Complications of Obesity: the mother of all diseases

Introduction

In my post ‘What is Obesity – is it merely about BMI? I had discussed the definition of obesity, as laid down by the WHO, as “A condition of abnormal or excessive body fat accumulation, to the extent that health may be impaired.” People who are obese are at increased risk for many serious diseases and health conditions, compared to those with a normal or healthy weight. However, in my post “Normal weight obesity – a myth or a reality?” I had discounted a widely prevalent myth amongst the general populace that ‘normal body weight always equals healthy weight’. There I had discussed a subset of individuals, among individuals with normal body weight, who develop and suffer from complications of obesity similar to individuals with a more ‘overt’ obesity.

Obesity affects almost every aspect of health, from reproductive and respiratory function to memory and mood. It decreases both the lifespan and the quality of life and increases costs of health care, both at the individual as well as at the national level. It does this through a variety of pathways; some as straightforward as the mechanical stress of carrying extra weight and some as a result of excessive secretion of certain products by enlarged fat cells and ectopic fat depots. The mechanisms by which obesity gives rise to its various ill-effects on health were discussed in my post “Is obesity a disease or a risk factor for other complications?”

However, the good news is that weight loss can reduce some of the risks associated with obesity. Loss of as little as 5 to 10 per cent of body weight provides substantial health benefits to people, and even if they begin to lose weight later in life.

 

Complications of obesity:

Various complications of obesity include the following:

1. Increased all-causes of death (mortality) and morbidity

A serious complication of obesity is increased incidence of premature death from all causes, including cardiovascular disease and cancer. According to WHO, worldwide, at least 2.8 million people die each year as a result of being overweight or obese, and an estimated 35.8 million (2.3%) of global Disability Adjusted Life Years (DALYs, defined as the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability) are caused by overweight and obesity. Mortality rates increase with increasing degrees of overweight, as measured by BMI and this risk of premature death increases as the time period from baseline increases.

2. Metabolic Syndrome

Metabolic syndrome is a major complication of obesity. Metabolic syndrome is the name for a group of risk factors that raises your risk for heart disease and other health problems, such as diabetes and stroke. The term “metabolic” denotes the biochemical processes involved in the normal functioning of the body. ‘Risk factors’ means traits, conditions or habits which increase your chances of developing a disease. It is estimated that around 20-25 per cent of the world’s adult population have the metabolic syndrome and they are twice as likely to die from and three times as likely to have a heart attack or stroke compared with people without the syndrome. In addition, people with metabolic syndrome have a fivefold greater risk of developing type 2 diabetes. The five most important metabolic risk factors, which adversely affect your health, including your risk for heart attacks and diabetes, are listed below. Though you can have any one of these risk factors by itself, they tend to occur together.

a) Abdominal obesity

Excess fat in the stomach area is a greater risk factor for heart diseases than excess fat in other parts of the body, such as on the hips. In my post “Waist size: Measure your waist, measure your risk”, I had discussed the health implications of abdominal obesity in details. The abdominal obesity can be easily assessed by measuring waist circumference. In the post, I had discussed the proper technique for measurement of waist circumference and had also given ethnic-specific values for waist circumference.

b) A high triglyceride level in the blood

Or on medications to treat high triglycerides. Triglycerides are a type of fat found in the blood.

c) A low HDL cholesterol level in the blood

Or on medications to treat low HDL cholesterol. HDL cholesterol helps remove cholesterol from the arteries and hence is also known as ‘good cholesterol’. A low HDL cholesterol level raises your risk for heart disease.

d) High blood pressure

Or on medications to treat high blood pressure.

e) High fasting blood sugar

Or on medications to treat diabetes. Mildly high blood sugar may be an early sign of diabetes.

