Description

Obesity is the excessive or abnormal accumulation of fat or adipose tissue in the body that impairs
health via its association to the risk of development of diabetes mellitus, cardiovascular disease,
hypertension, and hyperlipidemia. It is a significant public health epidemic which has progressively
worsened over the past 50 years.  Obesity is a complex disease and has multifactorial etiology. It is the
second most common cause of preventable death after smoking.  Obesity needs multiprong treatment
strategies and may require lifelong treatment. A 5% to 10% weight loss can significantly improve health,
quality of life, and economic burden of an individual and a country as a whole.

2.

Although several classifications and definitions for degrees of obesity are accepted, the
most widely accepted classifications are those from the World Health Organization
(WHO), based on BMI. The WHO designations include the following:
 Grade 1 overweight (commonly and simply called overweight) - BMI of 25-29.9
kg/m2
 Grade 2 overweight (commonly called obesity) - BMI of 30-39.9 kg/m 2
 Grade 3 overweight (commonly called severe or morbid obesity) - BMI greater
than or equal to 40 kg/m2
The cut-off for each grade varies according to an individual’s ethnic background. For
example, a BMI of 23 kg/m2 or higher may define grade 1 overweight and 27.5 kg/m 2 or
higher may define grade 2 overweight (obesity) in many Asian populations, in which the
risk was shown to be high and extremely high for grade 1 and 2 overweight at these
levels, respectively. Other BMI cutoffs identified as potential public health action points
in these populations are 32.5 and 37.5 kg/m 2.

3. patho

Obesity is associated with cardiovascular disease, dyslipidemia, and insulin resistance, in turn,
causing diabetes, stroke, gallstones, fatty liver, obesity hypoventilation syndrome, sleep apnea,
and cancers.
Association of genetics and obesity is already well established by multiple studies. FTO gene is
associated with adiposity. This gene might harbor multiple variants that increase the risk
of obesity.
Leptin is an adipocyte hormone which reduces food intake and body weight. Cellular leptin
resistance is associated with obesity. Adipose tissue secretes adipokines and free fatty acids
causing systemic inflammation which causes insulin resistance and increased triglyceride levels,
which subsequently contributes to obesity.
Obesity can cause increased fatty acid deposition in the myocardium causing left ventricular
dysfunction. It has also been shown to alter the renin-angiotensin system causing increasing salt
retention and elevated blood pressure.
Besides total body fat, the following also increase the morbidity of obesity:
  Waist circumference (abdominal fat carries a poor prognosis)
 Fat distribution (Body Fat Heterogeneity)
 Intra-abdominal pressure
 Age of onset of obesity
The body fat distribution is important in assessing the risk for cardiometabolic health. The
distribution of excess visceral fat is likely to increase the risk of cardiovascular disease. [6][7]
[8] Ruderman et al [9] introduced the concept of metabolic obese normal weight(MONW)
subjects with normal BMI suffer from metabolic complications normally found in obese
individuals.
Metabolically healthy obese (MHO) Individuals have BMI over 30 kg/m2 but do not have the
characteristics of insulin resistance or dyslipidemia [10][11] 
Adipocytes have been shown to have an inflammatory and prothrombotic activity which can
increase the risk of strokes. Adipokines are cytokines mainly produced by adipocytes and
preadipocytes, in obesity macrophages invading the tissue, also produce adipokines. [12][13]. 
Altered adipokine secretion causes chronic low-grade inflammation, which may cause altered
glucose and lipid metabolism and contribute to cardiometabolic risk in visceral obesity. [12]
Adiponectin has insulin-sensitizing and anti-inflammatory properties, the circulating levels are
inversely proportional to visceral obesity.
4. stat and incidence

 In 2016, more than 1.9 billion adults, 18 years and older, were overweight.
Of these over 650 million were obese.
 39% of adults aged 18 years and over were overweight in 2016, and 13%
were obese.
 Most of the world's population live in countries where overweight and
obesity kills more people than underweight.
 38 million children under the age of 5 were overweight or obese in 2019.
 Over 340 million children and adolescents aged 5-19 were overweight or
obese in 2016.

