Obesity And Diabetic Surgery

Obesity And Diabetic Surgery

What is Obesity?

Evidently, obesity is considered as a disease that manifests itself once the intake of energy (calorie) through foods is more than the energy spent, and the excess energy is stored as fat within the body (20% or more), and adversely affects the quality and length of life. 15 to 18% of the body weight of adult men and 20 to 25% of adult women is composed of fatty tissues. Obesity occurs when this percent goes beyond 25% in men and 30% in women.


How to measure obesity

Based on the obesity classification of the World Health Organization, the Body Mass Index (BMI) is commonly put to use to tell whether a person is obese or not. BMI is a value derived from dividing one's body weight (kg) by the square of his/her height (meter). BMI is adopted to estimate one's body weight in accordance with his/her height, without providing insight into the body's fat distribution.  The global classification of obesity released by the WHO is presented in the Chart 1.


Chart 1:  Classification of weakness, overweight and obesity by BMI for adults




Source: World Health Organization Obesity and Overweight Fact Sheet No:311,Geneva, WHO.



Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.



In the recent years, researchers have been focused on the location and distribution of the fat rather than the total amount of fat in the body. This is because the location and distribution of fat in the body are associated with morbidity and mortality of diseases. Regional fat distribution genetically differs between men and women. For android-type (male-type) obesity, fat is formed in upper parts of the body (apple-type) namely waist, epigastrium, chest and under skin. For gynoid-type (female-type) obesity, fat is formed around one body's lower parts (pear-type), namely hips, thighs, legs and under skin.

According to the WHO, the waist/hip rate greater than 0.85 in women and greater than 1.0 in men is called android-type obesity. While the waist/hip rate is adopted to determine such distribution, the waist circumference serves as a major and practical indicator for the fat distribution in the abdominal region and the deterioration in health. Formation of fat around abdomen and internal organs causes insulin resistance. Insulin resistance is a major factor that leads to association with type 2 Diabetes, hypertension, dyslipidemia and coronary artery diseases caused by obesity. A waist circumference of 94 cm or above in men and 80 cm or above in women is associated with a disease risk. The disease risk by waist circumference for adults is presented in the Chart 2.


Chart 2. Disease risk associated with obesity for adults and waist circumference measurements




While there is no specific classification for children and adolescents unlike adults, a variety of perspectives are offered for the description of overweight and obesity. One of the most common methods is the use of percentile on individual and social levels and/or z score values. However, World Health Organization released growth standards in 2006 for children aged 0 to 5, and growth references in 2007 for children aged 5 to 19, and for adolescents. Thus, BMI values by age are now adopted for the classification of overweight and obesity for children and adolescents.


The charts published by WHO for the classification of overweight and obesity concerning children and adolescents are presented in the Annex-2 and the Annex-3. According to these charts, overweight for children under the age of 5 is described as >+2 SD or >97 percentile while obesity is considered to be >+3 SD or >99 percentile. Overweight for children aged 5 to 19 is described as >+1 SD or >85 percentile while obesity is considered to be >+2 SD or >97 percentile.


What are the causes of obesity?

Although obesity-causing factors cannot be described to the full extent, excess nutrition and malnutrition and physical inactivity are billed as the major causes of obesity. In addition, obesity can be caused by many interrelated factors such as genetic, environmental, neurological, physiological, biochemical, socio-cultural and psychological factors. As the global increase in childhood obesity is too prevalent to be solely based on genetic mutations, it is considered that environmental factors play a role in obesity.


Main risk factors leading to obesity:

* Excess nutrition and malnutrition habits

* Insufficient physical activity

* Age

* Gender

* Educational background

* Socio-cultural factors

* Income status

* Hormonal and metabolic factors

* Genetic factors

* Psychological problems

* Extremely low-energy diet on a frequent basis

* Smoking - alcohol consumption

* Certain medicines (anti-depressants etc.)

* Number of birth and the length between births


Incidence of Obesity in Turkey

One of the factors to be taken into consideration in the progression of obesity is the way of nutrition at the early stage of life. Studies report that the incidence of obesity is lower in breastfed children, and that the length of breastfeeding and the type, amount and start of complementary food intake play a role in obesity.


