Download Evidence-Based Weight Management Guideline

Evidence-Based Weight
Management Guideline
M.E.Khamseh
Institute of Endocrinology and Metabolism
Iran University of Medical Sciences
Classification of overweight and obesity
BMI and Waist circumference :
Classify overweight and obesity
Estimate risk for disease
Identify treatment options
Determine the effectiveness of therapy
Classifications for BMI
BMI
Underweight
<18.5 kg/m2
Normal weight
18.5–24.9 kg/m2
Overweight
25–29.9 kg/m2
Obesity (Class 1)
30–34.9 kg/m2
Obesity (Class 2)
35–39.9 kg/m2
Extreme obesity (Class 3)
≥40 kg/m2
Classification of Overweight and Obesity by BMI,Waist
Circumference, and Associated Disease Risk*
BMI
(kg/m2)
Obesity
Class
Disease Risk*
(Relative to Normal Weigh and Waist Circumference)
Men ≤40 in (≤ 102 cm)
Women ≤ 35 in (≤ 88 cm)
Underweight
< 18.5
Normal†
18.5–24.9
Overweight
25.0–29.9
Obesity
30.0–34.9
35.0–39.9
Extreme
Obesity
≥ 40
40 in (> 102 cm)
> 35 in (> 88 cm)
Increased
Increased
High
I
II
High
Very High
Very High
Very High
III
Extremely High
Extremely High
*Substantial disease risk for type 2 diabetes, hypertension, and CVD.
† Increased waist circumference can also be a marker for increased risk even
in persons of normal weight.
Adapted from “Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity.” WHO,
Geneva, June 1997
Weight loss therapy is
recommended for patients:
• With a BMI ≥ 30
• With a BMI between 25 and 29.9/or
a high-risk waist circumference,
AND two or more risk factors.
Goals for Weight Loss

Reduced body weight

Maintain a lower body weight

Prevent further weight gain
Risk Factors or Co morbidities

High absolute risks:
 Established coronary heart disease


Other atherosclerotic diseases

type 2 diabetes

Sleep apnea
Three or more of the followings :

Hypertension

Cigarette smoking

High LDL

Low HDL

Impaired fasting glucose

Family history of early CVD

Age (male ≥ 45 years, female ≥ 55 years)
Comprehensive Weight Management Program

Diet

Physical activity

Behavior therapy
Optimal Length of Therapy

Medical Nutrition Therapy : at least 6 months or
until weight loss goals are achieved

Greater frequency of contacts between the
patient and practitioner: more successful weight
loss and maintenance

Realistic Weight Goal Setting
Realistic Weight Goals

Individualized goals of weight loss therapy

Optimal rate : 0.5-1 kg per week for the first 6
months

Achieve an initial weight loss goal of up to
10% from baseline
Exclusion from Weight Loss Therapy

Pregnancy & Lactation

Serious psychiatric illness

Other serious illness
Determining Energy Needs

Estimated energy needs based on RMR :
Indirect calorimetry
Mifflin-St. Jeor equation

10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) + 5 ( male)

10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) - 161( female)
Activity factor : 1.3( sedentary )
1.5(exercise)
1.4(walking)
1.8(heavy exercise)
Reduced Calorie Diet

Individualized reduced diet

Reducing fat and/or carbohydrates :
To create a caloric deficit of 500-1000 kcals below
estimated energy needs
Result in a weight loss of 0.5-1 kg per week .
Low-Calorie Step I Diet
Nutrient
Recommended Intake
Calories
Approximately 500 to 1,000 kcal/day reduction
Total fat
30 percent or less of total calories
Saturated fatty acids
8 to 10 percent of total calories
Monounsaturated fatty acids
Up to 15 percent of total calories
Polyunsaturated fatty acids
Up to 10 percent of total calories
Cholesterol
<300 mg/day
Protein
Approximately 15 percent of total calories
Carbohydrate
55 percent or more of total calories
Sodium chloride
No more than 100 mmol/day (approximately 2.4 g of
sodium or approximately 6 g of sodium chloride)
Calcium
1,000 to 1,500 mg/day
Fiber
20 to 30 g/day
Eating Frequency and Patterns

Total Caloric intake distributed throughout the day

4 to 5 meals/snacks per day

Consumption of greater energy intake during the
day may preferable to evening consumption
Portion Control

As part of a comprehensive weight
management program

Results in reduced energy intake and
Weight loss
Meal Replacements

Liquid meals, meal bars, and calorie-controlled
packaged meals may be used as part of the diet
component

Substituting one or two daily meals or snacks
with meal replacements
Nutrition Education

Individualized

Reading nutrition labels

Recipe modification

Cooking classes

Increases knowledge : improved food choices
Low Glycemic Index Diets

Not recommended !

Not been shown to be effective in weight
management program
Dairy/Calcium and Weight Management

3-4 serving of low fat dairy foods a day

Calcium intake lower than recommended
levels : increased body weight ?
Low Carbohydrate Diet

Reducing carbohydrate intake (<35% of kcals
from carbohydrates)

Greater weight and fat loss during the first 6
months

Differences not significant after 1 year
Physical Activity

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.
Physical Activity , cont.

Individualized

At least 30 minutes or more of moderate
intensity

Preferably , all days of the week

Decrease abdominal fat

Maintenance of weight loss
Behavior therapy

Patients must be active partners and
participate in setting goals

Focus on positive changes and adapt a
problem-solving approach toward the
shortfalls.

Weight control is a journey, not a destination.
Multiple Behavior Therapy Strategies

Necessary to prevent a return to baseline weight

Additional effect on weight loss

Self monitoring

Stress management

Stimulus control

Problem solving

Contingency management

Cognitive restructuring

Social support
Self-monitoring

Observing and recording some aspect of behavior,
caloric intake , exercise sessions , medication usage ,
and changes in body weight

Recording dietary intake (food choices, amounts,
times)

Regular self monitoring of weight is crucial for longterm maintenance
Focus on What Matters

Improvement of the patient’s health is the goal of
obesity treatment. Monitoring progress is a
continuous process of motivational importance to
the patient and provider

Use simple charts or graphs to summarize changes
in weight and the associated risk factors
Pharmacotherapy

Drugs may be used as adjunctive therapy in
patients with a BMI ≥ 30 or ≥ 27 with other risk
factors or diseases.

Drugs used only as part of a program that includes
diet, physical activity, and behavior therapy

Net weight loss attributable to drugs has generally
been reported to range from 2 to 10 kilograms
Use of Weight Loss Medications

FDA-approved weight loss medications

May enhance weight loss in some
overweight and obese adults
Bariatric Surgery for Weight Loss

People who have not achieved weight loss
goals with less invasive weight loss
methods
A Guide to Selecting Treatment
BMI category
≥ 40
25–26.9
27–29.9
30-34.9
35–39.9
With
comorbidities
With
comorbidities
+
+
+
+
+
+
Treatment
Diet, physical activity,
and behavior therapy
Pharmacotherapy
Surgery
With
comorbidities
With
comorbidities