Clinical Practice Guideline
The Prevention and Treatment of Obesity
Background: The high prevalence of obesity (24% of the adult population) and its adverse effects on health call for effective prevention and treatment.
Method: Pertinent articles were retrieved by a systematic literature search for the period 2005 to 2012. A total of 4495 abstracts were examined. 119 publications were analyzed, and recommendations were issued in a structured consensus procedure by an interdisciplinary committee with the participation of ten medical specialty societies.
Results: Obesity (body-mass index [BMI] ≥30 kg/m2) is considered to be a chronic disease. Its prevention is especially important. For obese persons, it is recommended that a diet with an energy deficit of 500 kcal/day and a low energy density should be instituted for the purpose of weight loss and stabilization of a lower weight. The relative proportion of macronutrients is of secondary importance for weight loss. If the BMI exceeds 30 kg/m2, formula products can be used for a limited time. More physical exercise in everyday life and during leisure time promotes weight loss and improves risk factors and obesity-associated diseases. Behavior modification and behavioral therapy support changes in nutrition and exercise in everyday life. With respect to changes in lifestyle, there is no scientific evidence to support any particular order of the measures to be taken. Weight-loss programs whose efficacy has been scientifically evaluated are recommended. Surgical intervention is more effective than conservative treatment with respect to reduction of bodily fat, improvement of obesity-associated diseases, and lowering mortality. Controlled studies indicate that, within 1 to 2 years, a weight loss of ca. 4 to 6 kg can be achieved by dietary therapy, 2 to 3 kg by exercise therapy, and 20 to 40 kg by bariatric surgery.
Conclusion: There is good scientific evidence for effective measures for the prevention and treatment of obesity.
Obesity is a significant issue for health policy because it is so widespread in the population as a whole, and because of the high risk of complications it carries (1). According to the findings of the DEGS study (Studie zur Gesundheit Erwachsener in Deutschland, German Health Interview and Examination Survey for Adults) carried out between 2008 and 2011 by the Robert Koch Institute in a cohort representative of the whole population, 23.3% of men and 23.9% of women were obese (2). The prevalence of obesity increases four-fold with age in both men and women in an age-dependent manner. In the period from 1999 to 2009, in particular, the prevalence of persons with a body mass index (BMI) of 35 kg/m2 or higher rose markedly (3).
Obesity is implicated in a wide variety of health problems such as impaired sense of wellbeing and impaired quality of life, numerous complications, high frequency of sick leave and early retirement, and increased mortality. The health-related complications are due to the increased proportion of body fat and associated disturbances of endocrine/metabolic function and due to increased mechanical load. Fatty tissue does not only store energy, it is also an active endocrine organ that is closely connected to the intermediary metabolism.
Twelve experts from ten medical professional societies/organizations took part in developing the Guideline (eBox). The literature search and evaluation of the evidence were carried out by the German Agency for Quality in Medicine (ÄZQ, Ärztliches Zentrum für Qualität in der Medizin) on behalf of the German Obesity Association (DAG, Deutsche Adipositas-Gesellschaft). Five guidelines identified as relevant were evaluated using the German instrument for the methodical evaluation of guidelines (DELBI, Deutsches Leitlinien-Bewertungsinstrument) and the key recommendations extracted. A total of 4495 abstracts were identified as published during the period covered by the literature search (from 2005 to March 2012). The MedLine database was searched via www.pubmed.org. In addition, other relevant publications dated up to April 2014 and located by the experts in a manual search were taken into account, so it may be assumed that no studies were missed that would fundamentally undermine the statements contained in the Guideline (eFigure). The selection (defined inclusion and exclusion criteria) and evaluation of the studies (in accordance with SIGN, the Scottish Intercollegiate Guidelines Network, eTable) were carried out by personnel of the ÄZQ. The recommendations formulated on the basis of the evidence tables and source guidelines were agreed during structured consensus conferences and during the Delphi process that followed (moderated by the ÄZQ). The final version of the Guideline was produced after external expert review.
The statements below reproduce the main content of the Guideline. The complete texts are available at www.adipositas-gesellschaft.de.
