obesity acp

Inthe

ClinicIn the Clinic

Physician WritersAdam Gilden Tsai, MD, MSCEThomas A. Wadden, PhD

Section EditorsDeborah Cotton, MD, MPHDarren Taichman, MD, PhDSankey Williams, MD

The content of In the Clinic is drawn from the clinical information and educationresources of the American College of Physicians (ACP), including PIER (PhysiciansInformation and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinicfrom these primary sources in collaboration with the ACPs Medical Education andPublishing divisions and with the assistance of science writers and physician writ-ers. Editorial consultants from PIER and MKSAP provide expert review of the con-tent. Readers who are interested in these primary resources for more detail canconsult http://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current evidence for the health consequences, screeningand prevention, diagnosis, treatment, and practice improvment of obesity.

The information contained herein should never be used as a substitute for clinicaljudgment.

2013 American College of Physicians

ObesityHealth Consequences page ITC3-2

Screening and Prevention page ITC3-3

Diagnosis page ITC3-4

Treatment page ITC3-6

Practice Improvement page ITC3-14

Tool Kit page ITC3-14

Patient Information page ITC3-15

CME Questions page ITC3-16

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What health problems areassociated with overweight andobesity?Obesity, particularly severe obesity,affects nearly every organ systemof the human body. Most obesity-related medical conditions arecaused by the metabolic effects ofadipose tissue, but some are causedby the increased body mass itself(see the Box: Obesity-RelatedHealth Problems). Obesity is asso-ciated with an overall increase inmortality. The relationship be-tween weight and mortality fol-lows a J-shaped curve, with thelowest mortality traditionally be-lieved to occur with a body massindex (BMI) of 20.024.9 kg/m2

(i.e., normal weight).

The relationship between obesity andmortality is somewhat controversial. A re-cent meta-analysis of 97 studies conclud-ed that overweight (BMI, 25.029.9 kg/m2)was associated with slightly lower mortal-ity risk than was the purportedly normalBMI range, and that class 1 obesity was as-sociated with mortality similar to normalBMI (1). The results of the meta-analysishave provoked debate and a renewed ex-amination of what constitutes optimalbody weight.

The relationship between obesityand mortality is complex, withBMI accounting for only part ofthe risk. Other factors that mayaffect mortality include body fatdistribution (i.e., visceral fat vs,subcutaneous fat, not captured byBMI), age, sex, race and ethnicity,smoking, associated health condi-tions (including unknown existingconditions), and fitness level.Larger studies with longer follow-up periods have been the mostlikely to show deleterious effectsof obesity (beginning at a BMI of30 kg/m2). Regardless of whetheroverweight or class I obesity areassociated with increased mortali-ty, they are strongly related to de-velopment of comorbid conditions, including type 2 diabetes, hyper-tension, sleep apnea, and othercardiovascular disease (CVD).

What is the evidence thatintentional weight loss improveshealth outcomes?There is strong evidence that in-tentional weight loss reduces theburden of obesity-related comor-bid disease and improves overallhealth-related quality of life. For

2013 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 3 September 2013

An estimated 36% of adults and 17% of children and adolescents in theUnited States are obese. Obesity is a serious health problem that hasphysical and psychosocial consequences. It increases health care costs toemployers and reduces productivity. Rates of obesity in the United States andthroughout the world have increased dramatically over the past 40 years andcontinue to rise in many countries.

Efforts to prevent and reduce obesity have met significant challenges. Howev-er, research has begun to identify dietary and behavioral strategies to promotehealthy eating and increased physical activity. Two pharmacologic agents forthe treatment of obesity were approved by the U.S. Food and Drug Adminis-tration (FDA) in 2012, the first new medications to be approved in 13 years.Bariatric surgery as a treatment for severe obesity has become safer.

Internal medicine physicians have an important role to play in reducing obesityin their patients. Internists can assist with weight management by highlightingthe health benefits of a 510% reduction in initial weight, helping patients setappropriate goals, providing intensive behavioral interventions (or referring pa-tients to those interventions), and prescribing weight loss medication or refer-ring for bariatric surgery in selected patients. Internists also play a critical role in monitoring and managing obesity-related comorbid conditions.

Health Consequences

Obesity-Related HealthProblems

Metabolic effectsEndocrine: Prediabetes and type 2

diabetes, dyslipidemia (low high-density lipoprotein and hightriglyceride levels)

Cardiovascular: Hypertension,coronary artery disease, stroke,congestive heart failure, atrialfibrillation, venous stasis, venousthromboembolic disease (deepvenous thrombosis, pulmonaryembolism)

Cancer: Multiple types, mostcommonly colorectal,postmenopausal breast,endometrial

Gastrointestinal: Gastroesophagealreflux disease, erosive gastritis,cholelithiasis, nonalcoholic fattyliver disease

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2013 American College of PhysiciansITC3-3In the ClinicAnnals of Internal Medicine3 September 2013

example, weight loss of 510% ofstarting weight reduces the riskfor type 2 diabetes among at-riskpersons (2).

Results from the multicenter randomizedLook AHEAD trial (n = 5145) showed thatmoderate weight loss (8.6% of startingweight after 1 year, 6.15% after 4 years) ledto better physical function, decreased sleepapnea, improved sexual function, im-proved mood, reduced urinary inconti-nence, improved health-related quality oflife, and reduced need for medication forCVD risk factors, compared with a usualcare condition.

The Look AHEAD study was stopped inlate 2012 because it did not show lowerCVD morbidity and mortality in the inter-vention group than in the usual caregroup (3). However, the Swedish ObeseSubjects (SOS) study showed that patientswho had bariatric surgery for severe obe-sity and who maintained a loss of1525% of initial weight 10 years laterhad a 29% reduction in all-cause mortali-ty, compared with a control group thatwas matched on 18 characteristics. Themajor reductions in mortality resultedfrom decreases in cardiovascular- andcancer-related deaths (4).

Insulin and certain other antiglycemicmedications (sulfonylureas, thiazolidene-diones) are associated with some weightgain, but in the context of a weight loss in-tervention (e.g., the Look AHEAD trial) per-sons receiving insulin can lose nearly asmuch weight as those not on insulin (6).One randomized trial showed that use ofbupropion after smoking cessation re-duced weight gain after 1 and 2 years (7).

In adults, obesity prevention behaviors include reading food labels, eating smaller portions, eating 5 servings of fruits and veg-etables per day, eating adequateamounts of fiber (25 g/d), and exercising for 4560 minutes perday. Other behaviors associatedwith less weight gain include re-ducing job stress (8), limiting carcommuting (9), and getting ade-quate sleep (69 h/night) (10).Most of these results are derivedfrom observational studies.