A number of expert groups have developed clinical criteria for defining metabolic syndrome. In general, you must have at least three metabolic risk factors to be diagnosed with metabolic syndrome. However, as a multitude of definitions has caused confusion and difficulties in clinical practice, and as abdominal (central) obesity is independently associated with each of the other metabolic risk factors, International Diabetes Federation (IDF) has come up with the IDF consensus worldwide definition of metabolic syndrome.
According to the new IDF definition, for a person to be defined as having the metabolic syndrome they must have:

Abdominal obesity (defined as waist circumference with ethnicity-specific values) plus any two of the following four factors:

(i) Raised triglycerides: ≥ 150 mg/dL (1.7 mmol/L)
or specific treatment for this lipid abnormality
(ii) Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females
or specific treatment for this lipid abnormality
(iii) Raised blood pressure: Systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg
or treatment of previously diagnosed hypertension
(iv) Raised fasting plasma glucose (FPG): ≥ 100 mg/dL (5.6 mmol/L),
or previously diagnosed type 2 diabetes. If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not necessary to define the presence of the syndrome.

As discussed in my post “Waist size: Measure your waist, measure your risk”, referred to above, if BMI is > 35 kg/m2, abdominal obesity can be assumed and waist circumference does not need to be measured.

What causes the metabolic syndrome?

There are several underlying causes which increase the risk of metabolic syndrome. The three most significant risk factors are – abdominal obesity, inactive lifestyles, and insulin resistance (Insulin is a hormone made by the pancreas that facilitates entry of glucose in the blood into cells in the muscles, fat, and liver, where it used for energy. Insulin resistance is when cells in your muscles, fat, and liver don’t respond well to insulin and as a result cannot easily take up glucose from your blood). Other factors such as genetics, age, and ethnicity may also have a causal effect.

The IDF has made abdominal (central) obesity as a prerequisite risk factor for the diagnosis of the metabolic syndrome in the new definition because abdominal obesity is independently associated with each of the other metabolic syndrome components, including insulin resistance. As discussed in my posts on Normal weight obesity and waist size, referred to above, abdominal obesity contributes to hypertension (high blood pressure), high blood cholesterol, low HDL-cholesterol, and high blood sugar levels and is independently associated with higher cardiovascular disease risk.

3. Diabetes

Diabetes is a disease condition in which blood sugar levels are above normal. Obesity is the major cause of type 2 diabetes. As many as 80 to 90 per cent of individuals with type 2 diabetes are reported to be overweight or obese; mainly ‘abdominally obese’. This type of diabetes usually begins in adulthood, but now its incidence has started increasing in children too. Type 2 diabetes mellitus arises as a result of either resistance to insulin, the hormone that regulates blood sugar, or due to its reduced secretion from pancreas; obesity can lead to one or both of these conditions. Statistical summary (or meta-analysis) of data from various studies has revealed that the risk of developing type 2 DM is higher in women and starts increasing from very low levels of BMI. Compared to women with a BMI of 21, the relative risk of diabetes may go up to 35 times in women with a BMI of 30. This risk further increases exponentially (more and more rapidly) with increasing BMI. The increase in risk is similar in men; the only difference being the rise is not as steep.

In view of the close relationship between obesity and diabetes, the term ‘diabesity’ has been coined. The World Health Organisation (WHO) has called this global increase in obesity and diabetes, the “21st-century epidemic” due to the spurt in cases of obesity and diabetes in the last few decades. Several large trials have shown that even moderate weight loss can prevent or delay the onset of diabetes in people who are at high risk. In spite of this, most physicians still focus only on blood sugar control rather than paying attention to weight management.

4. Cardiovascular diseases

Cardiovascular diseases (CVDs), a major complication of obesity, are a group of disorders of the heart and blood vessels and mainly include coronary artery disease (disease of the blood vessels supplying heart muscle and manifesting as heart attack), cerebrovascular disease (disease of the blood vessels supplying the brain and manifesting as stroke), and peripheral arterial disease (PAD; disease of blood vessels supplying the arms and legs; a condition similar to CAD and manifesting as painful muscle cramping [intermittent claudication] in the lower extremities while walking or exercising; can progress to gangrene [dead tissue] of the lower extremities). CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause. With the increase in BMI, there is a rise in blood pressure, low-density lipoprotein (LDL or “bad” cholesterol), triglycerides, blood sugar and low-grade inflammation. These changes translate into increased risk for CVDs.

a) Coronary artery disease

The American Heart Association has classified obesity as a major risk factor for CAD. It has been estimated that in men, for each 10 per cent increase in body weight, there is approximately a 20 per cent increase in the incidence of CAD. Both, the degree of obesity and distribution of body fat, independently and additively, contribute to the risk factors for CAD; risk being higher in abdominally obese. In fact, the impact of abdominal obesity on CAD is approximately equal to that of smoking and may even be more than that of raised levels of LDL or bad cholesterol. The effects of obesity on cardiovascular health can begin in childhood, which increases the risk of developing CAD in adulthood.

