AGA technical review on obesity Samuel Klein, Thomas Wadden, Harvey J. Sugerman  Gastroenterology  Volume 123, Issue 3, Pages 882-932 (September 2002) DOI: 10.1053/gast.2002.35514 Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 1 Relationship between BMI and cardiovascular mortality in 302,233 adult men and women in the United States who never smoked and had no preexisting illness. Vertical lines indicate overweight (BMI 25.0–29.9 kg/m2) and obese (BMI ≥30 kg/m2) cutoff values. (Data from Calle et al.9) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 2 Age-adjusted prevalence of overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) in adults (age 20–74 years) in the United States since 1960. Data obtained from 1960–1962 NHES I, 1971–1974 National Health and Nutrition Examination Survey I (NHANES I), 1976–1980 NHANES II, 1988–1994 NHANES III, and preliminary data from NHANES 1999. The prevalence of overweight or obesity increased (from 43% to 61%) between NHES I (1960–1962) and NHANES 1999 caused by a small increase in overweight (from 30.5% to 34%) and to more than a doubling in the prevalence of obesity (from 12.8% to 27%). (Data obtained from Flegal et al.28) and National Center for Health Statistics, Centers for Disease Control and Prevention web site www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm (accessed December 14, 2001).27 Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 3 Relationship between the incidence of symptomatic gallstones (defined as cholecystectomy or newly diagnosed symptomatic unremoved gallstones) and BMI in the Nurse's Health Study. (Data from Stampfer et al.112) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 4 Relationship between changes in dietary fat intake and body weight from selected dietary intervention studies that were designed to improve plasma lipids by following the National Cholesterol Education Program's Step I and Step II diets. (Reprinted with permission from Yu-Poth et al.330 © Am J Clin Nutr. American Society for Clinical Nutrition.) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 5 Energy density of selected commonly consumed foods. Foods that have a high fat content usually have a high energy density, whereas foods that have a high water content usually have a low energy density. (Figure provided courtesy of Liane Roe.) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 6 Relative risk (RR) of cardiovascular disease (CVD) mortality, stratified by body fatness and cardiorespiratory fitness in men. Body fat categories were classified by percentage body fat according to percentile scores: lean (<16.7% body fat; <25th percentile), normal (16.7%–24.9% body fat; 25th to <75th percentile), and obese (≥25% body fat; ≥75th percentile). Cardiorespiratory fitness was determined by oxygen consumption during a maximal treadmill exercise test. Unfit men (black bars) were defined as those who were in the lowest quartile (20%) of oxygen uptake (expressed as mL consumed/kg FFM/min) in each age group; all other men were considered fit (white bars). (Reprinted with permission from Lee et al.23 © Am J Clin Nutr. American Society for Clinical Nutrition.) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 7 Example of a behavior change that demonstrates how individual behaviors are linked together to contribute to an episode of overeating. Therefore, dietary indiscretion can be traced to a series of small decisions and behaviors. (Reprinted with permission from Brownell KD. Sample behavioral chain. The LEARN Program for weight management–2000. Dallas, Texas: American Health Publishing Company; 2000:204. All rights reserved. For ordering information, call 1-888-LEARN-41 or visit www.TheLifeStyleCompany.com. Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 8 Weight loss in women treated with anorexiant medication (sibutramine) alone (diamonds), medication plus group behavior modification therapy (squares), or medication plus group behavior modification therapy and meal replacements (triangles). These data demonstrate that greater weight loss is achieved when anti-obesity medications are used in conjunction with lifestyle modification than when they are used alone. (Reprinted with permission from Wadden et al.403 Arch Intern Med 2001;161:218–227. Copyrighted 2001, American Medical Association.) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 9 Dose-response relationship between orlistat treatment and fecal fat excretion. Data from individual subjects (open circles) and the curve that best fits the data (continuous line) are shown. Fat malabsorption increased sharply with increasing orlistat dose, up to a near plateau value of 360 mg/day (120 mg 3 times daily with meals). (Reprinted with permission from Zhi et al.411) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 10 Weight maintenance during 1 year of treatment with either sibutramine or orlistat after subjects achieved successful initial weight loss by diet alone. The amount of initial weight loss, achieved by 4 weeks of treatment with a very low-calorie diet in the sibutramine trial and after 6 months of treatment with a low-calorie diet in the orlistat trial, is represented by the black bars. Total weight loss 1 year after initial intensive diet therapy was stopped for those randomized to receive placebo (white bars) or drug (striped bars) during the maintenance period. (Data for the sibutramine trial were obtained from Apfelbaum et al.419 and data for the orlistat trial were obtained from Hill et al.425) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 11 Gastric restrictive surgical procedures: (A) GBP and (B) VBG. Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 12 Percentage of excess weight (± SD) lost over 36 months after the GBP and VBG. (Adapted with permission from Sugerman et al.449) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions

Fig. 13 Biliopancreatic diversion with duodenal switch. (Data from Marceau et al.474) Gastroenterology 2002 123, 882-932DOI: (10.1053/gast.2002.35514) Copyright © 2002 American Gastroenterological Association Terms and Conditions