The Healthy Eating Index (HEI), a measure of overall dietary quality, allows researchers to assess, at a population level, compliance with the Dietary Guidelines for Americans (DGA) and the relationship between total diet quality and health outcomes. The 2015-2020 DGA 1 2015 Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/2015/ Google Scholar are the current, prevention-focused nutrition and health policies of the United States. The DGA provide direction to policymakers and professionals as they design and implement nutrition-related programs and initiatives and conduct research to protect and improve the health and well-being of the American public. As Congressionally mandated directives, the DGA have major influence on the nation’s vast network of food programs, health care and nutrition services, and the research and educational activities overseen by the Department of Health and Human Services (DHHS) and the US Department of Agriculture (USDA). The DGA also have the potential to inform public health programming and professional practice at all levels where they influence the nutritional status and health of individuals, communities, and the entire population. Therefore, the DGA are an essential resource for nutrition and dietetics practitioners and others who seek to improve the nutrition-related well-being of individuals and communities they serve and attempt to reverse the prevalent diet-related problems of Americans. B. E. Millen is president, Millennium Prevention, Inc, Westwood, MA; chairman, Boston Nutrition, Inc, Westwood, MA.

For decades national nutrition guidelines have been developed to promote and maintain population health. In the United States, federal nutrition and health policies are far-reaching. They influence and shape nutrition programs, services and research priorities; healthcare and public health systems as well as other sectors such as food and agriculture. Dietary Reference Intakes and Dietary Guidelines for Americans (DGAs) are the primary sources of nutrition guidance and strategies to promote health at individual and population levels. The 2015–2020 DGAs base their recommendations on the most current, sound research evidence on nutrition and health and published clinical practice guidelines on disease prevention and health promotion. They also acknowledge that nutrition and other lifestyle behaviors are influenced by many factors operating at individual, socio-cultural, environmental, multisectoral and policy levels. As such, public health approaches that target individuals, communities, public policies, and environments are recommended to promote healthful dietary patterns and physical activity. Alliances and partnerships across multiple sectors are needed to facilitate changes such that healthy lifestyle choices become normative behaviors. Achieving healthful dietary patterns and physical activity that meet the 2015–2020 DGAs will reduce risks for major chronic diseases and promote wide-ranging favorable health outcomes.

The Dietary Guidelines for Americans (DGA) is published every 5 y jointly by the Department of Health and Human Services (HHS) and the USDA and provides a framework for US-based food and nutrition programs, health promotion and disease prevention initiatives, and research priorities. Summarized in this report are the methods, major conclusions, and recommendations of the Scientific Report of the 2015 US Dietary Guidelines Advisory Committee (DGAC). Early in the process, the DGAC developed a conceptual model and formulated questions to examine nutritional risk and determinants and impact of dietary patterns in relation to numerous health outcomes among individuals aged ≥2 y. As detailed in the report, an expansive, transparent, and comprehensive process was used to address each question, with multiple opportunities for public input included. Consensus was reached on all DGAC's findings, including each conclusion and recommendation, and the entire report. When research questions were answered by original systematic literature reviews and/or with existing, high-quality expert reports, the quality and strength of the evidence was formally graded. The report was organized around the following 5 themes: 1) food and nutrient intakes and health: current status and trends; 2) dietary patterns, foods and nutrients, and health outcomes; 3) diet and physical activity behavior change; 4) food and physical activity environments; and 5) food sustainability and food safety. The following 3 cross-cutting topics were addressed: 1) sodium, 2) saturated fat, and 3) added sugars. Physical activity recommendations from recent expert reports were endorsed. The overall quality of the American diet was assessed to identify overconsumed and underconsumed nutrients of public health concern. Common food characteristics of healthy dietary patterns were determined. Features of effective interventions to change individual and population diet and physical activity behaviors in clinical, public health, and community settings were identified. The report was used by the HHS and the USDA to develop the 2015 DGA.

