Received: 27 March 2019 Revised: 2 May 2019 Accepted: 13 May 2019

DOI: 10.1111/obr.12889

OBESITY MANAGEMENT

Management of overweight and obesity in primary care—A

systematic overview of international evidence‐based guidelines

Thomas Semlitsch1 | Florian L. Stigler1 | Klaus Jeitler1,2 | Karl Horvath1,3 |

Andrea Siebenhofer1,4

1
Institute of General Practice and Evidence‐
based Health Services Research, Medical Summary
University of Graz, Graz, Austria Overweight and obesity are increasing worldwide. In general practice, different
2
Institute for Medical Informatics, Statistics
approaches exist to treat people with weight problems. To provide the foundation
and Documentation, Medical University of
Graz, Graz, Austria for the development of a structured clinical pathway for overweight and obesity man-
3
Department of Internal Medicine, Division of agement in primary care, we performed a systematic overview of international
Endocrinology and Diabetology, Medical
University of Graz, Graz, Austria
evidence‐based guidelines. We searched in PubMed and major guideline databases
4
Institute of General Practice, Goethe for all guidelines published in World Health Organization (WHO) “Stratum A” nations
University Frankfurt am Main, Frankfurt, that dealt with adults with overweight or obesity. Nineteen guidelines including 711
Germany
relevant recommendations were identified. Most of them concluded that a multidis-
Correspondence ciplinary team should treat overweight and obesity as a chronic disease. Body mass
Thomas Semlitsch, Institute of General
Practice and Evidence‐based Health Services index (BMI) should be used as a routine measure for diagnosis, and weight‐related
Research, Medical University of Graz, complications should be taken into account. A multifactorial, comprehensive lifestyle
Auenbruggerplatz 2, 8036 Graz, Austria.
Email: [email protected] programme that includes reduced calorie intake, increased physical activity, and mea-
sures to support behavioural change for at least 6 to 12 months is recommended.
Funding information
Main Association of Austrian Social Security After weight reduction, long‐term measures for weight maintenance are necessary.
Institutions Bariatric surgery can be offered to people with a BMI greater than or equal to 35
kg/m2 when all non‐surgical interventions have failed. In conclusion, there was con-
siderable agreement in international, evidence‐based guidelines on how multidisci-
plinary management of overweight and obesity in primary care should be performed.

K E Y W OR D S

adults, obesity, overweight, systematic overview

1 | I N T RO D U CT I O N women.1 This trend is worrying, as a BMI of 30 kg/m2 is associated

with significantly increased rates of morbidity, such as diabetes
The global prevalence of obesity has risen in recent decades, with the mellitus2 and coronary artery disease,3 and of mortality.2,4,5
2
average body mass index (BMI) of adults rising from 22 kg/m in 1975 From a public health perspective, obesity is a major risk factor for a
to 24 kg/m2 in 2014. Correspondingly, the occurrence of obesity has range of chronic diseases including diabetes, cardiovascular diseases
increased from 3.2% to 10.8% in men and from 6.4% to 14.9% in and cancer.6 According to one modelling study, an increase of two

Thomas Semlitsch and Florian L. Stigler contributed equally to the publication.

--------------------------------------------------------------------------------------------------------------------------------
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
© 2019 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation

1218 wileyonlinelibrary.com/journal/obr Obesity Reviews. 2019;20:1218–1230.

SEMLITSCH ET AL. 1219

percentage points in the average BMI of a society reduces average life and overweight as search terms. Details of the searches can be
expectancy by 1 year.7 found as electronic supplementary materials in the appendix.
Numerous interventions can be recommended to people with
overweight or obesity, such as dietary modifications, physical
2.2 | Selection process
activity, behavioural changes, pharmacological treatment, and bariat-
ric surgery. General practitioners and multidisciplinary support
Guidelines had to fulfil all of the following criteria to be included in our
teams play a crucial role in helping patients achieve sustainable
systematic overview:
weight loss.8 Patients trust the advice of primary care providers on
weight management, but various barriers hinder the effective
• A target population of adults aged 18 or older with overweight or
counselling and treatment of patients with overweight or obesity.
obesity
On the one hand, physicians and other health professionals
• The inclusion of recommendations on diagnosis and/or therapy for
often lack training in the behavioural counselling and interdisciplinary
overweight or obesity
team work that is necessary for a comprehensive lifestyle interven-
tion and often have negative attitudes towards people with • Published in an industrial nation, as defined by the WHO Health
obesity.9 On the other hand, overweight and obesity is not only report 2003 (Stratum A)14
determined by lifestyle but also by hereditary factors. This often • A development process that included a systematic search for
discourages the appropriate implementation of effective evidence‐ evidence
based interventions.10,11 Difficulties changing behaviour on a lasting
• Published in English or German
basis may also explain the limited extent to which such interventions
• Published since 2011 and still valid
are implemented. One underlying reason for this may be the long‐
term increase in hunger‐stimulating hormones that follows significant
Two reviewers independently screened the titles and abstracts of
weight loss,12 combined with continuous exposure to an obesogenic
all identified publications. The full texts of potentially relevant guide-
environment and its multiple and continuous temptations.13
lines were assessed by the same reviewers. Discrepancies were
It is therefore essential to carefully select evidence‐based
resolved by discussion, or with the help of a third reviewer.
interventions when treating people with overweight or obesity in
primary care. A wide range of treatment options is available, but
the level of agreement between evidence‐based clinical guidelines 2.3 | Quality assessment
on how best to manage patients with overweight or obesity is
unclear. To provide the foundation for the development of a The methodological quality of all included guidelines was assessed
structured and evidence‐based clinical pathway for overweight and using the validated guideline appraisal tool of the Appraisal of
obesity management in primary care, we therefore performed a Guidelines for Research and Evaluation Collaboration (AGREE
systematic overview of international evidence‐based guidelines and II).15,16 The instrument consists of 23 items grouped into six
recommendations. domains (scope and purpose [three items], stakeholder involvement
[three items], rigour of development [eight items], clarity of
presentation [three items], applicability [four items], and editorial
Independence [two items]) and one overall assessment item. Two
2 | METHODS reviewers with experience in guideline quality assessment
appraised each guideline independently. Each item was rated on a
2.1 | Literature search 7‐point Likert scale ranging from 1 point (strong disagreement) to
7 points (strong agreement). In accordance with the AGREE II man-
To identify all current guidelines on overweight and obesity, we ual, scaled domain scores were calculated by summing up the scores
initially searched PubMed and the guideline databases of the assigned by the individual appraisers to the items in each of the six
Guideline International Network (G‐I‐N), the National Guideline domains, and by calculating the total as a percentage of the
Clearinghouse (NGC), the Association of the Scientific Medical maximum possible score for each domain. Overall guideline
Societies in Germany (AWMF), the National Institute for Health quality was also rated on a 7‐point Likert scale ranging from 1 point
and Care Excellence (NICE), and the Scottish Intercollegiate (lowest possible quality) to 7 points (highest possible quality), taking
Guidelines Network (SIGN), from 2011 to May 2016. In into account the previously evaluated individual items and the
addition, we hand searched the reference lists of included resulting domain scores. Guidelines were then ranked on the
publications and the websites of medical associations that deal with basis of their overall assessment scores. Since the AGREE II instru-
the topic. In February 2019, an update search was performed in ment does not provide a specific cut‐off to distinguish between
PubMed and the guideline databases, with the exception of high‐ and low‐quality guidelines, its users often apply a cut‐off based
NGC, which was closed in July 2018. We used a combination of on either the domain scores or overall guideline quality.17 For this
Medical subject heading (MeSH) terms and text words for obesity overview, guidelines with overall assessment scores greater than or
1220 SEMLITSCH ET AL.

equal to 6 points were rated as high quality, those with 4 to 5.9 3 | RESULTS
points as moderate quality, and those with less than 4 points as
low quality. 3.1 | Results of literature search

