|Year : 2013 | Volume
| Issue : 1 | Page : 18-30
Management of obesity: Saudi Clinical Guideline
Fahad S Al-Shehri1, Mohammed M Moqbel1, Abdullah M Al-Shahrani2, Yahia M Al-Khaldi3, Waleed S Abu-Melha4
1 Department of Family Medicine, Ministry of Health Affairs, Southern Region, Saudi Arabia
2 Department of Public Health, Ministry of Health Affairs, Southern Region, Saudi Arabia
3 Department of Family Medicine and Research, Health Affairs, Aseer Region, Saudi Arabia
4 Department of Preventive Medicine, Armed Forced Hospital, Southern Region, Saudi Arabia
|Date of Web Publication||8-Oct-2013|
Fahad S Al-Shehri
P. Box: 2653, Abha
Source of Support: None, Conflict of Interest: None
Overweight and obesity affect more than 75% of the total population in Saudi Arabia. Almost all age groups are affected in general and adults particularly. In order to introduce high quality health-care for these individual, it is mandatory to establish clinical guideline that will help health-care providers to manage this common problems at all levels. This guideline was adapted from Scottish Intercollegiate Guidelines Network for management of obesity after taking permission in this regard. The guideline will cover preventive and curative aspects of overweight and obesity and could be implemented at primary, secondary, and tertiary care levels in Saudi Arabia.
Keywords: Guideline, obesity, Saudi Arabia
|How to cite this article:|
Al-Shehri FS, Moqbel MM, Al-Shahrani AM, Al-Khaldi YM, Abu-Melha WS. Management of obesity: Saudi Clinical Guideline. Saudi J Obesity 2013;1:18-30
| Introduction|| |
Obesity could be defined as a disease process that results from excessive body fat accumulation due to many factors including of food intake, physical inactivity, and genetic. 
Magnitude of the problem
In Saudi Arabia, obesity has become one of the most common health problems affecting people of both sexes and all age groups. According to epidemiological studies and surveys, obesity was found to affect more than one quarter while overweight affects about one-third of the adults in Saudi Arabia. ,,, Four studies were conducted among four different age groups in Saudi Arabia revealed the following findings. Overweight among adult males and females were (30.7% and 28.4%) respectively while obesity among adult males and females were (14% and 23.6%) respectively.  The prevalence of overweight among adults population was 36% and prevalence of obesity among the adult population was 35.6%.  Prevalence of overweight and obesity among children and adolescent 5-18 years was 23.1%, 11.3% respectively.  Prevalence of overweight and obesity among females of childbearing age were 31.5% and 21% respectively.  The prevalence of overweight and obesity among college students were 21.8% and 15.7% respectively. 
Target users of guideline
This guideline will provide the concerned health-care providers with up-to-date evidence based recommendations, which will help them to introduce the high quality and safe preventive, curative health-care services for individuals at high-risk and patients suffering from overweight and obesity. This guideline could be used by nurses, general physicians, family physicians, and surgeons at primary, secondary and tertiary levels of health-care settings in Saudi Arabia.
Scope of guideline
This guideline address the following areas:
- Primary prevention of overweight and obesity in children and adults by education and counseling.
- Secondary prevention of overweight and obesity by screening of individuals at high-risk.
- Management of overweight and obesity by life-styles, drugs and surgical interventions.
This guideline aims to provide recommendations for the management of overweight/obesity in children and adults based on current evidence for best practice that suitable for our targeted population, culture, health-care system, and resources.
| Methodology|| |
In an effort to provide the current and evidence-based care of health services at health-care settings in the Kingdom, Saudi Arabian Society of Metabolic and Bariatric Surgery (SASMBS) established Guideline Adoption Group (GAG) to work on adopting evidence based clinical practice guidelines for prevention and management of obesity in Saudi Arabia. The guideline adoption work consisted of 5 stages:
Systematic searching for guidelines
- Systematically searching for practice guidelines.
- Appraising the quality of identified guidelines using a validated guideline appraisal instrument.
- Identification of the best quality guidelines.
- Adaptation recommendations into the guidelines.
- Editing the draft recommendations based on external reviewer feedback and updating the guideline followed a similar process.
Initial search was executed to identify relevant guidelines (local, national and international) followed by systematic review of the published literature from 2007 to 2012. Databases search included Guidelines International Network, National Guideline Clearinghouse, MEDLINE, Internet search engines, and reference list of relevant guidelines. Search terms included: Patients with obesity, management of obesity, clinical practice guidelines, and health-care settings.
In total, three guidelines were identified and retrieved for quality appraisal. The selected guidelines were:
Appraising the quality of existing guidelines
- Malaysia clinical practice guidelines on management of obesity, 2004. 
- Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, National Institute for Health and Clinical Excellence, December 2006. 
- Management of obesity national clinical guideline, Scottish Intercollegiate Guidelines Network (SIGN), February 2010. 
All selected relevant guidelines that met the inclusion criteria were put forward for a full appraisal. Appraisal was undertaken by four members of the GAG after they undertook specific training in critical appraisal of guidelines. Each guideline was scored independently by each GAG member, using the standardized Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument methodology. http://www.agreetrust.org/resource-centre/agree-ii/ 
The AGREE II consists of 23 key items organized within 6 domains followed by 2 global rating items ("Overall Assessment"). Each domain captures a unique dimension of guideline quality.
