A Strategies to increase physical activity

Many people live sedentary lives, have little training or skills in physical activity, and are difficult to motivate toward increasing their activity. For these reasons, starting a physical activity regimen may require supervision for some people. The need to avoid injury during physical activity is high. Extremely obese persons may need to start with simple exercises that can gradually be intensified. The practitioner must decide whether exercise testing for cardiopulmonary disease is needed...

Intervention Approaches

Considerable research is needed on intervention approaches to treat and prevent obesity. Increased research on behavioral theory specifically addressing obesity treatment and prevention for all individuals, including children and adolescents, needs to be conducted. Intervention methods to prevent weight gain with smoking cessation are of particularly high priority in helping achieve smoking cessation. More research is needed on behavioral intervention methods conducted in various settings,...

Abdominal Fat Body Weight and Disease Risk

The influence of abdominal fat independent of total body fat on health risk needs to be further defined. More information is needed on the relationship between differential body fat compartments and increased risk, the distribution of body fat compartments among various racial group populations, and the relationship between abdominal fat and disease risk in racial groups. Weight loss studies should include measurements of abdominal fat, as well as cardiorespira-tory fitness, to better assess...

Amount of Weight Loss

Randomized trials suggest that weight loss at the rate of 1 to 2 lb week (calorie deficit of 500 to 1,000 kcal day) commonly occurs for up to 6 months. Weight loss should be about 1 to 2 lb week for a period of 6 months, with the subsequent strategy based on the amount of weight lost. Evidence Category B. weight loss than lower-fat diets alone. Further, VLCDs produce greater initial weight losses than LCDs (over the long term of > 1 year, weight loss is not different than that of the LCDs)....

Obesity and Sleep Apnea

Obstructive sleep apnea is defined as an absence of breathing during sleep. Currently, it is recognized that sleep apnea is part of a continuum from health to disease. 649, 650 Apnea is currently defined as cessation of airflow for at least 10 seconds and is characterized as either central (if no respiratory effort occurs), obstructive (if continued effort is noted), or mixed (if both central and obstructive components are present). 651-653 Apnea is associated with either a fall in...

Glossary of Terms

Abdominal fat Fat (adipose tissue) that is centrally distributed between the thorax and pelvis and that induces greater health risk. Absolute risk The observed or calculated probability of an event in a population under study, as contrasted with the relative risk. Aerobic exercise A type of physical activity that includes walking, jogging, running, and dancing. Aerobic training improves the efficiency of the aerobic energy-producing systems that can improve cardiorespiratory endurance....

Box 5 BMI 25 OR Waist Circumference 88 cmF or 102 cmM

These cutpoints divide overweight from normal weight and are consistent with other national and international guidelines. The relation between weight and mortality is J-shaped, and evidence suggests that the right side of the J begins to rise at a BMI of 25. Waist circumference is incorporated as an or factor because some patients with BMI lower than 25 will have disproportionate abdominal fat, and this increases their cardiovascular risk despite their low BMI (see page 61). These abdominal...

Assessment of Risk Status

The patient's risk status should be assessed by determining the degree of overweight or obesity based on BMI, the presence of abdominal obesity based on waist circumference, and the presence of concomitant CVD risk factors or comor-bidities. Some obesity-associated diseases and risk factors place patients in a very high risk category for subsequent mortality. These diseases will require aggressive modification of risk factors in addition to their own clinical management. Other...

B Comparison of Behavior Therapy Strategies

Another way to examine the efficacy of behavior therapy in the treatment of overweight and obesity is to evaluate studies that compare various behavioral techniques with one another. Of 31 RCTs that compared one or more behavioral interventions, 19 were deemed acceptable. Evidence Statement No one behavior therapy appeared superior to any other in its effect on weight loss rather, multimodal strategies appeared to work best and those interventions with the greatest intensity appeared to be...

B Topics Included in the Guidelines

The panel decided to focus on all adult (18 years of age and older) overweight and obese patients with a body mass index (BMI) > 25, and particularly those with cardiovascular risk factors. Excluded from the analysis were patients with known genetic or hormonal syndromes and pharmacologically induced obesity. In addition, since pediatric obesity contributes to about one-third of adult obesity, the panel felt that some attention needed to be focused on the issue of overweight in children and...

B Treatment of Obese Individuals with Binge Eating Disorder

If a patient suffers from binge eating disorder (BED), consideration can be given to referring the patient to a health professional who specializes in BED treatment. Behavioral approaches to BED associated with obesity have been derived from cognitive behavior therapy (CBT) used to treat bulimia nervosa. 227 Among the techniques are self-monitoring of eating patterns, encouraging regular patterns of eating (three meals a day plus planned snacks), cognitive restructuring, and relapse prevention...

