Obesity

GUIDELINES (2013) FOR MANAGING

OVERWEIGHT AND OBESITY IN ADULTS

Full Report including the Executive Summary—published by

The Obesity Society with the ACC/AHA Task Force on Practice
Guidelines and based on a Systematic Evidence Review
supported by the NHLBI

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association,
American Society for Nutrition, American Society for Parenteral and Enteral Nutrition, American Society for Preventive
Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive
Cardiovascular Nurses Association, The Endocrine Society, and WomenHeart: The National Coalition for Women With
Heart Disease

This report was derived from the “2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in
Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline
and The Obesity Society” and “Managing Overweight and Obesity in Adults: Systematic Evidence Review from the
Obesity Expert Panel, 2013” which were both developed jointly by the AHA, ACC, TOS and the NHLBI.

To cite this document: Jensen MD, Ryan DH, Donato KA, Apovian CM, Ard JD, Comuzzie AG, Hu FB, Hubbard VS,
Jakicic JM, Kushner RF, Loria CM, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM,
Yanovski SZ. Guidelines (2013) for managing overweight and obesity in adults. Obesity 2014;22(S2):S1-S410.

C 2014 The Obesity Society

V
Obesity
Volume 22 / Issue S2
July 2014

Overweight and Obesity Expert Panel

Co-Chairs
Michael D. Jensen, MD Donna H. Ryan, MD
Mayo Clinic Endocrine Research Unit Pennington Biomedical Research Center
Rochester, MN Baton Rouge, LA

Members
Karen A. Donato, SM* Barbara E. Millen, Dr. PH, RD, FADA
Division for the Application of Research Discoveries Boston University School of Medicine
National Heart, Lung, and Blood Institute Boston Nutrition Foundation, Inc.
Bethesda, MD Millennium Prevention, Inc.
Boston, MA
Caroline M. Apovian, MD, FACP, FACN
Boston University School of Medicine Cathy Nonas, MS, RD
Boston Medical Center New York City Department of Health
Boston, MA and Mental Hygiene
New York, NY
Jamy D. Ard, MD
Wake Forest University Baptist Medical Center F. Xavier Pi-Sunyer, MD, MPH
Winston-Salem, NC St. Luke’s-Roosevelt Hospital Center
Columbia University
Anthony G. Comuzzie, PhD New York, NY
Southwest Foundation for Biomedical Research
Southwest National Primate Research Center June Stevens, MS, PhD
San Antonio, TX University of North Carolina at Chapel Hill
Chapel Hill, NC
Frank B. Hu, MD, PhD, MPH
Harvard University School of Public Health Victor J. Stevens, PhD
Boston, MA Kaiser Permanente Center for Health Research
Portland, OR
Van S. Hubbard, MD, PhD*
Division of Nutrition Thomas A. Wadden, PhD
Research Coordination University of Pennsylvania School of Medicine
National Institutes of Health Philadelphia, PA
Bethesda, MD
Bruce M. Wolfe, MD, FACS
John M. Jakicic, PhD Oregon Health and Science University
University of Pittsburgh Portland, OR
Pittsburgh, PA
Susan Z. Yanovski, MD*
Robert F. Kushner, MD Division of Digestive Diseases and Nutrition
Northwestern University National Institute of Diabetes and Digestive and Kidney Diseases
Feinberg School of Medicine Bethesda, MD
Chicago, IL

Catherine M. Loria, PhD*

Division of Cardiovascular Sciences
National Heart, Lung, and Blood Institute
Bethesda, MD

*ex officio members

 Obesity
Volume 22 / Issue S2
July 2014

Methodology Team
RTI International Science Applications International
Michael G. Trisolini, PhD, MBA Corporation (SAIC)
Harmon S. Jordan, ScD Karima A. Kendall, PhD
Linda J. Lux Roycelynn Mentor-Marcel, PhD, MPH

Laura C. Morgan, MA Janusz Wnek, PhD

Staff
Denise Simons-Morton, MD, PhD Kathryn Y. McMurry, MS
Division for the Application of Research Discoveries Division for the Application of Research Discoveries
National Heart, Lung, and Blood Institute National Heart, Lung, and Blood Institute
Bethesda, MD
Eva Erber, MS
Melinda Kelley, PhD University of North Carolina at Chapel Hill
Division for the Application of Research Discoveries
National Heart, Lung, and Blood Institute Randi Henderson, BA
Palladian Partners, Inc.
Melissa McGowan, MHS, CHES
Division for the Application of Research Discoveries Mary E. Lavelle
National Heart, Lung, and Blood Institute American Institutes for Research

