The recommendations for the screening and management of overweight and obesity are organized into 3 major modules. The algorithms, objectives and recommendations that accompany each module, and the evidence supporting the recommendations are presented below. The quality of evidence (QE) grading (I-III); overall quality (Good, Fair, Poor); and final grade of recommendations (R) (A-D, I) are provided for specific statements. These grades, along with "net effect of the interventions" are defined at the end of the "Major Recommendations" field.
Note: A list of all abbreviations is provided at the end of the "Major Recommendations" field.
Module A: Screening for Overweight and Obesity
Screening Algorithm
- 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.
- Obtain Height and Weight; Calculate Body Mass Index (BMI)
Objective
Screen all adults for overweight or obesity.
Recommendations:
- Adult patients should have their BMI calculated from their height and weight to establish a diagnosis of overweight or obesity. [B]
- Obese patients (BMI >30 kg/m2) should be offered weight loss treatment. [B] (See Module B: Treatment for Weight Loss and Weight Maintenance)
- 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]
- 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]
Classification |
BMI (kg/m2) |
Disease Risk with Normal Waist Circumference |
Disease Risk with Excessive Waist Circumference |
Underweight |
<18.5 |
- |
- |
Normal |
18.5-24.9 |
- |
- |
Overweight |
25.0-29.9 |
Increased |
Moderate |
Obese I |
30-34.9 |
Moderate |
Severe |
Obese II |
35.0-39.9 |
Severe |
Very Severe |
Obese III |
>40 |
Very Severe |
Very Severe |
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Adult patients should have their BMI calculated from their height and weight. |
McTigue et al., 2003
National Heart, Lung, and Blood Institute (NHLBI), 1998
U.S. Preventive Services Task Force (USPSTF), 2003
World Health Organization (WHO), 2000
|
I |
Fair |
B |
2 |
Overweight adults (BMI between 25 and 29.9 kg/m2) should be assessed for other risk factors to determine if they need treatment for overweight. |
McTigue et al., 2003
NHLBI, 1998
Strawbridge et al., 2000
USPSTF, 2003
WHO, 2000
|
I |
Fair |
B |
3 |
Obese patients should be offered weight loss treatment. |
Heiat, Vaccarino, & Krumholz, 2001
McTigue et al., 2003
NHLBI, 1998
WHO, 2000
|
I |
Good |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- Obtain Waist Circumference Measurement
Objective
Assess person's body fat distribution.
Recommendations
- For screening purposes, waist circumference should be obtained in patients with a BMI <30 kg/m2 as a predictor of disease risk. [C]
- 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.
- 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)
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Waist circumference should be obtained in patients with BMI <30 kg/m2 as a predictor of disease risk. |
NHLBI, 1998
Zhu et al., 2005
|
II-2 |
Fair |
C |
2 |
Gender-specific weight circumference (WC) cut-offs should be used as indicators of increased disease risk:
Men >40 inches (102cm)
Women >35 inches (88cm)
|
Janssen, Katzmarzyk, & Ross, 2002
NHLBI, 1998
WHO, 2000
|
III |
Poor |
C |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- 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
- 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
The presence of any of the following conditions that are directly influenced by weight warrants weight loss therapy:
Hypertension
Type 2 Diabetes
Dyslipidemia
Metabolic Syndrome *
Obstructive Sleep Apnea
Degenerative Joint Disease (DJD)
|
*For a definition of Metabolic Syndrome, see the Table in Annotation L
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Overweight adults (BMI between 25 and 29.9 kg/m2) should be assessed for other risk factors to determine if they need treatment for overweight. |
McTigue et al., 2003
NHLBI, 1998
Strawbridge et al., 2000
USPSTF, 2003
WHO, 2000
|
I |
Fair |
B |
2 |
Normal weight patients and overweight patients who do not have obesity-associated conditions should be educated to reinforce good lifestyle behaviors. |
NHLBI, 1998
WHO, 2000
|
III |
Poor |
I |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- Advise Patient to Maintain Weight and Prevent Weight Gain
Objective
Promote healthy lifestyles in low-risk patients.
