What is the recommended treatment for an obese patient with a weight of 137 kg?

Treatment Approach for a 137 kg Obese Patient

All obese patients, regardless of weight, should begin with intensive lifestyle modification consisting of dietary intervention (500-1000 kcal/day deficit), physical activity (at least 150 minutes/week of moderate-intensity exercise), and behavioral therapy, with pharmacotherapy added if weight loss goals are not met after 3-6 months, and bariatric surgery considered for those with BMI ≥40 kg/m² or ≥35 kg/m² with comorbidities who fail non-surgical interventions. 1, 2

Initial Assessment and Classification

Without knowing the patient's height, we cannot calculate exact BMI, but at 137 kg, this patient likely has Class II or III obesity. The initial evaluation must include: 1

• BMI calculation to determine obesity class (Class I: 30-34.9, Class II: 35-39.9, Class III: ≥40 kg/m²) 1, 2
• Waist circumference measurement (>102 cm in men or >88 cm in women indicates increased cardiometabolic risk) 2
• Assessment of obesity-related complications: hypertension, type 2 diabetes, dyslipidemia, sleep apnea, fatty liver disease, cardiovascular disease 1, 2
• Weight history: patterns of weight gain/loss, previous weight loss attempts, family history 1, 2
• Medication review to identify drugs contributing to weight gain (certain antidepressants, antidiabetics) 2
• Assessment of weight loss readiness: motivation, major life stresses, psychiatric conditions (depression, substance abuse, binge eating disorder), ability to commit 15-30 minutes daily for 6 months 1

Weight Loss Goals

Target an initial weight loss of 10% of body weight over 6 months (approximately 13.7 kg for this patient), which produces clinically meaningful improvements in blood pressure, glycemic control, and cardiovascular risk factors. 2, 3

• Even modest weight loss of 5% produces significant health benefits including reductions in triglycerides, blood glucose, and diabetes risk 3
• For Class II (BMI 35-39.9) or Class III (BMI ≥40) obesity, aim for more aggressive weight loss 1

Dietary Intervention (Foundation of All Treatment)

Prescribe a 500-1000 kcal/day energy deficit, which produces approximately 0.5-1 kg weight loss per week and about 10% weight reduction at 6 months. 1, 2, 3

Specific dietary strategies that enhance adherence: 1

• Portion-controlled servings using prepackaged meals or liquid formula meal replacements (obese patients underestimate energy intake when self-selecting foods) 1
• Low-fat diet with increased high-water-content foods (fruits, vegetables) to decrease energy density 1
• Eliminate sugary drinks and ultra-processed foods 2
• Limit high-energy-density foods (high-fat foods, dry snacks like crackers and pretzels) 1

For a typical patient at 137 kg, baseline caloric needs likely range from 2500-2800 kcal/day depending on activity level; creating a 500-1000 kcal deficit results in target intake of 1500-2300 kcal/day. 3

Physical Activity

Prescribe at least 150 minutes/week of moderate-intensity physical activity (30 minutes most days), progressing to 200-300 minutes/week for long-term weight maintenance. 2, 3

• Physical activity alone is not effective for initial weight loss but is crucial for long-term maintenance 1, 2, 3
• For patients with BMI >35 kg/m², choose activities that don't burden the musculoskeletal system 1
• Combine endurance exercise with strength training 1
• Reduce sedentary activities (TV watching, computer use) 1

Behavioral Therapy

Provide intensive behavioral therapy with at least 14 sessions over 6 months, focusing on self-monitoring, nutrition education, and cognitive restructuring. 2

• High-intensity intervention is defined as more than one person-to-person session per month for at least the first 3 months 1
• Regular self-monitoring of food intake, physical activity, and body weight significantly improves success rates 3
• Maximum weight loss typically occurs at 6 months with proper adherence 3

Pharmacotherapy (If Lifestyle Modification Fails)

Add anti-obesity medication if the patient has not achieved 5-10% weight loss after 3-6 months of intensive lifestyle modification. 1, 2

Medication options include: 1

• Semaglutide, liraglutide, or tirzepatide (newer GLP-1 agonists with greater efficacy) 2
• Orlistat (2.89 kg weight loss at 12 months; side effects: fecal urgency, oily spotting, flatulence) 1
• Sibutramine (4.45 kg at 12 months; side effects: increased blood pressure and heart rate) 1
• Phentermine (3.6 kg at 6 months) 1
• Diethylpropion (3.0 kg at 6 months) 1
• Bupropion (2.8 kg at 6-12 months) 1

Critical caveats about pharmacotherapy: 1

• Medications produce modest weight loss (<5 kg at 1 year) 1
• Long-term safety and efficacy data beyond 12 months are lacking (except orlistat) 1
• Weight loss is temporary; weight regain occurs after medication withdrawal 1
• Must always be combined with lifestyle modification 1, 2
• Continue medication only if patient loses at least 5% of initial body weight in first 3 months or 2 kg in first 4 weeks 1

Bariatric Surgery

Consider bariatric surgery for patients with BMI ≥40 kg/m² or BMI ≥35 kg/m² with weight-related complications when all non-surgical interventions have failed. 1, 2

• Surgery produces substantial weight loss (28 to >40 kg) 1
• Postoperative mortality rate is 0.2%; complications include wound infection, re-operation (up to 25%), vitamin deficiency, diarrhea, hemorrhage 1
• Requires comprehensive multidisciplinary assessment including psychological evaluation before surgery 1
• Mandatory long-term follow-up for at least 2 years (sometimes lifelong) with dietetic monitoring, micronutrient supplementation, and psychological support 1
• For BMI >50 kg/m², surgery may be considered without prior conservative interventions 1

Follow-up and Monitoring

Provide frequent follow-up with long-term contact to maintain weight loss and prevent regain. 1

• Obesity should be treated as a chronic disease requiring ongoing management 1
• Care should be multidisciplinary, involving trained primary care professionals 1
• Monitor for obesity-related complications and adjust treatment intensity accordingly 1