– Obesity is not just a cosmetic problem.
– It can lead to more than 200 medical problems including
- type 2 diabetes,
- high blood pressure (hypertension),
- high blood fat levels (hyperlipidemia),
- heart attack,
- brain stroke, joint pains (osteoarthritis),
- snoring (obstructive sleep apnea) and
– Females with obesity have irregular periods, higher incidence of abortions and difficult labor. – Obesity increases life risk by 50 to 100% and reduces life span by 5 to 20 years.
– Body mass index (BMI) is the most commonly used parameter to define obesity.
– Indians have more fat and less muscle compared to foreigners with the same height and weight. – Indians are at risk of developing several medical problems at lower BMI.
– So Indian BMI categories have been changed.
– BMI is ≥ 25 kg/m2 indicates obesity in Indians/ Asians (In western countries ≥ 30 kg/m2).
– It is easy to calculate BMI.
BMI = Body weight in kilograms/ height in meters2 = kg/ m2.
Based on BMI individuals are categorized as below
BMI for Indians/ Asians
BMI for Western Countries
18.50 to 22.99 kg/m2
18.50 to 24.99 kg/m2
23.00 to 24.99 kg/m2
25.00 to 29.99 kg/m2
Grade 1 Obesity (Mild Obesity)
25.00 to 29.99 kg/m2
30.00 to 34.99 kg/m2
Grade 2 Obesity (Severe Obesity)
≥ 30.00 kg/m2
35.00 to 39.99 kg/m2
Grade 3 Obesity (Morbid Obesity)
40.00 to 49.99 kg/m2
50.00 to 59.99 kg/m2
Super Super Obesity
60.00 kg/m2 and above
– Parameters like waist circumference (WC) and waist to hip ratio (WHR) are more specific parameters than BMI to define obesity.
Following parameters indicate obesity.
Waist Circumference > 80 cm in females and > 90 in males in Indians
Waist to Hip Ratio > 0.8 in females and > 0.9 in males in Indians
IS YOUR BMI ≥ 30 kg/m2 ?
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– We get energy from food.
– Part of this energy is utilized for metabolism, heat production and remaining energy is converted into fat. This total process is called energy balance.
– Several factors control body energy balance.
– These factors decide the amount of fat to be stored in the body. This amount is called “fat set point” or “fat mass”.
– Fat set point is high in individuals suffering from obesity and low in thin individuals.
– These factors include GLP1, Peptide YY, Ghrelin, Amylin, Leptin, Adiponectin, GIP and Anti-incretins. Ghrelin increases hunger. 80% of Ghrelin is produced from the upper part (fundus) of the stomach. When stomach is empty, Ghrelin increases and makes us feel hungry. When stomach is full, it comes down leading to satiety. In the last part of intestine, GLP 1 (Glucagon Like Peptide 1) and Peptide YY are produced. They suppress appetite. If you eat more, GLP 1 and Peptide YY increase and appetite comes down.
– Even bile acids and gut microorganisms control fat set point.
Triggers altering fat mass –
– Will power can’t alter ‘fat mass’.
– But following unhealthy lifestyle can trigger these factors and reset the ‘fat mass’ to a higher level.
Unhealthy life style includes
– Intake of unhealthy foods
– Lack of physical activity
– Irregular food habits
– Lack of sleep
– Increased stress
– Changes in circadian rhythm (working at night, sleeping in the morning)
– Even using certain medications (steroids, psychiatric medicines) can triggers these factors.
– Some people have genetic tendency to gain weight. In these individuals, unhealthy lifestyle can trigger weight gain.
– Overeating of unhealthy foods and lack of physical activity are most common triggers of weight gain.
– Endocrine and genetic problems are responsible for obesity in some individuals.
Are you gaining weight in spite of eating less?
– Lifestyle modifications are necessary to maintain fitness and prevent obesity. They are also necessary to lose weight.
– Healthy lifestyle includes
- Healthy diet,
- Regular exercise,
- Taking food on regular timings,
- Adequate sleep and
- Stress free life.
– Obesity prevention should start at childhood. Even children should follow healthy food habits and exercise daily.
– Majority of the individuals with mild obesity benefit from lifestyle modifications.
– If your BMI is < 30 kg/m2 you can get rid of excess fat by healthy lifestyle including diet modification, and regular physical activity.
– We need to find out the triggers for weight gain and those need to be addressed.
– If endocrine, genetic problems and medications are triggering weight gain, then they need to be dealt with.
– In most individuals overeating of unhealthy foods and lack of exercise trigger weight gain.
– Dieting (diet restriction) without altering food habits will not result in long lasting weight loss.
– If the cause of weight gain is unhealthy diet and lack of exercise, then changing to healthy diet and doing regular exercise can reduce ‘fat mass’.
– As long as healthy diet and regular exercise are followed ‘fat mass’ remains low. Once stopped, ‘fat mass’ increases again. So you need to continue healthy diet and exercise forever to prevent weight regain.
