Cardiac Risk Factor: Obesity

When Charles Dickens narrated the obesity-related lethargy, drowsiness, snoring, and somnolence (Pickwickian syndrome), in his most famous Pickwickian paper in 1836, it was all about great literature, good humor, money, and fame.

Today obesity is the most rapidly increasing cardiac risk factor in our community. In the 1980s, only 20% of Americans were obese, but now about 40% are obese. Lifetime health and economic consequences of obesity is staggering. One patient will cost us about $350,000.00 additional dollars for obesity-related medical problems, and lost productivity.

Obesity is a progressively increasing health problem, spreading in epidemic proportions all across the western world. Obesity is defined as a body mass index (BMI) of more than 30%. In the 1980s, about 20% of Americans were obese, and unfortunately, by the beginning of the new millenium, the number is now 40%.

Obesity is a major risk factor for the development of hypertension, diabetes, high triglycerides, high low-density lipid levels, and low high-density lipid levels, thereby increasing the risk of CAD. The impact of obesity on cardiac risk factors in men and women are shown in the table below. In addition, several varieties of cancers, musculoskeletal disorders, and respiratory dysfunction have been well documented.

As the BMI increases above 30%, there is an exponential increase in hypertension and diabetes mellitus in both groups. The LDL cholesterol rapidly accumulates, and the good cholesterol level goes down further.

A high fat and high sugar diet predisposes a person to obesity and insulin resistance. Such diets also produce resistance to a body hormone called leptin, which is supposed to make your body slim.

Living in America, with all of its fast food luxuries, can also be considered a risk factor. For example, Japanese people living in Japan are distinctly different from the Japanese living in San Francisco, California, in terms of their body fat and cardiac risk factor profile, as shown below.

The Japanese people living in San Francisco are 11 kg heavier than their counterparts in Japan, and bear the risk of high cholesterol, and three times the incidence of heart disease.

Weight reduction in an obese patient is probably the most challenging task, as it reflects and affects the personality and the dietary culture and lifestyle of the patient. For dieting to be effective, the person must change his/her lifestyle, and must be willing to do purposeful aerobic exercise. Moreover, there is a need for ongoing personal contact and reinforcement with a program supervisor. Support groups, such as Weight Watchers, are exceptionally useful.

Ever since the Phen-Fen era, physicians have great reluctance towards prescribing weight-reducing agents. I personally encourage people to consider pharmacological intervention in selected high-risk populations, as the benefits of these drugs often outweigh the side effects.

Obesity and Smoking Obesity and smoking with its related medical expenses and lost wages alone will cost us 250 billion dollars every year.

Recently I had an obese patient who came to me requesting a letter to the airlines that she will require a wide or double seat based on her medical condition, etc. Again, recently in my consulting office, a chair just split into two pieces, as a 380-pound patient sat on it for a summary discussion of the consultation. Fortunately, nothing happened to the patient. However, I am replacing those chairs with more sturdy ones.

I was unable to perform angiograms on two patients weighing more than 400 pounds within the last six months. The cardiac catheterization tables cannot handle more than 350 pounds, as it is a suspended table with one end connected to a central weight-bearing pole. Even 350 pounds is a strain to the machine, as we see the table bend, and the tail end bows down by several inches.

When it comes to invasive procedures, obese patients bear a higher risk than others. Venous and arterial access, at times, is difficult requiring multiple sticks; vascular complications are high; and deep groin bleeding is difficult to detect until late.

Obtaining an accurate blood pressure even with wider blood pressure cuffs is difficult, particularly at times of crisis. Even CPR may be ineffective in morbidly obese individuals, as the compression pressure is difficult to be translated into the thoracic cavity. Intubating a short-necked obese patient is highly challenging, even for an experienced person, and has been unsuccessful at times. Imaging these patients are challenging despite recent advances in imaging technology. Surgery-related wound infections, lung infections, deep vein thrombosis, etc., are much higher in obese subjects.

If the present trend of rapidly increasing incidence of obesity continues, it is my feeling that this disease entity alone will consume more of our resources and health care dollars than diabetes, let alone the impact of lost wages and productivity.

Consider the following in fighting Obesity A change in lifestyle is a must. Join a support group. (e.g., Weight Watcher, etc.) Strictly avoid high fat, high sugar diets. Engage in aerobic exercise. Consider taking weight-reducing agents. Gain a liking for fruits, vegetables, grains, and water. Consider these changes and sacrifices as an investment in your future.