- More than 78 million adults in the United States were obese in 2009-2010. Obesity raises the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes mellitus (diabetes), coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers. Obesity is also associated with increased risk in all-cause and cardiovascular disease (CVD) mortality.
- Overweight is defined as a body mass index (BMI) of 25-29.9 kg/m2 and obesity as a BMI of ≥30 kg/m2. Current estimates are that 69% of adults are either overweight or obese with approximately 35% obese.
- It has been reported that, compared with normal weight individuals, obese patients incur 46% increased inpatient costs, 27% more physician visits and outpatient costs, and 80% increased spending on prescription drugs. The medical care costs of obesity in the United States in 2008 totaled about $147 billion.
Comprehensive Lifestyle Intervention
Elements of High Intensity Comprehensive Lifestyle Intervention
- Lower calorie diet
- Increased physical activity
- Behavioral strategies to achieve diet and activity goals
- Delivered on site by a trained interventionista
- 14 or more sessions in the first 6 months
- Continued follow-up for 1 year
Recommendations for Obesity
|Recommendations||ACC/AHA COR||ACC/AHA LOE|
|Identifying Patients Who Need to Lose Weight (BMI and Waist Circumference)|
|1a. Measure height and weight and calculate BMI at annual visits or more frequently.||I||C|
|1b. Use the current cutpoints for overweight (BMI 25.0-29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes.||I||B|
|1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality.||I||B|
|1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults.|
Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either NIH/NHLBI or WHO/IDF) may continue to be used to identify patients who may be at increased risk until further evidence becomes available.
|Matching Treatment Benefits With Risk Profiles|
(Reduction in Body Weight Effect on CVD Risk Factors, Events, Morbidity and Mortality)
|2. Counsel overweight and obese adults with CV risk factors (high BP, hyperlipidemia, and hyperglycemia), that lifestyle changes that produce even modest, sustained weight loss of|
3%-5% produce clinically meaningful health benefits, and greater weight loss produces greater benefits.
|Diets for Weight Loss (Dietary Strategies for Weight Loss)|
|3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of||I||A|
|3b. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status and preferably refer to a nutrition professionalb for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults.||I||A|
|Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)|
|4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies.||I||A|
|4b. Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.a||I||A|
|4c. Electronically delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionista can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions.||IIa||A|
|4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy.||IIa||A|
|4e. Use a very-low-calorie diet (defined as <800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications.||IIac||A|
|4f. Advise overweight and obese individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program.||I||A|
|4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionista who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (i.e., weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight).||I||A|
|Selecting Patients for Bariatric Surgical Treatment for Obesity|
(Bariatric Surgical Treatment for Obesity)
|5a. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation.||IIad||A|
|5b. For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures.||N/A||N/A|
|5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility).||IIb||C|
a Trained interventionist: In the studies reviewed, trained interventionists included mostly health professionals (e.g., registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training) who adhered to formal protocols in weight management. In a few cases, lay persons were used as trained interventionists; they received instruction in weight management protocols (designed by health professionals) in programs that have been validated in high-quality trials published in peer-reviewed journals.
b Nutrition professional: In the studies that form the evidence base for this recommendation, a registered dietitian usually delivered the dietary guidance; in most cases, the intervention was delivered in university nutrition departments or in hospital medical care settings where access to nutrition professionals was available.
c There is strong evidence that if a provider is going to use a very low-calorie diet, it should be done with high levels of monitoring by experienced personnel; that does not mean that practitioners should prescribe very-low-calorie diets. Because of the concern that an ACC/AHA Class I recommendation would be interpreted to mean that patients should go on a very-low-calorie diet, it was the consensus of the Expert Panel that this maps more closely to an ACC/AHA Class IIa recommendation.
d There is strong evidence that the benefits of surgery outweigh the risks for some patients. These patients can be offered a referral to discuss surgery as an option. This does not mean that all patients who meet the criteria should have surgery. This decision-making process is quite complex and best performed by experts. The ACC/AHA criterion for a Class I recommendation states that the treatment/procedure should be performed/administered. This recommendation as stated does not meet the criterion that the treatment should be performed. Thus, the ACC/AHA classification criteria do not directly map to the NHLBI grade assigned by the Expert Panel.