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## Complete Summary

#### GUIDELINE TITLE

VA/DoD clinical practice guideline for screening and management of
overweight and obesity.

#### BIBLIOGRAPHIC SOURCE(S)

Management of Overweight and Obesity Working Group. VA/DoD clinical
practice guideline for screening and management of overweight and
obesity. Washington (DC): Department of Veterans Affairs, Department of
Defense; 2006. 117 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### 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)

Overweight and Obesity

#### GUIDELINE CATEGORY

Counseling\
Diagnosis\
Evaluation\
Management\
Screening\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Endocrinology\
Family Practice\
Internal Medicine\
Nursing\
Nutrition\
Pharmacology\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To describe the critical decision points in the management of
    obesity

-   To provide a clear and comprehensive guideline incorporating current
    information and evidence based practice recommendations for
    practitioners throughout the Department of Defense and Veterans
    Health Administration system

-   To improve local management of patients with obesity and improve
    patient outcome

#### TARGET POPULATION

Adults (age 18 years or older) with overweight or obesity who are
eligible for care in the Veterans Affairs (VA) or Department of Defense
(DoD) health care delivery system

**Note**: This guideline is not directed to the treatment of children,
adolescents (less than age 18) or pregnant/lactating women.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening**

1.  Measurement of height and weight ; calculation of body mass index
    (BMI)

2.  Measurement of waist circumference

3.  Determination of presence of obesity-associated health conditions

4.  Promotion of healthy lifestyles in low-risk and normal weight
    patients

5.  Annual screenings

**Assessment**

1.  Medical history, physical examination, and laboratory tests (fasting
    lipid profile, liver function tests \[LFTs\], fasting glucose) as
    indicated

2.  Social and psychological assessment

3.  Assessment of patient readiness to lose weight

4.  Incorporation of patient preferences in the treatment goals and plan

**Treatment/Management**

1.  Initiation of interventions based on risk level and patient
    preference

2.  Interventions that include diet therapy, increased exercise, and
    behavioral modification

3.  Pharmacotherapy (orlistat, sibutramine) in combination with a
    reduced-calorie diet and exercise interventions

4.  Bariatric surgery

5.  Assessment of response to therapy and adjustment of therapy to meet
    treatment goals

6.  Interventions for weight maintenance, relapse prevention (e. g.
    maintenance program, encouragement, medication), and follow-up

7.  Motivation of overweight or obese patients who are not ready to
    undertake weight loss

#### MAJOR OUTCOMES CONSIDERED

-   Incidence and severity of obesity-associated conditions

-   Obesity related morbidity and mortality

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

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

**Formulating of Questions**

The Working Group developed researchable questions and associated key
terms after orientation to the scope of the guideline and to goals that
had been identified by the Working Group. The questions specified
(adapted from the Evidence-Based Medicine (EBM) toolbox, Center for
Evidence-Based Medicine,
\[[http://www.cebm.net](http://www.cebm.net/)\]):

-   **P**opulation -- Characteristics of the target patient population

-   **I**ntervention -- Exposure, diagnostic, or prognosis

-   **C**omparison -- Intervention, exposure, or control used for
    comparison

-   **O**utcome -- Outcomes of interest

These specifications served as the preliminary criteria for selecting
studies. Research questions focused on the following areas of inquiry:
screening; risk assessment; and treatment strategies for weight loss
including diet, exercise and behavioral modification, drug therapy, and
bariatric surgery.

**Selection of Evidence**

Published, peer-reviewed randomized controlled trials (RCTs) were
considered to constitute the strongest level of evidence in support of
guideline recommendations. This decision was based on the judgment that
RCTs provide the clearest, scientifically sound basis for judging
comparative efficacy. The Working Group made this decision recognizing
the limitations of RCTs, particularly considerations of generalizability
with respect to patient selection and treatment quality. Evidence-based
systematic reviews were considered to be the strongest level of evidence
as well as meta-analyses that included randomized controlled studies.
The evidence selection was designed to identify the best available
evidence to address each key question and ensured maximum coverage of
studies at the top of the hierarchy of study types: evidence-based
guidelines, meta-analyses, and systematic reviews. When available, the
search sought out critical appraisals already performed by others that
described explicit criteria for deciding what evidence was selected and
how it was determined to be valid. The sources that have already
undergone rigorous critical appraisal include Cochrane Reviews, Best
Evidence, Technology Assessment, and Evidence-based Practice Center
(EPC) reports.

The search was performed using the National Library of Medicine\'s (NLM)
Medline database. The terms \"obesity\", \"weight gain\", \"body mass
index\" and \"overweight\" were used together with the following Boolean
expressions and terms:

-   Screening

-   Lifestyle

-   Caloric restriction, diet

-   Behavioral therapy

-   Anti-obesity agents

-   Gastric bypass

-   Patient education

-   Human, adults

In addition to Medline/PubMed, the following databases were searched:
Database of Abstracts of Reviews of Effectiveness (DARE) and Cochrane
Central Register of Controlled Trials (CCTR). For Medline/PubMed
searches, limits were set for language (English), date of publication
(1995 through 2004) and type of research (RCT, systematic reviews and
meta-analysis).

Once definitive reviews or clinical studies that provided valid relevant
answers to the question were identified, the search ended. The search
was extended to studies/reports of lower quality (observational studies)
only if there were no high-quality studies.

Exclusion criteria included reviews that omitted clinical course or
treatment. Some retrieved studies were rejected on the basis of
published abstracts, and a few were rejected after the researchers
scanned the retrieved citation for inclusion criteria. Typical
exclusions included studies with physiological endpoints or studies of
populations that were not comparable to the population of interest
(e.g., studies of obesity in children). The bibliographies of the
retrieved articles were hand-searched for articles that may have been
missed by the computer search. Working Group members also contributed
articles as part of the evidence gathering process.

The results of the search were organized and evidence reports as well as
copies of the original studies were provided to the Working Group for
further analysis.

**Literature Review and Inclusion Criteria**

As a result of the original and updated literature reviews, articles
were identified for possible inclusion. These articles formed the basis
for formulating the guideline recommendations. The following inclusion
criteria were used for selecting randomized controlled trial studies:

-   Articles published between 1995 and 2004, with some exceptions

-   English language only

-   Full articles only

-   Age limited to adults greater than 18 years

-   Randomized controlled trials only; no cross-over trials

-   Minimum 6 months of follow-up

-   Baseline body mass index (BMI) or body weight levels reported

-   Key outcomes cited (decrease in body weight, BMI)

For some questions, special inclusion criteria (mostly related to
minimum clinical trial size) were developed based upon research question
content and available literature.

The literature search for the guideline update was validated by: (1)
comparing the results to a search conducted by the independent research
and appraisal team, (2) a review of the database by the expert panel,
and (3) requesting articles pertaining to special topics from the
experts in the Working Group.

#### 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

**Quality of Evidence (QE)**

  ---------- -------------------------------------------------------------------
  **I**      At least one properly done randomized controlled trial (RCT)

  **II-1**   Well designed controlled trail without randomization

  **II-2**   Well designed cohort or case-control analytic study, preferably
             from more than one source

  **II-3**   Multiple time series evidence with/without intervention, dramatic
             results of uncontrolled experiment

  **III**    Opinion of respected authorities, descriptive studies, case
             reports, and expert committees
  ---------- -------------------------------------------------------------------

**Overall Quality**

  ---------- -----------------------------------------------------------------
  **Good**   High grade evidence (I or II-1) directly linked to health outcome

  **Fair**   High grade evidence (I or II-1) linked to intermediate outcome;\
             \
             *or*\
             \
             Moderate grade evidence (II-2 or II-3) directly linked to health
             outcome

  **Poor**   Level III evidence or no linkage of evidence to health outcome
  ---------- -----------------------------------------------------------------

**Net Effect of the Intervention**

  ------------------ ---------------------------------------------------------
  **Substantial:**   More than a small relative impact on a frequent condition
                     with a substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A large impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Moderate:**      A small relative impact on a frequent condition with a
                     substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A moderate impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Small:**         A negligible relative impact on a frequent condition with
                     a substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A small impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Zero or          Negative impact on patients;\
  Negative:**        \
                     *or*\
                     \
                     No relative impact on either a frequent condition with a
                     substantial burden of suffering, *or* an infrequent
                     condition with a significant impact on the individual
                     patient level.
  ------------------ ---------------------------------------------------------

#### 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

**Preparation of Evidence Tables (Reports) and Evidence Rating**

A group of research analysts with experience in evidence-based appraisal
independently read and coded each article that met inclusion criteria.
The articles have been assessed for methodological rigor and clinical
importance using the following criteria:

-   Appropriateness of inclusion and exclusion criteria

-   Concealment of allocation

-   Blinding of patients, interventions and providers

-   Objective method of data collection

-   Valid method of data analysis

-   Completeness and length of follow-up

-   Appropriateness of outcome measures

-   Statistical power of results

The information was synthesized and reported in a brief summary of the
critical appraisal of each article that included the following
components:

-   Description of patient population

-   Interventions

-   Comparisons

-   Outcomes

-   Summary of results

-   Analysis of findings

-   Evidence appraisal

-   Clinical significance

Quality of evidence ratings were assigned for each source of evidence
using the grading scale presented in \"Rating Scheme for the Strength of
the Evidence\" in this summary.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The development of the Screening and Management of Overweight and
Obesity Guideline was initiated in January 2005 and continued through
August 2005. The development process followed the steps described in
\"Guideline for Guidelines,\" an internal working document of Veterans
Health Affairs\' (VHA\'s) National Clinical Practice Guideline Council,
which requires an on-going review of the work in progress. The Working
Group of the VHA/Department of Defense (DoD) was charged to provide
evidence-based action recommendations whenever possible; hence, major
clinical randomized controlled trials (RCTs) and observational studies
published from 1995 through December 2004 in the areas of diagnosis and
treatment of overweight and obesity were used.

