Skip to main content Accessibility help
Hostname: page-component-84b7d79bbc-g5fl4 Total loading time: 0 Render date: 2024-07-25T15:23:46.822Z Has data issue: false hasContentIssue false

38 - Obesity

Published online by Cambridge University Press:  12 January 2010

John G. Kral
SUNY Downstate Medical Center, Brooklyn, New York
Michael F. Lubin
Emory University, Atlanta
Robert B. Smith
Emory University, Atlanta
Thomas F. Dodson
Emory University, Atlanta
Nathan O. Spell
Emory University, Atlanta
H. Kenneth Walker
Emory University, Atlanta
Get access



The increasing prevalence of obesity among adults and children, new insights into the pathogenesis of obesity, and significant changes in the practice of surgery through adoption of less traumatic laparoscopic approaches, all justify up-dating this chapter from the third edition (published in 1995, containing references through 1993).


The age-adjusted prevalence of obesity was 30.5% in 2000 according to a national examination survey, while the prevalence of overweight was 64.5%. The largest telephone survey in the USA reported a prevalence of 20.9% for obesity in 2000 giving an indication of the validity of telephone surveys related to this topic. Regardless of their relative validity, all studies unequivocally document disturbingly rapid yearly increases (P < 0.001) in obesity and overweight and their related serious diseases: diabetes, hypertension, dyslipidemia, asthma, etc. Class 3 obesity (BMI ≥ 40) tripled from 1990 to 2000, reaching a prevalence of 6% among black women, causing the authors of the study to conclude: “the incidence of various diseases will increase substantially in the future.” Increasing prevalences of childhood and adolescent overweight and obesity are especially troubling: adolescent overweight is a strong predictor of adult illness.

Two large epidemiological studies published in January 2003 comprising 3457 subjects (The Framingham Heart Study) and 23 659 subjects confirmed that obesity and overweight in adulthood markedly decrease life expectancy. Fontaine et al. determined that younger adults generally had greater number of years lost than did older adults and Peeters et al. found the decreases in life expectancy to be comparable to those seen with smoking.

Medical Management of the Surgical Patient
A Textbook of Perioperative Medicine
, pp. 465 - 478
Publisher: Cambridge University Press
Print publication year: 2006

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Flegal, K. M., Carroll, M. D., Ogden, C. al. Prevalence and trends in obesity among US adults, 1999–2000. J. Am. Med. Assoc. 2002; 288: 1723–1727.CrossRefGoogle ScholarPubMed
Mokdad, A. H., Ford, E. S., Bowman, B. al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. J. Am. Med. Assoc. 2003; 289: 76–79.CrossRefGoogle ScholarPubMed
Freedman, D. S., Khan, L. K., Serdula, M. al. Trends and correlates of class 3 obesity in the United States from 1990 through 2000. J. Am. Med. Assoc. 2002; 288: 1758–1761.CrossRefGoogle ScholarPubMed
Must, A., Jacques, P. F., Dallal, G. al. Long-term morbidity and mortality of overweight adolescents: a follow-up of the Harvard Growth Study of 1922 to 1935. N. Engl. J. Med. 1992; 327: 1350–1355.CrossRefGoogle ScholarPubMed
Peeters, A., Barendregt, J. J., Willekens, al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann. Intern. Med. 2003; 138: 24–32.CrossRefGoogle ScholarPubMed
Fontaine, K. R., Redden, D. T., Wang, al. Years of life lost due to obesity. J. Am. Med. Assoc. 2003; 289: 187–193.CrossRefGoogle ScholarPubMed
Hansen, B. C.The metabolic syndrome X. Ann. NY Acad. Sci. 1999; 892: 1–24.Google Scholar
Sinha, R., Fisch, G., Teague, al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N. Engl. J. Med. 2002; 346: 802–810.CrossRefGoogle ScholarPubMed
