NHLBI Obesity Education Initiative
The Practical
Guide
Identification,
Evaluation,
and Treatment
of Overweight and
Obesity in Adults
N
N AATT I I O
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N AA L L I I N
N SS TT I I TT U
U TT EE SS O
O FF H
H EE AA L LTT H
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N NA AT TI IO ON NA AL L H HE EA AR RT T, , L LU UN NG G, , A AN ND D B BL LO OO OD D I IN NS ST TI IT TU UT TE E
N O R T H A M E R I C A N A S S O C I A T I O N F O R T H E S T U D Y O F O B E S I T Y

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ACKNOWLEDGMENTS:
The Working Group wishes to acknowledge
the additional input to the Practical Guide from
the following individuals: Dr. Thomas Wadden,
University of Pennsylvania; Dr. Walter Pories,
East Carolina University; Dr. Steven Blair,
Cooper Institute for Aerobics Research; and
Dr. Van S. Hubbard, National Institute of
Diabetes and Digestive and Kidney Diseases.

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The Practical
Guide
Identification,
Evaluation,
and Treatment
of Overweight and
Obesity in Adults
National Institutes of Health
NHLBI Obesity Education Initiative
National Heart, Lung, and Blood Institute
North American Association for the Study of Obesity
NIH Publication Number 00-4084
October 2000

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NHLBI Obesity Education Initiative
Barbara C. Hansen, Ph.D.
David F. Williamson, Ph.D., M.S.
Expert Panel on the Identification,
University of Maryland School of Medicine
Centers for Disease Control and Prevention
Evaluation, and Treatment of
Millicent Higgins, M.D.
G. Terence Wilson, Ph.D.
Overweight and Obesity in Adults.
University of Michigan
Rutgers Eating Disorders Clinic
F.Xavier Pi-Sunyer, M.D., M.P.H.
James O. Hill, Ph.D.
Columbia University College
University of Colorado
EX-OFFICIO MEMBERS
of Physicians and Surgeons
Health Sciences Center
Clarice D. Brown, M.S.
Chair of the Panel
Barbara V. Howard, Ph.D.
Coda Research Inc.
Medlantic Research Institute
Karen A. Donato, M.S., R.D.*
MEMBERS
Robert J. Kuczmarski, Dr.P.H., R.D.
Executive Director of the Panel
National Center for Health Statistics
Coordinator, NHLBI Obesity
Diane M. Becker, Sc.D., M.P.H.
Centers for Disease Control and Prevention
Education Initiative
The Johns Hopkins University
Shiriki Kumanyika, Ph.D., R.D., M.P.H.
National Heart, Lung, and Blood Institute
Claude Bouchard, Ph.D.
The University of Pennsylvania
National Institutes of Health
Laval University
R. Dee Legako, M.D.
Nancy Ernst, Ph.D., R.D.*
Richard A. Carleton, M.D.
Prime Care Canyon Park
National Heart, Lung, and Blood Institute
Brown University School of Medicine
Family Physicians, Inc.
National Institutes of Health
Graham A. Colditz, M.D., Dr.P.H.
T. Elaine Prewitt, Dr.P.H., R.D.
D. Robin Hill, Ph.D.*
Harvard Medical School
Loyola University Medical Center
National Heart, Lung, and Blood Institute
William H. Dietz, M.D., Ph.D.
National Institutes of Health
Albert P. Rocchini, M.D.
National Center for Chronic Disease
University of Michigan Medical Center
Michael J. Horan, M.D., Sc.M.*
Prevention and Health Promotion
National Heart, Lung, and Blood Institute
Centers for Disease Control and Prevention
Philip L Smith, M.D.
National Institutes of Health
The Johns Hopkins Asthma
John P. Foreyt, Ph.D.
and Allergy Center
Van S. Hubbard, M.D., Ph.D.
Baylor College of Medicine
National Institute of Diabetes and
Linda G. Snetselaar, Ph.D., R.D.
Robert J. Garrison, Ph.D.
Digestive and Kidney Diseases
University of Iowa
University of Tennessee, Memphis
James P. Kiley, Ph.D.*
James R. Sowers, M.D.
Scott M. Grundy, M.D., Ph.D.
National Heart, Lung, and Blood Institute
Wayne State University School of Medicine
University of Texas Southwestern
National Institutes of Health
University Health Center
Medical Center at Dallas
Eva Obarzanek, Ph.D., R.D., M.P.H.*
Michael Weintraub, M.D.
National Heart, Lung, and Blood Institute
Food and Drug Administration
National Institutes of Health
*NHLBI Obesity Initiative Task Force Member
North American Association for the
Susan Fried, Ph.D.
Study of Obesity Practical Guide
Rutgers University
CONSULTANT
Development Committee
Patrick Mahlen O'Neil, Ph.D.
David Schriger, M.D., M.P.H., F.A.C.E.P.
Medical University of South Carolina
Louis J. Aronne, M.D., F.A.C.P.
University of California
Henry Buchwald, M.D.
Cornell University, Chair
Los Angeles School of Medicine
University of Minnesota
MEMBERS
George Cowan, M.D.
SAN ANTONIO COCHRANE CENTER
University of Tennessee
Charles Billington, M.D.
Elaine Chiquette, Pharm.D.
College of Medicine
University of Minnesota
Cynthia Mulrow, M.D., M.Sc.
Robert Brolin, M.D.
George Blackburn, M.D., Ph.D.
V.A. Cochrane Center at San Antonio
UMDNJ-Robert Wood Johnson
Harvard University
Audie L. Murphy Memorial
Medical School
Veterans Hospital
Karen A. Donato, M.S., R. D.
NHLBI Obesity Education Initiative
EX-OFFICIO MEMBERS
STAFF
National Heart, Lung, and
James O. Hill, Ph.D.
Blood Institute
Adrienne Blount, Maureen Harris, M.S., R.D.,
University of Colorado
National Institutes of Health
Anna Hodgson, M.A., Pat Moriarty, M.Ed.,
Health Sciences Center
R.D., R.O.W. Sciences, Inc.
Arthur Frank, M.D.
Edward Bernstein, M.P.H.
George Washington University
North American Association
for the Study of Obesity

