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Obesity

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

In the past, famines and food shortages were a common occurrence, and so being thin was linked with poverty and disease. Whereas excess body fat became a sign of wealth and success. Moreover, artwork from artists like Rubens often depicted women as full-bodied humans with curves and flesh<a href="#accordion">[1]</a>. Their voluptuous bodies signified beauty and fertility. However, soon enough, physicians and researchers realized the consequences of increased body mass. Today, being overweight and obesity are a worldwide epidemic, responsible for a large number of chronic, life-threatening diseases.&nbsp;

The World Health Organization (WHO) defines obesity and overweight as excessive accumulation of fat that may pose a health risk to the individual. In terms of body mass index (BMI) a value of 25 or above is overweight, while a value of 30 or above is considered obese<a href="#accordion">[2]</a>.

According to global statistics, the worldwide prevalence of obesity nearly tripled between 1975 and 2016. Approximately 13% of the world&rsquo;s adult population was considered obese in 2016, while 39% were overweight. Comparatively, in 2019, 38.2 million children under the age of 5 years were obese or overweight<a href="#accordion">[2]</a>. More global deaths can be attributed to obesity and being overweight than underweight.&nbsp;

Although high-income countries like the United States have higher rates of obesity, low- and middle-income countries have also been reporting a sharp incline in cases. However, due to the coexistence of undernutrition and obesity, these countries are facing a double burden of malnutrition and obesity. In Pakistan, this burden is mostly borne by women of reproductive age (15-49 years). As per the 2018 Pakistan National Nutrition Survey, 14.4% of women are underweight in the country, while 37.8% are overweight or obese<a href="#accordion">[3]</a>. Based on the Asian-specific BMI criteria, the estimated prevalence of obesity and overweight in Pakistan is 25%<a href="#accordion">[4]</a>.&nbsp;

Even though a majority of the country&rsquo;s population lives below the poverty line and does not have enough to eat, the country has high obesity rates. This can be blamed on the rising cost of fruits, vegetables, and cereals limiting one&rsquo;s access to fresh, healthy food options<a href="#accordion">[5]</a>. As a result, people have begun opting for cheap, ultra-processed items. Of course, the typical desi diet overloaded with meat, ghee, and carbs makes matters worse. Moreover, with increasing urbanization, lives have become increasingly sedentary for people. All these factors have led to an obesity epidemic in the country<a href="#accordion">[6]</a>.

<div>&nbsp;</div>

Being overweight means having a body weight above normal, but it does not always imply an excess fat accumulation in the body. On the other hand, obesity is a chronic condition characterized by excess accumulation of body fat and indicated by a BMI of above 30.&nbsp;

Fat itself is not bad and is essential for storing energy, protecting vital organs, hormone regulation, and other functions. However, an excess quantity of fat in the body and its distribution can pose several health risks. Accumulation of fat around abdominal organs, also called visceral fat, is largely responsible for obesity-related diseases<a href="#accordion">[1]</a>.

<div>&nbsp;</div>

BMI is a screening tool for overweight and obesity. It is calculated by dividing a person&rsquo;s weight in kilograms by the square of a person&rsquo;s height in meters (kg/m2). The WHO has designated different BMI values for various nutritional statuses<a href="#accordion">[7]</a>:

&nbsp;

Underweight: BMI &lt; 18.5 kg/m2

Normal Weight: BMI 18.5 - 24.9 kg/m2&nbsp;

Overweight: BMI 25.0 - &lt;30 kg/m2

Obesity: BMI 30.0 kg/m2 or higher

&nbsp;

For children under 5 years of age, obesity is defined as weight-for-height greater than 3 standard deviations above the WHO Child Growth Standards median<a href="#accordion">[2]</a>. Whereas, in children aged 5-19 years, obesity is greater than 2 standard deviations above the WHO Growth Reference median. BMI values can also be used to measure obesity in children. It is measured relative to the child&rsquo;s age and gender. In children older than 2 years of age, a BMI value greater than the 95th percentile for their age and weight is defined as obesity.&nbsp;

However, BMI is not an accurate tool for diagnosing obesity. While it can help assess whether one is of a healthy weight, it cannot measure body fat. Moreover, it cannot differentiate between fat, lean muscle, or bone mass. A high BMI value, as seen in athletes and bodybuilders, does not always indicate excess body fat. Furthermore, BMI values are influenced by gender, race, age, and several other factors.

