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American Society of Bariatric Physicians (ASBP) Algorithm
American Society of BariatricPhysicians (ASBP)
ASBP Obesity Algorithm:
Adult Adiposity Evaluation and Treatment 2013
Copyright2013ASBP: MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP
1
Citation:SegerJC,HornDB,WestmanEC,LindquistR,ScintaW,RichardsonLA,PrimackC,BrymanDA,McCarthyW,Hendricks
E,Sabowitz BN,SchmidtSL,BaysHE. AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposity
EvaluationandTreatment2013. www.obesityalgorithm.org (Accessed=[insertdate])
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American Society of Bariatric Physicians (ASBP) Algorithm
ASBP Obesity Algorithm:Adult Adiposity Evaluation and Treatment 2013
Copyright2013ASBP: MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP
2
Disclaimer
TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmwasdevelopedtoassisthealthcare
professionalsin
medical
decision
making;
however,
it
is
in
no
way
asubstitute
for
amedical
professional's
independent
judgmentandshouldnotbeconsideredmedicaladvice.Mostofthecontenthereinisbasedonthemedicalliterature
andtheclinicalexperienceofobesitymedicinespecialists.Inareasofuncertainty,professionaljudgmentofthe
authorswasapplied. TheObesityAlgorithmisaworkingdocumentthatreflectsthestateofthefieldofobesity
medicineatthetimeofpublication.Becauserapidchangesinthisareaareexpected,periodicrevisionsareinevitable.
Weencouragemedicalprofessionalstousethisinformationinconjunctionwith,andnotasareplacementfor,their
bestclinical
judgment.
The
presented
recommendations
may
not
be
appropriate
in
all
situations.
Any
decision
by
practitionerstoapplytheseguidelinesmustbemadeinlightoflocalresourcesandindividualpatientcircumstances.
Permissions
TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmisprotectedbycopyrightandmaynotbe
alteredinanyform.Thiscopyrightedmaterialmaybeaccessedforpersonalresearch,scientificand/orinformation
purposesonly.Nopartofthisalgorithmmaybedistributedforsaleorsoldinanyformorbyanymeanswithoutprior
writtenpermissionfromtheSociety.
OrderingReprintsand/orRequestingPermissionsforuseofASBP ObesityAlgorithm
Forreprintsorotherpermissions,pleasecontact:
Email: [email protected]
Phone:303.770.2526
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American Society of Bariatric Physicians (ASBP) Algorithm
Coauthors:
EricC.Westman,MD,MHS
RichardLindquist,
MD,
ABFM
WendyScinta,MD,MS
LarryA.Richardson,MD,FASBP
CraigPrimack,MD,FACP,FAAP
DavidA.Bryman DO
WilliamMcCarthy,
MD
EdHendricksMD,FASBP
BrianN.Sabowitz,MD,FACP
Stacy L.Schmidt,PhD
Harold
E
Bays
MD,
FTOS,
FACE,
FNLA
Copyright2013ASBP: Maynotbereproducedoralteredinanyformwithoutwritten permissionfromASBP
3
Administrativeassistance:
LaurieTraetow ,CAE
Citation:
Seger JC,HornDB,Westman EC,LindquistR,Scinta W,RichardsonLA,PrimackC,BrymanDA,McCarthyW,HendricksE,
Sabowitz BN,SchmidtSL,BaysHE. AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposityEvaluation
andTreatment2013. www.obesityalgorithm.org (Accessed=[insertdate])
ASBP Obesity Algorithm:
Adult Adiposity Evaluation and Treatment 2013
JenniferSeger,MD & DeborahBadeHorn,DO,MPH,FASBP CoChairs
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American Society of Bariatric Physicians (ASBP) Algorithm
ASBP Obesity Algorithm:Adult Adiposity Evaluation and Treatment 2013
Purpose
Toprovidecliniciansanoverviewofprinciples
important
to
the
care
of
patients
with
increasedbodyfat,baseduponscientific
evidence,supportedbythemedicalliterature,
andderivedfromtheclinicalexperiencesof
members
of
the
American
Society
of
Bariatric
Physicians.
