Comprehensive Assessment and Diagnosis of Metabolic and Biomechanical Complications in Obesity

Function

Metabolic and Endocrine Complications

Insulin resistance and type 2 diabetes

Type 2 diabetes represents one of the most significant complications of obesity, with obesity or excessive weight gain identified as the most critical risk factor in the development and progression of type 2 diabetes in all age groups.[1] The lifetime risk of developing diabetes increases dramatically with rising body mass index (BMI), from 7% in men with a BMI less than 18.5 kg/m² to 70% in those with a BMI greater than 35 kg/m².[2]

Clinical presentation and risk factors

Insulin resistance typically precedes the development of overt diabetes by several years and may be clinically evident through the presence of acanthosis nigricans, particularly in pediatric populations. Acanthosis nigricans is characterized by increased pigmentation and skin thickness in intertriginous folds, most commonly observed in the axillae and posterior neck. This dermatological condition is often associated with glucose intolerance in children and adolescents.[3] Other clinical manifestations include fatigue, increased hunger, and gradual weight gain.

Age-appropriate insulin resistance screening approaches

Screening recommendations differ between adults and children, reflecting developmental and physiological differences in diabetes progression (see Table 1).

Table 1. Diagnostic Criteria for Type 2 Diabetes

*Note: HbA1c may be less reliable in children due to hemoglobinopathies and should be confirmed with glucose-based tests.

Hemoglobin A1c interpretation in obesity: clinical pearls

HbA1c values can present falsely elevated results in patients with iron deficiency, potentially leading to misclassification of glycemic status. In pediatric populations, hemoglobinopathies also affect HbA1c accuracy; therefore, confirmation with a fasting glucose test is essential for a reliable diagnosis. Furthermore, HbA1c levels ranging from 5.7% to 6.4% fall within the prediabetes range and signal the need for intensive lifestyle intervention to reduce the risk of progression to type 2 diabetes. In individuals with obesity and an HbA1c of 5.7% or higher, further evaluation for insulin resistance should be considered to guide appropriate metabolic risk management and therapeutic decision-making.

Dyslipidemia

Elevated triglycerides characterize dyslipidemia in obesity, accompanied by reduced high-density lipoprotein (HDL) cholesterol and the presence of small, dense low-density lipoprotein (LDL) particles, which increase cardiovascular risk (see Table 2). Atherogenic dyslipidemia is common in obese children and adolescents. Elevated triglyceride levels, free fatty acid levels, decreased HDL cholesterol levels, and normal or mildly elevated serum LDL cholesterol levels are typical findings in childhood obesity.[3]

Table 2. Lipid Targets (Adult Versus Pediatric Guidelines)

American Academy of Pediatrics recommendations

The American Academy of Pediatrics recommends the following age-specific screening:

• Universal screening is recommended for all children aged 9 to 11 and again at ages 17 to 21.[4]
• Targeted screening starting at age 2 for high-risk children (eg, family history of premature cardiovascular disease, dyslipidemia, or other risk factors)
• Earlier and more frequent screening in patients with obesity.[4]

Metabolic syndrome

Metabolic syndrome represents a constellation of risk factors that increases cardiovascular disease risk and diabetes development. The diagnostic criteria vary between adults and children, reflecting physiological differences in growth and development (see Table 3). 

Table 3. Metabolic Syndrome Criteria by Age

Please refer to the StatPearls' companion resource, "Obesity and Type 2 Diabetes," for additional information on the relationship between obesity and diabetes. 

Cardiovascular Complications

Essential hypertension

Hypertension is one of the most frequent complications of obesity, with obese children at approximately a 3-fold higher risk for hypertension than nonobese children.[5] The relationship between obesity and hypertension begins in childhood and tracks into adulthood, making early detection and intervention crucial (see Table 4). The prevalence of hypertension in children and adolescents aged 12 to 19, based on data from the National Health and Nutrition Examination Survey in the United States, showed that the prevalence of hypertension among obese children was 9.43% from 2013 to 2016, which is greater than the prevalence of hypertension among all children.[6]

Hypertension pathophysiology

The mechanisms linking obesity to hypertension include activation of the sympathetic nervous system, insulin resistance, altered renal function, and increased cardiac output. As in adults, a combination of factors, including overactivity of the sympathetic nervous system, insulin resistance, and abnormalities in vascular structure and function, may contribute to obesity-related hypertension in children. See StatPearls' companion reference, "Public Health Considerations Regarding Obesity," for more information. 

