Weight Reduction Medications and Programs

Clinical Policy Bulletin:

Weight Reduction Medications and Programs

Number:Â 0039Policy

Note: Many Aetna plan benefit descriptions specifically exclude services and supplies for or relatedto treatment of obesity or for diet and weight control. Under these plans, claims for weight reductionmedications and for physician supervision of weight reduction programs will be denied based on thatexclusion. Please check benefit plan descriptions for details.

Aetna considers the following medically necessary treatment of obesity when criteria are met:

Weight reduction medications, and

Clinician supervision of weight reduction programs.

Weight Reduction Medications:

Note: Many Aetna benefit plans specifically exclude coverage of weight reduction medications underthe pharmacy benefit and/or under the health benefits plan. The medical necessity criteria set forthbelow do not apply to health plans that specifically exclude services and supplies for or related totreatment of obesity or for diet or weight control. Under these plans, claims for weight loss drugswill be denied based on this exclusion. For members whose medical policies do not exclude weightreduction medications or services and supplies for or related to weight reduction programs, Aetnacovers these drugs under the medical benefit, not the pharmacy benefit. Please check benefit plandescriptions for details.

Weight reduction medications are considered medically necessary for members who have failed tolose at least one pound per week after at least 6 months on a weight loss regimen that includes a lowcalorie diet, increased physical activity, and behavioral therapy, and who meet either of thefollowing selection criteria below:

Member has a body mass index** (BMI) greater than or equal to 30 kg/m²; or

Member has a BMI greater than or equal to 27 kg/m² with any of the following obesity-related riskfactors considered serious enough to warrant pharmacotherapy:

Coronary heart disease

Dyslipidemia:

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HDL cholesterol less than 35 mg/dL, or

LDL cholesterol greater than or equal to 160 mg/dL, or

Triglycerides greater than or equal to 400 mg/dL

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Hypertension (systolic blood pressure [SBP] higher than 140 mm Hg or diastolic blood pressure[DBP] higher than 90 mm Hg on more than one occasion)

Obstructive sleep apnea

Type 2 diabetes mellitus.

Weight reduction medications are considered experimental and investigational when these criteriaare not met.

**BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

The following medications have been approved by the FDA for weight reduction:

Benzphetamine [Didrex],

Diethylpropion [Tenuate],

Lorcaserin [Belviq],

Orlistat [Xenical, Alli],

Phendimetrazine [Bontril]Â

Phentermine [Adipex-P], and

Phentermine and topiramate [Qsymia].

For Aetna's clinical policy on surgical management of obesity, see CPB 0157 - Obesity Surgery.

Clinician Supervision of Weight Reduction Programs:

Up to a combined limit of 26 individual or group visits by any recognized provider per 12-monthperiod are considered medically necessary for weight reduction counseling in adults who are obese(as defined by BMI >= 30 kg/m2**). The number of medically necessary visits for obese childrenare left to the discretion of the member's physician.

** For a simple and rapid calculation of BMI, please click below and it will take you to the Obesity

Education Initiative:

BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

The following services are considered medically necessary for the evaluation of overweight orobese individuals:

Complete blood count

Comprehensive history and physical examination

Dexamethasone suppression test and 24-hour urinary free cortisol measures if symptoms suggestCushing's syndrome.

Electrocardiogram (EKG) -- adult

Glucose tolerance test (GTT)

Hand x-ray for bone age -- child

Lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides)

Metabolic and chemistry profile (serum chemistries, liver tests, uric acid) (SMA 20)

Thyroid function tests (T3, T4, TSH)

Urinalysis

Very Low Calorie Diets (VLCD):

For obese members who have been prescribed a very low calorie diet (VLCD) (less than 799Kcal/day) (e.g., Optifast, Medifast), the following services are considered medically necessary for upto 16 weeks after initiation of the VLCD:

EKG after 50 lbs of weight loss; and

Lipid profile at the beginning and end of the VLCD program; and

Serum chemistries and liver function tests (SMA 20)Â weekly during the rapid weight loss phase ofthe VLCD, then every 2 weeks thereafter up to 16 weeks.

