Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity (original) (raw)

Abstract

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format. Click here to check the Graphical Abstract.

Keywords: Obesity, Practice guideline, Republic of Korea, Diagnosis, Therapeutics, Comorbidity

INTRODUCTION

The prevalence of obesity is rapidly increasing in Korea, with the current obesity epidemic in the country characterized by a rapid increase in morbid obesity and obesity in children, adolescents, and young adults.1 This is a worrying trend as obesity is associated with a range of comorbidities such as diabetes and heart disease.2,3 While prevention of obesity is important in managing the condition, treatment also becomes crucial in controlling obesity-related comorbidities.4 It is vital that both prevention and treatment strategies be implemented to effectively combat the obesity epidemic in Korea. This will help to improve personal and public health in the long-term.5

The target audience of “Clinical Practice Guidelines for Obesity 2022” is primary healthcare professionals, including primary care physician who manage adults, children, and adolescents with obesity living in Korea. The guidelines have two main objectives. The first is to provide evidence-based recommendations that can assist primary care physicians in making safe and effective clinical decisions. To accomplish this, the guidelines are clear in their level of evidence and consider the balance between benefits and harms. The second objective is to improve the quality of care by providing high-quality, evidence-based information that helps primary care physicians avoid unnecessary and risky treatments, ultimately leading to better outcomes for patients.

METHODS

Development process

“Clinical Practice Guidelines for Obesity 2022” is the 8th edition of obesity management guidelines published by the Korean Society for the Study of Obesity (KSSO). To evaluate the 7th edition and gather opinions on appropriate updates for the 8th edition, a survey was conducted of members of the Committee of Clinical Practice Guidelines and executive members of KSSO. As a result, five new topics were added: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and obesity treatment using information and communication technology (ICT)-based interventions. As a result, the 8th edition of the guidelines now includes 14 topics.

The development period of the guidelines was from January 2021 to November 2022. Adaptation guideline development was applied to develop this edition of the guidelines according to the manual of the Korean Ministry of Health & Welfare and Korean Academy of Medical Science.6 The recommendations provided are clear and easy to understand.

Steering board

A steering board comprising seven experts was established to oversee the entire project and planned and confirmed all processes. The adequacy of key questions was discussed with their authors and the steering board to ensure relevance and appropriateness. Conflicts among authors and reviewers regarding recommendations were resolved with the steering board’s guidance to ensure that all final recommendations are fair and unbiased. The steering board played a crucial role in ensuring the success and integrity of the project by providing oversight and resolving any issues.

Personnel involved in the development of the guidelines

The Committee of Clinical Practice Guidelines comprised multidisciplinary experts in obesity management including family physicians, endocrinologists, clinical nutritionists, exercise specialists, pediatricians, surgeons, and psychiatrists. All members of the committee received education on developing clinical practice guidelines, developing key questions, and writing recommendations through literature review, through participation in multiple workshops. To effectively develop clinical practice guidelines, tasks such as literature and previous guidelines screening, evaluation of selected guidelines, and extraction of evidence for deriving recommendations were carried out by the committee members based on their professional areas of expertise. We used the extracted evidence to derive recommendations and develop clinical guidelines.

Key questions

The key questions for each topic were developed using the patient/ problem, intervention, comparison, outcomes (PICO) format so that the answers could be used as recommendations. This format clearly presents alternatives depending on the target population and clinical condition being addressed. Key questions and their corresponding recommendations are presented in Table 1.

Table 1.

Key questions and recommendations

Literature review

A medical librarian developed literature search strategies and formulas specifically tailored to each database search engine. Utilizing these strategies, the librarian systematically searched through literature- search software for selected topics and established key questions. These searches were executed in PICO format. The publication date range of the literature searched was between January 2010 and May 2021. Report types searched were systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and guidelines. Narrative reviews were also included for topics lacking randomized clinical trials. Electronic databases of Pubmed (Medline), Embase, Cochrane Library, KoreaMed, RISS (KERIS), ScienceOn, Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), National Health and Medical Research Council (NHMRC), and Google were searched.

