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NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults (US). Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda (MD): National Heart, Lung, and Blood Institute; 1998 Sep.

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

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

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Chapter 5Summary of Recommendations

A. Advantages of Weight Loss

  • Weight loss is recommended to lower elevated blood pressure in overweight and obese persons with high blood pressure. Evidence Category A.
  • Weight loss is recommended to lower elevated levels of total cholesterol, low-density lipoprotein cholesterol, and triglycerides and to raise low levels of high-density lipoprotein cholesterol in overweight and obese persons with dyslipidemia. Evidence Category A.
  • Weight loss is recommended to lower elevated blood glucose levels in overweight and obese persons with type 2 diabetes. Evidence Category A.

B. Measurement of Degree of Overweight and Obesity

  • Practitioners should use the body mass index (BMI) to assess overweight and obesity. Body weight alone can be used to follow weight loss, and to determine efficacy of therapy. Evidence Category C.
  • The BMI should be used to classify overweight and obesity and to estimate relative risk for disease compared to normal weight. Evidence Category C.
  • The waist circumference should be used to assess abdominal fat content. Evidence Category C.
  • For adult patients with a BMI of 25 to 34.9 kg/m2, sex-specific waist circumference cutoffs should be used in conjunction with BMI to identify increased disease risks. Evidence Category C.

C. Goals for Weight Loss

  • The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. With success, further weight loss can be attempted, if indicated, through further assessment. Evidence Category A.
  • Weight loss should be about 1 to 2 lb/week for a period of 6 months, with the subsequent strategy based on the amount of weight lost. Evidence Category B.

D. How To Achieve Weight Loss

1. Dietary Therapy

  • Low-calorie diets are recommended for weight loss in overweight and obese persons. Evidence Category A. Reducing fat as part of a low-calorie diet is a practical way to reduce calories. Evidence Category A.
  • Reducing dietary fat alone without reducing calories is not sufficient for weight loss. However, reducing dietary fat, along with reducing dietary carbohydrates, can facilitate caloric reduction. Evidence Category A.
  • 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 lb/week. Evidence Category A.

2. Physical Activity

  • Physical activity is recommended as part of a comprehensive weight loss therapy and weight maintenance program because it: (1) modestly contributes to weight loss in overweight and obese adults (Evidence Category A), (2) may decrease abdominal fat (Evidence Category B), (3) increases cardiorespiratory fitness (Evidence Category A), and (4) may help with maintenance of weight loss (Evidence Category C).
  • Physical activity should be an integral part of weight loss therapy and weight maintenance. Evidence Category A. Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week should be encouraged. 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. Evidence Category B.
  • The combination of a reduced calorie diet and increased physical activity is recommended since it produces weight loss, decreases abdominal fat, and increases cardiorespiratory fitness. Evidence Category A.

3. Behavior Therapy

  • Behavior therapy is a useful adjunct when incorporated into treatment for weight loss and weight maintenance. Evidence Category B.
  • Practitioners need to assess the patient's motivation to enter weight loss therapy; assess the readiness of the patient to implement the plan and then take appropriate steps to motivate the patient for treatment. Evidence Category D.
  • Behavior therapy strategies to promote diet and physical activity should be used routinely, as they are helpful in achieving weight loss and weight maintenance. Evidence Category B.

4. Combined Therapy

  • Weight loss and weight maintenance therapy should employ the combination of low-calorie diets, increased physical activity, and behavior therapy. Evidence Category A.

5. Pharmacotherapy

  • Weight loss drugs approved by the FDA may be used as part of a comprehensive weight loss program including diet and physical activity for patients with a BMI of ≥ 30 with no concomitant obesity- related risk factors or diseases, and for patients with a BMI of ≥ 27 with concomitant obesity-related risk factors or diseases. Drugs should never be used without concomitant lifestyle modification. Continual assessment of drug therapy for efficacy and safety is necessary. If the drug is efficacious in helping the patient lose and/or maintain weight loss and there are no serious adverse effects, it can be continued. If not, it should be discontinued. Evidence Category B.

6. Weight Loss Surgery

  • Weight loss surgery is an option in carefully selected patients with clinically severe obesity (BMI ≥ 40 or ≥ 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality. Evidence Category B.

E. Goals for Weight Loss Maintenance

  • After successful weight loss, the likelihood of weight loss maintenance is enhanced by a program consisting of dietary therapy, physical activity, and behavior therapy, which should be continued indefinitely. Drug therapy can also be used. However, drug safety and efficacy beyond 1 year of total treatment have not been established. Evidence Category B.
  • A weight maintenance program should be a priority after the initial 6 months of weight loss therapy. Evidence Category B.

F. How To Maintain Weight Loss

  • The literature suggests that weight loss and weight maintenance therapies that provide a greater frequency of contacts between the patient and the practitioner and are provided over the long term should be put in place. This can lead to more successful weight loss and weight maintenance. Evidence Category C.
  • 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, various health professionals with different expertise are available and helpful to a practitioner who would like assistance. Evidence Category B.

G. Special Treatment Groups

  • All smokers, regardless of their weight status, should quit smoking. Evidence Category A. Prevention of weight gain should be encouraged and if weight gain does occur, it should be treated through diet, physical activity, and behavior therapy, maintaining the primary emphasis on the abstinence from smoking. Evidence Category C.
  • A clinical decision to forego obesity treatment in older adults 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. 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. Evidence Category D.
  • The possibility that a standard approach to weight loss will work differently in diverse patient populations must be considered when setting expectations about treatment outcomes. Evidence Category B.

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