Recommendations
- 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]
- 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]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Brief advice for overweight adults (BMI 25-29.9 kg/m2) without other associated risk factors assists in weight loss and/or weight maintenance. |
Working Group Consensus |
III |
Poor |
I |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- Provide Brief Reinforcement and Lifestyle Education
Objective
Promote healthy lifestyles for patients with normal weight.
Recommendations
- 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
- Repeat Screening Annually
Objective
Follow up patients with normal weight.
Recommendation
- 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
- 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.
- Obtain Medical History, Physical Examination, and Laboratory Tests as Indicated
Objective
Identify medical disorders that may cause or complicate obesity.
Recommendations
- 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]
- 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]
- 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]
- 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]
- 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]
- Assess Patient's Readiness to Lose Weight
Objective
Identify the patient who is ready and willing to attempt weight loss.
Recommendations
- 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]
- 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
- 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
- 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]
- 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]
- A detailed treatment plan needs to be documented in the medical record to provide integrated care. [Expert Opinion]
Treatment For Weight Loss
- Initiate Interventions Based on Risk Level and Patient Preferences
Objective
Stratify patients according to risk and provide weight loss treatment accordingly.
Recommendations
- 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]
- 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]
- Weight loss interventions should combine dietary therapy, increased physical activity, and behavioral modification strategies rather than utilizing one intervention alone. [A]
- A reasonable initial goal of weight loss therapy (intervention) is a 10 percent reduction in body weight. [B]
- 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]
- 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]
- 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]
- 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
The presence of the following conditions, directly influenced by weight loss, warrants consideration of more intensive therapy with drugs or surgery:
Hypertension
Type 2 Diabetes
Dyslipidemia
Metabolic Syndrome
Obstructive Sleep Apnea
|
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss with diet, exercise, and behavioral modification is recommended for patients with a BMI >25 kg/m2 and hypertension. |
NHLBI, 1998
Appel et al., 2003
|
I |
Good |
A |
2 |
Orlistat is associated with lowering blood pressure as a secondary effect of weight loss in patients with a BMI >27 kg/m2 and hypertension. |
Sharma & Golay, 2002 |
I |
Good |
B |
3 |
Bariatric surgery is effective in lowering blood pressure in patients with a BMI >35 kg/m2 and hypertension. |
Buchwald et al., 2004
Sjostrom et al., 2004
|
I |
Fair |
B |
4 |
Sibutramine has been shown to raise blood pressure in patients with a BMI >27 kg/m2. |
Arterburn, Crane, & Veenstra, 2004 |
I |
Good |
D |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss with diet, exercise, and behavioral modification is recommended in patients with a BMI >25 kg/m2 and diabetes. |
Tuomilehto et al., 2001
The Diabetes Prevention Program, 2002
|
I |
Good |
A |
2 |
Orlistat and sibutramine modestly improve glycemic control in patients with a BMI >27 kg/m2 and type 2 diabetes. |
Didangelos et al., 2004
Hanefeld & Sachse, 2002
Kelley et al., 2002
Miles et al., 2002
Torgerson et al., 2004
|
I |
Fair |
B |
3 |
Bariatric surgery improves glycemic control or resolves diabetes in patients with a BMI >35 kg/m2. |
Buchwald et al., 2004 |
I |
Good |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss is recommended in all patients with a BMI >25 kg/m2 with dyslipidemia. |
"Third Report," 2002
NHLBI, 1998
|
I |
Good |
A |
2 |
Orlistat and sibutramine improve lipid levels in patients with a BMI >27 kg/m2 with dyslipidemia. |
Dujovne et al., 2001
Hutton & Fergusson, 2004
Klein, 2004
Lucas, Boldrin, & Reaven, 2003
Micic et. al., 1999
|
I |
Good |
B |
3 |
Bariatric surgery improves triglycerides in patients with a BMI >35 and dyslipidemia. |
Buchwald et al., 2004
Sjostrom et al., 2004
|
I |
Good |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
Diagnosis of Metabolic Syndrome ["Third Report,", 2002]
Three or more of the following risk factors indicate metabolic syndrome: |
Defining Level |
Abdominal Obesity: |
Waist Circumference (WC): |
Men*
| Greater than 102 cm (>40 in) |
Women |
Greater than 88 cm (>35 in)
|
Triglycerides |
Greater than or equal to 150 mg/dL |
HDL cholesterol: |
|
Men
| Less than 40 mg/dL |
Women |
Less than 50 mg/dL |
Blood pressure |
Greater than or equal to 130/85 mmHg |
Fasting glucose |
Greater than or equal to 110 mg/dL |
*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.
