OBESITY   74A

A 53-year-old woman came to the clinic to get help managing her weight. She has been overweight since childhood and has continued to gain weight throughout her adult life. She has tried numerous diets without lasting success. She initially loses weight but then regains it after a few months. She is otherwise healthy and is not taking any medications. Other family members are also overweight or obese. She does not do any regular exercise and has a sedentary office job. On examination, she is 5 feet, 3 inches tall and 260 lb, with a body mass index (BMI) of 46.2 (normal <25).

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Long-standing obesity; multiple failed diets; family history; sedentary lifestyle; elevated BMI

How to think through: A BMI of 46 places her into which class of obesity? In addition to excess caloric intake and inadequate exercise, what are the important causes of obesity to consider in your evaluation of this patient? What are the potential endocrine causes? What medications cause weight gain? Psychiatric causes? (Depression.) What are the major medical complications of obesity, and how would you screen for each? (Hypertension, dyslipidemia, diabetes mellitus, coronary artery disease, degenerative joint disease, cholelithiasis.) Does obesity increase her risk of any cancers? What are the elements of a comprehensive treatment strategy? (Nutrition education, exercise program, and weight loss counseling, including a diet log, an exercise log, motivational interviewing, and changes to environmental cues.) Is there a difference between the success of low-fat or low-carbohydrate diets over time? If she makes limited progress after 6 months of the above, what are possible next steps? (Medically managed very low-calorie diets and gastric bypass surgery.) Are there pharmacologic agents for weight loss? (Yes, but of limited utility. Orlistat is modestly effective but has frequent gastrointestinal [GI] side effects. Catecholaminergic agents have high abuse and dependence potential.)

OBESITY   74B

What are the essentials of diagnosis and general considerations regarding obesity?

Essentials of Diagnosis

Excess adipose tissue; BMI >30, where BMI = Weight (in kg)/Height (in m)²

Upper body obesity (abdomen and flank) of greater health consequence than lower body obesity (buttocks and thighs)

Associated with health consequences, including diabetes mellitus, hypertension, and hyperlipidemia, coronary artery disease, and early death

General Considerations

BMI: normal = 18.5 to 24.9, overweight = 25 to 29.9, class I obesity = 30 to 34.9, class II obesity = 35 to 39.9, class III (extreme) obesity >40

68% of Americans are overweight; 33.8% are obese

The relative risk associated with obesity decreases with age, and excess weight is no longer a risk factor in adults aged older than 75 years of age

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