Last updated January 18, 2022

Medical Care of Patients with Obesity

RECOMMENDATIONS

The principal outcome and therapeutic target in the treatment of obesity should be to improve the health of the patient by preventing or treating weightrelated complications using weight loss, not the loss of body weight per se. (, D)
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The evaluation of patients for risk and existing burden of weight-related complications is a critical component of care and should be considered in clinical decisions and the therapeutic plan for weight-loss therapy. (, D)
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Obesity and 3 Phases of Chronic Disease Prevention and Treatment

The modality and intensity of obesity interventions should be based on the primary, secondary, and tertiary phases of disease prevention; this 3-phase paradigm for chronic disease aligns with the pathophysiology and natural history of obesity and provides a rational framework for appropriate treatment at each phase of prevention. (IV, C)
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The Anthropometric Component of the Diagnosis of Obesity

All adults should be screened annually using a BMI measurement; in most populations a cutoff point of ≥25 kg/m2 should be used to initiate further evaluation of overweight or obesity. (II, A)
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BMI should be used to confirm an excessive degree of adiposity and to classify individuals as having overweight (BMI 25 to 29.9 kg/m2) or obesity (BMI ≥30 kg/m2), after taking into account age, gender, ethnicity, fluid status, and muscularity; therefore, clinical evaluation and judgment must be used when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and those with sarcopenia. (II, A)
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Other measurements of adiposity (e.g., bioelectric impedance, air/water displacement plethysmography, or dual-energy X-ray absorptiometry [DEXA]) may be considered at the clinician’s discretion if BMI and physical examination results are equivocal or require further evaluation. (II, C)
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However, the clinical utility of these measures is limited by availability, cost, and lack of outcomes data for validated cutoff points. (II, B)
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When evaluating patients for adiposity related disease risk, waist circumference should be measured in all patients with BMI <35 kg/m2. (II, A)
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In many populations, a waist circumference cutoff point of ≥94 cm in men and ≥80 cm in women should be considered at risk and consistent with abdominal obesity; in the United States (U.S.) and Canada, cutoff points that can be used to indicate increased risk are ≥102 cm for men and ≥88 cm for women. (II, A)
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A BMI cutoff point value of ≥23 kg/m2 should be used in the screening and confirmation of excess adiposity in South Asian, Southeast Asian, and East Asian adults. (II, B)
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Region- and ethnic-specific cutoff point values for waist circumference should be used as measures of abdominal adiposity and disease risk;  in South Asian, Southeast Asian, and East Asian adults, men with values ≥85 cm and women ≥74 to 80 cm should be considered at risk and consistent with abdominal obesity. (II, B)
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The Clinical Component of the Diagnosis of Obesity

