Guidelines for a Healthy and Safe

Weight Management
Program

Philippine Association for the Study of

Overweight and Obesity (PASOO)
Unit 2502, 25/F Medical Plaza Ortigas
San Miguel Avenue, Ortigas Center, Pasig City
Telephone Nos.: 632-1533/494-4233
Telefax No.: 632-1533
E-mail address: [email protected]
Website: http://www.obesity.org.ph/
 Weight Management
Philippine Association for the Study of
Overweight and Obesity (PASOO)
Unit 2502, 25/F Medical Plaza Ortigas
San Miguel Avenue, Ortigas Center, Pasig City
Telephone Nos.: 632-1533/494-4233; Telefax No.: 632-1533
E-mail address: [email protected]; Website: http://www.obesity.org.ph/

Officers and Board of Trustees

President Roberto C. Mirasol, MD

Vice President Rodolfo F. Florentino, MD, PhD
Secretary Edgardo L. Tolentino, Jr., MD
Treasurer Mia C. Fojas, MD

Board of Directors Ramon F. Abarquez, Jr., MD

Sanirose S. Orbeta, MS, RD, FADA
Celeste C. Tanchoco, MPH, RND, PhD
Juan Maria Ibarra O. Co, MD
Nemencio A. Nicodemus, Jr., MD

Immediate Past President Gabriel V. Jasul, Jr., MD

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 185

Weight Management
Algorithm for the Healthy and Safe Weight Management Program

Weight Problem
Suspect

Measure BMI

3 4

Y
BMI
Obese
>25.0?

5 N
6

Y
BMI
>23.0? Overweight

7 N
8

WHR (m) >1.0 Y

(f) >0.8 Abdominal Fat
distribution Go to Fig. 2
WC (m) ≥90 cm
(f) ≥80 cm

N
9

Normal Patient

Figure 1: Classifying Patients

Legend:

WC - Waist Circumference
WHR: Waist Hip Ratio

186
 Weight Management

Overweight/
Obese

2 3 4 5

Hypothyroid Y Y Treat as
signs & TSH Elevated? hypothyroid or
symptoms Refer

6 N

Assess for
Comorbidities

7 8 9 10

Cushing's Y Y Treat as Cushing's

Serum
signs & Elevated? or Refer
cortisol
symptoms

11 N
N

Assess for
Comorbidities

Fig. 3

Figure 2: Work-Up for Causes of Obesity

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 187

Weight Management

Overweight/
Obese

Check for PPG, lipid

profile, BP, signs &
symptoms of sleep
apnea, venous stasis
and cardiac disease

3 4

Y Treat with
Presence of appropriate Go to #5
comorbidities disease specific
therapy

N
5 6

Are there Treat risk factors

risk factors that Y appropriately before
will lead to weight weight management Fig. 4
management program is started or
failure? REFER

Fig. 4

Figure 3: Evaluation of Co-Morbidities & Risks Factors

188
 Weight Management

Overweight/
Obese

2
Presence
of exclusion
criteria for weight
management
program?
3

Offer weight
management

4 5 6

Advise patient to
Patient not Y at least address
ready to start risk factors and Monitor
the program? prevent further biannually
weight gain

7 N

Clinician & Patient

devise goals and
treatment strategies for
weight reduction and
risk factors control

Fig. 5

Figure 4: Preparation of Starting the Weight Management Program

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 189

Weight Management

Overweight/
Obese

Determine
Patient's BMI-
related
health risk

3 4

Y Moderate diet deficit;

Minimal? increase physical activity; Fig. 6
lifestyle change

N 6
5

Y
Increase physical activity;
Moderate? lifestyle change; LOW Fig. 6
CALORIE DIET

N 8
7

Increase physical
Y activity; lifestyle
High? change; low Fig. 6
calorie-diet;
Pharmacotherapy
N 10
9

Y Increase physical
activity; lifestyle change; Fig. 6
Very High? Pharmacotherapy; VERY LOW
CALORIE DIET

N 12
11
Increase physical
activity; lifestyle change;
Extremely Fig. 6
Pharmacotherapy; Very Low
High
Calorie diet; or REFER FOR
SURGERY

Figure 5: Treatment According to Risk

190
 Weight Management

Overweight/
Obesity

Monitor for
3-6 months

3 4

Wt. loss of >5 Y

kg or  Successful
5-10% of initial
BW?

