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Department of Veterans Affairs

Department of Defense

VA/DoD Clinical Practice Guideline

for 

SCREENING AND MANAGEMENT 

OF OVERWEIGHT AND OBESITY

Guideline Summary

Prepared by:

The Management of Overweight and Obesity Working Group

With support from:

The Office of Quality Safety and Value, VA, Washington, DC

and

Quality Performance Assurance Directorate, United States Army MEDCOM

Full guideline available at:

http://www.healthquality.va.gov or https://www.qmo.amedd.army.mil

QUALIFYING STATEMENTS

The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist decision-making. 

They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted 

as prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual 

patients, available resources, and limitations unique to an institution or type of practice. Every health care professional 

making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any 

particular clinical situation. 

Version 2.0 – 2014

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2 | Guideline Summary – 2014

TABLE OF CONTENTS

INTRODUCTION............................................................................................................................................................... 3

ALGORITHM...................................................................................................................................................................... 6

ANNOTATIONS:

SECTION A: SCREENING AND ASSESSMENT ............................................................................................................ 8

SECTION B: MANAGEMENT OF OVERWEIGHT AND OBESITY..............................................................................10

SECTION C: TREATMENT INTERVENTIONS.............................................................................................................12

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Screening and Management of Overweight and Obesity | INTRODUCTION | 3

INTRODUCTION

KEY ELEMENTS OF WEIGHT LOSS MANAGEMENT

1. Obesity is a chronic disease requiring lifelong commitment to treatment and long‐term maintenance

2. Obesity may not be the chief complaint in a patient encounter, yet it requires foremost attention

3. The primary care team plays an integral role in weight management

4. Screening, documentation, and regular assessment are critical to weight management

5. Assessment for obesity‐associated chronic health conditions is an essential component of treatment

decisions

6. Shared decision‐making and assessment of patient motivation are fundamental to weight

management

7. Comprehensive lifestyle intervention is central to successful and sustained weight loss

8. Tangible intermediate and long‐term weight loss goals are critical to weight loss success

9. Energy deficit should be achieved through decreased caloric intake and increased physical activity

10. Pharmacotherapy and bariatric surgery may be considered as adjuncts to comprehensive lifestyle

intervention

EXECUTIVE SUMMARY 

Obesity and associated chronic health conditions cause significant morbidity and negatively impact military readiness. 

Sixty‐one to 83% of Department of Defense (DoD) beneficiaries and 78% of Veterans are overweight or obese, and 

excess weight is estimated to cost at least $370 per patient per year in additional medical and non‐medical costs. 

Treatment of both overweight and obesity is consistent with the priorities outlined by the leadership of the Department 

of Veterans Affairs as a part of personalized, proactive Veteran‐driven care. Similarly, it is consistent with the DoD’s 

priority for a fit fighting force and embodied in the US Army’s Performance Triad of Nutrition, Physical Activity, and Sleep. 

Moreover, screening, treatment, and follow‐up of overweight and obesity can be successfully managed in the primary 

care setting with an interdisciplinary approach. 

Overweight and obesity are typically identified through screening or as a result of presentation for obesity‐associated 

chronic health conditions. Routine screening should include measurement of height and weight to calculate body mass 

index (BMI) in all patients. Normal adult weight is defined by a BMI of 18.5‐24.9 kg/m2. Overweight is defined by a BMI 

between 25.0 and 29.9 kg/m2. Obesity is defined by a BMI ≥ 30.0 kg/m2 and can be sub‐classified as Stage 1 (BMI 30.0 to 

34.9 kg/m2), Stage 2 (BMI 35.0 to 39.9 kg/m2), or Stage 3 (BMI ≥ 40 kg/m2). Measurement of waist circumference may also 

be useful to predict risk in overweight and obese patients as it is considered a comorbidity equivalent. In these patients, 

the presence of obesity‐associated chronic health conditions should be identified. Normal weight and overweight 

patients without obesity‐associated chronic health conditions may be offered education, information, and counseling 

about a healthy lifestyle and maintaining or achieving a healthy weight. Comprehensive lifestyle intervention for weight 

loss should be offered to all obese patients and overweight patients with obesity‐associated chronic health conditions. 

