Obesity Acp

Obesity
Physician Writers
Adam Gilden Tsai, MD, MSCE
Thomas A. Wadden, PhD
Section Editors
Deborah Cotton, MD, MPH
Darren Taichman, MD, PhD
Sankey Williams, MD
Health Consequences
page ITC3-2
Screening and Prevention
page ITC3-3
Diagnosis
page ITC3-4
Treatment
page ITC3-6
Practice Improvement
page ITC3-14
Tool Kit
page ITC3-14
Patient Information
page ITC3-15
CME Questions
page ITC3-16
The content of In the Clinic is drawn from the clinical information and education
resources of the American College of Physicians (ACP), including PIER (Physicians
Information and Education Resource) and MKSAP (Medical Knowledge and SelfAssessment Program). Annals of Internal Medicine editors develop In the Clinic
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Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can
consult http://pier.acponline.org, http://www.acponline.org/products_services/
mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.
CME Objective: To review current evidence for the health consequences, screening
and prevention, diagnosis, treatment, and practice improvment of obesity.
The information contained herein should never be used as a substitute for clinical
judgment.
2013 American College of Physicians
Downloaded From: http://annals.org/ by Mohammed Patwary on 01/10/2015
In theClinic
In the Clinic
n estimated 36% of adults and 17% of children and adolescents in the

United States are obese. Obesity is a serious health problem that has
physical and psychosocial consequences. It increases health care costs to
employers and reduces productivity. Rates of obesity in the United States and
throughout the world have increased dramatically over the past 40 years and
continue to rise in many countries.
Efforts to prevent and reduce obesity have met significant challenges. However, research has begun to identify dietary and behavioral strategies to promote
healthy eating and increased physical activity. Two pharmacologic agents for
the treatment of obesity were approved by the U.S. Food and Drug Administration (FDA) in 2012, the first new medications to be approved in 13 years.
Bariatric surgery as a treatment for severe obesity has become safer.
Internal medicine physicians have an important role to play in reducing obesity
in their patients. Internists can assist with weight management by highlighting
the health benefits of a 510% reduction in initial weight, helping patients set
appropriate goals, providing intensive behavioral interventions (or referring patients to those interventions), and prescribing weight loss medication or referring for bariatric surgery in selected patients. Internists also play a critical role
in monitoring and managing obesity-related comorbid conditions.
Health
health problems are
Consequences What
associated with overweight and
Obesity-Related Health
Problems
Metabolic effects
Endocrine: Prediabetes and type 2
diabetes, dyslipidemia (low highdensity lipoprotein and high
triglyceride levels)
Cardiovascular: Hypertension,
coronary artery disease, stroke,
congestive heart failure, atrial
fibrillation, venous stasis, venous
thromboembolic disease (deep
venous thrombosis, pulmonary
embolism)
Cancer: Multiple types, most
commonly colorectal,
postmenopausal breast,
endometrial
Gastrointestinal: Gastroesophageal
reflux disease, erosive gastritis,
cholelithiasis, nonalcoholic fatty
liver disease
(continued on next page)
obesity?
Obesity, particularly severe obesity,
affects nearly every organ system
of the human body. Most obesityrelated medical conditions are
caused by the metabolic effects of
adipose tissue, but some are caused
by the increased body mass itself
(see the Box: Obesity-Related
Health Problems). Obesity is associated with an overall increase in
mortality. The relationship between weight and mortality follows a J-shaped curve, with the
lowest mortality traditionally believed to occur with a body mass
index (BMI) of 20.024.9 kg/m2
(i.e., normal weight).
The relationship between obesity and
mortality is somewhat controversial. A recent meta-analysis of 97 studies concluded that overweight (BMI, 25.029.9 kg/m2)
was associated with slightly lower mortality risk than was the purportedly normal
BMI range, and that class 1 obesity was associated with mortality similar to normal
BMI (1). The results of the meta-analysis
have provoked debate and a renewed examination of what constitutes optimal
body weight.
ITC3-2
In the Clinic
The relationship between obesity

and mortality is complex, with
BMI accounting for only part of
the risk. Other factors that may
affect mortality include body fat
distribution (i.e., visceral fat vs,
subcutaneous fat, not captured by
BMI), age, sex, race and ethnicity,
smoking, associated health conditions (including unknown existing
conditions), and fitness level.
Larger studies with longer followup periods have been the most
likely to show deleterious effects
of obesity (beginning at a BMI of
30 kg/m2). Regardless of whether
overweight or class I obesity are
associated with increased mortality, they are strongly related to development of comorbid conditions,
including type 2 diabetes, hypertension, sleep apnea, and other
cardiovascular disease (CVD).
What is the evidence that
intentional weight loss improves
health outcomes?
There is strong evidence that intentional weight loss reduces the
burden of obesity-related comorbid disease and improves overall
health-related quality of life. For
Annals of Internal Medicine 3 September 2013
example, weight loss of 510% of

starting weight reduces the risk
for type 2 diabetes among at-risk
persons (2).
Results from the multicenter randomized
Look AHEAD trial (n = 5145) showed that
moderate weight loss (8.6% of starting
weight after 1 year, 6.15% after 4 years) led
to better physical function, decreased sleep
apnea, improved sexual function, improved mood, reduced urinary incontinence, improved health-related quality of
life, and reduced need for medication for
CVD risk factors, compared with a usual
care condition.
The Look AHEAD study was stopped in

late 2012 because it did not show lower
CVD morbidity and mortality in the intervention group than in the usual care
group (3). However, the Swedish Obese
Subjects (SOS) study showed that patients
who had bariatric surgery for severe obesity and who maintained a loss of
1525% of initial weight 10 years later
had a 29% reduction in all-cause mortality, compared with a control group that
was matched on 18 characteristics. The
major reductions in mortality resulted
from decreases in cardiovascular- and
cancer-related deaths (4).
Health Consequences... Obesity increases the risk for many chronic medical conditions. Moderate to severe obesity (BMI 35 kg/m2) clearly increases the risk for
mortality. Modest weight loss (510% of initial weight) reduces the burden of
comorbid disease in overweight or obese patients. Larger weight loss (1530%)
may reduce mortality.
Obesity-Related Health
Problems (continued)
Renal: Nephrolithiasis, proteinuria,
chronic kidney disease
Genitourinary: In women, the
polycystic ovarian syndrome,
infertility, pregnancy
complications; in men, benign
prostatic hypertrophy, erectile
dysfunction
Neurologic: Migraine, pseudotumor
cerebri
Infections: Greater severity of
influenza with morbid obesity,
skin and soft tissue infections
Mechanical effects
Pulmonary: Obstructive sleep apnea,
restrictive lung disease
Musculoskeletal: Osteoarthritis, low
back pain
Psychosocial effects
Depression and anxiety
Social stigmatization
CLINICAL BOTTOM LINE
Should clinicians screen patients

for overweight or obesity?
The U.S. Preventive Services Task
Force recommends that clinicians
screen all adult patients for obesity
and offer intensive, multicomponent behavioral interventions, or
refer patients to programs that offer
such interventions (5).
Insulin and certain other antiglycemic

medications (sulfonylureas, thiazolidenediones) are associated with some weight
gain, but in the context of a weight loss intervention (e.g., the Look AHEAD trial) persons receiving insulin can lose nearly as
much weight as those not on insulin (6).
One randomized trial showed that use of
bupropion after smoking cessation reduced weight gain after 1 and 2 years (7).
How can patients prevent obesity?