N
5

Failure

Re-assess
and re-define
treatment
options

7 8 9

Y CONTINUE
Adequate
maintain & Periodic weight
weight
prevent weight check
reduction?
gain

N
10

REFER

Figure 6: Follow-up

Rosa Allyn G. Sy, MD

Presented in the PCP Annual Convention 2002
Adapted by PASOO

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 191

192
THE FILIPINO PYRAMID ACTIVITY GUIDE

Keep HEALTHY by keeping ACTIVE • Sit; lie around

• Be a couch potato MINIMALLY
• Watch TV
• Play cards/Mahjong (a few times a month)
RECOMMENDATION FOR • Sit and do needle work
Weight Management

TOTAL HEALTH • Indulge in computer

games and surfing
Enjoy Leisure & Recreational Activities, (0.03 kcal/min/kg BW)
Aerobic, Strength
EXERCISE FOR
and Flexibility Activities as often LEISURE STRENGTH & OFTEN
as you can ACTIVITIES FLEXIBILITY:
• Go Mall-strolling • Stretching (2-3 times a week a least
• Play Golf • Yoga
DO DAY TO DAY • Go Bowling • Tai Chi 30-45 minutes or longer)
(0.04-0.09 kcal/ • Resistance Training
ACTIVITIES min/kg BW) (0.04-0.12 kcal/
HABITUALLY min/kg BW)
AND REGULARLY FOR AEROBIC EXERCISE: RECREATIONAL
REGULARLY
METABOLIC EFFICIENCY • Brisk Walking ACTIVITIES:
• Running/Jogging • Ballroom Dancing
(3-5 times a week:
• Bicycling • Badminton, Basketball, Softball
minutes • Aerobic Dancing • Skating/Roller Blading
at least 30-45
at a • Swimming • Tennis
• Aero - Kick Boxing • Piko, Sipa, Patintero
minutes or
time for
10 (0.08-0.23 kcal/min/kg BW) (0.05-0.14 kcal/min/kg BW)
minutes
longer)
a day at DAY-TO-DAY ACTIVITIES:
• Taking the stairs instead of the elevator • Adding extra steps to your daily routes
least
30 • Taking longer routes • Taking stretch breaks at home or work
HABITUALLY
• Walking to the store, church, banks or • Doing household chores
days a mailbox • Running errands
5 week • Parking your car farther away • Grocery Shopping
(as often as
(0.04-0.10 kcal/min/kg BW)
possible)
 Weight Management
III. Treatment Modalities Recommended by PASOO
Guidelines for a Healthy and Safe
Weight Management Program: A. Scientifically-based and Acceptable
PASOO Recommendations 1. Diet
I. Definition of Terminologies The diet must be supervised, well balanced and hypo­
caloric. In the morbidly obese, supervised modified fasts
Overweight - increased body weight in relation or very low calorie diet (VLCD) may be allowed for certain
to height periods of time. PASOO disapproves unsupervised or
Obesity - increased amount of body fat or unbalanced VLCDs, fat diets and quick loss regimen
adipose tissue: such as untested food mixes, and slimming teas which
are faulty weight loss aids.
How to assess body fat:
a. Use the basic Filipino Pyramid Food Guide for
1. Body mass index: Correlates closely with total body today's lifestyle as the healthy way to lose weight.
fat in relation to height and weight. However, this Eating the pyramid food way gives balance,
does not compensate for frame size and does not variety, moderation and proportionality.
indicate fat distribution and cannot be adjusted for b. Mineral and vitamin supplements are not neces­
age. It is determined by: sary unless dictated by specific deficiencies.
Adequate diet equates to adequate vitamins and
Weight in kilogram/Height in meter2. minerals.
Based on Asia-Pacific Obesity Guidelines 2. Exercise
Underweight <18.5 Aerobic exercise programs, formal or functional, are
Healthy 18.6 - 22.9 ­recommended. The guidelines modified from the propo­
Overweight ≥23.0 sals of AS Leon, WD McArdie and MM Toner are:
At risk 23 - 24.9
Obese I 25 - 29.9 a. Medical clearance should be obtained for those
Obese II ≥30 above 40 years as well as those below 40 years
with known risk factors which could compromise
2. Waist circumference: Many agree that the waist health. A graded exercise test should be in­­
circumference alone is an accurate measure of the cluded.
amount of visceral fat. b. Sessions should begin and end with 5-10 minutes
of light aerobic/flexibility activities.
Clinical thresholds: Men <90 cm c. Aerobic exercises should be performed at least
Women <80 cm three times a week and once during weekends.
d. The duration of exercise should be that which
To measure the waist, the subject should be unclothed would expend at least 300 kcal per session
at the waist, and standing with abdomen relaxed, arms ­(average of 30-60 minutes/session). For indivi­
at the sides, feet together. Use nonstretchable tape duals who are busy, thirty minute activity accumu-
measure and do not compress the skin. lated during the day maybe beneficial as well.
e. Maximum oxygen consumption should be 40-
80%, which is equivalent to about 60-90% of the
II. Overview of Current Perspective maximum heart rate (220 - age).
f. Weave more physical activity into daily routines
It is known that increasing body weight increases risk of - stairs instead of elevators, walk instead of ride
health. The risk from obesity is related to both the BMI as to work, etc. since it is the volume or duration of
measurement of the magnitude of obesity and the waist activity and not the intensity which improves the
circumference for the distribution of body fat. Thus, the metabolic profile of an individual better.
distribution of that excess weight should be a primary con- g. Chronic strenuous exercises should be done
sideration. The amount of intraperitoneal or visceral fat with caution. Recent studies suggest a suppres-
has been shown to be directly related to the morbidity and sion of the immune system brought about by the
mortality of fatness. Therefore, it is recommended that decrease in the natural killer cells.
the measurement of the waist circumference be utilized
clinically for the calculation of added risk. (It is known that 3. Behavior Modification - is an integral part of the
the most accurate means of determining excess body fat weight reducing regimen with personal or profes-
and its distribution is CT scan or MRI.) sional supervision.

