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

ABSTRACT

Obesity is a chronic metabolic disease that has become one of the leading causes of disability and death in the world, affecting not only adults but also children and adolescents. In Iraq, one third of the adult population is overweight and another third obese. Clinical diagnosis is accomplished by measuring body mass index (BMI) and waist circumference (a marker for intra-visceral fat and higher metabolic and cardiovascular disease risk). A complex interaction between behavioral, social (rapid urbanization), environmental and genetic factors underlies the etiology of the disease. Treatment options for obesity may include a multicomponent approach, involving dietary changes to reduce calorie intake, an increase in physical activity, behavioral modification, pharmacotherapy and bariatric surgery. The purpose for these recommendations is to develop a management plan and standards of care that are relevant to the Iraqi population and that can prevent/manage obesity and obesity-related complications, for the promotion of a healthy community.

KEYWORDS:

• Obesity
• overweight
• adult
• pediatric
• management
• guidelines

1. Introduction/rationale

The obesity and overweight pandemic continues to afflict global populations across all socioeconomic settings. The World Health Organization (WHO) estimates that close to 40% (1.9 billion) of adults were overweight in 2016, 13% (650 million) of whom were obese [1]. The dramatic rise in the rates of overweight and obesity was also reflected in younger individuals, with approximately 38.2 million children aged 5 years and below and more than 340 million children and adolescents aged 5–19 being overweight or obese in 2019 and 2016, respectively [1].

Simply defined by the WHO as ‘abnormal or excessive fat accumulation that may impair health’ [1], obesity and overweight were officially recognized by the American Medical Association (AMA) as a complex chronic disease in 2013 [2]. On a pathophysiological level, obesity is now widely recognized as a chronic, relapsing multifactorial neurobehavioral disease with serious implications on the level of metabolic, biomechanical, and psychosocial wellbeing [3].

The lethality of obesity has become more concerning than underweight and malnutrition seeing as obesity-related mortality has at least doubled since 1990 [4]. With around 5.4 million global deaths attributed to high body mass index (BMI) in 2019 [5], obesity remains one of the leading risk factors for premature deaths and is associated with a plethora of non-communicable diseases (metabolic diseases, cardiovascular diseases, and malignancies, etc.)[6], leading to a decrease in life expectancy [7,8] while also causing an impairment of quality of life and loss of productivity [9,10].

The pandemic proportions of obesity have also been reported from the Middle East, particularly among countries with upper-middle and high income [11]. Evidently, the high rates of obesity also extend to lower income countries such as Iraq, where the Non communicable Diseases Risk Factors Survey (STEPS) conducted in Iraq in 2015 showed that nearly one third (33.5%) of respondents were obese and 31.9% were overweight [12]. Women were more likely to be obese whereas overweight supervened among men [12]. These recommendations therefore aim to develop a management plan and standards of care that are relevant to the Iraqi population and can prevent/manage obesity and obesity-related complications for the promotion of a healthy community.

2. Methods

A multi-disciplinary panel of regional experts from different specialties (adult and pediatric endocrinologists, bariatric surgeons, nutritionists, family physicians, cardiologists, gynecologists and psychiatrists) who are involved in the management of obese patients convened in monthly meetings (from December 2019 till February 2021) to review the progress of the panel with ad-hoc meetings for each specialty. The latest literature and local studies were reviewed in writing these recommendations, which incorporated Canadian, European and WHO guidelines [13,14]. The recommendations are endorsed by the Iraqi Medical Association, the Iraqi Obesity Society, and the Iraqi Diabetes Association and will also be presented to the Iraqi ministry of health for endorsement.

3. Obesity management in adults

3.1. Screening

3.1.1. Rationale

Weight loss, whether via lifestyle/behavioral, medical therapy or surgical interventions, is recommended as it could lead to the reduction of a wide array of weight-related complications. Documented benefits of weight loss include a lower risk of developing diabetes, hypertension, and dyslipidemia as well as a reduction in the number of cardiovascular events, a lower risk of asthma, sleep apnea, and an improvement in quality of life [15–18]. Intentional weight loss could also lead to a decrease in all-cause mortality, as well as mortality due to cancer and cardiovascular disease [15]. Prevention and treatment of obesity is therefore much needed. Research from the Middle East lags far behind other regions in the world, despite the region’s high rates of obesity. The paucity and variability of available evidence in the Middle East prevents the establishment of the efficacy of dietary interventions among adults for weight loss [19]. Screening is therefore essential to ensure that high-risk patients receive the necessary counselling about the health risks of being overweight/obese, and the available risk factor reduction, lifestyle changes and obesity treatment options.

3.1.2. Barriers

That being said, the diagnosis of obesity could lead to negative changes for the patient, particularly considering the stigmatization and discrimination they might face even in the healthcare setting [20]. The obesity stigma should be eradicated, as it would most likely reflect in an improvement in the management of obesity by preventing the deleterious effects of stigmatization (i.e. weight gain and poor mental health) [21–23]. Healthcare providers involved in the management and counseling of such patients should therefore adopt positive attitudes, welcoming patients and avoiding the use of insensitive and/or discriminatory terms. It is also important to address weight misperceptions and misconceptions, commonly observed among the general population [24], in order to promote a proactive and healthy attitude towards weight loss and weight loss maintenance.