Internists can sometimes help
their patients prevent weight gain
by reviewing concurrent medications. Several medications are associated with weight gain (see the
Box: Medications Associated With
Weight Gain). The largest increases are associated with glucocorticoids and second-generation
antipsychotics, but many commonly used medications also result in
weight gain. Smoking cessation
also increases body weight by an
average of 35 kg in the first year.
(However, patients should be
counseled to prioritize smoking
cessation.)
In adults, obesity prevention

behaviors include reading food
labels, eating smaller portions,
eating 5 servings of fruits and vegetables per day, eating adequate
amounts of fiber (25 g/d), and
exercising for 4560 minutes per
day. Other behaviors associated
with less weight gain include reducing job stress (8), limiting car
commuting (9), and getting adequate sleep (69 h/night) (10).
Most of these results are derived
from observational studies.
3 September 2013
Annals of Internal Medicine
Screening and
Prevention
A study that combined 3 cohorts with a

total of 120 877 people followed for 1220
years each found that weight gain was
1. Flegal KM, Kit BK, Orpana H, Graubard BI.

Association of allcause mortality with
overweight and obesity using standard
body mass index categories: a systematic
review and metaanalysis. JAMA.
2013;309:71-82.
[PMID: 23280227]
2. Knowler WC, BarrettConnor E, Fowler SE,
et al; Diabetes Prevention Program Research Group. Reduction in the incidence
of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med.
2002;346:393-403.
[PMID: 11832527]
3. Wing RR, Bolin P,
Brancati FL, et al;
Look AHEAD Research Group. Cardiovascular effects of
intensive lifestyle intervention in type 2
diabetes. N Engl J
Med. 2013;369:14554. [PMID: 23796131]
ITC3-3
In the Clinic
Medications Associated With

Weight Gain
Glucocorticoids (prednisone)
Diabetes medications (insulin,
sulfonylureas, thiazolidindiones,
meglitinides)
First-generation antipsychotics
(thioridazine)
Second generation antipsychotics
(risperidone, olanzapine,
clozapine, quetiapine)
Neurologic and mood stabilizing
agents (carbamazepine,
gabapentin, lithium, valproate)
Antihistamines (especially
cyproheptadine)
Antidepressants (paroxetine,
citalopram, amitriptyline,
nortriptyline, imipramine,
mirtazapine)
Hormonal agents (especially
progestins, e.g.
medroxyprogesterone)
Beta-blockers (especially
propranolol)
Alpha-blockers (especially terazosin)
most strongly associated with intake of

potato chips, potatoes, red meat, and sugar-sweetened beverages and was inversely
associated with intake of vegetables, fruits,
whole grains, nuts, and yogurt (11).
In a randomized crossover trial, sleep deprivation (5.5 h/night vs. 8.5 h) reduced the
amount of weight lost during a calorierestricted diet and increased both loss of
lean body mass and neuroendocrine markers of hunger (12).
Emerging evidence suggests that

social and physical environments
affect weight. Evidence is mixed on
whether proximity to supermarkets
improves dietary intake and/or
weight. Having a friend or close
family member with obesity seems
to increase the risk for being obese

(13). Offspring of women who
have significant weight gain during
pregnancy or gestational diabetes
are at greater risk for being obese in
childhood (14).
In a randomized trial, 4498 low-income,
mostly African American women were assigned to a control group, receipt of a
housing voucher, or receipt of a housing
voucher that could only be redeemed in a
low-poverty area (where <10% of residents were poor). After 1214 years, the
low-poverty voucher group had lower
rates of moderate to severe obesity (BMI
35 kg/m2) than the control group and
lower rates of type 2 diabetes than either
of the other 2 groups (15).
Screening and Prevention... Clinicians should screen patients for obesity and refer them to intensive interventions for treatment. They should also review their
patients medication lists to assess whether changing a medication could reduce
weight gain. Certain behaviors can prevent weight gain, including several that are
not directly related to eating or exercise, such as adequate sleep.
Diagnosis
4. Sjstrm L, Narbro K,
Sjstrm CD, et al;
Swedish Obese Subjects Study. Effects of
bariatric surgery on
mortality in Swedish
obese subjects. N
Engl J Med.
2007;357:741-52.
[PMID: 17715408]
5. Moyer VA; U.S. Preventive Services Task
Force. Screening for
and management of
obesity in adults: U.S.
Preventive Services
Task Force recommendation statement. Ann Intern
Med. 2012;157:3738. [PMID: 22733087]
6. Pi-Sunyer X, Blackburn G, Brancati FL,
et al; Look AHEAD
Research Group. Reduction in weight
and cardiovascular
disease risk factors in
individuals with type
2 diabetes: one-year
results of the look
AHEAD trial. Diabetes Care.
2007;30:1374-83.
[PMID: 17363746]
How do clinicians diagnose

obesity?
Both the National Institutes of
Health (NIH) and the World Health
Organization (WHO) recommend
using BMI to diagnose overweight
and obesity. In the general population, BMI correlates well with total
adiposity, as well as with morbidity
and mortality. The accepted U.S. definitions of overweight and of classes
1, 2, and 3 obesity are 2529.9kg/m2,
3034.9 kg/m2, 3539.9 kg/m2, and
40.0 kg/m2, respectively (16). Class
3 obesity is also referred to as extreme or severe obesity, replacing
the earlier term morbid.
and South Asian patients (e.g., East

Indians). The AsiaOceania criteria
for obesity differ from those used by
the NIH and the WHO. Specifically, normal weight is defined as a
BMI of 18.522.9 kg/m2, overweight as 23.024.9 kg/m2, and
obese as 25.0 kg/m2. By contrast,
disease risk may be lower in African
Americans than in whites at the
same BMI.
When can BMI be misleading in

terms of health risk?
The diagnosis of obesity must be individualized. Risk for diabetes begins
to increase at a BMI of 23 kg/m2 for
East Asian (e.g., Chinese, Japanese)
Body fat is normally about 12%

higher in women than in men at the
same BMI (17). The higher level of
body fat in women, along with assessment of waist circumference (discussed later) and metabolic risk, must
be taken into account when determining whether obesity is adversely
affecting health. BMI may also be
misleading in elderly patients. Older
persons at a given BMI have a higher
risk for obesity-associated conditions
ITC3-4
In the Clinic
(e.g., diabetes) than younger persons.

This is because of the loss of muscle
mass in older patients (so called sarcopenic obesity). In elderly patients,
regular exercise has at least as important a role in maintaining good
health and function as does weight
loss (18). BMI may also be misleading in elite athletes, whose elevated
weight may be attributable to increased lean mass, which does not
increase risk.
When and how should clinicians
measure waist circumference?
Waist circumference provides
information on central adiposity beyond that provided by BMI. Central
adiposity correlates well with visceral
adiposity, which elevates the risk for
such obesity-related diseases as diabetes, hypertension, and nonalcoholic
fatty liver disease. Clinicians generally should measure waist circumference in patients who are overweight
or have class 1 obesity. However,
waist measurement does not usually
add additional risk information if the
BMI is < 25 kg/m2 or 35 kg/m2.
Waist circumference should be measured over the iliac crests in a horizontal plane after the patient exhales
following a normal breath. A waist
circumference of 35 inches (88 cm)
for women and 40 inches (102 cm)
for men is considered elevated.
What elements of the history
and physical examination are
important in patients with
obesity?
Secondary causes of obesity should
be ruled out but are uncommon in
adults. Traumatic brain injury, if accompanied by hypothalamic injury,
can cause weight gain. Several rare
genetic syndromes can cause obesity
in adults, most of which are associated with developmental delay or with
other abnormal physical features. The
patients medication list should also
be reviewed, as discussed previously.
The history of the present illness
should include a weight history (at
5- to 10-year intervals), including
3 September 2013
life events associated with significant weight gain (e.g., pregnancy).

