Academy Endorses Guideline on Identifying, Treating Adult Obesity

Recommendations Address Counseling, Diet, Weight Management

August 19, 2014 09:19 am Chris Crawford

(Editor's Note: In accordance with the AAFP's policy on endorsement of clinical practice guidelines developed by external organizations, the AAFP's endorsement of the management of overweight and obesity guideline developed by the American College of Cardiology, the American Heart Association and the Obesity Society has sunsetted, and the guideline has been removed from the AAFP website.)

In the United States, 69 percent of adults age 20 and older are overweight or obese, according to the most recent numbers from the CDC's National Center for Health Statistics(

[Doctor measuring large man's waistline]

To aid family physicians on the frontlines of fighting this public health battle, the AAFP recently endorsed a guideline( for identifying, evaluating and treating obesity in adults that was developed by the American College of Cardiology (ACC), the American Heart Association (AHA) and the Obesity Society. The guideline was originally published online Nov. 12 by the AHA's journal Circulation.

According to Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, this obesity guideline provides family physicians critical guidance on how to help their patients lose weight and keep it off.

"It is well known that we have an obesity epidemic in this country, which increases risks of high blood pressure, diabetes, heart disease and stroke," Frost told AAFP News. "This guideline encourages physicians to take a more active role in helping their patients lose weight. The guideline is not limited to obese individuals, however. It also recommends intervention for overweight individuals with one or more cardiovascular risks."

Story highlights
  • The AAFP has endorsed a guideline for identifying, evaluating and treating obesity in adults that was developed by the American College of Cardiology, the American Heart Association and the Obesity Society and published last November.
  • Overweight is defined as body mass index (BMI) of 25-29.9 kg/m2 or greater, and obesity is defined as BMI of 30 kg/m2 or greater.
  • Behavioral counseling is an important weight loss and maintenance strategy highlighted in the guideline, recommending that patients participate in a weight loss management program for at least a year.

Overview of Recommendations

In 2008, the National Heart, Lung and Blood Institute (NHLBI) initiated this guideline by sponsoring a rigorous systematic review of the topic by an expert panel that convened and developed five critical questions, interpreted the evidence provided and crafted the recommendation. Then, in June of last year, the NHLBI began collaboration with the ACC and AHA to work with other organizations to develop the recommendations.

Recommendations were written based on analysis of randomized trials, meta-analyses and observational studies that were evaluated for quality by a panel of experts with expertise in psychology, nutrition, physical activity, bariatric surgery, epidemiology, internal medicine, and other clinical specialties. The panel comprised 15 members plus three ex-officio members and met 23 times.

A peer review panel under the direction of the NHLBI that included 10 expert reviewers and representatives from multiple federal agencies initially examined the guideline. A second panel composed of experts nominated by the ACC, the AHA and the Obesity Society also reviewed the document.

A condensed version of the guideline's recommendations follows.

  • Overweight is defined as body mass index (BMI) of 25-29.9 kg/m2 or greater, and obesity is defined as BMI of 30 kg/m2 or greater.
  • Overweight and obese individuals should be advised that the greater their BMI, the greater the risk of cardiovascular disease (CVD), type 2 diabetes and all-cause mortality.
  • Overweight and obese adults with CVD risk factors (high blood pressure, hyperlipidemia and hyperglycemia) should be counseled that lifestyle changes that produce even modest sustained weight loss of 3 percent to 5 percent produce clinically meaningful health benefits, and greater weight loss produces greater benefits.
  • Overweight and obese adults should be prescribed a diet to achieve reduced calorie intake.
  • Overweight and obese individuals who would benefit from weight loss should be advised to participate for six months or more in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through use of behavioral strategies.
  • Overweight and obese individuals who have lost weight should be advised to participate long-term (one year or more) in a comprehensive weight loss maintenance program.
  • Adults with BMI of 40 kg/m2 or greater or BMI of 35 kg/m2 or greater with obesity-related comorbid conditions who are motivated to lose weight but have not had a sufficient response to behavioral treatment with or without pharmacotherapy should be informed about bariatric surgery and offered a referral for consultation and evaluation.
  • The evidence for the benefits and risks of pharmacotherapy for weight loss was not reviewed for this guideline.

What It Means for Family Physicians

Experts have argued for years about what the ideal weight loss diet is, Frost said. This guideline looked at the evidence and determined that there is no magic diet that patients should follow.

"The key recommendations focus on decreasing calorie intake, choosing a diet based on the patient's medical conditions (e.g., the DASH [Dietary Approaches to Stop Hypertension] diet for patients with high blood pressure), as well as the patient's food preferences, in conjunction with increased physical activity," she said.

Another important strategy in weight loss and maintenance is behavioral counseling. The guideline recommended that patients participate in a weight-loss management program for at least a year, a goal that in the past was slowed by financial hurdles.

"Historically, this has been a challenge because of cost," Frost said. "Under the (Patient Protection and) Affordable Care Act, this is now covered, as the (U.S. Preventive Services Task Force) recommends referral to intensive, multicomponent behavioral interventions for obese individuals."

An additional critical message from this guideline is that patients do not have to reach a normal weight to experience the benefits of weight loss, she said.

"Sustained weight loss of just 5 percent can significantly lower blood pressure and blood glucose, and improve lipid levels," Frost said. "Of course, there is a greater benefit to more weight loss, but it is not all or nothing."

Unlike two other ACC/AHA guidelines released late last year on cholesterol management to reduce atherosclerotic cardiovascular risk( and lifestyle management to reduce cardiovascular risk(, the obesity guideline was endorsed by the AAFP without qualifications. Frost said this is due to two factors: the number of recommendations and the evidence base.

"We encourage guidelines with a limited number of recommendations, focused on the most important questions," she said. "Otherwise, the guideline becomes cumbersome and difficult to implement. The obesity guideline has 17 recommendations, while the cholesterol guideline has more than 40."

Frost added that the majority of the obesity recommendations are based on quality evidence. Many of the cholesterol recommendations also are based on quality evidence, but the majority are based on expert opinion.