2014-Obesity.pdf

GUIDELINES (2013) FOR MANAGINGOVERWEIGHT AND OBESITY IN ADULTS

Full Report including the Executive Summarypublished byThe Obesity Society with the ACC/AHA Task Force on Practice

Guidelines and based on a Systematic Evidence Reviewsupported by the NHLBI

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association,

American Society for Nutrition, American Society for Parenteral and Enteral Nutrition, American Society for Preventive

Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive

Cardiovascular Nurses Association, The Endocrine Society, and WomenHeart: The National Coalition for Women With

Heart Disease

This report was derived from the 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in

Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline

and The Obesity Society and Managing Overweight and Obesity in Adults: Systematic Evidence Review from the

Obesity Expert Panel, 2013 which were both developed jointly by the AHA, ACC, TOS and the NHLBI.

To cite this document: Jensen MD, Ryan DH, Donato KA, Apovian CM, Ard JD, Comuzzie AG, Hu FB, Hubbard VS,Jakicic JM, Kushner RF, Loria CM, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM,

Yanovski SZ. Guidelines (2013) for managing overweight and obesity in adults. Obesity 2014;22(S2):S1-S410.

VC 2014 The Obesity Society

Obesity

Co-Chairs

Michael D. Jensen, MDMayo Clinic Endocrine Research Unit

Rochester, MN

Donna H. Ryan, MDPennington Biomedical Research Center

Baton Rouge, LA

Members

Karen A. Donato, SM*Division for the Application of Research Discoveries

National Heart, Lung, and Blood Institute

Bethesda, MD

Caroline M. Apovian, MD, FACP, FACNBoston University School of Medicine

Boston Medical Center

Boston, MA

Jamy D. Ard, MDWake Forest University Baptist Medical Center

Winston-Salem, NC

Anthony G. Comuzzie, PhDSouthwest Foundation for Biomedical Research

Southwest National Primate Research Center

San Antonio, TX

Frank B. Hu, MD, PhD, MPHHarvard University School of Public Health

Boston, MA

Van S. Hubbard, MD, PhD*Division of Nutrition

Research Coordination

National Institutes of Health

Bethesda, MD

John M. Jakicic, PhDUniversity of Pittsburgh

Pittsburgh, PA

Robert F. Kushner, MDNorthwestern University

Feinberg School of Medicine

Chicago, IL

Catherine M. Loria, PhD*Division of Cardiovascular Sciences


Bethesda, MD

Barbara E. Millen, Dr. PH, RD, FADABoston University School of Medicine

Boston Nutrition Foundation, Inc.

Millennium Prevention, Inc.

Boston, MA

Cathy Nonas, MS, RDNew York City Department of Health

and Mental Hygiene

New York, NY

F. Xavier Pi-Sunyer, MD, MPHSt. Lukes-Roosevelt Hospital Center

Columbia University

New York, NY

June Stevens, MS, PhDUniversity of North Carolina at Chapel Hill

Chapel Hill, NC

Victor J. Stevens, PhDKaiser Permanente Center for Health Research

Portland, OR

Thomas A. Wadden, PhDUniversity of Pennsylvania School of Medicine

Philadelphia, PA

Bruce M. Wolfe, MD, FACSOregon Health and Science University

Portland, OR

Susan Z. Yanovski, MD*Division of Digestive Diseases and Nutrition

National Institute of Diabetes and Digestive and Kidney Diseases

Bethesda, MD

*ex officio members

ObesityVolume 22 / Issue S2July 2014

Overweight and Obesity Expert Panel

Methodology Team

RTI International

Michael G. Trisolini, PhD, MBA

Harmon S. Jordan, ScD

Linda J. Lux

Laura C. Morgan, MA

Science Applications InternationalCorporation (SAIC)

Karima A. Kendall, PhD

Roycelynn Mentor-Marcel, PhD, MPH

Janusz Wnek, PhD

Staff

Denise Simons-Morton, MD, PhDDivision for the Application of Research Discoveries


Bethesda, MD

Melinda Kelley, PhDDivision for the Application of Research Discoveries


Melissa McGowan, MHS, CHESDivision for the Application of Research Discoveries


Kathryn Y. McMurry, MSDivision for the Application of Research Discoveries


Eva Erber, MSUniversity of North Carolina at Chapel Hill

Randi Henderson, BAPalladian Partners, Inc.

