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  • image Two clinical measures of excess body fat, regardless of sex, are the body mass index (BMI) and the waist circumference (WC). BMI and WC provide a better assessment of total body fat than weight alone and are independent predictors of obesity-related disease risk.

  • image Excessive central adiposity increases risk for development of type 2 diabetes, hypertension, and dyslipidemia.

  • image Weight loss of as little as 5% of total body weight can significantly improve blood pressure, lipid levels, and glucose tolerance in patients with overweight and obesity. Sustained, large weight losses (ie, after bariatric surgery) are associated with a lower risk of cardiovascular events and death and long-term improvements in many of the complications associated with obesity.

  • image Clinicians should consider the weight-altering effects of medications used to treat comorbid conditions (eg, antidepressants, antipsychotics, antiepileptics, and antidiabetics) and select medications that promote weight loss or are weight-neutral.

  • image Bariatric surgery is reserved for patients with extreme obesity having a BMI more than or equal 40 kg/m2 or BMI more than or equal to 35 kg/m2 with a significant comorbidity.

  • image Pharmacotherapy may be considered an adjunctive treatment in patients with a BMI more than or equal to 30 kg/m2 or BMI of 27 to 30 kg/m2 with a comorbidity if comprehensive lifestyle modifications (eg, diet, exercise, and behavioral modification) fail to achieve or sustain weight loss.

  • image Weight regain occurs with a high probability when pharmacotherapy for obesity is discontinued.

  • image Pharmacotherapy should be discontinued if weight loss of at least 5% is not achieved after 12 weeks of maximum-dose therapy with lorcaserin, phentermine–topiramate, or bupropion–naltrexone because significant weight loss is unlikely to be achieved despite continued therapy. Liraglutide should be discontinued if weight loss of at least 4% is not achieved after 16 weeks of therapy.

  • image The Food and Drug Administration (FDA) does not regulate labeling of herbal and food supplement diet agents, and content is not guaranteed.


Patient Care Process for Management of Obesity



  • Patient characteristics (eg, age, race, sex)

  • Patient history (past medical, family, social — dietary habits, tobacco use)

  • Obesity-related conditions (see Fig. 161-1)

  • Current medications including prescription, nonprescription, and herbal product use

  • Weight loss history and prior attempts to lose weight

  • Objective data

    • Height, weight, BMI, waist circumference, and blood pressure

    • Labs (eg, fasting glucose, hemoglobin A1c, lipid panel)


  • Causes of secondary obesity (eg, insulinoma, Cushing syndrome)

  • Current medications that may contribute to weight gain

  • Presence of obesity-related comorbidities (eg, hypertension, dyslipidemia, coronary artery disease, type 2 diabetes mellitus, sleep apnea, increased waist circumference; see Fig. 161-3)

  • Class of overweight and obesity determined by BMI, waist circumference, and obesity-related comorbidities (see Table 161-3)

  • Readiness to engage in weight loss efforts and potential barriers to success

  • Candidacy for treatment with implantable medical devices, bariatric surgery, or pharmacotherapy


  • Nonpharmacologic lifestyle intervention including low-calorie diet, physical activity, and behavioral modifications

  • Pharmacotherapy (if appropriate) including ...

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