Guidelines in Obesity management

Obesity is not synonymous of fat

1. Bray et al. Obes Rev 2017;18:715–723; 2. AMA resolutions. June 2012. Available here (accessed February 2020); 3. Obesity Canada. Available here; 4. EASO: 2015 Milan Declaration: A Call to Action on Obesity. Available here. Last accessed: June 2019; 5. Royal College of
Physicians. Anon. BMJ 2019;364:l45; https://www.rcplondon.ac.uk/news/rcp-calls-obesity-be-recognised-disease; 6. Raynor et al. J Acad Nutr Diet 2016; 116(1): 129-147; 7. AOASO position statement, Nagoya Declaration 2015. Available here
Obesity is recognised as a disease and a health
issue
“obesity and overweight as a
chronic medical condition (de
facto disease state) and urgent
public health problem…”
“A progressive disease, impacting
severely on individuals and society
alike,… obesity is the gateway to
many other disease areas…”
“Obesity is a progressive chronic
disease, similar to diabetes or
high blood pressure, …”
“obesity is a chronic, relapsing,
progressive disease process
….need for immediate action for
prevention and control of this
global epidemic”
“A pathological state (obesity disease) in which a
person suffers health problems caused by or
related to obesity thus making weight loss
clinically desirable …”
“The Treat and Reduce Obesity Act would allow a variety of
qualified practitioners, including registered dietitian
nutritionists, to more effectively treat this disease, which
impacts more than one-third of our nation."
“It (obesity) is not a lifestyle choice
caused by individual greed but a
disease caused by health
inequalities, genetic influences and
social factors..”
World Obesity Federation1 Obesity Canada3 European Association for the Study of Obesity4 American Medical Association2
Royal College of Physicians UK5 Academy of nutrition and dietetics6 Asia Oceania Association for the Study of Obesity6

Obesity-Related Complications
Obesity
Male hypogonadism,
female infertility
Cardiovascular
disease, hypertension,
hyperlipidemia
Type 2
diabetes
Asthma
Fatty liver
disease
GERD,
sleep apnea
Osteoarthritis
Depression
Garvey. Endocrine Practice. 2016;22:1.

6
Potential* Contributors to Obesity
*Potential contributors indicate anything that has been put forth in the research literature as a question of investigation and is not intended to be a verification of whether or not, or
the extent to which each may or may not contribute.
www.obesity.org.
2015
Inside the Person Outside the Person
Environmental Pressures
on Physical Activity
Biological/Medical
Maternal/Developmental
Economic
Food and Beverage
Behavior/Environment
Psychological
Social
Increased
Intake
Decreased
Expenditure
Thermogenesis
Gut Microbiota
Pain Sensitivity
Physical Disabilities
(ie. functional impairments
and regulatory dysfunction)
Gestational
Diabetes
Pre-natal
Air Pollution
Delayed Satiety
Hyper-reactivity to
Environmental Food Cues
Heightened Hunger
Response
Emotional Coping
Disordered Eating
(night eating syndrome
“food addiction”)
Age Related Changes
(ie, menopause, mobility
decline, hormones)
Chronic Inflammation
(ie, altered insulin signaling
and glucose homeostasis)
Genetic and
Epigenetic Factors
Central & Peripheral Regulators
of Appetite & Adipose Tissue
Pathological Sources of
Endocrine Dysregulation
(ie, thyroid dysfunction, PCOS,
Cushing’s Syndrome)
Social Anxiety
(ie, exercise avoidance)
Self-regulatory &
Coping Deficits
Intake &
Expenditure
(Or Unknown)
Trauma History
Mood Disturbance
(ie, depression, anxiety, bipolar, etc) Mental Disabilities
Environmental/
Chemical Toxins
Infection
(ie, human
adenovirus 36)
Weight
Gain
Inducing
Drugs
Smoking
Cessation
Sleep
Deficits
Market
Economy
Food Surplus
Pervasive Food
Advertising
Westernization &
Economic Development
Low SES &
Nutrition Support
Maternal
Employment
Breast Feeding and/or
Related Factors
Maternal
Stress
Maternal
Smoking
Maternal
Obesity
Delayed
Prenatal Care
Birth Order
(first-born in family)
Contributors to
Energy Storage
Having Children
(for women)
Non-parental
Childcare
Maternal Over-nutrition
During Pregnancy
Birth by
C-Section
Stress
Child
Maltreatment
Weight Cycling
(yo-yo dieting)
Increased Availability of
Energy Dense, Nutrient Poor
Foods & Beverages
Larger Portion
Sizes
Eating as
Recreation,
Snacking,
Special
Occasions
Increased
Intake
Lack of Nutritional
Education
Skipping Meals
Food Insecurity
Diet Patterns
Eating Away
From Home
Lack of Family
Meals
Labor Saving Devices
Decreased Opportunity for
Non-exercise Based
Physical Activity
(ie, driving vs. walking to
work and school,
sedentary jobs)
Consistent Temperature
(ie, air conditioning/heating,
thermoregulation)
Increased Sedentary Time
(ie, inactive leisure ”screen”
time, inactive job
requirements)
Built
Environment
(ie, stairwell
design/access
building design
absence of or
poor sidewalks)
Decreased
Expenditure
Family
Conflict
Social
Networks
Lack of Employer Preparedness
to Assist with Obesity
Entering Into a
Romantic Relationship
Weight Bias & Stigma
(ie, avoidance of medical care,
self esteem, teasing history)
Lack of Health Care Provider Support/Knowledge
& Inadequate Access to Care
Intake &
Expenditure
(Or Unknown)
Living in Crime-
prone Areas

