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Thiazolidinediones

Orlistat, sibutramine

Antihistamines

Diphenhydramine, others

Decongestants, inhaled steroids

h-Adrenergic blockers

Propranolol, others

ACE inhibitors, Ca-channel blockers

Source: Modified from Ref. 35.

Source: Modified from Ref. 35.

Figure 1 Measuring waist circumference. To measure waist circumference, locate the upper hip bone and the top of the right iliac crest. Place a measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. Before reading the tape measure, ensure that the tape is snug, but does not compress the skin, and is parallel to the floor. The measurement is made at the end of a normal expiration. Men with a waist circumferences >40 inches (>102 cm) and women with a waist circumferences >35 inches (>88 cm) are at higher risk because of excess abdominal fat and should be considered one risk category above that defined by their BMI. (From Ref. 8.)

Figure 1 Measuring waist circumference. To measure waist circumference, locate the upper hip bone and the top of the right iliac crest. Place a measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. Before reading the tape measure, ensure that the tape is snug, but does not compress the skin, and is parallel to the floor. The measurement is made at the end of a normal expiration. Men with a waist circumferences >40 inches (>102 cm) and women with a waist circumferences >35 inches (>88 cm) are at higher risk because of excess abdominal fat and should be considered one risk category above that defined by their BMI. (From Ref. 8.)

Look for the common disorders seen in the obese: type 2 diabetes, hyperlipidemia, coronary heart disease, osteoarthritis of the lower extremities, gallbladder disease, gout, colorectal and prostate cancer in men, and endometrial, gallbladder, cervical, ovarian, and breast cancer in women. Type 2 diabetes, gout, hyperlipide-mia, and hepatic steatosis are the disorders most often discovered by laboratory evaluation (Table 6). Other labs may indicate disorders that may be involved in the induction of obesity and require specific treatment, such as hypothyroidism and hyperinsulinemia. Complete laboratory evaluation might include blood glucose, uric acid, BUN, creatinine, uric acid, ALT, AST, total and direct bilirubin, alkaline phosphatase, total cholesterol, HDL, LDL, triglycerides, complete blood count, TSH, and urinalysis. In some cases, a 2-hr postprandial insulin level is of value in diagnosing hyper-insulinemia. Measurements of body composition utilizing methods such as bioelectrical impedence, while

motivating to some patients, are not necessary for treating the average patient.

Before beginning treatment, results of the physical examination and laboratory tests should be shared with cj the patient. Emphasis should be placed on any new findings, particularly those associated with obesity that would be expected to improve with weight loss. The patient should focus on improvements in these health parameters, rather than focus on achieving an ideal body weight or a similarly large weight loss that may not be attainable. Improvements in health complica-

Table 6 Laboratory and Diagnostic Evaluation of the Obese Patient Based on Presentation of Symptoms, Risk Factors, and Index of Suspicion

If there is a suspicion of ...

Alveolar hypoventilation (Pickwickian) syndrome (hypersomnolence, possible right-sided heart failure)

Cushing's syndrome

Gallstones

Hepatomegaly/nonalcoholic steatohepatitis

Hypothyroidism

Insulinoma

Sleep apnea

Polycystic ovarian syndrome (PCOS) (oligomenorrhea, hirsuitism, probable obesity, enlarged ovaries may be palpable)

CBC (to rule out polycythemia); pulmonary function tests (reduced lung volume), blood gases (pCO2 often elevated); ECG (to rule out right heart strain) Screen with 24-hr urine for free cortisol (>150 Ag/24 hr considered abnormal) and overnight dexamathasone suppression test: 1 mg qo at 11 PM. At precisely 8 AM next morning, draw serum cortisol (<5 is normal suppression; axis intact). Failure of suppression indicates dysregulation, possibly Cushing's syndrome Utrasonography of gallbladder Liver function tests

Serum TSH (normal generally<5 nU/mL) Elevated levels of insulin and C-peptide in absence of sulfonylurea in plasma, especially during hypoglycemic episode. Sleep studies for oxygen desaturation; apneic and hypopneic events; ENT examination for upper airway obstruction Increase in LH:FSH ratio, often >2.5. (Cycle of increased LH, stimulating increased testosterone and androstenedione in ovarian stroma, which is converted to estrone in adipose tissue, leading in turn to increased LH)

CBC, complete blood count; ECG, electrocardiogram; TSH, thyroid-stimulating hormine; ENT, ear, nose, and throat; LH, leuteinizing hormone; FSH, follicle-stimulating hormone.

tions should be discussed on an ongoing basis. Many patients find this a helpful motivator because, at some point, weight is likely to stabilize at a level above their own ''ideal'' weight. By focusing patients on the medical rather than the cosmetic benefits of weight loss, they may be more satisfied and better able to attain their goals and succeed long term.

The relative risk associated with a given degree of overweight and obesity can be estimated from Table 7.

2 Contraindications to Treatment

Obesity treatment is contraindicated in patients who are pregnant, have anorexia nervosa, or have terminal illness. Medical or psychiatric illnesses must be stable before weight reduction begins. Furthermore, patients with cholelithiasis and osteoporosis should be warned that these conditions might be aggravated by weight loss.

3 Consider the Patient's Readiness to Lose

Weight

The decision to attempt weight-loss treatment should consider the patient's readiness to make lifestyle changes. Evaluation of readiness should include the following: (1) reasons and motivation for weight loss; (2) previous attempts at weight loss; (3) support expected from family and friends; (4) an understanding of risks and benefits; (5) attitudes toward physical activity; (6) time availability; and (7) potential barriers, including financial limitations.

For the patient to succeed, he or she must be ready to make the effort to lose weight. An unwilling patient rarely if ever succeeds, frustrating both the patient and the practitioner. If the patient does not wish to lose weight and is not at high risk, weight maintenance should be encouraged. If the patient is at high risk as a

Table 7 Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Riska

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Reasonable care has been taken to ensure that the information presented in this book is accurate. However, the reader should understand that the information provided does not constitute legal, medical or professional advice of any kind.

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