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 HN 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

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 HN 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 EN O 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 PracticalGuide Identification,Evaluation, and Treatment of Overweight andObesity in Adults

NHLBI Obesity Education Initiative

ACKNOWLEDGMENTS:The Working Group wishes to acknowledgethe additional input to the Practical Guide fromthe following individuals: Dr. Thomas Wadden,University of Pennsylvania; Dr. Walter Pories,East Carolina University; Dr. Steven Blair,Cooper Institute for Aerobics Research; andDr. Van S. Hubbard, National Institute ofDiabetes and Digestive and Kidney Diseases.

The PracticalGuide Identification,Evaluation, and Treatment of Overweight andObesity in Adults

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication Number 00-4084October 2000

NHLBI Obesity Education Initiative

North American Association for the Study of Obesity

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 College of Physicians and Surgeons Chair of the Panel

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

The Johns Hopkins UniversityClaude Bouchard, Ph.D.

Laval UniversityRichard A. Carleton, M.D.

Brown University School of MedicineGraham A. Colditz, M.D., Dr.P.H.

Harvard Medical SchoolWilliam H. Dietz, M.D., Ph.D.

National Center for Chronic DiseasePrevention and Health Promotion Centers for Disease Control and Prevention

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

Robert J. Garrison, Ph.D.University of Tennessee, Memphis

Scott M. Grundy, M.D., Ph.D.University of Texas Southwestern Medical 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 Colorado Health 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 Asthma and Allergy Center

Linda G. Snetselaar, Ph.D., R.D. University of Iowa

James 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 Obesity Education InitiativeNational 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 and Digestive 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 California Los 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

STAFF Adrienne 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 the Study of Obesity Practical GuideDevelopment CommitteeLouis J. Aronne, M.D., F.A.C.P.

Cornell University, Chair

MEMBERSCharles Billington, M.D.

University of MinnesotaGeorge Blackburn, M.D., Ph.D.

Harvard UniversityKaren A. Donato, M.S., R. D.

NHLBI Obesity Education Initiative National Heart, Lung, and Blood Institute National 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 Tennessee College of Medicine

Robert Brolin, M.D.UMDNJ-Robert Wood Johnson Medical School

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

University of Colorado Health Sciences Center

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

iii

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 ..................................................................................................................26Physical Activity..................................................................................................................28Behavior Therapy ...............................................................................................................30

Making the Most of the Patient Visit............................................................................30Pharmacotherapy ...............................................................................................................35Weight Loss Surgery ..........................................................................................................38

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

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

Table of Contents

iv

Introduction to the Appendices ...............................................................................................45Appendix A. Body Mass Index Table..................................................................................46Appendix B. ShoppingWhat to Look For ........................................................................47Appendix C. Low Calorie, Lower Fat Alternatives..............................................................49Appendix D. Sample Reduced Calorie Menus...................................................................51Appendix E. Food Exchange List.......................................................................................57Appendix F. Food PreparationWhat to Do .....................................................................59Appendix G. Dining OutHow To Choose.........................................................................60Appendix H. Guide to Physical Activity ..............................................................................62Appendix I. Guide to Behavior Change ............................................................................68Appendix J. Weight and Goal Record ...............................................................................71Appendix K. Weekly Food and Activity Diary.....................................................................74Appendix L. Additional Resources.....................................................................................75

List of TablesTable 1. Classifications for BMI .....................................................................................1Table 2. Classification of Overweight and Obesity by BMI, Waist Circumference,

and Associated Disease Risk........................................................................10Table 3. A Guide to Selecting Treatment.....................................................................25Table 4. Low-Calorie Step I Diet .................................................................................27Table 5. Examples of Moderate Amounts of Physical Activity ....................................29Table 6. Weight Loss Drugs ........................................................................................36

List of FiguresFigure 1. Age-Adjusted Prevalence of Overweight (BMI 2529.9) and

Obesity (BMI 30) ..........................................................................................6Figure 2. NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),

