Guidlines for MANAGEMENT of Obesity 2000

8/14/2019 Guidlines for MANAGEMENT of Obesity 2000

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N A T I O N A L I N S T I T U T E S O F H E A L T H

N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E

A T I O N A L I N S T I T U T E S O F H E A L T H

A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T EO R T H A M E R I C A N A S S O C I A T I O N F O R T H E S T U D Y O F O B E S I T Y

The PracticalGuideIdentification,Evaluation,and Treatmentof Overweight andObesity in Adults

NHLBI Obesity Education Initiative


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ACKNOWLEDGMENTS:

The Working Group wishes to acknowledge

the additional input to the Practical Guide from

the following individuals: Dr.Thomas Wadden,

University of Pennsylvania; Dr. Walter Pories,

East Carolina University; Dr. Steven Blair,

Cooper Institute for Aerobics Research; and

Dr.Van S. Hubbard, National Institute of

Diabetes and Digestive and Kidney Diseases.


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The PracticalGuideIdentification,Evaluation,

and Treatmentof Overweight andObesity in Adults

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication Number 00-4084

October 2000

NHLBI Obesity Education Initiative

North American Association for the Study of Obesity


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NHLBI Obesity Education InitiativeExpert Panel on the Identification,Evaluation, and Treatment ofOverweight and Obesity in Adults.

F.Xavier Pi-Sunyer, M.D., M.P.H.Columbia University Collegeof Physicians and SurgeonsChair of the Panel

MEMBERSDiane M. Becker, Sc.D., M.P.H.

The Johns Hopkins University

Claude Bouchard, Ph.D.Laval University

Richard A. Carleton, M.D.Brown University School of Medicine

Graham A. Colditz, M.D., Dr.P.H.Harvard Medical School

William H. Dietz, M.D., Ph.D.National Center for Chronic DiseasePrevention and Health PromotionCenters for Disease Control and Prevention

John P. Foreyt, Ph.D.Baylor College of Medicine

Robert J. Garrison, Ph.D.

University of Tennessee, MemphisScott M. Grundy, M.D., Ph.D.

University of Texas SouthwesternMedical Center at Dallas

Barbara C. Hansen, Ph.D.University of Maryland School of Medicine

Millicent Higgins, M.D.University of Michigan

James O. Hill, Ph.D.University of ColoradoHealth Sciences Center

Barbara V. Howard, Ph.D.Medlantic Research Institute

Robert J. Kuczmarski, Dr.P.H., R.D.National Center for Health StatisticsCenters for Disease Control and Prevention

Shiriki Kumanyika, Ph.D., R.D., M.P.H.The University of Pennsylvania

R. Dee Legako, M.D.Prime Care Canyon Park Family Physicians, Inc.

T. Elaine Prewitt, Dr.P.H., R.D.Loyola University Medical Center

Albert P. Rocchini, M.D.University of Michigan Medical Center

Philip L Smith, M.D.The Johns Hopkins Asthmaand Allergy Center

Linda G. Snetselaar, Ph.D., R.D.

University of IowaJames R. Sowers, M.D.

Wayne State University School of MedicineUniversity Health Center

Michael Weintraub, M.D.Food and Drug Administration

David F. Williamson, Ph.D., M.S.Centers for Disease Control and Prevention

G. Terence Wilson, Ph.D.Rutgers Eating Disorders Clinic

EX-OFFICIO MEMBERSClarice D. Brown, M.S.

Coda Research Inc.

Karen A. Donato, M.S., R.D.*Executive Director of the PanelCoordinator, NHLBI ObesityEducation Initiative

National Heart, Lung, and Blood InstituteNational Institutes of Health

Nancy Ernst, Ph.D., R.D.*National Heart, Lung, and Blood InstituteNational Institutes of Health

D. Robin Hill, Ph.D.*National Heart, Lung, and Blood InstituteNational Institutes of Health

Michael J. Horan, M.D., Sc.M.*National Heart, Lung, and Blood InstituteNational Institutes of Health

Van S. Hubbard, M.D., Ph.D.National Institute of Diabetes andDigestive and Kidney Diseases

James P. Kiley, Ph.D.*National Heart, Lung, and Blood InstituteNational Institutes of Health

Eva Obarzanek, Ph.D., R.D., M.P.H.*National Heart, Lung, and Blood InstituteNational Institutes of Health

*NHLBI Obesity Initiative Task Force Member

CONSULTANTDavid Schriger, M.D., M.P.H., F.A.C.E.P.

University of CaliforniaLos Angeles School of Medicine

SAN ANTONIO COCHRANE CENTERElaine Chiquette, Pharm.D.

Cynthia Mulrow, M.D., M.Sc.V.A. Cochrane Center at San AntonioAudie L. Murphy MemorialVeterans Hospital

STAFFAdrienne Blount, Maureen Harris, M.S., R.D.,

Anna Hodgson, M.A., Pat Moriarty, M.Ed.,R.D., R.O.W. Sciences, Inc.

North American Association for theStudy of Obesity Practical GuideDevelopment Committee

Louis J. Aronne, M.D., F.A.C.P.Cornell University, Chair

MEMBERSCharles Billington, M.D.

University of Minnesota

George Blackburn, M.D., Ph.D.Harvard University

Karen A. Donato, M.S., R. D.NHLBI Obesity Education InitiativeNational Heart, Lung, andBlood InstituteNational Institutes of Health

Arthur Frank, M.D.George Washington University

Susan Fried, Ph.D.Rutgers University

Patrick Mahlen O'Neil, Ph.D.Medical University of South Carolina

Henry Buchwald, M.D.University of Minnesota

George Cowan, M.D.

University of TennesseeCollege of Medicine

Robert Brolin, M.D.UMDNJ-Robert Wood JohnsonMedical School

EX-OFFICIO MEMBERSJames O. Hill, Ph.D.

University of ColoradoHealth Sciences Center

Edward Bernstein, M.P.H.North American Associationfor the Study of Obesity


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Foreword ......................................................................................................................................v

How To Use This Guide..............................................................................................................vi

Executive Summary ....................................................................................................................1Assessment ..........................................................................................................................1

Body Mass Index...........................................................................................................1Waist Circumference.....................................................................................................1Risk Factors or Comorbidities.......................................................................................1Readiness To Lose Weight............................................................................................2

Management.........................................................................................................................2Weight Loss ..................................................................................................................2Prevention of Weight Gain ............................................................................................2

Therapies..............................................................................................................................2Dietary Therapy.............................................................................................................2Physical Activity ............................................................................................................3Behavior Therapy ..........................................................................................................3Pharmacotherapy..........................................................................................................3Weight Loss Surgery.....................................................................................................4

Special Situations.................................................................................................................4

Introduction..................................................................................................................................5The Problem of Overweight and Obesity .............................................................................5

Treatment Guidelines..................................................................................................................7Assessment and Classification of Overweight and Obesity .................................................8Assessment of Risk Status ................................................................................................11Evaluation and Treatment Strategy ....................................................................................15Ready or Not: Predicting Weight Loss ...............................................................................21Management of Overweight and Obesity...........................................................................23

Weight Management Techniques .............................................................................................25Dietary Therapy..................................................................................................................26

Physical Activity..................................................................................................................28Behavior Therapy ...............................................................................................................30Making the Most of the Patient Visit............................................................................30

Pharmacotherapy ...............................................................................................................35Weight Loss Surgery ..........................................................................................................38

Weight Reduction After Age 65 ...............................................................................................41

References .................................................................................................................................42

Table of Contents


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In June 1998, the Clinical Guidelines on the

Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence

Report was released by the National Heart, Lung,and Blood Institutes (NHLBI) Obesity Education

Initiative in cooperation with the National Instituteof Diabetes and Digestive and Kidney Diseases(NIDDK). The impetus behind the clinical practiceguidelines was the increasing prevalence of over-weight and obesity in the United States and the needto alert practitioners to accompanying health risks.

The Expert Panel that developed the guidelinesconsisted of 24 experts, 8 ex-officio members, and aconsultant methodologist representing the fields of primary care, clinical nutrition, exercise physiology,psychology, physiology, and pulmonary disease.The guidelines were endorsed by representativesof the Coordinating Committees of the NationalCholesterol Education Program and the NationalHigh Blood Pressure Education Program, the NorthAmerican Association for the Study of Obesity, andthe NIDDK National Task Force on the Preventionand Treatment of Obesity.

This Practical Guide to the Identification, Evaluation,and Treatment of Overweight and Obesity in Adults islargely based on the evidence report prepared by theExpert Panel and describes how health care practition-ers can provide their patients with the direction andsupport needed to effectively lose weight and keep it

off. It provides the basic tools needed to appropriatelyassess and manage overweight and obesity.The guide includes practical information on dietarytherapy, physical activity, and behavior therapy, whilealso providing guidance on the appropriate use of pharmacotherapy and surgery as treatment options.