– When BMI is ≥ 30 kg/m2 body already got adopted to a higher fat mass.
– Even if healthy diet and exercise are followed, there will not be much weight loss.
– Even if you lose more, you will regain weight.
– Lifestyle modifications are not enough for long lasting and effective weight loss when BMI is ≥ 30 kg/m2.
– 96 out of 100 members fail to lose weight or regain weight with non surgical methods, if BMI is ≥ 30 kg/m2.
– When you start dieting and exercise, you need to fight against the body factors controlling ‘fat mass’ to lose weight.
– If you fight, these factors won’t keep quiet. They fight back (increased Ghrelin, reduced GLP 1 & peptide YY) and induce counter changes in the body
- Hunger is increased,
- Metabolism and heat production are reduced to conserve energy.
– A stage will come when you can’t tolerate hunger, start eating more food resulting in weight regain.
– Even though there is initial weight loss, weight will come back over a period of several months and sometimes you gain more weight.
Very low calorie diet (VLCD)
can’t help when ‘fat set point’ is very high and BMI is ≥ 30 kg/m2.
– Those individuals who fail to achieve long lasting weight loss with non surgical methods, benefit from bariatric surgery.
– Bariatric surgery is very safe, highly effective and scientifically prove method for long lasting weight loss.
– Anti obesity medicines help you to increase weight loss to some extent, when you are already losing weight by diet modifications and exercise especially when BMI is < 30 kg/m2.
– These medicines include
- Phentermine + Topiramate (Qsymia),
- Liraglutide (Victoza),
- Dulaglutide (Trulicity) and
- Semaglutide (Rybelsus).
– Their effect is very less compared to bariatric surgeries.
– If you lose weight with medications, weight loss will be maintained as long as these medicines are taken.
– Once discontinued, all the lost weight will come back within two years, because of the effect of factors controlling fat mass.
Role of medicines in the treatment of obesity is limited.
– Sibutramine, an anti-obesity medicine which act on brain and reduces appetite, is discontinued in India, USA and other countries due to its cardiovascular side effects. Side effects of sibutramine include increased blood pressure, insomnia, headache, constipation, dryness of mouth, risk of heart attack and stroke.
– Orlistat prevents absorption of up to 30 percent of fat in food by antagonizing the action of pancreatic lipase enzyme in digestive juices. It has no effect on digestion & absorption of carbohydrates. So it is not useful for those consuming excess sugars and eating very excess fat foods. As certain percentage of fat is not absorbed, side effects include steatorrhoea (foul smelling sticky stools because of presence of undigested fat in stools) and sometimes incontinence of stools. According to several reports orlistat has been implicated in liver failure, acute kidney injury and pancreatic injury.
– Phentermine + Topiramate act on brain and reduce appetite.
– Liraglutide, Dulaglutide and Semaglutide are GLP1 analogs. They reduce appetite and delay gastric emptying. These can be used in the treatment of mild obesity. They are also used as an adjuvant therapy in those individuals who regain weight after gastric sleeve or gastric bypass surgery.
Liposuction & cool sculpting are for body shaping, not for weight loss
– Surgical liposuction including vaser liposuction, and non surgical liposuction including cool sculpting are body shaping procedures aimed at removal of unwanted fat deposits in a normal weight individuals.
– These are not for weight loss.
– In these procedures fat is removed from different body parts to improve cosmetic appearance.
– Liposuction and cool sculpting can’t alter body fat mass.
– So whatever amount of fat that is lost will come back in other parts of the body.
– They may help as a supplementary to healthy diet and exercise when BMI is < 30 kg/m2.
– Some feel they can get rid of few kilograms of fat by liposuction and remaining by diet control and exercise. But this never happens.
– Those individuals who can reduce weight by diet modifications and exercise don’t need liposuction.
– Those who can’t reduce weight by lifestyle modifications, will not achieve long lasting weight loss even after liposuction and cool sculpting.
– Bariatric surgery is scientifically proven, very safe method for long lasting and significant weight loss.
– Mechanism of weight loss after bariatric surgery is different from other methods.
– Sleeve gastrectomy, Gastric bypass, and Sleeve plus bypass combination surgeries re-set ‘fat mass’ to a lower level by inducing physiological changes altering body energy balance.
– These are performed on stomach and intestine by laparoscopic method (by putting small holes on the tummy).
– Bariatric and metabolic surgeries are essentially same. If the purpose of surgery is weight loss, then it is called bariatric surgery. If the purpose of surgery is remission from type 2 diabetes and other co-morbid medical conditions, it is called metabolic surgery.
– Majority of the individuals suffering from obesity fail to lose weight by diet control and regular exercise. Even if they lose initially, weight is regained due to the effect of factors controlling body fat mass. Bariatric surgery helps these individuals to achieve their weight loss goals.