The search in guideline databases yielded 978 potentially relevant

2.4 | Data extraction
guidelines, of which the full texts of 61 were screened further. Thir-
teen of these guidelines met our predefined inclusion criteria. The
To characterize the guidelines, we extracted information on the
2016 search in PubMed generated 1121 articles. Based on title and
topic of the guideline, the publishing society, country of origin, pub-
abstract, 1060 articles were excluded. Among the remaining 61 publi-
lication date, and the number of recommendations.
cations, 22, of which five were duplicates, met our inclusion criteria.
All clearly identifiable recommendations that were considered rel-
The hand search revealed no other relevant publications. The update
evant to general practitioners were extracted from the included
search in PubMed and in guideline databases in February 2019 yielded
guidelines, along with their respective grades of recommendation
634 additional, potentially relevant articles. After excluding 629
(GoR) where indicated. We only included recommendations that
of them, we included three publications on two additional guide-
could be used in individual patient management and excluded gen-
lines,18-20 and two updates21,22 of guidelines identified in the 2016
eral recommendations directed at the health care system as a whole,
search.23-26 Overall, 31 publications describing 19 current guide-
eg, public health strategies. Recommendations that explicitly
lines18-22,27-52 on overweight and obesity were included in the final
addressed children and adolescents were also excluded. In order to
synopsis. A flow diagram outlining the literature search and selection
enable the different approaches taken by the guidelines to grade
process is provided in Figure 1.
the strength of their recommendations to be compared (eg, AACE‐
guidelines use the letter “A” to mark strong recommendations, while
NICE guidelines use words like “must” and “should” to reflect them), 3.2 | Characteristics and quality of included
we developed a standardized GoR system for this overview that is guidelines
based on the different approaches described in the methodological
sections of the respective guidelines (GoR “A” for strong, GoR “B” Of the 19 included guidelines, two were published in 2018,20,21 two in
for moderate, GoR “C” for weak, GoR “D” for very weak recommen- 2016,18,19,22 three in 2015,38,40,50,51 six in 2014,30-37,39,47-49,52 five in
dations, and “EC” for expert consensus). 2013,27-29,43-46 and one in 2012.41,42 In 13 guidelines, the target pop-
To provide a structured evidence‐based systematic overview of ulation consisted of adults only, while the remaining six guidelines
international guidelines, two authors grouped the recommendations dealt with people of all ages.20,22,44-48,50,51 The guidelines were
by topic and compared them with each other. It was thus possible developed and issued by institutions in the United States (n =
to assess guideline recommendations for consistency and to com- 10),18,19,21,22,27-37,40,43,52 the United Kingdom (n = 3),47-51 Germany
pare them with one another with reference to the AGREE II scores (n = 2),20,39 Canada (n = 1),38 Australia (n = 1),46 Spain (n = 1),41,42
in the source guidelines. and by a European medical society (n = 1).44,45 Nine of the included

FIGURE 1 Flow chart of guideline selection process

SEMLITSCH ET AL. 1221

guidelines addressed all subject areas relating to the management of to the methodology section of the IFSO guideline, LoE corresponds to
overweight and obesity.18,19,22,30-36,38,39,43,46-48,52 The remaining 10 recommendation strength. Underlying evidence could be clearly
guidelines dealt with dietary interventions (n = 3),28,29,37,41,42 bariatric assigned to individual recommendations in only a few guidelines.
20,27,44,45 21,49
surgery (n = 3), lifestyle interventions (n = 2), pharmaco- In the guideline synopsis, the extracted recommendations on the
logical weight reduction (n = 1),40 and obesity prevention (n = 1).50,51 management of overweight and obesity were summarized and allo-
Details on the characteristics of the included guidelines can be found cated to one of nine groups, depending on topic. Table 3 provides
in Table 1. an overview of the topics covered by recommendations in each of
Table 2 shows the AGREE II domain scores and overall assessment the included guidelines. An overview of key guideline recommenda-
scores for each guideline. The mean overall assessment score for tions for overweight and obesity management can be found in
the methodological quality of the guidelines was 4.7 out of a Table 4. Further important recommendations on the nine topics are
maximum of 7 points (SD 1.5), as assessed using the AGREE II instru- summarized below, together with their GoR in the individual
ment. According to the classifications used in this overview, five guidelines.
guidelines were of high quality,20,21,30-36,38,46 nine of moderate
quality,18,19,27,39,41-43,47-52 and the remaining five of low qual- 3.3 | Summary of recommendations
ity.22,28,29,37,40,44,45 The highest overall rating was assigned to the
overweight and obesity management guideline developed by the 3.3.1 | General recommendations
Australian National Health and Medical Research Council (NHMRC).46
The methodological quality of the obesity prevention and manage- According to the nine guidelines covering the topic,18,19,28-
37,39,41,42,47-49,52
ment guideline published by the University of Michigan (UoM) was a multidisciplinary team (AACE‐2/AHA/NICE‐1/
22
rated lowest. An examination of the different AGREE II domains NICE‐2: GoR A) should be used to manage overweight and obesity
revealed that most of the guidelines achieved high scores in “Scope as a long‐term, chronic disease (AACE‐2: GoR A; DAG: GoR B; VA:
and Purpose,” which aims to analyse to what extent the guidelines' EC). The recommended therapeutic goal for all adults with overweight
objectives, the disease itself, and the target population are described, and obesity is weight loss of 0.25 to 1.0 kg per week (AACE‐2/AND
and in “Clarity of Presentation,” which evaluates the clarity and ease /FESNAD/VA: GoR A) and a 5% to 10% reduction in body weight over
of identification of recommendations. Only three guidelines attained 6 to 12 months (AACE‐2/AND/FESNAD/VA: GoR A; DAG: GoR B). In
50% or less of the maximum possible score in Scope and Pur- one guideline, the primary therapeutic goal was defined as improve-
pose22,40,44,45 and only two achieved 50% or less in Clarity of Presen- ment in the health of patients by preventing or treating weight‐related
22,44,45
tation. The mean score for these two domains was 76.6%. The complications (AACE‐3: GoR EC). The specific weight‐loss goals
AGREE II domain with the lowest scores was “Applicability,” which ranged from at least 5% to a 40% reduction in body weight, depending
describes facilitators and barriers to the application of the guidelines on the presence of weight‐related complications (AACE‐3: GoR A).
as well as potential resource implications and monitoring criteria. Only
two guidelines achieved more than 50% of the maximum in this 3.3.2 | Diagnosis and further assessment
domain.46,50,51 On the other hand, five guidelines provided no infor-
mation on applicability at all.18,19,40-42,44,45,52 The mean score for this This topic was covered in 12 guidelines,18,19,22,30-39,43,46-52 all of
domain was 27%. which recommended diagnosing and classifying overweight and obe-
In total, 711 relevant recommendations were identified in the 19 sity in adults on the basis of the BMI (AACE‐3/CTF/ NICE‐1/ NICE‐
guidelines. The number of recommendations extracted from each 2: GoR A; AND/ NHMRC/VA: GoR B). All guidelines defined a BMI
guideline ranged from 165 from one of the bariatric surgery guide- of 25 to 29.9 kg/m2 and greater than or equal to 30 kg/m2 as the
lines27 to only one recommendation from the US Preventive Task respective cut‐points for overweight and obesity. A BMI greater than
Force 2018 (USPTF) guideline on behavioural weight loss interven- or equal to 25 to less than 30 kg/m2 was considered to be associated
21
tions. Almost half the recommendations (n = 313; 44%) were classi- with increased risk of cardiovascular disease, and a BMI greater than
fied as strong, which corresponds to a standardized GoR of A, while or equal to 30 kg/m2 with increased risk of cardiovascular disease
132 were moderate and allocated a standardized GoR of B (19%), and mortality (AHA: GoR A). Although some guidelines suggested that
and 102 weak and received a C (14%). Sixteen recommendations were BMI cut‐points and corresponding cardiovascular risk may vary
designated very weak, corresponding to a standardized GoR of D (2%). among population groups, only one guideline recommended a specific
The remaining 148 recommendations (21%) were based on EC. In 15 BMI cut‐point of greater than or equal to 23 kg/m2 for overweight in
guidelines, the level of evidence (LoE) for the underlying studies was Asian adults (AACE‐3: GoR B). Waist circumference should not be
specified in addition to the GoR. The LoEs rank studies according to used as a routine measure to diagnose overweight and obesity
the probability of bias. Systematic reviews of RCTs and high‐quality (NICE‐1: GoR A), but it provides additional information on the risk of
RCTs are usually assigned the highest level, while case reports and developing obesity‐related long‐term health problems (AACE‐3/ICSI/
expert opinions are ranked lowest.53 The three guidelines from NICE NICE‐1/ NICE‐ 2: GoR A; VA: GoR B). A targeted assessment of
47-51
reported only GoRs, while one guideline (International Federation adults with overweight and obesity should be conducted and include
for the Surgery of Obesity [IFSO]) only provided LoEs.44,45 According information on possible causes, such as current weight history,
1222 SEMLITSCH ET AL.

