Obesity

Definition

The greases (and others Lipid S), just like the Sugar S (Glucid S), are used to store energy in the body. Sugars provide an energy quickly usable, greases make it possible to store much energy in little space.

Grease is stored in cells called lipocytes or Adipocyte S. In the event of important stock, one distinguishes two situations:

overweight: the adipocytes store grease more and more and enlarge
obesity: when the adipocytes arrive at saturation, they multiply.

The current evaluations of obesity utilize the mass (that one generally calls in an unsuitable way the “weight”) and cuts it: a person who weighs 100 kg will not have the same stoutness if it measures 2 m rather than 1,60 Mr.

The index of body mass

The principal indicator of measurement used is the Indice of body mass (IMC). It takes account of the morphology of the individual.

For the adults, the index of body mass is equal to the Masse (expressed in Kilogram S) divided by the square of the size of the person (in Mètre):

$IMC = {mass \ over size in m^2}$

example: 75kg: 1,75m ² (=3.0625) = 24,49

a IMC between 18,5 and 25 is regarded as normal in an adult.
Between 25 to 30, one speaks about overweight (ponderal overload).
Beyond 30, one speaks about obesity.
From 35 to 40, one speaks about severe obesity and, beyond 40, about morbid obesity.

One should not however, confuse the I.M.C with the index of lubricating mass, which does not take to him measurement of the proportionality between size and weight but simply of the rate of grease and muscle contained in the body of the individual. One can calculate it thanks to a balance specific to impedancemetry or by a rather complex calculation based on the diameters of, arm, front armlever, thighs, glutei ethanches. A normal level of grease ranges between 17 and 22%.

Other markers

There also exists of other indicators of overweight: the report/ratio waist measurement/hip measurement. It must be lower than 1 at the man and 0,85 at the woman.

It as should be known as the mass of grease is distributed differently among the men and women. It accounts for 10 to 15% of the body weight of the man and 20 to 25% of the weight of the woman. She generally accumulates on the abdomen and the thorax at the man, on the hips and the thighs at the woman. In both cases, the overweight is harmful because it involves mainly cardiovascular problems at the man and articular at the woman.

An indirect indicator, belonging to the definition of the metabolic Syndrome, is the abdominal perimeter. It must be lower than 102 cm for the men and 88 cm for the women. This parameter is correlated with a risk raised of occurred of a diabetes or cardiovascular diseases and would be a better marker of risk than the taking into single account of the index of body mass.

Some figures

In 2004, obesity touches 300 million people in the world. According to professor Barry Popkin, university of North Carolina, this figure would be rather of 800 million in 2006

Developed countries

Statistical table: overweight and obesity in some countries

In France, 1965, only 3 % of the children in school age were obese according to the IMC; they are 25 % in 2004, 26% with the Canada and 16 % in the United States. The obesity of the child is an main issue: acquired before 5 years, it persists at the adulthood.

A study of the Regional management of the social affairs (DRAS) going back to 2002 and carried out in Paris region makes it possible to refine this report: 6,2% of the pupils of great section (4 to 5 years) provided education for in public school suffer from an obesity of degree I and 3,3% of degree II. 11,8% of the children of networks of priority education (REFERENCE MARK, underprivileged populations), against 8,7% of the global population, are reached of obesity of degree I; 4,5% compared with 2,9% of degree II.

According to a report/ratio from International Association for the Study off Obesity (2007), 22,5% of the Germans and 23,3% of Allemandes are obese; 75,4% of the men and 58,9% of the women suffer from an excess of weight in Germany, thus placing them in first place to Western Europe. The evoked causes are the absence of school canteens and the strong beer consumption.

Consommation of calories per anybody and day (2000-2002)

Country in the process of development

One counts 115 million obese in the Pays in the process of development; there are paradoxically people suffering at the same time from obesity and from Malnutrition. This is explained, partly, by two phenomena:

the fall of the world rate of the Sugar;
the manufacture of oil is an activity subsidized by the States in many these countries.

oil and sugar are thus the least expensive food products, which does not prevent obviously the people from also suffering from deficiencies in Protéine S, Vitamine S, Oligo-élément S, etc

In any event obesity is a form of malnutrition.