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss is recommended in all patients with a BMI >25 kg/m2 with metabolic syndrome. |
"Third Report," 2002
NHLBI, 1998
|
I |
Good |
A |
2 |
Orlistat improves the components of the metabolic syndrome in patients with a BMI >27 kg/m2. |
Didangelos et al., 2004
Lindgarde, 2000
|
I |
Fair |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss is recommended in patients with a BMI >25 kg/m2 with sleep apnea. |
Carmelli et al., 2000
Kansanen et al., 1998
Smith et al., 1985
Suratt et al., 1992
|
II-3 |
Fair |
B |
2 |
The use of orlistat and sibutramine has not been adequately studied in obese or overweight patients with sleep apnea. |
N/A |
N/A |
N/A |
I |
3 |
Bariatric surgery is recommended in morbidly obese patients with sleep apnea. |
Buchwald et al., 2004
Dixon, Schacter, & O'Brien, 2001
Karason et al., 2000
Maggard et al., 2005
O'Brien et al.,2002
|
II-2 |
Good |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document) N/A = Not Applicable
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Weight loss is recommended in all obese or overweight patients with lower extremity DJD. |
Christensen, Astrup, & Bliddal, 2005
Felson et al., 1992
Messier et al., 2004
Rejeski et al., 2002
|
I |
Poor |
C |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
Weight Maintenance and Follow-Up
- Is Patient Losing Weight?
Objective
Assess response to therapy and progress toward weight loss goals.
Recommendations
- 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]
- Patients who have lost on average less than 1 pound per week should have their adherence to therapy assessed and treatment plan reevaluated. [I]
- 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.)
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
An energy deficit of 500-1,000 calories can lead to weight loss of 1 to 2 pounds per week. |
"Diet programs," 2004
NHLBI, 1998
|
I |
Good |
B |
2 |
A reasonable time to achieve a 10% reduction in body weight is 6 months of therapy. |
NHLBI, 1998 |
I |
Good |
B |
3 |
Patients who have lost on average 1 pound or more per week should continue with their current treatment. |
NHLBI, 1998 |
II |
Fair |
B |
4 |
Use of medications for maintenance. |
See Module C, Section C-4: Pharmacotherapy |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- Congratulate and Initiate Relapse Prevention/Maintenance
Objective
Continue the necessary interventions to maintain the weight loss and prevent weight gain.
Recommendations
- 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]
- 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]
- 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.)
- Lifelong follow-up after bariatric surgery is necessary to monitor adherence to treatment, adverse effects and complications, dietary restrictions, and behavioral health. [I]
- 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]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Continued contact with patients providing on-going support, encouragement, and monitoring to prevent weight regain. |
NHLBI, 1998 |
II |
Fair |
B |
3 |
A maintenance program of diet, physical activity, and behavioral support should be offered beginning at 6 months. |
NHLBI, 1998
Tremblay, Doucet, & Imbeault, 1999
|
II-2 |
Fair |
B |
4 |
Emphasize working with patients to solve problems that impede weight management. |
NHLBI, 1998
Perri et al., 1988, 2001
Tremblay Doucet, & Imbeault , 1999
Wing & Phelan, 2005
|
II-2 |
Fair |
B |
Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- Assess Adherence and Modify Treatment
Objective
Assess the patient's progress toward treatment goals and determine adjustments as needed.