Comprehensive lifestyle intervention is the foundation of treatment for overweight and obesity and should include at 

least 12 contacts over a year of an intervention that combines dietary, physical activity and behavioral components. Diet 

and physical activity together must create an energy deficit of 500¬1000 kcal/day for effective weight loss. Adherence to 

any particular calorie‐deficit diet is more important than choice of a specific diet. Physical activity, through short bursts 

of activity or a single longer episode, typically must accumulate to at least 150 minutes per week. On average, weight 

loss will occur at the rate of 0.5 to 2 pounds per week, plateauing between three and six months. After a plateau is 

reached, reassessment for weight maintenance or additional weight loss is required. 

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4 | Guideline Summary – 2014

A shared decision‐making model should be employed to reach a mutual understanding of risks and benefits of 

treatment, to explore patient priorities, and to determine if a patient is willing to commit to an intervention. For a 

patient who is unwilling, a motivational intervention should be used and reassessment should be undertaken at least 

biannually. For a patient who is willing to participate in an intervention, an individualized plan should be formulated, 

tangible intermediate and long‐term weight loss goals must be identified, and frequent reassessment should be 

arranged. 

Continued treatment should be guided by a patient’s intermediate weight loss goals. Patients who are meeting 

goals should continue current treatment until long‐term weight loss goals are achieved. For patients not meeting 

intermediate goals, the treatment plan should be modified to address any barriers to treatment adherence. When 

no further amelioration of barriers is possible and weight loss has plateaued, adjunctive interventions such as 

pharmacotherapy or referral for bariatric surgery may be considered in select patients. Patients who do not complete 

intensive treatment should be offered a motivational intervention and reassessed at least biannually. All patients 

reaching their long‐term goals should be offered a maintenance program, ongoing support, and periodic reassessment. 

Weight loss treatment for overweight and obesity can be effectively delivered through an interdisciplinary approach 

in a primary care setting. Comprehensive lifestyle intervention alone and comprehensive lifestyle intervention with 

adjunctive pharmacotherapy or bariatric surgery are effective for many. Though providing these interventions will 

require upfront resources from health‐care systems, they have the potential to reduce lifetime medical costs. Through 

effective management, morbidity from obesity‐associated chronic health conditions can be reduced and military 

readiness improved. 

Strength of Recommendation Rating [SR]

Strength of Recommendation (SR)

A A strong recommendation that the clinicians provide the intervention to eligible patients. 

Good evidence was found that the intervention improves important health outcomes and concludes that 

benefits substantially outweigh harm. 

B A recommendation that clinicians provide (the service) to eligible patients.

At least fair evidence was found that the intervention improves health outcomes and concludes that benefits 

outweigh harm.

C No recommendation for or against the routine provision of the intervention is made.

At least fair evidence was found that the intervention can improve health outcomes, but concludes that the 

balance of benefits and harms is too close to justify a general recommendation.

D Recommendation is made against routinely providing the intervention to asymptomatic patients.

At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.

I The conclusion is that the evidence is insufficient to recommend for or against routinely providing 

the intervention.

Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits 

and harms cannot be determined.

In annotations for which there is evidence-based research that supports the recommendations, the Strength of Recommendation [SR] based on the level of evidence is presented in brackets for these recommendations. Recommendations 

that are not based on evidence were derived by consensus of experts and are followed by the letters [EO] 

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed 

by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care 

options and health outcomes while rating both the quality of the evidence and the strength of the recommendations. 

The final guideline document represents a synthesis of current scientific knowledge and rational clinical practice on the 

assessment and treatment of adult patients diagnosed with overweight or obesity. It attempts to be as free as possible 

of bias toward any theoretical or empirical approach to treatment.

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Screening and Management of Overweight and Obesity | INTRODUCTION | 5

This Guideline is the product of many months of diligent effort and consensus building among knowledgeable 

individuals from the VA and the DoD. An experienced moderator facilitated the multidisciplinary Working Group. The 

draft document was discussed in a face-to-face group meeting. The content and validity of each section was thoroughly 

reviewed in a series of conference calls. The final document is the product of those discussions and has been approved 

by all members of the Working Group.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific 

testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. 

Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional 

TRICARE Managed Care Support Contractor.

ORGANIZATION OF THE GUIDELINE

Algorithm:

The clinical algorithm incorporates the information presented in the guideline in a format that maximally facilitates 

clinical decision-making. The algorithmic format allows the provider to follow a linear approach to critical information 

needed at the major decision points in the clinical process. The algorithm includes decisions to be considered and 

actions to be taken. Standardized symbols are used to display each step in the algorithm and arrows connect the 

numbered boxes indicating the order in which the steps should be followed.

The guideline is organized around two clinical algorithms:

Algorithm A: Screening and Assessment of Overweight and Obesity in Primary Care.

Algorithm B: Management of Overweight and Obesity.

Annotations 

The Annotations are presented in three sections addressing the following components of care:

Section A: Screening and Assessment

Section B: Management of a Patient Diagnosed with Overweight or Obesity 

Section C: Treatment Interventions

Annotations to the algorithm include recommendations. The annotations match the box numbers and letters (e.g., [A]) 

in the respective algorithms. 

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6 | Guideline Summary – 2014

Algorithm A: Screening and Assessment in Primary Care

2

3

6

4 5

7

9

12 8

13

14 10

11

1

Yes

Yes

Yes

No

No

No

Screen for overweight and obesity annually.

Obtain height and weight; 

Calculate Body Mass Index (BMI)

 [ A-2 ]

Is the person obese?

(BMI ≥ 30 kg/m2)

Is the person 

overweight?

(BMI 25-29.9 kg/m2)

Are any obesity-associated 

health conditions present?

Assess for obesity-associated

 health condition(s)

(See sidebar A)

[ A-3]

Adult person enrolled in the 

VHA or DoD healthcare systems

[ A-1 ]

Normal weight

(BMI 18.5 - 24.9 kg/m2)

Overweight without obesity 

associated conditions

(BMI 25 - 29.9 kg/m2)

Overweight with one or more obesity 

associated health conditions

(BMI 25 - 29.9 kg/m2)

Obese

(BMI ≥ 30 kg/m2)

Consider providing information and 

behavioral counseling about healthy diet 

and physical activity behaviors in order to 

pursue/maintain a healthy weight

[ B-1 ]

Repeat screening annually

[ A-2 ]

Recommend patient participate in 

comprehensive lifestyle interventions

(See sidebar C)

[ B-2 ]

Continue on Algorithm B

Management of Overweight and Obesity

Sidebar A. Common Obesity-associated Health Conditions *

Sidebar B. Behavioral Counseling

• Hypertension **

• Type 2 diabetes and pre-diabetes **

• Dyslipidemia** 

• Metabolic syndrome 

• Obstructive sleep apnea 

• Degenerative joint disease 

• Non‐alcoholic fatty liver disease

* Increased waist circumference is considered an obesity comorbidity equivalent

** At least moderate evidence exists for modifying these conditions with weight loss

Healthcare staff -delivered activities to assist patients to 

adopt, change or maintain healthy dietary and physical 

activity behaviors

Sidebar C. Comprehensive Lifestyle Intervention

Intervention that combines dietary, physical activity, 

and behavioral components and includes at least 12 

intervention sessions over a 12 month period

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Screening and Management of Overweight and Obesity | ALGORITHMS | 7

Algorithm B: Management of Overweight and Obesity

16

18

19

15

17

20 21

22

23

24

25

27 26

28

29

Yes

Yes

Yes

Yes

No

No

No

No

No

Obtain targeted medical history and 

physical examination.

Assess factors that may contribute to obesity

[ A-4 ]

Obese person or overweight with one or more 

obesity-associated health condition(s)

Return to Box 19

Offer comprehensive lifestyle intervention.