Table 4. Blood Pressure Classification by Age Group

Pediatric obesity-specific considerations

A BMI at or above the 85th percentile demonstrates a significant association with hypertension when compared to nonobese children. The prevalence of prehypertension and hypertension varies notably by weight category: 7.1% in children with normal weight, 21.9% in those classified as overweight, and 42.3% in those with obesity.[5] The pathophysiology of obesity-related hypertension in pediatric populations involves multiple mechanisms, including activation of the sympathetic nervous system, the presence of insulin resistance, and vascular dysfunction, all of which contribute to elevated blood pressure and increased long-term cardiovascular risk.[5]

Blood pressure measurement techniques

The following blood pressure measurement techniques are recommended for patients with obesity:

• Use an appropriately sized cuff: the bladder width should be 40% of the arm circumference, and the length should be 80% of the arm circumference.
• Use a large adult or thigh cuff on the arm if a standard cuff is too small.
• Ensure that the arm is supported at the level of the heart.
• The patient should be seated with feet flat on the floor for 3 to 5 minutes before taking the measurement.
• Avoid talking while measuring the blood pressure.
• Take initial measurements on both arms; use the arm with the higher reading for subsequent visits.

Atherosclerotic cardiovascular disease

Obesity accelerates the development of atherosclerotic cardiovascular disease through multiple mechanisms, including dyslipidemia, hypertension, insulin resistance, and chronic inflammation. The relationship between obesity and cardiovascular complications is well-established across various studies and clinical observations.

Heart failure and arrhythmias

Obesity-related heart failure occurs through multiple mechanisms, including increased blood volume, elevated cardiac output, and the development of obesity-related cardiomyopathy. Atrial fibrillation risk rises significantly with obesity, particularly in the presence of sleep apnea. Please refer to the StatPearls' companion resource, "Essential Hypertension," for additional information on the management of hypertension.

Gastrointestinal Complications

Metabolic dysfunction-associated steatotic liver disease 

MASLD (metabolic dysfunction-associated steatotic liver disease) is the newly adopted term replacing nonalcoholic fatty liver disease, as per recent consensus guidelines, for the hepatic manifestation of metabolic syndrome. MASLD is strongly associated with obesity and affects an estimated 25% to 30% of adults globally, and is increasingly recognized in children with obesity.[2]

Clinical presentation and risk factors

Most patients with MASLD are asymptomatic in the early stages of the disease. Symptoms may include fatigue, discomfort in the right upper quadrant, and hepatomegaly. Risk factors include central obesity, insulin resistance, type 2 diabetes, and dyslipidemia (see Table 5).

Table 5. MASLD Risk Stratification and Screening Approaches

ALT, alanine aminotransferase; AST, aspartate aminotransferase 

Laboratory and imaging interpretation

Alanine aminotransferase (ALT) levels may show mild elevation, typically 1.5 to 2 times the normal range, or remain within normal limits during the early stages of liver disease. An aspartate aminotransferase (AST) to ALT ratio less than 1 generally indicates more advanced fibrosis. Abdominal ultrasound usually reveals increased hepatic echogenicity in patients with steatosis, although mild cases may go undetected. Noninvasive scoring systems, eg, the Fibrosis-4 (FIB-4) score and the nonalcoholic fatty liver disease fibrosis score, provide valuable tools for evaluating the risk of hepatic fibrosis.[7] Please refer to the StatPearls' companion resource, "Nonalcoholic Fatty Liver Disease," for further information on liver disease in obesity.

Gastroesophageal reflux disease 

Gastroesophageal reflux disease (GERD) is significantly more common in patients with obesity due to increased intra-abdominal pressure, delayed gastric emptying, and alterations in lower esophageal sphincter function. Symptoms include heartburn, regurgitation, chest pain, and chronic cough.[7]

Clinical considerations for patients with obesity and GERD include:

• Central obesity is more strongly associated with GERD than BMI alone.
• Weight loss often significantly improves symptoms.
• Consider complications such as Barrett's esophagus in chronic cases.
• The effectiveness of medication may be reduced in individuals with severe obesity.

