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Obesity Cure
A large percentage of people all over the world are affected by this illness. Most of them however do not treat this as an illness but more as a fact of life!
Technically, obesity is defined as a state of being more than twenty percent above "normal" weight, or having a body-fat percentage greater than thirty percent for women and twenty-five percent for men. Another measurement of obesity is having a body mass index greater than 30.
Like any illness however, obesity is curable in many cases. Read on.
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General References for Obesity
Content Derived from Wikipedia Article on Obesity
Obesity is a condition in which the natural energy reserve, stored in the fatty tissue of humans and other mammals, is increased to a point where it is a risk factor for certain health conditions or increased mortality. Obesity develops from the interaction of individual biology and the environment. Excessive body weight has been shown to predispose to various diseases, particularly cardiovascular diseases, diabetes mellitus type 2, sleep apnea, and osteoarthritis. Obesity is both an individual clinical condition and is increasingly viewed as a serious public health problem.
Definition
In the clinical setting, obesity is typically evaluated by measuring BMI (body mass index), waist circumference, and evaluating the presence of risk factors and comorbidities. In epidemiological studies BMI alone is used to define obesity.
BMI
BMI, or Body Mass Index, was developed by the Belgian statistician and anthropometrist Adolphe Quetelet. It is calculated by dividing the subject's weight in kilograms by the square of his/her height in metres (BMI = kg / m2).
The current definitions commonly in use establish the following values, agreed in 1997 and published in 2000:
A BMI less than 18.5 is underweight A BMI of 18.5 - 24.9 is normal weight A BMI of 25.0 - 29.9 is overweight A BMI of 30.0 - 39.9 is obese A BMI of 40.0 or higher is severely (or morbidly) obese BMI is a simple and widely used method for estimating body fat. In epidemiology BMI alone is used as an indicator of prevalence and incidence.
BMI as an indicator of a clinical condition is used in conjunction with other clinical assessments, such as waist circumference. In a clinical setting, physicians take into account race, ethnicity, lean mass (muscularity), age, sex, and other factors which can affect the interpretation of BMI. BMI overestimates body fat in persons who are very muscular, and it can underestimate body fat in persons who have lost body mass (e.g. many elderly). Mild obesity as defined by BMI alone is not a cardiac risk factor, and hence BMI cannot be used as a sole clinical and epidemiological predictor of cardiovascular health.
Waist circumference
BMI does not take into account differing ratios of adipose to lean tissue; nor does it distinguish between differing forms of adiposity, some of which may correlate more closely with cardiovascular risk. Increasing understanding of the biology of different forms of adipose tissue has shown that visceral fat or central obesity (male-type or apple-type obesity) has a much stronger correlation, particularly with cardiovascular disease, than the BMI alone.
The absolute waist circumference (>102 cm in men and >88 cm in women) or waist-hip ratio (>0.9 for men and >0.85 for women) are both used as measures of central obesity.
Body fat measurement
An alternative way to determine obesity is to assess percent body fat. Doctors and scientists generally agree that men with more than 25% body fat and women with more than 30% body fat are obese. However, it is difficult to measure body fat precisely. The most accepted method has been to weigh a person underwater, but underwater weighing is a procedure limited to laboratories with special equipment. Two simpler methods for measuring body fat are the skinfold test, in which a pinch of skin is precisely measured to determine the thickness of the subcutaneous fat layer; or bioelectrical impedance analysis, usually only carried out at specialist clinics.
Other measurements of body fat include computed tomography (CT/CAT scan), magnetic resonance imaging (MRI/NMR), and dual energy X-ray absorptiometry (DXA).
Gestalt
In practice, for most examples of overweight that may designate risk, both doctor and patient can see "by eye" whether excess fat is a concern. In these cases, BMI thresholds provide simple targets all patients can understand.
Risk factors and comorbidities
The presence of risk factors and diseases associated with obesity are also used to establish a clinical diagnosis. Coronary heart disease, type 2 diabetes, and sleep apnea are possible life-threatening risk factors that would indicate clinical treatment of obesity. Smoking, hypertension, age and family history are other risk factors that may indicate treatment. Diabetes and heart disease are risk factors used in epidemiological studies of obesity.
