ASBP Obesity Algorithm.pdf

7/25/2019 ASBP Obesity Algorithm.pdf

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American Society of Bariatric Physicians (ASBP) Algorithm

American Society of BariatricPhysicians (ASBP)

ASBP Obesity Algorithm:

Adult Adiposity Evaluation and Treatment 2013

Copyright2013ASBP: MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP

1

Citation:SegerJC,HornDB,WestmanEC,LindquistR,ScintaW,RichardsonLA,PrimackC,BrymanDA,McCarthyW,Hendricks

E,Sabowitz BN,SchmidtSL,BaysHE. AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposity

EvaluationandTreatment2013. www.obesityalgorithm.org (Accessed=[insertdate])


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ASBP Obesity Algorithm:Adult Adiposity Evaluation and Treatment 2013


2

Disclaimer

TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmwasdevelopedtoassisthealthcare

professionalsin

medical

decision

making;

however,

it

is

in

no

way

asubstitute

for

amedical

professional's

independent

judgmentandshouldnotbeconsideredmedicaladvice.Mostofthecontenthereinisbasedonthemedicalliterature

andtheclinicalexperienceofobesitymedicinespecialists.Inareasofuncertainty,professionaljudgmentofthe

authorswasapplied. TheObesityAlgorithmisaworkingdocumentthatreflectsthestateofthefieldofobesity

medicineatthetimeofpublication.Becauserapidchangesinthisareaareexpected,periodicrevisionsareinevitable.

Weencouragemedicalprofessionalstousethisinformationinconjunctionwith,andnotasareplacementfor,their

bestclinical

judgment.

The

presented

recommendations

may

not

be

appropriate

in

all

situations.

Any

decision

by

practitionerstoapplytheseguidelinesmustbemadeinlightoflocalresourcesandindividualpatientcircumstances.

Permissions

TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmisprotectedbycopyrightandmaynotbe

alteredinanyform.Thiscopyrightedmaterialmaybeaccessedforpersonalresearch,scientificand/orinformation

purposesonly.Nopartofthisalgorithmmaybedistributedforsaleorsoldinanyformorbyanymeanswithoutprior

writtenpermissionfromtheSociety.

OrderingReprintsand/orRequestingPermissionsforuseofASBP ObesityAlgorithm

Forreprintsorotherpermissions,pleasecontact:

Email: [email protected]

Phone:303.770.2526


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Coauthors:

EricC.Westman,MD,MHS

RichardLindquist,

MD,

ABFM

WendyScinta,MD,MS

LarryA.Richardson,MD,FASBP

CraigPrimack,MD,FACP,FAAP

DavidA.Bryman DO

WilliamMcCarthy,

MD

EdHendricksMD,FASBP

BrianN.Sabowitz,MD,FACP

Stacy L.Schmidt,PhD

Harold

E

Bays

MD,

FTOS,

FACE,

FNLA

Copyright2013ASBP: Maynotbereproducedoralteredinanyformwithoutwritten permissionfromASBP

3

Administrativeassistance:

LaurieTraetow ,CAE

Citation:

Seger JC,HornDB,Westman EC,LindquistR,Scinta W,RichardsonLA,PrimackC,BrymanDA,McCarthyW,HendricksE,

Sabowitz BN,SchmidtSL,BaysHE. AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposityEvaluation

andTreatment2013. www.obesityalgorithm.org (Accessed=[insertdate])



JenniferSeger,MD & DeborahBadeHorn,DO,MPH,FASBP CoChairs


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Purpose

Toprovidecliniciansanoverviewofprinciples

important

to

the

care

of

patients

with

increasedbodyfat,baseduponscientific

evidence,supportedbythemedicalliterature,

andderivedfromtheclinicalexperiencesof

members

of

the

American

Society

of

Bariatric

Physicians.


4


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American Society of Bariatric Physicians (ASBP) Algorithm 5


The ASBP Algorithm was derived from input by volunteer ASBP membersconsisting of:

Academicians

Clinicians

Clinicaltrialists

Researchers

The ASBP Algorithm did not receive industry funding, had no input from

industry, and the authors received no payment for their contributions.

Process



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The ASBP Algori thm 2013 is intended to be a living document updated

once a year (as needed), and intended as an educational tool to assist in

the translation of medical science and the clinical experience of the

authors towards assisting clinicians better manage their overweight and

obese patients.

This algorithm is not intended to be interpreted as rules and/or directives

regarding medical care of an individual patient.

While it is hoped many clinicians may find this algorithm helpful, the finaldecision regarding the optimal care of the overweight and obese patient is

dependent upon the individual clinical presentation, and the judgment of

the clinician who is tasked with directing a treatment plan that is in the

best interest of the patient.

Intent of use




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Contents: Overall management goals

Obesity classification

Obesity as a disease

Diagnosis

Overall approach

Fat mass disease

Sick fat disease (adiposopathy)

History

Physical exam

Laboratory evaluation

Treatment

Nutritional therapy

Physical activity

Behavior therapy

Weight management pharmacotherapy

Early versus late weight management intervention

Bariatric surgery

Executive summary

References

Disclosures


7




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Reference/s:[4]

[5]

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[7]

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y y ( ) g

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ASBPObesityAlgorithm: ExecutiveSummary

AssessforthePresenceofObesity,Adiposopathy,FatMassDisease


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Prevention

BMI18.5 24.9

Referralto

an

Obesity

Medicine

Specialist

NoObesity Overweight Obesity

BMI30.034.9 ClassI

BMI3539.9ClassII

BMI>40.0ClassIII

BMI25.029.9BodyMassIndex

FatPercent male

25%

female> 32%

Obesitymay

be

assessed

using

several

criteria:

presence

of

adiposity

related

disease,

fat

percent,

waist

circumferenceorbodymassindex.Thresholdsvarybasedonethnicity.

