1. Obesity and Overweight Diagnosis and Management
Suman Khicher
PGY-1

2. How to diagnose obesity and overweight
The degree of obesity- BMI and Waist Circumference 
                 Body Mass Index(BMI)     BMI = Weight (kg)_______
                                                                            Height squared (m2) -
                   
               Obesity is further classified into classes
Keep in mind that while a high BMI usually indicates increased body fat, there are circumstances where this is not the case.

3. How to diagnose obesity and overweight
Measuring Waist Circumference
-In the office setting, clinicians can measure waist circumference to assess for increased abdominal fat, which is defined as a waist circumference >102cm (40 inches) in men and >88cm (35 inches) in women.
In 2012, the U.S. Preventive Services Task Force updated its recommendation that clinicians “screen all adults for obesity and offer or refer patients with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions”. These interventions include behavioral management activities such as goal-setting, diet and physical activity change, self-monitoring activities, as well as address barriers to change and strategies to maintain lifestyle changes.
-Individuals with more abdominal fat have been shown to have greater risk of mortality and morbidity (such as diabetes and coronary heart disease)

4. Assess medical risks associated with obesity
Prevalence of obesity has remained over 33% since 2007.
The effect of obesity on all-cause mortality increases as the BMI rises above 25 kg/m2 and is more pronounced in men than in women
Increased deaths from cardiovascular disease, diabetes, liver and kidney disease
Obesity is also associated with higher rates of multiple cancers and cancer related deaths
Also associated with an increased risk of many other diseases, including hypertension, stroke, hypercholesterolemia, osteoarthritis, sleep apnea, restrictive lung disease, nonalcoholic fatty liver disease, gallstones, and infertility.

5. Assess medical risks associated with obesity
The next step in assessment is to determine whether or not there is any impact of weight on other disease states.
The NIH guidelines recommend the following areas be assessed in each individual to determine overall risk for morbidity:
Diseases associated with a high risk of morbidity and mortality: existing coronary artery disease, other atherosclerotic vascular disease, type 2 diabetes mellitus, and obstructive sleep apnea
High waist circumference ( >40 inches in men and >35 inches in women)
Other cardiovascular risks: tobacco use, hypertension, dyslipidemia (high LDL-cholesterol, low HDL-cholesterol, and/or high triglycerides), impaired fasting glucose or glucose intolerance, family history of premature CAD, and sedentary lifestyle
Other obesity associated diseases: osteoarthritis, gallstones, stress urinary incontinence, or gynecological abnormalities such as polycystic ovarian syndrome
The presence of other disease states or risk factors should not only determine the time frame in which obesity is addressed, but also how aggressively obesity is treated.

6.  -Assess Weight and Lifestyle Histories
-Assess Readiness to Make Lifestyle Changes to Achieve Weight Loss
-understand the patient’s motivations and expectations
-Setting Weight Loss and Health Goals
-Which Approach to Use? Determining Intervention Strategies
Reductions in weight (5-10%) can have a significant impact on comorbidities such as diabetes, blood pressure and metabolic syndrome. Furthermore, a weight loss of this magnitude can reduce the risk of developing diabetes by >50% in people at high risk
Patients should have an initial goal of losing 5-10% of their current weight over the next six months.
Patients with comorbid conditions may need adjustment in medications as weight loss progresses, particularly patients who take antihypertensive and diabetes medications as hypotension and hypoglycemia, respectively, may occur.

7. The most effective behavioral weight loss treatment is in-person, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. 
The principal components of an effective high-intensity, on-site comprehensive lifestyle intervention include:
1) prescription of a moderately-reduced calorie diet;
2) a program of increased physical activity; and
3) the use of behavioral strategies to facilitate adherence to diet and activity recommendations.
While comprehensive lifestyle intervention is foundational to weight loss, adjunctive treatments with medications or bariatric surgery may be appropriate for some patients based on BMI and presence of comorbid conditions.

9. Commercial Weight Loss Programs
A 2015 review of the major U.S. commercial weight loss programs found evidence to support that Weight Watchers’ participants achieved at least 2.6% greater weight loss than control at 12 months and Jenny Craig participants achieved at least 4.9% greater weight loss than control or counseling at 12 months.
Clinicians should also keep in mind the costs associated with commercial programs, which can be substantial for programs that rely upon meal replacements.

10. Safe and Effective Rate of Weight Loss
With the following recommendations, patients should expect to lose 10% of their body weight over 6 months.
Patients with overweight or class I obesity (BMI kg/m2) should aim to lose lb/week by reducing their daily caloric intake by kcal/day.
Patients with Class II or III obesity (BMI >35 kg/m2) should reduce their daily caloric intake by kcal/day with the expectation of losing 1-2 lbs/week.

12. Understand the role of diet for weight control
The cornerstone of weight loss is to create a calorie deficit – that is the number of calories consumed must be less than the number of calories being spent.
A reduction in caloric intake by kcal per day generally results in a weight loss of 1-2 pounds per week.
Low calorie diets (LCD) typically provide kcal/day, whereas very low calorie diets (VLCD) provide <800 kcal/day.   At 6 months, VLCD resulted in greater weight loss than LCD, but there was no difference in weight loss results at 1 year
VLCD should be used only in limited circumstances under close medical supervision and in a setting where a high-intensity lifestyle intervention can also be provided

13. Popular diets

14. These diets may have differential effects on other cardiometabolic parameters. For example, low- carbohydrate diets tend to increase HDL and decrease triglycerides, while low-fat diets may decrease LDL.
Diets that reduce glycemic load may result in better weight loss outcomes among people with insulin resistance.
Similar to low-carbohydrate diets, low GI diets may reduce triglycerides and raise HDL cholesterol.
The “Mediterranean Diet” has led to improved blood pressure, lipids, and glycemic control as compared to low fat diets for the same amount of weight loss. Among patients at high cardiovascular risk, following a Mediterranean Diet reduced the number of major cardiovascular events as compared to a low-fat diet 

16. Role of physical activity
In the absence of dietary changes, however, exercise alone only results in a mean weight loss of 0.1 kg/week for a total of 2-3 kg, unless very high levels are attained (>300 min/week or ~2,000 calories expended) 
While more seems to be better, even 30 minutes per day of physical activity may seem out of reach for many patients, and setting inappropriately ambitious physical activity goals is likely to result in abandonment of the exercise program.
Thus it is important to work with the patient to start where they are and gradually increase their activity towards an achievable goal.
Programs shown to be effective typically include moderate aerobic physical activity (such as brisk walking) for >150 minutes/week (equal to >30 minutes/day), most days of the week
Physical activity is the best predictor of maintenance of weight loss, but this generally requires greater amounts of activity, minutes per week may be needed.
Physical activity and fitness have been shown to reduce morbidity and mortality of all individuals (not just the overweight or obese).

17. Exercise Guidelines

18. Negotiating a plan to change any behavior, including physical activity, must actively involve the patient because they have to engage in the behavior.
Effective strategy: have the patient suggest the plan.
Any plan should have the following SMART characteristics:
An example of a SMART goal that a physician and patient may negotiate is:  I will walk briskly for 20 minutes on Monday, Wednesday, and Friday mornings this coming week.  After I reach this goal, I will reward myself by purchasing a new CD.  Next week I will increase my time by 5 minutes each day.

