Obesity

What is obesity?

Obesity is a complex, chronic disease with several causes that lead to excessive body fat and sometimes, poor health. Body fat itself is not a disease, of course. But when your body has too much extra fat, it can change the way it functions. These changes are progressive, can worsen over time, and they can lead to adverse health effects.

The good news is that you can improve your health risks by losing some of your excess body fat. Even small changes in weight can have a big impact on your health. Not every weight loss method works for everyone. Most people have tried to lose weight more than once. And keeping the weight off is just as important as losing it in the first place.

Is obesity defined by your weight?

Healthcare providers commonly use the Body Mass Index (BMI) to define obesity in the general population. The BMI measures average body weight against average body height. As a generalization, healthcare providers associate a BMI of 30 or higher with obesity. Although BMI has its limitations, it’s an easily measurable indicator and can help alert you to obesity-related health risks.

Examples of limitations include bodybuilders and athletes, who have more muscle and may have higher BMI scores even though their fat levels are low. It’s also possible to have obesity at a “normal” weight. If your body weight is average but your body fat percentage is high, you may have the same health risks as somebody with a higher BMI.

Healthcare providers have also observed ethnic differences in how much extra weight different people can carry before it affects their health. For example, people of Asian descent are more likely to have health risks at a lower BMI, and Black people are more likely to have health risks at a higher BMI.

Another way of assessing obesity is by measuring waist circumference. If you have more body fat around your waist, you are statistically more at risk of obesity-related diseases. The risk becomes significant when your waist size is more than 35 inches for people assigned female at birth or 40 inches for people assigned male at birth.

What are the three types of obesity?

Healthcare providers classify obesity into class types based on how severe it is. They use BMI to do it. If your BMI is between 25.0 and 29.9 kg/m², they put you in the overweight category. There are three general classes of obesity that healthcare providers use to evaluate what treatments may work best for each person. They include:

• Class I obesity: BMI 30 to <35 kg/m².
• Class II obesity: BMI 35 to <40 kg/m².
• Class III obesity: BMI 40+ kg/m².

What is “morbid” obesity?

"Morbid obesity" is an outdated term for class III obesity. In medical language, “morbidity” means associated health risks. Doctors referred to class III obesity as “morbid” because it was most likely to come with related health problems. However, they retired the term because of its negative connotations.

How is childhood obesity assessed?

Healthcare providers also use BMI to calculate obesity in children, but they calculate it relative to the child’s age and assigned sex. A child older than 2 years may be diagnosed with obesity if their BMI is greater than 95% of their peers in the same category. Different growth charts may present slightly different BMI averages, based on the population they are sampling.

How common is obesity?

Obesity in American adults was last surveyed in 2017-2018. The prevalence was 42.5%, up from 30.5% in 1999-2000. In that same period, the prevalence of class III obesity almost doubled from 4.7% to 9.2%. Childhood obesity in America from 2017-2018 was 19.3%.

Worldwide, obesity has nearly tripled in the last 50 years. The rise has been especially dramatic in lower-income countries where malnutrition is common. These communities now have greater access to higher-calorie foods with low nutritional value. Obesity now commonly coexists with undernutrition in these countries.

How does obesity affect my body?

Obesity affects your body in many ways. Some are simply the mechanical effects of having more body fat. For example, you can draw a clear line between extra weight on your body and extra pressure on your skeleton and joints. Other effects are more subtle, such as chemical changes in your blood that increase your risk for diabetes, heart disease and stroke.

Some effects are still not well understood. For example, there is an increased risk of certain cancers with obesity. We don’t know why, but it exists. Statistically, obesity increases your risk of premature death from all causes. By the same token, studies show that you can significantly improve these risks by losing even a small amount of weight (5% to 10%).

Metabolic changes

Your metabolism is the process of converting calories into energy to fuel your body’s functions. When your body has more calories than it can use, it converts the extra calories into lipids and stores them in your adipose tissue (body fat). When you run out of tissue to store lipids in, the fat cells themselves become enlarged. Enlarged fat cells secrete hormones and other chemicals that produce an inflammatory response.

Chronic inflammation has many adverse health effects. One way that it affects your metabolism is by contributing to insulin resistance. This means your body can no longer use insulin to efficiently lower blood glucose and blood lipid levels (sugars and fats in your blood). High blood sugar and blood lipids (cholesterol and triglycerides) also contribute to high blood pressure.

