^{1 2}Obesity is an excess of body fat. The most commonly used method for measuring body composition is the body mass index (BMI; see Appendix H). BMI is expressed as weight in kilograms divided by height in meters squared (kg/m²). Normal weight is defined as a BMI of 18.5 to 24.9 kg/m²; overweight as a BMI between 25 and 29.9 kg/m²; mild obesity as a BMI between 30 and 34.9 kg/m²; moderate obesity, 35 to 39.9 kg/m²; and morbid obesity, greater than 40 kg/m². Health risks begin to surface with a BMI greater than 25 kg/m², with the risk increasing as the BMI increases.

Increasingly, a subset of obese patients is being identified with insulin resistant syndrome. This syndrome is a cluster of conditions that can lead to an increased risk of cardiovascular disease and diabetes. Criteria for diagnosis include

1. Obesity

   1. BMI greater than 30 kg/m²

   2. Increased visceral adipose tissue, with a waist circumference of greater than 35 inches in women

   3. A small number of persons who do not meet the criteria for obesity but present with laboratory values that identify them as metabolically obese

2. Dyslipidemia

   1. Hypertriglyceridemia 150 mg/dL or greater

   2. Decreased high-density lipoprotein cholesterol (HDL-C) levels less than 50 mg/dL in females

   3. Low-density lipoprotein cholesterol (LDL-C) levels may be normal.

3. Elevated blood pressure

   1. New Advanced Technology Program III guidelines define elevated blood pressure as 130/85 mmHg or greater (see www.atp.nist.gov/atp/psag-co.htm).

4. Impaired glucose function

   1. Fasting blood glucose of greater than 100 mg/dL

5. Increased fasting insulin levels

6. Polycystic ovary syndrome (PCOS) is not included in the criteria for diagnosis but is present in a great percentage of women with metabolic syndrome.

Obesity is among the most serious and prevalent health problems in the United States, second only to cigarette smoking. More than 97 million Americans are defined as having a weight problem. Of these, 58 million are obese.

Prevalence continued to rise over the past 10 years, increasing from 25% to 35%. Researchers have shown that prevalence varies greatly by sex, age, race, and socioeconomic status. More than 55% of the population defined as obese are women. Obesity in women is twice more common in lower socioeconomic groups than in women with higher socioeconomic status. Obesity itself is an independent risk factor for many medical conditions and negatively contributes to others.

1. Obesity is a multifactorial disorder, based on both genetics and behavior occurring because of an imbalance between energy expended and food consumed and with other contributing factors such as

   1. Metabolic issues (< 1% of obese)

      1. Hypothyroidism

      2. Cortisol excess (Cushing's syndrome)

      3. Stein–Leventhal syndrome (polycystic ovary disease)

   2. Medication

      1. Antidiabetics

      2. Antipsychotics

      3. Antidepressants

      4. Antiepileptics

      5. Adrenergic antagonists

      6. Serotonin and histamine antagonists

      7. Steroids

   3. Food consumption

      1. Portion size

      2. Selection of foods

         1. Foods high in fat

         2. Foods and beverages high in sugar and complex carbohydrates

   4. Lifestyles

      1. Sedentary/lack of physical activity

      2. Lack of calorie-burning (aerobic) exercise

      3. Use of food for comfort and to reduce stress

   5. Other

      1. Of lesser contribution

         1. Endocrine

         2. Deviant eating patterns (i.e., binge eating, night eating)

1. Obesity is associated with increased morbidity and mortality. It has been associated with more than 30 illnesses, among them are

   1. Type 2 diabetes

   2. Hypertension

   3. Stroke

   4. Coronary artery disease

   5. Dyslipidemia

   6. Gallstone formation

   7. Osteoarthritis

   8. Gastrointestinal (GI) disorders

   9. Sleep apnea

   10. Breast inflammation

   11. Respiratory diseases

   12. Some cancers, such as breast, colon, and endometrial

   13. Increased risks in pregnancy, such as miscarriage, preeclampsia, gestational diabetes, infertility, and possibly fetal anomalies such as neural tube defects

   14. Gouty arthritis

   15. Pickwickian syndrome

1. Risk assessment

   1. Overweight and obese patients may not present with the stated desire to lose weight.

   2. Presenting complaints most commonly are those associated with the risk factors listed in Risks Associated With Obesity, IV.A.