ACC/AHA Task Force Members (contributors to the Executive Summary)

Jeffrey L. Anderson, MD, FACC, FAHA, Chair E. Magnus Ohman, MD, FACC
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect Susan J. Pressler, PhD, RN, FAAN, FAHA
Nancy M. Albert, PhD, CCNS, CCRN, FAHA Frank W. Sellke, MD, FACC, FAHA
Biykem Bozkurt, MD, PhD, FACC, FAHA Win-Kuang Shen, MD, FACC, FAHA
Ralph G. Brindis, MD, MPH, MACC
Lesley H. Curtis, PhD, FAHA Subcommittee on Prevention Guidelines
David DeMets, PhD Sidney C. Smith, Jr, MD, FACC, FAHA, Chair
Judith S. Hochman, MD, FACC, FAHA Gordon F. Tomaselli, MD, FACC, FAHA, Co-Chair
Richard J. Kovacs, MD, FACC, FAHA

Martica Heaner, PhD

The Obesity Society
Editor for Compilation of Guidelines (2013) for Managing Overweight and Obesity in Adults
Obesity
Volume 22 / Issue S2
July 2014

Contents

OBESITY GUIDELINES—PART 1
Preface to the Full Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1
Evolution of the 2013 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1
Key Messages for Overweight and Obesity from The Obesity Society . . . . . . . . . . . . . . . . . . . . . S2
Who needs to lose weight? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2
For individuals who can benefit from weight loss, what is the optimum level of weight loss? . . . . . . . . . S2
Which diet is the most effective for weight loss? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2
Is diet or exercise the best way to lose weight?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2
How can weight loss be maintained? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2
Who should receive bariatric surgery?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S3
References for Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S3

OBESITY GUIDELINES—PART 2
Preface to the Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S4
Executive Summary: Guidelines (2013) for the Management of Overweight and Obesity in Adults
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S5
1. Introduction/Scope of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S6
1.1. Rationale for Updating Obesity Clinical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S7
1.2. CQ-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S7
1.3. Organization of the Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S9
1.4. Document Review and Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S8
2. Obesity Recommendations and Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S9
2.1. Summary of Evidence-Based Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S9
2.2. Chronic Disease Management Model for Primary Care of Patients With Overweight
and Obesity—Treatment Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S10
3. CQs and Corresponding ESs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18
3.1. CQ1: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18
3.1.1. Weight Loss and Risk of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S18
3.1.2. Weight Loss and Impact on Cholesterol/Lipid Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . S19
3.1.3. Weight Loss and Hypertension Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19
3.2. CQ2: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19
3.2.1. Current BMI Cutpoints and CVD-Related Risk and All-Cause Mortality . . . . . . . . . . . . . . . S20
3.2.2. Areas of Insufficient Evidence With Regard to Cutpoints for BMI
and for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S20
3.3. CQ3: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21
3.3.1. Overall Dietary Intervention and Composition—Creating Reduced Dietary
Energy Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21
3.3.2. Overall Dietary Intervention and Composition—Pattern of Weight Loss Over
Time With Dietary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21
3.3.3. Low-Fat Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21
3.3.4. Higher-Protein Approaches (25% to 30% of Energy) . . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.3.5. Low-Carbohydrate Approaches (<30 g/d) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22

(Continued)
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Volume 22 / Issue S2
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Contents