High Total Blood Cholesterol (TBC), and Low-HDL by Two BMI Categories ..6Figure 3. Measuring-Tape Position for Waist (Abdominal) Circumference in Adults ......9Figure 4. Treatment Algorithm ......................................................................................16Figure 5. Surgical Procedures in Current Use..............................................................38

vIn June 1998, the Clinical Guidelines on theIdentification, Evaluation, and Treatment ofOverweight and Obesity in Adults: EvidenceReport was released by the National Heart, Lung,and Blood Institutes (NHLBI) Obesity EducationInitiative in cooperation with the National Institute of 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 guidelines consisted of 24 experts, 8 ex-officio members, and aconsultant methodologist representing the fields ofprimary care, clinical nutrition, exercise physiology,psychology, physiology, and pulmonary disease. The guidelines were endorsed by representatives of the Coordinating Committees of the NationalCholesterol Education Program and the National High 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 itoff. 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 ofpharmacotherapy 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 in the 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 the working 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 DirectorNorth American Association National Heart, Lung,for the Study of Obesity and Blood Institute

National Institutes of Health

Foreword

vi

Overweight and obesity, serious and growing health problems, are not receiving the attention they deserve from primary care practitioners. Among the reasons cited for not treating overweight and obesity is the lack of authoritative information to 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 by the 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 effectively manage 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 patients and features the Expert Panels Treatment Algorithm, which provides a step-by-step approach to learning how to manage patients.

The Appendix contains practical tools related to diet, physical activity, and behavioral modification needed to educate and inform your patients. The Appendix has been formatted so 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 in evaluating and treating such patients. Also important are the special skills of nutritionists, registered dietitians, psychologists, and exercise physiologists. Each health care practitioner can help patients learn 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 is not 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

vii

23

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

Measure waist circumference as described on page 9.

Assess comorbidities as described on pages 1112 in the section on Assessment 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 and motivation for weight loss, (2) previousattempts at weight loss, (3) support expectedfrom family and friends, (4) understanding ofrisks and benefits, (5) attitudes toward physical 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 both a 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 dietary information (see Appendices BG),the Guide to Physical Activity (seeAppendix H), the Guide to Behavior Change (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 and to 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

1Successful treatment A lifelong effort.

Treatment of an overweight orobese person incorporates a two-step process: assessment and management. Assessment includesdetermination of the degree of obesity and overall health status.Management involves not onlyweight loss and maintenance ofbody weight but also measures tocontrol other risk factors. Obesity is a chronic disease; patient andpractitioner must understand thatsuccessful treatment requires a lifelong 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 individualsweight (in pounds) by 703, thendivide by the height (in inches)squared. This approximates BMI in kilograms per meter squared(kg/m2). 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 BMI in 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, adopted by the Expert Panel on theIdentification, Evaluation, andTreatment of Overweight andObesity in Adults and endorsed byleading organizations of health professionals, 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/m2since 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 riskfactors. Some diseases or risk factors associated with obesity placepatients at a high absolute risk for

Executive Summary

BMIUnderweight

2subsequent mortality; these willrequire aggressive management.Other conditions associated withobesity are less lethal but stillrequire treatment.

Those diseases or conditions thatdenote high absolute risk are established 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 following risk factors also confer highabsolute risk: hypertension, ciga-rette smoking, high low-densitylipoprotein cholesterol, low high-density lipoprotein choles-terol, impaired fasting glucose,family history of early cardiovas-cular disease, and age (male 45years, female 55 years). The integrated 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. Evaluation of readiness should include the following:

Reasons and motivation for weight lossPrevious attempts at weight loss

Support expected from family and friendsUnderstanding of risks and benefitsAttitudes toward physical activityTime availability Potential 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 longterm; 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 ofweight maintenance.

Prevention of Weight GainIn some patients, weight loss or a 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 nutritionaladjustments to reduce caloric intake.Dietary therapy includes instructionsfor modifying diets to achieve thisgoal. Moderate caloric reduction is 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 waist circumference, and two or more risk factors.

3lower 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 containing 1,000 to 1,200 kcal/day should beselected for most women; a dietbetween 1,200 kcal/day and 1,600kcal/day should be chosen for men and may be appropriate forwomen who weigh 165 pounds or 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 is important 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 TherapyIncluding behavioral therapy helps 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 ofdiet 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 helpfulfor 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 500 to 1,000 kcal/day

will produce a recom-mended weight loss of 1 to 2 pounds per week.

1,000 to 1,200 kcal/day for most women

1,200 to 1,600 kcal/dayshould be chosen for men

4should 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 provides medically significant sustainedweight loss for more than 5 years in 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 oftreatment. Surgery is an option for well-informed and motivatedpatients who have clinically severeobesity (BMI 40) or a BMI 35

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

Special Situations

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

A weight loss and maintenance program can be conducted by apractitioner without specializationin weight loss so long as that person has the requisite interest and knowledge. However, a variety of practitioners with special skills are available and may be enlisted to assist in thedevelopment of a program.

clinically severe obesity

(BMI 40) or a BMI 35 and serious comorbid conditions may warrant surgery for weight loss.