The Mexico is the second country of the world for the share the obese ones in the population, just behind the United States. Obesity touches 30% of the adults, that is to say 44 million Mexicans, and 40% know an excessive weight.

In 2002, the China knows an important obesity (2,6% of the population to one IMC equal to or higher than 30) and overweight in general (14,7% of the population to one IMC equal to or higher than 25), which touches thus approximately 215 million Chinese. The problem is mainly present in the young people (between 7 and 18 years) where he knows a very strong increase, about 28 times between 1985 and 2000, mainly at the boys. The causes are the same ones as for the Western countries, with in particular a put out of order food mode and a lack of physical exercise.

Causes

Obesity is often the result of an imbalance between:

the daily energy contribution, often called AET: total energy contribution, nap of the calories brought by:

the Glucid S (slow or fast sugars, with more or less high Index glycemic): Saccharose, Glucose, Fructose, etc;
the Lipid S (fatty-acids) found in the plant oils and animal greases in particular;
and the Protein S, vegetable (algae, lenses for example) or animal (meat, fish).

and summons it energy expenditure:

heat transfer with the environment, all the more important as the outside temperature is low;
energy necessary to the operation of the organization (digestion p. e.g.). The Cerveau with him only consumes approximately 20% of total energy;
physical efforts: go, sport, physical-activities of any kind.

When the organization receives more than he does not spend, he stores part of the contribution, in the form of greases in the fat Tissu. However the Metabolism of each one, very different according to the individuals, plays a great part, and certain people thus more easily will become obese than others (factors Génétique S in particular).

The recent explosion of the number of obese is allotted to several factors related to the lifestyle:

For the first time in the history of humanity, a great proportion of human have the possibility of feeding with sufficiency, even to overfeed themselves or of feeding without taking account of their needs (for example while eating too quickly, which does not make it possible to feel satiety and to stop the meal then). Previously one regularly met episodes of food shortages and of Famine S.
Of very many food are proposed, at any hour of the day, independently of the meals, which supports the nibbling and thus the Alimentation apart from the natural cycles. It is difficult to manage this profusion of food. In addition of many food proposed at the same time fatty and are sweetened without filling the stomach, which puts out of order the reference marks (the satiety is not obtained whereas the energy contributions are already largely sufficient). Lastly, when one always eats the same food (what was the case traditionally), satiety (loss of desire for eating) indicates that one has a sufficient energy contribution; when the consumed food is unusual, this information is distorted.

Agribusiness industry transformed too many food, increasing their index glicemic, and distorting the utility of the calories: the calories brought by proteins are not the same ones, on the level total assessment, that those brought by glucids. Result: many products " light" , without greases but also very low in proteínes and charged in sweetening substances. The refining and the presence of the taste sweetened in these new factory feedstuffs create true a " toxicodépendance" , which, to the length of the years, brings has a physiochimic suffering when the obese organization is private.

the sedentariness is an important cause: in the absence of sufficient physical-activity, the car and the Télévision are as harmful as the food Malnutrition or excesses.
the contemporary companies cause Stress, sometimes even of Sinistrose. Many individuals can then feel moral empty in them, which they compensate for by food. (See Bulimia).

Obesity is in any event multifactorielle. Among the causes, the role of the Hérédité is better known: responsible genes were identified, which intervene on the production by the Adipocytes of Leptine, a Protéine acting on the level of the central Nervous system on the control of the Appétit and the energy expenditure . One also noticed the influence of the lifestyles on the factors Génétique S. Our body was accustomed during millenia to face the lack, and the natural selection rather supported the people able to store in period of abundance to face the periods of food shortage. Paradoxically they are these people who are adapted to a regular abundance. In addition, with same a Food and the same physical practice, the catch of mass varies according to the individuals (according to their metabolism).

With regard to the food, the quantity of consumed sugar is not the only criterion, their quality (index glycemic, refined complete sugar versus) plays much; in the same way the content of greases is not the only criterion, their quality also plays a great part: oils of first cold pressure are for example much more favorable than refined oils (extracted hot, which in particular eliminates a good part of the contributions beneficial, antioxydant, and/or with solvents), and more favorable than saturated greases.

