Canadian Adult Obesity Clinical Practice Guidelines 1

KEY MESSAGES FOR HEALTHCARE PROVIDERS

• Obesity is a chronic, progressive and relapsing disease,characterizedbythepresenceofabnormalorexcessadipositythatimpairshealthandsocialwell-being.

• Screeningforobesityshouldbeperformedregularlybymea-suringbodymassindex(BMI)andwaistcircumference.

• Theclinicalassessmentofobesityshouldaimtoestablishthediagnosisandidentifythecausesandconsequencesofof

abnormalorexcessadiposityonapatient’sphysical,mentalandfunctionalhealth.

• Providersparticipatingintheassessmentofobesityshouldfocusonestablishingvaluesandgoalsoftreatment,identi-fyingwhichresourcesandtoolsmaybeneededandfoster-ingself-efficacywiththepatientinordertoachievelong-termsuccess.

• A non-judgmental, stigma-free environment is necessaryforaneffectiveassessmentofapatientlivingwithobesity.

Assessment of PeopleLiving with Obesity ChristianF.Rueda-ClausenMDPhDi,MeghaPoddarMDii,ScottA.LearPhDiii,PaulPoirierMDPhDiv,AryaM.SharmaMDPhDv

i) DepartmentofMedicine,UniversityofSaskatchewanii)DepartmentofEndocrinologyandMetabolism,McMaster

Universityiii)FacultyofHealthSciences,SimonFraserUniversityiv)QuebecHeartandLungInstitute,UniversitéLavalv)DepartmentofMedicine,UniversityofAlberta

Cite this Chapter

Rueda-ClausenCF,PoddarM,LearSA,PoirierP,SharmaAM.CanadianAdultObesityClinicalPracticeGuidelines:AssessmentofPeopleLivingwithObesity.Availablefrom: https://obesitycanada.ca/guidelines/assessment. Accessed[date].

Update History

Version1,August4,2020.TheCanadianAdultObesityClinicalPracticeGuidelinesarealivingdocument, withonlythelatestchapterspostedat obesitycanada.ca/guidelines.

RECOMMENDATIONS

1.Wesuggestthathealthcareprovidersinvolvedinscreening,assessingandmanagingpeoplelivingwithobesityusethe5Asframeworktoinitiatethediscussionbyaskingfortheirpermissionandassessingtheirreadinesstoinitiatetreatment(Level4,GradeD,Consensus).

2.Healthcareproviderscanmeasureheight,weightandcalculateBodyMassIndex(BMI)inalladults(Level2a,GradeB),1–9

andmeasurewaistcircumferenceinindividualswithaBMI25–35kg/m2(Level2b,GradeB).10–12

3.Wesuggestacomprehensivehistorytoidentifyrootcausesofweightgainaswellascomplicationsofobesityandpotentialbarrierstotreatmentbeincludedintheassessment(Level4,GradeD).13–15

4.Werecommendbloodpressuremeasurementinbotharms,fastingglucoseorglycatedhemoglobinandlipidprofiletodetermine cardiometabolic risk and, where appropriate,ALTtoscreenfornonalcoholicfattyliverdiseaseinpeoplelivingwithobesity(Level3,GradeD).16,17

5.WesuggestprovidersconsiderusingtheEdmontonObesityStagingSystemtodeterminetheseverityofobesityandtoguideclinicaldecisionmaking(Level4,GradeD).18,19

Canadian Adult Obesity Clinical Practice Guidelines 2

Introduction

Obesity isachronicdiseasethatrequiresasystematicandcom-prehensivediagnosis,assessmentandtreatmentapproach.20Theobjective of an obesity assessment is to gather information toconfirmthediagnosis,determinetheseverityofthediseaseandrelatedcomorbidities, identifytriggersanddrivers,andtoguideappropriatemanagement discussions in a non-biased and stig-ma-free clinical setting.21 Providers should initiate a discussionwiththepatientabouttheirvaluesandgoalsfortreatment, fa-cilitatereflectionandencourageaccountabilityandself-directedmanagementtopromotelong-termimprovementsinhealth.15

This chapter provides an evidence-based approach to assessingobesity in theprimarycaresetting throughastructuredhistory,physical exam and clinically appropriate laboratory testing. Theauthorsalsodiscussclinicaltoolsthatallowforeasyandefficientuseinroutineclinicalpractice.

Definition of obesity

Obesityisaprevalent,complex,progressiveandrelapsingchronicdiseasecharacterizedbyabnormalorexcessivebodyfat(adiposity)thatimpairshealth.22–24Obesityhastraditionallybeenviewedasariskfactorforawiderangeofotherhealth issues.TheCana-dian Medical Association,20 however now considers obesity tobeachronicdiseaseinitsownright,similartotype2diabetes,hypertension and dyslipidemia (in linewith other organizationsincludingObesity Canada, the AmericanMedical Association,25

theWorldHealthOrganization,24 theWorldObesity Federationandothers).25–27

Initiating a discussion about obesity management

Primarycareprovidersplayanimportantroleinthemanagementofmostchronicdiseases.However,duetothemultitudeofdemandsinprimarycareandlackofcomfortandtraining,theassessmentandmanagementofobesity isnoteasilyundertaken.The initialap-proach,communicationandattitudeof thephysicianduringanobesity assessment is a significant determinant to the patient’ssuccess.28,29

Many patients livingwith obesity have experienced some formofweightbiasinthesetting.30,31Thisisdueinparttoprofession-als’endorsementofnegativeattitudesandbeliefsaboutobesity,misinformationaboutcausalityandperceptionsthatpatientswithobesitymay be unmotivated and noncompliant.Many patientsfeeldiscriminatedagainst,and,asaresult,willoftenavoidseek-ing treatment and delay preventive care.32 This can affect theirhealth status, their relationshipwith professionals and their re-sponsetointerventions.33 Werecommendthathealthcareprovidersapproachpatientswithempathy and sensitivity. In addition, it’s important to acknowl-edgethecomplexityofthediseaseandthedifficultyinsustainingbehaviouralchangeaswellasavoidstereotypesandoversimplifi-cationofthedisease.34Asupportiveenvironmentwithappropri-ate equipment (for example, appropriately sizedbloodpressurecuffsandgowns,armlesschairsinwaitingrooms,aprivateroomforweigh-ins) andasking forpermission toweighpatients canhelpfosterpatientcomfortanddignity.Stigmatizationofpatientsleadstoworsenedoutcomesandpromotesdisorderedeating,in-creasedratesofdepressionandlowerratesofphysicalactivity.35

ThisisreviewedindetailinthechapterReducingWeightBiasinObesityManagement,PracticeandPolicy.

Theuseofstructuredinterviewformats(suchasObesityCanada’s5AsofObesityManagementTM)hasbeenproposedtohelpfacili-tatediscussionsaboutobesityinprimarycare.36,37Anadaptationofthe5As’templatehasbeendevelopedbyObesityCanadaforuseinclinicalpractice.Themaincomponentsofthisframeworkinclude:

1.ASKINGforpermissiontodiscussweightandexplorereadiness;

2.ASSESSINGobesity-relatedrisksandrootcausesofobesity;

3.ADVISINGonhealthrisksandtreatmentoptions;

4.AGREEINGonhealthoutcomesandbehaviouralgoals;and

5.ASSISTINGinaccessingappropriateresourcesandproviders.38,39

Finally,whenconductinganobesityassessmentand inorder toachievelong-termsuccess,itisimportanttoassesseachpatient’sreadiness to change, intrinsic motivation and value and goals

KEY MESSAGES FOR PEOPLE LIVING WITH OBESITY

• Obesityisachronicdiseasecharacterizedbytheaccumu-lationofexcessbodyfatthatcanhaveanegativeimpactonyourphysicalandmentalhealth,aswellasyouroverallqualityoflife.

• Toguideyouandyourclinicianonthebestobesitytreat-mentoptions,aclinicalevaluationisneededtodetermine

howyourweightimpactsyourhealthandwellbeing.Thismayincludebothamentalhealthassessmentandaphysicalexam.

• Weightbiasandstigmaarecommoninthesettingandcanbedetrimentaltohelpingyouachieveyourhealthgoals.Healthcareprovidersshouldconducttheirobesityassessmentinasensitiveandnon-judgmentalway.

Canadian Adult Obesity Clinical Practice Guidelines 3

when initiating a treatment plan.40 Personalizing the approach,recognizing patients’ strengths and reframing misconceptionsaboutobesityareimportantkeyprocessesthatcanhaveaposi-tiveimpactonthepatient’sabilitytomakelong-termchanges.15,24 TheseconceptsarereviewedindetailintheEffectivePsychologicalandBehaviouralInterventionsinObesityManagementchapter.

Screening for obesity

Priortoinitiatingscreeningorassessmentforobesity,itisimportanttoaskpatients’permissiontodiscussthetopicand/ortoconductanthropometricmeasurements.Evaluationofanthropometricpa-rameters is recommendedasapractical screening tool to iden-tify patients with increased adiposity in whom more intensiveassessments may be indicated.41 Moreover, performing regularanthropometricscreeningcanidentifypatientsatriskofdevelop-ingobesityinwhomawarenessoftheirriskandimplementationofpreventivemeasurescanhaveasignificantpositivelong-termeffectontheirhealth.42,43Manyanthropometricparametershavebeenrecommendedinthescreeningandassessmentofobesity;,however,acalculatedbodymassindex(BMI)andmeasuredwaistcircumference(WC)44arethemostwidelyused. Traditionally,BMI(weight[kg]/height2[m])hasbeenusedasasur-rogatemeasureofbodyfat,andthusanobjectiveparametertodefineobesity,bothinepidemiologicalandclinicalstudies.12,45–48

LargeepidemiologicalstudieshaveshownthatAsianpopulationsmayhaveincreasedadiposityandcardiometabolicriskatalowerBMI,andalternativecut-offpointshavebeenproposedfor thispatientpopulation.49–54WidelyacceptedclassificationofobesitybasedonspecificBMIcut-offsarepresentedinTable1.

