Screening Algorithm

1. Adult Person Enrolled in the Veterans Health Administration (VHA) or Department of Defense (DoD) Healthcare Systems

   Definition

   Any adult eligible for care in the VHA or the (DoD) healthcare delivery system should be screened and if necessary, treated for overweight or obesity as described in this guideline.

2. Obtain Height and Weight; Calculate Body Mass Index (BMI)

   Objective

   Screen all adults for overweight or obesity.

   Recommendations:

   1. Adult patients should have their BMI calculated from their height and weight to establish a diagnosis of overweight or obesity. [B]
   2. Obese patients (BMI >30 kg/m²) should be offered weight loss treatment. [B] (See Module B: Treatment for Weight Loss and Weight Maintenance)
   3. Overweight patients (BMI between 25 and 29.9 kg/m²) or patients with increased waist circumference (>40 inches for men; >35 inches for women) should be assessed for the presence of obesity-associated conditions that are directly influenced by weight, to determine the benefit they might receive from weight loss treatment. [B]
   4. Normal weight patients (BMI between 18.5 and 24.9 kg/m²) should be provided with education regarding healthy lifestyle behaviors, advised of their BMI and their weight range margins, and instructed to return for further evaluation should those margins be exceeded. [Expert Opinion]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

3. Obtain Waist Circumference Measurement

   Objective

   Assess person's body fat distribution.

   Recommendations

   1. For screening purposes, waist circumference should be obtained in patients with a BMI <30 kg/m² as a predictor of disease risk. [C]
   2. The waist circumference measurement should be made with a tape measure placed above the iliac crest and wrapped in a horizontal fashion around the individual's abdomen at the end of a normal expiration.
   3. Gender-specific cut-offs should be used as indicators of increased waist circumference. [C]
      • Men: waist circumference >40 inches (102 cm)
      • Women: waist circumference >35 inches (88 cm)

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

4. Determine Presence of Obesity-Associated Health Conditions that Increase Risk

   Objective

   Identify patients who are overweight and who will benefit from weight loss treatment.

   Recommendations

   1. Weight loss treatment should be offered to overweight patients (BMI 25-29.9 kg/m²) with one or more of the obesity-associated conditions that are directly influenced by weight loss (i.e., hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome, obstructive sleep apnea) [B]; or with degenerative joint disease (DJD). [I]

Table. Obesity-Associated Chronic Health Conditions

*For a definition of Metabolic Syndrome, see the Table in Annotation L

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

5. Advise Patient to Maintain Weight and Prevent Weight Gain

   Objective

   Promote healthy lifestyles in low-risk patients.

   Recommendations

   1. Overweight patients (BMI 25-29.9 kg/m²) who do not have associated risk factors should be offered brief advice, encouraged to maintain or lose weight, and offered assistance in establishing reasonable weight loss goals as well as diet and exercise plans if they seek help in losing weight. [I]
   2. Overweight patients without obesity-associated conditions should be provided with education regarding healthy lifestyle behaviors, be advised of their BMI and their weight range margins and instructed to return for further evaluation should those margins be exceeded. BMI and risk factors should be reassessed annually. [Expert Opinion]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

6. Provide Brief Reinforcement and Lifestyle Education

   Objective

   Promote healthy lifestyles for patients with normal weight.

   Recommendations

   1. Patients of normal weight should be praised, encouraged to maintain their normal weight, and educated regarding a healthy lifestyle to include: [Expert Opinion]
      • A balance between caloric intake and energy expenditure
      • A healthy diet emphasizing, whenever possible, fresh fruits and vegetables (see MyPyramid at http://www.mypyramid.gov)
      • Regular, moderately intense physical activity for more than 30 minutes, five or more days per week
      • Additional healthy lifestyle elements related to weight maintenance that may include tobacco use cessation, limited caffeine intake, sleep hygiene, and stress management

7. Repeat Screening Annually

   Objective

   Follow up patients with normal weight.

   Recommendation

   1. Screening for overweight and obesity should be performed at least annually. [Expert Opinion]

Module B: Treatment for Weight Loss and Weight Maintenance

Treatment Algorithm

Assessment

8. Obese Person or Overweight with Obesity-Associated Condition(s)

   Definition

   Patients who are obese, and patients who are overweight or have an elevated waist circumference with one or more obesity-associated conditions should be offered treatment for the reduction of body weight.

9. Obtain Medical History, Physical Examination, and Laboratory Tests as Indicated

   Objective

   Identify medical disorders that may cause or complicate obesity.

