What are the treatment options for obesity?

Treatment Options for Obesity

Obesity treatment requires a structured, stepwise approach beginning with comprehensive lifestyle modification (diet, exercise, and behavioral therapy), escalating to pharmacotherapy for patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with comorbidities when lifestyle changes are insufficient, and reserving bariatric surgery for severe obesity (BMI ≥40 kg/m² or BMI ≥35 kg/m² with complications) when other interventions have failed. 1, 2

First-Line Treatment: Comprehensive Lifestyle Intervention

Dietary Modification

• Create a caloric deficit of 500-1,000 kcal/day through an individualized low-calorie diet to achieve weight loss of 1-2 pounds per week 2, 1
• Reduce total caloric intake to 800-1,500 kcal/day (low-calorie diet) or less than 800 kcal/day (very low-calorie diet) depending on obesity severity 3
• Fat reduction is a practical approach to reduce calories, but reducing dietary fat alone without reducing total calories is insufficient—combine fat and carbohydrate reduction 2
• Ensure adequate protein, vitamins, and minerals while maintaining the caloric deficit 1, 4
• No single macronutrient composition has proven superior long-term—the best diet is one the patient will actually follow 2, 3
• Limit or avoid liquid calories including sodas, juices, and alcohol 2

Physical Activity

• Prescribe 150-300 minutes per week of moderate-intensity aerobic exercise (such as brisk walking), equivalent to 30-60 minutes on most days 1, 5
• Set a goal of >10,000 steps per day 2
• Include resistance/strength training 2-3 times weekly to enhance muscular strength and physical function 1, 5
• Exercise alone produces only modest weight loss but is critical for maintaining weight loss long-term and provides cardiovascular benefits independent of weight reduction 2
• Physical activity may specifically decrease abdominal fat and increase cardiorespiratory fitness 2

Behavioral Therapy

• Behavioral modification should be used routinely as it is essential for achieving and maintaining weight loss 2
• Implement self-monitoring strategies including daily food intake records, body weight tracking, and physical activity logs 2
• Help patients develop realistic goals—initial target should be 5-15% weight loss over 6 months 1, 6
• Address environmental triggers, stress, unhealthy sleep habits, and social dynamics that promote obesity 2
• High-intensity interventions require 14 visits over 6 months (weekly for month 1, biweekly for months 2-6), then monthly for 1 year 2

Critical Pitfall: Patients typically set unrealistic weight loss expectations. Even modest 5-10% weight loss significantly reduces obesity-related health risks 2, 6. Weight regain occurs in 25% or more of participants at 2-year follow-up, making long-term behavioral support essential 1.

Second-Line Treatment: Pharmacotherapy

Indications for Medication

• Consider anti-obesity medications for BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one obesity-related comorbidity (hypertension, type 2 diabetes, dyslipidemia, sleep apnea) when lifestyle interventions alone are insufficient 2, 1
• Pharmacotherapy should be used as an adjunct to—never a replacement for—lifestyle modification 2
• Medications are particularly appropriate for patients requiring more urgent weight loss due to severe obesity or inadequately controlled complications 2

Available Medications

• FDA-approved long-term options include GLP-1 agonists (semaglutide, liraglutide), tirzepatide, phentermine-topiramate, naltrexone-bupropion, and orlistat 1, 7
• Sibutramine and orlistat were the original FDA-approved agents for long-term use 2
• For adolescents age 12 and older, orlistat is the only approved weight control medication 1

Medication Management

• Discontinue medication if less than 5% of initial body weight is lost during the first 3 months 1
• Assess drug efficacy and safety continually 2
• Pharmacotherapy alone is less effective than when combined with behavioral modification—the difference between drug and placebo is often only a fraction of a pound per week 2, 8
• Weight regain typically occurs when medication is stopped, so long-term use should be anticipated 2

Critical Pitfall: The clinical impact of drug-induced weight loss is limited—studies show modest differences between drug and placebo groups 8. Review and consider alternatives for medications that may contribute to weight gain 1.

Third-Line Treatment: Bariatric Surgery

Indications

• Bariatric surgery is indicated for BMI ≥40 kg/m² or BMI ≥35 kg/m² with severe obesity-related complications (hypertension, type 2 diabetes, heart failure, sleep apnea) when non-surgical interventions have failed 2, 1
• For adults with BMI >50 kg/m², surgery may be considered independent of prior conservative interventions 4
• For adolescents, consider surgery for BMI ≥35 kg/m² with serious comorbidities or BMI ≥40 kg/m² with chronic comorbidities 1

Surgical Options and Outcomes

• Common procedures include laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) 1
• Expected weight loss is approximately 25% after LSG and 30% after RYGB at 12 months 1
• Surgery is the most effective approach for achieving long-term weight loss and leads to substantial improvement in comorbidities 2, 6
• Bariatric surgery reduces overall mortality by 25-50% during long-term follow-up 6

Post-Surgical Management

• Surgery should be used as an adjunct to lifestyle modification, with or without pharmacotherapy 2
• Evaluate patients at minimum every 3 months during the first year, then every 6 months while weight loss is maintained 2
• Intensify visits and therapy if weight regain occurs 2

Special Populations

Children and Adolescents

• Use BMI growth charts specific for the child's country, age, and sex 1, 4
• Work with parents/caregivers to support healthy eating habits including regular meals, limited energy-dense snacks and sugar-added beverages, and daily vigorous physical activity 2, 1
• Children should avoid dieting or consciously restrictive behaviors as these are associated with weight gain and binge eating—focus discussions on healthy lifestyle rather than weight 5
• 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

• Adults with Class 2 obesity (BMI 35-39.9 kg/m²) should be referred to a multidisciplinary program regardless of comorbidity status 1
• Identify or hire registered dietitian nutritionists, psychologists, health coaches, and physical therapists as part of the treatment team 2
• Commercial programs, online software, or mobile apps can support the intensive weight loss phase 2
• Regular follow-up with treatment providers improves long-term weight management success 2

Critical Pitfall: The natural history of obesity is measured over years, but most studies are restricted to weeks or months—recognize that obesity treatment is a lifelong task requiring sustained intervention and support 2, 8, 6.