**Guideline Development Process**

The Offices of Quality and Performance and Patient Care Services, in
collaboration with the network Clinical Managers, the Deputy Assistant
Under Secretary for Health, and the Medical Center Command of the DoD
identified clinical leaders to champion the guideline development
process. During a preplanning conference call, the clinical leaders
defined the scope of the guideline and identified a group of clinical
experts from the VA and DoD that formed the Guideline Development
Working Group. Working Group members included representatives of the
following specialties: internal medicine, cardiology, surgery,
endocrinology, medical nutrition therapy, social work, family practice,
nursing, pharmacy, and healthcare systems management and policy.

As a first step, the guideline development groups defined a set of
clinical questions within the area of the guideline. This ensured that
the guideline development work outside the meeting focused on issues
that practitioners considered important and produced criteria for the
search and the protocol for systematic review and, where appropriate,
meta-analysis.

The Working Group participated in an initial face-to-face meeting to
reach consensus about the guideline algorithm and recommendations and to
prepare a draft document. The draft continued to be revised by the
Working Group at-large through numerous conference calls and individual
contributions to the document. Following the initial effort, an
editorial panel of the Working Group convened to further edit the draft
document. Recommendations for the performance or exclusion of specific
procedures or services were derived through a rigorous methodological
approach that included the following:

-   Determining appropriate criteria, such as effectiveness, efficacy,
    population benefit, or patient satisfaction

-   Reviewing literature to determine the strength of the evidence in
    relation to these criteria

-   Formulating the recommendations and grading the level of evidence
    supporting the recommendation

**Selection of Evidence**

Each reference was appraised for scientific merit, clinical relevance,
and applicability to the populations served by the Federal healthcare
system. Recommendations were based on consensus of expert opinions and
clinical experience only when scientific evidence was unavailable.

**Recommendation and Overall Quality Rating**

Evidence-based practice involves integrating clinical expertise with the
best available clinical evidence derived from systematic research. The
Working Group received an orientation and tutorial on the evidence U.S.
Preventive Services Task Force (USPSTF) 2001 rating process, reviewed
the evidence and independently formulated Quality of Evidence ratings, a
rating of Overall Quality (see \"Rating Scheme for the Strength of the
Evidence\" in this summary), and a Strength of Recommendation (see
\"Rating Scheme for the Strength of the Recommendations\" in this
summary).

**Lack of Evidence -- Consensus of Experts**

The majority of the literature supporting the science for these
guidelines is referenced throughout the document and is based upon
systematic reviews and technology assessment that serve as the basis for
other evidence-based guidelines for overweight and obesity, and key RCTs
and longitudinal studies published from 1995 through 2004. Following the
independent review of the evidence, a consensus meeting was held to
discuss discrepancies in ratings and formulate recommendations. Where
existing literature was ambiguous or conflicting, or where scientific
data was lacking on an issue, recommendations were based on the clinical
experience of the Working Group. These recommendations are indicated in
the evidence tables as based on \"Working Group Consensus.\").

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

  -------------------------------------------------------------------------------------
                       *The net benefit                             
                       of the                                       
                       intervention*                                
  -------------------- ----------------- -------------- ----------- -------------------
  *Quality of          **Substantial**   **Moderate**   **Small**   **Zero or
  Evidence*                                                         Negative**

  *Good*               A                 B              C           D

  *Fair*               B                 B              C           D

  *Poor*               I                 I              I           I
  -------------------------------------------------------------------------------------

 

  --- -------------------------------------------------------------------
  A   A strong recommendation that the clinicians provide the
      intervention to eligible patients.\
      *Good evidence was found that the intervention improves important
      health outcomes and concludes that benefits substantially outweigh
      harm.*

  B   A recommendation that clinicians provide (the service) to eligible
      patients.\
      *At least fair evidence was found that the intervention improves
      health outcomes and concludes that benefits outweigh harm.*

  C   No recommendation for or against the routine provision of the
      intervention is made.\
      *At least fair evidence was found that the intervention can improve
      health outcomes, but concludes that the balance of benefits and
      harms is too close to justify a general recommendation.*

  D   Recommendation is made against routinely providing the intervention
      to asymptomatic patients.\
      *At least fair evidence was found that the intervention is
      ineffective or that harms outweigh benefits.*

  I   The conclusion is that the evidence is insufficient to recommend
      for or against routinely providing the intervention.\
      *Evidence that the intervention is effective is lacking, or poor
      quality, or conflicting and the balance of benefits and harms
      cannot be determined.*
  --- -------------------------------------------------------------------

#### COST ANALYSIS

Published cost analyses were reviewed in the preparation of the
guideline.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Experts from the Veterans Administration (VA) and the Department of
Defense (DoD) internal medicine, cardiology and primary care reviewed
the final draft band their feedback was integrated into the final draft
document.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations for the screening and management of overweight and
obesity are organized into 3 major modules. The algorithms, objectives
and recommendations that accompany each module, and the evidence
supporting the recommendations are presented below. The quality of
evidence **(QE)** grading (I-III); overall quality (**Good, Fair,
Poor**); and final grade of recommendations **(R)** (A-D, I) are
provided for specific statements. These grades, along with \"net effect
of the interventions\" are defined at the end of the \"Major
Recommendations\" field.

*Note: A list of all abbreviations is provided at the end of the \"Major
Recommendations\" field*.

**Module A: Screening for Overweight and Obesity**

[**Screening
Algorithm**](http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/content/algorithms/algoA.htm)

A.  **Adult Person Enrolled in the Veterans Health Administration (VHA)
    or Department of Defense (DoD) Healthcare Systems**

> *Definition*
>
> Any adult eligible for care in the VHA or the (DoD) healthcare
> delivery system should be screened and if necessary, treated for
> overweight or obesity as described in this guideline.

B.  **Obtain Height and Weight; Calculate Body Mass Index (BMI)**

> *Objective*
>
> Screen all adults for overweight or obesity.
>
> *Recommendations*:

1.  Adult patients should have their BMI calculated from their height
    and weight to establish a diagnosis of overweight or obesity.
    **\[B\]**

2.  Obese patients (BMI [\>]{.underline}30 kg/m^2^) should be offered
    weight loss treatment. **\[B\]** (See Module B: Treatment for Weight
    Loss and Weight Maintenance)

3.  Overweight patients (BMI between 25 and 29.9 kg/m^2^) or patients
    with increased waist circumference (\>40 inches for men; \>35 inches
    for women) should be assessed for the presence of obesity-associated
    conditions that are directly influenced by weight, to determine the
    benefit they might receive from weight loss treatment. **\[B\]**

4.  Normal weight patients (BMI between 18.5 and 24.9 kg/m^2^) should be
    provided with education regarding healthy lifestyle behaviors,
    advised of their BMI and their weight range margins, and instructed
    to return for further evaluation should those margins be exceeded.
    **\[Expert Opinion\]**

  -------------------------------------------------------------------------------------------
  **Classification**   **BMI (kg/m^2^)**    **Disease Risk with      **Disease Risk with
                                            Normal Waist             Excessive Waist
                                            Circumference**          Circumference**
  -------------------- -------------------- ------------------------ ------------------------
  Underweight          \<18.5               \-                       \-

  Normal               18.5-24.9            \-                       \-

  Overweight           25.0-29.9            Increased                Moderate

  Obese I              30-34.9              Moderate                 Severe

  Obese II             35.0-39.9            Severe                   Very Severe

  Obese III            [\>]{.underline}40   Very Severe              Very Severe
  -------------------------------------------------------------------------------------------

 

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Adult patients should     McTigue et al., 2003\       I        Fair        B
          have their BMI calculated National Heart, Lung, and                        
          from their height and     Blood Institute (NHLBI),                         
          weight.                   1998\                                            
                                    U.S. Preventive Services                         
                                    Task Force (USPSTF), 2003\                       
                                    World Health Organization                        
                                    (WHO), 2000                                      

  2       Overweight adults (BMI    McTigue et al., 2003\       I        Fair        B
          between 25 and 29.9       NHLBI, 1998\                                     
          kg/m^2^) should be        Strawbridge et al., 2000\                        
          assessed for other risk   USPSTF, 2003\                                    
          factors to determine if   WHO, 2000                                        
          they need treatment for                                                    
          overweight.                                                                

  3       Obese patients should be  Heiat, Vaccarino, &         I        Good        B
          offered weight loss       Krumholz, 2001\                                  
          treatment.                McTigue et al., 2003\                            
                                    NHLBI, 1998\                                     
                                    WHO, 2000                                        
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

C.  **Obtain Waist Circumference Measurement**

> *Objective*
>
> Assess person\'s body fat distribution.
>
> *Recommendations*

1.  For screening purposes, waist circumference should be obtained in
    patients with a BMI \<30 kg/m^2^ as a predictor of disease risk.
    **\[C\]**

2.  The waist circumference measurement should be made with a tape
    measure placed above the iliac crest and wrapped in a horizontal
    fashion around the individual\'s abdomen at the end of a normal
    expiration.