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Table of Contents
Foreword ......................................................................................................................................v
How To Use This Guide ..............................................................................................................vi
Executive Summary ....................................................................................................................1
Assessment ..........................................................................................................................1
Body Mass Index...........................................................................................................1
Waist Circumference .....................................................................................................1
Risk Factors or Comorbidities .......................................................................................1
Readiness To Lose Weight............................................................................................2
Management.........................................................................................................................2
Weight Loss ..................................................................................................................2
Prevention of Weight Gain ............................................................................................2
Therapies..............................................................................................................................2
Dietary Therapy.............................................................................................................2
Physical Activity ............................................................................................................3
Behavior Therapy ..........................................................................................................3
Pharmacotherapy ..........................................................................................................3
Weight Loss Surgery.....................................................................................................4
Special Situations.................................................................................................................4
Introduction..................................................................................................................................5
The Problem of Overweight and Obesity .............................................................................5
Treatment Guidelines ..................................................................................................................7
Assessment and Classification of Overweight and Obesity .................................................8
Assessment of Risk Status ................................................................................................11
Evaluation and Treatment Strategy ....................................................................................15
Ready or Not: Predicting Weight Loss ...............................................................................21
Management of Overweight and Obesity ...........................................................................23
Weight Management Techniques .............................................................................................25
Dietary Therapy ..................................................................................................................26
Physical Activity..................................................................................................................28
Behavior Therapy ...............................................................................................................30
Making the Most of the Patient Visit............................................................................30
Pharmacotherapy ...............................................................................................................35
Weight Loss Surgery ..........................................................................................................38
Weight Reduction After Age 65 ...............................................................................................41
References .................................................................................................................................42
iii

