Recommendations for the prevention and management of obesity in the Iraqi population

Figures & data

Table 1. BMI categories in the general population (including Middle-Eastern populations) (WHO 1997).

BMI <18.5:	Below normal weight
BMI ≥18.5 and <25:	Normal weight
BMI ≥25 and <30:	Overweight
BMI ≥30 and <35:	Class I Obesity
BMI ≥35 and <40:	Class II Obesity
BMI ≥40:	Class III Obesity

Table 2. Differential diagnosis/secondary causes of obesity/overweight.

Drugs	•	Glucocorticoids
	•	Diabetes medications (insulin, sulfonylureas, thiazolidinediones, meglitinides)
	•	First-generation antipsychotics (thioridazine)
	•	Second-generation antipsychotics (risperidone, olanzapine, clozapine, quetiapine)
	•	Neurologic and mood stabilizing agents (carbamazepine, gabapentin, lithium, valproate)
	•	Antihistamines (especially cyproheptadine)
	•	Antidepressants (paroxetine, citalopram, amitriptyline, nortriptyline, imipramine, mirtazapine)
	•	Hormonal agents (especially progestins, e.g. medroxyprogesterone)
	•	Beta-blockers (especially propranolol)
	•	Alpha-blockers (especially terazosin)
Dietary obesity	•	Infant feeding practices
	•	Progressive hyperplastic obesity
	•	Frequency of eating
	•	High-fat diets
	•	Overeating
Neuroendocrine	•	Hypothalamic obesity
	•	Hypothyroidism
	•	Seasonal affective disorder
	•	Cushing’s syndrome
	•	Polycystic ovary syndrome
	•	Hypogonadism
	•	Growth hormone deficiency
	•	Pseudohypoparathyroidism
Social and behavioral	•	Socioeconomic status
	•	Ethnicity
		Psychological factors
	•	Restrained eaters
	•	Night eating syndrome
	•	Binge eating
Sedentary lifestyle	•	Enforced inactivity (postoperative)
	•	Aging
Genetic	•	Autosomal recessive traits
	•	Autosomal dominant traits
	•	X-linked traits
	•	Chromosomal abnormalities
Other	•	Low birth weight

Table 3. Classification of patients.

Risk	BMI	Waist circumference	CVD comorbidities
Little to no risk	20–24.9 kg/m^2	Normal	None
Low risk	25–29.9 kg/m^2	Males <94 cm – Females <82 cm	None
Moderate risk	25–29.9 kg/m^2	Males 94–102 cm – Females 82–88 cm	1 or more CVD risk factor
	30–34.9 kg/m^2	Males 94–102 cm – Females 82–88 cm	Provide treatment regardless of CVD risk factors
High risk	35–40 kg/m^2 (particularly if aged 20–39 years)	Males > 102 cm – Females > 88 cm	Provide treatment regardless of CVD risk factors
	>40 kg/m^2	Males > 102 cm – Females > 88 cm	Provide treatment regardless of CVD risk factors

Figure 1. Overweight and obesity treatment algorithm a: only after agreement of multidisciplinary team b: only if comorbidities are present along with BMI between 35 and 40 kg/m.

Table 4. Management recommendations.

1. For all people who are overweight or obese, we recommend a 3–6 months trial of lifestyle changes:a. Reducing calorie intake by 500–750 kcal/day.b. b. Maintain total calories to less than 1200–1500 kcal/day for women and 1500–1800 kcal for men to preserve current weight.c. Exercise through 1) Brisk walking for 60 minutes at least 5 days/week; or 2) Running for 30–40 minutes at least 5 days/week2. If target weight is not achieved after lifestyle changes, drug therapy and/or surgery should be considered, as follows:a. If the patient has a BMI is between 27 and 29.9 kg/m^2 with comorbidities or BMI between 30 and 34.9 kg/m^2 without comorbidities (regardless of waist circumference):We recommend pharmacotherapy targeted toward obesity management. Options include 1) Orlistat 120 mg three times daily with each meal; or 2) Liraglutide 3 mg/day, starting with 0.6 mg/d and titrated with increment of 0.6 mg/week till maximum dose of 3 mg/d achieved or the maximum tolerated dose.b. If the patients has a BMI between 30 and 34.9 Kg/^2 but with comorbidities:In addition to pharmacotherapy, bariatric surgery can be suggested as a mode of therapy after agreement of multidisciplinary team.c. If the patient has a BMI between 35 and 40 kg/m^2 (regardless of waist circumference):We recommend the use of either pharmacotherapy, devices (e.g. laparoscopic adjustable gastric banding or intragastric balloon systems) or bariatric surgery*, the choice of which depends on patient preference, treating physician expertise and available facilities.*only in the presence of comorbiditiesd. If BMI is over 40 kg/m^2:Pharmacotherapy with lifestyle changes should be offered as mentioned above. Bariatric surgery can also be considered when medically appropriate and in case clinically significant/beneficial weight loss cannot be achieved for at least 6 months after trying all possible non-surgical measures. The type of bariatric surgery depends on patient preference, treating physician expertise and facilities that are available.3. We do not recommend any of the following for weight reduction: liposuction, over the counter dietary or herbal supplements and acupuncture either because of safety concerns or lack of evidence to support such interventions.

Table 5. Diagnostic Evaluation of Childhood Obesity and Its Comorbidities.

HISTORY
Etiology	Signs and symptoms
Genetics	Parent BMI, race, mental retardation
Epigenetics	Birth weight, gestational difficulties, prematurity
CNS	CNS insult, mental retardation or developmental delay
Endocrine	Slowdown in linear growth, red hair
Medication	Medication history, esp. atypical antipsychotics
Dietary	Calorie recall, esp. sugar-containing liquids, breastfeeding
Physical activity	Exercise history, television, computer, and cell phone recall
Stress	Socioeconomic status, number of caregivers, television recall, sleep status, atypical depression
Sleep Apnea	History of snoring, headache, waking up with headache
PCOS	Hirsutism, oligomenorrhea, amenorrhea
Type 2 Diabetes	Polyuria, polydipsia, nocturia, recent weight loss
Orthopedic morbidity	Knee or hip pain, limitation of motion
Depression	Activity level, school performance
PHYSICAL EXAMINATION
Co-morbidity	Signs and symptoms
Insulin resistance	Acanthosis nigricans, skin tags, waist circumference
Hypertension	Systolic BP or Diastolic BP > 90th percentile for age
Pseudotumor cerebri	Papilledema
Hepatic steatosis	Hepatomegaly
PCOS	Hirsutism
Precocious/delayed puberty	Gonadal and pubic hair status
Sleep apnea	Tonsillar hypertrophy
Myopathy	Decreased muscle tone, hyporeflexia
Syndromic obesity	Specific neurocutaneous stigmata, mental retardation
LABORATORY INVESTIGATIONS
Comorbidity	Tests
Hepatic steatosis	ALT, hepatic ultrasound
Glucose intolerance	Fasting glucose 100 or 2-hour glucose 140
Type 2 diabetes mellitus	Fasting glucose 125 or 2-hour glucose 200; HbA1c 6.5%
Dyslipidemia	Lipid profile with increased VLDL, TG: HDL > 2.5
Insulin resistance	Fasting insulin, glucose
Insulin hypersecretion	3-hour OGTT with insulin levels
PCOS	Free and total testosterone, SHBG
CNS lesion	MRI
Obstructive sleep apnea	Nocturnal polysomnography, if not available overnight oximetry