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10 Obesity - StatPearls - NCBI Bookshelf

Obesity
Panuganti KK, Nguyen M, Kshirsagar RK.

Continuing Education Activity

Obesity is the excessive or abnormal accumulation of fat or adipose tissue in the body that may impair health. Obesity has become an epidemic which
has worsened for the last 50 years. In the United States, the economic burden is estimated to be about $100 billion annually. Obesity is a complex
disease and has multifactorial etiology. It is the second most common cause of preventable death after smoking. This activity reviews the causes,
pathophysiology, presentation, and complications of obesity and highlights the role of the interprofessional team in its management.

Objectives:

Recall the epidemiology of obesity.

Describe the pathophysiology of obesity.
Summarize the treatment options for obesity.
Explore modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected
by obesity.

Access free multiple choice questions on this topic.

Introduction
Obesity is the excessive or abnormal accumulation of fat or adipose tissue in the body that impairs health via its association to the risk of development
of diabetes mellitus, cardiovascular disease, hypertension, and hyperlipidemia. It is a significant public health epidemic which has progressively
worsened over the past 50 years. Obesity is a complex disease and has multifactorial etiology. It is the second most common cause of preventable
death after smoking. Obesity needs multiprong treatment strategies and may require lifelong treatment. A 5% to 10% weight loss can significantly
improve health, quality of life, and economic burden of an individual and a country as a whole.[1][2][3][4][5]

Obesity has enormous healthcare costs exceeding $700 billion each year. The economic burden is estimated to be about $100 billion annually in the
United States alone. The body mass index (BMI) is used to define obesity, which is calculated as weight (kg)/height(m). While the BMI does correlate
with body fat in a curvilinear fashion, it may not be as accurate in as Asians and elderly people, where a normal BMI may conceal underlying excess
fat. Obesity can also be estimated by assessing skin thickness in the triceps, biceps, subscapular and supra-iliac areas. Dural energy radiographic
absorptiometry (DEXA) scan may also be used to assess fat mass.

Etiology
Obesity is the result of an imbalance between daily energy intake and energy expenditure resulting in excessive weight gain. Obesity is a
multifactorial disease, caused by a myriad of genetic, cultural, and societal factors. Various genetic studies have shone that obesity is extremely
heritable, with numerous genes identified with adiposity and weight gain. Other causes of obesity include reduced physical activity, insomnia,
endocrine disorders, medications, the accessibility and consumption of excess carbohydrates and high-sugar foods, and decreased energy metabolism.

The most common syndromes associated with obesity include Prader Willi syndrome and MC4R syndromes, less commonly fragile X, Bardet-Beidl
syndrome, Wilson Turner congenital leptin deficiency, and Alstrom syndrome.

Epidemiology
Nearly one-third of adults and about 17% of adolescents in the United States are obese. According to Center for Disease Control and Prevention
(CDC)'s 2011-2012 data, one out of five adolescents, one out of six elementary school age children, and one out of 12 preschool age children are
obese. Obesity is more prevalent in African Americans, followed by Hispanics and Caucasians. Southern US states have the highest prevalence,
followed by the Midwest, Northeast and the west.

Obesity rates are increasing at a staggering rate worldwide, affecting over 500 million adults.

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Pathophysiology
Obesity is associated with cardiovascular disease, dyslipidemia, and insulin resistance, in turn, causing diabetes, stroke, gallstones, fatty liver, obesity
hypoventilation syndrome, sleep apnea, and cancers.

Association of genetics and obesity is already well established by multiple studies. FTO gene is associated with adiposity. This gene might harbor
multiple variants that increase the risk of obesity.

Leptin is an adipocyte hormone which reduces food intake and body weight. Cellular leptin resistance is associated with obesity. Adipose tissue
secretes adipokines and free fatty acids causing systemic inflammation which causes insulin resistance and increased triglyceride levels, which
subsequently contributes to obesity.

Obesity can cause increased fatty acid deposition in the myocardium causing left ventricular dysfunction. It has also been shown to alter the renin-
angiotensin system causing increasing salt retention and elevated blood pressure.