3.  Gender-specific cut-offs should be used as indicators of increased
    waist circumference. **\[C\]**

    -   Men: waist circumference \>40 inches (102 cm)

    -   Women: waist circumference \>35 inches (88 cm)

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Waist circumference       NHLBI, 1998\                II-2     Fair        C
          should be obtained in     Zhu et al., 2005                                 
          patients with BMI \<30                                                     
          kg/m^2^ as a predictor of                                                  
          disease risk.                                                              

  2       Gender-specific weight    Janssen, Katzmarzyk, &      III      Poor        C
          circumference (WC)        Ross, 2002\                                      
          cut-offs should be used   NHLBI, 1998\                                     
          as indicators of          WHO, 2000                                        
          increased disease risk:\                                                   
          \                                                                          
          Men \>40 inches (102cm)\                                                   
          Women \>35 inches (88cm)                                                   
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

D.  **Determine Presence of Obesity-Associated Health Conditions that
    Increase Risk**

> *Objective*
>
> Identify patients who are overweight and who will benefit from weight
> loss treatment.
>
> *Recommendations*

1.  Weight loss treatment should be offered to overweight patients (BMI
    25-29.9 kg/m^2^) with one or more of the obesity-associated
    conditions that are directly influenced by weight loss (i.e.,
    hypertension, type 2 diabetes, dyslipidemia, metabolic syndrome,
    obstructive sleep apnea) **\[B\]**; or with degenerative joint
    disease (DJD). **\[I\]**

**Table. Obesity-Associated Chronic Health Conditions**

  -----------------------------------------------------------------------
  The presence of any of the following conditions that are directly
  influenced by weight warrants weight loss therapy:\
  \
  **Hypertension**\
  **Type 2 Diabetes**\
  **Dyslipidemia**\
  **Metabolic Syndrome \***\
  **Obstructive Sleep Apnea**\
  **Degenerative Joint Disease (DJD)**

  -----------------------------------------------------------------------

\*For a definition of Metabolic Syndrome, see the Table in Annotation L

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Overweight adults (BMI    McTigue et al., 2003\       I        Fair        B
          between 25 and 29.9       NHLBI, 1998\                                     
          kg/m^2^) should be        Strawbridge et al., 2000\                        
          assessed for other risk   USPSTF, 2003\                                    
          factors to determine if   WHO, 2000                                        
          they need treatment for                                                    
          overweight.                                                                

  2       Normal weight patients    NHLBI, 1998\                III      Poor        I
          and overweight patients   WHO, 2000                                        
          who do not have                                                            
          obesity-associated                                                         
          conditions should be                                                       
          educated to reinforce                                                      
          good lifestyle behaviors.                                                  
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

E.  **Advise Patient to Maintain Weight and Prevent Weight Gain**

> *Objective*
>
> Promote healthy lifestyles in low-risk patients.
>
> *Recommendations*

1.  Overweight patients (BMI 25-29.9 kg/m^2^) who do not have associated
    risk factors should be offered brief advice, encouraged to maintain
    or lose weight, and offered assistance in establishing reasonable
    weight loss goals as well as diet and exercise plans if they seek
    help in losing weight. **\[I\]**

2.  Overweight patients without obesity-associated conditions should be
    provided with education regarding healthy lifestyle behaviors, be
    advised of their BMI and their weight range margins and instructed
    to return for further evaluation should those margins be exceeded.
    BMI and risk factors should be reassessed annually. **\[Expert
    Opinion\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Brief advice for          Working Group Consensus     III      Poor        I
          overweight adults (BMI                                                     
          25-29.9 kg/m^2^) without                                                   
          other associated risk                                                      
          factors assists in weight                                                  
          loss and/or weight                                                         
          maintenance.                                                               

  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

F.  **Provide Brief Reinforcement and Lifestyle Education**

> *Objective*
>
> Promote healthy lifestyles for patients with normal weight.
>
> *Recommendations*

1.  Patients of normal weight should be praised, encouraged to maintain
    their normal weight, and educated regarding a healthy lifestyle to
    include: **\[Expert Opinion\]**

    -   A balance between caloric intake and energy expenditure

    -   A healthy diet emphasizing, whenever possible, fresh fruits and
        vegetables (see MyPyramid at
        [http://www.mypyramid.gov](http://www.mypyramid.gov/))

    -   Regular, moderately intense physical activity for more than 30
        minutes, five or more days per week

    -   Additional healthy lifestyle elements related to weight
        maintenance that may include tobacco use cessation, limited
        caffeine intake, sleep hygiene, and stress management

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G.  **Repeat Screening Annually**

> *Objective*
>
> Follow up patients with normal weight.
>
> *Recommendation*

1.  Screening for overweight and obesity should be performed at least
    annually. **\[Expert Opinion\]**

**Module B: Treatment for Weight Loss and Weight Maintenance**

[Treatment
Algorithm](http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/content/algorithms/algoB.htm)

**Assessment**

H.  **Obese Person or Overweight with Obesity-Associated Condition(s)**

> *Definition*
>
> Patients who are obese, and patients who are overweight or have an
> elevated waist circumference with one or more obesity-associated
> conditions should be offered treatment for the reduction of body
> weight.

I.  **Obtain Medical History, Physical Examination, and Laboratory Tests
    as Indicated**

> *Objective*
>
> Identify medical disorders that may cause or complicate obesity.
>
> *Recommendations*

1.  The clinical assessment of the overweight or obese patient should be
    done by the primary care provider. The assessment should include a
    basic medical history, a relevant physical examination, and
    laboratory tests as clinically indicated. The history should include
    age of onset or periods of rapid increase in body weight,
    precipitating factors, and maximum lifetime weight. **\[Expert
    Opinion\]**

2.  The clinical assessment should rule out organic and drug related
    causes and identify health risks and/or the presence of
    weight-related conditions. **\[Expert Opinion\]**

3.  In addition to a medical assessment, a social and psychological
    assessment may be indicated to identify barriers to participating in
    dietary or physical activity programs. The assessment may also
    include screening for behavioral health conditions that may hinder
    successful weight loss (i.e., depression, post-traumatic stress
    disorder, anxiety, bipolar disorder, addictions, binge eating
    disorder, bulimia, and alcoholism). **\[Expert Opinion\]**

4.  A nutritional evaluation should include an assessment of current
    intake as well as the use of supplements, herbs, and
    over-the-counter weight loss aides. In addition, meal and snack
    patterns and problem eating behaviors need to be assessed. The
    weight and dieting history should include the age of onset of weight
    gain, number and types of diets and attempts, possible triggers of
    weight gains and losses, and range of weight change. **\[Expert
    Opinion\]**

5.  Current levels of physical activity and sedentary lifestyle should
    be assessed, including exercise frequency, duration, and intensity
    as well as the patient\'s motivation to increase physical activity.
    **\[Expert Opinion\]**

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J.  **Assess Patient\'s Readiness to Lose Weight**

> *Objective*
>
> Identify the patient who is ready and willing to attempt weight loss.
>
> *Recommendations*

1.  Readiness to lose weight should be assessed by direct inquiry. Those
    indicating an adequate readiness to lose weight (preparation or
    action stage) should proceed to treatment. Those not yet ready to
    lose weight (precontemplation or contemplation stage) should receive
    motivational counseling. **\[Expert Opinion\]**

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K.  **Reach Shared Decisions about Goals and Treatment Plan**

> *Objective*
>
> Incorporate patient preferences in the treatment goals and plan to
> optimize the patient\'s success in achieving and maintaining sustained
> weight loss.
>
> *Recommendations*

1.  The clinical team, together with the patient, should reach shared
    decisions regarding the treatment program. **\[Expert Opinion\]**

    -   The clinical team should convey to the patient that obesity is a
        chronic disease that will require lifelong treatment

    -   The clinical team should suggest the personalized preferred
        treatment options based on disease risk and patient
        characteristics (e.g., describe to the patient/caregiver the
        treatment options, including behavioral modification, diet and
        activity patterns, prognosis, estimated length and frequency of
        therapy, and expectations)

    -   The patient should describe his or her needs, preferences, and
        resources and assist the team in determining the optimal
        environment for therapy and preferred interventions

    -   The patient and the clinical team together should reach
        conclusions on the goals of therapy and preferred treatment plan

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```
2.  The patient\'s family/caregiver may participate in the treatment
    process and should be involved in assisting the patient with
    changing lifestyle, diet and physical activity patterns. **\[Expert
    Opinion\]**

3.  Patient education should be provided in an interactive and written
    format. The patient should be given an information packet that
    includes printed material on subjects such as preferred foods to eat
    or foods to avoid, healthy lifestyle tips, support group
    information, and available audio/visual programs on weight loss.
    **\[Expert Opinion\]**

4.  A detailed treatment plan needs to be documented in the medical
    record to provide integrated care. **\[Expert Opinion\]**

**Treatment For Weight Loss**

L.  **Initiate Interventions Based on Risk Level and Patient
    Preferences**

> *Objective*
>
> Stratify patients according to risk and provide weight loss treatment
> accordingly.
>
> *Recommendations*

1.  Weight loss therapy should be tailored to risk level based on
    calculated BMI and based upon the balance of benefits and risks and
    patient preferences. **\[C\]**

2.  Patients who may benefit from weight loss should be offered
    interventions to improve their diet, increase exercise, and change
    related behaviors to promote weight loss. **\[A\]**

3.  Weight loss interventions should combine dietary therapy, increased
    physical activity, and behavioral modification strategies rather
    than utilizing one intervention alone. **\[A\]**

4.  A reasonable initial goal of weight loss therapy (intervention) is a
    10 percent reduction in body weight. **\[B\]**

5.  Drug therapy in combination with a reduced-calorie diet and exercise
    interventions should be considered for obese patients (BMI
    [\>]{.underline}30 kg/m^2^) or overweight patients (BMI
    [\>]{.underline}27 kg/m^2^) with an obesity-associated chronic
    health condition (i.e., hypertension, type 2 diabetes, dyslipidemia,
    metabolic syndrome, and sleep apnea). **\[B\]**

6.  Bariatric surgery to reduce body weight, improve obesity-associated
    comorbidities, and improve quality of life may be considered in
    adult patients with a BMI [\>]{.underline}40 kg/m^2^ and those with
    a BMI [\>]{.underline}35 kg/m^2^ with at least one
    obesity-associated chronic health condition (i.e., hypertension,
    type 2 diabetes, dyslipidemia, metabolic syndrome, and sleep apnea).
    **\[B\]**

