in this article:
Obesity is considered an endemic disease, as it is widespread in a geographically circumscribed population. Specifically, obesity is a typical, though not exclusive, prerogative of Western countries, where about 1/3 of the population is overweight.
It is not just a matter of weight. Among the many definitions of obesity, the following is distinguished by simplicity and completeness: obesity is defined as excessive weight gain due to abnormal accumulation of adipose tissue.
Therefore, to talk about obesity, it is not enough to observe an important overweight but it is also necessary to evaluate the percentage of fat mass. For example, at the same height, sex, age and weight, a sedentary long-line could be obese, while its short-lived and sporty counterpart could have a fat mass in the norm. In this last case we cannot talk about obesity because the weight excess is mainly due to the greater bone and muscle mass. The B.M.I is therefore an approximate indicator since the body weight is not only conditioned by the fat mass but also by the lean mass.
The fat mass can be measured in different ways: counting the folds of the skin, evaluating their thickness (plicometry), using bioimpedance (optional more and more required in common scales) or using very sophisticated techniques (magnetic resonance, hydrostatic weighing, TAC, BOD POD etc.).
According to the ISTAT data, in 1999 overweight Americans were about 33.6% of the population, while the obese were only 9.1%. Since then, the spread of obesity has not mentioned any slowdowns, so much so that it has now reached the 10% threshold (9.8%). The number of overweight Americans also grows, from 33.6% in 1999 to the current 34.2%. The most alarming fact is the spread of the problem among the children of which U.S. holds, along with Greece and Spain, the sad record. Over a third of American children between the ages of six and nine are in conditions of overweight or obesity (34.1%).
Obesity is a condition characterized by an excessive accumulation of body fat. This represents an important risk factor for the development of serious diseases, which include cardiovascular diseases, diabetes, various cancers, cholelithiasis, steatosis and cirrhosis of the liver, osteoarthritis, reproductive disorders and premature death. Almost all cases of obesity are the result of a combination of genetic predisposition and incorrect lifestyles (high calorie nutrition and physical inactivity). In particular, there is a chronic imbalance between energy input and consumption.
High fat content foods, processed products and diets high in refined carbohydrates, soft drinks and alcohol – together with a sedentary lifestyle – promote weight gain. More rarely, obesity is caused by eating disorders (BED), genetic conditions (e.g. Prader Willi syndrome) or endocrine diseases such as Cushing’s syndrome (causes hypercortisolism) and malfunctioning of the thyroid (hypothyroidism).
Other situations that may be associated with excessive weight gain are polycystic ovarian syndrome and the intake of certain medications, including antidepressants, antipsychotics and corticosteroids. Weight gain can also be caused by hyperinsulinism (pancreatic tumors) or by brain damage (in particular, secondary to tumor or hypothalamic infection) that can stimulate the consumption of excess calories.
Symptoms and most common signs of obesity are not all visible to the eye. Here is a full list of other indicators that it is time to lose weight for you health’s sake: alterations of the menstrual cycle, amenorrhea, arrhythmia, asthenia, increased appetite, weight gain, large child for gestational age, bromidrosis, decreased sexual desire, cardiomegaly, cardiopalmos, catalepsy, swollen ankles, cruralgia, depression, erectile dysfunction , bladder dysfunction, dyspnoea, abdominal distension, knee pain, chest pain, hip pain, joint pain, postpartum hemorrhage, erythema, skin erosions, shortness of breath, swollen legs, tired legs, heavy legs, abdominal swelling, insomnia, insulin resistance, hypercapnia, hyperphagia, hyperglycemia, hyperhidrosis, hypertension, hypertriglyceridaemia, hyperuricemia, hypofertility, hypoxia, social isolation, lymphedema, back pain, pressure sores, uterine prolapse, pruritus, rheumatism, penis size reduction, acid regurgitation, snoring, choking, nephrotic syndrome, drowsiness, cracked heels, further indications.
Obesity involves an increased risk of developing joint problems (back, knee and even pain), which can develop into arthritis and circulatory disorders (such as venous and lymphatic edema, venous insufficiency and cellulitis). People with lots of extra pounds present breathlessness after a low intensity physical activity and sweat profusely.
If excess fat at the neck compresses the airway while you are sleeping, obstructive sleep apnea may occur; this disorder can cause snoring and excessive daytime sleepiness. The increase in sweating and secretions held in the folds of the skin makes intertriginous infections and other skin disorders particularly frequent.
Obesity is also a risk factor for non-alcoholic steatohepatitis (which can lead to cirrhosis of the liver) and disorders of the reproductive system, such as low testosterone levels in men and polycystic ovary syndrome in women. Excess weight also predisposes to gastroesophageal reflux, cholelithiasis, gout, deep vein thrombosis, pulmonary embolism and various malignant tumor forms (especially colon and breast cancer).
In the long term, obesity can predispose to dyslipidemia, insulin resistance and arterial hypertension (metabolic syndrome), which often lead to type 2 diabetes mellitus and cardiovascular diseases, such as coronary artery disease, cerebral stroke and myocardial infarction. Obesity also leads to social and psychological problems.
Obesity is not a real pathology, but as such it must be addressed to avoid, or at least to mitigate, the many complications that it can cause; in fact, the superfluous fat is one of the major risk factors for the development of many diseases.
