3 Chapter Three: Intro to the Consequences of Obesity

Authored by: Sherri M. Cirignano, MS, RDN, LDN

 

Introduction

The list of health and other consequences of obesity has continued to grow over the past several decades with an increasing impact on individual physical and behavioral health, the economics of health systems and even the United States military. With the Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity in 2001,¹ and the declaration of obesity as a chronic disease by the American Medical Association in 2013,² an ever-growing focus on obesity and its implications have been realized.

Obesity is Declared a Chronic Disease

The process towards regarding obesity as a chronic disease was many years in the making,³ and its acceptance by society at large is still in progress. This process was preceded by significant “milestones” that involved several non-medical organizations including the Healthcare Financing Administration, now the Centers for Medicare and Medicaid Services, which stated in the 1970’s “obesity is not an illness.” Later in the timeline, other milestones included the National Institutes of Health stating in its 1998 clinical guidelines, “Obesity is a complex multifactorial chronic disease,” the Internal Revenue Service and the Social Security Administration, both in 2002, providing statements that supported obesity as a disease, and finally the CMS removing the statement “obesity is not an illness” in 2004. CMS allowed coverage for bariatric surgery under Medicare starting in 2006. Further support from the medical community helped to work towards the final determination by the AMA of declaring obesity as a chronic disease in 2013.³

Another organization that also played a role in the medical community towards the focus of obesity being viewed as a chronic disease was the Obesity Medicine Association (OMA). Created in 1950 as the National Obesity Society to focus on the clinical management of obesity, the group underwent five subsequent name changes³ until its current name was chosen. The OMA is an organization for all healthcare professionals who “take a comprehensive, evidence-based approach to treating obesity” with a focus on nutrition, physical activity, weight behaviors and medication.⁴

Physical Health Consequences of Obesity

Obesity can arise from a number of factors, including overeating, poor diet, sedentary lifestyle, limited sleep, genetic factors, and even diseases or drugs. Severe obesity (morbid obesity) or long-term obesity can result in serious medical conditions, including, but not limited to, coronary heart disease; type 2 diabetes; endometrial, breast, or colon cancer; hypertension (high blood pressure); dyslipidemia (high cholesterol or elevated triglycerides); stroke; liver disease; gall bladder disease; sleep apnea or respiratory diseases; osteoarthritis; and infertility. Research has shown that losing weight can help reduce or reverse the complications associated with these conditions.⁵

The following sections will explore some of the most common health consequences of obesity.

Metabolic Syndrome

Hg or diastolic greater than or equal to 85 mm Hg, or both; 5) elevated fasting glucose (greater than or equal to 100 mg/dl or on medication for elevated glucose.⁷

In the US, the prevalence of MetS has increased by more than 35% over the past three decades, with one in three US adults currently meeting the above criteria.⁷ The number of US adults with MetS and associated chronic diseases will likely continue to rise due to a large majority of the US population who are aging.

Cardiovascular Diseases

Cardiovascular diseases refer to a number of health conditions that are related to the heart and blood vessels including myocardial infarctions (heart attacks), strokes, hypertension, and dyslipidemia, which is the imbalance of lipids including cholesterol and triglycerides. Obesity is a leading contributor to hypertension, even in children,⁸ and dyslipidemia has long been associated with obesity.⁸ Both hypertension and dyslipidemia are considered to be risk factors for cardiovascular disease.⁹ Obesity increases the risk for strokes, and some research has indicated obesity significantly increases the risk of stroke in American women aged 45 years or above.⁸

Type 2 Diabetes

Approximately one in ten Americans have diabetes with a majority (90-95%) having Type 2 Diabetes (T2D).¹⁰ T2D is currently considered a world -wide pandemic,¹¹ and the rate of its diagnosis has been growing in proportion to that of overweight and obesity over the past several decades.

T2D occurs as a result of high blood glucose levels, also known as hyperglycemia, due to the body’s inability to produce or effectively utilize insulin. Insulin is a hormone that is produced in the beta cells of the pancreas which work towards controlling the amount of glucose that is circulating in the blood. This insulin resistance can develop slowly over time, eventually leading to chronic hyperglycemia. Blood glucose circulating in the body in this way can be detrimental to multiple organs including the kidneys and the eyes. Previously thought to be a solely metabolic disorder, T2D is now viewed by some as an autoinflammatory disease that is occurring due to poor regulation of the metabolic system.¹¹

Cancer

According to a report issued by the World Cancer Research Fund jointly with the American Institute for Cancer Research, cancer is responsible for one in eight deaths worldwide and is the leading cause of death over cardiovascular disease in many areas of the world.¹² Overweight and obesity are contributing to this growing statistic. The Report states that “the evidence that greater body fatness is a cause of many cancers is particularly strong, and has grown stronger over the last decade.” Because of current trends towards decreased activity and increased overweight and obesity, if these trends remain unchanged, overweight and obesity are expected to surpass smoking as the primary risk factor for cancer.

