Chapter 075. Evaluation and Management of Obesity (Part 1)

Harrisons Internal Medicine Chapter 75. Evaluation and Management of ObesityEvaluation and Management of Obesity: Introduction Over 66% of U.S. adults are currently categorized as overweight or obese, and the prevalence of obesity is increasing rapidly throughout most of the industrialized world. Based on statistics from the World Health Organization, overweight and obesity may soon replace more traditional public health concerns such as undernutrition and infectious diseases as the most significant contributors to ill health. Children and adolescents are also becoming more obese, indicating that the current trends will accelerate over time. Obesity is associated with an increased risk...
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Chapter 075. Evaluation and Management of Obesity (Part 1) Chapter 075. Evaluation and Management of Obesity (Part 1) Harrisons Internal Medicine > Chapter 75. Evaluation and Managementof Obesity Evaluation and Management of Obesity: Introduction Over 66% of U.S. adults are currently categorized as overweight or obese,and the prevalence of obesity is increasing rapidly throughout most of theindustrialized world. Based on statistics from the World Health Organization,overweight and obesity may soon replace more traditional public health concernssuch as undernutrition and infectious diseases as the most significant contributorsto ill health. Children and adolescents are also becoming more obese, indicatingthat the current trends will accelerate over time. Obesity is associated with anincreased risk of multiple health problems, including hypertension, type 2diabetes, dyslipidemia, degenerative joint disease, and some malignancies. Thus, itis important for physicians to routinely identify, evaluate, and treat patients forobesity and associated comorbid conditions. Evaluation The U.S. Preventive Services Task Force recommends that physiciansscreen all adult patients for obesity and offer intensive counseling and behavioralinterventions to promote sustained weight loss. This recommendation is consistentwith previously released guidelines from the National Heart, Lung, and BloodInstitute (NHLBI) and a number of medical societies. The five main steps in theevaluation of obesity are described below and include (1) focused obesity-relatedhistory, (2) physical examination to determine the degree and type of obesity, (3)comorbid conditions, (4) fitness level, and (5) the patients readiness to adoptlifestyle changes. The Obesity-Focused History Information from the history should address the following six questions: What factors contribute to the patients obesity? How is the obesity affecting the patients health? What is the patients level of risk from obesity? What are the patients goals and expectations? Is the patient motivated to begin a weight management program? What kind of help does the patient need? Although the vast majority of obesity can be attributed to behavioralfeatures that affect diet and physical activity patterns, the history may suggestsecondary causes that merit further evaluation. Disorders to consider includepolycystic ovarian syndrome, hypothyroidism, Cushings syndrome, andhypothalamic disease. Drug-induced weight gain should also to be considered.Common causes include antidiabetes agents (insulin, sulfonylureas,thiazolidinediones); steroid hormones; psychotropic agents; mood stabilizers(lithium); antidepressants (tricyclics, monoamine oxidase inhibitors, paraxetine,mirtazapine); and antiepileptic drugs (valproate, gabapentin, carbamazapine).Other medications such as nonsteroidal anti-inflammatory drugs and calcium-channel blockers may cause peripheral edema, but they do not increase body fat. The patients current diet and physical activity patterns may reveal factorsthat contribute to the development of obesity in addition to identifying behaviorsto target for treatment. This type of historical information is best obtained by usinga questionnaire in combination with an interview. BMI and Waist Circumference Three key anthropometric measurements are important to evaluate thedegree of obesity—weight, height, and waist circumference. The body mass index(BMI), calculated as weight (kg)/height (m)2, or as weight (lbs)/height (inches)2 x703, is used to classify weight status and risk of disease (Tables 75-1 and 75-2).BMI is used since it provides an estimate of body fat and is related to risk ofdisease. Lower BMI thresholds for overweight and obesity have been proposed forthe Asia-Pacific region since this population appears to be at-risk at lower bodyweights for glucose and lipid abnormalities. Table 75-1 Body Mass Index (BMI) TableMI 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 Body Weight, poundseight,inches8 1 6 00 05 10 15 19 24 29 34 38 43 48 53 58 62 679 4 9 04 09 14 19 24 28 33 38 43 48 53 58 63 68 730 7 02 07 12 18 23 28 33 38 43 48 53 58 63 68 74 791 00 06 11 16 22 27 32 37 43 48 53 58 64 69 74 80 852 04 09 15 20 26 31 36 42 47 53 58 64 69 75 80 86 913 07 13 18 24 30 35 41 46 52 58 63 69 75 80 86 91 974 10 16 22 28 34 40 45 51 57 63 69 74 80 86 92 97 045 14 20 26 32 38 44 50 56 62 68 74 80 86 92 98 04 106 18 24 30 36 42 48 55 61 67 73 79 86 92 98 04 10 167 2 ...