Causes
Causative factors When food energy intake exceeds energy expenditure, fat cells (and to a lesser extent muscle and liver cells) throughout the body take in the energy and store it as fat. In its simplest conception, therefore, obesity is only made possible when the lifetime energy intake exceeds lifetime energy expenditure by more than it does for individuals of "normal weight".
In all individuals, the excess energy utilized to generate fat reserves is minute relative to the total number of calories consumed. This means that very fine perturbations in the energy balance can lead to large fluctuations in weight over time. To illustrate, an obese 40 year old who carries 100 lb of adipose tissue has only consumed about 25 more calories per day than he has burned on average - or the equivalent of an apple every three days. In comparison a very lean 40-year-old who carries only 15 lb of body fat will have exceeded his daily energy expenditure by about four calories a day - the equivalent of an apple every 18 days.
Factors that have been suggested to contribute to the development of obesity include:
Evolutionary aspects
Although there is no definitive explanation for the recent increase of obesity, the thrifty gene hypothesis provides some understanding of this phenomenon, and suggests why certain populations and individuals may be more prone to obesity than others. In times when food was scarce, the ability to take advantage of rare periods of abundance and use such abundance by storing energy efficiently was undoubtedly an evolutionary advantage. Individuals with greater adipose reserves were more likely to survive famine. This tendency to store fat is likely maladaptive in a society with adequate and stable food supplies.
Neurobiological mechanisms
Scientists investigating the mechanisms and treatment of obesity may use animal models such as mice to conduct experiments. Flier summarizes the many possible pathophysiological mechanisms involved in the development and maintenance of obesity. This field of research had been almost unapproached until leptin was discovered in 1994. Since this discovery, many other hormonal mechanisms have been elucidated that participate in the regulation of appetite and food intake, storage patterns of adipose tissue, development of insulin resistance. Since leptin's discovery, ghrelin, orexin, PYY 3-36, cholecystokinin, adiponectin, and many other mediators have been studied. The adipokines are mediators produced by adipose tissue; their action is thought to modify many obesity-related diseases.
Leptin and ghrelin are considered to be complementary in their influence on appetite, with ghrelin produced by the stomach modulating short-term appetitive control (i.e. to eat when the stomach is empty and to stop when the stomach is stretched). Leptin is produced by adipose tissue to signal fat storage reserves in the body, and mediates long-term appetitive controls (i.e. to eat more when fat storages are low and less when fat storages are high). Although administration of leptin may be effective in a small subset of obese individuals who are leptin-deficient, many more obese individuals are thought to be leptin-resistant, and this resistance has been implicated in obesity in some people, is thought to explain in part why administration of leptin has not been shown to be effective in suppressing appetite in most obese subjects.
Neuroscientific approaches hinge on the action of the aforementioned mediators on the hypothalamus, the part of the brain that is thought to process signals related to metabolic state and energy storage and to shift the energy balance in either a positive or negative direction, primarily by acting on appetite and energy expenditure. Lesion studies in the 1940s and 1950s identified two regions of the hypothalamus the lateral hypothalamus (LH) and ventromedial hypothalamus (VMH) as the brain's hunger and satiety centers, respectively. Specific lesions to a mouse's LH suppressed its appetite while damaging the VMH caused overeating.
Studies of the distribution of the leptin receptor in the mid-1990s cast doubt upon this dual center theory of hunger and satiety. Leptin's effect on the arcuate nucleus melanocortin system is now considered central to the regulation of feeding and metabolism.
Poverty link
Some obesity co-factors are resistant to the theory that the "epidemic" is a new phenomenon. In particular, a class co-factor consistently appears across many studies. Comparing net worth with BMI scores, a 2004 study[10] found obese American subjects approximately half as wealthy as thin ones. When income differentials were factored out, the inequity persisted thin subjects were inheriting more wealth than fat ones. A higher rate of lack of education and tendencies to rely on cheaper fast foods is seen as a reason why these results are so dissimilar. Another study finds women who married into higher status are predictably thinner than women who married into lower status.
Complications
Obesity, especially central obesity (male-type or waist-predominant obesity), is an important risk factor for the "metabolic syndrome" ("syndrome X"), the clustering of a number of diseases and risk factors that heavily predispose for cardiovascular disease. These are diabetes mellitus type 2, high blood pressure, high blood cholesterol, and triglyceride levels (combined hyperlipidemia). An inflammatory state is present, which together with the above has been implicated in the high prevalence of atherosclerosis (fatty lumps in the arterial wall), and a prothrombotic state may further worsen cardiovascular risk.