Ageing is a natural process that also affects the entire blood vessel system. Among other things, ageing is almost always accompanied by atherosclerosis, a process in which blood vessels become thicker as a result of a build-up of fatty plaque within arteries, including those supplying blood to the heart muscle and brain, which can lead to heart attack, stroke or PAD. Research has shown that obese children have ‘accelerated ageing’ of the vascular system. A study presented at an American Heart Association conference in Nov 2008, claimed obese children as young as 10 years old had the arteries of 45-year-olds and other heart abnormalities that greatly raise their risk of heart disease. In other words, the “vascular age” of children was about 30 years older than their actual age. An old saying goes “you are as old as your arteries”, implying that the state of your arteries is more important than your actual age in the evolution of heart disease and stroke. This fact is well supported by the increasingly younger age in which patients are suffering from various CVDs. Many parents have the misconception that the “baby fat” will melt away as kids get older. But this is a myth which has not been supported by research. On the contrary, fat kids are likely to grow into fat adults, with many of the obesity-related health hazards. Obesity is not benign in children and adolescents.

b) Stroke

Stroke is the brain equivalent of heart attack and happens when the flow of blood to a part of your brain stops, causing brain cells to die. There are two types of stroke – ischemic stroke occurs when a blood clot blocks an artery that carries blood to the brain, and haemorrhagic stroke happens when a blood vessel in the brain bursts. Ischemic stroke follows a similar disease process and shares the same risk factors as CAD. Overweight and obesity increase the risk of stroke by up to 22 per cent and 64 per cent respectively. However, this increased risk of stroke due to obesity is mediated through its effects on blood pressure, cholesterol and diabetes. There is no significant association between obesity and haemorrhagic stroke.

c) High blood pressure (Hypertension)

Every time your heart beats, it pumps blood through your arteries to the rest of your body. Blood pressure is how hard your blood pushes against the walls of your arteries. Hypertension usually per se has no symptoms, but it may cause serious problems such as heart disease, stroke, and kidney failure. Several mechanisms are involved in the development of hypertension in obese people.

Additional fat tissue in the body needs oxygen and nutrients in order to live; to meet this additional requirement, the heart needs to pump more blood through additional blood vessels. This not only increases the workload of the heart, but increased volume of circulating blood also means more pressure on the artery walls, which increases the blood pressure. In addition, increased incidence of atherosclerosis (hardening of the arteries) in obese people, resulting in loss of elasticity and stiffening of the arteries and increased secretion of angiotensinogen, a precursor of the hormone angiotensin, which regulates blood pressure, from enlarged fat cells, contribute to high blood pressure.

5. Abnormal blood lipids (dyslipidemia)

Incidence of dyslipidemia rises many folds in obese people. Obese people have high LDL (or bad) cholesterol, low HDL (or good) cholesterol, or high levels of triglycerides. Dyslipidemia per se does not cause any symptoms, however, it significantly increases the risk of atherosclerosis, which is the primary underlying pathophysiology (the disordered physiological processes associated with disease or injury) for various CVDs.

6. Increased risk of cancer

Cancer occurs when cells in one part of the body, such as the colon, grow abnormally or out of control. Obesity increases the risk of developing a whole range of cancers. There is a direct association between obesity and cancers of breast, oesophagus, colon, rectum, uterus, kidney and pancreas. There is supportive evidence indicating the positive relationship of obesity to cancers of liver, cervix, gallbladder, and prostate in men. According to statistics released by the American Institute of Cancer Research, excessive body fat causes nearly one half of endometrial (inner mucous membrane lining the uterus) and one-third of oesophageal (related to the oesophagus) cancers. Excess weight can also decrease the chances of cancer survival. The American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention state: “Be as lean as possible throughout life without being underweight” to reduce cancer risk.

