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Comprehensive information on weight loss and weight maintenance, including the importance of a combination of low-calorie diets, increased physical activity, and behavior therapy. It also discusses the role of weight loss surgery and the use of medication for carefully selected patients. The document emphasizes the need for long-term monitoring and encourages the maintenance of simple records for tracking progress.
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N A T I O N A L I N S T I T U T E S O F H E A L T H N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E
N A T I O N A L I N S T I T U T E S O F H E A L T H N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E N O R T H A M E R I C A N A S S O C I A T I O N F O R T H E S T U D Y O F O B E S I T Y
NHLBI Obesity Education Initiative
ACKNOWLEDGMENTS: The Working Group wishes to acknowledge the additional input to the Practical Guide from the following individuals: Dr. Thomas Wadden, University of Pennsylvania; Dr. Walter Pories, East Carolina University; Dr. Steven Blair, Cooper Institute for Aerobics Research; and Dr. Van S. Hubbard, National Institute of Diabetes and Digestive and Kidney Diseases.
NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. F.Xavier Pi-Sunyer, M.D., M.P.H. Columbia University College of Physicians and Surgeons Chair of the Panel
MEMBERS Diane M. Becker, Sc.D., M.P.H. The Johns Hopkins University Claude Bouchard, Ph.D. Laval University Richard A. Carleton, M.D. Brown University School of Medicine Graham A. Colditz, M.D., Dr.P.H. Harvard Medical School William H. Dietz, M.D., Ph.D. National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention John P. Foreyt, Ph.D. Baylor College of Medicine Robert J. Garrison, Ph.D. University of Tennessee, Memphis Scott M. Grundy, M.D., Ph.D. University of Texas Southwestern Medical Center at Dallas
Barbara C. Hansen, Ph.D. University of Maryland School of Medicine Millicent Higgins, M.D. University of Michigan James O. Hill, Ph.D. University of Colorado Health Sciences Center Barbara V. Howard, Ph.D. Medlantic Research Institute Robert J. Kuczmarski, Dr.P.H., R.D. National Center for Health Statistics Centers for Disease Control and Prevention Shiriki Kumanyika, Ph.D., R.D., M.P.H. The University of Pennsylvania R. Dee Legako, M.D. Prime Care Canyon Park Family Physicians, Inc. T. Elaine Prewitt, Dr.P.H., R.D. Loyola University Medical Center Albert P. Rocchini, M.D. University of Michigan Medical Center Philip L Smith, M.D. The Johns Hopkins Asthma and Allergy Center Linda G. Snetselaar, Ph.D., R.D. University of Iowa James R. Sowers, M.D. Wayne State University School of Medicine University Health Center Michael Weintraub, M.D. Food and Drug Administration
David F. Williamson, Ph.D., M.S. Centers for Disease Control and Prevention G. Terence Wilson, Ph.D. Rutgers Eating Disorders Clinic
EX-OFFICIO MEMBERS Clarice D. Brown, M.S. Coda Research Inc. Karen A. Donato, M.S., R.D.* Executive Director of the Panel Coordinator, NHLBI Obesity Education Initiative National Heart, Lung, and Blood Institute National Institutes of Health Nancy Ernst, Ph.D., R.D.* National Heart, Lung, and Blood Institute National Institutes of Health D. Robin Hill, Ph.D.* National Heart, Lung, and Blood Institute National Institutes of Health Michael J. Horan, M.D., Sc.M.* National Heart, Lung, and Blood Institute National Institutes of Health Van S. Hubbard, M.D., Ph.D. National Institute of Diabetes and Digestive and Kidney Diseases James P. Kiley, Ph.D.* National Heart, Lung, and Blood Institute National Institutes of Health Eva Obarzanek, Ph.D., R.D., M.P.H.* National Heart, Lung, and Blood Institute National Institutes of Health *NHLBI Obesity Initiative Task Force Member CONSULTANT David Schriger, M.D., M.P.H., F.A.C.E.P. University of California Los Angeles School of Medicine SAN ANTONIO COCHRANE CENTER Elaine Chiquette, Pharm.D. Cynthia Mulrow, M.D., M.Sc. V.A. Cochrane Center at San Antonio Audie L. Murphy Memorial Veterans Hospital STAFF Adrienne Blount, Maureen Harris, M.S., R.D., Anna Hodgson, M.A., Pat Moriarty, M.Ed., R.D., R.O.W. Sciences, Inc.
