GUIDELINE

Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 25-40

Prevention and management of obesity: Saudi guideline update

Fahad S Al-Shehri¹, Mohammed M Moqbel¹, Yahia M Al-Khaldi¹, Abdullah M Al-Shahrani², Waleed S Abu-Melha³, Aayed R Alqahtani⁴, Adnan A Sabbahi⁵, Alhasan M Alkaud⁶, Haitham Alfalah⁷, Khalid I Alqumaizi⁸, Mohammad Y Saeedi⁹, Mohammed Y Alharbi¹⁰, Mourad Elmourad¹¹, Mustafa Salih Mustafa¹², Omar A Alobaid¹³, Saleh M AlRajhi¹⁴, Shaker A Alomary¹⁵, Ahmed Jafar Al Eid¹⁶, Syed Arif Hussain¹⁷, Yassin Hassan Alsa¹⁷, Mohamed E Ibrahim¹⁷, Fahad A Alamri¹⁷, Muteb Z Almalki⁷, Talal F Almoreished^17
1 Department of Family Medicine, Ministry of Health, Southern Region, KSA
² Department of Family Medicine, College of Medicine, University of Bisha, KSA
³ Department of Family Medicine, Armed Forced Hospital, Southern Region, KSA
⁴ Director of KSU Obesity Chair, College of Medicine, King Saud University, Riyadh, KSA
⁵ Consultant General, Laparoscopic and Bariatric Surgeon, Kind Saud Medical City, Riyadh, KSA
⁶ Family and Bariatric Medical Consultant, Kind Saud Medical City, Riyadh, KSA
⁷ Consultant Bariatric Surgery, Kind Saud Medical City, Riyadh, KSA
⁸ Consultant Family and Community Medicine, Dean, College of Medicine, Imam University, Riyadh, KSA
⁹ Consultant Family and Community Medicine -Director General for Genetic and Chronic Diseases, KSA
¹⁰ Consultant of Pediatric Endocrinology, Dialectology and Obesity, Director of Diabetes, Centers and Units Administration, KSA
¹¹ Consultant Endocrine, Senior Advisor for Genetics and Chronic Directorate, KSA
¹² Health Management, Policy and Planning, General Directorate for Genetic and Chronic Diseases, KSA
¹³ Associate Professor of Surgery, College of Medicine, King Saud University, Riyadh, KSA
¹⁴ Chairman of Obesity, Department Obesity Metabolic and Endocrine Center, King Fahad Medical City, Riyadh, KSA
¹⁵ Director of Obesity Control Program, KSA
¹⁶ Obesity Control Program in Eastern Province, KSA
¹⁷ General Directorate for Genetic and Chronic Diseases, MOH, KSA

Correspondence Address:
Dr. Fahad S Al-Shehri
Saudi Arabian Society of Metabolic and Bariatric Surgery (SASMBS), PO Box: 2653, Abha
KSA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2347-2618.184970

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 problem at all levels. This guideline was adapted from Scottish Intercollegiate Guidelines Network and other international guidelines for prevention and management overweight and obesity. 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: Saudi, Guideline, Obesity, overweight

Introduction

Guidelines Development Process

• Clinical practice guidelines for the management of overweight and obesity in adults, adolescents, and children in Australia ^[4]
• Canadian clinical practice guidelines on the management and prevention of obesity in adults and children ^[3]
• The National Institute for Health and Care Excellence guidelines (obesity: identification, assessment, and management of overweight and obesity in children, young people, and adults [November 2014]) ^[9]
• Institute for Clinical Systems Improvement (ICSI) (prevention and management of obesity for children and adolescents). ^[10]

Target Users of the Guideline

How to Use the Guideline

Primary Prevention of Obesity

• For all age groups, assess diet, physical activity, and sedentary behaviors annually (Institute for Clinical Systems Improvement [ICSI], strong recommendation, high-quality evidence) ^[10]