19. Starting an Exercise Program in High Risk Individuals
Exercise stress testing is not required to start a physical activity program, unless otherwise indicated by the history and physical exam
The American Heart Association recommends screening all patients with a history of cardiovascular disease or who are at high risk of a heart attack or stroke before they start a vigorous exercise program. 
Individualized counseling should be provided to patients who are obese or elderly, who have diabetes, COPD, or other serious medical problems, or who have been sedentary for a long time before starting any exercise program. 
High risk patients can also be referred for cardiopulmonary rehabilitation or physical therapy programs for structured teaching. 
 Additionally, patients with osteoarthritis, or history of stroke may require specialized exercise programs adapted to any physical disabilities, including water aerobics and walking programs

21. role of behavior strategies for weight control
Essential behavior change tool for most people is self-monitoring -- keeping track of weight, dietary intake, and physical activity
Food and physical activity diaries promote ongoing self-monitoring, essential to behavior change. 
More frequent weighing, perhaps daily weighing, may result in better weight loss and maintenance over time
Portion sizes have increased substantially over the last 20 years, and evidence suggests that people tend to underestimate their portions, and thus underestimate their calories
Stimulus control helps identify triggers or cues that may encourage unplanned eating. 
Meal planning can help control portions and avoid overeating
Relapse prevention
Group support

23. Pharmacotherapy and identifying appropriate candidates
Pharmacotherapy can be considered as an adjunct to a comprehensive lifestyle program that includes low-calorie diet, increased physical activity, and use of behavior change strategies for the following patients who are motivated to lose weight:
         Patients with a BMI of 30 kg/m2 or greater
         Patients with a BMI of 27 to 29.9 kg/m2 with at least one obesity-related comorbid condition
Guidelines from the American College of Physicians in 2005 state: “Pharmacologic therapy can be offered to obese patients who have failed to achieve their weight loss goals through diet and exercise alone.  However, a doctor-patient discussion is needed that includes the drugs’ side effects, the lack of long-term efficacy data, and the temporary nature of the weight loss achieved with medications before initiating therapy”
No matter which agent is used, weight is often regained after cessation of medication.
Only overweight patients who are at increased medical risk should use weight loss medications. These medications should not be used for cosmetic weight loss.

25. All are sympathomimetic appetite suppressants, which typically facilitate an additional 3.0 to 3.6 kg weight loss over placebo. All have similar side effects, which include insomnia, tachycardia, increased blood pressure, xerostomia, headache, nervousness, irritability, dizziness, tremors, and constipation.

27. Role of surgery and identify appropriate candidates
Bariatric Surgery for Weight Loss
If lifestyle modifications and/or pharmacotherapy are not tolerated or do not achieve the desired weight loss, consideration should be given to weight reduction surgery for appropriate candidates, which include:
            -Patients with a BMI ≥ 40 kg/m2 
            -Patients with BMIs of 35 to 39.9 kg/m2 with other comorbid conditions (cardiovascular disease, sleep apnea, uncontrolled type 2 diabetes) or weight-induced physical problems interfering with performance of daily activities.
-Any discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gall bladder disease, and malabsorption
Surgical procedures commonly used today can be classified as
         predominantly restrictive (vertical banded gastroplasty, adjustable gastric banding, sleeve gastrectomy) or
         malabsorptive (Roux-en Y gastric bypass, biliopancreatic diversion (BPD) with duodenal switch). 
In addition to weight loss, studies of bariatric surgery have found marked improvement in most obesity related comorbidities including type 2 diabetes (up to 77% resolve), hypertension (62% resolve), and sleep apnea (84% resolve), as well as improvements in lipids, left ventricular wall thickness, mobility, return of fertility and significant improvement in quality of life 

28. Results of Bariatric Surgery

30. Weight Loss Maintenance
Although achieving weight loss can be difficult, it is often even harder to keep the weight off.

31. In a nutshell
In summary, weight management should consist of multicomponent therapy, which is tailored to an individual patient’s risk and preferences.
Guidelines issued by ACC/AHA/TOS in 2013 recommend that clinicians refer patients to in-person, high- intensity comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.
Alternative strategies, including referral to Weight Watchers or Jenny Craig, may be recommended when such programs are unavailable. Clinicians should sequentially apply lifestyle modification, followed by pharmacotherapy and surgery when appropriate based on BMI and other risks.
Many people can achieve modest weight loss of 5% to 10% of body weight with resulting clinical improvements in disease risk. 
Obesity should be treated as a disease . As with treatment of any chronic disease, long-term follow-up and treatment are generally needed