Standard of Care

From Standard of Care

Most people are genetically susceptible with availability of highly processed foods, calorie dense foods, decreased physical activity, disrupted meal patterns, inadequate sleep, increased stress, social isolation, disturbed circadian rhythms, and exposure to medications that promote weight gain.

The mean weight of men in the United States is now 88.3 kg and the mean weight of women is 74.7 kg (Mcdowell M et al).

3 categories: obesity 1 BMI-30-34.9, obesity 2 BMI 35-39.9 and extreme obesity BMI≥40.

From 1986-2000 prevalence of BMI of 30 or higher approximately doubled while BMI of 40 or higher quadruples and that of BMI 50 or higher increased 5 times.

Prevalence in 1960 was about 13% and by 2000 about 31% of U.S. population.

WHO indicated that in 2008 more than 1.4 billion adults or 20% of the worlds population were overweight, and more than 500 million were obese.

65% of the world's population live in countries where overweight and obesity are associated with more deaths than underweight and malnutrition.

American adults who are obese has increased 140% over the last decade.

There are multiple loci, approximately 32, associated with body mass index and susceptibility to obesity..

Since 1999 the prevalence has stabilized at 35.5% in adult men, 35.8% among adults women, and 16.9% for children and adolescents.

National Health and Nutrition Examination Survey (NHANES) revealed in 2007-2008, 68% of US adults are overweight and 33.8% are obese: more men are obese with 72.3% compared to 64.1% for women.

National Health and Nutrition Examination Survey (NHANES) revealed in 2007-2008 indicate almost 17% of school aged children and adolescence are obese.

Children and adolescents with high body mass index often become obese adults and such adults are at risk for many chronic illnesses including diabetes, chronic kidney disease and end-stage renal disease.

As a result of obesity in adolescents type II diabetes has increased more than tenfold over the last two decades (Rocchini AP).

Previously metabolic syndrome, obstructive sleep apnea, dyslipidemia, hypertension, polycystic ovary syndrome, steatohepatitis were previously rarities and adolescents are presently commonplace as result of adolescent obesity (Daniels SR, Ludwig DS).

Life expectancy for obese adolescent individuals is reduced.

Excess weight accounts for 44% of worldwide burden of diabetes, 23% of coronary artery disease, and 7-41% of cancers (WHO).

immigrants in the US gain weight in proportion to the number of years been in the US.

Twin studies demonstrate genetic influence on obesity, but no single gene explains the process.

In a prospective study of 37,674 apparently healthy young men for incident angiography proven coronary heart disease and diabetes with follow up of 17.4 years: indicated an elevated BMI in adolescents constitutes a substantial risk for obesity-related disorders in midlife (Tirosh A et al).

In the above study the risk of diabetes was mainly associated with increased BMI close to the time of diagnosis, while the risk of coronary heart disease was associated with an elevated BMI both in adolescence and adulthood.

There is a graded increase in the risk of heart failure as BMI increases: for every 1 kg per meter squared increase in BMI the risk of heart failure increases 5% in men and 7% in women (Kenchaiah S et al).

Obesity has profound effects on systolic and diastolic function.

Obesity paradox is initially described the finding that obese patients undergoing percutaneous coronary intervention had lower mortality rates than normal weight counterparts (Gruberg L et al)

Obesity paradox has been noted in a range of studies of patients with and without cardiovascular disease.

Obesity paradox, refers to the suggestion that obese patients with heart failure have a better prognosis than leaner patients (Lavie CJ et al, Arthram SM et al).

Individuals with an elevated BMI, compared to individuals without an elevated BMI and heart failure, have a reduction in cardiovascular and all cause mortality during a 2.7 year follow-up (Oreopoulos A et al).

In an in-hospital mortality study of 108,927 patients would be compensated heart failure, a higher BMI was associated with a lower mortality: a 10% lower mortality was noted for every five unit increase in BMI (Fonarow GC et al).

