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Last Updated: 11/18/2013  

Obesity

Overweight and obesity are defined by BMI, which is calculated by dividing weight in kg by the square of height in meters. BMI <25 kg/m2 is normal; adults with BMI of 25-29 kg/m2 are overweight and those with BMI of 30 kg/m2 are obese.

Prevention
  • Provide counseling and preventive strategies for adults who are at risk for obesity, including those with weight gain, low activity, or family history of obesity.

Screening
  • Screen for obesity in all adults and children over age 6 by determining BMI.

Diagnosis
  • Measure BMI and look for comorbid conditions on physical exam and consider measurement of waist circumference.

  • Test for comorbidities including diabetes and hyperlipidemia in patients who are obese.

  • Consider the broad range of conditions associated with unhealthy weight.

Therapy
  • Initiate behavioral therapy with diet and exercise in overweight patients who are motivated to lose weight.

  • Consider drug therapy for patients with a BMI ≥30 kg/m2, or ≥27 kg/m2 with comorbidities such as hypertension, diabetes, or dyslipidemia.

  • Consider surgical treatment for very obese patients (BMI ≥35 kg/m2 with comorbidities or ≥40 kg/m2) in whom other measures have failed.

Provide counseling for pregnant women about nutrition, pregnancy-related weight gain, and other factors to prevent complications of pregnancy and adverse outcomes in their offspring. 
  • Counsel patients to maintain good nutrition and monitor for weight changes.

  • Advise overweight mothers of the increased risk for maternal and fetal complications and anomalies and of the risk for overweight children, particularly for nulliparous women.

  • Advise patients who smoke to stop smoking.

  • Control glucose in women with diabetes or who develop gestational diabetes.

  • See module Diabetes in Pregnancy.

Evidence
  • A 2012 systematic review of dietary and lifestyle interventions during pregnancy included 44 randomized trials. Overall, interventions related to diet, physical activity, or both reduced gestational weight gain by 1.42 kg compared with controls, and reduced rates of preeclampsia (RR, 0.74 [CI, 0.60 to 0.92]) and shoulder dystocia (RR, 0.39 [CI, 0.22 to 0.70]), with no effect on birth weight or rates of large or small for gestational age infants. Dietary interventions reduced maternal weight gain most effectively (3.84 kg [CI, 2.45 to 5.22]) (1).

  • A 2009 systematic review of the relationship between maternal weight and congenital anomalies included 39 observational studies, of which 18 were included in the meta-analysis. Compared with mothers with normal BMI, obese mothers were at increased risk for children with neural tube defects (OR, 1.87 [CI, 1.62 to 2.15]), spina bifida (OR, 2.24 [CI, 1.89 to 2.69]), hydrocephaly (OR, 1.68 [CI, 1.19 to 2.36]), limb abnormalities (OR, 1.34 [CI, 1.03 to 1.73]), cardiovascular abnormalities (OR, 1.30 [CI, 1.12 to 1.51]), cleft palate (OR, 1.23 [CI, 1.03 to 1.47]), and other abnormalities (2).

  • A 2008 AHRQ evidence report evaluated outcomes related to weight gain in pregnant women. The review found strong evidence that maternal weight gain is related to preterm birth, birth weight, macrosomia, and large for gestational age and small for gestational age newborns. Weight gain beyond Institute of Medicine recommendations was associated with high birth weight, caesarian delivery, and postpartum weight retention (3).

  • A 2008 systematic review of maternal smoking and childhood weight included data from 14 observational studies. Children of mothers who smoked were at increased risk for being overweight (OR, 1.50 [CI, 1.36 to 1.65]) across a wide range of ages (4).

  • A 2007 systematic review of obesity and the risk for gestational diabetes included 20 studies. The risk for gestational diabetes increased with increasing maternal weight (5).

  • A retrospective cohort study evaluated the relationship between pregnancy weight gain and childhood weight. Children of mothers who gained more weight than recommended were more likely to be overweight than children of mothers who gained weight appropriately (adjusted OR, 1.48 [CI, 1.06 to 2.06]). Odds of children overweight at age 7 years were increased by 3% for every 1 kg of gestational weight gain (6).

  • A follow-up study of cohorts of pregnant women found that children of women who were both overweight and gained a large amount of weight during gestation had a two-fold risk for attention-deficit hyperactivity disorder symptoms (OR, 2.10 [CI, 1.19 to 3.72]) compared with children of normal-weight women (7).

Rationale
  • High body weight affects fetal outcome, and intrauterine imprinting can affect long-term control of body weight.

  • Smoking during pregnancy is a risk factor for obesity in offspring.

  • Gestational diabetes is a risk factor for obesity in offspring.

Comments
  • The effect of smoking on the weight of offspring may vary based on patient race/ethnicity.

  • Infants who are small for gestational age are at higher risk for diabetes, hypertension, and the metabolic syndrome (8).

  • There is no clear evidence that unintended pregnancy is related to initial body weight.

Provide counseling and preventive strategies for children who are at risk for obesity or weight gain.  
  • Determine if the child is overweight or obese by noting:

    • Body weight in relation to height on the CDC growth charts

    • If the parents are overweight

  • Counsel at-risk children and their parents about:

    • The appropriate weight for the child

    • The loss of self-esteem associated with obesity

    • The value of breast-feeding for more than 3 months in preventing weight gain

    • Regular physical activity

    • Getting adequate sleep

    • Controlling caloric intake by using small portion sizes

    • Eating a lower fat diet

    • Eating lower glycemic load foods

    • Avoiding excessive protein intake

    • Influence of medications on weight gain

    • The potential value of higher calcium intake

    • The value of eating breakfast

    • Watching less television

    • Eating family meals together

    • Drinking fewer carbonated, sugar-sweetened beverages

  • If a child's weight is above the 99th percentile for height and rising, consider genotyping for genetic disorders associated with obesity.

  • See the CDC Growth Charts.

Evidence
  • A 2012 scientific statement from the American Heart Association on the role of parents and caregivers in the treatment of obesity in children found little evidence that parental involvement improved outcomes in children. Some studies found that parental adherence to behavioral strategies to lose weight predicted better outcomes for the children (9).

  • A 2005 systematic review for the USPSTF addressed screening and interventions for overweight children. Childhood BMI predicted adult weight, especially in older children and children with at least one obese parent. Overall, 10% of children aged 2 to 5 years and 16% of those aged 6 years and older were overweight, with higher rates among ethnic minorities. Children over age 13 years with BMI above the 95th percentile had greater than a 50% chance of having adult obesity. Studies of interventions to reduce obesity in children were small, with diverse interventions and limited follow-up times (10).

  • A 2013 systematic review of the effect of early childhood protein intake on later body weight included 41 studies. Increased protein intake early in life (between 15% and 20% of calories) was associated with being overweight later in life (11).

  • A 2006 systematic review of interventions to prevent obesity in children and adolescents included 24 studies with 24,896 participants. Eight studies found that the intervention lowered obesity rates and 16 found that obesity rates in the intervention and control groups were similar (12).

  • A 2008 systematic review of the relationship between sweetened soft drinks and obesity included 44 studies (both observational and intervention studies). Half of observational studies, mostly from the U.S., found that soft drink consumption was associated with higher BMI, generally at high levels of consumption (13).

  • A 2008 systematic review of the association between sleep duration and obesity in children included 11 studies. Overall, getting less sleep increased the risk for obesity later in life (OR, 1.58 [CI, 1.26 to 1.98]) (14).

  • A 2005 systematic review of the effect of breast-feeding on weight throughout life included 70 studies. In the unadjusted analysis, mean BMI was slightly lower in the exclusively breast-fed group (difference in BMI, 0.04). The difference did not persist after adjustment for smoking, socioeconomic status, and maternal BMI (15).

  • A 2011 systematic review of the effect of interventions to reduce screen time in children on BMI included 13 studies, of which 6 were included in the primary meta-analysis. Overall, interventions to reduce screen time did not reduce BMI (16).

  • A prospective cohort study evaluated childhood risk factors for premature death over a median follow-up time of 24 years. Children in the highest quartiles for BMI and glucose intolerance were at increased risk for death compared with those in the lowest quartiles, with incidence rate ratios of 2.30 (CI, 1.46 to 3.62) and 1.73 (CI, 1.09 to 2.74), respectively (17).

  • A cohort study of diet and obesity found that children eating foods high in energy density (more calories per gram) at age 7 years had a higher risk for excess adiposity at age 9 years (18).

  • An observational study of cereal consumption found that the number of days eating cereal for breakfast (but not breakfast overall) correlated with lower BMI (19).

  • A cross-sectional study found that juice consumption by overweight children in low-income families was associated with weight gain (20).

  • A cohort study evaluated prognostic factors for overweight children. Eating fewer family dinners together, watching television, and living in neighborhoods perceived by parents as unsafe for outdoor play were associated with more overweight children (21).

  • A case-control study of European patients with and without obesity identified several genetic markers including FTO, MC4R, and loci in NPC1 (22).

Rationale
  • Obesity results from an imbalance of energy intake vs. expenditure and a disturbance in the factors that regulate the feedback process.

Comments
  • The prevalence of overweight children is increasing (23).

  • Risk factors for obesity include childhood depression (24), poverty (25), low educational attainment (26), limited ability to delay gratification in childhood (27), poor coordination and clumsiness in childhood (28), and childhood television watching (29).

  • Interventions in preschool children, such as Head Start, may slow weight gain, but the evidence is mixed (30; 31; 32; 33; 34; 35).

  • A population-based cohort study found that both childhood obesity and early age of menarche were associated with adult obesity (36).

  • A retrospective cohort study evaluated the relationship between obesity and age of menarche. The odds of obesity decreased 18% for every 1-year increase in age of menarche (37).

  • Some types of sexual abuse in girls, but not boys, may increase risk for being overweight as adults (38). Court-substantiated records of physical abuse, but not sexual abuse or neglect, predicted higher BMI as adults (39).