Mary E. LavelleAmerican Institutes for Research

ACC/AHA Task Force Members (contributors to the Executive Summary)

Jeffrey L. Anderson, MD, FACC, FAHA, Chair

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect

Nancy M. Albert, PhD, CCNS, CCRN, FAHA

Biykem Bozkurt, MD, PhD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC

Lesley H. Curtis, PhD, FAHA

David DeMets, PhD

Judith S. Hochman, MD, FACC, FAHA

Richard J. Kovacs, MD, FACC, FAHA

E. Magnus Ohman, MD, FACC

Susan J. Pressler, PhD, RN, FAAN, FAHA

Frank W. Sellke, MD, FACC, FAHA

Win-Kuang Shen, MD, FACC, FAHA

Subcommittee on Prevention Guidelines

Sidney C. Smith, Jr, MD, FACC, FAHA, Chair

Gordon F. Tomaselli, MD, FACC, FAHA, Co-Chair

Martica Heaner, PhDThe Obesity Society

Editor for Compilation of Guidelines (2013) for Managing Overweight and Obesity in Adults

ObesityVolume 22 / Issue S2

July 2014

OBESITY GUIDELINESPART 1Preface to the Full Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1

Evolution of the 2013 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1Key Messages for Overweight and Obesity from The Obesity Society . . . . . . . . . . . . . . . . . . . . . S2Who needs to lose weight? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2For individuals who can benefit from weight loss, what is the optimum level of weight loss? . . . . . . . . . S2Which diet is the most effective for weight loss? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2Is diet or exercise the best way to lose weight?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2How can weight loss be maintained? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2Who should receive bariatric surgery?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S3References for Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S3

OBESITY GUIDELINESPART 2Preface to the Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S4Executive Summary: Guidelines (2013) for the Management of Overweight and Obesity in AdultsPreamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S5

1. Introduction/Scope of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S61.1. Rationale for Updating Obesity Clinical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71.2. CQ-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71.3. Organization of the Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S91.4. Document Review and Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S8

2. Obesity Recommendations and Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S92.1. Summary of Evidence-Based Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S92.2. Chronic Disease Management Model for Primary Care of Patients With Overweight

and ObesityTreatment Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S10

3. CQs and Corresponding ESs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S183.1. CQ1: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18

3.1.1. Weight Loss and Risk of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S183.1.2. Weight Loss and Impact on Cholesterol/Lipid Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . S193.1.3. Weight Loss and Hypertension Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19

3.2. CQ2: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S193.2.1. Current BMI Cutpoints and CVD-Related Risk and All-Cause Mortality . . . . . . . . . . . . . . . S203.2.2. Areas of Insufficient Evidence With Regard to Cutpoints for BMI

and for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S203.3. CQ3: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21

3.3.1. Overall Dietary Intervention and CompositionCreating Reduced DietaryEnergy Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21

3.3.2. Overall Dietary Intervention and CompositionPattern of Weight Loss OverTime With Dietary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21

3.3.3. Low-Fat Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S213.3.4. Higher-Protein Approaches (25% to 30% of Energy) . . . . . . . . . . . . . . . . . . . . . . . . . . . S223.3.5. Low-Carbohydrate Approaches (

3.3.6. Complex Versus Simple Carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223.3.7. Glycemic Load Dietary Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223.3.8. Dietary Patterns (Mediterranean Style, Vegetarian, and Other Dietary

Pattern Approaches). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223.3.9. Meal Replacement and Adding Foods to Liquid Diets. . . . . . . . . . . . . . . . . . . . . . . . . . . S223.3.10. Very-Low-Calorie Diet Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22