These include heart and respiratory diseases, non-insulin-dependent diabetes mellitus or type 2 diabetes, hypertension, osteoarthritis in the joints, cervicalgia, lumbago and lumbosciatalgie, some forms of cancer and the risk of early death; in addition, the negative influence on the quality of life and the arrival of psychological disorders related to the sense of discomfort should not be forgotten.
So the reasons that cause obese people to lose weight are numerous, but according to scientific realities, low back pain is not at the top of the list. The importance of weight loss in the obese person is certainly to be considered undoubted and physical activity is one of the best ways to achieve lasting results over time and to promote a physiological change in the subject, with a strong positive impact on the health of the person.
Often, doctors and therapists inform their patients about the fact that obesity causes back pain and that this disorder can increase proportionally to the weight load. Some recommend that patients lose weight and claim that maintaining a normal weight can prevent future problems with the spine.
The etiology of many painful conditions of the lower rachis remains, however, still unknown; currently identifying with certain confidence the exact tissues involved in most cases of lumbar pain is in fact impossible.
What is certain is that the pathogenesis of lumbar pain in the obese is largely related to tendon muscle strains rather than discus sufferings; low back muscle tenderness is observed especially in middle-aged, overweight people, who lead a sedentary lifestyle and who are continually subjected to stress resulting from work activities, to the constant maintenance of incorrect postures, but also to the accentuation of internal conflicts: in 30% of cases the painful condition depends on organic reasons, while in the remaining 70% the somatic aspect is secondary compared to the effects that emotional stress has on the central nervous system.
Lumbar pain can include the so-called nociceptive pain that comes from intervertebral joints in degeneration, neuropathic pain due to compression of the spinal roots from osteophytes or from a herniated disc, the dysregulatory pain due to a hypertonic reflex of the back muscles and pain psychosomatic relative to the inadequate ability to adapt the subject; moreover, the pain can arise suddenly, sharply, in relation to an effort or gradually.
In general, patients with a ligament muscle pain in which there is an evident mechanical component, report that the symptomatology disappears with bed rest and is accentuated in an upright position or increasing the load, while other patients with intervertebral disc disease may report a acute pain radiated to the legs especially when they cough and sneeze. Obviously, in the lumbago subject the sedentary lifestyle and above all the increase in body weight is very important: it is now well known that obesity and / or overweight are a factor aggravating these pathological conditions.
Obesity is strongly regarded as a frequent comorbidity among patients with back pain; obese patients present with worse health than people with normal weight. The excessive weight load, in fact, combined with the almost inevitable loss of tone of the abdominal wall muscles, generates an alteration of the vertebral static in all its elements: in fact an accentuation of the lumbar lordosis is observed, to be counterbalanced bring the dorsal column to pose in hypercifosis; reflexively, the cervical one, in order to maintain a normal visual axis, assumes an hyperextensional attitude.
The incorrect alignment of the back, typical of the obese person, leads to an excessive compression on the bony structures, especially when the subject has to bear the full weight of his body, i.e. in the upright position or in the sitting position (this can lead to a painful symptomatology in a gradual or acute manner, and often permanent in time), and excessive tension on muscles and ligaments both during (static) support and during movement.
It is also true, however, that an excessively fast weight loss activity, which leads the obese person to lose a high percentage of fat mass in a short time, as well as in women after gestation, can cause the establishment or the accentuate (if already existing) a considerable pain on the lumbar area (both in the obese and in pregnant women, in fact, there is atrophy and asthenia of the abdominal muscles) because, in this period, the containing, i.e. the muscular bundles, not they manage to follow the sudden decrease in content (adipose tissue located in the abdominal area); in order to prevent the bundles from becoming afflicted, the antigravity muscles intervene, especially the paravertebral muscles are constantly activated, which, practically always contracting, are subjected to fatigue with consequent muscular resentment and therefore pain.
In conclusion there is a documented relationship between low back pain and obesity, and there seems to be certainty on the improvement of the low back problem in people who have decreased their weight load; in general, however, it is not enough to lose weight through diet alone and / or through an aerobic activity aimed at depleting fat deposits, but it is necessary that this is associated and supported by a preventive and compensatory activity (programmed in intensity, volume and succession by a specialist in the field), which includes a constant strengthening of the abdominal muscles, an extension of the muscle chains initially evaluated retracted, postural activity to promote muscle rebalancing, a lumbar discharge to loosen muscle tendon tensions and a proprioceptive activity, and perceptive sense, directed towards the correct restructuring of the body.
It is important to work in a global way, trying not to underestimate the problem of lower back pain, aware that without a targeted activity and with the only loss of fat mass is difficult to achieve lasting improvements in this regard.
How to diagnose obesity
Fasting blood glucose and lipemia should be systematically measured in patients with a large waist circumference or a family history that is positive for type 2 diabetes mellitus or a premature cardiovascular disease.
The treatment of obesity consists in the reduction of body weight, to be carried out under strict medical supervision, following a correct diet and carrying out a regular program of physical activity, adapted to its possibilities. In some cases, the use of drugs (e.g. sibutramine and orlistat) is expected. In patients with severe obesity, an alternative is bariatric surgery.