The Guide was prepared by a working group con-vened by the North American Association for theStudy of Obesity and the National Heart, Lung, andBlood Institute. Three members of the AmericanSociety for Bariatric Surgery also participated inthe working group. Members of the Expert Panel,especially the Panel Chairman, assisted in the reviewand development of the final product. Special thanksare also due to the 50 representatives of the variousdisciplines in primary care and others who reviewedthe preprint of the document and provided theworking group with excellent feedback.

The Practical Guide will be distributed to primarycare physicians, nurses, registered dietitians, andnutritionists as well as to other interested health carepractitioners. It is our hope that the tools provided herehelp to complement the skills needed to effectivelymanage the millions of overweight and obese individ-uals who are attempting to manage their weight.

David York, Ph.D. Claude Lenfant,M.D.President Director

North American Association National Heart, Lung, for the Study of Obesity and Blood Institute

National Institutesof Health

Foreword


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Overweight and obesity, serious and growing health problems, are not receivingthe attention they deserve from primary care practitioners. Among the reasonscited for not treating overweight and obesity is the lack of authoritative informationto guide treatment. This Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults was developed cooperatively by

the North American Association for the Study of Obesity (NAASO) and the National Heart,Lung, and Blood Institute (NHLBI). It is based on the Clinical Guidelines on the Identification,

Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report developed bythe NHLBI Expert Panel and released in June 1998. The Expert Panel used an evidence-based

methodology to develop key recommendations for assessing and treating overweight and obesepatients. The goal of the Practical Guide is to provide you with the tools you need to effectivelymanage your overweight and obese adult patients in an efficient manner.

The Guide has been developed to help you easily access all of the information you need.

The Executive Summary contains the essential information in an abbreviated form.

The Treatment Guidelines section offers details on assessment and management of patientsand features the Expert Panels Treatment Algorithm, which provides a step-by-step approachto learning how to manage patients.

The Appendix contains practical tools related to diet, physical activity, and behavioralmodification needed to educate and inform your patients. The Appendix has been formattedso that you can copy it and explain it to your patients.

Managing overweight and obese patients requires a variety of skills. Physicians play a key role inevaluating and treating such patients. Also important are the special skills of nutritionists, registereddietitians, psychologists, and exercise physiologists. Each health care practitioner can help patientslearn to make some of the changes they may need to make over the long term. Organizing a teamof various health care practitioners is one way of meeting the needs of patients. If that approach isnot possible, patients can be referred to other specialists required for their care.

To get started, just follow the Ten Step approach.

How to Use This Guide


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23

Measure height and weight so that you canestimate your patients BMI from the tablein Appendix A.

Measure waist circumferenceas described on page 9.

Assess comorbidities as described onpages 1112 in the section onAssessment of Risk Status.

Should your patient be treated? Take theinformation you have gathered above and useFigure 4, the Treatment Algorithm, on pages1617 to decide. Pay particular attention toBox 7 and the accompanying explanatorytext. If the answer is yes to treatment,decide which treatment is best using Table 3on page 25.

Is the patient ready and motivated to loseweight? Evaluation of readiness shouldinclude the following: (1) reasons andmotivation for weight loss, (2) previousattempts at weight loss, (3) support expectedfrom family and friends, (4) understanding of risks and benefits, (5) attitudes towardphysical activity, (6) time availability,

and (7) potential barriers to the patientsadoption of change.

Which diet should you recommend?In general, diets containing 1,000 to 1,200kcal/day should be selected for most women;a diet between 1,200 kcal/day and 1,600kcal/day should be chosen for men and maybe appropriate for women who weigh 165pounds or more, or who exercise regularly. If

the patient can stick with the 1,600 kcal/daydiet but does not lose weight you may want totry the 1,200 kcal/day diet. If a patient oneither diet is hungry, you may want toincrease the calories by 100 to 200 per day.Included in Appendix D are samples of botha 1,200 and 1,600 calorie diet.

Discuss a physical activity goal with thepatient using the Guide to Physical Activity(see Appendix H). Emphasize the importanceof physical activity for weight maintenanceand risk reduction.

Review the Weekly Food and ActivityDiary (see Appendix K) with the patient.Remind the patient that record-keeping hasbeen shown to be one of the most successfulbehavioral techniques for weight loss andmaintenance. Write down the diet, physicalactivity, and behavioral goals you have agreedon at the bottom.

Give the patient copies of the dietaryinformation (see Appendices BG),the Guide to Physical Activity (seeAppendix H), the Guide to BehaviorChange (see Appendix I), and the WeeklyFood and Activity Diary (see Appendix K).

Enter the patients information and thegoals you have agreed on in the Weight andGoal Record (see Appendix J). It is importantto keep track of the goals you have set andto ask the patient about them at the next visitto maximize compliance. Have the patientschedule an appointment to see you or yourstaff for followup in 2 to 4 weeks.

4

5

7

8

9

6 10

1Ten Steps to Treating Overweight and Obesity in the Primary Care Setting


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Successful treatment A lifelong effort.

Treatment of an overweight orobese person incorporates a two-step process: assessment andmanagement. Assessment includesdetermination of the degree of obesity and overall health status.Management involves not onlyweight loss and maintenance of body weight but also measures tocontrol other risk factors. Obesityis a chronic disease; patient andpractitioner must understand thatsuccessful treatment requires alifelong effort. Convincing evidencesupports the benefit of weight lossfor reducing blood pressure,lowering blood glucose, andimproving dyslipidemias.

Assessment

Body Mass IndexAssessment of a patient shouldinclude the evaluation of body massindex (BMI), waist circumference,and overall medical risk. To esti-mate BMI, multiply the individuals

weight (in pounds) by 703, thendivide by the height (in inches)squared. This approximates BMIin kilograms per meter squared(kg/m 2). There is evidence to sup-port the use of BMI in risk assess-ment since it provides a more accu-rate measure of total body fat com-pared with the assessment of body

weight alone. Neither bioelectricimpedance nor height-weight tablesprovide an advantage over BMIin the clinical management of all adult patients, regardless of gender. Clinical judgment must beemployed when evaluating verymuscular patients because BMI mayoverestimate the degree of fatness inthese patients. The recommendedclassifications for BMI, adoptedby the Expert Panel on theIdentification, Evaluation, andTreatment of Overweight andObesity in Adults and endorsed byleading organizations of healthprofessionals, are shown in Table 1.

Waist CircumferenceExcess abdominal fat is an impor-

tant, independent risk factor for dis-ease. The evaluation of waist cir-cumference to assess the risks asso-ciated with obesity or overweight issupported by research. The measure-ment of waist-to-hip ratio providesno advantage over waist circumfer-ence alone. Waist circumferencemeasurement is particularly useful in

patients who are categorized as nor-mal or overweight. It is not neces-sary to measure waist circumferencein individuals with BMIs 35 kg/m 2

since it adds little to the predictivepower of the disease risk classifica-tion of BMI. Men who have waistcircumferences greater than 40 inch-es, and women who have waist cir-cumferences greater than 35 inches,are at higher risk of diabetes, dys-lipidemia, hypertension, and cardio-vascular disease because of excessabdominal fat. Individuals withwaist circumferences greater thanthese values should be consideredone risk category above that defined

by their BMI. The relationshipbetween BMI and waist circumfer-

ence for defining risk is shown inTable 2 on page 10.

Risk Factors or ComorbiditiesOverall risk must take into accountthe potential presence of other risk factors. Some diseases or risk factors associated with obesity placepatients at a high absolute risk for

Executive Summary

BMIUnderweight


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subsequent mortality; these willrequire aggressive management.Other conditions associated withobesity are less lethal but stillrequire treatment.

Those diseases or conditions thatdenote high absolute risk areestablished coronary heart disease,other atherosclerotic diseases,type 2 diabetes, and sleep apnea.Osteoarthritis, gallstones, stressincontinence, and gynecologicalabnormalities such as amenorrheaand menorrhagia increase risk butare not generally life-threatening .Three or more of the followingrisk factors also confer highabsolute risk: hypertension, ciga-rette smoking, high low -densitylipoprotein cholesterol, lowhigh-density lipoprotein choles-terol, impaired fasting glucose,family history of early cardiovas-cular disease, and age (male 45years, female 55 years). Theintegrated approach to assessmentand management is portrayed inFigure 4 on pages 1617(Treatment Algorithm).

Readiness To Lose WeightThe decision to attempt weight-losstreatment should also consider thepatients readiness to make the nec-essary lifestyle changes. Evaluationof readiness should include thefollowing:

Reasons and motivationfor weight lossPrevious attempts at weight loss

Support expected from familyand friendsUnderstanding of risksand benefitsAttitudes toward physicalactivityTime availabilityPotential barriers, includingfinancial limitations, to thepatients adoption of change

Management

Weight LossIndividuals at lesser risk should becounseled about effective lifestylechanges to prevent any further

weight gain. Goals of therapy are toreduce body weight and maintain alower body weight for the long

term; the prevention of furtherweight gain is the minimum goal.An initial weight loss of 10 percentof body weight achieved over 6months is a recommended target.The rate of weight loss should be 1to 2 pounds each week. Greaterrates of weight loss do not achievebetter long-term results. After thefirst 6 months of weight loss thera-

py, the priority should be weightmaintenance achieved through com-bined changes in diet, physical activi-ty, and behavior. Further weight losscan be considered after a period of weight maintenance.