3.1.3. Measurements: BMI and waist circumference

BMI is a practical tool for evaluating patient weight (Table 1). Measuring waist circumference is also suggested in overweight and obese adults with a BMI ≤ 35 kg/m² in order to assess abdominal obesity as an abnormal waist circumference correlates with a higher risk of metabolic and cardiovascular disease [25,26]. Internationally, high disease risk in relation to waist circumference was standardized at ≥102 cm for males and ≥88 cm for females [14,27]. Alternatively, local studies reported a waist circumference of ≥99 cm for Iraqi men and ≥97 cm for Iraqi women to be considered elevated and indicative of increased cardiometabolic risk [28].

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

3.2. Evaluation

In patients found to be overweight (body mass index [BMI] ≥25 kg/m²) or abdominally obese, assessment of the etiology of the weight gain and its associated health risk should be undertaken. Specifically, evaluation of the overweight or obese patient includes establishing patient history (age at onset, weight loss attempts, current or previous medications, behavioral/dietary pattern changes), physical examination, and measurement of fasting glucose (or glycated hemoglobin [A1C]), thyroid-stimulating hormone (TSH), liver enzymes, and fasting lipids.

3.2.1. Determining etiology

The majority of obesity cases are related to behavioral factors, such as excessive calories intake and sedentary lifestyle. That being said, other factors can contribute to the development of obesity. Although uncommon, secondary causes of overweight/obesity should be considered and ruled out prior to proceeding with management strategies (Table 2) [29]. Physical examination findings that might point to a secondary cause of obesity include goiter (hypothyroidism), proximal muscle weakness, purple striae, osteoporosis (Cushing’s syndrome), and acne/hirsutism (polycystic ovary syndrome (PCOS). If needed, additional testing should be conducted for the detection of possible involvement of the hypothalamic-pituitary axis (Cushing’s syndrome, growth hormone deficiency, or hypothalamic obesity). While it is possible that monogenetic disorders could be responsible for obesity, these occurrences are rare and predominately limited to childhood. Routine genetic testing is therefore not recommended in adult patients. To note that pathogenic mutations in the hypothalamic appetite-regulating melanocortin-4 receptor (MC4R) have a prevalence of 6% globally and are the most common cause of monogenic juvenile-onset obesity [30–32]. Developing countries such as Iraq exhibit a higher prevalence due to the existence of higher rates of consanguinity [33]. Early-onset obesity, hyperphagia, increased linear growth are characteristic manifestations of pathogenic MC4R mutations [34–36], in addition to a lesser risk of hypertension despite the presence of obesity [37]. Pathogenic MC4R mutations are worth considering seeing as patients carrying these mutations can still benefit from Glucagon-like Peptide-1 Receptor Agonists [38,39]. Measurement of metabolic rate is also not recommended, as it is not widely available and may be misinterpreted.

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

3.2.2. Assessing obesity-related CV risk and complications

Obesity is identified as a risk factor for cardiovascular disease and diabetes mellitus, among other metabolic and mechanical disorders. Cardiovascular risk factors should be identified and managed in order to reduce cardiovascular disease risk independently of weight loss. These risk factors include hypertension, dyslipidemia (reduced levels of high-density lipoprotein [HDL] or elevated levels of low-density lipoprotein [LDL]), elevated triglycerides, impaired fasting glucose or diabetes, obstructive sleep apnea, and cigarette smoking. Assessment of other obesity related disorders that do not increase cardiovascular risk but are associated with significant morbidity should also be undertaken. Examples include symptomatic osteoarthritis, cholelithiasis, nonalcoholic fatty liver disease, PCOS, depression, sleep apnea and impaired quality of life.

3.3. Approach to therapy

3.3.1. Goals of treatment

The management of obesity largely depends on available resources, clinical expertise as well as patient preference. It should be undertaken within the framework of a multidisciplinary team involving at least a primary health care physician, possibly a family physician, internist or an endocrinologist, a bariatric surgeon and a psychiatrist or psychologist. Management should not only target the prevention, treatment or reversal of the complications of obesity but also the improvement of quality of life. In fact, health benefits can be observed after weight loss as modest as 5% of body weight [40,41].

In general, management can rely on lifestyle/behavioral changes alone. In this case, 5–7% weight loss can be expected, but is difficult to maintain due to the great implication of patient adherence [42,43]. The supplementation of lifestyle interventions with pharmacologic therapy can also be considered. 5–10% weight loss can often be achieved with pharmacologic therapy [44,45], while the use of medical devices and bariatric surgery can ensure greater weight loss than medical therapy (> 10%) [46–48].

