For example, if the weight is 125 Kg and Height is 1.6 mt, the BMI will bte calculated as 125 / (1.6 x 1.6) = 48.8

The value thus obtained is analyzed against the standard Asian BMI guidelines for defining excess weight, which are as follows:

Obesity is a major health problem and has been found to be associated with the 3Ds (disease, disability and death). Nearly thirty diseases have been linked to obesity. Some important ones are: T2DM (diabetes) CAD(heart disease) Hypercholesterolemia

Apart from the above medical diseases, an obese person is also likely to suffer psychological, social, physical and economic co-morbidities. Obese persons are often victims of prejudice and public ridicule due to their size. This often results in psychological illness like depression. Medical costs for treating associated co-morbidities adds to the financial burden and all these factors get multiplied manifold with advancing age. Obesity is the second leading cause of preventable death after smoking. It is a known fact that every extra 10 Kg weight reduces life by 3 years.

The increasing affluence has resulted in a change in eating habits, decrease in dietary fibre, an increasing ratio of fats and sugars in the diet resulting in an unbalanced diet, to this can be added an increasingly sedentary lifestyle. Certain Indian practices like a high fatty diet with near total immobility post partum (following child birth) results in rapid weight gain.

Obesity is known to run in families. This implies a genetic predisposition. These genes cause increased fat storage and obesity when food is plenty and energy expenditure reduced. Certain hormonal disorders like hypogonadism, hyperthyroidism and cushing's syndrome are also associated with obesity.

Childhood obesity
Another major problem requiring urgent preventive measures is the increasing prevalance of obesity in children. Although obese children have fewer associated comorbidities, they are likely to grow up into obese adults. They also suffer prejudice and ridicule and are likely to have psychosocial problems. The sufferers are frequently held responsible for their condition.

Another alarming picture in India is the onset of obesity related medical diseases at much lower BMI i.e. the onset of diseases like HT, T2 Diabetes Mellitus and CAD occur at lower. BMI values compared to patients of obesity in the West.

Goals of the treatment
Treatment for morbid obesity is to reduce the excess body weight with maximum of safety and minimum of side effects and complications, control or prevention of obesity related comorbidity and long term weight control.

Lifestyle modification

Diet
Dietary restrictions follow a pattern of altering the quality and decreasing the quantity of intake. Lowering the carbohydrate and/ or fat content of the diet along with decrease in the size of each meal restricts caloric intake and decreases energy intake resulting in weight loss. A majority of patients regain weight (some even more than their previous weight) on stopping their dietary regime.

Exercise
Exercise works by increasing the energy output. However no amount of exercise however strenuous and prolonged can alone induce weight loss. Exercise tones the body and augments the weight loss effects of dietary restriction, however it alone cannot cause weight loss.

Drugs
Certain drugs cause loss of appetite and thus act by decreasing the energy intake. Some of the drugs commonly used are Sibutramine, Orlistat, Phentermine, Bupropion, Metformin, etc. However all drugs are associated with side effects such as nausea, bloating, oily stools, flatulence, etc. and a certain amount of tolerance may also develop. Only the first three of the above mentioned drugs are approved for long-term use. Drugs however induce a weight loss of only about 10% of excess weight and may not therefore be the answer for patients requiring large amount of weight loss.

Surgery (Bariatric Surgery):
By now one becomes aware that a multidisciplinary approach is the key to managing obesity. However, the mainstay or backbone of this multidisciplinary approach is surgery. Technically known as bariatric surgery, obesity surgery also known as Surgery for Weight Loss is a relatively new branch of surgical sciences to be introduced in India. It has however, existed in the west for over half a century. This discrepancy is due to the disease of obesity appearing much earlier in that part of the world. Bariatric surgery or obesity surgery/Surgery for Weight Loss has evolved and refined over the past 5 decades and today offers the most effective means of prophylaxis against life threatening complications and severe degenerative problems of obesity.

Bariatric Surgery/Surgery for Weight Loss provides the framework wherein the patient is able to easily follow dietary restrictions required for inducing and maintaining weight loss. Obesity surgery has two broad categories i.e. surgery of restriction e.g. gastric banding and surgery of malabsorption e.g. intestinal bypass.

Gastric Banding It is a procedure which is done by placing a band in the upper part of stomach dividing it into two sections. There is a small opening between the sections allowing the food to pass through. The section above the band acts like the stomach that fills with food quickly. As this section of the stomach is filled and stretches, signals are sent to the satiety center of the brain causing you to feel satisfied for several hours. This surgery does not restrict the quality food intake and high calorie liquid intake can hinder weight loss (Fig 3).

Gastric Bypass
It is a procedure which is both restrictive and malabsortive. In this procedure, stapling creates a small stomach pouch (15-20 ml), this forms the restrictive element. The outlet from this newly formed pouch empties directly into the lower portion of the small intestine, thus bypassing a certain length of the intestine. This forms the malabsorptive element as no absorption occurs in the segment of intestine bypassed. This surgery is more effective in inducing weight loss. It has other major advantages like significant improvement and even cure of diseases like diabetes mellitus, hypertension and metabolic syndrome(Fig 4)..

Sleeve Gastrectomy
It is a procedure which is restrictive in which the stomach is converted into a long sleeve. The stomach is stapled along its length and is converted to a reduced volume of about 100-150 ml (Fig 5)..

What needs to be understood beyond doubt is that bariatric surgery is not a cosmetic surgery. This surgery is aimed only to treat the comorbidities consequential to obesity thus increasing the longevity and quality of life in morbidly obese patients.
Bariatric surgery in the young is performed with the aim to increase longevity and quality of life whereas in the elderly it is primarily for improving quality of life.

Bariatric surgery cures Type II Diabetes & Metabolic Syndrome

The prevalence of obesity is increasing in epidemic proportions worldwide, and subsequently raises the risk for both type 2 diabetes and heart disease.

Obesity is a recognized cause of insulin resistance (IR) that leads to impaired glucose tolerance. Incidence of T2DM is increasing in Asia. India by 2025 is predicted to become the global capital for Diabetes. This can be related to the growing affluence & rising incidence of overweight & obesity. The multiple diseases or comorbidities associated with central obesity are termed the "Metabolic Syndrome," Despite aggressive management, current therapies fail to achieve satisfactory control in majority of patients (Fig 6)…

It has been seen that operations for morbid obesity not only induce significant weight loss but also have a significant impact on the course of the Metabolic Syndrome (MS) and Type II Diabetes. Resolution of all parameters of the metabolic syndrome occurs dramatically in operated patients. Resolution of diabetes occurs in > 90% patients following a gastric bypass surgery even before significant weight loss occurs. The procedure therefore appears to work beyond anti-obesity having a key metabolic impact towards improvement of obesity related co-morbidities.

Conclusion
We in India, have long battled under nutrition. Let us make an effort to prevent the pendulum from swinging to the other extreme of malnutrition (obesity). Obesity is a real problem and one which can no longer be ignored. The first step towards dealing with a problem is to acknowledge its existence and the second is to be aware that treatment is at hand. Morbid obesity once present is irreversible and the only cure for such obesity is Surgery for Weight Loss.