Prevention of Weight GainIn some patients, weight loss ora reduction in body fat is notachievable. A goal for thesepatients should be the preventionof further weight gain. Preventionof weight gain is also an appropri-ate goal for people with a BMIof 25 to 29.9 who are not other-wise at high risk.

Therapies

A combination of diet modification,increased physical activity, andbehavior therapy can be effective.

Dietary TherapyCaloric intake should be reduced by 500 to 1,000 calories per day(kcal/day) from the current level.Most overweight and obese peopleshould adopt long-term nutritional

adjustments to reduce caloric intake.Dietary therapy includes instructionsfor modifying diets to achieve thisgoal. Moderate caloric reductionis the goal for the majority of cases;however, diets with greater caloricdeficits are used during activeweight loss. The diet should be lowin calories, but it should not be toolow (less than 800 kcal/day). Diets

Weight loss therapy is

recommended for patients

with a BMI 30 and for patientswith a BMI between 25 and 29.9OR a high-risk waistcircumference, and twoor more risk factors.


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lower than 800 kcal/day have beenfound to be no more effective thanlow-calorie diets in producingweight loss. They should not beused routinely, especially not byproviders untrained in their use.In general, diets containing1,000 to 1,200 kcal/day should beselected for most women; a dietbetween 1,200 kcal/day and 1,600kcal/day should be chosen formen and may be appropriate forwomen who weigh 165 poundsor more, or who exercise.Long-term changes in food choicesare more likely to be successfulwhen the patients preferences aretaken into account and when thepatient is educated about food com-position, labeling, preparation, andportion size. Although dietary fat isa rich source of calories, reducingdietary fat without reducing calorieswill not produce weight loss.

Frequent contact with practitionersduring the period of diet adjustmentis likely to improve compliance.

Physical ActivityPhysical activity has direct and indirect benefits.Increased physical activity isimportant in efforts to lose weightbecause it increases energy expen-

diture and plays an integral role inweight maintenance. Physical activ-ity also reduces the risk of heartdisease more than that achieved byweight loss alone. In addition,increased physical activity may helpreduce body fat and prevent thedecrease in muscle mass oftenfound during weight loss. For theobese patient, activity should gener-ally be increased slowly, with caretaken to avoid injury. A wide vari-ety of activities and/or householdchores, including walking, dancing,gardening, and team or individualsports, may help satisfy this goal.All adults should set a long-termgoal to accumulate at least 30 min-utes or more of moderate-intensityphysical activity on most, andpreferably all, days of the week.

Behavior Therapy Including behavioral therapyhelps with compliance.Behavior therapy is a useful adjunctto planned adjustments in foodintake and physical activity.Specific behavioral strategiesinclude the following: self-monitor-

ing, stress management, stimuluscontrol, problem-solving, contin-gency management, cognitiverestructuring, and social support.Behavioral therapies may beemployed to promote adoption of diet and activity adjustments; thesewill be useful for a combinedapproach to therapy. Strong evi-dence supports the recommendationthat weight loss and weight mainte-nance programs should employ acombination of low-calorie diets,increased physical activity, andbehavior therapy.

PharmacotherapyPharmacotherapy may be helpful

for eligible high-risk patients.Pharmacotherapy, approved by theFDA for long-term treatment, canbe a helpful adjunct for the treat-ment of obesity in some patients.These drugs should be used only inthe context of a treatment programthat includes the elements describedpreviouslydiet, physical activitychanges, and behavior therapy.If lifestyle changes do not promoteweight loss after 6 months, drugs

Reductions of 500to 1,000 kcal/day

will produce a recom-mended weight loss of1 to 2 pounds per week.

1,000 to 1,200 kcal/day

for most women

1,200 to 1,600 kcal/day

should be chosen for men


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should be considered. Pharmaco-therapy is currently limited to thosepatients who have a BMI 30, orthose who have a BMI 27 if con-comitant obesity-related risk factorsor diseases exist. However, not allpatients respond to a given drug.If a patient has not lost 4.4 pounds(2 kg) after 4 weeks, it is not likelythat this patient will benefit fromthe drug. Currently, sibutramine andorlistat are approved by the FDAfor long-term use in weight loss.Sibutramine is an appetite suppres-sant that is proposed to work vianorepinephrine and serotonergicmechanisms in the brain. Orlistatinhibits fat absorption from theintestine. Both of these drugs haveside effects. Sibutramine mayincrease blood pressure and inducetachycardia; orlistat may reduce the

absorption of fat-soluble vitaminsand nutrients. The decision to add adrug to an obesity treatment pro-gram should be made after consid-eration of all potential risks andbenefits and only after all behav-ioral options have been exhausted.

Weight Loss SurgerySurgery is an option for patientswith extreme obesity.Weight loss surgery providesmedically significant sustainedweight loss for more than 5 yearsin most patients. Although there

are risks associated with surgery,it is not yet known whether theserisks are greater in the long termthan those of any other form of treatment. Surgery is an optionfor well-informed and motivatedpatients who have clinically severeobesity (BMI 40) or a BMI 35

and serious comorbid conditions.(The term clinically severeobesity is preferred to the oncecommonly used term morbidobesity.) Surgical patients shouldbe monitored for complications andlifestyle adjustments throughouttheir lives.

Special Situations

Involve other health professionals when possible,especially for special situations.Although research regardingobesity treatment in older peopleis not abundant, age should notpreclude therapy for obesity. Inpeople who smoke, the risk of weight gain is often a barrier tosmoking cessation. In thesepatients, cessation of smokingshould be encouraged first, andweight loss therapy should bean additional goal.

A weight loss and maintenanceprogram can be conducted by apractitioner without specializationin weight loss so long as that

person has the requisite interestand knowledge. However, avariety of practitioners withspecial skills are available andmay be enlisted to assist in thedevelopment of a program.

clinically severe obesity

(BMI 40) or a BMI 35and serious comorbidconditions may warrantsurgery for weight loss.

A combination of diet modification,increased physical activity, andbehavior therapy can be effective.

Effective Therapies


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Obesity is a complex,multifactorial diseasethat develops fromthe interactionbetween genotype

and the environment. Our under-standing of how and why obesityoccurs is incomplete; however, itinvolves the integration of social,behavioral, cultural, physiological,metabolic, and genetic factors. 1

Today, health care practitioners areencouraged to play a greater role inthe management of obesity. Manyphysicians are seeking guidance ineffective methods of treatment.This guide provides the basic toolsneeded to assess and manage over-weight and obesity in an office set-ting. A physician who is familiarwith the basic elements of these ser-vices can more successfully fulfillthe critical role of helping thepatient improve health by identify-ing the problem and coordinatingother resources within the commu-nity to assist the patient.

Effective management of overweightand obesity can be delivered by a

variety of health care professionalswith diverse skills working as ateam. For example, physicianinvolvement is needed for the initialassessment of risk and the prescrip-tion of appropriate treatment pro-grams that may include pharma-cotherapy, surgery, and the medicalmanagement of the comorbidities of obesity. In addition, physicians can

and should engage the assistance of other professionals. This guide pro-vides the basic tools needed toassess and manage overweight andobesity for a variety of health profes-sionals, including nutritionists, regis-tered dietitians, exercise physiolo-gists, nurses, and psychologists.These professionals offer expertisein dietary counseling, physical activ-ity, and behavior changes and can beused for assessment, treatment, andfollowup during weight loss andweight maintenance. The relation-ship between the practitioner andthese professionals can be a direct,formal one (as a team), or it maybe based on an indirect referral. Apositive, supportive attitude andencouragement from all profession-als are crucial to the continuing suc-cess of the patient.

The Problem ofOverweight and ObesityAn estimated 97 million adults in theUnited States are overweight orobese. 2 These conditions substantial-ly increase the risk of morbidityfrom hypertension, 3 dyslipidemia, 4

type 2 diabetes, 5,6,7,8 coronary artery

disease,9

stroke,10

gallbladder dis-ease, 11 osteoarthritis, 12 and sleepapnea and respiratory problems, 13 aswell as cancers of the endometrium,breast, prostate, and colon. 14 Higherbody weights are also associatedwith an increase in mortality fromall causes. 5 Obese individuals mayalso suffer from social stigmatizationand discrimination. As a major cause

of preventable death in the UnitedStates today,

15overweight and obesity

pose a major public health challenge.

