Obesity and Complication

Dr Suhazeli Abdullah
FMS PK Permaisuri
 Introduction
• The global burden of
overweight
(BMI=25.0) and
obesity (BMI=30.0) is
estimated > 1.1
billion.
• Asian sub-regions:
3.6 billion mean BMI
of 23.4 kg/m2
NHMS 1996 in Malaysia

overweight obese
Males 15.1% 2.9%
Females 17.9% 5.7%
 Classification of weight by BMI
(Evidence Level C)
Classifica BMI
tion (kg/m²) Risk of co-morbidities
Underweight Low (but increased risk of other
< 18.5 clinical problems)
Normal
range 18.5 – 22.9 Average

Overweight: > 23

Pre-obese 23.0 – 27.4 Increased

Obese I 27.5 – 34.9 Moderate

Obese II 35.0 – 39.9 Severe

Obese III > 40.0 Very severe

 Waist circumference (WC)
• Male < 94
• Female < 80
Pathophysiology
HOW SERIOUS IS OBESITY AND
BEING OVERWEIGHT?
• Metabolic Changes. diabetes, high blood
pressure, gallbladder disease, and some
cancers.
• Increased Mass. osteoarthritis and sleep apnea.
depression,
• Harmful Fat Cell Types. Weight concentrated
around the abdomen and in the upper part of the
body poses a higher health risk than fat that
settles in a pear-shape around the hips and
flank. Fat cells in the upper part of the body
appear to have different qualities from those
found in the lower parts.
 Health risks associated with obesity
Greatly increased Moderately increased Mildly increased
(RR>3) (RR 2-3) (RR 1-2)
• Type 2 diabetes • Coronary heart disease • Cancer (breast endometrial
mellitus • Cerebrovascular colo-rectal, liver, prostate,
• Hepatobiliary Disease gallbladder)
disease (Gallstone • Cardiac failure • Reproductive hormone
and Steatosis) • Left Ventricular abnormalities
• Dyslipidaemia Hypertrophy • Polycystic ovarian
• Metabolic • Hypertension syndrome
syndrome • Osteoarthritis (knees • Impaired fertility
• Breathlessness and hips) (Anovulation, reduced
• Sleep apnoea • Hyperuricaemia and testosterone levels)
Gout • Low back pain
• Increased anaesthetic risk
• Foetal defects associated
with maternal obesity
RR : Relative Risk
 Heart Disease

• BMI =30: 50% to 100% increased risk for

death vs BMI of 20 to 25.
• Mortality rates: 3 X risk for heart disease.
• Body apple-shaped: insulin resistance and
diabetes, heart disease, high blood
pressure, stroke, and unhealthy
cholesterol levels.
• Body pear-shape: fat around the hips and
flank have a lower association with these
conditions.
 Heart Disease and Stroke

• Damage in the Blood Vessels.