Formostpopulations,thepresenceofoverweight(BMI≥25kg/m2)representsanincreasedriskandrequiresfurtherevaluationofoth-eranthropometric,hemodynamicandbiochemicalparameters.4,55 ABMI≥30kg/m2isassociatedwithanincreaseincardiovascularriskfactorsandall-causemortalityandshouldbeusedasascreen-ing criterion to identify obesity in the general population.4,5 InadultswithSouth-,Southeast-orEastAsianethnicity,therecom-mendedBMIcut-offforoverweightshouldbe≥23kg/m2.Inspe-cialpopulationssuchas theelderly,verymuscularpatients,andthosewithextremetallorshortstature,theBMIcanbemisleadingandneedstobeinterpretedwithcaution.9

HealthCanadarecommendsthediagnosisofobesitynotbebasedonBMIalone.56Nevertheless,givenitssimplicity,objectivity,andreproducibility,BMIcontinuestobeanimportantmeasureinepi-demiologicalandpopulation-basedsurveillancestudies.Inaclin-icalsetting,BMIattherecommendedcut-offsshouldserveonlyasasimplescreeningmeasure.WhenusedtogetherwithotherclinicalindicatorssuchasWCandclinicalevaluationofcardiomet-abolicandotherobesityrelatedcomplications,BMIcanhelpiden-tifyindividualswhomaybenefitfromobesitymanagement.WChasbeenindependentlyassociatedtoincreasecardiovascularrisk;however,itisnotagoodpredictorofvisceraladiposetissueonanindividualbasis.57 IntegrationofbothBMI andWC in clinical

assessmentmayidentifythehigher-riskphenotypeofobesitybet-terthaneitherBMIorWCalone,particularlyinthoseindividualswithlowerBMI.58–60

RegularassessmentofBMI,WCandcardiometabolic risk factorscanhelpidentifypeopleatgreaterriskofdevelopingobesity.Reg-ular assessment should also inform care and allow for increasedvigilanceavoidingobesogenicmedications(seeTable8)andcoun-sellingontheavoidanceofweightgainduringhighrisktimeperi-ods,suchaspregnancyorforcedsedentarinessduetoinjury(seePreventionandHarmReductionofObesity[ClinicalPrevention]).

Box 1: Measuring Body Mass Index

Table 1: Recommended Classificationof BMI45,53

• Allanthropometricmeasurementsshouldbeconductedbarefootandinlightclothing.

• Weightandheightshouldbemeasuredbytrainedprofessionalsusingstandardizedtechniquesandequip-mentandrecordedtothenearest0.1kgand1cm.

• BMIshouldbecalculatedasweight(kg)dividedbythesquareofthebodyheightinmetres(kg/m2).

Category BMI (kg/m2)

Caucasian, Europid and North American ethnicity45

Underweight <18.5

Normal(healthyweight) 18.5–24.9

Overweight 25–29.9

ObesityClassI 30–34.9

ObesityClass2 35–39.9

ObesityClass3 40–49.9

ObesityClass4 50–59.9

ObesityClass5 ≥60

South-, Southeast- or East Asian ethnicity53

Underweight <18.5

Normalrange 18.5–22.9

Overweight—Atrisk 23–24.9

Overweight—Moderaterisk 25–29.9

Overweight—Severerisk ≥30

Canadian Adult Obesity Clinical Practice Guidelines 4

AlthoughBMI isa simple,objective,and reproduciblemeasure,ithascertainlimitationsthatneedtoberecognizedbycliniciansusingthesetools.36,37

• BMIisnotadirectmeasureofbodyfat,cardiovascularriskorhealth.

• BMIdoesnotindicatebodyfatdistribution.

• BMIdoesnotaccountformusclemass(itoverestimatesbodyfatinmuscularindividuals).

• BMIcanunderestimatebodyfatinpeoplewhohavelostmusclemass(sarcopenicobesity).

• BMIdoesnotdistinguishbetweenmen,womenorethnicity.

• BMIislessaccurateincertainpopulations(e.g.theelderly,peoplewithphysicaldisability,people<18yearsofage,peoplewithsevereobesity,duringpregnancyandinpatientswithascitesorsevereedema).

• BMIover-orunderestimatesbodyfatincertainethnicgroups,suchasIndigenousPeoples,SouthAsians,Chineseandotherpopulations.

Waist circumference

Considering the limitation of BMI in determining fat composi-tion anddistribution aswell as the anatomical variations in fatdeposition, theuseofWChas been recommended as a surro-gatemeasureof abdominalor visceral fat.61 There is epidemio-logicalevidencetosuggestthatWCcanhelpidentifyindividualsatincreasedriskforcardiometabolicdisease.57,62,63AstandardizedmethodforaccuratelymeasuringWCisoutlinedinBox2.CurrentrecommendedWCcut-offsareincludedinTable2.

IntheUnitedStatesandCanada,aWC≥102cm(inmen)or≥88cm(inwomen)indicatesanincreasedriskofvisceraladiposityandof developing cardiometabolic comorbidities. For adults with apredominantSouthAsian,SoutheastAsian,orEastAsianethnicity,alowercut-offforWC(≥85cminmenand≥75cminwomen)isrecommended.

Despite its low-techappealandsignificantstatisticalassociationwithcardiometabolic risk, thereare important limitationstotheroutineuseofWCmeasurementintheclinicalsetting:

• WCisnotadirectmeasureofvisceralfat.

• Considerabletrainingandstandardizationarerequiredtoen-sureinter-andintra-readerreproducibility.

• WC is sensitive toabdominaldistentiondue to foodorfluidintake,bloating,ascites,pregnancy,etc.

• Varyingcut-offsforethnicpopulations.

• LesssensitivemeasureofvisceralfatwithincreasingBMI.

• WCrequiresfurtherbodyexposureandcanbeperceivedasanintrusivemeasurementbysomepatients.

AswithBMI,WCcanbeusedasasimpleandpracticalscreeningtooltoidentifyindividualsathigherriskofcardiometabolicdisease.Thismaybeparticularly true for individualswho fall below theaccepted BMI cut-offs for obesity. A variety of optimal cut-offvalues havebeenproposed, dependingon ethnicity,measuringtechniqueandoutcomesofinterest.Mostcut-offsrangefrom65.5to101.2cmforwomenand72.5to103cmformen.63,69–71 Pa-tientswithanincreasedBMI(<35kg/m2)andanelevatedWCareassociatedwithan increased riskofdevelopingcardiometabolicriskfactorssuchasdiabetesmellitustype2andhypertension.72 ThosewithaBMI>35kg/m2arelikelytobeatanincreasedriskofcardiometabolicriskfactorsirrespectiveoftheirWC.

Integration of anthropometric measurements

BothBMIandWCprovidevaluableandcomplementaryinformationintheassessmentofobesityandtheestimationofcardiometabolicrisk.AmongindividualswithanelevatedBMI(<35kg/m2),havinganincreasedWCmayimplyagreaterriskofdevelopingsignificant

Box 2: Measuring Waist Circumference

1.Removeclothingfromthewaistline.

2.Standwithfeetshoulderwidthapart(25to30cmor10to12inches)andastraightback.

3.Palpatetheabdomentolocateinferiormarginofthelastribatthelevelofthemid-axillaryline.

4.Palpateandidentifythecrestoftheileuminbothsides.Usetheareabetweenthethumbandindexfingertofeelforthehipboneatthelevelofthemid-axillaryline.Thisisthepartofthehipboneatthesideofthewaist,notatthefrontofthebody.

5.WCshouldbemeasuredattheendofanormalexpi-ration,midwaybetweentheinferiormarginofthelastribandthecrestoftheileuminahorizontalplaneusingastretch-resistanttapethatprovidesaconstant100gtensionandshouldberecordedtothenearest1cm.

6.Havethepatienttaketwonormalbreaths,andontheexhaleofthesecondbreathtightenthetapemeasuresoitissnugbutnotdiggingintotheskin.

Canadian Adult Obesity Clinical Practice Guidelines 5

cardiometabolicoutcomes.Furthermore,amongpatientswithanormal BMI, an increase inWCmay imply intra-abdominal fatdeposition and an increased risk of cardiometabolic disease.73 Thesepatientsmaybenefit fromearly intervention to treatandprevent obesity-related complications. Finally,measuringWC inpatientswithaBMI>35kg/m2maynotchangemanagement,but it canprovidepatientswith valuable information regardingtheefficacyoftheirtreatmentduringtheirlong-termfollow-up.Somepatientscanseechanges inadiposedistributionbeforeasignificantchangeinbodyweightorBMI.

AssessingtheimpactofexcessorabnormaladiposityonhealthTheassociationbetweenthediagnosisofobesityandthedevel-opmentofobesity-relatedcomplicationsisstrongbutnotalwayslinear;therefore,comparablelevelsofexcessadiposityobesitycanhavedifferent levelsof impactonhealth andqualityof life fordifferentpatients.Similarly,multiplereportshavedocumentedasubgroupof“metabolicallyhealthy”patientswithobesity,char-acterizedbytheabsenceofanyobjectiveevidenceof increasedcardiometabolic risk despite having an elevated BMI andwaistcircumference.74,75Despitetheabsenceofconcurrentcardiometa-bolicriskfactors,theso-calledmetabolicallyhealthypatientswith

obesityshouldnotbeconsideredtobefullymedicallyhealthy,asthesepatientsareat increased riskofmortality,75andaremorelikely to suffer other non-metabolic conditions associated withobesity such as sleep apnea, depression and joint/back pain,among others. Information gathered in the obesity assessmentandanalyzedusingtheEdmontonobesitystagingsystem18,19can helptounderstandtheseverityofthediseaseandguidetheinten-sityoftreatmentrequired.

