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BMI 18.5-24.9 (normal wt)
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BMI 25-29.9 w/o ↑ CVD risk (HTN, dyslipidemia, DM/prediabetes, ↑ waist circ) or other obesity-related comorbidity (eg, sleep apnea)
Overweight w/o indication for wt ↓, per risk assessment1 - Advise to avoid weight gain2
- Self-measure wt frequently, self-adjust diet if wt ↑ > a few lbs
- Engage in physical activity
- Calculate BMI ≥1x/yr [E/C], measure waist circ3 ≥1x/yr [E/B]
Footnotes 1 Risk assessment for CVD, diabetes includes: hx, exam/BP, lab (including FBG, fasting lipid panel).
2 ↑ BMI assoc w/ ↑ risk of CVD/Type 2 DM/all-cause mortality [S/B].
3 Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in).
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BMI 25-29.9 with ↑ CVD risk (HTN, dyslipidemia, DM/prediabetes, ↑ waist circ) or other obesity-related comorbidity (eg, sleep apnea)
Not ready for lifestyle change Overweight. Identify barriers, address CVD risk factors1 and obesity-related comorbidities - Advise to avoid weight gain2
- Address/treat CVD risk factors3 (HTN/dyslipidemia/DM/prediabetes) and other obesity-related comorbidities (eg, sleep apnea)
- Calculate BMI ≥1x/yr [E/C], measure waist circ4 ≥1x/yr [E/B]
Footnotes 1 Risk assessment for CVD, diabetes includes: hx, exam/BP, lab (including FBG, fasting lipid panel). Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in).
2 ↑ BMI assoc w/ ↑ risk of CVD/Type 2 DM/all-cause mortality [S/B].
3 If CV risks (↑ BP, hyperlipidemia, hyperglycemia): counsel that lifestyle changes producing even modest, sustained wt ↓ of 3-5% produce clinically meaningful health benefits [S/A]. Sustained 3-5% wt ↓ is likely to meaningfully reduce TGs, BG, HbA1C, and Type 2 DM risk. Greater wt ↓ will ↓ BP, improve cholesterol, ↓ need for meds to control BP, glucose, and lipids, and further ↓ TGs, BG. [S/A]
4 Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in).
Ready for lifestyle change Overweight. Initial goal: 5-10% wt ↓ in 6 mo via lifestyle intervention (+/- adjunctive tx). Manage comorbidities, address/treat CVD risk factors1 (HTN/dyslipidemia/DM/prediabetes) & other obesity-related comorbidities (eg, sleep apnea) Diet based on pt preference, health status; nutrition professional preferred: [S/A] - Daily calorie limit:2 women: 1,200–1,500 kcal/day, men: 1,500–1,800 kcal/day
- Daily energy deficit: Remove 500 or 750 kcal/day via diet/exercise/both
- Food type (evidence-based): Restrict foods such as high-carb, low-fiber, or high-fat foods
Plus comprehensive lifestyle intervention [S/A]:3 high-intensity, on-site4 ≥14 sessions/6 mo (group/individual) on diet/activity/behavior by trained interventionist Consider drugs:5 If BMI ≥27 w/ ≥1 obesity-associated comorbidity, motivated to ↓ wt [E], individualize risk/benefit of optional FDA-approved obesity-drug adjunct to comprehensive lifestyle intervention Assess progress:6 ≥5% wt ↓, health goals; if goals not met, consider options.7 Follow w/ maintenance program.8 Footnotes 1 Risk assessment for CVD, diabetes includes: hx, exam/BP, lab (including FBG, fasting lipid panel). Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in). If CV risks (↑ BP, hyperlipidemia, hyperglycemia): counsel that lifestyle changes producing even modest, sustained wt ↓ of 3-5% produce clinically meaningful health benefits [S/A].
2 Adjust calorie restriction to current weight. Very low-cal diet (<800 kcal/day) used only in limited circumstances by trained practitioners in medical setting w/ medical monitoring/supervision and high-intensity lifestyle intervention [S/A].
3 Commercial programs can be prescribed, if peer-reviewed evidence of safety/efficacy [M/A].
4 Electronically delivered w/ personalized feedback from trained interventionist may result in smaller wt loss than face-to-face [M/A].
5 [Recommendations on specific drugs were not included in guideline.] If pt has not lost ≥5% initial weight after 12 wks on max-dose obesity drug, reassess risk/benefit, consider d/c.
6 Progress: If ≥5% wt ↓ w/ sufficient health improvements: maintenance program x ≥1 yr [S/A]. If <5% wt ↓ and/or insufficient health improvements: intensive behavioral tx, reassess medical/contributing factors, add/re-eval obesity-drug tx, consider referral to experienced bariatric surgeon; consider options. Calculate BMI ≥1x/yr [E/C], measure waist circ ≥1x/yr [E/B].
7 Options: More intensive behavioral tx, alternate diet including options for meal replacement, referral to a nutrition professional, adjunctive obesity drug, refer for bariatric surgery eval if otherwise appropriate. If BMI <35, insufficient evidence to recommend for/against bariatric surgery [N].
8 Maintenance: Face-to-face/phone w/ regular contact (≥ monthly) w/ trained interventionist on physical activity (200-300 min/wk), wt monitoring (≥ weekly) and diet [S/A].
