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. Author manuscript; available in PMC: 2018 Feb 20.
Published in final edited form as: Circulation. 2013 Nov 12;129(25 Suppl 2):S102–S138. doi: 10.1161/01.cir.0000437739.71477.ee

Table 4.

Summary of Recommendations for Obesity

Recommendations NHLBI Grade NHLBI ES ACC/AHA COR ACC/AHA LOE
Identifying Patients Who Need to Lose Weight (BMI and Waist Circumference)
1a. Measure height and weight and calculate BMI at annual visits or more frequently. E (Expert Opinion) CQ2 I C
1b. Use the current cutpoints for overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of mortality from all causes. A (Strong) CQ2 I B
1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. A (Strong) CQ2 I B
1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. E (Expert Opinion) CQ2 IIa B
Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either NIH/NHLBI or WHO/IDF) may continue to be used to identify patients who may be at increased risk until further evidence becomes available.
Matching Treatment Benefits With Risk Profiles (Reduction in Body Weight Effect on Risk Factors for CVD, Events, Morbidity and Mortality)
2. Counsel overweight and obese adults with cardiovascular risk factors (high BP, hyperlipidemia, and hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3%–5% produce clinically meaningful health benefits, and greater weight losses produce greater benefits.

  1. Sustained weight loss of 3%–5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes;

  2. Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose, and lipids as well as further reduce triglycerides and blood glucose.

 A (Strong) CQ1 I A
Diets for Weight Loss (Dietary Strategies for Weight Loss)
3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any one of the following methods can be used to reduce food and calorie intake:

  1. Prescribe 1200–1500 kcal/d for women and 1500–1800 kcal/d for men (kilocalorie levels are usually adjusted for the individual’s body weight);

  2. Prescribe a 500-kcal/d or 750-kcal/d energy deficit; or

  3. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.

 A (Strong) CQ3 I A
3b. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status, and preferably refer to a nutrition professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. A (Strong) CQ3 I A
Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention)
4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies. A (Strong) CQ4 I A
4b. Prescribe on-site, high-intensity (ie, ≥14 sessions in 6 mo) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.† A (Strong) CQ4 I A
4c. Electronically delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist† can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions. B (Moderate) CQ4 IIa A
4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. B (Moderate) CQ4 IIa A
4e. Use a very-low-calorie diet (defined as <800 kcal/d) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high-intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. A (Strong) CQ4 IIa‡ A
4f. Advise overweight and obese individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. A (Strong) CQ4 I A
4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequently) with a trained interventionist† who helps participants engage in high levels of physical activity (ie, 200–300 min/wk), monitor body weight regularly (ie, weekly or more frequently), and consume a reduced-calorie diet (needed to maintain lower body weight). A (Strong) CQ4 I A
Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity)
5a. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. A (Strong) CQ5 IIa§ A
5b. For individuals with a BMI <35 kg/m2, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. N (No Recommendation) CQ5 — —
5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility). E (Expert Opinion) CQ5 IIb C
*

Nutrition professional: In the studies that form the evidence base for this recommendation, a registered dietitian usually delivered the dietary guidance; in most cases, the intervention was delivered in university nutrition departments or in hospital medical care settings where access to nutrition professionals was available.

†

Trained interventionist: In the studies reviewed, trained interventionists included mostly health professionals (eg, registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training) who adhered to formal protocols in weight management. In a few cases, lay persons were used as trained interventionists; they received instruction in weight management protocols (designed by health professionals) in programs that have been validated in high-quality trials published in peer-reviewed journals.

‡

There is strong evidence that if a provider is going to use a very-low-calorie diet, it should be done with high levels of monitoring by experienced personnel; that does not mean that practitioners should prescribe very-low-calorie diets. Because of concern that an ACC/AHA Class I recommendation would be interpreted to mean that the patients should go on a very-low-calorie diet, it was the consensus of the Expert Panel that this maps more closely to an ACC/AHA Class IIa recommendation.

§

There is strong evidence that the benefits of surgery outweigh the risks for some patients. These patients can be offered a referral to discuss surgery as an option. This does not mean that all patients who meet the criteria should have surgery. This decision-making process is quite complex and is best performed by experts. The ACC/AHA criterion for a Class I recommendation states that the treatment/procedure should be performed/administered. This recommendation as stated does not meet the criterion that the treatment should be performed. Thus, the ACC/AHA classification criteria do not directly map to the NHLBI grade assigned by the Expert Panel.

ACC indicates American College of Cardiology; AHA, American Heart Association; BMI, body mass index; BP, blood pressure; COR, Class of Recommendation; CQ, critical question; CVD, cardiovascular disease; ES, evidence statement; HDL-C, high-density lipoprotein cholesterol; IDF, International Diabetes Federation; LDL-C, low-density lipoprotein cholesterol; LOE, Level of Evidence; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Health Institute; WHO, World Health Organization; and —, not applicable.