If left untreated, obesity tends to get worse. After weight loss, most people return to pre-treatment weight within 5 years. As a result, obesity requires a permanent management program similar to that of any other chronic disorder.
Regular physical activity and healthy eating improve physical fitness, control weight and help prevent diabetes mellitus and cardiovascular diseases. Sufficient and good quality night rest, stress management and moderation in alcohol consumption can help to improve general conditions.
Android obesity and gynoid obesity
In 1950 Jean Vague introduced the distinction between obesity and obesity and ginoid obesity, observing that the first was associated with a greater risk of hypercholesterolemia, hyperuricaemia, hypertension and reduced tolerance to carbohydrates. Apart from the quantitative point of view (excess fat mass) obesity must therefore be investigated also under the qualitative aspect.
Already in physiological conditions, male and female are distinguished by a different distribution of adipose mass. The body forms are in fact linked to the relationship between male (androgynous) and female (estrogen) sex hormones. This phenomenon becomes evident in the postmenopausal period, in which, due to the decrease in estrogenic levels, there is a redistribution of body fat. In pathological conditions, these differences can be exacerbated, giving rise to the two main types of obesity: android (or apple), typical of man, and gynoid (pear), typical of women. Also called central, visceral, truncular or ‘apple’: typically male, it is associated with a greater distribution of adipose tissue in the abdominal, thoracic, dorsal and cerviconucal region. The obesity of the android is also associated with a high deposition of fat in the intravisceral (abdominal or internal).
Also called peripheral, subcutaneous or ‘pear’: typically feminine, gynoid obesity is characterized by a distribution of adipose masses in the lower half of the abdomen, in the gluteal regions and in the femoral ones. In gynoid obesity, fat is present mainly in the subcutaneous compartment, resulting in a high ratio of superficial and deep fat.
Two forms of obesity are typical, but not exclusive of the two sexes, in fact, the cases of men with gynoid morphotype and of women with an android morphotype are not rare. The most dangerous obesity, with regards to cardiovascular and metabolic complications, is that of the android, whether it is established in man or appears in a woman.
Waist circumference and WHR
To evaluate the type of obesity that is being observed, it is sufficient to measure the circumference of life at its narrowest point (without wearing clothes that offset the measurement).
A more objective datum is obtained by calculating the ratio between the circumference measured at the umbilical level (waist) and gluteus (flanks). This relationship, called WHR (waist to hip ratio), relies on the following values:
we talk about obesity androids when the ratio WHR is greater than 0.85
we talk about gynoid obesity when the WHR ratio is less than 0.79.
In any case the waist / hip ratio should be less than 0.95 for men and 0.8 for women. Patients who exceed these values are considered to be at high risk for medical problems related to obesity. Similarly to B.M.I or I.M.C, WHR is also an approximate indicator, since it does not take into account the relationship between the muscle mass present in the gluteal region and in the abdominal region.
Android obesity is frequently associated with type II diabetes, dyslipidemia, cardiovascular disease and hyperuricaemia. All these conditions are often grouped together in the term ‘plurimetabolic syndrome’ and represent a serious risk to the patient’s health. The omental adipocytes (visceral adipose cells) are greater in the android obesity; in the gynoid instead the subcutaneous fatty deposits prevail.
Experimental investigations have shown that visceral or internal adipocytes are more sensitive to the lipolytic (‘weight loss’) activity of some hormones (catecholamines). People suffering from obesity android are therefore more fortunate on the one hand, since visceral fat tends to be disposed of more quickly than the subcutaneous fat, and more unfortunate on the other, since an excessively high intake of fatty acids in the blood has negative consequences for the whole organism.
When the adipose and non-fat molecules (the adipocytes also release hormones and pro-inflammatory substances) from the metabolism of visceral fat, they reach the liver, ‘flood it’ and alter its functioning. The modification of hepatic metabolism causes alterations of many blood values and facilitates the onset of hyperinsulinism / insulin resistance (type II diabetes) and cardiovascular diseases (hypertension, dyslipidemia, myocardial infarction).
At the origin of android obesity there are several constitutional (genetic, hormonal) and environmental (alcohol abuse) factors. Research has shown that even in normal and overweight people there may be important fat accumulations around the internal organs. Even apparently lean individuals may therefore be exposed to an increased risk for all diseases traditionally associated with android obesity.
Adipose tissue and obesity
Body fat is stored in many small fat cells, called adipocytes. The number and size of these cells varies from individual to individual. Body fat can increase as a result of one of the following processes: increase in the number of adipose cells (hyperplasia). Contrary to what happens for muscle fibers (see: hypertrophy and hyperplasia), adipose tissue has the possibility of increasing the number of cells that compose it. There is indeed a limit beyond which adipocytes cannot further increase in volume (maximum volume = 1μg). A further increase in fat reserves can only be achieved in this situation by increasing the number of adipocytes.
BAD NEWS: it is possible to reduce the volume of fat cells but not their number. When an obese person slims, fat cells lose a certain amount of fat, reducing their volume. Unfortunately, however, the number of adipocytes cannot be reduced. This phenomenon explains why an obese who suspends the weight loss treatment, reacquires in the short term much of the lost body fat.