• Recommend exclusive breastfeeding from birth up to the age of 6 months (ICSI, high-quality evidence) ^[8],[10]
• Gradually introduce solid food starting at the age of 6 months ^[8]
• Carefully introduce - one at a time-foods which may cause allergies such as milk, eggs, wheat, seeds, nuts, fish, and shellfish ^[8]
• Provide three meals and two between-meal snacks for children 1 year old; ^[8]
• Avoid high fiber foods and large volume of full-fat dairy products in below 2 years children ^[8]
• Introduce gradually, low-fat diary product, for normally growing above 2 years old children ^[8]
• Adjust salt intake to the age of the child; (<1 g/day up to age 12 months; from 1 to 3 years no more than 2 g/day; and a maximum of 3 g/day for 4-6 year old). ^[8]

• Recommend food in accordance with healthy eating guidelines from the age of 5 years onward unless there is specific clinical dietary requirement [Table 1]. Adjust portion sizes to age, gender, weight, and activity level ^[8],[10]
  • Encourage children to eat regular meals including breakfast (ICSI, strong recommendation, high-quality evidence) ^[10]
  • Discourage availing easy access to foods not recommended for the child ^[8]
  • Encourage intake of low salt foods and limit the intake of energy-dense foods and fast foods (SIGN, evidence Grade B) ^[8]
  • Follow the 5-2-1-0 message every day:
    • 5 = Encourage intake of daily 5 rations of fruits and vegetables (ICSI, strong recommendation, high-quality evidence)
    • 2 = Encourage eating with the child in a sociable atmosphere without distractions, separate eating from other activities and keep recreational screen time to <2 hour, (ICSI, strong recommendation, high-quality evidence) ^[10]
    • 1 = Include at least 1 hour or more of active play every day (physical activity section below)
    • 0 = Skip sugar-sweetened beverages and drink more water every day.
  • Advise patients using medications associated with weight gain on weight management (SIGN, evidence Grade B). ^[8]

Table 1: The eat-well plate guidelines Click here to view

• Encourage children gradually to perform at least 60 minutes of moderate to vigorous exercise daily (continuous or accumulated in short bouts) (ICSI, moderate recommendation, high-quality evidence) ^[8],[10]
• Encourage children to lead active daily life such as walking, cycling, skipping, and using the stairs and support them to practice regular physical activity appropriate to their age and ability such as football and swimming ^[8]
• Discourage sedentary behavior of more than 2 hour for children particularly of screen time (TV watching, computer use, and playing video games (ICSI, strong recommendation, high-quality evidence) ^[8],[10]
• Encourage family approach to physical exercise (e.g., walking and cycling to school and shops, going to the park or swimming). ^[8]

• Provide physical activity advice appropriate to specific individual situations. The focus should be on activities that can fit easily into their everyday life and are tailored to their individual preferences and circumstances. Attention should be given to pregnant women, postnatal weight retention, menopause or when stopping smoking ^[8]
• Inform the individuals about the benefits of physical activity on reducing the risk of cardiovascular disease (CVD) and type 2 diabetes, even without evident weight reduction ^[8]
• Encourage adults to do at least 30 minutes of moderate-intensity physical activity on 5 or more days a week. This should be built up over time; start by walking 10 minutes a day on a few days during the first couple of weeks then add more time and days gradually. ^[8]

A-Management of Childhood Obesity

• Use the Saudi sex-specific BMI for age percentile chart for assessing overweight and obesity in infants and children 0-19 years of age (there are two sets of charts, Birth to 36 months and 2-19 years) ^[12],[13] [Annex 7]. The Growth Chart for Saudi Children and adolescents categorizes overweight as between the 85 ^th and 95 ^th percentile and obesity as above the 95 ^th percentile [Annex 7]
• Inquire about the presence of parental obesity, type 2 diabetes, and CVD which are a strong predictor a child's weight and comorbidities (ICSI, strong recommendation, high-quality evidence) ^[4],[10]
• Assess child developmental history, physical and mental health and assess for current health problems, comorbidities (e.g., raised blood pressure, joint pain, gastrointestinal symptoms, insulin resistance, intertrigo, dental health) and risks for future disease (ICSI, strong recommendation, high-quality evidence). ^[4],[10]