3.3.6. Complex Versus Simple Carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22

3.3.7. Glycemic Load Dietary Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.3.8. Dietary Patterns (Mediterranean Style, Vegetarian, and Other Dietary
Pattern Approaches). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.3.9. Meal Replacement and Adding Foods to Liquid Diets. . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.3.10. Very-Low-Calorie Diet Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.4. CQ4: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22
3.4.1. Description of the Diet, Physical Activity, and Behavior Therapy Components
in High-Intensity, On-Site Lifestyle Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S23
3.4.2. Comprehensive Interventions Compared With Usual Care, Minimal Care,
or No-Treatment Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S23
3.4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions
in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S23
3.4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions
in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S23
3.4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within
a Primary Care Practice Setting Compared With Usual Care . . . . . . . . . . . . . . . . . . . . . . S23
3.4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions
in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24
3.4.7. Efficacy/Effectiveness of Very-Low-Calorie Diets, as Used as Part of
a Comprehensive Lifestyle Intervention, in Achieving Weight Loss . . . . . . . . . . . . . . . . . . S24
3.4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining
Lost Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24
3.4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss:
Intervention Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24
3.4.10. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss
or Weight Loss Maintenance: Individual Versus Group Treatment . . . . . . . . . . . . . . . . . . S24
3.4.11. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss
or Weight Loss Maintenance: On-Site Versus Electronically Delivered Interventions . . . . . . S24
3.5. CQ5: Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24
3.5.1. Component 1: Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S25
3.5.2. Component 2: Predictors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S26
3.5.3. Component 3: Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S26
3.5.3.1. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27
3.5.3.2. ROUX-EN-Y GASTRIC BYPASS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27
3.5.3.3. BILIOPANCREATIC DIVERSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27
3.5.3.4. LAPAROSCOPIC SLEEVE GASTRECTOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27
4. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . ..................... S27
4.1. CQ1 (Benefits of Weight Loss) . . . . . . . . . . . . . . . . . . . . . . . . . ...................... S27
4.2. CQ2 (Risks of Overweight and Obesity) . . . . . . . . . . . . . . . . . . . ...................... S28
4.3. CQ3 (Dietary Interventions for Weight Loss) . . . . . . . . . . . . . . . . ...................... S28
4.4. CQ4 (Lifestyle Interventions for Weight Loss) . . . . . . . . . . . . . . . ...................... S28
4.5. CQ5 (Surgical Procedures for Weight Loss) . . . . . . . . . . . . . . . . ...................... S28

(Continued)
Obesity
Volume 22 / Issue S2
July 2014

Contents

References for Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S29

Appendix 1 for Part 2. Author Relationships With Industry and Other Entities (Relevant) . . . . . . . S33
Appendix 2 for Part 2. Expert Reviewer Relationships With Industry and Other Entities . . . . . . . . S38
Appendix 3 for Part 2. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S39

OBESITY GUIDELINES—PART 3
Preface to the Expert Panel Report (comprehensive version which includes Systematic Evidence
Review, Evidence Statements, and Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S40
Expert Panel Report: Guidelines (2013) for the Management of Overweight and Obesity in Adults . . . S41
SECTION 1: Background and Description of the NHLBI Cardiovascular
Risk Reduction Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41
A. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41
B. Overview of the Evidence-Based Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S41
C. Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43
D. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43
E. Critical Questions on Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S43
i. Critical Questions on Weight-Related Health Risks and Benefits of Weight Loss . . . . . . . . . . . . . . S43
ii. Critical Questions on Treatments for Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . S44
F. Challenges of Achieving Weight Loss in Primary Care Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . S44
SECTION 2: Process and Methods Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45
A. Overview of Evidence-Based Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S45
i. System for Grading the Body of Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46
ii. Peer-Review Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46
B. Critical Question-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S47
i. Critical Questions on Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S47
SECTION 3: Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
i. By Population Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
ii. By Amount of Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
iii. By Weight Loss Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S48
C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S48
D. Methods for Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49
E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S51
i. Weight Loss and Risk for Diabetes: Spreadsheets 1.1.-1.4b. . . . . . . . . . . . . . . . . . . . . . . . . . . . S51
F. Weight Loss and Impact on Cholesterol/Lipid Profile—Spreadsheet 1.5a-1.5c. . . . . . . . . . . . . . . . . . . S54
G. Weight Loss and Hypertension Risk—Spreadsheets 1.6a-f.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S56
H. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S57
SECTION 4: Critical Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58
A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58
i. Subgroup Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58