Chronic non-communicable diseases (NCDs) are the leading causes of morbidity and mortality in the United States and globally, and are attributable largely to poor nutrition and suboptimal lifestyle behaviors. The 2015-2020 Dietary Guidelines for Americans promote healthy eating and lifestyle patterns across the lifespan to reduce risk of NCDs. Physicians are well positioned to provide lifestyle preventive interventions that are personalized to their patients' biological needs and cultural preferences through multidisciplinary team activities or referral to professional nutrition and physical activity experts. They can also advocate for environmental changes in healthcare and community settings that promote healthful lifestyle behaviors.

In their News and Views article (Have new guidelines overlooked the role of diet composition? Nat. Rev. Endocrinol. 10, 132–133; 2014),1 Arne Astrup and Jennie Brand-Miller have commented on the 2013 guidelines for the management of overweight and obesity jointly produced by the American Heart Association (AHA), the American College… Download references

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

In 2005, the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health recognized the need to update their guideline reports on cardiovascular disease (CVD) prevention and treatment. Stakeholder groups were convened to provide input on the process, including the Academy of Nutrition and Dietetics. These groups recommended the following integral and complementary steps1:

H EALTHY LIFESTYLE BEHAVIORS, INCLUDING optimal dietary and physical activity patterns, are the cornerstones of disease prevention and management. The maintenance of healthy lifestyle behaviors is particularly important in preventing cardiovascular disease (CVD), the leading cause of morbidity and mortality in the United States. Therefore, in 2008, the National Heart, Lung, and Blood Institute (NHLBI), in conjunction with efforts to update expert guidelines on overweight/obesity, cholesterol, and blood pressure (BP), assembled a Lifestyle Workgroup to examine the relationships between diet, physical activity, and CVD prevention and management. Lifestyle behaviors are not only factors associated with CVD risk reduction, but also determinants of overall health that the individual can manage in conjunction with sound professional guidance. In 2012, the NHLBI partnered with the American College of Cardiology (ACC) and American Heart Association (AHA) to adopt and publish the Lifestyle Workgroup’s recommendations and guidelines. In this commentary, we review and discuss the major findings and recommendations of the 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Disease Risk, published jointly by the ACC and AHA. This new guideline on lifestyle management was restricted to the following components of lifestyle: diet modification, dietary patterns, type of fat, sodium and potassium intake, and levels and types of physical activity. The Lifestyle Guideline is meant to provide clinicians with recommendations on the most effective diet and physical activity strategies to manage dyslipidemia and hypertension to promote cardiovascular health. In a companion commentary on the Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society, we summarize the background and general processes NHLBI followed in both guideline reports. In brief, during a 5-year period, the expert groups defined and evaluated Critical Questions and developed guidelines specific to their topic areas. Because of limitations in resources, only three questions were assessed by the Lifestyle Workgroup. For each specified question, the group reviewed published literature comprised of systematic reviews, randomized clinical trials, and observational studies (which included hard end points as outcomes) rated as fair and good quality, spanning the time frame from 1998 through 2009. It then utilized this body of evidence to formulate recommendations and to prepare the guideline. Given the limited scope of the Workgroup’s review (ie, only three Critical Questions), it is recognized that there are gaps in its expert recommendations.

