Obesity

Published on 06/06/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1761 times

Chapter 37 Obesity

INTRODUCTION

Description: Obesity is a state of increased fat and lean body mass (>20% higher ideal weight, body mass index [BMI] >28) associated with increased health risks. Obesity affects more women than men and is of special concern to adolescents and older women. Weight gained during pregnancy (in excess of that related to the pregnancy) is often not lost.
Prevalence: Varies with age: 30% to 40% of women.
Predominant Age: Any.
Genetics: Of the variance in body mass, 20% to 30% may be genetically determined. Rare genetic syndromes have been described.

ETIOLOGY AND PATHOGENESIS

Causes: Calorie consumption in excess of expenditure, insulinoma, hypothalamic disorders, Cushing’ syndrome, corticosteroid drugs.
Risk Factors: Parental obesity, pregnancy, sedentary lifestyle, high-fat diet (higher calorie density), low socioeconomic status.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Increased body mass and fat (male pattern obesity [abdominal] is associated with the greatest health risk)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Pathologic process other than excess dietary consumption

Associated Conditions: Increased morbidity and mortality (see Complications), cholelithiasis. Recent studies indicate an increase in the risks of ovarian and breast cancers.

Workup and Evaluation

Laboratory: No evaluation indicated. Consider thyroid testing in selected patients. Determine serum cholesterol, triglycerides, or glucose levels to assess risk factors for complications.
Imaging: No imaging indicated.
Special Tests: Body mass index = weight (kg)/height (m2), waist to hip circumference ratio (normal female gynecoid pattern is greater than 0.85).
Diagnostic Procedures: Physical examination, body mass index.

Pathologic Findings

Hypertrophy and/or hyperplasia of adipocytes. Cardiomegaly or hepatomegaly is common.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Risk assessment, diet and exercise counseling. Assistance with diet planning or selection of a commercial program.
Specific Measures: Behavior modification and hypnosis have been applied with variable success. In select patients (body mass index >40) surgical intervention (stapling or bypass) may be indicated. Surgery is the most effective long-term therapy for morbid obesity.
Diet: Restriction to 500 kcal below maintenance generally provides the best sustainable loss (1 lb/week). Verylow-calorie diets are associated with increased risk and occasional deaths.
Activity: A program of physical activity should accompany any calorie-restriction diet. Activity by itself is generally ineffective.
Patient Education: Diet and exercise instruction, behavior modification; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP045 (Exercise and Health: A Guide for Women), AP064 (Weight Control: Eating Right and Keeping Fit), AP101 (Cholesterol and Your Health).

Drug(s) of Choice

Drug therapy is not generally recommended. However, orlistat (Xenical) 120 mg PO three times a day, taken during or up to 1 hour after meals containing fat, may be recommended. In 2007 a reduced dose version of orlistat (Alli) was introduced as an over-the-counter adjunct for weight loss. With these agents, high-fat meals should be avoided to reduce cramping and diarrhea.
Contraindications: See individual agents. Most are contraindicated in the presence of atherosclerosis or other heart disease, hypertension, hyperthyroidism, or glaucoma. Patients with chronic malabsorption syndromes or cholestasis should avoid orlistat.
Precautions: Relapse common, abuse potential is high for stimulants. Diarrhea, fatty stools, increased frequency of bowel movements, fecal incontinence, abdominal pain, and nausea may occur with orlistat therapy.
Interactions: Some agents may cause arrhythmias with general anesthetic agents. Orlistat can interact with cyclosporine, fat-soluble vitamin absorption, and warfarin.

Alternative Drugs

Phenylpropanolamine (over-the-counter preparations).

FOLLOW-UP

Patient Monitoring: Long-term follow-up, screening for complications of drug therapy or obesity itself.

image

Prevention/Avoidance: Diet and exercise counseling (especially important for adolescents and children).
Possible Complications: Significant increase in risk for cardiovascular disease, diabetes mellitus, hypertension, hyperlipidemia, cholelithiasis, cholecystitis, osteoarthritis, gout, thromboembolism, and sleep apnea.
Expected Outcome: Long-term maintenance is difficult and relapses are common. Individual motivation is the best predictor of success.

MISCELLANEOUS

Pregnancy Considerations: Obesity complicates pregnancy, and pregnancy is often the time of onset of obesity for many women. Weight gain should be monitored and adjusted downward for patients who are obese. Orlistat is a Category B medication.
ICD-9-CM Codes: 278.00, 278.01 (Morbid).

