Introduction
The major concern of obesity is one of health and not appearance. The report of the Surgeon General of the U.S.A. (the equivalent of the Minister of Health in Lebanon) indicated that obesity is responsible for a large number of deaths per year and that the risk of death rises with increasing weight. Individuals who are obese have a 50 to 100% increased risk of premature death from all causes, compared to individuals with a healthy weight. Heart diseases, diabetes, cancer, breathing problems and arthritis are just few consequences of obesity and overweight. Pregnant women who are obese face an increased risk of death in both themselves and the baby in addition to many problems with labor and delivery. Add to all of the above, the psychological problems associated with obesity such as depression and the social problems such as self-isolation and also work-related issues such as job discrimination. The term obesity is defined in relationship to the height and weight of the individual person. When weight; expressed in kilograms, divided by the square of the height; expressed in meters, exceeds the value of 30, that person is considered obese. The above simple arithmetic operation defines an important value known as the Body Mass Index (BMI). According to international standards, an individual has a healthy weight when his/her BMI is between 19 and 25. A BMI of below 19 is considered an indication of “underweight”, a BMI of over 30 is an indication of “Obesity”, over 35 is an indication of “morbid obesity” and over 40 indicates extreme obesity.
Classification Underweight Healthy weight Overweight Obese Extremely obese
BMI (kg/m2) < 19 19-25 25 < < 30 30< < 40 > 40
Limitations of BMI
• BMI does not distinguish between weight associated with muscle and with fat.
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• BMI does not take into account the distribution of body fat, which also affects health risks e.g. central obesity is associated with a greater health risk than when fat collects around the hips & thighs. More important than the definitions of BMI classifications are the statistics associated with those classifications. If, for instance, the vast majority of a given population fell within the 19 to 25 range of BMI, then there would be no need to address this particular issue. Thus, it is important to describe the distribution of the population in terms of BMI values. Unfortunately, there are not any officially published statistics regarding the state of obesity in Lebanon. However, the statistics extracted from MedNet Liban database could very well be used to profile the BMI’s of the Lebanese population at large.
Methodology
Risk carriers adhering to the MedNet Liban system gather information related to the risks that have been shown to have a statistically significant impact on the cost of health insurance. One such piece of information relates to the Body Mass Index of the individual insured person. The gathered information is, in many cases, subject to scrutiny since the source of information is not a primary source. However, when an individual insured is admitted to a hospital facility for any reason, correct information regarding weight and height is recorded and his/her record gets updated. In coming up with the statistics shown in this bulletin, we relied on updated records of individual patients plus records of insureds who filled out the weight and height cells on their insurance applications. We, then, excluded all records that contain height and weight values outside reasonable ranges. The end result is a data set of 15,259 individuals over a four-year period of time (2004 to 2007). Children below the age of 20 were excluded from the study.
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Profile of Individuals in the study
a) More than half of the studied individuals fall within the normal range (19 to 25). Those who are overweight constitute around 30% of all individuals. Around 7% of all individuals are considered obese persons and less than 5% are considered underweight.
Table 1 Breakdown by BMI Range
Category Underweight Healthy weight Overweight Percent 4.20% 58.90% 29.80%
Obese/Very Obese 7.20% Source: MedNet Liban Data Base as at January 22, 2008
Percent
Graph 1 Percentage of Individuals by Body Mass Index Range 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 4% Underweight Normal
59% 30% 7% Overweight Obese/Very Obese BMI
Source: MedNet Liban Data Base as at January 22, 2008
b) Males are overweight or obese more than females.
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The percentage of males who are overweight or obese is around 59%, while that of females is around 21%. Obese or very obese males outnumber their female counterparts by a ratio of 3 to 1 (See Table 2 + Graph 2). A t-test procedure shows that the mean difference between the BMI values of males and females is 3.24 points; which is statistically significant at the .0001 level (t-value= 191.74, p<0.0001).
