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Definitions
Body Mass Index (BMI) describes relativeweight for height: weight (kg)/height (m2)
• Overweight = 25–29.9 BMI
• Obesity = > 30 BMI
Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)
37.8
23.6
10.4 15
.1
41.1
23.6
11.8 16
.1
39.1
24.3
12.2 16
.324
.9
39.4
24.7
19.9
0
10
20
30
40
50
Men Women Men Women
NHES I NHANES I NHANES II NHANES III
BMI > 30BMI 25–29.9
Perc
ent
CDC/NCHS, United States, 1960-94, ages 20-74 years
NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI
16.518.221.922.5 24.025.2
32.238.4
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
Perc
ent
*Defined as mean systolic blood pressure ≥ 140 mm Hg, as mean diastolic ≥ 90 mm Hg, or currently taking antihypertensive medication.
Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).
NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI
15.714.7
27.9
17.5
28.2
20.424.7
20.2
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
Perc
ent
*Defined as > 240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI
16.5
9.1
27.0
17.2
27.223.1
41.5
31.4
0
10
20
30
40
50
60
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as <35 mg/dL in men and <45 mg/dL in women.
Perc
ent
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Health Benefits of Weight Loss• Decreased cardiovascular risk• Decreased glucose and insulin levels• Decreased blood pressure• Decreased LDL and triglycerides, increased HDL• Decrease in severity of sleep apnea• Reduced symptoms of degenerative joint disease• Improved gynecological conditions
Care of Overweight/Obese Patients
Requires two steps:
• Assessment• Management
Assessment of Overweight and Obesity
• Body Mass Index– Weight (kg)/height (m2)– Weight (lb)/height (in2) x 703– Table
• Waist Circumference– High risk:
• Men >102 cm (40 in.)• Women >88 cm (35 in.)
Classification of Overweight and Obesity by BMI
Obesity Class BMI kg/m2
Underweight <18.5
Normal 18.5–24.9
Overweight 25–29.9
Obesity I 30.0–34.9
II 35.0–39.9
Extreme Obesity III ≥ 40.0
Determine Absolute Risk StatusEvaluate:• Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea)
(+ = very high risk)• Other obesity-associated diseases (e.g., gynecological
abnormalities, osteoarthritis)• Cardiovascular risk factors: smoking, hypertension,
high LDL, low HDL, IGT, family hx (>3 = high risk)• Other risk factors:
– Physical inactivity– High serum triglycerides (>200 mg/dL)
Patient Encounter
Hx of 25 BMI?≥
• Measure weight, height, and waistcircumference
• Calculate BMI
Brief reinforcement/ educate on weight management
Periodic weightcheck
Advise to maintainweight/addressother risk factors
Clinician and patientdevise goals andtreatment strategyfor weight loss andrisk factor control
Assess reasons forfailure to lose weight
Maintenance counseling: Dietary therapyBehavior therapyPhysical activity:
Assess risk factors
No
1
2
14
13
12
16
3
5 7
9
Yes
No
No
Hx BMI 25?≥
No
Yes
Yes
No
Doespatient want tolose weight?
Yes Progress being made/goal
achieved?
BMI 25 OR≥waist circumference
> 88 cm (F)> 102 cm (M)
BMI≥ 30 OR
{[BMI 25 to 29.9 OR waist circumference
>88 cm (F) >102 cm (M)]AND 2 risk≥
factors}
BMImeasured in past
2 years?
Treatment AlgorithmYes
4 6
8
Yes
15
No
Examination 11 10
Treatment
Treatment Algorithm(Part 1 of 3)Patient Encounter
Hx of ≥ 25 BMI?
• Measure weight, height, and waist circumference
• Calculate BMI
No
2
3
5Yes
No
BMI measured in past
2 years?
BMI ≥ 25 ORwaist > 88 cm (F)
> 102 cm (M)
1
ExaminationTreatment
Yes
No
BMI ≥ 30 OR
{[BMI 25 to 29.9 OR waist >88 cm (F)
>102 cm (M)] AND ≥ 2 risk
factors}
7
Yes
4
Assess risk factors
6
Devise goals andtreatment strategy forweight loss and riskfactor control
Assess reasons forfailure to lose weight
Maintenance counseling
12
9
No
Yes
Yes
No Desire tolose weight?
No
Progress made?
BMI ≥ 30 OR
{[BMI 25 to 29.9 OR waist >88 cm (F)
>102 cm (M)]AND ≥ 2 risk
factors}Examination
Treatment
7
Periodic weightcheck
• Advise to maintain weight
• Address other risk factors
16
Treatment Algorithm(Part 2 of 3)
8
Yes13
11 10
• Brief reinforcement • Educate on weight
management
Periodic weight check
• Advise to maintain weight
• Address other risk factors
14
13
16
5
No
No
Hx BMI ≥ 25?
BMI ≥ 25 OR waist > 88 cm (F)
> 102 cm (M)
* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovascular risk factors or diseases that are indicated.
Treatment Algorithm(Part 3 of 3)
Yes
Examination
Treatment
Yes
15
Goals of Weight Management/Treatment
• Prevent further weight gain (minimum goal).
• Reduce body weight.• Maintain a lower body weight
over long term.
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 frombaseline.• 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
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.
Strategies for Weight Loss and Maintenance
• Dietary therapy• Physical activity• Behavior therapy• “Combined” therapy• Pharmacotherapy• Weight loss surgery
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 (1 of 5)
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 practicalway to reduce calories. Evidence Category A.
Dietary Therapy (2 of 5)
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 (3 of 5)
Although lower fat diets without targeted caloriereduction help promote weight loss by producinga reduced calorie intake, lower fat diets coupledwith total calorie reduction produce greaterweight loss than lower fat diets alone. Evidence Category A.
Dietary Therapy (4 of 5)
Very low-calorie diets produce greater initialweight loss than low-calorie diets. However,long-term (>1 year) weight loss is not differentfrom an LCD. Evidence Category A.
Dietary Therapy (5 of 5)
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 DietNutrient 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
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