1. Garvey et al. Endocr Pract 2016;22:1-203; 2. Brauer et al. CMAJ 20015;187(3):184–95; 3. Yumuk et al. Obes Facts 2015;8:402–24; 4. NICE CG189 2014. Available at: http://www.nice.org.uk/; 5. Japan Society for the Study of Obesity (JASSO) 2016; 6. Abusnana et al. Obes Facts
2018; 11:413–428; 7. Apovian et al. J Clin Endocrinol Metab 2015;100:342–62; 8. Jensen et al. J Am Coll Cardiol 2014;63(25_PA); 9. ADA. Diabetes Care 2018;41(Suppl. 1):S65–72; 10. Davies et al. Diabetes Care. 2018; 11. Mechanick et al. Obesity (Silver Spring) 2013;21(Suppl. 1):S1–
S27; 12. Fried et al. Obes Facts 2013;449–468; 13. Dixon et al. Diabet Med 2011;28:628–42
Obesity management guidelines
Obesity and Bariatric
Surgery
Obesity and
Cardiovascular Risk
Obesity in patients with
T2D
EASD/ADA10
ADA9
AHA/ACC /TOS8
AACE/TOS/ASMBS11
IFSO/EASO12
IDF13
Pharmacological
Management of Obesity
Clinical Management of
Obesity in Adults
AACE/ACE1
Canadian Adult Obesity
Clinical Practice Guidelines 2
NICE4
EASO3
JAASO5
UAE6
ENDO/ESE/TOS7

*Only relates to patients with T2D.
AACE, American Association of Clinical Endocrinologists; ACC, American College of Cardiology; ACE, American College of Endocrinology; ADA, American Diabetes Association; AHA, American Heart Association; ASMBS, American Society for Metabolic & Bariatric Surgery; BMI, body
mass index; EASO, European association for the study of obesity; ENDO, Endocrine Society; ESE, European Society of Endocrinology; IDF, International Diabetes Federation; JASSO, Japan Society for the Study of Obesity; NICE, National Institute for Health and Care Excellence; TOS,
The Obesity Society; UAE, United Arab Emirates
Defining obesity
Measures used across all guidelines
Measures used to classify obesity
BMI Waist circumference Complications
AACE/ACE 2022  
Canadian Adult Obesity Clinical
Practice Guidelines 2020


EASO 2015   
NICE 2014  
JASSO 2016 
UAE 2018 
ENDO/ESE/TOS 2015  
AHA/ACC/TOS 2013  
EASD/ADA 2018 
ADA 2022* 
AACE/TOS/ASMBS 2013* 
IDF 2011* 

BMI and WC
Source: National Heart, Lung and Blood Institute. http://www.caloriecontrol.org.

Management Goals
• Obesity-related counseling should be offered to those with BMI ≥25 kg/m2
• A 3% to 5% weight loss can result in meaningful reductions in
triglycerides, blood glucose, hemoglobin A1c, and the risk of developing
type 2 diabetes
• Set an initial weight loss goal of 5% to 10% of current body weight over 6
mo
• After 6 mo, focus on weight maintenance before attempting further
weight loss
• Participating in a weight loss program long-term can help improve weight
maintenance
10
Jensen. Circulation. 2014;129:S102.

