2013 Obesity/Lifestyle Guidelines: Something Old, Something New

Melissa Walton-Shirley

Disclosures

November 13, 2013

I am ashamed to admit that I've always hated reading guidelines. Levels of evidence and classification of recommendations seem so arbitrary, subjective, dry, and academic. The idea of relying upon someone else's interpretation of data on the management of obesity and the implementation of a healthy lifestyle should stem from common sense instead of the halls of academia. Depending upon guidelines to make a decision somehow seems lazy to me, but it dawned on me that their development meant scores of meetings and endless hours devoted to the cause by some of the best medical minds on the planet. We should take advantage of their genius, their efforts, and their dedication.

But there is some psychology here

Sitting down with all those pages was a lot like watching Hawaii Five-0. Back in the day, my dad insisted upon watching that weekly cop drama on our old Zenith black and white, the only TV in the house. We got only two channels, and I always hoped for something a little more entertaining, but as soon as that iconic theme song started to play, pipeline waves crashed toward the beach, and Jack Lord's face popped up on the screen, I was secretly mesmerized. I enjoyed it thoroughly until the next week, when I'd cycle right back through those same emotions again. So, tonight, with my lap and my couch overflowing with loose-leaf papers, I muttered with a sigh, "This is exactly like watching Hawaii Five-0, as I rolled my eyes and blew my bangs away from my forehead.

On with it . . .

I tackled the lifestyle guidelines first, emphasizing the familiar Mediterranean and DASH diet "patterns" instead of a focus on "individual components." For LDL-C lowering, "nontropical vegetable oils" (meaning no coconut or palm sources), nuts (specifically walnuts, almonds, and hazelnuts), plenty of fruits and vegetables, poultry, fish, and low-fat dairy products are recommended, with an emphasis on limitation of red meat and sweets. To improve BP control, a max of 2400 mg of sodium daily is recommended, but the ever-elusive nadir of the sodium limbo pole is 1500 mg/day and is associated with even better BP lowering. Avoidance of butter in favor of margarines "blended with rapeseed or flaxseed oils in lieu of butter" was suggested. Avoiding "sugar-sweetened beverages" is mentioned numerous times.

The DASH diet impact on blood-pressure lowering was effective across all subgroups regardless of gender, age, or race. "The element" sodium was specifically addressed, because little is found in "naturally occurring food" and is "primarily added in preparation, preservation, and/or at the time of consumption." The advice for sodium reduction applies to two-thirds of the US population who suffer from either prehypertension or hypertension. A reduction in sodium intake of approximately 200 mg/day reduces CVD events by around 30%, so all the eye-rolling and sulking in the world at the mere mention of sodium restriction should be ignored.

Three to four sessions per week of 40 minutes of moderate-intensity physical activity affects blood pressure and LDL favorably. The authors call for additional research to investigate which patterns might be optimal. They also articulate the multibillion-dollar question, "How can primary-care providers, health systems, public-health agencies, local and federal government, community organizations, and other stakeholders effectively and 'cost-effectively' help patients adopt these physical-activity recommendations?" They also acknowledge that we need more examination of what racial, ethnic, and socioeconomic factors affect the adoption of these programs.

The obesity guidelines translated more easily into action points for clinical practice. There are 155 million US adults who are overweight, as defined by a BMI of 25 to 29, or obese, with a BMI of 30 or higher. The writers make specific recommendations to calculate the BMI of our patients at least annually and use a tape measure to spot disease-producing waist circumferences of >35 inches for women and >40 inches for men. Our approach should include the explanation of reduced-calorie diets, increased physical activity, and behavioral programs that encourage adherence.

Hmm . . . so who's going to fund all of this "directing?"

Patients should be directed to "work through their primary-care provider to access a dietician, behavioral psychologist, or trained weight-loss counselor." Specific mention is made that in 2014 under the Affordable Care Act, these services should be supported by third-party payers, including private insurance. So far, I've not been able to find the codes to support the "two to three in-person meetings per month" that are optimal. Our patients should understand at end of their office visit that obesity invites stroke and heart attack and increases all-cause mortality. The ultimate goal is that of a "sustained weight loss of 5% to 10% in the first six months."

The guidelines also articulate that obesity is an economic liability in our new healthcare climate, not that it hasn't always been, but it was rather taboo to state such, what with all the "obese people are people too" campaigns and the suffering we've all seen from the "big-is-beautiful" campaigns that drive up cost. The writers state that "obese patients incur an increase of 46% of in-patient costs, 27% more physician visits and out-patient costs," and a staggering "90% increase in prescription-drug spending." Obese individuals cost the US "$147 billion" in healthcare in 2008. Imagine adding "overweight" individuals to the list and how that much increases spending even more.

Morbidly obese individuals with BMIs of >40 or BMIs >35 with comorbidities who have failed conventional means should be advised that bariatric surgery may be an appropriate option to improve health. Referral to "an experienced bariatric surgeon" is mentioned on numerous occasions and can result in a weight loss of 16% that is sustained at 10 years. Fasting glucose and insulin levels are reduced, but BP elevation crept back up at the end of a decade following surgery, so monitoring is necessary. Periop complications are infrequent with laparoscopic adjustable gastric banding, at 1% to 3%, including DVT, reoperations, and wound infection. The panel "did not review comprehensive evidence of pharmacotherapy for weight loss," although it did point out that the addition of orlistat was associated with a reduction in fasting blood glucose levels.

A 5% to 10% reduction in weight should be considered "successful." Weight losses of 2.5 to 5.5 kg over two years or more achieved with lifestyle intervention reduced the risk of developing diabetes by 30% to 60%. Those with diabetes who intentionally lost 9 kg to 13 kg had a 25% decrease in mortality compared with stable control weights. Failing to lose weight is associated with a higher risk of ischemic and hemorrhagic stroke.

A strategy of high-intensity lifestyle interventions should include recommendations for a diet of 1200 to 1500 calories per day for women and 1500 to 1800 calories per day for men. Although 150 minutes per week of exercise is a fairly frequent recommendation, 200 to 300 minutes per week are recommended to maintain weight loss or minimize regaining weight. Self-monitoring of food intake, physical activity, and weight monitoring are behaviors recommended to maintain weight loss. Face-to-face meetings are recommended as well as electronically delivered information by a trained interventionalists. It made no difference as to whether these were individual or group support meetings (a price point here!). If phone contact is maintained for periods of up to 2.5 years, weight regain is reduced.

Cue the music. See the surf. Hear the waves rolling in. I hear a familiar "Book him, Danno," and voilà, here's your condensed version of the "Obesity and Lifestyle Guidelines for 2013." See, that wasn't so bad; as a matter of fact, it was kind of fun—just like Hawaii Five-0.

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