Musculoskeletal Osteoarthritis and Degenerative Joint Disease Complications

Obesity significantly increases the risk of osteoarthritis, particularly in weight-bearing joints such as the knees and hips. The relationship is not solely mechanical, as obesity-related inflammation contributes to cartilage degradation.

Clinical presentation

Patients often report joint pain that intensifies with physical activity and subsides with rest. Morning stiffness typically lasts less than 30 minutes. Additional findings may include reduced range of motion, functional limitations in daily activities, and progressive worsening of symptoms over time.

Assessment and management principles

Effective management begins with a focus on weight reduction, which significantly alleviates joint stress and improves symptoms. Low-impact exercise programs, such as swimming or cycling, help maintain joint mobility without exacerbating pain. Physical therapy offers functional improvement by enhancing strength, flexibility, and stability. For patients experiencing severe or limiting symptoms, early referral to orthopedic specialists supports timely evaluation and consideration of advanced interventions.

Pediatric-specific musculoskeletal conditions 

Slipped capital femoral epiphysis (SCFE) is a serious orthopedic condition that predominantly affects obese adolescents during periods of rapid growth. The condition involves femoral head displacement through the growth plate and requires immediate referral to an orthopedic specialist.

Red flags for SCFE in adolescents include:

• Hip, thigh, or knee pain in obese adolescents (especially boys)
• Limping or altered gait pattern
• Limited internal rotation of the affected hip
• Pain that worsens with activity
• Age 10 to 16 years (peak incidence 12 to 13 years)
• Consider bilateral evaluation, as 20% to 40% of cases are bilateral

Diagnostic approach

Clinicians should maintain a high index of suspicion when assessing obese adolescents who present with hip or leg pain, as these symptoms may indicate underlying orthopedic pathology. Physical examination findings of concern include restricted internal hip rotation and a positive Drehmann sign, where the thigh externally rotates and abducts during passive hip flexion. Radiologic assessment should consist of anteroposterior and frog-leg lateral views of the pelvis to confirm the diagnosis. All confirmed or suspected cases warrant an urgent referral to orthopedic care to ensure timely intervention and reduce the risk of long-term complications.

Blount disease

Blount disease is characterized by abnormal medial proximal tibial physis growth, resulting in a progressive genu varum (bow-legged appearance). This condition may be unilateral or bilateral and occurs more frequently in obese children. Clinical features include:

• Progressive bow-legged deformity
• Knee or leg pain
• Difficulty with ambulation
• More prevalent in Black children than in children of other ethnicities
• Associated with early independent walking and obesity [8]

Please refer to the StatPearls' companion resource, "Blount Disease," for additional information.

Pulmonary Complications

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is one of the most significant pulmonary complications of obesity, with at least 70% of patients with OSA having obesity.[9] The relationship is bidirectional, as OSA can also contribute to weight gain through hormonal changes affecting appetite regulation.[10] OSA also occurs in nearly 60% of children with obesity (see Table 6).[11] The underlying pathophysiologic mechanism of OSA involves excess weight, which creates adipose deposits in a person's neck, known as pharyngeal adiposity, that can block the upper airway during sleep when the airway is already relaxed. This anatomical narrowing and reduced neuromuscular control during sleep lead to repetitive upper airway collapse.

Table 6. Obstructive Sleep Apnea Screening Tools by Age Group

STOP-BANG, snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, gender

The clinical features of OSA include:

• Loud, habitual snoring with witnessed breathing pauses
• Excessive daytime sleepiness and fatigue
• Morning headaches and dry mouth
• Difficulty concentrating and irritability
• In children: behavioral problems, poor school performance, enuresis

Notably, children with OSA are often misdiagnosed with attention-deficit/hyperactivity disorder or behavioral disorders due to overlapping symptoms of inattention, hyperactivity, and mood disturbances. Several screening tools have been developed for children and adults to facilitate the recognition of OSA.

