Clinical Guidelines on the Identification, Evaluation, and ...

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  • 1. Definitions Body Mass Index (BMI) describes relative weight for height: weight (kg)/height (m2) • Overweight = 25–29.9 BMI • Obesity = > 30 BMI
  • 2. Age-Adjusted Standardized Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI >30) NHES I NHANES I NHANES II NHANES III 50 .1 .4 .1 41 .8 39 39 37 40 Percent .9 .7 .3 30 .6 .6 24 24 24 23 23 .9 19 .3 .1 .1 20 16 16 15 .2 .8 .4 12 11 10 10 0 Men Women Men Women BMI 25–29.9 BMI > 30 CDC/NCHS, United States, 1960-94, ages 20-74 years
  • 3. NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI BMI <25 BMI 25-26 BMI 27-29 BMI >30 50 38.4 40 32.2 Percent 30 25.2 24.0 22.5 21.9 18.2 16.5 20 10 0 Men Women *Defined as mean systolic blood pressure ≥ 140 mm Hg, as mean diastolic ≥ 90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).
  • 4. NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI BMI <25 BMI 25-26 BMI 27-29 BMI >30 50 40 Percent 27.9 28.2 30 24.7 20.4 20.2 20 17.5 15.7 14.7 10 0 Men Women *Defined as > 240 mg/dL. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
  • 5. NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI BMI <25 BMI 25-26 BMI 27-29 BMI >30 60 50 41.5 Percent 40 31.4 30 27.0 27.2 23.1 20 17.2 16.5 9.1 10 0 Men Women *Defined as <35 mg/dL in men and <45 mg/dL in women. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
  • 6. Health Benefits of Weight Loss • Decreased cardiovascular risk • Decreased glucose and insulin levels • Decreased blood pressure • Decreased LDL and triglycerides, increased HDL • Decrease in severity of sleep apnea • Reduced symptoms of degenerative joint disease • Improved gynecological conditions
  • 7. Care of Overweight/Obese Patients Requires two steps: • Assessment • Management
  • 8. Assessment of Overweight and Obesity • Body Mass Index – Weight (kg)/height (m2) – Weight (lb)/height (in2) x 703 – Table • Waist Circumference – High risk: • Men >102 cm (40 in.) • Women >88 cm (35 in.)
  • 9. Classification of Overweight and Obesity by BMI 2 Obesity Class BMI kg/m Underweight <18.5 Normal 18.5–24.9 Overweight 25–29.9 Obesity I 30.0–34.9 II 35.0–39.9 Extreme Obesity III ≥ 40.0
  • 10. Determine Absolute Risk Status Evaluate: • Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea) (+ = very high risk) • Other obesity-associated diseases (e.g., gynecological abnormalities, osteoarthritis) • Cardiovascular risk factors: smoking, hypertension, high LDL, low HDL, IGT, family hx (>3 = high risk) • Other risk factors: – Physical inactivity – High serum triglycerides (>200 mg/dL)
  • 11. 1 Patient Encounter 2 Hx of ≥ 25 BMI? Treatment Algorithm No Yes 3 BMI measured in past 2 years? 4 6 BMI ≥ 30 OR • Measure weight, 5 BMI ≥ 25 OR 7 {[BMI 25 to 29.9 height, and waist waist circumference Yes Assess risk OR waist circumference Yes circumference > 88 cm (F) factors >88 cm (F) >102 cm (M)] 8 • Calculate BMI > 102 cm (M) AND ≥ 2 risk factors} Clinician and patient devise goals and No treatment strategy No for weight loss and risk factor control 14 12 Does Yes Yes Hx BMI≥ 25? patient want to lose weight? 9 Progress Yes No No being made/goal 15 13 achieved? Brief reinforcement/ Advise to maintain educate on weight weight/address No management other risk factors Examination 11 10 16 Treatment Periodic weight Maintenance counseling: Assess reasons for check Dietary therapy failure to lose Behavior therapy weight : Physical activity
  • 12. Treatment Algorithm 1 Patient Encounter (Part 1 of 3) Examination 2 Hx of ≥ 25 Treatment BMI? No Yes 3 BMI measured in past 2 years? 4 7 BMI 6 ≥ 30 OR • Measure weight, 5 height, and waist BMI ≥ 25 OR Yes {[BMI 25 to 29.9 Yes waist > 88 cm (F) Assess risk OR waist >88 cm (F) circumference > 102 cm (M) factors >102 cm (M)] • Calculate BMI AND ≥ 2 risk factors} No No