3.4. CQ4: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223.4.1. Description of the Diet, Physical Activity, and Behavior Therapy Components

in High-Intensity, On-Site Lifestyle Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S233.4.2. Comprehensive Interventions Compared With Usual Care, Minimal Care,

or No-Treatment Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S233.4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions

in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S233.4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions

in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S233.4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within

a Primary Care Practice Setting Compared With Usual Care . . . . . . . . . . . . . . . . . . . . . . S233.4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions

in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S243.4.7. Efficacy/Effectiveness of Very-Low-Calorie Diets, as Used as Part of

a Comprehensive Lifestyle Intervention, in Achieving Weight Loss . . . . . . . . . . . . . . . . . . S243.4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining

Lost Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S243.4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss:

Intervention Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S243.4.10. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss

or Weight Loss Maintenance: Individual Versus Group Treatment . . . . . . . . . . . . . . . . . . S243.4.11. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss

or Weight Loss Maintenance: On-Site Versus Electronically Delivered Interventions . . . . . . S243.5. CQ5: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24

3.5.1. Component 1: Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S253.5.2. Component 2: Predictors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S263.5.3. Component 3: Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S26

3.5.3.1. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S273.5.3.2. ROUX-EN-Y GASTRIC BYPASS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S273.5.3.3. BILIOPANCREATIC DIVERSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S273.5.3.4. LAPAROSCOPIC SLEEVE GASTRECTOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27

4. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S274.1. CQ1 (Benefits of Weight Loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S274.2. CQ2 (Risks of Overweight and Obesity) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S284.3. CQ3 (Dietary Interventions for Weight Loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S284.4. CQ4 (Lifestyle Interventions for Weight Loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S284.5. CQ5 (Surgical Procedures for Weight Loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S28

(Continued)


Contents

(Continued)

References for Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S29Appendix 1 for Part 2. Author Relationships With Industry and Other Entities (Relevant) . . . . . . . S33Appendix 2 for Part 2. Expert Reviewer Relationships With Industry and Other Entities . . . . . . . . S38Appendix 3 for Part 2. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S39

OBESITY GUIDELINESPART 3Preface to the Expert Panel Report (comprehensive version which includes Systematic EvidenceReview, Evidence Statements, and Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S40Expert Panel Report: Guidelines (2013) for the Management of Overweight and Obesity in Adults . . . S41

SECTION 1: Background and Description of the NHLBI CardiovascularRisk Reduction Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41

A. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41B. Overview of the Evidence-Based Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41C. Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43D. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43E. Critical Questions on Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43

i. Critical Questions on Weight-Related Health Risks and Benefits of Weight Loss . . . . . . . . . . . . . . S43ii. Critical Questions on Treatments for Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . S44

F. Challenges of Achieving Weight Loss in Primary Care Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . S44

SECTION 2: Process and Methods Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45A. Overview of Evidence-Based Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45

i. System for Grading the Body of Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46ii. Peer-Review Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46

B. Critical Question-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S47i. Critical Questions on Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S47

SECTION 3: Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48

i. By Population Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48ii. By Amount of Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48iii. By Weight Loss Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48

B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S48D. Methods for Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S51

i. Weight Loss and Risk for Diabetes: Spreadsheets 1.1.-1.4b. . . . . . . . . . . . . . . . . . . . . . . . . . . . S51F. Weight Loss and Impact on Cholesterol/Lipid ProfileSpreadsheet 1.5a-1.5c. . . . . . . . . . . . . . . . . . . S54G. Weight Loss and Hypertension RiskSpreadsheets 1.6a-f.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S56H. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S57


i. Subgroup Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58


Contents

(Continued)

B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S58D. Methods for Critical Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S60E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S63

i. BMI Cutpoints and CVD-Related Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S63ii. Waist Circumference Cutpoints and CVD-Related Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S67

F. Recommedations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S68G. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S69