There is strong evidence that links overweight and obesity in adulthood with certain types of cancers. These include cancers of the esophagus, pancreas, liver, colon, kidney, lining of the uterus or endometrium, and breast cancer in women after menopause.¹² The evidence for each cancer site listed has been found by the distinguished panel of experts who reviewed and judged the currently available evidence to be strong or “convincing.” Evidence of this type often results in recommendations and public health and policy implications.

Health Consequences of the Respiratory, Reproductive and Musculoskeletal Systems

Excess weight can also lead to an increased risk for several other disorders including those of the respiratory, reproductive and musculoskeletal systems.^9,13 Respiratory diseases such as asthma or sleep apnea can occur due to obesity.⁹ Asthma is a breathing difficulty that affects the lungs by causing wheezing, breathlessness, chest tightness and coughing.¹⁴ Obese children and adults can both be at an increased risk for asthma and, individuals who are asthmatics can have more symptoms, more frequent and severe asthma attacks, and a decreased response from medications if they are obese.¹⁵

Sleep apnea is a chronic disorder that can occur in obese individuals due to excess adipose tissue in the next region that can push the soft tissues towards the lumen of the airway, causing the trachea to narrow. This can occur in children or adults, may last for several seconds or several minutes, and is characterized by the cessation of breathing during sleep. Sleep apnea leads to poor sleep, which is reflected in the symptoms of fatigue, evening napping, irritability, memory problems, and morning headaches. In addition, many individuals with sleep apnea experience a dry throat in the morning after waking from sleep, which may be due to excessive snoring.¹⁶

Overweight and obesity can lead to issues that can result in reproductive disorders including delayed puberty in young boys, advanced puberty in young girls, infertility and subfertility. Subfertility refers to a prolonged timeframe to achieve conception and an accelerated aging process to the ovaries.⁸ The risk of infertility is three times as high for women who are obese versus those who are not obese. Negative outcomes are also prevalent in women who are overweight or obese who undergo in vitro fertilization.¹⁷ Overall, the probability of pregnancy is reduced in obese women.^8,17

Musculoskeletal disorders such as osteoarthritis, a disabling degenerative disease of the joints, are also a potential health consequence of obesity¹³ due to the added weight and pressure put on the musculoskeletal system.

Obesity and COVID-19

In addition to the above known impact obesity can have on chronic disease, it has more recently been discovered that having obesity can also increase the risk for infectious diseases, in particular, severe COVID-19 illnesses for adults^18,19,20 and children.^21,22 Obesity has previously been found to be associated with an increase in inflammation which can result in a decreased response by the immune system when presented with bacterial, viral and other infections.²⁰ Although still a fairly new area of research, studies prior to the COVID-19 pandemic did reflect a relationship between obesity and lung function²⁰ particularly among those <65 years of age¹⁹ in times of illness. In addition, new information resulting from the pandemic indicate that overweight and obesity are at a higher risk for requiring invasive mechanical ventilation and obesity or severe obesity are at a higher risk for requiring hospitalization, ICU admission, and death for those ages 65 or above.^19,23 This was also the case for children aged 18 years and younger. Children with severe COVID-19 illnesses were more likely to be obese than those who were not.²²

Behavioral Health Consequences of Obesity

Psychosocial Issues

There is also the potential for psychosocial issues for individuals with obesity. Those with obesity can suffer from “issues related to their mood, self-esteem, quality of life, and body image.”²⁴ It has been estimated that between 20% and 60% of those with obesity or severe obesity suffer from a psychiatric illness including one of the following: depression, eating disorder and anxiety including social anxiety disorder.²⁴ These psychiatric disorders are also found amongst children who have obesity. Children can experience many other psychosocial issues related to their weight including stress, body shape concerns and low self-esteem.²⁵ For all ages who suffer from obesity, quality of life can be significantly affected.

Weight Bias and Stigma

Although some progress has been made regarding the public’s perception of obesity as a chronic disease, individuals with excess weight are faced with discrimination throughout many sectors of society. Weight bias and stigma can be found in educational institutions,²⁶ in the workplace^26,27 and in healthcare.^26,27,28 According to surveys of healthcare professionals, nurse practitioners and physicians report they have negative attitudes and beliefs regarding patients with obesity. Patients also rated physicians as the “second most common source of obesity bias.”²⁸

There are several movements underway to work towards ending weight bias and stigma, especially within healthcare. These efforts are being worked toward by organizations such as the National Association to Advance Fat Acceptance (NAAFA) and The Association for Size Diversity and Health (ASDAH). ASDAH includes the following five Health at Every Size (HAES) Principles and framework: 1) Weight inclusivity; 2) Health enhancement; 3) Eating for well-being; 4) Respectful care; and 5) Life-enhancing movement. Achievement of goals such as these hope to be realized through education of healthcare professionals with published studies and surveys including results of proof of bias²⁸ and through efforts by an international panel of 36 experts with a Consensus Statement in Nature Medicine by Francesco Rubino and colleagues.²⁹ The Consensus Statement includes a pledge which organizations and individuals are invited to sign to help end obesity stigma and recommendations for how to do so.

