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Robert Kushner, MD: I'm Dr Robert Kushner. Welcome to Medscape's InDiscussion series on obesity. This is episode four. Today we'll discuss a very important topic, which is medical evaluation of the patient who presents with obesity. First, let me introduce my guest, a long-term friend and colleague, Dr Amanda Velazquez. Dr Velazquez is the director of obesity medicine at Cedars-Sinai Medical Center in Los Angeles, California. Amanda, welcome to InDiscussion.
Amanda Velazquez, MD: Thank you for having me.
Kushner: Amanda, this is a critically important topic for primary care providers, residents, and medical students. In my experience, most patients who come in to see their medical provider are not making an appointment about their weight — it's really about other medical problems that bring them to the doctor that may or may not be weight related. How do you broach the topic of weight with your patients?
Velazquez: I always try to ask for permission because this is a sensitive topic, as you know. I make sure to use the framework of the 5 A's that we're familiar with from smoking cessation with patients. Similarly, I start off by asking questions like, "I'm concerned about your weight. Would it be okay to talk about your weight today?" Or "I've noticed that your weight has been increasing over the last few years. How do you feel about your weight? Is this a good time to chat about it?" Getting permission is a way to be respectful, free of judgment, and free of bias, which is so important to open that pathway to talk and establish trust because we know that words matter.
Kushner: I absolutely agree. When I talk to medical students, for example, I tell them to incorporate a weight history as part of your normal history if you're seeing a patient for the first time. That way, you've already broached the topic, just like talking about gun control, diet, cigarette smoking, or alcohol use. You get the information upfront, and you can go back to it later. That's a shout out to taking a weight history as part of history to begin with.
Velazquez: It definitely makes it more streamlined.
Kushner: If a patient is coming to talk about their weight — again, we've already said it's not the most common presentation, but if they are, what questions should patients be prepared to ask their healthcare provider?
Velazquez: I think one of the most important is to understand what treatment options are available for them. I think treatments are really underutilized when it comes to the available tools in the toolbox. We know that only 1% to 2% of patients who qualify for bariatric surgery are actually undergoing bariatric surgery, and only 1% of patients who qualify for weight loss medications are taking weight loss medication. We want patients to be aware of the treatments on the table for them. For the patient, it's about coming in, trying to understand what pathways they can take, what the best options to optimize health are, and how much weight loss is needed to optimize health. What are the aspects of health that need to be optimized and prioritized right now?
Kushner: I ask you that question so that our listeners can be prepared to answer those questions if patients are coming in and asking them. It's also a good time for a shout out for the Obesity Action Coalition. They have a website that lists those types of questions for patients. If any of our listeners have patients who want to get more involved or learn about that, they can go to obesityaction.org.
Velazquez: I love that website, and I am always telling trainees about it.
Kushner: What should patients expect from their medical provider when obesity is discussed? How resourceful should they be for patients?
Velazquez: Going back to what we said earlier, we want a detailed weight history. That's an opportunity to hear a patient's story and feel validated. We hope that a provider will take the opportunity to understand what all the pieces are — the contributing and the non-contributing factors — that have really added up over the years to lead to this person's weight when you're seeing them in the clinic. The other part to it is an individualized treatment plan, because it can't be cookie cutter when it comes to this. We know precision medicine is the answer. An individualized plan is what we would expect the providers to be working on: A tailored approach from healthy lifestyle to prescribing weight loss medications, plus or minus some type of procedure or bariatric surgery. Finally, talking about barriers, I think that's such an important one. How do we help our patients adhere to the treatment plan we're discussing? Social determinants of health that disproportionately affect our black and brown patients have to be addressed in order for us to help our patients be successful at adhering to the plan that we're developing for them.
Kushner: As a provider, you have to be prepared to have that conversation. Once you broach a topic like, "Is this a good time to talk about your weight?" and a patient says, "Yes, it is," then that opens the whole box. I want to dive a little deeper into taking an obesity-focused medical history. This is something that we're not typically trained in medical school or residency to do, but it's so important. For example, if you have somebody come to you with diabetes, I'll bet every practitioner will take a detailed diabetes history, right? But with obesity, providers aren't always sure what to do. What do you recommend? What is an obesity-focused history? What should that look like and sound like?
Velazquez: I think there are two hallmarks to it. Number one is looking at it from the life course, the trajectory of someone's weight. You can ask when the patient had difficulty with weight gain and how that's looked over the years. Again, that is validating their story and understanding all the factors over the course of their lifetime to today's encounter with them. The other part to it would be a patient-centered approach. We want to acknowledge that this is about letting patients' preferences and values guide us in our clinical decision making. We need those pieces when we're collecting the weight history. Technically, there's no fully adopted way to do this or standard of care for this; it's based off expert opinion. Nonetheless, one way to go about it would be doing the mnemonic of OPQRST: onset, precipitating factors, quality of life, remedy setting, temporal pattern. All of those are going to be important to understanding the weight journey. I really like graphing a patient's weight and looking at those changes over the lifetime. I think that is a really nice way to obtain a weight history.