   3. A weight loss assessment should be part of an annual exam.

   4. Weight-loss assessment

      1. Patient's recognition of need for weight reduction

      2. Patient's readiness to change

      3. Previous attempts at weight loss

      4. Dietary assessment

         1. Type and amounts of food typically consumed

         2. Patterns of eating

         3. Meals

         4. Snacks

         5. Spontaneous eating

      5. Alcohol consumption

         1. Amount

         2. Frequency

      6. Physical activity

         1. Type

         2. How often, for how long

      7. Obesity-related problems

      8. Family history of weight and weight-related problems

      9. Signs and symptoms of depression

      10. Medications: prescribed; over the counter (OTC), including herbals, homeopathics, and nutritional supplements

      11. Smoker/nonsmoker

1. As indicated by known problem or presenting complaint or to rule out a secondary cause of obesity

2. Regardless of previous statement, exam should include

   1. Height

   2. Weight

   3. Blood pressure

3. Head and neck examination for

   1. Moon facies

   2. Hirsutism

   3. Goiter

   4. Buffalo hump

4. Skin

   1. Striae

   2. Hirsutism

   3. Edema

   4. Dryness

5. Calculation of BMI

   1. BMI may be calculated by dividing the weight in pounds by the square of the height (square inches) and multiplying the result by 703.

   2. BMI may also be assessed by consulting a BMI table (see Appendix H).

6. Waist circumference measurement

   1. Waist circumference of greater than 35 cm for women

1. As indicated by known history or physical exam

2. The following should be considered if no underlying physical problem is indicated:

   1. Lipid profile

   2. Thyroid-stimulating hormone (TSH), free thyroxine 4 (T₄)

   3. Fasting blood sugar; 2-hour postprandial

   4. Complete blood cell count (CBC)

   5. Baseline electrocardiogram

   6. Sleep studies if indicated

3. If insulin resistant syndrome is to be ruled out

   1. Lipid levels

   2. Fasting blood sugar; 2-hour postprandial

   3. Fasting insulin level

   4. Laboratory workup specific for PCOS (see Chapter 19)

1. Intervention needs to be multifaceted and tailored to meet the patient's needs and readiness for change.

2. The need for weight loss should be presented to the patient in a nonjudgmental, nonconfrontational manner. Approach the problem as a partnership in an endeavor that will help the patient to enjoy a longer, healthier life.

3. Assessment of a patient's willingness to make a change includes the following:

   1. Patient may not be interested in making a change despite the identified risk and potential consequences

   2. Patient may be interested, acknowledge the risk factors, but may not yet be ready to take action

   3. Patient is ready to take on the challenge of weight loss

4. Assessment of the amount of weight to be lost based on physical findings and risk factors

5. Plan

   1. Assessment of caloric intake

   2. Assessment of energy expenditure and level of physical activity

   3. Assessment of limitations and/or existing factors

      1. Physical limitation

      2. Medications (alternatives may be considered)

      3. Financial limitations

      4. Cues or stimuli that affect eating

   4. Set realistic goals and expectations regarding the amount of weight to be lost

      1. Short term

         1. 5% to 10% loss in initial weight at a rate of 1 to 2 pounds per week

      2. Long term

         1. Realization of ideal weight

         2. Maintaining ideal weight

   5. Contract with patient a framework for realization of goals

6. Interventions

   1. Diet, with emphasis on long-range behavior changes

      1. Nutritionist for evaluation and plan

      2. Self-help

         1. Weight Watchers

         2. Take Off Pounds Sensibly (TOPS)

         3. Overeaters Anonymous

         4. Community-based programs

         5. Meal-replacement programs

         6. Books, magazine articles

         7. Website weight-loss programs

   2. Education in food selection and change in eating patterns (National Heart, Lung, and Blood Institute/National Institute of Diabetes and Digestive and Kidney Diseases [NHLBI/NIDDK] guidelines are a good source of information—see www.nhlbi.nih.gov)

      1. Low fats, increase omega 3 fatty acids

      2. Moderate use of complex carbohydrates

      3. Decrease consumption of simple carbohydrates (i.e., sugary drinks, candy)

      4. Moderate use of low-fat protein

      5. Decrease in portion size

      6. Omit late-night eating

      7. Eating more slowly (20 minutes should pass between first and last bites of a meal)

      8. Drinking eight (8-oz) glasses of water a day

      9. Use of daily food diary to keep track of consumption

   3. Physical activity

      1. Activity needs to be tailored to the patient's needs and limitation. Centers for Disease Control and Prevention (CDC) guidelines for appropriate physical activity according to age and limitations can be found at www.cdc.gov/physicalactivity/everyone/guidelines/adults.html.

      2. A general guideline of 30 to 40 minutes a day of aerobic exercise, three to four times a week for strenuous exercise; four to five times a week for moderate exercise. This may be done at divided times (i.e., three 10-minute sessions).

      3. Moderate-intensity physical activity provides significant health benefits but needs to be done more often.

      4. Aerobic exercise may include (according to patient's ability)

         1. Running/jogging

         2. Brisk walking (3 mph)

         3. Swimming

         4. Bicycling more than 10 mph for strenuous exercise; less than 10 mph for moderate exercise

         5. Cross-country skiing

         6. Rowing

      5. Flexibility and resistance/strength training are important components of an exercise program and provide additional health benefits. Activities include

         1. Light weight lifting

         2. Resistance bands

         3. Pilates

         4. Yoga

   4. Pharmacotherapeutic options

      1. Pharmaceutic intervention may be helpful in patients with a BMI of greater than 30 kg/m². This may also be helpful in patients who are slightly less obese (i.e., BMI of 27–29.9 kg/m²) but who have a comorbidity.