However, overweight and obesity arenot mutually exclusive, since obesepersons are also overweight. A BMIof 30 indicates an individual is about30 pounds overweight; it may beexemplified by a 221-pound personwho is 6 feet tall or a 186-pound indi-vidual who is 5 feet 6 inches tall. Thenumber of overweight and obese menand women has risen since 1960(Figure 1); in the last decade, the per-centage of adults, ages 20 years orolder, who are in these categories hasincreased to 54.9 percent. 2 Over-weight and obesity are especially evi-dent in some minority groups, aswell as in those with lower incomesand less education. 16,17

The presence of overweight and obe-

sity in a patient is of medical con-cern for several reasons. It increasesthe risk for several diseases, particu-larly cardiovascular diseases (CVD)and diabetes mellitus.

7,8Data from

NHANES III show that morbidityfor a number of health conditionsincreases as BMI increases in bothmen and women (Figure 2).

Introduction

According to the Expert Panel,overweight is defined as a bodymass index (BMI) of 25 to29.9 kg/m 2, and obesity isdefined as a BMI 30 kg/m 2.


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50

40

30

20

10

0Men Women

P e r c e n t

P r e v a l e n c e

Men Women

(BMI 2529.9) (BMI 30)

NHES I (1960-62)

NHANES I (1971-74)NHANES II (1976-80)

NHANES III (1988-94)

Source: CDC/NCHS. United States. 1960-94, Ages 20-74 years. For comparison across surveys, data for subjects ages 20to 74 years were age-adjusted by the direct method to the total U.S. population for 1980, using the age-adjusted categories20-29y, 30-39y, 40-49y, 50-59y, 60-69y, and 70-79y.

< 25 30

18.3

HBP TBC HDL

< 25 30 < 25 30

BMI

* Defined as mean systolic blood pressure > 140 mm Hg, mean diastolic blood pressure > 90 mm Hg,or currently taking antihypertensive medication.

Defined as > 240 mg/dl. Defined as < 35 mg/dl in men and < 45 mg/dl in women.

Source: Brown C et al. Body mass index and the prevalence of hypertension and dyslipidemia (in press).

45

40

35

30

25

20

15

10

5

0

16.2

39.2

32.4

14.7 14.6

20.2

24.3

9.3

16.3

31.5

42.0

37.8

41.139.1 39.4

23.6 23.624.3 24.7

10.4 11.312.2

19.9

15.116.1 16.3

24.9

Age-Adjusted Prevalence of Overweight (BMI 2529.9) and Obesity (BMI 30)

Figure 1

NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),* High TotalBlood Cholesterol (TBC), and Low-HDL by Two BMI Categories

Figure 2

Men

Women


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Although there is agreement about the health risks of overweight and obesity, there is less agreement abouttheir management. Some have argued against treatingobesity because of the difficulty in maintaininglong-term weight loss, and because of the potentially

negative consequences of weight cycling, a pattern frequently seenin obese individuals. Others argue that the potential hazards of treatment do not outweigh the known hazards of being obese.The treatment guidelines provided are based on the most thoroughexamination of the scientific evidence reported to date on theeffectiveness of various treatment strategies available for weight lossand weight maintenance.

Treatment of the overweight and obese patient is a two-step process:assessment and management.

Assessment requires determination of the degree of obesityand the absolute risk status.

Management includes the reduction of excess weight andmaintenance of this lower body weight, as well as the institutionof additional measures to control any associated risk factors.

The aim of this guide is to provide useful advice on how toachieve weight reduction and how to maintain a lower body weight.Obesity is a chronic disease; the patient and the practitioner needto understand that successful treatment requires a lifelong effort.

Treatment Guidelines

Tailor Treatment to theNeeds of the Patient

Standard treatment approaches

for overweight and obesity must

be tailored to the needs of various

patients or patient groups. Large

individual variation exists within

any social or cultural group; fur-

thermore, substantial overlap

occurs among subcultures within

the larger society. There is, there-

fore, no cookbook or standard-

ized set of rules to optimize weight

reduction with a given type of

patient.However, obesity treatment

programs that are culturally

sensitive and incorporate a

patients characteristics must do

the following:

Adapt the setting and staffing

for the program.

Understand how the obesity

treatment program integrates

into other aspects of the patients

health care and self-care.

Expect and allow modifications to

a program based on a patientsresponse and preferences.


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8

Although accurate methods toassess body fat exist, themeasurement of body fat by

these techniques is expensive and isoften not readily available to mostclinicians. Two surrogate measuresare important to assess body fat:

Body mass index (BMI)Waist circumference

BMI is recommended as a practicalapproach for assessing body fat inthe clinical setting. It provides amore accurate measure of totalbody fat compared with the assess-ment of body weight alone. 18

The typical body weight tables arebased on mortality outcomes, andthey do not necessarily predict mor-bidity. However, BMI has somelimitations. For example, BMI over-estimates body fat in persons whoare very muscular, and it can under-estimate body fat in persons whohave lost muscle mass (e.g., manyelderly). BMI is a direct calculationbased on height and weight, regard-less of gender.

Waist circumference is the mostpractical tool a clinician can use to

evaluate a patients abdominal fat

before and during weight loss treat-ment (Figure 3). Computed tomog-raphy 19 and magnetic resonanceimaging 20 are both more accuratebut are impractical for routine clini-cal use. Fat located in the abdomi-nal region is associated with agreater health risk than peripheralfat (i.e., fat in the gluteal-femoralregion). Furthermore, abdominal fatappears to be an independent risk predictor when BMI is not marked-ly increased. 21,22 Therefore, waist orabdominal circumference and BMIshould be measured not only for theinitial assessment of obesity butalso for monitoring the efficacyof the weight loss treatment forpatients with a BMI < 35.

The primary classification of over-weight and obesity is based on theassessment of BMI. This classifica-tion, shown in Table 2, relates BMIto the risk of disease. It should benoted that the relationship betweenBMI and disease risk varies amongindividuals and among differentpopulations. Some individuals withmild obesity may have multiple risk factors; others with more severe

obesity may have fewer risk factors.

Assessment and Classificationof Overweight and Obesity

You can calculate BMI as follows

Calculation Directions and Sample

Here is a shortcut method for calculatingBMI. (Example: for a person who is 5 feet5 inches tall weighing 180 lbs.)

1. Multiply weight (in pounds) by 703

180 x703 =126,540

2. Multiply height (in inches) by height(in inches)

65 x 65 =4,225

3. Divide the answer in step 1 by theanswer in step 2 to get the BMI.

126,540/4,225 = 29.9BMI = 29.9

High-Risk WaistCircumferenceMen: > 40 in (> 102 cm)

Women: > 35 in (> 88 cm)

If pounds and inches are used

BMI =weight (pounds) x 703

height squared (inches 2)

A BMI chart is provided in Appendix A.

BMI =weight (kg)

height squared (m 2)

A high waist circumference is associat-ed with an increased risk for type 2diabetes, dyslipidemia, hypertension,and CVD in patients with a BMIbetween 25 and 34.9 kg/m 2.

Disease Risks


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It should be noted that the risk lev-els for disease depicted in Table 2are relative risks; in other words,they are relative to the risk atnormal body weight. There are norandomized, controlled trials thatsupport a specific classification sys-

tem to establish the degree of dis-ease risk for patients during weightloss or weight maintenance.

Although waist circumference andBMI are interrelated, waist circum-ference provides an independentprediction of risk over and abovethat of BMI. The waist circumfer-

ence measurement is particularlyuseful in patients who are catego-rized as normal or overweight interms of BMI. For individuals witha BMI 35, waist circumferenceadds little to the predictive powerof the disease risk classification of

BMI. A high waist circumference isassociated with an increased risk fortype 2 diabetes, dyslipidemia,hypertension, and CVD inpatients with a BMI between25 and 34.9 kg/m. 2,25

In addition to measuring BMI,monitoring changes in waist cir-

cumference over time may be help-ful; it can provide an estimate of increases or decreases in abdominalfat, even in the absence of changesin BMI. Furthermore, in obesepatients with metabolic complica-tions, changes in waist circumfer-

To measure waist

circumference, locate

the upper hip bone and

the top of the right iliac

crest. Place a measur-

ing tape in a horizontal

plane around the abdo-

men at the level of the

iliac crest. Before read-

ing the tape measure,

ensure that the tape is

snug, but does not

compress the skin, and

is parallel to the floor.

The measurement is

made at the end of a

normal expiration.

