English Village, Gulan Street, Erbil, Kurdistan Region of Iraq

www.bcm-medical.com
Obesity

Differencial Diagnosis
CCushing's syndrome
DDeficiency in thyroid activity (hypothyroidism)
GGenetic disorders (e.g., Down syndrome)
SSevere familial high cholesterol (hyperlipidemia)
SSevere familial obesity
Tumors of the adrenal or pituitary gland

Specialist
CClinical Psychologist
EEndocrinologist
GGeneral Surgeon
InInternal Medicine Physician
NNeurologist
PPsychiatrist

Definition
Obesity is an increase in body weight beyond that considered ideal based on age,
height, and skeletal structure, as the result of an excessive accumulation of fat in the
body. Obesity predisposes the individual to an increased risk of diseases and conditions
("Overweight and Obesity").

One common standard to define increased body weight is the body mass index (BMI),
which is derived by dividing an individual's weight in kilograms by his or her height in
meters squared (BMI = kg/m2). Multiplying an individual's weight in pounds by 704 and
then dividing it twice by the individual's height in inches can also compute BMI.
Individuals with a BMI of 25.0 to 29.9 are considered overweight; those with BMI
greater than or equal to 30.0 kg/m2 are classified as obese; and individuals with a BMI
greater than 40.0 kg/m2 have severe (morbid) obesity ("Prevalence").

Simple obesity differs from morbid obesity. Morbidly obese individuals have a body
weight that is 2, 3, or more times the ideal weight and that begins to interfere with
normal physiological functions, such as breathing.
Risk: Most commonly, obesity occurs when energy intake (calories) exceeds energy use
(physical activity). Obesity can also result from disturbances in body hormones and
environmental or psychological factors. Certain rare illnesses (Cushing's disease,
polycystic ovary syndrome, depression) and medications (steroids, antidepressants) can
also increase the risk of excessive weight gain.

Obesity tends to run in families, which suggests a genetic cause in certain cases.
However, family members not only share genes but also diet and lifestyle habits that

English Village, Gulan Street, Erbil, Kurdistan Region of Iraq
www.bcm-medical.com
may contribute to obesity. An individual's environment includes lifestyle behaviors such
as what he or she eats and the amount of activity expended. Individuals may choose
high-fat diets because they often put taste and convenience ahead of nutritional
content.

In the US, more men than women are overweight, with 26.4% of men and 24.8% of
women having a BMI greater than 30.0 (Galuska). The proportion of men and women
who are obese varies greatly according to ethnicity: the prevalence of obesity is highest
for African-American women (39.0%) and African-American men (32.1%) (Galuska).

Obesity is most prevalent in the South (27.3%) and Midwest (26.5%), and least
prevalent in the Northeast (24.4%) and West (23.1%) (Galuska). The prevalence of
obesity also corresponds to education level, with the highest rates reported among
individuals with a high school diploma or lower level of education (29.1% of men and
32.6% of women), and the lowest rates among those who have graduated from college
(22.1% of men and 17.9% of women) (Galuska).
Incidence and Prevalence: The prevalence of obesity (defined as a BMI over 30.0)
has risen dramatically over the past several decades and continues to rise: in the US,
obesity rates increased 1.7% between 2005 and 2007 (Galuska). Overall, 25.6% of the
general population is obese (Galuska), and 67% of the population is either overweight
or obese (Prevalence).

Worldwide, about 1.6 billion individuals are overweight, of which 400 million are obese
(Obesity and Overweight). It is projected that by 2015, more than 2.3 billion adults
will be overweight, with 700 million of those individuals being obese (Obesity and
Overweight).
Diagnosis
History: Obese individuals are often cognizant of being overweight. Complaints may
include shortness of breath (Dyspnea); fatigue; joint pains in the hips, knees, and
ankles; poor mobility; and a general dissatisfaction with state of health. Family history
may point to diabetes or obesity.
Physical exam: The exam includes an assessment of body mass index (BMI). Other
measurements include the waist-to-hip ratio and skinfolds measurement, which are
taken by skinfold calipers and are measured at various locations on the individual's
body.

