complications of obesity · dyslipidemia findings related to obesity an inverse relationship...
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Complications of Obesity
Dr. Shahrzad ShahidiProfessor of Nephrology
Isfahan University of Medical Sciences
Mortality & MorbidityAssociated with Obesity
The effects of excess weight on mortality &morbidity have been recognized for more than2,000 years.
It was Hippocrates who recognized that “suddendeath” is more common in those who are naturallyfat than in the lean.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
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MortalityExcess Body Weight
Mortality associated with excess body weightincreases as the degree of obesity & overweightincreases.
It is estimated that 280,000 to 325,000 deaths ayear can be attributed to obesity in the US, > 80%of these deaths occur among individuals with aBMI > 30 kg/m2.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
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Regional fat distribution can contribute to mortality. This was first noted in the beginning of the 20th century. Obese individuals with an android (or apple) distribution of
body fat are at a greater risk for diabetes & heart diseasethan were those with a gynoid distribution (pear).
Android fat distribution results in higher free fatty acidlevels, higher glucose & insulin levels & reduced HDLlevels. It also results in higher BP & inflammatory markers.
MortalityRegional Fat Distribution
Android Gynoid
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
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MorbidityAssociated with Obesity
Overweight affects several diseases,although its degree of contributionvaries from one disease to another.
Additionally, the risk of developing adisease often differs by ethnic group, &by gender within a given ethnic group.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
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Cardiovascular disorders Obstructive sleep apnea Gastrointestinal disorders Metabolic disorders Cancers Psychological disorders
Complications of pregnancy Menstrual irregularities Low back pain Osteoarthritis Gout Carpal tunnel syndrome
MorbidityAssociated with Obesity
CDC
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Cardiovascular DisordersAssociated with Obesity
HypertensionStroke
Heart DiseaseVenous thrombosis 9
Hypertension HTN is identified when a BP is sustained at
≥140/90 mmHg. High BP is referred to as the “silent killer”
since there are usually no symptoms withHTN.
Some individuals find out that they havehigh BP when they have trouble with theirheart, brain, or kidneys.
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HypertensionThe Dangers
Heart failure, heart attack Brain aneurysms, stroke Kidney failure Vision changes that can result in blindness Peripheral vascular disease
Failure to find and treat HTN is serious, as untreated HTN can cause:
NHLBI11
Adapted from:http://www.obesityinamerica.org/trends.html
HypertensionPrevalence in the Overweight
0
5
10
15
20
25
30
35
Males Females
BMI < 25BMI > 25 & < 27BMI > 27 & <30
Prev
alen
ce o
f H
TN
Age-adjusted prevalenceof hypertension in
overweight U.S. adults
14.9
22.1
27.0
15.2
27.7
32.7
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Stroke
Sudden numbness or weakness, especially on one side of the body Sudden confusion or trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble with walking, dizziness, or loss of balance or coordination Sudden severe headache with no known cause
The symptoms of a stroke include:
NINDS13
Stroke With increasing BMI, the risk of ischemic stroke
increases progressively & is doubled in those with aBMI > 30 kg/m2 when compared to those having aBMI of < 25 kg/m2.
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Cardiovascular DisordersAssociated with Obesity
Heart disease: CAD
Heart failure
Myocardial steatosis
ECG findings
AF
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Coronary Artery Disease Obesity is associated with an increased risk for CAD. Abdominal fat distribution is believed to be related as well. Data from the Nurses Health Study illustrated that women in the lowest BMI but highest
waist-to-hip circumference ratio had a greater risk of heart attack than those in thehighest BMI but lowest waist-to-hip circumference ratio.
Regional fat distribution appears to have a greater effect on CAD risk than BMI alone.
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Gastrointestinal DisordersAssociated with Obesity
Hepatobiliary DiseaseGERD/Erosive esophagitis
GI cancer
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Gallbladder Disease Cholelithiasis is the primary hepatobiliary pathology
associated with overweight. Normally, a balance of bile salts, lecithin, & cholesterol keep
gallstones from forming. If there are abnormally high levels of bile salts or, more
commonly, cholesterol, then stones can form.
