NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

NORTH AMERICAN ASSOCIATION FOR THE STUDY OF OBESITY

The Practical

Guide 

Identification,

Evaluation, 

and Treatment 

of Overweight and

Obesity in Adults

NHLBI Obesity Education Initiative 
ACKNOWLEDGMENTS:

The Working Group wishes to acknowledge

the additional input to the Practical Guide from

the following individuals: Dr. Thomas Wadden,

University of Pennsylvania; Dr. Walter Pories,

East Carolina University; Dr. Steven Blair,

Cooper Institute for Aerobics Research; and

Dr. Van S. Hubbard, National Institute of

Diabetes and Digestive and Kidney Diseases.
The Practical

Guide 

Identification,

Evaluation, 

and Treatment 

of Overweight and

Obesity in Adults

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication Number 00-4084

October 2000

NHLBI Obesity Education Initiative

North American Association for the Study of Obesity
NHLBI Obesity Education Initiative

Expert Panel on the Identification,

Evaluation, and Treatment of

Overweight and Obesity in Adults.

F.Xavier Pi-Sunyer, M.D., M.P.H. 

Columbia University College 

of Physicians and Surgeons 

Chair of the Panel

MEMBERS

Diane M. Becker, Sc.D., M.P.H. 

The Johns Hopkins University

Claude Bouchard, Ph.D.

Laval University

Richard A. Carleton, M.D.

Brown University School of Medicine

Graham A. Colditz, M.D., Dr.P.H.

Harvard Medical School

William H. Dietz, M.D., Ph.D.

National Center for Chronic Disease

Prevention and Health Promotion 

Centers for Disease Control and Prevention

John P. Foreyt, Ph.D.

Baylor College of Medicine

Robert J. Garrison, Ph.D.

University of Tennessee, Memphis

Scott M. Grundy, M.D., Ph.D.

University of Texas Southwestern 

Medical Center at Dallas

Barbara C. Hansen, Ph.D. 

University of Maryland School of Medicine

Millicent Higgins, M.D.

University of Michigan

James O. Hill, Ph.D.

University of Colorado 

Health Sciences Center

Barbara V. Howard, Ph.D.

Medlantic Research Institute

Robert J. Kuczmarski, Dr.P.H., R.D.

National Center for Health Statistics

Centers for Disease Control and Prevention

Shiriki Kumanyika, Ph.D., R.D., M.P.H.

The University of Pennsylvania

R. Dee Legako, M.D.

Prime Care Canyon Park 

Family Physicians, Inc.

T. Elaine Prewitt, Dr.P.H., R.D.

Loyola University Medical Center

Albert P. Rocchini, M.D. 

University of Michigan Medical Center

Philip L Smith, M.D.

The Johns Hopkins Asthma 

and Allergy Center

Linda G. Snetselaar, Ph.D., R.D. 

University of Iowa

James R. Sowers, M.D.

Wayne State University School of Medicine

University Health Center

Michael Weintraub, M.D.

Food and Drug Administration

David F. Williamson, Ph.D., M.S. 

Centers for Disease Control and Prevention

G. Terence Wilson, Ph.D.

Rutgers Eating Disorders Clinic

EX-OFFICIO MEMBERS

Clarice D. Brown, M.S.

Coda Research Inc.

Karen A. Donato, M.S., R.D.*

Executive Director of the Panel

Coordinator, NHLBI Obesity 

Education Initiative

National Heart, Lung, and Blood Institute

National Institutes of Health

Nancy Ernst, Ph.D., R.D.*

National Heart, Lung, and Blood Institute

National Institutes of Health

D. Robin Hill, Ph.D.*

National Heart, Lung, and Blood Institute

National Institutes of Health

Michael J. Horan, M.D., Sc.M.*

National Heart, Lung, and Blood Institute

National Institutes of Health

Van S. Hubbard, M.D., Ph.D.

National Institute of Diabetes and 

Digestive and Kidney Diseases

James P. Kiley, Ph.D.*

National Heart, Lung, and Blood Institute

National Institutes of Health

Eva Obarzanek, Ph.D., R.D., M.P.H.* 

National Heart, Lung, and Blood Institute

National Institutes of Health

*NHLBI Obesity Initiative Task Force Member

CONSULTANT

David Schriger, M.D., M.P.H., F.A.C.E.P.

University of California 

Los Angeles School of Medicine

SAN ANTONIO COCHRANE CENTER

Elaine Chiquette, Pharm.D.

Cynthia Mulrow, M.D., M.Sc.

V.A. Cochrane Center at San Antonio

Audie L. Murphy Memorial

Veterans Hospital

STAFF 

Adrienne Blount, Maureen Harris, M.S., R.D.,

Anna Hodgson, M.A., Pat Moriarty, M.Ed.,

R.D., R.O.W. Sciences, Inc.

North American Association for the 

Study of Obesity Practical Guide

Development Committee

Louis J. Aronne, M.D., F.A.C.P.

Cornell University, Chair

MEMBERS

Charles Billington, M.D.

University of Minnesota

George Blackburn, M.D., Ph.D.

Harvard University

Karen A. Donato, M.S., R. D.

NHLBI Obesity Education Initiative 

National Heart, Lung, and 

Blood Institute 

National Institutes of Health

Arthur Frank, M.D.

George Washington University

Susan Fried, Ph.D.

Rutgers University

Patrick Mahlen O'Neil, Ph.D.

Medical University of South Carolina

Henry Buchwald, M.D.

University of Minnesota

George Cowan, M.D.

University of Tennessee 

College of Medicine

Robert Brolin, M.D.

UMDNJ-Robert Wood Johnson 

Medical School

EX-OFFICIO MEMBERS

James O. Hill, Ph.D.

University of Colorado 

Health Sciences Center

Edward Bernstein, M.P.H.

North American Association 

for the Study of Obesity
iii

Foreword ......................................................................................................................................v

How To Use This Guide..............................................................................................................vi

Executive Summary ....................................................................................................................1

Assessment ..........................................................................................................................1

Body Mass Index...........................................................................................................1

Waist Circumference.....................................................................................................1

Risk Factors or Comorbidities.......................................................................................1

Readiness To Lose Weight............................................................................................2

Management.........................................................................................................................2

Weight Loss ..................................................................................................................2

Prevention of Weight Gain ............................................................................................2

Therapies..............................................................................................................................2

Dietary Therapy.............................................................................................................2

Physical Activity ............................................................................................................3

Behavior Therapy ..........................................................................................................3

Pharmacotherapy..........................................................................................................3

Weight Loss Surgery.....................................................................................................4

Special Situations.................................................................................................................4

Introduction..................................................................................................................................5

The Problem of Overweight and Obesity .............................................................................5

Treatment Guidelines..................................................................................................................7

Assessment and Classification of Overweight and Obesity.................................................8

Assessment of Risk Status ................................................................................................11

Evaluation and Treatment Strategy ....................................................................................15

Ready or Not: Predicting Weight Loss ...............................................................................21

Management of Overweight and Obesity...........................................................................23

Weight Management Techniques .............................................................................................25

Dietary Therapy ..................................................................................................................26

Physical Activity..................................................................................................................28

Behavior Therapy ...............................................................................................................30

Making the Most of the Patient Visit............................................................................30

Pharmacotherapy ...............................................................................................................35

Weight Loss Surgery..........................................................................................................38

Weight Reduction After Age 65 ...............................................................................................41

References .................................................................................................................................42

Table of Contents
iv

Introduction to the Appendices ...............................................................................................45

Appendix A. Body Mass Index Table..................................................................................46

Appendix B. Shopping—What to Look For ........................................................................47

Appendix C. Low Calorie, Lower Fat Alternatives..............................................................49

Appendix D. Sample Reduced Calorie Menus...................................................................51

Appendix E. Food Exchange List.......................................................................................57

Appendix F. Food Preparation—What to Do .....................................................................59

Appendix G. Dining Out—How To Choose.........................................................................60

Appendix H. Guide to Physical Activity ..............................................................................62

Appendix I. Guide to Behavior Change ............................................................................68

Appendix J. Weight and Goal Record ...............................................................................71

Appendix K. Weekly Food and Activity Diary.....................................................................74

Appendix L. Additional Resources.....................................................................................75

List of Tables

Table 1. Classifications for BMI .....................................................................................1

Table 2. Classification of Overweight and Obesity by BMI, Waist Circumference, 

and Associated Disease Risk........................................................................10

Table 3. A Guide to Selecting Treatment.....................................................................25

Table 4. Low-Calorie Step I Diet .................................................................................27

Table 5. Examples of Moderate Amounts of Physical Activity ....................................29

Table 6. Weight Loss Drugs ........................................................................................36

List of Figures

Figure 1. Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and 

Obesity (BMI ≥ 30) ..........................................................................................6

Figure 2. NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP), 

High Total Blood Cholesterol (TBC), and Low-HDL by Two BMI Categories ..6

Figure 3. Measuring-Tape Position for Waist (Abdominal) Circumference in Adults ......9

Figure 4. Treatment Algorithm ......................................................................................16

Figure 5. Surgical Procedures in Current Use..............................................................38
v

I

n June 1998, the Clinical Guidelines on the

Identification, Evaluation, and Treatment of

Overweight and Obesity in Adults: Evidence

Report was released by the National Heart, Lung,

and Blood Institute’s (NHLBI) Obesity Education

Initiative in cooperation with the National Institute 

of Diabetes and Digestive and Kidney Diseases

(NIDDK). The impetus behind the clinical practice

guidelines was the increasing prevalence of overweight and obesity in the United States and the need

to alert practitioners to accompanying health risks. 

The Expert Panel that developed the guidelines 

consisted of 24 experts, 8 ex-officio members, and a

consultant methodologist representing the fields of

primary care, clinical nutrition, exercise physiology,

psychology, physiology, and pulmonary disease. 

The guidelines were endorsed by representatives 

of the Coordinating Committees of the National

Cholesterol Education Program and the National 

High Blood Pressure Education Program, the North

American Association for the Study of Obesity, and

the NIDDK National Task Force on the Prevention

and Treatment of Obesity.

This Practical Guide to the Identification, Evaluation,

and Treatment of Overweight and Obesity in Adults is

largely based on the evidence report prepared by the

Expert Panel and describes how health care practitioners can provide their patients with the direction and

support needed to effectively lose weight and keep it

off. It provides the basic tools needed to appropriately

assess and manage overweight and obesity. 

The guide includes practical information on dietary

therapy, physical activity, and behavior therapy, while

also providing guidance on the appropriate use of

pharmacotherapy and surgery as treatment options. 

The Guide was prepared by a working group convened by the North American Association for the

Study of Obesity and the National Heart, Lung, and

Blood Institute. Three members of the American

Society for Bariatric Surgery also participated in 

the working group. Members of the Expert Panel,

especially the Panel Chairman, assisted in the review

and development of the final product. Special thanks

are also due to the 50 representatives of the various

disciplines in primary care and others who reviewed

the preprint of the document and provided the 

working group with excellent feedback.

The Practical Guide will be distributed to primary

care physicians, nurses, registered dietitians, and

nutritionists as well as to other interested health care

practitioners. It is our hope that the tools provided here

help to complement the skills needed to effectively

manage the millions of overweight and obese individuals who are attempting to manage their weight.

David York, Ph.D. Claude Lenfant,M.D.

President Director

North American Association National Heart, Lung,

for the Study of Obesity and Blood Institute

National Institutes 

of Health

Foreword
vi

Overweight and obesity, serious and growing health problems, are not receiving 

the attention they deserve from primary care practitioners. Among the reasons 

cited for not treating overweight and obesity is the lack of authoritative information 

to guide treatment. This Practical Guide to the Identification, Evaluation, and 

Treatment of Overweight and Obesity in Adults was developed cooperatively by 

the North American Association for the Study of Obesity (NAASO) and the National Heart,

Lung, and Blood Institute (NHLBI). It is based on the Clinical Guidelines on the Identification,

Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report developed by 

the NHLBI Expert Panel and released in June 1998. The Expert Panel used an evidence-based 

methodology to develop key recommendations for assessing and treating overweight and obese

patients. The goal of the Practical Guide is to provide you with the tools you need to effectively 

manage your overweight and obese adult patients in an efficient manner.

The Guide has been developed to help you easily access all of the information you need.

The Executive Summary contains the essential information in an abbreviated form. 

The Treatment Guidelines section offers details on assessment and management of patients 

and features the Expert Panel’s Treatment Algorithm, which provides a step-by-step approach 

to learning how to manage patients. 

The Appendix contains practical tools related to diet, physical activity, and behavioral 

modification needed to educate and inform your patients. The Appendix has been formatted 

so that you can copy it and explain it to your patients.

Managing overweight and obese patients requires a variety of skills. Physicians play a key role in 

evaluating and treating such patients. Also important are the special skills of nutritionists, registered 

dietitians, psychologists, and exercise physiologists. Each health care practitioner can help patients 

learn to make some of the changes they may need to make over the long term. Organizing a “team”

of various health care practitioners is one way of meeting the needs of patients. If that approach is 

not possible, patients can be referred to other specialists required for their care. 

To get started, just follow the Ten Step approach.

How to Use This Guide
vii

2

3

Measure height and weight so that you can

estimate your patient’s BMI from the table 

in Appendix A.

Measure waist circumference 

as described on page 9.

Assess comorbidities as described on 

pages 11–12 in the section on 

“Assessment of Risk Status.”

Should your patient be treated? Take the

information you have gathered above and use

Figure 4, the Treatment Algorithm, on pages

16 –17 to decide. Pay particular attention to

Box 7 and the accompanying explanatory

text. If the answer is “yes” to treatment,

decide which treatment is best using Table 3

on page 25.

Is the patient ready and motivated to lose

weight? Evaluation of readiness should

include the following: (1) reasons and 

motivation for weight loss, (2) previous

attempts at weight loss, (3) support expected

from family and friends, (4) understanding of

risks and benefits, (5) attitudes toward 

physical activity, (6) time availability,

and (7) potential barriers to the patient’s

adoption of change.

Which diet should you recommend?

In general, diets containing 1,000 to 1,200

kcal/day should be selected for most women;

a diet between 1,200 kcal/day and 1,600

kcal/day should be chosen for men and may

be appropriate for women who weigh 165

pounds or more, or who exercise regularly. If

the patient can stick with the 1,600 kcal/day

diet but does not lose weight you may want to

try the 1,200 kcal/day diet. If a patient on

either diet is hungry, you may want to

increase the calories by 100 to 200 per day.

Included in Appendix D are samples of both 

a 1,200 and 1,600 calorie diet.

Discuss a physical activity goal with the

patient using the Guide to Physical Activity

(see Appendix H). Emphasize the importance

of physical activity for weight maintenance

and risk reduction.

Review the Weekly Food and Activity

Diary (see Appendix K) with the patient.

Remind the patient that record-keeping has

been shown to be one of the most successful

behavioral techniques for weight loss and

maintenance. Write down the diet, physical

activity, and behavioral goals you have agreed

on at the bottom.

Give the patient copies of the dietary 

information (see Appendices B–G),

the Guide to Physical Activity (see

Appendix H), the Guide to Behavior 

Change (see Appendix I), and the Weekly

Food and Activity Diary (see Appendix K).

Enter the patient’s information and the

goals you have agreed on in the Weight and

Goal Record (see Appendix J). It is important

to keep track of the goals you have set and 

to ask the patient about them at the next visit

to maximize compliance. Have the patient

schedule an appointment to see you or your

staff for followup in 2 to 4 weeks.

4

5

7

8

9

6 10

1

Ten Steps to Treating Overweight and Obesity in the Primary Care Setting

1

Successful treatment ... 

A lifelong effort.

Treatment of an overweight or

obese person incorporates a twostep process: assessment and 

management. Assessment includes

determination of the degree of 

obesity and overall health status.

Management involves not only

weight loss and maintenance of

body weight but also measures to

control other risk factors. Obesity 

is a chronic disease; patient and

practitioner must understand that

successful treatment requires a 

lifelong effort. Convincing evidence

supports the benefit of weight loss

for reducing blood pressure,

lowering blood glucose, and

improving dyslipidemias.

Assessment

Body Mass Index

Assessment of a patient should

include the evaluation of body mass

index (BMI), waist circumference,

and overall medical risk. To estimate BMI, multiply the individual’s

weight (in pounds) by 703, then

divide by the height (in inches)

squared. This approximates BMI 

in kilograms per meter squared

(kg/m2). There is evidence to support the use of BMI in risk assessment since it provides a more accurate measure of total body fat compared with the assessment of body

weight alone. Neither bioelectric

impedance nor height-weight tables

provide an advantage over BMI 

in the clinical management of 

all adult patients, regardless of 

gender. Clinical judgment must be

employed when evaluating very

muscular patients because BMI may

overestimate the degree of fatness in

these patients. The recommended

classifications for BMI, adopted 

by the Expert Panel on the

Identification, Evaluation, and

Treatment of Overweight and

Obesity in Adults and endorsed by

leading organizations of health 

professionals, are shown in Table 1. 

Waist Circumference

Excess abdominal fat is an important, independent risk factor for disease. The evaluation of waist circumference to assess the risks associated with obesity or overweight is

supported by research. The measurement of waist-to-hip ratio provides

no advantage over waist circumference alone. Waist circumference

measurement is particularly useful in

patients who are categorized as normal or overweight. It is not necessary to measure waist circumference

in individuals with BMIs ≥ 35 kg/m2

since it adds little to the predictive

power of the disease risk classification of BMI. Men who have waist

circumferences greater than 40 inches, and women who have waist circumferences greater than 35 inches,

are at higher risk of diabetes, dyslipidemia, hypertension, and cardiovascular disease because of excess

abdominal fat. Individuals with

waist circumferences greater than

these values should be considered

one risk category above that defined

by their BMI. The relationship

between BMI and waist circumference for defining risk is shown in

Table 2 on page 10.

Risk Factors or Comorbidities

Overall risk must take into account

the potential presence of other risk

factors. Some diseases or risk 

factors associated with obesity place

patients at a high absolute risk for

Executive Summary

BMI

Underweight <18.5 kg/m2

Normal weight 18.5–24.9 kg/m2

Overweight 25–29.9 kg/m2

Obesity (Class 1) 30–34.9 kg/m2

Obesity (Class 2) 35–39.9 kg/m2

Extreme obesity (Class 3) ≥40 kg/m2

Classifications for BMI

Table 1
2

subsequent mortality; these will

require aggressive management.

Other conditions associated with

obesity are less lethal but still

require treatment. 

Those diseases or conditions that

denote high absolute risk are 

established coronary heart disease,

other atherosclerotic diseases,

type 2 diabetes, and sleep apnea.

Osteoarthritis, gallstones, stress

incontinence, and gynecological

abnormalities such as amenorrhea

and menorrhagia increase risk but

are not generally life-threatening.

Three or more of the following 

risk factors also confer high

absolute risk: hypertension, cigarette smoking, high low-density

lipoprotein cholesterol, low 

high-density lipoprotein cholesterol, impaired fasting glucose,

family history of early cardiovascular disease, and age (male ≥ 45

years, female ≥ 55 years). The 

integrated approach to assessment

and management is portrayed in

Figure 4 on pages 16–17

(Treatment Algorithm).

Readiness To Lose Weight

The decision to attempt weight-loss

treatment should also consider the

patient’s readiness to make the necessary lifestyle changes. Evaluation 

of readiness should include the 

following:

Reasons and motivation 

for weight loss

Previous attempts at weight loss

Support expected from family 

and friends

Understanding of risks 

and benefits

Attitudes toward physical 

activity

Time availability 

Potential barriers, including

financial limitations, to the

patient’s adoption of change

Management

Weight Loss

Individuals at lesser risk should be

counseled about effective lifestyle

changes to prevent any further

weight gain. Goals of therapy are to

reduce body weight and maintain a

lower body weight for the long

term; the prevention of further

weight gain is the minimum goal.

An initial weight loss of 10 percent

of body weight achieved over 6

months is a recommended target.

The rate of weight loss should be 1

to 2 pounds each week. Greater

rates of weight loss do not achieve

better long-term results. After the

first 6 months of weight loss therapy, the priority should be weight

maintenance achieved through combined changes in diet, physical activity, and behavior. Further weight loss

can be considered after a period of

weight maintenance.

Prevention of Weight Gain

In some patients, weight loss or 

a reduction in body fat is not

achievable. A goal for these

patients should be the prevention

of further weight gain. Prevention

of weight gain is also an appropriate goal for people with a BMI

of 25 to 29.9 who are not otherwise at high risk.

Therapies 

A combination of diet modification,

increased physical activity, and

behavior therapy can be effective.

Dietary Therapy

Caloric intake should be reduced 

by 500 to 1,000 calories per day

(kcal/day) from the current level.

Most overweight and obese people

should adopt long-term nutritional

adjustments to reduce caloric intake.

Dietary therapy includes instructions

for modifying diets to achieve this

goal. Moderate caloric reduction 

is the goal for the majority of cases;

however, diets with greater caloric

deficits are used during active

weight loss. The diet should be low

in calories, but it should not be too

low (less than 800 kcal/day). Diets

Weight loss therapy is 

recommended for patients 

with a BMI ≥ 30 and for patients

with a BMI between 25 and 29.9

OR a high-risk waist 

circumference, and two 

or more risk factors.
3

lower than 800 kcal/day have been

found to be no more effective than

low-calorie diets in producing

weight loss. They should not be

used routinely, especially not by

providers untrained in their use. 

In general, diets containing 

1,000 to 1,200 kcal/day should be

selected for most women; a diet

between 1,200 kcal/day and 1,600

kcal/day should be chosen for 

men and may be appropriate for

women who weigh 165 pounds 

or more, or who exercise.

Long-term changes in food choices

are more likely to be successful

when the patient’s preferences are

taken into account and when the

patient is educated about food composition, labeling, preparation, and

portion size. Although dietary fat is

a rich source of calories, reducing

dietary fat without reducing calories

will not produce weight loss.

Frequent contact with practitioners

during the period of diet adjustment

is likely to improve compliance.

Physical Activity

Physical activity has direct 

and indirect benefits.

Increased physical activity is 

important in efforts to lose weight

because it increases energy expenditure and plays an integral role in

weight maintenance. Physical activity also reduces the risk of heart

disease more than that achieved by

weight loss alone. In addition,

increased physical activity may help

reduce body fat and prevent the

decrease in muscle mass often

found during weight loss. For the

obese patient, activity should generally be increased slowly, with care

taken to avoid injury. A wide variety of activities and/or household

chores, including walking, dancing,

gardening, and team or individual

sports, may help satisfy this goal.