In 2005 60.5% of adults in the U.S. were overweight with body mass index 25-30, 23.9% obese with body mass index 31-40 and 3% extremely obese with body mass index over 40.

Associated with more than 300,000 deaths annually in the U.S. overtaking cigarette abuse as the leading preventable cause of death.

A Swedish study found that obesity in late adolescence was comparable with light smoking of 11 cigarettes/day in increasing the risk of premature death (Neovius M).

Twin studies suggest genetic factors account for 50-70% of the predisposition for the development obesity.

Increases vascular risk related mortality 1-2 fold.

Obesity related mortality is highest in men and in minority patients who have high rates of comorbid diseases.

Class I obesity defined as a body mass index (BMI: weight [kg] / height [m2]) ≥30 but <35. Class II obesity defined as a BMI ≥35 but <40. Class III obesity defined as a BMI ≥40.

The prevalence of class II and III obesity is 14.3% of the US population 20 years of age or older.

Early obesity predicts for later cardiovascular disease.

Bariatric surgery ssociated with reduced number of cardiovascular deaths and lower incidence of cardiovascular events in obese patients (Sjostrom L et al).

In obese patients with type 2 DM 12 months of medical therapy plus bariatric surgery achieves greater glycemic control in significantly more patients than does medical management alone (Schauer PR et al).

In the above study of obese patients with poorly controlled diabetes who underwent either gastrric bypass orsleeve gastrectomy combined with medical therapy were significantly more likely to achieve hemoglobin A-1 C. levels of 6% or less one year after randomization then were patients receiving medical therapy alone.

By 2020 overall obesity and abdominal obesity are projected to affect up to 70% and 90% of black women, respectively, in the US.

90 minutes of aerobic exercise combined with 60 minutes of resistance exercise over 3 days per week is optimum to reduce insulin resistance and improve function on previously sedentary older abdominally obese adults (Davidson). 

Estimated to be responsible for 45% of 9.3 million cases of cardiovascular disease and 280,000 annual deaths, about 13% of all deaths.

Indicates the inability for homeostatic mechanisms to offset sedentary lifestyle and excessive intake of processed high energy foods.

Associated with increase risk of hypertension, dyslipidemia, coronary artery disease, type 2 diabetes, gallbladder disease, sleep apnea and osteoarthritis.

There is a threefold higher risk for end-stage renal disease during follow-up of overweight adolescents and an almost sevenfold higher risk for obese youth (Vivante A et al).

Genetic predisposition, metabolic needs and hedonistic aspects of food ingestion important considerations to understand body weight regulation and obesity.

Pathophysiology includes genetic, behavioral, psychological and other factors.

Results from over nutrition.

Body fat accumulation occurs proportionately to the amount of excess calories consumed and is not dependent on dietary protein.

Weight loss occurs with reduced calorie intake regardless of dietary composition.

Secondary diseases increase mortality that exceeds twofold in women and 12-fold in men.

Excess weight represents the most prevalent cardiovascular risk factor in myocardial infarction.

Excess body fat effects vascular system via dyslipidemia, obstructive sleep apnea, hypertension, insulin resistance, increased leptin levels, enhanced systemic inflammation and increased free fatty acid turnover with lipotoxic effects on myocardial cells.

Results from accumulation of excess body fat, but obesity is not simply excess body fat because overweight can occur from excess muscle or deposition of fat.

Predisposes to type 2 diabetes via insulin resistance, impaired glucose tolerance and pancreatic Beta-cell failure.

Adipose tissue dysfunction characterized by ectopic fat deposition in abdominal organs and liver, inflammatory and adipokine dysregulation and insulin resistance and may be an important mediator of the development of diabetes rather than total fat mass in obese individuals. 50-80% of cases of diabetes attributable to obesity.

Risk of diabetes increases continuously with increasing body mass index and the relationship between obesity and diabetes is also age-dependent.

