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Shamim I.  Ahmad
Editor

Obesity
Clinical, Surgical and Practical Guide
Second Edition
Editor
Shamim I. Ahmad
Nottingham, UK

ISBN 978-3-031-62490-2 ISBN 978-3-031-62491-9 (eBook)

https://doi.org/10.1007/978-3-031-62491-9

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The editor dedicates this book to his
late father and mother, Abdul Nasir and
Anjuman Ara, respectively, who played the
important roles to bring the editor to this
stage of academic achievements with their
esteemed love, sound care, and sacrifice.
Dedication also goes to his wife, Riasat
Jan, for her patience and persistence
encouragement to produce this book, as
well as to the children, Farhin, Mahrin,
Tamsin, Alisha, and Arsalan, especially
the latter two children for providing great
pleasure with their innocent interruptions,
leading to the energy of the editor to be
revitalized. Next, his best wishes go to the
people suffering from obesity, for their
recovery from this disease and avoid all
kinds of ailments resulting by this disease.
Finally, his dedication goes to his loving
and caring Prof. Dr. Fumio Hanaoka
who is continuing his work in Japan, and
Profs. Dr. Robert H. Pritchard of Leicester
University, England and Dr. Abe Eisenstark
of University of Missouri, Columbia, USA,
now no more with us.
Preface

It was the year 2015 when I realized that the number of obese people on the
street has increased in comparison with the people say for 10 years ago. My
research survey then confirmed that the obesity has gone up not only from
what I observed on the street but it is going up globally with a high rate. I
then decided and proposed my publisher about writing a book on obesity,
and this was approved. I then invited my co-author Dr. Khalid Imam to join
me in publishing a book, and in 2016, Springer published our first book on
obesity, and the title of the book is Obesity a Practical Guide.
We, as editors invited at global level those scientists working on obe-
sity to participate with their high quality research, esteemed knowledge and
superior publication abilities to contribute a chapter (or more) for our book.
Sixty-seven authors and co-authors contributed toward the book resulting in
27 chapters. Every chapter covers different aspects of obesity, comprehen-
sively, and with best quality.
Then in 2022, I approached again to the same publisher proposing three
different titles to be selected one of them for the next forthcoming publica-
tion. I was advised to work on a book “Obesity—edition 2”. It was said that
this second edition would be most appropriate because the rate the obesity
is continuously increasing and may not be that far that in certain population
this disease may slip on where 50% of the people may be suffering from
this disease.
On this occasion, due to my sub-editor’s other commitments, I was to
take-up solo this challenge. About deciding its title I noted that a number of
important chapters were missing or taken lightly in the first book. I focused
on them, and the title selected for this book is Obesity: Clinical, Surgical
and Practical Guide.
The contents of this book have been divided into 7 parts, and chapters are
numbered from 1 to 21.

Part I: Introduction to Obesity

In many parts of the world, obesity now has taken the form of epidemic,
and both developed and developing nations are becoming concerned about
it. The World Health Organization (WHO) predicted that by 2025, 167 mil-
lion adults and children will be affected due to this disease. Moreover, it

