Section 1. What Is the Disease of Obesity?
Obesity meets the three main criteria for a disease:1,2
  • The condition impairs normal function
  • The condition has characteristic signs or symptoms
  • The condition causes harm or morbidity

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations3
  • R1.A. The principal outcome and therapeutic target in the treatment of obesity should be to improve the health of the patient by preventing or treating weight-related complications using weight loss, not the loss of body weight per se.
  • R1.B. The evaluation of patients for risk and existing burden of weight-related complications is a critical component of care and should be considered in clinical decisions and the therapeutic plan for weight-loss therapy.
  • R2. The modality and intensity of obesity interventions should be based on the primary, secondary, and tertiary phases of disease prevention; this 3-phase paradigm for chronic disease aligns with the pathophysiology and natural history of obesity and provides a rational framework for appropriate treatment at each phase of prevention.

1.1 Obesity as a Chronic Disease

Key Points

  • Genetic, environmental, and behavioral factors all contribute to the pathogenesis of obesity
  • The pathophysiology of obesity involves neuroendocrine factors that regulate both appetite and energy balance
  • Impairments in physical and physiologic functioning contribute to high rates of morbidity and mortality

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1.2 Obesity Pathophysiology

Key Points

  • Obesity has a genetic basis as well as environmental and behavioral origins
  • Age contributes to a shift in balance between fat and muscle mass
  • Various negative feedback loops contribute to obesity
    • Increased caloric intake and reduced physical activity
      • Alters energy homeostasis, leading to a reduced metabolic rate
      • Alters neurohormonal signals, leading to increased appetite
    • Increased visceral adiposity
      • Promotes insulin resistance
      • Promotes inflammation
        • Worsens insulin resistance
        • Leads to macrophage mobilization into adipose tissue, which worsens inflammation
      • Together, inflammation and insulin resistance contribute to development of cardiovascular disease, type 2 diabetes, cancer, and other poor outcomes

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1.3 Anthropometric Evaluation

Key Points

  • Evaluation of patients for obesity should include a complete history and physical examination
  • Body mass index (BMI) cutpoints vary with race and ethnicity
  • Waist circumference
    • Adds information on cardiometabolic risk
    • Cutpoints vary with gender and race and ethnicity
  • Excess adiposity must be present for BMI to indicate obesity
    • Athletes and others with high muscle mass may have high BMI values but are not obese

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1
  • R3. All adults should be screened annually using a BMI measurement; in most populations a cutoff point of ≥25 kg/m2 should be used to initiate further evaluation of overweight or obesity.
  • R4. BMI should be used to confirm an excessive degree of adiposity and to classify individuals as having overweight (BMI 25 to 29.9 kg/m2) or obesity (BMI ≥ 30 kg/m2), after taking into account age, gender, ethnicity, fluid status, and muscularity; therefore, clinical evaluation and judgment must be used when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and those with sarcopenia.
  • R5. Other measurements of adiposity (e.g., bioelectric impedance, air/water displacement plethysmography, or dual-energy X-ray absorptiometry [DEXA]) may be considered at the clinician’s discretion if BMI and physical examination results are equivocal or require further evaluation. However, the clinical utility of these measures is limited by availability, cost, and lack of outcomes data for validated cutoff points.
  • R6. When evaluating patients for adiposity-related disease risk, waist circumference should be measured in all patients with BMI < 35 kg/m2. In many populations, a waist circumference cutoff point of ≥ 94 cm in men and ≥ 80 cm in women should be considered at risk and consistent with abdominal obesity; in the U.S. and Canada, cutoff points that can be used to indicate increased risk are ≥ 102 cm for men and ≥ 88 cm for women.
  • R7. A BMI cutoff point value of ≥ 23 kg/m2 should be used in the screening and confirmation of excess adiposity in South Asian, Southeast Asian, and East Asian adults.
  • R8. Region- and ethnic-specific cutoff point values for waist circumference should be used as measures of abdominal adiposity and disease risk; in South Asian, Southeast Asian, and East Asian adults, men with values ≥85 cm and women ≥74 to 80 cm should be considered at risk and consistent with abdominal obesity.

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Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

1.4 Clinical Evaluation

Key Points

  • Clinical evaluation of obese patients should include a complete history and physical examination.
  • Comorbidities and obesity complications should also be assessed.
  • Treatment plans should be designed according to severity of comorbidities and complications as well as body mass index (BMI).

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1
Overall
  • R29. All patients with overweight or obesity should be clinically evaluated for weight-related complications because BMI alone is not sufficient to indicate the impact of excess adiposity on health status; therefore, the diagnostic evaluation of patients with obesity should include an anthropometric assessment of adiposity and a clinical assessment of weight-related complications. Patients with overweight or obesity should be reevaluated at intervals to monitor for any changes in adiposity and adiposity-related complications over time.

