The American Medical Association (AMA) designated obesity as a chronic disease and the World Health Organization (WHO) defines obesity as a body mass index (BMI) of ≥ 30 kg/m2. It is associated with numerous health factors – diabetes, hypertension, arthritis, sleep disorder, high cholesterol, and other chronic health conditions.
The American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations for obesity management
1. Identifying Patients Who Need to Lose Weight (BMI and Waist Circumference)
- Measure height and weight and calculate BMI at annual visits or more frequently.
- Use the current cut points for overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI >30 kg/m2) to identify adults who may be at elevated risk of CVD and the current cut points for obesity (BMI >30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes.
- Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality.
- Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cut points currently in common use (from either NIH/NHLBI or WHO/IDF) may continue to be used to identify patients who may be at increased risk until further evidence becomes available.
2. Matching Treatment Benefits with Risk Profiles (Reduction in Body Weight Effect on Risk Factors for CVD, Events, Morbidity and Mortality)
- Counsel overweight and obese adults with cardiovascular risk factors (high BP, hyperlipidemia, and hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3%–5% produce clinically meaningful health benefits, and greater weight losses produce greater benefits.
- Sustained weight loss of 3%–5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes;
- Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose, and lipids as well as further reduce triglycerides and blood glucose.
3. Diets for Weight Loss (Dietary Strategies for Weight Loss)
- Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake:
- Prescribe 1,200–1,500 kcal/d for women and 1,500–1,800 kcal/d for men (kilocalorie levels are usually adjusted for the individual’s body weight);
- Prescribe a 500-kcal/d or 750-kcal/d energy deficit; or
- Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
- Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status, and preferably refer to a nutrition professional for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults.
4. Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
- Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies.
- Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.
- Electronically delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions.
- Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer reviewed published evidence of their safety and efficacy.
- Use a very-low-calorie diet (defined as <800 kcal/d) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. • Advise overweight and obese individuals who have lost weight to participate long term (>1 year) in a comprehensive weight loss maintenance program.
- For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200–300 min/wk), monitor body weight regularly (i.e., weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight).
5. Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
- Advise adults with a BMI >40 kg/m2 or BMI >35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation.
- For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures.
- Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility).
The Endocrine Society include the followings in obesity management guideline on the treatment of obesity:
- Diet, exercise, and behavioral modification should be included in all obesity management approaches for body mass index (BMI) of 25 kg/m2 or higher.
- Other tools, such as pharmacotherapy for BMI of 27 kg/m2 or higher with comorbidity or BMI over 30 kg/m2 and bariatric surgery for BMI of 35 kg/m2 with comorbidity or BMI over 40 kg/m2, should be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible.
Demographic and Clinical Factors
Following demographic and clinical characteristics should consider for obesity dose adjustment:
- Baseline BMI
- Baseline waist circumference
- Presence or absence of comorbid conditions
- Presence or absence of cardiovascular risk factors
- AHA/ACC/TOS Guideline for Obesity
- Endocrine Society Guideline for Obesity