The World Health Organization (WHO), the German Federal Court, the European Parliament, and the German Obesity Association regard obesity as a chronic disease caused by a complex interaction between genetic factors and environmental or lifestyle factors, which carries increased morbidity and mortality and needs lifelong treatment. Because it is a heterogeneous disorder, individualized assessment, risk stratification, and treatment are required.
Prevention of obesity
Given that obesity is so prevalent, and given how difficult it is to treat, prevention is particularly important. To prevent overweight and obesity, people should eat and drink according to their nutritional needs, get regular exercise, and check their weight regularly (evidence level [EL] 1–4, recommendation grade [RG] A, eTable). So far as nutrition is concerned, they should consume less food with a high energy density and more food with a low energy density (EL 2, RG B). Foods that have a low energy density due to their high water or fiber content, such as wholegrain products, fruit, and vegetables, are comparatively more filling and have a low energy content (4). According to the German College of General Practitioners and Family Physicians (DEGAM, Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin), there is insufficient evidence to support the proposition that persons with a BMI over 25 kg/m2 should avoid energy-dense foods. The German Society of Nutritional Medicine (DGEM, Deutsche Gesellschaft für Ernährungsmedizin) also says that a Mediterranean diet helps prevent overweight and obesity.
The Guideline also states that consumption of alcohol, fast food, and sugary drinks should be reduced (EL 2, RG B) (5). Fast food often contains a high proportion of fat and sugar and is thus very energy-dense (6). Not only drinks sweetened with sugar, but fruit juices and juice-based drinks too, have a high sugar content and are not very filling (7).
An inactive lifestyle with frequent sitting watching television or on the internet and similar activities promotes weight gain (EL 1–4, RG B). Getting exercise in everyday activities and as a leisure pursuit has a preventive effect. This goal is best achieved by endurance-focused physical exercise (use of large muscle groups) for more than 2 hours per week (8).
Who should lose weight?
Whether treatment is indicated for overweight and obesity depends on patient BMI and body fat distribution, taking into account any co-morbidities, risk factors, and patient preferences (EL 4, RG A). The following are indicators for treatment:
- BMI ≥ 30 kg/m2 (obesity)
- BMI of 25 to 30 kg/m2 (overweight) with concomitant
− overweight-related health impairments (e.g., hypertension, type 2 diabetes mellitus) or
− abdominal obesity or
− diseases that are exacerbated by overweight or
− high psychosocial distress.
Weight loss is contraindicated for persons with wasting diseases and for pregnant women.
Treatment for obesity
Treatment goals should be realistic and adapted to the individual patient (e.g., experiences, resources, risks) (EL 4, RG B). Goals are:
- Long-term weight reduction:
− BMI 25 to 35 kg/m2: >5% of initial weight
− BMI > 35 kg/m2: >10% of initial weight
- Improvement in obesity-related risk factors
- Reduction in obesity-related diseases
- Lowering of risk of early death
- Prevention of inability to work and early retirement
- Reduction of psychosocial disorders
- Improvement of quality of life
Obese individuals should received personalized nutritional recommendations adapted to their therapeutic goals and risk profile (EL 4, RG A). This can only be successful over the long term if the patient agrees to a change in lifestyle and recommendations that are practicable in daily life. No valid studies have been published on this recommendation.
To carry out dietary therapy, nutritional counseling (individual or in groups) should be offered within the program of medical management (EL 1, RG A). Group sessions are usually more effective than individual sessions. The DGEM gives a recommendation grade of B rather than A.
For weight reduction, patients should be recommended forms of nutrition that over a long enough time lead to an energy deficit but do not impair health (EL 1–4, RG A).
To reduce body weight, the aim should be to follow a reduction diet that will produce an energy deficit of about 500 kcal/day, or more in individual cases (EL 1–4, RG B). To achieve this, various nutrition strategies may be employed (EL 1–4, RG 0):
- Reduce fat consumption
- Reduce carbohydrate consumption
- Reduce both fat and carbohydrate consumption
The DGEM states that wide-ranging literature exists for this recommendation and a recommendation grade of A is justified.