A study that combined 3 cohorts with a total of 120 877 people followed for 1220years each found that weight gain was

Should clinicians screen patientsfor overweight or obesity?The U.S. Preventive Services TaskForce recommends that cliniciansscreen all adult patients for obesityand offer intensive, multicompo-nent behavioral interventions, orrefer patients to programs that offersuch interventions (5).

How can patients prevent obesity?Internists can sometimes helptheir patients prevent weight gainby reviewing concurrent medica-tions. Several medications are as-sociated with weight gain (see theBox: Medications Associated WithWeight Gain). The largest increas-es are associated with glucocorti-coids and second-generation antipsychotics, but many common-ly used medications also result inweight gain. Smoking cessationalso increases body weight by anaverage of 35 kg in the first year.(However, patients should becounseled to prioritize smokingcessation.)

Health Consequences... Obesity increases the risk for many chronic medical con-ditions. Moderate to severe obesity (BMI 35 kg/m2) clearly increases the risk formortality. Modest weight loss (510% of initial weight) reduces the burden of comorbid disease in overweight or obese patients. Larger weight loss (1530%)may reduce mortality.

CLINICAL BOTTOM LINE

Screening andPrevention

Obesity-Related HealthProblems (continued)Renal: Nephrolithiasis, proteinuria,

chronic kidney diseaseGenitourinary: In women, the

polycystic ovarian syndrome,infertility, pregnancycomplications; in men, benignprostatic hypertrophy, erectiledysfunction

Neurologic: Migraine, pseudotumorcerebri

Infections: Greater severity ofinfluenza with morbid obesity,skin and soft tissue infections

Mechanical effectsPulmonary: Obstructive sleep apnea,

restrictive lung diseaseMusculoskeletal: Osteoarthritis, low

back pain

Psychosocial effectsDepression and anxietySocial stigmatization

1. Flegal KM, Kit BK, Or-pana H, Graubard BI.Association of all-cause mortality withoverweight and obe-sity using standardbody mass index cat-egories: a systematicreview and meta-analysis. JAMA.2013;309:71-82.[PMID: 23280227]

2. Knowler WC, Barrett-Connor E, Fowler SE,et al; Diabetes Pre-vention Program Re-search Group. Reduc-tion in the incidenceof type 2 diabeteswith lifestyle inter-vention or met-formin. N Engl J Med.2002;346:393-403.[PMID: 11832527]

3. Wing RR, Bolin P,Brancati FL, et al;Look AHEAD Re-search Group. Car-diovascular effects ofintensive lifestyle in-tervention in type 2diabetes. N Engl JMed. 2013;369:145-54. [PMID: 23796131]


4. Sjstrm L, Narbro K,Sjstrm CD, et al;Swedish Obese Sub-jects Study. Effects ofbariatric surgery onmortality in Swedishobese subjects. NEngl J Med.2007;357:741-52.[PMID: 17715408]

5. Moyer VA; U.S. Pre-ventive Services TaskForce. Screening forand management ofobesity in adults: U.S.Preventive ServicesTask Force recom-mendation state-ment. Ann InternMed. 2012;157:373-8. [PMID: 22733087]

6. Pi-Sunyer X, Black-burn G, Brancati FL,et al; Look AHEADResearch Group. Re-duction in weightand cardiovasculardisease risk factors inindividuals with type2 diabetes: one-yearresults of the lookAHEAD trial. Dia-betes Care.2007;30:1374-83.[PMID: 17363746]


most strongly associated with intake of potato chips, potatoes, red meat, and sug-ar-sweetened beverages and was inverselyassociated with intake of vegetables, fruits,whole grains, nuts, and yogurt (11).

In a randomized crossover trial, sleep depri-vation (5.5 h/night vs. 8.5 h) reduced theamount of weight lost during a calorie-restricted diet and increased both loss oflean body mass and neuroendocrine mark-ers of hunger (12).

Emerging evidence suggests thatsocial and physical environmentsaffect weight. Evidence is mixed onwhether proximity to supermarketsimproves dietary intake and/orweight. Having a friend or closefamily member with obesity seems

to increase the risk for being obese(13). Offspring of women whohave significant weight gain duringpregnancy or gestational diabetesare at greater risk for being obese inchildhood (14).

In a randomized trial, 4498 low-income,mostly African American women were as-signed to a control group, receipt of ahousing voucher, or receipt of a housingvoucher that could only be redeemed in alow-poverty area (where


(e.g., diabetes) than younger persons.This is because of the loss of musclemass in older patients (so called sar-copenic obesity). In elderly patients,regular exercise has at least as impor-tant a role in maintaining goodhealth and function as does weightloss (18). BMI may also be mislead-ing in elite athletes, whose elevatedweight may be attributable to in-creased lean mass, which does not increase risk.

When and how should cliniciansmeasure waist circumference?Waist circumference provides information on central adiposity be-yond that provided by BMI. Centraladiposity correlates well with visceraladiposity, which elevates the risk forsuch obesity-related diseases as dia-betes, hypertension, and nonalcoholicfatty liver disease. Clinicians general-ly should measure waist circumfer-ence in patients who are overweightor have class 1 obesity. However,waist measurement does not usuallyadd additional risk information if theBMI is < 25 kg/m2 or 35 kg/m2.Waist circumference should be meas-ured over the iliac crests in a hori-zontal plane after the patient exhalesfollowing a normal breath. A waistcircumference of 35 inches (88 cm)for women and 40 inches (102 cm)for men is considered elevated.

What elements of the history and physical examination areimportant in patients withobesity?Secondary causes of obesity shouldbe ruled out but are uncommon inadults. Traumatic brain injury, if ac-companied by hypothalamic injury,can cause weight gain. Several raregenetic syndromes can cause obesityin adults, most of which are associat-ed with developmental delay or withother abnormal physical features. Thepatients medication list should alsobe reviewed, as discussed previously.

The history of the present illnessshould include a weight history (at5- to 10-year intervals), including

life events associated with signifi-cant weight gain (e.g., pregnancy).Clinicians should inquire about pre-vious weight loss attempts, with aparticular focus on successful efforts(i.e., resulting in a loss of 5% ofbody weight), as well as reasons attributed by the patient for recidi-vism. The medical history and re-view of systems should focus on themajor comorbid conditions listed inthe Box. The physical examinationcan be brief and focused (Table 1).