Some studies seem to demonstrate the existence of a relationship between number of adipocytes and regulation of appetite. According to this research, a large number of ’empty’ fat cells would be responsible for the increased hunger stimulation. This phenomenon explains why, for an obese individual, it is so difficult to follow a low-calorie diet.
GOOD NEWS: the increase in the number of adipocytes occurs only in special cases. Fortunately, the phenomenon of adipocyte hyperplasia occurs only in particular circumstances. There are three periods of life in which the number of fat cells increases significantly:
- the last semester of gestation
- the first year of life
- the beginning of the adolescent period.
In adults this phenomenon can occur only during the transition from a moderate obesity (BMI> 30) to a severe obesity (BMI> 35). With the exception of such cases, changes in body composition occur only by the change in the volume of fat contained in the individual fat cells.
According to the most recent scientific evidence, however, it must be said that adipocyte hyperplasia would be a positive factor in some respects. The fact that the increase in volume of adipocytes has a limit, means that the fat cells can meet two different destinies; the first, we have already seen, is that of ‘doubling’ (hyperplasia); the second is a cell death due to metabolic imbalance (inadequate organelles and compressed in the periphery), followed by an immune attack.
In particular, the action of macrophages on the adipose cell leads to the release of inflammatory substances called into question in the pathophysiology of the most common diseases associated with obesity (such as diabetes). According to this and other visions, it is much better to have many small adipocytes, rather than a few large fat cells (especially on the visceral level).
Childhood obesity is a problem of considerable social importance. The phenomenon, which affects one in four children in U.S., is the result of a positive energy balance over time; in practice, more calories are introduced than consumed. The definition of overweight and child obesity is more complex than that for an adult, whose ideal weight is calculated based on the BMI (Body Mass Index), which is equal to the weight in kg divided by height in meters exponentiated.
Despite having low observation error, low measurement error, good reliability and validity, BMI cannot be a sensitive measure of obesity in very high and low people, and in people who have unusual compositions of lean mass and fat mass. However, a competent committee, agreed in the International Obesity Task Force in 1999, determined that – although the BMI was not an ideal measure – it was still the most valid of all the formulas that calculate adiposity in an individual, and therefore could be used to define overweight and obesity in children and adolescents.
Based on these conclusions, the WHO (World Health Organization), to define overweight and obese a child, uses the BMI points developed by a Cole study in 2000 and developed using different world data. For this reason, they represent an international reference that can be used to compare the different world populations.
The scientists define obese a child whose weight exceeds 20% the ideal one, and overweight if it exceeds 10-20%; alternatively, it defines it when its BMI is greater than expected. The weight growth of the child is calculated by referring to the percentile tables, graphs that combine the percentage weight and height values of the children, distinguished by gender and age.
According to recent studies carried out in 2000 by the NCHS (National Center of Statistics for Health in the United States), growth is normal if it is around the 50th percentile, while the higher the average value, the greater the risk of obesity; therefore, from the 85th to the 95th percentile the child is defined as overweight while the 95th percentile is defined as obese.
The complications of childhood obesity
Until recently, the complications of childhood obesity were clinically evident only after many years. Clinical studies on obese children have suggested a number of medical conditions for which obese children are at greater risk. There are few apparatuses that severe obesity does not affect. These conditions are important because they are very common, potentially serious, and responsible for serious consequences for the health and well-being of life.
Among all the consequences of obesity, the most frequent are pulmonary disorders (breath fatigue, sleep apnea and asthma), and orthopedic type. Respiratory disorders during sleep are very frequent in children overweight and refer to a wide range of conditions that include increased resistance to airflow through the upper airway, resulting in reduced flow of air. air and finally the cessation of breath.
Asthma and its symptoms are a difficult topic of study and the link between excess weight and asthma should not be presumed: children with asthma should reduce the level of physical activity, and the medical treatment of asthma (cortisone therapy), can cause weight gain. Nonetheless, the observation that weight loss can improve lung function in obese adults, suggests that preventing obesity may decrease asthma, or better prevent its occurrence.
The complications of the orthopedic type are due to the excessive mechanical load that bones and joints endure. Flat feet, varus and valgus of the lower limbs are the most common paramorphisms. Not only that, excess weight can cause joint pain, reduce mobility and increase the risk of sprains and fractures.
Regarding the late consequences, it should be noted that childhood obesity is a predictor of obesity in adulthood. In addition to having a greater predisposition to overweight and obesity, the person who has been overweight as a child is more exposed to certain diseases, especially of a cardiovascular nature such as arterial hypertension and dyslipidemia (increased triglycerides and cholesterol in the blood); all this due to the wrong lifestyle typical of the obese.
Type 2 diabetes and hypersurenalism
There are also serious endocrine consequences, such as type 2 diabetes (insulin-resistant), typical of adults but also frequent among obese and overweight children, and hypersurenalism, i.e. the hypersecretion of corticosteroid hormones by the adrenal gland. Menstrual abnormalities, premature menarche and ovarian polycytosis represent endocrine responses to excess weight in girls, while overweight or obese children tend to develop later than their peers with normal weight.
