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Prevention and Management of Obesity – Adult – Ambulatory

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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

2
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 – Adult/Pediatric – 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. Prevention and Diagnosis Algorithm
2. BMI Index Ranges
3. 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

4
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

5
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

6
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 below or 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

www.icsi.org
Prevention and Diagnosis Algorithm
Copyright © 2013 by Institute for Clinical Systems Improvement 1
Text in blue in this algorithm
indicates a linked corresponding
annotation.
EBR = Evidence-based
recommendation included
Note: Not all numbered
boxes have annotated
content.
Health Care Guideline:
Prevention and Management of Obesity for Adults
Sixth Edition
May 2013
Negotiate goals and management strategy to achieve weight loss.
Refer to risk-appropriate resources as needed.
BMI Risk Nutrition Physical Behavioral Medications Surgery
Activity Management
25-29.9 – Overweight Low x x x *x+
30-34.9 – Obese Class I Moderate x x x x
35-39.9 – Obese Class II High x x x x *x
> 40 – Obese Class III Severe x x x x x
*May be considered if concomitant obesity-related risk factors or diabetes are present
+ May be initiated starting at a BMI of 27 or greater with comorbid disease
Lap band FDA-approved (not all insurances cover) for obesity with related comorbidities
10
Measure height and weight,
and calculate body mass index
Underweight
BMI < 18.5
Normal weight
BMI 18.5-24.9
Assess for major and minor
comorbid conditions
7
BMI > 25?
2
4
Out of guideline
5
no
Advise weight maintenance
and manage other risk factors
6
Reassess goals and risk
factors, and counsel
regarding weight
maintenance
13
Goals achieved?
yes
no
yes
3
1
Reassess at
regular intervals
11
12
Assess goals and risk factors,
and counsel regarding weight
maintenance
no
9
Is patient ready to
lose weight?
8
yes
Major comorbid conditions
• Waist circumference (males > 40 inches,
females > 35 inches)
• Established coronary artery disease
- History of myocardial infarction
- History of angioplasty
- History of CABG
- History of acute coronary syndrome
• Peripheral vascular disease
• Abdominal aortic aneurysm
• Symptomatic carotid artery disease
• Type 2 diabetes mellitus
• Obstructive sleep apnea
Minor comorbid conditions
• Cigarette smoking
• Hypertension (BP greater than or
equal to 140/90) or current use of
antihypertensives
• LDL cholesterol > 130 mg/dL
• HDH cholesterol < 40 mg/dL for men,
less than 50 mg/dL for women
• Prediabetes
• Family history of premature coronary
artery disease
• Age 65 years for males
• Age 55 years for females or
menopausal females
Return to Table of Contents
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

Health Care Guideline
Prevention and Management of Obesity for Adults
How to cite this document:
Fitch A, Everling L, Fox C, Goldberg J, Heim C, Johnson K, Kaufman T, Kennedy E, Kestenbaun C, Lano
M, Leslie D, Newell T, O’Connor P, Slusarek B, Spaniol A, Stovitz S, Webb B. Institute for Clinical Systems
Improvement. Prevention and Management of Obesity for Adults. Updated May 2013.
Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization’s
employees but, except as provided below, may not be distributed outside of the organization without the
prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally
constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of
the following ways:
copies may be provided to anyone involved in the medical group’s process for developing and
implementing clinical guidelines;
the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only,
provided that ICSI receives appropriate attribution on all written or electronic documents and
copies may be provided to patients and the clinicians who manage their care, if the ICSI Health
Care Guideline is incorporated into the medical group’s clinical guideline program.
All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical
Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap-
W D W L R Q V R U U H Y L V L R Q V R U P R G L F D W L R Q V P D G H W R W K L V , & 6 , + H D O W K & D U H * X L G H O L Q H
Copyright © 2013 by Institute for Clinical Systems Improvement

www.icsi.org

www.icsi.org
Prevention and Diagnosis Algorithm
Copyright © 2013 by Institute for Clinical Systems Improvement 1

Text in blue in this algorithm
indicates a linked corresponding
annotation.
EBR = Evidence-based
recommendation included
Note: Not all numbered
boxes have annotated
content.
Health Care Guideline:
Prevention and Management of Obesity for Adults
Sixth Edition
May 2013
Negotiate goals and management strategy to achieve weight loss.
Refer to risk-appropriate resources as needed.
BMI Risk Nutrition Physical Behavioral Medications Surgery
Activity Management
25-29.9 – Overweight Low x x x *x+
30-34.9 – Obese Class I Moderate x x x x
35-39.9 – Obese Class II High x x x x *x
> 40 – Obese Class III Severe x x x x x
*May be considered if concomitant obesity-related risk factors or diabetes are present
+ May be initiated starting at a BMI of 27 or greater with comorbid disease
Lap band FDA-approved (not all insurances cover) for obesity with related comorbidities
10
Measure height and weight,
and calculate body mass index
Underweight
BMI < 18.5
Normal weight
BMI 18.5-24.9
Assess for major and minor
comorbid conditions
7
BMI > 25?
2
4
Out of guideline
5
no
Advise weight maintenance
and manage other risk factors
6
Reassess goals and risk
factors, and counsel
regarding weight
maintenance
13
Goals achieved?
yes
no
yes
3
1
Reassess at
regular intervals
11
12
Assess goals and risk factors,
and counsel regarding weight
maintenance
no
9
Is patient ready to
lose weight?
8
yes
Major comorbid conditions
• Waist circumference (males > 40 inches,
females > 35 inches)
• Established coronary artery disease
- History of myocardial infarction
- History of angioplasty
- History of CABG
- History of acute coronary syndrome
• Peripheral vascular disease
• Abdominal aortic aneurysm
• Symptomatic carotid artery disease
• Type 2 diabetes mellitus
• Obstructive sleep apnea
Minor comorbid conditions
• Cigarette smoking
• Hypertension (BP greater than or
equal to 140/90) or current use of
antihypertensives
• LDL cholesterol > 130 mg/dL
• HDH cholesterol < 40 mg/dL for men,
less than 50 mg/dL for women
• Prediabetes
• Family history of premature coronary
artery disease
• Age 65 years for males
• Age 55 years for females or
menopausal females
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?a扬e o映䍯ntents
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Work Group Leader
Angela Fitch, MD
Baritrician, Park Nicollet
Medical Group
Work Group Members
Essentia Health
Kathy Johnson, PharmD
Pharmacy
Fairview Health Services
Bridget Slusarek, RN, BSN
Nursing
HealthPartners Medical Group
and Regions Hospital
Jennifer Goldberg, MS, RD, LD
Dietitian
Tracy Newell, RD, LD, CNSD
Dietitian
Patrick O’Connor, MD, MA,
MPH
Family Medicine and Geriatrics
Mayo Clinic
Tara Kaufman, MD
Family Medicine
Park Nicollet Health
Services
Claire Kestenbaun, RPh
Pharmacy
Ridgeview Medical Center
Mike Lano, MD
Family Medicine
Robbinsdale School District
#281
Amber Spaniol, RN, LSN, PHN
School Nurse
University of Minnesota
Claudia Fox, MD, MPH
Director of Pediatric Weight
Management Program
University of Minnesota
Physicians
Dan Leslie, MD
Surgery
Steven Stovitz, MD
Sports Medicine
ICSI Patient Advisory Council
Lynn Everling
Patient Representative
Erika Kennedy
Patient Representative
ICSI
Carla Heim
Clinical Systems Improvement
Coordinator
Beth Webb, RN, BA
Project Manager
Algorithms and Annotations ........................................................................................ 1-43
Algorithm .............................................................................................................................1
Evidence Grading ............................................................................................................. 3-4
Recommendations Table ......................................................................................................5
Foreword
Introduction ................................................................................................................. 6-7
Scope and Target Population ...........................................................................................7
Aims ................................................................................................................................7
Clinical Highlights ...................................................................................................... 7-8
Implementation Recommendation Highlights ............................................................ 8-9
5 H O D W H G , & 6 , 6 F L H Q W L F ’ R F X P H Q W V ................................................................................9
’ H Q L W L R Q ........................................................................................................................9
Annotations .................................................................................................................. 10-43
Quality Improvement Support .................................................................................. 44-57
Aims and Measures ............................................................................................................45
0 H D V X U H P H Q W 6 S H F L F D W L R Q V ................................................................................... 46-52
Implementation Recommendations ....................................................................................53
Implementation Tools and Resources .................................................................................54
Implementation Tools and Resources Table ................................................................. 55-57
Supporting Evidence ..................................................................................................... 58-91
References .................................................................................................................... 59-67
Appendices ................................................................................................................... 68-91
Appendix A Medications Associated with Weight Gain and Weight Loss ................ 68
Appendix B Physical Activity Prescription ..........................................................69-70
Appendix C FDA-Approved Medications for the Treatment of Obesity ..................71
Appendix D Overview of Bariatric Procedures ....................................................72-75
Appendix E Meal Tolerance Test Orders: High CHO Orders .................................... 76
Appendix F Meal Tolerance Test Orders: Low CHO Orders .................................... 77
Appendix G Nutritional Supplement Recommendations .......................................... 78
Appendix H Band Assessment Protocol .................................................................... 79
Appendix I Sample Weight-Loss Surgery Preoperative Laboratory
SUR and Checkout Orders ....................................................................................... 80
Appendix J Sample Post-Bariatric-Surgery Patient Diet ...........................................81
Appendix K Example SMART Goal .........................................................................82
Appendix L Readiness to Change Motivational Interviewing Sample
Scripting for Adults ............................................................................................ 83-84
Appendix M How to Utilize the 5 A’s Approach ................................................. 85-86
Appendix N ICSI Shared Decision-Making Model ............................................. 87-91
’ L V F O R V X U H R I 3 R W H Q W L D O & R Q ` L F W V R I , Q W H U H V W .......................................................... 92-95
Acknowledgements ........................................................................................................ 96-97
Document History and Development ...................................................................... 98-99
Document History ..............................................................................................................98
ICSI Document Development and Revision Process .........................................................99

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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
䕶iden捥 䝲ading
Literature Search
$ F R Q V L V W H Q W D Q G G H Q H G S U R F H V V L V X V H G I R U O L W H U D W X U H V H D U F K D Q G U H Y L H Z I R U W K H G H Y H O R S P H Q W D Q G U H Y L V L R Q R I
ICSI guidelines. 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 recommenda -
tions, 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.
GRADE Methodology
Following a review of several evidence rating and recommendation writing systems, ICSI has made a decision
to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
GRADE has advantages over other systems including the current system used by ICSI. Advantages include:
G H Y H O R S H G E \ D Z L G H O \ U H S U H V H Q W D W L Y H J U R X S R I L Q W H U Q D W L R Q D O J X L G H O L Q H G H Y H O R S H U V
H [ S O L F L W D Q G F R P S U H K H Q V L Y H F U L W H U L D I R U G R Z Q J U D G L Q J D Q G X S J U D G L Q J T X D O L W \ R I H Y L G H Q F H U D W L Q J V
F O H D U V H S D U D W L R Q E H W Z H H Q T X D O L W \ R I H Y L G H Q F H D Q G V W U H Q J W K R I U H F R P P H Q G D W L R Q V W K D W L Q F O X G H V D
W U D Q V S D U H Q W S U R F H V V R I P R Y L Q J I U R P H Y L G H Q F H H Y D O X D W L R Q W R U H F R P P H Q G D W L R Q V
F O H D U S U D J P D W L F L Q W H U S U H W D W L R Q V R I V W U R Q J Y H U V X V Z H D N U H F R P P H Q G D W L R Q V I R U F O L Q L F L D Q V S D W L H Q W V D Q G
S R O L F \ P D N H U V
H [ S O L F L W D F N Q R Z O H G J H P H Q W R I Y D O X H V D Q G S U H I H U H Q F H V D Q G
H [ S O L F L W H Y D O X D W L R Q R I W K H L P S R U W D Q F H R I R X W F R P H V R I D O W H U Q D W L Y H P D Q D J H P H Q W V W U D W H J L H V
, Q W K H * 5 $ ’ ( S U R F H V V H Y L G H Q F H L V J D W K H U H G U H O D W H G W R D V S H F L F T X H V W L R Q 6 \ V W H P D W L F U H Y L H Z V D U H X W L O L ] H G
U V W ) X U W K H U O L W H U D W X U H L V L Q F R U S R U D W H G Z L W K U D Q G R P L ] H G F R Q W U R O W U L D O V R U R E V H U Y D W L R Q D O V W X G L H V 7 K H H Y L G H Q F H
addresses the same population, intervention, comparisons and outcomes. The overall body of evidence for
H D F K W R S L F L V W K H Q J L Y H Q D T X D O L W \ U D W L Q J
2 Q F H W K H T X D O L W \ R I W K H H Y L G H Q F H K D V E H H Q G H W H U P L Q H G U H F R P P H Q G D W L R Q V D U H I R U P X O D W H G W R U H ` H F W W K H L U
V W U H Q J W K 7 K H V W U H Q J W K R I D U H F R P P H Q G D W L R Q L V H L W K H U V W U R Q J R U Z H D N / R Z T X D O L W \ H Y L G H Q F H U D U H O \ K D V D
V W U R Q J U H F R P P H Q G D W L R Q 2 Q O \ R X W F R P H V W K D W D U H F U L W L F D O D U H F R Q V L G H U H G W K H S U L P D U \ I D F W R U V L Q ` X H Q F L Q J D
recommendation and are used to determine the overall strength of this recommendation. Each recommen-
G D W L R Q D Q V Z H U V D I R F X V H G K H D O W K F D U H T X H V W L R Q
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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 or 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 a recommendation that
likely applies to most 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.

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Recommendations Table
The following table is a list of evidence-based recommendations for the Prevention and Management of
Obesity for Adults.
Note: Other recommendation language may appear throughout the document as a result of work group
consensus but is not included in this evidence-based recommendations table.


Topic Quality of
Evidence
Recommendations Strength of
Recommendation
Annotation
Number
Relevant
Resources
Measure height
and weight,
and calculate
body mass
index
High 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 (see
Table 3). Educate
patients about their
body mass index and
associated risks for
them.
Strong 1 LeBlanc, 2011;
McTigue, 2003
Measure height
and weight,
and calculate
body mass
index
Moderate Clinicians should
consider waist
circumference
measurement to
estimate disease risk for
patients who have
normal or overweight
BMI scores. Refer to
Table 2 for disease risk
relative to weight and
waist circumference.
Strong 1 National Heart,
Lung and Blood
Institute, 2013;
LeBlanc, 2011

Measure height
and weight,
and calculate
body mass
index
Moderate Clinicians need to
carefully consider BMI
and its associated
mortality risk across
different ethnicity, sex
and age groups.
Strong 1 LeBlanc, 2011
Assess for
major and
minor
comorbid
conditions
Moderate 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.
Weak 7 National Heart,
Lung and Blood
Institute, 2013
Is the patient
ready to lose
weight?
Moderate Clinicians should use
motivational
interviewing techniques
as a tool for
encouraging behavior
change.
Strong 8 Rollnick, 2000



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䙯re睯rd
䥮trod畣tion
Obesity is a chronic, multifactorial disease with complex psychological, environmental (social and cultural),
J H Q H W L F S K \ V L R O R J L F P H W D E R O L F D Q G E H K D Y L R U D O F D X V H V D Q G F R Q V H T X H Q F H V 7 K H S U H Y D O H Q F H R I R Y H U Z H L J K W
and obese people is increasing worldwide at an alarming rate in both developing and developed countries.
Environmental and behavioral changes brought about by economic development, modernization and urban-
L ] D W L R Q K D Y H E H H Q O L Q N H G W R W K H U L V H L Q J O R E D O R E H V L W \ 7 K H K H D O W K F R Q V H T X H Q F H V D U H E H F R P L Q J D S S D U H Q W
Obesity is a national epidemic in the United States with 78 million obese adults (Ogden, 2012 [Reference]) .
In 2009-2010, the prevalence of obesity was 35.5% among men and 35.8% among women (Flegal, 2012
[Reference]). The prevalence of extreme obesity has also increased. Approximately 6% of U.S. adults now
have a BMI of 40 kg/m2 or higher (The Surgeon General's Vision for a Healthy and Fit Nation, 2010 [Refer -
ence]). One in every three children (31.7%) is overweight or obese (White House Task Force on Childhood
Obesity, 2010 [Reference]) 0 R U H W K D Q R Q H T X D U W H U R I D O O $ P H U L F D Q V D J H V D U H X Q T X D O L H G I R U P L O L W D U \
service because they are too heavy (White House Task Force on Childhood Obesity, 2010 [Reference]).
6 S H F L F D O O \ R I F K L O G U H Q Z H U H F R Q V L G H U H G R E H V H L Q (Ogden, 2012 [Reference]). This data
is concerning, for the Healthy People 2010 goals for obesity prevalence in the United States were not met
(National Center for Health Statistics, 2012 [Reference]).
Medical costs associated with obesity were estimated at as much as $147 billion to $210 billion a year
(Robert Wood Johnson Foundation, 2012 [Reference]). Obese persons had estimated medical costs that
were $1,429 higher per person, per year than persons of normal weight (Finkelstein, 2009 [Reference]).
Obesity is the second leading cause of preventable death in the U.S., with only tobacco use causing more
deaths (New York State Department of Health, 2011 [Reference]). More than 112,000 preventable deaths per
year are associated with obesity (Surgeon General's Vision for a Healthy and Fit Nation, 2010 [Reference]).
2 E H V L W \ D Q G P D M R U G H S U H V V L R Q I U H T X H Q W O \ F R R F F X U $ P H W D D Q D O \ V L V V W X G \ V K R Z H G R E H V L W \ Z D V I R X Q G W R E H
an increased risk of depression, and depression was found to be a predictor of developing obesity (Floriana,
2010 [Reference]).
Several of the comorbidities associated with obesity include type 2 diabetes, heart disease, hypertension,
dyslipidemia and certain cancers (Withrow, 2010 [Reference]). The prevalence of various medical condi-
tions increases with those who are overweight and obese as shown in Tables 1 and 2.
1 R W H 6 R P H V W X G L H V V K R Z V L J Q L F D Q W H W K Q L F Y D U L D E L O L W \ (Flegal, 2012 [Reference]; Hedley, 2004 [Refer-
ence]; Ogden, 2002 [Reference]).
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Prevention and Management of Obesity for Adults
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?
7 D E O H 3 U H Y D O H Q F H R I & R P R U E L G & R Q G L W L R Q V E \ % R G \ 0 D V V , Q G H [ & D W H J R U \ $ G X O W V $ J H G 8 Q L W H G
States, 2000-2002 Behavioral Risk Factor Surveillance System

Body Mass Index 



Normal
(18.5-24.9)
Overweight
(25.0-29.9)
Obese Class 1
(30.0-34.9)
Obese Class 2
(35.0-39.9)
Obese Class 3
( 40.0)
Diabetes 4.8 (4.7-5.0) 7.5 (7.3-7.7) 13.4 (13.0-13.8) 19.8 (18.9-20.7) 26.4 (25.0-27.8)
Asthma 9.6 (9.4-9.8) 9.9 (9.7-10.1) 12.6 (12.2-13.0) 16.0 (15.2-16.8) 21.9 (20.5-23.2)
Arthritis 22.3 (21.9-22.6) 25.6 (25.2-26.0) 32.3 (31.8-32.9) 38.5 (37.4-39.5) 47.1 (45.4-48.7)
High blood
pressure
19.1 (18.6-19.6) 28.9 (28.3-29.4) 39.5 (38.6-40.5) 46.7 (44.9-48.4) 53.5 (51.0-55.9)
High
cholesterol
24.7 (24.1-25.3) 32.5 (31.9-33.2) 37.6 (36.5-38.7) 37.0 (35.1-39.0) 36.0 (33.4-38.7)
Fair/Poor
Health
13.1 (12.8-13.3) 14.7 (14.5-15.0) 20.9 (20.4-21.4) 28.6 (28.6-30.6) 39.4 (37.9-40.9

Jenkins TM. Prevalence of overweight, obesity, and comorbid conditions among U.S. and Kentucky
adults, 2000-2002. Prev Chronic Dis 2005 Jan. Available from URL: http://www.cdc.gov/pcd/issues/2005/
jan/04_0087.htm .
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卣o灥 and ?arget Po灵lation
This guideline addresses the prevention, diagnosis and management of obesity in adult patients, and includes
behavioral approaches, drug treatment and surgery.
This guideline does not address pregnant women or bodybuilders/weight trainers.
Return to Table of Contents
Aims
1. Increase percentage of patients 18 years and older who have an annual screening for obesity using body
P D V V L Q G H [ % 0 , P H D V X U H V S H F L F I R U D J H D Q G J H Q G H U Annotation #1)
2. Increase the percentage of patients age 18 years and older with BMI > 25 kg/m
2
who have received
education and counseling regarding weight management. (Annotations #8, 10)
3. Increase the percentage of patients age 18 years and older with BMI > 25 who have improved outcomes
from the treatment. (Annotations #8, 10)
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䍬ini捡l 䡩ghlights
Obesity is a chronic disease that is a multifactorial, growing epidemic with complex political, social,
psychological, environmental, economic and metabolic causes and consequences. Obesity affects
essentially every organ system in the body. Health consequences increase across the body mass index
span, not just for the extremely obese. (Introduction)
Calculate the body mass index; classify the individual based on the body mass index categories. Educate
patients about their body mass index and their associated risks. (Annotation #1; Aim #1)
Effective weight management strategies are available and include nutrition, physical activity, lifestyle
changes, medication and surgery. (Annotation #6; Aim #2)
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$ Z H L J K W O R V V F D Q U H G X F H D S D W L H Q W V U L V N R I K H D U W G L V H D V H D Q G G L D E H W H V W K D W L V F O L Q L F D O O \ V L J Q L F D Q W
and should be encouraged for all patients who are overweight and obese. This amount of weight loss
and maintenance should be considered a clinical success and commended. This can be achieved and
maintained with a high-intensity medical weight loss program even for the morbidly obese. (Annotation
#8; Aim #2)
The clinician should follow the 5 A’s (Ask, Advise, Assess, Assist, Arrange). Physician intervention
F D Q E H H I I H F W L Y H W K H F O L Q L F L D Q F D Q K D Y H D Q L P S R U W D Q W L Q ` X H Q F H D Q G V X F F H V V I X O Z H L J K W P D Q D J H P H Q W L V
possible. (Annotation #8; Aim #3)
: H L J K W P D Q D J H P H Q W U H T X L U H V D W H D P D S S U R D F K % H D Z D U H R I F O L Q L F D O D Q G F R P P X Q L W \ U H V R X U F H V 7 K H
patient needs to have an ongoing therapeutic relationship and follow-up with a health care team. Weight
F R Q W U R O L V D O L I H O R Q J F R P P L W P H Q W D Q G W K H K H D O W K F D U H W H D P F D Q D V V L V W Z L W K V H W W L Q J V S H F L F J R D O V Z L W K W K H
patient. (Annotations #10, 13; Aim #2)
Beyond their clinical role, primary care clinicians should be aware of their roles as community leaders
and public health advocates. (Annotations #10, 13; Aim #4)
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䥭灬ementation 剥捯mmendation 䡩ghlights
7 K H I R O O R Z L Q J V \ V W H P F K D Q J H V Z H U H L G H Q W L H G E \ W K H J X L G H O L Q H Z R U N J U R X S D V N H \ V W U D W H J L H V I R U K H D O W K F D U H
systems to incorporate in support of the implementation of this guideline.
( V W D E O L V K D V \ V W H P I R U X V L Q J D 3 D W L H Q W 5 H D G L Q H V V 6 F D O H W R G H W H U P L Q H L I W K H S D W L H Q W L V U H D G \ W R W D O N D E R X W
weight loss and/or would like information.
( V W D E O L V K D V \ V W H P I R U V W D I I W R H I F L H Q W O \ F D O F X O D W H % 0 , S U L R U W R W K H F O L Q L F L D Q H Q W H U L Q J W K H H [ D P U R R P
The BMI may provide more health risk information than traditional vital signs and should be built into
the patient assessment protocol. A BMI chart should be placed by each scale in the clinic. All orga-
nizations with electronic medical records should build BMI calculators as a component for immediate
calculation.
’ H Y H O R S D W U D F N L Q J V \ V W H P W K D W S H U L R G L F D O O \ U H Y L H Z V S D W L H Q W F K D U W V W R L G H Q W L I \ S D W L H Q W V Z K R D U H R Y H U Z H L J K W
or obese so that clinicians are aware of the need to discuss the issue with the patient.
( V W D E O L V K D V \ V W H P I R U V W D I I D Q G F O L Q L F L D Q W U D L Q L Q J D U R X Q G V N L O O V D Q G N Q R Z O H G J H L Q W K H D U H D V R I P R W L Y D W L R Q D O
L Q W H U Y L H Z L Q J E U L H I I R F X V H G D G Y L F H R Q Q X W U L W L R Q S K \ V L F D O D F W L Y L W \ D Q G O L I H V W \ O H F K D Q J H V D Q G H Y D O X D W L R Q
of evidence of effectiveness of treatment options.
( V W D E O L V K D V \ V W H P I R U F R Q W L Q X L Q J H G X F D W L R Q R Q H Y L G H Q F H E D V H G R E H V L W \ P D Q D J H P H Q W I R U F O L Q L F L D Q V
nurses and ancillary clinic staff.
5 H P R Y H E D U U L H U V W R U H I H U U D O S U R J U D P V I R U Z H L J K W O R V V E \ X Q G H U V W D Q G L Q J Z K H U H S U R J U D P V D U H D Q G Z K D W
S U R F H V V L V U H T X L U H G I R U U H I H U U D O V
’ H Y H O R S P H G L F D O U H F R U G V \ V W H P V W R W U D F N V W D W X V R I S D W L H Q W V X Q G H U W K H F O L Q L F L D Q V F D U H Z L W K W K H F D S D E L O L W \
to produce an outpatient tracking system for patient follow-up by clinician/staff.
8 V H W R R O V V X F K D V S R V W H U V D Q G E U R F K X U H V W K U R X J K R X W W K H I D F L O L W \ W R D V V L V W Z L W K L G H Q W L I \ L Q J D Q G Q R W L I \ L Q J
patients about health risk in relationship to NIH-based categories of BMI. Promote a healthy lifestyle
around nutrition and activity while encouraging patient knowledge of his or her BMI.
’ H Y H O R S S D W L H Q W F H Q W H U H G H G X F D W L R Q D Q G V H O I P D Q D J H P H Q W S U R J U D P V Z K L F K P D \ L Q F O X G H V H O I P R Q L W R U L Q J
self-management and skills such as journaling.
% X L O G V \ V W H P V W R W U D F N R X W F R P H V P H D V X U H V D V Z H O O D V R Q J R L Q J S U R F H V V P H D V X U H V 7 U D F N W K H U H V S R Q V H
rate to various treatments/strategies. Improvement rates the BMI is stable or has decreased over time.
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Prevention and Management of Obesity for Adults
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6 \ V W H P V W R F R R U G L Q D W H F D U H H Q V X U H F R Q W L Q X L W \ D Q G N H H S F O L Q L F L D Q V L Q I R U P H G R I S U R J U H V V
- Develop electronic tracking systems for panel or population management.
- Educate patients to foster awareness and knowledge of BMI for self-monitoring and reporting.
- Structure follow-up visits with patient per guideline recommendations.
Return to Table of Contents
Related ICSI Scientific Documents
Guidelines
Hypertension Diagnosis and Treatment
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults
Lipid Management in Adults
Major Depression in Adults in Primary Care
Preventive Services for Adults
Assessment and Management of Chronic Pain
Return to Table of Contents
Definition
Clinician All health care professionals whose practice is based on interaction with and/or treatment of a
patient.
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Prevention and Management of Obesity for Adults
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10
Algorithm Annotations
ㄮ 䵥as畲e 䡥ight and ? eightⰠand 䍡l捵late 䉯d礠䵡ss 䥮de?
Recommendations:
& O L Q L F L D Q V V K R X O G F D O F X O D W H E R G \ P D V V L Q G H [ % 0 , I R U W K H L U S D W L H Q W V R Q D Q D Q Q X D O E D V L V
for screening, and as needed for management. Classify BMI based on the National
Institute of Health categories (see Table 3). Educate patients about their BMI and
associated risks for them (Strong Recommendation, High Quality Evidence) (McTigue,
2003; LeBlanc, 2011).
& O L Q L F L D Q V V K R X O G F R Q V L G H U Z D L V W F L U F X P I H U H Q F H P H D V X U H P H Q W W R H V W L P D W H G L V H D V H U L V N
for patients who have normal or overweight BMI scores. Refer to Table 2 for disease
risk relative to weight and waist circumference (Strong Recommendation, Moderate
Quality Evidence) (National Heart, Lung and Blood Institute, 2013; LeBlanc, 2001).
& O L Q L F L D Q V Q H H G W R F D U H I X O O \ F R Q V L G H U % 0 , D Q G L W V D V V R F L D W H G P R U W D O L W \ U L V N D F U R V V
different ethnicity, sex and age groups (Strong Recommendation/Moderate Quality
Evidence) (LeBlanc, 2011).
BMI continues to be a common and reasonably reliable measurement to identify overweight and obese adults
Z K R P D \ E H D W D Q L Q F U H D V H G U L V N I R U I X W X U H P R U E L G L W \ $ O W K R X J K J R R G T X D O L W \ H Y L G H Q F H V X S S R U W V R E W D L Q L Q J D
BMI, it is important to recognize it is not a perfect measurement. BMI is not a direct measure of adiposity
D Q G D V D F R Q V H T X H Q F H L W F D Q R Y H U R U X Q G H U H V W L P D W H D G L S R V L W \ % 0 , L V D G H U L Y H G Y D O X H W K D W F R U U H O D W H V Z H O O
with total body fat and markers of secondary complications, e.g., hypertension and dyslipidemia (Barlow,
2007 [Reference]). An abnormally high body mass index does not address the distribution of body fat,
i.e., central versus peripheral or visceral versus subcutaneous. Central or visceral fat carry greater risk for
morbidity and mortality. BMI is solely dependent on height and weight, and does not consider other factors
such as a person’s physical activity level, sex or age.
In contrast, waist circumference is positively associated with abdominal fat, which is an independent predictor
of risk factors and morbidity of obesity-related diseases (Anuradha, 2012 [Reference]). Waist circumference
should be measured midway between the lowest ribs and the iliac crest (Ma, 2013 [Reference]). At BMIs
! R U H T X D O W R Z D L V W F L U F X P I H U H Q F H S U R Y L G H V O L W W O H Y D O X H R Y H U % 0 , Y D O X H L Q S U H G L F W L Q J G L V H D V H U L V N : D L V W
circumference cut points can generally be applied to all adult ethnic or racial groups (National Heart, Lung
and Blood Institute, 2013 [Moderate Quality Evidence]).
In contrast with waist circumference, BMI and its associated disease and mortality risk appear to vary among
ethnic subgroups. Female African American populations appear to have the lowest mortality risk at a BMI
of 26.2-28.5 kg/m
2
and 27.1-30.2 kg/m
2
for women and men, respectively. In contrast, Asian populations
may experience lowest mortality rates starting at a BMI of 23 to 24 kg/m
2
. The correlation between BMI
and diabetes risk also varies by ethnicity (LeBlanc, 2011 [Moderate Quality Evidence]). In addition, in
adults older than 65 years, waist circumference, but not BMI, is associated with greater mortality risk. It
is important to not rely solely on BMI scores to predict future mortality risk across different populations.
Other screening tools are available, as well. These include waist-to-hip ratio (WHR) measurement,
bioimpedance (BIA), dual-energy x-ray absorptiometry (DXA) and the recently proposed Body Adiposity
Index (BAI= [hip circumference]/[height] 1.5-18 (Suchanek, 2012 [Reference]). Some research indicates
if BMI is known, BAI provides little additional information of CHD risk factors and is not shown to be a
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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013

Institute for Clinical Systems Improvement


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11
replacement for BMI in the Caucasian population (Freedman, 2012 [Reference]; Suchanek, 2012 [Refer-
ence]). Further BAI measurement research is needed. In the clinical setting, BMI and waist circumference
P H D V X U H P H Q W V D U H Q R W D V V R F L D W H G Z L W K D Q \ G L U H F W S K \ V L F D O K D U P R Q H P X V W F R Q V L G H U S R V V L E O H V H F R Q G D U \ K D U P V
for example, potential negative self-esteem and associated stigma from BMI category label. Research is
extremely limited in this area but must be considered (LeBlanc, 2011 [Reference]).
7 D E O H & O D V V L F D W L R Q R I 2 Y H U Z H L J K W D Q G 2 E H V L W \ E \ % 0 , : D L V W & L U F X P I H U H Q F H D Q G $ V V R F L D W H G
Disease Risk*

Disease ?is欪 ?elative to ?ormal
?eight and ?aist ?ir捵m?eren捥

? ? 䤠??g⽭
?
? ? ?esit?
?lass
?en ? ㄰㈠捭
? ? ?? in⸩
?omen ? 㠸 捭
? ? ?? in⸩
?en ? ㄰㈠捭
? ? ?? in⸩
?omen ? 㠸 捭
? ? ?? in⸩
?n摥r?eight 1㠮?

ⴭⴭ? ⴭⴭ?
?ormal? 1㠮? ? 2㐮?
ⴭⴭ? ⴭⴭ?
?ver?eight 2㔮0 ? 2㤮?

