What is the recommended approach for managing obesity?

Obesity and MASH Management

Obesity requires a comprehensive, stepwise treatment approach starting with intensive lifestyle intervention (diet, exercise, behavioral therapy), escalating to pharmacotherapy when lifestyle changes are insufficient, and considering bariatric surgery for severe obesity (BMI ≥35 kg/m² with comorbidities or BMI ≥40 kg/m²), with all interventions requiring long-term maintenance strategies. 1

Initial Assessment and Risk Stratification

Diagnostic Criteria

• Measure BMI and waist circumference at every patient encounter to classify obesity severity: BMI ≥30 kg/m² indicates obesity, BMI 25-29.9 kg/m² indicates overweight 1, 2
• Measure waist circumference as an independent risk marker: ≥88 cm in women or ≥102 cm in men indicates increased cardiometabolic risk 1

Comprehensive Screening for Complications

Screen all patients with obesity for the following comorbidities 1:

• Type 2 diabetes: Fasting glucose ≥126 mg/dL or HbA1c ≥6.5% 1
• Hypertension: Blood pressure ≥130/80 mm Hg 1
• Dyslipidemia: Complete lipid panel including triglycerides, HDL-C, LDL-C 1
• Metabolic-associated steatohepatitis (MASH): Liver function tests, calculate Fibrosis-4 Index, imaging as indicated 1
• Obstructive sleep apnea: Neck circumference, STOP-BANG questionnaire, polysomnography if indicated 1
• Metabolic syndrome: Presence of ≥3 criteria (elevated waist circumference, triglycerides ≥150 mg/dL, fasting glucose ≥100 mg/dL, BP ≥130/85 mm Hg, low HDL-C) 1

Patient Readiness Assessment

• Ask permission before discussing weight: "Would it be alright if we discuss your weight?" 1
• Screen for social determinants of health including housing, food insecurity, education, and neighborhood environment that may impact treatment success 1
• Determine patient-centered goals that matter to the individual beyond just weight loss 1

First-Line Treatment: Intensive Lifestyle Intervention

Structure and Intensity Requirements

Prescribe high-intensity, on-site comprehensive lifestyle programs with ≥14 sessions over 6 months, delivered by trained interventionists in individual or group format. 1 This approach produces average weight losses of 5-10% (up to 8 kg) at 6 months, significantly greater than usual care. 1

Dietary Intervention

• Prescribe a calorie deficit of 500-1,000 kcal/day below maintenance requirements 1
  • Women: 1,200-1,500 kcal/day 1
  • Men: 1,500-1,800 kcal/day 1
• Macronutrient distribution: 55% carbohydrates, 10% protein, 30% fat (≤10% saturated fat) 2
• Target weight loss rate: 1-2 pounds per week 1

The 2013 AHA/ACC/TOS guidelines emphasize that various dietary approaches can produce weight loss, and the specific diet should be individualized based on patient preferences and adherence potential. 1 Fat reduction is a practical strategy for calorie reduction, but reducing fat alone without total calorie reduction is insufficient. 1

Physical Activity Prescription

• Initial goal: 150 minutes/week of moderate-intensity aerobic activity (e.g., brisk walking), equivalent to 30 minutes on most days 1
• For weight loss maintenance: Increase to 200-300 minutes/week of moderate-intensity activity 1
• Add resistance training: 2-3 times per week to enhance muscular strength and physical function 1
• Gradually escalate activity based on current fitness level, screening for complications and barriers before starting 1

Behavioral Therapy Components

Implement structured behavioral strategies including 1:

• Regular self-monitoring of food intake, physical activity, and weight 1
• Weekly or more frequent weight monitoring for maintenance 1
• Stimulus control and stress management techniques 2
• Motivational interviewing to enhance adherence 2

Alternative Delivery Methods

• Electronically-delivered programs (including telephone-based) with personalized feedback from trained interventionists can be prescribed but may produce smaller weight loss than face-to-face interventions 1
• Commercial weight loss programs with peer-reviewed published evidence of safety and efficacy can be considered as options 1