Kushner: I'll add to that: If you get down to the nuts and bolts and don't have a lot of time, what are key things to ask? Things that come to my mind — and you can add to this — are: What was your maximum weight? That gets into physiology and setting the appetite center. What was the lowest body weight you've gotten to? That gives you a range. What have you done to get your weight under control? What worked? What didn't work? I think it's important to have a set of questions that you learn and repeat that gets that key information about one's body weight. In that vein, Amanda, when we're doing a weight history, do we need to do a soup-to-nuts kind of history because time restraint is important?
Velazquez: Time is such a consideration, and I know that firsthand. We need to be changing the paradigm and having appointments in primary care, especially, that are dedicated to weight, the same way we have patients come back for a dedicated appointment for diabetes every 3 months or hypertension. Why aren't we doing that for obesity? That will give us a little bit more time. With that extra time, that can allow us to dive in and get those key points of highest weight and lowest weight. Trying to get at some of those factors that are controllable vs non controllable helps patients understand that this isn't about willpower. When we get at the family medical history of who's been dealing with obesity, understanding that there were pre- and postnatal factors, that really helps them to see that this has been going on for a very long time. It's not just about diet and exercise.
Kushner: Let's talk about the physical exam. For 30 years or so, we've been routinely using body mass index (BMI) to diagnose and code for obesity, and we need to know that for our ICD-10 coding. Are there other better methods currently used to diagnose obesity, which is excess body fat, more accurately? That's not really BMI.
Velazquez: I think other measurements we could look at would be waist circumference or a waist-to-hip ratio. These are very easy. Honestly, it takes a couple of minutes in the clinic. I know you do it at the Northwestern Medicine Center for Lifestyle Medicine. We do it here at the Cedars-Sinai Center for Weight Management Metabolic Health. It's a way to incorporate another metric of the person's weight, and I think it also helps to take away the emphasis on the scale, since we tend to have a culture that really hones in on the number on the scale. For waist circumference and waist-to-hip ratio, we have good data around that with its associated risk, with cardiovascular disease, diabetes, etc. That would be a recommendation I have for listeners to consider that in their practice: training the staff on intake to have the waist circumference and waist-to-hip ratio as part of the process for patients who are coming in overweight and with obesity.
Kushner: Great tip. It's kind of that secret sauce that no one seems to do. We'll get to discuss measurements a little bit more when identifying a high-risk patient, one of which is that upper-waist phenotype. Let's stick with physical exam a bit more. When you're seeing a patient with obesity, outside of the normal physical examination that all clinicians do, are there key aspects or anything you would do differently?
Velazquez: I would hone in on specific aspects of the traditional exam. For the head and neck exam, you may want to pay extra attention to the oropharynx to see if it is overly crowded. Are we thinking that there may be some degree of sleep apnea? You could be thinking about the Mallampati scoring system when you're assessing the abdomen and understanding the fat distribution. Are we looking at that central upper body fat, which we know poses more risk for metabolic syndrome? And then with the cardiovascular system, usually we just listen to the heart but you may also pay attention to whether the patient has some peripheral edema or some venous stasis going on. Finally, I always pay attention to those early signs of insulin resistance with the skin exam, acanthosis nigricans is important. Looking at the back of the neck, the axilla, is going to be key for doing the physical exam.
Kushner: You mentioned the skin, and it's so funny when I have residents with me, and they often don't raise a shirt or look at the skin. They listen over the shirt to the belly or don't lift the pants in a man. A skin exam is so important, whether it's dystrophic skin changes, problems within skin folds, or acanthosis.
Velazquez: Yes, skin tags.
Kushner: Striae, particularly. Not that Cushing's is common, but looking for that is important. Of course, in the exam, it's harder to examine a liver because of the excess adipose tissue, but you do the best you can. Statistically, four out of 10 adult patients a primary care provider sees has obesity, if we take the national statistics. That's a lot of time and effort. How do we identify the high-risk patient, the one whom we need to be spending more time on, maybe taking more detailed history outside of the waist circumference, which I think we recommend doing?
Velazquez: I think it'll be important to think about the staging systems. We do this in other frameworks for other types of diseases to determine the extent and severity of that disease. Similarly, we want to stratify our patients with obesity and understand who's at highest risk. There are a few different types of stratifications that we could use for the staging systems. Technically, none of them have been universally adopted, but we know that there are some that we could use and I use in my practice.
Kushner: Tell us more about these staging systems and why we would want to use them in obesity.
Velazquez: Let me start with the Edmonton Obesity Staging System (EOSS). This one includes five risk stages that evaluate the medical, psychological, and functional impacts of obesity. It's really looking at the level of impairment for this individual and quality of life. The stages go from 0 to 4. Stage 0 includes no impact on mental health, no complications related to their health, and no functional limitations. Stage 4 is looking at end-stage disease, medical complications, and severe limitations to functionality. For example, chair-bound with significant impacts on mental health. We know that the EOSS is a predictor for all-cause mortality and heart disease mortality. This is a useful tool. Another one that you could consider is the Cardiometabolic Disease Staging system, and that one tries to assess those with obesity who are at risk for diabetes. That one begins at stage 0, with an individual who is metabolically healthy, and goes all the way to stage 4 again, which is classified as end-stage disease. In summary, for clinicians who aren't using these staging systems, it's very helpful to get an idea of how high risk your patient is for progressing with weight-related medical conditions. With the cardiometabolic staging system, we're looking at trying to prevent diabetes. That's going to be helpful in deciding the intensity of treatment that you need to apply for these patients.
