obesity
OBESITY
Treatment Guideline Chart
Obesity is a chronic, progressive and relapsing medical condition characterized by the accumulation of abnormal or excessive body fat that impairs health.
Causes of obesity are multifactorial with complex interactions.
Treatment goals include addressing the principal cause of weight gain and focusing management on both weight loss and patient-centered health outcomes.
A multidisciplinary approach, that is a combination of dietary change, physical activity and behavioral modification, is recommended.

Obesity Patient Education

Lifestyle Modification

Advantages of Weight Loss

  • Reduction in blood pressure (BP), lipid levels (eg total cholesterol, TG, and LDL) and all-cause mortality
    • Decrease in BP (<130/80 mmHg), LDL <3.4 mmol/L, fasting blood glucose ≤6 mmol/L
  • Produce clinical benefits in ORCs, eg DM prevention/remission, ovulation and regularization of menses in PCOS, reduction in inflammation and fibrosis in NAFLD, improved symptomatology in OSA, OA, urinary stress incontinence, asthma and GERD

Diet/Calorie Restriction

  • Energy expenditure should be more than total energy intake (caloric deficit)
  • Patients are generally advised to decrease portion size of food, choose low energy-dense foods and drinks, avoid between-meal snacks, ultra-processed food, sugar-sweetened beverages, or refined carbohydrates, not skip breakfast and avoid nighttime eating, and reduce binge eating
    • Emphasize the need for a balanced, reduced caloric intake and adherence to dietary therapy for initial weight loss and maintenance
  • Consumption of low-fat, reduced-calorie diets are important for successful weight loss for 12 months
  • Calories
    • 500-1000 kcal/day reduction from usual intake to achieve weight loss of 0.5-1 kg/week (1-2 lb/week)
    • Every 24 kcal/day reduction will result in the long term in approximately 1 kg loss in body weight, or 15-30% reduction from habitual caloric intake can result in 5-10% weight loss and long-term maintenance 
    • Intake of 1200-1500 kcal/day for most women and 1500-1800 kcal/day for most men can help achieve treatment goals
    • Calorie reduction may also be simplified by using a 9-inch plate with half of the plate composed of vegetables and fruits and the other half divided between carbohydrates and protein 
  • Fats
    • Amount reduced will depend on each specific country’s national standard
    • Total fat should be ≤30% of total calories (trans fat <1%, saturated fat 7-10%, monosaturated fat up to 15% of total calories); with most fats coming from fish, nuts and vegetable oils
  • Carbohydrates
    • Should comprise 55% of total calories
    • Complex carbohydrate from fruits, vegetables and whole grains are preferred
  • Protein
    • Should be ≤15% of total calories
    • Derived from plant source or lean animal sources
  • Fiber
    • Should get ≥25-35 g/day
    • Delays gastric emptying causing a feeling of fullness and decreased appetite/hunger
    • Also helps decrease absorption of fat and cholesterol
    • May be obtained from oatmeal, whole wheat bread, rice, beans, citrus fruits, carrots, cauliflower, strawberries, peaches and apple with skin
  • Vitamins and minerals
    • Calcium: 1000 mg/day total daily intake which can be derived from diet with or without supplementation (especially for women at risk of osteoporosis)
    • Vitamin D: 10-20 mcg/day

Modified Diets

  • Low-Calorie Diet (LCD)
    • Food-based approach intended to lower caloric intake by 500 kcal/day from maintenance requirement regardless of macronutrient composition
    • Energy content is 800-1200 kcal/day; may require meal replacements to meet caloric and nutritional targets
    • An average of 8-10% reduction in total body weight was noted over a 6-month period
  • Very Low-Calorie Diet (VLCD)
    • Caloric intake of <800 kcal/day regardless of macronutrient composition 
    • Uses calorie-controlled, nutritionally-balanced, vitamin/mineral-fortified pre-prepared meal replacements utilized as the only nutrient source
    • Used for maximum of 12-16 weeks and monitored by experienced practitioners
      • Can be extended or used intermittently over longer periods of time at the discretion of the supervising healthcare provider 
    • Indicated in moderately to severely obese patients who are motivated but have failed with conservative methods, or in patients with BMI of 27-30 kg/m2 who have medical conditions that might respond to rapid weight loss 
    • Weight regain after rapid weight loss is not faster than in gradual weight loss
  • Can be done by a certified nutritionist or dietitian; needs to be clinically supervised     
    • Physicians should also consult with nutrition professionals when prescribing a particular weight loss diet, including individualized medical nutrition therapy, that will address the patient’s needs 
    • Patients with ORCs need to work with their physicians to adjust chronic medications

Other Dietary Strategies  

  • The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet are safe and recommended for individuals wanting to lose weight  
    • DASH diet was developed to reduce BP and emphasizes intake of foods low in sodium, cholesterol and saturated fats, eg fruits, vegetables and low-fat dairy foods  
    • Mediterranean diet requires a high consumption of olive oil, legumes, grains, cereals, fruits, vegetables and moderate to high consumption of fish and dairy products  
  • Intermittent fasting involves fasting and non-fasting periods, eg eating normally for 5 days and then taking in much less energy/calories on the remaining 2 days of the week  
    • Time-restricted feeding is also a form of intermittent fasting wherein food intake is limited to ≤8 hours daily
    • Fasting-related concerns include mood changes, fatigue or dizziness; CV events can be provoked and aggravated in the elderly  
    • Shows promise for obesity treatment but further research is needed before using it in the long-term  
  • Carbohydrate-limiting diets such as the Atkins and ketogenic diets derive a major portion of the caloric intake from fat sources  
    • Adverse effects include potential increase in LDL cholesterol levels and development of kidney stones
  • Paleo diet, also referred to as the caveman-like diet, is high in protein and low in carbohydrates and usually excludes grains, legumes and dairy products  
    • It may encourage consumption of large amounts of meat while inadequate intake of other foods may lead to the development of anemia, osteoporosis, T2DM or hypertension  
  • Patients are recommended to seek professional advice before starting any form of diet 

Physical Activity Interventions

  • There is very strong evidence supporting the role of regular physical activity in the prevention and management of risk factors for CVD and DM
  • Benefits of physical activity include reduced weight and fat mass, improved metabolic profile and increased CV fitness and improved well-being  
  • Can be daily unstructured physical activity or structured featuring aerobic and/or resistance training
  • Moderate- to vigorous-intensity aerobic exercises (eg swimming, table tennis, 4.3-6.4 kph brisk walking, 16 kph cycling) are recommended for 30-60 minutes, 5 days/week (>150 minutes a week) 
    • 30 minutes/day for cardiovascular fitness
    • At least 150 minutes/week combined with resistance exercise 3 times/week to increase muscle strength 
    • ≥150 minutes/week to maintain health and prevent diseases 
    • 150-420 minutes/week to achieve weight loss; a dose-response relationship exists between volume of exercise and amount of weight loss 
    • 200-300 minutes/week to maintain weight loss 
    • A total of 10-60 minutes/day is recommended with gradual increase over time for unfit or inactive individuals
  • Resistance training using major muscle groups in single-set exercises may also be advised 2-3 times/week to maintain weight or modestly increase mobility and muscular or fat-free mass
  • Appetite is suppressed during and immediately after exercise, but increases after an hour
  • Activity should be tailored to patient’s age, ability (eg fitness level, physical impairments) and cardiovascular risk 
  • Increase in daily activity and reduction in sedentary time should be encouraged (eg walking, climbing stairs)
Editor's Recommendations
Special Reports