The types of lipids of the food are the following, with the following properties for the organization:

Sterol:

Cholesterol (to the 2/3 manufactured by the liver): The cholesterol brought by food is generally not very harmful. On the other hand the production excessive (or too low) by the liver, starting from consumed greases, increases the cardiovascular risks. In the analyzes of blood, it is also necessary to distinguish the " good cholestérol" (HDL) and the " mauvais" (LDL), only causes some in the cardiovascular diseases. It is the relationship between the two which it is necessary to supervise, more than the total of cholesterol.
Phytosterol S (Oils, cocoa, fruits, vegetables): Regulation of the cholesterol level. Properties anti-inflammatory drugs. Reduction in the cancer risks and Hyperplasie of the prostate. Reinforcement of the immune system. Increase in the rate of DHEA.

Tocopherol S:

alpha (Vitamin E), Beta, Gamma, Delta Oils (except palm and copra): Antioxydant S: lower cardiovascular risks and cancers.

Phospholipide S and Sphingolipide S (Egg, soya, germ of corn): Useful for the cellular brain (neurons) and membranes.
Fatty-acids:

Saturated (Meats, butter, cream-coloured, corn oil…) : Increase in cardiovascular risks (C.V.), with the amounts consumed by the majority, in the majority of the developed countries. Agribusiness industry often prefers greasy substances of substitution for butter, but they are still worse by the Trans unsaturates than they contain:
“Unsaturated Trans” (refined Oils, chips and industrial chips, cracklings, viennoisery without butter, bakery of supermarket, margarines solid, dry cookies, of aperitif, craquelins, industrial pastry makings, sandwich breads, quiches, tarts and industrial pastes with tart, breaded products, pastes to be pasted, industrial sauces, vinaigrette, mayonnaises, greases of ox, sheep, dairy products): Very strong increase in risks C.V. : raise bad cholesterol (as butter) but also lowers good.
“Mono unsaturates (cis)”, of which the Ω9: (Olive oil, plant oils, grease of duck, goose, chocolate): Reduction in risks C.V
Poly-unsaturates Omega-3 (nut Oils, soya, colza, flax, currants, blackcurrant, olive, fatty fish, shellfish): Reduction in risks C.V., but in cardiovascular and immunizing turbid excesses. The Ω3 require sufficient Ω6 to be able to be comparable, but the amounts of Ω3 consumed in the developed countries are (much) too weak compared to Ω6.
Poly-unsaturates Omega-6 (Oils of grape pips, sunflower, nut, corn, soya, colza, olive, greases of poultries): Reduction in risks C.V., but in cardiovascular and immunizing turbid excesses. An obesity is thus noted in infants even of the fetuses, without being able to accuse nibbling or absence of exercise. The food, too rich in Ω6, of the mother is in question, even the composition of Lait S out of powder, copied on that of the milk of mothers consuming too many Ω6. (Studies of Gerard Ailhaud pp14-16).

In a very paradoxical way, the modes can support obesity. Indeed, the bad modes (low in proteins and too restrictive) support the muscular loss of mass, which is directly related to the metabolism. After these bad modes, there is deceleration of the Métabolisme and taken again accelerated Poids. These bad modes are deprived, mainly in proteinic contribution .

Obesity could also have a genetic cause: a change of the gene FTO would increase the risk very appreciably, and more especially as this change is Homozygote (i.e., present on the two chromosomes).

