What Is Morbid Obesity?

Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases, also known as comorbidities. These comorbidities are conditions or diseases that result in either significant physical disability or even death. As you read about morbid obesity you may also see the term "clinically severe obesity" used. Both are descriptions of the same condition and can be used interchangeably. Morbid obesity is typically defined as having a Body Mass Index of 40 or higher.

Bariatric surgery is currently the only modality that provides a significant, sustained weight loss for the patient who is morbidly obese, with resulting improvement in obesity-related comorbidities.

Causes of Morbid Obesity

The reasons for obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that in many cases a significant, underlying cause of morbid obesity is genetic. Studies have demonstrated that once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.

Science continues to search for answers. But until the morbid obesity disease is better understood, the control of excess weight is something patients must work at for their entire lives. That is why it is very important to understand that all current medical interventions, including weight loss surgery, should not be considered medical cures. Rather they are attempts to reduce the effects of excessive weight and alleviate the serious physical, emotional and social consequences of morbid obesity.

The Health Threat Of Morbid Obesity

Morbid obesity brings with it an increased risk for a shorter life expectancy. For individuals whose weight exceeds twice their ideal body weight, the risk of an early death is doubled compared to non- obese individuals. The risk of death from diabetes or heart attack is five to seven times greater. Even beyond the issue of obesity-related health conditions, weight gain alone can lead to a condition known as ‘end-stage’ obesity where, for most part, no treatment options are available. Yet an early death is not the only potential consequence. Social, psychological, and economic effects of morbid obesity, however unfair, are real and can be especially devastating.

Significant Obesity-Related Health Conditions

Obesity-related health conditions are health conditions that, whether alone or in combination, can significantly reduce your life expectancy. A partial list of some of the more common conditions follows.

Obesity-related health conditions include:

Type 2 diabetes:

People with obesity develop a resistance to the insulin that regulates blood sugar levels. Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body.

High blood pressure/heart disease:

Excess body weight strains the ability of the heart to function properly. The resulting hypertention (high blood pressure) can result in strokes, as well as inflict significant heart and kidney damage.

Osteoarthritis of weight-bearing joints:

The additional weight placed on joints, particularly knees and hips, results in rapid wear and tear, along with pain caused by inflammation. Similarly, bones and muscles of the back are constantly strained, resulting in disc problems, pain, and decreased mobility.

Sleep apnea/respiratory problems:

Fat deposits in the tongue and neck can cause intermittent obstruction of the air passage. Because the obstruction is increased when sleeping on your back, you may find yourself waking frequently to reposition yourself. The resulting loss of sleep often results in daytime drowsiness and headaches.

Gastroesophageal reflux/heartburn:

Acid belongs in the stomach and seldom causes any problem when it stays there. When acid escapes into the esophagus through a weak or overloaded valve at the top of the stomach, the result is called gastroesophageal reflux, and “heartburn” and acid indigestion are common symtoms. Approximately 10 to 15 percent of patients with even mild sporadic symtoms of heartburn will develop a condition called Barrett’s esophagus, which is a premalignant change in the lining membrane of the esophagus, a cause of esophageal cancer.

Depression:

People with weight-related conditions face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, cannot fit comfortably in theater seats, or ride in a bus or plane. No wonder that anxiety and depression may accompany years of suffering.

Infertility:

The inability or diminished ability to produce offspring.

Fatty liver or hepatic lipidosis:

Fatty liver disease is the accumulation of fat in liver cells. The greater the risk of developing liver inflammation, fibrosis, or cirrhosis (moderate or severe scarring of the liver).

Likeliness of Gallbladder disease:

Gallbladder disease is much more likely in obese individuals, being associated with formation of gallstones, usually composed of crystallized cholesterol, within the gallbladder. Although readily treatable by removal of the gallbladder (cholecystectomy), it may lead to life-threatening problems such as obstruction of the ducts from the liver, jaundice, and inflammation of the pancreas (gallstone pancreatitis).

