Barbara E. Millen

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 guidelines and the obesity society

Harmon S. Jordan, ScD, Karima A. Kendall, PhD, Linda J. Lux, Roycelynn Mentor-Marcel, PhD, MPH, Laura C. Morgan, MA, Michael G. Trisolini, PhD, MBA, Janusz Wnek, PhDnnJeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN,Obesity is a chronic, multifactor disease with sizeable socio sanitary and economic consequences and is an issue in public health, mostly in developing countries. It causes or exacerbates a large number of health problems: diabetes, coronary heart disease, hypertension, and the incidence of certain cancers. It has been linked to a greater risk of cardiovascular mortality, a higher prevalence of psychopathology disorders and social maladjustment with a higher health care cost and shorter life-expectancy. In Spain, nowadays, the prevalence of overweight and obesity is nearly 50% of population. SEEN has developed a Clinical Practice Guide on diagnosis, evaluation and treatment of overweight and obesity in adult people with two sections: 1) Definition and classification of adult obesity, its epidemiology, etiopathogeny, complications, benefits of weight reduction and clinical evaluation of patients with overweight or obesity, and 2) Identification of patients with obesity risk subsidiary to weight reduction treatment, therapy goals and therapeutical strategies available to achieve them indicating as well the degree of recommendation based upon scientific evidence on each aspect. Although obesity is a disease which is supposed to involve not only medical but also political authorities, social agents, educators and food industry among others, SEEN decided to develop this Guide taking into account the evident endocrinological and metabolical aspects of this disorder. The Guide contains scientific evidencebased recommendations intended to help doctors making decisions on diagnose, evaluations and treatment of adult overweight so that a more homogeneous attendance with settled quality can be

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

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2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

Loria, Barbara E. Millen, Cathy A. Nonas, F. Xavier Pi-Sunyer, June Stevens, Victor J. Stevens, Karen A. Donato, Frank B. Hu, Van S. Hubbard, John M. Jakicic, Robert F. Kushner, Catherine M. Michael D. Jensen, Donna H. Ryan, Caroline M. Apovian, Jamy D. Ard, Anthony G. Comuzzie, Practice Guidelines and The Obesity Society Report of the American College of Cardiology/American Heart Association Task Force on 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright

Practice Guideline2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines☆

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

The 2015 Dietary Guidelines Advisory Committee Scientific Report: Development and Major Conclusions

The Dietary Guidelines for Americans (DGA) is published every 5 y jointly by the Department of Health and Human Services (HHS) and the USDA and provides a framework for US-based food and nutrition programs, health promotion and disease prevention initiatives, and research priorities. Summarized in this report are the methods, major conclusions, and recommendations of the Scientific Report of the 2015 US Dietary Guidelines Advisory Committee (DGAC). Early in the process, the DGAC developed a conceptual model and formulated questions to examine nutritional risk and determinants and impact of dietary patterns in relation to numerous health outcomes among individuals aged ≥2 y. As detailed in the report, an expansive, transparent, and comprehensive process was used to address each question, with multiple opportunities for public input included. Consensus was reached on all DGACs findings, including each conclusion and recommendation, and the entire report. When research questions were answered by original systematic literature reviews and/or with existing, high-quality expert reports, the quality and strength of the evidence was formally graded. The report was organized around the following 5 themes: 1) food and nutrient intakes and health: current status and trends; 2) dietary patterns, foods and nutrients, and health outcomes; 3) diet and physical activity behavior change; 4) food and physical activity environments; and 5) food sustainability and food safety. The following 3 cross-cutting topics were addressed: 1) sodium, 2) saturated fat, and 3) added sugars. Physical activity recommendations from recent expert reports were endorsed. The overall quality of the American diet was assessed to identify overconsumed and underconsumed nutrients of public health concern. Common food characteristics of healthy dietary patterns were determined. Features of effective interventions to change individual and population diet and physical activity behaviors in clinical, public health, and community settings were identified. The report was used by the HHS and the USDA to develop the 2015 DGA.

Diet, the Global Obesity Epidemic, and Prevention

In 2008, 34% of adults (1.46 billion) globally were overweight and obese (body mass index [BMI] 25); of these, an equal proportion (502 million) were obese. This translates to a twofold increase over the last 30 years. Whereas the increase in mean BMI in high-income countries was highest in the United States, Nauru in the Oceania reported the greatest gain in BMI globally (1). China is expected to have the largest number of overweight and obese individuals in 2030 (2). Overweight and obesity are major risk factors for cardiovascular disease (CVD), type 2 diabetes mellitus, and certain forms of cancer (3,4), and account for approximately 10% of direct medical costs of countries globally (5). Furthermore, abdominal obesity and insulin resistance are the main underlying factors of the metabolic syndrome, a multiplex of cardiometabolic risk factors, generally considered to include abdominal obesity, elevated blood pressure, impaired fasting glucose, low highdensity lipoprotein (HDL) cholesterol, and elevated triglycerides (6-8). Metabolic syndrome is associated with a twofold risk for CVD and a fivefold risk for type 2 diabetes mellitus (6,9,10), and currently affects 20% to 30% of the global adult population (11). In Seychelles, a middleincome country with comprehensive data on CVD risk factors, the prevalence of metabolic syndrome increased by 16% over a 15-year period, from 20% in 1989 to 36% in 2004 (12), whereas South Korea, a high-income country, experienced an increase of 6% over 7 years from 1998 to 2005 (13,14). Medical costs for metabolic syndrome increase by approximately 24% for each additional metabolic syndrome trait present (15). The obesity epidemic and corresponding increase in metabolic syndrome prevalence are in part attributable to a global nutrition transition, with a shift from traditional plant-based foods to consumption of a more energy-