Table 2 Body Mass Index by Gender
BMI Range Underweight Normal Overweight
Males < 41% 47%
Females 7% 72% 17%
Obese / Very Obese 11% 4% Source: MedNet Liban Data Base as at January 22, 2008
Percent
Graph 2 BMI by Gender
80% 70% 60% 50% 40% 30% 20% 10% 0%
F M F M Underweight Normal F Overweight M F Obese / Very Obese M
BM I
Source: MedNet Liban Data Base as at January 22, 2008
c) Obesity increases with age.
Most obese/ very obese individuals are between the ages of 45 and 54 years. More than half of those over the age of 55 are overweight, obese or very obese. Most individuals below the age of 44 years have healthy weights. Those two statistics are an indication that obesity increases as we age (see Table 3 and Graph 3). A correlation analysis shows that BMI is positively correlated with age (r= 0.2487, p<0.0001).
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Table 3 Body Mass Index by Age
Age 20-34 35-44 45-54 55-64 65-74 75 or over Underweight 8.20% 3.81% 1.88% 0.94% 0.67% 0.56% Healthy 70.34% 60.09% 51.72% 47.52% 45.23% 45.68% Overweight 17.45% 29.39% 35.99% 41.41% 44.27% 45.13% Obese / Very Obese 4.01% 6.71% 10.42% 10.13% 9.83% 8.64%
Source: MedNet Liban Data Base as at January 22, 2008
Percent
Graph 3 BMI by Age
80% 70% 60% 50% 40% 30% 20% 10% 0% 20-34 35-44 45-54 55-64 65-74 75 or over
Underweight Healthy Overweight Obese / Very Obese
Age
Source: MedNet Liban Data Base as at January 22, 2008
Comparison with International Statistics on Obesity
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The above mentioned statistics were derived from the population of administered individuals by MedNet Liban. Another study published by the World Health Organization (WHO)1 in 1997 and based on the 1995-1996 population and Housing Survey shows that 14.3% of males are obese or very obese vs. 18.8% of females. MedNet Liban data revealed lower percentages (14% for males and 4% for females). Considering all individuals with a BMI of 25 or more, our data shows around 37% compared to 53% reported by the WHO study. A possible explanation for the reported differences in percentages could be due to the difference in sample sizes between the two studies and/or to the difference in the profiles of the studied samples. That remains to be investigated. Statistics from other countries are shown in Table 4 and Graph 4, following. Lebanon’s female population has the lowest percentage of obese (4%) and that could be due to the tendency of Lebanese females to hide their real weights and heights. Lebanese males compare to those in Belgium, Denmark, Portugal and Spain for example and have a lower percentage of obese than Cyprus, Germany, Greece and the USA for example.
Table 4
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World Health Organization. Prevalence and covariates of obesity in Lebanon: findings from the first epidemiological study, 1997 (InfoBase Ref. # 101901a1)
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Percent of population with a BMI of 30 or more Country Austria Belgium Cyprus Czech Republic Denmark England Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lebanon (MedNet) Lebanon (WHO) Lithuania Luxembourg Malta Netherlands Poland Portugal Slovakia Slovenia Spain Sweden USA Males 10.0 14.0 26.6 24.7 12.5 22.2 9.9 19.8 11.4 22.5 27.5 21.0 20.1 9.5 9.5 14.0 14.3 11.4 15.3 22.0 10.4 10.3 13.9 19.3 16.5 13.4 10.0 28.0 Females 14.0 13.0 23.7 26.2 11.3 23.0 15.3 19.4 11.3 23.3 38.1 21.2 15.9 9.9 17.4 4.0 18.8 18.3 13.9 35.0 10.1 12.4 26.1 18.9 13.8 15.8 11.9 34.0
Sources:
Health, United States, 2004 (published by the USDOH, CDC). 1999-2002 data International Association for the Study of Obesity Mednet Liban, 2007
World Health Organization. 1997
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Graph 4 Comparative Statistics: Lebanon vs. International data
BMI >=30
50.0 40.0
percent
Males
Females
30.0 20.0 10.0
Denmark Lebanon (MedNet) Lebanon (WHO) Czech Republic Germany Belgium England Finland Greece Ireland Malta Luxembourg Hungary Netherlands Slovakia Cyprus Latvia Lithuania Austria Portugal Estonia France Poland Slovenia Spain Sweden USA Italy
0.0
country
Consequences of obesity A. Health consequences
The health consequences of obesity are numerous and vary with risks the obese person has. Overall risk must take into account the potential presence of other risk factors. Some diseases associated with obesity place patients at a high absolute risk for subsequent mortality; these will require proactive management. Other conditions associated with obesity are less severe but still require treatment. The effects of excess weight on morbidity and mortality have been mentioned in the
