Obesity: Battle of the Bulge

Obesity, a major cause for concern worldwide, is more than a growing epidemic. It is time we tackled its many dangers effectively

ObesityFat people are generally thought of as jolly, good fellas. There ends the good news, because they are often identified as candidates for an early heart attack.

Though this is oversimplification of facts, being overweight, or obese, is a serious concern today.

Obesity is not just a malady. It is a sign-syndrome that is nothing short of a disease. Obesity may be defined as an "abnormal high body weight due to excessive accumulation of body fat."

During prehistoric times, man was basically a hunter and gatherer. Food supply, therefore, was intermittent and unpredictable, at best. It was important to store food in the form of energy, whenever extra food was available. It was necessary for survival. It still is.

Nature, therefore, devised cells, which could store food in the form of fat. These cells are fat cells; they release energy in the form of free fatty acids. Whatever we eat contains fats, proteins, and carbohydrates.

Fats give us nine calories per gm while carbohydrates and proteins give four each. Energy is counted, thus. This physiological mechanism operates through our nervous and glandular systems.

Excess food, excess fat

When there is abundant food, accompanied by a sedentary lifestyle, along with what is called as genetic predisposition, it can lead to increased fat tissue and unwanted consequences, including overweight problems and obesity.

Obesity is assessed by its linkage to morbidity [incidence, or prevalence rate] and mortality [death]. It is, however, not related to increased weight due to increased muscle mass in highly muscular individuals. Hence, increased weight may not be fatness, in such cases, and it needs to be distinguished as such. The most widely used method to gauge obesity is the Body Mass Index [BMI], which is equal to weight/ height2 [kg/sq mt]. There are other approaches, too:

  1. Anthropometry, where the skin-fold thickness is measured. Typically, the skin over triceps is measured with a calliper
  2. Computed Tomography [CT]
  3. Densitometry [Underwater weighing]
  4. Magnetic Resonance Imaging [MRI]
  5. Electrical impedance [measuring the body's fat percentage].

Keep Body Fat in Check

  • Eat a diet low in fat and cholesterol. Also, remember, that you need to derive no more than 30 per cent of your calories from fat, and just 10 per cent from saturated fat
  • Eat a high-fibre diet. Add more whole grains, fruits and vegetables instead of protein, fats and sugar
  • Restrict, or avoid, salt [sodium] ? Choose natural sugar substitutes, like honey, instead of sugar
  • Avoid alcohol and smoking. Nicotine is bad for obese individuals
  • Don't miss, or skip, meals
  • Shun"yo-yo" diets, or crash dieting
  • Incorporate at least 25-30 minutes of moderate-to-intense exercise, 4-5 days a week. Enhance the duration, if you wish to lose weight
  • Increase your aerobic exercise. Or, yoga. Better, if you combine them with strength training. This will help you maintain or gain muscle mass and tone. Remember, if you don't do exercise regularly, you lose about a kg of muscle each year
  • Meditate. Listen to soulful music. This will help you feel positive and confident
  • Speak to an expert and find out the best option that can work for you, not what could have worked for someone you know.

Being Fit is Not Thin

Do you know that if you are fat - in other words, overweight - and fit, you are better off health-wise than if you were thin and lazy? In the words of Prof Chris Riddoch of the Department of Exercise and Health Science, University of Bristol, UK: "There is evidence that fat people who achieve cardiovascular fitness through exercise have better health outcomes than lean people who don't."

For most people, being fit means being lean. Experts say that it is time we turned the idea on its head and focused on being fit. Notes Riddoch: "We have to [also] get away from the idea that exercise is something we can only do when we have lost weight."

BMI and waist-hip ratio

Ordinarily, for all height, body frame and gender, a Body Mass Index [BMI] of 19-25 kg/m2 is considered normal. A BMI of 30 is a limit beyond which substantial morbidity begins.

As a matter of fact, studies have shown that morbidity starts rising at BMI >25. Therefore, a BMI between 25 and 30 is now classified as overweight.

Doctors usually show concern if a person's BMI is above 25, especially if s/he also has high blood pressure [hypertension] and heart disease.

The distribution of fat cells also matters; for example, abdominal fat is worse than fat in the buttocks and arms. This is where waist-to-hip ratio [WHR] comes into play as a better tool. Waist-to-hip ratio looks at the proportion of fat stored on your body around your waist and hip. Most people store their body fat in two distinctive ways: a] around their middle [apple-shape] and b] around their hips [pear-shape]. WHR is calculated by dividing your waist measurement by your hip measurement. A ratio of >0.9 in women and >1.0 in men is abnormal.

It is worthwhile to mention that Asian males are more prone to develop the apple type of obesity. This is especially critical when it is accompanied by high blood pressure and diabetes. This is known as Syndrome X. Asian males are also more prone to develop obesity-related diseases than their counterparts elsewhere.