Level of evidence and recommendations

The level of evidence of the literature (or guidelines) used for developing the recommendations was classified into four categories (A, B, C, and D in Supplementary Table 1). The Committee of Clinical Practice Guidelines used the modified Grading of Recommendation Assessments, Development, and Evaluation (GRADE) method to determine the strength of the recommendations considering the level of evidence, benefits and harms, feasibility, acceptability, and level of applicability in primary care practice. There were four grades of recommendations (I, IIa, IIb, and III in Supplementary Table 1)7. Even if the level of evidence was low, recommendations that were considered to have clear benefits or high applicability in clinical practice were upgraded by agreement of the Committee of Clinical Practice Guidelines.

Employment of multi-level reviews and cross-checks

After initial development of the recommendations, a small group discussion method was used to review these recommendations. Review and cross-checking by the steering board and writing members resulted in revision of the initial recommendations and explanations. Then, at KSSO congresses, two public hearings on the updated management guidelines were held. The revised version after the public hearings was reviewed by executive members of KSSO who were not members of the guidelines committee. Finally, the steering board supervised and confirmed the final version. Endorsement was requested and received from relevant scientific societies and associations.

DIAGNOSTIC CRITERIA FOR OBESITY, ABDOMINAL OBESITY, AND METABOLIC SYNDROME

Diagnostic criteria for obesity, abdominal obesity, and metabolic syndrome remain the same as in the previous version (Table 2). Diagnosis of obesity based on body mass index (BMI) applies regardless of age in adults. However, in the elderly, the same BMI may indicate a higher body fat percentage due to changes in body composition caused by decreased muscle and bone mass, as well as a decrease in height. Therefore, we recommended evaluation of waist circumference (WC) in conjunction with BMI when diagnosing obesity in the elderly (I, A).8-10 For children and adolescents older than 2 years, use of the BMI percentile for age and sex based on the 2017 Korean National Growth Chart for Children and Adolescents is recommended; a BMI in the 85th percentile or higher is considered to indicate pre-obesity (overweight), while that in the 95th percentile or higher is considered to indicate obesity (I, A).11-14 Obesity in adults is divided into class 1, class 2, and class 3 obesity (extreme obesity) (BMI 35.0 kg/m2 or higher) in Korea (IIa, B).12,15 Criteria used to diagnose obesity and abdominal obesity have been established, taking into account the risk of obesity-related comorbidities.

Table 2.

Diagnostic criteria for obesity, abdominal obesity, and metabolic syndrome and risk of comorbidity according to BMI and WC in Koreans

Although the cut-off values for each criterion were the same as those used in the previous KSSO guidelines, levels of evidence and grades of recommendations were modified through evaluation.

EVALUATING OBESITY STATUS AND RELATED COMORBIDITIES AND SETTING TREATMENT GOALS PRIOR TO TREATMENT INITIATION

More than 90% of obesity cases are due to an imbalance between energy intake and expenditure, known as primary obesity. However, in some cases, secondary causes such as genetic and congenital disorders, medications, neurological and endocrine diseases, or psychiatric illnesses may be present (Table 3). Accurately identifying and addressing these underlying causes can lead to more effective weight loss. Therefore, prior to initiating obesity treatment, a medical interview and screening tests should be considered to identify secondary obesity and its causes (IIa, B).16,17

Table 3.

Causes of secondary obesity

People with obesity are at an increased risk for comorbidities stemming from metabolic abnormalities, such as hypertension, cardiovascular disease, type 2 diabetes, dyslipidemia, metabolic syndrome, gallbladder disease, gout, and some types of cancer. They also are at higher risk of developing weight-related conditions such as arthritis, low back pain, and obstructive sleep apnea compared to normal weight individuals. These obesity-related comorbidities are illustrated according to body system in Fig. 1. Refer to Table 4 for a list of tests used to evaluate obesity and its associated comorbidities.

Figure 1.