Edmonton Obesity Staging System

Elementsof theEdmontonObesityStagingSystem(EOSS)havebeenproposedtoguideclinicaldecisionsfromtheobesityassess-mentandateachBMIcategory.19Table3reviewstheproposedclinicalstaginganditsimpactonmanagement.EOSSisameasureofthemental,metabolicandphysicalimpactthatobesityhashadonthepatients’healthandusesthesefactorstodeterminetheirstageofobesity(fromstage0–4).Inpopulationstudies,EOSShasbeenshowntobeabetterpredictorofall-causemortalitywhencomparedtoBMIorwaistcircumferencemeasurementsalone.40

Table 2: Proposed Waist Circumference Cut-Off Points (cm) to Define Increase AbdominalAdiposity by Predominant Ethnicity

Predominant Ethnicity

CaucasianEuropid/UnitedStates/ Mid-eastMediterranean64

Latinocentral/SouthAmerican65

Sub-SaharanAfrican64

AfricanAmerican

African

Asian

Chinese66

Korean67

CanadianAboriginal68

Increased Abdominal Adiposity / Cardiovascular Risk

Significant Abdominal Adiposity / Greater Cardiovascular Risk

Women

80

83

80

90

71.5

80

81

75

80

Women

88

90

99

81.5

85

Men

94

88

94

80

76.5

85

83

80

94

Men

102

94

95

80.5

90

Canadian Adult Obesity Clinical Practice Guidelines 6

Table 3: Edmonton Obesity Staging System

Stage Description Management

0

1

2

3

4

Noapparentobesity-relatedriskfactors(e.g.,bloodpressure,serumlipids,fastingglucose,etc.withinnormalrange),nophysicalsymptoms,nopsychopathology,nofunctionallimitationsand/orimpairmentofwell-being

Presenceofobesity-relatedsubclinicalriskfactors(e.g.,borderlinehypertension,impairedfastingglucose,elevatedliverenzymes,etc.),mildphysicalsymptoms(e.g.,dyspneaonmoderateexertion,occasionalachesandpains,fatigue,etc.),mildpsychopathology,mildfunctionallimitations and/ormildimpairmentofwell-being

Presenceofestablishedobesity-relatedchronicdisease(e.g.,hypertension,type2diabetes,sleepapnea,osteoarthritis,refluxdisease,poly-cysticovarysyndrome,anxietydisorder,etc.),moderatelimitationsinactivitiesofdailylivingand/orwell-being

Establishedend-organdamagesuchasmyocardialinfarction,heartfailure,diabeticcomplications,incapacitatingosteoarthritis,significantpsycho-pathology,significantfunctionallimitationsand/orimpairmentofwell-being

Severe(potentiallyend-stage)disabilitiesfromobesity-relatedchronicdiseases,severedisablingpsychopathology,severefunctionallimitationsand/orsevereimpairmentofwell-being

Identificationoffactorscontributingtoincreasedbodyweight

Counsellingtopreventfurtherweightgainthroughbehaviouralmeasures,includinghealthyeatingandincreasedphysicalactivity

Investigationforother(non-weight-related)riskfactors

Moreintensebehaviouralinterventions,includingnutritiontherapy,exerciseandpsychologicaltreatmentstopreventfurtherweightgain

Monitoringofriskfactorsandhealthstatus

Initiationofobesitytreatment,includingconsiderationsofallpsychologicalinterventions,pharmacologicalandsurgicaltreatmentoptions

Closemonitoringandmanagementofcomorbiditiesas indicated

Moreintensiveobesitytreatmentincludingconsiderationofallpsychologicalinterventions,pharmacologicalandsurgicaltreatmentoptions

Aggressivemanagementofcomorbiditiesasindicated

Aggressiveobesitymanagementasdeemedfeasible

Palliativemeasuresincludingpainmanagement,occupationaltherapyandpsychosocialsupport

Adaptedfrom:SharmaAM,KushnerRF.Aproposedclinicalstagingsystemforobesity.IntJObes.2009;33(3):289–295.19

Oncethediagnosishasbeenestablished,theprimarygoalfortheclinicalassessmentforobesityshouldbetoidentifythepossi-blecausesleadingtoweightgain,determinetheextenttowhichweighthasaffectedthepatients’healthandtosystematicallylookforbarriersintheirmanagement.76Giventhatobesityisacomplexandheterogeneousdisease,thisisoftenadauntingtaskforprimarycareproviders.Usingaclinicaltoolsuchasthe4Ms

framework(Mentalhealth,Mechanical,Metabolic,Monetaryhealth/Milieu)canprovideapracticalapproachforprimarycarephysicianstoexploremajordrivers,barriersandcomplicationsofobesity(seeTable4).77Itcanbeusedtoprovideastructuretoperformanefficientandcompleteobesityassessment,includingthehistory,physicalexamandclinicallyindicatedinvestigations.

Canadian Adult Obesity Clinical Practice Guidelines 7

Mechanical

Metabolic

Osteoarthritis

Gout

Sleepapnea

Plantarfasciitis

Gastroesophagealreflux

Urinaryincontinence

Intertrigo

Idiopathicintracranial hypertension (PseudotumourCerebri)

Thrombosis

Type2diabetes

Hyperlipidemia

Nutritionaldeficiency

Gout

Hypertension

History,X-ray

Uricacidlevel

STOPBANGsleepapneaquestionnaire,BerlinQuestionnaire,overnightsleepstudy

A1c,fastingglucose

Totalcholesterol,triglycerides,HDL-C

25hydroxy-vitaminD,ironstudies,serumB12level

Uricacid

Ensureappropriatecuffsize(bladderwidth40%ofarmcircumference,length80–100%ofarmcircumference)54

Avoidsteroidsifpossible

CPAPtherapyifindicated

Considermedicationoptionsthatareweightneutral,promoteweightloss

VitaminD1000-3000units/day, supplementasneededtoachieve therapeuticlevels

Avoidprednisoneifpossible

DASHdiet,considersecondarycauses (eg.sleepapnea,pain)

Prioritizemedicationsthataffecttherenin-angiotensinsystem,avoidbetablockersasfirstline

+ +

+ + +

+ + +

+ + *

+ +

+ + *

+ + *

+

+

+ + +

+ + +

+ + +

+ + +

+ +

Table 4: Components of the 4ms Framework for Assessment of Obesity77

Category Complications Frequency Investigations Treatment Notes

MentalHealth

Knowledge/cognition

Expectations

Self-mage

Internalizedweightbias

Mood/Anxiety

Addiction

Sleep

Attention

Personality

Thiscanbeaccomplishedthroughsensitivequestioning/dialogue(e.g.,“Canyousharewithmeiforhowyourweight affectsyourperceptionofyourself/motiva-tionalinterviewing,”)orbyquestionnaire(WBIS).SeethechapterReducingWeightBiasinObesityManagement,PracticeandPolicyfordetails.

PHQ-9,GAD

YaleFoodAddictionScale

Unresolvedperceptionofweightbias canhaveaninfluenceonobesity management.

Copingstrategiestoaddressinternalizedweightbiasshouldbeincorporatedintobehaviouralinterventions,consistentwiththeprinciplesofcognitivebehaviouraltherapyandacceptanceandcommitmenttherapy.

Ifstartingpharmacotherapy,consideroptionsthatdonotincreaseweight(seethechapterPreventionandHarmReductionofObesity(ClinicalPrevention)

+ + *

+ + *

++*(F>M)

+ + +

++*(F>M)

+ + *

+ + *

+ + *

+ + *

Canadian Adult Obesity Clinical Practice Guidelines 8

MonetaryHealth/ ”Milieu”

PHQ-9:PatientHealthQuestionnaire-9;GAD:generalizedanxietydisorder;CPAP:continuouspositiveairwaypressure;PCOS:polycysticovariansyndrome;LH/FSH:luteinizinghormone/folliclestimulatinghormone;DHEAS:dehydroepiandrosterone;TSH:thyroidstimulatinghormone;ECG:electrocardiogram;ECHO:echocardiogram;DVT/PE:deepvenousthrombosis/pulmonaryembolism;FIB-4:Fibrosis-4,F:Female;M:Male;RR:RelativeRisk;*Dependingonpatientpopulation.

Endocrine

PCOS/hypogonadism

Infertility

Cardiovascular disease

Leftventricularhypertro-phy,atrialfibrillation

Chronicvenousstasis/ulcers/thrombophlebitis

Stroke,DVT/PE

Neurological

Pseudotumorcerebri

Gastrointestinal disease

FattyLiver

Gallstones

Oncology

Colorectal,gallbladder,pancreatic,breast,renal,uterine,cervical,prostate

Skin

Acanthosis,skintags

Candida

Intertrigo

Tinea

Folliculitis

Socioeconomicstatus

Education

Accesstofood

Occupation

Disability

Clothing

Weightlossprograms

Accesstopharmacotherapy

Surgery

Vitamins

Totaltestosterone,estradiol,prolactin,17hydroxyprogesterone,LH/FSH,DHEAS,TSHifclinicalsuspicionofhypothyroidism

ECG,ECHO,treadmill/bicycle/nuclearstresstestifindicatedandifpatientable

Hx:Headache,pulsatiletinnitus, papilledema

Liverenzymeelevation,increasedliverstiffness(elastography)abdominal ultrasound,FIB-4score

Routinecancerscreening

Considermetforminifinsulinresistant

Patientswithobesityareathighriskforcertaincancersandarelesslikelytobescreenedduetotechnicalissueswithdiagnostictestinganddelaysinseekingmedicalattention.