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Contents

B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S58

C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S58
D. Methods for Critical Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S60
E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S63
i. BMI Cutpoints and CVD-Related Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S63
ii. Waist Circumference Cutpoints and CVD-Related Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S67
F. Recommedations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S68
G. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S69
SECTION 5: Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70
A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70
B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S70
C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S70
D. Methods for Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71
E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S74
F. Overall Dietary Intervention and Composition—Summary Table 3.1 . . . . . . . . . . . . . . . . . . . . . . . . . S74
i. Creating Reduced Dietary Energy Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S74
ii. Diets of Differing Forms and Structures (Macronutrient Content, Carbohydrate and
Fat Quality, Nutrient Density, Amount of Energy Deficit, Dietary Pattern) or Other Dietary
Weight Loss Strategies (e.g., Meal Timing, Portion-Controlled Meal Replacements) . . . . . . . . . . . . S75
iii. Pattern of Weight Loss Over Time With Dietary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . S76
G. Low-Fat Approaches—Summary Table 3.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S77
H. Higher Protein (25 to 30 Percent of Energy) Approaches—Summary Table 3.3 . . . . . . . . . . . . . . . . . S77
I. Low-Carbohydrate (30g/Day) Approaches—Summary Table 3.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . S78
J. Complex Versus Simple Carbohydrates—Summary Table 3.5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79
K. Glycemic Load Dietary Approaches—Summary Table 3.6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79
L. Dietary Pattern (Mediterranean Style and Vegetarian and Other Dietary Pattern)
Approaches—Summary Table 3.7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S79
M. Meal Replacements and Adding Foods to Liquid Diets—Summary Table 3.8. . . . . . . . . . . . . . . . . . . S80
N. Very Low-Calorie Diet Approaches—Summary Table 3.9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S81
O. Recommendations—Dietary Strategies for Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S81
P. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82
SECTION 6: Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82
A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82
B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S82
C. Introduction and Rationale for Question and Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . S83
i. A Dictionary of Lifestyle Intervention Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83
ii. Comprehensive Lifestyle Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83
iii. Intervention Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83
iv. Intervention Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S83
v. Intervention Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84
vi. Individual Versus Group Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84
vii. Trained Interventionist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84
viii. Trials of Weight Loss Induction Versus Maintenance of Lost Weight . . . . . . . . . . . . . . . . . . . . . . S84

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D. Methods for Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S86

E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88
i. Introduction of Evidence Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88
F. Diet, Physical Activity, and Behavior Therapy Components in High-Intensity, Onsite Lifestyle
Interventions—Summary Tables 4.1a-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S88
G. Comprehensive Interventions Compared With Usual Care, Minimal Care, or No-Treatment
Control—Summary Tables 4.2a-d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S89
H. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving
Weight Loss—Summary Tables 4.3a-n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S91
I. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions in
Achieving Weight Loss—Summary Tables 4.4a-b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S91
J. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within a
Primary Care Practice Setting Compared With Usual Care—Summary Tables 4.5a-f . . . . . . . . . . . . . . S92
K. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions
in Achieving Weight Loss—Summary Table 4.6a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S92
L. Efficacy/Effectiveness of Very Low-Calorie Diets Used as Part of a Comprehensive Lifestyle
Intervention in Achieving Weight Loss—Summary Tables 4.7a-c . . . . . . . . . . . . . . . . . . . . . . . . . . . S93
M. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining Lost Weight—
Summary Tables 4.8a-e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S93
N. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss: Intervention
Intensity—Summary Tables 4.9a-f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S94
O. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss
Maintenance: Individual Versus Group Treatment—Summary Tables 4.1a-c . . . . . . . . . . . . . . . . . . . S95
P. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight
Loss Maintenance: Onsite Versus Electronically Delivered Interventions—
Summary Tables 4.10a-j . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S96
Q. Recommendation 4a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S96
R. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
SECTION 7: Critical Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
A. Statement of the Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
i. Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
ii. Predictors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S98
iii. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S99
B. Selection of the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S99
C. Introduction and Rationale for Question and the Inclusion/Exclusion Criteria . . . . . . . . . . . . . . . . . . . S99
i. Bariatric Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100
ii. Currently Used Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100
iii. Investigational Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S104
D. Methods for Critical Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S104
E. Evidence Statements and Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S106
i. Component 1: Efficacy—Summary Table 5.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S106
ii. Component 2: Predictors—Patient Characteristics—Summary Table 5.2 and
Types of Surgery—Summary Table 5.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S109

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iii. Component 3: Complications—Summary Table 5.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S110

iv. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S113
F. Recommendations—Bariatric Surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S113
G. Gaps in Evidence and Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S115
References for Part 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S115

APPENDIXES
Appendix A: Detailed Methods Applying to All Critical Questions . . . . . . . . . . .............. S125
Appendix B: Question-Specific Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. S150
Appendix C: Spreadsheets and Summary Tables . . . . . . . . . . . . . . . . . . . . . .............. S206
Critical Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... S206
Critical Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... S223
Critical Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... S237
Critical Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... S287
Critical Question 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... S356
Appendix D: Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . .............. S408
Appendix E: Names of Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. S409

