What is Obesity?

How Did I Get Like this? Obesity is generally defined as a progressive and life-threatening disease with a strong genetic component. Presently, there are over 300 genes that have been identified that are associated with an increased risk for obesity. However, these are not 'bad' genes but ones that once enabled us to survive when food was not plentiful, such as during the winter months or when there were droughts or crop failures. Individuals not having these genes would not have survived during periods of famine and, therefore, their gene pool would not have been passed along to the next generation. So, our ancestors are the 'survivors' of yesteryear and, therefore, most of us today have these 'survival' genes, along with the increased risk for obesity. Although there are numerous genes that are associated with obesity risk, genetics cannot explain why obesity has become such a serious problem over the last several decades. The gene pool, after all, would not have changed in such a short period of time. What, then, is responsible for the rampant increase in the severity and prevalence of obesity that is now occurring in the U.S. and throughout the industrialized world? Positive Energy Balance Weight gain generally happens when an individual consumes more calories than their body uses for energy. This is known as having a positive energy balance and occurs when we do not get enough physical exercise to compensate either for an over consumption of food or for selection of foods that are high in calories and low in nutrients, such as candy, cakes, and chips, and fries. Our lifestyles today contribute to a positive energy balance. Most of us have sedentary jobs, spending most of our time at work in front of a computer or at a desk. Our children also have less opportunity for physical activity than did young people of earlier societies. Few schools allow time for free play (recess) and most schools do not require that children attend physical education classes on a daily basis. After work or school, children, as well as adults, spend 3 to 4 hours per day in front of the television, an event that burns about as few calories as our body uses while sleeping. What leisure time is not spent in front of the TV is often spent at the home computer, further reducing time available for physical activity.

In addition to low physical activity, a positive energy balance occurs when we eat or drink more calories than our body needs for normal functions. High calorie intake may result from a variety of causes including: consuming foods that contain sugar or processed grains that are not only calorie-dense but also cause a rapid rise in blood sugar along with production of a hormone, insulin, that can cause your body to accumulate more fat, Drinking sodas, fruit juices, and other beverages that are high in sugar, Eating meals at restaurants or fast-food facilities where food is generally high in calories and fat, Purchasing super-size meals or eating at all-you-can eat food bars, Frying foods in oil or preparing foods at home that are high in fat, sugar and processed grains, and Failing to be mindful while eating, such as occurs when watching TV or performing any other activity that may distract you from those signals your stomach provides when it is full.

Low Intake of 'Obesity Prevention Foods' In addition to eating foods high in fat, sugar and processed grains, our society has also cut back dramatically on the consumption of foods that that help to protect the body from obesity. Fiber is important to help prevent obesity and the American diet is lower in fiber than anywhere else in the world. Fiber foods include fruits, vegetables, nuts, legumes, and whole grains and these foods help to prevent obesity in a variety of ways. First, foods high in fiber expand in the stomach, causing feelings of fullness. Secondly, these foods reduce the absorption of sugar and fat. Third, fiber foods cause your body to burn more fat and, by lowering certain hormones, such as insulin, also reduce the capacity of your body to accumulate fat. Finally, fiber foods are generally high in vitamins and minerals needed for your body to effectively convert the foods you eat to energy. Over the last several decades, our intake of dairy and other calciumcontaining foods has also fallen considerably. In fact, Americans are obtaining from their diets less than 40% of the recommended daily calcium needs. Dietary calcium, in turn, helps to prevent fat from being taken up and stored in fat tissue and also helps to reduce the number of fat cells available for fat accumulation. Dairy products are even more effective in the prevention of obesity than calcium alone because these products also contain other ingredients that help reduce the accumulation of body fat.