Blood Pressure

To evaluate the effect of weight loss on blood pressure and hypertension, 76 articles reporting RCTs were considered for inclusion in these guidelines. Of the 45 accepted articles, 35 were lifestyle trials and 10 were pharmacotherapy trials. There is strong and consistent evidence from these lifestyle trials in both overweight hypertensive and nonhypertensive patients that weight loss produced by lifestyle modifications reduces blood pressure levels. Limited evidence exists that decreases in...

Serum Plasma Lipids and Lipoproteins

Sixty-five RCT articles were evaluated for the effect of weight loss on serum plasma concentrations of total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein cholesterol. In 52 of these trials weight loss was induced by various lifestyle modifications, including diet modification and increased physical activity. 356, 365, 367-370, 373, 380, 384, 399-406, 412, 431, 433, 434, 440, 446, 447, 469, 470, 473, 475,...

BMI Levels

Ative risks for CHD were twice as high at BMIs of 25 to 28.9, and more than three times as high at BMIs of 29 or greater, compared with BMIs of less than 21. 90 Weight gains of 5 to 8 kg (11 to 17.6 lb) increased CHD risk (nonfatal myocardial infarction and CHD death) by 25 percent, and weight gains of 20 kg (44 lb) or more increased risk more than 2.5 times in comparison with women whose weight was stable within a range of 5 kg (11 lb). 90 In British men, CHD incidence increased at BMIs above...

Box 4 Measure Weight Height Waist Circumference Calculate BMI

Weight must be measured so that the BMI can be calculated. Most charts are based on weights obtained with the patient wearing undergarments and no shoes. BMI can be manually calculated (kg height in meters 2), but is more easily obtained from a nomogram (see Appendix V). Waist circumference is important because evidence suggests that abdominal fat is a particularly strong determinant of cardiovascular risk in those with a BMI of 25 to 34.9 kg m2. Increased waist circumference can also be a...

C Abdominal

Evidence Statement Limited evidence suggests that decreases in abdominal fat correlate with improvements in the lipid profile of overweight individuals, although these improvements have not been shown to be independent of weight loss. Evidence Category C. Rationale Four RCTs testing the effects of weight loss on blood lipids also included measures of abdominal fat, as measured by waist circumference. 365-373-375- 399 In each study, waist circumference was reduced along with weight, and blood...

Clinical Guidelines

Treatment of the overweight or obese patient is a two-step process assessment and treatment management. Assessment requires determination of the degree of overweight and overall risk status. Management includes both reducing excess body weight and instituting other measures to control accompanying risk factors. Assessment When assessing a patient for risk status and as a candidate for weight loss therapy, consider the patient's BMI, waist circumference, and overall risk status. Consideration...

Clinical model search citations by topic area 11268 total

Cardiovascular disease 1,866 citations 616 citations 380 citations 917 citations Evidence Model Questions Population Model (Top) abdominal fat to high blood pressure in abdominal fat to dyslipidemia in minority abdominal fat to diabetes in minority abdominal fat to cardiovascular disease abdominal fat to noncardiovascular mortality abdominal fat to cardiovascular mortality and weight to high blood pressure in minority weight to diabetes in minority populations weight to noncardiovascular...

Combined Therapy Diet and Physical Activity

Twenty-three RCT articles investigated the effects on body weight of a combination of a reduced calorie diet with increased physical activity. The control groups used diet alone or physical activity alone. Of the 15 studies deemed acceptable, each of them compared the combined intervention with diet alone, 346, 365, 375, 377, 380, 384, 434, 435, 445, 448, 469-473 and 6 of them also compared the combined intervention to physical activity alone. 346 365 375 434 448 474 The studies varied in terms...

D Fitness

Evidence Statement Increased cardiorespiratory fitness improves glucose tolerance in overweight individuals, but no evidence shows this relationship to be independent of weight loss. Evidence Category C. Rationale Two RCTs that examined the effects of weight loss on glucose tolerance in older men 369 and in persons with diabetes 404 also had measures of VO2 max (oxygen consumption) as a measure of fitness. In both studies, physical activity resulted in a net weight loss of approximately 2.3 to...