SECTION 5: Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S70D. Methods for Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S74F. Overall Dietary Intervention and CompositionSummary Table 3.1 . . . . . . . . . . . . . . . . . . . . . . . . . S74

i. Creating Reduced Dietary Energy Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S74ii. Diets of Differing Forms and Structures (Macronutrient Content, Carbohydrate and

Fat Quality, Nutrient Density, Amount of Energy Deficit, Dietary Pattern) or Other DietaryWeight Loss Strategies (e.g., Meal Timing, Portion-Controlled Meal Replacements) . . . . . . . . . . . . S75

iii. Pattern of Weight Loss Over Time With Dietary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . S76G. Low-Fat ApproachesSummary Table 3.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S77H. Higher Protein (25 to 30 Percent of Energy) ApproachesSummary Table 3.3 . . . . . . . . . . . . . . . . . S77I. Low-Carbohydrate (30g/Day) ApproachesSummary Table 3.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . S78J. Complex Versus Simple CarbohydratesSummary Table 3.5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79K. Glycemic Load Dietary ApproachesSummary Table 3.6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79L. Dietary Pattern (Mediterranean Style and Vegetarian and Other Dietary Pattern)

ApproachesSummary Table 3.7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79M. Meal Replacements and Adding Foods to Liquid DietsSummary Table 3.8. . . . . . . . . . . . . . . . . . . S80N. Very Low-Calorie Diet ApproachesSummary Table 3.9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S81O. RecommendationsDietary Strategies for Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S81P. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82

SECTION 6: Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S83

i. A Dictionary of Lifestyle Intervention Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83ii. Comprehensive Lifestyle Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83iii. Intervention Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83iv. Intervention Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83v. Intervention Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84vi. Individual Versus Group Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84vii. Trained Interventionist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84viii. Trials of Weight Loss Induction Versus Maintenance of Lost Weight . . . . . . . . . . . . . . . . . . . . . . S84


Contents

(Continued)

D. Methods for Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S86E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88

i. Introduction of Evidence Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88F. Diet, Physical Activity, and Behavior Therapy Components in High-Intensity, Onsite Lifestyle

InterventionsSummary Tables 4.1a-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88G. Comprehensive Interventions Compared With Usual Care, Minimal Care, or No-Treatment

ControlSummary Tables 4.2a-d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S89H. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving

Weight LossSummary Tables 4.3a-n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S91I. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions inAchieving Weight LossSummary Tables 4.4a-b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S91

J. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within aPrimary Care Practice Setting Compared With Usual CareSummary Tables 4.5a-f . . . . . . . . . . . . . . S92

K. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventionsin Achieving Weight LossSummary Table 4.6a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S92

L. Efficacy/Effectiveness of Very Low-Calorie Diets Used as Part of a Comprehensive LifestyleIntervention in Achieving Weight LossSummary Tables 4.7a-c . . . . . . . . . . . . . . . . . . . . . . . . . . . S93

M. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining Lost WeightSummary Tables 4.8a-e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S93

N. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss: InterventionIntensitySummary Tables 4.9a-f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S94

O. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight LossMaintenance: Individual Versus Group TreatmentSummary Tables 4.1a-c . . . . . . . . . . . . . . . . . . . S95

P. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or WeightLoss Maintenance: Onsite Versus Electronically Delivered InterventionsSummary Tables 4.10a-j . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S96

Q. Recommendation 4a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S96R. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98


i. Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98ii. Predictors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98iii. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S99

B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S99C. Introduction and Rationale for Question and the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . S99

i. Bariatric Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100ii. Currently Used Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100iii. Investigational Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S104

D. Methods for Critical Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S104E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S106

i. Component 1: EfficacySummary Table 5.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S106ii. Component 2: PredictorsPatient CharacteristicsSummary Table 5.2 and

Types of SurgerySummary Table 5.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S109


Contents

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iii. Component 3: ComplicationsSummary Table 5.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S110iv. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S113