Economic Consequences of Obesity

Consequences of overweight and obesity include significant impacts financially to both individuals and the healthcare system. According to a review of costs associated with obesity-related medical care from the National Health and Nutrition Examination Survey (NHANES) 2011-2016, medical expenditures were estimated at nearly $173 billion for adults and $1.32

billion for children.³⁰ According to the Centers for Disease Control (CDC), productivity costs due to obesity-related absenteeism cost adults between $79 and $132 per individual with obesity and cost the United States between $3.38 and $6.38 billion annually.⁹ Studies have found that as BMI increases, productivity decreases and healthcare costs increase.³¹

These economic impacts can be divided into two categories, direct and indirect costs. Direct costs are those that are related to services that a patient receives such as physician appointments, diagnostic testing and treatments including medications. These costs can be higher due to the increased frequency of visits and hospitalizations and care that is required with the chronic diseases that are associated with obesity including heart disease, diabetes and cancer.³² Indirect costs include lost productivity when individuals are unable to work due to obesity-related illnesses, have decreased productivity while at work or succumb to obesity-related disability or premature death.^8,9

Additional impacts on the healthcare system as a result of the increasing number of patients with severe obesity include those listed below.³²

• Lifting injuries to healthcare workers
• Larger gowns and blood pressure cuffs
• Larger beds, operating tables, stretchers and wheelchairs
• Renovations to increase doorway sizes
• Scales able to accommodate higher weights
• Installation of overhead hoists and floor-mounted toilets

Implementation of preventive measures taken at the workplace, in communities and in society at large, could eventually work towards a reduction in the healthcare and personal costs of obesity. A supportive environment this would provide could be a key ingredient to creating a future where making the healthy choice could be the easy choice for all.

Other Consequences of Obesity

Military Readiness

There are growing concerns over the increasing number of young adults who are unfit to serve in the US military due to overweight and obesity. According to the CDC, just over one in three young adults aged 17-24 is too heavy to serve in the US military. There is also an issue with a decreasing ability for young adults to meet the physical activity requirements needed to be able to participate in basic training. Overall, “only two in five young adults are both weight-eligible and adequately active” to serve.^9,33

According to the 2018 Health Related Behaviors Survey, (HRBS) the survey used by the US Department of Defense to assess health and health-related behaviors of service members, of those in active duty, approximately 51% were in the category of overweight, 15% were obese and 33% were of normal weight.^34,35 Those in the overweight or obese categories are less likely to be fit to deploy. Musculoskeletal injuries are common among active-duty soldiers, with 3.6 million such injuries from 2008-2017. A study found that active-duty soldiers with obesity were 33% more likely to sustain this type of injury.³³

These obesity-related issues within the US military are costly. The Department of Defense is reported to spend about $1.5 billion annually in obesity-related health care costs and $103 million each year on lost workdays.³³ Mission Readiness: Council for a Strong America, was created in 2009 by retired top military leaders to work towards strengthening national security through “evidence-based bipartisan state and federal public policy solutions” that will encourage youth to be able to serve in the military if desired.³⁶

Summary

Obesity is a chronic disease that is widespread and has grown dramatically over the past four decades, nearly tripling over that timeframe.¹³ Obesity can be a source of several other chronic diseases including cardiovascular disease, type 2 diabetes and several types of cancer as well as an increased risk for a severe response to infectious diseases including COVID-19. The rate of increase of the disease of obesity and its complications are found in both children and adults, resulting in potential debilitating psychosocial disorders for both age groups which can further lead to a compromised quality of life.

The economic burden that overweight, obesity and severe obesity has on both individuals and the healthcare system are significant. These financial consequences result in direct costs such as care and treatment for those with obesity and indirect costs that include lost productivity and obesity-related disability or premature death. Economic costs are also found in the US military, with not only an increasing amount of diagnosed obesity within the ranks of those in active duty, but also a decreasing number of young adults who are fit and eligible to enter the military.

Creating environments through policies, systems and environmental changes that encourage healthful food and physical activity choices can be beneficial for future generations who have preventable obesity. Increased study and understanding of genetic predisposition or disease-related acquisition of obesity are needed to continue to alter the prevailing discrimination of those with obesity in the US and throughout the world.

Resources

National Association to Advance Fat Acceptance

Mission Readiness: Council for a Strong America

Unfit to Serve: Obesity is Impacting National Security

The Association for Size Diversity and Health – Health at Every Size

References

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