   Recommendations

   1. The clinical assessment of the overweight or obese patient should be done by the primary care provider. The assessment should include a basic medical history, a relevant physical examination, and laboratory tests as clinically indicated. The history should include age of onset or periods of rapid increase in body weight, precipitating factors, and maximum lifetime weight. [Expert Opinion]
   2. The clinical assessment should rule out organic and drug related causes and identify health risks and/or the presence of weight-related conditions. [Expert Opinion]
   3. In addition to a medical assessment, a social and psychological assessment may be indicated to identify barriers to participating in dietary or physical activity programs. The assessment may also include screening for behavioral health conditions that may hinder successful weight loss (i.e., depression, post-traumatic stress disorder, anxiety, bipolar disorder, addictions, binge eating disorder, bulimia, and alcoholism). [Expert Opinion]
   4. A nutritional evaluation should include an assessment of current intake as well as the use of supplements, herbs, and over-the-counter weight loss aides. In addition, meal and snack patterns and problem eating behaviors need to be assessed. The weight and dieting history should include the age of onset of weight gain, number and types of diets and attempts, possible triggers of weight gains and losses, and range of weight change. [Expert Opinion]
   5. Current levels of physical activity and sedentary lifestyle should be assessed, including exercise frequency, duration, and intensity as well as the patient's motivation to increase physical activity. [Expert Opinion]

10. Assess Patient's Readiness to Lose Weight

    Objective

    Identify the patient who is ready and willing to attempt weight loss.

    Recommendations

    1. Readiness to lose weight should be assessed by direct inquiry. Those indicating an adequate readiness to lose weight (preparation or action stage) should proceed to treatment. Those not yet ready to lose weight (precontemplation or contemplation stage) should receive motivational counseling. [Expert Opinion]

11. Reach Shared Decisions about Goals and Treatment Plan

    Objective

    Incorporate patient preferences in the treatment goals and plan to optimize the patient's success in achieving and maintaining sustained weight loss.

    Recommendations

    1. The clinical team, together with the patient, should reach shared decisions regarding the treatment program. [Expert Opinion]
       • The clinical team should convey to the patient that obesity is a chronic disease that will require lifelong treatment
       • The clinical team should suggest the personalized preferred treatment options based on disease risk and patient characteristics (e.g., describe to the patient/caregiver the treatment options, including behavioral modification, diet and activity patterns, prognosis, estimated length and frequency of therapy, and expectations)
       • The patient should describe his or her needs, preferences, and resources and assist the team in determining the optimal environment for therapy and preferred interventions
       • The patient and the clinical team together should reach conclusions on the goals of therapy and preferred treatment plan
    2. The patient's family/caregiver may participate in the treatment process and should be involved in assisting the patient with changing lifestyle, diet and physical activity patterns. [Expert Opinion]
    3. Patient education should be provided in an interactive and written format. The patient should be given an information packet that includes printed material on subjects such as preferred foods to eat or foods to avoid, healthy lifestyle tips, support group information, and available audio/visual programs on weight loss. [Expert Opinion]
    4. A detailed treatment plan needs to be documented in the medical record to provide integrated care. [Expert Opinion]

Treatment For Weight Loss

12. Initiate Interventions Based on Risk Level and Patient Preferences

    Objective

    Stratify patients according to risk and provide weight loss treatment accordingly.

    Recommendations

    1. Weight loss therapy should be tailored to risk level based on calculated BMI and based upon the balance of benefits and risks and patient preferences. [C]
    2. Patients who may benefit from weight loss should be offered interventions to improve their diet, increase exercise, and change related behaviors to promote weight loss. [A]
    3. Weight loss interventions should combine dietary therapy, increased physical activity, and behavioral modification strategies rather than utilizing one intervention alone. [A]
    4. A reasonable initial goal of weight loss therapy (intervention) is a 10 percent reduction in body weight. [B]
    5. Drug therapy in combination with a reduced-calorie diet and exercise interventions should be considered for obese patients (BMI >30 kg/m²) or overweight patients (BMI >27 kg/m²) with an obesity-associated chronic health condition (i.e., hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome, and sleep apnea). [B]
    6. Bariatric surgery to reduce body weight, improve obesity-associated comorbidities, and improve quality of life may be considered in adult patients with a BMI >40 kg/m² and those with a BMI >35 kg/m² with at least one obesity-associated chronic health condition (i.e., hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome, and sleep apnea). [B]
    7. There is insufficient evidence to recommend drug or surgical interventions specifically for patients who have documented coronary artery disease (CAD). [I] However, there is good evidence that drug and surgical weight loss interventions may improve cardiovascular risk factors, such as hypertension, dyslipidemia, and diabetes mellitus. [A]
    8. There is insufficient evidence to recommend drug or surgical interventions specifically for patients who have degenerative joint disease (DJD). However, physical activity and diet may improve physical function and chronic pain in patients with DJD. [I]

Table. Indications for More Intensive Weight Loss Therapy

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

Diagnosis of Metabolic Syndrome ["Third Report,", 2002]

*Some men can develop multiple metabolic risk factors when the WC is only marginally increased (e.g., 37-39 inches [94-102 cm]). Such persons may have a strong genetic contribution to insulin resistance. They should benefit from changes in life habits, similarly to men with categorical increases in WC.

