Guideline sources The following summarized guidelines for the evaluation and management of obesity are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2023), the American Diabetes Association (ADA 2023), the American Association for the Study of Liver Diseases (AASLD 2023; 2018), the World Health Organization (WHO 2023; 2015), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the American Association of Clinical Endocrinologists (AACE/AASLD 2022), the American Gastroenterological Association (AGA 2022; 2021), the American College of Gastroenterology (ACG 2021), the European Society of Cardiology (ESC 2021), the U.S. Preventive Services Task Force (USPSTF 2021; 2018; 2017; 2012), the American College of Obstetricians and Gynecologists (ACOG 2021; 2018), the European Society of https://web.pathway.md/diseases/recZS2sHS2211WWaQ 1/29 6/30/23, 1:22 AM Obesity Pathway Endocrinology (ESE 2020), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the Endocrine Society (ES 2020; 2015; 2013), the British Obesity and Metabolic Surgery Society (BOMSS 2020), the Hypertension Canada Guidelines (Hypertension Canada 2020), the American Thoracic Society (ATS 2019), the European Society of Cardiology (ESC/ESH 2018), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 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), the Society for Cardiovascular Angiography and Interventions (SCAI/PCNA/STS/AATS/AHA/ACC 2014), the American Society for Parenteral and Enteral Nutrition (ASPEN 2013), and the American Psychiatric Association (APA 2006). 1 2 3 4 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 40 41 42 Guidelines 1. Screening and diagnosis Indications for screening, adults: As per ADA 2023 guidelines: 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 As per ACE/AACE 2016 guidelines, screen all adults for obesity annually using a BMI measurement (with a cutoff point of 25 kg/m in most populations). B As per AHA/ACC 2014 guidelines, measure height and weight and calculate BMI at least annually. B As per USPSTF 2012 guidelines, screen all adults for obesity. B Indications for screening, pediatrics: As per AAP 2023 guidelines, 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 https://web.pathway.md/diseases/recZS2sHS2211WWaQ 2/29 6/30/23, 1:22 AM Obesity Pathway As per USPSTF 2017 guidelines, screen 6 years old children and adolescents for obesity. B Diagnostic criteria: As per AACE 2016 guidelines, measure BMI to confirm an excessive degree of adiposity and to classify patients as having overweight (BMI of 25-29.9 kg/m ) or obesity (BMI 30 kg/m ), after taking into account age, gender, ethnicity, fluid status, and muscularity. Obtain clinical evaluation and use clinical judgment when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and patients with sarcopenia. B Show 4 more As per AHA 2014 guidelines, use the current cutpoints for overweight (BMI of 25.0-29.9 kg/m ) and obesity (BMI 30 kg/m ) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity (BMI 30 kg/m ) to identify adults who may be at elevated risk of mortality from all causes. B 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 As per AACE 2016 guidelines: Assess risk factors for CVD in patients with overweight/obesity. B Screen for active CVD by history, physical examination, and with additional testing or expert referral based on CVD risk status in patients with overweight/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 Assessment of secondary causes (hypercorticolism): do not test for hypercortisolism in patients with obesity. Do not obtain biochemical testing in patients with clinical suspicion of hypercortisolism. D Use the same reference ranges in patients with obesity as for patients without obesity. D Assessment of secondary causes (hypopituitarism): do not obtain IGF-1/GH measurements routinely in patients with obesity. Consider obtaining IGF-1/GH testing (with a dynamic test as a minimum) only in patients with suspected hypopituitarism. D https://web.pathway.md/diseases/recZS2sHS2211WWaQ 3/29 6/30/23, 1:22 AM Obesity Pathway Assessment of secondary causes (PCOS): elicit history and perform a physical examination to screen for PCOS in premenopausal female patients with overweight/obesity and/or metabolic syndrome. B Assessment of secondary causes (binge eating syndrome): screen