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AACE/ACE Guidelines AMERICAN ASSOCIATION of CLINICAL AACE/ACE Guidelines AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY W. Timothy Garvey, MD, FACE1; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU2; Elise M. Brett, MD, FACE, CNSC, ECNU3; Alan J. Garber, MD, PhD, FACE4; Daniel L. Hurley, MD, FACE5; Ania M. Jastreboff, MD, PhD6; Karl Nadolsky, DO7; Rachel Pessah-Pollack, MD8; Raymond Plodkowski, MD9; and Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines* American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice are systematically devel- oped statements to assist health care professionals in medical decision-making for specific clinical conditions. Most of the content herein is based on a systematic review of evidence published in peer-reviewed literature. In areas in which there was some uncertainty, professional judgment was applied. These guidelines are a working document reflecting the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this infor- mation in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. From 1Professor and Chair, Department of Nutrition Sciences, University of Alabama at Birmingham, Director, UAB Diabetes Research Center, GRECC Investigator & Staff Physician, Birmingham VA Medical Center, Birmingham, Alabama; 2Director, Metabolic Support, Clinical Professor of Medicine, Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; 3Associate Clinical Professor, Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; 4Professor, Departments of Medicine, Biochemistry and Molecular Biology, and Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas; 5Assistant Professor of Medicine, Mayo Clinic, Rochester, Minnesota; 6Assistant Professor, Yale University School of Medicine, Internal Medicine, Endocrinology, Pediatrics, Pediatric Endocrinology, New Haven, Connecticut; 7Walter Reed National Military Medical Center, Diabetes Obesity & Metabolic Institute, Bethesda, Maryland; 8Assistant Clinical Professor, Mount Sinai School of Medicine, NY, ProHealth Care Associates, Division of Endocrinology, Lake Success, New York; 9Center for Weight Management, Division of Endocrinology, Diabetes and Metabolism, Scripps Clinic, San Diego, California. Address correspondence to American Association of Clinical Endocrinologists, 245 Riverside Ave, Suite 200, Jacksonville, FL 32202. E-mail: [email protected]. DOI:10.4158/EP161365.GL To purchase reprints of this article, please visit: www.aace.com/reprints. Copyright © 2016 AACE. *A complete list of the Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines can be found in the Acknowledgement. ENDOCRINE PRACTICE Vol 22 (Suppl 3) July 2016 1 2 AACE/ACE Obesity CPG, Endocr Pract. 2016;22(Suppl 3) Table of Contents: Appendix Introduction and Executive Summary 4-30 Evidence Base 30 Post-hoc Question: By inductive evaluation of all evidence-based recommendations, what are the core 30 recommendations for medical care of patients with obesity? Q1. Do the 3 phases of chronic disease prevention and treatment (i.e., primary, secondary, and tertiary) apply to the 31 disease of obesity? Q2. How should the degree of adiposity be measured in the clinical setting? 33 Q2.1. What is the best way to optimally screen or aggressively case-find for overweight and obesity? Q2.2. What are the best anthropomorphic criteria for defining excess adiposity in the diagnosis of overweight 34 and obesity in the clinical setting? Q2.3. Does waist circumference provide information in addition to body mass index (BMI) to indicate 34 adiposity risk? Q2.4. Do BMI and waist circumference accurately capture adiposity risk at all levels of BMI, ethnicity, 34 gender, and age? Q3. What are the weight-related complications that are either caused or exacerbated by excess adiposity? 37 Q3.1. Diabetes risk, metabolic syndrome, and prediabetes (IFG, IGT) 37 Q3.2. Type 2 diabetes 39 Q3.3. Dyslipidemia 40 Q3.4. Hypertension 41 Q3.5. Cardiovascular disease and cardiovascular disease mortality 42 Q3.6. Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis 44 Q3.7. Polycystic ovary syndrome (PCOS) 46 Q3.8. Female infertility 47 Q3.9. Male hypogonadism 48 Q3.10. Obstructive sleep apnea 50 Q3.11. Asthma/reactive airway disease 50 Q3.12. Osteoarthritis 51 Q3.13. Urinary stress incontinence 52 Q3.14. Gastroesophageal reflux disease (GERD) 52 Q3.15. Depression 56 Q4. Does BMI or other measures of adiposity convey full information regarding the impact of excess body weight 56 on the patient’s health? Q5. Do patients with excess adiposity and related complications benefit more from weight loss than patients 58 without complications, and, if so, how much weight loss would be required? Q5.1. Is weight loss effective to treat diabetes risk (i.e., prediabetes, metabolic syndrome) and prevent 59 progression to type 2 diabetes? How much weight loss would be required? Q5.2. Is weight loss effective to treat to type 2 diabetes? How much weight loss would be required? 