From the gastrointestinal point of view, obesity can cause minor complications, such as simple eating disorders, but also serious consequences, such as cholelithiasis (presence of cholesterol-formed stones within the biliary tract or gall bladder), fatty liver disease (degenerative process of liver tissue due to the massive presence of adipose tissue in the liver), and tumors of the gastrointestinal tract.
The psychological consequences
Not to be underestimated then the psychological consequences, which can be dragged and amplified over the years. Overweight children can feel uncomfortable and ashamed, until they come to a real rejection of their physical appearance; they are often mocking children, victims of jokes by their peers and at risk of losing their self-esteem and developing a sense of insecurity that can lead them to isolation: they leave the house less and spend more time in front of the television, establishing a vicious circle that leads them to reactive hypervetimentation.
Finally, the economic consequences that obesity generally causes are also to be mentioned. A real calculation of child obesity costs is very difficult to carry out since one would need a methodology that also takes into account costs for associated disorders. However, numerous studies have assessed the costs incurred by the various health systems of many industrialized countries for obesity in general. These studies suggest that costs for obesity vary between 2% and 7% of the total healthcare costs of these countries.
Consequences of childhood obesity
Even these data, however, are not completely true, as they do not take into account costs for diseases and problems related to obesity. For example, hepatic steatosis (linked to obesity) is the third common cause of liver transplantation in many industrialized countries, and therefore represents a significant medical expense not included in the total costs of obesity. Child obesity, according to the most expert nutritionists, is the result of a positive energy balance that has been prolonged over time. This means that the baby introduces more calories into his body than he consumes.
A child can be defined obese when his weight exceeds 20% the ideal one for sex, age, weight and height. An alarming fact is provided by the statistics, where in the United States are placed in the first places for number of overweight children; in fact, in our country one child out of 4 is obese.
The problems that occur when children are obese, often continuing to be adults, are in the exposure to certain diseases that affect the circulatory systems (such as arterial hypertension), skeletal muscle (e.g. arthrosis) and metabolic (e.g. diabetes mellitus). In addition to this, the obese child can develop a psychological discomfort due to his appearance, resulting in shame and rejection of his appearance, without neglecting the fact that often becomes a victim of jokes by friends and ‘friends’. This discomfort can also contribute to the onset of a disturbance in eating behavior. The main risk factors for childhood obesity are mainly three:
The solution to be adopted to prevent childhood obesity is provided to us by the Ministry of Health through the document ‘Strategies for nutrition education and nutrition’, according to which:
- children must be accustomed to 3 regular meals plus 2 snacks;
- parents should avoid rewarding them with too many snacks, especially if rich in sugars;
- they should not insist on making them eat at all costs by forcing them even when they are full;
- limit the protein intake by alternating meat, eggs and cheese and preferring fish;
- get them used to outdoor games and physical activity to burn calories and for proper physical development.
Regarding the last point, it is of fundamental importance (of course, always taking into account the other points). Today, unfortunately for various reasons – such as the lack of or very little physical education in schools, the spread of video games with the disappearance of those outdoors – is increasingly lacking the so-called street game, that is all those activities that up a few years ago they were carried out by children when they gathered in outdoor places, out on the streets, in the little streets, in the parishes of the churches, etc., represented by running, crawling, jumping, rolling, wrestling, climbing, kicking the ball, etc. etc., i.e. those simple basic motor activities that are very important for the harmonious development of the child.
Often the game is lacking because parents too easily scold their children while they play, saying ‘stay still’, ‘do not move’, watch television ‘, etc+. This causes the child to be active and not therefore moving (with consumption of calories), become passive and slowly begins to become a ‘stationary engine’ that receives only fuel (food).
The game is very important, it is training, it helps to burn, to grow and to interact with what surrounds us. Naturally, the game is not just that, according to Freud, it allows the elaboration and expression of emotional and unconscious experiences. Furthermore, playing is a way of passing on and acquiring new complex knowledge, even when not explicitly defined.
The game, therefore, can and must be inserted as a training method, useful in the prevention of childhood obesity.
The advantages that the play has as a training method are:
- development of motor skills and knowledge of the personal and the partner’s possibilities through reciprocal adaptation to the needs and abilities of the other;
- increase in interactions among the participants, thus pursuing socialization goals;
- focusing attention not only on what happens in your body, but also on what happens outside;
- establishing collaboration and emulation relationships among the participants;
- motivation of the subjects to participate;
- stimulation of creative abilities if personal solutions to motor problems are encouraged.
Thanks to the play training, it will be possible to train both conditional and coordinative skills. The resistance, for example, can be trained through paths with ascents, descents, obstacles, or trying to grab a companion with the game of ‘guard and thieves’.
It will be possible to train the strength climbing, doing battle games, or playing with the ‘tug of war’. You can train speed through the relays, doing the ‘slalom among the companions’. Above all, it will be possible to train neuromotor coordination among the abilities that are becoming more and more lost. Therefore through the training game it will be possible to train correctly in a playful way respecting the correct physical development of the child.
The most important duty therefore belongs to parents who have the task of accustoming children to avoid bad eating habits, to too much time in front of the children playing exercises TV and videogames, but above all they must pay attention to obtaining objectives that they refer to the improvement of the health status and the harmonious development of the child, allowing him to play and train through an extensive variety of recreational and sporting activities for the achievement of results related to psychophysical health.