Apart from the metabolic syndrome, obesity is also correlated (in population studies) with a variety of other complications. For many of these complaints, it has not been clearly established to what extent they are caused directly by obesity itself, or have some other cause (such as limited exercise) that causes obesity as well. Most confidence in a direct cause is given to the mechanical complications in the following list:
Therapy
The mainstay of treatment for obesity is an energy-limited diet and increased exercise. In studies, diet and exercise programs have consistently produced an average weight loss of approximately 8% of total body mass on average (excluding study drop-outs). While not all dieters will be satisfied with this outcome, studies have shown that a loss of as little as 5% of body mass can create enormous health benefits.
A more intractable therapeutic problem appears to be weight loss maintenance. Of dieters who manage to lose 10% or more of their body mass in studies, 80-95% will regain that weight within two to five years. It appears that the homeostatic mechanisms regulating body weight are very robust (see leptin, for example), and vigorously defend against weight loss. Much important research is now being devoted to determining what factors can improve the currently dismal weight loss maintenance rates.
Recent scientific research has cast some doubt over whether or not dieting actually improves health, with some studies indicating that dieting may in fact be more detrimental than remaining overweight.
In a clinical practice guideline by the American College of Physicians, the following five recommendations are made:
Medication most commonly prescribed for diet/exercise-resistant obesity is orlistat (Xenical, which reduces intestinal fat absorption by inhibiting pancreatic lipase) and sibutramine (Reductil, Meridia, an anorectic). In the presence of diabetes mellitus, there is evidence that the anti-diabetic drug metformin (Glucophage) can assist in weight loss rather than sulfonylurea derivatives and insulin, which often lead to further weight gain. The thiazolidinediones (rosiglitazone or pioglitazone) can cause slight weight gain, but decrease the "pathologic" form of abdominal fat, and are therefore often used in obese diabetics.
Increasingly, bariatric surgery is being used to combat obesity. The most common weight loss surgery in Europe and Australia is the adjustable gastric band where a silicone ring is placed around the top of the stomach to help restrict the amount of food eaten in a sitting. This surgery has been FDA approved in the United States since 2001 but has been being used in other parts of the world since the early 1990s. It is considered the safest and least invasive of the available weight loss surgeries such as Roux-en-Y gastric bypass surgery (RNY), biliopancreatic diversion, and stomach stapling (also known as "vertical banded gastroplasty", VBG). Unlike those more invasive techniques the band surgery does not cut into or reroute any of the digestive tract and is completely reversible. Removing the implant returns the stomach to its pre-surgical norm. All of these surgeries can be done laparoscopically. The more invasive of the surgeries usually bypass or remove some portion of the patient's intestines which causes malabsorption and dumping.
All of these surgeries come with risk to the patient. For instance a recent study by the U.S. Department of Health and Human Service showed a 40% complication rate within 180 days of bariatric surgery.[14] Moreover these surgeries do not guarantee either successful weight loss or reduced morbidity and mortality. Patients are also required to make lifelong changes to their diet if they are to keep the lost weight off in the long term. Therefore, as with any major surgery, patients needs to carefully evalute the long term ramifications of their choice.
Cultural and social significance
Etymology
Obesity is the nominal form of obese which comes from the Latin obēsus, which means "stout, fat, or plump." Ēsus is the past participle of edere (to eat), with ob added to it. In Classical Latin, this verb is seen only in past participial form. Its first attested usage in English was in 1651, in Noah Biggs's Matζotechnia Medicinζ Praxeos.[15]
History and obesity
In several human cultures, obesity was associated with physical attractiveness, strength, and fertility. Some of the earliest known cultural artifacts, known as Venus figurines, are pocket-sized statuettes representing an obese female figure. Although their cultural significance is unrecorded, their widespread use throughout pre-historic Mediterranean and European cultures suggests a central role for the obese female form in magical rituals, and suggests cultural approval of (and perhaps reverence for) this body form. This is most likely due to their ability to easily bear children and survive famine.
