Obesity (adiposity)

Obesity is the relative increase in fat mass. This means that there is a disproportionate amount of fat in contrast to the other building materials of the body. Several quantifications are used to distinguish obesity from overweight.

The Body Mass Index (BMI)

Currently, the BMI plays a major role in the diagnosis of obesity. This value relates the height to the weight. The BMI is calculated by applying the formula "(weight in kg) / (height in m)²".

Depending on the BMI, several weight classes are divided:

• Underweight: BMI below 18.5
• Normal weight: BMI between 18.5 and 25
• Overweight: BMI between 25 and 30
• Obesity: BMI over 30

Even though the BMI is probably the most common measure for assessing body weight today, there is also a decisive disadvantage with this. The composition of the body weight is not taken into account at all. This is why overweight or even obesity is often indicated, especially in athletes, even if their fat percentage is within the normal range.

Hip-Waist-Ratio (Waist-Hip-Ratio)

Another important assessment criterion for body weight is the ratio between hip circumference and waist circumference. To do this, simply divide the waist circumference by the hip circumference.

According to the risk limits set by the WHO, the hip-waist ratio should be less than 0.85 in women and less than 1.00 in men. Other institutes suggest a lower hip-waist ratio. For example, it should be less than 0.80 for women and less than 0.90 for men.

Measurement of the abdominal girth

The abdominal circumference can also be used to evaluate body weight. Especially in recent studies, it has been found that this has a great importance in assessing a healthy body weight.

For women, the abdominal circumference should be less than 80cm, for men less than 94cm. An abdominal circumference of more than 88 cm in women or more than 102 cm in men is considered to be a questionable fat distribution, which entails a greatly increased risk of secondary diseases.

Classification of fat distribution

Obesity can be classified into two forms based on fat distribution.

• Abdominal obesity: This is also known as a beer belly and occurs mainly in men. The risk of secondary diseases is considerably increased with this type of fat distribution. This is why it is often referred to as dangerous abdominal fat.
• Peripheral obesity: In this case, the fat accumulates evenly in the subcutaneous fatty tissue. Larger fat deposits are mainly found on the extremities, such as the hips. This form of distribution is often called the female form and is less dangerous than abdominal obesity.

Obesity is divided into primary and secondary causes. In secondary obesity, there is an underlying disease that can be considered as the cause. In primary obesity, the condition exists without an underlying causative disease being found.

Primary obesity

In this case, the exact cause is unknown in many cases. Since there is often a familial accumulation, it is assumed that both genes and psychosocial factors play a role. In addition to genes, we also inherit certain behaviours from our parents. These mainly concern lifestyle, which is usually inherited from parents, even if it is anything but healthy.

Secondary obesity

In terms of numbers, this only plays a minor role. Nevertheless, it is important to exclude this form before starting a therapy. Otherwise, the treatment used may not only be ineffective, but above all dangerous.

Possible underlying diseases that can trigger obesity include:

• hormonal changes
• hypothyroidism
• Cushing's disease
• polycystic ovary
• benign tumour of the pancreas with insulin secretion
• Central nervous changes
• Damage to the hypothalamus
• neoplasms in or on the hypothalamus

In addition to other diseases, drugs can also be involved in the development of obesity. These include mainly antidepressants, neuroleptics, hypnotics, antiepileptics, steroids, antihistamines, oral antidiabetics and insulin.

Research into other causes

Even though obesity affects a great many people and also has very negative effects on health, there is still relatively little data on its development and treatment. Today, more and more research is being done in this field. This is to develop new and more effective methods of treatment and prevention.

For example, it is now believed that due to an imbalance of certain neurotransmitters in the brain, the regulation of appetite and satiety does not work in many obese people. Thus, a hunger signal continues to be sent even when there is an energy surplus. In addition, the feeling of satiety remains absent, which increases the oversupply of nutrients even more.

This theory is supported by the fact that every patient with obesity has a positive energy balance. This means that more nutrients are taken in than the body uses. However, the reason why this is so, why the body does not prevent this itself, is unknown.

Poor lifestyle and obesity

However, with all the attempts to find out the causes of severe obesity, it must be mentioned that lifestyle, above all, also plays a major role. Physical inactivity and too much energy intake must simply lead to fat reserves being built up.

It can also be observed in many obese people that psychological stress and drastic changes in life in particular cause the weight to get out of control. These include marriage, separation or a career change. In women, pregnancies also play a major role. Mental disorders such as depression also often lead to weight gain.

In the course of life, body weight increases almost automatically. It is a slow process that continues until about the age of 65. And even at an advanced age, weight gain can often be observed, as physical activities are restricted by wear and tear of the musculoskeletal system and other diseases. Therefore, it is often already a success if you can keep your weight constant over many years.

