MORBID OBESITY -
OBESITY IN AMERICA PART 1

Table of Contents

What is Morbid Obesity?

Did you know that in the United States, over 40% of people struggle with obesity?1 And, many of those people struggle with morbid obesity. Obesity is a health condition that is characterized by excessive fat accumulation that poses health risks. To diagnose obesity, a body mass index (BMI) is used. Morbid obesity is on the higher end of the BMI scale.

BMI is a person’s weight (in pounds) divided by the square of his or her height (in inches) multiplied by 703 (the conversion factor). A BMI equal to or more than 25 indicates a high body weight for that height and size. A BMI of equal to or more than 30 signifies being obese and a BMI of over 35 is considered morbidly obese.2

How Do I Know if I am Morbidly Obese?

There are three sets of criteria that lead to a diagnosis of morbid obesity. The first is having a BMI greater to 40. The second is having a BMI greater to 35 while also having at least one serious obesity-related condition and the third is being more than 100 pounds over your ideal body weight (IBW).

What are the Body Mass Index Ranges?

The Body Mass Index is calculated using the following equation: weight (lb) / [height (in)]2 x 703 (3). The BMI ranges provide insight into the health status of your weight. The higher your BMI, the more health complications you are at risk for. The ranges are:3

Normal: 19.0–24.9

Overweight: 25.0-29.9

Obesity Stage 1: 30.0-34.9

Obesity Stage 2: 35.0-39.9

Morbid Obesity Stage 3: 40.0 or greater

What is the Average BMI of American Females?

According to the Centers for Disease Control and Prevention, the average American female is 63.6 inches tall and weighs 170.5 lbs., making the average BMI for females 29.6.4

This means that the average American woman is overweight.

What is the Average BMI of American Males?

According to the Centers for Disease Control and Prevention, the average American male is 69 inches tall and weighs 197.8 lbs., making the average BMI for males 29.2 which also means that the average American man is overweight.4

What is a Normal BMI?

While BMI doesn’t indicate everything about health, it can be a helpful measurement. A normal BMI typically falls in the range of 19.0-24.9.3

Video - What is Obesity?

Is Obesity a Disease?

While many people view obesity as a matter of physical appearance, it is considered to be a disease, particularly because of the health issues that come with it.

According to Jason Fung, author of The Obesity Code, obesity is much more about hormonal imbalances and insulin levels, than it is just about caloric intake. Therefore, he thinks, tackling obesity and morbid obesity should be about understanding our hormones and the way they affect our weight, rather than focusing simply on calories in and calories out.

Apart from the BMI ranges, there are scales of obesity that are used to determine the level of health risk to a person. These are the following classifications of obesity:5

Overweight: BMI 25.0-29.9

Class l Obesity: BMI 30.0-34.9

Class ll Obesity: BMI 35.0-39.9

Class lll Obesity: BMI >40.0

Making a particular obesity diagnosis based on the scale will allow your doctor to determine your health risk, including potential disability and the risk of early death.

What are the ICD-10 Codes for Obesity Management?

The International Classification of Diseases outlines the following codes for diagnosing morbid obesity.6 They are:

ICD-10 Obesity CodesLabels for ICD-10 Obesity Codes
E66.1Drug-induced Obesity
E66.2Severe Obesity with Hypoventilation
E66.3Overweight
E66.8Other Obesity
E66.9Obesity, Unspecified
ICD-10 BMI Codes Z68.XX: Labels for ICD-10 BMI Codes
Z68.25-29.9Body mass index (BMI) 25-29.9, adult
Z68.30-Z68.39Body mass index (BMI) 30.0-39.9, adult
Z68.4Body mass index (BMI) 40 or greater, adult
Z68.41Body mass index (BMI) 40.0-44.9, adult
Z68.42Body mass index (BMI) 45.0-49.9, adult
Z68.43Body mass index (BMI) 50-59.9, adult
Z68.44Body mass index (BMI) 60.0-69.9, adult
Z68.45Body mass index (BMI) 70 or greater, adult

What are the Risk Factors and Causes of Morbid Obesity?

