Obesity Management

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Introduction   

Obesity is becoming a global health crisis, significantly increasing the risk of several serious non-communicable diseases, including cardiovascular disease, diabetes, and cancer. This issue is driven by multiple factors. However, the surge in sedentary lifestyles and unhealthy eating habits are primary culprits. 

Effective weight management interventions could not only help control the obesity epidemic but also reduce the associated health risks. This course will explore the various factors contributing to obesity and related health outcomes. 

We will highlight the major health risks linked to obesity and delve into management guidelines and treatment. 

Definition and Background 

Obesity is defined as an abnormal or excessive fat accumulation that presents a risk to health (12).  

Obesity is considered a disease based on rigorous criteria. Many organizations have debated for decades about whether or not obesity is a disease; in 2004, the Centers for Medicare and Medicaid Services (CMS) removed their language that obesity is not a disease, and organizations like the Obesity Society, Obesity Medicine Association, American Association of Clinical Endocrinologists, and Endocrine Society strongly argued that it should be classified as a disease. The American Medical Association recognized obesity as a disease in 2013 when the scientific committee approved this label and debated it within their house of delegates (6).  

The AMA has criteria to determine if they will label something as a disease: (1) the disease must show impairment of normal functions and cause morbidity, which obesity met by the impairment of normal functions due to inflammation, insulin resistance, dyslipidemia, as well as the impairment of hypothalamus (6). The characteristic of harm or morbidity was met due to obesity-related complications such as cardiovascular disease, type II diabetes, metabolic syndrome, cancers, and early death (6). The majority of the medical organizations accepted the AMA’s determination.  

A chronic disease can be defined as a disease that causes the entire body, specific organ(s), or system to malfunction over time (6). Chronic stages of diseases have the potential to initiate end-organ dysfunction and cause other diseases. The Obesity Society supports that obesity is a chronic disease. Obesity leads to structural abnormalities such as left ventricular hypertrophy, ectopic fat deposits, lymphedema, and excess or enlarged adipose tissue; manifestations include insulin resistance, dyslipidemia, chronic inflammation, and urinary incontinence (6).  

Obesity has been associated with 236 other conditions and is a positive cause for many chronic conditions such as diabetes, hypertension, hyperlipidemia, and non-alcoholic fatty liver disease (NAFLD) (6).  

Essentially, these terms and definitions are used to illustrate the desperate need to manage obesity to reduce morbidity and mortality. A prominent physician, Dr. Hamdy, proclaimed; “obesity is indisputably the greatest preventable health-related cause of mortality after cigarette smoking” (6). 

Epidemiology 

Recent studies found that roughly 16% of adults across the world are obese, and the worldwide prevalence of obesity more than doubled between 1990 and 2022 (12). The prevalence of overweight and obesity among children and adolescents aged 5–19 has risen dramatically from just 8% in 1990 to 20% in 2022 (12). Nearly one-third of adults in the United States are obese (9).  

Obesity was once considered to be an issue only among high-income countries; however, obesity is on the rise in low- and middle-income countries. 

The prevalence of obesity is slightly higher among women than men and is currently highest among adults aged 40–59 (4). In the United States, the economic burden is estimated to be about $100 billion annually (9). 

Obesity is complex and involves a variety of genetic, environmental, and physiological factors.  

Here is an overview of the key components: 

Genetic Factors 

Genetics plays a significant role in determining an individual’s susceptibility to obesity. Variations in genes that control appetite, metabolism, and fat storage can contribute to obesity. Epigenetic changes and environmental factors can cause changes in gene expression, which doesn’t alter the DNA sequence, but potentially affects body weight regulation (4). 

Environmental Factors 

Obesity occurs when energy intake exceeds energy expenditure over a prolonged period. The body stores excess energy as fat. High-calorie, high-fat, and high-sugar diets contribute to excessive calorie intake and weight gain. Sedentary lifestyles and low physical activity reduce energy expenditure and promote weight gain. 

Significant physiological factors include hormonal regulation, energy balance, adipose tissue function, inflammation, neuroendocrine abnormalities, and psychological factors (11). This will be further explored in the next section.  

Etiology 

The traditional understanding of obesity solely focuses on increased caloric intake compared to energy expenditure (10). However, obesity can also occur secondary to diseases, medications, and other dysregulation of normal body functions. Essentially, nutrition management and increased activity are vital to weight loss, they are no longer the sole appropriate management.  

Common mechanisms involved in the development of obesity include lifestyle, inflammation, dysbiosis in the microbiome of the GI system, and genetic mutations. 

Genetics and epigenetics can cause alterations or resistance in storing adipose tissue or driving appetite (10). The microbiome of the GI system can alter the gut’s immunologic and absorptive ability as well. Diseases and medications can cause large shifts in metabolism, which causes higher adiposity (10).  

Physical Activity and Diet 

An individual’s lifestyle as a cause of obesity mainly accounts for physical activity and diet. The pathophysiology of obesity is closely linked with physical activity and diet, and are the first behavioral factors that are modified in the initial treatment of obesity. Minimal physical activity leads to lowering energy expenditure and expediting age-related loss of lean mass, coactively resulting in fat weight gain.  

