Obesity in adults: Clinical practice guideline adapted for Chile

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Summary of recommendations adopted from the original guideline.
Interventions to reduce biases in obesity management, practice, and policy
Recommendation 1Healthcare providers should assess their attitudes and beliefs regarding obesity and consider how they may influence care delivery (Level 1a; Grade A).
Recommendation 2Healthcare professionals can recognize that internalized bias (bias toward self) in people living with obesity may affect behavioral and health outcomes (Level 2a; Grade B).
Recommendation 3Health professionals should avoid using judgmental words toward patients living with obesity (Level 1a; Grade A).
Health professionals should avoid using judgmental images toward patients living with obesity (Level 2b; Grade B).
Health professionals should avoid judgmental practices toward patients living with obesity (Level 2a; Grade B).
Recommendation 4We recommend that healthcare professionals avoid assuming that an ailment or complaint presented by a patient is related to his or her body weight (Level 3; Grade C).
Epidemiology of obesity in adults
Recommendation 5Health professionals can recognize and treat obesity as a chronic disease caused by an abnormal or excessive accumulation of body fat (adiposity), which impairs health and increases the risk of morbidity and premature mortality (Level 2b; Grade B).
Recommendation 6Developing evidence-based strategies for policy-makers can be directed at managing obesity in adults (Level 2b; Grade B).
Recommendation 7Ongoing longitudinal surveillance of obesity at national and regional levels, including self-reported and measured data (i.e., height, weight, waist circumference), should be collected on a regular basis (Level 2b; Grade B).
Interventions that impact daily activities in people with obesity
Recommendation 8We recommend that healthcare professionals ask people living with obesity concerns about managing self-care activities, including bathing; dressing; genital, bowel, and bladder management; skin and wound care; and foot care (Level 3; Grade C).
Recommendation 9We recommend that healthcare professionals assess fall risk in people living with obesity, as this may interfere with their ability and interest in performing physical activity (Level 3; Grade C).
Assessment of people living with obesity
Recommendation 10We suggest that healthcare professionals involved in the screening, assessment, and management of people living with obesity use the "5As" framework to initiate a discussion by asking for their permission and assessing their willingness to begin treatment (Level 4; Grade D, consensus).
Recommendation 11Health professionals can measure height and weight and calculate BMI in all adults with a BMI of 25 to 35 kg/m2 (Level 2a; Grade B).
Health professionals can measure waist circumference in adults with a BMI of 25 to 35 kg/m2 (Level 2b; Grade B).
Recommendation 12We suggest that the evaluation include a complete history to identify the root causes of weight gain, complications of obesity, and possible barriers to treatment (Level 4; Grade D).
Recommendation 13We recommend measuring blood pressure in both arms, fasting glucose or glycosylated hemoglobin, and lipid profile to determine cardiometabolic risk and alanine aminotransferase levels for nonalcoholic fatty liver disease screening in persons with obesity (Level 3; Grade D).
Recommendation 14We suggest that healthcare professionals consider using the Edmonton Obesity Staging System to determine the severity of obesity and guide clinical decision-making (Level 4; Grade D).
The role of mental health in the treatment of obesity
Recommendation 15Periodic monitoring of weight, glycemia, and lipid profile are recommended for persons with a mental health-related diagnosis who are taking medications associated with weight gain (Level 3; Grade C).
Recommendation 16Healthcare professionals may consider both efficacy and adverse effects on body weight when choosing medications to treat psychiatric pathologies (Level 2a; Grade B).
Recommendation 17Metformin and psychological treatment (e.g., cognitive behavioral therapy) should be considered to prevent weight gain in persons with severe psychiatric illness who are treated with antipsychotic medications associated with weight gain (Level 1a; Grade A).
Recommendation 18Healthcare professionals should consider lisdexamfetamine and topiramate as adjunctive therapy to psychological treatment for managing excess weight in persons with obesity and binge eating disorder (Level 1a; Grade A).
Medical nutrition therapy for the treatment of obesity
Recommendation 19We suggest that nutritional recommendations for adults of any body size be individualized to meet values, preferences, and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally acceptable, and affordable for long-term adherence (Level 4; Grade D).
Recommendation 20Adults living with obesity should receive personalized nutritional therapy provided by a professional nutritionist to improve outcomes for body weight, BMI, waist circumference, glycemic control, and established lipid and blood pressure targets (Level 1a; Grade A).
Recommendation 21Adults with obesity and impaired glycemic control (prediabetes) or type 2 diabetes may receive nutritional therapy provided by a professional nutritionist to reduce body weight and waist circumference and improve glycemic control and blood pressure (Level 2a; Grade B).
