Obesity and metabolic syndrome: Clinical sciences

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Introduction0:00–1:06

Obesity is a condition characterized by excessive fat accumulation in the body, and is strongly associated with the development of other conditions, such as type 2 diabetes mellitus, dyslipidemia, cardiovascular disease, and even malignancy.
Multiple factors contribute to the development of obesity, including genetics, western diet, sedentary lifestyle, inadequate sleep, and certain medication side effects.
Body fat, also known as adipose tissue, secretes adipokines, which can lead to widespread systemic inflammation and insulin resistance.
Based on the body mass index, or BMI for short, individuals with obesity can be categorized into 4 main groups that include overweight, class I obesity, class II obesity, and class III obesity.Now, if you suspect obesity, first you should obtain a focused history and physical.

Focused H&P1:06–2:55

History may reveal symptoms like joint pain, snoring, fatigue, and dyspnea, as well as mood symptoms, such as depression.
Additionally, the patient might present with obesity-related comorbidities, such as metabolic syndrome, diabetes mellitus, hypertension, and dyslipidemia.
On the other hand, physical exam will reveal excess adipose tissue and larger waist circumference, and some patients may also have abdominal striae, acanthosis nigricans, and lower extremity edema.Okay, the next step is to calculate the BMI using the patient’s weight in kilograms and height in meters.
If the BMI is 25 to 29.9, the patient is overweight; if the BMI is between 30 and 34.9, the patient falls under class I obesity; between 35 and 39.9 is class II obesity; and finally, a BMI greater than or equal to 40 is class III obesity.
Here’s a clinical pearl for you! Though the diagnosis of obesity hinges on BMI, keep in mind that it's an imperfect individual measure.
In fact, certain racial and ethnic groups, such as those with ancestry from some parts of Asia, may experience complications of obesity at lower BMIs, while others with higher BMIs but low adiposity have a lower risk of these complications.Now, patients who are overweight or class I obesity get the same approach.

Overweight/Class I Obesity2:55–7:21

In both groups, your next step is to assess for obesity-related comorbidities like hypertension, obstructive sleep apnea or OSA, non-alcoholic fatty liver disease or NAFLD, and dyslipidemia, as well as prediabetes and type 2 diabetes mellitus.Now, here’s a high yield fact to keep in mind!
It’s important to note that obesity is an independent risk factor for the development of cardiovascular diseases, such as coronary artery disease; but also conditions like hypertension, dyslipidemia, and diabetes mellitus, which further increase the risk.
In other words, make sure to screen your patients regularly for these conditions and treat them appropriately to minimize the risk of cardiovascular events.
Many overweight and obese individuals will also have metabolic syndrome, which is diagnosed if there are three or more of the following criteria.
The first one is a waist circumference of 40 inches or more in a biological male, or 35 inches or more in a biological female.
The second one is a systolic blood pressure of 130 mmHg or more, and diastolic blood pressure of 85 mmHg or more. Keep in mind that this second criterion is also met if an individual is already on antihypertensive medications.
Next up is a triglyceride level of 150 mg/dL or more, or an individual already on medications to lower their triglycerides.
The fourth criterion is HDL cholesterol less than 40 mg/dL in biologically male individuals, or less than 50 mg/dL in biologically female individuals, or a patient already on medication for low HDL.
Finally, the fifth criterion is a fasting glucose equal to or greater than 100 mg/dL, a prior diagnosis of type 2 diabetes mellitus, or the use of antihyperglycemic medications.Okay, now first, let’s focus on individuals with no obesity-related comorbidities.
For these patients, encourage lifestyle modifications, like a low calorie diet and increased low impact exercise. Don’t forget to yearly follow up on these patients to monitor their BMI.
However, if comorbidities are present, then you should implement more comprehensive lifestyle modifications, which involves a multidisciplinary team including a nutritionist and an exercise specialist.
After 6 months, assess the patient’s weight loss. If by 6 months, they have successfully lost 5% or more of their total starting body weight, then continue the current lifestyle modifications, but with close follow up to ensure weight loss maintenance.
On the other hand, if in 6 months they’ve lost less than 5% of their total starting body weight, your options include medical therapy or surgical consultation.
Begin weight loss medications as adjunctive therapy to diet and exercise to help reach weight loss goals. Commonly used medications for long-term management of obesity include glucagon-like peptide-1 agonists, or GLP-1 agonists for short, like semaglutide; lipase inhibitors, like orlistat; combination drugs containing a sympathomimetic and an anti-epileptic, like phentermine with topiramate; and combination drugs containing an opioid receptor antagonist and an antidepressant, like naltrexone with bupropion.
Finally, you can also use phentermine, for short-term weight loss management for up to 12 weeks. Lastly, in some patients, surgical intervention might be appropriate, so you should consult the bariatric surgical team to discuss options, placement of an intragastric balloon device or a gastric bypass.
Next up are patients with BMI between 35 and 39.9, which are classified as class II obesity. In these individuals, you should also implement comprehensive lifestyle modifications and start the patient on weight loss medications.

Class II Obesity7:21–7:48

In addition, you should screen for and treat any comorbidities, and consider surgical consultation and referral for bariatric surgery.
Finally, patients with a BMI greater than or equal to 40 fall under class III obesity. In these individuals, regardless of the presence of comorbidities, you should implement comprehensive lifestyle modifications, begin weight loss medication, and screen for and treat any comorbidities.

Class III Obesity7:48–8:14

Lastly, you can recommend early surgical consultation and referral for bariatric surgery. Alright, as a quick recap… If your patient presents with signs and symptoms suggestive of obesity, first you should calculate the patient’s BMI.

Review8:14–9:54

A BMI between 25 to 29.9 is overweight, and a BMI between 30 and 34.9 refers to class I obesity. In both groups, first, assess for obesity-related comorbidities.
If no comorbidities are present, encourage lifestyle modifications and follow up yearly to monitor weight loss. On the other hand, if comorbidities are present, implement comprehensive lifestyle modifications and assess the patient’s weight loss after 6 months.
If your patient lost 5% or more of their body weight, continue lifestyle modifications and schedule regular follow-ups. However, if they lost less than 5%, consider medical therapy or surgical consultation for bariatric surgery referral.
Next up are patients with BMI between 35 and 39.9, which are classified as class II obesity. These patients should implement comprehensive lifestyle modifications, start weight loss medications; in addition, you should screen for and treat comorbidities, and consider referral for bariatric surgery.
Finally, individuals with BMI greater than or equal to 40 are classified as class III obesity. These patients should implement comprehensive lifestyle modifications, start weight loss medications; in addition, you should screen for and treat comorbidities,