Ford, E. S., Giles, W. H., & Dietz, W. H. Jr.Prevalence of the metabolic syndrome among US adults: findings from the Third National Health and Nutrition Examination Survey. J. Am. Med. Assoc. 2002; 287: 356–359.CrossRefGoogle ScholarPubMed
Lakka, H.-M., Laaksonen, D. E., Lakka, T. al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. J. Am. Med. Assoc. 2002; 288: 2709–2716.CrossRefGoogle ScholarPubMed
Calle, E. E., Rodriguez, C., Walker-Thurmond, K., & Thun, M. J.Overweight, obesity and mortality from cancer in a prospectively studied cohort of US adults. N. Engl. J. Med. 2003; 348: 1625–1638.CrossRefGoogle Scholar
Zhang, Y., Proenca, P., Maffei, al. Positional cloning of the mouse obese gene and its human homologue. Nature 1994; 372: 425–432.CrossRefGoogle ScholarPubMed
Gupta, A. & Watson, D. I.Effect of laparoscopy on immune function. Br. J. Surg. 2001; 88: 1296–1306.CrossRefGoogle ScholarPubMed
Nguyen, N. T., Ho, H. S., Palmer, L. al. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J. Am. Coll. Surg. 2002; 191: 149–155.CrossRefGoogle Scholar
Kral, J. G.Morbidity of severe obesity. In Sugerman, H. J., ed. Obesity Surgery. Surg. Clin. North Am. 2001; 81:1039–1061.CrossRefGoogle ScholarPubMed
Law, C. M., Barker, D. J. P., Osmond, al. Early growth and abdominal fatness in adult life. J. Epidemiol. Commun. Health 1992; 46: 184–186.CrossRefGoogle ScholarPubMed
Shen, W., Wang, Z., Punyanita, al. Adipose tissue quantification by imaging methods: a proposed classification system. Obes. Res. 2003; 13: 15–16.Google Scholar
Sjöström, L.A CT based multicompartment body composition technique and anthropometric predictions of lean body mass, total and subcutaneous adipose tissue. Int. J. Obes. 1991; 15(Suppl. 2): 19–30.Google Scholar
Folsom, A. R., Kushi, L. H., Anderson, K. al. Associations of general and abdominal obesity with multiple health outcomes in older women: the Iowa Women's Health Study. Arch. Intern. Med. 2000; 160: 2117–2128.CrossRefGoogle ScholarPubMed
Cornier, M.-A., Tate, C. W., Grunwald, G. al. Relationship between waist circumference, body mass index and medical care costs. Obes. Res. 2002; 10: 1167–1172.CrossRefGoogle ScholarPubMed
Alexander, J. K.Obesity and cardiac performance. Am. J. Cardiol. 1964; 14: 860–865.CrossRefGoogle ScholarPubMed
Agarwal, N., Shibutani, K., San Fillipo, al. Hemodynamic and respiratory changes in surgery of the morbidly obese. Surgery 1982; 92: 226–234.Google Scholar
Zarich, S. W., Kowalchuk, G. J., McGuire, M. al. Left ventricular filing abnormalities in asymptomatic morbid obesity. Am. J. Cardiol. 1991; 68: 377–381.CrossRefGoogle Scholar
Tang, S., Kral, J. G., Barnard, J. al. Android fat distribution predicts ventricular dysfunction in obese women. Eur. J. Clin. Invest. 1988; 18: A10.Google Scholar
Alpert, M. A., Terry, B. E., Cohen, M. al. The electrocardiogram in morbid obesity. Am. J. Cardiol. 2000; 85: 908–910.CrossRefGoogle ScholarPubMed
Alpert, M. A., Terry, B. E., Hamm, C. al. Effect of weight loss on the ECG of normotensive morbidly obese patients. Chest 2001; 119: 507–510.CrossRefGoogle ScholarPubMed
Iacobellis, G., Ribando, M. C., Zappaterreno, al. Relationship of insulin sensitivity and left ventricular mass in uncomplicated obesity. Obes. Res. 2003; 11: 518–524.CrossRefGoogle ScholarPubMed
Biring, M. S., Lewis, M. I., Liu, J. al. Pulmonary physiological changes of morbid obesity. Am. J. Med. Sci. 1999; 318: 293–297.CrossRefGoogle Scholar
Alexander, K. L., Amad, K. H., & Cole, V. W.Observations on some clinical features of extreme obesity with particular reference to the cardiorespiratory effects. Am. J. Med. 1962; 32: 512–524.CrossRefGoogle Scholar
