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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 September 10, 2019 e609 CLINICAL STATEMENTS AND GUIDELINES

4 OTHER FACTORS AFFECTING

CARDIOVASCULAR RISK

4.1 Adults With Overweight and Obesity

Recommendations for Adults With Overweight and Obesity Referenced studies that support recommendations are summarized in Online Data Supplements 8 and 9.

COR LOE Recommendations

I B-R 1.  In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.0650

I B-R 2.  Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.S4.1-1,S4.1-2

I C-EO 3.  Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations.

IIa B-NR 4.  It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk.S4.1-3–S4.1-6

Synopsis

The increased availability of affordable, palatable, and high-calorie foods and the decreased physical demands of many jobs have fueled the epidemic of obesity and the consequent increases in hypertension and T2DM.S4.1-7 Adults diagnosed as obese (BMI ≥30 kg/m2) or overweight (BMI=25 to 29.9 kg/m2) are at increased risk of ASCVD, heart failure, and atrial fibrillation, compared with those of a normal weight.S4.1-8,S4.1-9 The nutritional aspects of obesity revolve around the principle of balancing caloric intake with caloric expenditure. Following the 2013 Guideline for the Management of Overweight and Obesity in Adults from the AHA, ACC, and The Obesity Society (TOS), adults with overweight/ obesity are advised to participate in comprehensive lifestyle programs of ≥6 months’ duration that assist participants in adhering to a low-calorie diet (800 to 1500 kcal/day) and increased physical activity. Existing clinical guidance strongly recommends face-to-face or telephone-delivered weight-loss maintenance programs that provide regular contact (at least monthly) with a trained interventionist to help participants engage in high levels of physical activity (200 to 300 minutes/ week), monitor body weight regularly (at least weekly), and consume a reduced-calorie diet.S4.1-10 US Food and Drug Administration (FDA)–approved pharmacological therapiesS4.1-1,S4.1-11 and bariatric surgery,S4.1-12 adjunctive to complementary lifestyle interventions, additionally reduce weight and may have a role in weight loss for select patients. The present guideline document focuses primarily on lifestyle interventions for overweight and obesity, as outlined in the 2013 AHA/ACC/TOS Guideline for the Management

of Overweight and Obesity in Adults.S4.1-10 Weight loss interventions should be cautiously implemented and individualized, especially in older adults, to avoid detrimental effects, such as loss of lean body/muscle mass and nutritional deficiencies.S4.1-13–S4.1-15

Recommendation-Specific Supportive Text

1 Clinically meaningful weight loss (≥5% initial

weight) is associated with moderate improvement in BP, low-density lipoprotein cholesterol (LDL-C), triglyceride, and glucose levels among individuals with overweight/obesity.S4.1-1 Weight loss reduces or delays the development of T2DM in persons with obesity.S4.1-1,S4.1-16,S4.1-17 High-intensity (≥14 sessions in 6 months) comprehensive weight-loss interventions provided by a trained interventionist work best.S4.1-10 However, other modalities, such as electronically delivered weight-loss programs with personalized feedback and some commercial-based programs, have also shown moderate results. 2.	Comprehensive lifestyle intervention consists of a structured program, which includes regular selfmonitoring of food intake, physical activity, and weight. Increased physical activity, preferably aerobic physical activity (eg, brisk walking) for ≥150 minutes/ week (equal to ≥30 minutes/day on most days of the week), is recommended for initial weight loss.S4.1-10 Higher levels of physical activity, approximately 200 to 300 minutes/week, are recommended to maintain weight loss or minimize weight regain after 1 year. Adults with obesity are also typically prescribed a diet designed to reduce caloric intake by ≥500 kcal/ day from baseline, which often can be attained by limiting women to 1200 to 1500 kcal/day and men to 1500 to 1800 kcal/day.S4.1-10 A very-low-calorie diet (defined as <800 kcal/day) should be prescribed only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision.S4.1-10 Comprehensive lifestyle intervention has been shown to produce on average 8 kg of weight loss (5% to 10% of initial body weight) in the short term (≤6 months) and intermediate term (6 to 12 months), compared with usual care.S4.1-1,S4.1-10 However, longer interventions after 1 year are associated with gradual weight gain of 1 or 2 kg/year (on average), compared with usual care. Weight loss of 5% to 10% of initial weight, achieved through comprehensive lifestyle intervention, has been shown to improve BP, delay the onset of T2DM, improve glycemic control in T2DM, and improve lipid profile.S4.1-1,S4.1-2

3 Measures used to estimate body fat and quan-

tify the associated health risks include BMI, waist

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