Increase? ?igh
?besity 30?0 ? 3㐮? I ?igh ?ery ?igh

3㔮0 ? 3㤮? II ?ery ?igh ?ery ?igh
?硴reme
?besity
? 㐰 III ?硴remely ?igh ?硴remely ?igh

⨠ ?isease ris? for type 2 摩abetes? hypertension? an搠C噄?
? Increase搠?aist circumference can also be a mar?er for increase搠ris? even in persons of normal ?eight?
剥捯mmendation? 䙯r a摵lt patients 睩th a
䉍I of 2㔠to 3㐮㤠歧⽭
2
Ⱐse砭specific 睡ist
circumference cutoffs shoul搠be use搠in
con橵nction 睩th 䉍I to i?entify increase搠
摩sease ris欮

Table 3: Adult BMI Categories
BMI Category
Less than 18.5 Underweight
18.5-24.9 Normal weight
25-29.9 Overweight
30-34.9 Obese – class I
35-39.9 Obese – class II
40 or more Extreme obesity – class III
Return to Algorithm Return to Table of Contents
㘮 Advise ? eight 䵡intenan捥 and 䵡nage 佴her 剩s欠䙡捴ors
Lifetime risk of obesity is high for residents of the United States. Lifetime risk of diabetes is about 32.4%
for men and 35.5% for women, and lifetime risk for obesity is higher than this (Flegal, 2010 [Referemce]).
Therefore, it is important to address the issue of weight maintenance for those with body mass index in
the normal range (18.5 to 24.9 kg/m
2
6 X F F H V V I X O Z H L J K W P D Q D J H P H Q W U H T X L U H V D O L I H V W \ O H D S S U R D F K W K D W
integrates physical activity, nutrition, behavioral management and attention to psychosocial needs.
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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

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12
) L U V W H Q F R X U D J H U H J X O D U S K \ V L F D O D F W L Y L W \ D W U H F R P P H Q G H G O H Y H O V 5 H J X O D U S K \ V L F D O D F W L Y L W \ L V
strongly related to maintaining normal weight. In selecting types of physical activity, it is important
to consider the age of the patient, musculoskeletal limitations and availability of exercise facilities.
For inactive patients, this may include as little as 10 minutes of physical activity a day. Ideally, 30 to
60 minutes of moderate physical activity on most days of the week is recommended (> 150 minutes
a week). However, for those who have lost a considerable amount of weight, higher amounts of
S K \ V L F D O D F W L Y L W \ P D \ E H U H T X L U H G I R U Z H L J K W P D L Q W H Q D Q F H ! P L Q X W H V D Z H H N ( Q M R \ P H Q W D Q G
variety of physical activity are also key features for adherence (Jakicic, 2011 [Reference]; Donnelly,
2009 [Reference]) .
6 H F R Q G S U R Y L G H V W U X F W X U H G O L I H V W \ O H P R G L F D W L R Q V X J J H V W L R Q V W K D W L Q F O X G H V S H F L F Q X W U L W L R Q U H F R P-
P H Q G D W L R Q V H G X F D W L R Q D O V H V V L R Q V D Q G I U H T X H Q W F R Q W D F W Z L W K K H D O W K F D U H F O L Q L F L D Q V V X F K D V D G L H W L W L D Q
Focus on calorie balancing, using a combination of decreased caloric intake with increased calorie
H [ S H Q G L W X U H , Q F O X G H Q X W U L W L R Q H G X F D W L R Q H J L Q W H U S U H W L Q J I R R G O D E H O V P D Q D J L Q J U H V W D X U D Q W D Q G
V R F L D O H D W L Q J V L W X D W L R Q V P D N L Q J K H D O W K \ Q X W U L W L R X V I R R G F K R L F H V X V L Q J S R U W L R Q F R Q W U R O D Q G U H F L S H
P R G L \ L Q J
There is considerable evidence that individuals consuming low-fat, low-calorie diets are successful at
maintaining weight loss for 12 months and longer. Data from the National Weight Control Registry demon -
strates that successful weight maintainers consume a low-calorie diet containing ~ 40 g fat (24% of calories),
200 g carbohydrate (56% of calories) and 70 g protein (19% of calories). A low-fat diet (25-30%
calories from fat) is considered the conventional therapy for treating obesity (Klein, 2004 [Refer-
ence]). Data is emerging to suggest that patients who are insulin resistant may respond better to
a lower carbohydrate diet (< 30% carbohydrate). This may also be linked to genetics (Gardner,
2007 [Reference]).
7 K L U G H Q F R X U D J H E H K D Y L R U P D Q D J H P H Q W V W U D W H J L H V W K D W P D \ L Q F O X G H Z H H N O \ Z H L J K W F K H F N V I R R G
journals and monitoring daily routine that focuses on a balanced lifestyle. Balance includes eating a
nutritionally balanced breakfast soon after awakening and eating balanced meals at regular intervals
W K H U H D I W H U L Q F R U S R U D W L Q J I X Q S K \ V L F D O D F W L Y L W \ L Q W R W K H G D \ D Q G V F K H G X O L Q J W K H Z H H N W R L Q F O X G H U H V W
play and social interactions along with work, school and family responsibilities.
6 S H F L F E H K D Y L R U D O V W U D W H J L H V W R S U R P R W H E H K D Y L R U F K D Q J H L Q F O X G H V H O I P R Q L W R U L Q J V R P H D V S H F W R I
E H K D Y L R U W K D W L Q L W V H O I W \ S L F D O O \ U H V X O W V L Q E H K D Y L R U F K D Q J H Q R Q I R R G U H Z D U G V D Q G S R V L W L Y H U H L Q-
I R U F H P H Q W V U H P L Q G H U V V W L P X O X V F R Q W U R O F K D Q J L Q J V R F L D O R U H Q Y L U R Q P H Q W D O F X H V W K D W W U L J J H U H D W L Q J
E H K D Y L R U V W U H V V P D Q D J H P H Q W S U R E O H P V R O Y L Q J D Q G K H O S L Q J S D W L H Q W V E H O L H Y H W K H \ F D Q E H V X F F H V V I X O
Return to Algorithm Return to Table of Contents
㜮 Assess 景r 䵡橯r and 䵩nor 䍯mor扩d 䍯nditions
Recommendation:
: D L V W F L U F X P I H U H Q F H J U H D W H U W K D Q R U H T X D O W R L Q F K H V I R U P D O H V D Q G L Q F K H V I R U
females is an additional risk factor for complications related to obesity. Measuring waist
circumference is recommended to further assess the patient (Weak Recommendation,
Moderate Quality Evidence) (National Heart, Lung and Blood Institute, 2013).
, W L V L P S R U W D Q W W R D V V H V V I R U F R P R U E L G F R Q G L W L R Q V D V W U H D W P H Q W G H F L V L R Q V D Q G R X W F R P H V P D \ E H L Q ` X H Q F H G
by their presence. Evaluation for depression, eating disorders and sleep disorders in particular are encour-
D J H G $ V V H V V P H Q W V K R X O G L Q F O X G H D F R P S O H W H P H G L F D O K L V W R U \ L Q F O X G L Q J L G H Q W L F D W L R Q R I P H G L F D W L R Q V W K D W
may include weight gain or interfere with weight loss.
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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

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www.icsi.org
13
Table 4. Prevention and Management of Obesity Interventions
BMI Comorbid
Condition
25- 30 kg/m
2
30- 35 kg/m
2
35- 40 kg/m
2
40 + kg/m
2

0 Counsel and
educate:
% ! $
% #
!
Counsel and educate:
% ! $
% #
!
% !
t
Counsel and educate:
% ! $
% #
!
% !
t
Counsel and educate:
% ! $
% #
!
% a ! and
"
t
1 - 2 Minor
Comorbid
Conditions
Counsel and
educate:
% ! $
% #
!
Counsel and educate:
% ! $
% #
!
% !
t
Counsel and educate:
% ! $
% #
!
% ! ! $
% " !
Counsel and educate:
% ! $
% #
!
% a ! and
"
t
Major
Comorbid
Conditions
OR
3 Minor
Comorbid
Conditions
Counsel and
educate:
% ! $
% #
!
% !
t
#
" ! $ $
! !
27
2
.
Counsel and educate:
% ! $
% #
!
% ! and
"
t

Counsel and educate:
% ! $
% #
!
% t and
s "
t
Counsel and educate:
% ! $
% #
!
% a ! and
s "
t

Minor Comorbid Conditions Major Comorbid Conditions

Cigarette smoking
Hypertension (BP greater than or equal to
140/90) or current use of antihypertensives


LDL cholesterol > 130 mg/dL
HDL cholesterol < 40 mg/dL

for men; less
than 50 mg/dL for women


Prediabetes*


Family history of premature coronary artery
disease
Age > 65 years for males
Age > 55 years for females or
menopausal females
Waist circumference (males > 40 inches,
females > 35 inches)


Established coronary artery disease
History of myocardial infarction
History of angioplasty
History of CABG
History of acute coronary syndrome
Peripheral vascular disease
Abdominal aortic aneurysm
Symptomatic carotid artery
disease
Type 2 diabetes mellitus
Obstructive sleep apnea

* The term pre-diabetes has been adopted by the American Diabetes Association and others, and refers to those who have a
fasting plasma glucose of 100 mg/dL to 125 mg/dL, those with a two-hour plasma glucose post- 75-gram-oral-glucose toler -
ance test value of 140 mg/dL to 199 mg/dL or those with a hemoglobin A1C in the range of 5.7-6.4%.
g
7 K H F O X V W H U L Q J R I W K H V H V \ P S W R P V K D V E H H Q G H V F U L E H G D V W K H P H W D E R O L F V \ Q G U R P H 6 H Y H U D O I R U P D O G H Q L W L R Q V H [ L V W (National
Heart, Lung and Blood Institute, 2013 [Moderate Quality Evidence]; de Ferranti, 2004 [Reference]; World Health Organi-
zation, 2004 [Reference]).
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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

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1?
Assessing for Depression
The evidence showing the linkage between depression and obesity is mixed (Jorm, 2003 [Reference]; Roberts,
2003 [Reference]; Friedman, 1995 [Reference]; DiPietro, 1992 [Reference]). Higher rates of depression
have been found in severely obese people, especially younger women with poor body image (Dixon, 2003
[Reference]; Onyike, 2003 [Reference]) , W L V G L I F X O W W R V W X G \ Z K H W K H U W K H G H S U H V V L R Q L V V H F R Q G D U \ W R
the obesity or to existing comorbid conditions (Stunkard, 2003 [Reference]). Weight loss often leads to
improvement of depression scores (Dixon, 2003 [Reference]).
’ H S U H V V L R Q L V L G H Q W L H G P R U H R I W H Q L Q R E H V H Z R P H Q D Q G W H H Q D J H U V D Q G L V O H V V O L N H O \ W R E H G L D J Q R V H G L Q P H Q
(Jorm, 2003 [Reference]; Stunkard, 2003 [Reference]; Palinkas, 1996 [Reference]; Istvan, 1992 [Refer-
ence]). Depression in the elderly is often associated with weight loss, while depression in younger females
can be associated with weight gain (DiPietro, 1992 [Reference]).
In the past, depression has been associated with poor weight-loss outcomes (Linde, 2004 [Reference]).
However, this is not necessarily the case. People with depression can do well in weight-loss treatment, and
their symptoms can improve (Linde, 2011 [Reference]).
Bariatric surgery patients with poorly managed depression or anxiety are at greater risk for weight regain
Z L W K L Q W K H U V W Y H S R V W R S H U D W L Y H \ H D U V (Waters, 1991 [Reference]). One explanation for this may be found
in a line of research investigating biological pathways that link depressive symptomatology to increased
adiposity and weight gain (Miller, 2003 [Reference]). Weight-loss studies have often excluded people with
depression (Linde, 2004 [Reference]). More studies to address this issue are warranted.
6 F U H H Q L Q J I R U G H S U H V V L R Q F D Q L Q F O X G H D V N L Q J W K H I R O O R Z L Q J T X H V W L R Q V
Over the past month, have you been bothered by:
O L W W O H L Q W H U H V W R U S O H D V X U H L Q G R L Q J W K L Q J V "
I H H O L Q J G R Z Q G H S U H V V H G R U K R S H O H V V "
, I W K H S D W L H Q W D Q V Z H U V \ H V W R H L W K H U R Q H R I W K H D E R Y H T X H V W L R Q V F R Q V L G H U X V L Q J D T X H V W L R Q Q D L U H W R I X U W K H U D V V H V V
Z K H W K H U W K H S D W L H Q W K D V V X I F L H Q W V \ P S W R P V W R Z D U U D Q W D I X O O F O L Q L F D O L Q W H U Y L H Z D Q G D G L D J Q R V L V R I F O L Q L F D O
P D M R U G H S U H V V L R Q $ Q H [ D P S O H R I V X F K D T X H V W L R Q Q D L U H L V W K H 3 + 4 3 D W L H Q W + H D O W K 4 X H V W L R Q Q D L U H
This should not be considered a comprehensive screening for depression, which is beyond the scope of
this guideline. See the ICSI Major Depression in Adults in Primary Care guideline for more information.
The work group’s opinion is that patients who are clinically depressed should undergo treatment with
medication and/or psychotherapy to maximize their ability to lose weight. An antidepressant that does not
contribute to weight gain should be chosen. Medications such as bupropion, venlafaxine and sertraline have
been shown in clinical studies to be associated with the least weight gain over time.
Assessing for an Eating Disorder
Eating disorders, particularly binge eating disorder, may complicate the treatment of obesity.
$ V V H V V L Q J I R U H D W L Q J G L V R U G H U V F D Q L Q F O X G H D V N L Q J W K H I R O O R Z L Q J T X H V W L R Q V
’ R \ R X H D W D O D U J H D P R X Q W R I I R R G L Q D V K R U W S H U L R G R I W L P H † O L N H H D W L Q J P R U H I R R G W K D Q D Q R W K H U
S H U V R Q P D \ H D W L Q V D \ D W Z R K R X U S H U L R G R I W L P H "
’ R \ R X H Y H U I H H O O L N H \ R X F D Q W V W R S H D W L Q J H Y H Q D I W H U \ R X I H H O I X O O "
: K H Q \ R X R Y H U H D W Z K D W G R \ R X G R H J + D Y H \ R X H Y H U W U L H G W R J H W U L G R I W K H H [ W U D F D O R U L H V W K D W
\ R X Y H H D W H Q E \ G R L Q J V R P H W K L Q J O L N H 7 D N H O D [ D W L Y H V " 7 D N H G L X U H W L F V > R U Z D W H U S L O O V @ " 6 P R N H F L J D-
U H W W H V " 7 D N H V W U H H W G U X J V O L N H F R F D L Q H R U P H W K D P S K H W D P L Q H " 0 D N H \ R X U V H O I V L F N > L Q G X F H Y R P L W L Q J @ "
Return to Algorithm Return to Table of Contents
Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

Institute for Clinical Systems Improvement


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1?
, I W K H S D W L H Q W D Q V Z H U V \ H V W R D Q \ R I W K H D E R Y H T X H V W L R Q V F R Q V L G H U I X U W K H U H Y D O X D W L R Q R U D U H I H U U D O W R D
dietitian or a behavioral health specialist who specializes in eating disorders or in health psychology and
working with bariatric patients.
0 R U H F R P S U H K H Q V L Y H D V V H V V P H Q W W R R O V L Q F O X G H W K H 6 & 2 ) ) 4 X H V W L R Q Q D L U H R U ( D W L Q J $ W W L W X G H V 7 H V W ( $ 7
Assessing for Medication Use That Contributes to Weight Gain
The assessment of the obese patient should include a complete medication history to identify medications that
P D \ L Q G X F H Z H L J K W J D L Q R U L Q W H U I H U H Z L W K Z H L J K W O R V V 1 R Q V W H U R L G D O D Q W L L Q ` D P P D W R U \ G U X J V D Q G F D O F L X P
channel blockers may cause peripheral edema rather than body fat weight gain. HIV protease inhibitors are
associated with lipodystrophy (central obesity) that is actually a change in body fat distribution rather than a
body fat weight gain. If possible, alternative medications that are weight-neutral or that induce weight loss
should be selected (Kushner, 2003b [Reference]; Vanina, 2002 [Reference]; Ganguli, 1999 [Reference]). A
common belief exists among women and clinicians that there is an association between the use of combina-
tion hormonal contraceptives and weight gain. This belief may prevent some women from starting hormonal
contraception or cause early discontinuation of medication. A review of 42 clinical trials including three
U D Q G R P L ] H G S O D F H E R F R Q W U R O O H G W U L D O V † G L G Q R W Q G H Y L G H Q F H W R V X S S R U W D F D X V D O U H O D W L R Q V K L S E H W Z H H Q W K H
use of combination oral contraceptives and weight gain. The authors of the review concluded that current
H Y L G H Q F H L V Q R W V X I F L H Q W W R G H W H U P L Q H W K H H I I H F W R I F R P E L Q D W L R Q F R Q W U D F H S W L Y H V R Q Z H L J K W E X W Q R O D U J H H I I H F W
is evident (Gallo, 2004 [Reference]).
Please see Appendix A, "Medications Associated with Weight Gain and Weight Loss," and the ICSI Diagnosis
and Management of Type 2 Diabetes Mellitus in Adults guideline for more information.
Assessing for a Sleep Disorder
Overweight and obese patients who have not had a sleep study should be encouraged to do so if they show
signs of sleep disturbance such as daytime somnolence, snoring, evidence of apnea episodes provided by a
partner, or issues with daytime memory and attention.
Assessing for sleep disorders such as sleep apnea and sleep-related eating disorder is important. Patients
with documented sleep apnea need to be encouraged to be compliant with their treatment plan in order to
improve their ability to lose weight. Sleep duration is important for weight loss, as well. Sleep curtailment
decreased the proportion of weight lost as fat by a total of 2.4% if patients slept for 5.5 hours compared to
5.4% if the patient slept for 8.5 hours (Nedeltcheva, 2010 [Reference]).
Return to Algorithm Return to Table of Contents
㠮 䥳 Patient 剥ad礠to 䱯se ? eight?
Recommendation:
& O L Q L F L D Q V V K R X O G X V H P R W L Y D W L R Q D O L Q W H U Y L H Z L Q J W H F K Q L T X H V D V D W R R O I R U H Q F R X U D J L Q J
behavior change (Strong Recommendation, Moderate Quality Evidence) (Rollnick,
2000).
Knowing the patient’s readiness to change can help the clinician understand a patient’s level of motivation
and how to tailor communication about weight loss. Patients will need to set realistic, achievable goals and
be held accountable to practice new behaviors that produce and maintain weight loss.
Introduction to Weight Management/Lifestyle Change
Weight management is a skill. Patients need to set realistic, achievable goals and to be held accountable to
practicing the new behaviors that produce and maintain weight loss. Recordkeeping or self-monitoring of
S U R J U H V V R Q V S H F L F E H K D Y L R U V L V N H \ W R V X F F H V V I X O Z H L J K W P D Q D J H P H Q W
Return to Algorithm Return to Table of Contents
Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

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1?
The ICSI Patient Advisory Council reviewed this guideline and supports the value of the clinician initiating
the conversation and suggested that patients were more likely to act on the recommendations of their clini-
cian. Also, because obesity can be an overwhelming condition for the patient, creating small achievable
goals and celebrating those achievements are important for continued success and healthy choices. We
U H F R P P H Q G W K D W F O L Q L F L D Q V J X L G H J R D O V X V L Q J W K H D F U R Q \ P 6 0 $ 5 7 V S H F L F P H D V X U D E O H D F W L R Q E D V H G
realistic, and time based).
Refer to Appendix K for a SMART Goal example tool.
Stages of Change Model
When evaluating a patient with obesity, it is recommended to get a general sense of his or her readiness to
F K D Q J H V S H F L F G L H W D U \ D Q G S K \ V L F D O D F W L Y L W \ K D E L W V
The Transtheorectical Model of Change, also known as the Stages of Change model, can be helpful to
X Q G H U V W D Q G Z K H U H L Q W K H S U R F H V V R I F K D Q J H W K H S D W L H Q W V W D Q G V 7 K L V F D Q E H R U J D Q L ] H G L Q W R Y H V W D J H V L Q F O X G L Q J
precontemplation, contemplation, preparation, action and maintenance.
During the precontemplation stage, patients are not willing to change at all. They may have tried to lose
weight unsuccessfully and given up. They may not see that a clinician’s advice to change their poor health
habits may apply to them directly.
In the contemplation stage, patients are starting to think about change but fearful about moving forward.
They know they should but have reservations perhaps about giving up something they enjoy very much.
The patient is interested in learning ways to lose weight. This is when the patient thinks about the pros and
cons of changing his or her behavior. The patient is not considering the change in the near future.
During the preparation stage, the patients are ready to make a change in their life but they do so in small
ways. They experiment with these changes. The patient may make the change in the next month.
The action stage occurs when a patient has made a determined effort to reach a goal. This should be recog-
nized by clinicians, and the patient should be encouraged to continue these good health practices. This is
usually about three to six months long.
The maintenance stage involves continuing to maintain the new behavior over time and therefore reinforcing
healthy habits. This stage is more than six months long.
Table 5. Stages of Change

Stage of Change Definition
Pre-Contemplation Not interested in changing behavior
Contemplation Starting to think about change but not
ready
Preparation Planning to change behavior
Action Practicing new behavior for a few months
Maintenance Continuing the new behavior for more
than six months

Overview of Motivational Interviewing (MI)
0 R W L Y D W L R Q D O L Q W H U Y L H Z L Q J L V D Q H P S D W K \ E D V H G S D W L H Q W F H Q W H U H G D S S U R D F K W R E H K D Y L R U P R G L F D W L R Q , W
has been shown to help patients set realistic, achievable goals and be held accountable to practicing new
behaviors. This is a reversal from the traditional role of the physician as advisor and expert "problem solver"
(Rollnick, 2008 [Reference]).
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Prevention and Management of Obesity for Adults
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7 K H V S L U L W R I 0 , L V W R H O L F L W I U R P S D W L H Q W V W K H L U R Z Q J R R G P R W L Y D W L R Q V I R U P D N L Q J E H K D Y L R U F K D Q J H V L W L V
collaborative, evocative and honors a patient’s autonomy. It recognizes that there is something in human
nature that resists being told what to do or being coerced (Rollnick, 2008 [Reference]).
The Guiding Principles of MI = RULE:
R: 5 H V L V W W K H U L J K W L Q J U H ` H [ 5 D W K H U V H H N W R [ D S D W L H Q W U H F R J Q L ] H W K H Q D W X U D O K X P D Q W H Q G H Q F \
to resist persuasion (especially the ambivalent). Aim to support the patient’s own discovery of the
reasons for change.
U: Understand your patient’s motivations. If your consultation time is limited, you are better off
asking patients why they would want to make a change and how they might do it, rather than telling
them that they should.
L: / L V W H Q W R \ R X U S D W L H Q W 0 , L Q Y R O Y H V D V P X F K O L V W H Q L Q J D V L Q I R U P L Q J P D L Q W D L Q H P S D W K H W L F L Q W H U H V W
and acknowledge that the answers most likely lie within the patient.
E: Empower your patient. MI helps patients explore how they can make a difference in their health.
A patient who is active in the consultation, thinking aloud about the why and how of change, is
more likely to do something about this afterward. Recognize and guide through "change talk" in
which the patient states the good reasons for and steps toward change, rather than resisting change.
(Rollnick, 2008 [Reference])
The goal of motivational interviewing is to move the patient along the "stages of change," from one stage
W R W K H Q H [ W 7 K H P D M R U L W \ R I S D W L H Q W V L Q W K H S U L P D U \ F D U H R I F H D U H H L W K H U S U H F R Q W H P S O D W L R Q R U F R Q W H P S O D-
tive (Prochaska, 1992 [Reference]). As such, the success of motivational interviewing lies in the physician
allowing the patient to "set the agenda" regarding which health behavior he or she is willing to address.
2 Q F H D W R S L F K D V E H H Q L G H Q W L H G 5 R O O Q L F N H W D O H P S K D V L ] H V H S D U D W L Q J U H D G L Q H V V W R F K D Q J H L Q W R W Z R E D V L F
H O H P H Q W V L P S R U W D Q F H D Q G F R Q G H Q F H 7 K H S D W L H Q W L V D V N H G W R U D W H K L V R U K H U S H U F H S W L R Q R I W K H L P S R U W D Q F H
R I K D E L W F K D Q J H R Q D V F D O H I R U H [ D P S O H I U R P 7 K H V D P H L V G R Q H I R U F R Q G H Q F H L Q V X F F H V V I X O K D E L W
change. Patients who attribute little importance to behavior change can be asked to assess what they like
about the particular behavior and what bothers them. Patients can then be asked to assess the pros and cons
R I P D N L Q J W K H E H K D Y L R U F K D Q J H 6 F D O L Q J T X H V W L R Q V F D Q D J D L Q E H D V N H G D V Z H O O D V F R P H E D F N T X H U L H V V X F K
D V < R X U D W H G ; D « Z K \ Q R W D "
3 D W L H Q W V Z K R O D F N F R Q G H Q F H L Q W K H L U D E L O L W \ W R H I I H F W D E H K D Y L R U F K D Q J H P D \ E H Q H W I U R P L Q Y H V W L J D W L R Q R I
S D V W V X F F H V V H V D Q G L G H Q W L F D W L R Q R I R E V W D F O H V , Q G L V F X V V L R Q R I K R Z W K H S D W L H Q W P L J K W R Y H U F R P H L G H Q W L H G
obstacles, it is important that the patient himself or herself generate solutions to his or her own problem,
and that the clinician refrain from slipping into the familiar role of advisor. In the event of a "mental block,"
S D W L H Q W V F D Q E H J L Y H Q E U D L Q V W R U P L Q J K R P H Z R U N W R E H D G G U H V V H G D W D V X E V H T X H Q W L Q W H U Y D O (Simons, 2007
[Reference]).
Refer to Appendix L for a sample of motivational interviewing scripting for adults.
See the Implementation Tools and Resources Table for links to video examples of motivational interviewing
W H F K Q L T X H V
The clinician should follow the 5 A’s (Ask, Advise, Assess, Assist, Arrange). Clinician intervention can be
H I I H F W L Y H D Q G W K H L Q ` X H Q F L D O D Q G V X F F H V V I X O P D Q D J H P H Q W L V S R V V L E O H
ASK about weight, measure height and weight and calculate BMI.
ADVISE to lose weight. In a clear, strong but sensitive and personalized manner, urge every over-
weight or obese patient to lose weight.
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Prevention and Management of Obesity for Adults
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1?
ASSESS U H D G L Q H V V W R O R V H Z H L J K W $ V N H Y H U \ R Y H U Z H L J K W R U R E H V H S D W L H Q W L I K H R U V K H L V U H D G \ W R
P D N H D Z H L J K W O R V V D W W H P S W D W W K H W L P H H J Z L W K L Q W K H Q H [ W G D \ V
ASSIST L Q Z H L J K W O R V V D W W H P S W + H O S W K H S D W L H Q W Z L W K D Z H L J K W O R V V S O D Q 5 H I H U W R D S S U R S U L D W H
U H V R X U F H V
ARRANGE I R O O R Z X S 6 F K H G X O H I R O O R Z X S F R Q W D F W H L W K H U L Q S H U V R Q R U Y L D W H O H S K R Q H
6 H H $ S S H Q G L [ 0 I R U G H W D L O V R Q W K H $ V
Return to Algorithm Return to Table of Contents
㤮 Assess 䝯als and 剩s欠䙡捴orsⰠand 䍯畮sel 剥garding ?eight
䵡intenan捥
6 H H $ Q Q R W D W L R Q 5 H D V V H V V * R D O V D Q G 5 L V N ) D F W R U V D Q G & R X Q V H O 5 H J D U G L Q J : H L J K W 0 D L Q W H Q D Q F H I R U
D G G L W L R Q D O L Q I R U P D W L R Q
Return to Algorithm Return to Table of Contents
㄰? 乥gotiate 䝯als and 䵡nagement 却rateg礠to A捨ieve ? eight
䱯ss⸠ 剥晥r to 剩s欭A灰ro灲iate 剥so畲捥s as 乥eded?
Nutrition
$ S S U R S U L D W H Q X W U L W L R Q W K H U D S \ I R U Z H L J K W P D Q D J H P H Q W Z L O O E H G H Y H O R S H G F R O O D E R U D W L Y H O \ Z L W K W K H S D W L H Q W
$ V V H V V P H Q W D Q G H G X F D W L R Q P D \ U H T X L U H D F O L Q L F L D Q Z L W K H [ S H U W L V H L Q Q X W U L W L R Q W K H U D S \ , W L V L P S R U W D Q W W K D W
F O L Q L F L D Q V X Q G H U V W D Q G D Q G V X S S R U W W K H J H Q H U D O S U L Q F L S O H V R I Q X W U L W L R Q U H F R P P H Q G D W L R Q V I R U Z H L J K W P D Q D J H P H Q W
Diet history or eating pattern history. $ I R R G E H Y H U D J H I U H T X H Q F \ F K H F N O L V W W K U H H G D \ I R R G E H Y H U D J H
U H F R U G D Q G Z H H N O \ I R R G E H Y H U D J H G L D U \ D U H F R P P R Q W R R O V X V H G W R F R O O H F W L Q I R U P D W L R Q D E R X W G L H W D U \ K D E L W V
Nutrition assessment. ( Y D O X D W H W K H S D W L H Q W V F X U U H Q W I R R G D Q G E H Y H U D J H F K R L F H V D Q G H D W L Q J D Q G G U L Q N L Q J
K D E L W V $ V V H V V P H Q W P D \ L Q F O X G H W K H I R O O R Z L Q J
Current intake of I R R G D Q G E H Y H U D J H calories and fat
Portion sizes and inclusion of all food groups
Under- or overconsumption of nutrients
Use of supplements
Use of meal replacements
Stage of behavior change for specific behaviors, such as fruit and vegetable consumption
Symptoms of possible eating disorder – triggers for overeating
Timing/consistency of meals and snacks
) R U P R U H L Q I R U P D W L R Q L Q F O X G L Q J L Q W H U D F W L Y H J X L G D Q F H I R U H Y D O X D W L Q J S R U W L R Q V L ] H V D Q G F D O R U L H D Q D O \ V L V W K H
Z R U N J U R X S U H F R P P H Q G V W K H & H Q W H U I R U 1 X W U L W L R Q 3 R O L F \ D Q G 3 U R P R W L R Q : H E V L W H D W K W W S Z Z Z X V G D J R Y
F Q S S D Q G F K R R V H P \ S O D W H J R Y
Nutrition recommendations. 6 H O H F W D P H D O S O D Q Q L Q J D S S U R D F K W K D W W K H S D W L H Q W L V Z L O O L Q J D Q G U H D G \ W R
L Q F R U S R U D W H L Q W R S U H V H Q W O L I H V W \ O H ’ L H W D U \ J X L G D Q F H V K R X O G E H L Q G L Y L G X D O L ] H G D Q G W D L O R U H G W R I R R G D Q G
E H Y H U D J H S U H I H U H Q F H V L W V K R X O G D O O R Z I R U ` H [ L E O H D S S U R D F K H V W R U H G X F L Q J F D O R U L H L Q W D N H 7 K H L Q L W L D O J R D O R I
Z H L J K W O R V V W K H U D S \ V K R X O G E H W R U H G X F H E R G \ Z H L J K W E \ D E R X W I U R P E D V H O L Q H : L W K V X F F H V V D Q G L I
Z D U U D Q W H G I X U W K H U Z H L J K W O R V V F D Q E H D W W H P S W H G (National Heart, Lung and Blood Institute, 2013 [Moderate
Quality Evidence])
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Prevention and Management of Obesity for Adults
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1?
Recommend:
$ F K L H Y L Q J Z H L J K W O R V V E \ D U H G X F W L R Q L Q F D O R U L H L Q W D N H $ P R G H U D W H G H F U H D V H L Q F D O R U L H V
kcal per day) can result in a progressive weight loss of 1-2 pounds per week. Weight loss should be
D E R X W R Q H W R W Z R S R X Q G V S H U Z H H N I R U D S H U L R G R I V L [ P R Q W K V Z L W K W K H V X E V H T X H Q W V W U D W H J \ E D V H G
on the amount of weight lost (National Heart, Lung and Blood Institute, 2013 [Moderate Quality
Evidence]).
$ Z H L J K W O R V V H D W L Q J S O D Q W K D W V X S S O L H V D W O H D V W N F D O G D \ I R U Z R P H Q D Q G
kcal/day for men (National Heart, Lung and Blood Institute, 2013 [Moderate Quality Evidence]).
A useful tool is the BMR calculator and can be accessed at bwsimulator.niddk.nih.gov.
Table 6: *Lower- Calorie Meal Plan for Weight Loss (NHLBI, 2000; NHLBI 2002)
Nutrient Recommended Intake
Calories 500 -1,000 kcal/day reduction from usual intake
Total fat 30% or less of total calories
Trans f at Less than or equal to 1% of total calorie s
Saturated fat 7- 10% of total calories
Monounsaturated fat Up to 15% of total calories
Protein 15% of total calories
Carbohydrates, complex, from variety of
vegetables, fruits and whole grains
55% of total calories
Fiber
Equal to or greater than 2 5- 35 grams