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

Effective Therapies

5Obesity is a complex,multifactorial diseasethat develops fromthe interactionbetween genotypeand 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 avariety 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 ofobesity. In addition, physicians can

and should engage the assistance ofother 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 of Overweight 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,4type 2 diabetes,5,6,7,8 coronary arterydisease,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,15 overweight and obesitypose 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.7,8 Data fromNHANES 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/m2, and obesity isdefined as a BMI 30 kg/m2.

650

40

30

20

10

0 Men Women

Perc

ent

Prev

ale

nce

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.

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

MenWomen

7Although there is agreement about the health risks ofoverweight and obesity, there is less agreement abouttheir management. Some have argued against treatingobesity because of the difficulty in maintaining long-term weight loss, and because of the potentiallynegative 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 the effectiveness 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 obesity and the absolute risk status.

Management includes the reduction of excess weight and maintenance 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 to achieve weight reduction and how to maintain a lower body weight.Obesity is a chronic disease; the patient and the practitioner need to understand that successful treatment requires a lifelong effort.

Treatment Guidelines

Tailor Treatment to the Needs of the Patient

Standard treatment approaches for overweight and obesity must be tailored to the needs of variouspatients or patient groups. Largeindividual variation exists withinany social or cultural group; fur-thermore, substantial overlapoccurs among subcultures withinthe larger society. There is, there-fore, no cookbook or standard-ized set of rules to optimize weightreduction with a given type ofpatient. However, obesity treatmentprograms that are culturally sensitive and incorporate apatients characteristics must dothe following:

Adapt the setting and staffing for the program.

Understand how the obesity treatment program integrates into other aspects of the patientshealth care and self-care.

Expect and allow modifications toa program based on a patientsresponse and preferences.

8Although accurate methods toassess body fat exist, themeasurement of body fat bythese techniques is expensive and is often 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.18The 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 toevaluate a patients abdominal fat

before and during weight loss treat-ment (Figure 3). Computed tomog-raphy19 and magnetic resonanceimaging20 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 riskpredictor 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 efficacy of 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 riskfactors; others with more severeobesity may have fewer risk factors.

Assessment and Classification of Overweight and Obesity

You can calculate BMI as follows

Calculation Directions and SampleHere 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 the answer 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 703height squared (inches2)

A BMI chart is provided in Appendix A.

BMI =weight (kg)height squared (m2)

A high waist circumference is associat-ed with an increased risk for type 2 diabetes, dyslipidemia, hypertension,and CVD in patients with a BMIbetween 25 and 34.9 kg/m2.

Disease Risks

9It 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 at normal body weight. There are no randomized, 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 power of the disease risk classification ofBMI. A high waist circumference isassociated with an increased risk fortype 2 diabetes, dyslipidemia,hypertension, and CVD in patients with a BMI between 25 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 ofincreases 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, locatethe upper hip bone andthe top of the right iliaccrest. Place a measur-ing tape in a horizontalplane around the abdo-men at the level of theiliac crest. Before read-ing the tape measure,ensure that the tape issnug, but does notcompress the skin, andis parallel to the floor.The measurement ismade at the end of anormal expiration.

Waist Circumference Measurement

Figure 3

Clinical judgment must beused in interpreting BMIin situations that may affect itsaccuracy as an indicator of totalbody fat. Examples of these situations include the presence of edema, high muscularity, musclewasting, and individuals who arelimited in stature. The relationshipbetween BMI and body fat contentvaries somewhat with age, gender,and possibly ethnicity because ofdifferences in the composition oflean tissue, sitting height, andhydration state.23,24 For example,older persons often have lost muscle mass; thus, they have more fat for a given BMI thanyounger persons. Women may have more body fat for a given BMI than men, whereas patientswith clinical edema may have lessfat for a given BMI compared withthose without edema. Nevertheless,these circumstances do notmarkedly influence the validity ofBMI for classifying individuals intobroad 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

10

ence are useful predictors ofchanges in cardiovascular disease(CVD) risk factors.27 Men are atincreased relative risk if they have a 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 distributionthat 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.28For older individuals, waist circum-ference assumes greater value forestimating risk of obesity-relateddiseases. Table 2 incorporates bothBMI and waist circumference in the classification of overweight andobesity and provides an indicationof 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 High

35.039.9 II Very High Very HighExtreme 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

11

Assessment of the patients riskstatus includes the determina-tion of the following: thedegree 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 on several cardiovascular risk factors.Identification of these risk factors isrequired to determine the intensity of a clinical intervention.