Note: VLCDs extending beyond 16 weeks are subject to medical review to determine if additionalservices are medically necessary.

Notes: Prepackaged food supplements or substitutes and grocery items are generally excluded fromcoverage under most benefit plans. Diagnostic tests required by, for or as a result of non-coveredweight loss programs (e.g., those not requiring physician supervision) are not covered. Pleasecheck benefit plan descriptions for details.

Excluded Services:

The following interventions are considered experimental and investigational for weight reduction:

Acupuncture for weight loss

Body plethysmography (diagnostic study)

Dual-energy X-ray (DEXA) body composition (diagnostic study)

Gastric electrical stimulation (see CPB 0678 - Gastric Pacing and Gastric Electrical Stimulation)

Human chorionic gonadotropin (HCG) or vitamin injections for weight loss

Indirect calorimetry (e.g., ReeVue Indirect Calorimeter) (diagnostic study)

Whole body calorimetry and composition is considered experimental and investigational for weightreduction and other indications.

Hospital confinement is considered not medically necessary for a weight reduction program.

Note: Under most benefit plans, the following services and supplies for weight reduction arespecifically excluded from coverage (please check benefit plan descriptions for details)

Exercise programs or use of exercise equipment

Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid proteinmeals, NutriSystem pre-packaged foods, or phytotherapy), see CPB 0061 - Nutritional SupportÂ

Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.

Background

This policy is supported by NHLBI Guidelines on Diagnosis and Management of Obesity.

Weight reduction medications should be used as an adjunct to caloric restriction, exercise, andbehavioral modification, when these measures alone have not resulted in adequate weight loss.Factors influencing successful weight loss are: weight loss during dieting alone, adherence to diet,eating habits, motivation and personality.

Weight loss due to weight reduction medication use is generally temporary. In addition, the potentialfor development of physical dependence and addiction is high. Because of this, their use to aid inweight loss is not regarded as therapeutic, but rather involves a risk/benefit ratio, which makes itmedically inappropriate in most cases.

Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at riskof medical complications of obesity are an exception to this; for these persons, the risk of physicaldependence or other adverse effects may present less of a risk than continued obesity. For suchindividuals, use of weight reduction medication may need to be chronic.

Tests with weight loss drugs have shown that initial responders tend to continue to respond, whileinitial non-responders are less likely to respond even with an increase in dosage. If a person does notlose 2 kg (4.4 lb) in the first four weeks after initiating therapy, the likelihood of long-term response

is very low. If weight is lost in the initial 6 months of therapy or is maintained after the initial weightloss phase, this should be considered a success and the drug may be continued.

Other than orlistat (Xenical), which is approved for use in adolescents aged 12 years or older, weightreduction medications have not been proven to be safe and effective for treatment of obesity inchildren and adolescents.  Orlistat (Xenical) is contraindicated in persons with chronicmalabsorption syndromes and cholestasis. Qsymia is contraindicated in pregnancy, glaucoma,hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days oftaking monoamine oxidase inhibitors. Belviq is contraindicated in pregnancy. Other drugs listedin this policy are contraindicated in the following conditions: hypertension, atherosclerosis,coronary artery disease, and stroke.

Ioannides-Demos et al (2006) stated that there is limited safety and effectiveness data foramfepramone (diethylpropion) and phentermine and their approvals for the management of obesityare limited to short-term use.  The authors stated that, although the benefit-risk profiles ofsibutramine and orlistat appear positive, sibutramine continues to be monitored because of long-term safety concerns. The safety and effectiveness of currently approved drug therapies have notbeen evaluated in children and elderly patient populations.

On October 8, 2010, Abbott Laboratories announced that that it was withdrawing its diet drugMeridia (sibutramine) from the United States, Australian and Canadian markets as a consequence ofheightened concerns that the medication can trigger heart attack or stroke, especially in patientswith underlying cardiovascular disease.