Interactive tool for meal planning is at nhbli: http://hp2010.nhlbihin.net/menuplanner/menu.cgi
* The macronutrient composition of weight loss diets continues to be controversial and the subject of
ongoing research.
$ Q H D W L Q J S O D Q W K D W L V E D O D Q F H G D Q G F R Q V L V W H Q W Z L W K R W K H U Q D W L R Q D O G L H W D U \ J X L G H O L Q H V (Esposito, 2003
[Reference]) ( Q F R X U D J H D W O H D V W Y H V H U Y L Q J V R I I U X L W V D Q G Y H J H W D E O H V S H U G D \ / L P L W I D W L Q W D N H W R
R I F D O R U L H V I U R P I D W R I F D O R U L H V I U R P V D W X U D W H G I D W O H V V W K D Q R U H T X D O W R W U D Q V I D W
( P S K D V L ] H Z K R O H J U D L Q V Z L W K D E H U L Q W D N H R I J U D P V R U P R U H G D L O \
. H H S W U D Q V I D W L Q W D N H E H O R Z D E R X W R I F D O R U L H V 7 K H O R Z H U W K H F R P E L Q H G L Q W D N H R I V D W X U D W H G D Q G
W U D Q V I D W D Q G W K H O R Z H U W K H G L H W D U \ F K R O H V W H U R O L Q W D N H W K H J U H D W H U W K H F D U G L R Y D V F X O D U E H Q H W Z L O O E H
(USDA, 2005 [Reference]). Reduce the amount of trans fat by limiting foods that contain "partially
hydrogenated" vegetable oils that may be found in some margarines, shortenings, crackers, candies,
baked goods, cookies, snack foods, fried foods, salad dressings and other processed foods.
All low-calorie diets will produce weight loss in the short term (3 to 12 months) (Bravata, 2003
[Reference]; Freedman, 2001 [Reference]; National Heart, Lung and Blood Institute, 2013
[Moderate Quality Evidence]). 0 R U H V W X G L H V D U H Q H H G H G W R G H W H U P L Q H O R Q J W H U P H I F D F \ R I Z H L J K W
loss and maintenance of low-carbohydrate (less than 100 grams) diets. Guidelines from the American
Diabetes Association state that for short-term weight loss, either a low-carbohydrate or low-fat
calorie-restricted diet may be effective. Initiated with a two-week phase of carbohydrate restriction
of 20-25 g daily depending on baseline weight, participants lost weight and were able to increase
carbohydrate intake at 5 g increments each week. Patients who are insulin resistant may respond
better to a lower-carbohydrate meal plan (< 30% carbohydrate) (Garder, 2007 [Reference]).
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Prevention and Management of Obesity for Adults
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20
Low-carbohydrate diets have been found to result in more rapid short-term weight loss than conven-
W L R Q D O O R Z F D O R U L H G L H W V D W W K U H H D Q G V L [ P R Q W K V E X W W K H G L I I H U H Q F H Z D V Q R W V L J Q L F D Q W D W R Q H \ H D U
Over a one-year period, low-carbohydrate diets have been found to result in greater improvements
than conventional diets in triglycerides and HDL cholesterol levels but not LDL cholesterol. Long-
term safety and effectiveness of low-carbohydrate diets for weight loss and cardiovascular risk
factor improvements are not yet known.
) R U L Q I R U P D W L R Q R Q S R S X O D U G L H W V V H H W K H Implementation Tools and Resources Table.
: H L J K W O R V V U H F R P P H Q G D W L R Q V W K D W H [ F O X G H I R R G J U R X S V D Q G R U U H V W U L F W P D F U R Q X W U L H Q W V V X E V W D Q W L D O O \
E H O R Z W K H G L H W D U \ U H I H U H Q F H L Q W D N H V D Q G 5 ’ $ V F D Q F D X V H Q X W U L H Q W G H F L H Q F L H V D Q G L Q F U H D V H K H D O W K
risks (Bonow, 2003 [Reference]; Freedman, 2001 [Reference]). A dietitian can assess food and
E H Y H U D J H U H F R U G V X V L Q J D Y D U L H W \ R I W R R O V $ T X L F N P H W K R G L V W R H Y D O X D W H S R U W L R Q V L ] H V D Q G Q X P E H U
of servings recommended for food groups http://www.choosemyplate.gov. There are also food
guide assessment tools available on the USDA Web site that calculate calories and total nutrients
from food records that are entered. See the Implementation Tools and Resources Table for more
information.
7 K H U H D U H U H Y L H Z V R I O R Z F R V W P R G H U D W H F R V W D Q G K L J K F R V W I R R G S O D Q V D Y D L O D E O H D W W K H 8 6 ’ $ : H E
site that evaluate the weekly cost of healthy eating plans. The Web site is http://www.cnpp.usda.
gov/USDAFoodPlansCostofFood.htm.
$ Q R W K H U P H D O S O D Q Q L Q J D S S U R D F K L V X W L O L ] L Q J P H D O U H S O D F H P H Q W V 7 K L V W \ S L F D O O \ L Q Y R O Y H V X V L Q J
frozen meals, formula shakes or bars or prepackaged meals to control portion sizes and simplify
food decisions. Drinks and bars are used to replace two meals and one snack per day. Most meal
replacements contain 200-400 calories, and additional servings of fruits and vegetables are recom-
mended. Weight maintenance usually involves replacing one meal per day (Delahanty, 2002
> 5 H I H U H Q F H @ + H \ P V H O G > 5 H I H U H Q F H @ . X V K Q H U D > 5 H I H U H Q F H @ .
Low-calorie diets (LCD) are less than 1,000 calories/day for weight loss in overweight and obese
persons. Reducing fat as part of an LCD is a practical way to reduce calories (Clinical Guidelines
R Q W K H , G H Q W L F D W L R Q ( Y D O X D W L R Q D Q G 7 U H D W P H Q W R I 2 Y H U Z H L J K W D Q G 2 E H V L W \ L Q $ G X O W V ( Y L G H Q F H
Report, 1998 [Reference]).
9 / & ’ V Y H U \ O R Z F D O R U L H G L H W V V K R X O G E H X V H G R Q O \ I R U Z H L J K W O R V V W K H U D S \ E \ H [ S H U L H Q F H G S U D F-
titioners with specialized monitoring and use of supplements (National Heart, Lung and Blood
Institute, 2000 [Reference]). , I 9 / & ’ V D U H X V H G Z H L J K W O R V V F D Q E H H [ S H F W H G L Q W K H U V W V L [ P R Q W K V
a N J R Q O H V V W K D Q F D O R U L H V G D \ K R Z H Y H U W K H U H L V U D S L G Z H L J K W U H J D L Q E H W Z H H Q W R
months if a maintenance program is not included. Weight loss is typically not maintained without
ongoing dietary and behavioral support (Paisey 2002 [Reference]; Torgerson, 1999 [Reference]).
6 X F F H V V I X O Z H L J K W O R V V P D L Q W H Q D Q F H L V V X V W D L Q H G E \ D F R P E L Q D W L R Q R I O R Z H U F D O R U L H L Q W D N H D Q G
increased physical activity (Franz, 2007 [Reference]; Freedman, 2001 [Reference]; Wing, 2001
[Reference]; McGuire, 1998 [Reference]). Analysis of data from the National Weight Control
Registry indicates weight-loss maintainers have an average intake of 1,400 kcal/day, get one hour
of moderate activity per day and eat breakfast daily.
$ O R Z J O \ F H P L F L Q G H [ G L H W L V Q R W P R U H H I I H F W L Y H W K D Q W U D G L W L R Q D O O R Z I D W G L H W I R U Z H L J K W O R V V R U
Z H L J K W P D L Q W H Q D Q F H L Q J H Q H U D O E X W P D \ E H E H Q H F L D O I R U S D W L H Q W V Z L W K F H U W D L Q U L V N I D F W R U V V X F K D V
insulin resistance (Gardner, 2007 [Reference]). More studies are needed to determine long-term
effect on hunger and satiety, as well as possible genetic predictors of dietary success (Ebbeling,
2005 [Reference]; Thompson, 2005 [Reference]).
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Prevention and Management of Obesity for Adults
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21
Physical Activity
Physical activity refers to all types and intensities of body movement, including activities of daily living.
( [ H U F L V H S K \ V L F D O W Q H V V D Q G W U D L Q L Q J D U H W H U P V W K D W V X J J H V W H O H Y D W H G L Q W H Q V L W \ D V H Q V H R I R E O L J D W L R Q R U V S R U W V
participation. These terms may have negative connotations for some obese patients. Physical activity is a
more inclusive, attainable and acceptable term.
3 K \ V L F D O L Q D F W L Y L W \ R U V H G H Q W D U \ O L I H V W \ O H K D V E H H Q S U H Y L R X V O \ L G H Q W L H G D V D Q L Q G H S H Q G H Q W U L V N I D F W R U I R U
cardiovascular disease (CVD) by the American Heart Association (Fletcher, 1992 [Reference]). Physical
inactivity is currently seen as a key contributor to the obesity problem. With approximately 60% of adults
in the United States overweight (Flegal, 2002 [Reference]), it is essential to improve physical activity levels
for the prevention and management of obesity.
While physical activity has long been recognized as an important component of a healthy lifestyle and
longevity (Paffenbarger, 1986 [Reference]), the work group recognizes that the literature on physical
activity in obesity prevention and management is extensive and the overall results are variable. Some of
the confusion arises from inherent individual variability in response to exercise (Skinner, 2001 [Reference]).
7 K H U H L V D O V R V L J Q L F D Q W L Q W H U V W X G \ Y D U L D E L O L W \ H J V H O I U H S R U W H G S K \ V L F D O D F W L Y L W \ F R P S D U H G W R P H D V X U H G
physical activity). There are variable exercise regimens and research designs that confound comparison of
results. This would suggest that selecting physical activity for weight loss is still largely patient preference
and compatibility with lifestyle.
Evidence still remains that increasing calorie expenditure by increasing physical activity is necessary for
improved weight-loss outcomes and weight maintenance (Esposito, 2003 [Reference]; Rejeski, 2002 [Refer-
ence]; National Heart, Lung and Blood Institute, 2000 [Reference]; Miller, 1997 [Reference]).
Improved outcomes for long-term weight reduction occur when a low-calorie intake is combined with
increased physical activity and behavior therapy (Diabetes Prevention Program Research Group, 2002
[Reference]; Rejeski, 2002 [Reference]; Freedman, 2001 [Reference]; Tuomilehto, 2001 [Reference]; Chao,
2000 [Reference]; National Heart, Lung and Blood Institute, 2000 [Reference]; National Heart, Lung and
Blood Institute, 1998 [Reference]; Miller, 1997 [Reference]).
6 S H F L F 5 R O H V I R U 3 K \ V L F D O $ F W L Y L W \ L Q 2 E H V L W \
Physical activity has several potential roles in obesity: prevention, acute weight loss, long-term weight loss,
Z H L J K W P D L Q W H Q D Q F H D Q G P H W D E R O L F W Q H V V Z L W K R U Z L W K R X W Z H L J K W O R V V $ E U L H I U H Y L H Z R I W K H O L W H U D W X U H Z L O O
be done for each potential role.
3 U H Y H Q W L R Q R I R E H V L W \
There is general consensus that energy expended in physical activity has the potential to affect energy
balance and weight regulation. There is some evidence that physical activity can minimize weight
gain (Jakicic, 2002 [Reference]). However, physical activity alone cannot be expected to over-
come unhealthy eating habits. Both must be balanced to prevent excessive weight gain. Evidence
has shown that it takes > 250 minutes/week to maintain weight after weight loss (Donnelly, 2009
[Reference]) , Q G L Y L G X D O U H T X L U H P H Q W V Z L O O O L N H O \ Y D U \ J L Y H Q D J H J H Q G H U R F F X S D W L R Q D O H Q H U J \
expenditure and habitual caloric intake. The current activity recommendation of 30 to 60 minutes
R I P R G H U D W H L Q W H Q V L W \ Y H G D \ V S H U Z H H N L V D U H D V R Q D E O H S R L Q W R I G H S D U W X U H I R U D Q L Q G L Y L G X D O L ] H G
activity prescription (Jakicic, 2001 [Reference]). However, 200-300 minutes/week of moderate-
intensity physical activity is recommended for long-term weight loss (Donnelly, 2009 [Reference]).
Becoming physically active is recognized as an important component of overall behavioral change
in obesity. See "Behavioral Management" further in this section.
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22
$ F X W H Z H L J K W O R V V
Without some control of caloric intake, studies suggest limited weight loss with exercise alone.
There is a 2 kg weight loss that is additive to dietary loss when patients exercise more than 150
minutes per week (Jakicic, 2011 [Reference]). There appear to be gender differences in exercise
effect while on ad libitum diets. Men were more likely to lose weight while women only prevented
weight gain (Donnelly, 2003 [Reference]). In the HERITAGE Family Study, men and women
of various ages (16-65), two races (black and white), and variable body composition were given
20 weeks of cycle ergometry endurance training, three days per week. All measures of body fat
decreased with training, and fat-free mass increased. The magnitude of the changes was judged
R I O L P L W H G E L R O R J L F D O V L J Q L F D Q F H * H Q G H U G L I I H U H Q F H V L Q W U D L Q L Q J U H V S R Q V H Z H U H Q R W H G (Wilmore,
1999 [Reference]).
/ R Q J W H U P Z H L J K W P D L Q W H Q D Q F H
The literature shows more support for the role of physical activity in preventing weight regain
(Pronk, 1994 [Reference]; Jeffery, 1984 [Reference]). A 16-week randomized controlled trial with
a one-year follow-up data on 40 obese women found that diet plus lifestyle activity was a suitable
alternative to diet plus structured aerobic activity (Andersen, 1999 [Reference]). Total weight
loss was not improved with aerobic exercise or strength training, but regular exercisers regained
V L J Q L F D Q W O \ O H V V Z H L J K W D W W K H R Q H \ H D U I R O O R Z X S (Wadden, 1998 [Reference]). Evidence shows
that weight maintenance is improved with > 250 minutes/week of moderate physical activity after
weight loss. However, no evidence from well-designed randomized controlled trials exists to judge
the effectiveness of physical activity for prevention of weight regain after weight loss (Donnelly,
2009 [Reference]).
/ R Q J W H U P Z H L J K W P D L Q W H Q D Q F H P D \ U H T X L U H D V P X F K S K \ V L F D O D F W L Y L W \ D V H [ S H Q G H G G X U L Q J W K H
weight-loss phase. As cited previously, data from the National Weight Control Registry indicates
that weight-loss maintainers get one hour or more of moderate activity per day.
0 H W D E R O L F W Q H V V Z L W K R U Z L W K R X W Z H L J K W O R V V
7 K H E H Q H F L D O H I I H F W V R I S K \ V L F D O D F W L Y L W \ H [ W H Q G E H \ R Q G Z H L J K W O R V V 7 K H U H L V Y H U \ V W U R Q J H Y L G H Q F H
that physical activity is important in the prevention and management of cardiovascular disease
(and related risk factors) and type 2 diabetes mellitus. The literature supports a role for physical
activity in improving metabolic syndrome with 5 to 10% weight loss (Goldstein, 1992 [Reference]).
, Q W H U P L W W H Q W H [ H U F L V H W Z R P L Q X W H E U L V N Z D O N V Y H G D \ V S H U Z H H N G L G Q R W U H V X O W L Q Z H L J K W O R V V
E X W G L G V L J Q L F D Q W O \ L P S U R Y H + ’ / D Q G L Q V X O L Q O H Y H O V L Q P R G H U D W H O \ R E H V H I H P D O H V (Donnelly, 2000
[Reference]). In men, weight loss induced by increased daily physical activity without caloric
restriction reduced abdominal obesity and insulin resistance. Exercise without weight loss reduced
D E G R P L Q D O I D W D Q G L P S U R Y H G F D U G L R Y D V F X O D U W Q H V V E X W Q R W L Q V X O L Q O H Y H O V (Ross, 2000 [Reference]).
Obese men and women with impaired glucose tolerance who received lifestyle intervention and
H [ H U F L V H F R X Q V H O L Q J K D G L P S U R Y H G Z H L J K W O R V V D Q G V L J Q L F D Q W O \ U H G X F H G S U R J U H V V L R Q W R G L D E H W H V
(Tuomilehto, 2001 [Reference]).
There are studies of physical activity that do not show an independent metabolic effect beyond
weight loss. In obese women, aerobic exercise and resistance exercise had no additional affect over
diet alone on weight loss, change in regional adiposity nor improvement in insulin or lipid levels
(Janssen, 2002 [Reference]).
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Prevention and Management of Obesity for Adults
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23
Physical activity prescription
Over 20 years ago it was suggested that clinicians write individualized exercise prescriptions (Gibson, 1983
[Reference]). The previously introduced National Heart, Lung and Blood Institute and AMA clinician guides
on obesity management contain sections on physical activity. Please see Appendix B, "Physical Activity
Prescription," for an example of a physical activity prescription.
Certain commercially available products such as pedometers and heart rate monitors may be helpful to
patients in order to monitor the daily physical activity levels (Stovitz, 2005 [Reference]).
Frequency
, Q J H Q H U D O W K U H H G D \ V S H U Z H H N L V D P L Q L P X P I U H T X H Q F \ W R L Q G X F H S K \ V L R O R J L F D G D S W D W L R Q V ’ L U H F W L P S U R Y H-
P H Q W V L Q E O R R G S U H V V X U H R U L Q V X O L Q V H Q V L W L Y L W \ U H T X L U H D O P R V W G D L O \ H [ H U F L V H 0 D Q \ F X U U H Q W D F W L Y L W \ U H J L P H Q V
U H F R P P H Q G Y H R U P R U H G D \ V S H U Z H H N W R U H D S H [ H U F L V H E H Q H W V ) U R P D E H K D Y L R U D O S H U V S H F W L Y H L W L V E H W W H U
W R V W D U W Z L W K D Q D W W D L Q D E O H I U H T X H Q F \ J R D O D Q G S U R J U H V V D V H [ H U F L V H F D S D F L W \ L P S U R Y H V + D Y L Q J D Y D U L H W \ R I
D F W L Y L W L H V D X J P H Q W V J U H D W H U I U H T X H Q F \ Z L W K R X W R Q V H W R I E R U H G R P R U E X U Q R X W ( Q M R \ P H Q W R I S K \ V L F D O D F W L Y L W \
is also a key feature for adherence.
Duration
The recommended duration of activity I R U W Q H V V H I I H F W V L V Y D U L D E O H 7 K H W U D G L W L R Q D O F D U G L R Y D V F X O D U W Q H V V
J X L G H O L Q H Z D V P L Q X W H V R I F R Q W L Q X R X V H [ H U F L V H D W R I P D [ L P D O K H D U W U D W H I R U W K U H H W R Y H G D \ V
per week. The current American College of Sports Medicine position is 30 minutes of moderate-intensity
activity on most days per week (Jakicic, 2001 [Reference]). Multiple short bouts of exercise for 10 minutes
duration also achieved cardiovascular improvement and weight loss with better program adherence (Jakicic,
1995 [Reference]). It has been found that moderate-intensity physical activity between 150 and 200 minutes/
week will improve weight loss in conjunction with moderate diet restriction. If this amount of physical
activity is used alone without diet restriction, there is only modest weight loss (Donnelly, 2009 [Reference]).
The Institute of Medicine has recommended 60 minutes a day of total physical activity time t o control
body weight. Prescribing a weekly energy expenditure of 2,500 kcal (~ 300 cal /day) improved weight
loss for overweight men and women compared to the standard 1,000 kcal/week (~150 cal/day) (Jeffery,
2003 [Reference]).
Intensity
7 K H D S S U R S U L D W H L Q W H Q V L W \ R I D F W L Y L W \ L V G L I F X O W W R D G M X V W I R U L Q G L Y L G X D O S D W L H Q W V 7 K H R E H V H S K \ V L F D O O \
deconditioned patient will have greater effort and perceived exertion at lower levels of exercise. At-risk,
obese patients with cardiovascular disease may warrant a treadmill evaluation to benchmark their current
exercise tolerance. Appropriate intensity may be estimated by the patient’s ability to talk during activity.
, Q D E L O L W \ W R F R Q Y H U V H V X J J H V W V D I D L U O \ U L J R U R X V H I I R U W W K D W Z L O O E H G L I F X O W W R V X V W D L Q ( [ F H V V L Y H L Q W H Q V L W \ R I
activity increases the risk of injury and likelihood of lost activity time. It is better to start at a sustainable
intensity level and progress as tolerated to continue improvement. Varying the intensity level by adding
intermittent hills or stairs will also improve capacity. Slowing the pace to recover breathing and complete
the duration of the exercise session is preferable.
3 K \ V L F D O D F W L Y L W \ L Q W H Q V L W \ F D Q E H T X D Q W L H G E \ F D O R U L F H [ S H Q G L W X U H S H U P L Q X W H R U K R X U 7 K H H V W L P D W L R Q
of calories used depends on weight and intensity of movement. There are extensive reference tables for
caloric expenditure by occupation, household activities, recreation and sports (Katch, 1993 [Reference]).
See Table 7 as an example.
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Table 7: Energy Expended in Common Physical Activities
Light
(less than 3.0 metabolic
equ ivalent task (M ET s )or less
than 4 kcal/min)
Moderate
(3.0 - 6.0 METs or 4 - 7 kcal/min)
Hard/Vigorous
(greater than 6.0 METs or greater
than 7 kcal/min)
Walking slowly ( strolling) (1 -2 mph) Walking briskly (3 -4 mph) Walking briskly uphill or with a load
Cycling, stationary (less than 50 W) Cycling for pleasure or
transportation (less than or equal to
10 mph)
Cycling, fast or racing (greater than 10
mph)
Swimming, slow t reading Swimming, moderate effort Swimming, fast treading or crawl
Conditioning exercise, light
stretching
Conditioning exercise, general
calisthenics
Conditioning exercise, stair ergometer,
ski machine
Racquet sports, table tennis R acquet sports, single tennis,
racquetball
Golf, power cart Golf, pulling cart or carrying clubs
Bowling
Fishing, sitting Fishing, standing/casting Fishing in str eam
Boating, power Canoeing leisurely (2.0 -3.9 mph) Canoeing rapidly (greater than or
equal to 4 mph)
Home care, carpet sweeping Home care, general cleaning Moving furniture
Mowing lawn, riding mower Mowing lawn, power mower Mowing lawn, hand mower
Hom e repair, carpentry Home repair, painting
Source: Journal of the American Medical Association, 1995 Feb 1; 273(5):404.

As a rule of thumb, sitting at rest or reading consumes ~ 1 kcal/minute. An average-weight person burns
approximately 5 kcal/minute walking, 10 kcal/minute jogging a 10-minute mile and 15 kcal/minute running
a 7-minute mile. These same activities done by someone weighing 300 lbs. approximately double the energy
expenditures.
$ Q R W K H U P H D V X U H R I D F W L Y L W \ L Q W H Q V L W \ L V W K H P H W D E R O L F H T X L Y D O H Q F \ 7 K H P H W D E R O L F H T X L Y D O H Q F \ L V G H Q H G D V
W K H H Q H U J \ H [ S H Q G L W X U H I R U V L W W L Q J T X L H W O \ D W U H V W ) R U W K H D Y H U D J H D G X O W W K L V L V N F D O N J E R G \ Z H L J K W K R X U
$ F R P S H Q G L X P R I D F W L Y L W L H V Z L W K W K H L U P H W D E R O L F H T X L Y D O H Q F \ Y D O X H V F D Q E H X V H G W R H V W L P D W H W R W D O H Q H U J \
H [ S H Q G L W X U H P H W D E R O L F H T X L Y D O H Q F \ Y D O X H I R U W K H D F W L Y L W \ [ Z H L J K W L Q N J V [ D F W L Y L W \ W L P H (Ainsworth,
2000 [Reference]; Ainsworth, 1993 [Reference]).
The recommended daily goal for physical activity ranges from 150 calories (kcal) to 300 calories. An
L Q L W L D O O H Y H O R I S K \ V L F D O W Q H V V P X V W E H H V W D E O L V K H G W R V X V W D L Q W K H G X U D W L R Q R I D F W L Y L W \ D W P R G H U D W H O H Y H O V W K D W
L V U H T X L U H G I R U Z H L J K W O R V V $ S R X Q G R I E R G \ I D W F R Q W D L Q V N F D O R I H Q H U J \ D Q G F D Q V X V W D L Q P L O H V
of walking for the average-weight person. Energy expenditure by physical activity is easily negated by
uncontrolled caloric intake. A moderate level of physical activity (5 kcal/min) for 30 minutes expends
N F D O 7 K L V L V H T X L Y D O H Q W W R I U H Q F K I U L H V V Q D F N F K L S V R U R Q H R X Q F H F D Q R I V X J D U H G E H Y H U D J H
Physical activity and nutritional recommendations must be coordinated in any weight-management effort.
Although there is consensus on the value of physical activity in obesity management, there is not a stan-
dard format for recommending physical activity. The closest examples in the literature are Project PACE
(Physician-based Assessment and Counseling for Exercise) (Patrick, 1994 [Reference]) and the Activity
Pyramid developed by Norstrom at Park Nicollet HealthSource (Park Nicollet Medical Foundation, 1999
[Reference]).
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2 I F H E D V H G D V V H V V P H Q W R I S K \ V L F D O D F W L Y L W \ Z D V S L R Q H H U H G E \ 3 U R M H F W 3 $ & ( 7 K H R Q H S D J H T X H V W L R Q Q D L U H
determines the patient’s level of physical activity and readiness to increase activity. The counseling proto -
cols are designed to tailor the message to different patient needs. The program may be administered by
clinicians, nurses or other health professionals (Patrick, 1994 [Reference]).
Written advice to exercise was found to be more effective than just verbal recommendation (Swinburn, 1998
[Reference]) < H W D F W L Y L W \ S U H V F U L S W L R Q V V H H P P R U H G L I F X O W W R Z U L W H W K D Q G U X J S U H V F U L S W L R Q V , Q G L Y L G X D O-
ized activity prescriptions appear to be very context-dependent. They must take into account individual
P R W L Y D W L R Q V H O I H I F D F \ W \ S H R I D F W L Y L W \ D Y D L O D E O H U H V R X U F H V S R W H Q W L D O S K \ V L F D O F R Q V W U D L Q W V R U S R V V L E O H
medical contraindications (CME Resource, 2004 [Reference]). The "dosages" must be individualized to
current patient capacity and then titrated toward improvement (Bhaskarabhatla, 2004 [Reference]; Ward,
1991 [Reference]). The time course for expected improvement also varies across patients.
Patient handouts for improving physical activity can be very informative and helpful but often have a target
population in mind. Handouts for older patients (Barry, 1993 [Reference]), "Walking Your Way to Feeling
Better" and "Getting Stronger by Using Weights," can be extended to obese patients with similar current
activity capacity.
A prototype general Physical Activity Prescription is offered in Appendix B. It represents a composite of
key features suggested from the literature (CME Resource, 2004 [Reference]; Patrick, 1994 [Reference]).
It has not been evaluated and is intended only as a suggestion for operationalizing the written physical
activity prescription. The ICSI Obesity Guideline work group will continue to search for an evidence-based
activity prescription format.
$ Q H [ D P S O H R I D S K \ V L F D O D F W L Y L W \ T X H V W L R Q Q D L U H F D Q E H I R X Q G L Q W K H $ P H U L F D Q 0 H G L F D O $ V V R F L D W L R Q V 5 R D G
Maps for Clinical Practice Assessment and Management of Adult Obesity" at http://www.ama-assn.org/
ama/pub/category/10931.html E R R N O H W J X U H
Behavioral Management
Self-monitoring of weight, nutrition and activity
A key component of successful weight loss and maintenance is regular self-monitoring of energy intake,
expenditure and body weight. Participants in weight-loss trials who regularly self-monitor their diet and
activity tend to lose more weight compared to those who don’t (Boutelle, 1999 [Reference]; Boutelle, 1998
[Reference]). Regular monitoring of weight is also a predictor of successful weight control. Evidence from
the National Weight Control Registry (NWCR), which was created to compile data on individuals who were
successful at losing at least 13.6 kg and maintaining that loss for one year or more, shows that over 75%
of these successful weight-loss maintainers report weighing themselves at least once a week (Klem, 1997
[Reference]).
Patients should be encouraged to keep track of their dietary intake, physical activity level and body weight.
Dietary intake and activity should be recorded on a daily basis, and weight should be recorded on a weekly
basis. For example, see the American Medical Association’s "Road Maps for Clinical Practice Assess -
ment and Management of Adult Obesity," http://www.ama-assn.org/ama/pub/category/10931.html , booklet
J X U H V D Q G
$ G G L W L R Q D O E H K D Y L R U D O P R G L F D W L R Q V W U D W H J L H V W K D W S O D \ D N H \ U R O H L Q V X F F H V V I X O Z H L J K W O R V V D Q G P D L Q-
tenance include:
Stimulus control: Stimulus control refers to a set of behavioral procedures designed to help people reduce
environmental cues associated with eating behavior and inactivity. Individuals should be taught to limit the
S U H V H Q F H R I K L J K F D O R U L H K L J K I D W I R R G V L Q W K H K R P H W R U H G X F H W K H Y L V L E L O L W \ R I X Q K H D O W K \ I R R G F K R L F H V L Q
W K H K R P H W R O L P L W Z K H U H D Q G Z K H Q W K H \ H D W W R D Y R L G G L V W U D F W L R Q V Z K H Q H D W L Q J V X F K D V W H O H Y L V L R Q Z D W F K L Q J
and to eat more slowly.
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Cognitive restructuring: Negative thinking (e.g., perfectionistic thinking, dichotomous/"all-or-none"
thinking, pessimistic thinking and self-doubt) often interferes with behavior change efforts. Individuals
need to be taught to identify negative thoughts that interfere with their weight-loss efforts and counter them
with positive self-statements that promote adherence to healthy eating and activity patterns.
Goal setting: Individuals need to be taught the importance of setting short-term goals for enhancing moti -
Y D W L R Q V H W W L Q J G D L O \ D Q G Z H H N O \ J R D O V W K D W D U H U H D V R Q D E O H D Q G D W W D L Q D E O H I R U H D W L Q J S K \ V L F D O D F W L Y L W \ D Q G
weight loss should be encouraged.
Problem solving: Teaching problem-solving strategies to deal with barriers to changing eating and physical
D F W L Y L W \ S D W W H U Q V L V D Q L P S R U W D Q W F R P S R Q H Q W R I Z H L J K W O R V V L Q W H U Y H Q W L R Q 6 W U D W H J L H V V X F K D V G H Q L Q J W K H
problem, brainstorming solutions, selecting a solution, and evaluating the success of the solution are recom-
mended.
Social support: Spouses, family members, friends and co-workers can serve as both barriers and facilita-
tors of successful weight loss. Individuals need to be able to engage their social support systems in ways
W K D W I D F L O L W D W H Z H L J K W O R V V H D W L Q J D Q G S K \ V L F D O D F W L Y L W \ E H K D Y L R U F K D Q J H 3 D U W L F L S D Q W V P D \ D O V R E H Q H W I U R P
learning how to be assertive in social situations involving eating and physical activity so that they can adhere
to their behavior change efforts.
Relapse prevention: 剥starts are common in be桡vior c桡nge⸠ Patients 睨o relapse s桯uld be encouraged
to try again when they are ready. In fact, a permanent change may never be achieved.
The relapse prevention model (RPM), originally developed to address cognitive and behavioral factors
associated with the relapse process for addictive behaviors (e.g., alcohol abuse) (Marlatt, 1984 [Refer-
ence]), has been shown to be helpful for long-term weight management (Baum 1991 [Reference]; Perri,
1984 [Reference]). A key component of relapse prevention model is its distinction between "lapses" and
U H O D S V H / D S V H V D U H G H Q H G D V D V L Q J O H H Y H Q W D U H H P H U J H Q F H R I D S U H Y L R X V K D E L W Z K L F K P D \ R U P D \ Q R W
lead to the state of relapse," whereas "relapse" refers to a full return to an unhealthy state. An individual’s
response to a "lapse" is thought to determine the likelihood of relapse. The "abstinence violation effect" is
W K H U H D F W L R Q W R D E H K D Y L R U D O V O L S J X L O W D Q G S H U F H L Y H G O R V V R I F R Q W U R O Z K H Q W K L V R F F X U V D Q L Q G L Y L G X D O L V P R U H
likely to experience a full relapse. Alternatively, when framed as a "lapse," people can respond proactively
to a slip in behavior, thus avoiding complete relapse. Additional relapse prevention strategies may include
helping individuals manage lapses in behavior, identifying high-risk situations for relapse, enhancing skills
I R U F R S L Q J Z L W K W K H V H V L W X D W L R Q V D Q G L Q F U H D V L Q J V H O I H I F D F \ I R U D Y R L G L Q J U H O D S V H (Larimer, 1999 [Reference]).
Behavior therapy: L Q F O X G H V Q X W U L W L R Q D Q G S K \ V L F D O D F W L Y L W \ I R U W K H W U H D W P H Q W R I R E H V L W \ L W K D V R I W H Q S U R G X F H G
poor long-term results and has led to an increased interest in a drug treatment component.
Follow-up
: H L J K W O R V V U H T X L U H V I U H T X H Q W I R O O R Z X S L Q L W L D O O \ Z H H N O \ Z L W K S O D Q Q H G H G X F D W L R Q F R X Q V H O L Q J E \ K H D O W K
care clinicians to be most effective (i.e., improve adherence) (Rejeski, 2002 [Reference]; Tuomilehto, 2001
[Reference]; Chao, 2000 [Reference]; National Heart, Lung and Blood Institute, 2000 [Reference]).
Pharmacologic Therapy
3 K D U P D F R W K H U D S \ Z K H Q X V H G I R U V L [ P R Q W K V W R R Q H \ H D U D O R Q J Z L W K O L I H V W \ O H P R G L F D W L R Q L Q F O X G L Q J Q X W U L W L R Q
D Q G S K \ V L F D O D F W L Y L W \ S U R G X F H V Z H L J K W O R V V L Q R E H V H D G X O W V % H K D Y L R U D O P R G L F D W L R Q S U R J U D P V L Q F O X G L Q J
dietary and exercise counseling typically result in a 5% weight loss (Klein, 2002 [Reference]). The average
weight loss with pharmacological agents is 10-15% of initial weight (Frank, 2004 [Reference]) or 2-10 kg
(4.4 to 22 lbs). However, it is not possible to predict the exact amount of weight an individual may lose.
0 R V W R I W K H Z H L J K W O R V V Z L W K W K H V H D J H Q W V Z L O O R F F X U G X U L Q J W K H U V W V L [ P R Q W K V R I W K H U D S \ 7 K H D P R X Q W R I
weight lost with medications is more likely to be maintained if medications are able to be continued long
W H U P 7 K H U H I R U H P H G L F D W L R Q V I R U R E H V L W \ D U H P R V W H I I H F W L Y H L I W K H \ D U H F R Q W L Q X H G L Q G H Q L W H O \ X Q O H V V Z H L J K W
L V U H J D L Q H G R U L I V L J Q L F D Q W V L G H H I I H F W V G H Y H O R S
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Weight-loss drugs should only be used as part of a comprehensive weight-loss regimen that includes a
low-calorie diet, increased physical activity and behavior therapy. If a patient has been on a combina-
W L R Q U H J L P H Q W K D W L Q F O X G H V Q X W U L W L R Q W K H U D S \ S K \ V L F D O D F W L Y L W \ D Q G E H K D Y L R U P R G L F D W L R Q D Q G K D V Q R W O R V W
lb./week, the addition of pharmacotherapy should be considered.
3 D W L H Q W V F R Q V L G H U H G I R U S K D U P D F R W K H U D S \ V K R X O G K D Y H D E R G \ P D V V L Q G H [ R I J U H D W H U W K D Q R U H T X D O W R R U
D E R G \ P D V V L Q G H [ R I J U H D W H U W K D Q R U H T X D O W R Z L W K F R Q F R P L W D Q W R E H V L W \ U H O D W H G U L V N I D F W R U V R U G L V H D V H V
The risk factors and diseases that are serious enough to support pharmacotherapy at a body mass index of
27 to 29.9 include hypertension, dyslipidemia, CVD, type 2 diabetes, fatty liver disease and sleep apnea.
0 H G L F D W L R Q W K H U D S \ V K R X O G F R Q V L V W R I D Q L Q L W L D O W U L D O S H U L R G Z L W K D V L Q J O H G U X J W R H V W D E O L V K H I F D F \ L Q D J L Y H Q
patient. If a patient does not respond to a drug with reasonable weight loss, the patient should be evaluated
to determine adherence with the medication regimen and adjunctive therapies, or to consider the need for a
dosage adjustment. If the patient continues to be unresponsive to the medication, or serious adverse effects
occur, the medication should be discontinued.
3 D W L H Q W V Z K R U H V S R Q G W R S K D U P D F R W K H U D S \ V K R X O G O R V H D W O H D V W N J O E L Q W K H U V W I R X U Z H H N V D I W H U
L Q L W L D W L Q J W K H U D S \ , I D S D W L H Q W K D V Q R W O R V W N J O E L Q W K H U V W I R X U Z H H N V W K H F K D Q F H R I D O R Q J W H U P
U H V S R Q V H L V O R Z D Q G W K H \ P D \ E H F R Q V L G H U H G Q R Q U H V S R Q G H U V 7 K H D P R X Q W R I Z H L J K W O R V W L Q W K H U V W I R X U
Z H H N V P D \ E H X V H G D V D J X L G H W R V X E V H T X H Q W W K H U D S \ 0 H G L F D W L R Q F D Q E H F R Q W L Q X H G L Q S D W L H Q W V P H H W L Q J W K H
appropriate response criteria. Consideration should be given to stopping medication in those patients who
I D L O W R P H H W W K H I R X U Z H H N Z H L J K W O R V V J X L G H 6 X F F H V V I X O W K H U D S \ L V F K D U D F W H U L ] H G E \ Z H L J K W O R V V L Q W K H U V W
six months of therapy or weight maintenance after the initial weight-loss-phase, and consideration should be
given to continued use of medication. Drug therapy may be continued as long as there is a clinical response
and there are no serious or unmanageable adverse effects. Patients should be monitored for adverse events
as long as they continue on a medication regimen.
Patient monitoring
Patient monitoring is important once weight-loss medications have been initiated. A suggested monitoring
schedule would include return visits between two and four weeks, then monthly for three months, and then
H Y H U \ W K U H H P R Q W K V I R U W K H U V W \ H D U D I W H U V W D U W L Q J W K H P H G L F D W L R Q U H J L P H Q 7 K H S X U S R V H R I W K H V H Y L V L W V Z R X O G
be to measure weight, BMI, waist circumference, blood pressure and heart rate to assess any adverse effects,
D Q G W R F R Q G X F W O D E R U D W R U \ W H V W V D Q G D Q V Z H U T X H V W L R Q V
Therapy should be considered successful if, after six months of therapy, a weight loss of greater than or
H T X D O W R R I E R G \ Z H L J K W L V D F K L H Y H G D Q G W K H U H K D Y H E H H Q Q R V H U L R X V D G Y H U V H H I I H F W V I U R P W K H P H G L F D W L R Q
After six months of drug therapy, the rate of weight loss generally reaches a plateau, and weight maintenance
V K R X O G W D N H S U L R U L W \ 7 R D F K L H Y H D G G L W L R Q D O Z H L J K W O R V V O L I H V W \ O H P R G L F D W L R Q V W R I X U W K H U G H F U H D V H F D O R U L F
intake and increase energy expenditure should be implemented.
To be considered successful weight maintenance, weight regain should be less than 3 kg (6.6 lb.) in two
years and there should be a sustained reduction in waist circumference of at least 4 cm (National Heart,
Lung and Blood Institute/NIH, 1998 [Reference]).
Please see Appendix C, "FDA-Approved Medications for the Treatment of Obesity," for more information.
Phentermine
Phentermine is an appetite suppressant with stimulant-like properties that is approved for the treatment of
obesity. It is widely available in the United States and is effective in weight loss. In one large meta-analysis
study, phentermine was associated with an average of 3.6 kg (7.9 pounds) additional weight loss at six months
as compared to placebo (Pharmacological and Surgical Treatment of Obesity, Shekelle, 2003 (Reference)).
Three long-term studies have been done with phentermine, ranging from 14 weeks to 36 weeks and showing
an average weight loss of 8.7 to 13% body weight compared to 2 to 5.1% with placebo.
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Prevention and Management of Obesity for Adults
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2?
Patients taking phentermine or any other anorexiant should have their blood pressure monitored carefully
during treatment due to the possibility of increased blood pressure as a side effect of this medication.
+ R Z H Y H U R Q H V W X G \ V K R Z H G Q R V L J Q L F D Q W G L I I H U H Q F H V L Q E O R R G S U H V V X U H E H W Z H H Q S O D F H E R W U H D W H G S D W L H Q W V
and patients treated with phentermine (Kim, 2006 [Reference]).
Due to its anticholenergic effects, phentermine can cause severe constipation and severe dry mouth. Usually
however, these side effects are relatively mild and are manageable. Insomnia can also occur but usually
U H V R O Y H V L I W K H S D W L H Q W F R Q W L Q X H V W R W D N H W K L V P H G L F D W L R Q L W F D Q E H P L Q L P L ] H G E \ S U H V F U L E L Q J D Q \ D I W H U Q R R Q
dose to be taken by 3:00 p.m.
While phentermine is indicated as short-term monotherapy as an adjunct in the management of exogenous
obesity in patients with initial body mass index (BMI) of > or = 30 or > or = 27 in the presence of other risk
factors, it is often prescribed long term (off-label use). As mentioned earlier, most of the weight loss with
W K H V H D J H Q W V Z L O O R F F X U G X U L Q J W K H U V W V L [ P R Q W K V R I W K H U D S \ 7 K H D P R X Q W R I Z H L J K W O R V W Z L W K P H G L F D W L R Q V
is more likely to be maintained if it is possible for these medications to be continued long term. Therefore,
P H G L F D W L R Q V I R U R E H V L W \ D U H P R V W H I I H F W L Y H L I W K H \ D U H F R Q W L Q X H G L Q G H Q L W H O \ X Q O H V V Z H L J K W L V U H J D L Q H G R U L I
V L J Q L F D Q W V L G H H I I H F W V G H Y H O R S
As also mentioned earlier, anorexiant medications are typically less effective if not combined with dietary
and exercise counselling. It is recommended that anorexiant medications be stopped if the patient does not
continue appropriate dietary changes and a documented exercise program or is not maintaining weight loss.
Amphetamines have been used in the past to treat obesity but are not approved and may have dangerous side
H I I H F W V ) H Q ` X U D P L Q H Z D V F R P E L Q H G Z L W K S K H Q W H U P L Q H L Q W K H O D W H V S K H Q I H Q D Q G U H V X O W H G L Q V L J Q L F D Q W
Z H L J K W O R V V E X W Z D V D V V R F L D W H G Z L W K F D U G L D F Y D O Y X O D U L Q V X I F L H Q F \ D Q G S X O P R Q D U \ K \ S H U W H Q V L R Q D Q G Z D V
Z L W K G U D Z Q I U R P W K H P D U N H W 3 K H Q W H U P L Q H Z K H Q X V H G L Q L V R O D W L R Q L V Q R W D V V R F L D W H G Z L W K D V L J Q L F D Q W U L V N
of pulmonary hypertension or regurgitant valvular heart lesions.However, patients who receive long-term
anorexiant therapy (off-label use) should be carefully evaluated for dyspnea, chest pain, syncope and edema.
Orlistat
Orlistat is another FDA approved medication for the treatment of obesity.
The adverse events of orlistat are mainly gastrointestinal. Absorption of the drug is minimal.
Table 8 : Incidence of Adverse Events Commonly Observed During the First Year of Treatment
Adverse Event Orlistat Placebo
Oily spotting 26.6% 1.3%
Flatulence 23.9% 1.4%
Fecal urgency 22.1% 6.7%
Oily stool 20.0% 2.9%
Oily evacuation 11.9% 0.8%
Increase d defecation 10.8% 4.1%
Fecal incontinence 7.7% 0.9%

