Obesity is the excessive or abnormal accumulation of fat or adipose tissue in the body that may impair health. Obesity has become an epidemic which has worsened for the last 50 years. In the United States, the economic burden is estimated to be about $100 billion annually. Obesity is a complex disease and has multifactorial etiology. It is the second most common cause of preventable death after smoking. Obesity is associated with multiple medical conditions and can cause serious complications in chronic conditions. Obesity needs multiprong treatment strategies and may require lifelong treatment. A 5% to 10% weight loss can significantly improve health, quality of life, and economic burden of an individual and a country as a whole.
Obesity has enormous healthcare costs exceeding $700 billion each year. Today the body mass index (BMI) is used to define obesity. The BMI is calculated as weight/heightThe weight being in kilograms and the height in meters. While the BMI does correlate with body fat in a curvilinear fashion in Asians and elderly people, a normal BMI may conceal underlying excess fat. Obesity can also be estimated by assessing skin thickness in the triceps, biceps, subscapular and supra-iliac areas. Dural energy radiographic absorptiometry scan can also be used to assess fat mass.
Obesity is the result of an imbalance between daily energy intake and energy expenditure resulting in excessive weight gain. Obesity is caused by multiple factors which can be genetic, cultural, and societal can be considered common. Other causes of obesity include reduced physical activity, insomnia, food habits, endocrine disorders, medications, food advertisements, and energy metabolism.
Most common syndromes associated with obesity include Prader Willi syndrome and MC4R syndromes, others like fragile X, Bardet-Beidl syndrome, Wilson Turner congenital leptin deficiency, and Alstrom syndrome are also associated with obesity.
Nearly one-third of adults and about 17% of adolescents in the United States are obese. According to Center for Disease Control and Prevention (CDC), 2011 to 2012 data, one out of five adolescents, one out of six elementary school age children, and one out of 12 preschool age children are obese. Obesity is more prevalent in African Americans, followed by Hispanics and whites. Southern US states have the highest prevalence, followed by the Midwest, Northeast and the west.
Obesity is a global problem with rates even higher than what are seen in North America.
Obesity is associated with cardiovascular disease, dyslipidemia, and insulin resistance, in turn, causing diabetes, stroke, gallstones, fatty liver, obesity hypoventilation syndrome, sleep apnea, and cancers.
Association of genetics and obesity is already well established by multiple studies. FTO gene is associated with adiposity. This gene might harbor multiple variants that increase the risk of obesity.
Leptin is an adipocyte hormone which reduces food intake and body weight. Cellular leptin resistance is associated with obesity. Adipose tissue secretes adipokines and free fatty acids causing systemic inflammation which causes insulin resistance and increased triglyceride levels, which subsequently contributes to obesity.
Obesity can cause increased fatty acid deposition in the myocardium causing left ventricular dysfunction. It has also been shown to alter the renin-angiotensin system causing increasing salt retention and elevated blood pressure.
Besides total body fat, the following also increase the morbidity of obesity:
The body fat distribution is important in assessing the risk for cardiometabolic health. The distribution of excess visceral fat is likely to increase the risk of cardiovascular disease.  Ruderman et al  introduced the concept of metabolic obese normal weight(MONW) subjects with normal BMI suffer from metabolic complications normally found in obese individuals.
Adipocytes have been shown to have an inflammatory and prothrombotic activity which can increase the risk of strokes. Adipokines are cytokines mainly produced by adipocytes and preadipocytes, in obesity macrophages invading the tissue, also produce adipokines. .
Altered adipokine secretion causes chronic low-grade inflammation, which may cause altered glucose and lipid metabolism and contribute to cardiometabolic risk in visceral obesity. 
Adiponectin has insulin-sensitizing and anti-inflammatory properties, the circulating levels are inversely proportional to visceral obesity.
All children six years and older, adolescents, and all adults should be screened for obesity according to the United States Preventative Services Task Force (USPSTF) recommendations.
Physicians should carefully screen for underlying causes contributing to obesity. A complete history should include:
Complete Physical examination Should be done and should include body mass index (BMI) measurement, weight circumference, body habitus, vitals.