In addition to our not getting enough calcium in our diets or not eating enough fiber, our diets are also very low in an essential fatty acid that can help to reduce the risk for obesity. This essential fatty acid is known as omega 3 and used to be readily available in eggs, milk, and meat prior to our more recent practice of grain-feeding beef, pork, fish and foul for rapid growth. Deficiencies in omega 3 can cause weight gain by: 1. 2. 3. 4. Increasing the uptake of fat into fat storage depots Altering certain brain chemicals that cause food cravings Enhancing production of lipids and insulin Causing the body to handle stress through activation of a pathway that can also cause fat accumulation and food cravings

Foods available today that remain high in omega 3 include salmon, herring, anchovies, and various other sea foods, caught but not grain-fed. Omega 3 is also high in breast milk and may one of the reasons why studies find that children who were breast fed are less likely to gain weight than those who were not. Obesity as a Cause for Obesity As is apparent from the above discussion, changes in the amount and kind of food that we now eat, along with the way that food is grown or processed, has contributed to the rise in obesity prevalence over recent years. But, did you know that obesity is also a cause for obesity? With weight gain, there are a number of changes that occur in your body that increase the capacity of your body to store fat. In other words, more of the food that you eat turns into body fat. Furthermore, these changes happen in order to protect your body from the toxic effects that fat can have on your heart, liver, muscle, and all other parts of your body. Among all the tissues of your body, only adipose (fat) tissue is designed to take up and store high amounts of fat But with weight gain, fat spills over into other tissues, like the liver and heart and cells along the blood vessels and muscle to cause serious complications and disease including heart disease, liver disease and elevated lipids, insulin resistance, diabetes, hypertension and much more. In order to protect non-adipose tissue from the toxic effects of fat, the body increases its capacity for fat storage in adipose tissue, increasing fat cell size and numbers and reducing the breakdown of stored fat. In addition, there is a reduction in the uptake and use fat by non-adipose tissues, such as the muscle, making more fat available for storage.

In addition to an increased capacity for fat storage with weight gain, there are also hormone changes associated with obesity that drive fat into fat storage depots or prevent its breakdown, increasing your chances for further weight gain. To make matters worse, obesity can cause chronic depression and stress which can alter certain brain messengers and hormones in such manner as to increase the uptake of fat into fat storage depots while, at the same time, increasing appetite and interfering with your ability to feel 'full'. Weight gain also promotes further weight gain by causing joint pain, arthritis, swollen legs and other health problems that impedes mobility or your desire to be physically active. A reduction in physical activity would, in turn, decrease the number of calories your body burns, increasing the risk for further weight gain. Furthermore, many of the health problems caused by obesity are treated with medications that cause even greater weight gain and risk for obesity. This includes many of the drugs used to treat diabetes, hypertension, depression, and inflammatory conditions.

Summary Based on the information discussed above, how is it that you got to be obese? First, you have the 'genes' that enable you to become obese. Secondly, you went through a period of positive energy balance or, in other words, you ate more calories than your body used for energy. Third, you chose foods that promoted weight gain (those high in sugar, processed grains and fat) and you ate too little of the obesity prevention foods (those high in fiber, calcium, and omega 3 essential fatty acids). Finally, your body reacted to the increase in fat by causing conditions that led to further weight gain, setting in motion a vicious cycle and making weight loss extremely difficult, if not impossible, by means other than obesity surgery, as is discussed in the next section entitled, "Why Is It so Hard to Maintain Weight Loss?"

Why Can't I Keep the Weight Off? How much weight do you estimate that you have lost from diets, obesity medications, and behavioral therapy over the course of your lifetime? A hundred pounds? More? How much weight do you estimate that you have regained? Did you know that most people who go on a diet will regain all of their weight back over time and many people will regain all of their weight loss plus even more?

Why is it so hard to keep from regaining weight following a diet or any other weight loss regimen? Most people believe that a loss of willpower or a return to old eating and exercise habits are solely responsible for weight regain. Such a belief causes extreme feelings of guilt and failure when weight regain happens. There is little doubt that weight regain is, in part, behavioral in origin. A return to old behaviors, such as eating in response to stress, consuming foods high in sugar, fat or processed grains, failing to get enough exercise or to eat sufficient amounts of the obesity prevention foods (fiber, calcium containing foods, and those high in omega) can most assuredly contribute to weight regain. However, physical factors associated with previous obesity, as well as weight loss, also play a very significant role in the inability of the majority of individuals who have lost weight to maintain such over time. What are these physical factors that adversely affect long-term weight loss success? Obesity results in changes in adipose tissue (fat) metabolism, increasing the capacity for fat storage and reducing the breakdown of fat at times that the body needs fat for fuel, such as during exercise or when hungry or under stress. Weight gain also reduces the ability of muscle and certain other tissues to utilize (oxidize) fat, making more fat available to be taken up into adipose tissue and stored. Weight loss, unfortunately, does not reverse defects in the ability of muscle to utilize fat and, in fact, may even worsen such defects. Since muscle comprises a significantly large portion of the body and, under normal circumstances, utilizes large amounts of fat, a defect in the capacity for fat utilization by muscle would substantially increase the post-obese persons chances for weight regain. Obesity, in addition to increasing fat storage capacity and reducing fat utilization, increases the capacity for fat accumulation by increasing fat cell numbers. Serious obesity is associated with high numbers of fat cells, and studies have found that the greater number of fat cells an individual has, the more difficult it is for them to control their body size. A greater number of fat cells in previously obese persons, then, would increase the risk for weight regain. Obesity also increases levels of certain messengers in the body known as endocannabinoids (pronounced en doe can nab i no ids). These messengers can contribute to further weight gain because they stimulate appetite, cause you to crave certain foods, increase the storage of fat into your fat storage depots, and stimulate the production of fat by the liver. Evidence suggests

