While many individuals have a general understanding that obesity refers to an excessive buildup of weight caused by an excess of fat, its nature is actually more complex. The medical definition of "obesity" refers to a condition where a person's weight in relation to their height exceeds the considered norm, resulting from excess fat stored in tissues.

Today, the accepted measure for "what is obesity" used by health organizations to assess obesity is the Body Mass Index (BMI). This index is calculated by dividing the body weight (in kilograms) by the height squared (in meters).

There are different degrees of obesity based on BMI values:

  • BMI between 18.5 to 24.9: Normal weight
  • BMI between 25 to 29.5: Overweight
  • BMI above 30: Obesity
  • BMI between 30 to 34.9: Obesity Class 1
  • BMI between 35 to 39.9: Obesity Class 2
  • BMI above 40: Morbid Obesity

According to different health organizations' classifications, morbid obesity might include a BMI above 35 (Obesity Class 2) along with additional health conditions such as diabetes, high blood lipid levels, osteoarthritis, obstructive sleep apnea, and more.


Issues with BMI measurement

The BMI measure can be problematic as it is not entirely accurate and does not consider factors such as age, gender, muscle mass, and the distribution of body fat (which can have significant health implications). For example, athletes often have a higher BMI due to a higher muscle mass, not excess fat, so they may not fall into the definition of obesity even if their weight is high.

Due to these limitations, the Obesity Medicine Association (OMA) proposed an alternative definition of obesity as a chronic, relapsing, multifactorial, neurobehavioral disease. In this definition, an increase in body fat leads to impaired adipose tissue function, causing metabolic, biochemical, and physiological changes with significant health consequences.


Abdominal obesity and waist circumference

Because of BMI's limitations, it is common to use an additional measure to assess whether there is visceral obesity (abdominal obesity). This refers to the accumulation of excess fat around the abdomen, resulting in an apple-shaped body structure. Abdominal obesity has serious health implications, as research links it to the development of chronic diseases such as metabolic diseases, cardiovascular diseases, fatty liver, hypertension, respiratory problems, digestive issues, certain types of cancer, and more.

The reason for this is that the adipose tissue in the center of the body secretes biological substances that have an effect on blood vessels, on factors that cause inflammation in the body and on insulin resistance. Studies indicate that the type of obesity (abdominal or peripheral) has a hereditary background, and that in women there is a closer connection between abdominal obesity and metabolic diseases. Hence, when comparing two people who are in the same BMI range, the person with the higher risk of developing heart disease and metabolic disease will be the one suffering from abdominal obesity. This is compared to a person with a pear-shaped body structure, whose fat accumulation is mainly in the buttocks and thighs.

One way to estimate abdominal obesity is by measuring waist circumference or the ratio between waist and hip circumference. If the waist circumference is above 94 cm for men and 80 cm for women, it is strongly recommended to lose weight.

If the waist circumference is above 102 cm in men and above 88 cm in women, or alternatively, when the waist-to-hip ratio is above 1, comprehensive intervention is required for weight reduction, due to the high risk of developing cardiovascular and vascular diseases.

To perform the measurement - after exhaling, a measuring tape is stretched along a line that passes between the lower border of the ribs and the upper border of the hip bone.

It is important to remember that while assessing abdominal obesity does not replace the BMI measurement, it is an important factor when considering weight management options, including medical treatment or surgery.


Obesity as a disease

Obesity is considered a global epidemic. In 2018, the medical community and the Society for Research and Treatment of Obesity officially recognized obesity as a chronic disease. This decision indicates a change in perception and acknowledgment that it is not merely a behavioral problem but rather a disease that does not resolve on its own, resulting from impaired physiological-genetic mechanisms. Hence, individuals with excess weight require comprehensive professional assistance from specialized clinics that combine various types of treatments. All of these are aimed at reducing the number of patients with the disease and the numerous complications associated with it, including mental health, as well as extending life expectancy, which can be significantly shortened due to the significant increase in weight (for example, an individual with a normal weight has an 80% chance of reaching the age of 70, while for an individual suffering from chronic excess weight, the chance drops to 50%).


What are the causes of obesity?

