Evidence-Based Weight Management Guideline

M.E.Khamseh

Institute of Endocrinology and Metabolism

Iran University of Medical Sciences

Classification of overweight and obesityClassification of overweight and obesity Classification of overweight and obesityClassification of overweight and obesity

BMI and Waist circumference : BMI and Waist circumference :

Classify overweight and obesity

Estimate risk for disease

Identify treatment options

Determine the effectiveness of therapy

Classifications for BMIClassifications for BMIBMI

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 Classification of Overweight and Obesity by BMI,Waist Circumference, and Associated Disease Risk*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)

40 in (> 102 cm) >35 in (> 88 cm)

Underweight <18.5

Normal† 18.5–24.9 Increased

Overweight 25.0–29.9 Increased High

Obesity 30.0–34.935.0–39.9

III

HighVery High

Very HighVery High

Extreme Obesity

≥40 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 LossGoals for Weight LossGoals for Weight LossGoals for Weight Loss

Reduced body weight

Maintain a lower body weight

Prevent further weight gain

Risk Factors or Co morbiditiesRisk Factors or Co morbiditiesRisk Factors or Co morbiditiesRisk 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 ProgramComprehensive Weight Management ProgramComprehensive Weight Management ProgramComprehensive Weight Management Program

Diet

Physical activity

Behavior therapy

Optimal Length of TherapyOptimal Length of TherapyOptimal Length of TherapyOptimal 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 GoalsRealistic Weight Goals Realistic Weight GoalsRealistic 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 TherapyExclusion from Weight Loss TherapyExclusion from Weight Loss TherapyExclusion from Weight Loss Therapy

Pregnancy & Lactation

Serious psychiatric illness

Other serious illness

Determining Energy NeedsDetermining Energy NeedsDetermining Energy NeedsDetermining Energy Needs

Estimated energy needs based on RMR : Estimated energy needs based on RMR :

Indirect calorimetry

Mifflin-St. Jeor equation

10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) + 5 ( male)( male)

10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) - 161( female)( female)

Activity factor : 1.3( sedentary ) 1.4(walking)

1.5(exercise) 1.8(heavy exercise)

Reduced Calorie DietReduced Calorie DietReduced Calorie DietReduced Calorie Diet

Individualized reduced diet Individualized reduced diet

Reducing fat and/or carbohydrates : 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 DietLow-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 PatternsEating Frequency and PatternsEating Frequency and PatternsEating 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 ControlPortion ControlPortion ControlPortion Control

As part of a comprehensive weight

management program

Results in reduced energy intake and

Weight loss

Meal ReplacementsMeal ReplacementsMeal ReplacementsMeal 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 EducationNutrition Education Nutrition EducationNutrition Education

Individualized

Reading nutrition labels

Recipe modification

Cooking classes

Increases knowledge : improved food choices

Low Glycemic Index DietsLow Glycemic Index DietsLow Glycemic Index DietsLow Glycemic Index Diets

Not recommended !

Not been shown to be effective in weight

management program

Dairy/Calcium and Weight ManagementDairy/Calcium and Weight Management Dairy/Calcium and Weight ManagementDairy/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 DietLow Carbohydrate Diet Low Carbohydrate DietLow 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 ActivityPhysical ActivityPhysical ActivityPhysical 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 , contPhysical Activity , cont..Physical Activity , contPhysical 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 therapyBehavior therapyBehavior therapyBehavior 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 StrategiesMultiple Behavior Therapy Strategies Multiple Behavior Therapy StrategiesMultiple 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-monitoringSelf-monitoringSelf-monitoringSelf-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 long-

term maintenance

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

Focus on What MattersFocus on What MattersFocus on What MattersFocus on What Matters

PharmacotherapyPharmacotherapyPharmacotherapyPharmacotherapy

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 MedicationsUse of Weight Loss MedicationsUse of Weight Loss MedicationsUse of Weight Loss Medications

FDA-approved weight loss medications

May enhance weight loss in some

overweight and obese adults

Bariatric Surgery for Weight LossBariatric Surgery for Weight LossBariatric Surgery for Weight LossBariatric Surgery for Weight Loss

People who have not achieved weight loss

goals with less invasive weight loss

methods

A Guide to Selecting TreatmentA Guide to Selecting Treatment

2525––26.926.9 2727––29.929.9 30-34.930-34.9 3535––39.939.9 ≥ ≥4040

Diet, physical activity ,and behavior therapy

With With comorbiditiescomorbidities

With With comorbiditiescomorbidities

++ ++ ++

PharmacotherapyWithWith

comorbiditiescomorbidities ++ ++ ++

SurgeryWithWith

c o m o r b i d i t i e sc o m o r b i d i t i e s

BMI categoryBMI category

Treatment