Obesity Education Initiative C LINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS The Evidence Report NATIONAL INSTITUTES OF HEALTH NATIONAL HEART, LUNG, AND BLOOD INSTITUTE C LINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS The Evidence Report NIH PUBLICATION NO. 98-4083 SEPTEMBER 1998 NATIONAL INSTITUTES OF HEALTH National Heart, Lung, and Blood Institute in cooperation with The National Institute of Diabetes and Digestive and Kidney Diseases NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults F. Xavier Pi-Sunyer, M.D., M.P.H. William H. Dietz, M.D., Ph.D. Chair of the Panel Director Chief, Endocrinology, Diabetes, and Nutrition Division of Nutrition and Physical Activity Director, Obesity Research Center National Center for Chronic Disease Prevention St. Luke's/Roosevelt Hospital Center and Health Promotion Professor of Medicine Centers for Disease Control and Prevention Columbia University College of Physicians and Atlanta, GA Surgeons New York, NY John P. Foreyt, Ph.D. Professor of Medicine and Director Diane M. Becker, Sc.D., M.P.H. Nutrition Research Clinic Director Baylor College of Medicine Center for Health Promotion Houston, TX Associate Professor Department of Medicine Robert J. Garrison, Ph.D. The Johns Hopkins University Associate Professor Baltimore, MD Department of Preventive Medicine University of Tennessee, Memphis Claude Bouchard, Ph.D. Memphis, TN Professor of Exercise Physiology Physical Activity Sciences Scott M. Grundy, M.D., Ph.D. Laboratory Director Laval University Center for Human Nutrition Sainte Foy, Quebec University of Texas CANADA Southwestern Medical Center at Dallas Dallas, TX Richard A. Carleton, M.D. Professor of Medicine Barbara C. Hansen, Ph.D. Brown University School of Medicine Professor of Physiology Pawtucket, RI Director of Obesity and Diabetes Research Center University of Maryland School of Medicine Graham A. Colditz, M.D., Dr.P.H. Baltimore, MD Associate Professor of Medicine Harvard Medical School Millicent Higgins, M.D. Channing Laboratory Department of Epidemiology Boston, MA School of Public Health University of Michigan Ann Arbor, MI ii James O. Hill, Ph.D. Albert P. Rocchini, M.D. Associate Director of Research Chief of Cardiology Center for Human Nutrition University of Michigan Medical Center University of Colorado Health Sciences Center Ann Arbor, MI Denver, CO Philip L. Smith, M.D. Barbara V. Howard, Ph.D. Professor of Medicine President Division of Pulmonary and Critical Care Medlantic Research Institute Medicine Washington, DC The Johns Hopkins Asthma and Allergy Center Baltimore, MD Robert C. Klesges, Ph.D. Professor Linda G. Snetselaar, Ph.D., R.D. University of Memphis Prevention Center Associate Professor University of Memphis Head of Preventive Nutrition Education Memphis, TN Department of Preventive Medicine University of Iowa Robert J. Kuczmarski, Dr.P.H., R.D. Iowa City, IA Nutrition Analyst National Center for Health Statistics James R. Sowers, M.D. Centers for Disease Control and Prevention Professor of Medicine and Physiology Hyattsville, MD Director Division of Endocrinology, Metabolism, and Shiriki Kumanyika, Ph.D., R.D., M.P.H. Hypertension Professor and Head Wayne State University School of Medicine Department of Human Nutrition and Dietetics University Health Center The University of Illinois at Chicago Detroit, MI Chicago, IL Michael Weintraub, M.D. R. Dee Legako, M.D. Director Prime Care Canyon Park Family Physicians, Inc. Office of Drug Evaluation V Edmond, OK Food and Drug Administration Rockville, MD T. Elaine Prewitt, Dr.P.H., R.D. Assistant Professor David F. Williamson, Ph.D., M.S. Department of Preventive Medicine and Epidemiologist Epidemiology Division of Diabetes Translation Loyola University Medical Center Centers for Disease Control and Prevention Maywood, IL Chamblee, GA iii G. Terence Wilson, Ph.D. Van S. Hubbard, M.D., Ph.D. Oscar K. Buros Professor of Psychology Director, NIH Division of Nutrition Research Director, Rutgers Eating Disorders Clinic Coordination Piscataway, NJ Chief, Nutritional Sciences Branch National Institute of Diabetes and Digestive and Kidney Diseases Ex-Officio Members National Institutes of Health Bethesda, MD Clarice D. Brown, M.S. Project Manager James P. Kiley, Ph.D.* CODA Research, Inc. Director Silver Spring, MD Airway Biology and Disease Program Division of Lung Diseases Karen A. Donato, M.S., R.D.* National Heart, Lung, and Blood Institute Executive Director of the Panel National Institutes of Health Coordinator Bethesda, MD NHLBI Obesity Education Initiative National Heart, Lung, and Blood Institute Eva Obarzanek, Ph.D., R.D., M.P.H.