(See sidebar C)

Set intermediate and long-term 

weight loss goals, and address barriers

[ B-5 ]

Consider pharmacotherapy and/or 

bariatric surgery as an adjunct therapy

 if appropriate

[ C-4, C-5 ]

Reassess patient’s readiness 

to lose weight

Return to Box 17

Offer comprehensive weight 

maintenance program

[ B-7 ]

Continue with current 

treatment plan and reassess 

as needed

Assess adherence and modify 

treatment

[ B-6 ]

Is patient willing to commit to an 

effective weight loss program? 

Use motivational interviewing 

to reinforce knowledge, 

motivation, skills and support

(See sidebar D)

[ B-4 ]

Discuss treatment options

Reach shared decision about goals and 

treatment plan

[ B-3 ]

Reassess willingness at 

subsequent visits

Return to Box 17

Has patient met intermediate 

weight-loss goals?

Has long-term weight-loss 

goals been met?

Can barriers be further 

modified?

 Assess patient’s readiness to lose weight 

Sidebar D. Principles and Core

Strategies of Motivational Interviewing

• Resist directing

• Understand the patient’s motivation

• Listen with empathy

• Empower the patient by building confidence

• Ask open-ended questions to evoke change talk

• Provide affirmation, reflection, and summaries

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8 | Guideline Summary – 2014

Section A: Screening and Assessment

Annotation A-1 Adult person Enrolled in the VHA or DOD Healthcare Systems

Any adult eligible for care in the Veterans Health Administration (VHA) or the Department of Defense (DoD) healthcare 

delivery system should be screened and if necessary, treated for overweight or obesity as described in this guideline.

Annotation A-2. Obtain Height and Weight; Calculate Body Mass Index (BMI)

RECOMMENDATIONS

1. Screen adult patients to establish a diagnosis of overweight or obesity by calculating body mass index (BMI), and

document the presence of overweight or obesity in the medical record. [B]

2. Screen for overweight and obesity at least annually. [EO]

For BMI calculators and tables see: www.cdc.gov/nccdphp/dnpa/bmi 

Annotation A-3. Determine Presence of Obesity-Associated Health Conditions that Increase 

Risk

RECOMMENDATIONS 

3. Assess for the presence of obesity‐associated conditions among overweight patients or patients with increased

waist circumference. [B]

Annotation A-4. Obtain Medical History, Physical Examination, and Factors 

Contributing to Obesity

RECOMMENDATIONS

4. Perform a targeted assessment on overweight and obese patients. In addition to the basic medical history and

physical examination, assess for factors contributing to obesity. [EO]

Table 1 Classification of Overweight and Obesity by BMI

Classification BMI (kg/m2)* 

Underweight < 18.5 

Normal 18.5 – 24.9 

Overweight 25.0 – 29.9 

Obese I 30.0 – 34.9 

Obese II 35.0 – 39.9 

Obese III ≥ 40.0 

* Disease risk for obesity‐associated chronic health conditions is directly correlated with increasing BMI and waist

circumference (WC)

Disease risk for obesity‐associated chronic health conditions is directly correlated with increasing BMI and waist circumference (WC)

Gender‐specific cutoffs for increased waist circumference: 

- Men waist circumference > 40 inches (102 centimeters) 

- Women waist circumference > 35 inches (88 centimeters)

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Screening and Management of Overweight and Obesity | A: Screening And Assessment | 9

Table 2 Common Obesity-Associated Conditions*

The following conditions are directly influenced by weight:

Hypertension ** 

Type 2 diabetes and pre-diabetes ** 

Dyslipidemia ** 

Metabolic syndrome 

Obstructive sleep apnea 

Degenerative joint disease 

Non-alcoholic fatty liver disease 

* Increased waist circumference is considered an obesity comorbidity equivalent

** At least moderate evidence exists for modifying these conditions with weight loss.

Table 3 Diagnosis of Metabolic Syndrome [NCEP ATP-III, 2002]

Three or more of the following risk factors indicate metabolic syndrome:

Abdominal obesity: - Men* > 40 inches (>102 centimeters) 

- Women > 35 inches (>88 centimeters)

Triglycerides ≥ 150 mg/dL

HDL cholesterol: - Men < 40 mg/dL

- Women < 50 mg/dL

Blood pressure ≥ 130/85mmHg

Fasting glucose ≥ 100 mg/dL

* Some men can develop multiple metabolic risk factors when the WC is only marginally increased (e.g., 37‐39 in (94‐102 cm). Such persons may have a strong 

genetic contribution to insulin resistance, and should benefit from lifestyle changes (i.e., diet, exercise).