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Introduction to the Appendices ...............................................................................................45
Appendix A. Body Mass Index Table..................................................................................46
Appendix B. Shopping—What to Look For ........................................................................47
Appendix C. Low Calorie, Lower Fat Alternatives..............................................................49
Appendix D. Sample Reduced Calorie Menus...................................................................51
Appendix E. Food Exchange List.......................................................................................57
Appendix F. Food Preparation—What to Do .....................................................................59
Appendix G. Dining Out—How To Choose.........................................................................60
Appendix H. Guide to Physical Activity ..............................................................................62
Appendix I. Guide to Behavior Change ............................................................................68
Appendix J. Weight and Goal Record ...............................................................................71
Appendix K. Weekly Food and Activity Diary.....................................................................74
Appendix L. Additional Resources.....................................................................................75
List of Tables
Table 1.
Classifications for BMI .....................................................................................1
Table 2.
Classification of Overweight and Obesity by BMI, Waist Circumference,
and Associated Disease Risk........................................................................10
Table 3.
A Guide to Selecting Treatment.....................................................................25
Table 4.
Low-Calorie Step I Diet .................................................................................27
Table 5.
Examples of Moderate Amounts of Physical Activity ....................................29
Table 6.
Weight Loss Drugs ........................................................................................36
List of Figures
Figure 1.
Age-Adjusted Prevalence of Overweight (BMI 25–29.9) and
Obesity (BMI ≥ 30) ..........................................................................................6
Figure 2.
NHANES III Age-Adjusted Prevalence of High Blood Pressure (HBP),
High Total Blood Cholesterol (TBC), and Low-HDL by Two BMI Categories ..6
Figure 3.
Measuring-Tape Position for Waist (Abdominal) Circumference in Adults ......9
Figure 4.
Treatment Algorithm ......................................................................................16
Figure 5.
Surgical Procedures in Current Use..............................................................38
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Foreword
In June 1998,the Clinical Guidelines on the The Guide was prepared by a working group con-
Identification, Evaluation, and Treatment of
vened by the North American Association for the
Overweight and Obesity in Adults: Evidence
Study of Obesity and the National Heart, Lung, and
Report was released by the National Heart, Lung,
Blood Institute. Three members of the American
and Blood Institute’s (NHLBI) Obesity Education
Society for Bariatric Surgery also participated in
Initiative in cooperation with the National Institute
the working group. Members of the Expert Panel,
of Diabetes and Digestive and Kidney Diseases
especially the Panel Chairman, assisted in the review
(NIDDK). The impetus behind the clinical practice
and development of the final product. Special thanks
guidelines was the increasing prevalence of over-
are also due to the 50 representatives of the various
weight and obesity in the United States and the need
disciplines in primary care and others who reviewed
to alert practitioners to accompanying health risks.
the preprint of the document and provided the
working group with excellent feedback.
The Expert Panel that developed the guidelines
consisted of 24 experts, 8 ex-officio members, and a
The Practical Guide will be distributed to primary
consultant methodologist representing the fields of
care physicians, nurses, registered dietitians, and
primary care, clinical nutrition, exercise physiology,
nutritionists as well as to other interested health care
psychology, physiology, and pulmonary disease.
practitioners. It is our hope that the tools provided here
The guidelines were endorsed by representatives
help to complement the skills needed to effectively
of the Coordinating Committees of the National
manage the millions of overweight and obese individ-
Cholesterol Education Program and the National
uals who are attempting to manage their weight.
High Blood Pressure Education Program, the North
American Association for the Study of Obesity, and
the NIDDK National Task Force on the Prevention
and Treatment of Obesity.
This Practical Guide to the Identification, Evaluation,
David York, Ph.D.
Claude Lenfant,M.D.
and Treatment of Overweight and Obesity in Adults is
President Director
largely based on the evidence report prepared by the
North American Association
National Heart, Lung,
Expert Panel and describes how health care practition-
for the Study of Obesity
and Blood Institute
ers can provide their patients with the direction and
National Institutes
support needed to effectively lose weight and keep it
of Health
off. It provides the basic tools needed to appropriately
assess and manage overweight and obesity.
The guide includes practical information on dietary
therapy, physical activity, and behavior therapy, while
also providing guidance on the appropriate use of
pharmacotherapy and surgery as treatment options.
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How to Use This Guide
Overweight and obesity,serious and growing health problems,are not receiving
