The Evidence Report - National Institutes of Health

1 CLINICALGUIDELINESONTHEIDENTIFICATION,EV ALUATION, ANDTREATMENTOFOVERWEIGHTANDOBESITYINADUL TSThe Evidence ReportNATIONAL Institutes OF HEALTHNATIONAL HEART, LUNG, AND BLOOD INSTITUTEO besity Education InitiativeCLINICALGUIDELINESON THEIDENTIFICATION,EVALUATION, ANDTREATMENT OFOVERWEIGHT ANDOBESITY INADULTSThe Evidence ReportNIH PUBLICATIONNO. 98-4083 SEPTEMBER1998 NATIONALINSTITUTESOFHEALTHN ational Heart, Lung, and Blood institute in cooperation with The National institute ofDiabetes and Digestive andKidney DiseasesiiNHLBI Obesity Education Initiative Expert Panel on the Identification,Evaluation, and Treatment of Overweight and Obesity in AdultsF. Xavier Pi-Sunyer, , Chair of the PanelChief, Endocrinology, Diabetes, and Nutrition Director, Obesity Research CenterSt. Luke's/Roosevelt Hospital CenterProfessor of MedicineColumbia University College of Physicians and SurgeonsNew York, NY Diane M.

2 Becker, , for Health PromotionAssociate ProfessorDepartment of MedicineThe Johns Hopkins UniversityBaltimore, MDClaude Bouchard, of Exercise PhysiologyPhysical Activity SciencesLaboratoryLaval UniversitySainte Foy, QuebecCANADAR ichard A. Carleton, of MedicineBrown University School of MedicinePawtucket, RI Graham A. Colditz, , Professor of MedicineHarvard Medical School Channing LaboratoryBoston, MA William H. Dietz, , of Nutrition and Physical ActivityNational Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and PreventionAtlanta, GA John P. Foreyt, of Medicine and Director Nutrition Research ClinicBaylor College of MedicineHouston, TX Robert J. Garrison, ProfessorDepartment of Preventive MedicineUniversity of Tennessee, MemphisMemphis, TN Scott M. Grundy, , for Human NutritionUniversity of TexasSouthwestern Medical Center at DallasDallas, TX Barbara C.

3 Hansen, of PhysiologyDirector of Obesity and Diabetes Research CenterUniversity of Maryland School of MedicineBaltimore, MD Millicent Higgins, of EpidemiologySchool of Public HealthUniversity of MichiganAnn Arbor, MI iiiJames O. Hill, Director of ResearchCenter for Human NutritionUniversity of Colorado Health Sciences CenterDenver, CO Barbara V. Howard, Research InstituteWashington, DC Robert C. Klesges, of Memphis Prevention CenterUniversity of MemphisMemphis, TNRobert J. Kuczmarski, , AnalystNational Center for Health StatisticsCenters for Disease Control and PreventionHyattsville, MD Shiriki Kumanyika, , , and HeadDepartment of Human Nutrition and Dietetics The University of Illinois at ChicagoChicago, ILR. Dee Legako, Care Canyon Park Family Physicians, , OK T. Elaine Prewitt, , ProfessorDepartment of Preventive Medicine and EpidemiologyLoyola University Medical CenterMaywood, IL Albert P.

4 Rocchini, of CardiologyUniversity of Michigan Medical CenterAnn Arbor, MI Philip L. Smith, of MedicineDivision of Pulmonary and Critical Care MedicineThe Johns Hopkins Asthma and Allergy CenterBaltimore, MD Linda G. Snetselaar, , ProfessorHead of Preventive Nutrition EducationDepartment of Preventive MedicineUniversity of IowaIowa City, IA James R. Sowers, of Medicine and PhysiologyDirectorDivision of Endocrinology, Metabolism, and HypertensionWayne State University School of MedicineUniversity Health CenterDetroit, MI Michael Weintraub, of Drug Evaluation VFood and Drug AdministrationRockville, MD David F. Williamson, , of Diabetes Translation Centers for Disease Control and PreventionChamblee, GA ivG. Terence Wilson, K. Buros Professor of PsychologyDirector, Rutgers Eating Disorders ClinicPiscataway, NJ Ex-Officio MembersClarice D. Brown, ManagerCODA Research, Spring, MD Karen A.

5 Donato, , *Executive Director of the PanelCoordinatorNHLBI Obesity Education InitiativeNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD Nancy Ernst, , *Nutrition CoordinatorOffice of the DirectorDivision of Epidemiology and Clinical ApplicationsNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD D. Robin Hill, *Social Science AnalystBehavioral Medicine BranchDivision of Epidemiology and Clinical ApplicationsNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD Michael J. Horan, , *DirectorDivision of Heart and Vascular DiseasesNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD Van S. Hubbard, , , NIH Division of Nutrition Research CoordinationChief, Nutritional Sciences BranchNational institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesda, MD James P.

6 Kiley, *DirectorAirway Biology and Disease ProgramDivision of Lung DiseasesNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD Eva Obarzanek, , , *Research NutritionistPrevention Scientific Research GroupDivision of Epidemiology and Clinical ApplicationsNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, MD ConsultantDavid Schriger, , , ProfessorUCLA Emergency Medicine CenterUniversity of California at Los AngelesSchool of MedicineLos Angeles, CA San Antonio Cochrane CenterElaine Chiquette, Cochrane Center at San AntonioAudie L. Murphy Memorial Veterans HospitalSan Antonio, TX * NHLBI Obesity Education Initiative Task Force MembersvCynthia Mulrow, , Cochrane Center at San AntonioAudie L. Murphy Memorial Veterans HospitalSan Antonio, TX StaffAdrienne Blount, Sciences, , MD Maureen Harris, , Sciences, , MD Anna Hodgson, Sciences, , MD Pat Moriarty, , Sciences, , MD The panel acknowledges the assistance of Chotani, Johns Hopkins University; Klesges, University of Memphis; Pories, East Carolina University; Dr.

7 IvanBaines, NHLBI; Dr. Christine Kelly, NHLBI;Glen Bennett, NHLBI; Dr. Fred Heydrick,BioReview; Debbie Lurie, Prospect Associates;Estelle Schwalb, Prospect Associates; LoriMcCray, Sciences, Inc.; and Niyati Pandya, Sciences, Summaryxi1. Introduction1A. Rationale for Guidelines Development1B. Objectives of the Guidelines2C. Guideline Development Methodology2D. Statement of Assumptions5E. Intended Users of These Guidelines52. Overweight and Obesity: Background6A. Health and Economic Costs61. Prevalence and Time Trends62. Demographic Variations in Overweight and Obesity Prevalence93. Economic Costs of Overweight and Obesity9B. Prevention of Overweight and Obesity11C. Health Risks of Overweight and Obesity121. Morbidity122. Overweight/Obesity and Morbidityin Minority Populations233. Obesity and Mortality23D. Weight Loss and Mortality25E. Environment26F. Genetic Influence in the Developmentof Overweight and Obesity273 Examination of Randomized ControlledTrial Evidence29A.

8 Why Treat Overweight and Obesity?291. Blood Pressure292. Serum/Plasma Lipids and Lipoproteins333. Impaired Glucose Toleranceand Diabetes394. Decreases in Abdominal Fat withWeight Loss41B. What Treatments are Effective?421. Dietary Therapy422. Physical Activity443. Combined Therapy474. Behavior Therapy485. Pharmacotherapy536. Surgery547. Other Interventions for Overweightand Obesity Treatment554. Treatment Guidelines56A. Overview56B. Assessment and Classification ofOverweight and Obesity561. Assessment of Overweight and Obesity562. Classification of Overweight andObesity58C. Assessment of Risk Status62D. Evaluation and Treatment Strategy65E. Exclusion from Weight Loss Therapy70F. Patient Motivation70G. Goals of Weight Loss and Management711. Weight Loss712. Weight Maintenance at Lower Weight723. Prevention of Further Weight Gain73H. Strategies for Weight Loss andWeight Maintenance731.

9 Dietary Therapy732. Physical Activity773. Behavior Therapy814. Combined Therapy835. Pharmacotherapy836. Surgery 86I. Smoking Cessation in the Overweight or Obese Patient91J. Role of Health Professionals inWeight Loss Therapy925. Summary of Recommendations956. Future Research98A. Intervention Approaches98B. Causes and Mechanisms ofOverweight and Obesity99C. Abdominal Fat, Body Weight andDisease Risk99D. Assessment Methods997. Appendices100 Appendix Guidelines Development Methodology100 Appendix Literature Review109 Appendix II Description of Evidence112 Appendix III Special Populations117 Appendix IV Obesity and Sleep Apnea137 Appendix V Body Mass Index Chart How to Measure Obesity139 Appendix VI Practical Dietary TherapyInformation141 Appendix VII Resource List165 Appendix VIII Glossary of Terms168 List of Abbreviations179 Reference List181 Publication List226viiFOREWORDIn 1995, the National Obesity EducationInitiative of the National Heart, Lung, andBlood institute (NHLBI), in cooperation withthe National institute of Diabetes and Digestiveand Kidney Diseases (NIDDK)

10 , convened thefirst Expert Panel on the Identification,Evaluation, and Treatment of Overweight andObesity in Adults to develop clinical practiceguidelines for primary care impetus for these guidelines was the recog-nition that the prevalence of overweight andobesity in the United States is increasing, andthat practitioners need to be alerted to theaccompanying Health risks. According to the lat-est statistics from the third National Health andNutrition Examination Survey, 97 millionAmericans are overweight or obese. Excessweight is often accompanied by high blood pres-sure, high blood cholesterol, type 2 diabetes,coronary heart disease, and other Health prob-lems. The total costs attributable to obesity-relat-ed disease approach $100 billion annually in theUnited States. The panel used the principles of Evidence -basedmedicine, including an Evidence model and evi-dence categories.