Each of the AGREE II items and the two global rating items are rated on a 7-point scale (1 - strongly disagree to 7 - strongly agree).
Domain scores are calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain.
Overall assessment includes the rating of the overall quality of the guideline and whether the guideline would be recommended for use in practice. The scores were compared, and any discordant scores were resolved by discussion between the appraisers.
Identifying best quality guidelines
Based on the data, the GAG selected the most comprehensive guideline with current evidence recommendations, which was management of obesity national clinical guideline, Scottish Intercollegiate Guidelines Network, February 2010.  Level of evidence and grade of recommendations that used in this guideline are summarized in the following table.
There is no funding body behind this guideline. It is supervised by the SASMBS, Saudi Arabia.
Updating this guideline will be considered every 5 years.
In fact, there is no preceding internationally approved "guidelines" in Kingdom of Saudi Arabia (KSA). It followed that the guideline adopting group has no option but to cite from the best evidence based currently adapted international guidelines in the hope that it would fit the local circumstances in the KSA. This guideline is not intended to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The ultimate judgment must be made by the appropriate health-care professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan after discussion of the options with the patient.
In order to assess the quality and applicability of the guideline four external reviewers (consultants) from different specialties (pediatric endocrinology, bariatric surgery, diabetology and obesity) were invited to do external review. Their suggestions and comments were considered.
| Elements of Clinical Guideline|| |
This guideline consists of the following parts; definitions, risk factors, comorbidities, consequences of obesity, primary and secondary prevention, diagnosis, assessment, and management of obesity.
In this guideline, we should be familiar with important definitions and term that will be used frequently.
Diagnosis of overweight/obesity
- Children: Those individuals of less than 12 year old.
- Adolescents: Those individuals between 12 years and 17 years old.
- Adults: Those individuals of 18 year and above.
- Body mass index (BMI): Is an equation that is applied to determine and classify the grade of weight disorders. BMI is calculated by dividing weight (in kg) by the square of height in meter. BMI = weight (kg)/ht (m) 2 .
- Primary prevention: An intervention that tries to hinders the occurrence of problem such as health education, vaccination and sanitation.
- Secondary prevention: An intervention that is utilized to detect of disease in its early asymptomatic status.
- Screening: Early detection of diseases before its clinical manifestation such as measuring blood pressure, checking blood glucose, and lipids.
- Health education: It is the process of informing individuals with relevant health information in order to change their knowledge, attitude, and behaviors.
- Health promotion: It is the process of enabling people to change their attitude and behaviors concerning their health.
Overweight/obesity could be diagnosed by many methods including BMI, waist circumference (WC) and waist to hip ratio. In this guideline, we will use BMI as it is it acceptable tool to measure general adiposity, easy, simple, and practical to use at all health-care settings. In muscular patients, it may not suitable and we can measure WC also.
WC is a good predictor of visceral fat more than BMI and it could be used as a predictor for obesity related complications such as heart diseases, hypertension, diabetes type-2, and dyslipidemia. Males with WC ≥ 94 cm and females with WC ≥80 cm are at high-risk of the above mentioned complications.
Based on BMI, body weight could be classified into the following 6 categories.
Risk factors of obesity
Studies found that all the following individuals are at high-risk of developing overweight and obesity.
Comorbidities and consequences of obesity
- After smoking cessation.
- Person use the following drugs (insulin, sodium valproate, propranolol, lithium, sulphonylureas, antipsychotics, pioglitazone, tricyclic anti-depressant).
- Polycystic ovarian syndrome.
Overweight and obesity are associated with many conditions affecting almost all systems and organs all over the body. In general, obesity is associated with a high rate of mortality. Different studies found that obesity is a risk factor for the following medical problems:
- Nervous system (stroke, dementia, depression, obstructive sleep apnea).
- Cardiovascular system (hypertension, coronary heart disease, heart failure, atrial fibrillation).
- Respiratory system (asthma, deep venous thrombosis, pulmonary embolism).
- Metabolic (diabetes, gout, dyslipidemia).
- Gastro-intestinal system (gastro-esophageal reflux, fatty liver diseases, pancreatitis, gallstones).
- Reproductive system (infertility, abortion, fetal anomalies, instrumental deliveries, pre-eclampsia).
- Loco-motor (osteoarthritis and low back pain).
- Cancers (breast, colon, gallbladder, prostate, uterus, ovaries, pancreas, kidney, esophagus, and leukemia).
| Primary Prevention of Overweight/Obesity|| |
Health education and health promotion programs could reduce the incidence and prevalence of obesity in the community. The following recommendations could be implemented in this regard.
Birth to 5 years
Children over 5 years and adults
- Exclusive breastfeeding is recommended for all infants from birth to the age of 6 months as it offers significant health benefits for babies and for mothers.
- Introduction of solid foods should be avoided until infants are 6 months old. Six months is also the recommended age for a first introduction of solid foods for formula fed infants.