7.  There is insufficient evidence to recommend drug or surgical
    interventions specifically for patients who have documented coronary
    artery disease (CAD). **\[I\]** However, there is good evidence that
    drug and surgical weight loss interventions may improve
    cardiovascular risk factors, such as hypertension, dyslipidemia, and
    diabetes mellitus. **\[A\]**

8.  There is insufficient evidence to recommend drug or surgical
    interventions specifically for patients who have degenerative joint
    disease (DJD). However, physical activity and diet may improve
    physical function and chronic pain in patients with DJD. **\[I\]**

**Table. Indications for More Intensive Weight Loss Therapy**

  -----------------------------------------------------------------------
  The presence of the following conditions, directly influenced by weight
  loss, warrants consideration of more intensive therapy with drugs or
  surgery:\
  \
  **Hypertension**\
  **Type 2 Diabetes**\
  **Dyslipidemia**\
  **Metabolic Syndrome**\
  **Obstructive Sleep Apnea**

  -----------------------------------------------------------------------

 

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss with diet,    NHLBI, 1998\                I        Good        A
          exercise, and behavioral  Appel et al., 2003                               
          modification is                                                            
          recommended for patients                                                   
          with a BMI                                                                 
          [\>]{.underline}25                                                         
          kg/m^2^ and hypertension.                                                  

  2       Orlistat is associated    Sharma & Golay, 2002        I        Good        B
          with lowering blood                                                        
          pressure as a secondary                                                    
          effect of weight loss in                                                   
          patients with a BMI                                                        
          [\>]{.underline}27                                                         
          kg/m^2^ and hypertension.                                                  

  3       Bariatric surgery is      Buchwald et al., 2004\      I        Fair        B
          effective in lowering     Sjostrom et al., 2004                            
          blood pressure in                                                          
          patients with a BMI                                                        
          [\>]{.underline}35                                                         
          kg/m^2^ and hypertension.                                                  

  4       Sibutramine has been      Arterburn, Crane, &         I        Good        D
          shown to raise blood      Veenstra, 2004                                   
          pressure in patients with                                                  
          a BMI [\>]{.underline}27                                                   
          kg/m^2^.                                                                   
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss with diet,    Tuomilehto et al., 2001\    I        Good        A
          exercise, and behavioral  The Diabetes Prevention                          
          modification is           Program, 2002                                    
          recommended in patients                                                    
          with a BMI                                                                 
          [\>]{.underline}25                                                         
          kg/m^2^ and diabetes.                                                      

  2       Orlistat and sibutramine  Didangelos et al., 2004\    I        Fair        B
          modestly improve glycemic Hanefeld & Sachse, 2002\                         
          control in patients with  Kelley et al., 2002\                             
          a BMI [\>]{.underline}27  Miles et al., 2002\                              
          kg/m^2^ and type 2        Torgerson et al., 2004                           
          diabetes.                                                                  

  3       Bariatric surgery         Buchwald et al., 2004       I        Good        B
          improves glycemic control                                                  
          or resolves diabetes in                                                    
          patients with a BMI                                                        
          [\>]{.underline}35                                                         
          kg/m^2^.                                                                   
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss is            \"Third Report,\" 2002\     I        Good        A
          recommended in all        NHLBI, 1998                                      
          patients with a BMI                                                        
          [\>]{.underline}25                                                         
          kg/m^2^ with                                                               
          dyslipidemia.                                                              

  2       Orlistat and sibutramine  Dujovne et al., 2001\       I        Good        B
          improve lipid levels in   Hutton & Fergusson, 2004\                        
          patients with a BMI       Klein, 2004\                                     
          [\>]{.underline}27        Lucas, Boldrin, & Reaven,                        
          kg/m^2^ with              2003\                                            
          dyslipidemia.             Micic et. al., 1999                              

  3       Bariatric surgery         Buchwald et al., 2004\      I        Good        B
          improves triglycerides in Sjostrom et al., 2004                            
          patients with a BMI                                                        
          [\>]{.underline}35 and                                                     
          dyslipidemia.                                                              
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

**Diagnosis of Metabolic Syndrome *\[\"Third Report,\", 2002\]***

  -----------------------------------------------------------------------
  **Three or more of the following risk factors **Defining Level**
  indicate metabolic syndrome:**                
  --------------------------------------------- -------------------------
  Abdominal Obesity:                            Waist Circumference (WC):

  Men\*                                         Greater than 102 cm (\>40
                                                in)

  Women                                         Greater than 88 cm (\>35
                                                in)

  Triglycerides                                 Greater than or equal to
                                                150 mg/dL

                                                

  HDL cholesterol:                               

  Men                                           Less than 40 mg/dL

  Women                                         Less than 50 mg/dL

  Blood pressure                                Greater than or equal to
                                                130/85 mmHg

  Fasting glucose                               Greater than or equal to
                                                110 mg/dL
  -----------------------------------------------------------------------

\*Some men can develop multiple metabolic risk factors when the WC is
only marginally increased (e.g., 37-39 inches \[94-102 cm\]). Such
persons may have a strong genetic contribution to insulin resistance.
They should benefit from changes in life habits, similarly to men with
categorical increases in WC.

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss is            \"Third Report,\" 2002\     I        Good        A
          recommended in all        NHLBI, 1998                                      
          patients with a BMI                                                        
          [\>]{.underline}25                                                         
          kg/m^2^ with metabolic                                                     
          syndrome.                                                                  

  2       Orlistat improves the     Didangelos et al., 2004\    I        Fair        B
          components of the         Lindgarde, 2000                                  
          metabolic syndrome in                                                      
          patients with a BMI                                                        
          [\>]{.underline}27                                                         
          kg/m^2^.                                                                   
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss is            Carmelli et al., 2000\      II-3     Fair        B
          recommended in patients   Kansanen et al., 1998\                           
          with a BMI                Smith et al., 1985\                              
          [\>]{.underline}25        Suratt et al., 1992                              
          kg/m^2^ with sleep apnea.                                                  

  2       The use of orlistat and   N/A                         N/A      N/A         I
          sibutramine has not been                                                   
          adequately studied in                                                      
          obese or overweight                                                        
          patients with sleep                                                        
          apnea.                                                                     

  3       Bariatric surgery is      Buchwald et al., 2004\      II-2     Good        B
          recommended in morbidly   Dixon, Schacter, &                               
          obese patients with sleep O\'Brien, 2001\                                  
          apnea.                    Karason et al., 2000\                            
                                    Maggard et al., 2005\                            
                                    O\'Brien et al.,2002                             
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document) N/A = Not Applicable

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Weight loss is            Christensen, Astrup, &      I        Poor        C
          recommended in all obese  Bliddal, 2005\                                   
          or overweight patients    Felson et al., 1992\                             
          with lower extremity DJD. Messier et al., 2004\                            
                                    Rejeski et al., 2002                             

  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

**Weight Maintenance and Follow-Up**

M.  **Is Patient Losing Weight?**

> *Objective*
>
> Assess response to therapy and progress toward weight loss goals.
>
> *Recommendations*

1.  Patients on diet, exercise, and behavioral therapy who have lost on
    average 1 to 2 pounds per week should continue with their current
    treatment until their weight loss goal is achieved. **\[B\]**

2.  Patients who have lost on average less than 1 pound per week should
    have their adherence to therapy assessed and treatment plan
    reevaluated. **\[I\]**

3.  Obese patients with a BMI [\>]{.underline}30 kg/m^2^, and overweight
    patients with a BMI [\>]{.underline}27 kg/m^2^ and
    obesity-associated chronic health conditions who fail to achieve
    adequate weight loss through non-pharmacologic interventions may be
    candidates for pharmacotherapy with orlistat or sibutramine.
    **\[B\]** (See Module C, Section C-4 Pharmacotherapy.)

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       An energy deficit of      \"Diet programs,\" 2004\    I        Good        B
          500-1,000 calories can    NHLBI, 1998                                      
          lead to weight loss of 1                                                   
          to 2 pounds per week.                                                      

  2       A reasonable time to      NHLBI, 1998                 I        Good        B
          achieve a 10% reduction                                                    
          in body weight is 6                                                        
          months of therapy.                                                         

  3       Patients who have lost on NHLBI, 1998                 II       Fair        B
          average 1 pound or more                                                    
          per week should continue                                                   
          with their current                                                         
          treatment.                                                                 

  4       Use of medications for    See Module C, Section C-4:                       
          maintenance.              Pharmacotherapy                                  
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

N.  **Congratulate and Initiate Relapse Prevention/Maintenance**

> *Objective*
>
> Continue the necessary interventions to maintain the weight loss and
> prevent weight gain.
>
> *Recommendations*

1.  Patients who have met their weight loss goals or have stopped losing
    weight and are ready to sustain current weight loss should be
    offered a maintenance program consisting of diet, physical activity,
    and behavioral support. Weight status should be reevaluated and diet
    and physical activity should be adjusted so that energy balance is
    maintained (energy intake is equal to energy expenditure). **\[B\]**

2.  Providers should continue to maintain contact with patients
    providing on-going support, encouragement, and close monitoring
    during the maintenance phase of weight loss to prevent weight
    regain. **\[B\]**

3.  Patients who achieve their weight loss goal with a combination of
    medication, diet, and exercise may be considered candidates to
    include their medication as a component of their weight maintenance
    program with continued monitoring of effectiveness and adverse
    effects. **\[B\]** (See Module C, Section C-4 Pharmacotherapy
    recommendations below.)