• In children and prepubertal adolescents, the goal should be weight maintenance rather than weight loss. Maintaining weight during growth will result in a declining BMI and will prevent potential adverse effects (Australian National Health and Medical Research Council [NHMRC], evidence Grade D)
• In postpubertal adolescents, the goal is weight loss rather than weight maintenance. ^[4]

• Recommend early start of weight management in children and adolescents with the objectives of preventing adulthood overweight or obesity, reducing risk of comorbidities and enhancing positive lifestyle behaviors ^[4]
• Target weight management of the child or adolescent through family approach (addressing healthy lifestyle behavior of the whole family) (ICSI, strong recommendation, high-quality evidence) (NHMRC, evidence Grade PP) ^[4]
• Recommend frequent contacts with health professionals for children and adolescents (NHMRC, evidence Grade B) ^[4]
• Consider child preference, ability, and strength when choosing lifestyle activities. It is recommended that the activities should be fun, recreational, and tailored to the relative strengths of child and family (Canadian, evidence Grade A, Level 2) ^[3]
• Lifestyle interventions should focus on changing the health behaviors, healthy diet, and physical activity: ^[4],[10]
  • Advice the reduction of screen time to <2 h/day (ICSI, strong recommendation, high-quality evidence)
  • Encourage daily 60 minutes of moderate and vigorous exercise (e.g., household tasks, walking to school, sports clubs, swimming pool, walking tracks., etc.) (ICSI, strong recommendation, moderate quality evidence)
  • Encourage children to have regular meals in a sociable atmosphere (ICSI, strong recommendation, high-quality evidence)
  • Encourage children to eat a nutrient-dense breakfast daily (ICSI, high-quality evidence)
  • Discourage eating energy-dense food (fast food) (ICSI, high-quality evidence)
  • Encourage children to eat to appetite (ICSI, moderate quality evidence)
  • Advice on availing healthy food choices
  • Encourage water drinking instead of sugary drinks and energy drinks (ICSI, strong recommendation, high-quality evidence)
  • Advice on separating eating from other activities (e.g., watching TV) (ICSI, moderate quality evidence).

• Specialist services may be required for the following ^[4] (NHMRC, Evidence Grade D);
  • Disordered eating,
  • Poor body image,
  • Depression and anxiety,
  • Presence of comorbidities (e.g., sleep apnea, orthopedic problems, risk factors for CVD or type 2 diabetes, and psychological distress), ^[11]
  • Suspected underlying medical or endocrine cause,
  • Concerns about height and development
• Referral to pharmacologic or bariatric surgery may be considered in postpubertal adolescents, with severe obesity (a BMI >40 kg/m ² (or >35 kg/m ² with obesity-related complications) who failed to respond to lifestyle interventions (NHMRC, Evidence Grade D). ^[4]
• Follow-up the cases regularly every 3 months (NHMRC, Evidence Grade PP). ^[4]

B-Adulthood Obesity Management

• Conduct a thorough history and a general physical examination to assess obesity, overweight, and obesity-related risks and to exclude secondary causes of obesity (Canadian, Evidence Grade A, Level 3) [Table 2], [Table 3], [Table 4], [Table 5], [Table 6] ^[3],[4]
• Measure body mass index (BMI) (weight in kilograms divided by height in meters squared) to assess overweight or obesity in adults [Box 1] (Canadian, Evidence Grade A, Level 3) ^[3],[4]
• Measure waist circumference (WC) [Box 2] in addition to BMI to assess for abdominal fat and risk of obesity-related comorbidities particularly CVD and diabetes (Canadian, Evidence Grade A, Level 3) ^[3] (males with WC ≥102 cm and females with WC ≥88 cm are at high-risk of many complications) [Table 5] ^[8]
• Request/conduct laboratory tests when appropriate to assess for comorbidities. Recommended tests include:
  • Fasting plasma glucose level, lipid profile (including total cholesterol, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein (HDL) and ratio of total cholesterol to HDL) (Canadian, Evidence Grade A, Level 3), ^[3]
  • Liver enzyme tests, urinalysis and sleep studies (Canadian, Evidence Grade B, Level 3) ^[3]
• Refer for professional assessment as appropriate for eating disorders, depression, and psychiatric disorders (Canadian, Evidence Grade B, Level 3). ^[3]

