What are the latest guidelines for managing obesity?

Latest Guidelines for Managing Obesity

Obesity should be treated as a chronic disease requiring a multifactorial, comprehensive lifestyle intervention for at least 6-12 months that includes calorie reduction, increased physical activity, and behavioral modification strategies. 1, 2

Diagnosis and Assessment

• BMI should be used as the primary diagnostic measure, with BMI ≥30 kg/m² indicating obesity and BMI ≥25 kg/m² indicating overweight in Western countries (≥23 kg/m² in many Asian countries) 1, 2
• Waist circumference should be measured as an additional assessment tool to evaluate abdominal adiposity and associated health risks (≥88 cm for women and ≥102 cm for men in Western countries) 1, 2
• A comprehensive clinical assessment should identify obesity-related complications including diabetes, hypertension, dyslipidemia, sleep apnea, and cardiovascular disease 2

First-Line Treatment: Lifestyle Modification

• A multifactorial lifestyle program should include individualized dietary intervention, increased physical activity, and behavioral modification strategies 1, 2
• Dietary intervention should reduce caloric intake by at least 500 kcal/day while ensuring adequate nutrition (approximately 55% calories from carbohydrates, 10% from proteins, and 30% from fats) 1, 2
• Very low calorie diets (≤800 kcal/day) should not be used routinely and always require medical supervision 1
• Physical activity recommendations include 150-300 minutes/week of moderate-intensity activity with gradual increases based on individual capabilities 1, 2
• For persons with BMI >35 kg/m², activities should be chosen that do not burden the musculoskeletal system 1
• Reduction in sedentary activities (e.g., watching TV, computer use) is strongly recommended 1

Pharmacological Treatment

• Pharmacological weight reduction should only be used as an adjunct to lifestyle interventions 1
• Medications are indicated for adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related complications 1, 3
• Pharmacotherapy should only be continued when a person has lost at least 5% of initial body weight during the first 3 months, or at least 2 kg during the first 4 weeks of treatment 1
• FDA-approved medications include orlistat, naltrexone/bupropion, liraglutide, and GLP-1 receptor agonists 2, 4
• Phentermine is indicated only as short-term (a few weeks) monotherapy for obesity management 3

Bariatric Surgery

• Bariatric surgery should be considered for patients with BMI ≥40 kg/m² or BMI ≥35 kg/m² with weight-related complications when non-surgical interventions have failed 1, 2
• For patients with BMI >50 kg/m², bariatric surgery may be considered whether or not conservative weight-reducing interventions have been previously attempted 1
• Bariatric surgery may also be considered in patients with diabetes and BMI between 30-34.9 kg/m², although long-term data are limited 1
• Surgical options include gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass, achieving approximately 25-30% weight loss 2, 4
• Long-term follow-up care should be provided after bariatric surgery 1

Treatment Goals and Monitoring

• Realistic weight loss targets should be 5-15% over 6 months, followed by long-term weight maintenance 2, 5
• Regular monitoring of progress and adjustment of treatment approach is essential 2
• In the era of new weight-loss medications, moderate calorie restriction and at least 150 minutes of moderate-intensity aerobic exercise with two sessions of muscle-strengthening activities per week may be more achievable goals 6

Special Considerations

• For adolescents, weight management goals should focus on weight maintenance rather than weight loss in growing teenagers 7
• Family involvement is beneficial, particularly for children and adolescents 7, 2
• Use respectful, non-stigmatizing language in all patient interactions 7, 2
• Avoid common pitfalls such as treating obesity as a temporary condition rather than a chronic disease, focusing solely on weight rather than overall health improvements, and discontinuing support after initial weight loss 2

Emerging Approaches

• With newer incretin-based medications producing substantial weight loss, lifestyle modification approaches may need to be streamlined and simplified 6
• The combination of strength plus endurance exercise for a minimum of 175 min per week with a customized hypocaloric diet based on patient-specific metabolic needs appears to be most effective 5