Problems with obesity

How to lose useless kilos?

I come from a small town situated about 100 km of the capital of the Wielkopolska region. After I graduated from Primary School I moved to Poznań for good. It was in Poznań where I continued my education in a Vocational School and at the same time I picked up a job as a driver in a transport company. Since then I did not live with my parents. I rented a room at an older landlady in the city center and actually I did not have either money or time to cook for myself. So, I used to be a very slim young man. I visited my parents from time to time usually at Christmas time and other family reunions. Every time I visited my parents, my mother gave me a huge amount of home-made food. However, it was not huge enough to cause a few spare kilos in my weight.

After a few years when I graduated from my school and passed my final exams, I met a girl, fell in love with her and finally I got married. According to the tradition, my marriage welfare helped me to gain a few kilos. My wife graduated from Gastronomic School so she could cook very well. She also had a talent for baking cakes. After a few years of working in the transport company I decided to set up my own business. I bought a few years old car and started working as a taxi driver. My sitting lifestyle, limited physical activity and quite a good salary resulted in my gaining weight. At the age of 45 being, 178cm high I weighted 120kg. I felt really heavy and it was more difficult for me to move smoothly. Sitting job, enormous home meals and lack of physical activities influenced my horrible mood. My knee joint, calves and feet hurt me, and I had huge difficulties to come up to the second floor because on the first floor I was out of breath. Many times after even slight house works or a longer Sunday walk I felt very tired and weak. I decided to visit a doctor and consult my troubles. The diagnosis was very easy and fast. My obesity was the main cause of my troubles. At the very beginning the doctor measured my blood pressure that turned out to exceed the norms at my age. She also asculated my heart beats and said that it was overworked and needed treatment. My knees, claves and feet hurt me due to excessive weight. The only way to get rid of them was to lose weight. How can I do it? , I thought. The doctor prescribed me 1000kcal diet, walks and bike riding and weight control in four weeks time.

I came back home and together with my wife we established a schedule. At first we decided not to eat sweets. It meant no cakes, cream cakes, sponge cakes and ice cream. Instead we were to eat fruits and vegetables, yogurts and sweetener instead of sugar. I also needed to give up eating my favorite marmalade and home made preserves. It was all possible to implement but I also needed to reduce food doses. According to the saying – Eat the whole breakfast, share your dinner with your friend and give your supper to your enemy. I needed to give up eating soups with milk added, knuckles of pork, bigos (our traditional dish) and fat meat poured with juicy sauces. How shall I do it?, How can I change the diet completely at my age and start starving? , I thought. For one month I followed the doctor,s prescriptions with a great effort. During the first few days I felt weak. It was difficult to concentrate at work. I was very sleepy. I suffered from constant headaches and I was very irritated. I did not want to work, not to mention walk or bike riding. In the meantime I bought scales to have the control over my weight every day. So one week lapsed. As soon as the week finished, I noticed that to my surprise my weight did not differ significantly to the original one a week before. I thought, I am torturing myself and nothing . I wanted to give up and accept myself as I was. However, my wife advised me to be patient. She read in some women magazines that it was something normal and after a few weeks the positive results could be visible. The second week was easier. Probably my organism accustomed to the new situation and I had the feeling that I am not so tired and sleepy, and I did not suffer from any headaches anymore. After four weeks of my dieting I went for a control visit. Weighing again and – only 5 kilos less. It is a very good result, I heard from the doctor. I was a little bit comforted. Maybe there was a chance for me? At least I had my own motivation. I was still very young and I wanted to change my appearance.

Christmas and New Year was coming. The atmosphere at home was filled with intensive cooking preparations. My wife prepared my favorite dishes like bigos, turkey, pierogi, sponge cakes and cream cakes. I was worried a little that my strong will would get weakened a bit. But, on the other hand, I could not impose my diet on the rest of the households not to mention the guests who could visit us. During the first few days I followed the doctor,s recommendations. However, I was so strongly encouraged by my household that I could not bear it anymore. I came back to my old bad habits comforting myself that from the 2 of January I would come back to my diet. Family reunions were also a good occasion to drink some alcohol, which has, the so called, empty calories. In the New Year I weighed myself, and …… phew!. My weight not only came back to the original one but what was even worse, it exceeded significantly the original weight. I weighed then 130kg. All my efforts end up with a failure. It was a real tragedy.

