1. Evidence-Based Weight Management Guideline M.E.Khamseh Institute of Endocrinology and Metabolism Iran University of Medical Sciences

2. 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

3. Classifications for BMI BMI Underweight<18.5 kg/m2 Normal weight18.5–24.9 kg/m2 Overweight25–29.9 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

4. Classification of Overweight and Obesity by BMI,Waist Circumference, and Associated Disease Risk* BMI (kg/m2) Obesity ClassDisease 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†18.5–24.9Increased Overweight25.0–29.9IncreasedHigh Obesity30.0–34.9 35.0–39.9 I II High Very High Extreme Obesity ≥ 40IIIExtremely 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

5. 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.

6. Goals for Weight Loss Reduced body weight Maintain a lower body weight Prevent further weight gain

7. 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)

8. Comprehensive Weight Management Program Diet Physical activity Behavior therapy

9. 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

10. 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

11. Exclusion from Weight Loss Therapy Pregnancy & Lactation Serious psychiatric illness Other serious illness

12. Determining Energy Needs Estimated energy needs based on RMR : Estimated energy needs based on RMR : Indirect calorimetry Mifflin-St. Jeor equation ( male) 10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) + 5 ( male) ( female) 10 × Wt(kg) + 6.25 × Ht(Cm) – 5 × Age (yrs) - 161( female) Activity factor : 1.3( sedentary ) 1.4(walking) 1.5(exercise) 1.8(heavy exercise)

13. Reduced 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.

14. Low-Calorie Step I Diet Nutrient Recommended Intake CaloriesApproximately 500 to 1,000 kcal/day reduction Total fat30 percent or less of total calories Saturated fatty acids8 to 10 percent of total calories Monounsaturated fatty acidsUp to 15 percent of total calories Polyunsaturated fatty acidsUp to 10 percent of total calories Cholesterol<300 mg/day ProteinApproximately 15 percent of total calories Carbohydrate55 percent or more of total calories Sodium chlorideNo more than 100 mmol/day (approximately 2.4 g of sodium or approximately 6 g of sodium chloride) Calcium1,000 to 1,500 mg/day Fiber20 to 30 g/day

15. 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

16. Portion Control As part of a comprehensive weight management program Results in reduced energy intake and Weight loss

17. 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

18. Nutrition Education Individualized Reading nutrition labels Recipe modification Cooking classes Increases knowledge : improved food choices

19. Low Glycemic Index Diets Not recommended ! Not been shown to be effective in weight management program

20. Dairy/Calcium and Weight Management 3-4 serving of low fat dairy foods a day Calcium intake lower than recommended levels : increased body weight ?

21. 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

22. 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.

23. 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

24. 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.

25. 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

26. Self-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

27. 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

28. PharmacotherapyPharmacotherapy 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

29. Use of Weight Loss Medications FDA-approved weight loss medications May enhance weight loss in some overweight and obese adults

30. Bariatric Surgery for Weight Loss People who have not achieved weight loss goals with less invasive weight loss methods

31. A Guide to Selecting Treatment 25–26.927–29.930-34.935–39.9 ≥ 40 Diet, physical activity, and behavior therapy With comorbidities +++ PharmacotherapyWithcomorbidities+++ SurgeryWith c o m o r b i d i t i e s BMI category Treatment