ASBP Obesity Algorithm PDF

American Society of Bariatric Physicians (ASBP) Algorithm
American Society of Bariatric

Physicians (ASBP)
ASBP Obesity Algorithm:
Adult Adiposity Evaluation and Treatment 2013
Citation:
SegerJC,HornDB,WestmanEC,LindquistR,ScintaW,RichardsonLA,PrimackC,BrymanDA,McCarthyW,Hendricks
E,Sabowitz BN,SchmidtSL,BaysHE.AmericanSocietyofBariatricPhysiciansObesityAlgorithm:AdultAdiposity
EvaluationandTreatment2013.www.obesityalgorithm.org (Accessed=[insertdate])
Copyright2013ASBP:MaynotbereproducedoralteredinanyformwithoutwrittenpermissionfromASBP

Disclaimer
TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmwasdevelopedtoassisthealthcare
professionalsinmedicaldecisionmaking;however,itisinnowayasubstituteforamedicalprofessional'sindependent
judgmentandshouldnotbeconsideredmedicaladvice.Mostofthecontenthereinisbasedonthemedicalliterature
andtheclinicalexperienceofobesitymedicinespecialists.Inareasofuncertainty,professionaljudgmentofthe
authorswasapplied.TheObesityAlgorithmisaworkingdocumentthatreflectsthestateofthefieldofobesity
medicineatthetimeofpublication.Becauserapidchangesinthisareaareexpected,periodicrevisionsareinevitable.
Weencouragemedicalprofessionalstousethisinformationinconjunctionwith,andnotasareplacementfor,their
bestclinicaljudgment.Thepresentedrecommendationsmaynotbeappropriateinallsituations.Anydecisionby
practitionerstoapplytheseguidelinesmustbemadeinlightoflocalresourcesandindividualpatientcircumstances.
Permissions
TheAmericanSocietyofBariatricPhysicians(ASBP)ObesityAlgorithmisprotectedbycopyrightandmaynotbe
alteredinanyform.Thiscopyrightedmaterialmaybeaccessedforpersonalresearch,scientificand/orinformation
purposesonly.Nopartofthisalgorithmmaybedistributedforsaleorsoldinanyformorbyanymeanswithoutprior
writtenpermissionfromtheSociety.
OrderingReprintsand/orRequestingPermissionsforuseofASBP ObesityAlgorithm
Forreprintsorotherpermissions,pleasecontact:
Email:info@asbp.org
Phone:303.770.2526

JenniferSeger,MD &DeborahBadeHorn,DO,MPH,FASBP CoChairs
Coauthors:
EricC.Westman,MD,MHS
RichardLindquist,MD,ABFM
WendyScinta,MD,MS
LarryA.Richardson,MD,FASBP
CraigPrimack,MD,FACP,FAAP
Administrativeassistance:
LaurieTraetow ,CAE
DavidA.Bryman DO
WilliamMcCarthy,MD
EdHendricksMD,FASBP
BrianN.Sabowitz,MD,FACP
StacyL.Schmidt,PhD
HaroldEBaysMD,FTOS,FACE,FNLA
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])

Purpose
Toprovidecliniciansanoverviewofprinciples
importanttothecareofpatientswith
increasedbodyfat,baseduponscientific
evidence,supportedbythemedicalliterature,
andderivedfromtheclinicalexperiencesof
membersoftheAmericanSocietyofBariatric
Physicians.

Process
The ASBP Algorithm was derived from input by volunteer ASBP members
consisting 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.

Intent of use
The ASBP Algorithm 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 final
decision 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.

