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Prevention and Management of Obesity – Adult – Ambulatory

Prevention and Management of Obesity – Adult – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


1
Prevention and Management of Obesity
– Adult – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 5
METHODOLOGY ............................................................................................................ 6
INTRODUCTION ............................................................................................................. 6
RECOMMENDATIONS ................................................................................................... 7
UW HEALTH IMPLEMENTATION.................................................................................. 7
REFERENCES ................................................................................................................ 7
CPG Contact for Content:
Name: Vincent Cryns, Department of Medicine - Endocrinology
Phone Number: (608) 263-7780
Email Address: vcryns@wisc.edu
CPG Contact for Changes:
Name: Janna Lind, MSN, RN – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

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Guideline Author(s): Institute for Clinical Systems Improvement (ICSI)
Coordinating Team Members:
Vincent Cryns, MD – Endocrinology
Luke Funk, MD, MPH – Minimally Invasive and Bariatric Surgery
Ann Schmidt, MD – Internal Medicine
Mary O’Connell – Medical and Surgical Weight Management Program
Magnolia Larson, DO – Family Medicine
Nicole Weathers, MD – Family Medicine
Cassandra Vanderwall, MS, RDN, CD, CDE, CPT – Clinical Nutrition
Diane Olson, RDN – Clinical Nutrition
Alisa Sunness, RDN – Clinical Nutrition
Karen Block – Clinical Support-Health Ed.
Melody Cole, MS, RDN, CD, CDE – Clinical Staff Education
Cindy Gaston, PharmD – Drug Policy Program
Jen Grice, PharmD – Center for Clinical Knowledge Management
Lindsey Spencer, MS – Center for Clinical Knowledge Management
Vernon Partello, MD – Meriter Medical Group
Elaine Rosenblatt, MSN, FNP-BC – UWMF
Review Individuals/Bodies:
Alexander Young, MD – Family Medicine
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (05/28/2015)
Release Date: May 2015
Next Review Date: May 2017
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
UW Health has agreed to endorse the 2013 Prevention and Management of Obesity for
Adults created by the Institute for Clinical Systems Improvement (ICSI).1
In lieu of the recommendations in the ICSI 2013 guideline, UW Health recommends the
following modifications:
1. Annual screening for depression should be completed in all patients 12 years or
older using the Patient Health Questionnaire-2 (PHQ-2). (UW Health Very low quality
evidence, strong recommendation) A total score of 3 points or greater on the PHQ-2
constitutes a positive screen and need for further follow-up assessment using the
PHQ-9.2,3 For further recommendations related to assessment and treatment,
reference the UW Health Depression – Pediatric/Adult – Ambulatory Guideline.
2. The laparoscopic adjustable gastric banding (lap banding) procedure outlined in the
ICSI guideline is not currently performed at UW Health.
Key Practice Recommendations
1. Clinicians should calculate body mass index (BMI) for their patients on an annual
basis for screening and as needed for management. Classify BMI based on the body
mass categories. Educate patients about their body mass index and associated risks
for them. (ICSI Strong Recommendation, High Quality Evidence)
2. Clinicians should consider waist circumference measurement to estimate disease
risk for patients who have normal or overweight BMI scores. (ICSI Strong
Recommendation, Moderate Quality Evidence)
3. Clinicians need to carefully consider BMI and its associated mortality risk across
different ethnicity, sex and age groups. (ICSI Strong Recommendation/Moderate Quality
Evidence)
4. Waist circumference greater than or equal to 40 inches for males and 35 inches for
females is an additional risk factor for complications related to obesity. Measuring
waist circumference is recommended to further assess the patient. (ICSI Weak
Recommendation, Moderate Quality Evidence)
5. Clinicians should use motivational interviewing techniques as a tool for encouraging
behavior change. (ICSI Strong Recommendation, Moderate Quality Evidence)
Companion/Collateral Documents
1. BMI Index Ranges
2. FDA Approved Treatment of Obesity in Adults
Related UW Health Clinical Practice Guidelines
1. Standard Rooming Criteria – Pediatric/Adult – Ambulatory Guideline
2. Preventive Health Care – Pediatric/Adult – Ambulatory Guideline
3. Depression – Pediatric/Adult – Ambulatory Guideline
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