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10 | Guideline Summary – 2014

Section B: Management of Overweight and Obesity

Annotation B-1. Reinforcement and Lifestyle Education

RECOMMENDATIONS

Normal Weight Patients 

5. Consider providing normal weight patients with information and behavioral counseling regarding healthy diet

and physical activity behaviors, in order to maintain a healthy weight. [C]

Overweight Patients Without Obesity‐Associated Condition(s)

6. Consider providing overweight patients without obesity‐associated conditions with information and behavioral

counseling regarding healthy diet and physical activity behaviors, in order to pursue a healthy weight. [C]

Annotation B-2. Comprehensive Lifestyle Interventions

RECOMMENDATIONS

Overweight Patients With Obesity‐Associated Condition(s) (see Table 4)

7. Offer comprehensive lifestyle intervention to achieve weight loss and to improve blood pressure and/or glucose

control in overweight patients. [A]

8. Offer comprehensive lifestyle intervention to overweight patients with dyslipidemia for weight loss and to

improve lipid levels. [B]

9. Current evidence is insufficient to recommend for or against offering comprehensive lifestyle intervention for

weight loss to overweight patients with degenerative joint disease, non‐alcoholic fatty liver disease, and/or

obstructive sleep apnea to reduce harms of these conditions. [I]

Obese Patients (See Table 4)

10. Offer obese patients comprehensive lifestyle intervention for weight loss to improve lipid levels, blood pressure,

and/or glucose control. [A]

11. Offer obese patients comprehensive lifestyle intervention for weight loss to reduce harms of obstructive sleep

apnea. [B]

12. Consider offering obese patients comprehensive lifestyle intervention for weight loss to reduce harms of

degenerative joint disease. [C]

13. Current evidence is insufficient to support weight loss through comprehensive lifestyle intervention for reducing

harms of non‐alcoholic fatty liver disease. [I]

Annotation B-3. Shared Decision‐Making 

RECOMMENDATIONS

14. Reach a shared understanding with overweight and obese patients about the risks of overweight and obesity,

and the benefits of weight management. [EO]

15. Perform an in‐depth clinical assessment in order to assess the risks and benefits of different weight management

treatments and to develop a weight management plan. [EO]

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Screening and Management of Overweight and Obesity | B: Management of Overweight and Obesity | 11

Table 4 Weight Loss Interventions Based on Risk and BMI (kg/m2)

Patient Classification

Interventions Based on Risk and BMI

Level 1 Level 2 Level 3

Overweight

BMI ≥ 25 kg/m2 with obesity-associated condition(s) †

Diet, exercise, and 

behavior modification

Obese

BMI ≥ 30 kg/m2, or

BMI ≥ 27 kg/ m2 with obesity-associated condition(s) †

Diet, exercise, and 

behavior modification

Consider drug 

therapy

Obese

BMI ≥ 40 kg/m2, or

BMI ≥ 35 kg/m2 with obesity-associated condition(s) †

Diet, exercise, and 

behavior modification

Consider drug 

therapy Consider surgery

† Obesity‐associated conditions, see Table 2 

General Treatment Principles of Weight Loss 

Annotation B-4. Reinforce Knowledge, Motivation, Skills, and Support

RECOMMENDATIONS

16. Use motivational interviewing techniques to evoke patient motivation to accept and participate in weight loss

treatments. [EO]

17. Convey the importance of weight loss and maintenance as a lifelong commitment rather than a brief episode of

treatment. [EO]

Annotation B-5. Comprehensive Lifestyle Intervention

RECOMMENDATIONS

18. Offer patients at least 12 contacts within 12 months of a comprehensive lifestyle intervention that combines

dietary, physical activity and behavioral strategies. [B]

