Overweight is defined as a body-mass index (BMI) over 25 and obesity as a BMI
over 30 (BMI is defined as the weight in kilograms divided by the square of the
height in meters). A BMI over 25 is associated with increased health risks.
Historically, obesity was defined as a body weight greater than 20% above a
desirable weight as defined by the Metropolitan Life Insurance Company tables of
weights and heights. However, the BMI is the current standard. Approximately 33%
of Americans 20 to 75 years of age are overweight, and of these, approximately
one-third are severely obese. For both men and women, the prevalence of
overweight increases with age.
While there is no single underlying etiology of simple obesity, excessive
weight reflects an imbalance between energy input and energy output. However,
genetic and environmental factors may also play a role; for example, total body
fat stores and the total number of fat cells are determined genetically and can
make an individual susceptible to obesity. In addition, there are a number of
rare congenital syndromes in which all affected individuals are obese, such as
Prader–Willi syndrome, Cushing's syndrome, Alström's
syndrome, Laurence-Moon-Biedl syndrome, Cohen's syndrome, and Carpenter's
- Genetic predisposition
- Hypothalamic disorders
- High-fat diet
- Decreased physical activity
- Prescription medications (e.g., steroids, phenothiazines, tricyclic
antidepressants, antiepileptics, antihypertensives)
- Psychological factors (e.g., disturbance in body image, reaction to
separation or death)
- Familial predisposition
- Sedentary lifestyle
- High-fat diet
|Signs and Symptoms|
BMI over 25 to 30
- Cushing's disease—characterized by weight
gain in the face, thorax, and abdomen, but sparing the buttocks and
- Hypothyroidism (60% of patients have only a modest weight
- Hypothalamic tumors (e.g., craniopharyngiomas)
- Stein–Leventhal syndrome (in
women)—characterized by obesity, hirsutism, and
- Klinefelter's syndrome (in
men)—characterized by increased adipose tissue and
reduced muscle mass
After determining the level of obesity in an individual patient, it is
essential to determine whether complications such as diabetes,
hypertriglyceridemia, and hypertension exist. It is also important to assess an
obese patient's willingness and motivation to lose weight. Many obese patients
are content being "overweight" and do not view 30 or 50 extra pounds as a
problem. In addition, careful assessment of any previous history of weight loss;
factors related to the onset of obesity; details of the patient's current eating
habits; emotional well-being; and the patient's weight-losing goals is essential
to the success of any treatment program.
- Fasting serum glucose
- Thyroid function tests
- Serum cholesterol and
Android (male) fat distribution is characterized by fat distributed above the
waist. Upper body fat distribution appears to occur by hypertrophy of
adipocytes. There is a higher morbidity and mortality associated with upper body
than lower body fat distribution. Gynecoid (female) fat distribution is
characterized by fat distributed in the lower body such as the buttocks, hips,
and thighs. Lower body fat distribution appears to occur by hyperplasia (i.e.,
differentiation of new fat cells). Because it is easier to reduce the size of
fat cells than the number of them, people with a lower body fat distribution
often have a harder time losing weight.
- Hyperplasia of adipocytes: Even if weight is lost, the number of fat
cells is fixed.
- Hypertrophy of adipocytes: Cell size will return to normal with
- Generally not necessary for diagnosis
- Dual energy X-ray absorptiometry—to analyze
- Magnetic resonance imaging and computed
tomography—to measure regional fat distribution
- Waist measure—above 35" in women or 40" in
men is abnormal
- Waist:hip ratio—to measure abdominal girth
(>0.85 in women and >1.0 in men is abnormal)
- Body-mass index (BMI)—to measure level of
obesity (BMI of 20 to 25 is considered normal)
- Weight and height tables from Metropolitan Life Insurance
Company—to indicate the weight at which longevity is
highest (does not distinguish between obesity and overweight)
- Skinfold thickness measured by skin calipers (triceps, biceps,
subscapular, suprailiac)—to estimate total body
- Underwater weighing—to calculate fat-free
mass and body fat.
- Measure total body water (fixed fat-free mass (FFM) equals water
mass/0.73), which is subtracted from total body weight to obtain total body
Lifelong lifestyle changes (e.g., exercise, behavior modification) and diet
modification are necessary to control weight in obese patients. Many obese
patients may have consumed more calories than they metabolized in their
weight-gaining phase but currently may be eating enough merely to maintain
weight gained previously. Health care providers must assess the risks associated
with obesity on an individual basis, using the BMI and fat distribution as well
as comorbidities as guides for treatment. Risk assessment may be critical to the
process of setting goals and providing motivation. No drug treatment has been
shown to be safe and effective for long-term weight loss. Surgical therapies for
morbid obesity include gastric bypass (Roux-en-Y procedure), or stapling and
liposuction for moderate fat redistribution.
