The worldwide obesity epidemic: a Review
(A 15,000 years'
Daniel O. Belluscio,
Venus of Willendorf
(ca. 15,000-10,000 BCE)
Venus of Laussel
(ca. 15,000-10,000 BCE)
To browse comments on this
industrialized world, obesity has reached epidemic proportions: Recently it has
been declared a major health problem.(1- 7- 24- 29- 43- 76- 85- 104- 112- 117-118-131- 132-
140- 143- 157 -201- 225- 232- 238-239- 291- 338- 339-459-487-488). At
the same time, in today's body-conscious society, overweight individuals are
subjected to diverse
degrees of subjective and objective discrimination. This causes them social adjustment
disorders that range from moderate to severe.
the desire for career advancement and a better self-image, and/or to avoid
overweight individuals flock to any weight control center that offers a cure
for the disease.
In addition to a lowered
self-esteem that can lead to mental instability, obese individuals also must cope with external and internal threats (122).
Keeping a normal weight
is a constant battle. They gain back the weight that they loose the
minute they go off their diet. (86-173-339-364-421).
After many years of this back and
forth, clinical complications arise. Relapses are very common, despite patients'
continuous efforts to keep the weight off.
A common affliction is
that the weight increases with a near normal or a greater than normal intake
of food (5-68- 107-150-164-
208-214-220-243-370- 380- 429- 446- 450- 451). This common clinical
complaint, scientifically ignored for many years, has now been accepted as the main cause
for the difficulty obese people experience in maintaining a desirable weight
after continuous dieting (set-point of body weight
Even when their intake
of food is the same a normal weight these patients have a tendency to gain
weight well beyond what would be expected for the number of calories
consumed. They keep their set-point of body weight control at a higher level than what it should be
according to their age, sex, or height
Obesity is not just a matter of
being overweight. It is also hazardous to health. Although some
near-normal weight subjects also may suffer the same clinical complications
as obese individuals, such
as hypertension, gout and the non-insulin dependent type of diabetes (125- 126-427).
On the other hand, despite an increased accumulation of adipose tissue (Figure
1), some moderately
overweight subjects do not show the classical complications of
obesity. This is particularly true of females. For these
patients, just reducing body weight is enough to improve their clinical
There are some diseases
that are often associated with obesity. The most important of these
disorders that obesity appears to play a role in precipitating or at least
aggravating are: The stable type
of diabetes (now called NIDDM), non-insulin dependent diabetes mellitus, gout, rheumatism, arthritis, high blood pressure and
atherosclerosis, coronary disease, cerebral
hemorrhage and cancer. (11-27-33-34-41-60-90-100-103-114-137- 144- 146-147- 154-
162-163- 185- 206 - 229- 251- 267- 281- 286- 294- 385- 397- 408- 411- 430- 433- 471- 490-
Today's body conscious
society tends to discriminate
against obese individuals. This not only contributes to lowering
self-esteem, but it causes obese individuals to be more prone to bouts of depression.(6-187-386-463-496).
Social discrimination and
obesity: Two studies found that notwithstanding comparable scholastic performance,
obese students are not accepted prestigious colleges as often as their
normal-weight counterparts (94-95-356).
Discrimination in the
workplace: A study by Roe and Eichwort, reported that 16% of employers would not employ
obese individuals under
any circumstances, and an additional 44% would employ them only under special
Another study revealed
that only 9% of individuals who enjoyed incomes between $ 25,000 and $ 50,000 were more than 10 Pounds overweight,
whereas 39 % of those earning $ 10,000 to $ 20,000 were similarly overweight. Each pound
of excess fat costs an executive $ 1,000 a year (512).
The Police, Army and Fire Departments
do not enlist obese individuals.
Landlords are less likely to rent
to overweight individuals.(252)
Almost twice as many obese women
experience bouts of depression as they rise in income class (compared to those who stay at the same social
In every aspect of daily life, obese
subjects are reminded they are not welcomed by their social milieu. Society
dislikes fat as much as obese patients dislike themselves for being overweight. (271-405)..
Loss of self-esteem
Many of obese patients, male
and female, become upset when they look at themselves in the mirror. This Body Image
Disparagement disorder leads to intimacy problems, poor relationship with their
environment, job loss, and decreased self-esteem.(455-458-459).
