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2. Rationale for Guidelines Development

Treatment of the overweight or obese patient is a two-step process: assessment and treatment management. Assessment requires determination of the degree of overweight and overall risk status.

Management includes both reducing excess body weight and instituting other measures to control accompanying risk factors. Assessment: When assessing a patient for risk status and as a candidate for weight loss therapy, consider the patient’s BMI, waist circumference, and overall risk status. Consideration also needs to be given to the patient’s motivation to lose weight.

2.1 Body Mass Index

The BMI, which describes relative weight for height, is significantly correlated with total body fat content. The BMI should be used to assess overweight and obesity and to monitor changes in body weight. In addition, measurements of body weight alone can be used to determine efficacy of weight loss therapy. BMI is calculated as weight (kg)/height squared (m2). To estimate BMI using pounds and inches, use: [weight (pounds)/height (inches)2] x 703.

 2. 2 Waist Circumference.

The presence of excess fat in the abdomen out of proportion to total body fat is an independent predictor of risk factors and morbidity. Waist circumference is positively correlated with abdominal fat content. It provides a clinically acceptable measurement for assessing a patient's abdominal fat content before and during weight loss treatment. The sex-specific cutoffs noted on the next page can be used to identify increased relative risk for the development of obesity-associated risk factors in most adults with a BMI of 25 to 34.9 kg/m2:

These waist circumference cut points lose their incremental predictive power in patients with a BMI ³ 35 kg/m2 because these patients will exceed the cut points noted above. These categories denote relative risk, not absolute risk; that is, relative to risk at normal weight. They should not be equated with absolute risk, which is determined by a summation of risk factors. They relate to the need to institute weight loss therapy and do not directly define the required intensity of modification of risk factors associated with obesity.

 2.3 Risk Status.

Assessment of a patient’s absolute risk status requires examination for the presence of:

  •  Disease conditions: established coronary heart disease (CHD), other atherosclerotic diseases, type 2 diabetes, and sleep apnea; patients with these conditions are classified as being at very high risk for disease complications and mortality.
  •  Other obesity-associated diseases: gynecological abnormalities, osteoarthritis, gallstones and their complications, and stress incontinence.
  •  Cardiovascular risk factors: cigarette smoking, hypertension (systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg, or the patient is taking antihypertensive agents), high-risk LDL-cholesterol (160mg/dL), low HDL-cholesterol (< 35 mg/dL), impaired fasting glucose (fasting plasma glucose of 110 to 125 mg/dL), family history of premature CHD (definite myocardial infarction or sudden death at or before 55 years of age in father or other male first-degree relative, or at or before 65 years of age in mother or other female first-degree relative), and age (men  45 years and women  55 years or postmenopausal). Patients can be classified as being at high absolute risk if they have three of the aforementioned risk factors. Patients at high absolute risk usually require clinical management of risk factors to reduce risk. Patients who are overweight or obese often have other cardiovascular risk factors. Methods for estimating absolute risk status for developing cardiovascular disease based on these risk factors are described in detail later on. The intensity of intervention for cholesterol disorders or hypertension is adjusted according to the absolute risk status estimated from multiple risk correlates.
  • These include both the risk factors listed above and evidence of end-organ damage present in hypertensive patients. In overweight patients, control of cardiovascular risk factors deserves equal emphasis as weight reduction therapy.
  • Reduction of risk factors will reduce the risk for cardiovascular disease whether or not efforts at weight loss are successful.

 Other risk factors:

Pphysical inactivity and high serum triglycerides (> 200 mg/dL). When these factors are present, patients can be considered to have incremental absolute risk above that estimated from the preceding risk factors. Quantitative risk contribution is not available for these risk factors, but their presence heightens the need for weight reduction in obese persons.

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