Obesity was occasionally considered a symbol of wealth and social status in cultures prone to food shortages or famine. Well into the early modern period in European cultures, it often served this role. But as food security was realised, it came to serve more as a visible signifier of "lust for life", appetite, and immersion in the realm of the erotic. This was especially the case in the visual arts, such as the paintings of Rubens (15771640), whose regular use of the full female figures gives us the description Rubenesque for plumpness. Obesity can also be seen as a symbol within a system of prestige. "The kind of food, the quantity, and the manner in which it is served are among the important criteria of social class. In most tribal societies, even those with a highly stratified social system, everyone - royalty and the commoners - ate the same kind of food, and if there was famine everyone was hungry. With the ever increasing diversity of foods, food has become not only a matter of social status, but also a mark of one's personality and taste."
Contemporary culture
In modern Western culture, the obese body shape is widely regarded as unattractive. Obese bodies are rarely positively represented in mainstream media. Many negative stereotypes are commonly associated with obese people, such as the belief that they are lazy, dirty, stupid, or even evil. Some point to gluttony, the second of the seven deadly sins, when referring to the this last stereotype. Obese children, teenagers and adults face a heavy social stigma. Obese children are frequently the targets of bullies and are often shunned by their peers. Obesity in adulthood can lead to a slower rate of career advancement. Most obese people have experienced negative thoughts about their body image, and many take drastic steps to try to change their shape.
Not all contemporary cultures disapprove of obesity. There are many cultures which are traditionally more approving (to varying degrees) of obesity, including some African, Arabic, Indian, and Pacific Island cultures. Especially in recent decades, obesity has come to be seen more as a medical condition in modern Western culture.
Recently emerging is a small but vocal fat acceptance movement that seeks to challenge weight-based discrimination. Obesity acceptance and advocacy groups have initiated litigation to defend the rights of obese people and to prevent their social exclusion.
Popular culture
In cartoons, obesity is often used for comic effect.Various stereotypes of obese people have found their way into expressions of popular culture. A common stereotype is the obese character who has a warm and dependable personality, but equally common is the obese vicious bully. (Dudley Dursley from the Harry Potter book series is a perfect example of this) Gluttony and obesity are commonly depicted together in works of fiction. In cartoons, obesity is often used to comedic effect, with fat cartoon characters having to squeeze through narrow spaces, frequently getting stuck or even exploding. Another, more unusual example of obesity-related humour is Jennyanydots, the "Old Gumbie Cat" from Cats (musical), whose claim to fame is that she sits around the house all day and at night she goes to the basement to teach manners to the mice and cockroaches. Her physical appearance is often humourous to the audience, as her costume is designed to look like rolls of fat and bounce when she moves.
It can be argued that depiction in popular culture adds to and maintains commonly perceived stereotypes, in turn harming self esteem of obese people. A charge of discrimination on the basis of appearance could be leveled against these depictions.
On the other hand, obesity is often associated with positive characteristics such as good humor (the stereotype of the jolly fat man like Santa Claus), and some people are more sexually attracted to obese people than to slender people (see chubby culture, fat admirer).
Environmental factors
While it may often appear obvious why a certain individual gets fat, it is far more difficult to understand why the average weight of certain societies have recently been growing. While genetic causes are central to understanding obesity, they cannot fully explain why one culture grows fatter than another.
This is most notable in the United States. In the years from just after the Second World War until 1960 the average person's weight increased, but few were obese. In the two and a half decades since 1980 the growth in the rate of obesity has accelerated markedly and is increasingly becoming a public health concern.
There are a number of theories as to the cause of this change since 1980. Most believe it is a combination of various factors.
Lack of activity: obese people appear to be less active in general than lean people, and not just because of their obesity. A controlled increase in calorie intake of lean people did not make them less active; correspondingly when obese people lost weight they did not become more active. Weight change does not affect activity levels, but the converse seems to be the case.
One of the most important is the much lower relative cost of foodstuffs: massive changes in agricultural policy in the United States and Europe have led to food prices for consumers being lower than at any point in history. Sugar and corn syrup, two huge sources of food energy, are some of the most subsidized products by the United States government. This can raise costs for consumers in some areas but greatly lower it in others. Current debates into trade policy highlight disagreements on the effects of subsidies.
Increased marketing has also played a role. In the early 1980s in America the Reagan administration lifted most regulations pertaining to sweets and fast food advertising to children. As a result, the number of advertisements seen by the average child increased greatly, and a large proportion of these were for fast food and sweets.