All adults should set a long-term

goal to accumulate at least 30 minutes or more of moderate-intensity

physical activity on most, and

preferably all, days of the week.

Behavior Therapy

Including behavioral therapy 

helps with compliance.

Behavior therapy is a useful adjunct

to planned adjustments in food

intake and physical activity.

Specific behavioral strategies

include the following: self-monitoring, stress management, stimulus

control, problem-solving, contingency management, cognitive

restructuring, and social support.

Behavioral therapies may be

employed to promote adoption of

diet and activity adjustments; these

will be useful for a combined

approach to therapy. Strong evidence supports the recommendation

that weight loss and weight maintenance programs should employ a

combination of low-calorie diets,

increased physical activity, and

behavior therapy.

Pharmacotherapy

Pharmacotherapy may be helpful

for eligible high-risk patients.

Pharmacotherapy, approved by the

FDA for long-term treatment, can

be a helpful adjunct for the treatment of obesity in some patients.

These drugs should be used only in

the context of a treatment program

that includes the elements described

previously—diet, physical activity

changes, and behavior therapy. 

If lifestyle changes do not promote

weight loss after 6 months, drugs

Reductions of 500 

to 1,000 kcal/day 

will produce a recommended weight loss of 

1 to 2 pounds per week.

1,000 to 1,200 kcal/day 

for most women

1,200 to 1,600 kcal/day

should be chosen for men 
4

should be considered. Pharmacotherapy is currently limited to those

patients who have a BMI ≥ 30, or

those who have a BMI ≥ 27 if concomitant obesity-related risk factors

or diseases exist. However, not all

patients respond to a given drug. 

If a patient has not lost 4.4 pounds

(2 kg) after 4 weeks, it is not likely

that this patient will benefit from

the drug. Currently, sibutramine and

orlistat are approved by the FDA

for long-term use in weight loss.

Sibutramine is an appetite suppressant that is proposed to work via

norepinephrine and serotonergic

mechanisms in the brain. Orlistat

inhibits fat absorption from the

intestine. Both of these drugs have

side effects. Sibutramine may

increase blood pressure and induce

tachycardia; orlistat may reduce the

absorption of fat-soluble vitamins

and nutrients. The decision to add a

drug to an obesity treatment program should be made after consideration of all potential risks and

benefits and only after all behavioral options have been exhausted.

Weight Loss Surgery

Surgery is an option for patients

with extreme obesity.

Weight loss surgery provides 

medically significant sustained

weight loss for more than 5 years 

in most patients. Although there 

are risks associated with surgery,

it is not yet known whether these

risks are greater in the long term

than those of any other form of

treatment. Surgery is an option 

for well-informed and motivated

patients who have clinically severe

obesity (BMI ≥ 40) or a BMI ≥ 35

and serious comorbid conditions.

(The term “clinically severe 

obesity” is preferred to the once

commonly used term “morbid 

obesity.”) Surgical patients should

be monitored for complications and

lifestyle adjustments throughout

their lives.

Special Situations

Involve other health 

professionals when possible,

especially for special situations.

Although research regarding 

obesity treatment in older people 

is not abundant, age should not 

preclude therapy for obesity. In

people who smoke, the risk of

weight gain is often a barrier to

smoking cessation. In these

patients, cessation of smoking

should be encouraged first, and

weight loss therapy should be 

an additional goal. 

A weight loss and maintenance 

program can be conducted by a

practitioner without specialization

in weight loss so long as that 

person has the requisite interest 

and knowledge. However, a 

variety of practitioners with 

special skills are available and 

may be enlisted to assist in the

development of a program.

clinically severe obesity 

(BMI ≥ 40) or a BMI ≥ 35 

and serious comorbid 

conditions may warrant 

surgery for weight loss.

A combination of diet modification,

increased physical activity, and 

behavior therapy can be effective.

Effective Therapies
5

Obesity is a complex,

multifactorial disease

that develops from

the interaction

between genotype

and the environment. Our understanding of how and why obesity

occurs is incomplete; however, it

involves the integration of social,

behavioral, cultural, physiological,

metabolic, and genetic factors.1

Today, health care practitioners are

encouraged to play a greater role in

the management of obesity. Many

physicians are seeking guidance in

effective methods of treatment. 

This guide provides the basic tools

needed to assess and manage overweight and obesity in an office setting. A physician who is familiar

with the basic elements of these services can more successfully fulfill

the critical role of helping the

patient improve health by identifying the problem and coordinating

other resources within the community to assist the patient.

Effective management of overweight

and obesity can be delivered by a

variety of health care professionals

with diverse skills working as a

team. For example, physician

involvement is needed for the initial

assessment of risk and the prescription of appropriate treatment programs that may include pharmacotherapy, surgery, and the medical

management of the comorbidities of

obesity. In addition, physicians can

and should engage the assistance of

other professionals. This guide provides the basic tools needed to

assess and manage overweight and

obesity for a variety of health professionals, including nutritionists, registered dietitians, exercise physiologists, nurses, and psychologists.

These professionals offer expertise

in dietary counseling, physical activity, and behavior changes and can be

used for assessment, treatment, and

followup during weight loss and

weight maintenance. The relationship between the practitioner and

these professionals can be a direct,

formal one (as a “team”), or it may

be based on an indirect referral. A

positive, supportive attitude and

encouragement from all professionals are crucial to the continuing success of the patient.

The Problem of 

Overweight and Obesity

An estimated 97 million adults in the

United States are overweight or

obese.2 These conditions substantially increase the risk of morbidity

from hypertension,3 dyslipidemia,4

type 2 diabetes,5,6,7,8 coronary artery

disease,9 stroke,10 gallbladder disease,11 osteoarthritis,12 and sleep

apnea and respiratory problems,13 as

well as cancers of the endometrium,

breast, prostate, and colon.14 Higher

body weights are also associated

with an increase in mortality from

all causes.5 Obese individuals may

also suffer from social stigmatization

and discrimination. As a major cause

of preventable death in the United

States today,15 overweight and obesity

pose a major public health challenge.

However, overweight and obesity are

not mutually exclusive, since obese

persons are also overweight. A BMI

of 30 indicates an individual is about

30 pounds overweight; it may be

exemplified by a 221-pound person

who is 6 feet tall or a 186-pound individual who is 5 feet 6 inches tall. The

number of overweight and obese men

and women has risen since 1960

(Figure 1); in the last decade, the percentage of adults, ages 20 years or

older, who are in these categories has

increased to 54.9 percent.2 Overweight and obesity are especially evident in some minority groups, as

well as in those with lower incomes

and less education.16,17

The presence of overweight and obesity in a patient is of medical concern for several reasons. It increases

the risk for several diseases, particularly cardiovascular diseases (CVD)

and diabetes mellitus.7,8 Data from

NHANES III show that morbidity

for a number of health conditions

increases as BMI increases in both

men and women (Figure 2).

Introduction

According to the Expert Panel,

overweight is defined as a body

mass index (BMI) of 25 to

29.9 kg/m2, and obesity is

defined as a BMI ≥ 30 kg/m2

.
6

50

40

30

20

10

0 Men Women

Percent Prevalence

Men Women

(BMI 25–29.9) (BMI ≥ 30)

NHES I (1960-62)

NHANES I (1971-74)

NHANES II (1976-80)

NHANES III (1988-94)

Source: CDC/NCHS. United States. 1960-94, Ages 20-74 years. For comparison across surveys, data for subjects ages 20

to 74 years were age-adjusted by the direct method to the total U.S. population for 1980, using the age-adjusted categories

20-29y, 30-39y, 40-49y, 50-59y, 60-69y, and 70-79y.

<25 ≥30

18.3

HBP TBC HDL

<25 ≥30 <25 ≥30

BMI 

* Defined as mean systolic blood pressure > 140 mm Hg, mean diastolic blood pressure > 90 mm Hg,

or currently taking antihypertensive medication.

† Defined as > 240 mg/dl.

‡ Defined as < 35 mg/dl in men and < 45 mg/dl in women.

Source: Brown C et al. Body mass index and the prevalence of hypertension and dyslipidemia (in press).

45

40

35

30

25

20

15

10

5

0

16.2

39.2

32.4

14.7 14.6

20.2

24.3

9.3

16.3

31.5

42.0

37.8

41.1 39.1 39.4

23.6 23.6

24.3 24.7

10.4 11.3 12.2

19.9

15.1 16.1 16.3

24.9

Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI ≥ 30)

Figure 1

NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),* High Total

Blood Cholesterol (TBC),† and Low-HDL‡ by Two BMI Categories

Figure 2

Men

Women
7

Although there is agreement about the health risks of

overweight and obesity, there is less agreement about

their management. Some have argued against treating

obesity because of the difficulty in maintaining 

long-term weight loss, and because of the potentially

negative consequences of weight cycling, a pattern frequently seen

in obese individuals. Others argue that the potential hazards of 

treatment do not outweigh the known hazards of being obese. 

The treatment guidelines provided are based on the most thorough

examination of the scientific evidence reported to date on the 

effectiveness of various treatment strategies available for weight loss

and weight maintenance.

Treatment of the overweight and obese patient is a two-step process:

assessment and management. 

Assessment requires determination of the degree of obesity 

and the absolute risk status. 

Management includes the reduction of excess weight and 

maintenance of this lower body weight, as well as the institution

of additional measures to control any associated risk factors. 

The aim of this guide is to provide useful advice on how to 

achieve weight reduction and how to maintain a lower body weight.

Obesity is a chronic disease; the patient and the practitioner need 

to understand that successful treatment requires a lifelong effort.

Treatment Guidelines

Tailor Treatment to the 

Needs of the Patient

Standard treatment approaches 

for overweight and obesity must 

be tailored to the needs of various

patients or patient groups. Large

individual variation exists within

any social or cultural group; furthermore, substantial overlap

occurs among subcultures within

the larger society. There is, therefore, no “cookbook” or standardized set of rules to optimize weight

reduction with a given type of

patient. However, obesity treatment

programs that are culturally 

sensitive and incorporate a

patient’s characteristics must do

the following:

Adapt the setting and staffing 

for the program.

Understand how the obesity 

treatment program integrates 

into other aspects of the patient’s

health care and self-care.

Expect and allow modifications to

a program based on a patient’s

response and preferences.
8

Although accurate methods to

assess body fat exist, the

measurement of body fat by

these techniques is expensive and is 

often not readily available to most

clinicians. Two surrogate measures

are important to assess body fat:

Body mass index (BMI)

Waist circumference

BMI is recommended as a practical

approach for assessing body fat in

the clinical setting. It provides a

more accurate measure of total

body fat compared with the assessment of body weight alone.18

The typical body weight tables are

based on mortality outcomes, and

they do not necessarily predict morbidity. However, BMI has some

limitations. For example, BMI overestimates body fat in persons who

are very muscular, and it can underestimate body fat in persons who

have lost muscle mass (e.g., many

elderly). BMI is a direct calculation

based on height and weight, regardless of gender.

Waist circumference is the most

practical tool a clinician can use to

evaluate a patient’s abdominal fat

before and during weight loss treatment (Figure 3). Computed tomography19 and magnetic resonance

imaging20 are both more accurate

but are impractical for routine clinical use. Fat located in the abdominal region is associated with a

greater health risk than peripheral

fat (i.e., fat in the gluteal-femoral

region). Furthermore, abdominal fat

appears to be an independent risk

predictor when BMI is not markedly increased.21,22Therefore, waist or

abdominal circumference and BMI

should be measured not only for the

initial assessment of obesity but

also for monitoring the efficacy 

of the weight loss treatment for

patients with a BMI < 35.

The primary classification of overweight and obesity is based on the

assessment of BMI. This classification, shown in Table 2, relates BMI

to the risk of disease. It should be

noted that the relationship between

BMI and disease risk varies among

individuals and among different

populations. Some individuals with

mild obesity may have multiple risk

factors; others with more severe

obesity may have fewer risk factors.

Assessment and Classification 

of Overweight and Obesity

You can calculate BMI as follows

Calculation Directions and Sample

Here is a shortcut method for calculating

BMI. (Example: for a person who is 5 feet

5 inches tall weighing 180 lbs.)

1. Multiply weight (in pounds) by 703 

180 x703 =126,540

2. Multiply height (in inches) by height 

(in inches) 

65 x 65 =4,225

3. Divide the answer in step 1 by the 

answer in step 2 to get the BMI.

126,540/4,225 = 29.9

BMI = 29.9

High-Risk Waist

Circumference

Men: > 40 in (> 102 cm)

Women: > 35 in (> 88 cm)

If pounds and inches are used

BMI = weight (pounds) x 703

height squared (inches2)

A BMI chart is provided in Appendix A.

BMI = weight (kg)

height squared (m2)

A high waist circumference is associated with an increased risk for type 2 

diabetes, dyslipidemia, hypertension,

and CVD in patients with a BMI

between 25 and 34.9 kg/m2.

Disease Risks
9

It should be noted that the risk levels for disease depicted in Table 2

are relative risks; in other words,

they are relative to the risk at 

normal body weight. There are no 

randomized, controlled trials that

support a specific classification system to establish the degree of disease risk for patients during weight

loss or weight maintenance.

Although waist circumference and

BMI are interrelated, waist circumference provides an independent

prediction of risk over and above

that of BMI. The waist circumference measurement is particularly

useful in patients who are categorized as normal or overweight in

terms of BMI. For individuals with

a BMI ≥ 35, waist circumference

adds little to the predictive power 

of the disease risk classification of

BMI. A high waist circumference is

associated with an increased risk for

type 2 diabetes, dyslipidemia,

hypertension, and CVD in 

patients with a BMI between 

25 and 34.9 kg/m.2,25

In addition to measuring BMI,

monitoring changes in waist circumference over time may be helpful; it can provide an estimate of

increases or decreases in abdominal

fat, even in the absence of changes

in BMI. Furthermore, in obese

patients with metabolic complications, changes in waist circumferTo measure waist 

circumference, locate

the upper hip bone and

the top of the right iliac

crest. Place a measuring tape in a horizontal

plane around the abdomen at the level of the

iliac crest. Before reading the tape measure,

ensure that the tape is

snug, but does not

compress the skin, and

is parallel to the floor.

The measurement is

made at the end of a

normal expiration.

Waist Circumference Measurement

Figure 3

Clinical judgment must be

used in interpreting BMI

in situations that may affect its

accuracy as an indicator of total

body fat. Examples of these 

situations include the presence 

of edema, high muscularity, muscle

wasting, and individuals who are

limited in stature. The relationship

between BMI and body fat content

varies somewhat with age, gender,

and possibly ethnicity because of

differences in the composition of

lean tissue, sitting height, and

hydration state.23,24 For example,

older persons often have lost 

muscle mass; thus, they have 

more fat for a given BMI than

younger persons. Women may 

have more body fat for a given 

BMI than men, whereas patients

with clinical edema may have less

fat for a given BMI compared with

those without edema. Nevertheless,

these circumstances do not

markedly influence the validity of

BMI for classifying individuals into

broad categories of overweight 

and obesity in order to monitor 

the weight status of individuals 

in clinical settings.23

Measuring-Tape Position for Waist

(Abdominal) Circumference in Adults
10

ence are useful predictors of

changes in cardiovascular disease

(CVD) risk factors.27 Men are at

increased relative risk if they have 

a waist circumference greater than

40 inches (102 cm); women are at

an increased relative risk if they

have a waist circumference greater

than 35 inches (88 cm).

There are ethnic and age-related

differences in body fat distribution

that modify the predictive validity

of waist circumference as a surrogate for abdominal fat.23 In some

populations (e.g., Asian Americans

or persons of Asian descent), waist

circumference is a better indicator

of relative disease risk than BMI.28

For older individuals, waist circumference assumes greater value for

estimating risk of obesity-related

diseases. Table 2 incorporates both

BMI and waist circumference in 

the classification of overweight and

obesity and provides an indication

of relative disease risk.

Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk*

Disease Risk*

BMI Obesity Class (Relative to Normal Weight

(kg/m2) and Waist Circumference)

Men ≤40 in (≤ 102 cm) > 40 in (> 102 cm)

Women ≤ 35 in (≤ 88 cm) > 35 in (> 88 cm)

Underweight < 18.5 - -

Normal† 18.5–24.9 - -

Overweight 25.0–29.9 Increased High

Obesity 30.0–34.9 I High Very High

35.0–39.9 II Very High Very High

Extreme Obesity ≥ 40 III Extremely High Extremely High

* Disease risk for type 2 diabetes, hypertension, and CVD.

† Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

Adapted from “Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity.” WHO, Geneva, June 1997.26

Table 2
11

Assessment of the patient’s risk

status includes the determination of the following: the

degree of overweight or obesity

using BMI, the presence of abdominal obesity using waist circumference, and the presence of concomitant CVD risk factors or comorbidities. Some obesity-associated diseases and risk factors place patients

in a very high-risk category for subsequent mortality. Patients with these

diseases will require aggressive modification of risk factors in addition to

the clinical management of the disease. Other obesity-associated diseases are less lethal but still require

appropriate clinical therapy. Obesity

also has an aggravating influence on 

several cardiovascular risk factors.

Identification of these risk factors is

required to determine the intensity 

of a clinical intervention.

1. Determine the relative risk 

status based on overweight

and obesity parameters. Table

2 defines relative risk categories

according to BMI and waist 

circumference. They relate to 

the need to institute weight loss

therapy, but they do not define

the required intensity of risk 

factor modification. The latter 

is determined by the estimation 

of absolute risk based on the

presence of associated disease 

or risk factors.

2. Identify patients at very high

absolute risk. Patients with the

following diseases have a very

high absolute risk that triggers

the need for intense risk-factor

modification and management 

of the diseases present:

Established coronary heart 

disease (CHD), including a 

history of myocardial infarction,

angina pectoris (stable or unstable), coronary artery surgery,

or coronary artery procedures 

(e.g., angioplasty).

Presence of other atherosclerotic

diseases, including peripheral 

arterial disease, abdominal aortic

aneurysm, or symptomatic carotid

artery disease.

Type 2 diabetes (fasting plasma

glucose ≥ 126 mg/dL or 2-h 

postprandial plasma glucose

≥ 200 mg/dL) is a major risk factor for CVD. Its presence alone

places a patient in the category 

of very high absolute risk. 

Sleep apnea. Symptoms and

signs include very loud snoring

or cessation of breathing during

sleep, which is often followed 

by a loud clearing breath, then

brief awakening.

3. Identify other obesity-associated diseases. Obese patients 

are at increased risk for several

conditions that require detection

and appropriate management 

but that generally do not lead 

to widespread or life-threatening

consequences. These include

gynecological abnormalities

(e.g., menorrhagia, amenorrhea),

osteoarthritis, gallstones and

Assessment of Risk Status

Men are at increased relative risk for disease if they have a waist

circumference greater than 40 inches (102 cm); women are at an

increased relative risk if they have a waist circumference greater

than 35 inches (88 cm).
12

their complications, and stress

incontinence. Although obese

patients are at increased risk for

gallstones, the risk of this disease increases during periods of

rapid weight reduction.

4. Identify cardiovascular risk

factors that impart a high

absolute risk. Patients can be

classified as being at high

absolute risk for obesity-related

disorders if they have three or

more of the multiple risk factors

listed in the chart above. The

presence of high absolute risk

increases the attention paid to

cholesterol-lowering therapy29

and blood pressure management.30

Other risk factors deserve special

consideration because their presence heightens the need for weight

reduction in obese persons. 

Physical inactivity imparts an

increased risk for both CVD and

type 2 diabetes.31 Physical inactivity exacerbates the severity of

other risk factors, but it also has

been shown to be an independent risk factor for all-cause

mortality or CVD mortality.32,33

Although physical inactivity is

not listed as a risk factor that

modifies the intensity of therapy

required for elevated cholesterol

or blood pressure, increased

physical activity is indicated for

management of these conditions

(please see the Adult Treatment

Cigarette smoking.

Hypertension 

(systolic blood pressure

of ≥140 mm Hg or diastolic

blood pressure ≥ 90 mm Hg) 

or current use of antihypertensive agents.

High-risk low-density 

lipoprotein (LDL) cholesterol

(serum concentration

≥ 160 mg/dL). A borderline 

high-risk LDL-cholesterol 

(130 to 159 mg/dL) plus two 

or more other risk factors also

confers high risk.

Low high-density lipoprotein

(HDL) cholesterol (serum 

concentration < 35 mg/dL).

Impaired fasting glucose

(IFG) (fasting plasma glucose

between 110 and 125 mg/dL).

IFG is considered by many

authorities to be an independent

risk factor for cardiovascular

(macrovascular) disease, thus

justifying its inclusion among 

risk factors contributing to 

high absolute risk. IFG is 

well established as a risk 

factor for type 2 diabetes.

Family history of premature

CHD (myocardial infarction 

or sudden death experienced 

by the father or other male 

first-degree relative at or before

55 years of age, or experienced

by the mother or other female

first-degree relative at or before

65 years of age).

Age ≥ 45 years for men or

age ≥ 55 years for women 

(or postmenopausal).

Risk Factors
13

Panel II [ATP II29] of the

National Cholesterol Education

Program and the Sixth Report of

the Joint National Committee on

the Prevention, Detection,

Evaluation, and Treatment of

High Blood Pressure [JNC VI30]).

Increased physical activity is

especially needed in obese

patients because it promotes

weight reduction as well as

weight maintenance, and 

favorably modifies obesityassociated risk factors.

Conversely, the presence of

physical inactivity in an obese

person warrants intensified

efforts to remove excess body

weight because physical inactivity and obesity both heighten

disease risks.

Obesity is commonly 

accompanied by elevated 

serum triglycerides.

Triglyceride-rich lipoproteins

may be directly atherogenic,

and they are also the most 

common manifestation of 

the atherogenic lipoprotein 

phenotype (high triglycerides,

small LDL particles, and low

HDL-cholesterol levels).34 In

the presence of obesity, high

serum triglycerides are commonly associated with a clustering 

of metabolic risk factors known

as the metabolic syndrome

(atherogenic lipoprotein 

phenotype, hypertension,

insulin resistance, glucose 

intolerance, and prothrombotic

states). Thus, in obese patients,

elevated serum triglycerides 

are a marker for increased 

cardiovascular risk.