5. Etiology
Obesity is the result of an imbalance between daily energy intake and energy expenditure
resulting in excessive weight gain. Obesity is a multifactorial disease, caused by a myriad of
genetic, cultural, and societal factors.  Various genetic studies have shown that obesity is
extremely heritable, with numerous genes identified with adiposity and weight gain. Other
causes of obesity include reduced physical activity, insomnia, endocrine disorders, medications,
the accessibility and consumption of excess carbohydrates and high-sugar foods, and decreased
energy metabolism. 
 The most common syndromes associated with obesity include Prader Willi syndrome
and MC4R  syndromes, less commonly fragile X, Bardet-Beidl syndrome, Wilson Turner
congenital leptin deficiency, and Alstrom syndrome.
6 CM
 . Difficulty in sleeping. Obesity is associated with sleep apnoea, which is the
cause of daytime drowsiness and insufficient restful sleep.
 Back and/or joint pains.
 Excessive sweating.
 Intolerance to heat.
 Infections in skin folds.
 Fatigue.
 Depression.
 Feeling of shortness of breath (dyspnoea).
7. assessment and dx
All children six years and older, adolescents, and all adults should be screened
for obesity according to the United States Preventative Services Task Force (USPSTF)
recommendations.
Physicians should carefully screen for underlying causes contributing to obesity. A complete
history should include:
 Childhood weight history
 Prior weight loss efforts and results
 Complete nutrition history
 Sleep patterns
 Physical activity
 Associated past medical histories like cardiovascular, diabetes, thyroid, and depression
 Surgical history
 Medications which can promote weight gain
 Social histories of tobacco and alcohol use
 Family history
Complete Physical examination Should be done and should include body mass index (BMI)
measurement, weight circumference, body habitus, vitals.
Obesity focus findings like acne, hirsutism, skin tags, acanthosis nigricans, striae, Mallampati
scoring, buffalo hump, fat pad distribution, irregular rhythms, gynecomastia, abdominal pannus,
hepatosplenomegaly, hernias, hypoventilation, pedal edema, varicoceles, stasis dermatitis, and
gait abnormalities can be present.
Obesity is diagnosed when your body mass index (BMI) is 30 or higher. To determine your
body mass index, divide your weight in pounds by your height in inches squared and multiply by
703. Or divide your weight in kilograms by your height in meters squared.

8.

Medications: Antiobesity medications can be used for BMI greater than or equal to 30 or BMI greater
than or equal to 27 with comorbidities. Medications can be combined with diet, exercise, and behavior
interventions. FDA-approved antiobesity medications include phentermine, orlistat, lorcaserin,
liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine. All the
agents are used for long-term weight management. Orlistat is usually the first choice because of its lack
of systemic effects due to limited absorption. Lorcaserin should be avoided with other serotonergic
medications due to the risk of serotonin syndrome. High responders usually lose more than 5% weight in
the first three months. 

The dietary modification should be individualized with close monitoring of regular weight loss.
Low-calorie diets are recommended. Low calorie could be carbohydrate or fat restricted. A low-
carbohydrate diet can produce greater weight loss in the first months compared to a low-fat diet.
The patient's adherence to their diet should frequently be emphasized.
Behavior Interventions: The  USPSTF recommends obese patients to be referred for intensive
behavior interventions. Several psychotherapeutic interventions are available which includes
motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and
interpersonal psychotherapy. Behavior interventions are more effective when they are combined
with diet and exercise.
Surgery: Indications for surgery are a BMI greater or equal to 40 or a BMI of 35 or greater with severe
comorbid conditions. The patient should be compliant with post-surgery lifestyle changes, office visits,
and exercise programs. Patients should have an extensive preoperative evaluation of surgical risks.
Commonly performed bariatric surgeries include adjustable gastric banding, Rou-en-Y gastric bypass,
and sleeve gastrectomy. Rapid weight loss can be achieved with a gastric bypass, and it is the most
commonly performed procedure. Early postoperative complications include leak, infection,
postoperative bleeding, thrombosis, cardiac events. Late complications include malabsorption, vitamin
and mineral deficiency, refeeding syndrome, dumping syndrome.

Nursing Management
 Review risk factors for obesity in the patient
 Encourage healthy eating
 Encourage exercise
 Educate patients about the harms of obesity
 Enhance self-care and self-esteem
 Develop a food diary
  Avoid fast foods
 Be realistic about weight loss
 Eat at scheduled times
 Slowly cut down on food portions
 Use weight loss drugs with caution
 Consider surgery if medical methods fail to help you lose weight
 Consult with a dietitian about a healthy diet
10.

11.

Imbalanced Nutrition: More Than Body Requirements

Disturbed Body Image

Impaired Social Isolation

Deficient Knowledge
12.
13. evaluation
A standard screening tool for obesity is the measurement of body mass index (BMI). BMI is
calculated using weight in kilograms divided by the square of height in meters.[6][7][8][9]
[10] Obesity can be classified according to BMI:
 Underweight: less than 18.5 kg/m2
 Normal range: 18.5 kg/m2 to 24.9 kg/m2
 Overweight: 25 kg/m2 to 29.9 kg/m2
 Obese, Class I: 30 kg/m2 to 34.9 kg/m2
 Obese, Class II: 35 kg/m2 to 39.9 kg/m2
 Obese, Class III: more than 40 kg/m2
Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:8 is
considered significant.
Further evaluation studies like skinfold thickness, bioelectric impedance analysis, CT, MRI,
DEXA, water displacement, and air densitometry studies can be done.
Laboratory studies include complete blood picture, basic metabolic panel, renal function, liver
function study, lipid profile, HbA1C, TSH, vitamin D levels, urinalysis, CRP, other studies like
ECG and sleep studies can be done for evaluating associated medical conditions.