Adam H Gilden Obesity 2024

Annals of Internal MedicineT
In the ClinicT
Obesity
O
besity is a common condition and a major
cause of morbidity and mortality.
Fortunately, weight loss treatment can
reduce obesity-related complications. This review
summarizes the evidence-based strategies physi-
Screening and Prevention
cians can employ to identify, prevent, and treat
obesity, including best practices to diagnose and
counsel patients, to assess and address the burden Diagnosis
of weight-related disease including weight stigma,
to address secondary causes of weight gain, and
to help patients set individualized and realistic Management
weight loss goals and an effective treatment plan.
Effective treatments include lifestyle modification Practice Improvement
and adjunctive therapies such as antiobesity medi-
cations and metabolic and bariatric surgery.
CME/MOC activity available at Annals.org.
Physician Writers doi:10.7326/AITC202405210

Adam H. Gilden, MD, MSCE This article was published at Annals.org on 14 May 2024.
Victoria A. Catenacci, MD
John Michael Taormina, MD CME Objective: To review current evidence for screening and prevention,
Anschutz Health and Wellness diagnosis, and treatment of obesity.
Center, and Division of General
Internal Medicine, University of Funding Source: American College of Physicians.
Colorado School of Medicine, Disclosures: All relevant financial relationships have been mitigated. Disclosures
Aurora, Colorado (A.H.G.) can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.
Anschutz Health and Wellness do?msNum¼M24-0583.
Center, and Division of
Endocrinology, University of
Colorado School of Medicine, With the assistance of additional physician writers, the editors of Annals of
Aurora, Colorado (V.A.C.) Internal Medicine develop In the Clinic using MKSAP and other resources of
Anschutz Health and Wellness the American College of Physicians.
Center, and Department of
In the Clinic does not necessarily represent official ACP clinical policy. For ACP
Family Medicine, University of clinical guidelines, please go to https://www.acponline.org/clinical_information/
Colorado School of Medicine, guidelines/.
Aurora, Colorado (J.M.T.)
Correction: This article was updated on 14 May 2024 to correct the authors'
affiliations.
© 2024 American College of Physicians
Downloaded from https://annals.org by Weill Medical College on 05/17/2024.

Obesity is a common condition and a Genetics account for 40% to 75% of the
major cause of morbidity and mortality variability in BMI. Polygenic cause is
1. Obesity Medicine (1). The prevalence of obesity (body thought to be most common, with
Association. Obesity
Medicine Algorithm. 2024.
mass index [BMI] ≥30 kg/m2) among more than 1200 loci linked to obesity
Accessed at https:// adults in the U.S. is 42.4%, with an addi- in genome-wide association studies
obesitymedicine.org/
resources/obesity- tional 30.7% of adults having over- (4). These genes likely conferred a sur-
algorithm/ on 20 March
2024.
weight (BMI 25 to <30 kg/m2) (2). vival advantage during human evolu-
2. National Institute for Important racial and ethnic disparities tion, allowing for energy conservation
Diabetes and Digestive and
Kidney Diseases. exist: The prevalence in adults is 49.6% and storage during periods of food
Overweight & Obesity scarcity. However, in our current envi-
Statistics. Accessed at www.
among African Americans, 44.8% among
niddk.nih.gov/health- Hispanic Americans, 42.2% among White ronment with widely available, highly
information/health-
statistics/overweight- Americans, and 17.4% among Asian palatable, energy-dense food, these
obesity on 20 March 2024.
3. Ryan DH, Yockey SR.
Americans. The prevalence in Asian genes promote overweight and obesity.
Weight loss and improve- Americans is likely higher if a lower BMI
ment in comorbidity: differ- Research also demonstrates that obesity
ences at 5%, 10%, 15%, threshold more appropriate for Asian
and over. Curr Obes Rep. tends to be maintained over time through
populations is used.
2017;6:187-194. [PMID:
28455679]
a series of “metabolic adaptations” that
4. Loos RJF, Yeo GSH. The Obesity is a chronic condition and a affect both energy expenditure and
genetics of obesity: from
discovery to biology. Nat risk factor for other chronic conditions energy intake after weight loss (5). Both
Rev Genet. 2022;23:120-
133. [PMID: 34556834]
in many other organ systems. Compli- resting and physical activity energy ex-
5. Hall KD. Metabolic cations of obesity can be divided into penditure decline with weight loss
Adaptations to Weight
Loss. Obesity (Silver metabolic (e.g., type 2 diabetes [T2D], because body mass is reduced. How-
Spring). 2018;26:790-791.
[PMID: 29637734] hypertension, atherosclerotic cardio- ever, energy expenditure is reduced
6. Leibel RL, Rosenbaum M, vascular disease [CVD]), biomechanical more than expected based on changes
Hirsch J. Changes in
energy expenditure result- (e.g., knee osteoarthritis, gastroesoph- in body mass alone. A landmark physi-
ing from altered body
weight. N Engl J Med. ageal reflux disease, obstructive sleep ologic study showed that a 10% reduc-
1995;332:621-628. [PMID:
7632212]
apnea [OSA]), and psychosocial (e.g., tion in body weight resulted in a 15%
7. Rosenbaum M, Hirsch J, depression, weight stigma) (1). reduction in total energy expenditure
Gallagher DA, et al. Long-
term persistence of adapt- (6). A second matched cohort study
ive thermogenesis in sub- Weight loss of as little as 5% to 10% of
jects who have maintained starting body weight has been shown suggests that this “adaptive thermo-
a reduced body weight. Am
J Clin Nutr. 2008;88:906- to improve CVD risk factors (e.g., glyce- genesis” persists for 1 year after weight
912. [PMID: 18842775]
8. Szmygin H, Szmygin M, mic control, blood pressure, lipids), to loss (7).
Cheda M, et al. Current improve health-related quality of life,
insights into the potential Metabolic adaptations after weight loss
role of fMRI in discovering and to lower health care costs. Greater
the mechanisms underly- also include a physiologic drive to
ing obesity. J Clin Med. weight loss (10% to 15%) may be
2023;12:4379. increase caloric intake through a rise in
needed to improve other health con-
9. Sumithran P, Prendergast hunger hormones and in the hedonic
LA, Delbridge E, et al. ditions (e.g., OSA, metabolic-associ-
Long-term persistence of response to food. This drive is part of
hormonal adaptations to ated steatohepatitis) and to provide
weight loss. N Engl J Med. homeostatic pathways in the hypothal-
2011;365:1597-1604.
mortality benefit (3).
[PMID: 22029981]
amus regulated through feedback
10. Polidori D, Sanghvi A, What causes obesity and what is the loops from adipose tissue and the gas-
Seeley RJ, et al. How
strongly does appetite role of genetic factors? trointestinal tract (5). Functional mag-
counter weight loss?
Quantification of the feed-
The traditional view of obesity as result- netic resonance imaging studies show
back control of human ing from “lack of willpower”—that that weight loss achieved by lifestyle
energy intake. Obesity
(Silver Spring). patients simply need to eat less and modification leads to increased activa-
2016;24:2289-2295.
[PMID: 27804272]
exercise more—has been shown to be tion in brain areas responsible for food
11. Curry SJ, Krist AH, Owens overly simplistic. Evidence suggests reward (8). A study of patients who had
DK, et al; US Preventive
Services Task Force. that the cause of obesity is multifacto- lost 13.5% of body weight showed
Behavioral weight loss
interventions to prevent rial, with genetic, environmental (e.g., increases in subjective hunger and in
obesity-related morbidity neighborhood environment, psycho- hunger hormones (e.g., ghrelin) persist-
and mortality in adults:
US Preventive Services logical stress), metabolic (e.g., adapta- ing 1 year after weight loss (9). A second-
Task Force
Recommendation tions to weight loss), and behavioral ary analysis of a randomized controlled
Statement. JAMA.
2018;320:1163-1171.
(eating, physical activity, sleep pat- trial (RCT) reported that for every 1 kg of
[PMID: 30326502] terns) contributors. body weight lost (in response to sodium-
© 2024 American College of Physicians ITC2 In the Clinic Annals of Internal Medicine

glucose cotransporter-2 medication), loss challenging, and weight regain may
there was a response of 100 kcal per day not reflect nonadherence. Thus, obesity
increase in food intake (10). Metabolic is a chronic condition requiring ongoing
adaptations make maintaining weight care.
12. Eckel N, Li Y, Kuxhaus O,
Screening and Prevention et al. Transition from met-

