Release Date : September 21 2021
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity (2020)
About the Guideline
- The U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD) reviewed data through February 2013 to publish in 2014 a Clinical Practice Guideline (CPG) for the Screening and Management of Overweight and Obesity, with a recommendation to initiate an update in 2018.
- The CPG was updated in 2020 and provides objective, evidence-based information to assist providers in all aspects of care for the overweight and obese adult.
- Patients who are overweight or obese should be viewed individually in collaboration with the provider; patient-centered care optimizes healthy outcomes and improves quality of life, while minimizing preventable complications and morbidity.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you work in an acute care setting.
Screening and Assessment
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- Calculate body mass index (BMI) and document it in the patient's medical record.
- Normal adult weight is defined by a BMI of 18.5 to 24.9 kg/m2.
- Overweight is defined by a BMI between 25.0 and 29.9 kg/m2.
- Obesity is defined by a BMI greater than 30.0 kg/m2 and can be subclassified as Class I (BMI 30.0 to 34.9 kg/m2), Class II (BMI 35.0 to 39.9 kg/m2), or Class III (BMI greater than 40 kg/m2).
- Screen for overweight or obesity at least annually to identify issues and engage in discussions about maintaining healthy weight.
- Assess for factors contributing to obesity while conducting a specific assessment, medical history, and physical examination.
Normal Weight Patients
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- Provide information and behavioral counseling regarding a healthy diet and physical activities to maintain a healthy weight.
Overweight Patients without Obesity-Associated Condition(s)
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- Provide information and behavioral counseling regarding a healthy diet and physical activities to pursue a healthy weight.
Overweight Patients with Obesity-Associated Condition(s)
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- Provide comprehensive lifestyle interventions for achieving weight loss and for improving blood pressure and/or glucose control.
- Provide comprehensive lifestyle interventions for weight loss and for improving lipid levels in those patients with dyslipidemia.
- Offer pharmacotherapy to patients with a BMI greater than 27 and obesity-associated conditions, in conjunction with comprehensive lifestyle interventions, to achieve desired weight loss.
- There is insufficient evidence to support a recommendation for or against comprehensive lifestyle interventions to reduce the harms of degenerative joint disease, nonalcoholic fatty liver disease, and/or obstructive sleep apnea in overweight patients.
Obese Patients
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- Offer comprehensive lifestyle interventions for weight loss and for improving blood pressure, lipid levels, and/or glucose control.
- Offer comprehensive lifestyle interventions for weight loss to decrease the harms of obstructive sleep apnea and degenerative joint disease.
- Offer at least 12 contacts within 12 months that combine dietary, physical, and behavioral strategies.
- Plan diet and physical activity to achieve 5% to 10% reduction in body weight over 6 months, or a weight loss of 0.5 to 2 pounds per week.
- Offer pharmacotherapy to patients with BMI greater than 30 and obesity-associated conditions, in conjunction with comprehensive lifestyle interventions, to achieve desired weight loss.
- There is insufficient evidence that weight loss through comprehensive lifestyle interventions will decrease the harm of nonalcoholic fatty liver disease in obese patients.
Shared Decision-Making
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- Reach a common understanding with obese and overweight patients about the risks of being overweight or obese and the benefits of weight management.
General Treatment Principles of Weight Loss
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- Assess the risks and benefits of different weight-management treatments and develop a weight- management plan after performing an in-depth clinical assessment.
- Use motivational interviewing procedures to promote acceptance of treatments.
- Stress the importance of a lifelong commitment to treatment.
- Offer at least 12 contacts within 12 months to promote the comprehensive lifestyle interventions.
- Plan a reduction of 500 to 1000 kcal/day to achieve weight loss of 0.5 to 2 pounds per week.
- Assess compliance with the program one to two times per month and provide support.
- Re-evaluate the treatment plan if weight loss is less than an average of 0.5 pounds/week.
- Offer a comprehensive maintenance program when the weight-loss goal is met.
Behavioral and Lifestyle Approaches
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- Provide comprehensive lifestyle interventions in individual or group settings.
- Suggest telephone-based comprehensive lifestyle interventions as an alternative.
- There is insufficient evidence for or against recommending internet-based comprehensive lifestyle interventions as an alternative to or in conjunction with face-to-face intervention.
Dietary Approaches
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- Offer any of several diets to produce a safe caloric deficit, such as the Dietary Approach to Stop Hypertension (DASH) or low-fat diet.
- Offer meal replacements to achieve low- or very-low calorie diets.
- Offer physical activity in combination with weight loss to produce a caloric deficit.
Physical Activity Approaches
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- Propose short, intermittent bursts of physical activity elements leading to weight loss, in addition to longer continuous exercise.
- Propose moderate-intensity physical activity for 150 minutes per week for weight loss.
- Propose 200 to 300 minutes per week to prevent weight regain after initial weight loss.
Pharmacotherapy
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- When lifestyle interventions alone have not achieved the desired weight loss, offer a combination of phentermine/topiramate ER to patients with a BMI of 30 kg/m2 or more, and to patients with a BMI of 27 kg/m2 or more who have obesity-associated conditions.
- When lifestyle interventions alone have not achieved the desired weight loss, offer orlistat or lorcaserin to patients with a BMI of 30 kg/m2 or more, and to patients with a BMI of 27 kg/m2 or more plus obesity-associated conditions.
Bariatric Surgery
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- Offer bariatric surgery as an adjunct to comprehensive lifestyle interventions for patients with a BMI of 40 kg/m2 or more, or for those with a BMI of 35.0 to 39.9 kg/m2 with one or more obesity-associated conditions.
- Offer bariatric surgery, in conjunction with comprehensive lifestyle interventions, for patients with a BMI of 35.0 kg/m2 or more to improve some obesity-associated conditions.
- There is insufficient evidence to support bariatric surgery in patients over age 65.
Reference
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Link to Practice Guideline
https://www.healthquality.va.gov/guidelines/CD/obesity/VADoDObesityCPGFinal5087242020.pdf
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