Written by Steven A. Kaplan, MD
Obesity is the national health crisis of our generation. It affects men and women of all ages, economic groups, races and ethnicities. Most recently, it has been noted that the incidence of obesity and related disorders commonly referred to as the metabolic syndrome, that is, dyslipidemia, hypertension and diabetes, is rising as well. Rates of adult obesity increased in six US states and fell in none last year, and in more states than ever—20—at least 30 per cent of adults are obese. The 2013 adult obesity rate exceeds 20 per cent in every state, while 42 have rates above 25 per cent. Moreover, obesity also tracked demographics, with higher rates correlating with poverty, which is associated with lower availability of healthy foods and fewer safe neighborhoods where people can walk and children can play for exercise. For instance, more than 75 per cent of African Americans are overweight or obese, compared with 67.2 per cent of whites.(1) The ethnic disparities are alarming. For African Americans the obesity rates are at or above 40 percent in 11 states, 35 percent in 29 states and 30 percent in 41 states. In Latinos, adult obesity among Latinos exceeded 35 percent in five states and 30 percent in 23 states, and finally among Caucasians adult obesity rates topped 30 percent in 10 states. Nine out of the 10 states with the highest obesity rates are in the South. Finally Baby Boomers (45-to 64-year-olds)* have the highest obesity rates of any age group—topping 35 percent in 17 states and 30 percent in 41 states.(1)
Urologists have become increasingly aware of the role that metabolic dysfunction and central obesity have on pelvic health. For example, in hypercholesterolemic US men participating in a lipid treatment study there was an inverse relationship between total serum testosterone and the occurrence of marked elevations of a low-density lipoprotein(LDL)-like particle, lipoprotein(a). (2). In another study, our group reported that waist circumference and central obesity were associated with higher rates of metabolic syndrome as well as voiding dysfunction.(3) Kupellian et al reported the significant association between LUTS and chronic illnesses such as heart disease, diabetes, hypertension and depression in men and women.(4) These were consistent by gender and associated with depression and various urologic symptoms. In addition, nocturia was associated with heart disease. Finally, in men a dose-response relationship was reported between symptom severity and/or duration of urinary intermittency and frequency with heart disease, and in the association of urinary urgency with diabetes.(4)
It should be noted that the date is not unanimous and some investigators have reported that metabolic syndrome with an increasing number of risk factors such as hypertension and hypertriglyceridemia had favourable effects on the likelihood of having moderate-to-severe lower urinary tract symptoms in middle-aged men with larger prostate volume.(5) It is plausible that different populations and ethnic groups may have different manifestations of metabolic dysfunction, that is, central obesity versus hypertension, etc., and this may lead to variable reports. Nevertheless, it seems that the overwhelming data sets, when taken in toto, suggest a very strong association between metabolic dysfunction and urologic symptoms in both genders.
So why does this matter? Urologists need to be cognizant of these associations and act as a facilitator to help deliver more holistic care and value to our patients. That is, when we are evaluating a man (or a woman) who has central obesity and/or components of metabolic dysfunction, the high likelihood of concomitant disorders, such as voiding and sexual dysfunction, should be front and centre in our diagnostic and therapeutic algorithms. The corollary is true as well. That is, when we are evaluating men and women with pelvic disorders, be mindful of potential underlying cardiovascular and metabolic abnormalities that they may herald.
Ultimately, the vision for urology should be to be advocates and to take a leadership position in men’s health. We should be setting the policy and research agenda, thereby increasing our visibility and ensuring that we remain at the forefront of providing specialty care for men’s health needs, not just pelvic disorders. In the future, the urologist can and should be the authority and coordinator of care for men navigating through the health care system. In an era of telemedicine, digital informatics and preventive care, we can gain a foothold with leading health care institutions and providers in delivering quality, information and trust. With this in mind, we have a unique opportunity to help improve the quality of health care delivery for men in a more efficient, comprehensive and scalable fashion.
Steven A. Kaplan, MD
E. Darracott Vaughan Jr Professor of Urology
Weill Cornell Medical College
Director, Iris Cantor Men’s Health Center
New York Presbyterian Hospital
1) The State of Obesity: Better Policies for a Healthier America 2014. Trust for America’s Health and the Robert Wood Johnson Foundation. https://stateofobesity.org
2) Kaplan SA, Lin J, Johnson-Levonas AO, Shah AK, Meehan AG: Increased occurrence of marked elevations of lipoprotein (a) in aging, hypercholesterolemic men with low testosterone. Aging Male 13(1): 40-43, 2010.
3) Lee R, Chung D, Chugthai B, Te AE, Kaplan SA: Central obesity as measured by waist circumference is predictive of severity of lower urinary tract symptoms. BJUI 110(4): 540-545, 2012.
4) Kupelian V, McVary KT, Kaplan SA, Hall SA, Link CL, Padmanabhan Aiyer L, Mollon P, Tamimi N, Rosen RC, McKinlay JB: Association of lower urinary tract symptoms and the metabolic syndrome: results from the Boston Area Community Health Survey. J Urol 182(2): 616-625, 2009.
5) Kim JH, Doo SW, Yun JH, Yang WJ: Lower likelihood of having moderate to severe lower urinary tract symptoms in middle-aged healthy Korean men with metabolic syndrome. Urology 84 (3): 665-669, 2014.
*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
+Guam and Puerto Rico were the only US territories with obesity data available on the 2013 BR