Together, these combined risk factors are known as metabolic syndrome. They are grouped together because they all tend to reinforce each other. They also reinforce further weight gain and make it harder to lose weight and sustain weight loss. Metabolic syndrome is a common factor in obesity and contributes to many related diseases, including:

• Type 2 diabetes. Obesity specifically raises the risk of Type 2 diabetes seven-fold in people assigned male at birth and 12-fold in people assigned female at birth. The risk increases by 20% for every additional point you gain on the BMI scale. It also diminishes with weight loss.
• Cardiovascular diseases. High blood pressure, high cholesterol, high blood sugar and inflammation are all risk factors for cardiovascular diseases, including coronary artery disease, congestive heart failure, heart attack and stroke. These risks increase hand-in-hand with your BMI. Cardiovascular disease is the leading cause of preventable death worldwide and in the U.S.
• Fatty liver disease. Excess fats circulating in your blood make their way to your liver, which is responsible for filtering your blood. When your liver begins storing excess fat, it can lead to chronic liver inflammation (hepatitis) and long-term liver damage (cirrhosis).
• Kidney disease. High blood pressure, diabetes and liver disease are among the most common contributors to chronic kidney disease.
• Gallstones. Higher blood cholesterol levels can cause cholesterol to accumulate in your gallbladder, leading to cholesterol gallstones and potential gallbladder diseases.

Direct effects

Excess body fat can crowd the organs of your respiratory system and put stress and strain on your musculoskeletal system. This contributes to:

• Asthma.
• Sleep apnea.
• Obesity hypoventilation syndrome.
• Osteoarthritis.
• Back pain.
• Gout.

According to the U.S. Centers for Disease Control and Prevention, 1 in 3 adults with obesity also has arthritis. Studies have shown that for every 5 kg in weight gain, your risk of knee arthritis increases by 36%. The good news is that, together with exercise, weight loss of 10% can significantly reduce arthritis-related pain and improve your quality of life.

Indirect effects

Obesity is also associated indirectly with:

• Memory and cognition, including a heightened risk of Alzheimer’s disease and dementia.
• Female infertility and pregnancy complications.
• Depression and mood disorders.
• Certain cancers, including esophageal, pancreatic, colorectal, breast, uterine and ovarian.

What causes obesity?

On the most basic level, obesity is caused by consuming more calories than your body can use. Many factors contribute to this. Some factors are individual to you. Others are built into the structure of our society, either on a national, local or family level. In some ways, preventing obesity requires consciously working against these multiple factors.

Factors that may increase calorie consumption include:

• Fast and convenience foods. In communities and families where highly-processed fast and convenience foods are dietary staples, it’s easy to consume a lot of calories. These foods are high in sugar and fat and low in fiber and other nutrients, which can leave you hungrier. Their ingredients promote addictive eating patterns. In some communities, these may be the only types of foods readily available, due to both cost and access. The Centers for Disease Control estimate that 40% of households in America live more than a mile from healthy food retailers.
• Sugar is in everything. The food industry is not designed to maintain our health. It’s designed to sell products that we will become addicted to and want to buy more of. High on that list of products are sweets and sugary drinks, which have no nutritional value and a lot of added calories. But even standard foods have high levels of added sugar to make them more appealing and addictive. It’s so common that it’s changed our taste expectations.
• Marketing and advertising. Pervasive advertising pushes processed foods, sweets and sugary drinks, the products that we need the least but that the industry needs us to buy the most. Advertising makes these products seem like a normal and necessary part of everyday life. Advertising also plays a large role in selling alcohol, which adds a lot of empty calories.
• Psychological factors. Boredom, loneliness, anxiety and depression are all common in modern society, and can all lead to overeating. They may especially lead to eating certain types of foods that activate pleasure centers in our brains, foods that tend to be higher in calories. Eating to feel better is a primal human instinct. We evolved to find food, and evolution hasn’t caught up to the kind of abundance of food that Western societies now enjoy.
• Hormones. Hormones regulate our hunger and satiety signals. Many things can disrupt these regulatory processes, including common things like stress and lack of sleep and less common things like genetic variations. Hormones can cause you to continue to crave more food even when you don’t need any more calories. They can make it hard to tell when you’ve had enough.
• Certain medications. Medications that you take to treat other conditions may contribute to weight gain. Antidepressants, steroids, anti-seizure medications, diabetes medications and beta-blockers are among them.