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Not ready for lifestyle change Obese. Identify barriers, address CVD risk factors1 and obesity-related comorbidities - Advise to avoid weight gain2
- Address/treat CVD risk factors3 (HTN/dyslipidemia/DM/prediabetes) and other obesity-related comorbidities (eg, sleep apnea)
- Calculate BMI ≥1x/yr [E/C], measure waist circ4 ≥1x/yr [E/B]
Footnotes 1 Risk assessment for CVD, diabetes includes: hx, exam/BP, lab (including FBG, fasting lipid panel). Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in). If BMI >35, not necessary to measure waist circ.
2 ↑ BMI assoc w/ ↑ risk of CVD/Type 2 DM/all-cause mortality [S/B].
3 If CV risks (↑ BP, hyperlipidemia, hyperglycemia): counsel that lifestyle changes producing even modest, sustained wt ↓ of 3-5% produce clinically meaningful health benefits [S/A]. Sustained 3-5% wt ↓ is likely to meaningfully reduce TGs, BG, HbA1C, and Type 2 DM risk. Greater wt ↓ will ↓ BP, improve cholesterol, ↓ need for meds to control BP, glucose, and lipids, and further ↓ TGs, BG [S/A].
4 Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in).
Ready for lifestyle change Obese. Initial goal: 5-10% wt ↓ in 6 mo via lifestyle intervention (+/- adjunctive tx). Manage comorbidities, address/treat CVD risk factors1 (HTN/dyslipidemia/DM/prediabetes) & other obesity-related comorbidities (eg, sleep apnea) Diet based on pt preference, health status; nutrition professional preferred [S/A]: - Daily calorie limit:2women: 1,200–1,500 kcal/day, men: 1,500–1,800 kcal/day
- Daily energy deficit: Remove 500 or 750 kcal/day via diet/exercise/both
- Food type (evidence-based): Restrict foods such as high-carb, low-fiber, or high-fat foods
Plus comprehensive lifestyle intervention [S/A]:3 high-intensity, on-site4 ≥14 sessions/6 mo (group/individual) on diet/activity/behavior by trained interventionist Consider adjuncts to comprehensive lifestyle intervention, if motivated to ↓ wt: - Drug:5 Consider individualized risk/benefit of optional FDA-approved obesity-drug adjunct to comprehensive lifestyle intervention [E]
- If BMI ≥40 (or ≥35 w/ obesity-associated comorbidity): offer referral to experienced bariatric surgeon for eval/consult6 for pts not sufficiently responsive to behavioral tx w/ or w/o obesity-drug tx [S/A]
Assess progress:7 ≥5% wt ↓, health goals; if goals not met, consider options.8 Follow w/ maintenance program.9 Footnotes 1 Risk assessment for CVD, diabetes includes: hx, exam/BP, lab (including FBG, fasting lipid panel). Waist circ cutpoints indicate ↑ cardiometabolic risk [E]: women: >88 cm (>35 in); men: >102 cm (>40 in). If BMI >35, not necessary to measure waist circ. If CV risks (↑ BP, hyperlipidemia, hyperglycemia): counsel that lifestyle changes producing even modest, sustained wt ↓ of 3-5% produce clinically meaningful health benefits [S/A].
2 Adjust calorie restriction to current weight. Very low-cal diet (<800 kcal/day) used only in limited circumstances by trained practitioners in medical setting w/ medical monitoring/supervision and high-intensity lifestyle intervention [S/A].
3 Commercial programs can be prescribed, if peer-reviewed evidence of safety/efficacy [M/A].
4 Electronically delivered w/ personalized feedback from trained interventionist may result in smaller wt loss than face-to-face [M/A].
5 [Recommendations on specific drugs were not included in guideline.] If pt has not lost ≥5% initial weight after 12 wks on max-dose obesity drug, reassess risk/benefit, consider d/c.
6 Bariatric surgery: Procedure choice affected by pt factors (age, obesity severity/BMI, obesity-related comorbidities, other operative risk factors, short-/long-term complication risks, behavior/psychosocial factors, pt risk tolerance, provider factors (surgeon, facility), etc) [E/C]. Benefits of bariatric surgery: Greater weight loss/maintenance of lost weight, favorable impact on obesity-related comorbid conditions (↓ fasting glucose/insulin, ↓ T2DM incidence, ↑ T2DM remission, ↓ BP/use of BP meds, ↓ TGs, ↑ HDL-C, ↓ total:HDL-C ratio), improved health-related QOL, ↓ total mortality. Complications of bariatric surgery vary by procedure and pt-derived risk factors and may include: DVT/PE, need for reoperation, wound infxn, hemorrhage, anemia, iron/zinc/protein/vit D deficiency, neuropathy, ↑ PTH.
7 Progress: If ≥5% wt ↓ w/ sufficient health improvements: maintenance program x ≥1 yr [S/A]. If <5% wt ↓ and/or insufficient health improvements: intensive behavioral tx, reassess medical/contributing factors, add/re-eval obesity-drug tx, consider referral to experienced bariatric surgeon; consider options. Calculate BMI ≥1x/yr [E/C], measure waist circ ≥1x/yr [E/B].
8 Options: More intensive behavioral tx, alternate diet including options for meal replacement, referral to a nutrition professional, adjunctive obesity drug, refer for bariatric surgery eval if otherwise appropriate. If BMI <35, insufficient evidence to recommend for/against bariatric surgery [N].
9 Maintenance: Face-to-face/phone w/ regular contact (≥ monthly) w/ trained interventionist on physical activity (200-300 min/wk), wt monitoring (≥ weekly) and diet [S/A].
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