CANADIAN ADULT
OBESITY CLINICAL
PRACTICE GUIDELINES

HCP, healthcare provider.
Obesity in adults: a clinical practice guideline. CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707; Twells LK, et al. Canadian Adult Obesity Clinical Practice Guidelines: Epidemiology of Adult Obesity. Available from: https://obesitycanada.ca/guidelines/epidemiology.
Accessed August 10, 2020.
Rationale for the New Clinical Practice Guidelines
Almost 15 years
without an update
to the Clinical
Practice Guidelines
Lack of recognition
of obesity as a
chronic disease
HCPs do not feel
equipped to
effectively manage
obesity
Increased
prevalence of
obesity
2006

BMI, body mass index; HCP, healthcare provider.
Brown J, et al. Canadian Adult Obesity Clinical Practice Guidelines: Medical Nutrition Therapy in Obesity Management. Available from: https://obesitycanada.ca/guidelines/nutrition. Accessed August 10, 2020.
Obesity Redefined to Support the Evidence
“Obesity is a complex chronic disease in
which abnormal or excess body fat
(adiposity) impairs health, increases the
risk of long-term medical complications
and reduces lifespan.”
“Obesity is defined by a BMI of ≥ 30 kg/m2
Then… Now…
The new Canadian Adult Obesity Clinical Practice Guidelines call for a shift in the obesity
treatment paradigm, focusing on patient centric care, moving away from “eat less and
move more”, and advocating for HCPs to focus on a patient’s overall health and
experience rather than solely on their weight, to determine the root causes of obesity.

HCP, healthcare provider; PwO, people living obesity.
Kirk, SFL, et al. Canadian Adult Obesity Clinical Practice Guidelines: Reducing Weight Bias, Stigma and Discrimination in Obesity Management, Practice and Policy. Available from Reducing Weight Bias in Obesity Management, Practice & Policy - Obesity Canada. Accessed August
10, 2020.
Reducing Weight Bias in Obesity Management
in Canada
1. HCPs should assess their own attitudes and beliefs regarding obesity and consider how their
attitudes and beliefs may influence care delivery
2. HCPs should recognize that internalized weight bias (bias towards oneself) in PwO can affect
behavioural and health outcomes
3. HCPs should avoid using judgmental words, images, and practices when working with PwO
Recommendations

Don’t start like that
• Doctor: “Wow! You certainly seem to have gained weight since the last time I saw
you… Don’t you realise that your weight will probably kill you if you don’t stop eating
all that junk food..?”
• Mr Brown: “Well... Yeah… I know… I am too heavy but that’s not really why I’m here
today. Actually I think I hurt my back…”
• Doctor: “Well of course you hurt your back – look at all that weight you’re carrying!
That’s what’s hurting your back!”
• Mr Brown: “Well actually I think I hurt it moving boxes, you know, I work in a
warehouse and have to move about 400 boxes a day so I spend most of my time on
my feet lifting things…”
• Doctor: “Those can’t be very heavy boxes. After all, if you had been exercising, you
would hardly be so fat..! I’m sorry, if you don’t start losing some weight, I can’t help
you with your back.”

Using the 5As of Obesity Management
Ask for permission.
1
Do a complete
assessment before
offering any advice.
2
Make sure that you
agree with the patient
on the treatment plan,
then assist the patient.
3

1
The patient journey in obesity management should follow an evidence-based approach
BMI, body mass index
Obesity in adults: a clinical practice guideline. CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707.
Assessment and Diagnosis of People Living With
Obesity
• Approach patients with
compassion and empathy
• Use Obesity Canada’s 5As
of Obesity Management™
to initiate the discussion
• Acknowledge the
complexity of this disease
ASK for permission
“Would it be okay if
we discussed your
weight today?”
Doctor: “Definitely. If the pain doesn’t get
better and you’re not sleeping and not
moving, I’m afraid you may even put on a
few more pounds.
In fact, I see here that you’ve gained a few
pounds since your last visit. Is this
something you’re concerned about?
Mr Brown: “Actually, I think I’m down five
pounds since last month. I’ve been skipping
lunch and I never have breakfast…”

The patient journey in obesity management should follow an evidence-based approach
BMI, body mass index
Obesity
• Obesity classification
• BMI and waist circumference
• Disease severity
• Edmonton Obesity Staging System
ASSESS their story
Use the 4Ms Framework to perform a complete
obesity assessment:
Mechanical Mental Social Milieu
Metabolism
2
• Doctor: “Hi Mr Brown, so I guess you’re
here to talk about losing weight. How
about we talk about healthy eating and
maybe I’ll have you see our dietitian..?”
• Mr Brown: “Well I don’t know, I’ve seen
a dietitian before, they’re just going to
put me on a diet…”
• Doctor: “Yes – but if you don’t eat less,
how are you going to lose weight?
Exercise. It’s calories in, and calories
out. Simple enough, no magic formula.”