An energy deficit of 500 to 600 kcal/day will allow weight loss to occur at around 0.5 kg/week over a period of 12 up to a maximum of 24 weeks (9). The consumption of fat, which in Germany is still high, can be reduced by simple steps (10). A low-carb diet will lead to sharper weight loss at the beginning than other diets, but after a year the difference can no longer be seen (11). Several large studies in the past few years have shown convincingly that the macronutrient composition (ratio of fats to carbohydrates to protein) has no relevance for weight loss (Figure 1) (12, 13). Various reduction diets (fat reduction alone, low-carb diet, reduced-energy balanced diet, Mediterranean diet) lead to loss of around 4 kg in 1 to 2 years (Table 1). Individual experience, knowledge, and resources are more important than nutrient relationships. The DGEM regards a recommendation grade of B rather than 0 as justified for this procedure.
To attain the therapeutic objective, the use of formula products supplying 800 to 1200 kcal/day may be considered (EL 1, RG 0). This form of nutrition is recommended for persons with a BMI of 30 kg/m2 or more for a maximum of 12 weeks; weight loss of 0.5 to 2.0 kg/week may be expected (17). This treatment should be carried out under a physician’s supervision because of the increased risk of side effects (EL 1, RG A). In the opinion of the DGEM, formula diets have been well investigated in high-quality cohort studies and for this reason a recommendation grade of A rather than 0 is favored. Formula diets are the most effective diet method for initial weight reduction.
Extremely one-sided diets should not be recommended because of the high medical risks they entail and their lack of long-term success (EL 4, RG A). Diets involving extreme nutrient distributions (e.g., so-called crash diets) are widely followed in Germany. No robust studies on their effectiveness and safety have been published. Since their effectiveness and safety are unknown, they cannot be recommended.
Effective weight loss requires >150 min/week of exercise with an energy consumption rate of 1200 to 1800 kcal/week (8). Strength training alone is not very effective for weight reduction (EL 2–4, RG B) (18). The amount of energy used up during exercise is often overestimated. When large muscle groups are used, the intensity is moderate to high, and the exercise work is of long duration, weight loss can be expected. Well-controlled studies and meta-analyses show a weight reduction of about 2 kg and about a 6% loss of abdominal fat in 6 to 12 months (Table 2).
It should be ascertained that overweight and obese persons do not have any contraindications to additional physical activity. This is particularly the case for patients with a BMI of 35 kg/m2 or higher (EL 4, RG B).
Overweight and obese persons should have the health advantages (metabolic, cardiovascular, and psychosocial) of physical activity explained to them, which accrue irrespective of loss of weight (EL 4, RG A). Even in obese individuals, the health value of increased exercise is seen in more than just a loss of weight (23).
Interventions for behavior modification
Interventions based on a behavioral approach, in a group or individual setting, should form part of a program of weight reduction (EL 1, RG A). The intervention should be aimed primarily at altering lifestyle in terms of nutrition and exercise and may be carried out by qualified non-psychotherapists. If the symptoms accompanying overweight or obesity are more serious (e.g., co-morbid depression, eating disorders, motivation problems), psychiatrists or psychotherapists should be involved in the patient management, and patients should be supported in their dietary therapy and exercise (24).
Various strategies are available for intervention. They should be adapted to the individual situation and the wishes of the patient involved (25) (Box).
Weight reduction program
Obese patients should be offered weight reduction programs that are adapted to their individual situation and targeted at the therapeutic goals (EL 4, RG B). The weight reduction programs should include the elements of the basic program (exercise, diet, and behavioral therapy) (EL 1–2, RG A). Table 3, which gives an overview, includes only programs for which published data are available.
The DGEM mentions that obese persons should only be offered programs that have received a positive assessment, which are geared to the individual situation and the therapeutic goals. Programs whose effectiveness is not clear, because (for example) there are no measured data to show the course of body weight over time, should be excluded.
Drug therapy should only be carried out in combination with a basic program (diet, exercise, behavioral therapy). The only drug that may be considered is orlistat (EL 1, RG A). Orlistat treatment is indicated in patients with a BMI above 28 kg/m2 who also have other risk factors or co-morbidities, or with a BMI ≥30 kg/m2 who have less than 5% weight loss after 6 months on the basic program (32).
Patients with type 2 diabetes mellitus and a BMI ≥30 kg/m2 may, if their glycemic control is inadequate on metformin, also use GLP-1 mimetics and SGLT2 inhibitors (EL 1, RG 0). These drugs should be considered as an alternative to antidiabetic drugs that promote weight increase, such as sulfonylureas, glinides, glitazones, and insulin (33).
