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Obesity

And its Associated Risk Factors

Pennington Biomedical Research Center


Division of Education

Obesity
An Overview

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.

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CDC

Energy Imbalance
What is it?

Energy balance can be compared to a scale.


An energy imbalance arises when the number of calories consumed is not equal to the number of calories used by the body. Weight gain usually involves the combination of consuming too many calories and not expending enough through physical activity.

Weight Gain Calories Consumed > Calories Used Weight Loss Calories Consumed < Calories Used No Weight Change Calories Consumed = Calories Used

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CDC

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

Fat Cell Enlargement


Hypertrophy

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

Weight Classifications
A Review

Body mass index (BMI) is a mathematical ratio which is calculated as weight (kg)/ height squared (m2). It is used to describe an individuals relative 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: Below 18.5 18.5 - 24.9 25.0 - 29.9 30 or higher

You are considered: Underweight Healthy Weight Overweight 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

or
http://www.nhlbisupport.com/bmi
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CDC

Mortality and Morbidity


Associated 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.

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

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

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

Mortality
Regional Fat Distribution

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 risk for 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 blood pressure and inflammatory markers.

Android

Gynoid

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

Mortality
Weight Gain

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 increasing degrees of weight gain.

2006

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

Mortality
Sedentary Lifestyle

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 with normal body fat.

2006

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

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

Morbidity
Associated with Obesity
Individuals who are obese are at a greater risk of developing:

Obstructive sleep apnea Osteoarthritis Cardiovascular disorders Gastrointestinal disorders Metabolic disorders

Endometrial, prostate and breast cancers Complications of pregnancy Menstrual irregularities Psychological disorders
CDC

2006

Cardiovascular Disorders
Associated with Obesity
Obese individuals are at a greater risk of developing these cardiovascular disorders:

Hypertension Stroke Coronary Artery Disease


2006

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.

2006

NHLBI

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

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.

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NHLBI

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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J La State Med Soc .2005; 157 (1): S42-49.

Hypertension
Prevalence in the Overweight
35 30
27.0 22.1 27.7

32.7

Age-adjusted prevalence of hypertension in overweight U.S. adults

Prevalence of HTN

25 20

14.9

15.2

15 10 5 0 Males Females
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BMI < 25 BMI > 25 & < 27 BMI > 27 & <30

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

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 to part 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.

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NINDS

Stroke
The symptoms of a stroke include:

Sudden numbness or weakness, especially on one side of the body Sudden confusion or trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble with walking, dizziness, or loss of balance or coordination Sudden severe headache with no known cause

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NINDS

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 is doubled 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.

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

Coronary Artery Disease


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.

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NHLBI

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 This is 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.
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Angina Heart Attack

NHLBI

Coronary Artery Disease

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 heart has 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 normal beating rhythm of the heart. They can be either faster or slower than normal. Some arrhythmias can be quite serious.

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NHLBI

Coronary Artery Disease


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

Gastrointestinal Disorders
Associated with Obesity
Obese individuals are at greater risk of developing these gastrointestinal disorders:

Colon Cancer Gall stones

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Colon Cancer

Colorectal cancer is 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 and its 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.

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American Cancer Society

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.

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American Cancer Society

Colon Cancer
Findings Relating to Obesity

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

An increased risk of colon cancer has been consistently reported for men with high BMIs.
Women with high BMI are not at increased risk of colon cancer.
There is evidence that abdominal obesity may be important in colon cancer risk.
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NCI

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 from forming. However, if there are abnormally high levels of bile salts or, more commonly, cholesterol, then stones can form.

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

Gallstones
Findings 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.

2006

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

Gallstones
Findings Related to Obesity

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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J La State Med Soc .2005; 157 (1): S42-49.

Gallstones
Findings Related to Obesity

Ironically, weight loss leads to an increased risk of gallstones-because of the increased flux of cholesterol through the biliary system.
Diets with moderate levels of fat that trigger gallbladder contraction and subsequent emptying of the cholesterol content may reduce the risk of gallstone formation. Bile acid supplementation can be used to lower ones risk for gallstone formation.

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J La State Med Soc .2005; 157 (1): S42-49.

Metabolic Disorders
Associated 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 with overweight and obesity in both genders and in all ethnic groups. The risk for Type 2 DM increases with the degree and duration of overweight in individuals. The risk for Type 2 DM also increases in individuals with a more central distribution of body fat (abdominal).

