Impact of Bariatric Surgery on Comorbidities
Section snippets
Type 2 diabetes mellitus
The prevalence of type 2 diabetes mellitus (DM) is increasing worldwide and, from an epidemiologic point of view, almost 90% of diabetes cases could be prevented by avoiding obesity.11, 12 The estimated attributable risk of excess body weight leading to development of type 2 DM is extremely high and no other modifiable factor has such an impact on the health of the general population.12 Total costs of diabetes care were estimated to be $132 billion in 2002.13 Most (67%) people with type 2 DM
Hypertension
Hypertension is one of the most common comorbidities associated with obesity. About 40% to 70% of patients undergoing BS are hypertensive.7, 54 Mechanisms proposed to explain the contribution of obesity to the development of hypertension include an altered renin-angiotensin-aldosterone system, increased intra-abdominal pressure,55 increased sympathetic nervous system activity, development of insulin resistance, hyperleptinemia, leptin resistance, altered coagulation factors, as well as
Hyperlipidemia
Hyperlipidemia is present in up to 50% of morbidly obese patients and is a major modifiable risk factor in development of atherosclerosis and CAD.71 Hyerlipidemia refers to high levels of low-density lipoprotein (LDL), triglycerides (TG), and/or total cholesterol, as well as low high-density lipoprotein (HDL). BS greatly improves secondary hypercholesterolemia and mixed forms of hyperlipidemia. There is a relationship among measures of central obesity, insulin resistance, and impaired glucose
Congestive Heart Failure
The combination of increased adipose cells and increased lean muscle mass in obese patients results in high cardiac output and an increased circulating volume. Weight loss caused by caloric restriction or surgery promotes favorable hemodynamic changes referred to as reverse remodeling. Regression of left ventricle (LV) mass and chamber size has been shown universally.81
BS in morbidly obese patients decreases the thickness of the LV wall and the overall ventricular mass,82, 83 promotes both
Obstructive sleep apnea and asthma
Obstructive sleep apnea (OSA) is a common problem among obese patients,7 with a prevalence rate as high as 77%.98 Neck circumference more than 17 inches in men and 16 inches in women is a good predictor of OSA.99 Some studies suggest that, despite availability of prediction models, the diagnosis of OSA cannot be made easily98, 100 without routine polysomnography testing for all patients considering BS.98 Chronic obstructive pulmonary disease (COPD) and other pulmonary disorders (including OSA)
Renal disorders
The pathophysiology underlying obesity-associated renal disorders includes insulin resistance, adiponectin deficiency, hyperaldosteronism, and many other pathogenetic factors.107 The abnormalities of renal structure in obese and morbidly obese individuals include increased kidney weight, glomerulomegaly, disorder of podocytes, mesangial expansion, and abnormalities of the renal interstitium. These abnormalities are accompanied by functional abnormalities like renal hyperperfusion, increased
Digestive disorders
Obese patients have up to 2.4 times more gastroesophageal symptoms compared with nonobese patients.123 They also have higher distal esophageal acid exposure124 and a higher number of gastroesophageal reflux episodes.125 Cremieux and colleagues10 found a significant decrease (39.4% before surgery vs 13.5% after BS) in medication use for gastroenterologic disorders after BS.
As expected, different BS procedures have varying effects on gastroesophageal reflux disease (GERD). A recent meta-analysis
Musculoskeletal disorders
Obesity is associated with a range of mobility problems, musculoskeletal pains, osteoarthritis and gout, all of which significantly affect quality of life.135 For every 2-unit increase (5 kg) in BMI, there is a 36% increase in the risk of developing painful joint conditions such as osteoarthritis.136 Disease of the musculoskeletal and connective system, such as arthropathies, osteoporosis, and rheumatism, decreased significantly after BS.10, 16, 63 There is also sustained improvement in
Psychological, neurologic, and sexual disorders
Psychological factors are intimately connected with morbid obesity and food may be used to satisfy certain cravings. Weight loss greatly improves depression caused by obesity.76, 139 A Greek study140 surveying 59 obese women before and after bariatric procedures found significant reductions in depression (P<.001) and sexual pain levels (P = .014) as well as significant improvements in sexual desire, arousal (P = .001), lubrication (P = .003), satisfaction (P = .012), and total sexual function (P
Cancer
In the United States, approximately 85,000 new cancer cases per year are related to obesity. Recent research has found that, when the BMI increases by 5 kg/m2, cancer mortality increases by 10%.146 The cancer-protective role of metabolic surgery is strongest for obesity-related tumors in women; however, the underlying mechanisms may involve both weight-dependent and weight-independent effects. These effects include the improvement of insulin resistance with attenuation of the metabolic syndrome
Summary
Published data show that BS not only leads to significant and sustained weight loss but also resolves or improves multiple comorbidities associated with morbid obesity. Evidence suggests that the earlier the intervention the better the resolution of comorbidities. Patients with metabolic syndrome and comorbidities associated with morbid obesity should be promptly referred for consideration for BS earlier in the disease process.
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The authors gratefully acknowledge the help of Mr Donald A. Risucci PhD in editing this manuscript.