Morbid Obesity

MORBID OBESITY

NUR FARHANA BINTI ABDUL HADI

NATIONAL ASSOCIATION FOR STRENGTH AND CONDITIONING RESEARCH

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Morbid Obesity

Introduction

Obesity is one of the leading risk factors known to be capable of causing devastating effects on
(1)
various body system contributing to 15% of the world obese population. The prevalence in

overweight and obesity in worldwide has been increasing and became epidemic. It results from

imbalance between physical activity and dietary energy intake. Physically not active and

unhealthy diet contribute to excessive weight gain. Once considered a problem only in high

income countries, overweight and obesity are now dramatically on the rise in low- and middle-

income countries, particularly in urban settings.

World Health Organisation (WHO) defined overweight and obesity as abnormal or excessive fat

accumulation that presents a risk to health. A crude population measure of obesity is the body

mass index (BMI), a person's weight (in kilograms) divided by the square of his or her height (in

metres). Normal or healthy weight status in adult is based on BMI between 18.5- 24.9 and in

children between the 5th and 85th percentile on the CDC growth chart. (2,3)

There are 17.7% (3.3 million) of Malaysian are obese and given ratio 1 in 3 person in Malaysia

are overweight. The ‘westernization’ of global eating habits has also brought about an increase in

the number of fast-food outlets in Malaysia during the last decade. (4)

The Malays have a greater prevalence of underweight, but overweight and obesity dominate the

picture in all ethnic groups. Male Chinese show the greatest prevalence of obesity, with Malay

adults showing the greatest spread of values in terms of both underweight and of overweight and

obesity prevalence. Obesity appears to be more prevalent in women than men and the rate in

female Indians and Malays is particularly high. (5)

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Morbid Obesity

Overweight and obesity are major risk factors for a number of non-communicable disease.

Young adults with increased body mass index may continue into consequences such as type 2

diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, polycystic ovarian disease

and coronary artery disease. Being overweight as a child can also impact on self-esteem and

quality of life, and cause depression. (1,6)

Regular moderate intensity physical activity, a healthy diet, and avoiding unhealthy weight gain

are effective and safe ways to prevent obesity. Numerous studies have shown that continued

adherence to diet and exercise strategies are associated with long-term success.

Children are a particularly important focus because of the growing body of evidence

documenting the vital role that optimal nutrition plays throughout the lifespan.

It is important to develop strategies to increase habitual physical activity and to prevent

overweight and obesity in collaboration with communities, families, schools, work sites, health

care professionals, media and policymakers.

Types of Obesity

According to fat distribution, obesity is classified central and peripheral type. In the central type

of obesity, the fat occupies the abdominal region of subjects. In the peripheral type, fat is

accumulated around the hip and thigh areas; this means that the hips are almost rounded and the

buttocks look larger compared to normal subjects.

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Morbid Obesity

Central obese are more at risk of having diseases related to obesity such as type 2 diabetes,

metabolic syndrome and heart disease. In addition, the possibility of developing cardiovascular

diseases, gout manifested as hypertension and the majority of cancers are linked to the central-

type fat distribution.

Causes

1. Genetics

Obesity can be inherited from one generation to another generation in the family. Obese parents

commonly have obese children. Obesity that runs in families can be due to environmental factors

(such as poor eating habits learned during childhood), or due to relational and behavioural

factors (such as poor boundary setting), as well as certain genetic traits being inherited from

parents. Therefore, family involvement in interventions is important to ensure improvements in

outcomes benefit the whole family and can be maintained. Proven in a study whereas children of

mothers with gestational diabetes facing great risk of being obese in adulthood. (6, 7)

2. Damage brain control system

Eating habit is being controlled by hypothalamus, located in a brain. Binge eating episodes are

characterized by uncontrollable, distressing eating of a large amount of highly palatable food and

represent a central feature of bingeing related eating disorders. Research suggests that

inflammation plays a role in the onset and maintenance of eating-related maladaptive behaviour.