Clinicians should inquire about previous weight loss attempts, with a
particular focus on successful efforts
(i.e., resulting in a loss of 5% of
body weight), as well as reasons
attributed by the patient for recidivism. The medical history and review of systems should focus on the
major comorbid conditions listed in
the Box. The physical examination
can be brief and focused (Table 1).
7. Hays JT, Hurt RD, Rigotti NA, et al. Sustained-release

bupropion for pharmacologic relapse
prevention after
smoking cessation. a
randomized, controlled trial. Ann Intern Med.
2001;135:423-33.
[PMID: 11560455]
8. Brunner EJ, Chandola
T, Marmot MG.
Prospective effect of
job strain on general
and central obesity
in the Whitehall II
Study. Am J Epidemiol.
2007;165:828-37.
[PMID: 17244635]
9. Lopez-Zetina J, Lee H,
Friis R. The link between obesity and
the built environment. Evidence from
an ecological analysis of obesity and vehicle miles of travel
in California. Health
Place. 2006;12:65664. [PMID: 16253540]
10. Patel SR, Hu FB.
Short sleep duration
and weight gain: a
systematic review.
Obesity (Silver
Spring). 2008;16:64353. [PMID: 18239586]
11. Mozaffarian D, Hao T,
Rimm EB, Willett WC,
Hu FB. Changes in
diet and lifestyle and
long-term weight
gain in women and
men. N Engl J Med.
2011;364:2392-404.
[PMID: 21696306]
12. Nedeltcheva AV,
Kilkus JM, Imperial J,
Schoeller DA, Penev
PD. Insufficient sleep
undermines dietary
efforts to reduce adiposity. Ann Intern
Med. 2010;153:43541. [PMID: 20921542]
Is a family history of obesity

important?
A strong family history of obesity,
particularly severe obesity, suggests a genetic component, although genetic polymorphisms
are more common than the genetic abnormalities responsible for
many of the rare syndromes. Genetics accounts for approximately
4070% of the variability in BMI,
although genetic factors alone are
unlikely to explain the explosive
increase in obesity and severe
obesity in the United States over
the past 30 years. Clinicians
should help patients understand
that obesity and its related diseases are responsive to lifestyle
modification even if a genetic
predisposition is suspected. The
reader is referred elsewhere for
Clinical Findings in Patients With Obesity

Organ/Organ System
Physical Finding
Associated Condition
Skin
Acne/hirsutism
The polycystic ovary

syndrome
Insulin resistance
The Cushing syndrome
Hypothyroidism
Hypertension, deconditioning
Atrial fibrillation
Congestive heart failure
Abdominal obesity
Venous stasis, pulmonary
hypertension
Pseudotumor cerebri
Thyroid
Cardiovascular system
Abdomen
Extremities
Eyes
Musculoskeletal system
Acanthosis nigricans
Striae*
Nodules/goiter
Blood pressure/pulse
Cardiac rhythm
S3/S4 gallop
Waist circumference
Peripheral edema
Papilledema
Proximal muscle weakness
Osteoporosis
* Striae in the Cushing syndrome are classically purple in color and broad-based.
In the Clinic
ITC3-5
more detailed information on the

role of genetics (19).
13. Christakis NA, Fowler

JH. The spread of
obesity in a large social network over 32
years. N Engl J Med.
2007;357:370-9.
[PMID: 17652652]
14. Wrotniak BH, Shults
J, Butts S, Stettler N.
Gestational weight
gain and risk of overweight in the offspring at age 7 y in a
multicenter, multiethnic cohort study.
Am J Clin Nutr.
2008;87:1818-24.
[PMID: 18541573]
15. Ludwig J, Sanbonmatsu L, Gennetian
L, et al. Neighborhoods, obesity, and
diabetes-a randomized social experiment. N Engl J
Med. 2011;365:150919. [PMID: 22010917]
16. Clinical Guidelines
on the Identification,
Evaluation, and
Treatment of Overweight and Obesity
in Adults-The Evidence Report. National Institutes of
Health. Obes Res.
1998;6 Suppl 2:51S209S.
[PMID: 9813653]
17. Gallagher D, Heymsfield SB, Heo M, et al.
Healthy percentage
body fat ranges: an
approach for developing guidelines
based on body mass
index. Am J Clin
Nutr. 2000;72:694701.
[PMID: 10966886]
18. Villareal DT, Chode S,
Parimi N, et al.
Weight loss, exercise,
or both and physical
function in obese
older adults. N Engl J
Med. 2011;364:121829. [PMID: 21449785]
What laboratory tests or other

evaluations should be done in
patients with obesity?
Routine laboratory studies in patients with obesity should include
measurement of levels of fasting
glucose and/or hemoglobin A1c,
thyroid-stimulating hormone, liver-associated enzymes, and fasting
lipids. Optional tests depend on
the results of the history, physical
examination, and initial blood
tests and may include electrocardiography, echocardiography,
overnight sleep study, right upper
quadrant ultrasound (fatty liver),
transvaginal ultrasound (ovarian
cysts), or imaging and laboratory
tests to assess the ypothalamic
pituitaryadrenal axis for the uncommon patient with suspected
hypothalamic obesity.
Beyond measurement of BMI and
waist circumference, no additional
methods are recommended for
routine assessment of body composition or adiposity. Bioelectrical impedance analysis is not substantially
more accurate than estimates based
on demographic and physical characteristics alone (e.g., age, sex,
weight, height). Dual energy x-ray
absorptiometry provides a more accurate estimate of body composition.
Computed tomography or magnetic
resonance imaging can accurately
quantify central and visceral adiposity,
but both are expensive, and computed tomography exposes the patient
to radiation. Assessment of resting
metabolic rate, together with level of
physical activity, can provide an estimate of total energy requirements,
but in a randomized trial (n = 111)
did not increase weight loss when
added to a behavioral weight loss intervention (20). Energy requirements
can be estimated using equations
that incorporate information about
weight, height, demographic factors,
and level of physical activity. Patients
and clinicians can easily access the
Harris-Benedict equation online.
Diagnosis... BMI should be used to diagnose obesity and should be combined with
other patient characteristics to assess weight-related health risk. Waist circumference should also be measured in patients with BMI 2534.9 kg/m2 to assess for
abdominal obesity, which increases health risk. The history and physical examination should focus primarily on weight-related conditions, weight trajectory, and
previous weight loss attempts. Lab testing should include screening for diabetes,
nonalcoholic fatty liver disease, thyroid dysfunction, and dyslipidemia.
Treatment
How should clinicians counsel

patients about their weight?
Excess weight is a sensitive subject
for many overweight and obese persons. Studies indicate that patients
prefer that clinicians use the terms
weight or weight problem, in
lieu of obesity, to discuss the topic.
Clinicians can start by asking,
Could we talk about your weight
today? The conversation should
provide patients an opportunity to
discuss their concerns, rather than

simply being told that they need to
reduce (which most already know).
A key challenge for clinicians is to
offer patients hope about weight
management. This sometimes can
be achieved by explaining that a loss
of only 510% of initial weight may
significantly improve comorbid conditions. Patients frequently believe
they must lose 25% or more of their
starting weight to be successful (21).
ITC3-6
In the Clinic
The Centers for Medicare & Medicaid Services (CMS), in its 2011 decision to reimburse primary care
providers for obesity treatment, recommended using a 5A approach: Assess (weight and risk factors); advise
(weight loss, personalize the recommendation to the patient); agree (on a
target for behavior change); Assist
(with a referral); Arrange (follow-up).
An algorithm developed by the National Heart, Lung, and Blood Institute can assist patients and clinicians
in selecting an intervention (Table 2).
The algorithm recommends a comprehensive program of lifestyle modification for patients with a BMI 25
kg/m2 who need to reduce (16).
Weight loss medications may be considered with persons with a BMI
30 kg/m2 (or 27 kg/m2 with a comorbid condition) who are unable to
reduce satisfactorily with lifestyle
modification alone. Surgery is an option for persons with a BMI 40
kg/m2 (or 35 kg/m2 with a comorbid condition).
What are the lifestyle
modifications for obesity?
Comprehensive lifestyle modification programs for obesity have 3
components: diet, physical activity,
and behavior modification (Table 3)
(22). Behavior modification provides a set of principles and techniques, such as goal-setting and
recordkeeping. Obese persons
should typically try to achieve an
energy deficit of 5001000 kcal/d
to induce a corresponding weight
loss of approximately 12 pounds