Table 2: Risk factors of obesity[11] Click here to view

Table 3: Assess readiness to change in adults who are overweight or obese (NHMRC, Evidence Grade D)[4] Click here to view

Table 4: Initial assessment of overweight/obese patients Click here to view

Table 5: Comorbidities and consequences of obesity[11] Click here to view

Table 6: Evaluation of obese patient[11] Click here to view

• Assess readiness to change in adults who are [Table 3] overweight or obese (NHMRC, Evidence Grade D) ^[4]
• Inform all obese or overweight adults that modest or even minor weight reduction could bring health benefits (NHMRC, Evidence Grade D) including;
  • decreasing cardiovascular risk (reduced blood pressure and improved lipid profiles (NHMRC, Evidence Grade A) ^[4]
  • preventing, delaying progression of, or improving control of type 2 diabetes (NHMRC, Evidence Grade A), kidney disease, sleep apnea, musculoskeletal problems (NHMRC, Evidence Grade B), gastroesophageal reflux or urinary incontinence (NHMRC, Evidence Grade C) ^[4]
  • improving quality of life, self-esteem, and depression (NHMRC, Evidence Grade C)
• Lifestyle modification, e.g., physical exercise and reduced energy intake, is likely to produce some health benefits even without actual weight loss (NHMRC, Evidence Grade C). ^[4]

• The ultimate goal of weight management is to improve health and to reduce the risk of obesity-related comorbidities ^[8]
  • For adults with BMI 25-35 kg/m ² the target is to lose 5-10% of body weight (0.5-1 kg/week) ^[3],[8]
  • For adults with BMI >35 kg/m ² and obesity-related comorbidities, the target is to lose a >15-20% of body weight. ^[8]

• The focus of lifestyle modification goals should be on improving health rather than reducing weight ^[4]
• Lifestyle modification should target the following: reducing energy intake, increasing energy expenditure and assisting in behavioral change (NHMRC, Evidence Grade A) ^[4]
• Optimal dietary plan for achieving healthy body weight should be developed with a qualified and experienced health professionals team together with the individual and family ^[8]
• On discussing weight management with the patient and family, health professionals are encouraged to create a nonjudgmental atmosphere and to address barriers to weight management (Canadian, Evidence Grade C, Level 4). ^[3]

• Target energy deficit of 500-1000 kcal/day (3500 kcal/week). Attention should be given to the dietary preferences of the individual (NHMRC, Evidence Grade A) ^[4]
• Provide advice on dietary modification appropriate to the patient condition (type, quantity, and/or frequency) to achieve and maintain a hypocaloric intake (a high-protein or a low-fat diet with acceptable macronutrient distribution ranges). Patients should be advised to
  • Choose low-energy-dense foods (e.g., whole-grains, cereals, fruits, vegetables, and salads) and reduce intake of energy-dense foods (e.g., animal fats, sugary drinks (SIGN, Evidence Grade B) ^[8]
  • Reduce consumption of junk food ^[8]
  • Undertake regular self-weighing (SIGN, Evidence Grade B) ^[8]
• Strictly supervise patients on very low-calorie diets prescribed for rapid weight loss (SIGN, Evidence Grade D). ^[8]