TABLE 1 Characteristics of included guidelines

Number of
Year of Relevant
Guideline Publication Title Publisher Country Main Topic Recommendations
27
AACE‐1 2013 Clinical Practice Guidelines for the American Association of clinical USA Bariatric surgery 165
perioperative nutritional, metabolic, Endocrinologists/The
and nonsurgical support of the Obesity Society/American
bariatric surgery patient—2013 Society for metabolic &
Update bariatric Surgery)
AACE‐228,29 2013 Clinical practice guidelines for healthy American Association of clinical USA Dietary 15
eating for the prevention and Endocrinologists/American interventions
treatment of metabolic and College of Endocrinology/
endocrine diseases in adults The Obesity Society
AACE‐318,19 2016 Comprehensive clinical practice American Association of clinical USA Management of 160
guidelines for medical care of Endocrinologists/American overweight/
patients with obesity College of Endocrinology obesity
AHA30-36 2014 Guideline for the management of American Heart Association/ USA Management of 17
overweight and obesity in adults American College of overweight/
Cardiology/The Obesity obesity
Society
AND37 2014 Adult Weight Management Academy of Nutrition and USA Dietary 31
Dietetics interventions
CTF38 2015 Recommendations for prevention of Canadian Task Force on Canada Management of 4
weight gain and use of behavioral Preventive Health Care overweight/
and pharmacologic interventions to obesity
manage overweight and obesity in
adults in primary care
DAG39 2014 Prevention and therapy of obesity [OT: German Obesity Society Germany Management of 59
Prävention und Therapie der (Deutsche Adipositas‐ obesity
Adipositas] Gesellschaft e.V.)
DGAV20 2018 Surgery for obesity and metabolic German society for general and Germany Bariatric surgery 36
diseases [OT: Chirurgie der visceral surgery [Deutsche
Adipositas und metabolischer Gesellschaft für Allgemein‐
Erkrankungen] und Viszeralchirurgie e.V.]
ES40 2015 Pharmacological Management of Endocrine Society‐appointed USA Pharmacological 19
Obesity Task Force of experts interventions
FESNAD41,42 2012 Evidence‐based nutritional Spanish Federation of Spain Dietary 16
recommendations for the prevention Nutrition, Food and Dietetic interventions
and treatment of overweight and Association/Spanish
obesity in adults Association for the Study of
Obesity
ICSI43 2013 Prevention and management of obesity Institute for Clinical Systems USA Management of 5
for adults Improvement obesity
IFSO44,45 2013 Interdisciplinary European Guidelines International Federation for the Europe Bariatric surgery 19
on Metabolic and Bariatric Surgery Surgery of Obesity—
European Chapter/European
Association for the Study of
Obesity
NHMRC46 2013 Clinical practice guidelines for the Australian Government, Australia Management of 13
management of overweight and National Health and Medical overweight/
obesity in adults, adolescents and Research Council, obesity
children in Australia Department of Health
NICE‐147,48 2014 Obesity: identification, assessment and NICE/National Clinical UK Management of 80
management (CG189) Guideline Centre overweight/
obesity

(Continues)
SEMLITSCH ET AL. 1223

TABLE 1 (Continued)

Number of
Year of Relevant
Guideline Publication Title Publisher Country Main Topic Recommendations
49
NICE‐2 2014 Weight management: lifestyle services NICE/National Clinical UK Lifestyle 7
for overweight or obese adults Guideline Centre interventions
(PH53)
NICE‐350,51 2015 Obesity prevention (CG43) NICE/National Clinical UK Prevention of 3
Guideline Centre obesity
UoM22 2016 Obesity Prevention and Management University of Michigan USA Management of 31
overweight/
obesity
USPTF21 2018 Behavioral weight loss interventions to U.S. Preventive Services Task USA Lifestyle 1
prevent obesity‐related morbidity Force interventions
and mortality in adults
VA52 2014 Screening and management of Department of Veterans USA Management of 40
overweight and obesity Affairs/Department of overweight/
Defense, The Management obesity
of Overweight and Obesity
Working Group

Abbreviations: AACE, American Association of Clinical Endocrinologists; AHA, American Heart Association; AND, Academy of Nutrition and Dietetics; CTF,
Canadian Task Force; DAG, German Obesity Society [Deutsche Adipositas Gesellschaft]; DGAV, German Society for General and Visceral Surgery
[Deutsche Gesellschaft für Allgemein‐ und Viszeralchirurgie]; ES, Endocrine Society; FESNAD, Spanish Federation of Nutrition, Food and Dietetic Societies
[Federación Española de Sociedades de Nutrición, Alimentación y Dietética]; IFSO, International Federation for the Surgery of Obesity; ICSI, Institute for
Clinical Systems Improvement; NHMRC, National Health and Medical Research Council; NICE, National Institute for Health and Care Excellence; OT, orig-
inal title; UoM, University of Michigan; USPTF, US Preventive Task Force; VA, Department of Veterans Affairs.

personal lifestyle, psychosocial stress, other psychological issues, pre- hypertension) (AHA /ES/ NHMRC: GoR A). A multifactorial, compre-
vious attempts to lose weight, social background, and the motivation hensive lifestyle programme that includes a reduction in calorie intake,
and willingness to lose weight (AND/NICE‐1/UoM: GoR A, an increase in physical activity, and measures to support behavioural
DAG/NICE‐3: GoR B, NHMRC: GoR D, VA: EC). change is recommended as a baseline therapy (AACE‐ 2/AACE‐3/
AHA/ AND/DAG/NHMRC/NICE‐1/NICE‐2/VA: GoR A; CTF:
3.3.3 | Weight‐related complications and other GoR C). Treatment duration should be at least 6 (AHA/AND: GoR A)
comorbidities to 12 months (VA: GoR B) and involve individual or group sessions
provided by a trained interventionist (AHA/AND: GoR A; VA: GoR
Weight‐related complications and other comorbidities and/or risk fac- B). For adults with overweight but without any weight‐related compli-
tors were mentioned in five guidelines18,19,22,39,40,47,48 and are consid- cations, information and advice should be provided on how to change
ered to be an important part of a patient's medical history (AACE‐3/ behaviours to achieve a healthier diet and increase physical activity
NICE‐1: GoR A; UoM: GoR B). However, weight‐related complications (VA: GoR C).
and other comorbidities should be managed independently of any Recommendations on lifestyle interventions aimed at maintaining a
weight‐loss therapy (NICE‐1/UoM: GoR A). In addition, a medication healthy weight were found in six guidelines.28,29,37,39,46-48,52 It was
review of substances potentially responsible for weight gain should noted that after weight reduction, long‐term measures to maintain
be carried out (UoM: GoR A), and weight‐neutral medications, or reduced weight are also necessary (AHA/DAG/NHMRC/NICE‐1:
drugs with weight‐reducing effects, should be used to treat weight‐ GoR A). These should include a low‐calorie, balanced diet, increased
related complications and other comorbidities (AACE‐3/ES: GoR A; physical activity, and behavioural support (DAG: GoR B). For this pur-
DAG: GoR D). pose, patients should be regularly contacted in person or by phone at
least monthly for at least a year (AHA/AND/DAG: GoR A; VA: GoR B).
3.3.4 | Lifestyle change Specific recommendations on dietary interventions were reported in
10 guidelines.18,19,22,28-37,39,41,42,46-48,52 To reduce weight, nutrition
Suggested lifestyle changes included recommendations on diets, phys- professionals should provide dietary interventions (AHA / AND /
ical activity, and behavioural interventions and was covered in all but DAG: GoR A) that produce a daily energy deficit of 500 to 750 kcal
three18-20,44,45 of the 19 included guidelines. Weight‐reduction is rec- (AACE‐3 / AHA / AND / FESNAD / NHMRC/ NICE‐1: GoR A, DAG:
ommended for people with a BMI greater than or equal to 30 kg/m2 GoR B). According to the guidelines, the composition of nutritional ther-
(USPTF: GoR B; VA: GoR C), or a BMI greater than or equal to 25 apy was unimportant (AHA/ AND /UoM/VA: GoR A; DAG/ FESNAD:
kg/m2 and weight‐related complications (eg, diabetes mellitus type 2, GoR D) as long as the diet was balanced and healthy (AACE‐2 /
1224 SEMLITSCH ET AL.

