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Obese Patients

According to the National Health and Nutrition Examination Survey (NHANES) 2005-2006, 65.7% of adult Americans, representing nearly 100 million individuals, are classified as overweight or obese (defined as a BMI of 25 kg/m2 or higher). Among the general population, 35% are considered overweight (BMI of 25 to 29.9), and 30.7% are considered obese (BMI of 30 or higher). Thus, obesity represents the most significant diet-related health problem encountered by health-care professionals.

There are several lifestyle factors that may predispose to obesity. When calorie intake continuously exceeds requirements, obesity results. The converse is likewise true. Fewer than 1% of all cases of obesity are related to neuroendocrine causes, and these conditions rarely cause massive obesity. These syndromes include hypothyroidism, hypopituitarism, adrenocortical excess, polycystic ovary syndrome, and hypothalamic tumors or other damage to this part of the brain, as well as some rare inherited conditions. Prader-Willi syndrome is a rare chromosomal microdeletion syndrome associated with childhood massive obesity, mental retardation, and failure of sexual development. A patient with Prader-Willi syndrome and morbid obesity is pictured in Figure 5-2.

Obesity-Focused History

An obesity-focused history should include a chronologic history of the patient's weight, identifying age at onset, description of weight gain, and inciting events. For women, weight gain often occurs during adolescence, pregnancy, child-rearing years, and menopause. For many patients, weight gain occurs with smoking cessation or other changes in lifestyle, such as changes in marital status, occupation, or housing. The patient's history may be suggestive of, as already mentioned, several endocrinologic causes for weight gain. With the exception of polycystic ovary syndrome, these conditions are uncommon causes of obesity. Several medications are known to cause weight gain as an unintended side effect. The most common drug groups are antidepressants (tricyclic agents and mirtazapine), lithium, antipsychotics (phenothiazines, butyrophenones, olanzapine, clozapine, and risperidone), anticonvulsants (valproic acid, car-bamazepine), steroid hormones (corticosteroid derivatives, megestrol acetate, estrogen), and antidiabetics (insulin, sulfonylureas, thiazolidinediones).

Figure 5—2 Patient with Prader-Willi syndrome.

Figure 5—2 Patient with Prader-Willi syndrome.

Short Dick Syndrome

When a patient's weight history is documented, it is important to be sensitive. Many patients feel discriminated against because of their obesity or feel ashamed and frustrated about not being able to control their weight. The following questions should be considered part of an obesity-focused history:

''When did you first consider yourself overweight or have a weight problem?''

''Do you remember what you weighed when you were in high school? College? Your 20s, 30s, and so forth?''

''What was your lowest weight as an adult?'' ''What was your highest weight as an adult?''

' 'Were there any particular life events that caused you to gain weight, such as pregnancy, stopping smoking, changing jobs, getting a divorce, and so forth?''

''Did you experience weight gain after taking any medication?'' If so, ' 'Which medication, and how much weight did you gain?''

In addition to characterizing the chronologic history of the patient's weight, it is important to appreciate what impact the obesity has had on the patient. Obesity may affect the physical and mental health functioning of the patient, both of which are important aspects of quality of life. Physical effects of obesity include difficulties with mobility, such as bending, kneeling, and stair climbing;mental health effects may include low self-esteem, poor body image, shame, and social isolation. You should also ascertain whether the patient participated in any weight management programs in the past and what the response to treatment was. You can obtain this information through the following questions:

' 'How does your body weight affect you?'' ''Is there anything that you cannot do because of your weight?'' ''Does your weight affect your own sense of self-worth?''

''Have you participated in any weight management programs in the past?'' If so, ' 'What were they, and how did you respond?''

Obesity-Focused Physical Examination

According to the most recent National Heart, Lung, and Blood Institute (1998) guidelines, assessment of risk status according to overweight and obesity is based on the patient's BMI, waist circumference, and existence of comorbid conditions.

