The Practical Guide

1 NATIONAL INSTITUTES OF HEALTHNATIONAL HEART, LUNG, AND BLOOD INSTITUTENATIONAL INSTITUTES OF HEALTHNATIONAL HEART, LUNG, AND BLOOD INSTITUTENORTH AMERICAN ASSOCIATION FOR THE STUDY OF OBESITYThe PracticalGuide Identification,Evaluation, and Treatment of Overweight andObesity in AdultsNHLBI Obesity Education Initiative ACKNOWLEDGMENTS:The Working Group wishes to acknowledgethe additional input to the Practical Guide fromthe following individuals: Dr. Thomas Wadden,University of Pennsylvania; Dr. Walter Pories,East Carolina University; Dr. Steven Blair,Cooper Institute for Aerobics Research; andDr. Van S. Hubbard, National Institute ofDiabetes and Digestive and Kidney PracticalGuide Identification,Evaluation, and Treatment of Overweight andObesity in AdultsNational Institutes of HealthNational Heart, Lung, and Blood InstituteNIH Publication Number 00-4084 October 2000 NHLBI Obesity Education InitiativeNorth American Association for the Study of ObesityNHLBI Obesity Education InitiativeExpert Panel on the Identification,Evaluation, and Treatment ofOverweight and Obesity in Pi-Sunyer, , Columbia University College of Physicians and Surgeons Chair of the PanelMEMBERSD iane M.

2 Becker, , The Johns Hopkins UniversityClaude Bouchard, UniversityRichard A. Carleton, University School of MedicineGraham A. Colditz, , Medical SchoolWilliam H. Dietz, , Center for Chronic DiseasePrevention and Health Promotion Centers for Disease Control and PreventionJohn P. Foreyt, College of MedicineRobert J. Garrison, of Tennessee, MemphisScott M. Grundy, , of Texas Southwestern Medical Center at DallasBarbara C. Hansen, University of Maryland School of MedicineMillicent Higgins, of MichiganJames O. Hill, of Colorado Health Sciences CenterBarbara V. Howard, Research InstituteRobert J. Kuczmarski, , Center for Health StatisticsCenters for Disease Control and PreventionShiriki Kumanyika, , , University of PennsylvaniaR.

3 Dee Legako, Care Canyon Park Family Physicians, Elaine Prewitt, , University Medical CenterAlbert P. Rocchini, University of Michigan Medical CenterPhilip L Smith, Johns Hopkins Asthma and Allergy CenterLinda G. Snetselaar, , University of IowaJames R. Sowers, State University School of MedicineUniversity Health CenterMichael Weintraub, and Drug AdministrationDavid F. Williamson, , Centers for Disease Control and PreventionG. Terence Wilson, Eating Disorders ClinicEX-OFFICIO MEMBERSC larice D. Brown, Research A. Donato, , *Executive Director of the PanelCoordinator, NHLBI Obesity Education InitiativeNational Heart, Lung, and Blood InstituteNational Institutes of HealthNancy Ernst, , *National Heart, Lung, and Blood InstituteNational Institutes of HealthD.

4 Robin Hill, *National Heart, Lung, and Blood InstituteNational Institutes of HealthMichael J. Horan, , *National Heart, Lung, and Blood InstituteNational Institutes of HealthVan S. Hubbard, , Institute of Diabetes and Digestive and Kidney DiseasesJames P. Kiley, *National Heart, Lung, and Blood InstituteNational Institutes of HealthEva Obarzanek, , , * National Heart, Lung, and Blood InstituteNational Institutes of Health*NHLBI Obesity Initiative Task Force MemberCONSULTANTD avid Schriger, , , of California Los Angeles School of MedicineSAN ANTONIO COCHRANE CENTERE laine Chiquette, Mulrow, , Cochrane Center at San AntonioAudie L. Murphy MemorialVeterans HospitalSTAFF Adrienne Blount, Maureen Harris, , ,Anna Hodgson, , Pat Moriarty, , , Sciences, American Association for the Study of Obesity Practical GuideDevelopment CommitteeLouis J.

