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More than 70% of U.S. adults are considered to be overweight or have obesity, 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, obstructive sleep apnea, nonalcoholic fatty liver disease, degenerative joint disease, and some malignancies. Thus, it is important for health care providers to identify, evaluate, and treat patients for obesity and associated comorbid conditions.
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Health care providers should screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss. The four main steps in the evaluation of obesity, as described below, are (1) a focused obesity-related history that includes lifestyle questions about diet, physical activity, sleep, and stress; (2) a physical examination to determine the degree and type of obesity; (3) assessment of comorbid conditions; and (4) assessment of the patient’s readiness to adopt lifestyle changes.
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The Obesity-Focused History
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The first step in taking an obesity-focused history is to approach the topic in a sensitive manner. The reason for this concern is that the word obesity is a highly charged, emotive term. It has a significant pejorative meaning for many patients, leaving them feeling judged and blamed when labeled as such. This is not the case when patients are told that they have other chronic diseases such as diabetes or hypertension. Patients prefer that clinicians use more neutral words or terms such as weight, excess weight, body mass index (BMI), or unhealthy weight, versus more stigmatizing terms such as obesity, morbid obesity, or fatness.
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Information from the history should address the following seven questions:
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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 does the patient find difficult about managing weight?
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?
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Although the vast majority of cases of obesity are promoted by behavioral factors 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, antipsychotic agents (clozapine, olanzapine, risperidone), 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.
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