Metabolic Complications Screening
  • R9. Patients with overweight or obesity and patients experiencing progressive weight gain should be screened for prediabetes and type 2 diabetes (T2D) and evaluated for metabolic syndrome by assessing waist circumference, fasting glucose, A1C, blood pressure, and lipid panel, including triglycerides and HDL-C.
  • R10. Due to variable risk for future diabetes, patients with overweight or obesity should be evaluated for risk of T2D, which can be estimated or stratified using indices or staging systems that employ clinical data, glucose tolerance testing, and/or metabolic syndrome traits.
  • R11. Patients with T2D should be evaluated for the presence of overweight or obesity.

Cardiovascular Disease and Cardiovascular Risk Factors
  • R12. All patients with overweight or obesity and individuals experiencing progressive weight gain should be screened for dyslipidemia with a lipid panel that includes triglycerides, HDL-C, calculated LDL-C, total cholesterol, and non-HDL-C; all patients with dyslipidemia should be evaluated for the presence of overweight or obesity.
  • R13. Blood pressure should be measured in all patients with overweight or obesity as a screen for the presence of hypertension or prehypertension; all patients with hypertension should be evaluated for the presence of overweight or obesity.
  • R14. Risk factors for cardiovascular disease should be assessed in patients with overweight or obesity.
  • R15. Patients with overweight or obesity should be screened for active cardiovascular disease by history, physical examination, and with additional testing or expert referral based on cardiovascular disease risk status.

Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis
  • R16. Screening for nonalcoholic fatty liver disease should be performed in all patients with overweight or obesity, T2D, or metabolic syndrome with liver function testing, followed by ultrasound or other imaging modality if transaminases are elevated; all patients with nonalcoholic fatty liver disease should be evaluated for the presence of overweight or obesity.

Polycystic Ovary Syndrome (PCOS)
  • R17. Premenopausal female patients with overweight or obesity and/or metabolic syndrome should be screened for PCOS by history and physical examination; all patients with PCOS should be evaluated for the presence of overweight or obesity.

Female Infertility
  • R18. Women with overweight or obesity should be counseled when appropriate that they are at increased risk for infertility and, if seeking assisted reproduction, should be informed of lower success rates of these procedures regarding conception and the ability to carry the pregnancy to live birth. All female patients with infertility should be evaluated for the presence of overweight or obesity.

Male Hypogonadism
  • R19. All men who have an increased waist circumference or who have obesity should be assessed for hypogonadism by history and physical examination and be tested for testosterone deficiency if indicated; all male patients with hypogonadism should be evaluated for the presence of overweight or obesity.
  • R20. All male patients with T2D should be evaluated to exclude testosterone deficiency.

Obstructive Sleep Apnea
  • R21. All patients with overweight or obesity should be evaluated for obstructive sleep apnea during medical history and physical examination; this is based on the strong association between these disorders. Polysomnography and other sleep studies, at home or in a sleep lab, should be considered for patients at high risk for sleep apnea based on clinical presentation, severity of excess adiposity, and symptomatology. All patients with obstructive sleep apnea should be evaluated for the presence of overweight or obesity.

Asthma/Reactive Airway Disease
  • R22. All patients with overweight or obesity should be evaluated for asthma and reactive airway disease based on the strong association between these disorders. Medical history, symptomatology, physical examination, and spirometry and other pulmonary function tests should be considered for patients at high risk for asthma and reactive airway disease. All patients with asthma should be evaluated for the presence of overweight or obesity.

Osteoarthritis (OA)
  • R23. All patients with overweight or obesity should be screened by symptom assessment and physical examination for OA of the knee and other weight-bearing joints. All patients with OA should be evaluated for the presence of overweight or obesity.

Urinary Stress Incontinence
  • R24. All female patients with overweight or obesity should be screened for urinary incontinence by assessing symptomatology, based on the strong association between these disorders; all patients with urinary stress incontinence should be evaluated for the presence of overweight or obesity.

Gastroesophageal Reflux Disease (GERD)
  • R25. Patients with overweight or obesity or who have increased waist circumferences should be evaluated for symptoms of GERD; all patients with GERD should be evaluated for the presence of overweight or obesity.
  • R26. Patients with obesity and GERD symptoms should be evaluated by endoscopy if medical treatment fails to control symptoms.
  • R27. Endoscopy should be considered in patients with obesity and GERD symptoms prior to bariatric surgery.

Depression
  • R28. Patients with overweight or obesity should be screened for depression; all patients with depression should be evaluated for the presence of overweight or obesity.
  • R103. Patients with overweight or obesity who are being considered for weight-loss therapy should be screened for binge eating disorder and night eating syndrome.

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Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.