Introducing the 2nd edition of the clinical practice guidelines for obesity management

June 9, 2023
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(3rd left) Professor Dr Norlaila Mustafa, Chairperson, CPG Development Committee presenting a copy of the CPG to Dr Ridzwan Mohd Shahari, Deputy Director of the Medical Service Development Branch, Medical Development Division (MOH) together with (1st left) Dr Nurain Mohd Noor, President, Malaysian Endocrine & Metabolic Society (MEMS) and (4th left) Dr Salbiah Mohamed Isa, Senior Family Medicine Specialist.
As the prevalence of overweight and obesity continues to rise relentlessly among Malaysian adults, children and adolescents, experts are emphasizing the need for newer and more robust strategies to effectively prevent and manage this disease.

In response to this pressing concern, the Ministry of Health (MOH) of Malaysia, in collaboration with the Malaysian Endocrine & Metabolic Society (MEMS), the Malaysian Society for the Study of Obesity (MASO), the Malaysian Dietitians' Association (MDA), and the Family Medicine Specialists Association of Malaysia (FMSA), has developed the Clinical Practice Guidelines (CPG) for the Management of Obesity, now in its 2nd edition.

The official launch of this highly anticipated CPG was held today in a ceremony officiated by Dr Mohd Ridzwan Shahari, Deputy Director of the Medical Development Branch within the Medical Development Division. Dr Shahari represents Dato' Dr Asmayani Khalib, Deputy Director-General of Health (Medical) at the Ministry of Health Malaysia.

During the launch ceremony, a diverse panel of experts shared their valuable insights and perspectives derived from the guidelines. 

New criteria for obesity diagnosis 
According to Professor Dr Rohana Abdul Ghani, senior consultant endocrinologist, a lower cut-off point for diagnosis of obesity is required. She said: “A lower cut-off point for diagnosis is needed as we Asians generally have higher body fat percentages compared to Caucasians, and studies revealed that the risk of getting diabetes, hypertension and other cardiovascular risks factors begin to increase at lower body mass index (BMI) for Asians.” 

For this reason, she urged all adults to undergo annual screening using the BMI measurement. She further highlighted that the updated cut-off points to initiate further evaluation on overweight is at 23kg/m2 to 27.4kg/m2, whereas for obesity it is at 27.5 kg/m2. These values are lower than the BMI standards of 25 kg/m2 for overweight and 30kg/m2 for obesity set by the World Health Organization.

A mindful approach to obesity
Dr Umi Adzlin Silim, a consultant-liaison psychiatrist brought up the issue that persons with obesity struggle with mental health issues due to the stigma of being obese and negative attitudes they receive. “The general beliefs towards individuals who are obese include prejudice and stereotype labelling such as being lazy, unmotivated, lacking willpower and discipline. This is not helpful as it reduces the motivation among patients to engage in healthy behaviours such as exercising and adhering to diet and medication.” 

She highlighted that psychological and behavioural interventions can improve adherence to lifestyle modifications and medications as it enhances self-efficacy and provides motivation . She said: “Psychological and behavioural interventions used by healthcare providers should include enhancing communication, avoiding any or further stigmatising, psychoeducation, and motivational interviewing. Patients should also be guided by setting SMART-- Specific, Measurable, Achievable, Realistic and Relevant and Time-based goals and action planning.” 

Focus on calorie deficit  
Associate Professor Dr Geeta Appannah, President of Malaysian Society for the Study of Obesity (MASO) stressed that dietary management is mainstay when it comes to managing overweight and obesity. “As we all know, energy or calorie deficit is important for weight loss. A deficit of up to 500-1000 kcal per day will lead to weight losses of about 1 kg per week. In fact, to achieve initial weight loss, an energy intake of 1200-1500 kcal/day for women and 1500-1800 kcal/day for men is recommended.” 

On the effectiveness of different dietary approaches, she explained that evidence-based dietary patterns that restrict certain food type such as high carbohydrate or high fat foods yielded better results when combined with calorie restriction. Regarding special diets and its effectiveness, she explained: "We've noticed a growing trend of people trying intermittent fasting, which can be beneficial as it is easy to follow. However, its long-term sustainability is uncertain. We need more research to fully understand its effectiveness."

Adopt effective exercising strategies
In the exercise avenue, Associate Professor Dr Norasyikin A Wahab, senior consultant physician and endocrinologist reminded that exercise is an integral part of any weight loss programme as it increases total energy expenditure and promotes negative energy balance. The two main types of exercise are aerobic exercises and resistance training.

She emphasised the need for proper assessment among patients prior to starting on any exercise plan. She said: “Persons with obesity should be assessed for their heart and lung capacity, bone strength, flexibility, and range of motion prior to embarking on any exercise plan. This helps determine the type of exercise that individuals with obesity can safely engage in, ensuring their safety and maximising the benefits of physical activity.” Additionally, she stressed that no matter which exercise is chosen, it is important to start gradually and progressively increase the frequency, intensity, and duration over time.

Pharmacotherapy for obesity
Professor Dr Shireene Vethakkan, as a senior consultant endocrinologist stated: “Individuals with BMI ≥30 kg/m2 without comorbidities and BMI ≥27 kg/m2 with comorbidity or could not achieve weight loss goals or weight maintenance with lifestyle or behavioural modifications alone may need to be treated with pharmacotherapy.” 

“There are 5 class of anti-obesity drugs currently approved for chronic management of obesity, namely orlistat, combination of phentermine and topiramate, combination of naltrexone and bupropion, and high dose liraglutide and semaglutide. Among these, high-dose semaglutide at around 2.4 mg per week and the combination of phentermine and topiramate have shown the most significant weight loss, with a reduction of more than 10%.” However, she emphasised that careful consideration of the side effects of these drugs is required before initiation of pharmacotherapy.
 
Early prevention of obesity begins with the family
Focusing on the younger population, Dr Nalini M Selveindran, a senior paediatric endocrinologist remarked that to achieve better weight management in children, a family focused lifestyle intervention aimed at reducing overall dietary intake and sedentary behaviours, increasing physical activity, addressing sleep behaviour and psychosocial intervention should be applied.

“Recent studies have shown that family-based therapy is a successful approach for treating obesity. This means that involving the whole family, including parents, right from the first consultation and throughout the obesity care process is crucial. Parents should be supported and encouraged as they make positive changes not only for their children but for the entire family, including themselves.” 

A copy of the CPG can be downloaded at: 
www.moh.gov.my/moh/resources/Penerbitan/CPG/Endocrine/CPG_Management_of_Obesity_(Second_Edition)_2023.pdf

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