vii
viii Preface

will lead to the development of several comorbidities, including type-2 dia-

betes, cancer, fatty liver diseases, hypertension, hormonal disturbances, car-
diovascular disease, and inflammatory disorders. Most common causes of
obesity are overeating, lack of exercise sedentary life style, and consump-
tion of junk and unhealthy food. Additional causes extracted from Google
are poor nutrition, hormonal problems (such as caused by hypothyroidism),
and problems with the metabolism, e.g., weight cycling (the so-called yo-yo
effect), depression, and lack of sleep.
Chapter 1 is contributed by Angela Golden, and she is presenting the data
of 2016 from the WHO that since 1975 the population of obese people has
tripled and causing a huge burden on the global economy of two trillion dol-
lars per year? Further important point added is that Adiposopathy, which
is caused by obesity, impacts almost every system in the human body with
over 200 obesity-associated disorders now identified, including 14 types of
cancers.
Obesity is defined as the weight gain in human over and above the nor-
mal weight one should have. Until recently obesity was considered as a con-
dition but now with the global uncontrolled and speedy increase of obesity
it has been declared as a disease. Obesity has been classified into two major
types: pre-obesity or overweight and obesity. The measurement of obesity
is known as Body Mass index or BMI. BMI is calculated by dividing the
weight in kilograms by the height in meters squared. For example, a weight
of 73 kg and height of 1.70 m = 73 kg/2.89 m = 25.26 kg/m2 or a BMI of
25. A BMI below 18.5 is underweight; between 18.5 and 24.9 is healthy,
between 25 and 29.9 is overweight and 30 or over is obese. A fourth reading
of above 35 is regarded as morbidly obese. This measurement is only for the
fully grown adult and is different from the BMI measurement for children.

Part II: Diseases Associated with Obesity

Chapter 2 presented by Carmo-Silva and Nobrega explores the relationship

between the brain and body weight regulation, focusing on the disruptive
impact of obesity.
To start with the hypothalamus part of the brain has been identified to
play a pivotal role in regulating food intake and energy balance. Also that
certain molecular and structural alterations can induce, impacting hormo-
nal and neurotransmitter signaling revealing a finely tuned system govern-
ing hunger and satiety. These authors carried out some brain imaging that
revealed how obesity promotes different structural changes within the brain
promoting impaired neuronal activity and connectivity, and brain atrophy
affecting different structural changes within the brain correlating obesity
and complex disorders such as dementia, certain neurodegenerative dis-
eases, sleep disturbances, anxiety, and depression. It is suggested that such
impairments can be overcome by changing the life style, bariatric changes,
and anti-obesity drugs.
In Chap. 3, Md. S. Hossen and the co-authors have highlighted the rela-
tionship between changes in adipose tissue mass and inflammation as well
as their genetic linkage with cancer and insulin resistance. Earlier studies
Preface ix

found that various inflammatory disorders are developed in fatty people due
to the elevated level of inflammatory mediators, playing the cabalistic role
in the development of the disease. Especially factors, such as leptin, plas-
minogen activator inhibitor-1, and adiponectin, and these contribute to car-
cinogenesis and carcinogenic progression. Also cytokines in obese adipose
tissue promote the spread of tumor cells, leading to metastasis.
The same authors in Chap. 17 have presented a detail analysis of genetic
variants connected to obesity—thus included in this part.
Genetic variation significantly affects how individuals respond to an
“obesogenic” environment. Genetics of obesity is divided into subgroups
like monogenic, syndromic, and polygenic or common obesity based on
genetic aetiology. As yet eleven genes have been identified as causative
agent of monogenic obesity. These include POMC, LEP, LEPR, PCSK1,
and MC4R. Polygenic obesity is linked with mutations in TFAP2B,
CYP27A1, IFNGR1, PARK2, UCP2 and UCP3, ADRB1-3, SLC6A14,
NPY, MC3R, and FTO. Studies of these candidate gene genome-wide
association studies (GWAS) have been playing important roles for study-
ing polygenic obesity. Also the GWAS study has played important roles
to determine the association between SH2B1, FTO, MC4R, KCTD15,
NEGR1, and TMEM18 genes with the pathogenesis of obesity.
In Chap. 4, the studies of T. Tabassum and S. Khan although found that
the obesity-linked leptin is positively correlated with cancer progression in
some cancers, yet the information remains unclear whether the defect is in
the genome or in the signaling pathways. To put more light on this infor-
mation, they incorporated two most important common gynaecological can-
cers literature searches, found both in vivo patient and animal models. This
review offers up-to-date and cohesive views of both upstream and down-
stream pathways of leptin in gynaecological cancers. The understanding
of the pathogenesis will tie together all current evidence of similarities or
differences in how leptin affects major types of cancers in women with the
hope of designing better therapeutic strategies in the future for those obese/
overweight women with cancers.
In Chap. 5, G. Seravalle and G. Grassi have critically analyzed the occur-
rence of hypertension in obese people and this is what they have said: Obesity
pandemic worldwide affecting the obese people to suffer from hypertension
and to the cardiovascular morbidity leading to a significant increased pressure
to hospitals and cost increased to the healthcare system. Several pathophysi-
ological mechanisms have been discovered to prevail both in obesity and obe-
sity-induced hypertension. These include the increase in adrenergic tone and
impairment in reflex mechanisms, renal hyperfiltration, activation of rennin-
angiotensin-aldosterone system, endothelial dysfunction, and increase in oxi-
dative stress.
In Chap. 6, P. Ginod and M. Dahan described and highlighted the links
between polycystic ovary syndrome (PCOS), obesity in women, and adverse
obstetrics outcomes, which has only recently started to be studied.
It is claimed that the obesity induces gynaecologic and obstetric compli-
cations throughout women’s reproductive life spans. Also PCOS appears to
be a risk factor for obstetrical complications, problematic reproductive and
x Preface

