Obesity is a complex, multifactorial chronic disease linked to significant morbidity and mortality, affecting individual health outcomes and life expectancy. As body mass index (BMI) increases, so does the prevalence of serious health conditions such as diabetes, heart disease, and various cancers, with obesity-related healthcare costs exceeding $200 billion annually. The societal stigma against obesity also impacts psychosocial aspects of life, leading to decreased educational and employment opportunities, and a higher risk of depression.

1. Overweight and
obesity in adults:
Clinical
Syndromes
CME PRESENTATION
By :Dr. Darayus P. Gazder
PG-R1

2. Genetic
Environmental
Behavioral
Psychological
Physiological
Metabolic
American Obesity Association. Fact Sheet: Obesity in the U.S. May 2, 2005. http://www.obesity.org
Obesity is a complex, multi-
factorial, chronic metabolic
disease

3. • The mortality and morbidity associated with being overweight or obese
have been known to the medical profession for more than 2000 years
• It has been suggested that the steady rise in life expectancy during the
past two centuries may come to an end because of the increasing
prevalence of obesity.
• Individuals who are both obese and smoke have a substantially greater
reduction in life expectancy than non obese smokers or obese
nonsmokers

4. Health consequences

6. Morbidity
Morbidity
Overweight children and adolescents are at increased risk for future
adverse health effects, including the following:
❏ Increased prevalence of traditional cardiovascular risk factors such
as hypertension, hyperlipidemia, and DM.
❏ Poor school performance, tobacco use, alcohol use, and poor diet.
❏ Other associated health conditions, such as asthma, hepatic
steatosis, sleep apnea, stroke, cancers (breast, colon, and kidney),
renal insufficiency, musculoskeletal disorders, and gallbladder
disease.
Heart Disease and Stroke Statistics—2014 Update: Chapter 6

7. Morbidity
❏ Data from 4 Finnish cohort studies examining childhood and adult BMI
with a mean follow-up of 23 years found that overweight or obese children
who remained obese in adulthood had increased risks of the following:
Type 2 DM, Hypertension, Dyslipidemia, and Carotid atherosclerosis.
❏ The CARDIA study showed that young adults who were overweight or
obese had lower health-related quality of life than normal-weight
participants 20 years later.
Umer A, Kelley GA, Cottrell LE, Giacobbi P, Innes KE, Lilly CL.
Childhood obesity and adult cardiovascular disease risk
factors: a systematic review with meta-analysis. BMC public
health. 2017 Dec;17(1):683.
Coronary Artery Risk Development in Young
Adults Study (CARDIA).

8. Prevalence of Significant Morbidities per Weight
Stommel M, Schoenborn CA. Variations in BMI and prevalence of health risks in
diverse racial and ethnic populations. Obesity 2010; 18(9):1821-1826.
As a patient’s BMI rises, so does
the prevalence of co-morbid
conditions
4% 4%
19%
8%
5%
29%
17%
6%
45%
22%
6%
49%
0%
10%
20%
30%
40%
50%
60%
Diabetes Chronic Heart Disease Hypertension
BMI 25 BMI 30 BMI 40 BMI 40+

9. Morbidity
❏ One study, using NCI Surveillance, Epidemiology, and End Results (SEER)
data, estimated that in 2007 in the United States, about 34,000 new cases of
cancer in men (4 percent) and 50,500 in women (7 percent) were due to
obesity. The percentage of cases attributed to obesity varied widely for
different cancer types but was as high as 40 percent for some cancers,
particularly endometrial cancer and esophageal adenocarcinoma.
❏ A projection of the future health and economic burden of obesity in 2030
estimated that continuation of existing trends in obesity will lead to about
500,000 additional cases of cancer in the United States by 2030.
❏ This analysis also found that if every adult reduced their BMI by 1 percent,
which would be equivalent to a weight loss of roughly 1 kg (or 2.2 lbs) for an
adult of average weight, this would prevent the increase in the number of
cases and result in the avoidance of about 100,000 new cases of cancer

10. Morbidity
• Bone and cartilage degeneration (Osteoarthritis)
Obesity is an important risk factor for osteoarthritis (Knee Joint) / Obesity
confers a nine times increased risk in knee joint osteoarthritis in women
• Gallbladder disease
• Several cancers
In 2002, approximately 41,000 new cases of cancer in the USA were thought
to be due to obesity. In other words, about 3.2% of all new cancers are linked
to obesity.
• Sleep apnea
Obesity has been found to be linked to sleep apnea. Also, weight reduction
has been associated with comparable reductions in the severity of sleep
apnea. (NHLBI)
Polednak AP. Trends in incidence rates for
obesity-associated cancers in the US. Cancer
detection and prevention. 2003 Jan
1;27(6):415-21.