Waist Circumference Measurement

Figure 3

Clinical judgment must beused in interpreting BMIin situations that may affect its

accuracy as an indicator of total

body fat. Examples of these

situations include the presence

of edema, high muscularity, muscle

wasting, and individuals who are

limited in stature. The relationship

between BMI and body fat content

varies somewhat with age, gender,

and possibly ethnicity because of

differences in the composition of

lean tissue, sitting height, and

hydration state. 23,24 For example,

older persons often have lost

muscle mass; thus, they have

more fat for a given BMI than

younger persons.Women may

have more body fat for a given

BMI than men, whereas patients

with clinical edema may have less

fat for a given BMI compared with

those without edema. Nevertheless,

these circumstances do not

markedly influence the validity of

BMI for classifying individuals into

broad categories of overweight

and obesity in order to monitor

the weight status of individuals

in clinical settings.23

Measuring-Tape Position for Waist(Abdominal) Circumference in Adults


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10

ence are useful predictors of changes in cardiovascular disease(CVD) risk factors. 27 Men are atincreased relative risk if they havea waist circumference greater than40 inches (102 cm); women are atan increased relative risk if theyhave a waist circumference greaterthan 35 inches (88 cm).

There are ethnic and age-relateddifferences in body fat distribution

that modify the predictive validityof waist circumference as a surro-

gate for abdominal fat. 23 In somepopulations (e.g., Asian Americansor persons of Asian descent), waistcircumference is a better indicatorof relative disease risk than BMI. 28

For older individuals, waist circum-ference assumes greater value forestimating risk of obesity-relateddiseases. Table 2 incorporates bothBMI and waist circumference inthe classification of overweight andobesity and provides an indication

of relative disease risk.

Classification of Overweight and Obesity by BMI,Waist Circumference, and Associated Disease Risk*

Disease Risk*BMI Obesity Class (Relative to Normal Weight

(kg/m2) and Waist Circumference)

Men 40 in ( 102 cm) > 40 in (> 102 cm)Women 35 in ( 88 cm) > 35 in (> 88 cm)

Underweight < 18.5 - -Normal 18.524.9 - -

Overweight 25.029.9 Increased HighObesity 30.034.9 I High Very High35.039.9 II Very High Very High

Extreme Obesity 40 III Extremely High Extremely High

* Disease risk for type 2 diabetes, hypertension, and CVD.

Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

Adapted from Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997. 26

Table 2


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11

Assessment of the patients risk status includes the determina-tion of the following: the

degree of overweight or obesityusing BMI, the presence of abdomi-nal obesity using waist circumfer-ence, and the presence of concomi-tant CVD risk factors or comorbidi-ties. Some obesity-associated dis-eases and risk factors place patientsin a very high-risk category for sub-sequent mortality. Patients with thesediseases will require aggressive mod-ification of risk factors in addition tothe clinical management of the dis-ease. Other obesity-associated dis-eases are less lethal but still requireappropriate clinical therapy. Obesityalso has an aggravating influence onseveral cardiovascular risk factors.Identification of these risk factors isrequired to determine the intensityof a clinical intervention.

1. Determine the relative riskstatus based on overweightand obesity parameters. Table2 defines relative risk categories

according to BMI and waistcircumference. They relate tothe need to institute weight losstherapy, but they do not definethe required intensity of risk factor modification. The latteris determined by the estimationof absolute risk based on thepresence of associated diseaseor risk factors.

2. Identify patients at very highabsolute risk. Patients with thefollowing diseases have a veryhigh absolute risk that triggersthe need for intense risk-factormodification and managementof the diseases present:

Established coronary heart disease (CHD), including ahistory of myocardial infarction,angina pectoris (stable or unsta-ble), coronary artery surgery,or coronary artery procedures(e.g., angioplasty).Presence of other atheroscleroticdiseases, including peripheral

arterial disease, abdominal aorticaneurysm, or symptomatic carotidartery disease.Type 2 diabetes (fasting plasmaglucose 126 mg/dL or 2-h

postprandial plasma glucose 200 mg/dL) is a major risk fac-tor for CVD. Its presence aloneplaces a patient in the categoryof very high absolute risk.Sleep apnea. Symptoms andsigns include very loud snoringor cessation of breathing duringsleep, which is often followedby a loud clearing breath, thenbrief awakening.

3. Identify other obesity-associ-ated diseases. Obese patientsare at increased risk for severalconditions that require detectionand appropriate managementbut that generally do not leadto widespread or life-threateningconsequences. These includegynecological abnormalities(e.g., menorrhagia, amenorrhea),osteoarthritis, gallstones and

Assessment of Risk Status

Men are at increased relative risk for disease if they have a waist

circumference greater than 40 inches (102 cm); women are at an

increased relative risk if they have a waist circumference greater

than 35 inches (88 cm).


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12

their complications, and stressincontinence. Although obesepatients are at increased risk forgallstones, the risk of this dis-ease increases during periods of rapid weight reduction.

4. Identify cardiovascular riskfactors that impart a highabsolute risk. Patients can be

classified as being at highabsolute risk for obesity-relateddisorders if they have three ormore of the multiple risk factors

listed in the chart above. Thepresence of high absolute risk increases the attention paid tocholesterol-lowering therapy 29

and blood pressure manage-ment. 30

Other risk factors deserve specialconsideration because their pres-ence heightens the need for weight

reduction in obese persons.

Physical inactivity imparts anincreased risk for both CVD and

type 2 diabetes. 31 Physical inac-tivity exacerbates the severity of other risk factors, but it also hasbeen shown to be an indepen-dent risk factor for all-causemortality or CVD mortality. 32,33

Although physical inactivity isnot listed as a risk factor thatmodifies the intensity of therapyrequired for elevated cholesterol

or blood pressure, increasedphysical activity is indicated formanagement of these conditions(please see the Adult Treatment

Cigarette smoking.

Hypertension(systolic blood pressureof 140 mm Hg or diastolicblood pressure 90 mm Hg)or current use of antihyperten-sive agents.

High-risk low-densitylipoprotein (LDL) cholesterol(serum concentration 160 mg/dL). A borderlinehigh-risk LDL-cholesterol(130 to 159 mg/dL) plus twoor more other risk factors alsoconfers high risk.

Low high-density lipoprotein(HDL) cholesterol (serumconcentration < 35 mg/dL).

Impaired fasting glucose(IFG) (fasting plasma glucosebetween 110 and 125 mg/dL).IFG is considered by manyauthorities to be an independentrisk factor for cardiovascular(macrovascular) disease, thus

justifying its inclusion amongrisk factors contributing tohigh absolute risk. IFG iswell established as a riskfactor for type 2 diabetes.

Family history of prematureCHD (myocardial infarctionor sudden death experiencedby the father or other malefirst-degree relative at or before55 years of age, or experiencedby the mother or other femalefirst-degree relative at or before65 years of age).

Age 45 years for men orage 55 years for women(or postmenopausal).

Risk Factors


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Panel II [ATP II 29] of theNational Cholesterol EducationProgram and the Sixth Report of the Joint National Committee onthe Prevention, Detection,Evaluation, and Treatment of High Blood Pressure [JNC VI 30]).Increased physical activity isespecially needed in obesepatients because it promotes

weight reduction as well asweight maintenance, andfavorably modifies obesity-associated risk factors.

Conversely, the presence of physical inactivity in an obeseperson warrants intensifiedefforts to remove excess bodyweight because physical inac-tivity and obesity both heightendisease risks.

Obesity is commonlyaccompanied by elevated serum triglycerides.Triglyceride-rich lipoproteinsmay be directly atherogenic,and they are also the mostcommon manifestation of the atherogenic lipoproteinphenotype (high triglycerides,small LDL particles, and lowHDL-cholesterol levels). 34 Inthe presence of obesity, highserum triglycerides are common-ly associated with a clusteringof metabolic risk factors knownas the metabolic syndrome(atherogenic lipoproteinphenotype, hypertension,insulin resistance, glucoseintolerance, and prothromboticstates). Thus, in obese patients,elevated serum triglycerides

are a marker for increasedcardiovascular risk.

Risk Factor Management

Management options of risk

factors for preventing CVD,

diabetes, and other chronic

diseases are described in detail in

other reports. For details on the

management of serum cholesterol

and other lipoprotein disorders,

refer to the National Cholesterol

Education Programs Second

Report of the Expert Panel on the

Detection, Evaluation, and

Treatment of High Blood

Cholesterol in Adults (Adult

Treatment Panel II, ATP II). 29 For the

treatment of hypertension, see the

National High Blood Pressure

Education Programs Sixth Report

of the Joint National Committee on

the Prevention, Detection,

Evaluation, and Treatment of High

Blood Pressure (JNC VI). 30

See the Additional Resources

list for ordering information from

the National Heart, Lung, and

Blood Institute (see Appendix L).

Risk Factors and Weight Loss

In overweight and obese persons

weight loss is recommended to

accomplish the following:

Lower elevated blood pressure

in those with high blood pressure.

Lower elevated blood glucose

levels in those with type

2 diabetes.

Lower elevated levels of total

cholesterol, LDL-cholesterol,

and triglycerides, and raise low

levels of HDL-cholesterol in

those with dyslipidemia.