Provide counseling and preventive strategies for adults who are at risk for obesity.  
  • Identify individuals who are at risk for obesity and its associated comorbidities by noting:

    • Body weight increasing at a rate above 1 to 2 pounds per year

    • Strong family history of being overweight

    • Abnormal waist circumference: >102 cm (40 in) for males or >88 cm (35 in) for females (for Asians, >90 cm [35.4 in] for males or >80 cm [31.5 in] for females)

    • Increased WHR: >0.95 for males or >0.85 for females

    • Low level of physical activity

    • Presence of the metabolic syndrome

  • Counsel at-risk individuals about the importance of:

    • Exercising for 30 minutes or more, five times per week

    • Getting adequate sleep

    • Controlling calorie intake

    • Lowering fat intake for weight loss or weight maintenance

    • Increasing dietary fiber

    • Eating breakfast

    • Controlling blood pressure

    • Treating components of the metabolic syndrome if weight loss does not accomplish this

    • Controlling stress

  • Explain the importance of understanding the increased risk for:

    • Weight gain in smokers who stop smoking

    • Increasing weight with age

    • Diabetes

    • Heart disease

    • Sleep apnea

Evidence
  • A 2013 AHRQ evidence review of strategies to prevent weight gain among adults included 51 studies with over 500,000 participants. The review found moderate-level evidence for two interventions: workplace interventions with individual and environmental components and home exercise for women with cancer. The review also found low-level evidence for two additional interventions: eating home-prepared meals for college graduates and reducing television viewing among patients with colorectal cancer (40).

  • A 2008 systematic review of the association between short sleep duration and weight gain included 36 studies. In adults, results of studies of weight and sleep duration were mixed, but longitudinal studies found that short sleep duration predicted future weight, especially in younger patients (41).

  • An observational study showed a rise in the prevalence of obesity between 1999 and 2004 (23).

  • A prospective cohort study evaluated the effect of adult obesity on life expectancy using the Framingham cohort. Both being overweight and obese were associated with lower life expectancy; BMI at age 30 to 49 years was predictive of life expectancy at age 50 to 69 years. Obese smokers had shorter life expectancy compared with normal-weight smokers (7.2 years in women and 6.7 years in men) and compared with normal-weight nonsmokers (13.3 years in women and 13.7 years in men) (42).

  • A population-based study of prognostic factors for cardiovascular disease in Australia found that WHR was an independent predictor of coronary disease and cardiac death (43).

  • An analysis of data from the National Health and Nutrition Examination Survey evaluated the association between breakfast consumption and BMI. In women, consumers of breakfast were less likely to have BMI ≥25 kg/m2 (OR, 0.76) (30).

Rationale
  • Obesity results from an imbalance of energy expenditure and intake.

Comments
  • A BMI <25 kg/m2 is normal for most people; overweight is BMI 25 to 29 kg/m2; and obese is BMI ≥30 kg/m2 (44; 45).

  • Factors associated with obesity in adults include sedentary lifestyle (46), cessation of smoking (47; 48), familial factors, genetic factors (49), and job stress and strain (50).

  • Dietary fat intake is associated with obesity and people who keep weight off tend to reduce fat intake (51).

  • A patient with BMI ≥30 has better 30-day prognosis after onset of acute coronary syndrome (obesity paradox), but in the longer term this disappears (52).

  • Weight cycling among male athletes is associated with more weight gain than in nonathlete controls (53), but is not detrimental in women (54).

  • Providing information on global CHD risk, of which obesity is a part, may increase the intent to initiate preventive steps (55).

Advise patients to reduce BMI and central adiposity to decrease health risks and improve quality of life, especially in patients with BMI ≥30 kg/m2.  
  • Identify patients at risk by determining BMI and family history of obesity.

  • Identify patients at risk due to increasing body weight or low levels of activity.

  • Acquaint at-risk patients with potential danger of obesity, including increased mortality and higher risks for:

    • Diabetes

    • Heart disease

    • Hypertension

    • Stroke

    • Gall bladder disease

    • Osteoarthritis

    • Sleep apnea

    • Some forms of cancer

    • Erectile dysfunction

  • Develop a plan to reduce body weight.

  • Develop a plan to treat comorbidities if weight loss does not ameliorate them.

  • See figure Body Mass Index.

Evidence
  • A 2008 systematic review of the relationship between obesity and kidney disease included 47 studies. Compared with normal-weight people, overweight (RR, 1.40 [CI, 1.30 to 1.50]) and obese (RR, 1.83 [CI, 1.57 to 2.13]) people were at increased risk for kidney disease, with a larger effect in women than in men (RR, 1.92 [CI, 1.78 to 2.07]) (56).

  • A prospective cohort study evaluated the effect of adult obesity on life expectancy using the Framingham cohort. Both being overweight and obese were associated with lower life expectancy; BMI at age 30 to 49 years was predictive of life expectancy at age 50 to 69 years. Obese smokers had shorter life expectancy compared with normal-weight smokers (7.2 years in women and 6.7 years in men) and compared with normal-weight nonsmokers (13.3 years in women and 13.7 years in men) (42).

  • A study pooled data from 57 observational trials with nearly 900,000 participants to examine the relationship between BMI and mortality. Participants were mostly from North America and Europe. Mortality was lowest at BMI 22.5 to 25 kg/m2; higher BMI was associated with higher overall mortality (HR per 5 kg/m2, 1.29 [CI, 1.27 to 1.32]) , higher vascular mortality (HR per 5 kg/m2, 1.41 [CI, 1.37 to 1.45]), higher mortality from diabetic disease (HR per 5 kg/m2, 2.16 [CI, 1.89 to 2.46]), higher renal mortality (HR per 5 kg/m2, 1.59 [CI, 1.27 to 1.99]), and higher mortality from liver disease (HR per 5 kg/m2, 1.82 [CI, 1.59 to 2.09]) (57).

  • A cohort study examined the effect of body weight on disability and life expectancy. The lowest rate of disability was seen in adults with BMI 18.5 to <30 kg/m2 and the highest in those with BMI >40 kg/m2 (HR, 2.49). The lowest mortality rate was seen in adults with BMI 25 to <30 kg/m2 (HR, 0.78 compared with the BMI 18 to <25 kg/m2 group) and highest in adults with BMI <18.5 kg/m2 (HR, 1.53) (58).

  • A study used several cohorts to evaluate the association between body weight and risk factors for cardiovascular disease in U.S. adults. Obese individuals had higher rates of hyperlipidemia, hypertension, and diabetes than those with normal body weight, but the difference related to BMI declined over time between 1960 and 2000, presumably due to more aggressive treatment (59).

  • A cohort study evaluated the relationship between body weight and stroke. In the multivariate analysis, the rate of total stroke was increased in overweight (HR, 1.23 [CI, 1.10 to 1.37]) and obese (HR, 1.59 [CI, 1.37 to 1.83]) men compared with normal-weight men, with similar increases in rates of ischemic stroke. In women, rates of total stroke were increased in lean (HR, 1.87 [CI, 1.12 to 3.14]) and obese women (HR, 1.30 [CI, 1.14 to 1.50]) but not in overweight women compared with normal-weight women (60).

  • A cohort study found that BMI was associated with the risk for heart failure (HR for obese compared with normal-weight women, 2.12 [CI, 1.51 to 2.97]; HR for obese compared with normal-weight men, 1.90 [CI, 1.30 to 2.79]) (61).

  • A cohort study evaluated the relationship between body weight and atrial fibrillation. Obese men (adjusted HR, 1.52 [CI, 1.09 to 2.13]) and women (adjusted HR, 1.46 [CI, 1.03 to 2.07]) were at higher risk for atrial fibrillation than those with normal body weight (62).

  • A prospective cohort study in women assessed the relationship between weight and the risk for gallstones. Obese women (BMI >32 kg/m2) were more likely to have symptomatic gallstones (RR, 6.0 [CI, 4.0 to 9.0]) than those with BMI <20 kg/m2, and overweight women were at slightly increased risk (63).

  • A study evaluated obese patients with type 2 diabetes for the presence of sleep apnea and found a prevalence of 86%; severe sleep apnea was more common in patients with higher BMI (64).

  • A study evaluated the relationship between weight and health status in the Third National Health and Nutrition Examination Survey cohort. Among men and women there was a linear relationship between obesity and self-assessed health, with obese participants reporting poorer health in the white, black, and Hispanic sub-cohorts (65).

  • A prospective cohort study evaluated the effect of intentional weight loss on mortality among overweight and obese individuals. After a follow-up time of 9 years, patients initially reporting intentional weight loss had lower risk for death (HR, 0.76 [CI, 0.60 to 0.97]), but the effect was independent of the actual loss of weight (66).

Rationale
  • A high BMI and/or increased central adiposity increase the risk for health problems and impair quality of life.

  • Weight loss may improve metabolic cardiac risk factors and lifestyle.

Comments
  • If obesity or its comorbidities persist after weight loss, consider treating comorbidities with appropriate medications.

Screen for obesity in all adults and children over age 6 years by determining BMI. 
Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended measuring height and weight and calculating BMI at least annually. The guideline recommended defining overweight as BMI >25.0 to 29.9 kg/m2 and obesity as BMI ≥30 kg/m2 (67).

  • A 2012 guideline from the USPSTF recommended screening all adults for obesity and referring those with BMI ≥30 kg/m2 for intensive behavioral interventions (68).

  • A 2010 guideline from the USPSTF recommended screening all children and adolescents over age 6 years for obesity using BMI, and offering intensive behavioral and counseling interventions to those who are overweight or obese. The guideline defined overweight as BMI ≥85th and ≤94th percentile for age and gender, and obese as BMI >95th percentile (69).

  • A 2010 systematic review of the diagnostic accuracy of BMI compared with body fat percentage included 25 articles. BMI had pooled sensitivity of 50% (CI, 43% to 57%) and pooled specificity of 90% (CI, 86% to 94%) for the diagnosis of high body adiposity (70).

  • A 2007 systematic review of the association of being overweight (BMI 25 to 29.9 kg/m2) and obese (BMI ≥30 kg/m2) with coronary heart disease included 21 studies with over 300,000 participants. After adjustment for age, sex, smoking, activity level, hypertension and hyperlipidemia, being overweight (RR, 1.17 [CI, 1.11 to 1.23]) and obese (RR, 1.49 [CI, 1.32 to 1.67]) remained risk factors for cardiac events (71).

  • A 2008 systematic review of the relationship between obesity and kidney disease included 47 studies. Compared with normal-weight patients, overweight (RR, 1.40 [CI, 1.30 to 1.50]) and obese (RR, 1.83 [CI, 1.57 to 2.13]) people were at increased risk for kidney disease, with a larger effect in women than in men (RR, 1.92 [CI, 1.78 to 2.07]) (56).