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literature for over two thousand years. Hippocrates mentioned that naturally fat people are subject to sudden death more than the lean. Obesity is a chronic disease just as hypertension. The cause of obesity is an imbalance between the energy ingested in food and the energy expended. Excess energy stored in fat cells causes those cells to enlarge thus leading to clinical problems such as type 2 diabetes, coronary heart disease, sleep apnea and some forms of cancer. Osteoarthritis, gallstones, urinary stress incontinence, and gynecological abnormalities increase risk but are not generally life-threatening (please refer to Figure 1 for a visual listing of those diseases). Risk factors that also confer high risk include hypertension, cigarette smoking, high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, impaired fasting glucose, family history of early cardiovascular disease, and age (male ≥45 years, female ≥55 years Figure 1 Diseases Associated with Obesity
Stroke Respiratory disease Heart disease Gall bladder disease Cardiovascular risk factors Diabetes: three fold relative risk Osteoarthritis Cancer
Hormonal abnormalities
Hyperuricaemia and gout
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The following will address the prevalence of the above mentioned diseases among the insured lives administered by MedNet Liban and will shed some light on international findings.
Diabetes
Type 2 diabetes mellitus has been found to be strongly associated with overweight in both women and men2,3. The risk of type 2 diabetes mellitus increases with the concentration and duration of body fat4. MedNet Liban data shows that the risk of diabetes increases with the value of BMI. As shown in Graph 5, the prevalence of diabetes is three to four times more in obese persons than in those with healthy weights. Graph 5
Diabetes and BMI
14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Underweight
Source: MedNet Liban data, 2004 to 2007
Healthy weight
Overweight
Obese
Very Obese
2
Golditz GA, Willett WC, Rotnitzky A, Manson JE 1995. Weight gain as a risk factor for clinical diabetes in women. Ann Intern Med 122:481-486 3 Chan JM et al. 1994 Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 17:961-969 4 Bray GA, Medical Consequences of Obesity 2004. The Journal of Clinical Endocrinology & Metabolism 89(6):2583-2589
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Lipid metabolism
Known as abnormal levels of blood or tissue lipids, it increases rapidly for overweight and obese persons; causing disorders such as Hypercholesterolemia (an abnormally high concentration of cholesterol in the blood) and Hypertriglyceridemia (a condition characterized by an elevated concentration of triglycerides in the blood). Graph 6 shows that the risk of developing disorders of lipoid metabolism is 2 to 4 times greater for obese persons than for those with a healthy weight. Graph 6
BMI and Lipoid Metabolism
25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Underweight Healthy weight Overweight Obese Very Obese
Hypertension
The risk of hypertension increases as BMI increases. In a study conducted on more than 40,000 nurses between the ages of 38 and 63 years, the risk of hypertension over a 4-year follow-up increased among overweight and obese nurses5 relative to those with normal weights. Our data shows that the relative risk of hypertension among obese persons is more than 5 times that among “healthy weight” persons (Graph 7).
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A scherio etal., 1996. Prospective study of nutritional factors, blood pressure, and hypertension among U.S. women. Hypertension: 27:1065-72.
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Graph 7
Hypertension
4 .0 % 00 3 .0 % 50 3 .0 % 00 2 .0 % 50 2 .0 % 00 1.0 % 50 1.0 % 00 50 .0 % 00 .0 % Underweight Healthy weight Overweight Obese Very Obese
Sleep Disorder
Also known as “sleep apnea” is a condition that causes breathing problems during sleep, high blood pressure, memory problems, impotence and headaches. Most people with sleep apnea have a BMI greater than 30. Obesity is a risk factor for sleep apnea and has been shown to be related to its severity6. The relative risk of developing sleep disorders among the obese persons is more than six times than among those with healthy weights (Graph 8).