It was very difficult to maintain the diet so I thought of some pharmacological treatment. After a telephone consultation with my doctor I bought a set of tablets and herbs stimulating digestion. Since then I used the diet prescribed by the doctor and the medications. Two months more passed. After this period I went for a control visit and ….. the effect was poor. The weight was less as I weighed 115kg but still I had hypertension, problems with breathing and advanced degenerative changes in my knee joints. I asked my doctor whether she knew some other ways to lose unnecessary kilograms. Maybe an operation was a solution?, I suggested. Pharmacological way of blocking the feeling of fullness did not work in my case. Then, the doctor informed me about the possibility of surgical treatment of obesity and the surgery itself consists in reducing the volume of the stomach which consequently forces the patient to eat often and small doses. Additionally, low calories diet quite fast, radically and safely reduces the body mass. Knowing that I would not manage on my own, I asked for a referral to the surgical clinic and, finally, I went to Zabrze. I consulted my problems with a friendly surgeon who asked me about my troubles in details, applied ways of dieting and examined me. He estimated the condition of my circulation and respiratory system as well as my joints, blood parameters and the so called obesity index. Taking into consideration this index, my age and my general condition he referred me to the surgery. I made up my mind at once. I came back home waiting impatiently the term of my surgery. The surgery was performed quickly and my stay in the clinic lasted two weeks. Since then my life has changed totally. I needed to change my diet, way of working even way of thinking.

Since that moment 9 months have passed and I managed to lose 40kg. It is a very good result and my happiness was even greater. Unfortunately it did not last too long. While looking into the mirror I did not look well. Of course, I was slim but when I took off my clothes, my body was flabby, droopy folds of skin especially in the region of the abdomen, arms and thighs looked horrible. I also noticed some meaningful glances of my wife. Once I asked her about her opinion on corrective surgeries and my undergoing one. She did not support my decision at first. With time, however, she said that we were still a young couple and we would go to Riviera to sunbathe a little. The question was how one can go to the beach with such a strange creature as I was.

In autumn I went to the clinic of esthetic surgery that deals with body corrective surgeries. During the consultations, the doctor listened to my life story and examined me carefully. He admired my determination and courage. He informed me that the surgery would allow to correct the skin on the abdomen. It was called abdominoplasty. The arms and thighs that left a lot to desire could be operated in the second stage. There were supposed to be two huge surgeries. We established together the schedule and terms of meetings. I was to undergo the first surgery in one month time and the second one after three months. This is how I will become young and beautiful again, I thought.
On the appointed day I arrived at the clinic and the surgery was performed on the same day. The effect was visible next day. During the change of the dressing I could notice impressive slenderness of my stomach and waist. It was the day of great joy. After three-day-long stay in the clinic I came back home. I felt great. One week later I went for a control visit and the doctor removed the itches. The operated region was slightly swollen, bruised and numb but looked great. For 6 weeks I carried a special pressure abdominal belt so that the skin could adjust to the new shape of my body.

Another visit in the clinic took place three months later. This time I underwent the corrective surgery of arms and thighs. The surgery was also performed under a general anesthetic similarly to the first surgery. It consisted in excision of the skin by longitudinal cuts along the arms in their internal part, from the axilla fosse down to the elbow, whereas, in the region of the thighs it consisted in a round excision of the skin in the groins. Next day having the body covered with bandages, plasters and a special pressure shorts I came back home. One week later during a control visit, the doctor removed all the plasters, whereas the itches were to dissolve on their own. The effect was really impressive. My arms and thighs were modeled very well. I wore special pressure shorts for the next three weeks. After two months I arrived again in the clinic but this time to praise the effects achieved thanks to the surgeries. The scar on my abdomen was smooth, light and slightly visible. It looked as a gum from the pants that left a trace on the skin. The scars around the thighs were slightly pink whereas in the region of the arms they looked as the itches of the sweater that left its trace. That time we were going for vacation with my family. For the first time since 5 years I could afford to go to the seaside. Our destination was Majorca. We spent there two wonderful weeks. I went to the beach, swimming pool and I learnt to play tennis. I looked very well and I felt fantastic as if I was 30 years old again.

