Dr. Ashish Vashistha, a Senior Robotic laparoscopic Surgeon, Director & HOD Department of Surgery and Robotics Max Super Specialty Hospital Saket Delhi. Share information on Addressing Obesity Surgery !
Let’s address Obesity ?
Obesity is characterized by excessive fat build up to the point that our health and well being are at risk.
It is a chronic disease and have detrimental effects on health.
How do you diagnose obesity ?
1.BMI (Body mass index )
It is a screening tool to have a general look at obesity. It takes into account of person’s height and weight and classify obesity.
It is calculated as person’s weight in kilogram divided by square of their height in meters ( kg / m2)
Different people of the same BMI may have different body shapes depending on distribution of body fat and skeletal muscle
A high BMI is a strong parameter for occurrence of Non communicable diseases like diabetes, hypertension , high lipid and many malignancies .
Although the BMI typically correlates closely with percentage body fat in a curvilinear fashion, some important caveats apply to its interpretation. In athletes (muscular) persons, BMIs that usually indicate overweight or mild obesity may be spurious, whereas in some persons with lean sarcopenic eg, elderly individuals and persons of Asian descent, particularly from South
Asia, a typically normal BMI may conceal underlying excess adiposity characterized by an increased percentage of fat mass and reduced muscle mass.
In view of these limitations, some authorities advocate a definition of obesity based on percentage of body fat. For men, a percentage of body fat greater than 25% defines obesity, with 21-25% being borderline. For women, over 33% defines obesity, with 31-33% being borderline.
Classification of obesity
Among several classifications and definitions for degrees of obesity, the following is widely used:
- Overweight – BMI greater than or equal to 25 to 29.9 kg/m2
- Obesity class I – BMI 30 to 34.9 kg/m2
- Obesity class II – BMI 35 to 39.9 kg/m2
- Obesity class III – BMI greater than or equal to 40 kg/m2 (also termed severe, extreme, or massive obesity)
Under this classification, the cutoff points differ for Asian and South Asian populations like Indians , with overweight being classified as 23-24.9 kg/m2, and obesity as 25 kg/m2 or greater.
In children, a BMI above the 85th percentile (for age-matched and sex-matched control subjects) is commonly used to define overweight, and a BMI above the 95th percentile is commonly used to define obesity.
WHO classification of BMI for the Asian
population .
Underweight | <18.5 kg/m2 |
Normal Weight | 18.5–22.9 kg/m2 |
Overweight | >23 kg/m2 |
Obese | >25kg/m2 |
2.Waist circumference
Waist circumference is simple to measure and it avoids any consideration of the hip as they convict of bone and skeletal muscle along with fat –
The technique for measuring WC is with measuring tape halfway between the lower rib and iliac crest
it is a measure of central /abdominal obesity when is more than 90 cm in men and more than 80 cm in women ,they are associated with metabolic problems.
Fat distribution is important to identify
Android obesity, in which adiposity is predominantly abdominal (including visceral and, to a lesser extent, subcutaneous), is strongly correlated with worsened metabolic and clinical consequences of obesity.
3.Hip circumference (HC)
It is measured at widest circumference over greater trochanters.
4.Waist – Hip ratio (WHR)
WHR is obtained by dividing the WC by HC using same units of measurements for both.
WHR is straight forward indicator of central obesity.
The WHO classifies abdominal obesity in men if WHR >0.9 and women >0.85
The ratio greater than 1.0 in either sex indicates increased risk of metabolic complications.
Classification of -Waist-Hip ratio.
Health Risk | Women | Men |
Low | 0.80 or lower | 0.95 or lower |
Moderate | 0.81–0.85 | 0.96–1.0 |
High | 0.86 or high | 1.0 or high |
5. Neck circumference ( NC)
NC >35.5cm in men
NC >32cm in women
is harmful
6. Body fat percentage
Bioelectrical impedance analysis (BIA)is very accurate in diagnosing body fat.
It is more accurate then BMI .
Body impedance analyst is (BIA) is relatively simple quick and noninvasive method to assess body composition .
BIA allows the calculation of fat free mass and body fat percentage.
Body fat percentage of more than 25% men and more than 30% in women are considered obese by Endocrine society of India
A person’s body fat percentage can be indirectly estimated by using the Deurenberg equation, as follows:
body fat percentage = 1.2(BMI) + 0.23(age) – 10.8(sex) – 5.4
with age being in years and sex being designated as 1 for males and 0 for females. This equation has a standard error of 4% and accounts for approximately 80% of the variation in body fat.
Important Parameters to look at-
Indian cut-offs for Indicators
PARAMETER | INDIAN CUT-OFF MALE | INDIAN CUT-OFF FEMALE |
Waist Circumference (WC | >90 cm | >80cm |
Waist-Hip Ratio (WHR) | >0.9 | >0.85 |
Wrist circumference | 16.5 cm | 15.7 cm |
Neck circumference (NC) | 35.25 cm | 34.25 cm |
Body Fat Percentage | >25% | >30% |
Body Mass Index | >23 kg/m2 – Overweight, | |
Imaging
-CT scan
-MRI
Can identify visceral fat and subcutaneous fat .
