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

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...