Current Obesity Management in Primary Care

1. Current Obesity Management in Primary Care Eileen L. Seeholzer, M.D., M.S. Asst. Professor Case Western University School of Medicine Department of Medicine MetroHealth Medical Center

2.  Obesity Defined � ��Traditionally defined as a weight 20% greater than ideal body weight ���Severe obesity or morbid obesity is defined traditionally defined as a weight 100% greater than ideal body weight

3. Fat Distribution Upper-body obesity or abdominal obesity or androgenic obesity: An independent risk factor for diabetes mellitus, cardiovascular disease, hypertension, arthritis, menstrual irregularities and gallbladder disease (Diabetes mellitus is thirty times higher in highest waist-to-hip ratio (whr)compared to lowest quartile whr)

5. Body Mass Index Chart Body mass index chart Body mass index can be determined rapidly by using existing tables, such as the one shown here. This table can be used to identify patients who are underweight (BMI <18 kg/m2, light green area), normal weight (BMI 18.5�24.9 kg/m2, dark green area), overweight (BMI 25�29.9 kg/m2, yellow area), obese (BMI ?30 kg/m2, light orange area), or extremely obese (BMI ?40 kg/m2, dark orange area).Body mass index chart Body mass index can be determined rapidly by using existing tables, such as the one shown here. This table can be used to identify patients who are underweight (BMI <18 kg/m2, light green area), normal weight (BMI 18.5�24.9 kg/m2, dark green area), overweight (BMI 25�29.9 kg/m2, yellow area), obese (BMI ?30 kg/m2, light orange area), or extremely obese (BMI ?40 kg/m2, dark orange area).

6. Scope of the problem in the U.S. The prevalence of obesity in the United States is between 30 and 35% (Women 34%) Overweight and obesity prevalence is 64.5% Obesity rates are highest in lowest socioeconomic levels and in minorities and women. Rates of obesity often 50%

7. Scope of the problem in the U.S. The prevalence of obesity has risen steeply in the last 20 years and continues to rise, especially in children, adolescents, and young adults �More than 78 million Americans are estimated to be obese and more the 8 million Americans are estimated to be severely obese 

9. Increased Risk for Adult Obesity Gender/Ethnicity: Women, blacks, Hispanics and Native Americans Family History Childhood Obesity In lower socioeconomic status Sedentary lifestyle Increased time-spent watching TV

10. Local Public Health Data The Behavior Risk Factor Survey: a survey of 40,000 people conducted annually by the Centers for Disease Control. Subjects are asked about their weight and activity levels. Of forty thousand subjects 2,700 of the subjects live in Ohio 350 live in Cuyahoga County:

11. Local Public Health Data Obesity rates in Ohio rose from 25% in 1988 to 35% in 1995 ? Figures for Cuyahoga County are similar. ? 1995 obesity rate for African Americans of 48% in Cuyahoga County ? Obesity is linked strongly to sedentary lifestyle. Forty percent of Ohio subjects reported a sedentary lifestyle

12. Associated Medical Problems Cardiovascular: HTN, cardiomyopathy, sudden death, CHF Endocrine: DM, dyslipidemia, hypothyroidism Pulmonary: OSA, disordered sleep, asthma GI: GERD, cholelithiasis, NAFLD/NASH Oncologic: Breast, colon, cervical, prostate Neurologic: CVA, idiopathic intracranial hypertension, meralgia paresthetica

13. Associated Medical Problems Renal: Proteinuria/glomerulosclerosis, CRF Dermatologic: intertrigo, venous stasis, cellulitis, hidradenitis suppurativa, acanthosis nigricans Psychiatric: depression, binge eating disorder, night eating syndrome GU: stress incontinence, PCOS, infertility, pregnancy risk Rheumatologic: DJD- knee, hip, low back pain General: fatigue, pain, disability, lower socio- economic status, poorer quality of life

14. Obesity associated Increased Risks in Pregnancy Gestational Diabetes Hypertension Disordered breathing/Obstructive Sleep Apnea Cesarean section rate (RR1.5-1.8) Congenital heart defects (OR 1.4-2.0) Spina Bifida (OR 3.5) Omphalocele (OR 3.3) Increased levels of leptin, crp and tnf-alpha

15. Birth Weight and Obesity LBW and (<2000gm)OR2.16 and high birth weight (>4000gm)OR 1.53 increased gestational DM risk LBW associated with increased overweight adolescence Prolonged breast feeding associated with lower rates of adult obesity