3.3.2. Candidate identification

Patient management should be individualized and the best candidates for each approach should be identified and categorized based on the degree of obesity (BMI), the presence of abdominal obesity (waist circumference), the presence of cardiovascular disease risk factors (hypertension, diabetes and dyslipidemia) and the presence of other comorbidities (sleep apnea, nonalcoholic fatty liver disease) (Table 3). We suggest that all patients must be checked for H. pylori, as it is a common infection, and it is prevalent in patients with excess weight or obesity

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

Management recommendations and treatment algorithm are provided in Table 4 and Figure 1, respectively.

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.

3.3.3. Psychological assessment

1. Initial assessment of patients should include psychological assessment

2. Any patient with history of a psychiatric illness or psychotropic medication use should be referred to a psychiatrist.

3. Preoperative psychological assessment should be done and must include the following areas: consent, expectations, social support, mental health, chemical abuse/dependence, eating behaviour, adherence, and coping and stressors.

4. Before deciding on surgery, patients must try behavioural modification. This will give an idea about the patient’s commitment, which might influence relapse after surgery

5. Psychological opinion should be an integral part of a multidisciplinary team that manage obesity.

3.3.4. Initial treatment

3.3.4.1. Comprehensive lifestyle intervention

The cornerstone of obesity and overweight management is a comprehensive lifestyle intervention which combines diet, exercise and behavioral modification. Initial treatment includes regular self-monitoring of food intake, physical activity and weight. The modification of patient lifestyle facilitates adherence to physical activity and weight loss interventions/mainte[49]nance. To that end, the adoption of lifestyle intervention program of the Diabetes Prevention Program (DPP) (targeting a minimum of 7% weight loss through a low-fat, hypocaloric diet and a minimum of 150 minutes of exercise per week as brisk walking) is recommended [50]. Weight development can be predicted by behavioral (dietary intake and meal patterns) and psychological factors (motivation and self-efficacy) [51]. For successful weight maintenance, appropriate eating behavior seems crucial and is evaluated by assessing eating restraint, disinhibition and hunger. Several psychometric measures of weight maintenance predictors consider control over eating as a crucial criteria such as the Three Factor Eating Questionnaire (TFEQ) [52]. For reduction of caloric intake, self-control and careful decision making is necessary and are the building blocks of primary behavioral weight loss concepts such as restraint, disinhibition, self-efficacy [53], and locus of control [54]. Patient choice along with control is considered to be fundamental as patients have to exercise control in daily decisions on what foods to eat.

3.3.4.2. Dietary therapy

Adherence to dietary therapy is a more critical consideration for its success than the type of diet [55], which could be a balanced low-calorie diet, a low-fat/low-calorie diet, a moderate fat/low-calorie diet, a low carbohydrate diets or a Mediterranean diet. The choice of diet should aim to reduce energy intake below energy expenditure while taking into consideration individual patient preferences in order to improve adherence, seeing as macronutrient composition is of lesser concern for weight loss [56]. Diets are an effective strategy for the reduction of body mass [57] and an energy deficit of 500 to 750 kcal/day should be targeted when individualizing diets (which could generally be restricted to 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men). More significant weight loss is achieved with diets of 1000 kcal/day or less, compared to higher energy intake (1500 Kcal/day) [58]. Very-low-calorie diets (420 kcal or 530 kcal/day) and low-calorie diets (880 kcal/day) seem to yield comparable weight loss even on long-term follow-up [30]. Thus, weight loss can be expected even in patients concerned that they are ‘metabolically resistant’ to weight loss in case of compliance with a diet of 800 to 1200 kcal/day. Regardless, comorbidities and patient capacity to follow the diet should also be taken into account. Dietary counselling and psychological support could facilitate weight loss and long-term weight maintenance [59]. Return visits with the dietitian or clinician should be scheduled at regular intervals to assess barriers, discuss next steps and offer encouragement. Pharmacotherapy should be considered when weight loss does not exceed 5% total body weight over 6 months.

3.3.4.3. Exercise

While exercise is a less potent approach for weight loss compared to dietary restriction, its addition to a diet (particularly resistance training) leads to more effective changes to body composition and biomarkers of metabolic tissue [57]. In addition to weight loss[60], exercise can attenuate muscle leas mass loss [61], while preventing weight regain and improving cardiovascular health [62,63]. More significant weight loss is achieved with increasing amounts of exercise. In general, patients should be recommended to complete at least thirty minutes of a multicomponent program that includes aerobic and resistance training, five to seven days a week [64]. Exercise should be of moderate intensity for meaningful weight and adiposity loss [64]. Safety during exercise should be ensured and patients should be medically evaluated for physical fitness prior to initiation of physical exercise regimens.

