Obesity means a fatness condition which needs treatment.  Measure of fatness which requires treatment is determined by a formula called body mass index (BMI). BMI is the number obtained by diving square of your body length to your body weight.  The unit is kg/m2.

BMI= body weight / body length x body length Kg/m2 = kg / meter x meter

BMI value of normal people is between 20 and 34.9 kg/m2.  We define individuals with BMI value between 25 kg/m2 and 29.9 kg/m2 as over weighted.  If your BMI value is ≥ 30 kg/m2, this means your fatness creates a risk for your health.  You must be treated if you are such fat.  Because obesity (fatness requiring treatment) is not a condition progressing solely.

BMI (kg/m2)	Body Shape
≤ 19.9	Slim
20 - 24.9	Normal
25 - 29.9	Over weighted (Sturdy)
30 - 40	Obesity (fatness to be treated)
≥ 40	Morbid Obesity (fatal fatness)

Important diseases that obesity causes directly include diabetes (Type 2 Diabetes), heart diseases, heart attack, stroke, vascular obstructions, osteoporosis, articular diseases and calcification, sleep-apnea syndrome (interruption of breath during sleep), increase on bad cholesterol, hypertension, asthma and cancer.  Obesity causes billions dollars cost worldwide because of these problems.

BMI is not enough only for evaluation of obesity. Because body mass index does not show distribution of fat deposits.  Risk of obesity for metabolic syndrome is determined by intensification of lipoidosis in the abdomen.  The simplest way to asses this is to measure abdominal circumference.  If abdominal circumference measurement is more than 88 cm in women and more than 102 cm in men, risk of metabolic syndrome is high.  Intraabdominal lipoidosis is called abdominal obesity.  Abdominal obesity is also called as apple type fatness.  Abdominal obesity is directly associated with increased insulin resistance, heart diseases and vascular obstruction (atherosclerosis).  Conditions that increase risk of atherosclerotic dyslipidemia (cholesterol disorders causing obstructive vascular disease) are increase on Triglyceride and bad cholesterol (LDL) and decrease on good cholesterol (HDL) level.  Abdominal obesity creates a high risk for these cholesterol disorders.

Excessive lipoidosis appears in all intraabdominal organs, mainly in liver in individuals with abdominal obesity.   Fatty liver disorder is seen in slightly over weighted individuals.  This does not mean that it is not important.  Quite the opposite, it is important indicating that lipoidosis starts earlier when obesity starts to occur and may cause organ damage by rapid progress.

Raeven has defined combination of a group of metabolic disease under title of Insulin resistance Syndrome first in 1988.  Then all these diseases which create coagulation tendency, diabetes tendency and vascular obstruction tendency have been described as Metabolic Syndrome.  Early diagnosis of Metabolic Syndrome is very important.  Because metabolic syndrome increases deaths caused by heart attack by 4 times.

Obesity is the most important underlying cause of metabolic syndrome because it causes increase on insulin resistance and bad cholesterol solely.  Each individual with obesity should be accepted as under very high risk group for metabolic syndrome.  There are patients who do not have any complaint and whom no abnormality is detected in blood tests.  We call these patients healthy obese. Actually, it is a temporary concept.  Because obesity will cause insulin resistance eventually.  Once insulin resistance appears, if obesity continues, it will cause Type 2 Diabetes and Metabolic Syndrome rapidly by snowballing. So, individuals classified as healthy obese should be taken into treatment programs like obesity patients who present clinical symptoms.

Your blood fats, blood glucose and blood pressure may be normal although you are over weighted. Moreover, you may survive an active life.  However, remember that this is a honeymoon period.  If required preventions are not taken during this period, insulin resistance and diabetes will appear rapidly.  Metabolic Syndrome will be the inevitable final of this way.   

	Morbid Obesity

The most efficient and permanent treatment of obesity in earliest period will completely eliminate the risks.  Lifestyle changes, healthy and low calorie diets and exercise programs provide a complete recovery when they are applied together in a discipline.  This recovery is preserved as long as this order is preserved.  However, one of each ten individuals with obesity or morbid obesity may achieve this.  Remaining nine individuals do not obey these diets or regain weights in les than a year.  This increase and decrease strengthen insulin resistance and accelerate the progress to diabetes and metabolic syndrome.  Furthermore, weight loss and gain spoil motivation of the patients.

Although diet and exercise programs provide a partial success to resolve obesity and obesity-associated problems, they are away tp produce permanent and long term solutions.  Multiple drug treatments used on continuation of these programs loose their efficacies because of tolerance development and dise effects due to high doses.  ○These patients are referred for metabolic surgery as patients who obtained all treatments, tried all methods and could not succeed.  Of course many permanent damages have appeared because it is late.  Benefits of metabolic surgery is more than all current drug therapies even at such stage.