Dual-energy X-ray (DEXA) was developed for the diagnosis of osteoporosis and was employedoriginally to clinically significant locations of the forearm, femoral neck, and lumbar spine. Withbody composition measurements by means of DEXA, a controlled x-ray beam scans the entirebody to ascertain bone mineral content, body fat and lean tissue mass. The comprehensive viewof body composition provided by DEXA is thought to be the method of choice for evaluating bodycomposition by its advocates because of its speed, ease of application as well as relatively low-doseof ionizing radiation. Its purported uses entail determining appropriate nutritional supportduring disease progression and monitoring response to therapeutic interventions.

Available evidence does not support the use of whole body DEXA for managing obesity. There is alack of reliable evidence demonstrating that whole body DEXA measurement improves themanagement of persons with obesity over simpler methods of measuring body composition(including BMI and anthropomorphic measures), such that clinical outcomes are significantlyimproved. Published data have focused on the level of agreement between whole body DEXA andvarious other methods of measuring body composition, and on the use of DEXA as an endpoint inresearch studies. Well-designed studies are needed to assess the clinical value of whole bodyDEXA scanning (Ball and Altena, 2004; Williams et al, 2006; Ritz et al, 2007; Pineau et al, 2007;Pineau et al, 2009).

Balázs (2010) stated that the rapidly increasing prevalence of over-weight and diabetes mellitus is aserious global threat to healthcare. Nowadays, medicinal plants and natural treatments arebecoming more and more popular. Diabetes has historically been treated with plants or plant-derived formulations in different cultures, mainly in China, Asia and India. Different mechanisms forthe anti-diabetic effect of plants have been proposed: increased release of insulin, reduction ofintestinal glucose absorption, as well as enhancement of glycogen synthesis. The scientific evidencesfor most of these plants are still incomplete. The large market for plant remedies has resulted in anarray of unauthorized products or marketed as dietary supplements and, at the same time, no

reliable pharmaceutical-grade products are registered for this purpose.

Borel et al (2012) conducted a prospective intervention study in 104 viscerally obese men classifiedaccording to their glucose tolerance status. They were followed for one year while participating ina healthy eating-physician activity/exercise lifestyle modification program while their insulinsensitivity was tracked. The goals of the study were to evaluate glucose tolerance as well as toevaluate the respective contribution so fo changes in body fat distribution versus changes incardiorespiratory fitness (CRF) to the improvements in indices of plasma glucose/insulinhomeostasis. The results showed insulin sensitivity improved in assocication with decreases inbothvisceral (VAT) and subcutaneous adiposity (SAT) as well as improvement in CRF, regardless ofbaseline glucose tolerance. The results of this study also shoed that reduction in VAT wasassociated with an improvement in homeostasis model assessment of insulin resistance, whereasreduction in SAT was rather associated with improvement of the insulin sensitivity index ofMatsuda. The authors concluded that a one year lifestyle intervention improved plasmaglucose/insulin homeostasis in viscerally obese men, including those with normal glucose tolerancestatus at baseline.Â

Garvey et al (2012) conducted a placebo-controlled, double-blind, 52-week extension study toevaluate the long-term efficacy and safety of controlled-release phentermine/topiramate (PHEN/TPMCR) in overweight and obese subjects with cardiometabolic disease. Subjects were randomlyassigned to placebo, 7.5 mg phentermine/46 mg controlled-release topiramete, or 15 mgphentermine/92 mg controlled-release topiramate.  Of the 676 extension study participants, 84%completed the study. At week 108 PHEN/TPM-CR was associated with significant, sustainedweight loss. Significantly more PHEN/TPM CR-treated subjects at each dose achieved >= 5%, >=10%, >= 15%, and >= 20% weight loss compared with placebo (P < 0.001). The authors thereforeconcluded that PHEN/TPM CR, in conjunction with lifestyle modification, may provide a well-tolerated and effective option for the sustained treatment of obesity complicated by cardiometabolicdisease.