Decreases in Abdominal Fat With Weight Loss

Evidence Statement Weight loss is associated with decreases in abdominal fat, as measured by waist circumference. Evidence Category A. Rationale Six acceptable RCTs on weight loss that measured waist circumferences all show that weight loss is associated with reductions in waist circumference. 365, 369, 373, 375, 384, 399 Waist circumference is commonly used as a surrogate measure for abdominal visceral fat. 420, 421 Although no RCTs examined changes in visceral fat per se, one observational...

DFitness

Evidence Statement Increased aerobic activity to increase cardiorespiratory fitness reduces blood pressure independent of weight loss. Evidence Category A. Rationale Seven RCTs testing the effects of weight loss on blood pressure in overweight and obese individuals also had measures of cardiores- piratory fitness, as measured by maximal oxygen uptake 346, 363, 369, 375, 377, 380 or submaximal heart rate tests. 365 Weight loss was accompanied by increased fitness, primarily if the intervention...

Environment

The environment is a major determinant of overweight and obesity. Environmental influences on overweight and obesity are primarily related to food intake and physical activity behaviors 71. In countries like the United States, there is an overall abundance of palatable, calorie-dense food. In addition, aggressive and sophisticated food marketing in the mass media, supermarkets, and restaurants, and the large portions of food served outside the home, promote high calorie consumption. Many of our...

Evaluation and Treatment Strategy

When physicians encounter patients in the clinical setting, the opportunity exists for identifying overweight and obesity and accompanying risk factors and for initiating treatment for both the weight and the risk factors, as well as chronic diseases such as CVD and type 2 diabetes. When assessing a patient for treatment of overweight and obesity, consider the patient's weight, waist circumference, and the presence of risk factors. The strategy for the evaluation and treatment of overweight...

Impaired Glucose Tolerance and Diabetes

Forty-nine articles of RCTs were reviewed to evaluate the effect of weight loss on fasting blood glucose and fasting insulin. Studies were conducted in individuals with normal blood glucose levels (fasting plasma glucose < 115 mg dL < 6.4 mmol L ), in individuals with impaired glucose tolerance (fasting plasma glucose of < 140 mg dL 7.8 mmol L or 2 hours postprandial plasma glucose of > 140 to < 200 mg dL 7.8-11.1 mmol L ), or in individuals with diabetes (fasting plasma glucose of...

LgGallstones

The risk of gallstones increases with adult weight. Risk of either gallstones or cholecystec-tomy is as high as 20 per 1,000 women per year when BMI is above 40, compared with 3 per 1,000 among women with BMI < 24. 14 According to NHANES III data, the prevalence of gallstone disease among women increased from 9.4 percent in the first quartile of BMI to 25.5 percent in the fourth quartile of BMI. Among men, the prevalence of gallstone disease increased from 4.6 percent in the first quartile of...

Serum Plasma Lipids

Sixty-five RCT articles were evaluated for the effect of weight loss on serum plasma concentrations of total cholesterol, LDL-cholesterol, very low-density lipoprotein (VLDL)-cholesterol, triglycerides, and HDL-cholesterol. Studies were conducted on individuals over a range of obesity and lipid levels. Of the 22 articles accepted for inclusion in these guidelines, 14 RCT articles examined lifestyle trials while the remaining 8 articles reviewed pharmacotherapy trials. There is strong evidence...

Surgery for Weight Loss

Surgery is one option for weight reduction for some patients with severe and resistant obesity. The aim of surgery is to modify the gastrointestinal tract to reduce net food intake. Most authorities agree that weight loss surgery should be reserved for patients with severe obesity, in whom efforts at other therapy have failed, and who are suffering from the complications of obesity. Considerable progress has been made in developing safer and more effective surgical procedures for promoting...

Weight Loss Surgery

Fourteen RCTs compared the weight-reducing effect of different surgical interventions. 515-522, 524 692, 706, 733 756, 757 One study compared the effectiveness of a very low-calorie diet to surgery. 515 Another study compared the effectiveness of horizontal-banded to vertical-banded gastroplas-ty in a pretreated, very low-calorie formula diet group. 516 Six studies compared two or more of the following procedures gastroplasty (vertical or horizontal), gastric bypass, and gastric partitioning....

Weight Maintenance at Lower Weight

Once the goals of weight loss have been successfully achieved, maintenance of a lower body weight becomes a major challenge. In the past, obtaining the goal of weight loss has been considered the end of weight loss therapy. Unfortunately, once patients are dismissed from clinical therapy, they frequently regain the lost weight. This report recommends that observation, monitoring, and encouragement of patients who have successfully lost weight be continued on a long-term basis. Evidence...