F. RecommendationsBariatric Surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S113G. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S115References for Part 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S115

APPENDIXESAppendix A: Detailed Methods Applying to All Critical Questions . . . . . . . . . . . . . . . . . . . . . . . . S125Appendix B: Question-Specific Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S150Appendix C: Spreadsheets and Summary Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S206Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S206Critical Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S237Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S287Critical Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S356Appendix D: Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S408Appendix E: Names of Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S409

LIST OF TABLESTable 1. Evidence Quality Grading System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46Table 2. Criteria for Selection of Publications for CQ1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49Table 3. Criteria for Selection of Publications for CQ2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S59Table 4. Criteria for Selection of Publications for CQ3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71Table 5. Criteria for Selection of Publications for CQ4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84Table 6. Criteria for Selection of Publications for CQ5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100

Table A-1. Quality Assessment Tool for Controlled Intervention Studies . . . . . . . . . . . . . . . . . . . . . . . . S128Table A-2. Quality Assessment Tool for Systematic Reviews and Meta-Analyses. . . . . . . . . . . . . . . . . . S131Table A-3. Quality Assessment Tool for Cohort and Cross-Sectional Studies. . . . . . . . . . . . . . . . . . . . . S134Table A-4. Quality Assessment Tool for Case-Control Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S138Table A-5. Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group . . . . . . . . S142Table A-6. Quality Assessment Tool for Case Series Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S145Table A-7. Evidence Quality Grading System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S147

Table B-1. Examples of Simple Queries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S150Table B-2. Attributes, Their Values, and Explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S151Table B-3. Common Macro Queries Used in Search Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S151Table B-4. Criteria for Selection of Publications for CQ1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S155Table B-5. Criteria for Selection of Publications for CQ2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S158Table B-6. Criteria for Selection of Publications for CQ3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S163Table B-7. Criteria for Selection of Publications for CQ4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S168Table B-8. Criteria for Selection of Publications for CQ5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S171Table B-9. CQ1 Studies Rated Fair or Good. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S174


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Table B-10. CQ1 Studies Rated as Poor With Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S176Table B-11. CQ2 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S178Table B-12. CQ2 Studies Rated as Poor With Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S179Table B-13. CQ3 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S181Table B-14. CQ3 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S182Table B-15. CQ4 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S188Table B-16. CQ4 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S192Table B-17. CQ5 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S200Table B-18. CQ5 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S202

LIST OF SPREADSHEET TABLESSpreadsheet 1.1. Effect of Weight Loss From Lifestyle Interventions in Patients With Diabetes

on Blood Glucose and HbA1c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S206Spreadsheet 1.2. Effect of Weight Loss From Lifestyle Interventions in Persons at Risk

for Developing Diabetes (Prediabetes) on Risk for Converting to Type 2 Diabetes . . . . . . . . . . . . . . . . S207Spreadsheet 1.3. Effect of Intentional Weight Loss From Lifestyle Interventions in Patients

With or Without Diabetes on Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S208Spreadsheet 1.4A. Effect of Weight Loss From Orlistat Interventions in Patients With Diabetes

on Blood Glucose and HbA1c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S209Spreadsheet 1.4B. Effect of Weight Loss From Orlistat Interventions in Patients at Risk for

Diabetes on Blood Glucose and HbA1c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S209Spreadsheet 1.5A. Effect of Weight Loss on Serum Lipids: Lifestyle Interventions . . . . . . . . . . . . . . . . S210Spreadsheet 1.5B. Effect of Weight Loss on Serum Lipids: Orlistat Interventions . . . . . . . . . . . . . . . . . S213Spreadsheet 1.5C. Effect of Weight Loss on Serum Lipids: Diabetes Subjects . . . . . . . . . . . . . . . . . . . S215Spreadsheet 1.6A. Weight Loss and Hypertension Risk: Orlistat Trials, All Subjects . . . . . . . . . . . . . . . S217Spreadsheet 1.6B. Weight Loss and Hypertension Risk: Orlistat Trials, Diabetes Subjects . . . . . . . . . . . S219Spreadsheet 1.6C. Weight Loss and Hypertension Risk: Hypertension Subjects . . . . . . . . . . . . . . . . . . S219Spreadsheet 1.6D. Weight Loss and Hypertension Risk: Lifestyles Trials, All Subjects . . . . . . . . . . . . . . S220Spreadsheet 1.6E. Weight Loss and Hypertension Risk: Lifestyles Trials, Diabetes Subjects . . . . . . . . . . S221Spreadsheet 1.6F. Weight Loss and Hypertension Risk: Lifestyles Trials, Hypertension Subjects . . . . . . . S222