for binge eating disorder and night eating syndrome in patients with overweight or obesity eligible for weight-loss therapy. B Assessment of obesity-related complications (general principles): Assess the risk and existing burden of weight-related complications for making clinical decisions and developing a therapeutic plan for weight-loss therapy. B Obtain clinical evaluation for weight-related complications (anthropometric assessments of adiposity and clinical assessment of weight-related complications) in all patients with overweight or obesity because BMI alone is not sufficient to indicate the impact of excess adiposity on health status. Reevaluate patients with overweight/obesity at intervals to monitor for any changes in adiposity and adiposity-related complications over time. B Assessment of obesity-related complications (dyslipidemia): obtain screening for dyslipidemia with a lipid panel (including triglycerides, HDL cholesterol, calculated LDL cholesterol, total cholesterol, and non-HDL cholesterol) in all patients with overweight/obesity and in patients experiencing progressive weight gain. B Assessment of obesity-related complications, diabetes mellitus: As per ADA 2023 guidelines: Consider obtaining screening for prediabetes and/or T2DM in asymptomatic adult patients of any age with overweight or obesity (BMI 25 kg/m or 23 kg/m in Asian Americans) having 1 risk factor: first-degree relative with diabetes high-risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific Islander) history of CVD hypertension ( 140/90 mmHg or on therapy for hypertension) HDL cholesterol < 35 mg/dL (0.90 mmol/L) and/or triglycerides > 250 mg/dL (2.82 mmol/L) females with PCOS physical inactivity other clinical conditions associated with insulin resistance (such as severe obesity, acanthosis nigricans). C Consider obtaining risk-based screening for prediabetes and/or T2DM after the onset of puberty or after 10 years of age, whichever occurs earlier, in pediatric and adolescent patients with overweight (BMI 85th percentile) or obesity (BMI 95th percentile) and if having 1 risk factor for diabetes. C As per USPSTF 2021 guidelines, obtain screening for prediabetes and T2DM in 35-70 years old patients with overweight or obesity. Ooffer or refer patients with prediabetes to effective preventive interventions. B https://web.pathway.md/diseases/recZS2sHS2211WWaQ 4/29 6/30/23, 1:22 AM Obesity Pathway As per ACE/AACE 2016 guidelines: Obtain screening for prediabetes and T2DM mellitus and evaluate for metabolic syndrome by assessing waist circumference, fasting glucose, HbA1c, BP, and lipid panel (including triglycerides and HDL cholesterol) in patients with overweight/obesity and in patients experiencing progressive weight gain. B Assess the risk of T2DM by estimating or stratifying with indices or staging systems employing clinical data, glucose tolerance testing, and/or metabolic syndrome traits in patients with overweight or obesity. B Assessment of obesity-related complications (hypertension): Measure BP to screen for hypertension or prehypertension in all patients with overweight or obesity. B Screen for active CVD by history, physical examination, and additional testing or expert referral based on CVD risk status in patients with overweight or obesity. B Assessment of obesity-related complications (NAFLD): screen for nonalcoholic fatty liver disease with liver function testing, followed by ultrasound or other imaging modality if transaminases are elevated, in all patients with overweight or obesity. B Assessment of obesity-related complications (obstructive sleep apnea): assess for obstructive sleep apnea during medical history and physical examination in all patients with overweight or obesity. B Consider obtaining polysomnography and other sleep studies, at home or in a sleep lab, in patients at high risk for sleep apnea based on clinical presentation, the severity of excess adiposity, and symptoms. B Assessment of obesity-related complications (osteoarthritis): obtain screening for OA of the knee and other weight-bearing joints by symptom assessment and physical examination in all patients with overweight or obesity. B Assessment of obesity-related complications (urinary incontinence): screen for urinary incontinence by assessing symptoms in all female patients