Obesity: A health appraisal

Key points: History and physical examination can often reveal clues of decompensation due to being overweight and obese. Some of these subtle clues are attributable to other conditions or reasons. Most people who have an elevated BMI in the obesity or upper overweight range likely have some signs and symptoms owing to their weight.

A person who comes into a clinic and would like a preventive visit with a physical examination and bloodwork is often looking to identify an underlying health condition that may develop into a greater concern.  Sometimes, they are hoping to verify that their current health is good enough or to make sure that they won’t get a condition that a family member had, like cancer or a heart attack or stroke.  Sadly, the yield of a general health check is fairly low.  One review of 14 trials by Krogsboll in 2012 showed no reduction in morbidity of mortality in cardiovascular or cancer related causes with physical examinations.   

Is there any benefit in performing a physical examination and evaluation?  Perhaps, we shouldn’t throw out the baby with the bathwater just yet.  It may be that some issues are not completely addressed with the provider’s (in)attention to early examination findings that may characterize a health risk.  Most doctors will pick up the skin lesion that needs to be biopsied, but it may be less obvious if a patient has mild lower extremity swelling or a slightly elevated blood pressure.  Also, it is often more difficult to provide recommendations for a person who has an insidious disease process such as being overweight, beyond “lose weight” and “exercise more”.  In my practice, there have been numerous occasions when I have found a patient with obesity having near normal routine bloodwork screening, including normal cholesterol, kidney function and electrolytes and mild elevated liver tests.  Yet, there may be adjustments occurring in the body to maintain homeostasis that are resulting in some effect, even without more than a subtle change on the exam.  Perhaps what we are not checking on the exam and not seeing in these blood tests that gives us a more complete picture.

As the body usually compensates for being overweight to a certain point, it is useful to look for clues that might alert one of early decompensation.  The best place to start is a recall of any signs of symptoms such as with a review of systems checklist.  You can fill this out before you are seen by the clinician.   I look for several things: fatigue, shortness of breath, sleep issues, dry mouth, nighttime urination, increased thirst, night sweats, palpitations, swelling in the legs, weight gain and fibromyalgia.  Any of these items leads me to ask follow-up questions and directs me in the examination.  Sometimes, when asked further, people will comment on things that they weren’t sure should be included, e.g. increased swelling after eating a high salt meal, during the summer months or with traveling or see an indentation where the socks were on their legs.  Patients with insomnia may describe having no problem sleeping during the day but racing thoughts that prevent them from sleeping at night or waking up from sleep because of pain or the need to urinate.  What is difficult is that sometimes these behaviors get normalized by the patient, such as “I used to work the graveyard shift before I retired” or “I have always been a night owl” or “I drink a lot of fluid”.       

Sometimes people who have signs of decompensation try medications over the counter or take substances to aide them. When people drink more than 3 to 4 cups of coffee or 1 to 2 cans of soda, it alerts me to the possibility that they could be stimulating themselves in the setting of poor sleep efficacy, such as in obstructive sleep apnea. They may also be taking common over the counter sleeping medications, such as benadryl or other products and even alcohol. Unfortunately, these substances can feed into behavioral cycles and make it more complex to evaluate a patient.

On the examination, I will look at several physical measurements, which have been found as risk factors to conditions seen with increasing rate in obesity.  I use the body mass index (see body mass index table), which factors in height and weight, as a useful estimator of risk.   A BMI of 30 is associated with obesity.   Certainly, in someone who has a high muscle mass, the BMI can be a less useful predictor.   A lower BMI cutoff of 26 for a person of Asian ancestry has been associated with similar metabolic consequences as a BMI of 30. In addition to that the waist measurement (at level of umbilicus) can often be a useful finding for visceral obesity. A waist circumference of greater than 40 inches in a man or 35 inches in a women is a sign of increased risk of obesity-associated health problems. A neck circumference greater than 17 inches in a man and 15 inches in a woman can also signal possibility of obstructive sleep apnea (OSA). Another measurement which is useful for looking at risk of OSA is the mallampati index. It refers to how visible your posterior mouth (uvula and pharynx) is on examination. The higher the index (I to IV), the greater the risk of obstructive sleep apnea. Consult with your physician to determine the role of weight on your health.  Sometimes, we attribute our health issues to short-term concerns, while the health problems linked to our weight persist.  A trained clinician can determine subtle physical findings that may raise concerns of health impact of your weight.

Other examination findings are present. Vital signs may often signal obesity-related decompensation. These include an elevated blood pressure, systolic and possibly diastolic and a rapid heart rate. These are signs of increased resistance from increased fatty tissue around the vascular beds. A narrow pulse pressure (subtracting systolic from diastolic numbers) can be a sign of low functioning thyroid. The heart sounds can be heard on the chest wall — sometimes more dampened from obesity but a louder pulmonic site (just left of the upper sternum) second heart sound is common, as the heart as to pump harder into the pulmonary bed from increased tissue resistance.

There are also a number of skin findings from obesity on the examination. The body may have darker, scalier, sometimes velvety-appearing skin in the back of the neck or sometimes in the groin area or under the arm. This is known as acanthosis nigricans and is related to a higher insulin production in the body and “insulin resistance”. This can be a marker of diabetes and prediabetes. There may be vertical markings on the abdominal wall from tissue stretching. A very red or violaceous appearance could be a sign of the body producing too much cortisol, such as in a condition known as Cushing’s syndrome. The skin of the legs can be compressed and leave a marking known as “pitting edema”. This can be a seen in the setting of decompensated obesity and indicate likelihood of obesity-associated sleep apnea and high blood pressure.

In summary, there are multiple signs and symptoms of obesity. These findings become more apparent at higher levels, as the body is no longer able to compensate from the excess weight. As these changes are gradual, they may be misattributed to other causes or syndromes. Anyone who assess their BMI, waist circumference, neck circumference and mallampati index or who has been found to have an elevated blood pressure or fasting glucose should consider working on a health optimization plan to reduce the harms of excess weight.

Thank for reading. Dr. Cirino