Image Quizzes

Mild shortness of breath

Reviewed by W. Scott Butsch, MD, MSc

ZEPHYR / Science Source

A 33-year-old African American woman presents for an initial consultation. The patient states that it has been several years since she received regular medical care because she did not have health insurance. She recently started a new job as an IT professional that has healthcare benefits. She does not currently take any medications. She reports mild shortness of breath upon exertion, which has worsened in the last year. She denies dizziness, chest pain, wheezing, cough, fever, or other associated symptoms. There is no history of any cardiac or pulmonary diseases as a child. The patient does not smoke or engage in recreational drug use. She is conscious of her diet and avoids red meat as well as sugary and processed foods. Although she was active in the past, she notes that she has been less intentional with her physical activity and has been living a more sedentary lifestyle recently. She has gained more than 40 lb over the past 3 years.

The patient is 5 ft 8 in, her weight is 266 lb (BMI 40.4), and her blood pressure is 140/90 mm Hg. Her pulse oximeter is 97%; however, this result should be interpreted with caution and in consideration of the patient's other signs and symptoms because numerous studies have shown inaccuracies in pulse oximeter readings among people with darker skin. Her physical exam is unremarkable except for a waist circumference of 49 in; breathing sounds are normal and no dermatologic abnormalities are noted.

An ECG is performed and is normal. A chest radiograph shows normal heart and blood vessel structures and airways of the lungs. Pertinent laboratory findings include A1c of 6.4%, HDL cholesterol of 37 mg/dL, LDL cholesterol of 185 mg/dL, serum creatinine of 1.1 mg/dL; AST of 27 U/L; ALT of 35 IU/L; and TSH of 4.2 mIU/L.

What is the primary diagnosis explaining her symptoms?

Fatty liver disease



Cushing syndrome

This patient's clinical presentation of weight gain and associated symptoms are most closely related to a diagnosis of obesity. In addition, her laboratory findings are consistent with common obesity complications, including prediabetes and dyslipidemia, and her blood pressure is borderline high.

Obesity is a chronic, multifactorial disease with a complex pathogenesis comprising of genetic, biological, psychosocial, socioeconomic, and environmental factors. It is a heterogeneous disease characterized by a dysfunction of the normal pathways and mechanisms that are involved in body fat regulation (often referred to as weight regulation), which may lead to variable presentation and complications. According to the US Centers for Disease Control and Prevention, the highest age-adjusted prevalence of obesity is seen in non-Hispanic Black adults (49.9%), followed by Hispanic adults (45.6%), non-Hispanic White adults (41.4%), and non-Hispanic Asian adults (16.1%).

Epidemiologic studies have defined obesity as a BMI > 30, which is then subclassified into class 1 (BMI of 30-34.9), class 2 (BMI of 35-39.9), or class 3 (BMI ≥ 40) obesity. Though BMI is widely used to evaluate and classify obesity, it mainly represents general adiposity and can be confounded by excessive muscle mass or frailty. Guidelines from the American Diabetes Association state that in addition to weight and BMI, clinicians should consider weight distribution (including predisposition for central/visceral adipose deposition) and weight gain pattern and trajectory because these can help guide risk stratification and treatment options.

Increasingly, evidence supports visceral adiposity, or abdominal obesity, as a marker of cardiovascular risk. Abdominal obesity has been shown to be a strong independent predictor of mortality. On its own, BMI is an insufficient biomarker of abdominal obesity. Not all individuals with obesity have a central distribution of their weight; some individuals may have central obesity without meeting the criteria for the BMI definition of obesity. This can lead to misclassification and underdiagnosis of health risks in clinical practice. Consequently, numerous organizations and expert panels have recommended that waist circumference be measured along with BMI, specifically when the BMI < 35. Measurement of both BMI and waist circumference provides valuable opportunities to counsel patients regarding their risk for cardiovascular disease and other complications of obesity. Waist-to-hip ratio has also been shown to be a stronger predictor for mortality compared with BMI; however, it is rarely measured in clinical practice.

Although rarely performed outside of research settings, measurement of epicardial and pericardial fat via CT is also emerging as a potentially useful approach for informing predictive and precision medicine strategies. Recently, the Jackson Heart Study showed pericardial and visceral fat volumes were associated with incident heart failure, particularly heart failure with preserved ejection fraction, and all-cause mortality among Black participants even after adjusting for age, sex, education, and smoking status. Another recent study showed an increased risk of heart failure, particularly heart failure with preserved ejection fraction, among men and women with high pericardial fat volume. The Multi-Ethnic Study of Atherosclerosis showed that pericardial fat was associated with a higher risk of all-cause cardiovascular disease, hard atherosclerotic cardiovascular disease, and heart failure. Epicardial fat is directly correlated with BMI, visceral adiposity, and waist circumference.

Best practices for the management of obesity begin with recognizing and treating it as a complex chronic disease rather than the result of an individual's lifestyle choices. According to a 2020 joint international consensus statement for ending the stigma of obesity, the assumption that choosing to eat less and/or exercise more can entirely prevent or reverse obesity is contradicted by a definitive body of biological and clinical evidence that shows obesity results primarily from a complex combination of genetic, epigenetic, and environmental factors. When diagnosing patients with obesity, it may be helpful for clinicians to acknowledge that the term obesity is often perceived as an undesirable term because it has been associated with stigma but that it is in fact a clinical diagnosis, not a judgement. Many patients prefer the neutral term unhealthy weight over obesity.

As with other chronic diseases, individualized treatment and long-term support along with shared decision-making are essential for optimizing outcomes. Key components of obesity management include diet, exercise, and behavioral modification. In addition, an increasing array of pharmacologic therapies are also showing unprecedented efficacy for weight management, including several drugs that are also approved for the management of type 2 diabetes. In particular, the glucagonlike peptide 1 (GLP-1) agonists, semaglutide and liraglutide, and the novel glucose-dependent insulinotropic polypeptide (GIP)–GLP-1 receptor agonist, tirzepatide have been associated with significant weight loss. Semaglutide and liraglutide have been US Food and Drug Administration (FDA)–approved for chronic weight management and tirzepatide was granted fast track designation for the treatment of obesity by the FDA in October 2022. These drugs may also help to prevent the progression of prediabetes to diabetes. For individuals with severe obesity, metabolic and bariatric surgery is an effective treatment option that is associated with clinically significant and relatively sustained weight reduction in addition to significant amelioration of related complications.

W. Scott Butsch, MD, MSc, Director of Obesity Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.

Dr. Butsch has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novo Nordisk, Inc.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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