Physical activity is particularly important to energy balance, and minimal physical activity is associated with higher rates of chronic diseases and reduced life expectancy (10). The medical community proclaims that physical inactivity is on par with the risk factors established with smoking. 

In a study that followed 50,277 women for 6 years, each was diagnosed with obesity but free from diagnosed cardiovascular disease, diabetes, and cancer, it was found the following: (1) A 2-hour increment per day in TV-watching was associated with a 23% increase in obesity, (2) each 2-hour additional increment per day sitting at work was associated with a 5% increase in obesity; but with the addition of a 1-hour daily spent brisk walk, there was a 24% reduction in obesity (10). 

Similarly, diet is an important component of healthy weight. The number of calories is important; however, the composition of the nutrients in food intake is a critical aspect. 

Food distribution and processed foods (since the 1970s) have shifted the average diet towards increased caloric intake, increased carbohydrates, refined fats, increased glycemic index, and increased portion sizes at each meal. Between 1962 and 1990, the use of vegetable oils correlated with a 10–13% global increase in fat availability, with an overall decrease availability of fruits, fiber, and other complex carbohydrates (10). These dietary fats negatively affect metabolism and alter gut epithelial permeability, which ultimately compromises macronutrient absorption, inflammation, and microbiome flora. In addition, the decrease in fiber causes a decrease in bowel motility, intestinal absorption, colonic microbiota, and fermentation (10). 

Pathophysiology 

Understanding the pathophysiology of obesity requires a holistic approach that considers the various factors, including adipose tissue function, inflammation, hormonal imbalances, gut microbiome impact, and psychological health. 

Adipose tissue is essentially known as body fat. Adipose tissue is a key part of maintaining physiologic homeostasis because it stores lipids as a long-term energy reservoir. This tissue is found all over the body, including under the subcutaneous skin layer (subcutaneous fat), packed around internal organs (visceral fat), between muscles, within the bone marrow, and in breast tissue (11).  

In obesity, adipose tissue enlarges and expands to adapt to higher demands of energy storage. Adipose inflammation presents as enlarged adipocytes which turn apoptotic, which are surrounded by macrophages, and appear as crown-like structures (10). These interactions between adipocytes and immune cells cause increased inflammatory responses, which target tissue and ultimately result in insulin resistance and hyperinsulinemia, hyperglycemia, hyperlipidemia, and vascular injury (10).  

• Adipose Tissue Function (11): 
• Adipocyte Hypertrophy: The adipocytes (adipose tissue cells) enlarge as they store more fat. 
• Adipokines: Adipose tissue cells secrete various signaling molecules (adipokines) that can influence inflammation, insulin sensitivity, and energy metabolism. 

Insulin resistance can lead to increased fat storage and difficulty regulating blood sugar levels. Inflammation and poor energy metabolism further the damage and fat storage, and a cycle occurs. 

Inflammation 

Chronic low-grade inflammation is common in obesity, driven by increased production of pro-inflammatory adipokines and infiltration of immune cells into adipose tissue (10). This inflammation is seen in the circulatory system and often seen in organs that impact metabolism, such as the liver, brain, pancreas, and adipose tissue (10).  

The immune system is then impacted as well. Additionally, this inflammation is linked to an increased risk of cancer and infectious disease in obese patients. It is estimated that 3.6% of all new cancer diagnoses are due to excess adiposity (10). 

Hormonal Imbalance 

Hormonal regulation and appetite are a key factor in obesity. Leptin is produced by fat cells and signals the brain to reduce appetite. Obesity is often associated with leptin resistance, where the brain does not respond appropriately to leptin signals.  

Ghrelin is a peptide hormone, known as the “hunger hormone,” and is responsible for the stimulation of appetite, energy homeostasis, and carbohydrate metabolism (13). Ghrelin’s orexigenic (appetite-stimulating) effects are controlled by a need-driven homeostatic state and have central actions on reward, memory, and motivated feeding behavior (10). Levels of ghrelin increase before meals and decrease after eating. Studies have found that ghrelin is commonly lower among those with obesity (10). 

Adiponectin is an adipocyte-derived hormone with complex biology. It is widely researched as a possible treatment for obesity due to reported anti-hyperglycemic, anti-atherogenic, and anti-inflammatory effects (11). 

Gut Microbiome Dysbiosis 

The composition of gut bacteria can influence nutrient absorption, energy balance, and inflammation. Disturbances in gut microbiota have been linked to obesity. Gut bacteria can instigate obesity and insulin-resistance (IR)-associated inflammatory state through lipopolysaccharide (LPS; a component of gram-negative bacterial cell-wall), which triggers inflammation by binding to toll-like receptor-4 (TLR-4) complex at the surface of innate immune cells. A high-fat-high-carbohydrate meal induces significant elevations in postprandial plasma LPS, revealing that endotoxemia may play a pathological role in an obesity-associated inflammatory state and that food ingestion may affect plasma endotoxin levels (10). 

Neuroendocrine Factors 

The hypothalamus, located in the brain, plays a role in regulating hunger and energy expenditure. Dysregulation of hypothalamic function can contribute to obesity. Foods high in sugar and fat can activate the brain’s reward system, involving neurotransmitters like dopamine, which can also influence eating behavior and lead to overeating.  

