What are the treatment options for obesity?

Treatment Options for Obesity

A comprehensive multidisciplinary approach to obesity management is essential, including lifestyle interventions (diet, physical activity, behavior modification), pharmacotherapy, and bariatric surgery when appropriate, tailored to the severity of obesity and presence of complications. 1

Initial Assessment and Diagnosis

• Obesity should be recognized and treated as a chronic, progressive, relapsing disease 1
• Diagnosis requires measurement of BMI and waist circumference using country-specific cut points 1
• Comprehensive clinical assessment should identify obesity-related complications, health risks, and potential barriers to treatment 1
• Cardiovascular risk assessment using validated tools is recommended for adults with overweight or obesity 1

Treatment Goals

• Realistic short-term weight loss goal is 5-15% over 6 months, followed by long-term weight maintenance 1
• Treatment should be tailored to obesity severity and related complications 1
• Regular assessment of treatment effectiveness is necessary, with intensification or de-intensification as needed 1

First-Line Treatment: Comprehensive Lifestyle Intervention

Dietary Modification

• Individualized dietary intervention reducing caloric intake by at least 500 kcal/day 1, 2
• Ensure sufficient protein, vitamins, and minerals while maintaining caloric deficit 1, 2
• Consider personal and cultural preferences when selecting dietary interventions 1

Physical Activity

• Adults should engage in 30-60 minutes of moderate-intensity aerobic exercise 5+ days/week (≥150 min/week) 1, 2
• More intensive exercise (200-300 min/week moderate or ≥150 min/week vigorous) alongside dietary modification may be needed for weight loss and maintenance 1
• Include resistance exercises 2-3 times weekly to enhance muscular strength and physical function 1, 2
• Activity interventions should be gradually increased and tailored to the individual's age, fitness level, and complications 1

Behavioral Modification

• High-intensity behavioral intervention (more than one session per month for at least 3 months) is recommended 2
• Key strategies include setting realistic goals, self-monitoring, identifying barriers, and regular follow-up 2
• Schedule follow-up visits every 4-6 weeks to monitor progress and provide support 2

Second-Line Treatment: Pharmacotherapy

• Consider anti-obesity medications for patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with obesity-related comorbidities when lifestyle interventions alone are insufficient 2
• FDA-approved medications include GLP-1 agonists (semaglutide, liraglutide), tirzepatide, phentermine-topiramate, naltrexone-bupropion, and orlistat 2
• Orlistat is approved for weight loss in overweight adults when used with a reduced-calorie and low-fat diet 3
• Medications should only be continued if at least 5% of initial body weight is lost during the first 3 months 2
• For children age 12 and older, orlistat is the only approved weight control medication 1

Third-Line Treatment: Bariatric Surgery

• Consider bariatric surgery for patients with BMI ≥40 kg/m² or BMI ≥35 kg/m² with obesity-related complications after failed non-surgical interventions 4, 2
• Common procedures include laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) 4
• Expected weight loss is approximately 25% after LSG and 30% after RYGB at 12 months 4, 2
• For adolescents, bariatric surgery may be considered for those with BMI ≥35 kg/m² with serious comorbidities or BMI ≥40 kg/m² with chronic comorbidities 1
• Patients must be physically and emotionally mature, participate in a structured weight management program for 6 months before surgery, and have adequate support 1

Special Populations

Children and Adolescents

• Use BMI growth charts specific for the child's country, age, and sex 1
• Work with parents/caregivers to support healthy eating and exercise habits 1
• Encourage regular meals, limit energy-dense snacks and sugar-added beverages, and provide daily opportunities for physical activity 1
• For younger children with mild obesity, maintaining weight while growing in height may be sufficient 1

Women of Reproductive Age

• Women with pregestational obesity who wish to become pregnant should be referred to a multidisciplinary program 1
• Multidisciplinary lifestyle-based programs can enhance fertility, maternal, and child health outcomes 1

Multidisciplinary Approach

• A multidisciplinary approach should be used to support and maintain weight loss 1
• Adults with Class 2 obesity (BMI 35-39.9), with or without comorbidities, should be referred to a multidisciplinary program 1
• The team may include physicians, dietitians, exercise specialists, and behavioral therapists 5, 6
• Multidisciplinary treatment shows higher adherence rates and better outcomes compared to standard dietetic treatment alone 6

Common Pitfalls and Caveats

• Weight regain occurs in 25% or more of participants at 2-year follow-up even with comprehensive programs 2
• Medications that may contribute to weight gain should be reviewed and alternatives considered 2
• Pharmacotherapy alone is less effective than when combined with behavioral modification therapy 2
• Long-term weight maintenance strategies are usually needed throughout life for stabilization of body weight 7