11. MORTALITY
• In general, greater body mass index (BMI), is associated with
increased rate of death from all causes and from cardiovascular
disease (CVD)

12. Whitlock G, Lewington S, Sherliker P,
et al. Body-mass index and cause-
specific mortality in 900,000 adults:
collaborative analyses of 57
prospective studies. Lancet 2009;
373:1083.

13. Mortality
❏ Researchers looked at data from more than 10.6 million participants from
239 large studies, conducted between 1970 and 2015, in 32 countries. A
combined 1.6 million deaths were recorded. Participants were followed
for an average of 14 years
EXCLUSION: Participants who were current / former smokers / Chronic diseases at
the beginning of the study, and any who died in the first five years of follow-up
22.5-<25 kg/m2 : Lowest mortality risk
25-<27.5 kg/m2: :7% higher risk of mortality
27.5-<30 kg/m2 :with a 20% higher risk
30.0-<35.0 kg/m2 :with a 45% higher risk
35.0-<40.0 kg/m2 :with a 94% higher risk
40.0-<60.0 kg/m2 :was associated with a nearly three-fold risk
Every 5 units higher BMI above 25 kg/m2was associated with about 31% higher
risk of premature death Di Angelantonio E, Bhupathiraju SN, Wormser D, Gao P, Kaptoge S, de
Gonzalez AB, Cairns BJ, Huxley R, Jackson CL, Joshy G, Lewington S. Body-
mass index and all-cause mortality: individual-participant-data meta-
analysis of 239 prospective studies in four continents. The Lancet. 2016
Aug 20;388(10046):776-86.

14. Mortality
❏ Obesity is associated with higher mortality rates for both CVD
and cancer.
❏ BMI is most strongly associated with cardiovascular disease
mortality among men (RR=2.90), but significantly increased risks
of CVD death were found at all BMIs of greater than 25.0 in
women and 26.5 in men.
The findings showed an increase of 40% to 80% in risk of dying from
cancer among both men and women in the highest weight
categories.
❏ Suggest that the gains in life expectancy from smoking cessation
are beginning to be outweighed by the loss of life expectancy
related to obesity.
Heart Disease and Stroke Statistics—2014 Update:
Chapter 6

15. Cost of Medical Care rises with
Obesity
• Currently, estimates for these costs range from $147 billion to nearly $210
billion per year.
• Obese adults spend 42 percent more on direct healthcare costs than adults
who are a healthy weight.
• Per capita healthcare costs for severely or morbidly obese adults (BMI >40) are
81 percent higher than for healthy weight adults
Cawley J The
Medical Care
Costs of Obesity:
An Instrumental
Variables
Approach. Journa
l of Health
Economics,2013

16. Obesity has serious consequences!!
Life expectancy decreases as BMI increases
For people with obesity, there is a 33% to 179% higher risk of mortality
Graph represents years of life lost for white men.
Fontaine KR, Redden DT, Wang C et al. Years of life lost due to obesity. JAMA 2003;289:187.