Obesity in childhood is a strong predictor of young adult obesity.

Cardiovascular risk in young adulthood is highly related to the degree of obesity as early as the age of 13.

Adolescent obesity associated with cardiovascular risk factors, orthopedic conditions, lower self-esteem, and adverse social and economic outcomes in young adulthood.

Higher rates in rural counties in the U.S.

A risk factor for colorectal cancer in men.

A risk factor for pancreatic cancer.

Association of increased waist circumference and pancreatic cancer risk, especially in women, suggests the distribution of body fat may play a role.

Overweight and obesity associated with it the increased risk of developing breast cancer in postmenopausal women, colorectal cancer, endometrial cancer, renal cancer, adenocarcinoma of the esophagus, pancreatic cancer, and probably associated cancer of the gallbladder and liver, non-Hodgkin's lymphoma, multiple myeloma, cancer of the cervix, ovarian cancer, an aggressive prostate cancer.

Associated with insulin resistance with elevated markers including high circulating levels of C-peptide and insulin like growth factor binding protein 1 (IGFBP1) and an association with colorectal cancer.

A proposed mechanism for the relationship obesity and cancer is that patients develop insulin resistance and chronic hyperinsulinemia as a result of increased free fatty acids, tumor necrosis factor alpha, and resistin and decreased release of adiponectin: Increased insulin levels and increased insulin-like growth factor1 act as growth factors and promote cell proliferation and inhibit apoptosis.

A proposed mechanism for the relationship obesity and cancer is that patients develop insulin resistance and chronic hyperinsulinemia as a result of increased free fatty acids, tumor necrosis factor alpha, and resistin and decreased release of adiponectin: Increased insulin levels and increased insulin-like growth factor1 act as growth factors and promote cell proliferation and inhibit apoptosis.

There is epidemiological and biological evidence suggesting adiposity, hyperinsulinemia, altered glucose homeostasis an elevated insulin growth hormone axis abnormalities may impair the prognosis of colorectal cancer.

Increased adiposity is associated with increased colon cancer-specific mortality.

Excess body weight increases the risk of colorectal adenomas in patients with Lynch syndrome, and this is seen only in men.

Increased adiposity associated with worse disease free colon cancer survival among women.

In women associated with a higher mortality rate for breast and cervical cancer than in thinner women.

Patients with breast, prostate and colorectal cancer who are overweight have an increased risk of cancer recurrence and death.

At time of diagnosis of prostate cancer associated with increased risk of metastases and death.

Associated with poor prognostic factors such associated high grade and non localized disease in prostate cancer.

Hiigher risk of biochemical recurrence and disease progression after radical prostatectomy for prostate cancer.

Known risk factor for postmenopausal cancer of the breast as a result circulating estrogens derived from aromatization of plasma androstenedione to estrone in adipose tissue.

A high BMI is associated with a decreased risk of premenopausal breast cancer but an increased risk for postmenopausal breast cancer (Chang S et al).

Defined as a body mass index (BMI) as weight in kg divided by the square of height in meters of over 30 or more for adults 18 years or older.

33% of African American women and 17% of white women are obese with a body mass index greater than 30.

African Americans have the highest prevalence at 33.9%.

69% of African-American men and 81% of African Women are overweight (Ogden CL).

In U.S. s have a 51% higher prevalence of obesity and Hispanics have a 21%, higher obesity prevalence compared with whites.

Approximately 65% of individuals over the age of 20 years in the U.S. have a BMI of 25 or greater and are defined as overweight, of that number 30% are obese with a BMI of 30 or greater with 5% are extremely obese with a BMI of 40 or greater.

European Prospective Investigation into Cancer and Nutrition (EPIC) followed 14,723 participants for a mean 9.7 years revealed that general adiposity and abdominal adiposity are associated with the risk of death and support the use of waist circumference or waist-to-hip ratio in addition to BMI in assessing the risk of death.