Patients with overweight or obesity and patients experiencing progressive weight gain should be screened for prediabetes and type 2 diabetes mellitus (T2DM) and evaluated for metabolic syndrome by assessing waist circumference, fasting glucose, A1C, blood pressure, and lipid panel, including triglycerides and HDL-C. (II, A)
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Due to variable risk for future diabetes, patients with overweight or obesity should be evaluated for risk of T2DM, which can be estimated or stratified using indices or staging systems that employ clinical data, glucose tolerance testing, and/or metabolic syndrome traits. (II, B)
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Patients with T2DM should be evaluated for the presence of overweight or obesity. (II, A)
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All patients with overweight or obesity and individuals experiencing progressive weight gain should be screened for dyslipidemia with a lipid panel that includes triglycerides, HDL-C, calculated LDL-C, total cholesterol, and non- HDL cholesterol. All patients with dyslipidemia should be evaluated for the presence of overweight or obesity. (II, A)
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Blood pressure should be measured in all patients with overweight or obesity as a screen for the presence of hypertension or prehypertension. All patients with hypertension should be evaluated for the presence of overweight or obesity. (II, A)
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Risk factors for cardiovascular disease should be assessed in patients with overweight or obesity. (II, A)
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Patients with overweight or obesity should be screened for active cardiovascular disease by history, physical examination, and with additional testing or expert referral based on cardiovascular disease risk status. (II, A)
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Screening for nonalcoholic fatty liver disease should be performed in all patients with overweight or obesity, T2DM, or metabolic syndrome with liver function testing, followed by ultrasound or other imaging modality if transaminases are elevated; all patients with nonalcoholic fatty liver disease should be evaluated for the presence of overweight or obesity. (II, B)
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Premenopausal female patients with overweight or obesity and/or metabolic syndrome should be screened for PCOS by history and physical examination; all patients with PCOS should be evaluated for the presence of overweight or obesity. (II, B)
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Women with overweight or obesity should be counseled when appropriate that they are at increased risk for infertility and, if seeking assisted reproduction, should be informed of lower success rates of these procedures regarding conception and the ability to carry the pregnancy to live birth. (II, B)
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All female patients with infertility should be evaluated for the presence of overweight or obesity. (II, B)
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All men who have an increased waist circumference or who have obesity should be assessed for hypogonadism by history and physical examination and be tested for testosterone deficiency if indicated; all male patients with hypogonadism should be evaluated for the presence of overweight or obesity. (II, B)
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All male patients with T2DM should be evaluated to exclude testosterone deficiency. (II, B)
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All patients with overweight or obesity should be evaluated for obstructive sleep apnea during medical history and physical examination. This is based on the strong association between these disorders. (II, B)
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Polysomnography and other sleep studies, at home or in a sleep lab, should be considered for patients at high risk for sleep apnea based on clinical presentation, severity of excess adiposity, and symptomatology. (, D)
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All patients with obstructive sleep apnea should be evaluated for the presence of overweight or obesity. (II, B)
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All patients with overweight or obesity should be evaluated for asthma and reactive airway disease based on the strong association between these disorders. (II, B)
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Medical history, symptomatology, physical examination, and spirometry and other pulmonary function tests should be considered for patients at high risk for asthma and reactive airway disease. (, D)
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All patients with asthma should be evaluated for the presence of overweight or obesity. (, D)
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All patients with overweight or obesity should be screened by symptom assessment and physical examination for OA of the knee and other weight-bearing joints. (II, B)
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All patients with OA should be evaluated for the presence of overweight or obesity. (, D)
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All female patients with overweight or obesity should be screened for urinary incontinence by assessing symptomatology, based on the strong association between these disorders; all patients with urinary stress incontinence should be evaluated for the presence of overweight or obesity. (II, B)
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Patients with overweight or obesity or who have increased waist circumferences should be evaluated for symptoms of GERD. (II, B)
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All patients with GERD should be evaluated for the presence of overweight or obesity. (III, C)
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Patients with obesity and GERD symptoms should be evaluated by endoscopy if medical treatment fails to control symptoms. (II, B)
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Endoscopy should be considered in patients with obesity and GERD symptoms prior to bariatric surgery. (II, B)
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Patients with overweight or obesity should be screened for depression; all patients with depression should be evaluated for the presence of overweight or obesity. (II, B)
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Other measures of adiposity

All patients with overweight or obesity should be clinically evaluated for weight-related complications because BMI alone is not sufficient to indicate the impact of excess adiposity on health status. Therefore, the diagnostic evaluation of patients with obesity should include an anthropometric assessment of adiposity and a clinical assessment of weight-related complications. (II, A)
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Patients with overweight or obesity should be reevaluated at intervals to monitor for any changes in adiposity and adiposity-related complications over time. (II, A)
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Therapeutic Benefits of Weight Loss in Patients with Overweight or Obesity