16. Metabolic Syndrome Three or more of the following present: Abdominal obesity(>102cm M/88cm F) Elevated triglycerides (>150mg/dl) Low HDL (<40 for men mg/dl; <50 for mg/dl for women) Hypertension High fasting blood sugar

17. Metabolic Syndrome High risk and high cost constellation of medical problems U.S. prevalence overall is about 23% Prevalence by BMI: 6% of normal weight adults, 60% moderately obese

21. Metabolic Syndrome: Impact on Mortality Metabolic syndrome: impact on mortality Isomaa and colleagues also evaluated differences in mortality between subjects with and without the metabolic syndrome (as defined by WHO). The all-cause mortality rate was significantly higher in subjects with the metabolic syndrome (18.0% vs 4.6%, P < 0.001), as was cardiovascular mortality (12.0% vs 2.2%, P < 0.001). Isomaa B et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001;24:683-689.Metabolic syndrome: impact on mortality Isomaa and colleagues also evaluated differences in mortality between subjects with and without the metabolic syndrome (as defined by WHO). The all-cause mortality rate was significantly higher in subjects with the metabolic syndrome (18.0% vs 4.6%, P < 0.001), as was cardiovascular mortality (12.0% vs 2.2%, P < 0.001). Isomaa B et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001;24:683-689.

22. Nature/Nurture Genetics are estimated to explain about 30-40% of BMI variance Certain groups highly susceptible(Pima Indians, Samoans) Environmental factors are estimated to explain about 60- 70% of BMI variance

23. Neuroendocrine Environment Leptin/Leptin receptor resistance (at VMH) TNF-a, IL-6, adiponectin (aconitase theory � decreased cellular ATP,increased FFA and glucose, Wlodek, et. Al. 2003) CRP Dopamine, serotonin, norepinephrine Low growth hormone levels observed Higher cortisol levels sometimes seen

24. Ghrelin and Peptide YY Ghrelin is orexigenic (hunger signal) � secreted by stomach and duodenum �serum level rise before and fall after meals Ghrelin levels increase with dieting, but decrease with gastric bypass PYY (satiety signal) secreted post-prandially by distal small bowel and colon � decreases appetite and food consumption PYY decreases ghrelin levels Ghrelin acts on growth hormone secretagogue receptors to increase growth hormone

25. National Weight Loss Registry Cohort: 784 in initial cohort(629 female) Eligible subjects had maintained 13.6kg loss for over a year (avg. loss 28kg) FINDINGS: Food strategy High levels of physical exercise Weight maintenance method Later study found maintenance less difficult with time

26. Impact of Weight Loss on Risk Factors Impact of weight loss on risk factors Weight losses of 5%-10% have been shown to have a significant impact on several aspects of the metabolic syndrome, including well-recognized risk factors for cardiovascular disease and diabetes. For example: Wing and colleagues at Brown University evaluated the effect of modest weight loss in 114 patients with type 2 diabetes. Those who lost 5% or more of their baseline weight showed statistically significant decreases in serum HbA1c levels [4]. The Trial of Antihypertensive Interventions and Management Study found that weight losses of 5% or more produced reductions in diastolic pressure that were equivalent to those produced by a single dose of antihypertensive medication [3]. Numerous studies have shown that weight losses of 5%-10% improve total cholesterol, LDL-to-HDL ratio, and the ratio of total-to-HDL cholesterol [1]. In one study, weight reduction of just 5.8% was associated with a 16% reduction in total cholesterol, an 18% increase in HDL cholesterol, and a 12% decrease in LDL cholesterol [1]. More recently, Ditschunheit and colleagues documented significant decreases in total cholesterol, triglycerides, and VLDL in obese patients with baseline hyperlipidemia who maintained a weight loss of 7.6% [2]. Blackburn G. Ob Res 1995;3(Suppl2):211S-216S. Ditschunheit HH, et al. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr 2002;56:264-270. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: The effects of modest weight reduction. Ob Res 2000;8(3):270-278. Wing RR, et al. Long-term effects of modest weight loss in Type 2 diabetic patients. Arch Intern Med 1987;147:1749-1753.Impact of weight loss on risk factors Weight losses of 5%-10% have been shown to have a significant impact on several aspects of the metabolic syndrome, including well-recognized risk factors for cardiovascular disease and diabetes. For example: Wing and colleagues at Brown University evaluated the effect of modest weight loss in 114 patients with type 2 diabetes. Those who lost 5% or more of their baseline weight showed statistically significant decreases in serum HbA1c levels [4]. The Trial of Antihypertensive Interventions and Management Study found that weight losses of 5% or more produced reductions in diastolic pressure that were equivalent to those produced by a single dose of antihypertensive medication [3]. Numerous studies have shown that weight losses of 5%-10% improve total cholesterol, LDL-to-HDL ratio, and the ratio of total-to-HDL cholesterol [1]. In one study, weight reduction of just 5.8% was associated with a 16% reduction in total cholesterol, an 18% increase in HDL cholesterol, and a 12% decrease in LDL cholesterol [1]. More recently, Ditschunheit and colleagues documented significant decreases in total cholesterol, triglycerides, and VLDL in obese patients with baseline hyperlipidemia who maintained a weight loss of 7.6% [2]. Blackburn G. Ob Res 1995;3(Suppl2):211S-216S. Ditschunheit HH, et al. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr 2002;56:264-270. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: The effects of modest weight reduction. Ob Res 2000;8(3):270-278. Wing RR, et al. Long-term effects of modest weight loss in Type 2 diabetic patients. Arch Intern Med 1987;147:1749-1753.

