- Record: found
- Abstract: found
- Article: found
Probability of 5% or Greater Weight Loss or BMI Reduction to Healthy Weight Among Adults With Overweight or Obesity
research-article
Author(s):
Lyudmyla Kompaniyets , PhD
1
,
,
David S. Freedman , PhD
1 ,
Brook Belay , MD
1 ,
Samantha L. Pierce , MPH
1 ,
Emily M. Kraus , PhD
1
,
2
,
3 ,
Heidi M. Blanck , PhD
1 ,
Alyson B. Goodman , MD, MPH
1
Publication date (Electronic):
7 August 2023
Journal:
JAMA Network Open
Publisher:
American Medical Association
Read this article at
There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
This cohort study evaluates the changes over 3 to 14 years in body mass index and the differences in these changes by sex and race and ethnicity of US ambulatory patients.
Key Points
Question
What is the probability of health care–seeking adults with overweight or obesity observing a 5% or greater weight loss or body mass index (BMI) reduction to the healthy weight category?
Findings
In this cohort study of 18 461 623 US patients with overweight and obesity, the annual probability of 5% or greater weight loss was low (1 in 10) but increased with higher initial BMI. The annual probability of reducing BMI to the healthy weight category was less likely, especially for individuals with initial BMI of 45 or higher.
Abstract
Importance
Information on the probability of weight loss among US adults with overweight or obesity is limited.
Objective
To assess the probability of 5% or greater weight loss, 10% or greater weight loss, body mass index (BMI) reduction to a lower BMI category, and BMI reduction to the healthy weight category among US adults with initial overweight or obesity overall and by sex and race.
Design, Setting, and Participants
This cohort study obtained data from the IQVIA ambulatory electronic medical records database. The sample consists of US ambulatory patients 17 years or older with at least 3 years of BMI information from January 1, 2009, to February 28, 2022. Minimum age was set at 17 years to allow for the change in BMI or weight starting at 18 years. Maximum age was censored at 70 years.
Exposures
Initial BMI (calculated as weight in kilograms divided by height in meters squared) category was the independent variable of interest, and the categories were as follows: lower than 18.5 (underweight), 18.5 to 24.9 (healthy weight), 25.0 to 29.9 (overweight), 30.0 to 34.9 (class 1 obesity), 35.0 to 39.9 (class 2 obesity), and 40.0 to 44.9 and 45.0 or higher (class 3 or severe obesity).
Main Outcomes and Measures
The 2 main outcomes were 5% or greater weight loss (ie, a ≥5% reduction in initial weight) and BMI reduction to the healthy weight category (ie, BMI of 18.5-24.9).
Results
The 18 461 623 individuals in the sample had a median (IQR) age of 54 (40-66) years and included 10 464 598 females (56.7%) as well as 7.7% Black and 72.3% White patients. Overall, 72.5% of patients had overweight or obesity at the initial visit. Among adults with overweight and obesity, the annual probability of 5% or greater weight loss was low (1 in 10) but increased with higher initial BMI (from 1 in 12 individuals with initial overweight to 1 in 6 individuals with initial BMI of 45 or higher). Annual probability of BMI reduction to the healthy weight category ranged from 1 in 19 individuals with initial overweight to 1 in 1667 individuals with initial BMI of 45 or higher. Both outcomes were generally more likely among females than males and were highest among White females. Over the 3 to 14 years of follow-up, 33.4% of persons with overweight and 41.8% of persons with obesity lost 5% or greater of their initial weight. At the same time, 23.2% of persons with overweight and 2.0% of persons with obesity reduced BMI to the healthy weight category.
Conclusions and Relevance
Results of this cohort study indicate that the annual probability of 5% or greater weight loss was low (1 in 10) despite the known benefits of clinically meaningful weight loss, but 5% or greater weight loss was more likely than BMI reduction to the healthy weight category, especially for patients with the highest initial BMIs. Clinicians and public health efforts can focus on messaging and referrals to interventions that are aimed at clinically meaningful weight loss (ie, ≥5%) for adults at any level of excess weight.