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

according to BMI and waist circumference. They relate to the need to institute weight losstherapy, but they do not definethe required intensity of risk factor modification. The latter is determined by the estimation of absolute risk based on thepresence of associated disease or 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 management of the diseases present:

Established coronary heart disease (CHD), including a history 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 category of very high absolute risk. Sleep apnea. Symptoms andsigns include very loud snoringor cessation of breathing duringsleep, which is often followed by a loud clearing breath, thenbrief awakening.

3. Identify other obesity-associ-ated diseases. Obese patients are at increased risk for severalconditions that require detectionand appropriate management but that generally do not lead to 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 waistcircumference greater than 40 inches (102 cm); women are at anincreased relative risk if they have a waist circumference greaterthan 35 inches (88 cm).

12

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

4. Identify cardiovascular riskfactors that impart a highabsolute risk. Patients can beclassified 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 riskincreases the attention paid tocholesterol-lowering therapy29and blood pressure manage-ment.30

Other risk factors deserve specialconsideration because their pres-ence heightens the need for weightreduction in obese persons.

Physical inactivity imparts anincreased risk for both CVD and

type 2 diabetes.31 Physical inac-tivity exacerbates the severity ofother risk factors, but it also hasbeen shown to be an indepen-dent risk factor for all-causemortality or CVD mortality.32,33Although physical inactivity isnot listed as a risk factor thatmodifies the intensity of therapyrequired for elevated cholesterolor 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-density lipoprotein (LDL) cholesterol(serum concentration 160 mg/dL). A borderline high-risk LDL-cholesterol (130 to 159 mg/dL) plus two or more other risk factors alsoconfers high risk.

Low high-density lipoprotein(HDL) cholesterol (serum concentration < 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, thusjustifying its inclusion among risk factors contributing to high absolute risk. IFG is well established as a risk factor for type 2 diabetes.

Family history of prematureCHD (myocardial infarction or sudden death experienced by the father or other male first-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

13

Panel II [ATP II29] of theNational Cholesterol EducationProgram and the Sixth Report ofthe Joint National Committee onthe Prevention, Detection,Evaluation, and Treatment ofHigh Blood Pressure [JNC VI30]).Increased physical activity isespecially needed in obesepatients because it promotesweight reduction as well asweight maintenance, and favorably modifies obesity-associated risk factors.

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

Obesity is commonly accompanied by elevated serum triglycerides.Triglyceride-rich lipoproteinsmay be directly atherogenic,and they are also the most common manifestation of the atherogenic lipoprotein phenotype (high triglycerides,small LDL particles, and lowHDL-cholesterol levels).34 Inthe presence of obesity, highserum triglycerides are common-ly associated with a clustering of metabolic risk factors knownas the metabolic syndrome(atherogenic lipoprotein phenotype, hypertension,insulin resistance, glucose intolerance, and prothromboticstates). Thus, in obese patients,elevated serum triglycerides are a marker for increased cardiovascular risk.

Risk Factor Management

Management options of risk factors for preventing CVD, diabetes, and other chronic diseases are described in detail inother reports. For details on themanagement of serum cholesteroland other lipoprotein disorders,refer to the National CholesterolEducation Programs SecondReport of the Expert Panel on theDetection, Evaluation, andTreatment of High BloodCholesterol in Adults (AdultTreatment Panel II, ATP II).29 For thetreatment of hypertension, see theNational High Blood PressureEducation Programs Sixth Reportof the Joint National Committee onthe Prevention, Detection,Evaluation, and Treatment of HighBlood 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 personsweight 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 lowlevels of HDL-cholesterol in those with dyslipidemia.

Evaluation and Treatment Strategy

W hen health care practitioners encounter patients in the clinical setting,opportunities exist for identifying overweight and obesity and theiraccompanying 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.

16

Treatment Algorithm*

Yes

Yes

No

Patient encounter

5

6

Hx of 25 BMI?

BMI measured inpast 2 years?