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 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 Expert Panel Reports (Part 3) 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. There is high certainty based on evidence that the net benefity is substantial. There is moderate certainty based on evidence that the net benefitis moderate to substantial, or there is high certainty that the net benefit is moderate. There is at least moderate certainty based on evidence that there is a small net benefit. There is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits. Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area. Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area. 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. 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. See Tables 2 and 3 for an explanation of the NHLBI recommendation grading methodology. Meta-analyses of such studies. Highly certain about the estimate of effect. Further research is unlikely to change our confidence in the estimate of effect. Meta-analyses of such studies. Moderately certain about the estimate of effect. Further research may have an impact on our confidence in the estimate of effect and may change the estimate. Meta-analyses of such studies. Low certainty about the estimate of effect. Further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate. 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 U.S. 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 Expert Panel Report (Part 3). The Expert 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. 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. 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. 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. 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,appealthequalityratings 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. 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 ofthe 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 ofthe 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. 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 overweight 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. The Expert Panel provides a treatment algorithm, Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity (Figure), 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. Treatment Algorithm—Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity* *This algorithm applies to the assessment of overweight and obesity and subsequent decisions based on that assessment. Each step (designated by a box) in this process is reviewed in Section 2.2 and expanded on in subsequent sections. †BMI cutpoint determined by the FDA and listed on the package inserts ofFDA-approved obesity medications. BMI indicates body mass index; CVD, cardiovascular disease; and FDA, U.S. Food and Drug Administration. 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. A patient encounter for obesity prevention and management is defined as an interaction with a PCP who assesses a patient's weight status to determine presence of overweight or obesity and need for further assessment and treatment. With the patient wearing light clothing or an examination gown and no shoes, weight and height are measured and the BMI calculated. BMI can be calculated manually (weight in kg/[height in meters]2) or electronically by using the electronic medical record or other resources. The BMI should be documented in the patient medical record. These BMI cutpoints define overweight and class I to III obese individuals and identify adults who may be at increased risk for CVD and other obesity-related conditions. Within these categories, additional personal risk assessment is needed because degree of risk can vary (Box 4 and CQ2). Assess risk of CVD and/or presence of obesity-related comorbidities. Risk assessment for CVD and diabetes in a person with overweight or class I to III obesity includes history; physical examination; and clinical and laboratory assessments, including BP, fasting blood glucose, and fasting lipid panel (expert opinion). A waist circumference measurement is recommended for individuals with BMI 25-34.9 kg/m2 to provide additional information on risk. It is unnecessary to measure waist circumference in patients with BMI >35 kg/m2 because the waist circumference will likely be elevated and will add no additional risk information. The Expert Panel recommends, by expert opinion, using the current cutpoints (>88 cm [>35 in] for women and >102 cm [>40in] for men) as indicative of increased cardiometabolic risk. Because obesity is associated with increased risk of hypertension, dyslipidemia, diabetes, and a host of other comorbidities, the clinician should assess for associated conditions. The Expert Panel recommends, by expert opinion, that intensive management of cardiovascular risk factors (hypertension, dyslipidemia, prediabetes, or diabetes) or other obesity-related medical conditions (e.g., sleep apnea) be instituted if they are found, regardless of weight loss efforts. The Expert Panel recommends, by expert opinion, that the clinician assess weight and lifestyle histories and determine other potential contributory factors: Ask questions about history of weight gain and loss over time, details of previous weight loss attempts, dietary habits, physical activity, family history of obesity, and other medical conditions or medications that may affect weight. Answers to these questions may provide useful information about the origins of or maintaining factors for overweight and obesity, including success and difficulties with previous weight loss or maintenance efforts. This information can help the clinician determine any adjustments to the patient's medical regimen that can assist weight management efforts and provide appropriate advice on lifestyle change. The information may also impact recommendations for treatment. Weight loss treatment is indicated for 1) obese individuals and 2) overweight individuals with >1 indicators of increased cardiovascular risk (e.g., diabetes, prediabetes, hypertension, dyslipidemia, elevated waist circumference) or other obesity-related comorbidities. NO: BMI <25 or BMI 25-29.9 without additional risk. Normal-weight patients (BMI 18.5-24.9 kg/m2) should be advised to avoid weight gain (Box 7). Patients who are overweight (BMI 25-29.9 kg/m2) who do not have indicators of increased cardiovascular risk (e.g., diabetes, prediabetes, hypertension, dyslipidemia, elevated waist circumference) or other obesity-related comorbidities should be advised to avoid additional weight gain (Box 7). Normal weight: Individuals who are normal weight (BMI 18.5-24.9 kg/m2) and do not have a history of overweight or obesity should be counseled on the desirability of avoiding weight gain to prevent the health risks of increased body weight. B. Overweight without additional risk factors or normal weight with a history of overweight or obesity: For individuals who are overweight (BMI 25-29.9kg/m2) and who do not have indicators of increased cardiovascular risk (e.g., diabetes, prediabetes, hypertension, dyslipidemia, elevated waist circumference) or other obesity-related comorbidities, and for individuals who have a history of overweight and are now normal weight with risk factors at acceptable levels, advise patients to frequently measure their own weight and to avoid weight gain by adjusting their food intake if they start to gain more than a few pounds. Also, advise patients that engaging in regular physical activity will help them avoid weight gain. C. Overweight or obese individuals who would benefit from weight loss but who are not currently prepared or able to lose weight: Periodically assess the patient's interest in and readiness for weight loss as shown in Box 8, and counsel the patient on the desirability of avoiding additional weight gain to prevent greater health risk. Regardless of patient's interest in or readiness for weight loss intervention, any cardiovascular risk factors and obesity-related health conditions should be evaluated and treated. The Expert Panel advises (expert opinion) that the clinician and patient agree on whether weight loss is appropriate. The clinician, together with the patient, should assess whether the patient is prepared and ready to undertake the measures necessary to succeed at weight loss before beginning comprehensive counseling efforts. The clinician can ask, “How prepared are you to make changes in your diet, to be more physically active, and to use behavior change strategies such as recording your weight and food intake?” These are the components of a comprehensive lifestyle intervention. The decision to undertake weight loss efforts must be made in the context of competing priorities (e.g., smoking cessation may supersede a weight loss effort; life events may make the effort at weight reduction futile until a future time). If the patient is not prepared to undertake these changes, attempts to counsel the patient on how to make lifestyle changes are likely to be counterproductive. Clinician and patient devise weight loss and health goals and comprehensive lifestyle treatment strategies to achieve these goals. Recommended goals for weight loss: A realistic and meaningful weight loss goal is an important first step. Although sustained weight loss of as little as 3%-5% of body weight may lead to clinically meaningful reductions in some cardiovascular risk factors, larger weight losses produce greater benefits. The Expert Panel recommends as an initial goal the loss of 5%-10% of baseline weight within 6 months. Recommended methods for weight loss: Weight loss requires creating an energy deficit through caloric restriction, physical activity, or both. An energy deficit of >500 kcal/d typically may be achieved with dietary intake of 1,200-1,500 kcal/d for women and 1,500-1,800 kcal/d for men. The choice of calorie-restricted diet can be individualized to the patient's preferences and health status (CQ3). Very-low-calorie diets (<800 kcal/d) should be used only in limited circumstances in a medical care setting where medical supervision and a high-intensity lifestyle intervention can be provided. If a specialized diet for CVD risk reduction, diabetes, or other medical conditions is also prescribed, referral to a nutrition professional* is recommended (CQ3). Recommendations for management of medical conditions during weight loss: While weight loss treatment is ongoing, manage risk factors such as hypertension, dyslipidemia, and other obesity-related conditions. This includes monitoring the patient's requirements for medication change as weight loss progresses, particularly for antihypertensive medications and diabetes medications that can cause hypoglycemia. All patients for whom weight loss is recommended should be offered or referred for comprehensive lifestyle intervention (Box 11 and 12). Comprehensive lifestyle intervention, preferably with a trained interventionist† or nutrition professional*, is foundational to weight loss (Box 11) regardless of augmentation by medications or bariatric surgery. By expert opinion, if the weight and lifestyle history indicates that the patient has never participated in a comprehensive lifestyle intervention program as defined in CQ4 and in Box 11, it is recommended that he or she be encouraged to undertake such a program before the addition of adjunctive therapies since a substantial proportion of patients will lose sufficient weight to improve health with comprehensive lifestyle treatment alone. This recommendation may be modified by the availability of comprehensive lifestyle intervention or by patient factors, such as medical conditions that warrant earlier initiation of more intensive treatment. If the patient has been unable to lose weight or sustain weight loss with comprehensive lifestyle intervention and he or she has a BMI >30 kg/m2 or BMI >27 kg/m2 with comorbidity, adjunctive therapies may be considered. Patients who are otherwise appropriate candidates for obesity drug treatment or bariatric surgery, whose weight and lifestyle history indicate a history of inability to achieve or sustain weight loss and who have previously participated in a comprehensive lifestyle intervention, may be offered the option to add pharmacotherapy at the time of initiation of a lifestyle intervention program (BMI >30 kg/m2 or BMI >27 kg/m2 with comorbidity) or to be referred for evaluation for bariatric surgery (BMI >40kg/m2 or BMI >3 5 kg/m2 with comorbidity) (expert opinion).‡ The most effective behavioral weight loss treatment is an in-person, high-intensity (i.e., >14 sessions in 6 months) comprehensive weight loss intervention provided in individual or group sessions by a trained interventionist† (CQ4). The principal components of an effective high-intensity, on-site comprehensive lifestyle intervention include 1) prescription of a moderately redu

