clinical guidelines on the identification, evaluation, and

Definitions

Body Mass Index (BMI) describes relativeweight for height: weight (kg)/height (m2)

• Overweight = 25–29.9 BMI

• Obesity = > 30 BMI

Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)

37.8

23.6

10.4 15

.1

41.1

23.6

11.8 16

.1

39.1

24.3

12.2 16

.324

.9

39.4

24.7

19.9

0

10

20

30

40

50

Men Women Men Women

NHES I NHANES I NHANES II NHANES III

BMI > 30BMI 25–29.9

Perc

ent

CDC/NCHS, United States, 1960-94, ages 20-74 years

NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI

16.518.221.922.5 24.025.2

32.238.4

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

Perc

ent

*Defined as mean systolic blood pressure ≥ 140 mm Hg, as mean diastolic ≥ 90 mm Hg, or currently taking antihypertensive medication.

Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).

NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI

15.714.7

27.9

17.5

28.2

20.424.7

20.2

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

Perc

ent

*Defined as > 240 mg/dL.

Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).

NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI

16.5

9.1

27.0

17.2

27.223.1

41.5

31.4

0

10

20

30

40

50

60

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as <35 mg/dL in men and <45 mg/dL in women.

Perc

ent

Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).

Health Benefits of Weight Loss• Decreased cardiovascular risk• Decreased glucose and insulin levels• Decreased blood pressure• Decreased LDL and triglycerides, increased HDL• Decrease in severity of sleep apnea• Reduced symptoms of degenerative joint disease• Improved gynecological conditions

Care of Overweight/Obese Patients

Requires two steps:

• Assessment• Management

Assessment of Overweight and Obesity

• Body Mass Index– Weight (kg)/height (m2)– Weight (lb)/height (in2) x 703– Table

• Waist Circumference– High risk:

• Men >102 cm (40 in.)• Women >88 cm (35 in.)

Classification of Overweight and Obesity by BMI

Obesity Class BMI kg/m2

Underweight <18.5

Normal 18.5–24.9

Overweight 25–29.9

Obesity I 30.0–34.9

II 35.0–39.9

Extreme Obesity III ≥ 40.0

Determine Absolute Risk StatusEvaluate:• Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea)

(+ = very high risk)• Other obesity-associated diseases (e.g., gynecological

abnormalities, osteoarthritis)• Cardiovascular risk factors: smoking, hypertension,

high LDL, low HDL, IGT, family hx (>3 = high risk)• Other risk factors:

– Physical inactivity– High serum triglycerides (>200 mg/dL)

Patient Encounter

Hx of 25 BMI?≥

• Measure weight, height, and waistcircumference

• Calculate BMI

Brief reinforcement/ educate on weight management

Periodic weightcheck

Advise to maintainweight/addressother risk factors

Clinician and patientdevise goals andtreatment strategyfor weight loss andrisk factor control

Assess reasons forfailure to lose weight

Maintenance counseling: Dietary therapyBehavior therapyPhysical activity:

Assess risk factors

No

1

2

14

13

12

16

3

5 7

9

Yes

No

No

Hx BMI 25?≥

No

Yes

Yes

No

Doespatient want tolose weight?

Yes Progress being made/goal

achieved?

BMI 25 OR≥waist circumference

> 88 cm (F)> 102 cm (M)

BMI≥ 30 OR

{[BMI 25 to 29.9 OR waist circumference

>88 cm (F) >102 cm (M)]AND 2 risk≥

factors}

BMImeasured in past

2 years?

Treatment AlgorithmYes

4 6

8

Yes

15

No

Examination 11 10

Treatment

Treatment Algorithm(Part 1 of 3)Patient Encounter

Hx of ≥ 25 BMI?

• Measure weight, height, and waist circumference

• Calculate BMI

No

2

3

5Yes

No

BMI measured in past

2 years?

