What is the recommended approach for managing obesity?

Comprehensive Management of Obesity

The recommended approach for managing obesity is a comprehensive, evidence-based treatment that combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures as appropriate for individual patients. 1

Diagnosis and Assessment

• Use BMI as the primary diagnostic measure with country-specific cut points: ≥30 kg/m² indicating obesity and ≥25 kg/m² indicating overweight in Western countries, and ≥23 kg/m² indicating overweight in many Asian countries 2
• Measure waist circumference to assess abdominal adiposity: ≥88 cm for women and ≥102 cm for men in Western countries; ≥80 cm for women and ≥90 cm for men in Asian countries 1, 2
• Screen for obesity-related comorbidities including type 2 diabetes, hypertension, hyperlipidemia, sleep apnea, cardiovascular disease, osteoarthritis, and fatty liver disease 1
• Assess social determinants of health (housing, food insecurity, education, neighborhood environment) that may impact treatment success 1, 2
• Determine patient's readiness to change and goals that matter to them 1

Treatment Approach

First-Line: Comprehensive Lifestyle Intervention

1. Dietary Modification

   • Reduce caloric intake by 500-1000 kcal/day to achieve 1-2 lb weight loss per week 1
   • Typical calorie targets: 1200-1500 kcal/day for women, 1500-1800 kcal/day for men 1
   • Ensure sufficient protein, vitamins, and minerals 1
   • Consider patient preferences and cultural factors when selecting dietary approach 1

2. Physical Activity

   • Initially aim for 150 minutes/week of moderate-intensity activity (30 minutes, 5 days/week) 1
   • Progress to 200-300 minutes/week for long-term weight maintenance 1, 2
   • Include resistance training 2-3 times weekly to enhance muscular strength 2
   • Gradually increase activity based on individual fitness level and capabilities 1

3. Behavioral Therapy

   • Implement regular self-monitoring of food intake, physical activity, and weight 1
   • Use behavioral strategies including stimulus control, stress management, and problem-solving 1, 2
   • Provide frequent contact with healthcare providers (weekly initially, then bimonthly or monthly) 1
   • Consider technology-based tools to support adherence 3

Second-Line: Pharmacotherapy

• Consider FDA-approved medications when lifestyle interventions alone are insufficient 2, 4
• Options include:
  • Phentermine (short-term use only, for BMI ≥30 kg/m² or ≥27 kg/m² with risk factors) 5
  • GLP-1 receptor agonists (can achieve 8-21% weight loss) 1, 4
  • Orlistat, naltrexone/bupropion, and liraglutide 4
• Avoid using phentermine in patients with cardiovascular disease, hyperthyroidism, glaucoma, or history of drug abuse 5

Third-Line: Bariatric Surgery

• Consider for patients with BMI ≥35 kg/m² when non-surgical interventions have failed 2, 4
• Options include gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass 4
• Can achieve 25-30% weight loss and significant improvements in obesity-related comorbidities 1, 2

Treatment Goals and Monitoring

• Set realistic weight loss targets of 5-15% over 6 months, followed by long-term weight maintenance 1
• A 5-10% weight loss can provide significant health benefits 1, 6
• Greater weight loss (>10%) may be required for specific clinical goals 1
• Regularly assess progress and adjust treatment approach as needed 1
• Continue behavioral support even when using pharmacotherapy or after bariatric surgery 2

Common Pitfalls to Avoid

• Treating obesity as a temporary condition rather than a chronic disease requiring long-term management 1, 7
• Focusing solely on weight rather than overall health improvements 6
• Discontinuing support after initial weight loss without addressing maintenance 1
• Using stigmatizing language or approaches that may reduce patient engagement 2
• Attempting to increase medication dosage when tolerance develops rather than discontinuing the medication 5

Multidisciplinary Care Model

• Involve various healthcare specialties when possible, including dietitians, exercise specialists, behavioral therapists, and obesity medicine specialists 1, 2
• Use a stratified approach where patients with more severe obesity are referred to specialists 1
• In settings with limited resources, primary care physicians can effectively support patients in weight management 1, 7