- From 6 months, solid foods should be introduced gradually; starting with mashed (not pureed) fruits and vegetables and then moving on to easily manageable finger foods such as soft cooked vegetables, rice, cakes, and small pieces of bread.
- Foods, which may cause allergies (milk, eggs, wheat, seeds, nuts, fish and shellfish) should be introduced one at a time to ensure any reaction is spotted immediately. From approximately 1-year-old, children would normally be expected to eat three meals a day and two between-meal snacks.
- Foods particularly high in fat and sugar such as sweets, cakes, crisps, and deep fried foods are not necessary and should be kept to a minimum or avoided altogether.
- Care should also be taken to limit salt intake (less than 1 g/day up to age 12 months; from 1 year to 3 years no more than 2 g/day; and a maximum of 3 g/day for 4-6 year olds).
- To ensure children up to the age of two consume adequate energy for growth and development from relatively small volumes of food, full-fat versions of dairy products are recommended and foods very high in fiber should be avoided.
- From 2 years onward, gradual introduction of low-fat dairy products should be considered for children who are growing well and eating a varied diet, so that by the age of 5 most children are eating in accordance with the eat-well plate. Portion sizes should be appropriate to the age and size of the child.
- It is recommended that breastfeeding mothers take a supplement containing 10 mcg vitamin D. All babies and young children should be given vitamin drops containing vitamin D from age 6 months up to 4 years of age. Children from dark skinned minority ethnic groups are at particular risk of vitamin D deficiency.
Checking the labels
- From age 5 a healthy, balanced diet in line with adult healthy eating guidelines should be encouraged for everyone except those with specific clinical dietary requirements.
- Patients should be advised to choose foods from the 5 food groups in the proportions shown in the eat-well plate below. This includes everything eaten during the day, including snacks. Balance between the different groups is best achieved over a day or a few days rather than at each individual meal.
- The eat-well plate is suitable for healthy people of all ethnic origins and people who are of a healthy weight or overweight. It is also suitable for vegetarians.
- In line with the eat-well plate, individuals should aim to eat:
- Bread, rice, potatoes, pasta, and other starchy foods
- Eat plenty, choose wholegrain varieties when you can.
- Fruit and vegetables
- Eat plenty, at least 5 portions of a variety of fruit and vegetables a day.
- Milk and dairy foods
- Eat some, choose lower fat alternatives whenever possible or eat higher fat versions infrequently or in smaller amounts.
- Meat, fish, eggs, beans, and other non-dairy sources of protein
- Eat some, choose lower fat alternatives whenever possible or eat higher fat versions infrequently or in smaller amounts. Aim for at least two portions of fish a week, including a portion of oily fish.
- Foods and drinks high in fat and/or sugar
- Consume just a small amount.
- Try to choose options that are lower in salt when you can.
- To aid weight management it is important to encourage limiting the intake of energy-dense foods including confectionery, sugary drinks, fast foods, and alcohol.
- Portions must be appropriate for the individual's age, gender, current weight and activity level. It is very important to highlight that children require smaller portion sizes than adults.
Helping children and young people to maintain a healthy weight
- Reading labels can help individuals to choose lower fat and lower energy items.
Encourage parents and cares to:
- Ensure their children have regular meals, including breakfast, in a sociable atmosphere without distractions (such as watching television)
- Whenever possible, eat meals with their children
- Comfort their children with attention, listening and hugs instead of food
- Separate eating from other activities such as watching television or using the computer
- Encourage their children to listen to internal hunger cues and to eat to appetite
- Avoid classifying foods as good or bad
- Keep foods that their child should be avoiding out of the house.
| Physical Activity|| |
Children and young people
- Children and young people should be encouraged to increase their physical activity to manage their weight and because of the other known health benefits, such as reduced risk of type 2 diabetes and cardiovascular disease (CVD).
- Children should be encouraged to do at least 60 min of moderate to vigorous activity each day. This can be accumulated in short bouts. Children who are already overweight may need to do more than 60 min activity, but should build up their physical activity time gradually.
- Parents should be aware that more than 2 h of sedentary behavior, particularly of screen time (TV watching, computer use and playing video games), for children per day should be discouraged.
- Children should be given the opportunity and support to be more active in their daily lives (such as walking, cycling, using the stairs and active play such as skipping) and supported to do more regular, structured physical activity (such as football, swimming).
- The choice of activity should be made with the child, and be appropriate to their age, ability and confidence.
- Encourage people to try to be more active as a family-for example, walking and cycling to school and shops, going to the park or swimming.
- Providing information on local opportunities to be active will make it easier for individuals to access them and enable them to make a longer term commitment to being active.
- Physical activity advice should be tailored for different groups and individuals. This is particularly important for people who are already overweight or obese (and may have comorbidity), or at a life stage with increased risk for weight gain (such as excess weight gain in pregnancy, weight retention postnatally, at the menopause or when stopping smoking).
- Adults should be encouraged to increase their physical activity, and not expect to lose weight as a result, because of the other health benefits physical activity can bring, such as reduced risk of type 2 diabetes and CVD.
- Adults should be encouraged to do at least 30 min of moderate-intensity physical activity on 5 or more days a week.