Wei, M., Kampert, J. B., Barlow, C. al. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight and obese men. J. Am. Med. Assoc. 1999; 282: 1547–1553.CrossRefGoogle ScholarPubMed
Brooks-Brunn, J. A.Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997; 1111: 564–571.CrossRefGoogle Scholar
Pelosi, P., Croci, M., Ravagnan, al. The effects of body mass on lung volumes, respiratory mechanics and gas exchange during general anesthesia. Anesth. Analg. 1998; 87: 654–660.Google ScholarPubMed
Sugerman, H. J., Baron, P. L., Fairman, R. al. Hemodynamic dysfunction in obesity hypoventilation syndrome and the effects of treatment with surgically induced weight loss. Ann. Surg. 1988; 207: 604–613.CrossRefGoogle ScholarPubMed
Sugerman, H. J., Windsor, A., Bessos, al. Intraabdominal pressure, sagittal abdominal diameter and obesity comorbidity. J. Intern. Med. 1997; 241: 71–79.CrossRefGoogle ScholarPubMed
Sugerman, H. J.Effects of increased intra-abdominal pressure in severe obesity. Surg. Clin. North Am. 2001; 81: 1063–1075.CrossRefGoogle ScholarPubMed
Sugerman, H.Pulmonary function in morbid obesity. Gastroenterol. Clin. North Am. 1987; 16: 225–237.Google ScholarPubMed
Balsiger, B. M., Murr, M. M., Mai, al. Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass. J. Gastrointest. Surg. 2000; 4: 276–281.CrossRefGoogle ScholarPubMed
Mercer, C. D., Rue, C., Hanelin, al. Effect of obesity on esophageal transit. Am. J. Surg. 1985; 149: 177–181.CrossRefGoogle ScholarPubMed
Camargo, C. A. Jr.Weiss, S. T., Shang, al. Prospective study of body mass index, weight change, and risk of adult-onset asthma in women. Arch. Int. Med. 1999; 159: 2582–2588.CrossRefGoogle ScholarPubMed
Dejgard, A., Andersen, T., & Gluud, C.The influence of insulin on the raised plasma fibronectin concentration in human obesity. Acta Med. Scand. 1986; 220: 269–272.CrossRefGoogle ScholarPubMed
Rillaerts, E., Gaal, L., Xiang, D. al. Blood viscosity in human obesity: relation to glucose tolerance and insulin status. Int. J. Obes. 1989; 13: 739–745.Google ScholarPubMed
Gabriely, I., Yang, X. M., Cases, J. al. Hyperglycemia induces PAI-1 gene expression in adipose tissue by activation of the hexosamine biosynthetic pathway. Atherosclerosis 2002; 160: 115–122.CrossRefGoogle ScholarPubMed
Marceau, P., Biron, S., Hould, F. al. Liver pathology and the metabolic “syndrome X” in severe obesity. J. Clin. Endocrinol. Metab. 1999; 84: 1513–1517.CrossRefGoogle Scholar
Hansson, P. O., Eriksson, H., Welin, al. Smoking and abdominal obesity: risk factors for venous thromboembolism among middle-aged men: “the study of men born in 1913”. Arch. Intern. Med. 1990; 159: 1886–1890.CrossRefGoogle Scholar
Reaven, G. M.Syndrome X: six years later. J. Int. Med. 1994; 236(Suppl. 736): 13–22.Google Scholar
Alessi, M. C., Peiretti, F., Morange, al. Production of plasminogen activator inhibitor by human adipose tissue. Diabetes 1997; 46: 860–867.CrossRefGoogle ScholarPubMed
Juhan-Vague, I., Thompson, S. G., & Jespersen, J.Involvement of the hemostatic system in the insulin resistance syndrome: a study of 1500 patients with angina pectoris. Arterioscler. Thromb. 1993; 13: 1865–1873.CrossRefGoogle ScholarPubMed
Prandoni, P., Bilora, F., Marchiori, al. An association between atherosclerosis and venous thrombosis. N. Engl. J. Med. 2003; 348: 1435–1441.CrossRefGoogle ScholarPubMed
Cohen, A. H.Massive obesity and the kidney. Am. J. Pathol. 1975; 81: 117–130.Google ScholarPubMed
Carr, S., Mbanya, J. C., Thomas, al. Increase in glomerular filtration rate in patients with insulin-dependent diabetes and elevated erythrocyte sodium–lithium countertransport. N. Engl. J. Med. 1990; 322: 500–505.CrossRefGoogle ScholarPubMed
Schmeider, R. E., Messerli, F. H., Garavaglia, al. Glomerular hyperfiltration indicates early target organ damage in essential hypertension. J. Am. Med. Assoc. 1990; 264: 2775–2780.CrossRefGoogle Scholar
