Overweight and obesity have a prevalence that is clearly increasing in Western societies. In France, in adults, the prevalence of obesity is from about 8 to 10% (vs. 30% in the USA) while overweight regard 25 to 30% of the population.
The secular increase in this “epidemic” makes it a real public health problem. If the adverse health consequences of excess adiposity are well known, the means of action, prevention and treatment seem difficult to enforce.Immediately dispel a misunderstanding: this common condition is largely due to environmental and behavioral changes (decreased physical activity and sedentary lifestyle, behavior and food and nutritional quality and quantity availability), much more than that genetic background nevertheless interacts with the environment and promotes or not the expression of certain medical complications related to being overweight. The increased frequency of overweight in children (multiplied by 4 for 30 years) and young adulthood is a worrying changing epidemiology of obesity in France tends to join that of many States States.
The diagnosis of obesity is usually obvious by simple inspection: there is a visible symptom and subject to a judgment of social value. As against the objectification of simple overweight usually requires weighing and measuring the patient’s height, underlining the importance of systematic collection of these settings when the medical consultation. It is useful to help the WHO classification of overweight (Table I), based on the calculation of body mass index (weight in kg on high height in meters squared) or BMI (indirect reflection of adiposity ). Importantly we must quickly distinguish two clinical forms of obesity, gynoid (predominance of overloading the hips) and android (abdominal obesity or perivisceral predominance).
The gynoid obesity, domain of women, causes little medical consequence outside venous disorders. The android obesity and mixed, dominated by men and all significant overweight (. BMI over 30, ie actual obesity), is the largest medically to consider: it is constantly associated with a syndrome of insulin resistance and constitutes a risk factor for cardiovascular complications (coronary artery disease and stroke mainly). The diagnosis of abdominal fat android overload can simply be objectified by measuring the waist circumference at umbilical level: a waist circumference> 90 cm for women and> 100 cm for men is highly predictive of an abdominal visceral obesity peri . This is a risk factor for morbidity and mortality independent of BMI and without reaching the limit of IMC 30, overweight can be harmful to health.
The differential diagnosis of obesity is usually simple: lipomatoses, lipodystrophy syndromes (especially in the treated HIV disease) and especially systemic edematous syndromes (decompensated cirrhosis, heart failure …) are easy to dismiss.
Integration of multifactorial data (medical, psychological, social …) is essential. Clinical examination should focus on simple data: measurement of blood pressure (with a cuff adapted) if possible on both arms, cardiopulmonary examination and ECG, seeking hepatomegaly, research trophic disorders of the lower limbs … Obviously the clinical examination will be targeted to certain areas depending on the context and the patient’s complaint.
Schematically the practitioner may need to see an obese patient in three circumstances:
– Fortuitously for intercurrent problem, a priori unrelated to nutritional status. Of the practitioner’s discretion not to get into an unspoken request, but depending on context, guidance can be offered;
– Fortuitously or not for a problem or complication clearly favored by overweight (comorbidities such as diabetes, high blood pressure: see Table II). The practitioner should certainly advise a support for the weight problem.Nevertheless, the patient in this case often tried with varying degrees of success different therapeutic methods. The discovery of a complication may be an opportunity for a reframing of the approach;
– An application specifically for weight loss, the patient feeling “too big”. In the latter situation it is for the doctor to make sense of things and objectify reality or not in the medical sense, overweight.
In the latter two cases it will be important:
– Seek history: family history of obesity, event or personal history of cardiovascular risk factor …
This will include inquiring of active smoking, taking drugs: lithium, anticonvulsants, antipsychotics, corticosteroids …
– To have details on the patient’s weight history: including start date of the overload, weight at age 20 (it is physiological to gain weight with age: 2-3 kg per decade in women from 20 years and in men from 30 years);number and amplitude weight changes; investigate the influence of psychological factors and potentially triggering environment (depression, stressful events, changes in living conditions …). For example it will be recalled that it is usual to grow by an average of 3 to 5 kg with an active stop smoking;
– To focus the balance towards research of metabolic complications mechanical view.
Biologically it will take to perform a minimum fasting glucose, lipid profile, serum uric acid levels and liver function tests (overweight is the main cause of increase in transaminases). Depending on age and other cardiovascular risk factors, explorations will be further.
In severe obesity (BMI> 35) it is particularly important to detect and treat respiratory complications (of sleep apnea, hypoventilation), sudden death source and aggravation of cardiovascular risk.
It is good to remember that all medical specialties may face complications in obese patients and specificities.
Particularly at-risk patients should be individualized: these patients within the scope of plurimetabolic syndrome or insulin resistance. These patients have little or no abdominal overweight (sometimes without obesity: BMI can be less than 30), abnormal glucose tolerance see a true type 2 diabetes, dyslipidemia (HDL cholesterol and elevated triglycerides drop ) and hypertension. Due to a high absolute risk cardiovascular, often> 10% over 10 years, metabolic support, nutritional and drug often is essential.
A survey on eating behavior and quality and quantity of inputs, research problems to be corrected is a prerequisite for support.
In particular, look for a real binge prandial (linked to the simple greed, loneliness or very rarely a lack of satiety …), a snack (sweet and / or salty) or more characterized disorders (compulsive eating, craving or desire irresistible manger, nocturnal food intake …), often alternating with periods of food restriction …
Analysis of the patient’s motivation to lose weight is fundamental to collect. We must remember that the obese patient has always had at least during the phase of constitution of his obesity, higher dietary intakes its energy needs. This intangible thermodynamic reality does not mean that, at State 0phase, ingesta can be low, which will contribute to the resistance to the desired weight loss. The “secondary” obesity (hypothalamic, endocrine) and “constitutional” (high key family) are rare but because of the frequency of hypothyroidism frustrating sometimes revealed by an isolated hypercholesterolemia, a TSH assay should be at most made of cases.
