Obesity in America: Is it Affecting our Urologic Health

Like many Americans, Diane Brown* struggles with her weight. "It's always been an issue for me," said the 51-year-old part-time accountant and full-time caretaker for her mother and sister, "but it's gotten much worse in recent years."

The same could be said for the country as a whole. Today, 68 percent, or more than two-thirds, of adults in the United States are either overweight or obese. The percentage of American adults who are obese has risen particularly rapidly in the past half-century. In 1960, the obesity rate of U.S. adults ages 20 to 74 was 13.4 percent. That has risen to 35.7 percent today. Our activity levels are lower, but our portion sizes are larger. Processed, unhealthy foods are cheaper and more readily available than whole, healthy foods. At the same time, Americans are reporting higher levels of stress than ever before. All of these factors contribute to weight gain. And it's having a terrible effect on our health. Many people already know that obesity has a terrible impact on heart health. People who are obese have an increased risk for high cholesterol, high blood pressure, stroke and congestive heart failure. Obesity is also associated with increased rates of diabetes, gallstones, arthritis and other joint problems, sleep apnea and other breathing problems. But did you know that being overweight or obese can also have a negative impact on your urologic health?

Diane is no stranger to urologic conditions. Twelve years ago, she and her sister started taking care of their mother, who suffers from dementia. In 2008, their mother was hit by a string of severe urinary tract infections. "It was very serious; she was in and out of intensive care for many months," Diane remembered. Shortly afterwards, Diane's sister was permanently disabled as a result of a car accident. This left Diane as the primary caretaker for both her sister and their 82-year-old mother. Later that year, the oldest of Diane's four daughters got married. "The wedding was a very happy time for our family. It was a little stressful, but after everything that had happened to us, it was nice for my husband, Carl*, and me to see our oldest daughter get married and have that happy memory," said Diane fondly. Two weeks later, Carl was diagnosed with kidney cancer. Diane tried her best to look at the bright side. "We were very lucky because we caught it early. That's not often the case with kidney cancer." Carl had felt a pain in his side, had a CAT scan, and American Urological Association (AUA) member urologist Dr. Soroush A. Ramin was able to remove the tumor before it spread. Luckily, the kidney cancer went into remission. However, Carl, who is obese himself, was also experiencing prostatitis (inflammation of the prostate).

In the face of all this, Carl lost his job. To take care of her family, Diane left her office to do part-time accounting work from home. At this point, Diane was the primary caretaker for three people, and she did not have time to take care of herself. "When you have others to take care of, your own health becomes less of a priority," she explained. "I didn't have time to exercise, cook for myself, sit down for a proper meal, or even go grocery shopping. I can't begin to tell you how many ‘meals' I've made from food in hospital vending machines. I was exhausted because I didn't have time to sleep, and that made me even hungrier. I also think I eat more when I feel stressed, and I can certainly tell you that I was stressed. I gained about 80 pounds around that time."

Diane developed health problems as a result of her weight gain. "It took me a while to notice them," she said. "I was so focused on other things. I did notice sharp pains in my knees, and I had trouble catching my breath sometimes, but I just ignored it." The change in her urologic health crept up on her gradually. A little more than a year ago, after Carl was feeling better, Diane and Carl had the opportunity to go away for a weekend together. "It was really the first time the two of us had been alone and out of the house in a very long time," Diane remembers. The couple went for a walk, which was something they used to love to do together years before when they had the time. "The two of us really do try to exercise when we can," Diane explained. During their hour-long walk, Diane had to stop and use the restroom every 10 to 15 minutes. "Carl pointed out how strange it was. It was bizarre, because I had never noticed it before," Diane said. "I guess I just needed someone else to bring it to my attention. We just hadn't focused on each other in a long time."

Once Diane took notice, she found that she was going to the bathroom as many as 30 or 40 times per day. "Even when I didn't have to go, I felt the urge to go," she explained. Diane went to see AUA member urologist Dr. Ramin, and learned that she had common symptoms of overactive bladder (OAB).

These symptoms include a strong, sudden urge to urinate that she could not ignore, as well as frequent urination. She also had some signs of a separate condition called stress urinary incontinence (SUI). People with SUI leak urine while sneezing, laughing or doing other physical activities. "Sometimes that would happen to me if I was picking up my mother," she remembers.

Diane wasn't sure what to expect when Dr. Ramin discussed her options. "He told me that weight loss could be a significant help, which surprised me," she said. "I just had no idea that this kind of problem could be connected to my weight. It sort of opened my eyes a bit, and made me feel motivated to lose weight. But it was also kind of overwhelming. I knew that with my life the way it was, it would be very difficult." Dr. Ramin encouraged Diane to add weight loss to her treatment plan. He also prescribed medication to help control the feeling of urgency. Another recommendation Dr. Ramin made to help reduce Diane's symptoms was limiting "bladder-irritating" foods and drinks. Certain foods and drinks can irritate the bladder and make OAB symptoms worse. These "bladder irritants" include coffee, tea, alcohol, soda and other fizzy drinks, citrus fruit and spicy foods. "This was hard to hear," Diane said. "I tend to drink a lot of coffee and soda from vending machines to get me through the day." Dr. Ramin also asked Diane to try "timed urination," or going to the bathroom at certain scheduled points during the day. "I hate to say it, but I also thought this would be hard with my schedule," Diane explained. "[I was overwhelmed by] changing my schedule, cutting out foods that are convenient for me, making time to eat right and exercise-all while being a full-time caretaker and working part-time to help support my family. It's a huge overhaul."