Is a family history of obesityimportant?A strong family history of obesity,particularly severe obesity, sug-gests a genetic component, al-though genetic polymorphismsare more common than the genet-ic abnormalities responsible formany of the rare syndromes. Ge-netics accounts for approximately4070% of the variability in BMI,although genetic factors alone areunlikely to explain the explosiveincrease in obesity and severeobesity in the United States overthe past 30 years. Cliniciansshould help patients understandthat obesity and its related dis-eases are responsive to lifestylemodification even if a geneticpredisposition is suspected. Thereader is referred elsewhere for

Clinical Findings in Patients With ObesityOrgan/Organ System Physical Finding Associated Condition

Skin Acne/hirsutism The polycystic ovary syndrome

Acanthosis nigricans Insulin resistanceStriae* The Cushing syndrome

Thyroid Nodules/goiter HypothyroidismCardiovascular system Blood pressure/pulse Hypertension, deconditioning

Cardiac rhythm Atrial fibrillationS3/S4 gallop Congestive heart failure

Abdomen Waist circumference Abdominal obesityExtremities Peripheral edema Venous stasis, pulmonary

hypertensionEyes Papilledema Pseudotumor cerebriMusculoskeletal system Proximal muscle weakness The Cushing syndrome

Osteoporosis The Cushing syndrome

* Striae in the Cushing syndrome are classically purple in color and broad-based.

7. Hays JT, Hurt RD, Rig-otti NA, et al. Sus-tained-releasebupropion for phar-macologic relapseprevention aftersmoking cessation. arandomized, con-trolled trial. Ann In-tern Med.2001;135:423-33.[PMID: 11560455]

8. Brunner EJ, ChandolaT, Marmot MG.Prospective effect ofjob strain on generaland central obesityin the Whitehall IIStudy. Am J Epi-demiol.2007;165:828-37.[PMID: 17244635]

9. Lopez-Zetina J, Lee H,Friis R. The link be-tween obesity andthe built environ-ment. Evidence froman ecological analy-sis of obesity and ve-hicle miles of travelin California. HealthPlace. 2006;12:656-64. [PMID: 16253540]

10. Patel SR, Hu FB.Short sleep durationand weight gain: asystematic review.Obesity (SilverSpring). 2008;16:643-53. [PMID: 18239586]

11. Mozaffarian D, Hao T,Rimm EB, Willett WC,Hu FB. Changes indiet and lifestyle andlong-term weightgain in women andmen. N Engl J Med.2011;364:2392-404.[PMID: 21696306]

12. Nedeltcheva AV,Kilkus JM, Imperial J,Schoeller DA, PenevPD. Insufficient sleepundermines dietaryefforts to reduce adi-posity. Ann InternMed. 2010;153:435-41. [PMID: 20921542]


13. Christakis NA, FowlerJH. The spread ofobesity in a large so-cial network over 32years. N Engl J Med.2007;357:370-9.[PMID: 17652652]

14. Wrotniak BH, ShultsJ, Butts S, Stettler N.Gestational weightgain and risk of over-weight in the off-spring at age 7 y in amulticenter, multi-ethnic cohort study.Am J Clin Nutr.2008;87:1818-24.[PMID: 18541573]

15. Ludwig J, Sanbon-matsu L, GennetianL, et al. Neighbor-hoods, obesity, anddiabetes-a ran-domized social ex-periment. N Engl JMed. 2011;365:1509-19. [PMID: 22010917]

16. Clinical Guidelineson the Identification,Evaluation, andTreatment of Over-weight and Obesityin Adults-The Evi-dence Report. Na-tional Institutes ofHealth. Obes Res.1998;6 Suppl 2:51S-209S.[PMID: 9813653]

17. Gallagher D, Heyms-field SB, Heo M, et al.Healthy percentagebody fat ranges: anapproach for devel-oping guidelinesbased on body massindex. Am J ClinNutr. 2000;72:694-701.[PMID: 10966886]

18. Villareal DT, Chode S,Parimi N, et al.Weight loss, exercise,or both and physicalfunction in obeseolder adults. N Engl JMed. 2011;364:1218-29. [PMID: 21449785]


more detailed information on therole of genetics (19).

What laboratory tests or otherevaluations should be done inpatients with obesity?Routine laboratory studies in pa-tients with obesity should includemeasurement of levels of fasting glucose and/or hemoglobin A1c, thyroid-stimulating hormone, liv-er-associated enzymes, and fastinglipids. Optional tests depend onthe results of the history, physicalexamination, and initial bloodtests and may include electrocar-diography, echocardiography,overnight sleep study, right upperquadrant ultrasound (fatty liver),transvaginal ultrasound (ovariancysts), or imaging and laboratorytests to assess the ypothalamicpituitaryadrenal axis for the un-common patient with suspectedhypothalamic obesity.

Beyond measurement of BMI andwaist circumference, no additionalmethods are recommended for

routine assessment of body composi-tion or adiposity. Bioelectrical im-pedance analysis is not substantiallymore accurate than estimates basedon demographic and physical char-acteristics alone (e.g., age, sex,weight, height). Dual energy x-rayabsorptiometry provides a more ac-curate estimate of body composition.Computed tomography or magneticresonance imaging can accuratelyquantify central and visceral adiposity,but both are expensive, and comput-ed tomography exposes the patientto radiation. Assessment of restingmetabolic rate, together with level ofphysical activity, can provide an esti-mate of total energy requirements,but in a randomized trial (n = 111)did not increase weight loss whenadded to a behavioral weight loss in-tervention (20). Energy requirementscan be estimated using equationsthat incorporate information aboutweight, height, demographic factors,and level of physical activity. Patientsand clinicians can easily access theHarris-Benedict equation online.

Treatmentdiscuss their concerns, rather thansimply being told that they need toreduce (which most already know).A key challenge for clinicians is tooffer patients hope about weightmanagement. This sometimes canbe achieved by explaining that a lossof only 510% of initial weight maysignificantly improve comorbid con-ditions. Patients frequently believethey must lose 25% or more of theirstarting weight to be successful (21).

How should clinicians counselpatients about their weight?Excess weight is a sensitive subjectfor many overweight and obese per-sons. Studies indicate that patientsprefer that clinicians use the termsweight or weight problem, inlieu of obesity, to discuss the topic.Clinicians can start by asking,Could we talk about your weighttoday? The conversation shouldprovide patients an opportunity to

Diagnosis... BMI should be used to diagnose obesity and should be combined withother patient characteristics to assess weight-related health risk. Waist circumfer-ence should also be measured in patients with BMI 2534.9 kg/m2 to assess forabdominal obesity, which increases health risk. The history and physical examina-tion should focus primarily on weight-related conditions, weight trajectory, andprevious weight loss attempts. Lab testing should include screening for diabetes,nonalcoholic fatty liver disease, thyroid dysfunction, and dyslipidemia.




The Centers for Medicare & Medi-caid Services (CMS), in its 2011 de-cision to reimburse primary careproviders for obesity treatment, rec-ommended using a 5A approach: As-sess (weight and risk factors); advise(weight loss, personalize the recom-mendation to the patient); agree (on atarget for behavior change); Assist(with a referral); Arrange (follow-up).