Most people think that obesity is caused simply by consistently consuming more calories than you are burning. When you eat more calories than you burn, your body stores them as fat, and eventually your body will build up fat stores, eventually leading to obesity. There are other factors that impact your risk of obesity and make some people more likely to become obese than others. Some of the risk factors for obesity and morbid obesity are:

Mental Factors: Stress and anxiety cause the body to produce more of the stress hormone cortisol. Cortisol contributes to fat storage and therefore, weight gain.

Sleeping Habits: A lack of sleep can contribute to weight gain as the body is not in its resting state as frequently.

Behavioral Factors: Eating habits, daily activity levels being busy, inactive office job.

Medication: Antidepressants and birth control are two types of medication that can cause weight gain.

Medical Conditions: Such as hypothyroidism.

Genetic Factors: Having a family history of obesity.

Being Female: Pregnancy can lead to weight gain in women as can menopause.

Apart from the diagnostic criteria for obesity, other symptoms of obesity and morbid obesity are:

Excess fat stores on the body

Feeling out of breath

Having trouble breathing

Having difficulty walking or standing up

What is Obesity Hypoventilation Syndrome?

Obesity hypoventilation syndrome, also known as Pickwickian Syndrome is a breathing disorder that affects people with morbid obesity. This disorder is characterized by having too much carbon dioxide and not enough oxygen in your blood. Hypoventilation occurs when a reduced amount of air enters the lungs.

There are a few reasons that morbid obesity causes Hypoventilation Syndrome/Pickwickian Syndrome. The first is that extra fat deposits on your neck, chest, and abdomen can make it more difficult to breathe deeply. The excess fat can also lead to the production of hormones that affect your breathing patterns.

Additionally, hypoventilation can occur as a result of breathing that is too shallow, too slow, or from diminished lung function. Many people who have hypoventilation syndrome also suffer from sleep apnea which is a condition where you stop and start breathing repeatedly through the night. If untreated, morbid obesity hypoventilation syndrome can lead to serious health problems such as pulmonary hypertension and heart failure.

Video - Obesity Hypoventilation Syndrome

What are the Symptoms of Obesity Hypoventilation Syndrome?

Symptoms of obesity hypoventilation syndrome include: 

Feeling tired or sluggish throughout the day

Headaches

Feeling out of breath

Loud snoring, choking, or gasping

Having trouble breathing

Respiratory failure

What Can You Do if You Have Obesity Hypoventilation Syndrome?

If you have Obesity Hypoventilation Syndrome, to help with your breathing, a continuous positive airway pressure (CPAP) device or an oxygen concentrator can help you breathe. Both CPAP devices and oxygen concentrators work by helping to keep airways open and increasing blood oxygen levels.

CPAP machines help to expand your airways and oxygen concentrators filter the air around you, allowing you to gain more oxygen into your lungs. To truly overcome Obesity Hypoventilation Syndrome however, healthy lifestyle changes are recommended. A reduction in weight and fat deposits will alleviate a lot of the strain on breathing, improving the ability to breathe without help.

What Other Conditions are Caused by Morbid Obesity?

When morbid obesity goes untreated for a prolonged period, there is an increased risk of suffering from other serious health problems that are either caused by obesity or make it worse. These conditions include:

Osteoarthritis

Excess weight can cause stress on your joints such as your knees and hips. This can cause pain, inflammation, and the deterioration of your joints. Strain caused by excess weight also impacts your bones and your muscles, leading to back problems, disk problems, pain, and decreased mobility.

Heart Disease

Having excess fat on your body can put a strain on the heart which can head to hypertension (high blood pressure). This can result in strokes and other heart problems.

Type 2 Diabetes

People who are obese can become resistant to insulin, resulting in high blood sugar. This can result in the development of Type 2 diabetes.

Sleep Apnea

The fat that is collected in the tongue and the neck can block your air passages, making it difficult to breathe. This can result in sleep apnea which is a condition where breathing repeatedly stops and starts during sleep.

Reproductive Problems

Obesity is directly linked to your hormones and can result in big hormone changes and imbalances. This can impact fertility negatively and can make it difficult to conceive. Obese can cause a reduced sperm count in males and polycystic ovary syndrome in females.