27. Obesity Treatment Pyramid Obesity treatment pyramid The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid.Obesity treatment pyramid The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid.

28. Non-Pharmacologic Treatments Weight loss goals � 5-15% considered achievable and will improve health Components of Basic Program Diet Recommendations Exercise Recommendations Behavior Therapy Regular f/u in maintenance phase

29. Short-term Obesity Therapy Does Not Result in Long-term Weight Loss Short-term obesity therapy does not result in long-term weight loss Obesity is a chronic disease that requires long-term therapy for successful long-term weight management. Often, patients who are able to lose weight with obesity therapy regain their lost weight after therapy is discontinued. This figure represents data from 76 obese women (mean body mass index 39.4 kg/m2) who were were randomly assigned to one of three treatment groups: 4 months of a very-low-calorie diet (VLCD) of 400�500 kcal/d, 6 months of behavior therapy and a 1000�1200 kcal/d balanced deficit diet, or 6 months of a combination of a VLCD and behavior therapy. Each treatment program was effective in achieving short-term weight loss. However, most subjects regained a considerable amount of weight by 1 year and had returned to their pretreatment weight at 5 years. Wadden TA, Sternberg JA, Letizia KA, et al. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes 1989;13 (suppl 2):39-46.Short-term obesity therapy does not result in long-term weight loss Obesity is a chronic disease that requires long-term therapy for successful long-term weight management. Often, patients who are able to lose weight with obesity therapy regain their lost weight after therapy is discontinued. This figure represents data from 76 obese women (mean body mass index 39.4 kg/m2) who were were randomly assigned to one of three treatment groups: 4 months of a very-low-calorie diet (VLCD) of 400�500 kcal/d, 6 months of behavior therapy and a 1000�1200 kcal/d balanced deficit diet, or 6 months of a combination of a VLCD and behavior therapy. Each treatment program was effective in achieving short-term weight loss. However, most subjects regained a considerable amount of weight by 1 year and had returned to their pretreatment weight at 5 years. Wadden TA, Sternberg JA, Letizia KA, et al. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes 1989;13 (suppl 2):39-46.

30. Long-term Weight Loss is Improved with Long-term Maintenance Therapy Long-term weight loss is improved with long-term maintenance therapy Maintenance therapy is important for long-term weight management success after initial weight loss is achieved by diet and behavior therapy. In this study, Perri and colleagues [1] randomized obese subjects who lost weight after 5 months of diet and behavior modification therapy to �no maintenance� or a �maintenance program� that involved biweekly contact. At 1 year after initial weight loss was achieved, participants who received maintenance therapy maintained long-term weight loss, whereas those who did not receive maintenance therapy regained half of their lost weight. Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56:529-534.Long-term weight loss is improved with long-term maintenance therapy Maintenance therapy is important for long-term weight management success after initial weight loss is achieved by diet and behavior therapy. In this study, Perri and colleagues [1] randomized obese subjects who lost weight after 5 months of diet and behavior modification therapy to �no maintenance� or a �maintenance program� that involved biweekly contact. At 1 year after initial weight loss was achieved, participants who received maintenance therapy maintained long-term weight loss, whereas those who did not receive maintenance therapy regained half of their lost weight. Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56:529-534.