If you have obesity and your doctor has mentioned about insulin resistance and moreover, she/he has suggested drugs, it is time to think about it.  To loose years by fluctuating with drugs and diets or to prefer surgery for exact and permanent solution?

If you have a strong will and you have power to preserve your gains, we do not recommend surgery to you.  You may completely control your metabolic syndrome and loose sufficient weight by diet and exercise.  If you preserve these gains, this means that you have managed your ideal treatment.

What if you struggle to achieve this?  You can not apply diet? It is not possible to assuage your hunger?

Then, obesity and metabolic surgery will be an ideal treatment for you.

• WHO reports and recommends that the surgery is the most efficient treatment for obesity and accompanying diseases for the patients with BMI>35 kg/m2 and one or more accompanying disease; and for patients with BMI>40 kg/m2 even no accompanying disease exists (WHO Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO technical report series 894.Geneva: World Health Organistion, 2000).
• Obesity and metabolic surgical methods should be assessed as an alternative treatment for the patients with a BMI value between 30 and 35 kg/m2 who receive treatment because of Type 2 Diabetes and can not control their blood sugar levels with standard medical diet and life style changes especially if diabetes-induced cardiovascular risk factors exist. (Declaration of International Diabetes Federation: Bariatric Surgical and Procedural Interventions
  in the Treatment of Obese Patients with Type 2 Diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention-2011)
• Despite a weight loss of 15 kg is obtained with medical obesity treatment and diet within a year, patients gain these weights back within 1 to 3 years.  (NIH Con. Dev. Conf. Sta. March 25-27,1991. Am J Clin Nutr 1992:55:615S-9S.) (Treatment of obesity by moderate and severe caloric restriction. Wadden TA . Ann Intern Med 1993. Oct: 1;119:688-93)
• There is not any drug or drug group appeared as an efficient option for medical treatment of obesity yet.  (Pharmacotherapy for obesity: Haddock CK et al. Int J of Obesity (2002) 26, 262-273)

What Type of Obesity Is Important?

• Fatness is not seen same for everyone.  In other words, fat accumulation does not appear same in every individual.  Therefore, fatness should be divided into two for metabolic syndrome:
• Apple Type Fatness: Central Obesity or Abdominal Obesity expressions are also used.  Fat accumulation is in and around the abdomen in this type of fatness.  Regions where such fat accumulation are roughly three:
• Lipoidosis under abdominal skin,
• Lipoidosis around intraabdominal organs (like hepatic lipoidosis).
• Fat accumulation behind peritoneum.
• Central obesity is a high risk lipoidosis for metabolic syndrome.
• Pear Type Fatness: Fat deposits are dominantly on hips and legs in this type.  No significant fat accumulation appears on upper part of the body. Risk of metabolic syndrome is not different from individuals who are on normal weight.

Central Obesity and Insulin resistance

	Obesity Metabolic Syndrome

In case of central obesity, lipolysis of fats deposited in the liver and mixing with blood is very fast. Fats deposited on other parts of the body do not mix with the blood as fat as the fats in the abdomen.  Because of fats mixing with the blood, quantity of fat acids increase in the blood.  Fat acids are the smallest fat particles.  These fat particles increased in the blood come to liver again and cause liver to present resistance to insulin.  While insulin should suppress glucose production in the liver, liver starts to send much glucose to the blood without limitation by insulin because of this resistance.  Blood sugar starts to increase and Type 2 Diabetes appears.

Increase of fat acids in the blood stimulates beta cells which are responsible from insulin production in pancreas and causes much insulin release into the blood. This excessive insulin production causes hyperinsulinism (excessively high insulin level).  Insulin resistance increases more.

When insulin respond decreases in the liver, activity of an enzyme called lipase increases in the liver.  This enzyme causes production of bad cholesterols smaller and densely in the liver.  Dense bad cholesterol particles with smaller diameter (LDL) stick onto the vascular walls fast and densely, cause vascular obstructions.  Blood cholesterol levels of these patients is much higher than other individuals because of vascular obstruction risks.

Appearance of Central Obesity and Cardiovascular Diseases

We know that fat deposit caused by obesity causes insulin resistance and increase in blood fats.  Obesity therefore creates a very high risk for increase of bad cholesterols and atherosclerosis.  Studies conducted on individuals with cardiac diseases have shown that heart attacks are severer during earlier ages of patients.  Furthermore, death ratios in heart attacks appeared on obesity basis is higher than slim individuals.   Obesity creates a very important risk solely for heart attack and heart attack-dependent deaths and shortens the expected lifetime.