         1. Orlistat (Xenical), a pancreatic lipase inhibitor

            1. How it works

               1. Blocks absorption of about 30% of ingested dietary fats

               2. Not an appetite suppressant

               3. Improves comorbid conditions related to obesity, especially hyperlipidemia and diabetes

            2. Dosage

               1. 120 mg orally, three times a day, taken just prior to a meal

               2. In patients with side effects, medication may be started by taking one 120-mg tablet with the largest fat-containing meal of the day and gradually titrating up to advised dosage as patient adjusts.

            3. Side effects are directly related to amount of fat in meal consumed

               1. Soft stools

               2. Diarrhea (may be explosive and foul smelling)

               3. Anal leakage

            4. Additional information

               1. A daily multiple vitamin should be recommended because orlistat inhibits absorption of fat-soluble vitamins

            5. An OTC preparation, Alli, is now available and U.S. Food and Drug Administration (FDA) approved; dosage is 60 mg three times a day.

         2. Phentermine (Adipex-P)

            1. How it works

               1. Appetite suppressant

               2. FDA approved for short-term use (up to 12 weeks) in adults only

            2. Dosage/administration: 37.5 mg three times a day

               1. Best taken on an empty stomach 1 hour prior to a meal

               2. If a dose is missed, take as soon as possible. Patient should never take two doses to make up for a missed dose.

            3. Side effects

               1. Blurred vision

               2. Dry mouth

               3. Sleeplessness

               4. Irritability

               5. Stomach upset

               6. Constipation

                  Note: These side effects may occur in the first few days of use. The patient should be advised to call her prescriber if these symptoms persist.

               7. Chest pain, nervousness, pounding heart, difficulty urinating, mood changes, or breathing problems—the patient should be instructed to call her prescriber immediately.

            4. Precautions

               1. Women with high blood pressure, hyperthyroidism, glaucoma, diabetes, or mental health problems should not be prescribed Adipex-P.

               2. Alcohol should not be used when taking Adipex-P. Alcohol can increase side effects, especially dizziness.

               3. Should not be taken in pregnancy or while breastfeeding

               4. Overdose symptoms may include confusion, diarrhea, nausea, rapid breathing, restlessness, GI symptoms (nausea, vomiting). If these symptoms are present, the patient should be instructed to call her local poison control center or hospital emergency room immediately.

         3. Diethylpropion hydrochloride (Tenuate)

            1. How it works

               1. Appetite suppressant

               2. FDA approved for short-term use (up to 12 weeks) in adults only

               3. Recommended for use in patients with an initial BMI of greater than 30 kg/m² who have not responded to a diet and/or exercise regimen

               4. Not for use with another weight-loss medication

            2. Dosage/administration

               1. Conventional tablets: 25 mg three times daily, taken 1 hour prior to meals. Note: An additional 25-mg dose may be taken midevening if necessary to overcome hunger.

               2. Extended-release tablets: 75-mg tablet taken midmorning; must be taken whole

            3. Side effects

               1. Dizziness

               2. Headache

               3. Sleeplessness

               4. Blurred vision

               5. Overstimulation

               6. GI complaints, constipation, vomiting

               7. Rash

            4. Precautions

               1. Should not be taken when pregnant or nursing

               2. Should not be prescribed to patients who have arrhythmias, hypertension, epilepsy, glaucoma, arteriosclerosis, history of drug abuse, known heart murmur, or valvular disorder

               3. Potential for abuse, psychological dependence is possible. Use with caution in patients who have known mental health issues.

               4. Prescribe and dispense in smallest feasible quantities to minimize possibility of overdosage.

               5. Should not be used within 14 days of monoamine oxidase (MAO) inhibitor therapy

               6. Alcohol should not be used while taking diethylpropion HCl.

               7. Should not be used concomitantly with other appetite suppressant preparations, including herbal and OTC preparations

               8. Mental alertness and physical coordination may be impaired. Patients should not operate machinery or drive until they know the effect of the drug.

         4. Phendimetrazine (Obezine, Bontril PDM, Plegine, and Anorex, to name a few)

            1. How does it work?

               1. Appetite suppressant

               2. FDA approved for short-term use, up to 12 weeks

               3. Recommended for use in patients with an initial BMI of greater than 30 kg/m² who have not responded to diet and/or exercise regimen

            2. Dosage/administration

               1. 35 mg (immediate-release tablets), taken three times daily in 4-hour intervals

               2. 105 mg (extended-release tablets) are classified by the Drug Enforcement Administration as a Schedule III controlled substance. The extended-release capsule is taken in the morning 30 to 60 minutes before morning meal.

