American Society of Bariatric Physicians (ASBP) Algorithm 1 American Society of Bariatric Physicians (ASBP)

ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013

Citation: SegerJC,HornDB,WestmanEC,LindquistR,ScintaW,RichardsonLA,PrimackC,BrymanDA,McCarthyW,Hendricks E,Sabowitz BN,SchmidtSL,BaysHE.AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposity EvaluationandTreatment2013.www.obesityalgorithm.org (Accessed=[insertdate])

ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013

Disclaimer TheAmericanSocietyofBariatricPhysicians®(ASBP)ObesityAlgorithmwasdevelopedtoassisthealthcare professionalsinmedicaldecisionmaking;however,itisinnowayasubstituteforamedicalprofessional'sindependent judgmentandshouldnotbeconsideredmedicaladvice.Mostofthecontenthereinisbasedonthe medicalliterature andtheclinicalexperienceofobesitymedicinespecialists.Inareasofuncertainty,professionaljudgmentofthe authorswasapplied.TheObesityAlgorithmisaworkingdocumentthatreflectsthestateofthefieldofobesity medicineatthetimeofpublication.Becauserapidchangesinthisareaareexpected, periodicrevisionsareinevitable. Weencouragemedicalprofessionalstousethisinformationinconjunctionwith,andnotasareplacementfor,their bestclinicaljudgment.Thepresentedrecommendationsmaynotbeappropriateinallsituations.Anydecisionby practitionerstoapplytheseguidelinesmustbemadeinlightoflocalresourcesandindividualpatientcircumstances.

Permissions TheAmericanSocietyofBariatricPhysicians®(ASBP)ObesityAlgorithmisprotectedbycopyrightandmaynotbe alteredinanyform.Thiscopyrightedmaterialmaybeaccessedforpersonalresearch,scientificand/orinformation purposesonly.Nopartofthisalgorithmmaybedistributedforsaleorysoldinan formorbyanymeanswithoutprior writtenpermissionfromtheSociety.

OrderingReprintsand/orRequestingPermissionsforuseofASBP ObesityAlgorithm Forreprintsorotherpermissions,pleasecontact: EͲmail:[email protected] Phone:303.770.2526

Copyright©2013ASBP:MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP American Society of Bariatric Physicians (ASBP) Algorithm 3 ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013

JenniferSeger,MD &DeborahBadeHorn,DO,MPH,FASBP CoͲChairs

CoͲauthors: EricC.Westman,MD,MHS DavidA.Bryman DO RichardLindquist,MD,ABFM WilliamMcCarthy,MD WendyScinta,MD,MS EdHendricksMD,FASBP LarryA.Richardson,MD,FASBP BrianN.Sabowitz,MD,FACP CraigPrimack,MD,FACP,FAAP StacyL.Schmidt,PhD HaroldEBaysMD,FTOS,FACE,FNLA Administrativeassistance: LaurieTraetow ,CAE Citation: Seger JC,HornDB,Westman EC,LindquistR,Scinta W,RichardsonLA,PrimackC,BrymanDA,McCarthyW,HendricksE, Sabowitz BN,SchmidtSL,BaysHE.AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposityEvaluation andTreatment2013.www.obesityalgorithm.org (Accessed=[insertdate])

ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013

Purpose

• Toprovidecliniciansanoverviewofprinciples importanttothecareofpatientswith increasedbodyfat,baseduponscientific evidence,supportedbythemedicalliterature, andderivedfromtheclinicalexperiencesof membersoftheAmericanSocietyofBariatric Physicians.

ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013

Process

The ASBP Algorithm was derived from input by volunteer ASBP members consisting of:

• Academicians • Clinicians • Clinicaltrialists • Researchers

The ASBP Algorithm did not receive industry funding, had no input from industry, and the authors received no payment for their contributions.

Copyright©2013ASBP:MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP American Society of Bariatric Physicians (ASBP) Algorithm 6 ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013 Intent of use

The ASBP Algorithm 2013 is intended to be a “living document” updated once a year (as needed), and intended as an educational tool to assist in the translation of medical science and the clinical experience of the authors towards assisting clinicians better manage their overweight and obese patients.

This algorithm is not intended to be interpreted as “rules” and/or directives regarding medical care of an individual patient.

While it is hoped many clinicians may find this algorithm helpful, the final decision regarding the optimal care of the overweight and obese patient is dependent upon the individual clinical presentation, and the judgment of the clinician who is tasked with directing a treatment plan that is in the best interest of the patient.