Recommendation 22Adults with obesity can consider multiple nutritional therapies to improve health-related outcomes. They can choose the dietary regimens and diet-focused approaches that best suit them over the long term (full recommendation, category, and level of evidence available in the chapter titled "Medical Nutrition Therapy in the Treatment of Obesity").
Recommendation 23Adults living with obesity and prediabetes should consider undergoing intensive behavioral interventions to reduce their weight by 5% to 7%. This reduction aims at improving glycemic control and blood pressure, meeting plasma lipid targets, reducing the likelihood of type 2 diabetes (Level 1a; Grade A), microvascular complications (retinopathy, nephropathy, and neuropathy), and cardiovascular and all-cause death (Level 1a; Grade B).
Recommendation 24Adults living with obesity and type 2 diabetes should consider intensive behavioral interventions to reduce their weight by 7% to 15% to enhance remission of type 2 diabetes and reduce the incidence of nephropathy, obstructive sleep apnea, and depression (Level 1a; Grade A).
Recommendation 25We recommend a non-diet approach that improves the quality of life, psychological aspects (general well-being, perception of body image), cardiovascular parameters, weight, physical activity, and control of eating behaviors (Level 3; Grade C).
Physical activity interventions in the treatment of obesity
Recommendation 26Aerobic physical activity (30 to 60 minutes of moderate to vigorous intensity most days of the week) can be considered for adults who wish to:
- Achieve small weight and body fat loss (Level 2a; Grade B).
- Achieve reductions in abdominal and ectopic fat, such as liver and heart fat, even without weight loss (Level 1a; Grade A).
- Promote weight maintenance after weight loss, promote maintenance of fat-free mass during weight loss, and increase cardiorespiratory fitness and mobility (Level 2a; Grade B).
Recommendation 27For overweight or obese adults, resistance training may promote weight maintenance or a modest increase in muscle mass or fat-free mass and mobility (Level 2a; Grade B).
Recommendation 28Increased exercise intensity, including high-intensity interval training, may achieve greater cardiorespiratory fitness and reduce the time required to achieve benefits similar to moderate-intensity aerobic activity (Level 2a; Grade B).
Recommendation 29Regular physical activity, with and without weight loss, can improve many cardiometabolic risk factors in overweight or obese adults, including hyperglycemia and insulin sensitivity (Level 2a; Grade B), hypertension (Level 1a; Grade B), and dyslipidemia (Level 2a; Grade B).
Recommendation 30Regular physical activity can improve health-related quality of life, mood disorders (i.e., depression, anxiety), and body image in overweight or obese adults (Level 2b; Grade B).
Effective psychological and behavioral interventions for the treatment of obesity
Recommendation 31- Multicomponent psychological interventions – combining behavior modification (goal setting, self-management, problem-solving), cognitive therapy (restructuring), and value-based strategies to modify diet and activity – should be incorporated into plans of care for weight loss, and improved health status and quality of life (Level 1a; Grade A).
- Multicomponent psychological interventions should promote adherence, confidence, and intrinsic motivation (Level 1b; Grade A).
Recommendation 32Healthcare professionals should provide longitudinal care with consistent motivation to people living with obesity in order to: support the development of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal and meaningful reasons to change); encourage the patient to set and sequence health goals that are realistic and achievable; self-monitor behavior and analyze setbacks using problem-solving and adaptive thinking (cognitive restructuring), including clarifying and reflecting on values-based behaviors (Level 1a; Grade A).
Recommendation 33Health professionals should seek permission from people living with obesity to educate them that treatment success is related to improved health, function, and quality of life resulting from attainable behavioral goals and not in the amount of weight loss (Level 1a; Grade A).
Recommendation 34Health professionals should provide repeated and consistent follow-up sessions relevant to support the development of self-efficacy and intrinsic motivation. Once an agreement to follow a pathway (health behavior and/or medication and/or surgical pathways) has been established, follow-up sessions should review previous messages in a manner consistent with repetition (provider role) and with relevance (patient role) to support the development of self-efficacy and intrinsic motivation (Level 1a; Grade A).
Pharmacotherapy in the treatment of obesity
Recommendation 35Pharmacotherapy for weight loss can be used in individuals with a BMI ≥ 30 kg/m2 or a BMI ≥ 27 kg/m2 with adiposity-related complications, along with nutritional therapy, physical activity, and psychological interventions (e.g., liraglutide 3.0 mg, a combination of naltrexone and bupropion, or orlistat) (Level 2a; Grade B).
Recommendation 36For people living with type 2 diabetes and a BMI ≥ 27 kg/m2, pharmacotherapy can be used in conjunction with healthy behavioral changes for weight loss and improved glycemic control. Physicians may consider:
- Liraglutide 3.0 mg (Level 1a; Grade A).
