The Obesity Encounter

Robert F. Kushner

CASE STUDY 1

A 42-year-old single man is seen for an initial appointment after relocating to the area for a new job. Medical problems include hypertension, dyslipidemia, gastroesophageal reflux disease (GERD), arthritis of knees, and a weight gain of 20 lb over the past 10 years. He attributes the weight gain to eating out more often, longer commute times in the car, and less physical activity. Medications include metoprolol succinate ER 50 mg q d, omeprazole 20 mg q d, and diclofenac sodium 100 mg ER q d. Family history is notable for hypertension, type 2 diabetes, and obesity. His diet is unplanned and unstructured, consuming the majority of foods at restaurants or ordered from meal delivery services. Physical activity is limited to walking. He drinks about 10 beers a week and does not smoke cigarettes. On physical examination, height is 70 inches, weight 237 lb, blood pressure 134/88, heart rate 92, body mass index (BMI) 34 kg/m², and waist circumference 102 cm. The remainder of examination is notable for acanthosis nigricans around the neck, flesh-colored striae, no goiter, bruising or proximal muscle weakness, normal reflexes, abdominal panniculus, and palpable crepitus of both the knees. Laboratory tests are significant for fasting glucose 110 mg/dL, HbA_1c 6.0%, total cholesterol 220 mg/dL, triglycerides 170 mg/dL, low-density lipoprotein (LDL) cholesterol 148 mg/dL, high-density lipoprotein (HDL) cholesterol 38 mg/dL, and thyroid-stimulating hormone (TSH) 2.25 mIU/L.

CLINICAL SIGNIFICANCE

Obesity is one of the most common medical conditions seen in primary care that affects nearly 40% of adults and 18% of children and adolescents.¹ Obesity affects every organ system and is linked to the most prevalent and costly medical problems seen in daily practice. However, despite its high occurrence rate, associated medical problems, and impact on daily functioning and quality of life, patients infrequently present to the healthcare team with “obesity” as their chief concern. For this reason, it commonly falls on the healthcare professional (HCP) to proactively broach the subject of weight management even if the patient does not raise the subject. Depending upon the patient’s readiness to address his or her weight, the HCP needs to be able conduct a thorough assessment that includes taking a comprehensive history, performing a physical examination, and ordering pertinent laboratory diagnostic tests. This information is then assimilated to develop a personalized treatment plan. This chapter will focus on the elements of the clinical encounter that encompass a comprehensive obesity-focused assessment.

DIAGNOSIS

Measurement of Body Mass Index

Although the definition of obesity is “an abnormal or excessive fat accumulation that presents a risk to health,”² in clinical practice, it is routinely assessed by measuring BMI, an anthropometric calculation of body weight (kg) divided by height squared (m²). Current assessment and management guidelines recommend measuring the patient’s height and weight and calculating BMI at annual visits or more frequently depending upon the patient’s risk factors.³ The US Preventive Services Task Force also recommends screening all adults for obesity.⁴ Since BMI is routinely and automatically displayed in the electronic health record, it is readily available as a reference in all patient charts. BMI is useful due to its simplicity and practicality in the office setting, its utility to assess population-based mortality and disease-specific morbidity, and high correlation with excess body fat (adiposity).

Although BMI has been adapted as a universal screener for obesity, there are four major limitations that HCPs need to be aware of when using BMI to diagnose obesity: (1) inaccurate assessment of body fat, (2) inability to measure distribution of body fat, (3) lack of assessment of individuals’ health status, and (4) need to interpret according to ethnic and racial differences.

Inaccurate Assessment of Body Fat

BMI does not distinguish between weight associated with muscle and weight associated with fat, the variability of fatness across ethnically and racially diverse populations, and changes in body composition that occur with aging. This is particularly concerning regarding the elderly population who may be misclassified as having a healthy BMI but have a reduced lean body mass. Since aging is often associated with loss of skeletal muscle mass and function (strength or performance) while fat mass is preserved or even increased, the BMI may be in the normal range. This condition has been called sarcopenic obesity, which is a clinical diagnosis (i.e., no specific diagnostic criteria). Nonetheless, despite the low sensitivity to identify body fat, BMI has been shown to be a strong predictor of cardiovascular disease mortality and disease-specific morbidity.⁵

FIGURE 2.1 Body fat distribution. The location of body fat as lower (gynoid) or upper (android) fat distribution is independently associated with risk for metabolic syndrome, type 2 diabetes, hypertension, and cardiovascular disease. Body mass index (BMI) does not measure body fat distribution and needs to be assessed in addition to height and weight in individuals with a BMI <35 kg/m². In patients with BMI ≥35 kg/m², nearly all have elevated waist circumference, and thus measurement of waist does not aid in risk assessment.