Obstructive sleep apnea risk factors beyond obesity

• Advancing age
• Family history of sleep apnea
• Anatomical factors: enlarged tonsils, retrognathia, macroglossia
• Medical conditions: hypothyroidism, acromegaly
• Male gender (although the gap narrows after menopause)

Obesity hypoventilation syndrome

Obesity hypoventilation syndrome (OHS) occurs in approximately 10% to 20% of patients with severe obesity and OSA. OHS is characterized by daytime hypercapnia (eg, partial pressure of arterial carbon dioxide greater than 45 mm Hg) without other causes of hypoventilation. Clinicians should suspect OHS in patients with severe obesity and daytime hypercapnia in the absence of alternative causes (eg, chronic obstructive pulmonary disease).

Clinical features of OHS include: 

• More severe daytime sleepiness than OSA alone
• Cor pulmonale and right heart failure
• Polycythemia
• Morning confusion and headaches
• Higher mortality risk than OSA alone

Asthma and respiratory considerations

Obesity worsens asthma control via multiple mechanisms, including reduced lung volumes, increased airway inflammation, and altered respiratory mechanics. In patients with obesity, the differential diagnosis of dyspnea encompasses the full spectrum of potential respiratory, cardiovascular, metabolic, and mechanical etiologies.[3]

Differential diagnoses of dyspnea in obesity include:

• Asthma exacerbation or poor control
• Obstructive sleep apnea
• Obesity hypoventilation syndrome
• Deconditioning
• Heart failure
• Pulmonary embolism (increased risk in obesity) [12]

Please refer to the StatPearls' companion resource, "Obstructive Sleep Apnea," for additional information.

Reproductive and Gynecologic Complications

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, with a prevalence ranging between 5% and 26%, depending on the diagnostic criteria applied (see Table 7).[13] PCOS has a strong bidirectional relationship with obesity, as insulin resistance plays a central role in both conditions. The pathophysiology of PCOS primarily involves insulin resistance and elevated levels of visceral adiposity, regardless of obesity, which lead to disruptions in hormonal communication between the hypothalamus, pituitary gland, and ovaries.[13] This dysfunction causes hyperandrogenism, anovulation, and metabolic complications.

Table 7. PCOS Diagnostic Criteria (Rotterdam Versus Pediatric Considerations)

PCOS diagnostic studies 

Laboratory and imaging studies recommended for the evaluation of PCOS include:

• Total testosterone, free testosterone, or free androgen index
• 17-hydroxyprogesterone (to exclude congenital adrenal hyperplasia [CAH])
• Thyroid-stimulating hormone and prolactin (to exclude other causes such as nonclassic CAH, androgen-secreting tumors, Cushing syndrome, and hypogonadotropic hypogonadism)
• Fasting glucose and insulin (to assess insulin resistance)
• Lipid profile (to evaluate cardiovascular risk)
• Pelvic ultrasound (if indicated, to support the diagnosis in adults or clarify atypical presentations)

Associated complications

Complications associated with PCOS include: 

• Metabolic syndrome and type 2 diabetes
• Cardiovascular disease risk
• Endometrial hyperplasia and cancer
• Mood disorders and reduced quality of life
• Infertility and pregnancy complications

Pubertal disorders

Obesity significantly affects pubertal timing and development, with important implications for growth, bone health, and psychological well-being (see Table 8).

Table 8. Tanner Staging (Sexual Maturity Rating) Classification

Clinical implications of altered pubertal timing

Altered pubertal timing in children and adolescents with obesity presents significant clinical concerns (see Table 9). Early puberty increases the risk of behavioral problems, mood disorders, and earlier initiation of sexual activity. In contrast, delayed puberty may lead to psychological distress and reduced bone mineral density during critical developmental periods. These risks highlight the importance of careful growth and pubertal monitoring, with timely referral to pediatric endocrinology for further evaluation when abnormalities are detected.

Table 9. Normal Versus Precocious and Delayed Puberty Timing

Other reproductive complications include:

• Male hypogonadism
  • Obesity-related reduction in testosterone levels
  • Symptoms: decreased libido, erectile dysfunction, fatigue, mood changes
  • Evaluation: morning total testosterone, repeat if low, consider free testosterone
  • Treatment: weight loss is the primary intervention, and testosterone replacement if appropriate
• Infertility and pregnancy complications
  • Reduced fertility in both men and women with obesity
  • Increased risk of pregnancy complications: gestational diabetes, preeclampsia, cesarean delivery
  • Importance of preconception counseling and weight optimization

Please refer to StatPearls' companion resource, "Polycystic Ovarian Syndrome," for additional information on PCOS management.