HomeCirculationVol. 129, No. 25_suppl_22013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsOpen AccessResearch ArticlePDF/EPUB2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in AdultsA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society Michael D. Jensen, MD, Donna H. Ryan, MD, Caroline M. Apovian, MD, FACP, Jamy D. Ard, MD, Anthony G. Comuzzie, PhD, Karen A. Donato, SM, Frank B. Hu, MD, PhD, FAHA, Van S. Hubbard, MD, PhD, John M. Jakicic, PhD, Robert F. Kushner, MD, Catherine M. Loria, PhD, FAHA, Barbara E. Millen, DrPH, RD, Cathy A. Nonas, MS, RD, F. Xavier Pi-Sunyer, MD, MPH, June Stevens, PhD, Victor J. Stevens, PhD, Thomas A. Wadden, PhD, Bruce M. Wolfe, MD and Susan Z. Yanovski, MD Michael D. JensenMichael D. Jensen , Donna H. RyanDonna H. Ryan , Caroline M. ApovianCaroline M. Apovian , Jamy D. ArdJamy D. Ard , Anthony G. ComuzzieAnthony G. Comuzzie , Karen A. DonatoKaren A. Donato , Frank B. HuFrank B. Hu , Van S. HubbardVan S. Hubbard , John M. JakicicJohn M. Jakicic , Robert F. KushnerRobert F. Kushner , Catherine M. LoriaCatherine M. Loria , Barbara E. MillenBarbara E. Millen , Cathy A. NonasCathy A. Nonas , F. Xavier Pi-SunyerF. Xavier Pi-Sunyer , June StevensJune Stevens , Victor J. StevensVictor J. Stevens , Thomas A. WaddenThomas A. Wadden , Bruce M. WolfeBruce M. Wolfe and Susan Z. YanovskiSusan Z. Yanovski Originally published12 Nov 2013https://doi.org/10.1161/01.cir.0000437739.71477.eeCirculation. 2014;129:S102–S138is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S1031. Introduction/Scope of Guideline S1041.1. Rationale for Updating Obesity Clinical Guidelines S1061.2. CQ-Based Approach S1071.3. Organization of the Panel S1071.4. Document Review and Approval S1082. Obesity Recommendations and Algorithm S1082.1. Summary of Evidence-Based Recommendations S1082.2. Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity—Treatment Algorithm S1083. CQs and Corresponding ESs S1103.1. CQ1: Statement of the Question S1173.1.1. Weight Loss and Risk of Diabetes S1173.1.2. Weight Loss and Impact on Cholesterol/Lipid Profile S1183.1.3. Weight Loss and Hypertension Risk S1183.2. CQ2: Statement of the Question S1183.2.1. Current BMI Cutpoints and CVD-Related Risk and All-Cause Mortality S1193.2.2. Areas of Insufficient Evidence With Regard to Cutpoints for BMI and for Waist Circumference S1193.3. CQ3: Statement of the Question S1203.3.1. Overall Dietary Intervention and Composition—Creating Reduced Dietary Energy Intake S1203.3.2. Overall Dietary Intervention and Composition—Pattern of Weight Loss Over Time With Dietary Intervention S1203.3.3. Low-Fat Approaches S1213.3.4. Higher-Protein Approaches (25% to 30% of Energy) S1213.3.5. Low-Carbohydrate Approaches (<30 g/d) S1213.3.6. Complex Versus Simple Carbohydrates S1213.3.7. Glycemic Load Dietary Approaches S1213.3.8. Dietary Patterns (Mediterranean Style, Vegetarian, and Other Dietary Pattern Approaches) S1213.3.9. Meal Replacement and Adding Foods to Liquid Diets S1213.3.10. Very–Low–Calorie Diet Approaches S1213.4. CQ4: Statement of the Question S1223.4.1. Description of the Diet, Physical Activity, and Behavior Therapy Components in High-Intensity, On-Site Lifestyle Interventions S1223.4.2. Comprehensive Interventions Compared With Usual Care, Minimal Care, or No-Treatment Control S1223.4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving Weight Loss S1233.4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions in Achieving Weight Loss S1233.4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within a Primary Care Practice Setting Compared With Usual Care S1233.4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions in Achieving Weight Loss S1233.4.7. Efficacy/Effectiveness of Very–Low-Calorie Diets as Used as Part of a Comprehensive Lifestyle Intervention in Achieving Weight Loss S1233.4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining Lost Weight S1233.4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss: Intervention Intensity S1233.4.10. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss Maintenance: Individual Versus Group Treatment S1243.4.11. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss Maintenance: On-Site Versus Electronically Delivered Interventions S1243.5. CQ5: Statement of the Question S1243.5.1. Component 1: Efficacy S1253.5.2. Component 2: Predictors S1263.5.3. Component 3: Complications S1263.5.3.1. Laparoscopic Adjustable Gastric Banding S1263.5.3.2. Roux-En-Y Gastric Bypass S1263.5.3.3. Biliopancreatic Diversion S1263.5.3.4. Laparoscopic Sleeve Gastrectomy S1274. Gaps in Evidence and Future Research Needs S1274.1. CQ1 (Benefits of Weight Loss) S1274.2. CQ2 (Risks of Overweight and Obesity) S1274.3. CQ3 (Dietary Interventions for Weight Loss) S1274.4. CQ4 (Lifestyle Interventions for Weight Loss) S1274.5. CQ5 (Surgical Procedures for Weight Loss) S128References S128Appendix 1. Author Relationships With Industry and Other Entities (Relevant) S133Appendix 2. Expert Reviewer Relationships With Industry and Other Entities S137Appendix 3. Abbreviations S138Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular RiskThe 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.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn 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.Table 2. NHLBI Grading of the Strength of RecommendationsGradeStrength of Recommendation*AStrong recommendationThere is high certainty based on evidence that the net benefit† is substantial.BModerate recommendationThere is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate.CWeak recommendationThere is at least moderate certainty based on evidence that there is a small net benefit.DRecommendation againstThere is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits.EExpert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area.NNo recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area.*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (eg, strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce CVD risk or ordering an ECG as part of the initial diagnostic work-up for a patient presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.†Net benefit is defined as benefits minus risks/harms of the service/intervention.CVD indicates cardiovascular disease; ECG, electrocardiogram; MI, myocardial infarction; and NHLBI, National Heart, Lung, and Blood Institute.Table 3. NHLBI Quality Rating of the Strength of EvidenceType of EvidenceQuality Rating*Well-designed, well-executed† RCT that adequately represent populations to which the results are applied and directly assess effects on health outcomes.Meta-analyses of such studies.Highly certain about the estimate of effect. Further research is unlikely to change our confidence in the estimate of effect.HighRCT with minor limitations‡ affecting confidence in, or applicability of, the results.Well-designed, well-executed nonrandomized controlled studies§ and well-designed, well-executed observational studies‖.Meta-analyses of such studies.Moderately certain about the estimate of effect. Further research may have an impact on our confidence in the estimate of effect and may change the estimate.ModerateRCT with major limitations.Nonrandomized controlled studies and observational studies with major limitations affecting confidence in, or applicability of, the results.Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports).Physiological studies in humans.Meta-analyses of such studies.Low certainty about the estimate of effect. Further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate.Low*In some cases, other evidence, such as large all-or-none case series (eg, jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.†“Well-designed, well-executed” refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (eg, quasi-experimental study design).‖Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.NHLBI indicates National Heart, Lung, and Blood Institute; and RCT, randomized controlled trial.1. Introduction/Scope of GuidelineMore 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.7The 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 GuidelinesThe 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 ApproachThe 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 PanelIn 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 G

