Obesity and Classification of Patients; Historical Perspectives and Current Practice.pdf

1. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 1
Assessment of Obesity
and Classification of Patients:
George A. Bray, MD, MACP, MACE
Pennington Center/LSU System
Baton Rouge, LA
HistoricalPerspective and Current Practice
2
Obesity is not a new problem
Paleolithic times
3
Venus of Willendorf
The Venus of Willendorf
was found in 1908
during excavations
along the Danube River;
It is a small
limestone statuette
measuring a little over
4 inches (11 cm) in height;
The arms are small,
there are no feet
or facial features,
but there is clear-cut
abdominal obesity
and pendulous breasts

2. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 2
4
Map showing locations
of Venuses across Europe
5
Diagram of several figurines
6
Obesity is not a new problem
Paleolithic times
Neolithic times

3. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 3
7
Venus of Catalhoyuk (Turkey)
Baked clay figure
from the first half
of the 6th millennium BCE;
The female figure
is sitting
on a leopard throne
Very heavy buttocks,
thighs and arms
8
Obesity is not a new problem
Paleolithic times
Neolithic times
MesoAmerican times
9
Mayan figurine
This baked
decorated clay figure
of a Mayan man
shows the large
protuberant abdomen
of central adiposity

4. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 4
10
Obesity is not a new problem
Paleolithic times
Neolithic times
MesoAmerican times
Historical times to 1500 AD
11
Historical cultures
Mesopotamian
Egyptian
Chinese Tibetan
Indian
Greco-Roman
12
Hippocrates on treatment of obesity
Hippocrates (460-370 BC)
is called
the “Father of Medicine”;
Born on the Island of Cos;
His major achievements
were to Separate medicine
from Philosophy,
to give a scientific base
for clinical care
and to give physicians
high moral aspirations

5. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 5
13
Hippocrates on treatment of obesity
Obese people
and those desiring to lose weight
should perform hard work before food
Meals should be taken after exertion
and while still panting from fatigue
and with no other refreshment
before meals except only wine,
diluted and slightly cold
14
Obesity is not a new problem
Paleolithic times
Neolithic times
MesoAmerican times
Historical times to 1500 AD
Modern times from to 2000 AD
15
Malcolm Flemyng
on obesity as a disease - 1760
Corpulency,
when in an extraordinary degree,
may be reckoned a disease,
as it in some measure
obstructs the free exercise
of the animal functions;
and has a tendency to shorten life,
by paving the way
to dangerous distempers

6. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 6
16
William Wadd - 1810
Title of his 1810 monograph:
“Cursory Remarks on Corpulence;
or Obesity Considered as a Disease”
17
William Wadd – 1810
“If the increase of wealth and refinement
of modern times,
have tended to banish plague
and pestilence from our cities,
they have probably introduced
the whole train of nervous disorders,
and increased the frequency of corpulence”
18
William Wadd’s patient - 1810
Indeed, inactivity somnolency,
depression of spirits,
and an inaptitude for study,
were symptoms sufficient
to produce anxiety;
By an abstemious mode of living,
and a vegetable diet, he became lighter,
more capable of mental exertion,
and in every respect improved in health
but whenever he resumed
his former habits,
his complaints returned in full force

7. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 7
19
Modern themes
Metabolism is like a burning candle
20
Picture of Lavoisier
Antoine-Laurent Lavoisier
(1743-1794)
demolished
the phlogiston theory
and replaced it
with the oxygen theory
of metabolism
“He and he alone
discovered the meaning
of oxygen in metabolism”
21
Modern themes
Metabolism is like a burning candle
Not all obesity is the same

8. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 8
22
Picture of Cushing
Harvey Williams Cushing
(1869-1939)
was the father
of neurosurgery
He identified
the basophil of the pituitary
as one cause of obesity,
hypertension,
and pigmented skin changes
23
Not all obesities are the same:
classifications 1900-1950
Author Year Classes
Noorden 1900
Exogenous
Endogenous
Zondek 1926
Alimentary (gluttony)
Endocrine
Localized (lipomatosis)
Jarlov 1932
Hypertrophic – diffuse
Plethoric
Myxematoid
Lipomatoid
Rony 1940
Specific forms (endocrine)
Essential
Mixed
24
Author Year Classes
Vague 1956 Gynoid
Android
Mayer 1960 Metabolic
Regulatory
Hirsch 1970 Hypercellular
Normocellular
Bray York 1971 Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Not all obesities are the same:
classifications 1950-1970

9. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 9
25
Modern themes
Metabolism is like a burning candle
Not all obesity is the same
Body mass index and risk to health
26
Quetelet and the body mass index
Lambert-Adolphe-Jacques
Q uetelet (1796-1874)
Introduced the concept
of the body mass index
as a tool to assess differences
among human beings in 1835
In addition to statistics,
Q uetelet taught mathematics,
astronomy and physics
27
Quetelet - a treatise on man
and the development of his faculties 1835
“If we compare two individuals who are fully
developed and well-formed with each other,
to ascertain the relations existing
between the weight and stature, we shall find that
the weight of developed persons, of different heights,
is nearly as the square of the stature
Whence it naturally follows, that a transverse section,
giving both the breadth and thickness,
is just proportional to the height of the individual;
We furthermore conclude that,
proportion still being attended, width predominates
in individuals of small stature”

10. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 10
28
Distribution curve for body weight
0.00
0.05
0.10
Body weight groups
Probability
density
-15 -10 -5 0 5 10 15 20 25 30 35 40 45
29
Relative risk of mortality in average
or underweight insured people - 1913
Deviation
Weight in lbs
Actual
Deaths
Expected
Deaths
Mortality
Ratio
-25 to –30 9,873 9,442 1.04
-15 to –20 7,997 7,481 1.07
-10 1,574 1,637 .96
-5 1,480 1,529 .97
Average 1,381 1,422 .97
Medico-Actuarial Mortality Investigation NY 1913;2:5-9,44-47
All Ages at Entry and Policy Years Combined
30
Relative risk of mortality
for overweight people - 1913
Medico-Actuarial Mortality Investigation NY 1913;2:5-9,44-47
All Ages at Entry and Policy Years Combined
Mortality
Ratio
Expected
Deaths
Actual
Deaths
Deviation in
Weight in lbs
.97
1,422
1,381
Average
2.23
106
236
+ 85 and more
1.65
695
1,144
+65 to + 80
1.44
2,563
3,697
+50 to + 60
1.31
3,876
5,061
+35 to +45
1.13
1,122
1,267
+25 to +30
1.04
1,443
1,497
+15 to +20
.97
999
970
+ 10
.99
1,188
1,176
+ 5
Mortality
Ratio
Expected
Deaths
Actual
Deaths
Deviation in
Weight in lbs
.97
1,422
1,381
Average
2.23
106
236
+ 85 and more
1.65
695
1,144
+65 to + 80
1.44
2,563
3,697
+50 to + 60
1.31
3,876
5,061
+35 to +45
1.13
1,122
1,267
+25 to +30
1.04
1,443
1,497
+15 to +20
.97
999
970
+ 10
.99
1,188
1,176
+ 5

11. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 11
31
Insurance data 1913
Medico-Actuarial Mortality Investigation NY 1913;2:5-9,44-47
-30 -20 -10 0 10 20 30 40 50 60 70 80 90
1.0
1.5
2.0
2.5
Percent Deviation
Relative
Risk
of
Mortality
Men
W omen
32
Framingham study - women
90
0
100
100 110 120 130 140
200
300
400
500
600
700
Metropolitan relative weight
Deaths
per
1000
6
12
18
24
30
33
Cohort size, duration of follow-up
and risk of mortality with increased BMI
Adapted from Sjostrom AJCN 1992
0 10 20 30 40
10 2
Years of Follow-up
10 3
10 4
10 5
10 6
10 7
10 8
Population
Size
(log
Scale)
Positiv e
Negativ e

12. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 12
34
Mortality ratios
as a function of time
Mortality Ratios
by Duration of Policy Years
1-5 6-10 11-15 16-22
Men aged 15-69
25 % underweight
1.27 1.19 1.14 1.05
Men 15-25 %
overweight
1.06 1.14 1.23 1.31
Women aged 15-69
25 % underweight
1.67 1.28 1.34 0.90
Women 15-25 %
overweight
1.06 1.03 1.13 1.12
Sjostrom AJCN 1992;55:16S-23S
35
Is overweight a risk to your health?
T he authorities say obesity is a disease
that increases dysfunction as it gets more severe
Population studies show heavier people
have higher risk of death
than average weight ones
Underweight people have high early risk
T he discrepancies occur when short-term
or small size studies are used
36
Very
High
Risk
High
Risk
Moderate
Risk
Very
Low
Risk
Low
Risk
Body mass index cut-points
based on life insurance data
15 20 25 30 35 40
Body Mass Index (Kg/(m)2)
Mortality
Ratio
300
250
200
150
100
50
0
20-29
30-39
Age at Issue
Digestive
Pulmonary
Disease
Cardiovascular
Gall Bladder
Diabetes Mellitus

13. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 13
37
Clinical History
Clinical Classification
Vital Signs
Laboratory Measures
Evaluation
38
Evaluation: clinical history
Previous weight
• At 18-20 years of age
• One year earlier
Activity level
• Since age 18-20
• Recent
Nutrition history
• Foods consumed
• Changes in diet
When did the problem start?
• Recent
• Long term
39
Clinical History
Vital Signs
Laboratory Measures
Clinical Classification
Evaluation

14. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 14
40
Vital signs
Body mass index
41
Permits population-based studies of trends
in obesity and is used for clinical guidelines
Does not correlate well with fat mass
in both over-muscled (athletic)
and under-muscled (sarcopenic) patients
Does not reveal differences in fat distribution
(visceral vs. subcutaneous)
Does not measure fat directly but correlates
with body fat over thousands of average patients
At any given BMI,
women have about 12% more fat than men
Utility and limitations of the BMI
A T
able of Body Mass Index (BMI)
Copyright 1997 George A. Bray
91
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100
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156
96
99
102
106
109
113
116
120
124
127
131
135
139
143
147
151
155
160
164
100
104
107
111
115
118
122
126
130
134
138
142
146
150
154
159
163
168
172
105
109
112
116
120
124
128
132
136
140
144
149
153
157
162
166
171
176
180
110
114
118
122
126
130
134
138
142
146
151
155
160
165
169
174
179
184
189
115
119
123
127
131
135
140
144
148
153
158
162
167
172
177
182
186
192
197
119
124
128
132
136
141
145
150
155
159
164
169
174
179
184
189
194
200
205
124
128
133
137
142
146
151
156
161
166
171
176
181
186
191
197
202
208
213
129
133
138
143
147
152
157
162
167
172
177
182
188
193
199
204
210
216
221
134
138
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153
158
163
168
173
178
184
189
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200
206
212
218
224
230
138
143
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174
179
185
190
196
202
208
213
219
225
232
238
148
153
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164
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175
180
186
192
198
203
209
216
222
228
235
241
248
254
167
173
179
185
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197
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236
243
250
258
265
272
279
287
191
198
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211
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225
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255
262
270
278
286
294
302
311
319
328
38 39
143
148
153
158
164
169
174
180
186
191
197
203
209
215
221
227
233
240
246
153
158
163
169
175
180
186
192
198
204
210
216
222
229
235
242
249
256
263
158
163
168
174
180
186
192
198
204
211
216
223
229
236
242
250
256
264
271
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168
174
180
186
191
197
204
210
217
223
230
236
243
250
257
264
272
279
172
178
184
190
196
203
209
216
223
230
236
243
250
257
265
272
280
287
295
177
183
189
195
202
208
215
222
229
236
243
250
257
265
272
280
287
295
304
181
188
194
201
207
214
221
228
235
242
249
257
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272
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288
295
303
312
186
193
199
206
213
220
227
234
241
249
256
263
271
279
287
295
303
311
320
BMI
4’10”
4’11”
5’
5’1”
5’2”
5’3”
5’4”
5’5”
5’6”
5’7”
5’8”
5’9”
5’10”
5’11”
6’”
6’1”
6’2”
6’3”
6’4”
25 30 35 40
Good W eights Increasing Risk
Height 19 20 21 22 23 24 26 27 28 29 31 32 33 34 36 37

15. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 15
43
Classification using BMI
*Note that these values are age-independent and the same for both sexes;
However, BMI may not correspond to the same degree of fatness across different
populations (see section 2.3.2);
**Note that both BMI and a measure of fat distribution (waist circumference
or waist hip ratio etc.) are important in calculating the risk of obesity co-morbidities;
BMI 18.5 kg/m2
signifies an increased risk of developing other clinical problems
Classification
Underweight
Normal range
Overweight
Obese
Class I
Class II
Class III
BMI (kg/m2
)*
18.5
18.5 - 24.9
25.0 - 29.9
30.0
30.0 - 34.9
35.0 - 39.9
40.0
Risk of co-morbidities**
Low
Very Low
Low
Moderate
High
Very High
44
Vital signs
Body mass index
Waist circumference
45
Intra-abdominal Fat
Abdominal
Muscle Layer
Subcutaneous Fat
AbbottLaboratories
Measure waist
between iliac crest
and lower ribs
Waste circumference
and visceral adiposity

16. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 16
46
Type 2 Diabetes
Normal
Courtesy of Wilfred Y
. Fujimoto, MD.
Visceral fat distribution
normal vs. type 2 diabetes
47
Waist Circumference
– Measure only for patients with BMI between 25 and 34.9
Abdominal obesity: risk factor for CV D
Measure abdomen horizontally at level of iliac crest
40” (102 cm) male
35” (88 cm) female
Body Mass Index
weight (kg) ÷ height (cm)2
OR
weight (lb) x 703 ÷ height (in)2
Definitions
BMI 25 kg/m2 =
Overweight
BMI 30 kg/m2 =
Obesity
Summary – two new vital signs
Definitions
48
National Institutes of Health. Obes Res. 1998;6(suppl 2):51S–209S
High Waist Circumference: Men 40˝ Women 35˝
This is correlated with visceral fat mass
Obesity Waist Circumference
BMI Class Low High
Overweight 25.0 - 29.9 Increased High
Obesity 30.0 - 34.9 I High V ery High
Obesity 35.0 - 39.9 II Very High V ery High
Extreme ≥ 40 III Extremely Extremely
Obesity High High
Risk Category
BMI classification
of overweight and obesity

17. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 17
49
Vital signs
Body mass index
Waist circumference
Blood pressure
50
Blood pressure categories
from JNC VII
ADA. Diabetes Care. 2002;25(suppl 1):S33-S49
Normal 120/80
Prehypertension 120-139/80-89
Hypertension 140/90
Stage 1 140-159/90-99
Stage 2 160/100
51
Clinical History
Vital Signs
Laboratory Measures
Clinical Classification
Evaluation

18. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 18
52
Laboratory measurements
Body Composition
Lipids
Instrumental methods
for body composition
Methods
Hydrodensitometry
Air Displacement
Plethysmography
Dual x-rayabsorptiometry
(DXA)
Isotope Dilution
Impedance (BIA)
40K Counting
Conductivity (TOBEC)
CT Scan
MRI Scan
Neutron Activation
Ultrasound
Cost
$$
$$$$
$$$
$$
$$
$$$$
$$$
$$$$
$$$$
$$$$+
$$
Ease
of Use
Easy
Easy
Easy
Moderate
Easy
Difficult
Difficult
Difficult
Difficult
Difficult
Moderate
Can Measure
Regional Fat
No
No
+
No
+
No
±
++
++
No
+
External
Radiation
tr
++
+++
* Special Equipment; $=Inexpensive;$$=Some expense;$$$=Expensive;$$$$=Very Expensive;tr+trace
E=Easy;M=Moderate Experience Needed;D=Difficult
54
Lev el I
(Whole Body)
Five levels of body composition
Lev el III
(Cellular)
Lev el II
(Tissue and
Organ-System)
Lev el IV
(Molecular)
Lev el V
(Atomic)
Other
Blood
Skeletal
Muscle
Skeleton
Adipose
Tissue
ECF
ECS
CellMass
(connective
tissue,neural,
muscle,
epithelial)
Fat Cell
Mass
Glycogen
Protein
Water
Lipid
Minerals
Other
Other
Hydrogen
Oxygen
Carbon
Calcium
Nitrogen

19. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 19
55
BodyComposition
Lean Obese
Weight
(kg)
Fat
Protein
Water
Other
100
80
60
40
20
0
40
80
120
160
200
240
280
320
360
Lean Obese
Energy
Content
(
kcal
x
10
3
)
Body composition
and energy content with weight gain
EnergyContent
56
0
20
40
60
80
100
10-19 20-29 30-39 40-49 50-59 60-69 70-79
Relative
segmental
fat
volume
(%)
Head
Fore-arm
Upper arm
Chest
Abdomen
(subcutaneous)
Abdomen
(visceral)
Thigh
Calf
MEN
Age (years)
Changes in different fat
volumes with age in men
57
0
20
40
60
80
100
10-19 20-29 30-39 40-49 50-59 60-69 70-79
Relative
segme
ntal
fat
volume
(%)
Head
Fore-arm
Upper arm
Chest
Abdomen
(subcutaneous)
Abdomen
(visceral)
Thigh
Calf
W OMEN
Age (years)
Changes in different fat
volumes with age in women

20. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 20
58
Prevalence of obesity
10.4
11.8 12.3
22.0
27.5
15.0
16.2 16.5
24.9
33.5
0
5
10
15
20
25
30
35
Percent
Obese
(BMI
30
kg/m
2
)
Men W omen
1960-62 1971-74 1976-80 1988-91 1999-02
59
Prevalence of obesity
in different ethnic groups
MEN WOMEN
White White
Black Mexican-
American
Black Mexican-
American
12
15
20
21.3
25.4
15.4
0
10
20
30
40
Prev
alence
of
Ov
erweight
(BMI
30
kg/m
2
)
22
30
34.2
14.8
21.3
25.4
2nd survey
1st survey
60
Laboratory measurements
Body Composition
Lipids

21. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 21
61
Lipid targets in diabetes
1. ADA. Diabetes Care. 2002;25(suppl 1):S33-S49. 2. Expert Panel on Detection, Evaluation,
and T
reatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-249 7
ADA Target1
mg/dL
NCEP Guidelines2
mg/dL
Total cholesterol 200
LDL cholesterol 100 100
HDL cholesterol 45 men
60 women
60
Triglycerides 150 Normal 150
Borderline 150-190
62
Laboratory measurements
Body Composition
Lipids
Glucose
63
Diagnosis of diabetes:
plasma glucose cutoff points
Category mg/dL mmol/L mg/dL mmol/L
Normal 100 5.5 140 7.8
IFG 110 to
126
5.5 to
6.9
_ _
IGT _ _ 140 to
200
7.8 to
11.1
Diabetes ≥126 ≥7.0 ≥200 ≥11.1
Fasting Plasma Glucose 2-Hour on OGTT
Data from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care. 1997;20:1183-1197

22. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 22
64
NCEP: ATPIII clinical diagnosis
of the metabolic syndrome*
Risk Factor Defining Measures
Abdominal obesity Waist circumfere nce
Men 40 in (102 cm)
Women 35 in (88 cm)
TG ≥150 mg/dL
HDL-C
Men 40 mg/dL
Women 50 mg/dL
Blood pressure ≥130/85 mm Hg
Fasting glucose ≥110 mg/dL
*
≥3 risk factors comprise a diagnosis of the metabolic syndrome;
Expert Panel on Detection, Evaluation, and T
reatment of High Blood Cholesterol in Adults;
JAMA. 2001;285:2486-2497
65
Laboratory measurements
Body Composition
Lipids
Glucose
C-reactive protein
66
Clinical History
Vital Signs
Laboratory Measures
Clinical Classification
Evaluation

23. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 23
67
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary
68
Genetic causes of obesity
Monogenic Obesities
Melanocortin-4 receptor defects
Leptin deficiency
Leptin receptor deficiency
POMC deficiency
Proconvertase-1 deficiency
PPAR-γ
Syndromic Obesities (Prader-Willi Syndrome)
Polygenic Obesities (Others)
Heritability of body weight
Twins:
Bjoreson
Identical
Fraternal

24. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 24
70
Type of Studies Heritability
Nuclear Families 30 - 50%
Adoption 10 - 30%
Twin Studies 50 - 80%
Combined Strategy 25 - 40%
Heritability of obesity
71
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary
72
Hypothalamic obesity
Pathological Lesion
1. Tumors
2. Inflammation
3. Trauma
Clinical Features
Endocrine Disturbances
1. Amenorrhea/Impotence
2. Impaired growth
3. Diabetes insipidus
4. Thyroid/Adrenal insufficiency
Increased Intracrani al Pressure
1. Papilledema
2. Vomiting
Neurological Disturbances
1. Thirst
2. Somnolence

25. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 25
73
Patient with hypothalamic obesity
100
90.9
81.8
72.7
63.6
54.5
Body
W
eight
(kg)
Onset 6 12 18 24 30 36
120
140
160
180
200
220
Body
W
eight
(lbs)
Duration of Illness
(months)
Amenorrhea
C. Age 18 - F Diabetes Insipidus
Lethargy, headache
Decreased memory
Galactorrhea
+
74
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary
75
Some dietary factors
Trigger Foods
Large Portion Sizes
High Energy Dense Food

26. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 26
76
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary
77
Physical inactivity
New Job with Less Activity
Injury with Hospitalization
Aging
78
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary

27. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 27
79
Cushings syndrome
Central Obesity
Hypertension
Plethoric Facies
Amenorrhea
Virilism (Hirsutism)
Edema of Low er Extremities
Hemorrhagic Features
80
Polycystic ovary syndrome
Oligomenorrhea/Amenorrhea
Hirsutism
Poly cy stic Ovaries
LH/FSH
Testosterone/ SHBG
Insulin Resistance
Normal IGF-I
IGF-I Binding Protein
81
Clinical classification
Genetic
Hypothalamic
Dietary
Physical inactivity
Endocrine
Summary

28. Assessment of Obesity
and Classification of Patients:
Historical Perspective and Current Practice
Prof. George A. Bray
The screenversions of these slides have full details of copyright and acknowledgements 28
82
Summary:
Obesity has been a growing clinical problem
for a long time
The BMI, waist circumference,
laboratory measurements
provide a frame of reference
of evaluating the risk
Overweight and obesity are risks to health