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Internal Resources
1. UW Health Medical and Surgical Weight Management Program
2. Nutrition Services Flyer
External Resources
1. Unity Health Insurance - Weight Management
2. Group Health Cooperative - Weight Management
3. Physicians Plus - Weight Management
4. Dean - Weight Management
Pertinent UW Health Policies & Procedures
1. UWMF Policy- Measuring Weight in Adults and Children
2. UWMF Policy- Measuring Height in Adults and Children
3. UWHC Policy #8.02- Assessment and Reassessment of Patients and
Documentation in Clinics
Patient Resources
Recommended for use in the Primary Care Setting
1. Healthy Plate Handout
2. HFFY#358 Weight Management: Body Composition Screening and Body Mass Index
3. HFFY #531 Weight Management: Smart Weight Loss
4. HFFY #403 Weight Management: Fiber Focus
5. HFFY #409 Weight Management: Frequently Asked Questions
6. HFFY #412 Weight Management: Nutrition and Recipe Resources
7. HFFY #411 Weight Management: Starting a Walking Program
8. HFFY #407 Weight Management: Exploring Why you Eat
9. HFFY#401 Weight Management: Seven Ways to Size Up Your Servings
10. HFFY#413 Weight Management: Exercise Opportunities in the Madison Area
For use by Clinical Nutrition
1. HFFY#399 Weight Management: Empty Calories Count
2. HFFY#406 Weight Management: The Alternative to “Diets”
3. HFFY#404 Weight Management: Tips to Boost Your Metabolism
4. HFFY#405 Weight Management: Eating More Fruits and Vegetables
5. HFFY#509 Weight Management: Planning Meals to Maximize Energy and Control Hunger
Additional Resources
1. Healthwise: Weight: Overweight
2. Healthwise: Weight: Starting a Weight Loss Plan
3. Health Information: Obesity
4. Health Information: Obesity and Pregnancy
5. Health Information: Gastric Banding for Obesity
6. Health Information: Gastric Bypass for Obesity
7. Health Information: Stomach Stapling for Obesity
8. Health Information: Obesity: Should I Have Weight-Loss Surgery?
9. Health Information: Obesity: Should I Take Weight-Loss Medicine?
10. Health Information: Obesity: Should I Use a Diet Plan to Lose Weight?
11. Health Information: Weight and Health Risk Calculator
12. Health Information: Weight Loss by Limiting Calories
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

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13. Health Information: Weight Management
14. Health Information: Weight Management: Should I Use Over-the-Counter Diet Aids?
15. Health Information: Weight Management: Stop Negative Thoughts
Scope
Disease/Condition(s): Obesity, Overweight
Clinical Specialty: Endocrinology, Family Medicine, Internal Medicine, Nursing,
Nutrition, Preventive Medicine, and Surgery
Intended Users: Primary Care Physicians, Specialty Care Physicians, Advanced
Practice Providers, Registered Dietitians, Pharmacists, Nursing
Objective(s): To establish evidence-based recommendations for obesity prevention,
diagnosis, and weight management in adult patients.
Target Population: All adults 18 years of age and older.
This guideline does not address pregnant women or bodybuilders/weight trainers.
Interventions and Practices Considered:
ξ Behavioral approaches
o Motivational Interviewing
o Goal setting
o Nutrition recommendations
o Physical activity prescription
o Behavioral management strategies
ξ Drug treatment
o Phentermine
o Orlistat
o Qsymia
o Lorcaserin
ξ Surgery.
o Adjustable Band
o Sleeve Gastrectomy
o Gastric Bypass
o Duodenal Switch
Major Outcomes Considered: Weight loss, weight maintenance
Guideline Metrics:
ACO
1. Percentage of patients aged 18 years and older with a BMI documented during
the current encounter or during the previous six months AND with a BMI outside
of normal parameters, a follow-up plan is documented during the encounter or
during the previous six months of the current encounter.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

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Methodology
Methods Used to Collect/Select the Evidence:
Identification and selection of the evidence was completed by the Institute for Clinical
Systems Improvement (ICSI). Literature search terms for the current revision of this
document included adults (18 years and older), published since January 2005 –
systematic reviews, randomized control trials, meta-analysis restricted to human
studies, in the following topic areas: prevention, screening, treatments/drug studies,
medications, gastric bypass and/or bariatric surgery, lipid and cholesterol screening,
activity recommendations, genetic studies, activity recommendations, family-based
therapy, readiness for change, motivational interviewing, goal setting, managing chronic
conditions, binge eating disorders, binge eating disorder assessment and scale, and
obesity with diabetes.
Rating Scheme for the Strength of the Evidence/Recommendations:
The quality of the evidence was rated using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE). See table below.
Table 1. ICSI GRADE Scheme
Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality
Evidence
Further research is
very unlikely to
change our
confidence in the
estimate of effect.
The work group is confident that
the desirable effects of adhering
to this recommendation
outweigh the undesirable
effects. This is a strong
recommendation for or against.
This applies to most patients.
The work group recognizes that the
evidence, though of high quality, shows
a balance between estimates of harms
and benefits. The best action will
depend on local circumstances, patient
values of preferences.
Moderate
Quality
Evidence
Further research is
likely to have an
important impact on
our confidence in the
estimate of effect and
may change the
estimate.
The work group is confident that
the benefits outweigh the risks
but recognizes that the
evidence has limitations.
Further evidence may impact
this recommendation. This is
likely a recommendation that
applies to all patients.
The work group recognizes that there is
a balance between harms and benefits,
based on moderate quality evidence, or
that there is uncertainty about the
estimates of the harms and benefits of
the proposed intervention that may be
affected by new evidence. Alternative
approaches will likely be better for some
patients under some circumstances.
Low Quality
Evidence
Further research is
very likely to have an
important impact on
our confidence in the
estimate of effect and
is likely to change.
The estimate or any
estimate of effect is
very uncertain.
The work group feels that the
evidence consistently indicates
the benefit of this action
outweighs the harms. This
recommendation might change
when higher quality evidence
becomes available.
The work group recognizes that there is
significant uncertainty about the best
estimates of benefits and harms.
Introduction
Over one third of adults in the United States are obese.4 Obesity is the second leading
cause of preventable death, and associated with medical costs as much as $147 billion
to $210 billion a year.5 Comorbidities include Type 2 diabetes, heart disease,
hypertension, dyslipidemia, and certain cancers. Depression and obesity frequently co-
occur.6 A 5-10% weight loss can reduce a patient’s risk of heart disease and diabetes
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