Most common adverse reactions were mild and transient, and decreased during the second treatment year.
( Y H Q W V X V X D O O \ E H J D Q Z L W K L Q W K H U V W W K U H H P R Q W K V R I W K H U D S \ $ S S U R [ L P D W H O \ R I D O O H S L V R G H V R I * ,
adverse events lasted for less than one week, and most lasted for no more than four weeks. However, adverse
GI events may occur in some individuals over a period of six months or longer.
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Prevention and Management of Obesity for Adults
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2?
Adherence with a low-fat diet containing less than 30% of calories derived from fat can lessen or avoid the
fat-intake-related adverse effects. Since orlistat is useful only if taken with a meal containing some fat, a
dose should be skipped when a meal is fat-free. Cardiac abnormalities have not been reported in associa-
tion with the use of orlistat.
In May 2010, the FDA approved a revised label for orlistat that included new safety information about cases
of severe liver injury that are reported rarely with use of the drug. New warnings about reports of rare liver
injury were also added to the label of the over-the-counter version of orlistat.
7 K H Q H Z V D I H W \ L Q I R U P D W L R Q L V E D V H G R Q D Q ) ’ $ U H Y L H Z W K D W L G H Q W L H G W R W D O U H S R U W V R I V H Y H U H O L Y H U L Q M X U \
with orlistat: 12 foreign reports and one U.S. report with the over-the-counter version. A cause and effect
U H O D W L R Q V K L S R I V H Y H U H O L Y H U L Q M X U \ Z L W K R U O L V W D W X V H K D V Q R W E H H Q G H Q L W L Y H O \ H V W D E O L V K H G E H F D X V H R I W K H
following factors:
2 Q H 8 6 F D V H Z L W K $ O O L D Q G I R U H L J Q F D V H V Z L W K ; H Q L F D O U H S R U W H G E H W Z H H Q D Q G R X W R I
an estimated 40 million people who have used one of the two products.
6 R P H S D W L H Q W V L Q W K H U H S R U W H G F D V H V D O V R X V H G R W K H U G U X J V R U K D G R W K H U F R Q G L W L R Q V W K D W P D \ K D Y H
contributed to the development of severe liver injury.
6 H Y H U H O L Y H U L Q M X U \ F D Q R F F X U L Q S H R S O H Q R W W D N L Q J G U X J V D Q G Z L W K R X W D G L V W L Q F W F D X V H
7 K H S U L P D U \ L Q W H Q W R I W K H ) ’ $ L Q U H T X L U L Q J W K H D G G L W L R Q R I W K H L Q I R U P D W L R Q D E R X W U H S R U W H G F D V H V R I O L Y H U
injury to the label of orlistat is to educate the public about the signs and symptoms of liver injury and the
need to see a clinician promptly should they occur.
( I F D F \
Patients taking orlistat as part of a program of nutritional and physical activity changes can expect a weight
loss of 3.9 to 10.6 kg after one year of treatment and 4.6 to 7.6 kg after two years of treatment. A weight loss
of at least 5% of initial body weight at one year is reported by 30 to 73% (vs. 13 to 45% of patients taking
S O D F H E R D Z H L J K W O R V V R I D W O H D V W R I L Q L W L D O E R G \ Z H L J K W D W R Q H \ H D U L V U H S R U W H G E \ W R Y V W R
21% of patients taking placebo (Torgeson, 2004 [Reference]; Rissanen, 2003 [Reference]; Hauptman, 2000
[Reference]; Rössner, 2000 [Reference]; Sjöström, 1998 [Reference]).
Drug interactions
The potential for drug-drug interactions should be assessed before initiating therapy with weight-loss
agents.
Phentermine is contraindicated for use with MAO inhibitors, and it should not be started within 14 days
of discontinued MAOI. Phentermine should be used with caution with SSRIs or stimulant medications.
Orlistat has also been shown to reduce serum concentrations of fat-soluble vitamins (vitamins A, D, E and
K). Although most patients’ plasma levels remained within normal ranges during clinical trials, a daily
multivitamin supplement containing fat-soluble vitamins at bedtime is recommended. Caution should also
be exercised with concomitant use of orlistat and other lipophilic drugs, as their overall bioavailability may
be compromised.
: L W K R U O L V W D W S D W L H Q W V V K R X O G K D Y H W K H L U F \ F O R V S R U L Q H O H Y H O V P R Q L W R U H G P R U H I U H T X H Q W O \ , Q F U H D V H G P R Q L W R U L Q J
should also apply to patients taking other medications with a narrow therapeutic index, such as warfarin,
that could be affected by fat malabsorption.
Summary
As an adjunct to intensive nutritional and lifestyle changes, both phentermine and orlistat are associ -
ated with greater weight loss than placebo.
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Prevention and Management of Obesity for Adults
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30
: K H Q R Q R U O L V W D W J D V W U R L Q W H V W L Q D O V L G H H I I H F W V D U H F R P P R Q E X W W K H I U H T X H Q F \ D Q G V H Y H U L W \ G H F U H D V H
over time (typically after one week) and can be reduced by careful attention to dietary fat content.
0 H G L F D O R S L Q L R Q L V F X U U H Q W O \ V K L I W L Q J W R Z D U G W K H Q H H G I R U F K U R Q L F S K D U P D F R O R J L F D O W K H U D S \ L Q R E H V L W \
as it is a chronic disease. However, with the current paucity of weight-loss medications available,
this remains a clinical challenge.
7 K H O R Q J W H U P V D I H W \ R I S K H Q W H U P L Q H D Q G R W K H U D Q R U H [ L D Q W V D V Z H O O D V R U O L V W D W L V X Q N Q R Z Q 7 K H U H-
I R U H P R U H V W X G L H V Q H H G W R E H G R Q H R Q W K H V D I H W \ D Q G H I F D F \ R I Z H L J K W O R V V P H G L F D W L R Q V X V H G I R U
the long-term treatment of obesity.
Qsymia
4 V \ P L D L V D F R P E L Q D W L R Q R I W Z R ) ’ $ D S S U R Y H G G U X J V S K H Q W H U P L Q H D Q G W R S L U D P D W H L Q D Q H [ W H Q G H G U H O H D V H
formulation. The drug was approved in July 2012.
Regulatory history
The original New Drug Application (NDA) for phentermine/topiramate was submitted to the Food and Drug
$ G P L Q L V W U D W L R Q X Q G H U W K H E U D Q G Q D P H 4 1 ( ; $ L Q ’ H F H P E H U D Q G Z D V U H Y L H Z H G L Q - X O \ 7 K H
P H G L F D W L R Q Q D P H Z D V O D W H U F K D Q J H G D Q G D S S U R Y H G X Q G H U W K H E U D Q G Q D P H 4 V \ P L D
The NDA included results of a clinical development program conducted by the manufacturer involving
W K H H I F D F \ D Q G V D I H W \ R I W K U H H G R V H V R I 4 1 ( ; $ I R U W K H W U H D W P H Q W R I R E H V L W \ ) ’ $ I R X Q G Q R G H F L H Q F L H V
S H U W D L Q L Q J W R W K H H V W D E O L V K P H Q W R I 4 1 ( ; $ H I F D F \ L Q W K H 1 ’ $ ) ’ $ G L G K R Z H Y H U L V V X H D & R P S O H W H
5 H V S R Q V H / H W W H U & 5 / I R U 4 1 ( ; $ L Q 2 F W R E H U E D V H G R Q W Z R V D I H W \ F R Q F H U Q V U H O D W H G W R W K H D S S U R Y H G
component products.
7 K H & 5 / U H T X H V W H G D F R P S U H K H Q V L Y H D V V H V V P H Q W R I W K H W H U D W R J H Q L F S R W H Q W L D O R I W R S L U D P D W H D Q G S K H Q W H U P L Q H
topiramate, including a plan and strategy to evaluate and mitigate potential teratogenic (orofacial cleft) risks
L Q Z R P H Q R I F K L O G E H D U L Q J S R W H Q W L D O 7 K H & 5 / D O V R U H T X H V W H G H Y L G H Q F H W K D W W K H 4 1 ( ; $ D V V R F L D W H G K H D U W
rate elevations (mean of 1.6 bpm at the highest dose) do not increase the risk for major adverse cardiovas -
cular events.
6 L J Q L F D Q W L P S U R Y H P H Q W V Z H U H Q R W H G L Q E O R R G S U H V V X U H Z D L V W F L U F X P I H U H Q F H O L S L G V E O R R G J O X F R V H D Q G
L Q ` D P P D W R U \ E L R P D U N H U V Z L W K S K H Q W H U P L Q H W R S L U D P D W H F R P S D U H G W R S O D F H E R , P S U R Y H P H Q W V Z H U H P R V W
pronounced in patients with pre-existing comorbid diseases (Gadde, 2011 [Reference]).
7 K H ) ’ $ D S S U R Y H G 4 V \ P L D Z L W K D 5 L V N ( Y D O X D W L R Q D Q G 0 L W L J D W L R Q 6 W U D W H J \ 5 ( 0 6 Z K L F K L Q F O X G H V D
Medication Guide advising patients about important safety information, a patient brochure and a formal
training program for prescribers. The purpose of the REMS is to inform prescribers and their patients about
W K H L Q F U H D V H G U L V N R I E L U W K G H I H F W V D V V R F L D W H G Z L W K U V W W U L P H V W H U H [ S R V X U H W R 4 V \ P L D W K H Q H H G I R U S U H J-
nancy prevention and the need to discontinue therapy if pregnancy occurs. For prescribing processes, see
K W W S Z Z Z T V \ P L D F R P K F S S K D U P D F L V W V D V S [
, Q D G G L W L R Q 9 L Y X V , Q F W K H V S R Q V R U Z L O O E H U H T X L U H G W R F R Q G X F W V H Y H U D O S R V W P D U N H W L Q J U H T X L U H P H Q W V
L Q F O X G L Q J D O R Q J W H U P F D U G L R Y D V F X O D U R X W F R P H V W U L D O W R D V V H V V W K H H I I H F W R I 4 V \ P L D R Q W K H U L V N I R U P D M R U
adverse cardiac events such as heart attack and stroke.
Indications and use
Phentermine is indicated for short-term weight loss in overweight or obese adults who are exercising and
eating a reduced-calorie diet. Topiramate is indicated to treat certain types of seizures in people who have
epilepsy and to prevent migraine headaches.
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Prevention and Management of Obesity for Adults
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31
Phentermine is a sympathomimetic amine with pharmacologic activity similar to amphetamine and is
commonly known as anorectice or anorexigenic. The mechanism of action on weight management is medi-
ated by release of catecholamines resulting in reduced appetite and decreased food consumption. Because
R I W K H S K H Q W H U P L Q H F R P S R Q H Q W 4 V \ P L D L V D & , 9 F R Q W U R O O H G V X E V W D Q F H
The exact mechanism of action of topiramate on chronic weight management is unknown but may be due
to both appetite suppression and satiety enhancement through a variety of actions.
4 V \ P L D L V L Q G L F D W H G D V D Q D G M X Q F W W R D U H G X F H G F D O R U L H G L H W D Q G L Q F U H D V H G S K \ V L F D O D F W L Y L W \ I R U F K U R Q L F Z H L J K W
management in adults with:
$ E R G \ P D V V L Q G H [ R I N J P
2
or greater (obese)
N J P
2
or greater (overweight) who also have at least one weight-related comorbidity such as
hypertension, type 2 diabetes mellitus, or dyslipidemia
4 V \ P L D L V D Y D L O D E O H L Q I R X U F R P E L Q D W L R Q F D S V X O H V W U H Q J W K V D Q G L V W D N H Q R Q F H G D L O \ L Q W K H P R U Q L Q J ( Y H Q L Q J
administration should be avoided due to the possibility of insomnia. Treatment is started with the lowest
strength combination (phentermine 3.75 mg/topiramate 23 mg extended-release) for 14 days and then
increased to the next higher strength (phentermine 7.5 mg/ topiramate 46 mg extended-release). Clinicians
P D \ S U H V F U L E H D G D \ V X S S O \ Z L W K Y H U H O O V
Patients should be evaluated for weight loss after 12 weeks of treatment. If a patient has not lost at least
R I E D V H O L Q H E R G \ Z H L J K W R Q 4 V \ P L D P J P J W K H P H G L F D W L R Q V K R X O G H L W K H U E H G L V F R Q W L Q X H G R U W K H
dosage should be increased.
) R U G R V H H V F D O D W L R Q 4 V \ P L D L V L Q F U H D V H G W R P J P J G D L O \ I R U G D \ V I R O O R Z H G E \ P J P J G D L O \
Weight loss should be evaluated following dose escalation to 15 mg/92 mg after an additional 12 weeks of
treatment. If the patient has not lost at least 5% of baseline body weight, it is unlikely that the patient will
D F K L H Y H D Q G V X V W D L Q F O L Q L F D O O \ V L J Q L F D Q W Z H L J K W O R V V Z L W K F R Q W L Q X H G W U H D W P H Q W D Q G W K H P H G L F D W L R Q V K R X O G
be discontinued. The 3.75 mg/23 mg and 11.25 mg/69 mg strengths are intended only for titration purposes.
4 V \ P L D P J P J V K R X O G E H G L V F R Q W L Q X H G J U D G X D O O \ E \ G R V L Q J H Y H U \ R W K H U G D \ I R U D W O H D V W R Q H Z H H N
before stopping completely because of the possibility of inducing a seizure. Dosing adjustments are neces -
sary for patients with renal or hepatic impairment.
Contraindications, warnings and precautions
4 V \ P L D L V F R Q W U D L Q G L F D W H G L Q S D W L H Q W V Z K R D U H S U H J Q D Q W R U Z K R K D Y H J O D X F R P D K \ S H U W K \ U R L G L V P D N Q R Z Q
hypersensitivity or idiosyncrasy to sympathomimetic amines, or who are taking or have taken within the
past 14 days a monoamine oxidase inhibitor.
4 V \ P L D P X V W Q R W E H X V H G G X U L Q J S U H J Q D Q F \ E H F D X V H L W F D Q F D X V H K D U P W R D I H W X V ’ D W D I U R P S U H J Q D Q F \ U H J L V-
W U L H V D Q G H S L G H P L R O R J \ V W X G L H V V K R Z W K D W D I H W X V H [ S R V H G W R W R S L U D P D W H Z K L F K L V D F R P S R Q H Q W R I 4 V \ P L D
L Q W K H U V W W U L P H V W H U R I S U H J Q D Q F \ K D V D Q L Q F U H D V H G U L V N R I R U D O F O H I W V F O H I W O L S Z L W K R U Z L W K R X W F O H I W S D O D W H
) H P D O H V R I U H S U R G X F W L Y H S R W H Q W L D O P X V W Q R W E H S U H J Q D Q W Z K H Q V W D U W L Q J 4 V \ P L D R U E H F R P H S U H J Q D Q W Z K L O H W D N L Q J
4 V \ P L D ) H P D O H V R I U H S U R G X F W L Y H S R W H Q W L D O V K R X O G K D Y H D Q H J D W L Y H S U H J Q D Q F \ W H V W E H I R U H V W D U W L Q J 4 V \ P L D
and every month while using the drug, and should use effective contraception consistently while taking
4 V \ P L D , I D S D W L H Q W E H F R P H V S U H J Q D Q W Z K L O H W D N L Q J 4 V \ P L D W U H D W P H Q W V K R X O G E H L P P H G L D W H O \ G L V F R Q W L Q X H G
4 V \ P L D F D Q L Q F U H D V H U H V W L Q J K H D U W U D W H W K L V G U X J V H I I H F W R Q K H D U W U D W H L Q S D W L H Q W V D W K L J K U L V N I R U K H D U W D W W D F N
R U V W U R N H L V Q R W N Q R Z Q 7 K H X V H R I 4 V \ P L D L Q S D W L H Q W V Z L W K U H F H Q W Z L W K L Q W K H O D V W V L [ P R Q W K V R U X Q V W D E O H
heart disease or stroke is not recommended. Regular monitoring of heart rate is recommended for all patients
W D N L Q J 4 V \ P L D H V S H F L D O O \ Z K H Q V W D U W L Q J 4 V \ P L D R U L Q F U H D V L Q J W K H G R V H
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32
Antiepileptic drugs including topiramate can increase the risk of suicidal thoughts or behavior in patients
Z K R D U H W D N L Q J W K H P I R U D Q \ L Q G L F D W L R Q 3 D W L H Q W V R Q 4 V \ P L D V K R X O G E H P R Q L W R U H G I R U W K H G H Y H O R S P H Q W
or worsening of depressing, suicidal thoughts or behavior and any unusual changes in mood or behavior.
4 V \ P L D X V H V K R X O G E H D Y R L G H G L Q S D W L H Q W V Z L W K D K L V W R U \ R I V X L F L G D O D W W H P S W V R U D F W L Y H V X L F L G D O L G H D W L R Q D Q G
should be discontinued if a patient experiences suicidal thoughts or behavior.
4 V \ P L D F D Q D O V R F D X V H P R R G G L V R U G H U V L Q F O X G L Q J G H S U H V V L R Q D Q G D Q [ L H W \ L Q V R P Q L D D Q G F R J Q L W L Y H G \ V I X Q F-
W L R Q V X F K D V L P S D L U H G F R Q F H Q W U D W L R Q D Q G D W W H Q W L R Q P H P R U \ G L I F X O W L H V D Q G S U R E O H P V Z L W K O D Q J X D J H D Q G
V S H H F K ’ R V D J H U H G X F W L R Q R U G U X J G L V F R Q W L Q X D W L R Q P D \ E H U H T X L U H G
Acute myopia associated with secondary angle closure glaucoma has been reported in patients taking topi-
ramate. Symptoms include acute onset of decreased visual acuity with or without ocular pain. The primary
W U H D W P H Q W L V W R G L V F R Q W L Q X H W R S L U D P D W H F R Q W D L Q L Q J 4 V \ P L D
Hyperchloremic, non-anion gap, metabolic acidosis with a decreased serum bicarbonate level (below the
normal reference range and not related to chronic respiratory alkalosis) has been reported. Concomitant use
R I 4 V \ P L D D Q G D F D U E R Q L F D Q K \ G U D V H L Q K L E L W R U P D \ L Q F U H D V H W K H V H Y H U L W \ R I P H W D E R O L F D F L G R V L V D Q G P D \ D O V R
increase the risk of kidney stone formation. It is recommended that serum electrolytes including bicarbonate
E H P H D V X U H G S U L R U W R D Q G G X U L Q J W K H U D S \ Z L W K 4 V \ P L D
4 V \ P L D P D \ D O V R L Q F U H D V H V H U X P F U H D W L Q L Q H D Q G P H D V X U H P H Q W R I V H U X P F U H D W L Q L Q H S U L R U W R D Q G G X U L Q J
therapy is recommended.
3 D W L H Q W V Z L W K K \ S H U W H Q V L R Q R U W \ S H G L D E H W H V V K R X O G E H P R Q L W R U H G F O R V H O \ 4 V \ P L D K D V E H H Q V K R Z Q W R
improve glucose control and blood pressure. Thus, patients may need to have medications adjusted or
discontinued as they lose weight.
7 K H P R V W F R P P R Q D G Y H U V H U H D F W L R Q V L G H Q W L H G G X U L Q J F O L Q L F D O W U L D O V D Q G R F F X U U L Q J D W D U D W H R I J U H D W H U W K D Q R U
H T X D O W R D Q G D W D U D W H R I D W O H D V W W L P H V J U H D W H U W K D Q S O D F H E R L Q F O X G H S D U H V W K H V L D G L ] ] L Q H V V G \ V J H X V H D
insomnia, constipation and dry mouth.
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33
Qsymia Clinical Trial Results
Table 9. 56-Week Trial Results
E Q U IP (BM I greater than 35 kg/m
2
)

CONQUER (BMI 27- 45 mg/m
2
plus
two or more comorbidities)
Analysis
Placebo Qsymia
3.75 mg/23 mg
Qsymia
15 mg/92 mg
Placebo Qsymia
7.5 mg/46 mg
Qsymia
15 mg/92 mg
Number 514 241

512 994 498 995
Baseline
mean
weight in
kg
115.7 118.6 115.2 103.3 102.8 103.1
W eight
loss as a
percentage
of baseline
weight
1.6 % 5.1 % 10.9% 1.2 % 7.8 % 9.8 %
Percentage
of patients
with 5%
W eight
loss
17.3% 44.9% 66.7% 21 % 62 % 70 %
Percentage
of patients
with
1 0%
weight loss
7% 19 % 47 % 7% 37 % 48 %

Table 10. 108-Week Extension Trial Results

SEQUEL (52 week extension trial for patients
completing the CONQU E R trial)

Analysis
Placebo Qsymia
7.5 mg/46 mg
Qsymia
15 mg/92 mg
Number 227 15 3

295
W eight
loss as a
percentage
of baseline
weight
1.8 % 9.3 % 10.5%
Percentage
of patients
with 5%
Wt loss
30 % 75.2% 79.3%
Percentage
of patients
with
10%
weight loss
11.5% 50.3% 53.9%

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2013 review Lorcaserin (Belviq)
Lorcaserin is intended for weight management as an adjunct to life style changes of reduced calorie intake
and increased activity. Patients with a BMI of > 30 kg/m
2
or a BMI of > 27 kg/m
2
with an additional weight
U H O D W H G F R P R U E L G F R Q G L W L R Q K \ S H U W H Q V L R Q W \ S H G L D E H W H V G \ V O L S L G H P L D T X D O L I \ I R U O R U F D V H U L Q
Pharmacology: Lorcaserin is a selective serotonin 2C receptor agonist. The exact mechanism of action
L V Q R W N Q R Z Q K R Z H Y H U L W L V E H O L H Y H G W R D F K L H Y H V D W L H W \ E \ V H O H F W L Y H O \ D F W L Y D W L Q J W K H + 7 F U H F H S W R U V R Q
anorexigenic pro-opiomelonocortin neurons in the hypothalamus.
Extensively metabolized by the liver, lorcaserin has a half-life of 11 hours and is primarily excreted in the
urine.
Dose: Recommended adult dose and maximum dose for lorcaserin is 10 mg twice daily with or without
food. Weight-loss progress should be monitored after 12 weeks. Discontinue lorcaserin if patients have not
lost > 5% of their baseline weight. No dosage change has been recommended for the elderly. Lorcaserin is
not recommended for children under the age of 18. Do not use lorcaserin in severe renal impairment (Cl
cr

< 30 mL/minute) and use with caution in severe hepatic impairment. Use in ESRD is not recommended as
this has not been studied.
Cautions: Lorcaserin has the potential to cause serotonin syndrome like effects and should not be used with
other drugs that can cause this potentially life-threatening syndrome. If symptoms of serotonin syndrome
appear, lorcaserin should be discontinued.
Mitral valve regurgitation has been linked with lorcaserin through its seratonergic pathway. If signs and
symptoms of valvular disease appear, it may be necessary to discontinue lorcaserin. Use with caution in
S D W L H Q W V Z L W K D K L V W R U \ R I E U D G \ F D U G L D R U K H D U W E O R F N J U H D W H U W K D Q U V W G H J U H H
Lorcaserin can cause cognitive impairment, leading to memory and attention changes. Caution patients with
the operation of hazardous machinery when starting lorcaserin.
Do not exceed the maximum dose of 10 mg twice daily, as psychiatric disorders of euphoria and dissociation
have been reported. Monitor patients for suicidal thoughts.
Lorcaserin has abuse potential when taken in dosages exceeding the maximum dose of 10 mg twice daily. The
U.S. Drug Enforcement Agency (DEA) is evaluating lorcaserin for abuse potential and possible controlled
F O D V V L F D W L R Q
Monitor blood glucose when taking lorcaserin with antidiabetic drugs, as additional weight loss can cause
hypoglycemia.
Priapism has been associated with lorcaserin. Use with caution in patients predisposed to priapism.
Lorcaserin can cause a decrease in red and white blood cell count. Monitor patient’s complete blood count
while taking this drug.
Lorcaserin moderately elevates prolactin. Prolactin should be measured when patient’s exhibit signs and
symptoms of excessive prolactin.
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Table 11. Incidence of Adverse Reactions

A dverse Reactions Percent
H eadache, hypoglycemia, decrease in lymphocytes, back pain, upper respiratory tract
infection, nasopharyngitis
> 10%
Peripheral edema, hypertension, valvulopathy, dizziness, fatigue, anxiety, insomnia,
depression, cognitive impa irment, psychiatric disorders, rash, diabetes melatis
exacerbation, prolactin increased, nausea, diarrhea, constipation, xerostomia,
vomiting, gastroenteritis, toothache, appetite decreased, UTI, hemoglobin decreased,
neutrophils decreased, muscle spasm, m uscle pain, eye disorders, oropharyngeal pain,
sinus congestion, seasonal allergy, stress
1- 10%
B radycardia, dissociation, euphoria, serotonin syndrome, suicidal ideation < 1%

Contraindications: Lorcaserin is contraindicated in pregnancy, risk factor X, and should not be taken by
nursing mothers.
Drug/Drug Interactions: Lorcaserin is a selective serotonin 2C receptor agonist with the potential to cause
serotonin syndrome (sweating, hyperthermia, tachycardia). Care should be taken when prescribing lorcaserin
with other drugs that work through the seratonergic pathway, as the potential for serotonin syndrome can
be enhanced.
Clinical Trials: Approval of lorcaserin was based on three one-year randomized double-blind studies in
obese and overweight adults.
, Q W K H % O R R P W U L D O V X E M H F W V Z K R O R V W ! R I W K H L U E R G \ Z H L J K W L Q W K H U V W \ H D U Z H U H U D Q G R P L ] H G W R F R Q W L Q X H
lorcaserin in year two or switch to a placebo. At the end of year, two patients who continued with lorcaserin
had regained 25% of their initial weight loss and those who took lorcaserin during year one and were switched
to a placebo for year two lost an average of 1.2 kg more than those who took placebo during year one.
Table 12. 52-week trial results

T rial Average
baseline
weight
Mean weight
l oss (52 wks)
Dose Number Percentag e of
p atients with
> 5% weight
l oss
BLOOM 100 kg 5.8 kg 10 mg twice daily 1, 538 47.5%
Placebo 2.2 kg 1, 499 20.3%

BLOSSOM

100 kg

4.7 kg
5.8 kg
10 mg daily
10 mg twice daily
801
1, 602
40.2%
47.2%


Placebo 2.9 kg 1, 601 25 %

BLOOM DM 102 -106 kg 5 kg
4.7 kg
10 mg daily
1 0 mg twice daily
95
251
44.7%
37.5%
Placebo 1.6 kg 248 16.1%