Stiffness in the aorta, the major artery
leading from the heart.
• C-reactive protein (CRP) in people
with obesity and abdominal fat
considered to be a marker for
inflammation and damage in the
arteries.
 Hypertension and MI
• High Blood: serious risks
for stroke, heart attack,
and heart failure.
• risk of high blood
pressure, sleep apnea,
and diabetes, and leads
to Heart Failure
• Unhealthy Cholesterol
Levels and Lipid Levels.
The effect of obesity on
cholesterol levels is
complex.
 Insulin Resistance, Type 2
Diabetes
• Most people with type 2 diabetes are obese and, in fact, studies strongly suggest that
weight loss may be the key in controlling the current epidemic in diabetes type 2. It
should be noted that only a minority of obese people is diabetic.
• People with type 2 diabetes have abnormalities that produce an inability to use
insulin, a critical hormone in the metabolism of sugar. This condition, called insulin
resistance, has the effect of increasing blood glucose (sugar in the blood), the
hallmark of diabetes. (Insulin resistance is also associated with high blood pressure
and abnormalities in blood clotting.)
• Although the exact mechanisms of the relationship between obesity and diabetes
type 2 is not entirely clear, fat cells may release certain chemicals that inhibit the
body's sensitivity to insulin. [For more information, see the Well-Connected Report
#60, Diabetes Type 2.]
• Metabolic Syndrome (also called Syndrome X). Of particular concern is a set of
conditions referred to as metabolic syndrome (also called syndrome X), which
consists of obesity marked by abdominal fat, unhealthy cholesterol levels, high blood
pressure, and insulin resistance. It appears to have a genetic component, although
up to 47 million Americans may have this condition. Obesity itself and rapid eating
may also play role in the development of the syndrome. Metabolic syndrome is
significantly associated with heart disease and higher mortality rates from all causes.
 Metabolic syndrome
• Defined as Glucose intolerance (IGT, IFG or diabetes
• mellitus) or insulin resistance,
• together with 2 or more of other components listed
below:-
– Impaired glucose tolerance (IGT) or diabetes
– Insulin resistance
– Raised arterial pressure 140/90 mmHg
– Raised plasma triglycerides 1.7mmol/L and / or low HDL-C <0.9
mmol/L (men); <1.0 mmol/L (women)
– Central obesity (Waist Hip Ratio : Men >0.9, Women >0.85) and
/ or BMI > 30 kg/m2
– Microalbuminuria (Urinary albumin excretion 20 mg/min or
albumin creatinine ratio of 30 mg/g of creatinine
• Cancer
• Obesity has been associated with certain cancers, and some experts believe that effective weight control for children and adults could
reduce cancer rates by 30% to 40%. One way obesity may increase the risk for cancer is its association with high levels of hormones
called growth factors, which can trigger rapid cell proliferation leading to cancer.
• Uterine Cancers. Women who are obese appear to have two to three times the risk for uterine cancer as thinner women.
• Prostate Cancer. A Western lifestyle is associated with prostate cancer, although direct causal role for either obesity or dietary fats has
not been established. A 2001 study did find obesity to be associated with a modest increase in prostate cancer mortality, although not with
the risk for prostate cancer itself. In a previous study of Chinese men, however, it was not obesity itself but an unhealthy fat distribution
that was associated with a higher risk. High-risk individuals in the study were those whose fat was more centered in the abdomen, the so-
called apple-shape. Either one or both of the hormones that are associated with both obesity and diabetes, leptin and insulin, could
theoretically stimulate prostate cancer growth.
Click the icon to see an image of prostate cancer.

• Breast Cancer. Studies have reported mixed effects on the association between obesity and breast cancer. A number of studies have
linked obesity to breast cancer in postmenopausal women, particularly in women who begin to gain weight after age 18. One study in fact
suggested that being heavier as a child conferred a lower risk for breast cancer after menopause.
Click the icon to see an illustrated series detailing a breast cancer surgery.

• Gallbladder Cancer. Obese women are at higher risk for gallbladder cancer.
• Gastrointestinal Cancers. A number of cancers in the gastrointestinal tract have been associated with obesity:
• Cancer of the esophagus. The increased risk may be due to a higher incidence of gastroesophageal reflux disorder (heartburn) in people
who are overweight.
• Colon cancer. There is a demonstrated link between increased body mass and colon cancer risk for both men and women.
Click the icon to see an illustrated series detailing a colon cancer surgery.