Advice to individuals about increasing their physical activity should focus on activities that can fit easily into their everyday life and are tailored to their individual preferences and circumstances. The typical desirable activity patterns will comprise a mix of personal transport and job-related household and recreational activities.
Adults who are overweight or obese
- Encourage individuals to start by doing what they can, and then to look for ways to do more. If they have not been active for a while, they should start out slowly. After several weeks or months, activities can be built up by doing them for longer and more often.
- Walking is one way to encourage building physical activity into everyday life. When first starting, advise walking 10 min a day on a few days during the first couple of weeks.
- Add more time and days. Encourage individuals to walk a little longer. Trying 15 min instead of 10 min and walking on more days a week.
- Pick up the pace. Once this is easy to do, encourage them to try walking faster. After regular brisk walking for a couple of months, try, for example, adding biking or swimming at weekends for variety.
- Overweight or obese individuals should be encouraged to increase energy expenditure by increasing the daily amount of physical activity they do as well as decreasing the amount of time spent on sedentary behaviors, for example television watching. The recommendations for physical activity are summarized as follows:
- To prevent the gradual adult transition to overweight or obesity requires 45-60 min of moderate-intensity activity per day, particularly if energy intake is not reduced.
- People who have been obese and who have lost weight should be advised that they may need to do at least 60 min of moderate-intensity activity a day to sustain their weight loss.
- Adults who come into contact with the primary care should be offered an assessment of the health risks associated with their level of inactivity and then be referred to appropriate counseling and to community activities that are tailored to their specific interests.
- Adults who are overweight or obese will need to recognize that their daily requirement for the physical activity has to increase from 30 min of moderate activity to at least 60 min of moderate activity. For example:
- Making enjoyable activities part of everyday life, for example walking to and from work as part of a journey.
- Building activity into the working day, for example, taking the stairs instead of the lift, enjoying a walk at lunchtime.
- Participating in supervised exercise programs.
- Adults should be encouraged to build up to the recommended levels for weight maintenance, using a managed approach with agreed goals. Providing local information will make it easier for patients to access opportunities and enable them to make a longer term commitment to being active. Any activity should take into account the person's current physical fitness and ability.
- A reduction in sedentary activities (such as sitting for long periods, watching television, at a computer or playing video games) should be encouraged.
To participate in physical activity safely and reduce risk of injuries and other adverse events, people should:
- Understand the potential risks associated with any type of activity.
- Choose to do types of physical activity that are appropriate for their current fitness level and health goals.
- Increase physical activity gradually over time whenever more activity is necessary to meet guidelines or health goals. Inactive people should "start low and go slow" by gradually increasing how often and how long activities are carried out.
- Wear appropriate clothing and use suitable equipment where necessary.
- Be under the care of a health practitioner if they have chronic conditions or symptoms, and consult on appropriate types and amounts of activity.
| Screening for Overweight and Obesity|| |
Screening for overweight and obesity are recommended for those individuals at high-risk of developing overweight and obesity: The following individuals are at high-risk of developing overweight and obesity and should be screened using BMI.
- Smokers who cessation.
- Patient on insulin, lithium, anti-diabetes drugs, sodium valproate, steroids, oral contraceptives, hormone replacement therapy, tricyclic antidepressant, and beta blockers.
- Family history of obesity.
| Management of Obesity|| |
No-non pharmacological treatment of obesity in children and adults
Objectives of weight loss
The aims of weight loss and weight maintenance interventions include:
Health benefits of weight loss in adults
- Improve pre-existing obesity-related comorbidities
- Reduce the future risk of obesity-related comorbidities
- Improve physical, mental, and social well-being.
Healthcare professionals should make patients aware of the following health benefits associated with sustained modest weight loss:
Targets of weight loss
- Improved lipid profiles (Evidence-A).
- Reduced osteoarthritis-related disability (Evidence-B).
- Lowered all-cause, cancer, and diabetes mortality in some patient groups (Evidence-B).
- Reduced blood pressure (Evidence-B).
- Improved glycemic control (Evidence-B).
- Reduction in risk of type 2 diabetes (Evidence-B).
- Potential for improved lung function in patients with asthma (Evidence-B).
Most children managed in the Primary Health-Care Center have 'simple' obesity with no underlying medical cause, and have no comorbidity. Weight management programs should be offered to those ready and willing to make positive life-style changes.
The SIGN guideline development group made the following practical recommendations in this regard:
Weight loss targets should be based on the individual's comorbidities and risks, rather than their weight alone:
- In patients with BMI 25-35 kg/m 2 obesity-related comorbidities are less likely to be present and a 5-10% weight loss (approximately 5-10 kg) is required for CVD and metabolic risk reduction.
- In patients with BMI>35 kg/m 2 obesity-related comorbidities are likely to be present therefore weight loss interventions should be targeted to improving these comorbidities; in many individuals a greater than 15-20% weight loss (will always be over 10 kg) will be required to obtain a sustained improvement in comorbidity.
- In planning weight management programs for children and young people, treatment goals should ideally be determined by knowledge of the extent of weight or BMI (or other parameter) change, which would reduce obesity-related comorbidities.