For example, Asians often have different BMI cut-offs (&gt;23 kg/m2) for obesity and overweight compared to other ethnicities. Their risk of diseases such as diabetes and hypertension is related to lower BMI values than those of whites, blacks, or Hispanics<a href="#accordion">[8]</a>.&nbsp;A study comparing South Asian adults from India and Pakistan with US blacks and whites found a greater incidence of diabetes, despite lower BMI values<a href="#accordion">[9]</a>.&nbsp;Another study, conducted among patients in Karachi, Pakistan, found body fat percentage to be a better tool for classifying obesity than BMI<a href="#accordion">[10]</a>.&nbsp;

<div>&nbsp;</div>

The WHO classifies obesity into different types based on BMI values<a href="#accordion">[2]</a>. The types are as follows:

&nbsp;

<ul>
	<li>Class I Obesity: BMI of 30 to &lt;35 kg/m&sup2;</li>
	<li>Class II Obesity: BMI of 35 to &lt;40 kg/m&sup2;</li>
	<li>Class III Obesity: BMI 40+ kg/m&sup2;</li>
</ul>

&nbsp;

Class III obesity is also called &lsquo;morbid obesity&rsquo; due to its association with health risks.&nbsp;

<div>&nbsp;</div>

Signs And Symptoms

Obesity can lead to multiple health problems. Moreover, the chronic condition itself provides several barriers to daily activities. Common symptoms of obesity include:

&nbsp;

<ul>
	<li>Joint and back pain</li>
	<li>Tiredness</li>
	<li>Breathlessness</li>
	<li>Snoring</li>
	<li>Difficulty doing physical activity, such as walking long distances&nbsp;</li>
	<li>Increased sweating</li>
	<li>Self-esteem issues</li>
	<li><a href="https://www.merisehat.pk/disease/depression" target="_blank">Depression</a>, <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety</a></li>
</ul>

<div>&nbsp;</div>

Causes

A combination of several different factors can bring about obesity. These include:

&nbsp;

<ul>
	<li>Calories - Researchers hypothesize that when we consume more calories than we burn, the extra calories get stored as fat in the body. Excess fat leads to an increase in weight and distribution of body fat.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Genetics - Genetics control fat utilization, fat deposition, appetite, and even eating habits. Therefore, having an obese parent predisposes one to obesity.</li>
</ul>

&nbsp;

<ul>
	<li>Diet - A poor diet composed of a high level of carbohydrates, sugars, and saturated fats is associated with obesity. Pakistani diets generally consist of high proportions of ghee, meat, and carbohydrates, which further contributes to the obesity epidemic in the country. Moreover, there has been an increase in the consumption of carbonated beverages, further contributing to the disease burden in the country<a href="#accordion">[11]</a>.</li>
</ul>

&nbsp;

<ul>
	<li>Physical Activity -&nbsp; A sedentary lifestyle leads to reduced physical activity. As a result, people burn fewer calories and gain weight.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Medical Conditions - Certain diseases such as hypothyroidism, polycystic ovary syndrome (PCOS), Cushing&rsquo;s syndrome, and insulin resistance can also lead to obesity.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Medications - Drugs such as corticosteroids, antidepressants, anti-seizure medications, and beta-blockers can cause weight gain and contribute to obesity.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Psychological Factors - Mental health issues such as depression and anxiety may lead to overeating or eating more &lsquo;comfort food&rsquo; high in fat and sugars.&nbsp;</li>
</ul>

<div>&nbsp;</div>

<h4>"Weight gain can also increase blood pressure. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> and get your blood pressure reading now!"</h4>

Diagnosis

A BMI typically gives an estimate of a person&rsquo;s weight in relation to their height. However, other tests are often conducted to get an accurate measure of body fat and its distribution. These include:

&nbsp;

<ul>
	<li>Skinfold Thickness Tests - Using a skinfold caliper, skinfold measurements are taken from the biceps, triceps, above the upper hip bone (suprailiac skinfold), and under the shoulder blade (subscapular skinfold). The total amount of body fat can then be estimated by the sum of all four skinfolds.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Waist Circumference - Accumulation of visceral fat increases the risk of several non-communicable diseases. For women, a waist circumference of more than 35 inches, and for men a waist circumference of more than 40 inches is associated with a higher risk of obesity-related conditions such as <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes </a>and heart disease<a href="#accordion">[12]</a>. Therefore, waist measurements are often employed in obesity.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Waist-To-Hip Ratio (WHR) - The ratio of your waist circumference to the hip circumference helps determine the fat distribution on the waist, hips, and buttocks. The WHO has determined a WHR of 0.9 or less for men and 0.85 or less for women as moderate<a href="#accordion">[13]</a>. Moreover, people with an apple-shaped body (more weight around the midsection) are at a higher risk of heart disease and diabetes, rather than pear-shaped bodies (more weight around hips and thighs)<a href="#accordion">[14]</a>.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Other - Other tests such as dual-energy radiographic absorptiometry (DEXA), underwater weighing, bioelectrical impedance analysis, and ultrasonography can also be used to assess the degree of body fat. Doctors may also conduct MRI or CT scans to measure visceral fat.&nbsp;</li>
</ul>

&nbsp;

Other tests may also be conducted to diagnose the risk of obesity-related health risks. These include:

&nbsp;

<ul>
	<li>Lipid Profile - A lipid profile will measure levels of cholesterol, triglycerides, and high- and low-density lipoprotein (LDL, HDL) levels. Obese individuals may typically have high total cholesterol and LDL levels. A lipid profile can also help identify dyslipidemia in obese people.</li>
</ul>

&nbsp;

<ul>
	<li>Liver Function Tests - Measurement of liver enzymes, proteins, and bilirubin allows doctors to diagnose fatty liver and other liver abnormalities.</li>
</ul>

&nbsp;

<ul>
	<li>Thyroid Profile - A thyroid profile test helps assess for hypothyroidism in obese patients.</li>
</ul>

&nbsp;

<ul>
	<li>Diabetes Screening - Tests such as fasting blood glucose, HbA1c, and random blood glucose help diagnose diabetes.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Insulin Studies - In obesity, insulin resistance may be evident by increased serum levels of fasting insulin. However, obesity may also be associated with normal insulin levels.&nbsp;</li>
</ul>

<div>&nbsp;</div>

Treatment

Treatment of obesity requires a multi-system approach. The goal is to not only lose excess weight but also maintain a healthy weight. Even a loss of 5-10% of your total weight can lead to improvements in cholesterol and blood pressure<a href="#accordion">[15]</a>. While treatment methods may vary depending on the severity of obesity, a combination of healthy eating habits and increased physical activity is often advised.&nbsp;

&nbsp;

<h5>Dietary Changes</h5>

A study looking at dietary patterns in Pakistani households found a greater consumption of fried snacks, bakery items, meat products, and Pakistani sweets and bread<a href="#accordion">[16]</a>. Poor food choices play a significant role in weight gain and obesity. Therefore, doctors recommend the consumption of a healthy, balanced diet consisting of low-calorie foods and small portions.&nbsp;

An increase in the incidence of obesity and overweight has also made people more weight conscious. As a result, many have turned to fad diet trends such as the keto diet and intermittent fasting. However, starting diets without a doctor&rsquo;s consultation can have a detrimental effect on the body. Moreover, rapid weight loss is not always beneficial and poses problems in the management of a healthy weight. Therefore, it is best to consult an experienced dietician and work together to develop a meal plan that gives the required calories and helps the individual attain a healthy weight.