Neurologic and Other Complications

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a serious neurological condition strongly associated with obesity, particularly in women of childbearing age. Obesity is a significant risk factor for IIH, although the precise pathophysiology remains multifactorial.[14]

The characteristic presentation of IIH is typically associated with the following:

• Headache (often described as severe, throbbing)
• Visual disturbances: blurred vision, diplopia, visual field defects
• Transient visual obscurations
• Tinnitus (pulsatile)
• Nausea and vomiting

Physical examination findings commonly noted in patients with IIH include:

• Papilledema (bilateral optic disc swelling)
• Visual field defects (particularly enlargement of the blind spot)
• Cranial nerve VI palsy may be present
• Normal neurological examination otherwise

Diagnostic criteria

The following diagnostic findings should be present to meet the criteria for the diagnosis of IIH:

• Symptoms and signs of increased intracranial pressure
• Normal neurological examination except for cranial nerve abnormalities
• Normal brain imaging (computed tomography or magnetic resonance imaging)
• Elevated opening pressure on lumbar puncture (>250 mm H₂O in adults, >280 mm H₂O in children)
• Normal cerebrospinal fluid composition

Idiopathic intracranial hypertension management considerations

Patients with suspected idiopathic intracranial hypertension require urgent referral to both ophthalmology and neurology for comprehensive evaluation and management. Weight loss remains a critical component of long-term treatment, as sustained reduction in body weight significantly lowers intracranial pressure and reduces symptom recurrence. Medical therapy may include agents, eg, acetazolamide or topiramate, to decrease cerebrospinal fluid production and alleviate symptoms. Ongoing monitoring for signs of progressive visual loss is essential to prevent permanent visual impairment. Please refer to StatPearls' companion resource, "Pseudotumor Cerebri," for additional information.[15]

Lymphedema and Obesity

Obesity contributes to the development and progression of lymphedema and presents significant challenges in its management. This association is particularly relevant in individuals with a history of cancer treatment or congenital lymphatic abnormalities, where lymphatic flow may already be compromised. Increased amounts of adipose tissue impair lymphatic drainage and raise interstitial pressure, especially in the lower extremities, further exacerbating fluid retention and tissue swelling.

Clinical features of lymphedema include:

• Progressive, typically asymmetric swelling
• Nonpitting edema that doesn't resolve with elevation
• Skin changes (eg, thickening, fibrosis, recurrent infections)
• Functional impairment and reduced quality of life

Assessment and management

Clinicians must differentiate lymphedema from other causes of edema, such as venous insufficiency, heart failure, or renal disease. Evaluation should include investigating underlying contributors, such as malignancy, infection, and congenital abnormalities. Weight reduction is crucial in enhancing lymphatic function and alleviating symptom burden. Management strategies include compression therapy and manual lymphatic drainage. Referral to a lymphedema specialist is recommended for complex or refractory cases to ensure comprehensive management and optimize patient outcomes.

Issues of Concern

Cancer Screening Considerations

Obesity increases the risk for several malignancies, including breast, endometrial, ovarian, colorectal, liver, and kidney cancers. This elevated risk underscores the importance of adhering to age-appropriate guidelines for cancer screening. Clinicians should prioritize timely screenings and maintain heightened vigilance in patients with obesity to support early detection and improve long-term outcomes.

Additional cancer screening considerations in patients with obesity include:

• Earlier initiation of routine screening may be appropriate in select high-risk patients.
• Clinicians should address barriers to screening, including equipment limitations and patient concerns about comfort.
• Annual mammography may be more challenging in women with severe obesity due to breast size.
• Colonoscopy preparation and procedure may require modifications.
• Consider increased surveillance for endometrial cancer in women with PCOS and obesity.

Current evidence is limited regarding obesity-specific cancer screening thresholds; most major professional societies recommend following standard age-based guidelines while addressing practical barriers to screening in patients with obesity.

