Treatment of obesity.

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Assessment of the Need of Treatment

Overweight (mild obesity): body mass index (BMI) 25 to 30 kg/m²
- Usually no treatment is indicated.
- Treatment is indicated in central obesity, metabolic syndrome (see the Finnish Medical Society Duodecim guideline "Metabolic Syndrome"), or non-insulin-dependent diabetes.
- In children even mild obesity should be treated.
Moderate obesity: BMI 30 to 35 kg/m²
- Treatment is always indicated if the patient has diabetes, hypertension, hyperlipidaemia, or other associated disease (Douketis et al., 1999) [B].
- A young obese person with good health should be treated. The treatment of middle-aged persons is decided individually according to the available resources.
Severe obesity: BMI >35 kg/m²
- Must always be treated

Treatment Principles

There are effective methods available for the treatment of obesity (Glenny & O'Meara, 1997; Avenell et al., 2004) [A].
The target should be moderate, a 5–10% reduction in weight.
The patient should have an own desire to make the necessary changes in the dietary and exercise habits.
Some patients succeed in reducing weight on their own, as they have understood its importance and received the necessary information.
Many patients require professional counselling and support.

Selecting the Method of Treatment

Basic treatment consisting of a gradual and permanent change in living habits by counselling and guidance.
- Well suited for patients with mild and moderate obesity and for the majority of patients with severe obesity; should always be included in other forms of conservative treatment.

Basic treatment and a very low calorie diet
- Well suited for morbid and severe obesity
- A choice in moderate obesity if the basic treatment has been unsuccessful and there is a strong indication for reducing weight (associated diseases)

Drugs (orlistat, sibutramine, rimonabant)
- Do not automatically help all patients
- An alternative especially if other approaches have been failed
- Life-style counselling must also be included.

Surgical treatment
- Suitable only for selected patients with morbid obesity (see criteria below).

Basic Treatment

Organisation

Group treatment is less costly and as effective as individualised treatment
- At least 10 meetings are arranged with about one-week intervals.
- Group size 10 to 15 persons
- The group leader is a nurse or a dietician with special training in the treatment of obesity.

Goals That Can Be Measured

The optimal rate of weight reduction is 0.5 kg/week. As the adipose tissue contains about 30 MJ (7,000 kcal)/kg, a daily reduction of 2,100 kJ (500 kcal) in the energy intake will result in this rate of weight reduction.
The goal is to reduce weight by 5 to 10%, which already results in significant benefit in the treatment of diseases associated with obesity.
A permanent result is always aimed at. This means that the changes in living habits must be permanent.
In growing children, weight should be kept constant so that the growth of height corrects the relative weight.
There are many treatments with no proven efficacy. Appetite-suppressant drugs may result in a moderate weight reduction but the effect is transient.

Aims and Contents of Counselling

Changes in knowledge and attitudes
- Human energy consumption is reduced if the body weight is reduced. In order to sustain the weight that has been achieved the changes in living habits must be permanent.
Changes in meals (Franz et al., 2007; Miller, Koceja, & Hamilton, 1997) [A]
- Find out the present contents of meals.
- Reduce intake by about 2,000 kJ (500 kcal) daily.
- The emphasis is on the reduction of energy intake in the diet by reducing the amount of fat (Pirozzo et al., 2008) [B] and by increasing the amount of vegetables.
- Remember alcohol as a cause of obesity.
- Small daily changes are effective in the long run.
- Keep three daily meals.
Changes in physical exercise (Franz et al., 2007; Miller, Koceja, & Hamilton, 1997) [A]
- The advice depends on the degree of obesity.
- Exercise during daily activities should be encouraged (climbing up stairs, walking or cycling to work).
- If a pedometer is used, the target is at least 10,000 steps per day.
Changes in eating behaviour
- The most common goal is to change behaviour, not to "hunt kilograms."
- Identify the circumstances that trigger eating. Craving or hunger?
- Grocery shopping with a pre-planned list.
- Reduce temptations (no food in sight!).
- Do nothing else when eating (such as watch TV, read magazines).
- Eat slowly.

Very Low Calorie Diet (VLCD)

Constituents
- 1,700 to 2,100 kJ (400 to 500 kcal) of energy, a maximum of 3,300 kJ (800 kcal) daily.
- Protein as needed (at least 50 g daily).
- Essential fatty acids, trace elements, and vitamins as needed
Schedule
- Ready-made commercial formulas that fulfil the VLCD criteria should be used.
- They are consumed as the only food continuously for 8 to 12 weeks. The diet is discontinued earlier if BMI 25 is reached.
- The patient is followed up at 1 to 2 week intervals.
- Suitable for patients with non-insulin-dependent (type 2) diabetes and hypertension. Insulin treatment is stopped or the dose is reduced considerably, and the dose of sulphonylureas is halved (risk of hypoglycaemia!) before starting VLCD. The doses of other drugs need not be reduced.
- The rate of weight reduction is about 1.5 to 2 kg/week, and the immediate weight reduction is 2 to 2.5 times that on basic treatment.
- A VLCD alone does not yield permanent results. Basic treatment for permanent life-style changes is applied in the normal fashion.