with overweight or obesity. B Assessment of obesity-related complications (GERD): Assess for symptoms of GERD in patients with overweight/obesity or patients with an increased waist circumference. Perform endoscopy if medical treatment fails to control symptoms of GERD in patients with obesity. B Consider performing endoscopy in patients with obesity and GERD symptoms before bariatric surgery. C Assessment of obesity-related complications (pancreatitis): monitor all patients with obesity for typical symptoms of pancreatitis (abdominal pain or gastrointestinal distress). A Assessment of obesity-related complications, hypogonadism: As per ESE 2020 guidelines, do not obtain biochemical testing for hypogonadism routinely in male patients with obesity. Asses for key clinical symptoms/signs of hypogonadism. D Show 2 more https://web.pathway.md/diseases/recZS2sHS2211WWaQ 5/29 6/30/23, 1:22 AM Obesity Pathway As per ACE/AACE 2016 guidelines, elicit history and perform a physical examination to assess for hypogonadism in all male patients with an increased waist circumference or obesity. Test for testosterone deficiency if indicated. B Assessment of obesity-related complications (hyperparathyroidism): avoid screening for hyperparathyroidism routinely in patients with obesity. D Assessment of obesity-related complications (vitamin D deficiency): avoid screening for vitamin D deficiency routinely in patients with obesity. D Assessment of obesity-related complications (asthma): assess for asthma and reactive airway disease in all patients with overweight/obesity. B Consider eliciting a medical history, performing a physical examination, and obtaining spirometry and other pulmonary function tests in patients at high risk for asthma and reactive airway disease. B Assessment of obesity-related complications (depression): screen for depression in patients with overweight or obesity. B 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 As per AACE 2016 guidelines, initiate pharmacotherapy only as an adjunct to lifestyle therapy in patients with overweight or obesity. Recognize that the addition of pharmacotherapy produces greater weight loss and weight loss maintenance compared with lifestyle therapy alone. A Show 2 more As per ES 2015 guidelines: Initiate pharmacotherapy as an adjunct to behavioral modification when possible to reduce food intake and increase physical activity in patients with a BMI > 30 kg/m and in patients with a BMI 27 kg/m with comorbidities. A Consider initiating approved weight-loss medications to ameliorate comorbidities, amplify adherence to behavior changes, improve physical functioning, allow for greater physical activity, and promote long-term weight maintenance in patients with a BMI 30 kg/m and in patients with a BMI 27 kg/m with 1 obesity-associated comorbidity (such as hypertension, dyslipidemia, T2DM, and obstructive sleep apnea). C Choice of agent: As per AGA 2022 guidelines, consider offering any of the following agents in addition to lifestyle modifications in adult patients with obesity or overweight with weight-related complications: semaglutide 2.4 mg C liraglutide 3.0 mg C phentermine-topiramate ER C https://web.pathway.md/diseases/recZS2sHS2211WWaQ 6/29 6/30/23, 1:22 AM Obesity Pathway naltrexone-bupropion ER C phentermine C diethylpropion. C Show 2 more Landmark trials: STEP 1 In patients with a body-mass index of 30 (or 27 with 1 weight-related coexisting condition) who did not have diabetes, semaglutide was superior to placebo with respect to relative weight reduction at week 68. John P.H. Wilding et al. N Engl J Med. 2021 Feb 10. As per AACE 2016 guidelines: Take into consideration differences in efficacy, side effects, cautions, and warnings characterizing medications approved for chronic management of obesity, and the presence of weight-related complications and medical history when deciding on the optimal weight-loss medication. A Offer combinations of U.S. FDA-approved weight-loss medications only in a manner approved by the FDA A or when sufficient safety and efficacy data are available to assure informed judgment regarding a favorable benefit-to-risk ratio. B Metformin: do not use metformin with the sole aim to reduce body weight. D 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 As per AACE 2016 guidelines, offer