Obesity is the most important public health problem in resource-rich countries. With the increased prevalence of obesity has come the increase prevalence of its comorbidities, such as the metabolic syndrome and cardiovascular disease (CDV). Obesity isn’t just being above ideal body weight. Obesity means an excess of fat. Although not perfect for clinical application, the standard estimate that is used to assess the degree of obesity is the relation between weight and height–the body mass index (BMI).
Adults with a BMI between 25-30 kg/m2 are considered overweight. Beyond that, designations such as obese and morbidly obese are applied to a progressive BMI score template.
While it is felt by some that overeating is an addiction, this analogy falls short in that one must eat to survive. The gift of taste as a sense is a double-edged sword, in that the pleasure invoked from eating something that is delicious is associated with the release of the “reward” neurotransmitter, dopamine. When men were hunter-gatherers and women worked hard with children and household chores, they ate to survive. The pleasures of today’s culinary arts, combined with the epidemic of physical inactivity, portends poorly for society, now trending toward obesity at an epidemic scale.
While the analogy to addiction falls short, it isn’t completely untrue. Cravings for the pleasures of eating or due to the necessity for psychological crutches (“comfort food”) that afflict persons with depression and anxiety can make management very difficult.
The problem is obesity and the solution is weight management. Weight management, however, is fraught with pitfalls that conspire to defeat the best intentions:
Today’s social climate: we are social animals. We meet together, we entertain together, we savor special occasions, all of which involve eating. Birthday parties, the Superbowl, romantic dinners–every day offers sabotage to any diet.
Today’s social media: we are constantly barraged by succulent items on fast-food commercials. We are also seduced by advertisements that promise magical weight loss by use of pills or special exercise devices.
Psychological issues: the food-hoarding of abused children is revealing into how psychological disturbances can affect our eating habits. Many obese individuals who fail to lose weight consider themselves victims–and many rightfully are–which make them feel hopeless. With hopelessness comes a lack of all motivation.
Unreasonable expectations: weight was gained slowly, so the best way to lose it is slowly. Rapid weight loss always fails, simply because a person suffers until a goal was met, only to re-emerge into the same old habits, instead of changing his or her entire life to attain and live that goal comfortably.
Barriers to weight loss: family obesity dooms any individual’s diet by the close proximity of poor food choices. Insurance companies often will not cover consultations by dietitians or nutritionists, and certainly will not cover the expense of gym memberships.
Can Obesity Be Diagnosed?
As part of any evaluation of obesity, first other causes (besides improper diet) should be ruled out, such as a neuroendocrine cause, e.g., hypothalamic obesity and hypothyroidism. When obesity is felt to be due to dietary excess, explorations into eating frequency, overeating with large portions, and high fat diets are considered. Finally, psychological causes are considered, such as depression, anxiety, or a history of abuse.
Obesity refers to excess fat, but there isn’t a way to directly measure someone’s actual fat content. The current standard is to compute a “body mass index” (BMI), which is the relationship between height and weight.
BMI as kg/m2 = body weight (kg) ÷ [height (m)]2
The result is plotted against a BMI template in which there are assignments that range from underweight to severely obese. Children must be adjusted for advancing growth, but for adults, a BMI of:
- < 18.5 kg/m2 : UNDERWEIGHT.
- 18.5 -24.9 kg/m2: NORMAL.
- 25-30 kg/m2: OVERWEIGHT.
- ≥ 30 kg/m2: OBESE; ≥ 35 kg/m2: SEVERE OBESITY (Class II); ≥ 40 kg/m2: SEVERE OBESITY (Class III)
Waist circumference is also part of the evaluation of obesity, especially as it relates to the abdominal obesity consistent with the metabolic syndrome and its association with insulin resistance.
- A circumference of ≥40 inches for men or ≥ 35 inches or women is considered abnormal and increases cardiovascular risk.
