Morbid Obesity

Overview

Morbid Obesity is a severe disorder that can disrupt daily living, including fundamental bodily activities like breathing and walking. Obesity has become an epidemic that has become worse over the previous 50 years. The economic cost in the United States is estimated to be around $100 billion each year. Obesity is a multifaceted illness with a multifactorial origin. After smoking, it is the second most prevalent avoidable cause of death.

Morbid Obesity definition

Morbid Obesity is defined as the excessive or abnormal accumulation of fat or adipose tissue in the body, which negatively impacts health by increasing the chance of developing diabetes mellitus, cardiovascular disease, hypertension, and hyperlipidemia.

Obesity requires numerous treatment techniques and may necessitate lifetime therapy. A 5% to 10% weight loss can greatly improve an individual's and a country's health, quality of life, and economic burden.

Each year, morbid obesity costs the healthcare system more than $700 billion. The yearly economic burden in the United States is projected to be over $100 billion. Obesity is defined by the body mass index (BMI), which is computed as weight (kg)/height (m). While the BMI does have a curvilinear relationship with body fat, it may not be as accurate in Asians and the elderly, when a normal BMI may disguise underlying excess fat. Skin thickness in the triceps, biceps, subscapular, and supra-iliac regions can also be used to evaluate obesity. A DEXA scan (dural energy radiographic absorptiometry) scan may also be used to determine fat mass.

Obesity prevention will require a multifaceted strategy, encompassing interventions at the community, family, and individual levels, despite the fact that there is no effective, well-defined, evidence-based intervention. Dietary changes and exercise are the major therapies advocated by doctors. Diet quality may be improved by eating less energy-dense meals, such as those heavy in fat or sugar, and eating more dietary fiber.

Large-scale studies, however, have discovered an inverse association between energy density and energy cost of meals in wealthy countries. To suppress appetite or fat absorption, medications can be used in conjunction with a healthy diet. If diet, exercise, and medication are ineffective, a gastric balloon or surgery to lower stomach capacity or intestine length may be performed, resulting in feeling full sooner or a reduced ability to absorb nutrients from meals.

Epidemiology

Obesity affects over one-third of adults and approximately 17% of adolescents in the United States. Obesity affects one out of every five teenagers, one out of every six elementary school-aged children, and one out of every twelve preschool-aged children, according to the Centers for Disease Control and Prevention (CDC). Morbid obesity is more common among African Americans, Hispanics, and Caucasians. The southern states of the United States have the highest incidence, followed by the Midwest, Northeast, and West.

Morbid Obesity Causes

Morbid Obesity is caused by an imbalance in daily energy intake and expenditure, which results in excessive weight growth. Obesity is a complex condition that is influenced by a variety of genetic, cultural, and socioeconomic variables. Several genetic investigations have revealed that obesity is highly heritable, with multiple genes associated with adiposity and weight increase. Obesity is also caused by a lack of physical exercise, sleeplessness, endocrine abnormalities, drugs, the availability and intake of excess carbs and high-sugar meals, and a reduction in energy metabolism.

Pathophysiology

Morbid Obesity is linked to cardiovascular disease, dyslipidemia, and insulin resistance, all of which contribute to diabetes, stroke, gallstones, fatty liver, obesity hypoventilation syndrome, sleep apnea, and cancer.

Multiple studies have previously proven a link between genetics and obesity. The FTO gene is linked to obesity. This gene may have many variations that enhance the risk of obesity.

Leptin is an adipocyte hormone that regulates appetite and body weight. Obesity is linked to cellular leptin resistance. Adipose tissue secretes adipokines and free fatty acids, which promote systemic inflammation, insulin resistance, and elevated triglyceride levels, all of which lead to obesity.

Obesity can promote fatty acid buildup in the heart, resulting in left ventricular dysfunction. It has also been proven to affect the renin-angiotensin system, resulting in increased salt retention and blood pressure.

Besides total body fat, the following also increase the morbidity of obesity:

• Waist circumference (abdominal fat carries a poor prognosis)
• Fat distribution (Body Fat Heterogeneity)
• Intra-abdominal pressure
• Age of onset of obesity

Adipocytes have been demonstrated to exhibit prothrombotic and inflammatory activities, which can raise the risk of stroke. Adipokines are cytokines that are primarily generated by adipocytes and preadipocytes; however, macrophages infiltrating the tissue in obesity also create adipokines.