The causes of obesity are very complex, and it is now understood that an explanation based on the claim of "eating too much and exercising too little" is too simplistic. Obesity is caused by a combination of factors, including genetic and epigenetic factors, metabolic factors, psychological factors, socio-economic factors, and, of course, direct links to eating habits and the level of physical activity. Here is an overview of some of the factors involved in excess weight:

Genetic factors

Excess weight has a genetic basis, and for some individuals, certain inherited genes predispose them to weight gain. However, current research goes beyond genetics and discusses epigenetics, which refers to the influence of environmental factors on genetic expression. For example, two individuals with similar genetics can have different weight outcomes based on exposure to environmental factors in early life. Additionally, studies indicate that "junk food" may cause excess weight gain in specific individuals due to its specific impact on their genetics. The field of research in epigenetics brings hope that a deeper understanding of these factors will open the door to treatments that cause weight-related genes to behave in a way that promotes more moderate weight gain. Furthermore, in recent years, research has linked the unique composition of friendly bacteria in each person's gut to the level of weight gain, which is another area under investigation.

Metabolic factors

It is now known that even if the diet of certain individuals is very similar, its impact on weight gain can be different. This occurs because internal factors and processes directly influence how our bodies process the food we eat. This is also one of the reasons why it is very easy to regain all the weight lost through dieting. It happens because when the body "detects" weight loss, it automatically slows down the metabolism because it is programmed to maintain the weight to which it is accustomed. This fact makes it very difficult to maintain a normal weight. However, today it is known that medical treatment or bariatric surgery, for example, can address some of these factors. In addition, it is now known that the disruption of the balance between the satiety and hunger mechanisms in the brain is directly responsible for excess weight gain, and this factor often requires pharmaceutical intervention as a treatment for the disease.

Environmental factors

There are several ways in which the environment affects overweight, and new research in the field brings new information and insights into the risk factors for obesity. Environmental factors have a very early impact, even from the prenatal period. Parental exposure to air pollution and other factors affects the body weight of their children. The living environment and modern lifestyle, including excessive TV viewing, contribute significantly to obesity, as well as the availability of fast food and processed foods influenced by cultural norms, work stress, and family stress - all of these are environmental factors that contribute to excessive food consumption and the choice of non-nutritious foods.

Dietary habits and physical activity

While they are not the sole causes of the problem, the choices related to our lifestyle form the basis for addressing obesity. While everyone knows that the amount of food we eat affects weight gain, not everyone is aware of factors such as eating speed, nutrient balance, and the timing of meals, which also influence weight gain. Stress, low mood, and sleep disturbances (obesity is a risk factor for sleep apnea) increase the risk of overeating and weight gain. Therefore, comprehensive treatment should include nutritional counseling and guidance for a healthy lifestyle by experts in the field, who will empower the individual's knowledge and strengthen their confidence in daily life, even when the choice involves medical treatment or surgery.

Background diseases and medication use

There are health conditions that lead to weight gain, such as underactivity of the thyroid gland, Cushing's disease, and in women, polycystic ovary syndrome (PCOS) causing abdominal obesity. There are diseases that cause weight gain as a result of fluid accumulation, such as kidney disease and heart failure. Medications that may lead to weight gain include steroids, antidepressants, insulin, and sometimes contraceptive pills.


What are the health consequences of obesity?

Reduced life expectancy is one of the main health consequences of obesity. Studies show that in people with obesity, the risk of premature death is 50-100% higher compared to individuals with normal body weight, resulting in a decrease of approximately 8 years in life expectancy. In individuals with a BMI over 40, this risk is equivalent to the risks of smoking.

In addition, people with obesity are at risk of developing chronic diseases such as:


Type 2 diabetes - while in the past type 2 diabetes was mainly diagnosed in adults over the age of 40, the obesity epidemic has led to many young people being affected by the disease and diagnosed in their early teens. Obesity and diabetes are closely related, with 90% of diagnosed individuals with diabetes also having excess weight or obesity.

Bone and joint problems - each year, the number of people requiring joint replacement surgery for weight-related reasons rises, and skeletal and joint diseases organizations claim that 1 in 3 people with obesity will suffer from joint disease. This is particularly concerning as joint pain limits the ability to engage in physical activity, which is important for weight loss. In a state of obesity, any weight gain puts immense pressure on the knees, leading to pain and difficulties in mobility and daily functioning.