Psychological Factors 

Stress, depression, and other psychological factors can impact eating habits, physical activity levels, inflammation, hormonal balances, and other disease processes. Psychological stress has significant indirect and direct roles in the development of obesity over time. Stress impacts decision-making capacity, reasoning, and self-regulation.  

Stress also causes the release of glucocorticoids, which cause physiological changes in the hypothalamic-pituitary-adrenal axis, which affects reward processing in the brain and can lead to “emotional eating” (10).  

The HUNT-2 study assessed 65,648 adults between 20 and 89 years of age and found a pattern between abdominal obesity and both anxiety and depression (10).  

Complications of Obesity 

Obesity may cause the following complications: 

• Type 2 diabetes 
• High blood pressure 
• High cholesterol 
• Heart disease 
• Stroke 
• Metabolic syndrome 
• Fatty liver diseases 
• Some cancers, such as pancreatic, colon, breast, and liver cancers 
• Respiratory problems 
• Osteoarthritis 
• Gout 
• Diseases of the gallbladder and pancreas 
• Kidney disease 
• Pregnancy problems 
• Fertility problems 
• Sexual function problems 
• Urinary incontinence  
• Mental health problems 

Medications Associated with Weight Gain 

Anti-hypertensive medications are sometimes associated with body weight gain; these include some beta-blockers and calcium channel blockers (8). Hormone therapies can promote body weight gain, including glucocorticoids and injectable progestins (8). Certain anti-seizure medications are associated with weight gain including carbamazepine, gabapentin, valproate, and pregabalin. Antidepressants that are associated with body weight gain include some tricyclic antidepressants, selective serotonin reuptake inhibitors (paroxetine), some selective serotonin and norepinephrine reuptake inhibitors (venlafaxine), as well as mirtazapine, brexpiprazole, and trazodone (8). Migraine medications most associated with body weight gain include amitriptyline, gabapentin, paroxetine, valproic acid, and some beta-blockers. Antipsychotics, chemotherapeutic, and anti-inflammatory agents are also reported to cause weight gain (8). 

Social Determinants of Health (SDOH) and Obesity 

Social determinants of health (SDOH) refer to the conditions in which people are born, grow up, reside, work, and age (7). These factors significantly influence health outcomes, including the prevalence of obesity. Understanding the relationship between SDOH and obesity is vital in creating effective interventions to combat this complex health issue.  

Figure 1. Social Determinants of Health (7) 

Here are key social determinants that impact obesity: 

• Healthcare Access and Quality 
• Access to preventive services, including nutritional counseling and weight management programs, is essential.  
• Disparities in healthcare access and quality can exacerbate obesity rates in underserved communities. 
• Economic Stability 
• Lower income levels are often associated with higher rates of obesity (7). Limited financial resources can restrict access to healthy foods and opportunities for physical activity. Individuals or families with lower incomes may rely on cheap, calorie-dense foods, leading to weight gain. 
• Job security and job environments can influence lifestyle choices. Sedentary jobs, long working hours, and stress can contribute to weight gain (7). 
• Education 
• A lack of knowledge about healthy eating and cooking can result in poor dietary choices. 
• Higher levels of education are generally linked to better health outcomes, including lower obesity rates. Education provides knowledge about nutrition and healthy lifestyles that can improve health literacy. 
• Access to education about healthy eating and physical activity within the community and schools is crucial.  
• Social and Community Context 
• Strong and positive social networks can promote healthy behaviors through shared activities and encouragement. Conversely, social isolation can lead to unhealthy eating and inactivity. 
• Cultural attitudes toward nutrition, body image, and physical activity can impact obesity rates.  
• Neighborhood and Physical Environment 
• Access to healthy and affordable food options is meaningful to weight management. Living in a food desert, where access to fresh, healthy foods is limited, can increase the risk of obesity. Conversely, areas with abundant fast-food outlets and convenience stores can promote unhealthy eating habits.  
• Unsafe neighborhoods can discourage outdoor physical activities, leading to sedentary lifestyles. 
• The availability of walking areas, parks, recreational facilities, sidewalks, and safe neighborhoods encourages physical activity. Urban planning that promotes walkability and physical activity can help reduce obesity rates. 
• Cramped living conditions can have a negative impact on nutritional choices and physical activity. 
•  

Addressing Social Determinants 

Effective strategies to combat obesity must address these social determinants. This includes (7): 

• Policy Interventions: Implementing policies that ensure equitable access to healthy foods, safe environments for physical activity, and affordable healthcare. 
• Community Programs: Developing community-based initiatives that educate and support individuals in making healthy choices. 
• Cross-Sector Collaboration: Engaging multiple sectors, including education, healthcare, housing, and urban planning, to create a supportive environment for healthy living. 

Understanding and addressing the social determinants of health is crucial in the fight against obesity. By tackling these underlying factors, we can create a healthier society and reduce the prevalence of obesity-related health issues. By understanding the demographics of obesity, healthcare providers, public health officials, and policymakers can design and implement more effective strategies to reduce its prevalence and associated health risks

Assessment 

Screening for obesity is critical. The United States Preventative Services Task Force (USPSTF) recommends that all children six years and older, adolescents, and all adults should be screened for obesity (9). This screening is an ongoing assessment. 