BMI 25 OR waist circumference > 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 (m2)

If pounds and inches are used:

BMI =weight (pounds) x 703height squared (inches2)

Calculate BMI as follows:

1

2

3

4

17

Does patient want to lose weight?

Progress being made/goal

achieved?

Yes

Yes

Yes No

No

No

Clinician and patientdevise goals and treatment strategy

for weight loss and riskfactor control

Maintenance counseling: Dietary therapy Behavior therapy Physical activity

Assess reasons for failure 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}

18

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

History of overweight or 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 ofobesity in particular patients.

BMI measured in past 2 years For those who have not been overweight, a 2-year interval isappropriate for the reassessment of BMI. Although this timespan isnot evidence-based, it is a reason-able compromise between the need to identify weight gain at an early stage and the need to limit the time, effort, and cost of repeated measurements.

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

BMI 25 OR waist circumference > 35 in(88 cm) (women) or > 40 in(102 cm) (men) These cutoff values divide overweight from normal weightand are consistent with othernational and international guidelines. The relationshipbetween weight and mortality is J-shaped, and evidence suggeststhat the right side of the J beginsto rise at a BMI of 25. Waist circumference is incorporated asan or factor because somepatients with a BMI lower than 25 will have a disproportionateamount of abdominal fat, whichincreases their cardiovascular riskdespite their low BMI (see pages910). These abdominal circumference values are not necessary for patients with aBMI 35 kg/m2.

Assess risk factorsRisk assessment for CVD and diabetes in a person with evidentobesity will include special considerations for the medical history, physical examination, andlaboratory examination. Detectionof existing CVD or end-organ

damage presents the greatesturgency. Because the major risk ofobesity is indirect (obesity elicits oraggravates hypertension, dyslipi-demias, and type 2 diabetes; each of these leads to cardiovascularcomplications), the management of obesity should be implementedin the context of these other riskfactors. Although there is no directevidence that addressing risk factorsincreases weight loss, treating therisk factors through weight loss is a recommended strategy. The riskfactors 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/m2and who have one or no risk factorsshould work on maintaining theircurrent weight rather than embarkon a weight reduction program. The panel recognizes that the decision to lose weight must bemade in the context of other riskfactors (e.g., quitting smoking ismore important than losing weight)and patient preferences.

1

3

4

6

7

25

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

19

Clinician and patientdevise goalsThe decision to lose weight must be made jointly between the clinician and patient. Patientinvolvement and investment is crucial to success. The patient maychoose as a goal not to lose weightbut rather to prevent further weightgain. As an initial goal for weightloss, the panel recommends the lossof 10 percent of baseline weight ata rate of 1 to 2 pounds per weekand the establishment of an energydeficit of 500 to 1,000 kcal/ day(see page 23). For individuals whoare overweight, a deficit of 300 to500 kcal/day may be more appro-priate, providing a weight loss ofabout 0.5 pounds per week. Also,there is evidence that an average of8 percent of body weight can belost over 6 months. Since thisobserved average weight lossincludes people who do not loseweight, an individual goal of 10percent is reasonable. After6 months, most patients will equili-brate (caloric intake balancing energy expenditure); thus, they will require an adjustment of theirenergy balance if they are to losemore weight (see page 24).

The three major components ofweight loss therapy are dietary ther-apy, increased physical activity, andbehavior therapy (see pages 26 to34). These lifestyle therapies should

be attempted for at least 6 months before considering pharmacotherapy. In addition,pharmacotherapy should be considered as an adjunct to lifestyle therapy for patients with a BMI 30 kg/m2 and who haveno concomitant obesity-related riskfactors or diseases. Pharmaco-therapy may also be considered forpatients with a BMI 27 kg/m2 andwho have concomitant obesity-related risk factors or diseases. Therisk factors or diseases consideredimportant enough to warrant pharmacotherapy at a BMI of 27 to 29.9 kg/m2 are hypertension,dyslipidemia, CHD, type 2 diabetes,and sleep apnea.

Two drugs approved for weight lossby the FDA for long-term use are sibutramine and orlistat. However,sibutramine should not be used inpatients with a history of hyperten-sion, CHD, congestive heart failure,arrhythmias, or stroke. Certainpatients may be candidates forweight loss surgery.

Each component of weight losstherapy should be introduced to the patient briefly. The selection of weight loss methods should bemade in the context of patient pref-erences, analysis of failed attempts,and consideration of availableresources.

