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Obesity

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Updated 2024 ESAIC/AATS guidelines for perioperative venous thromboembolism prophylaxis in patients undergoing bariatric surgery.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of obesity are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the American Diabetes Association (ADA 2024), the Endocrine Society (ES 2024,2020,2015,2013), the European Hip Society (EHS/EAU/ISTH/EACTAIC/EACTS/AATS/ESTS/EBCOG/EKS/ESAIC/NATA/SRLF/EURAPS 2024), the European Society of Cardiology (ESC 2024,2023,2021), the European Society of Cardiology (ESC/EACTS 2024), ...
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Screening and diagnosis

Indications for screening, adults
As per ADA 2024 guidelines:
Measure height and weight to calculate BMI and obtain additional measurements of body fat distribution, such as waist circumference, waist-to-hip ratio, and/or waist-to-height ratio, in patients with diabetes to support the diagnosis of obesity. Ensure privacy during anthropometric measurements.
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Monitor obesity-related anthropometric measurements in patients with diabetes at least annually to inform treatment considerations.
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  • Indications for screening (pediatrics)

  • Diagnostic criteria

Classification and risk stratification

CVD risk assessment
As per ES 2020 guidelines:
Assess components of the metabolic syndrome and body fat distribution to accurately determine the level of CVD risk in patients with obesity.
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Assess the 10-year risk for ASCVD to guide the use of lipid-lowering therapy in patients with obesity.
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Diagnostic investigations

Assessment of secondary causes, hypothyroidism: as per ESE 2020 guidelines, obtain thyroid function testing in all patients with obesity.
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obtain TSH, and free T4 and anti-TPO antibodies if TSH is elevated.
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consider using the same reference ranges in patients without obesity as for patients with obesity.
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  • Assessment of secondary causes (hypercortisolism)

  • Assessment of secondary causes (hypopituitarism)

  • Assessment of secondary causes (PCOS)

  • Assessment of secondary causes (binge eating syndrome)

  • Assessment of obesity-related complications (general principles)

  • Assessment of obesity-related complications (dyslipidemia)

  • Assessment of obesity-related complications (diabetes mellitus)

  • Assessment of obesity-related complications (hypertension)

  • Assessment of obesity-related complications (MASLD)

  • Assessment of obesity-related complications (obstructive sleep apnea)

  • Assessment of obesity-related complications (osteoarthritis)

  • Assessment of obesity-related complications (urinary incontinence)

  • Assessment of obesity-related complications (GERD)

  • Assessment of obesity-related complications (pancreatitis)

  • Assessment of obesity-related complications (hypogonadism)

  • Assessment of obesity-related complications (hyperparathyroidism)

  • Assessment of obesity-related complications (vitamin D deficiency)

  • Assessment of obesity-related complications (asthma)

  • Assessment of obesity-related complications (depression)

Medical management

Indications for pharmacotherapy: as per AAFP 2024 guidelines, initiate pharmacotherapy for obesity in addition to lifestyle measures in nonpregnant patients with a BMI ≥ 30 kg/m² or with a BMI ≥ 27 kg/m² with any metabolic comorbidities (hypertension, T2DM, or dyslipidemia).
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  • Choice of agent

  • Metformin

Nonpharmacologic interventions

Multicomponent lifestyle/behavioral interventions: as per USPSTF 2018 guidelines, offer intensive multicomponent behavioral interventions in adult patients with a BMI ≥ 30.
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  • Dietary management

  • Non-sugar sweeteners

Therapeutic procedures

Indications for endoscopic procedures: as per ASGE/ESGE 2024 guidelines, consider offering endoscopic bariatric and metabolic therapies plus lifestyle modifications over lifestyle modifications alone in patients with a BMI ≥ 30 kg/m² with or without obesity-related comorbidities or a BMI of 27-29.9 kg/m² with at least one obesity-related comorbidity.
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  • Intragastric balloon therapy

  • Endoscopic gastric remodeling

  • Other procedures

Perioperative care

Preoperative laboratory assessment: as per BOMSS 2020 guidelines, obtain a comprehensive preoperative nutritional assessment in all bariatric surgery candidates.
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  • Perioperative thromboprophylaxis