North American Association for the Study of Obesity Practical Guide Development Committee Louis J. Aronne, M.D., F.A.C.P. Cornell University, Chair MEMBERS Charles Billington, M.D. University of Minnesota George Blackburn, M.D., Ph.D. Harvard University Karen A. Donato, M.S., R. D. NHLBI Obesity Education Initiative National Heart, Lung, and Blood Institute National Institutes of Health Arthur Frank, M.D. George Washington University
Susan Fried, Ph.D. Rutgers University Patrick Mahlen O'Neil, Ph.D. Medical University of South Carolina Henry Buchwald, M.D. University of Minnesota George Cowan, M.D. University of Tennessee College of Medicine Robert Brolin, M.D. UMDNJ-Robert Wood Johnson Medical School EX-OFFICIO MEMBERS James O. Hill, Ph.D. University of Colorado Health Sciences Center Edward Bernstein, M.P.H. North American Association for the Study of Obesity
Foreword ......................................................................................................................................v
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n June 1998, the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report was released by the National Heart, Lung, and Blood Institute’s (NHLBI) Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The impetus behind the clinical practice guidelines was the increasing prevalence of over- weight and obesity in the United States and the need to alert practitioners to accompanying health risks.
The Expert Panel that developed the guidelines consisted of 24 experts, 8 ex-officio members, and a consultant methodologist representing the fields of primary care, clinical nutrition, exercise physiology, psychology, physiology, and pulmonary disease. The guidelines were endorsed by representatives of the Coordinating Committees of the National Cholesterol Education Program and the National High Blood Pressure Education Program, the North American Association for the Study of Obesity, and the NIDDK National Task Force on the Prevention and Treatment of Obesity.
This Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults is largely based on the evidence report prepared by the Expert Panel and describes how health care practition- ers can provide their patients with the direction and support needed to effectively lose weight and keep it off. It provides the basic tools needed to appropriately assess and manage overweight and obesity. The guide includes practical information on dietary therapy, physical activity, and behavior therapy, while also providing guidance on the appropriate use of pharmacotherapy and surgery as treatment options.
The Guide was prepared by a working group con- vened by the North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. Three members of the American Society for Bariatric Surgery also participated in the working group. Members of the Expert Panel, especially the Panel Chairman, assisted in the review and development of the final product. Special thanks are also due to the 50 representatives of the various disciplines in primary care and others who reviewed the preprint of the document and provided the working group with excellent feedback.
The Practical Guide will be distributed to primary care physicians, nurses, registered dietitians, and nutritionists as well as to other interested health care practitioners. It is our hope that the tools provided here help to complement the skills needed to effectively manage the millions of overweight and obese individ- uals who are attempting to manage their weight.
David York, Ph.D. Claude Lenfant,M.D. President Director North American Association National Heart, Lung, for the Study of Obesity and Blood Institute National Institutes of Health
Foreword
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To get started, just follow the Ten Step approach.
How to Use This Guide
1
Treatment of an overweight or obese person incorporates a two- step process: assessment and management. Assessment includes determination of the degree of obesity and overall health status. Management involves not only weight loss and maintenance of body weight but also measures to control other risk factors. Obesity is a chronic disease; patient and practitioner must understand that successful treatment requires a lifelong effort. Convincing evidence supports the benefit of weight loss for reducing blood pressure, lowering blood glucose, and improving dyslipidemias.