Recommendations
- Adherence to weight loss programs should be assessed by periodically measuring the patient's BMI and waist circumference and providing feedback. [Expert Opinion]
- 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]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Provide patient with objective evidence of goal attainment. |
Marlatt & Gordon, 2000
Wadden, 1999
|
II-2 |
Fair |
B |
2 |
Analysis/reinforcement of food logs, exercise records, and personal diaries confirms compliance. |
DiLillo, Siegfried,& Smith-West, 2003
NHLBI, 1998
|
II |
Poor |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
- 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
- Motivational interviewing techniques should be utilized to motivate patients to improve their dietary habits. [B]
- Motivational interviewing techniques should be considered to motivate patients to increase their physical activity. [Expert Opinion]
- 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
- 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
- Dietary programs should at a minimum reduce the usual caloric intake by 500 to 1,000 kcal/day to achieve modest weight loss. [B]
- 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]
- 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]
- 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]
- 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]
- Low-carbohydrate diets can be recommended to reduce serum triglyceride levels for overweight patients with mixed dyslipidemia. [B]
- 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]
- Low-calorie diets (LCDs) or very low-calorie diets (VLCDs) may include meal replacements (e.g., bars and shakes). [A]
- 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
- 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
Diet Approach |
Content (% of total calories) |
Fat |
Carbohydrates |
Protein |
Very-low carbohydrates
(High-fat)
|
55–65 |
<20 (<100g) |
25–30 |
Low carbohydrates
(Moderate-fat)
|
20–30 |
30–40 |
25–30 |
Moderate-fat, balanced nutrient reduction
(Low-calorie)
|
20–30 |
55–60 |
15–20 |
Low-fat |
11–19 |
>65 |
10–20 |
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
An energy deficit of 500-1,000 kcal/day will lead to weight loss of 1 to 2 pounds per week. |
"Diet programs," 2004
NHLBI, 1998
|
I |
Fair |
B |
2 |
Energy deficit (calories in vs. calories out), rather than macronutrient composition is the major determinant of weight loss. |
Avenell et al., 2004
Freedman, King, & Kennedy, 2001
"Diet programs," 2004
McTigue et al., 2003
|
I |
Fair |
B |
3 |
No single type of diet has been shown to be more effective than the others. |
Avenell et al., 2004
Dansinger et al., 2005
"Diet programs," 2004
McTigue et al., 2003
|
I |
Fair |
B |
4 |
LCDs may result in moderate weight loss for patients that adhere to the diet program (3 to 18 months). |
Avenell et al., 2004
"Diet programs," 2004
McTigue et al., 2003
NHLBI, 1998
|
I |
Good |
A |
5 |
VLCDs (less than 800 kcal/day) produce greater initial weight loss than other forms of calorie restriction at 12 to 16 weeks. |
Wadden & Stunkard, 1986;
Wadden et al., 1994
Williams et al., 1998
Wing et al., 1994
|
I |
Good |
B |
6 |
VLCDs should be monitored under medical supervision. |
"Very low-calorie diets," 1993 |
III |
Poor |
C |
7 |
Greater initial weight loss induced without changes in lifestyle (e.g., VLCD) may improve long-term weight maintenance. |
Anderson et al., 2001 |
I |
Fair |
I |
8 |
Low-fat diets produce a caloric deficit and lead to modest weight loss at 3 to 6 months. Greater weight loss is observed in patients with greater baseline weights. |
NHLBI, 1998 |
I |
Good |
A |
9 |
Low-fat, calorie restricted diets may lead to weight loss and reduction in Low density lipoprotein (LDL) cholesterol for patient with dyslipidemia. |
"Third Report," 2002
NHLBI, 1998
|
I |
Fair |
B |
10 |
Low-carbohydrate diets result in more rapid short-term (6 months) weight loss than low-fat LCDs.