abolic healthy to unheal-
thy phenotypes and
Who should clinicians screen for medications (mean difference of 3.27 kg) association with cardiovas-
cular disease risk across
overweight and obesity? (14). BMI categories in 90257
women (the Nurses'
The U.S. Preventive Services Task Force Clinicians should also counsel patients
Health Study): 30 year fol-
low-up from a prospective
(USPSTF) recommends screening all on behaviors shown to mitigate weight cohort study. Lancet
Diabetes Endocrinol.
adults for obesity (11), as even meta- gain, including promoting diets high in 2018;6:714-724. [PMID:
bolically healthy adults with obesity are 29859908]
fiber and lean protein and low in satu- 13. Garvey WT, Mechanick JI,
at higher risk for cardiometabolic dis- rated fat (increased intake of whole
Brett EM, et al; Reviewers
of the AACE/ACE Obesity
ease compared with lean peers (12). Clinical Practice
grains, fruits, and vegetables), and dis- Guidelines. American
Guidelines recommend monitoring BMI
couraging intake of sugar-sweetened Association of Clinical
at least annually (13). Endocrinologists and
beverages, refined grains, foods pre- American College of
Endocrinology compre-
pared outside of the home, and red hensive clinical practice
How can clinicians help patients and processed meats (13, 15) and guidelines for medical
care of patients with obe-
prevent the development of obesity? heavy alcohol use. Patients should also sity. Endocr Pract.
2016;22 Suppl 3:1-203.
Clinicians can help patients prevent be encouraged to sleep 7 to 9 hours [PMID: 27219496]
14. de Silva VA, Suraweera C,
obesity through risk factor modifica- per night (16), as sleep deprivation is Ratnatunga SS, et al.
Metformin in prevention
tion. A review of medications can iden- associated with increased hunger and and treatment of antipsy-
tify those that increase risk for weight consumption of high-fat and sugary chotic induced weight
gain: a systematic review
gain (Table 1) so that clinicians can snacks. and meta-analysis. BMC
Psychiatry. 2016;16:341.
consider substituting with weight-neu- [PMID: 27716110]
tral or weight loss–promoting alterna- A small RCT (n ¼ 80) showed that an 15. Wan Y, Tobias DK, Dennis
KK, et al. Association
tives. A meta-analysis of 12 RCTs (n ¼ intervention designed to increase sleep between changes in car-
bohydrate intake and
743) concluded that metformin was time to 8.5 hours/night (vs. maintaining long term weight
effective in preventing and reversing habitual sleep restriction of <6.5 hours/ changes: prospective
cohort study. BMJ.
weight gain associated with antipsychotic night) resulted in a decrease in energy 2023;382:e073939.
[PMID: 37758268]
16. Itani O, Jike M, Watanabe
N, et al. Short sleep dura-
tion and health out-
Table 1. Common Medications Associated With Weight Gain comes: a systematic
review, meta-analysis,
Medication Linked to Weight Gain Less Weight-Promoting Alternative and meta-regression.
Sleep Med. 2017;32:246-
Glucocorticoids Nonsteroidal anti-inflammatory drugs, disease- 256. [PMID: 27743803]
modifying antirheumatic drugs, biologics 17. Tasali E, Wroblewski K,
Kahn E, et al. Effect of
Diabetes medications (insulin, sulfonylureas, Metformin, glucagon-like peptide-1 receptor sleep extension on objec-
thiazolidinediones, meglitinides) agonists, sodium–glucose cotransporter-2 tively assessed energy
inhibitors, dipeptidyl peptidase-4 inhibitors intake among adults with
overweight in real-life set-
Medications for schizophrenia and bipolar Ziprasidone, lamotrigine tings: a randomized clini-
disorder (clozapine, olanzapine, quetiapine, cal trial. JAMA Intern
risperidone, lithium, valproate) Med. 2022;182:365-374.
[PMID: 35129580]
Antihypertensive medications; b-blockers Carvedilol, calcium-channel blockers, angiotensin- 18. Piercy KL, Troiano RP,
(metoprolol, propranolol) converting enzyme inhibitors, diuretics Ballard RM, et al. The
physical activity guide-
Anticonvulsants and agents for chronic pain Zonisamide, topiramate lines for Americans.
(carbamazepine, gabapentin, pregabalin) JAMA. 2018;320:2020-
Antidepressants/insomnia (e.g., paroxetine, Bupropion, fluoxetine, duloxetine, venlafaxine, 2028. [PMID: 30418471]
19. Jakicic JM, Powell KE,
mirtazapine, tricyclic antidepressants, trazodone Campbell WW, et al;
doxepin) 2018 Physical Activity
Progesterone-based contraceptives Combination estrogen–progesterone oral contra- Guidelines Advisory
Committee. Physical activ-
(medroxyprogesterone) ceptives; barrier methods, intrauterine device; ity and the prevention of
abstinence weight gain in adults: a
First-generation antihistamines (diphenhydr- Newer antihistamines (loratadine, cetirizine), systematic review. Med
Sci Sports Exerc.
amine, cyprohepatadine) nasal saline, glucocorticoid/antihistamine nasal 2019;51:1262-1269.
spray [PMID: 31095083]
Annals of Internal Medicine In the Clinic ITC3 © 2024 American College of Physicians

intake of 270 kcal per day (95% CI, television viewing, which has been
393 to 147 kcal/d) with no effect on associated with weight gain (18).
energy expenditure (17). Several organizations recommend at
least 150 minutes of moderate- to
20. Pi-Sunyer FX, Becker DM,
Guidelines recommend that patients vigorous-intensity physical activity
Bouchard C, et al. Clinical engage in regular physical activity and per week, ideally including at least 2
guidelines on the identifi-
cation, evaluation, and limit sedentary activities, particularly days of strength training (19).
treatment of overweight
and obesity in adults:
Executive summary. AmJ
Clin Nutr. 1998;68:899- Screening and Prevention... Clinicians should screen all adults for obesity at least
917.
21. WHO Consultation on annually, using BMI. Where possible, clinicians can discontinue medications that cause
Obesity 1999: Geneva, weight gain and counsel patients on behaviors to prevent obesity, including high-fiber,
Switzerland) & World
Health Organization.
low-fat diets; at least 150 minutes of moderate- to vigorous-intensity physical activity per
(2000). Obesity: week; and 7 to 9 hours of restful sleep per night.
preventing and managing
the global epidemic:
report of a WHO
consultation. World CLINICAL BOTTOM LINE
Health Organization.
2000;894:i-xii, 1-253
https://iris.who.int/
handle/10665/42330
22. Shah NS, Luncheon C,
Kandula NR, et al.
Heterogeneity in obesity
prevalence among Asian
American adults. Ann
Diagnosis
Intern Med. How do clinicians diagnose obesity? iliac crest, or at the superior border of
2022;175:1493-1500.
[PMID: 36191316] The World Health Organization and the the iliac crest. Either measurement cor-
23. WHO Expert Consultation.
National Institutes of Health have iden- relates with mortality and disease risk.
Appropriate body-mass
index for Asian tified BMI thresholds for the diagnosis Clinicians should be consistent with
populations and its
and staging of obesity (Table 2) (20, whichever protocol they use. Because
implications for policy
and intervention 21). These thresholds were developed BMI is not a perfect measure, clinicians
strategies. Lancet.
primarily in White populations and would ideally use direct measures of
2004;363:157-163.
[PMID: 14726171] have been shown to perform less well adiposity (e.g., visceral fat, body adi-
24. Khan SS, Ning H, Wilkins
JT, et al. Association of in Asian populations (22). Thus, differ- posity index, body composition) for di-
body mass index with life- ent thresholds should be used for diag- agnosis when BMI is equivocal or
time risk of cardiovascular
disease and compression nosis and staging of obesity in Asian unreliable (1, 13).
of morbidity. JAMA
Cardiol. 2018;3:280-287.
persons, although the World Health What are the strengths and
[PMID: 29490333] Organization has acknowledged im- limitations of BMI as an obesity
25. Aune D, Sen A, Prasad M,
et al. BMI and all cause
portant variations within different Asian
measure?
mortality: systematic subgroups (23). Measurement of waist
review and non-linear
circumference (WC) is useful to further BMI is an inexpensive and accessible
dose-response meta-anal-
ysis of 230 cohort studies assess cardiometabolic risk. WC can be measure that correlates strongly with
with 3.74 million deaths
among 30.3 million par- measured at the midpoint between the measures of total adiposity, as ass-
ticipants. BMJ. 2016;353:
i2156. [PMID: 27146380]
lower border of the rib cage and the essed by advanced imaging (dual energy
26. Bhaskaran K, dos-Santos-
Silva I, Leon DA, et al.
Association of BMI with
overall and cause-specific Table 2. BMI and Waist Circumference Thresholds for Elevated Disease Risk in Adults
mortality: a population-
based cohort study of 3·6 Categories Most Populations Asian Population* U.S. and Canada†
million adults in the UK.
Lancet Diabetes BMI, kg/m2
Endocrinol. 2018;6:944-
953. [PMID: 30389323] Overweight 25 23 —
27. Narayan KM, Boyle JP, Obesity 30 27.5 —
Thompson TJ, et al. Effect
of BMI on lifetime risk for Class I 30 —
diabetes in the U.S.
Diabetes Care.
Class II 35 —
2007;30:1562-1566. Class III 40 —
[PMID: 17372155]
28. Aggarwal R, Bibbins- Waist circumference, cm
Domingo K, Yeh RW, et Men ≥94 ≥85 ≥102
al. Diabetes Screening by
Race and Ethnicity in the Women ≥80 ≥74 to 80 ≥88
United States: Equivalent
Body Mass Index and Age BMI ¼ body mass index.
Thresholds. Ann Intern
Med. 2022;175:765-773.
* Refers to South Asian, Southeast Asian, and East Asian.
[PMID: 35533384] † BMI thresholds are the same as for “Most populations.”

