Obesity

What it is

Obesity is defined as a BMI more than 30. The weight classification by BMI category runs: underweight below 18.5, normal weight 18.5-24.9, overweight 25-29.9, obesity class I 30-34.9, obesity class II 35-39.9, and obesity class III above 40.

Two measurements carry it at the bedside, and both are used. BMI: overweight is more than 25 kg/m2 and obese is more than 30 kg/m2. Waist circumference: more than 94 cm for men and more than 80 cm for women. The waist is what shows the central obesity that the BMI may not.

Adults diagnosed as obese, that is a BMI of 30 kg/m2 or more, or overweight, a BMI of 25-29.9 kg/m2, are at increased risk of ASCVD, heart failure and atrial fibrillation compared with those of a normal weight. Atrial fibrillation is therefore one of the named consequences of the weight itself, not only the metabolic ones.

How it is treated

Weight loss has a point at which it starts to pay. Clinically meaningful weight loss, taken as 5% or more of the initial weight, is associated with improvement in blood pressure, LDL-C, triglycerides and glucose levels among obese or overweight individuals, and it delays the development of T2DM.

The lifestyle program is written out. Obese and overweight adults are advised to participate in comprehensive lifestyle programs for six months that assist participants in adhering to a low-calorie diet - a decrease by 500 kcal, or 800-1500 kcal/day - and high levels of physical activity, 200-300 minutes per week. In addition to diet and exercise, FDA-approved pharmacologic therapies and bariatric surgery may have a role for weight loss in select patients.

The pharmacologic side is written from the pregnancy end. Preconception use of weight-loss medications should include discussion about the waiting time between medication stoppage and pregnancy: general recommendations based on the pharmacodynamics of glucagon-like peptides in animal studies are to stop use two months before pregnancy, and phentermine hydrochloride with topiramate, Qsymia, should be stopped when a pregnancy is planned or identified, on topiramate's known risk for neural tube defects and cleft palate. Intensive individual counseling, effective dietary support, and behavioral and exercise modification are some of the most effective elements of the planning, and patients are encouraged to engage in 75 minutes of vigorous activity, or 150 minutes of moderate activity, each week in addition to muscle strengthening sessions at least twice per week.

Inclusion criteria for bariatric surgery are two:

1. A BMI of 40 kg/m2 or more without coexisting medical problems
2. A BMI of 35 kg/m2 or more with one or more severe obesity-related comorbidities such as diabetes mellitus

Exclusion criteria are four:

1. Active substance abuse
2. Uncontrolled severe psychiatric illness
3. Severe cardiopulmonary disease that makes the surgical risk prohibitive
4. Lack of cognitive function to comprehend the associated risks, benefits, and required lifestyle changes

The national guideline sets its own criteria, and they do not read like those. Referral to tertiary care is for any individual with a BMI of 45 or more with comorbidities related to the weight, for example hypertension, dyslipidemia, type 2 diabetes or obstructive sleep apnea; or any individual with a BMI of 50 or more without co-morbidities. Referral to bariatric surgery, considered on a case-by-case basis following assessment of risk and benefit, is for a BMI of 40 kg/m2 or more with one or more severe comorbidities which are expected to improve significantly with weight reduction, or which failed non-surgical modalities - metabolic obesity; or a BMI of 50 kg/m2 or more with no co-morbidities and failed medical management and lifestyle modifications - non-metabolic obesity. All patients should undergo a psychological program assessment and a weight reduction program for at least 6 months.

After bariatric surgery, NSAIDs such as ibuprofen should be completely avoided if possible, because they are thought to increase the risk of anastomotic ulcerations or perforations; alternative pain medications should be identified prior to the surgery, and acetaminophen, gabapentin, hydrocodone and tramadol can be considered if they are clinically appropriate otherwise. Where obesity is part of polycystic ovary syndrome, management is directed at menstrual irregularity, hirsutism and acne, obesity and insulin resistance, with COCP for menstrual irregularity and hyperandrogenism plus metformin for insulin resistance and obesity.