Gill, I. S., Hodge, E. E., Steinmuller, D. al. The impact of obesity on renal transplantation. Transplant Proc. 1992; 25: 1047.Google Scholar
Howard, R. J., Thai, V. B., Patton, P. al. Obesity does not portend a bad outcome for kidney transplant recipients. Transplantation 2002; 73: 53–55.CrossRefGoogle Scholar
Waki, M., Kral, J. G., Mazariegos, al. Relative expansion of extracellular fluid in obese versus non-obese women. Am. J. Physiol. 1991; 26: E199–E203.Google Scholar
Mazariegos, M., Kral, J. G., Wang, al. Body composition and surgical treatment of obesity: effects of weight loss on fluid distribution. Ann. Surg. 1992; 216: 69–73.CrossRefGoogle ScholarPubMed
Raison, J., Achimastos, A., Asmar, al. Extracellular and interstitial fluid volume in obesity with and without associated systemic hypertension. Am. J. Cardiol. 1986; 57: 2223–2226.CrossRefGoogle ScholarPubMed
Shenkman, Z., Shir, Y., & Brodsky, J. B.Perioperative management of the obese patient. Br. J. Anaesth. 1993; 70: 349–359.CrossRefGoogle ScholarPubMed
Fronzo, R. A., Cooke, R. E., & Andres, R.The effects of insulin and renal handling of sodium, potassium, calcium, and phosphate in man. J. Clin. Invest. 1975; 55: 845–855.CrossRefGoogle Scholar
Colt, E. W. D., Wang, J., Stallone, al. A possible low intracellular potassium in obesity. Am. J. Clin. Nutr. 1981; 34: 367–372.CrossRefGoogle ScholarPubMed
Kral, J. G., Lundholm, K., Sjöström, al. Hepatic lipid metabolism in severe human obesity. Metabolism 1977; 26: 1025–1031.CrossRefGoogle ScholarPubMed
Benoist, S., Panis, Y., Alves, al. Impact of obesity on surgical outcomes after colorectal resection. Am. J. Surg. 2000; 179: 275–281.CrossRefGoogle ScholarPubMed
Weber, D. J., Rutala, W. A., Samsa, G. al. Impaired immunogenicity of hepatitis B vaccine in obese persons. (Letter) N. Engl. J. Med. 1986; 314: 1393.Google ScholarPubMed
Friedman, J. B.Obesity in the new millennium. Nature 2000; 404: 632–634.CrossRefGoogle ScholarPubMed
Smith, A. I. & Funder, J. W.Proopiomelanocortin processing in the pituitary, central nervous system, and peripheral tissues. Endocr. Rev. 1988; 9: 159–179.CrossRefGoogle ScholarPubMed
Hotamisligil, G. S., Arner, P., Caro, J. al. Increased adipose tissue expression of tumor necrosis factor-α in human obesity and insulin resistance. J. Clin. Invest. 1995; 95: 2409–2415.CrossRefGoogle ScholarPubMed
Krishnan, E. C., Trost, L., Aarons, al. Study of function and maturation of monocytes in morbidly obese individuals. J. Surg. Res. 1982; 33: 89–97.CrossRefGoogle ScholarPubMed
Kolterman, O. G., Olefsky, J. M., Kurakara, al. A defect in cell-mediated immune function in insulin-resistant diabetic and obese subjects. J. Lab. Clin. Med. 1980; 96: 535–543.Google ScholarPubMed
Felber, J.-P. & Golay, A.Pathways from obesity to diabetes. Int. J. Obes. 2002; 26(Suppl. 2): S39–S45.CrossRefGoogle ScholarPubMed
Wang, Y.-X., Lee, C.-H., Tiep, al. Peroxisome-proliferator-activated receptor δ activates fat metabolism to prevent obesity. Cell 2003; 113: 159–170.CrossRefGoogle ScholarPubMed
Kral, J. G., Buckley, M. C.Kissileff, H. R., & Schaffner, F.Metabolic correlates of eating behavior in severe obesity. Int. J. Obes. 2001; 25: 258–264.CrossRefGoogle ScholarPubMed
Neel, J. V.Diabetes mellitus: a thrifty genotype rendered detrimental by progress? Am. J. Hum. Genet. 1962; 14: 353–362.Google ScholarPubMed
Branson, R., Potoczna, N., Kral, J. G., Lentes, K. U., Hoehe, M. R., & Horber, F. F.Binge eating is a major phenotypic characteristic of melanocortin-4 receptor gene mutations. N. Engl. J. Med. 2003; 348: 1096–1103.CrossRefGoogle ScholarPubMed
Farooqui, I. S., Keogh, J. M., Yeo, G. S. al. Clinical spectrum of obesity and mutations in the melanocortin 4 receptor gene. N. Engl. J. Med. 2003; 348: 1085–1095.CrossRefGoogle Scholar