3.3.4.4. Behavior modification

Clinicians should also aim to aid patients in implementing long-term changes to their eating behavior, promoting the modification and monitoring of food intake and physical activity. Moreover, eating triggers (environmental cues and stimuli) should be identified and controlled. Behavior modification should take into account several elements, as follows [14]:

1. Setting initial goals: 0.5–1 kg/week or 5–10% within six months.

2. Self-monitoring: food diaries and self-regular weighing.

3. Controlling or modifying the stimuli that activate eating

4. Eating style: Slowing down the eating process.

5. Behavioral contracting and reinforcement: Providing rewards for weight loss.

6. Nutrition education and meal planning: Defined meal structure and use portion-controlled plates or diets.

7. Increasing physical activity

8. Social support

9. Cognitive restructuring: Adopting positive rather than negative self-talk.

10. Problem-solving: Developing strategies to manage food intake in difficult situations such as restaurants and parties.

3.3.5. Subsequent treatment

3.3.5.1. Drug therapy

Drug therapy is recommended for patients who have not met weight loss goals (loss of at least 5% of total body weight) 3–6 months after a comprehensive lifestyle intervention. This decision should be individualized according to patient profile (BMI and comorbidities) and made after a careful evaluation of the risks and benefits of all treatment options. Pharmacological therapy can be initiated in patients with a BMI above 30 Kg/m² in the absence of comorbidities, while the BMI threshold is lowered to above 27 Kg/m² in patients with comorbidities. Initiating therapy is recommended independently of waist circumference. Weight loss medication should be prescribed as a long term treatment as an adjunct to lifestyle modification, consistently with the management of other chronic conditions. If <5% weight loss is achieved after 12 weeks, medication should be withdrawn. Pharmacological options include 3 mg liraglutide (Saxenda®, daily injection), and 120 mg orlistat (Xenical®, Onlefit®, Refit®), both of which are approved by the Iraqi Ministry of Health to be used for obesity management. Other agents that are approved for chronic use in other countries are combination phentermine-extended release topiramate and combination naltrexone-bupropion. The choice of drug is governed by the comorbidities and relative contraindications in the individual patient. That being said, liraglutide is the preferred agent given its tolerability and beneficial effects on glycemia, cardiovascular risk reduction and modest weight loss even in a real-world setting [16,65–67]. Evidence suggests superior significant weight loss with liraglutide in comparison to orlistat [44,45]. However, temporary gastrointestinal side effects (nausea, vomiting), its daily administration, and its cost may limit its use. Orlistat also had proven benefits in regard to glycemia, blood pressure and lipid profile [68]. However, it frequently causes gastrointestinal side effects and is often not tolerated by patients [69]. Due to its limited tolerability, and the established safety and benefits of other available agent including liraglutide, we no longer consider orlistat to be a first-line agent for the treatment of obesity unless the cost of other therapy is problematic.

Risks of treatment.Most of the approved drugs have minor side effects that diminish with time (treatment). While a few serious side effects have been identified, these should not preclude the short-term use of pharmacologic therapy in the majority of overweight subjects. The occurrence of adverse events should be screened for at every visit, and patients should be carefully monitored every six weeks to establish weight-loss, blood pressure and heart rate. Blood sugar should also be assessed in patients with diabetes, especially in those on insulin or insulin secretagogues. Any modality that results in a significant weight loss may increase the likelihood of cholelithiasis due to the increase of the flux of cholesterol through the biliary system [70,71]. We therefore recommend diets with moderate amounts of fat that stimulate gallbladder contraction to reduce this risk [72]. For subjects with a rapid weight loss (> 1.5 kg/week), bile acid (e.g. ursodeoxycholic acid) may be advisable [72,73].

3.3.5.2. Devices

Several approaches are available for the treatment of obesity, including electrical stimulation (vagal blockade) systems and gastric emptying (aspiration) systems. However, both of these modalities are not available in Iraq and cannot at present be recommended. Intragastric balloon systems have been advocated for use as a bridge to a more definitive surgical procedure and have been shown to be safe and effective for weight loss [74,75]. Three devices, Orbera, Obalon, and ReShape balloons, have been approved by the US Food and Drug Administration (FDA) to treat obesity in adults with a BMI of 30 to 40 kg/m² with one or more comorbid conditions such as diabetes, hypertension, or hypercholesterolemia.

3.3.5.3. Bariatric surgery

Bariatric surgery should be considered for patients with a BMI of 35 kg/m² or higher with obesity-related comorbidities that are expected to improve with weight reduction, as well as patients with one anastomosis gastric bypass (MGB/OAGB). Bariatric surgery is the intervention of choice for patients with a BMI of 40 kg/m² or higher, AND:

1. No achievement or maintenance of clinically significant/beneficial weight loss for at least 6 months after trying all possible non-surgical measures.