60 Q5.3. Is weight loss effective to treat dyslipidemia? How much weight loss would be required? 63 Q5.4. Is weight loss effective to treat hypertension? How much weight loss would be required? 66 Q5.5. Is weight loss effective to treat or prevent cardiovascular disease? How much weight loss would be 70 required? Q5.5.1. Does weight loss prevent cardiovascular disease events or mortality? 70 Q5.5.2. Does weight loss prevent cardiovascular disease events or mortality in diabetes? 70 Q5.5.3. Does weight loss improve congestive heart failure? 71 Q5.6. Is weight loss effective to treat nonalcoholic fatty liver disease and nonalcoholic steatohepatitis? How 72 much weight loss would be required? Q5.7. Is weight loss effective to treat PCOS? How much weight loss would be required? 74 Q5.8. Is weight loss effective to treat infertility in women? How much weight loss would be required? 76 AACE/ACE Obesity CPG, Endocr Pract. 2016;22(Suppl 3) 3 Q5.9. Is weight loss effective to treat male hypogonadism? How much weight loss would be required? 78 Q5.10. Is weight loss effective to treat obstructive sleep apnea? How much weight loss would be required? 80 Q5.11. Is weight loss effective to treat asthma/reactive airway disease? How much weight loss would be 80 required? Q5.12. Is weight loss effective to treat osteoarthritis? How much weight loss would be required? 81 Q5.13. Is weight loss effective to treat urinary stress incontinence? How much weight loss would be required? 82 Q5.14. Is weight loss effective to treat gastroesophageal reflux disease (GERD)? How much weight loss would 83 be required? Q5.15. Is weight loss effective to improve symptoms of depression? How much weight loss would be 89 required? Q6. Is lifestyle/behavioral therapy effective to treat overweight and obesity, and what components of lifestyle 91 therapy are associated with efficacy? Q6.1. Meal plan and macronutrient composition 92 Q6.2. Physical activity 93 Q6.3. Behavior interventions 96 Q7. Is pharmacotherapy effective to treat overweight and obesity? 102 Q7.1. Should pharmacotherapy be used as an adjunct to lifestyle therapy? 102 Q7.2. Does the addition of pharmacotherapy produce greater weight loss and weight-loss maintenance than 102 lifestyle therapy alone? Q7.3. Should pharmacotherapy only be used in the short term to help achieve weight loss or should it be used 103 chronically in the treatment of obesity? Q7.4. Are there differences in weight-loss drug efficacy and safety? 104 Q7.5. Should combinations of weight-loss medications be used in a manner that is not approved by the U.S. 108 Food and Drug Administration? Q8. Are there hierarchies of drug preferences in patients with the following disorders or characteristics? 108 Q8.1. Chronic kidney disease 108 Q8.2. Nephrolithiasis 109 Q8.3. Hepatic impairment 110 Q8.4. Hypertension 111 Q8.5. Cardiovascular disease and arrhythmia 113 Q8.6. Depression with or without selective serotonin reuptake inhibitors 115 Q8.7. Anxiety 118 Q8.8. Psychotic disorders with or without medications (lithium, atypical antipsychotics, monoamine oxidase 119 inhibitors) Q8.9. Eating disorders including binge eating disorder 121 Q8.10. Glaucoma 123 Q8.11. Seizure disorder 124 Q8.12. Pancreatitis 124 Q8.13. Opioid use 125 Q8.14. Women of reproductive potential 126 Q8.15. The elderly, age ≥65 years 127 Q8.16. Addiction/alcoholism 130 Q8.17. Post-bariatric surgery 131 Q9. Is bariatric surgery effective to treat obesity? 131 Q9.1. Is bariatric surgery effective to treat obesity and weight-related complications? 132 Q9.2. When should bariatric surgery be used to treat obesity and weight-related complications? 132 References 134 Algorithms 192-203 4 AACE/ACE Obesity CPG, Endocr Pract. 2016;22(Suppl 3) ABSTRACT = binge eating disorder; BEL = best evidence level; Objective: Development of these guidelines is BLOOM = Behavioral Modification and Lorcaserin for mandated by the American Association of Clinical Overweight and Obesity Management; BLOSSOM = Endocrinologists (AACE) Board of Directors and the Behavioral
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