An algorithm developed by the Na-tional Heart, Lung, and Blood Insti-tute can assist patients and cliniciansin selecting an intervention (Table 2).The algorithm recommends a com-prehensive program of lifestyle modi-fication for patients with a BMI 25kg/m2 who need to reduce (16).Weight loss medications may be con-sidered with persons with a BMI 30 kg/m2 (or 27 kg/m2 with a co-morbid condition) who are unable toreduce satisfactorily with lifestylemodification alone. Surgery is an op-tion for persons with a BMI 40kg/m2 (or 35 kg/m2 with a comor-bid condition).

What are the lifestylemodifications for obesity?Comprehensive lifestyle modifica-tion programs for obesity have 3components: diet, physical activity,and behavior modification (Table 3)(22). Behavior modification pro-vides a set of principles and tech-niques, such as goal-setting andrecordkeeping. Obese personsshould typically try to achieve anenergy deficit of 5001000 kcal/dto induce a corresponding weight

loss of approximately 12 pounds(0.51 kg) per week. The U.S. Pre-ventive Services Task Force has rec-ommended only high-intensitylifestyle modification programs (de-fined as 1226 sessions in the firstyear [5]) because lower-intensity pro-grams have not shown consistent ef-fectiveness. High-intensity lifestylemodification programs provide week-ly individual or group treatment ses-sions (of 3060 minutes) for 1626weeks (16, 22). High-intensity inter-ventions produce mean weight loss ofapproximately 69 kg (approximately69% of initial weight). For example,the Diabetes Prevention Programproduced a mean loss of approxi-mately 7 kg in 6 months (2).

A recent meta-analysis concluded thatprograms that provided 1226 sessionsover 1 year produced mean weight loss of47 kg, whereas those that offered

23. Lichtman SW, Pisars-ka K, Berman ER, etal. Discrepancy be-tween self-reportedand actual caloric in-take and exercise inobese subjects. NEngl J Med.1992;327:1893-8.[PMID: 1454084]

24. Hooper L, Abdel-hamid A, Moore HJ,et al. Effect of reduc-ing total fat intakeon body weight: sys-tematic review andmeta-analysis of ran-domised controlledtrials and cohortstudies. BMJ.2012;345:e7666.[PMID: 23220130]

25. Foster GD, Wyatt HR,Hill JO, et al. Weightand metabolic out-comes after 2 yearson a low-carbohy-drate versus low-fatdiet: a randomizedtrial. Ann Intern Med.2010;153:147-57.[PMID: 20679559]


interventions focusing on physicalactivity. Physical activity, however,is an important component ofweight management programs andis particularly important in main-taining weight loss in adults (seebelow). Clinicians can help over-weight and obese persons identifythe daily calorie target needed tolose weight by using equations toestimate daily energy expenditure,and then subtracting 500 to 1000kcal from this value.

This calorie prescription, however,assumes that persons can preciselymeasure food intake. Studies haveshown that overweight and obesepersons underestimate caloric in-take by approximately 40% per day(23). Because of this finding, menand women who weigh

26. Shai I, SchwarzfuchsD, Henkin Y, et al; Di-etary InterventionRandomized Con-trolled Trial (DIRECT)Group. Weight losswith a low-carbohy-drate, Mediter-ranean, or low-fatdiet. N Engl J Med.2008;359:229-41.[PMID: 18635428]

27. Heymsfield SB, vanMierlo CA, van derKnaap HC, Heo M,Frier HI. Weightmanagement usinga meal replacementstrategy: meta andpooling analysisfrom six studies. Int JObes Relat MetabDisord. 2003;27:537-49. [PMID: 12704397]

28. Sacks FM, Bray GA,Carey VJ, et al. Com-parison of weight-loss diets with differ-ent compositions offat, protein, and car-bohydrates. N Engl JMed. 2009;360:859-73. [PMID: 19246357]

29. Church TS, Blair SN,Cocreham S, et al. Ef-fects of aerobic andresistance trainingon hemoglobin A1clevels in patientswith type 2 diabetes:a randomized con-trolled trial. JAMA.2010;304:2253-62.[PMID: 21098771]

30. Sumithran P, Pren-dergast LA, Del-bridge E, et al. Long-term persistence ofhormonal adapta-tions to weight loss.N Engl J Med.2011;365:1597-604.[PMID: 22029981]


calories from carbohydrate for a2000-calorie diet). These diets ex-perienced renewed popularity in theearly 2000s after publication of 2randomized trials showing greatershort-term weight loss with anAtkins-type diet (25, 26). However,2 larger randomized trials, donesince those initial studies, showedthat results of a low-carbohydratediet was similar to calorie-restrictedversions of a low-fat diet or to aMediterranean diet (25, 26).

Meal-replacement dietsMeal replacements (shakes, mealbars) and portion-controlled entreesare an easy way to count caloriesand to simplify meal preparation.

A meta-analysis of 6 randomized trialsconcluded that a partial meal replace-ment regimen (replacing 2 meals per daywith a shake, plus eating fruits and veg-etables during the day) led to an addition-al 2.53 kg of weight loss beyond a pre-scribed diet with the same number ofcalories from self-selected food (27).

Which diet is best for long-termweight loss?Most evidence suggests that dietsthat differ in macronutrient contentproduce similar amounts of weightloss over the long term. Thus, acalorie-deficit diet that follows fed-eral dietary guidelines (5060% ofcalories from complex carbohy-drate) and that emphasizes foodsthat are widely considered to behealthy (e.g., vegetables, nuts, fish)should serve as the initial choice formost patients.

A randomized trial (n = 811) assigned pa-tients in a 2 x 2 fashion to diets with averageor high-protein content (15% or 25%) andto low fat or high fat (20% or 40%), with car-bohydrate making up the remainder. After 2 years, weight loss was similar in all 4groups, and attendance at group sessionscorrelated more closely with weight lossthan treatment group assignment (28).

What is the role of exercise inweight loss and maintenance?Regular exercise is critical for over-all health, but in randomized trials

contributed only 13 kg of weightloss when combined with a struc-tured diet program. Exercise seemsto be more important for main-taining lost weight than for initialreduction. Persons who are able toperform 275 minutes per week(about 40 minutes/day) of exerciseare significantly more likely tomaintain weight loss over time.Aerobic and resistance training ex-ercise combined may have furtherhealth benefits beyond either typeof exercise alone (29).

How can clinicians assessreadiness for weight loss?Relatively little evidence exists toguide clinicians on which patients aremost ready to participate in high-intensity obesity treatment programs.The consensus among bariatric clini-cians is that patients must be com-mitted to monitoring their food intake and physical activity, be free ofuntreated major depression, and notin the middle of a major life event. A practical approach to screen forreadiness to participate in a high-intensity program is to ask patients tomonitor their food intake and physi-cal activity for at least 1 week.