x-ray absorptiometry, computed tomog- any given BMI; WC should be meas-
raphy, magnetic resonance imaging) (24). ured if BMI is 23 kg/m2 or greater in
The correlation is stronger in women than persons of South Asian, Southeast 29. Davidson KW, Barry MJ,
in men and weakens with age. In epide- Asian, and East Asian descent (13). Mangione CM, et al; US
Preventive Services Task
miologic studies, BMI predicts all-cause What elements of history and physical Force. Screening for
Prediabetes and Type 2
mortality (25, 26) and cardiometabolic examination are important in patients Diabetes: US Preventive
disease risk (24, 27), with increasing risk with obesity?
Services Task Force
Recommendation
above a BMI of 25 kg/m2. Much of the Statement. JAMA.
A weight-focused history (32) includes 2021;326:736-743.
supporting data for current BMI thresh- [PMID: 34427594]
questions about history of childhood
olds come from higher-income and/or obesity; adult weight trajectory; past
30. Teufel F, Seiglie JA,
Geldsetzer P, et al. Body-
non-Hispanic White populations. Cross- weight loss attempts; current dietary, mass index and diabetes
risk in 57 low-income and
sectional and longitudinal data suggest psychosocial, physical activity, and middle-income countries:
a cross-sectional study of
that BMI thresholds for risk vary among sleep patterns; and evaluation for med- nationally representative,
racial and ethnic groups (23–28). The ications and medical conditions that individual-level data in
685616 adults. Lancet.
USPSTF recommends screening for T2D can influence weight (Appendix Table 1, 2021;398:238-248.
available at Annals.org). A 24-hour recall [PMID: 34274065]
in persons of Asian descent starting at a 31. Hussain SM, Newman AB,
BMI of 23 kg/m2 (29). A recent cross-sec- of all food and beverage consumption Beilin LJ, et al.
Associations of Change in
tional study also reported increased risk can be focused on intake of total calories, Body Size With All-Cause
for T2D at a lower BMI threshold in 57 protein, fiber, sugar-sweetened bever- and Cause-Specific
Mortality Among Healthy
low-income and middle-income countries, ages, and processed and restaurant Older Adults. JAMA Netw
food. Patients should be asked about Open. 2023;6:e237482.
compared with high-income countries [PMID: 37036703]
emotional and stress eating, including 32. Kushner RF, Batsis JA,
(30). disordered eating (e.g., binge eating) Butsch WS, et al. Weight
History in Clinical
Because BMI is not a direct measure of (33). Exercise and nonexercise activity Practice: The State of the
adiposity, body weight distribution, or (e.g., step count), exercise enjoyment, Science and Future
Directions. Obesity (Silver
body composition, BMI may under- or and barriers as well as sedentary time Spring). 2020;28:9-17.
[PMID: 31858735]
overestimate risk in persons with cen- (commute, screen time) should be 33. Giel KE, Bulik CM,
assessed. Sleep quality and duration Fernandez-Aranda F, et al.
tral versus peripheral adiposity, abnor- Binge eating disorder.
should also be evaluated and include Nat Rev Dis Primers.
mal fat distribution (e.g., lipodystrophy screening for OSA with a validated 2022;8:16. [PMID:
and lipedema), or extremes of muscle screening tool (e.g., STOP-BANG). Psycho- 35301358]
34. Buso G, Depairon M,
mass (e.g., persons with sarcopenia or social influences, such as family support Tomson D, et al.
Lipedema: a call to
athletes). Furthermore, BMI does not and weight stigma, are also part of a action!. Obesity (Silver
account for loss of muscle mass that weight-focused history. Spring). 2019;27:1567-
1576. [PMID: 31544340]
occurs with aging. In studies of older 35. van der Valk ES, van den
adults, BMI in the overweight and class The key elements of the physical exam- Akker ELT, Savas M, et al.
A comprehensive diag-
I obesity categories correlates with ination include vital signs (e.g., weight, nostic approach to detect
height, resting heart rate and blood underlying causes of obe-
improved mortality, compared with sity in adults. Obes Rev.
BMI in the “normal” range (31). In sum- pressure, oxygen saturation), calcula- 2019;20:795-804.
[PMID: 30821060]
mary, BMI is a helpful screening tool tion of BMI, cardiopulmonary examina- 36. Knowler WC, Barrett-
Connor E, Fowler SE, et
but the interpretation of BMI in the tion, and evaluation of fat distribution al; Diabetes Prevention
upper normal through class I obesity (e.g., WC, neck circumference) (Appendix Program Research Group.
Reduction in the inci-
range (23 to 35 kg/m2) should be indi- Table 2, available at Annals.org). Dispro- dence of type 2 diabetes
with lifestyle intervention
vidualized to the race and ethnicity, portionate adipose tissue accumulation in or metformin. N Engl J
age, weight distribution, and, ideally, the extremities, particularly the lower Med. 2002;346:393-403.
[PMID: 11832527]
body composition of the individual extremities, with sparing of the hands 37. Lincoff AM, Brown-
Frandsen K, Colhoun HM,
patient when diagnosing obesity. and feet may be an indication of lipe- et al. Semaglutide and
dema (34). Lipedema is almost exclu- cardiovascular outcomes
in obesity without diabe-
Because BMI and WC in combination sively found in people assigned female tes. N Engl J Med.
better predict morbidity and mortality at birth, is commonly misdiagnosed as 2023;389:2221-2232.
[PMID: 37952131]
than either measure alone, guidelines obesity, and is typically associated with 38. Wiggins T, Antonowicz SS,
Markar SR. Cancer risk fol-
recommend that clinicians use WC to easy bruising and joint hypermobility. lowing bariatric surgery-
estimate adiposity-related disease risk systematic review and
meta-analysis of national
in patients with BMI below 35 kg/m2 What are secondary causes of obesity? population-based cohort
(13). Compared with White persons, Medications are a common secondary studies. Obes Surg.
2019;29:1031-1039.
Asian persons have greater adiposity at cause of obesity and should be reviewed [PMID: 30591985]

for all patients diagnosed with obesity monogenic cause; thus, routine gene-
(Table 1), as are mental health conditions tic testing is not warranted. In patients
39. Jensen MD, Ryan DH,
Apovian CM, et al;
(e.g., depression, post-traumatic stress with suspected monogenic obesity,
Obesity Society. 2013 disorder, psychological stress) and sleep free genetic testing is available (www.
AHA/ACC/TOS guideline
for the management of
insufficiency (35). Endocrine conditions uncoveringrareobesity.com).
overweight and obesity in (e.g., hypothyroidism, hypogonadism,
adults: a report of the What laboratory tests or other
American College of Cushing syndrome) and hypothalamic
Cardiology/American disorders (e.g., traumatic brain injury, evaluations should be considered in
Heart Association Task
Force on Practice craniopharyngioma) are uncommon sec- patients with obesity?
Guidelines and The ondary causes.
Obesity Society. Experts recommend that laboratory
Circulation. 2014;129(25
Suppl 2):S102-38. [PMID: Rarely, patients will have syndromic or evaluation in patients with obesity
24222017]
monogenic obesity, which usually man- include screening for T2D (fasting
40. Rubino F, Puhl RM,
Cummings DE, et al. Joint ifests with severe and early-onset dis- blood glucose, hemoglobin A1c, oral
international consensus
statement for ending ease. Syndromic obesity may manifest glucose tolerance test), dyslipidemia
stigma of obesity. Nat
Med. 2020;26:485-497. with characteristic physical features, in- (fasting lipids), and hepatic steatosis
[PMID: 32127716] tellectual disability, or developmental (liver-associated enzymes) (13). Further
41. Ryan L, Coyne R, Heary C,
et al. Weight stigma expe- delay and abnormal growth parame- testing should be guided by the review
rienced by patients with
obesity in healthcare set- ters. Prader-Willi syndrome, Bardet- of systems and physical examination.
tings: A qualitative evi- Biedl syndrome, pseudohypoparathyr- Thyroid-stimulating hormone, 24-hour
dence synthesis. Obes
Rev. 2023;24:e13606. oidism type 1, and Albright hereditary urine cortisol, or 1-mg dexamethasone
42. Dickinson JK, Bialonczyk
D, Reece J, et al. Person- osteodystrophy are recognized syn- suppression test and sex-hormone test-
first language in diabetes dromic causes of obesity. Monogenic
and obesity scientific pub- ing can be ordered if hypothyroidism,
lications. Diabet Med. causes of obesity are not associated
2023;40:e15067. [PMID: Cushing syndrome, or hypogonadism
36786059] with intellectual disability but are char-
43. Albury C, Webb H, Stokoe acterized by hyperphagia and a young or polycystic ovary syndrome, respec-
E, et al. Relationship
between clinician lan- age of obesity onset. Examples of mon- tively, is suspected. Polysomnography,
guage and the success of
ogenic obesity include mutations in abdominal (liver or gallbladder) or
behavioral weight loss
interventions: a mixed- POMC, LEPR, MC4R, and PCSK1 (35). transvaginal ultrasonography (ovaries),
methods cohort study.
Ann Intern Med. Currently, only a small percentage of echocardiography, and radiography
2023;176:1437-1447.
[PMID: 37931269] patients with suspected genetic obesity (knee, hip, chest) may also be indicated
44. Kahan SI. Practical strat- have an identifiable syndromic or depending on the clinical picture.
egies for engaging indi-
viduals with obesity in
primary care. Mayo Clin
Proc. 2018;93:351-359.
[PMID: 29502565] Diagnosis... Obesity is diagnosed by BMI thresholds, with additional use of WC and
45. Hall KD, Ayuketah A, direct measures of adiposity and body composition for improved risk stratification.
Brychta R, et al. Ultra-proc-
essed diets cause excess Clinicians should use lower BMI and WC thresholds for Asian persons. A weight-focused
calorie intake and weight history includes current eating and activity patterns, and a review of concomitant medica-
gain: an inpatient
randomized controlled tions. Physical examination and laboratory evaluation help identify secondary causes of
trial of ad libitum food obesity and weight-related medical conditions.
intake. Cell Metab.
2019;30:226. [PMID:
31269427]
46. Jabbour J, Rihawi Y,
Khamis AM, et al. Long
CLINICAL BOTTOM LINE
term weight loss diets
and obesity indices:
results of a network meta-
analysis. Front Nutr.
2022;9:821096. [PMID:
35479754]
47. Lin SH, Cienfuegos S,
Ezpeleta M, et al. Time-re-
Management
stricted eating without cal-
orie counting for weight
What is the overall approach to based approaches. Because obesity is a
loss in a racially diverse treating obesity? chronic condition without a “cure,” clini-
population: a randomized
controlled trial. Ann Intern cians should use the chronic disease
Med. 2023;176:885-895. Weight loss has been shown to prevent
[PMID: 37364268] paradigm. Thus, any treatment method
48. Liu D, Huang Y, Huang C,
and treat weight-related conditions
et al. Calorie restriction including T2D, CVD, and cancer (36– (dietary/behavioral, pharmacologic) that
with or without time-re-
38). Thus, the overall approach to obe- helps patients achieve weight loss is con-
stricted eating in weight
loss. N Engl J Med. sity treatment is to help patients achieve tinued long-term to facilitate mainte-
2022;386:1495-1504.
[PMID: 35443107] sustained weight loss using evidence- nance of weight loss. There are at least 3