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GallstonesFindings Related to Obesity
More cholesterol is produced at higher body fat levels. Approximately 20 mg of additional cholesterol is synthesized for each
kg of extra body fat. High cholesterol concentrations relative to bile acids & phospholipids
in bile increase the likelihood of precipitation of cholesterolgallstones in the gallbladder.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
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GallstonesFindings Related to Obesity
In the Nurses’ Health Study, when compared to those having a BMI of 24or less, Women with a BMI > 30 kg/m2 had a 2-fold increased risk for
symptomatic gallstones. Women with a BMI > 45 kg/m2 had a 7-fold increased risk for
symptomatic gallstones.
The relative increased risk of symptomatic gallstone development withincreasing BMI appears to be less for men than for women.
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Liver Disease Nonalcoholic fatty liver disease (NAFLD) is the
term given to describe a collection of liverabnormalities that are associated with obesity.
In a cross-sectional analysis of liver biopsies ofobese patients, it was found that the prevalenceof steatosis, steatohepatitis, & cirrhosis wereapproximately 75%, 20%, & 2% respectively.
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Liver DiseaseFatty Liver
A gradual weight reduction can helpto reduce the enlargement of the liverdue to fat, and it can normalize theassociated liver test abnormalities.
The American Liver Foundation22
Metabolic DisordersAssociated with Obesity
Diabetes MellitusDyslipidemia
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Diabetes Mellitus
Type 2 DM is strongly associated with overweight & obesity in bothgenders & in all ethnic groups.
The risk for Type 2 DM increases with the degree & duration ofoverweight in individuals.
The risk for Type 2 DM also increases in individuals with a morecentral distribution of body fat (abdominal).
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Diabetes MellitusFindings Related to Obesity
The Nurses’ Health Study demonstrated the curvilinear relationshipbetween increasing BMI and the risk of diabetes in women: Women with a BMI below 22 kg/m2 had the lowest risk of DM At a BMI of 35 kg/m2, the relative risk of DM increased 40-fold or 4,000%
The Health Professionals Follow-up Study demonstrated a similarrelationship between increasing BMI and the risk of diabetes inmen: Men with a BMI below 24 kg/m2 had the lowest risk of DM At a BMI of 35 kg/m2, the relative risk of DM increased 60-fold or 6,000%
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Diabetes MellitusFindings Relating to Weightloss
Weight loss reduces the risk of developing DM.
In the Health Professionals Follow-up Study, aweight loss of 5-11 kg decreased the relative riskfor developing diabetes by nearly 50%.
Type 2 DM was almost nonexistent with a weightloss of more than 20 kg or in those with a BMIbelow 20.
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DyslipidemiaFindings Related to Obesity
An inverse relationship between HDL cholesterol & BMI has beennoted.
This relationship may be more important than the relationshipbetween BMI & TG levels.
Low level of HDL carries more relative risk for developing heartdisease than do elevated triglyceride levels.
Central fat distribution also plays an important role in lipidabnormalities.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
HDL
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Obstructive sleep apneaOsteoarthritis
CancersComplications of pregnancy
Menstrual irregularitiesPsychological disorders (Depression, Dementia)
Other DisordersAssociated with Obesity
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Obstructive Sleep Apnea Obstructive sleep apnea is caused by repetitive upper airway obstruction
during sleep as a result of narrowing of the respiratory passages. Patients having the disorder are most often overweight with associated
peripharyngeal infiltration of fat and/or increased size of the soft palateand tongue.
American Academy of Family Physicians29
Obstructive Sleep Apnea Common complaints are loud snoring, disrupted sleep,
& excessive daytime sleepiness. Individuals with sleep apnea suffer from fragmented
sleep & may develop cardiovascular abnormalitiesbecause of the repetitive cycles of snoring, airwaycollapse, & arousal.
Because many individuals are not aware of heavysnoring & nocturnal arousals, obstructive sleep apneamay remain undiagnosed.
American Academy of Family Physicians30
Obstructive Sleep ApneaFindings Relating to Obesity
Obstructive sleep apnea affects around 4% of middle-agedadults.
