Obesity and Marital Quality - Case Study Example

Obesity Obesity is a of excess storage of body fat. It is prevalent all over the world, particularly in the developed nations. Approximately 7% of the estimated current world population is obese (Uwaifo, 2006). In the United States, it is estimated that 35% of women and 31% of men older than 19 years are either obese or overweight (Uwaifo, 2006). In the Europe, at least 15% of men and 22 % of women are obese (Uwaifo, 2006). Obesity affects all races. The Pima Indians of Arizona and other ethnic groups native to North America have a particularly high prevalence of obesity. It is prevalent equally in both the sexes. Obesity is associated with increase in mortality and morbidity rates. These rates are further modulated by several associated factors which include age of onset and duration of obesity, severity of obesity, amount of central adiposity, other comorbidities, sex, and level of cardiorespiratory fitness (Uwaifo, 2006). Obesity also leads to various psychological and marital problems (Raushenbach, 1995). Measurements The most commonly used measure of obesity is body mass index (BMI) or Quetelet Index. It is calculated as follows: BMI = weight/height2, where weight is in kilograms and height is in meters. Deurenberg equation can be used to calculate the body fat percentage. Body fat percentage = 1.2(BMI) + 0.23(age) - 10.8(sex) - 5.4, where age is in years and sex is 1 for male and 0 for female. BMI cannot be the correct measure of obesity in all types of people. For example, in muscular persons, BMIs indicating obesity may actually be spurious and in some Asians, normal BMI may suggest excess adiposity. Hence some researchers define obesity based on percentage body fat. Thus, body percentage fat greater than 25% defines obesity in men and in women, over 33% defines obesity. 21-25% is considered borderline in men and 31-33% is considered borderline in women. In children, BMI greater than the 85th percentile is considered as obesity (Uwaifo, 2006). According to the World Health Organization, obesity is classified into 3 grades (Uwaifo, 2006): Grade-1: BMI of 25-29.9 kg/m2 Grade-2: BMI of 30-39.9 kg/m2 Grade-3: BMI greater than or equal to 40 kg/m2 Other indices which may be useful in estimating the degree and distribution of obesity include 4 standard skin thicknesses (ie, subscapular, triceps, biceps, suprailiac) and waist and hip circumferences (Uwaifo, 2006). Etiology Obesity can be primary or secondary. The etiology is actually multifactorial in most cases. These factors include metabolic, genetic, activity levels, behavior, hormones, age, race, sex, socio-economic status, dietary habits, pregnancy, menopause, psychologic factors and ethnic and cultural factors. Secondary causes of obesity include certain endocrine disorders like hypothyroidsm, Cushing syndrome, insulinoma, growth hormone deficiency and poly cystic ovarian disease; genetic disorders like Prader- Willi syndrome and Bardet- Biedl syndrome, intake of medications like phenothiazines, oral contraceptive pills and glucocorticoids; presence of eating disorders like binge eating and iatrogenic causes like tube feeding (Uwaifo, 2006). Cardiovascular - Essential hypertension, coronary artery disease, left ventricular hypertrophy, cor pulmonale, obesity-associated cardiomyopathy, accelerated atherosclerosis, pulmonary hypertension of obesity CNS - Stroke, idiopathic intracranial hypertension, meralgia paresthetica GI - Gall bladder disease (cholecystitis, cholelithiasis), nonalcoholic steatohepatitis (NASH), fatty liver infiltration, reflux esophagitis Respiratory - Obstructive sleep apnea, obesity hypoventilation syndrome (Pickwickian syndrome), increased predisposition to respiratory infections, increased incidence of bronchial asthma Malignant - Association with endometrial, prostate, gall bladder, breast, colon, and, possibly, lung cancer Psychologic - Social stigmatization, depression Orthopedic - Osteoarthritis, coxa vera, slipped capital femoral epiphyses, Blount disease and Legg-Calvé-Perthes disease, chronic lumbago Metabolic - Insulin resistance, hyperinsulinemia, type 2 diabetes mellitus, dyslipidemia (characterized by high total cholesterol, high triglycerides, normal or elevated low-density lipoprotein, and low high-density lipoprotein) Reproductive - Anovulation, early puberty, infertility, hyperandrogenism and polycystic ovaries in women, hypogonadotrophic hypogonadism in men Obstetric and perinatal - Pregnancy-related hypertension, fetal macrosomia, pelvic dystocia Surgical - Increased surgical risk and postoperative complications, including wound infection, deep venous thrombosis, pulmonary embolism, and postoperative pneumonia Pelvic - Stress incontinence Cutaneous - Intertrigo (bacterial and/or fungal), acanthosis nigricans, hirsutism, increased risk for cellulitis and carbuncles Extremity - Venous varicosities, lower extremity venous and/or lymphatic edema Miscellaneous - Reduced mobility, difficulty maintaining personal hygiene Table-1: Comorbid conditions associated with obesity (Uwaifo, 2006) Visceral accumulation of fat reduces the sensitivity to insulin in skeletal muscle, liver tissue, and