a structured lifestyle intervention program designed for weight loss (lifestyle therapy) and consisting of a healthy meal plan, physical activity, and behavioral interventions in patients with overweight or obesity. A Show 10 more As per ES 2015 guidelines, offer behavioral modifications and exercise as part of initial management in all patients with a BMI 25 kg/m . A As per AHA 2014 guidelines, offer a comprehensive lifestyle program for 6 months assisting in adhering to a lower-calorie diet and in increasing physical activity through the use of behavioral strategies in patients with overweight and obesity. A Show 3 more Dietary management: https://web.pathway.md/diseases/recZS2sHS2211WWaQ 7/29 6/30/23, 1:22 AM Obesity Pathway As per AACE 2016 guidelines, offer reducing total energy (caloric) intake as the main component of any weight loss intervention. A Updated evidence: TREATY In adult patients with obesity, time-restricted eating was not superior to daily calorie restriction with respect to reduction in body weight at 1 year. Deying Liu et al. N Engl J Med. 2022 Apr 21. As per ES 2015 guidelines, offer dietary modifications as part of initial management in all patients with a BMI 25 kg/m . A As per AHA 2014 guidelines, offer a diet to achieve reduced calorie intake as part of a comprehensive lifestyle intervention in patients with obesity or overweight. Consider offering any of the following methods to reduce food and calorie intake: 1,200-1,500 kcal/day in females and 1,500-1,800 kcal/day in males (calories adjusted for the individual's body weight) 500-750 kcal/day energy deficit an evidence-based diet restricting certain food types (such as high-carbohydrate foods, low- fiber foods, or high-fat foods) in order to create an energy deficit by reducing food intake. A Show 2 more As per ASPEN 2013 guidelines, consider offering a trial of hypocaloric (started with 50-70% of estimated energy needs or < 14 kcal/kg actual weight), high-protein (started with 1.2 g/kg actual weight or 2-2.5 g/kg ideal body weight, with adjustment of goal protein intake by the results of nitrogen balance studies) diet in patients without severe renal or hepatic dysfunction. C Sugar intake: advise reducing intake of free sugars throughout the life course. Advise reducing the intake of free sugars to < 10% of total energy intake in both adults and children. A Consider advising further reduction of the intake of free sugars to < 5% of total energy intake. B Non-sugar sweeteners: avoid using non-sugar sweeteners as a means of achieving weight control or reducing the risk of noncommunicable diseases. D 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 Show 5 more https://web.pathway.md/diseases/recZS2sHS2211WWaQ 8/29 6/30/23, 1:22 AM Obesity Pathway 7. Perioperative care Preoperative laboratory assessment: obtain a comprehensive preoperative nutritional assessment in all bariatric surgery candidates. B Show 3 more 8. Surgical interventions Indications for bariatric surgery: As per AACE 2020 guidelines, consider offering bariatric surgery to achieve optimal outcomes regarding health and quality of life when the amount of weight loss required to prevent or treat clinically significant obesity-related complications cannot be achieved using only structured lifestyle change with medical therapy. C Show 4 more As per AACE 2016 guidelines, offer bariatric surgery in patients with a BMI of 40 kg/m without coexisting medical issues and with no excessive procedural risks. A Show 2 more As per ES 2015 guidelines, offer bariatric surgery as an adjunct to behavioral modification when possible to reduce food intake and increase physical activity in patients with a BMI > 40 kg/m and in patients with a BMI 35 kg/m with comorbidities. A As per AHA 2014 guidelines, consider offering bariatric surgery in motivated adult patients with a BMI 40 kg/m or BMI 35 kg/m with obesity-related comorbid conditions not responding to behavioral treatment (with or without pharmacotherapy). Offer referral to an experienced bariatric surgeon for consultation and evaluation. B Choice of procedure: As per AACE 2020 guidelines, decide on the choice of a bariatric procedure based on individualized goals of therapy (weight-loss target and/or improvements in specific obesity- related complications), available