+

+

+ +

+

++/+++

+ + +

+

+ + +

++*

+*

+*

+*

+

+ RR1–2(rare)butincreasedriskwithobesity

++ RR2–3(uncommon)screenifappropriate

+++ RR>3(common)screenmostpatients

Canadian Adult Obesity Clinical Practice Guidelines 9

Components of an obesity-centred history

Anobesity-centred history should include all parts of a routineclinicalinterview,suchaspastmedicalandsurgicalhistory,med-ications,allergiesandsocialandfamilyhistory.However,anem-phasisshouldbeplacedonscreeningforunderlyingrootcausesandconsequencesofobesity(reviewedinTable4).Keyelementsofthehistoryincludescreeningforsleepdisorders,physical,sexualandpsychologicalabuse,descriptionofeatingpatterns,physicalac-tivityandscreentime,internalizedweightbias,moodandanxietydisorders,aswellassubstanceabuseandaddiction.13,14A thor-oughhistoryofmedicationsshouldscreenforweight-promotingmedications. Consider alternative options where possible. Themostcommonweight-promotingmedicationsareoutlinedinTa-ble8.Theclinicianconductingtheassessmentshouldalsoidentifyanddocument thepatient’s valuesandgoals around treatmentand foster insight tohelpwith long-termcopingand self-man-agementskills.15,24Table5reviewssomekeycomponentswhichare specific to anobesity-focused interview.Keyprocessesof apersonalizedobesityassessmentinprimarycarearehighlightedinTable5;thesehavebeenshowntohaveapositiveimpactonthepatient’s’abilitytofostereverydaychangeandfacilitateimprove-mentsintheirphysical,mentalandsocialhealth.15,24

Components of an obesity-centered physical exam

An obesity-centered physical exam should be focused on de-termining the obesity phenotype, drivers of weight gain andtreatment barriers for all patients. The key components of anobesity-centredphysicalexamareoutlinedinTable6.Routinean-thropometricmeasurementsshould includeheight,weight,BMIandwaistcircumference.Bloodpressureshouldbemeasuredwithanappropriatelysizedcuffaccordingtothepatient’sarmcircum-ference.Ifalargeupperarmsizeisprohibitive,systolicbloodpres-surecanbemeasuredintheforearmselectingthecuffsize[smallcuff(20.0–26.0cm),standardcuff(25.4–40.6and25.0–34.0cm)andlargecuff[>32.0cm])accordingtoparticipant’sforearmcir-cumference.Forcuffinstallationintheforearmpositionthedistaledgeofthecuffshouldbelocatedabout6cmproximaltothestyloidprocessoftheulna.81,82Neckcircumferenceandairwaypatencyarealsohelpfultoestimatetheriskofsleepapnea.Inadditiontoaroutinecardiorespiratory,ahead,neckandgastrointestinalexamshouldbeperformedalongwith ageneral skin examination toruleoutcommonskinfindings(seeTable6).Ajointandgaitex-aminationisalsorecommendedtoassessforbarriersinmobility.AcursoryendocrineexamincludespalpatingforanenlargedthyroidglandandscreeningforsignsofCushingsyndromeandpolycysticovariansyndrome.Thesesigns,ifpresent,shouldpromptfurtherbiochemicalscreening.

Investigations to assess obesity

Diagnostictestingiscommonlyorderedduringtheinitialassess-mentofobesitytoidentifymetabolicproblemsandtotailortherapy.

Thereisnosinglebloodtestordiagnosticevaluationthatisindicatedforall patientswithobesity. The specificevaluationsperformedshouldbebasedonthepresentingsymptoms, thepatient’s riskfactorsandindexofsuspicion.Table7reviewssomebloodanddi-agnostictestingforclinicianstoconsiderwhenassessingapatientwithobesity.ScreeningformetabolicsyndromewithaHbA1corfastingbloodsugar,totalcholesterol,serumtriglyceridesandHDLlevelisrecommendedinmostpatients.84Patientswhoareathighriskoffattyliverdisease,includingthosewithtype2diabetesormetabolicsyndrome,shouldbescreenedwithanALTlevelandanabdominalultrasound.Areferraltogastroenterology/hepatologymaybeappropriateinpatientswithpersistentlyelevatedliveren-zymes(greaterthantwotimestheupperlimitofnormaloversixmonthsand/orhighFIB-4scores).Thegoldstandardtodiagnosenon-alcoholicfattyliverdiseaseisaliverbiopsy.85

Evaluation of coronary artery disease

Largeprospectivestudieshavedocumentedobesityasbeinganindependentpredictorofcoronaryarterydisease.86Thisrelation-shipwas stronger in younger individuals. Susceptibility to obe-sity-relatedcardiovascularcomplicationsisnotonlymediatedbyoverallbody fatmass,but is largelydependentupon individualdifferencesinregionalbodyfatdistribution.73,87Largecohortstud-iesusingimagingtechniqueshaveidentifiedexcessabdominalvis-ceraladiposetissueasastrongpredictorinthedevelopmentofcardiovasculardiseaseovertime,independentlyoftotalbodyfatmass.88 Numerous noninvasive tests can diagnose atherosclero-sisormyocardial ischemia,orboth.Thecorrectchoicedependsonlocalexpertise,therelativestrengthsandweaknessesofeachmodalityandindividualpatientcharacteristics,aswellaspretestlikelihoodofcoronaryarterydisease.

Electrocardiogram

ObesityhasthepotentialtoimpacttheECGinseveralways,in-cluding displacement of the heart by elevating the diaphragmin the supine position, increasing the cardiacworkload and in-creasingthedistancebetweentheheartandtherecordingelec-trodes.BesideslowQRSvoltageandleft-wardtrendintheaxis,otheralterationsfrequentlyseenarenonspecificflatteningoftheT-wavesintheinfero-lateralleads(attributedtothehorizontaldis-placementoftheheart)andvoltagecriteriaforleftatrialabnor-mality.Anincreasedincidenceoffalsepositivecriteriaforinferiormyocardialinfarctioninindividualslivingwithobesity,duetotheelevationofthediaphragmhasbeenreported.89LeftventricularhypertrophyisprobablyunderdiagnosedbasedontheusualECGcriteriainindividualswithgreaterthanClassIIobesity.Sincebase-lineECGmaybeinfluencedbyobesity(falsepositiveforinferiormyocardial infarction, microvoltage, nonspecific ST-T changes)and patientswith obesitymay have impairedmaximal exercisetestingcapacity(dyspnea,mechanicallimitations,leftventriculardiastolicdysfunction),othermodalitiesmaybeofinterestintheevaluationofcoronaryarterydisease inthispopulation. Indeed,due to impaired exercise tolerance because ofmechanical and

Canadian Adult Obesity Clinical Practice Guidelines 10

Table 5: Recommended Key Components of an Obesity-Centred Medical History

InterviewComponent Details

Implication/Significance /Recommended Actions

Weighthistory

Nutritionhistory

Physicalactivity

Depressionandanxietyscreening

Othermentalhealthissues/drivers

Addiction/ dependency

Documentageofonsetofobesityandmajorweighttrajectoriesovertime

Previousweightlossattemptsandresponsetointerventions(includingbehaviouralinterventions,medications,endoscopicandsurgicalinterventions

Highestandlowestweight

Majorlifeevent(s)associatedwithweightchange

Currentphaseofweight(e.g.,gaining,losing,stable)

Assessnutritionliteracy

Assessenergyintake

Identifycurrentnutritionalrestrictions(Celiacdisease,allergies)

Currentphysicalactivityincludingtimespentinsedentaryactivities

Limitationstoactivity(e.g.,pain,time,motivation)

Identifysociallimitingfactorrestrictingaccesstoincreasingphysicalactivity

Screenfordepressionandanxiety

Screenforattentiondeficithyperactivitydisorder,post-traumaticstressdisorder,chronicgrief

Psychologicalimpactofpreviousweightjourney

Smokingstatus

Alcoholintake

Useofcannabinoidsandotherpsychoactivesubstances

Currentorpreviousabuseofsubstance

Excessiveuseofcaffeinecontainingbeverages(e.g.sugarsweetenedbeverages)

Canhelptounderstandpatientsweightjourney,success/failuresofpastattemptsandcausesofweightgain/lossinthepast,childhoodvsadultobesity

Canhelptoestablishrealisticexpectations

Canhelptopreventfutureweightgainandtargetbehaviouralandpsychologicaltreatment

Canhelptomakeappropriategoals(ex.weightstabilizationifcurrentlygainingweight)

KeyProcesses15,24

•Showcompassion•Reallistening(paraphraseandsummarizetoensureyou

understandandvalidatethepatient’sthoughts)•Helppatientsmakesenseoftheirstory(findrootcauses,

fosterinsight,findpatterns/triggers,identifyvalues/goals,reflectontimelinetoacknowledgeimpactonlifeincontexttoweight)

Isthereconcernofphysiologicalhunger,emotionaleating,mindlesseating,knowledgedeficit?78

SeethechapterMedicalNutritionTherapyinObesityManagementfordetails

Helppatienttomakeself-directedactivitygoals

Addresslimitationsindependently(ex.painmanagementforjointpainetc.)

SeethechapterPhysicalActivityinObesityMedicine

KeyProcesses:15,24

• Recognizestrengths• Shiftbeliefs• Reframemisconceptions• Helpestablishwholepersonvaluegoalsandfunctional

outcomesinsteadofweight-basedgoals

Considerreferraltopsychiatry/psychology

Considerreferraltopsychiatry/psychology

Reviewchallengeswithbodyimage,self-esteem

Considerreferraltopsychiatry/psychology

Canadian Adult Obesity Clinical Practice Guidelines 11

Abuse

Sleephistory

Medicationhistory

Socialhistory

Familyhistory

Interpersonalassessment

Screenforpreviousandcurrentformsofabusephysical,psychologicalandsexual.

Numberofhoursofsleeppernight

Useofpharmacologicsleepingaids

Sleepapnea-hypopneascreening(suchasSTOPBANGSleepApneaQuestionnaire)

Reviewmedicationsthatcanhaveasignificantimpactonweight.80

Age,sex,ethnicity,maritalstatus,occupation/workschedule:numberofhoursperweek,nightshiftwork

Incomesupport,medicalcoverage,accesstoexercisefacilities

Leveloffunctionalindependence

Historyoffirst-degreerelativewithoverweight/obesityorrelatedcomplications?

Overweightandobesityinotherhouseholdmembers

Motivation

Confidence

Readinesstochange

Expectations

Unresolvedhistoryofabuseandcurrentabusecanbeabarriertoobesitymanagementandcanhaveanimpactonfoodbehavioursandrelationshipwithfood.

Interdisciplinaryapproachmayberequired.

Poorsleepqualityandquantitycanbeabarriertoobesitymanagement.79

Ifpositivescreening(STOPBANG>4),considerreferraltoruleoutsleepapnea.

SeeTable8.