Other Testing Indicated with Obesity Includes the Following:
- Fasting blood sugar, oral glucose tolerance test, or hemoglobin A1c, as part of diabetic management or screening
- Lipid panel
- Appropriate cardiovascular testing
- Thyroid function tests (TSH initially) to rule out an endocrine cause of obesity, such as hypothyroidism
- In women, evaluation of menstrual cycles (specifically, ovulation) and serum testosterone and other hormonal levels are necessary to rule out Polycystic Ovarian Syndrome (PCOS), a gynecological endocrine disorder that causes weight gain and virilization due to elevated testosterone
Management of Weight and Obesity
Management of obesity is its treatment. Because of its numerous causes and contributions from a complex assortment of factors, treatment must be individualized for the patient. For example, depression requires including its treatment as part of weight management. The psychological aspects of obesity can include unipolar and bipolar disorders and personality disorders all the way to psychosis.
Any drugs that have weight gain as a side effect should be replaced with another equally effective drug for its indication. Since any drug can do anything to anybody, it is often necessary to make adjustments based on trial and error. This emphasizes that weight management is a long-term process.
In women, hormonal shifts can add more weight than just fluid retention. Some hormonal birth control methods (e.g., Depo Provera injections) can result in monthly weight gain. Also, the insulin-resistance condition of Polycystic Ovarian Syndrome (PCOS) causes weight gain as well as virilizing signs due to elevations in a woman’s testosterone.
Comorbidities such as cardiovascular disease, diabetes, and the metabolic syndrome require management as well.
All overweight persons should be counseled about diet, physical exercise, alterations of lifestyle and behavior, and reasonable goals for weight loss.
The mind-body connection is not well understood, but how it benefits from exercise has been well established. Besides just burning calories, helpful in any calorie-restriction diet, it also benefits mental health to defuse any psychological influences on behavior that may interfere with attaining one’s goals.
Psychological aspects that lead to obesity should be addressed via a social worker, psychologist, or psychiatrist, depending on the severity of the mental illness. Care must bet taken when antidepressants are prescribed as some may cause weight gain.
The linchpin to management is the diet. It should be designed by a professional dietitian/nutritionist and personalized for the patient to take into account non-dietary influences on the diet. Of crucial importance is that the diet should not be drastic or unreasonable. Anything less is doomed as a recipe for failure, which will only keep the patient in the vicious cycle of repeated unsuccessful attempts to lose weight.
Overweight and obese patients face a problem that is bigger than themselves and require a dedicated multi-prong approach from many providers to meet their goals. Once weight management is needed, it is then a lifelong commitment to good physical and mental health.
Weight Management & Obesity Prevention
Any individual is either overweight or not. Except for those with endocrine disorders, there are two warning signals that identify the risk for becoming obese for someone not overweight:
- Family history of obesity
- Crossing the threshold from a normal weight to overweight
Prevention of obesity should take into account all of the physical, biological, therapeutic, and mental conditions that contribute to it:
- Physiologic alterations due to endocrine disorders should be identified early when there is a family history of obesity. Hypothyroidism and Polycystic Ovarian Syndrome (PCOS), Cushing Syndrome, and kidney disease can cause weight gain. Treating the underlying disorder that causes weight gain will prevent weight gain. Diabetics should maintain optimal glycemic control, which not only prevents obesity, but decreases the risks of diabetic complications and cardiovascular disease.
- Drugs that can cause weight gain should be replaced with equally efficacious ones for those at risk.
- Poor choices in lifestyle should be corrected. This means a proper, nutritious, and a calorie-restricted diet. Excessive caloric intake is a bad behavior that requires correction.
- Family therapy can be the key to success if there is a family history of obesity. Having others in the household making bad dietary choices will expose a patient to undue temptation, making attaining his or her goals less likely. An entire family with similar goals will act as its own support group, enhancing the chances of meeting dietary goals.
- Utilize psychological evaluations to identify triggers for overeating, old (previous abuse and depression) or current (depression, anxiety, or hopelessness).
- Nutritional counseling can be helpful in identifying dietary choices that can push someone from “at risk for obesity” to actual obesity. Education is always helpful in accelerating and strengthening the entire process of prevention.
- Physical exercise/activity is the other half (with diet) of a prime prevention strategy. Even for individuals not overweight, a commitment to fitness is a healthy lifestyle across all demographics, not just for those at risk for becoming overweight.