





































Clinical Medicine Insights
Received 25 Dec 2020 | Revised 20 Jan 2021 | Accepted 24 Feb 2021 | Published Online 30 Mar 2021

DOI: https://doi.org/10.52845/CMI/2021-2-1-3 
CMI JOURNAL 2 (1), 64−79 (2021)

ISSN (O) 2694-4626 

REVIEW ARTICLE

Obesity and Non-Communicable Diseases: Part  I Cardiovascular Diseases, 
Respiratory Diseases, Depression, Liver Diseases

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902,USA

Abstract
Obesity has become a pandemic. Obesity is associated with a wide
array of physical and emotional health ailments. It is associated with
a reduced quality of life. Comorbid disorders often result in premature
mortality. Although BMI is the widely used standard for defining
overweight and obesity, abdominal or visceral obesity has a more
significant association with several noncommunicable diseases.Weight
loss is beneficial in halting the deleterious effects of excess body
weight. Part I of thismanuscript, discusses the harmful effects of obesity
on cardiovascular diseases, respiratory diseases, depression, and liver
diseases.
Keywords: obesity, non-communicable diseases, cardiovascular dis-
eases, respiratory diseases, obesity, depression, liver diseases

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

Obesity is growing exponentially all over the
world1. Obesity is recognized and classi-
fied according to a person’s body mass

index (BMI)2. BMI is a person’s weight [kilo-
grams] divided by the square of his or her height
[meters])2. According to theWorld Health Organiza-
tion (WHO), a BMI between 20 and 25 kg/m2 is nor-
mal, a BMI between 25 and 30 kg/m2 is considered
overweight, while a BMI of >30 kg/m2 represents
obesity3. These numbers are different for the Asian
population (Asian people have a high risk of type

2 diabetes and CVD at a lower BMI) 3. Obesity is
further divided into 3 classes (class 1, BMI > 30
and < 35; class 2, BMI > 35 and < 40; class 3,
BMI > 40)4. In the USA in 2017-2018, 42.2% of all
adults were obese5. Europe has the second highest
proportion of overweight or obese people, with obe-
sity rates of over 30% in most countries6. Several
low- and middle-income countries, like China, India,
and Brazil, have also seen a major rise in the preva-
lence of obesity7−9. It has also been increasing at an
alarming rate in African countries10. TheGlobal Bur-
den of Disease Group reported in 2017 that “since
1980, the prevalence of obesity has doubled in more

CMI JOURNAL 2 (1), 64−79 MEERP LTD 64

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than 70 countries and has continuously increased
in most other countries”11. Excessive weight gain
is not limited to adults, it also affects children and
adolescents12. This puts them at a higher risk to de-
velopmajor noncommunicable diseases like diabetes
and cardiovascular diseases at a younger age13. It is
estimated that obesity will affect 1.12 billion people
by 203014.
BMI is unable to specify the type of collection of
fat – subcutaneous adiposity or visceral adiposity15.
The latter represents central obesity or abdominal
obesity15. Abdominal fat is metabolically active16,
unlike subcutaneous fat – it induces inflammation17,
insulin resistance18, and a procoagulant state19, re-
sulting in a high risk of several chronic diseases.
Subcutaneous fat, on the other hand, protects the
body from lipotoxicity15,20. Several anthropometric
measurements are now routinely done to objectively
diagnose central obesity21,22. These include the waist
circumference (WC), waist hip ratio (WHR), and the
weight height ratio (WHtR)21,22. WC is measured
to the nearest 0.1 cm at the umbilical level while
standing23. It should ideally be <102 cm inmales and
<88 cm in females23. TheWHR is normal if it is 0.85
or less in women and 0.9 or less in men24. TheWHtR
is calculated by dividing theWC by height (< 0.5 (no
central obesity) and > 0.5 (central obesity)25.
Besides the nine chronic diseases discussed in this
two-part manuscript, obesity is also implicated in
several other disorders, including gastroesophageal
reflux disease26, pancreatitis27, osteoporosis28,
infertility29,30, and can increase complications
related to pregnancy31. It may lead to psycho-
social distress and obese people may have low
self-esteem and feelings of rejection32. They often
have heightened anxiety, body image dissatisfaction,
and may face weight bias and sigma33,34. Stigma