pregnancy outcome, and PCOS remains a risks factor for infertility. Indeed,
PCOS patients with or without obesity present specific obstetrics complica-
tions likely linked to altered endometrial function mediated by hyperandro-
genism, hyperinsulinism, and insulin resistance.
In Chap. 7, T. Barber and his co-authors discussed aspects of PCOS, in
that there is a close association between female obesity and the development
of hyperandrogenism, insulin resistance, and cardiometabolic dysfunction.
These clinical features are most notable in women with PCOS. The under-
lying mechanisms are changes in adipose-related enzyme activities and the
effects of hyperinsulinemia as a co-gonadotrophin within the ovarian theca
cells. Hyperinsulinemia also increases adrenal androgen production and the
pituitary release of luteinizing hormone and suppresses the hepatic produc-
tion of sex hormone binding globulin, thereby increasing the free androgen
index. The development of hyperandrogenemia likely promotes a prepon-
derance of visceral adipose tissue with its attendant effects on enhanced
insulin resistance and cardiometabolic risk.
Further it is proposed that female obesity with hyperandrogenism and
cardiometabolic dysfunction can be controlled by effective and sustained
weight loss. In some women this strategy may be combined with the anti-
androgen therapy and/or metformin.
Chapter 8 by N. C. C. Tapia is on non-alcoholic steatohepatitis which is
one of the earliest diseases first described in 1980. Then in 2020, its name
was changed to Metabolic Associated Fatty Liver Disease (MAFLD).
Patients with MAFLD are older, have a higher body mass index, and higher
proportions of metabolic comorbidities. Also MAFLD has been shown to be
associated with a higher risk of diabetes, chronic kidney disease, and cardio-
vascular disease. The association of fatty liver disease with obesity and/or
type-2 diabetes mellitus has been well established.

Part III: Treatment of Obesity: Clinical, Surgical,

and Physical Activities

Scientists and researchers are still remaining to find a suitable ‘cure’ for
obesity which is easy to be implemented by most people. This is evident
from the fact that most people who lose weight regain their obesity within a
few years. Despite this fact, non-fattening diet and regular exercise remains
the best alternative to control obesity. My search reveals that the only
weight loss drug approved by the Food and Drug Administration (FDA) for
long-term use is orlistat. Yet it remains a contradicted issue based on the
claim that this medicine can make people to eat less or make less of the
energy from food to be absorbed by their elementary canals.
In Chap. 9, T. Lopez and co-authors indicate that the prevalence of over-
weight and obesity worldwide has seen a significant increase since 1980,
with rates approximately doubling. Currently, more than one-third of the
global population is classified as overweight or obese and if the current
trends persist, it is projected that 57.8% of the world’s population will be
overweight or obese by the year 2030. As a consequence of this escalating
trend, anesthesiologists, critical care physicians, and emergency physicians
Preface xi