Waist circumferance of more than 40 inches in men or 35 inches in women associated with increased risks for type 2 diabetes, hypertension, and coronary artery disease.

The risk of death from any cause among black women increases with increasing BMI of 25.0 or higher, and is similar to the pattern among whites.

Waist circumference is associated with increased of death among non-obese women.

EPIC study associated the BMI with the risk of death as J-shaped, with higher risks of death in the lower and upper BMI categories than in the middle categories.

Approximately one third of Americans overweight, one third obese and 4.5% have extreme obesity.

16% of children between 6 and 19 years of are rate overweight.

10.3 percent of African American women are extremely obese defined as a BMI of 40 or more compared to 6.2 percent of white women.

Obese individuals who are physically active have a lower incidence of developing many chronic diseases, compared with unfit obese counterparts.

Physical activity at maintained at high levels through young adulthood may lessen weight gain as young adults transition to middle age, and this is particularly true for women (Hankinson AL et al).

May be the most important risk factor for osteoarthritis of the knee.

The likelihood of conceiving steadily decreases as BMI increases.

Confers a relative pulmonary embolism risk of 3.4 in the Nurses Health Study.

Accounts for approximately 6% of expenditures for healthcare in the U.S.

Gastric bypass produces about a 10% greater weight loss over 8 years than to other surgical procedures.

15% of adults over the age of 70 years. Obesity-increases the risk of kidney disease.

Mild to moderate overweight status in the elderly does not confer an excess mortality risk.

May be protective compared to thinness of normal weight in older community-dwelling individuals.

Increased risk for complications for patients undergoing surgery with problems ranging from cardiac ischemia, pulmonary embolism, nausea, vomiting, wound infections, wound dehiscence, and incision hernia.

Associated with problems related to upper airway access and maintaining ventilation with surgery.

Not associated with unplanned admissions t the hospital after ambulatory surgery, suggesting obesity should not prevent such procedures (Hofer).

In adults, disease risk increased independently with increasing BMI and excess abdominal fat.

Cardiovascular and other obesity-related disease risks increase significantly when BMI exceed 25.0 kg per meter square.

Overall mortality increased most dramatically as BMI surpasses 30 kg per meter square.

Obesity mortality increases logarithmically for body mass indices that exceed 30.

Associated with sexual maturation among adolescent girls and young female adults.

Obesity associated with Cushing's syndrome, hypothyroidism, leptin gene mutation, and congenital syndromes such as Prader-Willi.

Weight gain promoted by antidepressant drugs, antiepleptic agents, sulfonylureas, and corticosteroids.

Waist circumference measurements greater than 40 inches in men and 35 inches in women indicate an increased risk of obesity-related comorbidities.

Even a small weight loss as little as 10% of initial body weight in overweight and obese adults reduces various chronic disease risk factors such as hypertension, hyperlipidemia, and hyperglycemia.

Central obesity with waist:hip ration greater than 0.8 associated with a disproportionate increase in coronary risk.

Sarcopenic obesity-weight gain without concurrent gains in lean body mass.

Sarcogenic obesity-gradual obesity associated with increased age and menopause.

Acute sarcopenic obesity-observed in corticosteroids use, hypopituitarism, hypogonadism and prolonged physical inactivity or bed rest.

More than 90% of seriously obese individuals will regain their weight after it is lost with dieting.

Hypoventilation syndrome-patients are older than patients with pure obstructive sleep apnea.

Hypoventilation syndrome-mild to moderate restrictive ventilatory pattern due to obesity with gas exchange impairment and pulmonary hypertension being quite frequent.

Hypoventilation syndrome-frequently associated with obstructive sleep apnea.

A genetic contribution is supported by the findings of greater similarity of body mass between monozygotic vs dizygotic twins and correlation of BMI with biological but not adoptive parents.

Contributes to endothelial dysfunction, hyperinsulinemia and elevated C-reactive protein.