Related collections
Most cited references46
- Record: found
- Abstract: found
- Article: not found
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover 3 main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors, to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Eighteen items are common to all 3 study designs and 4 are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available at http://www.annals.org and on the Web sites of PLoS Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
- Record: found
- Abstract: found
- Article: found
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies
Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study’s generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control and cross-sectional studies. We convened a two-day workshop, in September 2004, with methodologists, researchers and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results and discussion sections of articles. Eighteen items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the web sites of PLoS Medicine, Annals of Internal Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
- Record: found
- Abstract: found
- Article: found
2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults
Michael D. Jensen, Donna Ryan, Caroline M Apovian … (2013)
Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk The goals of the American College of Cardiology (ACC) and the American heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National heart, lung, and blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults. In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence, and craft recommendations. In response to the 2011 report from the Institute of Medicine on the development of trustworthy clinical guidelines, 1 the NHLBI Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations. 2, 3 Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the Expert Panels/Work groups did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA, and collaborating societies plan to begin updating these guidelines starting in 2014. The joint ACC/AHA task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations, and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBI Advisory Council, key federal agencies, and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes because the bulk of the content was undisputed. Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs on each topic based on the highest-quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel/Work group reports include more detailed information about the evidence statements (ESs) that serve as the basis for recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Classification of Recommendation/Level of evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable. In consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA requested that panel authors resubmit RWI disclosures as of July 2013. Relationships relevant to this guideline are disclosed in Appendix 1. None of the ACC/AHA expert reviewers had relevant RWI (Appendix 2). See Appendix 3 for a list of abbreviations used in this guideline. Systematic evidence reports and accompanying summary tables were developed by the expert panels and NHLBI. The guideline was reviewed by the ACC/AHA Task Force and approved by the ACC board of trustees, the AHA Science Advisory and Coordinating Committee, and The Obesity Society. In addition, ACC/AHA sought endorsement from other stakeholders, including professional organizations. It is the hope of the writing panels, stakeholders, professional organizations, NHLBI, and Task Force that the guidelines will garner the widest possible readership for the benefit of patients, providers, and the public health. These guidelines are meant to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, clinicians can employ the recommendations confidently to reduce the risks of atherosclerotic CVD events. See Tables 2 and 3 for an explanation of the NHLBI recommendation grading methodology. 1. Introduction/Scope of Guideline More than 78 million adults in the United States were obese in 2009 and 2010. 4 Obesity raises the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes mellitus (diabetes), coronary heart disease (CHD), stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers. Obesity is also associated with increased risk of all-cause and CVD mortality. The biomedical, psychosocial, and economic consequences of obesity have substantial implications for the health and well-being of the US population. According to the 1998 “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report,” 5 overweight is defined as a body mass index (BMI) of 25 kg/m2 to 29.9 kg/m2 and obesity as a BMI of ≥30 kg/m2. Current estimates are that 69% of adults are either overweight or obese, with approximately 35% obese. 6 These latest data from the National Health and Nutrition Examination Surveys indicate that for both men and women, obesity estimates for 2009 and 2010 did not differ significantly from estimates for 2003 to 2008 and that increases in the prevalence rates of obesity appear to be slowing down or leveling off. 6 Nevertheless, overweight and obesity continue to be highly prevalent, especially in some racial and ethnic minority groups, as well as in those with lower incomes and less education. Overweight and obesity are major contributors to chronic diseases in the united states and present a major public health challenge. Compared with normal-weight individuals, obese patients incur 46% higher inpatient costs, 27% more physician visits and outpatient costs, and 80% higher spending on prescription drugs. 7 the medical care costs of obesity in the United States are staggering. In 2008 dollars, these costs totaled about $147 billion. 7 The Expert Panel was first convened in September 2008 by the NHLBI in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases to update the 1998 Clinical Guidelines Report. 