7. Gastrointestinal complications of obesity

Gastrointestinal tract (GI tract or alimentary canal) is an organ system which takes in food, digests it to extract and absorb energy and nutrients, and expels the remaining waste as faeces. The mouth, oesophagus (food pipe) stomach and intestines are part of the GI tract. Various accessory organs such as liver, pancreas and gallbladder assist the GI tract by secreting enzymes to help break down food into its component nutrients.

Obesity gives rise to various gastrointestinal and hepatic (relating to the liver) diseases. While it is a direct cause of some disease conditions such as nonalcoholic fatty liver disease (NAFLD), it is a significant risk factor for several other disease conditions of the GI tract such as gastroesophageal reflux disease, erosive oesophagitis, Barrett’s oesophagus, oesophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including non-alcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Some of these gastrointestinal complications will be discussed here briefly.

a) Nonalcoholic fatty liver disease (NAFLD)

NAFLD is a condition in which excess fat is stored in your liver. It is a major complication of obesity and results from a complex interplay of nutritional overload, metabolic, microbial, and genetic factors. Fat accumulation in the liver results from excess caloric intake (i.e. caloric overload). As the storage capacity of adipose tissue (connective tissue in which fat is stored) gets saturated due to over-accumulation of fats, excess fats ‘spill over’ to non-adipose tissues such as the liver, muscle, heart, and pancreas. Under these circumstances, such ectopic (in an abnormal place or position) deposition of fat contributes to lipotoxicity, which can be broadly defined as the deleterious consequences of accumulated fats. It results in cell dysfunction and cell death.

There are two types of NAFLD – simple fatty liver and non-alcoholic steatohepatitis (NASH).

i. Simple fatty liver – Simple fatty liver, also called nonalcoholic fatty liver (NAFL), is a form of NAFLD in which you have fat in your liver but little or no inflammation or liver cell damage. The simple fatty liver normally does not progress to cause liver damage or any complications.

ii. NASH – This is a form of NAFLD in which, in addition to fat in your liver, there is inflammation of the liver and liver cell damage, a condition known as hepatitis in medical terms. Inflammation is the body’s normal protective response to injury, irritation, or infection of tissues. It is the body’s attempt to heal itself after an injury; defend itself against foreign invaders such as viruses and bacteria, and repair damaged tissue. However, when our body’s powers of correction go wrong, they can work against us. Unlike the inflammation that follows a sudden infection or injury, the chronic (persisting for a long time or constantly recurring) kind produces a steady, low level of inflammation within the body that can contribute to the development of disease.

In NASH, inflammation and liver cell damage can cause fibrosis or scarring of the liver and eventually cirrhosis or liver cancer. Cirrhosis due to NASH is the third leading indication for a liver transplant and is projected to be the most frequent indication in the near future.
It is not clear as to why some people with NAFLD have NASH and others have simple fatty liver. Research suggests that genetic factors may play a role. However, certain conditions predispose to the risk of NASH. These include – obesity (especially abdominal obesity), high blood pressure, dyslipidemia, type 2 diabetes, and metabolic syndrome.

Usually, NAFLD and NASH are silent diseases with few or no symptoms. You may not have symptoms even if you develop cirrhosis due to NASH. If you do have symptoms, you may feel tired or have discomfort in the upper right side of your abdomen.

b) Gallbladder disease

Gallbladder is a small pear-shaped sac located on the right side of the abdomen, just below the liver. It stores bile, a liquid which is made in the liver and helps in the digestion of fats. Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. If the content of cholesterol, bile salts or bilirubin is high in the bile, these can harden into small, pebble-like substances called gallstones. Depending on their composition, there are two types of gallstones – cholesterol stones and pigment stones. Cholesterol gallstones account for 80 per cent of gallstones and are made mainly of hardened cholesterol. Pigment stones, on the other hand, are made of bilirubin.