Risk Factor Management

Management options of risk 

factors for preventing CVD, 

diabetes, and other chronic 

diseases are described in detail in

other reports. For details on the

management of serum cholesterol

and other lipoprotein disorders,

refer to the National Cholesterol

Education Program’s Second

Report of the Expert Panel on the

Detection, Evaluation, and

Treatment of High Blood

Cholesterol in Adults (Adult

Treatment Panel II, ATP II).29 For the

treatment of hypertension, see the

National High Blood Pressure

Education Program’s Sixth Report

of the Joint National Committee on

the Prevention, Detection,

Evaluation, and Treatment of High

Blood Pressure (JNC VI).30

See the Additional Resources 

list for ordering information from 

the National Heart, Lung, and 

Blood Institute (see Appendix L).

Risk Factors and Weight Loss

In overweight and obese persons

weight loss is recommended to 

accomplish the following:

Lower elevated blood pressure 

in those with high blood pressure.

Lower elevated blood glucose 

levels in those with type 

2 diabetes.

Lower elevated levels of total 

cholesterol, LDL-cholesterol, 

and triglycerides, and raise low

levels of HDL-cholesterol in 

those with dyslipidemia.

Evaluation and 

Treatment Strategy

When health care practitioners encounter patients in the clinical setting,

opportunities exist for identifying overweight and obesity and their

accompanying risk factors, as well as for initiating treatments for 

reducing weight, risk factors, and chronic diseases such as CVD and type 2 diabetes. When

assessing a patient for treatment of overweight and obesity, consider the patient’s weight, waist

circumference, and presence of risk factors. The strategy for the evaluation and treatment of

overweight patients is presented in Figure 4 (Treatment Algorithm). This algorithm applies

only to the assessment for overweight and obesity; it does not reflect the overall evaluation of

other conditions and diseases performed by the clinician. Therapeutic approaches for cholesterol disorders and hypertension are described in ATP II and JNC VI, respectively.29,30 In overweight patients, control of cardiovascular risk factors deserves the same emphasis as weight

loss therapy. Reduction of risk factors will reduce the risk for CVD, whether or not weight loss

efforts are successful.
16

Treatment Algorithm*

Yes

Yes

No

Patient encounter

5

6

Hx of ≥ 25 BMI?

BMI measured in

past 2 years?

BMI ≥ 25 OR waist 

circumference > 35 

in (88 cm) (F) > 40 in

(102 cm) (M)

Assess risk factors

No

Hx BMI ≥ 25?

Brief reinforcement/

educate on weight

management

Periodic weight, BMI, and

waist circumference check

Advise to maintain

weight/address other

risk factors

Figure 4.

• Measure weight,

height, and waist

circumference

• Calculate BMI

14

15 13

16

Yes

Each step (designated by a box) in this process is reviewed in

this section and expanded upon in subsequent sections.

High Risk Waist Circumference

Men >40 in (>102 cm)

Women >35 in (>88cm)

BMI = weight (kg)

height squared (m2)

If pounds and inches 

are used:

BMI = weight (pounds) x 703

height squared (inches2)

Calculate BMI as follows:

1

2

3

4
17

Does patient want 

to lose weight?

Progress 

being made/goal 

achieved?

Yes

Yes

Yes No

No

No

Clinician and patient

devise goals and 

treatment strategy 

for weight loss and risk

factor control

Maintenance counseling:

• Dietary therapy

• Behavior therapy

• Physical activity

Assess reasons for 

failure to lose weight

12

8

9

11 10

7

* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not reflect any initial overall

assessment for other cardiovascular risk factors that are indicated.

Examination

Treatment

BMI ≥ 30 OR 

{[BMI 25 to 29.9 OR

waist circumference 

> 35 in (F) > 40 in

(M)] AND ≥ 2 risk 

factors}
18

Patient encounter 

Any interaction between a 

health care practitioner (generally

a physician, nurse practitioner, or

physician’s assistant) and a patient

that provides the opportunity to

assess a patient’s weight status 

and provide advice, counseling,

or treatment.

History of overweight 

or recorded BMI ≥ 25

Seek to determine whether the

patient has ever been overweight. 

A simple question such as “Have

you ever been overweight?” may

accomplish this goal. Questions

directed toward weight history,

dietary habits, physical activities,

and medications may provide useful

information about the origins of

obesity in particular patients.

BMI measured 

in past 2 years 

For those who have not been 

overweight, a 2-year interval is

appropriate for the reassessment 

of BMI. Although this timespan is

not evidence-based, it is a reasonable compromise between the 

need to identify weight gain at 

an early stage and the need to 

limit the time, effort, and cost 

of repeated measurements.

Measure weight,

height, waist circumference;

calculate BMI 

Weight must be measured so BMI

can be calculated. Most charts are

based on weights obtained with

the patient wearing undergarments

and no shoes. 

BMI ≥ 25 OR 

waist circumference > 35 in

(88 cm) (women) or > 40 in

(102 cm) (men) 

These cutoff values divide 

overweight from normal weight

and are consistent with other

national and international 

guidelines. The relationship

between weight and mortality is 

J-shaped, and evidence suggests

that the right side of the “J” begins

to rise at a BMI of 25. Waist 

circumference is incorporated as

an “or” factor because some

patients with a BMI lower than 

25 will have a disproportionate

amount of abdominal fat, which

increases their cardiovascular risk

despite their low BMI (see pages

9–10). These abdominal 

circumference values are not 

necessary for patients with a

BMI ≥ 35 kg/m2.

Assess risk factors

Risk assessment for CVD and 

diabetes in a person with evident

obesity will include special 

considerations for the medical 

history, physical examination, and

laboratory examination. Detection

of existing CVD or end-organ 

damage presents the greatest

urgency. Because the major risk of

obesity is indirect (obesity elicits or

aggravates hypertension, dyslipidemias, and type 2 diabetes; each 

of these leads to cardiovascular

complications), the management 

of obesity should be implemented

in the context of these other risk

factors. Although there is no direct

evidence that addressing risk factors

increases weight loss, treating the

risk factors through weight loss is 

a recommended strategy. The risk

factors that should be considered are

provided on pages 11–13. A nutrition assessment will also help to

assess the diet and physical activity

habits of overweight patients.

BMI ≥ 30 OR ([BMI 25 to

29.9 OR waist circumference

> 35 in (88 cm) (women) or

> 40 in (102 cm) (men)]

AND ≥ 2 risk factors)

The panel recommends that all

patients who meet these criteria

should attempt to lose weight.

However, it is important to ask the

patient whether or not he or she

wants to lose weight. Those with 

a BMI between 25 and 29.9 kg/m2

and who have one or no risk factors

should work on maintaining their

current weight rather than embark

on a weight reduction program. 

The panel recognizes that the 

decision to lose weight must be

made in the context of other risk

factors (e.g., quitting smoking is

more important than losing weight)

and patient preferences.

1

3

4

6

7

2

5

Each step (designated by a box) in the treatment algorithm is

reviewed in this section and expanded upon in subsequent sections.
19

Clinician and patient

devise goals

The decision to lose weight must 

be made jointly between the 

clinician and patient. Patient

involvement and investment is 

crucial to success. The patient may

choose as a goal not to lose weight

but rather to prevent further weight

gain. As an initial goal for weight

loss, the panel recommends the loss

of 10 percent of baseline weight at

a rate of 1 to 2 pounds per week

and the establishment of an energy

deficit of 500 to 1,000 kcal/ day

(see page 23). For individuals who

are overweight, a deficit of 300 to

500 kcal/day may be more appropriate, providing a weight loss of

about 0.5 pounds per week. Also,

there is evidence that an average of

8 percent of body weight can be

lost over 6 months. Since this

observed average weight loss

includes people who do not lose

weight, an individual goal of 10

percent is reasonable. After

6 months, most patients will equilibrate (caloric intake balancing 

energy expenditure); thus, they 

will require an adjustment of their

energy balance if they are to lose

more weight (see page 24).

The three major components of

weight loss therapy are dietary therapy, increased physical activity, and

behavior therapy (see pages 26 to

34). These lifestyle therapies should 

be attempted for at least 6 

months before considering 

pharmacotherapy. In addition,

pharmacotherapy should be 

considered as an adjunct to 

lifestyle therapy for patients 

with a BMI 30 kg/m2 and who have

no concomitant obesity-related risk

factors or diseases. Pharmacotherapy may also be considered for

patients with a BMI 27 kg/m2 and

who have concomitant obesityrelated risk factors or diseases. The

risk factors or diseases considered

important enough to warrant 

pharmacotherapy at a BMI of 27 

to 29.9 kg/m2 are hypertension,

dyslipidemia, CHD, type 2 diabetes,

and sleep apnea. 

Two drugs approved for weight loss

by the FDA for long-term use are 

sibutramine and orlistat. However,

sibutramine should not be used in

patients with a history of hypertension, CHD, congestive heart failure,

arrhythmias, or stroke. Certain

patients may be candidates for

weight loss surgery. 

Each component of weight loss

therapy should be introduced to 

the patient briefly. The selection 

of weight loss methods should be

made in the context of patient preferences, analysis of failed attempts,

and consideration of available

resources.

Progress being 

made/goal achieved

During the acute weight loss 

period and at the 6-month and 

1-year followup visits, patients

should be weighed, their BMI

should be calculated, and their

progress should be assessed. If at

any time it appears that the program

is failing, a reassessment should

take place to determine the reasons

(see Box 10). If pharmacotherapy 

is used, appropriate monitoring for

side effects is recommended (see

pages 35–37). If a patient can

achieve the recommended 10-percent reduction in body weight 

within 6 months to 1 year, this

change in weight can be considered

good progress. The patient can 

then enter the phase of weight

maintenance and long-term 

monitoring. It is important for the

practitioner to recognize that some

persons are more apt to lose or gain

weight on a given regimen; this

phenomenon cannot always be

attributed to the degree of compliance. However, if significant 

obesity persists and the obesityassociated risk factors remain, an

effort should be made to reinstitute

weight loss therapy to achieve further weight reduction. Once the limit

of weight loss has been reached, the

practitioner is responsible for longterm monitoring of risk factors and

for encouraging the patient to maintain the level of weight reduction.

8 9
Assess reasons for failure 

to lose weight

If a patient fails to achieve the recommended 10-percent reduction in

body weight within 6 months or

1 year, a reevaluation is required. A

critical question to consider is

whether the patient’s level of motivation is high enough to continue clinical therapy. If motivation is high,

revise goals and strategies (see

Box 8). If motivation is not high,

clinical therapy should be discontinued, but the patient should be

encouraged to embark on efforts to

lose weight or to avoid further

weight gain. Even if weight loss

therapy is stopped, risk factor management must be continued. Failure

to achieve weight loss should prompt

the practitioner to investigate the following: (1) energy intake (i.e.,

dietary recall including alcohol

intake and daily intake logs),

(2) energy expenditure (physical

activity diary), (3) attendance at psychological/behavioral counseling sessions, (4) recent negative life events,

(5) family and societal pressures,

and (6) evidence of detrimental psychiatric problems (e.g., depression,

binge eating disorder). If attempts 

to lose weight have failed, and the

BMI is ≥ 40, or 35 to 39.9 with

comorbidities or significant reduction in quality of life, surgical therapy should be considered.

Maintenance counseling

Evidence suggests that more than 80

percent of the individuals who lose

weight will gradually regain it.

Patients who continue to use weight

maintenance programs have a greater

chance of keeping weight off.

Maintenance includes continued contact with the health care practitioner

for education, support, and medical

monitoring (see page 24).

Does the patient want 

to lose weight?

Patients who do not want to lose

weight but who are overweight

(BMI 25 to 29.9), without a high

waist circumference and with one or

no cardiovascular risk factors, should

be counseled regarding the need to

maintain their weight at or below its

present level. Patients who wish to

lose weight should be guided according to Boxes 8 and 9. The justification of offering these overweight

patients the option of maintaining

(rather than losing) weight is that

their health risk, although higher

than that of persons with a BMI

< 25, is only moderately increased

(see page 11).

Advise to maintain

weight/address other 

risk factors

Patients who have a history of 

overweight and who are now at an

appropriate body weight, and those

patients who are overweight but 

not obese and who wish to focus on

maintenance of their current weight,

should be provided with counseling

and advice so their weight does not

increase. An increase in weight

increases their health risk and

should be prevented. The clinician

should actively promote prevention

strategies, including enhanced attention to diet, physical activity, and

behavior therapy. See Box 6 for

addressing other risk factors; even 

if weight loss cannot be addressed,

other risk factors should be treated.

History of BMI ≥ 25

This box differentiates those who

presently are not overweight and

never have been from those with a

history of overweight (see Box 2).

Brief reinforcement

Those who are not overweight and

never have been should be advised of

the importance of staying in this category.

Periodic weight, BMI,

and waist circumference check

Patients should receive periodic

monitoring of their weight, BMI, and

waist circumference. Patients who

are not overweight or have no history

of overweight should be screened for

weight gain every 2 years. This

timespan is a reasonable compromise

between the need to identify weight

gain at an early stage and the need to

limit the time, effort, and cost of

repeated measurements.

10

15

12

11

14

16

13
21

Ready or Not:

Predicting Weight Loss

Predicting a patient’s readiness

for weight loss and identifying

potential variables associated

with weight loss success is an important step in understanding the needs

of patients. However, it may be easier said than done. Researchers have

tried for years with some success to

identify predictors of weight loss.

Such predictors would allow health

care practitioners, before treatment,

to identify individuals who have a

high or low likelihood of success.

Appropriate steps potentially could

be taken to improve the chances of

patients in the latter category. Among

biological variables, initial body

weight and resting metabolic rate

(RMR) are both positively related

to weight loss. Heavier individuals

tend to lose more weight than do

lighter individuals, although the

two groups tend to lose comparable

percentages of initial weight. Studies

have not found that weight cycling

is associated with a poorer treatment

outcome. Behavioral predictors of

weight loss have proved to be less

consistent. Depression, anxiety, or

binge eating may be associated

with suboptimal weight loss, though

findings have been contradictory.

Similarly, measures of readiness or

motivation to lose weight have generally failed to predict outcome. By

contrast, self-efficacy—a patient’s

report that she or he can perform

the behaviors required for weight

loss—is a modest but consistent

predictor of success. Several studies have also suggested that positive coping skills contribute to

weight control.

Exclusion From 

Weight Loss Therapy

Patients for whom weight loss 

therapy is not appropriate are

most pregnant or lactating

women, persons with a serious

uncontrolled psychiatric illness

such as a major depression, and

patients who have a variety of

serious illnesses and for whom

caloric restriction might exacerbate the illness. Patients with

active substance abuse and those

with a history of anorexia 

nervosa or bulimia nervosa should

be referred for specialized care.

Consider a patient’s readiness for weight loss and

identify potential variables

associated with weight loss

success.
22

Clinical experience suggests that

health care practitioners briefly 

consider the following issues when

assessing an obese individual’s

readiness for weight loss:

“Has the individual sought weight

loss on his or her own initiative?”

Weight loss efforts are unlikely to

be successful if patients feel that

they have been forced into treatment

by family members, their employer,

or their physician. Before initiating

treatment, health care practitioners

should determine whether patients

recognize the need and benefits of

weight reduction and want to lose

weight.

“What events have led the patient

to seek weight loss now?”

Responses to this question will provide information about the patient’s

weight loss motivation and goals. In

most cases, individuals have been

obese for many years. Something

has happened to make them seek

weight loss. The motivator differs

from person to person. 

“What are the patient’s stress

level and mood?” There may not

be a perfect time to lose weight,

but some are better than others.

Individuals who report higher-thanusual stress levels with work, family

life, or financial problems may not

be able to focus on weight control.

In such cases, treatment may be

delayed until the stressor passes, thus

increasing the chances of success. 

Briefly assess the patient’s mood to

rule out major depression or other

complications. Reports of poor

sleep, a low mood, or lack of pleasure in daily activities can be followed up to determine whether

intervention is needed: it is usually

best to treat the mood disorder

before undertaking weight reduction.

“Does the individual have an

eating disorder, in addition to

obesity?” Approximately 20 percent to 30 percent of obese individuals who seek weight reduction at university clinics suffer

from binge eating. This involves

eating an unusually large amount

of food and experiencing loss of

control while overeating. Binge

eaters are distressed by their

overeating, which differentiates

them from persons who report

that they “just enjoy eating and eat

too much.” Ask patients which

meals they typically eat and the

times of consumption. Binge

eaters usually do not have a regular meal plan; instead, they snack

throughout the day. Although

some of these individuals respond

well to weight reduction therapy,

the greater the patient’s distress or

depression, or the more chaotic

the eating pattern, the more likely

the need for psychological or

nutritional counseling. 

“Does the individual understand

the requirements of treatment

and believe that he or she can

fulfill them?” Practitioner and

patient together should select a

course of treatment and identify

the changes in eating and activity

habits that the patient wishes to

make. It is important to select

activities that patients believe they

can perform successfully. Patients

should feel that they have the

time, desire, and skills to adhere

to a program that you have

planned together.

“How much weight does the

patient expect to lose? What 

other benefits does he or she

anticipate?” Obese individuals 

typically want to lose 2 to 3 times

the 8 to 15 percent often observed

and are disappointed when they do

not. Practitioners must help patients

understand that modest weight 

losses frequently improve health

complications of obesity. Progress

should then be evaluated by

achievement of these goals, which

may include sleeping better, having

more energy, reducing pain,

and pursuing new hobbies or 

rediscovering old ones, particularly

when weight loss slows and 

eventually stops.

A Brief Behavioral Assessment
23

The initial goal of weight loss 

therapy for overweight

patients is a reduction in

body weight of about 10 percent. If

this target is achieved, consideration may be given to further weight

loss. In general, patients will wish

to lose more than 10 percent of

body weight; they will need to be

counseled about the appropriateness of this initial goal.35,36 Further

weight loss can be considered after

this initial goal is achieved and

maintained for 6 months. The rationale for the initial 10-percent goal

is that a moderate weight loss of 

this magnitude can significantly

decrease the severity of obesityassociated risk factors. It is better

to maintain a moderate weight loss

over a prolonged period than to

regain weight from a marked

weight loss. The latter is counterproductive in terms of time, cost,

and self-esteem. 

Rate of Weight Loss

A reasonable time to achieve a 

10-percent reduction in body weight

is 6 months of therapy. To achieve a

significant loss of weight, an energy

deficit must be created and maintained. Weight should be lost at a

rate of 1 to 2 pounds per week,

based on a caloric deficit between

500 and 1,000 kcal/day. After

6 months, theoretically, this caloric

deficit should result in a loss of

between 26 and 52 pounds.

However, the average weight loss

actually observed over this time is

between 20 and 25 pounds. A greater

rate of weight loss does not yield a

better result at the end of 1 year.37

It is difficult for most patients to

continue to lose weight after 6

months because of changes in resting metabolic rates and problems

with adherence to treatment strategies. Because energy requirements

decrease as weight is decreased, diet

and physical activity goals need to

be revised so that an energy deficit 

is created at the lower weight,

allowing the patient to continue to

lose weight. To achieve additional

weight loss, the patient must further

Management of 

Overweight and Obesity

Goals for Weight Loss 

and Management

The following are general goals

for weight loss and management:

Reduce body weight

Maintain a lower body weight 

over the long term

Prevent further weight gain 

(a minimum goal)

A 10 percent reduction in body weight reduces

disease risk factors. Weight should be lost at a

rate of 1 to 2 pounds per week based on a 

calorie deficit of 500–1,000 kcal/day.
24

decrease calories and/or increase

physical activity. Many studies show

that rapid weight reduction is almost

always followed by gain of the 

lost weight. Moreover, with rapid

weight reduction, there is an

increased risk for gallstones and,

possibly, electrolyte abnormalities.

Weight Maintenance at a 

Lower Weight

Once the goals of weight loss have

been successfully achieved, maintenance of a lower body weight

becomes the major challenge. In the

past, obtaining the goal of weight

loss was considered the end of

weight loss therapy. Unfortunately,

once patients are dismissed from

clinical therapy, they frequently

regain the lost weight.

After 6 months of weight loss, the

rate at which the weight is lost 

usually declines, then plateaus. 

The primary care practitioner and

patient should recognize that, at this

point, weight maintenance, the second phase of the weight loss effort,

should take priority. Successful

weight maintenance is defined as 

a regain of weight that is less than

6.6 pounds (3 kg) in 2 years and 

a sustained reduction in waist 

circumference of at least 1.6 inches

(4 cm). If a patient wishes to lose

more weight after a period of

weight maintenance, the procedure

for weight loss, outlined above,

can be repeated.

After a patient has achieved the 

targeted weight loss, the combined

modalities of therapy (dietary therapy, physical activity, and behavior

therapy) must be continued indefinitely; otherwise, excess weight

will likely be regained. Numerous

strategies are available for motivating the patient; all of these require

that the practitioner continue to

communicate frequently with the

patient. Long-term monitoring and

encouragement can be accomplished in several ways: by regular

clinic visits, at group meetings, or

via telephone or e-mail. The longer

the weight maintenance phase 

can be sustained, the better the

prospects for long-term success in

weight reduction. Drug therapy

with either of the two FDAapproved drugs for weight loss 

may also be helpful during the

weight maintenance phase.

Long-term monitoring and

encouragement to maintain

weight loss requires regular

clinic visits, group meetings,

or encouragement via 

telephone or e-mail.
25

Weight Management Techniques

E

ffective weight control

involves multiple techniques and strategies

including dietary therapy,

physical activity, behavior

therapy, pharmacotherapy, and

surgery as well as combinations of

these strategies. Relevant treatment

strategies can also be used to foster

long-term weight control and prevention of weight gain. 

Some strategies such as modifying

dietary intake and physical activity

can also impact on obesity-related

comorbidities or risk factors. Since

the diet recommended is a low calorie Step-1 diet, it not only modifies

calorie intake but also reduces saturated fat, total fat, and cholesterol

intake in order to help lower high

blood cholesterol levels. The diet also

includes the current recommendations for sodium, calcium and fiber

intakes. Increased physical activity is

not only important for weight loss

and weight loss maintenance but also

impacts on other comorbidities and

risk factors such as high blood pressure, and high blood cholesterol levels. Reducing body weight in overweight and obese patients not only

helps reduce the risk of these comorbidities from developing but also

helps in their management. 