Pediatric-Specific Considerations for Obesity-Related Complications

Age-appropriate assessment strategies

Evaluating obesity-related complications in children and adolescents requires special considerations for normal growth and development patterns, age-specific diagnostic criteria, and the potential for intervention to prevent adult complications (see Table 10).

Table 10. Comprehensive Age-Appropriate Screening Timeline

BMI, body mass index; PCOS, polycystic ovary syndrome

Obesity Management Considerations in Pediatric Populations

Adolescent considerations

Adolescents present unique challenges in obesity management due to their rapid physical growth and developmental transitions, which can affect the interpretation of laboratory values. The psychological impact of obesity often includes concerns related to body image, self-esteem, and mental health. Risk-taking behaviors and susceptibility to peer influence complicate adherence to healthy lifestyle changes. Effective management requires balancing family involvement and promoting adolescent autonomy in health-related decisions.

Growth and development monitoring in pediatrics 

Accurate assessment begins with plotting height and weight on age- and sex-appropriate growth charts. Clinicians note any signs of linear growth deceleration, which may indicate an underlying endocrine disorder. Early or delayed onset of puberty warrants evaluation, and bone age assessment provides additional data when growth concerns arise. Please refer to StatPearls' companion resource, "Obesity in Pediatric Patients," for additional information.

Family-centered approach

Including parents and caregivers in the care plan strengthens the foundation for sustainable lifestyle modifications. Addressing family dynamics and evaluating the home food environment support behavior change. Screening for food insecurity, providing community resources, and identifying barriers to access enhance individualized care. Interventions tailored to cultural norms and preferences promote long-term engagement and success in managing adolescent obesity.

Pediatric obesity prevalence and trends

The prevalence of childhood obesity has increased at an alarming rate. The overall burden of obesity has almost tripled since 1975. However, an 8-fold increase in obesity burden in the 5 to 19-year age group has occurred between 1975 and 2016.[3] Currently, about 18.5% of United States children present with obesity.[3] When one parent is obese, children have approximately a 40% chance of becoming obese. When both parents are overweight or obese, their children have an 80% chance of becoming obese.

Screening Protocol Integration Coordinated Care Models

Interprofessional health teams should coordinate screening recommendations in various clinical settings, including:

• The primary care physician coordinates overall care.
• Refer to specialists based on standardized criteria.
• Integrate with school-based health services.
• Participate in community health and fitness programs. 

Documentation and tracking

Standardized assessment forms and protocols support consistent evaluation and management of obesity-related complications across clinical settings. Structured documentation accurately tracks growth patterns, comorbidities, and treatment progress. Optimizing electronic health records enhances the ability to monitor key clinical indicators, facilitate timely interventions, and coordinate care among clinicians. Integrating patient- and family-centered education materials into the clinical workflow promotes understanding and engagement with the care plan. Ongoing outcome monitoring contributes to informed clinical decision-making and highlights areas for targeted quality improvement. Systematic tracking of metrics, eg, BMI trends, laboratory results, and behavioral goals, helps guide individualized care and evaluate program effectiveness. 

Clinical Significance

Systematic Clinical Approach and Integration of the Comprehensive Assessment Framework

A systematic approach to evaluating obesity-related complications requires integrating historical, physical, and laboratory findings with an understanding of the patient's individual risk factors, family history, and psychosocial context.

History-taking strategies 

Chief complaint and history of present illness

• Weight history: onset, progression, and contributing factors
• Review of systems targeting obesity-related complications
• Previous weight loss attempts and outcomes
• Medications that may contribute to weight gain

Past medical history

• Prior diagnosis of obesity-related complications
• Surgical history, particularly bariatric procedures
• Hospitalizations related to weight or complications
• Growth and development history (pediatric patients)

Family history

• Obesity, diabetes, and cardiovascular disease
• Sleep disorders, cancer, and autoimmune conditions
• Age of onset of complications in family members
• Genetic syndromes associated with obesity

Social history

• Dietary patterns, eating behaviors, and food environment
• Physical activity levels and barriers to exercise
• Sleep patterns and quality
• Psychosocial stressors and support systems
• Educational and occupational factors affecting health

