What are the recommended steps for weight loss treatment?

Weight Loss Treatment: Recommended Steps

Begin with combined lifestyle therapy consisting of a calorie-restricted diet (500-1000 kcal/day deficit), physical activity (150 minutes/week initially), and behavioral modification, with consideration for pharmacotherapy when BMI ≥30 or BMI ≥27 with comorbidities, and bariatric surgery reserved for BMI ≥40 or BMI ≥35 with comorbidities when other methods fail. 1

Initial Goals and Expectations

• Target an initial weight loss of approximately 10% from baseline body weight 1
• Aim for a weight loss rate of 1-2 pounds per week over 6 months 1, 2
• Maximum weight loss typically occurs at 6 months with proper adherence 2
• Even modest weight loss of 3-5% produces clinically meaningful health benefits including reductions in triglycerides, blood glucose, and risk of developing type 2 diabetes 2

Dietary Therapy (Foundation of Treatment)

Create an individualized calorie deficit of 500-1000 kcal/day below maintenance requirements: 1, 2

• For women: 1200-1500 kcal/day 1
• For men: 1500-1800 kcal/day 1, 2
• Adjust these targets based on individual body weight and physical activity levels 1, 2

Key dietary principles: 1

• Reducing dietary fat alone without reducing total calories is insufficient for weight loss 1
• Reducing both dietary fat and carbohydrates together facilitates caloric reduction 1
• No long-term superiority exists between different macronutrient composition diets 1
• Avoid low-carbohydrate diets restricting total carbohydrate to <130 g/day, as the long-term effects are unknown and they eliminate important sources of energy, fiber, vitamins, and minerals 1
• Limit or avoid liquid calories (sodas, juices, alcohol) 1
• Adhere to a balanced diet providing variety from all food groups while limiting added sugars, sodium, and alcohol 1

Physical Activity (Essential Component)

Initial phase: 1

• Start with moderate-intensity activity for 30-45 minutes per day, 3-5 days per week 1
• Prescribe 150 minutes/week of aerobic physical activity (such as brisk walking) 1, 2
• Set a goal of >10,000 steps per day 1

Long-term maintenance: 1, 2

• Increase to 200-300 minutes/week to maintain weight loss or minimize weight regain beyond 1 year 1, 2

Benefits of physical activity: 1

• Contributes modestly to weight loss 1
• Decreases abdominal fat 1
• Increases cardiorespiratory fitness 1
• Helps maintain weight loss 1

Behavioral Therapy (Critical Adjunct)

Assess patient motivation and readiness before implementing the weight management plan: 1

Implement structured behavior strategies: 1

• Regular self-monitoring of food intake 1
• Daily body weight monitoring (weekly or more frequent for maintenance) 1
• Physical activity tracking 1
• Food craving monitoring 1

Visit frequency for high-intensity lifestyle interventions: 1

• 14 visits during the first 6 months: weekly for the first month, biweekly for months 2-6 1
• Monthly visits thereafter for 1 year 1
• Greater frequency improves outcomes 1

Pharmacotherapy (When Lifestyle Therapy Insufficient)

Indications for weight loss medications: 1

• BMI ≥30 kg/m² with no accompanying obesity-related risk factors or diseases 1
• BMI ≥27 kg/m² with accompanying obesity-related risk factors or diseases 1

Critical principles: 1

• Lifestyle therapy must be considered before drug therapy 1
• Never use drugs without accompanying lifestyle modification 1
• Assess drug efficacy and safety continually 1
• Discontinue if ineffective or serious adverse effects occur 1
• Pharmacotherapy cannot be expected to remain effective after cessation 1

Currently available FDA-approved medications: 3

• Orlistat (use with reduced-calorie, low-fat diet; take 1 capsule with each meal containing fat, maximum 3 capsules daily; take multivitamin at bedtime) 4
• Phentermine/topiramate 3
• Naltrexone/bupropion 3
• Liraglutide 3.0 mg 3
• Semaglutide 2.4 mg 3

Newer medications under investigation (semaglutide and tirzepatide) show significantly improved efficacy: 5

Bariatric Surgery (For Severe Obesity)

Indications: 1

• BMI ≥40 kg/m² when less invasive methods have failed 1
• BMI ≥35 kg/m² with comorbid conditions when less invasive methods have failed and patient is at high risk for obesity-related morbidity and mortality 1

Post-surgical monitoring: 1

• Evaluate at minimum every 3 months during the first year 1
• Then every 6 months while weight loss is maintained 1
• Intensify visits and therapy for relapse 1

Multidisciplinary Team Approach

Identify or hire the following professionals: 1

• Registered dietitian nutritionists (for individualized meal planning tailored to unique needs including insulin resistance) 1
• Psychologists 1
• Health coaches 1
• Physical therapists 1

Alternative support options: 1

• Commercial weight loss programs 1
• Online software 1
• Mobile apps 1

Common Pitfalls to Avoid

• Most persons trying to lose weight do not use the recommended combination of reducing calorie intake and engaging in leisure-time physical activity 150 minutes or more per week 6
• A common ineffective strategy is consuming less fat but not fewer calories (used by 34.9% of men and 40.0% of women attempting weight loss) 6
• Weight regain is common without continued support and follow-up; patients usually regain lost weight without ongoing intervention 1
• There is enormous variability in weight loss outcomes across all treatments, and obesity requires a continuous treatment model across the lifespan 5