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## Complete Summary

#### GUIDELINE TITLE

Prevention and management of obesity (mature adolescents and adults).

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Prevention and
management of obesity (mature adolescents and adults). Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2006 Nov. 105 p.
\[226 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical
Systems Improvement (ICSI). Prevention and management of obesity (mature
adolescents and adults). Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Nov. 100 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Obesity

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Prevention\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Internal Medicine\
Nutrition\
Pediatrics\
Preventive Medicine\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Health Plans\
Hospitals\
Managed Care Organizations\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To increase awareness of body mass index (BMI)

-   To improve the percentage of patients who have received education
    and counsel regarding weight loss

-   To improve the outcome of the treatment for obesity

-   To improve community (employers, schools) involvement in the
    prevention and treatment of obesity

#### TARGET POPULATION

Mature adolescent and adult patients

This guideline does not include the patient population of pregnant women
or body builders/weight trainers.

While this guideline does not address the pediatric population, the work
group acknowledges the importance of addressing this epidemic and is
continuing to gather evidence for future guideline expansion.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention/Diagnosis/Risk Assessment**

1.  Measure height and weight and calculate body mass index (BMI),
    preferably annually

2.  Assess for major and minor comorbid conditions including
    hypertension, cigarette smoking, peripheral vascular disease, type 2
    diabetes mellitus, depression, eating disorders

3.  Advise weight maintenance and manage other risk factors

4.  Assess readiness to lose weight

**Treatment/Management**

1.  Follow the 5 As (Ask, Advice, Assist, Assess, Arrange)

2.  Provide lower calorie balanced eating plan, encourage calorie
    reduction, and provide referral to a dietitian

3.  Physical activity

4.  Behavioral management and counseling including self-monitoring of
    weight, nutrition, and activity; stimulus control; cognitive
    restructuring; goal setting, social support, etc.

5.  Pharmacologic therapy including:

    -   Food and Drug Administration (FDA) approved medication, such as
        sibutramine and orlistat

    -   Nonprescription and natural medications.

> **Note**: Most of dietary supplements used for weight loss are not FDA
> approved for weight loss and not recommended. Refer to Appendix F in
> the original guideline document for the list of these supplements and
> their safety and efficacy profile.

6.  Surgical procedures including vertical banded gastroplasty,
    laparoscopic adjustable gastric band, biliopancreatic diversion,
    duodenal switch, and Roux-en-Y gastric bypass

7.  Regular follow-ups

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of weight loss interventions (e.g., diet, physical
    activity, medication)

-   Effect of weight loss interventions on prevention and management of
    type 2 diabetes mellitus and cardiovascular risk factors

-   Adverse events and complications associated with pharmacological
    agents and surgery

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Key conclusions (as determined by the work group) are supported by a
conclusion grading worksheet that summarizes the important studies
pertaining to the conclusion. Individual studies are classed according
to the system presented below, and are designated as positive, negative,
or neutral to reflect the study quality.

**Conclusion Grades**:

**Grade I**: The evidence consists of results from studies of strong
design for answering the question addressed. The results are both
clinically important and consistent with minor exceptions at most. The
results are free of any significant doubts about generalizability, bias,
and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.

**Grade II**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is some
uncertainty attached to the conclusion because of inconsistencies among
the results from the studies or because of minor doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from weaker
designs for the question addressed, but the results have been confirmed
in separate studies and are consistent with minor exceptions at most.

**Grade III**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is substantial
uncertainty attached to the conclusion because of inconsistencies among
the results of different studies or because of serious doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from a
limited number of studies of weak design for answering the question
addressed.

**Grade Not Assignable**: There is no evidence available that directly
supports or refutes the conclusion.

**Study Quality Designations**:

The quality of the primary research reports and systematic reviews are
designated in the following ways on the conclusion grading worksheets:

**Positive**: indicates that the report or review has clearly addressed
issues of inclusion/exclusion, bias, generalizability, and data
collection and analysis.

**Negative**: indicates that these issues (inclusion/exclusion, bias,
generalizability, and data collection and analysis) have not been
adequately addressed.

**Neutral**: indicates that the report or review is neither
exceptionally strong nor exceptionally weak.

**Not Applicable**: indicates that the report is not a primary reference
or a systematic review and therefore the quality has not been assessed.

**Classes of Research Reports**:

A.  Primary Reports of New Data Collection:

> Class A:

-   Randomized, controlled trial

> Class B:

-   Cohort study

> Class C:

-   Non-randomized trial with concurrent or historical controls

-   Case-control study

-   Study of sensitivity and specificity of a diagnostic test

-   Population-based descriptive study

> Class D:

-   Cross-sectional study

-   Case series

-   Case report

B.  Reports that Synthesize or Reflect upon Collections of Primary
    Reports:

> Class M:

-   Meta-analysis

-   Systematic review

-   Decision analysis

-   Cost-effectiveness analysis

> Class R:

-   Consensus statement

-   Consensus report

-   Narrative review

> Class X:

-   Medical opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Clinical Validation-Pilot Testing\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

**Institute Partners: System-Wide Review**

The guideline draft, discussion, and measurement specification documents
undergo thorough review. Written comments are solicited from clinical,
measurement, and management experts from within the member medical
groups during an eight-week period of review period.

Each of the Institute\'s participating medical groups determines its own
process for distributing the guideline and obtaining feedback.
Clinicians are asked to suggest modifications based on their
understanding of the clinical literature coupled with their clinical
expertise. Representatives from all departments involved in
implementation and measurement review the guideline to determine its
operational impact. Measurement specifications for selected measures are
developed by the Institute for Clinical Systems Improvement (ICSI) in
collaboration with participating medical groups following general
implementation of the guideline. The specifications suggest approaches
to operationalizing the measure.

**Guideline Work Group**

Following the completion of the review period, the guideline work group
meets 1 to 2 times to review the input received. The original guideline
is revised as necessary and a written response is prepared to address
each of the responses received from member groups. Two members of the
Committee on Evidence-Based Practice carefully review the input, the
work group responses, and the revised draft of the guideline. They
report to the entire committee their assessment of four questions: (1)
Is there consensus among all ICSI member groups and hospitals on the
content of the guideline document? (2) Has the drafting work group
answered all criticisms reasonably from the member groups? (3) Within
the knowledge of the appointed reviewer, is the evidence cited in the
document current and not out-of-date? (4) Is the document sufficiently
similar to the prior edition that a more thorough review (critical
review) is not needed by the member group? The committee then either
approves the guideline for release as submitted or negotiates changes
with the work group representative present at the meeting.