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document) N/A = Not Applicable

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

Weight Maintenance and Follow-Up

13. Is Patient Losing Weight?

    Objective

    Assess response to therapy and progress toward weight loss goals.

    Recommendations

    1. Patients on diet, exercise, and behavioral therapy who have lost on average 1 to 2 pounds per week should continue with their current treatment until their weight loss goal is achieved. [B]
    2. Patients who have lost on average less than 1 pound per week should have their adherence to therapy assessed and treatment plan reevaluated. [I]
    3. Obese patients with a BMI >30 kg/m², and overweight patients with a BMI >27 kg/m² and obesity-associated chronic health conditions who fail to achieve adequate weight loss through non-pharmacologic interventions may be candidates for pharmacotherapy with orlistat or sibutramine. [B] (See Module C, Section C-4 Pharmacotherapy.)

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

14. Congratulate and Initiate Relapse Prevention/Maintenance

    Objective

    Continue the necessary interventions to maintain the weight loss and prevent weight gain.

    Recommendations

    1. Patients who have met their weight loss goals or have stopped losing weight and are ready to sustain current weight loss should be offered a maintenance program consisting of diet, physical activity, and behavioral support. Weight status should be reevaluated and diet and physical activity should be adjusted so that energy balance is maintained (energy intake is equal to energy expenditure). [B]
    2. Providers should continue to maintain contact with patients providing on-going support, encouragement, and close monitoring during the maintenance phase of weight loss to prevent weight regain. [B]
    3. Patients who achieve their weight loss goal with a combination of medication, diet, and exercise may be considered candidates to include their medication as a component of their weight maintenance program with continued monitoring of effectiveness and adverse effects. [B] (See Module C, Section C-4 Pharmacotherapy recommendations below.)
    4. Lifelong follow-up after bariatric surgery is necessary to monitor adherence to treatment, adverse effects and complications, dietary restrictions, and behavioral health. [I]
    5. There is no established optimum visit length or duration between maintenance visits, but it seems reasonable to establish a minimum of quarterly follow-up (every three months) for the sustainment of weight loss and more frequently if the patient requests it. [I]

Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

15. Assess Adherence and Modify Treatment

    Objective

    Assess the patient's progress toward treatment goals and determine adjustments as needed.

    Recommendations

    1. Adherence to weight loss programs should be assessed by periodically measuring the patient's BMI and waist circumference and providing feedback. [Expert Opinion]
    2. Patients should be encouraged to record activities by using food logs, exercise logs, and personal diaries to provide structure and allow the provider to identify compliance or relapse issues. [B]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

16. Reinforce Knowledge, Motivation, Skills, and Support

    Objective

    Motivate overweight or obese patients who are presently not ready to undertake weight loss to do so in the future.

    Recommendations

    1. Motivational interviewing techniques should be utilized to motivate patients to improve their dietary habits. [B]
    2. Motivational interviewing techniques should be considered to motivate patients to increase their physical activity. [Expert Opinion]
    3. Patients who may benefit from weight loss but are not willing to attempt to lose weight at this time should receive brief, non-judgmental motivational counseling designed to increase their motivation to lose weight. This counseling should include discussion about: [Expert Opinion]
       • Relevance: connection between overweight and current symptoms, disease, and medical history
       • Risks: risks of continued overweight status, tailored to individual risk/relevance of cardiovascular disease or exacerbation of pre-existing disease
       • Rewards: potential benefits for losing excess weight to patients' medical, financial, and psychosocial well-being
       • Roadblocks: barriers to losing weight, with options and strategies to address patient's barriers
       • Repetition: reassess willingness to lose weight at subsequent visits; repeat intervention for unmotivated patients at every visit

Module C: Interventions for Weight Loss

C-1 Diet Therapy

Recommendations

Weight Loss

1. Dietary interventions should be individually planned, in conjunction with physical activity, to create a caloric deficit of 500 to 1,000 kcal/day. Such negative energy balance may lead to a weight loss of 1 to 2 pounds per week. [B]

