Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

 

Obesity

 

Obesity is a growing epidemic in the United States. Obesity is associated with many medical conditions such as diabetes, hypertension, heart disease and osteoarthritis. Mastery of the approach to patients who are not at an ideal body weight is important to prevent and treat potential comorbid illnesses.

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Prerequisites

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 Describe and discuss:

  • anatomy, physiology, and pathophysiology of the gastrointestinal tract and digestion
  • pharmacology of the available drugs used to treat obesity
  • nutrition and caloric requirements
  • psychology associated with addictive behavior

 Demonstrate:

  • ability to perform a complete medical history and physical exam
  • ability to communicate with patients of diverse backgrounds

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Apply Medical Knowledge

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  1. Describe the signs and symptoms that suggest obesity understanding the definition and classification of overweight and obese using BMI.
  2. Describe the clinical features that help to differentiate one etiology from another including excessive caloric intake, insufficient energy expenditure leading to low resting metabolic rate, genetic predisposition, environmental factors affecting weight gain, psychologic stressors, and lower socioeconomic status.
  3. Describe health implications that being overweight or obese may have on the patient.

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Diagnose

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1.     Obtain, document and present an age-appropriate medical history that includes:

  • weight history from childhood
  • activity level and diet
  • patient’s past experience with losing weight and determining barriers encountered in prior attempts
  • assessment of the patient’s motivation for losing weight
  • the risk factors for obesity related conditions such as tobacco and drug use, diabetes, heart disease, and osteoarthritis
  • a focused review of systems including signs, and symptoms of secondary causes of obesity such as Cushing’s syndrome, hypothyroidism, and hypogonadism
  • an appreciation of the impact obesity has on a patient’s quality of life, well-being, ability to work and family.

2.     Perform a physical exam to establish the diagnosis and severity of obesity including: 

  • calculating the degree of obesity from the patient’s height and weight by calculating BMI
  • assessing patient for signs of endocrine abnormalities, including: striae, peripheral neuropathy, depressed tendon reflexes, bruising, and signs of dyslipidemia (e.g. xanthomas and xanthalasma)

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that suggest specific etiology of primary and secondary obesity.

4.     Recommend when to order diagnostic tests to discern secondary causes of obesity and to assess for comorbid conditions (diabetes, HTN, sleep apnea, dyslipidemia). When appropriate, laboratory tests could include:

  • serum glucose
  • TSH
  • lipid profile
  • HbA1c
  • BUN/Cr
  • urine microalbumin
  • ECG
  • 24-hour urinary cortisol 

5.     Record, present, research, critique, and manage clinical information.

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Develop a Management Plan

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Make decisions about what to include from the following items and explain why each item selected should be included:

1.     Calculate daily caloric requirements and the caloric deficit required to achieve a 5 to 10 percent weight reduction in 6 to 12 months.

2.     Determine when to obtain consultation from an endocrinologist, dietician, or obesity management specialist.

3.     Develop reasonable weight loss goals with the patient, assisting the patient to understand that attainment of ideal body weight may not necessarily be a realistic goal and that health benefits may be achieved with losses for 5 to 10 percent body weight.

4.     Develop a dietary plan and a prescription for physical activity in a open mutually agreeable fashion with the patient.

5.     Identify indications for pharmacotherapy.

6.     Identify indications for bariatric surgery.

7.     Access and utilize appropriate information systems and resources to help delineate issues related to obesity.

8.     Appreciate the negative impact that obesity has on one’s self image and the challenges that patients with obesity face in terms of access to resources and lifestyle modifications.

9.     Consider the cost-effectiveness of the management plan.

10.  Plan for follow-up.

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Differential Diagnosis

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  • excessive caloric intake
  • insufficient energy expenditure
  • genetic predisposition
  • endocrine (hypothyroidism, cushings, hypogonadism)
  • psychological (depression, binge eating, bulimia)
  • medicine induced (hypoplymics, steroids)
  • metabolic syndrome