comprehensive treatment guidelines on when their clinician used a “good news”
49. Astbury NM, Piernas C,
obesity (1, 13, 39). approach to describe the opportunity Hartmann-Boyce J, et al.
A systematic review and
for a weight loss program than when a meta-analysis of the effec-
High-intensity lifestyle modification is “bad news” or neutral approach was tiveness of meal replace-
the cornerstone of weight manage- ments for weight loss.
used (43). Obes Rev. 2019;20:569-
ment and can produce moderate 587. [PMID: 30675990]
weight loss, but with a high risk for 50. Karam G, Agarwal A,
A 5A’s approach to counseling about Sadeghirad B, et al.
weight regain, in part due to metabolic weight (Ask, Assess, Advise, Agree, Comparison of seven pop-
ular structured dietary
adaptations. Pharmacologic and surgi- and Assist; see also Appendix Table 3, programmes and risk of
cal intervention can be considered de- available at Annals.org) creates a struc- mortality and major cardi-
ovascular events in
pending on patients’ baseline weight, ture for setting specific targets and patients at increased car-
diovascular risk: system-
related conditions and health status, helping patients with a structured plan atic review and network
prior treatments, and individual goals and may be useful to increase patient meta-analysis. BMJ.
2023;380:e072003.
and preferences. engagement (44). Patients often have [PMID: 36990505]
51. McLay-Cooke RT, Gray AR,
How should clinicians counsel unrealistic weight loss goals. Thus, one Jones LM, et al.
Prediction equations over-
patients about their weight? of the clinician’s most important tasks is estimate the energy
Before discussing weight with patients, to help the patient set a realistic weight requirements more for
obesity-susceptible indi-
clinicians should first assess their own loss target (part of the “agree” discus- viduals. Nutrients.
2017;9:1012.
biases toward people with obesity (40). sion): 5% to 10% with lifestyle modifica- 52. Verreijen AM, Engberink
Weight stigma, defined as the social tion alone; 5% to 25% with medication MF, Memelink RG, et al.
Effect of a high protein
devaluation of a person based on body (depending on which medication); and diet and/or resistance
exercise on the preserva-
weight, is prevalent across health care 20% to 30% with metabolic and bariatric tion of fat free mass dur-
settings (40) and has been associated surgery (MBS). The clinician can empha- ing weight loss in
overweight and obese
with reduced quality of health care, size that even 5% to 10% weight loss older adults: a random-
ized controlled trial. Nutr
avoidance of health care, maladaptive confers important health benefits, while J. 2017;16:10. [PMID:
eating behaviors, and poorer physical acknowledging that larger weight losses 28166780]
53. Michalopoulou M, Ferrey
and mental health outcomes (40). have greater health benefits. AE, Harmer G, et al.
Effectiveness of motiva-
tional interviewing in
A recent review, informed by patient What are the evidence-based dietary managing overweight
perspectives, provides recommenda- strategies for weight loss and and obesity: a systematic
review and meta-analysis.
tions to reduce weight stigma (41). maintenance? Ann Intern Med.
2022;175:838-850.
Clinicians should not make assump- The language of “eating plan” rather [PMID: 35344379]
tions about patients’ lifestyles and than “diet” may help to frame for 54. Apovian CM, Aronne LJ,
Bessesen DH, et al;
should offer evidence-based treat- patients that whatever the regimen, it Endocrine Society.
Pharmacological manage-
ments without oversimplifying the com- must be sustainable over the long ment of obesity: an
plexity of weight management. Health term. Any eating plan can be successful Endocrine Society clinical
practice guideline. J Clin
care settings should accommodate for induction and long-term mainte- Endocrinol Metab.
2015;100:342-362.
patients with obesity (e.g., examination nance of weight loss if it achieves reduc- [PMID: 25590212]
tables that support higher weights, tion of total calorie intake, whether by 55. Wilding JPH, Batterham
RL, Davies M, et al; STEP
wider chairs, and larger blood pressure explicitly limiting calories through calo- 1 Study Group. Weight
cuffs). When discussing weight, guide- rie counting or through other structured
regain and cardiometa-
bolic effects after with-
lines recommend use of appropriate eating. Weight loss eating plans gener- drawal of semaglutide:
the STEP 1 trial extension.
language (1). Research shows that ally fall under 3 categories—daily calorie Diabetes Obes Metab.
patients prefer the terms weight or restriction (including calorie counting
2022;24:1553-1564.
[PMID: 35441470]
unhealthy weight over obesity or fat. and meal replacement plans), macronu- 56. Wadden TA, Foreyt JP,
Foster GD, et al. Weight
The term obesity, while technically cor-
trient restriction, and intermittent energy loss with naltrexone sr/
rect, might carry the connotation of a bupropion sr combination
restriction (Appendix Table 4, available therapy as an adjunct to
person with a more severe manifesta- behavior modification:
at Annals.org). A feature of most healthy
tion of the condition. Use of person-first the COR-BMOD trial.
language is recommended, such as eating plans is the elimination of ultra- Obesity (Silver Spring).
2011;19:110-120.
patient with obesity, rather than obese processed foods (45). Effectiveness for [PMID: 20559296]
57. Wilding JPH, Batterham
patient (42). weight loss is overall similar provided RL, Calanna S, et al; STEP
that the eating plan is sustained (46). 1 Study Group. Once-
weekly semaglutide in
A secondary analysis of a weight loss Recently, small RCTs suggest that time- adults with overweight or
intervention study found that patients restricted eating produces comparable obesity. N Engl J Med.
2021;384:989-1002.
were more likely to join the program weight loss at 12 months compared with [PMID: 33567185]

daily caloric restriction (47, 48). Meal to 3 kg of additional weight loss. How-
replacements are also effective, pro- ever, because of the difficulty of creat-
vided they are sustained (49). Although ing a 500-kcal deficit through exercise
the best eating plan is one that an indi- alone, exercise is often viewed as an
58. Wadden TA, Bailey TS,
Billings LK, et al; STEP 3 vidual patient can adhere to over time, important tool to maintain weight loss.
Investigators. Effect of evidence for health benefits beyond Current exercise guidelines for overall
subcutaneous semaglu-
tide vs placebo as an weight loss alone varies depen- health and to maintain weight recom-
adjunct to intensive be-
havioral therapy on body
ding on the eating plan. Most guidelines mend at least 150 minutes per week of
weight in adults with endorse diets rich in vegetables and moderate- to high-intensity exercise,
overweight or obesity:
The STEP 3 randomized fruits and including high-quality lean pro- including 2 days per week of muscle
clinical trial. JAMA.
2021;325:1403-1413.
tein sources (45). For example, the DASH strengthening activity. Many individuals
[PMID: 33625476] eating style may have additional benefits will need higher levels of physical activ-
59. Shi Q, Wang Y, Hao Q, et
for treatment of hypertension; a low-car-
al. Pharmacotherapy for ity (≥300 minutes per week) to maintain
adults with overweight bohydrate or very-low-carbohydrate eat-
and obesity: a systematic weight loss (18). A combination of
review and network meta- ing plan may have additional benefits for
higher protein intake (1 to 1.4 g/kg of
analysis of randomised prevention and treatment of T2D; and a
controlled trials. Lancet.
2022;399:259-269. Mediterranean-style eating plan may body weight) and resistance training
[PMID: 34895470]
improve metabolic-associated fatty liver may be helpful for maintenance of lost
60. Torgerson JS, Hauptman
J, Boldrin MN, et al. disease and reduce risk for CVD (50). weight (52). Clinicians can help patients
XENical in the prevention
of diabetes in obese sub-
formulate a realistic exercise plan based
jects (XENDOS) study: a A recent network meta-analysis of RCTs on time constraints as well as access to
randomized study of orli-
stat as an adjunct to life-
(40 trials; n ¼ 35 548) (50) reported that exercise equipment and safe spaces.
style changes for the a Mediterranean eating plan reduced
prevention of type 2 dia-
overall (odds ratio [OR], 0.72 [95% CI, What is the role of behavioral
betes in obese patients.
Diabetes Care. 0.56 to 0.92]) and cardiovascular (OR, counseling in weight management?
2004;27:155-161. [PMID:
14693982] 0.55 [CI, 0.39 to 0.78]) mortality, and The 2013 guidelines from the American
61. Apovian CM, Aronne L,
Rubino D, et al; COR-II that a low-fat eating plan reduced over- Heart Association, the American College
Study Group. A random- all mortality (OR, 0.84 [CI, 0.74 to 0.95]) of Cardiology, and The Obesity Society
ized, phase 3 trial of nal-
trexone SR/bupropion SR and nonfatal myocardial infarction (OR, (AHA/ACC/TOS) on treatment of obesity
on weight and obesity-
related risk factors (COR- 0.77 [CI, 0.61 to 0.96]). (39), as well as guidelines from the
II). Obesity (Silver Spring). USPSTF (11), recommend intensive life-
2013;21:935-943. [PMID: Regardless of eating plan, the initial goal style intervention (ILI) to support diet and
23408728]
62. Simon JA, Duncan C, of dietary modification is to help the physical activity changes during the
Carmody TP, et al.
Bupropion for smoking
patient establish an energy deficit of 500 induction of weight loss. High-intensity is
cessation: a randomized to 1000 kcal per day. Online equations defined by AHA/ACC/TOS as ≥14 ses-
trial. Arch Intern Med.
(Harris-Benedict, Mifflin St. Jeor) can esti-
2004;164:1797-1803. sions within the initial 6 months (39). The
[PMID: 15364675] mate a patient’s calorie target for weight
63. Lewis KH, Fischer H, Ard guidelines also recommend at least
J, et al. Safety and effec- loss but may overestimate calorie needs
tiveness of longer-term (51). The clinician should keep in mind monthly contact for maintenance of
phentermine use: clinical
outcomes from an elec- that underestimation of calorie intake is weight loss and the use of trained inter-
tronic health record
common. The National Institutes of Health ventionists (registered dietitians, behav-
cohort. Obesity (Silver
Spring). 2019;27:591- body weight planner is a helpful resource ioral psychologists, or persons with
602. [PMID: 30900410]
64. Gadde KM, Allison DB, that accounts for metabolic adaptations to specific training in weight management).
Ryan DH, et al. Effects of weight loss and can recommend lifestyle High-intensity weight loss counseling
low-dose, controlled-
release, phentermine plus changes needed to achieve and maintain
topiramate combination has been shown to induce a weight
a particular weight (www.niddk.nih.gov/
on weight and associated loss of 5% to 10% of starting body
comorbidities in over- bwp).
weight and obese adults weight at 6 to 12 months, enough to
(CONQUER): a rando-
mised, placebo-controlled,
What is the role of exercise in weight show clinically important improve-
phase 3 trial. Lancet. management? ments in CVD risk factors (blood glu-
2011;377:1341-1352.
[PMID: 21481449] Exercise has many health benefits, cose level, blood pressure, lipids). The
65. Pi-Sunyer X, Astrup A,
Fujioka K, et al; SCALE including reduction of blood pressure, most common ILI is cognitive behavioral
Obesity and Prediabetes improvement in mood, strengthening therapy, a group of behavioral techni-
NN8022-1839 Study
Group. A randomized, of bone density, reduction of CVD risk, ques that include self-monitoring, goal
controlled trial of 3.0 mg
of liraglutide in weight and preservation of lean mass during setting, stimulus control, problem solv-
management. N Engl J
Med. 2015;373:11-22.
weight loss. Increased exercise during ing, social support, (nonfood) rewards,
[PMID: 26132939] the induction of weight loss can add 1 and relapse prevention. Motivational