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J La State Med Soc .2005; 157 (1): S42-49.

Obesity and Type 2 DM


In the United States
Among people diagnosed with Type 2 diabetes, 55 percent have 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 as normal weight).

15%
BMI < 25 BMI > 25 or BMI < 30 BMI > 30

55%

30%

2006

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

Diabetes Mellitus
Findings 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/m2 had 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/m2 had 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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J La State Med Soc .2005; 157 (1): S42-49.

Diabetes Mellitus
Findings 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 for developing 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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J La State Med Soc .2005; 157 (1): S42-49.

Dyslipidemia

Dyslipidemia is defined as abnormal concentration of lipids or lipoproteins in the blood.


As BMI increases, there is an increased risk for heart disease. This is because a positive correlation between BMI and triglyceride (TG) levels has been demonstrated.

2006

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

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

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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J La State Med Soc .2005; 157 (1): S42-49.

Liver Disease
Fatty Liver

Steatosis is the term for fatty liver and it is not actually a disease, but rather a pathological finding. 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

2006

Liver Disease
Fatty 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.

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The American Liver Foundation

Importance of a Healthy Liver


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:

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 the bloodstream. 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.

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Mayo Clinic

Other Disorders
Associated with Obesity
Obese individuals are at greater risk of developing these metabolic disorders:

Obstructive sleep apnea Osteoarthritis Endometrial, prostate, and breast cancers Complications of pregnancy Menstrual irregularities Psychological 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.

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American Academy of Family Physicians

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.

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American Academy of Family Physicians

Obstructive Sleep Apnea


Findings 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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J La State Med Soc .2005; 157 (1): S42-49.

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.

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NSLS

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

2006

Cancer
Findings 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 for 25 to 30 percent of several major cancers, including--- colon, breast (postmenopausal), endometrial, kidney, and cancer of the esophagus.

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J La State Med Soc .2005; 157 (1): S42-49.

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

Endocrine Changes
Associated with Obesity
Common hormonal abnormalities associated 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

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

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.

J La State Med Soc .2005; 157 (1): S42-49.


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

Psychological Disorders
Weight 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 than population norms.

J La State Med Soc .2005; 157 (1): S42-49.


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

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

Diabetes mellitus Hypertension Gallbladder Disease Liver Disease Cancer Coronary Artery Disease Cerebrovascular disease (stroke) Endocrine Changes

Psychosocial Function Obstructive Sleep Apnea Osteoarthritis

These diseases have been found to be associated with increased fat mass

These diseases have been found to be associated with increased metabolic activity (secretion) of fat cells in obesity 2006

Pennington Biomedical Research Center


Division of Education
Phillip Brantley, PhD, Director Heli J Roy, PhD, RD, Associate Professor Shanna Lundy, BS

2006

References

CDC: Overweight and Obesity -- Contributing Factors. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm Bellanger T, Bray G. Obesity related morbidity and mortality. J La State Med Soc. 2005; 156(1): S42-49. Bray G. Risks of obesity. Endocrinol Metab Clin N Am. 2003; 32: 787-804. National Heart, Lung, and Blood Institute (NHLBI). High Blood Pressure. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_WhatIs.html Obesity in America. Obesity Trends. Available at: http://www.obesityinamerica.org/trends.html

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References

National Institute of Neurological Disorders and Stroke. NINDS Stroke Information Page. Available at: http://www.ninds.nih.gov/disorders/stroke/stroke.htm National Heart, Lung, and Blood Institute (NHLBI). What is Coronary Artery Disease? Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html American Cancer Society (ACS). What is Colorectal Cancer? Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Is_Colon_and_Rect um_Cancer.asp?rnav=cri National Cancer Institute (NCI). Obesity and Cancer. Available at: http://www.cancer.gov/cancertopics/factsheet/Risk/obesity

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References

American Liver Foundation. Diet and Your Liver. Available at: http://www.liverfoundation.org/cgibin/dbs/articles.cgi?db=articles&uid=default&ID=1022&view_records=1 Mayo Clinic. Your Liver: An Owners Guide. Available at: http://www.mayoclinic.com/health/liver/DG00038 American Academy of Family Physicians (AAFP). Obstructive Sleep Apnea. Available at: http://www.aafp.org/afp/991115ap/2279.html National Synchrotron Light Source (NSLS). Osteoarthritis. Available at: http://www.nsls.bnl.gov/about/everyday/osteoarthritis.html

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