Spreadsheet 2.1. Study Descriptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223Spreadsheet 2.2.1A. Combined Fatal and Nonfatal CHDResults for BMI . . . . . . . . . . . . . . . . . . . . . . S227Spreadsheet 2.2.1B. Fatal CHDResults for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S228Spreadsheet 2.2.2A. Combined Fatal and Nonfatal StrokeResults for BMI . . . . . . . . . . . . . . . . . . . . S228Spreadsheet 2.2.2B. Fatal StrokeResults for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S229Spreadsheet 2.2.3A. Combined Fatal and Nonfatal CVDResults for BMI . . . . . . . . . . . . . . . . . . . . . . S230Spreadsheet 2.2.3B. Fatal CVDResults for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S230Spreadsheet 2.2.4. Incident DiabetesResults for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S231Spreadsheet 2.2.5. Overall MortalityResults for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S232Spreadsheet 2.3.1. Combined Fatal and Nonfatal CHDResults for Waist Circumference . . . . . . . . . . . S234Spreadsheet 2.3.2. Combined Fatal and Nonfatal StrokeResults for Waist Circumference . . . . . . . . . . S234Spreadsheet 2.3.3. Combined Fatal and Nonfatal CVDResults for Waist Circumference . . . . . . . . . . . S235


Contents

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Spreadsheet 2.3.4. Overall MortalityResults for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . S235Spreadsheet 2.3.5. Incident DiabetesResults for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . S236

LIST OF SUMMARY TABLESSummary Table 3.1. Overall Dietary Intervention and Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . S237Summary Table 3.2. Low-Fat Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S251Summary Table 3.3. Higher (25-30% of Energy) Protein Approaches . . . . . . . . . . . . . . . . . . . . . . . . . S259Summary Table 3.4. Low Carbohydrate Approaches (

Summary Table 4.3C. Compared With Usual Care, Minimal Control, or No Intervention(Includes Self-Directed): Electronic InternetOutcome Data at Greater Than 6 Monthsas First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S306

Summary Table 4.3D. Compared With Usual Care, Minimal Control, or No Intervention(Includes Self-Directed): Electronic InternetOutcome Data at Greater Than 12 Monthsas First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S306

Summary Table 4.3E. Compared with Other Comprehensive Electronic Interventions:Electronic InternetOutcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . . . . . S306

Summary Table 4.3F. Compared with Other Comprehensive Electronic Interventions: ElectronicInternetOutcome Data at Greater Than 6 Months as First Time Period Reporting. . . . . . . . . . . . . . . S307

Summary Table 4.3G. Compared with Other Comprehensive Electronic Interventions: ElectronicInternetOutcome Data at Greater Than 12 Months as First Time Period Reporting . . . . . . . . . . . . . . S308

Summary Table 4.3H. Compared With Other Comprehensive Interventions (Includes Onsiteand/or Electronic): Outcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . . . . . . S308

Summary Table 4.3I. Compared With Other Comprehensive Interventions (Includes Onsite and/orElectronic): Outcome Data at Greater Than 6 Months as First Time Period Reporting . . . . . . . . . . . . . S310

Summary Table 4.3J. Compared With Other Comprehensive Interventions (Includes Onsite and/orElectronic): Outcome Data at Greater Than 12 Months as First Time Period Reporting. . . . . . . . . . . . . S310