Physical Examination Techniques

Anthropometric measurements

• Accurate height and weight measurement
• BMI calculation and interpretation
• Waist circumference measurement
• Blood pressure with appropriate cuff sizing

Systems-based examination

• Skin: acanthosis nigricans, hirsutism, striae, and skin tags
• Cardiovascular: heart rate, rhythm, murmurs, and edema
• Pulmonary: respiratory effort, signs of sleep apnea 
• Abdominal: hepatomegaly, masses, and hernias
• Musculoskeletal: joint range of motion, gait assessment
• Neurological: mood, cognitive function, and reflexes (see Table 11)

Clinical Decision-Making

Table 11. Criteria for Referral to a Specialist versus Management in Primary Care

CPAP, continuous positive airway pressure; HbA1c, glycated hemoglobin; HTC, hematocrit; HTN, hypertension; IIH, idiopathic intracranial hypertension; MASLD, metabolic dysfunction–associated steatotic liver disease; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome; SCFE, slipped capital femoral epiphysis

Risk Stratification Approaches

Low risk

• BMI 25–29.9 kg/m² with no complications
• Family history negative for obesity-related conditions
• Normal screening laboratory values
• Good functional status

Moderate risk

• BMI 30–34.9 kg/m² with 1 to 2 complications
• Family history positive for diabetes or cardiovascular disease
• Mild abnormalities in screening tests
• Some functional limitations

High risk

• BMI ≥35 kg/m² with multiple complications
• Established cardiovascular disease or diabetes
• Significant abnormalities requiring specialist care
• Substantial functional impairment

Documentation Pearls for Obesity-Related Complications

• Use specific BMI values for adults and BMI with percentiles for children.
• Document all screening results and interpretations.
• Note family history and risk stratification.
• Include the patient education provided and the patient's response.
• Record specialist referrals and follow-up plans.
• Track progress toward weight and health goals.
• Document barriers to care and interventions to overcome them.

Quality Improvement and Follow-up Monitoring Strategies

• Regular weight and BMI tracking
• Serial laboratory monitoring based on risk factors
• Symptom assessment and functional status
• Medication adherence and side effects
• Patient-reported outcomes and quality of life

Care Coordination

• Communication with specialists and consultants.
• Integrate care with professionals in nutrition and exercise.
• Coordinate with mental health providers when indicated.
• Collaborate with school health services for pediatric patients. 
• Employ community resources.
• Utilize transition planning tools, such as the Six Core Elements of Health Care Transition, for adolescents transitioning to adult care.

Other Issues

Systematic Assessment Algorithm for Obesity-Related Complications 

Initial assessment

• Anthropometric measurements (BMI, waist circumference, blood pressure)
• Comprehensive history (weight trajectory, family history, symptoms)
• Physical examination (systems-based approach)
• Risk stratification (low/moderate/high)

Screening protocol by risk stratification

• Low risk: Basic metabolic panel, lipid studies every 2 to 3 years
• Moderate risk: Annual screening, targeted complications assessment
• High risk: Comprehensive metabolic panel, specialist referrals as indicated

Age-specific considerations

• Pediatric (2–17 years): Growth curves, Tanner staging, family involvement
• Transition (18–21 years): Care coordination, independence building
• Adult (older than 21 years): Standard adult screening protocols

Specialist Consultation based on the Clinical Severity of the Obesity-related complication

• Urgent: SCFE, IIH, severe OSA
• Semi-urgent: Uncontrolled diabetes, resistant hypertension
• Routine: PCOS in adolescents, advanced MASLD, infertility

Ongoing Management and Follow-up

• Weight and BMI tracking
• Complication-specific monitoring
• Quality of life assessment
• Care coordination documentation