Comorbidities of obesity by body system.

Table 4.

Evaluation of obesity and its related comorbidities

The goal of obesity treatment is not exclusively centered on achieving weight loss, but rather a reduction in the risk of obesity-related diseases and an increase in overall health. A weight loss of 5% to 10%, along with improvements in lifestyle, have been shown to have clinically significant benefits. We recommend losing 5% to 10% of initial body weight within 6 months (I, A).18-20

Obesity in the elderly increases the risk of various diseases and medical costs, but there is insufficient evidence to show that weight loss can effectively prevent or treat obesity-related complications. Additionally, elderly individuals have a high incidence of osteopenia and osteoporosis, which increases the risk of fractures. Weight loss in this population may also be associated with decreased bone density and muscle mass. When treating obesity in older adults, evaluation of osteoporosis should be considered in high-risk groups, and weight loss should be considered when the benefits outweigh the risks (IIa, B).21-34 Compared to the previous version of these guidelines, the current version recommends evaluation of osteoporosis and sarcopenia when treating obesity in the elderly (IIb, B).21,35-37

LIFESTYLE-RELATED THERAPY

Diet, exercise, and behavioral therapy that induce lifestyle improvements are the mainstays of obesity treatment. General principles in this field remain unchanged from the previous edition of the guidelines. See Table 1 for detailed recommendations.

This edition of the guidelines recommends individualizing the amount of energy restriction and the composition of macronutrients (carbohydrates, fats, proteins) for weight loss. Adequate protein intake is important to prevent sarcopenic obesity in the treatment of elderly obesity. A very low energy diet (VLED) that severely restricts calorie intake to 800 kcal or less per day can result in significant short-term weight loss; however, this rapid weight loss method can cause various medical problems. Therefore, VLED should only be performed under the supervision of trained professionals under limited circumstances. In the 8th edition guidelines, we recommend a nutritionally appropriate diet and reduction of energy intake as was recommended in the previous edition of the guidelines and additionally emphasize “healthy eating habits” (I, A).38-40 Refer to Table 5 for the diverse types of diets that can be implemented.

Table 5.

Summary of the characteristics of diverse diet therapies

With regard to exercise therapy, individuals with symptoms of cardiovascular, metabolic, or renal diseases or those with a history of these diseases but who do not regularly exercise should consult a doctor before starting. In other cases, it is safe to start a low to moderate intensity exercise regimen without obtaining medical clearance. This edition of the guidelines recommends aerobic exercise for at least 150 minutes per week, 3 to 5 times a week, and resistance exercise using large muscle groups 2 to 3 times per week for weight loss. Furthermore, increasing aerobic exercise to 250 to 300 minutes per week is suggested for more meaningful weight loss. Compared to exercise therapy alone, it has been shown that body weight, BMI, and WC are more improved when exercise therapy is combined with dietary therapy.

Comprehensive lifestyle improvement such as reducing energy intake and increasing physical activity based on behavioral therapy are recommended for weight loss in this edition of the guidelines, similar to the previous edition. Additionally, third-wave cognitive behavioral therapy, such as mindfulness-based cognitive therapy and acceptance and commitment therapy, is newly introduced in this edition of the guidelines.41-45 Compared with the previous version of the guidelines, this edition recommends intensifying lifestyle interventions based on behavioral therapy if weight loss of 2.5% is not achieved within 1 month of starting therapy and highlights the roles of alcohol consumption and smoking during behavioral therapy for weight loss and maintenance.

PHARMACOTHERAPY

Despite the development of many new peptide anti-obesity medications, with some of these currently under consideration for approval by the Korean Ministry of Food and Drug Safety, there have been no new approvals of anti-obesity medications for adults with obesity since the 7th edition of the guidelines (up to February 2023). However, liraglutide was newly approved during that period for patients with obesity aged 12 years or older. Therefore, currently available anti-obesity medications for children and adolescents in Korea are phentermine (for those aged 16 or older) for short-term treatment and orlistat (for those aged 12 or older) and liraglutide (for those aged 12 or older) for long-term treatment (Table 6).46 In adults with obesity, orlistat, naltrexone/bupropion extended release (ER), liraglutide, and phentermine/topiramate ER are available for long-term weight loss, while phentermine, diethylpropion, phendimetrazine, and mazindol are available for short-term treatment in Korea.