Metabolic Syndrome

Metabolic syndrome is a condition made up of a group of other conditions such as high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels. All of these conditions can increase your risk of having a heart attack or a stroke.

Depression

People with obesity face constant challenges in life from discrimination to negative comments from friends, family and strangers, the potential of failed attempts to lose weight, and the embarrassment of not always fitting comfortably into public spaces. Altogether, this can result in mental health issues such as depression or anxiety.

Cancer

Obesity can increase the risk of developing certain kinds of cancer such as cancer of the uterus, breast cancer, prostate cancer, colon cancer, and gallbladder cancer.

Gallstones

Excess fat and weight can increase the amount of cholesterol in the bile which can put you at risk of developing gallstones.

Video - What is Morbid Obesity?

What is Fat Shaming and Body Shaming?

Fat shaming or body shaming is the practice of humiliating someone based on their size or body type. Everyone knows that there is a problem of glorifying only certain types of “skinny” bodies, particularly with the rise of technology and media. Even though the majority of Americans are considered to be overweight or obese, fat shaming and body shaming is a big part of our culture and society.

The fact is that the media does not accurately reflect what American’s truly look like. Most campaigns feature people who are considered to be skinny, yet most American’s are overweight. This sends the message that to be accepted in society, you have to be a smaller size.

Weight Discrimination in the Workplace

From discrimination in the workplace to a world that is physically designed to only fit a certain size of people (aka the size of seats in public spaces), body shaming is a big problem and does nothing to help people with obesity to manage their condition. Did you know that Michigan is the only state that has passed a law that forbids employers from penalizing overweight and obese people in the workplace? What that means is that in all of the remaining states, it is legal for your employer to discriminate against you, fire you, or deny promotions, based on your weight. According to a 2017 survey, overweight employees are less likely to be hired than “straight-size” applicants as employer’s associate obesity with laziness. Overweight employees also earn an average of $1.25 less per hour than straight-size employees.7

Fat Shaming at the Doctor's Office

Fat shaming even pervades the medical field. A 2003 study found that over 50% of primary care physicians consider obese patients to be awkward, unattractive, and noncompliant.7

This stems from the stereotype that obese people are simply lazy, and that morbid obesity is a behavioral problem more than it is a medical one. This makes it more difficult for people dealing with these health conditions to even seek medical help, isolating them further from society.

Video - Weight Bias in Healthcare

Body Shaming Statistics

One of the main results of body shaming within our society is an extremely negative body image. Unfortunately, body image issues and low self-esteem affect many people and can cause problems throughout your life. Here are some important body shaming statistics:8

80% of U.S. Women Do Not Like How They Look
80%
34% of Men Are Dissatisfied with Their Body
34%
Over 50% of Americans are Unhappy with Their Weight
50%
70% of Women Who are Considered to be of a Normal Weight Want to Be Thinner
70%
Over 80% of 10 Year Olds are Afraid of Being Overweight
80%
53% of 13 Year-Old American Girls are Unhappy with Their Bodies
53%
78% of 17 Year-Old American Girls are Unhappy with Their Bodies
78%
94% of Teenage Girls Have Been Shamed for the Way Their Body Looks
94%
64% of Teenage Boys Have Been Shamed for the Way Their Body Looks
64%

These body shaming statistics indicate that we have a huge problem with body shaming and fat shaming in the U.S. Almost everyone will experience body shaming or insecurity over their body or weight. This can be debilitating and dangerous to your self-esteem.

What is Fat Acceptance?

Fat acceptance is the belief that all bodies, regardless of size or shape, have equal value. Fat acceptance, as a movement, fights for people who are overweight to have the same rights and dignity as everyone else. Fat acceptance is not about glorifying morbid obesity, but rather, it is about the equal treatment of all human beings. Many factors impact and affect morbid obesity. Fat acceptance is about fighting against discrimination and allowing people with morbid obesity to be respected and treated equally, in the workplace, in schools, in the medical field, and more.

What is the Obesity Code?

