See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/264734096

Diet and exercise in management of obesity and overweight

Article  in  Journal of Gastroenterology and Hepatology · December 2013

DOI: 10.1111/jgh.12407

CITATIONS READS

146 3,232

2 authors:

Kwong ming Fock Joan Khoo

Changi General Hospital Changi General Hospital
257 PUBLICATIONS   6,182 CITATIONS    76 PUBLICATIONS   1,091 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

LiNASH View project

Aldosterone Potassium Ratio View project

All content following this page was uploaded by Joan Khoo on 26 July 2019.

The user has requested enhancement of the downloaded file.

bs_bs_banner

doi:10.1111/jgh.12407

OBESITY AND THE DIGESTIVE SYSTEM

Diet and exercise in management of obesity and overweight

Kwong Ming Fock* and Joan Khoo†
Departments of *Gastroenterology and †Endocrinology, Changi General Hospital, Singapore

Keywords
BMI, diet, exercise, NAFLD, obesity.
Accepted for publication 30 September 2013.
Correspondence
Professor Kwong Ming Fock, Division of
Gastroenterology, Department of Medicine,
Changi General Hospital, 2 Simei Street 3,
Singapore 529889. Email:
kwong_ming_fock@cgh.com.sg
Abstract
According to World Health Organization, in 2010 there were over 1 billion overweight
adults worldwide with 400 million adults who were obese. Obesity is a major risk factor for
diabetes, cardiovascular disease, musculoskeletal disorders, obstructive sleep apnea, and
cancers (prostate, colorectal, endometrial, and breast). Obese people may present to the
gastroenterologists with gastroesophageal reflux, non-alcoholic fatty liver, and gallstones.
It is important, therefore, to recognize and treat obesity.
The main cause of obesity is an imbalance between calories consumed and calories
expended, although in a small number of cases, genetics and diseases such as hypothy-
roidism, Cushing’s disease, depression, and use of medications such as antidepressants and
anticonvulsants are responsible for fat accumulation in the body.
The main treatment for obesity is dieting, augmented by physical exercise and supported
by cognitive behavioral therapy. Calorie-restriction strategies are one of the most common
dietary plans. Low-calorie diet refers to a diet with a total dietary calorie intake of
800–1500, while very low-calorie diet has less than 800 calories daily. These dietary
regimes need to be balanced in macronutrients, vitamins, and minerals. Fifty-five percent
of the dietary calories should come from carbohydrates, 10% from proteins, and 30% from
fats, of which 10% of total fat consist of saturated fats. After reaching the desired body
weight, the amount of dietary calories consumed can be increased gradually to maintain a
balance between calories consumed and calories expended. Regular physical exercise
enhances the efficiency of diet through increase in the satiating efficiency of a fixed meal,
and is useful for maintaining diet-induced weight loss. A meta-analysis by Franz found that
by calorie restriction and exercise, weight loss of 5–8.5 kg was observed 6 months after
intervention. After 48 months, a mean of 3–6 kg was maintained.
In conclusion, there is evidence that obesity is preventable and treatable. Dieting and
physical exercise can produce weight loss that can be maintained.

obesity is based on data gathered from population-based epidemi-

Introduction
Since 1980, obesity has more than doubled globally and is now
considered as a major health hazard and a global epidemic. This
review aims to evaluate the current management of obesity and
overweight employing a combination of dietary interventions,
exercise, and behavioral modification. For some patients, pharma-
cological therapy or bariatric surgery is required.
Definition of obesity
Obesity can be defined as an excessive amount of fat that increases
the risk of medical illness and premature death. A simple and
convenient way of defining obesity and overweight led by the
World Health Organization (WHO) and the National Institute of
Health (NIH) is based on body mass index (BMI).
BMI is derived by dividing one’s weight in kilograms by the
square of one’s height in meters. Classification of overweight and
ology studies that evaluated the relationship between obesity and
rates of mortality and morbidity that are adiposity related. A BMI
(kg/m2) between 25 and 29.9 is deemed to be overweight. Obesity
is defined as BMI ≥ 30 and is further subdivided into Class I–III.
There is some evidence to suggest that risks of adiposity-related
complications occur at lower BMIs in Asians. Hence, China1 used
a BMI of 28 for obesity and Japan2 used a BMI cut-off of 25 kg/m2
for cut-off. The WHO has recommended that BMI > 27.5 kg/m2
be used as a cutoff for Asians, taking into consideration the
increased cardiovascular risk at the BMI.
Health consequences of obesity
Mortality. On average, obesity reduces life expectancy by 6 to
7 years:3 a BMI of 30–35 reduces life expectancy by 2–4 years
while severe obesity (BMI > 40) reduces life expectancy by
10 years.4

Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 59

© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
Diet and exercise for weight management
Morbidity. Complications of obesity are either directly caused
by obesity or indirectly related through mechanisms sharing a
common cause such as a sedentary life style or poor diet. The
strongest link is with type 2 diabetics. Obesity accounts for 64% of
cases of diabetics in men and 79% of cases in women. Other
diseases attributable to obesity are cardiovascular disease—
hypertension, stroke, coronary artery disease, venous stasis deep
vein thrombosis, osteoarthritis, gastrointestinal disease, gastro-
esophageal reflux disease, cholelithiasis, non-alcoholic fatty liver
disease (NAFLD), endometrial breast cancer, and colorectal
cancer. Obesity is the leading cause of cancer just behind smoking.
Metabolic disorders include metabolic syndrome, prediabetic
state, hyperlipidemia, and polycystic ovary syndrome. Most
patients with obstructive sleep apnea (OSA) are obese, although in
lean persons, other factors such as cephalometric defects contrib-
uted to risk of OSA. In addition to BMI and waist circumference,
it is important to look out for comorbidities that are associated
with obesity such as diabetes, NAFLD, polycystic ovary syn-
drome, OSA, and osteoarthritis.
Clinical evaluation of obesity in adults:
waist circumference
Central or truncal obesity, as measured by waist circumference, is
also associated with increased risk for heart disease, diabetes mel-
litus, hypertension, and hyperlipidemia.5
The WHO STEPwise approach to surveillance protocol for
measuring waist circumference requires waist circumference to be
measured at the midpoint between the lower margin of the pal-
pable rib and the top of the iliac crest.6 The NIH, which provided
the protocol for use in the National Health and National Exami-
nation Survey, determines that waist circumference be measured
at the top of the iliac crest. Ethnic differences exist, and in Asia,
waist circumference > 80 cm for females and > 90 cm for men are
considered outside the normal range.7
Establishing the cause of overweight
and obesity
Although excessive food energy intake and a sedentary lifestyle
account for most cases of overweight and obesity, it is important
to recognize that medical illness and drug treatment of medical
illness can increase the risk of obesity and are amenable to
treatment. The neuroendocrine causes of obesity include hypothy-
roidism, Cushing’s syndrome, growth hormone deficiency, hypo-
gonadism, and polycystic ovary syndrome. Eating disorders,
notably binge eating disorders and night eating syndrome, also
give rise to obesity.
Obesity is not regarded as a psychiatric disorder, but the
risk of obesity is increased in patients with psychiatric disorders
such as depression. Medications that can cause weight gain
include antidepressants, antidiabetic drugs, anticonvulsants, anti-
psychotic medication, beta-blockers, and steroid hormones.
Cessation of smoking is associated with weight gain. It is
important to note comorbidities associated with obesity: dia-
betes mellitus, hyperlipidemia, hypertension, and cardiovascular
disease.
60
© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
KM Fock and J Khoo
Medical treatment of overweight and
obesity
The management of overweight and obesity is lifestyle interven-
tion, consisting of dietary intervention, exercise, and behavioral
treatment.
Setting a goal for weight loss
Setting a goal for weight loss is the first step in planning a weight
loss program. The patient needs to accept that the goal is reason-
able, realistic, and attainable. An initial weight loss of 5–7% of
bodyweight within 6 months is achievable. The Diabetes Preven-
tion Program is an example of a successful lifestyle intervention
program that set the weight loss target of 7% of bodyweight.8
Dietary intervention
Dietary intervention is the cornerstone of weight loss therapy.
Most of the dietary regimens proposed for weight loss focus on
energy content and macronutrient composition. It is the energy
content that determines the efficiency of the dietary regimens.
Obesity treatment guidelines issued by the NIH recommend that
persons who are overweight or who have class I obesity and who