that with diet-induced weight loss, the elevated levels of these messengers may not decline, thereby, increasing the risk for weight regain. Weight loss is also associated with changes in your body that increase you risk for weight regain. With weight loss, your body not only loses fat tissue but also loses muscle and other lean tissue. A loss of muscle would increase your risk for weight gain by decreasing fat utilization and by causing an overall reduction in resting energy expenditure or, in other words, a reduction in the number of calories your body is capable of burning while at rest. As resting energy expenditure accounts for approximately 70% of all the calories your body burns in a day, a lowered resting energy expenditure would substantially increase your risk for weight regain. With weight loss, a hormone that is known as leptin, which is produced by your body fat, declines to very low levels. This hormone ordinarily acts to stimulate energy expenditure (calories burned) and to reduce appetite. The reduction in appetite results from the ability of this hormone to reduce production of certain brain messengers that, otherwise, cause you to eat more food. With weight loss and a decline in leptin, the body thinks it is starving and, in response, the brain produces a number of appetitepromoting messengers and reduces production of those messengers that would reduce appetite and cause feelings of fullness. The result of these changes, then, would be a very strong and, sometimes, uncontrollable drive to eat. A hormone produced by the stomach may further increase the drive to eat with weight loss. This hormone, called ghrelin, stimulates appetite and food intake. Ghrelin levels increase when the stomach is empty and there is also a substantial increase in production of ghrelin when dieting. This rise in ghrelin, is another reason for potential weight regain. Unresolved and pre-existing psychological issues may also cause physical changes that contribute to weight regain. Most of us during the weight loss phase of any obesity regimen go through what is called a pink cloud period when the excitement and self-esteem derived from the weight loss, along with the compliments of others, overshadow any existing psychological stressors. Often, too, we believe that with weight loss all of our problems will resolve. With the realization that those emotional problems that existed prediet remain, we often become anxious and depressed which, in turn, cause changes in the production of certain brain messengers that stimulate appetite and changes in the production of specific hormones that promote fat accumulation.

As is apparent from the above discussion, weight regain is a far cry from being a matter of willpower and is even much more than a return to previous weight-promoting behaviors. Rather, with weight loss there are numerous metabolic, neurochemical and hormonal changes that cause a nearly overwhelming and irresistible physical drive toward weight gain. For all of these reasons, weight regain following diet or anti-obesity meds or even behavioral therapy, is generally the rule rather than the exception. . What are the Health Consequences of Obesity? The general consensus among medical professionals today is that obesity is NOT a cosmetic problem but IS a life-threatening disease. Obesity is the one of the leading causes for preventable death in this country, responsible for the lives of hundreds of thousands of individuals each year. Obesity not only shortens our lifespan but may increase our risk for death from any cause by as much as 12-fold. Why is obesity life-threatening? Obesity causes organ and tissue damage from lipid (fat) toxicity, chronic inflammation, high levels of oxidative stress, DNA damage, and numerous other conditions that are responsible for most of todays common diseases. And, these diseases, in turn, are the major causes for death in this country. 1. Cardiovascular Disease Cardiovascular disease is the number 1 cause of death in the U.S., accounting for the loss of well over 700,000 lives per year. The American Heart Association considers obesity to be a major risk factor for cardiovascular disease. Studies have found that as levels of obesity increase so does the risk for cardiovascular disease and associated death. Weight gain alters both the structure and function of the cardiovascular system. An enlargement (hypertrophy) of the major pumping chamber of the heart (the left ventricle) is common with obesity. The enlarged heart results from the extra workload imposed upon the heart by the increased needs of the larger body. Over time, this condition can lead to congestive heart failure which, if left unattended, can be fatal. Studies estimate that approximately 15% of individuals with morbid obesity are in congestive heart failure. The enlarged heart can also cause irregular heartbeats or arrhythmias. Irregular heartbeats, in turn, are a primary cause for sudden death. Individuals who are morbidly obese have a higher incidence of arrhythmias