31. Assessing Weight Loss Readiness Motivation: Stress level: Psychiatric issues: Time availability: Assessing weight loss readiness Patient motivation, commitment, and compliance are critical for weight loss success. Therefore, knowledge of the patient�s readiness to lose weight will help in developing an appropriate treatment strategy. Good candidates for treatment are patients who decide they want to lose weight for appropriate reasons, are not currently experiencing major life stressors, do not have psychiatric or medical illnesses that prevent effective weight loss, and are willing to devote the time needed to make lifestyle changes. In addition, the patient�s work, social, and family environment should be considered in deciding if it is a good time to implement weight loss therapy. If the patient is considered to be ready to lose weight, weight loss therapy should be initiated. If the patient is not ready to lose weight, the immediate goal is to prevent further weight gain and explore barriers to weight reduction. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000; 84:441-461. NHLBI Obesity Education Initiative and North American Association for the Study of Obesity. The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NIH publication number 00-4084, October 2000.Assessing weight loss readiness Patient motivation, commitment, and compliance are critical for weight loss success. Therefore, knowledge of the patient�s readiness to lose weight will help in developing an appropriate treatment strategy. Good candidates for treatment are patients who decide they want to lose weight for appropriate reasons, are not currently experiencing major life stressors, do not have psychiatric or medical illnesses that prevent effective weight loss, and are willing to devote the time needed to make lifestyle changes. In addition, the patient�s work, social, and family environment should be considered in deciding if it is a good time to implement weight loss therapy. If the patient is considered to be ready to lose weight, weight loss therapy should be initiated. If the patient is not ready to lose weight, the immediate goal is to prevent further weight gain and explore barriers to weight reduction. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am 2000; 84:441-461. NHLBI Obesity Education Initiative and North American Association for the Study of Obesity. The practical guide. Identification, evaluation, and treatment of overweight and obesity in adults. NIH publication number 00-4084, October 2000.

32. Results from Non-pharmacologic Programs Patient overwhelmingly regain the weight. Behavior therapy and exercise key to weight loss maintenance This therapy only addresses external environment and not biologic environment

33. Is it reasonable for an obese individual to exert continuous control over both biologic factors and environmental factors to successfully maintain weight loss?

34. Pharmacologic Treatments Older meds increased noradrenergic output (i.e. phenteramine, diethylproprion) or increased serotonin release(dexfenfluramine � Redux) � withdrawn from market Sibutramine (Meridia) inhibits norepinephrine and serotonin reuptake. It induces 4-12% decreases in weight. A longer term study showed 5% reduction

35. Pharmacologic Treatments Orlistat (Xenical) decreases fat absorption. It induces 5-13% decreases in weight and may have the benefit of a food avoidance behavioral mechanism. Losses of 3-5% observed long-term Ephedrine/caffeine over the counter supplements may induce 5-10% losses - not reliable ingredients and risk of arrhythmia/cardiac events

36. Pharmacotherapy helps maintain weight loss best in combination with behavioral, diet and exercise interventions

37. Other Agents Topiramate (Topamax)- anticonvulsant. Mechanism for weight loss unknown. Doses of 64-384mg given. Weight loss at higher doses about 4% higher than placebo group(n=385) (24 week) Bupropion (Wellbutrin) � norepinephrine reuptake inhibitor and antidepressant. Weight loss found to be 5% higher in treatment group 400mg (24 week) (n=327)

38. Experimental Agents - Phase 3 SR141716 (Rimonabant) - blocks a cannabinoid receptor in then central nervous system that stimulates hunger when activated Recombinant human variant ciliary neurotrophic factor or CNTF (Axokine) - Binds to the CNTF receptor and activates signaling pathways in neurons of an appetite-control center in the hypothalamus Vastag, JAMA 4/9/2003

39. Medications That May Promote Weight Gain Antipsychotics: risperidone, clonazepine, olanzepin Antidepressants: Tri-cyclics, SSRI Antiepileptics: valproic acid, gabapentin, carbemazepine Lithium DM treatments: Sulfonylureas, insulin Progestin steroids Cortisone Antihistamines Beta blockers

40. Surgical Treatment In U.S, 40,000 done in 2001, estimated 80,000 done in 2002 NIH criteria - BMI>40 or BMI>35 with 2 medically important comorbid conditions Age not a contraindication Presurgical evaluation extensive Goal is to lose 50% of excess weight and improve comorbid conditions

