Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity.

What is Morbid Obesity?
Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases that result either in significant physical disability or even death. Morbid obesity is typically defined as being 100 lbs. or more over ideal body weight or having a Body Mass Index of 40 or higher. According to the National Institutes of Health Consensus Report, morbid obesity is a serious disease and must be treated as such.

Causes of Obesity
Research shows that the recent rise in obesity is due to changed lifestyles, energy-dense diets and low-levels of physical activity. Various possible causes of obesity, as suggested by renowned doctors, are given below:

• Heredity : Research shows that heredity influences fatness and the distribution of fat tissue. Weight regulation in the human body depends upon various hormonal and neural factors which are genetically determined.

• Metabolic Factors : Basal metabolism rate (BMR) is the energy (measured in calories) used by the body at rest to maintain normal bodily functions. Increased activity increases the BMR and the amount of calories burnt. Most obese people lead an inactive life, thus their energy expenditure is minimal. Low levels of spontaneous physical activity leads to vulnerability towards obesity.

• Endocrinological Causes : Sometimes obesity may be a result of a hormonal imbalance or glandular problem. However this is a rare occurrence and contributes to less than 1% of all weight gain in the world.

• Medication : Certain drugs may contribute to weight gain, such as corticosteroids, sulfonylureas for diabetes, steroidal contraceptives and anticonvulsants such as valproate used in epileptic therapy. Antipsychotics, antidepressants, mood stabilizers like lithium are medicines that have weight gain as a side effect.

• Psychological Causes : Though these factors play a minor role in the development of obesity, they are important in relation to responses to treatment. For example, many patients reduce depressive symptoms by eating.

• Dietary Factors : Changes in lifestyle, food systems, and increased portion sizes have been cited as causes for increased caloric intake. Larger portion sizes have led to a 30% increase in overeating. Eating out frequently also leads to increased calorie intakes as one meal served in restaurants and fast food outlets exceeds a person’s caloric needs for the entire day.

Facts about Morbid Obesity

• There is a world epidemic of obesity, estimated to encompass 1.7 billion people. 20% of this population is known to be morbidly obese.

• According to the World Watch Institute, the number of overweight people is approximately equal to the number of underweight people.

• The caloric value of the food offered by restaurants and fast food outlets for one meal often exceeds a person’s caloric needs for the entire day.

• Even modest degrees of overweight have a significant adverse effect on the outcome of pregnancy.

• The incidence of large-for-gestational-age infants in obese mothers is higher than in lean mothers.

• Weight fluctuations have worse impact on the risk of death than weight stability.

• The risk of mortality associated with obesity is greater for younger people as compared to older people.

Diseases related to Morbid Obesity

• Obesity alone accounts for 78% and 65% of essential hypertension in men and women respectively.
• The occurrence of myocardial infarction, hypertension and congestive heart failure are all significantly higher among obese people than among people with normal weight.

• Central adiposity is also more closely associated with the development of metabolic syndrome than the absolute degree of fatness.
• Researchers have observed that increased visceral adipocyte in Asian Indians is associated with increased generalized obesity, which is not perceptible from their non-obese BMI. This often results in prevalence of diabetes mellitus and cardiovascular disease.
 

• A population of 19 million in India is already affected by diabetes and the figure is expected to go up to a whopping 57 million by the 2005, a World Health Organisation (WHO) study indicated.
• The prevalence of diabetes increases proportionately with the severity of obesity, duration of obesity, and age.
• Studies have reported that about 75% of type 2 diabetics are overweight.
• Diabetes related mortality can be reduced by 30-40% by losing nine kilograms of weight.
• Glycosylated Haemoglobin can be reduced by 7% and fasting blood glucose by 15% with a 5% weight loss.
• Central distribution of fat as reflected by waist circumference above 100 cm independently increases the risk of diabetes by 3.5 fold even after controlling for BMI in both the genders.

Morbid obesity (MO) can be associated with changes in respiratory function. Among others, they are the obesity hypoventilation syndrome (OHS) and the obstructive sleep apnea syndrome (SAS), which may occur either independently or in combination.
 

In the clinically severe obese with BMI exceeding 40, only 2% have normal livers, 56% show fatty infiltration alone, whereas 42% have fatty infiltration associated with fibrosis or cirrhosis.
 

• Colorectal cancer was the principal site of excess cancer mortality in obese males, whereas in females cancer of the gallbladder and biliary passages was more prominent.
• In women aged 60-69 years with a BMI of 25-29 kg/m2 the risk of endometrial cancer is more than double and increases 5.4-fold in those with BMI of more than 30 kg/m2.
• An intentional weight loss of even 0.5-9.0 kg was associated with a decrease of 40-50% in mortality from obesity related cancers
 

• A child who is obese after 6 years of age, has a 50% probability of obesity during adult years; and the risks are significantly higher if either parent is obese.
• Adult obesity stemming from childhood obesity is known to be even more severe.
• It has been estimated that children consume 20 - 25% of their daily energy while television viewing and this ‘eating while watching television is a potential mechanism linking television viewing to obesity.
• A study conducted by the Nutrition Foundation of India on over 4000 children aged 4-18 years in a public school in Delhi, showed that the incidence of overweight reached its peak in boys by 12-14 years and in girls by 9-11 years whereas the incidence of obesity reached its peak between 6-8 years in both boys and girls.

Weight Loss Surgery Options :

Restrictive weight loss surgery works by reducing the amount of food consumed at one time. The theory is simple; due to the restriction created, you feel satiated with small amounts of food and because of a smaller outlet, food stays in the stomach for a longer time. The net result is - a reduction in daily caloric intake without a feeling of deprivation.

Effects

In a cooperative and compliant patient, the reduced stomach capacity, along with behavioural changes, can result in consistently lower caloric intake and consistent weight loss. Patients who see the best results from a restrictive procedure are those who learn to eat slowly, eat less and avoid drinking too many caloric fluids, particularly carbonated beverages. If the patient fails to follow these guidelines, they can stretch the stomach pouch and/or the stoma outlet and defeat the purpose of the surgery. The effectiveness of a restrictive procedure is reduced by constant snacking or by drinking high-calorie, high-fat liquids.

Roux -En-Y Gastric Bypass
Procedures that alter digestion are known as malabsorptive procedures. Malabsorptive techniques reduce the length of intestine that comes in contact with food so that the body absorbs fewer calories.

According to the American Society for Bariatrics Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is completely stapled shut and divided from the stomach pouch. It is not completely removed. The length of either segment of the intestine can be adjusted to produce lower or higher levels of malabsorption.

Advantages
• The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
• One year after surgery, weight loss can average 77% of excess body weight.

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