have two or more risk factors should reduce their energy intake by
500 kcal/day.9 Persons with class II and class III obesity should
strive for 500–1000 kcal/day reduction. With a reduction of
500 kcal/day energy intake, a weight reduction of 0.5 kg/week can
be achieved.
To provide a diet that results in the desired energy deficit, it is
necessary to determine the patient’s daily energy requirement,
which can be estimated by using the Harris–Benedict equation10 or
the WHO equation11 or American Gastroenterological Association
dietary guidelines.12
Type of diets
In general, there are four types of dietary regimens used in the
treatment of the overweight or obese persons: (Table 1)
1 Low-calorie diet (LCD)
2 Low-fat diet
3 Low-carbohydrate diet
4 Very low-calorie diet (VLCD)
The first three diets are 800–1500 kcal/day while VLCD is
< 800 kcal/day.
LCD. LCDs are high in carbohydrate (55–60%), low in fat (less
than 30% of energy intake), and high in fiber and have a low-
glycemic index. Alcohol and energy-dense snacks should be
avoided. LCD has been shown in 34 randomized trials to reduce
body weight by 8% during 3–12-month period.13 Overweight or
obese patients tend to underestimate their energy intake. To help
them overcome this, portion-controlled or prepackaged meals that
make up the required energy intake are available. Replacement
meals are available as drinks, nutrition bars, or prepackaged meals.
A 4-year study demonstrated weight loss improvement in blood
sugar and blood pressure for persons taking meal replacement
diets.14
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63
KM Fock and J Khoo
Table 1 Comparison of different weight-loss diets13–19
Diet Daily caloric content/ Mean weight loss
composition
Low calorie 800–1500 kcal ∼ 10% in 3–12 months
55–60% carbohydrate
(high fiber, low GI)
< 30% fat
Low fat 1000–1500 kcal ∼ 5% in 2–12 months
20–25% fat
Low carbohydrate 1000–1500 kcal ∼ 5% in 2–12 months
60–150 g of carbohydrate
< 60 g (very low carbohydrate)
Very low-calorie diet 200–800 kcal > 10% in 2–8 weeks
55–60% carbohydrate
(high fiber, low GI)
< 30% fat
BP, blood pressure; GI, glycemic index; LDL, serum low-density lipoprotein cholesterol; TG, serum triglyceride.
Low-fat diets. These diets reduce the daily intake of fat to
20–25% of total energy intake. For a person on a 1500-calorie diet,
this translates to 30–37 g of fat, which can be counted using food
label from packages. Alternatively, a dietician can provide the
person with a specific menu plan that has reduced fat.
According to a meta-analysis of 16 trials, low-fat diet used over
2–12 months resulted in mean weight loss of 3.2 kg and improved
cardiovascular risk factors (Table 1).15
Low-carbohydrate diet. The carbohydrate content of the
diet is an important determinant of short-term (less than 2 weeks)
weight loss. Low-carbohydrate (60–150 g of carbohydrate/day)
and very low-carbohydrate diet (0 to < 60 g) have been popular for
many years. Glycogen utilization occurs when carbohydrate intake
is restricted. When the carbohydrate intake is less than 50 g/day,
ketosis will develop from glycogenolysis, resulting in fluid loss.
Many of the current low-carbohydrate diets (e.g. Atkins diet) limit
carbohydrate intake to 20 g/day but allow unrestricted amounts of
fat and protein. A meta-analysis of five trials found that weight loss
at 6 months favoring low-carbohydrate over low-fat diet is not
sustained at 12 months.16 Triglycerides and high-density lipopro-
tein (HDL) cholesterol changed more favorably in people assigned
to low-fat diet. There are data from the National Health Study and
Health Professional, Follow Up study that low-carbohydrate diet
with the highest decile for animal protein and fat were associated
with higher all-cause and cardiovascular mortality.17
VLCD. VLCDs are diets with energy content of 200–800 kcal/
day. Diets below 200 kcal/day are starvation diets. VLCDs are not
recommended for general use, as there are significant adverse
events such as electrolyte unbalance, low blood pressure, and
increased risk of gallstones. Its use needs to be supervised by
trained medical personnel.
Each of the four types of diet for weight loss has its proponents.
