Diagnosis and classification

of obesity

Post-graduate
Diploma in Diabetes
2021-2022

Dr Rasha Bennaji
 How big is the problem?
Some WHO facts
 Worldwide obesity has nearly tripled since 1975 >>> 2030 ~ 60% of
the worldwide population either obese or overweight.

 In 2016 18 years and over >>> 13% were obese & 39%
overweight
5-17 years >>> Over 340 million overweight or
obese

 In 2020 children under < 5 >>> 39 million were overweight or

obese.
GRWOING pandemic
Why we are concerned?
 Obesity is not just a cosmetic concern, it's a risk for some health
problems: diabetes type 2, hypertension, CVD, gallstones, gastro-
oesophageal reflux as well as psychological and psychiatric
morbidities

• Overweight/obesity
80% of global diabetes problem
23%of the problems for IHD
7-41% specific cancers.
• Obesity is also associated with an increased risk of premature death in
adults < 65, it can take up to 8 years off a person’s life expectancy.

• Economic impact on healthcare systems: obese individuals on average

incurring healthcare related costs 30% greater that their healthy
weight peers.

• Linked to cancer ( liver, kidney, breast, endometrial, prostate, and

colon).
>>> One study estimated that in 2012, 3.6% of all new cancers
worldwide were attributable to high body mass index.

(( Global burden of cancer attributable to high body-mass index in 2012:

a population-based study Lancet Oncol. 2015 Jan; 16(1): 36–46))
The Most Obese Countries In The World

F>M
Benefits of weight loss in treating these obesity related conditions
What causes obesity and overweight?
We are living in an Obesogenic environment

 increased intake of high caloric foods / processed food

marketing/distribution
 increase in physical inactivity / increasingly sedentary
( work, transportation, urbanization ….
 Hypercellular vs. Hypertrophic
• Hyper-cellular obesity
 Often begins in early/middle childhood
 Increased total number of fat cells, typically affects patients with a BMI
< 40 kg/m2 , may be a lower risk form of disease.
 Difficult to lose weight through non-surgical interventions.

• Hypertrophic obesity
 Often begins in adulthood.
 Increased size of existing fat cells >>> enlarge and produce proteins
involved in the pathophysiology of obesity such as lipoprotein lipase
(which contributes to hydrolysis of the TGs of VLDL) and cytokines
(TNF- and IL-6).
 Correlates with metabolic complications of obesity as IGT,
dyslipidemia, hypertension, and CHD.
 Responds quickly to weight reduction measures.
 How to approach and assess
an obese patient?
• Evaluation should include specific elements of the history, physical
examination, and laboratory tests that help clinicians identify those at
greatest risk for morbidity and mortality from obesity-related
disorders.

• The assessment should include classification (degree of obesity)

because treatment guidelines are based in part on classification.

• Screening for medical conditions established to contribute to obesity.

• Identification of related health risks may either interfere with weight

loss or require and benefit from specific treatments.

• Patient’s motivations (readiness to lose weight).

Taking obesity history:

• Weight: when you noticed it, how long you have been obese, what
factors make you obese
?? event that led to the onset of weight gain: beginning or graduating
college, childbirth, marriage, divorce, or a job change.

• Life style :
 Diet/eating behaviors: what, how, where & when you eat (Diary) +
any change in dietary habitus that led to obesity.
 Daily activities
 Smoke or drink >>> hypercortisolism and a central obesity
 Psychosocial stress that affected weight

• Other medical problems/ Medication.

• Family ( any one overweight/obese) >>> any environmental, economical,

social family factors
Physical examinations

• Full general physical and systemic examination.

• Target signs or conditions that predispose to or are complications of
obesity:

 Large neck size (sleep apnea)

 Thyroid tenderness or goiter (hypothyroidism),
 Slowed reflexes (hypothyroidism)
 Proximal muscle weakness (Cushing’s syndrome, hypothyroidism)
 Skin findings:
- Striae (Cushing syndrome’s, steroid use)
- Hirsutism, acne (Cushing syndrome’s, PCOS)
- Dry or coarse skin and hair (hypothyroidism)
Laboratory:

Blood tests to look for the causes/complications of the obesity.

• Fasting Lipid profile
• Fasting glucose/OGTT/HbA1c
• Insulin level
• Liver function test
• Thyroid tests.
• 24-hour urine collection for free cortisol (Cushing’s syndrome)
• Other hormones: LH,FSH, androgens
 Classification of Obesity
• BMI is recommended for use in clinical practice as a practical way to
identify individuals who are overweight or obese
>>> initial step in evaluation of obesity is calculation of BMI.

