Of Overweight Patients

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Overweight is now recognized as a risk factor for cardiovascular disease and as a contributing factor in the development of other diseases, most notably diabetes and gallbladder disease. In this context, it is important to evaluate and treat the obesity and other risk factors so as to reduce the overall likelihood for developing disease and to reduce the social consequence of being obese.

The section addresses the clinical evaluation of the overweight patients (1,100,101). It then reviews criteria for successful outcomes of treatment and goals of preventing progression from being at risk for overweight to becoming overweight, then developing the clinical sequelae of overweight (clinical overweight). Both clinical and laboratory information are needed for this evaluation. To make this evaluation effective, it must be done in the context of a sympathetic office practice concerned with the care and treatment of overweight patients. For additional insights into Care of the

Obese Patient in a Primary Care Setting, the reader is referred to the chapter by Kushner and Aronne.

A Information from the Clinical Interview

The clinician or therapist who sees an overweight patient needs to obtain certain basic information which is relevant to assessing its risk (Table 9) (100-108). This includes an understanding of the events that led to the development of obesity, what patients have done to deal with the problem, and how successful and unsuccessful they were in these efforts. Several of these items are listed in Table 10. The family constellation is important for identifying attitudes about obesity and the possibility of finding rare genetic causes. Information about the amount of weight gain (>20 lb or >10 kg) since age 18-20 and the rate of weight gain is important because this is related to the risk of developing complications from obesity (109). The type and regularity of physical activity are also important since physical inactivity increases cardiovascular risk, particularly in overweight individuals (110). Information about comorbid conditions such as diabetes, hypertension, heart disease, sleep apnea, and gallbladder disease also needs to be elicited. Since a number of drugs can cause significant weight gain, a history of medication use for mental health problems, depression, convulsive disorders, diabetes, and for the use of steroids for asthma should be elicited as well. Information about whether the patient/client is ''ready'' to put in the effort needed to lose weight can help you decide with the patient whether this is the right time to proceed with treatment. Information about possible etiologies for obesity also needs to be obtained, for example, altered menstrual history in women suggesting polycystic ovary syndrome, purplish abdominal striae suggesting Cushing's disease.

B Clinical Evaluation

1 Step 1: Physical Measurements a. Vital Signs

As part of any clinical encounter, the nurse or physician should measure several so-called vital signs including height, weight (BMI), pulse, blood pressure, waist circumference, and if indicated by the patient's complaints, temperature.

b. Body Mass Index

Accurate measurement of height and weight which are used to calculate the BMI is the initial step in the clinical assessment of overweight (107,111). This index is calculated as the body weight (kg) divided by the stature (height [m]) squared (wt/ht2), or body weight (lb) x 703 divided by the height (stature) squared (Wt(lb) x 703/[Ht(in)]2. Table 10 lists BMI values for height in centimeters or inches and weight in kilograms or pounds. BMI correlates well with body fat, and is relatively unaffected by height.

This is the first step in assessing risk. Current classifications of obesity are based on BMI and waist circumference. The one recommended by the World Health Organization (105) and the National Heart, Lung and Blood Institute (100) is shown in Table 11.

BMI has a curvilinear relationship to risk (Fig. 5). Several levels of risk can be identified using the BMI. These cut-points are derived from data collected on Caucasians. It is now clear that different ethnic groups

Table 9 Clinical Information from Interview

Yes No

Are members of your family overweight?

Do your parents or grandparents have diabetes?

Do you have diabetes?

Do you have high blood pressure?

Do you take thyroid hormone?

Have you gained 20 or more lb (10 kg) since age 20?

Do you fall asleep easily during the day?

Do you exercise regularly?

Do you have gallstone or gallbladder disease

Do you take medications regularly? If so, specify

Are you depressed?

For women: Do you have normal menstrual periods?

Table 10 Body Mass Indexa (Using Either Pounds and Inches or Kilograms and Centimeters)

Table 10 Body Mass Indexa (Using Either Pounds and Inches or Kilograms and Centimeters)

Inches

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