Low-carbohydrate diets may reduce serum triglyceride levels and improve High density lipoprotein cholesterol (HDL-C) in patients with mixed dyslipidemia.
|
Bravata et al., 2003
Brehm et al., 2003
Foster et al., 2003
Samaha et al., 2003
|
I |
Fair |
B |
11 |
Low-carbohydrate diets are contraindicated in patients with renal or hepatic disease and patients with diabetes that cannot monitor their blood sugars. |
Working Group Consensus |
III |
Poor |
I |
12 |
Meal replacements are safe to promote weight loss in conjunction with LCDs and VLCDs. |
Bowerman et al., 2001
Flechtner-Mors et al., 2000
Heymsfield et al., 2003
Noakes et al., 2004
|
I |
Good |
A |
13 |
The evidence is insufficient to substantiate the recommendation of a diet based on the glycemic index, without caloric reduction. |
|
III |
Poor |
I |
14 |
Low-energy-dense diets can help lower calorie intake without reducing food volume and lead to weight loss. |
McCrory et al., 2000
Rolls & Bell, 2000
|
I |
Fair |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
C-2 Physical Activity
Recommendations
- 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].
- Home fitness/lifestyle activities or structured supervised programs may be effectively used to produce a caloric expenditure leading to weight loss. [A]
- Moderate levels of physical activity should be performed at least 30 minutes most days of the week. [B]
- Physical activity may include short intermittent bursts (10 minutes or longer) as well as longer continuous exercise. [A]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Physical Activity/Exercise should occur to:
|
a. Promote weight loss |
NHLBI, 1998
Ross et al., 2000
|
I |
Good |
A |
b. Maintain weight loss |
Miller et al., 1997 |
I |
Good |
A |
c. Decrease abdominal obesity |
NHLBI, 1998 |
I |
Fair |
B |
d. Improve cardiovascular fitness |
NHLBI, 1998 |
I |
Good |
A |
e. Reduce cardiovascular risk factors |
Bassuk & Manson, 2004
NHLBI, 1998
|
I |
Good |
A |
f. Decrease all-cause and cardiovascular mortality |
Blair et al., 1995
Lee, Blair, & Jackson, 1999
Paffenbarger et. al., 1993
|
II-2 |
Fair |
B |
2 |
Lifestyle physical activities (home fitness programs) are just as effective in promoting weight loss as structured supervised exercise programs. |
Anderson et al., 1999
Fogelholm et al.,2000
|
I |
Good |
A |
3 |
Moderate levels of physical activity should be performed at least 30 minutes most days of the week. |
Jakicic et al., 2001
NHLBI, 1998
Saris et al., 2003
|
I |
Fair |
B |
4 |
Short intermittent bursts of physical activity are just as effective as longer continuous exercise. |
Frick et al., 2001
Jakicic et al., 1999
|
I |
Good |
A |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
C-3 Behavioral Modification Strategies
Recommendations
- Behavioral modification interventions to improve adherence to diet and physical activity should be given to overweight or obese individuals. [B]
- 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]
- Multiple behavioral modification strategies should be used in combination for greater effectiveness. [A]
- Behavioral modification intervention should be delivered in a group format when possible rather than individually. [B]
- For individuals unable or unwilling to participate in weight loss treatment in person, telephone or internet-based behavioral modification intervention may be considered. [B]
- Behavioral modification intervention should be continued on a long-term basis to promote maintenance of weight loss. [B]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Behavioral modification interventions add effectiveness to diet and exercise interventions in promoting weight loss. |
Avenell et al., 2004
ICSI, 2005
McTigue et al., 2003
NHLBI, 1998
Wadden & Butryn, 2003
|
I |
Fair |
B |
2 |
Behavioral modification interventions with greater intensity are more effective than those with less intensity in promoting weight loss. |
NHLBI, 1998
McTigue et al., 2003
|
I |
Fair |
B |
3 |
Combined behavioral modification strategies are more effective than a single behavioral modification strategy in promoting weight loss. |
NHLBI, 1998 |
I |
Good |
A |
4 |
Group-based behavioral modification counseling is more effective than individual counseling in promoting weight loss. |
Renjilian et al., 2001 |
I |
Fair |
B |
5 |
Telephone and internet behavioral treatment is effective in promoting weight loss. |
Boucher et al., 1999
Harvey-Barino et al., 2004
Jeffery et al., 2003
Tate, Jackvony, & Wing, 2003
|
I |
Fair |
B |
6 |
Continued behavioral modification interventions are effective in sustaining weight loss. |
Jeffery et al., 2000
Latner et al., 2002
McTigue et al., 2003
NHLBI, 1998
Perri et al., 1988
Perri et al., 2001
Wadden & Butryn, 2003
|
I |
Fair |
B |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
C4 Pharmacotherapy
Recommendations
- 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]
- 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]
- If the patient continues to be unresponsive to the medication, or serious adverse effects occur, the use of medication should be discontinued. [I]
Orlistat
- Orlistat may be considered to reduce body weight [B] and improve obesity-associated cardiovascular risk factors [C].