Two studies reported that obese young women
reported significant dissatisfaction and worry about their weight and the
shape of their bodies. Klesges reported similar results among college
students. He concluded these results may
negatively affect these individuals' quality of life. (494).
Stunkard and Mendelson concluded
makes no difference whether the person in also talented, wealthy or intelligent; weight is
his only matter of concern, and he sees the whole world in terms of his
Upper middle-class women were
affected, because sanctions against overweight are very severe at this social level.(441).
Adolescence may be the more delicate period
for body image disorders.(24).
Thus, constrained by a myriad of social and
subjective factors; receiving no solution to their despair; subjected to many clinical
complications; the strong become indignant and decide that modern medicine is a fraud and
their representatives are fools. The weak just give up the struggle.
In either case, the result is the same:
Further weight gain, resignation to an abominable fate and a resolution to
live a tolerable life during the short span allotted to them - a fight for doctors and Insurance Companies.
treatment: Why did we miss the target?.
Weight control statistics
disappointing results. Treatment of the disease remains a mayor challenge
Medicine (Graphic 1)(1- 2-12-37-42-54-55- 73- 91- 108-116- 135- 136- 165- 176-184-
193- 195- 203- 219- 220-228- 235-247- 259- 269- 299 - 300- 334- 343-349-
363-364-388- 389- 422-431-434- 443- 445- 453- 455- 459- 461-486-495-507-509).
Since no effective treatment has been found so far, several Investigators have
recently adhered to the nihilistic hypothesis that "no treatment is much better that
any treatment at all".
In our opinion, we have missed the target
1. For centuries
obesity has been considered a
minor health problem and has not been given much attention by Medical Community.(179).
2. Highly refined foods
are easily available today. With these foods the digestive system is
spared of the natural and physiologic work that would otherwise be required
to get rid of useless extra calories.(358-360)
3. Tendency to inherit the genetic
trait of obesity.
Looking back, looking
"Obesity problems are perhaps not so
dramatic as the problems of cancer or polio, but often cause life-long suffering. How many
promising careers have been ruined by excessive fat; how many lives have been shortened.
If some way - however cumbersome - can be found to cope effectively with this universal
problem of modern civilized man, our world will be a happier place for countless fellow
men an women." (ATW Simeons 1966).
The term Obesity derives from
the Greek expression: ob-edere, which means over-eating.
For centuries, it was considered a matter
of gluttony, or craving for food.
For many years, women were preferred
chubby, because chubbiness was erroneously linked to a proper motherhood.
No longer. Many obese patients are rejected
by a society that tends to believe that the reason they are obese if because
they are unable to control what they eat.
Pregnant women are strongly advised to maintain their weight within reasonable
Obesity, like fever and anemia, is a
symptom rather than single disease entity: A variety of causes for obesity have been identified in
humans and laboratory animals, but the etiology of obesity
cannot be determined in the overwhelming majority of patients.
Since the underlying causes are poorly
understood, it follows that no effective treatment has been established.
This is unfortunate, because
obesity is a very common disorder, that shortens the life-span of millions of people
around the world.(421)
During the past fifty years, several
treatments have been presented as the solution to this problem.
Some could be classified
others almost useful, and several as health hazardous. Nevertheless, anxious to find
relief, patients flock to Medical Centers, Clinics or any other
entity that offers a cure, .
Unlike a fever, where an
increase in temperature to above 37.8º or 38º C indicates an clinical
condition, obesity is much more difficult to characterize. Several methods for
assessing the disorder have been published recently.
According to classical
height/weight tables, obesity can be broadly described as excess weight
as per the usual Life Insurance Tables.
This method is not a good
determination of body fat because it only estimates weight. Take for example two
individuals of the same weight. The one who tends to gain weight around
the abdomen may be at a greater risk
for heart disease and
diabetes mellitus than another whose fat accumulates in the are of the
Therefore, what method can
we use to establish what makes an individual obese and another normal?
Obesity can be assessed from different
The definition of obesity as an increase
in body weight has prevailed for many years as the most common clinical
tool. It is still being used, although it is not an accurate measure
Recently, relative weight
has become the most
popular and convenient obesity indicator. Relative weight is calculated
by dividing an actual weight by ideal weight according
to and individual's height, age
and sex. A relative weight of 1.20 or greater (i.e.,20% or more over ideal
weight) defines obesity (National Institutes Consensus Development Panel on the Health
implication of Obesity, 1985) (230).