7
that is clinically significant. This can be achieved and maintained with a high-intensity
medical weight loss program even for the morbidly obese.1
Recommendations
Recommendations related to the prevention, diagnosis and management of obesity in
adult patients can be found in the 2013 ICSI guideline online at
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines
/catalog_endocrine_guidelines/obesity__adults/.
UW Health Implementation
Implementation Plan/Tools
1. Guideline will be housed on a U-Connect webpage dedicated to UW Health CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including the Adult Overweight/Obese BMI [5074] Smart Set.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
References
1. Fitch A, Everling L, Fox C, et al. Prevention and Management of Obesity for Adults.: Institute
for Clinical Systems Improvement; Updated May 2013.
2. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for
major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353.
3. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-
item depression screener. Med Care. 2003;41(11):1284-1292.
4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the
United States, 2011-2012. JAMA. 2014;311(8):806-814.
5. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to
obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822-831.
6. Jenkins TM. Prevalence of overweight, obesity, and comorbid conditions among U.S. and
Kentucky adults, 2000-2002. Prev Chronic Dis. 2005;2(1):A08.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

Body Mass Index Ranges
Category BMI (kg/m2 )
Underweight Less than 18.5
Normal Weight* 18.5-24.9*
Overweight** 25-29.9**
Obese – Class I 30-34.9
Obese – Class II 35-39.9
Extreme obesity – Class III 40 or more
NOTE: Clinicians should carefully consider BMI and its associated
mortality risk across different ethnicity, sex and age groups. (ICSI Moderate
quality of evidence, strong recommendation)
* Normal BMI for persons age 65 and older is • �� and � �0 kg�m�.
** Asian Americans: Considered overweight starting at a BMI of 23 kg/m2.
** African Americans appear to have the lowest mortality risk at BMI of
26.2-28.5 kg/m2 (females) and 27.1-30.2 kg/m2 (males).
Last revised: 05/2015
Last reviewed: 05/2015
Contact CCKM for revisions.
Obesity – Adult – Ambulatory Clinical Practice Guideline
Reference: Fitch A, Everling L, Fox C, et al. Prevention and Management of Obesity for Adults.: Institute
for Clinical Systems Improvement; Updated May 2013.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