Body Mass Index Assessment of a patient should include the evaluation of body mass index (BMI), waist circumference, and overall medical risk. To esti- mate BMI, multiply the individual’s weight (in pounds) by 703, then divide by the height (in inches) squared. This approximates BMI in kilograms per meter squared (kg/m^2 ). There is evidence to sup- port the use of BMI in risk assess- ment since it provides a more accu- rate measure of total body fat com- pared with the assessment of body
weight alone. Neither bioelectric impedance nor height-weight tables provide an advantage over BMI in the clinical management of all adult patients, regardless of gender. Clinical judgment must be employed when evaluating very muscular patients because BMI may overestimate the degree of fatness in these patients. The recommended classifications for BMI, adopted by the Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults and endorsed by leading organizations of health professionals, are shown in Table 1.
Waist Circumference Excess abdominal fat is an impor- tant, independent risk factor for dis- ease. The evaluation of waist cir- cumference to assess the risks asso- ciated with obesity or overweight is supported by research. The measure- ment of waist-to-hip ratio provides no advantage over waist circumfer- ence alone. Waist circumference measurement is particularly useful in
patients who are categorized as nor- mal or overweight. It is not neces- sary to measure waist circumference in individuals with BMIs ≥ 35 kg/m^2 since it adds little to the predictive power of the disease risk classifica- tion of BMI. Men who have waist circumferences greater than 40 inch- es, and women who have waist cir- cumferences greater than 35 inches, are at higher risk of diabetes, dys- lipidemia, hypertension, and cardio- vascular disease because of excess abdominal fat. Individuals with waist circumferences greater than these values should be considered one risk category above that defined
by their BMI. The relationship between BMI and waist circumfer- ence for defining risk is shown in Table 2 on page 10.
Risk Factors or Comorbidities Overall risk must take into account the potential presence of other risk factors. Some diseases or risk factors associated with obesity place patients at a high absolute risk for
Executive Summary
BMI Underweight <18.5 kg/m 2 Normal weight 18.5–24.9 kg/m 2 Overweight 25–29.9 kg/m 2 Obesity (Class 1) 30–34.9 kg/m 2 Obesity (Class 2) 35–39.9 kg/m 2 Extreme obesity (Class 3) ≥40 kg/m 2
Classifications for BMI
Table 1
3
lower than 800 kcal/day have been found to be no more effective than low-calorie diets in producing weight loss. They should not be used routinely, especially not by providers untrained in their use. In general, diets containing 1,000 to 1,200 kcal/day should be selected for most women; a diet between 1,200 kcal/day and 1, kcal/day should be chosen for men and may be appropriate for women who weigh 165 pounds or more, or who exercise. Long-term changes in food choices are more likely to be successful when the patient’s preferences are taken into account and when the patient is educated about food com- position, labeling, preparation, and portion size. Although dietary fat is a rich source of calories, reducing dietary fat without reducing calories will not produce weight loss. Frequent contact with practitioners during the period of diet adjustment is likely to improve compliance.
Physical Activity Physical activity has direct and indirect benefits. Increased physical activity is important in efforts to lose weight because it increases energy expen-
diture and plays an integral role in weight maintenance. Physical activ- ity also reduces the risk of heart disease more than that achieved by weight loss alone. In addition, increased physical activity may help reduce body fat and prevent the decrease in muscle mass often found during weight loss. For the obese patient, activity should gener- ally be increased slowly, with care taken to avoid injury. A wide vari- ety of activities and/or household chores, including walking, dancing, gardening, and team or individual sports, may help satisfy this goal. All adults should set a long-term goal to accumulate at least 30 min- utes or more of moderate-intensity physical activity on most, and preferably all, days of the week.
Behavior Therapy Including behavioral therapy helps with compliance. Behavior therapy is a useful adjunct to planned adjustments in food intake and physical activity. Specific behavioral strategies include the following: self-monitor-
ing, stress management, stimulus control, problem-solving, contin- gency management, cognitive restructuring, and social support. Behavioral therapies may be employed to promote adoption of diet and activity adjustments; these will be useful for a combined approach to therapy. Strong evi- dence supports the recommendation that weight loss and weight mainte- nance programs should employ a combination of low-calorie diets, increased physical activity, and behavior therapy.