Prevention of Further Weight Gain

Some patients may not be able to achieve significant weight reduction. In such patients, an important goal is to prevent further weight gain that would exacerbate disease risk. Thus, prevention of further weight gain may justify entering a patient into weight loss therapy. Prevention of further weight gain can be considered a partial therapeutic success for many patients. Moreover, if further weight gain can be prevented, this achievement may be an important first step toward beginning the...

Box 12 Does the Patient Want to Lose Weight

All patients who are overweight (BMI 25 to 29.9), or do not have a high waist circumference, and have few (0 to 1) cardiovascular risk factors and do not want to lose weight, should be counseled regarding the need to keep their weight at or below its present level. Patients who wish to lose weight should be guided per Boxes 8 and 9. The justification for offering these overweight patients the option of maintaining (rather than losing) weight is that their health risk, while higher than that of...

Weight Gain During Pregnancy

Infant mortality rate. 181 However, data from the Pregnancy Nutrition Surveillance System from the CDC showed that very overweight women would benefit from a reduced weight gain during pregnancy to help reduce the risk for high-birth-weight infants. 181 The 1990 Institute of Medicine report made recommendations concerning maternal weight her BMI measured and recorded at the time of entry into prenatal care. For women with a BMI of less than 20, the target weight gain should be 0.5 kg (1.1 lb)...

Identification of other obesityassociated diseases

Obese patients are at increased risk for several conditions that require detection and appropriate management, but that generally do not lead to widespread or life-threatening consequences. These include 3.a. Gynecological abnormalities 3.b. Osteoarthritis 3.c. Gallstones and their complications 3.d. Stress incontinence Management options of risk factors for preventing CVD, diabetes mellitus, and other chronic diseases are described in detail in other reports. For details on the management of...

Causes and Mechanisms of Overweight and Obesity

The regulation of energy balance needs to be explored, including the neuroendocrine factors that control energy intake, energy expenditure, and the differentiation of adipose tissue resulting from excess calories. The genes that are important in human obesity need to be identified. These include those that alter eating and physical activity behaviors, those that affect thermoge-nesis, and those associated with the comorbidi-ties of obesity. The roles of environmental and behavioral influences...

AAssociation of Body Mass Index With Mortality

Many of the observational epidemiologic studies of BMI and mortality have reported a 'U-' or 'J-shaped' relationship between BMI and mortality. 28 Mortality rates are elevated in persons with low BMI (usually below 20) as well as in persons with high BMI. 28, 31 32 In some studies, adjustment for factors that potentially confound the relationship between BMI and mortality, such as smoking status and pre-existing illness, tends to reduce the upturn in mortality rate at low BMI ,31 but in a...

Smoking Cessation in the Overweight or Obese Patient

Cigarette smoking is a major risk factor for cardiopulmonary disease. Because of its attendant high risk, smoking cessation is a major goal of risk-factor management. This aim is especially important in the overweight or obese patient, who usually carries excess risk from obesity-associated risk factors. Thus, smoking cessation in such patients becomes a high priority for risk reduction. Evidence Statement Smoking and obesity together increase cardiovascular risk, but fear of weight gain upon...

High Blood Cholesterol

Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP II). Provides guidelines for detecting, evaluating, and treating high blood cholesterol in adult patients. Discusses classification of blood cholesterol, patient evaluation, and dietary and drug treatment. Includes helpful tools for the clinician including a dietary questionnaire, menus, and patient handouts. Cholesterol Lowering in the Patient with Coronary Heart Disease Physician...

Enhance your Patient Education with Nhlbi Materials

Obesity and Physical Activity Check Your Weight and Heart Disease I.Q. A true false quiz that helps the public determine what they know about weight and heart disease. Correct answers are explained on the back of the quiz sheet. Check Your Physical Activity and Heart Disease I.Q. Uncovers exercise myths and provides information on ways to improve heart health through physical activity. Exercise and Your Heart A Guide to Physical Activity. Provides your patients with information on the effects...

DCoronary Heart Disease

Observational studies have shown that overweight, obesity, and excess abdominal fat are directly related to cardiovascular risk factors, including high levels of total cholesterol, LDL-cholesterol, triglycerides, blood pressure, fibrino-gen and insulin, 86 and low levels of HDL-cho-lesterol. 42 Plasminogen activator inhibitor-1 causing impaired fibrinolytic activity is elevated in persons with abdominal obesity. 763 Overweight, obesity, and abdominal fat are also associated with increased...