Weight management techniques need

to take into account the needs of individual patients so they should be culturally sensitive and incorporate the

patient’s perspectives and characteristics. Treatment of overweight and

obesity is to be taken seriously since

it involves treating an individual’s

disease over the long term as well as

making modifications to a way of life

for entire families. 

Table 3 illustrates the therapies

appropriate for use at different BMI

levels taking into account the 

existence of other comorbidities 

or risk factors.

Table 3 

A Guide to Selecting Treatment

BMI category

Treatment 25–26.9 27–29.9 30-34.9 35–39.9 ≥ 40

Diet, physical activity, With With + + +

and behavior therapy comorbidities comorbidities

Pharmacotherapy With + + +

comorbidities

Surgery With 

comorbidities

Prevention of weight gain with lifestyle therapy is indicated in any patient with a BMI ≥ 25 kg/m2, 

even without comorbidities, while weight loss is not necessarily recommended for those with a BMI 

of 25–29.9 kg/m2 or a high waist circumference, unless they have two or more comorbidities.

Combined therapy with a low-calorie diet (LCD), increased physical activity, and behavior therapy 

provide the most successful intervention for weight loss and weight maintenance.

Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of 

combined lifestyle therapy.

The + represents the use of indicated treatment regardless of comorbidities.
26

I

n the majority of overweight and

obese patients, adjustment of the

diet will be required to reduce

caloric intake. Dietary therapy

includes instructing patients in the

modification of their diets to

achieve a decrease in caloric intake.

A diet that is individually planned

to help create a deficit of 500 to

1,000 kcal/day should be an integral

part of any program aimed at

achieving a weight loss of 1 to

2 pounds per week. A key element

of the current recommendation is

the use of a moderate reduction in

caloric intake, which is designed to

achieve a slow, but progressive,

weight loss. Ideally, caloric intake

should be reduced only to the level

that is required to maintain weight

at a desired level. If this level of

caloric intake is achieved, excess

weight will gradually decrease. In

practice, somewhat greater caloric

deficits are used in the period of

active weight loss, but diets with a

very low-calorie content are to be

avoided. Finally, the composition

of the diet should be modified 

to minimize other cardiovascular

risk factors.

The centerpiece of dietary therapy

for weight loss in overweight or

obese patients is a low calorie diet

(LCD). This diet is different from a

very low calorie diet (VLCD) (less

than 800 kcal/day). The recommended LCD in this guide, i.e., the

Step I Diet, also contains the nutrient composition that will decrease

other risk factors such as high blood

cholesterol and hypertension. The

composition of the diet is presented

in Table 4. In general, diets containing 1,000 to 1,200 kcal/day should

be selected for most women; a diet

between 1,200 kcal/day and 1,600

kcal/day should be chosen for 

men and may be appropriate for

women who weigh 165 pounds or

more, or who exercise regularly. 

If the patient can stick with the

1,600 kcal/day diet but does not

lose weight you may want to try the

1,200 kcal/day diet. If a patient 

on either diet is hungry, you may

want to increase the calories by 

100 to 200 per day.

VLCDs should not be used 

routinely for weight loss therapy

because they require special monitoring and supplementation.50

VLCDs are used only in very limited circumstances by specialized

practitioners experienced in their

use. Moreover, clinical trials show

that LCDs are as effective as

VLCDs in producing weight loss

after 1 year.37

Successful weight reduction by

LCDs is more likely to occur when

consideration is given to a patient’s

food preferences in tailoring a 

particular diet. Care should be

taken to ensure that all of the 

recommended dietary allowances

are met; this may require the use

of a dietary or vitamin supplement.

Dietary education is necessary 

to assist in the adjustment to a

LCD. Educational efforts should

pay particular attention to the 

following topics:

Energy value of different foods.

Food composition—fats,

carbohydrates (including dietary

fiber), and proteins.

Evaluation of nutrition labels to

determine caloric content and food

composition.

New habits of purchasing—give

preference to low-calorie foods.

Food preparation—avoid adding

high-calorie ingredients during

cooking (e.g., fats and oils).

Avoiding overconsumption of

high-calorie foods (both high-fat

and high-carbohydrate foods).

Adequate water intake.

Reduction of portion sizes.

Limiting alcohol consumption.

Dietary Therapy

Low calorie diet (LCD)

1,000 to 1,200 kcal/day 

for most women

1,200 to 1,600 kcal/day 

should be chosen for men 

See Appendices B-H for diets 

and information on physical 

activity that you can use 

with your patients.
27

Table 4

Low-Calorie Step I Diet

Nutrient Recommended Intake

Calories1 Approximately 500 to 1,000 kcal/day reduction from usual intake

Total fat2 30 percent or less of total calories

Saturated fatty acids3 8 to 10 percent of total calories

Monounsaturated fatty acids Up to 15 percent of total calories

Polyunsaturated fatty acids Up to 10 percent of total calories

Cholesterol3 <300 mg/day

Protein4 Approximately 15 percent of total calories

Carbohydrate5 55 percent or more of total calories

Sodium chloride No more than 100 mmol/day (approximately 2.4 g of sodium or 

approximately 6 g of sodium chloride)

Calcium6 1,000 to 1,500 mg/day

Fiber 5 20 to 30 g/day

1. A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 pounds/week.

Alcohol provides unneeded calories and displaces more nutritious foods. Alcohol consumption not only 

increases the number of calories in a diet but has been associated with obesity in epidemiologic studies38-41

as well as in experimental studies.42-45 The impact of alcohol calories on a person’s overall caloric intake 

needs to be assessed and appropriately controlled.

2. Fat-modified foods may provide a helpful strategy for lowering total fat intake but will only be effective if they 

are also low in calories and if there is no compensation by calories from other foods.

3. Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions in 

LDL-cholesterol levels; in the Step II diet, saturated fats are reduced to less than 7 percent of total calories, 

and cholesterol levels to less than 200 mg/day. All of the other nutrients are the same as in Step I.

4. Protein should be derived from plant sources and lean sources of animal protein.

5. Complex carbohydrates from different vegetables, fruits, and whole grains are good sources of vitamins, 

minerals, and fiber. A diet rich in soluble fiber, including oat bran, legumes, barley, and most fruits and 

vegetables, may be effective in reducing blood cholesterol levels. A diet high in all types of fiber may also 

aid in weight management by promoting satiety at lower levels of calorie and fat intake. Some authorities 

recommend 20 to 30 grams of fiber daily, with an upper limit of 35 grams.46-48

6. During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals. Maintenance

of the recommended calcium intake of 1,000 to 1,500 mg/day is especially important for women who may be at risk of

osteoporosis.49
28

Physical activity should be an

integral part of weight loss

therapy and weight maintenance. Initially, moderate levels of

physical activity for 30 to 45 minutes, 3 to 5 days per week, should

be encouraged. 

An increase in physical activity is an

important component of weight loss

therapy,31 although it will not lead to

a substantially greater weight loss

than diet alone over 6 months.51

Most weight loss occurs because of

decreased caloric intake. Sustained

physical activity is most helpful in

the prevention of weight regain.52,53

In addition, physical activity is beneficial for reducing risks for cardiovascular disease and type 2 diabetes,

beyond that produced by weight

reduction alone. Many people live

sedentary lives, have little training 

or skills in physical activity, and are

difficult to motivate toward increasing their activity. For these reasons,

starting a physical activity regimen

may require supervision for some

people. The need to avoid injury during physical activity is a high priority. Extremely obese persons may

need to start with simple exercises

that can be intensified gradually. The

practitioner must decide whether

exercise testing for cardiopulmonary

disease is needed before embarking

on a new physical activity regimen.

This decision should be based 

on a patient’s age, symptoms, and 

concomitant risk factors.

For most obese patients, physical

activity should be initiated slowly,

and the intensity should be

increased gradually. Initial activities

may be increasing small tasks of

daily living such as taking the stairs

or walking or swimming at a slow

pace. With time, depending on

progress, the amount of weight lost,

and functional capacity, the patient

may engage in more strenuous

activities. Some of these include 

fitness walking, cycling, rowing,

cross-country skiing, aerobic dancing, and jumping rope. Jogging provides a high-intensity aerobic exercise, but it can lead to orthopedic

injury. If jogging is desired, the

patient’s ability to do this must first

be assessed. The availability of a

safe environment for the jogger is

also a necessity. Competitive sports,

such as tennis and volleyball, can

provide an enjoyable form of physical activity for many, but again,

care must be taken to avoid injury,

especially in older people. 

As the examples listed in Table 5

show, a moderate amount of physical activity can be achieved in a

variety of ways. People can select

activities that they enjoy and that 

fit into their daily lives. Because

amounts of activity are functions of

duration, intensity, and frequency,

the same amounts of activity can 

be obtained in longer sessions of

moderately intense activities (such

as brisk walking) as in shorter sessions of more strenuous activities

(such as running).

A regimen of daily walking is an

attractive form of physical activity

for many people, particularly those

who are overweight or obese. The

patient can start by walking 10 minutes, 3 days a week, and can build

to 30 to 45 minutes of more intense

walking at least 3 days a week and

increase to most, if not all, days.52,53

With this regimen, an additional 

Physical Activity

All adults should set 

a long-term goal to 

accumulate at least 

30 minutes or more 

of moderate-intensity 

physical activity on 

most, and preferably 

all, days of the week.
29

100 to 200 kcal/day of physical

activity can be expended. Caloric

expenditure will vary depending on

the individual’s body weight and

the intensity of the activity.

This regimen can be adapted to

other forms of physical activity,

but walking is particularly attractive

because of its safety and accessibility. With time, a larger weekly

volume of physical activity can be

performed that would normally

cause a greater weight loss if it

were not compensated by a higher

caloric intake.

Reducing sedentary time, i.e.,

time spent watching television or

playing video games, is another

approach to increasing activity.

Patients should be encouraged to

build physical activities into each

day. Examples include leaving

public transportation one stop

before the usual one, parking farther than usual from work or shopping, and walking up stairs instead

of taking elevators or escalators.

New forms of physical activity

should be suggested (e.g., gardening, walking a dog daily, or new

athletic activities). Engaging in

physical activity can be facilitated

by identifying a safe area to perform the activity (e.g., community

parks, gyms, pools, and health

clubs). However, when these 

sites are not available, an area 

of the home can be identified and

perhaps outfitted with equipment

such as a stationary bicycle or a

treadmill. Health care professionals should encourage patients to

plan and schedule physical activity

1 week in advance, budget the

time necessary to do it, and document their physical activity by

keeping a diary and recording the

duration and intensity of exercise.

The following are examples of

activities at different levels of

intensity. A moderate amount of

Examples of Moderate Amounts of Physical Activity*

Common Chores Sporting Activities

Washing and waxing a car for 45–60 minutes Playing volleyball for 45–60 minutes 

Washing windows or floors for 45–60 minutes Playing touch football for 45 minutes

Gardening for 30–45 minutes Walking 13/4 miles in 35 minutes (20 min/mile)

Wheeling self in wheelchair for 30–40 minutes Basketball (shooting baskets) for 30 minutes

Pushing a stroller 11/2 miles in 30 minutes Bicycling 5 miles in 30 minutes

Raking leaves for 30 minutes Dancing fast (social) for 30 minutes

Walking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutes

Shoveling snow for 15 minutes Swimming laps for 20 minutes

Stairwalking for 15 minutes Basketball (playing a game) for 15–20 minutes 

Jumping rope for 15 minutes

Running 11/2 miles in 15 minutes (15 min/mile)

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 

150 calories of energy per day, or 1,000 calories per week.

† Some activities can be performed at various intensities; the suggested durations correspond to expected 

intensity of effort.

Table 5 

More

Vigorous,

Less Time

Less

Vigorous,

More Time†
30

physical activity is roughly equivalent to physical activity that uses

approximately 150 calories of

energy per day, or 1,000 calories

per week.

For the beginner, or someone who

leads a very sedentary lifestyle,

very light activity would include

increased standing activities, room

painting, pushing a wheelchair,

yard work, ironing, cooking, and

playing a musical instrument.

Light activity would include slow

walking (24 min/mile), garage

work, carpentry, house cleaning,

child care, golf, sailing, and recreational table tennis.

Moderate activity would include

walking a 15-minute mile, weeding and hoeing a garden, carrying

a load, cycling, skiing, tennis, and

dancing.

High activity would include

jogging a mile in 10 minutes,

walking with a load uphill, tree

felling, heavy manual digging,

basketball, climbing, and soccer.

Other key activities would

include flexibility exercises to

attain full range of joint motion,

strength or resistance exercises,

and aerobic conditioning.

Behavior therapy provides

methods for overcoming

barriers to compliance with

dietary therapy and/or increased

physical activity, and these methods are important components of

weight loss treatment. The following approach is designed to assist

the caregiver in delivering behavior therapy. The importance of

individualizing behavioral strategies to the needs of the patient

must be emphasized for behavior

therapy, as it was for diet and

exercise strategies.54

In addition, the practitioner must

assess the patient’s motivation to

enter weight loss therapy and the

patient’s readiness to implement

the plan. Then the practitioner can

take appropriate steps to motivate

the patient for treatment.

Making the Most of 

the Patient Visit 

Consider Attitudes, Beliefs,

and Histories.

In the patient-provider interaction,

individual histories, attitudes, and

beliefs may affect both parties.

The diagnosis of obesity is rarely

new or news for the patient.

Except for patients with very

recent weight gain, the patient

brings into the consulting room a

history of dealing with a frustrating, troubling, and visible problem. Obese people are often the

recipients of scorn and discrimination from strangers and, sometimes, hurtful comments from 

previous health care professionals.

The patient with obesity may be

understandably defensive about

the problem.

Be careful to communicate 

a nonjudgmental attitude that

distinguishes between the

weight problem and the patient

with the problem. Ask about 

the patient’s weight history and

how obesity has affected his or

her life. Express your concerns

about the health risks associated

with obesity, and how obesity is

affecting the patient.

Similarly, most providers have had

some frustrating experiences in

dealing with patients with weight

problems. Appropriate respect for

the difficulty of long-term weight

control may mutate into a reflexive sense of futility. When efforts

to help patients lose weight are

unsuccessful, the provider may be

disappointed and may blame the

patient for the failure, seeing

obese people as uniquely noncompliant and difficult. Providers too

may feel some antifat prejudice.

Objectively examine your own

attitudes and beliefs about obesity and obese people.

Remember, obesity is a chronic

disease, like diabetes or hypertension. In a sense, patients are

struggling against their own

body’s coordinated effort to

Behavior Therapy
31

stop them from losing weight.

Remember, compliance with

most long-term treatment regimens that require behavior

change is poor. Keep your

expectations realistic regarding

the ease, amount, speed, and

permanence of weight change.

Build a Partnership with 

the Patient.

The patient must be an active partner in the consultation and must

participate in setting goals for

behavior change. It is the patient

who must make the changes to

achieve weight loss; the patient

already has goals concerning

weight loss and how to achieve it.

These goals may be different from

those the provider would select.

The provider can be a source of

general information, perspective,

support, and some measure of

guidance but cannot cause the

patient to meet goals that he or 

she does not endorse.

When weight is first brought up,

ask what the patient’s weight

goals are. You may indicate that

the patient’s weight goals are

more ambitious than necessary

for health improvement, but

acknowledge that the patient

may have many other reasons

for selecting a different goal.

Distinguish between the 

long-term result of weight loss

and the short-term behavior

changes (diet, activity, etc.) that

are the means to that end.

Emphasize that the patient will

judge which specific goals to

attempt and that your review of

goal attainment is meant to

evaluate the plan, not the

patient. Also, emphasize that the

most important thing the patient

can do is to keep return

appointments, even if goals have

not been met.

Set Achievable Goals.

Setting goals should be a collaborative activity. From all the available dietary and physical activity

changes that might be made, a

small number should be selected

on the basis of their likely impact

on weight and health, the patient’s

current status, and the patient’s

willingness and ability to implement them. Once goals are selected, an action plan can be devised

to implement change.

After considering the recommended dietary and physical

activity guidelines, the patient

should be encouraged to select

two or three goals that he or

she is willing and able to take

on. If the patient does not select

an area that appears in need of

change, inquire about the perceived costs and benefits of that

achievement, without presenting

it as mandatory. (“One thing

that seems very important for

most patients is physical activity. What are your thoughts

about increasing your activity

level?”) Assess the patient’s

perceived ability to meet a specific goal. (“On a scale from 1

to 10, how confident are you

that you can meet 

this goal?”)

Effective goals are specific,

attainable, and forgiving (less 

than perfect). Thus, “exercise

more” would become “walk for 

Patients must be active

partners and participate in

setting goals for behavioral

changes.
32

30 minutes, 3 days a week, for

now.” Shaping is a behavioral

technique that involves selecting a

series of short-term goals that get

closer and closer to the ultimate

goal (e.g., an initial reduction of

fat intake from 40 percent of calories to 35 percent of calories and

later to 30 percent). Once the

patient has selected a goal, address

briefly what has to be done to

achieve it. (“What are the best

days for you to take your walks?

What time of day is best for you?

What arrangements will you need

to make for child care?”) Provide

the patient with a written behavioral “prescription” listing the

selected goals. 

The Weight and Goal Record 

(see Appendix J) can be copied 

for use in the chart to keep track

of the patient’s goals and weight

changes. Write down the patient’s

goals on the Weekly Food and

Activity Diary (see Appendix K).

Cultivate the Partnership

Followup visits are occasions for

monitoring health and weight status and for monitoring responses 

to any medication regimens. They

also provide the opportunity to

assess progress toward the goals

selected at the previous visit, to

provide support and additional

information, and to establish goals

for the next visit. Imperfect goal

attainment is often the norm. Focus

on the positive changes, and adopt

a problem-solving approach

toward the shortfalls. This is

achieved by communicating that

the goal, not the patient, is at issue.

While in the waiting room, the

patient can write down the outcomes of the previous goals,

effects of the various aspects of

the treatment program (diet,

activity, medication), items to

discuss with you, and possible

targets for new goals. In the

consultation, a matter-of-degree

approach can be communicated

by questions such as “How

many days a week were you

able to walk?” rather than

“Did you meet your walking

goal?” Successes should

receive positive attention and

praise. If the patient has not

successfully met a desired goal,

emphasize the extent to which

he or she approached the goal.

(“So even though you weren’t

able to walk 4 days each week,

you did get out there at least

twice a week.”)

Acknowledge the challenging

nature of weight control by adopting problem-solving responses to

goals that are not fully met.

Emphasize that examining the circumstances of unmet goals can

lead to new and more effective

strategies. (“What do you think

interfered with your walking plans

on the days you didn’t walk?”)

Emphasize that weight control is 

a journey, not a destination, and

that some missteps are inevitable

opportunities to learn how to be

more successful.

Focus on positive

changes and adapt a

problem-solving

approach toward the

shortfalls. Weight 

control is a journey,

not a destination.
33

Set goals for the next visit in

collaboration with the patient.

These goals should be based on

the outcome of the previous

goals, consideration of the

patient-selected targets, and

assessment of the patient’s status. If a previous goal was

missed by a wide margin, it may

be useful to lower the goal

somewhat.

Keep in Touch.

Frequency of treatment contact is

a major determinant of success at

weight control, but the contact

need not be limited to direct, inperson visits with the provider.

Use whatever means exist to

maintain frequent contact with

patients.

Encourage patients to drop by

the office between consultations

for a weight check (with the

office nurse or other staff), to

bring in the Weekly Food and

Activity Diary, to view educational videotapes, or to pick up

other materials. Such interim

visits can be scheduled or left

on an as-needed basis, depending on the patient’s needs and

preferences. Educational material or responses from you or

your staff may be transmitted by

mail, e-mail, or telephone. 

A member of your staff may

contact the patient between visits for support.

Help the Patient to 

Modify Behaviors.

Proven behavior modification

techniques can be used to assist

patients in weight control. Some

can be communicated readily in

person or via written materials.

Goals may include the use of 

one or more of these techniques. 

Copy the written handouts in

Appendix J for your patients.

Self-monitoring refers to

observing and recording some

aspect of behavior, such 

as caloric intake, exercise 

sessions, medication usage, etc.,

or an outcome of these behaviors, such as changes in body

weight. Self-monitoring of a

behavior usually changes the

behavior in the desired direction and can produce real-time

records for your review. Some

patients find that specific selfmonitoring forms make it easier, while others prefer to use

their own recording system.

Recording dietary intake (food

choices, amounts, times),

although seen as a chore by

some patients, is a very useful

application of self-monitoring.

Although some patients prefer

daily weighing and others do

better with less frequent steps

on the scale, regular selfmonitoring of weight is crucial

for long-term maintenance.

Rewards can be used to encourage attainment of behavioral

goals, especially those that have

been difficult to reach. An effective reward is something that is

desirable, timely, and contingent

on meeting the goal. Patientadministered rewards may be

tangible (e.g., a movie, music

CD, or payment toward buying a

more costly item) or intangible

(e.g., an afternoon off work or

an hour of quiet time away from

family). Numerous small

rewards, delivered for meeting

smaller goals, are preferable to

bigger rewards that require a

long, difficult effort.

Stimulus control changes

involve learning what social or

environmental cues seem to

encourage undesired eating and

then modifying those cues. For

example, a patient may learn

from reflection or from selfmonitoring records that he or

she is more likely to overeat

while watching television, or

whenever treats are on display

by the office coffeepot, or when

around a certain friend. The

resulting strategies may be to

sever the association of eating

from the cue (do not eat while

watching television), avoid or

eliminate the cue (leave the coffee room immediately after

pouring coffee), or change the

circumstances surrounding the

cue (plan to meet with the friend
34

in a setting where food is not

available). In general, visible

and accessible food items are

often cues for unplanned eating.

Dietary behavior changes can

make it easier to eat less without

feeling deprived. An important

change is to slow the rate of 

eating to allow satiety signals to

begin to develop before the end 

of the meal. Another tactic is to

use smaller plates so that moderate

portions do not appear meager.

Changing the scheduling of 

eating can be helpful for patients

who skip or delay meals, then

overeat later.

Focus on What Matters.

Improvement of the patient’s

health is the goal of obesity treatment. Monitoring progress is a

continuous process of motivational

importance to the patient and

provider. Simple, clear records of

body weight, relevant risk factors,

other health parameters, and goal

attainment should be kept.