interviewing has been shown to have termine is recommended by some guide-
66. Bezin J, Gouverneur A,
only modest benefit as a primary lines as an option for long-term use (54) Penichon M, et al. GLP-1
receptor agonists and the
method for treatment of obesity (53). under specific conditions, primarily for its risk of thyroid cancer.
Self-monitoring is consistently associ- lower cost. However, long-term evidence Diabetes Care.
2023;46:384-390.
ated with better weight loss. for benefit and safety is limited. Although [PMID: 36356111]
67. Alves C, Batel-Marques F,
lifestyle modification is necessary to bene- Macedo AF. A meta-analy-
The Diabetes Prevention Program was
fit from AOM, the benefits of concurrent sis of serious adverse
a landmark randomized trial of ILI tar- events reported with exe-
participation in an ILI program might natide and liraglutide:
geting 7% weight loss versus usual care acute pancreatitis and
depend on which AOM is being used. cancer. Diabetes Res Clin
that showed a 58% reduced incidence Pract. 2012;98:271-284.
of T2D at 3 years (36), with health bene- An RCT showed 5.1% weight loss in [PMID: 23010561]
68. Kosiborod MN,
fits persisting for at least 15 years after persons randomly assigned to receive Abildstrøm SZ, Borlaug
BA, et al; STEP-HFpEF Trial
the original intervention. bupropion–naltrexone alone versus Committees and
The Diabetes Prevention Program is 9.3% weight loss in persons receiving Investigators.
Semaglutide in patients
now offered in community recreation medication plus ILI (56). In contrast, in 2 with heart failure with
preserved ejection fraction
spaces, including many YMCAs, and is separate RCTs of semaglutide, patients and obesity. N Engl J
Med. 2023;389:1069-
available to Medicare beneficiaries at who received medication alone lost 1084. [PMID: 37622681]
risk for T2D. The Centers for Medicare 14.9% of starting weight (57), whereas 69. Jastreboff AM, Aronne LJ,
Ahmad NN, et al;
& Medicaid Services also reimburses a those who received semaglutide plus SURMOUNT-1
Investigators. Tirzepatide
series of brief 15-minute counseling ILI lost 16% of starting weight (58). once weekly for the treat-
ment of obesity. N Engl J
visits for treatment of obesity for Medi- What medications are FDA approved Med. 2022;387:205-216.
care beneficiaries with a BMI ≥30 kg/m2, for the long-term treatment of
[PMID: 35658024]
70. Jastreboff AM, Kushner
although uptake of this service has been obesity? RF. New frontiers in obe-
sity treatment: GLP-1 and
low. The 6 medications approved by the nascent nutrient-stimu-
lated hormone-based
When should antiobesity medication FDA for long-term treatment of obesity therapeutics. Annu Rev
Med. 2023;74:125-139.
be considered? are presented in order from least to [PMID: 36706749]
Antiobesity medication (AOM) can be most effective as estimated in a 2022 71. Mechanick JI, Apovian C,
Brethauer S, et al. Clinical
considered for patients with a BMI of network meta-analysis (59). Their effi- practice guidelines for the
perioperative nutrition,
30 kg/m2 (27.5 kg/m2 for Asian persons) cacy, dosing, and concomitant cardiometabolic, and nonsurgi-
or with a BMI of 27 kg/m2 (25 kg/m2 for metabolic benefits and other consi- cal support of patients
undergoing bariatric pro-
Asian persons) and a major weight- derations are listed in Table 3. These cedures - 2019 update:
cosponsored by American
related condition (e.g., T2D, hyperten- AOMs have been extensively tested for Association of Clinical
Endocrinologists/
sion, or OSA) (1, 13, 39). AOMs are a safety and efficacy and are undergoing American College of
tool to help patients reduce energy postmarketing surveillance. All AOMs Endocrinology, The
Obesity Society, American
intake but they do not increase energy are contraindicated during pregnancy Society for Metabolic &
Bariatric Surgery, Obesity
expenditure. Patients should under- and breastfeeding. Medicine Association, and
stand that AOMs are used on a long- Orlistat (Alli, Xenical)
American Society of
Anesthesiologists. Surg
term basis for both induction and main- Orlistat, approved for long-term treat-
Obes Relat Dis.
2020;16:175-247.
tenance of weight loss. RCTs suggest ment of obesity since 1999, is the least [PMID: 31917200]
that AOM-associated weight loss is 72. Eisenberg D, Shikora SA,
prescribed of all AOMs, due to modest Aarts E, et al. 2022
accompanied by concomitant improve- American Society of
efficacy and frequent side effects. The Metabolic and Bariatric
ments in cardiometabolic risk factors Surgery (ASMBS) and
estimated placebo-subtracted weight International Federation
(54). Weight regain is expected if an
loss is 3.16% (CI, 2.78% to 3.53%) in 1 for the Surgery of Obesity
AOM is discontinued (55). and Metabolic Disorders
systematic review (59), producing an (IFSO) indications for met-
abolic and bariatric sur-
The 6 AOMs currently approved by the estimated total weight loss of 5% to 6% gery. Obes Surg.
U.S. Food and Drug Administration (FDA) of initial body weight (60). It is available 2023;33:3-14. [PMID:
36336720]
for long-term use (orlistat, phentermine- in both over-the-counter and prescrip- 73. American Diabetes
Association Professional
topiramate ER, bupropion–naltrexone ER, tion doses. Orlistat inhibits intestinal Practice Committee. 8.
liraglutide, semaglutide, tirzepatide) are lipase, blocking absorption of approxi- Obesity and Weight
Management for the
summarized in Table 3. In addition, 4 mately 25% to 30% of ingested dietary Prevention and Treatment
of Type 2 Diabetes:
medications are approved by the FDA for fat. Common gastrointestinal side effects Standards of Care in
short-term use, with phentermine being include oily stools, fecal discharge, and Diabetes-2024. Diabetes
Care. 2024;47(Suppl 1):
the most commonly prescribed. Phen- flatus. Patients are advised to take a S145-S57.

Table 3. Antiobesity Medications (AOM)
Medication Mechanism Dose Monthly cost, $* Weight Loss Demonstrated Other Notes
Efficacy† Benefits
(Reference)
FDA approved for long-term use
Orlistat Inhibits intestinal 60 mg TID 45–55 (OTC); 280 Modest; 5–6% Decreased CVD Prescribe with
lipase (OTC);120 mg (prescription) loss of initial risk factors; low- MVI to avoid
TID weight (60) ering of LDL deficiency (vita-
(prescription) independent min D, E, A, K);
of weight loss caution in
patients with
malabsorption,
nephrolithiasis,
or on meds
requiring reli-
able absorp-
tion, e.g.,
levothyroxine,
warfarin
Bupropion– Inhibits neuronal Start 90/8 mg/d, 100–515 Modest; 6% Decreased CVD Contraindicated
naltrexone uptake of nor- increase to weight loss of risk factors; may if seizure disor-
epinephrine 360/32 mg/d initial weight have additional der, end-stage
and dopamine (61) benefit in nico- renal disease,
(bupropion); tine depend- current eating
inhibits nega- ence and disorder, opiate
tive feedback alcohol misuse use, or high-risk
loop on bupro- alcohol use is
pion present.
(naltrexone)
Phentermine– Sympathomi- Start 3.75/23 mg/d, 100–160 Moderate to Decreased CVD Teratogenic; con-
topiramate metic (phenter- increase to high; 8–10% risk factors; top- traindicated in
ER mine); CNS 7.5/46 mg/d or loss of initial iramate may nephrolithiasis,
activity and 15/92 mg/d weight (64) have additional uncontrolled
dysgeusia benefit for hypertension,
(topiramate) migraine tachycardia,
concurrent stim-
ulant use, seri-
ous CVD and
closed-angle
glaucoma.
Liraglutide Glucagon like Start 0.6 mg/d, 1350–1400 High; 8% loss Decreased CVD GI side effects,
3.0 mg peptide-1 increase to of initial weight risk factors; pancreatitis;
receptor 3.0 mg/d (65) improves glyce- contraindicated
agonist mic control in- with history of
dependent of medullary thy-
weight loss roid cancer or
pancreatitis, fam-
ily history of
MEN 2; caution
in chronic kidney
disease, GI motil-
ity disorders.
Semaglutide Glucagon like Start 0.25 mg/wk, 1350–1400 High; 15% loss Decreased CVD Similar to
2.4 mg peptide-1 increase to of initial weight risk factors; liraglutide.
receptor 2.4 mg/wk (57, 58) improves glyce-
agonist mic control in-
dependent of
weight loss;
improved out-
comes in
HFpEF and in
secondary pre-
vention of CVD
Tirzepatide Dual glucacon- Start 2.5 mg/wk, 1000 High; 20–22% Decreased CVD Similar to
like peptide-1 increase to loss of initial risk factors; liraglutide.
and gastric in- 10–15 mg/wk weight (69) improves glyce-
hibitory peptide mic control in-
agonst dependent of
weight loss;
Continued on following page