TABLE 2 Methodological quality of the included guidelines (AGREE II scores)

Domain 2: Overall
Domain 1: Scope Stakeholder Domain 3: Rigour Domain 4: Clarity Domain 5: Domain 6: Editorial assessment
Guideline and Purposea Involvementa of Developmenta of Presentationa Applicabilitya Independencea (Rank)b

NHMRC46 89% 83% 94% 100%d 65%d 92% 7 (1)d

AHA30-36 86% 47% 81% 92% 4% 71% 6 (3.5)
CTF38 97%d 53% 90% 94% 42% 83% 6 (3.5)
DGAV20 92% 100%d 93% 94% 10% 100%d 6 (3.5)
USPTF21 86% 25% 96%d 100%d 23% 83% 6 (3.5)
AACE‐127 83% 42% 79% 100%d 50% 96% 5.5 (7.5)
18,19 c
AACE‐3 81% 42% 70% 94% 0% 79% 5.5 (7.5)
NICE‐147,48 78% 56% 77% 64% 15% 88% 5.5 (7.5)
52 c c
VA 89% 44% 77% 89% 0% 0% 5.5 (7.5)
49 d
NICE‐2 97% 91% 93% 69% 44% 33% 5 (10.5)
NICE‐350,51 92% 81% 86% 61% 58% 92% 5 (10.5)
39
DAG 83% 53% 58% 89% 4% 96% 4.5 (12.5)
ICSI43 72% 58% 57% 75% 48% 83% 4.5 (12.5)
41,42 c
FESNAD 58% 28% 58% 75% 0% 46% 4 (14)
28,29
AACE‐2 58% 19% 25% 72% 19% 33% 3 (15.5)
ES40 31%c 11%c 46% 86% 0%c 38% 3 (15.5)
AND37 83% 39% 44% 56% 19% 0%c 2.5 (17.5)
44,45 c c c c
IFSO 50% 17% 9% 28% 0% 0% 2.5 (17.5)
UoM22 44% 22% 10% 39% 15% 38% 2 (19)c
Mean score [SD] 76.6% [15.5%] 47.1% [22.3%] 66.9% [24.7%] 76.6% [16.6%] 27.0% [18.8%] 70.1% [24.8%] 4.7 [1.5]

Abbreviations: AACE, American Association of Clinical Endocrinologists; AHA, American Heart Association; AND, Academy of Nutrition and Dietetics; CTF,
Canadian Task Force; DAG, German Obesity Society [Deutsche Adipositas Gesellschaft]; DGAV, German Society for General and Visceral Surgery
[Deutsche Gesellschaft für Allgemein‐ und Viszeralchirurgie]; ES, Endocrine Society; FESNAD, Spanish Federation of Nutrition, Food and Dietetic Societies
[Federación Española de Sociedades de Nutrición, Alimentación y Dietética]; IFSO, International Federation for the Surgery of Obesity; ICSI, Institute for
Clinical Systems Improvement; NHMRC, National Health and Medical Research Council; NICE, National Institute for Health and Care Excellence; SD, Stan-
dard deviation; UoM, University of Michigan; USPTF, US Preventive Task Force; VA, Department of Veterans Affairs.
a
Scaled domain scores: percentage reached of the maximum possible score.
b
Overall assessment: 1 point = lowest possible quality, 7 points = highest possible quality.
c
Lowest score.
d
Highest score.

AACE‐3 /DAG/ NICE‐1: GoR A). In addition, to optimize adherence, die- Eight guidelines discussed the importance of physical activ-
18,19,22,37,39,46-48,50-52
tary interventions should be individualized and based on personal and ity. Interventions to increase physical activity
cultural preferences (AACE‐3 / AHA/NICE‐1/DAG: GoR A). Structured should be individualized to include activities that take account of
meal plans (AACE‐3/ AND: GoR A), portion control (AACE‐2 / AND: patients' capabilities and preferences (NICE‐1 / NICE‐3: GoR A; DAG:
GoR A), and meal replacements (AACE‐3/AND /VA: GoR A; FESNAD: GoR B; AACE‐3: GoR C) and should focus on activities of daily living
GoR D) are recommended as possible interventions. Unduly restrictive (eg, walking, cycling, and gardening) (DAG/ NICE‐1/NICE‐3: GoR A).
and nutritionally unbalanced diets, or fad diets, are explicitly not recom- For persons with a BMI greater than 35 kg/m2, activities should be cho-
mended (AACE‐2/DAG/FESNAD/NICE‐1: GoR A). Very low calorie sen that do not burden the musculoskeletal system (DAG: GoR B). The
diets (calorie intake ≤800 kcal/day) should not be used routinely in majority of guidelines recommended at least 30 minutes of moderate‐
the treatment of obesity (AACE‐3/FESNAD/NICE‐1: GoR A), but only intensity endurance exercise five or more days a week, in combination
for certain indications and medical conditions, eg, in case of weight‐ with strength training (AACE‐3/NICE‐1/UoM/VA: GoR A; DAG: GoR
related complications or circumstances that require faster weight loss B; AND: EC). One guideline indicated that resistance exercise alone
(AACE‐2/AHA: GoR B; NICE‐1: GoR C; FESNAD: GoR D). Very low cal- does not reduce weight effectively (DAG: GoR B). In general, a reduc-
orie diets always need medical supervision (AACE‐2/AACE‐3: GoR A; tion in sedentary activities (eg, watching TV, computer use) is recom-
AHA/FESNAD/VA: GoR B). mended (AACE‐3/NICE‐1/UoM: GoR A).
SEMLITSCH ET AL. 1225

TABLE 3 Topics covered by recommendations in included guidelines

Lifestyle Change
Diagnosis
General and Further Dietary Physical Behavioural Pharmacological Bariatric
Guideline Recommendations Assessment Comorbidities General Interventions Activity Interventions weight‐reduction surgery

AACE‐127 ●
AACE‐2 28,29
● ● ● ●
AACE‐318,19 ● ● ● ● ● ● ● ● ●
AHA 30-36
● ● ● ● ● ●
AND 37
● ● ● ● ● ●
CTF38 ● ● ● ●
DAG 39
● ● ● ● ● ● ● ● ●
DGAV20 ●
ES40
● ● ● ●
FESNAD 41,42
● ●
ICSI43 ● ●
IFSO 44,45
●
NHMRC 46
● ● ● ● ● ● ●
NICE‐147,48 ● ● ● ● ● ● ● ● ●
NICE‐2 49
● ● ●
NICE‐350,51 ● ●
UoM 22
● ● ● ● ●
USPTF 42,45,46
● ●
VA21 ● ● ● ● ● ● ● ●