BMI is derived by dividing an individual's weight in kilograms by his or her height in
meters squared (BMI = kg/m2). Multiplying an individual's weight in pounds by 704 and

English Village, Gulan Street, Erbil, Kurdistan Region of Iraq
www.bcm-medical.com
then dividing it twice by the individual's height in inches can also compute BMI. To
calculate an individual's waist-to-hip ratio, divide the waist measurement (measured at
narrowest point) by the hip measurement (measured at fullest point). Women with
waist-to-hip ratios of more than 0.8 or men with waist-to-hip ratios of more than 1.0 are
called apples (because of their apple shape). Apples are at considerably greater risk
for coronary heart disease, diabetes, high cholesterol, stroke, and sleep apnea because
of their fat distribution than are pears (Obesity).
Tests: Blood sugar (glucose) measurements taken at various times, including after
fasting or after ingestion of glucose (tolerances), are used to evaluate diabetes. Blood
tests may also reveal high cholesterol, high fats (hyperlipidemia), and elevated uric acid
levels (hyperuricemia). Thyroid-stimulating hormone (TSH) should be measured to
exclude thyroid deficiency. The amount of body fat can be measured more accurately
using bio-impedance testing or air displacement plethysmography.
Treatment

The five medically accepted treatment modalities are diet modification, exercise,
behavior modification, drug therapy, and surgery. All these modalities, alone or in
combination, are capable of inducing weight loss sufficient to produce significant health
benefits in many obese individuals. Unfortunately, health benefits are not maintained if
weight is regained. With the exception of surgery, it is difficult for most individuals to
adhere to these modalities in a manner sufficient to maintain long-term weight loss.

Calorie restriction has remained the cornerstone of the treatment of obesity. The
standard dietary recommendations for losing weight include reducing total calorie intake
to 1,200 to 1,500 calories per day for women, and to 1,500 to 1,800 calories per day for
men (Obesity). Saturated fats should be avoided in favor of unsaturated fats, but the
low-calorie diet should remain balanced. Keeping a food journal of food and drink intake
each day helps individuals to stay on track.

The addition of an exercise program to diet modification results in more weight loss than
dieting alone and seems especially helpful in maintaining weight loss and preserving
lean body mass. Moderate activity (walking, cycling up to 12 miles per hour) should be
performed for at least 30 minutes per day, 5 days a week or more. Vigorous activity that
increases the heart rate (jogging, cycling faster than 12 miles per hour, and playing
sports) should occur for at least 20 minutes, 3 days a week or more. Although vigorous
workouts do not immediately burn great numbers of calories, the metabolism remains
elevated after exercise. The more strenuous the exercise, the longer the metabolism
continues to burn calories before returning to its resting level. Although the calories lost
during the postexercise period are not high, over time they may count significantly for
maintaining a healthy weight. Included in any regimen should be resistance or strength
training 3 or 4 times a week. Even moderate regular exercise helps improve insulin
sensitivity and in turn helps prevent heart disease and diabetes. Exercising regularly is
critical because it improves psychological well-being, replaces sedentary habits that
usually lead to snacking, and may act as a mild appetite suppressant.

English Village, Gulan Street, Erbil, Kurdistan Region of Iraq
www.bcm-medical.com

Behavior modification for obesity refers to a set of principles and techniques designed to
modify eating habits and physical activity. It is most helpful for mildly to moderately
obese individuals. One frequently used form of behavior modification called cognitive
therapy is very useful in preventing relapse after initial weight loss.

Drug options include anorexiants, which help individuals feel full after eating less food
and which lower the appetite, and a drug that blocks the absorption of fat from the diet.
These drugs are adjunctive rather than solo therapy.

Surgery for weight loss (bariatric surgery), which carries significant morbidity and
mortality, is reserved for well-informed and motivated severely obese adults (more than
180% overweight or whose BMI is greater than 40) whose condition has failed to
respond to medical weight control. Surgery may also be considered for individuals with
less severe obesity (BMI between 35 and 40) who have disabling joint disease,
pulmonary insufficiency, heart disease, hypertension, or diabetes. The most common
surgical procedures used to achieve weight loss are gastric bypass and gastric banding.
Other procedures include gastroplasty, partial biliopancreatic bypass, and jejunoileal
bypass.

After losing a great amount of weight due to bariatric surgery or a weight reduction
program, some individuals choose a cosmetic procedure called body contouring, which
involves the removal of excessive saggy fat and skin from the abdomen, arms, and/or
thighs. Liposuction, which involves the suctioning of fat, is not a substitute for weight
loss, but rather a procedure to treat isolated areas of fat that persist in spite of exercise
and diet.

Prognosis

Weight gain of just 11 to 18 pounds doubles an individuals risk of developing diabetes,
and gaining 44 pounds or more quadruples the risk (The Surgeon General). Weight
gain of 10 to 20 pounds increases the risk of coronary heart disease by 1.25 times in
women and 1.6 times in men (The Surgeon General). Obesity (BMI greater than 30)
has an increased risk of premature death from all causes, with an estimated 300,000
obesity-attributed deaths occurring annually (The Surgeon General).