In general, the risk of secondary diseases increases the longer and more pronounced the obesity is. So-called pro-inflammatory adipokines, i.e. hormone-based messenger substances produced in human fatty tissue, can be involved in the development of diabetes mellitus type 2 or arteriosclerosis, for example.

In the following, some body systems and exemplary damages caused by obesity are described. This is by no means a complete list of the possible consequences of obesity.

Cardiovascular system

• Arteriosclerosis
• coronary heart disease
• apoplexy
• hypertension
• heart failure
• sudden cardiac death

Respiratory system

• exertional dyspnea
• obstructive sleep apnea syndrome
• respiratory insufficiency
• atelectasis
• hyperventilation syndrome

Metabolic system

• lipometabolic disorders
• Diabetes mellitus type II and its complications
• Hyperuricemia
• Gout

Other

• Erysipelas
• Fatty liver
• Carcinoma
• Osteoarthritis
• Thrombosis
• Salt sensitivity
• increased perioperative risks

According to several studies and statistics, mortality increases with BMI. The more pronounced the obesity, the more likely early death is. However, the damage caused by obesity is not necessarily permanent. Many changes and disorders can be reversed or at least reduced by reducing one's weight.

By stating weight and height and measuring abdominal and hip circumference, it is possible to quickly and easily determine whether or not a normalized body weight is present.

The anamnesis

In order to be able to provide treatment, a detailed medical history must still be taken. This should include a whole series of points which serve to make an exact diagnosis and facilitate the choice of the right therapy.

This should cover at least the following topics:

• Family history: discussion of genetics as well as social inheritance of behaviors, as both play a significant role in the development of obesity.
• Social history: seeking information on the patient's socioeconomic status. It is important that the patient's environment, living situation, family structures and circle of friends are taken into account in the diagnosis and therapy in order to achieve success.
• Medication history: Both current and previous medications can provide an indication of causes, organ damage that has already occurred, and unsuccessful therapeutic approaches. Not only prescription medications should be discussed, but also over-the-counter medications and dietary supplements.
• Weight history: In addition to the current weight, the weight history must also be documented. This provides clues to the causes and thus also to possible therapeutic approaches.
• Diet history: Failed attempts at weight reduction give indications of the suffering caused by the excess weight and help to use better methods in new attempts.
• Dietaryhistory: This can consist of an honest and detailed eating diary. This is not only for diagnosis but can also be implemented for therapeutic purposes.
• Motivesfor weight loss: to be able to develop a plan, it is important to know the motives. The target values also depend on the motivation.

Physical examinations

After taking a medical history, a complete internal and physical examination is indicated to check the extent to which obesity has already caused damage to other organ systems. In particular, the cardiovascular system, lipid metabolism, sugar metabolism and blood pressure are negatively affected by obesity.

Treatment of obesity is generally only indicated above a BMI of 30. However, certain factors can lead to medical intervention being useful even from a BMI of 25. This is particularly useful in the case of abdominal obesity or two additional risk factors. The same applies to existing diseases that can be improved by weight reduction.

For a successful therapy an individual and realistic time schedule has to be set up. The aim should first be to stabilize the current weight and then to reduce it slowly. The following are some strategies that could be used in weight loss.

Reducing calorie intake

The main focus should be on reducing fat intake, and ideally the total energy consumed should be reduced. A total daily energy deficit of 500 to 800 kcal should be aimed for.

Physical activity

Physical activity can increase calorie consumption. In addition, exercise can also decrease appetite and better control stress. For many, exercise is also a stabilizing social event. In addition, exercise always has a positive effect on the cardiovascular system, which is particularly negatively affected by obesity.

Ideally, one should exercise at least three times a week for 30 minutes. Of course, it is better to exercise more often and for longer periods. In general, however, one should set achievable goals. After all, it is better to exercise a little on a regular basis than to do irregular intensive workouts. These have no additional positive influence on the weight and can also have a demotivating effect.

Further support

Depending on the personal situation, weight reduction can be supported by many other measures. These include behavioural therapies, psychosocial support and participation in self-help groups.

Drug therapy

Both tablets and powder forms exist to help with weight loss. For example, the anti-adipositive Orlistat (Xenical) is used, which inhibits the pancreas so that fats can no longer be absorbed as well. Another drug is the anorectic Sibutramin (Reductil), which promotes the feeling of satiety via messenger substances in the brain. Other drugs are currently in development.