Graph 8
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Millman et al, 1995. Body fat distribution and sleep apnea severity in women. Chest, 107: 362-366.
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Sleep Disorder
3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Underweight Healthy weight Overweight Obese Very Obese
Osteoarthritis
Osteoarthritis usually affects joints in the knees and hips that support the body weight and in the joints with the most movement. Factors that increase the risk for developing Osteoarthritis include advanced age, excess weight, heredity, joint injury and sex (being female). An increase in weight is associated with an increased pain in the weight-bearing joints7. MedNet Liban data shows the relative risk of developing Osteoarthritis is about three folds for obese persons than for healthy weight persons (Graph 9).
Graph 9
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Cicuttini et al, 1996. The association of obesity with osteoarthritis of the hand and knee in women, a twin study. J. Rheumatol, 23: 1221-1226.
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Os te o arthritis
3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Unde rw e ight
He althy w e ight
Ove rw e ight
Ob e s e
Ve ry Ob e s e
Cardiac problems
As Shown in Graph 10, Overweight persons have a risk of developing cardiac problems 2.5 times greater than that of persons with healthy weights. That risk increases to 3 times for obese/very obese persons. In the nurses’ study, the risk for U.S. women developing heart diseases is increased 3.3-fold among obese women.
Graph 10
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Cardiac problems
50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Underweight Healthy weight Overweight Obese Very Obese
Gout
Gout is a condition that causes pain, inflammation and swelling due to accumulation of uric acid crystals in one, or more, of the joints. It usually affects the big toe, but can develop in any joint in the body. Gout affects approximately one in 200 adults, most commonly men between 30-60 years of age. There are some factors which can increase chances of developing gout; among those is obesity. As shown in Graph 11, obese persons are four times as likely to develop gout as those with health weights.
Graph 11
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Gout
0.20% 0.1 8% 0.1 6% 0.1 4% 0.1 2% 0.1 0% 0.08% 0.06% 0.04% 0.02% 0.00% Underw eight
Healthy w eight
O eight verw
O bese
B.
Cost of Obesity
Although not as explicit as medical consequences, the economic burden of overweight and obesity can be direct (health care related cost) or indirect (lost wages due to illness or disability and lost future earnings due to premature death). The estimations of direct costs of obesity range from as low as 2% of national health care costs to as high as 6%8. The amount of in patient care costs for obese adults is estimated to be about 40% higher than for normal weight persons9. The cost to business of obesity - related costs include lost productivity and increased absenteeism. Obese employees are nearly 75% more likely to have high rates of absenteeism than normal weight employees10. The assessment of indirect costs of obesity is beyond the scope of the present study. The direct medical costs are estimated from the study sample. The following findings are worth mentioning:
8 9
Wolf AM, Colditz GA. Obesity Research 1998 Thompson D, Brown JB, Nichols GA, Elmer PJ, Oster G. Body mass index and future healthcare costs: A retrospective cohort study. Obes Res 2001:9:210-218 10 Tucker LA, Friedman GM. Obesity and absenteeism: an epidemiologic study of 10,825 employed adults. Am J Health Promot 1998; 12(3):202-7.
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1. 2. 3.
The average annual cost per capita for in-patients is about 22% higher among obese persons than among healthy weight persons(Prob.<0.05) Obese persons are admitted 15% more often to hospitals than those with healthy weights. When obese persons are admitted to hospitals, they tend to stay longer than others by 1.2 days (P<0.05) and the average cost of their stay at hospitals is higher by about 7%.
The above results could be used to estimate the cost of obesity at the national level. Assuming that the percentage of obese adults in Lebanon was similar to that found from our data, It would be, then, estimated that the cost of obesity in Lebanon is around 5.6% of the total national health care cost or slightly below 1% of its GDP. In addition to medical and cost consequences, obesity has psychological and social consequences. Persons who are obese are more likely to suffer from depression and low self esteem than normal weight individuals11. Those individuals face increased risks for suicide, social isolation, and impaired job performance. Moreover, obesity can affect the quality of life by limiting mobility and decreasing physical activities. Other risks include social, academic and job discrimination12.