Consequences

A person suffering from obesity runs several risks:

physical:

diabetes: whereas the Diabète sweetened (Diabetes of the type 2) appears normally as from 40 years, one sees appearing diabetes sweetened as of adolescence at the obese ones;
Hypertension, Cerebral vascular accident and cardiovascular accident;
the incidence of certain cancers seems to increase with obesity: breast cancers after the menopause, of the endometer, the ovary, the prostate, colorectal and of the gall bladder;
at the obese expectant mother, the pregnancy and the childbirth is more at the risks (hta gravidic, accidents thrombo-embolic, Cesareans), and perinatal morbi-mortality is increased;
Apnea of the sleep;
various articular problems: Osteoarthritis, compressings vertebral…;
psychological dependence with food: feeling of depression, faintness, depresses and " vide" between the meals which from goes away when one eats.

psychological: depression, discomfort, complexes, inhibition, rejection of its body and its person;
social: Discrimination, put at the variation.
senile increased risk of Insanity and loss of cognitive acuity .
Plusieurs indices suggested a bond between obesity and senile insanity at the obese ones at a advanced age. CNRS and the INSERM in 2006 confirmed a linear relation connecting the excess of weight and certain cognitive capacities, at an earlier stage, in the adult of Middle Age in good health. The follow-up over 5 years (1996 - 2001) of a population (2.223 men and women from 32 to 62 years) showed a degradation of the results to the standard cognitive tests at the people of index of body mass (IMC) élevé.
L' study eliminated certain potential skews (level of education, diabetes, blood pressure), but one does not know yet if these performances are affected by obesity itself or the lifestyle or certain food more often consumed by those which are victim of obesity, or for genetic causes which would be supporting factors of obesity or for other reasons badly included/understood. Substances stored and/or emitted by the fat cells could inhibit the operation of the brain, like besides the vascular impacts of obesity, that one suspect to be responsible for certain insanities.
Chez these people, cognitive ageing thus seems to be able to be improved by precociously treating the factors of disordered state of the food behavior and of the métabolisme.
La memory is in particular affected; from 20 kg/m2 of IMC, 9 words out of 16 are memorized against 7 for those of which the IMC exceed 30 kg/m2, and the memory slightly dropped in 5 years for the IMC high ones within the framework of the study.
Cancer S: occurred the of certain ones cancer is correlated with the index of body mass. It is acted as praticulier of the cancers of the bladder, those of the pancreas, the stomach. At the woman, a high poid increases the risk of occurred of breast cancers, of the endometer, the kidney, the esophagus as that of some Leucémie S. obesity would be responsible of almost 5% to cancers to the ménopausée woman.

In 1992, obesity was the estimated cause of 55 000 deaths in France, primarily by cardiovascular diseases and diabetes. In addition, because of the complications of the diabetes, obesity is the first cause of Cécité before 65 years in France, and the first cause of Amputation. This on-mortality is found at all the ages, races or sexes

Prevention

Obesity is a problem which is treated on the means and the long run, with possibly an even psychological medical monitoring. For preventive measure, it is advisable to adopt a regular food, i.e. to respect the hours of the meals , which makes it possible to control what one consumes.

The agro-alimentary industrialists tend to put cheap raw materials in the dishes prepared in order to reduce the manufacturing costs, and in particular salt, Sucre S and grease S produced starting from hydrogenated oils containing unsaturated fatty-acids '' trans '', strongly increasing the cardiovascular risks.

The nutritional reference marks of the PNS National plan nutrition health (in France or Belgium) are very useful to know and apply.

It is also highly recommended to have a minimal Physical-activity. Failing to practice a Sport, to make at least half an hour of walking per day, for example while going to make its races on foot in the trade of proximity, or if one must borrow public transport, to go to the following station and not to go down to the station nearest but to that to front.

Finally the psychological factors (pleasure of eating) and social (to eat together, during a good meal) play very favorably.

The children are most exposed

The prevention near the children is important:

they are most sensitive to the advertizing requests for the food
they are naturally attracted by the sweetened tastes
a good part of the children was accustomed very early to an imbalance of the food, including in the belly of their mother, if it had an unbalanced food. It is all the more difficult to oppose these bad habits which they are older, that takes more time and of patience, for them and their entourage.

Because of the modern lifestyle, it becomes difficult for the parents to contribute to a good nutrition of their children:

work hours of the parents making that they are often less available;
distance of the grandparents for professional reasons, those cannot keep the children with the return of the school and transmit “culinary culture to them”
loss of the traditional nutritional reference marks which made the force of certain areas or country (in particular in France in the Southern West, or in the Mediterranean countries).