Summary Table 4.3K. Evidence of Weight Loss in Comprehensive Electronic (Interactive Equipment)Interventions: Compared With Other Comprehensive Intervention (Internet or Onsite)Weight LossOutcome Data at 4 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S310

Summary Table 4.3L. Evidence of Weight Maintenance in Comprehensive Electronic(Interactive Technology with Phone Feedback) Interventions: Comprehensive ElectronicIntervention Compared With Personal Contact or Self-Directed ControlWeight Loss OutcomeData at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S311

Summary Table 4.3M. Evidence of Weight Maintenance in Comprehensive Electronic (Internet)Interventions: Comprehensive Electronic Intervention Compared With Personal Contact orSelf-Directed ControlWeight Loss Outcome Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . S313

Summary Table 4.3N. Evidence of Weight Maintenance in Comprehensive Electronic (Internet)Interventions: Comprehensive Electronic Intervention Compared With Personal Contact orSelf-Directed ControlWeight Loss Outcome Data at 12 Months or Greater . . . . . . . . . . . . . . . . . . . S314

Summary Table 4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered LifestyleInterventions for Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S315

Summary Table 4.4A. Trials That Compared Onsite vs. Telephone Delivered Programs for InducingWeight Loss: Outcome Data at 6 Months Or Less as First Time Period Reporting . . . . . . . . . . . . . . . . S315

Summary Table 4.4B. Trials That Compared Onsite vs. Telephone Delivered Programs for InducingWeight Loss: Outcome Data at 12 Months or Greater as First Time Period Reporting . . . . . . . . . . . . . S316

Summary Table 4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in PatientsWithin a Primary Care Practice Compared With Usual Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S317

Summary Table 4.5A. Weight Loss Trials: Outcome Data at 6 Months or Less as First TimePeriod Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S317

Summary Table 4.5B. Weight Loss Trials: Outcome Data at Greater Than 6 Months as First Time PeriodReporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S318


Contents

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Summary Table 4.5C. Weight Loss Trials: Outcome Data at Greater Than 12 Months as First TimePeriod Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S319

Summary Table 4.5D. Weight Maintenance Trials: Outcome Data at 6 Months or Less as First TimePeriod Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S319

Summary Table 4.5E. Weight Maintenance Trials: Outcome Data at Greater Than 6 Months as FirstTime Period Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S320

Summary Table 4.5F. Weight Maintenance Trials: Outcome Data at Greater Than 12 months as FirstTime Period Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S320

Summary Table 4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive LifestyleInterventions in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S321

Summary Table 4.6A. Compared With Usual Care, Minimal Control, or No Intervention . . . . . . . . . . . . . S321Summary Table 4.7. Efficacy/Effectiveness of Very Low-Calorie Diets, as Used as Part of a

Comprehensive Lifestyle Intervention in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . S323Summary Table 4.7A. Evidence from Weight Loss Trials: Weight Loss Outcome Data at

6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S323Summary Table 4.7B. Evidence From Weight Maintenance Trials: Weight Maintenance Outcome

Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S324Summary Table 4.7C. Evidence From Weight Maintenance Trials: Weight Maintenance Outcome

Data at 9 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S325Summary Table 4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining

Lost Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S326Summary Table 4.8A. Onsite Interventions: Outcome Data at 6 Months or Less as the First Time

Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S326Summary Table 4.8B. Onsite Interventions: Outcome Data at 6 Months or Greater as First Time

Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S329Summary Table 4.8C. Onsite Interventions: Outcome Data at Greater Than 12 Months as the

First Time Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S331Summary Table 4.8D. Electronic Interventions: Outcome Data at 6 Months or Less as First Time

Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S332Summary Table 4.8E. Electronic Interventions: Outcome Data at Greater Than 12 Months as

First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S333Summary Table 4.8F. Comprehensive Weight Loss or Weight Loss Maintenance Trials That Reported