Consider

Criteria

EdmontonObesityStagingSystem



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STAGE0:

No

apparent

risk

factors

(e.g.,

blood

pressure,

serum

lipid

and

fasting

glucose

levels

within

normal

range),

physicalsymptoms,psychopathology,functionallimitationsand/orimpairmentofwellbeingrelatedtoobesity

STAGE1:Presenceofobesityrelatedsubclinicalriskfactors(e.g.,borderlinehypertension,impairedfastingglucose

levels,elevatedlevelsofliverenzymes),mildphysicalsymptoms(e.g.dyspneaonmoderateexertion,occasional

achesandpains,fatigue),mildpsychopathology,mildfunctionallimitationsand/ormildimpairmentofwellbeing

STAGE2:Presenceofestablishedobesityrelatedchronicdisease(e.g.,hypertension,type2diabetes,sleepapnea,

osteoarthritis),

moderate

limitations

in

activities

of

daily

living

and/or

well

being

)STAGE3:Establishedendorgandamagesuchasmyocardialinfarction,heartfailure,stroke,significant

psychopathology,significantfunctionallimitationsand/orimpairmentofwellbeing

STAGE4:Severe(potentiallyendstage)disabilitiesfromobesityrelatedchronicdiseases,severedisabling

psychopathology,severefunctionallimitationsand/orsevereimpairmentofwellbeing

[SharmaAM,KushnerRF.Aproposedclinicalstagingsystemforobesity.Int JObesity2009;33:289295.]

BodyMassIndex

FatPercent

WaistCircumference

BodyMassIndex=(weightinkg)/(heightinm)2 OR

703x(weightinpounds)/(heightininches)2

BodyFat

Percent

can

be

calculated

using

bioimpedance,

near

infrared

reactance,

DEXAscanorwholebodyairdisplacementplethysmography.

Waistcircumferencecanbemeasuredbytapemeasurearoundtheabdomen

attheleveloftheanteriorsuperioriliaccrests,paralleltothefloor. Tape

shouldbesnugagainstskinwithoutcompressing.

Obesity

Medicine

Specialists,

certified

by

the

American

Board

of

Obesity

Medicine,

dedicate

a

portion

or

all

of

their

practice

to

the

treatment

of

obesity.

They

perform

a

medical

evaluation

(history,

physical,

laboratory,

body

composition)

and

provide

medical

supervision

for

lifestyle

change

(nutrition,

activity,

behavior

change),

medications,

or

very

low

calorie

diets.

Obesity

is

a

chronic

medical

disease,

and

may

require

lifelong

treatment.

Obesity Medicine Specialist Evaluation may include:



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ObesityMedicineSpecialistEvaluationmayinclude:

History

PhysicalExamination

Laboratory

Tests

IndividualizedTreatmentPlanmayinclude:

DiagnosticTesting

Weighthistory,pastmedicalhistory,familyhistory,socialhistory,screening

forweightpromotingmedications,foodintake,activity,reviewofsystems

Height,weight,bloodpressure,bodycompositionanalysis,waist

measurement,completephysicalexamination

Completebloodcount,electrolytes,liverfunction,kidneyfunction,fasting

lipidprofile,

thyroid

tests,

hemoglobin

A1c,

uric

acid,

vitamin

D

EKG,Echocardiogram,exercisestresstest,sleepstudy,bariumswallowor

esophagoduodenoscopy

Diet

Activity

Counseling

Pharmacotherapy

Caloricrestriction,carbohydraterestriction,foodjournaling

VeryLowCalorieDiet(VLCD)programs

Giveexerciseprescription,usepedometers,limitTVandcomputertime,goal

of150minutes/weekofmoderateintensityphysicalactivity

Eliminateprovider

bias/stigma,

identify

self

sabotage,

develop

strong

support,stressmanagement,sleepoptimization,otherpsychologicalsupport

Usemedicationsaspartofacomprehensiveprogram

Ifineffective,considerreferraltoaMetabolicandBariatricSurgeon.

Optimalpre

and

post

operative

bariatric

surgery

care

includes

an

Obesity

Medicine

Specialist.

Current Treatment Options for Obesity


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Potency*

Risk, Cost

Lifestyle + Medication

Surgery

Lifestyle

* Potency includes many factors such as the amount, rate and sustainabili ty of weight loss, and

long-term resolution of adiposopathy and fat mass disease. Potency varies greatly for each

individual: long-term adherence to a lifestyle program can be as potent as gastric bypass surgery.

Lifestyle: Includes nutrition, exercise, behavioral programs

Lifestyle + Medication: May include Lifestyle, VLCDs w supplements, and weight loss

medications

Surgery: (in order of lowest risk/cost and potency): Gastric Banding < Gastric Sleeve

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