- In most obese children (BMI ≥98 th centile) weight maintenance is an acceptable treatment goal (Evidence-D).
- For children with a BMI ≥99.6 th centile a gradual weight loss to a maximum of 0.5-1.0 kg/month is acceptable (Evidence-D).
- In overweight children (91 st to <98 th BMI centile) weight maintenance is an acceptable goal. Annual monitoring of BMI centile may be appropriate to help reinforce weight maintenance and reduce the risk of overweight children becoming obese (Evidence-D).
| Life-Style Interventions|| |
*intake of energy-dense foods (including foods containing animal fats, other high fat foods, confectionery and sugary drinks) by selecting low energy-dense foods instead (for example, whole-grains, cereals, fruits, vegetables, and salads)
- Weight loss via dietary intervention requires modifications to the type, quantity and/or frequency of food and drink consumed to achieve and maintain a hypocaloric intake. A weight loss of approximately 0.5 kg/week results from a loss of adipose tissue that entails an energy deficit of 3,500 kcal/week. This requires a daily energy deficit of at least 500 kcal/day.
- Healthcare professionals should emphasize healthy eating.
- Dietary interventions, which produce a 600 kcal/day deficit result in sustainable modest weight loss.
- When discussing dietary change with patients, health-care professionals should emphasize achievable and sustainable healthy eating.
- Individuals consulting about weight management should be advised to reduce (Evidence-B):
*consumption of "fast foods'" (e.g., "take-aways")
Physical activity in adults
- Dietary interventions for weight loss should be calculated to produce a 600 kcal/day energy deficit (Evidence-A).
- Programs should be tailored to the dietary preferences of the individual patient.
- Where very low calorie diets are indicated for rapid weight loss, these should be conducted under medical supervision (Evidence-D).
- Adults consulting about weight management should be encouraged to undertake regular self-weighing (Evidence-B).
- Delivery of evidence based weight management programs through the internet should be considered as part of a range of options for patients with obesity (Evidence-B).
- Sustainable school based interventions to prevent overweight and obesity in children should be considered by and across agencies. Parental/family involvement should be actively facilitated (Evidence-C).
Good practice in physical activity interventions
- Weight management programs should include physical activity, dietary change, and behavioral components (Evidence-A).
- Individuals consulting about weight management should be encouraged to be physically active and reduce sedentary behavior, including television watching (Evidence-B).
- Overweight or obese individuals should be supported to undertake increased physical activity as part of a multicomponent weight management program (Evidence-A).
- Overweight and obese individuals should be prescribed a volume of physical activity equal to approximately 1,800-2,500 kcal/week. This corresponds to approximately 225-300 min/week of moderate intensity physical activity (which may be achieved through 5 sessions of 45-60 min/week, or lesser amounts of vigorous physical activity) (Evidence-B).
- The following good practice points are based on the clinical experience of the SIGN guideline development group and are provided to guide safe implementation of the physical activity recommendations.
- It is important to ensure that individuals have no contraindications to exercise before commencing a physical activity program. The physical activity readiness questionnaire (PAR-Q) provides a quick and validated mechanism for determining whether individuals should undergo further screening investigations prior to embarking on a program of increased physical activity.  PAR-Q consists of seven questions that could be administered to patients to give either yes or no response as following.
- Moderate intensity physical activity increases the rate of breathing and body temperature, but conversation is comfortable at this pace. Heart rate is in the range 55-70% of age-predicted maximum (220 minus age). For obese, sedentary individuals, brisk walking (i.e., walking at faster than normal pace) often constitutes moderate intensity physical activity.
- Energy is expended at a faster rate during vigorous activity compared with moderate intensity activity, which means that the same energy can be expended in a shorter period of time. In vigorous intensity physical activity, conversation is harder, but still possible. Heart rate is 70-90% of age-predicted maximum. Some individuals may prefer this approach, as it is less time consuming, but vigorous exercise is probably not appropriate for the very obese (BMI > approximately 35 kg/m 2 ).
- Physical activity can be accumulated over the course of the day in multiple small sessions (of at least 10 min duration each) and does not need to be performed in a single session.
- Sedentary individuals should build up to their physical activity targets over several weeks, starting with 10-20 min of physical activity every other day during the first 2 weeks of the program, to minimize potential muscle soreness and fatigue. Individuals choosing to incorporate vigorous intensity activity into their program should do this gradually and after an initial 4-12 week period of moderate intensity activity.
- Walking is an excellent form of physical activity for overweight and obese people. Walking one km (0.62 miles) on flat ground burns approximately 60 kcal for a 70 kg person and 90 kcal for a 100 kg person. Such weight-bearing physical activity may be difficult for some individuals with BMI over approximately 35 kg/m 2 , particularly, for those with joint problems. In these individuals, gradually increasing non-weight-bearing moderate intensity physical activities (e.g., cycling, swimming, water aerobics) should be encouraged.
- Individual or group based psychological interventions should be included in weight management program (Evidence-A).
- Psychological interventions should be tailored to the individual and their circumstances.
- The range of appropriate psychological interventions and strategies includes:
- Self-monitoring of behavior and progress.
