OBESITY & IT'S TREATMENT

me obese.

Obesity means accumulation of excess fat on the body. Obesity is considered a chronic (long-term) disease, like high blood pressure or diabetes. It has many serious long-term consequences for your health, and it is a leading cause of preventable deaths in the United States (with tobacco use and high blood pressure). Obesity is defined as having a body mass index (BMI) of greater than 30. The BMI is a measure of your weight relative to your height. See the Body Mass Index Calculator.

Obesity is an epidemic in the United States and in other developed countries. More than two-thirds of Americans are overweight, including at least one in five children. Nearly one-third are obese. Obesity is on the rise in our society because food is abundant and physical activity is optional. On the bright side, recent data suggest that childhood obesity, while still high, may no longer be on the rise.

Each year, Americans spend billions of dollars on dieting, diet foods, diet books, diet pills, and the like. Another $75 billion is spent on treating the diseases associated with obesity. Furthermore, businesses suffer an estimated $20 billion loss in productivity each year from absence due to illness caused by obesity.

Obesity Causes

Weight gain occurs when you eat more calories than your body uses up. If the food you eat provides more calories than your body needs, the excess is converted to fat. Initially, fat cells increase in size. When they can no longer expand, they increase in number. If you lose weight, the size of the fat cells decreases, but the number of cells does not.

• Obesity, however, has many causes. The reasons for the imbalance between calorie intake and consumption vary by individual. Your age, gender, genes, psychological makeup, and environmental factors all may contribute.
• Genes: Obesity tends to run in families. This is caused both by genes and by shared diet and lifestyle habits. Having obese relatives does not guarantee that you will be obese.
• Emotions: Some people overeat because of depression, hopelessness, anger, boredom, and many other reasons that have nothing to do with hunger. This doesn't mean that overweight and obese people have more emotional problems than other people. It just means that their feelings influence their eating habits, causing them to overeat.
• Environmental factors: The most important environmental factor is lifestyle. Your eating habits and activity level are partly learned from the people around you. Overeating and sedentary habits (inactivity) are the most important risk factors for obesity.
• Sex: Men have more muscle than women, on average. Because muscle burns more calories than other types of tissue, men use more calories than women, even at rest. Thus, women are more likely than men to gain weight with the same calorie intake.
• Age: People tend to lose muscle and gain fat as they age. Their metabolism also slows somewhat. Both of these lower their calorie requirements.
• Pregnancy: Women tend to weigh an average of 4-6 pounds more after a pregnancy than they did before the pregnancy. This can compound with each pregnancy.
• Certain medical conditions and medications can cause or promote obesity, although these are much less common causes of obesity than overeating and inactivity. Some examples of these are as follows:
• Cushing syndrome
• Depression
• Certain medications (examples are steroids, antidepressants, birth control pills)
• Prader-Willi syndrome
• Polycystic ovarian syndrome
• Obesity can be associated with other eating disorders, such as binge eating or bulimia.
• The distribution of your body fat also plays a role in determining your risk of obesity-related health problems. There are at least two different kinds of body fat. Studies conducted in Scandinavia have shown that excess body fat distributed around the waist ("apple"-shaped figure, intra-abdominal fat) carries more risk than fat distributed on the hips and thighs ("pear"-shaped figure, fat under the skin).

When to Seek Medical Care

If you are obese, you should have a primary care physician who follows you closely and monitors you for the known complications of obesity such as diabetes and hypertension.

• If you are overweight or obese and don't know how to lose weight
• If you are concerned about the effects of a weight-loss diet or increased physical activity on your other medical problems
• If you are unsuccessful at losing weight on your own
• If you are concerned about the safety of your weight-loss method

Diagnosis of Obesity

Weight-to-height tables

These tables give general ranges of healthy weights and overweight for adult height. The tables do not take into account individual conditions. For one thing, they do not distinguish fat from muscle, water, or bone. They are much less helpful than body mass index in identifying risk of health problems related to weight.

Body fat percentage

Many health professionals agree that percentage of body weight that is fat is a good marker of obesity. Men with more than 25% fat and women with more than 32% fat are considered obese.

Body fat percentage is difficult to measure accurately, however. Special equipment is needed that is not found at most medical offices. The methods used at health clubs and weight-loss programs may not be accurate if not done properly. Inexpensive scales for home use that estimate body fat are now widely available. They may not be entirely accurate, but are generally consistent, so may be used over time to track one's progress.