Conclusion: As an adjunct to diet and exercise, lorcaserin offers some success with increased weight loss
G X U L Q J W K H U V W \ H D U R I W K H U D S \ + R Z H Y H U I X U W K H U Z H L J K W O R V V L V Q R W V H H Q L Q \ H D U W Z R R I W K H U D S \
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Non-Prescription and alternative medicine
Numerous products, touted as weight-loss preparations, are available to patients without a prescription.
These products contain a wide range of ingredients either alone or in combination.
Alternative therapy agents have become attractive options for the treatment of obesity. Herbal and dietary
supplements are thought to be natural products and perceived to be safer than prescription medications.
Also, patients do not perceive a need to seek professional assistance with these products. Obese patients
Z L W K O L P L W H G Q D Q F L D O U H V R X U F H V P D \ Q G W K L V W R E H D F K H D S H U V R O X W L R Q 2 W K H U S D W L H Q W V F K R R V H D O W H U Q D W L Y H
therapies after previous failed attempts at weight loss with more conventional treatments.
No long-term data (longer than one year) is available for any of these herbal agents. While there has been a
J U R Z L Q J S R S X O D U L W \ D Q G L Q W H U H V W L Q K H U E D O W K H U D S L H V W K H U H L V Q R D G H T X D W H G D W D W R V X S S R U W W K H L U X V H I R U Z H L J K W
loss. The short- and long-term adverse effects of these agents are largely unknown. Since many herbal
products are not standardized, the content of the ingredients can vary substantially from the label and among
lots of the same product (Gurley, 2000 [Reference]). Patients who use non-prescription or herbal preparations
should be cautioned about adverse effects, drug interactions and the potential impurities of herbal products
(Miller 1998 [Reference]; Winslow, 1998 [Reference]). The combination of these agents with 500-calorie
diets is not safe and should be discouraged.
Safety and adverse effects
The safe and effective use of any weight-loss drug beyond two years has not been established.
Clinicians considering pharmacotherapy should obtain complete medication histories on their patients
including the use of other prescription, non-prescription or herbal preparations for weight loss before recom-
mending or prescribing prescription weight-loss medications.
Adverse side effects from the use of weight-loss drugs have been observed in patients. Dose-related minor
effects may occur soon after beginning therapy. These effects are often mild and spontaneously resolve
over time. Initial adverse effects can be avoided or minimized by:
D G M X V W L Q J G R V D J H D Q G D G P L Q L V W U D W L R Q V F K H G X O H V
L G H Q W L I \ L Q J S D W L H Q W V D W K L J K U L V N I R U D G Y H U V H H I I H F W V D Q G V H O H F W L Q J G U X J W K H U D S \ D F F R U G L Q J O \ D Q G
S U R Y L G L Q J S D W L H Q W H G X F D W L R Q D Q G P R Q L W R U L Q J I R U D G Y H U V H H I I H F W V D W W K H E H J L Q Q L Q J R I W K H U D S \ R U Z K H Q
making dosage adjustments
, Q I U H T X H Q W E X W S R W H Q W L D O O \ V H U L R X V H I I H F W V F D Q D O V R R F F X U P X F K O D W H U L Q W K H F R X U V H R I W K H U D S \
7 K H S U D F W L F H R I F R P E L Q D W L R Q G U X J W K H U D S \ I R U R E H V L W \ P D \ L Q F U H D V H W K H I U H T X H Q F \ R I D G Y H U V H H Y H Q W V 8 V L Q J
the lowest possible effective dose may also reduce the chance of an adverse event.
None of the weight-loss drugs is approved for use in pregnant or lactating women, and the safe use of these
drugs in pregnant or lactating women has still not been determined.
Surgery for Obesity
Introduction
Bariatric operations are tools designed to produce substantial weight loss in patients who are morbidly
obese. Bariatric surgery should be considered as an adjunct to the overall treatment paradigm, rather than
as a separate and independent therapy for obesity. Please see Table 13, "Overview of Bariatric Procedures"
and Appendix D, "Overview of Bariatric Procedures" for more information.
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Patient selection
Patients undergoing bariatric surgery must be aware of operative and longer-term risks. While BMI crite-
rion may be a starting point for determining appropriate candidates to undergo surgery, additional factors
contribute to determining appropriate candidacy for surgery.
The current indications, for bariatric surgery include:
% R G \ P D V V L Q G H [ J U H D W H U W K D Q N J P
2
.
% R G \ P D V V L Q G H [ J U H D W H U W K D Q N J P
2
Z L W K V L J Q L F D Q W F R P R U E L G L O O Q H V V L Q F O X G L Q J G L D E H W H V K \ S H U-
W H Q V L R Q G \ V O L S L G H P L D V O H H S D S Q H D F D U G L R Y D V F X O D U G L V H D V H J D V W U R H V R S K D J H D O U H ` X [ G L V H D V H D Q G
pseudotumor cerebri.
2 W K H U L Q G L F D W L R Q V P D \ L Q F O X G H Q H H G I R U V L J Q L F D Q W Z H L J K W O R V V L Q R U G H U W R I D F L O L W D W H V R O L G R U J D Q
transplant operations, abdominal wall hernia repair or joint replacement.
0 H G L F D O P D Q D J H P H Q W W R D H [ F O X G H X Q W U H D W H G H Q G R F U L Q R S D W K L H V E V W D E L O L ] H P H G L F D O S U R E O H P V
L Q F O X G L Q J K \ S H U W H Q V L R Q D Q G W \ S H G L D E H W H V D Q G F G H P R Q V W U D W H S D W L H Q W F R P S O L D Q F H L Q F O X G L Q J
preoperative weight loss and smoking cessation.
3 V \ F K R O R J L F V W D E L O L W \ D V G H W H U P L Q H G L Q K H D O W K D Q G E H K D Y L R U D O D V V H V V P H Q W S H U I R U P H G E \ D Q H [ S H U L-
enced practitioner.
Shared decision-making
6 X U J H U \ R I D Q \ V R U W L V D V L J Q L F D Q W G H F L V L R Q I R U D Q \ S D W L H Q W 7 K H L Q I R U P H G F R Q V H Q W S U R F H V V Z K L O H S U R Y L G L Q J
D V L P S O H I U D P H Z R U N I R U H [ S O D L Q L Q J W K H S U R F H G X U H U L V N V D Q G E H Q H W V G R H V Q W S U R Y L G H D G H H S H U X Q G H U V W D Q G L Q J
of the patient values, lifestyle changes, or implications for the future. Shared decision-making between the
clinician and the patient for bariatric surgery can include some decision support tools to guide the patient
D V K H R U V K H F R Q V L G H U V W K L V V X U J H U \ 2 Q H U H V R X U F H I R U H Y D O X D W L Q J W K H S D W L H Q W V U H D G L Q H V V I R U V K D U H G G H F L V L R Q
P D N L Q J L V W K H 2 W W D Z D 3 H U V R Q D O ’ H F L V L R Q $ L G $ G H F L V L R Q D L G V S H F L F D O O \ I R U J X L G L Q J W K H S D W L H Q W D Q G I D P L O \
through the pros and cons of surgery and to support the discussion with the clinician can be found here:
K W W S Z Z Z K H D O W K Z L V H Q H W F R F K U D Q H G H F L V L R Q D L G & R Q W H Q W 6 W G ’ R F X P H Q W D V S [ " ’ 2 & + : , ’. For more discus-
sion on shared decision-making, see $ S S H Q G L [ 1.
Bariatric surgery for patients with class I obesity (BMI of 3.0-34.9 kg/m
2
)
% D U L D W U L F V X U J H U \ P L J K W E H L Q G L F D W H G I R U D V H O H F W J U R X S R I S D W L H Q W V Z L W K % 0 , R I N J P
2
, with severe
associated comorbid illness.
, Q D U H F H Q W U D Q G R P L ] H G W U L D O I U R P 6 K D X H U D Q G F R O O H D J X H V R E H V H S D W L H Q W V % 0 , N J P
2
Z L W K X Q F R Q-
W U R O O H G W \ S H G L D E H W H V Z H U H H Q U R O O H G 3 D W L H Q W V Z H U H U D Q G R P L ] H G L Q W R W K U H H D U P V L Q F O X G L Q J P H G L F D O W K H U D S \
V O H H Y H J D V W U H F W R P \ D Q G 5 R X [ H Q J D V W U L F E \ S D V V * O \ F H P L F F R Q W U R O P H D V X U H G E \ Q R U P D O L ] D W L R Q R I + E $ F
was superior in both surgical arms.
$ U D Q G R P L ] H G V W X G \ I U R P 2 % U L H Q D Q G F R O O H D J X H V L Q S D W L H Q W V Z L W K F O D V V , R E H V L W \ % 0 , N J P
2
under-
J R L Q J D G M X V W D E O H E D Q G L Q J F R P S D U H G W R O L I H V W \ O H P R G L F D W L R Q W K H U H D U H V X E V W D Q W L D O L P S U R Y H P H Q W V R Y H U W Z R
years in both weight loss and improvement of the metabolic syndrome in the surgical group compared to
those who are medically managed (O'Brien, 2006 [Reference]).
, Q D V O L J K W O \ K H D Y L H U F R K R U W R I S D W L H Q W V % 0 , N J P
2
, dramatic improvements were seen in patients with
P L O G O H V V W K D Q W Z R \ H D U K L V W R U \ G L D E H W H V & O H D U O \ W K H U H D U H L Q G L F D W L R Q V W K D W P D \ V X J J H V W D U R O H I R U X V H R I
bariatric surgery in patients with obesity who may not meet traditional criteria (Dixon, 2008 [Reference]).
/ D S D U R V F R S L F D G M X V W D E O H J D V W U L F O D S E D Q G L Q J K D V E H H Q D S S U R Y H G E \ W K H ) ’ $ I R U W K H V H S D W L H Q W V 0 R U H U H V H D U F K
L V Q H H G H G W R F O D U L I \ Z K L F K S D W L H Q W V Z R X O G E H Q H W D Q G Z K L F K S U R F H G X U H V D U H R S W L P D O I R U E D U L D W U L F V X U J H U \
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Review of bariatric procedures
The most common bariatric procedures performed in the United States include the Roux-en-Y gastric bypass,
laparoscopic adjustable gastric banding, the sleeve gastrectomy, and the duodenal switch (SRC). At this
M X Q F W X U H W K H U H L V O L W W O H M X V W L F D W L R Q I R U S U L P D U \ E D U L D W U L F V X U J H U \ W R E H G R Q H L Q D Q R S H Q I D V K L R Q H [ F H S W L Q
the setting of a reoperative abdomen (Nguyen, 2001 [Reference]). Functionally speaking, procedures are
divided into either a restrictive or a malabsorptive category. The restrictive operations include laparoscopic
adjustable banding for which there are two types of bands available on the market, and the vertical sleeve
gastrectomy. The malabsorptive group includes the gastric bypass and the duodenal switch operation. The
latter group involves varying components of restriction and malabsorption. Table 13, "Overview of Bariatric
Procedures," provides selected information about the advantages and limitations of various bariatric proce -
dures. Additional information on each procedure can also be found in Appendix D, "Overview of Bariatric
Procedures." See Appendix H, "Band Assessment Protocol," for band adjustment scheduling.
Impact on mortality
Long-term data suggests that bariatric surgery in properly selected patients may reduce overall mortality
over a 15-year period compared to conservative medical management. The Swedish obesity study (SOS)
demonstrated less percentage chance of mortality for those who underwent surgery. 6.3% in the control group
died as compared with 5.0% in the surgery group (Sjöström, 2007 [Reference]). Another study by Christou
and colleagues reported the mortality rate in the bariatric surgery cohort to be 0.68% compared with 6.17%
in controls (Christou, 2004 [Reference]). Another study by Adams did note a small increase in suicide rate
and accidental death in patients who have undergone gastric bypass operation. Rates of accidental death
and suicide were 0.11% in the surgical group and 0.064% in the control group (Adams, 2007 [Reference]).
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Table 13. Overview of Bariatric Procedures

?摪usta扬e
?an?
?leeve
? astrecto??
?astric ?祰ass Duo摥nal
??itc?
?ec?anis? ?estrictive ? ?


?alabsorptive


?ot?
? ?
?sti?ate? ?eig?t
loss
㐵?ㄥ
at ? year
㐵? at ㄠyr 㐹? at ㄴ yrs 㜵? at ㄲ yrs
Rea??ission rate ㄥ 㔥 㘥 ㄲ?
?ortalit? 〮〲 ?⸲ ㈥〮 ?⸴
?ontrain?ications ?ll procedures?
unstable
psyc桯logical
conditions?
endocrine
disorders? and
pregnancy
?sop桡geal
dysmotility
?nflammatory
bo?el disease

?? of gastric cancer
乥ed for 乓䅉?
bile duct pat桯logy?
?nflammator y bo?el
disease
?egetarians?
inflammatory
bo?el disease


? ??ect co?or?i?
illness

?iabetes ⬫ ⬫ ⬫? ⬫⬫
?ypertension ⬫ ⬫ ⬫? ⬫⬫
Sleep ?pnea ⬫ ⬫ ⬫ ⬫?

?䕒? ? — ⬫⬫ —

?ailure rate
㈰- ㌵?
-
?- ㄸ?
-
?o?plications
an搠卩摥 ???ects
? ll procedures?
?air lossⰠ
e?cess skin?
nausea? vomiting
and de桹dration
Slippage
?rosion
Concentric
dilation
Port-related
problems
?eak
Stenosis
?o?el
obstruction
?utritional
?eak
Stricture
?arginal ulcer
?o?el obstruction
?nternal ?ernia
?alnutrition
?eak
Stricture
?o?el
obstruction
?o??on
?utritional
De?iciencies
(See Appendix G)

?/? ??cept in t?e presence of
complications
䥲on
?ㄲ
T?iamine
?itamins ?Ⱐ? Ⱐ? Ⱐ
?
?nato?ical
?or歵ps
U?? including
motility
乯 ?- Pylori
??? if 桸 of ulcer

?reoperative
?or歵p
T桲ee mont桳 to
document
compliance
Psyc桯logical
?utritional
?andatory ?eig桴 -loss
Sleep study
?e?ical ?ollo? ? up

?and
assessment
protocol
(?ee ?灰en摩? ? )
? Ⱐ? ? 㘠and ㄲ
mont桳? t桥n
annually
ㄬ ㌬ 㘠and ㄲ mont桳?
t桥n annually
ㄬ ㌬ 㘠and ㄲ
mont桳? t桥n
annually
Ra?iolog? ?nnual U??

?ollo? ? up la扳
(See Appendix I)
T桲ee mont桳
after surgery?
t桥n annually
? ? ? ?
?f bariatric patient presents in emergency department ?o not provide glucose-containing ?? fluids
� ?t five years pati ents ?it? ??? ? ??
? ??? ? ?current ?eig桴 – ??? / initial ?eig?t – ???? 砠㄰?
⬠ - ???? ?elative effectiveness? less to greater
? ?o effect
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Preoperative workup of the bariatric surgical patient
$ V P H Q W L R Q H G R Q F H L W K D V E H H Q G H W H U P L Q H G W K D W D S D W L H Q W K D V P H W W K H S U H R S H U D W L Y H U H T X L U H P H Q W V D Q G K D V
undergone the necessary weight loss, it is important to prepare patients and screen them for surgery. For
patients undergoing laparoscopic adjustable gastric banding it is helpful, though not mandatory, to obtain
D S U H R S H U D W L Y H X S S H U * , V W X G \ 7 K R X J K Q R W V S H F L F W K H S U H V H Q F H R I H V R S K D J H D O D Q D W R P L F D E Q R U P D O L W \ P D \
S U H F O X G H D E D Q G 7 K H S U H V H Q F H R I S U H R S H U D W L Y H G \ V S K D J L D R U D W \ S L F D O J D V W U R H V R S K D J H D O U H ` X [ G L V H D V H P D \
warrant workup including pH probe studies and manometry. All patients who are obese, regardless of
intended procedure, should undergo careful nutritional screening including vitamin status and an albumin
level. For those patients undergoing malabsorptive procedures, a vitamin B panel should be checked to
L Q F O X G H W K L D P L Q H U L E R ` D Y L Q I R O L F D F L G D Q G F \ D Q R F R E D O D P L Q % ) R U S D W L H Q W V S O D Q Q L Q J 5 R X [ H Q < J D V W U L F
bypass, careful history of ulcers or family history of gastric cancer would suggest the need for preopera-
tive upper endoscopy. Whether such patients should have biopsy and screening for H. Pylori is unknown.
Please see Appendix I, "Sample Weight Loss Surgery Preoperative Laboratory SUR and Checkout Orders."
Medical Emergencies Following Bariatric Surgery
?ariatric ?urger? ??ergencies
?an?
?扤o?inal ?ain ??cute?

?ssociated ?it? nausea/vomiting

?dminister t?iamin e 䥍 ? ㄰〠mg

?an?


? ?esis ?ain ?it?out e?esis
䑄堺 slippage ?associated ?it栠signs must e硣lude erosion
and symptoms of gastric obstruction? port infection

uprig桴 C?? to evaluate angle of band ? refer to surgeon ? 䕇?
? 桯rizontal indicates slippage ?


? remove fluid ? remove fluid ? 桹drate

symptoms better better


? upper ?? as outpt ? referral ?S?P ? dietary counseling ? U䝉

Surgeon f/u first available clinic treatment based on finding
彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 彟彟?

?ariatric ?urger? ??ergencies
Rou? ? en ?
?扤o?inal ?ain ??cute?

?ssociated ?it? nausea/vomiting

?dminister t?iamin e ㄰〠mg ??

?pigastric pain
䑄堺 ulcer ??? ⬠PP?

?pigastric and 剕?
?? ? 㨠c?olelit?iasis/c?olecystitis 剕?

Crampy abdominal pain
???? constipation or internal 桥rnia CT ?it栠oral and ?? contrast
⠫⤠? perating ? oom


CT negative – treat constipation CT positive – go to operating room
? ? ?es ? 㴠?o
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Postoperative nutritional follow-up
Please see Appendix G, "Nutritional Supplement Recommendations," for more information. Also, please
see Appendix J, "Sample Post-Bariatric-Surgery Patient Diet," for more information.
7 K H Q D O S K D V H L Q W U R G X F H V W K H O L I H O R Q J Z D \ R I H D W L Q J I R U S D W L H Q W V 3 D W L H Q W V V K R X O G I R F X V R Q H D W L Q J S U R W H L Q U V W
as they add solid foods back into their diet. Tougher foods like fruits, vegetables and whole grains should
be introduced more slowly. These foods, unless chewed well, have a tendency to plug the outlet from the
stomach pouch. Patients should be advised to introduce new foods at separate times to assess for tolerance.
To maintain success with weight management, patients need to do the following:
’ U L Q N ` X L G V P L Q X W H V E H I R U H D Q G R U P L Q X W H V D I W H U P H D O V not during the meal.
( D W O H D Q V R X U F H V R I S U R W H L Q U V W I R O O R Z H G E \ I U X L W V Y H J H W D E O H V D Q G Z K R O H J U D L Q V
$ L P I R U D P L Q L P X P R I W R J U D P V R I S U R W H L Q S H U G D \
$ Y R L G K L J K I D W R U K L J K V X J D U I R R G V
’ U L Q N D W O H D V W V L [ W R H L J K W F X S V R I Q R Q F D O R U L H ` X L G V G D L O \ F K R R V H Z D W H U P R V W R I W H Q
’ U L Q N W Z R J O D V V H V V N L P R U P L O N G D L O \ L Q D G G L W L R Q W R Z D W H U E H W Z H H Q P H D O V
/ L P L W ` X L G V Z L W K F D O R U L H V W R V N L P R U P L O N W Z R F X S V G D L O \
( D W W K U H H P H D O V D G D \
7 D N H P X O W L Y L W D P L Q V D Q G V X S S O H P H Q W V G D L O \
Protein. The newly formed anatomy of the stomach reduces availability of rennin, pepsin and hydrochloric
D F L G F R Q V H T X H Q W O \ O L P L W L Q J S U R W H L Q G L J H V W L R Q 7 K H V H D O W H U D W L R Q V L Q D Q D W R P \ F R X S O H G Z L W K D V L J Q L F D Q W O \
U H G X F H G L Q W D N H R I I R R G P D N H L W G L I F X O W W R P H H W W K H U H T X L U H P H Q W V I R U S U R W H L Q D Q G S U H Y H Q W F D W D E R O L V P L P P H-
diately following surgery. Protein supplements should be considered, especially in the early postoperative
phase, to prevent excess loss of lean tissue (Moize, 2003 [Reference]).
& R X Q V H O L Q J S D W L H Q W V R Q D G H T X D W H S U R W H L Q L Q W D N H L V S H U W L Q H Q W E R W K E H I R U H D Q G D I W H U V X U J H U \ 0 D Q \ S D W L H Q W V
cannot tolerate high-protein foods, which may jeopardize their ability to take in recommended amounts.
These intolerances may be long term, particularly with red meat (Avinoah, 1992 [Reference]; Kushner,
2000 [Reference]) 6 X S S O H P H Q W V D U H R I W H Q X V H G X Q W L O D G H T X D W H S U R W H L Q L Q W D N H W K U R X J K V R O L G I R R G V F D Q E H
maintained, usually about six months after surgery (Deitel, 2002 [Reference]; Moize, 2003 [Reference]).
* D V W U L F E \ S D V V Q X W U L W L R Q D O G H F L H Q F L H V Because gastric bypass surgery excludes critical portions of the
J D V W U R L Q W H V W L Q D O W U D F W L Q F O X G L Q J W K H I X Q G X V G X R G H Q X P D Q G X S S H U S R U W L R Q R I W K H M H M X Q X P Q X W U L H Q W G H F L H Q-
cies are predictable and should be proactively treated. Patients should be advised to take a multivitamin or
prenatal vitamin in addition to the nutrients discussed below.
Calcium and vitamin D. & D O F L X P G H F L H Q F \ L V G L I F X O W W R G H W H F W E H F D X V H D Q R U P D O E O R R G F D O F L X P
level can be maintained despite poor intake. Several factors affect calcium intake following surgery,
including reduced dairy intake as a result of decreased stomach capacity or as a result of lactose intol-
erance, food dislikes and patient adherence with the meal plan. Since the primary absorption pathway
for calcium has been removed with gastric bypass, supplementation is vital to bone health (Elliot, 2003
[Reference]). Calcium citrate with added vitamin D would be the preferable source, since it does not
rely on stomach acidity for absorption (Elliot, 2003 [Reference]; Kushner, 2000 [Reference]). Fifty-
H L J K W S H U F H Q W R I S H R S O H K D Y H Y L W D P L Q ’ G H F L H Q F \ Z K H Q W K H \ S U H V H Q W (Gemmel, 2009 [Reference]). The
American Association of Clinical Endocrinologists Guideline recommends 400-800 IU of vitamin D
per day (Mechanick, 2008 [Reference]).
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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013
Iron. , U R Q G H F L H Q F \ S R V W J D V W U L F E \ S D V V R F F X U V L Q W R R I S D W L H Q W V (Deitel, 2002 [Reference]).
’ H F L H Q F \ P D \ E H G X H W R V H Y H U D O I D F W R U V L Q F O X G L Q J S R V V L E O H I R R G L Q W R O H U D Q F H S D W L H Q W V P D \ Q R W E H W D N L Q J
L Q V X I F L H Q W K H P H L U R Q E \ S D V V H G D E V R U S W L R Q V L W H G X R G H Q X P D Q G X S S H U M H M X Q X P D Q G U H G X F H G V W R P D F K
D F L G L W \ , U R Q V K R X O G E H V X S S O H P H Q W H G W R S U H Y H Q W G H F L H Q F \ (Elliot, 2003 [Reference]; Avinoah, 1992
[Reference]), with special attention to premenopausal women (Klein, 2002 [Reference]). In addition,
the iron may need to be administered either by intravenous or intramuscular methods due to absorption
change. Ferritin levels may need to be monitored annually as the levels can decline for up to seven
years post bypass (Buchwald, 2004 [Reference]). After six weeks of oral repletion, iron infusions can be
instituted. Provide sodium ferric gluconate (125 mg in 100 cc of normal saline) and infuse for over one
hour once per week in six doses for a total of six infusions. Follow-up with patient includes checking
CBC and ferritin in two to three months.
B vitamins
B12
% G H F L H Q F \ R F F X U V L Q J U H D W H U W K D Q R I S D W L H Q W V Z L W K J D V W U L F E \ S D V V (Kushner, 2000 [Reference]),
and the American Gastroenterological Association reports it may reach greater than 50% if supplemental
B12 is not used (Klein, 2002 [Reference]). Of note, most multivitamins do not have enough B12 to return
post-gastric bypass patients to their normal plasma levels (Buchwald, 2004 [Reference]). Vitamin B12
has a complex method of absorption, which is greatly impaired by gastric bypass surgery. Addition-
D O O \ S D W L H Q W V P D \ K D Y H G L I F X O W \ W R O H U D W L Q J I R R G V U L F K L Q % P H D W H J J V D Q G P L O N D Q G F R Q V X P H Y H U \
little, if any, of these. Supplemental B12 greater than the recommended daily intake has been found
to maintain normal plasma cobalamin levels (Elliot, 2003 [Reference]; Kushner, 2000 [Reference]).
Thiamine
7 K L D P L Q H G H F L H Q F \ F D Q R F F X U D V D U H V X O W R I E \ S D V V R I W K H M H M X Q X P Z K H U H W K L D P L Q H L V S U L P D U L O \ D E V R U E H G
or as a result of impaired nutritional intake from recurrent emesis. Neurologic symptoms one to three
P R Q W K V D I W H U V X U J H U \ D U H W K H S U H G R P L Q D Q W L Q G L F D W L R Q I R U W K L D P L Q H G H F L H Q F \ 3 D U H Q W H U D O V X S S O H P H Q W D W L R Q
with thiamine (100 mg/d) should be initiated in patients with active neurologic symptoms. After a 7-14
day course, an oral preparation (10 mg/d) can be used until neurologic symptoms resolve (Mechanick,
2008 [Reference]).
’ X R G H Q D O V Z L W F K Q X W U L W L R Q D O G H F L H Q F L H V
Further considerations exist for the duodenal switch patients due to fat malabsorption, particularly for vita-
mins A, D, E, K. Water miscible preparations exist as a combination and patients can take these. Additional
supplementation is warranted when levels dip. Additionally, hypoalbuminemia can be observed in duodenal
switch patients manifested by postoperative edema. Therapy is to institute pancrelipase 1-3 tablets/meal
for six weeks until prealbumin and albumin have normalized.
Medications
It is important to individually evaluate every post-procedure bariatric patient on an ongoing basis to determine
Z K H W K H U R U Q R W F K U R Q L F P H G L F D W L R Q V V K R X O G E H F R Q W L Q X H G , Q D G G L W L R Q F H U W D L Q P H G L F D W L R Q V U H T X L U H G R V L Q J
adjustments due to their method of absorption or narrow therapeutic window. Changes in a patient’s weight
P D \ U H T X L U H G R V H P R G L F D W L R Q V W R D Y R L G W R [ L F L W \ D Q G L Q F U H D V H G V L G H H I I H F W V
Extended-release medications may be problematic in some patients since the mechanism by which delayed
absorption occurs might be affected. Drugs with narrow therapeutic windows should be monitored especially
closely. For example, warfarin dosing may need to be monitored due to alterations in dietary intake post-
procedure or due to any possible changes in absorption. Until more research is done in this area, there are no
standard rules for adjustments of medications following bariatric surgery. Patients taking any medications
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V K R X O G E H F O R V H O \ P R Q L W R U H G I R U E R W K W R [ L F L W \ D Q G L Q F U H D V H G V L G H H I I H F W V $ O V R G U X J V Z L W K Z H L J K W U H T X L U H-
P H Q W V I R U G R V L Q J V K R X O G E H U H H Y D O X D W H G I U H T X H Q W O \ D V S D W L H Q W V H [ S H U L H Q F H Z H L J K W O R V V 6 L Q F H P D Q \ G U X J V D U H
monitored for a therapeutic outcome, the dose can be titrated to this outcome (Buchwald, 2004 [Reference]).
Surgery for adolescents
Bariatric surgery in adolescents is highly controversial and must be carried out on a case-by-case basis for
patients in a high-volume center (O'Brien, 2010 [Reference]).
Failed bariatric surgery
Bariatric surgery can fail. At 10 years it is estimated that 23% of patients with a BMI less than 50 fail bariatric
surgery. Also at 10 years, it is estimated that 58% of patients with a BMI greater than 50 fail bariatric surgery.
Failed bariatric surgery is when the patient will achieve less than 25% of excess weight lost (Christou, 2006
[Reference]). Besides beginning BMI, we have no good indicator for prediction of weight-loss.
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ㄳ? 剥assess 䝯als and 剩s欠䙡捴orsⰠand 䍯畮sel 剥garding ? eight
䵡intenan捥
Patients need regular follow-up for obesity, which is a lifelong problem in most cases. Regular follow-up
conveys the message that the condition is important to the patient, and it affords the opportunity for moni-
toring body mass index, as well as evaluation and management of any of the common complications that
are often associated with obesity.
, Q W H Q V L Y H L Q W H U Y H Q W L R Q Z L W K Z H H N O \ F R Q W D F W I R U W K H U V W W K U H H P R Q W K V D Q G W K H Q F R Q W L Q X H G V X S S R U W R X W W R I R X U
years such as the Look AHEAD program is the most successful at creating and maintaining the 5-10% weight
O R V V Q H H G H G W R U H G X F H F O L Q L F D O O \ V L J Q L F D Q W K H D O W K U L V N V (Wadden, 2009 [Reference]).
3 D W L H Q W V R Q S K D U P D F R W K H U D S \ I R U R E H V L W \ Q H H G R Q J R L Q J H Y D O X D W L R Q I R U E O R R G S U H V V X U H D G H T X D F \ R I Q X W U L W L R Q
D Q G V X U Y H L O O D Q F H I R U V S H F L F Q X W U L H Q W G H F L H Q F L H V V X F K D V O R Z O H Y H O V R I I D W V R O X E O H Y L W D P L Q V L Q W K R V H R Q R U O L V W D W
3 D W L H Q W V Z K R K D Y H K D G E D U L D W U L F V X U J H U \ P D \ D O V R Q H H G S U R F H G X U H V S H F L F I R O O R Z X S
Ongoing reinforcement of important behavior strategies may include provision of new information on
obesity management, control of local food environment, strategies to cope with restaurant eating, strategies
to limit perimeal snacking and high-calorie beverages, and strategies for achieving regular physical activity.
See Annotation #6, "Advise Weight Maintenance and Manage Other Risk Factors."
The primary care clinician also may serve as community leader and public health advocate. Such advocacy
may occur in a variety of forms and settings:
Schools: Priorities for school activities that limit risk of obesity include control of the food environment,
enhancement of regular physical activity including lifelong forms of physical activity as a regular part of
the school curriculum, and education of students on advantages and practical approaches for healthy eating
and regular physical activity.
Work sites: Advocate for healthy food choices at worksites, including both healthy food choices in cafete -
rias and healthy food choices in vending machines. Especially consider limiting availability of sweetened
carbonated beverages and high-calorie, high-fat snacks in vending machines.
Other community settings: There are opportunities for political advocacy and community health educa-
tion that emphasize the importance of healthy lifestyle. Issues such as availability of sidewalks, pedestrian
access to commercial establishments, and availability of public affordable exercise facilities of different
sorts are among the issues that may be relevant.
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Prevention and Management of Obesity for Adults
Algorithm Annotations Sixth Edition/May 2013

