What are the treatment options for obesity?

Treatment Options for Obesity

The comprehensive management of obesity requires a stepwise approach that includes lifestyle modifications as first-line therapy, followed by pharmacotherapy and bariatric procedures for eligible patients who do not achieve adequate weight loss with lifestyle changes alone. 1

Initial Assessment and Treatment Goals

• Obesity should be recognized and treated as a chronic, progressive, relapsing disease 1
• Evaluate BMI and waist circumference to assess excess adiposity:
  • Overweight: BMI 25.0-29.9 kg/m²
  • Class I obesity: BMI 30.0-34.9 kg/m²
  • Class II obesity: BMI 35.0-39.9 kg/m²
  • Class III obesity: BMI ≥40 kg/m² 1
• Conduct comprehensive clinical assessment to identify obesity-related complications and potential barriers to treatment 1
• Set realistic weight loss goals of 5-15% over 6 months, followed by long-term weight maintenance 1

First-Line Treatment: Lifestyle Modifications

Dietary Intervention

• Reduce caloric intake by 500-1000 kcal/day to achieve 1-2 pounds of weight loss per week 1
• For overweight individuals with risk factors and those with Class I obesity: decrease energy intake by approximately 500 kcal/day 1
• For Class II and III obesity: aim for a more aggressive energy deficit of 500-1000 kcal/day 1
• Dietary strategies include:
  • Portion-controlled servings
  • Low-fat diets
  • Low-energy density foods (fruits, vegetables)
  • Prepackaged meals or meal replacements 1

Physical Activity

• Initially aim for 30-60 minutes of moderate-intensity aerobic exercise at least 5 days per week (≥150 min/week) 1
• Progress to 200-300 minutes per week of moderate-intensity activity for weight loss maintenance 1
• Include resistance exercises 2-3 times per week to enhance muscular strength 1
• Physical activity alone is not effective for initial weight loss but is crucial for long-term weight maintenance 1

Behavior Modification

• Include behavior therapy in any weight loss program to facilitate changes in eating and activity behaviors 1
• Key components include:
  • Setting realistic goals
  • Self-monitoring (daily records of food intake and physical activity)
  • Problem-solving skills
  • Stimulus control (removing trigger foods)
  • Regular follow-up visits 1, 2
• Group behavior therapy should be considered for patients who have not succeeded with less intensive approaches 1

Second-Line Treatment: Pharmacotherapy

Pharmacotherapy should be considered for patients with:

• BMI ≥30 kg/m² with no complications, or
• BMI ≥27 kg/m² with obesity-related complications 1, 3

FDA-approved medications for long-term use include:

1. GLP-1 agonists (semaglutide, liraglutide) - particularly useful for patients with type 2 diabetes 1, 3
2. Tirzepatide (GIP/GLP-1 agonist) - most effective with mean weight loss of 21% at 72 weeks 1
3. Phentermine-topiramate - average weight loss of 6.6% per year 3
4. Naltrexone-bupropion - average weight loss of 4.8% at 56 weeks 3
5. Orlistat - average weight loss of 2.89 kg per year 3

Short-term medication option:

• Phentermine - appetite suppressant for short-term use (few weeks), with average weight loss of 3.6 kg at 6 months 3, 4

Key considerations for pharmacotherapy:

• Always use in conjunction with lifestyle modifications, never alone 3
• Evaluate efficacy at 3 months; if weight loss <5%, consider changing medication 3
• Continue treatment with periodic evaluations if weight loss ≥5% 3

Third-Line Treatment: Bariatric Procedures

Endoscopic Procedures

• Intragastric balloon and endoscopic sleeve gastroplasty can achieve 10-13% weight loss at 6 months 1

Bariatric Surgery

• Consider for patients with:
  • BMI ≥40 kg/m², or
  • BMI ≥35 kg/m² with obesity-related comorbidities 1
• Surgical options include gastric bypass, sleeve gastrectomy, and laparoscopic banding 1
• Leads to substantial improvement of comorbidities and reduction in overall mortality by 25-50% during long-term follow-up 5

Special Considerations

For Children and Adolescents

• Focus on healthy habits rather than weight loss
• Work with parents/caregivers to support healthy eating and exercise habits
• Regular meals, limited consumption of energy-dense foods and sugar-added beverages
• Daily opportunities for physical activity 1
• Orlistat is the only weight control medication approved for children age 12 and older 1

Common Pitfalls to Avoid

1. Setting unrealistic weight loss goals - aim for 5-15% weight loss rather than "ideal body weight" 1
2. Focusing only on short-term weight loss without a maintenance strategy 6
3. Using pharmacotherapy without concurrent lifestyle modifications 3
4. Failing to provide regular follow-up and support, which is critical for long-term success 1
5. Neglecting to address psychological factors that may impede weight loss efforts 1
6. Expecting quick results - sustainable weight loss is gradual (1-2 pounds per week) 1

Remember that obesity is a chronic disease requiring ongoing management. The most effective approach combines dietary modification, increased physical activity, and behavior therapy, with pharmacotherapy and bariatric procedures reserved for appropriate candidates who don't achieve adequate results with lifestyle changes alone.