High blood pressure and heart disease - high blood pressure is a risk factor for heart and vascular damage. It can lead to stroke and even heart attack or dementia. In the Framingham Heart Study, which lasted for 44 years, excess weight and obesity were associated with 26-28% of cases of high blood pressure. Excess fat puts an additional burden on the heart and can lead to life-threatening artery blockages. Cardiac health organizations warn that individuals with obesity are at a higher risk of developing heart disease. Weight loss in individuals with high blood pressure can contribute to a noticeable decrease in blood pressure, reduced medication intake, and a lower risk of hypertension-related diseases.

Digestive system diseases - Reflux (GERD) is a common condition in overweight individuals, where food in the stomach rises up to the esophagus, causing irritation of the tissue and symptoms such as heartburn. However, beyond the discomfort caused by reflux, it can lead to a condition called Barrett's esophagus, which significantly increases the risk of esophageal cancer.

Oncology diseases -Obesity is linked to a significant increase in the risk of various types of cancer, including colorectal, esophageal, breast, ovarian, kidney, pancreatic, and thyroid cancer. Studies estimate that thousands of new cancer diagnoses related to obesity are added each year, reflecting the correlation between increasing obesity rates and cancer cases.

Respiratory problems - Excess fat can obstruct the expansion of the chest, making breathing difficult. The lungs also accumulate excess fat, which affects oxygen exchange in the body. Furthermore, research shows that asthmatic adults with obesity are approximately five times more likely to be hospitalized for asthma-related complications compared to non-obese asthmatic individuals. Respiratory problems also manifest as obstructive sleep apnea, characterized by brief interruptions in regular breathing during sleep, resulting from the pressure exerted by excess fat on the upper airways. Obstructive sleep apnea can lead to snoring, daytime sleepiness, headaches, and high blood pressure, posing a risk for various serious conditions.

Depression - Depression is common among individuals with obesity. Research findings indicate that people with excess weight have a 20% higher risk of developing depression, which, in some cases, can reach up to 44% compared to individuals with normal weight. Symptoms of depression include fatigue, low energy levels, sleep disturbances, and excessive eating.


Can obesity be treated?

The answer is yes!,

And not only that, but treating obesity is critical due to the fact that excess weight is the fifth leading cause of death worldwide and a significant risk factor for a wide range of severe chronic diseases. Studies show that obese individuals have an earlier onset of diseases. Therefore, it is important to address relevant medical factors and initiate early treatment whenever possible.

There are various ways to achieve weight loss, and they all involve changes in diet and lifestyle, including regular physical activity. Nowadays, there are also medications available for weight loss specifically designed for cases where the BMI (Body Mass Index) is above 30 or above 27 in combination with other risk factors such as diabetes, hypertension, high blood lipid levels, and more. Pharmacological treatment is intended for long-term use in conjunction with balanced nutrition and physical activity to maintain its effects over time. In cases of severe obesity, with a BMI above 40 or above 35 with additional medical conditions (such as diabetes or hypertension), bariatric surgery may be recommended if combined treatment with dietary changes and physical activity is insufficient.

One of the main methods that has gained momentum in recent years for treating excess weight and promoting weight loss is pharmacotherapy. In recent years, several medications have entered the global and Israeli markets, operating through different mechanisms to promote weight loss, and it is important to familiarize oneself with them. Medications help patients undergo changes in their dietary and behavioral habits and establish new habits more smoothly. However, medications alone cannot replace the necessary efforts from the patient. Even with pharmacological treatment, weight gain may occur if there are no lifestyle changes. Naturally, the impact of medications is limited to the period of their intake. When they are discontinued, their effects cease. Therefore, it is essential to closely monitor patients both during the period of medication intake and after its discontinuation.

In order for a medication to be defined as a treatment for weight loss, it needs to meet the following criterion: a 5% weight loss in total body weight should be achieved by 35% of the treated individuals using the medication. The weight loss is typically observed within the first 3 months of taking the medication. It's important to note that medications have different effects on individuals, and the role of the physician is to prescribe the appropriate medication with the correct dosage for each patient.

One of the "popular" medications today is called Rybelsus, which is manufactured in Denmark. Rybelsus is used to treat adults with type 2 diabetes. However, based on positive results from clinical trials, Rybelsus may also receive approval for the treatment of excess weight in the future. What makes Rybelsus unique is that it comes in tablet form for oral administration, unlike most other medications for diabetes/obesity treatment available in the market, which are administered by subcutaneous injection. Similar to Ozempic, it affects hunger and satiety mechanisms and contributes to slowing down intestinal emptying. Studies have demonstrated its effectiveness in weight reduction compared to other medications for diabetes.