Hamilton, B. S. & Doods, H. N.Chronic application of MT II in a rat model of obesity results in sustained weight loss. Obes. Res. 2002; 10: 182–187.CrossRefGoogle Scholar
Kral, J. G. Side-effects, complications and problems in anti-obesity surgery: introduction of the obesity severity index. In Angel, A., Anderson, H., Bouchard, C., Lau, D., Leiter, L., & Mendelson, R., eds. Progress in Obesity Research: 7. London: John Libbey, 1996: 655–661.Google Scholar
Drenick, E. J. & Fisler, J. S.Sudden cardiac arrest in morbidly obese surgical patients unexplained after autopsy. Am. J. Surg. 1988; 155: 720–726.CrossRefGoogle ScholarPubMed
Isner, J. M., Sours, H. E., Paris, A. al. Sudden unexpected death in avid dieters using the liquid-protein modified-fast diet: observations in 17 patients and the role of the prolonged Q–T interval. Circulation 1979; 60: 1401–1412.CrossRefGoogle Scholar
Drenick, E. J., Blumfield, D. E., Fisler, J. S., & Lowy, S. Cardiac function during very low calorie reducing diets with dietary protein of good and poor nutritional quality. In Blackburn, G. L. & Bray, G. A., eds. Management of Obesity by Severe Caloric Restriction. Littleton, MA: PSG Publishing, 1985: 223–234.Google Scholar
Messerli, H., Ventura, H. O., Elizardi, D. al. Hypertension and sudden death: increased ventricular ectopic activity in left ventricular hypertrophy. Am. J. Med. 1984; 77: 18–22.CrossRefGoogle ScholarPubMed
Spirito, P., Bellone, P., Harris, K. al. Magnitude of left ventricular hypertrophy and risk of sudden death in hypertrophic cardiomyopathy. N. Engl. J. Med. 2000; 342: 1778–1785.CrossRefGoogle ScholarPubMed
Messerli, F. H., Nunez, B. D., Ventura, H. al. Overweight and sudden death: increased ventricular ectopy in cardiopathy of obesity. Arch. Intern. Med. 1987; 147: 1725–1728.CrossRefGoogle ScholarPubMed
Ernst, E., Hammerschmidt, D. E., Bagge, al. Leukocytes and the risk of ischemic diseases. J. Am. Med. Assoc. 1987; 257: 2318–2324.CrossRefGoogle ScholarPubMed
Palmer, M. & Schaffner, F.Effect of weight reduction on hepatic abnormalities in overweight patients. Gastroenterology 1990; 99: 1408–1413.CrossRefGoogle ScholarPubMed
Vaughan, R. W. Biochemical and biotransformation alterations in the obese. In Brown, B. R. Jr., ed. Anesthesia and the Obese Patient. Philadelphia: FA Davis Co, 1982: 55.Google Scholar
Terry, B. E.Morbid obesity: cardiac evaluation and function. Gastroenterol. Clin. North Am. 1987; 16: 215–223.Google ScholarPubMed
Criqui, M. H., Heiss, G., Gohn, al. Plasma triglyceride level and mortality from coronary heart disease. N. Engl. J. Med. 1993; 328: 1220–1225.CrossRefGoogle ScholarPubMed
Kral, J. G., Brolin, R. E., Buchwald, al. Workshop summary: research considerations in obesity surgery. Obes. Res. 2002; 10: 63–64.CrossRefGoogle Scholar
Sugerman, H. J., ed. Obesity surgery. Surg. Clin. North Am. 2001; 81(5): 1001–1198.Google Scholar
Rennotte, M. T., Baele, P., Aubert, al. Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery. Chest 1994; 102: 367–364.Google Scholar
Bern, M. M., Bothe, A. Jr., Bistrian, al. Effects of low-dose warfarin on antithrombin III levels in morbidly obese patients. Surgery 1983; 94: 78–83.Google ScholarPubMed
Janvrin, S. B., Davies, G., & Greenhalgh, R. M.Postoperative deep vein thrombosis caused by intravenous fluids during surgery. Br. J. Surg. 1980; 67: 680–693.CrossRefGoogle ScholarPubMed
Vaughan, R. W. Anesthesia and morbid obesity. In Björntorp, B. & Brodoff, J. B., eds. Obesity. Philadelphia: JB Lippincott Co, 1992; 720–730.Google ScholarPubMed
Brown, B. R. Jr., ed. Anesthesia and the Obese Patient. Philadelphia: FA Davis, 1982.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats