What is the recommended protocol for establishing an obesity service for patients with a body mass index (BMI) of 30 or higher, or those with a BMI of 27 or higher and at least one weight-related condition, such as hyperglycemia, hypertension, or impaired renal function?

Establishing an Obesity Service: Protocol and Implementation Framework

Service Eligibility Criteria

Establish your obesity service for adults with BMI ≥30 kg/m², or BMI ≥27 kg/m² with at least one weight-related complication (diabetes, prediabetes, hypertension, dyslipidemia, elevated waist circumference, or impaired renal function). 1 This threshold is supported by the strongest evidence demonstrating that pharmacotherapy combined with lifestyle intervention produces clinically meaningful improvements in morbidity and mortality outcomes. 1

• Screen all patients using BMI calculation (weight in kg divided by height in meters squared, or weight in pounds divided by height in inches squared multiplied by 703). 1
• Measure waist circumference as an additional risk stratification tool: men >102 cm (>40 inches) and women >88 cm (>35 inches) indicate increased cardiovascular risk independent of BMI. 1
• Note that waist circumference thresholds become unreliable at BMI >35. 1

Core Service Structure: Multidisciplinary Team Composition

Your obesity service must be structured around a multidisciplinary team that delivers high-intensity interventions, defined as more than one person-to-person session per month for at least the first 3 months. 1 This intensity level is critical because moderate- and low-intensity interventions show mixed results and insufficient evidence for sustained weight loss. 1

Essential Team Members:

• Primary obesity care provider or coordinator (can be a non-physician trained professional who manages day-to-day patient care). 2
• Physician providing medical oversight, prescribing pharmacotherapy, managing comorbidities, and determining surgical candidacy. 3, 2
• Registered dietitian for nutrition education, meal planning, and caloric prescription. 4
• Behavioral health specialist (psychologist or trained behavioral therapist) for cognitive-behavioral strategies and addressing psychological barriers. 5
• Exercise physiologist or physical therapist for physical activity programming and reconditioning. 5
• Bariatric surgeon (available for consultation and referral, not necessarily on-site). 6

Clinical Pathway: Initial Assessment Phase

Baseline Evaluation Components:

• Anthropometric measurements: BMI, waist circumference, body composition if available. 1, 4
• Laboratory assessment: fasting glucose, HbA1c, lipid panel, liver function tests, thyroid function, renal function. 4
• Cardiovascular risk assessment: blood pressure measurement, screening for coronary artery disease, heart failure, and arrhythmias. 4
• Comorbidity screening: sleep apnea (using validated questionnaires), osteoarthritis, gastroesophageal reflux disease, nonalcoholic fatty liver disease. 1
• Medication review: identify weight-promoting medications that could be substituted. 3
• Psychosocial assessment: eating behaviors, mood disorders, readiness to change, barriers to adherence. 1, 5

Readiness Assessment:

Before initiating intensive treatment, explicitly assess patient readiness by asking: "How prepared are you to make changes in your diet, to be more physically active, and to use behavior change strategies such as recording your weight and food intake?" 1 If the patient is not prepared, focus on preventing further weight gain and address competing priorities (such as smoking cessation) before launching comprehensive weight loss efforts. 1

Treatment Protocol: Structured Intervention Phases

Phase 1: Intensive Lifestyle Intervention (Months 0-6)

Deliver a minimum of 14 sessions over 6 months using the 5-A framework: Assess, Advise, Agree, Assist, and Arrange. 1, 4 This high-intensity approach is the only intervention level with evidence supporting sustained weight loss. 1

Nutritional Intervention:

• Prescribe caloric restriction to 1,200-1,500 kcal/day for women or 1,500-1,800 kcal/day for men, creating a 500-750 kcal/day deficit. 4, 7
• Emphasize structured meal planning with fruits, vegetables, whole grains, and high-fiber foods. 4
• Consider portion-controlled servings or meal replacements to enhance compliance. 7

Physical Activity Prescription:

• Start with 30-40 minutes per day, 3-5 days per week of moderate-intensity aerobic activity. 4
• Progress toward ≥150 minutes per week, with a goal of ≥10,000 steps daily. 4
• Add resistance training 2-3 times weekly to preserve muscle mass. 7

Behavioral Strategies:

• Implement self-monitoring of weight (weekly), food intake (daily), and physical activity (daily). 4
• Teach stimulus control, problem-solving, and relapse prevention techniques. 1
• Provide skills training for managing eating patterns and maintaining physical activity. 1

Phase 2: Pharmacotherapy Decision Point (Month 3)

Add FDA-approved anti-obesity medication if the patient has not achieved ≥5% weight loss after 3 months of adherent lifestyle intervention. 1, 7 The 2022 AGA guideline provides the most current evidence on medication selection.

First-Line Pharmacotherapy Options (in order of preference based on efficacy and safety):

1. Semaglutide 2.4 mg subcutaneous weekly (produces 15-21% weight loss; provides cardiovascular benefits). 1, 4
2. Liraglutide 3.0 mg subcutaneous daily (produces 8% weight loss; cardiovascular benefits demonstrated). 1, 4
3. Phentermine-topiramate ER (effective but contraindicated in cardiovascular disease). 1, 4
4. Naltrexone-bupropion ER (moderate efficacy, acceptable safety profile). 1

Avoid orlistat due to poor tolerability and limited efficacy. 1 Phentermine and diethylpropion have only low-certainty evidence and should be reserved for short-term use when other options are unavailable. 1

Medication Continuation Criteria:

• Assess efficacy at 12 weeks: continue only if patient achieves ≥5% weight loss. 7
• Plan for long-term pharmacotherapy, as medications support both weight loss and weight maintenance. 4

Phase 3: Maintenance and Long-Term Management (Month 6 onward)

Transition to monthly contact with a trained interventionist after the initial 6-month intensive phase to prevent weight regain. 4 Weight regain is the primary challenge in obesity management, and ongoing support is essential. 3

• Continue self-monitoring indefinitely. 4
• Maintain pharmacotherapy if it was effective during weight loss. 4
• Adjust caloric intake and physical activity targets to maintain achieved weight loss. 1

Bariatric Surgery Referral Pathway

Refer patients for bariatric surgery evaluation if they have BMI ≥35 kg/m² with weight-related complications and fail to achieve adequate weight loss after 6-12 months of lifestyle intervention plus pharmacotherapy. 4 Surgery produces 25-30% weight loss at 12 months and dramatically improves cardiovascular risk profile. 4

Pre-surgical Requirements:

• Comprehensive multidisciplinary assessment including psychological evaluation. 8, 6
• Documentation of failed medical management attempts. 6
• Optimization of comorbidities prior to surgery. 6

Expected Outcomes and Quality Metrics

Target 5-10% weight loss as the initial goal, which produces clinically meaningful improvements in triglycerides, blood glucose, blood pressure, and cardiovascular risk. 4, 7 With combined lifestyle intervention and pharmacotherapy, expect 10-21% weight loss depending on medication chosen and adherence. 4

Service Performance Indicators:

• Drop-out rate <10% (multidisciplinary approach reduces drop-out from 54% to 5.5%). 5
• ≥50% of patients achieving ≥5% weight loss at 6 months. 7
• Blood pressure reduction of approximately 3 mmHg per 5% weight loss. 4
• Improvement in quality of life scores and reduction in anxiety/depression symptoms. 5

Critical Implementation Considerations

Recognize that obesity is a chronic, relapsing disease requiring lifelong management, not a short-term condition. 3, 9 Structure your service accordingly:

• Avoid time-limited "programs" that imply a defined endpoint. 3
• Plan for indefinite follow-up with varying intensity based on patient needs. 4
• Address weight regain proactively rather than viewing it as treatment failure. 3

The physician's role should focus on medical oversight, pharmacotherapy, and surgical referral, while non-physician team members deliver the majority of intensive behavioral and lifestyle counseling. 2 This model is essential for scalability given the large numbers of affected patients and inadequate physician training in obesity management. 2

Common Pitfalls to Avoid:

• Do not use very low-calorie diets (≤800 kcal/day) routinely; they require medical supervision and are not appropriate for standard care. 8
• Do not recommend unbalanced or fad diets that lack nutritional adequacy. 8
• Do not apply evidence from obese patients (BMI ≥30) to overweight patients (BMI 25-29.9) without comorbidities, as the evidence is insufficient for this population. 1
• Do not delay pharmacotherapy indefinitely in patients who meet criteria and have inadequate response to lifestyle intervention alone. 1

Financing and Sustainability

Address insurance coverage limitations proactively by documenting medical necessity, emphasizing comorbidity management, and advocating for coverage of evidence-based treatments. 2 The inadequacy of financing mechanisms remains a major barrier to obesity care delivery. 2