H. Lichtenstein, Catherine M. Loria, Barbara E. Millen, Nancy Houston Miller, Cathy A. Nonas, Robert H. Eckel, John M. Jakicic, Jamy D. Ard, Van S. Hubbard, Janet M. de Jesus, I-Min Lee, Alice Guidelines of the American College of Cardiology/American Heart Association Task Force on Practice 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2013 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation published online November 12, 2013; Circulation. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1.citation World Wide Web at: The online version of this article, along with updated information and services, is located on the http://circ.ahajournals.org/content/suppl/2013/11/07/01.cir.0000437740.48606.d1.DC1.html Data Supplement (unedited) at:

H. Lichtenstein, Catherine M. Loria, Barbara E. Millen, Nancy Houston Miller, Cathy A. Nonas, Robert H. Eckel, John M. Jakicic, Jamy D. Ard, Van S. Hubbard, Janet M. de Jesus, I-Min Lee, Alice Guidelines of the American College of Cardiology/American Heart Association Task Force on Practice 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2013 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation published online November 12, 2013; Circulation. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1.citation World Wide Web at: The online version of this article, along with updated information and services, is located on the http://circ.ahajournals.org/content/suppl/2013/11/07/01.cir.0000437740.48606.d1.DC1.html Data Supplement (unedited) at:

