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Clinical assessment of obesity and its metabolic complications |
Traditional training in clinical assessment addresses the patient history (including past, family and social history), examination and investigation of the cardiovascular, respiratory, neurological, gastrointestinal, etc. systems. It is still the mainstay of teaching medical students the basics of clinical methods. Computers and technology cannot replace good clinical method.
However, where change may be needed in teaching future medical students is to ensure obesity and the metabolic system are also included as part of the routine assessment of a patient.
GPs may also need to address this need as one in two adult women and around two in three adult men are presenting to our practices overweight or obese. 22% of children and adolescents in Australia are overweight or obese. Obesity has been declared an epidemic by the World Health Organisation. The resulting increase in co-morbidities has become apparent to us, particularly type 2 diabetes, cardiovascular disease, gallstones, sleep apnoea, back and arthritic problems.
Rather than just treat the end result of this problem, doctors need to develop new skills in assessing and managing obesity. There are already warning signs that the PBS has blown its budget as doctors reach for the script pad to deal with preventable lifestyle related disease amongst their patients. The current rate of increase in usage of statins, anti-diabetics, antihypertensives and so on is unsustainable in the longer term and somehow we are going to have be more active in preventative health measures.
The number of times a patient will present to a GP asking how to lose weight might be quite small but there is plenty of opportunity for GPs to bring the matter up with patients if they present either with an unrelated problem or with a complication of the obesity. The question is how to go about the consultation.
Having broached the topic it is then reasonable to ask about the history of this problem. For example, when did the weight go on and what was happening in life at the time in terms of stress or major changes. The next question concerns family history. If there is a strong family history of being overweight, a discussion on how one cannot control one’s genetic makeup is often comforting for the patient and takes away at least some of the blame for the situation.
Genetic factors are said to account for at least 40% of the reason for being obese. Remaining reasons are environmental and we don’t always have control of our environment either, so an understanding attitude to obesity rather than a blaming attitude (sloth and gluttony) is imperative.
Asking about medications is important as so many commonly used medications do influence weight (eg. some antidepressants, some antidiabetics, cortisone, psychotropic drugs, etc.)
Next some history relating to a typical day’s eating and drinking (both alcohol and soft drink) will elicit whether diet is the major problem. This can be followed by questioning on the amount of daily physical activity. Whilst some will have a mixture of these problems others will be weighted one way or the other and this may influence management.
Other questions about past medical history and medications with particular enquiry about the many medical complications of being overweight, including things like the symptoms of sleep apnoea.
It is really quite quick to weigh a patient and today all GP consulting rooms should have a simple cheap measuring device for height. If the patient is morbidly obese scales that go up to 120 kgm may not be of much use. Ideally scales should go to 200-300 kgm but these cost over $1,000 and most GPs will not have these. BMIs can be calculated either by using a simple wheel supplied by some drug companies or using computer programs like Medical Director, which can nicely record such information and provide printouts if required to encourage the patient to keep trying to lose fat.
It cannot be emphasised enough that weight and BMI are not good measures of dangerous abdominal fat and are really of more use when looking at populations. The simplest and best measure of risky fat is a simple waist measurement (>88 cm for women and >102 cm for men). Tape measures are very cheap and should be on every doctor’s desk - this is more important than scales. Other important measures of progress are functional things like ease of fitting in to clothes, pulling in the belt a notch and ease of doing up shoelaces.
Always remember it is fat that we are trying to get off. Muscle is heavier than fat and for someone who increases their level of physical activity the weight may not go down but the waistline does, which is the main objective.
Blood pressure measurement is also very important and so often is raised as part of the metabolic syndrome (the combination of obesity, hypertension, hyperlipidaemia, hyperglycaemia).
Finally, investigations of the metabolic system should always involve fasting lipids, blood sugar, liver function tests (which often show evidence of a fatty liver). Serum testosterone may be relevant for some older
obese men and may be low which can be important with sexual dysfunction and is treatable.
Is it necessary to check for other hormonal causes of obesity such as hypothyroidism, Cushings syndrome, etc? The actual number of cases of obesity attributable to hormonal causes is very small and there are usually other reasons to support such diagnoses. It is not necessary to order these tests routinely for obesity.
Having done this assessment the whole approach to management should then be decided. This will be the subject of future articles in GPSpeak.
STOPPRESS
New figures released in the latest Australian Medical Journal have revealed that between 1985-95 the prevalence of overweight in children aged 7-15 years has increased almost twofold while that of obesity almost tripled.(MJA 2001;174:553-554)
It is important that we do not put blame on children for this problem. Our whole society, and families, needs to look at the structure of our environment to address this concern. What is urgently needed is less use of motor vehicles; less sedentary activity such as TV watching and time spent with computers; less consumption of high energy dense food; more traditional eating patterns, eg. three meals a day sitting at a table rather than uncontrolled grazing on energy dense snacks; dealing with safety concerns in public parks, walkways, cycle tracks, etc.; changes in family work patterns that allow families more time to spend on physical activities. If we do not address this problem our health budget will blow out to an unsustainable level very soon. Haven’t we already run out of money for statins?
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