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Obesity: Pathophysiology, Risk

Assessment, and Prevalence

Krishna W Sucipto
Endocrine and Metabolic Division of Internal Department
Faculty of Medicine Syiahkuala University – dr Zainoel Abidin Hospital
Banda Aceh

Obesity
• Excessive amount of body fat
• Women with > 35% body fat
• Men with > 25% body fat
• Increased risk for health problems
• Are usually overweight, but can have
healthy BMI and high % fat
• Measurements using calipers

Desirable % Body Fat
• Men: 8-25%
• Women 20-35%

Regional Distribution
• The regional distribution of body fat affects
risk factors for the heart disease and type 2
diabetes

Body Fat Distribution: Gynecoid
• Lower-body obesity--Pear shape
• Encouraged by estrogen and progesterone
• Less health risk than upper-body obesity
• After menopause, upper-body obesity
appears

Body Fat Distribution: Android • Upper-body obesity--apple shape • Associated with more heart disease. HTN. Type II Diabetes • Abdominal fat is released right into the liver • Encouraged by testosterone and excessive alcohol intake • Defined as waist measurement of > 40” for men and >35” for women .

Body Fat Distribution .

Weight Management • Balancing energy intake and energy expenditure is the basis of weight management throughout life .

Set Point Theory • Body tends to preserve a given weight • Energy expenditure increases and decreases with weight loss and gain • Effect may be temporary. energy needs drop during calorie restriction and normalize when energy balance is achieved . e.g.

Component of Energy Expenditure .

1993) .Components of Energy Expenditure • Resting energy expenditure: expressed as RMR • Energy expended in voluntary activity • Thermic effect of food (TEF) or diet-induced thermogenesis (DIT) • Related to energy value of food consumed and adaptive response to overeating • TEF may decline as day progresses (Romon. AJCN.

Resting Metabolic Rate • Increases with increased muscle mass • Declines with age • Declines during restriction of energy intake (up to 15%) • Explains 60-70% of total energy expenditure .

Voluntary Energy Expenditure (activity thermogenesis) • The most variable component of energy expenditure • Accounts for 15-30% of total • Most of us will require increasing voluntary energy expenditure as we age to offset declining fat free mass and RMR in order to maintain weight .

may account for increase in appetite after dieting • Cravings for sweet high-fat foods among obese and bulimic patients may involve the endorphin system .Role of Brain Neurotransmitters • Neurotransmitters govern the body’s response to starvation and dietary intake • Decreases in serotonin and increases in neuropeptide Y are associated with an increase in carbohydrate appetite • Neuropeptide Y increases during deprivation.

.Hormonal Regulation of Body Weight • Norepinephrine and dopamine—released by sympathetic nervous system in response to dietary intake • Fasting and semistarvation lead to decreased levels of these neurotransmitters—more epinephrine is made and substrate is mobilized.

Hormones and Weight • Hypothyroidism may diminish adaptive thermogenesis • Insulin resistance may impair adaptive thermogenesis • Leptin is secreted in proportion to percent adipose tissue and may regulate (decrease) appetite .

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Satiety • Satiety—postprandial state when excess food is being stored • Hunger—postabsorptive state when stores are being mobilized • Short-term regulation affected .Hunger vs.

Hunger vs. Satiety—cont’d • Feedback mechanism with signal from adipose mass when weight loss occurs— eating is the natural result • Not always identified in the elderly • This occurs mostly in young people • Long-term regulation affected .

brain chemistry. fuel use.Nature vs Nurture • Identical twins raised apart have similar weights • Genetics account for ~40%-70% of weight differences • Genes affect metabolic rate. body shape • Thrifty metabolism gene allows for more fat storage to protect against famine .

Nature vs Nurture Obesity tends to run in families • If both parents are normal weight – 10% chance of obesity in offspring • If one parent is obese – 40% chance • If both parents obese – 80% chance Is it genetics or learned eating behavior? .

Nurture vs Nature • Environmental factors influence weight • Learned eating habits • Activity factor (or lack of) • Poverty and obesity • Female obesity is rooted in childhood obesity • Male obesity appears after age 30 .

Nurture vs Nature • Overeating learned early in childhood • Bottle vs breast • Urging children to eat more. clean their plates • Use of food as a reward .

Food = Love Shelly Thorene Photography .

Nature and Nurture • Obesity is nurture allowing nature to express itself • Location of fat is influenced by genetics • A child of obese parents must always be concerned about his weight .

Nature and Nurture • The influence of environment is apparent in the fact that the prevalence of obesity has increased dramatically in the US in the past 40 years .

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Causes of Obesity .

Causes of Excessive Energy Intake • Active: large portion sizes. frequent meals and snacks • Passive: excessive intake of energy-dense foods containing hidden calories • Variety of options: the greater the variety of foods offered. the greater the intake • Sensory-specific satiety: as foods are consumed they become less appealing .

Low Energy Expenditure • There is a mismatch between our thrifty metabolic genetic heritage and the sedentary American lifestyle .

Obesity: A Major Health Issue • Obesity is the No. stroke. 2 preventable cause of death and disability (smoking is #1) • Obesity is associated with increased risk of heart disease. osteoarthritis. sleep apnea • Obesity-related health problems cost $75 billion annually (2003 data) • The public pays about $39 billion a year -.or about $175 per person -. cancer.for obesity through Medicare and Medicaid programs . gallbladder disease.

colon. gallbladder) • HTN • Infertility • CVD • Pregnancy.difficult delivery • Bone and joint disorders (gout.Health Problems Associated with Excess Body Fat • Surgical risk • Type 2 diabetes • Lung (pulmonary) • Gallstones disease • Cancers (breast. osteoarthritis) • Reduced agility • Early death . • Sleep apnea pancreas.