The Obesity Code is a book that was written by Jason Fung in 2015.9 In The Obesity Code, Fung looks at the science behind obesity, and the relationship between hormones, insulin and obesity.9

The Obesity Code says that everything that happens in our bodies is related to hormonal signals. Whether the calories that we eat are burned as energy or stored is fat is largely controlled by hormones. Therefore, more important than the calories we eat is how the calories are spent.

Is Insulin the Most Important Hormone?

The most important hormone relevant to this is insulin. Insulin is a fat-storing hormone and when we eat, insulin goes up indicating to the body to store some of the food energy as body fat. When we aren’t eating, insulin goes down, signaling to the body to burn the stored energy and body fat. Higher insulin levels indicate to our body to store more food as body fat. People who are obese have around 20% higher insulin levels than other people.9 These higher levels of insulin are directly correlated to your waist circumference and waist/hip ratio.

Jason Fung believes morbid obesity is better seen as a hormone issue rather than a caloric imbalance, The Obesity Code suggests that we must understand morbid obesity as a hormonal imbalance, and therefore look for ways to decrease insulin levels. To control insulin, we must make changes to our diet in two main ways: focusing on what we eat (which determines insulin level spikes) and when we eat (which determined how persistent insulin is).

Carbohydrates Aren’t Necessarily Bad

As explained in The Obesity Code, a common misconception is that carbohydrates will make you gain weight. This is not necessarily true, many societies have had carb-heavy diets consisting of rice, potatoes, and bread, and have not struggled with population obesity. The Obesity Code states that what is more important is to not be eating all the time and to allow your insulin levels to remain a bit more stable. The Obesity Code recommends one common practice which follows this theory: intermittent fasting. Intermittent fasting allows your body time to burn through energy and stored fat.

Medical Professionals Express Some Concerns

The main critique medical professionals have expressed is the practicality of the eating practices recommended by Jason Fung and how sustainable the eating practices are. They feel that throwing out scheduled mealtimes in our modern lifestyles will be too hard and that the jury is still out on intermittent fasting. Most of the professionals feel that a balanced diet and calorie reduction is still the best-proven way to lose weight.10

What Are Fad Diets?

A fad diet is a diet that is popular for a certain amount of time, the same way that fashion trends come in and out of fashion. If you know anything about dieting, you’ve probably heard the terms intermittent fasting, keto diet, paleo diet, Atkins diet, cabbage soup diet, south beach diet, and more before. Most of these fad diets are based on sound advice that is taken out of context to make the diet seem attractive.

While some fad diets do work, many do not. With various “skinny teas” being promoted on the internet and different meal replacement shakes, fad diets often promote a fast way to lose weight, that isn’t sustainable or healthy. To lose weight in the long term, a routine of eating healthy and exercise must be developed. There are no shortcuts. Drinking a weight loss tea for a certain time will not lead to sustainable weight loss and could ultimately be harmful in the long run.

How to Relieve the Strain of Morbid Obesity

Mobility Scooters

Apart from morbid obesity treatment, which encompasses many different treatment options, there are also products on the market to help people with morbid obesity comfortably get through their day to day activities. Because morbid obesity may impact your mobility, ability to breathe, stamina, and put a strain on your joints, muscles, and bones, mobility scooters and power wheelchairs might be useful for helping you to get around the house, to get from one place to another, and to be able to travel with ease.

Lift Chairs

If you struggle with getting up from a seated position, a lift chair might be useful as well. A lift chair works by moving up with you to help you reach a standing position.

CPAP Machines and Oxygen Concentrators

Due to the breathing issues that are often a result of morbid obesity, CPAP machines and oxygen concentrators will be useful in helping to expand airways and increase the amount of oxygen being taken in. CPAP machines, which are continuous positive airway pressure machines, will help you breathe throughout the day and night.

CPAP Masks and Tubes

CPAP machines include a mask that fits over your nose, or your nose and mouth, along with a tube that connects your mask to the machine’s motor. The machine’s motor blows air into the tube which blows air into your airways. CPAP machines are particularly useful in the treatment of sleep apnea as well to ensure that you are breathing throughout the night.

What are the Treatment Options for Morbid Obesity?