Surgical interventions

Indications for bariatric surgery: as per ESC 2023 guidelines, consider offering bariatric surgery in high and very high-risk patients with BMI ≥ 35 kg/m² when repetitive and structured efforts of lifestyle changes combined with weight-loss medications do not result in maintained weight loss.
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  • Choice of procedure

Specific circumstances

Pediatric patients, screening: as per AAP 2023 guidelines, measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific growth charts or growth charts for children with severe obesity at least annually to screen for overweight (BMI ≥ 85th to < 95th percentile), obesity (BMI ≥ 95th percentile), and severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) in all 2-18 years old children.
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  • Pediatric patients (evaluation for comorbidities)

  • Pediatric patients (general principles of management)

  • Pediatric patients (lifestyle management)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (bariatric surgery)

  • Elderly patients

  • Pregnant patients

  • Postmenopausal patients

  • Patients with binge eating syndrome

  • Patients with dyslipidemia

  • Patients with CVD (hypertension, prevention)

  • Patients with CVD (hypertension, management)

  • Patients with CVD (ASCVD)

  • Patients with CVD (HF)

  • Patients with CVD (cardiac arrhythmia)

  • Patients with diabetes mellitus (screening)

  • Patients with diabetes mellitus (lifestyle changes)

  • Patients with diabetes mellitus (pharmacotherapy)

  • Patients with diabetes mellitus (bariatric surgery)

  • Patients with diabetes mellitus (post-bariatric care)

  • Patients with MASLD (lifestyle changes)

  • Patients with MASLD (pharmacotherapy)

  • Patients with MASLD (bariatric surgery)

  • Patients with MASLD (liver transplantation)

  • Patients with chronic liver disease

  • Patients with cholelithiasis

  • Patients with acute pancreatitis

  • Patients with chronic pancreatitis

  • Patients with GERD (nutritional assessment)

  • Patients with GERD (weight loss)

  • Patients with GERD (bariatric surgery)

  • Patients with kidney disease (renal impairment)

  • Patients with kidney disease (nephrolithiasis)

  • Patients with urinary incontinence

  • Patients with hypoventilation syndrome (evaluation)

  • Patients with hypoventilation syndrome (weight loss)

  • Patients with hypoventilation syndrome (respiratory support)

  • Patients with obstructive sleep apnea

  • Patients with asthma

  • Patients with female infertility

  • Patients with PCOS (lifestyle changes)

  • Patients with PCOS (pharmacotherapy)

  • Patients with PCOS (bariatric surgery)

  • Patients with male hypogonadism

  • Patients with thyroid disorders

  • Patients with GH abnormalities

  • Patients with chronic inflammatory diseases

  • Patients with osteoarthritis

  • Patients with critical illness

  • Patients with glaucoma

  • Patients with seizure/epilepsy

  • Patients with anxiety/depression

  • Patients with substance use disorder

  • Patients on opioids

  • Patients on oral contraceptives

  • Patients on psychotropic medications

  • Patients on antiretroviral drugs

Patient education

General counseling: as per AACE/ACE 2016 guidelines, advise female patients with overweight or obesity when appropriate that they are at increased risk for infertility and, if seeking assisted reproduction, inform of lower success rates of these procedures regarding conception and the ability to carry the pregnancy to live birth.
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Preventative measures

Carbohydrate intake: as per WHO 2023 guidelines, advise consuming carbohydrates primarily from whole grains, vegetables, fruits, and pulses.
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  • Fat intake

Follow-up and surveillance

Monitoring of pharmacotherapy: as per ES 2020 guidelines, consider reassessing the lipid profile to evaluate the risk of CVD and pancreatitis in patients with obesity on weight loss pharmacotherapy.
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  • Maintenance of weight loss

Quality improvement

Use of nonjudgmental language: as per ADA 2024 guidelines, use person-centered, nonjudgmental language fostering collaboration between patients and health care professionals, including people-first language (such as "person with obesity" rather than "obese person").
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