Obesity Complications and Management
Obesity is a chronic, progressive disease characterized by excess adiposity that causes multisystem complications affecting cardiovascular, metabolic, respiratory, musculoskeletal, gastrointestinal, reproductive, and mental health, requiring comprehensive assessment and evidence-based treatment targeting both weight reduction and complication management. 1
Major Complications by Body System
Cardiovascular Complications
- Hypertension, atherosclerotic heart disease, myocardial infarction, stroke, peripheral vascular disease, atrial fibrillation, heart failure, thrombophlebitis, and pulmonary embolism are the leading cardiovascular complications, representing the most significant cause of obesity-related mortality 1, 2
- Dysfunctional adipose tissue releases pro-inflammatory, diabetogenic, and atherogenic signals that directly cause endothelial dysfunction 1, 2
Metabolic and Endocrine Complications
- Type 2 diabetes mellitus, prediabetes (impaired fasting glucose/glucose tolerance), dyslipidemia, and metabolic syndrome are core metabolic complications 1
- Metabolic dysfunction-associated steatotic liver disease (MASLD), hepatic cirrhosis, and hepatocellular carcinoma represent progressive liver complications 1
- Polycystic ovary syndrome, female infertility, increased pregnancy complications, fetal abnormalities, and male hypogonadism affect reproductive health 1
Respiratory Complications
- Obstructive sleep apnea, obesity-hypoventilation syndrome, and asthma are the primary respiratory manifestations 1
Musculoskeletal Complications
- Osteoarthritis of weight-bearing joints, lumbar muscle strain, degenerative disc disease cause significant functional limitation 1
- In children: Blount's disease and slipped capital femoral epiphysis 1
Gastrointestinal Complications
- Cholelithiasis, gastroesophageal reflux disease, and colorectal carcinoma 1
Cancer Risk
- Endometrial, breast, ovarian, prostate, pancreatic, esophageal, and colon cancers have increased incidence 1
Mental Health Complications
- Depression, anxiety, binge eating disorder, and body image disturbance require specific assessment and treatment 1
Other Complications
- Idiopathic intracranial hypertension (neurological) 1
- Stress urinary incontinence (urologic) 1
- Plantar fasciitis (musculoskeletal) 1
Comprehensive Clinical Assessment
Initial Evaluation Components
Three essential elements must be completed: extensive history, physical examination, and laboratory/diagnostic testing 1
History Taking
- Identify drivers of weight gain: medical conditions, medications, metabolism, dietary habits, energy intake, sleep patterns, sedentary lifestyle 1
- Assess psychological factors: stress, anxiety, eating disorders, depression 1
- Evaluate family and financial circumstances as barriers to treatment 1
- Screen for cardiovascular risk factors: smoking, hypertension, dyslipidemia, prediabetes, family history of CVD 1
- Document impact on physical and mental health, function, and quality of life 1
Physical Examination
- Anthropometric assessment: BMI (≥30 kg/m² indicates obesity in Western populations; ≥23 kg/m² in Asian populations), waist circumference (≥88 cm women/≥102 cm men in Western; ≥80 cm women/≥90 cm men in Asian populations) 3
- Signs and symptoms of obesity-related complications 1
- Factors affecting daily function and physical activity ability 1
Laboratory and Diagnostic Testing
Initial tests for all adults with obesity 1:
- Fasting glucose and glycated hemoglobin
- Lipid profile
- Liver function tests and liver enzymes
- Kidney function (creatinine, eGFR)
- Thyroid function tests
- Uric acid
Secondary tests based on suspected abnormalities 1:
- Cushing's syndrome workup
- Metabolic-associated fatty liver disease assessment
- Polycystic ovary syndrome evaluation
- Sleep apnea studies
- Cancer screening (especially in older adults)
- Cardiovascular disease assessment
Disease Staging and Risk Stratification
Edmonton Obesity Staging System (EOSS)
Use EOSS to classify disease severity and guide treatment intensity 1:
- Stage 0: No evident risk factors or complications; avoid further weight gain, weight loss may not be required 1
- Stage 1: Subclinical risk factors or mild health impairments; avoid further weight gain, weight loss may not be required 1
- Stage 2: Clinical manifestation of obesity-related chronic diseases and/or moderate functional limitations; weight loss is a clinical priority—consider lifestyle, pharmacological, and surgical interventions 1
- Stage 3: Established end-organ damage and/or significant functional limitations; weight loss is a clinical priority—consider lifestyle, pharmacological, and surgical interventions 1
- Stage 4: End-stage disease requiring palliative care 1
EOSS stages correlate with all-cause mortality risk and incident CVD and cancer 1
Management Approach
First-Line: Multidisciplinary Lifestyle Intervention
Implement a multifactorial lifestyle program for at least 6-12 months as the foundation of treatment 1, 3:
Medical Nutrition Therapy
- Reduce caloric intake by at least 500 kcal/day 3
- Target macronutrient distribution: approximately 55% carbohydrates, 10% protein, 30% fats (≤10% saturated fats) 3
- Ensure sufficient protein, vitamins, and minerals 3
- Provide personalized recommendations based on patient characteristics, history, values, preferences, and treatment goals 1
- Delivered ideally by a certified nutritionist experienced in obesity management 1
Physical Activity
- Prescribe 150-300 minutes/week of moderate-intensity activity 3
- Gradually increase activity levels based on individual fitness and capabilities 3