5 The Expert Panel considered new evidence related to key issues on overweight and obesity evaluation and treatment, particularly in individuals with other risk factors for CVD and diabetes. The key issues identified included the appropriateness of the current BMI and waist circumference cutpoints that are used for determining risk in overweight and obese adults across diverse populations; the impact of weight loss on risk factors for CVD and type 2 diabetes, as well as CVD morbidity and mortality; optimal behavioral, dietary intervention, and other lifestyle treatment approaches for weight loss and weight loss maintenance; and benefits and risks of various bariatric surgical procedures. The Expert Panel’s ultimate goal was to systematically develop ESs and recommendations for 5 CQs to assist clinicians in primary care. The recommendations are based on evidence from a rigorous systematic review and synthesis of recently published medical literature. This guideline is based on the Full Panel Report, which is provided as an online-only data supplement to the guideline. The Full Panel Report contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review, which can be found at http://www.nhlbi.nih.gov/guidelines/obesity/ser/. Refer to the “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults,” “2013 AHA/ACC guideline on Lifestyle Management to Reduce Cardiovascular Risk,” and “2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk” 8–10 for topics outside the scope of the 2013 AHA/ACC/TOS Obesity Guideline. 1.1. Rationale for Updating Obesity Clinical Guidelines The NHLBI, in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases, released the 1998 “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report” 11 as a systematic review of the published scientific literature found in MEDLINE from January 1980 to September 1997 on important topics reviewed by the Expert Panel. The published literature was evaluated to determine appropriate treatment strategies that would constitute evidence-based clinical guidelines on overweight and obesity. The San Antonio Cochrane Center assisted in literature abstraction and in organizing the data into evidence tables, and a methodology consultant worked with the Expert Panel to develop ESs and recommendations. In 2005, the NHLBI initiated the process to update the overweight/obesity guidelines and convened stakeholder groups to provide input on what should be the next-generation guideline development process. The resulting recommendations were used to design the process. To continually improve the quality and impact of the guidelines, the process was updated to assure rigor and minimize bias through the use of strict, evidence-based methodologies to guide the development of ESs and recommendations based on a systematic review of the biomedical literature for a specific period of time. 1.2. CQ-Based Approach The Expert Panel began its deliberations by developing 23 possible CQs, and after considerable discussion, narrowed the possibilities to 5 targeted CQs. Questions were chosen to aid primary care practitioners (PCPs) and providers who frequently work with obese patients to identify patients at health risk of weight-related comorbidities and to update them on the benefits and risks of weight loss achieved by various approaches. Examples of CQs that were not included for this review included consideration of genetics of obesity, binge-eating disorders, pharmacotherapy, and cost-effectiveness of interventions to manage obesity. For each of the chosen CQs, Expert Panel members reviewed the final list of included and excluded articles, along with the quality ratings, and had the opportunity to raise questions and appeal the ratings to the methodology team. The team then reexamined these articles and presented their rationale for either keeping or changing the quality rating of the articles. Expert Panel members also played a key role in examining the evidence tables and summary tables to be certain the data from each article were accurately displayed. The body of the present report is organized by CQ and the following information is included for each CQ: The rationale for its selection is provided, and methods are described. The body of evidence is summarized, and ESs are presented, which include a rating for quality and a supportive narrative summary. Recommendations and their strength are accompanied by a narrative summary of how the recommendation was derived from the evidence and a discussion of issues considered by the Expert Panel in formulating the recommendation. CQ1 and CQ2 were chosen to help providers determine the appropriate criteria to guide a weight loss recommendation. CQ1 addresses the expected health benefits of weight loss as a function of the amount and duration of weight loss. CQ2 addresses the health risks of overweight and obesity and seeks to determine if the current waist circumference cutpoints and the widely accepted BMI cutpoints defining persons as overweight (BMI 25–29.9 kg/m2) and obese (BMI ≥30 kg/m2) are appropriate for population subgroups. Because patients are interested in popular diets that are promoted for weight loss and see the PCP as an authoritative source of information, CQ3 asks which dietary intervention strategies are effective for weight loss efforts. CQ4 seeks to determine the efficacy and effectiveness of a comprehensive lifestyle approach (diet, physical activity, and behavior therapy) to achieve and maintain weight loss. CQ5 seeks to determine the efficacy and safety of bariatric surgical procedures, including benefits and risks. CQ5 also seeks to determine patient and procedural factors that may help guide decisions to enhance the likelihood of maximum benefit from surgery for obesity and related conditions. 1.3. Organization of the Panel In 2007, the NHLBI sought nominations for panel membership that would ensure adequate representation of key specialties and appropriate expertise. The NHLBI staff reviewed the nominees and selected potential chairs and co-chairs for the panels. A Guidelines Executive Committee was formed, consisting of the chairs from each of the 3 panels (obesity, high blood pressure [BP], and high blood cholesterol) and 3 cross-cutting working groups (lifestyle, risk assessment, and implementation). This committee worked with the NHLBI to select panel members from the list of nominees. The Obesity Expert Panel comprised 15 members and 3 ex-officio members, including individuals with specific expertise in psychology, nutrition, physical activity, bariatric surgery, epidemiology, internal medicine, and other clinical specialties. The full Obesity Expert Panel met 23 times throughout the years (5 times face-to-face and 18 times via Webinar). Expert Panel chairs asked all members to disclose any conflicts of interest to the full Expert Panel in advance of the deliberations; members with conflicts were asked to recuse themselves from voting on any aspect of the guideline for which a conflict might exist. Each of the 5 CQs had working groups consisting of a leader and various Expert Panel members who met via conference calls to discuss all aspects of the CQ; to review the list of included and excluded articles along with the quality ratings; to review the evidence tables and summary tables; and to develop spreadsheets, ESs, resulting recommendations, and research/evidence gaps. Expert Panel members had the opportunity to raise questions about the included and excluded articles, submit additional articles that were not identified in the original search, appeal the quality ratings on articles, and question articles that were excluded. Each working group presented their findings to the full Expert Panel for all final decisions on ESs and recommendations, including the strength of the evidence. The evidence-based process followed most of the standards from the Institute of Medicine’s report, Clinical Practice Guidelines We Can Trust. 