17. Cardiovascular involvement in obesity:
overview
• Hypertension — Blood pressure is often increased in obese
subjects. The risk of hypertension is greatest in those subjects
with upper body and abdominal obesity. Weight loss in obese
subjects is associated with a decline in blood pressure.
• Heart disease — Obesity is also associated with increased risks
of CHD, heart failure. Weight loss (if achieved through lifestyle
interventions, medication, or surgery) is associated with an
improvement in cardiovascular risk factors.
• Coronary heart disease – It is compounded by the frequent
coexistence of other CHD risk factors, such as hypertension,
dyslipidemia, and diabetes.
Obesity, weight reduction, and
cardiovascular disease"
Bariatric operations for
management of obesity: Indications
and preoperative preparation

18. Obesity-RelatedMechanismsofCardiovascularDysfunction
Asimplisticschematicofacomplexproblem.

19. • Heart failure – There is an important association between obesity and heart
failure. Mechanisms:

20. • Myocardial steatosis – One potential mechanism for heart disease
in obesity is thought to be excessive lipid accumulation in the
myocardium
• Electrocardiogram findings – Morbid obesity can cause changes in
cardiac morphology that can alter the surface electrocardiogram
(ECG).
• Atrial fibrillation – Obese individuals (BMI >30 kg/m2) are
significantly more likely to develop atrial fibrillation (AF) than those
with a normal BMI (<25 kg/m2).
For each point increase in BMI there is a 4% increase in the risk of
developing atrial fibrillation this is related to left atrial enlargement
and congestive heart failure
Nalliah CJ, Sanders P, Kottkamp H, Kalman JM. The role of
obesity in atrial fibrillation. European heart journal. 2015 Sep
14;37(20):1565-72.

21. Diabetes Mellitus
• One of the strongest risk factors for type 2 diabetes is
obesity,(Modifiable)
Risk of diabetes increases 53 times with severe obesity
• The risk of developing T2DM increases by 20% for each 1
kg/m2 increase in the BMI
• The risk of T2DM:
Does not increase up to a BMI <27.2 kg/m2
BMI of 27.2 to 29.4 kg/m2 the risk will rise by 100
Increases to about 300% for BMI >29.4 kg/m2
J La State Med Soc .2005; 157 (1): S42-49.

23. Obesity and Type 2 DM
In the United States
Among people diagnosed with
Type 2 diabetes,
55 percent have a BMI ≥ 30
(classified as obese),
30 percent have a
BMI ≥ 25 or ≤30
(classified as overweight), and
only 15 percent have a
BMI ≤ 25 (classified as
normal weight).
Adapted from:
http://www.obesityinamerica.org/trends/2016.html
BMI < 25
BMI > 25 or BMI < 30
BMI > 30
15%
30%55%

24. Diabetes Mellitus
Findings Relating to Weight loss
• Weight loss reduces the risk of developing diabetes.
• In the Health Professionals Follow-up Study, a weight loss of 5-11 kg
decreased the relative risk for developing diabetes by nearly 50%.
• Type 2 DM was almost nonexistent with a weight loss of more than 20 kg
(44 lbs) or in those with a BMI below 20.
J La State Med Soc .2005; 157 (1): S42-49.

25. CANCERS

28. A prospective study of 900,000
adults in the United States
showed that obesity accounts for
14% of all deaths from cancer in
men and for 20% of all deaths
from cancer in women
Calle et al., 2003

30. Breast Cancer
• Increased postmenopausal breast cancer
• Obesity acts as a protective factor for premenopausal breast
cancer
• Obesity is associated with increased risk of breast cancer
recurrence especially in Hormone receptor postive patients
Colon Cancer
• For men, increased BMI = increased risk
• The strongest association with abdominal obesity (waist
circumference)
• Also, increased BMI is associated with rectal cancer

31. Esophageal Cancer
• Esophageal adenocarcinoma is 2X’s higher in those who are
overweight and obese
• Associated link with gastroesophageal reflux and Barrett’s
esophagus
• Obesity exacerbates esophageal inflammation
Prostate Cancer
• Pooled data: obesity is associated with a slight increased risk
• Obese men have more aggressive cancers
• Linked to hormone and growth factors (esp IGF-1)

32. Other Cancers
• Obesity is associated with renal cell cancer
• Related to high insulin levels
• Associated with thyroid cancer
• Mechanism is unknown
• Associated with gallbladder cancer
• Possible mechanism related to frequency of gallstones

33. Endometrial Cancer
• Most common gynecologic cancer
• Its associated with obesity
• Hormone related cancer
• 23% of complex atypical hyperplasia (CAH)
progresses to endometrial cancer
• Excess of estrogen and lack of progesterone
causes abnormal proliferative drive

