Obesity Clinical Presentation

Updated: Mar 02, 2017
  • Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Presentation

History

In most patients, the presentation of obesity is straightforward, with the patient indicating problems with weight or repeated failure in achieving sustained weight loss. In other cases, however, the patient may present with complications and/or associations of obesity.

A full history must include a dietary inventory and an analysis of the patient’s activity level. Screening questions to exclude severe or untreated depression are vital because depression may be a consequence or a cause of excessive dietary intake and reduced activity.

Because almost 30% of patients who are obese have eating disorders, screen for these in the history. The possibility of bingeing, purging, lack of satiety, food-seeking behavior, night-eating syndrome, and other abnormal feeding habits must be identified because management of these habits is crucial to the success of any weight-management program.

When taking the history, the clinician should investigate whether other members of the patient's family have weight problems, inquire about the patient's expectations, and estimate the patient's level of motivation. The clinician should also determine whether the patient has had any of the comorbidities related to obesity, including the following [3] :

  • Respiratory: Obstructive sleep apnea, [4] greater predisposition to respiratory infections, increased incidence of bronchial asthma, and Pickwickian syndrome (obesity hypoventilation syndrome)
  • Malignant: Association with endometrial (premenopausal), prostate, colon (in men), rectal (in men), breast (postmenopausal), gall bladder, gastric cardial, biliary tract system, pancreatic, ovarian, renal, and possibly lung cancer, as well as esophageal adenocarcinoma and multiple myeloma [5, 6, 7]
  • Psychological: Social stigmatization and depression
  • Cardiovascular: Coronary artery disease, [8] essential hypertension, left ventricular hypertrophy, cor pulmonale, obesity-associated cardiomyopathy, accelerated atherosclerosis, and pulmonary hypertension of obesity
  • Central nervous system (CNS): Stroke, idiopathic intracranial hypertension, and meralgia paresthetica
  • Obstetric and perinatal: Pregnancy-related hypertension, fetal macrosomia, and pelvic dystocia [9]
  • Surgical: Increased surgical risk and postoperative complications, including wound infection, postoperative pneumonia, deep venous thrombosis, and pulmonary embolism
  • Pelvic: Stress incontinence
  • Gastrointestinal (GI): Gall bladder disease (cholecystitis, cholelithiasis), nonalcoholic steatohepatitis (NASH), fatty liver infiltration, and reflux esophagitis
  • Orthopedic: Osteoarthritis, coxa vera, slipped capital femoral epiphyses, Blount disease and Legg-Calvé-Perthes disease, and chronic lumbago
  • Metabolic: Type 2 diabetes mellitus, prediabetes, metabolic syndrome, and dyslipidemia
  • Reproductive: In women: Anovulation, early puberty, infertility, hyperandrogenism, and polycystic ovaries; in men: hypogonadotropic hypogonadism
  • Cutaneous: Intertrigo (bacterial and/or fungal), acanthosis nigricans, hirsutism, and increased risk for cellulitis and carbuncles
  • Extremity: Venous varicosities, lower extremity venous and/or lymphatic edema
  • Miscellaneous: Reduced mobility and difficulty maintaining personal hygiene

Include questions to exclude secondary causes of obesity, some of which are rare. (See the chart below.)

Secondary causes of obesity. Secondary causes of obesity.
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Physical Examination

In the clinical examination, measure anthropometric parameters and perform the standard, detailed examination required in evaluating patients with any chronic, multisystem disorder, such as obesity.

Waist and hip circumference are useful surrogates in estimating visceral fat; serial tracking of these measurements helps in estimating the clinical risk over time. Neck circumference is predictive of a risk of sleep apnea, and its serial measurement in the individual patient is clinically useful for risk stratification. [4]

Examination of organ systems should include the following:

  • Cutaneous - Search for intertriginous rashes from skin-on-skin friction; also search for hirsutism in women, acanthosis nigricans, and skin tags, which are common with insulin resistance secondary to obesity
  • Cardiac and respiratory - Exclude cardiomegaly and respiratory insufficiency
  • Abdominal - Attempt to exclude tender hepatomegaly, which may suggest hepatic fatty infiltration or NASH, and distinguish the striae distensae from the pink and broad striae that suggest cortisol excess

When examining the extremities, search for joint deformities (eg, coxa vara), evidence of osteoarthritis, and any pressure ulcerations. Localized and lipodystrophic fat distribution should also be identified, because of their common association with insulin resistance.

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