The United States as a whole may need a huge overhaul to reduce obesity and its impact on overall health. "Incontinence is not the only urologic issue that can be caused by obesity," Dr. Ramin explained. "There are a whole range of conditions in urology alone with which obesity is either a risk factor or a direct cause." For example, as an obese person, Carl was at a higher risk for kidney cancer than someone with a normal weight. Kidney stones also occur more frequently in obese people. According to AUA member urologist Dr. Christopher Saigal, co-principal investigator and principal investigator for the "Urologic Diseases in America 2012" Project, "There is a correlation between body mass index and kidney stones. While 11.2 percent of obese Americans have kidney stones, the rate is only 6.1 percent in normal-weight Americans. The incidence of kidney stones has risen in the United States as a whole, correlating with the national rise in obesity. The increased rate of these stones is also associated with an increased meat intake in the national diet." Additionally, according to AUA member urologist Dr. Neil Baum, associate clinical professor of urology at Tulane Medical School and Louisiana State University Medical School, "Kidney stones can result from dehydration. Because, on average, an obese person's body needs more water than a normal-weight body, obese people are much more likely to be dehydrated."

Approximately 50 percent of obese men will have abnormally low levels of testosterone, a condition called hypogonadism. In line with obesity, about 40 percent of men with high blood pressure, 40 percent of men with high cholesterol levels, and 50 percent of men with diabetes will have low testosterone levels. Increased body fat is a symptom of hypogonadism, along with decreased energy and fatigue, reduced muscle mass and depression. Hypogonadism is also characterized by poor erectile function, low libido (desire for sex), weaker and fewer erections, and reduced sexual activity. However, hypogonadism is not the only link between obesity and erectile dysfunction (ED). Obese men also have a higher rate for ED due to weaker blood vessels. Reduced blood circulation may lead to difficulty in achieving erections.

Obesity is a risk factor for prostate cancer, which is also linked to poor diet. Additionally, obesity makes diagnosis and treatment of prostate cancer more difficult. The PSA test, used to detect prostate cancer, measures the level of a substance called prostate-specific antigen (PSA) in the blood. A higher level of PSA may indicate prostate cancer. Unfortunately, a hormone imbalance in obese males may make the PSA level reading lower than it should be. As a result, many obese men with prostate cancer are diagnosed at a later stage than their normal-weight counterparts. This can lead to worse outcomes. If an obese man has a biopsy after the PSA test, his chances of developing an infection from the biopsy are higher. After treatment for prostate cancer, obese men are more likely to develop complications. These complications can range from incontinence and erectile dysfunction to postoperative infection and deep-vein thrombosis.

If you are overweight or obese, losing weight can help prevent all of these conditions. Weight loss can also help reverse some urologic conditions, including incontinence, benign prostatic hyperplasia (BPH, or enlarged prostate), hypogonadism and ED. "There is a clear benefit from weight loss," explained Dr. Baum. "For example, I see many men with erectile dysfunction. When I prescribe medication for them, I also suggest that they eat right and exercise. This is a great opportunity for urologists to have a teachable moment and positive impact on our patients' overall health. A man may hear his whole life that he should eat right and exercise, and think to himself ‘yeah, sure, I'll get around to that at some point.' But when you tell him it can reverse his erectile dysfunction-that can be a great motivator. I have seen many of my patients lose weight after being given this information, and they didn't need the ED medication anymore."

For other urologic conditions, such as prostate cancer and kidney cancer, losing weight will not cure the cancer that has already developed, but it can slow the progression of the disease and make treatment easier. If you are in remission, losing weight can help prevent the cancer from coming back. Weight loss can also help someone who has a history of stone disease prevent recurrence of kidney stones.

Maintaining a healthy weight should be a priority for all Americans, for our urologic health and for our overall health. Despite her busy schedule, Diane has made an effort to start exercising regularly. "I fit it in when I have a moment to myself, when I'm waiting or between appointments," she explains. She is also fitting "timed urination" into her schedule. Additionally, she has made an effort to eat a healthy diet. She now avoids "bladder-irritating" foods and brings nutritious food with her when she knows she will not be at home. Diane explained her new perspective: "I realized that if I was in the bathroom all the time, or I was too unhealthy to take care of others, I wouldn't be any help to my family, myself or anyone else."

Want to learn more about Overactive Bladder? The Urology Care Foundation has developed a national public education campaign called It's Time To Talk About OAB.

*Names have been changed.