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Managing Obesity: Clinical Practice Guideline from the ACP

New guidelines on obesity management bring attention to a major public health problem and offer a cautious approach to riskier treatments.

In 2003, the U.S. Preventive Services Task Force recommended that clinicians screen all adults for obesity (body-mass index, >30) and offer intensive behavioral counseling to obese adults (Journal Watch Dec 30 2003). The American College of Physicians now has published guidelines on the management of obesity. They recommend the following:

• Assess comorbid conditions (e.g., hypertension, diabetes).
  
• Determine patients' goals and time frames for achieving them. Goals might be focused on weight loss or on intermediate outcomes, such as blood pressure and blood glucose control.
  
• Provide counseling on weight loss, diet, and physical activity.
  
• Discuss the use of medications (bupropion, diethylpropion, fluoxetine, orlistat, phentermine, sibutramine) with patients who are not meeting their goals through diet and exercise alone. Discuss the modest benefits typically achieved with such drugs (<5 kg loss at 1 year), known risks, lack of long-term safety data, and temporary nature of the weight loss.
  
• Consider surgery for patients with BMIs 40 in whom adequate exercise and diet programs are failing and who have obesity-related comorbidity. Review with them the possible adverse effects of surgery (e.g., gall bladder disease, malabsorption, need for reoperation), as well as the lack of outcome data on these procedures: No randomized trials have been done to compare surgical versus nonsurgical treatment, surgery has no proven benefit in terms of mortality or cardiovascular morbidity, and no single procedure has been proven to be better than another.
  
• Refer patients who choose surgery to experienced surgeons at high-volume centers.
  

Comment: These guidelines (and the underlying evidence reviews) bring attention to a major public health problem and offer a cautious approach to riskier treatments. Clearly, more work should be done to prevent obesity, so that these management guidelines are less necessary.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine April 26, 2005

Citation(s):

Snow V et al. Pharmacologic and surgical management of obesity in primary care: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2005 Apr 5; 142:525-31.

• Original article (Subscription may be required)
• Medline abstract (Free)

Li Z et al. Meta-analysis: Pharmacologic treatment of obesity. Ann Intern Med 2005 Apr 5; 142:532-46.

• Original article (Subscription may be required)
• Medline abstract (Free)

Maggard MA et al. Meta-analysis: Surgical treatment of obesity. Ann Intern Med 2005 Apr 5; 142:547-59.

• Original article (Subscription may be required)
• Medline abstract (Free)