• Encourage overweight or obese individuals to be physically active and to avoid sedentary behavior (SIGN, Evidence Grade B) ^[8]
• Prescribe a volume of physical activity that produce energy deficit of approximately 1800-2500 kcal/week. This could be achieved through 5 sessions of 45-60 minutes/week of moderate-intensity physical activity, or lesser amounts of vigorous physical activity (SIGN, Evidence Grade B); ^[8] however, the individuals can perform multiple small sessions of at least 10 min duration during the day to accumulate the required physical activity volume ^[8]
• Clinically assess the individual physical fitness to perform the required physical exercise ^[8]
• Build up the pace of physical activity gradually over time. The volume of physical exercise should be sustainable and tailored to the individual condition (Canadian, Evidence Grade A, Level 2); ^[3]
  • Sedentary individuals should start with 10-20 minutes of physical activity every other day during the first 2 weeks ^[8]
  • Vigorous intensity activity should be introduced gradually after an initial 4-12 week period of moderate intensity activity ^[8]
  • Encourage nonweight-bearing moderate intensity physical activities (e.g., cycling, swimming, water aerobics) for obese patients suffering from joint problems (BMI over 35 kg/km ² ) ^[8]
  • Brisk walking can be classified as moderate intensity physical activity in obese individuals. 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. ^[8]

• Psychological interventions should be part of any weight management program (SIGN, Evidence Grade A) ^[8]
• It should be adjusted to circumstances of the individuals or their families. ^[8] The objectives are to decrease dietary energy intake, increasing physical activity, and decreasing sedentary behaviors (SIGN, Evidence Grade B) ^[8]
• Weight management of obese child should include a family-based behavior change components targeting lifestyle change of the whole family (SIGN, Evidence Grade B) ^[8]
• Sustained behavioral changes are essential to achieve weight maintenance and/or weight loss in children (SIGN, Evidence Grade D). ^[8]

• Devise strategies appropriate to specific individual situations to prevent or minimize weight regain in adults who successfully achieved weight loss (NHMRC, Evidence Grade A) ^[4]
• Advice adults who successfully achieved weight loss, to consult health professionals if they observed small amount of weight regain (approximately 3 kg). Health professionals should reassess the lifestyle modification maintenance program for the individual (NHMRC, Evidence Grade PP) ^[4]
• Encourage motivation for long-term weight management through approaches including self-management (e.g., manage hunger, reviewing goals, and regular self-weighing), continuing contact with health professionals and behavioral strategies (NHMRC, Evidence Grade PP). ^[4]

• Referral to pharmacologic treatment may be considered as an adjunct to lifestyle interventions in individuals with BMI >30 kg/m ² or BMI >28 kg/m ² with comorbidities or in adults who are not attaining, or who are unable to maintain clinically important weight loss with dietary and exercise therapy (Canadian, Evidence Grade B, Level 2, SIGN Evidence Grade A) ^[3],[4]
• Refer for specialist services if needed for comorbidities such as musculoskeletal, physiological, endocinological, sleep apnea and type 2 diabetes (NHMRC, Evidence Grade D) or when a very low-energy diet is recommended ^[4]
• Refer when bariatric surgery is a consideration;
  • Adults with BMI >40 kg/m ² ,
  • Adults with BMI >35 kg/m ² and comorbidities not adequately improved with the lifestyle intervention
  • Adults with a BMI >30 kg/m ² with poorly controlled type 2 diabetes and high risk of CVDs.

Pharmacological Treatment

Table 7: Characteristics of anti-obesity medications[15],[16],[17],[18],[19],[20],[21] Click here to view

• Consider adding pharmacologic agent to lifestyle interventions on an individual case basis after assessment of risks and benefits;
  • In obese adults (BMI ≥30 kg/m ² ) who failed to achieve or maintain weight loss with lifestyle modification program, (Canadian, Evidence Grade B Level 2), (SIGN, Evidence Grade A) ^[3],[8]
  • In obese or overweight individuals (BMI ≥28 kg/m ² with comorbidities) to assist in reducing obesity-related comorbidities (type 2 diabetes, impaired glucose tolerance or risk factors for type 2 diabetes), (Canadian, Evidence Grade B Level 2), (SIGN, Evidence Grade A) ^[3],[8]
  • In prepubertal obese children, pharmacological therapy is generally not recommended; however, it can be considered only (treatment with Orlistat) under supervision of specialized team, if severe comorbidities are present (e.g., orthopedic problems, sleep apnea, severe psychological disease) or within the context of a supervised clinical trial (Canadian, Evidence Grade C, Level 4) (the National Institute for Health and Care Excellence [NICE], 2006, amended 2014) ^[3],[9]
• Discuss with the patient the potential benefits, limitations, drugs' side effects, and the temporary nature of the weight loss achieved with medications before initiating therapy (NICE, 2006, amended 2014) ^[9]
• Discontinue use if the drug is ineffective, or if there are serious adverse effects ^[9]
• Do not continue orlistat therapy in adults beyond 12 weeks unless the patient has lost at least 5% of their initial body weight with treatment. Continuation of treatment should be judged on the presence of clinical benefits (e.g., prevention of significant weight regain). ^[8]