To measure BMI:
- Weight: in underclothes and no shoes.
- Height: measured without shoes.

BMI is calculated by dividing weight (in kilograms) by square height (in

meters).
Weight classes are defined based on a person's body mass index
(BMI) as follows:

Healthy weight: 18.5–24.9 kg/m2

Overweight: 25–29.9 kg/m2 Obesity is defined as
Obesity I: 30–34.9 kg/m2 having a Body Mass
Obesity II: 35–39.9 kg/m2 Index of 30 or more.
Obesity III: ≥ 40 kg/m2 .

Additional categories used

in bariatric surgery
Super morbid obesity
•BMI 50.0-59.9 kg/m2

Super-super morbid obesity

•BMI ≥60 kg/m2.
 Waist circumference
• Waist circumference (WC) is an important measure of obesity risk.
• WC is measured at the level of the top of the iliac crest.
• The measuring tape should be snug but not compressing the skin and
held parallel to the floor.
• The measurement is made at normal respiration.

• WC should be used as a routine measure.

• It is an indicator of visceral abdominal
fat which carries a higher health risk than
peripheral fat.
• It gives additional information on the
risk of developing other long-term health
problems.
Classification of overweight and obesity by BMI, waist circumference,
and associated disease risk

> 88 cm for women

risk
> 102 cm for men
The InBody Test
provides a comprehensive view of body composition balance. Body
water, proteins, minerals, and body fat, which are the components of the
human body closely relate to the status of our health.
 Causes of Obesity
• Calories come from food we eat Vs. Calories burned by exercise and
daily bodies activities & metabolic reactions (warm up in cold
weather and to sweat in the hot days).
>>> when food calories amounts exceed the body need, they will be
stored in the body as fat

• There is a combination of states and RFs that work together to store

more fat in the body, and these factors include:
 Sedentary/inactive life
 Poor diet
 Lack of sleep: hormonal disturbances and increase in appetite.
 Drugs
 Medical conditions
 Genetics
 Family/ environmental factors.
 Age
Factors that contribute to obesogenic state are
• Diseases—hypothyroidism, Cushing’s disease
• Drugs—corticosteroids, antidepressants, antipsychotics
• Diet—intake > activity
• Drink—beer, wine, sugar drinks
• Decreased—physical activity
• Depression and psychosocial

Endocrine causes of obesity in humans

Commonest
• Hypothyroidism: slowing the metabolic rate and some weight gain may be
because of development of edema
Rare
• Cushing’s syndrome
• Pancreatic insulinoma
• Growth hormone Deficiency
• Hypothalamic insufficiency.
 Complications/Consequences
of obesity
Obese people are at risk to have one or more of a great number of
obesity health problems:
• Type 2 diabetes.
• High blood pressure.
• Stroke.
• Heart disease.
• Gallbladder disease.
• Osteoarthritis.
• Poor wound healing.
• Sleep apnea (dangerous sleep disorder breathing repeatedly stops and starts).
• High cholesterol and triglycerides.
• Metabolic syndrome.
• Cancer.
• Depression/Social isolation.
Proportion of disease prevalence attributable to obesity
Cardiovascular system Neurologic system
Coronary heart disease Idiopathic intracranial hypertension
Hypertension Meralgia paresthetica
Pulmonary embolism Stroke
Varicose veins

Gastrointestinal system Psychosocial

Depression
Cholelithiasis Social discrimination
Gastroesophageal reflux disease (GERD) Work disability/disqualfication
Bullying
Colon cancer
Hepatic steatosis Reproductive/endocrine
systems
Hernias Amenorrhea
Nonalcoholic steatohepatitis (NASH) Cushing syndrome
Type 2 diabetes, IGT
Insulin resistance, dyslipidemia
Hypothyroidism
Infertility
Uterine caner/Breast cancer
PCOS
Musculoskeletal system Genitourinary system
Immobility Hypogonadism

Low back pain Urinary stress incontinence

Hyperuracemia and gout
Osteoarthritis Prostate cancer

Respiratory system Others

Dyspnea and fatigue Carbuncles

Obesity-hypoventilation syndrome Hygiene problems

Obstructive sleep apneas (OSA) Intertrigo

Cellulitis
Venous stasis of legs
Lymphatic edema
Practical Guide to Obesity Medicine,
1st Edition 12/2017
Author: Jolanta Weaver