Table 6.

Anti-obesity medications for the pediatric population

Obesity pharmacotherapy is recommended as an additional treatment method for Korean adults with a BMI of 25 kg/m² or higher after failure of non-pharmacological methods. Medication selection should consider accompanying diseases (Table 7). Given the diverse responses of individuals to these medications and the potential for adverse events, it is recommended to discontinue the medication in the event of a lack of response. In adults, if greater than 5% weight loss is not achieved within 3 months of maintenance dosage, the medication should be discontinued or changed. In children and adolescents, if there is less than a 4% decrease in BMI or BMI z-score despite 12 weeks of medication, the medication should be considered ineffective and changed or discontinued.

Table 7.

Selection of anti-obesity medication according to comorbidities

BARIATRIC AND METABOLIC SURGERY

The indications for bariatric/metabolic surgery for obesity are the same as in the previous version of the guidelines and are shown in Table 1. A standard procedure that has been proven to be effective and safe, such as sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, or biliopancreatic diversion/duodenal switch, is recommended based on patient condition (I, A).40,47 After bariatric/metabolic surgery, multidisciplinary follow-up management should be scheduled for all patients (I, B).47-50 In addition, micronutrient supplementation should be initiated, and regular follow- up examinations should be conducted according to the surgical procedure (I, B).47,48,51 For children and adolescents with obesity, in cases where weight gain and obesity-related comorbidities remain despite intensive multidisciplinary treatment and pharmacotherapy for obesity, surgical therapy may be considered in limited cases, only after completion of growth and puberty (IIb, C).52-55 In pediatric and adolescent cases, surgery may be considered if the BMI is 35 kg/m2 or higher, the BMI is higher than 120% of the 95th percentile, and there are obesity-related comorbidities or if BMI is 40 kg/m2 or higher or exceeds 140% of the 95th percentile. Bariatric surgery in the elderly is considered safe and effective; however, indications for bariatric surgery in obese elderly people in Asia, including Korea, have not been established. Age does not seem to increase the risk of complications after bariatric surgery. Therefore, if the risk of complications after surgery is not greater than the impact of obesity-related disabilities, surgical treatment for elderly people with obesity may be considered, taking into account accompanying diseases, medications, and safety (IIb, B).21,40,56-59

NEW TOPICS INCLUDED IN THIS EDITION OF THE GUIDELINES

To stay current with the constantly evolving field of obesity, new main topics such as obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of ICT-based interventions for obesity treatment are included in the 8th edition guidelines.

Women should maintain a normal weight before pregnancy due to the higher obstetric and perinatal risks associated with obesity. However, there is limited evidence to support the obstetric and perinatal benefits of non-pharmacological and pharmacological weight loss methods in women with obesity. Although a metaanalysis has shown positive impacts of bariatric surgery on spontaneous pregnancy in infertile women, these findings should be approached with caution due to the quality of the included data.

The current guidelines also address pregnancy-related weight gain and the relationship between obesity and menopause. During pregnancy, women with obesity should maintain a balanced diet and engage in regular physical activity to achieve appropriate weight gain. After delivery, active lifestyle interventions are recommended for weight management. Appropriate weight management is also recommended for women who are obese and in the menopausal period due to the increased risk of obesity-related comorbidities. Hormone therapy should not be used solely for the purpose of weight loss in menopausal women.

Severe mental illness has been linked to obesity and its comorbidities. Additionally, depression may also contribute to the development of obesity and an unhealthy metabolic state. Another important factor to consider in the clinical context is that many medications used to treat severe mental illness can cause weight gain. In light of this, the guidelines include key questions about screening tests for obesity and metabolic diseases and comprehensive lifestyle interventions for weight loss in patients with severe mental illness who are taking medications; recommendations are shown in Table 1.