  • A study used data from the Framingham Offspring Study to assess prognostic factors for predicting future coronary heart and cerebrovascular disease. BMI was predictive of future CHD (HR, 1.28 for each 1 standard deviation change in BMI in the unadjusted model; HR, 1.1 in the fully adjusted model). For cerebrovascular disease, when fully adjusting for other prognostic factors, the HR was 1.09 for every 1 standard deviation increase in BMI (72).

  • A prospective cohort study evaluated the effect of adult obesity on life expectancy using the Framingham cohort. Both being overweight and obese were associated with lower life expectancy; BMI at age 30 to 49 years was predictive of life expectancy at age 50 to 69 years. Obese smokers had shorter life expectancy compared with normal-weight smokers (7.2 years in women and 6.7 years in men) and compared with normal-weight nonsmokers (13.3 years in women and 13.7 years in men) (42).

  • A study pooled data from 57 observational trials with nearly 900,000 participants to examine the relationship between BMI and mortality. Participants were mostly from North America and Europe. Mortality was lowest at BMI 22.5 to 25 kg/m2; higher BMI was associated with higher overall mortality (HR per 5 kg/m2, 1.29 [CI, 1.27 to 1.32]) , higher vascular mortality (HR per 5 kg/m2, 1.41 [CI, 1.37 to 1.45]), higher mortality from diabetic disease (HR per 5 kg/m2, 2.16 [CI, 1.89 to 2.46]), higher renal mortality (HR per 5 kg/m2, 1.59 [CI, 1.27 to 1.99]), and higher mortality from liver disease (HR per 5 kg/m2, 1.82 [CI, 1.59 to 2.09]) (57).

  • A cohort study found that BMI was associated with the risk for heart failure (HR for obese compared with normal-weight women, 2.12 [CI, 1.51 to 2.97]; HR for obese compared with normal-weight men, 1.90 [CI, 1.30 to 2.79]) (61).

  • A cohort study evaluated the relationship between body weight and atrial fibrillation. Obese men (adjusted HR, 1.52 [CI, 1.09 to 2.13]) and women (adjusted HR, 1.46 [CI, 1.03 to 2.07]) were at higher risk for atrial fibrillation than those with normal body weight (62).

  • A prospective cohort study in women assessed the relationship between weight and the risk for gallstones. Obese women (BMI <32 kg/m2) were more likely to have symptomatic gallstones (RR, 6.0 [CI, 4.0 to 9.0]) than those with BMI <20 kg/m2, and overweight women were at slightly increased risk (63).

  • A retrospective analysis of a prospective cohort study evaluated the relationship between obesity and osteoarthritis and included 1854 participants with 10-year follow-up. After adjusting for other factors, obesity (BMI >30 kg/m2) was associated with osteoarthritis of the knee (OR, 2.81 [CI, 1.32 to 5.96]) and hand (OR, 2.81 [CI, 1.32 to 5.96]) but not the hip (OR, 1.11 [CI, 0.41 to 2.97]) (73).

Rationale
  • BMI correlates with risks associated with obesity and body fat, such as diabetes, heart disease, osteoarthritis, gall bladder disease, and certain types of cancer.

Comments
  • The National Heart, Lung and Blood Institute and World Health Organization define normal weight range as BMI 18.5 to 24.9 kg/m2, overweight as BMI 25 to 29.9 kg/m2, and obese as BMI >30 kg/m2 (44; 45). For Asians, BMI >23 kg/m2 is defined as overweight, and BMI >25 kg/m2 is defined as obese (74).

  • At the same BMI, body fat is about 12% higher in women than men (75).

Consider measuring waist circumference to better risk stratify patients, particularly overweight women. 
  • Consider measuring waist circumference with a steel tape, especially in overweight women.

  • Note that a waist measurement of >102 cm (40 in) in men or >85 cm (35 in) in women (for Asians, waist measurement of >90 cm [35.4 in] in men or >80 cm [31.5 in] in women) is considered high risk and is a predictor of mortality in both men (RR=2.05) and women (RR=1.78) for the highest compared with the lowest quintile.

  • Recognize that increased waist circumference is a criterion for diagnosing the metabolic syndrome.

  • In elderly patients, measure hip circumference and calculate WHR, noting that WHR >0.95 is increased in men and WHR >0.85 is increased in women.

  • See table Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk.

  • See table Clinical Features of the Metabolic Syndrome.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended measuring waist circumference in overweight and obese adults and noted that patients with a higher waist circumference are at greater risk for cardiovascular disease (67).

  • A 2007 systematic review of the risk for cardiac events based on waist circumference and WHR included 15 studies. After adjusting for age, treatment, and cohort year, in both men and women a 1-cm increase in waist circumference was associated with a 2% (CI, 1% to 3%) increase in the risk for a cardiac event, and a 0.01-unit increase in WHR was associated with a 5% (CI, 4% to 7%) increase in the risk for a cardiac event (76).

  • A study used data from the Framingham Study to assess the incremental prognostic value of BMI and waist circumference. Waist circumference was not independently associated with the risk for cardiovascular disease in normal-weight or obese people or in overweight men. In overweight women, waist circumference was independently associated with the risk for cardiovascular disease. A 1-standard deviation increase in waist circumference (15.6 cm) was associated with an increased risk for cardiovascular disease (OR, 1.86 [CI, 1.03 to 3.36]) (77).

  • A 2007 study assessed the association between various measures of body weight and overall mortality in a large cohort of Australian patients followed for a median of 11 years. Men in the top quintile for each measure (BMI, waist circumference, WHR) were at increased risk for death, with HRs of 1.2 to 1.3 compared with men in the second quintile for each measure. Women in the top quintile for WHR (HR, 1.5 [CI, 1.2 to 1.8]) and waist circumference (HR, 1.3 [CI, 1.1 to 1.6]) were at increased risk for death, but women in the top quintile for BMI were not (HR, 1.1 [CI, 0.9 to 1.3]) (78).

  • A study evaluated the relationship between measures of obesity and the development of chronic kidney disease and death in 13,000 patients from two large cohorts with a 9-year follow-up time. WHR (OR for every standard deviation increase, 1.22 [CI, 1.05 to 1.43]), but not BMI (OR, 1.05 [CI, 0.93 to 1.20]), predicted chronic kidney disease (79).

  • A cohort study evaluated the prognostic significance of measures of weight in adults age 75 years or older with a median follow-up time of 5.9 years. In nonsmoking men in the fully adjusted model, higher BMI was associated with lower mortality (adjusted HR, 0.64 [CI, 0.55 to 0.75] for the highest quintile compared with the lowest); higher waist circumference was associated with lower mortality (adjusted HR, 0.85 [CI, 0.72 to 1.00] for the highest compared with the lowest quintile); WHR was not associated with mortality. In nonsmoking women in the fully adjusted model, higher BMI was associated with a lower mortality (adjusted HR, 0.72 [CI, 0.62 to 0.84] for the highest quintile compared with the lowest); higher waist circumference was associated with a lower mortality (adjusted HR, 0.83 [CI, 0.69 to 0.99] for the highest compared with the lowest quintile); higher WHR was associated with higher mortality (adjusted HR, 1.21 [CI, 1.04 to 1.42] for the highest compared with the lowest quintile) (80).

  • The metabolic syndrome is a defined entity that is present when three of the five characteristics in the table Clinical Features of the Metabolic Syndrome are present (81).

Rationale
  • Waist circumference has a good correlation with visceral fat and is the easiest anthropometric measure for making this estimate.

  • Increased waist circumference is associated with increased risk for disease.

  • Waist circumference is an independent predictor of cardiovascular disease in overweight women.

Comments
  • Sagittal diameter and waist circumference divided by hip circumference are alternative methods to waist circumference alone for estimating central fat.

  • Waist-to-height ratio may be better than WHR or BMI (82).

Assess change in weight over time to optimize risk assessment. 
  • Determine annual rate of weight gain and identify patients who gain >1 kg (2 pounds) per year as high-risk for comorbidities.

Evidence
  • A prospective cohort study assessed the effect of weight parameters on cardiovascular disease in over 115,000 women with 14 years of follow-up. BMI was predictive of cardiac events. In addition, adjusting for baseline BMI as well as other prognostic factors, women who gained at least 5 kg of weight after age 18 years were at increased risk for cardiovascular disease compared with those whose weight was stable (RR for a weight gain of 5 to 7.9 kg, 1.25 [CI, 1.01 to 1.55]; RR for a weight gain of 8 to 10.9 kg, 1.64 [CI, 1.33 to 2.04]; RR for a weight gain of 11 to 19 kg, 1.92 [CI, 1.61 to 2.29]; and RR for a weight gain of 20 kg or more, 2.65 [CI, 2.17 to 3.22]) (83).

Rationale
  • A number of factors modify interpretation of BMI and waist circumference.

Ask patients about risk factors for obesity. 
  • Take a thorough history to determine:

    • If parents are or were overweight

    • The occurrence of any life events such as stopping smoking, pregnancy, surgery with disability, or recent injury

    • Snoring or daytime sleepiness

    • Membership in a minority population with high prevalence of obesity, such as black, Latino, or Polynesian

    • Level of physical activity

    • Medication history, looking for drugs that can promote weight gain

    • Alcohol consumption

    • Eating pattern, because skipping breakfast and eating late in the day are associated with being overweight

  • See table Drugs That Produce Weight Gain and Alternatives.

  • See figure Obesity Risk in Ethnic Groups.

Evidence
  • A 2005 systematic review for the USPSTF addressed screening and interventions for overweight children. Childhood BMI predicted adult weight, especially in older children and children with at least one obese parent. Overall, 10% of children age 2 to 5 years and 16% of those age 6 years and older were overweight, with higher rates among ethnic minorities. Children over the age of 13 years with BMI above the 95th percentile had greater than a 50% chance of having adult obesity. Studies of interventions to reduce obesity in children were small, with diverse interventions and limited follow-up times (10).

  • A case-control study of European patients with and without obesity identified several genetic markers including FTO, MC4R, and loci in NPC1 (22).

  • A follow-up study to the Lung Health Study assessed weight gain after smoking cessation. Change in smoking predicted change in weight; within a given year men who quit smoking gained a mean of 2.95 kg and women who quit smoking gained a mean of 3.09 kg (47).