Keyprocesses:15,24

• Makesenseofthestory• Helpestablishrootcauses

Eatingbehavioursinshiftworkersmayrequireadditionalconsiderationwhendecidingtherapeuticoptions

Evaluatepatients’accesstofoodoptions,nutritionaleduca-tion,cookingskills

Considerinvolvingasocialworker/counsellorincaseswhereincome,medicationcoverageandresourceaccessmaybelimited.

Inpatientswithdecreasedindependence,considerinvolvingcaregiversanddecisionmakers

Canhelpdeterminepatients’riskofobesityorrelated complications

Groupinterventionsaremorechallengingbutmorelikelytobefeasibleandsustainableinpatientsexposedtoenvironmentswhereobesityishighlyprevalent

SeethechapterEffectivePsychologicalandBehavioural InterventionsinObesityManagement

KeyProcesses:15,24

• Recognizestrengths• Shiftbeliefs(helpmanageexpectations,focusonthewhole

healthofthepatient)• Co-constructanewstory(contextintegration,prioritizing

goals)• Orientvaluesandplanactions(helpestablishdirection)• Fosterreflection(insight,motivation,accountability)• Helpinternalizecoremessages(helpestablishcopingskills)

Canadian Adult Obesity Clinical Practice Guidelines 12

Table 6: Key Components of An Obesity-Centred Physical Exam

Vital signs: bloodpressure(appropriatelysizedcuff),heartrate

Anthropometric measurement:weight,height,waistcircumference,BMI

Head and neck•Neckcircumference,Mallampatiscore•Thyroidexam•Cushing’s(moonfacies,prominentsupraclavicularanddorsocervicalfatpad)•Polycysticovarysyndrome(acanthosisnigricans,hirsutism,acne)

Cardiorespiratory•Heartrateandrhythm•Signsofheartfailure(addedheartsounds,pedaledema,pulmonaryrales)

Gastrointestinal•Liverspan•Umbilical,incisionalhernias•Screeningforstigmataofchronicliverdisease(encephalopathy,ascites,jaundice,palmarerythema,etc.)

Musculoskeletal•Osteoarthritis(Heberdens/Bouchardsnodes,weightbearingjoints)•Gout•Gaitexam

Skin•Candida,intertrigo,tinea,skintags,psoriasis,acanthosisnigricans•Nutritionaldeficiencies(pallorofconjunctiva,palmarcreaserubor,atrophicglossitis,neuropathy)83•Abdominalstriae(violaceousstriaewiderthan1cm)

Lower limbs•Lymphedema(non-painful,pittingedema,typicallyarms/legs)•Lipedema(oftenpainfulfatdeposition,non-pittingedema,typicallyinarmsandlegswithsparingofthehandsandfeet)•Venousinsufficiency,ulcers,stasis,thrombophlebitis

physiologicallimitationsrelatedtostresstestinginpatientsatveryhighBMIs,aperfusionscanmaybeusedinsteadofexercisetest-ingforevaluatingthepresenceofischemicheartdisease.

Exercise stress test

Standardstresstestperformanceislimitedinpatientswithobesityforanumberoffactors.ECGmodificationmightlimitaccuratein-terpretation.Aerobiccapacityisdiminishedbecauseofpulmonarydysfunction, orthopaedic limitations and left ventricular diastolicdysfunction.Many patientswith obesity fail to achieve 80–85%oftheage-predictedheartrateneededfordiagnosticallyvalidre-sults.90,91StandardBruceandmodifiedrampprotocolsachievevalidresultsinmostpatients,withpatientsterminatingthetestbecause

of fatigue, legpainordyspnea.92 Patientswithobesitymayalsoexperiencemobility, joint and balance issues limiting their abilitytouseatreadmill.Inthesepatients,theuseofabikeergometerisrecommended.Highersystolicanddiastolicbloodpressuresaretyp-icallyfoundduringtheexercisestresstestinpatientswithobesity.93

Nuclear imaging techniques

Technetiumsestamibiisthemarkerofchoiceinpatientswithobesitybecauseofgreaterenergyemission,whichgeneratesbetter im-ages.94–96Weight-basedlimitationsmightoccurinpatientswithabodyweightabove350pounds(~160kg),whichmightrequireplanarimaging.Newerandmoresensitivecamerasmighteliminatesomeoftheseissues,buttheirusestill leadstochallengeswith

Canadian Adult Obesity Clinical Practice Guidelines 13

tableweightandsize,giventhatproperpositioningofthepatientisrequiredinordertousethissystem.Positronemissiontomog-raphy (PET) computed tomography rubidium has a 91% sensi-bility, 89% specificity, is faster than sestamibi-SPECT, produceslessradiationexposure,betterquality imagesandcorrectionforattenuation,andhasagreaterdegreeofdiagnosticprecisionandareducedneedforinvasiveexaminations.97ThePETrubidiumisthenuclearimagingtechniqueofchoiceforpatientswithobesity.

Stress echocardiography

Despitesomelimitations,exercisestressechocardiographyisavalidtechniqueforpatientswithobesity.98Thefeasibilityofstressecho,us-ingeitherphysiologicalstress(treadmillexercise)orpharmacologicalstress(dobutamine)isexcellentinmostcases.Itiswidelyavailable,low-cost,radiationfreeandhasnoweightlimits.Stressechocardiog-raphyishighlyoperator-dependentandcanbelimitedinthepres-enceofpooracousticwindowsrelatedtopulmonarydisease,obesityand respiratorymotion. If severe limitations exist, transesophagealechocardiographywithdobutaminemightbeuseful.99

Evaluation of other conditions associated with obesity

WomenwithobesityandsymptomsofpolycysticovarysyndromeshouldbescreenedforLH,FSH,totaltestosterone,DHEAS,prolactin,

TSHand17hydroxyprogesterone levels.Otherendocrinopathies,including thyroid dysfunction, Cushing’s’ or acromegaly are notroutinelyrecommendedunlessclinicallywarranted.Weencourageage-appropriatecancerscreeningforpatientswithobesityastheyareatanincreasedriskandoftenhavepooroutcomesduetolowerratesofroutinescreeninganddelaysinseekingtreatment.

Can you have a high BMI and be healthy?

Aswithmost health indicators (e.g. bloodpressure, bloodglu-cose,cholesterol),thereexistsacurvilinearrelationshipbetweentheamountofbodyfatanditsimpactonhealth.Inepidemiolog-icalstudiestherelationshipbetweenbodyfat(orBMIasasurro-gate) andhealth impacts followsaU-shapedcurvewithhealthrisksprogressivelyincreasingatboththelowerandhigherendsoftheBMIspectrum.100Whilethereisastatisticallysignificantrela-tionshipbetweenincreasingBMIandhealthrisks,agivenindivid-ualcanpresentwithvirtuallynorelevanthealthissuesoverawiderangeofBMI levels.101,102Although individualswithanelevatedBMIwho appear healthymay have amodestly elevated healthrisk (and a high likelihood of developing complications in thelong-term),103thereiscurrentlynoevidencetosupportlong-termbenefitsofintentionalweightlossintheseindividuals.AprudentapproachtoindividualspresentingwithanelevatedBMIwithoutthepresenceofovertimpairmenttohealth,wouldbetoreinforcehealthbehavioursaimedatpreventing furtherweightgainandreducingthedevelopmentofrelevantcomplications.

Table 7: Laboratory and Diagnostic Tests to Consider in the Assessment of Patients with Obesity

Consider for most patients:•HbA1C•Electrolytesrenalfunctiontests(creatinine,eGFR)•Totalcholesterol,HDL-andLDL-cholesterol,triglycerides•Alanineaminotransferase(ALT)•Ageappropriatecancerscreening

Consider only if clinically indicated:•Complete(full)bloodcount•Thyroidstimulatinghormone/thyroidfunctiontests•Uricacid•Assessmentofiron(TIBC,%saturation,serumferritin,serumiron)•VitaminsB12andDlevels•Urinalysis•Urineformicro-proteinuria

Women with obesity and symptoms of polycystic ovary syndrome:•LH,FSH,totaltestosterone,DHEAS,prolactinand17hydroxyprogesteronelevels

LH:luteinizinghormone;FSH:folliclestimulatinghormone;DHEAS:dehydroepiandrosterone;TIBC:totalironbindingcapacity.

Canadian Adult Obesity Clinical Practice Guidelines 14

Table 8: Summary of Weight Promoting Medications and Alternate Therapies

Category Class Name Weight gain Alternative therapy

Antihyperglycemics

Antidepressants

Antipsychotics

Anticonvulsants

Corticosteroids

Hormonereplacementtherapy

Antihistamines

Betablockers

Antihypertensive

DPP4i:Inhibitorsofdipeptidylpeptidase4;GLP-1:Glucagon-likepeptide-1receptoragonists;NSAIDs:Nonsteroidalanti-inflammatorydrugs:SGLT-2:Sodiumglucoseco-transporter2;AGI:Alpha-glucosidaseinhibitor;ACEi:Angiotensinconvertinginhibitors;ARBs:AngiotensinIIreceptorsblockers;CCBs:Calciumchannelblockers;MAOIs:Monoamineoxidaseinhibitors;SSRIs:Selectiveserotoninreuptakeinhibitors;*Combinationtherapyislesslikelytocauseweightgain;h/hvariablereportedeffect;hupto5kgweightgain;hh5to10kgweightgain;hhhmorethan10kgweightgain.