Inability to Distinguish Body Fat Distribution

Measuring fat distribution aids in identifying higher risk individuals because increased abdominal (visceral) fat predicts development of metabolic syndrome, type 2 diabetes, and total and cardiovascular risk mortality better than total body fat.⁶ From a practical view, if two presenting patients have the same gender, age, height, and weight (and thus BMI), the patient who has upper body fat “apple-shaped” or android obesity will have a higher risk for metabolic diseases compared with the patient who has lower body fat “pear-shaped” or gynoid obesity (Figure 2.1). The distribution of body fat can be estimated by a variety of techniques; however, for practical purposes, waist circumference is used as a surrogate measurement of visceral fat (measurement of waist circumference is discussed further under physical examination). Although women more commonly seek treatment for obesity, men more commonly have “apple-shaped” obesity and are at higher risk for the metabolic complications of obesity.

Does Not Assess Individual Risk Status

The lack of inclusion of individual and social determinants of health such as genetic, biological, behavioral, social, environmental, racial, or medical factors is not
assessed by the BMI. Treatment decisions should not be based on BMI alone. Rather, the BMI should be interpreted as a screener to identify patients who may be at risk for obesity-related complications. Obesity staging systems that help with risk stratification and facilitate decisions on which patients with obesity warrant more intensive treatment are discussed in Chapter 3.

Need to Interpret According to Ethnic and Racial Differences

Although the BMI calculation is universally used to assess obesity, its interpretation into risk categories or classes varies by race and ethnicity. The BMI cutoff points for overweight and obesity displayed in Table 2.1 were primarily generated from Caucasian populations. However, Asian populations are at higher risk for diabetes, high blood pressure, and high cholesterol at lower BMI thresholds.⁷ Using standard BMI definitions for overweight and obesity among Asian Americans may fail to identify people at increased cardiovascular risk. For this reason, the World Health Organization suggests using lower cutoff points of ≥23 kg/m² for overweight and ≥27.5 kg/m² for obesity for this population.⁷

Due to the limitations of using BMI alone, a more appropriate clinical use of this anthropometric measurement is to assist in identifying patients who present with weight-related complications. This is consistent with a complication-centered approach to obesity care as advocated by the American Association of Clinical Endocrinologists.⁸

BROACHING THE TOPIC OF OBESITY

Patients seldom present to healthcare providers with “obesity” as their chief concern. Therefore, it is incumbent upon the healthcare provider to proactively broach the topic if excess weight or obesity is considered a significant contributor to the patients’ overall health. However, there are often competing barriers and demands that preclude raising the topic of obesity. Lack of time and more important issues/concerns to discuss during the clinical encounter are the two most common reasons HCPs may not institute a discussion about weight with their patients.⁹ This is a dilemma since compelling data from the National Health and Nutrition Examination Survey (NHANES) show that patients whose weight problem was diagnosed and who were told of their weight status by their HCP were significantly more likely to perceive themselves as overweight, attempt to lose weight,¹⁰ and report a 5% weight loss over the year.¹¹

TABLE 2.1 Body Mass Index (BMI) Classification

Healthy body weight		18.5 – 24.9 kg/m²
Overweight		25.9 – 29.9 kg/m²
Obesity		≥30 kg/m²
	Class 1 obesity	30.0 – 34.9 kg/m²
	Class 2 obesity	35.0 – 39.9 kg/m²
	Class 3 obesity	≥40 kg/m²