Copyright©2013ASBP:MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP American Society of Bariatric Physicians (ASBP) Algorithm 7 ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013 Contents: • Overall management goals • Obesity classification • Obesity as a disease • Diagnosis • Overall approach • Fat mass disease • Sick fat disease (adiposopathy) • History • Physical exam • Laboratory evaluation • Treatment • Nutritional therapy • Physical activity • Behavior therapy • Weight management pharmacotherapy • Early versus late weight management intervention • Bariatric surgery • Executive summary • References • Disclosures

Reference/s:[15][32][51][52][53]Copyright©2013ASBP:Maynotbereproducedoralteredinanyformwithoutwrittenpermissionfrom [54][55][56][57][58][59] ASBP American Society of Bariatric Physicians (ASBP) Algorithm 39

AssessforthePresenceofObesity,Adiposopathy,FatMassDisease

Obesitymaybeassessedusingseveralcriteria:presenceofadiposityͲrelateddisease,fatpercent,waist circumferenceorbodymassindex.Thresholdsvarybasedonethnicity. Criteria EdmontonObesity Stage0,1,2,3,4 StagingSystem male<25% male>25% FatPercent female<32% female> 32% male<40in male>40in WaistCircumference female<35in female>35in

BodyMassIndex BMI18.5– 24.9 BMI25.0Ͳ29.9 BMI>30.0

Obesity Prevention NoObesity Overweight BMI30.0Ͳ34.9ClassI BMI35Ͳ39.9ClassII BMI>40.0ClassIII

PrimaryCareProviderorDietitian Consider

Iftreatmentineffective ReferraltoanObesityMedicineSpecialist ASBPObesityAlgorithm:ExecutiveSummary

EdmontonObesityStagingSystem

STAGE0:Noapparentriskfactors(e.g.,bloodpressure,serumlipidandfastingglucoselevelswithinnormalrange), physicalsymptoms,psychopathology,functionallimitationsand/orimpairmentofwellͲbeingrelatedtoobesity STAGE1:PresenceofobesityͲrelatedsubclinicalriskfactors(e.g.,borderlinehypertension,impairedfastingglucose levels,elevatedlevelsof liverenzymes),mildphysicalsymptoms(e.g.dyspneaonmoderateexertion,occasional achesandpains,fatigue),mildpsychopathology,mildfunctionallimitationsand/ormildimpairmentofwellͲbeing STAGE2: PresenceofestablishedobesityͲrelatedchronicdisease(e.g.,hypertension,type2diabetes,sleepapnea, osteoarthritis),moderatelimitationsinactivitiesofdailylivingand/orwellͲbeing) STAGE3: EstablishedendͲorgandamagesuchasmyocardialinfarction,heartfailure,stroke,significant psychopathology,significantfunctionallimitationsand/orimpairmentofwellͲbeing STAGE4:Severe(potentiallyendͲstage)disabilitiesfromobesityͲrelatedchronicdiseases,severedisabling psychopathology,severefunctionallimitationsand/orsevereimpairmentofwellͲbeing [SharmaAM,.Kushner RF Aproposedclinicalstagingsystemforobesity.Int JObesity2009;33:289Ͳ295.]

FatPercent BodyFatPercentcanbecalculatedusingbioimpedance,nearinfraredreactance, DEXAscanorwholeͲbodyͲairͲdisplacementplethysmography. Waistcircumferencecanbemeasuredbytapemeasurearoundtheabdomen WaistCircumference attheleveloftheanteriorsuperioriliaccrests,paralleltothefloor.Tape shouldbesnugagainstskinwithoutcompressing.

BodyMassIndex BodyMassIndex=(weightinkg)/(heightinm)2 OR 703x(weightinpounds)/(heightininches)2

ObesityMedicineSpecialists,certifiedbytheAmericanBoardofObesityMedicine,dedicateaportionoralloftheir practicetothetreatmentofobesity.Theyperformamedicalevaluation(history,physical,laboratory,body composition)andprovidemedicalsupervisionforlifestylechange(nutrition,activity,behaviorchange),medications, orverylowcaloriediets.Obesityisachronicmedicaldisease,andmayrequirelifelongtreatment. ASBPObesityAlgorithm:ExecutiveSummary

ObesityMedicineSpecialistEvaluationmayinclude:

History Weighthistory,pastmedicalhistory,familyhistory,socialhistory,screening forweightpromotingmedications,foodintake,activity,reviewofsystems

PhysicalExamination Height,weight,bloodpressure,bodycompositionanalysis,waist measurement,completephysicalexamination LaboratoryTests Completebloodcount,electrolytes,liverfunction,kidneyfunction,fasting lipidprofile,thyroidtests,hemoglobinA1c,uricacid,vitaminD

DiagnosticTesting EKG,Echocardiogram,exercisestresstest,sleepstudy,bariumswallowor esophagoduodenoscopy

IndividualizedTreatmentPlanmayinclude:

Diet Caloricrestriction,carbohydraterestriction,foodjournaling VeryLowCalorieDiet(VLCD)programs Giveexerciseprescription,usepedometers,limitTVandcomputertime,goal Activity of150minutes/weekofmoderateintensityphysicalactivity

Counseling Eliminateproviderbias/stigma,identifyselfͲsabotage,developstrong support,stressmanagement,sleepoptimization,otherpsychologicalsupport

Pharmacotherapy Usemedicationsaspartof acomprehensiveprogram

Ifineffective,considerreferraltoaMetabolicandBariatricSurgeon. OptimalpreͲ andpostͲoperativebariatricsurgerycareincludesanObesityMedicineSpecialist. Current Treatment Options for Obesity