41. Surgical Outcomes Weight nadir 12-24 months BMI reduction 12 months after surgery of 16.4, at 24 months � 13.3 Vertical banded gastroplasty � only 38% meet weight loss goal RGB - 5yr post-op excess weight loss 50-60% and 75-89% successful at losing 50% excess weight (57% in super-obese)

42. Predictors of Better Surgical Outcomes Age <40 Employment Marital status Social support Female gender Diet compliance Appt compliance Preoperative weight loss Tobacco cessation Knowledge of eating rules

43. Predictors of poorer Surgical outcomes Psychiatric admission history MMPI psychopathology Public assistance Negative life events Snacking Codependency Childhood abuse Denial of disease Black ethnicity Prior bariatric procedure

44. Improvement in Comorbid Conditions s/p Gastric Bypass Cures 85% of Diabetes Mellitus Cures 50%-66% Hypertension Cures 85% hyperlipidemia Cures 89% gerd(lap-band) LVH regression seen after a year Improved fertility Pregnancy safer � fewer complications compared to obese counterparts � watch vitamins Depression decreases Increase in work and decreased disability/assistance

45. Common longer-term Complications after Gastric Bypass Dumping syndrome Nutritional deficiencies: iron 20-50%, B-12 26-70%, folate 9-35% Higher rates of nutritional deficiencies in biliopancreatic diversion Rarely can have neuropathy or protein deficiency

46. Screening For Obesity in Adults The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for adults December, 2003

47. Office Assessment Assess BMI and if possible waist circumference Assess for co-morbid conditions* and other risk factors (smoking, family history) Assess patient�s willingness to lose weight If ready take diet and activity history and set goals.

48. Office Assessment Follow progress frequently with goal re-assessment for at least 6 months � consider dietary or other referrals If BMI > 30 consider medications If BMI >40, or 35 with risk factors, consider surgical assessment

49. Weight Management Clinic Currently two � days weekly � likely to expand This clinic is for obese patients (BMI>30) who are READY to commit to lifestyle changes to maintain weight loss.

50. Weight Management Clinic Evaluation for gastric bypass: appropriateness/readiness Medical management of co-morbid problems through weight loss Evaluation for pharmacologic treatment Pre-operative gastric bypass evaluation Post-operative gastric bypass follow-up for medical problems and adherence to diet and exercise recommendations

51. Obesity Treatment Guidelines Obesity treatment guidelines The National Institutes of Health in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) and the North American Association for the Study of Obesity have developed a Practical Guide for the identification, evaluation, and treatment of overweight and obesity in adults [1]. The Practical Guide is based on the clinical guidelines that were developed by the NHLBI�s Obesity Education Initiative, in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases, in June 1998. The Practical Guide contains useful information on diet therapy, physical activity, and behavior therapy and also provides guidance on the appropriate use of pharmacotherapy and surgery for healthcare practitioners. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub No 00-4084.Obesity treatment guidelines The National Institutes of Health in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) and the North American Association for the Study of Obesity have developed a Practical Guide for the identification, evaluation, and treatment of overweight and obesity in adults [1]. The Practical Guide is based on the clinical guidelines that were developed by the NHLBI�s Obesity Education Initiative, in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases, in June 1998. The Practical Guide contains useful information on diet therapy, physical activity, and behavior therapy and also provides guidance on the appropriate use of pharmacotherapy and surgery for healthcare practitioners. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub No 00-4084.