Mulholland et al (2012) stated that evidence from the literature supports the safe use of very-lo--energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet atarget weight loss using a standard low-fat, reduced-energy approach.  There is, however, a needfor longer-term outcomes on obesity and associated morbidities following a VLED.  Theseresearchers investigated longer-term outcomes from studies using VLED, with a minimum durationof 12 months, published between January 2000 and December 2010.  Studies conducted in bothchildren and adults, with a mean/median BMI of greater than or equal to 28 kg/m2 were included. PubMed, Medline, Web of Science and Science Direct were searched.  Reference lists of studiesand reviews were manually searched.  Weight loss or prevention of weight gain and morbiditieswere the main outcomes assessed.  A total of 32 out of 894 articles met the inclusion criteria.  Theduration of the studies ranged from 12 months to 5 years.  Periods of VLED ranged from 25 d to 9months.  Several studies incorporated aspects of behavior therapy, exercise, low-fat diets, low-carbohydrate diets or medication.  Current evidence demonstrated significant weight loss andimprovements in blood pressure, waist circumference and lipid profile in the longer term following aVLED.  Interpretation of the results, however, was restricted and conclusions with which to guidebest practice were limited due to heterogeneity between the studies.  The authors concluded thatthe present review clearly identified the need for more evidence and standardized studies to assessthe longer-term benefits from weight loss achieved using VLED.

The ReeVue Indirect Calorimeter (KORR Medical Technologies, Salt Lake City, UT) was designed tomeasure an individual's oxygen consumption. Using this measurement, the device calculates aperson's resting energy expenditure (REE), also known as resting metabolic rate (RMR). Clinicians

supposedly can screen for abnormally low metabolic rates, teach energy balance, and identify theprecise caloric intake needed for weight loss. Clinical applications of the ReeVue IndirectCalorimeter include obesity treatment, as well as treating obesity related diseases such as diabetes,dysmetabolic syndrome X, hypothyroidism, hyperthyroidism, hypertension, cardiovascular disease,as well as sleep apnea. Under strict laboratory protocol, the ReeVue can also be used to measurebasal metabolic rate.

Fioravante et al (2012) evaluated nutritional status, body composition, and (REE in patients withchronic hepatitis C before and during treatment with pegylated interferon and ribavirin. This wasa prospective study with the evaluation of patients with hepatitis C virus before and after 12 weeksof treatment with pegylated interferon and ribavirin. The evaluation consisted of anthropometry(weight, height, BMI, and waist circumference), and body composition was determined bybioelectrical impedance analysis. The REE of each individual was obtained by indirectcalorimetry. To compare the 2 phases of treatment, the Wilcoxon test was used. The significancelevel was 5 %. Subjects had significant weight loss during treatment with a consequent decreasein BMI. This weight decrease was accompanied by a significant decrease in body fat and nodecrease in fat-free mass. There was a significant decrease in energy intake as assessed by 24-hour recall. However, there was no change in REE and in REE corrected for fat-free mass. Theauthors concluded that patients with hepatitis C treatment had significant weight loss and this wasnot associated with changes in energy expenditure.

Furthermore, an UpToDate review on "Palliative care: Assessment and management of anorexia andcachexia" (Bruera and Dev, 2013) states that "Handheld indirect calorimetry, which is more accuratethan equations at estimating basal energy needs but less precise than traditional devices used in theresearch setting, may be useful in the outpatient setting. Close to one-half of cancer patients beingevaluated in an outpatient cachexia clinic are noted to be hypermetabolic by indirect calorimetry. These assessments are appropriate in the research setting, but have little if any utility in the clinic".

Appendix

Ideal Weight Chart:

The following indicates maximum ideal weight in shoes with one-inch heels based on body frame andheight:

Ideal weights for adult men:

Height

Weight (lbs.)

Â

Small Frame

Medium Frame

Large Frame

5'2"

134

141

150

5'3"

136

143

153

5'4"

138

145

156

5'5"

140

148

160

5'6"

142

151

164

5'7"

145

154

168Â

5'8"

148

157

172

5'9"

151

160

176Â

5'10"

154

163

180

5'11"

157

166

184

6'0"

160

170

188

6'1"

164

174

192Â

6'2"

168

178

197

6'3"

172

182

202

6'4"

176

187

207Â

Ideal weights for adult women:

Height

Weight (lbs.)Â Â

Â

Small Frame

Medium Frame

Large Frame

4'10"

111

121

131

4'11"

113

123

134

5'0"

115

126

137

5'1"

