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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. Developing an effective approach to patients who are not at an ideal body weight is important to prevent and treat potential comorbid illnesses.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with OBESITY can include:

Medical Knowledge Learning Topics related to OBESITY

1. Signs and symptoms of obesity and the definition and classification of overweight and obese using BMI
2. 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. Health implications that being overweight or obese may have on the patient

Diagnostic Evaluation Learning Topics related to OBESITY

1. Age-appropriate medical history including:

  • 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
    • risk factors for obesity related conditions such as tobacco and drug use, diabetes, heart disease, and osteoarthritis
    • focused review of systems including signs, and symptoms of secondary causes of obesity such as Cushing’s syndrome, hypothyroidism, and hypogonadism
    • appreciation of the impact obesity has on a patient’s quality of life, well-being, ability to work and family

2. Physical exam establishing the diagnosis and severity of obesity including:

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

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

4. Diagnostic tests discerning secondary causes of obesity and assessing 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

Management Plan Learning Topics related to OBESITY

1. Calculation of daily caloric requirements and the caloric deficit required to achieve a 5 to 10 percent weight reduction in 6 to 12 months
2. Consulting an endocrinologist, dietician, or obesity management specialist as warranted.
3. Development of 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. Formulation of a dietary plan and a prescription for physical activity in a open mutually agreeable fashion with the patient.
5. Indications for pharmacotherapy
6. Indications for bariatric surgery
7. Appreciation of 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
8. Cost-effectiveness of the management plan
9. Follow-up planning

Potential Differential Diagnosis Topics Include:

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