Being overweight or obese substantially increases the risk of morbidity and mortality from hypertension, type 2 diabetes mellitus, dyslipidemia, coronary artery disease, stroke, gallstones, osteoarthritis, respiratory problems (including sleep apnea), several cancers, and the metabolic syndrome, which is a clustering of risk factors for cardiovascular disease and diabetes. Factors characteristic of this syndrome are abdominal obesity, elevated triglyceride levels, low high-density lipoprotein cholesterol level, raised blood pressure, and impaired fasting blood glucose. Excess abdominal fat, a hallmark of the metabolic syndrome, can be clinically defined as a waist circumference greater than 40 inches (102 cm) in men and greater than 35 inches (88 cm) in women. To measure waist circumference, a horizontal mark is drawn just above the uppermost lateral border of the iliac crest. A cloth or metal tape is then placed in a horizontal plane around the abdomen at the level of the mark (Fig. 5-3). The measurement is made at a normal minimal respiration. An increased waist circumference can indicate increased risk even at a healthy weight. In contrast, waist circumference is less useful as an independent marker of medical risk when the BMI is greater than 35. Table 5-5 lists the classification of weight status and risk of disease.

The physical examination process for patients with obesity is identical to that for other adult patients, with the exception of specific measures to determine the obesity category (height, weight, and waist circumference) and the use of an appropriate blood pressure cuff. A bladder cuff that is not the appropriate width for the patient's arm circumference can cause a systematic error in blood pressure measurement; if the bladder is too narrow, the pressure will be overestimated and lead to a false diagnosis of hypertension. The most frequent error in measuring blood pressure is "miscuffing/' with undercuffing large arms accounting for

Figure 5-3 Measuring tape position for determining abdominal circumference.

Figure 5-3 Measuring tape position for determining abdominal circumference.

84% of the ''miscuffings.'' To avoid errors, the ''ideal'' cuff should have a bladder length that is 80% and a width that is at least 40% of arm circumference (a length-to-width ratio of 2:1). Therefore, a large adult cuff (16 x 36 cm) should be chosen for patients with mild to moderate obesity (or arm circumference of 14 to 17 inches [36 to 43 cm]) while an adult thigh cuff (16 x 42 cm) must be used for patients whose arm circumferences are greater than 17 inches.

When the interviewer completes the review of systems section of the history and performs the physical examination, it is important to have a high index of suspicion for obesity-related diseases. Clinically, obesity affects at least nine organ systems. Obesity has been linked with an increased risk of breast and endometrial cancers in women. The mechanism is thought to be

Table 5-5 Classification of Weight Status and Risk of Disease

Classification Body Mass Index

Risk of Disease*

Women: <35 inches Women: >35 inches (88 cm); Men: (88 cm); Men:

Underweight Healthy weight Overweight Obesity Obesity

Extreme obesity

t tt ttt tttt tt ttt ttt tttt

*Waist circumference is measured just above the iliac crest. An increased waist circumference may indicate increased disease risk even at a normal weight.

Adapted from National Institutes of Health and National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Rockville, Md, U.S. Department of Health and Human Services, Public Health Service, 1998.

Table 5—6 Review of Obesity-Related Organ Systems

Cardiovascular Hypertension Congestive heart failure Cor pulmonale Varicose veins Pulmonary embolism Coronary artery disease Atrial fibrillation

Respiratory Dyspnea

Obstructive sleep apnea Hypoventilation syndrome Pickwickian syndrome Asthma

Endocrine Metabolic syndrome Type 2 diabetes mellitus Dyslipidemia

Polycystic ovary syndrome/androgenicity Amenorrhea/infertility/menstrual disorders

Gastrointestinal Gastroesophageal reflux disease Nonalcoholic fatty liver disease Cholelithiasis Hernias Colon cancer

Musculoskeletal Hyperuricemia and gout Immobility

Osteoarthritis (knees and hips) Low back pain

Genitourinary Urinary stress incontinence Obesity-related glomerulopathy End-stage renal disease Hypogonadism (male) Breast and uterine cancer Pregnancy complications