The prevalence of obesity is about 30 per cent in middle-income groups in Asia, whereas it is 50 per cent in the US, and the developed world. It is not only adults, but also children that are equally affected, especially those that come from affluent homes, thanks to sitting in front of TV, munching junk-food.

Extreme obesity [BMI >40] is prevalent in about 5 per cent of the population in the US. It won't be long before it makes its presence felt in India, too. Obesity, as a matter of point, is more common among affluent women in India, whereas in the developed nations it is working class women that suffer most from this malady.

Body weight in human beings is regulated by the endocrine and neural components. On the one hand, the equation is very simple. If you do not spend as much energy as you take in, it accumulates and produces obesity.

For example, if your calorie intake is 2,000 per day and if you spend only 1,820 calories, you accumulate 180. This means 180/9 = 20 gm [fat]. So, over a period of 100 days you will accumulate two kg.

Hormone and appetite

A signalling hormone, or molecule, leptin encourages the body to stop eating. It also plays a role in increasing energy expenditure, appetite and other functions. In fact, the word, leptin, comes from the Greek, leptos, which means "thin!"

Appetite is an unpredictable phenomenon; it is influenced by many factors. It also depends upon appearance, smell and flavour of food.

Obese individuals classically give in to the "food" stimuli and over-eat, whereas a normally weighing individual will eat only to satisfy his/her hunger. Obese persons have a habit of eating frequently in-between meals too, even when they are not hungry. Cooks and housewives become obese because they frequently taste food while cooking. Individuals who eat in a hurry are also likely to become obese, because they eat so quickly that they have already over-eaten before their brain centres can perceive that they have satisfied their hunger. The area in the brain, which identifies these signals, is known as the satiety centre.

There are many obese individuals who insist that they eat less and still gain weight. It may be that their metabolism is extremely efficient in utilising all their energy intake, and their expenditure of energy is extremely low. Normally, for a given body weight, energy expenditure is extremely high in obese individuals, but it drops as they begin losing weight. Hence, it is easy to lose weight initially, but this becomes more difficult as normal weight is arrived at.

Fat cells also contain hormones that regulate blood pressure and insulin sensitivity. Therefore, obesity, blood pressure, and diabetes go hand-in-hand.

Obesity: Psychosocial Effects

By SHARITA K Shah

Obesity is accepted as a serious medical condition across the world today. It brings immense social and psychological trauma.

Our society's view is: overweight individuals are responsible for their problem, and they reflect a troubled personality. At one time, it was also commonly believed that overweight and obese people were compulsive eaters, anxious, depressed, under stress, or trying to compensate for inadequate upbringing, family conflict, or other deficiencies in their lives. Today, when almost everyone seems to be getting heavier, and obesity has become a global issue, both experts and the public are turning away from the idea that weight gain is a personal emotional problem.

There are two principal features of the stigma of being overweight. On one hand is the "stigmatisation" of bodily appearance: obesity is a highly visible, undesirable state. On the other, there is "stigmatisation" of character, or the moral view that holds obese individuals personally responsible for their own state, and blames them for their fatness.

The most frequently encountered "stigmatising" situations are mocking comments, ridicule, negative personal assumptions, physical barriers, and being stared at. Obese individuals experience problems in public settings too, such as restaurants, theatres, buses, trains, and airplanes, because of inadequate seat size. This leads to anxiety about, and avoidance, of social activities. Fat jokes and derogatory portrayals of obese people in popular media are common too. Also, social "disgrace" of obesity appears to hold as true for children and adolescents as for adults.

Like most mind-body interactions, this one goes both ways. Obesity can lead to ill-health, which is linked to depression and anxiety. Then, again, depression may also bring on obesity, if the individual lacks the energy to exercise, or is immobilised by stress. It may even disrupt the normal hormonal pathways.

A person's psychological wellbeing influences his/her choices about eating and physical activity. If they feel rejected as unattractive, or suffer from social discrimination, further emotional strain may only lead to additional weight gain.

Counselling and behaviour modification can improve one's health physically, physiologically, socially, emotionally, and spiritually. To lose weight and keep it off, you need to also make changes in your lifestyle. Tips that are effective in helping you change include:

  • Motivating yourself
  • Making lifestyle changes a priority
  • Having a plan
  • Setting small goals
  • Surrounding yourself with good examples
  • Avoiding food "triggers"
  • Keeping a record
  • Focusing on the positive
  • Not giving up.

Dealing with obesity may also mean taking a hard look at how you live and making some tough changes too. Changing people's attitudes and those of society is not easy. However, with knowledge, right attitude, and a good plan of action, you can - and, will - lose weight.

- Sharita K Shah, MD, DPM, DNB, MNAMS, is Consultant Psychiatrist, Dr L H Hiranandani Hospital, Mumbai.

BMR to BAT

Energy expenditure in human beings has several components. These include Basal Metabolic Rate [BMR], energy cost of storing and metabolising food, effects of exercise etc., BMR accounts for 70 per cent of daily energy expenditure, whereas physical activity/exercise accounts for 5-10 per cent.