Waist measurement is also an important factor. People with "apple" shapes, who tend to put on weight around their waist, have a higher risk of obesity-related health problems. This includes women with a waist measurement of greater than 35 inches and men with a waist measurement of greater than 40 inches.

Body mass index

A measure called the body mass index (BMI) is used to assess your weight relative to your height. It is defined as weight in kilograms divided by height in meters squared (kg/m ²). It can also be calculated for weight in pounds and height in inches.

Body mass index is closely related to body fat percentage but is much easier to measure. Therefore, it is used by many primary care providers to identify obesity. The greater your BMI, the higher your risk of developing health problems related to excess weight.

To calculate your body mass index, follow these steps:

• Multiply your weight in pounds by 705
• Then divide by your height in inches
• Divide this by your height in inches again

What does BMI tell you?

• Normal weight = 18.5-24.9
• Overweight = 25.0-29.9
• Obese = 30 or greater
• Morbidly obese = 40 or greater

To calculate your body mass index on the Internet, fill in your height and weight at the web site of the government's National Heart, Lung, and Blood Institute's Obesity Education Initiative.

Obesity Treatment

For most people who are overweight or obese, the safest and most effective way to lose weight is to eat less and exercise more. If you eat less and exercise more, you will lose weight. It is as simple as that. There are no magic pills. Diets that sound too good to be true are just that.

Self-Care at Home

By decreasing daily calorie intake by 500 calories or expending an extra 500 calories during exercise each day, you will lose about 1 pound per week.

Decreasing your calorie intake by 10 calories a day will equal one pound of weight loss after one year.

Any good diet plan will include exercise. It helps to increase metabolism and is one less opportunity to eat during the day. You should exercise for at least 30 minutes, five times a week. Regular exercise also helps your heart and lungs and lowers triglyceride levels that can cause heart disease. It also increases the HDL ("good cholesterol") levels. Even simple measures such as taking the stairs instead of the elevator and short walks eventually add up to a lot of calories burned. Commercial fitness programs such as Boot Camp can help you start or improve upon a fitness program.

Group support programs such as Weight Watchers or Take Off Pounds Sensibly, known as TOPS, provide peer support and promote healthy habits.

For those who don't have the time to make it to support groups, there are now many free or low cost apps available for the iPhone, iPad, or Android which help determine and track calories, nutrition, and calorie expenditure. Try LoseIt!, Weight Watchers Mobile, Restaurant Nutrition, 40:30:30, Diet Point, or Noom Weight Loss Coach.

For a more complete discussion of lifestyle changes that are helpful in losing weight, see Weight Loss and Control.

Of special interest to women who have gained weight after having a baby is the fact that breastfeeding helps you shed some extra pounds. Besides the positive effects for the baby, breastfeeding burns approximately 500 extra calories each day.

Medical Treatment

Medical treatment of obesity focuses on lifestyle changes such as eating less and increasing activity level. There are medications that can promote weight loss, although they work only in conjunction with eating less and exercising more.

Most medications that promote weight loss work by suppressing the appetite. Some medications used in the past have been shown to be unsafe and are no longer available. The newer appetite-suppressing medications are thought to be safe, but they do have side effects and may interact with certain other drugs. They are used only under the supervision of a health care provider.

For more information about weight-loss medications, go to the article Medication in the Treatment of Obesity.

Some weight-loss products are known to be dangerous. The safety of others is in question. This includes certain prescription and over-the-counter drugs and herbal supplements. Avoid them.

• "Phen-fen" and Redux: These prescription drugs have been removed from the market in the United States and many other countries. They are linked to heart valve problems and pulmonary hypertension. Pulmonary hypertension affects the blood vessels in the lungs and is often fatal.
• Ephedra: This natural substance is essentially an herbal phen-fen. It is the active ingredient in MaHuang and is used as a stimulant and appetite suppressant. Ephedra resembles the amphetamines -- the popular "diet drugs" that were banned in the 1970s -- in that it is highly addictive. Ephedra is often combined with caffeine and aspirin ("the Stack"), which increases the thermogenic (fat-burning) effect of ephedra. Ephedra increases the risk of high blood pressure, irregular heartbeat, insomnia, seizures, heart attack, stroke, and death. The FDA has recently banned ephedra because it has been linked to more than 100 deaths.
• Phenylpropanolamine (PPA) is often found in appetite suppressants as well as over-the-counter cough and cold remedies. The FDA has recommended that products containing PPA be removed from the market. Studies have suggested that this product is associated with an increased risk of hemorrhagic (bleeding) stroke in women.
• Sibutramine is an oral anorexiant that was removed from the U.S. market in 2010 due to the risk of serious adverse cardiovascular events.

