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Table of contents

Obesity

Key sources
The following summarized guidelines for the evaluation and management of obesity are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the United European Gastroenterology (UEG/ESPEN 2023), the World Health Organization (WHO 2023; 2015), the American Academy of Pediatrics (AAP 2023), the European Society of Hypertension (ESH 2023), the National Lipid Association (NLA/PCNA/ASPC/ACC/AHA/ACCP 2023), the American Association for the Study of Liver Diseases (AASLD 2023), the European Society of Cardiology (ESC 2023; 2021), the American Gastroenterological Association (AGA 2022; 2021), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the American Association of Clinical Endocrinologists (AACE/AASLD 2022), the U.S. Preventive Services Task Force (USPSTF 2021; 2018; 2017; 2012), the American College of Obstetricians and Gynecologists (ACOG 2021; 2018), the American College of Gastroenterology (ACG 2021), the Endocrine Society (ES 2020; 2015; 2013), the European Society of Endocrinology (ESE 2020), the British Obesity and Metabolic Surgery Society (BOMSS 2020), the Hypertension Canada (HC 2020), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the American Thoracic Society (ATS 2019), the European Society of Cardiology (ESC/ESH 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2018), the American College of Endocrinology (ACE/AACE 2016), the European Association for the Study of Obesity (EASO/EASD/EASL 2016), the American Heart Association (AHA/ACC 2014), the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2014), the Royal College of Obstetricians and Gynaecologists (RCOG 2014), and the American Society for Parenteral and Enteral Nutrition (ASPEN 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening, adults, ADA
Measure height and weight and calculate BMI at annual visits or more frequently. Assess weight trajectory to inform treatment considerations. Ensure privacy during weighing.
B
Consider monitoring and evaluating weight more frequently based on clinical considerations, such as the presence of comorbid HF or significant unexplained weight gain or loss.
C
Consider obtaining inpatient evaluation if a deterioration of medical status is associated with significant weight gain or loss, especially focused on associations between medication use, food intake, and glycemic status.
C
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  • Indications for screening (pediatrics)

  • Diagnostic criteria

2.Classification and risk stratification

CVD risk assessment
As per ES 2020 guidelines:
Assess components of the metabolic syndrome and body fat distribution to accurately determine the level of CVD risk in patients with obesity.
E
Assess the 10-year risk for ASCVD to guide the use of lipid-lowering therapy in patients with obesity.
B

3.Diagnostic investigations

Assessment of secondary causes, hypothyroidism: obtain thyroid function testing in all patients with obesity.
B
obtain TSH, and free T4 and anti-TPO antibodies if TSH is elevated.
B
consider using the same reference ranges in patients without obesity as for patients with obesity.
B

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  • Assessment of secondary causes (hypercortisolism)

  • Assessment of secondary causes (hypopituitarism)

  • Assessment of secondary causes (PCOS)

  • Assessment of secondary causes (binge eating syndrome)

  • Assessment of obesity-related complications (general principles)

  • Assessment of obesity-related complications (dyslipidemia)

  • Assessment of obesity-related complications (diabetes mellitus)

  • Assessment of obesity-related complications (hypertension)

  • Assessment of obesity-related complications (NAFLD)

  • Assessment of obesity-related complications (obstructive sleep apnea)

  • Assessment of obesity-related complications (OA)

  • Assessment of obesity-related complications (urinary incontinence)

  • Assessment of obesity-related complications (GERD)

  • Assessment of obesity-related complications (pancreatitis)

  • Assessment of obesity-related complications (hypogonadism)

  • Assessment of obesity-related complications (hyperparathyroidism)

  • Assessment of obesity-related complications (vitamin D deficiency)

  • Assessment of obesity-related complications (asthma)

  • Assessment of obesity-related complications (depression)

4.Medical management

Indications for pharmacotherapy: as per AGA 2022 guidelines, initiate pharmacotherapy in addition to lifestyle interventions in adult patients with obesity or overweight with weight-related complications and an inadequate response to lifestyle interventions.
B

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  • Choice of agent

  • Metformin

5.Nonpharmacologic interventions

Multicomponent lifestyle/behavioral interventions: as per USPSTF 2018 guidelines, offer intensive multicomponent behavioral interventions in adult patients with a BMI ≥ 30.
B