&nbsp;

<h5>Physical Activity</h5>

Depending on a person&rsquo;s health status and severity of obesity, a doctor may recommend moderate to high-intensity physical activity. 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity exercise a week is typically recommended<a href="#accordion">[17]</a>. Examples of moderate-intensity exercises include brisk walking, swimming, dancing, and cycling. Whereas vigorous activity may include running and competitive sports.&nbsp;

However, it is important to choose an activity that keeps one engaged and motivated. Exercise should not feel like a chore, but instead, be an enjoyable experience. Luckily, the health culture in Pakistan has given rise to fun, fitness-based activities, for both men and women. From CrossFit to water aerobics, health enthusiasts across the country are promoting a healthier lifestyle among their clients. Female-centered kickboxing classes not only provide women with a full-body workout but also help release stress and anxiety<a href="#accordion">[18]</a>. Moreover, such classes promote a sense of confidence in women, tackling self-esteem issues commonly associated with obesity.&nbsp;

&nbsp;

<h5>Medications</h5>

Along with dietary changes and exercise plans, doctors may prescribe weight loss drugs. Typically, they are only prescribed if other methods have failed to cause weight loss in the individual and the BMI is 27kg/m2 or more. These medications work by either reducing appetite or preventing fat absorption.

&nbsp;

The common FDA-approved weight-loss drugs include:

<ul>
	<li>Orlistat&nbsp;</li>
	<li>Liraglutide</li>
	<li>Semaglutide&nbsp;</li>
	<li>Bupropion</li>
	<li>Topiramate</li>
</ul>

&nbsp;

These medications are prescribed alongside dietary changes and exercise plans. However, they may not work for everyone. Moreover, they can cause side effects such as flatulence, fatty stools, frequent bowel movements, and bowel urgency.&nbsp;

&nbsp;

<h5>Behavioral Therapies</h5>

Often, traumatic events can cause our bodies to adopt harmful coping mechanisms such as unhealthy eating habits. Anxiety and depression can also lead to overeating and behavioral issues related to eating. Therefore, counseling and support groups can prove beneficial for such patients. A trained professional can help one identify triggers, handle cravings, and heal mental trauma.&nbsp;

Cognitive behavioral therapy is one method that can also help support one&rsquo;s weight loss journey. It helps patients replace unhealthy habits with positive changes conducive to long-term weight control.&nbsp;

&nbsp;

<h5>Surgery</h5>

Also called bariatric surgery, these procedures are reserved for people who are severely obese (Class II or III)&nbsp; and have comorbidities. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), weight loss surgery is only recommended for adults with a BMI of 30-35kg/m2 and who<a href="#accordion">[19]</a>:

<ul>
	<li>Suffer from obesity-related comorbidity such as diabetes</li>
	<li>Haven&rsquo;t seen significant results from lifestyle changes such as a healthy diet and exercise</li>
</ul>

&nbsp;

The common surgical procedures are:

&nbsp;

<ul>
	<li>Gastric Sleeve Surgery - This involves the removal of a part of the stomach and leaving behind a small &lsquo;sleeve&rsquo;. Reducing the size of the stomach restricts the amount of food one can eat. Thus, controlling hunger and reducing food intake.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Gastric Bypass Surgery - In this procedure, a small pouch is created above the stomach and connected directly to the small intestine. As a result, food that enters the digestive system can bypass the stomach and the first part of the small intestine. Hence, the digestive system is unable to absorb nutrients from the food. Moreover, since the stomach is functionally reduced, fewer calories are consumed. However, the procedure is associated with adverse events such as dumping syndrome, malabsorption, hernias, and small bowel obstruction.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Laparoscopic Adjustable Gastric Banding (LAGB) - This is a reversible procedure that separates the stomach into two pouches. An adjustable silicone band, called the LAP-Band, is placed around the stomach and helps reduce the size of the stomach. Thus, restricting the amount of food a person can eat at one time.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Duodenal Switch - It is a combination of gastric sleeve surgery and intestinal bypass. As a result, the stomach holds a lesser amount of food. Moreover, the procedure restricts the amount of nutrition the small intestine can absorb from the food.&nbsp;</li>
</ul>

<div>&nbsp;</div>

While obesity may seem like a cosmetic concern for many individuals, its association with chronic medical diseases is more concerning. As per data from an endocrinology clinic in Karachi, Pakistan, elevated BMI values were most commonly associated with dyslipidemia,<a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank"> type 2 diabetes</a> mellitus, <a href="https://www.merisehat.pk/disease/hypertension-57" target="_blank">hypertension</a>, and thyroid disorders<a href="#accordion">[4]</a>.