1 The process had support from a methodology contractor and a systematic review and general support contractor and included the following steps: Constructed CQs relevant to clinical practice. Identified (a priori) inclusion/exclusion (I/E) criteria for each CQ. Developed a literature search strategy, based on I/E criteria, for each CQ. Executed a systematic electronic search of the published literature from relevant bibliographic databases for each CQ. The date range for the overall literature search was from January 1998 to December 2009. Because CQ1 and CQ2 used systematic reviews and meta-analyses, the literature search included those published from January 2000 to October 2011. CQ3 and CQ4 added major randomized controlled trials (RCTs) published after 2009 with >100 people per treatment arm. CQ5 added some major studies published after 2009 that met the I/E criteria. Screened, by 2 independent reviewers, thousands of abstracts and full-text articles returned from the search to identify relevant original articles, systematic reviews, and meta-analyses. Rigorous validation procedures were applied to ensure that the selected articles met the pre-established detailed I/E criteria before being included in the final review results. Determined, by 2 independent raters on the methodology team, the quality of each included study (good, fair, and poor). Abstracted relevant information from the included studies into an electronic central repository database using common templates and types of data elements. Constructed detailed evidence tables, which organized the data from the abstraction database. Analyzed the evidence tables and constructed summary tables, which display the evidence in a manageable format to answer specific parts of each CQ. Used summary tables to develop ESs for each CQ. The quality of evidence for each ES was graded as high, moderate, or low on the basis of scientific methodology, scientific strength, and consistency of results. For CQ1 and CQ2, spreadsheets with relevant data from systematic reviews and meta-analyses were developed rather than summary tables. Used the graded ESs to write clinical recommendations, and graded the strength of each recommendation. Recommendations were graded as Strong Recommendation (Grade A), Moderate Recommendation (Grade B), Weak Recommendation (Grade C), Recommendation Against (Grade D), Expert Opinion (Grade E), or No Recommendation For or Against (Grade N). Performed Guideline Implementability Appraisals, planned and coordinated by the NHLBI Implementation Work Group, to identify and address barriers to guideline implementation. 1.4. Document Review and Approval A formal peer review process was initially completed under the auspices of the NHLBI and included 10 expert reviewers and representatives from multiple federal agencies. This document was also reviewed by 6 expert reviewers nominated by the ACC, AHA, and The Obesity Society after the management of the guideline transitioned to the ACC/AHA. The ACC, AHA, and The Obesity Society reviewers’ RWI information is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC, the AHA, and The Obesity Society and is endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Parenteral and Enteral Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, The Endocrine Society, and WomenHeart: The National Coalition for Women With Heart disease. 2. Obesity Recommendations and Algorithm 2.1. Summary of Evidence-Based Recommendations The recommendations in Table 4 serve as a guide for PCPs in making evaluations and treatment decisions for overweight and obese patients. The CQs answered by evidence-based recommendations summarize current literature on the risks of over-weight and obesity and the benefits of weight loss. They also summarize knowledge on the best diets for weight loss, the efficacy and effectiveness of comprehensive lifestyle interventions on weight loss and weight loss maintenance, and the benefits and risks of bariatric surgery. This information will help PCPs decide who should be recommended for weight loss and what health improvements can be expected. The Expert Panel did not choose a CQ that dealt with various aspects of pharmacotherapy for a comprehensive evidence assessment, because at the time the CQs were chosen there was only one approved medication (orlistat) for weight loss. However, CQ1 includes some ESs on the efficacy of orlistat because the effect of pharmacotherapy on weight loss was included in its evidence review. 2.2. Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity—Treatment Algorithm The Expert Panel provides a treatment algorithm, Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity (Figure 1), to guide PCPs in the evaluation, prevention, and management of excess body weight in their patients. The algorithm incorporates, wherever possible, the recommendations derived from the 5 CQs that yielded ESs and recommendations. However, because the 5 CQs that were considered did not cover the entire scope of evaluation, prevention, and management of overweight/obesity, the panelists provided advice based on other guidelines and expert opinion to give providers a more comprehensive approach to their patients with weight-related issues. The algorithm is not intended to supplant initial assessment for cardiovascular risk factors or diseases but rather focuses on the identification of patients with excess body weight and those at risk for obesity-related health problems. Its purpose is to guide weight management decision making. The algorithm incorporates the recommendations from CQ3 and CQ4 that patients who have sufficient health risk from overweight or obesity receive comprehensive lifestyle intervention. These approaches were all found effective under conditions in which multidisciplinary teams of medical, nutrition, and behavioral experts and other highly trained professionals worked intensively with individuals on weight management. This intervention should be foundational to additional weight management efforts, such as medications or bariatric surgery. It also emphasizes a fundamental principle of chronic disease management—that is, the need to complement a committed patient with informed providers to effectively manage a chronic condition like obesity and its associated cardiovascular risk factors. 