White Paper AGA: POWER — Practice Guide on Obesity and Weight Management, Education, and Resources

The epidemic of obesity continues at alarming rates, with a high burden to our economy and society. The American Gastroenterological Association understands the importance of embracing obesity as a chronic, relapsing disease and supports a multidisciplinary approach to the management of obesity. Because gastrointestinal disorders resulting from obesity are more frequent and often present sooner than type 2 diabetes mellitus and cardiovascular disease, gastroenterologists have an opportunity to address obesity and provide an effective therapy early. Patients who are overweight or obese already fill gastroenterology clinics with gastroesophageal reflux disease and its associated risks of Barrett’s esophagus and esophageal cancer, gallstone disease, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, and colon cancer. Obesity is a major modifiable cause of diseases of the digestive tract that frequently goes unaddressed. As internists, specialists in digestive disorders, and endoscopists, gastroenterologists are in a unique position to play an important role in the multidisciplinary treatment of obesity. This American Gastroenterological Association paper was developed with content contribution from Society of American Gastrointestinal and Endoscopic Surgeons, The Obesity Society, Academy of Nutrition and Dietetics, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, endorsed with input by American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery, American Association for the Study of Liver Diseases, and Obesity Medicine Association, and describes POWER: Practice Guide on Obesity and Weight Management, Education and Resources. Its objective is to provide physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management. The epidemic of obesity continues at alarming rates, with a high burden to our economy and society. The American Gastroenterological Association understands the importance of embracing obesity as a chronic, relapsing disease and supports a multidisciplinary approach to the management of obesity. Because gastrointestinal disorders resulting from obesity are more frequent and often present sooner than type 2 diabetes mellitus and cardiovascular disease, gastroenterologists have an opportunity to address obesity and provide an effective therapy early. Patients who are overweight or obese already fill gastroenterology clinics with gastroesophageal reflux disease and its associated risks of Barrett’s esophagus and esophageal cancer, gallstone disease, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, and colon cancer. Obesity is a major modifiable cause of diseases of the digestive tract that frequently goes unaddressed. As internists, specialists in digestive disorders, and endoscopists, gastroenterologists are in a unique position to play an important role in the multidisciplinary treatment of obesity. This American Gastroenterological Association paper was developed with content contribution from Society of American Gastrointestinal and Endoscopic Surgeons, The Obesity Society, Academy of Nutrition and Dietetics, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, endorsed with input by American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery, American Association for the Study of Liver Diseases, and Obesity Medicine Association, and describes POWER: Practice Guide on Obesity and Weight Management, Education and Resources. Its objective is to provide physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management. See similar articles on pages 619 and 650. See similar articles on pages 619 and 650. The POWER model presents a continuum of care that is based on 4 phases: (1) assessment, (2) intensive weight loss intervention, (3) weight stabilization and re-intensification when needed, and (4) prevention of weight regain. Although lifestyle changes including reduced calorie diet and physical activity are the cornerstones of treatment, new medications, bariatric endoscopy, and surgery are important tools to help patients with obesity achieve realistic goals.Management Summary1.Nutrition: reduce dietary intake below that required for energy balance by consuming 1200–1500 calories per day for women and 1500–1800 calories per day for men.2.Physical Activity: reach the goal of 10,000 steps or more per day.3.Exercise: reach the goal of 150 minutes or more of cardiovascular exercise/week.4.Limit consumption of liquid calories (ie, sodas, juices, alcohol, etc).5.Utilize a tool to support and adhere to the low calorie food intake. To create a comprehensive, multidisciplinary process to guide personalized, innovative obesity care for safe and effective weight management. Experts in each field of obesity developed this practice guide that is based, in its majority, in societal guidelines. The epidemic of obesity continues at alarming rates, with a high burden to our health, economy, and society. The American Gastroenterological Association (AGA) understands the importance of embracing obesity as a chronic disease and supports a multidisciplinary approach to the management of obesity. Because gastrointestinal disorders resulting from obesity are more frequent and often present sooner than type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), gastroenterologists have an opportunity to address obesity and provide effective therapy. People who are overweight and obese are overrepresented in gastroenterology clinics, because they present with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), gastroesophageal reflux disease (GERD), and other diseases associated with increased risk related to obesity, such as Barrett’s esophagus and esophageal cancer, gallstone disease, and colon cancer. Obesity is a major modifiable cause of diseases of the digestive tract that routinely goes unaddressed. The gastroenterologist is in a unique position to play an important role in the multidisciplinary treatment of obesity. We are internists, specialists in digestive disorders, and endoscopists. Hence, in this paper, the AGA partnered with Society of American Gastrointestinal and Endoscopic Surgery (SAGES), The Obesity Society (TOS), Academy of Nutrition and Dietetics, and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) to develop “POWER: Practice Guide on Obesity and Weight Management, Education and Resources,” with the mission of providing physicians a comprehensive, multidisciplinary process to guide innovative obesity care for safe and effective weight management. Further input and official endorsement of POWER were provided by the American Society for Metabolic and Bariatric Surgery, the Obesity, Metabolism and Nutrition section of the American Gastroenterological Association Institute Council, the American Society for Gastrointestinal Endoscopy and its Association for Bariatric Endoscopy, the American Association for the Study of Liver Diseases, and Obesity Medicine Association. Obesity is a chronic, relapsing, multifactorial disease defined as abnormal or excessive adipose tissue accumulation that may impair health and increase disease risks significantly.1Yach D. Stuckler D. Brownell K.D. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes.Nat Med. 2006; 12: 62-66Google Scholar Multiple pathogenic adipocyte and/or adipose tissue endocrine and immune dysfunctions contribute to metabolic disease (adiposopathy or “sick fat” disease). Separate but overlapping physical forces from excessive body fat cause damage to other body tissues (fat mass disease), including adverse metabolic, biomechanical, and psychosocial health consequences.2Seger JC, Horn DB, Westman EC, et al. Obesity algorithm: presented by the Obesity Medicine Association, 2015-2016. www.obesityalgorithm.org.Google Scholar The excess of adipose tissue is the outcome of a multifactorial etiopathogenesis: genetics, biological, microbial, and environmental factors. These factors promote a positive energy balance mainly driven by an increase in food intake and a decrease in energy expenditure.3Bray G.A. Bouchard C. Handbook of obesity: epidemiology, etiology, and physiopathology.3rd ed. CRC Press, Boca Raton2014Google Scholar, 4Acosta A. Abu Dayyeh B.K. Port J.D. et al.Recent advances in clinical practice challenges and opportunities in the management of obesity.Gut. 2014; 63: 687-695Google Scholar Normal weight, overweight, and obesity can be measured by body mass index (BMI). BMI is calculated by weight (kg) divided by the square of the height (m2). The BMI for a normal-weight adult ranges from 18.5 to 24.9 kg/m2, overweight is from 25 to 29.9 kg/m2, and obese is 30 kg/m2 or above. Obesity is considered severe when BMI is higher than 40 kg/m2.5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar In children, obesity is measured as BMI higher than the 95th percentile related to age and sex.6Daniels S.R. Jacobson M.S. McCrindle B.W. et al.American Heart Association Childhood Obesity Research Summit: executive summary.Circulation. 