Morbid obesity: BMI, consequences, management

Obesity is a multi-factorial 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, its impact is increasingly resounding: it affects nearly 8 million French people (source 1).

In adults, obesity is assessed on the basis of body mass index calculation (BMI): We divide the weight (in kilos) by the height (in meters) squared. A person is said to be « obese » 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 massive obesity (BMI greater than 40 kg/m²).

We sometimes speak of supra-morbid obesity, when the body mass index is greater than 50 kg/m². But this term does not fit into the WHO classification.

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

In case of morbid obesity, the excess fat mass can be distributed in several areas of the body : face, neck, arms, stomach, thighs, buttocks, etc.

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

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

• From metabolic complications : insulin resistance, hypothyroidism, dyslipidemia (bad cholesterol), hyperuricemia (too much uric acid), type 2 diabetes;
• From cardiovascular complications : cerebrovascular accident, myocardial infarction, cardiac arrhythmias, heart failure, arterial hypertension;
• From pulmonary complications : breathing rhythm disorders, shortness of breath, sleep apnoea, dyspnoea (breathing difficulty), asthma;
• From musculoskeletal complications : osteoarthritis, back pain, rheumatoid arthritis;
• From digestive complications : hiatal hernia, reflux, lithiasis, steatosis which can lead to NASH (fatty liver disease, non-alcoholic cirrhosis);
• From skin complications : stretch marks, fungal 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, colon) or prostate cancer.

As stated above, obesity increases the risk of infertility. It is therefore recommended that obese women, who consult for infertility, try to lose weight first, before implementing medically assisted procreation (PMA) protocols. Note: the risk of complications during pregnancy decrease with weight loss, but persist throughout pregnancy and until delivery, for the baby and for the mother. Strict monitoring is therefore essential.

Contrary to harmful prejudices, overeating and lack of physical activity are not the main causes of obesity, whether it is 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 of the parents is obese. It increases 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 his own basic metabolism and spends calories differently at rest. Some metabolisms burn fat more 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 in the balance.

• from anxiety or depressive disorders;
• from psychological suffering (stress, hypersensitivity, trauma, aggression or emotional shocks linked to death, divorce, job loss, sexual violence, etc.);
• from sleeping troubles (or even night work);
• the sedentarization which promotes the reduction of energy expenditure;
• a unbalanced diet and/or poor quality (excess industrial food, too large portions, too high energy density), sometimes induced by the food marketing;
• the taking certain medications (oestrogen-progestogen contraceptive pill, anti-diabetics, anticancer or HIV, antihypertensives and beta-blockers, antipsychotics, neuroleptics, antiepileptics, replacement therapy for menopause, etc.) whose molecules can induce either directly or by modifying the appetite a more or less significant weight;
• a excessive alcohol consumption ;
• I’quitting, unaccompanied, smoking ;
• etc

Obesity is not a disease that can be fought alone in a corner: it requires multidisciplinary care, adapted to each patient. Often, however, the latter are faced with a long diagnostic wanderingwhich reinforces their sense of guilt and increases the risk of ending up with massive obesity requiring surgery.

To avoid this, it is essential to overcome one’s shame or fears and consult your general practitionerinitially, who can refer to an endocrinologist and/or a nutritionist to look for a secondary cause or to highlight the main mechanisms (hygieno-dietetic and/or psychological) involved.

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.

The management of morbid or massive obesity often begins with a visit to a general practitioner, a nutritionist or a dietitian. Patients can be followed by liberal professionals or benefit from 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). From follow-up care and rehabilitation structure (SSR) also offer to accommodate people with severe, massive or supra-morbid obesity over the long term.

The objective is to stop weight gain and reduce waist circumference to limit the risk of co-morbidities, then to ensure gradual weight loss, to guarantee its durability. This goes through :

• an rfood balancing,
• the practice of a physical activity adapted to the state of health of each patientyou
• and psychological support.

Whatever the situation, the first treatment for morbid obesity is the diagnosis : we are looking for the cause of obesity to propose a targeted treatment. Depending on their profile, patients may be asked to consult a nutritionist, gynecologist, endocrinologist, sleep doctor, etc. Etiological treatment can thus be offered to each patient, in addition to general hygiene and dietary measures.

No drug treatment can overcome obesity. The only drug authorized is orlistat (Xenical®) which limits the intestinal absorption of lipids by approximately 30%. “In view of its modest efficacy, adverse effects, in particular digestive, and drug interactions (among others with anticoagulants and oral contraceptives), the prescription of orlistat is not recommended”, underlines however the High Authority of Health which recalls that the prescription of drug treatments aimed at causing weight loss and not having Marketing Authorizations (granted by the Ansm) in the context of overweight or obesity is prohibited (source 3) .

Moreover, the misuse of « appetite suppressant » drugs is also strongly discouraged.

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

• 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 located about one meter downstream, to reduce the surface area for food absorption;
• I’Gastric Bandplaced in the upper part of the stomach to slow the passage of food.

Secondly, the plastic and functional surgery (liposuction or lipectomy) can be useful to eliminate disabling fatty deposits, in order to improve mobility.