AbstractObjectiveTo evaluate long-term patterns of weight change and progression to overweight and obesity during adulthood.DesignProspective study. Changes in mean BMI, waist circumference (WC) and weight were assessed over a mean 26-year follow-up (1971–1975 to 1998–2001). Mean BMI (95 % CI) and mean WC (95 % CI) of men and women in BMI and age groups were computed. Mean weight change in BMI and age categories was compared using analysis of covariance.SettingFramingham Heart Study Offspring/Spouse Nutrition Study.SubjectsMen and women (n2394) aged 20–63 years.ResultsDuring follow-up, increases in BMI (men: 2·2 kg/m2; women: 3·7 kg/m2) and WC (men: 5·7 cm; women: 15·1 cm) were larger in women than men. BMI gains were greatest in younger adults (20–39 years) and smallest in obese older adults (50–69 years). The prevalence of obesity doubled in men (to 33·2 %) and tripled in women (to 26·6 %). Among normal-weight individuals, abdominal obesity developed in women only. The prevalence of abdominal obesity increased 1·8-fold in men (to 53·0 %) and 2·4-fold in women (to 71·2 %). Weight gain was greatest in the youngest adults (20–29 years), particularly women. Gains continued into the fifth decade among men and then declined in the sixth decade; in women gains continued into the sixth decade.ConclusionsPatterns of weight change and progression to obesity during adulthood differ in men and women. Preventive intervention strategies for overweight and obesity need to consider age- and sex-specific patterns of changes in anthropometric measures.

Data on the relationship between empirical dietary patterns and metabolic syndrome (MetS) and its components in prospective study designs are limited. In addition, demographic and lifestyle determinants of MetS may modify the association between dietary patterns and the syndrome. We prospectively examined the relationship between empirically derived patterns and MetS and MetS components among 1146 women in the Framingham Offspring/Spouse cohort. They were aged 25–77 y with BMI ≥18.5 kg/m2and free of cardiovascular disease, diabetes, cancer, and MetS at baseline, and followed for a mean of 7 y. Five dietary patterns, Heart Healthier, Lighter Eating, Wine and Moderate Eating, Higher Fat, and Empty Calorie, were previously identified using cluster analysis from food intake collected using a FFQ. After adjusting for potential confounders, we observed lower odds for abdominal obesity for Higher Fat [OR = 0.48 (95% CI: 0.25, 0.91)] and Wine and Moderate Eating clusters [OR = 0.28 (95% CI: 0.11, 0.72)] compared with the Empty Calorie cluster. Additional adjustment for BMI somewhat attenuated these OR [Higher Fat OR = 0.52 (95% CI: 0.27, 1.00); Wine and Moderate Eating OR = 0.34 (95% CI: 0.13, 0.89)]. None of the clusters was associated with MetS or other MetS components. Baseline smoking status and age did not modify the relation between dietary patterns and MetS. The Higher Fat and Wine and Moderate Eating patterns showed an inverse association with abdominal obesity; certain foods might be targeted in these habitual patterns to achieve optimal dietary patterns for MetS prevention.