The term obesity refers to the condition in which the BMI of the patient is above 30. Weight loss Surgery is recommended in patients who are morbidly obese ie BMI above 40.
PROBLEMS OF EXCESS WEIGHT
Being overweight is associated with real physical problems (side-effects) which are now well recognized. The most obvious is an increased mortality rate directly related to weight increase. In a 12 year follow-up of 336,442 men and 419,060 women, it was found that the mortality rates for men 50 percent above the average weight were increased approximately two fold (ie x2). In the same weight group the mortality was increased five fold (x5) for diabetics and four fold for those with digestive tract disease. In women, the mortality was also increased two fold, while in female diabetics the mortality risk increased eight fold and three fold in those with digestive tract disease.
It is apparent therefore that overweight people of both sexes, especially young overweight people, tend to die sooner than their lean contemporaries. While obesity, of itself, is a risk factor, most mortality and morbidity is associated with the co-morbid conditions. This applies to non-operated as well as peri-operative mortality and morbidity. These conditions have been outlined in the 1985 National Institutes of Health Consensus Conference and include:
A Veterans Administration study of 200 morbidly obese men aged 23 to 70 years, with an average weight of 316 lbs (143.5 kg) showed a twelve fold increase in mortality in the 25-34 year age group and a six fold increase in the 35-44 year age group. During the average follow-up period of 7 ½ years, 50 of the original group had died. An interesting ongoing study in this regard is the Swedish Obesity Study (SOS) in which 2000 patients have been randomized to diet therapy and gastric restrictive surgery. The study is still incomplete but indicates reduction in diabetes, hypertension and lipid disturbances in the surgically treated group who had bariatric surgical treatment.
The Nurses Health Study has reported obesity related health risks in women at much less impressive degrees of obesity. Weight gain after the age of 18 years was shown to be a strong predictor of cardiovascular risk. This large prospective cohort study involving 115,886 women apparently healthy at baseline, showed a strong association between BMI and cardiovascular disease. As compared with women whose BMI was less than 21 kg/m2, the age and smoking adjusted relative risk of non-fatal myocardial infarction and fatal coronary artery disease for women with BMI of 25-29 was 1.8 (95%CI: 1.2-2.5), and that for women with BMI ≥ 29 was 3.3 (95%CI:2.3-4.5).
The Framington study noted that the first cohort to terminate because of demise of all participants was the morbidly obese. Finally, in this litany of risk, the Guinness Book of Records memorializes the worlds heaviest individuals. Note that none of these lived over 40 years of age. Recent work suggests that the significantly increased mortality risk of morbid obesity reverts to normal following successful weight loss surgery.
CARDIOVASCULAR
Obesity is dangerous to health because of the associated increased prevalence of cardiovascular risk factors such as
Statistically significant improvements have been observed in both diabetes and hypertension, with >10 percent weight loss, and in cardiovascular conditions, with 5 percent weight loss.
Data from the Framingham study support the estimate that a ten percent reduction in body weight corresponds to a twenty percent reduction in the risk of developing coronary heart disease.
The serious consequences of severe obesity are well documented and include
DIABETES
The association between average weight of population groups and the prevalence of non-insulin-dependent diabetes has been repeatedly observed. The risk for diabetes has been reported to be about twofold in the mildly obese, fivefold in moderately obese and tenfold in severely obese persons. The duration of obesity is also an important determinant of the risk for developing diabetes.[28] In cross-sectional studies, obesity has been shown to be associated with an increased prevalence of non-insulin-dependent diabetes in both men and women. The NHANES II data found that the overall relative risk of developing diabetes was 2.9 times higher for obese persons who are 20-75 years old. The risk of developing diabetes also increases with age, if a family history is present and if the obesity is central.
A prospective study in Scandinavia showed that moderate obesity was associated with a 10 fold increase in the risk of diabetes. This risk increased sharply as obesity became more severe. In patients who are morbidly obese and candidates for surgical treatment, diabetes and hypertension are highly correlated with body weight and waist-hip ratio.
CANCER
Cancer mortality rates are increased in severely obese females; e.g. endometrium (5.4 times), gallbladder (3.6 times), uterine cervix (2.4 times), ovary (1.6 times), breast (1.5 times). Cancer mortality rates are increased in severely obese males; e.g. colorectum (1.7 times), and prostate (1.3 times).
The 2000 US Census estimates the adult population ≥ 20 years and < 70 years at 185,634,000 persons. Prevalence estimates, using NHANES III data obtained a few years previously, are 2.8% for US adults with a body mass index (BMI) ≥40 kg/m2 and 8% for those with a BMI ≥35 kg/m2,[37] These numbers approximate to six million morbidly obese adults and another 9.6 million (8.0-2.8 =5.2%) with BMI >35 but <40. The relative risk for all cause mortality is increased at BMI levels ≥30 kg/m2.
PSYCHOSOCIAL ISSUES
Health care for the six million morbidly obese adults in the United States of America, eighty percent of whom are women of childbearing age, has been hampered by the misconception that body weight is not a physiologically regulated variable, but rather determined by acquired food habits and conscious and unconscious desires. Obesity represents a management challenge for physicians and a psychological and biological challenge for patients.
Lack of respect for the morbidly obese is an issue of concern. A survey of severely obese individuals found that nearly eighty percent reported being treated disrespectfully by the medical profession.
There are widespread negative attitudes that the morbidly obese adult is weak-willed, ugly, awkward, self-indulgent and immoral. This intense prejudice cuts across age, sex, religion, race, and socioeconomic status. Numerous studies have documented the stigmatization of obese persons in most areas of social functioning. This can promote psychological distress and increase the risk of developing a psychological disorder. The morbidly obese patient is at risk for affective, anxiety and substance abuse disorders.
The obese often consider their condition as a greater handicap than deafness, dyslexia or blindness.
These rationales demonstrate the value of bariatric surgery for both increasing life expectancy and quality of life for the morbidly obese.