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Morbid Obesity

Considering the role of this region of the hypothalamus in controlling feeding related behaviour,

this can be relevant in eating disorders and obesity. (8)

3. Emotional Factor

Depressive symptom markedly associated with eating disorder and increased BMI. (9)

Individuals with anxiety, extreme happiness, and depression overeat even though they are not

hungry. Using food to find happiness, peace of mind, and/or gain control in one’s life is the

beginning of addiction. Under the influence of addiction, overweight or obese individuals may

hide stores of food or eat in concealment to hide their addiction from others.

4. Lifestyle

Obesity rates increase over the past 2 decades and markedly due to technology advances.

Computers, gadgets, internet, indoor activity become major part in someone’s life. These

automatic systems lead world population into sedentary lifestyle and result negative calorie

output. TV watching was suggested to be a major source of inactivity especially in children

which may contribute to the risk of developing obesity in adolescence and adulthood. . Today,

too many children are consuming diets with too many calories and not enough nutrients and are

not getting enough physical activity. Approximately 32 percent of children and adolescents ages

2 to 19 years are overweight or obese, with 17 percent of children being obese. (10)

Measurements

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Morbid Obesity

The ideal of body fat levels for men are 12 – 17 % and 12 – 22% for women. Exceeding the

normal level risk a person to be obese. There are various methods in determining the amount of
(11)
body fat, none are exact. The most accurate is hydrostatic weighing. Body mass index is

introduced by WHO as acceptable indicator to screen obesity but not accurate for athletic builds.

Meanwhile Durnin method equations was significantly different from percentage body fat in four

of eight race/ethnicity and sex-specific groups, particularly in Asian women and African

American men. (12)

1. Body mass index

According to World Health Organisation, obesity is measured by calculating individual body

mass index (BMI), calculated as kilograms (body weight)/metres (height). The results are

categorized into low body weight (less than 18.5), normal (18.5 – 24.9), overweight (25.0 – 29.9)

and obese (more than 30).

BMI is interpreted differently for children and teens even though it is calculated as weight ÷

height2. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the

same age and sex. Because there are changes in weight and height with age, as well as their

relation to body fatness, BMI levels among children and teens need to be expressed relative to

other children of the same sex and age. These percentiles are calculated from the CDC growth

charts, which were based on national survey data collected from 1963-65 to 1988-94. (13)

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2. Durnin Method

The percentage of the total body fat was estimated from the sum of values of skin fold thickness

measured at four sites (biceps, triceps, subscapular, suprailliac). Using the thumb and forefinger

of hand, grasp the skin above the site location. Hold the calipers perpendicular to the site and

measure while still grasping the skin. Four points are measured on the right side of the body and

interpreted according to Durnin percentage body fat table.

3. Waist line

(4)
A normal waist line for men is less than 90cm and less than 80cm in women. Increased waist

line indicates high visceral fat in the body which provide higher chances to suffer type 2 diabetes

mellitus.

4. Ideal Body Weight

Using formula Ideal Body Weight (kg) = {Height (cm) – 100} – 10%

Obesity if body weight is more the 25% of ideal body weight in men and 30% in women.

Complications

Obesity is associated with increased morbidity and mortality due to hypertension, diabetes,

dyslipidemia, and cardiovascular and renal diseases. The prevalence of obesity and obesity-

related disease is increasing worldwide. Among obese adults, hypertension rates were at or

above 70% in Asia and above 80% in Europe and 90% of type 2 diabetics are overweight or

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obese. The association of hypertension with obesity is primarily related to visceral obesity,

which in turn is associated with insulin resistance and dyslipidemia. (13, 14)

1. Hypertension

Obesity-related hypertension is associated with renal sodium retention and impaired pressure

natriuresis. Obese humans and subjects with the metabolic syndrome tend to be relatively salt

sensitive. Increased renal tubular reabsorption of sodium has been attributed to increased

sympathetic outflow to the kidney. (15)

It has also been suggested that increased intrarenal pressures caused by fat surrounding the

kidneys and increased abdominal pressure associated with visceral obesity may impair

natriuresis. Vascular endothelial dysfunction is associated with a number of cardiovascular risk

factors, including obesity, insulin resistance, and hypertension. Reduced endothelium-dependent

coronary and peripheral arterial vasodilation are more strongly correlated with waist-to-hip ratio

than with BMI.

2. Type 2 Diabetes Mellitus

People who are overweight or have obesity have added pressure on their body's ability to use

insulin to properly control blood sugar levels, and are therefore more likely to develop diabetes.

