Obesity

The diagnosis of obesity is defined by a body mass index over 30 kilograms per metre squared.

Does the patient want to lose weight? 

If the patient is happy with their weight, and has been coerced into attending, they are very unlikely to comply with lifestyle recommendations.  

What is the primary reason for seeking medical help with their weight now, and what are they hoping to gain from consultation? 

Identifying triggers to the consultation may be helpful, for example if the patient has asked for help following a specific life event, this may be a unique opportunity to change their lifestyle.

Understanding what the patient is hoping for is also crucial, for example knowing that a patient is very keen for bariatric surgery and is not interested in any other treatments, will inform future discussions.

Take a detailed history of the patient's weight gain: birth weight, school weight and height, timing of weight gain and body shape change. When were they at their maximum and minimum adult weights, and what were they? What did they weigh at key life events, such as for their wedding or before and after pregnancies? 

Identifying the pattern and timing of weight gain is crucial to identify the reasons behind it.

For example, weight gain frequently follows an injury or retirement from professional or regular sports activity.

The timing and pattern of weight gain may also help to identify associated or underlying medical conditions, such as Cushing’s or hypothyroidism.

How motivated is the patient and are there any specific motivating factors? 

Identifying and using specific motivating factors, for example being able to play more with children or grandchildren, may improve compliance.

Are other family members obese: parents, siblings as well as partner and children? 

This may provide clues to psychological or inherited influences, or it may provide an opportunity to improve the health of the rest of the family.

Are there psychological or psychiatric issues? 

A past history of sexual or physical abuse is more common in the obese and can be a trigger to weight gain.

Depression is also associated with obesity, and many people without overt depression comfort eat when feeling low or lonely.

Some people will only eat or drink when alone, or at night time, or when bored in the evenings.

These issues need to be addressed before progress is likely to be made, though they are not a bar to treatment.

What previous attempts have been made at weight loss, and how effective were they: diets, diet clubs, prescribed or non prescribed medications? 

It is useful to identify what has, and has not, helped the patient's weight to inform future choices. It is also useful to know the maximum amount of weight the patient has been able to loose in the past as a guide to possible future loss, and to identify why and when patients have stopped using these measures.

Are there any symptoms suggestive of eating disorders, for example self induced vomiting, guilt after eating, self professed over eating, only eating alone, pre-occupation with food and preparing food for others? 

Identification and treatment of the underlying psychological cause is essential.

What is the diet history of a typical and a 'bad' day? What is the pattern of eating, for example do they eat more when bored, lonely or tired at night? Specifically ask about drinks - soft drinks, milk and alcohol consumption

Many people eat when feeling low or lonely. Some people will only eat or drink when alone or at night time or when bored and alone in the evenings.

Some people will eat an apparently healthy diet and be highly knowledgeable about food, but use excessive portion sizes. Others may have a specific weakness, for example cheese, chocolate or fizzy drinks.

Some people will deny any excess food intake and may feel that their weight gain has a specific but unidentified cause. These issues need to be addressed before progress is likely to be made.

What is their level of exercise? Do joint or other physical symptoms prevent physical activity? 

Reduced exercise capacity is common in the obese and reduces energy expenditure. There may be multiple causes of this reduction in physical activity which will again influence the best individual approach. For example, embarrassment in being seen exercising requires emotional support, breathlessness may be improved by using tailored and graded exercise to improve fitness; patients with joint symptoms may benefit from swimming or aqua-aerobics, or may require specific physiotherapy or orthopaedic attention.  

Are specific complications of obesity present, for example hypertension, diabetes, osteoarthritis, obstructive sleep apnoea? 

This may affect treatment criteria as well as fitness for surgery.

What is the state of the patient's general health and energy? 

Low energy may be a sign of an underlying condition, for example depression or hypothyroidism.

What is the quality of the patient's sleep? Do they snore, are they refreshed by sleep, or are they tired and go to sleep during the day? Have there been witnessed apnoeic episodes? 

A high Epworth sleepiness score indicates possible obstructive sleep apnoea (OSA) which is more common in the obese. Treatment of OSA improves energy and so can increase physical activity and may also improve mood.

Identification and treatment of OSA is also mandatory prior to bariatric surgery.

Are there any symptoms suggestive of Cushing's syndrome? 

Though Cushing's syndrome is rare, it should always be considered in patients with new weight gain.

Are there any symptoms suggestive of hypothyroidism?

Hypothyroidism is a common condition, though most patients presenting with obesity have normal thyroid function.

Are there any symptoms suggestive of polycystic ovarian syndrome?

PCOS is a very common condition, exacerbated by weight gain, and should be treated on its own merits as well as any specific treatments undertaken for obesity.