The therapeutic management of overweight patients is difficult and often unrewarding.
It is imperative to register in time.
The role of the clinician is to try to understand each patient’s predominant factors and those that are treatable. The care and treatment goals are not limited to weight loss. If obesity consists evolving for at least 10 years, the medium-term success rate – about the weight parameter – different approaches “nutritional” and medical are below 10%, contributing to the loss of esteem and problems common psychological side in this syndrome. The resistance,biological and psychological, to weight loss is indeed the common lot of these patients. In some cases overweight will be respected: patient aged over 75 years, refusal, certain psychiatric conditions …
The logical therapeutic approach strategy to adapt in individual cases is:
– 1. Correcting eating disorders “obvious” correction of gross dietary errors. Psychotherapeutic approach may be justified in some cases. Encouraging moderate exercise (30 minutes / day) is essential to improve outcomes of taking dietary burden and decrease insulin resistance.
– 2. In the event of adherence and patient motivation, a food project through a “food model” realistic, socially adapted to the constraints of the patient’s life, is to be proposed. A coherent and coordinated weight goal should be proposed: a matter of 45 years with a BMI 35 and above do not will not continue will return to a BMI of 25. Very penny wind in common obesity, loss of 10 to 15 kg or 5 to 10% of body weight already results in improved functional impairment (decreased dyspnea …) and improves metabolic tolerance (increased insulin sensitivity) and hemodynamics. It is useful to help a dietician for the development of the food project. The food model is mildly hypocaloric (reduced by about 30% compared to the level of spontaneous contributions reported by the patient, suitable for resting energy expenditure theoretically) with reduction of excess caloric intake (fat, alcohol …) without restriction “prohibited” sources of non-rapid patient compliance. Obese subjects often tend to underestimate their food intake: it must be considered in the development of guidance and “diet”. The “plan” is to follow indefinitely because the objective is thelong term. In the long-term efficacy is obtained in case of actual patient adherence … All methods, nature and very diverse inspiration, offered for a limited time are clearly ineffective (weight almost constant in kickback stopping and effect of “yo-yo” weight) and sometimes sources of micronutrient deficiencies.
– 3. Medications can have their place in second line in case of obesity or overweight associated with severe comorbidities. Are available in France Orlistat (Xénical®), which causes a moderate malabsorption (30%) dose-dependent of dietary lipids by reversible functional pancreatic insufficiency and Sibutramine (Sibutral®) which acts as an antagonist reuptake central endogenous amines . The initial prescription and 3 months with an extension up to 2 years in responders (loss of more than 5% of initial weight or improvement of comorbidities).
Other drugs should soon be available. No anti-obesity drug has truly demonstrated its usefulness over the long term.
– 4. The bariatric digestive surgery is the last line of therapy considered. Two main methods are possible: the gastric band (and other types of gastroplasty) and gastric bypass. The latter, causing malabsorption, should be reserved for severe cases. The results are often dramatic: in terms of weight reduction it is unquestionably the most effective method in the medium term (5 years), both in terms weight (weight loss of 20 to 40%) and reduction comorbidities.But there are 10 to 20% of complications, including digestive, sometimes debilitating or severe, and about 15% of failures. Bariatric surgery is a strict food hygiene. In the absence of cons-indications (including psychiatric and digestive), it should be reserved for severe obesity, BMI> 40 in the absence of comorbidities, or> 35 in the presence of comorbidities associated with overweight, non responder to an outlet multidisciplinary medical management of at least 1 year. Plastic surgery (lipectomy abdominal apron, liposuction …) is to consider that after stabilization of weight reduction.
ROLE OF THE GENERAL PRACTITIONER IN THE PREVENTION OF OBESITY:
The GP is the heart of the healthcare system to coordinate the multidisciplinary management of chronic diseases.This is especially the case in obesity.
It is early detection of risk situations, including and increasingly in children, and participate in nutrition education of his patients: encouraging moderate but regular physical activity – 30 to 50% of adolescent or adult population young with no physical activity, advise the decrease in caloric density of the diet … This also involves the actions of continuing education in which there is expressed a need nutrition training, compensating for the absence or inadequacy initial training.
Nevertheless, the physician should be aware that changing food availability and consumption for 50 years, reduction of complex sugars in favor of simple sugars and increased lipid ration animal low satiating power, does not favor his patients or public health … The doctor may also participate in different networks which total care, especially under the leadership of the PNNS (National Nutrition and Health Plan), participate in an educational activity in schools … The message conveyed should avoid being too prescriptive because the thinness ideal concept or ideal weight might generate drifts type anorexic restrictive behavior in adolescents (e).
Obesity is a common disease and rising in the general population. Easy to diagnose, prevent not so obvious (deleterious role of advertising and contemporary lifestyle), it generates a certain cardiovascular risk and contributes to social stigma and psychological problems difficult to manage. A consistent treatment plan tailored to the patient, is to be found case by case. It will focus on the management of comorbidities and project a realistic weight correcting dietary errors and proposing a “diet” suitable not restrictive. Bariatric surgery, fashionable and undoubtedly effective, is not the panacea some checking, it can also cause serious complications justifying its indications and its implementation should be entrusted to specialized teams.