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Obesity

Dr. Tjatur Winarsanto SpPD

RS Ciremai

Cirebon 2011

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Obesity

Overweight and obesity are both chronic

conditions that are the result of an energy

imbalance over a period of time.

The cause of this energy imbalance can be

due to a combination of several different

factors and varies from one person to

another.

Individual behaviors, environmental factors,

and genetics all contribute to the complexity

of the obesity epidemic.

CDC

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Energy ImbalanceWhat is it?

Energy balance can be compared to a scale.

An energy imbalance arises when the number

of calories consumed is not equalto the

number of calories used by the body.

Weight gain usually involves the combination

of consuming too many calories and notexpending enough through physical activity.

Weight Gain

Calories Consumed > Calories Used

Weight Loss

Calories Consumed < Calories Used

No Weight Change

Calories Consumed = Calories Used

CDC

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Energy ImbalanceEffects in the Body

Excess energy is stored in fat cells, which enlarge or multiply.

Enlargement of fat cells is known as hypertrophy,whereas multiplication of fat cells is known as hyperplasia.

With time, excesses in energy storage lead to obesity.

Fat cells

J La State Med Soc.2005; 156 (1): S42-49.

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Fat Cell EnlargementHypertrophy

Enlarged fat cells produce the

clinical problems associated with obesity,

due to the following:

The weight or mass of the extra fat

The increased secretion of free fatty acids

and peptides from enlarged fat cells.


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Weight ClassificationsA Review

Body mass index (BMI) is a

mathematical ratio which is calculated

as weight (kg)/ height squared (m2).

It is used to describe an individualsrelative weight for height, and is

significantly correlated with total

body fat content. BMI is intended for

those 20 years of age and older.

With a BMI

of:

You are considered:

Below 18.5 Underweight

18.5 - 24.9 Healthy Weight

25.0 - 29.9 Overweight

30 or higher Obese

You can find tables on the web that have done the math and metric conversions for you.http://www.pbrc.edu/Division_of_Education/Tools/BMI_Calculator.asp

orhttp://www.nhlbisupport.com/bmi

CDC
http://www.pbrc.edu/Division_of_Education/Tools/BMI_Calculator.asphttp://www.nhlbisupport.com/bmihttp://www.nhlbisupport.com/bmihttp://www.pbrc.edu/Division_of_Education/Tools/BMI_Calculator.asp

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Mortality and MorbidityAssociated with Obesity

The effects of excess weight on mortality and morbidity have been recognized

for more than 2,000 years. It was Hippocrates who recognized that sudden

death is more common in those who are naturally fat than in the lean.

Today, obesity is increasing rapidly. Research shows that many factors related

to obesity influence mortality and morbidity.

Endocrinol Metab Clin N Am. 2003; 32: 761-786.

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Mortality

Weight, Fat Distribution, and Activity The following factors have been shown to increase

mortality in individuals:

Excess body weight Regional fat distribution

Weight gain patterns

Sedentary Lifestyle


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MortalityExcess Body Weight

Mortality associated with excess body weight increases as

the degree of obesity and overweight increases.

It is estimated that 280,000 to 325,000 deaths a year can

be attributed to obesity in the United States, more than 80%

of these deaths occur among individuals with a BMI greater

than 30 kg/m2.


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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 riskfor diabetes and heart disease than were those with a gynoid

distribution (pear).

Android fat distribution results in higher free fatty acid levels, higher glucose

and insulin levels and reduced HDL levels. It also results in higher bloodpressure and inflammatory markers.

MortalityRegional Fat Distribution

Android Gynoid


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In addition to overweight and central fatness,

the amount of weight gain after ages 18 to 20

also predicts mortality.

The Nurses Health Study and the Health

Professionals Follow-up Study showed that

a marked increase in mortality from heart

disease is associated with increasingdegrees of weight gain.

MortalityWeight Gain


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Sedentary lifestyle is another important component

in the relationship of excess mortality to obesity.

A sedentary lifestyle increases the risk of death

at all levels of BMI.

Unfit men in the BMI range of less than 25 kg/m2

had a significantly higher risk than men with a

high level of cardiovascular fitness.

Obese men with a high level of fitness had risks

of death that were not different from fit men withnormal body fat.

MortalitySedentary Lifestyle


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MorbidityAssociated with Obesity

Overweight affects several diseases, although

its degree of contribution varies from one

disease to another.

Additionally, the risk of developing a disease

often differs by ethnic group, and by gender

within a given ethnic group.