Released by the WHO and UNICEF, a variety of documents indicate that 6 month-long breastfeeding, persistence of breastfeeding after the month 6, starting complementary foods in proper quality and amount, and persistence of breastfeeding for at least 2 years are likely to reduce the risk of obesity and chronic diseases in the short and long terms.


Healthcare Problems Caused by Obesity

Obesity causes many healthcare problems due to its adverse effects on body systems (endocrine system, cardiovascular system, respiratory system, gastrointestinal system, skin, genitourinary system, musculoskeletal system) and psycho-social state. Obesity is known to be associated with various diseases, and its effect to enhance morbidity and mortality is well-documented. Overweight causes 1 million deaths per year and 12 million life years of morbidity in Europe.


Healthcare problems/risk factors caused by obesity:

Insulin resistance - Hyperinsulinemia

Type 2 Diabetes Mellitus 


Coronary artery disease

Hyperlipidemia - Hypertriglyceridemia

Metabolic syndrome

Gall bladder diseases

Certain types of cancer (gall bladder, endometrium, ovarian and breast cancer for women, colon and prostate cancer for men)



Sleep apnea

Hepatic steatosis


Respiratory distress

Pregnancy complications

Menstrual irregularities

Excessive body hair

Increasing risks of operation

Mental problems (anorexia nervosa (eating disorder) or bulimia (binge eating followed by purging), binge eating, night eating syndrome or attempt to achieve psychological satisfaction by eating something much more).

Social disharmony

Skin infections and fungal infections in the groin and feet due to the excessive subcutaneous fat tissues as a result of weight loss and gain on an extremely frequent basis.

Musculoskeletal problems


Obesity in the World

Obesity is a major public health problem on a global scale. Obesity exponentially increases day by day in both developed and developing countries. Conducted by WHO in 6 locations of Asia, Africa and Europe over 12 years, MONICA study reports that the prevalence of obesity has increased by 10 to 30% in 10 years.

According a study reported by NHANES (USA - The National Health and Nutrition Examination Survey) commissioned by the Centers for Disease Control and Prevention (CDC) in the USA where obesity is more common, the prevalence of obesity (BMI > 30) corresponded to 31.1% in men, 33.2% in women between 2003 and 2004, and 33.3% in men and 35.3% in women between 2005 and 2006.

The prevalence of overweight in European adults ranges from 32 to 79% in men and 28 to 78% in women. Overweight is most common in Albania, Bosnia-Herzegovina and the United Kingdom (Scotland). Turkmenistan and Uzbekistan are the two countries with the lowest prevalence.  In those countries, prevalence of obesity ranges from 5 to 23% in men, and 7 to 36% in women. Overall obesity status reported by the WHO for Europe is presented by the following table.




Source: The Challenge Of Obesity in The WHO European Region And The Strategies For Response, Ed. Francesco Branca, Haik Nikogosian and Tim Lobstein, WHO, Denmark, 2007.


According to the WHO figures, overweight and obesity account for 80% of Type-2 Diabetes, 35% of ischemic heart diseases and 55% of hypertension cases, and cause more than 1 million deaths per year. In case of no measure taken and given the increasing prevalence of obesity at a pace similar to in 1990s, it is estimated that 150 million adults and 15 million children and adolescents are going to be obese in Europe by the year 2010.

Obesity tendency is at an alarming level for children and adolescents in particular. Childhood obesity keeps rising every year. Today, it is reported that the prevalence of childhood obesity is 10 times more than what it was in 1970s.

Conducted by CDC in the USA over the prevalence of obesity in children and adolescents, NHANES study reports that 16.3% of children and adolescents aged 2 to 19 are obese (2003 and 2006) (>95 percentile, according to BMI growth trends by age for the year 2000).

The prevalence of overweight for school-age children in both genders is highest in Spain (35% for the age of 6 to 9) and Portugal (32% for the age of 7 to 9) while it is the lowest in Slovakia (15% for the age of 7 to 9), France (18% for the age of 7 to 9), Switzerland (18% for the age of 6 to 9) and Iceland (18% for the age of 9).

