Dr. Patrick Rhoades
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Today we are going to talk about obesity, its effects and how it contributes to poor health.  First of all, it was estimated that obesity was directly responsible in 1995 for $70 billion of health care expenditure.  That is approximately 7% of the entire health care budget directly on obesity.  It has been noted that in 2002 64.5% of the U.S. population was either overweight or obese.  I would imagine that this would be much higher now.  Obesity is costly both from a health care and from a financial point of view. 

Obesity is a chronic disease in the same sense as hypertension and atherosclerosis.  It is caused by an imbalance between energy ingested and energy expended.  The excess energy is stored in fat cells.  The hyperplasia (increase in number) and hypertrophy (increase in size) of these fat cells is the cause of obesity.  Enlarged fat cells produce clinical problems associated with obesity either because of the weight or mass of the extra fat or because of increased secretion of free fatty acid and numerous peptides from the enlarged fat cells.  It must be noted that fat is not an innocuous substance.  It is sort of an endocrine organ that secretes many nasty things.  The consequences of these two mechanisms are other diseases such as diabetes mellitus, gallbladder disease, osteoarthritis, heart disease and some forms of cancer.  It has been estimated that between 280,000 and 325,000 deaths could be attributed to obesity annually in the United States.  Think of that as the size of a city close to twice the size of Stockton, California. 

It must be noted that the heavier you are the more likely you are to have these sorts of problems.   There is a markedly elevated risk of developing diabetes, hypertension, gallbladder disease and coronary artery disease when the BMI is greater than 40kg/m2.  We are going to talk about each of these. 

Everyone knows somebody with diabetes and probably has a relative with diabetes.  Up to 65% of the cases of type 2 diabetes mellitus can be attributed to overweight, that is two-thirds of the amount of diabetes mellitus.  Also, in 7 million cases of diabetes, overweight may be responsible for two-thirds of the diabetic deaths.  Weight gain often seems to precede the onset of diabetes.  There are some studies of people who underwent gastric bypass surgery and those that lost weight.  Sixty nine percent of them went into remission and only 0.5% of those that did not have diabetes prior to the gastric bypass surgery ended up developing it.  Also, keeping your weight in check moderates the risk of diabetes mellitus.  There is also something called pre-diabetes which has to do with insulin resistance.  The pancreas is able to keep the level of glucose in check.  However, it has to secrete very high levels of insulin to do so.  It is associated with lack of energy and eventually the pancreas cannot keep up and one develops diabetes. 

Next we will talk about gallbladder disease.  It is the primary hepatobiliary pathology associated with overweight.  The reason that gallbladder disease is related to overweight is because of the increased cholesterol turnover related to total body fat.  Cholesterol production is related to body fat and approximately 20mg of additional cholesterol is synthesized for each kilogram of body fat.  If you are 10 kilograms overweight with body fat you will secrete 200mg more of cholesterol.  That in turn is excreted in bile which causes the bile to have a higher concentration.  That makes it more likely to form gallstones and to have gallbladder disease requiring surgery. 

Hypertension is most often high in people who are obese.  It has been suggested that perhaps control of obesity would eliminate 48% of the hypertension in Whites and 28% of they hypertension in Blacks.  For each decline of 1 millimeter in mercury in diastolic blood pressure, the risk of a heart attack decreases by 2-3%.  As one can see this is a very important risk factor to moderate.  Decrease in body fat will decrease blood pressure. 

Heart disease is also much greater in patients with a BMI in the obese category.  In fact, there is a three point three fold increase with a BMI greater than 29kg/m2.  Probably the most important reason is the dyslipidemia.  However, heart hypertension is also a risk factor for coronary artery disease and may also be related.  In addition, cardiac weight, which is associated with obesity, increases with increasing body weight suggesting increasing cardiac work.  Weight loss would decrease heart weight.  Also, central fat distribution, or apple shape, is associated with small, low density lipid proteins as opposed to large, fluffy LDL particles.  The small, low density lipid lipoproteins are a strong predictor of heart disease. 

Cancer is increased significantly in overweight individuals; specifically males face the increased risk for neoplasm of the colon, rectum and prostate.  Females have increased risk of reproductive system cancer and gallbladder cancer.  This may be by increased production of estrogen to both sexes from adipose tissue. 

Other diseases include disease of the bone, joint, muscles, connective tissue and skin, including arthritis and so on.  As one can easily imagine, the higher load we place on our joints the more likely they are to develop problems such as osteoarthritis, tears in tendons or ligaments. 

Sleep apnea is also much higher in people who are overweight.  It is basically a linear increase in the apnea, hypoapnea index compared to the change in weight.  Decreasing weight can markedly reduce sleep apnea and sequelae.  However, it is very difficult in patients who have sleep apnea to reduce weight. 

Finally, there is a lot of stigma associated with weight.  Overweight individuals are exposed to consequences by public disapproval for their fatness and there is a fat prejudice persistent in our society.  These effects are more evident in females than males.  One cannot enjoy full quality of life being markedly obese. 

Hopefully this newsletter is somewhat helpful in understanding the cost of being obese.  It is very important that we understand that this is a very significant disease that affects not only how you look in clothes, but also your quality of life and health.  It will most likely lead to a premature death due to causes of obesity.  Further along in our series of newsletters we will talk about strategies on reducing body fat with lifestyle changes, including exercise, diet and psychological aspects. 

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