IM14.6-10 | Obesity Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

The clinical evaluation of obesity is a structured five-step skills process:

1. Identify the indication: BMI ≥23 kg/m² (overweight, Asian-Indian) at any consultation; all patients with obesity-related complications; unexplained rapid weight gain (≥5 kg in 3 months).

1. Structured 7-domain history: weight trajectory (gradual vs rapid onset), dietary history (24-h recall, SSBs, UPFs, emotional eating), physical activity (structured and lifestyle), medications (steroids, antipsychotics, insulin, sulphonylureas), family history, secondary cause symptoms (hypothyroidism, Cushing, PCOS, OSA screening), and motivational/psychosocial assessment (Stages of Change).

1. Systematic examination: BMI (Asian-Indian: overweight ≥23, obese ≥25 kg/m²); waist circumference (men ≥90 cm, women ≥80 cm = central obesity); BP with correct cuff size; acanthosis nigricans (insulin resistance); striae width/colour (purple/wide = Cushing red-flag); hirsutism (Ferriman-Gallwey ≥8); proximal myopathy test; thyroid; heart, lungs, liver.

1. Prioritised differential: primary multifactorial (most common) vs secondary (hypothyroidism, Cushing syndrome, PCOS, hypothalamic obesity, medication-induced); red-flags demanding urgent workup.

1. Targeted investigations: mandatory (TSH, FPG/HbA1c, lipid profile, LFT, uric acid, creatinine, ECG); targeted (DST for Cushing, free testosterone/pelvic ultrasound for PCOS, polysomnography for OSA, MRI pituitary for hypothalamic obesity).

Key measurements: waist circumference at mid-point between lowest rib and iliac crest; blood pressure with age-appropriate cuff; modified Ferriman-Gallwey score for hirsutism.

REFLECT

Return to the 42-year-old woman from the opening hook. You have now taken her history — she gained weight steadily after her second pregnancy 10 years ago, eats at irregular times due to her night-shift job, consumes 2–3 sugar-sweetened beverages daily, and has not exercised regularly since school. Her previous attempts at dieting lasted 2–3 weeks. She has fatigue and snores loudly at night. Her husband has witnessed her stop breathing during sleep. On examination: BMI 35.3, waist 96 cm (above the 80 cm cut-off), acanthosis at the nape of the neck, BP 148/92 with a large-adult cuff. TSH is normal. How would you structure her management priorities? And equally importantly: she has never successfully sustained weight loss. How do you counsel her without reinforcing the shame she already carries about her weight — and what aspects of her life (night shifts, sugar-sweetened beverages, irregular meal timing) are most actionable in the next 4 weeks?