Abbreviations: AACE, American Association of Clinical Endocrinologists; AHA, American Heart Association; AND, Academy of Nutrition and Dietetics; CTF,
Canadian Task Force; DAG, German Obesity Society [Deutsche Adipositas Gesellschaft]; DGAV, German Society for General and Visceral Surgery
[Deutsche Gesellschaft für Allgemein‐ und Viszeralchirurgie]; ES, Endocrine Society; FESNAD, Spanish Federation of Nutrition, Food and Dietetic Societies
[Federación Española de Sociedades de Nutrición, Alimentación y Dietética]; IFSO, International Federation for the Surgery of Obesity; ICSI, Institute for
Clinical Systems Improvement; NHMRC, National Health and Medical Research Council; NICE, National Institute for Health and Care Excellence; UoM,
University of Michigan; USPTF, US Preventive Task Force; VA, Department of Veterans Affairs.
Note. ● Topic covered by guideline recommendations

Recommendations on specific behavioural interventions were 3.3.5 | Pharmacological weight‐reduction

found in eleven guidelines.18,19,21,28-39,43,46-48,52 These guidelines
recommended supportive structured behavioural interventions In seven guidelines,18,19,38-40,46-48,52 pharmacological weight‐reduction
(AACE‐3 /CTF/ DAG: GoR A; AACE‐2/USPTF: GoR B) for all adults using medications approved for long‐term weight‐management is only
with an indication for weight loss, possibly in the form of individual recommended as an adjunct to lifestyle interventions. Specifically, rec-
or group sessions (NICE‐1: GoR A). Behavioural interventions should ommendations were for adults with a BMI greater than or equal to 30
contain various strategies such as motivational interviewing (AACE‐3 kg/m2, a BMI greater than or equal to 27 kg/m2 and weight‐related
/AND/DAG/ICSI/ NICE‐1: GoR A; VA: EC), stimulus control (AACE‐ complications (AACE‐3/ES/NHMRC/VA: GoR A), a BMI of greater than
3/DAG/ NICE‐1: GoR A; AND: GoR B), and cognitive restructuring or equal to 28 kg/m2 and additional risk factors (NICE‐1: GoR A; DAG:
(AACE‐3/DAG/NICE‐1: GoR A; AND: GoR B). In addition, self‐ GoR D), and when sufficient weight loss could not be achieved through
monitoring is recommended as an essential part of behavioural lifestyle interventions alone (VA: GoR B, NICE‐1: GoR C). Pharmacolog-
interventions. Patients should be encouraged to keep track of their ical weight reduction should only be maintained when a person has lost
dietary intake, physical activity level, and body weight (AACE‐2/ at least 5% of their initial body weight during the first 3 months (ES/
AACE‐3/AHA/ICSI/NICE‐1/NICE‐3: GoR A; USPTF: GoR B; NICE‐1: GoR A), or at least 2 kg during the first 4 weeks (DAG: GoR B)
NHMRC: GoR C). According to one recent guideline, behavioural of treatment. In patients with obesity and for whom the potential ben-
interventions should be intensified if a 2.5% weight loss is not efits outweigh the risks, weight‐reducing medication should be offered
achieved during the first month of therapy (AACE‐3: GoR A), since for chronic weight‐maintenance (AACE‐3: GoR A; AACE‐1/NICE‐1:
early weight loss contributes strongly towards long‐term success. GoR C). The use of weight‐reducing drugs in pregnant (AACE‐3: GoR
1226 SEMLITSCH ET AL.

TABLE 4 Key recommendations for obesity management in guide- After bariatric surgery, long‐term multidisciplinary follow‐up care
lines from high‐income countries (NICE‐1: GoR A; DGAV: GoR EC) is required for at least 2 years
(NICE‐1: GoR A) and sometimes for the remainder of the patient's life
Obesity should be treated as a chronic disease.
(DAG: GoR A; DGAV/VA: EC). The frequency of care appointments
Overweight and obesity should be managed by a multidisciplinary team.
depends on the type of surgical procedure and the severity of
BMI should be used as a routine measure for diagnosis.
weight‐related complications and other comorbidities (AACE‐1: EC).
BMI ≥25 to <30 kg/m2 is associated with increased risk of Furthermore, an appointment with a physician familiar with the treat-
cardiovascular disease, and BMI ≥30 kg/m2 with increased risk of
ment of obesity and bariatric surgery is recommended at least once a
cardiovascular disease and mortality.
year (NICE‐1: GoR A; DGAV: GoR EC). Specific recommendations on
Waist circumference should be used as an additional measure to assess
the content of such long‐term follow‐up were made in four guidelines
the risk of developing obesity‐related long‐term health problems.
(NICE‐1: GoR A, AACE‐1/IFSO: GoR B; DGAV: GoR EC) and include
A multifactorial, comprehensive lifestyle intervention for at least 6 to 12
months that includes a reduction in calorie intake, an increase in dietetic and micronutrient monitoring, individualized nutritional sup-
physical activity, and measures to support behavioural change, is plementation, and psychological support.
essential in the treatment of overweight and obesity.
Pharmacological weight reduction is only recommended as an adjunct to 3.3.7 | Participation of healthcare professionals
lifestyle interventions
When all non‐surgical interventions have failed, bariatric surgery may be All guidelines stated that the care of patients with overweight and
a treatment option for people with a BMI of at least 35 kg/m2.
obesity should be multidisciplinary and performed by trained primary
After bariatric surgery, long‐term follow‐up care should be provided. care professionals. The choice of specific health professionals
Abbreviation: BMI, body‐mass‐index depended on the recommended treatment (general recommendations,
lifestyle changes, dietary interventions, physical activity, and bariatric
surgery). The information was provided in general terms for behav-
A) and lactating or breast‐feeding women (AACE‐3: GoR EC) is not rec- ioural, pharmacological, and weight‐maintaining interventions.
ommended, while in elderly persons, pharmacological weight‐reduction Details on individual recommendations can be found in the online
should be used with extra caution (AACE‐3: GoR A). The guidelines also supplement.
discourage the off‐label use of medications approved for other diseases
(eg, amphetamines, diuretics, and thyroxine) for the sole purpose of pro-
ducing weight loss (DAG: GoR A, ES: EC) and the use of other 4 | DISCUSSION
dietary supplements and medical products to achieve weight reduction
(DAG: GoR A). This systematic guideline overview identified and gathered informa-
tion on how to structure treatment for overweight and obesity in adult
patients in primary care from 19 international guidelines18-22,27-52 that
3.3.6 | Bariatric surgery
were published in WHO “Stratum A” countries.14 Altogether, 711 rel-

Eleven guidelines recommend undertaking bariatric surgery,18- evant recommendations were identified and almost half the recom-
20,22,27,30-36,39,40,44-48,52
which is a treatment option in adults with a mendations were described as strong.
2
BMI greater than or equal to 40 kg/m or a BMI greater than or equal
to 35 kg/m2 with weight‐related complications (AACE‐1/AACE‐3/ES/ 4.1 | Key findings (see also Table 4)
IFSO/NHMRC/ NICE‐1, VA: GoR A; DGAV: GoR EC), when all non‐
surgical weight loss interventions have failed (DAG/NICE‐1: GoR A, Most of the guidelines included a clear statement that overweight and
AHA/IFSO/UoM: GoR B; DGAV: GoR EC). In adults with a BMI above obesity should be treated as a chronic disease and managed by a mul-
50 kg/m2, bariatric surgery is considered a treatment option whether tidisciplinary team.
or not conservative weight‐reducing interventions have been carried The identified guidelines were in agreement that BMI should be
out previously (NICE‐1: GoR A; DAG: GoR D). The decision to offer used as a routine measure for diagnosis and that a BMI greater than
surgery should follow a comprehensive multidisciplinary assessment or equal to 25 to less than 30 kg/m2 is associated with an increased
(AACE‐3/DAG: GoR A; IFSO: GoR B; DGAV: GoR EC). Bariatric sur- risk of cardiovascular disease, and a BMI greater than or equal to 30
gery may also be considered in patients that have diabetes and a kg/m2 with an increased risk of cardiovascular disease and mortality.
BMI between 30 and 34.9 kg/m2 (AACE‐1: GoR B; AACE‐3/NICE‐1: Furthermore, waist circumference should be used as an additional
GoR C; DGAV: GoR EC), although available evidence is limited and measure for the risk of developing obesity‐related long‐term health
long‐term data lacking. According to the guidelines, higher age is not problems. In all cases, weight‐related complications, other comorbidi-
a contraindication for bariatric surgery (DGAV: GoR EC). However, ties, and medications that may be responsible for weight gain should
an assessment of the benefits and harms of bariatric surgery in per- be taken into account.
sons aged 65 years or older is currently impossible due to insufficient A multifactorial, comprehensive lifestyle programme that includes
evidence (VA: GoR A; AACE‐1: GoR B; NICE‐1: GoR C; AHA: GoR D). a reduction in calorie intake, an increase in physical activity, and
SEMLITSCH ET AL. 1227

