Morbid obesity: BMI, consequences, management

Obesity is a multifactorial adipose tissue disease, characterized by excessive accumulation of fat. The World Health Organization (WHO) has recognized it as a chronic disease since 1997. In France, it is still recognized – and treated – as a long-term condition (ALD). However, the impact is getting louder: it affects almost 8 million French people (source 1).

What is Morbid or Mass Obesity?

In adults, obesity is assessed based on: body mass index calculation (BMI): We divide the weight (in kilograms) by the height (in meters) squared. One speaks of “obesity” when their BMI is between 30 and 39.9 kg/m². But there are three stages of the disease:

  • moderate obesity (BMI between 30 – 34.9 kg/m²),
  • severe obesity (BMI between 35 – 39.9 kg/m²),
  • And morbid obesity, also called mass obesity (BMI higher than 40 kg/m²).

What is supramorbid obesity?

We sometimes speak of supramorbid obesity, when the body mass index is the same greater than 50 kg/m²† But this term does not fit the WHO classification.

Note: BMI is not the only criterion for diagnosing obesity. Besides the weight we recommend: measure waist circumference and body fat to assess the distribution and type adipose tissue.

Morbid obesity: symptoms and health consequences?

In morbid obesity, the excess fat mass can be distributed in different parts of the body : face, neck, arms, abdomen, thighs, buttocks, etc.

This excess weight can have a strong impact on the daily lives of patients, who have difficulty getting around, have health problems and develop low self-esteem, which can lead to depression.

According to the WHO, massive obesity exposes you to very serious complications, some of which can be fatal, such as:

  • By metabolic complications : insulin resistance, hypothyroidism, dyslipidemia (bad cholesterol), hyperuricemia (too much uric acid), type 2 diabetes;
  • By cardiovascular complications : cerebrovascular accident, myocardial infarction, arrhythmias, heart failure, arterial hypertension;
  • By pulmonary complications : respiratory arrhythmias, shortness of breath, sleep apnea, dyspnea (difficulty breathing), asthma;
  • By musculoskeletal complications : osteoarthritis, back pain, rheumatoid arthritis;
  • By digestive complications : hiatal hernia, reflux, lithiasis, steatosis which can lead to NASH (fatty liver, non-alcoholic cirrhosis);
  • By skin complications : stretch marks, yeast infections, excessive sweating;
  • An abnormality of the lymphatic system (lymphedema);
  • Disorders of the menstrual cycle in women;
  • An increased risk of gynecological cancers (endometrium, breast, ovaries), of the digestive tract (liver, gallbladder, large intestine) or prostate cancer

Pregnancy and morbid obesity

As mentioned above, obesity increases the risk of infertility. It is therefore recommended that obese women, who are consulting for infertility, try to lose weight before implementing assisted reproduction (PMA) protocols. Notice risk of complications during pregnancy decrease with weight loss, but persist during pregnancy and until delivery, for the baby and for the mother. Strict supervision is therefore essential.

What are the causes and risk factors?

Contrary to harmful prejudices, overeating and lack of exercise are not the main causes of obesity, whether moderate, severe or massive obesity. Many other factors come into play:

  • A genetic predisposition to weight gain. Remember that the risk of obesity increases by 50% if one parent is obese. It rises to 80% if both parents are obese.
  • Some genetic diseases, such as Prader-Willi syndrome or MCR4 deficiency, implicated in the development of obesity.
  • Some metabolic specificities can be taken into account: each individual has its own basic metabolism and spends calories differently at rest. Some metabolism burns more fat than others.
  • The endocrine dysfunctions and hormonal changes can also lead to significant weight gain. Puberty, pregnancy, but also polycystic ovary syndrome, growth hormone deficiency or hypothyroidism can weigh on the balance.

Social-environmental factors also promote obesity:

  • by anxiety or depressive disorders;
  • by psychological suffering (stress, hypersensitivity, trauma, aggression or emotional shock related to death, divorce, job loss, sexual violence, etc.);
  • by sleeping problems (or even night work);
  • the sedentary which promotes the reduction of energy consumption;
  • a unbalanced diet and/or poor quality (too much industrial food, too large portions, too high energy density), sometimes caused by the food marketing;
  • the taking certain medications (estrogen-progestogen contraceptive pill, antidiabetics, anticancer or HIV, antihypertensives and beta-blockers, antipsychotics, neuroleptics, anticonvulsants, menopausal replacement therapy, etc.) whose molecules either directly or by modifying the appetite more or less considerable weight;
  • a excessive use of alcohol
  • l’quit smoking alone
  • and so forth

Who to consult in case of massive obesity?

Obesity is not a disease that can only be fought in a corner: it requires: multidisciplinary care, adapted to each patient. However, the latter are often confronted with a long diagnostic errorwhich amplifies their guilt and increases the risk of ending up with massive obesity requiring surgery.

To avoid this, it is essential to overcome your shame or fears and consult your doctorwhich may initially refer to an endocrinologist and/or a nutritionist to look for a secondary cause or to emphasize the main mechanisms (hygienic-diet and/or psychological).

In a second step, the doctor will set up a program to promote weight loss. In all cases, psychological support is important for improving self-esteem and supporting motivation.

What support to get out of morbid obesity?

Treatment of morbid or massive obesity often begins with a visit to a primary care physician, nutritionist, or dietitian. Patients can be followed by liberal professionals or take advantage of multidisciplinary care (medical, nutritional, sports, psychological, etc.) in a obesity center (CSO). As of March 2, 2021, the Ministry of Solidarity and Health lists 37 specialized centers (source 2). By aftercare and rehabilitation structure (SSR) also offer to accommodate people with long-term severe, massive, or supramorbid obesity.

The goal is to stop weight gain and reduce waist circumference to reduce the risk of co-morbidities, and then to ensure gradual weight loss, to ensure its durability. This continues:

  • an Rbalancing food
  • the practice of a physical activity adapted to the health status of each patientyou
  • and psychological support.

Whatever the situation, the first treatment for morbid obesity is the diagnosis : We look for the cause of obesity to propose a targeted treatment. Depending on their profile, the patient may be asked to see a nutritionist, gynecologist, endocrinologist, sleep physician, etc. etiological treatment can thus be offered to any patient, in addition to general hygiene and dietary measures.

What drugs for morbid obesity?

No drug treatment can overcome obesity. The only approved drug is orlistat (Xenical®) which limits the intestinal absorption of lipids by approximately 30%. “Given its modest efficacy, side effects, especially digestion, and drug interactions (including with anticoagulants and oral contraceptives), prescribing orlistat is not recommended,” emphasizes the High Authority of Public Health, recalling that the prescribing orlistat drug treatments aimed at causing weight loss and not having a marketing authorization (issued by the Ansm) in the context of overweight or obesity is prohibited (source 3).

Otherwise, the misuse of “appetite suppressing” drugs is also strongly discouraged

When should you consider bariatric surgery?

Bariatric surgery is not an easy solution. She considered only as a last resort, when lifestyle and dietary measures are not enough to achieve a BMI that limits health risks. There are three intervention techniques, accessible under different circumstances:

  • the sleeve gastrectomywhich corresponds to a reduction of the stomach by vertical section, to accelerate the feeling of satiety;
  • the gastric bypass (bypass)which connects the stomach to a portion of the small intestine about a meter downstream, to reduce the surface area for food intake;
  • l’gastric bandplaced in the upper part of the stomach to slow the passage of food.

Second, the plastic and functional surgery (liposuction or lipectomy) may be helpful to eliminate disabling fat deposits, thereby improving mobility.

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