Clinical presentation and diagnosis

Any interaction between a patient and a healthcare provider presents an opportunity to evaluate the patient's height and weight. From these parameters, the BMI should be determined as well as waist circumference and the presence of comorbidities or associated risks. BMI, waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. The BMI is calculated using the measured weight in kilograms divided by the height in meters squared (kg/m ) for all adult patients regardless of gender. The BMI distribution changes with age for children just as height and weight. Percentiles specific for age and gender are used to define overweight and obesity as well as healthy and underweight (pediatrics). The BMI is classified according to Table 102-1. Waist circumference should also be determined for adult patients by placing a measuring tape at the top of the right iliac crest and proceed around the abdomen, ensuring that the tape is tight but not constricting the skin. The value is measured following normal expiration. Table 102-2 defines high-risk waist circumference.6 Measurement of waist circumference is not recommended for children and adolescents as reference values

identifying risk are unavailable. After obtaining patient appropriate parameters, further assess the adult patient for the presence of comorbidities and cardiovascular risk factors. Presence of comorbidities (CHD, atherosclerosis, type 2 diabetes mel-litus, and sleep apnea) and cardiovascular risk factors (cigarette smoking, hypertension, elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impairedfasting glucose, family history of premature CHD, and age) requires identification and aggressive management for overall effective treatment of the overweight or obese patient. A patient is at very high absolute risk if diagnosed with CHD or other atherosclerotic diseases, type 2 diabetes mellitus, or sleep apnea or if three or more of the risk factors listed in Table 102-3 are present.6 Aggressive disease management should be initiated and not limited to weight loss. If the patient is a child or adolescent and the BMI is greater than the 85th percentile, determine the patient's risk for future obesity-related problems or presence of obesity-related medical problems

such as sleep, respiratory, GI, endocrine, cardiovascular, and psychiatric disorders. Table 102-1 BMI Classification

Ext rem e obesity (C l ass g reate r th a n o r eq u a I to 40 kg/m3 Children (Does Not Pertain to Those Less Than 2 Years of Age°)

■Weight for height values should be plotted and monitored over

Table 102-2 High-Risk Waist Circumference

Women Greater than in. (88 c:m}

Hrom U.S. Department of Health and hljman Services, NEH-IMHLBE. Ginital guidelines oi'i the identificationrevaluation, and treatment of ovefweight and obesity in adults. Nil I publication no. 00-4034. Bcthesda, MD: National Institutes of Health, 2000.

Table 102-3 Risk Factors

• Cigarette smoking

• Hypertension (systolic blood pressure greater than or equal to 140 mm Hg or diastolic blood pressure greater than or equal to 90 mm Hg) or current use of blood pressure lowering medication(s)

• Low-density lipoprotein cholesterol greater than or equal to 160 mg/dL (4.14 mmol/L)

• Low-density lipoprotein cholesterol greater than or equal to 130-159 mg/dL (3.37-4.12 mmol/L) plus two additional risk factors

• High-density lipoprotein cholesterol less than 40 mg/dL (1.03 mmol/L)

• Impaired fasting glucose (fasting blood glucose 100-125 mg/dL [5.6-6.9 mmol/L])

• Family history of premature CHD (first degree male relative less than 55 years of age or first degree female relative less than 65 years of age)

• Males greater than or equal to 45

• Females greater than or equal to 55

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