Use simple charts or graphs 

to summarize changes in weight

and the associated risk factors

that were present initially or 

suggested by the patient’s family

history. For example, for a

patient presenting with a BMI 

of 33, hypertension, and a family

history of type 2 diabetes, a 

chart might include successive

measures of weight, BMI, waist

circumference, blood pressure,

and fasting blood glucose. Copy

these records for the patient.

Provide the patient with a written

behavioral “prescription” listing

the selected goals. The Weight

and Goal Record (see Appendix

J) can be copied for use in the

chart to keep track of the patient’s

goals and weight changes.

Focus on What Matters

Improvement of the patient’s health is the goal 

of obesity treatment. Monitoring progress is a 

continuous process of motivational importance 

to the patient and provider.
35

Weight loss drugs

approved by the FDA

for long-term use may

be useful as an adjunct to diet and

physical activity for patients with

a BMI ≥ 30 and without concomitant obesity-related risk factors 

or diseases. Drug therapy may also

be useful for patients with a

BMI ≥ 27 who also have concomitant obesity-related risk factors 

or diseases.

Our thinking about drug 

therapy has undergone radical

changes over the past few years.

Following the publication of the 

4-year trials with phentermine 

and fenfluramine by Weintraub in

1992 and the discovery of leptin,

an adipose-tissue hormone, drug

therapy began to change from

short-term to long-term use.

Dexfenfluramine, fenfluramine,

and the combination of phentermine and fenfluramine were used

long term. However, reported concerns about unacceptable side

effects, such as regurgitant valvular lesions of the heart,55 led to the

withdrawal of dexfenfluramine

and fenfluramine from the market

in September 1997.56 No drug

approved by the FDA for use

beyond 3 months remained 

available until November 1997,

when the FDA approved sibutramine for long-term use in obesity.

In April 1999, the FDA approved

orlistat for long-term use.

The purpose of weight loss and

weight maintenance is to reduce

health risks. If weight is regained,

health risks increase. A majority of

patients who lose weight regain

it,57 so the challenge to the patient

and the practitioner is to maintain

weight loss. Because of the tendency to regain weight after

weight loss, the use of long-term

medication to aid in the treatment

of obesity may be indicated for

carefully selected patients.

The drugs used to promote weight

loss have been anorexiants or

appetite suppressants. Three classes

of anorexiant drugs have been

developed, all of which affect neurotransmitters in the brain. They

may be designated as follows:

(1) those that affect catecholamines,

such as dopamine and norepinephrine; (2) those that affect serotonin;

and (3) those that affect more than

one neurotransmitter. These drugs

work by increasing the secretion of

dopamine, norepinephrine, or serotonin into the synaptic neural cleft,

by inhibiting the reuptake of these

neurotransmitters into the neuron,

or by a combination of both 

mechanisms. Sibutramine inhibits

the reuptake of norepinephrine 

and serotonin. Orlistat is not an

appetite suppressant and has a 

different mechanism of action; it

blocks about one-third of fat

absorption. Very few trials longer

than 6 months have been done 

with any of the new drugs.

These drugs are modestly effective

in their ability to produce weight

loss. Net weight loss attributable

to drugs has generally been reported to range from 2 to 10 kilograms

Pharmacotherapy

Drugs may be used as 

adjunctive therapy in 

patients with a BMI ≥ 30 

or ≥ 27 with other risk 

factors or diseases.

as part of a program that 

includes diet, physical 

activity, and behavior therapy.

Drugs used only
36

Weight Loss Drugs*

Drug Dose Action Adverse Effects

Sibutramine

(Meridia)

Orlistat

(Xenical)

5, 10,15 mg

10 mg po qd to start,

may be increased to 15

mg or decreased to 5 mg

120 mg

120 mg po tid before

meals

Norepinephrine,

dopamine, and serotonin reuptake inhibitor.

Inhibits pancreatic

lipase, decreases fat

absorption.

Increase in heart rate and

blood pressure.

Decrease in absorption of 

fat-soluble vitamins; soft

stools and anal leakage.

* Ephedrine plus caffeine, and fluoxetine have also been tested for weight loss but are not approved for use in the treatment of obesity.

Mazindol, diethylpropion, phentermine, benzphetamine, and phendimetrazine are approved for only short-term use for the treatment of

obesity. Herbal preparations are not recommended as part of a weight loss program. These preparations have unpredictable amounts 

of active ingredients and unpredictable, and potentially harmful, effects.

Table 6 

(4.4 to 22 lbs), although some

patients lose significantly more

weight. It is not possible to predict

precisely how much weight an

individual may lose. Most of the

weight loss occurs within the first

6 months of therapy.

Adverse effects noted for sibutramine therapy include increases

in blood pressure and pulse.58

People with high blood pressure,

CHD, congestive heart failure,

arrhythmias, or history of stroke

should not take sibutramine. 

The package insert for sibutramine

states that because substantial

increases in blood pressure occur

in some patients, regular monitoring of blood pressure is required

when prescribing sibutramine.

With orlistat, a possible decrease

in the absorption of fat-soluble vitamins, and oily and loose stools

are side effects; a multivitamin

supplement is recommended when

taking this drug. Side effects from

these drugs are generally mild and

may improve with continued use,

although their persistence may

result in discontinuation of drug

treatment. Table 6 provides the

dose, action, and adverse effects of

sibutramine and orlistat.

Ephedrine plus caffeine, and 

fluoxetine have also been tested

for weight loss but are not

approved for use in the treatment

of obesity. Mazindol, diethylpropion, phentermine, benzphetamine,

and phendimetrazine are approved

for only short-term use for the

treatment of obesity. Herbal preparations are not recommended as

part of a weight loss program.

These preparations have unpredictable amounts of active ingredients and unpredictable,

and potentially harmful, effects.

If a patient has not lost the recommended 1 pound per week after 

at least 6 months on a weight loss

regimen that includes an LCD,

increased physical activity, and

behavior therapy, then careful 

consideration may be given to

pharmacotherapy. There are few

long-term studies that evaluate the

safety or efficacy of most currently

approved weight loss medications.

At present, sibutramine and orlistat

are available for long-term use.

Based on their risk/benefit ratio,

these drugs can be recommended
37

for use as an adjunct to diet and

physical activity for patients with 

a BMI ≥ 30, without concomitant

obesity-related risk factors or 

diseases, and for patients with a

BMI ≥ 27 who have concomitant

obesity-related risk factors or diseases.59 Only patients who are at

increased medical risk because of

their weight should use weight loss

medications; they should not be

used for cosmetic weight loss. 

Not every patient responds to drug

therapy. Trials have shown that

initial responders tend to continue

to respond, whereas initial nonresponders are less likely to respond,

even with an increase in dosage.60,61

If a patient does not lose 2 kilograms (4.4 lbs) in the first 4 weeks

after initiating therapy, the likelihood of long-term response is very

low.61 This may be used to guide

treatment by continuing medication for the responders or by discontinuing it for the nonresponders. If weight is lost within the

initial 6 months of therapy or if

weight is maintained after the initial weight loss phase, the drug

may be continued. It is important

to remember that the major role 

of these medications is to help

patients comply with their diet 

and physical activity plans while

losing weight. Medications cannot

be expected to continue to be

effective in weight loss or weight

maintenance once the drug has

been stopped.62,63 The use of a drug

may be continued as long as it is

effective and the adverse effects

are manageable and not serious.

There are no indications for specifying how long a weight loss drug

should be continued. Therefore, an

initial trial period of several weeks

with a given drug may help determine its efficacy for a given

patient. If a patient does not

respond to a drug with reasonable

weight loss, the clinician should

reassess the patient to determine

adherence to the medication regimen and adjunctive therapies, or

he/she should consider the need

for adjustment of the dosage. If

the patient continues to be unresponsive to the medication, or

serious adverse effects occur, the

clinician should consider 

discontinuing the treatment.64

There is great interest in weight

loss drugs among consumers.

Because of the possibility of serious adverse effects, it is incumbent

upon the practitioner to use drug

therapy with caution. Herbal medications are not recommended as

part of a weight loss program.

These preparations have unpredictable amounts of active ingredients and unpredictable—and potentially harmful—effects. In those

patients with a lower risk of obesity, nonpharmacologic therapies are

the treatments of choice. It is

important that the clinician monitor

the efficacy and side effects of the

drugs currently on the market.

Because adverse events may

increase with combination drug

therapy, it seems wise that, until

further safety data are available,

using weight loss drugs individually would be more prudent. Some

patients will respond to lower

doses, so the full dosage is not

always necessary.

Drugs should be used only as part

of a comprehensive program that

includes behavior therapy, diet,

and physical activity. Appropriate

monitoring for side effects must

be continued while drugs are part

of the regimen. Patients will need

to return for followup visits in 

2 to 4 weeks, then monthly for 

3 months, then every 3 months for

the first year after initiating the

medication. After the first year, the

doctor will advise the patient on

appropriate return visits. The purpose of these visits is to monitor

weight, blood pressure, and pulse,

discuss side effects, conduct laboratory tests, and answer the

patient’s questions.

Since obesity is a chronic disease,

the short-term use of drugs is not

helpful. The health professional

should include drugs only in the

context of a long-term treatment

strategy.65The risk/benefit ratio

cannot be predicted at this time,

since not enough long-term data

(> 1 year) are available on any of

the available drugs.
38

Weight loss surgery is an

option for weight reduction in patients with

clinically severe obesity, i.e., a

BMI ≥40, or a BMI ≥ 35 with

comorbid conditions. Weight loss

surgery should be reserved for

patients in whom other methods 

of treatment have failed and who

have clinically severe obesity

(once commonly referred to as

“morbid obesity”66). Weight loss

surgery provides medically significant sustained weight loss for

more than 5 years in most patients.

Two types of operations have

proven to be effective: those that

restrict gastric volume (banded

gastroplasty) and those that, in

addition to limiting food intake,

also alter digestion (Roux-en-Y

gastric bypass). See Figure 5.

Lifelong medical monitoring after

surgery is a necessity. Perioperative complications vary with

weight and the overall health of

the individual. In the published

literature, young patients 

without comorbidities with a

BMI < 50 kg/m2 who have undergone surgery have mortality rates

less than 1 percent, whereas 

massively obese patients with a

BMI > 60 kg/m2 who are also 

diabetic, hypertensive, and in 

cardiopulmonary failure may 

have mortality rates that range

from 2 to 4 percent. Operative

complications, including anastomotic leak, subphrenic abscess,

splenic injury, pulmonary

embolism, wound infection, and

stoma stenosis, occur in less than

10 percent of patients.67

An integrated program that provides guidance on diet, physical

activity, and psychosocial concerns before and after surgery is

necessary. Most patients fare

remarkably well with reversal of

diabetes, control of hypertension,

marked improvement in mobility,

return of fertility, cure of pseudotumor cerebri, and significant

improvement in quality of life.

Late complications are uncommon, but some patients may develop incisional hernias, gallstones,

and, less commonly, weight loss

failure and dumping syndrome.

Patients who do not follow the

instructions to maintain an adequate intake of vitamins and minerals may develop deficiencies of

vitamin B12 and iron with 

anemia. Neurologic symptoms

may occur in unusual cases. 

Thus, surveillance should include

monitoring indices of inadequate

nutrition. Documentation of

improvement in preoperative

comorbidities is beneficial and

advised.

Vertical Banded Gastroplasty Roux-en-Y Gastric Bypass

Figure 5 

Surgical Procedures in Current Use

Weight Loss Surgery
39

Pretreatment Evaluation

A physical examination and routine laboratory evaluation should

be performed on an obese patient

starting a weight loss regimen if

this has not been done within the

past year. The medical history and

physical exam should focus on

causes and complications of 

obesity. BMI should be calculated

and waist circumference measured

to better assess risk and to offer 

measures of outcome in addition

to weight loss. Although the 

causes of obesity are not fully

known, certain factors clearly play

a role. Family history is important

because of the strong heritability

of obesity; polycystic ovarian 

disease and hypothyroidism are

known causes of overweight. 

The use of antidepressants, lithium, phenothiazines, glucocorticoids, progestational hormones,

cyproheptadine and perhaps other

antihistamines, sulfonylureas,

insulin, and other medications is

associated with weight gain. 

In some cases, it may be possible

to change medications in favor 

of those that do not promote

weight gain.

The practitioner should search for

complications of obesity, such as

hypertension, type 2 diabetes,

hyperlipidemia, atherosclerotic cardiovascular disease, osteoarthritis

of the lower extremities, gallbladder disease, gout, and cancers. 

In men, obesity is associated with

colorectal and prostate cancer; 

in women, it is associated with

endometrial, gallbladder, cervical,

ovarian, and breast cancer.3 Signs

and symptoms of these disorders

may have been overlooked by the

patient and should be carefully

reviewed by the practitioner. For

example, weight loss is frequently 

a symptom of the onset of type 

2 diabetes. Some patients may

come to their initial visit, proud 

of their recent weight loss and

unaware of its significance.

The practitioner should also be 

alert to the possible presence of

obstructive sleep apnea, a disorder

that is often overlooked in obese

patients. Symptoms and signs

include very loud snoring or 

cessation of breathing during sleep,

which is often followed by a loud

clearing breath, then brief awakening. The patient may be a restless

sleeper; some find that they can

sleep comfortably only in the sitting position. The patient’s partner

may best describe these symptoms.

Daytime fatigue, with episodes of

sleepiness at inappropriate times,

and morning headaches also occur.

On exam, hypertension, narrowing

of the upper airway, scleral injection, and leg edema, secondary to 

pulmonary hypertension, may be

observed. Laboratory studies may

show polycythemia. If signs of

sleep apnea are present, referral to 

a pulmonologist, or sleep specialist,

is appropriate.

Examine the thyroid and look for

manifestations of hypothyroidism.

In addition, leg edema, cellulitis,

acanthosis nigricans (coarse 

pigmented skin that is a sign 

of hyperinsulinemia), and intertriginous rashes with signs of skin

breakdown are commonly seen 

in the very obese.

Laboratory Tests

Baseline and diagnostic laboratory

tests may include assessment of

electrolytes, liver function tests,

complete blood counts, total cholesterol, HDL- and LDL-cholesterol, triglycerides, and thyroidstimulating hormone, or full 

thyroid function tests. A recent

baseline electrocardiogram should

be available; if not, it should 

be performed. Other laboratory

studies should be performed on 

the basis of findings from the 

initial evaluation.

Medical Evaluation, Treatment, and Monitoring of the Obese Patient on a Weight Loss Regimen—

A Clinician’s Approach and Perspective
40

Lifestyle, Diet, and 

Physical Activity

If the patient is not seeing a 

registered dietitian or other 

counselor, food and exercise

records should be reviewed 

during office visits in order to

assess compliance with the 

prescribed dietary and exercise

recommendations. A supportive,

sympathetic approach (rather than

a judgmental one) is recommended, as described on pages 30–33.

Frequent visits to weigh patients

and review their adherence to

medication, diet, and exercise may

be associated with better weight

loss. Such visits may be brief and

may be conducted by a nurse or

other staff person.

Routine Monitoring

In general, healthy patients on 

a weight loss regimen should be

seen in the office within 2 to 4

weeks of starting treatment in

order to monitor both the treatment’s effectiveness and its side

effects. Visits approximately

every 4 weeks are adequate 

during the first 3 months if the

patient has a favorable weight 

loss and few side effects. More

frequent visits may be required

based on clinical judgment,

particularly if the patient has 

medical complications. Blood

pressure, pulse, and weight 

should be monitored each visit,

with waist circumference 

measured intermittently. Less 

frequent followup is required after

the first 6 months.

Demonstrating Medical

Improvement

Before beginning treatment,

results of the physical examination

and laboratory tests should be

shared with the patient. Emphasis

should be placed on any new 

findings, particularly those associated with obesity that would be

expected to improve with weight

loss. The patient should focus on

improvements in these health parameters, rather than focus on

achieving an ideal body weight or

a similarly large weight loss that

may or may not be attainable.

Improvements in health complications should be discussed on an

ongoing basis. Many patients find

this a helpful motivator because,

at some point, weight is likely to

stabilize at a level above their 

own “ideal” weight. By focusing

patients on the medical rather than

the cosmetic benefits of weight

loss, you may better help them 

to attain their goals.
41

T

here is a growing

prevalence of obesity

among older persons.

Age alone should not

preclude treatment for

obesity in adult men and women.

A clinical decision to forgo obesity treatment in an older adult

should be guided by an evaluation

of the potential benefits of weight

reduction for day-to-day functioning and reduction of the risk of

future cardiovascular events, as

well as the patient’s motivation for

weight reduction. Being obese

does not appear to benefit older

persons. However, care must be

taken to ensure that any weight

reduction program minimizes the

likelihood of adverse effects on

bone health or other aspects of

nutritional status. There is little

evidence at present to indicate that

obesity treatment should be withheld from adult men and women

on the basis of age alone up to 

80 years of age.

The higher prevalence of cardiovascular risk factors in overweight

versus nonoverweight persons is

clearly observed at older ages. In

addition, obesity is a major predictor of functional limitations and

mobility impairments in older

adults. Weight loss reduces risk

factors and improves functional

status in older persons in the 

same manner as in younger adults.

Weight loss requires proper nutritional and exercise counseling,

including resistance training and

moderate weight-bearing exercise.

However, the weight control 

program must often be individually

tailored to have a desirable outcome.

This would include preservation of

body cell mass and its function,

and loss of fat mass.68-75

Weight Reduction After Age 65

Age alone should not 

preclude treatment 

for obesity. However, care

must be taken to minimize

the likelihood of adverse

effects on bone health or

other aspects of nutritional

status.

Obesity at older ages
42

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on Diet and Health. Implications for

reducing chronic disease risk.

Washington, DC: National Academy

Press; 1989.

2. Kuczmarski RJ, Carrol MD, Flegal

KM, Troiano RP. Varying body 

mass index cutoff points to describe 

overweight prevalence among U.S.

adults: NHANES III (1988 to 1994).

Obes Res.1997;5:542-548.

3. Dyer AR, Elliott P. The INTERSALT

study: relations of body mass index to

blood pressure. INTERSALT 

Co-operative Research Group. J Hum

Hypertens. 1989;3:299-308.

4. Tchernof A, Lamarche B, Prud’Homme

D, et al. The dense LDL phenotype:

association with plasma lipoprotein levels, visceral obesity, and hyperinsulinemia in men. Diabetes Care. 1996;19(6):

629-637.

5. Lew EA, Garfinkel L. Variations in

mortality by weight among 750,000

men and women. J Chronic Dis.

1979;32:563-576.

6. Larsson B, Bjorntorp P, Tibblin G. The

health consequences of moderate obesity. Int J Obes. 1981;5:97-116.

7. Ford ES, Williamson DF, Liu S. Weight

change and diabetes incidence: findings

from a national cohort of U.S. adults.

Am J Epidemiol. 1997;146:214-222.

8. Lipton RB, Liao Y, Cao G, Cooper RS,

McGee D. Determinants of incident

non-insulin-dependent diabetes mellitus

among blacks and whites in a national

sample. The NHANES I Epidemiologic

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44
Introduction

to the

Appendices

In order to lose weight and

maintain weight loss, your

patients need to know what to

do and be motivated to do it.

These Appendices contain all

the basic information they

need to eat better, get in better

condition, and improve health.

You can help them to decide

what’s best for them, and this

is a good place to start.
46

Appendix A. Body Mass Index Table

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Height Body Weight (pounds)

(inches)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287

BMI 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

58 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258

59 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

60 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295

63 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
47

Foods Lower in Calories and Fat

Use this guide to help you shop for foods that are

nutritious and lower in calories and fat to help you

achieve your weight goal. Learning how to read a

Nutrition Facts food label will help you save time

in the store and fill your kitchen with low calorie

foods.

Read labels as you shop. Pay attention to the

serving size and the servings per container. All

labels list total calories and fat in a serving size of

the product. Compare the total calories in the

product you choose with others like it; choose the

Appendix B. Shopping—What To Look For

 

 

 

•

•

Check for:

one that is lowest in calories and fat. Below is a

label that identifies important information.

To achieve your weight goal, you may need to eat

much less than this reference amount. For

example, if you eat 1,600 calories per day, your

total daily fat limit should be 53 grams (30 percent

calories from fat) and 18 grams of saturated fat 

(10 percent calories from fat). If you eat 1,200

calories per day, your total daily fat limit should be

40 grams (30 percent calories from fat), and your

total daily saturated fat limit would be 13 grams

(10 percent calories from fat).

Product:

Here you can see the recommended daily amount for

each nutrient for two calorie levels. If you eat a 2,000

calorie diet, you should be eating less than 65 grams of fat

and less than 20 grams of saturated fat. If you eat 2,500

calories a day, you should eat less than 80 grams of fat

and 25 grams of saturated fat. Your daily amounts may be

higher or lower, depending on the calories you eat.

The “% Daily Value” shows you how much of the

recommended amounts the food provides in one serving,

if you eat 2,000 calories a day. For example, one serving

of this food gives you 18 percent of your total fat

recommendation.

• Calories

• Total fat in grams

• Saturated fat in grams

• Cholesterol in milligrams

• Sodium in milligrams

Here, the label gives the amounts for the different nutrients

in one serving. Use it to help you keep track of how many

calories and how much fat, saturated fat, cholesterol, and

sodium you are getting from different foods.

• Serving size

• Number of servings
48

Fat Matters, but Calories Count

A calorie is a calorie is a calorie whether it comes

from fat or carbohydrate. Anything eaten in excess

can lead to weight gain. You can lose weight by

eating less calories and by increasing your

physical activity. Reducing the amount of fat and

saturated fat that you eat is one easy way to limit

your overall calorie intake. However, eating fat

free or reduced fat foods isn’t always the answer to

weight loss. This is especially true when you eat

more of the reduced fat food than you would of the

regular item. For example, if you eat twice as

many fat free cookies, you have actually increased

your overall calorie intake.

The following list of foods and their reduced fat

varieties will show you that just because a product

is fat free, it doesn’t mean that it is “calorie free.”

And, calories do count!

Nutrient data taken from Nutrient Data System for Research, Version v4.02/30, Nutrition Coordinating Center, University of Minnesota.