4.  Lifelong follow-up after bariatric surgery is necessary to monitor
    adherence to treatment, adverse effects and complications, dietary
    restrictions, and behavioral health. **\[I\]**

5.  There is no established optimum visit length or duration between
    maintenance visits, but it seems reasonable to establish a minimum
    of quarterly follow-up (every three months) for the sustainment of
    weight loss and more frequently if the patient requests it.
    **\[I\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Continued contact with    NHLBI, 1998                 II       Fair        B
          patients providing                                                         
          on-going support,                                                          
          encouragement, and                                                         
          monitoring to prevent                                                      
          weight regain.                                                             

  3       A maintenance program of  NHLBI, 1998\                II-2     Fair        B
          diet, physical activity,  Tremblay, Doucet, &                              
          and behavioral support    Imbeault, 1999                                   
          should be offered                                                          
          beginning at 6 months.                                                     

  4       Emphasize working with    NHLBI, 1998\                II-2     Fair        B
          patients to solve         Perri et al., 1988, 2001\                        
          problems that impede      Tremblay Doucet, & Imbeault                      
          weight management.        , 1999\                                          
                                    Wing & Phelan, 2005                              
  -------------------------------------------------------------------------------------------

Quality of Evidence; SR = Strength of Recommendation (see Appendix A in
the original guideline document)

O.  **Assess Adherence and Modify Treatment**

> *Objective*
>
> Assess the patient\'s progress toward treatment goals and determine
> adjustments as needed.
>
> *Recommendations*

1.  Adherence to weight loss programs should be assessed by periodically
    measuring the patient\'s BMI and waist circumference and providing
    feedback. **\[Expert Opinion\]**

2.  Patients should be encouraged to record activities by using food
    logs, exercise logs, and personal diaries to provide structure and
    allow the provider to identify compliance or relapse issues.
    **\[B\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Provide patient with      Marlatt & Gordon, 2000\     II-2     Fair        B
          objective evidence of     Wadden, 1999                                     
          goal attainment.                                                           

  2       Analysis/reinforcement of DiLillo, Siegfried,&        II       Poor        B
          food logs, exercise       Smith-West, 2003\                                
          records, and personal     NHLBI, 1998                                      
          diaries confirms                                                           
          compliance.                                                                
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

P.  **Reinforce Knowledge, Motivation, Skills, and Support**

> *Objective*
>
> Motivate overweight or obese patients who are presently not ready to
> undertake weight loss to do so in the future.
>
> *Recommendations*

1.  Motivational interviewing techniques should be utilized to motivate
    patients to improve their dietary habits. **\[B\]**

2.  Motivational interviewing techniques should be considered to
    motivate patients to increase their physical activity. **\[Expert
    Opinion\]**

3.  Patients who may benefit from weight loss but are not willing to
    attempt to lose weight at this time should receive brief,
    non-judgmental motivational counseling designed to increase their
    motivation to lose weight. This counseling should include discussion
    about: **\[Expert Opinion\]**

    -   Relevance: connection between overweight and current symptoms,
        disease, and medical history

    -   Risks: risks of continued overweight status, tailored to
        individual risk/relevance of cardiovascular disease or
        exacerbation of pre-existing disease

    -   Rewards: potential benefits for losing excess weight to
        patients\' medical, financial, and psychosocial well-being

    -   Roadblocks: barriers to losing weight, with options and
        strategies to address patient\'s barriers

    -   Repetition: reassess willingness to lose weight at subsequent
        visits; repeat intervention for unmotivated patients at every
        visit

**Module C: Interventions for Weight Loss**

C-1 **Diet Therapy**

*Recommendations*

[Weight Loss]{.underline}

1.  Dietary interventions should be individually planned, in conjunction
    with physical activity, to create a caloric deficit of 500 to 1,000
    kcal/day. Such negative energy balance may lead to a weight loss of
    1 to 2 pounds per week. **\[B\]**

[Selection of Specific Diets]{.underline}

2.  Dietary programs should at a minimum reduce the usual caloric intake
    by 500 to 1,000 kcal/day to achieve modest weight loss. **\[B\]**

3.  Low-calorie diets (LCDs) should generally include 1,000 to 1,200
    kcal/day for women and 1,200 to 1,600 kcal/day for men and should
    include the major nutrients in appropriate proportions (see Appendix
    C, Table C-1 in the original guideline document). **\[B\]**

4.  Very-low-calorie diets (VLCDs) that restrict calories to less than
    800 kcal/day \[15 kcal/kg ideal body weight\] are not recommended
    for weight loss, but may be used short term (12 to 16 weeks) under
    medical supervision. **\[B\]**

5.  Low-fat intake (20 to 30 percent of total calories/day), as part of
    low-calorie diets (LCDs), can be recommended to induce weight loss
    and should be recommended for patients with cardiovascular disease
    or lipid abnormalities. **\[B\]**

6.  Low-carbohydrate diets (less than 20 percent of total calories) may
    be used for short-term weight loss, but are not recommended for
    long-term dieting or weight maintenance. **\[B\]**

7.  Low-carbohydrate diets can be recommended to reduce serum
    triglyceride levels for overweight patients with mixed dyslipidemia.
    **\[B\]**

8.  Low-carbohydrate diets are not recommended for patients with hepatic
    or renal disease or for patients with diabetes who are unable to
    monitor blood glucose. **\[C\]**

9.  Low-calorie diets (LCDs) or very low-calorie diets (VLCDs) may
    include meal replacements (e.g., bars and shakes). **\[A\]**

10. There is insufficient evidence to recommend for or against a diet
    limited to foods with a glycemic index less than 55 as a means of
    producing weight loss. **\[C\]**

[Commercial Diets]{.underline}

11. Patients should be encouraged to adhere to a specific diet, as
    adherence to any diet plan from a variety of programs (e.g., Atkins,
    Ornish, Weight Watchers, and Zone) has been shown to be the most
    important factor in achieving weight reduction. **\[B\]**

**Table. Definitions of Common Diets**

  ------------------------------------------------------------------------------------------
  **Diet Approach**                          **Content (%                      
                                             of total                          
                                             calories)**                       
  ------------------------------------------ ------------- ------------------- -------------
                                             **Fat**       **Carbohydrates**   **Protein**

  **Very-low carbohydrates\                  55--65        \<20 (\<100g)       25--30
  (High-fat)**                                                                 

  **Low carbohydrates\                       20--30        30--40              25--30
  (Moderate-fat)**                                                             

  **Moderate-fat, balanced nutrient          20--30        55--60              15--20
  reduction\                                                                   
  (Low-calorie)**                                                              

  **Low-fat**                                11--19        \>65                10--20
  ------------------------------------------------------------------------------------------

 

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       An energy deficit of      \"Diet programs,\" 2004\    I        Fair        B
          500-1,000 kcal/day will   NHLBI, 1998                                      
          lead to weight loss of 1                                                   
          to 2 pounds per week.                                                      

  2       Energy deficit (calories  Avenell et al., 2004\       I        Fair        B
          in vs. calories out),     Freedman, King, & Kennedy,                       
          rather than macronutrient 2001\                                            
          composition is the major  \"Diet programs,\" 2004\                         
          determinant of weight     McTigue et al., 2003                             
          loss.                                                                      

  3       No single type of diet    Avenell et al., 2004\       I        Fair        B
          has been shown to be more Dansinger et al., 2005\                          
          effective than the        \"Diet programs,\" 2004\                         
          others.                   McTigue et al., 2003                             

  4       **LCDs** may result in    Avenell et al., 2004\       I        Good        A
          moderate weight loss for  \"Diet programs,\"  2004\                        
          patients that adhere to   McTigue et al., 2003\                            
          the diet program (3 to 18 NHLBI, 1998                                      
          months).                                                                   

  5       **VLCDs** (less than 800  Wadden & Stunkard, 1986;\   I        Good        B
          kcal/day) produce greater Wadden et al., 1994\                             
          initial weight loss than  Williams et al., 1998\                           
          other forms of calorie    Wing et al., 1994                                
          restriction at 12 to 16                                                    
          weeks.                                                                     

  6       **VLCDs** should be       \"Very low-calorie diets,\" III      Poor        C
          monitored under medical   1993                                             
          supervision.                                                               

  7       Greater initial weight    Anderson et al., 2001       I        Fair        I
          loss induced without                                                       
          changes in lifestyle                                                       
          (e.g., **VLCD**) may                                                       
          improve long-term weight                                                   
          maintenance.                                                               

  8       **Low-fat** diets produce NHLBI, 1998                 I        Good        A
          a caloric deficit and                                                      
          lead to modest weight                                                      
          loss at 3 to 6 months.                                                     
          Greater weight loss is                                                     
          observed in patients with                                                  
          greater baseline weights.                                                  

  9       **Low-fat**, calorie      \"Third Report,\" 2002\     I        Fair        B
          restricted diets may lead NHLBI, 1998                                      
          to weight loss and                                                         
          reduction in Low density                                                   
          lipoprotein (LDL)                                                          
          cholesterol for patient                                                    
          with dyslipidemia.                                                         

  10      **Low-carbohydrate**      Bravata et al., 2003\       I        Fair        B
          diets result in more      Brehm et al., 2003\                              
          rapid short-term (6       Foster et al., 2003\                             
          months) weight loss than  Samaha et al., 2003                              
          low-fat LCDs.\                                                             
          \                                                                          
          **Low-carbohydrate**                                                       
          diets may reduce serum                                                     
          triglyceride levels and                                                    
          improve High density                                                       
          lipoprotein cholesterol                                                    
          (HDL-C) in patients with                                                   
          mixed dyslipidemia.                                                        

  11      **Low-carbohydrate**      Working Group Consensus     III      Poor        I
          diets are contraindicated                                                  
          in patients with renal or                                                  
          hepatic disease and                                                        
          patients with diabetes                                                     
          that cannot monitor their                                                  
          blood sugars.                                                              

  12      **Meal replacements** are Bowerman et al., 2001\      I        Good        A
          safe to promote weight    Flechtner-Mors et al.,                           
          loss in conjunction with  2000\                                            
          LCDs and VLCDs.           Heymsfield et al., 2003\                         
                                    Noakes et al., 2004                              

  13      The evidence is                                       III      Poor        I
          insufficient to                                                            
          substantiate the                                                           
          recommendation of a diet                                                   
          based on the **glycemic                                                    
          index**, without caloric                                                   
          reduction.                                                                 

  14      Low-**energy**-dense      McCrory et al., 2000\       I        Fair        B
          diets can help lower      Rolls & Bell, 2000                               
          calorie intake without                                                     
          reducing food volume and                                                   
          lead to weight loss.                                                       
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

C-2 **Physical Activity**

*Recommendations*

1.  Weight loss interventions should include exercise to promote weight
    loss **\[A\]**, maintain weight loss **\[A\]**, decrease abdominal
    obesity **\[B\]**, improve cardiovascular fitness **\[A\]**, improve
    cardiovascular outcomes **\[A\]**, and decrease all-cause and
    cardiovascular mortality **\[B\]**.