Patients with overweight or obesity and with either metabolic syndrome or prediabetes, or patients identified to be at high risk of T2DM based on validated risk-staging paradigms, should be treated with lifestyle therapy that includes a reduced-calorie healthy meal plan and a physical activity program incorporating both aerobic and resistance exercise to prevent progression to diabetes. (I, A)
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The weight-loss goal should be 10%. (II, B)
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Medication-assisted weight loss employing dphentermine/topiramate ER, liraglutide 3 mg, or orlistat should be considered in patients at risk for future T2DM and should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy. (I, A)
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Diabetes medications including metformin, acarbose, and thiazolidinediones can be considered in selected high-risk patients with prediabetes who are not successfully treated with lifestyle and weight-loss medications and who remain glucose intolerant. (I, A)
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Patients with overweight or obesity and T2DM should be treated with lifestyle therapy to achieve 5 to 15% weight loss or more as needed to achieve targeted lowering of A1C. (I, A)
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Weight-loss therapy should be considered regardless of the duration or severity of T2DM, both in newly diagnosed patients and in patients with longer-term disease on multiple diabetes medications. (I, A)
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Weight-loss medications should be considered as an adjunct to lifestyle therapy in all patients with T2DM as needed for weight loss sufficient to improve glycemic control, lipids, and blood pressure. (I, A)
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Patients with obesity (BMI ≥30 kg/m2) and diabetes who have failed to achieve targeted clinical outcomes following treatment with lifestyle therapy and weight-loss medications may be considered for bariatric surgery, preferably Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion. (I, B)
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Diabetes medications that are associated with modest weight loss or are weight-neutral are preferable in patients with obesity and T2DM, although clinicians should not refrain from insulin or other medications when needed to achieve A1C targets. (II, A)
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Patients with overweight or obesity and dyslipidemia (elevated triglycerides and reduced HDL-c) should be treated with lifestyle therapy to achieve 5 to 10% weight loss or more as needed to achieve therapeutic targets. (I, A)
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The lifestyle intervention should include a physical activity program and a reduced-calorie healthy meal plan that minimizes sugars and refined carbohydrates, avoids trans fats, limits alcohol use, and emphasizes fiber. (I, B)
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Patients with overweight or obesity and dyslipidemia should be considered for treatment with a weight-loss medication combined with lifestyle therapy when necessary to achieve sufficient improvements in lipids (i.e., elevated triglycerides and reduced HDL-C). (I, A)
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Patients with overweight or obesity and elevated blood pressure or hypertension should be treated with lifestyle therapy to achieve 5 to 15% weight loss or more as necessary to achieve blood pressure reduction goals in a program that includes caloric restriction and regular physical activity. (I, A)
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Patients with overweight or obesity and elevated blood pressure or hypertension should be considered for treatment with a weight-loss medication combined with lifestyle therapy when necessary to achieve sufficient weight loss for blood pressure reduction. (I, A)
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Patients with hypertension considering bariatric surgery should be recommended for Roux-en-Y gastric bypass or sleeve gastrectomy, unless contraindicated, due to greater long-term weight reduction and better remission of hypertension than with laparoscopic adjustable gastric banding. (I, B)
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Weight-loss therapy is not recommended based on available data for the expressed and sole purpose of preventing CVD events or to extend life, although evidence suggests that the degree of weight loss achieved by bariatric surgery can reduce mortality. (II, B)

Cardiovascular outcome trials assessing medication-assisted weight loss are currently ongoing or being planned.

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Weight-loss therapy is not recommended based on available data for the expressed and sole purpose of preventing CVD events or to extend life in patients with diabetes. (I, B)

Cardiovascular outcome trials assessing medication-assisted weight loss are currently ongoing or being planned.