2. General fitness for anaesthesia and surgery.

3. Commitment to long-term follow-up.

4. Skeletal and sexual maturity (14 years for girls and 15 years for boys)

5. No significant psychiatric disease.

The choice of operation type depends on the surgical team and patient preferences. When considering gastric surgery, patients should undergo perioperative assessment by a multidisciplinary team comprised of a bariatric surgeon, dietitian, endocrinologist, general physician or cardiologist, psychiatrist, anesthetist and physiotherapist, as well as a gastroenterologist, plastic surgeon, gynecologist and orthopedist when needed. Gastric surgery is best undertaken in specialized obesity centers with the necessary provisions and equipment (e.g. suitable seating, bed frames, pressure-relieving mattresses and other tools for bariatric surgery, in addition to trained staff in their use). The availability of competent staff and a qualified bariatric surgeon is important for the successful conduction of gastric surgery. During the surgical assessment and counselling, the potential benefits of the procedure should be weighed against perioperative morbidity and mortality as well as expected complications. Medical assessment is critical to establish cardiopulmonary status and fitness for general anesthesia. Endocrinological function should also be examined both before and after surgery to determine the degree of diabetes and level of control, gonadal axis and fertility, lipid disorders, and thyroid status. In addition to medical assessment, psychological factors are frequent in patients eligible for bariatric surgery and should also be considered [76]. Psychological diseases contraindicating surgery should be determined prior to surgery and psychological support should be provided perioperatively to improve outcomes [77]. Patients’ ability to comply with pre- and post-operative dietary, behavioral and lifestyle changes should also be assessed, while taking into account current nutrition status and medical/weight loss history, educational needs as well as micronutrient screening. Pre-operative workup should also include a series of laboratory tests to determine liver function, complete blood count with differential, serum levels of iron, ferritin, calcium, vitamin B12, Vitamin B1 (thiamin), folate, TIBC, alkaline phosphatase, PTH and 25-hydroxyvitamin D. Before bariatric surgery is attempted, micronutrient deficiencies and insufficiencies should be corrected (particularly iron, zinc, vitamin B12 and vitamin D). Moreover, appropriate preoperative diet should be initiated, and a high protein and/or liquid diet may be recommended [78,79] at least 2 weeks prior to the scheduled bariatric surgery to ensure adequate protein intake, hydration as well as to provide practice in the use of protein supplements. Weight loss of 5% to 10% is also recommended to decrease total liver volume, facilitate the laparoscopic procedure and improve surgical outcomes. After surgery, patient compliance to the prescribed diet should be assessed, and rehabilitation (training and exercises) should be initiated to achieve maximum health improvement [80,81].

3.3.6. Therapies not currently recommended

3.3.6.1. Laparoscopic adjustable gastric banding

This is a purely restrictive procedure that is no longer recommended due to its relatively modest amount of expected weight loss, coupled with high rates of revision and weight recidivism.

3.3.6.2. Liposuction

We do not currently suggest liposuction as a strategy for long-term weight loss. While it appears to potentially improve insulin sensitivity and cardiovascular disease risk, available evidence remains insufficient and conflicting [82–84].

3.3.6.3. Dietary supplements

Over-the-counter dietary supplements are widely used by individuals attempting to lose weight and misinformation regarding them is rampant [85]. We recommend against the use of dietary supplements (e.g. ephedra, green tea, guar gum) seeing as they are poorly regulated and evidence to support their efficacy and safety are limited and generally of low quality [86,87].

3.3.6.4. Acupuncture

Although it has also been studied for the treatment of obesity, evidence regarding the efficacy of acupuncture is limited and of insufficient quality as most of the studies have been either uncontrolled trials, or of small samples and short durations, or do not includes adequate placebo controls[88].

3.3.6.5. Off label medication

We do not recommend use of off label medications for weight reduction due to lack of evidence of efficacy and safety for the treatment of obesity.

3.4. Maintenance of weight loss

Maintenance of weight loss is made difficult by the decrease in energy expenditure and the favor of weight reinstatement that is induced by weight loss [89]. Weight regain (or recidivism) is a common problem after obesity treatment [90]. Besides the long-term use of the drug therapy, we recommend continued behavioral interventions such as frequent self-weighing [91,92], consumption of a reduced-calorie diet [93], and high levels of physical activity [94]. Continued access to weight loss programs ensures slower weight regain [95] and the combination of drug therapy (i.e. liraglutide) with exercise leads to better weight loss maintenance[96].

3.5. Obesity in special groups

3.5.1. Obesity in children and adolescents

The global obesity and overweight epidemic also affects children of all ages, among whom it a serious health issue. Childhood obesity is highly likely to continue into adolescence and adulthood [97,98]. Early adiposity rebound is an established predictor of later obesity and overweight [97,99]. Parental obesity, maternal gestational weight gain and infant overnutrition/high birth weight affect the development of childhood obesity [100–102]. Genetic (monogenic disorders of the energy balance pathway, race and ethnicity) and environmental factors (lifestyle, stress, sleep deprivation, screen time) also contribute to childhood and adolescent obesity [100,103]. Other factors that should be considered include endocrine disorders with an obesity phenotype (e.g. Hypothyroidism, Cushing syndrome, GH deficiency and Pseudohypoparathyroidism type 1a (PHP1a)), insulin dynamic disorders, syndromic obesity and the use of certain medications. That being said, early obesity diagnosis and treatment is faced with societal hindrances, poor parental recognition and inadequate healthcare provider training. This results in delayed interventions and advanced disease stages, and consequently, poorer long-term health outcomes [104]. It is therefore critical to improve screening initiatives for childhood obesity and provide comprehensive management, as necessary.