Insulins

Thiazolidinedione

Sulfonylureas

Meglitinides

Tricyclics

Atypical

MAOIs

SelectiveSerotoninReuptakeInhibitors(SSRIs)

Lithium

Oralsteroids

Inhaledsteroids

EstrogensProgestogens

Insulin

Pioglitazone

Glipizide

Glyburide

Glimepiride

ChlorpropamideTolbutamideGliclazide

Repaglinide

AmitriptylineDoxepinImipramineNortriptylineMirtazapine

PhenelzineTranylcypromine

SertralineParoxetineCitalopramEscitalopramFluoxetineLithium

HaloperidolLoxapineClozapineChlorpromazineFluphenazineRisperidoneOlanzapineQuetiapineIloperidoneSertindole

ValproicAcidCarbamazepineGabapentin

PrednisonePrednisoloneCortisone

CiclesonideFluticasone

Diphenhydramine

Propranolol

MetoprololAtenolol

Clonidine

hh

hh

h

hh

hh

hhhhhh

h

hhhhhhhhhhhh

hhhhhh

hhhhhhhhhhhhh

hhhhhhhhhhhhhhhhhh

hhhhhhhhh

hhhhhhhhh

hh

hhh

h

h

hhh

h

Biguanide(metformin)

DPP4i(alogliptin,linagliptin,sitagliptin,saxagliptin)

GLP1analogs(exenatide,liraglutide,dulaglutide,semaglutide)

AGI(acarbose,miglitol)

SGLT2inhibitors(canagliflozin,dapagliflozin,empagliflozin)

Pioglitazone/metformin*Glipizide/metformin*Glyburide/metformin*

BupropionNefazodoneDuloxetineVenlafaxineDesvenlafaxineTrazodoneLevomilnacipranVilazodoneVortioxetineSelegiline(topicalMAOIs)

Fluvoxamine(variableweighteffect)

ZiprasidoneLurasidoneAripiprazole

TopiramateZonisamideLamotrigine

BudesonideNSAIDs

Oxymetazoline

ACEiARBsCCBs(maycausefluidretention)Timolol

PrazosinACEiARBsDiuretics

Canadian Adult Obesity Clinical Practice Guidelines 15

Correspondence:guidelines@obesitynetwork.ca

References

1. WormserD,KaptogeS,DiAngelantonioE,etal.Separateandcombinedasso-ciationsofbody-massindexandabdominaladipositywithcardiovasculardis-ease:collaborativeanalysisof58prospectivestudies.Lancet.377(9771):1085-1095.doi:10.1016/S0140-6736(11)60105-0

2. WhitlockG,LewingtonS,SherlikerP,ClarkeR,EmbersonJ,HalseyJ.Body-massindexandcause-specificmortalityin900000adults:collaborativeanalysesof57prospec-tive.Lancet.2009;373(9669):1083-1096.doi:10.1016/S0140-6736(09)60318-4

3. Cornier M, Despre J, Lopez-jimenez F, Rao G. A Scientific Statement Fromthe American Heart Association. Circulation. 2011;124(18):1996-2019.doi:10.1161/CIR.0b013e318233bc6a

4. GuhDP,ZhangW,BansbackN,AmarsiZ,BirminghamL,AnisAH.Theincidenceofco-morbiditiesrelatedtoobesityandoverweight:Asystematicreviewandmeta-analysis.BMCPublicHealth.2009;9(1):88.doi:10.1186/1471-2458-9-88

5. BerringtondeGonzalezA,HartgeP,CerhanJR,etal.Body-MassIndexandMor-talityamong1.46MillionWhiteAdults.NEnglJMed.2011;363(23):2211-2219.

6. Cerhan JR,Moore SC, Jacobs EJ, et al.Apooled analysis ofwaist circumfer-ence andmortality in 650,000 adults.MayoClin Proc. 2014;89(3):335-345.doi:10.1016/j.mayocp.2013.11.011.A

7. LassaleC,Tzoulaki I,MoonsKGM,etal.Separateandcombinedassociationsofobesityandmetabolichealthwithcoronaryheartdisease:apan-Europeancase-co-hortanalysis.EurHeartJ.2018;39(5):397-406.doi:10.1093/eurheartj/ehx448

8. WHO Expert Consultation. Appropriate body-mass index for Asian popu-lations and its implications for policy and intervention strategies. Lancet.2004;363(9403):157-163.

9. GavriilidouNN,PihlsgårdM,ElmståhlS.Anthropometricreferencedataforel-derlySwedesanditsdisease-relatedpattern.EurJClinNutr.2015;69(09):1066-1075.doi:10.1038/ejcn.2015.73

10. BalkauB,JeD,JpD,etal.InternationalDayfortheEvaluationofAbdominalObesity ( IDEA ):a studyofwaist circumference, cardiovasculardisease,anddiabetesmellitusin168,000primarycarepatientsin63countries.Circulation.2007;116(17):1942-1951.

11. DeKoningL,MerchantAT,PogueJ,AnandSS.Waistcircumferenceandwaist-to-hipratioaspredictorsofcardiovascularevents:Meta-regressionanalysisofprospec-tivestudies.EurHeartJ.2007;28(7):850-856.doi:10.1093/eurheartj/ehm026

12. VazquezG,DuvalS,JacobsDR,SilventoinenK.Comparisonofbodymassindex,waist circumference, andwaist/hip ratio in predicting incident diabetes: Ame-ta-analysis.EpidemiolRev.2007;29(1):115-128.doi:10.1093/epirev/mxm008

13. LuppinoFS,deWitLM,BouvyPF,etal.Overweight,obesity,anddepression:asystematicreviewandmeta-analysisoflongitudinalstudies.ArchGenPsychia-try.2010;67(3):220-229.

14. FosterGD,BorradaileKE,SandersMH,etal.Arandomizedstudyontheeffectofweightlossonobstructivesleepapneaamongobesepatientswithtype2diabetes:TheSleepAHEADstudy.ArchInternMed.2009;169(17):1619-1626.

15. LuigT,AndersonR,SharmaAM,Campbell-SchererDL.Personalizingobesityassessment and care planning in primary care: patient experience and out-comesineverydaylifeandhealth.ClinObes.2018;8(6):411-423.doi:10.1111/cob.12283

16. WildmanRP.Theobesewithoutcardiometabolicriskfactorclusteringandthenormalweightwithcardiometabolicriskfactorclustering:prevalenceandcor-relatesof2phenotypesamongtheUSpopulation(NHANES1999-2004).ArchInternMed.2008;168(15):1617-1624.doi:10.1001/archinte.168.15.1617

17. Campbell-scherer D, Ba JR, Mclsc DM, et al.Guideline harmonization andimplementation plan for the BETTER trial: Building on Existing Tools to Im-proveChronicDiseasePreventionandScreening in Family Practice.COpen.2014;2(1):E1-10.doi:10.9778/cmajo.20130040

18. GrammatikopoulouMG,ChourdakisM,GkiourasK,etal.Edmontonobesitystag-ingsystemamongpediatricpatients:avalidationandobesogenicriskfactoranaly-sis.JEndocrinolInvest.2018;41(8):947-957.doi:10.1007/s40618-017-0821-9

19. SharmaAM,KushnerRF.Aproposedclinicalstagingsystemforobesity. IntJObes.2009;33(3):289-295.doi:10.1038/ijo.2009.2

20. WisniewskiAE.Theweightofcommunication:TheCanadianMedicalAssoci-ation Journal’sdiscourseonobesity. PublicUnderstSci.2013;22(3):351-364.doi:10.1177/0963662511412861

21. PhelanSM,BurgessDJ,YeazelMW,HellerstedtWL,Griffin JM,RynMVan.Impactofweightbiasandstigmaonqualityofcareandoutcomesforpatientswithobesity.ObesRev.2015;16(4):319-326.doi:10.1111/obr.12266

22. Mechanick JI, Hurley DL, Garvey WT. Adiposity-based chronic disease as anew diagnostic term: The American association of clinical endocrinologistsand American college of endocrinology position statement. Endocr Pract.2017;23(3):372-378.doi:10.4158/EP161688.PS

23. Garvey WT, Mechanick JI. Proposal for a Scientifically Correct and Medi-cally Actionable Disease Classification System (ICD) for Obesity. Obesity.2020;28(3):484-492.doi:10.1002/oby.22727

24. WorldHealthOrganization.Obesity:preventingandmanagingtheglobalepidemicReportofaWHOConsultation(WHOTechnicalReportSeries894).2000:252.

25. Kyle T, Dhurandhar E, DB. A. RegardingObesity as a Disease: Evolving Pol-icies and Their Implications. Endocrinol Metab Clin. 2016;45(3):511-520.doi:10.1016/j.ecl.2016.04.004.Regarding

26. VallgårdaS,NielsenMEJ,HansenAKK,etal.ShouldEuropefollowtheUSanddeclareobesityadisease?:adiscussionoftheso-calledutilitarianargument.EurJClinNutr.2017;71(11):1263-1267.doi:10.1038/ejcn.2017.103

27. Ortiz SE, Kawachi I, Boyce AM. Themedicalization of obesity, bariatric sur-gery, and population health. Health (Irvine Calif). 2017;21(5):498-518.doi:10.1177/1363459316660858

28. WelzelFD,SteinJ,PabstA,etal.FiveA’scounselinginweightmanagementofobese patients in primary care:A cluster-randomized controlled trial (INTER-ACT).BMCFamPract.2018;19(1):97.doi:10.1186/s12875-018-0785-7

29. RetatL,PimpinL,WebberL,etal.Screeningandbriefinterventionforobesityinprimarycare:cost-effectivenessanalysisintheBWeLtrial.IntJObes.2019;1.

30. PuhlRM,LuedickeJ,GriloCM.Obesitybiasintraining:Attitudes,beliefs,andobservationsamongadvancedtraineesinprofessionalhealthdisciplines.Obesity.2014;22(4):1008-1015.doi:10.1002/oby.20637

Downloadedfrom:https://obesitycanada.ca/guidelines/assessment

ThisworkislicensedunderaCreativeCommonsAttribution-NonCommercial-NoDerivatives4.0InternationalLicense(CCBY-NC-ND4.0)

ThesummaryoftheCanadianAdultObesityClinicalPracticeGuidelineispublishedintheCanadian Medical Association Journal,andcontainsinformationonthefullmethodology, managementofauthors’competinginterests,abriefoverviewofallrecommendationsandotherdetails.MoredetailedguidelinechaptersarepublishedontheObesityCanadawebsiteatwww.obesitycanada.ca/guidelines.