  • 13. Treatment Algorithm BMI ≥ 30 OR (Part 2 of 3) 7 {[BMI 25 to 29.9 OR waist >88 cm (F) Yes >102 cm (M)] 8 AND ≥ 2 risk factors} Devise goals and Examination treatment strategy for Treatment No weight loss and risk 12 factor control No Desire to Yes lose weight? Yes 9 Progress 13 made? • Advise to maintain weight No • Address other risk factors 16 11 10 Periodic weight Maintenance Assess reasons for check counseling failure to lose weight
  • 14. Treatment Algorithm 5 (Part 3 of 3) BMI ≥ 25 OR Yes waist > 88 cm (F) > 102 cm (M) Examination Treatment No 14 Yes Hx BMI ≥ 25? 15 No 13 • Brief reinforcement • Advise to maintain weight • Educate on weight management • Address other risk factors * This algorithm applies only to the 16 assessment for overweight and obesity and subsequent decisions based on that Periodic weight assessment. It does not include any check initial overall assessment for cardiovascular risk factors or diseases that are indicated.
  • 15. Goals of Weight Management/Treatment • Prevent further weight gain (minimum goal). • Reduce body weight. • Maintain a lower body weight over long term.
  • 16. Target Weight: Realistic Goals • Substitute “healthier weight” for ideal or landmark weight. • Accept slow, incremental progress to goal. — Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week. — Interim goal: Maintenance. — Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.
  • 17. Weight Loss Goals Goal: Decrease body weight by 10 percent from baseline. • If goal is achieved, further weight loss can be attempted if indicated. • Reasonable timeline: 6 months of therapy. – Moderate caloric deficits – Weight loss 1 to 2 lb/week
  • 18. Weight Loss Goals • Start weight maintenance efforts after 6 months. – May need to be continued indefinitely. • If unable to lose weight, prevent further weight gain.
  • 19. Strategies for Weight Loss and Maintenance • Dietary therapy • Physical activity • Behavior therapy • “Combined” therapy • Pharmacotherapy • Weight loss surgery
  • 20. Weight Loss Therapy Whenever possible, weight loss therapy should employ the combination of • Low-calorie/low-fat diets • Increased physical activity • Behavior modification
  • 21. Dietary Therapy (1 of 5) Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons. Evidence Category A. Reducing fat as part of an LCD is a practical way to reduce calories. Evidence Category A.
  • 22. Dietary Therapy (2 of 5) Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.
  • 23. Dietary Therapy (3 of 5) Although lower fat diets without targeted calorie reduction help promote weight loss by producing a reduced calorie intake, lower fat diets coupled with total calorie reduction produce greater weight loss than lower fat diets alone. Evidence Category A.
  • 24. Dietary Therapy (4 of 5) Very low-calorie diets produce greater initial weight loss than low-calorie diets. However, long-term (>1 year) weight loss is not different from an LCD. Evidence Category A.
  • 25. Dietary Therapy (5 of 5) Very Low-Calorie Diets (less than 800 kcal/day): • Rapid weight loss • Deficits are too great • Nutritional inadequacies • Greater weight regain • No change in behavior • Greater risk of gallstones
  • 26. Low-Calorie Step I Diet Nutrient Recommended Intake Calories 500 to 1,000 kcal/day reduction Total Fat 30 percent or less of total calories SFA 8 to 10 percent of total calories MUFA Up to 15 percent of total calories PUFA Up to 10 percent of total calories Cholesterol <300 mg/day
  • 27. Low-Calorie Step I Diet (continued) Nutrient Recommended Intake Protein ~ 15 percent of total calories Carbohydrate 55 percent or more of total calories Sodium Chloride No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride) Calcium 1,000 to 1,500 mg Fiber 20 to 30 g