**Pilot Test**

Member groups may introduce the guideline at pilot sites, providing
training to the clinical staff and incorporating it into the
organization\'s scheduling, computer, and other practice systems.
Evaluation and assessment occur throughout the pilot test phase, which
usually lasts for three-six months. At the end of the pilot test phase,
ICSI staff and the leader of the work group conduct an interview with
the member groups participating in the pilot test phase to review their
experience and gather comments, suggestions, and implementation tools.

The guideline work group meets to review the pilot sites\' experiences
and makes the necessary revisions to the guideline, and the Committee on
Evidence-Based Practice reviews the revised guideline and approves it
for release.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC) and the Institute
for Clinical Systems Improvement (ICSI)**: For a description of what has
changed since the previous version of this guidance, refer to \"[Summary
of Changes \-- November
2006](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/preventive_health_maintenance/obesity/obesity__prevention_and_management_of__mature_adolescents_and_adults___.html).\"

The recommendations for the prevention and management of obesity in
mature adolescents and adults are presented in the form of an algorithm
with 12 components, accompanied by detailed annotations. An algorithm is
provided for [Prevention and
Diagnosis](http://www.guideline.gov/algorithm/5389/NGC-5389.html).
Clinical highlights and selected annotations (numbered to correspond
with the algorithm) follow.

Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not
Assignable) definitions are repeated at the end of the \"Major
Recommendations\" field.

**[Clinical Highlights]{.underline}**

-   Obesity is a chronic disease that is multi-factorial 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 (BMI) span, not just for the extremely obese.
    (*Annotation #1*)

-   Calculate the BMI; classify the individual based on the BMI
    categories. Educate patients about their BMI and their associated
    risks. (*Annotation #1, 2*)

-   Effective weight management strategies are available and include
    nutrition, physical activity, lifestyle changes, medication, and
    surgery. (*Annotation #9*)

-   The physician should follow the 5 A\'s (Ask, Advise, Assess, Assist,
    Arrange). Physician intervention can be effective, the physician can
    have an important influence, and successful weight management is
    possible. (*Annotation #8, 9*)

-   Weight management requires a team approach. Be aware of clinical and
    community resources. The patient needs to have an ongoing
    therapeutic relationship and follow-up with a health care team.
    Weight control is a lifelong commitment and the health care team can
    assist with setting specific goals with the patient. (*Annotation
    #8, 9*)

-   Beyond their clinical role, primary care physicians should be aware
    of their roles as  community leaders and public health advocates.
    (*Annotation #12*)

[**[Prevention and Diagnosis Algorithm
Annotations]{.underline}**](http://www.guideline.gov/algorithm/5389/NGC-5389.html)

1.  **Measure Height, Weight, and Calculate BMI (Preferably Annually for
    Screening and as Needed for Management)**

> **Key Points**:

-   Health consequences exist across the BMI span and obesity is a
    multi-factorial chronic disease.

-   BMI should be calculated preferably annually for screening and as
    needed for management.

-   BMI calculation extends to all age groups. Adolescents less than
    Tanner stage 5 and children should be evaluated by available growth
    charts.

> **1a. Calculate BMI**
>
> Calculate the BMI at least annually for screening and as needed for
> management. Classify it based on the BMI categories. Educate patients
> about their BMI and associated risks for them.
>
> BMI = weight (kg)/height squared (m^2^) or (pounds x 703)/inches^2^
>
> **Adult BMI Categories**

  -----------------------------------------------------------------------
  **BMI**                  **Category**
  ------------------------ ----------------------------------------------
  Less than 18.5           Underweight

  18.5 to 24.9             Normal weight

  25 to 29.9               Overweight

  30 to 34.9               Obese \-- class I

  35 to 39.9               Obese \-- class II

  40 or more               Extreme obesity \-- class III
  -----------------------------------------------------------------------

> **Mature Adolescents**
>
> Physiologically speaking, maturation refers to the tempo of sexual
> development during puberty. The physiologic progression of pubertal
> stages proceeds in a definable sequence but the age of onset and the
> rate of progression exhibit significant inter-individual variability.
> Pubertal stages from prepuberty to mature adult have been categorized
> by Tanner in 1962. Tanner identified 5 stages of maturation based on
> progressive changes in external genitalia.
>
> For the purpose of this guideline, Tanner stage 5 will be considered
> physiologic maturity. The extension of guideline medication and
> surgery recommendations to this population is physiologically
> feasible. However, given the complexity of obesity variables and
> psychosocial issues, the use of medications and surgery in
> physiologically mature but younger adolescents needs to be discussed
> and decided within provider community practice standards.
>
> Adults may be sub-classified using absolute values for BMI. These
> absolute cutoffs for BMI may also be used for the sexually mature
> (Tanner stage 5) fully grown adolescent. However, absolute cut-off
> values cannot be directly applied to all adolescent patients.
> Adolescence is characterized by variable growth rate and variable
> tempo for sexual maturation. This variability in height and body
> composition complicates the determination of absolute BMI cutoffs for
> a normally changing individual. Growth, maturation, and ethnic
> differences also make it difficult to determine a definite chronologic
> age for using adult BMI criteria.
>
> The normative value for pediatric and adolescent BMI is highly age
> dependent.
>
> See Appendix A, \"Body Mass Index-For-Age Percentiles\" in the
> original guideline document.
>
> Since BMI is based on height and weight, it reflects the underlying
> variability in these features at a given chronologic age. Given the
> confounding effects of growth and maturation, the traditional
> pediatric approach to establishing normative values is to develop
> percentiles based on a reference population. The National Health and
> Nutrition Examination Survey (NHANES) has been done three times:
> NHANES I (1963-1970), II (1976-1980), and III (1988-1991). More
> recently, Rosner, et al. combined data from nine United States
> studies, including NHANES II and III, on over 66,000 participants.
> From this data set they determined BMI percentiles for ages 5-17. BMI
> tables are presented for boys and girls with ethnic subsets: Asian,
> Black, Hispanic, and White. United States weighted mean values are
> also provided (<http://www.cdc.gov/nchs/nhanes.htm>). Medical
> definitions of obesity may differ from cultural perceptions.
>
> In the pediatric literature, the \"at risk\" group has been defined as
> the 85th percentile. The 95th percentile has been used to identify the
> obese or grade 2 overweight individual. Specific cutoff values for a
> given gender, age and ethnic group are available from the previously
> mentioned percentile tables.
>
> A BMI calculation is worthwhile in the growing patient because it
> provides a reference point for future comparison. Subsequent
> observations establish a relative trajectory for this index of
> obesity. Although there are no standards for rate of change of BMI per
> year, a rapid increase or decrease warrants clinical attention. The
> separation between 50th and 75th percentile is approximately 2-3 BMI
> units for adolescent girls across ethnic groups. Adolescent boys have
> approximately 2 BMI units difference between these percentiles. An
> annual increase of greater than 3 units suggests excessive gain.
>
> The clinical significance of an abnormal or rapidly changing BMI is
> assessed with the following in mind:

-   BMI is not a direct measure of adiposity. It is a derived value that
    correlates well with total body fat and markers of secondary
    complications (e.g., hypertension and dyslipidemia).