Pharmacotherapy Pharmacotherapy may be helpful for eligible high-risk patients. Pharmacotherapy, approved by the FDA for long-term treatment, can be a helpful adjunct for the treat- ment of obesity in some patients. These drugs should be used only in the context of a treatment program that includes the elements described previously—diet, physical activity changes, and behavior therapy. If lifestyle changes do not promote weight loss after 6 months, drugs
Reductions of 500 to 1,000 kcal/day
will produce a recom- mended weight loss of 1 to 2 pounds per week.
1,000 to 1,200 kcal/day
1,200 to 1,600 kcal/day
4
should be considered. Pharmaco- therapy is currently limited to those patients who have a BMI ≥ 30, or those who have a BMI ≥ 27 if con- comitant obesity-related risk factors or diseases exist. However, not all patients respond to a given drug. If a patient has not lost 4.4 pounds (2 kg) after 4 weeks, it is not likely that this patient will benefit from the drug. Currently, sibutramine and orlistat are approved by the FDA for long-term use in weight loss. Sibutramine is an appetite suppres- sant that is proposed to work via norepinephrine and serotonergic mechanisms in the brain. Orlistat inhibits fat absorption from the intestine. Both of these drugs have side effects. Sibutramine may increase blood pressure and induce tachycardia; orlistat may reduce the
absorption of fat-soluble vitamins and nutrients. The decision to add a drug to an obesity treatment pro- gram should be made after consid- eration of all potential risks and benefits and only after all behav- ioral options have been exhausted.
Weight Loss Surgery Surgery is an option for patients with extreme obesity. Weight loss surgery provides medically significant sustained weight loss for more than 5 years in most patients. Although there are risks associated with surgery, it is not yet known whether these risks are greater in the long term than those of any other form of treatment. Surgery is an option for well-informed and motivated patients who have clinically severe obesity (BMI ≥ 40) or a BMI ≥ 35
and serious comorbid conditions. (The term “clinically severe obesity” is preferred to the once commonly used term “morbid obesity.”) Surgical patients should be monitored for complications and lifestyle adjustments throughout their lives.
Involve other health professionals when possible, especially for special situations. Although research regarding obesity treatment in older people is not abundant, age should not preclude therapy for obesity. In people who smoke, the risk of weight gain is often a barrier to smoking cessation. In these patients, cessation of smoking should be encouraged first, and weight loss therapy should be an additional goal.
A weight loss and maintenance program can be conducted by a practitioner without specialization in weight loss so long as that person has the requisite interest and knowledge. However, a variety of practitioners with special skills are available and may be enlisted to assist in the development of a program.
clinically severe obesity
(BMI ≥ 40) or a BMI ≥ 35 and serious comorbid conditions may warrant surgery for weight loss.
A combination of diet modification, increased physical activity, and behavior therapy can be effective.
6
50
40
30
20
10
(^0) Men Women
Percent
Prevalence
Men Women (BMI 25–29.9) (BMI^ ≥^ 30)
NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94) Source: CDC/NCHS. United States. 1960-94, Ages 20-74 years. For comparison across surveys, data for subjects ages 20 to 74 years were age-adjusted by the direct method to the total U.S. population for 1980, using the age-adjusted categories 20-29y, 30-39y, 40-49y, 50-59y, 60-69y, and 70-79y.
< 25 ≥ 30
HBP TBC HDL
< 25 ≥ 30 < 25 ≥ 30 BMI
45 40 35 30 25 20 15 10 5 0
14.7 14.
41.1 39.1 39.
23.6 23. 24.3 24.
10.4 11.3^ 12.
15.1 16.1 16.
Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI ≥ 30)
Figure 1
NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP), High Total Blood Cholesterol (TBC),† and Low-HDL‡ by Two BMI Categories*
Figure 2
Men Women
7
Treatment Guidelines
Tailor Treatment to the Needs of the Patient
Standard treatment approaches for overweight and obesity must be tailored to the needs of various patients or patient groups. Large individual variation exists within any social or cultural group; fur- thermore, substantial overlap occurs among subcultures within the larger society. There is, there- fore, no “cookbook” or standard- ized set of rules to optimize weight reduction with a given type of patient. However, obesity treatment programs that are culturally sensitive and incorporate a patient’s characteristics must do the following:
Adapt the setting and staffing for the program.
Understand how the obesity treatment program integrates into other aspects of the patient’s health care and self-care.
Expect and allow modifications to a program based on a patient’s response and preferences.
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It should be noted that the risk lev- els for disease depicted in Table 2 are relative risks; in other words, they are relative to the risk at normal body weight. There are no randomized, controlled trials that support a specific classification sys- tem to establish the degree of dis- ease risk for patients during weight loss or weight maintenance.
Although waist circumference and BMI are interrelated, waist circum- ference provides an independent prediction of risk over and above that of BMI. The waist circumfer-
ence measurement is particularly useful in patients who are catego- rized as normal or overweight in terms of BMI. For individuals with a BMI ≥ 35, waist circumference adds little to the predictive power of the disease risk classification of BMI. A high waist circumference is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and CVD in patients with a BMI between 25 and 34.9 kg/m.2,
In addition to measuring BMI, monitoring changes in waist cir-
cumference over time may be help- ful; it can provide an estimate of increases or decreases in abdominal fat, even in the absence of changes in BMI. Furthermore, in obese patients with metabolic complica- tions, changes in waist circumfer-
To measure waist circumference, locate the upper hip bone and the top of the right iliac crest. Place a measur- ing tape in a horizontal plane around the abdo- men at the level of the iliac crest. Before read- ing the tape measure, ensure that the tape is snug, but does not compress the skin, and is parallel to the floor. The measurement is made at the end of a normal expiration.
Waist Circumference Measurement
Figure 3
Clinical judgment must be used in interpreting BMI in situations that may affect its accuracy as an indicator of total body fat. Examples of these situations include the presence of edema, high muscularity, muscle wasting, and individuals who are limited in stature. The relationship between BMI and body fat content varies somewhat with age, gender, and possibly ethnicity because of differences in the composition of lean tissue, sitting height, and hydration state.23,24^ For example, older persons often have lost muscle mass; thus, they have more fat for a given BMI than younger persons. Women may have more body fat for a given BMI than men, whereas patients with clinical edema may have less fat for a given BMI compared with those without edema. Nevertheless, these circumstances do not markedly influence the validity of BMI for classifying individuals into broad categories of overweight and obesity in order to monitor the weight status of individuals in clinical settings.^23
Measuring-Tape Position for Waist (Abdominal) Circumference in Adults
10
ence are useful predictors of changes in cardiovascular disease (CVD) risk factors.^27 Men are at increased relative risk if they have a waist circumference greater than 40 inches (102 cm); women are at an increased relative risk if they have a waist circumference greater than 35 inches (88 cm).
There are ethnic and age-related differences in body fat distribution that modify the predictive validity of waist circumference as a surro-
gate for abdominal fat.^23 In some populations (e.g., Asian Americans or persons of Asian descent), waist circumference is a better indicator of relative disease risk than BMI.^28 For older individuals, waist circum- ference assumes greater value for estimating risk of obesity-related diseases. Table 2 incorporates both BMI and waist circumference in the classification of overweight and obesity and provides an indication of relative disease risk.
Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk*
Disease Risk BMI Obesity Class (Relative to Normal Weight (kg/m2) and Waist Circumference)*
Men ≤ 40 in ( ≤ 102 cm) > 40 in (> 102 cm) Women ≤ 35 in ( ≤ 88 cm) > 35 in (> 88 cm)
Underweight < 18.5 - - Normal † 18.5–24.9 - - Overweight 25.0–29.9 Increased High Obesity 30.0–34.9 I High Very High 35.0–39.9 II Very High Very High Extreme Obesity ≥ 40 III Extremely High Extremely High
Table 2