are encountering an increasing number of obese patients requiring elective

or urgent procedures under general anesthesia, which often involves airway
manipulation. In this chapter, the authors describe how the airways can be
managed in obese people when required.
Managing the airway in obese patients poses a considerable challenge
due to their unique anatomical and physiological characteristics, which can
lead to more rapid de-saturation compared to lean patients. Consequently,
a carefully planned approach to airway management in these individuals
is crucial. It necessitates establishing alternative strategies in case the pri-
mary plan fails, as well as focusing on correct positioning, preoxygenation,
apneic oxygenation, and optimization of various techniques to ensure the
safe and effective management of the airway in obese patients. By incorpo-
rating these elements into their practice, medical professionals can enhance
patient safety and minimize complications during airway interventions for
obese individuals.
In Chap. 10, Lucia F. C. Pedrosa and co-authors have presented a com-
prehensive and important issue about the role of vitamin D in metabolic
syndromes. The primary function of vitamin D is to maintain serum calcium
and phosphorus levels to ensure bone homeostasis. People at risk group
including older people, individuals suffering from metabolic syndrome (Met
S), osteoporosis, and chronic renal failure, obese, and pregnant and lactating
women should be checked for vitamin D deficiency.
Different pathophysiological mechanisms have been proposed to underlie
the effect of vitamin D on Met S components. Serum 25 (OH) D concen-
trations have been negatively associated with Met S components including
fasting blood glucose, blood pressure, and triglycerides. Among the genetic
factors underlying the hereditary risk of Met S, some involve polymor-
phisms (SNPs) in genes associated with vitamin D pathways. Other genetic
functions and events have been highlighted in great detail in this chapter.
Surgery of different type has been considered important tool to treat obe-
sity, and the gastric pass remains the most common weight loss surgery. In
this surgery, the stomach of the patient made smaller; this makes the patient
feel full after eating less food and results in their body to absorb less calo-
ries. Normally very obese people are selected to undergo this surgery. The
other treatment obese patients undergo is bariatric surgery.
In Chap. 11, A. M. Yerdel and G. Ozgen have presented a comprehensive
information with critical analysis of bariatric surgery on obese patients with
its pros and cons. It says that the bariatric surgery remains an invaluable
option in chronically obese people who cannot manage their weight loss by
other means. Bariatric surgery can affect the patients through the resolution
metabolic syndrome and cardiovascular risk reduction and may also be due
to cancer risk reduction.
Referring to the introduction and the importance of bariatric surgery it
is said that in late 1980s, upon introduction of laparoscopy to the general
surgical practice, bariatric surgery increasingly became a valid option for
the therapy of chronic obesity in patients with repeat failures of diet efforts.
Initially, the age limit of 18–60 was applied, but latter it was changed from
puberty to 65.
xii Preface

In Chap. 12, M. Kundu and L. R. M. Salazar have presented a review on

the neurosurgical consideration for the obese patients. The increased preva-
lence of obesity brings about a challenge to the neurosurgeons in treating
this group of patient including various neurosurgical aspects and challenges
associated with obese patients. It examines the impact of obesity on surgical
risk assessment, anaesthetic management, positioning, intraoperative moni-
toring, and postoperative care. Also discussed is the incidence of obesity-
related complications and recommend weight management strategies before
surgery took place and after neurosurgical procedures. Also highlighted is
the importance of a multidisciplinary approach to address the specific needs
and potential complications of obese patients undergoing neurosurgery.
Chapter 13 by H. Hamasaki has presented a critical and comprehensive
review on the subject of global pandemic obesity inducing a critical health
problem for humans.
Structured exercise and daily physical activities (PA) retain the key to
solving this issue. Clinical evidence regarding the role of PA in the man-
agement of obesity is highlighted and discussed how to use these activities
by obese individuals. The author overviewed nine systematic reviews and
meta-analyses assessing the effects of exercise interventions and four sys-
tematic reviews and meta-analyses assessing the effects of PA promotions/
interventions on obesity. Structured exercise programs, especially the com-
bination of aerobic exercise and resistance training, effectively decreased
weight and improved body composition in obese people. However, the
amount of its effect found was small compared with structured exercise
and body composition seemed not to be changed. Non-exercise activity
thermogenesis (NEAT) also plays a key role in energy expenditure in peo-
ple. Several studies investigated the effect of NEAT on health outcomes in
humans. However, it is not fully clear because of the limitations of studies
and the inaccuracy of measuring NEAT.

