The Management of Obesity for the Primary Care Physician

At this year's meeting of the American College of Gastroenterology, a symposium on the management of obesity was held. The slant was toward what gastroenterologists can do, but, clearly, the talks have an impact on the interdisciplinary role needed for clinicians to deal with this growing American problem. The talks were classified into 3 general areas: medical management, surgical management, and management of bariatric surgery complications.

Medical Management of Obesity

Almost 65% of Americans are either overweight or obese. After smoking, obesity is the second most preventable cause of death in our country.

Obesity is also rampant in our children, who comprise the fastest-growing group becoming overweight or obese. There are many reasons to reduce this epidemic. Among them are that obese individuals have a higher rate of cancer and that the costs to care for obese patients are about 38% higher than the costs of caring for nonobese patients.

Many GI problems exist in the obese population that need care, including gallbladder disease, pancreatitis, reflux, and liver disease. Of note is that obesity-related liver disease (nonalcoholic fatty liver disease) is likely to become a major indication for liver transplantation in the very near future. Also, for those individuals who undergo surgical treatment of obesity, there will be a need for physicians to provide postoperative care.

Many individuals would like to blame their genetic makeup for their weight problems; however, only 40% of the tendency to be overweight comes from what is inherited. It appears that the environment has a major input. Higher caloric intake with less energy expended is a formula for weight gain.

The first thing that patients and physicians alike must understand is that obesity is a chronic problem. Unfortunately, we have not been as successful in treating this problem as we have in treating hypertension or hyperlipidemia. Office or hospital evaluations should begin with the determination of the body mass index (BMI), which is usually a good indicator of excess body fat. Note that individuals with excess muscle mass may have a BMI suggesting obesity. Also, some people with BMI in the normal range may have reduced muscle mass and excess fat.

Table 1 shows the derivation of the BMI. However, it is much easier to use tables, wall charts, or calculations done on your personal digital assistants.

Table 1. Body Mass Index Calculation and Meaning

BMI = Weight (kg)/height² m²)

Overweight: BMI = 25.0-29.9Obese: BMI >/=30