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Weight-loss therapy is not recommended based on available data for the expressed purpose of preventing CVD events or to extend life in patients with congestive heart failure, although evidence suggests that weight loss can improve myocardial function and congestive heart failure symptomatology in the short term. (II, B)
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Patients with overweight or obesity and nonalcoholic fatty liver disease should be primarily managed with lifestyle interventions, involving calorie restriction and moderate-to-vigorous physical activity, targeting 4 to10% weight loss (a range over which there is a dose-dependent beneficial effect on hepatic steatosis). (I, A)
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Weight loss as high as 10 to 40% may be required to decrease hepatic inflammation, hepatocellular injury, and fibrosis. (I, A)
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In this regard, weight loss assisted by orlistat, (II, B)
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  • liraglutide and
(IA)
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  • bariatric surgery
(II, B)
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may be effective.
A Mediterranean dietary pattern or meal plan can have a beneficial effect on hepatic steatosis independent of weight loss. (I, A)
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Women with overweight or obesity and PCOS should be treated with lifestyle therapy with the goal of achieving 5 to 15% weight loss or more to improve hyperandrogenism, oligomenorrhea, anovulation, insulin resistance, and hyperlipidemia. Clinical efficacy can vary among individual patients. (I, A)
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Patients with overweight or obesity and PCOS should be considered for treatment with orlistat, metformin, or liraglutide, alone or in combination, because these medications can be effective in decreasing weight or improving PCOS manifestations, including insulin resistance, glucose tolerance, dyslipidemia, hyperandrogenemia, oligomenorrhea, and anovulation. (I, A)
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Selected patients with obesity and PCOS should be considered for laparoscopic Roux-en-Y gastric bypass to improve symptomatology, including restoration of menses and ovulation. (II, B)
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Weight loss is effective to treat infertility in women with overweight and obesity and should be considered as part of the initial treatment to improve fertility; weight loss of ≥10% should be  targeted to augment the likelihood of conception and live birth. (I, A)
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Treatment of hypogonadism in men with increased waist circumference or obesity should include weight-loss therapy. (II, B)
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Weight loss of more than 5 to 10% is needed for significant improvement in serum testosterone. (, D)
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Bariatric surgery should be considered as a treatment approach that improves hypogonadism in most patients with obesity, including patients with severe obesity (BMI >50 kg/m2) and T2DM. (I, A)
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Men with true hypogonadism and obesity who are not seeking fertility should be considered for testosterone therapy in addition to lifestyle intervention because testosterone in these patients results in weight loss, decreased waist circumference, and improvements in metabolic parameters (glucose, A1C, lipids, and blood pressure). (I, A)
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Patients with overweight or obesity and obstructive sleep apnea should be treated with weight-loss therapy including lifestyle interventions and additional modalities as needed, including phentermine/topiramate extended release (ER) or bariatric surgery. The weight-loss goal should be at least 7% to 11% or more. (I, A)
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Patients with overweight or obesity and asthma should be treated with weight loss using lifestyle interventions. Additional treatment modalities may be considered as needed including bariatric surgery. The weight-loss goal should be at least 7% to 8%. (I, A)
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Patients with overweight or obesity and OA involving weight-bearing joints, particularly the knee, should be treated with weight-loss therapy for symptomatic and functional improvement and reduction in compressive forces during ambulation. The weight-loss goal should be ≥10% of body weight. (I, A)
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A physical activity program should also be recommended in this setting because the combination of weightloss therapy achieving 5 to 10% loss of body weight combined with physical activity can effectively improve symptoms and function. (I, A)
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Patients with overweight or obesity and OA should undergo weight-loss therapy before and after total knee replacement. (II, C)
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Women with overweight or obesity and stress urinary incontinence should be treated with weight-loss therapy; the weight-loss goal should be 5 to 10% of body weight or greater. (I, A)
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Patients with overweight or obesity and gastroesophageal reflux should be treated using weight loss. The weight-loss goal should be 10% of body weight or greater. (I, A)
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Proton pump inhibitor (PPI) therapy should be administered as medical therapy in patients with overweight or obesity and persistent gastroesophageal reflux symptoms during weight-loss interventions. (I, A)
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Roux-en-Y gastric bypass should be considered as the bariatric surgery procedure of choice for patients with obesity and moderate to severe gastroesophageal reflux symptoms, hiatal hernia, esophagitis, or Barrett’s esophagus. (II, B)
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Intragastric balloon for weight loss may increase gastroesophageal reflux symptoms and should not be used for weight loss in patients with established gastroesophageal reflux. (I, A)
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Patients with overweight or obesity and depression interested in losing weight should be offered a structured lifestyle intervention. (I, A)
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Lifestyle/Behavioral Therapy for Overweight and Obesity