Part IV: Controls of Obesity

Chapter 14 by F. Shidfar and M. Sohouli has presented in detail a critical

analysis on the effects of omega-3 supplementation on obesity and over-
weight. Although a number of international studies have evaluated the poten-
tials of weight-reduction effect of omega-3, to obtain better information the
authors of this chapter went through an exhausting search to the already pub-
lished research articles and determined the effects of omega-3 supplementa-
tion on weight loss in the healthy and unhealthy groups of people.
For this Scopus, PubMed/Medline, Web of Science, Cochrane, and Embase
databases were searched using standard keywords to identify all controlled tri-
als investigating the weight loss effects of omega-3. Pooled weighted mean
difference and 95% confidence intervals were achieved by random-effects
model analysis for the best estimation of outcomes. Thirty-six studies were
included in this review and meta‐regression analysis. Analysis and the results
of their studies have been presented in great detail in this chapter.
Chapter 15 by C. Gezer describes the anti-obesity effects of anti-inflam-
matory polyphenols. The effect has been observed in the microenvironment
Preface xiii

of adipose tissue which changes in obesity, and this poses a health risk.
Hypertrophy, infiltration of immune cells, hypoxia, and fibrosis as micro-
environmental changes have been occurring as a result of excessive lipid
accumulation of adipocytes. Obesity-associated inflammation basically
depending on microenvironmental changes of adipose tissue, but when die-
tary polyphenols are present they can modify adipose tissue microenviron-
ment against obesity.
Various polyphenols are secondary plant metabolites, characterized as a
phenolic compound. Polyphenols-associated obesity via anti-inflammatory
roles are flavonoids, phenolic acids, and non-flavonoids. The anti-obesity
effects of polyphenols via anti-inflammatory pathways have been studied
with the cell culture (3T3-L1 adipocytes) and animal (C57BL/6J mice).
Resveratrol and catechins, these two polyphenols have drawn more atten-
tion of the researchers and extensive studies carried out. In spite of these
studies there is lack of clinical studies to demonstrate the anti-inflammatory
response of those polyphenols.
Chapter 16 by M. A. de Souza Pinhel and co-authors took an unusual
path and presented the truth about the influence of endocrine disruptors on
obesity and that what can be done.
Endocrine disruptor can be defined as an exogenous substance or mixture
with the potential to disrupt hormonal regulation, the normal endocrine sys-
tem, and consequently causes adverse health effects in humans. Among var-
ious toxicological mechanisms of action, non-essential heavy metals have
been considered as endocrine disruptors (EDs) through interference with the
adipose tissue metabolism.
One of the known risk factor for a number of chronic conditions is obe-
sity which is triggered by the disruption of adipose tissue homeostasis and
has been proven to favor a pro-oxidative and pro-inflammatory environment.
Human exposure to heavy metals such as arsenic, cadmium, and lead has
been associated with metabolic alterations, especially because they induce
oxidative stress by inhibiting the activity of superoxide dismutase, reduc-
ing antioxidants, or binding to -SH groups of proteins. Also addresses the
main elements recognized as EDs and how they can alter genetic and epi-
genetic mechanisms, creating a risk scenario for obesity and associated
comorbidities.

Part V: Genetics of Obesity

Chapter 17: This chapter by Md. S. Hossen and the co-authors with the title
“Genetics Variants Connected to the Obesity” has been combined with Chap. 3.