Shopping—What To Look For continued

Fat Free or Reduced Fat Regular

Calories Calories

Reduced fat peanut butter, 187 Regular peanut butter, 191

2 T 2 T

Cookies: Cookies:

Reduced fat chocolate chip cookies, 118 Regular chocolate chip cookies, 142

3 cookies (30 g) 3 cookies (30 g)

Fat free fig cookies, 102 Regular fig cookies, 111

2 cookies (30 g) 2 cookies (30 g)

Ice cream: Ice cream:

Nonfat vanilla frozen yogurt (< 1% fat), 100 Regular whole milk vanilla 104

1

/2 cup frozen yogurt (3–4% fat), 1/2 cup

Light vanilla ice cream (7% fat), 111 Regular vanilla ice cream (11% fat), 133

1

/2 cup 1/2 cup

Fat free caramel topping, 103 Caramel topping, homemade with butter 103

2 T 2 T

Lowfat granola cereal, 213 Regular granola cereal, 257

approx. 1

/2 cup (55 g) approx. 1/2 cup (55 g)

Lowfat blueberry muffin, 131 Regular blueberry muffin, 138

1 small (21

/2 inch) 1 small (21/2 inch)

Baked tortilla chips, 113 Regular tortilla chips, 143

1 oz. 1 oz.

Lowfat cereal bar, 130 Regular cereal bar, 140

1 bar (1.3 oz.) 1 bar (1.3 oz.)
49

These low calorie alternatives provide new ideas

for old favorites. When making a food choice,

remember to consider vitamins and minerals.

Some foods provide most of their calories from

sugar and fat but give you few, if any, vitamins and

minerals.

Appendix C. Low Calorie, Lower Fat Alternatives

This guide is not meant to be an exhaustive list.

We stress reading labels to find out just how many

calories are in the specific products you decide to

buy.

Cereals, Grains,

and Pasta Dairy Products Meat, Fish, and Poultry

Instead of... Replace with...

• Evaporated whole milk • Evaporated fat free (skim) or reduced fat (2%) milk

• Whole milk • Lowfat (1%), reduced fat (2%), or fat free (skim) milk

• Ice cream • Sorbet, sherbet, lowfat or fat free frozen yogurt, or ice

milk (check label for calorie content)

• Whipping cream • Imitation whipped cream (made with fat free [skim] 

milk) or lowfat vanilla yogurt

• Sour cream • Plain lowfat yogurt

• Cream cheese • Neufchatel or “light” cream cheese or fat free cream 

cheese

• Cheese (cheddar, Swiss, jack) • Reduced calorie cheese, low calorie processed 

cheeses, etc.

• Fat free cheese

• American cheese • Fat free American cheese or other types of fat free 

cheeses

• Regular (4%) cottage cheese • Lowfat (1%) or reduced fat (2%) cottage cheese

• Whole milk mozzarella cheese • Part skim milk, low-moisture mozzarella cheese

• Whole milk ricotta cheese • Part skim milk ricotta cheese

• Coffee cream (half and half) or nondairy creamer • Lowfat (1%) or reduced fat (2%) milk or nonfat 

(liquid, powder) dry milk powder

• Ramen noodles • Rice or noodles (spaghetti, macaroni, etc.)

• Pasta with white sauce (alfredo) • Pasta with red sauce (marinara)

• Pasta with cheese sauce • Pasta with vegetables (primavera)

• Granola • Bran flakes, crispy rice, etc.

• Cooked grits or oatmeal

• Whole grains (e.g., couscous, barley, bulgur, etc.)

• Reduced fat granola

• Cold cuts or lunch meats • Lowfat cold cuts (95% to 97% fat free lunch meats, 

(bologna, salami, liverwurst, etc.) lowfat pressed meats)

• Hot dogs (regular) • Lower fat hot dogs

• Bacon or sausage • Canadian bacon or lean ham

• Regular ground beef • Extra lean ground beef such as ground round or 

ground turkey (read labels)

• Chicken or turkey with skin, duck, or goose • Chicken or turkey without skin (white meat)

• Oil-packed tuna • Water-packed tuna (rinse to reduce sodium content)
50

Meat, Fish,

and Poultry (continued) Baked Goods Snacks and Sweets Fats, Oils, and Salad Dressings Miscellaneous

Instead of... Replace with...

• Beef (chuck, rib, brisket) • Beef (round, loin) (trimmed of external fat) 

(choose select grades)

• Pork (spareribs, untrimmed loin) • Pork tenderloin or trimmed, lean smoked ham

• Frozen breaded fish or fried fish • Fish or shellfish, unbreaded (fresh, frozen, canned 

(homemade or commercial) in water)

• Whole eggs • Egg whites or egg substitutes

• Frozen TV dinners (containing more than • Frozen TV dinners (containing less than 

13 grams of fat per serving) 13 grams of fat per serving and lower in sodium)

• Chorizo sausage • Turkey sausage, drained well (read label)

• Vegetarian sausage (made with tofu)

• Croissants, brioches, etc. • Hard french rolls or soft “brown ’n serve” rolls

• Donuts, sweet rolls, muffins, scones, or pastries • English muffins, bagels, reduced fat or fat free

muffins or scones 

• Party crackers • Lowfat crackers (choose lower in sodium)

• Saltine or soda crackers (choose lower in sodium)

• Cake (pound, chocolate, yellow) • Cake (angel food, white, gingerbread)

• Cookies • Reduced fat or fat free cookies (graham crackers, 

ginger snaps, fig bars) (compare calorie level)

• Nuts • Popcorn (air-popped or light microwave),

fruits, vegetables

• Ice cream, e.g., cones or bars • Frozen yogurt, frozen fruit, or chocolate 

pudding bars

• Custards or puddings (made with whole milk) • Puddings (made with skim milk)

• Regular margarine or butter • Light-spread margarines, diet margarine, 

or whipped butter, tub or squeeze bottle

• Regular mayonnaise • Light or diet mayonnaise or mustard

• Regular salad dressings • Reduced calorie or fat free salad dressings, 

lemon juice, or plain, herb-flavored, or wine vinegar

• Butter or margarine on toast or bread • Jelly, jam, or honey on bread or toast

• Oils, shortening, or lard • Nonstick cooking spray for stir-frying or sautéing

• As a substitute for oil or butter, use applesauce 

or prune puree in baked goods

• Canned cream soups • Canned broth-based soups

• Canned beans and franks • Canned baked beans in tomato sauce

• Gravy (homemade with fat and/or milk) • Gravy mixes made with water or homemade 

with the fat skimmed off and fat free milk included

• Fudge sauce • Chocolate syrup

• Avocado on sandwiches • Cucumber slices or lettuce leaves

• Guacamole dip or refried beans with lard • Salsa

Low Calorie, Lower Fat Alternatives continued
51

Calories Fat % Fat Exchange for:

Breakfast (grams)

• Whole wheat bread, 1 medium slice 70 1.2 15 (1 bread/starch)

• Jelly, regular, 2 tsp 30 0 0 (1/2 fruit)

• Cereal, shredded wheat, 1/2 cup 104 1 4 (1 bread/starch)

• Milk, 1%, 1 cup 102 3 23 (1 milk)

• Orange juice, 3/4 cup 78 0 0 (11/2 fruit)

• Coffee, regular, 1 cup 5 0 0 (free)

Breakfast total 389 5.2 10

Lunch

• Roast beef sandwich:

Whole wheat bread, 2 medium slices 139 2.4 15 (2 bread/starch)

Lean roast beef, unseasoned, 2 oz 60 1.5 23 (2 lean protein)

Lettuce, 1 leaf 1 0 0

Tomato, 3 medium slices 10 0 0 (1 vegetable)

Mayonnaise, low calorie, 1 tsp 15 1.7 96 (1/3 fat)

• Apple, 1 medium 80 0 0 (1 fruit)

• Water, 1 cup 0 0 0 (free)

Lunch total 305 5.6 16

Dinner

• Salmon, 2 ounces edible 103 5 44 (2 lean protein)

• Vegetable oil, 11/2 tsp 60 7 100 (11/2 fat)

• Baked potato, 3/4 medium 100 0 0 (1 bread/starch)

• Margarine, 1 tsp 34 4 100 (1 fat)

• Green beans, seasoned, with margarine, 1/2 cup 52 2 4 (1 vegetable) (1/2 fat)

• Carrots, seasoned 35 0 0 (1 vegetable)

• White dinner roll, 1 small 70 2 28 (1 bread/starch)

• Iced tea, unsweetened, 1 cup 0 0 0 (free)

• Water, 2 cups 0 0 0 (free)

Dinner total 454 20 39

Snack

• Popcorn, 21/2 cups 69 0 0 (1 bread/starch)

• Margarine, 3/4 tsp 30 3 100 (3/4 fat)

Total 1,247 34–36 24–26

Appendix D. Sample Reduced Calorie Menus 

Calories . . . . . . . . . . . . . . . . . . . . . . 1,247

Total carbohydrate, % kcals . . . . . . . . . 58

Total fat, % kcals. . . . . . . . . . . . . . . . . . 26

*Sodium, mg . . . . . . . . . . . . . . . . . . 1,043

Saturated fat, % kcals. . . . . . . . . . . . . . . 7

Cholesterol, mg . . . . . . . . . . . . . . . . . . 96

Protein, % kcals . . . . . . . . . . . . . . . . . . 19

Note: Calories have been rounded.

1,200: 100% RDA met for all nutrients except vitamin E 80%, vitamin B2 96%, vitamin B6 94%, calcium 68%, iron 63%, and zinc 73%.

* No salt added in recipe preparation or as seasoning. Consume at least 32 ounces of water.

Traditional American Cuisine—1,200 Calories

You can use the exchange list in Appendix E to give yourself more choices.
52

Calories . . . . . . . . . . . . . . . . . . . . . .1,613

Total carbohydrate, % kcals . . . . . . . . .55

Total fat, % kcals . . . . . . . . . . . . . . . . . .29

*Sodium, mg . . . . . . . . . . . . . . . . . .1,341

Saturated fat, % kcals . . . . . . . . . . . . . . .8 

Cholesterol, mg . . . . . . . . . . . . . . . . .142

Protein, % kcals . . . . . . . . . . . . . . . . . .19

Note: Calories have been rounded.

1,600: 100% RDA met for all nutrients except vitamin E 99%, 

iron 73%, and zinc 91%.

* No salt added in recipe preparation or as seasoning. Consume

at least 32 ounces of water.

Calories Fat % Fat Exchange for:

Breakfast (grams)

• Whole wheat bread, 1 medium slice 70 1.2 15.4 (1 bread/starch)

• Jelly, regular, 2 tsp 30 0 0 (1/2 fruit)

• Cereal, shredded wheat, 1 cup 207 2 8 (2 bread/starch)

• Milk, 1%, 1 cup 102 3 23 (1 milk)

• Orange juice, 3/4 cup 78 0 0 (11/2 fruit)

• Coffee, regular, 1 cup 5 0 0 (free)

• Milk, 1%, 1 oz 10 0.3 27 (1/8 milk)

Breakfast total 502 6.5 10

Lunch

• Roast beef sandwich:

Whole wheat bread, 2 medium slices 139 2.4 15 (2 bread/starch)

Lean roast beef, unseasoned, 2 oz 60 1.5 23 (2 lean protein)

American cheese, lowfat and low sodium, 

1 slice, 3/4 oz 46 1.8 36 (1 lean protein)

Lettuce, 1 leaf 1 0 0

Tomato, 3 medium slices 10 0 0 (1 vegetable)

Mayonnaise, low calorie, 2 tsp 30 3.3 99 (2/3 fat)

• Apple, 1 medium 80 0 0 (1 fruit)

• Water, 1 cup 0 0 0 (free)

Lunch total 366 9 22

Dinner

• Salmon, 3 ounces edible 155 7 40 (3 lean protein)

• Vegetable oil, 11/2 tsp 60 7 100 (11/2 fat)

• Baked potato, 3/4 medium 100 0 0 (1 bread/starch)

• Margarine, 1 tsp 34 4 100 (1 fat)

• Green beans, seasoned, with margarine, 1/2 cup 52 2 4 (1 vegetable) (1/2 fat)

• Carrots, seasoned, with margarine, 1/2 cup 52 2 4 (1 vegetable) (1/2 fat)

• White dinner roll, 1 medium 80 3 33 (1 bread/starch)

• Ice milk, 1

/2 cup 92 3 28 (1 bread/starch) (1/2 fat)

• Iced tea, unsweetened, 1 cup 0 0 0 (free)

• Water, 2 cups 0 0 0 (free)

Dinner total 625 28 38

Snack

• Popcorn, 21/2 cups 69 0 0 (1 bread/starch)

• Margarine, 1/2 tsp 58 6.5 100 (11/2 fat)

Total 1,613 50 28

Traditional American Cuisine—1,600 Calories

You can use the exchange list in Appendix E to give yourself more choices.

Sample Reduced Calorie Menus continued
53

Asian American Cuisine—Reduced Calorie

1,600: 100% RDA met for all nutrients except zinc 95%, iron 87%, and calcium 93%.

1,200: 100% RDA met for all nutrients except vitamin E 75%, calcium 84%, magnesium 98%, iron 66%, and zinc 77%.

* No salt added in recipe preparation or as seasoning. Consume at least 32 ounces of water.

Breakfast 1,600 Calories 1,200 Calories

• Banana 1 small 1 small

• Whole wheat bread 2 slices 1 slice

• Margarine 1 tsp 1 tsp

• Orange juice 3/4 cup 3/4 cup

• Milk 1%, lowfat 3/4 cup 3/4 cup

Lunch

• Beef noodle soup, canned, low sodium 1/2 cup 1/2 cup

• Chinese noodle and beef salad:

Roast beef 3 oz 2 oz

Peanut oil 11

/2 tsp 1 tsp

Soy sauce, low sodium 1 tsp 1 tsp

Carrots 1/2 cup 1/2 cup

Zucchini 1/2 cup 1/2 cup

Onion 1/4 cup 1/4 cup

Chinese noodles, soft type 1/4 cup 1/4 cup

• Apple 1 medium 1 medium

• Tea, unsweetened 1 cup 1 cup

Dinner

• Pork stir-fry with vegetables:

Pork cutlet 2 oz 2 oz

Peanut oil 1 tsp 1 tsp

Soy sauce, low sodium 1 tsp 1 tsp

Broccoli 1/2 cup 1/2 cup

Carrots 1 cup 1/2 cup

Mushrooms 1/4 cup 1/2 cup

• Steamed white rice 1 cup 1/2 cup

• Tea, unsweetened 1 cup 1 cup

Snack

• Almond cookies 2 cookies —

• Milk 1%, lowfat 3/4 cup 3/4 cup

Calories . . . . . . . . . . . . . . .1,609

Total carbohydrate, % kcals . . .56

Total fat, % kcals . . . . . . . . . . .27

*Sodium, mg . . . . . . . . . . . .1,296

Saturated fat, % kcals . . . . . . . .8

Cholesterol, mg . . . . . . . . . . .148

Protein, % kcals . . . . . . . . . . .20

Calories . . . . . . . . . . . . . . .1,220

Total carbohydrate, % kcals . . .55

Total fat, % kcals . . . . . . . . . . .27

*Sodium, mg . . . . . . . . . . . .1,043

Saturated fat, % kcals . . . . . . . .8

Cholesterol, mg . . . . . . . . . . .117

Protein, % kcals . . . . . . . . . . .21

Sample Reduced Calorie Menus continued
54

Southern Cuisine—Reduced Calorie

1,600: 100% RDA met for all nutrients except vitamin E 97%, 

magnesium 98%, iron 78%, and zinc 90%.

1,200: 100% RDA met for all nutrients except vitamin E 82%, 

vitamin B1 & B2 95%, vitamin B3 99%, vitamin B6 88%, 

magnesium 83%, iron 56%, and zinc 70%.

* No salt added in recipe preparation or as seasoning.

Consume at least 32 ounces of water.

Breakfast 1,600 Calories 1,200 Calories

• Oatmeal, prepared with 1% milk, lowfat 1/2 cup 1/2 cup

• Milk, 1%, lowfat 1/2 cup 1/2 cup

• English muffin 1 medium —

• Cream cheese, light, 18% fat 1 T —

• Orange juice 3/4 cup 1/2 cup

• Coffee 1 cup 1 cup

• Milk, 1%, lowfat 1 oz 1 oz

Lunch

• Baked chicken, without skin 2 oz 2 oz

• Vegetable oil 1 tsp 1

/2 tsp

• Salad:

Lettuce 1/2 cup 1/2 cup

Tomato 1/2 cup 1/2 cup

Cucumber 1/2 cup 1/2 cup

• Oil and vinegar dressing 2 tsp 1 tsp

• White rice 1/2 cup 1/4 cup

• Margarine, diet 1/2 tsp 1/2 tsp

• Baking powder biscuit, prepared with vegetable oil 1 small 1/2 small

• Margarine 1 tsp 1 tsp

• Water 1 cup 1 cup

Dinner

• Lean roast beef 3 oz 2 oz

• Onion 1/4 cup 1/4 cup

• Beef gravy, water-based 1 T 1 T

• Turnip greens 1/2 cup 1/2 cup

• Margarine, diet 1

/2 tsp 1/2 tsp

• Sweet potato, baked 1 small 1 small

• Margarine, diet 1

/2 tsp 1/4 tsp

• Ground cinnamon 1 tsp 1 tsp

• Brown sugar 1 tsp 1 tsp

• Corn bread prepared with margarine, diet 1

/2 medium slice 1/2 medium slice

• Honeydew melon 1/4 medium 1/8 medium

• Iced tea, sweetened with sugar 1 cup 1 cup

Snack

• Saltine crackers, unsalted tops 4 crackers 4 crackers

• Mozzarella cheese, part skim, low sodium 1 oz 1 oz

Calories . . . . . . . . . . . . . . .1,653

Total carbohydrate, % kcals . . .53

Total fat, % kcals . . . . . . . . . . .28

*Sodium, mg . . . . . . . . . . . .1,231

Saturated fat, % kcals . . . . . . . .8

Cholesterol, mg . . . . . . . . . . .172 

Protein, % kcals . . . . . . . . . . .20

Calories . . . . . . . . . . . . . . .1,225

Total carbohydrate, % kcals . . .50

Total fat, % kcals . . . . . . . . . . .31

*Sodium, mg . . . . . . . . . . . . .867

Saturated fat, % kcals . . . . . . . .9

Cholesterol, mg . . . . . . . . . . .142

Protein, % kcals . . . . . . . . . . .21

Sample Reduced Calorie Menus continued
55

Mexican American Cuisine—Reduced Calorie

Breakfast 1,600 Calories 1,200 Calories

• Cantaloupe 1 cup 1/2 cup

• Farina, prepared with 1% lowfat milk 1/2 cup 1/2 cup

• White bread 1 slice 1 slice

• Margarine 1 tsp 1 tsp

• Jelly 1 tsp 1 tsp

• Orange juice 11/2 cup 3/4 cup

• Milk, 1%, lowfat 1/2 cup 1/2 cup

Lunch

• Beef enchilada:

Tortilla, corn 2 tortillas 2 tortillas

Lean roast beef 21

/2 oz 2 oz

Vegetable oil 2/3 tsp 2/3 tsp

Onion 1 T 1 T

Tomato 4 T 4 T

Lettuce 1/2 cup 1/2 cup

Chili peppers 2 tsp 2 tsp

Refried beans, prepared with vegetable oil 1/4 cup 1/4 cup

• Carrots 5 sticks 5 sticks

• Celery 6 sticks 6 sticks

• Milk, 1%, lowfat 1/2 cup —

• Water — 1 cup

Dinner

• Chicken taco:

Tortilla, corn 1 tortilla 1 tortilla

Chicken breast, without skin 2 oz 1 oz

Vegetable oil 2

/3 tsp 2/3 tsp

Cheddar cheese, lowfat and low sodium 1 oz 1

/2 oz

Guacamole 2 T 1 T

Salsa 1 T 1 T

• Corn, seasoned with 1

/2 cup 1/2 cup

Margarine 1/2 tsp —

• Spanish rice without meat 1/2 cup 1/2 cup

• Banana 1 large 1/2 large

• Coffee 1 cup 1/2 cup

• Milk, 1% 1 oz 1 oz

Calories . . . . . . . . . . . . . . .1,638

Total carbohydrate, % kcals . . .56

Total fat, % kcals . . . . . . . . . . .27

*Sodium, mg . . . . . . . . . . . .1,616

Saturated fat, % kcals . . . . . . . .9

Cholesterol, mg . . . . . . . . . . .143 

Protein, % kcals . . . . . . . . . . .20

Calories . . . . . . . . . . . . . . .1,239

Total carbohydrate, % kcals . . .58

Total fat, % kcals . . . . . . . . . . .26

*Sodium, mg . . . . . . . . . . . .1,364

Saturated fat, % kcals . . . . . . . .8

Cholesterol, mg . . . . . . . . . . . .91

Protein, % kcals . . . . . . . . . . .19

Sample Reduced Calorie Menus continued

1,600: 100% RDA met for all nutrients except vitamin E 97% 

and zinc 84%.

1,200: 100% RDA met for all nutrients except vitamin E 71%, 

vitamin B1 & B3 91%, vitamin B2 & iron 90%, and calcium 92%.

* No salt added in recipe preparation or as seasoning.

Consume at least 32 ounces of water.
56

Lacto-Ovo Vegetarian Cuisine—Reduced Calorie

1,600: 100% RDA met for all nutrients except vitamin E 92%,

vitamin B3 97%, vitamin B6 67%, iron 73%, and zinc 68%.

1,200: 100% RDA met for all nutrients except vitamin E 75%, vitamin B1

92%, vitamin B3 69%, vitamin B6 59%, iron 54%, and zinc 46%.

* No salt added in recipe preparation or as seasoning.

Consume at least 32 ounces of water.

