Obesity and its Risks
Obesity is a chronic disease that develops from metabolic, hormonal, behavioral, and environmental interactions. While there are still uncertainties regarding the exact mechanism and etiology, it is known that obesity can lead to serious risk factors or comorbidities. 1
Two key factors can be used to assess the degree of obesity and the related risk factors: 1
Obesity-related risk factors and comorbidities associated with a high absolute risk of subsequent mortality include:1
- Established coronary heart disease (CHD)
- Presence of other atherosclerotic diseases (peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid artery disease)
- Type 2 diabetes (fasting plasma glucose ≥ 126 mg/dL or 2-h postprandial plasma glucose ≥ 200 mg/dL)
- Obstructive sleep apnea (OSA)
- Metabolic syndrome (atherogenic lipoprotein phenotype, hypertension, insulin resistance, glucose intolerance, prothrombotic states)
- Three or more of the following factors are also associated with increased absolute risk:
- Cigarette smoking
- Hypertension
- Dyslipidemia
- Impaired fasting glucose (between 110 and 125 mg/dL)
- Family history of early cardiovascular disease
- Age (male ≥ 45 years, female ≥ 55 years)
In addition to the risk factors described above, additional obesity-related comorbidities include:
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Type 2 Diabetes
Description
In adults, type 2 diabetes (T2D) accounts for about 90% to 95% of all diagnosed cases of diabetes. T2D is characterized by insulin resistance, in which cells do not use insulin properly, and the pancreas gradually loses its ability to produce it.27
Obesity-related Effects
Obesity is a risk factor for T2D. Approximately 80% of individuals with T2D have a BMI of 30 or greater, with the risk of developing T2D increasing as the severity of obesity increases.24 Diabetes can lead to serious complications, such as blindness, kidney damage, cardiovascular disease, and lower-limb amputations. Many people with diabetes need to take medication to control their blood pressure and cholesterol.27
Improvement
Improvements are observed soon after sustained weight loss is achieved following bariatric surgery. Remission of T2D is dependent on weight loss.8 Four prospective studies and case series have reported a 45% to 80% rate of improvement or resolution of T2D at 1 to 4 years following laparoscopic adjustable gastric banding (LAGB). 15,24,36,40 In addition, a 2008 meta-analysis by Cunneen87 cited 14 studies reporting a statistically significant 60% rate of T2D resolution in 246 LAP-BAND® patients at two years following surgery.
Both Ahroni et al37 and Ponce et al24 have noted that 80% of patients with pre-operative T2D are able to reduce or discontinue diabetic-related medications following weight loss with LAGB. As well, two publications in Diabetes Care15,40 have reported 0% progression to T2D in post-LAGB non-diabetic patients after follow-up of more than 3,000 patient-years and 4 years respectively.
Obstructive Sleep Apnea
Description
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and is characterized by gasping or “snorting” noises during sleep, causing irregular, interrupted sleep. Patients with OSA may experience excessive daytime sleepiness.28
Obesity-related Effects
Obesity is a risk factor for the symptoms of OSA, the severity of which are associated with the percentage of excess body weight.8 Frequently undiagnosed, OSA predisposes patients to excessive daytime sleepiness, and patients are at increased risk of cognitive impairment, such as driving and workplace accidents.35
Improvement
Surgically-induced weight loss may cause complete resolution or significant improvement of OSA.8 Three prospective analyses of obese patients undergoing laparoscopic adjustable gastric banding (LAGB) have reported 31% to 64% rates of improvement and/or resolution of OSA following the surgical procedure.16,36,37 Ahroni et al37 also cited a significant reduction (from 81% to 34%) in the use of positive airway pressure machines following LAGB. Additionally, a review by Dixon et al84 noted reports of improvements in sleep quality, excessive daytime sleepiness, snoring, and nocturnal choking following LAP-BAND® System surgery.
Metabolic Syndrome
Description
ATP III diagnostic criteria for metabolic syndrome, as defined by AHA/NHLBI, is the presence of any three of five factors. Abdominal obesity is an identified risk factor. Other factors are elevated triglycerides, reduced HDL-cholesterol, elevated blood pressure and elevated fasting glucose.