There is a close association between obesity and type 2 diabetes. The likelihood and severity of

type 2 diabetes are closely linked with body mass index (BMI). There is a seven times greater

risk of diabetes in obese people compared to those of healthy weight, with a threefold increase in

risk for overweight people. A recent study found that severely obese people (BMI ≥40) were at

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Morbid Obesity

an even greater risk of type 2 diabetes, when compared to obese people with a lower BMI (BMI

30- 39.9). (13, 14)

Theories of why obesity may lead to type 2 diabetes include: (17,18)

i. abdominal obesity may cause fat cells to release pro-inflammatory chemicals. These

chemicals can make the body less sensitive to the insulin it produces by disrupting the

function of insulin responsive cells and their ability to respond to insulin.

ii. obesity may trigger changes to the body's metabolism that cause fat tissue to release

increased amounts of fatty acids, glycerol, hormones, cytokines and other factors that

are involved in the development of insulin resistance. When insulin resistance is

accompanied by dysfunction of pancreatic islet beta-cells (the cells that release

insulin) it leads to failure to control blood glucose levels.

3. Osteoarthritis

Obesity is a major problem causing osteoarthritis. National Health and Nutrition Examination

Survey indicated that obese women had nearly 4 times the risk of knee osteoarthritis as

compared with non-obese women; for obese men, the risk was nearly 5 times greater. Other

investigations, which performed repeated x-rays over time also, have found that being

overweight significantly increases the risk of developing knee osteoarthritis. Even small

amounts of weight loss reduce the risk of developing knee osteoarthritis. Preliminary

studies suggest weight loss decreases pain substantially in those with knee osteoarthritis.

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4. Infertility

Obesity is associated with poly-cystic ovary syndrome (PCOS), a common cause of infertility. It

can affect fertility by causing hormonal imbalances and problems with ovulation, particularly

for obese women having their first baby. Compared to women of normal body weight, obese

women submitted to IVF may present reduced rates of clinical pregnancy and live births, with an
(19)
increased rate of abortion. In addition, obese pregnant women have a higher incidence of

maternal and fetal complications, such as gestational diabetes, hypertensive disorders of

pregnancy and increased perinatal morbidity/mortality.

With respect to men, male obesity has been linked to reduced rates of pregnancy and live births.

Spermatogenesis requires a controlled testicular environment and intact endocrine signalling

through the hypothalamic-pituitary-testicle axis; and the impact of obesity on fertility can be

attributed mainly to the endocrine mechanisms that alter this relationship. (20)

Therapy

The American Heart Association recommends obese patients participate in a medically

supervised weight loss program two or three times a month for at least six months.

The treatment plan for weight loss involves eating fewer calories than your body needs, getting

regular aerobic exercise and learning the skills to change unhealthy behaviours.

1. Diet control

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Morbid Obesity

Healthy eating is one of the best things we can do to prevent and control health problem.

According to a statistic, a 5- to 10-percent reduction of your body weight if you are overweight

can lessen the risk of diabetes and heart disease. (21)

Dieting and body metabolism are closely related for a successful weight management. It’s stated

that basal metabolic rate is the minimal rate of energy expenditure per unit time by endothermic
(22)
animals at rest. It affects the rate that a person burns calories and ultimately whether that

individual maintains, gains, or loses weight. Then, calorie intake is calculated by adding BMR

with estimated energy needed according to level of activity. From a calculation, one pound

equals to 3,500 calories, you need to reduce your caloric intake by 500—1000 calories per day to
(23)
lose about 1 to 2 pounds per week. Therefore, calorie controlled diet is a good practice for

weight management.

There is also a study stated that high protein diets is importance for weight loss by providing a

satiating effect. (24) It is often recommended to help in building muscle and diet control.

Apart from that, sugar intake also plays a significant role in diet control. It mentioned that, added

sugars should comprise no more than 25 percent of total calories consumed. Added sugars are

those incorporated into foods and beverages during production which usually provide

insignificant amounts of vitamins, minerals, or other essential nutrients. Major sources include

soft drinks, fruit drinks, pastries, candy, and other sweets. Intake of sugar sweetened beverages

likely contribute to growing obesity rate. (25)

Ministry of health Malaysia suggest a healthy eating plate should contain of ¼ rice or noodles or

bread, ¼ side dish, ½ fruits or vegetables.