Second-Line Treatment: Pharmacotherapy

Indications for Adding Medications

Consider anti-obesity medications when lifestyle interventions alone are insufficient to achieve weight loss goals, particularly for patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with obesity-related comorbidities. 1, 2

FDA-Approved Medications

Current evidence supports the following pharmacotherapy options 1, 3:

• GLP-1 receptor agonists (e.g., liraglutide): Produce approximately 8% weight loss 1
• Dual GIP/GLP-1 receptor agonists: Achieve approximately 15-21% weight loss 1
• Orlistat: Lipase inhibitor, take 1 capsule (120 mg) with each fat-containing meal, maximum 3 capsules daily 4
• Naltrexone/bupropion combination: Available option for chronic weight management 3

Important caveat: Pharmacotherapy must be combined with ongoing lifestyle intervention, not used as monotherapy. 1, 2 Patients should take a daily multivitamin at bedtime when using orlistat due to fat-soluble vitamin malabsorption. 4

Third-Line Treatment: Bariatric Surgery

Indications

Recommend bariatric surgery for 1:

• BMI ≥40 kg/m² regardless of comorbidities, OR
• BMI ≥35 kg/m² with obesity-related comorbidities (type 2 diabetes, hypertension, sleep apnea)
• When behavioral treatment with or without pharmacotherapy has failed to achieve sufficient weight loss for targeted health outcomes 1

Surgical Options and Outcomes

Available procedures include gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass, producing approximately 25-30% weight loss and significant improvements in obesity-related comorbidities. 1, 3 Bariatric surgery can reduce mortality in patients with severe obesity. 3

Referral requirement: Patients must be referred to experienced bariatric surgery centers with long-term multidisciplinary follow-up capabilities. 5

Long-Term Weight Maintenance Strategy

Maintenance Program Structure

After initial weight loss, prescribe long-term (≥1 year) comprehensive weight maintenance programs with the following components 1:

• Regular contact: Monthly or more frequent sessions with trained interventionist 1
• High levels of physical activity: 200-300 minutes/week 1
• Regular weight monitoring: Weekly or more frequently 1
• Continued reduced-calorie diet to maintain lower body weight 1

Expected Weight Trajectory

Patients typically experience gradual weight regain of 1-2 kg/year after the first year, but long-term weight losses remain larger than usual care when maintenance programs continue. 1 Most weight loss occurs in the first 6 months of treatment. 4

Treatment Goals and Monitoring

Realistic Weight Loss Targets

• Initial goal: 5-15% weight loss over 6 months 1, 2
• Minimum clinically meaningful loss: Even 5-10% weight loss significantly improves obesity-related comorbidities 1, 5
• Reassess treatment at 3 months: Evaluate effectiveness and intensify treatment if needed 1

Treatment Intensification Algorithm

Follow this stepwise approach 1, 2:

1. Start with intensive lifestyle intervention (6 months minimum)
2. If insufficient response at 3-6 months, add pharmacotherapy while continuing lifestyle intervention
3. If still insufficient response with BMI ≥35 kg/m² with comorbidities or BMI ≥40 kg/m², refer for bariatric surgery evaluation
4. Continue behavioral support even when using pharmacotherapy or after surgery

Special Considerations for MASH

For patients with obesity and MASH specifically, weight loss through the comprehensive approach outlined above is the primary treatment, as 5-10% weight loss can improve liver histology and reduce hepatic steatosis. 1 Screen with liver function tests and calculate the Fibrosis-4 Index, with imaging as indicated to assess disease severity. 1

Common Pitfalls to Avoid

• Do not treat obesity as a temporary condition: It is a chronic disease requiring long-term management, not a short-term fix 2, 5
• Do not focus solely on weight: Emphasize overall health improvements and quality of life 1
• Do not discontinue support after initial weight loss: Maintenance requires ongoing intervention to prevent regain 1
• Do not use very-low-calorie diets (<800 kcal/day) outside medical supervision: These require trained practitioners and medical monitoring due to rapid weight loss and potential complications 1
• Do not prescribe pharmacotherapy without concurrent lifestyle intervention: Medications are adjuncts, not replacements for behavioral changes 1, 2