(0.51 kg) per week. The U.S. Preventive Services Task Force has recommended only high-intensity
lifestyle modification programs (defined as 1226 sessions in the first
year [5]) because lower-intensity programs have not shown consistent effectiveness. High-intensity lifestyle
modification programs provide weekly individual or group treatment sessions (of 3060 minutes) for 1626
weeks (16, 22). High-intensity interventions produce mean weight loss of
approximately 69 kg (approximately
69% of initial weight). For example,
the Diabetes Prevention Program
produced a mean loss of approximately 7 kg in 6 months (2).
A recent meta-analysis concluded that
programs that provided 1226 sessions
over 1 year produced mean weight loss of
47 kg, whereas those that offered <12 sessions averaged 1.54 kg.
What dietary strategies are used

in lifestyle modification?
Calorie restriction is the principal
method for inducing weight loss
because most patients find it far
easier to reduce their food intake
by 5001000 kcal/d than they do
to increase their energy expenditure by an equivalent amount. For
example, to achieve a 500 kcal/d
energy deficit, on a daily basis a
patient could either eliminate two
20-ounce sugar-sweetened drinks
or walk 5 miles. Moreover, research suggests that in adults,
greater weight loss can be achieved
via dietary interventions than by
A Guide to Selecting Treatment*

Treatment
BMI
Diet, physical activity,

and behavior therapy
Pharmacotherapy
2526.9 kg/m2
2729.9 kg/m2
3034.9 kg/m2
3539.9 kg/m2
40 kg/m2
With comorbid
conditions
With comorbid
conditions
With comorbid
conditions
With comorbid
conditions
Surgery
BMI = body mass index.

* From reference 41.
3 September 2013
In the Clinic
ITC3-7
19. Farooqi IS, ORahilly

S. Genetic evaluation
of obese patients. In:
Bray GA, Bouchard C,
eds. Handbook of
Obesity: Clinical Applications, 3rd ed.
New York: Informa;
2008:45-54.
20. McDoniel SO,
Wolskee P, Shen J.
Treating obesity
with a novel handheld device, computer software program, and Internet
technology in primary care: the
SMART motivational
trial. Patient Educ
Couns. 2010;79:18591. [PMID: 19699049]
21. Foster GD, Wadden
TA, Vogt RA, Brewer
G. What is a reasonable weight loss? Patients expectations
and evaluations of
obesity treatment
outcomes. J Consult
Clin Psychol.
1997;65:79-85.
[PMID: 9103737]
22. Wadden TA, Webb
VL, Moran CH, Bailer
BA. Lifestyle modification for obesity:
new developments
in diet, physical activity, and behavior
therapy. Circulation.
2012;125:1157-70.
[PMID: 22392863]
Key Components of a Comprehensive Lifestyle Modification Program to Achieve and Maintain a 710% Weight Loss at 1 Year
or Longer
Component
Weight Loss
Maintenance
Frequency, duration, and type of

treatment contact
At least 1226 visits in person or by

telephone in the first y, as recommended by
the USPSTF (Internet/e-mail contact yields
smaller weight loss); group or individual
contact
Low-calorie diet (12001500 kcal for persons
<250 lb; 15001800 kcal for those 250 lb);
typical macronutrient composition: <30% fat
(<7% saturated fat); 15% protein; remainder
from carbohydrates (diet composition may
vary based on individual needs or preferences)
180 min/wk of moderately vigorous aerobic
activity (e.g., brisk walking); strength training
also desirable
Daily monitoring of food intake and physical
activity using paper or electronic diaries;
weekly weight monitoring; structured
curriculum of behavior change (e.g., diabetes
prevention program); regular feedback from
an interventionist
Contact every other wk for 52 wk (or longer)

(monthly contact may be adequate); group or
individual contact
Dietary prescription
Physical activity prescription
Behavior therapy prescription
Hypocaloric diet to maintain reduced body

weight; typical macronutrient composition
similar to that for weight loss
200300 min/wk of moderately vigorous

aerobic activity (e.g., brisk walking); strength
training also desirable
Occasional to daily monitoring of food intake
and physical activity using similar diaries;
twice-weekly to daily weight monitoring;
curriculum of behavior change, including
relapse prevention and individualized
problem solving; periodic feedback from an
interventionist
interventions focusing on physical

activity. Physical activity, however,
is an important component of
weight management programs and
is particularly important in maintaining weight loss in adults (see
below). Clinicians can help overweight and obese persons identify
the daily calorie target needed to
lose weight by using equations to
estimate daily energy expenditure,
and then subtracting 500 to 1000
kcal from this value.
monitoring and the difficulty in

maintaining the greater weight loss.
23. Lichtman SW, Pisarska K, Berman ER, et

al. Discrepancy between self-reported
and actual caloric intake and exercise in
obese subjects. N
Engl J Med.
1992;327:1893-8.
[PMID: 1454084]
24. Hooper L, Abdelhamid A, Moore HJ,
et al. Effect of reducing total fat intake
on body weight: systematic review and
meta-analysis of randomised controlled
trials and cohort
studies. BMJ.
2012;345:e7666.
[PMID: 23220130]
25. Foster GD, Wyatt HR,
Hill JO, et al. Weight
and metabolic outcomes after 2 years
on a low-carbohydrate versus low-fat
diet: a randomized
trial. Ann Intern Med.
2010;153:147-57.
[PMID: 20679559]
This calorie prescription, however,

assumes that persons can precisely
measure food intake. Studies have
shown that overweight and obese
persons underestimate caloric intake by approximately 40% per day
(23). Because of this finding, men
and women who weigh <250 lb
(113.6 kg) are commonly prescribed 12001499 kcal/d, whereas
those 250 lb are prescribed
15001800 kcal/d (to compensate
for underestimation of calorie intake). Greater calorie restriction, as
achieved with very-low-calorie diets
(<800 kcal/d), produces greater,
more rapid initial weight loss but is
not recommended for most patients
because of the cost of closer medical
Fat has 9 calories per gram, compared with 4 calories per gram for
carbohydrate and protein. Therefore,
if not compensated by increased intake of other calorie sources, restriction of fat intake facilitates caloric
restriction, which in turn should lead
to greater weight loss.
ITC3-8
In the Clinic
A variety of diets can be incorporated in lifestyle modification programs. A unifying feature of several
diets is consumption of foods that
are low in energy density (number
of calories per weight of food), such
as fruits, vegetables, lean protein,
and whole grain carbohydrates that
are high in fiber.
Low-fat diets
A recent meta-analysis that included 33 randomized trials (n = 74 000 participants) concluded that participants assigned to low-fat
diets ( 30% of calories from fat) lost 1.6 kg
more than persons assigned to control
diets (with 2843% of calories from fat) (24).
Low-carbohydrate diets
Low-carbohydrate diets typically

provide fewer than 50 grams of carbohydrate per day (< 10% of total
calories from carbohydrate for a