- 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]
- Orlistat may be considered as a component of weight maintenance programs for up to 4 years. [B]
- Patients prescribed orlistat should take a multiple vitamin that includes fat soluble vitamins. [Expert Opinion]
Sibutramine
- Sibutramine may be considered to reduce body weight [B] and improve glycemic and lipid parameters [C].
- 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]
- 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]
- Sibutramine may be considered as a component of weight maintenance programs for up to 2 years. [B]
- Sibutramine should be discontinued if it is not efficacious in helping the patient to lose or maintain weight loss. [B]
- Sibutramine should be used with caution as it can elevate blood pressure and heart rate. [A]
- 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]
- 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]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
Weight |
CV risk |
Morbidity
Mortality
|
1 |
Pharmacotherapy may be considered for BMI greater than 30 kg/m2 or a BMI greater than 27 kg/m2 with one or more obesity related risk factors. |
Apfelbaum et al., 1999
Arterburn, McDonell, & Hedrick, 2004
James et al., 2000
Li et. al., 2005
McTigue et al., 2003
O'Meara et al., 2002
Shekelle et al., 2004
Torgerson et al., 2004
|
I |
Fair |
B |
C |
I |
2 |
Orlistat may be considered to reduce body weight and improve obesity-associated cardiovascular risk factors. |
Lindegarde, 2000
Padwal, Li, & Lau, 2004
Shekelle et al., 2004
|
I |
Fair |
B |
C |
I |
3 |
Patients who have lost greater than or equal to 5% of their body weight after 12 weeks of treatment with orlistat are more likely to experience sustained improvement. |
Rissanen et al., 2003 |
II-2 |
Fair |
B |
C |
I |
4 |
Orlistat may be considered as a component of weight maintenance programs for up to 4 years. |
Padwal, Li, & Lau, 2004
Shekelle et al., 2004
Torgerson et al., 2004
|
I |
Fair |
B |
C |
B
(new onset diabetes)
|
5 |
Sibutramine may be considered to reduce body weight and improve glycemic and lipid parameters. |
Arterburn, Crane, & Veenstra, 2004
Arterburn, McDonell, & Hedrick, 2004
McTigue et al., 2003
Padwal, Li, & Lau, 2004
Shekelle et al., 2004
|
I |
Fair |
B |
C |
I |
6 |
Sibutramine may be considered as a component of weight maintenance program for up to 2 years. |
Arterburn, Crane, & Veenstra, 2004
Arterburn, McDonell, & Hedrick, 2004
Padwal, Li, & Lau, 2004
Shekelle et al., 2004
|
I |
Fair |
B |
C |
I |
7 |
Sibutramine should be used with caution as it can elevate blood pressure and heart rate. |
Arterburn Crane, & Veenstra, 2004
Arterburn, McDonell, & Hedrick, 2004
Padwal, Li, & Lau, , 2004
|
I |
Good |
A |
8 |
Avoid sibutramine in adult patients with uncontrolled hypertension, cardiovascular disease, and history of MI or stroke due to the increased risk of harm. |
Arterburn Crane, & Veenstra, , 2004
Arterburn, McDonell, & Hedrick, 2004
Padwal, Li, & Lau., 2004
|
II-3 |
Fair |
D |
QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A in the original guideline document)
C-5 Bariatric Surgery
Recommendations
- 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].
