The first step in treating the obese patient is the medical assessment. The patient may desire weight loss or may be reluctant. By all means encourage the reluctant patient with medical complications of obesity to lose weight, but recognize that any attempt at weight loss will be almost certain to fail, even in the short run, if the patient is not self-motivated to change and does not believes that this change is attainable (self-efficacy).
Begin with a thorough history and physical. The weight history may be of value in identifying precipitants of weight gain and suggesting fruitful avenues for treatment. For example, a change in job leading to a reduction in physical activity may be detected. Also of interest is whether the onset of obesity was in childhood or later in life. Although only about one-fifth of obese adults were obese children, about four-fifths of obese children become obese adults. Obesity in childhood often results in only an increase in average cell size, not number. Treatment of the hyperplas-tic form of obesity is said to be more difficult because weight reduction does not greatly reduce the number of fat cells, only their average size.
Other information that can be gleaned from the weight history include postpartum weight gain (the average woman weighs about 10 lb more 2 years postpartum compared with prepregnancy, but the amount is extremely variable), weight gain after smoking cessation (average gain of about 6 lb, again highly variable, and the most common
Table 35-2. Components of Comprehensive Weight Control Programs
1. Medical assessment and monitoring
2. Behavioral assessment and modification
3. Dietary assessment and modification
5. Long-term maintenance support excuse women give for not wanting to quit), and evidence of yo-yo dieting and disorders such as binge eating (consuming inordinately large amounts of food within a specified period 3 times a week or more in private for over 1 year with loss of control and negative emotional sequelae) or bulimia nervosa (binging plus purging, either by vomiting, use of diuretics, or excessive exercise). When an eating disorder is suspected, referral to a center experienced in the treatment of these problems is recommended. There is a separate chapter on anorexia and bulimia (see Chapter 38, "Anorexia Nervosa and Bulimia").
The history should also include questions to help rule out endocrine causes of obesity, such as hypothyroidism, hyperadrenalism, and neuroendocrine tumors, though in adults even the most common of these, hypothyroidism, is rarely a significant factor in causing obesity. Also inquire about drugs that may be associated with weight gain, such as sulfonylureas, insulin, steroids, most psychotropics, and antiseizure medications. Also assess for symptoms suggestive of diseases that often complicate obesity, such as type 2 diabetes, coronary artery disease, hypertension, and sleep apnea. Symptoms and signs of depression should also be sought, as depression is a common accompaniment of severe obesity and may require additional treatment. Childhood or later sexual or physical abuse is also common, and is usually not volunteered, so it needs to be specifically elicited after rapport has been established. Individual or group counseling may be helpful when sexual or other abuse is detected. The family history is of particular interest for endocrine disorders, obesity, and its complications.
The physical examination may be somewhat limited when the patient is morbidly obese, but it can yield evidence of endocrine causes and detect complicating conditions. It is necessary to obtain not only an accurate weight and height for calculation of the BMI but also the simple tape measurement of the waist circumference, an important modifier of the risk in obesity, as previously noted. Laboratory evaluations should serve to screen for the complications of obesity. Blood chemistries should include, in particular, counts of fasting serum glucose, cholesterol, and triglycerides and liver function tests.A thyroid stimulating hormone level should be obtained, as well as other endocrine and metabolic tests if a problem is suspected.
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