Zdzislaw

Overweight and obesity: epidemics of the contemporary civilization

Nowadays overweight and obesity are the most common topics of our discussions and talks. There is a wide coverage in magazines, radio and TV programs almost every day. The fact is that the problem of an excessive amount of adipose tissue is becoming more and more common not only among adults but also among children. As a result it has become an epidemic in many civilized countries. We meet people with the symptoms of obesity more often and it is becoming more common that the overweight are among us.

However, let us not forget that obesity is a very serious, chronic and dangerous disease. It poses a huge risk of heart diseases, namely ischaemic changes and even heart attack, hypertension, diabetes and lipids anomalies in blood. Also our joints condition worsens due to huge weight they need to bear. We need to mention the competence disorders of veins system of the lower limbs. Gallstones let us know about their presence as well. Cancer is also inevitable in the case of the obese. Together with the increase of weight, the frequency of breast, cervical, large intestine, and rectum cancer also increases. Obese people often suffer from respiratory system diseases, too, especially sleep apnea. Due to the increase in death rate, obesity is becoming a risk factor more dangerous than smoking or alcohol abuse.

Let us analyze for a while the results of some statistic research carried out in the United States. We will analyze the graphs, where the increasing number of obese people is clearly visible. Especially the last 20 years has become the climax of this process. The percent of obese men tripled and at women is more the doubled.

The figures give us some food for thought and some of us, especially the obese ones, may even be encouraged to make a hard decision concerning the modification of their own lifestyle. It is really worth!

Anna Modelska-Ziółkiewicz, M.D., Ph.D.

Who is obese?

In order to answer this question, many scientists and doctors have worked on the creation of some specific procedures and parameters which would facilitate measuring adipose tissue accumulated in our organisms as well as classifying obesity. Contemporary medicine takes advantage of some of those achievements. They are very reliable and are not difficult to carry out and interpret.
The easiest way to measure an adequate body mass is to use the following formula:

For men: (height in cm – 100) – 5%
For women: (height in cm – 100) – 10%

If our body mass is over 110% of the adequate body mass, it means we are overweight, but when the percentage exceeds the value of 120 we are obese. I am sure that probably most of us came across the definition of BMI (body mass index) in some publications connected with the topics of nutrition.
BMI can be calculated on the basis of this uncomplicated formula:

BMI = body mass in kg / height in meters raised to the second power

Right now let us analyze the value we achieved and find it in the table.
underweight < 20 norm 20 – 25 overweight > 25
obesity > 30
extreme obesity > 40

BMI is a very good index. It shows visibly the correlation between the frequency of occurrence of many serious and dangerous diseases as well as the intensification of death cases.
In the case of people whose BMI is higher than 30, we can define the type of obesity very easily by means of measuring the waist and the circumference of the hips. Their numeral ratio is called waist-hip ratio (WHR). According to those two figures one may determine two types of obesity. The table below presents them well.

men
WHR >1.0
women
WHR >0.8 apple type of obesity
men
WHR <1.0
women
WHR <0.8 Pear type of obesity

Let us remember that the apple type of obesity is very unfavorable to our health. It often becomes the cause of hypertension, coronary heart disease, lipids anomalies in blood and diabetes, while the pear type of obesity often results in complications during pregnancy and delivery, the occurrence of breast and cervical cancer, and varices of the lower limbs. This type of obesity weighs down significantly bones and joints.

There is also the possibility to measure the components of the body, namely the proportions between adipose tissue and non-fatty tissue. These measurements, however, require a special equipment based on densitometry and bioelectrical impedance.

When it turns out that we can classify ourselves into the group of obese people, we should not jump to quick conclusions and think of some magical diseases which could create our problem. 95% of obese people has the so called positive energetic balance. It simply means that they eat more than their real needs require.

There remains only slight percent of those whose obesity is the result of diseases. It is usually connected with hypothyroidism as well as to some extend with other endocrinological diseases such as adrenal glands and gonad dysfunctions, genetic diseases or the diseases of the central nervous system. The increase of the body mass can be also caused by some medications. However, it is usually the matter of a few kilograms more and it does not lead to obesity. Certainly, a physician, specialist in this field, should exclude any diseases that may cause such condition in order to select the most optimal way of treatment.