There is no clearly established method for raising the topic of weight with patients; however, due to its sensitivity, words matter (Table 2.2). The approach HCPs use to broach this potentially sensitive topic may influence how patients react emotionally and cognitively to the discussion and advice provided.¹² Language used by the provider sets the stage for the interaction. The reason for this concern is that the word “obesity” is a highly charged, emotive term. It has a significant pejorative meaning for many patients, leaving them feeling judged and blamed when labeled as such. This is not the case when patients are told that they have other chronic diseases such as diabetes or hypertension. Patients prefer that clinicians use more neutral words such as “weight, excess weight, BMI, or unhealthy weight” compared with more stigmatizing terms such as “obesity, morbid obesity, or fatness.” Asking permission to have the discussion is recommended as the first “A” in a modified 5 A’s framework for counseling that is directed toward obesity (the 5 A’s framework is discussed in more detail in Chapter 7).

STRUCTURING THE ENCOUNTER

Taking an Obesity-Focused History

Similar to any other presenting problem, the “history of present illness” (HPI) is an important and required section of the medical history when evaluating obesity as a distinct medical problem. The HPI includes the following:

The changes in health that led the patient to seek medical attention, including a clear, chronological explanation of the patient’s symptoms.
Information relevant to the chief complaint, including answers to questions of what, when, how, where, which, who, and why.
Information that informs the provider on the sequential development of the underlying pathologic process.

However, providers have not traditionally learned how to conduct an obesity-focused HPI. The two overarching features of an obesity history are to take a life course perspective and a patient-centered approach. The life
course perspective suggests that various biological, psychosocial, and cognitive factors throughout life influence health and disease risk.¹³ This perspective is consistent with the complex nature of obesity. Patient–centered approach is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”¹⁴ Information from the history should address the following six general questions:

TABLE 2.2 Broaching the Topic of Obesity: Putting the Conversation Into Words

The following phrases are examples of provider dialogue:

I am concerned about your weight and would like to talk with you about it. Is that ok?
- Asking permission demonstrates respect for the patient and should foster a more therapeutic patient-provider relationship.
Monitoring your weight is as important as measuring your blood pressure and heart rate. I have noticed that your weight is up from last year. Is this a good time to talk to you about your weight? Has anything been going on that may have contributed to the weight gain?
- Identifying body weight as a clinical marker similar to other familiar and routine measurements places weight in a medical context.
I think that some of your medical concerns (e.g., shortness of breath, knee pain, heartburn, diabetes, hypertension, sleep disorder) may be related to your weight. What do you think?
- Remark relates the patients’ current health concerns to their weight and assesses their insight into the problem.
What do you know about the risks of being overweight? Do you think that your weight is contributing to your health problems?
- The open-ended question inquires about the patient’s understanding about medical problems that are obesity-related.

Follow-up questions to assess motivation, readiness, and barriers to initiating a weight management program, and a more detailed weight history may follow these broaching remarks. Additional questions may include the following:

What aspects of your weight would you like to talk about?
What is hard about managing your weight?
How does your weight affect you?
Would you be interested in talking about options for working on your weight?
Do you have some thoughts about things you might want to do to address your weight?
Can I be of any help to you in how you might work on your weight?
How motivated do you feel (0-10) to make long-term changes in your diet and physical activity?

If the patient is not interested or ready to talk about weight, the healthcare professional can either gently probe the reasons why and/or acknowledge the patient’s response or not pursue the topic further during this encounter. However, if clinically indicated, it is important to revisit weight at a follow-up visit.

Adapted from American Medical Association. Talking about weight with your patients. Accessed February 28, 2020. https://northwestern.cloud-cme.com/assets/northwestern/pdf/Obesity%202018%20talking-about-weight-kushner.pdf

1. What factors contribute to the patient’s obesity?
2. How is the obesity affecting the patient’s health?
3. What is the patient’s level of risk regarding obesity?
4. What are the patient’s goals and expectations?
5. Is the patient motivated and engaged to enter a weight management program?
6. What kind of help does the patient need and want?

Weight History

Many of the elements of an obesity-focused history are included in an expanded social history that includes diet, physical activity, sleep habits, stress, etc. and the Review of Systems section. However, the skill of how to obtain a weight history and how to use it in developing individualized care plans is generally new to providers. The mnemonic “OPQRST” is commonly used for ascertaining the patient’s chief complaint and HPI and can be adapted for taking a weight history. The mnemonic stands for onset, precipitating events, quality of life/health, remedy, setting, and temporal pattern.¹⁵ Examples of questions that can be used to explore these features are provided in Table 2.3.