Copyright2013ASBP: Maynotbereproducedoralteredinanyformwithoutwritten permissionfromASBP
4
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American Society of Bariatric Physicians (ASBP) Algorithm 5
Copyright2013ASBP: Maynotbereproducedoralteredinanyformwithoutwritten permissionfromASBP
The ASBP Algorithm was derived from input by volunteer ASBP membersconsisting of:
Academicians
Clinicians
Clinicaltrialists
Researchers
The ASBP Algorithm did not receive industry funding, had no input from
industry, and the authors received no payment for their contributions.
Process
ASBP Obesity Algorithm:Adult Adiposity Evaluation and Treatment 2013
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American Society of Bariatric Physicians (ASBP) Algorithm 6
The ASBP Algori thm 2013 is intended to be a living document updated
once a year (as needed), and intended as an educational tool to assist in
the translation of medical science and the clinical experience of the
authors towards assisting clinicians better manage their overweight and
obese patients.
This algorithm is not intended to be interpreted as rules and/or directives
regarding medical care of an individual patient.
While it is hoped many clinicians may find this algorithm helpful, the finaldecision regarding the optimal care of the overweight and obese patient is
dependent upon the individual clinical presentation, and the judgment of
the clinician who is tasked with directing a treatment plan that is in the
best interest of the patient.
Intent of use
Copyright2013ASBP: Maynotbereproducedoralteredinanyformwithoutwritten permissionfromASBP
ASBP Obesity Algorithm:Adult Adiposity Evaluation and Treatment 2013
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American Society of Bariatric Physicians (ASBP) Algorithm
Contents: Overall management goals
Obesity classification
Obesity as a disease
Diagnosis
Overall approach
Fat mass disease
Sick fat disease (adiposopathy)
History
Physical exam
Laboratory evaluation
Treatment
Nutritional therapy
Physical activity
Behavior therapy
Weight management pharmacotherapy
Early versus late weight management intervention
Bariatric surgery
Executive summary
References
Disclosures
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Adult Adiposity Evaluation and Treatment 2013
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American Society of Bariatric Physicians (ASBP) Algorithm 8
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American Society of Bariatric Physicians (ASBP) Algorithm 9
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American Society of Bariatric Physicians (ASBP) Algorithm 10
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American Society of Bariatric Physicians (ASBP) Algorithm 11
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American Society of Bariatric Physicians (ASBP) Algorithm 12
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American Society of Bariatric Physicians (ASBP) Algorithm 13
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American Society of Bariatric Physicians (ASBP) Algorithm 14
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American Society of Bariatric Physicians (ASBP) Algorithm 15
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American Society of Bariatric Physicians (ASBP) Algorithm 16
Reference/s:[4]
[5]
[6]
[7]
[8]
[9]
[10]
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American Society of Bariatric Physicians (ASBP) Algorithm 17
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American Society of Bariatric Physicians (ASBP) Algorithm 18
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American Society of Bariatric Physicians (ASBP) Algorithm 19
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American Society of Bariatric Physicians (ASBP) Algorithm 20
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American Society of Bariatric Physicians (ASBP) Algorithm 21
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American Society of Bariatric Physicians (ASBP) Algorithm 22
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American Society of Bariatric Physicians (ASBP) Algorithm 23
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American Society of Bariatric Physicians (ASBP) Algorithm 24
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American Society of Bariatric Physicians (ASBP) Algorithm 25
Reference/s:
[21][22]
[23]
[24]
[25]
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American Society of Bariatric Physicians (ASBP) Algorithm 26
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American Society of Bariatric Physicians (ASBP) Algorithm 27
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American Society of Bariatric Physicians (ASBP) Algorithm 28
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American Society of Bariatric Physicians (ASBP) Algorithm 29
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[32][205]
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A i S i t f B i t i Ph i i (ASBP) Al ith 30
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American Society of Bariatric Physicians (ASBP) Algorithm 30
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[15][32]
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American Societ of Bariatric Ph sicians (ASBP) Algorithm 31
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American Society of Bariatric Physicians (ASBP) Algorithm 31
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[34]
[35]
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American Society of Bariatric Physicians (ASBP) Algorithm 32
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American Society of Bariatric Physicians (ASBP) Algorithm 32
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[16][36]
[37]
[38]