Changes in the price of petrol (i.e. gasoline) are also believed to have had an effect, as unlike during the 1970s it is now affordable in the United States to drive everywhere at a time when public transit goes underused. At the same time more areas have been built without sidewalks and parks.
The changing workforce as each year a greater percent of the population spends their entire workday behind a desk or computer, seeing virtually no exercise. In the kitchen the microwave oven has seen sales of calorie-dense frozen convenience foods skyrocket and has encouraged more elaborate snacking.
A social cause that is believed by many to play a role is the increasing number of two income households in which one parent no longer remains home to look after the house. This increases the number of restaurant and take-out meals. Urban sprawl may be a factor: obesity rates increase as urban sprawl increases, possibly due to less walking and less time for cooking.
Since 1980 both sit-in and fast food restaurants have seen dramatic growth in terms of the number of outlets and customers served. Low food costs, and intense competition for market share, led to increased portion sizes for example, McDonalds french fries portions rose from 200 Calories (840 kilojoules) in 1960 to over 600 Calories (2,500 kJ) today. Increased food production is a probable factor. The U.S. produces three times more food than U.S. residents eat. Increasing affluence itself (including many of the above factors as accompaniments of affluence) may be a cause, or contributing factor since obesity tends to flourish as a disease of affluence in countries which are developing and becoming westernised [5]. This is supported by a dip in American GDP after 1990, followed by a substantial increase. U.S. obesity statistics followed the same pattern, offset by two years.
An aging population may also be a major factor, as the likelihood of becoming obese increases with age. Beyond their twenties, the older a person becomes the slower their metabolism becomes, reducing the amount of calories required to sustain the body, thus if a person does not reduce their intake of food with age, they will become obese over time. As the average age of individuals within a society increases, the rate of obesity also increases. This situation is exacerbated by the baby boom generation, which represents a disproportionately large portion of the population in many countries and is currently nearing the latter end of the typical lifespan in affluent nations, and therefore is in the high-risk zone for obesity.
Interestingly an increase in the number of Americans who exercise and diet occurred before the increase in obesity, and some scholars have even argued that these trends actually encouraged obesity. Nearly all diets fail, with participants resuming their previous eating habits or even engaging in binge eating. Many then see an overall increase in their weight. If the diet is then repeated and abandoned again, a pattern of rising and falling weight is established, known as weight cycling. Similarly those who work out but then stop can end up being heavier than those who never exercised.
Public health and policy responses
On top of controversies about the causes of obesity, and about its precise health implications, come policy controversies about the correct approach to obesity. The main debate is between "personal responsibility" advocates, who resist regulatory attempts to intervene in citizen's private dietary habits, and "public interest" advocates, who promote regulations, on the same public health grounds as the restrictions applied to tobacco products. In the U.S., a recent bout in this controversy involves the so-called Cheeseburger Bill, an attempt to indemnify food industry businesses from what some consider to be frivolous lawsuits by obese clients.
"Personal responsibility" advocates work on the basis that, as the microbiologist Rene Dubos once said, health ought not to be considered an end in itself, but "the condition best suited to reach goals that each individual formulates for himself". Any other definition permits authorities to curtail the autonomy of the self-determining individual, imposing quantity over quality of life onto them, undermining his civil liberties. As much as principled doctors, personal responsibility arguments have also been offered by food producer lobbies. In 1961, for example, as President John F Kennedy raised concerns about a lack of fitness in American society, a spokesman for the U.S. Dairy industry, Frank R. Neu, wrote advertorials warning We May Be Sitting Ourselves To Death. Not food regulation, but personal exercising, is mooted as the solution.
When it comes to childhood obesity, personal responsibility also means parental responsibility. A survey by the nonpartisan group Public Agenda found 68 percent of American parents said it was "absolutely essential" to teach their children good eating habits, but only 40 percent believe they had succeeded. Fewer parents say it is essential to teach their children about physical fitness (51 percent), but more believe they have succeeded (53 percent). Overall, parents said they found it difficult to protect their children from negative social messages on a range of topics, including bad nutrition.
On July 15, 2004, the United States Department of Health and Human Services announced a new policy from HHS' Centers for Medicare & Medicaid Services (CMS) removing language in the Medicare Coverage Issues Manual stating that obesity is not an illness. According to the press release "This step allows members of the public to request that Medicare review medical evidence to determine whether specific treatments related to obesity would be covered by Medicare. By law, Medicare covers specified medically necessary services for illness and injury. The prior manual language, because it stated that obesity was not an illness, could prevent Medicare from covering treatments for diseases related to obesity."