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  • Dietary management

  • Non-sugar sweeteners

6.Therapeutic procedures

Intragastric balloon therapy: consider offering intragastric balloon therapy along with lifestyle modifications in patients with obesity seeking a weight loss intervention failed a trial of conventional weight loss strategies.
C
offer moderate- to high-intensity concomitant lifestyle modifications to maintain and augment weight loss in patients with obesity undergoing intragastric balloons therapy.
B
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7.Perioperative care

Preoperative laboratory assessment: obtain a comprehensive preoperative nutritional assessment in all bariatric surgery candidates.
B
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8.Surgical interventions

Indications for bariatric surgery: as per ESC 2023 guidelines, consider offering bariatric surgery in high and very high-risk patients with BMI ≥ 35 kg/m² when repetitive and structured efforts of lifestyle changes combined with weight-loss medications do not result in maintained weight loss.
C

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  • Choice of procedure

9.Specific circumstances

Pediatric patients, screening, AAP: measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific growth charts or growth charts for children with severe obesity at least annually to screen for overweight (BMI ≥ 85th to < 95th percentile), obesity (BMI ≥ 95th percentile), and severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) in all 2-18 years old children.
B

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  • Pediatric patients (evaluation for comorbidities)

  • Pediatric patients (general principles of management)

  • Pediatric patients (lifestyle management)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (bariatric surgery)

  • Elderly patients

  • Pregnant patients

  • Postmenopausal patients

  • Patients with binge eating syndrome

  • Patients with dyslipidemia

  • Patients with CVD (hypertension, prevention)

  • Patients with CVD (hypertension, management)

  • Patients with CVD (ASCVD)

  • Patients with CVD (HF)

  • Patients with CVD (cardiac arrhythmia)

  • Patients with diabetes mellitus (screening)

  • Patients with diabetes mellitus (lifestyle changes)

  • Patients with diabetes mellitus (pharmacotherapy)

  • Patients with diabetes mellitus (bariatric surgery)

  • Patients with diabetes mellitus (post-bariatric care)

  • Patients with NAFLD (lifestyle changes)

  • Patients with NAFLD (pharmacotherapy)

  • Patients with NAFLD (bariatric surgery)

  • Patients with NAFLD (liver transplantation)

  • Patients with chronic liver disease

  • Patients with cholelithiasis

  • Patients with acute pancreatitis

  • Patients with chronic pancreatitis

  • Patients with GERD (nutritional assessment)

  • Patients with GERD (weight loss)

  • Patients with GERD (bariatric surgery)

  • Patients with kidney disease (renal impairment)

  • Patients with kidney disease (nephrolithiasis)

  • Patients with urinary incontinence

  • Patients with hypoventilation syndrome (evaluation)

  • Patients with hypoventilation syndrome (weight loss)

  • Patients with hypoventilation syndrome (respiratory support)

  • Patients with obstructive sleep apnea

  • Patients with asthma

  • Patients with female infertility

  • Patients with PCOS (lifestyle changes)

  • Patients with PCOS (pharmacotherapy)

  • Patients with PCOS (bariatric surgery)

  • Patients with male hypogonadism

  • Patients with thyroid disorders

  • Patients with GH abnormalities

  • Patients with chronic inflammatory diseases

  • Patients with OA

  • Patients with critical illness

  • Patients with glaucoma

  • Patients with seizure/epilepsy

  • Patients with anxiety/depression

  • Patients with substance use disorder

  • Patients on opioids

  • Patients on oral contraceptives

  • Patients on psychotropic medications

  • Patients on antiretroviral drugs

10.Patient education

General counseling: as per AACE 2016 guidelines, advise female patients with overweight or obesity when appropriate that they are at increased risk for infertility and, if seeking assisted reproduction, inform of lower success rates of these procedures regarding conception and the ability to carry the pregnancy to live birth.
B

11.Preventative measures

Carbohydrate intake: as per WHO 2023 guidelines, advise consuming carbohydrates primarily from whole grains, vegetables, fruits, and pulses.
A
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  • Fat intake

12.Follow-up and surveillance

Monitoring of pharmacotherapy: as per ES 2020 guidelines, consider reassessing the lipid profile to evaluate the risk of CVD and pancreatitis in patients with obesity on weight loss pharmacotherapy.
C

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  • Maintenance of weight loss

13.Quality improvement

Use of nonjudgmental language: use person-centered, nonjudgmental language fostering collaboration between patients and health care professionals, including people-first language (such as "person with obesity" rather than "obese person").
B