Providers should carefully screen for underlying causes contributing to obesity.  

Obesity is a key pathophysiologic driver of diabetes, other cardiovascular risk factors (e.g., hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and inflammatory state), and ultimately cardiovascular and kidney disease (10). Diabetes can further exacerbate obesity, setting up a vicious cycle that contributes to disease progression and the occurrence of complications.  

A thorough history and physical exam are essential. 

Collect History 

• Childhood weight history 
• Prior weight patterns 
• Weight loss efforts and results 
• Sleep patterns 
• Physical activity routine 
• Nutritional intake and diet regimen 
• Past medical histories  
• Cardiovascular, diabetes, thyroid disorders, mental health disorders. 
• Surgical history 
• Medications 
• Note and discuss medications that contribute to weight gain 
• Social histories 
• Tobacco, alcohol, or illicit drug use 
• Family history (8) 

Body Weight History 

• The pattern of body weight gain over their lifetime (e.g., slow & gradual, rapid & sudden, or combination) 
• Factors influencing weight change  
• Physical health or surgeries 
• Mental health  
• Medications 
• Life circumstances (family, newborn, stress, work, moving, finances, abuse) 
• Past strategies/behaviors/interventions proven effective and ineffective 
• Impact of current and past body weight on mobility, interaction with family and friends, work 
• Current or anticipated barriers to future weight loss (8) 

Nutrition History 

• Meals and Snacks: 
• Frequency or timing 
• Nutritional content and amount 
• Food preparation habits 
• Physical/financial access to foods 
• Location of food sources 
• Behavior 
• History of diets (successful or unsuccessful) 
• If unsuccessful, what were short- and long-term barriers to achieving or maintaining weight loss 
• Triggers (hunger, cravings, anxiety, boredom, reward, etc.) 
• Nighttime eating habits 
• Readiness for change 

Physical Activity History 

• Success and/or failure of previous physical activity/exercise efforts 
• If routine physical activity/exercise regimen was discontinued: 
• When? (Date of change) 
• What? (Cause of change) 
• Why? (Identify barriers to re-engagement) 
• Current physical activity (FITTE) 
• Frequency 
• Intensity 
• Time or Duration  
• Type 
• Enjoyment (physical activity/exercise preferences) 
• Endurance capacity 
• Mobility limitations 
• Access to locations amenable to increased physical activity/exercise (e.g., exercise facilities, walking paths, urban or rural home settings) 
• Physical, social, financial, and perceived barriers to increased physical activity 

Focused Physical Examination  

Following a general head-to-toe physical examination, a focused examination is vital. This should include body mass index (BMI) measurement, weight circumference, and vitals. 

A standard screening tool for obesity is the measurement of body mass index (BMI). BMI is calculated using weight in kilograms divided by the square of height in meters. 

Obesity can be classified according to BMI (9): 

• Underweight: Less than 18.5 kg/m2 
• Normal range: 18.5 kg/m2 to 24.9 kg/m2 
• Overweight: 25 kg/m2 to 29.9 kg/m2 
• Obese, Class I: 30 kg/m2 to 34.9 kg/m2 
• Obese, Class II: 35 kg/m2 to 39.9 kg/m2 
• Obese, Class III: more than 40 kg/m2 

The waist-to-hip ratio should be measured. More than 1:1 in men and more than 0:8 in women is considered significant. 

Make note of the following:  

• Acne patterns and appearance 
• Excessive hair growth (Hirsutism) 
• Skin tags 
• Darkening or thickening of the skin (Acanthosis nigricans) 
• Usually occurs in intertriginous areas. This hyperpigmentation usually occurs in skin fold areas, such as the back of the neck, axilla, and groin, and may include thickening of the skin (3).  
• Gynecomastia, abdominal pannus, hepatosplenomegaly, hernias, hypoventilation, pedal edema, varicoceles, stasis dermatitis, and gait abnormalities can be present. 

The following additional evaluations can be performed (9): 

• Skinfold thickness 
• Bioelectric impedance analysis 
• CT, MRI, DEXA 
• Water displacement 
• Air densitometry studies 

Laboratory Studies 

Laboratory studies include a complete blood count, basic metabolic panel, renal function, liver function study, lipid profile, HbA1C, TSH, and vitamin D levels. Labs should be ordered based on individualized care for higher risk factors, signs and symptoms, and medical conditions. 

• Complete blood count (CBC) 
• Comprehensive metabolic panel (CMP)  
• Fasting blood glucose  
• Liver enzymes 
• Renal function 
• Electrolytes  
• Fasting lipids 
• Triglycerides 
• Low-density lipoprotein (LDL) cholesterol  
• High-density lipoprotein (HDL) cholesterol  
• Total cholesterol 
• Hemoglobin A1c (HbA1c) 
• Thyroid-stimulating hormone (TSH) 
• 25-hydroxyvitamin levels 

Individualized Laboratory Studies: 

• Urinalysis and/or urine for microalbumin/creatinine for patients at risk for kidney disease 
• Diabetes, hypertension, nephrotic syndrome, etc. 
• Glucose tolerance testing 
• Fasting insulin testing or other indices of insulin resistance 
• Prolactin, estradiol, follicle-stimulating hormone, luteinizing hormone, and pregnancy test in women with unexplained oligomenorrhea or amenorrhea.  
• Testosterone for men with impotence or hypogonadism. 
• Iron studies in patients with a history of bariatric surgery. 
• High-sensitive C-reactive protein (hs-CRP) can also be used for cardiovascular risk management (8) 

Diagnostic Testing 

Additional studies such as ECG, cardiac testing, and sleep studies may also be appropriate to evaluate associated medical conditions (8, 9). 