A structured lifestyle intervention program designed for weight loss (lifestyle therapy) and consisting of a healthy meal plan, physical activity, and behavioral interventions should be available to patients who are being treated for overweight or obesity. (I, A)
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Reducing total energy (caloric) intake should be the main component of any weight-loss intervention. (I, A)
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Even though the macronutrient composition of meals has less impact on weight loss than adherence rates in most patients, in certain patient populations, modifying macronutrient composition may be considered to optimize adherence, eating patterns, weight loss, metabolic profiles, risk factor reduction, and/or clinical outcomes. (I, A)
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Aerobic physical activity training should be prescribed to patients with overweight or obesity as a component of lifestyle intervention. The initial prescription may require a progressive increase in the volume and intensity of exercise, and the ultimate goal should be ≥150 min/week of moderate exercise performed during 3 to 5 daily sessions per week. (I, A)
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Resistance training should be prescribed to patients with overweight or obesity undergoing weight-loss therapy to help promote fat loss while preserving fat-free mass. The goal should be resistance training 2 to 3 times per week consisting of single-set exercises that use the major muscle groups. (I, A)
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An increase in nonexercise and active leisure activity should be encouraged to reduce sedentary behavior in all patients with overweight or obesity. (I, A)
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The prescription for physical activity should be individualized to include activities and exercise regimens within the capabilities and preferences of the patient, taking into account health-related and physical limitations. (IV, C)
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Involvement of an exercise physiologist or certified fitness professional in the care plan should be considered to individualize the physical activity prescription and improve outcomes. (I, A)
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Lifestyle therapy in patients with overweight or obesity should include behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem solving; stress reduction; cognitive restructuring [i.e., cognitive behavioral therapy]; motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures). (I, A)
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The behavior intervention package is effectively executed by a multidisciplinary team that includes dietitians, nurses, educators, physical activity trainers or coaches, and clinical psychologists. (IV, C)
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Psychologists and psychiatrists should participate in the treatment of eating disorders, depression, anxiety, psychoses, and other psychological problems that can impair the effectiveness of lifestyle intervention programs. (II, B)
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Behavioral lifestyle intervention and support should be intensified of patients do not achieve a 2.5% weight loss in the first month of treatment, as early weight reduction is a key predictor of longterm weight-loss success. (I, A)
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A stepped-care behavior approach should teach skills for problem solving and should evaluate outcomes. (I, A)
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Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background. (II, B)
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Pharmacotherapy for Overweight and Obesity

Pharmacotherapy for overweight and obesity should be used only as an adjunct to lifestyle therapy and not alone. (I, A)
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The addition of pharmacotherapy produces greater weight loss and weight-loss maintenance compared with lifestyle therapy alone. (I, A)
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The concurrent initiation of lifestyle therapy and pharmacotherapy should be considered in patients with weight-related complications that can be ameliorated by weight loss. (I, A)
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Pharmacotherapy should be offered to patients with obesity, when potential benefits outweigh the risks, for the chronic treatment of the disease. (I, A)
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Short-term treatment (3 to 6 months) using weight-loss medications has not been demonstrated to produce longer-term health benefits and cannot be generally recommended based on scientific evidence. (I, B)
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In selecting the optimal weight-loss medication for each patient, clinicians should consider differences in efficacy, side effects, cautions, and warnings that characterize medications approved for chronic management of obesity, and the presence of weight-related complications and medical history. These factors are the basis for individualized weight-loss pharmacotherapy. A generalizable hierarchical algorithm for medication preferences that would be applicable to all patients cannot currently be scientifically justified. (I, A)
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Clinicians and their patients with obesity should have available access to all approved medications to allow for the safe and effective individualization of appropriate pharmacotherapy.  (, D)
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 Combinations of FDA-approved weight-loss medications should only be used in a manner approved by the FDA. (I, A)
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  • or when sufficient safety and efficacy data are available to assure informed judgment regarding a favorable benefit-to-risk ratio.
(, D)
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Individualization of Pharmacotherapy in the Treatment of Obesity