This is why education with the nutrition is very important, at the school. The experiments undertaken in several French cities (Epode program) show the utility and the effectiveness of this education, at the same time for the children and their parents: they are the children who are made the ambassadors of a food balanced near their parents…

The children are less anxious in connection with their physics and eat with their hunger and nibbles between the meals what is not advised for them.

For the obese children, it is necessary to consult a general doctor or even the family practitioner and not only it is necessary to do what the doctor known as but it is necessary to respect them and to have the will to lose but also it will have to be followed your child so that it does not nibble.

Examples of prevention policies

In the United States

There exist many fight associations against obesity in the United States: Stop Obesity Alliance (Alliance against obesity) is based at Washington DC.
In California, the code of education envisages courses of physical education in the public schools: 200 minutes of sport at least every 10 days of school in the primary education; 400 minutes in the secondary
the States of Florida, Arkansas and Pennsylvania recently launched sensitization programs of the parents on childhood obesity, via the schools: for example, the schools of Arkansas send to the families a mail informing them of the obesity of their children since 2003. The schools introduced more fruits and vegetables into the menus and increased drinks without sugar. The governor of Arkansas, Mike Huckabee and Bill Clinton announced into 2006 that the producers of soda decided to replace drinks sweetened in the distributers. This policy made it possible to stop the progression of obesity in the children. Cadburry Schweppes, Pepsi and Coca-Cola announced that they will withdraw their sodas of the schools to the re-entry 2008. Coca-Cola also launched a new drink which would make lose called Enviga.
the company McDonald's decided to finance the fight against obesity and the diabetes by making a gift of two million dollars to the Scripps Institute.
In 2002, the exit of the book Fast Food Nation revival the debate on obesity in the United States. In 2004, the documentary film Super Size Me of the American Morgan Spurlock highlights the dangers of the Fast-food which involve the increase in obesity.
the health authorities of the municipality of New York decided to prohibit greases of industrial origin in the 24.000 restaurants which account the city. They also force fast-food to post into large the calories on their menus. With Chicago, a project of prohibition of greases resulting from industrial hydrogenation are being studied in 2006. The chain of fast food Kentucky Fried Chicken announced in October 2006, the substitution of these greases by an oil of Soja in its 5.500 American restaurants as from April 2007.
the municipality of Los Angeles plans in September 2007 to propose “a two years moratorium on the construction of new fast-food in the disadvantaged districts of the south of the city”.

In France

In France, a public awareness campaign launched in 2002 encourages people to eat at least 5 fruit and vegetables per day, and to practice the equivalent of one 1/2 hour of walk per day (National plan nutrition-health - PNS, then PNS 2). In 2007, the publicities intended for the food products for children must be fewer and a message must indicate the risks that the excess of this kind of products can generate.

In Belgium

Belgium develops its Program PNNS-B 2006 - 2010.

Treatments

Nonmedicamentous

They aim, in theory, the heating restriction to obtain a ponderal reduction. Among the means used, there are the mode, the physical-activity and the personalized support.

Modes

They are several kinds:

the heating restriction " équilibrée" and moderate which consists with a reduction of 600 kcal per day compared to the usual ration. It is it which with the best effectiveness on the weight because it makes it possible to reduce the weight of approximately 5 kg to one year
the food modifications without heating restriction: reduction of greases, increase in the fruits, cereals and vegetables. The effect is tiny but considerable: 2 kg at one year.
the Mediterranean Mode, which proved reliable in term of benefit in the prevention of the cardiovascular diseases. He is proposed among patients hypercholesterolemic, when there exists a disease of the coronary ones.
modes very low calories: less than 800 with less than 600 kcal/j. They can be sources of deficiencies if they are prolonged. Sudden deaths were even reported
the modes low in greases where the lipids account for nothing any more but 10 to 15% of the contributions
the hyperprotéinés modes, low in carbohydrates (mode Atkins), but rich in greases and proteins, not imposing any heating restriction, but which make it possible to increase satiety. Serious undesirable effects were reported
the fast, being limited to drink contributions only expose at the serious medical risks.

