QUICK REFERENCE GUIDE
Overweight and obesity in adults: first-line medical management September 2011
WHY SHOULD WE MONITOR EXCESS WEIGHT? Obesity is a chronic disease. Excess weight increases morbidity. BMI)1 kg/mif 282 above, or Total mortality increases in line with body mass index ( BMI is except in elderly patients. The benefits of losing weight should be emphasised to individuals with obesity, in order to reduce associated comorbidities. A 5-10% weight loss reduces the risk of developing type 2 diabetes. ECIt is recommended that overweight and obesity be identified at the first consultation and regularly thereafter for patients attending general practice. People with obesity are subject to discrimination in many areas of life. It is recommended that doctors measure the impact of this. It is recommended that doctors advise patients against serial dieting, which causes weight fluctuations that can endanger health, and against the use of drug treatments.
WHEN SHOULD OVERWEIGHT AND OBESITY BE DI GNOSED? ECA general practitioner should weigh patients regularly, ideally at every appointment. Waist size should be measured at the first appointment. Height and weight should be recorded in the patient's file in order to calculate BMI and track any changes.
1BMI is calculated by dividing weight in kg by height in m2
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Factors that promote weight gain excessive energy consumption (overly rich food that is too dense in calories, sugary drinks, large portion size) sedentary lifestyle having stopped or reduced physical activity or sports stopping smoking without taking appropriate steps alcohol consumption some drugs (including antipsychotics, antidepressants, anti-epileptic drugs, insulin, sulfonylureas and corticosteroids) genetic factors and family history of obesity history of obesity in childhood pregnancy menopause eating disorder (impulsiveness related to food, compulsive eating, binge-
eating disorder) anxiety and depression, and periods of psychological or social vulnerability job-related factors (including stress at work, shift work) lack of sleep
HOW ARE OVERWEIGHT AND OBESITY DI Diagnosis of overweight and obesity is based on BMI
Classification of overweight and obesity using BMI* Class of obesity BMI (kg/m²) Normal weight - 24.9 18.5
25.0 29.9 -
30.0 - 34.9
Obesity 35.0II severe - 39.9 III morbid≥40 *.World Health Organisation. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. WHO Technical Report series 2003;(894).
Cgreater than 25 kg/m² and less than 35 kg/m², waist circumferenceIf the BMI is (midway between the last ribs and the iliac crest) should be measured as part of the clinical examination. Waist size can indicate excessive fat in the abdome n. Excessive abdominal fat is associated, irrespective of BMI, with development o f metabolic and vascular complications of obesity.
WHAT SHOULD BE OFFERED? See the initial assessment table and th for the initial interviewe resource s heet assessment. ECA patient who is carrying excess weight must receive specific management from the primary care physician, in the context of dedicated consultations with planned follow-u . The management of obesity is based on the principles of therapeutic patient education. The doctor is recommended to avoid language that suggests that the overweight person is solely responsible for his/her weight and makes him/her feel guilty.
For overweight patients, the primary aim is to avoid gaining weight. If the waist size is large (≥ 80 for women and cm≥ 94 cm for men), the aim is to stabilise weight and reduce the waist size. If there are associated comorbidities, the aim is weight loss and/or reduction in waist size. For patients with obesity, it is recommended that a weight loss goal of 5-15% of initial weight is set, and that associated comorbidities be managed. Stabilising weight is a useful goal for people with obesity whose previous therapies have failed.
GENERAL ADVICE A patient who is carrying excess weight needs education about diet, advice about physical activity, a psychological approach and medical follow-up, which can be provided by the general practitioner in most cases. If treatment goals are not reached despite such management after six months to one year, the doctor can refer the patient to other professionals (dietician or doctor specialised in nutrition, psychologist and/or psychiatrist, professionals involved in suitable physical activity), with the patient's agreement, while continuing to monitor him/her. It is necessary to inform overweight patients of the health benefits of not gaining weight. If the patient wishes to lose weight, he/she should be warned of the risks of overly restrictive and unbalanced diets. Realistic weight loss goals should be set with the patient (with an average weight loss of 1-2 kg/month), by defining appropriate ways to do this as part of a treatment contract.
ADVICE AIMED AT CHANGING FOOD HABITS
If weight loss is being considered (in cases of overweight + comorbidity or obesity), nutritional advice aims to reduce energy intake by guiding the patient towards food with lower ener densit and/or controllin ortion size. Doctors should seek to correct excess energy intake, and help the patient to achieve a balanced diet usin sustainable chan es to dietar habits. In the context of therapeutic education, doctors can suggest simple and personalised steps to take that are appropriate to the patient's circumstances, which enable patients to achieve balanced and diverse diets (see sheet on dietary advice).
ADVICE ON INCREASING PHYSICAL ACTIVITY AND AVOIDING A SEDENTARY LIFESTYLE BPatients must be encouraged to do at least 2.5 hours of moderate-intensity physical activity throughout the week. For additional health benefits, adults should increase their moderate-intensity physical activity to 5 hours per week (or 2.5 hours of vigorous-intensity physical activity per week or an equivalent combination of moderate and vigorous-intensity activit see information sheet for examples of ph sical activit . ECDaily physical activity must be presented as a part of life that is just as essential as sleep and hygiene. Choice of physical activity must be explained to and negotiated with the patient, depending on his/her abilities and motivation.
PSYCHOLOGICAL AND COGNITIVE-BEHAVIOURAL APPROACH Any approach that promotes a good doctor-patient relationship and attitude to change can be considered; but cognitive behavioural techniques have been shown to be effective. Other techniques have not yet been evaluated.
DRUG TREATMENT Because of modest levels of efficacy and adverse effects, particularly involving the digestive system, and drug interactions (particularly with anticoagulants and oral contraceptives), prescription of orlistat is not recommended. The prescription of drug treatments for the purpose of weight loss that do not have marketing authorisation for overweight or obesity is prohibited.
FOLLOW-UP The frequency of consultations should be adjusted in order to achieve and maintain the desired weight loss. Management by the primary care physician should continue over the long term. Behavioural changes in physical activity and eating should be maintained over the lon term.
GRADES OF RECOMMENDATIONS AEstablished scientific evidence BScientific presumption CLow level of evidence ECExpert consensus
This summary presents the main points of the good practice guidelines: "Overweight and obesity in adults: first-line medical management" Clinical practice guideline - September 2011. -