19. Plan a net deficit of 500 to 1,000 kcal/day addressing both diet and physical activity to achieve a weight loss of

0.5 to 2 pounds per week, resulting in a 5‐10% reduction in body weight over 6 months. [A]

Annotation B-6. Assess Adherence and Modify Treatment

RECOMMENDATIONS

20. Assess adherence to the weight loss program one‐to‐two times per month by measuring the patient’s weight

and providing feedback and ongoing support. [EO]

21. Re‐evaluate the treatment plan for patients who have lost an average of less than 0.5 pound per week. [EO]

Annotation B-7. Congratulate and Initiate Maintenance Program

RECOMMENDATIONS 

22. Offer patients who have met their weight loss goals a comprehensive maintenance program consisting of

behavioral components and ongoing support. [B]

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12 | Guideline Summary – 2014

Section C: Treatment Interventions

C-1 Behavioral and Lifestyle Approaches 

23. Offer comprehensive lifestyle interventions for weight loss, in either individual or group setting. [B]

24. Offer telephone‐based comprehensive lifestyle intervention for weight loss, either as an alternative or an adjunct

to face‐to‐face intervention. [B]

25. There is insufficient evidence for or against offering internet‐based comprehensive lifestyle intervention for

weight loss, as an alternate or adjunct to face‐to‐face intervention. [I]

C-2 Dietary Approaches 

26. Offer any of several diets that produce a caloric deficit and have evidence for weight loss efficacy and safety (e.g.,

low‐carbohydrate, Dietary Approaches to Stop Hypertension (DASH), low‐fat). [A]

27. Offer very‐low‐calorie diets for weight loss, but only for short durations (12‐16 weeks) and under close medical

supervision. [B]

28. Offer meal replacements to achieve low‐calorie or very low‐calorie diets. [A]

C-3 Physical Activity Approaches 

29. Offer physical activity elements (e.g., home fitness, lifestyle, or structured/supervised physical activities) that can

be combined to produce a caloric deficit leading to weight loss. [A]

30. Offer physical activity options that include short intermittent bursts (at least 10 minutes) as well as longer

continuous exercise. [A]

31. Offer, as part of a comprehensive lifestyle intervention, moderate‐intensity physical activity performed for at

least 150 minutes/week to result in weight loss. [A]

32. Offer, as part of comprehensive lifestyle intervention, moderate‐intensity physical activity performed for 200‐300

minutes per week to prevent weight regain after initial weight loss.[EO]

C-4 Pharmacotherapy 

33. Offer pharmacotherapy with the combination phentermine/topiramate extended‐release to patients with

a body mass index (BMI) ≥30 kg/m2 and to those with a BMI ≥27 kg/m2 who also have obesity‐associated

conditions, as an adjunct to comprehensive lifestyle intervention, when lifestyle interventions alone do not

produce the desired weight loss. [A]

34. Offer pharmacotherapy with orlistat or lorcaserin to patients with a body mass index (BMI) ≥30 kg/m2 and to

those with a BMI ≥27 kg/m2 who also have obesity‐associated conditions, as an adjunct to comprehensive

lifestyle intervention, when lifestyle interventions alone do not produce the desired weight loss. [B]

35. Offer pharmacotherapy (i.e., orlistat, lorcaserin, combination phentermine/topiramate extended‐release) as an

adjunct to comprehensive lifestyle intervention, to patients with obesity‐associated conditions, for its beneficial

effects on type 2 diabetes, hypertension, and/or dyslipidemia. [B]

36. Offer patients who achieve their weight loss goal a program that includes continued use of medication for

weight maintenance. [B]

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Screening and Management of Overweight and Obesity | C: Treatment Interventions | 13

Table 5 Recommended Dosages for Selected Obesity Drug Therapy *

Orlistat -Gastrointestinal Lipase Inhibitor

Usual Dosage Range: 120 mg capsule three times daily

• Taken with or within 1 hour of each meal containing fat

• Omit dose if a meal is skipped or a meal contains no fat

• Must take once daily multivitamin (containing fat soluble vitamins A, D, E and K) at least 2 hours prior to orlistat