3. CQs and Corresponding ESs Each of the CQs are stated below, together with the number of articles screened against their individual I/E criteria and the number of articles that met the inclusion criteria and were rated as fair or good quality. For CQs that did not have many articles rated fair or good, the articles rated as poor were used (ie, CQ2). The resulting ESs reflect the Expert Panel’s review of the literature. The stated strength of evidence applies to the overall ES, including any bulleted items, unless noted otherwise. 3.1. CQ1: Statement of the Question Among overweight and obese adults, does achievement of reduction in body weight with lifestyle and pharmacological interventions affect cardiovascular risk factors, CVD events, morbidity, and mortality? 1a Does this effect vary across population subgroups defined by the following demographic and clinical characteristics: Age Sex Race/ethnicity Baseline BMI Baseline waist circumference Presence or absence of comorbid conditions Presence or absence of cardiovascular risk factors 1b What amount (shown as percent lost, pounds lost, etc.) of weight loss is necessary to achieve benefit with regard to cardiovascular risk factors, morbidity, and mortality? Are there benefits of cardiovascular risk factors, CVD events, morbidity, and mortality from weight loss? What are the benefits of more significant weight loss? 1c What is the effect of sustained weight loss for ≥2 years in individuals who are overweight or obese, on cardiovascular risk factors, CVD events, and health and psychological outcomes? What percent of weight loss needs to be maintained at ≥2 years to be associated with health benefits? CQ1 was initially intended to be a de novo systematic review of original studies plus systematic reviews and meta-analyses. Because of resource and time constraints, CQ1 was restricted to systematic reviews and meta-analyses published only between January 2000 and October 2011. The titles and abstracts of 1630 publications were screened against the I/E criteria independently by 2 reviewers, which resulted in 669 publications being excluded and 697 publications being retrieved for full-text review to further assess eligibility.* Six hundred ninety-seven full-text publications were independently screened by 2 reviewers, who assessed eligibility by applying the I/E criteria; 669 of these publications were excluded on the basis of ≥1 of the I/E criteria. Of the 697 full-text publications, 42 publications met the criteria and were included. The quality (internal validity) of these 42 publications was assessed using the quality assessment tool developed to assess systematic reviews, meta-analyses, or RCTs. Of these, 14 publications were rated as poor quality. The remaining 28 publications were rated to be of good or fair quality and were included in the evidence base that was used to formulate the ESs and recommendations. 12–39 Although the issue of pharmacotherapy was not by itself a CQ, CQ1 was tasked to evaluate this evidence, and several meta-analyses included the effect of orlistat on weight loss and risk factors. None of the systematic reviews or meta-analyses included the Look AHEAD (Action for Health in Diabetes) trial data, which the Expert Panel considered unique in that the number of participants equaled or exceeded the total number of observations in most systematic reviews and meta-analyses. The Look AHEAD papers were included in the database as a critical supplement to the systematic review and meta-analysis information. The ESs were developed from the published literature available as of October 2011 and could not take into account published or unpublished reports of outcomes subsequent to the approval of the statements. The following ESs reflect the Expert Panel’s review of the literature. See the Full Panel Report supplement for the supportive evidence and spreadsheets. 3.1.1. Weight Loss and Risk of Diabetes ES1 In overweight and obese adults at risk for type 2 diabetes, average weight losses of 2.5 kg to 5.5 kg at ≥2 years achieved with lifestyle intervention (with or without orlistat) reduce the risk of developing type 2 diabetes by 30% to 60%. Strength of Evidence: High ES2 In overweight and obese adults with type 2 diabetes, 2% to 5% weight loss achieved with 1 to 4 years of lifestyle intervention (with or without orlistat) results in modest reductions in fasting plasma glucose concentrations and lowering of hemoglobin A1c by 0.2% to 0.3%. Strength of Evidence: High ES3 In overweight and obese adults with type 2 diabetes, those who achieve greater weight loss at 1 year with lifestyle intervention (with or without orlistat) have greater improvements in hemoglobin A1c. Weight loss of 5% to 10% is associated with hemoglobin A1c reductions of 0.6% to 1.0% and reduced need for diabetes medications. Strength of Evidence: High ES4 In overweight and obese adults with type 2 diabetes treated for 1 year with lifestyle intervention (with or without orlistat), those who lose more weight achieve greater reductions in fasting plasma glucose concentrations. Those who achieve weight losses of 2% to 5% are more likely to have clinically meaningful (>20 mg/dL) reductions in fasting glucose than those who remain weight stable (defined as gaining ≤2% or losing 102 cm (male) and >88 cm (female) associated with elevated CVD-related risk? How do these cutpoints compare with other cutpoints in terms of elevated CVD-related risk and overall mortality? Fatal and nonfatal CHD, stroke, and CVD (CHD and stroke) Overall mortality Incident type 2 diabetes Incident dyslipidemia Incident hypertension 2b Are differences across population subgroups in the relationships of BMI and waist circumference cutpoints with CVD, its risk factors, and overall mortality sufficiently large to warrant different cutpoints? If so, what should they be? Fatal and nonfatal CHD, stroke, and CVD Overall mortality Incident type 2 diabetes Incident dyslipidemia Incident hypertension Groups being considered include: Age Sex (both male and female) Race/ethnicity(African American, Hispanic, Native American, Asian, white) 2c What are the associations between weight maintenance and weight gain with elevated CVD-related risk in normal-weight, overweight, and obese adults? Because of resource limitations, the literature search