In obese people there is an increased turnover of cholesterol – each kg of extra body fat produces an extra 20 mg of cholesterol each day that needs to be secreted by the biliary system (organs and ducts that create and store bile and release it into the duodenum [first part of small intestine]). In individuals with a propensity for gallstone formation, this extra load of cholesterol from increased body fat may be the tipping point for the development of gallstones and gallbladder disease. Weight cycling, i.e. rapid weight loss and then regaining it, further increases cholesterol production in the liver, which results in supersaturation of bile with cholesterol leading to an increased risk for gallstones. The risk is also higher in people who have dramatic weight changes.

8. Respiratory problems:

a) Obstructive Sleep Apnoea (OSA)

Sleep apnoea is a potentially serious disorder characterised by episodes of interruption of normal breathing during sleep. The interruption in breathing can be total due to complete blockage of the airway – it’s called apnoea when the airflow is blocked for 10 seconds or more. When there is partial blockage of the airway, resulting in airflow reduction of greater than 50 per cent for 10 seconds or more, it’s called hypopnoea. People with untreated sleep apnoea stop breathing repeatedly during their sleep, sometimes hundreds of times. As a result, the brain and the rest of the body may not get enough oxygen. There are two types of sleep apnoea:

i. Central sleep apnoea – It is the rarer form of sleep apnoea, which is caused by the brain not sending signals to the breathing muscles during sleep.

ii. Obstructive sleep apnoea (OSA) – It is the more common form of apnea and is caused by blockage of the airway. It mainly results from loss of tone of muscles in the wall of the back of the throat, leading to the collapse of the walls and narrowing of the respiratory passage, and loss of tone of muscles controlling tongue movement, allowing the base of the tongue to fall back against the back of the throat. Also, obese people generally have more fat stored around their neck, which narrows the airways. Men with a collar size greater than 43 cm and women with collar size greater than 40.5 cm have an increased risk of developing OSA.

OSA is characterised by loud snoring, noisy and laboured breathing, and repeated short periods where breathing is interrupted by gasping or snorting. During an episode of apnoea, lack of oxygen triggers your brain to pull you out of deep sleep – either to a lighter sleep or to wakefulness so that your airways reopen to enable you to breathe normally. These repeated episodes of sleep interruptions can make you feel very tired and sleepy during the day. You may also suffer from a morning headache, attention problems, irritability, lack of energy, and even depression; thus affecting the overall quality of your life. Patients usually have no memory of their interrupted breathing.

Obesity is a major contributor to OSA – between 50 per cent and 75 per cent of individuals with OSA being obese. Excess weight impairs respiratory function, both via mechanical as well as metabolic pathways. The diaphragm is the primary muscle used in the process of inspiration or inhalation. It is a dome-shaped sheet of muscle that is inserted into the lower ribs. It lies at the base of the chest cavity and separates it from the abdominal cavity. When you breathe-in or inhale, your diaphragm contracts (tightens) and moves downward. This increases the space in your chest cavity, into which your lungs expand and draw in more air from the atmosphere. The accumulation of excess fat in the abdomen may limit the descent of the diaphragm, and in turn, lung expansion, while the accumulation of fat in the chest wall can reduce the flexibility of the chest wall and thus the lung volume. Such changes are significantly exaggerated when an obese person lies down flat. In addition to these mechanical factors, fat stored in the neck and throughout the body produces certain substances that cause low-grade inflammation. This inflammatory state that accompanies obesity may impede lung function.