Morbidity

Above a BMI of 20 kg m2, morbidity for a number of health conditions increases as BMI increases. Higher morbidity in association with overweight and obesity has been observed for hypertension, 2-6 76-80 type 2 diabetes, 7 8, 10 81 82, 84-89 coronary heart disease (CHD), 1142,86,8890 stroke, 11-13 gallbladder disease, 14,15 osteoarthritis, 16-18, 91-95 sleep apnea and respiratory problems 21, 96-98 and some types of cancer (endometrial, breast, prostate, and colon). 107-115 Obesity is also...

A1 Lifestyle Trials in Hypertensive Patients

Evidence Statement Weight loss produced by lifestyle modifications reduces blood pressure in overweight hypertensive patients. Evidence Category A. Rationale A 1987 meta-analysis 381 covering five of the acceptable studies 351, 352, 356-358 in hypertensive patients concluded that weight loss accomplished by dietary interventions significantly lowered blood pressure. In hypertensive patients, 10 kg (22 lb) of weight loss was associated with an average reduction of 7 mm Hg systolic and 3 mm Hg...

AHypertension

Data from NHANES III show that the age-adjusted prevalence of high blood pressure increases progressively with higher levels of BMI in men and women (Figure 2). 2 High blood pressure is defined as mean systolic blood pressure > 140 mm Hg, or mean diastolic blood pressure > 90 mm Hg, or currently taking anti-hypertensive medication. The prevalence of high blood pressure in adults with BMI > 30 is 38.4 percent for men and 32.2 percent for women, respectively, compared with 18.2 percent for...

Evidence Report Endorsements

NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) Coordinating Committee Member Organizations Theodore G. Ganiats, M.D., American Academy of Family Physicians, Gary Graham, M.D., American Academy of Insurance Medicine, Ronald Kleinman, M.D., American Academy of Pediatrics, Ann Smith, R.N., C.O.H.N.-S., American Association of Occupational Health Nurses, Richard C. Pasternak, M.D., F.A.C.C., American College of Cardiology, Gerald T. Gau, M.D., American College of Chest Physicians, Ruth Ann Jordan,...

Advantages of Weight Loss

The recommendation to treat overweight and obesity is based not only on evidence that relates obesity to increased mortality but also on RCT evidence that weight loss reduces risk factors for disease. Thus, weight loss may not only help control diseases worsened by obesity, it may also help decrease the likelihood of developing these diseases. The panel reviewed RCT evidence to determine the effect of weight loss on blood pressure and hypertension, serum plasma lipid concentrations, and fasting...

Sex Specific Measurements

Evidence from epidemiological studies indicates that a high waist circumference is associated with an increased risk for type 2 diabetes, dys-lipidemia, hypertension, and CVD. Therefore, the panel judged that sex-specific cutoffs for waist circumference can be used to identify increased risk associated with abdominal fat in adults with a BMI in the range of 25 to 34.9. These cutpoints can be applied to all adult ethnic or racial groups. On the other hand, if a patient is very short, or has a...

LhOsteoarthritis

Individuals who are overweight or obese increase their risk for the development of osteoarthritis. 16-18,91,92 The association between increased weight and the risk for development of knee osteoarthritis is stronger in women than in men. 92 In a study of twin middle-aged women, it was estimated that for every kilogram increase of weight, the risk of developing osteoarthritis increases by 9 to 13 percent. The twins with knee osteoarthritis were generally 3 to 5 kg (6.6 to 11 lb) heavier than the...

BMI To Assess Overweight and Obesity

There are a number of accurate methods to assess body fat (e.g., total body water, total body potassium, bioelectrical impedance, and dual-energy X-ray absorptiometry), but no trial data exist to indicate that one measure of fatness is better than any other for following overweight and obese patients during treatment. Since measuring body fat by these techniques is often expensive and is not readily available, a more practical approach for the clinical setting is the measurement of BMI...

Measurement of Degree of Overweight and Obesity

Patients should have their BMI and levels of abdominal fat measured not only for the initial assessment of the degree of overweight and obesity, but also as a guide to the efficacy of weight loss treatment. Although there are no RCTs that review measurements of overweight and obesity, the panel determined that this aspect of patient care warranted further consideration and that this guidance was deemed valuable. Therefore, the following four recommendations that are included in the Treatment...