The DEGAM states that insufficient study data exist for GLP-1 analogs in relation to clinical end points. It points out that they may be associated with an increased risk of pancreatic disease.
Drugs such as amphetamines, diuretics, human chorionic gonadotrophin (HCG), testosterone, thyroxine, and growth hormones, and medical products / dietary supplements should not be recommended as a way to lose weight (EL 4, RG A). The drugs have an unacceptable risk–benefit ratio, and in regard to the medical products and dietary supplements, evidence of their effectiveness is lacking.
Long-term weight stabilization
Measures to stabilize body weight long term should take into account aspects of diet, exercise, and behavioral therapy together with the motivation of the patient involved (EL 4, RG B).
To support weight stabilization, treatments and consultations should be made available over the long term after successful weight loss, and should include cognitive behavioral therapy (EK 1, RG A) (34).
Patients should be advised, after a period of weight reduction, to maintain an increased level of physical exercise (EL 1–2, RG A). Experience has shown that almost all patients who maintain their weight after a period of weight loss have remained or become physically active (35). After losing 7 to 14 kg, physically active persons regain half their lost weight within 1 to 2 years (Table 4).
Patients should be told that a low-fat diet will help prevent weight regain (EL 1–2, RG B) (39). In persons who lost 12 to 24 kg on a very low calorie diet, weight regain of <5 kg was seen after 1 to 2 years on a reduced-energy balanced diet (Table 5).
Regular weighing contributes to better weight stabilization after successful weight loss (EL 4, RG B) (e2).
Surgical intervention in extremely obese patients
For extremely obese patients, surgical intervention should be considered (EL 1–3, RG A). Compared to conservative treatment, surgical treatment is more effective in terms of body fat reduction, improvement of obesity-related diseases, and reduction of mortality risk (e3–e5) (Figure 2).
Obesity surgery is indicated according to BMI as follows, if all conservative treatment methods have been unsuccessful (EL 4, RG A):
- Grade III obesity (BMI ≥40 kg/m2) or
- Grade II obesity (BMI ≥35 kg and <40 kg/m2) with significant co-morbidities (e.g., type 2 diabetes) or
- Grade I obesity (BMI >30 and <35 kg/m2) in patients with type 2 diabetes (special cases)
If multimodal conservative therapy for 6 months leads to ≤10% weight loss in patients with a BMI of 35 to 39.9 kg/m2 and ≤20% in those with a BMI of ≥40 kg/m2, surgery should be considered (1). The DGEM states: surgery is indicated in patients with a BMI ≥40 kg/m2 if ≤10% of the initial weight has been lost. For patients with type 2 diabetes, the recommendation grade is B, as the data are insufficient.
Surgical treatment can also be given as a primary therapy, without any preceding conservative treatment, if conservative treatment is judged to have no chance of success or the patient’s health does not allow surgery to be delayed in order to attempt improvement by weight reduction (EL 4, RG 0). Patients with severe concomitant disease, a BMI ≥50 kg/m2, and difficult psychosocial circumstances are eligible. The DGEM regards surgery as indicated in patients who are immobile, in whom diet-based treatment has failed, and in those with a high insulin requirement.
Before surgery, patients should undergo an assessment that includes metabolic, cardiovascular, psychosocial, and dietary details (EL 4, RG A). After bariatric surgery, lifelong interdisciplinary follow-up is required (EL 4, RG A) (e6). For quality assurance, patients who undergo weight loss surgery should be entered in a central national register (EL 4, RG B).
Conflict of interest statement
Professor Hauer has received consultancy fees from Weight Watchers International and Apothecom (advisory boards). He has received third-party funding from Weight Watchers International and from Riemser GmbH and Certmedica.
Professor Wirth has received consultancy fees from Riemser GmbH.
Professor Wabitsch has received consultancy fees from Johnson and Johnson Medical GmbH.
Manuscript received on 17 July 2014, revised version accepted on
23 July 2014.
Translated from the original German by Kersti Wagstaff, MA.
Prof. Dr. med. Alfred Wirth
49214 Bad Rothenfelde, Germany
@For eReferences please refer to:
eBox, eFigure, eTable:
Schulungsprogramm: Bewegungstherapie und Lebensstilintervention bei Adipositas und diabetes. Diabet Aktuel 2013; 11: 5–11.