local regional expertise (obesity specialists, bariatric surgeon, and institution), patient preferences, personalized risk stratification prioritizing safety, and other nuances as they become apparent. B Show 5 more As per AHA 2014 guidelines, decide on the choice of a specific bariatric surgical procedure based on patient factors, including age, the severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk, as well as provider factors (surgeon and facility). B 9. Specific circumstances Pediatric patients, screening: https://web.pathway.md/diseases/recZS2sHS2211WWaQ 9/29 6/30/23, 1:22 AM Obesity Pathway As per AAP 2023 guidelines, 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 As per USPSTF 2017 guidelines, screen 6 years old children and adolescents for obesity. B Pediatric patients (evaluation for comorbidities): Elicit a comprehensive patient history, obtain mental and behavioral health screening, evaluation of social determinants of health, physical examination, and the following diagnostic studies to evaluate for obesity-related comorbidities in 2-18 years old patients with overweight or obesity: B Situation Guidance Obtain a fasting lipid panel to evaluate for dyslipidemia in 10 years old pediatric and adolescent patients with obesity or overweight B . Consider evaluating for lipid abnormalities also in patients aged 2-9 years with obesity. B Dyslipidemia Obtain a fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance test, or HbA1c to evaluate for abnormal glucose metabolism in 10 years old pediatric and adolescent patients with obesity B or with overweight in the presence of risk factors for T2DM or nonalcoholic fatty liver disease. B Diabetes Obtain an alanine transaminase measurement B to evaluate for abnormal liver function in 10 years old pediatric and adolescent patients with obesity B or with overweight in the presence of risk factors for T2DM or nonalcoholic fatty liver disease. B Nonalcoholic fatty liver disease Measure BP at every visit starting at 3 years of age to evaluate for hypertension in pediatric and adolescent patients with overweight and obesity. B Hypertension Assess for symptoms and signs of the following comorbidities in pediatric and adolescent patients with obesity: https://web.pathway.md/diseases/recZS2sHS2211WWaQ 10/29 6/30/23, 1:22 AM Obesity Pathway Situation Guidance Elicit a sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, to to evaluate for obstructive sleep apnea in pediatric and adolescent patients with obesity. Obtain polysomnography in case of at least one symptom of disordered breathing Obstructive sleep apnea Assess for menstrual irregularities and signs of hyperandrogenism (hirsutism, acne) to assess the risk for PCOS in female adolescent patients with obesity PCOS Monitor for symptoms of depression in pediatric and adolescent patients with obesity. Obtain annual evaluation for depression with a formal self-report tool in 12 years old adolescent patients Depression Obtain a musculoskeletal review of systems and perform a physical examination (internal hip rotation in growing child, gait) as part of obesity evaluation. Instruct immediate and complete activity restriction, non-weight- bearing with use of crutches and refer to an orthopedic surgeon for emergent evaluation in patients with suspected slipped capital femoral epiphysis. Consider referring the patient to an emergency department if an orthopedic surgeon is not available Slipped capital femoral epiphysis Maintain a high index of suspicion for idiopathic intracranial hypertension with new-onset or progressive headaches in the context of significant wt gain, especially in females. E Idiopathic intracranial hypertension Pediatric patients (general principles of management): manage pediatric and adolescent patients with overweight or obesity following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach acknowledging obesity's biologic, social, and structural drivers. B Show 4 more https://web.pathway.md/diseases/recZS2sHS2211WWaQ 11/29 6/30/23, 1:22 AM Obesity Pathway Pediatric patients, lifestyle management: As per AAP 2023 guidelines: Offer intensive health behavior and lifestyle treatment in 6 years old patients with overweight or obesity. B Consider offering this treatment also in patients aged 2-5 years. B Offer greater contact hours ( 26 hours of face-to-face, family-based, multicomponent treatment over a 3-12-month period) of health behavior and lifestyle treatment for better results. B As per USPSTF 2017 guidelines, offer comprehensive, intensive behavioral interventions to promote improvements in weight status in 6 years old pediatric and adolescent patients with obesity. B Pediatric patients (pharmacotherapy): offer weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment in 12 years old adolescent patients with obesity. B Consider offering weight loss pharmacotherapy also in patients aged 8-11 years. E Pediatric patients (bariatric surgery): refer 13 years old adolescent patients with severe obesity (BMI 120% of the 95th percentile for age and sex) to a local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery center for evaluation for metabolic and bariatric surgery. B Elderly patients: offer weight-loss therapy involving structured lifestyle interventions, including reduced calorie meal plans and exercise, with clear health-related goals in mind, including prevention of T2DM in high-risk patients with prediabetes, BP lowering, and improvements in OA, mobility, and physical function in elderly patients ( 65 years) with overweight or obesity. A Show 2 more Pregnant patients: As per AACE 2016 guidelines: Prescribe weight-loss medications in conjunction with appropriate forms of contraception in females of reproductive potential. A Do not use weight-loss medications during pregnancy. D or breastfeeding. D Postmenopausal patients: do not use estrogen substitution therapy with the sole aim to reduce body weight in postmenopausal patients with obesity. D Patients with binge eating syndrome: As per AACE 2016 guidelines, offer a structured behavioral/lifestyle program in conjunction with CBT or other psychological interventions in patients with overweight or obesity and binge eating disorder. A Show 2 more As per RANZCP 2014 guidelines: Consider offering topiramate or orlistat for weight loss in patients with binge eating syndrome and comorbid obesity. C Monitor adverse effects of any antiepileptic or antidepressants used in patients with binge eating syndrome and modify as required. B https://web.pathway.md/diseases/recZS2sHS2211WWaQ 12/29 6/30/23, 1:22 AM Obesity Pathway As per APA 2006 guidelines, consider offering orlistat in addition to a guided self-help CBT program for weight reduction in patients with binge eating syndrome and obesity. C Patients with dyslipidemia: As per ES 2020 guidelines, consider offering lifestyle measures as first-line therapy to reduce plasma triglycerides to lower cardiovascular and pancreatitis risk in patients with obesity. C As per AACE 2016 guidelines: Offer lifestyle therapy (including physical activity program and a reduced-calorie healthy meal plan minimizing sugars and refined carbohydrates, avoiding trans fats, limiting alcohol use, and emphasizing fiber) to achieve 5-10% weight as needed to achieve therapeutic targets in patients with overweight or obesity and dyslipidemia (elevated triglycerides and reduced HDL cholesterol). A Consider initiating weight-loss medications combined with lifestyle therapy when necessary to achieve sufficient improvements in lipids (elevated triglycerides and reduced HDL cholesterol) in patients with overweight or obesity and dyslipidemia. B Patients with cardiovascular disease, hypertension: As per Hypertension Canada 2020 guidelines: Advise maintaining a healthy body weight (BMI 18.5-24.9) and waist circumference (< 102 cm for males and < 88 cm for females) for nonhypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP. B Offer weight loss in all patients with hypertension and overweight. Offer a multidisciplinary approach for weight loss, including dietary education, increased physical activity, and behavioral intervention. B As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines: Offer weight loss to reduce BP in adult patients with overweight or obesity and elevated BP/hypertension. A Offer effective behavioral and motivational strategies to achieve a healthy lifestyle, including weight loss and increased physical activity, in adult patients with hypertension. B As per ESH/ESC 2018 guidelines, advise body weight control to avoid obesity and aim for healthy BMI and waist circumference values to