LIST OF TABLES
Table 1. Evidence Quality Grading System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S46
Table 2. Criteria for Selection of Publications for CQ1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S49
Table 3. Criteria for Selection of Publications for CQ2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S59
Table 4. Criteria for Selection of Publications for CQ3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S71
Table 5. Criteria for Selection of Publications for CQ4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S84
Table 6. Criteria for Selection of Publications for CQ5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S100
Table A-1. Quality Assessment Tool for Controlled Intervention Studies . . . . . . . . . . . . . . . . . . . . . . . . S128
Table A-2. Quality Assessment Tool for Systematic Reviews and Meta-Analyses. . . . . . . . . . . . . . . . . . S131
Table A-3. Quality Assessment Tool for Cohort and Cross-Sectional Studies. . . . . . . . . . . . . . . . . . . . . S134
Table A-4. Quality Assessment Tool for Case-Control Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S138
Table A-5. Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group . . . . . . . . S142
Table A-6. Quality Assessment Tool for Case Series Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S145
Table A-7. Evidence Quality Grading System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S147
Table B-1. Examples of Simple Queries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S150
Table B-2. Attributes, Their Values, and Explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S151
Table B-3. Common Macro Queries Used in Search Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S151
Table B-4. Criteria for Selection of Publications for CQ1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S155
Table B-5. Criteria for Selection of Publications for CQ2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S158
Table B-6. Criteria for Selection of Publications for CQ3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S163
Table B-7. Criteria for Selection of Publications for CQ4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S168
Table B-8. Criteria for Selection of Publications for CQ5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S171
Table B-9. CQ1 Studies Rated Fair or Good. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S174

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Table B-10. CQ1 Studies Rated as Poor With Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S176

Table B-11. CQ2 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S178
Table B-12. CQ2 Studies Rated as Poor With Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S179
Table B-13. CQ3 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S181
Table B-14. CQ3 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S182
Table B-15. CQ4 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S188
Table B-16. CQ4 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S192
Table B-17. CQ5 Studies Rated Fair or Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S200
Table B-18. CQ5 Studies Rated Poor With Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S202

LIST OF SPREADSHEET TABLES

Spreadsheet 1.1. Effect of Weight Loss From Lifestyle Interventions in Patients With Diabetes
on Blood Glucose and HbA1c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... S206
Spreadsheet 1.2. Effect of Weight Loss From Lifestyle Interventions in Persons at Risk
for Developing Diabetes (Prediabetes) on Risk for Converting to Type 2 Diabetes . . . . . . . . . . ...... S207
Spreadsheet 1.3. Effect of Intentional Weight Loss From Lifestyle Interventions in Patients
With or Without Diabetes on Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... S208
Spreadsheet 1.4A. Effect of Weight Loss From Orlistat Interventions in Patients With Diabetes
on Blood Glucose and HbA1c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... S209
Spreadsheet 1.4B. Effect of Weight Loss From Orlistat Interventions in Patients at Risk for
Diabetes on Blood Glucose and HbA1c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S209
Spreadsheet 1.5A. Effect of Weight Loss on Serum Lipids: Lifestyle Interventions . . . . . . . . . . . . . . . . S210
Spreadsheet 1.5B. Effect of Weight Loss on Serum Lipids: Orlistat Interventions . . . . . . . . . . . . . . . . . S213
Spreadsheet 1.5C. Effect of Weight Loss on Serum Lipids: Diabetes Subjects . . . . . . . . . . . . . . . . . . . S215
Spreadsheet 1.6A. Weight Loss and Hypertension Risk: Orlistat Trials, All Subjects . . . . . . . . . . . . . . . S217
Spreadsheet 1.6B. Weight Loss and Hypertension Risk: Orlistat Trials, Diabetes Subjects . . . . . . . . . . . S219
Spreadsheet 1.6C. Weight Loss and Hypertension Risk: Hypertension Subjects . . . . . . . . . . . . . . . . . . S219
Spreadsheet 1.6D. Weight Loss and Hypertension Risk: Lifestyles Trials, All Subjects . . . . . . . . . . . . . . S220
Spreadsheet 1.6E. Weight Loss and Hypertension Risk: Lifestyles Trials, Diabetes Subjects . . . . . . . . . . S221
Spreadsheet 1.6F. Weight Loss and Hypertension Risk: Lifestyles Trials, Hypertension Subjects . . . . . . . S222
Spreadsheet 2.1. Study Descriptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S223
Spreadsheet 2.2.1A. Combined Fatal and Nonfatal CHD—Results for BMI . . . . . . . . . . . . . . . . . . . . . . S227
Spreadsheet 2.2.1B. Fatal CHD—Results for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S228
Spreadsheet 2.2.2A. Combined Fatal and Nonfatal Stroke—Results for BMI . . . . . . . . . . . . . . . . . . . . S228
Spreadsheet 2.2.2B. Fatal Stroke—Results for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S229
Spreadsheet 2.2.3A. Combined Fatal and Nonfatal CVD—Results for BMI . . . . . . . . . . . . . . . . . . . . . . S230
Spreadsheet 2.2.3B. Fatal CVD—Results for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S230
Spreadsheet 2.2.4. Incident Diabetes—Results for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S231
Spreadsheet 2.2.5. Overall Mortality—Results for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S232
Spreadsheet 2.3.1. Combined Fatal and Nonfatal CHD—Results for Waist Circumference . . . . . . . . . . . S234
Spreadsheet 2.3.2. Combined Fatal and Nonfatal Stroke—Results for Waist Circumference . . . . . . . . . . S234
Spreadsheet 2.3.3. Combined Fatal and Nonfatal CVD—Results for Waist Circumference . . . . . . . . . . . S235