- 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.
- 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]
- 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]
- 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).
- Lifelong medical follow-up after surgery is necessary to monitor adherence to treatment, adverse effects and complications, dietary restrictions, and behavioral health. [I]
|
Recommendation |
Sources of Evidence |
QE |
Overall Quality |
SR |
1 |
Bariatric surgery (RYGB, AGB, & VBG) to promote substantial long-term (3 years) weight loss in patient with BMI >40 or BMI >35 with comorbid conditions. |
ECRI, 2004
Maggard et al., 2005
Shekelle et al., 2004
|
I |
Good |
B |
2 |
Bariatric surgery (RYGB, AGB, & VBG) to improve or resolve comorbid conditions. |
Buchwald et al., 2004
ECRI, 2004
Sjostrom et al., 2004
|
I |
Fair* |
B |
3 |
Bariatric surgery (RYGB, AGB, & VBG) to improve quality of life. |
ECRI, 2004
Karlsson, Sjostrom, & Sullivan, 1998
Shekelle et al., 2004
|
I |
Fair* |
B |
4 |
Bariatric surgery to improve long-term (greater than 5 years) survival. |
Christou et al., 2004
Flum & Dellinger, 2004
|
II-2 |
Poor |
I |
5 |
RYGB to promote greater weight loss than VBG or AGB |
Buchwald et al., 2004
ECRI, 2004
Maggard et al., 2005
Shekelle et al., 2004
|
I |
Fair |
B |
6 |
Bariatric surgery in those over 65 years of age has higher risk of mortality |
ECRI, 2004
Shekelle et al., 2004
|
II-3 |
Fair |
I |
7 |
Preoperative requirements or effective means to prepare patients for surgery. |
Expert Opinion
Saltzman et al,, 2005
|
III |
Poor |
I |
8 |
Contraindication for bariatric surgery. |
Expert Opinion |
III |
Poor |
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)
I |
At least one properly done randomized controlled trial (RCT) |
II-1 |
Well designed controlled trail without randomization |
II-2 |
Well designed cohort or case-control analytic study, preferably from more than one source |
II-3 |
Multiple time series evidence with/without intervention, dramatic results of uncontrolled experiment |
III |
Opinion of respected authorities, descriptive studies, case reports, and expert committees |
Overall Quality
Good |
High grade evidence (I or II-1) directly linked to health outcome |
Fair |
High grade evidence (I or II-1) linked to intermediate outcome;
or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
|
Poor |
Level III evidence or no linkage of evidence to health outcome |
Net Effect of the Intervention
Substantial: |
More than a small relative impact on a frequent condition with a substantial burden of suffering;
or
A large impact on an infrequent condition with a significant impact on the individual patient level.
|
Moderate: |
A small relative impact on a frequent condition with a substantial burden of suffering;
or
A moderate impact on an infrequent condition with a significant impact on the individual patient level.
|
Small: |
A negligible relative impact on a frequent condition with a substantial burden of suffering;
or
A small impact on an infrequent condition with a significant impact on the individual patient level.
|
Zero or Negative: |
Negative impact on patients;
or
No relative impact on either a frequent condition with a substantial burden of suffering, or an infrequent condition with a significant impact on the individual patient level.
|
Strength of the Recommendation
|
The net benefit of the intervention |
Quality of Evidence |
Substantial |
Moderate |
Small |
Zero or Negative |
Good |
A |
B |
C |
D |
Fair |
B |
B |
C |
D |
Poor |
I |
I |
I |
I |
A |
A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
|
B |
A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
|
C |
No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
|
D |
Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
|
I |
The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting and the balance of benefits and harms cannot be determined.
|
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