Cautions:

• Increased gastrointestinal events (adverse effects) when orlistat is taken with diet high in fat (greater than 30% total

daily calories from fat)

• Contraindicated during pregnancy (FDA category X) and not recommended in breast-feeding mothers

Lorcaserin

Usual Dosage Range: 10 mg tablet two times a day (Maximum 20 mg/day)

• Taken with or without food

• Consider stopping after 12 weeks if lorcaserin has not been effective in reducing weight more than 5% of initial body 

weight

Cautions:

• Not recommended in severe renal impairment or end stage renal disease

• Has not been studied in severe hepatic impairment; use with caution

• Contraindicated during pregnancy (FDA category X) and not recommended in breast-feeding mothers

Phentermine/topiramate

Dose Titration: One phentermine 3.75 mg/topiramate 23 mg extended-release capsule each morning for 14 days; 

then increase to 7.5 mg/46 mg each morning for an additional 12 weeks

• If a weight loss of 3% of baseline body weight is not achieved discontinue or increase the dose to 11.25 mg/69 mg

each morning for 14 days; then increased to 15 mg/92 mg (maximum dose) each daily

• If after 12 weeks on 15 mg/92 mg the patient has not lost at least 5% of baseline body weight, discontinue treatment 

gradually using every other day weaning over one week thereby decreasing risk of seizure

Cautions:

• Dose in patients with renal Impairment should not exceed 7.5 mg/46 mg once daily if creatinine clearance <50 mL/

min, and avoid in severe renal disease

• The dose in moderate hepatic impairment (Child‐Pugh 7‐9) should not exceed 7.5 mg/46 mg once daily, and avoid

use in severe hepatic impairment

• Contraindicated during pregnancy (FDA category X) and not recommended in breast-feeding mothers

*Drug is indicated if the patient’s BMI is ≥30 kg/m2 or ≥27 kg/m2 in the presence of one or more obesity‐associated conditions

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14 | Guideline Summary – 2014

Table 6 Drug or Nutrient Interactions with Anti-Obesity Agents *

Orlistat

• May decrease cyclosporine whole blood concentrations (possibly resulting in a decrease in the

immunosuppressive action of cyclosporine) monitor and adjust as necessary. Take cyclosporine 2 hours before or

after orlistat. More frequent monitoring of cyclosporine levels should be considered.

• May decrease absorption of some fat soluble vitamins (A, D, E, and K). Levels of vitamin D and beta-carotene

may be low in obese patients compared with non-obese subjects. The supplement should be taken 2 hours

before or after orlistat.

• Patients taking warfarin should be monitored closely and warfarin dose adjusted accordingly

• Patients taking levothyroxine should be monitored for changes in thyroid function

• Efficacy of anticonvulsant may be reduced

Lorcaserin

• Serotonin syndrome or neuroleptic malignant syndrome (NMS)‐like reactions are theoretically possible

• Extreme caution is advised if lorcaserin is combined with serotonergic or antidopaminergic drugs

• Use with caution in patients with valvular heart disease, bradycardia, congestive heart failure, or those using drugs

known to be 5‐HT2B agonists

• Potential for cognitive impairment and psychiatric reactions including sedation, euphoria and suicidal thoughts

• Potential risk of hypoglycemia in patients being treated for diabetes

• As a 5‐HT2C receptor agonists, use with caution in patients predisposed to priapism or using PDE‐5 inhibitors

• Risk for anemia, neutropenia, hyperprolactinemia

Drug Interactions

• Theoretical risk for serotonin syndrome such as with concomitant SSRIs/SNRIs

• Moderate CYP 2D6 inhibitor

Phentermine/topiramate

• Avoid use in glaucoma, hyperthyroidism, or within 14 days following use of a MAOI

• Not recommended in patients with unstable cardiac or cerebrovascular disease

• Potential for cognitive, mood and sleep disorders and topiramaterelated general class warning for suicidal thoughts