b) Obesity Hypoventilation Syndrome

In some severely obese cases, in addition to the OSA, poor breathing occurs during the daytime also, which is known as ‘daytime hypoventilation’ (excessively slow or shallow breathing). This results in low blood oxygen levels and high blood carbon dioxide levels. This triad of obesity, daytime hypoventilation, and sleep-disordered breathing in the absence of an alternative neuromuscular, mechanical or metabolic explanation for hypoventilation, is known as Obesity hypoventilation syndrome (OHS). It is also referred to as Pickwickian Syndrome as patients with OHS may have symptoms similar to the character Joe in Charles Dickens’s essay The Posthumous Papers of the Pickwick Club. However, what is of concern is that if left untreated, OHS is potentially life-threatening because of its bad effects on your heart and blood vessels. Patients with OHS are more likely to have a high blood pressure – almost 50 per cent of people with OHS have high blood pressure; also, it may be more difficult to control your blood pressure. Frequent bouts of low oxygen levels are thought to damage blood vessels. Lack of oxygen in the body may also lead to rhythm disorders of the heart (cardiac arrhythmias). OHS can also cause stress on your heart resulting in enlargement of the heart, which further aggravates the state of deficient oxygen supply to your heart. Because of the above factors, people with untreated OHS are more likely to develop CAD and heart failure. In addition, sleepiness and tiredness during the day may cause accidents at work, poor work performance, and accidents while driving.

c) Asthma

Obesity is associated significantly with the development of asthma, worsening asthma symptoms, and poor control of asthma. And for reasons not yet understood, incidence is higher in obese women. As on date, the link between obesity and asthma is not well understood. However, some possible explanations for the link between obesity and asthma are as under:

i. Extra weight around the chest and abdomen might constrict the lungs and make it more difficult to breathe.

ii. Obese patients may get more inflammation in their body. In my post, Is obesity a disease, referred to above, I had highlighted that fat cells are a veritable endocrine factory and produce a variety of chemical substances including inflammatory substances that might affect lungs and a number of studies have suggested these substances affect asthma.

Associated co-morbidities such as OSA and depression and low levels of fitness may worsen the symptoms of asthma.

9. Osteoarthritis and other musculoskeletal disorders

Osteoarthritis (OA) is a type of joint disease that results from the breakdown of joint cartilage (a firm tissue that covers the ends of bones where they come together to form joint; it allows the bones to glide over each other with very little friction) and underlying bone. OA is more prevalent in obese people. Excess body fat not only places mechanical stress due to increased body weight but also produces certain substances which cause low-grade inflammation, which can contribute to OA. The role of inflammatory factors in OA is evident from the fact that even non-weight bearing joints are affected by OA in obese patients. OA of the knee and hip is more commonly associated with obesity. Joint replacement surgery, while commonly performed on damaged joints, may not be an advisable option for an obese patient, because the artificial joint has a higher risk of loosening and causing further damage. Obesity also increases the risk of back pain, lower limb pain and other musculoskeletal (relating to the musculature and skeleton together) conditions.

10. Reproductive and sexual health

Obesity influences various aspects of reproduction – from sexual activity to conception. Risk of infertility in women is increased with both low and high BMI. Various studies suggest that up to 25 per cent of cases of infertility in women can be attributed to obesity; obesity has been identified as an important modifier of reproductive hormones. Obesity may affect sexual function in males too with odds of developing erectile dysfunction increasing with increasing BMI.

Obesity is also one of the most frequent causes of complications during pregnancy. Not only do obese women experience a greater number of complications, when compared to women who have normal weight, but also the babies born to obese mothers are more likely to have complications compared to babies born to women with normal weight. Most common complications of obesity in women include the following:

(a) Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is one of the most common hormonal disorders in women of reproductive age. The nomenclature ‘polycystic ovary syndrome’ is derived from the appearance of multiple (~poly) small cysts along the outer edge of ovaries, which are enlarged, in women with PCOS. Though exact cause of PCOS is unknown, it is believed to be related to the production of an excess amount of male sex hormones, androgens. Although all women produce some amount of androgens, when present in excess amount they disrupt normal menstrual cycle, cause infertility (by preventing ovulation [discharge of ova or egg from the ovaries]), acne and abnormal hair growth such as excess facial hair, or male pattern of baldness. Women with PCOS have irregular menstrual bleeding and often have difficulty getting pregnant. It challenges the quality of life of the women who suffer from it.