Selection of Specific Diets

2. Dietary programs should at a minimum reduce the usual caloric intake by 500 to 1,000 kcal/day to achieve modest weight loss. [B]
3. Low-calorie diets (LCDs) should generally include 1,000 to 1,200 kcal/day for women and 1,200 to 1,600 kcal/day for men and should include the major nutrients in appropriate proportions (see Appendix C, Table C-1 in the original guideline document). [B]
4. Very-low-calorie diets (VLCDs) that restrict calories to less than 800 kcal/day [15 kcal/kg ideal body weight] are not recommended for weight loss, but may be used short term (12 to 16 weeks) under medical supervision. [B]
5. Low-fat intake (20 to 30 percent of total calories/day), as part of low-calorie diets (LCDs), can be recommended to induce weight loss and should be recommended for patients with cardiovascular disease or lipid abnormalities. [B]
6. Low-carbohydrate diets (less than 20 percent of total calories) may be used for short-term weight loss, but are not recommended for long-term dieting or weight maintenance. [B]
7. Low-carbohydrate diets can be recommended to reduce serum triglyceride levels for overweight patients with mixed dyslipidemia. [B]
8. Low-carbohydrate diets are not recommended for patients with hepatic or renal disease or for patients with diabetes who are unable to monitor blood glucose. [C]
9. Low-calorie diets (LCDs) or very low-calorie diets (VLCDs) may include meal replacements (e.g., bars and shakes). [A]
10. There is insufficient evidence to recommend for or against a diet limited to foods with a glycemic index less than 55 as a means of producing weight loss. [C]

Commercial Diets

11. Patients should be encouraged to adhere to a specific diet, as adherence to any diet plan from a variety of programs (e.g., Atkins, Ornish, Weight Watchers, and Zone) has been shown to be the most important factor in achieving weight reduction. [B]

Table. Definitions of Common Diets

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

C-2 Physical Activity

Recommendations

1. Weight loss interventions should include exercise to promote weight loss [A], maintain weight loss [A], decrease abdominal obesity [B], improve cardiovascular fitness [A], improve cardiovascular outcomes [A], and decrease all-cause and cardiovascular mortality [B].
2. Home fitness/lifestyle activities or structured supervised programs may be effectively used to produce a caloric expenditure leading to weight loss. [A]
3. Moderate levels of physical activity should be performed at least 30 minutes most days of the week. [B]
4. Physical activity may include short intermittent bursts (10 minutes or longer) as well as longer continuous exercise. [A]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

C-3 Behavioral Modification Strategies

Recommendations

1. Behavioral modification interventions to improve adherence to diet and physical activity should be given to overweight or obese individuals. [B]
2. Behavioral modification interventions should be provided at a higher intensity when possible for greater effectiveness. Higher intensity is defined as more than one personal contact per month for the first three months (individual or group setting). Less frequent intervention may be an ineffective and inefficient use of manpower. [B]
3. Multiple behavioral modification strategies should be used in combination for greater effectiveness. [A]
4. Behavioral modification intervention should be delivered in a group format when possible rather than individually. [B]
5. For individuals unable or unwilling to participate in weight loss treatment in person, telephone or internet-based behavioral modification intervention may be considered. [B]
6. Behavioral modification intervention should be continued on a long-term basis to promote maintenance of weight loss. [B]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

C4 Pharmacotherapy

Recommendations

1. Adult patients with a BMI greater than 30 kg/m² or a BMI greater than 27 kg/m² with obesity-associated conditions may be considered for pharmacotherapy in combination with a reduced-calorie diet, increased physical activity and behavioral therapy. [B]
2. Patients who do not respond to medication with a reasonable weight loss should be evaluated for adherence to the medication regimen and adjunctive therapies or considered for an adjustment of dosage. [I]
3. If the patient continues to be unresponsive to the medication, or serious adverse effects occur, the use of medication should be discontinued. [I]

Orlistat

4. Orlistat may be considered to reduce body weight [B] and improve obesity-associated cardiovascular risk factors [C].
5. Patients who have lost 5 percent or more of their body weight after 12 weeks of treatment or lost an average of 1 pound or more per week with orlistat should continue their current treatment, as they are more likely to experience sustained weight loss. [B]
6. Orlistat may be considered as a component of weight maintenance programs for up to 4 years. [B]
7. Patients prescribed orlistat should take a multiple vitamin that includes fat soluble vitamins. [Expert Opinion]

