Obesity has been associated with metabolic syndrome, diabetes, coronary artery disease, hypertension, dyslipidemia, infertility, obstructive sleep apnea and certain cancers. The prevalence, diagnosis and management of obesity are elucidated in this article.

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Obesity

Obesity's recognition as a disease by the American Medical Association (AMA) will be a decade old in 2023. As per the obesity medical association, obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical and psychosocial health consequences.

As per the data we need to curb obesity as soon as possible as it gives rise to co-morbidities which is putting an extra burden on the overburdened health system of our country. Post-COVID pandemic the number of overweight and obese patients has increased in almost every age group due to decreased physical activity and a sedentary lifestyle. As per the American Heart Association (AHA), obesity is classified as a major modifiable risk factor for cardiovascular disease.

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Diagnosis

Body mass index (BMI) is the most widely used tool to diagnose obesity. Body mass index (BMI) is defined as a person's weight in kilograms divided by the square of height in meters.

As per BMI individuals are classified as follows as per CDC

1. If your BMI is less than 18.5, it falls within the underweight range.
2. If your BMI is 18.5 to <25, it falls within the healthy weight range.
3. If your BMI is 25.0 to <30, it falls within the overweight range.
4. If your BMI is 30.0 or higher, it falls within the obesity range.

Obesity can further be divided into the following categories:

• Class 1: BMI of 30 to < 35
• Class 2: BMI of 35 to < 40
• Class 3: BMI of 40 or higher. (Class 3 obesity is sometimes categorised as “severe” obesity.)

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Management

The principal aim of weight management is to induce negative energy balance by reducing the calorie intake to decrease body weight and maintain weight over a long period. Weight loss of >10kg can result in a 20 to 25% decrease in total mortality. 5-10% weight loss has been associated with significant improvement in obesity-related related co-morbidities.

As per the endocrine society guidelines treatment for obesity is based on BMI.

1. BMI ≥25 kg/m2 Diet, exercise and behavioural modification.
2. BMI ) ≥27 kg/m2 with comorbidity or BMI> 30: treat with pharmacotherapy along with diet and lifestyle modification.
3. BMI) ≥35 kg/m2 with comorbidity or BMI >40: bariatric surgery is indicated.

First step: Diet, physical activity and behaviour modification which includes self-monitoring, stress management, and social support remain the primary goal of management. Voluntary physical activity > 150min/ week is recommended by the endocrine society. As per dietary recommendation 500-600 Kcal/day energy deficit results in weight loss of 0.5 to 1.0 Kg/ week. Low carbohydrate diets like the Atkin diet and the south beach diet can be prescribed under the dietician's supervision. According to the American college of sports medicine weight loss expenditure of 300- 500 Kcal/ per session or 1000- 2000 kcal/ week is required.

Second step: When the patient fails to lose weight with lifestyle modification and diet alone, medicine prescription can help such patients and can aid in the prevention and management of obesity and thus improve health. It consists of pharmacotherapy, drugs approved for treating obesity are orlistat (120mg TDS), phentermine (15-37.5mg OD), topiramate(64-400mg daily), buprenorphine (360mg)/naloxone (32mg) 2 tablets QID, GLP1 analogues like liraglutide (0.6mg- 3mg daily)and semaglutide(2.4mg once weekly). Trizepatide(5mg-15mg once weekly) which is GLP 1 & GIP analogue combination when given once weekly has shown substantial weight loss as per trial. Orlistat, liraglutide and liraglutide are the anti-obesity medications that are available in India.

Pharmacological treatment recommendations from the Endocrine Society are as follows:

1. Patients who fail to lose or maintain weight and who meet label indications are candidates for weight loss medications.
2. To promote long-term weight maintenance to ameliorate co-morbidities the society recommends the use of anti-obesity medications.
3. In patients with a history of hypertension and heart disease society recommends against the use do sympathomimetic agents like phentermine and diethylpropion.
4. Efficacy and safety of the prescribed anti-obesity medication should be assessed at least monthly for the first 3 months and then at least every 3 months.
5. If a patient is having an effective response i.e weight loss of > 5 % at 3 months and without side effects, the society recommends the continuation of medications. In case of ineffective response i.e. weight loss of <5 % at months the medication should be discontinued and alternative medications or referral for alternative treatment approaches should be considered.
6. As per recommendation, the medication for obesity management should be initiated with dose escalation based on efficacy and tolerability to the recommended dose and not to exceed the upper approved dose.
7. In patients with type 2 diabetes who are overweight and obese, the anti-diabetic treatment that has additional actions to promote weight loss such as GLP-1 analogues or SGLT-2 inhibitors should be preferred along with metformin.
8. In patients with cardiovascular disease seeking treatment for weight loss medications which are not sympathomimetics like orlistat should be used.

The third step which is metabolic and bariatric surgery is reserved for morbid obesity and patients with comorbid disease.

As per 2022 guidelines from the American society for metabolic and bariatric surgery, there have been few changes in the indication of bariatric surgery to the last published 1991 NIH guidelines.

1. Regardless of the presence, absence or severity of co-morbidities now metabolic and bariatric surgery (MBS) is recommended with BMI ≥35 kg/m2.
2. For a BMI of 30-34.9 kg/m2 bariatric surgery should be considered in individuals with metabolic disorders.
3. As per the Adjusted BMI threshold for the Asian population, the individual with ≥27.5 kg/m2 should be offered bariatric surgery.

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Conclusion

The obesity pandemic is on the rise in India due to sedentary lifestyles and decreased physical activities in urban as well as rural populations. With co-morbidities and metabolic disease associated with obesity, it becomes the responsibility of the treating physician to counsel and motivate the patient to lose weight with lifestyle modification and exercise. The use of pharmacotherapy should be encouraged wherever indicated. Timely referral for bariatric surgery can save obese patient life from complications associated with it and improves their quality of life.

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References-

1. Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab [Internet]. 2015;100(2):342–62. Available from: http://dx.doi.org/10.1210/jc.2014-3415

2. Behl S, Misra A. Management of obesity in adult Asian Indians. Indian Heart J [Internet]. 2017;69(4):539–44. Available from: http://dx.doi.org/10.1016/j.ihj.2017.04.015

3. Misra A. Ethnic-specific criteria for classification of body mass index: A perspective for Asian Indians and American diabetes association position statement. Diabetes Technol Ther [Internet]. 2015;17(9):667–71. Available from: http://dx.doi.org/10.1089/dia.2015.0007

4. Eisenberg D, Shikora SA, Aarts E, Aminian A, Angrisani L, Cohen RV, et al. 2022 American society for metabolic and bariatric surgery (ASMBS) and international federation for the surgery of obesity and metabolic disorders (IFSO): Indications for metabolic and bariatric surgery. Surg Obes Relat Dis [Internet]. 2022; Available from: http://dx.doi.org/10.1016/j.soard.2022.08.013

5. Ahirwar R, Mondal PR. Prevalence of obesity in India: A systematic review. Diabetes Metab Syndr [Internet]. 2019;13(1):318–21. Available from: http://dx.doi.org/10.1016/j.dsx.2018.08.032

6. Jastreboff AM, Aronne LJ, Ahmad NN, Wharton S, Connery L, Alves B, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med [Internet]. 2022;387(3):205–16. Available from: http://dx.doi.org/10.1056/nejmoa2206038

Disclaimer- This article was published on November 23 2022. The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Hitesh Saraogi is a diabetologist, physician and an obesity specialist at Dhanvantari Hospital, Raj Nagar Extension, Ghaziabad.