However, there are some problems
with real or relative weight. For example, a person may be overweight without being
The degree of overweight at which an
individual develops a greater risk for cardiovascular complications remains an
Besides, ideal weight
specific populations have changed in recently. We need to be aware of these
Years ago, the Metropolitan Life Insurance
Company issued their Height-Weight Tables. According to these tables the risk of mortality begins to increase substantially at weights 20 per cent
above Desirable. A desirable weight was considered a
standard weight for any given age and height.
versions of these Height-Weight
Tables have become popular through the years.(318-319)
In these tables, the standard weight for a given age and height is based
on the weight that is associated with the lowest rate of mortality for a
given height. However, these tables have some limitations. For
example, since a table of standard weight is required to determine relative
weight, there is no single standard for all patients.
Another problem of these tables is that it is not know how closely an obese
patient must approach the standard to satisfactory reduce health risks.
Currently, the Body Mass Index ( BMI )
experiencing a heyday: This is calculated dividing weight by some power of height
(W/Hp). The power function p is selected for a population to
arrive at the maximum correlation with body fat and the minimum correlation with body
When p is two, the result is
the body mass or Quetelet Index (Kg per m2), the most commonly used weight-height
Body mass Index (BMI) closely relates to
body fat, while being independent of height.(40-263) (Figure 2)
Despite some controversy regarding an
index of 2 for the power function, a standard value of 2 is more practical, and studies
suggested that a value of 2 for p was adequate for men, whereas
a value of 1,5 for p was
preferable for women.
Since these calculations
need to be made every time that weight is estimated, nomograms have been published for
this purpose. (Tables.)
However, as in any mathematical calculation
relative to an indirect evaluation of body fat, BMI suffers from some
All these methods - almost accurate
as they may be - should be viewed with caution: Normal-weight individuals may show all the clinical
complications of obesity despite being of normal or less than normal weight
according to the weight reported by the scale.
This may be described as an excess of
fat. Accurate procedures to estimate fat belong in the realm of the Research
Laboratories. For example, determination of cytoplasmic mass from the naturally occurring isotopes, such as 40
K (316) measurements of the in vivo dilution of isotopes, like tritiated or deuterated
water (172-305) ; underwater weighing to determine body density (302-305); measurements of
total body electrical conductivity with electromagnetic techniques, computed tomography
scanning (170), nuclear magnetic resonance, neutron activation analysis, dual photon
absorptiomethry (84- 304- 315-501-504), and ultrasonography (115).
All these methods can estimate body fat
with variable degrees of accuracy, directly related to performance
However, these procedures are
cumbersome, time-consuming, require highly specialized settings and
facilities and cannot be applied
regularly to larger research studies or populations.
What the clinician needs is
an inexpensive, precise, adequate method that can be used in routine
consultation: Click here for clinical methods to estimate fat content
Genetic influences determine whether an
individual will become obese, but many other factors decide if that
individual will actually be obese (240- 241-257- 275-289- 320- 392- 418- 521).
There is a popular proverb that refers to the fact that no one becomes fat
under starvation conditions that relates to this.
As far as heredity is
several studies on families, adopted children and twins, concluded that a predisposition to
obesity may be genetically determined (14-202-508).
Family studies reported that rough
heredity estimates ranging from 0.40 to 0.60, suggest that genes are responsible for
approximately one-half of the total phenotypic variation in obesity.(454)
However, both reports
reflect only the common set of genes that influence obesity during the ages
being considered, but do not reflect
the impact of age-specific genetic effects. Thus, they may underestimate the
total heredity of obesity at any given point in time (64-65).
Despite the fact that genotype is determined by genes,
phenotype ( the genotype related to external factors) can be a determinant factor
in the genesis of obesity (61-75-462-505).
Phenotype is strongly influenced by
environmental factors (such as easy availability of refined foods), that can
influence the onset of the disorder.
The obese phenotype is a
multifactor trait, determined by genetic and non-genetic factors. Among non-genetic factors,
include total caloric intake, composition of the diet, psychological factors, and
habit-modifications (quitting smoking, for example) (63).
It would be interesting, therefore, to
consider two kinds of genetic effects: the additive effect of genetics and the result of
the genotype-environment interaction.