• Potential for metabolic acidosis and elevated creatinine

• Potential risk of hypotension, CNS depression, hypokalemia, kidney stones, withdrawal seizures, and hypoglycemia

in patients being treated for diabetes

Drug Interactions

• MAOI – phentermine is contraindicated during or within 14‐days following administration of a MAOI

• Oral contraceptives – a reduction in contraceptive efficacy is not anticipated but irregular bleeding (spotting) may

be more frequent

• Antiepileptic drugs – use with caution

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Screening and Management of Overweight and Obesity | C: Treatment Interventions | 15

C-5 Bariatric Surgery 

37. Offer bariatric surgery, as an adjunct to comprehensive lifestyle intervention, for weight loss in adult patients

with a body mass index (BMI) >40 kg/m2 or those with BMI 35.0‐39.9 kg/m2 with one or more obesity‐associated

conditions. [A]

38. Offer bariatric surgery, as an adjunct to comprehensive lifestyle intervention, to improve some obesity‐

associated conditions in adult patients with a body mass index (BMI) >35.0 kg/m2. [A]

39. Current evidence is insufficient to assess the balance of benefits and harms of offering bariatric surgery as

an adjunct to comprehensive lifestyle intervention, for weight loss or to improve some obesity‐associated

conditions, to patients over age 65 or with a body mass index (BMI) <35 kg/m2. [I]

40. Engage all patients who are candidates for bariatric surgery in a general discussion of the benefits and potential

risks. If more detailed information is requested by the patient to assist in the decision‐making process, a

consultation with a bariatric surgical team should occur. [EO]

41. Provide lifelong follow‐up after bariatric surgery to monitor adverse effects and complications, dietary

restrictions, adherence to weight management behaviors and psychological health. [EO]

Table 7 Schedule for Clinical and Biochemical Monitoring of the Post-Bariatric Surgery Patient

Preoperative 1 month 3 months 6 months 12 months 18 months 24 months Annually

Complete blood count X X X X X X X X

LFTs X X X X X X X X

Glucose X X X X X X X X

Creatinine X X X X X X X X

Electrolytes X X X X X X X X

Iron/ferritin X Xa Xa Xa Xa Xa

Vitamin B12 X Xa Xa Xa Xa Xa

Folate X Xa Xa Xa Xa Xa

Calcium X Xa Xa Xa X Xa

Intact PTH X Xa Xa Xa Xa Xa

25-D X Xa Xa Xa Xa Xa

Albumin/prealbumin X Xa Xa Xa Xa Xa

Vitamin A X Optional Optional

Zinc X Optional Optional Optional Optional

Bone mineral density and 

body composition X Xa Xa Xa

Vitamin B1 Optional Optional Optional Optional Optional Optional

X= indicate the suggested schedule for laboratory monitoring after bariatric surgery.; Xa = Examinations should only be performed after Roux‐en‐Y gastric bypass, biliopancreatic diversion, 

biliopancreatic diversion with duodenal switch. All of them are considered as suggested for patients submitted to restrictive surgery where frank deficiencies are less common. 

Adapted from: Heber et al. Endocrine and Nutritional Management of the Post‐Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, November 2010, 95(11):4823–43

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16 | Guideline Summary – 2014

Upper Limit Points for Category of Overweight/Obesity by Height (inches)

Normal Overweight Obese

BMI (kg/m2) 25 30 35 40 45

Stage 1 Stage 2 Stage 3

Height (inches) Body Weight (pounds)

58 119 143 167 191 215

59 124 148 173 198 222

60 128 153 179 204 230

61 132 158 185 211 238

62 136 164 191 218 246

63 141 169 197 225 254

64 145 174 204 232 262

65 150 180 210 240 270

66 155 186 216 247 278

67 159 191 223 255 287

68 164 197 230 262 295

69 169 203 236 270 304

70 174 209 243 278 313

71 179 215 250 286 322

72 184 221 258 294 331

73 189 227 265 302 340

74 194 233 272 311 350

75 200 240 279 319 359

76 205 246 287 328 369

Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report

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Screening and Management of Overweight and Obesity | APPENDICES | 17

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http://www.healthquality.va.gov

https://www.qmoamedd.army.mil

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