Supplementary information The online version
of this article (10.52845/CMI/2021-2-3-5) contains
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902,USA
Email: usacardiologist@gmail.com

may also be exhibited by health care providers35.
Obesity may also lead to disqualification from
the US military36. It reduces the health quality of
life37. It is associated with an increase in disability
and mortality38,39. Most of the deaths attributable
to obesity occur due to cardiovascular diseases40.
According to the GBD 2015 Obesity Collaborators,
obesity accounted for about four million deaths
worldwide41. It is amajor cause of preventable death,
second only after smoking42. Obesity care is also
expensive43. In the US alone, obesity related health
care is over $150 billion yearly44.
The obesity paradox is a phenomenon where obe-
sity is associated with increased survival, especially
in hospitalized patients45. It has been observed in
chronic diseases such as heart failure46, coronary
artery disease47, and end-stage kidney disease48. It
has also been observed in acute conditions such as
pneumonia49, sepsis50, acute respiratory distress syn-
drome (ARDS)51, and other critical illness52. Sev-
eral hypotheses have been advanced to explain this
phenomenon53−57.
The health effects of obesity on common chronic
medical conditions are discussed in this two-part
manuscript. Part I discusses the relationship between
obesity and cardiovascular diseases (CVD), chronic
obstructive pulmonary disease (COPD), depression,
and liver diseases. Part II discusses its impact on can-
cer, diabetes mellitus, kidney diseases, Alzheimer’s
disease, and arthritis.

2 DISCUSSION

The Centers for Disease Control and Prevention
(CDC) defines chronic diseases as “conditions that
last 1 year or more and require ongoing medical
attention or limit activities of daily living or both”58.
Most chronic diseases are noncommunicable dis-
eases (NCDs) and are gradually replacing infectious
diseases as the major health burden in developing
countries59. Out of the 17 million premature deaths
(under the age of 70) due to noncommunicable dis-
eases in 2015, 82% were in low- and middle-income
countries59.
The NCDs discussed in this part include cardiovas-
cular diseases (such as hypertension (HTN), coro-

MEERP LTD CMI JOURNAL 2 (1), 64−79 (2021) 65

mailto:usacardiologist@gmail.com


OBESITY AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
RESPIRATORY DISEASES, DEPRESSION, LIVER DISEASES
nary artery disease, stroke, and heart failure (HF)),
chronic respiratory diseases (such as chronic ob-
structive pulmonary disease (COPD), lung cancer,
tuberculosis, lung infections, asthma, and interstitial
lung diseases) depression, and liver diseases (such as
nonalcoholic and alcoholic hepatitis, viral hepatitis,
cirrhosis of liver). Cardiovascular diseases (CVD)
are the leading cause of morbidity worldwide60.
They are also the leading cause of global mortality
and were responsible for 17.9 million deaths in 2016
(representing 31% of all global deaths)61. Of all
the global deaths in 2015, 82% were in low- and
middle-income countries61. CVDs were responsible
for 37% of these deaths61. Men and women were
nearly equally affected59. The most common un-
derlying pathology is atherosclerosis (especially in
myocardial infarction, ischemic stroke and periph-
eral arterial disease)60. The most frequent chronic
respiratory diseases encountered include chronic ob-
structive pulmonary disease (COPD), lung cancer,
tuberculosis, lung infections, asthma, and interstitial
lung diseases (ILD). Chronic respiratory diseases
are responsible for about 7.5 million deaths per
year, and account for approximately 14% of annual
deaths worldwide63,64. COPD is the most common
cause, and is usually due to tobacco smoking65.
These patients experience airflow limitation, and
COPD can be diagnosed by the FEV1 /FVC ratio
of less than 0.7066. Asthma is a chronic inflam-
matory disorder of the airways67. Globally, one in
two hundred and fifty deaths are due to ashtma68.
The physical quality of life is impaired by bronchial
symptoms69, while social life is also impaired by
rhinitis co-morbidity70. Obstructive sleep apnea syn-
drome results from upper airway obstruction71. Pe-
riods of reduced or absent airflow through the nose
or mouth cause loud snoring and the hypoxemia
is usually terminated by arousal72. Sleep is espe-
cially disturbed in these patients73. Major depressive
disorder (MDD) is the primary cause of disability
worldwide74. It can be diagnosed by the presence of
at least five of the following symptoms occurring
independently of physical illness, normal bereave-
ment, alcohol or drugs: abnormal depressed mood;
abnormal loss of interest and pleasure; appetite or
weight disturbance; sleep disturbance; disturbance
in activity (agitation or slowing); abnormal fatigue

or loss of energy; abnormal self-reproach or inap-
propriate guilt; poor concentration or indecisiveness;
and morbid thoughts of death or suicide75. The five
diagnostic symptoms, which should include abnor-
mal depressed mood or loss of interest and pleasure,
are present nearly every day for at least two weeks
after the diagnosis75. TheWorldHealth Organization
predicts that depression will generate the greatest
global burden by 203076. Liver diseases affect more
than 10% of the world population77. The leading
liver disease globally (40% of all liver diseases)
is nonalcoholic fatty liver disease (NAFLD). Other
common liver diseases are Hepatitis B virus (HBV)
(30%), Hepatitis C virus (HCV) (15%) and excessive
consumption (11%)77. These patients may progress
to cirrhosis of the liver or develop liver cancer78.