2000-calorie diet). These diets experienced renewed popularity in the
early 2000s after publication of 2
randomized trials showing greater
short-term weight loss with an
Atkins-type diet (25, 26). However,
2 larger randomized trials, done
since those initial studies, showed
that results of a low-carbohydrate
diet was similar to calorie-restricted
versions of a low-fat diet or to a
Mediterranean diet (25, 26).
Meal-replacement diets
Meal replacements (shakes, meal

bars) and portion-controlled entrees
are an easy way to count calories
and to simplify meal preparation.
A meta-analysis of 6 randomized trials
concluded that a partial meal replacement regimen (replacing 2 meals per day
with a shake, plus eating fruits and vegetables during the day) led to an additional 2.53 kg of weight loss beyond a prescribed diet with the same number of
calories from self-selected food (27).
Which diet is best for long-term

weight loss?
Most evidence suggests that diets
that differ in macronutrient content
produce similar amounts of weight
loss over the long term. Thus, a
calorie-deficit diet that follows federal dietary guidelines (5060% of
calories from complex carbohydrate) and that emphasizes foods
that are widely considered to be
healthy (e.g., vegetables, nuts, fish)
should serve as the initial choice for
most patients.
A randomized trial (n = 811) assigned patients in a 2 x 2 fashion to diets with average
or high-protein content (15% or 25%) and
to low fat or high fat (20% or 40%), with carbohydrate making up the remainder. After
2 years, weight loss was similar in all 4
groups, and attendance at group sessions
correlated more closely with weight loss
than treatment group assignment (28).
What is the role of exercise in

weight loss and maintenance?
Regular exercise is critical for overall health, but in randomized trials
3 September 2013
contributed only 13 kg of weight

loss when combined with a structured diet program. Exercise seems
to be more important for maintaining lost weight than for initial
reduction. Persons who are able to
perform 275 minutes per week
(about 40 minutes/day) of exercise
are significantly more likely to
maintain weight loss over time.
Aerobic and resistance training exercise combined may have further
health benefits beyond either type
of exercise alone (29).
How can clinicians assess
readiness for weight loss?
Relatively little evidence exists to
guide clinicians on which patients are
most ready to participate in highintensity obesity treatment programs.
The consensus among bariatric clinicians is that patients must be committed to monitoring their food
intake and physical activity, be free of
untreated major depression, and not
in the middle of a major life event.
A practical approach to screen for
readiness to participate in a highintensity program is to ask patients to
monitor their food intake and physical activity for at least 1 week.
What makes maintaining weight
loss so difficult, and what
improves long-term results?
After completing a 6-month program, patients on average regain
one third of lost weight in the ensuing year, with continued regain
over time. Previously, it was assumed that regression to old behavior patterns explained weight
regain. However, a recent study
found that 1 year after a substantial weight loss, levels of hormones
that stimulate hunger (e.g., ghrelin) remained elevated, and levels
of hormones that mediate satiety
(e.g., leptin, amylin) remained depressed (30). These results suggest
a physiologic basis for weight regain. Some data suggest that obese
persons who have lost weight burn
fewer calories than persons with
the same lean body mass who were
In the Clinic
ITC3-9
26. Shai I, Schwarzfuchs

D, Henkin Y, et al; Dietary Intervention
Randomized Controlled Trial (DIRECT)
Group. Weight loss
with a low-carbohydrate, Mediterranean, or low-fat
diet. N Engl J Med.
2008;359:229-41.
[PMID: 18635428]
27. Heymsfield SB, van
Mierlo CA, van der
Knaap HC, Heo M,
Frier HI. Weight
management using
a meal replacement
strategy: meta and
pooling analysis
from six studies. Int J
Obes Relat Metab
Disord. 2003;27:53749. [PMID: 12704397]
28. Sacks FM, Bray GA,
Carey VJ, et al. Comparison of weightloss diets with different compositions of
fat, protein, and carbohydrates. N Engl J
Med. 2009;360:85973. [PMID: 19246357]
29. Church TS, Blair SN,
Cocreham S, et al. Effects of aerobic and
resistance training
on hemoglobin A1c
levels in patients
with type 2 diabetes:
a randomized controlled trial. JAMA.
2010;304:2253-62.
[PMID: 21098771]
30. Sumithran P, Prendergast LA, Delbridge E, et al. Longterm persistence of
hormonal adaptations to weight loss.
N Engl J Med.
2011;365:1597-604.
[PMID: 22029981]
never obese, thus impeding further

weight loss (31).
Continued participation in a
structured weight management
program (that offers at least
monthly and preferably twicemonthly treatment sessions) can
help patients maintain lost weight.
Other behaviors associated with
successful maintenance of weight
loss include engaging in physical
activity 60 minutes/day most
days of the week; monitoring
body weight frequently; eating a
reduced-calorie diet; and recording food intake periodically (particularly in response to weight
regain). These are the behaviors
practiced by members of the National Weight Control Registry,
all of whom have lost at least
30 lb (13.6 kg) and maintained
the loss for 1 year or more (32).
31. Leibel RL, Rosenbaum M, Hirsch J.

Changes in energy
expenditure resulting from altered
body weight. N Engl
J Med. 1995;332:6218. [PMID: 7632212]
32. Wing RR, Hill JO.
Successful weight
loss maintenance.
Annu Rev Nutr.
2001;21:323-41.
[PMID: 11375440]
33. Wadden TA,
Berkowitz RI,
Womble LG, et al.
Randomized trial of
lifestyle modification
and pharmacotherapy for obesity. N
Engl J Med.
2005;353:2111-20.
[PMID: 16291981]
34. James WP, Caterson
ID, Coutinho W, et al;
SCOUT Investigators.
Effect of sibutramine
on cardiovascular
outcomes in overweight and obese
subjects. N Engl J
Med. 2010;363:90517. [PMID: 20818901]
35. Hendricks EJ, Greenway FL, Westman EC,
Gupta AK. Blood
pressure and heart
rate effects, weight
loss and maintenance during longterm phentermine
pharmacotherapy
for obesity. Obesity
(Silver Spring).
2011;19:2351-60.
[PMID: 21527891]
When is pharmacotherapy
indicated for treatment of
obesity?
Pharmacotherapy is appropriate
for patients with a BMI 30 kg/m2
or those with a BMI 27 kg/m2
who have a significant weightrelated condition, such as type 2
diabetes or hypertension (16). Patients should be screened carefully
for contraindications to weight
loss medications. Ideally, patients
receiving weight loss medication
should pursue a structured program
of lifestyle modification, as this approximately doubles the weight
loss achieved (33).
sympathomimetic agent, patients

need to be followed closely to ensure that increases in blood pressure and pulse do not occur, as this
could increase risk for CVD,
thereby offsetting the other benefits of weight loss. (Sibutramine,
another agent with sympathomimetic effects, was removed
from U.S. and European markets
in 2010 for this reason [34]).
Phentermine is only approved for
short-term use in the United
States, which is commonly interpreted as 12 weeks. However,
some clinicians use the drug on a
long-term basis. One wellconducted observational study did
not show significant increases in
blood pressure or pulse among
patients receiving phentermine
for 1 year compared with a control group with similar weight
loss (35). Less commonly used
sympatho-mimetic agents are listed in Table 4.
Phentermine-topiramate
Phentermine is the most commonly prescribed weight loss drug in

the United States. Because it is a
Phentermine-topiramate (Qsymia,
Vivus Inc.) is a fixed-dose combination of these 2 drugs, both prescribed in a lower dose than as
monotherapy, with the goal of reducing side effects from either
agent alone. (Topiramate is an
FDA-approved agent for treatment
of seizures and was observed to
cause weight loss as a side effect.)
Of the currently approved agents,
phentermine-topiramate produces
the most weight loss (811% of
initial weight). Common side effects include paresthesias, change
in taste (topiramate), dry mouth,
constipation, and insomnia (phentermine). Contraindications include nephrolithiasis (topiramate)
as well as uncontrolled blood
pressure, resting tachycardia, or established CVD (phentermine). Because heart rate increased slightly
in clinical trials (0.61.6 beats/ min),
the manufacturer is performing a
large, prospective clinical trial to
further assess risk. Topiramate is
category X in pregnancy; women of
ITC3-10
The FDA approved 2 obesity agents

in 2012, phentermine-topiramate
and lorcaserin. A third agent,
bupropion-naltrexone, was given an
approvable decision by the FDA in
2012, subject to a long-term randomized trial of cardiovascular safety. Currently approved weight loss
agents are shown in Table 4.
Phentermine
In the Clinic
4. Currently Approved Weight Loss Agents