㐴Copyright © 2013 by Institute for Clinical Systems Improvement
The Aims and Measures section is intended to provide protocol users with a menu
of measures for multiple purposes that may include the following:
population health improvement measures,
T X D O L W \ L P S U R Y H P H Q W P H D V X U H V I R U G H O L Y H U \ V \ V W H P V,
P H D V X U H V I U R P U H J X O D W R U \ R U J D Q L ] D W L R Q V V X F K D V - R L Q W & R P P L V V L R Q
P H D V X U H V W K D W D U H F X U U H Q W O \ U H T X L U H G I R U S X E O L F U H S R U W L Q J
P H D V X U H V W K D W D U H S D U W R I & H Q W H U I R U 0 H G L F D U H 6 H U Y L F H V 3 K \ V L F L D Q 4 X D O L W \
Reporting initiative, and
R W K H U P H D V X U H V I U R P O R F D O D Q G Q D W L R Q D O R U J D Q L ] D W L R Q V D L P H G D W P H D V X U L Q J
population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing
the gap between current clinical practice and the recommendations set forth in the
guideline.
The subdivisions of this section are:
$ L P V D Q G 0 H D V X U H V
, P S O H P H Q W D W L R Q 5 H F R P P H Q G D W L R Q V
, P S O H P H Q W D W L R Q 7 R R O V D Q G 5 H V R X U F H V
, P S O H P H Q W D W L R Q 7 R R O V D Q G 5 H V R X U F H V 7 D E O H
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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Aims and 䵥as畲es
1. Increase percentage of patients age 18 years and older who have an annual screening for obesity using
E R G \ P D V V L Q G H [ % 0 , P H D V X U H V S H F L F I R U D J H D Q G J H Q G H U G R F X P H Q W H G (Annotation #1)
Measure for accomplishing this aim:
a. Percentage of patients who have an annual body mass index (BMI) measured and documented.
2. Increase the percentage of patients age 18 years and older with a BMI > 25 who have received education
and counseling regarding weight management. (Annotations #8, 10)
Measure for accomplishing this aim:
a. Percentage of patients with a BMI > 25 who received education and counseling for weight-manage -
ment strategies that include nutrition, physical activity, lifestyle changes, medication and/or surgical
considerations. Each education/counseling strategy is based on the BMI level as follows:
% 0 , / L I H V W \ O H F K D Q J H V D Q G E H K D Y L R U D O P D Q D J H P H Q W
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W D Q G P H G L F D W L R Q F R Q V L G H U D W L R Q V
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q D Q G V X U J L F D O F R Q V L G H U-
ations.
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q D Q G V X U J L F D O F R Q V L G H U D W L R Q V
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R V H W D Q L Q G L Y L G X D O L ] H G J R D O D O R Q J Z L W K W D U J H W G D W H I R U
reduction in BMI.
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R U H D F K W K H L U J R D O % 0 , E \ W K H V H W W D U J H W G D W H
, Q F U H D V H W K H S H U F H Q W D J H R I S D W L H Q W V D J H \ H D U V D Q G R O G H U Z L W K D % 0 , Z K R K D Y H L P S U R Y H G R X W F R P H V
from the treatment. (Annotations #8, 10)
Measures for accomplishing this aim:
a. Percentage of patients with a BMI > 25 who have reduced their weight by 5%.
b. Percentage of patients with a BMI > 25 who have 30 minutes of any type of physical activity docu -
P H Q W H G Y H W L P H V S H U Z H H N G R F X P H Q W H G
F 3 H U F H Q W D J H R I S D W L H Q W V Z L W K D % 0 , Z K R K D Y H U H G X F H G W K H L U Z H L J K W E \
d. Percentage of patients with a BMI > 40 who have been provided with a referral to a bariatric
specialist.
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Prevention and Management of Obesity for Adults
Aims and 䵥as畲es Sixth Edition/May 2013
Measurement Specifications
䵥as畲ement ⌱a
Percentage of patients who have an annual body mass index (BMI) measured and documented.
Population Definition
Patients age 18 years and older in the primary care panel.
Data o映䥮terest
# patients who have an annual body mass index (BMI) documented
# patients in the primary care panel
Numerator/Denominator Definitions
Numerator: Number of patients age 18 years and older who have an annual BMI documented.
Denominator: Total number of patients age 18 years and older in the clinic’s primary care panel.
䵥thod⽓o畲捥 o映Data 䍯lle捴ion?
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U W K H W R W D O Q X P E H U R I S D W L H Q W V L Q W K H F O L Q L F V S U L P D U \ F D U H S D Q H O Z K R Z H U H
age 18 years and older in the last 12 months from the measurement period date. The measurement period
F D Q E H P R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I W K R V H S D W L H Q W V Z K R K D G D Q
annual BMI documented.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is a process measure, and improvement is noted as an increase in the rate.
1 D W L R Q D O & R P P L W W H H I R U 4 X D O L W \ $ V V X U D Q F H 1 & 4 $ D O V R K D V D + ( ’ , 6 P H D V X U H I R U D Q Q X D O % 0 , V F U H H Q L Q J
I R U S D W L H Q W V D J H \ H D U V R O G ) X O O V S H F L F D W L R Q V I R U W K L V P H D V X U H F D Q E H R E W D L Q H G I U R P 1 & 4 $ D W
K W W S Z Z Z Q F T D R U J.
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䵥as畲ement ⌲a
Percentage of patients with a BMI > 25 who received education and counseling for weight-management
strategies that include nutrition, physical activity, lifestyle changes, medication therapy and/or surgical
considerations (each education/counseling strategy is based on the BMI level):
% 0 , / L I H V W \ O H F K D Q J H V D Q G E H K D Y L R U D O P D Q D J H P H Q W
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W D Q G P H G L F D W L R Q F R Q V L G H U D W L R Q V
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q W K H U D S \ D Q G V X U J L F D O
considerations.
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q D Q G V X U J L F D O
considerations.
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R V H W D Q L Q G L Y L G X D O L ] H G J R D O D O R Q J Z L W K W D U J H W G D W H I R U
reduction in BMI.
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R U H D F K W K H L U J R D O % 0 , E \ W K H V H W W D U J H W G D W H
Population Definition
Patients age 18 years and older with BMI > 25.
Data o映䥮terest
# of patients who receive education and counseling for weight management strategies appropriate to their
BMI
Patients with BMI > 25
Numerator/Denominator Definitions
Numerator: Number of patients with a BMI > 25 who receive education and counseling for weight
management appropriate to their BMI level, including nutrition, physical activity, lifestyle
changes, medication and/or sur gical considerations.
% 0 , / L I H V W \ O H F K D Q J H V D Q G E H K D Y L R U D O P D Q D J H P H Q W
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W D Q G P H G L F D W L R Q
considerations.
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q W K H U D S \
and surgical considerations.
% 0 , / L I H V W \ O H F K D Q J H V E H K D Y L R U D O P D Q D J H P H Q W P H G L F D W L R Q D Q G
surgical considerations.
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R V H W D Q L Q G L Y L G X D O L ] H G J R D O D O R Q J Z L W K W D U J H W
date for reduction in BMI.
3 H U F H Q W D J H R I S D W L H Q W V Z L W K % 0 , Z K R U H D F K W K H L U J R D O % 0 , E \ W K H V H W W D U J H W G D W H
Denominator: Number of patients with a BMI > 25.
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䵥thod⽓o畲捥 o映Data 䍯lle捴ion?
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U S D W L H Q W V Z K R K D Y H % 0 , ) R F X V \ R X U T X H U \ I R U S D W L H Q W V Z K R K D G
BMI done 12 months earlier from the measurement period date and were age 18 years or older at the time.
7 K H P H D V X U H P H Q W S H U L R G F D Q E H P R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I
those patients who had one or more of the weight-management strategies appropriate to their BMI at any
time over a 12-month period from the date of BMI done to the measurement period date.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is a process measure, and improvement is noted as an increase in the rate.
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Aims and 䵥as畲es Sixth Edition/May 2013

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Prevention and Management of Obesity for Adults
Aims and 䵥as畲es Sixth Edition/May 2013
䵥as畲ement ⌳a
3 H U F H Q W D J H R I S D W L H Q W V Z L W K D % 0 , Z K R K D Y H U H G X F H G W K H L U Z H L J K W E \
Population Definition
Patients age 18 years and older with a BMI > 25.
Data o映䥮terest
# of patients with a BMI > 25 who have reduced their weight by 5%
# of patients with BMI > 25
Numerator/Denominator Definitions
Numerator: Number of patients who have reduced their weight by 5%.
Denominator: Number of patients with a BMI > 25.
䵥thod⽓o畲捥 o映Data 䍯lle捴ion
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U S D W L H Q W V Z K R K D Y H % 0 , ) R F X V \ R X U T X H U \ I R U S D W L H Q W V Z K R K D G
BMI done 12 months earlier from the measurement period date and were age 18 years or older at the time.
7 K H P H D V X U H P H Q W S H U L R G F D Q E H P R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I
those patients who reduced their BMI by 5% over a 12-month period from the date of BMI done to the
measurement period date.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is an outcome measure, and improvement is noted as an increase in the rate.
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Prevention and Management of Obesity for Adults
Aims and 䵥as畲es Sixth Edition/May 2013
䵥as畲ement ⌳?
Percentage of patients with a BMI > Z K R K D Y H P L Q X W H V R I D Q \ W \ S H R I S K \ V L F D O D F W L Y L W \ Y H W L P H V S H U
week documented.
Population Definition
Patients age 18 years and older with a BMI > 25.
Data o映䥮terest
R I S D W L H Q W V Z K R K D Y H P L Q X W H V R I S K \ V L F D O D F W L Y L W \ Y H W L P H V S H U Z H H N G R F X P H Q W H G
# of patients with a BMI > 25
Numerator/Denominator Definitions
Numerator: Number of patients with a BMI > Z K R K D Y H P L Q X W H V R I S K \ V L F D O D F W L Y L W \ Y H W L P H V S H U
week documented.
Denominator: Number of patients with a BMI > 25.
䵥thod⽓o畲捥 o映Data 䍯lle捴ion
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U S D W L H Q W V Z K R K D Y H % 0 , ) R F X V \ R X U T X H U \ I R U S D W L H Q W V Z K R K D G
BMI done 12 months earlier from the measurement period date and were age 18 years or older at the time.
7 K H P H D V X U H P H Q W S H U L R G F D Q E H P R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I
W K R V H S D W L H Q W V Z K R K D Y H P L Q X W H V R I S K \ V L F D O D F W L Y L W \ Y H W L P H V S H U Z H H N R Y H U D P R Q W K S H U L R G I U R P
the date of BMI done to the measurement period date.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is an outcome measure, and improvement is noted as an increase in the rate.
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Prevention and Management of Obesity for Adults
Aims and 䵥as畲es Sixth Edition/May 2013
䵥as畲ement ⌳?
Percentage of patients with a BMI > 25 who have reduced their weight by 10%.
Population Definition
Patients age 18 years and older with a BMI > 25.
Data o映䥮terest
# of patients who reduced their BMI by 10%
# of patients with a BMI > 25
Numerator/Denominator Definitions
Numerator: Number of patients with a BMI > 25 who have reduced their BMI by 10%.
Denominator: Number of patients with a BMI > 25.
䵥thod⽓o畲捥 o映Data 䍯lle捴ion
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U S D W L H Q W V Z K R K D Y H % 0 , ) R F X V \ R X U T X H U \ I R U S D W L H Q W V Z K R K D G
BMI done 12 months earlier from the measurement period date and were age 18 years or older at the time.
7 K H P H D V X U H P H Q W S H U L R G F D Q E H P R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I
those patients who reduced their BMI by 10% over a 12-month period from the date of BMI done to the
measurement period date.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is an outcome measure, and improvement is noted as an increase in the rate.
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䵥as畲ement ⌳d
Percentage of patients with a BMI > 40 who have been provided with a referral to a bariatric specialist.
Population Definition
3 D W L H Q W V D J H \ H D U V D Q G R O G H U Z L W K D % 0 ,
Data o映䥮terest
# of patients were provided referrals to bariatric specialist
# of patients with BMI > 40
Numerator/Denominator Definitions
Numerator: Number of patients with BMI > 40 who provided referrals to a bariatric specialist.
Denominator: Number of patients with a BMI > 40.
䵥thod⽓o畲捥 o映Data 䍯lle捴ion
4 X H U \ H O H F W U R Q L F P H G L F D O U H F R U G V I R U S D W L H Q W V Z K R K D Y H % 0 , ) R F X V \ R X U T X H U \ I R U S D W L H Q W V Z K R K D G
BMI done 12 months earlier from the measurement period date and were age 18 years or older at the time and
whose set goal target date is within 12 months of the BMI done. The measurement period can be monthly,
T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ ’ H W H U P L Q H W K H Q X P E H U R I W K R V H S D W L H Q W V Z K R U H F H L Y H G D U H I H U U D O W R
a bariatric specialist over a 12-month period from the date of BMI done to the measurement period date.
?ime 䙲ame Pertaining to Data 䍯lle捴ion
0 R Q W K O \ T X D U W H U O \ V H P L D Q Q X D O O \ R U D Q Q X D O O \ 6 H O H F W W L P H I U D P H W K D W D O L J Q V E H V W Z L W K \ R X U F O L Q L F V T X D O L W \
improvement activities.
乯tes
This is an outcome measure, and improvement is noted as an increase in the rate.
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Aims and 䵥as畲es Sixth Edition/May 2013

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䥭灬ementation 剥捯mmendations
Prior to implementation, it is important to consider current organizational infrastructure that addresses the
following:
6 \ V W H P D Q G S U R F H V V G H V L J Q
7 U D L Q L Q J D Q G H G X F D W L R Q
& X O W X U H D Q G W K H Q H H G W R V K L I W Y D O X H V E H O L H I V D Q G E H K D Y L R U V R I W K H R U J D Q L ] D W L R Q
7 K H I R O O R Z L Q J V \ V W H P F K D Q J H V Z H U H L G H Q W L H G E \ W K H J X L G H O L Q H Z R U N J U R X S D V N H \ V W U D W H J L H V I R U K H D O W K F D U H
systems to incorporate in support of the implementation of this guideline:
( V W D E O L V K D V \ V W H P I R U X V L Q J D 3 D W L H Q W 5 H D G L Q H V V 6 F D O H W R G H W H U P L Q H L I W K H S D W L H Q W L V U H D G \ W R W D O N D E R X W
weight loss and/or would like information.
( V W D E O L V K D V \ V W H P I R U V W D I I W R H I F L H Q W O \ F D O F X O D W H % 0 , S U L R U W R W K H F O L Q L F L D Q H Q W H U L Q J W K H H [ D P U R R P
The BMI may provide more health risk information than traditional vital signs and should be built into
the patient assessment protocol. A BMI chart should be placed by each scale in the clinic. All orga-
nizations with electronic medical records should build BMI calculators as a component for immediate
calculation.
’ H Y H O R S D W U D F N L Q J V \ V W H P W K D W S H U L R G L F D O O \ U H Y L H Z V S D W L H Q W F K D U W V W R L G H Q W L I \ S D W L H Q W V Z K R D U H R Y H U Z H L J K W
or obese so that clinicians are aware of the need to discuss the issue with the patient.
( V W D E O L V K D V \ V W H P I R U V W D I I D Q G F O L Q L F L D Q W U D L Q L Q J D U R X Q G V N L O O V D Q G N Q R Z O H G J H L Q W K H D U H D V R I P R W L Y D W L R Q D O
L Q W H U Y L H Z L Q J E U L H I I R F X V H G D G Y L F H R Q Q X W U L W L R Q S K \ V L F D O D F W L Y L W \ D Q G O L I H V W \ O H F K D Q J H V D Q G H Y D O X D W L R Q
of evidence of effectiveness of treatment options.
( V W D E O L V K D V \ V W H P I R U F R Q W L Q X L Q J H G X F D W L R Q R Q H Y L G H Q F H E D V H G R E H V L W \ P D Q D J H P H Q W I R U F O L Q L F L D Q V Q X U V H V
and ancillary clinic staff.
5 H P R Y H E D U U L H U V W R U H I H U U D O S U R J U D P V I R U Z H L J K W O R V V E \ X Q G H U V W D Q G L Q J Z K H U H S U R J U D P V D U H D Q G Z K D W
S U R F H V V L V U H T X L U H G I R U U H I H U U D O V
’ H Y H O R S P H G L F D O U H F R U G V \ V W H P V W R W U D F N V W D W X V R I S D W L H Q W V X Q G H U W K H F O L Q L F L D Q V F D U H Z L W K W K H F D S D E L O L W \
to produce an outpatient tracking system for patient follow-up by clinician/staff.
8 V H W R R O V V X F K D V S R V W H U V D Q G E U R F K X U H V W K U R X J K R X W W K H I D F L O L W \ W R D V V L V W Z L W K L G H Q W L I \ L Q J D Q G Q R W L I \ L Q J
patients about health risk in relationship to NIH-based categories of BMI. Promote a healthy lifestyle
around nutrition and activity while encouraging patient knowledge of his or her BMI.
’ H Y H O R S S D W L H Q W F H Q W H U H G H G X F D W L R Q D Q G V H O I P D Q D J H P H Q W S U R J U D P V Z K L F K P D \ L Q F O X G H V H O I P R Q L W R U L Q J
self-management and skills such as journaling.
% X L O G V \ V W H P V W R W U D F N R X W F R P H V P H D V X U H V D V Z H O O D V R Q J R L Q J S U R F H V V P H D V X U H V 7 U D F N W K H U H V S R Q V H
rate to various treatments/strategies. Improvement rates the BMI is stable or has decreased over time.
6 \ V W H P V W R F R R U G L Q D W H F D U H H Q V X U H F R Q W L Q X L W \ D Q G N H H S F O L Q L F L D Q V L Q I R U P H G R I S U R J U H V V
- Develop electronic tracking systems for panel or population management.
- Educate patients to foster awareness and knowledge of BMI for self-monitoring and reporting.
- Structure follow-up visits with patient per guideline recommendations.
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䥭灬ementation ?ools and 剥so畲捥s
Criteria for Selecting Resources
7 K H I R O O R Z L Q J W R R O V D Q G U H V R X U F H V V S H F L F W R W K H W R S L F R I W K H J X L G H O L Q H Z H U H V H O H F W H G E \ W K H Z R U N J U R X S
Each item was reviewed thoroughly by at least one work group member. It is expected that users of these
tools will establish the proper copyright prior to their use. The types of criteria the work group used are:
7 K H F R Q W H Q W V X S S R U W V W K H F O L Q L F D O D Q G W K H L P S O H P H Q W D W L R Q U H F R P P H Q G D W L R Q V
: K H U H S R V V L E O H W K H F R Q W H Q W L V V X S S R U W H G E \ H Y L G H Q F H E D V H G U H V H D U F K
7 K H D X W K R U V R X U F H D Q G U H Y L V L R Q G D W H V I R U W K H F R Q W H Q W D U H L Q F O X G H G Z K H U H S R V V L E O H
7 K H F R Q W H Q W L V F O H D U D E R X W S R W H Q W L D O E L D V H V D Q G Z K H Q D S S U R S U L D W H F R Q ` L F W V R I L Q W H U H V W V D Q G R U
disclaimers are noted where appropriate.
Resources Available to ICSI Members Only
ICSI has knowledge resources that are only available to ICSI members (these are indicated with an asterisk in
far left-hand column of the Resources Table). In addition to the resources listed in the table, ICSI members
K D Y H D F F H V V W R D E U R D G U D Q J H R I P D W H U L D O V L Q F O X G L Q J W R R O N L W V R Q & R Q W L Q X R X V 4 X D O L W \ , P S U R Y H P H Q W S U R F H V V H V
and Rapid Cycling that can be helpful. To obtain copies of these or other Resources, go to Education and
4 X D O L W \ , P S U R Y H P H Q W on the ICSI Web site. To access these materials on the Web site, you must be logged
in as an ICSI member.
The resources in the table on the next page that are not reserved for ICSI members are available to the
public free-of-charge unless otherwise indicated.
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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013

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* Author/Organization Title/Description Audience Web sites/Order Information
America On the Move America On the Move (AOM):
Challenges you, your family and your
community to take small steps and
make small changes to a healthier
way of life. Get involved!
Patients and
Families
http://www.americaonthemove.
org
American Academy of
Family Physicians
American Family Physician: Patient
education article, "Exercise: How to
Get Started"
Patients and
Families
http://www.aafp.org/
afp/20030115/367ph.html
American Dietetic
Association
American Dietetic Association:
Provides information on nutrition and
current research
Patients and
) D P L O L H V
Health Care
Professionals
http://www.eatright.org
Calorie King Calorie King: Provides a review of
the most popular diets
Patients and
Families
http://www.calorieking.com
Centers for Disease
Control (CDC)
Overweight and Obesity: an over -
view. Includes a body mass index
calculator.
Physical Activity Guidelines for
Americans
Patients and
) D P L O L H V
Health Care
Professionals
http://www.cdc.gov/nccdphp/
dnpa/obesity/contributing_
factors.htm
http://www.cdc.gov/nccdphp/
dnpa/physical/pdf/PA_Fact_
Sheet_Adults.pdf
Crowley and Lodge Younger Next Year for Men
Younger Next Year for Women
Patients and
) D P L O L H V
Health Care
Professionals
http://www.youngernextyear.
com/books.php
Department of Food
Science and Human
Nutrition, University
of Illinois at Urbana-
Champaign
NAT (Nutritional Assessment Tools
for Good Health): Provides a free
Web-based program that allows one
to perform a nutritional analysis of
one’s diet
Patients and
Families
http://www.nat.uiuc.edu
Department of Health
and Human Services
President’s Council on Physical
Fitness and Sports: Online pamphlet
providing information on physical
W Q H V V I X Q G D P H Q W D O V
Physical Activity Guidelines for
Americans
Patients and
Families
K W W S Z Z Z W Q H V V J R Y
http://www.health.gov/paguide -
lines/factsheetprof.aspx
Dole Company Dole Super Kids: Provides basic
nutrition education for kids and class-
room ideas for teachers
Patients and
Families
http://www.dole5aday.com
䥭灬ementation ?ools and 剥so畲捥s ?a扬e
* Available to ICSI members only.
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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013

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Prevention and Management of Obesity for Adults
䥭灬ementation ?ools and 剥so畲捥s ?a扬e Sixth Edition/May 2013
* Author/Organization Title/Description Audience Web sites/Order Information
Health Wise Obesity: Should I have weight-loss
surgery?
Patients and
Families;
Health Care
Professionals
http://www.healthwise.net/
cochranedecisionaid/
Content/StdDocument.
aspx?DOCHWID=
ug2364#ug2364-Intro
* Institute for Clinical
Systems Improvement
Prevention and Management of
Obesity Guideline Pilot Summary:
$ I O L D W H G & R P P X Q L W \ 0 H G L F D O & H Q W H U V
D Q G 6 W 0 D U \ V ’ X O X W K & O L Q L F + H D O W K
System participated in a guideline
pilot from mid-2005 to early 2006.
This summary will tell their story and
provide information around strategies
for implementation, measurement/
outcomes and overall improvement in
processes.
Health Care
Professionals
http://www.icsi.org
Institute for Research
and Education - PNC
0 R U H ) O D Y R U / H V V ) D W † ( D V \ / R Z ) D W
Cooking; Nutrition pamphlet
Patients and
Families
800-372-7776
Institute for Research
and Education - PNC
Simple Strategies for Meal Planning:
Nutrition pamphlet
Patients and
Families
800-372-7776
Institute for Research
and Education - PNC
Simple Strategies for Eating Out:
Nutrition pamphlet
Patients and
Families
800-372-7776
Institute for Research
and Education - PNC
Simple Strategies for Weight
Management: Nutrition pamphlet
Patients and
Families
800-372-7776
Krames - Health and
Safety Education
Understanding Bariatric Surgery:
< R X U 6 X U J L F D O 2 S W L R Q V I R U : H L J K W / R V V
Surgery pamphlet
Patients and
Families
Call 1-800-333-3032
/ H W V 0 R Y HLet’s Move: 0 L F K H O O H 2 E D P D V : H E V L W H
to reduce obesity in kids.
Patients and
Families;
Health Care
Professionals
http://www.letsmove.gov
0 D \ R & O L Q L FMayo Clinic: Provides a wide variety
of information on nutrition, programs
and a food pyramid placing fruits and
vegetables at the bottom vs.
carbohydrates.
The Mayo Clinic Diet: Eat Well,
Enjoy Life, Lose Weight
Patients and
Families
http://www.mayoclinic.com
Book
1 D W L R Q D O + H D U W / X Q J
and Blood Institute
Aim for a Healthy Weight: provides
key recommendations from the National
+ H D U W / X Q J D Q G % O R R G , Q V W L W X W H Q D W L R Q D O
guidelines, how to get started and links
to other publications.
Patients and
Families
http://www.nhlbi.nih.gov/health/
public/heart/obesity/lose_wt/
index.htm
* Available to ICSI members only.
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* Author/Organization Title/Description Audience Web sites/Order Information
National Institutes of
Health
The National Institute of Diabetes
and Digestive and Kidney Diseases:
Provides science-based
information on obesity, weight
management and nutrition.
Patients and
) D P L O L H V
Health Care
Professionals
http://www.niddk.nih.gov/index.
htm
Paths to Healthy
Weight
At Paths to Healthy Weight, the Health
Care Innovations Exchange presents
new approaches for helping communi-
ties and clinicians prevent overweight
and obesity, in a joint effort of the
Agency for Healthcare Research and
4 X D O L W \ D Q G W K H + H D O W K 5 H V R X U F H V D Q G
Services Administrations.
Patients and
) D P L O L H V
Health Care
Professionals
K W W S Z Z Z L Q Q R Y D W L R Q V D K U T J R Y
healthyweight.aspx
Shape Up America Shape Up America: Provides infor-
mation on an interactive personalized
weight-loss program with links to
D V X S S R U W F H Q W H U U H F L S H V D Q G W Q H V V
information.
Patients and
Families
http://www.shapeup.org
The Discovery Health
Channel
Discovery Health: Provides informa-
W L R Q R Q Q X W U L W L R Q W Q H V V D Q G Z H L J K W
management.
Patients and
Families
http://www.health.discovery.com
U.S. Department of
Agriculture
Choose My Plate: Use the plate as an
interactive nutrition education tool.
Patients and
) D P L O L H V
Health Care
Professionals
http://www.choosemyplate.gov
We Can (Ways to
Enhance Children’s
Activity and Nutrition)
We Can: National Heart, Lung and
Blood Institutes national movement
designed to give parents, caregivers
and entire communities a way to help
children ages 8-13 stay at a healthy
weight.
Patients and
) D P L O L H V
Health Care
Professionals
http://wecan.nhlbi.nih.gov
* Available to ICSI members only.
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Prevention and Management of Obesity for Adults
䥭灬ementation ?ools and 剥so畲捥s ?a扬e Sixth Edition/May 2013


The subdivisions of this section are:
5 H I H U H Q F H V
$ S S H Q G L F H V
Copyright © 2013 by Institute for Clinical Systems Improvement
Supporting Evidence:
Prevention and Management of Obesity for Adults

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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
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Abid O, Galuska D, Khal KL, et al. Are health care professionals advising obese patients to lose weight?
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Rössner S, Sjöström L, Noack R, et al. Weight loss, weight maintenance, and improved cardiovascular
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A灰endi砠A 阠䵥di捡tions Asso捩ated 睩th ?eight
䝡in and ?eight 䱯ss
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Sources: (Aronne, 2009 [Reference]; Astrup, 2009 [Reference]; Moyers, 2005 [Reference])
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Therapeutic Class Mechaism of
Action or
Pharmaceutical
Class
Medication Weight
Neutral
Related to
Weight Gain
Related to
Weight Loss
Norepinephrine
and Dopamine RI
Bupropion



Venlafaxine

X (especially
when
combined with
naltrexone)
X
SSRI Fluoxetine

Sertraline


X



X (initially but
may gain over
time)
Tricyclics X

Monamine oxidase
inhibitors
X

Antidepressants

(Masand, 2000
[Reference]; Sussman,
2001 [Reference])
Multiple Mirtazapine X
GLP -1 analogs Exenatide
Liraglutide
X
X
Biguanides Metformin X
Amylin analog Pramlitide X
Alpha-Glucosidase
inhibitors
Acarbose
Miglitol
X
X
Insulin secretagogues
meglitinides
Nateglinide
Repaglinide

X
X

Insulin secretagogues
sulfonylureas

X

Thiazolidine- diones Pioglitazone Weight
neutral if
used with
metformin
X (when used
alone or in
combination
with
sulfonylurea)

Insulin X

Hypoglycemics

(The Diabetes Control
and Complic ations
Trial Research Group;
1993 [Reference];
Purnell, 1998
[Reference]; Williams,
1999 [Reference])
DPP -4 inhibitors Sitagliptin
Saxagliptin
X
X

Anticonvulsants

(Nemeroff, 2003
[Reference]; Isojarvi,
1996 [Reference];
DeToledo, 1997
[Reference]; Biton,
2001 [Reference];
Ben- Menachem, 2003
[Reference])

Topiramate
Zonisamide
Valproate
Gabapentin
Lamotrigine




X


X extreme
X extreme
X
X
O pioid Antagonist Naltrexone X
Mood Stabilizer Lithium X
Antihypertensives Beta and alpha -l
adrenergic blocking
agents
X
Antipsychotics
(consider empiric use
of metformin to
minimize weight gain)

(Aronne, 2003
[Reference])

Risperidone
Sertindole
Olanzapine
Clozapine
Ziprasidone

X
X
X
X
X (small
increase)



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A灰endi砠䈠阠Ph祳i捡l A捴ivit礠Pres捲i灴ion
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
?ame 彟彟彟彟彟彟彟彟彟彟?
?ate 彟彟彟彟彟?
?ollo? -up interval 彟彟彟?


?ealt? ?tatus ?or ??祳ical ?ctivit示
Current ?iagnoses ?see contraindications?? Current ?edications?
ㄮ 彟彟彟彟彟彟彟彟彟彟 ㄮ 彟彟彟彟彟彟彟彟彟彟?
㈮ 彟彟彟彟彟彟彟彟彟彟 ㈮ 彟彟彟彟彟彟彟彟彟彟?
㌮ 彟彟彟彟彟彟彟彟彟彟 ㌮ 彟彟彟彟彟彟彟彟彟彟?

?ssessment?
彟彟彟张? ? for a self -monitored activity program
彟彟彟张?? for a supervised activity program ?referral?
??????? ?eeds e?ercise tolerance testing ?referral?

?ctivit? ?lanner ? Season?s? of ?ear 彟彟彟彟彟彟?

䥮?oors ? ?lone 䥮?oors ? ?it? Ot?ers
ㄮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟 ㄮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟
?esources ?esources
a?彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 a?彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟?
b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 c? 彟彟? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟

㈮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟彟 ㈮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟?
?esources ?esources
a?彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 a?彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 ?
b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟?

Out?oors ? ?lone Out?oors ? ?it? Ot?ers
ㄮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟 ㄮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟?
?esources ?esources
a⸠彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 a? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 c? 彟彟? 彟彟彟彟彟彟彟彟彟彟彟彟彟?

㈮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 ㈮ ?ctivity 彟彟彟彟彟彟彟彟彟彟彟彟彟?
?esources ?esources
a?彟彟彟彟彟彟彟彟彟彟彟彟彟 彟彟彟彟彟 a? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 b? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟
c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟张 c? 彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟? ?


Patient s?ould identify at least t?o possible act楶楴楥? under eac? circumstance to ac?ieve variety?

?or eac? selected activity? identify key re獯?rce? needed to make it 桡ppen? ?esources include bot栠
p桹sical ?e?g?? e煵ipment? coac栬 time? and psyc? ological ?e⹧⸬ social supportⰠgoals??

?oals are to ad?ust activity plans for seasons and ?eat桥r? minimize boredom? develop social support and
personalize activity selection? given resources?
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A灰endi砠䈠阠Ph祳i捡l A捴ivit礠Pres捲i灴ion Sixth Edition/May 2013
Di?ensions ?or ??祳ical ?ctivit礠??prove?ent:
?re煵ency – recommended number of days per ?eek to perform selected activities?
ㄮ Cardiovascular – Start at ㍸/?eek and advance to most days per ?eek?
㈮ Strengt栠 – Start at ? -㌠砯?eek and advance to every ot桥r day for a given muscle group?
㌮ ?le?ibility – Start at every ot?er day and advance to most days per ?eek? especially stretc? after aerobic or resistance activities
during t桥 cool -do?n p桡se?

?uration – recommended amount of time or total ?ork per activity session? ?re煵ency and duration are more important fo r total caloric
e硰enditure and ?eig桴 management? T桥y s桯uld be increased 扥f潲e intensity?

?ntensity – recommended speed of movement ??alking pace? or amount of ?eig桴 to be lifted for eac栠repetition? ?ncreasing intensity
creates continued improvement after p桹siologic adaptation to a given fre煵ency and duration of activity? ?ntensity can be monitored
?it栠t桥 ?org Perceived ?硥rtion Scale? Typical target intensity on t桥 ?org ? -?? scale is㨠?? -ㄲ ?airly ?ig桴 to ㄳ -ㄴ Some?桡t ?ard?

?lsoⰠt?e ?talk test? indicates need to decrease intensity if difficulty in talking during aerobic activity?

?ctivit? ?rescription: ?ecord prescribed activity and amount of time for eac栠day of t桥 ?eek?

?ee? ?
Sun? ?on? Tues? ?ed? T桵rs? ?ri⸠ Sat?
?ndoors?
??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

?utdoors?
??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

?ee? ?
Sun? ?on? Tues? ?ed? T桵rs? ?ri⸠ Sat?
?ndoors?
??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

?utdoors?
??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

??ctivity? 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟 彟彟彟

?ork up to 彟彟张minutes for ?activity? in 彟彟 ?eeks? ?ork up to 彟彟彬bs? for ?activity? in 彟彟 ?eeks?

? agree t o t桩s activity prescription and to keep an activity log on my calendar from 彟彟彟to 彟彟彟?