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Spreadsheet 2.3.4. Overall Mortality—Results for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . S235

Spreadsheet 2.3.5. Incident Diabetes—Results for Waist Circumference . . . . . . . . . . . . . . . . . . . . . . . S236

LIST OF SUMMARY TABLES

Summary Table 3.1. Overall Dietary Intervention and Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . S237
Summary Table 3.2. Low-Fat Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S251
Summary Table 3.3. Higher (25-30% of Energy) Protein Approaches . . . . . . . . . . . . . . . . . . . . . . . . . S259
Summary Table 3.4. Low Carbohydrate Approaches (<30 g/day for at least a period). . . . . . . . . . . . . . S269
Summary Table 3.5. Complex Versus Simple Carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S272
Summary Table 3.6. Glycemic Load Dietary Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S273
Summary Table 3.7. CQ3—Dietary Patterns (Mediterranean Style and Vegetarian and
Other Dietary Pattern Approaches) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. S275
Summary Table 3.8. Meal Replacements and Adding Foods to Liquid Diets. . . . . . . . ............. S282
Summary Table 3.9. Very Low-Calorie-Diet (VLCD) Approaches . . . . . . . . . . . . . . . . ............. S284
Summary Table 4.1. Diet, Physical Activity, and Behavior Therapy Components in High-Intensity,
Onsite Lifestyle Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S287
Summary Table 4.1A. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . ... S287
Summary Table 4.1B. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at Greater Than 6 Months as First Time Period Reporting. . . . ... S291
Summary Table 4.1C. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at Greater Than 12 Months as First Time Period Reporting . . . ... S293
Summary Table 4.2. Evidence for the Comprehensive Interventions Compared With Usual
Care, Minimal Care, or No-Treatment Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S294
Summary Table 4.2A. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . ... S294
Summary Table 4.2B. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at Greater Than 6 Months as First Time Period Reporting. . . . ... S298
Summary Table 4.2C. Weight Loss Trials Compared With Usual Care, Minimal Care, or No Care
Control Interventions: Outcome Data at Greater Than 12 Months as First Time Period Reporting . . . ... S300
Summary Table 4.2D. Comprehensive Interventions Compared to Other Comprehensive Intervention
That Varied the Physical Activity or Behavior Therapy Component: Outcome Data at 6 Months or
Less as the First Time Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S301
Summary Table 4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive
Interventions in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S304
Summary Table 4.3A. Compared With Usual Care, Minimal Control, or No Intervention
(Includes Self-Directed): Electronic Text Messaging—Outcome Data at 6 Months or Less
as First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S304
Summary Table 4.3B. Compared With Usual Care, Minimal Control, or No Intervention
(Includes Self-Directed): Electronic Internet—Outcome Data at 6 Months or Less as First
Time Period Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S304

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Volume 22 / Issue S2
July 2014