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Evaluation andTreatment Strategy

When health care practitioners encounter patients in the clinical setting,

opportunities exist for identifying overweight and obesity and their

accompanying risk factors, as well as for initiating treatments for

reducing weight, risk factors, and chronic diseases such as CVD and type 2 diabetes. When

assessing a patient for treatment of overweight and obesity, consider the patients weight, waist

circumference, and presence of risk factors. The strategy for the evaluation and treatment of

overweight patients is presented in Figure 4 (Treatment Algorithm). This algorithm applies

only to the assessment for overweight and obesity; it does not reflect the overall evaluation of

other conditions and diseases performed by the clinician. Therapeutic approaches for choles-

terol disorders and hypertension are described in ATP II and JNC VI, respectively. 29,30 In over-

weight patients, control of cardiovascular risk factors deserves the same emphasis as weight

loss therapy. Reduction of risk factors will reduce the risk for CVD, whether or not weight loss

efforts are successful.


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Treatment Algorithm *

Yes

Yes

No

Patient encounter

5

6

Hx of 25 BMI?

BMI measured inpast 2 years?

BMI 25 OR waistcircumference > 35

in (88 cm) (F) > 40 in(102 cm) (M)

Assess risk factors

No

Hx BMI 25?

Brief reinforcement/ educate on weight

management

Periodic weight, BMI, andwaist circumference check

Advise to maintainweight/address other

risk factors

Figure 4.

Measure weight,height, and waistcircumference

Calculate BMI

14

15 13

16

Yes

Each step (designated by a box) in this process is reviewed inthis section and expanded upon in subsequent sections.

High Risk Waist CircumferenceMen >40 in (>102 cm)Women >35 in (>88cm)

BMI =weight (kg)

height squared (m 2)

If pounds and inchesare used:

BMI =weight (pounds) x 703

height squared (inches 2)

Calculate BMI as follows:

1

2

3

4


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Does patient wantto lose weight?

Progressbeing made/goal

achieved?

Yes

Yes

Yes No

No

No

Clinician and patientdevise goals and

treatment strategyfor weight loss and risk

factor control

Maintenance counseling: Dietary therapy Behavior therapy Physical activity

Assess reasons forfailure to lose weight

12

8

9

1011

7

* This algorithm applies only to the assessment for overweight and obesity and sub-sequent decisions based on that assessment. It does not reflect any initial overallassessment for other cardiovascular risk factors that are indicated.

Examination

Treatment

BMI 30 OR{[BMI 25 to 29.9 ORwaist circumference> 35 in (F) > 40 in(M)] AND 2 risk

factors}


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Patient encounterAny interaction between ahealth care practitioner (generallya physician, nurse practitioner, orphysicians assistant) and a patientthat provides the opportunity toassess a patients weight statusand provide advice, counseling,or treatment.

History of overweightor recorded BMI 25Seek to determine whether thepatient has ever been overweight.A simple question such as Haveyou ever been overweight? mayaccomplish this goal. Questionsdirected toward weight history,dietary habits, physical activities,and medications may provide usefulinformation about the origins of obesity in particular patients.

BMI measuredin past 2 yearsFor those who have not beenoverweight, a 2-year interval isappropriate for the reassessmentof BMI. Although this timespan isnot evidence-based, it is a reason-able compromise between the

need to identify weight gain atan early stage and the need tolimit the time, effort, and costof repeated measurements.

Measure weight,height, waist circumference;calculate BMIWeight must be measured so BMIcan be calculated. Most charts arebased on weights obtained withthe patient wearing undergarmentsand no shoes.

BMI 25 ORwaist circumference > 35 in(88 cm) (women) or > 40 in(102 cm) (men)These cutoff values divideoverweight from normal weightand are consistent with othernational and internationalguidelines. The relationshipbetween weight and mortality isJ-shaped, and evidence suggeststhat the right side of the J beginsto rise at a BMI of 25. Waistcircumference is incorporated asan or factor because somepatients with a BMI lower than25 will have a disproportionateamount of abdominal fat, whichincreases their cardiovascular risk despite their low BMI (see pages910). These abdominalcircumference values are not

necessary for patients with aBMI 35 kg/m2.

Assess risk factorsRisk assessment for CVD anddiabetes in a person with evidentobesity will include specialconsiderations for the medicalhistory, physical examination, andlaboratory examination. Detectionof existing CVD or end-organ

damage presents the greatesturgency. Because the major risk of obesity is indirect (obesity elicits oraggravates hypertension, dyslipi-demias, and type 2 diabetes; eachof these leads to cardiovascularcomplications), the managementof obesity should be implementedin the context of these other risk factors. Although there is no directevidence that addressing risk factorsincreases weight loss, treating therisk factors through weight loss isa recommended strategy. The risk factors that should be considered areprovided on pages 1113. A nutri-tion assessment will also help toassess the diet and physical activityhabits of overweight patients.

BMI 30 OR ([BMI 25 to29.9 OR waist circumference> 35 in (88 cm) (women) or> 40 in (102 cm) (men)]AND 2 risk factors)The panel recommends that allpatients who meet these criteriashould attempt to lose weight.However, it is important to ask thepatient whether or not he or shewants to lose weight. Those with

a BMI between 25 and 29.9 kg/m2

and who have one or no risk factorsshould work on maintaining theircurrent weight rather than embark on a weight reduction program.The panel recognizes that thedecision to lose weight must bemade in the context of other risk factors (e.g., quitting smoking ismore important than losing weight)and patient preferences.

1

3

4

6

7

2

5

Each step (designated by a box) in the treatment algorithm isreviewed in this section and expanded upon in subsequent sections.


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Assess reasons for failureto lose weightIf a patient fails to achieve the rec-ommended 10-percent reduction inbody weight within 6 months or1 year, a reevaluation is required. Acritical question to consider iswhether the patients level of motiva-tion is high enough to continue clini-cal therapy. If motivation is high,revise goals and strategies (seeBox 8). If motivation is not high,clinical therapy should be discontin-ued, but the patient should beencouraged to embark on efforts tolose weight or to avoid furtherweight gain. Even if weight losstherapy is stopped, risk factor man-agement must be continued. Failureto achieve weight loss should promptthe practitioner to investigate the fol-lowing: (1) energy intake (i.e.,dietary recall including alcoholintake and daily intake logs),(2) energy expenditure (physicalactivity diary), (3) attendance at psy-chological/behavioral counseling ses-sions, (4) recent negative life events,(5) family and societal pressures,and (6) evidence of detrimental psy-chiatric problems (e.g., depression,

binge eating disorder). If attemptsto lose weight have failed, and theBMI is 40, or 35 to 39.9 withcomorbidities or significant reduc-tion in quality of life, surgical thera-py should be considered.

Maintenance counselingEvidence suggests that more than 80percent of the individuals who loseweight will gradually regain it.Patients who continue to use weightmaintenance programs have a greaterchance of keeping weight off.Maintenance includes continued con-tact with the health care practitionerfor education, support, and medicalmonitoring (see page 24).

Does the patient wantto lose weight?Patients who do not want to loseweight but who are overweight(BMI 25 to 29.9), without a highwaist circumference and with one orno cardiovascular risk factors, shouldbe counseled regarding the need tomaintain their weight at or below itspresent level. Patients who wish tolose weight should be guided accord-ing to Boxes 8 and 9. The justifica-tion of offering these overweightpatients the option of maintaining(rather than losing) weight is thattheir health risk, although higherthan that of persons with a BMI< 25, is only moderately increased(see page 11).

Advise to maintainweight/address otherrisk factorsPatients who have a history of overweight and who are now at anappropriate body weight, and thosepatients who are overweight but

not obese and who wish to focus onmaintenance of their current weight,should be provided with counselingand advice so their weight does notincrease. An increase in weightincreases their health risk andshould be prevented. The clinicianshould actively promote preventionstrategies, including enhanced atten-tion to diet, physical activity, andbehavior therapy. See Box 6 foraddressing other risk factors; evenif weight loss cannot be addressed,other risk factors should be treated.

History of BMI 25This box differentiates those whopresently are not overweight andnever have been from those with ahistory of overweight (see Box 2).

Brief reinforcementThose who are not overweight andnever have been should be advised of the importance of staying in this cat-egory.

Periodic weight, BMI,and waist circumference check Patients should receive periodicmonitoring of their weight, BMI, and

waist circumference. Patients whoare not overweight or have no historyof overweight should be screened forweight gain every 2 years. Thistimespan is a reasonable compromisebetween the need to identify weightgain at an early stage and the need tolimit the time, effort, and cost of repeated measurements.