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American Society of Bariatric Physicians (ASBP) Algorithm 33
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American Society of Bariatric Physicians (ASBP) Algorithm 33
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American Society of Bariatric Physicians (ASBP) Algorithm 34
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American Society of Bariatric Physicians (ASBP) Algorithm 34
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American Society of Bariatric Physicians (ASBP) Algorithm 35
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American Society of Bariatric Physicians (ASBP) Algorithm
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[39][40]
[41]
[42]
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American Society of Bariatric Physicians (ASBP) Algorithm 36
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y y ( ) g
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[14][43]
[44]
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American Society of Bariatric Physicians (ASBP) Algorithm 37
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[49]
[50]
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American Society of Bariatric Physicians (ASBP) Algorithm 38
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[15][32]
[51]
[52]
[53]
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American Society of Bariatric Physicians (ASBP) Algorithm 39
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[61]
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American Society of Bariatric Physicians (ASBP) Algorithm 40
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American Society of Bariatric Physicians (ASBP) Algorithm 41
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Reference/s:[64]
[65]
[66]
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American Society of Bariatric Physicians (ASBP) Algorithm 42
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American Society of Bariatric Physicians (ASBP) Algorithm 43
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[69]
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American Society of Bariatric Physicians (ASBP) Algorithm 44
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[70][207]
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American Society of Bariatric Physicians (ASBP) Algorithm 45
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American Society of Bariatric Physicians (ASBP) Algorithm 46
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[73][74]
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American Society of Bariatric Physicians (ASBP) Algorithm 47
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[75][76]
[77]
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American Society of Bariatric Physicians (ASBP) Algorithm 48
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[78]
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American Society of Bariatric Physicians (ASBP) Algorithm 49
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[79]
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American Society of Bariatric Physicians (ASBP) Algorithm 50
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[80]
[81]
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American Society of Bariatric Physicians (ASBP) Algorithm 51
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American Society of Bariatric Physicians (ASBP) Algorithm 53
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American Society of Bariatric Physicians (ASBP) Algorithm 54
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American Society of Bariatric Physicians (ASBP) Algorithm 55
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American Society of Bariatric Physicians (ASBP) Algorithm 56
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American Society of Bariatric Physicians (ASBP) Algorithm 57
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American Society of Bariatric Physicians (ASBP) Algorithm 58
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[90][91]
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American Society of Bariatric Physicians (ASBP) Algorithm 59
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American Society of Bariatric Physicians (ASBP) Algorithm 60
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American Society of Bariatric Physicians (ASBP) Algorithm 61
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American Society of Bariatric Physicians (ASBP) Algorithm 62
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American Society of Bariatric Physicians (ASBP) Algorithm 63
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American Society of Bariatric Physicians (ASBP) Algorithm 64
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American Society of Bariatric Physicians (ASBP) Algorithm 65
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American Society of Bariatric Physicians (ASBP) Algorithm 66
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American Society of Bariatric Physicians (ASBP) Algorithm 67
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American Society of Bariatric Physicians (ASBP) Algorithm 68
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ASBPObesityAlgorithm: ExecutiveSummary
AssessforthePresenceofObesity,Adiposopathy,FatMassDisease
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Prevention
BMI18.5 24.9
Referralto
an
Obesity
Medicine
Specialist
NoObesity Overweight Obesity
BMI30.034.9 ClassI
BMI3539.9ClassII
BMI>40.0ClassIII
BMI25.029.9BodyMassIndex
FatPercent male
25%
female> 32%
Obesitymay
be
assessed
using
several
criteria:
presence
of
adiposity
related
disease,
fat
percent,
waist
circumferenceorbodymassindex.Thresholdsvarybasedonethnicity.
