Obesity Management Guidelines

Introduction

The problem of overweight and obesity is a focus of attention of several professional communities of physicians, who publish authoritative guidelines focused on this growing health issue. In the United States, the three most important current guidelines for the management of obesity include:

• The 2013 Guideline for the Management of Overweight and Obesity in Adults, published by the American Heart Association (AHA) together with the American College of Cardiology (ACC) and The Obesity Society (TOS)
• The 2016 Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity, published by the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE)
• The 2019 Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic and Nonsurgical Support of Patients Undergoing Bariatric Procedures, jointly sponsored and published by AACE/ACE, TOS, American Society for Metabolic & Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA) and American Society of Anesthesiologists (ASA)

Each of these three guidelines are discussed in separate sections below.

AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

The 2013 AHA/ACC/TOS guidelines provide 17 recommendations aimed to help primary care practitioners make evaluations and treatment decisions in the care of patients with overweight and obesity. The recommendations are organized under 5 critical questions, providing a summary of literature on the risks of obesity and benefits of weight loss, effective diets, lifestyle interventions and the benefits and risks associated with bariatric surgery. Each recommendation is assigned a class of recommendation (COR) and a level of evidence (LOE) (Figure 22-1).

The first and the second critical questions aim to assist healthcare providers establish appropriate criteria for guiding weight loss recommendations. The first question focuses on the health benefits of weight loss in relation to the amount and duration of weight loss, leading to 1 recommendation (Table 22-1). The second question assesses the health risks of overweight and obesity, and the suitability of the current criteria for different population subgroups, with 4 specific recommendations (Table 22-1).

The third critical question explores effective dietary intervention strategies, considering patients' interest in popular diets, resulting in 2 recommendations (Table 22-1).

The fourth critical question assesses the efficacy of a comprehensive lifestyle approach involving diet, physical activity, and behavior therapy for achieving and maintaining weight loss, producing 7 recommendations (Table 22-1).

The fifth critical question discusses the efficacy and safety of bariatric surgical procedures, considering their benefits and risks and seeks to identify factors guiding decisions to maximize benefits for obesity and related conditions, leading to 3 recommendations (Table 22-1).

While the ACC/AHA has not released new guidelines on the management of overweight and obesity since 2013, the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease includes 4 recommendations related to the management of obesity:

• In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile. (COR I, LOE B)
• Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity. (COR I, LOE B)
• Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations. (COR I, LOE C – Expert Opinion)
• It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk. (COR IIa, LOE B)

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AACE/ACE Clinical Practice Guidelines for Medical Care of Patients with Obesity

The AACE and ACE published their own guidelines in 2016. These guidelines follow strict AACE protocols for the standardized production of clinical practice guidelines, and contain 123 recommendations, including 160 specific statements, organized under 9 broad clinical questions. The clinical questions were formulated to guide obesity management and serve as evidence-based resources for healthcare professionals. Each statement is assigned with a strength-of-evidence rank (best level of evidence [BEL]: 1 – strong evidence; 2 – intermediate evidence; 3 – weak evidence; 4 – no evidence) and a recommendation Grade (A – strong recommendation, B – intermediate recommendation, C – weak recommendation, or D – recommendation is not evidence-based or lacks a two-thirds consensus).

The first clinical question discusses whether the three phases of chronic disease prevention and treatment (primary, secondary and tertiary) are applicable to obesity, prompting 1 recommendation (Table 22-2).

The second question addresses the measurement of adiposity in the clinical setting, leading to 6 recommendations (Table 22-3) made under 4 sub-questions. The sub-question inquire about the optimal methods for measuring the degree of adiposity, screening strategies for identifying overweight and obesity, the best criteria for defining excess adiposity in diagnosis, the additional information provided by waist circumference compared to BMI, and the accuracy of BMI and waist circumference in capturing adiposity risk across different demographic factors like ethnicity, gender and age. The third question explores weight-related complications associated with excess adiposity, including various health concerns such as diabetes, cardiovascular (CV) disease, liver diseases, reproductive issues, sleep disorders, respiratory conditions, joint problems, urinary issues, digestive problems and mental health issues. These topics are organized into 15 sub-questions and yield 20 recommendations (Table 22-4).

The fourth question examines the adequacy of BMI and other measures of adiposity in conveying the impact of excess body weight on patient health, yielding 1 recommendation in 2 statements (Table 22-5).

The fifth question comprises 15 sub-questions addressing the benefits of weight loss in overweight and obese patients, encompassing 34 recommendations (Table 22-6). The topics of these sub-questions align with the topics from the Q3 sub-questions, focusing on whether patients with excess adiposity and related complications experience greater therapeutic benefits from weight loss than those without complications. Additionally, they explore the potential use of weight loss as a treatment for the weight-related complications and examine the necessary amount of weight loss in such cases.

