The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Assessment of Body Mass Index (BMI)
- Measure weight, waist circumference, and calculate patient's BMI1 to determine if patient is overweight or obese and pattern of weight change [C]
- If overweight, assess for complicating risk factors:
- Established coronary heart disease (CHD) or stroke
- Other atherosclerotic disease
- Type 2 diabetes
- Sleep apnea
- Smoking
- High triglycerides
- Hypertension
- High low-density lipoprotein (LDL)
- Low high-density lipoprotein (HDL)
- Impaired fasting glucose
- Family history of premature congenital heart disease (CHD)
- Assess current eating, exercise behaviors, history of weight loss attempts, and psychological factors contributing to weight gain.
Frequency: At each periodic health exam; more frequently at the discretion of the physician
1BMI is an accurate proxy for body fat in average adults but may be misleading in muscular individuals.
Interventions to Promote Weight Management
Patients with BMI >25
- Ask patients how their weight impacts their health
- Advise and discuss patients' associated disease risks and importance of weight management.
- Assess and discuss patients' readiness to make positive behavior changes.
- Assist patients who are ready to make behavior changes related to food intake and physical activity:
- Work with your patients to establish realistic treatment goals2.
- Collaborate on strategies for reducing calories and adjusting as needed to maintain gradual weight loss [A] (reduce calories as needed to maintain 1 to 2 pound weight loss per week) and improving dietary quality.
- Recommend weight loss strategies and resources as needed (see www.michigan.gov/surgeongeneral).
- Collaborate on strategies for increasing daily physical activity (ideally 30 minutes of moderate physical activity most days of the week) [A].
- Arrange follow-up with your patients to monitor progress and provide support.
Frequency: At each periodic health exam; more frequently at the discretion of the physician
2Avoid weight gain or maintain weight loss, initial goal of 10% weight loss and reassess after goal achieved, maximum weight loss of ½ pound per week if overweight and 1–2 pounds per week if BMI >30.
Interventions to Promote Weight Management
Patients with BMI >30 or >27 with Other Risk Factors or Diseases
All of the above plus:
- Consider referral to a program that provides guidance on nutrition, physical activity, and psychosocial concerns.
- Consider pharmacotherapy only for patients with increased medical risk because of their weight with co-existing risk factors or comorbidities (monitor for weight loss and medication side effects; periodically review need for medication).
- Insurance coverage for weight loss medications varies; consult health plan for eligibility.
Frequency: At each periodic health exam; more frequently at the discretion of the physician
Surgical Treatment
Patients with BMI >40 or BMI >35 and Uncontrolled Comorbid Conditions3
- Weight loss surgery should be considered only for patients in whom other methods of treatment have failed and who have clinically severe obesity (i.e., BMI >40 or BMI >35 with life-threatening comorbid conditions3) [B].
- Evaluate for psychological factors that adversely affect surgical outcomes.
- Insurance coverage for bariatric surgery varies; consult health plan for eligibility.
3 Comorbidities: Severe cardiac disease (CHD, pulmonary hypertension, congestive heart failure, and cardiomyopathy); Type 2 diabetes, obstructive sleep apnea and other respiratory disease (chronic asthma, hypoventilation syndrome, Pickwickian syndrome); end-organ damage; pseudo-tumor cerebri; gastroesophageal reflux disease; hypertension; hyperlipidemia; severe joint or disk disease if interferes with daily functioning.
Definitions:
Levels of Evidence for the Most Significant Recommendation
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