- Stimulus control (where the patient is taught how to recognize and avoid triggers that prompt unplanned eating).
- Cognitive restructuring (modifying unhelpful thoughts/thinking patterns).
- Goal setting.
- Problem solving.
- Assertiveness training.
- Slowing the rate of eating.
- Reinforcement of changes.
- Relapse prevention.
- Strategies for dealing with weight regain.
- Treatment program for managing childhood obesity should incorporate behavior change components, be family based, involving at least one parent/carer and aim to change the whole family's life-style.
- Programs should target decreasing overall dietary energy intake, increasing levels of physical activity, and decreasing time spent in sedentary behaviors (screen time) (Evidence-B).
- Weight maintenance and/or weight loss in children can only be achieved by sustained behavioral changes (Evidence-D), e. g:
- Healthier eating, and decreasing total energy intake
- Increasing habitual physical activity (e. g., brisk walking). In healthy children, 60 min of moderate-vigorous physical activity/day is recommended.
- Reducing time spent in sedentary behavior (e. g., watching television and playing computer games) to<2 h/day on average or the equivalent of 14 h/week.
| Pharmacological Treatment in Adults|| |
- Orlistat is the only drug specifically licensed for use in the treatment of obesity.
- Orlistat reduces the absorption of energy-dense fat by inhibiting pancreatic and gastric lipases.
- Orlistat should only be used where diet, physical activity and behavioral changes are supported.
- Orlistat should be considered as an adjunct to life-style interventions in the management of weight loss.
- Patients with BMI ≥28 kg/m 2 (with comorbidities) or BMI ≥30 kg/m 2 should be considered on an individual case basis following assessment of risk and benefit (Evidence-A).
- Orlistat should only be prescribed for severely obese adolescents (those with a BMI ≥99.6 th centile of the (KSA 2000-2001 reference chart for age and sex)  with comorbidities or those with very severe to extreme obesity (BMI ≥3.5 SD above the mean of the (KSA 2000-2001 reference chart for age and sex  (Evidence-D).
- There should be regular reviews throughout the period of use, including careful monitoring for side-effects.
- Therapy with orlistat should be continued beyond 12 weeks only if the patient has lost at least 5% of their initial body weight since starting drug treatment.
- Therapy should then be continued for as long as there are clinical benefits (e. g., prevention of significant weight regain).
| Bariatric Surgery|| |
Roles of bariatric surgery
The role of bariatric surgery as part of the overall management pathway for obesity in adults has been examined. Health benefits, harms, and factors affecting efficacy have been considered. Types of surgery, anaesthetic practice and immediate post-operative care are out of the scope of this guideline.
Factors influencing the efficacy of surgery
- Bariatric surgery should be included as part of an overall clinical pathway for adult weight management.
- Bariatric surgery should be part of a program of care that is delivered by a multidisciplinary team including surgeons, dietitians, nurses, psychologists, and physicians. There should be close communication between health professionals for effective management of patients' comorbidities as weight loss occurs.
- Specialist psychological/psychiatric opinion should be sought as to which patients require assessment/treatment prior to or following surgery.
- Bariatric surgery can be considered for post-pubertal adolescents with very severe to extreme obesity (BMI ≥3.5 SD above the mean on KSA 2000-2001 reference chart for age and sex  and severe comorbidities (Evidence-D).
Predictors of efficacy (achieving 40-60% excess weight loss) of bariatric surgery (laparoscopic adjustable gastric banding) include lower age of patient, lower BMI, male gender and not having diabetes. Surgical experience (surgeon performing greater than 1 procedure/month) is a predictor of successful outcome.
Efficacy for weight loss
- Predictors of mortality from gastric bypass include BMI >50 kg/m 2 , male gender, hypertension, high-risk of pulmonary thromboembolism and age >45.
- Binge-eating disorder, dysfunctional eating behavior, past history of intervention for substance misuse, psychological dysfunction or depression should not be considered absolute contraindications for surgery (Evidence-C).
Bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in patients who fulfill the following criteria (Evidence-C):
*evidence of completion of a structured weight management program involving diet, physical activity, psychological, and drug interventions, not resulting in significant and sustained improvement in the comorbidities.
- BMI ≥35 kg/m 2
- Presence of one or more severe comorbidities, which are expected to improve significantly with weight reduction (e.g., severe mobility problems, arthritis, type 2 diabetes) and
- There is insufficient evidence in patients with BMI<35 kg/m 2 on which to base a recommendation.
Harms and the balance of risks
- Overall mortality is 29-40% lower in the seven to 10 years post-surgery in patients receiving bariatric surgery (adjustable or non-adjustable gastric banding, vertical banded gastroplasty or gastric bypass) compared to BMI-matched subjects not receiving surgery.
- On examining specific causes of death, there is a 49% lower mortality from CVD and a 60% lower mortality due to cancer in patients receiving gastric bypass surgery in the 7 years post-surgery compared to BMI-matched subjects not receiving surgery.
- There is a 58% higher mortality from non-disease causes (accidents, poisoning, suicide) in the 7 years post-surgery in patients receiving bariatric surgery compared with severely obese individuals from a general population.