for CQ2 was limited to studies published between 2000 and 2011, and the evidence review limited to systematic reviews, meta-analyses, and pooled analyses, to limit the number of individual articles to be searched, reviewed, and quality rated. Expert Panel members excluded studies that focused on specific subpopulations with a disease or condition (eg, women with breast cancer, adults on maintenance hemodialysis) and constructed summary evidence tables from the identified articles, and these tables were reviewed and checked by contractor staff for accuracy. Of the 1571 articles initially screened, 15 of the 482 full-text publications met the I/E criteria and were included. The quality (internal validity) of these 15 publications was assessed using the quality assessment tool developed to assess systematic reviews and meta-analyses. Of these, 3 publications were rated as fair 40–42 ; the rest were rated as poor quality but were included in the evidence base because the NHLBI policy indicated that poor studies could be used as part of the evidence base if the majority of included studies were not rated good or fair. The following ESs reflect the Expert Panel's review of the literature. 3.2.1. Current BMI Cutpoints and CVD-Related Risk and All-Cause Mortality ES1 Among overweight and obese adults, analyses of continuous BMI show that the greater the BMI, the higher the risk of fatal CHD and combined fatal and nonfatal CHD. The current cutpoints for overweight (BMI ≥25.0 kg/m2) and obesity (BMI ≥30 kg/m2) compared with normal weight (BMI 18.5 to 40% of total calories from fat). Comprehensive programs of lifestyle change were used in all trials. Comparator diets had ≥40% of total calories from fat, either with a low-carbohydrate or low-glycemic-load diet or one that targets higher fat with either average or low protein. Strength of Evidence: Moderate ES4b With moderate weight loss, lower-fat, higher-carbohydrate diets, compared with higher-fat, lower-carbohydrate diets, have the following differential effects: Greater reduction in LDL-C, Lesser reduction in serum triglycerides, and Lesser increases in HDL-C. Strength of Evidence: Moderate ES4c Evidence is inconsistent with regard to BP differences between lower-fat, higher-carbohydrate diets and higher-fat, lower-carbohydrate diets. Strength of Evidence: Low 3.3.4. Higher-Protein Approaches (25% to 30% of Energy) ES5a In overweight and obese adults, recommendations to increase dietary protein (25% of total calories) as part of a comprehensive weight loss intervention results in weight loss equivalent to that achieved with a typical protein diet (15% of total calories) when both diets are calorie restricted (500- to 750-kcal/d deficit). Strength of Evidence: High ES5b In overweight and obese adults, high-protein diets (25% of total calories) do not result in more beneficial effects on cardiovascular risk factors than typical protein diets (15% of total calories) in the presence of weight loss and other macronutrient changes. Strength of Evidence: Low ES5c On the basis of studies conducted in settings where all food is provided to deliver increased protein (25% of total calories) either as part of caloric restriction or with ad libitum energy consumption, there is insufficient evidence to inform recommendations for weight loss interventions in free-living overweight or obese individuals. 3.3.5. Low-Carbohydrate Approaches ( 1 year). Behavior therapy: Comprehensive lifestyle interventions usually provide a structured behavior change program that includes regular self-monitoring of food intake, physical activity, and weight. These same behaviors are recommended to maintain lost weight, with the addition of frequent (ie, weekly or more often) monitoring of body weight. Strength of Evidence: High 3.4.2. Comprehensive Interventions Compared With Usual Care, Minimal Care, or No-Treatment Control ES2a (Short-Term Weight Loss) In overweight and obese individuals in whom weight loss is indicated and who wish to lose weight, comprehensive lifestyle interventions consisting of diet, physical activity, and behavior therapy (all 3 components) produce average weight losses of up to 8 kg in 6 months of frequent (ie, initially weekly) on-site treatment provided by a trained interventionist† in group or individual sessions. Such losses (which can approximate reductions of 5% to 10% of initial weight) are greater than those produced by usual care (ie, characterized by the limited provision of advice or educational materials). Comparable 6-month weight losses have been observed in treatment-comparison studies of comprehensive lifestyle interventions, which did not include a usual-care control group. Strength of Evidence: High ES2b (Intermediate-Term Weight Loss) Longer-term comprehensive lifestyle interventions, which additionally provide weekly to monthly on-site treatment for another 6 months, produce average weight losses of up to 8 kg at 1 year, losses that are greater than those resulting from usual care. Comparable 1-year weight losses have been observed in treatment-comparison studies of comprehensive lifestyle interventions, which did not include a usual-care control group. Strength of Evidence: Moderate ES2c (Long-Term Weight Loss) Comprehensive lifestyle interventions that, after the first year, continue to provide bimonthly or more frequent intervention contacts, are associated with gradual weight regain of 1 to 2 kg/y (on average) from the weight loss achieved at 6 to 12 months. Long-term (>1 y) weight losses, however, remain larger than those associated with usual care. Comparable findings have been observed in treatment-comparison studies of comprehensive lifestyle interventions, which did not include a usual-care control group. Strength of Evidence: High 3.4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving Weight Loss ES3 Electronically delivered, comprehensive weight loss interventions developed in academic settings, which include frequent self-monitoring of weight, food intake, and physical activity—as well as personalized feedback from a trained interventionist†—can produce weight loss of up to 5 kg at 6 to 12 months. This loss is greater than that resulting from no or minimal intervention (ie, primarily knowledge based) offered on the Internet or in print. Strength of Evidence: Moderate 3.4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions in Achieving Weight Loss ES4 In comprehensive lifestyle interventions that are delivered by telephone or face-to-face counseling and that also include the use of commercially-prepared prepackaged meals or an interactive Web-based program, the