Table 3—Continued
Medication Mechanism Dose Monthly cost, $* Weight Loss Demonstrated Other Notes
Efficacy† Benefits
(Reference)
FDA-approved for short-term use only (long-term use is off-label)‡
Phentermine Sympathomimetic Start 8 mg/d, 15–25 6–8% of initial Decreased CVD Contraindicated
increase to weight (short- risk factors in in uncontrolled
37.5 mg/d term data) short-term hypertension,
tachycardia,
concurrent stim-
ulant use, CVD
and closed
angle glau-
coma; poor
long-term
tolerability
All AOM are contraindicated in pregnancy or breastfeeding. CVD ¼ cardiovascular disease; ER ¼ extended-release; FDA ¼ U.S. Food and
Drug Administration; GI ¼ gastrointestinal; HfpEF ¼ heart failure with preserved ejection fraction; LDL ¼ low-density lipoprotein; MEN 2 ¼
multiple endocrine neoplasia type 2; MVI ¼ multivitamin; OTC ¼ over-the-counter; REMS ¼ risk evaluation and mitigation strategy.
* From www.goodrx.com. In the case of phentermine–topiramate and bupropion–naltrexone, lowest cash price for each medicine is
from one specific mail order pharmacy.
† Reflect efficacy when drug is combined with lifestyle intervention (see text for source).
‡ Other medications approved for short-term use include diethylpropion, phendimetrazine, and benzphetamine.
multivitamin at least 2 hours apart eating disorder, any current opiate use, or
from any dose of orlistat to minimize high-risk alcohol use (i.e., binge drinking). 74. Bramante C, Wise E,
Chaudhry Z. Care of the
risk for fat-soluble vitamin deficiency patient after metabolic and
Phentermine–topiramate ER (Qsymia) bariatric surgery. Ann Intern
(vitamins A, D, E, and K). Orlistat should Med. 2022;175:ITC65-
ITC80. [PMID: 35533387]
be used with caution in patients with Phentermine–topiramate ER is a fixed- 75. Mulla CM, Middelbeek
RJW, Patti ME.
malabsorption or nephrolithiasis and dose combination of 2 medications Mechanisms of weight
those receiving L-thyroxine, warfarin, that both have the effect of reducing loss and improved metab-
olism following bariatric
immunosuppressant, or other medica- appetite. Topiramate leads to modest surgery. Ann N Y Acad
Sci. 2018;1411:53-64.
tions that require reliable absorption. weight loss when used for treatment of [PMID: 28868615]
76. Arterburn D, Wellman R,
Bupropion–naltrexone ER (Contrave) seizure disorders or for prevention of Emiliano A, et al;
PCORnet Bariatric Study
migraines. Phentermine is a central Collaborative. compara-
Bupropion–naltrexone ER is a combina- tive effectiveness and
nervous system stimulant that has been safety of bariatric proce-
tion agent in which both components are dures for weight loss: A
FDA approved since 1959 for short-term PCORnet cohort study.
already approved for other indications Ann Intern Med.
use (generally considered ≤6 months). 2018;169:741-750.
and have a good safety profile. It pro- [PMID: 30383139]
Some clinicians prescribe phentermine 77. Wölnerhanssen BK, Peterli R,
duces an average placebo-subtracted Hurme S, et al. Laparoscopic
monotherapy long-term off-label, pro- roux-en-Y gastric bypass ver-
weight loss of 4.11% (CI, 3.02% to 5.19%) sus laparoscopic sleeve gas-
vided that the patient is able to lose trectomy: 5-year outcomes of
(59) and total weight loss of approximately merged data from two
weight and maintain weight loss while randomized clinical trials
6% of starting weight (61). Bupropion (SLEEVEPASS and SM-BOSS).
taking the medication, although data Br J Surg. 2021;108:49-57.
leads to modest weight loss when used [PMID: 33640917]
suggest the long-term tolerability is low 78. Syn NL, Cummings DE,
for treatment of depression and helps
(63). Phentermine–topiramate ER is gen- Wang LZ, et al.
Association of metabolic-
attenuate weight gain when used for erally better tolerated than either compo- bariatric surgery with
long-term survival in
smoking cessation (62). Naltrexone is nent alone, in part because of the lower adults with and without
used for treating alcohol or opiate diabetes: a one-stage
phentermine dose and the extended- meta-analysis of matched
addiction. Naltrexone, through inhibi- release formulation. Contraindications to
cohort and prospective
controlled studies with
tion of an autoregulatory loop in the phentermine–topiramate include uncon-
174 772 participants.
Lancet. 2021;397:1830-
hypothalamus, enhances the appetite trolled blood pressure or tachycardia, 1841. [PMID: 33965067]
79. Doumouras AG, Hong D,
control effect of bupropion. Common closed-angle glaucoma, concurrent stim- Lee Y, et al. Association
between bariatric surgery
side effects include nausea, dizziness, ulant use or history of stimulant misuse, and all-cause mortality: a
population-based
changes in bowel habits, and insomnia. serious CVD, and nephrolithasis. Com- matched cohort study in a
Universal Health Care
Contraindications include seizure disor- mon side effects include paresthesia, System. Ann Intern Med.
2020;173:694-703.
ders, end-stage renal disease, current change in taste, dry mouth, constipation, [PMID: 32805135]

and insomnia. Less common side aindications include a history of receptor agonist approved for
effects include nephrolithiasis medullary thyroid carcinoma, a the treatment of obesity. It is
and cognitive dysfunction. family history of multiple endocrine also FDA approved for treat-
Clinicians who prescribe phen- neoplasia type 2, and pancreatitis. ment of T2D at the same doses.
termine–topiramate ER should The mechanism of action over-
Caution should be used in patients
laps with that of liraglutide and
be aware of the known terato- with chronic kidney disease and semaglutide; the addition of
genicity of topiramate and ensure those with gastrointestinal motility gastric inhibitory peptide ago-
that women of reproductive age disorders. Evidence has been con- nism has additional benefit for
have highly reliable birth control flicting about whether GLP-1 RAs appetite control. Common side
(or are sexually abstinent). are associated with medullary effects include nausea, diarrhea,
Randomized trials show that pla- thyroid cancer, with 1 case–con- constipation, dyspepsia, and vo-
cebo-subtracted weight loss is trol study reporting a small miting. Contraindications are the
7.97% (CI, 6.66% to 9.28%) (59) same as for liraglutide and se-
increased risk (number needed
with a total weight loss 8% to maglutide.
to harm, 3000) (66), and a meta-
10% of starting body weight (64). analysis of 25 studies (22 RCTs) In the SURMOUNT-1, participants
Average weight loss associated reporting no increased risk (67). randomly assigned to receive 10
with phentermine (30 to or 15 mg of tirzepatide lost
37.5 mg/d) when prescribed alone Although all FDA-approved long- 19.5% and 20.9% of starting
is approximately 6% of body term AOMs have been shown weight, respectively, compared
to reduce CVD risk factors via with 3.1% for those assigned to
weight. There have been no long-
weight loss in RCTs, 2 recent receive placebo (69).
term (≥1 year) RCTs documenting
studies demonstrate that sema- How should clinicians select
safety and efficacy of phenter-
glutide also improved CVD out- which AOM to prescribe?
mine alone.
comes. The choice of agent should con-
Liraglutide 3.0 mg (Saxenda) and sider a combination of efficacy,
semaglutide 2.4 mg (Wegovy) In the STEP-HFpEF Trial, an RCT
of 529 patients with heart failure cost, improvement in weight-
Liraglutide and semaglutide are related conditions, and effect on
glucagon-like peptide-1 recep- and preserved ejection fraction,
participants assigned to receive other comorbid conditions from
tor agonist (GLP-1 RA) medica- the medication’s non–weight loss
2.4 mg of semaglutide had sig-
tions that slow gastric emptying benefits. Ideally, a highly effective
nificantly greater weight loss
and reduce appetite through (13.3% vs. 2.6%), improvement in agent (semaglutide or tirzepatide)
effects in the central nervous sys- a composite heart failure score, would be selected for patients
tem. Both are approved for the greater improvement in 6-minute requiring weight losses of 15% or
treatment of obesity and for treat- walk time, and lower incidence of more, but lack of insurance cover-
ment of T2D (at lower doses). a composite end point that in- age and cost often dictate that less
Liraglutide 3.0 mg is given as a cluded hospitalization for heart expensive agents are selected first.
daily subcutaneous injection and failure when compared with pla- There are very few head-to-head
cebo (68). trials of AOMs; thus, decisions
produces an average placebo-
based on efficacy are mostly
subtracted weight loss with lira- In the SELECT Trial (n ¼ 17 604), based on data from RCTs of the
glutide of 4.68% (CI, 4.66% to patients with established CVD ran- individual medications.
5.30%) (59) and total weight loss domly assigned to receive sema-
of approximately 8% (65). Sema- glutide 2.4 mg achieved signi- There are special challenges
glutide 2.4 mg is given as a ficantly greater weight loss (9.4% with insurance coverage for
weekly subcutaneous injection vs. 0.9%) and had a lower inci- AOMs. Many insurance plans
dence of a combined cardiovascu- exclude coverage for AOMs, al-
and produces an average pla-
lar end point (death or nonfatal though as of April 2024, Medi-
cebo-subtracted weight loss of
heart attack/stroke) of 6.5%, versus care will cover semaglutide for
11.41% (CI, 10.27% to 12.54%) those with established cardio-
(59) with total weight loss of 15% 8.0% in the placebo group (37).
vascular disease. Some insuran-
(57). Common side effects include Tirzepatide (Zepbound) ces require that patients participate
nausea, vomiting, constipation or Tirzepatide is the first dual (GLP- in a program of lifestyle modifica-
diarrhea, and dyspepsia. Contr- 1 and gastric inhibitory peptide) tion for AOM to be covered. The