-   An abnormally high BMI does not address the distribution of body fat
    (i.e., central vs. peripheral or visceral vs. subcutaneous). Central
    or visceral fat carry greater risk for morbidity and mortality.

-   Waist circumference (as recommended by the National Heart Lung and
    Blood Institute \[NHLBI\], see Annotation #2 in the original
    guideline document) provides an additional dimension for assessing
    visceral adiposity and clinical risk.

-   Metabolic assessment is important in the patient at risk, especially
    if there is a family history for heart disease or type 2 diabetes
    mellitus.

-   Clinical conditions associated with adolescent obesity are found in
    Table 4 in the original guideline document. Depression, anxiety,
    eating disorders, and sexual abuse are also important clinical
    associations with adolescent obesity.

> ***Evidence supporting this recommendation is of classes: D, R***

2.  **Assess for Major and Minor Comorbid Conditions**

> **Key Points**:

-   It is important to assess for other conditions as treatment
    decisions and outcomes may be influenced by their presence.

-   Waist circumference greater than or equal to 40 inches for males and
    greater than or equal to 35 inches for females is an additional risk
    factor for complications related to obesity.

-   For depression and eating disorders, brief screenings should be
    conducted if appropriate.

-   Assessment should include a complete medical history to identify
    medications that may induce weight gain or interfere with weight
    loss.

> **Comorbid Condition Assessment**

  ---------------------------------------------------------------------------
  **Comorbid     **BMI**                                       
  Condition**                                                  
  -------------- ---------------- ------------- -------------- --------------
                 **25 to 30**     **30 to 35**  **35 to 40**   **40+**

  **0**          Lifestyle        Lifestyle     Lifestyle      Lifestyle
                 changes and      changes and   changes and    changes and
                 behavioral       behavioral    behavioral     behavioral
                 management       management.   management.    management.
                                  Consider drug Consider drug  Consider drug
                                  therapy       therapy        therapy and/or
                                                               surgical
                                                               evaluation.

  **1-3 minor    Lifestyle        Lifestyle     Lifestyle      Lifestyle
  comorbid       changes and      changes and   changes and    changes and
  conditions**   behavioral       behavioral    behavioral     behavioral
                 management       management.   management.    management.
                                  Consider drug Consider drug  Consider drug
                                  therapy       therapy and/or therapy and/or
                                                surgical       surgical
                                                evaluation.    evaluation.

  **Major        Lifestyle        Lifestyle     Lifestyle      Lifestyle
  comorbid       changes and      changes and   changes and    changes and
  conditions\    behavioral       behavioral    behavioral     behavioral
  OR\            management.      management.   management.    management.
  more than 3    Consider drug    Consider drug Consider drug  Consider drug
  minor comorbid therapy. The     therapy.      therapy and/or therapy and/or
  conditions**   Food and Drug                  surgical       surgical
                 Administration                 evaluation.    evaluation.
                 (FDA) approves                                
                 drug therapy                                  
                 only for BMI                                  
                 greater than 27.                              
  ---------------------------------------------------------------------------

> **Minor Comorbid Conditions**

-   Cigarette smoking

-   Hypertension (blood pressure \[BP\] greater than or equal to 140/90)
    or current use of antihypertensives\^

-   Low-density lipoprotein (LDL) cholesterol greater than 130 mg/dL\^

-   High-density lipoprotein (HDL) cholesterol less than 40 mg/dL

-   Pre-diabetes\*\^

-   Family history of premature coronary artery disease (CAD)

-   Age greater than or equal to 65 years for males

-   Age greater than or equal to 55 years for females or menopausal
    females

> **Major Comorbid Conditions**

-   Waist circumference (males [\>]{.underline}40 inches, females
    [\>]{.underline}35 inches)\^

-   Established coronary artery disease

    -   History of myocardial infarction

    -   History of angioplasty

    -   History of coronary artery bypass graft (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 recently 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 inclusive, as well as
> those with a two-hour post 75 gram oral glucose tolerance test value
> of greater than or equal to 140 mg/dL to 200 mg/dL.
>
> \^ The clustering of these symptoms has been described as the
> metabolic syndrome.
>
> **Other Conditions**
>
> Clinicians may use the waist circumference as a measure of central
> adiposity. Men with waist circumferences greater than or equal to 40
> inches (102 cm) and women with a waist circumference greater than or
> equal to 35 inches (88 cm) are at increased risk for cardiovascular
> disease.
>
> In the Health Professional Follow-up Study, overall and cardiovascular
> mortality in men increased linearly with baseline BMI in younger men
> (those initially younger than 65 years) and had no relationship with
> BMI in older men (those initially at least 65 years); by contrast,
> waist circumference predicted risk for overall and cardiovascular
> mortality among the younger men, and predicted risk for cardiovascular
> death among older men.
>
> The Iowa Women\'s Health Study found that the waist-hip ratio was a
> better predictor of total cardiovascular mortality than BMI, and that
> even in women in the lowest BMI quintile, there was a markedly
> increased risk for diabetes if they also had a high waist-hip ratio.
>
> Waist circumference is an additional risk factor for complications
> related to obesity for males measuring greater than or equal to 40
> inches, females greater than or equal to 35 inches. While the work
> group acknowledges potential difficulty implementing the measurement
> of waist circumference, evidence shows the importance of measuring
> waist circumference because of increased cardiovascular risk.
>
> ***Evidence supporting this recommendation is of class: B, C, D***
>
> **Screening for Depression**
>
> The evidence showing the linkage between depression and obesity is
> mixed. Higher rates of depression have been found in severely obese
> people, especially younger women with poor body image. It is difficult
> to study whether the depression is secondary to the obesity or to
> existing comorbid conditions. Weight loss often leads to improvement
> of depression scores.
>
> Depression is identified more often in obese women and teenagers and
> is less likely to be diagnosed in men. Depression in the elderly is
> often associated with weight loss while depression in younger females
> can be associated with weight gain.
>
> Depression has been associated with poor weight loss outcomes.
> Bariatric surgery patients with poorly managed depression or anxiety
> are at greater risk for weight regain within the first five
> postoperative years. 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. Weight loss
> studies have often excluded people with depression. More studies to
> address this issue are warranted.
>
> ***Evidence supporting this recommendation is of classes: B, C, D,
> R***
>
> Screening for depression can include asking the following questions.
>
> Over the past month, have you been bothered by:

1.  Little interest or pleasure in doing things?

2.  Feeling down, depressed, or hopeless?

> If the patient answers \"yes\" to either one of the above questions,
> consider using a questionnaire to further assess whether the patient
> has sufficient symptoms to warrant a full clinical interview and a
> diagnosis of clinical major depression. An example of such a
> questionnaire is the (Patient Health Questionnaire) PHQ-9.
>
> This should not be considered a comprehensive screening for
> depression, which is beyond the scope of this guideline. See the
> National Guideline Clearinghouse (NGC) summary of the Institute for
> Clinical Systems Improvement (ICSI) guideline [Major Depression in
> Adults in Primary
> Care](http://www.guideline.gov/summary/summary.aspx?doc_id=12617&nbr=6525)
> for more information.
>
> **Screening for an Eating Disorder**
>
> Eating disorders, particularly binge eating disorder, may complicate
> the treatment of obesity.
>
> Screening for eating disorders can include asking the following
> questions:

1.  Do you eat a large amount of food in a short period of time \-- like
    eating more food than another person may eat in, say, a two-hour
    period of time?

2.  Do you ever feel like you can\'t stop eating even after you feel
    full?

3.  When you overeat, what do you do? (e.g., Have you ever tried to
    \"get rid of\" the extra calories that you\'ve eaten by doing
    something like: Take laxatives? Take diuretics \[or water pills\]?
    Smoke cigarettes? Take street drugs like cocaine or crank? Make
    yourself sick \[induce vomiting\])?

> If the patient answers \"yes\" to any of the above questions, consider
> further evaluation or a referral to a dietitian or a behavioral health
> specialist who specializes in eating disorders or in health psychology
> and working with bariatric patients.
>
> More comprehensive screening tools include the SCOFF, ESP, or EAT.
>
> **Screening for Medication Use That Contributes to Weight Gain**
>
> The assessment of the obese patient should include a complete
> medication history to identify medications that may induce weight gain
> or interfere with weight loss including antidiabetic medication
> (insulin, insulin secretagogues, metformin, alfa-glucosidase
> inhibitors, thiazolidinediones) and psychotropic drugs. For more
> information regarding medications associated with weight gain, refer
> to the original guideline document.

5.  **Advise Weight Maintenance and Manage Other Risk Factors**

> **Key Points**:

-   It is important to address the issue of weight maintenance for those
    with BMI in the normal range.

-   Weight management includes physical activity, nutrition, and
    behavior management strategies.

> Lifetime risk of obesity is high for residents of the U.S. Lifetime
> risk of diabetes is about 30% for men and 35% for women, and lifetime
> risk for obesity is higher than this.
>
> Therefore, it is important to address the issue of weight maintenance
> for those with BMI in the normal range (18.5 to 24.9).
>
> Successful weight management requires a lifestyle approach that
> integrates physical activity, nutrition, behavioral management, and
> attention to psychosocial needs.

-   First, encourage regular physical activity at recommended levels.
    Regular physical activity is 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. However, for those who have lost a considerable
    amount of weight, higher amounts of physical activity may be
    required for weight maintenance. Enjoyment and variety of physical
    activity are also key features for adherence.

-   Second, provide structured lifestyle modification suggestions that
    include specific nutrition recommendations, educational sessions,
    and frequent contact with health-care providers such as a dietitian.
    Focus on calorie balancing, using a combination of decreased caloric
    intake with increased calorie expenditure. Include nutrition
    education (i.e., interpreting food labels); managing restaurant and
    social eating situations; making healthy, nutritious food choices;
    using portion control; and recipe modification.

> 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
> demonstrates that successful weight-maintainers consume a low-calorie
> diet containing approximately 40 g fat (24% of calories), 200 g
> carbohydrate (56% of calories), and 70 g protein (19% of calories). A
> low fat diet (25 to 30% calories from fat) is considered the
> conventional therapy for treating obesity.

-   Third, encourage behavior management strategies that may include
    weekly weight checks, food journals, and monitoring daily routine
    that focuses on a balanced lifestyle. Balance includes: (a) eating a
    nutritionally-balanced breakfast soon after awakening and eating
    balanced meals at regular intervals thereafter, (b) incorporating
    fun physical activity into the day, and (c) scheduling the week to
    include rest, play, and social interactions along with work, school,
    and family responsibilities.

> Specific behavioral strategies to promote behavior change include: (a)
> self-monitoring some aspect of behavior which, in itself, typically
> results in behavior change; (b) non-food rewards and positive
> reinforcements; (c) reminders; (d) stimulus control (changing social
> or environmental cues that trigger eating behavior); (e) stress
> management and problem solving; and (f) helping patients believe they
> can be successful.
>
> ***Evidence supporting this recommendation is of classes: C, R***

8.  **Assess Readiness to Lose Weight**

> **Key Points**:

-   Knowing the patient\'s readiness to change can help the provider
    understand a patient\'s level of motivation and how to tailor
    communication about weight loss.

-   Patients 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. Record keeping or
> self-monitoring of progress on specific behaviors is key to successful
> weight management. Strategies to reduce calorie intake are to
> incorporate more fruits and vegetables into meals and snacks, make
> lower-calorie, healthy choices at the grocery store and in social
> settings, and become more aware of portion sizes consumed.
> Additionally, portion-controlled, calorie-controlled meal replacements
> may be used. Every effort needs to be made to incorporate more
> physical activity on a daily basis.
>
> Patients and physicians must realize that the culture we live in
> continues to make eating less and being more physically active
> extremely challenging. It is easy for patients to become overwhelmed
> by the process if they believe all they need is willpower. It is
> discouraging if they think they have to quit eating all of their
> favorite foods and/or do hours of grueling exercise. It is even more
> challenging if they have a high level of stress in their lives.
>
> The physician should follow the 5 A\'s (Ask, Advise, Assist, Assess,
> Arrange). Physician intervention can be effective, the physician can
> have an important influence, and successful management is possible.

-   *ASK* about, and measure height and weight. Implement an office wide
    system to ensure that for every patient, preferably on an annual
    basis, weight is measured, body mass index is calculated, and that
    patients are educated about their BMI and risk status.

-   *ADVISE* to lose weight. In a clear, strong, but sensitive and
    personalized manner, urge every overweight or obese patient to lose
    weight.

-   *ASSESS* readiness to lose weight. Ask every overweight or obese
    patient if he or she is ready to make a weight loss attempt at the
    time (e.g., within the next 30 days).