  • A study assessed weight gain in a cohort of women. The risk for being overweight over a 10-year period increased by 60% to 110% in women who had live birth during the study period; weight gain increased in women with more live births (84).

  • A prospective cohort study evaluated predictors of weight gain. A high level of stress predicted weight gain at 6 years and, in older women, low levels of life satisfaction predicted weight gain (85).

  • A 2006 study evaluated rates of obesity among adults in the U.S. between 1999 and 2004. The prevalence of obesity was 30% among non-Hispanic whites, 45% for non-Hispanic blacks, and 36.8% among Mexican-Americans (23).

Rationale
  • Genetic and socioeconomic factors influence the prevalence of obesity.

Comments
  • For people taking medications that produce weight gain, alternatives may be available.

Measure BMI and look for comorbid conditions on physical exam. 
  • Measure weight and height and calculate BMI to classify patients:

    • Define normal-weight as BMI <25 kg/m2

    • Define overweight as BMI 25 to 29 kg/m2

    • Define obese as BMI ≥30 kg/m2

  • Consider measurement of waist circumference.

  • Look for physical findings associated with obesity conditions, including:

    • Hypertension

    • Endocrinopathies such as hypothyroidism and Cushing's syndrome

    • Reproductive disorders such as polycystic ovary disorders

    • Large neck circumference, somnolence, and facial plethora suggestive of sleep apnea

    • Phenotypic abnormalities suggesting rare genetic disorders in children

  • See BMI calculator.

  • See module Essential Hypertension.

  • See module Hypercortisolism.

  • See module Hypothyroidism.

  • See module Polycystic Ovary Syndrome.

  • See module Obstructive Sleep Apnea.

  • See table Clinical Features of the Metabolic Syndrome.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended measuring height and weight and calculating BMI at least annually. The guideline recommended defining overweight as a BMI >25.0 to 29.9 kg/m2 and obesity as a BMI ≥30 kg/m2 (67).

  • A 2006 NICE (UK) guideline on obesity recommended measuring BMI to diagnose obese and overweight patients, and stated that waist circumference may be used as well in patients with BMI <35 kg/m2 (86).

  • A 2012 guideline from the USPSTF recommended screening all adults for obesity and referring those with BMI ≥30 kg/m2 for intensive behavioral interventions (68).

  • A 2010 systematic review of the diagnostic accuracy of BMI compared with body fat percentage included 25 articles. BMI had pooled sensitivity of 50% (CI, 43% to 57%) and pooled specificity of 90% (CI, 86% to 94%) for the diagnosis of high body adiposity (70).

  • A cohort study assessed the prevalence of polycystic ovary disease in 113 consecutive women presenting for obesity treatment as a single center in Spain. The prevalence of polycystic ovary disease was 28.3% (CI, 20.0% to 36.6%) (87).

  • A study of 72 patients with morbid obesity undergoing evaluation for bariatric surgery found a prevalence of subclinical hypothyroidism of 25% (88).

  • A study of 78 obese patients referred for evaluation of sleep-disordered breathing found a prevalence of subclinical hypothyroidism of 11.5% (89).

Rationale
  • BMI defines patients as overweight or obese.

  • Identifying causes of obesity can show diseases for which specific treatment is needed or may become available.

Comments
  • Several genetic syndromes, such as Prader-Willi syndrome, have phenotypic features that make them recognizable, but most require genetic analysis (49; 90).

Test for comorbidities including diabetes and hyperlipidemia in obese patients.  
Evidence
  • A 2012 NICE (UK) guideline on diabetes risk assessment recommended screening for diabetes in high-risk patients, including those with obesity, using a fasting blood glucose or HbA1C (91).

  • A 2008 guideline from the USPSTF recommended screening for diabetes only in patients with blood pressure >135/80 mm Hg and does not specify screening obese patients (92).

  • A 2008 guideline from the USPSTF recommended screening all men age 35 years and older and other adults with obesity or other risk factors for CHD. The guideline does not recommend routine screening in women at any age without additional risk factors (93).

  • Metabolic syndrome can be diagnosed by several criteria. The metabolic syndrome and its individual components predicted the incidence of cardiovascular disease and stroke equally well (94).

Rationale
  • Lab testing can provide information not detectable on physical exam.

Comments
  • If a child's weight is above the 99th percentile for height and rising further above this upper bound, genotyping for genetic disorders associated with obesity may be considered. For example, children with high BMI may have genetic defects in melanocortin receptor or other genes (95).

Consider the broad range of conditions associated with unhealthy weight. 
Evidence
  • A cohort study assessed the prevalence of polycystic ovary disease in 113 consecutive women presenting for obesity treatment as a single center in Spain. The prevalence of polycystic ovary disease was 28.3% (CI, 20.0% to 36.6%) (87).

  • A study of 72 patients with morbid obesity undergoing evaluation for bariatric surgery found a prevalence of subclinical hypothyroidism of 25% (88).

  • A study of 78 obese patients referred for evaluation of sleep-disordered breathing found a prevalence of subclinical hypothyroidism of 11.5% (89).

  • Sleep studies can quantitate frequency of apneic episodes (96; 97) and indicate the need for C-PAP treatment; weight loss improves sleep apnea (98).

  • A cross-sectional study assessed risk factors for fatty liver disease. Obese participants were more likely than controls to have hepatic steatosis on ultrasound (75.8% vs. 16.4%; RR, 4.6 [CI, 2.5 to 11.0]). Obese participants who were also heavy drinkers were at even higher risk (RR, 5.8 [CI, 3.2 to 12.3]) (99).

Rationale
  • Many diseases can be identified or excluded through lab evaluation.

Comments
  • A 24-hour urinary measure for cortisol is the initial test for diagnosing Cushing's disease, to be followed by an overnight dexamethasone suppression test (100).

  • Karyotyping can detect abnormality at 15q11-13 present in Prader-Willi syndrome (90).

  • MRI/CT of the brain can detect pituitary or hypothalamic lesions.

  • Genotyping can detect melanocortin receptor defect (101), PPAR-γ defects, and leptin and leptin receptor deficiency (49).

Consider appropriate consultation if hypothalamic, endocrine, pulmonary, or genetic factors require evaluation. 
  • Refer to an endocrinologist if help is needed in evaluating patients with suspected Cushing's disease, polycystic ovary syndrome, or hypothyroidism.

  • Refer to a geneticist for evaluation of special obesities in children who may have Prader-Willi syndrome, Carpenter's syndrome, Bardet-Biedl syndrome, or other genetic syndromes associated with obesity.

  • Refer to a sleep lab to confirm diagnosis of sleep apnea.

Evidence
  • Mainly consensus.

  • Children with sleep apnea should have sleep studies and be evaluated for tonsillectomy before using C-PAP (102).

Rationale
  • Identification of special problems is important in providing optimal therapy.

Consider referring obese patients for specific lifestyle therapy.  
  • Consider referring obese patients for lifestyle therapy to:

    • Behavioral specialists such as clinical psychologists or trained dietitians

    • Self-help groups such as Weight Watchers, Take Off Pounds Sensibly (TOPS), or Overeaters Anonymous

  • Refer patients with a BMI ≥30 kg/m2 to intensive, multicomponent behavioral interventions.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended a comprehensive lifestyle program which includes behavioral strategies to help patients adhere to diet and exercise for at least 6 months in patients who would benefit from weight loss. The guideline also recommended referral to a dietician when possible (67).

  • A 2012 guideline from the USPSTF recommended that clinicians should offer or refer patients with BMI ≥30 kg/m2 to intensive, multicomponent behavioral interventions (68).

  • A 2005 Cochrane review of psychological interventions for overweight and obese patients included 36 studies with 3495 participants. Behavioral therapy was superior to placebo for weight loss, with a mean weight-loss difference of 2.5 kg (CI, 1.7 to 3.3), and the combination of behavioral therapy with diet and exercise was better than diet and exercise alone. Cognitive behavioral therapy with diet and exercise resulted in more weight loss than diet and exercise alone, with a mean of 4.9 kg more weight loss (CI, 2.4 to 7.3) (103).

Rationale
  • Behavioral therapists have more experience with weight loss therapy.

  • Exercise specialists have more training in the areas of weight loss and fitness.

  • Self-help groups provide long-term support.

Refer obese patients for surgical intervention when indicated. 
  • Refer obese patients to a surgical unit that has experience with bariatric surgery.

  • Note that such a team would optimally have an internist with experience caring for obese patients, a dietitian, and a behavior therapist or psychologist to help with perioperative problems.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended advising patients that bariatric surgery may be appropriate if they have BMI ≥40 kg/m2 or BMI ≥35 kg/m2 and at least one severe obesity-related comorbid condition (67).

  • A 2005 guideline from the American College of Physicians recommended surgery for obese patients with BMI >40 kg/m2 with comorbid complications for whom other therapies failed. The guideline recommended referring those patients to high-volume surgical centers (104).

  • A 2013 guideline from the American Association of Clinical Endocrinologists, Obesity Society, and American Society for Metabolic and Bariatric Surgery recommended bariatric surgery for patients with BMI ≥40 kg/m2 and patients with BMI ≥35 kg/m2 and at least one severe obesity-related comorbid condition (e.g., diabetes, hypertension, hyperlipidemia, sleep apnea). The guideline did not recommend specific procedures, but stated that, generally, laparoscopic procedures are preferred, and that options include laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion/duodenal switch (105).

Rationale
  • Bariatric surgery is most often performed in patients with comorbidities and carries significant risk.

  • A multidisciplinary team is best able to address all pertinent perioperative issues.

Hospitalize patients with serious complications of obesity. 
  • Hospitalize patients with:

    • Severe hypercapnia from alveolar hypoventilation requiring assisted ventilation

    • Symptomatic gallbladder disease requiring surgery

    • Acute cardiovascular events

Evidence
  • Acute oxygenation can produce apnea as respiratory drive shifts from low oxygen to CO2 (106).

Rationale
  • Complications of obesity-related disease may require measures not available in the outpatient setting.