• Cardiac stress testing  
• Echocardiogram  
• Coronary calcium scores  
• Ankle-brachial index  
• Sleep studies  
• Imaging of the liver  
• Resting metabolic rate (RMR) 

Diagnosis 

To diagnose obesity, BMI measurement and clinical assessment of weight-related complications are recommended (5). 

Figure 2. Body Mass Index (5) 

The severity of obesity should be evaluated based on an overall assessment of adipose tissue mass, distribution (using measurements like waist circumference, waist-to-hip circumference ratio, or waist-to-height ratio), and the presence of associated health or well-being harm, including metabolic, physical, or psychological well-being (6). 

Body mass index (BMI) is helpful in the overall classification, but BMI should not be solely relied on as a diagnostic and staging tool. BMI can lead to misclassification, especially in those who are very muscular or frail, as well as in populations with different body composition and cardiometabolic risk (6). BMI is an imperfect measurement of adipose tissue mass and does not measure adipose tissue distribution or function and does not factor in the presence of weight-related health or well-being consequences. 

Body composition is an optimal tool for determining health risks. In this regard, several techniques have been developed; for example, an Air Displacement Plethysmograph (ADP) that uses whole-body densitometry to determine body composition (body fat vs. muscle mass). Lean tissue, which is >70% water, is a good conductor of electrical current, whereas fatty tissue, which is hydrophobic and low in water, is not. An increase in body fat is associated with increased electrical resistance combined with a skinfold thickness measure for subcutaneous fat. 

Men and women have significant differences in their fat mass and distribution patterns. A healthy body fat amount in men is considered to be between 12 and 18% (3% is essential for insulation and protecting vital organs). For women, a healthy body fat level falls between 20 and 25% (12% is considered essential for normal reproductive function).  

Guidelines for Management of Obesity 

The current standard of care in the management of overweight and obesity in adults was outlined in two guidelines developed by the following organizations (5): 

• The American College of Cardiology (ACC), the American Heart Association (AHA), the Obesity Society (TOS) 
• The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) 

Figure 3. Timeline: Obesity Management  

Various leaders in the field have developed complementary guidance. Additionally, several pharmacotherapies have been approved by the FDA for the treatment of obesity, as well as procedures and devices for weight loss. Research in obesity treatment continues to progress.  

The primary entity in charge of guidelines for obesity and weight management in the United States is the National Institutes of Health (NIH), specifically the National Heart, Lung, and Blood Institute (NHLBI). This organization publishes the clinical guidelines for the identification, evaluation, and treatment of overweight and obesity in adults. 

The NIH collaborates with the American College of Cardiology (ACC) and the American Heart Association (AHA) to develop and endorse these guidelines. 

On a global scale, the World Health Organization (WHO) provides international guidelines and standards for obesity and weight management. 

Other notable organizations involved in creating and updating guidelines include: 

• Centers for Disease Control and Prevention (CDC) 
• American Medical Association (AMA) 
• American Academy of Pediatrics (AAP) 
• Obesity Society 

These organizations work together to provide evidence-based recommendations for healthcare providers and the general public. 

Treatment 

Weight management and weight loss are fundamental goals in treating obesity. Managing obesity requires ongoing collaboration with a committed patient and informed clinicians. In patients diagnosed with obesity, weight-related complications should be evaluated at regular intervals. Obesity requires a multifaceted, patient-centered, individual approach, not a “one size fits all” approach.  

A reduction in caloric intake forms the foundation of any weight-loss strategy. According to both guidelines, individuals with obesity who intend to lose weight should be given guidance on: 

Both guidelines recommend that patients pursue behavioral interventions that foster adherence to physical activity and meal plan prescriptions. Interventions are often multidisciplinary, including dietitians, psychologists, and psychiatrists. Participation could be in-person or remotely, but consistency is key. 

Several factors can impact the management of obesity: 

• Age 
• Race 
• Gender 
• Individual physiology  
• Economic status  
• Understanding of nutrition and physical activity 
• Current medications 
• Concurrent illnesses  
• Home environment (e.g., employment, food access, stressors, family dynamics, culture, school, travel) 
• Work environment (e.g., food access, stress, nature of work, wellness programs, travel 
• Use of apps, text messages, and social media 
• Ability to obtain wearable technologies 
• Bariatric surgery  

Use of Sensitive Terminology on Obesity 

It is meaningful to be mindful of the harm terminology can cause. Certain words are attached to shame, and shame has no place in the management of obesity. “People-first” language recognizes the potential hazards of referring to or labeling individuals by their disease. “Patient who has pre-obesity or obesity” or “patient with overweight or obesity” are preferred over “obese patient.”  