Department of Pediatrics and Adolescent Medicine, Section of Pediatric Endocrinology and Diabetes, University Medical Center Ulm, Ulm: Prof. Dr. med. Wabitsch
Else Kroener-Fresenius-Center for Nutritional Medicine, Klinikum rechts der Isar, Technische Universität München, Munich: Prof. Dr. med. Hauner
|1.||World Health Organization: Obesity – preventing and managing the global epidemic. Report of a WHO Consultation on obesity. Technical Report Series 894. Geneva 2000.|
|2.||Kurth BM: Erste Ergebnisse aus der „Studie zur Gesundheit Erwachsener in Deutschland” (DEGS). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55: 980–90 CrossRef|
|3.||Statistisches Bundesamt: Mikrozensus – Fragen zur Gesundheit – Körpermaße der Bevölkerung. 2011 [cited: 2013].|
|4.||Bes-Rastrollo M, van Dam RM, Martinez-Gonzalez MA, Li TY, Sampson LL, Hu FB: Prospective study of dietary energy density and weight gain in women. Am J Clin Nutr 2008; 88: 769–77 MEDLINE PubMed Central|
|5.||Sayon-Orea C, Martinez-Gonzalez MA, Bes-Rastrollo M: Alcohol consumption and body weight: a systematic review. Nutr Rev 2011; 69: 419–31 MEDLINE CrossRef|
|6.||Rosenheck R: Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk. Obes Rev 2008; 9: 535–47 MEDLINE CrossRef|
|7.||Vartanian LR, Schwartz MB, Brownell KD: Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health 2007; 97: 667–75 MEDLINE PubMed Central CrossRef|
|8.||Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK: American College of Sports Medicine Position Stand: Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009; 41: 459–71 MEDLINE CrossRef|
|9.||Witham MD, Avenell A: Interventions to achieve long-term weight loss in obese older people: a systematic review and meta-analysis. Age Ageing 2010; 39: 176–84 MEDLINE CrossRef|
|10.||Astrup A, Grunwald GK, Melanson EL, Saris WH, Hill JO: The role of low-fat diets in body weight control: a meta-analysis of ad libitum dietary intervention studies. Int J Obes Relat Metab Disord 2000; 24: 1545–52 CrossRef|
|11.||Nordmann AJ, Nordmann A, Briel M, et al.: Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166: 285–93 MEDLINE CrossRef|
|12.||Shai I, Schwarzfuchs D, Henkin Y, et al.: Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008; 359: 229–4 MEDLINE CrossRef|
|13.||Sacks FM, Bray GA, Carey VJ, et al.: Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009; 360: 859–73 MEDLINE PubMed Central CrossRef|
|14.||Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM: Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med 2007; 147: 41–50 CrossRef|
|15.||Schwingshackl L, Hoffmann G: Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis. Nutr J 2013; 12: 48 MEDLINE PubMed CentralCrossRef|
|16.||Esposito K, Kastorini CM, Panagiotakos DB, Guigliano D: Mediterranean diet and weight loss: meta-analysis of randomized controlled trials. Metab Syndr Relat Disord 2011; 9: 1–12 MEDLINE CrossRef|
|17.||Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report: National Institutes of Health. Obes Res 1998; 6: 51–209.|
|18.||Ismail, I, Keating SE, Baker MK, et al.: A systematic review and meta-analysis of the effect of aerobic vs:resistance exercise training on visceral fat. Obes reviews 2012; 13: 68–91 MEDLINE CrossRef|
|19.||McTiernan A, Sorensen B, Irwin ML, et al.: Exercise effect on weight and body fat in men and women. Obesity (Silver Spring) 2007; 15: 1496–512 MEDLINE CrossRef|
|20.||Slentz CA, Bateman LA, Willis LH, et al.: Effects of aerobic vs: resistance training on visceral and liver fat stores, liver enzymes, and insulin resistance by HOMA in overweight adults from STRRIDE AT/RT. Am J Physiol Endocrinol Metab 2011; 301: E1033-E9 MEDLINE PubMed Central CrossRef|