What makes maintaining weightloss so difficult, and whatimproves long-term results?After completing a 6-month pro-gram, patients on average regainone third of lost weight in the en-suing year, with continued regainover time. Previously, it was as-sumed that regression to old be-havior patterns explained weightregain. However, a recent studyfound that 1 year after a substan-tial weight loss, levels of hormonesthat stimulate hunger (e.g., ghre-lin) remained elevated, and levelsof hormones that mediate satiety(e.g., leptin, amylin) remained de-pressed (30). These results suggesta physiologic basis for weight re-gain. Some data suggest that obesepersons who have lost weight burnfewer calories than persons withthe same lean body mass who were


31. Leibel RL, Rosen-baum M, Hirsch J.Changes in energyexpenditure result-ing from alteredbody weight. N EnglJ Med. 1995;332:621-8. [PMID: 7632212]

32. Wing RR, Hill JO.Successful weightloss maintenance.Annu Rev Nutr.2001;21:323-41.[PMID: 11375440]

33. Wadden TA,Berkowitz RI,Womble LG, et al.Randomized trial oflifestyle modificationand pharmacothera-py for obesity. NEngl J Med.2005;353:2111-20.[PMID: 16291981]

34. James WP, CatersonID, Coutinho W, et al;SCOUT Investigators.Effect of sibutramineon cardiovascularoutcomes in over-weight and obesesubjects. N Engl JMed. 2010;363:905-17. [PMID: 20818901]

35. Hendricks EJ, Green-way FL, Westman EC,Gupta AK. Bloodpressure and heartrate effects, weightloss and mainte-nance during long-term phenterminepharmacotherapyfor obesity. Obesity(Silver Spring).2011;19:2351-60.[PMID: 21527891]


never obese, thus impeding furtherweight loss (31).

Continued participation in astructured weight managementprogram (that offers at leastmonthly and preferably twice-monthly treatment sessions) canhelp patients maintain lost weight.Other behaviors associated withsuccessful maintenance of weightloss include engaging in physicalactivity 60 minutes/day mostdays of the week; monitoringbody weight frequently; eating areduced-calorie diet; and record-ing food intake periodically (par-ticularly in response to weight regain). These are the behaviorspracticed by members of the Na-tional Weight Control Registry,all of whom have lost at least 30 lb (13.6 kg) and maintainedthe loss for 1 year or more (32).

When is pharmacotherapyindicated for treatment ofobesity?Pharmacotherapy is appropriate for patients with a BMI 30 kg/m2or those with a BMI 27 kg/m2who have a significant weight-related condition, such as type 2diabetes or hypertension (16). Pa-tients should be screened carefullyfor contraindications to weightloss medications. Ideally, patientsreceiving weight loss medicationshould pursue a structured programof lifestyle modification, as this ap-proximately doubles the weightloss achieved (33).

The FDA approved 2 obesity agentsin 2012, phentermine-topiramateand lorcaserin. A third agent, bupropion-naltrexone, was given anapprovable decision by the FDA in2012, subject to a long-term ran-domized trial of cardiovascular safe-ty. Currently approved weight lossagents are shown in Table 4.

PhenterminePhentermine is the most common-ly prescribed weight loss drug inthe United States. Because it is a

sympathomimetic agent, patientsneed to be followed closely to en-sure that increases in blood pres-sure and pulse do not occur, as thiscould increase risk for CVD,thereby offsetting the other bene-fits of weight loss. (Sibutramine,another agent with sympath-omimetic effects, was removedfrom U.S. and European marketsin 2010 for this reason [34]).Phentermine is only approved forshort-term use in the UnitedStates, which is commonly inter-preted as 12 weeks. However,some clinicians use the drug on along-term basis. One well-conducted observational study didnot show significant increases inblood pressure or pulse amongpatients receiving phenterminefor 1 year compared with a con-trol group with similar weightloss (35). Less commonly usedsympatho-mimetic agents are list-ed in Table 4.

Phentermine-topiramatePhentermine-topiramate (Qsymia,Vivus Inc.) is a fixed-dose combi-nation of these 2 drugs, both pre-scribed in a lower dose than asmonotherapy, with the goal of re-ducing side effects from eitheragent alone. (Topiramate is anFDA-approved agent for treatmentof seizures and was observed tocause weight loss as a side effect.)Of the currently approved agents,phentermine-topiramate producesthe most weight loss (811% ofinitial weight). Common side ef-fects include paresthesias, changein taste (topiramate), dry mouth,constipation, and insomnia (phen-termine). Contraindications in-clude nephrolithiasis (topiramate)as well as uncontrolled blood pressure, resting tachycardia, or es-tablished CVD (phentermine). Be-cause heart rate increased slightlyin clinical trials (0.61.6 beats/ min),the manufacturer is performing alarge, prospective clinical trial tofurther assess risk. Topiramate iscategory X in pregnancy; women of


36. Gadde KM, AllisonDB, Ryan DH, et al.Effects of low-dose,controlled-release,phentermine plustopiramate combi-nation on weightand associated co-morbidities in over-weight and obeseadults (CONQUER): arandomised, place-bo-controlled, phase3 trial. Lancet.2011;377:1341-52.[PMID: 21481449]

37. Garvey WT, Ryan DH,Look M, et al. Two-year sustainedweight loss andmetabolic benefitswith controlled-re-leasephentermine/topira-mate in obese andoverweight adults(SEQUEL): a random-ized, placebo-con-trolled, phase 3 ex-tension study. Am JClin Nutr.2012;95:297-308.[PMID: 22158731]

38. Connolly HM, CraryJL, McGoon MD, etal. Valvular heart dis-ease associated withfenfluramine-phen-termine. N Engl JMed. 1997;337:581-8. [PMID: 9271479]


reproductive age must use a highlyreliable form of birth control andhave monthly pregnancy tests whiletaking the drug.

In the CONQUER trial, 2487 overweight andobese persons with at least 2 risk factors forCVD were randomized to placebo or phen-termine-topiramate 7.5/46 mg or phenter-mine-topiramate 15/92 mg (36). Weight lossat 1 year was 1.2%, 7.8%, and 9.8% of initialweight, respectively. The SEQUEL extensionstudy, which continued with patients fromCONQUER in a double-blind fashion, ob-served weight loss at 2 years of 1.8%, 9.3%,and 10.5%, respectively (37).

LorcaserinLorcaserin (Belviq, Arena Pharma-ceuticals) is an agonist of the5HT2C receptor in the brain,which helps to regulate appetite.The drug was designed to avoidserotonin agonism in the heart,which was the mechanism deter-mined to cause cardiac valve diseasein some patients who receiveddexfenfluramine or fen-phen (fenfluramine-phentermine) in the

1990s. (Phentermine was not iden-tified as a cause of valvulopathy[38]). Lorcaserin must be used withcaution in patients receiving drugswith serotonergic mechanisms ofaction, such as selective serotoninreuptake inhibitors and serotoninnorepinephrine reuptake inhibitors.