Some people have tried combining more than one weight-loss drug or combining a weight-loss drug with other drugs for the purposes of losing weight. The safety and effectiveness of such drug "cocktails" is not known.

Medications for Obesity

The following medications are available in the United States by prescription. If you have been unsuccessful losing weight through diet and exercise, ask your doctor about these medications. For more information about these drugs, see Medication in the Treatment of Obesity. These are not a substitute for dietary management. Over the long term, successful long-term weight loss requires changes in overall eating patterns.

• Orlistat (Xenical 120 mg by prescription or Alli 60 mg available over the counter) is a medication approved by the FDA in 1999. Your doctor may prescribe it if you weigh more than 30% over your healthy body weight or have a BMI greater than 30. Over one year, people who followed a weight-loss diet and took orlistat lost an average of 13.4 pounds, almost 8 pounds more than people who used diet alone to lose weight. It works by reducing the absorption of fat from the intestine. Diarrhea and incontinence of stool may be side effects of this medicine.

Surgery for Obesity

Surgery to correct obesity (known as bariatric surgery) is a solution for some obese people who cannot lose weight on their own or have severe obesity-related medical problems. Generally, surgery is recommended only for morbidly obese people (body mass index 40 or greater). This means men who are at least 100 pounds overweight and women who are at least 80 pounds overweight.

The two types of bariatric surgery are malabsorptive and restrictive.

• Malabsorptive procedures decrease intestinal absorption of food by bypassing part of the digestive system. A greater proportion of food than usual passes through without being absorbed.
• Restrictive procedures decrease the amount of food that a person can take in by decreasing the size of the stomach.

Both surgical strategies entail changes in how food is processed in the body. While they are successful in helping some people lose weight, they also may cause cramps, diarrhea, and other unpleasant effects. For more information, go to the article Surgery in the Treatment of Obesity.

Liposuction is purely a cosmetic procedure that removes fat cells but has no beneficial effects on health, such as heart disease and diabetes.

Other Therapy

Behavior modification is a fancy name for changing your attitude toward food and exercise. These changes promote new habits and attitudes that help you lose weight. Many people find they cannot lose weight or keep it off unless they change these attitudes. Behavior modification techniques are easy to learn and practice. Most involve increasing your awareness of situations in which you overeat so that you can stop overeating.

Obesity Prevention

Reversing obesity and its health risks requires changing the habits of a lifetime. Eating less over the long term means learning to think about your eating habits and patterns.

What makes you overeat? Coffee break at work? Going out with friends? Watching TV? Late afternoon energy lag? Late night sweet tooth? Are you the one who finishes the last serving of dinner just so there won't be any leftovers? Do you eat high-calorie fast foods or snacks because you don't have time or energy to cook? Having some insight into your overeating habits helps you to avoid your problem situations and reach your weight goal.

Likewise, increasing your activity level is largely a matter of changing your attitude. You don't have to be a marathon runner. Look for ways to increase your activity level doing things you enjoy.

For some strategies that may help you change your habits, go to the article Weight Loss and Control.

Prognosis of Obesity

Obesity increases your risk of many other diseases and health problems, including the following:

• Heart disease
• Diabetes
• High blood pressure
• Stroke
• Osteoarthritis (especially knee, hip, and lower back pain)
• Gallstones
• Lung disease and sleep apnea
• Colon cancer
• Endometrial cancer
• Depression
• Gout
• Dementia

Depression may be one of the most common effects of obesity. Many obese people suffer emotional distress. Because of the emphasis on physical appearance in our culture, which equates slimness with beauty, obese people may feel unattractive. They also are subjected to prejudice, ridicule, and discrimination, which may make them feel ashamed or rejected.

Obesity is also a major risk factor for the development of diabetes mellitus. The good news is that this may be preventable. In clinical studies, patients who were at a high risk of developing diabetes decreased their risk by almost 60% with less than 10% weight loss in three years.

HERNIA& IT'STREATMENT

Hernia Information

A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply.

Different types of abdominal-wall hernias include the following:

• Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis.


• Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age.


• Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age.


• Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to be evaluated by a health-care provider.


• Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).


• Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.


• Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which is several inches to the side of the middle of the abdomen.


• Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose.


• Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Causes

Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness.

• Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include


• obesity,


• heavy lifting,


• coughing,


• straining during a bowel movement or urination,


• chronic lung disease, and


• fluid in the abdominal cavity.


• A family history of hernias can make you more likely to develop a hernia.

Hernia Symptoms and Signs

The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen (an incarcerated strangulated hernia).