Psychologic Depression/low self-esteem Body image disturbance Social stigmatization

Neurologic Stroke

Idiopathic intracranial hypertension Meralgia paresthetica

Integumentary Striae distensae (stretch marks) Stasis pigmentation of legs Lymphedema Cellulitis

Intertrigo, carbuncles Acanthosis nigricans/skin tags related to increased circulating estrogens as a consequence of increased conversion of andro-gens to estrogens in adipose tissue. Obesity increases the risk of gallstone formation by increasing gallbladder volume and bile stasis. Increased cholesterol production is also thought to play a role. Degenerative joint disease is seen in obese individuals more frequently than in persons of normal weight. Regardless of whether it is a causative factor, osteoarthritis aggravates joint symptoms. A positive association has been noted between serum triglyceride and low-density lipoprotein cholesterol levels and obesity. High-density lipoprotein cholesterol level tends to be lower in patients with obesity. The pickwickian, or obesity-ventilation, syndrome is characterized by marked obesity, somnolence, periodic apnea (transient cessation of breathing), chronic hypoxemia (deficient oxygenation of the blood), hypercapnia (carbon dioxide retention), and polycythemia (increased number of red blood cells). Table 5-6 lists the symptoms and diseases that are directly or indirectly related to obesity. Although individuals vary, the number and severity of organ-specific comorbid conditions usually rise with increasing levels of obesity.

Malnourished Patients

Malnutrition is associated with slower wound healing, increased number of medical complications, longer length of hospital stay, higher health-care costs, and increased mortality rate. By performing a nutritionally focused history and physical examination, you can identify individuals who are at high nutritional risk or are malnourished. Key elements from the history and physical examination were reviewed earlier in this chapter.

The Subjective Global Assessment (SGA) provides an integration of historical and physical examination data to arrive at an evaluation of the patient's nutritional status. As shown in Figure 5-4, five features of the history and eight features of the physical examination are combined to assess risk. The historical features are weight loss, changes in dietary intake, significant GI symptoms, functional status or energy level, and metabolic demand of the patient's underlying disease state. Physical findings are scored as normal (0), mild (1+), moderate (2+), or severe (3+), and include depletion of subcutaneous fat in the chest and triceps, muscle wasting in the quadriceps and deltoid muscles, and the presence of edema or ascites.

Select appropriate category with a checkmark, or enter numerical value where indicated by a "#". A. History

1. Weight change and height

Change in past 2 weeks:_increase,

2. Dietary intake change (relative to normal) _No change.

Type:

suboptimal solid diet,

_ weeks. full liquid diet, hypocaloric liquids, starvation.

Supplement: (circle) nil, vitamin, minerals, # .

. frequency/week.

Gastrointestinal symptoms (that persisted for > 2 weeks)

_none,_nausea,_vomiting,_diarrhea,

Functional capacity

_No dysfunction (e.g., full capacity).

_Dysfunction: duration #_weeks.

Type:

working suboptimally, ambulatory, bedridden.

Disease and its relation to nutritional requirements

Primary diagnosis (specify)_

Metabolic demand (stress):_no stress,_

stress,_high stress.

low stress, moderate

B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+

#_ Loss of subcutaneous fat (triceps, chest)

#_ Muscle wasting (quadriceps, deltoids, temporalis)

#_Ankle edema

C. SGA rating (select one) _Well nourished.

_Moderately (or suspected of being) malnourished.

_Severely malnourished.

severe) Ascites

Mucosal lesions Cutaneous lesions Hair change cm

Figure 5—4 Subjective Global Assessment (SGA). (From Jeejeebhoy KN: Clinical and functional assessments. In Shils ME, Olson JA, Shike M [eds]: Modern Nutrition in Health and Disease, 8th ed. Philadelphia, Lea & Febiger, 1994, p 805.)