The prevalence of PCOS has grown in parallel with the epidemic of obesity. But the link between PCOS and obesity is complicated: it is still not clear if being overweight causes PCOS or if PCOS results in obesity. However, what is clear is that women affected by obesity have a greater risk for PCOS and vice versa, women with PCOS have a greater risk for obesity. What is of concern is that apart from its ill-effects on reproductive health, PCOS increases the risk of a number of other diseases. These include high blood pressure, type 2 diabetes, sleep apnoea, abnormal uterine bleeding, cholesterol abnormalities, metabolic syndrome, heart disease, cancer of the uterus and complicated pregnancies. Experiments have revealed that the influence of obesity and PCOS on metabolic abnormalities are independent and additive, However, obesity has a greater role in the development of these metabolic abnormalities. Reproductive disturbances are also more common in obese women regardless of the diagnosis of PCOS.

Early diagnosis and treatment of PCOS can help reduce the risk of long-term complications such as type 2 diabetes, heart disease and stroke. Apart from medications to control hormones, engaging in regular exercise, keeping a healthy diet and losing excess weight form an important part of the treatment for PCOS. Maintaining normal weight in adolescents and young adults can help prevent PCOS.

(b) Gestational diabetes

Gestational diabetes is a form of high blood sugar that develops during pregnancy, in women who have never had diabetes before, and usually disappears after giving birth. Any women can develop gestational diabetes, however, obesity is an important predisposing factor. Even though it often disappears after delivery, gestational diabetes can cause problems for both the mother and the baby, during and after birth.

Extra glucose in the mother’s blood passes on to the baby in the womb. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat. This can lead to the baby being significantly larger than average, a condition termed as ‘foetal macrosomia’ or “fat” baby. This, in turn, creates complications during delivery, for both the mother and the baby. In the baby, it increases the risk of injuries, such as to the shoulders, during vaginal delivery and they are also at higher risk for breathing problems. Such children are also at a higher risk for developing obesity and diabetes later in life. Large baby size also causes problems during delivery for the mother, which may necessitate forceps- or vacuum-assisted vaginal delivery (which has its own inherent complications), or maybe even a caesarean section. It also increases the risk of premature birth. Rarely, the baby may be stillborn ([of an infant] born dead).

(c) Gestational hypertension

Also known as Pregnancy Induced Hypertension (PIH). It is the new onset of high blood pressure readings that develops after 20 weeks of pregnancy, in women whose blood pressure had been normal, and normalises after delivery. One potentially life-threatening complication of gestational hypertension, for both the mother and the baby, is its progression to a condition known as pre-eclampsia. Pre-eclampsia is characterised by high blood pressure, swelling of the hands and feet, and passing of protein in the urine. Obesity is one of the important predisposing factors for the development of pre-eclampsia.

Pre-eclampsia can lead to complications for both the mother and the baby. It affects the arteries carrying blood to the placenta (the organ that nourishes the foetus throughout the pregnancy), as a result of which your baby may not receive adequate oxygen and other nutrients. This can lead to slow growth of the baby, a condition known as ‘foetal growth restriction’, which results in a low birth weight baby. Low-birth-weight has its inherent complications; it predisposes these infants to develop obesity and diabetes, later in life. This happens as a result of permanent changes in the structure and physiology of key organ systems as a result of adaptations in the foetus during its development in the uterus, in response to a deficiency of various nutrients. In addition, changes in low-birth infants, contribute to increased risk of coronary heart disease, stroke, and hypertension later in adult life.

Pre-eclampsia can also lead to separation of the placenta from the inner walls of your uterus (known as placental abruption). Severe abruption can cause heavy bleeding, which can be life-threatening for both the mother and the baby. Pre-eclampsia also significantly increases the risk of stillbirth. Depending on the severity of pre-eclampsia, it can result in damage to vital organs such as heart, liver, and kidneys and increases the risk of developing cardiovascular diseases in the future. If left untreated, pre-eclampsia can lead to the following life-threatening conditions:

i. Eclampsia – It is a severe form of pre-eclampsia in which the mother develops seizures.

ii. HELP Syndrome – This usually occurs late in the pregnancy and is characterised by breakdown (haemolysis) of Red Blood Cells, elevated liver enzyme levels, and low platelet count in the mother.