• Encouraged Words: 
  • Weight 
  • Overweight 
  • Body mass index 
  • Affected by obesity 
  • “Patient who has obesity” 
• Discouraged Words: 
  • Morbidly obese 
  • Heavy 
  • Fat 
  • Large size 
  • “Obese patient” 

Healthcare Environment Consideration 

Patients with obesity may likely have negative feelings or prior experiences when in healthcare environments. Providers and staff should receive training on weight bias and providing a supportive environment. 

Appropriate medical equipment should be available, including large adult blood pressure cuffs (or thigh cuffs on patients with an upper-arm circumference greater than 34 cm), longer needles to draw blood, larger gowns, large vaginal specula, and scales with the capacity to measure weight more than 400 pounds. Privacy should be a priority, ensuring their right to privacy and dignity; thus, weight scales are optimally located in a private area wherein the value is only seen by the patient and provider (8). 

Initial Management of Overweight and Obesity  

A structured lifestyle intervention program designed for weight loss that includes a healthy meal plan, physical activity, and behavioral intervention is recommended for all patients who are overweight or obese (5). These include (5): 

• Recommend 30–60 min of moderate physical activity on most days of the week, taking physical impairments and medical conditions into consideration. 
• Nutrition education focuses on decreased caloric intake, encouraging healthy food choices, and minimizing restaurant and social eating situations.  
• Encourage consumption of 5–6 servings of fruits and vegetables daily. 
• Weekly weight checks. 
• Encourage nonfood rewards for positive reinforcement. 
• Stress management techniques. 

Nutrition Interventions 

Maintaining healthy nutrition habits is essential. It is important to emphasize life-long maintainable habits instead of “crash diets”.  

When providing guidance on nutrition, the following are important points to recognize (8): 

• Nutrition therapy has optimal health outcomes when the dietary interventions are evidence-based, quantitative, qualitative, and achieve patient adherence. 
• A low-calorie diet is 1200 to 1800 kcal/day; a very low-calorie diet is generally < 800 kcal/day. Each recommendation should be individualized. 
• The substitution of saturated fats with ultra-processed carbohydrates does not improve cardiovascular disease risk. 
• Low-carbohydrate diets typically consist of 50 – 150 grams of carbohydrates per day; very low-carbohydrate diet is < 50 grams of carbohydrates per day 
• A ketogenic diet plan restricts carbohydrate intake and typically encourages avoidance of ultra-processed and refined foods, foods high in glycemic index/load, and foods rich in trans fatty acids.  
• A Mediterranean diet plan encourages the intake of vegetables, fruits, legumes, whole grains, nuts, seeds, seafood, olive oil, poultry, eggs, and red wine; this diet discourages high amounts of red meats, meat products, and ultra-processed carbohydrates. 
• A DASH dietary pattern encourages vegetables, fruits, whole grains, fat-free or low-fat dairy products, fish, poultry, lean meats, nuts, seeds, legumes, fiber, high-calcium foods, potassium, and magnesium. A major component of this diet is the following restrictions: 
  • Sodium intake less than 2300 mg per day 
  • Total fat intake less than 27% of total daily calories 
  • Cholesterol intake of less than 150 mg per day  
• Vegetarian diets encourage vegetables, fruits, whole grains, legumes, seeds, and nuts. 
• Fasting (alternative day, intermittent, or time-restricted eating) has been shown to contribute to overall caloric restriction and weight reduction. 
• In general, low-calorie and non-nutritive sweeteners may have physiologic and/or metabolic effects of unknown clinical significance. Saccharin may increase body weight compared to aspartame, rebaudioside A, and sucralose (8).  

Figure 4. Energy Consumption Intended to Cause Negative Calorie Balance and Loss of Fat Mass (8) 

Consider the following: 

• Comorbidities that could be affected by the nutrition plan  
• Eating behaviors 
• Cultural background 
• Food availability 
• Time constraints and financial issues 
• Nutritional knowledge and cooking skills  

The AACE/ACE guidelines recommend that behavioral interventions be escalated for patients who do not achieve 2.5% weight loss within 1 month of starting treatment (5). An in-person, high-intensity program (≥14 sessions in 6 months) is considered the most effective behavioral treatment for overweight or obesity (5).  

Referral to a nutrition professional can be prescribed in patients who are agreeable to this intervention. It is important to evaluate their current understanding and habit

Individualized Exercise / Activity Guidance 

Physical activity is essential in the management of obesity, but the plan must be highly individualized.  

Considerations to ensure safety: 

• Assess current physical limitations and mobility status. 
• Review previous injuries or surgeries. 
• Assess the patient’s readiness 
• Discuss expectations and goals 
• Assess potential need for medical testing/evaluation (i.e., cardiac stress testing, pulmonary function tests, musculoskeletal assessment, etc.) 
• Evaluate medications for contraindications with activity  

Figure 5. Physical Activity and Mobility Considerations 

Metabolic Equivalent Tasks 

• Metabolic Equivalent Tasks (METS) are used to assess the intensity of physical exercise (Kcal = METS x weight x time) and are equal to the amount of energy expended in one minute while lying down at rest (8) 
• METS = 3.5 milliliters of oxygen consumption per kilogram of body weight per minute (3.5 ml/kg/min) 
• Note: Oxygen consumption and demand vary with increased age and respiratory or cardiac diseases.  
• Standing = 2 METS 
• Walking 4 miles per hour = 4 METS  
• Running 10 miles per hour = 16 METS 

Behavioral Interventions 

The recruitment of behavioral therapies can be an effective tool. The following specialties are resources: 

• Dietitian 
• Nurse educator 
• Physical activity professional trainer 
• Mental-health professional 
• Certified health coach 
• Web-based mental health support programs  

Therapies and techniques can include self-monitoring, stimulus control, cognitive restructuring, goal setting, problem-solving skills, and social support (8). 