Venous thromboembolic disease

Venous thromboembolic disease affects the legs, and causes swelling, thickening and discoloration of the skin, and ulceration of the skin. This condition begins with damage to the veins of the legs, associated with formation of blood clots (thrombophlebitis), often associated with an injury, a pregnancy (even use of birth-control pills or hormones), or a surgical operation. When a newly formed blood clot breaks loose, and floats through the veins to the heart and lungs, it is called a Pulmonary embolus, which may sometimes be fatal within minutes. More commonly, the blood clot remains in place locally, and heals by becoming a scar, which permanently damages the vein. Once damaged, the veins cannot fully function to return blood to the heart, and increased venous pressure in the legs causes swelling, impaired circulation in the skin, and sometimes skin breakdown. Obesity is a major risk factor in development of VTE, and may also aggravate the increased venous pressure in the legs.

Degenerative disc disease:

Degenerative disc disease is a progressive "wearing-out" of the cartilaginous disks between the vertebral bones of the spine. It occurs more often and earlier in life in obese persons, due to the markedly increased mechanical stress on the disks from the extra weight. Its most common sign is chronic low back pain, which may be disabling. This condition is also associated with sciatica, lumbar spondylosis, and spinal stenosis.

Skin breakdown:

Skin hygiene can be a significant problem for people struggling with obesity, as the layers of skin can rub against each other, causing skin breakdown and infection.

Swollen legs/skin ulcers:

Leg swelling is common and may be caused by blood clots in the leg veins. If untreated, skin breakdown can occur and the resulting wounds can be extremely hard to heal.

Urinary stress incontinence:

A large, heavy abdomen relaxes pelvic muscles, compounding the effects of childbirth. This weakens the valve on the urinary bladder allowing leakage when coughing, sneezing, or laughing.

Menstrual irregularities:

Morbidly obese individuals often experience menstrual disruptions, such as irregular or absent periods and increased pain during the cycle.

Cancer:

People suffering from morbid obesity are at an increased risk for some types of cancer eg., endometrial, gallbladder, uterine, cervical, ovary, and breast in females; colorectal and prostate in males.

Pulmonary embolus:

A pulmonary embolus is caused by a clot from the venous circulation. Most are caused from clots originating in the lower extremities, known as deep vein thrombosis (DVT). Because people with weight-related conditions are more susceptible to circulatory problems, their chances of experiencing a pulmonary embolus are higher.

Complications of Obesity

Psychosocial

• Eating disorders
• Poor self-esteem
• Body image disorder
• Social isolation and stigmatisation
• Depression

Pulmonary

• Exercise intolerance
• Obstructive Sleep apnea
• Asthma

Gastrointestinal

• Gallstones
• Gastro-oesophageal reflux
• Non-alcoholic fatty liver disorder

Renal

• Glomerulosclerosis

Musculoskeletal

• Ankle sprains
• Flat feet
• Tibia vara
• Slipped capital femoral epiphysis 
• Forearm fracture

Neurological

• Pseudotumour cerebri
  (idiopathic intracranial)

Cardiovascular

• Hypertension
• Dyslipidaemia
• Coagulophathy
• Chronic inflammation
• Endothelial dysfunction

Endocrine

• Insulin resistance
• Impaired fasting glucose or glucose intolerance
• Type 2 diabetes

Treatment available for Morbid Obesity

For anyone who has considered treatment for weight loss, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to have a history of medically supervised weight loss efforts. Most non-surgical weight loss programs are based on some combination of diet/ behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of individuals. It is estimated that less than 5 of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time. According to the National Institutes of Health, most people in these programs regain their weight within one year. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."

The fact remains that morbid obesity is a complex, multifactorial chronic disease. Weight loss surgery, when compared to other interventions, has provided the longest period of sustained weight loss in patients for whom all other therapies have failed.

For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.

Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.

Appropriate candidates for weight-loss surgical procedures?

In general, the indications for surgical treatment established by the 1991 National Institutes of Health Consensus Development Conference Panel include a BMI greater than 40 or a BMI greater than 35 in combination with life-threatening cardiopulmonary problems or severe diabetes mellitus. Nonetheless, strict absolute weight determinants should serve only as an overall guide, especially in regard to third-party payers. For instance, few thoughtful physicians would argue that a 40-year-old man with hypertension, type II diabetes mellitus, severe degenerative joint disease in his knees and lower back area, and sleep apnea who has a BMI of only 33 does not have morbid obesity. Thus, all patients with severe, direct weight-related morbidity may be considered, but each patient should be considered individually.