Progress being made/goal achievedDuring the acute weight loss period and at the 6-month and 1-year followup visits, patientsshould be weighed, their BMIshould be calculated, and theirprogress should be assessed. If atany time it appears that the programis failing, a reassessment shouldtake place to determine the reasons(see Box 10). If pharmacotherapy is used, appropriate monitoring forside effects is recommended (seepages 3537). If a patient canachieve the recommended 10-per-cent reduction in body weight within 6 months to 1 year, thischange in weight can be consideredgood progress. The patient can then enter the phase of weightmaintenance and long-term monitoring. It is important for thepractitioner to recognize that somepersons are more apt to lose or gainweight on a given regimen; thisphenomenon cannot always beattributed to the degree of compli-ance. However, if significant obesity persists and the obesity-associated risk factors remain, aneffort should be made to reinstituteweight loss therapy to achieve fur-ther weight reduction. Once the limitof weight loss has been reached, thepractitioner is responsible for long-term monitoring of risk factors andfor encouraging the patient to main-tain the level of weight reduction.

8 9

Assess reasons for failure to 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 attempts to 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 want to 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 other risk 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; even if 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 ofthe importance of staying in this cat-egory.

Periodic weight, BMI,and waist circumference checkPatients should receive periodicmonitoring of their weight, BMI, andwaist 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 ofrepeated measurements.

10

15

12

11

14

16

13

21

Ready or Not:Predicting Weight Loss

Predicting a patients readinessfor weight loss and identifyingpotential variables associatedwith 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 ofpatients 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 ofweight 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 From Weight Loss Therapy

Patients for whom weight loss therapy is not appropriate aremost pregnant or lactatingwomen, persons with a seriousuncontrolled psychiatric illnesssuch as a major depression, andpatients who have a variety ofserious illnesses and for whomcaloric restriction might exacer-bate the illness. Patients withactive substance abuse and thosewith a history of anorexia nervosa or bulimia nervosa shouldbe referred for specialized care.

Consider a patients readi-ness for weight loss andidentify potential variablesassociated with weight losssuccess.

22

Clinical experience suggests thathealth care practitioners briefly consider 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 ofweight 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 seekweight 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 ofcontrol 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 thetimes of consumption. Bingeeaters usually do not have a regu-lar meal plan; instead, they snackthroughout 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? What other benefits does he or sheanticipate? Obese individuals typically want to lose 2 to 3 timesthe 8 to 15 percent often observedand are disappointed when they donot. Practitioners must help patientsunderstand that modest weight losses frequently improve healthcomplications of obesity. Progressshould then be evaluated byachievement of these goals, whichmay include sleeping better, havingmore energy, reducing pain,and pursuing new hobbies or rediscovering old ones, particularlywhen weight loss slows and eventually stops.

A Brief Behavioral Assessment

23

The initial goal of weight loss therapy for overweightpatients is a reduction inbody weight of about 10 percent. Ifthis target is achieved, considera-tion may be given to further weightloss. In general, patients will wishto lose more than 10 percent ofbody 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 a 10-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 ofbetween 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 deficit is created at the lower weight,allowing the patient to continue tolose weight. To achieve additionalweight loss, the patient must further

Management of Overweight and Obesity

Goals for Weight Loss and Management

The following are general goalsfor 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 reducesdisease risk factors. Weight should be lost at arate 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 the lost weight. Moreover, with rapidweight reduction, there is anincreased risk for gallstones and,possibly, electrolyte abnormalities.

Weight Maintenance at a Lower 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 ofweight 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 lost usually 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 as a regain of weight that is less than6.6 pounds (3 kg) in 2 years and a sustained reduction in waist circumference of at least 1.6 inches(4 cm). If a patient wishes to losemore weight after a period ofweight maintenance, the procedurefor weight loss, outlined above,can be repeated.

After a patient has achieved the targeted 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 phase can be sustained, the better theprospects for long-term success inweight reduction. Drug therapywith either of the two FDA-approved drugs for weight loss may also be helpful during theweight maintenance phase.

Long-term monitoring andencouragement to maintainweight loss requires regularclinic 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, behaviortherapy, pharmacotherapy, andsurgery as well as combinations ofthese 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 the existence of other comorbidities or 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 With c 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/m2, even without comorbidities, while weight loss is not necessarily recommended for those with a BMI of 2529.9 kg/m2 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 therapy provide 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 of combined lifestyle therapy.