Pharmacological Treatment  

Research has found that pharmacotherapy used with lifestyle modifications correlates with greater and more sustained weight loss when compared with lifestyle modifications alone (8).  

The amount and duration of weight loss varies among patients taking an anti-obesity medication. Patients have an average of 5 – 10% weight reduction (8). 

FDA-approved Anti-obesity Medication Indications: 

• Patients with obesity (e.g., BMI > 30kg/m2) 
• Patients with overweight (e.g., BMI > 27kg/m2) with the presence of complications (e.g., type 2 diabetes mellitus, hypertension)  
• If no clinical improvement (e.g., at least 3 – 5% loss of baseline body weight) after 12-16 weeks, consider alternative anti-obesity medication or increasing dose of current regimen.  

BMI is the only measure listed in the prescribing information for these anti-obesity medications, but prescribers must recognize the limitations of BMI measurement, especially in those with higher mass of lean muscle. 

In general, anti-obesity drugs are contraindicated in pregnancy, and should be avoided in women who are pregnant, trying to become pregnant, or who are breastfeeding (8). 

All anti-obesity medications have contraindications for hypersensitivity to the drugs. 

Medications Approved for Short-Term Use: 

• Phentermine 
• Diethylpropion 
• Phendimetrazine 
• Benzphetamine 

Medications Approved for Long-Term/ Chronic Use: 

• Orlistat 
• Liraglutide 
• Phentermine HCl/topiramate extended-release 
• Naltrexone HCl/bupropion HCl extended-release 
• Semaglutide 

The table below outlines medications that are approved for use in obesity management. 

Table 1. Approved Obesity Managment Medications (6, 8, 11) 

Surgical Procedures and Devices 

Surgical treatment, often referred to as bariatric surgery, can be an effective option for individuals with severe obesity when other weight loss methods have failed, and the patient meets specific criteria. 

Bariatric surgery not only can reduce weight, but has the potential to improve obesity-related conditions. The surgery has significant risks to evaluate, so individualized care plans and risk mediation is vital.  

The main types of bariatric surgery include (2, 8): 

• Roux-en-Y Gastric Bypass (RYGB) 
• Sleeve Gastrectomy 
• Adjustable Gastric Banding (AGB) 
• Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 
• Intragastric Balloon 

Bariatric surgery programs must meet strict criteria and follow the guidance of the following: 

• MBSAQIP Center of Excellence  
  • Managed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program of the American College of Surgeons 
  • The most widely used credentialing program for bariatric surgery programs 
  • Health insurance providers may have specific qualifications. 

Eligibility is determined through a rigorous evaluation of patient status. The surgeries are typically only considered for individuals with a certain BMI (often 40 or higher, or a BMI of 35 or higher with obesity-related health conditions). 

A Pre-Surgical Evaluation is a core component of the process. A comprehensive assessment including medical, nutritional, psychological, and surgical evaluations occurs. All surgeries carry risks, including infection, bleeding, and respiratory complications. These particular surgeries require a lifelong commitment to dietary changes, regular follow-up, and possibly supplementation to prevent nutrient deficiencies. 

Roux-en-Y Gastric Bypass (RYGB) 

This procedure involves creating a small pouch at the beginning portion of the stomach and connecting it directly to the small intestine, bypassing a significant portion of the stomach and the upper part of the small intestine (2). Essentially, the process reduces food intake and calorie absorption by altering the digestive process. Providers need to discuss the risks of this surgery, which include but are not limited to nutrient deficiencies, dumping syndrome, complications in surgery, and the potential need for revisional surgery (2). 

Sleeve Gastrectomy 

This surgery involves removing roughly 80% of the stomach, leaving a tube-like structure in the gastrointestinal tract. The mechanism reduces the stomach’s capacity to hold food, leading to reduced food intake. The is no intestinal bypass involved in this surgery. Potential complications include nutrient deficiencies and surgical complications, such as bleeding or gastric leakage (2). 

Adjustable Gastric Banding (AGB) 

This procedure involves an adjustable band that is surgically placed around the upper part of the stomach, creating a small stomach pouch above the band. The purpose of the encased and reduced stomach size is to restrict food intake by making the patient feel full after eating small amounts of food (8). The benefits of this surgery are that this banding is adjustable and reversible, and there is a lower risk of nutrient deficiencies. However, risks and complications can occur, including band slippage or erosion (2). Weight loss is typically slower with this procedure. 

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 

This is a more complex procedure that involves two processes: a sleeve gastrectomy and the rerouting of the small intestine to separate the flow of food from bile and pancreatic juices. Significant and sustained weight loss has been noted, which effectively improves obesity-related conditions (8). However, the is a higher risk of nutrient deficiencies and increased risk for surgical complications (8). 

