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  • Multifactorial disease of excess body fat affecting any age group

    • Endogenous: endocrine illness

      • – Hypothyroid, polycystic ovarian syndrome, adrenal hyperandrogenism, imbalance of ghrelin, and leptin

    • Exogenous: positive energy balance is stored as adipose tissue

      • – Excess calories, sedentary lifestyle, minimal exercise

  • Clinical manifestations

    • Systemic

      • – Obesity in central areas, mammary region, buttocks

      • – Obesity in limbs, greater in upper arms and thighs; genu varum due to weight-bearing

    • Cutaneous

      • – Acrochordon: increases with severity of obesity, associated with Type 2 diabetes mellitus

      • – Striae distensae: "stretch marks"

      • – Keratosis pilaris: up to 21% of obese patients

      • – Plantar hyperkeratosis: due to increased foot girth and weight bearing

      • – Adiposis dolorosa (Dercum disease): rare, in postmenopausal obese women

        • Multiple symmetric painful lipomas sparing head/neck; commonly on trunk and lower extremities

    • Metabolic alterations

      • – Acanthosis nigricans: insulin resistance, correlates with subsequent development of Type 2 diabetes mellitus if untreated

      • – Polycystic ovarian syndrome (PCOS): infertility, dysmennorhea, insulin resistance, cystic ovaries on ultrasound

      • – Hyperandrogenism secondary to metabolic dysregulation

  • Diagnosis: obesity defined as BMI more than 30, or greater than 95% for age and gender

  • Treatment

    • Lifestyle and dietary modification: exercise and low-calorie diet

    • Social support: family, friends, provider–patient contact

    • Medications should be used with caution: phentermine, bHCG injections, orlistat

    • Surgical: gastric bypass, or gastric outlet surgeries; necessitate monitoring for nutritional deficiencies, especially B12

Anorexia Nervosa and Bulimia

  • Undernourishment due to abnormal patterns of food consumption and/or purging to achieve thinness; related to underlying psychiatric distburances

  • Most common in adolescent females

  • Clinical manifestations

    • Cutaneous: xerosis, pruritus, lower limb edema, Russell sign (knuckle calluses due to chronic self-induced vomiting)

    • Hair: thinning and increased fragility

    • Oral: gingivitis, tooth enamel erosion, parotid gland enlargement

  • Treatment

    • Cognitive behavioral therapy

    • Selective serotonin reuptake inhibitors

    • Hospitalization with parenteral nutrition in severe circumstances

Protein Energy Malnutrition: Undernutrtion, Marasmus, and Kwashiorkor

  • Undernutrition: all encompassing term for nutritional and caloric deficiencies (Fig. 20-1A,B)

    • Related to socioeconomic status and availability of nutrients in local region

    • Favors opportunistic infections: reduced cellular immunity, phagocytic function, adaptive immunity (decreased antibody production)

    • Secondary: from HIV, pneumonia, tuberculosis, and malaria

    • Diagnosis: investigate possible infectious etiologies, anemia, nutritional deficiencies (metals, vitamins, etc.)

      • – Urinalysis (UA) (infection), blood smear (malaria), PPD, fecal occult blood, parasites, or ova

  • Marasmus: "adapted" starvation from global nutrition deficiency

    • Occurs in developing countries: decreased intake of all macronutrients; rare in developed countries

    • Primary causes: congenital defects (difficulty feeding, degluttition), failure to thrive (neglect, inability to nurse), alcoholism, eating disorders

    • Secondary: lack of nutrient availability, low socioeconomic status, early and incorrect use of infant formula (not enough calories are given)

    • Clinical manifestations

      • – Constitutional: emaciated, growth deficiency, muscular atrophy

      • – Systemic involvement: hypotension, hypoglycmeia, hypothermia, constipation (in infants), anemia

      • – Cutaneous: loss of turgor, thinning of skin, xerosis, loss of elasticity

    • Diagnosis: typically on history and physical ...

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