Sibutramine

8. Sibutramine may be considered to reduce body weight [B] and improve glycemic and lipid parameters [C].
9. Patients who have lost an average of 1 pound or more per week during the first 4 weeks of therapy with sibutramine should continue treatment, barring any intolerable side effects. [Expert Opinion]
10. Patients who fail to lose 4 pounds after 4 weeks treated with sibutramine should have their adherence assessed and, if appropriate, an increase in the dose for an additional 4-week trial. [I]
11. Sibutramine may be considered as a component of weight maintenance programs for up to 2 years. [B]
12. Sibutramine should be discontinued if it is not efficacious in helping the patient to lose or maintain weight loss. [B]
13. Sibutramine should be used with caution as it can elevate blood pressure and heart rate. [A]
14. Adult patients with uncontrolled hypertension, cardiovascular disease, or a history of myocardial infarction (MI) or stroke should not include sibutramine as a part of their weight loss program due to the increased risk of harm. [D]
15. Sibutramine should be avoided in patients taking selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), triptans, pseudoephedrine, and other agents that affect serotonin. [D]

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

C-5 Bariatric Surgery

Recommendations

1. Adult patients with extreme obesity (BMI 40 kg/m² or more) or severe obesity (BMI 35 kg/m² or more with one or more obesity-associated chronic health condition) may be considered for bariatric surgery to reduce body weight [A], improve obesity-associated comorbidities [B], and improve quality of life [B].
2. Roux-en-y Gastric Bypass (RYGB) is recommended as the bariatric procedure with the most robust evidence for inducing sustained weight loss [B] for patients with BMI greater than 40 kg/m².
3. There is insufficient evidence to recommend for or against the routine use of bariatric surgery in those over 65 years of age and patients with a substantial surgical risk. [I]
4. Providers should engage all patients who are candidates for bariatric surgery in a detailed discussion of the benefits and potential risks of bariatric procedures. [I]
5. Relative contraindications to bariatric surgery that are supported only by expert consensus include:
   • Unstable coronary artery disease, severe pulmonary disease, portal hypertension or other conditions that can compromise anesthesia or wound healing
   • Patients who are unable to comprehend basic principles of surgery or follow-up postoperative instructions
   • Patients having had multiple abdominal operations, complicated incisional hernias
   • Patients who have illnesses that greatly reduce life expectancy and/or are unlikely to be improved in their medical condition by surgically-induced weight reduction (e.g., cancer).

6. Lifelong medical follow-up after surgery is necessary to monitor adherence to treatment, adverse effects and complications, dietary restrictions, and behavioral health. [I]

*Evidence quality was rated as fair, because few studies reported these outcomes consistently, and few studies were designed to examine the impact of surgery on these outcomes.

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)

AGB = Adjustable gastric band; RBG vertical banded gastroplasty

Definitions:

Evidence Rating System

Quality of Evidence (QE)

Overall Quality

Net Effect of the Intervention

Strength of the Recommendation

Abbreviations and Acronyms List

AGB - Adjustable Gastric Band

BMI - Body Mass Index

CAD – Coronary artery disease

DoD - Department of Defense

DJD - Degenerative Joint Disease

EBM - Evidence-Based Medicine

HDL-C - High Density Lipoprotein Cholesterol

LCD - Low-Calorie Diet

LDL – Low density Lipoprotein

MAOI - Monoamine Oxidase Inhibitors

MI - Myocardial Infarction

RYGB - Roux-en-y Gastric Bypass

SSRI - Selective Serotonin Reuptake Inhibitor

VHA – Veterans Health Administration

VBG - Vertical Banded Gastroplasty

VLCD - Very-Low-Calorie Diet

WC - Waist Circumference

• Screening for Overweight and Obesity
• Treatment for Weight Loss and Weight Maintenance

References open in a new window

• U.S. Preventive Services Task Force. Screening for Obesity in Adults: Recommendations and Rationale. November 2003. Agency for Health Care Research and Quality, Rockville, MD. (http://www.ahrq.gov/clinic/3rduspstf/obesity/obesrr.htm).
• National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI). Clinical Guidelines on the identification, evaluation, and treatment of overweight and obesity in Adults. The evidence report. NIH Publication No. 98-4083, 1998.

Electronic copies: Available from the Department of Veterans Affairs Web site.

Print copies: Available from the Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Electronic copies: Available from the Department of Veterans Affairs Web site.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

In addition, the VHA Web site provides references to related guidelines, performance measures, and other resources.

The following are also available:

• Guideline for Guidelines. Draft. Washington (DC): Veterans Health Administration, Department of Veterans Affairs. Available from the : VHA Web site.
• Guideline development process. Appendix A of the original guideline document
• Putting clinical practice guidelines to work [online tutorial]. Available from the Department of Veterans Affairs Web site.

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