Demographic Variations in Overweight and Obesity Prevalence

Although NHANES III data show that the prevalence of overweight and obesity is much higher in African-American and Mexican-American women than in white women or in men, these data provide ethnicity-specific estimates of overweight and obesity prevalence for only three racial-ethnic groups non-Hispanic whites, non-Hispanic blacks, and Mexican-Americans. Examination survey data indicating a high overweight and obesity prevalence in other ethnic groups (e.g., for Puerto Ricans and Cuban-Americans)...

Economic Costs of Overweight and Obesity

Alarm about the increasing prevalence of overweight and obesity in the United States in recent years 54, 55 centers on the link between obesity and increased health risks, 42, 56 which translates into increased medical care and disability costs. 46,57 The total cost attributable to obesity amounted to 99.2 billion in 1995. Approximately 51.6 billion of these dollars were direct medical costs associated with diseases attributable to obesity. The direct costs also associated with obesity...

Prevention of Overweight and Obesity

Prevention of overweight and obesity is as important as treatment. Prevention includes primary prevention of overweight or obesity itself, secondary prevention or avoidance of weight regain following weight loss, and prevention of further weight increases in obese individuals unable to lose weight. 44 64 National and international observational data suggest that environmental and behavioral factors are likely to be important in the tendency of individuals within and between populations to be...

KObesity and Womens Reproductive Health

Menstrual Function and Fertility Obesity in premenopausal women is associated with menstrual irregularity and amenorrhea. 112,116 As part of the Nurses' Health Study, a case control study suggested that the greater the BMI at age 18 years, even at levels lower than those considered obese, the greater the risk of subsequent ovulatory infertility. 117 The most prominent condition associated with abdominal obesity is polycystic ovarian syndrome, 118 a combination of infertility, menstrual...

L Psychosocial Aspects of Overweight and Obesity

A number of reviews have been published on the psychosocial aspects of obesity. 124-128 183 The specific topics that will be reviewed here include social stigmatization, psychopathology, binge eating, and body image perceptions. In American and other Westernized societies there are powerful messages that people, espe cially women, should be thin, and that to be fat is a sign of poor self-control. 125, 126, 128, 184, 185 Negative attitudes about the obese have been reported in children and...

Overweight Obesity and Morbidity in Minority Populations

The data on overweight and obesity in minority populations include men and women across a wide age range and geographic area. Relevant studies increasingly consist of well-designed, population-based surveys and longitudinal studies. These studies have standardized, objective measurements of overweight and obesity and risk factors or disease outcomes. There is now a wealth of evidence to demonstrate that overweight and obesity incidence (both generalized and abdominal) predisposes to chronic...

Obesity and Mortality

As stated in the introduction to the guidelines, in the majority of epidemiologic studies, mortality begins to increase with BMIs above 25 kg m2. 28-32 The increase in mortality generally tends to be modest until a BMI of 30 kg m2 is reached. 28, 29, 31 32 For persons with a BMI of 30 kg m2 or above, mortality rates from all causes, and especially from cardiovascular disease, are generally increased by 50 to 100 percent above that of persons with BMIs in the range of 20 to 25 kg m2. 28,31,32...

BAssociation of Body Mass Index With Mortality in Older Adults

Many of the observational epidemiologic studies suggest that the relationship between BMI and mortality weakens with increasing age, especially among persons aged 75 and above. 287- 290 Several factors have been proposed to explain this observation. Older adults are more likely than younger adults to have diseases that both increase mortality and cause weight loss leading to lower body weight. 291-293 In addition, as people age, they tend to have larger waist circumferences that increase their...

C Association of Body Mass Index With Mortality in Ethnic Minorities

The levels of BMI associated with increased mortality are based on epidemiological studies of primarily white populations. The interest in confirming the association between BMI and mortality in other racial ethnic groups stems partly from observations that lower-than-average total mortality has been observed among some populations with a high BMI level, 299 and partly from observations that within certain populations there appears to be no effect of obesity at all or at the BMI levels that are...

Genetic Influence in the Development of Overweight and Obesity

Obesity is a complex multifactorial chronic disease developing from interactive influences of numerous factors social, behavioral, physiological, metabolic, cellular, and molecular. Genetic influences are difficult to elucidate and identification of the genes is not easily achieved in familial or pedigree studies. Furthermore, whatever the influence the genotype has on the etiology of obesity, it is generally attenuated or exacerbated by nongenetic factors. A large number of twin, adoption, and...