FDA Approved Medications for Long-term Treatment of Obesity in Adults
First line treatment for obesity is lifestyle modification. Medication therapy may be considered in conjunction with lifestyle management in those with an unsatisfactory
response to lifestyle modification alone. Medication therapy is indicated only for patients with a %MI • �0 kg�m2 or a %MI • �� kg�m2 with weight-related comorbidities. They
typically have a modest weight loss benefit, are often are not reimbursed by health insurance companies, and are associated with multiple adverse reactions. Benefit of
therapy should be weighed carefully prior to initiation.
Medication Contraindications Common or Serious Adverse Effects Dosage
Liraglutide1
(Saxenda ® )
ξ Personal or family history of
medullary thyroid cancer or
multiple endocrine neoplasia
syndrome type 2
ξ Pregnancy
Constipation, diarrhea, dyspepsia, fatigue,
increased heart rate, hepatitis,
hypersensitivity, hypoglycemia (rare in
patients without diabetes), nausea, renal
impairment, suicidal ideation, vomiting
ξ Titrate dose to reduce GI side effects: Start with 0.6 mg once
daily, then increase the daily dose by 0.6 mg each week to a
target dose of 3 mg once daily at week five.
ξ If at 4% of baseline body weight is not los t within 16 weeks,
further benefit is unlikely
Lorcaserin2 - 4
(Belviq ® )
ξ Avoid use of other serotonergic
agents if possible
ξ Pregnancy
Headache, dizziness, fatigue, dry mouth,
constipation, cognitive impairment,
bradycardia, priapism, decreased WBC or
RBC
ξ 10 mg twice daily
ξ If the patient has not lost at least 5% of baseline body weight
within 12 weeks, further response is unlikely.
Orlistat5,6
(Xenical® , Alli ® )
ξChronic malabsorption
syndrome
ξCholestasis
ξPregnancy
Flatulence, oil spotting, fecal incontinence,
urgency or frequency, oily or fatty stool,
abdominal or rectal pain, nausea, hepatitis,
pancreatitis, cholelithiasis
ξ Xenical ® : 120 mg TID with each meal containing fat
ξ Alli ® : 60 mg up to TID with meals containing about 15 g of fat
Naltrexone/
bupropion
extended
release7- 9
(Contrave ® )
ξ Uncontrolled hypertension,
ξ Seizure disorder
ξ Patients taking
benzodiazepine, barbiturate,
MAOI and/or opioid
medications within 14 days
ξ Pregnancy
Nausea, constipation, headache, vomiting,
dizziness, dry mouth, insomnia, suicidal
ideation, mood changes, seizures, increased
heart rate and/or blood pressure,
hepatotoxicity, angle closure glaucoma
ξ Titrate dose starting with 1 tab every AM for one week then 1
tab twice daily for one week then, 2 tabs every AM and 1 tab
every PM for one week then one tab twice daily (full dose)
Phentermine/
topiramate
extended-
release10 - 13
(Qsymia ® )
ξ Glaucoma
ξ Hyperthyroidism
ξ MAOI use within 14 days
ξ History of suicide attempt or
active suicidal ideation
ξ Avoid in severe liver or renal
disease
ξ Pregnancy
Risk of birth defects (REMS)
Paraesthesia, dizziness, dysgeusia,
insomnia, constipation, dry mouth, anxiety,
suicidal ideation, fatigue, cognitive
impairment, kidney stones, decreased
sweating and increased body temperature,
angle closure glaucoma
ξ Titrate dose: one 3.75 mg/23 mg cap once daily for 14 days,
increase to one 7.5 mg/46 mg cap once daily.
ξ Evaluate weight loss after week 12 at the 7.5 mg/46 mg once
daily dose. If the patient has not lost at least 3% of baseline
body weight, discontinue or increase the dose to one 11.25
mg/69 mg capsule once daily for 14 days. Then increase to
one 15 mg/92 mg capsule once daily.
ξ Evaluate weight loss after week 12 at the 15 mg/92 mg once
daily dose. If the patient has not lost at least 5% of baseline
body weight, a response to continued treatment is unlikely.
Last revised: 05/2015 | Last reviewed: 05/2015
Contact CCKM for revisions. Obesity – Adult – Ambulatory Clinical Practice Guideline
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

References
1. Saxenda [package insert]. Plainsboro, NJ: Novo Nordisk 2014.
2. Belviq [package insert]. Woodcliff Lake, NJ: Eisai, Inc 2012.
3. Fidler MC, Sanchez M, Raether B, et al. A one-year randomized trial of lorcaserin for weight loss in obese and overweight adults: the BLOSSOM trial. The Journal of
clinical endocrinology and metabolism. 2011;96(10):3067-3077.
4. O'Neil PM, Smith SR, Weissman NJ, et al. Randomized placebo-controlled clinical trial of lorcaserin for weight loss in type 2 diabetes mellitus: the BLOOM-DM study.
Obesity (Silver Spring, Md.). 2012;20(7):1426-1436.
5. Xenical [package insert]. San Francisco, CA: Genentech, Inc 201 3.
6. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom 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(1):155-161.
7. Contrave [package labeling]. Deerfield, IL: Takeda Pharmaceuticals 2014. .
8. Apovian CM, Aronne L, Rubino D, et al. A randomized, phase 3 trial of naltrexone SR/bupropion SR on weight and obesity-related risk factors (COR-II). Obesity (ilver
Spring, Md.). 2013;21(5):935-943.
9. Greenway FL, Fujioka K, Plodkowski RA, et al. Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised,
double-blind, placebo-controlled, phase 3 trial. Lancet. 2010;376(9741):595-605.
10.Qsymia [package insert]. Mountainview, CA: Vivus, Inc 2014.
11.Allison DB, Gadde KM, Garvey WT, et al. Controlled-release phentermine/topiramate in severely obese adults: a randomized controlled trial (EQUIP). Obesity (Silver
Spring, Md.). 2012;20(2):330-342.
12.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(9774):1341-1352.
13.Garvey WT, Ryan DH, Look M, et al. Two-year 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. The American journal of clinical nutrition. 2012;95(2):297-308.
Last revised: 05/2015 | Last reviewed: 05/2015
Contact CCKM for revisions. Obesity – Adult – Ambulatory Clinical Practice Guideline
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org