GUIDELINES FOR THE INITIATION OF OBESITY TREATMENT

Obesity is epidemic in America. About 80 million Americans are obese, 33.4% of adults and about 20% to 25% of children. Obesity produces mor bidity and mortality: there are 300,000 obesity-related deaths annuall y in America. The definition of obesity has not been standard. Recentl y, the World Health Organization defined overweight as a body mass ind ex (BMI = kg/m(2)) of 25 and obesity as a BMI of greater than or equal to 30. A BMI of greater than or equal to 35 produces a high risk from obesity and of greater than or equal to 40 produces a severe risk. th e presence of complications of obesity (hypertension, diabetes, dyslip idemia, sleep apnea, etc.) increases the risk. Treatments of obesity d epend on the severity of obesity, the presence of complications, and t he absence of exclusions. Exclusions from obesity treatment include pr egnancy, lactation, terminal illness, major mental illness, anorexia n ervosa. Eating disorders and major medical disorders are strong cautio ns for obesity treatment. Obesity with a low or modest health risk (BM I: 25-30) is best treated with a diet lower in calories and fat than t he current diet, exercise, and lifestyle modification. With obesity th at produces a moderate to high health risk (BMI: 30-35), the above tre atments plus a very low calorie diet or obesity drugs may be indicated . High and very high health risk due to obesity may be treated with th e above regimen plus obesity surgery. In every category of obesity, th e presence of complications of obesity increases the risk and justifie s more aggressive forms of treatment. Treatment of obesity with drugs has gained acceptance in recent years. There are no absolute indicatio ns for drug treatment. Contraindications include pregnancy and lactati on, unstable cardiac disease, uncontrolled hypertension, severe psychi atric disorder or anorexia, and other drug therapy, if incompatible. C autions include the presence of any severe systemic illness and certai n other problems such as closed angle glaucoma. Obesity surgery is res erved as a last resort. Contraindications to surgery and significant m ental or physical diseases preclude obesity surgery. Whatever the form of treatment, individualized attention with careful follow-up is mand atory. Obesity is similar to other chronic diseases; if the treatment stops, the disease comes back. (C) Elsevier Science Inc. 1998.