Canadian Adult Obesity Clinical Practice Guidelines 16

31. Smigelski-Theiss R, Gampong M, Kurasaki J. Weight bias and psychosocialimplications for acute care of patients with obesity. AACN Adv Crit Care.2017;28(3):254-262.doi:10.4037/aacnacc2017446

32. HunteHER,WilliamsDR.Theassociationbetweenperceiveddiscriminationandobesity inapopulation-basedmultiracialandmultiethnicadultsample.AmJPublicHealth.2009;99(7):1285-1292.doi:10.2105/AJPH.2007.128090

33. PearlRL,HopkinsCH,BerkowitzRI,WaddenTA.Groupcognitive-behavioraltreatmentforinternalizedweightstigma:apilotstudy.EatWeightDisord-StudAnorexia,BulimObes.2018;23(3):357-362.doi:10.1007/s40519-016-0336-y

34. FruhSM,NadglowskiJ,HallHR,DavisSL,CrookED,ZlomkeK.ObesityStigmaandBias.JNursePract.2016;12(7):425-432.doi:10.1016/j.nurpra.2016.05.013

35. Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity.2009;17(5):941-964.doi:10.1038/oby.2008.636

36. AkpinarE,Bashan I,BozdemirN,SaatciE.Which isthebestanthropometrictechniquetoidentifyobesity:Bodymassindex,waistcircumferenceorwaist-hipratio?CollAntropol.2007;31(2):387-393.

37. FeldsteinCA,AkopianM,OlivieriAO,KramerAP,NasiM,GarridoD.Acompar-isonofbodymassindexandwaist-to-hipratioasindicatorsofhypertensionriskinanurbanArgentinepopulation:Ahospital-basedstudy.NutrMetabCardio-vascDis.2005;15(4):310-315.doi:10.1016/j.numecd.2005.03.001

38. Rueda-ClausenCF, Benterud E, Bond T,OlszowkaR,VallisMT, SharmaAM.Effect of implementing the 5As of Obesity Management framework onprovider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44.doi:10.1111/cob.12038

39. JayM,GillespieC,SchlairS,ShermanS,KaletA.Physicians’useofthe5Asincounselingobesepatients:Isthequalityofcounselingassociatedwithpatients’motivationandintentiontoloseweight?BMCHealthServRes.2010;10(1):159.doi:10.1186/1472-6963-10-159

40. SharmaAM,Campbell-SchererDL.Redefiningobesity:Beyondthenumbers.Obesity.2017;25(4):660-661.doi:10.1002/oby.21801

41. DouketisJD,MacieC,ThabaneL,WilliamsonDF.Systematicreviewoflong-termweightlossstudiesinobeseadults:Clinicalsignificanceandapplicabilitytoclini-calpractice.IntJObes.2005;29(10):1153-1167.doi:10.1038/sj.ijo.0802982

42. Littman AJ, Damschroder LJ, Verchinina L, et al.National evaluation of obe-sity screening and treatment among veterans with and without mentalhealth disorders. Gen Hosp Psychiatry. 2015;37(1):7-13. doi:10.1016/j.gen-hosppsych.2014.11.005

43. LauDCW,DouketisDJ,MorrisonKM,Hramiak IM,SharmaAM,UrE.2006Canadian clinical practice guidelines on themanagement andpreventionofobesity inadultsandchildren[summary].CanMedAssocJ.2007;176(8):S1-S13.www.cmaj.ca/cgi/content/full/176/8/S1/DC1.

44. OrtegaFB,SuiX,LavieCJ,BlairSN.Bodymassindex,themostwidelyusedbutalsowidelycriticizedindex:wouldacriterionstandardmeasureoftotalbodyfatbeabetterpredictorofcardiovasculardiseasemortality?MayoClinProc.2016;91(4):443-455.doi:10.1016/j.physbeh.2017.03.040

45. WorldHealthOrganization.Physicalstatus:Theuseandinterpretationofan-thropometry.1995;854.

46. SeidellJC,KahnHS,WilliamsonDF,LissnerL,ValdezR.Reportfromacentersfordiseasecontrolandpreventionworkshoponuseofadultanthropometryforpublichealthandprimaryhealthcare.AmJClinNutr.2001;73(1):123-126.doi:10.1093/ajcn/73.1.123

47. Pi-SunyerFX.Obesity:criteriaandclassification.ProcNutrSoc.2000;59(4):505-509.doi:10.1017/s0029665100000732

48. JavedA,JumeanM,MuradMH,etal.Diagnosticperformanceofbodymassindextoidentifyobesityasdefinedbybodyadiposityinchildrenandadolescents:Asystematicreviewandmeta-analysis.PediatrObes.2015;10(3):234-244.doi:10.1111/ijpo.242

49. MisraA,KhuranaL.Themetabolicsyndrome inSouthAsians:Epidemiology,determinants,andprevention.MetabSyndrRelatDisord.2009;7(6):497-514.doi:10.1089/met.2009.0024

50. HerathHMM,WeerasingheNP,WeerarathnaTP,AmarathungaA.ACompar-isonofthePrevalenceoftheMetabolicSyndromeamongSriLankanPatientswithType2DiabetesMellitusUsingWHO,NCEP-ATPIII,andIDFDefinitions.IntJChronicDis.2018:1-8.doi:10.1155/2018/7813537

51. JamesWPT,ChunmingC,InoueS.AppropriateAsianbodymassindices?ObesRev.2002;3(3):139-139.doi:10.1111/obr.12153

52. AltschulerEL.PrescientdescriptionoffrontallobesyndromeinanEdgarAllanPoetale.Lancet.2004;363(9412):902.

53. Pan W-H, Yeh W-T. How to define obesity? Evidence-based multiple ac-tion points for public awareness, screening, and treatment: an extension ofAsian-Pacific recommendations. Asia Pac J Clin Nutr. 2008;17(3):370-374.doi:10.6133/apjcn.2008.17.3.02

54. PanWH,YehWT,WengLC.EpidemiologyofmetabolicsyndromeinAsia.AsiaPacJClinNutr.2008;17:37-42.doi:10.1002/9780470779750.ch4

55. HarteminkN,BoshuizenHC,NagelkerkeNJD,JacobsMAM,VanHouwelingenHC.Combiningriskestimatesfromobservationalstudieswithdifferentexpo-surecutpoints:Ameta-analysisonbodymassindexanddiabetestype2.AmJEpidemiol.2006;163(11):1042-1052.doi:10.1093/aje/kwj141

56. HealthCanada.CanadianGuidelinesforBodyWeightClassificationinAdults:Quick Reference Tool for Professionals.; 2016. http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/cg_quick_ref-ldc_rapide_ref-eng.php.

57. YusufS,HawkenS,ÔunpuuS,etal.Obesityandtheriskofmyocardialinfarc-tion in 27 000participants from52 countries:A case-control study. Lancet.2005;366(9497):1640-1649.doi:10.1016/S0140-6736(05)67663-5

58. ThuTranNT,BlizzardCL,LuongKN,etal.Theimportanceofwaistcircumfer-enceandbodymassindexincross-sectionalrelationshipswithriskofcardio-vascular disease in Vietnam. PLoS One. 2018;13(5):e0198202. doi:10.1371/journal.pone.0198202

59. Du SM,MaGS, Li YP, et al.Relationship of bodymass index,waist circum-ferenceandcardiovascular risk factors inChineseadult.BiomedEnvironSci.2010;23(2):92-101.doi:10.1016/S0895-3988(10)60037-2

60. JanssenI,HeymsfieldSB,AllisonDB,KotlerDP,RossR.Bodymassindexandwaistcircumferenceindependentlycontributetothepredictionofnonabdomi-nal,abdominalsubcutaneous,andvisceralfat.AmJClinNutr.2002;75(4):683-688.doi:10.1093/ajcn/75.4.683

61. PinhoCPS,DinizAdaS,ArrudaIKG,LeiteAPDL,PetribuMdeMV,RodriguesIG.Waistcircumferencemeasurementsitesandtheirassociationwithvisceralandsubcutaneousfatandcardiometabolicabnormalities.ArchEndocrinolMe-tab.2018;62(4):416-423.doi:10.20945/2359-3997000000055

62. CsongováM,VolkovováK,GajdošM,et al.Gender-associateddifferences intheprevalenceofcentralobesityusingwaistcircumferenceandwaist-to-heightratio,andthatofgeneralobesity, inSlovakadults.CentEur JPublicHealth.2018;26(3):228-233.doi:10.21101/cejph.a4719

63. Wang Z,Ma J, Si D.Optimal cut-off values and populationmeans ofwaistcircumference in different populations. Nutr Res Rev. 2010;23(2):191-199.doi:10.1017/S0954422410000120

64. Alberti KGMM, Eckel RH,Grundy SM, et al.Harmonizing themetabolic syn-drome:Ajointinterimstatementoftheinternationaldiabetesfederationtaskforceonepidemiologyandprevention;Nationalheart, lung,andbloodinsti-tute;Americanheartassociation;Worldheartfederation;International.Circu-lation.2009;120(16):1640-1645.doi:10.1161/CIRCULATIONAHA.109.192644

65. HerreraVM,CasasJP,MirandaJJ,etal.Interethnicdifferencesintheaccuracyofanthropometricindicatorsofobesityinscreeningforhighriskofcoronaryheartdisease.IntJObes.2009;33(5):568-576.doi:10.1038/ijo.2009.35

66. PanJ,WangM,YeZ,etal.Optimalcut-offlevelsofobesityindicesbydifferentdefinitionsofmetabolicsyndromeinasoutheastruralChinesepopulation.JDiabetesInvestig.2016;7(4):594-600.doi:10.1111/jdi.12440

67. ChoGJ,YooHJ,HwangSY,etal.Differentialrelationshipbetweenwaistcircumfer-enceandmortalityaccordingtoage,sex,andbodymassindexinKoreanswithageof30–90years;anationwidehealthinsurancedatabasestudy.2018;16(1):131.