If our body mass index is too high, let us think what we can do to change it. Let us consult the doctor. Let us not be passive looking at our disfigured body. As soon as it is possible let us make a strong decision to implement some changes in our lives instead of consuming another cookie or steak in despair. This pleasure lasts only a second, the consequences, however, need to be taken for the rest of our lives.

Anna Modelska – Ziolkiewicz, M.D., Ph.D.

How to win the battle over some useless kilograms?

Let us be aware that the treatment of obesity should be a complex activity. A balanced and proper diet, physical activities, the change of life style and pharmacological therapy are the issues that should be included in the plan of curing an obese person. It is also very important that the person who decides to wage a fight against obesity should be driven by a strong and long-term motivation to achieve the goals set. A close contact with the doctor is of crucial importance as well, so that the patient could consult in the normal course his/her doubts and problems with the doctor. On the other hand, the doctor should explain in details every element of the therapy and provide the patient with the possibility of frequent sessions.

A diet in the treatment of obesity should be diversified and consist of all necessary, for a human body, ingredients. Carbohydrates, proteins and fat are crucial for the proper functioning of our body and we cannot give up consuming them. We should, however, eat them in reduced quantities.

Let us calculate how many calories we need to maintain the body mass at the same level. We can use the following formula: a proper body mass multiplied by 30. The number achieved from this simple calculation is the number of calories we may consume in a daily and normal diet. If we want to lose some kilograms, we need to reduce this number. When we reduce the food by 7000 kcal, we will lose 1kg of our adipose stock. Supposing one was to lose 1kg within one week, he/she would need to eat 1000kcal less every day. If we want to lose weight faster we need to reduce the number of calories even more. A person who weighs 60 kg and does some moderate physical effort during the day, he/she needs daily 1800 kcal., and if that person would like to lose weight, it means the reduction of calories to 800 kcal daily in order to lose1 kg.

At the very beginning it is worth keeping a diary where one may write down every single food eaten during the day. Looking at the book of calories one may also learn how energetic every product is. Such knowledge can be used all life long to estimate better caloric potential of the dishes eaten. While following any slimming diet, one should give up consuming full-cream milk and dairy products, fat meat and fish as well as cured meat, sugar, sweets and alcohol. It is recommended to drink only low fat milk and dairy products, whites of eggs, also low fat cured meat and fish, vegetables, fruits, all within the recommended calories limit. Generally speaking, a slimming diet should contain 800-1000 kcal daily. Let us not believe in any miracle diets which have never helped anybody. It is worth maintaining the implemented eating habits forever as it will guarantee the maintenance of reduced body mass for a long time.

Physical activity should be an inseparable element of our diet. It is important to do the exercises regularly. The best option is to do them every day and from 30 minutes to 1 hour. They should be adjusted to the abilities of a patient. The best type of physical exercises are riding a bike, swimming, marching and playing football. No exercises in the gym or of very short and intensive duration are recommended. The exercises should be intensified gradually, always bearing in mind the diseases that accompany obesity, namely hypertension or ischaemic heart disease. Physical activity should be associated with the modification of our lifestyles. Consequently, instead of using an elevator, one should use the steps, walk to the nearest shop and not go by car. Physical exercises have a beneficial effect on our fitness and muscle strength, lipids profile in blood, lowering the blood pressure and better physical efficiency.

Pharmacological therapy is recommended in the case of obese people whose BMI exceeds 30 or with BMI higher than 27 when the obesity is accompanied by such diseases as hypertension, diabetes, lipids disorders, sleep apnea syndrome or obesity of apple type.

One of the medications available is Orlistat (Xenical), an inhibitor of steapsin and stomach lipase- enzyme that decomposes fat. As a result, the digestion and fat absorption is blocked. 30% of fat eaten is excreted from the body in an unchanged form together with excrement. Additionally, the medication lowers the level of cholesterol in blood.

Another medication that should be paid attention to is sibutramina (Meridia). It works by blocking a reversing uptake of two neuromediators serotonin and noradrenaline. The patient has the feeling of fullness and his/her metabolism also increases. This double effect reduces body weight to a large extend. The patient does not feel any hunger, and additionally his/her organism uses the energy obtained from food much faster. It has also been proved that this medication effects beneficially the level of glucose in blood and lipids profile. It is necessary to control blood tension and the frequency of heart beat while taking this medication.