2.  Home fitness/lifestyle activities or structured supervised programs
    may be effectively used to produce a caloric expenditure leading to
    weight loss. **\[A\]**

3.  Moderate levels of physical activity should be performed at least 30
    minutes most days of the week. **\[B\]**

4.  Physical activity may include short intermittent bursts (10 minutes
    or longer) as well as longer continuous exercise. **\[A\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       ***Physical                                                                
          Activity/Exercise should                                                   
          occur to*:**                                                               

          a\. Promote weight loss   NHLBI, 1998\                I        Good        A
                                    Ross et al., 2000                                

          b\. Maintain weight loss  Miller et al., 1997         I        Good        A

          c\. Decrease abdominal    NHLBI, 1998                 I        Fair        B
          obesity                                                                    

          d\. Improve               NHLBI, 1998                 I        Good        A
          cardiovascular fitness                                                     

          e\. Reduce cardiovascular Bassuk & Manson, 2004\      I        Good        A
          risk factors              NHLBI, 1998                                      

          f\. Decrease all-cause    Blair et al., 1995\         II-2     Fair        B
          and cardiovascular        Lee, Blair, & Jackson,                           
          mortality                 1999\                                            
                                    Paffenbarger et. al., 1993                       

  2       Lifestyle physical        Anderson et al., 1999\      I        Good        A
          activities (home fitness  Fogelholm et al.,2000                            
          programs) are just as                                                      
          effective in promoting                                                     
          weight loss as structured                                                  
          supervised exercise                                                        
          programs.                                                                  

  3       Moderate levels of        Jakicic et al., 2001\       I        Fair        B
          physical activity should  NHLBI, 1998\                                     
          be performed at least 30  Saris et al., 2003                               
          minutes most days of the                                                   
          week.                                                                      

  4       Short intermittent bursts Frick et al., 2001\         I        Good        A
          of physical activity are  Jakicic et al., 1999                             
          just as effective as                                                       
          longer continuous                                                          
          exercise.                                                                  
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

C-3 **Behavioral Modification Strategies**

*Recommendations*

1.  Behavioral modification interventions to improve adherence to diet
    and physical activity should be given to overweight or obese
    individuals. **\[B\]**

2.  Behavioral modification interventions should be provided at a higher
    intensity when possible for greater effectiveness. Higher intensity
    is defined as more than one personal contact per month for the first
    three months (individual or group setting). Less frequent
    intervention may be an ineffective and inefficient use of manpower.
    **\[B\]**

3.  Multiple behavioral modification strategies should be used in
    combination for greater effectiveness. **\[A\]**

4.  Behavioral modification intervention should be delivered in a group
    format when possible rather than individually. **\[B\]**

5.  For individuals unable or unwilling to participate in weight loss
    treatment in person, telephone or internet-based behavioral
    modification intervention may be considered. **\[B\]**

6.  Behavioral modification intervention should be continued on a
    long-term basis to promote maintenance of weight loss. **\[B\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Behavioral modification   Avenell et al., 2004\       I        Fair        B
          interventions add         ICSI, 2005\                                      
          effectiveness to diet and McTigue et al., 2003\                            
          exercise interventions in NHLBI, 1998\                                     
          promoting weight loss.    Wadden & Butryn, 2003                            

  2       Behavioral modification   NHLBI, 1998\                I        Fair        B
          interventions with        McTigue et al., 2003                             
          greater intensity are                                                      
          more effective than those                                                  
          with less intensity in                                                     
          promoting weight loss.                                                     

  3       Combined behavioral       NHLBI, 1998                 I        Good        A
          modification strategies                                                    
          are more effective than a                                                  
          single behavioral                                                          
          modification strategy in                                                   
          promoting weight loss.                                                     

  4       Group-based behavioral    Renjilian et al., 2001      I        Fair        B
          modification counseling                                                    
          is more effective than                                                     
          individual counseling in                                                   
          promoting weight loss.                                                     

  5       Telephone and internet    Boucher et al., 1999\       I        Fair        B
          behavioral treatment is   Harvey-Barino et al., 2004\                      
          effective in promoting    Jeffery et al., 2003\                            
          weight loss.              Tate, Jackvony, & Wing,                          
                                    2003                                             

  6       Continued behavioral      Jeffery et al., 2000\       I        Fair        B
          modification              Latner et al., 2002\                             
          interventions are         McTigue et al., 2003\                            
          effective in sustaining   NHLBI, 1998\                                     
          weight loss.              Perri et al., 1988\                              
                                    Perri et al., 2001\                              
                                    Wadden & Butryn, 2003                            
  -------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

C4 **Pharmacotherapy**

*Recommendations*

1.  Adult patients with a BMI greater than 30 kg/m^2^ or a BMI greater
    than 27 kg/m^2^ with obesity-associated conditions may be considered
    for pharmacotherapy in combination with a reduced-calorie diet,
    increased physical activity and behavioral therapy. **\[B\]**

2.  Patients who do not respond to medication with a reasonable weight
    loss should be evaluated for adherence to the medication regimen and
    adjunctive therapies or considered for an adjustment of dosage.
    **\[I\]**

3.  If the patient continues to be unresponsive to the medication, or
    serious adverse effects occur, the use of medication should be
    discontinued. **\[I\]**

[Orlistat]{.underline}

4.  Orlistat may be considered to reduce body weight **\[B\]** and
    improve obesity-associated cardiovascular risk factors **\[C\]**.

5.  Patients who have lost 5 percent or more of their body weight after
    12 weeks of treatment or lost an average of 1 pound or more per week
    with orlistat should continue their current treatment, as they are
    more likely to experience sustained weight loss. **\[B\]**

6.  Orlistat may be considered as a component of weight maintenance
    programs for up to 4 years. **\[B\]**

7.  Patients prescribed orlistat should take a multiple vitamin that
    includes fat soluble vitamins. **\[Expert Opinion\]**

[Sibutramine]{.underline}

8.  Sibutramine may be considered to reduce body weight **\[B\]** and
    improve glycemic and lipid parameters **\[C\]**.

9.  Patients who have lost an average of 1 pound or more per week during
    the first 4 weeks of therapy with sibutramine should continue
    treatment, barring any intolerable side effects. **\[Expert
    Opinion\]**

10. Patients who fail to lose 4 pounds after 4 weeks treated with
    sibutramine should have their adherence assessed and, if
    appropriate, an increase in the dose for an additional 4-week trial.
    **\[I\]**

11. Sibutramine may be considered as a component of weight maintenance
    programs for up to 2 years. **\[B\]**

12. Sibutramine should be discontinued if it is not efficacious in
    helping the patient to lose or maintain weight loss. **\[B\]**

13. Sibutramine should be used with caution as it can elevate blood
    pressure and heart rate. **\[A\]**

14. Adult patients with uncontrolled hypertension, cardiovascular
    disease, or a history of myocardial infarction (MI) or stroke should
    not include sibutramine as a part of their weight loss program due
    to the increased risk of harm. **\[D\]**

15. Sibutramine should be avoided in patients taking selective serotonin
    reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs),
    triptans, pseudoephedrine, and other agents that affect serotonin.
    **\[D\]**

  -------------------------------------------------------------------------------------------------------------
  ** **   **Recommendation**   **Sources of           **QE**   **Overall   **SR**                
                               Evidence**                      Quality**                         
  ------- -------------------- ---------------------- -------- ----------- ------------ -------- --------------
                                                                           **Weight**   **CV     **Morbidity\
                                                                                        risk**   Mortality**

  1       Pharmacotherapy may  Apfelbaum et al.,      I        Fair        B            C        I
          be considered for    1999\                                                             
          BMI greater than 30  Arterburn, McDonell, &                                            
          kg/m^2^ or a BMI     Hedrick, 2004\                                                    
          greater than 27      James et al., 2000\                                               
          kg/m^2^ with one or  Li et. al., 2005\                                                 
          more obesity related McTigue et al., 2003\                                             
          risk factors.        O\'Meara et al., 2002\                                            
                               Shekelle et al., 2004\                                            
                               Torgerson et al., 2004                                            

  2       Orlistat may be      Lindegarde, 2000\      I        Fair        B            C        I
          considered to reduce Padwal, Li, & Lau,                                                
          body weight and      2004\                                                             
          improve              Shekelle et al., 2004                                             
          obesity-associated                                                                     
          cardiovascular risk                                                                    
          factors.                                                                               

  3       Patients who have    Rissanen et al., 2003  II-2     Fair        B            C        I
          lost greater than or                                                                   
          equal to 5% of their                                                                   
          body weight after 12                                                                   
          weeks of treatment                                                                     
          with orlistat are                                                                      
          more likely to                                                                         
          experience sustained                                                                   
          improvement.                                                                           