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Obstructive sleep

apnea Osteoarthritis

Cardiovascular

disorders

Gastrointestinaldisorders

Metabolic disorders

Endometrial, prostate

and breast cancers

Complications of pregnancy

Menstrual irregularities

Psychological disorders

Individuals who are obese are at a greater risk of developing:

MorbidityAssociated with Obesity

CDC

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Cardiovascular DisordersAssociated with Obesity

Hypertension

Stroke

Coronary Artery Disease

Obese individuals are at a greater risk of developing these cardiovascular disorders:

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Hypertension

Hypertension (HTN) is the term for high blood pressure.

Hypertension is identified when a blood pressure is

sustained at 140/90 mmHg.

High blood pressure is referred to as the

silent killer,

since there are usually no symptoms with HTN.

Some individuals find out that they have high blood

pressure when they have trouble with their heart, brain,

or kidneys.

NHLBI

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HypertensionThe Dangers

The heart to get larger, which may lead to heart failure.

Small bulges (aneurysms) to form in blood vessels.

Blood vessels in the kidney to narrow, which may lead to kidney failure. Arteries in the body to harden faster, especially those in the

heart, brain, kidneys, and legs. This can cause a heart attack, stroke,

kidney failure, or can lead to amputation of part of the extremities.

Blood vessels in the eye to burst or bleed. This may cause

vision changes and can result in blindness.

Failure to find and treat HTN is serious, as untreated HTN can cause:

NHLBI

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Hypertension

Blood pressure is often increased in overweight individuals.

Estimates suggest that control of overweight would eliminate 48%

of the hypertension in Caucasians and 28% in African Americans.

Overweight and hypertension interact with cardiac

function, leading to thickening of the ventricular

wall and larger heart volume, and thus to a

greater likelihood of cardiac failure.


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HypertensionPrevalence in the Overweight

0

5

10

15

20

25

30

35

Males Females

BMI < 25

BMI > 25 & < 27

BMI > 27 &

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Stroke

Normally, blood containing oxygen and

nutrients is delivered to the brain, and carbon

dioxide and cellular wastes are removed.

A stroke occurs when the blood supply topart of the brain is suddenly interrupted by a

blocked vessel or when a blood vessel in the

brain bursts.

Once their supply of oxygen and nutrients

from the blood is cut off to the brain cells,they die.

NINDS

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Stroke

Sudden numbness or weakness, especially on one side of the body Sudden confusion ortrouble speaking or understanding speech

Sudden trouble seeing in one or both eyes

Sudden trouble with walking, dizziness, orloss of balance or coordination

Sudden severe headache with no known cause

The symptoms of a stroke include:

NINDS

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Stroke

There are two forms of stroke: ischemic and hemorrhagic.

Ischemic stroke occurs when an artery to the brain is blocked.

Overweight and obesity increase the risk for ischemic stroke in men and women.

With increasing BMI, the risk of ischemic stroke increases progressively and isdoubled in those with a BMI greater than 30 kg/m2 when compared to those

having a BMI of less than 25 kg/m2.

Hemorrhagic strokes occur when a blood vessel in the brain erupts.

Overweight and obesity do not increase the risk for hemorrhagic strokes.

J La State Med Soc.2005; 156 (1): S42-49.NINDS

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Coronary artery disease (CAD) is a type of atherosclerosis that occurs when the arteries

supplying blood to the heart muscle (coronary arteries) become hardened and narrowed.

This hardening and narrowing is caused by plaque buildup.

As the plaque increases in size, the insides of the coronary arteries get narrower, and

eventually, blood flow to the heart muscle is reduced.

This is critical because blood carries much-needed oxygen to the heart.

NHLBI

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Coronary Arteries

Blood Flow

When the heart muscle is not

receiving the amount of oxygen

that it needs, one of two things

can happen:

Angina

Heart Attack

Angina

Thisis the chest pain or discomfort that occurs

when the heart is not getting enough blood.

Heart attack

This is what happens when a blood clot develops

at the site of the plaque in a coronary artery.

The result is a sudden blockage, which may block

all or most of the blood supply to the heart muscle.

Because cells in the heart muscle begin to die

when they are not receiving adequate amount of

oxygen, permanent damage to the heart muscle

can occur if blood flow is not quickly restored.

NHLBI

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Over time, CAD can

weaken the heart muscle

and contribute to:

Heart Failure

Arrhythmias

Heart Failure

In this condition, the heart cant pump

blood effectively to the rest of the body.

Heart failure does not mean that the hearthas stopped nor does it mean that it is

about to. It means that the heart is failing to

pump blood the way that it should.

Arrhythmias

Arrhytmias are changes in the normalbeating rhythm of the heart. They can be

either faster or slower than normal.