The mechanism of action of Rybelsus

Rybelsus, the trade name for the active substance semaglutide, is an orally administered medication available in three doses: 3mg, 7mg, and 14mg. It is a synthetic derivative of the hormone GLP-1 (glucagon-like peptide-1) and acts as an incretin mimetic.

It is a protein hormone produced in our intestinal cells, released from them during meals, and circulates in the bloodstream to target organs such as the liver, pancreas, intestines, and brain. GLP-1 has various roles in the human body, but its significance is primarily noticeable in the digestive process and maintaining proper metabolic function. One of its important roles is regulating blood sugar levels. After we eat, and sugar enters the bloodstream from the digestive system, the sugar needs to enter the cells - an essential process for cell survival and proper functioning. GLP-1 plays a crucial role in this task: it circulates in the bloodstream, reaches the pancreas, and stimulates the beta cells responsible for insulin production to increase insulin secretion into the blood. Insulin is another protein hormone that promotes the entry of sugar from the blood into the body's cells through specific pathways. Once inside the cells, sugar serves them as an energy source for various important functions. If the amount of GLP-1 is reduced, it will lead to a decrease in insulin secretion into the blood, and as a result, the cells will not receive the required amount of sugar for their activity. Additionally, the sugar that does not enter the cells will accumulate in the blood and may contribute to the development of diabetes. Therefore, GLP-1 also plays an important role in regulating the entry of sugar into the cells, providing the necessary energy for the cells, and preventing metabolic diseases.

In addition to that, GLP-1 has an important role in regulating the feeling of hunger. Firstly, the hormone causes the food entering the intestines to stay there for a longer period than usual before continuing to move through the digestive tract, reaching the intestine, and being absorbed into the bloodstream. Therefore, in the presence of this hormone, the intestine remains full for an extended period, signaling the hypothalamus in the brain that there is no need for more food, thus giving us a feeling of satiety. Secondly, GLP-1 also has an influence on the pancreas. In addition to the previously described effect, it also inhibits the production and secretion of the hormone glucagon by the alpha cells in the pancreas. Glucagon is responsible for signaling a state of hunger in the body, indicating low blood sugar levels. In such a state, it triggers the breakdown of energy stores and the release of sugar into the blood. Therefore, suppressing its release contributes to the regulation of blood sugar levels and the control of hunger.

Because of all the above,  Rybelsus is attributed with reducing hunger sensation, increasing satiety, and assisting in weight reduction.

Although Rybelsus is not a medication specifically indicated for weight loss, recent clinical studies have indicated the potential of the active substance in Rybelsus (semaglutide) to assist individuals with excess weight in achieving an average weight reduction of 10-15% - a highly significant weight loss percentage that can help reduce the risk of developing severe chronic diseases. These studies also showed greater improvements in obesity-related comorbidities and waist circumference reduction among the group receiving the medication. The safety profile was high, and the adverse effects were mild and similar to the placebo group. The side effects of Rybelsus include gastrointestinal disturbances, which typically resolve within a few days to few weeks. Nutritional therapy is also necessary to enhance the effectiveness of the medication.

By monitoring individuals taking the medication, several effects were observed:

  • They felt satisfied with smaller amounts of food.
  • It was easier for them to identify the point of satiety.
  • After a meal, they experienced mental tranquility and thought less about food.
  • Their ability to delay eating improved - they stopped before eating and considered what would be appropriate to eat.
  • The treated individuals required fewer meals per day and could easily perform fasting protocols.
  • Changes in taste preferences were noted.
  • The craving for sweets and overall food intake decreased.

To maximize the effectiveness of medications and prevent cases of weight regain, their use should be accompanied by a personalized diet and physical activity tailored to the individual. Only a comprehensive and multidisciplinary approach can ensure a genuine change in the patient's lifestyle, leading to healthier and more balanced lives, both physically and mentally.

Following the significant success of GLP-1 medications and their widespread promotion on social media, more and more people who want to lose weight but do not meet the criteria for legally obtaining a prescription turn to the "gray market" of counterfeit drugs, many of which are not the original medications. This worrying phenomenon prompted the FDA to issue a warning regarding the use of these counterfeit drugs, claiming that users may not receive the original ingredients contained in the authentic medication, and they may not be sufficiently effective. In more severe cases, users are putting their health at risk by consuming unregulated substances that can be toxic, all without the necessary medical supervision required for this type of medication.


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