and up to a 40-fold increased risk of sudden death. Sudden death, as well as congestive heart failure, also result from heart damage incurred by a blockage of the vessels that supply the heart with oxygen and nutrients, a condition known as coronary artery disease. Coronary artery disease (CAD) claims over a half million lives annually. The disease occurs when the coronary arteries (vessels) that supply blood to the heart become clogged by plaque formed in the arteries (atherosclerosis) or by a blood clot that occurs when the plaque is damaged (atherothrombosis). When this happens, the affected portion of the heart dies because it does not receive enough oxygen and nutrients from the blood. This may cause angina (pain or pressure in the chest), a heart attack, and death. Studies have found that obesity is not only an independent risk factor for CAD and associated mortality but also contributes significantly to the development of other major CAD determinants, i.e. hypertension, lipid abnormalities, chronic inflammation, oxidative stress, and diabetes. Hypertension is a major risk factor for CAD and, in addition, is a cause for, and an effect of, structural and functional cardiovascular abnormalities responsible for cardiac failure or sudden death. Studies suggest that greater than 75% of hypertension may be attributable to obesity and that the risk for hypertension increases in proportion to body fatness. Some studies have reported that more than half of obese individuals are hypertensive. Lipid abnormalities are another major risk factor for CAD. Obesity is associated with elevated blood lipids (triglyceride), reduced levels of the good (anti-heart disease) cholesterol carrier, HDL, and alterations in the composition and size of LDL, another cholesterol carrier that significantly increases the risk for heart disease. Studies, including our own, have found that individuals who are obese, compared to their leaner counterparts, have higher blood levels of LDL cholesterol, lower levels of HDL, and greater triglyceride production. Such alterations in lipids may explain, in part, why obesity increases ones risk for CAD and stroke. 2. Cancer Cancer is the second leading cause of death in this country, responsible for over 600,000 deaths per year, with over 90,000 of these deaths attributable to obesity. A long-term study supported by the American Cancer Association and involving nearly a million participants found that serious obesity, defined as 140% (or above) ideal body weight, is associated with an increased risk of all types of cancer (33% and 55% greater risk for males and females, respectively). The study showed that the risk of specific forms of cancer is

even higher. For females, obesity is associated with a high risk of endometrial, cervical, ovarian, breast and gallbladder cancer and for males, a high risk of prostate and colon cancer. 3. Cerebrovascular Disease Cerebrovascular disease including stroke is the 3rd leading cause of death in the U.S. A stroke is a brain attack that occurs when a vessel or artery supplying a particular area of the brain becomes clogged or breaks, interrupting blood flow to the affected area of the brain and causing death of the tissue. Obesity puts a strain on the entire circulatory system and, in this way, increases stroke risk. Obesity also is responsible for the development of other conditions that increase the risk for a stroke, such as heart disease, hypertension, lipid abnormalities, diabetes, and obstructive sleep apnea. 4. Respiratory Disorders Respiratory disorders are the 4th leading cause of death in the U.S. Studies have found that the obese are more susceptible to respiratory infections than are their non-obese counterparts. The obese are also more susceptible to obstructive airway diseases, such as asthma. The incidence of asthma with obesity has been reported to be increased by approximately 2-fold in adults and up to 5-fold among children. Obesity is believed to be a major cause for a very serious and potentially deadly, breathing disorder known as obstructive sleep apnea. This disorder occurs when fat in the neck, throat, and tongue obstruct air passageways during sleep, causing apnea which is a temporary absence of breathing. An individual with this breathing disorder may have hundreds of apnea episodes each night. Obstructive sleep apnea causes exceptionally low tissue and blood levels of oxygen and is associated with systemic hypertension, pulmonary hypertension, heart failure, sudden cardiac death and stroke. 5. Diabetes Diabetes is the 5th leading cause for death in the U.S. The disease is associated with an increased risk for amputations, cardiovascular disease, stroke and blindness, kidney disease, hypertension, lipid abnormalities, circulatory and nerve defects, hard-to-heal infections, impotence, and more. Diagnosis of diabetes is believed to reduce an individuals lifespan by as much as 35%. Obesity is a primary cause for Type 2 or non-insulin-dependent diabetes, a form of diabetes involving a resistance to insulin rather than a lack of. Type 2 diabetes accounts for 90 to 95% of all diabetes cases and 80% to 90% of

