Perspective:

The following are 10 points to remember about this article on assessing and managing adult obesity:

1. Overweight and obesity, as defined by the body mass index (BMI), affects two thirds of adults and one third of children and adolescents in the United States. While obesity is a risk factor for cardiovascular disease (CVD), diabetes mellitus, and many types of cancer, detection and counseling by physicians is limited by time, insufficient training, and resources for behavior-based treatments.

2. Physicians should obtain an obesity-focused history by lifestyle events: body weight such as weight gain in adolescence, pregnancy, marital status, smoking, job status, exercise patterns, stress and binge eating, depression, and family history.

3. Assessment of risk status resulting from overweight or obesity is based on the patient’s BMI, waist circumference, and existence of comorbid conditions. Misclassification can occur in body builders, the elderly, and those with relatively low BMI with an exaggerated waist (visceral fat), the latter of which varies by ethnic groups.

4. Obesity increases the risk for CVD primarily through the effect on other risk factors. There is an inverse correlation between BMI and mortality (the obesity paradox) in patients with congestive heart failure, coronary artery disease, and chronic kidney disease. Fit obese men have a lower risk of all-cause and CVD mortality than lean men, and in women, fitness is a more important predictor of all-cause mortality than baseline BMI.

5. Among US adults, approximately 50% of overweight adults and 30% of obese adults are metabolically healthy, defined as having 0 or 1 cardiometabolic abnormality. Overweight patients with clinical markers of the metabolic syndrome would benefit most by losing weight.

6. In >14,000 participants in National Health and Nutrition Examination Survey (HANES) III, 17.3% of adults reported losing 10% of maximum body weight and keeping it off for at least 1 year. The difficulty with weight loss by behavioral change is compounded by neurohumoral mechanisms that protect against weight loss with an increased hunger and urges to eat, and reduced energy expenditure attributable to increased skeletal muscle work efficiency.

7. The foundation of obesity care is assisting the patient in making healthier dietary and physical activity choices consistent with metabolic risk factors that will lead to a net negative energy balance, which is primarily dependent on reducing total caloric intake. The initial goal is to achieve a 5-10% weight loss over the initial 6 months of treatment.

8. Consultation with a registered dietitian for medical nutrition therapy, incorporating partial meal replacement, and commercial weight loss programs each have demonstrated considerable value.

9. According to current Food and Drug Administration guidance, pharmacotherapy is approved for patients with a BMI ≥30 kg/m² or ≥27 kg/m² when complicated by an obesity comorbidity. The two available drugs at the time of this writing include the appetite suppressant sympathomimetics phentermine and diethylpropion, and the gastrointestinal fat blockers.

10. Bariatric surgery under the care of a multidisciplinary team has been recommended for patients with a BMI ≥40 kg/m² or those with a BMI ≥35 kg/m² who have associated high-risk comorbid conditions such as cardiopulmonary disease or type 2 diabetes mellitus. Significant improvement in multiple obesity-related comorbid conditions, including type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, and quality of life, has been reported. A recent meta-analysis of controlled clinical trials comparing bariatric surgery and no surgery showed that surgery was associated with a reduced odds ratio (OR) risk of global mortality (OR, 0.55), cardiovascular mortality (OR, 0.58), and all-cause mortality (OR, 0.70).