Behavioral Therapy
- Implement self-monitoring, mindful eating, stimulus control, and stress management 3
- Consider motivational interviewing techniques and technology-based tools 3
- Use the "5As" framework (Ask, Assess, Advise, Agree, Assist) for structured patient engagement 1
Expected Outcomes
- Target realistic weight loss of 5-15% over 6 months 4, 3
- This level of weight loss improves metabolic parameters and reduces complication risk 4
Second-Line: Pharmacotherapy
Consider anti-obesity medications when lifestyle interventions alone are insufficient 3:
FDA-Approved Indications
- BMI ≥30 kg/m² without obesity-related complications, OR
- BMI ≥27 kg/m² with obesity-related complications (hypertension, dyslipidemia, coronary heart disease, type 2 diabetes, sleep apnea) 1
Available Agents
- GLP-1 receptor agonists (e.g., semaglutide, liraglutide) are highly effective 3, 5
- Semaglutide demonstrated significant weight reduction (mean 4.7-6.0 kg at 30 weeks) and cardiovascular benefit (hazard ratio 0.74 for MACE) 5
- Other options: orlistat, naltrexone/bupropion 3
Monitoring Requirements
- Carefully monitor for safety and efficacy 1
- Observe for pancreatitis (persistent severe abdominal pain, possibly radiating to back, with or without vomiting); discontinue if suspected 5
- Monitor for diabetic retinopathy progression in patients with history of retinopathy 5
- Assess renal function when initiating or escalating doses, especially with severe GI reactions 5
- Watch for hypoglycemia when used with insulin secretagogues or insulin; may require dose reduction of these agents 5
Third-Line: Bariatric Surgery
Consider bariatric surgery for patients meeting specific criteria 3, 6:
Indications
- BMI ≥40 kg/m² regardless of comorbidities, OR
- BMI ≥35 kg/m² with at least one obesity-related comorbidity (type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, non-alcoholic fatty liver disease), OR
- BMI ≥30 kg/m² with type 2 diabetes that could potentially achieve remission 6
- Lower BMI thresholds apply for Asian populations 6
Prerequisites
- Failed non-surgical weight loss methods (structured dietary interventions, physical activity programs, behavioral therapy, pharmacotherapy) 6
- Patient demonstrates motivation and ability to comply with long-term treatment and follow-up 6
- Comprehensive medical evaluation completed to assess obesity-related comorbidities 6
- Nutritional and mental health evaluations completed 6
Surgical Options
- Gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass 3
- Sleeve gastrectomy is preferred for selected patients with well-compensated cirrhosis 6
- Expected weight loss: approximately 25-30% with significant improvements in obesity-related comorbidities 3
Post-Surgical Requirements
- Long-term multidisciplinary follow-up for at least 2 years, sometimes lifelong 6
- Regular appointments with physicians familiar with obesity treatment and bariatric surgery 6
- Surgery must be performed by specialized surgeons in hospitals with dedicated multidisciplinary teams 6
Treatment Goals and Monitoring
Primary Goals
- Improvements in health and well-being, not solely weight loss 1
- Treatment and improvement (or remission when possible) of clinical manifestations of obesity 7
- Prevention of progression to end-organ damage 7
- Long-term weight maintenance after initial loss 3
Ongoing Management
- Tailor treatment intensity based on obesity severity and related complications 3
- Continue behavioral support even when using pharmacotherapy or after bariatric surgery 3
- Recognize obesity as a chronic disease requiring long-term management, not temporary treatment 1, 3
Critical Pitfalls to Avoid
Clinical Practice Errors
- Never share OZEMPIC or other injectable pens between patients, even if needle is changed—risk of blood-borne pathogen transmission 5
- Do not rely solely on BMI for diagnosis; BMI underestimates and overestimates adiposity and provides inadequate individual health information 7
- Avoid treating obesity as a temporary condition rather than recognizing it as a chronic, progressive disease requiring continuous management 1, 3
- Do not discontinue support after initial weight loss without addressing maintenance strategies 3
- Never blame patients for their weight; obesity has multifactorial causes including genetic, neurologic, metabolic, enteric, and behavioral processes 1, 8
Assessment Errors
- Do not focus solely on weight rather than overall health improvements and quality of life 3
- Avoid making assumptions about patients' lifestyles, health behaviors, interests, or motivations 1
- Do not initiate weight discussions without permission; use collaborative, non-judgmental approaches 1
Treatment Errors
- Recognize that lifestyle interventions alone provide substantial and durable response in only a minority of people 9
- Do not withhold effective treatments (pharmacotherapy, surgery) from eligible patients due to stigma or bias 7, 9
- Avoid inadequate follow-up; obesity requires continuous, long-term management with frequent monitoring 1
Special Populations
Pediatric Patients
- Use BMI percentile for age and sex (>85th percentile with complications or >95th percentile with/without complications warrants evaluation) 1
- Apply Edmonton Obesity Staging System for Pediatrics (EOSS-P) evaluating metabolic, biomechanical, mental health, and social milieu domains 1
- Emphasize family involvement; parents must actively participate in treatment programs 1, 3
- Focus on healthy eating and physical activity habits rather than ideal body weight attainment 1
- Provide long-term follow-up with frequent visits, continual monitoring, and reinforcement 1