Overview: Obesity

• In 2004, obesity was reclassified by ease. Obesity is characterized by Medicare as a chronic dis an excess of body fat and is most often defined by the body mass index (BMI), a mathematical formula that correlates well with excess weight at the population level. The BMI is measured by taking weight in kilograms, divided by height in meters squared (kg/m²).

• Worldwide, adults with a BMI of 25 to 30 are categorized as overweight, whereas obesity is classified according to stages or grades (Table 38-1).

• Grade III obesity was firmerly known as morbid obesity, but the term was appropriately changed for several reasons morbidity may not occur at a BMI higher than 40 but certainly can be found at BMIs lower than that.

• BMI can sometimes be inaccurate became it does not distinguish between fat and muscle, nurdoes it predict body fat distribution. On a population level, however.

• BMI does seem to o track trends in adipodty as opposed to mascularity, and those individuals with large muscle mass with resulting high BMIs are easily distinguishable from those with large amounts of adipose tissue.

Important Points to Consider

• Laboratory tests to consider in obesity include fasting blood the evaluation of sugar (100 to 125 indicates prediabetes), triglycerides (high in metabolic syndrome), high-density lipoprotein (low in vitamin D deficiency): 25-hydroxyvitamin D: thyroid-stimulating hormone (hypothyroidism); cortisol, B a spot or 24-hour urine (Cushing disease), high-sensitive C-reactive protein (inflammation); and aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase (steatohepatitis).

• Interventions must match readiness to change. Commitment to behavioral change is maximized when goals are self-selected and fit with personal lifestyle and values. Patient ambivalence is universal and should be recognized and acknowledged. Doing so will encourage the patient to argue for instead of against change.

• The best nutritional plan for weight loss is the one to which the patient will adhere.

Prevention Prescription

• The basis for prevention of weight gain is learning how to follow an anti-inflammatory diet that emphasizes vegetables and fruits from all parts of the color spectrum, whole grains, fish and other sources of omega-3 fatty acids, vegetable protein more than animal sources, monounsaturated fats, and low-fat dairy. To make this a long-term lifestyle change, fruits, vegetables, and high-fiber grains must be used to displace high-calorie processed foods of poor nutritional content (see Chapter 86, The Anti-inflammatory Diet).

• Fostering a healthy relationship with food and becoming aware of reactive, habitual patterns of eating are vital to preventing weight gain. Learning techniques of mindful eating can facilitate this process.

• Physical activity may play a role in the prevention of weight gain; 30 minutes/day, 5 to 7 days/week of any physical activity should be encouraged (see Chapter 88, Writing an Exercise Prescription).

Integrative therapeutics review

Medical History

• Assess for comorbid diseases and concomitant medications that induce weight gain.

Nutrition History

• Determine previous weight loss attempts and use 24-hour recall and food frequency questionnaires.

• Rule out clinically significant eating disorders (anorexia and bulimia nervosa, binge-eating disorder, nighttime eating syndrome).

Anthropometric Measurements

• Weight, height, BMI, waist circumference, body composition, blood pressure, heart rate

Laboratory Tests

• Complete blood count, metabolic profile, fasting lipids, thyroid-stimulating hormone, liver function tests, fasting serum glucose and insulin, hemoglobin Alc (if diabetic), high-sensitive C-reactive protein, 25-(OH) vitamin D Electrocardiogram, unless recent one (within 6 to 12 months) is available for review

General Evaluation

• Assess for motivation, importance, and confidence for weight loss, barriers to change, and realistic weight loss goals.

• Assess exercise history, sleep patterns, relevant stressors, and social support.

Therapeutic Options

• BMI 25 or higher

• Promote a balanced hypocaloric diet and physical activity, and provide behavioral modification counseling.

• Reduce caloric intake from baseline by 500 to 1000 cal/day to yield a 1 to 2-lb weight loss per week.

• Encourage purposeful activity for at least 60 minutes daily 6 to 7 days of the week. Total time may be broken into short bouts of 10 to 15 minutes each during the initial adoption of an exercise program only.

• Stress management techniques include mind-body therapies such as meditation, biofeedback, or hypnosis. Ensure adequate sleep and treatment of any concomitant sleep disorders.

• Suggest interactive individual or group support sessions for nutrition education and behavioral modification.

• Refer to a dietitian, mental health professional, or exercise specialist as needed.

• BMI 30 or higher or 27 or higher with comorbid conditions Full liquid fast, protein-sparing modified fast, and pharmacotherapy with dietary intervention are suitable for this BMI level.

• Orlistat, 120 mg orally three times daily, is the first option. This medication is localized to the gut and can be used in combination with phentermine.

• Phentermine can be taken alone (15 to 37.5 mg daily) or in combination with orlistat (approved for 3-month use by the Food and Drug Administration).

• Suggest omega-3 fatty acids, at 2 to 4 g/daily.

• Treat vitamin D deficiency appropriately to achieve serum 25-(OH) vitamin D levels between 40 and 60 ng/mL..

• Other dietary supplements should be used, if at all, on an individualized basis determined by risk-to-benefit ratio and by evaluating the efficacy and safety of each product or combination.

• BMI 40 or higher or 35 of higher with comorbid conditions Weight loss surgery, if other treatment modalities are ineffective, is suitable for this BMI level.

Key Web Sources

• http://www.csrees. usda.gov/nea/food/efnep/ers/documentation/24hour-recall.pdf.

• http://www. nutritionquest.com/assessment.

• http://www.calculator.org/calculate-online/health-fitness/basal-metabolic-rate.aspx.

• http://www.mayoclinic.com/health/

• http://www.fitday.com/.

• http://www.tcme.org/..