In a meta-analysis of 80 weight loss studies, mean weight loss of
5 to 8.5 kg (5–9%) was observed during the first 6 months from
interventions involving a reduced-energy diet and/or weight loss
medications with weight plateaus at approximately 6 months, with
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63
© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
Diet and exercise for weight management
Benefits Disadvantages
Reduction in blood glucose, Compliance difficult in long term
TG, LDL, BP
Reduction in blood glucose, Less palatable, feel hungry easily
LDL, BP Increase TG
Faster initial weight loss Ketosis when carbohydrate intake
than low-fat diets < 50 g/day
Reduced blood glucose,
TG, LDL, BP
Rapid weight loss Electrolyte imbalance, hypotension,
gallstones
Needs medical supervision
maintenance of 3 to 6 kg (3–6%) of weight loss at 48 months.18 A
randomized controlled trial comparing four weight loss diets with
different compositions of fat, carbohydrate and protein found no
difference in outcomes, with a 2- to 4-kg weight loss with all diets
after a year.19 After 2 years, all calorie-restricted diets result in
equal weight loss irrespective of the macronutrient composition.19
In contrast, all studies found that dietary adherence is an important
determinant of weight loss.13–19 Thus, choosing a diet with a mac-
ronutrient composition based on a subject’s taste preference can
achieve better compliance.
Exercise and obesity
Physical activity alone is not an effective method for achieving
initial weight loss, although most overweight or obese people tend
to choose exercise as the first interventional option. Without
calorie restriction, weight loss through exercise alone is quite
small, about 0.1 kg/week.20 A meta-analysis showed that exercise
alone did not result in significant weight loss attempts, although no
further weight gain was observed after 12 months.18 Although
exercise is not effective for initial weight loss, physical activity is
important for maintaining weight loss achieved through dietary
intervention. Meta-analyses of 493 studies have shown that people
who diet and exercise maintained their weight loss better than
those who relied on diet alone.21 Before starting an exercise
program, patients should be advised of joint and musculoskeletal
injuries as well as cardiovascular risks. The risk of exercise stress
testing before an exercise program is controversial. The American
College of Cardiology and American Heart Association recom-
mend treadmill for asymptomatic subjects with diabetes mellitus,
men older than 45 years of age, and women older than 55 years of
age before embarking on an exercise program.22 Other organiza-
tions recommend no stress testing for symptomatic subjects under-
going moderate-intensity exercise with guidance in exercise
intensity. In our hospital, we use a physical exercise readiness
questionnaire for screening purposes.
The American College of Sports Medicine recommended in
2009 that moderate-intensity exercising between 150 and 250 min
weekly is effective in preventing weight gain. To provide and
61
Diet and exercise for weight management
maintain a clinically significant weight loss, at least 200–300 min/
week of moderate-intensity aerobic exercise is required. Resis-
tance training does not enhance weight loss but may increase
fat-free mass. Even in the absence of significant weight loss,
regular aerobic and resistance exercise improves cardiovascular
fitness22 and obesity-related comorbidities such as NAFLD.23 A
supervised exercise program involving personal trainers induces
and maintains weight loss more effectively than unsupervised
physical activity.22 Exercise reduces food intake by increasing the
satiating efficiency of a fixed meal.24
NAFLD
NAFLD patients are usually overweight or obese and have under-
lying insulin and or leptin resistance leading to dysfunctional
energy metabolism. Weight loss of 10% in overweight NAFLD
patients improves liver biochemistry as well as hepatic steatosis
and necroinflammation. Lifestyle modification consisting of exer-
cise and diet can help the patients to achieve these goals. A 4–4.5%
weight loss can result in 50% reduction in serum alanine amino-
transferase, while with exercise alone and no weight loss, signifi-