There are two major international studies where some reliable data were gathered with regard to the measurement of height and body weight. One of them is called "The Pro Children" conducted in Europe in 2003 including 11-year old children in 9 countries. This study reports that overweight is more prevalent in boys (17%) than in girls (14%). Another major survey is “Health Behavior in School-Aged Children Survey (HBSC).”  Conducted in 41 countries for children aged 11, 13 and 15, the study suggests that 24% of girls aged 13 and 33% of boys aged 13 are overweight (2001-2002), while 31% of girls aged 15 and 28% of boys aged 15 are overweight. The prevalence of obesity corresponds to 5% for girls and 9% for boys aged 13 and 15.

The WHO European Regional Office points out that overweight is a case for 30 to 80% of the adults in Europe while nearly 20% of the children and adolescents are overweight, and one-third of those are obese.

The fact that obesity has become more and more widespread and turned into a public health problem has paved the way for actions to be taken all around the world to fight against obesity.


Obesity in Turkey

Just like it is the case in other countries, Turkey has seen the prevalence of obesity increasing every day.

According to the preliminary report of Nutrition and Healthcare Survey - 2010 in Turkey" commissioned by the Ministry of Health, it is reported that the prevalence of obesity in Turkey corresponds to

20.5% in men

41.0% in women

and 30.3% in total


It is 34.6% for overweight, 64.9% for overweight and obesity, and 2.9% for excessive obesity.


Frequency of obesity by geographic regions

NUTS1 Region

İstanbul 33.0

Western Marmara 30.7

Eastern Marmara 30.6

Aegean 28.0

Mediterranean 30.1

Western Anatolia 33.0

Central Anatolia 32.9

Western Black Sea 31.3

Eastern Black Sea 33.1

Northeastern Anatolia 23.5

Central-Eastern Anatolia 20.5

Southeastern Anatolia 22.9


In Children and Adolescents:

Commissioned by the Ministry of Health, the Department of Nutrition and Dietetics of the Faculty of Health Sciences of Hacettepe University, and Ankara Numune Training & Research Hospital carried out a survey called "Nutrition and Health Survey - 2010 Turkey" and released a preliminary report that suggests the prevalence of obesity is

8.5% for the age 0 to 5 (10.1% for boys, 6.8% for girls)

and 8.2% for the age 6 to 18 (9.1% for boys, 7.3% for girls)


Prevalence of overweight accounts for 17.9% for the age 0 to 5 while it is 26.4% for obesity.

Prevalence of overweight accounts for 14.3% for the age 6 to 18 while it is 22.5% for overweight and obesity combined.

According to the Survey (2009) on "the Project of Monitoring Growth for School-Age Children in Turkey" run by the Ministry of Health, the Ministry of National Education and the Department of Nutrition and Dietetics of the Faculty of Health Sciences of Hacettepe University, the prevalence of overweight and obesity in Turkey is as follows






Calculation of Body Mass Index

How to calculate the body mass index?

The body mass index is derived from dividing one's body weight by the square of height. The ultimate value, the body mass index, is evaluated within the following ranges.


0 to 18.4: Slim

This shows that your weight is not in line with your height and that you are thin. Being slim is an undesirable state that poses a risk for some diseases. In order to make sure your weight fits for your height, you need to keep a sufficient and balanced diet and make more efforts to improve your nutritional habits.


18.5 to 24.9: Normal

This shows that your weight is in line with your height. Make sure that you keep your weight by keeping a sufficient and balanced diet and regularly doing physical exercises.

25.0 to 29.9: Overweight

This means that your body weight is excess for your height. Unless necessary precautions are taken, overweight leads to obesity, a risk factor for many diseases.


30.0 to 34.9: Obese - Class I

This means that your body weight is excess for your height and that you are fat. Being fat is a risk factor for chronic diseases such as cardiovascular diseases, diabetes, hypertension etc.  It is very important for you to seek medical help and get back to your normal weight by losing weight under the supervision of a physician/dietitian. Please seek medical aid.


35.0 to 44.9: Obese - Class II

This means that your body weight is excess for your height and that you are fat. Being fat is a risk factor for chronic diseases such as cardiovascular diseases, diabetes, hypertension etc. It is very important for you to seek medical help and get back to your normal weight by losing weight under the supervision of a physician/dietitian. Please seek medical aid.


45.0 and Above: Severe Obese - Class III 

This means that your body weight is excess for your height and that you are fat. Being fat is a risk factor for chronic diseases such as cardiovascular diseases, diabetes, hypertension etc. It is critical for you to seek medical help and get back to your normal weight by losing weight under the supervision of a physician/dietitian. Please seek medical aid.