Some arrhythmias can be quite serious.

NHLBI

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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 the highest 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

Obese individuals are at greater risk of developing these gastrointestinal disorders:

Colon Cancer

Gall stones

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Colon Cancer

Colorectal canceris a term used to refer to cancer that

develops in the colon or the rectum.

The colon (a.k.a. the large intestine) is about 5 feet long andits role in the digestive system is to continue to absorb

water and mineral nutrients from food. Once this process of

absorption is complete, waste matter (feces) remains.

The rectum is the final 6 inches of the digestive system.Feces are passed from the large intestine to the rectum, to

exit the body through the anus.

American Cancer Society

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Colon Cancer

Colorectal cancer is the second leading cause of cancer-related deaths in the U.S.

It is estimated to cause about 55,170 deaths during 2006.

American Cancer Society

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Colon CancerFindings Relating to Obesity

Colon cancer has been shown to occur morefrequently in people who are obese than inpeople who are of a healthy weight.

An increased risk of colon cancer has beenconsistently reported for men with high BMIs.

Women with high BMI are not at increased riskof colon cancer.

There is evidence that abdominal obesity may be

important in colon cancer risk.

NCI

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Gallbladder Disease

Cholelithiasis is the primary hepatobiliary pathology associated with overweight.

Cholelithiasis is a condition characterized by the presence or formation of

gallstones in the gallbladder or bile ducts.

Normally, a balance of bile salts, lecithin and cholesterol keep gallstones fromforming. However, if there are abnormally high levels of bile salts or, more

commonly, cholesterol, then stones can form.


NIH

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GallstonesFindings Related to Obesity

Obesity appears to be associated with the development of gallstones.

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 and phospholipids in bile

increase the likelihood of precipitation of cholesterol gallstones in the gallbladder.


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In the Nurses Health Study, when compared to those having a BMI of 24 or 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 with increasing BMI

appears to be less for men than for women.


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Ironically, weight loss leads to an increased risk ofgallstones-- because of the increased flux of cholesterolthrough the biliary system.

Diets with moderate levels of fat that trigger gallbladdercontraction and subsequent emptying of the cholesterolcontent may reduce the risk of gallstone formation.

Bile acid supplementation can be used to lower ones risk for

gallstone formation.


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Metabolic DisordersAssociated with Obesity

Obese individuals are at greater risk of developing these metabolic disorders:

Diabetes Mellitus

Dyslipidemia

Liver Disease

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Diabetes Mellitus

Type 2 diabetes mellitus (DM) is strongly associated withoverweight and obesity in both genders and in all ethnic groups.

The risk for Type 2 DM increases with the degree and durationof overweight in individuals.

The risk for Type 2 DM also increases in individuals with amore central distribution of body fat (abdominal).


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Obesity and Type 2 DMIn the United States

Among people diagnosed

with Type 2 diabetes,

55 percenthave 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 asnormal weight).

Adapted from:http://www.obesityinamerica.org/trends.html

BMI < 25

BMI > 25 or BMI < 30

BMI > 30

15%

30%55%
http://www.obesityinamerica.org/trends.htmlhttp://www.obesityinamerica.org/trends.html

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Diabetes MellitusFindings Related to Obesity

The Nurses Health Study demonstrated the curvilinear relationship

between increasing BMI and the risk of diabetes in women:

Women with a BMI below 22 kg/m2had 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 similar

relationship between increasing BMI and the risk of diabetes in men:

Men with a BMI below 24 kg/m2had 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 diabetes.

In the Health Professionals Follow-up Study, a weight

loss of 5-11 kg decreased the relative risk fordeveloping 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.


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Dyslipidemia

Dyslipidemia is defined asabnormal concentration oflipids or lipoproteins in theblood.

As BMI increases, there is anincreased risk for heartdisease.

This is because a positivecorrelation between BMI andtriglyceride (TG) levels hasbeen demonstrated.


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DyslipidemiaFindings Related to Obesity

An inverse relationship between HDL cholesterol and BMI has been noted.

This relationship may be more important than the relationship between

BMI & TG levels. Low level of HDL carries more relative risk for developing heart disease

than do elevated triglyceride levels.

Central fat distribution also plays an important role in lipid abnormalities.

Excessive body fat in the abdominal region leads to increased circulating

triglyceride levels.


HDL

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Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the term

given to describe a collection of liver abnormalities

that are associated with obesity.

In a cross-sectional analysis of liver biopsies of

obese patients, it was found that the prevalence of

steatosis, steatohepatitis, and cirrhosis were

approximately 75%, 20%, and 2% respectively.