2009; 119: 2114-2123Google Scholar, 7Low S. Chin M.C. Deurenberg-Yap M. Review on epidemic of obesity.Ann Acad Med Singapore. 2009; 38: 57-59Crossref Google Scholar Obesity can also be assessed by waist circumference, with abdominal obesity defined as >102 cm (40 inches) or waist-to-hip ratios >0.9 in men and 88 cm (35 inches) or waist-to-hip ratios >0.85 in women. Elevated BMI and waist circumference are associated with increased health risks and obesity-related comorbidities.5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar Obesity has reached epidemic proportions in developed countries, and its prevalence is increasing in developing countries.7Low S. Chin M.C. Deurenberg-Yap M. Review on epidemic of obesity.Ann Acad Med Singapore. 2009; 38: 57-59Crossref Google Scholar In the United States, the prevalence of overweight adults is 69% and adults with obesity is 36.5%.8Ogden C.L. Carroll M.D. Kit B.K. et al.Prevalence of childhood and adult obesity in the United States, 2011-2012.JAMA. 2014; 311: 806-814Google Scholar, 9Ogden C.L. Carroll M.D. Fryar C.D. et al.Prevalence of obesity among adults and youth: United States, 2011-2014.NCHS Data Brief. Nov 2015; : 1-8Google Scholar In children and adolescents, obesity prevalence has increased to 16.9%.8Ogden C.L. Carroll M.D. Kit B.K. et al.Prevalence of childhood and adult obesity in the United States, 2011-2012.JAMA. 2014; 311: 806-814Google Scholar The World Health Organization indicated that globally in 2005 there were approximately 2 billion overweight adults and 500 million of those with obesity.10World Health Organisation. Fact sheet: obesity and overweight. Available at: http://www.who.int/gho/ncd/risk_factors/overweight_text/en/. 2014. Accessed January 5, 2017.Google Scholar This alarming obesity epidemic poses a heavy burden to the U.S. economy, costing more than $150 billion every year or 10% of the total health budget (Centers for Disease Control and Prevention, 2012). In the United States, obesity is linked to the top 10 causes of death and associated comorbidities before death.11Ogden C.L. Yanovski S.Z. Carroll M.D. et al.The epidemiology of obesity.Gastroenterology. 2007; 132: 2087-2102Google Scholar Mortality risk increases as BMI increases.12Guh D. Zhang W. Bansback N. et al.The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis.BMC Public Health. 2009; 9: 88Google Scholar Obesity is related to numerous pathologic conditions, including CVD,13Guize L. Pannier B. Thomas F. et al.Recent advances in metabolic syndrome and cardiovascular disease.Arch Cardiovasc Dis. 2008; 101: 577-583Google Scholar T2DM,14Hill M.J. Metcalfe D. McTernan P.G. Obesity and diabetes: lipids, ‘nowhere to run to'.Clin Sci (Lond). 2009; 116: 113-123Google Scholar sleep apnea,15Vgontzas A.N. Bixler E.O. Chrousos G.P. et al.Obesity and sleep disturbances: meaningful sub-typing of obesity.Arch Physiol Biochem. 2008; 114: 224-236Google Scholar, 16Vgontzas A.N. Does obesity play a major role in the pathogenesis of sleep apnoea and its associated manifestations via inflammation, visceral adiposity, and insulin resistance?.Arch Physiol Biochem. 2008; 114: 211-223Google Scholar, 17Vgontzas A.N. Lin H.M. Papaliaga M. et al.Short sleep duration and obesity: the role of emotional stress and sleep disturbances.Int J Obes (Lond). 2008; 32: 801-809Google Scholar, 18de Sousa A.G. Cercato C. Mancini M.C. et al.Obesity and obstructive sleep apnea-hypopnea syndrome.Obes Rev. 2008; 9: 340-354Google Scholar cancer,19Garfinkel L. Overweight and cancer.Ann Intern Med. 1985; 103: 1034-1036Google Scholar reproductive disorders,20Deitel M. To T.B. Stone E. et al.Sex hormonal changes accompanying loss of massive excess weight.Gastroenterol Clin North Am. 1987; 16: 511-515Google Scholar endocrine disorders,21Newbold R.R. Padilla-Banks E. Jefferson W.N. et al.Effects of endocrine disruptors on obesity.Int J Androl. 2008; 31: 201-208Google Scholar psychological disorders,22Bean M.K. Stewart K. Olbrisch M.E. Obesity in America: implications for clinical and health psychologists.J Clin Psychol Med Settings. 2008; 15: 214-224Google Scholar, 23Stunkard A.J. Wadden T.A. Psychological aspects of severe obesity.Am J Clin Nutr. 1992; 55: 524S-532SScopus (296) Google Scholar, 24Rapaka R. Schnur P. Shurtleff D. Obesity and addiction: common neurological mechanisms and drug development.Physiol Behav. 2008; 95: 2-9Google Scholar, 25Warren M.W. Gold M.S. The relationship between obesity and drug use.Am J Psychiatry. 