New ACC/AHA Guidelines -- Part 4: Management of Overweight and Obesity in Adults
On Nov. 12, 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) released four new sets of clinical practice guidelines to assist primary care clinicians in identifying adults who may be at high risk for developing atherosclerotic cardiovascular disease (ASCVD) and who may benefit from lifestyle changes or drug therapy for prevention.
This four-part series, published in MPR, summarizes the new guidelines, and how they differ from the earlier guidelines. The present article—the fourth in the series—discusses the Guideline for the Management of Overweight and Obesity in Adults.1
The new guideline is an update of the 1988 National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.2 It places greater emphasis on the role of primary health care providers in actively helping patients achieve and maintain a healthier body weight.
Part Four of a Special Four-Part Series.
According to the authors, "The panel's ultimate goal was to... assist clinicians in primary care" in "assessing body mass index (BMI) and waist circumference cutpoints... the impact of weight loss on risk factors for CVD and type 2 diabetes... CVD morbidity and mortality; optimal behavioral dietary intervention strategies, and other lifestyle treatment approaches... and benefits and risks of... bariatric surgical procedures."
Summary of Recommendations
Identifying patients who need to lose weight
1a. Measure height and weight and calculate BMI at annual visits or more frequently. (Evidence Grade E-Expert Opinion)
1b. Use current cutpoints to identify overweight/obese adults at risk for CVD and obese adults at risk for all-cause mortality. (Evidence Grade A-Strong)
- Overweight: BMI of >29.0-29.9 kg/m2
- Obesity: BMI of > 30 kg/m2
1c. Advise overweight/obese adults that elevated BMI raises the risk of CVD, type 2 diabetes, and mortality. (Evidence Grade A-Strong)
1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults; advise them of risks inherent in high waist circumference. Cutpoints continue to be those recommended by the NIH/NHLBI (> 40 inches in men and > 35 inches in women)2 or the WHO/IDF (> 94cm for men and > 80cm for women).3 (Evidence Grade E-Expert Opinion)
Matching treatment benefits with risk profiles
2a and 2b. Counsel overweight and obese adults with CV risk factors that even modest, sustained weight loss of 3 to 5 percent can produce meaningful health benefits, and greater weight loss produces even greater benefits. (Evidence Grade A-Strong)
Diets for weight loss
3a. Prescribe a diet for overweight and obese adults, which is part of a comprehensive lifestyle intervention. Clinicians can choose from one of three potential interventions. (Evidence Grade A-Strong)
- 1,200-1,500 kcal/day for women and 1,500-1,800 kcal/day for men
- 500 kcal/day or 750 kcal/day energy deficit
- One of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake
3b. Prescribe a calorie-restricted diet, based on the patient's preferences and health status, preferably under the guidance of a professional nutritionist (Evidence Level A-Strong)
Lifestyle intervention and counseling
4a. Advise overweight and obese individuals to participate for at least six months in a behaviorally based comprehensive lifestyle program that facilitates adherence to a lower calorie and increased physical activity regimen. (Evidence Grade A-Strong)
4b. Prescribe on-site high-intensity comprehensive weight loss intervention (individual or group sessions). (Evidence Grade A-Strong)
4c. Electronically or telephone-based weight loss programs that include personalized feedback can be utilized, but will yield less weight loss than face-to-face interventions. (Evidence Grade B-Moderate)
4d. Some evidence-based commercial programs that provide comprehensive lifestyle interventions can be prescribed as an option. (Evidence Grade B-Moderate)
4e. Very low calorie diets (<800 kcal/day) should be used only in limited circumstances under supervision of trained practitioners in a medical care setting. (Evidence Grade A-Strong)
4f. Advise patients to participate in their comprehensive program for at least one year. (Evidence Grade A-Strong)
4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered maintenance programs that provide regular contact with a trained interventionist. (Evidence Grade A-Strong)
To look at any of the articles in this series, click below.
|Part 1: Cardiovascular Risk Assessment|
|Part 2: Lifestyle Management|
|Part 3: Panel Member Addresses Controversies Surrounding New Cholesterol Guideline|
|Part 4: Management of Overweight and Obesity in Adults|