If an individual strictly follows a sensible diet and exercise program and loses the
needed number of pounds, the prognosis is excellent provided the individual continues
with the program or with a maintenance program based on the original. The benefits of
weight loss are dependent on the amount of weight lost: moderate weight loss of 4.4
pounds to 9.7 pounds can reduce blood pressure, losing 10% of body weight results in
improved sleep patterns for those with sleep apnea, and weight loss in general results in
lower blood sugar levels (Obesity).

For untreated obesity, the prognosis is poor, and the risk of serious comorbidities tends
to worsen.


English Village, Gulan Street, Erbil, Kurdistan Region of Iraq
www.bcm-medical.com
Complication

Obesity is associated with a number of complications detrimental to health and quality of
life. Included are the individual's continued inability to lose weight, the metabolic
syndrome (also called the insulin resistance syndrome or syndrome X), cardiovascular
disease, stroke, cataracts, diabetes, high blood pressure (hypertension), osteoarthritis,
cancer (the type varies for men and women), gum disease, gallstones, reproductive and
hormonal problems, lung diseases, stoppage of breathing during sleep (sleep apnea)
and other sleep disorders, binge eating and other eating disorders, and emotional and
social problems.

Diseases formerly associated only with adults are increasingly seen in children as the
prevalence of overweight and obesity grows. These diseases include type 2 diabetes,
hypertension, gallbladder disease, hyperlipidemia, sleep apnea, and orthopedic
conditions.

Return to Work (Restrictions / Accommodation)

Some obese individuals, especially those who are severely obese, may no longer be able
to perform their duties efficiently due to fatigue and poor mobility. Weight-related
conditions and diseases may also occur. Accommodations may include the possibility of
a more sedentary position or one that incorporates limited exertion. The work station
may need to be modified to accommodate obese individuals with a larger body size. A
position that involves walking and moving around may also be beneficial because it
engages the individual in exercise while working.

Individuals may need additional time away from work for appointments with the
physician, dietitian, or personal trainer. A flextime arrangement may be a consideration
for the individual whose weight reduction plan includes regular visits to a fitness club.


Failure to Recover

If an individual fails to recover within the expected maximum duration period, the
reader may wish to consider the following questions to better understand the specifics
of an individual's medical case.
Regarding diagnosis:
Does individual have a genetic predisposition to obesity?
Does individual have history of hypothyroidism, Cushing's syndrome, or
depression?
Is individual taking drugs that may cause weight gain, such as steroids or
certain antidepressants?
What does individual eat? Is individual active?
Does individual eat in response to negative emotions, such as boredom,

English Village, Gulan Street, Erbil, Kurdistan Region of Iraq
www.bcm-medical.com
sadness, or anger?
Is individual a binge eater?
Is individual very conscious of being overweight?
Does individual complain of shortness of breath (dyspnea); fatigue; joint pain
in the hips, knees, and ankles; or a general dissatisfaction with state of health?
Was individual's body mass index (BMI) measured? Was it 30 or greater? 40 or
greater?
Was individuals waist-hip ratio measured?
Was blood sugar (glucose) measured at various times, including after a fast or
ingestion of glucose (glucose tolerance)?
Were blood tests done to measure fats (lipids) and uric acid levels?
Was a diagnosis of obesity confirmed?

Regarding treatment:
Was caloric intake reduced to 1,200 to 1,500 calories per day (women), or
1,500 to 1,800 calories per day (men)?
Does individual avoid saturated fats? Is dietary content balanced?
Is individual involved in an exercise program that promotes recommended
amount of physical activity?
Would individual benefit from enrollment in a community exercise or weight-
loss program?
Did individual maintain weight loss? Was individual compliant with treatment
regimen? What could be done to increase compliance?
Would a behavior modification program be beneficial?
Did individual with more than 180% overweight or with a BMI greater than 40
have surgery?
What surgical procedure was performed? Gastric bypass or lap band? How
effective was the procedure?

Regarding prognosis:
Has individual depended on diet alone to lose weight?
Does individual understand the importance of following an exercise regimen?
How successful was individual in keeping weight off?
How much is obesity affecting individual's health?
Is individual a candidate for more stringent, multidisciplinary weight-loss
program or for surgical intervention?
Do the benefits of surgery outweigh the risks?
If weight does not decrease, can individual still perform daily activities?