Hospitalize obese patients who are undergoing bariatric surgery. 
Evidence
  • A 2013 guideline from the American Association of Clinical Endocrinologists, Obesity Society, and American Society for Metabolic and Bariatric Surgery made recommendations about various aspects of care before, during, and after bariatric surgery. The guideline recommended telemetry monitoring for 24 hours in patients at increased risk for myocardial infarction, staged postoperative meal progression under supervision of a dietician, monitoring of blood glucose and hydration status, and other interventions that require hospitalization (105).

Rationale
  • Complications of obesity need intensive inpatient care.

Comments
  • Complications of deep venous thromboembolism can be reduced by treatment with low-dose dalteparin (107).

Initiate behavioral therapy with diet and exercise in overweight patients who are motivated to lose weight.  
  • Recommend to overweight patients:

    • Behavioral therapy:

      • Recording food intake

      • Increasing physical activity

      • Rewards for success

    • Information about diets, emphasizing:

      • Amount and rate of weight loss, depending on degree of adherence to the diet

      • Importance of eating regularly

      • That at reduced energy intake under controlled conditions, diet composition is unimportant

      • That options include low-fat diets and low-carbohydrate diets

      • That portion-controlled foods provide an easy way to count calories using commercial formulas, bars, or frozen meals

    • Exercise:

      • For 30 to 60 minutes 5 or more days a week by increasing walking or other comparable activities

    • Self-help groups

    • Web-based tools, smartphone applications, or other electronic tools may facilitate behavioral change

  • Refer patients with a BMI ≥30 kg/m2 to intensive, multicomponent behavioral interventions.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended a calorie-restricted diet but did not favor any particular diet program (67).

  • A 2012 guideline from the USPSTF recommended screening all adults for obesity and referring those with BMI ≥30 kg/m2 for intensive multicomponent behavioral interventions (68).

  • A 2005 guideline from the American College of Physicians recommended counseling and behavior modification in obese patients, including counseling regarding diet and exercise. The guideline stated that drug therapy can be offered to patients who fail to meet weight targets with diet and exercise alone, after detailed discussion of the potential benefits and harms, and that surgery is an option for patients with BMI >40 kg/m2 and complications of obesity in whom diet and exercise have been ineffective (104).

  • A 2007 systematic review of dietary counseling for weight loss included 46 trials. In the meta-analysis there was overall net weight loss in the intervention groups of 1.9 BMI units (CI, 1.5 to 2.3), with weight loss over months 3 to 12 followed by weight regain in subsequent months (108).

  • A 2006 Cochrane review of exercise for overweight and obese patients included 43 trials with 3476 participants. Compared with no treatment, exercise resulted in small weight loss, and exercise combined with diet was more effective than diet alone, with mean difference of 1.1 kg of weight loss (109).

  • A 2005 Cochrane review of psychological interventions for overweight and obese patients included 36 studies with 3495 participants. Behavioral therapy was superior to placebo for weight loss (mean weight-loss difference, 2.5 kg [CI, 1.7 to 3.3]), and the combination of behavioral therapy with diet and exercise was better than diet and exercise alone. Cognitive behavioral therapy with diet and exercise resulted in more weight loss than diet and exercise alone, with a mean of 4.9 kg more weight lost (CI, 2.4 to 7.3) (103).

  • A 2011 evidence synthesis for the USPSTF addressed the management of overweight and obese adults. There were 38 trials of behavioral interventions and participants had average BMI 31.9 kg/m2. Overall, participants in behavioral interventions lost 3.0 kg more than control groups. Twelve trials addressed long-term weight loss, which was greater in the intervention group in 6 of the trials (110).

  • A 2006 systematic review of low-carbohydrate vs. low-fat diets included five trials with 447 participants. After 6 months, low-fat diets resulted in more weight loss than low-carbohydrate diets, with a mean difference of 3.3 kg (CI, 1.4 to 5.3), but after 12 months there was no significant difference between the groups (111).

  • A 2005 systematic review of commercial diets included studies of several programs, including Weight Watchers, OPTIFAST, and others. The largest study of Weight Watchers reported 3% body weight loss over 2 years. Studies of medically-supervised very low-calorie diets found significant weight loss (15% to 20% of body weight) among successful completers of the programs (112).

  • A 2007 Cochrane review of low-glycemic load and low-glycemic index diets for obesity included six trials with 202 participants; study duration was variable. Compared with control diets, low-glycemic diets resulted in more weight loss, with BMI difference of 1.3 kg/m2 (CI, 0.5 to 2.0) between the groups, and greater decrease in total and LDL cholesterol (113).

Rationale
  • Behavior therapy is the cornerstone of therapy for obesity.

  • Reduced energy intake is essential for weight loss and is one side of the energy balance equation.

  • Increasing physical activity helps increase energy expenditure, the other side of the energy balance.

  • Exercise can help maintain a lower weight.

Comments
  • A 2009 Cochrane review compared strategies for weight loss in children (114).

Consider drug therapy for patients with BMI ≥30 kg/m2, or ≥27 kg/m2 with comorbidities such as hypertension, diabetes, or dyslipidemia.  
  • Use metformin to treat obese patients with diabetes; consider its use in obese patients with prediabetes.

  • Consider using drug therapy with orlistat for obese patients with BMI ≥30 kg/m2 who:

    • Have failed with other treatments

    • Are using lifestyle modifications that have been unsuccessful or are no longer effective

  • Consider using newer drugs such as lorcaserin or phentermine/topiramate in select patients, recognizing that evidence of safety and efficacy is limited.

  • Consider using drug therapy for obese patients with BMI ≥27 kg/m2 who:

  • Consider discontinuing drug therapy, switching to another drug, or combining drugs:

    • If weight loss is less than 2 kg in 2 months

    • If weight loss is less than 5% after 6 months of therapy

    • If weight loss fails to remain less than 5% below baseline at 12, 18, or 24 months

  • Discuss potential side effects with patients considering drug therapy for obesity, and explain that long-term outcomes are generally unknown.

  • See table Drug Treatment for Obesity.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended pharmacotherapy as an option for patients with BMI ≥30 kg/m2, or ≥27 kg/m2 with comorbidities as an adjunct to comprehensive lifestyle interventions (67).

  • A 2005 guideline from the American College of Physicians recommended counseling and behavior modification in obese patients, including counseling regarding diet and exercise. The guideline stated that drug therapy can be offered to patients who fail to meet weight targets with diet and exercise alone, after detailed discussion of the potential benefits and harms, and that surgery is an option for patients with BMI >40 kg/m2 and complications of obesity in whom diet and exercise have failed. The guideline noted that options for pharmacological therapy include sibutramine, orlistat, phentermine, diethylpropion, fluoxetine, and bupropion (104).

  • A 2011 evidence synthesis for the USPSTF addressed the management of overweight and obese adults. There were 38 trials of pharmacotherapy, 18 evaluating orlistat and 3 evaluating metformin. Most trials of orlistat were of fair quality. Overweight or obese participants in the orlistat groups overall lost 3 kg more than those in the control groups over 12 months. Trials of metformin included participants with either prediabetes, polycystic ovary syndrome, or an elevated WHR. Two of the three studies found that the metformin group lost more weight (1.2 to 2.3 kg) than the control group and one study found equivalent weight loss in the groups (110).

  • A 2004 Cochrane review of long-term pharmacotherapy for overweight and obese patients included 11 studies of orlistat and 5 of sibutramine. Studies of both drugs had high rates of attrition during the weight loss phases (33% for orlistat and 33% for sibutramine). Compared with placebo, participants receiving orlistat lost 2.7 kg (CI, 2.3 to 3.1) and those receiving sibutramine lost 4.3 kg (CI, 3.6 to 4.9). Orlistat caused GI side effects and sibutramine caused elevated blood pressure and heart rate (115).

  • A 2005 Cochrane review of drugs for weight loss in patients with diabetes included 22 randomized trials assessing orlistat, sibutramine, and fluoxetine. Compared with control, orlistat (2 kg), sibutramine (5.1 kg), and fluoxetine (5.1 kg) all led to greater weight loss after 12 to 57 weeks' follow-up. Possible publication bias was noted (116).

  • A randomized, controlled trial compared lorcaserin to placebo in 3182 obese patients (average weight, 100 kg). After 1 year, patients randomly assigned to lorcaserin were randomly assigned to either lorcaserin or placebo. All patients received diet and exercise counseling. After 1 year, the lorcaserin group lost 3.6 kg more than the placebo group; more patients receiving lorcaserin lost at least 5% of body weight (NNT, 4). In year 2, patients from the lorcaserin group who were randomly assigned to placebo regained weight. There were no major harms due to the drug. This study had a high level of industry/sponsor involvement (117).

  • A randomized, controlled trial compared twice daily lorcaserin and placebo in 4008 obese or overweight patients; all patients received lifestyle modification. After 1 year, more patients in both lorcaserin groups lost at least 5% of body weight (NNT, ~5). There was slightly more weight lost in the group receiving twice daily lorcaserin. There were no major adverse effects (118).

  • A randomized trial of the effect of the combination of phentermine and topiramate on body weight in obese adults with comorbidities found weight loss at 56 weeks of 1.4 kg in the placebo group, 8.1 kg in the phentermine 7.5 mg/topiramate 46 mg group, and 10.2 kg in the phentermine 15 mg/topiramate 92 mg group, and differences in weight loss were statistically significant. Dry mouth, paresthesias, and constipation were common side effects in the active treatment groups (119).

Rationale
  • When lifestyle treatments are ineffective or the patient is unable to lose more weight, the addition of drug therapy may be helpful.

Comments
  • An FDA Advisory panel recommended approving the combination pill containing phentermine and topiramate in February 2012, and the combination of bupropion and naltrexone with a postmarketing outcomes trial in May 2012.

  • Marketing approval for sibutramine was withdrawn in Europe in January 2010; in October 2010, the manufacturer withdrew the drug from the U.S. market on the basis of data from the SCOUT study (120).

  • Diabetics treated with pramlintide (121; 122) or liraglutide (123) experience weight loss.

  • Bupropion is approved by the FDA as an antidepressant. The data showing weight loss are limited to three small clinical trials that do not meet FDA criteria for considering it a safe and effective drug to treat obesity.

  • Sympathomimetic drugs (phentermine, diethylpropion, benzphetamine, phendimetrazine) produce weight loss but are only FDA-approved for short-term treatment in the U.S. and are unavailable in Europe.

  • Phenylpropanolamine was withdrawn from the OTC market because of alleged stroke risk in women (124).