Obesity-related Effects
Obesity-related metabolic syndrome is a major public health problem, affecting nearly 25% of adults in the United States.53 Patients with metabolic syndrome are approximately twice as likely to develop cardiovascular disease and five times as likely to develop type 2 diabetes (T2D).31
Improvement
Weight loss is recommended as the first line of treatment for metabolic syndrome and its individual components.53 Significant, sustained weight loss following laparoscopic adjustable gastric banding (LAGB) may be associated with a substantial reduction in the criteria for metabolic syndrome.8 Each 2.2 lbs of weight lost represents an 8% reduction in the odds of having metabolic syndrome.53 It is increasingly recognized that disease related to metabolic syndrome (type 2 diabetes and impaired glucose tolerance, dyslipidemia, and hypertension) provides the greatest health risk to overweight and obese subjects. 84,111,112,113 Weight loss as a result of LAP-BAND surgery has had an effect on lowering hypertension in morbidly obese patients. A study of 147 hypertensive patients was conducted to ascertain changes in hypertension 12 months post-surgery. Prior to the procedure, 17 of the patients had normal BP. One year post-surgery, 105 patients had normal BP. It was concluded that 80 of the study patients had resolved their hypertension and another 45 had experienced improvement in their blood pressure. 84,111,112,113
Hypertension
Description
An estimated one-third of US adults has hypertension, or high blood pressure: systolic BP ≥ 140 mmHg and diastolic BP ≥ 90 mmHg.29
Obesity-related Effects
Obesity-associated hypertension is associated with increased direct pressure on renal veins, which impedes venous return to the heart and decreases cardiac output and renal arterial pressure.18 High blood pressure increases the chance for developing heart disease and strokes; however it may be asymptomatic until other serious problems arise.29
Improvement
Significant, sustained weight loss resulting from laparoscopic adjustable gastric banding (LAGB) surgery may be associated with significant long-lasting improvement in systemic hypertension, with a decrease or total elimination of blood pressure medication use in two-thirds to three-quarters of patients with hypertension.8 A number of studies have reported a 50% to 86% rate of improvement or resolution of hypertension at 1 to 5 years following LAGB.15,24,36,37,40,83,88,89,91 In a case series of 147 consecutive hypertensive patients who underwent LAP-BAND® System surgery, Dixon et al84 reported a decrease in mean blood pressure from 156/97 mmHg to 127/76 mmHg at 12 months after the procedure. In addition, a 4-year case-controlled study by Pontrioli et al40 demonstrated that LAGB actually prevented the incidence of arterial hypertension in patients undergoing the procedure.
Dyslipidemia
Description
Low-density lipoproteins (LDL) carry cholesterol in the bloodstream to the body, while high-density lipoproteins (HDL) remove cholesterol from the body to the liver. Higher levels of HDL are considered good, whereas an excess of either total cholesterol (TC) or LDL is a risk factor for heart disease and atherosclerosis.38
Obesity-related Effects
Being overweight or obese increases TC and LDL levels, and lowers HDL levels. Cholesterol build-up on artery walls can cause atherosclerosis; when the arteries that carry blood to the heart are affected, coronary artery disease or heart attacks can result.38
Improvement
Significant, sustained weight loss resulting from bariatric surgery has been found to be effective in treating dyslipidemia. A review of meta-analyses found that dyslipidemia significantly improved across all operations at a rate of approximately 70%.87 A number of studies following patients for 1 to 5 years after laparoscopic adjustable gastric banding (LAGB) surgery have reported improvements in lipid profile ranging from 64% to 95% of patients.36,83,88,89,15 Dixon et al90 demonstrated that the dyslipidemia-related change after LAP-BAND® System surgery appears to be the improvement in triglycerides and not in total cholesterol. Both Spivak36 and Brancatisano83 have reported significant decreases in triglycerides following LAGB, and Ahroni37 noted a 32% rate of discontinuation of hyperlipidemia medications.
Cardiovascular Disease
Description
Cardiovascular conditions, including coronary heart disease, can lead to heart attack, angina, and other serious conditions.
Obesity-related Effects
Obesity is a risk factor for cardiovascular disease. Over time, cardiovascular disease causes the heart muscles to weaken, leading to heart failure. Arrhythmias and acute coronary syndrome commonly develop.39
Improvement
Weight loss resulting from LAP-BAND® System surgery may lead to increased high-density lipoprotein cholesterol, decreased and/or normalized triglyceride concentrations and decreased blood pressure, resulting in a substantial reduction in cardiovascular risk.84
Asthma
Description
Asthma is a disease affecting the lungs, which causes wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. In severe cases, symptoms can be disabling.
Obesity-related Effects
Severe obesity is a risk factor that can either cause or worsen asthma through gastroesophageal reflux disease (GERD), complications from sleep-disordered breathing, breathing at low lung volume, chronic systemic inflammation, and endocrine factors, such as adipokines and reproductive hormones.81
Improvement
Weight reduction following laparoscopic adjustable gastric banding (LAGB) in obese patients with asthma may be associated with significant improvements in respiratory symptoms, rescue medication use and lung function. A number of prospective trials have reported 60% to 100% rates of resolution and/or improvement in asthma symptoms and medication use at 12 to 36 months following LAGB surgery.14,36,37,82,83 In one study, additional improvements in severity, daily impact, hospitalization, sleep and exercise were noted in 100% of 32 patients at least 12 months following LAP-BAND® System surgery.14
Gastroesophageal Reflux Disease
Description
Gastroesophageal reflux disease (GERD), or acid reflux, occurs when the lower esophageal sphincter opens spontaneously for varying periods of time, or does not close properly, and stomach contents rise up into the esophagus.