Long-term maintenance after weight loss is more beneficial for overall health and well-being than is short-term weight loss. One of the most significant benefits of weight maintenance is prevention of diabetes. Additionally, it can improve the apnea-hypopnea index in individuals with obesity and obstructive sleep apnea, improve cerebral blood flow, and lower blood pressure. Furthermore, weight maintenance has been found to be associated with a lower mortality rate in individuals with obesity. The importance of long-term maintenance of weight loss and maintenance methods are highlighted in Table 1.

Another new area addressed in this edition of the guidelines is the use of ICT-based interventions for obesity. ICT-based interventions can supplement the lack of psychological and behavioral counseling provided by healthcare professionals and can facilitate achievement and maintenance of lifestyle modifications. Based on available evidence, technology-based interventions are recommended for obesity treatment (Table 1).

CONCLUSION

The 8th edition of the Clinical Practice Guidelines for Obesity of KSSO was developed after reviewing all relevant scientific evidence and is intended for use by medical professionals, nutritionists, physical educators, and other related professionals in actual practice.

Methodologically, this edition of the guidelines features better links key questions in PICO format to recommendations and key references as answers to each key questions, increasing organization (Table 1). When developing clinical practice guidelines, it is important to involve stakeholders in the process, and our guideline development group included members from all relevant expert groups. However, a limitation of our work is the lack of investigation into the perspectives and preferences of the target population (patients, the general public, etc.) to whom the guidelines will be applied. Additional limitations include insufficient description of barriers and facilitators to executing the guidelines and lack of consideration of potential resources that may be required for application of the guidelines. In the future, clinical practice guidelines should address these methodological limitations.

The 8th edition of Clinical Practice Guidelines for Obesity has incorporated several new topics to keep up with the constantly evolving field of obesity. One of the new topics, ‘obesity in women,’ will be of great benefit to medical professionals treating women during their reproductive years, pregnancy, and postmenopausal stages. Additionally, two important topics, ‘obesity in patients with mental illness’ and ‘weight maintenance after weight loss,’ were added to provide strategies to address the most challenging issues faced by medical professionals treating obesity. The use of ICT is becoming increasingly important in medical fields, and the new topic ‘obesity treatment using ICT-based interventions’ will provide a foundation for further knowledge development in this area.

We are confident that the 8th edition of the Clinical Practice Guidelines for Obesity will be a useful tool for all healthcare professionals treating patients with obesity and will play a crucial role in improving the health of the Korean population.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found online at https://doi.org/10.7570/jomes23016.

ACKNOWLEDGMENTS

Financial support was received from Korean Society for the Study of Obesity. However, the financial supporter did not directly or indirectly influence the content or development process of these guidelines.

Footnotes

CONFLICTS OF INTEREST

In order to confirm the presence or absence of conflicts of interest among all members involved in the development of these guidelines, a survey was conducted on whether they had received more than 10 million Korean won in sponsorship or consulting fees over the past 2 years on topics related to the development of these guidelines, whether they have rights to economic benefits such as stock options from specific institutions or pharmaceutical companies, and whether they hold official/unofficial positions in pharmaceutical companies. The survey results indicated no conflicting or potential conflicts of interest.

Ga Eun Nam has worked as an Associate Editor of the Journal of Obesity and Metabolic Syndrome since 2020. However, she was not involved in peer reviewer selection, evaluation, or the decision process for this article. There are no other potential conflicts of interest relevant to this article to report.

AUTHOR CONTRIBUTIONS

Study concept and design: KKK, JHH, BTK, EMK, JHP, SYR, JHK, and CBL; acquisition of data: all authors; analysis and interpretation of data: all authors; drafting of the manuscript: KKK, JHK, and JHH; critical revision of the manuscript: KKK and JHK; obtained funding: CBL; administrative, technical, or material support: KKK, JHK, and JHH; and study supervision: JHK.

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