Bariatric Surgery

• Consider bariatric surgery as part of an overall clinical pathway for adult weight management. (SAGES evidence Level 1, Grade A) [Table 8] ^[22]
• Consider bariatric surgery on an individual case basis after assessing the risks and benefits (SIGN, evidence Grade C) ^[8]
• Consider bariatric surgery;
  • In adults with clinically severe obesity (BMI >40 kg/m ² ). It is the most effective treatment for morbid obesity, it leads to durable weight loss and improvement of comorbidities (SAGES evidence Level 1, Grade A) ^[22]
  • In adults with BMI >35 kg/m ² and severe comorbidities (SIGN, evidence Grade C) (Canadian, evidence Grade B, Level 2) ^[3],[8]
  • In adults with BMI >30 kg/m ² who have poorly controlled type 2 diabetes and are at increased cardiovascular risk (NHMRC, evidence Grade PP) ^[4]
  • In "postpubertal adolescents with very severe to extreme obesity and severe comorbidities (SIGN, evidence Grade D). ^[8]"
  • Bariatric surgery in adolescents is to be limited to exceptional cases and performed only by experienced teams (Canadian, evidence Grade C, Level 4) ^[3]
  • In cases of failure of significant and sustained improvement of obesity-related comorbidities with lifestyle interventions alone ^[8]
• It should be delivered by an experienced and well trained multidisciplinary team (including, surgeons, dietitians, nurses, psychologists and physicians) (SAGES evidence Level 3, Grade C). ^[22] However, types of surgery, anesthetic practice and immediate postoperative care are out of the scope of this guideline
• Assess for psychological disorders preoperatively (SAGES evidence Level 3, Grade C). Treated psychopathology does not prevent patients to undergo bariatric surgery (SAGES evidence Level 2, Grade B) ^[22]
• Intragastric balloon is a safe and effective procedure in weight reduction, but, unfortunately, the results are temporal and almost all patients return to their initial weights after balloon removal. ^[23],[24]