These six probing areas provide a contextual understanding of how and when patients gained weight, what management efforts were employed, and the impact of body weight on their health. The mnemonic is not intended to be used in a prespecified order of questions, rather it was developed as a technique to prompt recall of important information to cover during the history. A more efficient method to obtain much of this information is to ask patients to complete a previsit questionnaire that can be reviewed during the encounter. An example of a self-completed questionnaire is shown in Figure 2.2. From a practical point of view, a questionnaire can be given to patients at the end of a routine visit to be completed at home in anticipation of a return visit where obesity will be the central focus of the
encounter. Having patients reflect on these issues will save time and facilitate a more productive and therapeutic patient visit.

TABLE 2.3 Using the Mnemonic “OPQRST” to Take the Weight History

	SAMPLE QUESTIONS
Onset	“When did you first begin to gain weight?” “Have you struggled with your weight since childhood?” “Do you remember how much you weighed in high school, college, early 20s, 30s, 40s?” “Did the weight gain begin when you started taking a new medication?”
Precipitating	“What life events led to your weight gain, e.g., college, long commute, marriage, divorce, financial loss, depression, illness, etc.?” “How much weight did you gain with pregnancy?” “How much weight did you gain when you stopped smoking?” “How much additional weight did you gain when you started insulin?”
Quality of life	“At what weight did you feel your best?” “What is hard to do at your current weight?” “How does your weight affect how you feel and function?”
Remedy	“What have you done or tried in the past to control your weight?” “Have you made any changes to your diet?” Have you made any changes to your physical activity?” “Have you taken any medications to help control your weight?” “What is the most successful approach you tried to lose weight?” “What do you attribute the weight loss to?” “What caused you to regain your weight?” “What are the biggest challenges in maintaining your weight?”
Setting	“What was going on in your life when you last felt in control of your weight?” “What was going on when you gained your weight?” “What role has stress played in your weight gain?” “How important is social support or having a buddy to help you?” “Do you currently have social support from your family and friends to help you manage your weight?”
Temporal pattern	“What is the pattern of your weight gain?” “Did you gradually gain your weight over time, or is it more cyclic (yo-yo)?” “Are there large swings in your weight, and if so, what is the weight change?” “What was your lightest weight and heaviest weight as an adult?”
Reprinted from Kushner RF, Batsis JA, Butsch WS, et al. Weight history in clinical practice: The state of the science and future directions. Obesity. 2020;28:9-17.

An additional technique is to ask patients to graph their weight changes over time, inserting life events or treatments that they feel were temporally related to weight changes¹⁶ (Figure 2.3). Patients are then asked to reflect on and discuss their weight journey. This activity allows patients an opportunity to express any underlying burden, frustration, struggle, stigma, or shame that may have been associated with trying to manage body weight. Similar to the previsit questionnaire, this exercise is most useful if accomplished ahead of a visit that is dedicated to obesity care. If the weight history is conducted properly, patients will feel validated and acknowledged regarding their weight journey, while the clinician should feel more empathetic and informed to provide meaningful and practical patient-centered treatment.

Medication History

A thorough medication history should always be taken to uncover possible drug-induced weight gain as well as for medications interfering with weight loss. This is called iatrogenic weight gain. Table 2.4 provides a list of medications that are associated with a gain of body fat. Medications should always be considered when there is a change in the trajectory of body weight coincident with starting a new drug. The most common offenders are neuroleptics, antidiabetic agents, steroids, and antidepressants.¹⁷ A list of medications that promote weight gain along with alternatives is also shown in Chapter 8 on Pharmacotherapy.

Taking a Comprehensive Social History

In addition to obtaining a weight history, other elements of the social history that are important for understanding the cause of weight gain include diet, physical activity, sleep patterns, and stress. This information can be largely obtained by using a standard patient questionnaire that assesses social determinants of health related to weight or by conducting a structured patient interview. More in-depth information about diet and physical activity will be covered in Chapters 5 and 6.

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