10

15

12

11

14

16

13


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Ready or Not:Predicting Weight Loss

Predicting a patients readinessfor weight loss and identifyingpotential variables associated

with weight loss success is an impor-tant step in understanding the needsof patients. However, it may be easi-er said than done. Researchers havetried for years with some success toidentify predictors of weight loss.Such predictors would allow healthcare practitioners, before treatment,to identify individuals who have ahigh or low likelihood of success.Appropriate steps potentially couldbe taken to improve the chances of patients in the latter category. Amongbiological variables, initial bodyweight and resting metabolic rate(RMR) are both positively relatedto weight loss. Heavier individualstend to lose more weight than dolighter individuals, although the

two groups tend to lose comparablepercentages of initial weight. Studieshave not found that weight cyclingis associated with a poorer treatmentoutcome. Behavioral predictors of weight loss have proved to be lessconsistent. Depression, anxiety, orbinge eating may be associatedwith suboptimal weight loss, thoughfindings have been contradictory.Similarly, measures of readiness ormotivation to lose weight have gen-erally failed to predict outcome. Bycontrast, self-efficacya patientsreport that she or he can performthe behaviors required for weightlossis a modest but consistentpredictor of success. Several stud-ies have also suggested that posi-tive coping skills contribute toweight control.

Exclusion FromWeight Loss Therapy

Patients for whom weight loss

therapy is not appropriate are

most pregnant or lactating

women, persons with a serious

uncontrolled psychiatric illness

such as a major depression, and

patients who have a variety of

serious illnesses and for whom

caloric restriction might exacer-

bate the illness. Patients with

active substance abuse and those

with a history of anorexia

nervosa or bulimia nervosa should

be referred for specialized care.

Consider a patients readi-ness for weight loss and

identify potential variables

associated with weight loss

success.


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Clinical experience suggests thathealth care practitioners brieflyconsider the following issues whenassessing an obese individualsreadiness for weight loss:

Has the individual sought weightloss on his or her own initiative?Weight loss efforts are unlikely tobe successful if patients feel thatthey have been forced into treatmentby family members, their employer,or their physician. Before initiatingtreatment, health care practitionersshould determine whether patientsrecognize the need and benefits of weight reduction and want to loseweight.

What events have led the patientto seek weight loss now?Responses to this question will pro-vide information about the patientsweight loss motivation and goals. Inmost cases, individuals have beenobese for many years. Somethinghas happened to make them seek weight loss. The motivator differsfrom person to person.

What are the patients stresslevel and mood? There may notbe a perfect time to lose weight,but some are better than others.Individuals who report higher-than-usual stress levels with work, familylife, or financial problems may notbe able to focus on weight control.

In such cases, treatment may bedelayed until the stressor passes, thusincreasing the chances of success .Briefly assess the patients mood torule out major depression or othercomplications. Reports of poorsleep, a low mood, or lack of plea-sure in daily activities can be fol-lowed up to determine whetherintervention is needed: it is usuallybest to treat the mood disorderbefore undertaking weight reduction.

Does the individual have aneating disorder, in addition toobesity? Approximately 20 per-cent to 30 percent of obese indi-viduals who seek weight reduc-tion at university clinics sufferfrom binge eating. This involveseating an unusually large amountof food and experiencing loss of control while overeating. Bingeeaters are distressed by theirovereating, which differentiatesthem from persons who reportthat they just enjoy eating and eattoo much. Ask patients whichmeals they typically eat and the

times of consumption. Bingeeaters usually do not have a regu-lar meal plan; instead, they snack throughout the day. Althoughsome of these individuals respondwell to weight reduction therapy,the greater the patients distress ordepression, or the more chaoticthe eating pattern, the more likely

the need for psychological ornutritional counseling.

Does the individual understandthe requirements of treatmentand believe that he or she canfulfill them? Practitioner andpatient together should select acourse of treatment and identifythe changes in eating and activityhabits that the patient wishes tomake. It is important to selectactivities that patients believe theycan perform successfully. Patientsshould feel that they have thetime, desire, and skills to adhereto a program that you haveplanned together.

How much weight does thepatient expect to lose? Whatother benefits does he or sheanticipate? Obese individualstypically want to lose 2 to 3 timesthe 8 to 15 percent often observedand are disappointed when they donot. Practitioners must help patientsunderstand that modest weightlosses frequently improve health

complications of obesity. Progressshould then be evaluated byachievement of these goals, whichmay include sleeping better, havingmore energy, reducing pain,and pursuing new hobbies orrediscovering old ones, particularlywhen weight loss slows andeventually stops.

A Brief Behavioral Assessment


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The initial goal of weight losstherapy for overweightpatients is a reduction in

body weight of about 10 percent. If this target is achieved, considera-tion may be given to further weightloss. In general, patients will wishto lose more than 10 percent of body weight; they will need to becounseled about the appropriate-ness of this initial goal. 35,36 Furtherweight loss can be considered afterthis initial goal is achieved andmaintained for 6 months. The ratio-nale for the initial 10-percent goalis that a moderate weight loss of this magnitude can significantlydecrease the severity of obesity-associated risk factors. It is betterto maintain a moderate weight lossover a prolonged period than toregain weight from a marked

weight loss. The latter is counter-productive in terms of time, cost,and self-esteem.

Rate of Weight LossA reasonable time to achieve a10-percent reduction in body weightis 6 months of therapy. To achieve asignificant loss of weight, an energydeficit must be created and main-tained. Weight should be lost at arate of 1 to 2 pounds per week,based on a caloric deficit between500 and 1,000 kcal/day. After6 months, theoretically, this caloricdeficit should result in a loss of between 26 and 52 pounds.However, the average weight lossactually observed over this time isbetween 20 and 25 pounds. A greaterrate of weight loss does not yield abetter result at the end of 1 year. 37

It is difficult for most patients tocontinue to lose weight after 6months because of changes in rest-ing metabolic rates and problemswith adherence to treatment strate-gies. Because energy requirementsdecrease as weight is decreased, dietand physical activity goals need tobe revised so that an energy deficitis created at the lower weight,allowing the patient to continue tolose weight. To achieve additionalweight loss, the patient must further

Management ofOverweight and Obesity

Goals for Weight Lossand Management

The following are general goals

for weight loss and management:

Reduce body weight

Maintain a lower body weight

over the long term

Prevent further weight gain

(a minimum goal)

A 10 percent reduction in body weight reduces

disease risk factors.Weight should be lost at a

rate of 1 to 2 pounds per week based on a

calorie deficit of 5001,000 kcal/day.


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decrease calories and/or increasephysical activity. Many studies showthat rapid weight reduction is almostalways followed by gain of thelost weight. Moreover, with rapidweight reduction, there is anincreased risk for gallstones and,possibly, electrolyte abnormalities.

Weight Maintenance at aLower WeightOnce the goals of weight loss havebeen successfully achieved, mainte-nance of a lower body weightbecomes the major challenge. In thepast, obtaining the goal of weightloss was considered the end of weight loss therapy. Unfortunately,once patients are dismissed fromclinical therapy, they frequentlyregain the lost weight.

After 6 months of weight loss, therate at which the weight is lostusually declines, then plateaus.

The primary care practitioner andpatient should recognize that, at thispoint, weight maintenance, the sec-ond phase of the weight loss effort,should take priority. Successfulweight maintenance is defined asa regain of weight that is less than6.6 pounds (3 kg) in 2 years anda sustained reduction in waistcircumference of at least 1.6 inches(4 cm). If a patient wishes to losemore weight after a period of weight maintenance, the procedurefor weight loss, outlined above,can be repeated.

After a patient has achieved thetargeted weight loss, the combinedmodalities of therapy (dietary thera-py, physical activity, and behavior

therapy) must be continued indefi-nitely; otherwise, excess weightwill likely be regained. Numerousstrategies are available for motivat-ing the patient; all of these requirethat the practitioner continue tocommunicate frequently with thepatient. Long-term monitoring andencouragement can be accom-plished in several ways: by regularclinic visits, at group meetings, orvia telephone or e-mail. The longerthe weight maintenance phasecan be sustained, the better theprospects for long-term success inweight reduction. Drug therapywith either of the two FDA-approved drugs for weight lossmay also be helpful during theweight maintenance phase.

Long-term monitoring and

encouragement to maintain

weight loss requires regular

clinic visits, group meetings,

or encouragement via

telephone or e-mail.


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Weight Management Techniques

Effective weight controlinvolves multiple tech-niques and strategiesincluding dietary therapy,physical activity, behavior

therapy, pharmacotherapy, andsurgery as well as combinations of these strategies. Relevant treatmentstrategies can also be used to fosterlong-term weight control and preven-tion of weight gain.

Some strategies such as modifyingdietary intake and physical activitycan also impact on obesity-relatedcomorbidities or risk factors. Sincethe diet recommended is a low calo-rie Step-1 diet, it not only modifies

calorie intake but also reduces satu-rated fat, total fat, and cholesterolintake in order to help lower highblood cholesterol levels. The diet alsoincludes the current recommenda-tions for sodium, calcium and fiberintakes. Increased physical activity isnot only important for weight lossand weight loss maintenance but alsoimpacts on other comorbidities andrisk factors such as high blood pres-sure, and high blood cholesterol lev-els. Reducing body weight in over-weight and obese patients not onlyhelps reduce the risk of these comor-bidities from developing but alsohelps in their management.

