Approach to Patient with Obesity
Definition
- Obesity is defined based on percentage of body fat:
- For men, a percentage of body fat greater than 25% defines obesity, with 21-25% being borderline.
- For women, over 33% defines obesity, with 31-33% being borderline.
Classification of Obesity
Among several classifications and definitions for degrees of obesity, the following is widely used:
- Overweight - BMI greater than or equal to 25 to 29.9 kg/m²
- Obesity class I - BMI 30 to 34.9 kg/m²
- Obesity class II - BMI 35 to 39.9 kg/m²
- Obesity class III - BMI greater than or equal to 40 kg/m² (also termed severe, extreme, or massive obesity)
Under this classification, the cutoff points differ for Asian and South Asian populations, with overweight being classified as 23-24.9 kg/m², and obesity as 25 kg/m² or greater.
In children, a BMI above the 85th percentile (for age-matched and sex-matched control subjects) is commonly used to define overweight, and a BMI above the 95th percentile is commonly used to define obesity.
Epidemiology
- Saudi Arabia
- GCC
- Arab World
- Global Prevalence
Causes
- Metabolic factors
- Genetic factors
- Level of activity
- Endocrine factors
- Race, sex, and age factors
- Ethnic and cultural factors
- Socioeconomic status
- Dietary habits
- Smoking cessation
- Pregnancy and menopause
- Psychological factors
- History of gestational diabetes
- Lactation history in mother
Approach to Patient with Obesity
Clinical Assessment
History
- A full history must include a dietary inventory and an analysis of the patient’s activity level. Screening questions to exclude severe or untreated depression are vital because depression may be a consequence or a cause of excessive dietary intake and reduced activity.
- Because almost 30% of patients who have obesity have eating disorders, screen for these in the history. The possibility of bingeing, purging, lack of satiety, food-seeking behavior, night-eating syndrome, and other abnormal feeding habits must be identified because management of these habits is crucial to the success of any weight-management program.
- When taking the history, the clinician should investigate whether other members of the patient’s family have weight problems, inquire about the patient’s expectations, and estimate the patient’s level of motivation. The clinician should also determine whether the patient has had any of the comorbidities related to obesity.
History (Complications)
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Respiratory - Obstructive sleep apnea.
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Malignant - Reported association with endometrial (premenopausal), colon (in men), rectal (in men), breast (postmenopausal), gallbladder, gastric cardial, pancreatic, ovarian, renal, liver, and thyroid cancer, as well as with malignant meningioma, esophageal adenocarcinoma, and multiple myeloma.
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Psychological - Social stigmatization and depression.
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Cardiovascular - Coronary artery disease.
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Central Nervous System (CNS) - Stroke, idiopathic intracranial hypertension.
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Obstetric and Perinatal - Pregnancy-related hypertension, fetal macrosomia, and pelvic dystocia.
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Surgical - Increased surgical risk and postoperative complications, including wound infection, postoperative pneumonia, deep venous thrombosis, and pulmonary embolism.
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Pelvic - Stress incontinence.
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Gastrointestinal (GI) - Gallbladder disease (cholecystitis, cholelithiasis), nonalcoholic steatohepatitis (NASH), and reflux esophagitis.
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Orthopedic - Osteoarthritis.
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Metabolic - Type 2 diabetes mellitus, prediabetes, metabolic syndrome, and dyslipidemia.
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Reproductive - In women: Anovulation, early puberty, infertility, hyperandrogenism, and polycystic ovaries; in men: hypogonadotropic hypogonadism.
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Cutaneous - Intertrigo (bacterial and/or fungal), acanthosis nigricans, hirsutism, and increased risk for cellulitis and carbuncles.
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Extremity - Venous varicosities, lower extremity venous and/or lymphatic edema.
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Miscellaneous - Reduced mobility and difficulty maintaining personal hygiene.
Physical Examination
- Assessment of obesity
- Assessment of secondary causes
- Assessment of complications
Approach to Patient with Obesity
Comorbidity & Management
When to Refer
Referral to specialist care should be considered if:
- The underlying causes of overweight and obesity need to be assessed
- The person has complex disease states and/or needs that cannot be managed adequately in either primary or secondary care
- Conventional treatment has failed in primary or secondary care
- Specialist interventions (such as a very-low-calorie diet for extended periods) may be needed, or
- Surgery is being considered