Obesity Guidelines

Updated: Apr 26, 2023
  • Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Guidelines Summary

Endocrine Society

In January 2015, the Endocrine Society released new guidelines on the treatment of obesity to include the following [116, 117] :

  • Diet, exercise, and behavioral modification should be included in all obesity management approaches for body mass index (BMI) of 25 kg/m 2 or higher. Other tools, such as pharmacotherapy for BMI of 27 kg/m 2 or higher with comorbidity or BMI over 30 kg/m2 and bariatric surgery for BMI of 35 kg/m 2 with comorbidity or BMI over 40 kg/m 2, should be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible.
  • Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications.
  • To promote long-term weight maintenance, the use of approved weight loss medication (over no pharmacological therapy) is suggested to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI of 30 kg/m 2 or higher or in individuals with a BME of 27 kg/m 2 and at least one associated comorbid medical condition (eg, hypertension, dyslipidemia, type 2 diabetes mellitus, and obstructive sleep apnea).
  • If a patient's response to a weight loss medication is deemed effective (weight loss of 5% or more of body weight at 3 mo) and safe, it is recommended that the medication be continued. If deemed ineffective (weight loss less than 5% at 3 mo) or if there are safety or tolerability issues at any time, it is recommended that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered.
  • In patients with type 2 diabetes mellitus who are overweight or obese, antidiabetic medications that have additional actions to promote weight loss (such as glucagonlike peptide-1 [GLP-1] analogs or sodium-glucose-linked transporter-2 [SGLT-2] inhibitors) are suggested, in addition to the first-line agent for type 2 diabetes mellitus and obesity, metformin.
  • In obese patients with type 2 diabetes mellitus who require insulin therapy, at least one of the following is suggested: metformin, pramlintide, or GLP-1 agonists to mitigate associated weight gain due to insulin. The first-line insulin for this type of patient should be basal insulin. This is preferable to using either insulin alone or insulin with sulfonylurea.
  • Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers, rather than beta-adrenergic blockers, should be considered as first-line therapy for hypertension in patients with type 2 diabetes mellitus who are obese.
  • In women with BMI of more than 27 kg/m 2 with comorbidities or BMI of more than 30 kg/m 2 seeking contraception, oral contraceptives are suggested over injectable medications because of weight gain with injectables, provided that women are well informed about risks and benefits (ie, oral contraceptives are not contraindicated).

American Heart Association

In April 2021, the American Heart Association released a scientific statement on obesity and cardiovascular disease. It included the following information [204, 205] :

  • Overall body fat mass is not the sole mediator of susceptibility to obesity-associated cardiovascular complications, with such susceptibility being largely dependent on individual differences in regional body fat distribution
  • The onset of cardiovascular disease (CVD) may be better predicted by using a ratio of waist circumference to height than by employing waist circumference alone
  • The risk of sudden cardiac death (SCD) rises by 16% with every 5-unit increment in the body mass index (BMI), with obesity being the top nonischemic cause of SCD
  • An estimated 20% of atrial fibrillation (AF) cases and 60% of recently documented population increases in AF may stem from obesity; later-life incident AF is strongly tied to weight gain and a higher midlife BMI, and every 5-unit increment in BMI raises the risk of incident AF by about 29%
  • The risk of short-term, adverse CVD outcomes (10 y or less) does not consistently correlate with overweight or obesity (especially in patients with symptomatic CVD), BMI, and other body composition parameters
  • Prospective studies comparing patients with obesity who were treated with bariatric surgery with those who were not found the surgery to be associated with a reduced coronary artery disease risk
  • Lifestyle interventions as, for example, directed through the National Diabetes Prevention Program, may be at least as effective as medications in reducing body fat

American Gastroenterological Association

Guidelines on intragastric balloons (IGBs) in the management of obesity were published in April 2021 by the American Gastroenterological Association (AGA). They included the following [206, 207] :