patients with this form of diabetes are obese. As levels of obesity increase so does the risk of Type 2 diabetes. An individual with mild obesity may have a 2-fold greater risk of developing Type 2 diabetes, as compared to someone who is lean, whereas a severely obese person may have up to a 10-fold higher risk. 6. Accidents Accidents are the 6th leading cause of death in the U.S. As discussed above, obesity contributes to the development of sleep apnea which, in turn, interrupts normal sleep cycles, causing headaches, depression, fatigue, and daytime sleepiness. An individual with obstructive sleep apnea often falls asleep during the day which, in some occupations, could be particularly hazardous. Imagine the consequences of a bus driver falling asleep while on the job? A heavy machinery operator? A surgeon? A pilot? Joint diseases, such as gout and arthritis, are other ways that obesity increases the risk for accident mortalities. Gout is an inflammation of joints caused by elevated levels of uric acid, and studies have shown a positive association between increases in body weight and levels of uric acid in the blood. Weight gain also causes wear-and-tear on weight-bearing joints, such as the knees, hips, lower back and ankles. Such wear-and-tear often causes arthritis. Excessive joint pain, caused by either gout or arthritis, could increase the risk for falling. Additional consequences of obesity that could act to impair ones degree of mobilization and increase the risk for accidents (and death from such) include disc herniation and lumbar spine abnormalities such as scoliosis, kyphosis, or hyperlordosis. Pseudotumor cerebri (intracranial hypertension) is yet another condition worsened, or caused, by obesity. Such condition is associated with disorientation and visual impairment, which could significantly increase the risk of accidental death. 7. Pneumonia and Flu The 7th leading cause of death is pneumonia and flu and the obese are likely to be more susceptible to these diseases than would someone who is lean. Obesity significantly reduces the immune systems ability to protect and fight against viral and bacterial invasion. 8. Alzeheimers Disease Alzeheimers Disease is the 8th major cause of death in the U.S., and studies find that obese individuals are at greater risk for developing this debilitating disease.

9. Kidney Disease Kidney disease is the 9th leading reason for death. Conditions caused by obesity, including hypertension, diabetes, and congestive heart failure, are major contributors to renal failure. 10. Septicemia Septicemia is the 10th leading cause of mortality. The condition is a serious infection that rapidly progresses to septic shock and death. Studies show that the obese, particularly the morbidly obesity, are at much higher risk for septicemia than are individuals whose body size is normal. 11. Suicide 12. Fatty Liver Disease There are yet other obesity-associated co-morbidities that are lifethreatening. Fatty liver disease, the 12th major cause of death in the U.S. is far more prevalent among individuals who are obese than lean. Inflammation of the liver, a condition known as non-alcoholic steatohepatitis or NASH, occurs in about 1% to 3% of the normal weight population but as many as 60% of individuals with morbid obesity. NASH, over time, can, eventually, progress to cirrhosis and cause liver failure. Obesity also increases the risk of certain maternal complications, such as pre-eclampsia and eclampsia, that may endanger the life of both mother and child. Stillborn births and miscarriages are far more prevalent among females who are obese. Furthermore, obesity increases the risk for other health problems, such as gestational diabetes, that adversely influence pregnancy outcome. Various gastrointestinal complications are caused, or worsened, by obesity and some of these may be quite serious and even life-threatening, if left unattended. Such complications include gallstones, gastroesophageal reflux disease (GERD), gastritis and acute pancreatitis. Obesity may be responsible for other health-related defects that are not lifethreatening but reduce life quality, such as urinary stress incontinence, urinary infections, menstrual irregularity in females, hypogonadism in males, sex hormone abnormalities, and infertility. Quality of life, self-esteem, and overall sense of well-being are also dramatically compromised by the social and psychological burdens of obesity which, in turn, can negatively influence health status or even lead to suicide, the 11th major cause of death in the U.S.