Obesity also creates nerve damage on the heart.  This condition is called cardiac autonomic neuropathy. Stimulation balance of heart muscle changes because of obesity.  Therefore, obesity causes non-effort dependent tachycardia.  The palpitation triggered by tiredness after exercise is physiological.  In fact, palpitation also occurs during resting due to nerve damage in the heart muscle in case of obesity (fatness). Fatness also plays a role in increase of heart rhythm for a continuous inflammatory process even mildly. We define this case as obesity is a chronic inflammatory process.  This continuous mild inflammation process created by obesity causes increase of some substances triggering inflammation.  These substances increase operation rate of the heart and try to provide more blood flow into the tissues.  This effect also contributes into fast contraction of heart muscles and palpitation.

Operation of heart slightly over normal even during resting enlarges cardiac muscles and increases need for oxygen.  However, cardiac vessels have already narrowed due to atherosclerosis and can not provide sufficient blood flow.   When all these come together, heart attacks and deaths appear suddenly and earlier.

Treatment of Obesity-Induced Metabolic Syndrome

First stage treatment of obesity is diet and exercise.  However, diet and exercise can not provide desired weight loss solely in most cases.  Weight loss drugs are used in this case.  Most of drugs sold for weight loss in the market are not used because of severity of side effects.

• National Institute of Health (NIH) recommends controlled weight loss for individuals whose BMI >30 kg/m2 and fat individuals with a BMI > 25 kg/m2 value and at least two accompanying disease. (NIH: Clinical guidelines Obes Res6 (Suppl. 2): 51S-209S,1998)
• The average weight loss by 500 grams per week which is obtained with calorie restriction diets provides a healthy weight loss and this is insufficient for long term control of the weight loss.  (Wadden TA, Foster GD: Med Clin North Am84 : 441-461,2000)
• Although rapid weight loss is achieved with very low calorie diets, effects of these diets can not be preserved during a long period.  (NIH: Clinical guidelines Obes Res6 (Suppl. 2): 51S-209S,1998)
• Exercise programs added into the calorie restricting diets are much more effective than diet for preserving the weight loss obtained and for long term control of weight loss even these exercises do not increase weight loss ratios much. (McGuire MT, Wing RR. Obes Res7 : 334-341,1999)
• Behavior therapies may change the eating order, thoughts and behavior styles of the patients with obesity problems; a weight loss by 8 to 10% may be provided within 4 to 6 months when it is supported by diet and exercise.  Such weight loss may significantly reduce problems of the patients with problems due to obesity.  (Blackburn G: Obes Res3 (Suppl. 2):211S -216S, 1995)
• However, a large portion of these patients gain these weights lost, even more. (Tech. Asses. Conf. Pan.: Methods for voluntary weight loss and control. Ann Intern Med119: 764-770,1993)
• Despite a weight loss of 15 kg is obtained with medical obesity treatment and diet within a year, patients gain these weights back within 1 to 3 years.  (NIH Con. Dev. Conf. Sta. March 25-27,1991. Am J Clin Nutr 1992:55:615S-9S.) (Treatment of obesity by moderate and severe caloric restriction. Wadden TA . Ann Intern Med 1993. Oct: 1;119:688-93)
• There is not any drug or drug group appeared as an efficient option for medical treatment of obesity yet.  (Pharmacotherapy for obesity: Haddock CK et al. Int J of Obesity (2002) 26, 262-273)

Why Obesity Surgery?

• Conditions which increase in relation with obesity include Hypertension, Cardiac diseases, Hypercholesterolemia, Diabetes (Type II DM), Sleep-Apnea, Bone and Joint Disorders, Reflux and Vein Disorders. (The incidence of co-morbidities related to obesity and overweight: Daphne P Guh, Whei Zang, et al. BMC Public Health 2009, 9:88 doi:10.1186/1471-2458-9-88)
• WHO reports and recommends that the surgery is the most efficient treatment for obesity and accompanying diseases for the patients with BMI>35 kg/m2 and one or more accompanying disease; and for patients with BMI>40 kg/m2 even no accompanying disease exists.  (WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO technical report series 894.Geneva: World Health Organistion, 2000).
• Obesity and metabolic surgical methods should be assessed as an alternative treatment for the patients with a BMI value between 30 and 35 kg/m2 who receive treatment because of Type 2 Diabetes and can not control their blood sugar levels with standard medical diet and life style changes especially if diabetes-induced cardiovascular risk factors exist. (Declaration of International Diabetes Federation: Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention-2011)