What is morbid obesity?

Obesity is a multifactorial disease.

Many factors contribute to obesity: genetic predispositions, metabolic and behavioural factors, even viral infections, among many others. Independent of the factors which contribute to the development of obesity, it is the consequence of a positive energy balance. Energy balance of the body results from the energy ‘received’ and energy expended.

Obesity is a risk factor

Obesity is an essential risk factor for cardiovascular disease. Taking the clinical aspect into account, obesity is the most important factor predisposing for insulin resistance, dyslipidemia, hypertension and disorders of carbohydrate management - the metabolic syndrome.

The metabolic syndrome

The practical definition of metabolic syndrome was specified in 2001 by The National Programme of Cholesterol Education of the USA (Adult Treatment Panel III, NCEP). On the basis of the criteria then agreed-upon, the syndrome can be recognized when three or more of the following determinants are diagnosed:

1. the concentration of fasting glucose in the venous blood plasma is above 6.1 mmol/l (>110mg/dl)
2. arterial blood pressure is above 130/85 mmHg or medicines lowering the pressure are applied
3. the concentration of triglycerides in  blood ≥1.7 mmol/l (150 mg/dl),
4. the concentration of HDL cholesterol < 1.03 mmol/l (40mg/dl) in men and <1.29 mmol/l (50 mg/dl) in women,
5. abdominal obesity (waist circumference in men >102 cm, in women > 88 cm).

Obesity and cardiocascular disease

According to WHO, arterial hypertension and its complications are one of the most important risk factors for death worldwide. Almost one billion people all over the world are affected by this disease; 37.5% in developed countries and 22% in developing ones suffer from this disease.  Obesity is classified as one of the most important factors in the risk of arterial hypertension and ischaemic heart disease. In the Framingham study, it was concluded that the growth of body mass index correlates with the increase of arterial pressure. It was demonstrated that 70% of men and 61% of women with arterial hypertension are obese. The risk of arterial hypertension occurrence in obese persons is three times higher compared to those with normal body mass index.

Obesity and other associated diseases

Besides cadiovascular disease, obesity is associated with a number of other diseases: joint and back pain (arthrosis), sleep apnea, Type 2 diabetes and fatty acid disorders. All of these comorbidities significantly limit our patients quality of life.

The treatment of obesity

If we sucessfully treat obesity we can improve quality of life, decrease the risk for associated comorbidities, improve or even resolve associated comorbidities that are already there, improve activity and self-esteem and even extend the patients life span.

Behavioral therapy and change of lifestyle

Modification of behavioral factors is currently thought to be the most important method of obesity treatment, but for the individual patient it is also the most difficult. Increasing the level of physical activity (systematical  physical practice: 30-45 min of exercise daily for  3-5 days per week), quitting smoking and only moderate intake of alcohol decreases the cardiovascular risk and improves the body mass index. Unfortunately, the percentage of patients who are able to follow the above-mentioned guidelines is small.

Pharmacological therapy of obesity

Pharmacological treatment of obesity is indicated when there is no loss of body mass index within 6 months of starting behavioral therapy and when the BMI is ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 in patients with cardiovascular risk factors. The purpose of pharmacotherapy is to reduce body mass index and cardiovascular risk. Currently-applied medicines in treating obesity includes, among others: Sibutramin, Orlistat and Rimonabant.
Orlistat reduces the absorption of fat from the digestive system. Taking this medicine regularly results in body mass index reduction of 5-10% in 50-60% of patients, what positively influences lipid metabolism and insulin sensitivity. Undesirable symptoms most often affect the digestive system.
Sibutramin inhibits the neuronal uptake of noradrenalin and serotonin, and as a consequence produces a feeling of satiety. It reduces body mass index by 5-10% in 60-70% of patients. It might cause undesirable symptoms mainly regarding the circulatory system, such as an increase of arterial blood pressure and tachycardia. Therefore, in patients with arterial hypertension, coronary artery disease or known cardiac arrythmia, Silbutramin should be administered with great caution.
Rimonabant is an antagonist of the cannabinoid 1 receptor which restricts appetite. The reducing influence of this medicine on body mass index is comparable to the two previous ones. Improvement of the cardiometabolic profile might reduce cardiovascular risk although it demands further clinical research. In case of Rimonabant, the most essential side effect is its pro-depression effect. Psychological disorders limit the possibility of applying this medicine.

Surgical treatment of Obesity

Surgical treatment is considered for patients in whom the above-mentioned methods of obesity treatment were disappointing, in whom BMI is ≥40 kg/m2 or BMI is >35 kg/m2 with co-existence of risk factors (arterial hypertension, diabetes). Surgical treatment is characterized as  providing the highest effectiveness of achieving body mass index and risk factor reduction.

Obesity and related diseases pose a growing clinical problem. It is a challenge for modern medicine to find an effective method of obesity treatment. Appropriate treatment and taking care of an obese patient involve cooperation of an internist, diabetologist, cardiologist and metabolic surgeon. The effectiveness and progress in the therapy of obesity depends on the integrity and cooperation of the above- mentioned representatives of medical disciplines. Taking into account the low effectiveness of behavioral therapy and obstacles connected with pharmacotherapy (side effects, polipharmacotherapy, lack of discipline in drug intake) surgery remains the only effective therapy for many patients. Especially due to the fact, that contemporary laparoscopic surgical techniques applied in metabolic surgery are becoming less and less invasive and thus less aggravating, laparoscopic metabolic surgery offers the highest effectiveness in obesity treatment with low complications.