Visceral fat is responsible for metabolic abnormalities
7. Dual – energy -x-ray absorptiometry (DEXA)
DEXA scanning uses low-level X-rays that pass through different types of tissues at different rates providing estimates of fat mass, fat-free mass, and bone density. This method is widely used to measure bone density and can also accurately measure fat mass. A limitation of most DEXA scanners is the capacity to image extremely obese persons. However, half-body scans have been shown to provide an accurate body compositional analysis. DEXA is relatively simple to perform, less expensive, and more accessible than MRI or CT Scan.
8. Lab tests- like
– Liver function test
– Fasting glucose and glycosylated hemoglobin
– Thyroid function tests
– Lipid profile
Obesity can have many co-morbidities-
1) Respiratory – increased risk of bronchial asthma, COPD
2) Cardio vascular – High blood pressure, coronary artery disease, cardiomyopathy etc.
3) Psychological -social stigmatization and depression
4) Metabolic -type 2 Diabetes and dyslipidemia
5) Gastrointestinal – Gall bladder stone, fatty liver, reflux esophagitis .
6) Reproductive problems in women -early puberty, infertility ,PCO ,anovulation
7) Reproductive problems in men- hypogonadism
8) Pelvic problems -stress in continence
9) Obstetrics – Pregnancy related hypertension, Gestational diabetes, macrosomia and difficult labor .
10) Malignancies – Endometrial carcinoma , liver , colon , breast carcinomas etc
Management of Obesity
Complete evaluation on all aspects of obesity is must.
1. History taking-
– Duration of obesity
– Is obesity bothering the patient
– Family history of obesity
– Is he/ she worrisome person
– What is the sleep pattern
– Detailed dietaryhistory
– Medical history like – any metabolic disease like diabetes, high blood pressure,PCOS , high lipid , knee pain etc
– Social history – smoking, alcohol, drug abuse
– Any other compulsion disorders like binge eating , binge drinking etc
2. Measurement of height , weight and calculating BMI
3. Abdominal circumference is measured
4. Hip circumference is measured
5. W/H ratio calculated
6. Neck circumference noted
7. Look for signs of insulin resistance like , acne , acanthosis nigricans , increased hair growth on face abdomen etc
8. After assessment, talk with patient and identify his / her goal of weight loss.
9. Life style modification is first step.
10. A well-balanced diet with sufficient protein, nutrients is formulated with the help of nutritionist
11. A well-structured exercise regime is formed consisting of aerobics, strength training and yoga
12. Anti-obesity drugs are started if BMI is more than 30 or BMI more than 27 with co morbidities like type 2 diabetes / high blood pressure and patient is unable to shed weight only on diet and exercise.
Anti obesity medications When combined with lifestyle and behaviour changes, including healthy eating and increased physical activity, can help some people lose weight and maintain weight loss. On average, after 1 year, adults who take anti obesity medications as part of a lifestyle program lose 3% to 12% more of their starting body weight than people in a lifestyle program who do not take medication.
Orlistat
– Orlistat is a gastro – intestinal and pancreatic lipase by that indices weight loss by inhibiting dietary fat absorption.
– Orlistat should be taken up to 1 hour after taking fatty meal .
– It brings weight loss up to 5-7 percent and does not depend or systemic absorption.
– Full dose of 120 mg 3 times a day can give server GI events like flatulence, oily stool ,diarrhea and stool incontinence .
– -it is advisable to reduce fat content in meals to decrease side effects of orlistat.
Glucagon like peptide -1 agonist –
GLP -1agonists have shown to promote weight loss in patient with or without
Diabetes –
GLP-1 is an appetite regulator .
– Semaglutideis indicated for chronic weight management along with life style changes like diet and exercise In patient with BMI >27 with obesity related co morbidities like type 2 diabetes , high blood pressure , high cholesterol etc
– This medicine is also good for risk reduction with regard to major adversecardo- vascular events in obese people
– This is available in 3 , 7 and 14 mg tablets , it promotes insulin secretion and delay gastric emptying .
These medications should not be taken by own self. Always see a doctor , get yourself evaluated and let doctor decide which medication is right for you.
13. Metabolic / Bariatric Surgery is gold standard for sustained weight loss and correction of metabolic side effects of obesity like type 2 diabetes , high blood pressure , high cholesterol , PCOS etc .
According to recent guidelines, particularly from the Obesity and Metabolic Surgery Society of India (OSSI), bariatric surgery in India is recommended for individuals with a BMI exceeding 35 kg/m2, regardless of the presence or severity of co-morbidities; additionally, individuals with a BMI between 30-34.9 kg/m2 and metabolic disease should also be considered for surgery, with a special consideration for the Asian population where a BMI above 27.5 kg/m2 may indicate the need for bariatric surgery due to the lower BMI threshold for obesity in Asian populations.