  • A 2008 meta-analysis of 15 trials of chitosan showed a small weight loss (weighted mean difference, -1.7 kg) and a decrease in total cholesterol and blood pressure (125).

  • A 2008 meta-analysis of 14 trials of glucomannan showed a small weight loss (weighted mean difference, -0.79 kg) and a decrease in total cholesterol, glucose, and triglycerides (126).

Recognize that OTC herbal preparations sold for weight loss have limited efficacy and safety data and most are likely ineffective. 
Evidence
  • A 2005 systematic review of complementary and alternative therapies for weight loss included six systematic reviews and 25 randomized trials. Most interventions (e.g., acupuncture, acupressure) were ineffective. Hypnotherapy, ephedra, and dietary supplements containing ephedrine had some evidence for mild efficacy (127).

  • A 2009 systematic review of acupuncture for obesity included 29 randomized trials in the meta-analysis, although most studies were of poor quality. Compared with control interventions, acupuncture led to more weight loss (1.72 kg [CI, 0.50 to 2.93]) (128).

  • A 2008 Cochrane review of chitosan for overweight or obese patients included 15 trials. Overall, in short-term trials chitosan resulted in more weight loss than control (1.7 kg [CI, 1.3 to 2.1]), with no major adverse events (125).

  • A 12-week randomized clinical trial with Garcinia cambogia, which provides hydroxycitrate, showed no greater weight loss than with placebo (129).

  • A 12-week, double-blind, randomized, controlled trial of green tea extract vs. placebo reduced body fat, systolic blood pressure, and LDL cholesterol in a Japanese study (130).

  • Both green tea extract and higher protein intake improved weight maintenance, but they were not additive (131).

  • A 1-year trial of conjugated linoleic acid was no more effective than placebo in preventing weight regain (132).

Rationale
  • Limited information about OTC drugs and herbal preparations limits their use in treating obesity.

Comments
  • The FDA removed ephedra-containing dietary supplements from the market because of safety concerns (133), but this was overturned in a court trial.

  • Health concerns exist with ma huang with and without caffeine (133; 134).

Consider surgical treatment for very obese patients (BMI ≥40 kg/m2 or ≥35 kg/m2 with comorbidities) in whom other measures have failed. 
  • Consider surgical treatment for patients with BMI ≥35 kg/m2 with comorbidities or ≥40 kg/m2 without comorbidities in whom attempts at weight loss, including drug therapy, were unsuccessful.

  • Consider various surgical options, but understand that while gastric banding and gastroplasty may have lower rates of side effects than duodenal switch or gastric bypass, they lead to less weight loss.

  • See figure Anatomy of a Roux-en-Y Bypass.

  • See figure Various Gastroplasty Techniques.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended advising patients that bariatric surgery may be appropriate if they have BMI ≥40 kg/m2 or ≥35 kg/m2 and at least one obesity-related comorbid condition (67).

  • A 2005 guideline from the American College of Physicians recommended surgery for obese patients with BMI >40 kg/m2 and comorbid complications for whom other therapies failed. The guideline recommended referring those patients to high-volume surgical centers (104).

  • A 2013 guideline from the American Association of Clinical Endocrinologists, Obesity Society, and American Society for Metabolic and Bariatric Surgery recommended bariatric surgery for patients with BMI ≥40 kg/m2 and patients with BMI ≥35 kg/m2 and at least one severe obesity-related comorbid condition (e.g., diabetes, hypertension, hyperlipidemia, sleep apnea). The guideline did not recommend specific procedures, but stated that, generally, laparoscopic procedures are preferred and that options include laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion/duodenal switch (105).

  • A 2004 systematic review of outcomes after bariatric surgery included 136 studies with 22,094 participants. Participants lost a mean of 61.2% (CI, 58.1% to 64.4%) of excess weight, including 47.5% in patients undergoing gastric banding, 61.6% in patients undergoing gastric bypass, 68.2% in patients undergoing gastroplasty, and 70.1% in patients undergoing biliopancreatic diversion or duodenal switch. Operative mortality rates ranged from 0.1% for restrictive procedures to 1.1% for biliopancreatic diversion or duodenal switch. Improvement of comorbidities was common overall: diabetes resolved in 76.8%, hypertension resolved in 61.7%, obstructive sleep apnea resolved in 85.7%, and hyperlipidemia improved in 70% of patients undergoing surgery (135).

  • A 2009 systematic review of bariatric surgery in obese patients with type 2 diabetes included 621 studies. Overall, there was weight loss of 38.5 kg with surgery. Diabetes resolved in 78.1% of patients and improved or resolved in 86.6% (136).

  • A prospective controlled study (137) and a retrospective chart study (138) showed that bariatric surgery reduces mortality by 30% to 54% with 7 to 10.9 years' follow-up; cardiovascular deaths were reduced 53% (139), and cancer incidence was decreased (140).

  • A prospective study evaluated the long-term effects of bariatric surgery in obese patients who sought surgery and either did or did not receive it, and additional randomly selected patients. After 6 years, patients who underwent surgery lost an average of 27.7% of body weight, compared with a gain of 0.2% in control patients who sought surgery and 0% in randomly selected controls. Those undergoing surgery were more likely to have remission of diabetes (OR, 16.5 and 21.5 compared with each control group) (141).

  • A retrospective cohort study evaluated the effect of bariatric surgery on mortality, comparing surgical patients with individuals with severe obesity who had obtained a driver's license. During a mean follow-up time of 7.1 years, in the adjusted model patients who underwent surgery were at lower risk for death (adjusted HR, 0.60 [CI, 0.45 to 0.67]) and death from coronary disease (HR, 0.41 [CI, 0.21 to 0.78]), diabetes (HR, 0.08 [CI, 0.01 to 0.47]), and cancer (HR, 0.40 [CI, 0.25 to 0.65]) (137).

  • A 2013 cost-effectiveness analysis evaluated bariatric surgery for patients with severe obesity; the reference case was a patient with BMI 44 kg/m2. Compared with standard care, all bariatric surgical procedures were cost effective, with incremental cost-effectiveness ratio ranging from $6200 to $17,300 per quality-adjusted life year (142).

Rationale
  • Surgery produces long-term weight loss that can be more than 25% of body weight in 1 year.

  • Lost weight tends to be regained only slowly, if at all.

  • Surgery improves quality of life.

Provide realistic weight loss goals and suggest weight loss goals of 5% to 10% of body weight.  
  • Inform patients that their body loss will reach a plateau at which resistance to weight loss counteracts the effect of therapy.

  • Suggest that weight losses of 5% to 10% are realistically attainable through behavioral therapy, diet, and drug therapy, and are associated with proven health benefits.

  • Indicate that maintaining long-term weight loss is difficult and that exercise is one of the best strategies.

  • Inform patients that weight losses of less than 5% suggest that a change in therapy should be made.

  • Inform patients that only surgery provides weight losses consistently above 10%.

Evidence
  • A 2013 guideline from the ACC, AHA, and The Obesity Society on the management of overweight and obesity in adults recommended advising patients with risk factors for cardiovascular disease who are overweight or obese that lifestyle changes resulting in loss of 3% to 5% of body weight can reduce the risk for diabetes or improve glycemic control, and that greater degrees of weight loss can reduce cholesterol and blood pressure (67).

  • A 1998 NIH clinical guideline on overweight and obese adults recommended a goal of 10% loss of body weight (44).

  • A 2002 narrative review discussed the evidence that moderate (5% of body weight) weight loss can improve comorbid conditions (143).

Rationale
  • Understanding the likely outcome of therapy can help avoid disappointment for both the patient and physician.

Recommend techniques to help patients adhere to lifestyle changes, including behavioral therapy and outside groups. 
  • Use ongoing office visits or ongoing behavioral therapy to reinforce or boost previously learned procedures, or refer patients to outside groups such as Weight Watchers, Take Off Pounds Sensibly (TOPS), or Overeaters Anonymous.

Evidence
  • A 2005 Cochrane review of psychological interventions for overweight and obese patients included 36 studies with 3495 participants. Behavioral therapy was superior to placebo for weight loss, with a mean weight-loss difference of 2.5 kg (CI, 1.7 to 3.3), and the combination of behavioral therapy with diet and exercise was better than diet and exercise alone. Cognitive behavioral therapy with diet and exercise resulted in more weight loss than diet and exercise alone, with a mean of 4.9 kg more weight lost (CI, 2.4 to 7.3) (103).

  • A 2005 systematic review of commercial diets included studies of several programs, including Weight Watchers, OPTIFAST, and others. The largest study of Weight Watchers reported 3% body weight loss over 2 years. Studies of medically-supervised very low-calorie diets found significant weight loss (15% to 20% of body weight) among successful completers of the programs (112).

Rationale
  • Additional strategies such as self-help groups improve long-term weight loss results.

Comments
  • Portion-controlled meals can be helpful (144; 145).

  • Self-help groups produce weight loss (146).

Provide advice on reducing weight gain when stopping smoking. 
  • Advise patients that weight gain during smoking cessation is common.

  • Counsel patients to exercise.

  • Consider drug therapy for smoking cessation in select patients to prevent weight gain.

  • See module Smoking Cessation.

Evidence
  • A 2012 Cochrane review evaluated strategies to prevent weight gain from smoking cessation. Medications including bupropion, fluoxetine, varenicline, dexfenfluramine, phenylpropanolamine, and naltrexone led to reductions in weight gain during treatment compared with control, but not long-term. A very low-calorie diet reduced weight gain in the short term. Weight-management education and cognitive behavioral therapy did not affect weight gain but did improve rates of smoking abstinence. Exercise interventions did not improve weight gain in the short term but did improve weight gain at 6 months (48).

Rationale
  • Weight gain is one reason people resume smoking.

Schedule follow-up to monitor weight loss and comorbid conditions in all obese patients. 
  • Follow patients every 1 to 3 months during active weight loss attempts.

  • Follow patients who are overweight or obese but who are not actively attempting to lose weight every 6 to 12 months.

  • Use scheduled follow-up to:

    • Monitor weight

    • Review all treatments

    • Monitor for drug side effects

    • Check for surgical complications when applicable

    • Monitor comorbid conditions

    • Address relapse

Evidence
  • Consensus.

Rationale
  • Treatment of obesity requires ongoing perseverance and cooperation between the patient and caregivers.