the attention they deserve from primary care practitioners. Among the reasons
cited for not treating overweight and obesity is the lack of authoritative information
to guide treatment. This Practical Guide to the Identification, Evaluation, and
Treatment of Overweight and Obesity in Adults was developed cooperatively by
the North American Association for the Study of Obesity (NAASO) and the National Heart,
Lung, and Blood Institute (NHLBI). It is based on the Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report developed by
the NHLBI Expert Panel and released in June 1998. The Expert Panel used an evidence-based
methodology to develop key recommendations for assessing and treating overweight and obese
patients. The goal of the Practical Guide is to provide you with the tools you need to effectively
manage your overweight and obese adult patients in an efficient manner.
The Guide has been developed to help you easily access all of the information you need.
The Executive Summary contains the essential information in an abbreviated form.
The Treatment Guidelines section offers details on assessment and management of patients
and features the Expert Panel’s Treatment Algorithm, which provides a step-by-step approach
to learning how to manage patients.
The Appendix contains practical tools related to diet, physical activity, and behavioral
modification needed to educate and inform your patients. The Appendix has been formatted
so that you can copy it and explain it to your patients.
Managing overweight and obese patients requires a variety of skills. Physicians play a key role in
evaluating and treating such patients. Also important are the special skills of nutritionists, registered
dietitians, psychologists, and exercise physiologists. Each health care practitioner can help patients
learn to make some of the changes they may need to make over the long term. Organizing a “team”
of various health care practitioners is one way of meeting the needs of patients. If that approach is
not possible, patients can be referred to other specialists required for their care.
To get started, just follow the Ten Step approach.
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Ten Steps to Treating Overweight and Obesity in the Primary Care Setting
Measure height and weight so that you can
the patient can stick with the 1,600 kcal/day
estimate your patient’s BMI from the table
diet but does not lose weight you may want to
1 in AppendixA.
try the 1,200 kcal/day diet. If a patient on
either diet is hungry, you may want to
increase the calories by 100 to 200 per day.
2 Measure waist circumference
Included in Appendix D are samples of both
as described on page 9.
a 1,200 and 1,600 calorie diet.
3 Assess comorbiditiesas described on
Discuss a physical activity goal with the
pages 11–12 in the section on
patient using the Guide to Physical Activity
7
“Assessment of Risk Status.”
(see Appendix H). Emphasize the importance
of physical activity for weight maintenance
and risk reduction.
Should your patient be treated? Take the
information you have gathered above and use
4 Figure4,the Treatment Algorithm,on pages
Review the Weekly Food and Activity
16 –17 to decide. Pay particular attention to
Diary (see Appendix K) with the patient.
8
Box 7 and the accompanying explanatory
Remind the patient that record-keeping has
text. If the answer is “yes” to treatment,
been shown to be one of the most successful
decide which treatment is best using Table 3
behavioral techniques for weight loss and
on page 25.
maintenance. Write down the diet, physical
activity, and behavioral goals you have agreed
on at the bottom.
Is the patient ready and motivated to lose
weight? Evaluation of readiness should
5 include the following:(1)reasons and
Give the patient copies of the dietary
motivation for weight loss, (2) previous
information (see Appendices B–G),
9
attempts at weight loss, (3) support expected
the Guide to Physical Activity (see
from family and friends, (4) understanding of
Appendix H), the Guide to Behavior
risks and benefits, (5) attitudes toward
Change (see Appendix I), and the Weekly
physical activity, (6) time availability,
Food and Activity Diary (see Appendix K).
and (7) potential barriers to the patient’s
adoption of change.
Enter the patient’s information and the
goals you have agreed on in the Weight and
10
Which diet should you recommend?
Goal Record (see Appendix J). It is important
In general, diets containing 1,000 to 1,200
to keep track of the goals you have set and
6 kcal/day should be selected for most women;
to ask the patient about them at the next visit
a diet between 1,200 kcal/day and 1,600
to maximize compliance. Have the patient
kcal/day should be chosen for men and may
schedule an appointment to see you or your
be appropriate for women who weigh 165
staff for followup in 2 to 4 weeks.
pounds or more, or who exercise regularly. If
vii

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Document Outline

• Table of Contents
• Expert Panel Members
• Forward
• How to Use This Guide
• Executive Summary
  • Assessment
  • Management
  • Therapies
  • Special Situations
• Introduction
• Treatment Guidelines
  • Assessment & Classification
  • Assessment of Risk Status
  • Evaluation & Treatment Strategies
  • Predicting Weight Loss
  • Management
• Weight Management Techniques
  • Dietary Therapy
  • Physical Activity
  • Behavior Therapy
  • Pharmacotherapy
  • Weight Loss Surgery
• Weight Reduction After Age 65
• References
• Introduction to the Appendices
  • A. Body Mass Index Table
  • B. Shopping--What to Look For
  • C. Low Calorie, Lower Fat Alternatives
  • D. Sample Reduced Calorie Menus
  • E. Food Exchange List
  • F. Food Preparation--What to Do
  • G. Dining Out--How to Choose
  • H. Guide to Physical Activity
  • I. Guide to Behavior Change
  • J. Weight and Goal Record
  • K. Weekly Food and Activity Diary
  • L. Additional Resources

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