Surgery

Potency* Lifestyle + Medication

Lifestyle

Risk, Cost

Lifestyle: Includes nutrition, exercise, behavioral programs Lifestyle + Medication: May include Lifestyle, VLCDs w supplements, and weight loss medications Surgery: (in order of lowest risk/cost and potency): Gastric Banding < Gastric Sleeve < Gastric Bypass (Roux-en-Y) * Potency includes many factors such as the amount, rate and sustainability of weight loss, and long-term resolution of adiposopathy and fat mass disease. Potency varies greatly for each individual: long-term adherence to a lifestyle program can be as potent as gastric bypass surgery. American Society of Bariatric Physicians (ASBP) Algorithm 73 References Internet Website References:

[200] Seger JC, Horn DB, Westman EC, Lindquist R, Scinta W, Richardson LA, Primack C, Bryman DA, McCarthy W, Hendricks E, Sabowitz BN, Schmidt S, Bays HE. American Society of Bariatric Physician Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013. www.obesityalgorithm.org

[201] http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf National Heart, Lung, And Blood Institute, North American Association For The Study Of Obesty: The Practical Guide, Identification, Evaluation, And Treatment Of Overweight And Obesity In Adults. (Accessed July 26, 2013)

[202] http://www.acefitness.org/acefit/healthy_living_tools_content.aspx?id=2 American Counsel on Exercise Percent Body Fat (Accessed July 1, 2013)

[203] http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf The International Diabetes Federation consensus worldwide definition of the metabolic syndrome. (Accessed July 27, 2013)

[204] http://dictionary.reference.com Dictonary.com – Definition of Disease. (Accessed July 1, 2013)

[205] https://www.acponline.org/eBizATPRO/images/ProductImages/books/sample%20chapters/Obesity_Ch05.pdf. Mastbaum LI, Gumbiner B. Chapter 5: Medical Assessment and Treatment of the Obese Patient. (Accessed July 26, 2013)

[206] http://www.acsm.org/docs/brochures/pre-participation-physical-examinations.pdf American College of Sports Medicine Information on Pre-Participation Physical Examinations

[207] http://www.health.gov/paguidelines/guidelines/pdf/paguide.pdf US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans (Accessed August 20, 2013)

[208] http://www.belviq.com/pdf/Belviq_Prescribing_information.pdf Belviq Prescribing Information (Accessed July 28, 2013)

[209] http://www.vivus.com/docs/QsymiaPI.pdf Qsymia Prescribing Information (Accessed July 28, 2013)

[210] http://care.diabetesjournals.org/content/36/Supplement_1 American Diabetes Association Clinical Practice Guidelines 2013 (Accessed July 28, 2013)

[211] http://www.nhlbi.nih.gov/about/ncep/ National Heart and Lung Blood Institute, National Cholesterol Education Program (Accessed July 28, 2013)

[212] http://www.nhlbi.nih.gov/guidelines/hypertension/ Blood Pressure in Adults: Systematic Evidence Review from the Joint National Committee (JNC) (Accessed July 28, 2013]

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CoͲchairs: Jennifer Seger MD and Deborah Bade Horn DO report no disclosures.

CoͲauthors: Eric C. Westman MD reports advisor and speaker for Vivus; Richard Lindquist MD reports no disclosures; Wendy Scinta MD reports consultant for Optifast, committee member of OPMC (Office of Professional Misconduct) and expert witness for Bariatric Case Reviews, Medical Director of 3# Health, speaker for Vivus; Larry Richardson MD reports no disclosures; Craig Primack MD reports speaker for Nestle, Vivus and Eisai, and consultant for Vivus; David Bryman DO reports no disclosures; William McCarthy MD reports no disclosures; Ed Hendricks MD reports speaker for Eurodrug Laboratories and Akrimax Pharm, consultant for Citius Pharm and Rodman & Renshaw LLC, and member of GLG Healthcare & Biomedical Council; Brian Sabowitz MD reports speaker for Eisai Pharmaceuticals; Stacy Schmidt PhD reports no disclosures; Harold Bays MD reports having his research site receive research grants from Acurian, Alere, Amarin, Amgen, Ardea, Arena, BoehringerͲ Ingelheim, Cargill, California Raisin Board, Elcelyx, Eli Lilly, Esperion, Essentialis, Forest, Gilead, Given, GlaxoSmithKline, High Point, HoffmanͲLa Roche, Home Access, Johnson & Johnson, Merck, Micropharma, Necktar,Novartis,NovoNordisk,Omthera,Orexigen,Pfizer,Pozen,Regeneron,Takeda,TransTech,Trygg,TWIBio, Vivus, WPU, and Xoma; and has served as a consultant and/or speaker for Amgen, Amarin, BristolͲMyers Squibb, Catabasis, DaiichiͲSankyo, Eisai, Merck, Novo Nordisk, Vivus, and WPU.

ASBP Obesity Algorithm: Adult Adiposity Evaluation and Treatment 2013