Agent
Mechanism
Dose
Side Effects
Contraindications
Notes
Phentermine*
Sympathomimetic
1537.5 mg/d
Dry mouth, headache,

constipation, tachycardia,
insomnia
FDA Schedule IV
Diethylproprion*
Benzaphetamine*
Sympathomimetic
Sympathomimetic
2575 mg/d
2050 mg TID
Similar to phentermine
Established cardiovascular
disease, uncontrolled
hypertension, glaucoma,
hyperthyroidism, or active
drug abuse
Phendimetrazine*
Sympathomimetic
Phenterminetopiramate*
Sympathomimetic
(phentermine);
appetite reduction/
changes in taste of
food (topiramate)
Serotonin 5HT2C
agonist
17.535 mg BID to
TID (max 70 mg/d)
3.75/23 mg, 7.5/
46 mg, 15/92 mg
Same as phentermine,
plus paresthesias,
altered taste, dizziness
Same as phentermine,
plus pregnant or trying
to become pregnant,
or recent nephrolithiasis
Monthly birth
control tests
recommended
10 mg BID
Headache, back pain,

dizziness, fatigue,
nasopharyngitis,
nausea, constipation,
dry mouth
Oily stools, fecal discharge,
flatus, fat-soluble vitamin
deficiency
Severe depression,
established cardiac
valvular disease
Caution with
serotonergic
drugs (e.g., SSRIs,
SNRIs)
Use of immune suppressive

medications; caution with
concurrent warfarin
Take vitamin
supplement 2 h
before/after drug
Lorcaserin
Orlistat
Intestinal lipase
inhibitor
60 mg TID (OTC) or
120 mg TID
(prescription)
FDA Schedule IV
Use lowest
effective dose;
FDA Schedule III
FDA Schedule III
BID = twice daily; FDA = U.S. Food and Drug Administration; OTC = over-the-counter; SNRI = serotoninnorepinephrine reuptake inhibitor; SSRI = selective
serotonin reuptake inhibitor; TID = three times daily.
* Monitor blood pressure and pulse.
reproductive age must use a highly

reliable form of birth control and
have monthly pregnancy tests while
taking the drug.
In the CONQUER trial, 2487 overweight and
obese persons with at least 2 risk factors for
CVD were randomized to placebo or phentermine-topiramate 7.5/46 mg or phentermine-topiramate 15/92 mg (36). Weight loss
at 1 year was 1.2%, 7.8%, and 9.8% of initial
weight, respectively. The SEQUEL extension
study, which continued with patients from
CONQUER in a double-blind fashion, observed weight loss at 2 years of 1.8%, 9.3%,
and 10.5%, respectively (37).
Lorcaserin
Lorcaserin (Belviq, Arena Pharmaceuticals) is an agonist of the

5HT2C receptor in the brain,
which helps to regulate appetite.
The drug was designed to avoid
serotonin agonism in the heart,
which was the mechanism determined to cause cardiac valve disease
in some patients who received
dexfenfluramine or fen-phen
(fenfluramine-phentermine) in the
3 September 2013
1990s. (Phentermine was not identified as a cause of valvulopathy

[38]). Lorcaserin must be used with
caution in patients receiving drugs
with serotonergic mechanisms of
action, such as selective serotonin
reuptake inhibitors and serotonin
norepinephrine reuptake inhibitors.
In the BLOOM trial, 3182 persons were assigned to placebo or lorcaserin (10 mg)
twice daily. At 1 year, weight loss was 2.2%
and 5.8% of initial weight, respectively (39).
In the BLOOM and BLOOM-DM trials,
echocardiograms done on 2472 patients at
1 year and 1127 patients at 2 years showed
no increased risk for valvular disease.
Orlistat
Orlistat is available both as a prescription medication (120 mg 3

times daily) and as an over-thecounter agent (60 mg 3 times
daily). It induces weight loss by reducing absorption of fat from the
gastrointestinal tract. The modest
weight loss (34% greater than
placebo, similar to lorcaserin) and
side-effect profile (e.g., oily stools,
In the Clinic
ITC3-11
36. Gadde KM, Allison

DB, Ryan DH, et al.
Effects of low-dose,
controlled-release,
phentermine plus
topiramate combination on weight
and associated comorbidities in overweight and obese
adults (CONQUER): a
randomised, placebo-controlled, phase
3 trial. Lancet.
2011;377:1341-52.
[PMID: 21481449]
37. Garvey WT, Ryan DH,
Look M, et al. Twoyear sustained
weight loss and
metabolic benefits
with controlled-release
phentermine/topiramate in obese and
overweight adults
(SEQUEL): a randomized, placebo-controlled, phase 3 extension study. Am J
Clin Nutr.
2012;95:297-308.
[PMID: 22158731]
38. Connolly HM, Crary
JL, McGoon MD, et
al. Valvular heart disease associated with
fenfluramine-phentermine. N Engl J
Med. 1997;337:5818. [PMID: 9271479]
fecal discharge) have led to infrequent prescription. Side effects,

however, can be minimized by patients adherence to a low-fat diet,
and orlistat remains the only overthe-counter weight loss agent that
has been proven effective.
A 4-year randomized trial of orlistat
(n = 3305) showed that it reduced the incidence of type 2 diabetes by 37% (40), an effect similar to metformin in the Diabetes
Prevention Program (2).
39. Smith SR, Weissman

NJ, Anderson CM, et
al; Behavioral Modification and Lorcaserin for Overweight and Obesity
Management
(BLOOM) Study
Group. Multicenter,
placebo-controlled
trial of lorcaserin for
weight management. N Engl J Med.
2010;363:245-56.
[PMID: 20647200]
40. Torgerson JS, Hauptman J, Boldrin MN,
Sjstrm L. XENical
in the prevention of
diabetes in obese
subjects (XENDOS)
study: a randomized
study of orlistat as
an adjunct to
lifestyle changes for
the prevention of
type 2 diabetes in
obese patients. Diabetes Care.
2004;27:155-61.
[PMID: 14693982]
41. Munro JF, MacCuish
AC, Wilson EM, Duncan LJ. Comparison
of continuous and
intermittent anorectic therapy in obesity. Br Med J.
1968;1:352-4.
[PMID: 15508204]
42. Wirth A, Krause J.
Long-term weight
loss with sibutramine: a randomized controlled trial.
JAMA.
2001;286:1331-9.
[PMID: 11560538]
Should weight loss medications be

taken long-term?
Patients, on average, regain weight
after medications are terminated.
Trials of both orlistat and lorcaserin showed that patients who
lost weight during the first year
and were then randomly assigned
to remain on medication for a second year maintained significantly
greater weight loss at the end of
the second year than did persons
randomized to placebo (30). Thus,
patients should be counseled that
long-term pharmacotherapy will
probably be needed. Randomized,
controlled trials of previous medications found that treatment
could be provided approximately
every other month, rather than
continuously, with no loss of efficacy (41, 42). The plateau in
weight loss that occurs after approximately 68 months of pharmacologic treatment should not be
interpreted to mean that the
medication is no longer working.
The plateau, in part, reflects the
hormonal and metabolic adaptations to weight loss described
previously.
Patients and clinicians may have
concerns about the safety of longterm pharmacotherapy for obesity
raised by a history of unexpected
problems with these medications.
Medications currently approved for
chronic use have been subjected to
more rigorous safety testing than in
previous eras, which ultimately will
include trials to examine long-term
risk for cardiovascular events.
ITC3-12
In the Clinic
When is surgery indicated for