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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ASBPObesityAlgorithm:ExecutiveSummary
AssessforthePresenceofObesity,Adiposopathy,FatMassDisease
Obesitymaybeassessedusingseveralcriteria:presenceofadiposityrelateddisease,fatpercent,waist
circumferenceorbodymassindex.Thresholdsvarybasedonethnicity.
Criteria
EdmontonObesity
Stage0,1,2,3,4
StagingSystem
male<25%
male>25%
FatPercent
female<32%
female> 32%
male<40in
male>40in
WaistCircumference
female<35in
female>35in
BodyMassIndex
BMI18.5 24.9
BMI25.029.9
Prevention
NoObesity
Overweight
BMI>30.0
Obesity
BMI30.034.9ClassI
BMI3539.9ClassII
BMI>40.0ClassIII
PrimaryCareProviderorDietitian
Iftreatmentineffective
ReferraltoanObesityMedicineSpecialist
Consider
EdmontonObesityStagingSystem
STAGE0:Noapparentriskfactors(e.g.,bloodpressure,serumlipidandfastingglucoselevelswithinnormalrange),
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),moderatelimitationsinactivitiesofdailylivingand/orwellbeing)
STAGE3: Establishedendorgandamagesuchasmyocardialinfarction,heartfailure,stroke,significant
psychopathology,significantfunctionallimitationsand/orimpairmentofwellbeing
STAGE4:Severe(potentiallyendstage)disabilitiesfromobesityrelatedchronicdiseases,severedisabling
psychopathology,severefunctionallimitationsand/orsevereimpairmentofwellbeing
[SharmaAM,KushnerRF.Aproposedclinicalstagingsystemforobesity.Int JObesity2009;33:289295.]
FatPercent
WaistCircumference
BodyMassIndex
BodyFatPercentcanbecalculatedusingbioimpedance,nearinfraredreactance,
DEXAscanorwholebodyairdisplacementplethysmography.
Waistcircumferencecanbemeasuredbytapemeasurearoundtheabdomen
attheleveloftheanteriorsuperioriliaccrests,paralleltothefloor.Tape
shouldbesnugagainstskinwithoutcompressing.
BodyMassIndex=(weightinkg)/(heightinm)2 OR
703x(weightinpounds)/(heightininches)2
ObesityMedicineSpecialists,certifiedbytheAmericanBoardofObesityMedicine,dedicateaportionoralloftheir
practicetothetreatmentofobesity.Theyperformamedicalevaluation(history,physical,laboratory,body
composition)andprovidemedicalsupervisionforlifestylechange(nutrition,activity,behaviorchange),medications,
orverylowcaloriediets.Obesityisachronicmedicaldisease,andmayrequirelifelongtreatment.
ObesityMedicineSpecialistEvaluationmayinclude:
History
PhysicalExamination
Weighthistory,pastmedicalhistory,familyhistory,socialhistory,screening
forweightpromotingmedications,foodintake,activity,reviewofsystems
Height,weight,bloodpressure,bodycompositionanalysis,waist
measurement,completephysicalexamination
LaboratoryTests
Completebloodcount,electrolytes,liverfunction,kidneyfunction,fasting
lipidprofile,thyroidtests,hemoglobinA1c,uricacid,vitaminD
DiagnosticTesting
EKG,Echocardiogram,exercisestresstest,sleepstudy,bariumswallowor
esophagoduodenoscopy
IndividualizedTreatmentPlanmayinclude:
Diet
Caloricrestriction,carbohydraterestriction,foodjournaling
VeryLowCalorieDiet(VLCD)programs
Activity
Giveexerciseprescription,usepedometers,limitTVandcomputertime,goal
of150minutes/weekofmoderateintensityphysicalactivity
Counseling
Eliminateproviderbias/stigma,identifyselfsabotage,developstrong
support,stressmanagement,sleepoptimization,otherpsychologicalsupport
Pharmacotherapy
Usemedicationsaspartofacomprehensiveprogram
Ifineffective,considerreferraltoaMetabolicandBariatricSurgeon.
Optimalpre andpostoperativebariatricsurgerycareincludesanObesityMedicineSpecialist.
Current Treatment Options for Obesity

Surgery
Potency*
Lifestyle + Medication
Lifestyle
Risk, Cost
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 <
Gastric Bypass (Roux-en-Y)
* Potency includes many factors such as the amount, rate and sustainability 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.
73
References
Internet Website References:
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Sabowitz BN, Schmidt S, Bays HE. American Society of Bariatric Physician Obesity Algorithm: Adult Adiposity Evaluation and
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Disclosures
Cochairs: Jennifer Seger MD and Deborah Bade Horn DO report no disclosures.
Coauthors: Eric C. Westman MD reports advisor and speaker for Vivus; Richard Lindquist MD reports no
disclosures; Wendy Scinta MD reports consultant for Optifast, committee member of OPMC (Office of
Professional Misconduct) and expert witness for Bariatric Case Reviews, Medical Director of 3# Health, speaker
for Vivus; Larry Richardson MD reports no disclosures; Craig Primack MD reports speaker for Nestle, Vivus and
Eisai, and consultant for Vivus; David Bryman DO reports no disclosures; William McCarthy MD reports no
disclosures; Ed Hendricks MD reports speaker for Eurodrug Laboratories and Akrimax Pharm, consultant for Citius
Pharm and Rodman & Renshaw LLC, and member of GLG Healthcare & Biomedical Council; Brian Sabowitz MD
reports speaker for Eisai Pharmaceuticals; Stacy Schmidt PhD reports no disclosures; Harold Bays MD reports
having his research site receive research grants from Acurian, Alere, Amarin, Amgen, Ardea, Arena, Boehringer
Ingelheim, Cargill, California Raisin Board, Elcelyx, Eli Lilly, Esperion, Essentialis, Forest, Gilead, Given,
GlaxoSmithKline, High Point, HoffmanLa Roche, Home Access, Johnson & Johnson, Merck, Micropharma,
Necktar, Novartis, Novo Nordisk, Omthera, Orexigen, Pfizer, Pozen, Regeneron, Takeda, TransTech, Trygg, TWI Bio,
Vivus, WPU, and Xoma; and has served as a consultant and/or speaker for Amgen, Amarin, BristolMyers Squibb,
Catabasis, DaiichiSankyo, Eisai, Merck, Novo Nordisk, Vivus, and WPU.
85
American Society of Bariatric

Physicians (ASBP)
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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