2007; 164 (author reply 1268–1269): 1268Google Scholar bone, joint, and connective tissue disorders,26Anandacoomarasamy A. Fransen M. March L. Obesity and the musculoskeletal system.Curr Opin Rheumatol. 2009; 21: 71-77Google Scholar, 27Magliano M. Obesity and arthritis.Menopause Int. 2008; 14: 149-154Google Scholar and gastrointestinal disorders.28Acosta A. Camilleri M. Gastrointestinal morbidity in obesity.Ann N Y Acad Sci. 2014; 1311: 42-56Google Scholar Appendix 1 summarizes the quantified risks of gastrointestinal disorders in obesity.28Acosta A. Camilleri M. Gastrointestinal morbidity in obesity.Ann N Y Acad Sci. 2014; 1311: 42-56Google Scholar The increased prevalence of gastrointestinal morbidity in the general population may be related to the increased prevalence of obesity in Western countries. Thus, it is important to recognize the role of higher BMI and, particularly, increased abdominal adiposity in the development of gastrointestinal morbidity. Furthermore, higher BMI is associated with poorer response to treatment, and conversely, many gastrointestinal diseases improve with weight loss alone, eg, NAFLD and GERD. Treating obesity is best accomplished when physicians partner with other professionals with specific expertise in the nutritional, behavioral, and physical activity aspects of treatment. This partnership is referred to as a multidisciplinary team, and as with oncology or other chronic disease care teams, the program works best when there is regular, scheduled communication between members of the team. An ideal comprehensive team may include a physician with training in obesity medicine or gastroenterologist with expertise in nutrition, bariatric surgeons, endoscopists, a physician assistant, nurse practitioner or nurse, a registered dietitian nutritionist, a psychiatric social worker, psychiatrist or psychologist, and medical assistants. The composition of the team and roles that different team professionals fulfill can vary on the basis of the expertise and resources available in each clinical setting. The gastroenterologist can lead the multidisciplinary team and use the tools available or become part of a team and provide endoscopic support for bariatric endoscopy devices and manage complications of bariatric surgery. Obesity, a chronic, relapsing, multifactorial disease, needs a care model that is based on a continuum of 4 phases: (1) assessment, (2) intensive weight loss intervention, (3) weight stabilization, and re-intensification when needed, and (4) prevention of weight regain (Figure 1). Each phase should be addressed separately with the best evidence available with realistic goals and proceed through the phases as goals are met. Obesity prevention is as important as obesity treatment. When setting weight loss goals, it is important to educate the patient that the objectives should be driven by the medical consequences associated with obesity, along with the individual’s personal motivation to make healthy changes. Because patients’ willingness to participate in obesity treatment may be impacted by perceived prejudice or disapproval, the care of patients with obesity requires appropriate office equipment and supplies to ensure patient comfort. The office should be equipped with oversized chairs, appropriately sized gowns, oversized blood pressure cuffs, long tape measures for measuring waist circumference, and weighing scales that can accommodate patients weighing up to at least 500 pounds. An office with larger doorways to accommodate extra wide wheelchairs and motorized scooters is also beneficial. A facility that can accommodate a team of clinicians is ideal; however, referrals to other sites can also be a successful model. A successful existing model for ensuring structural standards for the obese patient is the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.29Metabolic and Bariatric Accreditation and Quality Improvement Program: 2016. Available at: https://www.facs.org/quality-programs/mbsaqip. Accessed July 25, 2016.Google Scholar It is important to assess patient readiness to embark on a weight loss program before initiating a treatment plan, because some patients are not motivated to make the necessary changes to lose weight or are not even ready to discuss their weight. The modified 5 A’s (Ask, Advise, Assess, Assist, and Arrange), which were developed for smoking cessation, also serve as an effective tool for obesity counseling.30Kushner R. Models of obesity care: implications for practice.Obesity Consults. 