Weight management techniques needto take into account the needs of indi-vidual patients so they should be cul-turally sensitive and incorporate thepatients perspectives and characteris-tics. Treatment of overweight andobesity is to be taken seriously sinceit involves treating an individualsdisease over the long term as well asmaking modifications to a way of lifefor entire families.

Table 3 illustrates the therapiesappropriate for use at different BMIlevels taking into account theexistence of other comorbiditiesor risk factors.

Table 3

A Guide to Selecting TreatmentBMI category

Treatment 2526.9 2729.9 30-34.9 3539.9 40

Diet, physical activity, With With + + +and behavior therapy comorbidities comorbidities

Pharmacotherapy With + + +comorbidities

Surgery Withc o m o r b i d i t i e s

Prevention of weight gain with lifestyle therapy is indicated in any patient with a BMI 25 kg/m 2,even without comorbidities, while weight loss is not necessarily recommended for those with a BMIof 2529.9 kg/m 2 or a high waist circumference, unless they have two or more comorbidities.

Combined therapy with a low-calorie diet (LCD), increased physical activity, and behavior therapyprovide the most successful intervention for weight loss and weight maintenance.

Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months ofcombined lifestyle therapy.

The + represents the use of indicated treatment regardless of comorbidities.


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Table 4

Low-Calorie Step I Diet

Nutrient Recommended Intake

Calories 1 Approximately 500 to 1,000 kcal/day reduction from usual intake

Total fat 2 30 percent or less of total calories

Saturated fatty acids 3 8 to 10 percent of total calories

Monounsaturated fatty acids Up to 15 percent of total calories

Polyunsaturated fatty acids Up to 10 percent of total calories

Cholesterol 3


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Physical activity should be anintegral part of weight losstherapy and weight mainte-

nance. Initially, moderate levels of physical activity for 30 to 45 min-utes, 3 to 5 days per week, shouldbe encouraged.

An increase in physical activity is animportant component of weight losstherapy, 31 although it will not lead toa substantially greater weight lossthan diet alone over 6 months. 51

Most weight loss occurs because of decreased caloric intake. Sustainedphysical activity is most helpful inthe prevention of weight regain. 52,53

In addition, physical activity is bene-ficial for reducing risks for cardio-vascular disease and type 2 diabetes,beyond that produced by weightreduction alone. Many people livesedentary lives, have little trainingor skills in physical activity, and aredifficult to motivate toward increas-ing their activity. For these reasons,starting a physical activity regimen

may require supervision for somepeople. The need to avoid injury dur-ing physical activity is a high priori-ty. Extremely obese persons mayneed to start with simple exercisesthat can be intensified gradually. Thepractitioner must decide whetherexercise testing for cardiopulmonarydisease is needed before embarkingon a new physical activity regimen.This decision should be basedon a patients age, symptoms, andconcomitant risk factors.

For most obese patients, physicalactivity should be initiated slowly,and the intensity should beincreased gradually. Initial activitiesmay be increasing small tasks of daily living such as taking the stairsor walking or swimming at a slowpace. With time, depending onprogress, the amount of weight lost,and functional capacity, the patientmay engage in more strenuousactivities. Some of these includefitness walking, cycling, rowing,

cross-country skiing, aerobic danc-ing, and jumping rope. Jogging pro-vides a high-intensity aerobic exer-cise, but it can lead to orthopedicinjury. If jogging is desired, thepatients ability to do this must firstbe assessed. The availability of asafe environment for the jogger isalso a necessity. Competitive sports,such as tennis and volleyball, canprovide an enjoyable form of physi-cal activity for many, but again,care must be taken to avoid injury,especially in older people.

As the examples listed in Table 5show, a moderate amount of physi-cal activity can be achieved in avariety of ways. People can selectactivities that they enjoy and thatfit into their daily lives. Becauseamounts of activity are functions of duration, intensity, and frequency,the same amounts of activity canbe obtained in longer sessions of moderately intense activities (suchas brisk walking) as in shorter ses-sions of more strenuous activities(such as running).

A regimen of daily walking is an

attractive form of physical activityfor many people, particularly thosewho are overweight or obese. Thepatient can start by walking 10 min-utes, 3 days a week, and can buildto 30 to 45 minutes of more intensewalking at least 3 days a week andincrease to most, if not all, days. 52,53

With this regimen, an additional

Physical Activity

All adults should set

a long-term goal to

accumulate at least30 minutes or more

of moderate-intensity

physical activity on

most, and preferably

all, days of the week.


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100 to 200 kcal/day of physicalactivity can be expended. Caloricexpenditure will vary depending onthe individuals body weight andthe intensity of the activity.

This regimen can be adapted toother forms of physical activity,

but walking is particularly attractivebecause of its safety and acces-sibility. With time, a larger weeklyvolume of physical activity can beperformed that would normallycause a greater weight loss if itwere not compensated by a highercaloric intake.

Reducing sedentary time, i.e.,time spent watching television orplaying video games, is anotherapproach to increasing activity.Patients should be encouraged tobuild physical activities into eachday. Examples include leavingpublic transportation one stop

before the usual one, parking far-ther than usual from work or shop-ping, and walking up stairs insteadof taking elevators or escalators.New forms of physical activityshould be suggested (e.g., garden-ing, walking a dog daily, or newathletic activities). Engaging inphysical activity can be facilitatedby identifying a safe area to per-

form the activity (e.g., communityparks, gyms, pools, and healthclubs). However, when thesesites are not available, an areaof the home can be identified andperhaps outfitted with equipmentsuch as a stationary bicycle or atreadmill. Health care profession-

als should encourage patients toplan and schedule physical activity1 week in advance, budget thetime necessary to do it, and docu-ment their physical activity bykeeping a diary and recording theduration and intensity of exercise.The following are examples of activities at different levels of intensity. A moderate amount of

Examples of Moderate Amounts of Physical Activity*

Common Chores Sporting Activities

Washing and waxing a car for 4560 minutes Playing volleyball for 4560 minutes

Washing windows or floors for 4560 minutes Playing touch football for 45 minutes

Gardening for 3045 minutes Walking 1 3 / 4 miles in 35 minutes (20 min/mile)

Wheeling self in wheelchair for 3040 minutes Basketball (shooting baskets) for 30 minutes

Pushing a stroller 1 1 / 2 miles in 30 minutes Bicycling 5 miles in 30 minutes

Raking leaves for 30 minutes Dancing fast (social) for 30 minutes

Walking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutes

Shoveling snow for 15 minutes Swimming laps for 20 minutes

Stairwalking for 15 minutes Basketball (playing a game) for 1520 minutes

Jumping rope for 15 minutes

Running 1 1 / 2 miles in 15 minutes(15 min/mile)

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately150 calories of energy per day, or 1,000 calories per week.

Some activities can be performed at various intensities; the suggested durations correspond to expectedintensity of effort.

Table 5

MoreVigorous,Less Time

LessVigorous,

More Time


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physical activity is roughly equiv-alent to physical activity that usesapproximately 150 calories of energy per day, or 1,000 caloriesper week.

For the beginner, or someone wholeads a very sedentary lifestyle,very light activity would includeincreased standing activities, roompainting, pushing a wheelchair,yard work, ironing, cooking, andplaying a musical instrument.

Light activity would include slowwalking (24 min/mile), garagework, carpentry, house cleaning,child care, golf, sailing, and recre-ational table tennis.

Moderate activity would includewalking a 15-minute mile, weed-ing and hoeing a garden, carryinga load, cycling, skiing, tennis, anddancing.

High activity would include jogging a mile in 10 minutes,walking with a load uphill, treefelling, heavy manual digging,basketball, climbing, and soccer.

Other key activities wouldinclude flexibility exercises toattain full range of joint motion,strength or resistance exercises,and aerobic conditioning.

Behavior therapy providesmethods for overcomingbarriers to compliance with

dietary therapy and/or increasedphysical activity, and these meth-ods are important components of weight loss treatment. The follow-ing approach is designed to assistthe caregiver in delivering behav-ior therapy. The importance of individualizing behavioral strate-gies to the needs of the patientmust be emphasized for behaviortherapy, as it was for diet andexercise strategies. 54

In addition, the practitioner mustassess the patients motivation toenter weight loss therapy and thepatients readiness to implementthe plan. Then the practitioner cantake appropriate steps to motivatethe patient for treatment.

Making the Most ofthe Patient Visit

Consider Attitudes, Beliefs,and Histories.In the patient-provider interaction,individual histories, attitudes, and

beliefs may affect both parties.The diagnosis of obesity is rarelynew or news for the patient.Except for patients with veryrecent weight gain, the patientbrings into the consulting room ahistory of dealing with a frustrat-ing, troubling, and visible prob-lem. Obese people are

Documents

Guidlines for MANAGEMENT of Obesity 2000