Childhood obesity has a multifactorial genesis; as such, it is the result of various causes, more or less evident, that interact with each other. In the first place, it is due to an excessive and bad diet, linked or not to reduced physical activity and to genetic – family factors. There are rare cases of obesity related to hormonal alterations such as hypothyroidism or adrenal dysfunction.
If it is true that an insufficient diet can lead to deficits of various types (proteins, calcium, iron, vitamins and other essential nutrients for growth), on the other hand, an excessive caloric intake initially determines an overweight of the child, then, in most cases, a manifested obesity.
Overeating in the first two years of life, in addition to causing an increase in the volume of fat cells (hypertrophy), also determines an increase in their number (hyperplasia); as adults, therefore, there will be a greater predisposition to obesity and a difficulty in getting down weight or keeping it within limits, because it will be possible to reduce the size of the cells, but it will not be possible to eliminate them. Intervening during the developmental age is therefore of fundamental importance, because it gives the guarantee of better and lasting results.
In addition to improper and unbalanced diet, it is not to be underestimated, as a risk factor, the reduced physical activity or the sedentary lifestyle, the result of a wrong lifestyle, but always more frequent feedback. The little ones, in fact, are often accompanied by their parents (even if the school or the gym are just a few meters from the house), they take the elevator even for a single floor, spend hours and hours in front of the computer and the television (with negative examples that accentuate the bad eating habits), come out less and less and so on.
In the report ‘Obesity in children and young people: A crisis in public health’ written by a group of international experts (IOTF) under the WHO (World Health Organization), and in collaboration with IASO (the International Association for the Study of Obesity), the main social trends that contribute to the increase in childhood obesity have been identified:
- increase in the use of motorized transport (for example to go to school);
- decrease in physical activity during free time and consequent increase in the sedentary lifestyle;
- increase in time spent in front of the TV;
- increasing the quantity and variety of fat and energy foods and increasing their advertising;
- increase in the use of restaurants and fast food for lunch and dinner, which offer large portions at a low price;
- increase in the number of meals during the day;
- increase in the use of soft and gaseous soft drinks as a replacement for water.
Exercise is of fundamental importance for the growing child, as, in addition to making it lose weight, it makes it more active, helping to redistribute the proportions between lean mass (muscle tissue) and fat mass (adipose tissue). To avoid weight gain, a ‘threshold level’ of exercise corresponding to about 80 minutes of moderate physical activity or 35 minutes of intense activity per day is conceivable.
It is therefore sufficient to practice, in a constant manner, a light aerobic activity, without too much strain on the body (such as cycling or walking); this subjects the muscles to a moderate but constant effort, inducing them to draw fuel, above all from the fat reservoir.
Family factors are not less decisive than previous ones. Obesity, in some respects, can be considered a hereditary problem and, in others, a consequence of environmental factors. A multi-purpose survey carried out by ISTAT in 2000 shows that about 25% of overweight children and adolescents have an obese or overweight parent, while the percentage of children rises to about 34% when both parents are obese or overweight.
The example of the family is fundamental: we cannot talk about nutritional education if parents do not start first to follow a balanced diet. Regarding the hereditary nature of obesity, alterations of some genes that have a role in the production of fat cells have been highlighted, but studies are still ongoing.
The improved socio-economic conditions, poor eating habits and an increasingly sedentary lifestyle have favored the formation of some physical alterations, which are the consequence of an imbalance between muscular, skeletal and weightless development. Such alterations have caused a noticeable increase in childhood obesity, which in some countries such as ours, is reaching peaks of 20% of the healthy juvenile population.
In most cases, the triggering factor is the scarce or even non-existent physical activity, due to a lacking family, school or environmental organization, in this sense. Physical activity is in fact a fundamental component of man, especially in the age of development.
The growth of the child, like that of all living beings, is in strict dependence on the functional demands that come from the environment in which he lives. Each function has developed as a consequence of the specific requests coming from the outside world and each organ has assumed its definitive characteristics as a consequence of the functional requirements. Muscular and skeletal systems develop harmonically in the body and in the individual organs, especially in individuals who continually stimulate and exercise them appropriately.
We can consider obesity as a real pathology, characterized by an excess of adipose tissue, due to both the increase in volume and the number of adipocytes (the cells that form the adipose tissue). It is essential to fight obesity since the age of development, because adolescence is the critical period in which the ‘potential for obesity of an individual’ is established, given by the number of adipocytes.
Among the serious consequences of obesity that can affect children and young people early, the most frequent are problems with the respiratory system (sleep apnea, fatigue); to the osteoarticular (varus-valgus lower limbs, reduced joint mobility, flat feet); to the digestive system and to the cardio-circulatory system (inability to respond adequately to an effort, even mild intensity and limited in time, less ventilatory efficiency).
Moreover, in the developmental age, the body overweight generates other unpleasant consequences on the psychological level. The obese child can frequently feel uncomfortable and ashamed, even going so far as to exclude himself from social life and from normal games and motor activities. Often they are children who tend to close at home and over-feed, establishing a dangerous vicious circle (overweight, motor inactivity, exclusion from group life, overeating). The lack of motor activity is very often both a cause and consequence of obesity.
