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management of obesity: ACP clinical guidelines, 2005
obesity defined as BMI > 30 kg/m2
Management:
1) assess co-morbid conditions
- especially diabetes & hypertension (metabolic syndrome X)
2) counsel on lifestyle & behavioral modifications
a) diet & exercise
b) continuous counseling necessary
3) determine goals & time frame for acheivement of goals on an individaul basis
a) weight loss
b) blood pressure reduction
c) improved glucose control
d) improved lipid panel
4) pharmacologic therapy may be offered to patients who fail more conservative measures (diet, exercise): discuss
a) adverse effects of pharmaceuticals
b) lack of long-term safety data
c) temporary weight loss achieved via pharmaceuticals
5) pharmacutical agents
a) sibutramine (4.45 kg)*
b) orlistat ( 2.89 kg)
c) phentermine (3.6 kg)*
d) diethylpropion ( 3.0 kg)*
e) fluoxetine (3.15 kg)*
f) bupropion (2.8 kg)*
6) choice of pharaceutical agent depends on side effects profile & patient's tolerance of those effects
7) no evidence for increased weight loss with combination therapy
8) no data about weight regain after medications are withdrawn
9) no long-term (>12 months) studies of efficacy or safety of pharmaceutical therapy
10) consider surgery for patients with:
a) BMI > 40 kg/m2 or greater
b) failed attempts of diet & exercise with or without adjunctive pharmacutical therapy
c) obesity-related comorbid conditions
- hypertension
- impaired glucose tolerance
- diabetes mellitus
- hyperlipidemia
- obstructive sleep apnea
11) discuss surgical risks
a) possible need for reoperation
b) gall bladder disease
c) malabsorption
12) surgery does not preclude continued need for life-style modification
a) diet & exercise
b) patients cannot resume their previous eating habits
13) insufficient evidence define best surgical procedure
14) surgery has not been shown to reduce cardiovascular morbidity or mortality
15) refer patients to high-volume centers with surgeons experienced in bariatric surgery.
a) bariatric surgical mortality rate 0.3%-1.9%
b) learning curve for surgeon
c) outcomes depend on
- skill of surgical team
- capacity of the system of care
* pooled data for average weight loss at 12 months from meta-analysis
Related
obesity
General
internal medicine
References
- Journal Watch 25(10):82, 2005
Snow V, Barry P, Fitterman N, Qaseem A, Weiss K
Clinical Efficacy Assessment Subcommittee of the American
College of Physicians.
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(7):525-31.
PMID: 15809464
- Li Z, Maglione M, Tu W, Mojica W, Arterburn D, Shugarman LR,
Hilton L, Suttorp M, Solomon V, Shekelle PG, Morton SC.
Meta-analysis: pharmacologic treatment of obesity.
Ann Intern Med. 2005 Apr 5;142(7):532-46. Summary for patients
in: Ann Intern Med. 2005 Apr 5;142(7):I55.
PMID: 15809465
- Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugarman HJ,
Livingston EH, Nguyen NT, Li Z, Mojica WA, Hilton L, Rhodes S,
Morton SC, Shekelle PG.
Meta-analysis: surgical treatment of obesity.
Ann Intern Med. 2005 Apr 5;142(7):547-59. Summary for patients
in: Ann Intern Med. 2005 Apr 5;142(7):I55.
PMID: 15809466