Scope
Weight loss
therapy is recommended for patients with a BMI > 30 (See Table I),
and for patients with a BMI between 25 and 29.9 with risk factors (See
Table 3, below), or a high-risk
waist circumference and two or more risk factors (See Tables 2 and 3,
below).
GoalTo provide criteria and guidelines to achieve the highest
likelihood of sustained weight loss[8]
and morbidity. ObjectivesTo encourage serious and morbidly obese patients to lose weight and maintain weight loss through conservative measures; to maintain salutary adjustments in their lifestyle choices; and, improve their overall health, thereby. To ensure that patients who are considered for surgical intervention have been appropriately evaluated and treated and are appropriate selected based upon their risk to benefit ratio. Relevance For the Patient: The quality of life and risk
of serious complications, disability and/or death is improved through
weight loss in the seriously and/or morbidly obese patient. For the Health Plan: Health care costs are also
reduced as body weight is controlled. Extraordinary Considerations The health care impact of obesity
is a complex calculation involving not only direct costs such as end-organ
damage, but also indirect costs including pharmaceuticals required,
for example, in the management of CAD and hypertension, and increased
office visits from injury to weight-bearing joints, strain, cardiac
inefficiency, sleep apnea and depression. Steps
and Specific Measures See the 12 Step “Obesity
Management Guideline Implementation Check List,” above for the specific components of this comprehensive
and medically supervised weight management program. Weight Classification Table 1
Weight Gain Management In some patients, weight loss or a reduction in body fat is not achievable. A goal for these patients should be the prevention of further weight gain. Prevention of weight gain is also an appropriate goal for people with a BMI of 25 to 29.9 who are not otherwise at high risk. Treatment of the overweight and obese patients is a two-step process: assessment and management. Assessment requires determination of the degree of obesity and the absolute risk status. Management includes the reduction of excess weight and maintenance of this lower body weight, as well as the institution of additional measures to control any associated risk factors. Strong evidence supports the recommendation that weight loss and weight maintenance programs should employ a combination of low-calorie diets, increased physical activity, and behavior therapy. Therapies A reduction of caloric intake by 500 to 1,000 kcal/day
will produce the recommended weight loss of 1 to 2 pounds per week.
Physical Activity All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. Pharmacotherapy Pharmacotherapy, approved by the FDA for a long-term treatment, should be used only in the context of a treatment program that includes all the elements described previously: diet, physical activity changes, and behavior therapy; and when lifestyle changes do not promote weight loss after at least six (6) months. However, Pharmacotherapy is currently limited to those patients who have a BMI > 30, or those who have a BMI > 27 if concomitant obesity-related risk factors or diseases exist. Not all patients respond to a given drug. Furthermore, if a patient has not lost 4.4 pounds (2 kg) after 4 weeks, it is not likely that this patient will benefit from the drug. The decision to add a drug to an obesity treatment program should be made after consideration of all potential risks and benefits and only after all behavioral options have been exhausted. Weight Loss Surgery Although there are risks associated with surgery, it is not yet know whether these risks are greater in the long term than those of any other form of treatment. Special Situations A practitioner can conduct a weight loss and maintenance program without specialization in weight loss management, so long as that person has the requisite interest and knowledge. Also, nutritionists, registered dietitians, exercise physiologists, nurses, and psychologist offer expertise in dietary counseling, physical activity, and behavior changes and can be used for assessment, treatment, and follow-up during weight loss and weight maintenance. The relationship between the practitioner and these professionals can be a direct, formal one (as in a “team”), or it may be based on an indirect referral. A positive, supportive attitude and encouragement from all professionals are crucial to the continuing success of the patient. Assessment of Risk Status Determine the relative risk status based on overweight and obesity parameters. In overweight and obese persons weight loss is recommended. It
Table 2
§ Established coronary heart disease (CHD), including a history of myocardial infarction, angina pectoris (stable or unstable), coronary artery surgery, or coronary artery procedures (e.g., angioplasty). § Presence of other atherosclerotic diseases, including peripheral arterial disease, abdominal aortic aneurysm, or symptomatic carotid artery disease. § Type 2 diabetes (fasting plasma glucose > 126mg/dL or 2-h postprandial plasma glucose > 200 mg/dL) is a major risk factor for CVD. Its presence alone places a patient in the category of very high absolute risk. § Sleep apnea. Symptoms and signs include very loud snoring or cessation of breathing during sleep, which is often followed by a loud clearing breath, then brief awakening.
Table
3 Risk Factors
Documentation and References Excerpted
from “The Practical Guide Identification, Evaluation, and Treatment
of Overweight and Obesity Adults” by the National Institutes of Health,
National Heart, Lung, and Blood Institute, NHLBI Obesity Education Initiative,
and the North American Association for the Study of Obesity. NIH Publication Number 00-4084
October 2000 [1] Goal: average caloric intake by 500 to 1,000 kcal [2] Goal for physical activity: 30 minutes or more of moderate-intensity on most, and preferably all, days of the week. [3] Hypertension (systolic blood pressure of > 140 mm Hg or diastolic blood pressure > 90 mm Hg) or current use of antihypertensive agents [4] High-risk low-density lipoprotein (LDL) cholesterol (serum concentration > 160 mg/dL). A borderline high-risk LDL-cholesterol (130 to 159 mg/dL) plus two or more other risk factors also confers high risk. [5] Low high-density lipoprotein (HDL) cholesterol (serum concentration < 35 mg/dL). [6] Impaired fasting glucose (IFG) (fasting plasma glucose between 110 and 125 mg/dL). IFG is considered by many authorities to be an independent risk factor for cardiovascular (macrovascular) disease, thus justifying its inclusion among risk factors contributing to high absolute risk. IFG is well established as a risk factor for type 2 diabetes. [7] Family history of premature CHD (myocardial infarction or sudden death experienced by the father or other male first-degree relative at or before 55 years of age or other female first-degree relative at or before 65 years of age). [8] 10% or less, measurable weight loss qualifies |
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