Factors that may decrease how many calories we spend include:

• Screen culture. As work, shopping and social life continue to move online, we increasingly spend more time in front of our phones and computers. Streaming media and binge-watching make long hours of sedentary entertainment more possible.
• Workforce changes. With industry changes trending toward automation and computers, more people now work at desks than on their feet. They also work longer hours.
• Fatigue. Sedentary lifestyles have a snowball effect. Studies show that the longer you sit still, the wearier and less motivated you become. Sitting makes your body stiff and contributes to aches and pains that discourage movement. It also causes general stress, which adds to fatigue.
• Neighborhood design. Many people lack local places to be active, either due to access or safety issues. More than half of Americans don’t live within half a mile of a park. They may not live in walkable neighborhoods, and they may not see others in their communities being active in day-to-day life. When there is no public transportation option, most people can only travel by car.
• Childcare trends. Children spend less time playing outside than they used to. They spend more time in enclosed childcare environments, which may not have adequate space or facilities for physical activity. This is partly due to cultural trends that don’t find it safe for children to play outside unattended. It’s also due to inadequate access to public spaces and inadequate access to quality childcare. Many childcare environments substitute TV for free play.
• Disability. Adults and children with physical and learning disabilities are most at risk for obesity. Physical limitations and lack of adequate specialized education and resources can contribute.

How is obesity diagnosed?

Your healthcare provider will measure your weight, height and waist circumference at your appointment.

More importantly, when you come to your healthcare provider for care, they will want to know your whole health story. They will ask you about your history of medical conditions, medications and weight changes. They’ll also want to know about your current eating, sleeping and exercise patterns and stress factors and whether you have tried any weight loss programs in the past. They may ask about your biological family’s health history.

They will also examine your vital functions by taking your heart rate and blood pressure and listening to your heart and lungs. They may give you a blood test to check your blood glucose and cholesterol levels and screen for hormone problems. They'll use this complete profile to diagnose your obesity and any related conditions you might have.

How is obesity treated?

Your complete health profile will determine your individual treatment plan. Your healthcare provider will target your most urgent health concerns first, then follow up with a longer-term weight loss plan. Sometimes there may be quick changes they can recommend for an immediate impact, like switching your medications. The overall treatment plan will be more gradual and probably involve many factors. Since everyone is different, it may take some trial and error to figure out which therapies work best for you. Studies have repeatedly shown that intense, team-based programs with frequent, personal communication between your provider and you are the most successful in helping people lose weight and keep it off.

Your treatment plan may include:

Dietary changes

The dietary changes you personally need to make to lose weight will be individual to you. Some people may benefit from cutting portion sizes or snacks between meals. For others, it may be more about changing what they eat than how much. Almost everyone can benefit from eating more plants. Fruits, vegetables, whole grains and legumes tend to be lower in fat and higher in fiber and micronutrients. They are more nutritious and can make you feel fuller and more satisfied after eating fewer calories.

Increased activity

Everyone has heard that diet and exercise are both important to weight loss and weight maintenance. But exercise doesn’t have to mean a gym membership. Just walking at a moderate pace is one of the most efficient types of exercise for weight loss. Just 30 minutes, five days a week is what healthcare providers suggest. A daily walk at lunchtime or before or after work can make a real difference.

Behavioral therapies

Counseling, support groups and methods such as cognitive behavioral therapy may have a role to play in supporting your weight loss journey. These methods can help rewire your brain to support positive changes. They can also help you manage stress and address emotional and psychological factors that may be working against you. Weight and weight loss efforts affect us on many levels, so it can be helpful to have support on the human side as well as on the practical side.

Medication

Your healthcare provider may recommend medications to use in conjunction with other treatments. Medications aren’t the whole answer to weight loss, but they can help tackle it from another angle. For example, appetite suppressants can intercept some of the pathways to your brain that affect your hunger. For some people, this might be a small piece of the puzzle, but for others, it might be a bigger one.