Consider
Criteria
EdmontonObesityStagingSystem
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STAGE0:
No
apparent
risk
factors
(e.g.,
blood
pressure,
serum
lipid
and
fasting
glucose
levels
within
normal
range),
physicalsymptoms,psychopathology,functionallimitationsand/orimpairmentofwellbeingrelatedtoobesity
STAGE1:Presenceofobesityrelatedsubclinicalriskfactors(e.g.,borderlinehypertension,impairedfastingglucose
levels,elevatedlevelsofliverenzymes),mildphysicalsymptoms(e.g.dyspneaonmoderateexertion,occasional
achesandpains,fatigue),mildpsychopathology,mildfunctionallimitationsand/ormildimpairmentofwellbeing
STAGE2:Presenceofestablishedobesityrelatedchronicdisease(e.g.,hypertension,type2diabetes,sleepapnea,
osteoarthritis),
moderate
limitations
in
activities
of
daily
living
and/or
well
being
)STAGE3:Establishedendorgandamagesuchasmyocardialinfarction,heartfailure,stroke,significant
psychopathology,significantfunctionallimitationsand/orimpairmentofwellbeing
STAGE4:Severe(potentiallyendstage)disabilitiesfromobesityrelatedchronicdiseases,severedisabling
psychopathology,severefunctionallimitationsand/orsevereimpairmentofwellbeing
[SharmaAM,KushnerRF.Aproposedclinicalstagingsystemforobesity.Int JObesity2009;33:289295.]
BodyMassIndex
FatPercent
WaistCircumference
BodyMassIndex=(weightinkg)/(heightinm)2 OR
703x(weightinpounds)/(heightininches)2
BodyFat
Percent
can
be
calculated
using
bioimpedance,
near
infrared
reactance,
DEXAscanorwholebodyairdisplacementplethysmography.
Waistcircumferencecanbemeasuredbytapemeasurearoundtheabdomen
attheleveloftheanteriorsuperioriliaccrests,paralleltothefloor. Tape
shouldbesnugagainstskinwithoutcompressing.
Obesity
Medicine
Specialists,
certified
by
the
American
Board
of
Obesity
Medicine,
dedicate
a
portion
or
all
of
their
practice
to
the
treatment
of
obesity.
They
perform
a
medical
evaluation
(history,
physical,
laboratory,
body
composition)
and
provide
medical
supervision
for
lifestyle
change
(nutrition,
activity,
behavior
change),
medications,
or
very
low
calorie
diets.
Obesity
is
a
chronic
medical
disease,
and
may
require
lifelong
treatment.
Obesity Medicine Specialist Evaluation may include:
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ObesityMedicineSpecialistEvaluationmayinclude:
History
PhysicalExamination
Laboratory
Tests
IndividualizedTreatmentPlanmayinclude:
DiagnosticTesting
Weighthistory,pastmedicalhistory,familyhistory,socialhistory,screening
forweightpromotingmedications,foodintake,activity,reviewofsystems
Height,weight,bloodpressure,bodycompositionanalysis,waist
measurement,completephysicalexamination
Completebloodcount,electrolytes,liverfunction,kidneyfunction,fasting
lipidprofile,
thyroid
tests,
hemoglobin
A1c,
uric
acid,
vitamin
D
EKG,Echocardiogram,exercisestresstest,sleepstudy,bariumswallowor
esophagoduodenoscopy
Diet
Activity
Counseling
Pharmacotherapy
Caloricrestriction,carbohydraterestriction,foodjournaling
VeryLowCalorieDiet(VLCD)programs
Giveexerciseprescription,usepedometers,limitTVandcomputertime,goal
of150minutes/weekofmoderateintensityphysicalactivity
Eliminateprovider
bias/stigma,
identify
self
sabotage,
develop
strong
support,stressmanagement,sleepoptimization,otherpsychologicalsupport
Usemedicationsaspartofacomprehensiveprogram
Ifineffective,considerreferraltoaMetabolicandBariatricSurgeon.
Optimalpre
and
post
operative
bariatric
surgery
care
includes
an
Obesity
Medicine
Specialist.
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Potency*
Risk, Cost
Lifestyle + Medication
Surgery
Lifestyle
* Potency includes many factors such as the amount, rate and sustainabili ty of weight loss, and
long-term resolution of adiposopathy and fat mass disease. Potency varies greatly for each
individual: long-term adherence to a lifestyle program can be as potent as gastric bypass surgery.
Lifestyle: Includes nutrition, exercise, behavioral programs
Lifestyle + Medication: May include Lifestyle, VLCDs w supplements, and weight loss
medications
Surgery: (in order of lowest risk/cost and potency): Gastric Banding < Gastric Sleeve