telephone-delivered and face-to-face–delivered interventions produce similar mean net weight losses of approximately 5 kg at 6 months and 24 months, compared with a usual-care control group. Strength of Evidence: Low 3.4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within a Primary Care Practice Setting Compared With Usual Care ES5 In studies to date, low- to moderate-intensity lifestyle interventions for weight loss provided to overweight or obese adults by primary care practices alone have not been shown to be effective. Strength of Evidence: High 3.4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions in Achieving Weight Loss ES6 Commercial-based, comprehensive weight loss interventions that are delivered in person have been shown to induce an average weight loss of 4.8 kg to 6.6 kg at 6 months in 2 trials when conventional foods are consumed and 6.6 kg to 10.1 kg at 12 months in 2 trials with provision of prepared food. These losses are greater than those produced by minimal-treatment control interventions. Strength of Evidence: Low 3.4.7. Efficacy/Effectiveness of Very–Low-Calorie Diets as Used as Part of a Comprehensive Lifestyle Intervention in Achieving Weight Loss ES7a Comprehensive, high-intensity, on-site lifestyle interventions that include a medically supervised very–low-calorie diet (often defined as 40 who achieve a mean long-term weight loss of 16%. Strength of Evidence: Low ES3 There are insufficient data on the efficacy of bariatric surgical procedures for weight loss and maintenance or risk factors for CVD ≥2 years after surgery in patients with a BMI 30 days) complications after bariatric surgery vary by procedure and patient-derived risk factors. When LAGB is performed by an experienced surgeon: Perioperative complications are infrequent and do not tend to be life-threatening: major adverse outcomes (1%), such as deep venous thrombosis and reoperations, and minor complications (3%), such as wound infection. Strength of Evidence: Moderate Longer-term complications continue to occur over time and may require operative correction: misplacement of band, approximately 3% to 4%; erosion of gastric wall, approximately 1%; and port complication, 5% to 11%. Strength of Evidence: Moderate The rate of longer-term LAGB failure leading to removal of the band with or without conversion to another bariatric procedure varies from 2% to 34%. Inadequate weight loss is the most often reported basis for removal of band. Strength of Evidence: Moderate 3.5.3.2. Roux-en-Y Gastric Bypass ES6 (continued) Perioperative (≤ 30 days) and longer-term (>30 days) complications after bariatric surgery vary by procedure and patient-derived risk factors. When gastric bypass is performed by an experienced surgeon: Perioperative complications consist of a major adverse outcome in approximately 4% to 5% of patients, including mortality (0.2%), deep vein thrombosis and/or pulmonary embolism (0.4%), and a need for reoperation (3% to 5%). The rate of any complication, major or minor, is 2% to 18%. Strength of Evidence: Moderate Perioperative complications are less frequent for the laparoscopic approach than for open incision. Strength of Evidence: Moderate When open gastric bypass is performed by an experienced surgeon: Perioperative complications consist of a major adverse outcome in approximately 8% of patients, including mortality (2%), deep vein thrombosis or pulmonary embolism (1%), and a need for reoperation (5%). Strength of Evidence: Low Perioperative complications are associated with extremely high BMI, inability to walk 200 feet, history of deep vein thrombosis or pulmonary embolism, and history of obstructive sleep apnea. Strength of the Evidence: Low 3.5.3.3. Biliopancreatic Diversion ES6 (continued) Perioperative (≤ 30 days) and longer-term (>30 days) complications after bariatric surgery vary by procedure and patient-derived risk factors. The mortality rate for BPD was reported by 2 of the 3 included studies. When BPD is performed by an experienced surgeon: Perioperative complications occur in 2% to 8% of cases and include mortality ( 30 days) complications after bariatric surgery vary by procedure and patient-derived risk factors. When laparoscopic sleeve gastrectomy is performed by an experienced surgeon: There is insufficient evidence to establish the incidence of perioperative and longer-term complications. 4. Gaps in Evidence and Future Research Needs The Expert Panel identified gaps in evidence supporting the 5 chosen CQs. For each CQ, the Expert Panel summarized recommendations for future research. See the Full Panel Report Supplement for a more detailed and comprehensive discussion. 4.1. CQ1. (Benefits of Weight Loss) The literature available in systematic reviews and meta-analyses did not specifically address whether age, sex, race, or baseline BMI or waist circumference modifies the beneficial effects of weight loss on cardiovascular risk factors. Likewise, the systematic reviews and meta-analyses did not specifically address the issue of how baseline comorbid conditions and cardiovascular risk factors modify the response to weight loss. Nevertheless, high-quality literature that addresses these issues could exist. Given that caveat and the present evidence review, future research in this area should address the following issues: Do the observed improvements in cardiovascular risk factors, need for medications, and improved quality of life associated with weight loss differ by age, sex, race, or BMI or waist circumference? What is the cost-effectiveness of modest weight loss as a preventive strategy for those at risk of developing type 2 diabetes? What is the best approach to identify and engage those who can benefit from weight loss? 4.2. CQ2. (Risks of Overweight and Obesity) Because evidence-based methods to identify patients with elevated risk for CVD, its risk factors, and all-cause mortality are essential for healthcare practitioners, more systematic reviews, meta-analyses, and pooled analyses are needed to inform future guidelines in the following areas: Studies are needed that compare current BMI and waist circumference cutpoints with alternative cutpoints for predicting risk to optimize the specificity of cutpoints. – Studies should examine the independent and combined effects of BMI and waist circumference to determine if both in combination are better at predicting elevated risk than either alone. – Such studies should explicate the methods and logical framework that guides the choice of optimal cutpoints. – Studies comparing the predictive ability of BMI and waist circumference with more objective measures of percent body fat, such as dual-energy x-ray absorptiometry or magnetic resonance imaging, may enhance risk prediction of cutpoints and/or combinations of BMI and waist circumference. Similar studies are needed to assess whether overall cutpoints are appropriate for population subgroups stratified by age, sex, and race/ethnicity. – Studies that compare risk across different age groups should report absolute risk estimates. This is especially important when examining age. – Studies are needed on racial-ethnic differences in risk within Western countries, particularly in Asian Americans and Hispanic Americans. Longitudinal studies are needed that assess the risks associated with weight change (accounting for intentionality) in normal-weight, overweight, and obese adults to determine the role of weight change trajectory in risk assessment. 