Besides total body fat, the following also increase the morbidity of obesity:

Waist circumference (abdominal fat carries a poor prognosis)

Fat distribution (Body Fat Heterogeneity)
Intra-abdominal pressure
Age of onset of obesity

The body fat distribution is important in assessing the risk for cardiometabolic health. The distribution of excess visceral fat is likely to increase the
risk of cardiovascular disease. [6][7][8] Ruderman et al [9] introduced the concept of metabolic obese normal weight(MONW) subjects with normal
BMI suffer from metabolic complications normally found in obese individuals.

Metabolically healthy obese (MHO) Individuals have BMI over 30 kg/m2 but do not have the characteristics of insulin resistance or dyslipidemia [10]
[11]

Adipocytes have been shown to have an inflammatory and prothrombotic activity which can increase the risk of strokes. Adipokines are cytokines
mainly produced by adipocytes and preadipocytes, in obesity macrophages invading the tissue, also produce adipokines. [12][13].

Altered adipokine secretion causes chronic low-grade inflammation, which may cause altered glucose and lipid metabolism and contribute to
cardiometabolic risk in visceral obesity. [12]

Adiponectin has insulin-sensitizing and anti-inflammatory properties, the circulating levels are inversely proportional to visceral obesity.

History and Physical

All children six years and older, adolescents, and all adults should be screened for obesity according to the United States Preventative Services Task
Force (USPSTF) recommendations.

Physicians should carefully screen for underlying causes contributing to obesity. A complete history should include:

Childhood weight history

Prior weight loss efforts and results
Complete nutrition history
Sleep patterns
Physical activity
Associated past medical histories like cardiovascular, diabetes, thyroid, and depression
Surgical history
Medications which can promote weight gain
Social histories of tobacco and alcohol use
Family history

Complete Physical examination Should be done and should include body mass index (BMI) measurement, weight circumference, body habitus, vitals.

Obesity focus findings like acne, hirsutism, skin tags, acanthosis nigricans, striae, Mallampati scoring, buffalo hump, fat pad distribution, irregular
rhythms, gynecomastia, abdominal pannus, hepatosplenomegaly, hernias, hypoventilation, pedal edema, varicoceles, stasis dermatitis, and gait
abnormalities can be present.

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Evaluation
A standard screening tool for obesity is the measurement of body mass index (BMI). BMI is calculated using weight in kilograms divided by the
square of height in meters.[14][15][16][17][18] Obesity can be classified according to BMI:

Underweight: less than 18.5 kg/m2

Normal range: 18.5 kg/m2 to 24.9 kg/m2
Overweight: 25 kg/m2 to 29.9 kg/m2
Obese, Class I: 30 kg/m2 to 34.9 kg/m2
Obese, Class II: 35 kg/m2 to 39.9 kg/m2
Obese, Class III: more than 40 kg/m2

Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:8 is considered significant.

Further evaluation studies like skinfold thickness, bioelectric impedance analysis, CT, MRI, DEXA, water displacement, and air densitometry studies
can be done.

Laboratory studies include complete blood picture, basic metabolic panel, renal function, liver function study, lipid profile, HbA1C, TSH, vitamin D
levels, urinalysis, CRP, other studies like ECG and sleep studies can be done for evaluating associated medical conditions.

Treatment / Management
Obesity causes multiple comorbid and chronic medical conditions, and physicians should have a multiprong approach in the management of obesity.
Practitioners should individualize treatment, treat underlying secondary causes of obesity, and focus on managing or controlling associated comorbid
conditions. Management should include dietary modification, behavior interventions, medications, and surgical intervention if needed.

The dietary modification should be individualized with close monitoring of regular weight loss. Low-calorie diets are recommended. Low calorie
could be carbohydrate or fat restricted. A low-carbohydrate diet can produce greater weight loss in the first months compared to a low-fat diet. The
patient's adherence to their diet should frequently be emphasized.

Behavior Interventions: The USPSTF recommends obese patients to be referred for intensive behavior interventions. Several psychotherapeutic
interventions are available which includes motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and interpersonal
psychotherapy. Behavior interventions are more effective when they are combined with diet and exercise.

Medications: Antiobesity medications can be used for BMI greater than or equal to 30 or BMI greater than or equal to 27 with comorbidities.
Medications can be combined with diet, exercise, and behavior interventions. FDA-approved antiobesity medications include phentermine, orlistat,
lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine. All the agents are used for long-term weight
management. Orlistat is usually the first choice because of its lack of systemic effects due to limited absorption. Lorcaserin should be avoided with
other serotonergic medications due to the risk of serotonin syndrome. High responders usually lose more than 5% weight in the first three months.