• Doctor: “I’m glad you’re better. So… today you’re here to talk about your
weight. Why don’t you begin by telling me about your concerns?”
• Mr Brown: “Well, you know, I’ve always been big, ever since I was a kid. It
never stopped me from doing anything – I played hockey, football all
my life – but then I guess I got too busy with other stuff.”
• Doctor: “It sounds like you are pretty busy. Why don’t we start at the
beginning, and I’ll ask you a few questions about your health?”
• Mr Brown: “OK, sure.”
• Doctor: “So why don’t you begin telling me about your stress levels? Are you
happy with your life?”
Right Approach in assessment

The 4 Ms of obesity
It is always important to assess mental health problems
Look for mechanical consequences of excess weight
Look for the metabolic issues that can arise from excess
weight
Also look at the monetary health of your patient.
• Obesity in adults: a clinical practice guideline. CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707.

Sharma AM & Kushner RF, Int J Obes 2009
The Edmonton Obesity Staging System

Don’t forget drug history
Medication Class Associated With Weight Gain Weight Neutral/Promote Weight Loss
Antidepressants
Selective serotonin reuptake inhibitors,
mirtazapine, tricyclic antidepressants
Bupropion
Antipsychotics
Clozapine, olanzapine, risperidone,
quetiapine, paliperidone
Zonisamide, ethosuximide
Mood stabilizers/
anticonvulsants
Divalproex, valproic acid, pregabalin,
gabapentin, lithium?
Lamotrigine, lithium?, topiramate,
felbamate, ziprasidone, zonisamide
Antidiabetic agents
Insulin, sulfonylureas,
sulfonylureas/rosiglitazone
Glucagon-like polypeptide-1
agonist, metformin, sodium–glucose
cotransporter-2 inhibitors
Hormonal contraception Injectable contraceptives Barrier methods, oral contraceptives
Corticosteroids Prednisone, methylprednisolone Nonsteroidal anti-inflammatories
Apovian. J Clin Endocrinol Metab. 2015; 100:342. Ethosuximide PI. Topiramate PI. Felbamate PI.
Chaudhury. Front Endocrinol. 2017;8:6. Verhaegen. Current Obesity Reports. 2021;10:1.

Obesity
3
Focus on building individualized care plans that:
• Address three root causes of obesity
• Support for behavioural change
ADVISE on management AGREE on goals
4
Medical Nutrition Therapy
Physical Activity
Psychological
& behavioural
interventions
Pharmacotherapy Bariatric
surgery
• HCPs should collaborate with
patients to:
• Create a personalized, sustainable
action plan
• Mitigate weight stigma
• Redefine success
ASSIST WITH DRIVERS & BARRIERS
5
• The personalized action plan should
be designed to address the patient’s
drivers of weight gain

Lifestyle interventions
• It is not that easy…

Slide credit: ProCE.com 28
Treatment of Obesity: Lifestyle Intervention
Dietary Therapy
Reduced-calorie healthy meal
plan (500-750 kcal daily deficit)
Individualized
Meal plan options:
Mediterranean, DASH,
low carb, low fat, etc
Increase Physical
Activity
Aerobic physical activity
progressing to >150 min/
wk on 3-5 separate days
Resistance exercise:
2-3 times/wk
Behavioral Therapy
Self-monitoring (food,
exercise, weight)
Goal setting
Education
Stimulus control
Stress reduction
Consider adding pharmacotherapy to lifestyle intervention in patients who qualify
Garvey. Endocrine practice. 2016;22:1.

