Etiologic Classification

As previously stated, the underlying cause of obesity in most cases is the chronic energy imbalance resulting from excessive energy intake relative to energy expenditure. However, this positive energy balance is a consequence of a complex interaction between environmental/societal influences (that affect dietary and physical activity) and the biologic/genetic milieu. Although the genetic contribution has been estimated from population studies to be as high as 40-70%, genetic factors cannot fully explain the current obesity epidemic. It is obvious that the rapid increases in obesity rates have occurred in too short a time for there to have been significant genetic changes within populations.

It is equally pertinent to note that specific and identifiable etiologies can only be ascribed to a minority of cases of obesity and, as such, do not significantly contribute to the current global obesity problem. However, it is important to be aware of these specific causes during the clinical evaluation of obesity since a number of these cases will be amenable to appropriate therapies. Examples include endocrinopathies such as insulinoma, Cushing's syndrome, hypothy-

roidism, hypogonadism, polycystic ovarian syndrome; hypothalamic lesions secondary to trauma, surgery, or primary or metastatic tumor; genetic syndromes like leptin deficiency, leptin receptor/melanocortin receptor defects, Prader-Willi, Bardet-Biedl, and Down's; and drugs such as insulin, sulfonylureas, glucocorticoids, antiepileptics, antipsychotics, and depoprovera.

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