It is important to enroll family members, especially spouses, in any
lifestyle and diet changes that will affect the interactions of the
relationship. Family activities such as shopping, cooking, and eating out all
have an impact on diet and caloric intake.
- Diuretics—for temporary use to reduce water
retention; does not reduce adipose tissue stores
- Ephedrine (20 to 60 mg/day) plus caffeine (200 to 600
mg/day)—to transiently increase the basal metabolic
rate. (These over-the-counter drugs should not be taken by patients with heart
disease, high blood pressure, thyroid disease, diabetes, or an enlarged
|Complementary and Alternative
The main thrust of alternative therapy is increasing basal body metabolism
and addressing the behavioral component. The bottom line is to expend more
calories than are consumed. Most obese people have tried many diets and are
frustrated with their lack of success. Alternative therapies can help stabilize
blood sugars, promote a custom tailored exercise plan, and treat emotional
well-being. Mind-body techniques can be helpful, especially in reframing the
goal of weight loss to the goal of health. Individual treatment plans addressing
family history, personal health risks, and past successes can be important
information in designing a plan. It is interesting to note that rates of both
obesity and eating disorders are rising rapidly in the United States.
Behavior modification (e.g., keeping a food journal, eating a diet low in
total and saturated fats, beginning an exercise program, counseling to change
eating and exercise habits) can be effective. Special emphasis should be placed
on what has and has not been successful in the past.
- Protein: While the standard weight loss diet is low protein, high
complex carbohydrates, some people will do better with a high protein, low
carbohydrate diet. Regular meals that contain protein are important for blood
sugar stabilization. In either diet, it is important to use many foods that the
patient enjoys. Liberal consumption of oat bran or garlic helps lower lipids
slightly. Anecdotally, some people lose weight by eating protein at breakfast,
which decreases afternoon or pre-dinner gorging and cravings for
- Fluid: Six to eight glasses daily of nonsugared, caffeine-free drinks
flush toxins, and increase a sense of satiety.
- Fiber: Increasing dietary fiber (e.g., fruits, vegetables, psyllium,
chitin, guar gum, glucomannan, gum karaya, and pectin) promotes weight loss by
enhancing blood sugar control, reducing the number of calories that are
absorbed, and increasing satiety.
- Allergies: Many people find that avoiding allergenic foods (wheat,
dairy, soy, eggs, and citrus) allows for diuresis and improved digestion. Other
allergic foods may be discovered by using an IgG ELISA food allergy
- Multiple vitamin to address any dietary imbalances
- Chromium picolinate (200 to 500 mcg one to two times per day):
claimed to preferentially burn fat, proven to increase insulin sensitivity,
stabilize blood sugars. Helpful in those patients with sugar
- Vitamin C (3,000 to 6,000 mg/day) speeds up metabolism, acts as an
anti-inflammatory, and is needed for cholesterol metabolism.
- Essential fatty acids (primrose oil, 2 to 4 g/day; flaxseed oil, 1 to
3 tbsp./day): One study showed reduction in appetite and some weight loss
without dieting. Fat cravings may be exacerbated by a fatty acid
- Lecithin, choline, methionine: (1 g/day of each) aids proper fat
metabolism and decreases fat cravings
- Thiamine: (2.5 mg/day) plays a role in fatty-acid metabolism and may
decrease ketone formation, increased ketones may play a role in excessive
hunger; in order to avoid imbalance, supplement with B-complex: B1 (50 to 100
mg), B2 (50 mg), B3 (25 mg), B5 (100 mg), B6 (50 to 100 mg), B12 (100 to 1,000
mcg), folate (400 mcg/day)
- Kelp (1,000 to 2,000 mg/day, equivalent to 250 to 500 mcg of iodine
per day) may aid in weight loss, as it provides nutrients for thyroid
- L-glutamine (1,000 mg tid) may blunt carbohydrate craving.
