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Overview of the Epidemiology of Obesity and the Early History of Procedures to Remedy Morbid Obesity

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Overview of the Epidemiology of Obesity and the Early History of Procedures to Remedy Morbid Obesity SPECIAL ARTICLE Overview of the Epidemiology of Obesity and the Early History of Procedures to Remedy Morbid Obesity Kenneth G. MacDonald, Jr, MD besity may be defined by weight, body mass index (BMI) (calculated by dividing weight in kilograms by height in meters squared), and percentage of body fat, although no categorization is universally accepted. The cause is multifactorial, with genetic, en- O vironmental, socioeconomic, and behavioral or psychological influences. Health conditions caused or exacerbated by overweight, while obesity is defined as a BMI obesity include hypertension, diabetes mel- of 30 or more. A BMI of 35 or more with litus (DM), sleep apnea and obesity hy- serious comorbidity, or a BMI of 40 or more, poventilation, back and joint problems, car- is considered morbid obesity. Other defi- diovascular disease, pseudotumor cerebri, nitions of morbid obesity include more than thromboembolic disease, and others. Ma- 45.2 kg (Ͼ100 lb) over the ideal body lignancies occur with increased incidence weight as defined by the 1983 Metropoli- in persons who are obese and include breast, tan Life Insurance Height and Weight tables endometrial, and colonic neoplasms. Nu- or a body weight exceeding 200% of the merous recent studies, increasingly re- ideal body weight. ported in the lay press, emphasize the in- While most obese people are over- creasing incidence of obesity in the United weight, not all overweight individuals are States, with concomitant increases in the re- obese. Included in this latter group would lated morbidity and mortality. An esti- be very muscular athletes, such as weight- mated 64.5% of American adults (Ͼ120 mil- lifters or football players, who do not have lion people) are overweight or obese, an excess body fat. Methods of calculating increase from 45% in 1960.1 The inci- body fat include underwater weighing, mea- dence of juvenile obesity has doubled in the suring total body water using isotopic di- last 20 years, affecting an estimated 15% of lution, measuring total body potassium children between 6 and 19 years old.2 Obe- level, bioelectrical impedance analysis, and sity is widely recognized as one of the pri- measurements using computed tomogra- mary national health issues and has been phy or magnetic resonance imaging. These predicted to soon surpass smoking as the techniques are not widely used in assess- leading cause of preventable mortality in the ment of obesity owing to expense, techni- United States. Health care costs associated cal difficulty, and lack of sufficient valida- with obesity are incalculable. Costs for DM tion.4 Circumference and skinfold thickness alone are estimated at $100 billion annu- measurements are more practical because ally. The incidence of DM has increased par- of simplicity; however, these measure- allel with that of obesity, from 9 million ments are more useful to determine re- adult cases in 1991 to 15 million in 2001.3 gional fat distribution rather than total body fat. Waist circumference as an indicator of DEFINITION OF OBESITY excess abdominal or visceral fat has been associated with dyslipidemia, hyperten- Obesity is strictly defined as an excessive ac- sion, and glucose intolerance.5 cumulation of body fat. The BMI has be- come the most commonly accepted mea- PREVALENCE surement. A BMI exceeding 25 is considered While estimates may vary between stud- From the Department of Surgery, Division of Gastrointestinal Surgery and Surgical ies, there is general agreement that the Endoscopy, The Brody School of Medicine at East Carolina University, Greenville, NC. prevalence of obesity has increased steadily (REPRINTED) ARCH SURG/ VOL 138, APR 2003 WWW.ARCHSURG.COM 357 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 over the last 2 to 3 decades in the United States and world- bined inheritance of obesity and DM, and even DM as a wide. The National Center for Health Statistics in 1999 cause of obesity.16 reported that 61% of adults in the United States were over- Improvement in glucose tolerance with weight loss weight (BMI Ն25) and that 26% were obese (BMI Ն30). following gastric bypass for morbid obesity has been well Prevalence rates differ with sex, age, race or ethnicity, documented in our series at East Carolina University, Green- and socioeconomic status. American women have a higher ville, NC. In a cohort of 608 morbidly obese patients,17 27% prevalence of obesity than men. African American and had DM type 2 and another 27% had impaired glucose tol- Mexican American women and men have higher rates of erance (IGT), which is a known risk factor for subsequent obesity than white women and men (Third