34. Endometrial Cancer: Annual Incidence and
Mortality
Year Cases Deaths
1987 35,000 2,900
2008 40,100 7,170*
American Cancer Society Estimates
*250% increase
American Cancer Society 2008

35. Pulmonary involvement in obesity:
overview
• Lung function in obesity
• Asthma and obesity
• Obstructive sleep apnea

36. Lung function in obesity
• Lung volume
 FRC, ERV, TLC, VC, TV
  RV
• Lung mechanics
 respiratory system compliance
 work of breathing (WOB)
• Flow limitation
 FEV1

37. Obesity and Asthma, Am J Respir Crit Care Med 2006 ; 174. 112–119,
Obesity and asthma :pathophysiology

38. Obesity and Asthma,Am J Respir Crit Care Med2006; 174. 112–119
Obesity and asthma: pathophysiology
Inflammatory factors

39. Obstructive Sleep Apnea (OSA)
and Obesity
• OSA : Disorder of breathing during sleep characterized by prolonged partial upper
airway obstruction / intermittent complete obstruction that disrupts normal ventilation
during sleep and normal sleep pattern . (ATS. AJRCC.1996; 153: 866-878)
• Prevalence of OSA in obesity 37%- 46%
Mallory GB. et al. J Pediatr. 1989:115(6):892-7
Silvestri JM. et al. Ped Pulm. 1993;16(2):124-9
Marcus CL. et al. Ped Pul. 1996;21(3):176-83

40. OSA and obesity :pathophysiology
OBESITY
UA caliber ↓
UA compliance ↑
UA collapsibility ↑ OSAS
Pharyngeal fat ↑
Abdominal and
chest wall fat ↑
Lung volumes ↓
Obesity and weight loss in obstructive sleep apnea: a critical review.
Sleep

41. Psychosocial function
• Obese subjects are often exposed to public disapproval because of
their fatness. This stigma is seen in education, employment, and
health care, among other areas.
• For adolescents with a BMI above the 95% for age and sex:
* Completed fewer years of school
* 20% less likely to be married
* lower household incomes
* Higher rates of household poverty
• Depression has been associated with obesity causing profound
sadness, crying, and loss of energy
Depression in association with severe obesity: changes with weight loss.
Dixon JB, Dixon ME, O'Brien PE Arch Intern Med. 2013;163(17):2058.

42. 2009
Psychological Disorders
Weight Loss
• Intentional weight loss has been
consistently associated with
improved quality of life.
• Severely obese patients who lost 43
kg through gastric bypass
demonstrated improved quality of life
scores to such an extent that their
post-weight loss scores were equal
to or even better than population
norms.
J La State Med Soc .2005; 157 (1): S42-49.
Endocrinol Metab Clin N Am. 2009; 32: 761-786.

43. • Dementia
• Obesity may be associated with an increased risk of dementia
• A recent meta-analysis of 15 prospective studies showed:
Alzheimers vs Vascular Dementia and
other Dementia’s
OVERWEIGHT: 1.35 1.26
OBESE : 2.04 1.64
• The inclusion of obesity in dementia forecast models
increases the estimated prevalence of dementia through
2050 by 9% in the United States and 19% in China.
Heart Disease and Stroke Statistics—2014 Update: Chapter 6

44. King’s obesity staging criteria

47. Summary
●Obesity is associated with significant excess morbidity and mortality.
There are over 200 comorbidities associated with obesity.
●In general, greater body mass index (BMI), calculated as weight (in
kg) divided by height (in m2), is associated with increased rate of death
from all causes and from cardiovascular disease (CVD)
●Specifically, obesity and increased central fat are associated with
diabetes mellitus, hypertension, heart disease, stroke, sleep apnea,
and many chronic and debilitating diseases. Even modest weight loss
improves these comorbidities.
●Obesity affects psychosocial function as obese individuals are often
exposed to public disapproval. This stigma is seen in education,
employment, and health care, among other areas.
●Treating obesity and obesity-related conditions represents an
enormous economic burden. In addition to direct health care
expenses, there are other costs, including lost work productivity and
lower household income.