Breakfast 1,600 Calories 1,200 Calories

• Orange 1 medium 1 medium

• Pancakes, made with 1% lowfat milk and eggs whites 3 4” circles 2 4” circles

• Pancake syrup 2 T 1 T

• Margarine, diet 11/2 tsp 11/2 tsp

• Milk, 1%, lowfat 1 cup 1/2 cup

• Coffee 1 cup 1 cup

• Milk, 1%, lowfat 1 oz 1 oz

Lunch

• Vegetable soup, canned, low sodium 1 cup 1/2 cup

• Bagel 1 medium 1

/2 medium

• Processed american cheese, lowfat 3/4 oz —

• Spinach salad:

Spinach 1 cup 1 cup

Mushrooms 1/2 cup 1/2 cup

• Salad dressing, regular calorie 2 tsp 2 tsp

• Apple 1 medium 1 medium

• Iced tea, unsweetened 1 cup 1 cup

Dinner

• Omelette:

Egg whites 4 large eggs 4 large eggs

Green pepper 2 T 2 T

Onion 2 T 2 T

Mozzarella cheese, made from part 1 oz 1/2 oz

skim milk, low sodium

Vegetable oil 1 T 1/2 T

• Brown rice, seasoned with 1

/2 cup 1/2 cup

Margarine, diet 1

/2 tsp 1/2 tsp

• Carrots, seasoned with 1/2 cup 1/2 cup

Margarine, diet 1

/2 tsp 1/2 tsp

• Whole wheat bread 1slice 1slice

• Margarine, diet 1tsp 1tsp

• Fig bar cookie 1bar 1bar

• Tea 1 cup 1 cup

• Honey 1 tsp 1 tsp

• Milk, 1%, lowfat 3/4 cup 3/4 cup

Calories . . . . . . . . . . . . . . .1,650

Total carbohydrate, % kcals . . .56

Total fat, % kcals . . . . . . . . . . .27

*Sodium, mg . . . . . . . . . . . .1,829

Saturated fat, % kcals . . . . . . . .8

Cholesterol, mg . . . . . . . . . . . .82 

Protein, % kcals . . . . . . . . . . .19

Calories . . . . . . . . . . . . . . .1,205

Total carbohydrate, % kcals . . .60

Total fat, % kcals . . . . . . . . . . .25

*Sodium, mg . . . . . . . . . . . .1,335

Saturated fat, % kcals . . . . . . . .7

Cholesterol, mg . . . . . . . . . . . .44

Protein, % kcals . . . . . . . . . . .18

Sample Reduced Calorie Menus continued
57

Appendix E. Food Exchange List

Within each group, these foods can be exchanged for each other. You can use this list to give yourself more choices.

Vegetables contain 25 calories and 5 grams of

carbohydrate. One serving equals:

• 1/2 cup Cooked vegetables (carrots,

broccoli, zucchini,

cabbage, etc.)

• 1 cup Raw vegetables or

salad greens

• 1

/2 cup Vegetable juice

If you’re hungry, eat more fresh or steamed 

vegetables.

Fat Free and Very Low Fat Milk contains 

90 calories and 12 grams of carbohydrate per

serving. One serving equals:

• 8 oz Milk, fat free or 1% fat

• 3

/4 cup Yogurt, plain

nonfat or

lowfat

• 1 cup Yogurt,

artificially sweetened

Very Lean Protein choices have 35 calories and

1 gram of fat per serving. One serving equals:

• 1 oz Turkey breast or chicken

breast, skin removed

• 1 oz Fish fillet (flounder,

sole, scrod, cod,

haddock, halibut)

• 1 oz Canned tuna in water

• 1 oz Shellfish (clams, lobster, scallop,

shrimp)

• 3

/4 cup Cottage cheese, nonfat or lowfat

• 2 each Egg whites

• 1

/4 cup Egg substitute

• 1 oz Fat free cheese

• 1

/2 cup Beans—cooked (black beans,

kidney, chickpeas, or lentils):

count as 1 starch/bread and 1

very lean protein

Fruits contain 15 grams of carbohydrates and 

60 calories. One serving equals:

• 1 small Apple, banana, orange, nectarine

• 1 medium Fresh peach

• 1 Kiwi

• 1

/2 Grapefruit

• 1

/2 Mango

• 1 cup Fresh berries (strawberries,

raspberries, or blueberries)

• 1 cup Fresh melon cubes

• 1

/8 Honeydew melon 

• 4 oz Unsweetened juice 

• 4 tsp Jelly or jam

Lean Protein choices have 55 calories and 

2 to 3 grams of fat per serving. One serving equals:

• 1 oz Chicken—dark meat, skin removed

• 1 oz Turkey—dark meat, skin removed

• 1 oz Salmon, swordfish,

herring, catfish, trout

• 1 oz Lean beef (flank

steak, London broil,

tenderloin, roast beef)*

• 1 oz Veal, roast, or lean chop*

• 1 oz Lamb, roast, or lean chop*

• 1 oz Pork, tenderloin, or fresh ham*

• 1 oz Lowfat cheese (3 grams or less of

fat per ounce)

• 1 oz Lowfat luncheon meats (with 

3 grams or less of fat per ounce)

• 1

/4 cup 4.5% cottage cheese

• 2 medium Sardines

* Limit to 1 to 2 times per week.
58

Medium Fat Proteins have 75 calories and 

5 grams of fat per serving. One serving equals:

• 1 oz Beef (any prime cut), corned beef,

ground beef **

• 1 oz Pork chop

• 1 each Whole egg (medium) **

• 1 oz Mozzarella cheese

• 1

/4 cup Ricotta cheese

• 4 oz Tofu (note that this is a

heart-healthy choice)

** Choose these very infrequently.

Starches contain 15 grams of carbohydrate and

80 calories per serving. One serving equals:

• 1 slice Bread (white, pumpernickel,

whole wheat, rye)

• 2 slice Reduced calorie or “lite” bread

• 1

/4 (1 oz) Bagel (varies)

• 1

/2 English muffin

• 1

/2 Hamburger bun

• 3

/4 cup Cold cereal

• 1

/3 cup Rice, brown or white—cooked

• 1

/3 cup Barley or couscous—cooked

• 1

/3 cup Legumes (dried beans, peas, or

lentils)—cooked

• 1

/2 cup Pasta—cooked

• 1

/2 cup Bulgur—cooked

• 1

/2 cup Corn, sweet potato, or green peas

• 3 oz Baked sweet or white potato

• 3

/4 oz Pretzels

• 3 cups Popcorn, hot-air popped or

microwave (80-percent light)

Fats contain 45 calories and 5 grams of fat per

serving. One serving equals:

• 1 tsp Oil (vegetable, corn, canola, 

olive, etc.)

• 1 tsp Butter

• 1 tsp Stick margarine

• 1 tsp Mayonnaise

• 1 T Reduced fat margarine or

mayonnaise

• 1 T Salad dressing

• 1 T Cream cheese

• 2 T Lite cream cheese

• 1

/8 Avocado

• 8 large Black olives

• 10 large Stuffed green olives

• 1 slice Bacon

Source: Based on the American Dietetic Association Exchange List

Food Exchange List continued
59

Appendix F. Food Preparation—What to Do

Low Calorie, Lowfat 

Cooking/Serving Methods

Cooking low calorie, lowfat dishes may not take a

long time, but best intentions can be lost with the

addition of butter or other added fats at the table. It

is important to learn how certain ingredients can

add unwanted calories and fat to lowfat dishes—

making them no longer lower in calories and lower

in fat. The following list provides examples of

lower fat cooking methods and tips on how to

serve your lowfat dishes.

Lowfat Cooking Methods

These cooking methods tend to be lower in fat:

• Bake

• Broil

• Microwave

• Roast—for vegetables and/or chicken without

skin

• Steam

• Lightly stir-fry or sauté

in cooking spray, small

amounts of vegetable oil, or

reduced sodium broth

• Grill seafood, chicken, or vegetables

How To Save Calories and Fat 

Look at the following examples for how to save

calories and fat when preparing

and serving foods. You

might be surprised at

how easy it is.

• Two tablespoons of

butter on a baked potato adds an extra 200

calories and 22 grams of fat. However, 1

/4 cup

salsa adds only 18 calories and no fat. 

• Two tablespoons of regular clear Italian salad

dressing adds an extra 136 calories and 14 grams

of fat. Reduced fat Italian dressing adds only 30

calories and 2 grams of fat.

Try These Lowfat Flavorings—Added

During Preparation or at the Table:

• Herbs—oregano, basil, cilantro,

thyme, parsley, sage, or

rosemary

• Spices—cinnamon, nutmeg,

pepper, or paprika

• Reduced fat or fat free salad

dressing

• Mustard

• Catsup

• Fat free mayonnaise

• Fat free or reduced fat sour cream

• Fat free or reduced fat yogurt

• Reduced sodium soy sauce

• Salsa

• Lemon or lime juice

• Vinegar

• Horseradish

• Fresh ginger

• Sprinkled buttered flavoring (not made with 

real butter) 

• Red pepper flakes

• Sprinkle of parmesan

cheese (stronger flavor

than most cheese)

• Sodium free salt

substitute

• Jelly or fruit preserves on toast or bagels
60

General Tips for Healthy Dining Out

Whether or not you’re trying to lose weight, you

can eat healthfully when dining out or bringing in

food, if you know how. The following tips will

help you move toward healthier eating as you limit

your calories, as well as fat, saturated fat,

cholesterol, and sodium, when eating out. 

You Are the Customer

• Ask for what you want. Most

restaurants will honor your

requests.

• Ask questions. Don’t be

intimidated by the menu—

your server will be able to tell

you how foods are prepared or suggest

substitutions on the menu.

• If you wish to reduce portion sizes, try ordering

appetizers as your main meal.

• General tips: Limiting your calories and fat can

be easy as long as you know what to order. Try

asking these questions when you call ahead or

before you order. Ask the restaurant, whether

they would, on request, do

the following:

– Serve nonfat (skim) milk

rather than whole milk or

cream.

– Reveal the type of cooking

oil used.

– Trim visible fat off poultry or meat.

– Leave all butter, gravy, or sauces off a side

dish or entree.

– Serve salad dressing on the side.

– Accommodate special requests if made in

advance by telephone or in person.

Above all, don’t get discouraged. There are usually

several healthy choices to choose from at most

restaurants.

Reading the Menu

• Choose lower calorie, lowfat cooking methods.

Look for terms such as “steamed in its own

juice” (au jus), “garden fresh,” “broiled,”

“baked,” “roasted,” “poached,” “tomato juice,”

“dry boiled” (in wine or lemon juice), or 

“lightly sautéed.”

• Be aware of foods high in calories, fat, and

saturated fat. Watch out for terms such as “butter

sauce,” “fried,” “crispy,” “creamed,”

“in cream or cheese sauce,” “au gratin,”

“au fromage,” “escalloped,” “parmesan,”

“hollandaise,” “bearnaise,” “marinated (in oil),”

“stewed,” “basted,” “sautéed,” “stir-fried,”

“casserole,” “hash,” “prime,” “pot pie,” and

“pastry crust.”

Specific Tips for Healthy Choices

Breakfast

• Fresh fruit or small glass of citrus juice

• Whole grain bread, bagel,

or English muffin with

jelly or honey

• Whole grain cereal with lowfat (1%) or nonfat

milk

• Oatmeal with nonfat milk topped with fruit

• Omelet made with egg whites or egg substitute

• Multigrain pancakes without butter on top

• Nonfat yogurt (Try adding cereal or fresh fruit.)

Beverages

• Water with lemon

• Flavored sparkling water

(noncaloric)

• Juice spritzer (half fruit juice and half sparkling

water)

• Iced tea

• Tomato juice (reduced sodium)

Appendix G. Dining Out—How To Choose
61

Bread

Most bread and bread sticks are low in calories

and low in fat. The calories add up when you add

butter, margarine, or olive oil to the bread. Also,

eating a lot of bread in addition to your

meal will fill you up with extra

unwanted calories and not leave

enough room for fruits and

vegetables.

Appetizers

• Steamed seafood

• Shrimp* cocktail (Limit

cocktail sauce—it’s high in

sodium.)

• Melons or fresh fruit

• Bean soups

• Salad with reduced fat dressing (Or add lemon

juice or vinegar.)

* If you are on a cholesterol-lowering diet, eat 

shrimp and other shellfish in moderation.

Entree

• Poultry, fish, shellfish, and

vegetable dishes are

healthy choices.

• Pasta with red sauce or with

vegetables (primavera)

• Look for terms such as “baked,” “broiled,”

“steamed,” “poached,” “lightly sauteed,” or “stirfried.”

• Ask for sauces and dressings on the side.

• Limit the amount of butter, margarine, and salt

you use at the table.

Salads/Salad Bars

• Fresh greens, lettuce, and

spinach

• Fresh vegetables—tomato,

mushroom, carrots, cucumber, peppers, onion,

radishes, and broccoli

• Beans, chickpeas, and kidney beans

• Skip the nonvegetable choices: deli meats,

bacon, egg, cheese, croutons. 

• Choose lower calorie, reduced fat, or fat free

dressing, lemon juice, or vinegar.

Side Dish

• Vegetables and starches (rice, potato, noodles)

make good additions to meals

and can also be combined

for a lower calorie

alternative to higher

calorie entrees.

• Ask for side dishes without butter or margarine.

• Ask for mustard, salsa, or lowfat yogurt instead

of sour cream or butter.

Dessert/Coffee

• Fresh fruit

• Nonfat frozen yogurt

• Sherbet or fruit sorbet

(These are usually fat

free, but check the calorie content.)

• Try sharing a dessert.

• Ask for lowfat milk for your coffee (instead of

cream or half-and-half).

Dining Out—How To Choose continued
Your exercise can be done all at one time or

intermittently over the course of the day. Initial

activities may be walking or swimming at a slow

pace. You can start by walking slowly for 30

minutes 3 days a week. Then build to 45 minutes

of more intense walking at least 5 days a week.

With this regimen, you can burn 100 to 200

calories per day. All adults should set a long-term

goal to accumulate at least 30 minutes or more of

moderate-intensity physical activity on most,

and preferably all, days of the week. This

regimen can be adapted to other forms of

physical activity, but walking is particularly

attractive because of its safety and accessibility. Also, try to change everyday activities;

for example, take the stairs instead of the elevator.

Reducing sedentary time is a good strategy to

increase activity by undertaking frequent, less

An increase in physical activity is an important

part of your weight management program. Most

weight loss occurs because of decreased caloric

intake. Sustained physical activity is most helpful

in the prevention of weight regain. In addition,

physical activity helps to reduce cardiovascular

and diabetes risks beyond what

weight reduction alone can

do. Start exercising

slowly, and gradually

increase the intensity.

Trying too hard at

first can lead to

injury.

62

Appendix H. Guide to Physical Activity

Examples of Moderate Amounts of Physical Activity*

Common Chores Sporting Activities

Washing and waxing a car for 45–60 minutes Playing volleyball for 45–60 minutes 

Washing windows or floors for 45–60 minutes Playing touch football for 45 minutes

Gardening for 30–45 minutes Walking 13/4 miles in 35 minutes (20 min/mile)

Wheeling self in wheelchair for 30–40 minutes Basketball (shooting baskets) for 30 minutes

Pushing a stroller 11/2 miles in 30 minutes Bicycling 5 miles in 30 minutes

Raking leaves for 30 minutes Dancing fast (social) for 30 minutes

Walking 2 miles in 30 minutes (15 min/mile) Water aerobics for 30 minutes

Shoveling snow for 15 minutes Swimming laps for 20 minutes

Stairwalking for 15 minutes Basketball (playing a game) for 15–20 minutes 

Jumping rope for 15 minutes

Running 11/2 miles in 15 minutes (15 min/mile)

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 

150 calories of energy per day, or 1,000 calories per week.

† Some activities can be performed at various intensities; the suggested durations correspond to expected 

intensity of effort.

More

Vigorous,

Less Time

Less

Vigorous,

More Time†
63

strenuous activities.76 With time, you may be able

to—and you may want to—engage in more

strenuous activities. Competitive sports such as

tennis and volleyball can provide an enjoyable

form of exercise, but you must take care to avoid

injury.

Overcoming Obstacles to 

Regular Activity

Many people who are completely inactive cite

various reasons for their inactivity. 

• I don’t have the time to exercise.

Physical activity does take time,

but only about 1 hour per week

of vigorous activity can greatly

benefit your heart, lungs,

muscles, and weight. Consider

the amount of time you spend

watching television. Many forms

of physical activity, such as

riding an exercise bicycle or

using hand weights, can be done while watching

television.

• I don’t like to exercise.

You have bad memories of

doing situps or running in high

school, sweating, puffing, and

panting. Now we know that

you can get plenty of gain

without pain! Activities you

already do, such as gardening and

walking, can improve your health, so

just do more of the activities you like.

• I don’t have the energy to be more active.

Once you become a little more active, you should

have more energy. As you progress, daily tasks

will seem easier.

• It’s hard to remember to exercise.

Leave your sneakers near the door to

remind yourself to walk, bring a change

of clothes to work and head

straight for exercise on the way

home, or put a note on your

calendar at work to remind

yourself to exercise. In addition,

simply try to develop the habit of

integrating more activity into your daily routine.

Gaining Health Benefits From 

Physical Activity 

It is much easier to control your weight when you

are active, and being active helps to prevent

osteoporosis (bone loss) and heart disease and

helps in the treatment of diabetes. In addition,

physical activity helps to increase your confidence

and decrease your stress. It can also decrease

sadness and improve depression.

Benefits of Regular Activity

• Your weight is much easier to 

control when you are active.

• Physical activity can be lots of fun.

• You can be with other people when you 

are active.

• You’ll feel better when you’re 

physically active.

• You’ll look better when you’re 

physically active.

• Physical activity is good for your heart.

• Physical activity is a great way to burn off

steam and stress.

• Physical activity helps you beat 

the blues.

• You’ll feel more confident when 

you are active.

• You’ll have more energy.

Guide to Physical Activity continued
64

Fitting Activity Into Your Schedule

• What time of day is best for you to exercise? 

Try walking before going to work or school, or

maybe you prefer evenings. Even a few minutes of

walking counts. Try to build up to accumulating 30

minutes per day. You can walk whenever it is

convenient for you, or you can take an aerobics

class instead. Whatever works for you is fine. The

important thing is that you try to be more active.

There is no one right time of day to exercise.

Try to think about the little things you can do to

add more activity to your daily life. For instance,

take the stairs instead of the elevator at work, park

farther away from the entrance to the mall, or walk

instead of driving to work or to shopping. These

little things add up and are easy to fit into your

schedule.

Some people want to be alone when they exercise,

whereas others prefer the company of a group or

class. Again, whatever works for you is fine.

• What activities have you enjoyed in the past?

Why did you stop? How can you 

start them again? 

You may enjoy other

activities that are better

suited to your current

lifestyle. The key is

to find one or two

you really like.

Consider varying

your activity to

prevent boredom. 

Planning To Become More Active

• Begin slowly.

If you have not been active for years, do not start

with a 3-mile walk! Pushing yourself too hard or

too fast will make you sore and discouraged. 

• Set realistic goals, and plan to succeed.

For example, set the goal of walking two times this

week. Even if you walk for only 5 minutes each

time, you will have met your goal. Next week, you

might try to walk two times for 10 minutes each

time. Being realistic helps you to feel good about

yourself, and it helps you to keep up the good

work. You may want to keep an activity log to

track your progress.

You can have fun and feel healthier by

doing any of the following:

• Walk or ride a bike in your 

neighborhood.

• Join a walking club at a mall 

or at work.

• Play golf at a local club.

• Join a dance class.

• Work in your garden.

• Use local athletic facilities.

• Join a hiking or biking club.

• Join a softball team or other sports team with

coworkers, friends, or family.

• Chase your kids in the park. If you don’t have

kids, take your neighbor’s. The parents will

appreciate the break, the neighbors will enjoy

it, and you’ll benefit from getting more activity.

• Walk your dog. If you don’t have a dog, 

pretend you do.

• Take a walk during your lunch break.

Guide to Physical Activity continued
65

• Reward yourself for reaching your goals.

Each time you meet an exercise goal, give yourself

a treat to mark the occasion. Some ideas include

the following: buy yourself new sports equipment,

ask your spouse to take the kids for an hour, visit a

friend, spend more time on your favorite hobby,

buy yourself flowers or a plant, enjoy a long hot

bath, or go to a movie or rent a video.

• Be active the healthy way.

Most healthy people can safely

start a program of moderate

activity. Talk to your doctor

first if you have heart

trouble or experience pain

or pressure in your chest, neck,

shoulder, or arm during or after exercise. 

Drink plenty of fluids while you are active. If the

weather is bad, have a backup plan. Do your

activity indoors. Use the proper equipment, such

as a bicycle helmet for safety, and wear

comfortable shoes or sneakers for

walking.

• How hard should you exercise?

For the beginner in a sedentary

lifestyle, activity level can be very

light. This would include increasing standing

activities, doing special chores like room painting,

pushing a wheelchair, doing yard work, ironing,

cooking, and playing a musical instrument.

The next level would be light activity such as

slow walking (24 minutes per mile), garage

work, carpentry, house cleaning, child care,

golf, sailing, and recreational table tennis. 

The next level would be moderate activity

such as walking at 15 minutes per mile,

weeding and hoeing a garden, carrying

a load, cycling, skiing, tennis, and

dancing.

Two Sample Activity Programs

There are many ways to begin an activity program.

Below are two examples—a walking program and

a jogging program. These activities are easy ways

for most people to get

regular exercise because

they do not require special

facilities or equipment other than

good, comfortable shoes. 

If you find a particular week’s

pattern tiring, repeat it before

going on to the next pattern. You do

not have to complete the walking

program in 12 weeks or the jogging

program in 15 weeks.

A sample jogging program

If you are older than 40 and have not been active,

you should not begin with a program as strenuous

as jogging. Begin with the walking program

instead. After completing the walking program,

you can start with week 3 of the jogging program

below. 

If walking or jogging does not meet your needs,

look for other exercise programs in pamphlets and

books on aerobic exercise and sports medicine.

Check out the programs and facilities of your local

park and recreation department

or community recreation

centers. Many programs

have adapted facilities

for the disabled and

for seniors. 

Guide to Physical Activity continued
66

A sample walking program

Warmup Exercising Cool down Total time

Week 1

Session A Walk 5 min. Then walk Then walk more 15 min.

briskly 5 min. slowly 5 min.

Session B Repeat 

above pattern

Session C Repeat 

above pattern

Continue with at least three exercise sessions during each week of the program.

Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min.

Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min.

Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min.

Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min.

Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min.

Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min.

Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min.

Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min.

Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min.

Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min.

Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min.

Week 13 on:

Gradually increase your brisk walking time to 30 to 60 minutes, three or four times a week.

Remember that your goal is to get the benefits you are seeking and enjoy your activity.

Walking Tips

• Hold your head up, and keep your back 

straight.

