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ScaleDiagnosis and Vertically Integrated Management of Obesity

Obesity, an excess body fat accumulation, ultimately results from an increase in energy intake over expenditure. However, there are individual variations in energy efficiency based in part on body composition. Body weight for height or body mass index ( BMI = weight divided by height squared) is used to diagnose obesity even though these measurements are only indirect measures of body fat. Body fat can be estimated using bioelectrical impedance analysis with the advantage that lean overweight individuals such as athletes can be differentiated from overfat overweight individuals. In addition, normal weight individuals with reduced muscle mass due to inadequate protein intake, reduced physical activity, or the effects of drugs that reduce muscle mass, can be identified as having excess body fat.

The therapeutic impact of this differentiation is significant. Individuals who have increased lean mass will have a higher than average target weight, and need to be encouraged to maintain their lean body mass through exercise and adequate protein intake. They must also be encouraged to accept their target weight which may be higher than what they imagined. Each pound of lean body mass burns about 14 Calories per day. Individuals with reduced lean body mass can be encouraged to increase lean body mass through heavy resistance exercise in order to increase basal metabolic rate.

Vertically integrated management of obesity is a system in which the modality used correlates with the severity of obesity as measured by body mass index. In overweight and mildly obese individuals, diet, exercise and lifestyle modalities are used. The behavioral tools available include confirming readiness to change, using stimulus control to minimize the intake of trigger foods, use of meal replacements and portion-controlled meals to reduce caloric intake, aerobic and heavy resistance exercise, relapse prevention, social support, and stress reduction. For individuals with BMI > 27 with co-morbid conditions or BMI >30, pharmacotheapy is added. Appetite suppressants, satiety agents, and lipase inhibitors are available while other approaches are still undergoing research. For individuals with BMI of 35 to 40 with sleep apnea or other significant morbidity, or with a BMI > 40, gastric surgery for obesity can be utilized. The patients using drugs or undergoing surgery utilize the same principles of diet, exercise and lifestyle utilized for milder forms of obesity. Drugs and surgery are adjuncts to diet and lifestyle change for the treatment of obesity.







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