Gastric Balloon

Renders volume in the stomach and creates a sense of satiety.

It is still quite popular.

There are types filled with liquid or air. In addition, there are some types with adjustable volume.

Liquid-containing ones are inflated with 400 to 800 mL of physiological saline solution and reconstituted methylene blue dye.

Depending on the type of the gastric balloon, it can remain in the stomach for no longer than 6 months to 1 year. Long-term administration may lead to complications such as infection, burst of the balloon,

and gastric ulcers. It can be administered repeatedly for 2 or 3 times.

A gastric balloon administered in company with a diet is likely to provide favorable outcomes in conscious and strong-willed patients.

However, its long-term consequences are controversial. Gastric balloon also serves as preliminary preparation for obesity surgery

in patients with super morbid obesity.

It is administered through sedation by anesthesia.

Patients may experience nausea, vomiting and pain such as gastric cramps, most of which are temporary, following the procedure.

A gastric balloon might come out earlier because of the aforementioned causes even if it is quite rare.


Sleeve Gastrectomy

Sleeve gastrectomy is the most commonly performed restrictive procedure in obesity surgery.

Sleeve gastrectomy is solely about making stomach smaller and it does not change the course of food flow. Therefore, absorption problems is less common

and the need for vitamin and mineral supplements is less.

It provides a sufficient treatment for most of the patients with obesity and metabolic disorder.

Longer side of the stomach is vertically incised all along and removed using laparoscopic method, forming a new stomach in a tube shape with a volume of 150 to 200 cc

. Making the volume of the stomach smaller in this way limits the food intake.

And the sense of fullness caused by the removal of the glands that excrete appetizing hormones (ghrelin) in the fundus of the stomach makes the person lose

appetite and consequently lose weight.

Among the potential complications of such an operation, as it is the case for all surgical procedures, are bleeding, organ injury,

embolism and anesthetic complications. One complication particular to this type of surgery is the leakage from the stomach line ceased and stitched.

Such complications are usually eliminated by non-operative procedures while they might require a second operation in rare cases.

The rate of mortality due to surgery is as low as 0.2%.

70 to 80% of the excess weight is lost in the first year to 1 and a half years following sleeve gastrectomy. The outcomes of many studies are reportedly similar to the outcomes of gastric bypass surgery


The weight regain rate is 15% in the long term, while the chance of returning to morbid obesity is around 2%.

In such cases, gastric bypass or duodenal switch can be options to resort to.


Gastric Bypass Surgery

Gastric bypass is an oler type of operation compared to other surgical methods for obesity.

The long-term consequences of such an operation as the most performed obesity operation

are well known and still quite popular for obesity and metabolic diseases (Diabetes, Hypertension, Hyperlipidemia etc.). .


Surgery is performed in a 2-stage laparoscopic (closed) procedure. At the first stage, a small stomach pouch is formed

as large as 30 to 40 mm at the gastric point of origin. At the second stage, the small intestine is connected to this small stomach pouch.

at a certain range.


There are two types of bypass operations.


One consists of connecting the small intestine to the stomach in the form of a loop without any split. This is called the mini gastric bypass. The other type requires the small intestine to be parted at a certain range and one side is connected to the stomach while the other side is connected to the small intestine at a certain range. This is called the Roux en Y gastric bypass.

Both methods provide similar surgical outcomes. The purpose herein is to make patients eat less as it is the case with sleeve gastrectomy, and to make food meet biliary and pancreatic enzymes going into the duodena in the small intestine, at a site that is far from where this is supposed to be. This makes it difficult for food to be absorbed and creates a mechanism

that would disrupt the consequential absorption. Patients eat less and make less use of what they eat. Changes in the hormones of the gastrointestinal system are more apparent than they are in a stomach tube. Sense of hunger decreases accordingly while sense of satiety increases along with reduced blood sugar and recovery in metabolic problems. This is a relatively reversible procedure. No organ has to be removed. This is a more complicated operation in technical terms. Thus, it requires adequate experience. The complication rate is higher than the stomach tube. It requires a long-term medication (vitamin, mineral, vitamin B12, ferrous, calcium, folate - folic acid -) The length of hospitalization is similar. It may require follow-up and medication for life.


Associate Professor


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