118

129

140

5'2"

121

132

143

5'3"

124

135

147

5'4"

127

138

151

5'5"

130

141

155

5'6"

133

144

159

5'7"

136

147

163

5'8"

139

150

167

5'9"

142

153

170

5'10"

145

156

173

5'11"

148

159

176

6'0"

151

162

179

Â

CPT codes covered if selection criteria are met:

97802

97803

97804

CPT codes not covered for indications listed in the CPB:

94690

94726

97810

+ 97811

97813

+ 97814

Other CPT codes related to the CPB:

77072

80048

80053

80076

80418

80420

81000

81001

81050

82465

82530

82533

82951

82952

83718

83719

83721

84443

84478

84479

84550

84560

85025

85027

93000 - 93010

HCPCS codes covered if selection criteria are met:

G0270

Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral insame year for change in diagnosis, medical condition or treatment regimen (including additionalhours needed for renal disease), individual, face to face with patient, each 15 minutes

G0271

Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral insame year for change in diagnosis, medical condition or treatment regimen (including additionalhours needed for renal disease), group, (2 or more individuals), each 30 minutes

HCPCS codes not covered for indications listed in the CPB:

S9449

Weight management classes, non-physician provider, per session

Other HCPCS Codes related to the CPB:

S9451

Exercise classes, non-physician provider, per session

S9452

Nutrition classes, non-physician provider, per session

ICD-9 codes covered if selection criteria are met:

278.00 - 278.02

Overweight and obesity

V85.23 - V85.44

Body mass index 27.0-70 and over, adult

Other ICD-9 Codes related to the CPB:

250.00, 250.02, 250.10, 250.12, 250.20, 250.22, 250.30, 250.32, 250.40, 250.42, 250.50, 250.52,250.60, 250.62, 250.70, 250.72, 250.80, 280.82, 250.90, 250.92

Diabetes

255.0

Cushing's syndrome

259.8 - 259.9

Other and unspecified endocrine disorders

272.0

Pure hypercholesterolemia

327.23

Obstructive sleep apnea (adult) (pediatric)

401.0 - 405.99

Hypertensive disease

414.00 - 414.9

Coronary atherosclerosis

783.1

Abnormal weight gain

783.6

Polyphagia

V85.0 - V85.22

Body mass index less than 19-26.9, adult

The above policy is based on the following references:

American Obesity Association, C. Everett Koop Foundation, and Shape Up America! Guidance fortreatment of adult obesity. Bethesda, MD: Shape Up America!; October 1996. Available at:

http://www.shapeup.org/sua. Accessed March 16, 2000.

Bra GA, Gray DS. Obesity. Part I. Pathogenesis. West J Med. 1988;149:429-441.

National Task Force on the Prevention and Treatment of Obesity, National Institutes ofHealth. Very low-calorie diets. JAMA. 1993;270:967-974.

National Task Force on the Prevention and Treatment of Obesity, National Institutes ofHealth. Long-term pharmacotherapy in the management of obesity.JAMA. 1996;276:1907-1915.

Foster DW. Gain and loss in weight. In: Harrison's Principles of Internal Medicine. 14th ed. ASFauci, E Braunwald, KJ Isselbacher, et al., eds. New York, NY: McGraw-Hill; 1998:244-246.

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition andyour health: Dietary guidelines for Americans. 3rd ed. Home and Garden Bulletin. No. 232.Washington, DC: U.S. Government Printing Office; 1990.

Goldstein DJ, Potvin JH. Long-term weight loss: The effect of pharmacologic agents. Am J Clin Nutr.1994;60(5):647-657.

Silverstone T. Appetite suppressants: A review. Drugs. 1992;43(6):820-836.

United States Pharmacopeial Convention, Inc. Appetite suppressants (systemic). In: USP DI: DrugInformation for the Health Care Professional. 19th ed. Rockville, MD: United States PharmacopeialConvention; 1999: 452-459.

No author listed. Weight control. In: Introductory Nutrition and Diet Therapy. 2nd ed. MMEschleman, ed. Philadelphia, PA: J.B. Lippincott Co. ;1991;368.

