The diagnosis of obesity is defined by a body mass index over 30 kilograms per metre squared.
If the patient is happy with their weight, and has been coerced into attending, they are very unlikely to comply with lifestyle recommendations.
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.
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.
Identifying and using specific motivating factors, for example being able to play more with children or grandchildren, may improve compliance.
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.
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.
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.
Identification and treatment of the underlying psychological cause is essential.
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.
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.
This may affect treatment criteria as well as fitness for surgery.
Low energy may be a sign of an underlying condition, for example depression or hypothyroidism.
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.
Though Cushing's syndrome is rare, it should always be considered in patients with new weight gain.
Hypothyroidism is a common condition, though most patients presenting with obesity have normal thyroid function.
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.