Guidelines to reduce risks associated with Obesity
Overweight and obesity, as well as their related diseases, are largely preventable. Effective weight management for individuals at risk of developing obesity involves a range of long-term strategies including prevention, weight maintenance, management of co-morbidities and weight loss. Some of those strategies include:
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U.S Department of Health and Human Services, Public Heath Service, office of the Surgeon General,2001. 12 Devlin MJ etal.2000.What mental health professionals need to know. AmJ Psychiatry,157 (6):854-866.
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1. Promoting healthy behaviors to encourage, motivate and enable individuals to lose weight by limiting their intakes of fats and eating more fruits and vegetables.
2. Engaging in moderate physical activities on a daily basis, when possible 3. Reducing work activities that require long hours of sitting still.
Recent studies have shown that reducing weight can significantly reduce blood pressure, improve abnormal lipid levels and reduce the risk of type 2 diabetes13. Medical intervention to reduce weight requires a long term program to achieve the desired results and maintain them. Surgical intervention is costly and may be painful. It is usually reserved for specific candidates. Surgical procedures such as Gastric banding (A), Gastric bypass (B), Gastric stapling, and Gastric balloon are available. Results may be encouraging but necessitate close monitoring of patients and continuous nutritional evaluation of their vitamins and minerals daily requirements.
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Sjostrom CD et al. 1997. Relationships between changes in body composition and changes in cardiovascular risk factors: the SOS Intervention Study, Swedish Obese Subjects. Obesity Res 5:519-530.
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Treatment of obesity
The goal of obesity treatment is to achieve and maintain a healthier weight. Just a 5 percent to 10 percent weight loss can bring health improvements. That means that if you weigh 100 Kgs and are obese by BMI standards, you would need to lose about 5 to 10 Kgs. You don't have to stop there, but it's a place to start. Slow and steady weight loss of up to 1 Kg a week is considered the safest way to lose weight and the best way to keep it off. Achieving a healthy weight is usually done through dietary changes, increased activity and behavior modification. Depending on your situation, your doctor may suggest prescription medication or weight-loss surgery to supplement these efforts.
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Dietary changes:
Adopting a new eating style that promotes weight loss must include lowering the total calorie intake. One way to lower the calorie intake is by eating more plant-based foods — fruits, vegetables and whole grains. Crash diets to reduce calories aren't recommended because they can cut so many calories and nutrients that they lead to other health problems, such as vitamin deficiencies. Fasting isn't the answer, either. Most of the weight lost is from water, and it's not good for the body to go without food for extended periods. Very low calorie liquid diets are sometimes prescribed as an intervention for seriously obese people. These mainly liquid diets, such as Medifast or Optifast, provide about 800 calories a day — most adults consume roughly 2,000 to 2,500 calories a day. While people are usually able to lose weight on these very low calorie diets, most people regain the weight just as quickly when they stop following these diets.
Increased physical activity:
The goal of exercise for weight loss is to burn more calories, although exercise offers many other benefits as well. How many calories are burnt depends on the frequency, duration and intensity of the activities. One of the best ways to lose body fat is through steady aerobic exercise — such as walking — for more than 30 minutes most days of the week.
Behavior modification:
To lose weight and keep it off, changes in lifestyle have to be made. But there's more to changing a lifestyle. A behavior modification program — led by a psychologist, therapist or other trained professional exploring your current eating and exercise habits gives a place to start when changing behaviors. Have a plan: to work out a strategy that will gradually change habits and attitudes. Set realistic goals: Such as exercising regularly, or outcome goals, such as losing 10 Kgs and make sure process goals are realistic. Avoid food triggers: Eat when hungry not when the clock says it's time to eat. Keep a record: Keep a food and activity diary to reinforce good habits and discover any behavior that need to improve on them.
Prescription weight-loss medication:
It’s best to lose weight through a healthy diet and regular exercise. But if you're among those who could not do it, prescription weight-loss drugs may be able to help. And your doctor may consider you a candidate for medication
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treatment if over weight is producing medical problems for you as hypertension, diabetes and sleep apnea and your BMI is above 30.