Obesity focus findings like acne, hirsutism, skin tags, acanthosis nigricans, striae, Mallampati scoring, buffalo hump, fat pad distribution, irregular rhythms, gynecomastia, abdominal pannus, hepatosplenomegaly, hernias, hypoventilation, pedal edema, varicoceles, stasis dermatitis, and gait abnormalities can be present.
A standard screening tool for obesity is the measurement of body mass index (BMI). BMI is calculated using weight in kilograms divided by the square of height in meters. Obesity can be classified according to BMI:
Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:8 is considered significant.
Further evaluation studies like skinfold thickness, bioelectric impedance analysis, CT, MRI, DEXA, water displacement, and air densitometry studies can be done.
Laboratory studies include complete blood picture, basic metabolic panel, renal function, liver function study, lipid profile, HbA1C, TSH, vitamin D levels, urinalysis, CRP, other studies like ECG and sleep studies can be done for evaluating associated medical conditions.
Obesity causes multiple comorbid and chronic medical conditions, and physicians should have a multiprong approach in the management of obesity. Practitioners should individualize treatment, treat underlying secondary causes of obesity, and focus on managing or controlling associated comorbid conditions. Management should include dietary modification, behavior interventions, medications, and surgical intervention if needed.
The dietary modification should be individualized with close monitoring of regular weight loss. Low-calorie diets are recommended. Low calorie could be carbohydrate or fat restricted. A low-carbohydrate diet can produce greater weight loss in the first months compared to a low-fat diet. The patient's adherence to their diet should frequently be emphasized.
Behavior Interventions: The USPSTF recommends obese patients to be referred for intensive behavior interventions. Several psychotherapeutic interventions are available which includes motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and interpersonal psychotherapy. Behavior interventions are more effective when they are combined with diet and exercise.
Medications: Antiobesity medications can be used for BMI greater than or equal to 30 or BMI greater than or equal to 27 with comorbidities. Medications can be combined with diet, exercise, and behavior interventions. FDA-approved antiobesity medications include phentermine, orlistat, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine. All the agents are used for long-term weight management. Orlistat is usually the first choice because of its lack of systemic effects due to limited absorption. Lorcaserin should be avoided with other serotonergic medications due to the risk of serotonin syndrome. High responders usually lose more than 5% weight in the first three months.
Surgery: Indications for surgery are a BMI greater or equal to 40 or a BMI of 35 or greater with severe comorbid conditions. The patient should be compliant with post-surgery lifestyle changes, office visits, and exercise programs. Patients should have an extensive preoperative evaluation of surgical risks. Commonly performed bariatric surgeries include adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy. Rapid weight loss can be achieved with a gastric bypass, and it is the most commonly performed procedure. Early postoperative complications include leak, infection, postoperative bleeding, thrombosis, cardiac events. Late complications include malabsorption, vitamin and mineral deficiency, refeeding syndrome, dumping syndrome.
Weight loss associated complications
When weight loss is rapid, it is also associated with complications that include:
Complications associated with bariatric surgery
Obesity has enormous morbidity and mortality rates. Obese patients have a high risk of adverse cardiac events and stroke. In addition, the quality of life is poor. Factors that worsen morbidity include:
Management of obesity should also include prevention strategies with physical activity, exercise, nutrition, and weight maintenance.
The obesity epidemic is continuing to worsen and has become a public health issue. The management and prevention of obesity is best done with an interprofessional team that includes a bariatric nurse, surgeon, internist, primary care provider, endocrinologist, and a pharmacist. There is no cure for obesity and almost every treatment available has limitations and potential adverse effects.
The key is to educate the patient on the importance of changes in lifestyle. All clinicians who look after obese patients have the onus to educate patients on the harms of the disorders. No intervention works if the patient remains sedentary. Even after surgery, some type of exercise program is necessary to prevent weight gain. So far there is no magic bullet to reverse obesity- all treatments have high failure rates and some like surgery also have life-threatening complications. There is an important need for collaboration between the fast-food industry, schools, physical therapists, dietitians, clinicians, and public health authorities to create better and safer eating habits.
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