Blood Glucose

To evaluate the effect of weight loss on fasting blood glucose and fasting insulin levels, 49 RCT articles were reviewed for inclusion in these guidelines. Of the 17 RCT articles accepted, 9 RCT articles examined lifestyle therapy trials and 8 RCT articles considered the effects of pharmacotherapy on weight loss and subsequent changes in blood glucose. There is strong evidence from the nine lifestyle therapy trials that weight loss produced by lifestyle modification reduces blood glucose levels...

Commentary Do the same treatment approaches for overweight and obesity fit diverse patient populations

Whether or not the same weight reduction program will accomplish equivalent weight change in ethnically diverse population groups can be questioned on theoretical grounds. Weight reduction programs address motivations and behaviors strongly influenced by sociocultural factors that vary with ethnicity. 257 496 497 Sociocultural factors may also influence the relative efficacy of behavioral programs in young, middle, and older adulthood men or women or any other patient groups where the...

Rationale for Guidelines Development

An estimated 97 million adults in the United States are overweight or obese, 1 a condition that substantially raises their risk of morbidity from hypertension, 2-6 type 2 diabetes, 7-10 stroke, 11-13 gallbladder disease, 14, 15 osteoarthritis, 16-18 sleep apnea and respiratory problems, 19-21 and endometrial, breast, prostate, and colon cancers. 22-24 As a major contributor to preventive death in the United States today, 25 overweight and obesity pose a major public health challenge. Not only...

C Development of the Evidence Model

The panel determined the evidence model used to develop the guidelines for the evaluation and treatment of obesity (Figure 7, and Figures 7a and 7b). The model contains two broad categories, the association of weight to cardiovascular and noncardiovascular mortality and morbidity in the population and the clinical issues related to the treatment of the overweight individual. The population portion of the model addresses such questions as, Is there an association between weight and...

BPharmacotherapy Trials

Evidence Statement Weight loss produced by weight loss medications and adjuvant lifestyle modifications produces no consistent change in blood lipids. Evidence Category B. Rationale The effects of pharmacological therapy on weight loss and subsequent changes in total serum cholesterol levels were evaluated by examining eight RCTs 386 390-393 395 407408 (Table III-3). The four trials of dexfenfluramine showed no consistent effects on total cholesterol three trials showed decreases in...

Identification of patients at very high absolute risk

The following disease conditions or target organ damage in hypertensive patients denote the presence of very high absolute risk that triggers the need for intense risk factor modification as well as disease management. For example, the presence of very high absolute risk indicates the need for aggressive cholesterol-lowering therapy. 142 2.a. Established coronary heart disease (CHD) 2.a.1. History of myocardial infarction 2.a.2. History of angina pectoris (stable or unstable) 2.a.3. History of...

Identification of cardiovascular risk factors that impart a high absolute risk

Patients can be classified as being at high absolute risk for obesity-related disorders if they have three or more of the multiple risk factors listed below. The presence of high absolute risk increases the intensity of cholesterol-lowering therapy 142 and blood pressure management. 545 4.b. Hypertension A patient is classified as having hypertension if systolic blood pressure is > 140 mm Hg or diastolic blood pressure is > 90 mm Hg, or if the patient is taking antihypertensive agents. 4.c....

Box 10 Assess Reasons for Failure to Lose Weight

If a patient fails to achieve the recommended 10 percent reduction in body weight in 6 months or 1 year, a reevaluation is required. A critical question is whether the level of motivation is high enough to continue clinical therapy. If motivation is high, revise the goals and strategies (see Box 8). If motivation is not high, clinical therapy should be discontinued, but the patient should be encouraged to embark on efforts to lose weight or to at least avoid further weight gain. Even if weight...

Hypercholesterolemia high blood cholesterol

Cholesterol is the most abundant steroid in animal tissues, especially in bile and gallstones. The relationship between the intake of cholesterol and its manufacture by the body to its utiliza tion, sequestration, or excretion from the body is called the cholesterol balance. When cholesterol accumulates, the balance is positive when it declines, the balance is negative. In 1993, the NHLBI National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High...

Box 8 Clinician and Patient Devise Goals

The decision to lose weight must be made jointly between the clinician and patient. Patient involvement and investment is crucial to success. The patient may choose not to lose weight but rather to prevent further weight gain as a goal. The panel recommends as an initial goal the loss of 10 percent of baseline weight, to be lost at a rate of 1 to 2 lb week, establishing an energy deficit of 500 to 1,000 kcal day. (See pages 71-72.) For individuals who are overweight, a deficit or 300 to 500...