- Combination of naltrexone and bupropion, or use of orlistat (Level 2a; Grade B).
Recommendation 37We recommend pharmacotherapy along with health behavior changes for persons living with prediabetes and overweight or obesity (BMI ≥ 27 kg/m2) to delay or prevent type 2 diabetes (liraglutide 3.0 mg; orlistat) (Level 2a; Grade B).
Recommendation 38We do not suggest using prescription or over-the-counter medications other than those approved for weight control (Level 4; Grade D, consensus).
Recommendation 39For individuals living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest choosing medications that are not associated with weight gain (Level 4; Grade D, consensus).
Bariatric surgery: selection and preoperative preparation
Recommendation 40We suggest performing a complete medical and nutritional evaluation and correcting nutritional deficiencies in candidates for bariatric surgery (Level 4; Grade D).
Recommendation 41Preoperative smoking cessation can minimize perioperative and postoperative complications (Level 2a; Grade B).
Recommendation 42We suggest screening and treatment of obstructive sleep apnea in individuals who wish to undergo bariatric surgery (Level 4; Grade D).
Bariatric surgery: surgical options and outcomes
Recommendation 43Bariatric surgery can be considered for individuals with BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one adiposity-related disease (Level 4; Grade D, consensus) to reduce long-term overall mortality (Level 2b; Grade B) and induce greater long-term weight loss compared with medical treatment alone (Level 1a; Grade A). Bariatric surgery also can improve control and remission of type 2 diabetes in combination with the best medical treatment competed with the best medical treatment alone (Level 2a; Grade B), significantly improves the quality of life (Level 3; Grade C), and can lead to long-term remission of most adiposity-related diseases, including dyslipidemia, hypertension, hepatic steatosis, and nonalcoholic steatohepatitis (Level 3; Grade C).
Recommendation 44Bariatric surgery should be considered in patients with poorly controlled type 2 diabetes and class one obesity (BMI 30 to 35 kg/m2) despite optimal medical treatment (Level 1a; Grade A).
Recommendation 45Bariatric surgery may be considered for weight loss and/or to control adiposity-related disease in persons with class one obesity in whom optimal medical and behavioral treatment has been insufficient to produce significant weight loss (Level 2a; Grade B).
Recommendation 46We suggest that the type of bariatric procedure (sleeve gastrectomy, gastric bypass, or duodenal switch) be decided according to patient needs in collaboration with an experienced interprofessional team (Level 4; Grade D, consensus).
Recommendation 47We do not recommend adjustable gastric banding due to unacceptable complications and long-term failure of this procedure (Level 4; Grade D).
Recommendation 48We suggest that single-anastomosis gastric bypass should not be routinely indicated because of long-term complications compared with Roux-en-Y gastric bypass (Level 4; Grade D).
Bariatric surgery: postoperative management
Recommendation 49Healthcare professionals can promote and encourage individuals who have undergone bariatric surgery to participate in and maximize their access to behavioral interventions and related health services at a bariatric surgery center (Level 2a; Grade B).
Recommendation 50We suggest that bariatric surgery centers provide primary care centers with a comprehensive care plan for discharged patients that include a report of the bariatric procedure, emergency contact numbers, required annual blood tests, long-term vitamin and mineral supplements, medications, and behavioral interventions, as well as when to refer them back if needed (Level 4; Grade D, consensus).
Recommendation 51After a patient has been discharged from the bariatric surgery center, we suggest that primary care centers perform annual check-ups that include: weight measurement, dietary intake, physical activity, compliance with multivitamin and mineral supplements, evaluation of comorbidities, and laboratory testing to assess and treat nutritional deficiencies as needed (Level 4; Grade D, consensus).
Recommendation 52We suggest that primary care centers consider referral to a bariatric surgery center or a local specialist for gastrointestinal symptoms, nutritional problems, pregnancy, need for psychological support, weight regains, or other medical problems related to bariatric surgery, as described in the chapter titled "Bariatric surgery: postoperative management" (Level 4; Grade D, consensus).
Recommendation 53We suggest that bariatric surgery centers provide appropriate follow-up and laboratory testing at regular intervals after surgery, with access to appropriate healthcare professionals (nutritionist, nurse, social worker, physician, surgeon, psychologist, or psychiatrist) until discharge is deemed appropriate for the patient (Level 4; Grade D, consensus).
Primary healthcare in the management of obesity
Recommendation 54We recommend that primary care physicians identify and diagnose overweight and obese individuals and initiate conversations with them that focus on the patient’s health (Level 3; Grade C).