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

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In the majority of overweight andobese patients, adjustment of thediet will be required to reducecaloric intake. Dietary therapyincludes instructing patients in themodification of their diets toachieve a decrease in caloric intake.A diet that is individually plannedto help create a deficit of 500 to1,000 kcal/day should be an integralpart of any program aimed atachieving a weight loss of 1 to2 pounds per week. A key elementof the current recommendation isthe use of a moderate reduction incaloric intake, which is designed toachieve a slow, but progressive,weight loss. Ideally, caloric intakeshould be reduced only to the levelthat is required to maintain weightat a desired level. If this level ofcaloric intake is achieved, excessweight will gradually decrease. Inpractice, somewhat greater caloricdeficits are used in the period ofactive weight loss, but diets with avery low-calorie content are to beavoided. Finally, the compositionof the diet should be modified to minimize other cardiovascularrisk factors.

The centerpiece of dietary therapyfor weight loss in overweight orobese patients is a low calorie diet(LCD). This diet is different from avery low calorie diet (VLCD) (lessthan 800 kcal/day). The recom-mended LCD in this guide, i.e., theStep I Diet, also contains the nutri-ent composition that will decreaseother risk factors such as high bloodcholesterol and hypertension. Thecomposition of the diet is presentedin Table 4. In general, diets contain-ing 1,000 to 1,200 kcal/day shouldbe selected for most women; a dietbetween 1,200 kcal/day and 1,600kcal/day should be chosen for men and may be appropriate forwomen who weigh 165 pounds ormore, or who exercise regularly. If the patient can stick with the1,600 kcal/day diet but does notlose weight you may want to try the1,200 kcal/day diet. If a patient on either diet is hungry, you maywant to increase the calories by 100 to 200 per day.

VLCDs should not be used routinely for weight loss therapybecause they require special moni-toring and supplementation.50VLCDs are used only in very limit-ed circumstances by specializedpractitioners experienced in theiruse. Moreover, clinical trials showthat LCDs are as effective asVLCDs in producing weight lossafter 1 year.37

Successful weight reduction byLCDs is more likely to occur whenconsideration is given to a patientsfood preferences in tailoring a particular diet. Care should betaken to ensure that all of the recommended dietary allowancesare met; this may require the useof a dietary or vitamin supplement.Dietary education is necessary to assist in the adjustment to aLCD. Educational efforts shouldpay particular attention to the following topics:

Energy value of different foods.Food compositionfats,carbohydrates (including dietaryfiber), and proteins.Evaluation of nutrition labels todetermine caloric content and foodcomposition.New habits of purchasinggivepreference to low-calorie foods.Food preparationavoid addinghigh-calorie ingredients duringcooking (e.g., fats and oils).Avoiding overconsumption ofhigh-calorie foods (both high-fatand high-carbohydrate foods).Adequate water intake.Reduction of portion sizes.Limiting alcohol consumption.

Dietary Therapy

Low calorie diet (LCD)

1,000 to 1,200 kcal/day for most women

1,200 to 1,600 kcal/day should be chosen for men

See Appendices B-H for diets and information on physical activity that you can use with your patients.

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Table 4

Low-Calorie Step I Diet

Nutrient Recommended IntakeCalories1 Approximately 500 to 1,000 kcal/day reduction from usual intakeTotal fat2 30 percent or less of total caloriesSaturated fatty acids3 8 to 10 percent of total caloriesMonounsaturated fatty acids Up to 15 percent of total caloriesPolyunsaturated fatty acids Up to 10 percent of total caloriesCholesterol3

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Physical activity should be anintegral part of weight losstherapy and weight mainte-nance. Initially, moderate levels ofphysical 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.51Most weight loss occurs because ofdecreased caloric intake. Sustainedphysical activity is most helpful inthe prevention of weight regain.52,53In 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 training or 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 based on a patients age, symptoms, and concomitant risk factors.

For most obese patients, physicalactivity should be initiated slowly,and the intensity should beincreased gradually. Initial activitiesmay be increasing small tasks ofdaily 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 include fitness 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 that fit into their daily lives. Becauseamounts of activity are functions ofduration, intensity, and frequency,the same amounts of activity can be obtained in longer sessions ofmoderately intense activities (suchas brisk walking) as in shorter ses-sions of more strenuous activities(such as running).

A regimen of daily walking is anattractive 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.52,53With this regimen, an additional

Physical Activity

All adults should set a long-term goal to accumulate