In the BLOOM trial, 3182 persons were as-signed to placebo or lorcaserin (10 mg)twice daily. At 1 year, weight loss was 2.2%and 5.8% of initial weight, respectively (39).In the BLOOM and BLOOM-DM trials,echocardiograms done on 2472 patients at1 year and 1127 patients at 2 years showedno increased risk for valvular disease.

OrlistatOrlistat is available both as a pre-scription medication (120 mg 3times daily) and as an over-the-counter agent (60 mg 3 times daily). It induces weight loss by re-ducing absorption of fat from thegastrointestinal tract. The modestweight loss (34% greater thanplacebo, similar to lorcaserin) andside-effect profile (e.g., oily stools,

4. Currently Approved Weight Loss AgentsAgent Mechanism Dose Side Effects Contraindications Notes

Phentermine* Sympathomimetic 1537.5 mg/d Dry mouth, headache, Established cardiovascular FDA Schedule IVconstipation, tachycardia, disease, uncontrolled insomnia hypertension, glaucoma,

hyperthyroidism, or active drug abuse

Diethylproprion* Sympathomimetic 2575 mg/d Similar to phentermine Similar to phentermine FDA Schedule IVBenzaphetamine* Sympathomimetic 2050 mg TID Similar to phentermine Similar to phentermine Use lowest

effective dose; FDA Schedule III

Phendimetrazine* Sympathomimetic 17.535 mg BID to Similar to phentermine Similar to phentermine FDA Schedule IIITID (max 70 mg/d)

Phentermine- Sympathomimetic 3.75/23 mg, 7.5/ Same as phentermine, Same as phentermine, Monthly birth topiramate* (phentermine); 46 mg, 15/92 mg plus paresthesias, plus pregnant or trying control tests

appetite reduction/ altered taste, dizziness to become pregnant, recommendedchanges in taste of or recent nephrolithiasisfood (topiramate)

Lorcaserin Serotonin 5HT2C 10 mg BID Headache, back pain, Severe depression, Caution with agonist dizziness, fatigue, established cardiac serotonergic

nasopharyngitis, valvular disease drugs (e.g., SSRIs, nausea, constipation, SNRIs)dry mouth

Orlistat Intestinal lipase 60 mg TID (OTC) or Oily stools, fecal discharge, Use of immune suppressive Take vitamin inhibitor 120 mg TID flatus, fat-soluble vitamin medications; caution with supplement 2 h

(prescription) deficiency concurrent warfarin before/after drug

BID = twice daily; FDA = U.S. Food and Drug Administration; OTC = over-the-counter; SNRI = serotoninnorepinephrine reuptake inhibitor; SSRI = selectiveserotonin reuptake inhibitor; TID = three times daily.

* Monitor blood pressure and pulse.


39. Smith SR, WeissmanNJ, Anderson CM, etal; Behavioral Modifi-cation and Lor-caserin for Over-weight and ObesityManagement(BLOOM) StudyGroup. Multicenter,placebo-controlledtrial of lorcaserin forweight manage-ment. N Engl J Med.2010;363:245-56.[PMID: 20647200]

40. Torgerson JS, Haupt-man J, Boldrin MN,Sjstrm L. XENicalin the prevention ofdiabetes in obesesubjects (XENDOS)study: a randomizedstudy of orlistat asan adjunct tolifestyle changes forthe prevention oftype 2 diabetes inobese patients. Dia-betes Care.2004;27:155-61.[PMID: 14693982]

41. Munro JF, MacCuishAC, Wilson EM, Dun-can LJ. Comparisonof continuous andintermittent anorec-tic therapy in obesi-ty. Br Med J.1968;1:352-4.[PMID: 15508204]

42. Wirth A, Krause J.Long-term weightloss with sibu-tramine: a random-ized controlled trial.JAMA.2001;286:1331-9.[PMID: 11560538]


fecal discharge) have led to infre-quent prescription. Side effects,however, can be minimized by pa-tients adherence to a low-fat diet,and orlistat remains the only over-the-counter weight loss agent thathas been proven effective.

A 4-year randomized trial of orlistat (n = 3305) showed that it reduced the inci-dence of type 2 diabetes by 37% (40), an ef-fect similar to metformin in the DiabetesPrevention Program (2).

Should weight loss medications betaken long-term?Patients, on average, regain weightafter medications are terminated.Trials of both orlistat and lor-caserin showed that patients wholost weight during the first yearand were then randomly assignedto remain on medication for a sec-ond year maintained significantlygreater weight loss at the end ofthe second year than did personsrandomized to placebo (30). Thus,patients should be counseled thatlong-term pharmacotherapy willprobably be needed. Randomized,controlled trials of previous med-ications found that treatmentcould be provided approximatelyevery other month, rather thancontinuously, with no loss of effi-cacy (41, 42). The plateau inweight loss that occurs after ap-proximately 68 months of phar-macologic treatment should not beinterpreted to mean that the medication is no longer working.The plateau, in part, reflects thehormonal and metabolic adapta-tions to weight loss describedpreviously.

Patients and clinicians may haveconcerns about the safety of long-term pharmacotherapy for obesityraised by a history of unexpectedproblems with these medications.Medications currently approved forchronic use have been subjected tomore rigorous safety testing than inprevious eras, which ultimately willinclude trials to examine long-termrisk for cardiovascular events.

When is surgery indicated fortreatment of obesity?Bariatric (weight loss) surgery is gen-erally indicated for patients with abody mass index 40 kg/m2 or forthose with a BMI 35 kg/m2 with atleast 1 serious weight-related comor-bid condition, such as type 2 dia-betes, sleep apnea, or disabling jointdisease. Laparoscopic gastric bandingis also FDA-approved for patientswith a BMI 30 kg/m2 and type 2diabetes. Before having surgery, pa-tients should have made sustained at-tempts at weight loss with lifestylemodification and/or pharmacothera-py. It is currently standard of care forpatients considering bariatric surgeryto undergo preoperative psychologi-cal evaluation to determine appropri-ateness for surgery. Patients must alsobe well informed of the potentialrisks of surgery and the need forlong-term monitoring of their weightand nutritional status.

Types of bariatric surgeryThe 3 types of surgeries most com-monly done in the United States areadjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gas-trectomy. All 3 can be performed laparoscopically. The gastric bandinvolves placing a band around theupper stomach, creating a smallproximal stomach pouch throughwhich food must pass before tra-versing the rest of the stomach andthe intestinal tract. The band is ad-justable, which allows the clinicianto loosen it (e.g., if the patient haspostprandial vomiting) or to tightenit if postsurgical results are subopti-mal (e.g., slow weight loss, low levelof satiety). Weight loss is achievedby restriction of food intake alone.