|21.||Thorogood A, Mottillo S, Shimony A, et al.: Isolated aerobic exercise and weight loss: a systematic review and meta-analysis of randomized controlled trials. Am J Medicine 2011; 124: 747–55 MEDLINE CrossRef|
|22.||Shaw G, Gennat H, O'Rourke P, Del Mar C: Exercise for overweight or obesity. Cochrane Date Base Syst Rev 2006; CD003817.|
|23.||Göhner W, Schlatterer M, Seelig H, Frey I, Berg A, Fuchs R: Two-year follow-up of an interdisciplinary cognitive-behavioral intervention program for obese adults. J Psychol 2012; 146: 371–91 MEDLINE CrossRef|
|24.||Anderson JW, Reynolds LR, Bush HM, Rinsky JL, Washnock C: Effect of a behavioral/nutritional intervention program on weight loss in obese adults: a randomized controlled trial. Postgrad Med 2011; 123: 205–13 MEDLINE CrossRef|
|25.||Shaw K, O'Rourke P, Del MC, Kenardy J: Psychological interventions for overweight or obesity. Cochrane Database Syst Rev 2005; CD003818 MEDLINE|
|26.||Scholz GH, Flehming G, Scholz M, et al.: Evaluation des Selbsthilfeprogramms „Ich nehme ab“: Gewichtsverlust, Ernährungsmuster und Akzeptanz nach einjähriger beratergestützter Intervention bei übergerwichtigen Personen. Ernährungs-Umschau 2005; 52: 226–31.|
|27.||Austel A, Podzuweit F, Tempelmann A, Stotz-Jonas B, Ellrott T: Evaluation eines tailorisierten computergestützten Gewichtsmanagementsprogramms mit 46.000 Teilnehmern. Obes Facts 2012; 5: 28–9.|
|28.||Jebb SA, Ahern AL, Olson AD, et al.: Primary care referral to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011; 378: 1485–92 MEDLINE PubMed Central CrossRef|
|29.||Walle H, Becker C: LEAN-Studie II: 1-Jahresergebnisse eines ambulanten, ärztlich betreuten Ernährungskonzepts. Adipositas 2011; 1: 15–24.|
|30.||Lagerstrom D, Berg A, Haas U, et al.: Das M.O.B.I.L.I.S.-|
Schulungsprogramm: Bewegungstherapie und Lebensstilintervention bei Adipositas und diabetes. Diabet Aktuel 2013; 11: 5–11.
|31.||Bischoff SC, Damms-Machado A, et al.: Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life—|
a prospective study. Int J Obes 2012; 36: 614–24 MEDLINE PubMed Central CrossRef
|32.||Sjöstrom L, Rissanen A, Andersen T, et al.: Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. European Multicentre Orlistat Study Group. Lancet 1998; 352: 167–72 MEDLINE CrossRef|
|33.||Monami M, Dicembrini I, Marchionni N, Rotella CM, Mannucci E: Effects of glucagon-like Peptide-1 receptor agonists on body weight: a meta-analysis. Exp Diabetes Res 2012; 2012: 672658 MEDLINE PubMed Central|
|34.||Ohsiek S, Williams M: Psychological factors influencing weight loss maintenance: an integrative literature review. J Am Acad Nurse Pract 2011; 23: 592–601 MEDLINE CrossRef|
|35.||Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO: A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997; 66: 239–46 MEDLINE|
|36.||Tate DF, Jeffery RW, Sherwood NE, Wing RR: Long-term weight losses associated with prescription of higher physical activitry goals: Are higher levels of physical activity protective against weight regain? Am J Clin Nutr 2007; 85: 954–9 MEDLINE|
|37.||Hunter GR, Brock DW, Byrne NM, et al.: Exercise training prevents regain of visceral fat for 1-year following weight loss. Obesity 2010; 18: 690–5 MEDLINE PubMed Central CrossRef|
|38.||Catenacci VA, Ogden LG, Stuht J, et al.: Physical activity patterns in the National Weight Control Registry. Obesity 2008; 16: 153–61 MEDLINE CrossRef|
|39.||Toubro S, Astrup A: Randomised comparison of diets for |
maintaining obese subjects' weight after major weight loss: ad lib, low fat, high carbohydrate diet v fixed energy intake. BMJ 1997; 314: 29–34 MEDLINE PubMed Central CrossRef