A1C, glycated hemoglobin; ALT, alanine aminotransferase; BMI, body mass index; BP, blood pressure; EOSS, Edmonton Obesity Staging System; HCP, healthcare professional; PwO, people living with obesity.
Rueda-Clausen CF, et al. Canadian Adult Obesity Clinical Practice Guidelines: Assessment of People Living with Obesity. Available from: https://obesitycanada.ca/guidelines/assessment . Accessed August 10, 2020.
Assessment and Diagnosis of People Living with
Obesity
1. We suggest that HCPs use the 5As framework to initiate the discussion by asking for their permission and
assessing their readiness to initiate treatment
2. Healthcare providers can measure height, weight and calculate BMI in all adults, and measure waist
circumference in individuals with a BMI of 25–35 kg/m2
3. We suggest a comprehensive history to identify root causes of weight gain as well as complications of
obesity and potential barriers to treatment be included in the assessment
4. We recommend BP measurement in both arms, fasting glucose or A1C and lipid profile to determine
cardiometabolic risk and, where appropriate, ALT to screen for nonalcoholic fatty liver disease in PwO
Recommendations

A1C, glycated hemoglobin; ALT, alanine aminotransferase; BMI, body mass index; BP, blood pressure; EOSS, Edmonton Obesity Staging System; HCP, healthcare professional; PwO, people living with obesity.
Rueda-Clausen CF, et al. Canadian Adult Obesity Clinical Practice Guidelines: Assessment of People Living with Obesity. Available from: https://obesitycanada.ca/guidelines/assessment . Accessed August 10, 2020.
Medical Nutrition Therapy in Obesity Management
1. We suggest that nutrition recommendations for adults of all body sizes should be personalized to meet
individual values, preferences and treatment goals to support a dietary approach that is safe, effective,
nutritionally adequate, culturally acceptable and affordable for long-term adherence
2. Adults living with obesity should receive individualized medical nutrition therapy provided by a registered
dietitian (when available) to improve weight outcomes (body weight, BMI), waist circumference, glycemic
control, established lipid, and blood pressure targets
3. Adults living with obesity and impaired glucose tolerance (prediabetes) or type 2 diabetes may receive
medical nutrition therapy provided by a registered dietitian (when available) to reduce body weight and
waist circumference and improve glycemic control and blood pressure.
4. Adults living with obesity can consider any of the multiple medical nutrition therapies to improve health-
related outcomes, choosing the dietary patterns and food-based approaches that support their best
long-term adherence
Recommendations

Patient Counseling Tips: Diet
Do not drink your calories, except for milk
Track your food intake
Limit the extras to 200 calories/day
Increase water intake
Make nonstarchy vegetables the star of your plate
Limit restaurant meals to once/wk

Bests Diets for 2021: US News
• Mediterranean diet
• DASH diet
• Flexitarian diet
• MIND diet
• Mayo Clinic diet
health.usnews.com/best-diet/best-diets-overall
Image used with permission of Mayo Foundation for Medical Education and Research, All rights reserved.
Mayo Clinic Diet

QoL, quality of life.
Boulé NG, Prud’homme D. Canadian Adult Obesity Clinical Practice Guidelines: Physical Activity in Obesity Management. Available from: https://obesitycanada.ca/guidelines/physicalactivity.
Accessed August 10, 2020.
Physical Activity in Obesity Management
1. Aerobic physical activity (30–60 minutes of moderate to vigorous intensity most days of the week) can be considered for
adults who want to:
a) Achieve small amounts of body weight and fat loss
b) Favour weight maintenance after weight loss
c) Favour the maintenance of fat-free mass during weight loss and;
d) Increase cardiorespiratory fitness and mobility
2. Regular physical activity, with and without weight loss, can improve many cardiometabolic risk factors in adults who have
overweight or obesity, including:
• Hyperglycaemia and insulin sensitivity
• High blood pressure
• Dyslipidaemia
Recommendations

Move Your Way Public Message
Practical Tips
 Start low and go
slow… BUT GO
 Schedule in activity—
make it a priority
 Increase daily activity
 Make it fun
 Vary the exercise
routine
 Exercise in a group
health.gov/moveyourway

Behavioral Therapy: Practical Tips
 Close the kitchen
 Keep food out of sight
 Practice mindful eating
 Get adequate sleep and reduce
stress
 Identify and avoid triggers
https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=353

Stress and Depression
 “Down” because of
recent weight gain
 No time to focus on “me”
 Frustration with
everything that’s failed
 Screen for depression
and anxiety
 Journaling, discussion
of priorities
 Setting realistic goals;
“rewriting your story”
Sharifi. Health Promot Perspect. 2013;3:11.