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Liver DiseaseFatty Liver

Steatosis is the term forfatty liver and it is notactually a disease, but rather a pathologicalfinding.

Most cases of fatty liver are due to obesity.

Other causes of fatty liver include:

Diabetes

Certain drugs Intestinal bypass operations

Starvation

Protein malnutrition

Alcoholism

The American Liver Foundation

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Liver DiseaseFatty Liver

A gradual weight reduction can help to

reduce the enlargement of the liver due to

fat, and it can normalize the associated liver

test abnormalities.

It is important to limit the amount of alcohol

consumed in the diet. Alcohol can decrease

the rate of metabolism and secretion of fat

in the liver.

The American Liver Foundation

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Importance of a Healthy Liver

The 300 billion cells of the liver control a process known as metabolism.

During metabolism, the liver breaks down nutrients into usable products.These products are then delivered to the rest of the body through thebloodstream.

The liver also metabolizes toxins into byproducts that can be safely

eliminated.

The liver also produces many important substances, such as: albumin, bile,cholesterol, clotting factors, globin, and immune factors.

The liver is the largest organ in the body and it plays a vital role in performing

many complex functions that are essential for life:

Mayo Clinic

O h Di d

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Obstructive sleep apnea

Osteoarthritis

Endometrial, prostate, and breast cancers

Complications of pregnancy

Menstrual irregularities

Psychological disorders

Other DisordersAssociated with Obesity

Obese individuals are at greater risk of developing these metabolic disorders:
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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 palate and tongue.

American Academy of Family Physicians

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Obstructive Sleep Apnea

Common complaints are loud snoring, disrupted sleep,

and excessive daytime sleepiness.

Individuals with sleep apnea suffer from fragmented sleep

and may develop cardiovascular abnormalities because of

the repetitive cycles of snoring, airway collapse, and arousal. Because many individuals are not aware of heavy snoring

and nocturnal arousals, obstructive sleep apnea may remain

undiagnosed.

American Academy of Family Physicians

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Obstructive Sleep ApneaFindings Relating to Obesity

Obstructive sleep apnea affects around 4% of middle-aged adults.

Individuals having a BMI of at least 30 are at greatest risk for sleep apnea.

Weight loss has been shown to improve the symptoms relating to sleep apnea.


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Osteoarthritis

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 over the age of 65, it is the most disabling disease.

Currently, only the symptoms of OA can be treated; there is no cure.

NSLS

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OsteoarthritisFindings Relating to Obesity

The incidence of OA is significantly increased in overweight individuals.

OA that develops in the knees and ankles is probably directly related to

the trauma associated with the degree of excess body weight.

Osteoarthritis in other non-weight bearing joints suggests that there

must be some component of the overweight syndrome responsible

for altering cartilage and bone metabolism, independent of the actual

stresses of body weight on joints.

Areas of the body

most commonly

affected by OA


NSLS

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CancerFindings Relating to Obesity

Overweight and obesity are associated with an increased risk

of:

esophageal, gallbladder, pancreatic, cervical, breast, uterine,

renal, and prostate cancers.

Obesity and physical inactivity may account for25 to 30

percent of several major cancers, including--- colon, breast

(postmenopausal), endometrial, kidney, and cancer of the

esophagus.


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Endocrine Changes

There are various endocrine changes associated with overweight.

Changes in the reproductive system are among the most common.

Irregular menses and frequent anovular cycles are common.

Rates of fertility may also be reduced.


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Endocrine ChangesAssociated with Obesity

Increased cortisol production

Insulin resistance

Decreased sex hormone-binding globulin in

women

Decreased progesterone levels in women

Decreased testosterone levels in men Decreased growth hormone production

Common hormonal abnormalities associated with obesity


P h l i l Di d

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Psychological Disorders

Associations with Obesity

Obesity is associated with an impaired quality of life.

Higher BMI values are associated with greater adverse effects.

When compared to obese men, obese women appear to be at

a greater risk for psychological dysfunction. This may be due to the societal pressure on women to be thin.



P h l i l Di d

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Psychological DisordersWeight 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 thanpopulation norms.



I C l i

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In Conclusion

Diabetes mellitus

Hypertension

Gallbladder Disease

Liver Disease

Cancer


Cerebrovascular disease(stroke)

Endocrine Changes

Psychosocial Function

Obstructive Sleep Apnea Osteoarthritis

The following conditions have been found to be associated with obesity:

These diseases have been found to be

associated with increased metabolic

activity (secretion) of fat cells in obesity

These diseases have been found to be

associated with increased fat mass

25 Obesity

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