Adenocarcinoma of the esophagus, gastric cardia, hepatic necrosis, cirrhosis, cholecystitis, reflux esophagitis associated with obesity.

Obesity among never smokers is independently associated with twofold worsening of disease specific survival, disease free survival, and overall survival after surgery for esophageal adenocarcinoma.

Obesity-in childhood and adolescence is a predictor of the eventual development of diabetes, hypertension, dyslipidemia and cardiovascular disease in adulthood.

More than 75% of patients with hypertension accounted for by obesity.

Risk of death from all causes, cancer and cardiovascular diseases increases throughout the ranges of obesity.

Nonsurgical weight loss by lifestyle interventions combined with anti-obesity medications have had no affect on primary cardiovascular end points.

A meta-analysis genomewide association studies as established 32 loci associated with a BMI.

In an analysis of genetic predisposition and intake of sugar sweetened beverages in relation to BMI and obesity risk in 6930 for women from the Nurses" Health Study, and 4423 men from the Health Professionals Followup Study and a cohort of 21,740 women from the Women's Genome Health Study: Blood genetic association with obesity is more pronounced with grade intake of sugar-sweetened beverages (Qibin Qi et al).

Virtually all patients have an increased leptin levels.

Endometrial cancer, of all malignancies, most associated with obesity.

Increases risk of left ventricular hypertrophy.

Trauma in obese patients associated with higher morbidity and mortality.

There are reported increases in the incidence of cardiovascular, pulmonary, venous thromboembolic, and infectious complications in obese trauma patients (Lazar MA).

Obese patients who sustain high-energy traumatic injuries often sustain orthopedic injuries to the pelvis or lower extremities.

Obese orthopedic trauma patients may be at higher risk for nerve injuries secondary to positioning, intraoperative complications, loss of reduction after surgery, increased intraoperative estimated blood loss, and increased operative times (Lazar MA).

Decreases the cardioprotective levels of high-density lipoprotein cholesterol.

Associated with propensity for complex dysrhythmias.

Generally, a decrease in body weight of 1% associated with a systolic blood pressure decrease by 1 mm Hg and a diastolic blood pressure drop of 2 mm Hg.

Among 20-30 year-olds associated with a decreased life expectancy of 5 years among black women, 8 years for white women, 13 years for white men and 20 years for black men.

Weight gain associated with insulin, Sulfonylureas, antidepressants and Beta-adrenergic receptor blockers.

Medical spending for obesity related conditions estimated to be 10% of total annual U.S. medical expenses in 2008 or $147 billion (CDC).

In 2006 the annual spending for obese people was 42% greater than spending for normal weight people.

Despite adverse effects of obesity on coronary heart disease, coronary risk factors, plasma lipids, inflammation, glucose abnormalities, insulin resistance, metabolic syndrome, type II diabetes, and LVH, many studies have demonstrated an inverse relationship exists between obesity, generally determined by body mass index on mortality is referred to as the obesity paradox.

Obesity paradox has been demonstrated in non-cardiovascular studies that included patients with renal disease and an elderly cohort.

The obesity paradox has been demonstrated in a large meta-analysis with 40 cohort studies and more than 250,000 patients with coronary artery disease (Romero-Corral A et al).

The obesity paradox may be related to the fact that BMI does not always reflect true body fatness, and that defining obesity by weight circumference, waist/hip ratio, percent body fat may be more accurate.

In cohorts with established cardiovascular diseases that include hypertension, atrial fibrillation, peripheral arterial disease, coronary artery disease patients with obesity have better clinical prognosis than do their lean counterparts, termed obesity paradox.

In an analysis of all cause mortality in patients with coronary artery disease, patients with low BMI have the highest mortality, whereas obese patients had lower risk (Romero-Corral et al)

In the above analysis overweight patients had lowest relative risk in their adjusted analysis, whereas obese and severely obese patients had no increased risk: obesity paradox.