&nbsp;

The common obesity-related health complications are:

&nbsp;

<ul>
	<li><a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">Diabetes </a>- Adipocytes, or fat cells, are more insulin resistant than muscle cells. This rise in insulin resistance can lead to diabetes.&nbsp;</li>
	<li>Cardiovascular Disorders - Hypertension and dyslipidemia, associated with obesity, lead to heart diseases and stroke in people.</li>
	<li>Musculoskeletal Disorders - Osteoarthritis is the most common musculoskeletal complication of obesity. It results from&nbsp;excess weight placing increased stress on the joints and promoting inflammation.&nbsp;</li>
	<li>Cancers - The risk of certain cancers (breast, endometrium, ovary, uterus, and colon) increases with obesity.</li>
	<li>Others - <a href="https://www.merisehat.pk/disease/infertility-in-men" target="_blank">Infertility</a>, gallstones, fatty liver disease, and <a href="https://www.merisehat.pk/disease/sleep-apnea-91" target="_blank">sleep apnea</a> are some common complications of obesity.</li>
</ul>

&nbsp;

Childhood obesity is associated with an increased risk of adult obesity; medical conditions such as fatty liver disease, sleep apnea, diabetes, and asthma; and social problems such as low self-esteem issues<a href="#accordion">[20]</a>. Moreover, it can also lead to premature death and disability.&nbsp;

<div>&nbsp;</div>

The following factors can further contribute to obesity:

&nbsp;

<ul>
	<li>Age - Although obesity can occur at any age, hormonal changes associated with aging can increase one&rsquo;s risk of obesity. Moreover, the metabolism may also decrease with age, making it harder to lose weight.&nbsp;</li>
	<li>Family - Obesity often runs in families and having an obese parent can increase the risk of obesity. Moreover, eating habits are inherited from your family and play a huge role in causing weight gain and obesity.&nbsp;</li>
	<li>Lifestyle - A poor diet consisting of saturated fats and sugar increases one&rsquo;s risk of obesity. Moreover, spending more time indoors reduces physical activity and predisposes one to obesity.</li>
	<li>Stress - Stress can lead the body to release the hormone cortisol which can lead to weight gain. Moreover, stress often results in emotional eating or consuming high in fat &lsquo;comfort&rsquo; foods.&nbsp;</li>
	<li>Sleeping Habits - Poor sleep can cause hormonal dysregulation and lead to obesity.</li>
</ul>

<div>&nbsp;</div>

Making tiny lifestyle changes can often play a huge role in preventing obesity. These include:

&nbsp;

<ul>
	<li>20 to 30 minutes of daily moderate exercise such as walking or biking</li>
	<li>Eating a balanced diet&nbsp;</li>
	<li>Replacing unhealthy snacks with healthy options, for example having apples instead of a packet of Oreos</li>
	<li>Reducing alcohol intake</li>
	<li>Reducing screen time and spending more time outdoors</li>
	<li>Quitting smoking</li>
	<li>Eat healthy, home-cooked meals instead of fast food</li>
</ul>