Obesity arises from a variety of causes, which demand Behavioral approaches to obesity should help patients
chronic attention. Drastic weight reduction is not encour- make lifelong changes in diet and exercise behaviors. Inter­
aged because obesity can only be palliated, but never ventions which focus on decreasing sedentary activities,
cured - thus weight management is a lifetime endeavor. rather than increasing physical activity maybe a way for
Management of obesity should be sought for, because obese persons to adhere to prescribed exercise programs.
reducing weight is the only way to reduce the ill-effects
of too much weight, as well as, to improve the quality of Following the Activity Pyramid Guide of PASOO may be
life of the obese person. helpful in starting the program.

www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 193

Weight Management
Encouraging restrictions of dietary fats and refined sugar Table 1.
as well as of total calories should be of immense value.
The earlier the intervention to modify behavior, the better Classification BMI Risk of Co-Morbidities
the outcome. (R.R. Wing, Current Opinion in Endocrino­ Waist Circumference
logy and Diabetes, 1996). <90 cm ≥90 cm
(men) (men)
4. Drug Therapy - should be an adjunct to diet, exercise <80 cm ≥80 cm
and behavior modification and not the primary means (women) (women)
to weight reduction. Underweight <18.5 Low, but Average
increased
The characteristics of an ideal weight loss drug are (G.A. risk of
Bray, Obesity Research, 1995): other
clinical
a. orally active problems
b. few or no side effects Normal range 18.6 - 22.9 Average Increased
c. dose-dependent reduction in body fat Overweight: ≥23
d. reduces visceral fat At risk 23 - 24.9 Increased Moderate
e. inexpensive Obese I 25 - 29.9 Moderate Severe
f. long-acting Obese II ≥30 Severe Very Severe
g. non-toxic
PASOO adopts and recommends this classification of
The choice of the drug should have as many of the char- treatment for obesity based on risk (See Table 2)
acteristics of the ideal drug as possible.
Table 2.
B. Questionable Modalities
Calorie Intake/Day
PASOO does not encourage certain modalities purpor­-
Risk <800* >800 Exercise Drugs Surgery
ted to reduce body fat which are not scientifically based.
Who to treat? Low 3 2 1 NA NA
Moderate 2 1-2 1 3 NA
Recommended or Preventive Strategies High 1 2 1 2 NA
Very High 1 1 3 1 1-2
1. Match your healthy weight to a good BMI of below Legend:
23.0 NA = not appropriate
2. Measured waist circumference not to exceed 90 cm * = very low caloric diet
1 = 1st choice
for males or 80 cm for females. 2 = 2nd choice
3. Weight maintenance is emphasized more than weight 3 = 3rd choice
loss alone.
4. Exercise is part of the weight loss therapy.
5. Go and seek for behavior therapy if having difficulty
managing yourself.

PASOO adopts and recommends this functional classi-

fication of the degree of risk from the BMI and the waist
circumference (See Table 1).

PASOO adopts and recommends this classification of

treatment for obesity based on risk (See Table 2)

194