Obesity-related Effects
Obesity is a risk factor for chronic GERD, which may damage esophageal lining and cause bleeding or ulcers. Scars from tissue damage can lead to a narrowing of the esophagus that makes swallowing difficult.17
Improvement
Several studies have demonstrated that significant, sustained weight loss following laparoscopic adjustable gastric banding (LAGB) procedures such as LAP-BAND® System are an effective treatment for GERD.84 Three prospective trials of patients undergoing LAGB surgery reported 69% to 90% rates of GERD resolution after 6 to 36 months following surgery.36,37,83 Of 48 consecutive LAP-BAND® patients with a significant history of reflux esophagitis requiring regular therapy preoperatively, Dixon et al17 retrospectively noted that no patients had symptoms or required treatment at one-year following surgery.
Degenerative Joint Disease & Osteoarthritis
Description
Degenerative joint disease is characterized by a decoupling of the normal degenerative/regenerative repair process, in which articular cartilage becomes fragmented, thin and denuded. Full loss of articular cartilage may leave the bony surface uncovered.66
Osteoarthritis (OA) is a degenerative joint disease characterized by a progressive loss of the hyaline cartilage of joints. Symptoms include pain and stiffness, which can develop gradually or suddenly.43
Obesity-related Effects
Morbid obesity leads to early degenerative arthritic changes of weight-bearing joints, especially the knees, hips, and spine. Approximately 80% of patients with OA have some degree of movement limitation, 25% cannot perform major activities of daily living, 11% need help with personal care, and 14% require help with routine needs.43 Morbid obesity is a risk factor for complications after intramedullary nailing of femoral fractures. Many orthopedic surgeons refuse to insert hip or knee replacements in obese patients due to the risk of the prosthetic loosening.18
Improvement
Four studies have reported a 50% to 84% rate improvement and/or resolution of arthritis or joint pain following weight loss surgery.37,44,83,85 In Obesity Surgery, Ahroni et al37 noted that 59% of patients taking arthritis medication had either decreased or discontinued its use at 12 months post-LAGB (n=22) and Korenkov et al86 reported a statistically significant decrease in the prevalence of significant knee pain as well as knee pain intensity (using the Wilcoxon test) in a series of 145 patients at 3 to 8 years post-LAGB.
Urinary Stress Incontinence
Description
Patients with urinary stress incontinence (USI) can leak urine during normal daily activities such as laughing, sneezing, coughing or bending. This condition can make daily social interactions difficult and uncomfortable.18
Obesity-related Effects
Obesity-related USI is more frequent in women, although obese men also report experiencing urinary urgency. Increased waist circumference caused by obesity results in increased intra-abdominal and urinary bladder pressure.18
Improvement
Laparoscopic adjustable gastric banding (LAGB) surgery has been shown to decrease waist circumference and excess weight, thus improving intra-abdominal pressure. A number of prospective trials have reported a 71% to 95% rate of resolution or improvement of urinary incontinence following weight loss surgery, including bypass and LAGB type procedures.18,37,94,95,96
Lower Back Pain
Description
Lower back pain (LBP) is a musculoskeletal dysfunction associated with paraspinal muscle spasm, and reduced range of spine motion.50
Obesity-related Effects
Obese individuals have more pain and physical dysfunction than people of normal weight. Studies show that excess weight was associated with an increased risk of degenerative discs. In several large population studies, obesity was found to be positively associated with recurrent or chronic LBP.50
Improvement
Significant, sustained weight loss resulting from laparoscopic adjustable gastric banding (LAGB) may significantly improve low back pain (LBP) and associated functional disabilities in morbidly obese patients.50 In a prospective analysis of 29 patients with pre-operative LBP, investigators reported statistically significant improvements in functional disability scores two years after vertical banded gastroplasty (including VAS1&2 scales, Roland-Morris Disability Questionnaire, Oswestry Low Back Questionnaire, and the Waddell Disability Index).92 With respect to laparoscopic adjustable gastric banding (LAGB), 81% of patients with joint or back pain who underwent the procedure reported improvement in their condition after one year, and 65% reduced or discontinued associated medication use (52 patients were surveyed at 1 year regarding back pain. 23 patients were taking medication at this time point).37
Depression
Description
Depression is a psychological and emotional dysfunction that may be symptomatic of underlying boredom, loneliness, chronic anger, anxiety, frustration, stress, problematic interpersonal relationships, and poor self-esteem.32,33
Obesity-related Effects
Obesity-related depression can cause overweight or obese individuals to experience social stigmatization and discrimination in employment and academic situations, as well as activities of daily living.
Improvement
Patients who achieve significant, sustained weight loss following laparoscopic adjustable gastric banding (LAGB) surgery may experience significant improvements in depressive mood and reductions in the use of depression medication. In two prospective trials of subjects undergoing LAGB surgery, 26% to 57% of patients with depression reported decreasing or discontinuing medications for this condition.37,83 In Ahroni et al37 specifically, 74% of depressive patients (n=98) reported that their condition improved (significantly associated with %EWL) and significant improvements were observed in all SF-36 mental health scale scores collected one year following surgery (n=141). Both Dixon84 and Brancatisano83 reported significant improvements in depressive mood following surgery as indicated by BDI or BDI-II score.