Percentage of Participants who Achieved A Loss 5% of Initial Weight at 2 YearsPost-Randomization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S334

Summary Table 4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss:Intervention Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S336

Summary Table 4.9A. Moderate Intensity Interventions: Outcome Data at 6 Months or Less asFirst Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S336

Summary Table 4.9B. Moderate Intensity Interventions: Outcome Data at Greater Than 6 Monthsas First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S338

Summary Table 4.9C. Moderate Intensity Interventions: Outcome Data at Greater Than 12 Monthsas First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S339


Contents

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Summary Table 4.9D. Low-Intensity Interventions: Outcome Data at 6 Months or Less asFirst Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S341

Summary Table 4.9E. Low-Intensity Interventions: Outcome Data at Greater Than 6 Months asFirst Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S341

Summary Table 4.9F. Low-Intensity Interventions: Outcome Data at Greater Than 12 Months asFirst Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S342

Summary Table 4.10. Characteristics of Lifestyle Intervention Delivery that May Affect WeightLoss or Weight Maintenance: Onsite Vs. Electronically Delivered Interventions . . . . . . . . . . . . . . . . . . S342

Summary Table 4.10A. Randomized Comparison of High-Intensity Onsite vs. Electronically Deliveredinterventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S342

Summary Table 4.10B. High-Intensity, Onsite Comprehensive Interventions: Weight Loss Outcome,Data at 6 Months or Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S343

Summary Table 4.10C. High-Intensity, Onsite Comprehensive Interventions: Weight Loss OutcomeData at Greater than 6 Months to 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S347

Summary Table 4.10D. High-Intensity, Onsite Comprehensive Interventions: Weight Loss OutcomeData at Greater than 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S349

Summary Table 4.10E. Comprehensive Electronically Delivered Interventions: Evidence of WeightLoss in Comprehensive Electronic (Telephone) InterventionsCompared With Usual Care,Minimal Control, or No Intervention (Includes Self-Directed): Weight Loss Outcome Dataat Greater Than 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S350

Summary Table 4.10F. Comprehensive Electronically Delivered Interventions: Evidence of WeightLoss in Comprehensive Electronic (Internet) InterventionsCompared With Usual Care, MinimalControl, or No Intervention (Includes Self-Directed): Weight Loss Outcome Data at6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S351

Summary Table 4.10G. Comprehensive Electronically Delivered Interventions: Evidence of WeightLoss in Comprehensive Electronic (Internet) InterventionsCompared With ComprehensiveElectronic Interventions: Weight Loss Outcome Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . S352

Summary Table 4.10H. Comprehensive Electronically Delivered Interventions: Evidence of WeightLoss in Comprehensive Electronic (Internet) InterventionsCompared With ComprehensiveElectronic Interventions: Weight Loss Outcome Data at 12 Months or Greater . . . . . . . . . . . . . . . . . . S353

Summary Table 4.10I. Comprehensive Electronically Delivered Interventions: Evidence of WeightLoss in Comprehensive Electronic (Internet) InterventionsCompared With Other ComprehensiveInterventions (includes Onsite and/or Electronic): Weight Loss Outcome Data at 4 Monthsor Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S354

Summary Table 4.10J. Comprehensive Electronically Delivered Interventions: Evidence ofWeight Loss in Comprehensive Electronic (Interactive Equipment) InterventionsComparedWith Other Comprehensive Intervention (Internet or Onsite): Weight Loss Outcome Dataat 4 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S355

Summary Table 5.1. Component 1: Efficacy of Weight Loss Surgery . . . . . . . . . . . . . . . . . . . . . . . . . S356Summary Table 5.2. Component 2: Predictors Associated with Long-Term EffectsPatient

Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S368


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Summary Table 5.3. Component 2: Predictors Associated with Long-Term EffectsTypes of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S370

Summary Table 5.4. Component 3: Complications Associated with Weight Loss Surgery. . . . . . . . . . . . S381


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