  4       Orlistat may be      Padwal, Li, & Lau,     I        Fair        B            C        B\
          considered as a      2004\                                                             (new onset
          component of weight  Shekelle et al., 2004\                                            diabetes)
          maintenance programs Torgerson et al., 2004                                            
          for up to 4 years.                                                                     

  5       Sibutramine may be   Arterburn, Crane, &    I        Fair        B            C        I
          considered to reduce Veenstra, 2004\                                                   
          body weight and      Arterburn, McDonell, &                                            
          improve glycemic and Hedrick, 2004\                                                    
          lipid parameters.    McTigue et al., 2003\                                             
                               Padwal, Li, & Lau,                                                
                               2004\                                                             
                               Shekelle et al., 2004                                             

  6       Sibutramine may be   Arterburn, Crane, &    I        Fair        B            C        I
          considered as a      Veenstra, 2004\                                                   
          component of weight  Arterburn, McDonell, &                                            
          maintenance program  Hedrick, 2004\                                                    
          for up to 2 years.   Padwal, Li, & Lau,                                                
                               2004\                                                             
                               Shekelle et al., 2004                                             

  7       Sibutramine should   Arterburn Crane, &     I        Good        A                     
          be used with caution Veenstra, 2004\                                                   
          as it can elevate    Arterburn, McDonell, &                                            
          blood pressure and   Hedrick, 2004\                                                    
          heart rate.          Padwal, Li, & Lau, ,                                              
                               2004                                                              

  8       Avoid sibutramine in Arterburn Crane, &     II-3     Fair        D                     
          adult patients with  Veenstra, , 2004\                                                 
          uncontrolled         Arterburn, McDonell, &                                            
          hypertension,        Hedrick, 2004\                                                    
          cardiovascular       Padwal, Li, & Lau.,                                               
          disease, and history 2004                                                              
          of MI or stroke due                                                                    
          to the increased                                                                       
          risk of harm.                                                                          
  -------------------------------------------------------------------------------------------------------------

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

C-5 **Bariatric Surgery**

*Recommendations*

1.  Adult patients with extreme obesity (BMI 40 kg/m^2^ or more) or
    severe obesity (BMI 35 kg/m^2^ or more with one or more
    obesity-associated chronic health condition) may be considered for
    bariatric surgery to reduce body weight **\[A\]**, improve
    obesity-associated comorbidities **\[B\]**, and improve quality of
    life **\[B\]**.

2.  Roux-en-y Gastric Bypass (RYGB) is recommended as the bariatric
    procedure with the most robust evidence for inducing sustained
    weight loss **\[B\]** for patients with BMI greater than 40 kg/m^2^.

3.  There is insufficient evidence to recommend for or against the
    routine use of bariatric surgery in those over 65 years of age and
    patients with a substantial surgical risk. **\[I\]**

4.  Providers should engage all patients who are candidates for
    bariatric surgery in a detailed discussion of the benefits and
    potential risks of bariatric procedures. **\[I\]**

5.  Relative contraindications to bariatric surgery that are supported
    only by expert consensus include:

    -   Unstable coronary artery disease, severe pulmonary disease,
        portal hypertension or other conditions that can compromise
        anesthesia or wound healing

    -   Patients who are unable to comprehend basic principles of
        surgery or follow-up postoperative instructions

    -   Patients having had multiple abdominal operations, complicated
        incisional hernias

    -   Patients who have illnesses that greatly reduce life expectancy
        and/or are unlikely to be improved in their medical condition by
        surgically-induced weight reduction (e.g., cancer).

```{=html}
<!-- -->
```
6.  Lifelong medical follow-up after surgery is necessary to monitor
    adherence to treatment, adverse effects and complications, dietary
    restrictions, and behavioral health. **\[I\]**

  -------------------------------------------------------------------------------------------
  ** **   **Recommendation**        **Sources of Evidence**     **QE**   **Overall   **SR**
                                                                         Quality**   
  ------- ------------------------- --------------------------- -------- ----------- --------
  1       Bariatric surgery (RYGB,  ECRI, 2004\                 I        Good        B
          AGB, & VBG) to promote    Maggard et al., 2005\                            
          substantial long-term (3  Shekelle et al., 2004                            
          years) weight loss in                                                      
          patient with BMI                                                           
          [\>]{.underline}40 or BMI                                                  
          [\>]{.underline}35 with                                                    
          comorbid conditions.                                                       

  2       Bariatric surgery (RYGB,  Buchwald et al., 2004\      I        Fair\*      B
          AGB, & VBG) to improve or ECRI, 2004\                                      
          resolve comorbid          Sjostrom et al., 2004                            
          conditions.                                                                

  3       Bariatric surgery (RYGB,  ECRI, 2004\                 I        Fair\*      B
          AGB, & VBG) to improve    Karlsson, Sjostrom, &                            
          quality of life.          Sullivan, 1998\                                  
                                    Shekelle et al., 2004                            

  4       Bariatric surgery to      Christou et al., 2004\      II-2     Poor        I
          improve long-term         Flum & Dellinger, 2004                           
          (greater than 5 years)                                                     
          survival.                                                                  

  5       RYGB to promote greater   Buchwald et al., 2004\      I        Fair        B
          weight loss than VBG or   ECRI, 2004\                                      
          AGB                       Maggard et al., 2005\                            
                                    Shekelle et al., 2004                            

  6       Bariatric surgery in      ECRI, 2004\                 II-3     Fair        I
          those over 65 years of    Shekelle et al., 2004                            
          age has higher risk of                                                     
          mortality                                                                  

  7       Preoperative requirements Expert Opinion\             III      Poor        I
          or effective means to     Saltzman et al,, 2005                            
          prepare patients for                                                       
          surgery.                                                                   

  8       Contraindication for      Expert Opinion              III      Poor        I
          bariatric surgery.                                                         
  -------------------------------------------------------------------------------------------

**\***Evidence quality was rated as fair, because few studies reported
these outcomes consistently, and few studies were designed to examine
the impact of surgery on these outcomes.

QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix
A in the original guideline document)

AGB = Adjustable gastric band; RBG vertical banded gastroplasty

**Definitions**:

**Evidence Rating System**

**Quality of Evidence (QE)**

  ---------- -------------------------------------------------------------------
  **I**      At least one properly done randomized controlled trial (RCT)

  **II-1**   Well designed controlled trail without randomization

  **II-2**   Well designed cohort or case-control analytic study, preferably
             from more than one source

  **II-3**   Multiple time series evidence with/without intervention, dramatic
             results of uncontrolled experiment

  **III**    Opinion of respected authorities, descriptive studies, case
             reports, and expert committees
  ---------- -------------------------------------------------------------------

**Overall Quality**

  ---------- -----------------------------------------------------------------
  **Good**   High grade evidence (I or II-1) directly linked to health outcome

  **Fair**   High grade evidence (I or II-1) linked to intermediate outcome;\
             \
             *or*\
             \
             Moderate grade evidence (II-2 or II-3) directly linked to health
             outcome

  **Poor**   Level III evidence or no linkage of evidence to health outcome
  ---------- -----------------------------------------------------------------

**Net Effect of the Intervention**

  ------------------ ---------------------------------------------------------
  **Substantial:**   More than a small relative impact on a frequent condition
                     with a substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A large impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Moderate:**      A small relative impact on a frequent condition with a
                     substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A moderate impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Small:**         A negligible relative impact on a frequent condition with
                     a substantial burden of suffering;\
                     \
                     *or*\
                     \
                     A small impact on an infrequent condition with a
                     significant impact on the individual patient level.

  **Zero or          Negative impact on patients;\
  Negative:**        \
                     *or*\
                     \
                     No relative impact on either a frequent condition with a
                     substantial burden of suffering, *or* an infrequent
                     condition with a significant impact on the individual
                     patient level.
  ------------------ ---------------------------------------------------------

**Strength of the Recommendation**

  -------------------------------------------------------------------------------------
                       *The net benefit                             
                       of the                                       
                       intervention*                                
  -------------------- ----------------- -------------- ----------- -------------------
  *Quality of          **Substantial**   **Moderate**   **Small**   **Zero or
  Evidence*                                                         Negative**

  *Good*               A                 B              C           D

  *Fair*               B                 B              C           D

  *Poor*               I                 I              I           I
  -------------------------------------------------------------------------------------

 

  --- -------------------------------------------------------------------
  A   A strong recommendation that the clinicians provide the
      intervention to eligible patients.\
      *Good evidence was found that the intervention improves important
      health outcomes and concludes that benefits substantially outweigh
      harm.*

  B   A recommendation that clinicians provide (the service) to eligible
      patients.\
      *At least fair evidence was found that the intervention improves
      health outcomes and concludes that benefits outweigh harm.*

  C   No recommendation for or against the routine provision of the
      intervention is made.\
      *At least fair evidence was found that the intervention can improve
      health outcomes, but concludes that the balance of benefits and
      harms is too close to justify a general recommendation.*

  D   Recommendation is made against routinely providing the intervention
      to asymptomatic patients.\
      *At least fair evidence was found that the intervention is
      ineffective or that harms outweigh benefits.*

  I   The conclusion is that the evidence is insufficient to recommend
      for or against routinely providing the intervention.\
      *Evidence that the intervention is effective is lacking, or poor
      quality, or conflicting and the balance of benefits and harms
      cannot be determined.*
  --- -------------------------------------------------------------------

**Abbreviations and Acronyms List**

AGB - Adjustable Gastric Band

BMI - Body Mass Index

CAD -- Coronary artery disease

DoD - Department of Defense

DJD - Degenerative Joint Disease

EBM - Evidence-Based Medicine

HDL-C - High Density Lipoprotein Cholesterol

LCD - Low-Calorie Diet

LDL -- Low density Lipoprotein

MAOI - Monoamine Oxidase Inhibitors

MI - Myocardial Infarction

RYGB - Roux-en-y Gastric Bypass

SSRI - Selective Serotonin Reuptake Inhibitor

VHA -- Veterans Health Administration

VBG - Vertical Banded Gastroplasty

VLCD - Very-Low-Calorie Diet

WC - Waist Circumference

#### CLINICAL ALGORITHM(S)

Algorithms are provided for:

-   [Screening for Overweight and
    Obesity](http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/content/algorithms/algoA.htm)

-   [Treatment for Weight Loss and Weight
    Maintenance](http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/content/algorithms/algoB.htm)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=10714)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The guideline is supported by the literature in a majority of areas,
with evidence-based tables and references throughout the document. The
evidence consists of key clinical randomized controlled trials and
longitudinal studies in the area of weight loss and weight maintenance
therapy. Where existing literature is ambiguous or conflicting, or where
scientific data are lacking on an issue, recommendations are based on
the expert panel\'s opinion and clinical experience. The guideline
contains a bibliography and discussion of the evidence supporting each
recommendation.