Let us remember that fight with overweight or obesity is a long-term action. The general change of lifestyle that we implement should help us to lose weight and should be continued throughout the whole life. If we lose weight, we should not come back to our old habits afterwards. The happiness we feel after we have achieved success, attractive and healthy-looking body, greater physical fitness, excellent mood will all be a strong motivator to stick to the habits. I do encourage everybody to start the fight with obesity because there is no man in the world who cannot lose weight. Just do some effort in a rational, patient and slow way and I can assure you that it will change into the joy of your life. Warmer and sunny days are coming, which will give us more strength and motivation for sure.

Anna Modelska – Ziolkiewicz, M.D., Ph.D.

Surgical treatment of obesity

The indication to perform a surgical treatment of advanced obesity is exceeding the value of BMI-Body Mass Index more than 40 kg per sq m of the body mass. Extreme obesity can pose a real danger for one,s health and life. The patients with huge obesity die earlier suffering from numerous diseases of heart, circulation and respiratory systems, problems with bones and joints and even cancer. The return to the proper weight and its maintenance can restore the proper predicted life expectancy since the death rate of the obese increases with the increase of BMI to the value of even three times larger in comparison to the control population of a proper body mass.

It was not until recently that the surgeons were quite skeptical as far as surgical treatment of obesity is concerned. It was the result of unsatisfactory results of the performed surgeries the aim of which was to increase the excretion or the limitation of food absorbed. In the last decade the results of research performed for many years and observation of the patients who underwent surgical treatment of obesity were published. There are more and more good and very good results.

There are usually young people, between 20-45 years of age, who are classified to undergo a surgery, suffering from the diseases which can be eliminated, alleviated or prevented due to the surgery. They are usually the following: ventricular diseases, atheroma of brain vessels, diabetes, sleep apnea syndrome, cardiomyopathy, effort breathlessness, hypertension, infertility, calculosis of gall bladder, incompetence of vein system of the lower limbs with lepers and degenerative problems of the joints.

We can differentiate two basic types of obesity. Abdominal obesity (the so called apple type), which is usually accompanied by ventricular diseases, atheroma of brain vessels, insulin-dependent diabetes and hypertension. The second type of obesity is of gluteal and femoral type (the so called pear type) which is usually connected with veins changes in the lower limbs and degenerative problems of the joints. However, those with the abdominal obesity are prior to undergo the surgery due to the diseases.

The results of the performed surgeries are estimated on the basis of a currently gained weight of a patient with his/her proper weight. Very good results are those where there are no fatal cases, the number of further complications is minimal and overweight is 0-25%. Good results are those when there is a maintenance of body mass by 26-50% higher than the proper weight. These are satisfying results. Satisfactory results are those when the weight exceeds 50-75% beyond the norm and unsatisfactory ones from 75-100%. If the weight is higher than 100% and higher than the proper value, then it means that the surgery failed.

The surgeries aiming at treating extreme obesity have been performed since 70s. Their main goal is to gain the loss of weight and maintain a constant improvement so that the patient would not be undernourished, and assure the feeling of fullness by following a constant and balanced diet. In the first stage, the surgeries consisting in avoiding small intestinal loops were performed to obtain a shortened passage of digested food and consequently the excretion of the food eaten without the possibility of its total digestion and absorption. However, after such surgeries there were some cases of proteins deficiencies and disorders of carbohydrates absorption with the harmful effects on the lever. Currently, the surgeries of stomach volume reduction are performed (gastroplasty) by installing proper mechanical stitches and bands or gastroenterostomy. After such surgeries there may happen some cases of undernourishment due to the deficiency in calories, but they occur extremely rarely. The sufficient volume of the stomach necessary to digest the food is less than 15 ml.

The patients who successfully underwent the surgery receive food in the form of liquids or the food is grated. In the further stage they can consume constant food, however, they have to have meals often but in small amounts. The patients can have the feeling of fullness in the epigastrium, the feeling of dizziness and the necessity of laying down after the meal may occur. These are, however, typical symptoms connected with the limitation of food taken and the loss of weight.

The loss of weight and what next?