measures to support behavioural change for at least 6 to 12 months Nevertheless, research on the importance of primary care has shown
is considered essential in the treatment of overweight and obesity. It that countries with a highly developed primary care sector that is
was noted that after weight reduction, long‐term measures for both comprehensive and coordinates its activities with other medical
weight maintenance are necessary that include a healthy, low‐calorie professionals achieve better population health outcomes and
balanced diet, increased physical activity, and behavioural support reduced socio‐economic health inequalities, both in the Organisation
involving regular contact, either in person or by telephone, for at for Economic Co‐operation and Development (OECD)62 and the
least 1 year. Pharmacological weight reduction is only recommended European Union.63 To develop clinical pathways, we relied mainly
as an adjunct to lifestyle interventions, and off‐label use of medica- on strong recommendations extracted from the included guidelines,
tions for the sole purpose of producing weight loss should be treatment algorithms identified during the search of other guidelines,
avoided. Bariatric surgery is mainly a treatment option for people and the webpages of relevant associations.
with a BMI of at least 35 kg/m2 when all non‐surgical interventions Further details are described in the full report of the Main Associ-
have failed. The final decision should be made by a multidisciplinary ation of Austrian Social Security Institutions.64
team that should also provide the patient with long‐term follow‐up
care after surgery.
4.3 | Strengths and limitations

4.2 | Overweight and obesity in primary care The strengths of this overview were the inclusion of all 19 current
evidence‐based guidelines that could be identified using a comprehen-
Overweight and obesity are complex conditions and maintaining sive search strategy. Another strength was the high number of recom-
weight loss over the long term is one of the biggest challenges in over- mendations classified as strong. Out of a total of 711 identified
weight and obesity management. In this context, one key factor, which recommendations, 44% were classified as strong (corresponding to a
is addressed in nearly all guidelines, is the adoption of a multicompo- standardized GoR of A) and a further 19% were classified as moderate
nent and multidisciplinary approach. Recent research has indicated (corresponding to a standardized GoR of B). A further strength is the
that comprehensive programmes administered by multiprofessional high degree of agreement between individual publishing associations
teams are required for success.54,55 In addition, a qualitative study and the groups of authors responsible for preparing the guidelines,
investigating the beliefs, skills, and knowledge of involved researchers, ie, there were no contradictory recommendations. Current guidelines
practitioners, and patients reported that close multidisciplinary collab- on hypertension, for example, show that this is not always the case.
oration and knowledge about the role of each participant in the man- Based on the same evidence, the European Society of Cardiology
agement process, combined with continuous monitoring, may (ESC) guideline65 and the American College of Cardiology/American
56
contribute towards treatment success. Heart Association (ACC/AHA) guideline66 define hypertension differ-
The aim of this project was to provide a clear and systematic ently, with greater than or equal to 140/90 mmHg for stage 1 hyper-
overview, based on which structured care processes could tension in the 2018 ESC guideline comparing with as low as greater
be defined for the management of overweight and obesity in than or equal to130/80 mmHg for stage 1 hypertension in the 2017
primary care. It was initiated by the Main Association of Austrian ACC/AHA guideline. Blood pressure target values also differ.
Social Security Institutions as the first of three overviews on Limitations of this study were the sole inclusion of guidelines from
overweight/obesity, chronic obstructive pulmonary disease, and high‐income WHO Stratum A countries and the exclusion of guide-
unspecific back pain. The results are to be incorporated in clinical lines that were not in English or German. The included guidelines
pathways for primary care teams. A scoping review published by therefore only reflected conditions in high‐income countries. Addi-
Sturgiss in 201857 showed that the literature is divided on the role tionally, more than half of them came from the United States, where
family doctors and other health professionals should play in obesity the healthcare system has different characteristics to those in other
management. Although general practitioners are mostly involved in high‐income countries. Although only evidence‐based guidelines were
diagnosis and assessment, their role in obesity care is often included and many of the specific recommendations were classified as
underestimated.57 Another review concluded that studies performed strong, the methodological quality (based on an AGREE II assessment)
in primary care provide little evidence on the effectiveness of over- of the included guidelines was only moderate in most of them. The
weight and obesity management and that further research is needed low quality of the included guidelines in the AGREE II domain
to define the role of primary care providers in the context of com- applicability made it difficult to draw conclusions on the clinical
prehensive and multi‐professional care.58 As most trials are per- implementability of recommendations. In most cases, the guidelines
formed in specialist obesity clinics and research centres, trials in did not address supporting factors and barriers to applications and
primary care and information on long‐term health outcomes are only provided no specific tools to enable recommendations to be put into
available to a limited degree.59-61 Based on our review, we were practice. As it may not be possible to directly transfer results from
therefore unable to clearly define which components of obesity one population group to another, a further limitation to applicability
management should be delivered in which healthcare setting, not is that recommended BMI cut‐points did not take different ethnic
least because of differences in healthcare systems themselves. groups and national health systems into account.
1228 SEMLITSCH ET AL.

5 | C O N CL U S I O N S 8. Bray G, Look M, Ryan D. Treatment of the obese patient in primary