• Bend your elbows as you swing your 

arms.

• Take long, easy strides.

For additional information about physical

activity, request the NHLBI booklet Exercise and

Your Heart: A Guide to Physical Activity. 
67

A sample jogging program

If you are older than 40 and have not been active, you should not begin with a program as strenuous as

jogging. Begin with the walking program instead. After completing the walking program, you can start with

week 3 of the jogging program below. 

Warmup Exercising Cool down Total time

Week 1

Session A

Session B

Session C

Continue with at least three exercise sessions during each week of the program.

Walk 5 min., 

then stretch and 

limber up

Repeat above pattern

Repeat above pattern

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Walk 5 min., then

stretch and limber up

Then walk 10 min.

Try not to stop.

Walk 5 min., jog 1 min.,

walk 5 min., jog 1 min.

Walk 5 min., jog 3 min., 

walk 5 min., jog 3 min.

Walk 4 min., jog 5 min., 

walk 4 min., jog 5 min.

Walk 4 min., jog 5 min., 

walk 4 min., jog 5 min.

Walk 4 min., jog 6 min., 

walk 4 min., jog 6 min.

Walk 4 min., jog 7 min., 

walk 4 min., jog 7 min.

Walk 4 min., jog 8 min., 

walk 4 min., jog 8 min.

Walk 4 min., jog 9 min., 

walk 4 min., jog 9 min.

Walk 4 min., jog 13 min.

Walk 4 min., jog 15 min.

Walk 4 min., jog 17 min.

Walk 2 min., jog slowly 

2 min., jog 17 min.

Walk 1 min., jog slowly 

3 min., jog 17 min.

Jog slowly 3 min., 

jog 17 min.

Then walk more

slowly 3 min. and

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Walk 3 min., 

stretch 2 min.

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week 13

Week 14

Week 15

Week 16 on: Gradually increase your jogging time from 20 to 30 minutes (or more, up to 60 minutes),

three or four times a week. Remember that your goal is to get the benefits you are seeking and enjoy

your activity.

20 min.

22 min.

26 min.

28 min.

28 min.

30 min.

32 min.

34 min.

36 min.

27 min.

29 min.

31 min.

31 min.

31 min.

30 min.
68

Why Weight Is Important 

Being overweight or obese can have a negative

effect on your overall health.

Overweight and obesity are

risk factors for developing

health problems such as

high blood

cholesterol, high

blood pressure,

diabetes, gallbladder disease,

gynecologic disorders, arthritis, some

types of cancer, and even some lung

problems.

People try to lose weight for a number of reasons.

You may already have a health problem that you

know about, such as high blood pressure, and want

to lose weight to improve your health. Others may

be losing weight in order to help prevent health

problems. Still others simply want to lose weight

to look thinner. For whatever reason, your health

care provider may have given you information to

help you lose weight. 

In some ways, weight is different from other

health problems since it is not something that is

hidden, such as high blood cholesterol levels.

Patients may have had experience with health care

providers who are insensitive about their weight.

They may have had encounters where they felt

blamed rather than helped. Please be assured that

when your health care provider discusses your

weight, it’s because it is an important

aspect of your overall health care.

Your provider also understands

that weight management is a

long-term challenge

influenced by

behavioral, emotional,

and physical factors. 

Appendix I. Guide to Behavior Change

How To Lose Weight and Maintain It

Set the Right Goals.

Setting the right goals is an important first step.

Did you know that the amount of weight loss

needed to improve health may be much less than

you want to lose to look thinner? If your provider

suggests an initial weight loss goal that seems too

heavy for you, please understand that your health

can be greatly improved by a loss of 5 percent to

10 percent of your starting weight. That doesn’t

mean you have to stop there, but it does mean that

an initial goal of 5 to 10 percent of your starting

weight is both realistic and valuable. 

Most people who are trying to lose weight focus

on one thing: weight loss. However, focusing on

dietary and exercise changes that will lead to

permanent weight loss is much more productive.

People who are successful at managing their

weight set only two to three goals at a time. 

Effective goals

are:

• specific

• realistic

• forgiving (less 

than perfect) 

For example:

“Exercise more” is a

fine goal, but it’s not 

specific enough. 

“Walk 5 miles every day”

is specific and measurable, but is it achievable if

you’re just starting out? 

“Walk 30 minutes every day” is more attainable,

but what happens if you’re held up at work one

day and there’s a thunderstorm during your

walking time on another day? 

“Walk 30 minutes, 5 days each week” is specific,

achievable, and forgiving. A great goal!
69

Nothing Succeeds Like Success.

Shaping is a technique where you set some

short-term goals that get you closer and closer

to the ultimate goal (e.g., reduce fat from 

40 percent of calories to 35 percent of calories,

and ultimately to 30 percent). It is based on the

concept that “nothing succeeds like success.”

Shaping uses two

important behavioral

principles:

• Continuous

goals that move

you ahead in

small steps to

reach a distant

point.

• Continuous rewards to

keep you motivated to make changes. 

Reward Success 

(But Not With Food).

Rewards that you control

can encourage

achievement of your goals,

especially ones that have been hard to reach.

An effective reward is something that is desirable,

timely, and dependent upon meeting your goal.

The rewards you choose may be material (e.g., a

movie, music CD, or payment

toward buying a larger item) or

an act of self-kindness

(e.g., an afternoon off

from work, a massage, or

personal time).

Frequent, small rewards

earned for meeting smaller

goals are more effective

than bigger rewards,

requiring a long, difficult effort. 

Balance Your (Food) Checkbook.

Self-monitoring refers to observing and recording

some aspect of your behavior, such as calorie

intake, servings of fruits and vegetables eaten, and

amount of physical activity, etc., or an outcome of

these behaviors, such as weight. Self-monitoring of

a behavior can be used at times when you’re not

sure of how you are doing and at times when you

want the behavior to improve. Self-monitoring of a

behavior usually moves you closer to the desired

behavior. When you record your behavior, you

produce real-time records for you and your health

care provider to discuss. For example, keeping a

record of your exercise can let you and your

provider know quickly how you are doing. When

your record shows that your exercise is increasing,

you’ll be encouraged to keep it up. Some

patients find that standard selfmonitoring forms make it

easier, while others like

their own recording

system. Use the form

in Appendix K to help

you keep track of your

daily diet and activity levels.

Regular monitoring of your weight is key to

keeping it off. Remember these four points if you

are keeping a weight chart or graph:

• One day’s diet and exercise routine won’t

necessarily affect your weight the next day. Your

weight will change quite a bit over the course of

a few days because of fluctuations in water and

body fat. 

• Try to weigh yourself at a set time once or twice

per week. This can be when you first wake up

and before eating and drinking, after exercise, or

right before dinner, etc. 

• Whatever time you choose, just make sure it is

always the same time and use the same scale to

help you keep the most accurate records. 

• It may also be helpful to create a

graph of your weight as a visual

reminder of how you’re

doing, rather than just

listing numbers.

Guide to Behavior Change continued
70

Avoid a Chain Reaction.

Stimulus (cue) control involves learning what

social or environmental cues encourage undesired

eating, and then changing those cues. For example,

you may learn from your self-monitoring

techniques or from sessions with your health care

provider that you’re more likely to overeat when

watching TV, when treats are on display by the

office coffee pot, or when around a certain friend.

Ways to change the situation

include:

• Separating the

association of eating

from the cue

(Don’t eat while

watching

television.)

• Avoiding or

eliminating

the cue

(Leave the

coffee room

immediately after

pouring coffee.)

• Changing the environment (Plan to meet this

friend in a nonfood setting.) 

In general, visible and reachable food items often

lead to unplanned eating. 

Get the (Fullness) Message.

Changing the way you eat can

help you to eat less and not

feel deprived. 

• Eating slowly will

help you to feel

satisfied when you’ve

eaten the right amount

of food for you. It takes 15 or

more minutes for your brain to get the

message you’ve been fed. Slowing the

rate of eating can allow you to feel

full sooner and, therefore, help you

eat less. 

• Eating lots of vegetables and fruit

and also starting a meal with a

broth-based soup can help you

feel fuller. 

• Using smaller plates helps to

moderate portions so they don’t

appear too small. 

• Drinking at least eight glasses of noncaloric

beverages each day will help you to feel full,

possibly eat less, and benefit you in other ways. 

• Changing your eating schedule, or setting one,

can be helpful, especially if you tend to skip or

delay meals and overeat later.

Guide to Behavior Change continued
71

PATIENT 

WEIGHT TOTAL 

DATE WEIGHT CHANGE WEIGHT WAIST BMI PATIENT GOALS SET THIS VISIT

THIS VISIT CHANGE

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

DIET

PHYSICAL ACTIVITY

BEHAVIOR

NOTES

Appendix J. Weight and Goal Record
72

Weight Management Chart 

You can’t drive a car if you can’t

see where you are going. You can’t

control your weight if you can’t see

where it’s going. An important

behavior change is to keep a visual

record of your weight, along

with your physical activity

habits. Beginning now,

weigh yourself every day

and record each day’s

weight and minutes of

physical activity using

the graph on the next

page, as shown in the

example below. Weigh

yourself at the same

time under the same

conditions every day. The

bottom horizontal lines show the

days of the month. The vertical

lines on the left side will show a

range of your weights, while the

vertical lines on the right side will

show the minutes of physical

activity. 

Chart Your Weight.

Write in your first weight on the

third line from the top of the graph

on the left side. List successive

weights up and down from there,

one pound per line. Each day go up

the line above that day

until you are on the

same horizontal line

as your weight that

day, and mark the

spot with a dot.

Connect the dots

with a solid line. 

Chart Your

Physical Activity.

Do the same for physical

activity. Write in 5 minutes

of physical activity on the first

line from the bottom of the graph

on the right side. List additional

minutes of activity up from there

using 5 minute intervals. Each day

go up the line above that day until

you are on the same horizontal line

as your physical activity for that

day, and mark the spot with a dot.

Connect the dots with a solid line.

See Your Success.

The beginning of a weight loss

program is when weight graphing

is most fun—a good time to start

the habit. Your graph will show ups

and downs because of changes in

fluid balance and differences in

fluid intake from day to day. 

You will learn to understand these

variations and use the overall trend

to guide your weight control plan.

Post the graph near your scale or

on your refrigerator as a reminder

of your progress.

Weight and Goal Record continued

Weigh yourself at the same time

under the same conditions every day.

The bottom horizontal lines show the

days of the month. The vertical lines

on the left side will show a range of

your weights, while the vertical lines

on the right side will show the

minutes of physical activity.

Source: Adapted from the Weight Management Center, Medical University of South Carolina
73
74

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Notes: __________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Weekly Food and Activity Diary Week of:

Breakfast Lunch Dinner Activity

Appendix K. Weekly Food and Activity Diary
75

Appendix L. Additional Resources

The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:

Evidence Report was developed by the NHLBI Expert Panel and released in June 1998. In addition to the

Evidence Report (NIH Publication # 4083), a number of professional and patient education resources based on

the report are available from the NHLBI. These resources include the executive summary of the report (NIH

Publication #55-892), evidence tables of data supporting the report, an electronic textbook, a slide kit, a BMI

calculator including a Palm top application, a menu planner, highlights for patients, and this Practical Guide to

the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. These resources are available

on the NHLBI’s Aim For a Healthy Weight Web page at www.nhlbi.nih.gov or by contacting the address

below:

In addition, the Clinical Guidelines Evidence Report was published in the September 1998 supplement of

Obesity Research which can be obtained from the North American Association for the Study of Obesity

(NAASO) at the following address:

National Heart, Lung, and Blood Institute

Health Information Center

P.O. Box 30105

Bethesda, MD 20824-0105

(301) 592-8573

(301) 592-8563 fax

www.nhlbi.nih.gov

Online publications on blood pressure,

overweight, cholesterol, heart disease,

sleep disorders and asthma

1. Second Report of the Expert Panel on Detection,

Evaluation, and Treatment of High Blood

Cholesterol in Adults (Adult Treatment Panel II).

NIH publication #3046. 

www.nhlbi.nih.gov.

2. The Sixth Report of the Joint National

Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood

Pressure.

NIH publication #4080. 

www.nhlbi.nih.gov.

3. Consensus Statement: Gastrointestinal 

Surgery for Severe Obesity. 

www.odp.od.nih.gov/consensus

North American Association 

for the Study of Obesity

8630 Fenton Street, Suite 412

Silver Spring, MD 20910

(301) 563-6526

(301) 587-2365 fax

www.naaso.org

Other materials available from the NHLBI include:
76

National Institute of Diabetes and

Digestive and Kidney Diseases

National Institutes of Health

Building 31, Room 9A52

31 Center Drive

Bethesda, MD 20892-1818

(301) 496-5877

(301) 402-2125 fax

http://www.niddk.nih.go/index.htm

The Weight-Control 

Information Network

National Institute of Diabetes and

Digestive and Kidney Diseases

National Institutes of Health

1 Win Way

Bethesda, MD 20892-0001

(301) 570-2177

(301) 570-2186 fax

1-800-WIN-8098

National Diabetes Information

Clearinghouse (NIDDK)

1 Information Way

Bethesda, MD 20892-3560

(301) 654-3327

(301) 907-8906 fax

American Society for 

Bariatric Surgery (ASBS)

140 Northwest 75th Drive,

Suite C

Gainesville, FL 32607 

(352) 331-4900

(352) 331-4975 fax

http://www.asbs.org/

American Dietetic Association

216 West Jackson Boulevard

Chicago, IL 60606-6995

(312) 899-0040

1-800-877-1600 fax

http://www.eatright.org

Eat Right America Program

Find a dietitian, 1-800-366-1655

American College of 

Sports Medicine

P.O. Box 1440

Indianapolis, IN 46206-1440

(317) 637-9200

(317) 634-7817 fax

http://www.acsm.org

American Diabetes Association

1660 Duke Street

Alexandria, VA 22314

1-800-DIABETES

http://www.diabetes.org

American Society of Bariatric

Physicians (ASBP)

5600 South Quebec Street,

Suite 109A

Englewood, CO 80111

(303) 770-2526, ext. 17 

(membership information only)

(303) 779-4833 

(303) 779–4834 fax

http://www.asbp.org

American Obesity Association

1250 24th Street, NW, Suite 300

Washington, DC 20037

202-776-7711

202-776-7712 fax

http://www.obesity.org

American Cancer Society

Atlanta, GA

1-800-ACS-2345

http://www.cancer.org

Office of Cancer Communications

National Cancer Institute

National Institutes of Health

Building 31, Room 10A-24

31 Center Drive, MSC 2580

Bethesda, MD 20892-2580

1-800-4-CANCER 

(1-800-422-6237)

http://www.nci.nih.gov

National Eating Disorders

Organization

6655 South Yale Avenue

Tulsa, OK 74136

(918) 481-4044

(918) 481-4076 fax

http://www.laureate.com/

aboutned.html

Eating Disorders Awareness and

Prevention, Inc.

603 Stewart Street, Suite 803

Seattle, WA 98101

(206) 382-3587

http://members.aol.com/edapinc/

home.html

American Anorexia/Bulimia

Association, Inc.

165 West 46th Street, #1108

New York, NY 10036

(212) 575-6200

http://members.aol.com/amanbu/

index.html

National Association of Anorexia

Nervosa and Associated Disorders

P.O. Box 7

Highland Park, IL 60035

(847) 831-3438

(847) 433-4632 fax

http://www.anad.org 

Additional Resources continued
77

American Heart Association

7272 Greenville Avenue

Dallas, TX 75231-4596

(214) 706-1220

(214) 706-1341 fax

1-800-AHA-USA1 

(1-800-242-8721)

http://www.americanheart.org

Stroke Connection 

1-800-553-6321

Hypertension Network, Inc.

http://www.bloodpressure.com

National Institute of Neurological

Disorders and Stroke

National Institutes of Health

P.O. Box 1350

Silver Spring, MD 20911

(800) 352-9424

http://www.ninds.nih.gov

National Center on Sleep Disorders

Research

National Heart, Lung,

and Blood Institute

National Institutes of Health

Two Rockledge Centre,

Suite 10038

6701 Rockledge Drive,

MSC 7920

Bethesda, MD 20892-7920

(301) 435-0199

(301) 480-3451 fax

www.nhlbi.nih.gov and click 

on NCSDR

American Academy of 

Sleep Medicine

6301 Bandel Road, Suite 101

Rochester, MN 55901

(507) 287-6006

(507) 287-6008 fax

http://www.aasmnet.org

National Mental Health Association

1201 Prince Street

Alexandria, Virginia 22314-2971

(703) 684-7722

(703) 684-5968 fax

1-800-969-NMHA 

(Information Center)

http://www.nmha.org
A Quick

Reference

Tool to ACT
79

BMI ≥ 25 OR 

waist > 35 in (88 cm) (F)

> 40 in (102 cm) (M)

• Advise to

maintain

weight

• Address other

risk factors

• Periodic

weight, BMI,

and waist circumference

check (every 2

years)

Patient

encounter Assess risk 

factors

Educate/Reinforce

• Established

Coronary

Heart Disease

• Other Atherosclerotic

Disease 

• Type 2

Diabetes

• Sleep Apnea

• Other Obesity

Associated

Diseases

Risk Factors

• Smoking

• Hypertension

• High LDL-C

• Low HDL-C

• Impaired fasting glucose

• Family history

of premature

CHD

• ≥45 yrs (M) and

≥55 yrs (F)

Does patient 

want to lose

weight?

BMI Table 

BMI

Height 25 27 30 35

58” 119 129 143 167

59” 124 133 148 173

60” 128 138 153 179

61” 132 143 158 185

62” 136 147 164 191

63” 141 152 169 197

64” 145 157 174 204

65” 150 162 180 210

66” 155 167 186 216

67” 159 172 191 223

68” 164 177 197 230

69” 169 182 203 236

70” 174 188 209 243

71” 179 193 215 250

72” 184 199 221 258

73” 189 204 227 265

For a complete BMI Table see

Appendix A.

No

No

No

Yes

Assessment (A) and Classification (C)

• Assess the

patient’s

weight 

status

• Provide 

advice,

counseling,

or treatment 

Yes Yes Yes

iIiac crest

Measuring-Tape Position

for Waist (Abdominal)

Circumference in Adults

A Quick Reference Tool to ACT Weight

Measure weight, height,

and waist circumference.

Calculate body mass index

(BMI)

Waist

Circumference

• Abdominal fat

increases risk.

• High risk 

F: >35 in (>88 cm)

M: >40 in (>102 cm)

Measure Waist

Circumference as

follows:

• locate the upper

hip bone and the

top of the right iliac

crest (below figure).

Place a measuring

tape in a horizontal

plane around the

abdomen at the

level of the iliac

crest. Before reading the tape measure, ensure that the

tape is snug, but

does not compress

the skin, and is parallel to the floor.

The measurement

is made at the end

of expiration. 

Body Mass 

Index (BMI)

• BMI categories:

Overweight: 

25-29.9 kg/m2

Obesity: ≥ 30 kg/m2

• Calculate BMI as 

follows:

BMI= weight (kg) 

height squared (m2)

If pounds and inches 

are used:

BMI=weight (pounds)x703 

height squared(inches2)

BMI ≥ 30 OR 

[(BMI 25 to 29.9 

waist > 35 in (F) > 40 

AND ≥ 2 risk

factors)]
80

Treatment (T)/Follow-up

R 

n (M) )

• Dietary therapy

• Behavior therapy

• Physical activity

Progress 

being

made/goal 

achieved?

Periodic weight,

BMI, and waist

circumference

check

Maintenance 

counseling

Set Goals

• Advise patent to lose

10% of initial weight

• 1-2 lbs/wk

for

• 6 months of therapy

Clinician and patient

devise goals and 

treatment strategy 

for weight loss and risk

factor control

Assess reasons for 

failure to lose 

weight

Yes

Lifestyle Therapy

• Diet:

500-1000 kcal/day

reduction 

30% or less total

kcal from fat

~15% total kcal

from protein

≥55% of total kcal

from CHO.

• Physical Activity:

Initially, 30-45

mins. of moderate 

activity, 3-5 times

a week. 

Eventually 30 mins

of moderate activity on most days.

• Behavior Therapy

BMI 25-29.9 and

≥ 2 risk factors or 

BMI ≥ 30

Pharmacotherapy

• Adjunct to lifestyle

therapy. Consider

if patient has not

lost 1 lb/wk after 6

months of lifestyle

therapy.

• Orlistat - 120 mg

or 120 mg po tid

before meals

• Sibutramine -

5,10,15 mg; 

10 mg po qd to

start may be

increased to 15

mg or decreased

to 5 mg.

BMI ≥ 27 and ≥ 2 risk

factors or 

BMI ≥ 30

Weight Loss

Surgery

• Consider if other

weight loss

attempts have

failed.

• Vertical banded

gastroplasty or

gastric bypass

• Lifelong medical

monitoring

BMI ≥ 35 and ≥ 2 risk

factors or 

BMI ≥ 40

OPTION 1 OPTION 2 OPTION 3

Yes

Yes

Yes Yes

No

Source: Full text of the Practical Guide to

the Identification, Evaluation and Treatment

of Overweight and Obesity in Adults is

available from the National Heart, Lung and

Blood Institute Health Information Center

at (301) 592-8573 or can be downloaded

from the NHLBI’s Aim for a Healthy

Weight Web page at www.nhlbi.nih.gov and

click on “Aim for a Healthy Weight.” Also,

available from NAASO at www.naaso.org

~


DISCRIMINATION PROHIBITED: Under

provisions of applicable public laws enacted

by Congress since 1964, no person in the

United States shall, on the grounds of race,

color, national origin, handicap, or age, be

excluded from participation in, be denied

the benefits of, or be subjected to discrimination under any program or activity (or, on

the basis of sex, with respect to any education program or activity) receiving Federal

financial assistance. In addition, Executive

Order 11141 prohibits discrimination on the

basis of age by contractors and subcontractors in the performance of Federal 

contracts, Executive Order 11246 states

that no federally funded contractor may 

discriminate against any employee or 

applicant for employment because of race,

color, religion, sex, or national origin and

Executive Order 13087 prohibits discrimination based on sexual orientation. Therefore,

the National Heart, Lung, and Blood

Institute must be operated in compliance

with these laws and Executive Orders.
aa

U.S. Department of Health and Human Services 

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 00-4084

October 2000