Download Obesity

Pre
eventiion an
nd Ma
anage
ementt of O
Obesitty
– Ad
dult – Amb
bulato
ory
Clinica
C
al Pra
actice
e Guid
deline
e
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TableofContents
EXECUTIVE SUMMARY .............................................................................................................. 3 SCOPE ......................................................................................................................................... 3 METHODOLOGY ......................................................................................................................... 4 INTRODUCTION .......................................................................................................................... 5 RECOMMENDATIONS ................................................................................................................ 5 REFERENCES ............................................................................................................................. 6 Release Date: May 2015
Next Review Date: May 2017
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ExecutiveSummary
Guideline Overview
The workgroup has agreed to endorse the 2013 Prevention and Management of
Obesity for Adults created by the Institute for Clinical Systems Improvement (ICSI).1
Key Practice Recommendations
1. Clinicians should calculate body mass index (BMI) for their patients on an annual
basis for screening and as needed for management. Classify BMI based on the body
mass categories. Educate patients about their body mass index and associated risks
for them. (ICSI Strong Recommendation, High Quality Evidence)
2. Clinicians should consider waist circumference measurement to estimate disease
risk for patients who have normal or overweight BMI scores. (ICSI Strong
Recommendation, Moderate Quality Evidence)
3. Clinicians need to carefully consider BMI and its associated mortality risk across
different ethnicity, sex and age groups. (ICSI Strong Recommendation/Moderate Quality
Evidence)
4. Waist circumference greater than or equal to 40 inches for males and 35 inches for
females is an additional risk factor for complications related to obesity. Measuring
waist circumference is recommended to further assess the patient. (ICSI Weak
Recommendation, Moderate Quality Evidence)
5. Clinicians should use motivational interviewing techniques as a tool for encouraging
behavior change. (ICSI Strong Recommendation, Moderate Quality Evidence)
Companion/Collateral Documents
1. Prevention and Diagnosis Algorithm
2. BMI Index Ranges
3. FDA Approved Treatment of Obesity in Adults
External Resources
1. Unity Health Insurance - Weight Management
2. Group Health Cooperative - Weight Management
3. Physicians Plus - Weight Management
4. Dean - Weight Management
Scope
Disease/Condition(s): Obesity, Overweight
Clinical Specialty: Endocrinology, Family Medicine, Internal Medicine, Nursing,
Nutrition, Preventive Medicine, and Surgery
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Intended Users: Primary Care Physicians, Specialty Care Physicians, Advanced
Practice Providers, Registered Dietitians, Pharmacists, Nursing
Objective(s): To establish evidence-based recommendations for obesity prevention,
diagnosis, and weight management in adult patients.
Target Population: All adults 18 years of age and older.
This guideline does not address pregnant women or bodybuilders/weight trainers.
Interventions and Practices Considered:

Behavioral approaches
o
o
o
o
o

Drug treatment
o
o
o
o

Motivational Interviewing
Goal setting
Nutrition recommendations
Physical activity prescription
Behavioral management strategies
Phentermine
Orlistat
Qsymia
Lorcaserin
Surgery.
o
o
o
o
Adjustable Band
Sleeve Gastrectomy
Gastric Bypass
Duodenal Switch
Methodology
Methods Used to Collect/Select the Evidence:
Identification and selection of the evidence was completed by the Institute for Clinical
Systems Improvement (ICSI). Literature search terms for the current revision of this
document included adults (18 years and older), published since January 2005 –
systematic reviews, randomized control trials, meta-analysis restricted to human
studies, in the following topic areas: prevention, screening, treatments/drug studies,
medications, gastric bypass and/or bariatric surgery, lipid and cholesterol screening,
activity recommendations, genetic studies, activity recommendations, family-based
therapy, readiness for change, motivational interviewing, goal setting, managing chronic
conditions, binge eating disorders, binge eating disorder assessment and scale, and
obesity with diabetes.
Rating Scheme for the Strength of the Evidence/Recommendations:
The quality of the evidence was rated using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE). See table below.
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Table 1. ICSI GRADE Scheme
Category
High Quality
Evidence
Quality Definitions
Further research is
very unlikely to
change our
confidence in the
estimate of effect.
Moderate
Quality
Evidence
Further research is
likely to have an
important impact on
our confidence in the
estimate of effect and
may change the
estimate.
Low Quality
Evidence
Further research is
very likely to have an
important impact on
our confidence in the
estimate of effect and
is likely to change.
The estimate or any
estimate of effect is
very uncertain.
Strong Recommendation
The work group is confident that
the desirable effects of adhering
to this recommendation
outweigh the undesirable
effects. This is a strong
recommendation for or against.
This applies to most patients.
The work group is confident that
the benefits outweigh the risks
but recognizes that the
evidence has limitations.
Further evidence may impact
this recommendation. This is
likely a recommendation that
applies to all patients.
The work group feels that the
evidence consistently indicates
the benefit of this action
outweighs the harms. This
recommendation might change
when higher quality evidence
becomes available.
Weak Recommendation
The work group recognizes that the
evidence, though of high quality, shows
a balance between estimates of harms
and benefits. The best action will
depend on local circumstances, patient
values of preferences.
The work group recognizes that there is
a balance between harms and benefits,
based on moderate quality evidence, or
that there is uncertainty about the
estimates of the harms and benefits of
the proposed intervention that may be
affected by new evidence. Alternative
approaches will likely be better for some
patients under some circumstances.
The work group recognizes that there is
significant uncertainty about the best
estimates of benefits and harms.
Introduction
Over one third of adults in the United States are obese.4 Obesity is the second leading
cause of preventable death, and associated with medical costs as much as $147 billion
to $210 billion a year.5 Comorbidities include Type 2 diabetes, heart disease,
hypertension, dyslipidemia, and certain cancers. Depression and obesity frequently cooccur.6 A 5-10% weight loss can reduce a patient’s risk of heart disease and diabetes
that is clinically significant. This can be achieved and maintained with a high-intensity
medical weight loss program even for the morbidly obese.1
Recommendations
Recommendations related to the prevention, diagnosis and management of obesity in
adult patients can be found in the 2013 ICSI guideline below or online at
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines
/catalog_endocrine_guidelines/obesity__adults/.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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References
1. Fitch A, Everling L, Fox C, et al. Prevention and Management of Obesity for Adults.: Institute
for Clinical Systems Improvement; Updated May 2013.
2. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for
major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353.
3. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a twoitem depression screener. Med Care. 2003;41(11):1284-1292.
4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the
United States, 2011-2012. JAMA. 2014;311(8):806-814.
5. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to
obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822-831.
6. Jenkins TM. Prevalence of overweight, obesity, and comorbid conditions among U.S. and
Kentucky adults, 2000-2002. Prev Chronic Dis. 2005;2(1):A08.
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