Genotype account for a significant fraction
of the individual differences in Resting Metabolic Rate, Thermic effect of Food (TEF) and
Thermal effect of exercise (TEE)
Genotype-environment interaction accounts
for the rest in this equation.
It would be reasonable to suppose that,
given a fixed percentage of hereditary factors in the genesis of obesity, the
environmental factors of contemporary society play a key role in the ever increasing
number of obese individuals who live in industrialized nations
Despite claims that increased
physical activity may be a useful method of weight control, several studies
could not confirm that it is the key treatment for the disorder (244-412).
The decrease in physical
activity that is observed in obese individuals could be related to adiposity
level. Basically, the
process of becoming obese requires an over-consumption of food and some basic regulatory
disorder, but once obesity is established, physical inactivity may contribute to aggravate
That over-consumption of food is not the only
cause for the genesis of obesity was clearly demonstrated in a series of
research studies concluding that some volunteers maintained a fairly stable weight throughout the
study, despite a food intake well over
their daily requirement, whereas
those prone to obesity gained weight (427).
However, physical exercise provides some benefits
in the management of obesity: It limits the amount of muscle tissue that is lost during a
weight reduction program; produces psychological benefits, including improvements in mood
and self-esteem, and prevents the urge to snack that is more prevalent
during periods of inactivity (120-379-414-466).
Obesity and overweight are highly prevalent
at every age and in both sexes (67-186). Data derived from NHANES 11 suggest that 32.6
million American adults are overweight as per the BMI definition. Of
million are severely overweight (BMI of 31 or higher (188-245-246-337-338).
It is estimated that in
the United States, about
deaths a year are caused directly or indirectly by obesity.
The frequency of
overweight appears to increase in frequency in the older population. Fifty
two percent of American women and 42 percent of
American men ages 50 to 59 are overweight, whereas the percentage for Americans
between the ages of 20
to 29 is 20. But the young are hardly exempt: 25 percent of children between the
ages of 6 and 17 are now obese according to any standard.(180).
Women have a higher tendency to
be overweight and obese than men. The NHANES 11 survey concluded that 25.8 per cent of American
women and 22.8 per cent of men are overweight, 24 percent of women and 22 percent of men are
Therefore, the prevalence of obesity among
Americans appears alarmingly high. Men's and women's body weights have
progressively increased between 1960 and 1980 (469).
American adults have shown an average
weight gain of nearly eight pounds per person, with 33.4 percent now considered obese, compared
to 25.4 per cent in 1980 and
24.3 per cent in 1962. (469).
Although African American and Hispanic women remain
the groups most prone to obesity (48,6 and 46,7 per cent respectively), the largest increases
have been among white men and women: 7.8 percent and 9.1 percent respectively are
overweight than a decade ago.
Many factors have helped to generate this
epidemic of modern society: Availability of highly refined foods that spares
body of the additional work to digest foods; the misconception that during pregnancy
there are two mouths to feed and a tendency to inactivity and
heredity tending to perpetuate obesity in future generations .
For example, the American food Industry
generates 3,700 calories a day for every man, women and child and spends $ 36
year to advertise its products.(469).
Up to 10,000 food commercials, specially
designed for children, are displayed every year : Nearly all food ads on Saturday
mornings are for sugary, fatty or salty foods.(469).
Concerning our tendency
to inactivity, Kelly Brownell concluded: "The amount of energy that people
used to expend even a decade ago is enormous compared to what they expend
While an increase in physical activity
does not contribute to further weight loss, it elevates the body's aerobic
increases the activity of plasmatic neuropeptides which creates a sense of well-being, and
replaces body fat with muscle mass (which is lighter, but has better aerobic
We still dont know for certain what
metabolic processes lead otherwise healthy subjects develop and maintain
obesity. Therefore, we have outlined a multifactor model encompassing all the
factors capable of causing the disorder.
Each contributes to or aggravates the
condition and the condition becomes more or less severe, depending on the
number of factors
For example: Male subjects with hereditary
obesity traits, who live in an industrialized nation, are subjected to different
psychological pressures and present the abdominal type of body fat
distribution, face greater health risks than a female subject, with no
hereditary obesity traits, with a gynoid type of body fat distribution.
As per the following diagram, all these
factors lead to the same conclusion: They aggravate or generate a subtle modification at the
hypothalamic neurotransmitter level, which in turn initiates an amount of
stored fat greatly exceeding daily energy requirement.
