Assess for Major and Minor Comorbid Conditions
Key Points:
- It is important to assess for other conditions as treatment decisions and outcomes may be influenced by their presence.
- Waist circumference greater than or equal to 40 inches for males and greater than or equal to 35 inches for females is an additional risk factor for complications related to obesity.
- For depression and eating disorders, brief screenings should be conducted if appropriate.
- Assessment should include a complete medical history to identify medications that may induce weight gain or interfere with weight loss.
Comorbid Condition Assessment
Comorbid Condition |
BMI |
25 to 30 |
30 to 35 |
35 to 40 |
40+ |
0 |
Lifestyle changes and behavioral management |
Lifestyle changes and behavioral management. Consider drug therapy |
Lifestyle changes and behavioral management. Consider drug therapy |
Lifestyle changes and behavioral management. Consider drug therapy and/or surgical evaluation. |
1-3 minor comorbid conditions |
Lifestyle changes and behavioral management |
Lifestyle changes and behavioral management. Consider drug therapy |
Lifestyle changes and behavioral management. Consider drug therapy and/or surgical evaluation. |
Lifestyle changes and behavioral management. Consider drug therapy and/or surgical evaluation. |
Major comorbid conditions
OR
more than 3 minor comorbid conditions
|
Lifestyle changes and behavioral management. Consider drug therapy. The Food and Drug Administration (FDA) approves drug therapy only for BMI greater than 27. |
Lifestyle changes and behavioral management. Consider drug therapy. |
Lifestyle changes and behavioral management. Consider drug therapy and/or surgical evaluation. |
Lifestyle changes and behavioral management. Consider drug therapy and/or surgical evaluation. |
Minor Comorbid Conditions
- Cigarette smoking
- Hypertension (blood pressure [BP] greater than or equal to 140/90) or current use of antihypertensives^
- Low-density lipoprotein (LDL) cholesterol greater than 130 mg/dL^
- High-density lipoprotein (HDL) cholesterol less than 40 mg/dL
- Pre-diabetes*^
- Family history of premature coronary artery disease (CAD)
- Age greater than or equal to 65 years for males
- Age greater than or equal to 55 years for females or menopausal females
Major Comorbid Conditions
- Waist circumference (males >40 inches, females >35 inches)^
- Established coronary artery disease
- History of myocardial infarction
- History of angioplasty
- History of coronary artery bypass graft (CABG)
- History of acute coronary syndrome
- Peripheral vascular disease
- Abdominal aortic aneurysm
- Symptomatic carotid artery disease
- Type 2 diabetes mellitus
- Obstructive sleep apnea
* The term pre-diabetes has recently been adopted by the American Diabetes Association and others, and refers to those who have a fasting plasma glucose of 100 mg/dL to 125 mg/dL inclusive, as well as those with a two-hour post 75 gram oral glucose tolerance test value of greater than or equal to 140 mg/dL to 200 mg/dL.
^ The clustering of these symptoms has been described as the metabolic syndrome.
Other Conditions
Clinicians may use the waist circumference as a measure of central adiposity. Men with waist circumferences greater than or equal to 40 inches (102 cm) and women with a waist circumference greater than or equal to 35 inches (88 cm) are at increased risk for cardiovascular disease.
In the Health Professional Follow-up Study, overall and cardiovascular mortality in men increased linearly with baseline BMI in younger men (those initially younger than 65 years) and had no relationship with BMI in older men (those initially at least 65 years); by contrast, waist circumference predicted risk for overall and cardiovascular mortality among the younger men, and predicted risk for cardiovascular death among older men.
The Iowa Women's Health Study found that the waist-hip ratio was a better predictor of total cardiovascular mortality than BMI, and that even in women in the lowest BMI quintile, there was a markedly increased risk for diabetes if they also had a high waist-hip ratio.
Waist circumference is an additional risk factor for complications related to obesity for males measuring greater than or equal to 40 inches, females greater than or equal to 35 inches. While the work group acknowledges potential difficulty implementing the measurement of waist circumference, evidence shows the importance of measuring waist circumference because of increased cardiovascular risk.
Evidence supporting this recommendation is of class: B, C, D
Screening for Depression
The evidence showing the linkage between depression and obesity is mixed. Higher rates of depression have been found in severely obese people, especially younger women with poor body image. It is difficult to study whether the depression is secondary to the obesity or to existing comorbid conditions. Weight loss often leads to improvement of depression scores.
Depression is identified more often in obese women and teenagers and is less likely to be diagnosed in men. Depression in the elderly is often associated with weight loss while depression in younger females can be associated with weight gain.
Depression has been associated with poor weight loss outcomes. Bariatric surgery patients with poorly managed depression or anxiety are at greater risk for weight regain within the first five postoperative years. One explanation for this may be found in a line of research investigating biological pathways that link depressive symptomatology to increased adiposity and weight gain. Weight loss studies have often excluded people with depression. More studies to address this issue are warranted.
Evidence supporting this recommendation is of classes: B, C, D, R
Screening for depression can include asking the following questions.
Over the past month, have you been bothered by:
- Little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?
If the patient answers "yes" to either one of the above questions, consider using a questionnaire to further assess whether the patient has sufficient symptoms to warrant a full clinical interview and a diagnosis of clinical major depression. An example of such a questionnaire is the (Patient Health Questionnaire) PHQ-9.
This should not be considered a comprehensive screening for depression, which is beyond the scope of this guideline. See the National Guideline Clearinghouse (NGC) summary of the Institute for Clinical Systems Improvement (ICSI) guideline Major Depression in Adults in Primary Care for more information.
Screening for an Eating Disorder
Eating disorders, particularly binge eating disorder, may complicate the treatment of obesity.
Screening for eating disorders can include asking the following questions:
- Do you eat a large amount of food in a short period of time -- like eating more food than another person may eat in, say, a two-hour period of time?
- Do you ever feel like you can't stop eating even after you feel full?
- When you overeat, what do you do? (e.g., Have you ever tried to "get rid of" the extra calories that you've eaten by doing something like: Take laxatives? Take diuretics [or water pills]? Smoke cigarettes? Take street drugs like cocaine or crank? Make yourself sick [induce vomiting])?
If the patient answers "yes" to any of the above questions, consider further evaluation or a referral to a dietitian or a behavioral health specialist who specializes in eating disorders or in health psychology and working with bariatric patients.
More comprehensive screening tools include the SCOFF, ESP, or EAT.
Screening for Medication Use That Contributes to Weight Gain
The assessment of the obese patient should include a complete medication history to identify medications that may induce weight gain or interfere with weight loss including antidiabetic medication (insulin, insulin secretagogues, metformin, alfa-glucosidase inhibitors, thiazolidinediones) and psychotropic drugs. For more information regarding medications associated with weight gain, refer to the original guideline document.