Weight-loss medications should not be used in the setting of end-stage renal failure, with the exception that orlistat and liraglutide 3 mg can be considered in selected patients with a high level of caution. (II, B)
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The use of naltrexone ER/bupropion ER, lorcaserin, or phentermine/topiramate ER is not recommended in patients with severe renal impairment (<30 mL/min). (II, B)
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All weight-loss medications can be used with appropriate cautions in patients with mild (50 to 79 mL/min) and moderate (30 to 49 mL/min) renal impairment, except that in moderate renal impairment the dose of naltrexone ER/bupropion ER should not exceed 8 mg/90 mg twice per day, and the daily dose of phentermine/topiramate ER should not exceed 7.5 mg/46 mg. (II, B)
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Orlistat should not be used in patients with, or at risk of, oxalate nephropathy. (III, C)
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Liraglutide 3 mg should be discontinued if patients develop volume depletion, for example, due to nausea, vomiting, or diarrhea. (II, B)
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Naltrexone ER/bupropion ER, lorcaserin, and liraglutide 3 mg are preferred weight-loss medications in patients with a history, or at risk, of nephrolithiasis. (, D)
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Caution should be exercised in treating patients with phentermine/ topiramate ER and orlistat who have a history of nephrolithiasis. (I, A)
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All weight-loss medications should be used with caution in patients with hepatic impairment and should be avoided in severe hepatic impairment (i.e., Child-Pugh score >9). (III, C)
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Dose adjustments for some medications are warranted in patients with moderate hepatic impairment: specifically, the maximum recommended dose of naltrexone ER/bupropion ER is 1 tablet (8 mg/90 mg) in the morning. The maximum recommended dose of phentermine/ topiramate ER is 7.5 mg/46 mg daily. (, D)
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Clinicians should maintain a high index of suspicion for cholelithiasis in patients undergoing weight-loss therapy, regardless of the treatment modality. In high-risk patients, liraglutide 3 mg should be used with caution. Effective preventive measures include a slower rate of weight loss, an increase in dietary fat, or administration of ursodeoxycholic acid. (I, A)
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In patients with existing hypertension, orlistat, lorcaserin, phentermine/topiramate ER, and liraglutide 3 mg are preferred weight-loss medications. (I, B)
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Heart rate should be carefully monitored in patients receiving liraglutide 3 mg and phentermine/topiramate ER. (I, A)
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Naltrexone ER/bupropion ER should be avoided if other weight-loss medications can be used because weight loss assisted by naltrexone ER/bupropion ER cannot be expected to reduce blood pressure, and the drug is contraindicated in uncontrolled hypertension. (I, B)
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Renin-angiotensin system inhibition therapy (angiotensin receptor blocker or angiotensin converting enzyme inhibitor) should be used as the first-line drug for blood pressure control in patients with obesity. (I, A)
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Combination antihypertension therapy with calcium channel blockers may be considered as second-tier treatment. (I, A)
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Beta-blockers and thiazide diuretics may also be considered in some patients but can have adverse effects on metabolism. Beta-blockers and alpha-blockers can promote weight gain. (I, A)
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In patients with established atherosclerotic cardiovascular disease, orlistat and lorcaserin are preferred weight-loss medications. (I, A)
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Liraglutide 3 mg, phentermine/topiramate ER, and naltrexone ER/bupropion ER are reasonable to use with caution, and to continue if weight-loss goals are met, with careful monitoring of heart rate and blood pressure. (I, A)
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Cardiovascular outcome trials are planned or ongoing for all weight-loss medications except orlistat.