For those of us who
refuse to be
discouraged there is hope. Buried deep in the human brain, there is a
part that humans have in common with all vertebrate animals, the diencephalon. It
is a very primitive part of the brain that, in humans, is buried under masses of nervous tissue
giving us the ability to think, reason and voluntarily move our body.
The diencephalon is the part
central nervous system that controls all spontaneous body functions, such as
breathing, heart-beat, digestion, sleep, sex, urinary system, autonomous or
vegetative nervous system and, via the pituitary, the whole network of endocrine
glands (32-35-113-158-159- 249-273-274-326)
Thus, it is not unreasonable to
assume that the complex operation of fueling the body might also be
controlled by the diencephalon (105-169-182-199- 242- 290-297)
It has been known that the destruction of
another diencephalic center produces a voracious appetite and rapid weight gain
animals that never become fat spontaneously (Simeons, Pounds and Inches)
The hypothalamus is the most studied and
best understood of all the Central Nervous System components regulating food intake and
It has long been recognized that it
plays a key role in the mechanisms regulating food intake and fat
Electrical or chemical destruction
hypothalamic region results in hyperphagia and obesity, or decreased hunger, depending on
the anatomic area where damage has taken place (438-448-449).
A Laboratory lesion of the Ventromedial
hypothalamus results in hyperphagia, hyperinsulinemia, decreased GH secretion, rapid
weight gain, and obesity that persist until a new plateau in body weight is achieved.
verified cases of human hypothalamic obesity due to tumors, inflammations or
injury due to surgery are extremely rare in the literature (71-101).
Therefore, as we have proposed
in a previous
report, slight changes at the hypothalamic neurotransmitters level might
account for the weight gain that obese patients experience despite continued
efforts at dieting.
In fact, some reports suggest that human
obesity might be characterized by a subtle hypothalamic disorder, still not accessible to
current diagnostic methods. Indirect evidence supporting this hypothesis can be presumed
from several data: (36-169-410).
Amatruda et al. demonstrated that a group
of obese males showed an abnormal response to 100 g. of GnrH (gonadotrophin Releasing
Hormone), indicating a dysfunction of the hypothalamus.(15).
Jung et.al. concluded that women with
hereditary obesity traits display a hypothalamic function
disorder that is not totally corrected after weight loss (248).
Kopelman et al., after investigating the
Prolactin response to insulin-induced hypoglycemia, concluded that hypothalamic
function is severely altered in human obesity.(273-264)
Although a hypothalamic regulation of energy
metabolism might be crucial in the genesis of obesity, the food-intake regulatory process
is a complex mechanism encompassing several CNS regions.
Destruction of various components of the
limbic system (temporal and frontal lobes for example) has been shown to cause obesity,
although these are very rare situations.
On the other hand, the hypothalamic region
receives signals from different regions of the body. Many of these
are mediated by neuropeptides (78-293-332).
The regulation of eating behavior, including
receipt of the signal to begin and stop eating, is facilitated by a series of
gastrointestinal humor factors including Cholecystokinin, bombesin, vasoactive
inhibitory peptide, pancreatic polypeptide and gastrin (437-491).
For example, the administration of
Cholecystokinin has been shown to decrease food intake both in laboratory animals and
humans (367). Parenteral administration of bombesin decreases eating in rats, an effect
not eradicated by vagotomy(491).
modifications observed in obesity, changes in the concentration of plasmatic hormones might
also send different signals to the hypothalamic region. For example,
an intracranial administration of insulin to rats and
baboons has been reported to decrease food intake.
Hyperphagia and hyperinsulinemia appear to
be two important factors in the development of hypothalamic obesity in experimental
animals. The later (hyperinsulinemia) seems to be essential for the development of obesity
in animals with a hypothalamic Ventromedial lesion (70).
Since insulin is a lipogenic hormone, an
increased plasmatic level of this substance might account for the excessive fat
that has been observed to accumulate in cases of obesity.