- There is some evidence that individuals who seek bariatric surgery have differing baseline psychological status (e.g., increased anxiety levels) compared to those at similar obesity levels, but who do not seek surgery.
- Adjustable gastric banding bariatric surgery resulted in remission of diabetes in 73% of the surgical group and 13% of the control group.
- Compared with the best available non-surgical weight loss treatment, bariatric surgery significantly reduces the likelihood of hypertriglyceridaemia and low high density lipoprotein (HDL) cholesterol at 2 years follow up.
- In patients on drug treatment for CVD, those receiving bariatric surgery (adjustable or non-adjustable gastric banding, vertical banded gastroplasty and gastric bypass) were 23% less likely to still be on these drugs 6 years post-surgery compared to patients receiving the best non-surgical weight loss treatment available.
- Weight loss with bariatric surgery results in significant improvement or resolution of the three components of non-alcoholic fatty liver disease-steatosis, steatohepatitis and fibrosis.
Preparation and follow-up
- Post-operative complications included bleeding (0.5%), thromboembolic events (0.8%), wound complications (1.8%), deep infection-abscess or leak (2.1%), pulmonary complications (6.2%), and miscellaneous complications (4.8%). Complications necessitated re-operation in 2.2% of patients.
- Mortality in the 1 st year post-surgery was 0.53% in the surgery group compared with 0.52% in the BMI-matched control group.
- In male patients who receive bariatric surgery (adjustable or non-adjustable gastric banding, vertical banding gastroplasty or gastric bypass) have a 4.2 times increased incidence of cholelithiasis, 4.5 times increased incidence of cholecystitis and a 5.4 times increased incidence of cholecystectomy compared to the patients receiving the best available non-surgical weight loss treatment.
Very little high quality evidence was identified on the effectiveness of supportive interventions in influencing safety or efficacy of surgery. The following sections outline this evidence base and provide good practice points based on clinical experience.
- Dietary counseling should be provided before and after surgery. A standard dose of a multivitamin and micronutrient supplement could be considered post bariatric procedures.
- Healthcare professionals should undertake the following in all patients post bariatric surgery:
- Simple clinical assessments of micronutrient status (e.g.,: Ask about hairloss, neuropathic symptoms, skin and oral lesions, muscle weakness)
- Simple blood tests (e.g.,: Full blood count, calcium, magnesium, phosphate and albumin).
- Only patients with abnormalities should be considered for formal biochemical measurements of micronutrient status.
- Calcium and vitamin D supplements (800 IU/day cholecalciferol) should be considered for all patients undergoing bariatric surgery. Baseline calcium and vitamin D should be measured to avoid iatrogenic hypercalcaemia.
- Patients should be supported to increase their physical activity in a sustainable manner post-surgery.
- Policies on the criteria for receiving plastic surgery post bariatric surgery should be developed. These should be based on both BMI and consideration of long-term benefit balanced against risks for the individual patient.
- Patients should be made aware of these policies as part of their informed consent for bariatric surgery.
- Plastic surgery should be delayed until weight loss post bariatric surgery has reached a plateau.
| Referral and Service Provision in Adults|| |
No specific evidence was identified on when to refer patients from primary to secondary care for weight management. Management pathways will depend on local service provision. The primary purposes of referral of children are to exclude underlying medical causes of obesity and to treat comorbidity. The vast majority of patients will not have an underlying medical cause.
The following groups should be referred to hospital or specialist pediatric services before treatment is considered:
- Children who may have serious obesity-related morbidity that requires weight loss (e.g., benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, orthopedic problems and psychological morbidity) (Evidence-D).
- Children with a suspected underlying medical (e.g., endocrine) cause of obesity including all children under 24 months of age who are severely obese (BMI ≥99.6 th centile).
- Suspect an underlying medical cause of obesity if a child is obese and also short for their age.
| Implementing the Guideline|| |
This section provides advice on the resource implications associated with implementing the key clinical recommendations, the possible barriers and advice on specific interventions and audit as a tool to aid implementation.
Implementation of national clinical guidelines is the responsibility of each health-care provider. Mechanisms should be in place to review care provided against the guideline recommendations. The reasons for any differences should be assessed and addressed where appropriate. Local arrangements should then be made to implement the national guideline in practice.
Recommendations with Suggested Resource Implication
Barriers Facing Implementations of the Guideline and their Interventions
| Auditing Current Practice|| |
A first step in implementing a clinical practice guideline is to gain an understanding of current clinical practice. Audit tools designed around guideline recommendations can assist in this process. Audit tools should be comprehensive but not time consuming to use. Successful implementation and audit of guideline recommendations requires good communication between staff and multidisciplinary team working.
The guideline group has identified the following as key points to assist with the implementation of this guideline:
- Percentage of identified adult patients with a BMI >30 kg/m 2 who have access to/are participating in a weight management program, which includes physical activity, dietary change, and behavioral components.
- Percentage of adult patients appropriately prescribed pharmacological treatment as an adjunct to life-style interventions.
- Percentage of severely obese adult patients, BMI≥35 kg/m 2 undergoing surgery as a treatment option for obesity, where locally derived criteria have been observed.
