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KEY CONCEPTS

KEY CONCEPTS

  • image Two clinical measures of excess body fat, regardless of sex, are the body mass index (BMI) and the waist circumference (WC). BMI and WC provide a better assessment of total body fat than weight alone and are independent predictors of obesity-related disease risk.

  • image Excessive central adiposity increases risk for development of type 2 diabetes, hypertension, and dyslipidemia.

  • image Weight loss of as little as 5% of total body weight can significantly improve blood pressure, lipid levels, and glucose tolerance in patients with overweight and obesity. Sustained, large weight losses (ie, after bariatric surgery) are associated with a lower risk of cardiovascular events and death and long-term improvements in many of the complications associated with obesity.

  • image Clinicians should consider the weight-altering effects of medications used to treat comorbid conditions (eg, antidepressants, antipsychotics, antiepileptics, and antidiabetics) and select medications that promote weight loss or are weight-neutral.

  • image Bariatric surgery is reserved for patients with extreme obesity having a BMI more than or equal 40 kg/m2 or BMI more than or equal to 35 kg/m2 with a significant comorbidity.

  • image Pharmacotherapy may be considered an adjunctive treatment in patients with a BMI more than or equal to 30 kg/m2 or BMI of 27 to 30 kg/m2 with a comorbidity if comprehensive lifestyle modifications (eg, diet, exercise, and behavioral modification) fail to achieve or sustain weight loss.

  • image Weight regain occurs with a high probability when pharmacotherapy for obesity is discontinued.

  • image Pharmacotherapy should be discontinued if weight loss of at least 5% is not achieved after 12 weeks of maximum-dose therapy with lorcaserin, phentermine–topiramate, or bupropion–naltrexone because significant weight loss is unlikely to be achieved despite continued therapy. Liraglutide should be discontinued if weight loss of at least 4% is not achieved after 16 weeks of therapy.

  • image The Food and Drug Administration (FDA) does not regulate labeling of herbal and food supplement diet agents, and content is not guaranteed.

PATIENT CARE PROCESS

Patient Care Process for Management of Obesity

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Collect

  • Patient characteristics (eg, age, race, sex)

  • Patient history (past medical, family, social — dietary habits, tobacco use)

  • Obesity-related conditions (see Fig. 161-1)

  • Current medications including prescription, nonprescription, and herbal product use

  • Weight loss history and prior attempts to lose weight

  • Objective data

    • Height, weight, BMI, waist circumference, and blood pressure

    • Labs (eg, fasting glucose, hemoglobin A1c, lipid panel)

Assess

  • Causes of secondary obesity (eg, insulinoma, Cushing syndrome)

  • Current medications that may contribute to weight gain

  • Presence of obesity-related comorbidities (eg, hypertension, dyslipidemia, coronary artery disease, type 2 diabetes mellitus, sleep apnea, increased waist circumference; see Fig. 161-3)

  • Class of overweight and obesity determined by BMI, waist circumference, and obesity-related comorbidities (see Table 161-3)

  • Readiness to engage in weight loss efforts and potential barriers to success

  • Candidacy for treatment with implantable medical devices, bariatric surgery, or pharmacotherapy

Plan*

  • Nonpharmacologic lifestyle intervention including low-calorie diet, physical activity, and behavioral modifications

  • Pharmacotherapy (if appropriate) including ...

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