5 Aronne, , University, ChairMEMBERSC harles Billington, of MinnesotaGeorge Blackburn, , UniversityKaren A. Donato, , R. Obesity Education Initiative National Heart, Lung, and Blood Institute National Institutes of HealthArthur Frank, Washington UniversitySusan Fried, UniversityPatrick Mahlen O'Neil, University of South CarolinaHenry Buchwald, of MinnesotaGeorge Cowan, of Tennessee College of MedicineRobert Brolin, Wood Johnson Medical SchoolEX-OFFICIO MEMBERSJ ames O. Hill, of Colorado Health Sciences CenterEdward Bernstein, American Association for the Study of ObesityiiiForeword ..vHow To Use This Guide ..viExecutive Summary ..1 Assessment ..1 Body Mass Circumference ..1 Risk Factors or Comorbidities.

6 1 Readiness To Lose Loss ..2 Prevention of Weight Gain .. Activity ..3 Behavior Therapy ..3 Pharmacotherapy ..3 Weight Loss Situations .. Problem of Overweight and Obesity ..5 Treatment guidelines ..7 Assessment and Classification of Overweight and Obesity ..8 Assessment of Risk Status ..11 Evaluation and Treatment Strategy ..15 Ready or Not: Predicting Weight Loss ..21 Management of Overweight and Obesity ..23 Weight Management Techniques ..25 Dietary Therapy ..26 Physical Therapy ..30 Making the Most of the Patient ..35 Weight Loss Surgery ..38 Weight Reduction After Age 65 ..41 References ..42 Table of ContentsivIntroduction to the Appendices ..45 Appendix A. Body Mass Index B. Shopping What to Look For ..47 Appendix C.

7 Low Calorie, Lower Fat Alternatives ..49 Appendix D. Sample Reduced Calorie E. Food Exchange F. Food Preparation What to Do ..59 Appendix G. Dining Out How To H. Guide to Physical Activity ..62 Appendix I. Guide to Behavior Change ..68 Appendix J. Weight and Goal Record ..71 Appendix K. Weekly Food and Activity L. Additional of TablesTable for BMI ..1 Table of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Guide to Selecting Step I Diet ..27 Table of Moderate Amounts of Physical Activity ..29 Table Loss Drugs ..36 List of FiguresFigure Prevalence of Overweight (BMI 25 ) and Obesity (BMI 30) ..6 Figure III Age-Adjusted Prevalence of High Blood Pressure (HBP), High Total Blood Cholesterol (TBC), and Low-HDL by Two BMI Categories.

8 6 Figure Position for Waist (Abdominal) Circumference in Adults ..9 Figure Algorithm ..16 Figure Procedures in Current June 1998, the Clinical guidelines on theIdentification, Evaluation, and Treatment ofOverweight and Obesity in Adults: EvidenceReportwas released by the National Heart, Lung,and Blood Institute s (NHLBI) Obesity EducationInitiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases(NIDDK). The impetus behind the clinical practiceguidelines was the increasing prevalence of over-weight and obesity in the United States and the needto alert practitioners to accompanying health risks. The Expert Panel that developed the guidelines consisted of 24 experts, 8 ex-officio members, and aconsultant methodologist representing the fields ofprimary care, clinical nutrition, exercise physiology,psychology, physiology, and pulmonary disease.

9 The guidelines were endorsed by representatives of the Coordinating Committees of the NationalCholesterol Education Program and the National High Blood Pressure Education Program, the NorthAmerican Association for the Study of Obesity, andthe NIDDK National Task Force on the Preventionand Treatment of Practical Guide to the Identification, Evaluation,and Treatment of Overweight and Obesity in Adults islargely based on the evidence report prepared by theExpert Panel and describes how health care practition-ers can provide their patients with the direction andsupport needed to effectively lose weight and keep itoff. It provides the basic tools needed to appropriatelyassess and manage overweight and obesity. The Guide includes Practical information on dietarytherapy, physical activity, and behavior therapy, whilealso providing guidance on the appropriate use ofpharmacotherapy and surgery as treatment options.

10 The Guide was prepared by a working group con-vened by the North American Association for theStudy of Obesity and the National Heart, Lung, andBlood Institute. Three members of the AmericanSociety for Bariatric Surgery also participated in the working group. Members of the Expert Panel,especially the Panel Chairman, assisted in the reviewand development of the final product. Special thanksare also due to the 50 representatives of the variousdisciplines in primary care and others who reviewedthe preprint of the document and provided the working group with excellent Practical Guide will be distributed to primarycare physicians, nurses, registered dietitians, andnutritionists as well as to other interested health carepractitioners.