The quality of the evidence supporting individual recommendations is
given for selected recommendations (see \"Major Recommendations\"
field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Weight loss improves blood pressure, cholesterol, glycemic control, and
obstructive sleep apnea and reduces incident hypertension and type 2
diabetes. Modest weight loss among overweight and obese adults will
reduce the incidence and severity of diabetes, a chronic condition that
is linked to significant morbidity, mortality, and healthcare costs.

#### POTENTIAL HARMS

-   Continuing a very low calorie diet (VLCD) for a long period may not
    be safe.

-   Potential adverse effects and precautions for drug therapy used in
    dyslipidemia are provided in Table F-1 in Appendix F of the original
    guideline document.

-   There are significant drug or nutrient interactions with
    anti-obesity agents. See Table F-3 in Appendix F in the original
    guideline document for a list of known drug interactions to date.

-   Bariatric surgery may be associated with stricture of
    gastrojejunonstomy, gastrointestinal bleeding, marginal ulcer, bowel
    obstruction, and complications of the *LapBand*. See Appendix G of
    the original guideline document for details.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Low-carbohydrate diets are contraindicated in patients with renal or
    hepatic disease and patients with diabetes that cannot monitor their
    blood sugars.

-   The use of sibutramine with a monoamine oxidase inhibitor (MAOI) is
    contraindicated.

-   Sibutramine is contraindicated in patients with uncontrolled
    hypertension and in patients who have a major eating disorder
    (anorexia nervosa or bulimia nervosa).

-   Women who are pregnant or who are considering pregnancy in the next
    two years should not be considered candidates for bariatric surgery.

-   Relative contraindications to bariatric surgery that are supported
    only by expert consensus include:

    -   Unstable coronary artery disease, severe pulmonary disease,
        portal hypertension or other conditions that can compromise
        anesthesia or wound healing

    -   Patients who are unable to comprehend basic principles of
        surgery or follow-up postoperative instructions

    -   Patients having had multiple abdominal operations, complicated
        incisional hernias

    -   Patients who have illnesses that greatly reduce life expectancy
        and/or are unlikely to be improved in their medical condition by
        surgically-induced weight reduction (e.g., cancer).

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The Department of Veterans Affairs (VA) and The Department of
    Defense (DoD) guidelines are based upon the best information
    available at the time of publication. They are designed to provide
    information and assist decision-making. They are not intended to
    define a standard of care, and should not be construed as one.
    Neither should they be interpreted as prescribing an exclusive
    course of management.

-   Variations in practice will inevitably and appropriately occur when
    clinicians take into account the needs of individual patients,
    available resources, and limitations unique to an institution or
    type of practice. Every healthcare professional making use of these
    guidelines is responsible for evaluating the appropriateness of
    applying them in the setting of any particular clinical situation.

-   Clinical practice guidelines, which are increasingly being used in
    health care, are seen by many as potential solutions to inefficiency
    and inappropriate variations in care. Guidelines should be
    evidenced-based as well as based upon explicit criteria to ensure
    consensus regarding their internal validity. However, it must be
    remembered that the use of guidelines must always be in the context
    of a health care provider\'s clinical judgment in the care of a
    particular patient. For that reason, the guidelines may be viewed as
    an educational tool analogous to textbooks and journals, but in a
    more user-friendly format.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Clinicians can use the algorithms to determine appropriate interventions
and timing of care for their patients and to better stratify obese and
overweight patients and optimize healthcare utilization. There is no
intent to restrict providers from using their clinical expertise in the
care of an individual patient. The guideline\'s recommendations should
facilitate, not replace, clinical judgment.

This guideline has been developed to assist Veterans Health
Administration (VHA) and Department of Defense (DoD) facilities to
implement processes of care that are evidence-based. The guideline is
designed to achieve maximum functionality and independence and improve
patient/family quality of life. The recommendations may provide
facilities lacking organized weight management care a structured
approach to confront the challenges in facing the obesity epidemic and
assure that veterans and active duty personnel who can benefit from
weight reduction will have access to comparable care, regardless of
geographic location. It is also meant to encourage each Veterans
Integrated Services Network (VISN) or DoD medical treatment facility
(MTF), or other care access sites in developing innovative plans, to
remove barriers that prevent patients from gaining prompt access to
preventive care and inhibit primary care providers, specialists, and
allied health professionals from working together.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Pocket Guide/Reference Cards\
Resources

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

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

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Management of Overweight and Obesity Working Group. VA/DoD clinical
practice guideline for screening and management of overweight and
obesity. Washington (DC): Department of Veterans Affairs, Department of
Defense; 2006. 117 p.

#### ADAPTATION

The guideline draws, in part, from:

-   U.S. Preventive Services Task Force. Screening for Obesity in
    Adults: Recommendations and Rationale. November 2003. Agency for
    Health Care Research and Quality, Rockville, MD.
    (<http://www.ahrq.gov/clinic/3rduspstf/obesity/obesrr.htm>).

-   National Institutes of Health (NIH), National Heart, Lung, and Blood
    Institute (NHLBI). Clinical Guidelines on the identification,
    evaluation, and treatment of overweight and obesity in Adults. The
    evidence report. NIH Publication No. 98-4083, 1998.

#### DATE RELEASED

2006 Dec

#### GUIDELINE DEVELOPER(S)

Department of Defense - Federal Government Agency \[U.S.\]\
Department of Veterans Affairs - Federal Government Agency \[U.S.\]\
Veterans Health Administration - Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

The Management of Obesity Working Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Veterans Affairs (VA) Working Group Members*: Nicky Goraya, MD
(*Co-chairman*); Alison Acerra, RD; Ariana Aoun, RD; Vanita Aroda, MD;
David Arterburn, MD; Charles Billington, MD; Mary Burdick, PhD; Melanie
Erskine, RN; Richard Harvey, PhD; Mary Jansen, PhD; Edward Livingston,
MD; Leonard Pogach, MD; Todd Semla, PharmD

*Department of Defense (DoD) Working Group Members*: Wayne Z. McBride,
DO (*Co-chairman*); Vincent F. Carr, DO; Sammy Choi, MD; Sally Glover,
RN; Joyce Grissom, MD; Vivian Hutson, RD; Dawn Johnson, DO; Subrina
Linscomb; Julie Liss, PharmD; Theresa Newlin, FNP; John Schriver, MD;
Michael Sigmon, MD; Margaret Voelker, RN, MN; Marjory Waterman, RN

*Facilitator*: Oded Susskind, MPH

*Evidence Appraisal Reports*: Vivian H. Coates, MPH; Eileen G. Erinoff;
Charles Turkelson, PhD

*Staff Support*: Rosalie Fishman, RN, MSN; Martha D\'Erasmo, MPH; Sarah
Carroll; Joanne Marko, MS, CCC; Kristyn O\'Reilley

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Department of Veterans Affairs
Web site](http://www.oqp.med.va.gov/cpg/OBE/OBE_base.htm).

Print copies: Available from the Department of Veterans Affairs,
Veterans Health Administration, Office of Quality and Performance (10Q)
810 Vermont Ave. NW, Washington, DC 20420.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Screening and management of overweight and obesity guideline summary
    -- update 2006. Washington (DC): Department of Veterans Affairs
    (U.S.); 2006. 23 p.

-   Management of overweight and obesity pocket guide -- update 2006.
    Washington (DC): Department of Veterans Affairs (U.S.); 2006. 2 p.

-   Screening and management of overweight and obesity key points card
    -- update 2006. Washington (DC): Department of Veterans Affairs
    (U.S.); 2006. 2 p.

Electronic copies: Available from the [Department of Veterans Affairs
Web site](http://www.oqp.med.va.gov/cpg/OBE/OBE_base.htm).

Print copies: Department of Veterans Affairs, Veterans Health
Administration, Office of Quality and Performance (10Q) 810 Vermont Ave.
NW, Washington, DC 20420.

In addition, the VHA Web site provides references to related guidelines,
performance measures, and other resources.

The following are also available:

-   Guideline for Guidelines. Draft. Washington (DC): Veterans Health
    Administration, Department of Veterans Affairs. Available from the :
    [VHA Web site](http://www.oqp.med.va.gov/cpg/policy.asp).

-   Guideline development process. Appendix A of the [original guideline
    document](http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/frameset.htm)

-   Putting clinical practice guidelines to work \[online tutorial\].
    Available from the [Department of Veterans Affairs Web
    site](http://www.oqp.med.va.gov/Training/WWW/010000000010.html).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on June 7, 2007.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

#### NGC DISCLAIMER

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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008