Social Pressure
 Family does not
support diet
 Friends want me to
go out
 Picky eaters at home
 First appointment:
Find a point person
 Set expectations;
preplan and bring food
 Joint appointments
with family; family
meetings with dietitian

Food Cravings
 Hunger
 Craving my “cheats”
 Cheat when food is
around
 Binge eating
 Water, water, water
 Increasing protein
 Medications
 Cheats not available:
Remove from house
 Screen for binge eating
 counseling

Cost
 Gym/healthy food is
expensive
 Reduced gym
memberships based on
income
 Free local events and
activities
 Outdoor hiking/walking
 Youtube videos
 Free tracking apps
(eg, MyFitnessPal)
 Preprinted recipes with
minimal ingredients

What’s New in the 2022 Pharmacotherapy Chapter Update?
• Recommendations updated to include fourth medication now approved in
Canada (Semaglutide 2.4mg weekly)
• Broadened search strategy to identify data in subpopulations with specific
obesity-related comorbidities
• New recommendations for pharmacotherapy for people with obesity and
• Obstructive sleep apnea
• Non-alcoholic steatohepatitis (NASH)
• Pharmacotherapy decision tool and table
• New sections on other health comorbidities, cravings and control of eating, and
quality of life
Pedersen SD, Manjoo P, Wharton S.
https://obesitycanada.ca/guidelines/pharmacotherapy

42
Why Use Pharmacotherapy For Obesity?
• Sustained weight loss is associated with improvements in comorbidities
associated with obesity
• Healthy behaviour changes alone generally achieve only a 3%–5% weight
loss, which is most often not sustained over the long term
• Obesity pharmacotherapy can facilitate weight management and
optimize health when healthy eating and physical activity alone have
been ineffective, insufficient or without sustained benefit.
• The focus of obesity management should be improvement of health
parameters (metabolic, mechanical, mental health, quality of life), not
solely weight reduction

44
Treat, Treat Early, And Treat Long Term
• Obesity medications are prescribed far less frequently than medications for other
chronic medical conditions, and adoption rate of new medications much slower
• Obesity pharmacotherapy should be considered early in the natural history of
obesity, as obesity related health complications tend to increase and progress with
time
• Obesity medications are intended as a long term treatment strategy. Clinical trials
consistently demonstrate weight regain when treatment is stopped.

Therapeutic Weight Loss Reduces Complications
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Diabetes (Prevention)
Hypertension
Dyslipidemia
Hyperglycemia (A1C)
NAFLD (Steatosis, Inflammation, Mild Fibrosis)
Sleep Apnea
Osteoarthritis (Symptoms and Joint Stress Mechanics)
Stress Incontinence
GERD (Men)
GERD (Women)
PCOS (Androgens, Ovulation, Insulin Sensitivity)
Weight Loss Required for Therapeutic Benefit (%)
3% to 10%
5% to > 15%
3% to > 15%
3% to > 15%
10%
10%
10%
5% to 10%
5% to 10%
5% to 10%
5% to 15% (> 10% optimal)
Cefalu. Diabetes Care. 2015;38:1567. Slide credit: clinicaloptions.com

*Approved for short-term use. FDA Drugs: http://www.fda.gov/Drugs/default.htm; EMA Medicines: http://www.ema.europa.eu/
Pharmacological options for weight management
Orlistat
(Xenical®, Alli®)   Energy wastage
Mode of action Indications
Phentermine/topiramate
(Qsymia®) 

Phentermine*
(Adipex-P®, Suprenza®) 
 Appetite reduction
Lorcaserin
(Belviq®, Belviq XR®) 
Naltrexone/bupropion
(Mysimba®, Contrave®)  
Liraglutide 3.0 mg
(Saxenda®)  
Adjunct to diet and physical activity for
chronic weight management in
a) obesity BMI ≥30 kg/m2
b) overweight BMI ≥27 kg/m2
with comorbidity
Semaglutide 2.4 mg
(Wegovy®)  
Appetite reduction
Appetite reduction
Appetite reduction
Appetite reduction
Appetite reduction


* Pharmacotherapy option listed if evidence is available and cited in the guidelines.
† Placebo subtracted.
CART, cocaine- and amphetamine-regulated transcript; CV, cardiovascular; GLP-1, glucagon-like peptide-1; GIP, gastric inhibitory polypeptide; NASH, nonalcoholic steatohepatitis; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome; POMC, pro-opiomelanocortin; QoL,
quality of life. Pedersen SD, Manjoo P, Wharton S. Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy for Obesity Management. Available from: https://obesitycanada.ca/guidelines/pharmacotherapy.
Pharmacotherapy in Obesity Management
Pharmacotherapy: Effects on weight loss and weight maintenance* Pharmacotherapy: Effects on other health parameters*
Prediabetes
• Liraglutide 3.0 mg
• Orlistat
Type 2 diabetes
• Semaglutide 2.4 mg
• Orlistat
• Naltrexone/bupropion
Other CV risk factors
NASH
PCOS
• Liraglutide 3.0 mg (NS)
OSA
Mental Health & QoL
Z
Z
Z
% Weight loss (1 year)†
• Orlistat
Weight over longer term†
• Orlistat
% of patients achieving ≥5%
weight loss (1 year)
• Orlistat
% of Patients achieving ≥10%
weight loss (1 year)
• Orlistat
Effect on maintenance of previous weight loss
• Orlistat

48
Choosing Obesity Pharmacotherapy – Decision Tool
Decision tool concept: Sharma AM

49
Choice of Obesity Pharmacotherapy: Medications Approved

BMI, body mass index; OTC, over the counter.
Pedersen SD, et al. Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy in Obesity Management. Available from: https://obesitycanada.ca/guidelines/pharmacotherapy. Accessed August 10, 2020.
Pharmacotherapy in Obesity Management
1. Pharmacotherapy for weight loss can be used for individuals with BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with adiposity-
related complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions
(semaglutide 2.4 mg weekly [Level 1a Grade A], liraglutide 3.0 mg daily [Level 2a, grade B], naltrexone/bupropion 16
mg/180 mg BID [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B])
2. Pharmacotherapy may be used to maintain weight loss that has been achieved by health behaviour changes, and to
prevent weight regain (liraglutide 3.0 mg or orlistat)
3. For people living with type 2 diabetes and a BMI ≥ 27 kg/m2, pharmacotherapy can be used in conjunction with health
behaviour changes for weight loss and improvement in glycaemic control (semaglutide 2.4 mg weekly, liraglutide 3.0
mg, naltrexone/bupropion combination, orlistat)
Recommendations

BMI, body mass index; OTC, over the counter.
Pedersen SD, et al. Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy in Obesity Management. Available from: https://obesitycanada.ca/guidelines/pharmacotherapy. Accessed August 10, 2020.
Pharmacotherapy in Obesity Management (cont.)
4. Pharmacotherapy for obesity management in conjunction with health-behaviour changes for people living with
prediabetes and overweight or obesity (BMI ≥ 27 kg/m2) can be used to delay or prevent type 2 diabetes (T2DM)
(liraglutide 3.0 mg daily or orlistat).
5. Pharmacotherapy can be considered in conjunction with health-behaviour changes in treating people with obstructive
sleep apnea and BMI ≥ 30 kg/m2, for weight loss and associated improvement in apnea-hypopnea index (liraglutide 3.0
mg)
6. Pharmacotherapy can be considered in conjunction with health-behaviour changes in treating people living with non-
alcoholic steatohepatitis (NASH) and overweight or obesity, for weight loss and improvement of NASH parameters
(liraglutide 1.8 mg daily, semaglutide).
7. We do not suggest the use of prescription or OTC medications other than those approved for weight management
Recommendations

Medications for Weight Loss
Several medications and medication
combinations approved in the US or
Europe for WL have been found to
improve glucose control in people with
diabetes
Metabolic surgery is a recommended
treatment option for adults with T2D
and:
• Metformin is the preferred initial
glucose-lowering medication for most
people with type 2 diabetes.
ACC, American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; T2D, type 2 diabetes; TOS, The Obesity Society, WL, weight loss
Jensen et al. J Am Coll Cardiol 2014;63(25_PA)
EASD/ADA Consensus Statement 2018
Obesity Management Beyond Lifestyle Intervention
For patients with obesity, efforts targeting WL, including lifestyle, medication,
and surgical interventions, are recommended

Diabetes Care 2022;45(Suppl. 1):S113–S124 | https://doi.org/10.2337/dc22-S008
Highlighted Updates 2022
Obesity Management for the Treatment of Type 2 Diabetes
● The concept of person-centred communication that uses nonjudgmental
language has been added as Recommendation 8.1, with additional
discussion in the “Assessment” subsection.
● More detail has been added to the “Pharmacotherapy” subsection,
particularly focused on assessing efficacy and safety.