Brown C et al. . mean diastolic 90 mm Hg. or currently taking antihypertensive medication .8:605-619. 2000. NHANES III Prevalence of Hypertension* Percent According to BMI *Defined as mean systolic blood pressure 140 mm Hg. Obes Res. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia.

113:144-156.Incidence of New Cases per 1. Am J Epidemiol 1981.000 Person-Years Obesity and Diabetes Risk BMI Levels Knowler WC et al. .

17:960- 969. . Diabetes Care 1994. Weight Gain and Diabetes Risk Weight Change Since Age 21 Relative Risk Body Mass Index at Age 21 Adapted from Chan JM et al.

National Cholesterol Education Program.Metabolic Syndrome Criteria* Three or more of the following abnormalities: • Waist circumference >102 cm (40 inches) in men and > 88 cm (35 inches) in women • Serum triglycerides of at least 150 mg/dL • High density lipoprotein level <40 mg/dL in men and <50 mg/dL in women • Blood pressure >=135/85 mm/hg • Serum glucose >=110 mg/dl • Includes 47 million US residents (27.7% of the population *ATP III Guidelines. 2001 .

acne. chronic anovulations resulting in multiple ovarian cysts. reproductive cancers .Polycystic Ovary Syndrome (PCOS) • Endocrine disorder characterized by hyperandrogenism and insulin resistance • Associated with android obesity • Affects 5-10% of reproductive age women • Erratic menstrual periods. infertility. type 2 diabetes. hirsutism and alopecia • Increased risk of heart disease.

as etiology is unclear • Individualized diet and exercise plan to promote weight loss and normalize insulin levels • Medications to alleviate symptoms .Management of PCOS • Symptom oriented.

26 -Year Incidence of Incidence/1.000 Coronary Heart Disease in Men BMI Levels Adapted from Hubert HB et al.67:968-977. . Metropolitan Relative Weight of 110 is a BMI of approximately 25. Circulation 1983.

Metropolitan Relative Weight of 110 is a BMI of approximately 25. 26 -Year Incidence of Incidence/1.67:968-977. . Circulation 1983.000 Coronary Heart Disease in Women BMI Levels Adapted from Hubert HB et al.

surgical procedures. . Int J Obes 1998. symptoms.22:520-528. Brown WJ et al. Hypertension 60 50 Percentage 40 30 20 10 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems. and health care utilization.

symptoms. Int J Obes 1998. and health care utilization. Diabetes 15 Percentage 10 5 0 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems. . surgical procedures. Brown WJ et al.22:520-528.

Brown WJ et al. and health care utilization. Int J Obes 1998.22:520-528. symptoms. . surgical procedures. Cholescystectomy 25 20 Percentage 15 10 5 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems.

Back Pain 35 30 Percentage 25 20 15 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems. Int J Obes 1998. surgical procedures. symptoms. Brown WJ et al. . and health care utilization.22:520-528.

Variations in mortality by weight among 750. Obesity. 1988.000 men and women. West J Med 149:429. Garfinkle L. J Clin Epidemiol 32:563. Gray DS. part 1: Pathogenesis. 1979.) . and Lew EA. Body Mass Index and Mortality Risk (Adapted from Bray GA.

0 – 29.9 Normal 25.5 Underweight 18.9 Overweight Monitor for risk 30.0 and Above Obese Increased health risk 40.5 – 24.0 and above Severely obese Major health risk .BMI and Health Below 18.

protein. hormonal status. Diets provide carbohydrate. Food intake is influenced by its availability and individual preference. nutritional status and ambient temperature.The Key Features of Nutrient System Can be Summarized as Follows: 1. 3. nutrient intake is periodic 2. metabolic size. 4. physical activity. gender. Oxidation rate is influenced by age. . Oxidation is continuous. fat. alcohol and micronutrients.

. or converted to fat 7. 8. 6. Macronutrient preference may be regulated separately for each macronutrient. Carbohydrate is the preferred fuel of brain and nerve and is used for bursts of muscular contraction. but is not converted to carbohydrate. 9. and can occur in liver or fat. Fat can be stored or oxidized. Carbohydrate can be oxidized. Lipogenesis from carbohydrate is energy expensive. stored as glycogen.The Key Features of Nutrient System Can be Summarized as Follows: 5.

12.The Key Features of Nutrient System Can be Summarized as Follows: 10. 11.e. i. When the fat to carbohydrate ratio in the diet rises (FQ falls) the oxidation of carbohydrate falls (RQ falls) and fat oxidation rises. . then food intake will rise to provide carbohydrate. fat and carbohydrate oxidized or respiratory quotient (RQ) must equal the carbohydrate to fat ratio or food quotient (FQ) in the diet. For nutrient balance. weight stability. If the fall in carbohydrate oxidation is not sufficient to match the fall in dietary carbohydrate.

The Key Features of Nutrient System Can be Summarized as Follows: 13. The sympathetic nervous system may modulate adaption to a low carbohydrate diet. A high RQ (high carbohydrate oxidation) predicts weight gain. 17. cytokines. A low metabolic rate may predict future weight gain. Fat cells synthesize and secrete peptides including complement D (Adipsin). . 15. 14. 16. angiotensinogen and ob protein (leptin). Fat is stored primarily in fat cells.