With gastric bypass, the stomach istransected proximally, and the mid-jejunum is also transected and con-nected to the remaining proximalstomach pouch. The remaining distalstomach, duodenum, and proximal je-junum are anastomosed to form ablind limb, which ends proximallyin the closed-off stomach and is no


43. Padwal R, Klaren-bach S, Wiebe N, etal. Bariatric surgery: asystematic reviewand network meta-analysis of random-ized trials. Obes Rev.2011;12:602-21.[PMID: 21438991]

44. Carlin AM, Zeni TM,English WJ, et al;Michigan BariatricSurgery Collabora-tive. The compara-tive effectiveness ofsleeve gastrectomy,gastric bypass, andadjustable gastricbanding proceduresfor the treatment ofmorbid obesity. AnnSurg. 2013;257:791-7. [PMID: 23470577]

45. Buchwald H, AvidorY, Braunwald E, et al.Bariatric surgery: asystematic reviewand meta-analysis.JAMA.2004;292:1724-37.[PMID: 15479938]

46. Maciejewski ML, Liv-ingston EH, SmithVA, et al. Survivalamong high-risk pa-tients after bariatricsurgery. JAMA.2011;305:2419-26.[PMID: 21666276]

47. Flum DR, Belle SH,King WC, et al; Lon-gitudinal Assess-ment of BariatricSurgery (LABS) Con-sortium. Periopera-tive safety in the lon-gitudinal assessmentof bariatric surgery.N Engl J Med.2009;361:445-54.[PMID: 19641201]


longer a part of the active digestiveprocess. Roux-en-Y gastric bypasscauses restricted food intake, partialmalabsorption, and changes in appetite-regulating hormones (e.g.,ghrelin), all of which contribute toweight loss. In sleeve gastrectomy, approximately 75% of the stomach isremoved, but the remainder of the in-testinal tract remains intact. Weightloss is achieved principally by food restriction, although the removal ofendocrine-rich gastric tissue and anaccelerated rate of gastric emptyingmay contribute to the greater weightloss than with gastric banding.

Effectiveness of bariatric surgeryBariatric surgery is the most effica-cious treatment for severe obesity.One meta-analysis of randomizedtrials concluded that, after 1 year,gastric banding, gastric bypass, andsleeve gastrectomy were associatedwith reductions in BMI of 2.4 kg/m2,9.0 kg/m2, and 10.1 kg/m2, respec-tively (43). A recent cohort study (n = 8847) that used propensity scor-ing also reported that sleeve gastrec-tomy was closer in effectiveness togastric bypass than to gastric band-ing (weight loss of approximately17.1%, 29.7%, and 34.8% of initialweight for gastric banding, sleevegastrectomy, and gastric bypass, re-spectively) (44).

The dramatic weight loss seen withbariatric surgery often amelioratescomorbid conditions (45). Type 2 di-abetes resolves more often with gas-tric bypass than would be expectedfrom weight loss alone, suggesting

that additional mechanisms accountfor this observation.

Data are somewhat conflicting onwhether bariatric surgery reduces mortali-ty. The SOS study, the cohort study in whichsurgical and control participants werematched on 18 characteristics, found thatthe large weight loss achieved withbariatric surgery resulted in reduced all-cause mortality (4). However, a well-doneobservational study from U.S. Veterans Ad-ministration data, using propensity scoreadjustment, did not show a mortality ben-efit from bariatric surgery (46).

Complications of bariatric surgeryAll 3 procedures reviewed are asso-ciated with complications. Potentialcomplications of gastric banding in-clude slippage or erosion of theband, which can lead to gastroe-sophageal reflux; obstruction; and inrare cases, esophageal or gastric per-foration. Potential complications ofgastric bypass include anastomoticbreakdown, stenosis or ulcers nearthe anastomotic site, and long-termmicronutrient deficiencies. Any pa-tient having bariatric surgery is atrisk for perioperative complications,including wound infection, venousthromboembolism, and mortality.

In a multicenter cohort study of patients un-dergoing surgery at bariatric surgical Cen-ters of Excellence in the United States, 4.3%of patients had at least one major adverseoutcome (death, venous thromboem-bolism, need for reintervention, or failure tobe discharged from the hospital); 30-daymortality rates were 0% for gastric banding,0.2% for laparoscopic gastric bypass, and2.1% for open gastric bypass (47).

Treatment... Clinicians should discuss weight with patients, using appropriate language.They should recognize that physiologic factors play a role in weight regain after initialweight loss. Clinicians should advise patients that keeping records of food intake andphysical activity are the most important tasks for weight loss. A calorie deficit diet, with5060% of calories from complex carbohydrates, should be the first choice for most pa-tients. Pharmacotherapy is appropriate for selected patients with obesity, with appropri-ate monitoring for potential side effects. Bariatric surgery is the most effective and themost high-risk treatment for severe obesity; it has been shown to improve and occa-sionally cure comorbid conditions and may reduce mortality from excess weight.



48. Snow V, Barry P, Fit-terman N, QaseemA, Weiss K; ClinicalEfficacy AssessmentSubcommittee ofthe American Col-lege of Physicians.Pharmacologic andsurgical manage-ment of obesity inprimary care: a clini-cal practice guide-line from the Ameri-can College ofPhysicians. Ann In-tern Med.2005;142:525-31.[PMID: 15809464]

49. Centers for Medicare& Medicaid Services.Decision Memo forIntensive BehavioralTherapy for Obesity(CAG-00423N). 2011.Accessed at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253& on 10 De-cember 2011.

Inthe

C linicTool Kit

In the Clinic

Obesity

PIER Modulehttp://pier.acponline.org/physicians/diseases/d161/d161.htmlPIER module on obesity from the American College of Physicians.

Patient Informationhttp://pier.acponline.org/physicians/diseases/d161/d161-pi.htmlPatient Information material that appears on the next page for

duplication and distribution to patients.www.acponline.org/patients_families/pdfs/health/obesity.pdfPatient handout on obesity from the American College of

Physicians: 100 Million Adult Americans Are Overweight and atRisk of Serious Disease.

www.acponline.orgInformation for clinicians and patients on obesity, includingrecruitment for obesity studies and treatment.

Clinical Guidelineshttp://annals.org/article.aspx?articleid=1355696U.S. Preventive Services Task Force recommendation statement on

screening for and management of obesity in adults, published inAnnals of Internal Medicine in September 2012.

http://annals.org/article.aspx?articleid=718309U.S. Preventive Services Task Force clinical practice guideline on

pharmacologic and surgical management of obesity in primarycare, published in Annals of Internal Medicine in April 2005.