Table Grahic Jump Location
 Laboratory and Other Studies for Obesity

Swipe to view table

TestNotes
Blood glucoseFor evaluating possibility of diabetes
CreatinineMay exclude use of metformin
Lipid profileLow HDL cholesterol and high triglycerides are associated with central obesity
24-hour urinary cortisolIf Cushing's disease is suspected
LH and FSH ratioIf polycystic ovaries are suspected
TSHWomen over age 50 years
ElectrocardiogramObese individuals are at high risk for sudden death suggesting concerns about arrhythmias
Ultrasound of gallbladder if patient has symptomsObtain if symptomatic. Gallstones are common in obesity and may be precipitated by rapid weight loss
Ultrasound of ovariesIf polycystic ovaries are suspected
MRI/CT of hypothalamusIf hypothalamic obesity suspected
KaryotypeIf Prader-Willi syndrome is suspected
GenotypingFor rare syndromic and nonsyndromic forms of obesity
Sleep studyFor evaluation of sleep apnea

CT = computed tomography; FSH = follicle-stimulating hormone; HDL = high-density lipoprotein; LH = luteinizing hormone; MRI = magnetic resonance imaging; TSH = thyrotropin stimulating hormone.

Table Grahic Jump Location
 Differential Diagnosis of Obesity

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DiseaseCharacteristics
ObesityNonspecific, often slow weight gain and family history
Hypothalamic injuryHeadache; endocrine dysfunction; hypothalamic symptoms
Order MRI or CT of brain
Cushing's diseaseCentral obesity; hypertension; plethora; striae
Measure urinary cortisol and overnight dexamethasone suppression test
Polycystic ovary syndromeOligomenorrhea; hirsutism; increased LH/FSH ratio; high testosterone levels; low SHBG; insulin resistance
Order ultrasound of ovaries to detect cysts, consider measurement of androgens
Drug-induced obesityAntipsychotics; antidepressants; antiepileptics; steroids; serotonin antagonists; antidiabetic drugs
Detected by history
Smoking cessationFormer smoker
Many patients gain weight after quitting smoking
HypothyroidismHigh TSH; low thyroxine; lethargy; cold intolerance; bradycardia
Growth hormone deficiencyShort stature; low growth hormone
Low growth hormone is associated with increase in subcutaneous fat and visceral fat
Prader-Willi syndromeHypotonia, small hands and feet, lowered mental function, obesity, hypogonadism
Genetic disorder; requires karyotype for confirmation (90)
Bardet-Biedl syndromePolydactyly, mental retardation, hypogonadism, renal impairment, obesity, retinitis pigmentosa
Autosomal recessive: six genetic variants are known, one of which is a defect in the chaperonin gene (147)
Ahlstrom's syndromeSimilar to Bardet-Biedl, but with normal stature and without mental retardation
Autosomal recessive (148)
Carpenter's syndromeAcrochondrodysplasia makes this syndrome recognizable clinically with flat nasal bridge, polydactyly, syndactyly, and genu valgum
Autosomal recessive (148)
Cohen's syndromeTruncal obesity beginning in mid-childhood: high nasal bridge, short philtrum, narrow hands and feet, and dysplastic ears
Autosomal recessive (148)
MC4R defectsNonsyndromic; detected on genetic screening of markedly overweight individuals
Genotyping needed in which the DNA is sequenced over the region of interest to identify abnormalities
Leptin deficiency or leptin receptor deficiencyInfancy onset; low leptin or absent leptin receptor
Genotyping needed in which the DNA is sequenced over the region of interest to identify abnormalities

CT = computed tomography; DNA = deoxyribonucleic acid; FSH = follicle-stimulating hormone; LH = luteinizing hormone; MC4R = melanocortin-4 receptor; MRI = magnetic resonance imaging; SHBG = sex hormone-binding globulin; TSH = thyrotropin stimulating hormone.

Table Grahic Jump Location
 Drug Treatment for Obesity

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Drug or Drug ClassDosingSide EffectsPrecautionsClinical Use
Orlistat (Xenical [Rx], Alli [OTC])Xenical: 120 mg tid with meals. Alli: 60 mg tid with mealsFlatulence, fecal urgency, steatorrhea, abdominal pain, nauseaAvoid with pregnancy. Decreases absorption of fat-soluble vitamins. May interfere with absorption of certain drugs.
Lorcaserin (Belviq)10 mg bidHeadache, dizziness, fatigue, nausea, constipation. Risk for: serotonin syndrome, NMSAvoid with: pregnancy, CrCl<30. Caution with: drugs that affect serotonin, severe hepatic disease, CrCl<50, diabetes. Inhibits CYP2D6.Limited safety and efficacy data
Phentermine/Topiramate (Qsymia)3.75/23 mg, 7.5/46 mg 11.25/69 mg, 15/92 mg, dosed 1 capsule qd in the AMParesthesia, dizziness, dysgeusia, insomnia, constipation, xerostomia, hypokalemia, nephrotoxicity, metabolic acidosis, nephrolithiasisAvoid abrupt withdrawal. Avoid with: pregnancy, glaucoma, hyperthyroidism, MAOI therapy, alcohol, severe hepatic disease. Use low dose with: moderate-severe CKD or hepatic disease.Limited safety and efficacy data
Sympathomimetic aminesCNS side effects, hypertension, tachycardia, constipation, xerostomia, dysgeusia, toleranceAvoid abrupt withdrawal. Avoid with: pregnancy, cardiac disease, severe hypertension, glaucoma, MAOI therapy, hyperthyroidism. Caution with: drugs affecting serotonin, CKD, hepatic disease, seizure disorder, substance abuse, depression, diabetes. Monitor for: cardiac valvulopathy, pulmonary hypertensionDo not combine agents. FDA approved for short-term use
Diethylpropion (Tenuate, Tenuate Dospan)Immediate-release: 25 mg tid 1 hr before meals. Extended-release: 75 mg qd mid-AMPsychosis, bradycardia, arrhythmias, blurred vision
Phentermine (Adipex-P, Suprenza) Phentermine resin complex15-37.5 mg qd in the AMPPH, cardiac valvulopathy, nausea, rare psychosis
Benzphetamine (Didrex)25-50 mg qd mid-AM or mid-afternoon. Maximum 50 mg tid
Phendimetrazine (Bontril, Bontril PDM)Regular-release: 17.5-35 mg bid-tid before meals. Extended-release: 105 mg qd before breakfastCardiac valvulopathy, ischemic events, blurred vision, nauseaAvoid with history of stroke

AM = morning; bid = twice daily; CKD = chronic kidney disease; CNS = central nervous system; CrCl = creatinine clearance; CYP = cytochrome P450 isoenzyme; FDA = Food and Drug Administration; GI = gastrointestinal; MAOI = monoamine oxidase inhibitor; NMS = neuroleptic malignant syndrome; OTC = over-the-counter (nonprescription); PO = oral; PPH = primary pulmonary hypertension; q12hr = every 12 hours; qd = once daily; qid = four times daily; Rx = prescription; SC = subcutaneous; SCr = serum creatinine; tid = three times daily.

ACP Smart Medicine provides key prescribing information for practitioners but is not intended to be a source of comprehensive drug information.

Table Grahic Jump Location
 Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk

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BMI (kg/m2)Obesity ClassDisease Risk (Relative to Waist Circumference)
NormalLarge
Men ≤40 in (≤102 cm)
Women ≤35 in (≤88 cm)
>40 in (>102 cm)
>35 in (>88 cm)
Underweight<18.5
Normal18.5-24.9
Overweight25.0-29.9IncreasedHigh
Obesity30.0-34.9IHighVery High
35.0-39.9IIVery highVery High
Extreme Obesity≥40IIIExtremely HighExtremely High

BMI = body mass index.

Table Grahic Jump Location
 Clinical Features of the Metabolic Syndrome

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Risk FactorDefining Level
Abdominal obesity (waist circumference)
Men>102 cm (>40 in)
Women>88 cm (>35 in)
HDL cholesterol
Men<40 mg/dL
Women<50 mg/dL
Triglycerides≥150 mg/dL
Fasting glucose≥110 mg/dL
Blood pressure≥130/≥85 mmHg

HDL = high-density lipoprotein.

Table Grahic Jump Location
 Drugs That Produce Weight Gain and Alternatives

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CategoryDrugs That Cause Weight GainPossible Alternatives
AntipsychoticsThioridazine , Olanzapine , Quetiapine , Risperidone , ClozapineMolindone , Haloperidol , Ziprasidone
Antidepressants
Tricyclics; quadricyclicsAmitriptyline , Nortriptyline , Imipramine , MirtazapineProtriptyline or atypical antidepressants ( Bupropion , Nefazodone )
Selective serotonin reuptake inhibitorsParoxetineFluoxetine , Sertraline
AnticonvulsantsValproate , Carbamazepine , GabapentinTopiramate , Lamotrigine , Zonisamide
Antidiabetic drugsInsulin ( regular insulin , insulin aspart , insulin lispro , insulin glulisine , isophane insulin [NPH] , lente insulin , ultralente insulin , insulin glargine , insulin detemir , insulin lispro, insulin lispro protamine , insulin aspart, insulin aspart protamine , regular insulin, isophane insulin [NPH] , semilente insulin , protamine zinc insulin [PZI] )
Sulfonylureas , Thiazolidinediones
Acarbose , Miglitol , Metformin
AntimigrainePizotifen*
, cyproheptadine
Timolol
AntihypertensivesPropranolol , TerazosinACE inhibitors , Calcium channel blockers , Selective β-blockers
Steroid hormonesContraceptives , Glucocorticoids, Progestational steroidsBarrier methods
, Nonsteroidal anti-inflammatory agents
β-Adrenergic blockersMetoprolol , PropranololCarvedilol (149)

* Not available in the U.S.

ACE = angiotensin-converting enzyme.