Systematic Assessment Algorithm

Integrated multi-system assessment approach for obesity-related complications

• Initial Assessment
  • +-- Anthropometric measurements (BMI, waist circumference, blood pressure)
  • +-- Comprehensive history (weight trajectory, family history, symptoms)
  • +-- Physical examination (systems-based approach)
  • +-- Risk stratification (Low/Moderate/High) 
• Screening Protocol by Risk Level
  • +-- Low Risk: Basic metabolic panel, lipids every 2–3 years
  • +-- Moderate Risk: Annual screening, targeted complications assessment
  • +-- High Risk: Comprehensive panel, specialist referrals as indicated
• Age-Specific Considerations
  • +-- Pediatric (2–17 years): Growth curves, Tanner staging, family involvement
  • +-- Transition (18–21 years): Care coordination, independence building
  • +-- Adult (>21 years): Standard adult screening protocols
• Specialist Referral Triggers
  • +-- Urgent: SCFE, IIH, severe OSA
  • +-- Semi-urgent: Uncontrolled diabetes, resistant hypertension
  • +-- Routine: PCOS in adolescents, advanced MASLD, infertility
• Follow-up and Monitoring
  • +-- Weight and BMI tracking
  • +-- Complication-specific monitoring
  • +-- Quality of life assessment
  • +-- Care coordination documentation

Patient Education Priorities

• Understanding the relationship between weight and health complications
• Realistic goal setting for weight management
• Lifestyle modification strategies
• When to seek urgent medical attention
• Long-term health monitoring and prevention

Evidence-Based Practice Integration 

Obesity is a complex disease with multifactorial etiology and is the second most common cause of preventable death after smoking.[CMAJ. Obesity may soon be the leading cause of preventable death. 2002] A 5% to 10% weight loss can significantly improve health, quality of life, and the economic burden for individuals and populations.[16] The economic burden of obesity exceeds $700 billion annually, with an estimated $100 billion in the United States alone.[17]

Summary and Key Takeaways

The comprehensive assessment and diagnosis of weight-related metabolic and biomechanical complications in obesity requires a systematic, evidence-based approach that recognizes the complex interrelationships between obesity and multiple organ systems. Key principles:

Clinical approach

• Utilize age-appropriate screening criteria and diagnostic standards.
• Implement systematic evaluation protocols for all organ systems.
• Recognize the bidirectional relationships between obesity and its complications.
• Prioritize early intervention to prevent progression of complications.

Pediatric considerations

• Apply developmental and growth-appropriate assessment tools.
• Understand unique pediatric complications such as SCFE and pubertal disorders.
• Involve families while building patient autonomy.
• Plan for a successful transition to adult care.

Integration and coordination

• Coordinate care among multiple specialists as needed.
• Provide patient education about the relationships between weight and overall health.
• Address psychosocial factors and barriers to care.
• Monitor long-term outcomes and adjust interventions accordingly.

The systematic evaluation of obesity-related complications offers opportunities for early intervention, disease progression prevention, and enhanced long-term health outcomes. Healthcare professionals must remain current with evolving diagnostic criteria and treatment recommendations while maintaining a patient-centered approach that addresses the complex needs of individuals with obesity.

Enhancing Healthcare Team Outcomes

The comprehensive evaluation of weight-related complications in patients with obesity requires age-specific, evidence-based strategies to identify and manage metabolic and cardiovascular risks. In children, obesity significantly increases the likelihood of hypertension, insulin resistance, and dyslipidemia, necessitating early, targeted screening and coordinated care to prevent lifelong complications. Adults with obesity also face elevated risks for metabolic syndrome, type 2 diabetes, dyslipidemia, and cardiovascular disease, underscoring the need for regular assessment and intervention. Physicians, advanced practitioners, nurses, pharmacists, and other healthcare professionals play vital roles in recognizing obesity-related complications and initiating appropriate management. Clinicians must be proficient in assessing BMI percentiles in children, interpreting HbA1c and lipid profiles, and identifying signs of insulin resistance, such as acanthosis nigricans.

Screening should follow established guidelines, with universal lipid and glucose monitoring at key developmental stages in children and tailored assessments for adults based on risk factors. Understanding underlying pathophysiologic mechanisms, including sympathetic nervous system activation and vascular dysfunction, supports timely diagnosis and treatment of obesity-related hypertension and metabolic disturbances. Interprofessional communication and coordination enhance the effectiveness of care by ensuring consistency across assessments, education, treatment plans, and follow-up. Nurses and pharmacists contribute to patient education and medication safety, while physicians and advanced practitioners lead comprehensive evaluation and management. Collaborative, patient-centered approaches enable early intervention, reduce long-term complications, and support evidence-based care that is developmentally appropriate for both pediatric and adult patients with obesity.