Kushner: You highlighted the two most common ones. I'm not sure they're ready for prime time, but they are moving forward. I want to emphasize one thing about the EOSS: BMI is not part of that staging system. It's looking at the health risk of the individual functionally, physiologically, mentally, and psychologically, independent of BMI. A higher BMI is correlated generally to a higher stage in the system but not necessarily.
Velazquez: Yes, good point.
Kushner: Here is another good question, which leads to some confusion among clinicians and patients. There's a concept called metabolically healthy obesity, and that means someone who has a higher BMI but doesn't have any metabolic problems. It's pretty common. Patients will say, "My BMI may be 35, but I am healthy. I don't have diabetes or hypertension. Why should I do anything?" What do we know about the long-term outcomes of these individuals who have obesity by BMI, let's say 35, but don't have any medical problems? What's in their future? What do we know about that?
Velazquez: It's unfortunately just a matter of time that cardiometabolic complications are going to occur. When does that flip the switch? We don't fully understand because there are so many variables at play, especially epigenetics. Ultimately, we want to start with prevention, and if we know that obesity carries risk with having excess adiposity, we should start tackling it now, similar to pre-diabetes. We wouldn't just say, "You have pre-diabetes," and walk away and not give that patient any type of treatment. We would start addressing it. We should think about obesity in the same capacity. I'm glad you brought this up, Bob, because I feel like it's a common question that is asked honestly by patients, especially in primary care. When I was doing that work, patients were hesitant to jump in or thought that treatment should not be started because it's not bad enough. I always then turn the question around and ask, "What are we waiting for?"
Kushner: Great comparison to pre-diabetes. If you diagnose it early, it's easier to treat and prevent before it advances. The same is true with obesity. Amanda, you run a specialty center like I do at Northwestern, and you may have this kind of criteria established. From a primary care perspective, when should they refer to a specialist vs working on themselves? What do you look for to escalate care to a specialist?
Velazquez: When you're escalating care to a specialist, I think about it as medically complex patients with obesity vs those who may have what I like to call simple obesity. In the case of looking at it comparable to diabetes, we don't send every patient with diabetes to the endocrinologist, but we do send those who are more medically complex — meaning they have greater disease burden. Again, looking at that staging system, maybe they're higher on the staging system of one of the ones we talked about today. Those individuals would warrant treatment in a specialty center. For example, here at Cedars-Sinai, we see a lot of patients with concomitant obesity (having obesity and a concomitant cancer) and in need of a transplant. Those are the type of patients whom we see who are higher medical complexity. Those patients lower on the staging system would be more appropriate for primary care to manage.
Kushner: I agree completely about getting the primary care provider more engaged in managing obesity. Amanda, before we end, what are the key takeaways that clinicians should know about assessing patients with obesity in the office setting? What do you want them to know from this podcast?
Velazquez: I want to sum it up with three things. Number one, I feel that it's our responsibility as clinicians to address obesity. It's essential for us to address it head on to be able to make headway in the current epidemic. Number two is that words matter. When you start these conversations with patients about obesity, which is really the first step in diving in, remember to ask permission because that's a respectful, non-judgmental, bias-free way to approach the conversation. Third, it's important to remember you can incorporate a weight history into your traditional history of present illness (HPI). If you want to really move the needle, start having patients come back for dedicated weight appointments. A dedicated weight appointment would be a way to get an extensive weight history and capture all the factors that contributed over their lifespan, and then have opportunity to look at staging systems and do a more detailed, obesity-focused physical exam. My hope is that we change the paradigm, especially in primary care, so that we start talking about weight first rather than having it be an afterthought.
Kushner: Amanda, thank you so much for joining us today for InDiscussion. It's been a pleasure, and I think you went over some great topics for our listeners to know about in-office practice.
Velazquez: Thank you, Bob.
Kushner: I want to thank all of you for joining us for episode four. I look forward to another great discussion in episode five. This is Dr Robert Kushner for InDiscussion.
Resources
Obesity Treatment & Management
A Primer on Smoking Cessation in Primary Care
Reasons for Underutilization of Bariatric Surgery: The Role of Insurance Benefit Design
Antiobesity Drug Therapy: An Individualized and Comprehensive Approach
Taking a Weight History – Using Mnemonics to Learn a Missing Skill in Medical Education [Version 1]
The Broadening Domain of the Metabolic Syndrome
Modern Epigenetics Methods in Biological Research
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Cite this: Medical Evaluation of the Patient Who Presents With Obesity - Medscape - Jun 06, 2023.
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