© Copyright 2001 George A. Bray

Table Grahic Jump Location
 Some Genetic Syndromes of Obesity with Hypogonadism and Mental Retardation

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FeaturePrader-WilliBardet-BiedlAhlstromCohenCarpenter
InheritanceSporadic
Two thirds have defect
Autosomal
recessive
Autosomal
recessive
Probably autosomal recessiveAutosomal recessive
StatureShortNormal
Infrequently short
Normal
Infrequently short
Short or tallNormal
ObesityGeneralized
Moderate to severe
Onset 1-3 years
Generalized
Early onset
1-2 years
Truncal
Early onset
2-5 years
Truncal
Mid childhood
Age 5
Truncal
Gluteal
Mid childhood
CranofaciesNarrow bifrontal diameter
Almond shaped eyes
Strabismus
V-shaped mouth
High arched palate
Not distinctiveNot distinctiveHigh nasal bridge
Arched palate
Open mouth
Short philtrum
Acrocephaly
Flat nasal bridge
High arched palate
LimbsSmall hands and feet
Hypotonia
PolydactylyNo abnormalitiesHypotonia
Narrow hands and feet
Polydactyly
Syndactyly
Genu valgum
Reproductive status1 degree hypogonadism1 degree hypogonadismHypogonadism in males but not in femalesNormal gonadal function or hypogonadotrophic hypogonadism2 degrees hypogondaism
Other featuresEnamel hypoplasia
Hyperphagia
Temper tantrums
Nasal speech
Dysplastic ears
Delayed puberty
Mental retardationMild to moderateNormal IQMildSlight
Table Grahic Jump Location
 Genotyping for Rare Syndromic and Nonsyndromic Forms of Obesity

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GeneMutationsChromosomeNo. and SexAgeWeight (kg)BMI (kg/m2)Reference
Pro-opiomelanocortin (POMC)G701T and C deletion at nt 7133 exon 3
C3804A exon 2
2p231 F
1 M
3-730
50
150
Melanocortin
4-Receptor
C705A (Tyr 35X)
ΔCTCT frame shift nt 631-634 codon 211
Y5X (Also D37V)
(S30F; P78L; T112M; R165W;G252S; I317T)
18q21.34 F
5 M
4-5828-57151; 152; 153
LeptinDeletion at codon 133
C to T codon 105 exon 3
7q314 F
2M
2-3429-13032-5695; 154; 155
Leptin receptorG to A exon 161p313 F13-19133-16652 to 72156
Prohormone convertase-1G483R
A to C intron 5
5q15-q211 F336157
Peroxisome proliferator-activated receptor-γP115Q3p251 F
3 M
32-7438-47158

BMI = body mass index.

Table Grahic Jump Location
 Summary of Data on Metabolic and Herbal Dietary Supplements

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Mineral or Herbal ProductUsual NameClinical TrialsComments
Minerals and metabolic products
Chromium picolinateChromiumMeta-analysis of 10 double-blind RCTs involving patients with BMI 28-33 kg/m2 showed weight loss of 1.1-1.2 kg over 6-14 weeksInsulin cofactor
Trial data relies heavily on one trial
In one trial in patients with diabetes, chromium slowed weight regain
Hydroxymethyl butyrateHMB2 RCTs reported significant differences in fat mass reductionInhibits protein breakdown in vitro
Further studies are needed
PyruvatePyruvate2 RCTs showed no significant effects on body weightIntermediary in glucose metabolism
Conjugated linoleic acidCLA13 RCTs lasting 6 months or less showed little evidence for weight loss“Conjugated” refers to location of double bonds at C10-12 rather than C9-11
There is concern about hepatic toxicity
CalciumCalcium; dairySmall trials have suggested that the effect of dairy may reduce fat. Larger trials with dairy or calcium have notIncreasing supplemental calcium from 0 to 2000 mg/d reduced BMI
Herbal dietary supplements
Ephedra sinicaEphedra3 RCTs show significant effect on reduction in body weightRCT with pure ephedrine and caffeine showed significant effects
Green tea extractEpigallocatechin gallate (EGCG)3 RCTs show a small increase in oxygen consumption and a small or no effect on body weightInhibits catechol-O-methyltransferase
Garcinia cambogiaGarcinia cambogia1 RCT showed no effect, but smaller studies have been suggestiveContains hydroxycitric acid
Pausinystalia yohimbeYohimbine3 RCTs give conflicting resultsα2-adrenergic receptor antagonist
Hoodia gordoniiHoodiaWeb site reports one small 15-day trial with weight lossAfrican cactus extract
Active ingredient is a steroidal glycoside
Citrus aurantiumBitter orange3 trials show no efficacyRisk of blood pressure increase
Fiber products
ChitosanChitosan14 trials lasting 4 weeks showed a significant 1.4-kg weight lossAcetylated chitin from crustaceans
Amorphophallus konjacGlucomannan1 RCT showed more weight loss
Cyamopsis tetragonolobusGuar gumMeta-analysis of 11 trials showed no effectGalactomannan
Plantago psylliumPsyllium1 RCT showed no effectCommon fiber source

BMI = body mass index; RCT = randomized, controlled trial.

Review based on data from 127 and 159.

© Copyright 2006 George A. Bray

  • Anatomy of a Roux-en-Y Bypass A small 50 mL pouch is made in the upper stomach, which is closed from the lower stomach with two staple lines. A Roux-en-Y loop is made with the jejunal end anastomosed to the small pouch. The gastric contents and the duodenal contents meet up when the two segments anastomose.
  • Various Gastroplasty Techniques In each of these procedures staple lines are used to separate the upper and lower stomach except for a small anastomotic opening. The most popular is the vertical-banded gastroplasty where the esophagus is elongated with a surgical staple line through the upper stomach paralleling the lesser curvature. At the lower end of the staple line the entry into the lower stomach is reinforced with a Mylar ring.
  • Body Mass Index (BMI)
  • Obesity Risk in Ethnic Groups
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ACE

angiotensin-converting enzyme

AHRQ

Agency for Healthcare Research and Quality

ALT

alanine aminotransferase

AST

aspartate aminotransferase

BMI

body mass index

C-PAP

continuous positive airway pressure

CDC

Centers for Disease Control and Prevention

CHD

Coronary heart disease

CI

confidence interval

CT

computed tomography

DNA

deoxyribonucleic acid

FDA

Food and Drug Administration

FSH

follicle-stimulating hormone

FTO

fat mass and obesity-associated gene

HDL

high-density lipoprotein

HR

hazard ratio

LDL

low-density lipoprotein

LH

luteinizing hormone

MC4R

melanocortin-4 receptor

MRI

magnetic resonance imaging

NAFLD

nonalcoholic fatty liver disease

NICE

National Institute for Health and Care Excellence

NIH

National Institutes of Health

NNT

number needed to treat

NPC1

Niemann-Pick C1 gene

OR

odds ratio

OTC

over the counter

PPAR-γ

peroxisome proliferator-activated receptor

RR

relative risk

SCOUT

Sibutramine Cardiovascular Outcome Trial

SHBG

sex hormone-binding globulin

TSH

thyrotropin stimulating hormone

USPSTF

United States Preventive Services Task Force

WHR

waist-to-hip ratio


Guidelines

Comparative Guidelines: Screening for Diabetes

American Heart Association/American College of Cardiology/The Obesity Society: 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society

Cardiovascular evaluation and management of severely obese patients undergoing surgery. A science advisory from the American Heart Association (2009)

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report (NIH Publication No. 98-4083, 1998)

Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

Evaluating Parents and Adult Caregivers as “Agents of Change” for Treating Obese Children: Evidence for Parent Behavior Change Strategies and Research Gaps: A Scientific Statement from the American Heart Association (2012)

Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (NICE clinical guideline 43, 2006)

Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians (2005)

Preventing type 2 diabetes: risk identification and interventions for individuals at high risk (NICE public health guidance 38, 2012)

Screening for and management of obesity in adults: U.S. Preventive Services Task Force Recommendation Statement (2012)

Screening for Obesity in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement (2009)

Screening for Type 2 Diabetes Mellitus in Adults: U.S. Preventive Services Task Force Recommendation Statement (2008)

Systematic Reviews

Acupuncture for obesity: a systematic review and meta-analysis

Association between obesity and kidney disease: A systematic review and meta-analysis

Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies

Association of Overweight With Increased Risk of Coronary Heart Disease Partly Independent of Blood Pressure and Cholesterol Levels: A Meta-analysis of 21 Cohort Studies Including More Than 300 000 Persons

Bariatric Surgery: A Systematic Review and Meta-analysis

Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies

Chitosan for overweight or obesity (Cochrane review)

Complementary therapies for reducing body weight: a systematic review

Diagnostic performance of body mass index to identify obesity as defined by body adiposity: a systematic review and meta-analysis

Effectiveness of Interventions Aimed at Reducing Screen Time in Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents: An Updated, Targeted Systematic Review for the USPSTF

Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence

Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials

Efficacy and safety of low-carbohydrate diets: a systematic review

Exercise for overweight or obesity (Cochrane review)

Interventions for preventing obesity in children (Cochrane review)

Interventions for preventing weight gain after smoking cessation (Cochrane review)

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese adults (Cochrane review)

Interventions to prevent obesity in children and adolescents: a systematic literature review

Is sleep duration associated with childhood obesity? A systematic review and meta-analysis

Long-term pharmacotherapy for obesity and overweight (Cochrane review)

Low glycaemic index or low glycaemic load diets for overweight and obesity (Cochrane review)

Maternal Obesity and Risk of Gestational Diabetes Mellitus

Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis

Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis

Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications

Meta-analysis: pharmacologic treatment of obesity

Meta-analysis: surgical treatment of obesity

Meta-analysis: the effect of dietary counseling for weight loss

Outcomes of Maternal Weight Gain (Evidence Reports/Technology Assessments, No. 168)

Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus (Cochrane review)

Protein intake from 0 to 18 years of age and its relation to health: a systematic literature review for the 5th Nordic Nutrition Recommendations

Psychological interventions for overweight or obesity (Cochrane review)

Screening for and Management of Obesity and Overweight in Adults (Evidence Syntheses, No. 89)

Strategies to Prevent Weight Gain Among Adults (Comparative Effectiveness Reviews, No. 97)

Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions

Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States

The effect of breastfeeding on mean body mass index throughout life: a quantitative review of published and unpublished observational evidence

Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies

Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis

DOI: 10.7326/d161
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Authors and Disclosures:
George A. Bray, MD has been a consultant for Vivus Corporation, received grants from the NIH and USDA, and receives royalties for Obesity: Origins and Solutions. George A. Bray, MD has been a consultant for Vivus Corporation, received grants from the NIH and USDA, and receives royalties for Obesity: Origins and Solutions.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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