Patient?s Signature 彟彟彟彟彟彟彟彟彟彟彟彟张 Provider?s Signature 彟彟彟彟彟彟彟彟彟彟彟彟?
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A灰endi砠䌠阠䙄Aⵁ灰roved 䵥di捡tions 景r the
?reatment o映佢esit?
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Generic Name Mechanism of Action
Diethylpropion Sympathomimetic amine; causes central nervous system stimulation and acts as an
anorectic.
Locaserin Selective agonist of the serotonin (5 -hydroxytryptamine) 2C (5 -HT
2c
) receptor that
reduces body weight by reducing food intake.
Orlistat Reversible inhibitor of lipases; exerts its therapeutic activity in the lumen of the
stomach and small intestine by forming a covalent bond with gastric and pancreatic
lipases and a subsequent reduction in triglyceride hydrolysis and absorption of dietary
fat, including cholesterol.
Phentermine Sympathomimetic amine; cause s central nervous system stimulation and acts as an
anorectic.
Phentermine
and topiramate
extended release
Sympathomimetic amine; causes central nervous system stimulation and acts as an
anorectic/antiepileptic that has effects on both appetite suppression and satiety
enhancement through multiple actions.
*Orlistat 60, TN Alli, available for over -the-counter use.
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A灰endi砠D 阠佶ervie眠o映䉡riatri挠Pro捥d畲es
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Restrictive procedures (adjustable band)
Figure 1: Adjustable Band




The most common restrictive procedure that is performed today is the adjustable band. At present there
are two types available in the United States, the Lap Band
TM
and the Realize Band
TM
. In principle both
devices function as circumferential balloons that are placed just below the level of the gastroesophageal
junction and then secured in a way to prevent migration. The band balloons are connected to a port (similar
to a chemotherapy port) that is secured to the anterior abdominal wall fascia below the skin, providing
access for saline placement. In most cases patients will have an overnight stay and beginning six weeks
S R V W R S H U D W L Y H O \ ` X L G Z L O O E H L Q W U R G X F H G L Q W R W K H E D Q G H L W K H U L Q W K H R I F H V H W W L Q J R U X Q G H U G L U H F W U D G L R O R J L F
guidance. Initially adjustment protocols were designed to produce a maximal amount of restriction, lending
some advantage to the radiologic adjustment model. However, the actual mechanism may also be related
to the direct pressure placed externally. Some studies show no actual delay in the progression of food from
the pouch into the remainder of the stomach (Burton, 2011 [Reference]). The bands differ slightly in terms
R I W K H S U H V V X U H J H Q H U D W H G R Q W K H V W R P D F K L Q U H O D W L R Q W R W K H V D P H D P R X Q W R I ` X L G L Q W K H E D Q G 7 K H U H D U H Q R
good control studies to suggest differences in outcomes of weight loss between the two groups (Cunneen,
2008 [Reference]). The weight-loss from banding is typically 45 to 55% of excess weight. Unlike other
bariatric operations, the weight loss is far more gradual and in many cases will reach the nadir between two
and three years following surgery.
Complications following adjustable banding and suggestions for management
/ D S D U R V F R S L F D G M X V W D E O H E D Q G L Q J F D U U L H V W K H E H V W V D I H W \ S U R O H R I D Q \ R S H U D W L R Q S H U I R U P H G L Q W K H V K R U W W H U P
The mortality rate is 0.05% ( Longitudinal Assessment of Bariatric Surgery [LABS[ Consortium, The, 2009
[Reference]). Despite this, appropriate preoperative workup including deep venous thrombosis (DVT)
S U R S K \ O D [ L V K D V E H H Q V K R Z Q W R E H D E H Q H W (Scholten, 2002 [Reference]). Four types of technical compli-
F D W L R Q V H [ L V W I R O O R Z L Q J E D Q G L Q J W K H V H L Q F O X G H V O L S S D J H F R Q F H Q W U L F G L O D W D W L R Q H U R V L R Q D Q G S R U W U H O D W H G
problems. In aggregate, this results in a substantial need postoperatively for re-operation. In most cases
including erosion, the patients will present with subacute symptoms. However, acute gastric distention,
necrosis and perforation can occur. Access of the patient and the primary care clinician to the original team
or an experienced team that is receptive to managing complications is imperative to minimize the long-term
V H T X H O D H R I W K H V H F R P S O L F D W L R Q V 7 K H U H L V D J U H D W G H D O R I Y D U L D E L O L W \ L Q K R Z F R P S O L F D W L R Q V D U H P D Q D J H G
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Illustrated by Farha Ikramuddin

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6 O L S S D J H L V G H Q H G E \ S D V V D J H R I V W R P D F K X V X D O O \ I X Q G X V D Q G E R G \ X Q G H U Q H D W K W K H E D Q G D Q G D E R Y H W K H E D Q G
In almost all cases the slippage occurs anteriorly. The classic presentation is obstruction usually preceded by
an episode of vomiting. Diagnostically, this can be suggested by a change in the angle of the band on plain
x-ray. Usually the band is oriented at a 45 angle from the left down to the right. In slippage, the band takes
D P R U H K R U L ] R Q W D O R U L H Q W D W L R Q 7 K H P D L Q V W D \ R I W K H U D S \ L V ` X L G U H P R Y D O I U R P W K H E D Q G D Q G R E V H U Y D W L R Q , I
V \ P S W R P V D U H L P P H G L D W H O \ L P S U R Y H G D Q G W K H V O L S S D J H L V V P D O O ` X L G P D \ E H U H L Q W U R G X F H G D I W H U D S H U L R G R I
four weeks with careful dietary counseling. In case of large slippage or persistent obstruction, emergent
surgery is performed. The stomach should be decompressed and the band either replaced, repositioned or
U H P R Y H G Z L W K F R Q Y H U V L R Q W R D O W H U Q D W L Y H S U R F H G X U H L I Z H L J K W O R V V K D V E H H Q L Q D G H T X D W H
Impact on comorbid illness
Despite being one of the more recently introduced procedures, some of the best data (randomized) exists for
laparoscopic adjustable banding. Dixon, et al. reported two studies looking at weight loss and improvement
of patients with type 2 diabetes (Dixon, 2008 [Reference]). The effect of the laparoscopic adjustable band
was demonstrably superior to medical management alone.
Vertical sleeve gastrectomy
7 K L V L V D U H O D W L Y H O \ Q H Z S U R F H G X U H W K D W K D V J D L Q H G F R Q V L G H U D E O H J U R Z W K R Y H U W K H O D V W Y H W R V L [ \ H D U V , Q
principle this operation involves removal of the greater curvature of the stomach including the fundus while
S U H V H U Y L Q J W K H D Q W U X P 8 Q O L N H W K H O D S D U R V F R S L F D G M X V W D E O H E D Q G W K L V U H V W U L F W L Y H S U R F H G X U H G R H V Q R W U H T X L U H
adjustments. It does, however, involve construction of a long staple line. This increases the potential for
leakage. Additionally, there is uncertainty about the best way to construct the sleeve in terms of size of
the sleeve caliber. This results in variations in both weight loss and complications. At present, use of the
sleeve gastrectomy is not covered by CMS. It remains, however, an intriguing procedure to use in select
F L U F X P V W D Q F H V , Q S D W L H Q W V Z L W K L Q ` D P P D W R U \ E R Z H O G L V H D V H , % ’ W K L V P D \ K D Y H D G Y D Q W D J H V R Y H U W K H J D V W U L F
bypass. The laparoscopic adjustable band includes IBD as a contraindication for surgery. The relative lack
of malabsorption, the lack of need for adjustments, and the potential for converting this to a more robust
operation such as the gastric bypass and the duodenal switch remain promising. The initial draw for the
sleeve gastrectomy was in patients considered high risk secondary to cardiopulmonary disease or extremes
R I R E H V L W \ 0 D Q \ D X W K R U V K D Y H I R X Q G W K D W S U H R S H U D W L Y H O L T X L G G L H W V F D Q H D V L O \ D Q G P R U H V D I H O \ V X E V W L W X W H D V
D U V W V W H S L Q W K H W U H D W P H Q W R I W K L V S D W L H Q W S R S X O D W L R Q (Still, 2007 [Reference]).
Complications of the sleeve gastrectomy
These are similar to those found in the Roux-en-Y gastric bypass. Complications include leakage, stricture
D Q G V L J Q L F D Q W L V V X H V Z L W K Q D X V H D D Q G Y R P L W L Q J
Figure 2: Roux-en-Y gastric bypass




Prevention and Management of Obesity for Adults
A灰endi砠D 阠佶ervie眠o映䉡riatri挠Pro捥d畲es Sixth Edition/May 2013
Illustrated by Farha Ikramuddin
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The gastric bypass represents the gold standard bariatric surgical operation. It produces a durable weight loss,
is the most intensively studied, and has the most predictable set of complications. It is, therefore, reasonable
W K D W R S H U D W L R Q V E H F R P S D U H G W R W K L V L Q W H U P V R I V X S H U L R U L W \ R U L Q I H U L R U L W \ 7 K H J D V W U L F E \ S D V V Z D V U V W X V H G
as an operation to treat ulcer disease. Observations that it produced massive weight loss in obese patients
prompted its use as a primary operation to treat obesity. Currently, the operation is performed laparoscopically.
There are a number of technical complications that can follow the gastric bypass. A high index of suspicion
should be maintained in patients, and prompt bariatric surgical input should be obtained (Podnos, 2003
[Reference]).
/ H D N V R F F X U H D U O \ Z L W K L Q W K H U V W Z H H N
, Q W H U Q D O E O H H G L Q J R F F X U V Z L W K L Q W K H U V W Z H H N D Q G F D Q E H L Q W K H * , W U D F W
$ Q D V W R P R W L F V W H Q R V L V R F F X U V P R V W R I W H Q E \ W K U H H I R X U Z H H N V
, Q W H U Q D O K H U Q L D I R U P D W L R Q R F F X U V P R V W R I W H Q E H \ R Q G V L [ P R Q W K V
: R X Q G L Q I H F W L R Q V F D Q R F F X U L Q X S W R R I S D W L H Q W V
$ Q D V W R P R W L F P D U J L Q D O X O F H U D W L R Q F D Q E H D V K L J K D V E X W W K H W U X H L Q F L G H Q F H L V O L N H O \ X Q N Q R Z Q
5 H F D O F L W U D Q W X O F H U V U D L V H W K H F R Q F H U Q R I J D V W U R J D V W U L F V W X O D I R U P D W L R Q W K D W F D Q E H V H H Q H Y H Q I R O O R Z L Q J
a divided gastric bypass.
6 H Y H U H O L I H W K U H D W H Q L Q J F R P S O L F D W L R Q V D S S H D U W R E H L Q ` X H Q F H G E \ J H Q G H U D Q G E \ Z H L J K W D Q G D J H 2 Y H U D O O
mortality of the gastric bypass is 0.5% (Schauer, 2000 [Reference]). Livingston, et al. found that patients
older than 55 years had a threefold higher mortality from surgery than younger patients, although the
complication rate (5.8%) was the same in both groups (Livingston, 2002 [Reference]). The risk for severe
life-threatening adverse outcomes in women increased from 4% for a 200 lb. female patient to 7.5% for a 600
lb. patient. In males, the risk increased from 7% for a 200 lb. male to 13% for a 600 lb. patient (Livingston,
2002 [Reference]).
7 K H Z D L V W W R K L S U D W L R P D \ D O V R F R U U H O D W H Z L W K W K H G L I F X O W \ R I V X U J H U \ D V L W P D \ F R U U H O D W H W R L Q F U H D V H G
Y L V F H U D O I D W V W R U H V D Q G P D \ F R Q W U L E X W H W R S R V V L E O H U H V S L U D W R U \ G L I F X O W \ (Schwartz, 2003 [Reference]).
The incidence of serious respiratory complications varies from 0% to 4.5% in both laparoscopic and open
procedures (Podnos, 2003 [Reference]).
’ H D O L Q J Z L W K W K H H [ F O X G H G O L P E I R O O R Z L Q J W K H J D V W U L F E \ S D V V F D Q E H D V L J Q L F D Q W L V V X H 8 V X D O O \ F R Q F H U Q L V
warranted to evaluate the excluded stomach in patients with unexplained pain or the presence of a mass. In
some cases it becomes useful to access the stomach to perform an ERCP in order to remove common duct
V W R Q H V 7 K H V W R P D F K F D Q E H D F F H V V H G X V L Q J L Q W H U Y H Q W L R Q D O U D G L R O R J L F W H F K Q L T X H V O D S D U R V F R S \ R U F R Q Y H Q-
tional surgery.
Pregnancy after the bypass operation is possible. Fertility can be increased following the bypass in some
patients. Patients should wait until weight loss has ceased prior to conceiving, which usually occurs at 18
months after surgery. Patients should undergo a thorough nutritional evaluation prior to and during preg-
nancy (Wittgrove, 1998 [Reference]).
Post-gastric-bypass hypoglycemia
This is a rare condition associated with low blood sugar following the ingestion of concentrated sweets. It
E H J L Q V X V X D O O \ D I W H U P D [ L P D O Z H L J K W O R V V K D V E H H Q D F K L H Y H G D Q G S D W L H Q W V E H J L Q Q L Q J W R U H V X P H K L J K H U T X D Q-
tity of food intake. It is characterized by symptoms of neuroglycopenia, which include dizziness, syncope,
confusion, blurred or double vision, or even seizure activity (Bantle, 2007 [Reference]). It is a variant of
the dumping syndrome. There are two phases. The earlier phase is associated with initial ingestion of
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concentrated carbohydrates symptoms include nausea, abdominal pain, palpitations, and the urge to lie
down. These are mediated by a number of intestinal peptides such as vip and neurotensin. Workup should
include determination that fasting hypoglycemia due to insulinoma is present. Phase two is associated with
increased insulin secretion and hypoglycemia in some patients. In patients who have neuroglycopenia, e.g.,
associated neurologic change, further workup is indicated. Please see Appendix E, "Meal Tolerance Test
Orders: High CHO Meals," and Appendix F, "Meal Tolerance: Low CHO Meals."
Figure 3: Duodenal switch




The duodenal switch procedure is a combination of the sleeve gastrectomy and a long intestinal bypass.
7 K H F R P P R Q F K D Q Q H O Z K L F K L V W K H O H Q J W K R I W K H E R Z H O H [ S R V H G W R E R W K I R R G D Q G E L O L R S D Q F U H D W L F ` X L G
is between 50 and 150 cm. The pylorus and most proximal portion of the duodenum are left intact. This
allows for improved food processing by the stomach and thus little if any dumping syndrome. The small
V H J P H Q W R I G X R G H Q X P F P L V T X L W H U H V L V W D Q W W R W K H G H Y H O R S P H Q W R I P D U J L Q D O X O F H U D W L R Q D F R P P R Q
problem associated with the gastric bypass. The presence of a large sleeve facilitates more food intake over
time than the gastric bypass. DS patients tend to suffer from diarrhea in comparison to patients with the
gastric bypass, who have constipation.
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Prevention and Management of Obesity for Adults
A灰endi砠D 阠佶ervie眠o映䉡riatri挠Pro捥d畲es Sixth Edition/May 2013

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A灰endi砠䔠阠䵥al ?oleran捥 ?est 佲ders㨠䡩gh 䍈传
佲ders
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Patient name: _____________________
Diagnosis: Symptomatic Hypoglycemia
Patient should be fasting for at least 8 hours prior to testing.
* Blood samples for plasma glucose (2 ml blood in grey-top tube) and serum insulin (3 ml in red-top tube).
** Time zero starts when patient is eating meal. Patient must eat the entire meal.
Record amount eaten: _________________________________________________________
High CHO meal: R ] R U D Q J H M X L F H R ] < R S O D L W I D W I U H H I U X L W ` D Y R U H G \ R J X U W V O L F H E U H D G R U W R D V W Z L W K
1 tsp. margarine and 2 tsp. jam. For patients who are lactose intolerant, cup applesauce can be substituted
for the yogurt.
, I S D W L H Q W E H F R P H V F R Q I X V H G F K H F N Q J H U S U L F N E O R R G J O X F R V H L I P J G / W U H D W Z L W K J O X F R V H W D E O H W V
and note in record. Continue drawing blood samples according to schedule.
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Time
Intervals
Chart
Time
Action Document
BP/H R /Symptoms
Baseline
(Pre -meal)

Obtain blood samples*

O min.**

Ask patient to eat High CHO meal within
10 minutes.

+ 15 min.

Obtain blood samples*

+ 30 min.

Obtain blood samples*

+ 45 min.

Obtain blood samples*

+ 60 min.

Obtain blood samples*

+ 90 min.

Obtain blood samples*

+ 120 min.

Obtain blood samples*

+ 180 min.

Obtain blood samples*

+ 240 min.

Obtain blood samples*



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A灰endi砠䘠阠䵥al ?oleran捥㨠䱯眠䍈传䵥als
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Patient name: _____________________
Diagnosis: Symptomatic Hypoglycemia
Patient should be fasting for at least eight hours prior to testing.
* Blood samples for plasma glucose (2 ml blood in grey-top tube) and serum insulin (3 ml in red-top tube).
** Time zero starts when patient is eating meal. Patient must eat the entire meal and within 10 minutes.
Record amount eaten:_________________________________________________________
Low CHO meal: decaffeinated black coffee or tea, one scrambled egg, two ounce sausage patties, one slice
(1.0 oz.) cheese. No sugar or cream with coffee.
, I S D W L H Q W E H F R P H V F R Q I X V H G F K H F N Q J H U S U L F N E O R R G J O X F R V H L I P J G / W U H D W Z L W K W K U H H J O X F R V H W D E O H W V
and note in record. Continue drawing blood samples according to schedule.
At each blood draw: document symptoms, check pulse and blood pressure.
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Time
Interval
Chart
Time
Action Document
BP/H R /Symptoms
Baseline
(Pre -meal)
Obtain blood samples*
O min.** Ask patient to eat Low
CHO meal within 10 minutes.

+ 15 min. Obtain blood samples*
+ 30 min. Obtain blood samples*
+ 45 min. Obtain blood samples*
+ 60 min. Obtain blood samples*
+ 90 min. Obtain blood samples*
+ 120 min. Obtain blood samples*
+ 180 min. Obtain blood samples*
+ 240 min. Obtain blood samples*


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A灰endi砠䜠阠乵tritional 卵灰lement
剥捯mmendations
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Supplement Amount recommended
Multivitamin containing thiamine
and 400 mcg folic acid
1- 2 each day
Vitamin B12 IM: Either mcg weekly, 1 , 000 mcg
monthly or 3,000 mcg every six
months
or
Sublingual: 350 mcg per day
Iron (ferrous sulfate, fumarate or
gluconate)
150 -300 mg per day (for
menstruating women)
Calcium citrate + vitamin D 400 -800 mg twice daily (to achieve
total dose of 1 , 200 -2, 000 mg per
day)
Vitamin A 5,000 to 10,000 units per day
Vitamin D 600 -50,000 units per day
Vitamin E 400 international units per day

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A灰endi砠䠠阠䉡nd Assessment Proto捯l
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013

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A灰endi砠䤠阠卡m灬e ?eightⵌoss 卵rger?
Preo灥rative 䱡扯rator礠阠单删and 䍨e捫o畴 佲ders
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013



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A灰endi砠䨠阠卡m灬e Postⵂariatri挭卵rger礠Patient
Diet
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Step 1: Clear Liquid Diet: Two Days
: D W H U R U V X J D U I U H H F O H D U O L T X L G G U L Q N V
6 X J D U I U H H - H O O 2
9 H J H W D E O H F K L F N H Q R U E H H I E U R W K U H J X O D U R U O R Z V R G L X P
’ L O X W H G M X L F H U H F R P P H Q G D S S O H Z K L W H J U D S H R U Z K L W H F U D Q E H U U \ M X L F H V
Step 2: Full Liquid Diet: Two Weeks
6 N L P Q R V X J D U D G G H G V R \ R U O D F W R V H I U H H P L O N (no more than two cups per day)
+ H D O W K \ & K R L F H + H D O W K \ 5 H T X H V W & D P S E H O O V R U R W K H U O R Z I D W V W U D L Q H G F U H D P V R X S V
7 K L Q Q H G O L J K W \ R J X U W V X J D U I U H H S X G G L Q J V D Q G X Q V Z H H W H Q H G D S S O H V D X F H
2 W K H U S U R W H L Q U L F K O R Z V X J D U O L T X L U G U L Q N V D W O H D V W J U D P V R I S U R W H L Q S H U R X Q F H V
Step 3: Pureed Diet: One Week
6 P R R W K O L J K W \ R J X U W Q R O X P S V R U I R R G S D U W L F O H V S U H V H Q W
+ R W F H U H D O P D G H Z L W K P L O N S U R W H L Q S R Z G H U R U Q R Q I D W G U \ P L O N S R Z G H U
& D Q Q H G W X Q D F K L F N H Q R U V D O P R Q E O H Q G H U L ] H G
% O H Q G H U L ] H G W H Q G H U P H D W V D Q G F R W W D J H F K H H V H
7 K L Q Q H G L Q V W D Q W P D V K H G S R W D W R H V P D G H Z L W K G U \ P L O N S R Z G H U R U S U R W H L Q S R Z G H U
% O H Q G H U L ] H G I U X L W V D Q G Y H J H W D E O H V D Y R L G V N L Q V S H H O V D Q G P H P E U D Q H V
Step 4: Soft Solids: Six to Eight Weeks
7 H Q G H U P R L V W P H D W V
& D Q Q H G F R R N H G Y H J H W D E O H V I U H V K Y H J H W D E O H V D V W R O H U D W H G † V N L Q V S H H O V P H P E U D Q H V Q R W W R O H U D W H G Z H O O
in the beginning)
% D N H G V K Q R Q E U H D G H G D Q G Z L W K R X W E R Q H V
/ R Z I D W R U I D W I U H H U H I U L H G E H D Q V
7 X Q D F K L F N H Q F U D E R U H J J V D O D G P D G H Z L W K I D W I U H H R U O L J K W P D \ R Q Q D L V H E O H Q G H U L ] H G
% D Q D Q D V H H G O H V V P H O R Q V R U F D Q Q H G I U X L W L Q L W V R Z Q M X L F H
$ G Y D Q F H W H [ W X U H V D V W R O H U D W H G W U \ R Q H Q H Z I R R G H Y H U \ R W K H U G D \
Step 5: Regular Bariatric Diet Avoid Foods with Skins, Peels, Membranes and Seeds
for the First Three Months After Surgery
6 N L Q O H V V E R Q H O H V V moist chicken and turkey breasts
3 R U N O R L Q S R U N W H Q G H U O R L Q
/ H D Q J U R X Q G P H D W V
/ H D Q D Q G H [ W U D O H D Q F X W V R I E H H I D Q G W X U N H \ V L U O R L Q U R X Q G ` D Q N K D P E X U J H U
& R W W D J H F K H H V H R U S D U W V N L P U L F R W W D F K H H V H
& R R N H G R U F D Q Q H G Y H J H W D E O H V
) U H V K I U R ] H Q R U F D Q Q H G I U X L W L Q L W V R Z Q M X L F H
& R R N H G F H U H D O V S R W D W R H V Z K R O H J U D L Q F U D F N H U V H W F
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A灰endi砠䬠阠䕸am灬e 卍A剔 䝯al
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
Go For Your Goal
It is important to set goals and make a plan when it comes to managing your diabetes, because having a
plan makes it easier to make daily choices.
Goals need to be SMART. They need to make SENSE and answer why you are setting the goal. They need
to be MEASURABLE and answer what will happen and where. Goals need to be ATTAINABLE and answer
how you are going to achieve your goal. They need to be REALISTIC and show yourself responsible as in
"I will" not "I will try." Goals include a TIME or when you will do something.
Sensible makes sense, answers "why" SMART Goal Sample
Measurable "what and where"
Attainable answers "how"
Realistic "I will" not "I will try"
Time "when"
: K D W L V \ R X U O R Q J W H U P J R D O W R L P S U R Y H \ R X U O L I H Z L W K G L D E H W H V " F K H F N R Q H
manage blood glucose manage cholesterol manage stress
manage weight establish support network
Not Very
important important
+ R Z L P S R U W D Q W L V L W W R \ R X " F L U F O H R Q H
: K \ L V W K L V L P S R U W D Q W W R \ R X "
Not Very
F R Q G H Q W F R Q G H Q W
+ R Z F R Q G H Q W D U H \ R X W K D W \ R X F D Q G R L W " F L U F O H R Q H
: K D W L V R Q H W K L Q J \ R X F D Q V W D U W G R L Q J W R Z R U N W R Z D U G \ R X U O R Q J W H U P J R D O " ) R U H [ D P S O H , Z L O O Z D O N
20 minutes three times a week after lunch.
: U L W H G R Z Q D T X H V W L R Q I R U \ R X U K H D O W K F D U H W H D P D E R X W U H D F K L Q J \ R X U J R D O
To increase my physical activity, I will walk three
times a week on the exercise trail outside of my
apartment complex in the morning between 7
and 8 a.m. for the next three months and wear my
pedometer to track my steps.
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A灰endi砠? 阠剥adiness to 䍨ange 阠䵯tivational
䥮tervie睩ng 卡m灬e 卣ri灴ing 景r Ad畬ts
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
I. Suggestions for Using Motivational Interviewing to Address Weight Management
: K \ L V Q R Z D J R R G W L P H I R U \ R X W R O R V H Z H L J K W "
: K D W K D Y H \ R X W U L H G L Q W K H S D V W W R O R V H Z H L J K W "
+ R Z Z R X O G \ R X G R W K L Q J V G L I I H U H Q W O \ W K L V W L P H "
+ R Z Z R X O G \ R X I H H O L I \ R X Z H U H V X F F H V V I X O O R V L Q J Z H L J K W "
: K D W V R Q H W K L Q J Z H F D Q G R W R J H W K H U W R P D N H D V W H S W R Z D U G V \ R X U Z H L J K W O R V V J R D O V "
6. Help me understand why you want to lose weight.
: K D W F R X O G Z R U N " 7 R Z K D W H [ W H Q W Z R X O G W K L V D I I H F W \ R X U O L I H "
II. Sample Script for 10-minute Motivational Interview for Weight Loss:
1. LISTEN: $ V N R S H Q H Q G H G T X H V W L R Q V ( [ K L E L W F X U L R V L W \ Y H U V X V E H L Q J M X G J P H Q W D O 5 H P H P E H U : $ , 7
: K \ D P , W D O N L Q J "
2. ASK PERMISSION: Acknowledge that the right and freedom not to change sometimes makes
the change possible.
3. ENGAGE: Take off the expert hat.
4. REFLECT: Clarify that you heard correctly.
Ask what patient wants to work on today.
Tell what you heard the patient say.
Ask patient if it is okay to provide information/input.
Set the agenda for the visit.
$ 6 . : K D W F R Q F H U Q V \ R X P R V W D E R X W \ R X U Z H L J K W "
P L Q X W H V ( / , & , 7
- "T ell me what you know (or what you’ve tried) about losing weight."
P L Q X W H 5 ( ) / ( & 7
- "It sounds like you are having trouble losing weight."
P L Q X W H V 3 5 2 9 , ’ (
- In non-judgmental fashion "May I share with you what has worked for other patients to lose
Z H L J K W "
P L Q X W H V ( / , & , 7
+ R Z G R \ R X I H H O D E R X W W K H V H L G H D V "
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P L Q X W H V * 2 $ /
: K D W Z R X O G E H R Q H V P D O O V W H S W K D W \ R X W K L Q N \ R X P L J K W E H D E O H W R G R P R Y L Q J I R U Z D U G "
, K H D U G \ R X V D \ \ R X Z L O O V W D U W N H H S L Q J D I R R G U H F R U G 2 Q D V F D O H R I K R Z F R Q G H Q W D U H
W K D W \ R X \ R X Z L O O E H D E O H W R G R W K L V " $ V F R U H R U R U K L J K H U L Q G L F D W L Q J V X F F H V V L Q W K L V J R D O , I
D « Z K \ Q R W D " R U : K D W Z R X O G L W W D N H W R J H W \ R X I U R P D W R D "
< R X V D L G
(Clinician or patient writes goals on a paper that goes home with patient.)
- I will keep a food record for two weeks.
- I will schedule a follow-up appointment in two weeks to review my food records.
- I will post my goals on the bathroom mirror.
- I will weigh myself once a week and record it.
& O D U L I \ , V W K D W F R U U H F W "
P L Q X W H 6 ( 6 6 , 2 1 & / 2 6 (
"Thank you for your time today. I can hear excitement in your voice about starting (or continuing) on the
S D W K W R O R V L Q J Z H L J K W , D P F R Q G H Q W W K D W \ R X Z L O O G R W K L V , Q W Z R Z H H N V , O R R N I R U Z D U G W R V H H L Q J \ R X W R
I R O O R Z X S D Q G D V N V R P H T X H V W L R Q V D E R X W \ R X U D F W L R Q J R D O
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A灰endi砠? ? 剥adiness to Prevention and Management of Obesity for Adults
䍨ange 阠䵯tivational 䥮tervie睩ng 卡m灬e 卣ri灴ing 景r Ad畬ts Sixth Edition/May 2013

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A灰endi砠䴠阠䡯眠to 啴ili穥 the 㔠A❳ A灰roa捨
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
ASK
, P S O H P H Q W D Q R I F H Z L G H V \ V W H P W R H Q V X U H W K D W I R U H Y H U \ S D W L H Q W S U H I H U D E O \ R Q D Q D Q Q X D O E D V L V Z H L J K W L V
measured, body mass index is calculated, and patients are educated about their body mass index and risk
status. See Annotation #1, "Measure Height and Weight, and Calculate Body Mass Index."
ADVISE to lose weight
Patients who are in the normal weight range should be encouraged to be physically active and eat a healthy
diet to help prevent future weight gain. If a patient is overweight or obese, physicians need to communicate
this in a direct but sensitive manner and also make the recommendation to consider losing weight. Research
suggests that adults who report that their physician advised them to lose weight are more likely to initiate
weight loss attempts. Obese patients who reported receiving advice to lose weight have been shown to be
almost three times as likely to report trying to lose weight compared with those who did not receive advice.
(Abid, 2005 [Reference]). The next important step will be to engage the patient in a discussion regarding
his/her current level of motivation for losing weight.
ASSESS readiness to change/motivation for weight loss
$ O W K R X J K G H Q L W L Y H H Y L G H Q F H U H J D U G L Q J W K H S U R J Q R V W L F V L J Q L F D Q F H R I D Q L Q G L Y L G X D O V V W D J H R I F K D Q J H L V Q R W
available, assessment of an individual’s readiness to make a weight-loss attempt is a key step in encour -
aging weight-loss efforts. There is evidence that moving into and/or staying longer in the "action" stage for
weight loss is associated with better weight outcomes. For example, Prochaska and colleagues found that
the more clients progressed into the action stage early in weight-loss therapy, the more successful they were
in losing weight by the end of treatment (Prochaska, 1992 [Reference]). A study showed that the elapsed
time in action or maintenance for multiple weight-loss-related target behaviors is longitudinally related to
weight loss over a two-year period (Logue, 2004 [Reference]). However, others have found no association
between baseline stage of change for weight loss and short- (Macqueen, 2002 [Reference]) and long-term
(e.g., three years) weight outcomes (Jeffery, 1999 [Reference]) 7 K H R Q O \ S X E O L V K H G U D Q G R P L ] H G W U L D O V S H F L -
F D O O \ H Y D O X D W L Q J W K H H I F D F \ R I D S U L P D U \ F D V H E D V H G W U D Q V W K H R U H W L F D O P R G H O V W D J H P D W F K H G Z H L J K W O R V V
intervention delivered was associated with weight maintenance, but not weight loss at one-year follow-up
(Logue, 2005 [Reference]). The authors note that their intervention (e.g., monthly telephone advice) was
Q R W L Q W H Q V L Y H H Q R X J K W R S U R G X F H F O L Q L F D O O \ V L J Q L F D Q W Z H L J K W O R V V H V Z K L F K L V F R Q V L V W H Q W Z L W K D O D U J H E R G \
R I H Y L G H Q F H V X J J H V W L Q J W K D W L Q W H U Y H Q W L R Q L Q W H Q V L W \ D Q G I U H T X H Q F \ R I F R Q W D F W D U H V W U R Q J O \ D V V R F L D W H G Z L W K
successful outcomes (Jeffery, 2000 [Reference]).
$ G G L W L R Q D O S V \ F K R O R J L F D O D Q G O L I H V W \ O H I D F W R U V F O H D U O \ K D Y H D Q L Q ` X H Q F H R Q Z H L J K W O R V V V X F F H V V ) R U H [ D P S O H
research suggests that depression status may adversely affect treatment outcome (Linde, 2004 [Reference])
and should be considered when making recommendations for weight loss to patients. It is recommended
that physicians assess patient motivation and support, stressful life events, psychiatric status, time avail-
ability and constraints, and appropriateness of goals and expectations to help establish the likelihood of
lifestyle change in the area of nutrition and physical activity. Assessing readiness to change involves more
W K D Q V L P S O \ D V N L Q J S D W L H Q W V $ U H \ R X U H D G \ W R O R V H Z H L J K W "
2 Q H K H O S I X O V W U D W H J \ W R E H J L Q D Q D V V H V V P H Q W L V W R D Q F K R U S D W L H Q W V L Q W H U H V W D Q G F R Q G H Q F H I R U F K D Q J H R Q D
numerical scale. "On a scale from 0 to 10, with 0 being not interested and 10 being very interested, how
L Q W H U H V W H G D U H \ R X L Q O R V L Q J Z H L J K W D W W K L V W L P H " 6 H H 0 , H [ D P S O H L Q Appendix L. Ask patients, "On a scale
of 0 to 10, with 0 being not important and 10 being very important, how important is it for you to lose
Z H L J K W D W W K L V W L P H " ) R O O R Z W K L V E \ D V N L Q J $ O V R R Q D V F D O H R I W R Z L W K E H L Q J Q R W F R Q G H Q W D Q G
E H L Q J Y H U \ F R Q G H Q W K R Z F R Q G H Q W D U H \ R X W K D W \ R X F D Q O R V H Z H L J K W D W W K L V W L P H " 3 K \ V L F L D Q V F D Q D O V R D V N
patients: "On a scale of 0 to 10, with 0 being not interested and 10 being very interested, how interested are
\ R X L Q O R V L Q J Z H L J K W D W W K L V W L P H "
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To obtain further information about patient readiness to change, a Patient Readiness Checklist can be admin -
istered. For example, see the American Medical Association’s "Road Maps for Clinical Practice Assess -
ment and Management of Adult Obesity" ( http://www.ama-assn.org/ama/pub/category/10931.html , booklet
J X U H 7 K L V F K H F N O L V W D V V H V V H V P X O W L S O H G R P D L Q V L Q F O X G L Q J S D W L H Q W P R W L Y D W L R Q V X S S R U W I R U F K D Q J H
V W U H V V I X O O L I H H Y H Q W V W K D W P D \ K L Q G H U F K D Q J H H I I R U W V S V \ F K L D W U L F L V V X H V H J G H S U H V V L R Q E L Q J H H D W L Q J W L P H
D Y D L O D E L O L W \ F R Q V W U D L Q W V D Q G Z H L J K W O R V V J R D O V H [ S H F W D W L R Q V ) L J X U H R I W K H $ 0 $ J X L G H O L Q H L V D Z H L J K W
loss questionnaire that may also be a useful tool.
$ Q R W K H U X V H I X O W R R O F D Q E H W K H 3 D W L H Q W $ F W L Y D W L R Q 0 H D V X U H R U 3 $ 0 7 K H 3 $ 0 L V D W R R O G H V L J Q H G W R D V V H V V
D Q L Q G L Y L G X D O V N Q R Z O H G J H V N L O O D Q G F R Q G H Q F H Z L W K U H V S H F W W R P D Q D J L Q J K L V R U K H U K H D O W K , W K D V E H H Q X V H G
D Q G V W X G L H G L Q V H Y H U D O F K U R Q L F G L V H D V H P D Q D J H P H Q W S U R J U D P V % D V H G R Q D L W H P V F D O H H D F K S D W L H Q W L V
D V V L J Q H G D Q D F W L Y D W L R Q V F R U H I U R P / H Y H O W R Z L W K E H L Q J W K H O R Z H V W K H D O W K D F W L Y D W L R Q S D W L H Q W V W H Q G W R
E H R Y H U Z K H O P H G D Q G X Q S U H S D U H G W R S O D \ D Q D F W L Y H U R O H L Q W K H L U R Z Q K H D O W K W R E H L Q J W K H K L J K H V W S D W L H Q W V
K D Y H D G R S W H G P D Q \ R I W K H E H K D Y L R U V Q H H G H G W R V X S S R U W D K H D O W K \ O L I H V W \ O H 8 V L Q J W K L V P H D V X U H F D Q K H O S
J X L G H D F O L Q L F L D Q D V W R Z K H U H W R E H J L Q W K H D V V H V V P H Q W S U R F H V V 3 D W L H Q W V Z L W K O R Z H U D F W L Y D W L R Q Q H H G D G L I I H U H Q W
approach and more health coaching to get them to a point where they can consider weight management.
(Hibbard, 2009 [Reference]; Schmittdiel, 2007 [Reference]; Hibbard, 2005 [Reference]; Hibbard, 2004
[Reference]).
ASSIST in weight-loss attempt
3 D W L H Q W Q R W F X U U H Q W O \ L Q W H U H V W H G P R W L Y D W H G I R U Z H L J K W O R V V " 3 D W L H Q W V P D \ W L Q W R W K L V F D W H J R U \ H L W K H U
because they are unaware that their weight status is a problem, or they are not interested in changing
S U H F R Q W H P S O D W R U R U W K H \ D U H D Z D U H R I W K H S U R E O H P E X W D U H M X V W V W D U W L Q J W R W K L Q N D E R X W F K D Q J L Q J
F R Q W H P S O D W R U 3 U R Y L G L Q J L Q I R U P D W L R Q D E R X W W K H K H D O W K U L V N V R I R E H V L W \ D Q G W K H S R W H Q W L D O K H D O W K E H Q H W V
of weight loss may be most appropriate for those who are not yet interested in changing. For patients
Z K R D U H M X V W E H J L Q Q L Q J W R F R Q W H P S O D W H F K D Q J H G L V F X V V L R Q R I D P E L Y D O H Q F H D E R X W F K D Q J H D Q G R I E D U U L H U V
to change may be helpful strategies. Patient readiness to lose weight should be reassessed at regular
L Q W H U Y D O V
3 D W L H Q W L Q W H U H V W H G P R W L Y D W H G I R U Z H L J K W O R V V " 3 D W L H Q W V Z K R D U H L Q W H U H V W H G D Q G P R W L Y D W H G W R O R V H Z H L J K W
O L N H O \ Q H H G L Q I R U P D W L R Q D E R X W D S S U R S U L D W H Q X W U L W L R Q D F W L Y L W \ D Q G E H K D Y L R U D O U H F R P P H Q G D W L R Q V D Q G
support in making these lifestyle changes. The sections below describe in detail recommendations for
H D W L Q J S K \ V L F D O D F W L Y L W \ D Q G E H K D Y L R U D O P R G L F D W L R Q 3 K \ V L F L D Q V Q H H G W R E H D Z D U H R I U H V R X U F H V D Q G
appropriate referral sources within their clinics and/or local communities for their patients. See the
4 X D O L W \ , P S U R Y H P H Q W 6 X S S R U W V H F W L R Q , P S O H P H Q W D W L R Q 7 R R O V D Q G 5 H V R X U F H V 7 D E O H, for Web sites and
further information about weight management.
ARRANGE follow-up
$ O W K R X J K S K \ V L F L D Q V P D \ Q R W Q H F H V V D U L O \ E H G L U H F W O \ L Q Y R O Y H G L Q Z H L J K W P D Q D J H P H Q W F R X Q V H O L Q J L W L V
U H F R P P H Q G H G W K D W D I R O O R Z X S D S S R L Q W P H Q W W R H Y D O X D W H S U R J U H V V E H V F K H G X O H G D S S U R [ L P D W H O \ W K U H H P R Q W K V
following initiation of a weight-loss program by a patient, and progress should be reassessed at appropriate
L Q W H U Y D O V W K H U H D I W H U
6 W X G L H V K D Y H V K R Z Q W K D W Z H H N O \ I R O O R Z X S I R U W K H U V W W K U H H P R Q W K V D Q G J U D G X D O O \ G H F U H D V L Q J W R P R Q W K O \ I R U
the next six months to four years can produce successful weight loss and maintenance (Wing, 2005 [Refer-
ence]) $ V X F F H V V I X O L Q W H Q V L Y H O L I H V W \ O H L Q W H U Y H Q W L R Q S U R J U D P V X F K D V W K H / R R N $ + ( $ ’ $ F W L R Q I R U + H D O W K
L Q ’ L D E H W H V S U R J U D P D V W X G \ R I Z H L J K W O R V V D Q G P D L Q W H Q D Q F H L Q G L D E H W L F S D W L H Q W V S U R G X F H G Z H L J K W O R V V
L Q R Q H \ H D U D Q G P D L Q W D L Q H G D Z H L J K W O R V V D W I R X U \ H D U V , Q V W L W X W L R Q V Z L V K L Q J W R V W D U W D Q L Q W H Q V L Y H O L I H V W \ O H
L Q W H U Y H Q W L R Q S U R J U D P I R U R Y H U Z H L J K W D Q G R E H V H S D W L H Q W V V K R X O G F R Q V L G H U P R G H O L Q J L W D I W H U W K L V V X F F H V V I X O
program (Wadden, 2009 [Reference]).
See Annotation #13, "Reassess Goals and Risk Factors, and Counsel Regarding Weight Maintenance."
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Prevention and Management of Obesity for Adults
A灰endi砠䴠阠 䡯眠to 啴ili穥 㔠A❳ A灰roa捨 Sixth Edition/May 2013