Drug Treatment for Obesity

Drugs are not a universal remedy in the management of obesity. They can be tried for patients who have the metabolic syndrome or some other "obesity disease" when lifestyle changes alone have not given sufficient results.
When prescribing a weight-reducing drug, the patient should also be provided with guidance in lifestyle changes.
A drug indicated for the treatment of obesity may be used when the patient has body mass index over 30 kg/m² (or over 27 to 28 kg/m², if the patient has diabetes or some other disease requiring weight reduction).
The patient should be informed that the drug treatment for obesity is aimed to last for several years. After discontinuation of the drug, weight will increase again in most cases.
Stop the drug, if there has not been a significant weight reduction in 3 months (at least 5% of the baseline weight).

Orlistat

Orlistat is a lipase inhibitor acting in the digestive tract. It partly prevents the absorption of dietary fat. The drug is not absorbed in the bloodstream.
Weight reduction in patients who have taken 120 mg of orlistat before main meals has been on the average 3 kg more than with placebo at one year (Padwal, Li & Lau, 2003) [B]. The proportion of patients who have lost more than 10% of the baseline weight has been 12 percentage points greater with orlistat than with placebo.
Due to the mode of action of the drug, low-density lipoprotein (LDL) cholesterol concentration will reduce more than would be achieved with the weight reduction alone.
When using the drug, a concomitant aim is to limit the proportion of dietary energy intake coming from fat to no more than 30%. The snacks should be low-fat. The patient should receive sufficient dietary counselling.
Common adverse effects include fatty or oily stools, faecal urgency and oily faecal spotting (>1/10 users).

Sibutramine

A centrally acting appetite suppressant that inhibits the reuptake of serotonin and noradrenalin
Weight reduction in patients who have taken 15 mg of sibutramine daily has been on the average 4 kg more than with placebo at one year (Padwal, Li & Lau, 2003) [B]. The proportion of patients who have lost more than 10% of the baseline weight at one year has been 15 percentage points greater with sibutramine than with placebo.
The most common adverse effects include insomnia, nausea, dry mouth and constipation. These have occurred in 7% to 20% of patients using sibutramine.
Because of the effects on blood pressure and heart rate, the drug is not recommended for patients with cardiovascular diseases.

Rimonabant

A centrally acting appetite suppressant that blocks the endocannabinoid receptor 1. CB1-receptors are also found in fat cells and in the digestive tract.
Weight reduction in patients who have taken 20 mg of rimonabant daily has been on the average 5 kg more than with placebo at one year (Curioni & Andre, 2006; Christensen et al., 2007) [A]. The proportion of patients who have lost more than 10% of the baseline weight at one year has varied between 17% and 26% with rimonabant compared to placebo, depending on the study.
The most common adverse effects include nausea, vertigo, diarrhoea, anxiety, depression, fatigue and insomnia.
Rimonabant should not be prescribed if the patient is concurrently in severe depression. It should be prescribed with caution and the patient should be carefully followed up if he/she has a history of depression.

Surgical Treatment

Criteria

Age 18 to 60 years
BMI at least 35 to 40 kg/m²
An efficient conservative treatment strategy has been tried.
The patient is cooperative.
There is no abuse of alcohol or drugs.

Method

Gastroplasty, gastric banding (Schneider, 2000; Chapman et al., 2002; Health Technology Assessment Database: HTA-20030005, 2004; "Newer techniques," 2003; Health Technology Assessment Database: HTA-20031130, 2004) [B], or gastric bypass so that the patient can eat only slowly and small amounts at a time. Laparoscopic procedures are also possible. Surgical treatment is associated with potential complications.
The operation is not sufficient alone. Adequate preoperative investigations, patient counselling, and follow-up for several years are necessary.
The outcome of successful surgical treatment is much better than that of conservative treatment (Colquitt et al., 2005; Clegg et al., 2002; "Special report," 2003; "Gastric restrictive surgery," 2000; "Newer techniques," 2003; Nilsen, 2003) [A]: the patients reduce 30 to 40 kg of their weight, and the result is long lasting.
Deficiency of the vitamins B₁₂ and D may develop after gastric bypass surgery.

Related Resources

Refer to the original guideline document for related evidence, including Cochrane reviews and other evidence summaries.

Definitions:

Classification of the Quality of Evidence

Code	Quality of Evidence	Definition
A	High	Further research is very unlikely to change our confidence in the estimate of effect. Several high-quality studies with consistent results In special cases: one large, high-quality multi-centre trial
B	Moderate	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate. One high-quality study Several studies with some limitations
C	Low	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate. One or more studies with severe limitations
D	Very Low	Any estimate of effect is very uncertain. Expert opinion No direct research evidence One or more studies with very severe limitations

GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

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