Recommendation 55We recommend that healthcare professionals ensure that they ask individuals for permission before discussing weight or taking anthropometric measurements (Level 3; Grade C).
Recommendation 56Primary care interventions should be used to increase patients' knowledge and skills about weight management as an effective way to control weight (Level 1a; Grade A).
Recommendation 57Primary care physicians should refer individuals with obesity to multidisciplinary primary care programs with personalized obesity management strategies as an effective way to support obesity management (Level 1b; Grade B).
Recommendation 58Primary healthcare professionals can use collaborative discussion through motivational interviewing to tailor action plans to the individuals' life context in a manageable and sustainable way to support improved physical and emotional health and weight management (Level 2b; Grade C).
Recommendation 59Interventions targeting a specific ethnic group should consider the diversity of psychological and social practices concerning excess weight, eating, and physical activity, as well as socioeconomic circumstances, as they may differ between and within groups (Level 1b; Grade B).
Recommendation 60Cross-cutting primary care interventions should focus on small, incremental, and personalized behavioral changes (the "small changes approach") to be effective in helping individuals manage their weight (Level 1b; Grade B).
Recommendation 61Multicomponent primary care programs should consider personalized obesity management strategies as an effective way to support people living with obesity (Level 1b; Grade B).
Recommendation 62Behavior-based primary care interventions (nutrition, exercise, lifestyle), as a sole therapy or in combination with pharmacotherapy, should be used to manage overweight and obesity (Level 1a; Grade A).
Recommendation 63Group diet and physical activity sessions based on the Diabetes Prevention Program and Look AHEAD (Action for Diabetes Health) programs should be used as an effective management option for overweight and obese adults (Level 1b; Grade A).
Recommendation 64Interventions that use technology to increase outreach should be a potentially viable lower-cost intervention in a community setting (Level 1b; Grade B).
Recommendation 65In undergraduate, graduate, and continuing education programs for primary healthcare professionals, educators should offer courses and clinical experiences to address skills gaps, evidence knowledge, and attitudes needed to confidently and effectively support people living with obesity (Level 1a; Grade A).
Commercial products and programs for obesity control
Recommendation 66We do not recommend using over-the-counter products to manage obesity due to a lack of evidence (Level 4; Grade D).
Recommendation 67We do not suggest using commercial weight loss programs to improve blood pressure and lipid control in adults with obesity (Level 4; Grade D).
Use of emerging technologies and telehealth in obesity treatment
Recommendation 68Implementing management strategies can be accomplished through web-based platforms (e.g., online education on medical nutrition therapy and physical activity) or mobile devices (e.g., daily weight reporting through a smartphone app) in obesity management (Level 2a; Grade B).
Recommendation 69We suggest that healthcare professionals incorporate individualized feedback and follow-up (e.g., one-on-one coaching or feedback via phone or email) into technology-based management strategies to improve weight loss outcomes (Level 4; Grade D).
Recommendation 70Portable activity-tracking technology should be part of an overall weight management strategy (Level 1a; Grade A).
Weight control during the reproductive age of adult women with obesity
Recommendation 71We recommend that primary care professionals discuss reproductive-age-specific weight control goals with adult women with obesity. This should include discussion of:
- Preconception weight loss (Level 3; Grade C).
- A suggested gestational weight gain of five to nine kg throughout pregnancy (Level 4; Grade D).
- Losing a minimum of the gestational weight gain in postpartum to reduce the risk of adverse outcomes in a future pregnancy (Level 3; Grade C).
Recommendation 72Primary care facilities should offer lifestyle change interventions that include both nutrition and physical activity to achieve weight goals to adult women with obesity who are:
- Considering pregnancy (Level 3; Grade C).
- Pregnant (Level 2a; Grade B).
- In postpartum (Level 1a; Grade A).
Recommendation 73We recommend that primary care providers encourage and support pregnant women with obesity to consume healthy foods to achieve their gestational weight gain goals (Level 3; Grade C).
Recommendation 74We recommend that primary care providers encourage and support pregnant patients with obesity (who do not have contraindications) to engage in at least 150 minutes per week of moderate-intensity physical activity to help manage gestational weight gain (Level 3; Grade C).
Recommendation 75Healthcare professionals should not prescribe metformin to manage gestational weight gain in pregnant women with obesity (Level 1b; Grade A).
We suggest not using medications for weight control during pregnancy or lactation (Level 4; Grade D).
Recommendation 76We recommend that women with obesity be offered additional support that promotes and facilitates breastfeeding because of the trend toward decreased rates of initiation and maintenance of breastfeeding (Level 3; Grade C).

BMI, Body Mass Index.