Canadian Adult Obesity Clinical Practice Guidelines 17

68. ManjooP,DannenbaumD,JosephL,TorrieJ.Utilityofcurrentobesitythresh-oldsinsignalingdiabetesriskintheJamesBayCreeofEeyouIstchee.BMJOpenDiabetesResCare.2015;3(1):e000114.doi:10.1136/bmjdrc-2015-000114

69. LearSA,JamesPT,KoGT,KumanyikaS.Appropriatenessofwaistcircumfer-enceandwaist-to-hipratiocutoffsfordifferentethnicgroups.EurJClinNutr.2010;64(1):42-61.doi:10.1038/ejcn.2009.70

70. CardinalTR,VigoA,DuncanBB,etal.Optimalcut-offpointsforwaistcircum-ference in the definition ofmetabolic syndrome in Brazilian adults: BaselineanalysesoftheLongitudinalStudyofAdultHealth(ELSA-Brasil).DiabetolMe-tabSyndr.2018;10(1):49.doi:10.1186/s13098-018-0347-0

71. ZaherZ,ZambariR,PhengC,MurugaV,NgB,AppannahG.Optimalcut-offlevelstodefineobesity:Bodymassindexandwaistcircumference,andtheirrelationshipto cardiovasculardisease,dyslipidaemia,hypertensionanddiabetes inMalaysia.AsiaPacJClinNutr.2009;18(2):209-216.doi:10.6133/apjcn.2009.18.2.09

72. Douketis JB,ParadisG,KellerH,MartineauC.Canadianguidelines forbodyweightclassificationinadults:Applicationinclinicalpracticetoscreenforover-weight andobesity and to assess disease risk.CMAJ. 2005;172(8):995-998.doi:10.1503/cmaj.045170

73. Yusuf PS, Hawken S, Ôunpuu S, et al.Investigators IS. Effect of potentiallymodifiable risk factors associatedwithmyocardial infarction in 52 countries(theINTERHEARTstudy):case-controlstudy.Lancet.2004;364(9438):937-952.doi:10.1016/S0140-6736(04)17018-9

74. LiH,HeD,ZhengD,etal.Metabolicallyhealthyobesephenotypeandriskofcar-diovasculardisease:ResultsfromtheChinaHealthandRetirementLongitudinalStudy.ArchGerontolGeriatr.2019;82:1-7.doi:10.1016/j.archger.2019.01.004

75. Neeland IJ,PoirierP,Després JP.CardiovascularandMetabolicHeterogeneityofObesity:ClinicalChallengesandImplicationsforManagement.Circulation.2018;137(13):1391-1406.doi:10.1161/CIRCULATIONAHA.117.029617

76. AronneLJ.Classificationofobesityandassessmentofobesity-relatedhealthrisks.ObesRes.2002;10(SUPPL.2):105-115.doi:10.1038/oby.2002.203

77. Sharma AM. M, M, M & M: a mnemonic for assessing obesity. Obes Rev.2010;11(11):808-809.doi:10.1111/j.1467-789X.2010.00766.x

78. SharmaAM,PadwalR.Obesityisasign-Over-eatingisasymptom:Anaetio-logicalframeworkfortheassessmentandmanagementofobesity.ObesRev.2010;11(5):362-370.doi:10.1111/j.1467-789X.2009.00689.x

79. VanCauterE,KnutsonKL.Sleepand theepidemicofobesity inchildrenandadults.EurJEndocrinol.2008;159(SUPPL_1):S59-S66.doi:10.1530/EJE-08-0298

80. DomecqJP,PrutskyG,LeppinA,etal.Drugscommonlyassociatedwithweightchange: A systematic review and meta-analysis. J Clin Endocrinol Metab.2015;100(2):363-370.doi:10.1210/jc.2014-3421

81. LeblancMÈ,AuclairA,LeclercJ,etal.BloodPressureMeasurementinSeverelyObesePatients:ValidationoftheForearmApproachinDifferentArmPositions.AmJHypertens.2019;32(2):175-185.doi:10.1093/ajh/hpy152

82. LeblancMÉ,CroteauS,FerlandA,etal.Bloodpressureassessment in severeobesity: Validation of a forearm approach. Obesity. 2013;21(12):533-541.doi:10.1002/oby.20458

83. AasheimET,AylwinSJB,RadhakrishnanST,etal.Assessmentofobesitybeyondbodymassindextodeterminebenefitoftreatment.ClinObes.2011;1(2-3):77-84.doi:10.1111/j.1758-8111.2011.00017.x

84. CanadianCardiovascularSociety.TheCanadianCardiovascularSociety’sDYS-LIPIDEMIAGuidelines.;2016.http://search.jamas.or.jp/link/ui/2016153831.

85. ChalasaniN,YounossiZ,LavineJE,etal.Thediagnosisandmanagementofnonal-coholicfattyliverdisease:PracticeguidancefromtheAmericanAssociationfortheStudyofLiverDiseases.Hepatology.2018;67(1):328-357.doi:10.1002/hep.29367

86. Poirier P,Giles TD,BrayGA,et al.Obesity and cardiovasculardisease: Patho-physiology, evaluation, and effect of weight loss: An update of the 1997AmericanHeartAssociationScientificStatementonobesityandheartdiseasefromtheObesityCommitteeoftheCouncilonNutrition,Physical.Circulation.2006;113(6):898-918.doi:10.1161/CIRCULATIONAHA.106.171016

87. KragelundC,HassagerC,HildebrandtP,Torp-PedersenC,KøberL.Impactofobesityonlong-termprognosisfollowingacutemyocardialinfarction.IntJCar-diol.2005;98(1):123-131.doi:10.1016/j.ijcard.2004.03.042

88. Abraham TM, Pedley A,Massaro JM, HoffmannU, FoxCS. Association be-tweenvisceralandsubcutaneousadiposedepotsand incidentcardiovasculardiseaseriskfactors.Circulation.2015;132(17):1639-1647.doi:10.1161/CIRCU-LATIONAHA.114.015000

89. FusterV,AlexanderR,O’RourkeR.Hurst’sTheHeart,10thEdition.;2000.

90. GondoniLA,TitonAM,NibbioF,AugelloG,CaetaniG,LiuzziA.Heart ratebehaviorduringanexercisestresstestinobesepatients.NutrMetabCardiovascDis.2009;19(3):170-176.doi:10.1016/j.numecd.2008.07.001

91. LearS,BrozicA,MyersJ,AI.Exercisestresstesting.Anoverviewofcurrentguidelines.SportMed.1999;27(5):285-312.doi:10.1016/B978-1-4557-4815-0.00006-4

92. Bires,AM,LawsonD,WasserTE,Raber-BaerD.Comparisonofbrucetreadmillexercisetestprotocols:Isrampedbruceequalorsuperiortostandardbruceinproducingclinicallyvalidstudiesforpatientspresentingforevaluationofcardi-acischemiaorarrhythmiawithbodymassindexequaltoorgrea.JNuclMedTechnol.2013;41(4):274-278.doi:10.2967/jnmt.113.124727

93. ChrysohoouC,SkoumasJ,GeorgiopoulosG,etal.Exercisecapacityandhae-modynamicresponseamong12,327individualswithcardio-metabolicriskfac-torsundergoingtreadmillexercise.EurJPrevCardiol.2017;24(15):1627-1636.

94. KorbeeR,BoitenH,OttenhofM,ValkemaR,vanDomburgR,SchinkelA.Whatisthevalueofstress(99m)Tc-tetrofosminmyocardialperfusionimagingfortheassessmentofverylong-termoutcomeinobesepatients?JNuclCardiol.2013;20(2):227-233.

95. FerraroS,Perrone-FilardiP,DesiderioA,etal.Leftventricularsystolicanddiastol-icfunctioninsevereobesity:Aradionuclidestudy.Cardiology.1996;87(4):347-353.doi:10.1159/000177118

96. FreedmanN,SchechterD,KleinM,MarcianoR,RozenmanY,ChisinR.SPECTattenuation artifacts in normal andoverweight persons: Insights froma ret-rospective comparison of Rb-82 positron emission tomography and TI-201SPECTmyocardialperfusionimaging.ClinNuclMed.2000;25(12):1019-1023.doi:10.1097/00003072-200012000-00014

97. YoshinagaK,ChowBJW,WilliamsK,etal.WhatisthePrognosticValueofMyo-cardialPerfusionImagingUsingRubidium-82PositronEmissionTomography?JAmCollCardiol.2006;48(5):1029-1039.doi:10.1016/j.jacc.2006.06.025

98. SupariwalaA,MakaniH,KahanJ,etal.Feasibilityandprognosticvalueofstressechocardiographyinobese,morbidlyobese,andsuperobesepatientsreferredforbariatricsurgery.Echocardiography.2014;31(7):879-885.doi:10.1111/echo.12481

99. MaduE.Transesophagealdobutaminestressechocardiographyintheevaluationofmyocardial ischemia inmorbidly obese subjects.Chest. 2000;117(3):657-661.doi:10.1378/chest.117.3.657

100.BhaskaranK,dos-Santos-SilvaI,LeonDA,DouglasIJ,SmeethL.AssociationofBMIwithoverallandcause-specificmortality:apopulation-basedcohortstudyof3·6millionadults in theUK.LancetDiabetesEndocrinol.2018;6(12):944-953.doi:10.1016/S2213-8587(18)30288-2

101.XuY,LiH,WangA,etal.Associationbetweenthemetabolicallyhealthyobesephenotypeandtheriskofmyocardialinfarction:ResultsfromtheKailuanstudy.EurJEndocrinol.2018;179(6):343-352.doi:10.1530/EJE-18-0356

102.Lee SJ, Arslanian S. Body Composition and Cardiorespiratory Fitness Be-tween Metabolically Healthy Versus Metabolically Unhealthy Obese BlackandWhite Adolescents. J Adolesc Heal. 2019;64(3):327-332. doi:10.1016/j.jadohealth.2018.08.024

103.LinH,ZhangL,ZhengR,ZhengY.Theprevalence,metabolicriskandeffectsoflifestyleinterventionformetabolicallyhealthyobesity:asystematicreviewandmeta-analysisAPRISMA-compliantarticle.Med(UnitedStates).2017;96(47).doi:10.1097/MD.0000000000008838