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Morbid Obesity

Lastly, increased knowledge of dietary guidelines and food-related knowledge are positively

related to more healthful; eating patterns. (26)

2. Physical activity

Eating well is only part of the battle; physical activity will further help in management of weight

loss and helps prevent many health conditions.

Catecholamine-induced lipolysis is enhanced in visceral fat but decreased in subcutaneous fat.

Many adaptive responses take place with physical training. These adaptations result in a more

productive system for oxygen transfer to muscle, which is now able to better employ the

unlimited lipid stores instead of the limited carbohydrate reserves available. In addition, the

reduced adipose tissue mass renders an important mechanical advantage, allowing better long-

term work. (27)

The body need to build more energy in order to keep positive calorie output in daily basis.

Physical exercise 3-5 days in a week, intensity level of 65-75% of maximum heart rate per

minute with duration 20-60 minutes is recommended. (27) There are certain exercises that help to

reduce weight in obese patient:

1. Continuous rhythm, using large group of muscle

2. Aerobic exercises

3. Weight resistance training

Besides, physical training helps prevent the permissive and affluent environment that predisposes

reduced-obese subjects to regain weight. An exercise program using weight resistance modalities

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Morbid Obesity

may also be included safely, and it improved program retention in a multidisciplinary weight

management program.

Active people are more likely to keep their weight steady rather than sedentary people who are

more likely to gain weight overtime. Strenuous activities seem to be more effective for weight

control than slow walking. In a study done among women, those who increased their physical

activity by 30 minutes per day gained less weight than women whose activity levels stayed
(28)
steady. And the type of activity made a difference: Bicycling and brisk walking helped

women avoid weight gain, but slow walking did not. (29)

There was a study involved a group of 65 overweight and obese adult subjects, aged 18-65 years,

participated during 12 sessions in a high intensity physical exercise program, 3

days/week. Each session consisted of 1 min stationary cycling exercise at high intensity,

followed by 2 min inactive rest. This cycle was repeated 10 times, thus the method is called

1*2*10. The training protocol lasting 12 weeks in association with nutrition counselling is

effective in reducing body fat in overweight persons. (30)

Apart from that, yoga practise has psychology effect in weight loss. As a stress level is reducing,

it may improve the eating habits and help in weight reduction. A study conducted by R.Shikesan

to assess the final outcome of the effects after 3 months of the 14 weeks yoga training on obesity

of adult male in an urban setting. The study used a randomized controlled trial with parallel

groups (Yoga and control groups) on male obese. After the 14 weeks of yoga training the Yoga

group was asked to continue the yoga practice for the next 3 months and the control group was

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Morbid Obesity

not given any physical activity. In the final outcome, results showed an improvement in

anthropometric and psychological parameters of Yoga group compared to control group. (31)

Realistic goals should be set between the clinician and the patient, with a weight loss of

approximately of 0.5 to 1 pound per week. The best long-term results may be achieved when
(32)
physical activity produces an energy expenditure of at least 2,500 kcal/week. It should be

kept in mind that since it generally takes years to become overweight or obese, a weight loss

pattern of 0.5 or 1 pound per week will require time and perseverance to rch the proposed

target. (27)

Conclusion

Obesity and obesity-related condition significantly increasing morbidity and mortality rate.

Furthermore, it causes burden to economics and society. Active participation in sports can be a

contributing factor in the prevention of obesity, and it is therefore recommended to combine

regular physical activities with an adequate diet. BMI screening of general population can

indicate a high number of children and adolescents at risk for obesity or who are already obese.

Regular moderate intensity physical activity, a healthy diet, and avoiding unhealthy weight gain

are effective and safe ways to prevent and treat cardiovascular diseases and to reduce premature

mortality in all population groups. Although the efforts to promote cardiovascular health concern

the whole population, particular attention should be paid to individuals who are physically

inactive, have unhealthy diets or are prone to weight gain. They have the highest risk for

worsening of the cardiovascular risk factor profile and for cardiovascular disease.

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Morbid Obesity

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