From the above discussion, it is apparent that obesity kills, contributing to all of the major diseases responsible for death in this country. Weight loss, even small amounts, i.e. 5 to 10%, improve these conditions and, the massive weight loss that accompanies bariatric surgery not only improves but even cures many of these deadly diseases. Weight loss surgery cures diabetes, hypertension, lipid abnormalities, infertility, depression, GERD, gastritis, sleep apnea, left ventricular hypertrophy, and cardiac arrest in more than 90% of cases and dramatically reduces the risk for coronary artery disease, stroke, cancer, accidents, Alzheimers Disease, kidney disease, septicemia, and more. Along with the resolution or improvement of life-threatening obesity-related diseases with weight loss is a highly significant increase in longevity. A recent Canadian study, for instance, involving a large number of morbidly obese bariatric surgical patients and their non-surgical morbidly obese controls found that weight loss with surgery reduces the risk for death by nearly 90%. In summary, obesity is a killer because obesity causes or contributes significantly to those diseases and conditions responsible for most of the deaths in the U.S. However, this apparent mother of death can be contained by weight loss with resolution or improvement of disease states, reduced risk for major illnesses, and a significant extension in longevity. . What's a BMI? BMI stands for Body Weight Index. Your BMI is a number calculated from your weight and height that approximates the percentage of your total weight that comes from fat, as opposed to muscle, bone or organ. The higher your BMI, the higher the percentage of fat in your body and risk of weight related disease and illness such as diabetes, high blood pressure and heart disease. A BMI between 20 and 25 is generally considered a healthy weight for height; over 25 is considered overweight, and over 35 is considered obese. A BMI of 40 or greater makes you a candidate for weight loss surgery, or 35 with other health-related conditions. What Are the Symptoms of Acid Reflux/GERD While heartburn is the most common symptom, there are many other symptoms, both acid-related and non-acid-related. Most GERD sufferers

attribute their symptoms to acid reflux, but reflux of non-acid stomach fluids can cause similar symptoms and can be just as harmful to the esophagus. Typical symptoms include: Heartburn Excessive salivation (waterbrash) Belching Bloating Pain or discomfort in the chest Reflux-related sleep disorders Yellow fluid or stains on pillow after sleep Intolerance of certain foods and liquids Atypical symptoms can include: Regurgitation Hoarseness or laryngitis Frequent swallowing Asthma or asthma-like symptoms Excessive clearing of the throat Persistent cough Burning in the mouth or throat (acid taste in the mouth) Dental erosions or therapy-resistant gum disease or inflammation Discomfort in the ears and nose

Some reflux is normal, but if you suffer symptoms of reflux more than twice a week, you may have GERD.

When Is Surgery Appropriate? When GERD has progressed to a level where pharmaceutical therapies are no longer satisfactory, surgical intervention may be warranted to correct the underlying anatomical cause of GERD, the defective antireflux valve. Over the last 50 years, antireflux surgery has become less invasive, evolving from an open procedure to a laparoscopic procedure and then to an incisionless procedure. Laparoscopic reconstruction of the antireflux valve has been shown to be effective in 75 to 90 percent of patients in alleviating heartburn and 50 to 75 percent in alleviating cough, asthma, and laryngitis. Studies and years of clinical use prove that an anatomical correction is key to long-term resolution of GERD and disease progression.

However, even laparoscopic surgical repair can be invasive, requiring from three to four small abdominal incisions, and typically has a high incidence of side effects like gas bloat and difficulty swallowing. The incisionless procedure called TIF (Transoral Incisionless Fundoplication), made possible by the innovative EsophyX device, is performed through the patient's mouth, or "transorally." TIF delivers similar benefits as the timeproven laparoscopic antireflux procedure. The key differences are that TIF reconstructs the antireflux valve through the mouth, does not require incisions, and does not dissect any part of the natural internal anatomy. Recovery and discomfort are reduced and most patients are able to return to work and normal activities within a couple of days following the procedure.