Vincenza Snow, MD; Patricia Barry, MD, MPH; Nick Fitterman, MD; Amir Qaseem, MD, PhD, MHA; Kevin Weiss, MD, MPH; for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*
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Potential Financial Conflicts of Interest: Employment: P. Barry (Merck Institute of Aging and Health); Stock ownership: P. Barry (Merck & Co., Inc.); Grants received: P. Barry (Merck Co. Foundation).
Requests for Single Reprints: Vincenza Snow, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Snow and Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Barry: Merck Institute of Aging and Health, 1100 New York Avenue NW, Washington, DC 20005.
Dr. Fitterman: North Shore Medical Group, 120 New York Avenue, Huntington, NY 11743.
Dr. Weiss: Hines Veterans Administration Hospital (151H), PO Box 5000, Hines, IL 60141.
This guideline is based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center. The American College of Physicians nominated this topic to the Agency for Healthcare Research and Quality Evidence-Based Practice Center program as part of a concerted effort to complement the guidelines of the U.S. Preventive Services Task Force. The College recommends that all clinicians refer to the Task Force recommendations as part of an overall strategy for managing overweight and obesity, which should always include appropriate diet and exercise for all patients who are overweight or obese. The intent of this guideline is to provide recommendations based on a review of the evidence on pharmacologic and surgical treatments of obesity. The target audience is all clinicians caring for obese patients, defined as a body mass index of 30 kg/m2 or greater. This guideline is not intended to be used by commercial weight loss centers or for direct-to-consumer marketing by manufacturers and does not apply to patients with body mass indices below 30 kg/m2.
*This paper, written by Vincenza Snow, MD; Patricia Barry, MD, MPH; Nick Fitterman, MD; Amir Qaseem, MD, PhD, MHA; and Kevin Weiss, MD, MPH, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Kevin Weiss, MD, MPH (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas K. Owens, MD; and Katherine D. Sherif, MD. Approved by the ACP Board of Regents in October 2004.
Algorithm for managing obesity.
Table. Medications Used for Weight Loss
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Prescription weight loss drugs are an option but they have side effects and the net weight loss is small to moderate. Surgery is option for severely obese patients who also have other medical problems.
Raymond E. Bourey
Regional Center for Sleep Medicine
April 8, 2005
Treatment of Sleep Disorders May Be Essential in Some Patients with Obesity
As an endocrinologist who is also board-certified and working full- time in sleep medicine, I have long observed that many obese patients who are unable to lose weight with efforts at diet and exercise suffer from the complications of sleep apnea and/or inadequate sleep. A growing body of clinical and basic research supports a relationship between sleep disorders, weight gain, and insulin-resistance. Beyond the complex hormonal and physiological basis for the this relationship, it is reasonable to simply assume that patients who suffer the decreased mental alertness of sleep deprivation will have trouble fighting strong, natural pressures toward sloth and gluttony.
Before consideration of drugs, many of which can further compromise sleep quality, and surgical procedures and their attendant complications, I would urge clinicians to simply screen for sleep disturbances. Does the patient snore? Do they have insufficient time for sleep? Morbidly obese patients have such a high incidence of sleep apnea, that many surgical programs for obesity require pre-operative sleep studies.
A sleep evaluation and appropriate treatment for a sleep disorder may be sufficient to provide the physiological "boost" needed for a successful program of diet and exercise which in turn will avoid the complexity, expense, and dangers of drugs and surgical procedures.
Raymond E. Bourey, MD, FACP, FACE, DABSM Clinical Ass't. Professor of Medicine Medical College of Ohio Sleep Medicine and Metabolism
Medical Director The Regional Center for Sleep Medicine 4041 West Sylvania Ave., Ste 202 Toledo, OH 43623 USA 1 419 292-1616 ph 1 419 472-2193 FAX
Snow V, Barry P, Fitterman N, Qaseem A, Weiss K, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*. Pharmacologic and Surgical Management of Obesity in Primary Care: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. ;142:525–531. doi: 10.7326/0003-4819-142-7-200504050-00011
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Published: Ann Intern Med. 2005;142(7):525-531.
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