• Reducible hernia


• It may appear as a new lump in the groin or other abdominal area.


• It may ache but is not tender when touched.


• Sometimes pain precedes the discovery of the lump.


• The lump increases in size when standing or when abdominal pressure is increased (such as coughing).


• It may be reduced (pushed back into the abdomen) unless very large.


• Irreducible hernia


• It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it.


• Some may be chronic (occur over a long term) without pain.


• An irreducible hernia is also known as an incarcerated hernia.


• It can lead to strangulation (blood supply being cut off to tissue in the hernia).


• Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.


• Strangulated hernia


• This is an irreducible hernia in which the entrapped intestine has its blood supply cut off.


• Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).


• The affected person may appear ill with or without fever.


• This condition is a surgical emergency.

When to Seek Medical Care

All newly discovered hernias or symptoms that suggest you might have a hernia should prompt a visit to the doctor. Hernias, even those that ache, if they are not tender and easy to reduce (push back into the abdomen), are not necessarily surgical emergencies, but all have the potential to become serious. Referral to a surgeon should generally be made so that the need for surgery can be established and the procedure can be performed as an elective surgery and avoid the risk of emergency surgery should your hernia become irreducible or strangulated.

If you find a new, painful, tender, and irreducible lump, it's possible you may have an irreducible hernia, and you should have it checked in an emergency setting. If you already have a hernia and it suddenly becomes painful, tender, and irreducible, you should also go to the emergency department. Strangulation (cut off blood supply) of intestine within the hernia sac can lead to gangrenous (dead) bowel in as little as six hours. Not all irreducible hernias are strangulated, but they need to be evaluated.

Hernia Diagnosis

If you have an obvious hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

Hernia Treatment

Self-Care at Home

In general, all hernias should be repaired unless severe preexisting medical conditions make surgery unsafe. The possible exception to this is a hernia with a large opening. Trusses and surgical belts or bindings may be helpful in holding back the protrusion of selected hernias when surgery is not possible or must be delayed. However, they should never be used in the case of femoral hernias.

Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size.

Medical Treatment

Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.

• Reducible hernia


• In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.


• If you have preexisting medical conditions that would make surgery unsafe, your doctor may not repair your hernia but will watch it closely.


• Rarely, your doctor may advise against surgery because of the special condition of your hernia.


• Some hernias have or develop very large openings in the abdominal wall, and closing the opening is complicated because of their large size.


• These kinds of hernias may be treated without surgery, perhaps using abdominal binders.


• Some doctors feel that the hernias with large openings have a very low risk of strangulation.


• The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place between the doctor and patient.


• Irreducible hernia


• All acutely irreducible hernias need emergency treatment because of the risk of strangulation.


• An attempt to reduce (push back) the hernia will generally be made, often after giving medicine for pain and muscle relaxation.


• If unsuccessful, emergency surgery is needed.


• If successful, however, treatment depends on the length of the time that the hernia was irreducible.


• If the intestinal contents of the hernia had the blood supply cut off, the development of dead (gangrenous) bowel is possible in as little as six hours.


• In cases in which the hernia has been strangulated for an extended time, surgery is performed to check whether the intestinal tissue has died and to repair the hernia.


• In cases in which the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged from the hospital.


o Because a hernia that was irreducible and is reduced has a dramatically increased risk of doing so again, you should therefore have surgical correction sooner rather than later.

o Occasionally, the long-term irreducible hernia is not a surgical emergency. These hernias, having passed the test of time without signs of strangulation, may be repaired electively.

Follow-up

To lower the risk of a hernia becoming irreducible or strangulated, the sooner a reducible hernia is repaired the better.

Hernia Prevention

You can do little to prevent areas of the abdominal wall from being or becoming weak, which can potentially become a site for a hernia.

Hernia Prognosis

• Risk of strangulation: In considering when to have a reducible hernia surgically repaired, it is important to know the risk of strangulation.


• The risk varies with the location and size of the hernia and the length of time it has been present.


• In general, hernias with large sac contents with a relatively small opening are more likely to become strangulated.


• Hernias that have been present for many years may become irreducible.


• Operative complications: Approximately 7% of people undergoing surgical hernia repair will have complications.


• These are short-term and usually treatable.


• The hernia that comes back after initial surgical repair can be repaired by the same or an alternate method.


• Complications include the following:


• recurrence (most common),


• urinary retention,


• wound infection,


• fluid build-up in scrotum (called hydrocele formation),


• scrotal hematoma (bruise), and


• testicular damage on the affected side (rare).