical activity. They are at increased risk of developing depression, gall stones, hernias, certain cancers etc. Obese females have irregular periods and higher incidence of abortions and difficult labor. Obesity and associated medical problems increase life risk and reduce life span by 5 to 20 years.
PREVENTION OF OBESITY
Prevention is always better than cure. It is always better to avoid becoming obese rather than trying to get rid of excess fat once it accumulates. Avoid unhealthy, refined foods. Avoid over eating, snacking. Whole grains are better than refined grains. So choose brown rice, brown bread in place of white rice and white bread. Remember even white rice is unhealthy! Eat chapathis made of whole multigrain atta. Use skimmed low fat milk (<1% Milk) instead of whole milk. Non vegetarians can eat fish, sea food, skinless chicken instead of mutton. Use egg white, discard egg yellow. Eat vegetarian high protein foods like beans, seeds, soy products, nuts. Choose water, fruit juices in place of soft drinks, alcohol. Alcohol provides lot of empty Calories. Eat fruits, small quantity of nuts as snacks in place of high sugary foods like biscuits, chocolates, candies, cookies, ice creams. But avoid fruits like mangoes, grapes that are very high in sugars. Avoid sweets, cakes, deep fried food like pizzas, burgers, mirchi bajji, samosa, potato chips, french fries which are high in trans fats. Prefer chapathi, bread, idly as breakfast in place of oil food like vada, poori etc. Reduce oil usage while preparing dishes. Use poly or mono unsaturated fatty acids (PUFA – sunflower oil, safflower oil, MUFA – peanut oil) in place of saturated fats like cocconut oil, palm kernel oil, cheese, vanaspati, ghee, butter and dalda.
It takes just half minute to eat a sweet having 200 calories. But to get rid of that energy you need to walk for 1 hr or run for 15 min. If you follow healthy food habits and do regular physical exercise then your children will follow the same. If you tell but don’t follow then your children won’t learn healthy habits.
Daily do physical exercise for a minimum of half an hour. You don’t need to do this at a stretch. Result of doing exercise three times daily of 10 min each stretch is equal to doing exercise for 30 min at a stretch.
DIET CONTROL & EXERCISE ALONE WON’T HELP FOR WEIGHT LOSS IN OBESE
Reducing the excess weight is a big problem for several obese individuals. While diet control and exercise are good for health, they alone are not sufficient to produce permanent weight loss in obese. As mentioned earlier obese individuals have higher fat set point. They may succeed in losing few kilos of fat by diet control and exercise. But this weight loss is temporary. Diet control, exercise can’t alter body fat set point. So as soon as they are initiated, set point brings hormonal changes in the body to counter their effect and makes sure to replace the lost fat over a period of 6 months to 5 years. These changes include increased Ghrelin, reduced GLP 1 leading to increased appetite and reduced energy loss in the form of heat from the body. So appetite increases and continues to increase until diet control and exercise are stopped. Fat set point is so powerful that these hormonal changes persist for several months even after stopping diet control and exercise. As a result, not only the lost fat is replaced but there will be few kilos additional weight gain. In the war between fat set point and will power the winner is always the former. Match has been fixed already!
I encourage my patients to restrict calorie intake, do regular physical activity and have commitment for both. If the weight burden is not high then it is not difficult to control weight with these methods. But if the BMI is ≥ 30 kg/m2 then it is almost impossible to reduce weight by these methods.
VERY LOW CALORIE DIET PRODUCTS, NATUROPATHY CAN’T ALTER FAT SET POINT
Diet control, exercise, very low calorie diet products, naturopathy, liposuction etc target the excess fat deposited in fat stores. They can’t alter the set point for fat storage. Any method that can’t alter the fat set point can’t produce permanent weight loss. There are several commercially available very low calorie diet products like Amway, Herablife etc. They mainly act by restricting Calorie intake. So there will be initial weight loss. But as fat set point is not altered, all the lost weight is replaced in due course of time. So their effect is temporary. There is no point in trying them if BMI is ≥ 30 kg/m2. Story of naturopathy is similar. Diet given during naturopathy treatment helps in initial weight loss. But as fat set point is not altered, weight is regained.
ROLE OF MEDICINES IS LIMITED IN THE TREATMENT OF OBESITY
There are several anti obesity medicines available in which Orlistat, Lorcaserin, Phenteramine + Topiramate have FDA (Food and Drug Administration) approval. These medicines are useful to increase weight loss only in those individuals who are already losing weight by diet restriction and exercise. Moreover weight is lost as long as these medicines are taken. Once discontinued, all the lost weight is regained over a period of time, again due to the effect of fat set point. Sibutramine, an anti-obesity drug which act on brain and reduces appetite, is banned in India, USA and other countries due to its cardiovascular side effects.
ENDOSCOPIC METHODS OF TREATMENT FOR OBESITY
Extensive research is being carried out on endoscopic bariatric procedures as they are more effective than medicines and less invasive than surgery. Certain procedures like intra gastric balloon are useful as a bridge to bariatric surgery as they reduce surgical risk by providing weight loss to certain extent before surgery. Presence of balloon inside the stomach reduces its effective volume. Individual with intra gastric balloon gets early satiety after taking even small quantity of food. Balloon has to be removed after 6 months. If it is left beyond 6 months there is risk of spontaneous deflation, intestinal obstruction. Intra gastric balloon is not suitable as a primary bariatric procedure due to its limited durability and effectiveness.
Endo luminal suturing procedures are used as early intervention endoscopic procedures in Grade 1 obesity patients who do not qualify for bariatric surgery. They are also used as revisional procedures after failed bariatric surgery. They can’t be used as primary bariatric procedures as the degree of weight loss is inadequate after these procedures. Endoscopic staplers function similar to adjustable gastric band. These devices are still in trials. They can be used as primary bariatric procedures in future if they are successful in trials.
LIPOSUCTION IS NOT A TREATMENT OPTION FOR OBESITY
Surgical liposuction, non surgical liposuction, cool sculpting, vaser liposuction are cosmetic procedures aimed at removal of unwanted fat deposits in a normal or over weight individual. These should not be used as treatment options for obesity. In liposuction maximum 10% of excess weight is removed at a time. Liposuction doesn’t alter the fat set point. All the lost weight is regained in due course of time. Some feel they can get rid of few kilos of fat by liposuction and remaining by diet control and exercise. But this never happens. Those individuals who can reduce weight by diet control and exercise don’t need liposuction. Those who can’t reduce in such way, will not reduce even after liposuction.
BARIATRIC SURGERY RESULTS IN PERMANENT, EFFECTIVE WEIGHT LOSS
Bariatric surgery is the only scientifically proven method for permanent and effective weight loss. Mechanism of weight loss after this is different from other methods. Sleeve gastrectomy and diversion procedures re-set the fat set point to a lower level. This new low fat set point in turn reduce fat burden and maintain low body fat stores.
Bariatric surgery is performed on stomach and small intestine. Excess fat is not removed in this method. Majority of the obese individuals fail to reduce weight by diet restriction and regular exercise. Even if they lose initially, weight is regained due to the effect of fat set point. These are benefited from bariatric surgery. Bariatric surgery is very safe and effective tool for permanent weight loss.
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