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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThree new obesity guidelines have been developed that should improve the management of this condition and its associated comorbidities. This discussion includes the development of recommendations on best practices in obesity treatment, overview of the American Association of Clinical Endocrinologist Obesity Guidelines, as well as a review of the American Society of Bariatric Physicians guidelines.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENutrition Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Endocrinology Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENutrition Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEndocrinology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Metabolic Syndrome\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Endocrinology Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThree new obesity guidelines have been developed that should improve the management of this condition and its associated comorbidities. Michael D. Jensen, MD, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, discussed the development of recommendations on best practices in obesity treatment, and he described the development of the American Heart Association\/American College of Cardiology\/The Obesity Society (AHA\/ACC\/TOS) Obesity Guidelines [Jensen MD et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2014]. In developing these guidelines, the ACC, AHA, and partner organizations collaborated with the National Heart, Lung, and Blood Institute (NHLBI) in an evidence-based approach, using systematic reviews of the literature and graded recommendations. The NHLBI systematic review and guideline development process included identifying topic areas; developing critical questions; searching for all eligible studies; evaluating, summarizing, and grading the evidence; developing recommendations; and developing, reviewing, revising, and disseminating the guidelines.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe highest-rated evidence included that derived from well-designed, randomized clinical trials (RCTs) or meta-analyses of such trials. Initially, more than 20 critical questions (CQs) were identified, of which 5 were chosen based on perceived importance and resources (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15550\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15550\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15550\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ECritical Questions Addressed in the AHA\/ACC\/TOS Obesity Guidelines\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EThe recommendations of the obesity panel of experts that crafted the guidelines are summarized in \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E. Identification of patients who need to lose weight is based on meta-analyses and systematic reviews because of the great volume of data; others are based on RCTs.\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15551\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15551\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15551\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ESummary of Recommendations for Obesity\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EThere are gaps in the AHA\/ACC\/TOS Obesity Guidelines, including pharmacotherapy. In addition, there are also no critical questions on physical activity protocols or weight gain caused by medications.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EAnother guideline was developed by the American Association of Clinical Endocrinologists (AACE), which used a different approach. An overview of the AACE Obesity Guidelines [Mechanick JI. \u003Cem\u003EEndocrine Practice\u003C\/em\u003E. 2014] was presented by Jeffrey Mechanick, MD, Icahn School of Medicine at Mount Sinai, New York, New York, USA.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe AACE Obesity Guidelines are an algorithm that is part of a larger comprehensive algorithm designed to optimize the care of patients with diabetes. This algorithm stresses prevention over treatment-oriented disease management. For diabetes, it moves from HbA\u003Csub\u003E1c\u003C\/sub\u003E-centric care to comprehensive care; for obesity, it is moving from defining obesity using weight and body mass index (BMI) to care that is complication-centric. The AACE guidelines include a level of subjectivity and, unlike the AHA\/ACC\/ TOS Obesity Guidelines, are not purely evidence based [Garber AJ et al. \u003Cem\u003EEndocrine Practice\u003C\/em\u003E. 2013].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EBMI is included in the algorithm because it is used to determine prescribing indications for pharmacotherapy. Cardiometabolic disease risk can be assessed using standard scoring systems. Therapies are suggested based on the risk for complications. There are currently not enough data to recommend a particular drug or bariatric procedure. Algorithms for other aspects of diabetic care, and a list of medications associated with weight loss or gain, are also available.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EDr Mechanick said that the strengths of the AACE algorithm are that it is based on the weight of evidence, does not rely solely on RCTs, and is part of a comprehensive strategy. It is a complication-centric, risk stratification preventive paradigm that recognizes roles for lifestyle, medicines, and surgery. Weaknesses, however, include a lack of defined lifestyle modifications, the continued incorporation of BMI cutoffs, and a lack of defined pharmacotherapy and surgical options.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EThe American Society of Bariatric Physicians (ASBP) has also developed an obesity guideline and algorithm (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Seger JC et al. \u003Cem\u003EASBP Obesity Algorithm\u003C\/em\u003E. 2013], which was discussed by Wendy M. Scinta, MD, American Society of Bariatric Physicians, Aurora, Colorado, USA. Dr Scinta pointed out that all obesity guidelines are complementary, not competitive. The ASBP algorithm is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the ASBP.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/47\/17\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022ASBP Obesity Algorithm Executive Summary\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-251372396\u0022 data-figure-caption=\u0022ASBP Obesity Algorithm Executive Summary\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/47\/17\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/47\/17\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/47\/17\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15549\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EASBP Obesity Algorithm Executive Summary\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ESeger JC, Horn DB, Westman EC, Lindquist R, Scinta W, Richardson LA, Primack C, Bryman DA, McCarthy W, Hendricks E, Sabowitz BN, Schmidt SL, Bays HE. Obesity Algorithm\u00ae, presented by the American Society of Bariatric Physicians\u00ae. \u003Ca href=\u0022http:\/\/www.obesityalgorithm.org\u0022\u003Ewww.obesityalgorithm.org\u003C\/a\u003E (accessed December 2, 2014). \u00a9American Society of Bariatric Physicians\u00ae 2013\u20132014: used with permission.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-16\u0022\u003EThe algorithm includes overall management goals, examinations and tests, and treatment modalities. Two components of obesity as a disease include adiposopathy (\u003Cem\u003Esick fat disease\u003C\/em\u003E), a derangement of fat cells that causes complications of the endocrine and immune systems (eg, elevated blood lipids and glucose); and fat mass disease, associated with stress on tissues (eg, leading to joint damage and sleep apnea).\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EPractitioners should focus on the individual because patients have different backgrounds that contribute to their obesity. Therefore, a thorough history should be taken, followed by a comprehensive physical examination and general and obesity-relevant laboratory tests, some of which will be patient specific, such as an echo-cardiogram if it shows abnormalities. Other tests could include resting metabolic rate and body com position analysis, which can be measured in a variety of ways.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EObesity treatment medicine should include nutrition, behavioral modification, physical activity, and medical management. Secondary and contributing causes like sleep apnea, bulimia, rare genetic disorders, or insulinoma should be ruled out or treated. Medications that are used to treat obesity-related comorbidities or other conditions can cause obesity (eg, some antidiabetic drugs and antiseizure medications). Another drug that does not cause weight gain can be identified and substituted.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EBoth Dr Jensen and Dr Scinta emphasized that the diet that works is the one the patient will follow. Among the useful options are negative caloric balance diets, meal substitutes, and low-carbohydrate diets. Also of importance is having the patient develop a maintenance plan. Physical activity is more important for maintenance than weight loss but has advantages even in the absence of weight loss, and ideally it should include aerobic and strength training.\u003C\/p\u003E\u003Cp id=\u0022p-20\u0022\u003EAnother important aspect of the ASBP algorithm is the use of motivational interviewing; although there is not a lot of evidence behind it, listening while the patient figures out issues rather than jumping in and giving advice may be helpful. Other behavioral components include stimulus control by restructuring the home environment, and cognitive restructuring, such as keeping a food and mood diary.\u003C\/p\u003E\u003Cp id=\u0022p-21\u0022\u003EOnly 3 weight management pharmacotherapies are currently approved: lorcaserin, phentermine HCl\/ topiramate extended-release, and naltrexone\/bupropion extended release. Additional agents are expected to be approved soon.\u003C\/p\u003E\u003Cp id=\u0022p-22\u0022\u003EHigh-quality treatments for obesity are available and can produce medically important weight loss; these must be tailored to the individual patient to improve the chances for success.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/47\/17.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlx1e\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlx1e\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlx1e\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}