* National Institutes of Health Research Nutritionist Bethesda, MD Prevention Scientific Research Group Division of Epidemiology and Clinical Nancy Ernst, Ph.D., R.D.* Applications Nutrition Coordinator National Heart, Lung, and Blood Institute Office of the Director National Institutes of Health Division of Epidemiology and Clinical Applications Bethesda, MD National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, MD Consultant D. Robin Hill, Ph.D.* David Schriger, M.D., M.P.H., F.A.C.E.P. Social Science Analyst Associate Professor Behavioral Medicine Branch UCLA Emergency Medicine Center Division of Epidemiology and Clinical University of California at Los Angeles Applications School of Medicine National Heart, Lung, and Blood Institute Los Angeles, CA National Institutes of Health Bethesda, MD San Antonio Cochrane Center Michael J. Horan, M.D., Sc.M.* Director Elaine Chiquette, Pharm.D. Division of Heart and Vascular Diseases V.A. Cochrane Center at San Antonio National Heart, Lung, and Blood Institute Audie L. Murphy Memorial Veterans Hospital National Institutes of Health San Antonio, TX Bethesda, MD * NHLBI Obesity Education Initiative Task Force Members iv Cynthia Mulrow, M.D., M.Sc. V.A. Cochrane Center at San Antonio Audie L. Murphy Memorial Veterans Hospital San Antonio, TX Staff Adrienne Blount, B.S. R.O.W. Sciences, Inc. Rockville, MD Maureen Harris, M.S., R.D. R.O.W. Sciences, Inc. Rockville, MD Anna Hodgson, M.A. R.O.W. Sciences, Inc. Rockville, MD Pat Moriarty, M.Ed., R.D. R.O.W. Sciences, Inc. Rockville, MD The panel acknowledges the assistance of Dr. Rashid Chotani, Johns Hopkins University; Dr. Robert Klesges, University of Memphis; Dr. Walter Pories, East Carolina University; Dr. Ivan Baines, NHLBI; Dr. Christine Kelly, NHLBI; Glen Bennett, NHLBI; Dr. Fred Heydrick, BioReview; Debbie Lurie, Prospect Associates; Estelle Schwalb, Prospect Associates; Lori McCray, R.O.W. Sciences, Inc.; and Niyati Pandya, R.O.W. Sciences, Inc. v Contents Foreword vii 2. Classification of Overweight and Executive Summary xi Obesity 58 C. Assessment of Risk Status 62 1. Introduction 1 D. Evaluation and Treatment Strategy 65 A. Rationale for Guidelines Development 1 E. Exclusion from Weight Loss Therapy 70 B. Objectives of the Guidelines 2 F. Patient Motivation 70 C. Guideline Development Methodology 2 G. Goals of Weight Loss and D. Statement of Assumptions 5 Management 71 E. Intended Users of These Guidelines 5 1. Weight Loss 71 2. Weight Maintenance at 2. Overweight and Obesity: Background 6 Lower Weight 72 A. Health and Economic Costs 6 3. Prevention of Further Weight Gain 73 1. Prevalence and Time Trends 6 H. Strategies for Weight Loss and 2. Demographic Variations in Weight Maintenance 73 Overweight and Obesity Prevalence 9 1. Dietary Therapy 73 3. Economic Costs of Overweight 2. Physical Activity 77 and Obesity 9 3. Behavior Therapy 81 B. Prevention of Overweight and Obesity 11 4. Combined Therapy 83 C. Health Risks of Overweight and Obesity 12 5. Pharmacotherapy 83 1. Morbidity 12 6. Surgery 86 2. Overweight/Obesity and Morbidity I. Smoking Cessation in the Overweight in Minority Populations 23 or Obese Patient 91 3. Obesity and Mortality 23 J. Role of Health Professionals in D. Weight Loss and Mortality 25 Weight Loss Therapy 92 E. Environment 26 F. Genetic Influence in the Development 5. Summary of Recommendations 95 of Overweight and Obesity 27 6. Future Research 98 3 Examination of Randomized Controlled A. Intervention Approaches 98 Trial Evidence 29 B. Causes and Mechanisms of A. Why Treat Overweight and Obesity? 29 Overweight and Obesity 99 1. Blood Pressure 29 C. Abdominal Fat, Body Weight and 2. Serum/Plasma Lipids and Disease Risk 99 Lipoproteins 33 D. Assessment Methods 99 3. Impaired Glucose Tolerance and Diabetes 39 7. Appendices 100 4. Decreases in Abdominal Fat with Appendix I.A.1 Guidelines Development Weight Loss 41 Methodology 100 B. What Treatments are Effective? 42 Appendix I.A.2 Literature Review 109 1. Dietary Therapy 42 Appendix II Description of Evidence 112 2. Physical Activity 44 Appendix III Special Populations 117 3. Combined Therapy 47 Appendix IV Obesity and Sleep Apnea 137 4. Behavior Therapy 48 Appendix V Body Mass Index Chart— 5. Pharmacotherapy 53 How to Measure Obesity 139 6. Surgery 54 Appendix VI Practical Dietary Therapy 7. Other Interventions for Overweight Information 141 and Obesity Treatment 55 Appendix VII Resource List 165 Appendix VIII Glossary of Terms 168 4. Treatment Guidelines 56 A. Overview 56 List of Abbreviations 179 B. Assessment and Classification of Reference List 181 Overweight and Obesity 56 1. Assessment of Overweight and Publication List 226 Obesity 56 vi FOREWORD In 1995, the National Obesity Education