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      Improving applicability of the new obesity classification based on weight history in severe obesity

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          Abstract

          DEAR EDITOR, We read with great enthusiasm the recently published Brazilian proposal for obesity classification based on weight history (1). In fact, it established a target for success in non-surgical obesity treatment. However, we would like to raise some discussions regarding its applicability in severe obesity. Adults living with severe obesity present specific challenges during clinical management of weight, what makes those unresponsive considered for bariatric surgery. At the same time as they are more likely to present weight reductions (2), they usually need greater weight loss to be healthier (3–5) and have difficulties in sustaining weight loss, culminating in greater instability in their weight trajectories (3). Furthermore, attaining normal weight during clinical treatment is rarer in severe obesity than in simple obesity (2), which increases the need to set specific weight loss goals for these individuals. International guidelines which have referred to specific goals for severe obesity (3,4) present bolder proposals in relation to BMI range and the respective goals, compared to the Brazilian proposal (1). While Brazilian proposal adopts generalist goals (5%-10%) for BMI between 30.0 to 40.0 kg/m2 and recommends greater weight loss (10%-15%) only for BMI ≥ 40.0 kg/m2 (1), international guidelines advice greater weight loss (15%-20% or even > 20%) already for BMI from 35.0 kg/m2 (3,4). According to the Brazilian classification (1), individuals with a BMI between 35.0 to 39.9 kg/m2 present obesity-controlled, while they are good responders to non-surgical treatment if they reach a weight loss greater than 10%. However, this could not represent real improvement in general health condition, especially for metabolic unhealthy individuals. Another discussion point is that the Brazilian proposal incorporated only BMI into their classification and international guidelines presuppose increased goals based not only on BMI, but also on the severity of the condition identified by the presence of comorbidities (4,5). This seems to make Brazilian classification simpler, but less accurate. Otherwise, disregarding the presence of comorbidities may impair its applicability during evaluation for bariatric surgery, once worldwide eligibility criteria include failure in non-surgical treatment for BMI between 35.0 to 40.0 kg/m2 with comorbidities or BMI between 40.0 to 50.0 kg/m2. Thus, proposed a double success classification criterion for these individuals does not seem to be the best alternative. In conclusion, we suggest a simple adaptation of the Brazilian proposal (1) represented by an asterisk (“*”) aside the BMI range of 30.0 to 40.0 kg/m2 in “Table 1”, followed by a footnote saying: “for individuals with BMI between 35.0 to 39.9 kg/m2 and comorbidities, consider the use of the same ranges of those with BMI from 40.0 to 50.0 kg/m2”. Besides, the ranges values in that table could be better defined (e.g. replace “40.0” by “39.9” in the first line, “>10” by “≥10” and “>15” by “≥15”). This adapted classification can be a useful and suitable alternative to guide clinical management of adults living with severity obesity.

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          European Guidelines for Obesity Management in Adults

          Obesity is a chronic metabolic disease characterised by an increase of body fat stores. It is a gateway to ill health, and it has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. In clinical practice, the body fatness is estimated by BMI, and the accumulation of intra-abdominal fat (marker for higher metabolic and cardiovascular disease risk) can be assessed by waist circumference. Complex interactions between biological, behavioural, social and environmental factors are involved in regulation of energy balance and fat stores. A comprehensive history, physical examination and laboratory assessment relevant to the patient's obesity should be obtained. Appropriate goals of weight management emphasise realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims. Balanced hypocaloric diets result in clinically meaningful weight loss regardless of which macronutrients they emphasise. Aerobic training is the optimal mode of exercise for reducing fat mass while a programme including resistance training is needed for increasing lean mass in middle-aged and overweight/obese individuals. Cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss and weight loss maintenance. Pharmacotherapy can help patients to maintain compliance and ameliorate obesity-related health risks. Surgery is the most effective treatment for morbid obesity in terms of long-term weight loss. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment. Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management.
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            Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records.

            We examined the probability of an obese person attaining normal body weight.
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              Guideline Recommendations for Obesity Management.

              It is an obligation for all health care providers to participate in obesity management. This article discusses obesity guidelines from The Obesity Society; the Endocrine Society; and the American Association of Clinical Endocrinologists. It reviews and compares findings and recommendations across these guidelines, identifies areas of controversy and concordance, and suggests how primary care practices may make use of the most appropriate recommendations for their circumstances.
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                Author and article information

                Journal
                Arch Endocrinol Metab
                Arch Endocrinol Metab
                aem
                Archives of Endocrinology and Metabolism
                Sociedade Brasileira de Endocrinologia e Metabologia
                2359-3997
                2359-4292
                28 November 2022
                2022
                : 66
                : 6
                : 934-935
                Affiliations
                [1 ] orgnameUniversidade Federal de Viçosa orgdiv1Departamento de Nutrição e Saúde Viçosa MG Brasil originalDepartamento de Nutrição e Saúde, Universidade Federal de Viçosa, Viçosa, MG, Brasil
                [2 ] orgnameUniversidade Federal de Viçosa orgdiv1Instituto de Políticas Públicas e Desenvolvimento Sustentável Viçosa MG Brasil originalInstituto de Políticas Públicas e Desenvolvimento Sustentável, Universidade Federal de Viçosa, Viçosa, MG, Brasil
                Author notes
                Correspondence to: Helen Hermana Miranda Hermsdorff, Departamento de Nutrição e Saúde, Universidade Federal de Viçosa Avenida PH Rolfs, s/n 36570-900 – Viçosa, MG, Brasil. helenhermana@ 123456ufv.br

                Disclosure: no potential conflict of interest relevant to this article was reported.

                Author information
                https://orcid.org/0000-0001-7687-6189
                https://orcid.org/0000-0002-8819-6305
                https://orcid.org/0000-0002-9273-5180
                https://orcid.org/0000-0002-4441-6572
                Article
                2359-3997000000572
                10.20945/2359-3997000000572
                10118762
                36394489
                a6c48024-a5ff-4288-b5d1-26401ef6c435

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 23 August 2022
                : 12 October 2022
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 5, Pages: 2
                Funding
                Funded by: Funarbe/Opas/UFV
                Award ID: SCON2021-00201
                Funded by: FG Cândido is CNPq postdoctoral fellowship
                Award ID: 151832/2022-6
                Funded by: HHM Hermsdorff is CNPq Fellowship in Research Productivity
                Award ID: 308772/2017-2
                Categories
                Letter to the Editor

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