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Excess adipose tissue, typically quantified in adults by body mass index (BMI), ([kg]/[m2]), ≥30 kg/m2.
Obesity is associated with negative health outcomes. Abdominal obesity increases the risk of morbidity and mortality.
System(s) affected: endocrine/metabolic, cardiac, respiratory, gastrointestinal, musculoskeletal, dermatologic, mental health
Synonym(s): overweight; adiposity
Predominant age: Incidence rises in the early 20s.
Predominant sex: female > male
35% of U.S. adults are obese 1,2.
40% of men and 25% of women are overweight.
Pediatric obesity is defined as a BMI ≥95th percentile, by age and sex specific WHO or CDC growth curves.
Obesity during adolescence and young adulthood is strongly associated with obesity in adulthood.
Obesity is caused by an imbalance between food intake, absorption, and energy expenditure.
Underlying organic causes include psychiatric disturbances, hypothyroidism, hypothalamic disorders, insulinoma, and Cushing syndrome.
Medications that contribute to obesity include corticosteroids, neuroleptics (particularly atypical antipsychotics), and antidepressants.
Genetic syndromes such as Prader-Willi and Bardet-Biedl are found in a minority of people with obesity.
Multiple genes are implicated in obesity.
Consumption of calorie-dense food
Low socioeconomic status
>2 hr/day of television viewing
Encourage at least 1 hour of daily exercise, limited television viewing, and moderation in portion size.
Avoid calorie-dense and nutrient-poor foods such as sugar-sweetened beverages and processed foods.
Diet and exercise habits
Prior attempts at weight loss
Reported readiness to change lifestyle
Social support and resources
Comorbidities: diabetes mellitus type 2, hypertension, hyperlipidemia, sleep apnea
Symptoms suggesting hypothyroidism, Cushing syndrome, and genetic syndromes
Screen for underlying physiologic causes as well as associated comorbid conditions.
Labs should be done while fasting (nonfasting labs within normal limits are considered adequate).
Glucose, total insulin, hemoglobin A1C, lipids
Thyroid function tests
LFTs (fatty liver)
Goal is to achieve and sustain loss of at least 10% of body weight.
Track nutritional intake and physical activity habits.
Use of commercial weight loss programs (e.g., Weight Watchers) can be more effective than “standard of care” counseling 3[B].
Behavior therapy and cognitive-behavioral methods result in modest weight loss and are most effective when combined with dietary and exercise treatments.
Include diet, exercise, and behavior therapy for all patients without comorbid conditions who are considering pharmacologic treatment.
NIH guidelines suggest at least 6 months nonpharmacologic treatment.
Consider medication for unsatisfactory weight loss in those with:
Relapse common after medications are discontinued.
Treat comorbidities (such as diabetes and hyperlipidemia).
When compared to placebo, medications have been associated with at least 5% weight loss at 52 weeks 4[B]. Orlistat (Xenical) is a lipase inhibitor that decreases the absorption of dietary fat. Dose: 120 mg PO TID with meals containing fat; omit dose if meal is skipped or does not contain fat. Patients must avoid taking fat-soluble vitamin supplements within 2 hours of taking orlistat. The FDA has approved orlistat (Alli) 60 mg PO TID to be sold over the counter as a weight loss aid. Adverse effects mainly GI (cramps, flatus, fecal incontinence)
Appetite suppressants recommended for short-term treatment (≤6 months) 5[A]
Only beneficial in patients who exercise and eat reduced calorie diet
Schedule IV drugs:
Requires complex presurgical evaluation, surgery, and follow-up in a skilled treatment center
Surgical procedures include biliopancreatic diversion, Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric banding, vagal blocking therapy (Maestro Rechargeable system), and gastric aspiration (AspireAssist).
Surgical treatment is the most effective long-term weight-loss treatment available for morbidly obese patients, but there is insufficient evidence on longterm outcomes 6[A].
Physical activity is an integral part of any weight loss program, yet physical activity alone rarely results in significant weight loss.
Combination of weight training and aerobic activity is preferred over aerobic activity alone.
Long-term studies suggest net calorie reduction (500 to 1,000 kcal/day) and ease of use are more important than the composition of the particular diet for long-term results:
Very low-calorie diet (400 to 800 kcal/day)
Healthy diet and physical activity patterns
Focus on behaviors (not numbers)
Recommended Web site:
Lowest mortality associated with a BMI of 22
Long-term maintenance of weight loss is difficult.
Patient motivation is associated with successful weight loss 7.
Stroke (in men)
Hypoventilation and sleep apnea syndromes
Higher death rates from cancer: colon, breast, prostate, endometrial, gallbladder, liver, kidney
Increased sick leave
E66.9 Obesity, unspecified
R63.5 Abnormal weight gain
E66.8 Other obesity
E66.09 Other obesity due to excess calories
E66.01 Morbid (severe) obesity due to excess calories
278.00 Obesity, unspecified
783.1 Abnormal weight gain
278.01 Morbid obesity
414916001 obesity (disorder)
238131007 overweight (finding)
161833006 abnormal weight gain (finding)
450451007 Overweight in childhood (finding)
238136002 Morbid obesity (disorder)
A majority of American adults are overweight or obese.
Modification in dietary and physical activity patterns remain the cornerstone of therapy for obesity. Consider bariatric surgery in patients with a BMI >40 who have failed more conservative treatment, particularly if there are associated risk factors.
Medication may be indicated when nonpharmacologic treatment for 6 months has been ineffective and the patient has a BMI >30 or a BMI >27 with associated risk factors.