Adipokine secretion changes produce persistent low-grade inflammation, which may affect glucose and lipid metabolism and contribute to cardiometabolic risk in visceral obesity. Adiponectin possesses insulin-sensitizing and anti-inflammatory characteristics, and its levels in the blood are negatively related to visceral obesity.

Clinical manifestations of Obesity

According to the guidelines of the United States Preventive Services Task Force (USPSTF), all children aged six and above, adolescents, and adults should be tested for obesity. Physicians should conduct thorough screenings for underlying causes of obesity. A full history should include the following:

• Childhood weight history
• Prior weight loss efforts and results
• Complete nutrition history
• Sleep patterns
• Physical activity
• Associated past medical histories like cardiovascular, diabetes, thyroid, and depression
• Surgical history
• Medications which can promote weight gain
• Social histories of tobacco and alcohol use
• Family history

Complete a physical exam Body mass index (BMI) measurement, weight circumference, body habitus, and vitals should all be performed.

Acne, hirsutism, skin tags, acanthosis nigricans, striae, buffalo hump, fat pad distribution, irregular rhythms, gynecomastia, abdominal pannus, hepatosplenomegaly, hernias, hypoventilation, pedal edema, varicoceles, stasis dermatitis, and gait abnormalities are common obesity focal findings.

Morbid Obesity Diagnosis

Body mass index assessment is a typical screening technique for morbid obesity (BMI). BMI is computed by dividing weight in kilograms by height in meters squared. Obesity can be categorized based on BMI:

• Underweight: less than 18.5 kg/m2
• Normal range: 18.5 kg/m2 to 24.9 kg/m2
• Overweight: 25 kg/m2 to 29.9 kg/m2
• Obese, Class I: 30 kg/m2 to 34.9 kg/m2
• Obese, Class II: 35 kg/m2 to 39.9 kg/m2
• Obese, Class III: more than 40 kg/m2

A waist-to-hip ratio of greater than 1:1 in men and more than 0:8 in women is regarded noteworthy. Skinfold thickness, bioelectric impedance analysis, CT, MRI, DEXA, water displacement, and air densitometry investigations can all be performed as additional evaluations.

Laboratory investigations include a full blood picture, basic metabolic panel, renal function, liver function study, lipid profile, HbA1C, TSH, vitamin D levels, urine, CRP, and additional studies such as ECG and sleep studies.

A healthy weight in children varies according to age and gender. Obesity in children and adolescents is measured relative to a historical normal group, with obesity defined as a BMI more than the 95th percentile. The reference data on which these percentiles are based range from 1963 to 1994, and hence are unaffected by recent weight rises.

Specific groups have made some changes to the WHO definitions. The surgical literature divides class II and III obesity, or simply class III obesity, into further categories, the exact values of which are still debated.

• Any BMI ≥ 35 or 40 kg/m2 is severe obesity.

• A BMI of ≥ 35 kg/m2 and experiencing obesity-related health conditions or ≥ 40 or 45 kg/m2 is morbid obesity.

• A BMI of ≥ 45 or 50 kg/m2 is super obesity.

Childhood obesity

The healthy BMI range varies according to the child's age and gender. Obesity is characterized in children and adolescents as a BMI more than the 95th percentile. These percentiles are based on reference data from 1963 to 1994, which has not been impacted by recent rises in obesity incidence. Childhood obesity has reached epidemic proportions in the twenty-first century, with rates growing in both industrialized and developing countries.

Obesity rates in Canadian boys climbed from 11% in the 1980s to over 30% in the 1990s, whereas rates among Brazilian youngsters increased from 4% to 14% over the same time period. In the United Kingdom, there were 60% more obese children in 2005 than in 1989. In the United States, the rate of overweight and obese children climbed to 16% in 2008, a 300% rise over the previous 30 years.

Many variables, like with adult obesity, contribute to the increased incidence of pediatric obesity. The two most major causes of the recent increase in the incidence of juvenile obesity are thought to be dietary changes and decreased physical activity. Antibiotic use in the first six months of life has been linked to obesity in children aged seven to twelve.

Children who are obese are frequently examined for hypertension, diabetes, hyperlipidemia, and fatty liver disease since childhood obesity commonly continues into adulthood and is related with a variety of chronic conditions. Treatments for children are mostly lifestyle changes and behavioral methods, with minimal success in increasing activity in youngsters.

Medication is not FDA authorized for usage in this age range in the United States. Multi-component behavior modification treatments that combine food and physical activity adjustments may lower BMI in children aged 6 to 11 years in the short term, however, the effects are limited and the quality of evidence is low.