BMI ≥ 25 ORwaist > 88 cm (F)

> 102 cm (M)

1

ExaminationTreatment

Yes

No

BMI ≥ 30 OR

{[BMI 25 to 29.9 OR waist >88 cm (F)

>102 cm (M)] AND ≥ 2 risk

factors}

7

Yes

4

Assess risk factors

6

Devise goals andtreatment strategy forweight loss and riskfactor control

Assess reasons forfailure to lose weight

Maintenance counseling

12

9

No

Yes

Yes

No Desire tolose weight?

No

Progress made?

BMI ≥ 30 OR

{[BMI 25 to 29.9 OR waist >88 cm (F)

>102 cm (M)]AND ≥ 2 risk

factors}Examination

Treatment

7

Periodic weightcheck

• Advise to maintain weight

• Address other risk factors

16

Treatment Algorithm(Part 2 of 3)

8

Yes13

11 10

• Brief reinforcement • Educate on weight

management

Periodic weight check

• Advise to maintain weight

• Address other risk factors

14

13

16

5

No

No

Hx BMI ≥ 25?

BMI ≥ 25 OR waist > 88 cm (F)

> 102 cm (M)

* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovascular risk factors or diseases that are indicated.

Treatment Algorithm(Part 3 of 3)

Yes

Examination

Treatment

Yes

15

Goals of Weight Management/Treatment

• Prevent further weight gain (minimum goal).

• Reduce body weight.• Maintain a lower body weight

over long term.

Target Weight: Realistic Goals• Substitute “healthier weight” for ideal or

landmark weight.• Accept slow, incremental progress to goal.

— Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week.

— Interim goal: Maintenance.— Long-term goal: Additional weight loss,

if desired, and long-term weight maintenance.

Weight Loss Goals

Goal: Decrease body weight by 10 percent frombaseline.• If goal is achieved, further weight loss can be

attempted if indicated.• Reasonable timeline: 6 months of therapy.

– Moderate caloric deficits– Weight loss 1 to 2 lb/week

Weight Loss Goals

• Start weight maintenance efforts after 6 months.– May need to be continued indefinitely.

• If unable to lose weight, prevent further weight gain.

Strategies for Weight Loss and Maintenance

• Dietary therapy• Physical activity• Behavior therapy• “Combined” therapy• Pharmacotherapy• Weight loss surgery

Weight Loss Therapy

Whenever possible, weight loss therapy should employ the combination of

• Low-calorie/low-fat diets

• Increased physical activity

• Behavior modification

Dietary Therapy (1 of 5)

Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons.Evidence Category A.

Reducing fat as part of an LCD is a practicalway to reduce calories. Evidence Category A.

Dietary Therapy (2 of 5)

Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.

Dietary Therapy (3 of 5)

Although lower fat diets without targeted caloriereduction help promote weight loss by producinga reduced calorie intake, lower fat diets coupledwith total calorie reduction produce greaterweight loss than lower fat diets alone. Evidence Category A.

Dietary Therapy (4 of 5)

Very low-calorie diets produce greater initialweight loss than low-calorie diets. However,long-term (>1 year) weight loss is not differentfrom an LCD. Evidence Category A.

Dietary Therapy (5 of 5)

Very Low-Calorie Diets (less than 800 kcal/day):• Rapid weight loss• Deficits are too great• Nutritional inadequacies• Greater weight regain• No change in behavior• Greater risk of gallstones

Low-Calorie Step I DietNutrient Recommended Intake

Calories 500 to 1,000 kcal/day reduction

Total Fat 30 percent or less of total calories

SFA 8 to 10 percent of total calories

MUFA Up to 15 percent of total calories

PUFA Up to 10 percent of total calories

Cholesterol <300 mg/day

Low-Calorie Step I Diet (continued)

Nutrient Recommended Intake

Protein ~ 15 percent of total calories

Carbohydrate 55 percent or more of total calories

Sodium Chloride No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride)

Calcium 1,000 to 1,500 mg

Fiber 20 to 30 g