In practice, the dietetic councils without accompaniment are of an effectiveness moderate and limited in time (strong probability of resumption of weight).

The physical-activity

Several studies showed that the association of the physical-activity to a mode is more effective than each taken element separately. It is not necessarily sporting, one will prefer to use the adapted Physical-activities . It is necessary to encourage the regular physical-activity by simple means and progressive.

The personalized support

It was shown that an active support of behavioral therapy type improves the effectiveness of dietetic measurements compared to groups without therapy (- 4 to -8 kg). The family therapies with the spouse were slightly more effective, contrary to the group therapies which are not more effective than the individual therapies.

Medicamentous

the central stimulants comprise many side effects, sometimes serious and are abandoned in the majority of the countries:

Fenfluramine and Dexfenfluramine withdrawn from the market on a world level in 1997.
Amfépramone (diéthylpropion, EPD), Clobenzorex, Fenbutrazate, Fenproponex, Mazindol, Méfénorex, Norpseudoéphédrine, Phendimétrazine, Phentermine and Propylhexédrine: prohibited in Belgium since October 2001.
Phénylpropanolamine (noréphédrine): prohibited in Belgium since October 1st, 2002.

Three drugs were developed recently and have a certain effectiveness:

the hydrochlorate monohydrate of sibutramine
the Orlistat: inhibiter of gastro-intestinal lipases
the Rimonabant, an inhibiter of the receivers to the Cannabinoïde S of the type I, allows a significant reduction of the weight as well as associated metabolic disorders (diabetes, Dyslipidémie S)

None of these drugs is higher compared to the other. They must be taken during at least several years and their stop often causes a resumption of the weight. One is unaware of if they have a positive effect in the prevention of the cardiovascular diseases, even if the orlistat and rimonabant it act in a favorable way on various cardiovascular Risk factors.

Bariatric surgery

The bariatric surgery consists in restricting the absorbtion of food, decreasing, in fact, the daily caloric intake. It is about a heavy technique, reserved in the event of major obesity with failure of the various attempts at mode. An evaluation and a psychological follow-up are necessary.

It gathers a whole of techniques which can be classified in two principal types of interventions.

the first aim at reducing the gastric capacity, i.e. the useful volume of the stomach, and/or, to reduce the speed of draining of the stomach in order to obtain a feeling of satiety more quickly ( gastric ring ).
the seconds, known as mixed, associate with this gastric restriction the creation of a system of derivation in the digestive tract in order to decrease the absorption of the nutritive elements by the intestine. These techniques are practiced by incision of the abdominal wall (laparotomy) and, for a few years, almost all could have also been realized by Laparoscopie.

Compared effectiveness of the techniques

The data analysis available indicates that the various techniques of bariatric surgery are effective.

As a whole, the mixed techniques, which associate gastric restriction and intestinal malabsorption, are more effective than the interventions which do nothing but reduce the gastric capacity.

The laparoscopic techniques offer as for them many advantages, like a reduction of the duration of hospitalization, although they are not free from complications. Only two laparoscopic approaches are enough at the enough known point and their effects not to be regarded as experimental more.

In the long run, the bariatric surgery significantly decreases the mortality of the patients while having profited.

Importance of a later follow-up

The patients who undergo an important weight loss must be followed annually by a multidisciplinary team which, in addition to the surgical team (in particular attentive with the early and late complications), includes nutritionnists, psychologists and specialist physicians. A plastic surgeon is often necessary.

Economic aspects

As a whole, the bariatric surgery proves to be an expensive intervention.

On the other hand, its costs could be compensated mainly by the reduction in the prevalence of the diseases associated with obesity (cardiac diseases and diabetes, for example), by the reduction of their consequences on the use of the resources of the health system and the losses of productivity caused by the incapacity, just as by the improvement of the quality of life of the patients especially in north.

See too

Iconography

Portrait supposed of the general Tuscan, Alessandro del Borro, traditionally allotted to the Lorraine painter Charles Mellin, Berlin, Gemäldegalerie.
Guillaume-Dominique Doncre, Portrait of an intendant of Picardy, Arras, museum of the Art schools.

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