cant improvement in aminotransferase levels can occur, but its
effect on liver histology is unknown.23 The American Association
for the Study of Liver Diseases, the American College of Gastro-
enterology, and the American Gastroenterology Association rec-
ommend weight loss as the preferred method in management of
NAFLD.25
Bariatric surgery
Bariatric surgery is defined as gastrointestinal surgery to help
severely obese patients lose weight. The US National Institutes
of Health’s 2013 guidelines recommended surgery for adults
with BMI ≥ 40 kg/m2 without comorbidities or 35 kg/m2 with
comorbidities who fail to lose weight by nonsurgical methods,26
and suggested that patients with BMI of 30–34.9 kg/m2 with dia-
betes or metabolic syndrome may also be offered a bariatric pro-
cedure, although current evidence is limited by the lack of long-
term data demonstrating net benefit. A recent Asian Consensus
Meeting on Metabolic Surgery27 also recommended that the BMI
cutoffs be lowered to 35 and 32.5, respectively, and that surgery be
considered for Asian adults with BMI ≥ 30 kg/m2 and central
obesity (WC > 80 cm in females or > 90 cm in males) and at least
two features of metabolic syndrome (raised triglycerides, low
HDL cholesterol, hypertension, high-fasting plasma glucose).
Gastric banding is a reversible restrictive procedure, while laparo-
scopic sleeve gastrectomy, Roux-en-Y gastric bypass, and bilio-
pancreatic diversion combine restrictive and malabsorptive effects
that produce 15–35% loss of baseline weight and improve other
comorbidities.26
Conclusion
Overweight and obesity are increasing at an alarming rate globally
and has reached epidemic proportions in almost every country.
Obesity has a significant contribution toward cardiovascular dis-
eases, metabolic disorders, gastrointestinal disorders, and cancers.
Yet in early stages of weight gain, when a person is overweight, its
progression to morbid obesity can be arrested through diet and
exercise, without the need for medication, endoscopic, or surgical
62
© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
KM Fock and J Khoo
procedures. We have attempted to put further evidence in support
of current best practices in dietary management and exercise.
Finally, we conclude with two mnemonics that some of our team
members found useful in clinical practice. Factors that contribute
to obesogenic state are
• Diseases—hypothyroidism, Cushing’s disease
• Drugs—corticosteroids, antidepressants, antipsychotics
• Diet—intake > activity
• Drink—beer, wine, sugar drinks
• Decreased—physical activity
• Depression and psychosocial
An ABCDE approach28 to obesity:
A For measurement of cardiovascular risk and comorbidity
B For blood pressure control
C For cholesterol management
D For diet control and text for diabetes
E For exercise therapy
References
1 Bei-Fan Z, Cooperative Meta-Analysis Group of Working Group on
Obesity in China. Predictive values of body mass index and waist
circumference for risk factors of certain related diseases in Chinese
adults: study on optimal cut-off points of body mass index and waist
circumference in Chinese adults. Asia Pac. J. Clin. Nutr. 2002; 11
(Suppl. 8): S685–93.
2 Kanazawa M, Yoshiike N, Osaka T, Numba Y, Zimmet P, Inoue S.
Criteria and classification of obesity in Japan and Asia-Oceania. Asia
Pac. J. Clin. Nutr. 2002; 11 (Suppl. 8): S132–8.
3 WHO Expert Constitution. Appropriate body mass index for Asian
population and its implications for policy and intervention strategies.
Lancet 2004; 363: 157–63.
4 Prospective Studies Collaboration, Whitlock G, Lewinoton S et al.
Body-mass index and cause-specific mortality in 900 000 adults:
collaborative analyses of 57 prospective studies. Lancet 2009; 373:
1083–96.
5 Janssen I, Katzmarzyk PT, Ross R. Waist circumference and not
body mass index explains obesity-related health risk. Am. J. Clin.
Nutr. 2004; 75: 379–84.
6 Nishida C, Ko GT, Kumanyika S. Body fat distribution and
noncommunicable diseases in populations: overview of the 2008
WHO expert consultation on waist circumference and waist-hip
ratio. Eur. J. Clin. Nutr. 2010; 64: 2–5.
7 Zimmet K, Alberti KG. Introduction: globalization and the
non-communicable disease epidemic. Obesity 2006; 14: 1–3.