reduce BP and cardiovascular risk. A As per ACE/AACE 2016 guidelines, prefer orlistat, lorcaserin, phentermine/topiramate ER, and liraglutide 3 mg in patients with existing hypertension. (Grade B; BEL 1) Obtain careful monitoring of HR in patients receiving liraglutide 3 mg and phentermine/topiramate ER. A Show 2 more As per ACE/AACE 2016 guidelines, offer lifestyle therapy to achieve 5-15% weight loss as necessary to achieve BP reduction goals in a program including caloric restriction and regular physical activity in patients with overweight or obesity and elevated BP or hypertension. A Show 3 more As per ES 2015 guidelines: Do not use sympathomimetic agents phentermine and diethylpropion in patients with uncontrolled hypertension or a history of heart disease. D https://web.pathway.md/diseases/recZS2sHS2211WWaQ 13/29 6/30/23, 1:22 AM Obesity Pathway Consider offering non-sympathomimetic agents (such as lorcaserin and/or orlistat) as weight loss pharmacotherapy in patients with CVD. C Patients with cardiovascular disease, ASCVD: As per ACE/AACE 2016 guidelines: Offer orlistat and lorcaserin as the preferred weight-loss medications in patients with established ASCVD. Be cautious when using liraglutide 3 mg, phentermine/topiramate ER, and naltrexone ER/bupropion ER, and continue if weight loss goals are met, with careful monitoring of HR and BP. A Do not offer weight-loss therapy for the sole purpose of preventing CVD events or extending life, although evidence suggests that the degree of weight loss achieved by bariatric surgery can reduce mortality. D As per STS/SCAI/PCNA/AATS/AHA/ACC 2014 guidelines, advise lifestyle modifications, including daily physical activity and weight management, in all patients with stable ischemic heart disease. B Patients with cardiovascular disease, heart failure: As per HFSA/ACC/AHA 2022 guidelines, encourage healthy lifestyle habits, such as regular physical activity, maintaining normal weight, and healthy dietary patterns, to reduce future risk of HF in the general population. B As per ESC 2021 guidelines, counsel against sedentary habits and obesity to prevent or delay the onset of HF. B As per ACE/AACE 2016 guidelines, do not offer weight loss for the expressed purpose of preventing cardiovascular events or to extend life in patients with congestive HF, although evidence suggests that weight loss can improve myocardial function and congestive HF symptomatology in the short term. D Patients with cardiovascular disease (cardiac arrhythmia): offer orlistat and lorcaserin as the preferred weight-loss medications in patients with a history or risk of cardiac arrhythmia. B Be cautious when using naltrexone ER/bupropion ER, liraglutide 3 mg, and phentermine/topiramate ER with careful monitoring of HR and rhythm. A Patients with diabetes mellitus, screening: As per ADA 2023 guidelines: 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 As per ACE/AACE 2016 guidelines, evaluate patients with T2DM for the presence of overweight or obesity. B Patients with diabetes mellitus, lifestyle changes: https://web.pathway.md/diseases/recZS2sHS2211WWaQ 14/29 6/30/23, 1:22 AM Obesity Pathway As per ADA 2023 guidelines, refer adult patients with overweight or obesity at high risk of T2DM to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through a healthy reduced-calorie diet and 150 minute/week of moderate-intensity physical activity. A Show 10 more As per ACE/AACE 2016 guidelines: Offer lifestyle therapy, including a reduced-calorie healthy meal plan and a physical activity program incorporating both aerobic and resistance exercise, with a goal of 10% weight loss B to prevent progression to diabetes in 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. A Offer lifestyle therapy to achieve 5-15% weight loss as needed to achieve targeted lowering of HbA1c in patients with overweight or obesity and T2DM. Consider offering weight-loss therapy regardless of the duration or severity of T2DM, both in newly diagnosed patients and in patients with a longer-term disease on multiple diabetes medications. A Patients with diabetes mellitus, pharmacotherapy: As per ADA 2023 guidelines, take into account the medication's effect on weight when choosing glucose-lowering medications in patients with T2DM and overweight/obesity. B Show 3 more As