Non-medical consequences
Besides increases in disease and mortality there are other implications of the present world trend in obesity. Among these are:
Increased pressure on airline revenues (or increased fares) due to lobbying efforts to increase seating width on commercial airplanes and due to higher fuel costs. (Extra weight of obese passengers is costing airlines and consumers US$275,000,000 per annum.)
Increased litigation by obese persons suing restaurants (over causation of obesity) and airlines (over airline seating width). Note that the Personal Responsibility in Food Consumption Act of 2005 was motivated by a need to reduce litigation from obesity activists.
Sizeable societal economic costs attributable to obesity, with medical costs attributable to obesity rising to 78.5 billion dollars or 9.1 percent of all medical expenditures in the U.S. as of 1998. However, such studies do not necessarily consider that earlier mortality of obese people may save health costs associated with aging.
Related Topics: Body image Body mass index Cardiovascular disease Childhood obesity Chubby culture Dieting Fat acceptance movement Fat admirer Feederism Healthy diet Honey we're killing the kids Human weight Junk food List of the most obese humans MOMO syndrome National Weight Control Registry Overweight Physical exercise Pickwickian syndrome Super Size Me
End of Wikipedia content
Synonyms & Common Misspellings for Obesity
Synonyms: Obese, Obesity, Fat, Heavyweight, corpulent, fat, fatso, fleshy, heavy, plump, stout, hefty, large, overweight, heavyset, meaty, massive, big, buxom, chubby, portly, squat Misspellings: Obesety, Pbesity, ibesity, onesity, Ibesity, Obrsity, Obwsity, 0besity, 9besity
Obesity Related Terms Glossary
A: Absorption - Process in which digested food is absorbed by the lower part of the small intestine into the bloodstream; Adipose; Anastomosis; B: Bariatric, Body Mass Index (BMI) C: Cardiovascular; Clinically Severe Obesity; Co-Morbid (Related illnesses (i.e., arthritis, hypertension) or disabling conditions related to clinically severe obesity or obesity-related health conditions), Colon, Contraindications - Any symptom or situation that is inappropriate for an otherwise recommended treatment, Criteria D: Digestion, Dilation (Process of enlarging or further opening a passage or anastomosis), Divided Gastric Bypass Surgery, Dumping Syndrome (Uncomfortable feeling of nausea, lightheadedness, upset stomach, vomiting, and/or diarrhea, related to ingestion of sweets, high-calorie liquids, or dairy products); Duodenum G: Gastric, Gastric Bypass Surgery, Gastrointestinal; Gastrojejunostomy Anastomosis; Gastroplasty; Genetic H: Hernia; Herniation, Hyperosmolality (Having highly concentrated substances that are capable of causing dumping syndrome), Hypertension I: Ileum J: Jejunum L: Laparoscopy M: Morbid, Morbid Obesity, Mortality, Multidisciplinary Bariatric Program (Team approach to testing and treatment of clinically severe obesity; includes surgical, internal medicine, nutrition, psychiatric, and exercise physiology, assessment, and treatment) N: NIH, NIH Consensus Report, NIH Surgical Criteria (The National Institutes of Health has established minimum requirements for deciding whether bariatric surgery is the right treatment option: 100 pounds or more above ideal body weight or a BMI of 40 or greater, BMI of 35 or greater with one or more obesity-related health condition), O: Obstructions (Narrowing of an anastomosis or a part of the gastrointestinal tract that slows down the normal passage of food or waste) P: Psychotherapy (Testing and treatment of mentally related disorders), Pulmonary R: Roux-en-Y Gastric Bypass Surgery (A surgical method of reconnecting the stomach and upper small intestines in roughly a Y shape) S: Staples (Surgically sterile devices for connecting tissue; usually they are permanent and made of stainless steel or titanium), Strictures (Narrowing of anastomosis or a section of intestine; often related to scarring or ulcers), Therapy: Type 2 Diabetes V: Vertical Banded Gastroplasty (A type of surgical operation to treat clinically severe obesity. Changes the shape of and restricts the stomach. Not performed very often)
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