Diagnostic Tests and Criteriahttp://pier.acponline.org/physicians/diseases/d161/tables/d161

-tlab.htmlTable listing laboratory and other studies for obesity.http://nhlbisupport.com/bmi/Online body mass index calculator, and information on the BMI

tables, from the NHLBI.

Quality-of-Care Guidelineshttp://qualitymeasures.ahrq.gov/

3 September 2013Annals of Internal MedicineIn the ClinicITC3-14 2013 American College of Physicians

PracticeImprovement minutes each) in the first 6 months,

and up to 6 additional monthly visitsif the patient loses at least 3 kg inthe first 6 months. This schedule ofvisits can be repeated annually, al-though the visits must be performedin the physical setting of the primarycare office. In 2010, the AmericanDiabetes Association officially rec-ommended using hemoglobin A1cto screen for diabetes. Because ofthis, many more persons have beendiagnosed with prediabetes, andgreater attention has been focusedon the value of moderate weight loss(510% of initial weight) in prevent-ing diabetes. For example, the na-tional Diabetes Prevention Programis undergoing dissemination throughcollaboration between YMCAs andthe Centers for Disease Control andPrevention.

What do professionalorganizations recommend withregard to management of obesity?The U.S. Preventive Services TaskForce updated its recommendationin 2012 for treatment of obesity. TheTask Force recommended that clini-cians offer or refer patients with aBMI 30 kg/m2 to intensive, multicomponent behavioral inter-ventions (5). The ACP publishedguidelines for pharmacologic andsurgical treatment of obesity in 2005(48). The NIH guidelines for evalu-ation and treatment of obesity wereoriginally published in 1998 (16),and an updated version of theseguidelines is currently underway (ex-pected in 2013/2014). The CMS hasrecently approved a benefit for in-tensive behavior therapy of obesity(49). It will pay for 14 visits (15


In the ClinicAnnals of Internal Medicine

Pati

ent

Info

rmat

ion

WHAT YOU SHOULDKNOW ABOUT OBESITY

Why is obesity a health problem? Being overweight means that you weigh more than

is healthy.

People who are overweight have medical problems,such as high cholesterol, diabetes, heart disease,arthritis, and breathing problems, as well as shorterlives.

Losing weight can be hard, but losing even a littlecan make you healthier.

How do you know if you areoverweight? Body mass index (BMI) measures how tall you are in

meters (m) and how much you weigh in kilograms(kg) to tell you if you weigh too much.

Normal BMI is under 25 kg/m2. You are overweightif your BMI is between 25 kg/m2 and 30 kg/m2. Youare obese if it is over 30 kg/m2.

What the best ways to lose weight? Eat less and exercise more.

Some diets are easier than others for some people.Sometimes getting advice or joining self-help groupsmakes it easier to stay on a diet.

Set a reachable goal for your new weight. Even afew pounds makes a difference.

If diet and exercise are not enough, your doctor maygive you medication to lose weight.

If you are very obese and have serious medical prob-lems, your doctor may consider surgery on yourstomach so that you eat less and lose weight.

Why Is Losing Weight So Hard? Its not easy to break the eating habits that lead to

weight gain.

It takes patience. Healthy, long-term weight losstakes time, and the slow results can dampen yourmotivation.

Its hard for your body to change. When you go on adiet, you lose some weight and then stop for a while.

For More Informationwww.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htmInformation resources from the National Heart, Lung, and Blood

Institutes Aim for a Healthy Weight! Program.

www.heart.org/HEARTORG/GettingHealthy/WeightManagement/Weight-Management_UCM_001081_SubHomePage.jspwww.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/Physical-Activity_UCM_001080_SubHomePage.jspGuidance on losing weight and on physical activity from the

American Heart Association.

www.eatright.org/Public/Information on food and nutrition, from the Academy of

Nutrition and Dietetics (formerly the American DieteticAssociation).


CME Questions

3 September 2013Annals of Internal MedicineIn the ClinicITC3-16 2013 American College of Physicians

Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/

to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

1. A 42-year-old man is evaluated forobesity. His weight has graduallyincreased over the past two decadesand is currently 168.2 kg (370 lb). Fiveyears ago, he was diagnosed with type2 diabetes mellitus, hypertension, andhyperlipidemia. Over the past 6 months,he has unsuccessfully tried diet andexercise therapy for his obesity. He triedover-the-counter orlistat but could nottolerate the gastrointestinal sideeffects. Medications are metformin,lisinopril, and simvastatin. His totalweight loss goal is 45.4 kg (100 lb).

On physical examination, temperature isnormal, blood pressure is 130/80 mmHg, pulse rate is 80/min, and respirationrate is 14/min. BMI is 48. Waistcircumference is 121.9 cm (48 in). Thereis no thyromegaly. Heart sounds arenormal with no murmur. There is nolower extremity edema.

Results of complete blood count,thyroid studies, and urinalysis areunremarkable.

Which of the following is the mostappropriate management of this patient?

A. Bariatric surgery evaluationB. Prescribe phentermineC. Reduce caloric intake to below 800

kcal/dD. Refer to an exercise program

2. A 48-year-old woman is evaluatedduring a routine examination. She isconcerned about her gradual weightgain over the years and requestscounseling on how she can mosteffectively lose weight.

Over 8 years, she has gainedapproximately 18 kg (40 lb). Withseveral commercial diets, she has lostweight but always gains it back. Shehas a sedentary job, and often skipsbreakfast or eats dinner on the run. Shestates she cannot fit exercise into herbusy day. She takes no medications andhas no allergies.

On physical examination, temperature isnormal, blood pressure is 132/70 mmHg, pulse rate is 80/min, and respirationrate is 12/min. BMI is 32. There is nothyromegaly. The abdomen is obese,soft, nontender, and without striae.Fasting plasma glucose level is 106 mg/dL (5.9 mmol/L) and thyroidfunction test results are normal.

Which of the following is the mostappropriate next step to help thispatient achieve long-term weightreduction?

A. Exercise 1530 minutes 5 days/wkB. Laparoscopic adjustable band surgeryC. OrlistatD. Reduce current caloric intake by

5001000 kcal/d

3. A 31-year-old woman is evaluatedduring a postpartum examination 6 months after giving birth to her firstchild. The patient was obese beforebecoming pregnant, developedgestational diabetes mellitus duringpregnancy, and was able to maintainher weight and glucose level within thetarget range throughout her pregnancywith diet alone. Her infant weighed4139 grams (146 ounces) at birth.

This patients infant is at increased riskfor which of the following disorders?

A. Childhood obesityB. Maturity-onset diabetes of the youngC. Type 1A diabetes mellitusD. Type 1B diabetes mellitus


obesity acp

Documents

diagnosis page itc3

treatment page itc3

prevention page itc3

severe obesity

obesity andmortality

patient information

practice improvement

tool kit page itc3