|40.||Anderson JW, Konz EC, Frederich RC, Wood CL: Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001; 74: 579–84 MEDLINE|
|e1.||Johansson K, Neovius M, Hemmingsson E: Effects of anti-obesity drugs, diet, and exercise on weight-loss maintenance after a very-low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2014; 99: 14–23 MEDLINE PubMed Central CrossRef|
|e2.||Butryn ML, Phelan S, Hill JO, Wing RR: Consistent self-monitoring of weight: a key component of successful weight loss maintenance. Obesity (Silver Spring) 2007; 15: 3091–6 MEDLINE CrossRef|
|e3.||Sjostrom L, Narbro K, Sjostrom CD, et al.: Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741–52 MEDLINE CrossRef|
|e4.||Dixon JB, Zimmet P, Alberti KG, Rubino F: Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med 2011; 28: 628–42 MEDLINE PubMed Central CrossRef|
|e5.||Schauer PR, Kashyap SR, Wolski K, et al.: Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366: 1567–76 MEDLINE PubMed Central CrossRef|
|e6.||Slater GH, Ren CJ, Siegel N, et al.: Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg 2004; 8: 48–55 MEDLINE CrossRef|
Pharmacological Research, 202210.1016/j.phrs.2022.106471
Osteopathic Family Physician, 202010.33181/12043
Attitude Matters! How Attitude towards Bariatric Surgery Influences the Effects of Behavioural Weight Loss TreatmentObesity Facts, 202110.1159/000517850
Effect of Acupuncture on Simple Obesity and Serum Levels of Prostaglandin E and Leptin in Sprague-Dawley RatsComputational and Mathematical Methods in Medicine, 202110.1155/2021/6730274
Voprosy kurortologii, fizioterapii i lechebnoi fizicheskoi kul'tury, 202110.17116/kurort20219804125
Applied Physiology, Nutrition, and Metabolism, 202010.1139/apnm-2019-0947
Effects of a Protein-Rich, Low-Glycaemic Meal Replacement on Changes in Dietary Intake and Body Weight Following a Weight-Management Intervention—The ACOORH TrialNutrients, 202110.3390/nu13020376
American Journal of Physiology-Gastrointestinal and Liver Physiology, 201810.1152/ajpgi.00044.2018
Obesity Facts, 201710.1159/000475842
gynäkologie + geburtshilfe, 202110.1007/s15013-021-4084-3
Deutsches Ärzteblatt international, 201410.3238/arztebl.2014.0816
Deutsches Ärzteblatt international, 201510.3238/arztebl.2015.0250b
Preclinical Research on a Mixture of Red Ginseng and Licorice Extracts in the Treatment and Prevention of ObesityNutrients, 202010.3390/nu12092744
Open Access Macedonian Journal of Medical Sciences, 202210.3889/oamjms.2022.9079
Indikationsstellung in der Adipositastherapie – Surgeons first? // Indications in obesity therapy - surgeons first?Zentralblatt für Chirurgie - Zeitschrift für Allgemeine, Viszeral-, Thorax- und Gefäßchirurgie, 202210.1055/a-1970-3664
Lotus (Nelumbo nucifera Gaertn.) Leaf-Fermentation Supernatant Inhibits Adipogenesis in 3T3-L1 Preadipocytes and Suppresses Obesity in High-Fat Diet-Induced Obese RatsNutrients, 202210.3390/nu14204348
Impacts of Physical Exercise and Media Use on the Physical and Mental Health of People with Obesity: Based on the CGSS 2017 SurveyHealthcare, 202210.3390/healthcare10091740
Journal of Obesity & Metabolic Syndrome, 202110.7570/jomes20100
Deutsches Ärzteblatt international, 201510.3238/arztebl.2015.0250a
American Journal of Physiology-Endocrinology and Metabolism, 202210.1152/ajpendo.00293.2021
Telomere length dynamics measured by flow-FISH in patients with obesity undergoing bariatric surgeryScientific Reports, 202310.1038/s41598-022-27196-6
The Influence of Supplementation of Anthocyanins on Obesity-Associated Comorbidities: A Concise ReviewFoods, 202010.3390/foods9060687
Obesity Facts, 201610.1159/000445381
Deutsches Ärzteblatt international, 201610.3238/arztebl.2016.0825