Medical treatment against obesity
Not to be forgotten, that the medium-long term efficacy of these medicines is often limited: once the admission is over, the lost weight is recovered within a few months, often with lots of interest.
The current legislation in U.S. recognizes – as weight loss adjuvants – only two active principles: sibutramine and orlistat (tetra-hydro-lipostatin). This does not mean, however, that these weight loss drugs should only be used in selected cases. On 24 January 2010, sibutramine was banned again by the American market, as the potential risks deriving from its intake would exceed the possible benefits. In 2015, the European medicines agency approved the use of two new ‘anti-obesity’ drugs to promote weight management in adult patients.
The two drugs based on the active ingredients naltrexone and bupropion and liraglutide act at the level of the brain centers that control satiety, reducing the appetite and the amount of food consumed by patients. Naltrexone and bupropion are available as extended-release tablets for oral intake, while liraglutide subcutaneous injection into the thigh, upper arm or abdomen.
Intragastric balloon (BIB) against obesity
An intragastric balloon is a prosthetic device that has been used successfully as an adjuvant for weight loss in moderately obese patients for several years. The BIB consists of a soft and expandable elastomer material, which is inserted into the stomach with an endoscopic procedure and subsequently filled with physiological solution. The intragastric balloon thus filled partially occupies the stomach, leaving less space for the quantities of food or drink ingested.
This device, therefore, aims to reduce the feeling of hunger and helps you feel full longer, even after consuming small meals. Sometimes, the intragastric balloon is used for severely obese patients who need short-term assistance to reduce their weight, up to a value that makes them candidates for a more complex and permanent surgical approach, such as a gastric banding or a gastric bypass.
The basic principle of BIB is the stimulation of the gastric bottom, the upper part of the stomach particularly rich in receptors, which once stimulated by the balloon (or the physiological gastric dilatation induced by food) send the satiety signal to the nervous system. Moreover, the partial occupation of the gastric volume also mechanically reduces the amount of food that the patient succeeds in swallowing.
The intragastric balloon was designed for people who have failed to achieve prolonged weight loss by conventional means, such as diet – possibly supplemented by weight loss supplements – physical activity and any medications. The balloon is indicated for patients with a high body mass index or who have other diseases related to obesity.
The gastric balloon is a non-permanent solution and is usually left in place for up to six months, after which it is removed. The technique has also been used successfully to induce a certain weight loss before subjecting the obese patient to a bariatric surgical procedure. Individuals who have only a slight overweight should NOT consider the intragastric balloon as a simple and effective solution for losing weight; rather, they should insist on addressing their problem with diet and exercise.
The placement of the intragastric balloon may not be suitable for patients with:
- Any disease and inflammatory condition of the gastrointestinal tract, such as: inflammation of the esophagus, ulceration of the stomach or duodenum, gastroesophageal reflux disease, chronic intestinal inflammation, stenosis of the esophagus or throat, tumors or tendency to gastritis (the balloon can worsen the condition and cause excessive bleeding);
- Conditions that predispose to haemorrhages (for example: varices) or suffering from coagulation disorders;
- Hiatal hernia> 4-5 cm;
- Previous gastric surgery;
- Patients with severe liver disease;
- Alcoholism or drug addiction;
- Patients in therapy with long-term anticoagulants or with gastroleptic drugs;
- Pregnant women and those who are breast-feeding.
- Other contraindications to BIB positioning intervention are:
- Crohn’s disease (increases the risk of intestinal obstruction);
- Patients taking non-steroidal anti-inflammatory drugs (for conditions such as osteoarthritis);
- Psychiatric or psychologically unstable patients (the high incidence of intolerance in these subjects requires the premature removal of BIB);
- Patients with an uncontrolled eating disorder (Binge Eating Disorder, BED, is a predictor for negative outcomes of the method).
Immediately after the insertion of the intragastric balloon into the stomach, it is necessary to limit the intake of oral fluids, which for this reason will be administered intravenously and gradually replaced by normal intake by mouth. The first few days can be associated with a certain discomfort: for many patients, it is common to experience nausea, vomiting, swelling, diarrhea and cramps, until their body fully adapts to the presence of the intragastric balloon.
Symptoms can last up to two weeks and some medications may be prescribed to help alleviate them. For the first three days following the procedure, all patients are severely limited to a liquid diet, namely: water, fruit juice, milk or soup. Gradually, the ability to tolerate solid foods should improve, even if the volume of food that the patient is able to consume in a single intake must be substantially reduced and the appropriate dietary guidelines must be respected. Depending on the level of nausea, the patient can be discharged the day after the operation or after a longer stay (about 2-4 days).
In the first days of recovery, patients are advised to avoid any activity that could cause excessive pressure or trauma to the abdominal area. Some subjects may not be able to tolerate the balloon for the entire period (equal to six months) and, when this happens, the device must be removed earlier than established.
There is the possibility that this intolerance may occur even in the first days after the placement of the balloon, especially if the side effects (including nausea and vomiting), do not resolve or present themselves in a more serious form than expected. After surgery, patients may return to their work after about 7 days of rest, but must abstain from exercise for at least 8 weeks.