-   *ASSIST* in weight loss attempt. Help the patient with a weight loss
    plan. Refer to appropriate resources

-   *ARRANGE* follow-up. Schedule follow-up contact, either in person or
    via telephone.

> Refer to the original guideline document for more detailed information
> on the 5 As.
>
> ***Evidence supporting this recommendation is of classes: A, B, C, M,
> R***
>
> See Annotation #12, \"Reassess Goals and Risk Factors and Counsel
> Regarding Weight Maintenance.\"

9.  **Negotiate Goals and Management Strategy to Achieve Weight Loss.
    Refer to Risk Appropriate Resources as Needed**

> **Key Points**:

-   Nutrition recommendations include calorie reduction by evaluating
    portion size and number of servings recommended in the United States
    Department of Agriculture (USDA) Food Guide Pyramid.

-   The physiological effects of physical activity greatly depend on the
    frequency, duration, and intensity of movement.

-   Pharmacotherapy, when used for six months to one year, along with
    lifestyle modification including nutrition and physical activity,
    can produce weight loss in obese adults.

-   Bariatric surgery is indicated in carefully selected patients with a
    BMI greater than or equal to 40 or 35 to 39.9 who are at a very high
    absolute risk for increased morbidity or premature mortality (see
    the Table in Annotation #2 above). Patients are to be motivated,
    well-informed in disease management, psychologically stable, and
    accepting of operative risks

> **Management Recommendations Based on BMI/Risk of Disease**

  -------------------------------------------------------------------------------------------
  **BMI**                     **25 to     **30 to 34.9** **35 to     **[\>]{.underline}40**
                              29.9**                     39.9**      
  --------------------------- ----------- -------------- ----------- ------------------------
  **Risk**                    **Low**     **Moderate**   **High**    **Severe**

  **Nutrition**               **X**       **X**          **X**       **X**

  **Physical Activity**       **X**       **X**          **X**       **X**

  **Behavioral Management**   **X**       **X**          **X**       **X**

  **Medication**              **\*X**     **X**          **X**       **X**

  **Surgery**                 ** **       ** **          **\*X**     **X**
  -------------------------------------------------------------------------------------------

> \*May be considered if concomitant obesity-related risk factors or
> diseases are present.
>
> **Nutrition (Balanced healthy eating plan or lower calorie balanced
> eating plan)**

1.  Encourage at least 5 servings of fruits and vegetables per day,
    whole grains with a fiber intake of 35 grams or more daily, less
    than or equal to 30% of calories from fat (7 to 10% as saturated and
    trans fat).

2.  For weight loss, encourage calorie reduction by evaluating portion
    sizes and number of servings recommended.

3.  Provide tips for managing eating in social situations, dining out,
    take-out foods, and food label reading.

4.  Provide referral to a dietitian, nutritionist, or structured
    medically supervised nutrition program if available.

> Refer to the original guideline document for additional information on
> Nutrition Assessment and Therapy, including the following topics:

-   Diet history or eating pattern history

-   Nutrition assessment

-   Nutrition recommendations

-   Nutrition outcomes and goals

> **Physical Activity**

1.  Minimally, all patients should be encouraged to do at least 10
    minutes of physical activity above what they are already doing each
    day and gradually increase the amount of time, followed by an
    increase in intensity.

2.  Ideally, all patients should meet the current recommendations of 30
    to 60 minutes of moderate intensity activity on most days per week.

3.  Patients with chronic activity limitations (e.g., arthritis,
    respiratory dysfunction, neuropathy, morbid obesity) should be
    evaluated and managed to establish or enhance patient mobility.

4.  Provide tips for adding small bouts of physical activity to daily
    activities, for example, taking the stairs, parking farther away,
    exercising while watching TV. Activity breaks from screens (TV,
    computer, other media screens) is also important.

> Refer to the original guideline document for additional information on
> Physical Activity, including the following topics:

-   Specific roles for physical activity in obesity

-   Prevention of obesity

-   Acute weight loss

-   Long-term weight maintenance

-   Metabolic fitness with or without weight loss

-   Physical activity prescription

-   Frequency

-   Duration

-   Intensity

> **Behavioral Management**

1.  Identify behaviors that may lead to increased weight gain, for
    example: stress, emotional eating, boredom.

2.  Help patients set specific, measurable, time-limited goals to
    decrease calorie intake and increase physical activity as
    appropriate.

3.  Suggest patients weigh themselves weekly and record on a daily bases
    the amount and type of food/beverages consumed and physical activity
    completed.

4.  Provide support and encourage patients to also seek support from
    family, friends, and support groups in order to assist them with
    their eating, activity, and weight goals.

> Refer to the original guideline document for additional information on
> Behavioral Management, including the following topics:

-   Self-monitoring of weight, nutrition, and activity

-   Teach life skills

-   Additional behavioral modification strategies that play a key role
    in successful weight loss and maintenance including:

    -   Stimulus control

    -   Cognitive restructuring

    -   Goal setting

    -   Problem solving

    -   Social support

    -   Relapse prevention

> **Medications (Pharmacologic Therapy)**

1.  The short-term use of drugs (less than 3 months) has not generally
    been found to be effective.

2.  Pharmacotherapy should only be included in the context of a
    comprehensive treatment strategy.

3.  Sibutramine and Orlistat are safe for most patients when carefully
    monitored by a physician and may be part of a program for weight
    management or maintenance, which should include nutrition and
    physical activity when indicated.

> Refer to the original guideline document for additional information on
> Pharmacologic Therapy, including the following topics:

-   Safety and adverse effects (see also \"Potential Harms\" field in
    this summary)

-   Drug interactions (see also \"Potential Harms\" field in this
    summary)

-   Efficacy

-   Therapeutics

-   Patient monitoring

-   Nonprescription and natural medications (see also Appendix F in the
    original guideline document)

> **Surgery**

1.  Bariatric surgery is indicated in carefully selected patient (see
    \"Key points\" above)

> Refer to the original guideline document for additional information on
> Surgical Management, including the following topics:

-   Patient selection

-   Contraindications for surgery (see also the \"Contraindications\"
    field of this summary)

-   Evidence

-   Restrictive procedures, including:

    -   Vertical banded gastroplasty

    -   Laparoscopic adjustable gastric band

-   Malabsorptive procedures, including:

    -   Biliopancreatic diversion

    -   Duodenal switch

    -   Roux-en-Y gastric bypass

-   Surgical procedure selection process

-   Resolution of comorbidities

-   Measurement of success and failure

-   Adolescent bariatric surgery

-   The patient process

-   Medical evaluation including obstructive sleep apnea, preoperative
    weight loss, and cholelithiasis

-   Postoperative care

-   Nutrition recommendations, including:

    -   Gastric bypass diet progression

    -   Strategies to maintain success with weight management

-   Suggested requirements for bariatric surgery facilities

-   Suggested minimum requirements for bariatric surgeons

12. **Reassess Goals and Risk Factors and Counsel Regarding Weight
    Maintenance**

> **Key Points**:

-   Follow-up and long-term management of weight loss is crucial.