Currently, pharmacological options include 3 mg liraglutide (Saxenda®, daily injection) which is approved for the children above the age of 12 with BMI corresponding to 30 or more.

3.5.1.1. Screening and Evaluation

The assessment of an obese child requires establishing a complete history as well as physical examination and health risk assessment.

BMI assessment is not applicable for infants younger than 2 years of age. Infants’ weight percentile is instead compared to length percentile, and weight group is determined based on applicable growth charts. If the weight for recumbent length is equal to or exceeds the 97.7^th percentile of WHO growth standards, a child younger than 2 years of age is considered obese.

BMI charts are used for children aged 2–20 years (Center for Disease Control (CDC) charts (Appendixes 1 and 2) or WHO charts (Appendixes 3 and 4). Using the revised CDC charts from 2000, a BMI ≥ 85th percentile, but < 95th percentile is indicative of overweight, while obesity is diagnosed if the BMI is ≥ 95th percentile for age and gender. Extreme obesity is defined as a BMI ≥120% of the 95th percentile or ≥ 35 kg/m2 (also referred to as class 2 obesity), and a BMI ≥140% of the 95th percentile or ≥40 kg/m2 indicates class 3 obesity.

To note that BMI is age- and puberty-dependent in children, which is reflected in the higher accuracy of BMI z-score compared to standard BMI for the assessment of childhood adiposity (Appendixes 3,4). According to the WHO growth reference for school aged children and adolescents, overweight is indicated by one standard deviation BMI for age and sex, and obese is indicated by two standard deviations BMI for age and sex.

Waist circumference is also recognized as a strong predictor of the later development of metabolic disturbance in children and adolescents [105,106] and might be more predictive than BMI which fails to discriminate between muscle, bone and both subcutaneous and visceral fat [107,108].

Diagnostic evaluation should focus on establishing history, followed by physical examination and laboratory investigations. Guidance for the initial evaluation of children are listed in Table 5.

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

Moreover, it is important to note that many of the obesity-related comorbidities recognized in adulthood begin to develop in childhood and should also be considered during child assessment. These comorbidities include:

• Metabolic syndrome (clustering of type 2 diabetes, hypertension and dyslipidemia)

• Nonalcoholic fatty liver disease

• PCOS

• Earlier age of pubertal initiation.

• Infertility in older adolescents due PCOS in females and excessive aromatization of androgen to estrogen by peripheral adipose tissue in male.

• Gynecomastia in male

• Decreased GH secretion.

• Subclinical hypothyroidism

• Elevated cortisol level

• Vitamin D deficiency.

• Pseudotumor cerebri.

• Obstructive sleep apnea.

• Orthopedic morbidity: slipped capital femoral epiphysis, Blount's disease, scoliosis

• Cholelithiasis in obese adolescents especially females.

• Psychological distress including clinical depression, eating disorders

3.5.1.2. Approach to therapy for childhood obesity

3.5.1.2.1. Comprehensive lifestyle modification

Comprehensive lifestyle modification is also the cornerstone of obesity therapy in children. Weight maintenance rather than weight loss is recommended in children among whom the prevention of obesity is more cost-effective and feasible compared to its treatment. In order to achieve this, establishing a healthy lifestyle through adequate diets and physical activity is effective and encouraged as early as possible [109–111]. In addition to preventing the development of obesity, such lifestyle, dietary and behavioral interventions could also be reflected in immediate benefits during childhood/adolescence (e.g. better fitness, more energy, better nutrition) and long-term improvement of adult health and habits, and by extension, lower chronic disease risk. A weight-maintenance program is advised by the American Academy of Pediatrics for overweight children aged 2 and above for the limitation of weight gain and the progressive decrease of BMI. The modification of eating habits could be preferable for children that are obese, with a target of gradual weight loss of no more than around 0.5 Kg/month in ages 6–11, and 1 Kg/week for older children and adolescents. Weight maintenance programs consist of monitoring the type and amount of food intake in addition to the increase of physical activity. Family commitment remains essential for the successful implementation and adherence to weight management interventions among children.

Dietary intervention

The optimal modification of food intake during childhood remains debated with no universally accepted approach. That being said, clinical decisions should be based on a robust understanding of appropriate intake for a child of normal weight. Childhood obesity management is age-dependent. Exclusive breast feeding is the diet of choice in the first 6 months of life, with the avoidance of early complementary food introduction. The latter was found to be associated with increased BMI in childhood and adolescence. Moreover, sugar intake should be limited, with no sugar-containing beverages allowed for infants [112]. Children and adolescents can be allowed 5% to 10% of total daily energy from sugar, with the exception of sugar-containing fruit and vegetable due to their higher fiber content. Successful approaches to encourage weight loss or maintenance are not limited to the elimination of sugar intake, but also shifting to a low glycemic load diet, reducing portion sizes, fast-food consumption and snacking, promoting breakfast as well as increasing the consumption of fruits and vegetables.

