Diagnosis and Treatment of Obesity in Adults: An Applied Evidence-Based Review

A. John Orzano; John G. Scott

doi:10.3122/jabfm.17.5.359

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Figure 1.
Treatment flow diagram for obese and overweight patients.

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Table 1.

Effectiveness of Weight Loss Treatments

Strength of Recommendation	Treatment	Comment
A	Dietary therapy	LCDs (1000 to 1200 kcal/day) can reduce total body weight by an average of 8% over 3 to 12 months
		Very-low-calorie diets produce greater initial weight loss than LCDs. However, the long term (>1 year) weight loss is not different from that of LCD
A	Aerobic physical activity	Exercise at 60% to 85% of estimated maximum heart rate over 3 to 7 30- to 60-min sessions per week produce a modest change (3 to 6 lb) at 1 year
A	Diet and physical activity	Combination results 3.3 to 6.6 lb greater weight loss over diet alone up to 2 years
B	Behavior therapy	9 lb over 4 years when used in combination with other weight loss approaches
		No one behavior therapy seemed superior
B	Pharmacotherapy	Part of comprehensive program of diet/exercise for BMI ≥30 or BMI ≥27 with obesity-related risk factors or disease. Produce modest change in weight (3 lb) at 6 months to 1 year
B	Surgery	BMI ≥40 or BMI ≥35 with obesity-related risk factors or disease and after less invasive methods have failed can produce weight loss of 90 lb at 1 year

LCD, low-calorie diet; BMI, body mass index.
Adapted from ref. 6.

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Table 2.

Clinical Trials of Effective Treatments for Weight Loss

Treatment	Reference Citation	Selection Criteria/Sample Size	Duration	Design	Outcome	NNT
Dietary (nutritionists LCD)	34	155 men, age 30 to 59 120% to 160% of IBW	1 year	RCT	Decrease of 8 lb of fat weight (∼10 lb total weight)	9
Exercise (treadmill 30 minutes ∼3 to 5days/week)	34	155 men, age 30 to 59 120% to 160% of IBW	1 year	RCT	Decrease of 8 lb of fat weight (∼10 lb total weight)	17
Combination of Diet and Exercise	65	165 M/F, ≥31 lb overweight, ages 25 to 45	2 years	RCT	Decrease 10 lb of total weight	7
Behavior (psychologists)	78	59 M/F, community volunteers >55 lb overweight	1 year	RCT	Mean weight loss 21 lb at 1 year	Unable to Calculate
Drug sibutramine (and diet) vs diet only 1 year) 10 and 15 mg	45	485 M/F, mean BMI 32.7, ages 27 to 40	1 year	RCT double-blind/placebo	Decrease 10% or more of body weight	8, 4
Drug orlistat 120 mg	39	399 M/F, age >18, BMI 28 to 40, with DM	1 year	RCT double-blind/placebo	Decrease ≥5% of body weight	4
Surgery gastroplasty	71	57 M/F ages, BMI versus VLCD	5 year	RCT	Maintained weight loss of ≥22 lb	8
Surgery gastric bypass/gastroplasty	72	310 M/F, ages 18 to 62, weight 160% to 318% >IBW, gastric bypass/gastroplasty	3 years	RCT	Loss of >50% excess weight	2, 3

LCD, low-calorie diet; IBW, ideal body weight; BMI, body mass index; M/F, men and women; DM, diabetes mellitus; RCT, randomized controlled trial; VLCD, very-low calorie diet; NNT, number needed to treat.

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Table 3.

Key Points For Clinicians Managing Obese Patients

Manage obesity as a chronic relapsing disease.

Use BMI as a tool to establish a diagnosis in obese patients and to decide on treatment.

Modest weight loss (10% reduction in total body weight) results in improvement or prevention of hypertension, diabetes, and hyperlipidemia.

Effective treatments exist for overweight and obese patients. Diet and exercise combined provide the best results. Use sibutramine with caution pending FDA review.

Counsel patients to achieve a goal of 10% reduction in total body weight (500 to 800 kcal/day decrease to affect 1- to 2-lb weight loss/week) rather than attain an ideal body weight

Counsel patients to exercise to achieve increased energy expenditure rather than to attain aerobic fitness.

Consider referral to a behavioral program to leverage your office counseling.

Serve as advocates for social policies that promote good nutrition and increased physical activity.