-   The primary care physician also may serve as a community leader and
    a public health advocate.

> 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 affords the opportunity for
> monitoring BMI as well as evaluation and management of any of the
> common complications that are often associated with obesity.
>
> A general recommendation of visits every 3 months is based on expert
> opinion, and may be varied to meet the particular needs of individual
> patients.

**[Definitions]{.underline}**:

**Conclusion Grades**:

**Grade I**: The evidence consists of results from studies of strong
design for answering the question addressed. The results are both
clinically important and consistent with minor exceptions at most. The
results are free of any significant doubts about generalizability, bias,
and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.

**Grade II**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is some
uncertainty attached to the conclusion because of inconsistencies among
the results from the studies or because of minor doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from weaker
designs for the question addressed, but the results have been confirmed
in separate studies and are consistent with minor exceptions at most.

**Grade III**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is substantial
uncertainty attached to the conclusion because of inconsistencies among
the results of different studies or because of serious doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from a
limited number of studies of weak design for answering the question
addressed.

**Grade Not Assignable**: There is no evidence available that directly
supports or refutes the conclusion.

**Classes of Research Reports**:

A.  Primary Reports of New Data Collection:

> Class A:

-   Randomized, controlled trial

> Class B:

-   Cohort study

> Class C:

-   Non-randomized trial with concurrent or historical controls

-   Case-control study

-   Study of sensitivity and specificity of a diagnostic test

-   Population-based descriptive study

> Class D:

-   Cross-sectional study

-   Case series

-   Case report

B.  Reports that Synthesize or Reflect upon Collections of Primary
    Reports:

> Class M:

-   Meta-analysis

-   Systematic review

-   Decision analysis

-   Cost-effectiveness analysis

> Class R:

-   Consensus statement

-   Consensus report

-   Narrative review

> Class X:

-   Medical opinion

#### CLINICAL ALGORITHM(S)

A detailed and annotated clinical algorithm is provided in the original
guideline document for [Prevention and Diagnosis of
Obesity](http://www.guideline.gov/algorithm/5389/NGC-5389.html).

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is classified for selected
recommendations (see \"Major Recommendations.\")

In addition, key conclusions contained in the Work Group\'s algorithm
are supported by a grading worksheet that summarizes the important
studies pertaining to the conclusion. The type and quality of the
evidence supporting these key recommendations is graded for each study.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved awareness of obesity through documentation of body mass
    index (BMI)

-   Improved outcomes in the treatment for obesity

-   Improved community involvement in the prevention and treatment of
    obesity

-   Improved education and counsel regarding weight loss

#### POTENTIAL HARMS

**Safety and Adverse Effects**

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:

-   Adjusting dosage and administration schedules

-   Identifying patients at high risk for adverse effects and selecting
    drug therapy accordingly

-   Providing patient education and monitoring for adverse effects at
    the beginning of therapy or when making dosage adjustments

Infrequent, but potentially serious, adverse effects can also occur much
later in the course of therapy.

*Sibutramine*

The adverse effects associated with *sibutramine* include abnormal
electrocardiogram (ECG), hypertension, palpitations, tachycardia, dry
mouth (17%), headache (30%), insomnia (10%), anorexia (13%), and
constipation (11.5%).

Combinations of sibutramine and other serotonergic drugs should be
avoided. If such a combination is used, patients should be informed
about the signs and symptoms of serotonin syndrome, which include
excitement, hypomania, restlessness, loss of consciousness, confusion,
disorientation, anxiety, agitation, motor weakness, myoclonus, tremor,
hyperreflexia, ataxia, incoordination, hyperthermia, shivering pupillary
dilation, diaphoresis, emesis, and tachycardia.

*Orlistat*

The adverse events of *orlistat* are mainly gastrointestinal (GI)
including abdominal pain/discomfort, oily spotting, flatulence, fecal
urgency, oily stool, oily evacuation, increased defecation, fecal
incontinence.

Orlistat has also been shown to reduce serum concentrations of
fat-soluble vitamins (vitamins A, D, E, and K).

*Combination Drug Therapy*

The practice of combination drug therapy may increase the frequency of
adverse events. There is also a lack of safety data on the use of
combination therapy. Until data is available, it would be more prudent
to use weight loss medications as single agents. Using the lowest
possible effective dose may also reduce the chance of an adverse event.

Refer to Appendix D, \"Adverse Effects of FDA Approved Medications for
the Treatment of Obesity\" and Appendix E, \"Drug Interactions of FDA
Approved Medications for Treatment of Obesity\" in the original
guideline document for more information on adverse effects of these and
other medications.

**Complications of Surgical Procedures**

-   *Vertical Banded Gastroplasty* (VBG) may cause outlet obstruction or
    gastroesophageal reflux; food intolerance, especially to meat and
    breads; persistent vomiting. VBG has been replaced with newer
    techniques and is rarely performed due to failure in up to 79% of
    patients at 10 years.

-   *Laparoscopic Adjustable Banding* is associated with erosion (0.15%)
    and slippage of the band (1.5%); port and tubing complication (8%);
    mortality rate: less than 0.2%

-   *Biliopancreatic Diversion/Duodenal Switch* (BPD/DS) is associated
    with nutritional complications including iron deficiency (9% to
    52%), B12 deficiency (11%), protein malnutrition and diarrhea. There
    is also a significant incidence of marginal ulceration, leak,
    bleeding, stenosis of the duodenoileostomy, and internal hernia
    formation with this operation.

-   *Roux-en-Y Gastric Bypass* (RYGB) may cause iron, vitamin B12, and
    folate deficiency; up to 76% incidence of dumping syndrome
    characterized by the presence of nausea, lightheadedness, the urge
    to lie down and palpitations. Technical complications include leaks
    (3%), internal bleeding (1%), anastomotic stenosis (2% to 20%),
    internal hernia formation (1% to 5%), and wound infection (6.6%).
    The incidence of marginal ulceration can be as high as 15%. Severe
    life-threatening complications appear to be influenced by gender and
    by weight and age. Mortality rate: 0.5%.

**Emergencies of Surgical Procedures**

-   *Pulmonary Embolus* is the most common fatal complication from
    weight loss surgery, and the risk extends more than 90 days from
    surgery in the high-risk group. The patient may present to primary
    care or a remote emergency room (ER).