The sixth question discusses the effectiveness of lifestyle/behavioral therapy in treating overweight and obese patients. This question comprises three sub-questions, focusing on components of lifestyle therapy such as reduced-calorie meal plans, macronutrient composition, physical activity and behavior interventions. A total of 12 recommendations are given in response (Table 22-7).

The seventh question investigates the efficacy of pharmacotherapy in treating patients with overweight and obesity, exploring its role as an adjunct to lifestyle therapy, its comparative effectiveness with lifestyle therapy alone, the duration of its use, the safety and efficacy of different weight-loss medications, and the use of potential combinations not approved by the Food and Drug Administration (FDA). A total of five sub-questions yielded 7 recommendations (Table 22-8).

The eighth question explores the individualization of pharmacotherapy for the treatment of obesity, specifically the hierarchies of drug preferences in patients with certain comorbidities or characteristics. This question includes 17 sub-questions addressing specific conditions, including: kidney disease, hepatic impairment, CV issues, mental health concerns, eating disorders, glaucoma, seizure disorders, pancreatic disease, substance use, age-related factors and specific post-surgery scenarios; a total of 37 recommendations are given (Table 22-9).

The nineth question consists of 2 sub-questions assessing the effectiveness of bariatric surgery in treating obesity and its associated complications. The first sub-question focuses on exploring the overall effectiveness of the surgical approach, while the second focuses on the optimal timing for its application in addressing obesity and weight-related issues. The two sub-questions yield 4 recommendations (Table 22-10).

Finally, an additional post hoc question was evaluated, focused on the inductive assessment of all evidence-based recommendations, aiming to identify the core recommendations for medical care of patients with overweight and obesity. This yielded 2 “core” recommendations (Table 22-11).

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AACE/ACE/TOS/ASMBS/OMA/ASA Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic and Nonsurgical Management of the Bariatric Surgery Patient

In 2019, the boards of directors of several professional societies, including AACE/ACE, TOS, ASMBS, OMA and ASA, commissioned an update to the 2013 AACE/TOS/ASMBS Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic and Nonsurgical Management of the Bariatric Surgery Patient. Since 2013, a number of scientific and clinical advances regarding obesity as a disease and the role of nonsurgical therapies and bariatric surgery have occurred.

The significance of bariatric surgery in the management of type 2 diabetes has become clearer, accompanied by improvements in CV outcomes and overall quality of life. The updated clinical practice guidelines aim to guide physicians in the clinical care of patients with obesity who undergo surgical and nonsurgical bariatric procedures, as well as to enhance precision in clinical decision-making and emphasize the importance of a collaborative team approach to patient care.

The 2019 AACE/ACE/TOS/ASMBS/OMA/ASA guidelines contain 85 updated recommendations, including 61 revised from the 2013 version and 12 completely new recommendations. The recommendations are organized under 7 clinical questions, and each consists of one or more statements, with an accompanying BEL rank and (described above for the 2016 AACE/ACE guidelines).

The first question addresses eligibility criteria for bariatric procedures, considering patient’s BMI and obesity-related comorbidities. It yields 5 recommendations (Table 22-12) - 1 new and 4 revised.

The second question includes 1 revised recommendation with 6 statements (Table 22-13). The emphasis of this question is on selecting bariatric procedures while taking into account individualized therapy goals, patient preferences and personalized risk assessment.

The third question focuses on the management of potential candidates before bariatric procedures. There are a total of 6 recommendations (Table 22-14), all of which are revised. These recommendations cover topics such as preprocedure patient evaluation, patient education and in-depth clinician-patient discussions, financial information and preprocedure weight loss programs.

The fourth question provides guidelines on medical clearance elements for bariatric procedures. It comprises 22 recommendations (Table 22-15), with 2 new and 20 revised. The topics discussed include lifestyle assessment (new recommendation), preprocedure health optimization, pregnancy considerations, hormone therapy, postprocedure fertility status, obesity genetic screening, sleep apnea evaluation, tobacco use, vascular health assessment, gastrointestinal (GI) evaluation, psychosocial-behavioral assessments, nutritional evaluations, follow-up and cancer screening, and preoperative optimization strategies (new recommendation).

The fifth question explores care optimization strategies during and within 5 days of a bariatric procedure through 14 recommendations (Table 22-16). Four of these are new, addressing topics such as perioperative pathways, pulmonary management, intraoperative medication use, bleeding site detection, fluid therapy goals, postoperative checklists, preemptive medications, and diagnostic workup for respiratory distress. The remaining 10 recommendations are revised. The sixth question produces 34 recommendations (Table 22-17), discussing multiple aspects related to the optimization of care five days after a bariatric procedure. These recommendations include 5 new ones that cover micronutrient supplementation, optimizing diabetes medication dosages, monitoring and adjusting hormone replacement therapies, managing persistent GI symptoms, and the treatment of anastomotic ulcers.

Finally, the seventh question addresses the criteria for hospital admission after a bariatric procedure and considerations for revision or reversal of previous bariatric surgeries in cases of serious complications, covering these topics with 3 revised recommendations (Table 22-18).

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