Substances such as norepinephrine, serotonin, Thyrotrophin Releasing Hormone, dopamine and
neural peptides (b-endorphins, Cholecystokinin, dynorphin, enkephalins,
bombesin, etc. act as intermediates in this complex network
These substances might play an important
role also in the genesis of obesity: for example, several data suggest that
a CNS opioid system
regulates energy metabolism and ingestion of nutrients
B-endorphin has been
researched the most
(56-189-200-227-276- 278-296-316-330- 331-332-333- 368- 406- 407-515).This neuropeptide
acts upon the mechanisms, eliciting eating through a food-rewarding
system. For example, food ingestion might increase CNS opioids levels
thus creating a feeling of self gratification. Obese subjects could, therefore, feel compelled to increase their food intake to
maintain CNS neuropeptide concentration elevated.
Gluttony, as observed in obese patients,
would consequently be explained biochemically. Addiction to food could be a
recognizable CNS opioid disorder (308).
Gambert reported that fasting decreases the
content of hypothalamic B-endorphin in rats. Therefore, food restriction, as observed during
dieting, might account for the feeling of weakness, hunger and physical distress
associated with a low calorie diet (174).
Finally, some evidence suggests
that the diencephalic region plays a regulatory role on the mechanisms that
are responsible for the storage and release of fat (98). Research on hypothalamic neuropeptides may shed
on the interpretation of obesity, i.e., subtle biochemical modifications in the hypothalamic
opioids concentration may be the cause (or the indication) of an underlying
neuromodulator disorder (99-109-406).
In turn, this would initiate and
perpetuate the metabolic changes leading to the obese condition (427).
Conversely, a persistent elevated food
intake could lead to metabolic modifications in the diencephalic region, as observed in
obesity. These modifications might be mediated by the Autonomic Nervous System (ANS), or
the endocrine system.
This system influences
energy insulin secretion, which in turns affects the storage, uptake and
expenditure of energy.
Also, it acts upon cathecholamines and other endocrine neural factors thus regulating
energy utilization (79-80-181-183-236-237-287).
For many years it was generally believed
that the main cause for obesity was a glandular problem.
One of the glands suspected
thyroid, because it was observed that hypothyroid patients showed, among other physical
signs, moderate degrees of obesity. However, recent research demonstrates that thyroid tests are within normal
limits in the vast
majority of obese patients .
In the few cases where thyroid
dysfunction appears to be associated with obesity, the lcondition may be easily
corrected with the proper administration of thyroid hormones indicated for the management of
Therefore, it would appear that
thyroid dysfunction only plays a role in obesity when the condition is not
Adrenal cortical hormones
also have been associated with obesity, however, hypercorticism appears in a
few cases of obesity, and nearly
always in the context of abdominal or android type of body fat distribution (402).
Modifications of growth
hormone (GH) secretion
were observed in some obese patients (57-77-156). However, it appears that this is a
consequence rather than the cause of obesity.
However, some attempts were made to treat
obesity with Growth Hormone (92). This approach should be viewed with caution, since
prolonged administration of GH may provoke the onset of Parkinsonian
Gonadal steroids do not appear to play a
role in the genesis of obesity. Rather, they are related to the peripheral
conversion of estrogen and testosterone, since this conversion is carried out mainly in
adipose tissue (375-377-378).
Metabolic gonadal steroids activity might
account for the selective accumulation of fat in certain regions, as observed in gynoid
(Estrogen), or android (Testosterone) obesity.
Some would believe that the only thing that obese individuals need to do to
stop being obese is eat less.
After many years of experience on the
subject and a careful review of all the information previously cited, we
have concluded that
this belief, reasonable as it may seem, is not the total solution.
First, several reported studies
conclude that weight regain after dieting was the rule rather than the exception.
Next, it has been repeatedly demonstrated
that, under very controlled conditions (same Hypercaloric Diet), some subjects failed to
gain weight, or saw their weight remain stable despite broad changes in their food intake,
Finally, some obese patients failed to lose
weight despite following a strictly controlled diet.
No patient is so enthusiastic as an
overweight patient who is anxious to lose those unwanted pounds. Yet, often no
patient has been so disappointed.
While some patients are grossly
obese, the vast majority of these present moderately overweight. They are the case
problems for plastic surgeons, since the disease usually recurs or
an hazardous surgical procedure.
Patients should discuss the problem of
obesity with their physicians. Both need to understand what they are facing
is a chronic problem like diabetes or hypertension, that ranges from
moderate to severe, and they must treat the disease as a serious health hazard. In any case, a pre-surgical
weight management program is likely to yield better results, both from the patient's
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