The weight loss that is obtained is variable and, initially, can be quite rapid. Indicatively, the average weight loss obtained during the 6 months of maintenance of the intragastric balloon is about 15-20 kg. Ultimately, the extent of weight loss depends on patient compliance, that is, the degree of adherence to a controlled diet and a program that allows one to change one’s lifestyle, starting from the practice of regular physical exercise.
BIB can be used for up to six months, longer periods are not recommended. In fact, over time, the acidic contents of the stomach tend to weaken the material that constitutes the balloon and can deflate it. If it is considered necessary to use the intragastric balloon for more than 6 months, the patient may undergo a substitution. During the maintenance of BIB in situ, it may be necessary to follow an oral drug therapy, in order to reduce the acidity of the stomach. This can lower the risk of irritation of the gastric cavity and any damage to the balloon.
At the end of the initial period of 6 months, the competent surgeon can evaluate options for the next phase (replacement with a new BIB or surgical procedure). The intragastric balloon is normally removed in the same way it was placed, through the esophagus and the mouth. Prior to removal, a sedative and local anesthetic are administered to numb the throat. Using an endoscopic camera the doctor will introduce a catheter through the mouth to the stomach. The balloon is then drilled. Once deflated, this can be grasped by a forceps and removed from the stomach.
- The technique is less invasive and generally does not require the patient to undergo surgery under general anesthesia;
- The procedure is much less expensive because it does not involve anesthetics or prolonged hospitalizations;
- The procedure is easily reversible;
- Many patients achieve satisfactory weight loss over the period (about 6 months) in which the intragastric balloon is maintained in the stomach, provided they follow a low calorie diet and regular physical activity.
All medical procedures have some disadvantages and can cause side effects; to this rule the positioning of the intragastric balloon does not escape, but it presents a lower risk of complications compared to other more invasive bariatric surgery.
On rare occasions, the intragastric balloon can deflate and / or migrate through the stomach and into the intestine. In this case it will be easy to detect it, since the saline solution contains a dye (methylene blue) which facilitates early identification through a change in urine color. The patient should seek immediate medical attention for the removal of the balloon, as a damaged or deflated device may result in gastrointestinal erosion or obstruction, which can have very serious consequences. Although intragastric balloon placement procedures are performed regularly without complications, it is very important that all candidates are fully aware of the benefits and potential risks before undertaking this type of intervention.
Pain, nausea and, in some cases, vomiting, occur in the majority of patients within a few hours after inserting the balloon. Some drugs may be prescribed to reduce these side effects, which usually resolve spontaneously within a few days. If these symptoms persist, they can cause dehydration and lead to further complications. An increase in the incidence of gastrointestinal problems may occur, such as gastric ulcers (erosions to the lining of the digestive tract). Some patients do not achieve the desired weight loss after placement of the intragastric balloon. In many cases, this is due to the early removal of the balloon due to psychological intolerance or lack of adherence to their prescribed diet.
As with other gastric procedures, there is a risk of injury to the lining of the digestive tract, either by direct contact with the instruments used to place the balloon, or as a result of an increase in the production of gastric acids. This could lead to the formation of ulcers, pain, internal bleeding or perforation. Perforation is a serious complication that normally requires emergency surgery and could be fatal, especially in obese patients.
The most serious complication is the risk of intestinal obstruction. If the intragastric balloon is deflated, it can be pushed into the intestine and advanced to the rectum without problems; considering the small size, it will be eliminated through the faeces. However, in some cases it may become blocked in the intestine causing intestinal obstruction, with serious consequences for health.
Surgery as a radical treatment for obesity
Bariatric surgery can be performed through standard ‘open’ approaches, which involve laparotomy with incision of the abdominal wall, or by laparoscopy. With the second technique, doctors insert surgical instruments through small cuts on the abdomen, guided by a small camera that transmits images to a monitor. Currently, in most cases laparoscopic bariatric procedures are performed because they are minimally invasive, require smaller incisions, create less tissue damage and are associated with less post-operative problems. However, not all patients are suitable for laparoscopy.
Extremely obese patients (e.g.> 350kg) who have undergone previous surgery in the stomach or who have complex health problems (severe cardiac and pulmonary disease) may require the open approach.
There are four types of operations most commonly performed:
- adjustable gastric banding (AGB);
- Roux-en-Y gastric bypass (RYGB);
- biliopancreatic diversion with duodenal switch (BPD-DS);
- vertical sleeve gastrectomy (or sleeve gastrectomy, VSG).
Adjustable gastric banding (AGB): gastroreceptive intervention that reduces food intake by placing an elastic band of silicone around the upper portion of the stomach. Lap band LAGBThis band allows you to create a small gastric pouch that communicates with the rest of the stomach through a narrow, non-dilating emptying hole. The containment capacity of the gastric pouch can be adjusted according to the needs of the patient without resorting to further surgical procedures; in fact, the bandage houses a saline solution that can be increased or decreased, varying the constricting effect, through a thin catheter connecting to a reservoir placed just under the skin.
Weight loss is mainly due to the limited amount of food that can be ingested in a single meal (early satiety) and the increase in the time needed to digest the foods introduced. It is often performed by laparoscopy (LAGB) and represents a reversible intervention: the gastric cavity is not sectioned and the bandage can be removed. Weight loss: about 50% of excess weight.