Obesity Effects on health

• Mortality

Obesity is one of the biggest avoidable causes of mortality around the world. A number of studies have revealed that mortality risk is lowest in nonsmokers with a BMI of 20–25 kg/m2 and highest in current smokers with a BMI of 24–27 kg/m2, with risk increasing with increases in either direction. This appears to be the case on at least four continents. Overweight (BMI 25–29.9) was connected with "lower" mortality than normal weight (BMI 18.5–24.9).

• Morbidity

Obesity raises the risk of a variety of physical and mental illnesses. These comorbidities are most typically seen in metabolic syndrome, a grouping of medical conditions that includes type 2 diabetes, high blood pressure, high blood cholesterol, and high triglyceride levels.

Obesity causes complications either directly or indirectly through processes that have a common origin, such as a bad diet or a sedentary lifestyle. The degree of association between obesity and particular illnesses varies. One of the most compelling is the relationship to type 2 diabetes. Excess body fat is responsible for 64% of diabetes cases in men and 77% of cases in women.

Common Obesity Related Conditions

Obesity-related health problems shorten people's lives. The following are some of the most frequent conditions. Please see your doctor if you require any further information.

• Type 2 diabetes. Obese people develop resistance to insulin, which regulates blood sugar levels. They develop high blood sugar, which leads to Type 2 diabetes.
• High blood pressure/heart disease. When the body is carrying extra weight, the heart does not function properly. As a result, the obese individual is more likely to develop hypertension (high blood pressure), which can lead to strokes and damage to the heart and kidneys.
• Osteoarthritis of weight-bearing joints. Additional weight on joints, particularly the knees and hips, produces quick wear and tear, as well as discomfort and inflammation. Similarly, tension on the back's bones and muscles causes disk issues, discomfort, and limited movement.
• Sleep apnea/respiratory problems. Fat deposits in the tongue and neck, particularly in people who sleep on their backs, can obstruct airways. This leads individuals to lose sleep and produces tiredness and headaches during the day.  
• Gastroesophageal reflux disease (hiatal hernia and heartburn). Excess weight weakens and overloads the upper valve of the stomach, allowing stomach acid to leak into the esophagus. This is known as gastroesophageal reflux, and frequent symptoms include "heartburn" and acid indigestion. Barrett's esophagus, a pre-malignant alteration in the lining membrane and a cause of esophageal cancer, affects around 10-15% of people with even mild heartburn.
• Depression. Obese people face frequent, gloomy emotional challenges: failing diets, condemnation from family and friends, and comments from strangers. Furthermore, individuals frequently face prejudice and are unable to feel at ease in public areas.
• Infertility. Obesity disrupts the regular cycles and function of male and female hormones, making it difficult or impossible to conceive.
• Urinary stress incontinence. The symptoms of delivery are exacerbated when the abdomen is big and hefty. This weakens the bladder valve, causing leakage while coughing, sneezing, or laughing.

Morbid Obesity Management

Morbid Obesity causes a number of comorbid and chronic medical disorders, and clinicians should treat obesity in a multifaceted manner. Individualize treatment, address underlying secondary causes of obesity, and concentrate on treating or reducing related comorbid disorders. Management should include dietary changes, behavioral therapy, medicines, and, if necessary, surgical intervention.

Dietary changes should be tailored to the person, with regular weight reduction closely monitored. Diets low in calories are advised. A low calorie can refer to carbohydrate or fat restriction. In the first few months, a low-carbohydrate diet can cause more weight reduction than a low-fat diet. The patient's adherence to their diet should be reinforced on a regular basis.

Patients who are obese will be referred for extensive behavioral therapy. Motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and interpersonal psychotherapy are among the psychotherapeutic therapies accessible. When paired with diet and exercise, behavioral therapies are more successful.

• Medications: 

Antiobesity drugs can be utilized if your BMI is more than or equal to 30 or if you have comorbidities and your BMI is greater than or equal to 27. Medications can be used with dietary, physical activity, and behavioral treatments. Antiobesity drugs authorized by the FDA include phentermine, orlistat, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, and phendimetrazine. All of the compounds are used to help people lose weight over time.

Because of its limited absorption, orlistat is typically the first option because to its lack of systemic effects. Lorcaserin should not be used with other serotonergic drugs since it increases the risk of serotonin syndrome. In the first three months, high responders often lose more than 5% of their body weight.