2013 American Heart Association/American College of Cardiology Guideline on Lifestyle Management to Reduce Cardiovascular Risk: Practice Opportunities for Registered Dietitian Nutritionists

H EALTHY LIFESTYLE BEHAVIORS, INCLUDING optimal dietary and physical activity patterns, are the cornerstones of disease prevention and management. The maintenance of healthy lifestyle behaviors is particularly important in preventing cardiovascular disease (CVD), the leading cause of morbidity and mortality in the United States. Therefore, in 2008, the National Heart, Lung, and Blood Institute (NHLBI), in conjunction with efforts to update expert guidelines on overweight/obesity, cholesterol, and blood pressure (BP), assembled a Lifestyle Workgroup to examine the relationships between diet, physical activity, and CVD prevention and management. Lifestyle behaviors are not only factors associated with CVD risk reduction, but also determinants of overall health that the individual can manage in conjunction with sound professional guidance. In 2012, the NHLBI partnered with the American College of Cardiology (ACC) and American Heart Association (AHA) to adopt and publish the Lifestyle Workgroup’s recommendations and guidelines. In this commentary, we review and discuss the major findings and recommendations of the 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Disease Risk, published jointly by the ACC and AHA. This new guideline on lifestyle management was restricted to the following components of lifestyle: diet modification, dietary patterns, type of fat, sodium and potassium intake, and levels and types of physical activity. The Lifestyle Guideline is meant to provide clinicians with recommendations on the most effective diet and physical activity strategies to manage dyslipidemia and hypertension to promote cardiovascular health. In a companion commentary on the 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 Guidelines and the Obesity Society, we summarize the background and general processes NHLBI followed in both guideline reports. In brief, during a 5-year period, the expert groups defined and evaluated Critical Questions and developed guidelines specific to their topic areas. Because of limitations in resources, only three questions were assessed by the Lifestyle Workgroup. For each specified question, the group reviewed published literature comprised of systematic reviews, randomized clinical trials, and observational studies (which included hard end points as outcomes) rated as fair and good quality, spanning the time frame from 1998 through 2009. It then utilized this body of evidence to formulate recommendations and to prepare the guideline. Given the limited scope of the Workgroup’s review (ie, only three Critical Questions), it is recognized that there are gaps in its expert recommendations.

Executive summary: Guidelines (2013) for the management of overweight and obesity in adults

In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence, and craft recommendations. In response to the 2011 report from the Institute of Medicine on the development of trustworthy clinical guidelines (1), the NHLBI Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations (2,3). Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the guidelines noted above and make them available to the widest possible constituency. Recognizing that the expert panels/work groups did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA and collaborating societies plan to begin updating these guidelines starting in 2014.

Nutrition for the Prevention of Chronic Diseases

Chronic non-communicable diseases (NCDs) are the leading causes of morbidity and mortality in the United States and globally, and are attributable largely to poor nutrition and suboptimal lifestyle behaviors. The 2015-2020 Dietary Guidelines for Americans promote healthy eating and lifestyle patterns across the lifespan to reduce risk of NCDs. Physicians are well positioned to provide lifestyle preventive interventions that are personalized to their patients biological needs and cultural preferences through multidisciplinary team activities or referral to professional nutrition and physical activity experts. They can also advocate for environmental changes in healthcare and community settings that promote healthful lifestyle behaviors.

Dietary Behavior Assessment: Historical and Recent Innovations

e p a s s d h ssessment of nutritional status involves the consideration of a complex array of factors across four major domains: dietary behavior, physical anthroometry, clinical history and examinations, and biochemcal parameters (1). Registered dietitians possess the nique training to guide and implement these assessents and to provide the careful interpretation of data eeded to achieve the most accurate appraisal of nutriional risk in individuals and populations. Techniques of ietary behavior assessment and methodological validaion are particularly important topics given their broad pplications in nutrition research and clinical settings nd relatively recent advances that may have profound ractice implications. In this issue of the Journal, Araujo and her Brazilian olleagues’ elegant paper (2), a model for other investigaors, provides an opportunity to comment on historical nd recent advancements in techniques of assessing food nd nutrient intake as well as other dimensions of human ietary behaviors. It also enables the examination of staistical techniques applied in new or innovative ways ith dietary data to improve estimates of food and nutrint intake or to refine the characterization of dietary ehaviors and their determinants. These accomplishents have expanded the validated options for dietary xposure assessment, improved the application of these ethods and interpretation of the data generated, and nhanced the abilities of researchers and clinicians to xamine relationships among diet, disease risk, and ealth outcomes to better inform public policy and pracice.