Common FDA-approved drugs for treating obesity include:

• Orlistat (Xenical®, Alli®): Reduces absorption of fat from your gut.
• Phentermine (Adipex-P®, Lomaira®, Suprenza®): Decreases your appetite. It’s approved for use for three months at a time.
• Benzphetamine (Didrex®, Regimex®): Decreases your appetite.
• Diethylpropion (Depletite # 2®, Radtue®, Tenuate®): Decreases your appetite.
• Phendimetrazine (Bontril®, Melfiat®): Decreases your appetite.
• Bupropion-naltrexone (Contrave®): May reduce cravings and food intake.
• Liraglutide (Saxenda®): Reduces appetite and slows digestion.
• Semaglutide (Wegovy®): Suppresses appetite.
• Cellulose and citric acid (Plenity®): Makes you feel full.
• Lisdexamfetamine dimesylate (Vyvanse®): Helps manages symptoms of binge eating disorder.
• Phentermine-topiramate (Qsymia®): Makes you less hungry.
• Combination of SGLT2 inhibitors and glucagon-like-1 receptor agonists.

Weight loss surgery

If you have been diagnosed with class III obesity, bariatric surgery may be an option for you. Surgery is a severe but highly effective solution to long-term, significant weight loss. It works by changing your biology instead of just your mind or your habits. All bariatric surgery procedures alter your digestive system in some way. They restrict the number of calories you can consume and absorb. They also change hormonal factors in your digestive system that affect your metabolism and hunger.

Bariatric surgery procedures include:

• Gastric sleeve (sleeve gastrectomy).
• Gastric band (LAP band).
• Gastric bypass (Roux-en-Y).
• Duodenal switch.

How can I prevent obesity?

Preventing obesity is easier than treating it once it has taken hold. Once your body has established a new high “set point," it will consider that to be your new baseline weight. Your body works to modulate your hunger signals and energy expenditure to maintain the same body mass, in spite of your weight-loss intentions.

If you’ve noticed a pattern of recent weight gain in yourself or your child, or if you have a family history of obesity, you might want to take steps to intervene sooner rather than later. Examining your habits and making reasonable changes now can help you prevent future obesity and weight loss struggles.

For example:

• Make a small sacrifice. Do you have a daily snack habit or “pick-me-up,” such as a sugary drink, that is high in calories? Consider replacing it. Just 150 extra calories a day can add up to 10 extra pounds in a year. That’s equal to a snack-size bag of potato chips, or just two double-stuffed Oreos.
• Add a small activity. Alternatively, consider what you might do to spend an extra 150 calories in a day. For example, go for a hike or use an elliptical machine for 25 minutes, or take the dog for a brisk walk for 35 minutes.
• Shop intentionally. Stock your home with healthy foods and save sweets and treats for special occasions when you go out. Whole foods are higher in fiber and lower on the glycemic index, so they don’t cause your blood sugar to spike and drop the way processed snacks and treats do.
• Cultivate overall wellness. Reduce your screen time, go outside and go for a walk. Manage your stress and try to get adequate sleep to keep your hormone levels in check. Focus on positive changes and healthy activities rather than how your efforts affect your weight.

What is the outlook for me if I have obesity?

Obesity puts you at risk of certain adverse health conditions. That doesn’t mean you have those conditions right now. And it doesn't mean that you can’t do anything about them. The risks are worth your concern, but they’re also reversible or manageable. Your healthcare provider will encourage you to reduce them by losing weight. While it will be challenging, it can be done.

Remember, weight loss of just 5% to 10% can significantly improve your health risks. It can slow or stop the progression of fatty liver disease, metabolic syndrome and diabetes. With medical guidance, weight loss of at least this much is achievable, and possibly much more. Sticking with a long-term treatment plan can help you maintain weight loss.

A note from Cleveland Clinic

You may have experienced a bias that obesity is a personal choice or a moral failure. If you’re seeking medical advice for obesity, chances are you’ve already tried to manage it several times on your own.

The good news is that as research continues, breakthroughs in medicine continue to offer new hope for treating obesity. It might take some exploring to land on the right formula for you, but together with your healthcare provider, you can take your health back into your own hands. Even a little weight loss can improve your health on almost every level, and you can reap lifelong benefits from healthy diet and lifestyle changes.