Physical activity intervention

Physical activity interventions should be prioritized, long-term, sustained and implemented into behavioral modifications at several levels, namely the individual, the family, the school and the community [113].

The current recommendation of the WHO is moderate to vigorous intensity physical activity for at least 60 minutes every day for children 5–17 years old. Increasing the duration of physical activity is associated with increased health benefits. Daily activity should primarily be aerobic, with the integration of vigorous intensity activities targeting muscle and bone strength 3 or more times every week. As for infants, activity should be encouraged in addition to direct interaction with parents as much as possible.

Appropriate physical activity interventions include:

1. Making school-based physical education mandatory for every child and school.

2. Increasing access to after-school recreation.

3. Increasing culturally appropriate activities.

4. Reducing the competitive nature of sports so that more children will participate.

5. Increasing the incorporation of physical activity into daily life (e.g. stairs, walking to school as appropriate).

6. Increasing the participation of parents in physical recreation, for their own weight management and as role models for their children.

Other behavioral interventions

Increased screen time is a risk factor for obesity in childhood and adolescence [114]. Children under 2 years of age must have no screen time, while those aged 2–5 years should have limited use of no more than an hour. Ideally, any screen time should be spent co-watching with engaged adults.

Enhancing children’s sleep may also be an effective strategy for preventing and treating pediatric obesity [115]. Infants 1–2 years need 11–14 hours of nightly sleep, preschool children need 10–13 hours and school aged children need 9–11 hours with regular sleep and wake-up times.

Family intervention

Parental involvement is critical for the success of obesity management in children and adolescents [116,117]. Often enough, various caretakers (grandmothers, babysitters, etc.) will feed children and allow unrestricted television access, and some parents are known to use food as a reward to obtain the child’s love. The family itself must therefore be the target of lifestyle intervention and the concept of ‘food is not love’ must be emphasized. Eating meals together as a family and eating at the table as opposed to in front of the television, removing over controlling behaviors towards meal consumption, promoting slow eat and food enjoyment are some of most important family interventions.

3.5.1.2.2. Drug therapy

Drug-based therapy remains limited in children with obesity and is primarily restricted till after the failure of formal and intensive lifestyle modifications to reduce weight gain and improve health outcomes. The majority of available weight-loss medication do not have FDA approval for use in children. Available options for children include orlistat (>12 years of age) and phentermine (>16 years of age), both of which induce only small to moderate weight loss albeit with concerning side effects [118,119]. Orlistat is associated with oily stools while phentermine may cause anxiety, tremors, and slightly increased blood pressure. Other medications can be used in children but have not received approval for the treatment of obesity in children, namely: metformin (used for type 2 diabetes mellitus in children ≥ 12 years of age) [119], octreotide (used for hypothalamic obesity) [120], leptin (used only in leptin deficiency) [121], Glucagon-like peptide 1 (recently approved for treatment type 2 diabetes mellitus in children ≥ 10 years of age, with some weight reduction effect) [122] and growth hormone (used in Prader-Willi syndrome) [123].

3.5.1.2.3. Surgery

Bariatric surgery should be reserved for the treatment of severe obesity in adolescents [124,125]. Current adolescent bariatric recommendations include[112]:

• BMI >35 kg/m² with moderate to severe comorbidities

or

• BMI >40 kg/m² and skeletal and sexual maturity (generally age 14 for girls and 15 for boys).

3.5.2. Obesity in pregnancy

The impact of obesity on pregnancy outcome emerged along with the rise of obesity among the antenatal population. In addition to its risk of cardiovascular disease, obesity is associated with subfertility and higher rates of miscarriage [126,127]. Obesity and overweight also affect fetal growth [128] and increase the risk of pregnancy-related adverse outcomes such as gestational diabetes, gestational hypertension, caesarean delivery, birth trauma, infections and still birth [129,130]. The deleterious effect of pre-conception maternal BMI extend after delivery, affecting offspring in the neonatal period well into their adult life. Children born to women who were overweight/obese are significantly more likely to be born large for gestational weight and to become overweight/obese at later stages in life [131]. Congenital abnormalities, preterm birth, and higher risk of admission to the neonatal intensive care unit are also more frequent among women who are overweight or obese [132–134].

The prevention and management of obesity in women of childbearing age is therefore a public health issue. Women should be advised to enter pregnancy with a normal BMI (20–24.9 Kg/m²). Overweight women (BMI of 25–29.9 Kg/m²) and obese women (BMI ≥ 30 Kg/m²) should be informed of the adverse pregnancy outcomes associated with obesity and should be counseled to lose weight by dieting and exercise before conceiving. Women with a BMI of 40 kg/m² or more should be strongly advised to avoid pregnancy until they have lost weight. A multidisciplinary approach is generally preferable and mothers may require referral to a dietitian/nutritionist [135] for counseling and behavioral interventions, which can reduce the risk of adverse pregnancy outcomes [136].