On the basis of the history and physical examination findings, patients are ranked according to the following three categories: A, good nutrition;B, moderate or suspected malnutrition; and C, severe malnutrition. Weight loss, poor dietary intake, loss of subcutaneous tissue, muscle wasting, and functional impairment are considered the most significant factors. These nutritional categories can be used to classify the severity of nutritional risk and the need for intervention. In addition, a low BMI, generally less than 19, should be considered an important predictor of mortality in a hospitalized patient. Figure 5-5 depicts three patients with protein-energy malnutrition, or deficiency of macronutrients. Note the severe loss of subcutaneous fat reserves and muscle mass and the prominence of the bones.

Impairment of function secondary to loss of body protein and energy reserves is the most important component of the assessment of nutritional status. You can evaluate function while performing the physical examination and by watching the patient's activity. You can assess grip strength by asking the patient to squeeze your index and middle fingers hard for at least 10 seconds. You can assess respiratory muscle function by asking the patient to exhale quickly or cough deeply. Shortness of breath may be noted at rest. You can assess leg muscle strength by asking the patient to push his or her legs and feet against your hand and by watching the patient ambulate.

Elderly Patients

Elderly people represent a diverse group who are at specific risk for a variety of nutritional problems. These problems are caused by a combination of environmental, social, and economic factors and are compounded by numerous physiologic changes that occur at different rates as individuals age. The Nutrition Screening Initiative, a multidisciplinary effort to promote nutrition screening and better nutritional care in America's health-care system, has identified the following risk factors associated with poor nutritional status in older Americans: inappropriate food intake, poverty, social isolation, dependency or disability, acute or chronic diseases or conditions, and chronic medication use.

These factors have been incorporated into a risk factor checklist with the acronym DETERMINE, which identifies several warning signs for individuals at risk for poor nutritional status:

Disease: Any disease can cause the patient to change the way he or she eats or make it hard to eat, cook, or shop. Confusion or memory loss can make it hard for people to remember what or how to eat. Depression can lead to changes in appetite, energy level, and weight.

Eating poorly: This may involve eating too little or too much, drinking too much alcohol, or not eating the foods needed for health every day. A diminished sense of taste and smell can decrease appetite and influence food choices. Many elderly people have a decreased ability to taste salt, which results in the liberal salting of foods. A reduced sense of smell may make it difficult for an elderly person to detect whether food has spoiled. Elderly patients should be advised to read all dates stamped on food products. Tooth loss or mouth pain: Some people do not eat well because they have lost teeth or have problems with their mouth, teeth, or gums.

Economic hardship: When a patient has very little money to spend on food, he or she may not eat enough food or may eat foods that do not have enough vitamins, minerals, or calories to stay healthy. The individual may buy prepackaged or convenience foods that are typically high in sodium, potassium, and sugar.

Reduced social contact: Cooking and eating alone are hard. Some people who live alone do not feel like shopping for or preparing the food they need. Loss of a spouse, retirement, or social isolation can lead to loneliness, depression, and lack of motivation to eat.

Multiple medications or drugs: Drugs and other medications can depress the appetite and alter nutrient absorption and excretion. Drugs can further alter the sense of taste and smell, change the secretion of saliva, irritate the stomach, and cause nausea. Some drugs can contribute directly to dietary deficiencies; for example, antacids absorb folic acid and calcium, laxatives absorb fat-soluble vitamins, and aspirin increases the excretion of folic acid. Involuntary weight loss or gain. Need for assistance with self-care. Elderly years: older than 80 years.

Specific nutritional interventions are vital components of the health-care delivery system for elderly patients. The elderly person may overeat as a way of coping with feelings of loneliness. Some of these individuals, however, can be overweight but malnourished;their diet consists of cake and candy, which are high in calories but low in nutrients. The National Institute on Aging suggests that the daily diet for the geriatric population include the following:

# Two servings of milk or dairy products low in lactose (3 cups per day) Two servings of high-protein foods (5-5 2 ounces per day)

• Four servings of fruit and vegetables, including a citrus fruit and a dark green leafy vegetable (2-2| cups per day)

Four servings of bread or cereal products (3 ounces per day)

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