Orlistat and lorcaserin are preferred weight-loss medications in patients with a history or risk of cardiac arrhythmia. (I, B)
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Naltrexone ER/bupropion ER, liraglutide 3 mg, and phentermine/ topiramate ER are not contraindicated but should be used cautiously with careful monitoring of heart rate and rhythm. (I, A)
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All patients undergoing weight-loss therapy should be monitored for mood disorders, depression, and suicidal ideation. (II, A)
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Orlistat, liraglutide 3 mg, and phentermine/topiramate ER at initiation (3.75 mg/23 mg) and low treatment (7.5 mg/46 mg) doses may be considered in patients with obesity and depression. (I, A)
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Lorcaserin and naltrexone ER/bupropion ER should be used with caution in patients with obesity and depression or avoided if patients are taking medications for depression. (I, A)
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Maximal dose (15 mg/92 mg) phentermine/ topiramate ER should be used with caution in patients with obesity and anxiety disorders. (I, A)
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Patients with psychotic disorders being treated with antipsychotic medications should be treated with a structured lifestyle intervention to promote weight loss or prevent weight gain. (I, A)
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Treatment with metformin may be beneficial in promoting modest weight loss and metabolic improvement in individuals with psychotic disorders who are taking antipsychotic medications. (I, A)
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Caution must be exercised in using any weight-loss medication in patients with obesity and a psychotic disorder due to insufficient current evidence assessing safety and efficacy. (, D)
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Patients with overweight or obesity who are being considered for weight-loss therapy should be screened for binge eating disorder and night eating syndrome. (III, B)
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Patients with overweight or obesity who have binge eating disorder should be treated with a structured behavioral/lifestyle program in conjunction with cognitive behavioral therapy or other psychological interventions. (I, A)
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In patients with overweight or obesity and binge eating disorder, treatment with orlistat or approved medications containing topiramate or bupropion may be considered in conjunction with structured lifestyle therapy, cognitive behavioral therapy, and/or other psychological interventions. (I, A)
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Structured lifestyle therapy and/or selective serotonin reuptake inhibitor therapy may be considered in patients with obesity and night eating syndrome. (I, B)
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Liraglutide 3 mg, orlistat, and lorcaserin are preferred weight-loss medications in patients with a history, or at risk of, glaucoma. (II, B)
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Phentermine/topiramate ER should be avoided and naltrexone ER/bupropion ER used with caution in patients with glaucoma. (II, C)
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Phentermine/topiramate, lorcaserin, liraglutide, and orlistat are preferred weight-loss medications in patients with a history, or at risk, of seizure/epilepsy. (I, B)

The use of naltrexone ER/bupropion ER should be avoided in these patients.

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All patients with obesity should be monitored for typical symptoms of pancreatitis (e.g., abdominal pain or gastrointestinal [GI] distress) due to a proven association between these diseases. (I, A)
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Patients receiving glyburide, orlistat, or incretin-based therapies (glucagon-like peptide-1 receptor agonists or dipeptidyl peptidase 4 inhibitors) should be monitored for the development of pancreatitis. (III, C)
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Glyburide, orlistat, and incretin-based therapies should be withheld in cases of prior or current pancreatitis. Otherwise, there are insufficient data to recommend withholding glyburide for glycemic control, orlistat for weight loss, or incretin-based therapies for glycemic control or weight loss due to concerns regarding pancreatitis. (, D)
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In patients requiring chronic administration of opioid or opiate medications, phentermine/topiramate ER, lorcaserin, liraglutide 3 mg, and orlistat are preferred weight-loss medications, while naltrexone ER/bupropion ER should not be used. (I, B)
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Weight-loss medications must not be used in pregnancy. (II, A)
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All weight-loss medications should be used in conjunction with appropriate forms of contraception in women of reproductive potential. (I, A)
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Weight-loss medications should not be used in women who are lactating and breast-feeding. (, D)
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Elderly patients (≥65 years) should be selected for weight-loss therapy involving structured lifestyle interventions that include reducedcalorie meal plans and exercise, with clear healthrelated goals in mind that include prevention of T2DM in high-risk patients with prediabetes, blood pressure lowering, and improvements in OA, mobility, and physical function. (I, A)
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Elderly patients with overweight or obesity being considered for weight-loss therapy should be evaluated for osteopenia and sarcopenia. (II, B)
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Weight-loss medications should be used with extra caution in elderly patients with overweight or obesity. (I, A)