52. Obesity-Related ResourcesProfessional Associations North American Association for the Study of Obesity (NAASO) American Academy of Family Physicians (AAFP) American College of Sports Medicine (ACSM) American Diabetes Association (ADA) American Dietetic Association (ADA) American Gastroenterological Association (AGA) American Heart Association (AOA) American Obesity Association (AOA) American Society for Bariatric Surgery (ASBS) Obesity-related resources - professional associations The North American Association for the Study of Obesity (NAASO) website provides obesity-related news updates, press releases, a calendar of events, and links to discussion groups. The American Academy of Family Physicians (AAFP) offers an obesity management program for physicians and the website includes a topic search engine that can be used to find clinical information on obesity management. The American College of Sports Medicine (ACSM) provides publications, audio tapes, and video tapes on physical fitness and weight loss to health professionals and the general public. The American Diabetes Association (ADA) offers news updates, nutrition and exercise tips and guidelines, clinical trial information, and local and national resource information. The American Dietetic Association (ADA) website contains nutrition information, obesity-related news releases, Nutrition Fact Sheets, consumer FAQs, and a reading list for good nutrition. This website also offers the �Find a Dietitian� feature to help users locate a local dietitian. The American Gastroenterological Association (AGA) website offers information on digestive health and nutrition for the public and for health care providers, as well as links to additional obesity resources. The American Heart Association (AHA) is a good source for publications on diet, nutrition, weight reduction, and exercise. AHA cookbooks are available at local bookstores. The American Obesity Association (AOA) offers comprehensive information on education, research, prevention and treatment of obesity, as well as consumer protection advice for weight loss products and services. The American Society for Bariatric Surgery (ASBS) provides information on obesity, gastric surgery, and related topics to the public. Patients can seek referrals to physicians specializing in obesity. Obesity-related resources - professional associations The North American Association for the Study of Obesity (NAASO) website provides obesity-related news updates, press releases, a calendar of events, and links to discussion groups. The American Academy of Family Physicians (AAFP) offers an obesity management program for physicians and the website includes a topic search engine that can be used to find clinical information on obesity management. The American College of Sports Medicine (ACSM) provides publications, audio tapes, and video tapes on physical fitness and weight loss to health professionals and the general public. The American Diabetes Association (ADA) offers news updates, nutrition and exercise tips and guidelines, clinical trial information, and local and national resource information. The American Dietetic Association (ADA) website contains nutrition information, obesity-related news releases, Nutrition Fact Sheets, consumer FAQs, and a reading list for good nutrition. This website also offers the �Find a Dietitian� feature to help users locate a local dietitian. The American Gastroenterological Association (AGA) website offers information on digestive health and nutrition for the public and for health care providers, as well as links to additional obesity resources. The American Heart Association (AHA) is a good source for publications on diet, nutrition, weight reduction, and exercise. AHA cookbooks are available at local bookstores. The American Obesity Association (AOA) offers comprehensive information on education, research, prevention and treatment of obesity, as well as consumer protection advice for weight loss products and services. The American Society for Bariatric Surgery (ASBS) provides information on obesity, gastric surgery, and related topics to the public. Patients can seek referrals to physicians specializing in obesity.

53. Centers for Disease Control (CDC): Obesity and Overweight Centers for Disease Control (CDC): Prevalence data and growth charts National Institutes of Health (NIH) National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight-Control Information Network (WIN) National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight Loss and Control National Library of Medicine, MEDLINE Plus Obesity-Related ResourcesGovernment Organizations Obesity-related resources - government organizations The Centers for Disease Control (CDC) offers basic information on overweight and obesity, including obesity trends, recommendations and guidelines, growth charts, and a listing of state-funded obesity programs. The National Institutes of Health (NIH) sponsors medical research and communication of medical information. The website provides updates on health information and guidelines, grants and funding information, news and events, and scientific resources. The National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK), a division of NIH, offers the Weight-control Information Network (WIN), which produces, collects, and disseminates educational materials on obesity, weight control, and nutrition. The NIDDK website also offers the Weight Loss and Control Health Information Section, which discusses general weight loss and weight control topics, research information, statistics, and offers publications and videos on weight control for health professionals and the public. The National Library of Medicine, a division of the NIH, offers MEDLINE Plus. This service provides the latest obesity-related news and information, NIH updates, general overviews of obesity, clinical trial information, nutrition topics, statistics, and information on prevention, screening, diagnosis, and treatment of obesity.Obesity-related resources - government organizations The Centers for Disease Control (CDC) offers basic information on overweight and obesity, including obesity trends, recommendations and guidelines, growth charts, and a listing of state-funded obesity programs. The National Institutes of Health (NIH) sponsors medical research and communication of medical information. The website provides updates on health information and guidelines, grants and funding information, news and events, and scientific resources. The National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK), a division of NIH, offers the Weight-control Information Network (WIN), which produces, collects, and disseminates educational materials on obesity, weight control, and nutrition. The NIDDK website also offers the Weight Loss and Control Health Information Section, which discusses general weight loss and weight control topics, research information, statistics, and offers publications and videos on weight control for health professionals and the public. The National Library of Medicine, a division of the NIH, offers MEDLINE Plus. This service provides the latest obesity-related news and information, NIH updates, general overviews of obesity, clinical trial information, nutrition topics, statistics, and information on prevention, screening, diagnosis, and treatment of obesity.