Bariatric surgery :weight-loss surgery):
Weight-loss surgery may be considered if: 1) Your body mass index (BMI) is 40 or higher 2) Your BMI is 35 to 39.9, and you have a serious weight-related health problem such as diabetes or high blood pressure and sleep apnea. 3) Long term medication is not an option by your doctor. The top surgical procedures recognized are: Gastric bypass Gastric banding Gastric stapling Gastric balloon Jaw wiring
Gastric bypass surgery: changes the anatomy of digestive system to limit the amount of food you can eat and
digest, is the favored weight-loss surgery in the US and around the world. The surgeon creates a small pouch at the top of the stomach. The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food and liquid flow directly from the pouch into this part of the intestine, bypassing most of the stomach. The stomach continues to make digestive juices to help break down food. So the portion of the intestines still attached to the stomach is reattached farther down. This allows the digestive juices to flow to the small intestine. Weight loss is achieved by restricting the amount of food that the stomach can hold and to a lesser extent by reducing the amount of calories that are absorbed.
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Weight-loss surgery does have side effects, however. Complications such as pneumonia, blood clots and infection can occur with any type of surgery. Rapid weight loss can result in gallstones; a hernia or weakness, which may require surgery to correct, may develop at the site of the incision. Gastric bypass can also cause dumping syndrome, a condition in which stomach contents move too quickly through the small intestine, causing nausea, vomiting, diarrhea, dizziness and sweating. Adjustable gastric banding is a surgical operation intended for weight loss in obese people with a body mass index of at least 35. It is best done laparoscopically under general anesthesia. Usually, it takes about one hour. It consists in inserting a hollow plastic band around the stomach. This band is connected by a tubulure to a small box implanted in the abdominal wall. You can constrict the band by filling the box with physiologic serum. Band constriction has a restrictive effect on gastric filling capacity and forces the patient to lower his food intake and it can be modulated by emptying or filling the box with a percutaneous needle. This operation is practised only if the patient is highly motivated for changing his/her eating habits and after a psychiatric assessment. Like any other surgical procedures, it has risks and side-effects: failure, infections, gastric perforation, and intragastric migration.
Nutrient Absorption
Some risks associated with gastric banding include band erosion and slippage, swallowing problems and the risk of injuries to stomach and nearby organs during surgery.
Gastric stapling
Gastric stapling surgery, also called gastric banding surgery, is a type of bariatric surgery (weight loss surgery) procedure performed to limit the amount of food a person can eat. Bariatric surgery is the only option today that effectively treats morbid obesity in people for whom more conservative measures such as diet, exercise, and medication have failed. In gastric banding surgery, no part of the stomach is removed and the digestive process remains intact. Either staples or a band are used to separate the stomach into two parts, one of which is a very small pouch that can hold about one ounce of food. The food from this “new” stomach empties into the closed-off portion of the stomach and then resumes the normal digestive process. Over time, the pouch can expand to hold two to three ounces of food. Because the size of the stomach is reduced so dramatically, this type of procedure is referred to as a restrictive procedure.
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Gastric balloon:
The Gastric Balloon is a ball that is placed in the stomach to help the person feel full and therefore reduce the food intake. This solution is suggested to avoid the complications of pharmaceutical diet and weight-loss pills and drugs. The gastric balloon has a number of benefits: • Feeling full after eating normally • Weight loss is more effective than dieting alone The 500cc ball is inserted into stomach through the mouth, and then later filled with sterile saline solution. This is usually performed under local anesthetic and sedation. This means that recovery is normally very swift.
Jaw Wiring: Jaw wiring is not a bariatric operation. In fact, it is not even a surgical procedure. But it is a
possible treatment for obesity and compulsive eating. Jaw wiring is performed in a dental chair, in less than 60 minutes, and is painless thus requiring no anesthesia. The goal of this orthodontic method of weight control is to prevent the consumption of solid food, thus causing a drastic reduction in calorie intake. Once the required weight loss is achieved, the wiring is removed and the patient is free to eat normally. Unfortunately the success rate of jaw-wiring
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as a long term method of achieving a normal weight is very low. In addition, the fixed position of the teeth and jaw may make speech and movement difficult, which patients might find distressing.
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