Chapter 39 Weight Gain (Case 10)
Patient Care
Clinical Thinking
• Measure height and weight, calculate BMI, classify by BMI percentile: less than 5%, underweight; 5% to 84%, normal weight; 85% to 94%, overweight; greater than 95%, obese; and greater than 99%, morbid (severe) obesity.
• Use family history, review of systems, and physical examination to gather critical information and establish the case for intervention.
• Identify comorbid conditions and any need for intervention. Signs and symptoms of obesity-related comorbidities help assess disease risk and burden, and delineate the urgency and intensity of the intervention.
History
• Medications such as oral corticosteroids, antidepressants, antiepileptic and psychotropic agents may contribute to weight gain and also provide insight into conditions affecting potential for lifestyle change (e.g., depression, asthma, or seizure disorder).
• Check for family history of obesity, diabetes, cardiovascular disease and hypertension, and early death from myocardial infarction or stroke.
• Assess lifestyle: Eating behaviors; including fast food and eating out; diet history; amount of physical activity; daily screen time; and readiness for change.
• Short stature, linear growth deceleration, and delayed puberty are clues to an endocrine disorder.
• Environmental factors such as food exposure, income, culture, and ethnicity are variables that are crucial to understanding the nutritional/activity environment and individualizing interventions.
• Screen for signs of comorbid conditions:
• Snoring, restless sleep, heavy breathing, orthopnea, frequent night awakening, enuresis and apnea at night, morning headache, daytime tiredness, napping, poor school performance, and irritability with obstructive sleep apnea syndrome (OSAS).
• Type 2 diabetes presentations can range from asymptomatic glycosuria to ketonuria or ketoacidosis with dehydration and weight loss.
• Slipped capital femoral epiphysis (SCFE) may present with knee, hip, groin, or thigh pain, loss of internal rotation, flexion and abduction of the hip.
• Blount disease presents with tibial bowing and possible tenderness of proximal tibia, abnormal gait, and leg length discrepancy.
• Nonalcoholic fatty liver disease (NAFLD): Signs may be absent or subtle: mild abdominal pain and fatigue with progression to pruritus, anorexia, nausea, and cirrhosis.
• Asthma under poor control may lead to decreased activity and deconditioning, and excess use of systemic steroids will predispose to further weight gain.
Physical Examination
• Vital signs should always include blood pressure, taken seated in the right arm using the proper size cuff.
• Sensitivity to using proper size gowns and to self-consciousness about body size and shape is crucial.