Women should be weighed in preconception care visits and weight gain during pregnancy should be tightly controlled. Adequate energy and nutrient intake during pregnancy is essential to prevent excessive or suboptimal weight gain and related adverse outcomes. Excessive gestational weight gain and obesity are associated with the development of maternal diabetes and child overweight [137], while higher rates of low birthweight and neonatal/intrauterine mortality can result from inadequate weight gain [130,138]. Maternal diet should be supplemented as necessary during pregnancy with protein, fat and vitamins (e.g. cheese, beans, eggs).

3.5.3. Overweight and obesity in the elderly

When screening elderly patients and evaluating their weight, it is important to take into consideration the physiological changes incurred by older age. BMI may actually underestimate cardiometabolic risk in the elderly [139–141] possibly due to the decline in muscle mass and quality with age, and the increased burden of excess fat mass on weak muscles [142]. Fat-free mass index and waist circumference are probably more accurate than BMI as a measure of obesity and predictor of mortality in the elderly [143,144]. While debatable, evidence suggests the protective effect of obesity in elderly patients, among whom BMI was inversely correlated with mortality in what became known as the ‘obesity paradox’ [145]. Weight-loss therapy which involves lifestyle modifications (diet and exercise) should be offered for elderly people with the aim to reduce the risk of type 2 diabetes mellitus and hypertension, as well as to improve osteoarthritis, mobility, and physical function [146]. Aerobic and resistance exercise should also be encouraged in the elderly as it will lead to improvements in physical function and to the amelioration of frailty [147]. Exercise should be of moderate intensity, generally aiming at pulse rate of 100/min for patients aged 60–70 years. Osteosarcopenia is common in elderly people and should be assessed before considering initiating obesity therapy as this condition might worsen with weight loss therapy [148]. Extra caution should be taken when prescribing weight-loss medications in elderly as they are more likely to have nutritional deficiencies, polypharmacy, abnormalities in renal and hepatic function, subclinical cardiovascular disease, and impaired cognition, which can increase the risks associated with various weight-loss interventions. Other pharmacological approaches include testosterone replacement in elderly men with hypogonadism, an intervention which produces long-term benefits on the level of weight loss [149]. As for surgical interventions, data on the efficacy and safety of bariatric surgery in the elderly are limited. It seems that elderly patients could benefit from bariatric surgery, which are relatively safe and effective in this population for weight loss and improvement in weight-related comorbidities [150–153], albeit to a potentially lesser extent when compared to younger patients.

4. Conclusions

One third of the adult population in Iraq is overweight and another third is obese. The contribution of obesity and overweight to morbidity and mortality in adults as well as children and adolescents call for serious concerted efforts towards its prevention and management. These recommendations outline a management plan and standards of care that are relevant to the Iraqi population and that can prevent/manage obesity and obesity-related complications. Clinical diagnosis depends on body mass index (BMI) and waist circumference. Exploring the etiology of this disease reveals a complex interaction between behavioral, social (rapid urbanization), environmental and genetic factors, which should be addressed. Treatment should initially rely solely on comprehensive lifestyle interventions involving dietary changes to reduce calorie intake, an increase in physical activity, and behavioral modification. Pharmacotherapy, medical devices and bariatric surgery can be considered as needed when non-pharmacological approaches fail.

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

A reviewer on this manuscript has disclosed receiving a research grant from Novo Nordisk. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Author contributions

The main frame of the guidelines are written by Dr Hussein Ali Nwayyir; the introduction was written by Dr Faris Abdulkareem; pediatric sections were written by Esraa Majid Mutasher and revised by Munib AlZubaidi; obesity in the elderly was written by Dr Majid Hameed; nutrition sections were written by Muthana Abdulrazzaq Jabbar and Wefaq Hassan; surgical sections were written by Osama Muhammed Ali and agreed upon by Faleh Muhsen and Ali Dawood; pregnancy section was written by Muhammed Chabek; Ali Albayati, Hilal Alsaffar, Haidar Iyad, Ibtihal Shukri and Lajeen Al Khazrajiare members of the revision team; editing, framing, referencing and logistics were done by Alhassan Zalzala.

Acknowledgments

The authors would like to thank Professor Abbas Mahdi Rehma, assistant Professor Musa Qasim Husain and Consultant Dr Hani Alansari for providing a comprehensive review of the guideline.

The authors would also like to thank Racha Aaraj, Pharm D, MSc, MPH and Nancy Al Akkary, BSc, MSc from Phoenix Clinical Research, Lebanon for providing editorial and medical writing assistance for the preparation of this manuscript.

Additional information

Funding

Novo Nordisk Iraq Affiliate – Medical, Regulatory and quality department provided support for the panel meetings, technical editorial and manuscript drafting assistance.