Individuals having a BMI of at least 30 are at greatest riskfor sleep apnea.
Weight loss has been shown to improve the symptomsrelating to sleep apnea.
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Osteoarthritis
OA is the most common type of arthritis. 40 million Americans currently have osteoarthritis. It is a degenerative disease which frequently leads to
chronic pain and disability. For individuals > 65, it is the most disabling disease. Currently, only the symptoms of OA can be treated; there is
no cure.
NSLS32
OsteoarthritisFindings Relating to Obesity
The incidence of OA is significantly increased inoverweight individuals.
OA that develops in the knees and ankles isprobably directly related to the trauma associatedwith the degree of excess body weight.
Areas of the bodymost commonlyaffected by OA33
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CancerFindings Relating to Obesity
Associations for only 11 cancers(oesophageal adenocarcinoma, multiplemyeloma, & cancers of the gastric cardia,colon, rectum, biliary tract system,pancreas, breast, endometrium, ovary, &kidney) were supported bystrongevidence.
Kyrgiou M, et al. BMJ 2017;356
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CancerFindings Relating to Obesity
Obesity & physical inactivity may accountfor 20% of several major cancers.
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Endocrine Changes Changes in the reproductive system are among the most
common. Irregular menses & frequent anovular cycles are common. Rates of fertility may also be reduced. Disorders of sexual arousal & orgasm in women. Erectile dysfunction in men.
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Psychological DisordersAssociations with Obesity
Obesity is associated with an impaired qualityof life.
Higher BMI values are associated withgreater adverse effects.
When compared to obese men, obesewomen appear to be at a greater risk forpsychological dysfunction.
This may be due to the societal pressure onwomen to be thin.
Endocrinol Metab Clin N Am. 2003; 32: 761-786.
J La State Med Soc .2005; 157 (1): S42-49.38
Psychological DisordersWeight Loss
Intentional weight loss has been consistently associated withimproved quality of life.
Severely obese patients who lost 43 kg through gastric bypassdemonstrated improved quality of life scores to such an extent thattheir post-weight loss scores were equal to or even better thanpopulation norms.
J La State Med Soc .2005; 157 (1): S42-49.
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Other DisordersAssociated with Obesity
InfectionSkin changes
(steriae, Akanthosis nigricans,Hirsutism)Gout
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References CDC: Overweight and Obesity -- Contributing Factors. Available at:
http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm Bellanger T, Bray G. Obesity related morbidity and mortality.
J La State Med Soc. 2005; 156(1): S42-49. Bray G. Risks of obesity. Endocrinol Metab Clin N Am. 2003; 32: 787-804. National Heart, Lung, and Blood Institute (NHLBI). High Blood Pressure.
Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_WhatIs.html Obesity in America. Obesity Trends. Available at:
http://www.obesityinamerica.org/trends.html
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References National Institute of Neurological Disorders and Stroke. NINDS Stroke Information Page.
Available at: http://www.ninds.nih.gov/disorders/stroke/stroke.htm National Heart, Lung, and Blood Institute (NHLBI). What is Coronary Artery Disease?
Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html American Cancer Society (ACS). What is Colorectal Cancer? Available at:
http://www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Is_Colon_and_Rectum_Cancer.asp?rnav=cri
National Cancer Institute (NCI). Obesity and Cancer. Available at:http://www.cancer.gov/cancertopics/factsheet/Risk/obesity
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References American Liver Foundation. Diet and Your Liver. Available at:
http://www.liverfoundation.org/cgi-bin/dbs/articles.cgi?db=articles&uid=default&ID=1022&view_records=1
Mayo Clinic. Your Liver: An Owner’s Guide. Available at:http://www.mayoclinic.com/health/liver/DG00038
American Academy of Family Physicians (AAFP). Obstructive Sleep Apnea.Available at: http://www.aafp.org/afp/991115ap/2279.html
National Synchrotron Light Source (NSLS). Osteoarthritis. Available at:http://www.nsls.bnl.gov/about/everyday/osteoarthritis.html
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