eMedicine Specialties > Endocrinology > Metabolic Disorders

Obesity: Follow-up

Author: Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, MedStar Research Institute and Washington Hospital Center
Coauthor(s): Elif Arioglu, MD, Assistant Professor of Medicine, Division of Endocrinology and Metabolism, University of Michigan
Contributor Information and Disclosures

Updated: May 21, 2009

Follow-up

Further Inpatient Care

  • Although weight-management programs may be based in an outpatient or inpatient setting, no rigorous evidence suggests that inpatient programs are necessarily superior to outpatient programs of similar structure and content.
    • Inpatient programs may offer the convenience of easy access to patients and ease of monitoring, but they are expensive to run, difficult to reimburse, and generally considerably disrupt the patients' regular routine. In addition, they offer little guarantee of sustained effect.
    • The major role for inpatient evaluations is in the immediate postoperative period after antiobesity surgery and in the management of major complications, such as clinically significant respiratory or cardiac compromise.

Further Outpatient Care

  • As with the management of other chronic medical conditions that are not presently curable (eg, diabetes mellitus, hypertension, bronchial asthma), long-term success in the management of obesity is contingent on long-standing follow-up with the program.

    • Visits may not need to occur as frequently during follow-up as during the initial weight-loss phase, but they are paramount if the lessons learned regarding diet, exercise habits, and behavioral patterns are to be maintained.
    • Experience from the lifestyle intervention group of subjects in the Diabetes Prevention Program and the ongoing Diabetes Prevention Program Observation study have borne out the importance of regular follow-up.

Deterrence/Prevention

  • Because of the sheer prevalence of obesity and the anticipated worsening of the pandemic in the next few decades, prevention is by far the most desirable means to curb the consequences and economic load of obesity. However, few trials have addressed this issue, and those performed thus far have had mixed results.
  • Results of some public health education initiatives in Singapore and parts of China that are only now being evaluated suggest, as hoped, that such programs have the potential for reducing the incidence and prevalence of obesity and the major comorbidities of obesity, such as type 2 diabetes and hypertension.
  • Until recombinant DNA methods are developed enough to enable the alteration of genes that predispose individuals to obesity, the only options available are to develop a massive public health education program aimed at both adults and children to change their eating, activity, and behavioral habits.
  • The potential for possible leptin sensitizers may assist in changing feeding habits.
  • Given the global proportions of obesity, a concerted approach is needed and should involve cooperative efforts among public health authorities, caterers, the fast food industry, and organizers of sports and outdoor games.

Complications

  • The potential complications and associations of obesity are detailed in Image 2.
  • The so-called Pickwickian syndrome named after the boy who was obese in Charles Dickens’ Pickwick Papers is a combined syndrome of obesity-related hypoventilation (related to the severe mechanical respiratory limitations to chest excursion from severe obesity) and sleep apnea (which may be from obstructive, central, or both mechanisms).
  • Apart from the metabolic complications associated with obesity, a paradigm of increased intra-abdominal pressure has been recognized. This pressure effect is most apparent in the setting of marked obesity (BMI ≤50) and is espoused by bariatric surgeons, including Sugerman and colleagues (1992).31

    • Given findings from bariatric surgery and animal models, this change in pressure may play a (potentially major) role in the pathogenesis of comorbidities of obesity, such as pseudotumor cerebri, lower-limb stasis, ulcers, dermatitis, thrombophlebitis, reflux esophagitis, abdominal hernias, and possibly hypertension and nephrotic syndrome.
    • Some reports, including those by Adelman and colleagues and Kasiske and Jennette, suggest an association between severe obesity and focal glomerulosclerosis.35,36,37 These complications, in particular, improve substantially or resolve early after bariatric surgery, well before clinically significant weight loss is achieved.

Prognosis

  • The association between obesity and morbidity is not in doubt.
    • However, the previous notion that the increased mortality and morbidity in patients who are obese was not entirely due to comorbidities was controversial.
    • Results of several observational studies detailed by the Expert Panel on the Identification, Evaluation, and Treatment of Overweight Adults and results from other reports by Allison, Bray, and others exhaustively show that obesity, on its own, is associated with increased cardiovascular morbidity and mortality and increased all-cause mortality.
  • For a person with a BMI of 25-28.9 kg/m2, the relative risk for coronary heart disease is 1.72. This risk progressively increases with an increasing BMI. Therefore, with BMIs greater than 33 kg/m2, the relative risk is 3.44.
    • Similar trends were demonstrated in the relationship between obesity and stroke or congestive heart failure.
    • Overall, obesity is estimated to increase the cardiovascular mortality rate 4-fold and the cancer-related mortality rate 2-fold.
    • As a group, people who are severely obese have a 6- to 12-fold increase in the all-cause mortality rate.