Surgery: Indications for surgery are a BMI greater or equal to 40 or a BMI of 35 or greater with severe comorbid conditions. The patient should be
compliant with post-surgery lifestyle changes, office visits, and exercise programs. Patients should have an extensive preoperative evaluation of
surgical risks. Commonly performed bariatric surgeries include adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy. Rapid
weight loss can be achieved with a gastric bypass, and it is the most commonly performed procedure. Early postoperative complications include leak,
infection, postoperative bleeding, thrombosis, cardiac events. Late complications include malabsorption, vitamin and mineral deficiency, refeeding
syndrome, dumping syndrome.[19][20][21]

Weight loss associated complications

When weight loss is rapid, it is also associated with complications that include:

Electrolyte abnormalities (Esp hypokalemia)

Cardiac arrhythmias
Hyperuricemia
Cholelithiasis
Mood and behavior alterations

Complications associated with bariatric surgery

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Strictures
Wound dehiscence
Ulcers
Malabsorption
Dumping syndrome
Post-surgery diarrhea
Vitamin and nutrient deficiency
Anastomotic leaks
Failed surgery

Differential Diagnosis
Acromegaly

Adipose Dolorosa

Ascites

Cushing syndrome

Hypothyroidism

Iatrogenic Cushing syndrome

Insulinoma

Kallman syndrome and idiopathic hypogonadotropic hypogonadism

Generalized lipodystrophy

Polycystic ovarian disease

Prognosis
Obesity has enormous morbidity and mortality rates. Obese patients have a high risk of adverse cardiac events and stroke. In addition, the quality of
life is poor. Factors that worsen morbidity include:

Age of onset of obesity

Amount of central adiposity
Severity of obesity
Gender
Associated comorbidity
Race

Pearls and Other Issues

Management of obesity should also include prevention strategies with physical activity, exercise, nutrition, and weight maintenance.

Enhancing Healthcare Team Outcomes

The obesity epidemic is continuing to worsen and has become a public health issue. The management and prevention of obesity is best done with an
interprofessional team that includes a bariatric nurse, surgeon, internist, primary care provider, endocrinologist, and a pharmacist. There is no cure for
obesity and almost every treatment available has limitations and potential adverse effects.

The key is to educate the patient on the importance of changes in lifestyle. All clinicians who look after obese patients have the onus to educate
patients on the harms of the disorders. No intervention works if the patient remains sedentary. Even after surgery, some type of exercise program is
necessary to prevent weight gain. So far there is no magic bullet to reverse obesity- all treatments have high failure rates and some like surgery also
have life-threatening complications. There is an important need for collaboration between the fast-food industry, schools, physical therapists,
dietitians, clinicians, and public health authorities to create better and safer eating habits.

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Lifestyle changes alone can help obese people reverse the weight gain, but the problem is most people are not motivated to exercise.[21][22]

Review Questions
Access free multiple choice questions on this topic.
Comment on this article.

Figure
BMI chart with obesity classifications adopted from the WHO 1998 report. Contributed by the World Health Organization - "Report of a
WHO consultation on obesity. Obesity Preventing and Managing a Global Epidemic."

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Disclosure: Kiran Panuganti declares no relevant financial relationships with ineligible companies.

Disclosure: Minhthao Nguyen declares no relevant financial relationships with ineligible companies.

Disclosure: Ravi Kshirsagar declares no relevant financial relationships with ineligible companies.

Publication Details

Author Information and Affiliations

Authors

Kiran K. Panuganti1; Minhthao Nguyen2; Ravi K. Kshirsagar3.

Affiliations
1
Texas health Presbyterian, Denton
2
University Hospitals Richmond and Bedford Medical Center
3 Lowell General Hospital / Tufts Medical Center

Publication History

Last Update: August 8, 2022.

Copyright
Copyright © 2023, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) (
http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not
required to obtain permission to distribute this article, provided that you credit the author and journal.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

Panuganti KK, Nguyen M, Kshirsagar RK. Obesity. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

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