*Gastric Bypass Procedure or Malabsorptive Procedures*

-   *Closed Loop Bowel Obstruction* with Roux-en-Y may present with
    subtle or no findings beyond symptoms. Computed tomography (CT) is
    unreliable for diagnosis, and diagnostic laparoscopy may be
    required. Early consultation with a surgeon who is familiar with
    these issues can avoid catastrophe.

-   *Anastomotic Leak* or perforation of marginal ulcer may present with
    equivocal symptoms and subtle findings. Any sustained tachycardia
    greater than 120 mandates bariatric surgical consultation prior to
    or concurrent with cardiac workup. A patient\'s sense of \"impending
    doom\" should be taken very seriously.

-   *Neuropathy/encephalopathy* - usually in setting of intractable
    vomiting and noncompliance with supplemental vitamins (after RYGB or
    BPD/DS).

*Laparoscopic Adjustable Band*

-   *Slip or erosion* often presents as nighttime reflux or abdominal
    pain. Peritoneal signs are usually absent. Port site infection also
    requires surgical care.

Refer to the original guideline document for more information on
complications of surgical procedures.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Contraindications to Medications**

*Sibutramine* is contraindicated in patients with anorexia nervosa,
concomitant monoamine oxidase (MAO) inhibitor use, concomitant use of
centrally acting appetite suppressants, use of other serotonergic drugs,
coronary heart disease, congestive heart failure, stroke, arrhythmia,
uncontrolled hypertension, history of substance abuse, pregnancy, or
lactation.

*Orlistat* is contraindicated in patients with cholestasis, chronic
malabsorption syndrome, clinically significant gastrointestinal (GI)
disease, and patients at risk for fat-soluble vitamin deficiency.

Refer to Annotation Appendix D \"Adverse Effects of FDA Approved
Medications for the Treatment of Obesity\" in the original guideline
document for contraindications to other drugs.

**Contraindications for Surgery**

The decision to use surgery to manage morbid obesity requires the
surgeon to weigh the risks against the sustained benefits of the
surgical procedure. On occasion, the risk of not having bariatric
surgery may be greater than the risk of a contraindication.

*Strong Contraindications*

1.  Life-threatening multi-system organ failure

2.  Uncontrolled or metastatic malignancy, or other serious medical
    illness where caloric restriction may compromise the patient

3.  Uncontrolled human immunodeficiency virus (HIV) infection

4.  Hypercarbic respiratory failure

5.  Active systemic infection

6.  Untreated endocrine dysfunction

7.  Pregnancy and/or lactation

8.  Current abuse of alcohol or other substances

9.  Severe or unstable psychiatric illness that would prevent adjustment
    to the surgical procedure

*Relative Contraindications*

1.  Reversible obstructive sleep apnea (that can be medically optimized
    before surgery)

2.  Presence of severe liver, renal or gastrointestinal disease

3.  Current tobacco abuse (nicotine addiction)

4.  Binge eating at an average frequency of twice a week for the past
    six months

5.  Problems with impulse control

6.  Documented history of noncompliance (either medical or psychosocial)

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These clinical guidelines are designed to assist clinicians by
    providing an analytical framework for the evaluation and treatment
    of patients, and are not intended either to replace a clinician\'s
    judgment or to establish a protocol for all patients with a
    particular condition. A guideline will rarely establish the only
    approach to a problem.

-   This guideline should not be construed as medical advice or medical
    opinion related to any specific facts or circumstances. Patients are
    urged to consult a health care professional regarding their own
    situations and any specific medical questions.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Once a guideline is approved for general implementation, a medical group
can choose to concentrate on the implementation of that guideline. When
four or more groups choose the same guideline to implement and they wish
to collaborate with others, they may form an action group.

In the action group, each medical group sets specific goals they plan to
achieve in improving patient care based on the particular guideline(s).
Each medical group shares its experiences and supporting measurement
results within the action group. This sharing facilitates a
collaborative learning environment. Action group learnings are also
documented and shared with interested medical groups within the
collaborative.

Currently, action groups may focus on one guideline or a set of
guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented in the original guideline
document to help close the gap between clinical practice and the
guideline recommendations. Summaries of the measures are provided in the
National Quality Measures Clearinghouse (NQMC).

**Key Implementation Recommendations**

The following system changes were identified by the guideline work group
as key strategies for health care systems to incorporate in support of
the implementation of this guideline.

1.  Establish a system for using a \"Patient Readiness Scale.\" The
    scale can be used to determine if the patient is \"ready\" to talk
    about weight loss and/or would like information.

2.  Establish a system for staff to calculate body mass index (BMI)
    prior to the physician entering the exam room. This action may be
    considered a vital sign and built into the rooming protocol.

3.  Develop tracking systems to produce periodic audits for use in
    developing solutions to identified problems.

4.  Establish a system for staff and physician training around skills
    and knowledge in the areas of motivational interviewing; brief,
    focused advice on nutrition, physical activity and lifestyle
    changes; and evaluation of evidence of effectiveness of treatment
    options.

5.  Establish a system for continuing education on evidence-based
    obesity management for providers, nurses, and ancillary clinic
    staff.

6.  Remove barriers to referral programs for weight loss. Know where
    your resources are and what processes are required: for example, if
    your organization refers patients to an outside source, what are the
    criteria for referral?

7.  Develop medical record systems to track status of patients under the
    provider\'s care with the capability to produce a tickler system for
    patient follow-up by provider/staff.

8.  Use tools such as posters and brochures throughout the facility to
    promote healthy life style around nutrition and activity while
    encouraging patient knowledge of their BMI.

9.  Develop patient-centered education and self-management programs,
    which may include self-monitoring, self-management, and skills such
    as journaling.

10. Outcomes measurement:

    -   Build systems for outcomes measures, as well as ongoing process
        measures.

    -   Response rate to various treatments/strategies.

    -   Improvement rates -- the BMI is stable or has decreased over
        time.

11. Systems to coordinate care ensure continuity and keep providers
    informed of progress.

    -   Build electronic systems or tickler system (if no electronic
        medical record \[EMR\]).

    -   Educate patients to foster awareness and knowledge of BMI for
        self-monitoring and reporting.