Intragastric Balloon 

In this procedure, a balloon is endoscopically placed in the stomach and filled with saline or gas (2). This serves to reduce stomach capacity and reduce food intake. This procedure is minimally invasive and temporary. Common adverse effects and complications include nausea, vomiting, and deflation or migration of the balloon. 

Bariatric surgery can be a life-changing option for many individuals struggling with severe obesity, offering substantial and sustained weight loss and improvement in health. However, it requires careful consideration, thorough and individualized evaluation, and a strong commitment of the patient to post-surgical lifestyle changes. 

Self-Management 

“When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates.” – Pearson’s Law 

Losing weight can be overwhelming. Changing lifestyle habits and adjusting to nutrition changes, increased activity, and medications take time and patience. Advocacy and support are essential. These are helpful tips to help maintain and achieve a healthy weight: 

• Track progress 
• Recruit trusted family and friends for encouragement and accountability. 
• Use daily activity logs to track daily food intake and physical activity  
  • Apps 
  • Journals 
  • Notebook  
  • Whiteboard  
  • Pedometer logs 
  • Dynamic training metrics (i.e., miles run, laps swam, etc.)  
• Daily weighing has been shown to have a positive impact on long- and short-term weight loss for many people. 
  • Set specific goals 
  • Examples: “Walk 30 minutes, 4 days a week” 
• Goals must be realistic about time and abilities. 
  • Gradual changes lead to success.  
• Lifestyle is a long-term process.  
  • Use rewards that are meaningful and non-food if goals are met. 
• Identify environments or social activities that hinder goals. 
  • Example: Specific restaurants, emotional triggers, etc.  

Case Study: Management of a Patient with Obesity and Hypertension 

Mr. T is a 52-year-old male who presents to the clinic for a routine check-up. He reports feeling increasingly fatigued and has noticed a significant weight gain over the past year. His blood pressure readings at home are consistently high. He reports taking his medications as prescribed. Mr. T denies any regular exercise, he works full-time as a bank manager. 

Assessment 

• Blood Pressure: 150/95 mmHg (medication taken at 0700 this morning) 
• Heart Rate: 80 bpm 
• Height: 5’10” (178 cm) 
• Weight: 280 lbs. (127 kg) 
• BMI: 40.1  
• Waist Circumference: 45 inches 
• Medical History: Diagnosed with hypertension 10 years ago, family history of cardiovascular disease, obesity, kidney disease, and diabetes. 
• Medications: Lisinopril (10 mg daily) for hypertension. 

Laboratory Test Results 

• Fasting Blood Glucose: 110 mg/dL  
  • Lipid Profile: 
    • Total Cholesterol: 240 mg/dL 
    • LDL: 150 mg/dL 
    • HDL: 35 mg/dL 
    • Triglycerides: 200 mg/dL 

Diagnosis 

• Primary Diagnosis: Obesity (Class III) 
• Secondary Diagnosis: Hypertension, uncontrolled 

Management Plan 

Lifestyle Modifications 

• Diet: Referral to a registered dietitian for a personalized nutrition plan focusing on a caloric deficit, balanced macronutrients, and reduction of sodium intake. 
  • Goals: Achieve a weight loss of 1-2 lbs per week through dietary changes. Emphasize whole foods, fruits, vegetables, lean proteins, and whole grains. 
• Physical Activity: Encourage a gradual increase in physical activity. 
  • Begin with 30 minutes of moderate-intensity exercise, such as walking, 5 days a week, increasing intensity and duration as tolerated. 

Behavioral Therapy 

• Referral to a behavioral therapist for cognitive-behavioral therapy (CBT) to address emotional eating and establish healthier coping mechanisms. 
• Goals: Develop strategies for managing stress, triggers for overeating, and adherence to lifestyle changes. 

Mr. T is motivated and desires to make these changes to improve his overall health. He becomes active in establishing short and long-term goals with his provider.  

• Short-Term Goals (3-6 months): 
  • Begin walking in the evenings with his wife, after work, for 20-30 minutes at least 5 days per week. 
  • A coworker attends a weight loss support group that has educational offerings on nutrition and exercise; Mr. T plans to join and become active in this group. 
  • Achieve a 5-10% reduction in body weight. 
• Long-Term Goals (1 year and beyond): 
  • Maintain weight loss and prevent weight regain. 
  • Sustain blood pressure control with minimal medication adjustments. 
  • Reduce the risk of cardiovascular disease. 
  • Reduce the risk of diabetes. 

Follow-Up 

• Schedule follow-up visits every 1-2 months to monitor progress, and blood pressure, and adjust the treatment plan as needed. Repeat fasting blood glucose, lipid profile, and other relevant labs every 3-6 months. 
• If lifestyle modifications are not effective, consider and discuss pharmacotherapy for weight loss with Mr. T. Evaluate appropriate indications for Phentermine, Phentermine/Topiramate, Orlistat, or Liraglutide, based on the patient’s tolerance and contraindications. 

Conclusion

Understanding the etiology, pathophysiology, and complications of obesity is essential in developing a plan to manage obesity. This requires a holistic approach and effective obesity management, and prevention strategies often involve addressing multiple aspects of this complex condition. 

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