- Coenzyme Q10 is important in fatty-acid metabolism, may help break
down fat into energy
- 5-Hydroxytryptophan (5-HTP; 100 to 300 mg/day) to reduce food intake
by promoting satiety. Acts as an antidepressant, especially with sleep
- Fasting: For patients who don't have diabetes, fasting or juice
fasting one day a week is helpful to reset the appetite control
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
Ma huang (Ephedra sinica) is used to stimulate the sympathetic nervous
system in order to burn more fat. It is a constituent of most OTC weight loss
products (1 cup tea or 30 drops tincture/day in the morning). Reacts with
cardiac glycosides (arrhythmias), MAO-inhibitors (potentiates sympathomimetic
effects), and secale alkaloids (hypertension). Patients need to be warned of the
side effects and only use ephedra short term (if at all).
A combination of four to six of the following herbs can be taken tid before
meals (1 cup tea or 30 drops tincture).
- Peppermint (Mentha piperita) carminative, spasmolytic,
historically to reduce appetite
- Bladderwrack (Fucus vesiculosus) historic use in
- Parsley (Petroselinum crispum) diuretic, historic use in
- Dandelion (Taraxacum officinale) diuretic,
- Hawthorn (Crataegus monogyna) reduces peripheral vascular
resistance, historically a sedative
- St. John's wort (Hypericum perforatum) antidepressant,
historically with nerve pain
- Valerian (Valeriana officinalis) bitter spasmolytic,
- Milk thistle (Silybum marianum) dyspepsia, specifically for
liver and gallbladder
- Lavender (Lavandula angustifolia) carminative, spasmolytic,
- Gentian (Gentiana lutea) carminative, digestive
Homeopathic remedies may be of help in treating obesity, but the
constitutional remedy for the specific individual should be prescribed by an
Daily exercise program: exercise is critical to maintaining weight loss.
While 20 minutes of aerobic execise a day is ideal, as little as 10 minutes/day
can help stabilize blood sugar and thereby reduce cravings. Gentle exercise
(walking, yoga, swimming, biking) can increase cardiovascular health without
undue stress on joints.
Acupuncture can be used to help balance the body's metabolism, stabilize
blood sugar, correct digestive disorders, control certain eating disorders, aid
in elimination and relieve stress, anxiety, and depression that may lead to
May be beneficial. By decreasing stress, cortisol is decreased, which will
help to stabilize blood sugar and help prevent or treat
A good provider–patient relationship is an essential
ingredient for a successful treatment program. All obese patients must be
monitored for the medical and psychological complications of
Lifestyle changes are the key to successful weight loss in obese patients.
Regular exercise and a long-term low-calorie diet can help to raise the basal
metabolic rate (the rate at which calories are burned) and reset the set point
(the weight the body tries to maintain by regulating the amount of food and
There is a known increase in morbidity (and mortality) associated with many
of the complications of obesity.
- Type II diabetes mellitus (adult-onset
diabetes)—rare in individuals with a BMI <22
- Hypertension (blood pressure >160/95 mm
Hg)— especially in patients 20% over ideal
- Coronary artery disease
- Hypertriglyceridemia as a result of increased insulin resistance and
- Congestive heart failure and sudden death as a result of increased
blood volume, stroke volume, cardiac output, and left ventricular end-diastolic
- Respiratory problems (e.g., pickwickian syndrome, pulmonary
- Circulatory problems, such as varicose veins and venous stasis, which
predisposes patients to venous thromboembolic disease
- Endometrial and postmenopausal breast cancer in women, prostate
cancer in men, and colorectal cancer in men and women
- Gallbladder disease as a result of increased secretion of biliary
- Obstructive sleep apnea as a result of fat accumulation in the
- Arthritis as a result of excess stress on joints especially of the
- Skin problems, such as acanthosis
Eating and exercise habits are hard to change. Most obese patients have long
histories of unsuccessful attempts to lose weight. Approximately 10% to 60% of
patients who attempt diet therapy are able to lose at least 20 pounds; however,
only between 10% and 20% of patients are able to maintain their weight loss over
time. Patients should be told that losing 15 to 20 pounds is often responsible
for a 10% to 25% decrease in health risks associated with
The complications of obesity can complicate pregnancy, resulting in increased
risk for the fetus. Pregnancies in obese women should be considered high
- Gestational diabetes
- Abnormally large infants resulting in difficult deliveries
- Increase rate of cesarean sections with complications
- Increased incidence of fetal distress and meconium
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Copyright © 2007 Drugs Area
This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
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The reader is advised to check product information (including package inserts)
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interactions, and contraindications before administering any drug, herb, or
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