What are the current guidelines for managing obesity in 2025?

Obesity Management Guidelines 2025

Treat obesity as a chronic disease requiring comprehensive lifestyle intervention as the foundation, with pharmacotherapy added for BMI ≥30 kg/m² (or ≥27 kg/m² with comorbidities) when lifestyle changes alone are insufficient, and consider bariatric surgery for BMI ≥40 kg/m² or ≥35 kg/m² with complications when non-surgical approaches fail. 1

Diagnostic Approach

Use BMI as the primary diagnostic tool but supplement with waist circumference measurements to assess obesity-related health risks, as BMI alone is an imperfect measure of adiposity 1. The 2025 American Diabetes Association guidelines emphasize that BMI misclassifies individuals who are very muscular or frail, and recommend additional anthropometric measurements including waist-to-hip ratio or waist-to-height ratio 1.

• Measure anthropometric parameters at least annually, increasing to every 3 months during active weight management 1
• Waist circumference thresholds: >102 cm in men or >88 cm in women indicates increased cardiometabolic risk 2
• Provide privacy during measurements to avoid stigmatizing experiences 1

Diagnostic categories remain: overweight (BMI 25-29.9 kg/m²), obesity class I (30-34.9 kg/m²), class II (35-39.9 kg/m²), class III (≥40 kg/m²) 1

Weight Loss Targets and Expected Outcomes

Set an initial goal of 5-10% body weight reduction over 6 months, as this produces clinically meaningful improvements in glycemia, blood pressure, and lipids 1, 3. The 2025 guidelines emphasize that any magnitude of weight loss provides benefit, but greater losses confer additional advantages 1.

• 3-7% weight loss: Improves glycemia and cardiovascular risk factors, reduces diabetes progression in at-risk individuals 1
• >10% weight loss: Produces disease-modifying effects including possible diabetes remission, improved cardiovascular outcomes, resolution of metabolic dysfunction-associated steatohepatitis (MASH), and improved quality of life 1
• >20% weight loss (typically from bariatric surgery): Strongly improves glycemia, often leads to diabetes remission, and reduces mortality 1

Lifestyle Intervention: The Foundation

Implement comprehensive lifestyle intervention for at least 6-12 months combining reduced-calorie diet, increased physical activity, and behavioral therapy 1. This remains the essential first-line treatment across all current guidelines 1.

Dietary Recommendations

Create a 500-750 kcal/day energy deficit to achieve 0.5-1 kg weight loss per week 1, 2, 3. The 2025 American Diabetes Association guidelines specify that nutritional plans should create an energy deficit regardless of macronutrient composition 1.

• Macronutrient distribution: 55% carbohydrates, 10% protein, 30% fat (with ≤10% saturated fat) 1
• Eliminate sugary drinks and ultra-processed foods 2
• Use portion control strategies including meal replacements or pre-packaged meals to improve adherence 2
• Very low-calorie diets (<800 kcal/day) should not be used routinely but only for specific indications requiring faster weight loss, and always require medical supervision 1

Physical Activity Requirements

Prescribe at least 150 minutes of moderate-intensity aerobic activity per week (30 minutes, 5 days/week), combined with strength training 1. The 2025 guidelines emphasize that physical activity is crucial for long-term weight maintenance 2.

• For weight loss maintenance: Progress to 60-90 minutes daily of moderate-vigorous activity 2, 3
• For BMI >35 kg/m²: Choose activities that minimize musculoskeletal burden 1
• Reduce sedentary behaviors including TV watching and computer use 1
• Individualize activities based on patient capabilities and preferences, focusing on daily living activities like walking, cycling, and gardening 1

Behavioral Therapy

Deliver high-intensity behavioral counseling with at least 16 sessions over 6 months focusing on nutrition changes, physical activity, and behavioral strategies 1. The 2025 American Diabetes Association guidelines upgraded this to a stronger recommendation compared to 2024 1.

• Minimum of 14 sessions over 6 months produces 5-10% weight loss, with maximum loss typically occurring at 6-12 months 2
• Include self-monitoring, nutrition education, and cognitive restructuring 2
• Consider alternative structured programs (face-to-face or remote) if access to intensive in-person counseling is limited 1

Pharmacotherapy

Add anti-obesity medications for BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related complications when lifestyle interventions alone fail to achieve 5-10% weight loss after 3-6 months 1, 2. Pharmacotherapy should always be used as an adjunct to, not a replacement for, lifestyle modification 1.

FDA-Approved Medications (2025)

GLP-1 receptor agonists and tirzepatide are the most effective options, with tirzepatide achieving mean weight loss of 21% at 72 weeks 3. The 2025 American Diabetes Association guidelines specifically recommend GLP-1 receptor agonists for dual glycemic and weight benefits in patients with type 2 diabetes 4.

• Semaglutide, liraglutide, tirzepatide: Produce 8-21% weight loss 1, 4
• Naltrexone/bupropion, orlistat: Also FDA-approved options 4, 5
• Phentermine: FDA-approved only for short-term use (a few weeks) at 15-30 mg daily, taken 2 hours after breakfast; indicated for BMI ≥30 kg/m² or ≥27 kg/m² with risk factors 6

Continuation Criteria

Continue pharmacotherapy only if the patient loses at least 5% of initial body weight during the first 3 months, or at least 2 kg during the first 4 weeks 1. Medications should be offered for chronic weight maintenance when potential benefits outweigh risks 1.

Important caveat: SGLT2 inhibitors like dapagliflozin produce only 2-3% weight loss, which is insufficient to meet obesity treatment efficacy standards (≥5% at 3 months), and are not FDA-approved for obesity treatment 4.

Bariatric Surgery

Offer bariatric surgery for BMI ≥40 kg/m² or BMI ≥35 kg/m² with weight-related complications when all non-surgical interventions have failed 1, 2. Surgery produces 25-30% weight loss at 12 months and reduces overall mortality by 25-50% during long-term follow-up 1, 3.

• For BMI >50 kg/m²: Surgery is a treatment option regardless of whether conservative interventions were attempted 1
• For diabetes with BMI 30-34.9 kg/m²: Surgery may be considered, though evidence is limited and long-term data lacking 1
• Require comprehensive multidisciplinary assessment before surgery 1
• Provide long-term follow-up care after surgery 1
• Refer to high-volume centers with experienced surgeons 2

Special Populations

For patients with type 2 diabetes and obesity, weight management should be a primary treatment goal alongside glycemic management 1. The 2025 American Diabetes Association guidelines emphasize that weight loss can produce diabetes remission and improve cardiovascular outcomes and mortality 1.

For older adults (≥65 years): Age is not a contraindication for bariatric surgery, but assess benefits versus harms carefully 1.

Communication and Approach

Use person-first language ("person with obesity" rather than "obese person") and employ a person-centered communication style with inclusive, nonjudgmental language 1. This approach optimizes health outcomes and health-related quality of life 1.

Treat obesity as a chronic disease requiring lifelong management by a multidisciplinary team 1. The team should include the primary physician, registered dietitian, exercise specialist, and behavioral therapist 3.

Monitoring Strategy

Schedule initial monthly visits, then every 3 months to assess treatment efficacy and safety 3. Reassess and adjust treatment if weight loss plateaus or regain occurs 3. Long-term weight maintenance requires continued lifestyle modification and potentially long-term pharmacotherapy 3.