care: targeting and meeting goals and expectations. Postgrad Med.
2013;125(5):67‐77.
To the best of our knowledge, this is the first time a structured sys-
tematic overview of international guidelines has been performed that 9. Dietz WH, Baur LA, Hall K, et al. Management of obesity: improvement
of health‐care training and systems for prevention and care. Lancet
includes all subjects relating to overweight and obesity management.
(London, England). 2015;385(9986):2521‐2533.
These range from general recommendations, diagnoses, and assess-
10. Farooqi IS, O'Rahilly S. Recent advances in the genetics of severe child-
ments to the various treatment options. The 19 identified evidence‐ hood obesity. Arch Dis Child. 2000;83(1):31‐34.
based guidelines included 711 distinct recommendations and there
11. Stunkard AJ, Sorensen TI, Hanis C, et al. An adoption study of human
were no relevant discrepancies between them. Thus there is consider- obesity. N Engl J Med. 1986;314(4):193‐198.
able international agreement on how best to define a multidisciplinary
12. Sumithran P, Prendergast LA, Delbridge E, et al. Long‐term persis-
clinical pathway for the management of overweight and obesity in pri- tence of hormonal adaptations to weight loss. N Engl J Med.
mary care in high‐income countries. 2011;365(17):1597‐1604.
13. Kirk SF, Penney TL, McHugh TL. Characterizing the obesogenic envi-
ACKNOWLEDGEMEN TS ronment: the state of the evidence with directions for future
research. Obes Rev. 2010;11:109‐117.
Andreas Domke, Muna Abuzahra, and Nicole Posch supported us dur-
14. World Health Organization (WHO). The World Health Report 2003:
ing the screening process. We would also like to thank Bettina
Shaping The Future. Geneva 2003.
Maringer for her helpful comments on this manuscript and Phillip
15. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing
Elliott who edited it.
guideline development, reporting and evaluation in health care. J Clin
Epidemiol. 2010;63(12):1308‐1311.
CONF LICT S OF INTE R ES T 16. Brouwers M, Kho ME, Browman GP, et al. Appraisal of Guidelines for
This manuscript is based on the report “(Be‐)Handlungspfad Research & Evaluation II. https://www.agreetrust.org/wp‐content/
uploads/2017/12/AGREE‐II‐Users‐Manual‐and‐23‐item‐Instrument‐
Übergewicht & Adipositas auf Primärversorgungsebene, Version 1.2;
2009‐Update‐2017.pdf. Published May, 2009. Updated December,
2016,” which was funded by the Main Association of Austrian Social 2017. Accessed March 30, 2019.
Security Institutions (http://www.hauptverband.at). None of the
17. Hoffmann‐Esser W, Siering U, Neugebauer EAM, Lampert U,
authors have conflicts of interest to declare. Eikermann M. Systematic review of current guideline appraisals per-
formed with the Appraisal of Guidelines for Research & Evaluation II
ORCID instrument‐a third of AGREE II users apply a cut‐off for guideline qual-
ity. J Clin Epidemiol. 2018;95:120‐127.
Thomas Semlitsch https://orcid.org/0000-0002-1763-7855
18. Garvey WT, Mechanick JI, Brett EM, et al. American Association of
Clinical Endocrinologists and American College of Endocrinology com-
RE FE R ENC E S prehensive clinical practice guidelines for medical care of patients with
1. NCD Risk Factor Collaboration. Trends in adult body‐mass index in obesity—executive summary. Endocr Pract. 2016;22(7):842‐884.
200 countries from 1975 to 2014: a pooled analysis of 1698 19. Garvey WT, Mechanick JI, Brett EM, et al. American Association of
population‐based measurement studies with 19.2 million participants. Clinical Endocrinologists and American College of Endocrinology com-
Lancet (London, England). 2016;387:1377‐1396. prehensive clinical practice guidelines for medical care of patients with
2. Bell JA, Kivimaki M, Hamer M. Metabolically healthy obesity and risk of obesity. Endocr Pract. 2016;22(Suppl 3):1‐203.
incident type 2 diabetes: a meta‐analysis of prospective cohort studies. 20. Deutsche Gesellschaft für Allgemein‐ und Vizeralchirurgie (DGAV).
Obes Rev. 2014;15(6):504‐515. Chirurgie der Adipositas und metabolischer Erkrankungen, version
2.3. https://www.awmf.org/uploads/tx_szleitlinien/088‐001l_S3_
3. Mongraw‐Chaffin ML, Peters SAE, Huxley RR, Woodward M. The sex‐
Chirurgie‐Adipositas‐metabolische‐Erkrankugen_2018‐02.pdf.
specific association between BMI and coronary heart disease: a sys-
Published 2010. Updated February, 2018. Accessed March 01, 2019.
tematic review and meta‐analysis of 95 cohorts with 1.2 million
participants. Lancet Diabetes Endo. 2015;3(6):437‐449. 21. Curry SJ, Krist AH, Owens DK, et al. Behavioral weight loss interven-
tions to prevent obesity‐related morbidity and mortality in adults: US
4. Aune D, Sen A, Prasad M, et al. BMI and all cause mortality: systematic
preventive services task force recommendation statement. JAMA.
review and non‐linear dose‐response meta‐analysis of 230 cohort
2018;320(11):1163‐1171.
studies with 3.74 million deaths among 30.3 million participants. BMJ
(Clinical research ed). 2016;353:i2156. 22. University of Michigan Health System. Obesity prevention and man-
agement. https://www.med.umich.edu/1info/FHP/practiceguides/
5. Global BMIMC, Di Angelantonio E, Bhupathiraju Sh N, et al. Body‐mass obesity/obesity.pdf. Published December 2004. Updated July, 2016.
index and all‐cause mortality: individual‐participant‐data meta‐analysis Accessed March 01, 2019.
of 239 prospective studies in four continents. Lancet (London, England).
2016;388:776‐786. 23. U.S. Preventive Services Task Force. Screening for and management of
obesity in adults: recommendation statement. Am Fam Physician.
6. World Health Organization (WHO). Health topics ‐ Obesity. https:// 2012;86:1‐3.
www.who.int/topics/obesity/en/. Published 2019. Updated 2019.
24. U.S. Preventive Services Task Force. Summaries for patients. Summa-
Accessed March 01, 2019.
ries for patients. Screening for and management of obesity in adults:
7. Peto R, Whitlock G, Jha P. Effects of obesity and smoking on US life US preventive services task force recommendation. Ann Intern Med.
expectancy. N Engl J Med. 2010;362:855‐856. author reply 56‐7 2012;157:I‐32.
SEMLITSCH ET AL. 1229