National development of type 2 DM, as well as an independent risk Health and Nutrition Examination Survey [NHANES III], factor for cardiovascular disease.18 On long-term fol- 1988-1994).6 While the prevalence of obesity tends to low-up after Roux-en-Y gastric bypass, 82.9% of the pa- be lower in less well-developed countries, it is higher in tients with DM maintained normal levels of plasma glu- lower socioeconomic and less educated groups in the cose, glycosylated hemoglobin, and insulin. During an United States.7 average follow-up of 7.6 years after Roux-en-Y gastric by- Of great concern is the increased US prevalence of pass, 98.7% of the IGT group remained euglycemic, while childhood and adolescent obesity. Rates of obesity among 1.2% developed type 2 DM. In a previous comparison of children aged 6 to 11 years increased from 4% in the Na- the surgical IGT group with a control group of nonoper- tional Health Examination Survey for 1963-1965 to 13% ated on obese patients with IGT, there was a greater than in 1999 (NHANES-IV). There was a similar increase in 30-fold decrease in risk of developing type 2 DM in the pa- adolescents aged 12 through 19 years from 5% for 1966- tients in the surgical IGT group.19 Analysis of those pa- 1970 to 14% in 1999.8 As in adults, prevalence rates are tients in both the DM and IGT groups who did not remain highest for Hispanic and Native American children of both euglycemic revealed that 37% had inadequate weight loss sexes and for African American females. Genetic, socio- owing to failure of the surgery. The remaining nonre- economic, environmental, and dietary influences are all sponders were an average of 7.3 years older and had had implicated. The incidence of type 2 DM in adolescents their DM diagnosed for 3 years longer than the euglyce- has increased in proportion to the increase in obesity, with mic patients. The observation that the probability of re- an average BMI of 38 in patients who have newly diag- version to normal glucose metabolism with weight loss de- nosed DM in this age group.9,10 creases with age and duration of DM suggests that there is a deterioration of islet cell function over time. HEALTH EFFECTS OR COMORBIDITIES In a retrospective comparison of an obese cohort with DM who underwent Roux-en-Y gastric bypass with a The hallmark study by Drenick et al11 in 1980 clearly dem- matched group of obese control subjects with DM who onstrated excess mortality in a group of 200 morbidly did not undergo surgery for nonmedical reasons, the in- obese males followed up for a mean of 71⁄2 years. During cidence of death in the control group was 4.5 times that the course of the study, 25% of the group died. There of the surgical patients.20 Of the control group, 28% died was a 12-fold excess mortality compared with the gen- during 6.2 years of follow-up, while only 9% of the sur- eral population in the 25- to 34-year-old group and 6-fold gical group died during a longer 9-year follow-up, in- excess mortality in the 35- to 44-year-old group. Car- cluding perioperative deaths. The largest reduction was diovascular disease was the most common cause of death, in cardiovascular mortality, representing 54.5% of the con- while injuries (trauma, eg, motor vehicle, falls, indus- trol deaths vs only 14.3% of the surgical group deaths. trial injuries, and others) were surprisingly frequent. Over- weight (Ͼ110% of the ideal body weight) nonsmoking Hypertension men in the Framingham study had 30-year mortality rates as high as 3.9 times that of normal-weight men.12 Many population-based studies have documented the as- sociation of obesity with hypertension. The NHANES data Diabetes Mellitus showed that the prevalence of hypertension in over- weight adults was 2.9 times that of normal-weight adults.21 The association of obesity and type 2 DM is well known. This correlation was more pronounced in younger age The increase in prevalence of obesity over the last de- groups. There is a clear relationship among hyperten- cade has been accompanied by a 25% increase in preva- sion, insulin resistance, and hyperinsulinemia.22 Effects lence of DM,13 which increases dramatically with a BMI on tubular sodium resorption and on the renin- exceeding 25.14 Diabetes mellitus is a major cause of angiotensin-aldosterone system have been suggested as stroke, blindness, renal failure, lower extremity ampu- possible mechanisms. Hyperinsulinemia has further been tations, and ischemic cardiac disease. The mortality rate associated with hyperlipidemias and atherogenesis, termed from cardiovascular disease is substantially higher for pa- “syndrome X.”23 tients with DM than without DM.15 There is an increased risk of DM in many groups EARLY SURGICAL TREATMENT OF OBESITY that also have an increased prevalence of obesity, such as African Americans, Hispanics, Native Americans, and Jejunoileal Bypass those of low socioeconomic status.
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