1 In patients who appear to be obese, make the diagnosis of obesity using a clear definition (i.e., currently body mass index) and inform them of the diagnosis.
BMI = kg/m² – poor predictor of obesity
- Should be measured in all adults to assess obesity-related health risks
- Specific cutoff for different ethnic backgrounds
- Measure of waist-hip ratio has no advantage over waist circumference alone
- Associated disease risks increased with men >102cm (40′) or women >88cm (35′)
- BMI < 18.5 = underweight
- BMI 18.5-24.9 = normal
- BMI 25-29.9 = overweight
- BMI 30-34.9 = Obesity class I
- BMI 35-39.9 = Obesity Class II
- BMI >40 = Obesity Class III – extreme obesity
2 In all obese patients, assess for treatable co-morbidities such as hypertension, diabetes, coronary artery disease, sleep apnea, and osteoarthritis, as these are more likely to be present.
Adverse Medical Consequences of Obesity
- DMII, CAD, CHF, Stroke, HTN
- Dyslipidemia, Non-alcoholic steatohepatitis, gallbladder dz
- OA, Low back pain, OSA
- Increased total mortality, certain cancers
clinical evaluation of overweight and obese adults and children include a history and a general physical examination to exclude secondary (endocrine or syndrome-related) causes of obesity and obesity-related health risks and complications
Conduct clinical & lab Ix to assess comorbidities:
- BP, HR
- Hyperlipidemia Signs
- Atheromata – plaques in blood vessel walls
- Xanthoma – plaques / nodules composed of lipid-laden histoiocytes in the skin (esp the eyelids)
- Tendinous xanthoma – lipid deposit in tendon (esp achilles)
- Corneal arcus (arcus senilis) – lipid deposite in cornea
- Fasting glucose, lipid profile (total cholesterol, triglycerides, LDL & HDL, ratio of total cholesterol to HDL)
- LDL can’t be calculated when TG ≥ 4.5
- Repeat these tests at regular intervals
- LFT, U/A, Sleep studies to exclude other obesity related comorbidities
3 In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated TSH testing.
4 In obese patients, inquire about the effect of obesity on the patient’s personal and social life to better understand its impact on the patient.
- Assess and screen for depression, eating and mood disorders, and psychiatric disorders
- create a nonjudgmental atmosphere when discussing weight management
5 In a patient diagnosed with obesity, establish the patient’s readiness to make changes necessary to lose weight, as advice will differ, and reassess this readiness periodically.
Assess readiness to change behaviours & barriers to wt loss
- Devise goals & lifestyle modification program for wt loss & reduction of risk factors
- Wt loss goal: 5-10% body wt or 0.5-1kg per week for 6 months
- A modest wt loss of 5-10% of body wt is beneficial
- Wt maintenance & prevention of wt regain should be considered as long-term goals
- In children, ongoing follow-up for a minimum of 3 months
Satisfactory progress or goal achieved
- regular monitoring – assist with wt maintenance & reinforce healthy eating & physical activity
1) Pharmacotherapy: BMI ≥ 30 or BMI ≥ 27 + risk factors (DM2 or CVD risk factors)
- Adjunct to lifestyle modifications – consider if pt has not lost 0.5-1kg per week by 3-6 mo after lifestyle changes
- Orlistat: GI lipase inhibitor –
- reduces fat absorption by 30% by inhibition of pancreatic lipase
- Associated with adverse effects & not approved for clinical use >2yr
- Avoid in people with inflammatory or chronic bowel dz
2) Bariatric Sx: BMI ≥ 40 or BMI≥ 35 + risk factors
- Consider if other wt loss attempts have failed.
- Requires lifelong medical monitoring
6 Advise the obese patient seeking treatment that effective management will require appropriate diet, adequate exercise, and support (independent of any medical or surgical treatment), and facilitate the patient’s access to these as needed and as possible.
Lifestyle Modification program
- Wt loss achieved by increased activity &/or decreased caloric intake – 0.5-1kg wt loss / wk
- Nutrition: reduce energy intake by 500-1000 kcal/d than TDEE (Total daily energy expenditure)
- Atkins, Ornish, Weight Watchers, Zone diets for Weight loss are associated with modest wt loss & reduction of cardiac risk factors.
- Adherence level, and not diet type was the most important predictor of wt loss & cardiac risk factor reduction
- developed with a qualified and experienced health professional
- a high-protein or a low-fat diet (within acceptable macronutrient distribution ranges indicated in the Dietary Reference Intakes) as a reasonable short-term
(6–12 months) treatment option for obese adults as part of a weight-loss program
- Physical activity: initially 30min of moderate intensity 3-5x/wk, eventually >60min on most days
- Add endurance exercise training: may reduce the risk of cardiovascular morbidity in healthy postmenopausal women
- Medical evaluation is advised before starting activity program
- 3500kcal are used for 1 pound of human fat burned during activity
- Comprehensive lifestyle interventions (combining behaviour modification techniques, CBT, activity enhancement and dietary counselling) for all obese adults
- weight management programs be provided with education and support in behaviour modification techniques as an adjunct to other interventions
- treating obesity in children, use family-oriented behaviour therapy
- Work with other health care team members to develop a comprehensive weight management program for the overweight or obese person to promote and maintain weight loss
7 As part of preventing childhood obesity, advise parents of healthy activity levels for their children.
- Overweight and obesity rates in children are directly proportional to screen time
- encourage children and adolescents to reduce sedentary pursuits and “screen time” (i.e., television, video games)
- activity prescribed for children be fun and recreational, with lifestyle activities tailored to the relative strengths of the individual child and family
- Exclusive breast-feeding of infants is encouraged until at least 6 months of age to prevent later obesity
8 In managing childhood obesity, challenge parents to make appropriate family-wide changes in diet and exercise, and to avoid counterproductive interventions (e.g., berating or singling out the obese child).
- Discussion of the prevention of childhood obesity with the pregnant mother is encouraged
- limiting consumption of energy-dense snack foods high in sugar and fat during childhood and adolescence is encouraged
- limiting “screen time” (i.e., watching television, playing video or computer games) to no more than 2 hours a day to encourage more activity and less food consumption, and to limit exposure to food advertising
- Health professionals are encouraged to emphasize the short-term benefits of physical activity rather than the long-term health benefits to children