Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Weight Management I NHLBI Obesity Education Initiative National Heart, Lung, and Blood Institute in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health The expert panel that developed the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults was convened by the National Heart, Lung, and Blood Institute (NHLBI) in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The Clinical Guidelines are the first Federal guidelines released that deal with the issues related to the assessment and treatment of overweight and obesity in adults. They were officially released by NHLBI on June 17, 1998.

Goals of Weight Management/Treatment Prevent further weight gain (minimum goal). Reduce body weight. Maintain a lower body weight over long term. The general goals of weight loss and management are: At a minimum, to prevent further weight gain. To reduce body weight if prescribed. To maintain a lower body weight over the long term. Specific targets for each of these goals can be considered.

Target Weight: Realistic Goals Substitute “healthier weight” for ideal or landmark weight. Accept slow, incremental progress to goal. Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week. Interim goal: Maintenance. Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.

Weight Loss Goals Goal: Decrease body weight by 10 percent from baseline. If goal is achieved, further weight loss can be attempted if indicated. Reasonable timeline: 6 months of therapy. Moderate caloric deficits Weight loss 1 to 2 lb/week The initial target goal of weight loss therapy is to decrease body weight by 10 percent. Once this target is achieved, further weight loss can be attempted if indicated. The rationale for this initial goal of moderate weight loss, i.e., 10 percent of initial body weight, is that It can decrease the severity of obesity-associated risk factors. It can set the stage for further weight loss, if indicated. It is realistic and can be achieved and maintained over time. A reasonable timeline for a 10 percent reduction in body weight is 6 months of therapy. For overweight patients with BMIs in the typical range of 27 to 35, caloric deficits of 300 to 500 kcal/day will result in weight losses of ½ to 1 lb/week and a 10 percent weight loss in 6 months. For more severely obese patients with BMIs > 35, deficits of up to 500 to 1,000 kcal/day will lead to weight losses of 1 to 2 lb/week and a 10 percent weight loss in 6 months. Theoretically, this caloric deficit should result in a loss of 26 to 52 pounds in a year. However, the average amount of weight lost usually is in the range of 20 to 25 pounds.

Weight Loss Goals Start weight maintenance efforts after 6 months. May need to be continued indefinitely. If unable to lose weight, prevent further weight gain. Once weight loss goals have been achieved, maintaining a lower body weight becomes a major challenge. Weight maintenance efforts should begin after 6 months of weight loss, since at this point it is difficult for most patients to continue to lose weight owing to changes in resting metabolic rates and difficulty in adhering to treatment strategies. To achieve additional weight loss, the patient must further decrease calories and/or increase physical activity since energy requirements decrease as weight is decreased. For weight maintenance, the combined modalities of therapy (dietary therapy, physical activity, and behavior therapy) must be continued indefinitely; otherwise, excess weight likely will be regained. Observation, monitoring, and encouragement of patients who have successfully lost weight should be continued on a long-term basis in order to help prevent weight regain.

Strategies for Weight Loss and Maintenance Dietary therapy Physical activity Behavior therapy “Combined” therapy Pharmacotherapy Weight loss surgery In the guidelines, six strategies for weight loss and maintenance are discussed: dietary therapy, physical activity, behavior therapy, combined therapy, pharmacotherapy, and weight loss surgery. Each of these strategies will be featured in turn.

Weight Loss Therapy Whenever possible, weight loss therapy should employ the combination of Low-calorie/low-fat diets Increased physical activity Behavior modification

Dietary Therapy Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons. Evidence Category A. Reducing fat as part of an LCD is a practical way to reduce calories. Evidence Category A.

Dietary Therapy Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.

Dietary Therapy Although lower fat diets without targeted calorie reduction help promote weight loss by producing a reduced calorie intake, lower fat diets coupled with total calorie reduction produce greater weight loss than lower fat diets alone. Evidence Category A.

Dietary Therapy Very low-calorie diets produce greater initial weight loss than low-calorie diets. However, long-term (>1 year) weight loss is not different from an LCD. Evidence Category A.

Dietary Therapy Very Low-Calorie Diets (less than 800 kcal/day): Rapid weight loss Deficits are too great Nutritional inadequacies Greater weight regain No change in behavior Greater risk of gallstones

Low-Calorie Step I Diet Nutrient Recommended Intake Calories 500 to 1,000 kcal/day reduction Total Fat 30 percent or less of total calories SFA 8 to 10 percent of total calories MUFA Up to 15 percent of total calories PUFA Up to 10 percent of total calories Cholesterol <300 mg/day The LCD recommended in the guidelines for weight loss has a nutrient composition that also will help decrease other risk factors, notably high serum cholesterol and hypertension. The Step I diet recommended by the National Cholesterol Education Program provides the appropriate nutrient composition in terms of fats. A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 lbs/week. Total fat should be no more than 30 percent of total calories; saturated fat should provide 8 to 10 percent of total calories, and dietary cholesterol should be <300 mg/day. Fat-modified foods may provide a helpful strategy for lowering total fat intake, but they are effective only if they are low in calories and there is no compensation of calories from other foods. Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions in LDL-cholesterol level. In the Step II diet, saturated fat should be reduced to less than 7 percent of total calories and cholesterol levels to less than 200 mg/day. All other nutrients should be the same as in Step I.

Low-Calorie Step I Diet (continued) Nutrient Recommended Intake Protein ~ 15 percent of total calories Carbohydrate 55 percent or more of total calories Sodium Chloride No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride) Calcium 1,000 to 1,500 mg Fiber 20 to 30 g Protein should be no more than 15 percent of total calories and should be derived from plant sources and lean sources of animal protein. Dietary carbohydrate should be approximately 55 percent or more of total calories and should be rich in complex carbohydrates from different vegetables, fruits, and whole grains—all good sources of vitamins, minerals, and fiber. Sodium chloride should be no more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride). During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals, particularly calcium. 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. Some authorities recommend 20 to 30 grams/day of dietary fiber, with an upper limit of 35 grams. 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 calorie and fat levels.

Do You Know How Food Portions Have Portion Distortion: Do You Know How Food Portions Have Changed in 20 Years? One recent addition to the Aim Website is Portion Distortion, to educate consumers on how portion sizes in the U.S. have increased over the years. And have probably had some impact on the increasing rates of obesity. As you will see, it is an interactive quiz. Take out a pencil and paper and take the quiz to see how well you all do. A study by Dr. Paul Rozen, of the University of PA, revealed that portions in Philadelphia restaurants were on average 25% larger than those served in Paris. He recommends that public health experts pay more attention to the “ecology of eating”…we are not built to resist the highly palatable food available to us.

French Fries 20 Years Ago Today 210 Calories 610 calories 2.4 ounces How many calories are in these fries? Calorie Difference: 400 calories How long will you have to walk to burn* 400 calories? How to burn* 400 calories:  Walk leisurely for 1 hr 10 Minutes *Based on 160 pound person

Soda 20 Years Ago Today 85 Calories 250 calories 6 ½ ounces 20 ounces How many calories are in this soda? Calorie Difference: 165 calories How to burn* 165 calories: Garden for 35 Minutes How long would you have to garden to burn 165 calories?. *Based on 160 pound person