adipose tissue. This is known as insulin resistance. This leads to glucose intolerance and hypertriglyceridemia (Schwarz, 2007). Pathophysiology Excess fat accumulates when total energy intake exceeds total energy expenditure. This imbalance occurs due to excessive energy intake and/or reduced energy expenditure. In children and adolescents, the commonest cause of this imbalance is excessive television viewing, excessive computer use, and insufficient physical activity (Schwarz, 2007). The latest proposed theory is about dysfunction in the gut-brain-hypothalamic axis via the ghrelin/leptin hormonal pathway (Schwarz, 2007). This pathway has been suggested to have a role in abnormal appetite control and excess energy intake. Leptin is a 16-kD protein which the researchers presume to be produced predominantly in white adipose tissue and, to a lesser extent, in the placenta, skeletal muscle, and stomach fundus. It is involved in carbohydrate, bone, and reproductive metabolism and also plays an important role in body weight regulation by signalling satiety to the hypothalamus and, thus, reducing dietary intake and fat storage while modulating energy expenditure and carbohydrate metabolism to prevent further weight gain. Thus leptin deficiency causes obesity. It is believed that most humans who are obese are actually not leptin deficient but leptin resistant. Hence the circulating leptin levels in them are high (Uwaifo, 2006). There are 2 important hormones which are proposed to reduce dietary intake. They are Proopiomelanocortin (POMC) and alpha–melanocyte-stimulating hormone (alpha-MSH). Both these hormones act centrally on the melanocortin receptor 4 (MC 4) to reduce dietary intake. Genetic defects involving POMC production (band 2p23) and mutations in the MC4 gene (band 18q21.3) can lead to obesity and are considered as monogenic causes of obesity in humans (Uwaifo, 2006). Other obesity genes which have been discovered and studied are on chromosome arms 2p, 10p, 5p, 11q, and 20q. Band 5q15-21 is involved in the production of prohormone convertase involved in the conversion of POMC to alpha-MSH. Mutations of this gene can also lead to obesity. Mutation of PPAR-gamma is known to cause severe obesity. PPAR- gamma is a transcription factor that is involved in adipocyte differentiation (Uwaifo, 2006). Weight loss programs Weight loss programs are the core for treatment of obesity. There are 3 main phases in these programs which include preinclusion screening phase, a definitive weight- loss program and a maintenance phase. The goal for weight-loss in a medical treatment program is individualized and in most cases it is approximately 0.9-1.5 kg/wk (Uwaifo, 2006). Before starting weight loss programs, chronic diseases must be evaluated and treatment started. Starvation is not recommended for achieving weight loss. However, calorie deficit is important to achieve sustained weight loss. Of all the low-calorie diets, Very low-calorie diets are the best. These diets involve reducing caloric intake to 800 kcal/d or less. Simultaneously, exercise is also vital to any weight- management program. But this has to be initiated after cardiorespiratory fitness is evaluated. As far as medications are concerned, there are not many medicines to treat obesity. 3 major groups of drugs are used to manage obesity: 1. Centrally acting medications that impair dietary intake. E.g.: Sibutramine 2. Medications that act peripherally to impair dietary absorption. Eg: Orlistat 3. Medications that increase energy expenditure. E.g.: Ephedrine These drugs can have side effects like tolerance, abuse and aggravation of other health problems like glaucoma, blood pressure and depression (Schwarz, 2007). Of these the most extensively studied drug is orlistat. When administered for about 2 years, it promotes weight loss, minimizes weight regain, improves lipid profile, blood pressure, and quality of life (Rossner et al, 1999). Surgical removal of excess fat is recommended in those with morbid obesity. Conclusion Obesity is now considered a chronic disease with onset in childhood or adolescence as a result of energy input- output imbalance. It is associated with many comorbid conditions and increased mortality and morbidity. Currently, the focus of research is on dysfunction in the gut-brain-hypothalamic axis via the ghrelin/leptin hormonal pathway. The main stay of management in most obese patients is weight loss program through exercise and low-calorie diet. References Emedicine health, 2008. Obesity. Available at: http://www.emedicinehealth.com/medication_in_the_treatment_of_obesity/page5_em.htm [Accessed 5 may 2008] Schwarz, S.M., 2007. Obesity. Emedicine from WebMD. Available at: http://www.emedicine.com/ped/topic1699.htm [Accessed 5 may 2008] Uwaifo, G.I., 2006. Obesity. Emedicine from WebMD. Available at: [Accessed 5 may 2008] http://www.emedicine.com/med/TOPIC1653.HTM [Accessed 5 may 2008] Rauschenbach, B.S., 1995. Obesity and Marital Quality. Journal of Family Issues, 16, 6, 746-764. Rossner et al, 2000. Weight Loss, Weight Maintenance, and Improved Cardiovascular Risk Factors after 2 Years Treatment with Orlistat for Obesity. Obesity research, 8, 49-61. Read More