- Percentage of identified obese children with serious obesity-related morbidity or suspected underlying cause who have been referred to hospital or specialist pediatric services.
- Percentage of identified overweight or obese children, who are offered a multicomponent family based weight management intervention.
| Key Recommendations|| |
The following recommendations and good practice points were highlighted by the guideline development group as being clinically very important. They are the key clinical recommendations that should be prioritized for implementation.
Prevention of overweight and obesity in children and young people
Sustainable school based interventions to prevent overweight and obesity should be considered by and across agencies. Parental/family involvement should be actively facilitated (Evidence-C).
Prevention of overweight and obesity in adults
Individuals consulting about weight management should be advised to reduce (Evidence-B):
Intake of energy-dense foods (including foods containing animal fats, other high fat foods, confectionery and sugary drinks) by selecting low energy-dense foods instead (for example wholegrains, cereals, fruits, vegetables, and salads).
Individuals consulting about weight management should be encouraged to be physically active and reduce sedentary behavior, including television watching (Evidence-B).
- Consumption of "fast foods" (e.g., "take-aways")
- Alcohol intake.
Diagnosis and screening in children and young people
BMI centiles should be used to diagnose overweight and obesity in children (Evidence-C).
Assessment in adults
Health-care professionals should discuss willingness to change with patients and then target weight loss interventions according to patient willingness around each component of the behavior required for weight loss, e.g., specific dietary and/or activity changes (Evidence-D).
Weight management in adults
Weight management programs should include physical activity, dietary change, and behavioral components (Evidence-A).
Dietary interventions in adults
Dietary interventions for weight loss should be calculated to produce a 600 kcal/day energy deficit. Programs should be tailored to the dietary preferences of the individual patient (Evidence-A).
Physical activity in adults
Overweight and obese individuals should be prescribed a volume of physical activity equal to approximately 1,800-2,500 kcal/week. This corresponds to approximately 225-300 min/week of moderate intensity physical activity (which may be achieved through 5 sessions of 45-60 min/week, or lesser amounts of vigorous physical activity) (Evidence-B).
Pharmacological treatment in adults
Orlistat should be considered as an adjunct to life-style interventions in the management of weight loss. Patients with BMI ≥28 kg/m 2 (with comorbidities) or BMI ≥30 kg/m 2 should be considered on an individual case basis following assessment of risk and benefit (Evidence-A).
Bariatric Surgery in Adults
Bariatric surgery should be included as part of an overall clinical pathway for adult weight management. Bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in patients who fulfill the following criteria: (Evidence-C)
And evidence of completion of a structured weight management program involving diet, physical activity, psychological, and drug interventions, not resulting in significant and sustained improvement in the comorbidities.
- BMI ≥35 kg/m 2
- Presence of one or more severe comorbidities, which are expected to improve significantly with weight reduction (e.g., severe mobility problems, arthritis, type 2 diabetes).
Treatment of obesity in children and young people
Treatment programs for managing childhood obesity should incorporate behavior change components, be family based, involving at least one parent/carer and aim to change the whole family's lifestyle. Programs should target decreasing overall dietary energy intake, increasing levels of physical activity and decreasing time spent in sedentary behaviors (screen time) (Evidence-B).
Bariatric surgery can be considered for post pubertal adolescents with very severe to extreme obesity (BMI≥3.5 SD above the mean on Saudi Growth Charts) and severe comorbidities (Evidence-D).
- In most obese children (BMI ≥98 th centile) weight maintenance is an acceptable treatment goal (Evidence-D).
- Weight maintenance and/or weight loss can only be achieved by sustained behavioral changes, (Evidence-D), e.g.,
- Healthier eating, and decreasing total energy intake.
- Increasing habitual physical activity (e.g., brisk walking). In healthy children, 60min of moderate-vigorous physical activity/day is recommended.
- Reducing time spent in sedentary behavior (e.g., watching television and playing computer games) to <2 h/day on average or the equivalent of 14 h/week.
- The following groups should be referred to hospital or specialist pediatric services before treatment is considered: (Evidence-D).
- Children who may have serious obesity-related morbidity that requires weight loss (e.g., benign intracranial hypertension, sleep apnea, obesity hypoventilation syndrome, orthopaedic problems and psychological morbidity).
- Children with a suspected underlying medical (e.g., endocrine) cause of obesity including all children under 24 months of age who are severely obese (BMI ≥99.6 th centile).
- Orlistat should only be prescribed for severely obese adolescents (those with a BMI ≥ 99.6 th centile) with comorbidities or those with very severe to extreme obesity (BMI ≥3.5 SD above the mean) attending a specialist clinic. (Evidence-D).
- There should be regular reviews throughout the period of use, including careful monitoring for side-effects.
| Acknowledgments|| |
Saudi Arabian Society of Metabolic and Bariatric Surgery (SASMBS) introduce deep appreciation to Scottish Intercollegiate Guidelines Network (SIGN) for giving us the permission to adapt SIGN guideline on obesity in Saudi Arabia. SASMBS extends the greatest thank to the members of GAG and the reviewers for their hard effort and spending their valuable times to adapting, editing and reviewing this guideline.
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