2.1 CARDIOVASCULAR DISEASES

Obesity has a strong detrimental relationship with
CVDs79,80. An increased CVD risk of 6% for each
1.1 kg/m2 increase in BMI was noted by Ember-
son et al. among 6452 British men81. Weight loss,
on the other hand, reduces CVDs82. In the Look
AHEAD trial, with amedian follow-up of 10.2 years,
weight loss decreased CVD outcomes82. A 10%
body weight reduction in the first year of the study
resulted in a 21% lower risk of the primary CVD out-
come and a 24% reduced risk of the secondary out-
come compared with individuals who were weight
stable or gained weight82.
Obesity has been associated with an in-
creased risk of HTN83, coronary artery
disease84,stroke85,86, HF87,cardiac arrhythmias88,
and sudden cardiac death (SCD)89. It is estimated
that obesity may result in a 3.5-fold increase in the
likelihood of being hypertensive, and obesity may
be responsible for about 70% of HTN in adults90,91.
An increase in weight by 5% appears to increase
the incidence of hypertension by 20–30%92. On
the other hand, weight loss is effective in lowering
blood pressure (BP)93. Studies indicated that a 10 Kg
weight loss would result in a 6 mmHg in BP94. Obese
patients are twice as likely to have coronary artery
disease and their lesions are more complex95,96.
They do not heal well after coronary artery bypass
grafting97 and have a higher mortality98. Obesity is

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SHASHI K. AGARWAL, MD

an independent risk factor for heart failure (HF)99.
In the Framingham Heart Study of 5881 patients,an
increase in BMI of 1 kg/m2 increased the risk of
heart failure by 5% in men and 7% in women100.
They also do not do well after a left ventricular
assist device implantation101 or heart transplant
surgery102. Bariatric surgery induced weight
loss in HF patients resulting in a significant
reduction in their New York Heart Association
classification103. Ischemic stroke risks are also
increased in obese patients104. In the Physicians’
Health Study, men with BMI >30 kg/m2 had a >2-
fold increase in risk for stroke105. In a prospective
study of >39,000 healthy women, those with BMI
>35 kg/m2 had a 3-fold increase in the risk of
ischemic stroke compared with women with BMI
<20 kg/m2106. It is estimated that for each 1-U
increase in BMI, there is an increase of 4% in the risk
of ischemic stroke107,108. Obese patients also have
a higher risk of atrial fibrillation, with the risk
being 1.52 times compared to that of the normal
weight population109. Obesity increases the risk
of SCD110. There is also a detrimental association
noted between obesity and several other CVDs,
including aortic stenosis111, peripheral artery
disease112, erectile dysfunction113, and venous
thromboembolism114. Obesity is also associated
with diabetes mellitus, dyslipidemia, and sleep
apnea syndrome – disorders that further increase
the risk of cardiovascular disorders115.
Obesity results in several pathophysiological
mechanisms that damage the cardiovascular sys-
tem. The adipose tissue releases proinflammatory
adipokines, elevates free radicals, causes endothe-
lial dysfunction, and activates macrophages, T
cells, and B cells within fat deposits leading to
atherosclerosis116.

2.2 RESPIRATORY DISEASES

Increased BMI results in reduced lung function, with
reductions in forced expiratory volume in 1 s (FEV1)
and forced vital capacity (FVC)117,118. Obesity is
detrimentally associated with obstructive sleep ap-
nea (OSA)119 and bronchial asthma120. Obesity pro-
motes OSA by causing enlargement of soft tissue
structures within and surrounding the airway121. An