components of phentermine–topir- lower BMI thresholds: all patients Appendix Figure, available at
amate and bupropion–naltrexone with BMI ≥35 kg/m2, and patients Annals.org). Other procedures,
are available in generic form al- with BMI ≥30 kg/m2 and meta- including the gastric band and
though not always in the same bolic disease (e.g., T2D) (72). How- biliopancreatic diversion with
doses. Liraglutide is expected to ever, these guidelines have not yet duodenal switch, are now rarely
be available in generic form in been adopted by insurance payers offered because of inferior efficacy
2024, which may lower the cost. in the U.S. The American Diabetes and high risk for complication,
Association recommends consider- respectively.
When should clinicians ing MBS in people with difficult-
consider discontinuing or to-control diabetes with a BMI In sleeve gastrectomy, approxi-
switching AOM for lack of ≥30.0 kg/m2 (≥27.5 kg/m2 in mately 75% of the stomach is
effectiveness? Asian American persons) who are resected, and the remainder of
With oral medications, the gen- otherwise good candidates for the intestinal tract remains intact.
eral rule is to discontinue or surgery (73). Weight loss is achieved by a
change medication if the patient combination of food restriction
does not lose at least 5% of body Clinical guidelines recommend and a reduction in ghrelin, the
weight after the first 12 weeks but do not require that patients gastric hormone that signals hun-
(with phentermine–topiramate, make structured attempts at ger to the brain (75). In RYGB,
guidance is to increase from weight loss with ILI programs the stomach is transected proxi-
7.5/46 mg to 15/92 mg if the and/or AOM before pursuing mally, and the mid-jejunum also
patient has not lost at least 3% MBS (1). The standard of care in is transected and connected to
by week 12). With liraglutide, patients considering MBS is that the proximal stomach pouch.
discontinuation is recommended they undergo preoperative nutri- The remaining distal stomach,
if the patient does not lose at tion education, a medical preop- the entire duodenum, and the
least 4% by week 16. No formal erative evaluation, and a psycho- proximal jejunum are anasto-
guidance exists on discontinua- logical evaluation (71). Patients mosed to form a “blind limb,”
tion of semaglutide or tirzepatide should be well informed of the which ends proximally in the
based on weight loss achieved. risks and benefits of MBS, includ- closed-off stomach and is no lon-
Dose escalation with semaglu- ing the possibility of long-term ger part of the active digestive
tide and tirzepatide requires at nutritional, metabolic, and psy- process. RYGB restricts food
least 4 months; thus, decisions chological adverse outcomes intake and results in partial mal-
about efficacy typically are made and weight regain (74) and the absorption. RYGB also leads to
after 4 to 6 months of treatment. need for lifetime vitamin supple- increases in GLP-1 and to
mentation and follow-up to mon- changes in bile acids and gut
What are some future therapies itor weight and nutritional status.
under investigation? microbiota, all of which are
A review of the follow-up and believed to contribute to weight
Additional medications are in clin- complications after MBS are loss (75). Several studies have
ical trials and will likely expand described in detail in a separate compared the effectiveness of
the available repertoire (70). The publication of In the Clinic (74). sleeve gastrectomy versus RYGB.
most promising of these are so-
called NUSH (nutrient stimulated MBS is ideally performed in a cen- In the PCORNet Cohort Study (n ¼
hormone-based) therapeutics, inter of excellence that participates 65 093), weight losses at 1 year
cluding amylin agonists; new oral in the Metabolic and Bariatric with RYGB and sleeve gastrectomy
GLP-1 RAs; and dual- and triple- Surgery Accreditation and Quality were 31.2% and 25.2%, respec-
receptor agonists. Improvement Program. Bariatric tively. Weight losses after 5 years
centers of excellence typically were 25.5% and 18.8%, respec-
Metabolic and bariatric surgery have multidisciplinary teams and
Which patients should be
tively (76). A meta-analysis combin-
higher surgical volume, which is ing 2 randomized trials of sleeve
considered for MBS?
thought to improve safety and versus bypass, SLEEVEPASS and SM-
MBS is indicated for patients
long-term surgical outcomes (74). BOSS, reported that total weight loss
with a BMI ≥40 kg/m2, or those
with a BMI ≥35 kg/m2 and at What are the comparative after 5 years was 27.8% for RYGB
least 1 serious weight-related effectiveness and risks of different and 23.9% for sleeve gastrectomy
comorbid condition, such as T2D, MBS procedures? (P<0.001). Improvement in hyper-
OSA, or osteoarthritis of the hip The most commonly performed tension was greater with RYGB, but
or knee (71). Recently, the Ame- MBS procedures in the U.S. are there were no differences in diabetes
rican Society for Metabolic and the sleeve gastrectomy and remission, changes in OSA, or
Bariatric Surgery recommended roux-en-Y gastric bypass (see health-related quality of life (76, 77).

Several large epidemiologic stud- 27 358), patients who had bariatric sleeve gastrectomy, endoscopic
ies have suggested a mortality surgery had a lower mortality rate revision (for RYGB), or place-
benefit from MBS. of 1.4%, compared with 2.5% for ment of a gastric balloon. The
control participants, after a median balloon must be removed after
In a meta-analysis that included 17
follow-up period of 4.9 years (79). 6 months. These procedures are
observational studies with 174 772
participants, surgery was associ- What is the role of endoscopic generally not covered by insur-
ated with a median increase in treatment of obesity? ance because the evidence for
life expectancy of 6.1 years (78). Primary endoscopic treatment long-term efficacy and benefit is
In a matched cohort study (n ¼ of obesity includes endoscopic limited.
Management... Clinicians should reduce weight stigma when caring for patients, including use of person-first
language and patient-preferred terms. Patients are encouraged to follow an effective dietary pattern that they will
be able to maintain long-term, including daily caloric restriction, macronutrient restriction, or intermittent energy
restriction. Regular exercise is encouraged for improved overall health and weight loss maintenance. Intensive
lifestyle interventions are recommended for all patients with overweight or obesity and lead to 5% to 10% weight
loss. AOM produces 5% to 25% weight loss (depending on the medication) and should be considered and must
be continued long-term to maintain weight loss. MBS leads to 25% to 30% weight loss and requires long-term
follow-up with close monitoring of nutritional status. Treatment should consider desired weight loss, medical his-
tory, and patient preferences.
CLINICAL BOTTOM LINE
Practice Improvement
What do professional Obesity Medicine Association, and org) has offered certification in
organizations recommend an older guideline from the AHA/ obesity medicine. Board certifica-
regarding the care of patients ACC/TOS. All of these guidelines tion can be obtained through
with obesity? recommend high-intensity lifestyle continuing medical education or
The USPSTF has published rec- interventions and consideration of through a fellowship pathway.
ommendations on evaluation AOMs and MBS. The American There are currently 27 fellowship
and treatment of obesity (www. Society for Metabolic and Bariatric programs in obesity medicine ac-
uspreventiveservicestaskforce.org/ Surgery also has updated guide- ross the country (www.omfellowship.
uspstf/recommendation/obesity- lines for MBS that recommend sur- org), although obesity medicine
in-adults-interventions), as have gery at lower BMI cutoffs (see is not yet formally recognized as
several major professional soci- earlier discussion). a subspecialty by the American
eties including the American Gas- Board of Medical Specialties.
troenterological Association, the How can clinicians get The American College of Physi-
American Diabetes Association, additional training on the cians has freely available resour-
the American Association of management of obesity? ces including online educational
Clinical Endocrinologists/American Since 2012, the American Board materials (www.acponline.org/
College of Endocrinology, the of Obesity Medicine (www.abom. obesity-care).

Patient Information
In the Clinic https://medlineplus.gov/obesity.html
Tool Kit
Information on obesity for patients from the
National Institutes of Health MedlinePlus
in English and other languages.
http://health.gov/our-work/nutrition-
physical-activity/dietary-guidelines
Obesity 2020–2025 Dietary Guidelines for
Americans from the U.S. Department of
Agriculture.
www.niddk.nih.gov/health-information/
weight-management
Health information for patients on weight
management from the National Institute of
Diabetes and Digestive and Kidney Diseases.
www.acponline.org/clinical-information/
clinical-resources-products/obesity-
management-learning-hub#patient-
education
Patient education materials on obesity manage-
ment from the American College of Physicians.
https://uconnruddcenter.org/research/
weight-bias-stigma/
Resources on weight bias and stigma for
In the Clinic
patients from the Rudd Center at the
University of Connecticut.
Information for Health Professionals
https://diabetesjournals.org/care/article/
47/Supplement_1/S145/153942/8-Obesity-
and-Weight-Management-for-the-
Prevention
American Diabetes Association's 2024
Standards of Care in Diabetes on Obesity
and Weight Management for the
Prevention and Treatment of Type 2
Diabetes.
https://gastro.org/practice-resources/
practice-tools/obesity-practice-guide/
Obesity practice resources for health profes-
sionals from the American
Gastroenterological Association.
www.acponline.org/clinical-information/
clinical-resources-products/obesity-
management-learning-hub
ACP developed obesity management curric-
ulum that addresses multiple aspects of
patient engagement and care to assure a
team-based approach to managing obesity.