  • For obese patients (BMI >30 kg/m 2) desiring weight loss but for whom conventional weight-loss strategies have failed, a combination of IGB placement and moderate- to high-intensity lifestyle modifications (to maintain and augment weight loss) may be more effective than lifestyle modifications alone
  • Concomitant perioperative antiemetic therapy with an intraoperative anesthetic that is unlikely to cause nausea is recommended during IGB placement, as well as postprocedure prophylactic administration of proton pump inhibitor (PPI) therapy; AGA suggests a scheduled antiemetic regimen for 2 weeks after IGB placement
  • For individuals who undergo IGB therapy, AGA suggests against perioperative laboratory screening for nutritional deficiencies
  • Following IGB placement, daily supplementation with 1-2 adult-dose multivitamins is suggested
  • Following IGB removal, subsequent weight-loss or maintenance strategies are suggested that include dietary interventions, pharmacotherapy, repeat IGB, or bariatric surgery; use shared decision making to determine the selection of post-IGB weight-loss or maintenance methods based on a patient’s individual clinical situation and comorbidities

American Academy of Pediatrics

In 2023, the American Academy of Pediatrics published the following clinical guidelines on the assessment and management of pediatric obesity [208] :

  • On at least a yearly basis, all children aged 2-18 years should be screened for overweight (BMI ≥85th percentile to < 95th percentile), obesity (BMI ≥95th percentile), and severe obesity (BMI ≥120% of the 95th percentile for age and sex) by pediatricians and other pediatric health care providers (PHCPs), with the assessment made by measuring height and weight, calculating BMI, and evaluating BMI percentile via age- and sex-specific CDC growth charts or growth charts for children with severe obesity)
  • Children aged 2-18 years with overweight or obesity should be assessed by pediatricians and other PHCPs for obesity-related comorbidities, with the evaluation made using a comprehensive patient history, mental and behavioral health screening, a social determinants of health (SDoH) evaluation, a physical examination, and diagnostic studies
  • Children and adolescents aged 10 years or older with obesity should be assessed by pediatricians and other PHCPs for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function, while patients in the same age group with overweight should be assessed by these health care providers for lipid abnormalities
  • Children and adolescents with overweight or obesity should receive concurrent treatment, from pediatricians and other PHCPs, for this condition and comorbidities
  • Children aged 10 years or older with overweight or obesity should be assessed, by pediatricians and other PHCPs, for dyslipidemia via a fasting lipid panel, while children aged 2-9 years with obesity may be assessed by these providers for dyslipidemia
  • Fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance test (OGTT), or glycosylated hemoglobin (HbA1c) should be employed by pediatricians and other PHCPs to assess for prediabetes and/or diabetes mellitus
  • Evaluation for nonalcoholic fatty liver disease (NAFLD) should be carried out by pediatricians and other PHCPs via an alanine transaminase (ALT) test
  • Starting at age 3 years, at every visit with a pediatrician or other PHCP, children and adolescents with overweight or obesity should be assessed for hypertension via blood pressure measurement
  • In treating overweight and obesity in children and adolescents, pediatricians and other PHCPs should follow “the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers”
  • Patients and families should be engaged by pediatricians and other PHCPs, through motivational interviewing, in treating overweight and obesity
  • In children with overweight or obesity, referral to or provision of intensive health behavior and lifestyle treatment should be offered by pediatricians and other PHCPs to youngsters aged 6 years or older and may be given to those aged 2-5 years; greater contact hours lead to more effective health behavior and lifestyle treatment, with the treatment being most beneficial if it includes at least 26 hours of face-to-face, family based, multicomponent treatment over 3-12 months
  • Adjunctive to health behavior and lifestyle treatment, weight-loss pharmacotherapy, as based on medication indications, risks, and benefits, should be offered by pediatricians and other PHCPs to adolescents aged 12 years or older with obesity
  • Adolescents aged 13 years or older with severe obesity should be offered, by pediatricians and other PHCPs, referral for metabolic and bariatric surgery assessment at local or regional comprehensive, multidisciplinary pediatric metabolic and bariatric surgery centers