¶For more details on metabolic surgery please refer to the source document for full recommendations
* Recommended cut points for Asian American individuals (expert opinion).
BMI, body mass index; T2D, type 2 diabetes
† Treatment may be indicated for select motivated patients.
Diabetes Care 2022;45(Suppl. 1):S113–S124 | https://doi.org/10.2337/dc22-S008
Treatment options for overweight and obesity
in T2D - ADA SoC 2022
BMI category (kg/m2)
Treatment
25.0–26.9
(or 23.0–24.9*)
27.0–29.9
(or 25.0–27.4*)
≥30.0
(or ≥27.5*)
Diet, physical activity, and behavioral therapy † † †
Pharmacotherapy † †
Metabolic surgery †

• Persons with prediabetes, T1D or T2D, and obesity/adiposity-based
chronic disease (ABCD) have 2 diseases, and each should be
treated effectively with the goal of optimizing their respective
outcomes.
• For most adults, BMI values that indicate excess body weight are 25
to 29.9 kg/m2 for overweight and 30 kg/m2 for obesity, and WC
threshold values 102 cm for men and 88cm for women
• Persons with T2D and ABCD should be treated with weight-loss
interventions which will both improve glycemic control and prevent or
treat ABCD complications. The target for weight loss should be
>5% to ≥10% of baseline body weight.
AACE 2022 Recommendation in obesity

IFSO/EASO Guidelines
on Metabolic and
Bariatric Surgery

*BMI criterion may be the current BMI or previously maximum attained BMI of this severity; ‡For example metabolic disorders, cardiorespiratory disease, severe joint disease or obesity-related severe psychological problems; BMI, body mass index; EASO, European Association
for the Study of Obesity; IFSO-EC, International Federation for the Surgery of Obesity – European Chapter; QoL, quality of life; T2D, type 2 diabetes
Fried et al. Obes Facts 2013;449–468
IFSO/EASO Guidelines on Metabolic and
Bariatric Surgery 2013
• Adults (aged 18–60 years) with BMI ≥40 kg/m2* or BMI 35–40 kg/m2 with
complications in which surgically induced weight loss is expected to improve the disorder‡
• Patients with BMI ≥30–<35 kg/m2 with T2D may be considered for bariatric surgery on an
individual basis
• In patients aged >60 years, the primary objective of surgery is to improve QoL, even though
surgery is unlikely to increase lifespan
• The proof of favourable risk benefit must be demonstrated before surgery is contemplated
Guideline recommendations: which patients should be granted bariatric surgery?
Guideline recommendations: which patients should be granted bariatric surgery?

EASO, European Association for the Study of Obesity; IFSO-EC, International Federation for the Surgery of Obesity – European Chapter
Fried et al. Obes Facts 2013;449–468
IFSO/EASO Guidelines on Metabolic and
Bariatric Surgery 2013
• A laparoscopic technique should be considered as the preferable operation in bariatric
surgery, providing no contraindications for the approach are present
• A decision to offer surgery should follow a comprehensive interdisciplinary assessment
• Psychological assessment of behavioural, nutritional, familial and personality factors should
be an integral part of the patient’s pre-operative evaluation
• After bariatric all procedures require regular lifelong qualified surveillance
• Upon failure to lose weight or to maintain weight loss following bariatric surgery, if medically
indicated and if the patient is willing, further bariatric surgery should be considered
Guideline recommendations: other recommendations for bariatric surgery

Final Bottomline

Obesity is chronic disease
• Include lifestyle counseling for all patients with obesity
• Behavioral therapy may be beneficial for some patients
• Pharmacotherapy may be used adjunctively for BMI ≥30 kg/m2 or
BMI ≥27 kg/m2 with concomitant obesity-related disease or risk factors
• There are multiple FDA-approved weight loss pharmacotherapy options—choose the
one that best fits your patient

62
Consider pharmacologic treatment early
• Pharmacotherapy is an important Pillar in the management of obesity
• The focus of treatment should be the improvement of health
parameters, not solely weight reduction, and should include outcomes
that the patient identifies as important
• Obesity medications are intended as part of a long-term treatment
strategy

Thank you

Guidelines in Obesity management

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Guidelines in Obesity management

Similar to Guidelines in Obesity management (20)

More from Usama Ragab

More from Usama Ragab (20)

Recently uploaded

Recently uploaded (20)

Guidelines in Obesity management