A4 Annotated Bibliography of Studies Specifically Designed To Achieve Weight Reduction in Special Populations

The following annotations describe weight reduction studies in special populations or situations. From the total number of studies identified in which minorities or other special populations were included, the studies listed below are those for which the treatment or intervention program included design features specifically geared to the needs of a minority population or other special population of interest. Thus, these studies provide examples of ways in which researchers or service...

Percentage of Medicare Beneficiaries who are Overweight by Race Gender and Education 1991

* Overweight is defined as a BMI > 27.8 kg m2 for males and > 27.3 kg m2 for females. ** Based on samples of fewer than 30 persons. Source Medicare Current Beneficiary Survey 1991, Non-Institutionalized Persons only (N 9,721). 630 * Overweight is defined as a BMI > 27.8 kg m2 for males and > 27.3 kg m2 for females. ** Based on samples of fewer than 30 persons. Source Medicare Current Beneficiary Survey 1991, Non-Institutionalized Persons only (N 9,721). 630 Percentage of Medicare...

Very lowdensity lipoprotein VLDL

Lipoprotein particles that initially leave the liver, carrying cholesterol and lipid. VLDLs contain 10 to 15 percent of the total serum cholesterol along with most of the triglycerides in the fasting serum VLDLs are precursors of LDL, and some forms of VLDL, particularly VLDL remnants, appear to be atherogenic. Visceral fat One of the three compartments of abdominal fat. Retroperitoneal and subcutaneous are the other two compartments. VO2 max Maximal oxygen uptake is known as VO2 max and is the...

Strategies for Weight Loss and Weight Maintenance

Dietary Therapy A diet that is individually planned and takes into account the patient's overweight status in order to help create a deficit of 500 to 1,000 kcal day should be an integral part of any weight loss program. A patient may choose a diet of 1,000 to 1,200 kcal day for women and 1,200 to 1,500 kcal day for men. Depending on the patient's risk status, the low-calorie diet (LCD) recommended should be consistent with the NCEP's Step I or Step II Diet (see page 74 of the guidelines)....

Introduction

An estimated 97 million adults in the United States are overweight or obese, a condition that substantially raises their risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality. Obese individuals may also suffer from social stigmati-zation and...

Examples of Moderate Amounts of Activity

Washing and waxing a car for 45-60 minutes Washing windows or floors for 45-60 minutes Playing touch football for 30-45 minutes Wheeling self in wheelchair for 30-40 minutes Walking 1 miles in 35 minutes (20 min mile) Basketball (shooting baskets) for 30 minutes Dancing fast (social) for 30 minutes Pushing a stroller 1M miles in 30 minutes Walking 2 miles in 30 minutes (15 min mile) Wheelchair basketball for 20 minutes Basketball (playing a game) for 15-20 minutes Running 1M miles in 15 minutes...

Instructions for Measuring Waist Circumference According to Nhanes Iii Protocol

Nhanes Waist Circumference

To define the level at which waist circumference is measured, a bony landmark is first located and marked. The subject stands and the examiner, positioned at the right of the subject, palpates the upper hip bone to locate the right iliac crest. Just above the uppermost lateral border of the right iliac crest, a horizontal mark is drawn, then crossed with a vertical mark on the midaxillary line. The measuring tape is placed in a horizontal plane around the abdomen at the level of this marked...

Obesity and Physical Activity

Strategy Development Workshop for Public Education on Weight and Obesity--Summary Report. Summary of a 1992 workshop held to identify issues in educating the public, identifying priority audiences, approaches, and communications channels for weight and physical activity. Available at http www.nhlbi.nih.gov nhlbi cardio obes prof obeshc.htm Methods for Voluntary Weight Loss and Control (National Institutes of Health Technology Assessment Conference). An edited summary of a 1992 NIH Technology...

Assessing Abdominal

For the most effective technique for assessing abdominal fat content, the panel considered measures of waist circumference, waist-to-hip ratio (WHR), magnetic resonance imaging (MRI), and computed tomography. Evidence from epidemiological studies shows waist circumference to be a better marker of abdominal fat content than WHR, and that it is the most practical anthropometric measurement for assessing a patient's abdominal fat content before and during weight loss treatment. Computed tomography...

Pharmacotherapy

Drug therapy has undergone radical changes in the last 2 years. With the publication of the trials with phentermine and fenfluramine by Weintraub in 1992 (210 weeks), drug therapy began to change from short-term to long-term use. Both dexfenfluramine and fenfluramine alone, as well as the combination of phenter-mine fenfluramine, were used long term. However, concerns about recently reported unacceptable side effects, such as valvular lesions of the heart causing significant insufficiency of...