treatment of obesity?
Bariatric (weight loss) surgery is generally indicated for patients with a
body mass index 40 kg/m2 or for
those with a BMI 35 kg/m2 with at
least 1 serious weight-related comorbid condition, such as type 2 diabetes, sleep apnea, or disabling joint
disease. Laparoscopic gastric banding
is also FDA-approved for patients
with a BMI 30 kg/m2 and type 2
diabetes. Before having surgery, patients should have made sustained attempts at weight loss with lifestyle
modification and/or pharmacotherapy. It is currently standard of care for
patients considering bariatric surgery
to undergo preoperative psychological evaluation to determine appropriateness for surgery. Patients must also
be well informed of the potential
risks of surgery and the need for
long-term monitoring of their weight
and nutritional status.
Types of bariatric surgery
The 3 types of surgeries most commonly done in the United States are
adjustable gastric banding, Rouxen-Y gastric bypass, and sleeve gastrectomy. All 3 can be performed
laparoscopically. The gastric band
involves placing a band around the
upper stomach, creating a small
proximal stomach pouch through
which food must pass before traversing the rest of the stomach and
the intestinal tract. The band is adjustable, which allows the clinician
to loosen it (e.g., if the patient has
postprandial vomiting) or to tighten
it if postsurgical results are suboptimal (e.g., slow weight loss, low level
of satiety). Weight loss is achieved
by restriction of food intake alone.
With gastric bypass, the stomach is
transected proximally, and the midjejunum is also transected and connected to the remaining proximal
stomach pouch. The remaining distal
stomach, duodenum, and proximal jejunum are anastomosed to form a
blind limb, which ends proximally
in the closed-off stomach and is no
longer a part of the active digestive

process. Roux-en-Y gastric bypass
causes restricted food intake, partial
malabsorption, and changes in
appetite-regulating hormones (e.g.,
ghrelin), all of which contribute to
weight loss. In sleeve gastrectomy,
approximately 75% of the stomach is
removed, but the remainder of the intestinal tract remains intact. Weight
loss is achieved principally by food
restriction, although the removal of
endocrine-rich gastric tissue and an
accelerated rate of gastric emptying
may contribute to the greater weight
loss than with gastric banding.
Effectiveness of bariatric surgery
Bariatric surgery is the most efficacious treatment for severe obesity.

One meta-analysis of randomized
trials concluded that, after 1 year,
gastric banding, gastric bypass, and
sleeve gastrectomy were associated
with reductions in BMI of 2.4 kg/m2,
9.0 kg/m2, and 10.1 kg/m2, respectively (43). A recent cohort study
(n = 8847) that used propensity scoring also reported that sleeve gastrectomy was closer in effectiveness to
gastric bypass than to gastric banding (weight loss of approximately
17.1%, 29.7%, and 34.8% of initial
weight for gastric banding, sleeve
gastrectomy, and gastric bypass, respectively) (44).
The dramatic weight loss seen with
bariatric surgery often ameliorates
comorbid conditions (45). Type 2 diabetes resolves more often with gastric bypass than would be expected
from weight loss alone, suggesting
that additional mechanisms account

for this observation.
Data are somewhat conflicting on
whether bariatric surgery reduces mortality. The SOS study, the cohort study in which
surgical and control participants were
matched on 18 characteristics, found that
the large weight loss achieved with
bariatric surgery resulted in reduced allcause mortality (4). However, a well-done
observational study from U.S. Veterans Administration data, using propensity score
adjustment, did not show a mortality benefit from bariatric surgery (46).
Complications of bariatric surgery
All 3 procedures reviewed are associated with complications. Potential

complications of gastric banding include slippage or erosion of the
band, which can lead to gastroesophageal reflux; obstruction; and in
rare cases, esophageal or gastric perforation. Potential complications of
gastric bypass include anastomotic
breakdown, stenosis or ulcers near
the anastomotic site, and long-term
micronutrient deficiencies. Any patient having bariatric surgery is at
risk for perioperative complications,
including wound infection, venous
thromboembolism, and mortality.
In a multicenter cohort study of patients undergoing surgery at bariatric surgical Centers of Excellence in the United States, 4.3%
of patients had at least one major adverse
outcome (death, venous thromboembolism, need for reintervention, or failure to
be discharged from the hospital); 30-day
mortality rates were 0% for gastric banding,
0.2% for laparoscopic gastric bypass, and
2.1% for open gastric bypass (47).
Treatment... Clinicians should discuss weight with patients, using appropriate language.
They should recognize that physiologic factors play a role in weight regain after initial
weight loss. Clinicians should advise patients that keeping records of food intake and
physical activity are the most important tasks for weight loss. A calorie deficit diet, with
5060% of calories from complex carbohydrates, should be the first choice for most patients. Pharmacotherapy is appropriate for selected patients with obesity, with appropriate monitoring for potential side effects. Bariatric surgery is the most effective and the
most high-risk treatment for severe obesity; it has been shown to improve and occasionally cure comorbid conditions and may reduce mortality from excess weight.
3 September 2013
In the Clinic
ITC3-13
43. Padwal R, Klarenbach S, Wiebe N, et

al. Bariatric surgery: a
systematic review
and network metaanalysis of randomized trials. Obes Rev.
2011;12:602-21.
[PMID: 21438991]
44. Carlin AM, Zeni TM,
English WJ, et al;
Michigan Bariatric
Surgery Collaborative. The comparative effectiveness of
sleeve gastrectomy,
gastric bypass, and
adjustable gastric
banding procedures
for the treatment of
morbid obesity. Ann
Surg. 2013;257:7917. [PMID: 23470577]
45. Buchwald H, Avidor
Y, Braunwald E, et al.
Bariatric surgery: a
systematic review
and meta-analysis.
JAMA.
2004;292:1724-37.
[PMID: 15479938]
46. Maciejewski ML, Livingston EH, Smith
VA, et al. Survival
among high-risk patients after bariatric
surgery. JAMA.
2011;305:2419-26.
[PMID: 21666276]
47. Flum DR, Belle SH,
King WC, et al; Longitudinal Assessment of Bariatric
Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment
of bariatric surgery.
N Engl J Med.
2009;361:445-54.
[PMID: 19641201]
Practice
Improvement
What do professional
organizations recommend with
regard to management of obesity?
The U.S. Preventive Services Task
Force updated its recommendation
in 2012 for treatment of obesity. The
Task Force recommended that clinicians offer or refer patients with a
BMI 30 kg/m2 to intensive,
multicomponent behavioral interventions (5). The ACP published
guidelines for pharmacologic and
surgical treatment of obesity in 2005
(48). The NIH guidelines for evaluation and treatment of obesity were
originally published in 1998 (16),
and an updated version of these
guidelines is currently underway (expected in 2013/2014). The CMS has
recently approved a benefit for intensive behavior therapy of obesity
(49). It will pay for 14 visits (15
In the Clinic
PIER Module
Tool Kit
Patient Information
Obesity
minutes each) in the first 6 months,

and up to 6 additional monthly visits
if the patient loses at least 3 kg in
the first 6 months. This schedule of
visits can be repeated annually, although the visits must be performed
in the physical setting of the primary
care office. In 2010, the American
Diabetes Association officially recommended using hemoglobin A1c
to screen for diabetes. Because of
this, many more persons have been
diagnosed with prediabetes, and
greater attention has been focused
on the value of moderate weight loss
(510% of initial weight) in preventing diabetes. For example, the national Diabetes Prevention Program
is undergoing dissemination through
collaboration between YMCAs and
the Centers for Disease Control and
Prevention.
http://pier.acponline.org/physicians/diseases/d161/d161.html
PIER module on obesity from the American College of Physicians.
http://pier.acponline.org/physicians/diseases/d161/d161-pi.html
Patient Information material that appears on the next page for
duplication and distribution to patients.
www.acponline.org/patients_families/pdfs/health/obesity.pdf
Patient handout on obesity from the American College of
Physicians: 100 Million Adult Americans Are Overweight and at
Risk of Serious Disease.
www.acponline.org
Information for clinicians and patients on obesity, including
recruitment for obesity studies and treatment.
Clinical Guidelines
http://annals.org/article.aspx?articleid=1355696
U.S. Preventive Services Task Force recommendation statement on
screening for and management of obesity in adults, published in
Annals of Internal Medicine in September 2012.
http://annals.org/article.aspx?articleid=718309
U.S. Preventive Services Task Force clinical practice guideline on
pharmacologic and surgical management of obesity in primary
care, published in Annals of Internal Medicine in April 2005.
Diagnostic Tests and Criteria

http://pier.acponline.org/physicians/diseases/d161/tables/d161
-tlab.html
Table listing laboratory and other studies for obesity.
http://nhlbisupport.com/bmi/
Online body mass index calculator, and information on the BMI
tables, from the NHLBI.
Quality-of-Care Guidelines
http://qualitymeasures.ahrq.gov/
ITC3-14
In the Clinic
In the Clinic
48. Snow V, Barry P, Fitterman N, Qaseem

