Obesity & Metabolic Syndrome  Other: GERD, gallstones, cancer (breast, colon), osteoarthritis, nephrolithiasis,

pseudotumor cerebri, infertility

 Waist to hip ratio: >0.9 F, >1.0 M abnormal
 Waist measurement: >88cm (35in) F; >102cm (40in) M History
 Establish pattern of weight gain – helpful in determining if there is secondary cause
Weight ( kg ) o Secondary cause unlikely if lifelong history of being overweight/obese or if
BMI = stable adult weight
Height ( m )2 o If weight gain over few months or years, look for prescription meds, steroids,
newest antipsychotics, disease known to cause obesity (hypothyroidism,
Weight Obesity Class BMI (kg/m2) Risk of Disease Cushing disease)
Classification  Symptoms: fatigue, aches, cold intolerance, constipation, poor exercise tolerance,
Underweight 18.5 Increased central obesity, loss of libido, erectile dysfunction, menstrual irregularity, depression
Normal 18.5 -24.9 Normal  Survey of types of food eaten – calorically dense foods & frequency of meals outside of
Overweight 25.0 -29.9 Increased home
Obesity I 30.0 -34.9 High
II 35.0 -39.9 Very High Secondary causes
Extreme Obesity III 40.0 Extremely High  Hypothyroidism: pretibial edema, delayed tendon reflexes, low BP
 Cushing’s: purple striae (stretch marks), supraclavicular fat pad enlargement, muscle
Comparing apples to pears weakness, round face
 “Apple” fat distribution  HTN:  BP
o Proportionally greater amount of fat in abdomen or trunk  Insulin resistance: acanthosis nigricans ( pigmentation)
o  Risk of DM, HTN, & HD in men & women  Hepatosteatosis: hepatomegaly
 Abdominal obesity reported as wait-to-hip ratio (WHR)  Xanthoma:  blood levels of chylomicrons
o Waist circumference at level of superior ilial crest
o Overweight + abdominal fat accumulation at higher risk (even if not obese by Lab tests
BMI)  DM  blood glucose
 Macrovascular risk  ECG, fasting lipid profile
 Risk of comorbid conditions with higher BMI – HTN, type 2 DM, & CVD  Hepatosteatosis  liver panel
 Thyroid function  TSH, T3, T4
Hormones contributing to weight gain
 Weight loss (mean 12.5 +/- 0.5 kg) led to: Ddx: hypothyroidism, hypercortisolemia (Cushing’s), GH deficiency, testosterone deficiency,
o  Leptin, peptide YY, CCK, insulin, amylin drug side effect (long term glucocorticoids, immunosuppression, intensive insulin treatment of
o  Ghrelin, GIP, pancreatic polypeptide type 1 DM, HAART, neuropsychotropic drugs)
o  Subjective appetite
Initial management
 1yr after initial weight reduction  Dietary fat restriction (25-30% of calories), calorie restriction (protein & carbs), & 
 Bad news: hormone levels that  weight regain after diet, take time to revert to levels dietary fiber
recorded before weight loss o Added fiber (25-30g/day) improves weight and CV risk factors,  glycemic
load, risk of colorectal cancer and may risk of death from CV, infectious &
Aging: dysregulation of hypothalamic-pituitary systems contribute to  fat mass and sarcopenia
respiratory diseases
( muscle mass), ↓ GH, ↓ fat/↑ lean tissue, ↓ central fat, ↓ testosterone levels in men, ↓ estrogen
 Aerobic activity: 3-5hrs/wk
levels in women, ↑ levels of cortisol in both sexes
o Increasing energy expenditure
o Leads to continues & sustained weight loss
Complications
o Average weight loss from exercise alone – 1.6kg (3.5lb)
 Metabolic: type 2 DM, hyperlipidemia, hyperuricemia & gout, hepatic steatosis
o Average reduction in waist circumference – 2cm (0.8in)
 Cardiovascular disease: HTN, a. fib
 Respiratory: sleep apnea, asthma, obesity hypoventilation
Pharmacological management
 Social:  self-esteem in children, depression,  likely to marry,  schooling,  income
  Centrally acting drugs suppress hunger – release NE & inhibit uptake of NE &
serotonin
 Peripherally acting drugs  fat absorption (Orlistat)
 Average weight loss does not usually exceed 10% of baseline weight
Surgical therapy
 Indications:
o BMI ≥ 40 kg/m2 or
o BMI ≥ 35 kg/m2 plus obesity-related diseases

Metabolic syndrome: metabolic abnormalities that confers  risk of CVD & DM

 Risk factors: overweight, obesity, sedentary lifestyle, aging
 Associated with CVD, type 2 DM, lipodystrophy, non-alcoholic fatty liver disease,
hyperuricemia, polycystic ovary syndrome, obstructive sleep apnea

Notice:
CentralSmoking
obesity & LDL are not included
+ 2:
  Triglycerides >150mg/dl (1.7 mmol/l)
  HDL cholesterol < 40mg/dl (91.3mmol/l) in males, 50mg/dl (1.9 mmol/l) in
females
  BP ≥ 130/85 mm Hg.
 Hyperglycemia: fasting blood glucose ≥ 100mg/dl (5.6mmol/l) (oral glucose
tolerance test recommended but not required for diagnosis of metabolic syndrome)
 Previous diagnosis of diabetes