Key Clinical Summary of Guideline-Concordant Obesity Care

This is a micro-learning module summary of Dr Sue Pedersen’s session which you can find here. Before participating, please read our CME and disclosure information which can be found here.

Acknowledgment: This activity is supported by an independent medical educational grant from Lilly. This online education program has been designed for healthcare professionals globally.

This summary integrates the core principles of initiating, adjusting, sustaining, and communicating obesity management, based on evidence and contemporary guidelines.

Initiation, Assessment, and Therapeutic Pillars

🤝 Bias-Aware Communication and Initiating Care

Bias-aware communication is foundational to effective obesity care. Many patients carry a history of stigma and negative clinical interactions.

• Ask Permission: Always begin the conversation by explicitly asking permission to discuss weight. This builds trust, respects autonomy, and creates psychological safety. It is the first step in the structured management framework.
• People-First Language: Use respectful language, focusing on the person, not the condition (e.g., "has obesity," not "is obese"). Avoid judgmental terms like "failure" or "struggling."
• Reframing Weight Cycling: Explain that weight cycling ("yo-yoing") is a recognized biological phenomenon, not a personal failure or lack of discipline. The body actively defends its weight, reinforcing the need for long-term, sustained therapy. Weight cycling is also associated with adverse cardiometabolic changes and increased risk of Type 2 Diabetes and CV events.

📝 The 5 A's and Comprehensive Assessment

The 5 A's of Obesity Management provide a structured, empathetic approach:

1. Ask permission and explore readiness for change.
2. Assess the patient’s story, goals, contributors, and classification.
3. Advise on evidence-based options (nutrition, activity, psychological support, medication, surgery).
4. Agree on personalized, sustainable goals.
5. Assist with drivers, barriers, referrals, and long-term support.

Assessment Beyond BMI: While clinical trials often use BMI, it is insufficient alone. Assessment must be holistic (clinical and emotional) and include:

• Anthropometrics: Vital signs, waist circumference, and waist-to-height ratio (which better reflect visceral adiposity and cardiometabolic risk).
• The 4M Framework: A structured history to cover key contributors:
• Metabolic: T2D, hypertension, dyslipidaemia, CV disease.
• Mechanical: OSA, OA, GI reflux, lower-limb pain.
• Mental health: Mood, anxiety, stigma, substance use.
• Monetary/social milieu: SES, job demands, access to care/healthy food.

🔑 The Three Pillars of Obesity Therapy

Most individuals cannot achieve or sustain meaningful weight loss through lifestyle changes alone due to complex biology. Guideline-based therapy is anchored on three integrated pillars:

1. Psychological/Behavioural Interventions: Cognitive restructuring, self-monitoring, goal setting, sleep optimization, and stress management.
2. Pharmacotherapy: Used to support weight reduction, improve comorbidities, and enhance adherence.
3. Metabolic/Bariatric Surgery: For appropriate candidates.

Pharmacotherapy: Structured Approach:

• Define Goals: Weight loss magnitude, maintenance, and/or improvement of related conditions.
• Select Medication: Use decision tables to align approved medications (e.g., GLP-based therapies, orlistat) with demonstrated benefits across cardiometabolic, mechanical, and patient-reported outcomes, considering contraindications, access, and preferences.

Adjustment, Long-Term Care, and Follow-up

🔄 Adjusting Therapy for Suboptimal Response

When a patient’s response plateaus or fails to meet co-created targets, therapy must be re-evaluated before modification. A suboptimal response does not automatically mean treatment failure.

Reassessment Checklist:

• Access/Affordability: Consistent treatment acquisition.
• Adequacy of Dose: Maximum tolerated dose achieved.
• Adherence/Tolerance: Missed doses, side effects, or interruptions.
• Barriers/Contributors: New medications, mental health burdens, or weight-promoting conditions.

Switching Medications: If targets remain unmet at the maximal tolerated dose, alternative therapies should be selected based on comparative evidence and patient-defined goals.

• Example: Tirzepatide vs. Semaglutide: Head-to-head trials (SURMOUNT-5) show that tirzepatide generally offers a higher magnitude of weight reduction and a greater probability of achieving 15% weight loss compared to semaglutide.
• Comorbidity Evidence: Select medications with robust evidence for specific, burdensome conditions. For example, tirzepatide has strong evidence for improving Obstructive Sleep Apnea (OSA), especially in patients not using CPAP (SURMOUNT-OSA).

Post-Switch Monitoring: Highly effective therapies can influence comorbidities rapidly, requiring prompt adjustment of other medications.

• Blood Pressure: May decrease early; monitor and adjust anti-hypertensive drugs.
• Thyroid Hormone: Levothyroxine needs may reduce; check TSH 1-2 months after a switch or dose change.

🕰️ Designing Structured, Long-Term Follow-up

Effective obesity management is a chronic commitment that requires sustaining progress long-term.

Pharmacotherapy Must Continue Long-Term:

• Weight Regain: Evidence from trials (STEP-4, SURMOUNT-4) shows that switching from active pharmacotherapy to placebo results in rapid and progressive weight regain and accompanying loss of health benefits.
• Chronic Disease Model: Obesity is a chronic, relapsing disease. Long-term pharmacotherapy, paired with consistent lifestyle support, is essential to maintain weight loss and sustain cardiometabolic improvement.
• Cardiovascular Protection: Medications with strong CV outcomes data (e.g., semaglutide in SELECT) should be continued indefinitely, especially in high-risk patients (e.g., post-MI), as stopping therapy significantly increases CV risk.

Guideline Recommendations:

• Obesity pharmacotherapy should be used long-term when effective, alongside behaviour change strategies.
• Medications with strong evidence for preventing weight regain include Semaglutide 2.4 mg, Tirzepatide 10-15 mg, and Orlistat.

Ongoing Care Principles:

• Frequent Follow-up: More frequent follow-up improves adherence and long-term success.
• Proactive Outreach: Intervene early at the first sign of waning motivation, missed appointments, or weight regain.
• Tailored Goals: Follow-up should focus on improving Metabolic, Mechanical, Mental, and Quality-of-Life outcomes, not just the number on the scale.