After a great loss of weight from 40 to 60 kg, earlier excessively stretched skin can shrink. In such cases a huge amount of it may droop in the region of the abdomen, arms and hips. In order to improve the aesthetical appearance, the patients undergo a range of corrective surgeries as abdominoplasty (excision of abdomen skin connected with the plasty of straight muscles of the abdomen), skin lift of the arm and hips skin. Those surgeries are extensive surgeries so they are performed under a general unaesthetic and usually consist of two stages. In the case of women there is usually the third surgery, namely breast raising.

An excessive amount of skin and adipose tissue of the abdomen is not only an esthetic problem but also makes life functions difficult. A droopy fold of skin and adipose tissue makes it difficult to practice good hygiene of the intimate regions and the hypogastrium, where skin chafing may occur very often. In some extreme cases it makes even difficult to move. The surgery of skin and adipose tissue reduction in the region of the abdomen is usually connected with the plasty of fasciae and straight muscles. It is a very extensive surgery and is performed under a general unaesthetic. Its most serious risk are embolism complications. In order to prevent them, prophylactic anti-embolism treatment is applied in the form of micromolecular heparin and the patient is recommended to move soon after the surgery. The result of the surgery is visible next day. A new shape of the abdomen, new and more beautiful navel provide such a pleasure that any bruises, induration and pain in the region of the operated regions cannot destroy the happiness. The stay in the clinic usually lasts 3-4 days. Directly after the surgery the patients is provided with a special pressure abdominal belt to model a new body shape, and it is recommended to wear it for 4-6 weeks. The effect is even better as it does not leave huge scars, only a long horizontal, running a few centimeters below the navel one which does not disturb at all. It is very easy to hide it under an underwear or a swimming suit.

The first abdominoplasty was performed by Demars and Marx in 1890. Depending on the skin changes and the amount of adipose tissue of the abdomen region, the following surgeries may be performed: liposuction, abdominoplasty with or without moving the navel, the so called lower abdominoplasty in region of the hypogastrium, which usually women after pregnancy undergo. In the last phase, after a huge loss of kilograms, full abdominoplasty with moving the navel and suturing abdominal straight muscles, which due to weight gain were stretched is performed.

Estimated in adolescence the outline of the arms is changing with age. At the beginning a smooth skin between the axilla fosse and the elbow becomes less elastic with time. The first corrective surgery of arms outline was reported in the 70s of 20thc. The surgery consists in the excision of an excessive amount of skin that droops unaesthetically. We can classify the patients into three groups while taking into consideration Pitman,s classification. The first group consists of people with a moderate amount of adipose tissue in the region of the internal part of the arm, and tensed elastic skin. In such cases liposuction can be performed. The second group consists of those patients who have a moderate amount of adipose tissue and slightly flabby skin. In such cases liposuction is performed as well as the excision of an excessive amount of adipose tissue, leaving circular scar around the axilla. The third group consists of all those people who lost a huge amount of kilograms. In such cases an unaesthetically drooping skin fold needs surgical intervention. The cut is made along long ax in the internal part of the arm starting from the axilla fosse down to the elbow.

In recent years during the excision of an excessive amount of skin, most often its full depth is not cut but just the epidermis is removed (deepitelialisation) and its lips are simply itched. This, in turn, protects the veins and nerves of the axilla fosse against harmful effects and it also prevents the creation of post-operational veins and lymphatic oedema of distal lying forearm and arm. Thanks to this technique haematomata and other bodies of liquids occur rarely.

The correction of the medial part of the thighs called thigh lift allows to improve the appearance of the upper part of their third part. Similarly, as in the case of the arms, Pitman,s classification can be applied here. So, depending on the amount of adipose tissue and the condition of the skin liposuction can be performed or liposuction together with the excision of excessive amount of skin, leaving semicircular scars in groins. In the case of patients who lost a lot of weight, a cut is made in the internal surface of the thighs going vertically from the groins down to the knees. The application of skin deepitelialisation technique protects important veins and nerves in the region of the groins responsible for the proper functioning of the reproductive organs and the lower limbs.

After the corrective surgeries of the arms and thighs a special pressure dressing is put for 2 weeks of convalescence. However, only after 2 months one may come back to practising sports.

Małgorzata Kolenda, M.D., Ph.D.

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