Institute for Clinical Systems Improvement


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A灰endi砠丠阠䥃卉 卨ared De捩sionⵍa歩ng 䵯del
Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
The technical aspects of Shared Decision-Making are widely discussed and understood.
’ H F L V L R Q D O F R Q ` L F W occurs when a patient is presented with options where no single option satis-
H V D O O W K H S D W L H Q W V R E M H F W L Y H V Z K H U H W K H U H L V D Q L Q K H U H Q W G L I F X O W \ L Q P D N L Q J D G H F L V L R Q R U Z K H U H
H [ W H U Q D O L Q ` X H Q F H U V D F W W R P D N H W K H F K R L F H P R U H G L I F X O W
Decision support F O D U L H V W K H G H F L V L R Q W K D W Q H H G V W R E H P D G H F O D U L H V W K H S D W L H Q W V Y D O X H V D Q G S U H I-
erences, provides facts and probabilities, guides the deliberation and communication and monitors
the progress.
Decision aids D U H H Y L G H Q F H E D V H G W R R O V W K D W R X W O L Q H W K H E H Q H W V K D U P V S U R E D E L O L W L H V D Q G V F L H Q W L F
X Q F H U W D L Q W L H V R I V S H F L F K H D O W K F D U H R S W L R Q V D Y D L O D E O H W R W K H S D W L H Q W
However, before decision support and decision aids can be most advantageously utilized, a Collaborative
Conversation
TM
should be undertaken between the provider and the patient to provide a supportive frame-
work for Shared Decision-Making.
Collaborative Conversation
TM
A collaborative approach toward decision-making is a fundamental tenet of Shared Decision-Making
(SDM). The Collaborative Conversation
TM
is an inter-professional approach that nurtures relationships,
H Q K D Q F H V S D W L H Q W V N Q R Z O H G J H V N L O O V D Q G F R Q G H Q F H D V Y L W D O S D U W L F L S D Q W V L Q W K H L U K H D O W K D Q G H Q F R X U D J H V
them to manage their health care.
Within a Collaborative Conversation , the perspective is that both the patient and the provider play key
roles in the decision-making process. The patient knows which course of action is most consistent with his/
her values and preferences, and the provider contributes knowledge of medical evidence and best practices.
Use of Collaborative Conversation
TM
elements and tools is even more necessary to support patient, care
provider and team relationships when patients and families are dealing with high stakes or highly charged
issues, such as diagnosis of a life-limiting illness.
The overall framework for the Collaborative Conversation
TM
approach is to create an environment in which
the patient, family and care team work collaboratively to reach and carry out a decision that is consistent with
the patient’s values and preferences. A rote script or a completed form or checklist does not constitute this
D S S U R D F K 5 D W K H U L W L V D V H W R I V N L O O V H P S O R \ H G D S S U R S U L D W H O \ I R U W K H V S H F L F V L W X D W L R Q 7 K H V H V N L O O V Q H H G W R E H
used artfully to address all aspects involved in making a decision: cognitive, affective, social and spiritual.
Key communication skills help build the Collaborative Conversation
TM
approach. These skills include
P D Q \ H O H P H Q W V E X W L Q W K L V D S S H Q G L [ R Q O \ W K H T X H V W L R Q L Q J V N L O O V Z L O O E H G H V F U L E H G ) R U F R P S O H W H L Q V W U X F W L R Q
V H H 2 & R Q Q R U - D F R E V H Q ’ H F L V L R Q D O & R Q ` L F W 6 X S S R U W L Q J 3 H R S O H ( [ S H U L H Q F L Q J 8 Q F H U W D L Q W \ D E R X W 2 S W L R Q V
Affecting Their Health" [2007], and Bunn H, O’Connor AM, Jacobsen MJ "Analyzing decision support and
related communication" [1998, 2003].)
1. Listening skills:
Encourage patient to talk by providing prompts to continue such as "go on, and then?, uh huh," or by
repeating the last thing a person said, " It's confusing."
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Paraphrase content of messages shared by patient to promote exploration, clarify content and to
F R P P X Q L F D W H W K D W W K H S H U V R Q V X Q L T X H S H U V S H F W L Y H K D V E H H Q K H D U G 7 K H S U R Y L G H U V K R X O G X V H K L V K H U R Z Q
words rather than just parroting what he/she heard.
5 H ` H F W L R Q R I I H H O L Q J V usually can be done effectively once trust has been established. Until the provider
I H H O V W K D W W U X V W K D V E H H Q H V W D E O L V K H G V K R U W U H ` H F W L R Q V D W W K H V D P H O H Y H O R I L Q W H Q V L W \ H [ S U H V V H G E \ W K H
S D W L H Q W Z L W K R X W R P L W W L Q J D Q \ R I W K H P H V V D J H V P H D Q L Q J D U H D S S U R S U L D W H 5 H ` H F W L R Q L Q W K L V P D Q Q H U
communicates that the provider understands the patient’s feelings and may work as a catalyst for further
S U R E O H P V R O Y L Q J ) R U H [ D P S O H W K H S U R Y L G H U L G H Q W L H V Z K D W W K H S H U V R Q L V I H H O L Q J D Q G U H V S R Q G V E D F N L Q
his/her own words like this: "So, you're unsure which choice is the best for you."
Summarize the person’s key comments D Q G U H ` H F W W K H P E D F N W R W K H S D W L H Q W 7 K H S U R Y L G H U V K R X O G
condense several key comments made by the patient and provide a summary of the situation. This assists
the patient in gaining a broader understanding of the situations rather than getting mired down in the
details. The most effective times to do this are midway through and at the end of the conversation. An
example of this is, "You and your family have read the information together, discussed the pros and
cons, but are having a hard time making a decision because of the risks."
Perception checks ensure that the provider accurately understands a patient or family member, and
P D \ E H X V H G D V D V X P P D U \ R U U H ` H F W L R Q 7 K H \ D U H X V H G W R Y H U L I \ W K D W W K H S U R Y L G H U L V L Q W H U S U H W L Q J W K H
message correctly. The provider can say "So you are saying that you're not ready to make a decision
at this time. Am I understanding you correctly?"
2. Questioning Skills
Open and closed questions D U H E R W K X V H G Z L W K W K H H P S K D V L V R Q R S H Q T X H V W L R Q V 2 S H Q T X H V W L R Q V D V N
I R U F O D U L F D W L R Q R U H O D E R U D W L R Q D Q G F D Q Q R W K D Y H D \ H V R U Q R D Q V Z H U $ Q H [ D P S O H Z R X O G E H "What else
Z R X O G L Q ` X H Q F H \ R X W R F K R R V H W K L V " & O R V H G T X H V W L R Q V D U H D S S U R S U L D W H L I V S H F L F L Q I R U P D W L R Q L V U H T X L U H G
such as "Does your daughter support your decision?"
2 W K H U V N L O O V V X F K D V V X P P D U L ] L Q J S D U D S K U D V L Q J D Q G U H ` H F W L R Q R I I H H O L Q J F D Q E H X V H G L Q W K H T X H V W L R Q L Q J
S U R F H V V V R W K D W W K H S D W L H Q W G R H V Q W I H H O S U H V V X U H G E \ T X H V W L R Q V
Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational
skill (Ivey & Bradford-Ivey). An example of this is the provider saying, "You mentioned earlier…"
3. Information-Giving Skills
Providing information and providing feedback are two methods of information giving. The distinction
between providing information and giving advice is important. Information giving allows a provider to
supplement the patient’s knowledge and helps to keep the conversation patient centered. Giving advice,
R Q W K H R W K H U K D Q G W D N H V W K H D W W H Q W L R Q D Z D \ I U R P W K H S D W L H Q W V X Q L T X H J R D O V D Q G Y D O X H V D Q G S O D F H V L W R Q
those of the provider.
3 U R Y L G L Q J L Q I R U P D W L R Q F D Q E H V K D U L Q J I D F W V R U U H V S R Q G L Q J W R T X H V W L R Q V $ Q H [ D P S O H L V "If we look at the
evidence, the risk is…" Providing feedback gives the patient the provider’s view of the patient’s reaction.
For instance, the provider can say, "You seem to understand the facts and value your daughter's advice."
Additional Communication Components
Other elements that can impact the effectiveness of a Collaborative Conversation
TM
include:
( \ H F R Q W D F W
% R G \ O D Q J X D J H F R Q V L V W H Q W Z L W K P H V V D J H
5 H V S H F W
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Prevention and Management of Obesity for Adults
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( P S D W K \
3 D U W Q H U V K L S V
Self-examination by the provider involved in the Collaborative Conversation
TM
can be instructive. Some
T X H V W L R Q V W R D V N R Q H V H O I L Q F O X G H
’ R , K D Y H D F O H D U X Q G H U V W D Q G L Q J R I W K H O L N H O \ R X W F R P H V "
’ R , I X O O \ X Q G H U V W D Q G W K H S D W L H Q W V Y D O X H V "
+ D Y H , I U D P H G W K H R S W L R Q V L Q F R P S U H K H Q V L E O H Z D \ V "
+ D Y H , K H O S H G W K H G H F L V L R Q P D N H U V U H F R J Q L ] H W K D W S U H I H U H Q F H V P D \ F K D Q J H R Y H U W L P H "
$ P , Z L O O L Q J D Q G D E O H W R D V V L V W W K H S D W L H Q W L Q U H D F K L Q J D G H F L V L R Q E D V H G R Q K L V K H U Y D O X H V H Y H Q Z K H Q
his/her values and ultimate decision may differ from my values and decisions in similar circum -
V W D Q F H V "
When to Initiate a Collaborative Conversation
TM
A Collaborative Conversation
TM
can support decisions that vary widely in complexity. It can range from a
straightforward discussion concerning routine immunizations to the morass of navigating care for a life-
limiting illness. Table 1 represents one health care event. This event can be simple like a 12 year-old coming
to the clinic for routine immunizations, or something much more complex like an individual receiving a
diagnosis of congestive heart failure. In either case, the event is the catalyst that starts the process represented
L Q W K L V W D E O H 7 K H U H D U H F X H V I R U S U R Y L G H U V D Q G S D W L H Q W Q H H G V W K D W H [ H U W L Q ` X H Q F H R Q W K L V S U R F H V V 7 K H \ D U H
described below. The heart of the process is the Collaborative Conversation
TM
. The time the patient spends
within this health care event will vary according to the decision complexity and the patient’s readiness to
make a decision.
Regardless of the decision complexity there are cues applicable to all situations that indicate an opportune
time for a Collaborative Conversation
TM
. These cues can occur singularly or in conjunction with other cues.
Cues for the Care Team to Initiate a Collaborative Conversation
TM
Life goal changes: Patient’s priorities change related to things the patient values such as activities,
relationships, possessions, goals and hopes, or things that contribute to the patient’s emotional and
spiritual well-being.
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Diagnosis/prognosis changes: Additional diagnoses, improved or worsening prognosis.
Change or decline in health status: Improving or worsening symptoms, change in performance
status or psychological distress.
Change or lack of support: Increase or decrease in caregiver support, change in caregiver, or
F D U H J L Y H U V W D W X V F K D Q J H L Q Q D Q F L D O V W D Q G L Q J G L I I H U H Q F H E H W Z H H Q S D W L H Q W D Q G I D P L O \ Z L V K H V
Change in medical evidence or interpretation of medical evidence: Providers can clarify the
change and help the patient understand its impact.
Provider/caregiver contact: Each contact between the provider/caregiver and the patient presents
D Q R S S R U W X Q L W \ W R U H D I U P Z L W K W K H S D W L H Q W W K D W K L V K H U F D U H S O D Q D Q G W K H F D U H W K H S D W L H Q W L V U H F H L Y L Q J
are consistent with his/her values.
3 D W L H Q W V D Q G I D P L O L H V K D Y H D U R O H W R S O D \ D V G H F L V L R Q P D N L Q J S D U W Q H U V D V Z H O O 7 K H Q H H G V D Q G L Q ` X H Q F H U V
brought to the process by patients and families impact the decision-making process. These are described
below.
Patient and Family Needs within a Collaborative Conversation
TM
Request for support and information: ’ H F L V L R Q D O F R Q ` L F W L V L Q G L F D W H G E \ D P R Q J R W K H U W K L Q J V
the patient verbalizing uncertainty or concern about undesired outcomes, expressing concern about
choice consistency with personal values and/or exhibiting behavior such as wavering, delay, preoc-
F X S D W L R Q G L V W U H V V R U W H Q V L R Q * H Q H U D W L R Q D O D Q G F X O W X U D O L Q ` X H Q F H U V P D \ D F W W R L Q K L E L W W K H S D W L H Q W I U R P
actively participating in care discussions, often patients need to be given "permission" to participate
as partners in making decisions about his/her care.
Support resources may include health care professionals, family, friends, support groups, clergy and
social workers. When the patient expresses a need for information regarding options and his/her
S R W H Q W L D O R X W F R P H V W K H S D W L H Q W V K R X O G X Q G H U V W D Q G W K H N H \ I D F W V D E R X W R S W L R Q V U L V N V D Q G E H Q H W V
and have realistic expectations. The method and pace with which this information is provided to
the patient should be appropriate for the patient’s capacity at that moment.
Advance Care Planning: With the diagnosis of a life-limiting illness, conversations around advance
care planning open up. This is an opportune time to expand the scope of the conversation to other
W \ S H V R I G H F L V L R Q V W K D W Z L O O Q H H G W R E H P D G H D V D F R Q V H T X H Q F H R I W K H G L D J Q R V L V
Consideration of Values: The personal importance a patient assigns potential outcomes must
E H U H V S H F W H G , I W K H S D W L H Q W L V X Q F O H D U K R Z W R S U L R U L W L ] H W K H S U H I H U H Q F H V Y D O X H F O D U L F D W L R Q F D Q E H
achieved through a Collaborative Conversation
TM
and by the use of decision aids that detail the
E H Q H W V D Q G K D U P V R I S R W H Q W L D O R X W F R P H V L Q W H U P V W K H S D W L H Q W F D Q X Q G H U V W D Q G
Trust: 7 K H S D W L H Q W P X V W I H H O F R Q G H Q W W K D W K L V K H U S U H I H U H Q F H V Z L O O E H F R P P X Q L F D W H G D Q G U H V S H F W H G
by all caregivers.
Care Coordination: 6 K R X O G W K H S D W L H Q W U H T X L U H F D U H F R R U G L Q D W L R Q W K L V L V D Q R S S R U W X Q H W L P H W R
discuss the other types of care-related decisions that need to be made. These decisions will most
likely need to be revisited often. Furthermore, the care delivery system must be able to provide
coordinated care throughout the continuum of care.
Responsive Care System: The care system needs to support the components of patient- and family-
centered care so the patient’s values and preferences are incorporated into the care he/she receives
throughout the care continuum.
The Collaborative Conversation
TM
Map is the heart of this process. The Collaborative Conversation
TM
Map
F D Q E H X V H G D V D V W D Q G D O R Q H W R R O W K D W L V H T X D O O \ D S S O L F D E O H W R S U R Y L G H U V D Q G S D W L H Q W V D V V K R Z Q L Q 7 D E O H
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3 U R Y L G H U V X V H W K H P D S D V D F O L Q L F D O Z R U N ` R Z , W K H O S V J H W W K H 6 K D U H G ’ H F L V L R Q 0 D N L Q J S U R F H V V L Q L W L D W H G D Q G
provides navigation for the process. Care teams can used the Collaborative Conversation
TM
to document
W H D P E H V W S U D F W L F H V D Q G W R I R U P D O L ] H D F R P P R Q O H [ L F R Q 2 U J D Q L ] D W L R Q V F D Q E X L O G H O G V I U R P W K H & R O O D E R U D-
tive Conversation
TM
Map in electronic medical records to encourage process normalization. Patients use the
map to prepare for decision-making, to help guide them through the process and to share critical information
with their loved ones.
Evaluating the Decision Quality
$ G D S W H G I U R P 2 & R Q Q R U - D F R E V H Q ’ H F L V L R Q D O & R Q ` L F W 6 X S S R U W L Q J 3 H R S O H ( [ S H U L H Q F L Q J 8 Q F H U W D L Q W \ D E R X W
Options Affecting Their Health" [2007].
When the patient and family understand the key facts about the condition and his/her options, a good deci-
V L R Q F D Q E H P D G H $ G G L W L R Q D O O \ W K H S D W L H Q W V K R X O G K D Y H U H D O L V W L F H [ S H F W D W L R Q V D E R X W W K H S U R E D E O H E H Q H W V
D Q G K D U P V $ J R R G L Q G L F D W R U R I W K H G H F L V L R Q T X D O L W \ L V Z K H W K H U R U Q R W W K H S D W L H Q W I R O O R Z V W K U R X J K Z L W K K L V
her chosen option. There may be implications of the decision on patient’s emotional state such as regret or
E O D P H D Q G W K H U H P D \ E H X W L O L ] D W L R Q F R Q V H T X H Q F H V
’ H F L V L R Q T X D O L W \ F D Q E H G H W H U P L Q H G E \ W K H H [ W H Q W W R Z K L F K W K H S D W L H Q W V F K R V H Q R S W L R Q E H V W P D W F K H V K L V K H U
values and preferences as revealed through the Collaborative Conversation
TM
process.
Support for this project was provided in part by a grant from the Robert Wood Johnson Foundation.
W K $ Y H 6 R X W K 6 X L W H % O R R P L Q J W R Q 0 1 3 K R Q H Z Z Z L F V L R U J
' 2012 Institute for Clinical Systems Improvement. All rights reserved.
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Prevention and Management of Obesity for Adults
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, & 6 , K D V O R Q J K D G D S R O L F \ R I W U D Q V S D U H Q F \ L Q G H F O D U L Q J S R W H Q W L D O F R Q ` L F W L Q J D Q G
competing interests of all individuals who participate in the development, revision
and approval of ICSI guidelines and protocols.
, Q W K H , & 6 , & R Q ` L F W R I , Q W H U H V W 5 H Y L H Z & R P P L W W H H Z D V H V W D E O L V K H G E \ W K H
Board of Directors to review all disclosures and make recommendations to the board
Z K H Q V W H S V V K R X O G E H W D N H Q W R P L W L J D W H S R W H Q W L D O F R Q ` L F W V R I L Q W H U H V W L Q F O X G L Q J
recommendations regarding removal of work group members. This committee
K D V D G R S W H G W K H , Q V W L W X W H R I 0 H G L F L Q H & R Q ` L F W R I , Q W H U H V W V W D Q G D U G V D V R X W O L Q H G L Q
the report, Clinical Practice Guidelines We Can Trust (2011).
: K H U H W K H U H D U H Z R U N J U R X S P H P E H U V Z L W K L G H Q W L H G S R W H Q W L D O F R Q ` L F W V W K H V H D U H
disclosed and discussed at the initial work group meeting. These members are
expected to recuse themselves from related discussions or authorship of related
U H F R P P H Q G D W L R Q V D V G L U H F W H G E \ W K H & R Q ` L F W R I , Q W H U H V W F R P P L W W H H R U U H T X H V W H G
by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI .
Funding Source
The Institute for Clinical Systems Improvement provided the funding for this
J X L G H O L Q H U H Y L V L R Q , & 6 , L V D Q R W I R U S U R W T X D O L W \ L P S U R Y H P H Q W R U J D Q L ] D W L R Q
based in Bloomington, Minnesota. ICSI’s work is funded by the annual dues of
W K H P H P E H U P H G L F D O J U R X S V D Q G Y H V S R Q V R U L Q J K H D O W K S O D Q V L Q 0 L Q Q H V R W D D Q G
Wisconsin. Individuals on the work group are not paid by ICSI but are supported
by their medical group for this work.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI, member medical groups and sponsoring health plans review and provide
feedback but do not have editorial control over the work group. All recommenda-
tions are based on the work group’s independent evaluation of the evidence.
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Copyright © 2013 by Institute for Clinical Systems Improvement
’ L V F O R V X U H R I 3 R W H Q W L D O & R Q ` L F W V R I , Q W H U H V W
Prevention and Management of Obesity for Adults

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Disclosure of Potential Conflicts of Interest
Lynn Everling (Work Group Member)
Patient Representative, ICSI Patient Advisory Council
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Angela Fitch, MD (Work Group Leader)
Bariatrician, Park Nicollet Medical Group
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Claudia Fox, MD, MPH (Work Group Member)
Director of Pediatric Weight Management Program, University of Minnesota
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
* X L G H O L Q H 5 H O D W H G $ F W L Y L W L H V ) D L U Y L H Z 3 H G L D W U L F $ P E X O D W R U \ 4 X D O L W \ & K L O G K R R G 2 E H V L W \ : R U N * U R X S
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Jennifer Y. Goldberg, MS, RD, LD (Work Group Member)
Dietician, HealthPartners Medical Group and Regions Hospital
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Kathy Johnson, PharmD (Work Group Member)
Pharmacy, Essentia Health
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Tara Kaufman, MD (Work Group Member)
Family Medicine, Mayo Clinic
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Erika Kennedy (Work Group Member)
Patient Representative, ICSI Patient Advisory Council
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
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Prevention and Management of Obesity for Adults
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Claire Kestenbaum, RPh (Work Group Member)
Pharmacy, Park Nicollet Medical Group
1 D W L R Q D O 5 H J L R Q D O O R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Mike Lano, MD (Work Group Member)
Family Medicine, Ridgeview Medical Center
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Daniel Leslie, MD (Work Group Member)
GI and Bariatric Surgery, University of Minnesota Physicians
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Tracy L. Newell, RD, LD, CNSD (Work Group Member)
Dietician, HealthPartners Medical Group and Regions Hospital
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Patrick O’Connor, MD, MA, MPH (Work Group Member)
Family Medicine and Geriatrics, HealthPartners Medical Group and Regions Hospital
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: ICSI Diabetes Guideline
5 H V H D U F K * U D Q W V 1 , + ’ L D E H W H V + \ S H U W H Q V L R Q $ + 5 4 % D U L D W U L F 6 X U J H U \
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 3 D W H Q W 3 H Q G L Q J G U X J V R I W Z D U H % 3 * O X F R V H P R Q L W R U L Q J
Bridget Slusarek, RN, BSN (Work Group Member)
Nurse Manager, Fairview Health Services
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities:
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 2 Q H W L P H 1 X U V L Q J ( G X F D W L R Q † ( W K L F R Q
Amber Spaniol, RN, LSN, PHN (Work Group Member)
Health Services Program Director, Robbinsdale School District 281
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: None
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
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Prevention and Management of Obesity for Adults
Disclosure of Potential Conflicts of Interest Sixth Edition/May 2013

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Steven D. Stovitz, MD (Work Group Member)
Sports Medicine, University of Minnesota Physicians
1 D W L R Q D O 5 H J L R Q D O / R F D O & R P P L W W H H $ I O L D W L R Q V 1 R Q H
Guideline-Related Activities: American Academy of Orthopedic Surgery
Research Grants: None
) L Q D Q F L D O 1 R Q Q D Q F L D O & R Q ` L F W V R I , Q W H U H V W 1 R Q H
Return to Table of Contents
Prevention and Management of Obesity for Adults
Disclosure of Potential Conflicts of Interest Sixth Edition/May 2013


All ICSI documents are available for review during the revision process by
member medical groups and sponsors. In addition, all members commit to
U H Y L H Z L Q J V S H F L F G R F X P H Q W V H D F K \ H D U 7 K L V F R P S U H K H Q V L Y H U H Y L H Z S U R Y L G H V
information to the work group for such issues as content update, improving
clarity of recommendations, implementation suggestions and more. The
V S H F L F U H Y L H Z H U F R P P H Q W V D Q G W K H Z R U N J U R X S U H V S R Q V H V D U H D Y D L O D E O H W R
ICSI members at http://Obesity .
The ICSI Patient Advisory Council meets regularly to respond to any
V F L H Q W L F G R F X P H Q W U H Y L H Z U H T X H V W V S X W I R U W K E \ , & 6 , I D F L O L W D W R U V D Q G Z R U N
groups. Patient advisors who serve on the council consistently share their
experiences and perspectives in either a comprehensive or partial review of a
G R F X P H Q W D Q G H Q J D J L Q J L Q G L V F X V V L R Q D Q G D Q V Z H U L Q J T X H V W L R Q V , Q D O L J Q P H Q W
with the Institute of Medicine’s triple aims, ICSI and its member groups are
committed to improving the patient experience when developing health care
recommendations.
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Copyright © 2013 by Institute for Clinical Systems Improvement
Acknowledgements:
Prevention and Management of Obesity for Adults

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A捫no睬edgements
ICSI Patient Advisory Council
The work group would like to acknowledge the work done by the ICSI Patient Advisory Council in reviewing
the Prevention and Management of Obesity (Adults) guideline. ICSI would like to recognize two ICSI
Patient Advisory Council members who participated in the work group review and revision: Lynn Everling
and Erika Kennedy.
Invited Reviewers
During this revision, the following groups reviewed this document. The work group would like to thank
them for their comments and feedback.
Allina Medical Clinic, Mineapolis, MN
CentraCare Health System, St. Cloud, MN
HealthPartners Health Plan
0 D U V K H O G & O L Q L F 0 D U V K H O G : ,
Mayo Clinic, Rochester, MN
Medica Health Plans, Minnetonka, MN
Minnesota Association of Community Health Centers, Minneapolis, MN
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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013

㤸Copyright © 2013 by Institute for Clinical Systems Improvement
Released in May 2013 for Sixth Edition.
The next scheduled revision will occur within 24 months.
Contact ICSI at:
W K $ Y H Q X H 6 R X W K 6 X L W H % O R R P L Q J W R Q 0 1 I D [
Online at http://www.ICSI.org
Document Drafted
Dec 2003 May 2004
Critical Review
Jun 2004
First Edition
Dec 2004
Second Edition
Dec 2005
Third Edition
Dec 2006
Fourth Edition
Feb 2009
Fifth Edition
May 2011
Sixth Edition
Begins Jun 2013

Original Work Group Members
Lynne Hemann, PA
Health Education
Olmsted Medical Center
Sayeed Ikramuddin, MD
Surgery Consultant
U of MN Physicians
Kathy Johnson, PharmD
Pharmacy
St. Mary’s/Duluth Clinic
Kathryn Nelson, MD
Family Practice
$ I O L D W H G & R P P X Q L W \ 0 H G L F D O
Center
Patrick O’Connor, MD
Family Practice
HealthPartners
Teri Barker Connor, RN
Health Education
Park Nicollet Health Services
George Biltz, MD
Pediatrics
HealthPartners
Beth Green, MBA, RRT
Measurement/Implementation
Advisor
ICSI
Nancy Greer, PhD
Evidence Analyst
ICSI
David Hanekom, MD
Internal Medicine, Work Group
Leader
MeritCare
Pam Pietruszewski
Facilitator
ICSI
Julie Roberts, MS, RD
Dietitian
HealthPartners
Paula Roe
Employer Representative
Wells Fargo
Nancy Sherwood, PhD
Psychology
HealthPartners Research
Foundation
Document History
6 W D W H Z L G H + H D O W K , P S U R Y H P H Q W 3 U R J U D P V H O H F W H G , & 6 , 2 E H V L W \
guideline for implementation.
Document History and Development:
Prevention and Management of Obesity for Adults
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Institute for Clinical Systems Improvement


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Prevention and Management of Obesity for Adults
Sixth Edition/May 2013
䥃卉 Do捵ment Develo灭ent and 剥vision Pro捥ss
Overview
Since 1993, the Institute for Clinical Systems Improvement (ICSI) has developed more than 60 evidence-based
health care documents that support best practices for the prevention, diagnosis, treatment or management of a
given symptom, disease or condition for patients.
Audience and Intended Use
The information contained in this ICSI Health Care Guideline is intended primarily for health professionals and
other expert audiences.
This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any
V S H F L F I D F W V R U F L U F X P V W D Q F H V 3 D W L H Q W V D Q G I D P L O L H V D U H X U J H G W R F R Q V X O W D K H D O W K F D U H S U R I H V V L R Q D O U H J D U G L Q J W K H L U
R Z Q V L W X D W L R Q D Q G D Q \ V S H F L F P H G L F D O T X H V W L R Q V W K H \ P D \ K D Y H , Q D G G L W L R Q W K H \ V K R X O G V H H N D V V L V W D Q F H I U R P D
health care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case.
This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the
evaluation and treatment of patients, and is not intended either to replace a clinician’s judgment or to establish a
protocol for all patients with a particular condition.
Document Development and Revision Process
The development process is based on a number of long-proven approaches and is continually being revised
based on changing community standards. The ICSI staff, in consultation with the work group and a medical
librarian, conduct a literature search to identify systematic reviews, randomized clinical trials, meta-analysis,
other guidelines, regulatory statements and other pertinent literature. This literature is evaluated based on the
GRADE methodology by work group members. When needed, an outside methodologist is consulted.
7 K H Z R U N J U R X S X V H V W K L V L Q I R U P D W L R Q W R G H Y H O R S R U U H Y L V H F O L Q L F D O ` R Z V D Q G D O J R U L W K P V Z U L W H U H F R P P H Q G D W L R Q V
and identify gaps in the literature. The work group gives consideration to the importance of many issues as they
develop the guideline. These considerations include the systems of care in our community and how resources
Y D U \ W K H E D O D Q F H E H W Z H H Q E H Q H W V D Q G K D U P V R I L Q W H U Y H Q W L R Q V S D W L H Q W D Q G F R P P X Q L W \ Y D O X H V W K H D X W R Q R P \ R I
clinicians and patients and more. All decisions made by the work group are done using a consensus process.
ICSI’s medical group members and sponsors review each guideline as part of the revision process. They provide
F R P P H Q W R Q W K H V F L H Q W L F F R Q W H Q W U H F R P P H Q G D W L R Q V L P S O H P H Q W D W L R Q V W U D W H J L H V D Q G E D U U L H U V W R L P S O H P H Q W D W L R Q
This feedback is used by and responded to by the work group as part of their revision work. Final review and
approval of the guideline is done by ICSI’s Committee on Evidence-Based Practice. This committee is made up
of practicing clinicians and nurses, drawn from ICSI member medical groups.
Implementation Recommendations and Measures
These are provided to assist medical groups and others to implement the recommendations in the guidelines.
Where possible, implementation strategies are included that have been formally evaluated and tested. Measures
D U H L Q F O X G H G W K D W P D \ E H X V H G I R U T X D O L W \ L P S U R Y H P H Q W D V Z H O O D V I R U R X W F R P H U H S R U W L Q J : K H Q D Y D L O D E O H U H J X-
latory or publicly reported measures are included.
Document Revision Cycle
6 F L H Q W L F G R F X P H Q W V D U H U H Y L V H G H Y H U \ P R Q W K V D V L Q G L F D W H G E \ F K D Q J H V L Q F O L Q L F D O S U D F W L F H D Q G O L W H U D W X U H
ICSI staff monitors major peer-reviewed journals every month for the guidelines for which they are responsible.
Work group members are also asked to provide any pertinent literature through check-ins with the work group
P L G F \ F O H D Q G D Q Q X D O O \ W R G H W H U P L Q H L I W K H U H K D Y H E H H Q F K D Q J H V L Q W K H H Y L G H Q F H V L J Q L F D Q W H Q R X J K W R Z D U U D Q W
document revision earlier than scheduled. This process complements the exhaustive literature search that is done
R Q W K H V X E M H F W S U L R U W R G H Y H O R S P H Q W R I W K H U V W Y H U V L R Q R I D J X L G H O L Q H
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