In the Clinic
WHAT YOU SHOULD KNOW Annals of Internal Medicine
ABOUT OBESITY
What Is Obesity? week). Include muscle-strengthening activities at least
2 days per week.
Obesity is a chronic medical condition where you • Finding a support network. There are many
have more body fat than is healthy. Too much online and in-person weight loss groups. There
body fat can cause serious health problems, are also free smartphone apps for weight loss.
including diabetes, heart disease, and sleep • Making sure to get more than 6 hours of sleep
apnea, and can even shorten your life. Hormonal each night (ideally 8 hours).
changes occur when one loses weight, making it • For some, your doctor may recommend a weight
harder to lose additional weight and keep it off. loss medication or weight loss surgery.
Many factors play a role in how much you weigh,
including your family history; foods you eat; how What Eating Plan Is Best for Long-
active you are; your sleep habits; taking certain
medicines; and other health problems. Term Weight Loss?
How Is It Diagnosed? Research shows that there is not much difference
in long-term weight loss among different eating
Your doctor or other health care clinician will ask plans, although some eating plans may lead to
you about your health and weight history This health benefits in addition to weight loss. The
may include questions about your eating habits, most important thing is finding a plan that is easy
activity level, previous weight loss attempts and for you to stick with in the long-term. Many pop-
how your weight has changed, sleep patterns, ular diets are similar in recommending lean pro-
medications, and causes of stress in your life.
teins, vegetables and fruits, and some healthy
Your provider will measure your weight and height
to calculate your body mass index (BMI). In gen- fats (nuts, avocados) while limiting refined carbo-
eral, if your BMI is between 25 and 29.9, you will hydrates (sugar, most breads, white rice, and
be diagnosed as having overweight; if it is greater most snack foods). Alternative eating plans such
than 30, you will be diagnosed as having obesity. as meal-replacement diets and intermittent fast-
Your doctor may also measure your waist circum- ing also may help with weight loss.
ference. Persons of Asian descent may be diag-
nosed with overweight and obesity at lower levels Will I Need Medicine or Surgery to
of BMI because of differences in weight distribution Lose Weight?
and weight-related health risk.
You will have a physical examination and simple If you are not able to lose enough weight through
blood tests may be done. diet and exercise alone, your doctor may talk to
Patient Information
you about medication options. For long-term
How Is It Treated? health, these medications will need to be contin-
Your doctor will talk to you about how you can lose ued over the long term as weight will usually be
weight and review your medications to see regained if you stop the medication. If you have
whether they might be causing weight gain. severe obesity and have other health problems
They may also rule out other treatable causes of because of it, surgery may be an option. Both
obesity. medicine and surgery lower the amount of food
Even a small amount of weight loss (5%–10%) can your body can take in and help you eat less.
improve your health and lower your risk for com-
plications, such as diabetes. Together, you and Questions for My Doctor
your doctor will agree on a weight loss goal and a • How much weight should I lose?
plan that is right for you. Some strategies include: • How many calories should I eat to lose weight?
• Eating less calories but eating plenty of fruits and • How can I become more active?
vegetables. • Where can I find weight loss support?
• Limiting red meats, processed foods (chips, cookies, • I can't seem to stop eating. What should I do?
sugary cereals), and sugar-sweetened beverages • Are any of the medicines I take causing me to
like soda and juice. gain weight? Are there alternatives?
• Eating out less often. • Should I consider taking medicine to help me
• Slowly increasing physical, working up to 150 minutes lose weight?
per week (about 30 minutes per day most days of the • Should I consider weight loss surgery?
For More Information

MedlinePlus
https://medlineplus.gov/obesity.html
American College of Physicians
www.acponline.org/clinical-information/clinical-resources-
products/obesity-management-learning-hub#patient-education

Appendix Table 1. Important Elements of History in Patients With Obesity
Category Specific Questions
Weight history History of childhood obesity; period of most rapid weight gain during childhood; highest and lowest
adult weight; previous weight loss attempts, methods, and results; history of underweight, disordered
eating, and binge eating (e.g., BEDS-7 findings)
Weight loss goals Patient weight and other health-related goals (e.g., improved mobility); goals from other clinicians (e.g.,
weight optimization prior to surgery)
Medical history Weight-related medical conditions (e.g., type 2 diabetes, osteoarthritis); contraindications to weight
loss medications (e.g., nephrolithiasis, gastroparesis) and surgery (e.g., tobacco use)
Dietary history/eating 24-hour diet recall; intake of sugar-sweetened beverages, daily servings of fruits and vegetables
patterns
Exercise/physical activity Minutes of moderate to vigorous activity per week; step count; barriers to exercise
Psychosocial Support from family and friends; experience with weight stigma; abuse/trauma history; history of weight
bullying; history of adverse childhood event(s)
Sleep Screening questions for obstructive sleep apnea (STOP-BANG); assessment of duration and quality of
sleep (e.g., Berlin Questionnaire, Epworth Sleepiness Scale)
Review of systems Symptoms of secondary causes of obesity: mood disorders (anhedonia, sleep disturbance); hypothyr-
oidism (fatigue, cold intolerance); Cushing syndrome (easy bruising, wide purple striae); PCOS (irregu-
lar menses, hirsutism), hypogonadism (erectile dysfunction, infertility); genetic obesity (hyperphagia)
BEDS-7 ¼ Binge Eating Disorder Screener-7; PCOS ¼ polycystic ovary syndrome.
Annals of Internal Medicine In the Clinic © 2024 American College of Physicians

Appendix Table 2. Physical Assessment in Patients With Obesity
Organ/Organ System Physical Finding Associated Condition
Skin Acne/hirsutism PCOS
Acanthosis nigricans Insulin resistance/type 2 diabetes
Striae (>0.4 in [>1 cm], purple); bruising Cushing syndrome
Face Facial dysmorphism Syndromic/genetic obesity
Neck Increased neck circumference (≥17 in Increased risk of obstructive sleep apnea
in men, ≥16 in in women)
Thyroid Small/firm/nodules/goiter Hypothyroidism
Cardiovascular Blood pressure Hypertension
Resting tachycardia Anxiety; physical deconditioning
Resting oxygen saturation Pulmonary hypertension
Cardiac rhythm Atrial fibrillation
S3/S4 gallop Congestive heart failure
Extremities Edema/hyperpigmentation Venous insufficiency, pulmonary hypertension,
or heart failure
Disproportionate adipose tissue distribution Lipedema
in extremities; Stemmer sign or cuff sign
Polydactyly; short stubby fingers Syndromic/genetic obesity
Ophthalmic Papilledema Pseudotumor cerebri
Musculoskeletal Proximal muscle weakness Cushing syndrome
Decreased range of motion; bony Osteoarthritis
hypertrophy
Liver Ascites; jaundice Cirrhosis (metabolic associated
steatohepatitis)
PCOS ¼ polycystic ovary syndrome.
© 2024 American College of Physicians In the Clinic Annals of Internal Medicine

Appendix Table 3. The 5A Approach to Weight Loss Counseling
Step Intervention
Ask Ask permission to discuss weight
Assess Assess weight-related health risk (BMI, degree of abdominal obesity, number and severity of weight-related conditions)
Advise Advise weight loss, giving a realistic and individualized goal based on starting weight and related health conditions
Agree Agree on goals for diet and physical activity
Assist Assist with a referral to a program, with a prescription, and/or with a weight-focused follow-up visit
BMI ¼ body mass index.

Appendix Table 4. Common Eating Plans for Weight Loss
Eating Plan Examples/Specifics of Plan
Daily caloric restriction* Reduction of calorie intake by 500–1000/day or by 30% from base-
line; alternatively, initial prescription of 1200–1500 kcal per day
for women and 1500–1800 per day for men, and adjust energy
intake based on observed weight loss
Intermittent energy restriction Time-restricted eating (limits eating window to 8 hours per day).
Intermittent fasting or alternate day fasting (e.g., 5:2, regular
healthy eating on 5 days alternating with <500 kcal on 2 days;
4:3, healthy eating on 4 days alternating with <500 kcal on 3 days).
Macronutrient restriction and other popular eating plans Ketogenic (very-low-carbohydrate) plan: restriction of all bread,
rice, potatoes, pasta, and corn; limited quantities of fruit;
increased intake of unsaturated fat (nuts, avocados, salmon);
effective for weight loss but restrictive and difficult to maintain.
Low fat: limitation of fat to <30% of total calories; increased intake
of lean proteins, fruits, and vegetables
Mediterranean: reduced intake of saturated fat (beef, pork);
increased intake of unsaturated fats, fish, fruits, and vegetables,
extra virgin olive oil
DASH: low-sodium eating plan including low-fat dairy, whole
grains, increased fruits and vegetables
Vegetarian and semivegetarian: centering on whole, unprocessed,
or minimally processed plants: fruits, vegetables, tubers, whole
grains, and legumes and exclusion of meats and dairy to varying
degrees. Examples include vegan (excludes all animal products
including seafood, eggs, dairy, honey; primarily plant-based
foods, grains, etc); lacto-ovo vegetarian (excludes all meat, poul-
try, and seafood but allows eggs and dairy products); pescatarian
(excludes all meat and poultry but allows fish, eggs, and dairy),
and flexitarian (primarily a plant-based diet but allows meat,
dairy, eggs, poultry, and fish on occasion or in small quantities).
Meal replacement: replacement of 2 meals per day with a protein
shake or bar (weight loss phase) and 1 meal per day (weight loss
maintenance phase); meal replacement products should have
150–250 kcal, 20 g of protein, and ≥5 g of fiber; can also include
use of portion-controlled meals (300–400 kcal with 20 g of lean
protein and vegetables)
* Although many of the structured eating plans also lead to caloric reduction, the caloric restriction eating plan is explicitly focused
on active calorie counting.
© 2024 American College of Physicians In the Clinic Annals of Internal Medicine

Appendix Figure. Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
Pouch
Esophagus
Gastric
Small sleeve
intestine
Removed
Stomach portion
of stomach
Roux-en-Y Gastric Vertical Sleeve

Bypass (RYGB) Gastrectomy (SG)
Used with permission from Levine JW, Feng ZL, Feng DP, Melvin WV. Perioperative patient care involved with robotic-assisted bari-
atric surgery. Ann Laparosc Endosc. 2017;2:136.

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Screening and Prevention et al. Transition from met-

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Continued on following page

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CLINICAL BOTTOM LINE

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For More Information

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BEDS-7 ¼ Binge Eating Disorder Screener-7; PCOS ¼ polycystic ovary syndrome.

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PCOS ¼ polycystic ovary syndrome.

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BMI ¼ body mass index.

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Roux-en-Y Gastric Vertical Sleeve

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