excess of fat deposition has also been observed under
the mandible and in the tongue, soft palate, and
uvula122. Further, obesity may reduce lung volumes
by a combination of increased abdominal fat mass123
and disturbed neuroanatomic interactions124. Several
longitudinal epidemiological studies have shown
that obesity is a major risk factor for asthma in
children125,126. Obesity and weight gain during preg-
nancy in the mother are both associated with an
increased risk of asthma in the offspring127. Several
prospective studies in adults have also found a rela-
tionship between obesity and incident asthma128,129.
Obesity in adults with asthma has been associated
with reduced response to asthma medications, result-
ing in worse disease control, higher risk of hospital-
ization and lower quality of life, when compared to
lean asthma patients130,131. Weight loss intervention
by caloric restriction132 or bariatric surgery leads to
an improvement in asthma outcomes133. Abdominal
or central obesity, even with a normal BMI, appears
to be linked with an increased risk of lung cancer134.
Yu et al estimated this increased risk to be 40%
greater in these patients 135. Carreras-Torres et al,
using Mendelian randomization, recently reported
that genetically predicted BMI,WHR, and insulin re-
sistance increased the risk of lung cancer, especially
for squamous cell and small cell lung cancer136. An
obesity paradox has been noted in COPD patients,
especially those with severe disease137. Patients with
a higher BMI survive longer when compared to those
with low or normal BMI138. It has been suggested
that the severity of COPD may be overestimated in
obese patients, as when CO2 levels and muscle mass
and exercise capacity are looked at, there appears to
be no obesity paradox139.

2.3 DEPRESSION

Several studies have found that obesity and
mental health problems are linked140−142. Si-
mon et al concluded that there was an approx-
imately 25% increase in mood disorders and
anxiety in obese patients143. Obesity and depres-
sion also frequently co-exist144,145 and the pres-
ence of one not only increases the risk of the
other, but also causes significant adverse health
outcomes when they co-occur146,147. The preva-

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OBESITY AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
RESPIRATORY DISEASES, DEPRESSION, LIVER DISEASES
lence of depression in obese individuals is esti-
mated to be twice as high as in those of normal
weight148. Negative body image, and low self-
esteemare common in obese patients149. They also
face stigma in social and professional lives150,151.
These factors contribute to the development and
maintenance of depression152,153. Other patho-
physiological processesmay also play a role in this
connection154,155. Depression also increases weight
gain and obesity156−160. Depressed individuals may
be less physically active and indulge in excessive
‘comfort’ eating156−158. Certain antidepressant med-
ications can also contribute to weight gain159,160.
The relationship between obesity and depres-
sion is therefore bidirectional161. The biological
pathways include genetic influence162, HPA axis
disturbances163,164, immuno-inflammatory dys-
regulation166, and insulin abnormalities167.

2.4 LIVER DISEASES

NAFLD is prevalent in obese individuals168. Obese
individuals have a prevalence of 30% to 37% of
NAFLD169. In those who have undergone bariatric
surgery, the prevalence rises to 84% to 96%170. Li
et al. estimated that obesity produced a 3.5-fold
increased risk of developing NAFLD171 and is more
closely related to waist circumference172. Pang et
al. in a meta-analysis, concluded that for each 1
unit increase in waist circumference, the odds ratio
of NAFLD increased by 1.07, and for each 1 unit
increase in BMI, the odds ratio increased by 1.25173.
Obesity also worsens the prognosis in patients with
hepatitis174. Obese patients with alcoholic hepatitis,
are twice as likely to die in the short term, com-
pared to those who are nonobese174. Obesity is also
common in chronic HCV infected individuals175.
This increases their risk of developing serious liver
related complications and dying early176. Antiviral
treatment in these patients may sometimes result in
weight gain177.

3 CONCLUSIONS

The increasing epidemic of obesity has resulted in
a greater development, aggressive progression, and

poor outcomes for many common chronic diseases
and ailments. The evidence for the preventive and
therapeutic effects of a BMI of 25 or more on NCDs
is strong. Weight loss, including that with bariatric
surgery, helps most obesity related conditions.
Acknowledgment: None
Funding: None
Conflict of interest: None
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How to cite this article: Agarwal S.K,, MD, 
OBESITY AND NON-COMMUNICABLE 
DISEASES: PART I Cardiovascular Diseases, 
Respiratory Diseases, Depression, Liver 
Diseases. Clinical Medicine Insights. 2021;64−79. 
https://doi.org/ 10.52845/CMI/2021-2-1-3

MEERP LTD CMI JOURNAL 2 (1), 64−79 (2021) 79


	Introduction
	Discussion
	 CARDIOVASCULAR DISEASES
	RESPIRATORY DISEASES
	DEPRESSION
	LIVER DISEASES

	Conclusions