per ACE/AACE 2016 guidelines, consider offering phentermine/topiramate ER, liraglutide 3 mg, or orlistat, in conjunction with lifestyle therapy, to achieve 10% weight loss in patients at risk for future T2DM. B Show 4 more As per ES 2015 guidelines, consider initiating antidiabetic medications having additional actions to promote weight loss (such as GLP-1 analogs or SGLT-2 inhibitors) in addition to metformin in patients with obesity/overweight and T2DM. C Show 4 more Patients with diabetes mellitus, bariatric surgery: As per ADA 2023 guidelines, offer metabolic surgery in patients with T2DM and a BMI 40 kg/m ( 37.5 kg/m in Asian American individuals) and in adult patients with BMI 35.0-39.9 kg/m (32.5-37.4 kg/m in Asian American individuals) not achieving durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A Show 4 more As per ASA/OMA/ASMBS/OS/ACE/AACE 2020 guidelines: Consider offering bariatric surgery in patients with a BMI 35 kg/m and T2DM or high risk for T2DM (insulin resistance, prediabetes, and/or metabolic syndrome). C Consider offering bariatric surgery in patients with a BMI of 30-34.9 kg/m and T2DM with inadequate glycemic control despite optimal lifestyle and medical therapy. C As per ACE/AACE 2016 guidelines, consider offering bariatric surgery, preferably Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion in patients with obesity (BMI https://web.pathway.md/diseases/recZS2sHS2211WWaQ 15/29 6/30/23, 1:22 AM Obesity Pathway 30 kg/m ) and diabetes failed to achieve targeted clinical outcomes following lifestyle therapy and weight-loss medications. B Patients with diabetes mellitus (post-bariatric care): offer long-term medical and behavioral support and obtain routine micronutrient, nutritional, and metabolic status monitoring in patients undergoing metabolic surgery. B Show 2 more Patients with nonalcoholic fatty liver disease, lifestyle changes: As per AASLD 2023 guidelines: Offer a diet leading to a caloric deficit in patients with nonalcoholic fatty liver disease with overweight or obesity. Encourage diets with limited carbohydrates and saturated fat and enriched with high fiber and unsaturated fats (such as the Mediterranean diet) when possible due to their additional cardiovascular benefits. E Encourage increasing physical activity to the extent possible in patients with nonalcoholic fatty liver disease. Consider providing individualized prescriptive exercise recommendations to increase sustainability and benefits independent of weight loss. E As per AASLD/AACE 2022 guidelines, offer lifestyle changes in patients with excess adiposity and nonalcoholic fatty liver disease with a goal of at least 5% (preferably 10%) weight loss for liver histologic and cardiometabolic benefit. Advise participating in a structured weight loss program, when possible, tailored to the patient's lifestyle and personal preferences. B Show 2 more As per AGA 2021 guidelines, offer lifestyle modifications, including diet and exercise, to achieve weight loss in all patients with nonalcoholic fatty liver disease. Recognize that weight loss 5% of total body weight can decrease hepatic steatosis, weight loss 7% of total body weight can lead to NASH resolution, and weight loss 10% of total body weight can result in fibrosis regression or stability. E Show 6 more As per AASLD 2018 guidelines: Offer weight loss to reduce hepatic steatosis, achieved either by a hypocaloric diet alone or in conjunction with increased physical activity. Strive for a 7-10% weight loss to improve the majority of the histopathological features of NASH, including fibrosis. E Advise exercising to prevent or reduce hepatic steatosis in adult patients with nonalcoholic fatty liver disease. E As per ACE/AACE 2016 guidelines: Offer lifestyle interventions involving calorie restriction and moderate-to-vigorous physical activity targeting 4-10% weight loss in patients with overweight or obesity and nonalcoholic fatty liver disease. A Consider advising a Mediterranean dietary pattern or meal plan for improving hepatic steatosis, independent of weight loss. B As per EASO/EASD/EASL 2016 guidelines, set a 7-10% weight loss as the target of most lifestyle interventions in patients with overweight/obesity to improve liver enzymes and histology. https://web.pathway.md/diseases/recZS2sHS2211WWaQ 16/29