Table 8: Common types of bariatric surgery[22] Click here to view

References

1.	World Health Organisation (WHO). Obesity: Preventing and Managing the Global Epidemic. Report on a WHO Consultation. (WHO Technical Report Series 894). Geneva: WHO; 2000. Available from: http://www.apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol =10 &codcch=894#. [Last accessed on 2016 Apr 03].
2.	The Scottish Government. Preventing Overweight and Obesity in Scotland: A Route Map towards Healthy Weight. Edinburgh: The Scottish Government; 2010. Available from: http://www.dumgal.gov.uk/CHttpHandler.ashx?id=10075&p = 0. [Last access on 2016 Apr 03].
3.	Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176:S1-13.
4.	Australian Government: Department of Health and Aging. Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia. Canberra; 2003. Available from: http://www.healthyactive.gov.au/internet/main/publishing.nsf/Content/obesityguidelines-guidelines-adults.htm; https://www.healthyactive.gov.au/internet/main/publishing.nsf/Content/obesityguidelines-index.htm. [Last accessed on 2016 Apr 04].
5.	Australian National Health and Medical Research Council. Summary Guide for the Management of Overweight and Obesity in Primary Care. Canberra, Commonwealth of Australia; 2013. Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57b_obesity_guidelines_summary_guide_131219.pdf. [Last accessed on 2015 Jan 14].
6.	Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al. Obesity and Associated Factors -Kingdom of Saudi Arabia, 2013.Prev Chronic Dis. 2014 Oct 9;11:E174.
7.	Al Shehri A, Al Fattani A, Al Alwan I. Obesity among Saudi children. Saudi J Obesity 2013;1:3-9.
8.	Scottish Intercollegiate Guidelines Network (SIGN). Management of Obesity: A National Clinical Guideline. Edinburgh: SIGN; 2010. Available from: http://www.sign.ac.uk/pdf/sign115.pdf. [Last accessed on 2016 Apr 04].
9.	National Institute for Health and Clinical Excellence (NICE). Obesity: Identification, Assessment and Management of Overweight and Obesity in Children, Young People and Adults. London: NICE; 2014. Available from: http://www. nice.org. uk/guidance/cg189/resources/guidance-obesity-identificationassessment-and-management-of-overweight-and-obesity-in children-young-people-and-adults-pdf. [Last accessed on 2016 Apr 04].
10.	Fitch A, Fox C, Bauerly K, Gross A, Heim C, Judge-Dietz J, et al. Institute for Clinical Systems Improvement (ICSI). Prevention and Management of Obesity for Children and Adolescents. Published July, 2013.
11.	The National Guidelines for Management of Cardio-Metabolic Risk Factors in Primary Health Care; 2014.
12.	Al Herbish AS, El Mouzan MI, Al Salloum AA, Al Qureshi MM, Al Omar AA, Foster PJ, et al. Body mass index in Saudi Arabian children and adolescents: A national reference and comparison with international standards. Ann Saudi Med 2009;29:342-7.
13.	El-Mouzan MI, Al-Herbish AS, Al-Salloum AA, Qurachi MM, Al-Omar AA. Growth charts for Saudi children and adolescents. Saudi Med J 2007;28:1555-68.
14.	Snow V, Barry P, Fitterman N, Qaseem A, Weiss K. Pharmacologic and surgical management of obesity in primary care: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2005;142:525-31.
15.	Contrave ® Prescribing Information. Deerfield, IL: Takeda Pharmaceuticals America, Inc.; 2014.
16.	Nuffer WA, Trujillo JM. Liraglutide: A new option for the treatment of obesity. Pharmacotherapy 2015;35:926-34.
17.	Belviq ® Prescribing Information. Woodcliff Lake. Vol. 4. NJ: Eisai Inc.; 2014. [Saal of Obesity 2016 37].
18.	Qsymia ® Prescribing Information. Mountain View, CA: VIVUS, Inc.; 2014.
19.	Xenical ® Prescribing Information. South San Francisco, CA: Genentech USA, Inc.; 2013.
20.	Astrup A, Carraro R, Finer N, Harper A, Kunesova M, Lean ME, et al. Safety, tolerability and sustained weight loss over 2 years with the once-daily human GLP-1 analog, liraglutide. Int J Obes (Lond) 2012;36:843-54.   [PUBMED]
21.	Astrup A, Rössner S, Van Gaal L, Rissanen A, Niskanen L, Al Hakim M, et al. Effects of liraglutide in the treatment of obesity: A randomised, double-blind, placebo-controlled study. Lancet 2009;374:1606-16.
22.	Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for Clinical Application of Laparoscopic Bariatric Surgery. SAGES Guidelines Committee Endorsed by the ASMBS Received: 20 March, 2008/Accepted: 25 March, 2008 ©SAGES 2008. Available from: http://www.sages.org/ publications/guidelines/guidelines-for-clinical-application-oflaparoscopic-bariatric-surgery/. [Last accessed on 2016 Apr 04].
23.	Saruç M, Böler D, Karaarslan M, Baysal Ç, Rasa K, Çakmakçi M, et al. Intragastric balloon treatment of obesity must be combined with bariatric surgery: A pilot study in Turkey. Turk J Gastroenterol 2010;21:333-7.
24.	Angrisani L, Lorenzo M, Borrelli V, Giuffré M, Fonderico C, Capece G. Is bariatric surgery necessary after intragastric balloon treatment? Obes Surg 2006;16:1135-7.

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