The good news is that there are many treatment options for obesity and morbid obesity. While people who struggle with obesity typically have many challenges to losing weight, various options can help people with obesity to manage their condition.

The main goal of obesity treatment is to reach and stay at a healthy weight. While many people will succeed in losing weight at some point in their lifetime, many people also end up gaining the weight back at some point. Therefore, maintaining a healthy weight is just as challenging as losing weight. Because both physical and mental health are deeply impacted by morbid obesity, it may be helpful to work with multiple health professionals to get the help that you need. This may include a dietitian, a behavioral counselor, an obesity specialist, or more.

The first step in most obesity treatment plans is to lose a modest amount of weight – typically 5% to 10% of your total weight.3 For example, if you weight 200 pounds, the first step would be to try to lose 10-20 pounds in order for your health to begin to improve.3 This weight loss happens in multiple ways.

Dietary Changes to Treat Morbid Obesity

Eating Healthier Foods

One of the main factors of obesity treatment is changing your diet. This includes healthier eating choices, so eating more fruits, vegetables, whole-grain carbohydrates, lean proteins, and fish. You should limit your salt, added sugar and junk food intake, and focus on eating healthy fats such as olive oil, avocados, and nuts.

Reducing Calorie Intake

This also includes reducing your calorie intake. Firstly, you need to identify how many calories you typically eat and find ways to reduce your calorie intake. While your doctor will be able to give you a specific number of calories to eat per day in order to lose weight, typically, women need between 1,200 to 1,500 calories a day and men need about 1,500 to 1,800 calories a day to lose weight.

High Volume – Low-Calorie Food

Another useful change is to eat higher volume and lower calorie food, allowing you to eat more food, but at a lower calorie count. Most processed and packaged food contains a high number of calories for a small portion whereas fruits and vegetables are larger in portion size but smaller in calories. By eating larger amounts of lower-calorie food, you won’t feel like you are starving yourself and you won’t be struggling with hunger and cravings as much.

Avoid Fad Diets

Try to avoid fad diets. Many fad diets produce short term results but do not produce long-lasting results. Rather than being overly restrictive and trying out fad diets, focus on creating healthy eating habits. Rather than punishing yourself, try to find foods that you enjoy eating that are also good for you.

Exercise and Activity to Treat Morbid Obesity

Moderate Intensity Exercise

The second part of the weight-loss equation includes burning more calories than you take in, also known as exercise. Exercise and daily activity help you to burn calories, allowing you to burn more calories than you consume, leading to weight loss and fat loss. People with obesity are recommended to get at least 150 minutes of moderate intensity exercise every week to prevent further weight gain or to maintain initial weight loss. For more significant weight loss, 300 minutes of exercise or more per week is recommended.3

Add Movement to Your Everyday Tasks

In addition to exercise, it is important to try to stay active and moving throughout the day. Whether this means getting up more frequently, doing some gardening, walking to the store instead of driving, small changes will add up. A goal of 10,000 steps per day is also a good starting point for people who are obese and want to start slowly incorporating movement and exercise into their daily routines.

Behavior Changes to Treat Morbid Obesity

Understanding Your Relationship with Food

A big part of obesity treatment involves understanding your relationship with food and what stressors might affect your morbid obesity or weight gain. This could be a triggering event, mental health issues, a stressful job, a lack of time, a busy lifestyle, stress-eating, and more.

Counseling to Discover Underlying Issues

Counseling might be useful in helping you to understand any emotional and behavioral issues that you might have relating to eating. Counseling can help you to find ways to cope with stress and anxiety that don’t involve food, as well as help you understand your eating triggers, and help you to avoid food cravings.

Many different types of therapy may help you understand the causes of your issues. These therapies include cognitive-behavioral therapy (CBT), dialectic-behavioral therapy (DBT), eye movement desensitizing and reprocessing (EMDR), and more.

Support Groups

You may also look into support groups where you can find the support and understanding of people who are also struggling with obesity.

