1. VA/DoD 2006 Clinical Practice Guideline For Screening and Management of Overweight and Obesity Guideline Summary: Key Elements

2. Key Elements of the Guidelines 1. Routine primary care screening for overweight and obesity

3. Screening BMI best correlates with disease risk. Waist circumference (WC) should be measured in those who are not obese as it independently confers disease risk. –Abnormal WC is defined as > 40 inches in men and > 35 inches in women.

4. Classification of Overweight and Obesity by BMI and Associated Disease Risk ClassificationBMIDisease Risk with Normal Waist Circumference Disease Risk with Excessive Waist Circumference Underweight<18.5-- Normal18.5-24.9Low- Overweight25.0-29.9IncreasedModerate Obese I30.0-34.9ModerateSevere Obese II35.0-39.9SevereVery Severe Obese III> 40Very Severe

5. Key Elements of the Guidelines 1. Routine primary care screening for overweight and obesity. 2. Assessment of risk factors and obesity- associated conditions influenced by weight.

6. Obesity-Associated Conditions Hypertension Type 2 Diabetes Dyslipidemia Metabolic Syndrome Obstructive Sleep Apnea Degenerative Joint Disease

7. Key Elements of the Guidelines 1. Routine primary care screening for overweight and obesity. 2. Assessment of risk factors and obesity- associated conditions influenced by weight. 3. Evidence-based strategies for weight loss and weight maintenance for patients who are overweight or obese.

8. Evidence-Based Does weight loss improve glycemic control, lipid values, and blood pressure? Does improved glycemic control, lipid values, and blood pressure translate into improved cardiovascular morbidity and mortality? Does weight loss improve cardiovascular morbidity and mortality? Epidemiology versus evidence.

9. Strength of Recommendation A: A strong recommendation that clinicians provide the intervention to eligible patients. Quality of evidence is good. B: A recommendation that clinicians provide the intervention to eligible patients. Quality of evidence is fair. C: No recommendation either for or against. Fair evidence exists that the intervention can improve outcomes but the balance of benefits and harms is to close to justify a general recommendation. D: Recommendation is made against routinely providing the intervention. At least fair evidence exists that either the intervention is ineffective or that harm outweighs benefit. I: Inconclusive exists to make any recommendation. Evidence is lacking, poor, or conflicting and the balance of risk versus benefit cannot be determined.

10. Key Elements of the Guidelines 4. Promotion of lifestyle changes (diet and exercise) in persons with normal weight to prevent weight gain. 5. Advice for persons, who are overweight (BMI of 25- 29.9) without obesity-associated conditions, to maintain or lose weight and prevent weight gain. 6. The involvement of patients in their education, goal setting, and decision-making process.

11. Key Elements of the Guidelines 7. Strategies to achieve sustained weight loss by creating an energy deficit (when energy expenditure is greater than caloric intake). 8. The combination of dietary therapy, increased physical activity, and behavioral modification therapy as the key components of weight loss therapy.

12. Lifestyle Interventions: Do They Work? Ross, Annals of Internal Medicine 2000;133:92-103. Men with BMI >27, WC > 100 cm, and stable weight over the previous 6 months. Randomized to control, diet, exercise, or exercise without weight loss. Goal was 700 kcal reduction per day for 12 weeks for predicted weight loss of 16.8 lbs Control group and exercise plus calories maintained weight; weight loss groups both loss 16.5 lbs

13. Strong Levels of Evidence for Lifestyle Interventions Adherence to a diet is more important than the specific diet. [A] A calorie deficit of 500-1000 kcal per day should be created to lose 1-2 lbs per week. [B] Physical activity should be for at least 30 minutes most days of the week. [B] Behavioral modification enables compliance with diet and exercise programs. [B] Multiple behavioral modifications strategies should be used. [A] High intensity intervention is essential. [B]

14. Key Elements of the Guidelines 9. Weight loss drug therapy as an adjunct to long-term diet and physical activity for patients who are obese (BMI > 30) or are overweight with a BMI > 27 and with obesity-associated conditions. 10. Weight loss surgery as an option for patients with extreme obesity (BMI > 40) or a BMI > 35 with obesity-related conditions in whom other methods of weight loss treatment have failed.

15. Obesity-Associated Conditions Hypertension Type 2 Diabetes Dyslipidemia Metabolic Syndrome Obstructive Sleep Apnea Degenerative Joint Disease

16. Roux-en-Y Gastric Bypass

17. Interventions Based on Risk and BMI BMI > 25 with obesity- associated condition(s) Diet, exercise and behavioral modification BMI > 30 or BMI > 27 with obesity- associated condition(s) Diet, exercise and behavioral modification Consider drug therapy * (insufficient evidence to recommend for degenerative joint disease) BMI > 40 or BMI > 35 with obesity- associated condition(s) Diet, exercise and behavioral modification Consider drug therapy* Consider surgery * *.

18. Behavioral Modification Diet Exercise Medication Surgery