    -   Structure follow-up visits with patient per guideline
        recommendations.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Patient Resources\
Pocket Guide/Reference Cards\
Quality Measures\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

#### RELATED NQMC MEASURES

-   [Prevention and management of obesity (mature adolescents and
    adults): percentage of patients with a documented Body Mass Index
    (BMI) equal to or greater than 25 who were given education and
    counsel for weight loss
    strategies.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=10232)

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Prevention and
management of obesity (mature adolescents and adults). Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2006 Nov. 105 p.
\[226 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Nov (revised 2006 Nov)

#### GUIDELINE DEVELOPER(S)

Institute for Clinical Systems Improvement - Private Nonprofit
Organization

#### GUIDELINE DEVELOPER COMMENT

Organizations participating in the Institute for Clinical Systems
Improvement (ICSI): Affiliated Community Medical Centers, Allina Medical
Clinic, Altru Health System, Aspen Medical Group, Avera Health,
CentraCare, Columbia Park Medical Group, Community-University Health
Care Center, Dakota Clinic, ENT Specialty Care, Fairview Health
Services, Family HealthServices Minnesota, Family Practice Medical
Center, Gateway Family Health Clinic, Gillette Children\'s Specialty
Healthcare, Grand Itasca Clinic and Hospital, HealthEast Care System,
HealthPartners Central Minnesota Clinics, HealthPartners Medical Group
and Clinics, Hutchinson Area Health Care, Hutchinson Medical Center,
Lakeview Clinic, Mayo Clinic, Mercy Hospital and Health Care Center,
MeritCare, Mille Lacs Health System, Minnesota Gastroenterology,
Montevideo Clinic, North Clinic, North Memorial Care System, North
Suburban Family Physicians, Northwest Family Physicians, Olmsted Medical
Center, Park Nicollet Health Services, Pilot City Health Center, Quello
Clinic, Ridgeview Medical Center, River Falls Medical Clinic, Saint
Mary\'s/Duluth Clinic Health System, St. Paul Heart Clinic, Sioux Valley
Hospitals and Health System, Southside Community Health Services,
Stillwater Medical Group, SuperiorHealth Medical Group, University of
Minnesota Physicians, Winona Clinic, Ltd., Winona Health

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425;
telephone, (952) 814-7060; fax, (952) 858-9675; e-mail:
<icsi.info@icsi.org>; Web site: [www.icsi.org](http://www.icsi.org/).

#### SOURCE(S) OF FUNDING

The following Minnesota health plans provide direct financial support:
Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica,
Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind
support is provided by the Institute for Clinical Systems Improvement\'s
(ICSI) members.

#### GUIDELINE COMMITTEE

Committee on Evidence-Based Practice

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Work Group Members*: David Hanekom, MD (Work Group Leader) (MeritCare)
(Internal Medicine); Julie Roberts, MS, RD (HealthPartners Medical
Group) (Dietitian); Kate Pyzdrowski, MD (NorthPoint Health & Wellness
Center) (Endocrinology); Kathryn Nelson, MD (Affiliated Community
Medical Center) (Family Practice); Patrick O\'Connor, MD (HealthPartners
Medical Group) (Family Practice); Andrea Carruthers, RN (Affiliated
Community Medical Center) (Nursing); George Biltz, MD (HealthPartners
Medical Group) (Pediatrics); Kathy Johnson, PharmD (St. Mary\'s/Duluth
Clinic) (Pharmacy); Nancy Sherwood, PhD (HealthPartners Research
Foundation) (Psychology); Walt Medlin, MD (St. Mary\'s/Duluth Clinic)
(Surgery); Penny Fredrickson (Institute for Clinical Systems
Improvement) (Measurement/Implementation Advisor); Pam Pietruszewski, MA
(Institute for Clinical Systems Improvement) (Facilitator)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

In the interest of full disclosure, Institute for Clinical Systems
Improvement (ICSI) has adopted the policy of revealing relationships
work group members have with companies that sell products or services
that are relevant to this guideline topic. The reader should not assume
that these financial interests will have an adverse impact on the
content of the guideline, but they are noted to fully inform readers.
Readers of the guideline may assume that only work group members listed
below have potential conflicts of interest to disclose.

No work group members have potential conflicts of interest to disclose.

ICSI\'s conflict of interest policy and procedures are available for
review on ICSI\'s website at [www.icsi.org](http://www.icsi.org/).

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical
Systems Improvement (ICSI). Prevention and management of obesity (mature
adolescents and adults). Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Nov. 100 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Institute for Clinical Systems
Improvement (ICSI) Web
site](http://www.icsi.org//guidelines_and_more/guidelines__order_sets___protocols/).

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Prevention and management of obesity (mature adolescents and
    adults). Executive summary. Bloomington (MN): Institute for Clinical
    Systems Improvement, 2006 Nov. 1 p. Electronic copies: Available
    from the [Institute for Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/preventive_health_maintenance/obesity/obesity__prevention_and_management_of__mature_adolescents_and_adults___.html).

-   Body mass index-for-age percentiles. Appendix A in the original
    guideline document. Electronic copies: Available from the [Institute
    for Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/preventive_health_maintenance/obesity/obesity__prevention_and_management_of__mature_adolescents_and_adults___.html).

-   Physical activity prescription. Appendix H in the original guideline
    document. Electronic copies: Available from the [Institute for
    Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/preventive_health_maintenance/obesity/obesity__prevention_and_management_of__mature_adolescents_and_adults___.html).

-   ICSI pocket guidelines. April 2006 edition. Bloomington (MN):
    Institute for Clinical Systems Improvement, 2006. 298 p.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### PATIENT RESOURCES

The following is available:

-   Prevention and management of obesity (mature adolescents and
    adults). Bloomington (MN): Institute for Clinical Systems
    Improvement, 2006 Nov. 50 p.

Electronic copies: Available from the [Institute for Clinical Systems
Improvement (ICSI) Web
site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/for_patients_families/obesity__mature_adolescents_and_adults___prevention___management_of__for_patients___families_.html).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on January 12, 2005. It was
updated by ECRI on January 11, 2006 and January 30, 2007.

#### COPYRIGHT STATEMENT

This NGC summary (abstracted Institute for Clinical Systems Improvement
\[ICSI\] Guideline) is based on the original guideline, which is subject
to the guideline developer\'s copyright restrictions.

The abstracted ICSI Guidelines contained in this Web site may be
downloaded by any individual or organization. If the abstracted ICSI
Guidelines are downloaded by an individual, the individual may not
distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization,
copies may be distributed to the organization\'s employees but may not
be distributed outside of the organization without the prior written
consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are
reserved by the Institute for Clinical Systems Improvement, Inc. The
Institute for Clinical Systems Improvement, Inc. assumes no liability
for any adaptations or revisions or modifications made to the abstracts
of the ICSI Guidelines.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
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<http://www.guideline.gov/about/inclusion.aspx> .

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Readers with questions regarding guideline content are directed to
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Date Modified: 11/3/2008