Patient Education

For excellent patient education resources, visit eMedicine's Diabetes Center, and Eating Disorders Center. Also, see eMedicine's patient education articles Obesity, Weight Loss and Control, High Cholesterol, Understanding Your Cholesterol level, and Lifestyle Cholesterol Management.

Miscellaneous

Medicolegal Pitfalls

  • Before enrolling any subjects in a weight-loss program, the clinician must have a clear idea of their expectations. Subjects with unrealistic expectations should not be enrolled until these expectations are changed to realistic and attainable goals.
  • Also crucial is a clear assessment of the subject's level of motivation to maintain the dietary, exercise, and behavioral changes required. This assessment should be completed before the subject is enrolled in a weight-loss program.
  • Comprehensive written informed consent must be obtained and should address details of the expected weight loss and the required dietary, exercise, and behavioral changes to maintain the achieved weight loss.

Special Concerns

  • Because of the potential harm of attempting weight loss in an unsuitable candidate, all patients to be enrolled in any surgical, medical, or other weight-loss program must be exhaustively screened for underlying psychiatric, psychologic, and/or eating disorders.
  • Although many of the psychologic and psychiatric problems commonly associated with obesity are not contraindications to enrollment in a weight-loss program, clinicians and patients must be aware of these problems before enrollment.
  • In addition, the clinician must ensure that any such problems are relatively stable, quiescent, or well managed before the patient begins a weight-loss program.
 


More on Obesity

Overview: Obesity
Differential Diagnoses & Workup: Obesity
Treatment & Medication: Obesity
Follow-up: Obesity
Multimedia: Obesity
References
Further Reading
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Further Reading

Clinical guidelines:
Adult weight management evidence-based nutrition practice guideline. American Dietetic Association - Professional Association. 2006 May. Various pagings. NGC:006622

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. American Association of Clinical Endocrinologists - Medical Specialty Society
American Society for Metabolic and Bariatric Surgery - Professional Association
The Obesity Society - Disease Specific Society. 2008 Jul-Aug. 83 pages. NGC:006716

Pediatric weight management evidence-based nutrition practice guideline. American Dietetic Association - Professional Association. 2007 Jun. Various pagings. NGC:006623

Prevention and treatment of pediatric obesity: an Endocrine Society clinical practice guideline. The Endocrine Society - Disease Specific Society. 2008 Dec. 38 pages. NGC:006944

SAGES guideline for clinical application of laparoscopic bariatric surgery. Society of American Gastrointestinal and Endoscopic Surgeons - Medical Specialty Society. 2003 Jul (revised 2008 Oct). 20 pages. NGC:006413

Screening for obesity in adults: recommendations and rationale. United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2003 Dec 2). 13 pages. NGC:003163

Clinical trials:
Evaluating the Transferability of a Successful, Hospital-Based, Childhood Obesity Clinic to Primary Care: a Pilot Study

Investigating the Use of Quercetin on Glucose Absorption in Obesity, and Obesity With Type 2 Diabetes

Mitochondrial Function in Pediatric Obesity

Observational Study of Early Metabolic and Vascular Changes in Obesity (STYJOBS)

Medscape Resource Center:
Obesity Resource Center

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Keywords

obesity, weight loss, diet, BMI, overweight, type 2 diabetes, obese, gastric bypass, body mass index, weight loss surgery, weight control, childhood obesity, bariatric surgery, insulin resistance, leptin, over weight, overeating, child obesity, gastric bypass surgery, hypertension, obesity children, obesity in children, obesity America, obesity surgery, adipose tissue, causes of obesity, obesity treatment, adipocyte, adiponectin, increased BMI, excess body fat, excess adiposity, increased body mass index, Quetelet index, POMC, MC4, satiety, weight loss, weight gain, severe obesity, morbid obesity, super obese, body weight, percentage body fat, fat distribution, android obesity, gynecoid obesity, waist circumference, Atkinsdiet, South Beach diet

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Contributor Information and Disclosures

Author

Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, MedStar Research Institute and Washington Hospital Center
Gabriel I Uwaifo, MBBS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Society of Hypertension, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Elif Arioglu, MD, Assistant Professor of Medicine, Division of Endocrinology and Metabolism, University of Michigan
Elif Arioglu, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, and Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Harris C Taylor, MD, Clinical Professor of Medicine, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine
Harris C Taylor, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Romesh Khardori, MD, Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Professor, Department of Internal Medicine, Southern Illinois University School of Medicine
Romesh Khardori, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society of Andrology, Endocrine Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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