No author listed. Metabolic drugs: Drugs used in obesity. In: AMA Drug Evaluations Subscription.DR Bennett, ed. Chicago, IL: American Medical Association (AMA); 1992: III/MET 6:7.

Scheen AJ, Desaive C, Lefebvre PJ. Therapy for obesity--today and tomorrow. Baillieres ClinEndocrinol Metab. 1994;8(3):705-727.

Bjorntorp P. Treatment of obesity. Int J Obes Relat Metab Disord. 1992;16(suppl 3):S81-S84.

Bray GA. Use and abuse of appetite-suppressant drugs in the treatment of obesity. Ann Intern Med.1993;119(7 pt 2):707-713.

Mosby-Year Book, Inc. Mosby's GenRx: TheComplete Reference for Generic and Brand Drugs.8th ed. St. Louis, MO: Mosby; 1998.

American Society of Health-System Pharmacists,Inc. American Hospital Formulary Service DrugInformation 98. Bethesda, MD: American Societyof Health-System Pharmacists; 1998.

U.S. Department of Health and Human Services,National Institutes of Health (NIH). Clinicalguidelines on the identification, evaluation, andtreatment of overweight and obesity in adults. National Heart, Lung, and Blood Institute andNational Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD: NIH; June 1998.

Jarvis M, McNaughton L, Seddon A, Thompson D. The acute 1-week effects of the Zone diet onbody composition, blood lipid levels, and performance in recreational endurance athletes. JStrength Cond Res. 2002;16(1):50-57.

Haller C, Schwartz JB. Pharmacologic agents for weight reduction. J Gend SpecifMed. 2002;5(5):16-21.

Shepherd TM. Effective management of obesity. J Fam Pract. 2003;52(1):34-42.

Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structuredcommercial program: A randomized trial. JAMA. 2003;289(14):1792-1798.

Institute for Clinical Systems Improvement (ICSI). Pharmacological approaches to weight loss inadults. Technology Assessment Report No. 71. Bloomington, MN: ICSI; February 2003.

Asp N G, Bjorntorp P, Britton M, et al. Obesity - problems and interventions. SBU Report No. 160.Stockholm, Sweden: Swedish Council on Technology Assessment in Health Care (SBU); 2002.

O'Meara S, Riemsma R, Shirran L, et al. A rapid and systematic review of the clinical effectivenessand cost-effectiveness of orlistat in the management of obesity. Health TechnolAssess. 2001;5(18):1-81.

NHS Centre for Reviews and Dissemination (CRD). The prevention and treatment of childhoodobesity. Effective Health Care. York, UK: CRD; 2002; 7(6).

U.S. Preventive Services Task Force. Screening for obesity in adults: Recommendations andrationale. Ann Intern Med. 2003;139(11):930-932.

U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthydiet: Recommendations and rationale. Am J Prev Med. 2003;24(1):93-100.

U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote physicalactivity: Recommendation and rationale. Ann Intern Med. 2002;137(3):205-207.

American Gastroenterological Association medical position statement on obesity. Gastroenterology.2002;123(3):879-881.

National Institute for Clinical Excellence (NICE). Guidance on the use of orlistat for the treatment ofobesity in adults. Technology Appraisal Guidance No.22. London, UK: NICE; 2001.

O'Meara S, Riemsma R, Shirran L, et al. The clinical effectiveness and cost-effectiveness ofsibutramine in the management of obesity: A technology assessment. Health Technol Assess. 2002;6(6):1-97.

Shekelle P, Morton S, Maglione M. Ephedra and ephedrine for weight loss and athletic performanceenhancement: Clinical efficacy and side effects. Evidence Report/Technology Assessment 76.Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2003.

McTigue K, Harris R, Hemphill MB, et al. Screening and interventions for overweight and obesity inadults. Preventive Services Task Force Systematic Evidence Review No. 21. Rockville, MD: Agencyfor Healthcare Research and Quality (AHRQ); 2003.

Jain A. What works for obesity? A summary of the research behind obesity interventions. London,UK: BMJ Publishing Group Ltd.; April 30, 2004.