8 Diabetes Prevention. Programme (DPP) Research Group. The
Diabetes Prevention Program (DPP). Description of lifestyle
intervention. Diabetes Care 2002; 25: 2165–71.
9 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 (Suppl. 2): 51S–209S.
10 Harris JA, Benedict FG. Standard bowel metabolism constants for
physiogists and constants in The Carnegie Institute of Washington. A
biometric study of basal metabolism in man. Publication 279,
Philadelphia, Pennsylvannia: Lippincott 1919.
11 FAO/WHO/UNU. Energy and protein requirements. Report of a
joint FAO/WHO/UNU expert consultation. World Health Organ.
Tech. Rep. Ser. 1985; 724: 1–206.
12 Klein S, Wadden T, Sugeman HJ. AGA technical review on obesity.
Gastroenterology 2002; 123: 882–932.
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63
 KM Fock and J Khoo
13 Strychar I. Diet in the management of weight loss. CMAJ 2006; 174:
56–63.
14 Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA,
Adler G. Metabolic and weight loss effects of long term obesity
intervention in obese patients: four-year results. Obes. Res. 2000;
8: 399–402.
15 Astrup A, Ryan L, Grunwald GK et al. The role of dietary fat in
body fatness: evidence from a preliminary meta-analysis of ad
libitum low-fat dietary intervention studies. Br. J. Nutr. 2000; 83
(Suppl. 1): S25–32.
16 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.
17 Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC,
Hu FB. Low-carbohydrate diets and all-cause and cause-specific
mortality: two cohort studies. Ann. Intern. Med. 2010; 153: 289–98.
18 Franz MJ, VanWormer JJ, Crain AL. Weight-loss outcomes: a
systematic review and meta-analysis of weight-loss clinical trials
with a minimum 1-year follow-up. J. Am. Diet. Assoc. 2007; 107:
1755–67.
19 Sacks FM, Bray GA, Carey VJ. Comparison of weight-loss diets
with different compositions of fat, protein, and carbohydrates.
N. Engl. J. Med. 2009; 360: 859–73.
20 Slentz CA, Duscha BD, Johnson JL et al. Effects of the amount of
exercise on body weight, body composition, and measures of central
obesity: STRIDE—a randomized controlled study. Arch. Intern.
Med. 2004; 164: 31–9.
21 Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past
25 years of weight loss research using diet, exercise or diet plus
exercise intervention. Int. J. Obes. Relat. Metab. Disord. 1997; 21:
941–7.
Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63
© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
View publication stats
Diet and exercise for weight management
22 Donelly JE, Blair SN, Jackicic JM. American College of Sports
Medicine. ACSM position stand. Appropriate physical activity
intervention strategies for weight loss and prevention of
weight regain in adults. Med. Sci. Sports Exerc. 2009; 41:
459–71.
23 Harrison SA, Day CP. Benefits of lifestyle modification in NAFLD.
GUT 2007; 56: 1760–9.
24 King NA, Caudwell PP, Hopkins M, Stubbs JR, Naslund E,
Blundell JE. Dual-process action of exercise on appetite control:
increase in orexigenic drive but improvement in meal-induced
satiety. Am. J. Clin. Nutr. 2009; 90: 921–7.
25 Chalasani N, Younossi Z, Lavine JE et al. The diagnosis and
management of non-alcoholic fatty liver disease: practice guideline
by the American Association for the Study of Liver Diseases,
American College of Gastroenterology, and the American
Gastroenterological Association. Hepatology 2012; 55:
2005–23.
26 Mechanick JI, Youdim A, Jones DB et al. Clinical practice guidelines
for the perioperative nutritional, metabolic, and nonsurgical support of
the bariatric surgery patient—2013 update: cosponsored by American
Association of Clinical Endocrinologists, The Obesity Society, and
American Society for Metabolic & Bariatric Surgery. Obesity (Silver
Spring) 2013; 21 (Suppl. 1): S1–27.
27 Lakdawala M, Bhasker A, Asian Consensus Meeting on Metabolic
Surgery (ACMOMS). Asian Consensus Meeting on Metabolic
Surgery. Recommendations for the use of Bariatric and
Gastrointestinal Metabolic Surgery for Treatment of Obesity and
Type II Diabetes Mellitus in the Asian Population. Obes. Surg. 2010;
20: 929–36.
28 Blaha MJ, Bansal S, Rouf R, Golden SH, Blumenthal RS, AP
Defilippis. A practical “ABCDE” approach to the metabolic
syndrome. Mayo Clin. Proc. 2008; 83: 932–41.
63