Chapter 78

Over 66% of U.S. adults are categorized as overweight or obese, and the prevalence of obesity is increasing rapidly in most of the industrialized world. Children and adolescents also are becoming more obese, indicating that the current trends will accelerate over time. Obesity is associated with an increased risk of multiple health problems, including hypertension, Type 2 diabetes, dyslipidemia, degenerative joint disease, and some malignancies. Thus, it is important for physicians to identify, evaluate, and treat patients for obesity and associated comorbid conditions.

Evaluation

Physicians should screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss. The five main steps in the evaluation of obesity, as described below, are (1) focused obesity-related history, (2) physical examination to determine the degree and type of obesity, (3) comorbid conditions, (4) fitness level, and (5) the patient's readiness to adopt lifestyle changes.

The Obesity-Focused History

Information from the history should address the following six questions:

• What factors contribute to the patient's obesity?
• How is the obesity affecting the patient's health?
• What is the patient's level of risk from obesity?
• What are the patient's 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 cases of obesity can be attributed to behavioral features that affect diet and physical activity patterns, the history may suggest secondary causes that merit further evaluation. Disorders to consider include polycystic ovarian syndrome, hypothyroidism, Cushing's syndrome, and hypothalamic disease. Drug-induced weight gain also should be considered. Common causes include medications for diabetes (insulin, sulfonylureas, thiazolidinediones); steroid hormones; psychotropic agents; mood stabilizers (lithium); antidepressants (tricyclics, monoamine oxidase inhibitors, paroxetine, mirtazapine); and antiepileptic drugs (valproate, gabapentin, carbamazepine). Other medications, such as nonsteroidal anti-inflammatory drugs and calcium channel blockers, may cause peripheral edema but do not increase body fat.

The patient's current diet and physical activity patterns may reveal factors that contribute to the development of obesity in addition to identifying behaviors to target for treatment. This type of historic information is best obtained by using a questionnaire in combination with an interview.

BMI and Waist Circumference

Three key anthropometric measurements are important to evaluate the degree of obesity: weight, height, and waist circumference. The body mass index (BMI), calculated as weight (kg)/height (m)2, or weight (lbs)/height (inches)2 × 703, is used to classify weight status and risk of disease (Tables 78-1 and 78-2). BMI is used since it provides an estimate of body fat and is related to risk of disease. Lower BMI thresholds for overweight and obesity have been proposed for the Asia-Pacific region since this population appears to be at risk for glucose and lipid abnormalities at lower body weights.

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