Bariatric Surgery

In people with morbid obesity and comorbidities, surgical treatment for obesity (bariatric surgery) is the only current therapeutic method linked with clinically substantial and reasonably persistent weight loss. Evidence suggests that well-executed bariatric surgery, undertaken in carefully chosen patients with a skilled multidisciplinary support team, significantly improves the morbidities associated with extreme obesity.

Although bariatric surgery is the only treatment option linked with large and quick weight loss, it is costly, procedure and surgeon specific, and far from a solution to the increasing obesity pandemic. Patient selection for bariatric surgeries must follow the same strict guidelines as those outlined before for patient selection for medicinal weight-management regimens.

Patients should be considered candidates for these operations only if their BMI is more than 40 kg/m2 and/or their weight is more than 45 kg above the age- and gender-defined optimum weight. To justify these operations, individuals with BMIs of 35-40 kg/m2 must have at least one serious comorbidity. Comorbidities are not a contraindication to bariatric surgery; nonetheless, the patient's condition must be stabilized and effectively addressed prior to surgery.

The following comorbidities have been reported to be improved, ameliorated, or resolved as a result of bariatric surgery:

• Obstructive sleep apnea
• Type 2 diabetes mellitus
• Hypertension
• Heart failure
• Peripheral edema
• Respiratory insufficiency
• Asthma
• Dyslipidemia
• Esophagitis
• Pseudotumor cerebri
• Operative risk
• Osteoarthritis
• Thromboembolism
• Urinary incontinence

Other studies indicate that bariatric surgery improves the quality of life and fertility. Although some results are harder to establish and need detailed documentation, these operations may significantly reduce macrovascular problems (e.g., myocardial infarction), stroke, amputations, obesity-related cancers, infection, hernias, and varicose veins.

Although the majority of bariatric operations were created in the context of laparotomies, they are now increasingly being performed laparoscopically, with lower postoperative morbidity. In Europe, the laparoscopic approach to bariatric surgery is extremely advanced.

Among the standard bariatric procedures are the following:

• Roux-en-Y gastric bypass
• Adjustable gastric banding
• Gastric sleeve surgery
• Vertical sleeve gastrectomy
• Horizontal gastroplasty
• Vertical banded gastroplasty
• Duodenal-switch procedures
• Biliopancreatic bypass
• Biliopancreatic diversion

Many of these techniques have relatively little evidence on their efficacy. However, data and meta-analyses from vast numbers of patients on the most routinely done procedures (gastric restriction and gastric bypass) add credibility to bariatric surgery's long-term success.

The American Association of Clinical Endocrinologists recommends sleeve gastrectomy as a viable alternative to gastric banding, gastric bypass, and other types of bariatric surgery, stating that the procedure has progressed beyond the investigational stage. The recommendations, however, do not advocate one bariatric treatment over another for people with extreme obesity.

• Vertical-banded gastroplasty

that over a year, almost 60% of them dropped more than 50% of their extra body weight No patient lost less than 25% of their body weight, and following a year of the surgery, the average BMI had dropped from 44.8 to 32.5 kg/m2.

• Gastric bypass

After an evaluation of 210 Roux-en-Y gastric bypass patients, a mean weight loss of 51 kg was found in 18 months, which was subsequently maintained during 36 months of follow-up. Only 4% of the patients required a second procedure. Two-thirds of patients receiving gastric bypass lost two-thirds of their extra body weight after two years, 60% of excess body weight reduction was maintained at 5 years, and more than 50% of excess body weight loss was maintained at 8-9 years' follow-up.

Roux-en-Y and other gastric-bypass surgeries result in more weight reduction than gastric-restriction treatments. Gastric bypass (but not restriction surgery) appears to lower the risk of type 2 diabetes and myocardial infarction in morbidly obese patients compared to the general population. Nonetheless, the mortality risk in these individuals remains greater than in the general population.

• Gastric pacing

Emerging evidence suggests that gastric pacing done with implanted electrodes can result in considerable weight reduction. This result was observed originally with the use of gastric pacemaker devices for gastroparesis in diabetic patients.

At the 3-year follow-up, patients who had a pacing device laparoscopically implanted had a mean excess weight decrease of nearly 25%. 

Conclusion 

Morbid obesity (BMI > or =40 kg/m(2)) is a risk factor for mortality in surgical patients suffering from catastrophic diseases that need extended critical care. Obesity is becoming more common, both in the critical care unit and in the general community. Because of the greater risk of complications and mortality in this population, we must design personalized care approaches to particularly treat this distinct and difficult subset of patients.