REFERENCES

Level I

Ebbeling CB, Leidig MM, Feldman HA, et al. Effects of a low-glycemic load vs low-fat diet in obese young adults: a randomized trial. JAMA. 2007;297:2092.

Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007;297:969.

Mathus-Vliegen EM, de Wit LT. Health-related quality of life after gastric banding. Br J Surg. 2007;94:457.

McMillan-Price J, Petocz P, Atkinson F, et al. Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial. Arch Intern Med. 2006;166:1466.

Scholze J, Grimm E, Herrmann D, et al. Optimal treatment of obesity-related hypertension: the Hypertension-Obesity-Sibutramine (HOS) study. Circulation. 2007;115:1991. Epub 2007 Apr 2

Level II

Alexander CI, Liston WA. Operating on the obese woman—A review. BJOG. 2006;113:1167.

Carmichael AR. Obesity and prognosis of breast cancer. Obes Rev. 2006;7:333.

Janssen I, Mark AE. Elevated body mass index and mortality risk in the elderly. Obes Rev. 2007;8:41.

Olsen CM, Green AC, Whiteman DC, et al. Obesity and the risk of epithelial ovarian cancer: a systematic review and meta-analysis. Eur J Cancer. 2007;43:690. Epub 2007 Jan 12

Level III

Bray GA. Obesity. Endocrinol Metab Clin North Am. 1996:25.

Catalano PM. Management of obesity in pregnancy. Obstet Gynecol. 2007;109:419.

Danford D, Fletcher JW. Methods for voluntary weight loss and control. National Institutes of Health Technology Assessment Conference. Ann Intern Med. 1993;119:41.

ESHRE Capri Workshop Group. Nutrition and reproduction in women. Hum Reprod Update. 2006;12:193. Epub 2006 Jan 31

Gray AD, Power ML, Zinberg S, Schulkin J. Assessment and management of obesity. Obstet Gynecol Surv. 2006;61:742.

Haslam D, Sattar N, Lean M. ABC of obesity. Obesity—Time to wake up. BMJ. 2006;333:640.

Kral JG. ABC of obesity. Management: Part III—Surgery. BMJ. 2006;333:900.

Lawlor DA, Lean M, Sattar N. ABC of obesity: obesity and vascular disease. BMJ. 2006;333:1060.

Lean M, Lara J, Hill JO. ABC of obesity. Strategies for preventing obesity. BMJ. 2006;333:959.

Legato MJ. Gender-specific aspects of obesity. Int J Fertil Womens Med. 1997;42:184.

Malnick SD, Knobler H. The medical complications of obesity. QJM. 2006;99:565. Epub 2006 Aug 17

Milewicz A, Jedrzejuk D. Clinical aspects of obesity in the gynecological endocrinology practice. Maturitas. 2007 Feb;56:113. Epub 2006 Sep 12.

Mitrakou A. Women’s health and the metabolic syndrome. Ann N Y Acad Sci. 2006;1092:33.

Pasquali R. Obesity, fat distribution and infertility. Maturitas. 2006;54:363. Epub 2006 May 24

Pasquali R, Gambineri A, Pagotto U. The impact of obesity on reproduction in women with polycystic ovary syndrome. BJOG. 2006;113:1148. Epub 2006 Jul 7

Pettigrew R, Hamilton-Fairley D. Obesity and female reproductive function. Br Med Bull. 1997;53:341.

Pujol P, Galtier-Dereure F, Bringer J. Obesity and breast cancer risk. Hum Reprod. 1997;12:116.

Ramsay JE, Greer I, Sattar N. ABC of obesity. Obesity and reproduction. BMJ. 2006;333:1159.

Regulation of body weight. Science. 1998;280:1363.

Schneider JG, Tompkins C, Blumenthal RS, Mora S. The metabolic syndrome in women. Cardiol Rev. 2006;14:286.

Wyatt SB, Winters KP, Dubbert PM. Overweight and obesity: prevalence, consequences, and causes of a growing public health problem. Am J Med Sci. 2006;331:166.

Yu CK, Teoh TG, Robinson S. Obesity in pregnancy. BJOG. 2006;113:1117. Epub 2006 Aug 10

Related posts:

Cervical Incompetence Vaginitis: Bacterial (Nonspecific) and Bacterial Vaginosis Rh Incompatibility Sexually Transmitted Infections: Human Immunodeficiency Virus Breast: Galactocele Sheehan’s Syndrome