4.3. CQ3. (Dietary Interventions for Weight Loss) More research is needed to inform future guidelines about dietary interventions for weight loss. Because long-term dietary adherence is problematic in weight management, to determine the best dietary approach to sustain weight loss over the long term, studies are needed that: Test the impact of tailoring choice of dietary interventions on the individual’s ability to adhere in the long term. Test pragmatic approaches to diet intervention delivery in free-living individuals for at least 2 years duration. Evaluate the physiological and biological adaptations to weight loss, so as to refine methods of caloric restriction during weight reduction and maintenance. 4.4. CQ4. (Lifestyle Interventions for Weight Loss) More research is needed to inform future guidelines focusing on improvements in efficiency and efficacy, optimizing delivery and dissemination, and targeting special populations. The research is needed in the following areas: On-site (face-to-face), comprehensive, high-intensity lifestyle interventions (14 or more contacts in first 6 months) represent the standard for behavioral weight loss interventions. Further research can help improve efficiency of these interventions with studies that: – Evaluate optimal frequency (and duration) of contact. – Evaluate characteristics of those who lose less weight in response to a standard, comprehensive behavioral intervention, and develop alternative approaches for their treatment. – Evaluate effective methods of delivering lifestyle interventions remotely (eg, Internet, mobile phone, text messaging, telephone, DVDs, or some combination of these) to achieve and maintain clinically meaningful weight loss. Because of changing demographics, there is a need for further research to understand the most appropriate strategies and prescriptions for weight loss for some key populations, including older adults and racial/ethnic groups. Because the efficacy of on-site (face-to-face), comprehensive, high-intensity lifestyle intervention has been established in academic settings, translational studies are needed that: – Evaluate programs that can be delivered in community, work-site, and other settings (including commercial programs). – Determine the personal characteristics, skills, and training required of a lifestyle interventionist. – Identify the optimal role for PCPs to play in the management of obesity by lifestyle modification. – Evaluate head-to-head comparisons of the relative effectiveness and associated costs of delivering interventions on site (face-to-face), remotely, or by a combination of approaches (ie, hybrid delivery). Because maintenance of lost weight over the long term has been challenging, studies are needed that: – Evaluate strategies to promote additional weight loss beyond the first 6 months, the time at which weight loss plateaus in most individuals. – Evaluate novel methods of improving the maintenance of lost weight. Further study is needed on the effect of weight loss treatment on healthcare utilization and cost. 4.5. CQ5. (Surgical Procedures for Weight Loss) More research is needed to inform future guidelines in the following areas: Because bariatric surgery offers the potential for prevention or remission of diabetes, better control of cardiovascular risk factors, improvement in quality of life and possibly decreased mortality, there is a need for research to better characterize those patients who are most likely to benefit from and least likely to suffer adverse consequences of bariatric surgical procedures. Large and well-designed experimental, quasi-experimental, and observational studies with long-term follow-up are needed to determine whether the risks and benefits of bariatric surgery are sustained over time. Studies are needed that: – Evaluate which surgical procedures are best applied to different populations, on the basis of factors such as presence and duration of comorbid conditions, age, sex, race/ethnicity, degree and duration of obesity, underlying genetic etiologies, and psychosocial or behavioral characteristics. – Evaluate the implementation of bariatric surgery in nonacademic settings, which may be more reflective of real-world clinical practice. Supplementary Material Full Panel Report Supplement
Author and article information
Journal
Journal ID (nlm-ta): JAMA Netw Open
Journal ID (iso-abbrev): JAMA Netw Open
Title:
JAMA Network Open
Publisher:
American Medical Association
ISSN
(Electronic):
2574-3805
Publication date
(Electronic):
7
August
2023
Publication date Collection:
August
2023
Publication date PMC-release: 7
August
2023
Volume: 6
Issue: 8
Electronic Location Identifier: e2327358
Affiliations
Author notes
Article Information
Open Access: This is an open access article distributed under the terms of the
CC-BY License. © 2023 Kompaniyets L et al.
JAMA Network Open.
Corresponding Author: Lyudmyla Kompaniyets, PhD, 4770 Buford Hwy, MS S107-5, Atlanta, GA 30341 (
opt4@
123456cdc.gov
).
Author Contributions: Dr Kompaniyets had full access to all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the data analysis.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention
or the US Public Health Service.
Data Sharing Statement: See
Supplement 2.
Article
Publisher ID: zoi230793DOI: 10.1001/jamanetworkopen.2023.27358
PMC ID: 10407685
PubMed ID: 37548978
SO-VID: b9a20ed1-234c-41d8-bcd3-078d053f795f
Copyright © Copyright 2023 Kompaniyets L et al.
JAMA Network Open.
License:
This is an open access article distributed under the terms of the CC-BY License.
History
Date
received
: 14
February
2023
Date
accepted
: 24
June
2023
Categories
Subject:
Research
Subject:
Original Investigation
Subject:
Online Only
Subject:
Nutrition, Obesity, and Exercise
Data availability: