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some cases, there is evidence for strong genetic influences on the development of obesity Adopted children demonstrate a close relationship between their body mass index and that of their biologic parents No such relationship is found between the children and their adoptive parents Twin studies also demonstrate substantial genetic influences on BMI with little influence from the childhood environment As much as 40 70% of obesity may be explained by genetic influences Genetic determinants of some types of obesity have now been established Five genes affecting control of appetite have been identified in mice Mutations of each gene result in obesity, and each has a human homolog One gene codes for a protein expressed by adipose tissue leptin and another for the leptin receptor in the brain The other three genes affect brain pathways downstream from the leptin receptor Numerous other candidate genes for human obesity have been identified Only a small percentage (4 6%) of human obesity is thought to be due to single gene mutations Most human obesity undoubtedly develops from the interactions of multiple genes, environmental factors, and behavior
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Medical Evaluation of the Obese Patient
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Historical information should be obtained about age at onset, recent weight changes, family history of obesity, occupational history, eating and exercise behavior, cigarette and alcohol use, previous weight loss experience, and psychosocial factors including assessment for depression and eating disorders Particular attention should be directed at use of laxatives, diuretics, hormones, nutritional supplements, and over-thecounter medications Physical examination should assess the degree and distribution of body fat, overall nutritional status, and signs of secondary causes of obesity Less than 1% of obese patients have an identifiable secondary, nonpsychiatric, cause of obesity Hypothyroidism and Cushing s syndrome are important examples that can usually be diagnosed by physical examination in patients with unexplained recent weight gain Such patients require further endocrinologic evaluation, including serum thyroid-stimulating hormone (TSH) determination and dexamethasone suppression testing (see 26) All obese patients should be assessed for medical consequences of their obesity by screening for the metabolic syndrome Blood pressure, waist circumference, fasting glucose, low-density lipoprotein (LDL) and HDL cholesterol, and triglycerides should be measured
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Obesity is associated with significant increases in both morbidity and mortality A great many disorders occur with greater frequency in obese people The most important and common of these are hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary artery disease, degenerative joint disease, and psychosocial disability Approximately 60% of individuals with obesity in the United States have the metabolic syndrome (including three or more of the following factors: elevated abdominal circumference, blood pressure, blood triglycerides, and fasting blood sugar, and low high-density lipoprotein [HDL] cholesterol) Certain cancers (colon, rectum, and prostate in men; uterus, biliary tract, breast, and ovary in women), thromboembolic disorders, digestive tract diseases (gallstones, reflux esophagitis), and skin disorders are also more prevalent in the obese Surgical and obstetric risks are greater Obese patients also have a greater risk of pulmonary functional impairment, endocrine abnormalities, proteinuria, and increased hemoglobin concentration In young and middle-aged adults, mortality from all causes and mortality from cardiovascular disease increase in proportion to the degree of obesity The relative risk associated with obesity, however, decreases with age, and weight is no longer a risk factor in adults over age 75 years
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Using conventional dietary techniques, only 20% of patients will lose 20 lb and maintain the loss for over 2 years; 5% will maintain a 40-lb loss Average weight loss is approximately 7% of baseline weight Continued close provider patient contact appears to be more important for success of treatment than the specific features of any given treatment regimen Careful patient selection will improve success rates and decrease frustration of both patients and therapists Only sufficiently motivated patients should enter active treatment programs Specific attempts to identify motivated patients eg, requesting a 3-day diet record are often useful
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