            3. Side effects

               1. Insomnia

               2. Nervousness/restlessness/agitation

               3. Dizziness

               4. Blurred vision

               5. Dryness of mouth

               6. GI symptoms, nausea, diarrhea, constipation, stomach pain

               7. Palpitations/tachycardia

               8. Elevated blood pressure

               9. Urinary frequency, dysuria

               10. Overdose symptoms include confusion, belligerence, hallucinations, and panic attack and should be handled as an emergency in a hospital emergency room setting.

            4. Precautions

               1. Should not be used in pregnancy or lactation

               2. Should not be used concomitantly with other appetite suppressant preparations, including herbal and OTC preparations

               3. Should not be prescribed to patients who have hypertension, diabetes, hyperthyroidism, glaucoma, known heart murmur, or valvular disease and to agitated patients or patients with a history of substance abuse. Alcohol use should be avoided.

               4. Should not be used for patients on MAO inhibitors or within 14 days of discontinuing use.

               5. Because mental alertness and physical coordination may be impaired, patients should not drive or operate machinery until they know the effect of drug.

               6. Potential for dependence. Abuse may be associated with intense psychological dependence and severe social dysfunction. Patients exhibiting these symptoms should be seen in a hospital emergency room setting. Overdose can result in convulsions, coma, and death.

         5. Other medications have been associated with weight-loss pharmacology. They include

            1. Bupropion (Wellbutrin), an antidepressant

            2. Topiramate (Topamax), an antiseizure medication

            3. Zonisamide (Zonegran), an antiseizure medication

            4. Metformin, a diabetes treatment

            Note: We have not elaborated on these as first-line weight-loss pharmaceuticals because their use is off label.

   5. Herbal or alternative medications

      1. Currently not recommended as alternative medications

         1. Not under any regulation

         2. Ingredients (i.e., ma huang) possess the potential for serious side effects

   6. Behavioral

      1. Stimulus control

         1. Identifying factors contributing to overeating and underexercising

         2. Identify ways in which contributory factors may be eliminated

         3. Structuring mechanism for elimination of the negative stimuli

      2. Stress management

         1. Meditation, progressive relaxation

         2. Guided imagery

      3. Cognitive restructuring

         1. Identification of inner dialogue (i.e., self-talk, distorted/negative self-image)

         2. Replacement of these negative and self-defeating cognitions with more positive ones

      4. Social support

         1. Seek out support/educational groups as noted in Treatment, VIII.F.1

         2. Join and participate in exercise groups and other recreation programs geared toward physical well-being and body conditioning

         3. Seek support systems within family or peer group

         4. Daily journal

   7. Surgical

      1. May be considered for patients who have failed trials of diet, lifestyle changes, pharmacotherapy

      2. Most often used for patients younger than age 55 in good health with a BMI greater than 40 kg/m² and possessing a significant cofactor

      3. Prior to surgery, patient should undergo assessment by multidisciplinary team. Assessment should include the following areas:

         1. Medical

         2. Surgical

         3. Psychological

         4. Nutritional

      4. Patient should be well motivated and well informed about potential benefits and risks

      5. Types of procedures

         1. Gastric banding—restricting gastric volume

         2. Roux-en-Y gastric bypass—in addition to restricting volume alters digestion

      6. Success rates

         1. Regardless of procedure, most patients lose one half to two thirds their excess weight within 18 months.

      7. Risks/side effects

         1. Postoperative wound infection

         2. Atelectasis

         3. Dehiscence

         4. Deep vein thromboembolism

         5. Anastomotic leaks

         6. Marginal ulcers

         7. Pouch and distal esophageal dilation

         8. Persistent vomiting

         9. Cholecystitis

         10. Development of dumping syndrome

         11. Vitamin deficiencies (i.e., B₁₂, folate, iron)

   8. Other

      1. Preconception counseling

      2. Preconception weight stabilization

      3. Counseling of pregnant women regarding micronutrient and vitamin supplementation and close monitoring for appropriate weight maintenance and weight gain

1. BMI greater than 40 kg/m² (morbidly obese)

2. Psychiatric disorder (bulimia/depression)

3. Sleep apnea

4. Uncontrolled cofactor

   1. Hypertension

   2. Diabetes

   3. Heart disease

5. Assessment and treatment for insulin resistant syndrome (consider endocrinologist)

6. Medication

1. Weight checks on regularly scheduled contracted schedule—4 weeks, if no adverse events and weight loss is being achieved

2. Measurements as part of weight checks

3. Review and reassessment of goals on regular schedule

4. Review of food and exercise diaries

5. Review and assessment of problems, concerns, and side effects associated with pharmaceutical interventions