Institute for Clinical Systems Improvement (ICSI). Diet programs for weight loss in adults. Technology Assessment ReportNo.83.Bloomington,MN:ICSI;August2004.Availableat:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1742. Accessed September 21, 2004.

Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economicconsequences of treatments for obesity and implications for health improvement. Health TechnolAssess. 2004;8(21): iii-iv, 1-182.

O'Meara S, Riemsma R, Shirran L, et al. A systematic review of the clinical effectiveness of orlistatused for the management of obesity. Obes Rev. 2004;5(1):51-68.

Padwal R, Li SK, Lau DC. Long-term pharmacotherapy for obesity and overweight. CochraneDatabase Syst Rev. 2004;(3):CD004094.

Pittler MH, Ernst E. Dietary supplements for body-weight reduction: A systematic review. Am J ClinNutr. 2004;79(4):529-536.

Smartt P. Evidence based review of weight loss medicines:Â A report commissioned by the NewZealand Accident Compensation Corporation (ACC). NZHTA Report. Christchurch, New Zealand:New Zealand Health Technology Assessment (NZHTA); 2004;7(6).

Day P. What is the evidence for the safety and effectiveness of surgical and non-surgicalinterventions for patients with morbid obesity? NZHTA Technical Brief Series. Christchurch, NewZealand: New Zealand Health Technology Assessment (NZHTA); 2005;4(1).

Institute for Clinical Systems Improvement (ICSI). Diet programs for weight loss in adults.Technology Assessment Report No. 83. Bloomington, MN: ICSI; March 2004.Â

Institute for Clinical Systems Improvement (ICSI). Behavioral therapy programs for weight loss in

adults. Technology Assessment Report No.87. Bloomington,MN:ICSI; January2005. Available at:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1993. Accessed February 7, 2006.

Institute for Clinical Systems Improvement (ICSI). Treatment of obesity in children andadolescents. Technology Assessment Report No.90. Bloomington,MN:ICSI;2005. Available at:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=2243. Accessed February 7, 2006.

Shekelle PG, Morton SC, Maglione MA, et al. Pharmacological and surgical treatment of obesity.Evidence Report/Technology Assessment No. 103. Prepared by the Southern California-RANDEvidence-Based Practice Center, Santa Monica, CA, under contract no. 290-02-0003. AHRQPublication No. 04-E028-2. Rockville, MD: Agency for Healthcare Research and Quality; July 2004.Available at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.19289. Accessed June13, 2005.

Snow V, Barry P, Fitterman N, et al. Pharmacologic and surgical management of obesity in primarycare: A clinical practice guideline from the American College of Physicians. Ann Intern Med.2005:142(7):525-531.

Li Z, Maglione M, Tu W, et al. Meta-analysis: Pharmacologic treatment of obesity. Ann Intern Med.2005;142(7):532-546.

Tsai AG, Wadden TA. Systematic review: An evaluation of major commercial weight loss programs inthe United States. Ann Intern Med. 2005;142(1):56-66.

Whitlock EP, Williams SB, Gold R, et al. Screening and interventions for childhood overweight: Asummary of evidence for the US Preventive Services Task Force. Pediatrics. 2005;116(1):e125-e144.

Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle modification andpharmacotherapy for obesity. N Engl J Med. 2005;353(20):2111-2120.

Swedish Council on Technology Assessment in Healthcare (SBU). Interventions to prevent obesity: Asystematic review. Stockholm, Sweden; SBU; 2005.

Ioannides-Demos LL, Proietto J, Tonkin AM, McNeil JJ. Safety of drug therapies used for weight lossand treatment of obesity. Drug Saf. 2006;29(4):277-302.

Abell TL, Minocha A, Abidi N. Looking to the future: Electrical stimulation for obesity. Am J Med Sci.2006;331(4):226-232.

Dixon JB. Weight loss medications--where do they fit in? Aust Fam Physician. 2006;35(8):576-579.

Blissmer B, Riebe D, Dye G, et al. Health-related quality of life following a clinical weight lossintervention among overweight and obese adults: Intervention and 24 month follow-up effects.Health Qual Life Outcomes. 2006;4:43.

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