A, Weiss K; Clinical
Efficacy Assessment
Subcommittee of
the American College of Physicians.
Pharmacologic and
surgical management of obesity in
primary care: a clinical practice guideline from the American College of
Physicians. Ann Intern Med.
2005;142:525-31.
[PMID: 15809464]
49. Centers for Medicare
& Medicaid Services.
Decision Memo for
Intensive Behavioral
Therapy for Obesity
(CAG-00423N). 2011.
Accessed at www
.cms.gov/medicare
-coverage-database/
details/nca-decision
-memo.aspx?&Nca
Name=Intensive%20
Behavioral%20
Therapy%20for%20
Obesity&bc=ACAAA
AAAIAAA&NCAId
=253& on 10 December 2011.
WHAT YOU SHOULD

KNOW ABOUT OBESITY
In the Clinic
Why is obesity a health problem?

Being overweight means that you weigh more than
is healthy.
People who are overweight have medical problems,
such as high cholesterol, diabetes, heart disease,
arthritis, and breathing problems, as well as shorter
lives.
Losing weight can be hard, but losing even a little
can make you healthier.
How do you know if you are

overweight?
Body mass index (BMI) measures how tall you are in
meters (m) and how much you weigh in kilograms
(kg) to tell you if you weigh too much.
Normal BMI is under 25 kg/m2. You are overweight
if your BMI is between 25 kg/m2 and 30 kg/m2. You
are obese if it is over 30 kg/m2.
What the best ways to lose weight?

Eat less and exercise more.
Why Is Losing Weight So Hard?
Set a reachable goal for your new weight. Even a

few pounds makes a difference.
Its not easy to break the eating habits that lead to

weight gain.
If diet and exercise are not enough, your doctor may

give you medication to lose weight.
It takes patience. Healthy, long-term weight loss

takes time, and the slow results can dampen your
motivation.
If you are very obese and have serious medical problems, your doctor may consider surgery on your
stomach so that you eat less and lose weight.
Its hard for your body to change. When you go on a

diet, you lose some weight and then stop for a while.
For More Information

www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm
Information resources from the National Heart, Lung, and Blood

Institutes Aim for a Healthy Weight! Program.
www.heart.org/HEARTORG/GettingHealthy/WeightManagement/Weight
-Management_UCM_001081_SubHomePage.jsp
www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/Physical
-Activity_UCM_001080_SubHomePage.jsp
Guidance on losing weight and on physical activity from the

American Heart Association.
www.eatright.org/Public/
Information on food and nutrition, from the Academy of

Nutrition and Dietetics (formerly the American Dietetic
Association).
Patient Information
Some diets are easier than others for some people.

Sometimes getting advice or joining self-help groups
makes it easier to stay on a diet.
CME Questions
1. A 42-year-old man is evaluated for

obesity. His weight has gradually
increased over the past two decades
and is currently 168.2 kg (370 lb). Five
years ago, he was diagnosed with type
2 diabetes mellitus, hypertension, and
hyperlipidemia. Over the past 6 months,
he has unsuccessfully tried diet and
exercise therapy for his obesity. He tried
over-the-counter orlistat but could not
tolerate the gastrointestinal side
effects. Medications are metformin,
lisinopril, and simvastatin. His total
weight loss goal is 45.4 kg (100 lb).
On physical examination, temperature is

normal, blood pressure is 130/80 mm
Hg, pulse rate is 80/min, and respiration
rate is 14/min. BMI is 48. Waist
circumference is 121.9 cm (48 in). There
is no thyromegaly. Heart sounds are
normal with no murmur. There is no
lower extremity edema.
Results of complete blood count,
thyroid studies, and urinalysis are
unremarkable.
Which of the following is the most
appropriate management of this patient?
A. Bariatric surgery evaluation

B. Prescribe phentermine
C. Reduce caloric intake to below 800
kcal/d
D. Refer to an exercise program
2. A 48-year-old woman is evaluated

during a routine examination. She is
concerned about her gradual weight
gain over the years and requests
counseling on how she can most
effectively lose weight.
Over 8 years, she has gained

approximately 18 kg (40 lb). With
several commercial diets, she has lost
weight but always gains it back. She
has a sedentary job, and often skips
breakfast or eats dinner on the run. She
states she cannot fit exercise into her
busy day. She takes no medications and
has no allergies.
On physical examination, temperature is
normal, blood pressure is 132/70 mm
Hg, pulse rate is 80/min, and respiration
rate is 12/min. BMI is 32. There is no
thyromegaly. The abdomen is obese,
soft, nontender, and without striae.
Fasting plasma glucose level is
106 mg/dL (5.9 mmol/L) and thyroid
function test results are normal.
3. A 31-year-old woman is evaluated

during a postpartum examination
6 months after giving birth to her first
child. The patient was obese before
becoming pregnant, developed
gestational diabetes mellitus during
pregnancy, and was able to maintain
her weight and glucose level within the
target range throughout her pregnancy
with diet alone. Her infant weighed
4139 grams (146 ounces) at birth.
This patients infant is at increased risk

for which of the following disorders?
A. Childhood obesity
B. Maturity-onset diabetes of the young
C. Type 1A diabetes mellitus
D. Type 1B diabetes mellitus
Which of the following is the most

appropriate next step to help this
patient achieve long-term weight
reduction?
A. Exercise 1530 minutes 5 days/wk
B. Laparoscopic adjustable band surgery
C. Orlistat
D. Reduce current caloric intake by
5001000 kcal/d
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.
ITC3-16
In the Clinic

Obesity Acp

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Obesity

Screening and Prevention

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n estimated 36% of adults and 17% of children and adolescents in the

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2013 American College of Physicians

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The relationship between obesity

Annals of Internal Medicine 3 September 2013

example, weight loss of 510% of

The Look AHEAD study was stopped in

CLINICAL BOTTOM LINE

Should clinicians screen patients

Insulin and certain other antiglycemic

How can patients prevent obesity?

In adults, obesity prevention

Annals of Internal Medicine

A study that combined 3 cohorts with a

1. Flegal KM, Kit BK, Orpana H, Graubard BI.

2013 American College of Physicians

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Medications Associated With

most strongly associated with intake of

Emerging evidence suggests that

to increase the risk for being obese

CLINICAL BOTTOM LINE

2013 American College of Physicians

How do clinicians diagnose

and South Asian patients (e.g., East

When can BMI be misleading in

Body fat is normally about 12%

Annals of Internal Medicine 3 September 2013

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(e.g., diabetes) than younger persons.

Annals of Internal Medicine

life events associated with significant weight gain (e.g., pregnancy).

7. Hays JT, Hurt RD, Rigotti NA, et al. Sustained-release

Is a family history of obesity

Clinical Findings in Patients With Obesity

The polycystic ovary

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2013 American College of Physicians

more detailed information on the

13. Christakis NA, Fowler

What laboratory tests or other

CLINICAL BOTTOM LINE

2013 American College of Physicians

How should clinicians counsel

discuss their concerns, rather than

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loss of approximately 12 pounds

What dietary strategies are used

A Guide to Selecting Treatment*

Diet, physical activity,

BMI = body mass index.

Annals of Internal Medicine

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19. Farooqi IS, ORahilly

2013 American College of Physicians

Frequency, duration, and type of

At least 1226 visits in person or by

Contact every other wk for 52 wk (or longer)