For some patients who have a history of failed conservative treatments and a BMI of approximately 35, a trial of pharmacologic appetite suppression might be the next reasonable choice, especially if the weight-related morbidity is not severe. Substantial and prolonged weight loss (greater than 50% of excess body weight), however, would be distinctly unusual with this approach, and thus this type of regimen should not be expected to be successful in most patients with morbid obesity and severe comorbidities due to weight.

The overall guidelines should be as follows. Patients who fulfill the absolute weight criteria and have active weight-related morbidity or younger obese subjects (older than 20 years of age) who have a family history of weight-related morbidity but who have not yet experienced any complications should be considered preliminary candidates. Chronologic age, previous abdominal operations, or previous bariatric procedures that are functionally ineffective are not necessarily contraindications. In contrast, active substance abuse and psychiatric disorders (for example, schizophrenia, borderline personality disorder, active suicidal ideation, or uncontrolled depression) should be considered absolute contraindications.

The Gastrointestinal System

The gastrointestinal system is essentially a long tube running through the body with specialized sections that are capable of digestive material put in the mouth and extracting any useful components from it, then expelling the waste products from the anus.

Food after ingestion undergoes three types of processes in the body:

• Digestion
• Absorption
• Excretion

The entire GI system is under hormonal control with the presence of food in the mouth triggering a cascade of hormonal actions. When food reaches the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc.

Nutrients from the GI tract are not processed on- site but instead will be absorbed and taken to the liver through the blood circulation to be broken down further, stored, or distributed.

Esophagus

Once food is chewed and mixed with saliva in the mouth, it is swallowed and passes down the esophagus.  The esophagus has a stratified squamous epithelial lining (SE) which protects the esophagus from trauma.  The submucosa lining (SM) secretes mucus from mucous glands (MG) which aid the passage of food down the esophagus.  The esophageal wall muscle layer helps to push the food into the stomach by waves of motion called peristalsis.

Stomach

The stomach is a ‘J’-shaped organ with two openings- the esophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions including mixing of the food with digestive enzymes and strong acid. The layer of mucus produced prevents the stomach from digesting itself.

The stomach’s major functions are:Temporary food storageControl the rate at which food enters the smallintestine

• Acid secretion and antibacterial action
• Fluidization of stomach contents
• Preliminary digestion with pepsin, lipases etc.

Small intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials occurs.The whole of the small intestine is lined with an absorptive mucosal layer, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion through the intestine (peristalsis). 

There are three main setions to the small intestine:

The duodenum forms a ‘C’ shape around the head of the pancreas. Its main function is to neutralize the acidic gastric contents (called ‘chyme’) and to initiate further digestion; Brunner’s glands in the submucosa secrete alkaline mucus which neutralizes the acidic chyme of the stomach and protects the surface of the duodenum.

The jejunum and the ileum are greatly coiled parts of the small intestine, and together are about 4-6 meters long; the junction between the two sections is not wll-defined. The mucosa of these sections is highly folded (the folds are called plica), increasing the surface area available for absorption dramatically.

Large intestine

The large intestine is the last part of the digestive tube and the location of the terminal phases of digestion. It is the part of the digestive tube between the terminal small intestine and anus. Within the large intestine, three major segments are recognized:

The cecum is a blind-ended pouch that in humans carries a worm-like extension called the vermiform appendix.

The colon constitutes the majority of the length of the large intestine and is sub-classified into ascending, transverse, and descending segments.

The rectum is the short, terminal segment of the digestive tube, continuous with the anal canal.

Functions of the Large Intestine

Recovery of water and electrolytes from digested food:

A considerable amount of water and electrolytes like sodium and chloride remain and must be recovered by absorption in the large intestine. This is what goes wrong when you have diarrhea and constipation

Formation and storage of feces:

As digested food passes through the large intestine, it is dehydrated, mixed with bacteria and mucus, and formed into feces.

Microbial fermentation:

Fermentation is the enzymatic decomposition and utilization of foodstuffs, particularly carbohydrates, by microbes. The large intestine does not produce its own digestive enzymes, but contains huge numbers of bacteria which have the enzymes to digest and utilize many substrates.