Additional studies are needed to assess efficacy and safety of weightloss medications in the elderly.

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In patients with obesity and alcohol or other addictions, consider using orlistat or liraglutide 3 mg. (I, A)
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Lorcaserin (abuse potential due to euphoria at suprapharmacologic doses) and naltrexone ER/bupropion ER (lowers seizure threshold) should be avoided in patients with alcohol abuse, and naltrexone ER/bupropion ER is contraindicated during alcohol withdrawal. (I, A)
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Patients that have undergone bariatric surgery should continue to be treated with an intensive lifestyle intervention. (I, A)
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Patients that have regained excess weight (≥25% of the lost weight), have not responded to intensive lifestyle intervention, and are not candidates for reoperation may be considered for treatment with liraglutide (1.8 to 3.0 mg) or phentermine/ topiramate ER. The safety and efficacy of other weight-loss medications have not been assessed in these patients. (III, D)
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Bariatric Surgery

Patients with a BMI of ≥40 kg/m2 without coexisting medical problems and for whom the procedure would not be associated with excessive risk should be eligible for bariatric surgery. (I, A)
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Patients with a BMI of ≥35 kg/m2 and 1 or more severe obesity-related complications, including T2DM, hypertension, obstructive sleep apnea, obesity-hypoventilation syndrome, Pickwickian syndrome, nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, pseudotumor cerebri, gastroesophageal reflux disease, asthma, venous stasis disease, severe urinary incontinence, debilitating arthritis, or considerably impaired quality of life may also be considered for a bariatric surgery procedure. Patients with BMI of 30 to 34.9 kg/m2 with diabetes or metabolic syndrome may also be considered for a bariatric procedure, although current evidence is limited by the number of patients studied and lack of long-term data demonstrating net benefit.
  • BMI ≥35 kg/m2 and therapeutic target of weight control and improved biochemical markers of CVD risk,
(I, A)
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  • BMI ≥30 kg/m2 and therapeutic target of weight control and improved biochemical markers of CVD risk.
(II, B)
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  • BMI ≥30 kg/m2 and therapeutic target of glycemic control in T2DM and improved biochemical markers of CVD risk.
(III, C)
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Independent of BMI criteria, there is insufficient evidence for recommending a bariatric surgical procedure specifically for glycemic control alone, lipid lowering alone, or CVD risk reduction alone. (, D)
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All patients should undergo pre-operative evaluation for weight-related complications and causes of obesity, with special attention directed to factors that could affect a recommendation for bariatric surgery or be ameliorated by weight loss resulting from the procedure. (I, A)
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Recommendation Grading

Overview

Title

Medical Care of Patients with Obesity

Authoring Organization

Publication Month/Year

July 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Dietician nutritionist

Scope

Counseling, Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D009767 - Obesity, Morbid, D009765 - Obesity, D019440 - Anti-Obesity Agents, D000073319 - Obesity Management

Keywords

obesity, overweight

Source Citation

W. Timothy Garvey, Jeffrey I. Mechanick, Elise M. Brett, Alan J. Garber, Daniel L. Hurley, Ania M. Jastreboff, Karl Nadolsky, Rachel Pessah-Pollack, Raymond Plodkowski, and Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines (2016) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocrine Practice: July 2016, Vol. 22, No. Supplement 3, pp. 1-203.