<div>&nbsp;</div>

Key Points

<ul>
	<li>The World Health Organization defines obesity as an excess accumulation of body fat that poses health risks to the person. As per the diagnostic criteria, those with a body mass index (BMI) of 30 or above are considered obese.&nbsp;</li>
	<li>Researchers hypothesize that when we consume more calories than we burn, the extra calories get stored as fat in the body. Excess fat leads to an increase in weight and body fat distribution. Thus, leading to being overweight or obese. Other factors such as diet, genetics, level of physical activity, and certain medical diseases can also lead to obesity.</li>
	<li>Obesity increases the risk of several non-communicable diseases such as <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes</a>, <a href="https://www.merisehat.pk/disease/hypertension-57" target="_blank">hypertension</a>, <a href="https://www.merisehat.pk/disease/osteoarthritis-64627" target="_blank">osteoarthritis</a>, heart diseases, <a href="https://www.merisehat.pk/disease/stroke" target="_blank">stroke</a>, <a href="https://www.merisehat.pk/disease/sleep-apnea-91" target="_blank">sleep apnea</a>, and certain cancers.</li>
	<li>Dietary changes and physical activity are mostly recommended for treating obesity. However, in some people, these might not have desired effects and so doctors may prescribe weight-loss medications or conduct bariatric surgery.&nbsp;</li>
</ul>

<div>&nbsp;</div>

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[2] Obesity and overweight. World Health Organization

[3] NATIONAL NUTRITION SURVEY 2018 - Key Findings Report. UNICEF.

[4] Ghaus S, Ahsan T, Sohail E, Erum U, Aijaz W. Burden of Elevated Body Mass Index and Its Association With Non-Communicable Diseases in Patients Presenting to an Endocrinology Clinic. Cureus. 2021;13(2):e13471. Published 2021 Feb 21.

[5] Amin Baig A. Obesity in Pakistan; current and future perceptions. Current Trends in Biomedical Engineering & Biosciences. 2018;17(2).

[6] Tanzil, S., Jamali, T. Obesity, an emerging epidemic in Pakistan-a review of evidence. J Ayub Med Coll Abbottabad. 2016;28(3): 597-600.

[7] A healthy lifestyle - WHO recommendations. World Health Organization.

[8] Shai I, Jiang R, Manson JE, et al. Ethnicity, obesity, and risk of type 2 diabetes in women: a 20-year follow-up study. Diabetes Care. 2006;29(7):1585-1590.

[9] Narayan KMV, Kondal D, Daya N, et al. Incidence and pathophysiology of diabetes in South Asian adults living in India and Pakistan compared with US blacks and whites. BMJ Open Diabetes Res Care. 2021;9(1):e001927.

[10] Fatima SS, Rehman R, Chaudhry B. Body mass index or body fat! Which is a better obesity scale for Pakistani population?. J Pak Med Assoc. 2014;64(11):1225-1228.

[11] Datta BK, Husain MJ. Carbonating the household diet: a Pakistani tale. Public Health Nutr. 2020;23(9):1629-1637.

[12] Healthy Weight, Nutrition, and Physical Activity - Assessing Your Weight. Centers for Disease Control and Prevention.

[13] World Health Organization. Waist Circumference And Waist-Hip Ratio: Report Of A WHO Expert Consultation. Geneva: World Health Organization; 2008.

[14] Moosaie F, Fatemi Abhari S, Deravi N et al. Waist-To-Height Ratio Is a More Accurate Tool for Predicting Hypertension Than Waist-To-Hip Circumference and BMI in Patients With Type 2 Diabetes: A Prospective Study. Front Public Health. 2021;9.

[15] Ryan DH, Yockey SR. Weight Loss and Improvement in Comorbidity: Differences at 5%, 10%, 15%, and Over. Curr Obes Rep. 2017;6(2):187-194.

[16] Safdar NF, Bertone-Johnson E, Cordeiro L, Jafar TH, Cohen NL. Dietary patterns of Pakistani adults and their associations with sociodemographic, anthropometric and life-style factors. J Nutr Sci. 2014;2:e42. Published 2014 Jan 2.

[17] Healthy Weight, Nutrition, and Physical Activity - Physical Activity for a Healthy Weight. Centers for Disease Control and Prevention.

[18] Shirazi M. "kickboxing is therapeutic." – Alizeh Zainab Razvi: Instep. thenews.

[19] Aminian A, Chang J, Brethauer SA, Kim JJ. ASMBS updated position statement on Bariatric Surgery in class I obesity (BMI 30–35 kg/m2). Surgery for Obesity and Related Diseases. 2018;14(8):1071-1087.

[20] Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Prim Care. 2015;4(2):187-192.