Endoscopic Procedures to Treat Morbid Obesity

No Incision in the Skin

Endoscopic weight loss procedures do not require any incisions in the skin which is why some people prefer these procedures to traditional weight-loss surgeries. The way that endoscopic procedures work is that flexible tubes and tools are inserted through your mouth, down your throat, and into your stomach while you are under anesthesia. Then, the doctor will either place stitches in your stomach to reduce its size and reduce the amount that you can eat, or they will insert a small balloon into your stomach that is filled with water and occupies space in your stomach so that you feel full faster.

Helping You Eat Less After Unsuccessful Diet and Exercise

Both procedures will help you to eat less and therefore lose weight. These procedures are typically only used in people with a BMI over 30 or when diet and exercise are not successful.3

Fighting Morbid Obesity with Prescription Weight-Loss Medication

While a healthy diet and regular exercise will always be necessary to combating obesity and achieving a healthy weight, in situations where people cannot lose weight through diet and exercise alone, they might be prescribed weight-loss medication.

There is No Magic Pill

To be clear, weight-loss medication should be used together with diet and exercise, and not instead of. Unfortunately, there is no magic pill that will make you lose weight. Weight-loss medications can help you to lose weight by curbing your hunger, helping you to feel full, and therefore allowing you to stick to lower calorie diets.

Consult Your Doctor Before Using Weight-Loss Medication

You should discuss the possibility of weight-loss medication with your doctor so he or she can determine if it is a suitable option for you. The Food and Drug Administration (FDA) has approved the following weight-loss medications:3

Orlistat, (Alli, Xenical)

Phentermine and Topiramate (Qsymia)

Bupropion and Naltrexone (Contrave)

Liraglutide (Saxenda, Victoza)

Treating Morbid Obesity with Weight Loss Surgery

Weight loss surgery, also known as bariatric surgery, is typically one of the last options used for morbid obesity treatment.3 Weight-loss surgery limits the amount of food that you can eat and/or decreases your absorption of food and calories.

There Are Risks

While weight loss surgery can help you to lose a lot of weight, it also poses some serious risks. To qualify for weight-loss surgery, you need to have a BMI of 40 or higher, or a BMI of over 35 with a serious weight-related problem such as diabetes or high blood pressure.

You Still Have to Make Lifestyle Changes

You also need to be ready to make the necessary lifestyle changes that will help the surgery to work and help you to maintain a healthy weight. While weight-loss surgery can help people lose up to 35% of their body weight, it is not a miracle cure, and for the weight to stay off, healthy lifestyle habits must be adopted.3

Recovering from Morbid Obesity

This guide has discussed what morbid obesity is, how it happens, and how to treat it. We also discussed your right not to be shamed or discriminated against while you recover from morbid obesity. The guide also touched on technology to ease the strain of morbid obesity while you lose weight. Another focus topic in this article is that there is no magic pill to weight loss and you should avoid fad diets, sticking with well-supported weight-loss strategies.

Losing weight requires difficult lifestyle choices, but the benefits to your health make them all worthwhile. You are not struggling with obesity alone, many other people are struggling right along with you, and there are many professionals to help your weight loss journey. We hope this guide can inspire you to start, or continue, your weight loss efforts. You can do it!


Resources

  1. https://www.cdc.gov/nchs/products/databriefs/db360.htm#:~:text=The%20age%2Dadjusted%20prevalence%20of%20severe%20obesity%20among%20U.S.%20adults,60%20and%20over%20(5.8%25)
  2. https://www.lifespan.org/centers-services/center-bariatric-surgery/health-risks-morbid-obesity
  3. https://www.mayoclinic.org/diseases-conditions/obesity/diagnosis-treatment/drc-20375749
  4. https://www.cdc.gov/nchs/fastats/body-measurements.htm
  5. https://obesitymedicine.org/what-is-morbid-obesity/
  6. https://bit.ly/apa-icd-10-codes
  7. https://www.yesmagazine.org/social-justice/2019/06/24/fat-acceptance-movement/
  8. https://www.macmh.org/wp-content/uploads/2014/05/18_Gallivan_Teens-social-media-body-image-presentation-H-Gallivan-Spring-2014.pdf
  9. https://www.dietdoctor.com/my-single-best-weight-loss-tip
  10. https://www.healthline.com/health-news/debunking-the-obesity-code-diet#Heres-what-the-experts-think