However, even the best over-the-counter drug is not suitable as the sole means of weight reduction, which is why drugs should be taken in combination with other weight-reducing measures if necessary. In addition, it is only indicated in special cases and after the failure of conservative, non-drug measures.

Surgical therapy

In the case of these, patients must always be informed in detail about the risks and consequences of the operation. This is because the existing obesity also greatly increases the risk during surgery.

The indication for surgery is only given from a BMI of 40. With a BMI above 35, surgery can be considered if concomitant diseases require rapid weight reduction or if all other attempts at therapy have failed.

In principle, these surgical interventions attempt to reduce the volume of the stomach. This results in limited food intake, which in turn leads to weight reduction.

The various procedures include:

• GastricBanding:a silicone band is placed around the stomach and then filled with fluid as needed. This makes the entrance to the stomach smaller, and only small amounts of food can be taken in at a time.
• Vertical gastroplasty: Part of the stomach is separated by staple sutures and secured by a silicone band.
• Gastricballoon: A balloon is inserted into the stomach, which is filled with more or less liquid as required. This method is rarely used today because it involves some complications.

However, for a permanent reduction in body weight, eating habits should also be changed and optimized. In addition, intensive internal, nutritional and psychological care of the patient is still required after the operation.

Dietary recommendations for obesity

In order to be able to improve one's own diet, one first has to come to terms with one's own energy requirements. This depends, among other things, on height, weight, gender and physical strain in everyday life. On the basis of the energy requirement, it is then possible to estimate how many calories one should consume daily.

It is important to ensure that all food components are consumed in sufficient quantities. In order to be able to achieve this, one must deal intensively with the composition of the food and its quantitative and qualitative energy content. Even when shopping, care must be taken to buy the right foods. To do this, one should practice reading and interpreting the nutritional information on food packages correctly.

Not only the type of food consumed, but also its preparation plays a major role. Thus, one should revert to low-fat preparation methods that also do not destroy the vitamin content of the food.

No short-term changes

No matter how you change your diet, it should always be a long-term optimization and not short-term diets. These often lead to a quick weight reduction, but the feared yo-yo effect is rarely absent.

In order to be able to realize this, one should only engage in changes with which one can also live in the long term. It probably has little sustainability to say that you never snack again, however, you can drastically reduce the amount of sweets.

Concrete tips for a better diet

But what specific changes can you make now to achieve a better diet? In the following some hints are given. Ultimately, you have to try out what is feasible and effective for you.

Possible changes for a good diet:

• Eliminating or drastically reducing alcohol.
• Cutting down on carbohydrates, which prevent the body from breaking down fats
• Increasing the amount of protein in the diet, which above all also curbs the appetite
• Reducing fat intake, concentrating on unsaturated fatty acids
• Sufficient fluid intake in the form of unsweetened drinks

General measures to improve eating habits

• Meals should always be eaten in the same place, if possible.
• You should take enough time to enjoy your meal.
• An attractive preparation and presentation of the food increases the enjoyment factor.
• Distractions while eating should be completely avoided.
• Instead of ladling up, an appropriate portion should be served at the outset.
• Improved feeling of satiety through high protein intake and fat reduction
• Carbohydrates in the form of complex carbohydrates (fibre, whole grains)
• Reduction of simple carbohydrates (sugar)
• Should a feeling of hunger arise, distraction can be achieved through sporting activity, hobbies or simple measures such as brushing teeth.

The actual weight reduction is not the big problem for many sufferers. Through diets and sports they always manage to reduce a few kilograms of weight. But after the diet it is often almost impossible to keep the new weight. The yo-yo effect usually ensures that the weight is already a few months after the diet even higher than before the diet.

A permanent weight reduction can only be achieved by long-term treatment concepts. One should not want to reach a certain desired weight in a certain time, but rather lead a healthier life through a permanent change in lifestyle, which slowly but permanently eliminates the excess kilos.

A diet should therefore not be primarily success-oriented, but should function as a lifelong and balanced diet. You should optimize it so that it is healthy and tastes good. Because only then it is also permanently feasible. Good nutrition alone is also not enough, but must always be combined with sufficient physical activity.

The most important and effective measure to prevent obesity is to reach and maintain a stable weight. In the course of life, the tendency of body weight is always increasing. It is already a success if one can maintain the current weight and defy the general tendency of weight gain.

For this purpose, importance should be attached to a low-fat and high-fibre food composition. Especially foods with low energy density are suitable to prevent weight gain. These have few calories because they are rich in water or fibre.

Snacks, fast food and sugary or alcoholic drinks should be avoided as much as possible.

When exercising, endurance training is particularly useful, as it increases calorie consumption disproportionately. In this way, increased muscle activity can permanently prevent obesity.