Part VI: COVID-19 and Obesity

Chapter 18 by S. Chiappetta and co-authors has addressed the role of

COVID-19 in chronic inflammation in patients with obesity. The virus plays
a pivotal role in the pathophysiology, induces a multifactorial chronic dis-
ease with systemic inflammation, and elevates pro-inflammatory cytokines
xiv Preface

and adipokines. Patients with obesity are additionally more prone to comor-
bidities that exacerbate the clinical course of COVID-19, comprising of
type-2 diabetes mellitus, cardiovascular disease, and lung disease. Lastly,
patients with obesity are at a heightened risk of clinically severe illness and
mortality from COVID-19.

Part VII: Psychosocial Aspects of Obesity

Chapter 19 by S. M. Ramalho et al. presents an overview of psychological

approaches for addressing childhood obesity, emphasizing the importance
of patient-centered care. It is a complex and multifaceted health issue and
that it has become a significant public health concern worldwide. Also that
this obesity is steadily increasing, leading to a range of physical, psycholog-
ical, and social consequences. Naturally childhood obesity demands a holis-
tic multisectoral approach, often involving behavioral weight loss treatment
as a core component. Furthermore, it highlights the key role of collaborative
efforts among healthcare practitioners, families, and children, exploring the
current evidence-based practices and frameworks to combat this growing
concern.
Chapter 20 is attended by S. Felix and her team which is presented as an
overview on a unique psychological subject associated with obesity. This is
picked from the current literature on emotion regulation and obesity-related
eating behaviors in adolescents. Firstly, the authors contextualized emotion
regulation in the light of the main well-known theories and discussed about
current evidence about emotion regulation as a transdiagnostic mechanism
in psychopathology. Then moved to highlight the core reasons why ado-
lescence is a critical period to develop difficulties in emotion regulation.
Integrate the existing knowledge into a conceptual framework that considers
the influence of emotion regulation in the development and maintenance of
disordered eating behaviors related to weight gain and obesity is critically
presented. Also explores the underlying factors and discusses implications
for prevention and treatment.
Chapter 21 attended by the team of E. M. Conceicao describes the role
of well-being in bariatric surgery treatment for severe obesity. This obesity
is considered as the most worrying disease and is associated with various
medical and psychological comorbidities. Bariatric surgery has been iden-
tified as the most effective and standard intervention for the treatment of
severe obesity. The surgery contributes to sustained weight loss and better
health outcomes. Understanding the results of bariatric surgeries and psy-
chosocial impact of obesity along with incorporating interventions that
promote well-being are essential to achieving more significant and lasting
results. It is consistently emphasized that psychological well-being plays a
critical role in the success of bariatric surgery. The key factors in achiev-
ing satisfactory long-term weight loss results are emotional support, char-
acteristic of cognitive-behavioral therapy, the promotion of healthy lifestyle
habits and social competence, as well as problem-solving and social sup-
port. Nevertheless, the continued attention given to patients’ mental health
and their support, taking into account the physical, social, psychological,
Preface xv

and emotional aspects associated with the surgery and post-bariatric surgery
periods, contributes to the success of the treatment, a better quality of life,
and the well-being of this population.

Nottingham, UK Dr. Shamim I. Ahmad B.Sc., M.Sc., Ph.D.

Acknowledgements

The editor cordially acknowledges the authors of various chapters to con-

tribute their works, employing their in-depth knowledge, high skills, and
professional presentations. Without their input it would not have been pos-
sible to bring out this valuable book on such highly topical and important
subject. He would also like to acknowledge Melissa Morton, Sanjievkumar
Mathiyazhagan, Emma Kitsell, Kokila Durairaj and Naomi Portnoy of
Springer Publication for their input and friendly approach of handling of
the work. Finally, a special acknowledgement is presented to my son-in-law,
Mir Azam Ali Khan, for his highly skilled, professional class, valuable, and
dedicated IT input to shine this book up to the stage of submission to the
publisher. Without this help, it would have been extremely difficult to pub-
lish this work.

xvii