Obesity has reached epidemic proportions in the U.S.A. and many other parts of the world. Obesity increases the risk of a number of adverse health conditions including type 2 diabetes, insulin resistance, dyslipidemia, hypertension, and hepatic steatosis. Adipocyte hypertrophy occurs during weight gain and is associated with recruitment of immune cells, mainly macrophages, into the adipose tissue (AT). These cells typically surround a dying or dead adipocyte with the formation of crown-like structures that are present in experimental models of obesity as well as obese humans. The immune infiltration of AT results in increased production of various adipokines, cytokines, and chemokines that play a crucial role in the development of insulin resistance and hepatic steatosis. The pathogenic mechanisms resulting in AT macrophage recruitment are under intense investigation and remain incompletely understood. Recent evidence suggests that various programmed cell death pathways are activated in stressed hypertrophied adipocytes and may result in cell death. These events appear to occur at early stages and be important in triggering the metabolic dysregulation associated with obesity.