Contents

Summary Table 4.3C. Compared With Usual Care, Minimal Control, or No Intervention
(Includes Self-Directed): Electronic Internet—Outcome Data at Greater Than 6 Months
as First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S306
Summary Table 4.3D. Compared With Usual Care, Minimal Control, or No Intervention
(Includes Self-Directed): Electronic Internet—Outcome Data at Greater Than 12 Months
as First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S306
Summary Table 4.3E. Compared with Other Comprehensive Electronic Interventions:
Electronic Internet—Outcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . . . . . S306
Summary Table 4.3F. Compared with Other Comprehensive Electronic Interventions: Electronic
Internet—Outcome Data at Greater Than 6 Months as First Time Period Reporting. . . . . . . . . . . . . . . S307
Summary Table 4.3G. Compared with Other Comprehensive Electronic Interventions: Electronic
Internet—Outcome Data at Greater Than 12 Months as First Time Period Reporting . . . . . . . . . . . . . . S308
Summary Table 4.3H. Compared With Other Comprehensive Interventions (Includes Onsite
and/or Electronic): Outcome Data at 6 Months or Less as First Time Period Reporting . . . . . . . . . . . . S308
Summary Table 4.3I. Compared With Other Comprehensive Interventions (Includes Onsite and/or
Electronic): Outcome Data at Greater Than 6 Months as First Time Period Reporting . . . . . . . . . . . . . S310
Summary Table 4.3J. Compared With Other Comprehensive Interventions (Includes Onsite and/or
Electronic): Outcome Data at Greater Than 12 Months as First Time Period Reporting. . . . . . . . . . . . . S310
Summary Table 4.3K. Evidence of Weight Loss in Comprehensive Electronic (Interactive Equipment)
Interventions: Compared With Other Comprehensive Intervention (Internet or Onsite)—Weight Loss
Outcome Data at 4 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S310
Summary Table 4.3L. Evidence of Weight Maintenance in Comprehensive Electronic
(Interactive Technology with Phone Feedback) Interventions: Comprehensive Electronic
Intervention Compared With Personal Contact or Self-Directed Control—Weight Loss Outcome
Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S311
Summary Table 4.3M. Evidence of Weight Maintenance in Comprehensive Electronic (Internet)
Interventions: Comprehensive Electronic Intervention Compared With Personal Contact or
Self-Directed Control—Weight Loss Outcome Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . S313
Summary Table 4.3N. Evidence of Weight Maintenance in Comprehensive Electronic (Internet)
Interventions: Comprehensive Electronic Intervention Compared With Personal Contact or
Self-Directed Control—Weight Loss Outcome Data at 12 Months or Greater . . . . . . . . . . . . . . . . . . . S314
Summary Table 4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle
Interventions for Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S315
Summary Table 4.4A. Trials That Compared Onsite vs. Telephone Delivered Programs for Inducing
Weight Loss: Outcome Data at 6 Months Or Less as First Time Period Reporting . . . . . . . . . . . . . . . . S315
Summary Table 4.4B. Trials That Compared Onsite vs. Telephone Delivered Programs for Inducing
Weight Loss: Outcome Data at 12 Months or Greater as First Time Period Reporting . . . . . . . . . . . . . S316
Summary Table 4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients
Within a Primary Care Practice Compared With Usual Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S317
Summary Table 4.5A. Weight Loss Trials: Outcome Data at 6 Months or Less as First Time
Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S317
Summary Table 4.5B. Weight Loss Trials: Outcome Data at Greater Than 6 Months as First Time Period
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S318

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Obesity
Volume 22 / Issue S2
July 2014

Contents

Summary Table 4.5C. Weight Loss Trials: Outcome Data at Greater Than 12 Months as First Time
Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S319
Summary Table 4.5D. Weight Maintenance Trials: Outcome Data at 6 Months or Less as First Time
Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S319
Summary Table 4.5E. Weight Maintenance Trials: Outcome Data at Greater Than 6 Months as First
Time Period Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S320
Summary Table 4.5F. Weight Maintenance Trials: Outcome Data at Greater Than 12 months as First
Time Period Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S320
Summary Table 4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle
Interventions in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S321
Summary Table 4.6A. Compared With Usual Care, Minimal Control, or No Intervention . . . . . . . . . . . .. S321
Summary Table 4.7. Efficacy/Effectiveness of Very Low-Calorie Diets, as Used as Part of a
Comprehensive Lifestyle Intervention in Achieving Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . .. S323
Summary Table 4.7A. Evidence from Weight Loss Trials: Weight Loss Outcome Data at
6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S323
Summary Table 4.7B. Evidence From Weight Maintenance Trials: Weight Maintenance Outcome
Data at 6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S324
Summary Table 4.7C. Evidence From Weight Maintenance Trials: Weight Maintenance Outcome
Data at 9 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S325
Summary Table 4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining
Lost Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S326
Summary Table 4.8A. Onsite Interventions: Outcome Data at 6 Months or Less as the First Time
Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S326
Summary Table 4.8B. Onsite Interventions: Outcome Data at 6 Months or Greater as First Time
Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S329
Summary Table 4.8C. Onsite Interventions: Outcome Data at Greater Than 12 Months as the
First Time Period Reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S331
Summary Table 4.8D. Electronic Interventions: Outcome Data at 6 Months or Less as First Time
Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S332
Summary Table 4.8E. Electronic Interventions: Outcome Data at Greater Than 12 Months as
First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S333
Summary Table 4.8F. Comprehensive Weight Loss or Weight Loss Maintenance Trials That Reported
Percentage of Participants who Achieved A Loss ‡5% of Initial Weight at ‡2 Years
Post-Randomization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S334
Summary Table 4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss:
Intervention Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S336
Summary Table 4.9A. Moderate Intensity Interventions: Outcome Data at 6 Months or Less as
First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S336
Summary Table 4.9B. Moderate Intensity Interventions: Outcome Data at Greater Than 6 Months
as First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S338
Summary Table 4.9C. Moderate Intensity Interventions: Outcome Data at Greater Than 12 Months
as First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S339