It is unclear as to how important BMR is for us, but Brown Adipose Tissue [BAT], a recent invention, is now known to play an important role in energy dissipation, which is released as heat. With further scientific research, experts say that new therapies could be introduced that can turn adipose tissue into BAT, and excessive adipose [fat] in the body can subsequently be dissipated as thermal energy.

Genetics

The role of genes is also important in obesity. This is commonly seen in the same families where body weight is similar to that of height. Likewise, identical twins have similar BMI, whether reared together, or apart. Infants who were obese are likely to become obese adults because they have more number of fat cells. Adults, when they become fat, do so by increasing the size of their fat cells.

Dangers

The consequences of obesity are devastating. Morbidly obese individuals have a 12-fold increase in mortality [death] risk. Also, 80 per cent of diabetics are obese.

Cardiovascular diseases, cerebrovascular stroke and congestive heart failure are common in obese individuals.

Obesity can lead to respiratory diseases such as obstructive sleep apnoea and obesity hypoventilation [shallow breathing] syndrome. They are sometimes life-threatening. Other diseases include osteoarthritis [OA], gout, an inflammatory disorder, and risk of fungal and yeast infections. Gallstones are another common by-product of obesity. Paradoxically, fasting and fad-diets also increase the chances of gall bladder disease. Obese people are also prone to reproductive disorders such as hypogonadism [hormonal imbalance].

Obesity in males is associated with a higher death rate from cancer of the oesophagus, colon, rectum, pancreas, liver, and prostate; in women, it can be cancer of gall bladder, breast, endometrium, cervix and the ovaries. Darkening and thickening of skin-folds in the neck and elbow areas are also quite common in obese individuals.

Upper-body obesity in women is linked with menstrual irregularities and polycystic ovarian syndrome. With weight loss, however, a normal menstrual cycle is likely.

Management

Effective treatment of obesity consists of sustained attainment of ideal body weight [height/weight index] without producing any treatment-induced dangers [or, morbidity]. This is, of course, a difficult task, but not impossible.

Consultation with your physician/therapist is especially valuable to manage easily treatable causes such as hypothyroidism, while paying attention to complex causes, if any. Behavioural modification is another cornerstone of obesity therapy. Typically, the obese person is asked to monitor and record circumstances related to eating. Most people realise by themselves as to where they need not eat. Snacking between meals, or constantly consuming even small quantities of calorie-giving foods are all bad behaviours. This needs to be emphasised in obese individuals. Counselling in a stable group setting may also help.

The following can also be used to tackle obesity.

Diet

Reduced calorie intake is the gold standard. The fundamental goal is a "negative" balance between energy intake and expenditure. The basic principles that go the distance in reducing weight are: a deficit of around 7,500 calories to produce weight loss of approximately one kg per week. Again, the rate of reduction will vary according to the stage of weight loss. With diets, that are restricted to less than 600 calories per day, the initial weight loss is predominantly due to loss of salt [sodium] and fluids. In select individuals, very low energy diets, for example 400-600 calories per day, are given if complications threaten life. Low calorie diets of less than 800 kilo calories are suitable to most individuals.

A diet rich in fruits, vegetables, and whole grains, promotes good weight loss, while following a low carbohydrate intake. One important aspect of diet is the person's knowledge of actual calorie values of foodstuffs they eat. This helps to curtail regaining, or reappearance, of weight.

Socially Contagious

According to a recent study, published in The New England Journal of Medicine and funded by National Institute on Aging, US, obesity is "socially contagious." The study found a person's chances of becoming obese went up 57 per cent if a friend did; 40 per cent, if a sibling did; and, 37 per cent, if a spouse did. In the closest friendships, the risk almost tripled. Researchers think it's more than just people with similar eating and exercise habits hanging out together. Instead, it may be that having relatives and friends who become obese changes one's idea of what is acceptable weight.

Exercise

Increased energy expenditure is obviously the most effective mechanism. Exercise as a sole means of losing weight is unlikely to produce the desired results. However, when it is combined with proper diet, it produces good results. Exercise also has a statutory effect on high blood pressure, diabetes and heart disease. It is, however, advisable to assess your exercise capacity with your physician/therapist before beginning any exercise routine.

Medicine, surgery

Anti-obesity medications and pills are part of our treatment vocabulary, but there are concerns about their safety. There are also new weight-management products, like Lipobind, now available in the market. Speak to your physician/therapist, for professional information and guidance on the subject. Extreme obesity, because of its increased mortality, is a worthwhile candidate for surgery.

Speak to your physician/therapist, and find out what it is that has gone wrong with your weight and/or diet.

It ain't easy to wage your battle with bulge, yes. But, where there is a will, there is always a way to beat its many dangers.

- With additional inputs from RAJGOPAL Nidamboor

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