• Pancreatic cancer. One study has linked obesity to pancreatic cancer, but also found that overweight patients who are physically active
have a lower risk.
• (Obesity does not appear to be related to a higher risk for stomach cancer.)
• Muscles and Bones
• Effects of Weight on Muscles and Bones. Obesity places stress on
bones and muscles, and overweight people are at higher risk for
hernias, low back pain, and aggravation of gout and other arthritic
conditions. Studies report that the incidence of osteoarthritis is
significantly increased in people who are overweight. People who
are obese are also at higher risk for carpal tunnel syndrome and
other problems involving nerves in their wrists and hands. It should
be noted that some weight may be protective against osteoporosis
(loss of bone density).
• Osteoporosis. Some extra weight is beneficial for maintaining bone
density in women after menopause. Before menopause, however,
overweight women who lose weight and who also increase their
intake of dietary calcium are not at increased risk for bone loss.
• Eyes and Mouth Disorders
• Obesity increases the risk for the following
mouth and eye disorders:
• Gum disease.
• Cataracts. A study of 17,150 men concluded that
there is a higher association between cataracts
and greater body mass, height, and carrying fat
around the abdomen.
• Maculopathy. Maculopathy is an eye disease
related to aging. Obesity also appears to be
related to this disease.
• Reproductive and Hormonal Problems
• Infertility. Abnormal amounts of body fat, either 10% to 15% too high
or too low, can contribute to infertility in women. Obesity is specially
related to certain problems related to infertility, such as uterine
fibroids or menstrual irregularities. In men, obesity can contribute to
reduced testosterone levels.
• Effect on Pregnancy. The dangerous effects of obesity on
pregnancy are multifold. They include high blood pressure,
gestational diabetes (diabetes, usually temporary, that occurs during
pregnancy), urinary tract infections, blood clots, prolonged labor, a
higher fetal mortality rate in late stages of pregnancy, and cesarean
delivery. Infants of women who are obese are also at higher risk for
neural tube birth defects, which affect the brain or spine. Folic acid
supplements, ordinarily effective in preventing these conditions, may
not be as protective in overweight women.
• Effects on the Lungs
• Obesity is thought to be a risk factor for adult-onset asthma,
although there is some evidence that although obesity causes
wheezing and shortness of breath, it does not appear to be strongly
associated with the disease mechanisms in the lungs that cause
true asthma.
• Obesity also puts people at risk for hypoxia, in which oxygen is
insufficient to meet the body's needs. Obese people need to work
harder to breathe and tend to have inefficient respiratory muscles
and diminished lung capacity. The Pickwickian syndrome, named
for an overweight character in a Dickens novel, occurs in severe
obesity when lack of oxygen produces profound and chronic
sleepiness and, eventually, heart failure.
• Effect on the Liver
• Nonalcoholic Fatty Liver Disease. People with obesity, particularly if
they also have diabetes type 2, are at higher risk for a condition
called nonalcoholic fatty liver disease, also called nonalcoholic
steatohepatitis (NASH). It may occur in about half of people with
diabetes and 20% to 50% of obese people, depending on how
severe the obesity is. It can also occur in overweight children. This
condition causes liver damage that is similar to liver injury seen in
alcoholism. In some cases, it can be very serious and require liver
transplantation.
• Gallstones. The incidence of gallstones is significantly higher in
obese women and men. The risk for stone formation is also high if a
person loses weight too quickly. In people on ultra-low calorie diets,
gallstones may be prevented by taking ursodeoxycholic acid
(Actigall).
• Sleep Disorders
• People who are obese and nap tend to fall asleep faster and sleep longer during the
day. At night, however, it takes them longer to fall asleep and they sleep less than
people with normal weights. In an apparent vicious circle, studies have suggested
that not only can obesity interfere with sleep, but that sleep problems may actually
contribute to obesity.
• Sleep Apnea. Obesity, particularly the apple-shape, is stongly associated with sleep
apnea, which occurs when the upper throat relaxes and collapses at intervals during
sleep, thereby temporarily blocking the passage of air. Sleep apnea is increasingly
being viewed as a potentially serious health problem, including heart disease and
stroke. Some studies suggest that among overweight people, those who have sleep
apneas have a greater heart risk than those without them. Obesity may contribute to
sleep apnea simply by fatty cells infiltrating the throat tissue, which could narrow the
airways. In one study, the more obese a person with sleep apnea was, the higher the
pressure on the airway and therefore the greater the obstruction of the airway.
(Obstructive sleep apnea may also cause obesity itself, however, as sleepy people
tend to be sedentary.) Some studies are even indicating that treating sleep apnea
may help people lose abdominal fat.
• Narcolepsy. A small European study found a link between narcolepsy (a sleep
disorder characterized by excessive daytime sleepiness with frequent daily sleep
attacks) and high BMI.
• Emotional and Social Problems
• A study that followed obese adolescents for seven years found that,
compared to thinner peers, overweight girls completed fewer years of
school, were 20% less likely to be married, and had 10% higher rates of
household poverty. A 2000 study of third graders found a direct relationship
between depressive symptoms and body mass index in girls, but not boys.
Women and girls tend to blame themselves for being heavy while males
tend to attribute being overweight to outside factors. Studies consistently
show that overweight males (both boys and men) are not as severely
emotionally affected as females of any age. Nevertheless, in the first study
mentioned above, 11% of obese men were less likely to be married than
non-obese men and their incomes were lower.
• No evidence exists, however, that obese people suffer from emotional
disorders, such as major depression or anxiety, to any greater degree than
thinner people. Generally, depression and anxiety are caused by the weight
problem and are usually resolved by weight loss.
 Other Complications Obesity
• Sex hormone binding globulin levels low (serum)
• Thrombophilia
• Striae
• Cortisol levels raised (serum or plasma)
• Pickwickian syndrome
• Hyperlipidaemia
• Abdominal distension
• Arthropathy
• Hyperinsulinaemia
• Female infertility
• Uric acid levels raised (plasma or serum)
• Amenorrhoea
• Carpal tunnel syndrome