In patients with pre-eclampsia, if you are close to your date and the baby is developed enough, delivery of the baby is the advisable course of treatment, for the safety of both mother and the baby. Good news is that most women still can deliver a healthy baby if hypertension is detected and treated early. Obesity during pregnancy can lead to other complications too. It slightly increases the chances of bearing a child with congenital anomalies. Babies born to obese mothers are at increased risk of developing various serious defects like Spina Bifida (a birth defect in which a developing baby’s spinal cord fails to develop properly) and anencephaly (a serious developmental defect of the central nervous system in which the major portion of the brain, skull and scalp are missing).

Though these defects can often be detected early in pregnancy, through the use of ultrasound imaging, however, in women who are obese, blurring images are produced during ultrasound imaging because ultrasound waves have trouble penetrating extra layers of fat. This results in a missed or delayed diagnosis. Labour is also more likely to be slow and prolonged in women who are obese. This can give rise to various problems like increased distress for the baby which might necessitate vacuum- or forceps-assisted vaginal delivery or maybe even a caesarean section.

11. Urinary incontinence

The unintentional leakage of urine can be a complication of obesity. Obesity can weaken pelvic muscles, making it harder to maintain bladder control. While it can happen to both sexes, it usually affects women as they age.

12. Psycho-social effects

Society shapes us in many ways, possibly more than we realise; how society perceives us affects us on many levels. Physical appearance is one of the various characteristics people possess that could possibly have an effect on their environment (other people, basically), and which, in turn, at least partially determines how other people behave towards us. Body image is the perception that a person has of his or her physical self and the thoughts and feelings that result from that perception. These feelings can be positive, negative, or both and are influenced by both how people perceive their bodies visually and how they feel about their physical appearance, as well as by our sense of how other people view our bodies.

Body size and shape provides a visual read-out to the observer about the physical appearance of the person they are seeing and this plays a dominant role in the stigmatization of obesity in children and adults, by both the general public and by health professionals alike. This may lead to discrimination and contribute to depression and anxiety.

It is at an early age, perhaps before age ten or so that children begin to recognise how others react to them. Naturally, people react with certain biases to people who look one way or another. Individuals with obesity often face persistent societal stigmatisation, prejudice and discrimination. Common negative stereotypes include obese individuals being lazy, unmotivated, lacking in self-discipline, less competent, and noncompliant. This unfair treatment or prejudice because of body weight is referred to as “weight bias” and negatively affects not only psychological well-being but physical health as well. Impairment in body image is the major form of psychological disturbance specific to obese persons. In fact, the mental health effects of obesity can be as damaging as the physical effects. This is more marked in females compared to males, especially in these times of zero figure syndrome.

As highlighted above, weight bias is common among healthcare providers too. They perceive individuals with obesity as lacking self-control, unmotivated to improve health, noncompliant with treatment, and personally to blame for their weight. As a result of such attitudes, individuals with obesity who perceive bias from their healthcare providers have less trust in them and avoid appointments. This significantly interferes with effective obesity treatment.

Weight bias is also associated with various social and economic problems. Individuals with obesity often face prejudice or discrimination at school, while looking for a job, at workplace and even in personal relationships; this results in inequities in education and employment. A large prospective study (a longitudinal cohort study that follows over time a group of similar individuals [cohorts] who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome) in the USA has shown that women who were overweight during adolescence and young adulthood were more likely to have lower family incomes, higher rates of poverty and lower rates of marriage then women with various other forms of chronic physical disability during adolescence.

Complications of obesity in childhood have been discussed in my post “Childhood obesity: a serious public health challenge.”

Conclusion

People who are overweight or obese suffer from various complications of obesity and are at increased risk of many serious diseases and health conditions, compared to those with normal or healthy weight. Obesity affects almost every aspect of health, from cardiovascular to respiratory and reproductive function to memory and mood. It decreases both the lifespan and the quality of life and increases costs of healthcare, both at the individual as well as at the national level. However, the good news is that weight loss can reduce some of the risks associated with obesity. Loss of as little as 5 to 10 per cent of body weight provides substantial health benefits to people, and even if they begin to lose weight later in life. Adopting Holistic Health Approaches can be the way to wellness.