2015; 3: 17-29Google Scholar It has been demonstrated that simply giving patients advice to change is often unrewarding and ineffective; motivational interviewing is a useful technique to communicate with patients about weight management.31Rollnick S. Butler C.C. Kinnersley P. et al.Motivational interviewing.BMJ. 2010; 340: c1900Google Scholar The 2013 American Heart Association/American College of Cardiology/TOS Guidelines for the Management of Overweight and Obesity in Adults recommends that the clinician, together with the patient, assess whether the patient is prepared and ready to undertake the measures necessary to succeed at weight loss before beginning comprehensive counseling efforts.5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar Motivational interviewing by using Open-ended Questions, Affirmation, Reflections, and Summaries (OARS) is another useful tool.32Kisely S. Ligate L. Roy M.A. et al.Applying motivational interviewing to the initiation of long-acting injectable atypical antipsychotics.Australas Psychiatry. 2012; 20: 138-142Google Scholar, 33Searight R. Realistic approaches to counseling in the office setting.Am Fam Physician. 2009; 79: 277-284Google Scholar If the patient is not prepared to undertake these changes, attempts to counsel the patient on how to make lifestyle changes are likely to be ineffective and potentially counterproductive.5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar Clinical encounters for obesity-related comorbidities in gastroenterology practice include NAFLD, reflux esophagitis, gallbladder disease, pancreatitis, and colon cancer. Visits for these conditions are opportunities to address weight management. The 2013 American Heart Association/American College of Cardiology/TOS Obesity Guidelines recommend that patients with overweight or obesity and cardiovascular risk factors (hypertension, hyperlipidemia, and hyperglycemia) be counseled that lifestyle changes that produce even modest, sustained weight loss of 3%–5% produce clinically meaningful health benefits, and that greater weight loss produces greater benefits.5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar Patients should be informed that this amount of weight loss is likely to result in clinically meaningful reductions in triglycerides, blood glucose, and hemoglobin A1c and the risk of developing T2DM. Gastrointestinal disorders, including NAFLD34Tapper E.B. Lai M. Weight loss results in significant improvements in quality of life for patients with nonalcoholic fatty liver disease: a prospective cohort study.Hepatology. 2016; 63: 1184-1189Google Scholar and GERD,35Singh M. Lee J. Gupta N. et al.Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial.Obesity. 2013; 21: 284-290Google Scholar have also been shown to improve with weight loss. Importantly, addressing obesity decreases the risk of multiple types of cancer. Identifying patient’s personal concerns can help identify areas that will foster motivation and inspiration and represent an important strategy. The medical evaluation of a patient with obesity should include an assessment for underlying etiologies, a screen for causes of secondary weight gain, and identification of obesity-related comorbidities. Table 1 illustrates the steps a clinician should take in a clinical encounter. Patients should be asked about contributing factors, including family history, sleep disorders, and medications associated with weight gain (Appendix 2). If history and/or physical examination raise suspicion for identifiable causes of obesity (Table 2), patients should undergo appropriate screening, eg, for cardiac disease or obstructive sleep apnea.Table 1Steps a Clinician Should Take in a Clinical Encounter With a Patient With Overweight or Obesity•Annual and symptom-based screening for chronic conditions associated with obesity•Timely adherence to national cancer screening guidelines (patients with obesity are at increased risk for many malignancies)101Calle E.E. Rodriguez C. Walker-Thurmond K. et al.Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.N Engl J Med. 2003; 348: 1625-1638Google Scholar•Identification of contributing factors including genetics, disordered eating, sleep disorders, family history, and environmental/socioeconomic causes•Identification of and appropriate screening for secondary causes of obesity (Table 2) if history and/or physical exam is suggestive•Identify important comorbidities of obesity and metabolic syndrome: cardiac, T2DM, hyperlipidemia, hypertension, NAFLD/NASH•Identification of medications that contribute to weight gain (Table 4); prescription of medications that are weight-neutral or promote weight loss when possible•Adherence to the AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, which was updated in 2013 and includes recommendations for assessment and treatment with diet, exercise, and bariatric surgery5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar•Adherence to the Endocrine Society Clinical Practice Guideline for Pharmacological Management of Obesity if pharmacotherapy is indicated•Formulation of a treatment plan that is based on diet, exercise, and behavioral modifications on the basis of multidisciplinary team evaluation and recommendationsNOTE. Adapted from Apovian CM, Aronne LJ, Bessesen DH, et al.44Apovian C.M. Aronne L.J. Bessesen D.H. et al.Pharmacological management of obesity: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 342-362Google Scholar Open table in a new tab Table 2Selected Causes of ObesityPrimary causes•Monogenic disorders○Leptin deficiency○Melanocortin-4 receptor mutation○POMC deficiency•Syndromes○Alström○Bardet-Biedl○Cohen○Froehlich○Prader-WilliSecondary causes•Drug-induced○Anticonvulsants○Antidepressants (eg, tricyclic antidepressants)○Antidiabetics (eg, sulfonylureas, glitazones)○Antihypertensives (eg, beta blockers)○Antipsychotics○Glucocorticoids○Oral contraceptives•Endocrine○Cushing syndrome○Growth hormone deficiency○Hypothyroidism○Pseudohypoparathyroidism•Neurologic○Brain injury○Brain tumor○Cranial irradiation○Hypothalamic obesity•Psychological○Depression○Eating disordersNOTE. Adapted from Apovian CM, Aronne LJ, Bessesen DH, et al.44Apovian C.M. Aronne L.J. Bessesen D.H. et al.Pharmacological management of obesity: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 342-362Google Scholar Open table in a new tab NOTE. Adapted from Apovian CM, Aronne LJ, Bessesen DH, et al.44Apovian C.M. Aronne L.J. Bessesen D.H. et al.Pharmacological management of obesity: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 342-362Google Scholar NOTE. Adapted from Apovian CM, Aronne LJ, Bessesen DH, et al.44Apovian C.M. Aronne L.J. Bessesen D.H. et al.Pharmacological management of obesity: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 342-362Google Scholar The 2013 Obesity Guidelines provide an algorithm for approaching patients with overweight and obesity (Appendix 3).5Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Google Scholar When eliciting a medical history, providers should make sure to ask about prior weight loss attempts, history of weight gain and loss, dietary habits, physical activity and limitations, family history of obesity and comorbidities, and medications that could affect weight (Appendix 2). Assessment of all patients should include evaluation of BMI, waist circumference, and a complete physical examination. Central obesity is an independent risk factor for mortality,36Sahakyan K.R. Somers V.K. Rodriguez-Escudero J.P. et al.Normal-weight central obesity: implications for total and cardiovascular mortality.Ann Intern Med. 2015; 163: 827-835Google Scholar so it is also important to measure waist circumference or waist-to-hip ratio.37Sharma S. Batsis J.A. Coutinho T. et al.Normal-weight central obesity and mortality risk in older adults with coronary artery disease.Mayo Clin Proc. 2016; 91: 343-351Google Scholar The physical exam should focus on characterizing obesity and evaluating for causes and associated complications. A routine physical exam should include inspection for acanthosis nigricans (associated with insulin resistance), hirsutism (associated with polycystic ovarian syndrome), large neck circumference (associated with obstructive sleep apnea), and thin, atrophic skin (associated with Cushing’s disease). Basic laboratory evaluation should include a comprehensive metabolic panel, fasting lipid profile, and thyroid function tests. The U.S. Preventive Services Task Force now recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40–70 years with overweight or obesity.38Siu A.L. Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2015; 163: 861-868Google Scholar Laboratory testing for specific conditions should be done, depending on the findings on history and physical examination. It is important to screen for symptoms suggestive of CVD and other obesity-related comorbidities. Obstructive sleep apnea and obesity hypoventilation syndrome are common in patients with obesity, particularly severe obesity. The Epworth Sleepiness Scale39Johns M.W. A new method for measuring daytime sleepiness: the Epworth sleepiness scale.Sleep. 1991; 14: 540-545Google