25. Moyer VA. Screening for and management of obesity in adults: US pre- 38. Brauer P, Connor Gorber S, Shaw E, et al. Recommendations for pre-
ventive services task force recommendation statement. Ann Intern vention of weight gain and use of behavioural and pharmacologic
Med. 2012;157(5):373‐378. interventions to manage overweight and obesity in adults in primary
care. CMAJ: Can Med Assoc J. 2015;187(3):184‐195.
26. University of Michigan Health System. Obesity prevention and manage-
ment. https://www.uofmhealth.org/provider/clinical‐care‐guidelines. 39. Deutsche Adipositas‐Gesellschaft (DAG). Adipositas ‐ Prävention und
Published December 2004. Updated May, 2014. Accessed April 18, Therapie, Version 2.0. http://www.awmf.org/leitlinien/detail/ll/050‐
2016. 001.html. Published 2007. Updated April 30, 2014. Accessed March
20, 2019.
27. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for
the perioperative nutritional, metabolic, and nonsurgical support of the 40. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological manage-
bariatric surgery patient—2013 update: cosponsored by American ment of obesity: an Endocrine Society clinical practice guideline. J Clin
Association of Clinical Endocrinologists, the Obesity Society, and Endocrinol Metab. 2015;100(2):342‐362.
American Society for Metabolic & Bariatric Surgery. Endocr Pract. 41. Gargallo Fernandez Manuel M, Breton Lesmes I, Basulto Marset J,
2013;19:337‐372. Quiles Izquierdo J, Formiguera Sala X, Salas‐Salvado J. Evidence‐based
28. Gonzalez‐Campoy JM, St Jeor ST, Castorino K, et al. Clinical practice nutritional recommendations for the prevention and treatment of
guidelines for healthy eating for the prevention and treatment of met- overweight and obesity in adults (FESNAD‐SEEDO consensus docu-
abolic and endocrine diseases in adults: cosponsored by the American ment). The role of diet in obesity treatment (III/III). Nutr Hosp.
Association of Clinical Endocrinologists/the American College of Endo- 2012;27(3):833‐864.
crinology and the Obesity Society. Endocr Pract. 2013;19(Suppl 3): 42. Gargallo Fernandez M, Basulto Marset J, Breton Lesmes I, Quiles
1‐82. Izquierdo J, Formiguera Sala X, Salas‐Salvado J. Evidence‐based nutri-
29. Gonzalez‐Campoy JM, St Jeor ST, Castorino K, et al. Clinical practice tional recommendations for the prevention and treatment of
guidelines for healthy eating for the prevention and treatment of met- overweight and obesity in adults (FESNAD‐SEEDO consensus docu-
abolic and endocrine diseases in adults: cosponsored by the American ment). Methodology and executive summary (I/III). Nutr Hosp.
Association of Clinical Endocrinologists/the American College of Endo- 2012;27(3):789‐799.
crinology and the Obesity Society: executive summary. Endocr Pract. 43. Fitch A, Everling L, Fox C, et al. Institute for Clinical Systems Improve-
2013;19:875‐887. ment. Prevention and management of obesity for adults. https://www.
30. Millen BE, Wolongevicz DM, Nonas CA, Lichtenstein AH. 2013 icsi.org/guidelines/. Published December, 2004. Updated May, 2013.
American Heart Association/American College of Cardiology/the Obe- Accessed April 18, 2016.
sity Society Guideline for the Management of Overweight and Obesity 44. Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary European Guide-
in Adults: implications and new opportunities for registered dietitian lines on metabolic and bariatric surgery. Obes Facts. 2013;6(5):449‐468.
nutritionists. J Acad Nutr Diet. 2014;114(11):1730‐1735.
45. Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary European guide-
31. American College of Cardiology/American Heart Association Task lines on metabolic and bariatric surgery. Obes Surg. 2014;24(1):42‐55.
Force on Practice Guidelines—Obesity Expert Panel, Jensen MD, Ryan 46. National Health and Medical Research Council. Clinical practice guide-
DH, et al. Executive summary: Guidelines (2013) for the management lines for the management of overweight and obesity in adults,
of overweight and obesity in adults. Obesity (Silver Spring, Md). adolescents and children in Australia. https://www.nhmrc.gov.au/
2014;22(Suppl 2):S5‐S39. about‐us/publications/clinical‐practice‐guidelines‐management‐over-
32. American College of Cardiology/American Heart Association Task weight‐and‐obesity#block‐views‐block‐file‐attachments‐content‐
Force on Practice Guidelines—Obesity Expert Panel. Guidelines block‐1. Published October, 2013. Updated October, 2013. Accessed
(2013) for managing overweight and obesity in adults. Preface to the March 20, 2019.
Expert Panel Report. Obesity (Silver Spring, Md). 2014;22(Suppl 2):S40. 47. National Institute for Health and Care Excellence (NICE). Obesity:
33. American Heart Association, American College of Cardiology, Obesity identification, assessment and management (CG189). https://www.
Society. Reprint: 2013 AHA/ACC/TOS Guideline for the Management nice.org.uk/guidance/cg189. Published November 27, 2014. Updated
of Overweight and Obesity in Adults. J Am Pharm Assoc. 2014;63: November 27, 2014. Accessed March 20, 2019.
2985‐3023. 48. Stegenga H, Haines A, Jones K, Wilding J. Identification, assessment,
34. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guide- and management of overweight and obesity: summary of updated
line for the management of overweight and obesity in adults: a report NICE guidance. BMJ (Clinical research ed). 2014;349:g6608.
of the American College of Cardiology/American Heart Association 49. National Institute for Health and Care Excellence (NICE). Weight man-
Task Force on Practice Guidelines and The Obesity Society. J Am Coll agement: lifestyle services for overweight or obese adults (PH53).
Cardiol. 2014;63(25):2985‐3023. https://www.nice.org.uk/guidance/ph 53. Published May 28, 2014.
35. American College of Cardiology/American Heart Association Task Updated May 28, 2014. Accessed March 20, 2019.
Force on Practice Guidelines—Obesity Expert Panel. Expert Panel 50. National Institute for Health and Care Excellence (NICE). Obesity pre-
Report: Guidelines (2013) for the management of overweight and obe- vention (CG43). https://www.nice.org.uk/guidance/cg43. Published
sity in adults. Obesity (Silver Spring, Md). 2014;22(Suppl 2):S41‐S410. December 13, 2006. Updated March, 2015. Accessed March 20, 2019.
36. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guide- 51. National Clinical Guideline C. National Institute for Health and Clinical
line for the management of overweight and obesity in adults: a report Excellence: guidance. Obesity: Identification, Assessment and Manage-
of the American College of Cardiology/American Heart Association ment of Overweight and Obesity in Children, Young People and Adults:
Task Force on Practice Guidelines and The Obesity Society. Circulation. Partial Update of CG43. London: National Institute for Health and Care
2014;129(25 suppl 2):S102‐S138. Excellence (UK); 2014.
37. Academy of Nutrition and Dietetics. Adult weight management 52. Department of Defense, Department of Veterans Affairs, Veterans
evidence‐based nutrition practice guideline. https://www.andeal.org/ Health Administration. Va/Dod Clinical Practice Guideline For Screen-
topic.cfm?menu = 5276. Published May, 2006. Updated October, ing And Management Of Overweight And Obesity. https://www.
2014. Accessed March 20, 2019. healthquality.va.gov/guidelines/CD/obesity/
1230 SEMLITSCH ET AL.

CPGManagementOfOverweightAndObesityFINAL041315.pdf. Pub- 63. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe's
lished April 18, 2014. Updated April 18, 2014. Accessed March 20, strong primary care systems are linked to better population health
2019. but also to higher health spending. Health Aff (Project Hope).
53. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role 2013;32(4):686‐694.
in evidence‐based medicine. Plast Reconstr Surg. 2011;128(1):305‐310. 64. Stigler F, Jeitler K, SemlitschT, et al. (Be)‐Handlungspfad Übergewicht &
54. Montesi L, El Ghoch M, Brodosi L, Calugi S, Marchesini G, Dalle Grave Adipositas auf Primärversorgungsebene. http://www.hauptverband.at/
R. Long‐term weight loss maintenance for obesity: a multidisciplinary cdscontent/load?contentid = 10008.636045&version = 1486475079.
approach. Diabetes Metab Syndr Obes. 2016;9:37‐46. Published November, 2016. Updated December 5, 2016. Accessed
December 17, 2018.
55. Fernandez‐Ruiz VE, Armero‐Barranco D, Paniagua‐Urbano JA,
Sole‐Agusti M, Ruiz‐Sanchez A, Gomez‐Marin J. Short‐medium‐long‐ 65. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for
term efficacy of interdisciplinary intervention against overweight and the management of arterial hypertension: the Task Force for the man-
obesity: Randomized controlled clinical trial. Int J Nurs Pract. agement of arterial hypertension of the European Society of
2018;24(6):e12690. Cardiology and the European Society of Hypertension: The Task Force
for the management of arterial hypertension of the European Society
56. Cochrane AJ, Dick B, King NA, Hills AP, Kavanagh DJ. Developing
of Cardiology and the European Society of Hypertension. J Hypertens.
dimensions for a multicomponent multidisciplinary approach to obesity
2018;36:1953‐2041.
management: a qualitative study. BMC Public Health. 2017;17(1):814.
66. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/
57. Sturgiss EA, Elmitt N, Haesler E, van Weel C, Douglas KA. Role of the
ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the
family doctor in the management of adults with obesity: a scoping
prevention, detection, evaluation, and management of high blood pres-
review. BMJ Open. 2018;8(2):e019367.
sure in adults: executive summary: a Report of the American College of
58. Ard J. Obesity in the US: what is the best role for primary care? BMJ Cardiology/American Heart Association Task Force on Clinical Practice
(Clinical research ed). 2015;350:g7846. Guidelines. J Am Coll Cardiol. 2018;71(19):2199‐2269.
59. Astbury NM, Aveyard P, Nickless A, et al. Doctor referral of over-
weight people to low energy total diet replacement Treatment
(DROPLET): pragmatic randomised controlled trial. BMJ (Clinical SUPPORTING INFORMATION
research ed). 2018;362:k3760. Additional supporting information may be found online in the
60. Carvajal R, Wadden TA, Tsai AG, Peck K, Moran CH. Managing obesity Supporting Information section at the end of the article.
in primary care practice: a narrative review. Ann N Y Acad Sci.
2013;1281(1):191‐206.
61. LeBlanc E, Patnode C, Webber E, Redmond N, Rushkin M, O'Connor E.
Behavioral and pharmacotherapy weight loss interventions to prevent How to cite this article: Semlitsch T, Stigler FL, Jeitler K,
obesity‐related morbidity and mortality in adults: an updated system- Horvath K, Siebenhofer A. Management of overweight and
atic review for the U.S. preventive services task force. Evidence
obesity in primary care—A systematic overview of interna-
Synthesis No 168. Agency for Healthcare Research and Quality: Rock-
ville, MD 2018. tional evidence‐based guidelines. Obesity Reviews.

62. Starfield B, Shi L, Macinko J. Contribution of primary care to health 2019;20:1218–1230. https://doi.org/10.1111/obr.12889
systems and health. Milbank Q. 2005;83(3):457‐502.