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Volume 22 / Issue S2
July 2014

Contents

Summary Table 4.9D. Low-Intensity Interventions: Outcome Data at 6 Months or Less as

First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S341
Summary Table 4.9E. Low-Intensity Interventions: Outcome Data at Greater Than 6 Months as
First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S341
Summary Table 4.9F. Low-Intensity Interventions: Outcome Data at Greater Than 12 Months as
First Time Period Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S342
Summary Table 4.10. Characteristics of Lifestyle Intervention Delivery that May Affect Weight
Loss or Weight Maintenance: Onsite Vs. Electronically Delivered Interventions . . . . . . . . . . . . . . . ... S342
Summary Table 4.10A. Randomized Comparison of High-Intensity Onsite vs. Electronically Delivered
interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S342
Summary Table 4.10B. High-Intensity, Onsite Comprehensive Interventions: Weight Loss Outcome,
Data at 6 Months or Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S343
Summary Table 4.10C. High-Intensity, Onsite Comprehensive Interventions: Weight Loss Outcome
Data at Greater than 6 Months to 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S347
Summary Table 4.10D. High-Intensity, Onsite Comprehensive Interventions: Weight Loss Outcome
Data at Greater than 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S349
Summary Table 4.10E. Comprehensive Electronically Delivered Interventions: Evidence of Weight
Loss in Comprehensive Electronic (Telephone) Interventions—Compared With Usual Care,
Minimal Control, or No Intervention (Includes Self-Directed): Weight Loss Outcome Data
at Greater Than 12 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S350
Summary Table 4.10F. Comprehensive Electronically Delivered Interventions: Evidence of Weight
Loss in Comprehensive Electronic (Internet) Interventions—Compared With Usual Care, Minimal
Control, or No Intervention (Includes Self-Directed): Weight Loss Outcome Data at
6 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S351
Summary Table 4.10G. Comprehensive Electronically Delivered Interventions: Evidence of Weight
Loss in Comprehensive Electronic (Internet) Interventions—Compared With Comprehensive
Electronic Interventions: Weight Loss Outcome Data at 6 Months or Greater . . . . . . . . . . . . . . . . ... S352
Summary Table 4.10H. Comprehensive Electronically Delivered Interventions: Evidence of Weight
Loss in Comprehensive Electronic (Internet) Interventions—Compared With Comprehensive
Electronic Interventions: Weight Loss Outcome Data at 12 Months or Greater . . . . . . . . . . . . . . . ... S353
Summary Table 4.10I. Comprehensive Electronically Delivered Interventions: Evidence of Weight
Loss in Comprehensive Electronic (Internet) Interventions—Compared With Other Comprehensive
Interventions (includes Onsite and/or Electronic): Weight Loss Outcome Data at 4 Months
or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S354
Summary Table 4.10J. Comprehensive Electronically Delivered Interventions: Evidence of
Weight Loss in Comprehensive Electronic (Interactive Equipment) Interventions—Compared
With Other Comprehensive Intervention (Internet or Onsite): Weight Loss Outcome Data
at 4 Months or Greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... S355
Summary Table 5.1. Component 1: Efficacy of Weight Loss Surgery . . . . . . . . . . . . . . . . . . . . . . . . . S356
Summary Table 5.2. Component 2: Predictors Associated with Long-Term Effects—Patient
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S368

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Volume 22 / Issue S2
July 2014

Contents

Summary Table 5.3. Component 2: Predictors Associated with Long-Term Effects—

Types of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S370
Summary Table 5.4. Component 3: Complications Associated with Weight Loss Surgery. . . . . . . . . . . . S381