VA/DoD CLINICAL PRACTICE GUIDELINE

FOR THE MANAGEMENT OF

ADULT OVERWEIGHT AND OBESITY

Department of Veterans Affairs

Department of Defense

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense 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. 

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 recommendation. 

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

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

healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of 

applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent Department of Veterans Affairs or 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. 

Version 3.0 – 2020
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Prepared by:

The Management of Adult Overweight and Obesity Work Group

With support from:

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

& 

Office of Evidence Based Practice, U.S. Army Medical Command

Version 3.0 – 2020

Based on evidence reviewed through April 2019

 
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Table of Contents

I. Introduction..................................................................................................................................... 6

II. Background...................................................................................................................................... 6

A. Epidemiology and Impact in the General Population ........................................................................ 6

B. Overweight and Obesity in the Department of Defense and the Department of Veterans 

Affairs Populations............................................................................................................................... 8

C. Impact of Weight Loss on Obesity-associated Conditions................................................................. 8

III. About this Clinical Practice Guideline ............................................................................................... 8

A. Methods............................................................................................................................................... 9

a. Grading Recommendations.......................................................................................................10

b. Reconciling 2014 Clinical Practice Guideline Recommendations.............................................11

c. Peer Review Process..................................................................................................................12

B. Summary of Patient Focus Group Methods and Findings................................................................12

C. Conflicts of Interest ...........................................................................................................................13

D. Scope of this Clinical Practice Guideline ...........................................................................................13

E. Highlighted Features of this Clinical Practice Guideline...................................................................14

F. Patient-centered Care .......................................................................................................................14

G. Shared Decision Making ....................................................................................................................14

H. Co-occurring Conditions....................................................................................................................15

I. Implementation................................................................................................................................. 15

IV. Guideline Work Group ................................................................................................................... 17

V. Algorithm ...................................................................................................................................... 18

Algorithm Module......................................................................................................................................19

VI. Standards of Care for the Patient with Overweight and Obesity..................................................... 23

A. Screening and Assessment for Overweight and Obesity ................................................................. 23

a. Screening....................................................................................................................................23

b. Obesity-associated Conditions..................................................................................................24

c. Medical Assessment of Patients with Overweight or Obesity..................................................24

B. Counseling Normal Weight Patients................................................................................................. 24

C. Shared Decision Making to Choose Among Weight Management Options....................................25

a. Motivational Interviewing.........................................................................................................26

b. Eliciting a Commitment to Participate in Weight Management and Choosing Among 

Treatment Options ....................................................................................................................26

D. Emphasizing the Central Role of Comprehensive Lifestyle Intervention ........................................27

E. Assessment of Progress Toward Weight Loss Goals........................................................................28
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VII. Recommendations......................................................................................................................... 29

A. Management of Overweight or Obesity...........................................................................................31

a. Comprehensive Lifestyle Interventions.....................................................................................31

b. Physical Activity Component of a Comprehensive Lifestyle Intervention ................................40

c. Dietary Component of a Comprehensive Lifestyle Intervention...............................................42

d. Long-term Pharmacotherapy....................................................................................................44

e. Metabolic/Bariatric Procedures and Devices ...........................................................................51

B. Short-term Weight Loss (Up to Six Months).....................................................................................56

VIII. Knowledge Gaps and Recommended Research.............................................................................. 59

Appendix A: Evidence Review Methodology ....................................................................................... 64

A. Developing the Scope and Key Questions........................................................................................64

B. Conducting the Systematic Review...................................................................................................70

C. Convening the Face-to-face Meeting................................................................................................74

D. Grading Recommendations...............................................................................................................75

E. Recommendation Categorization .....................................................................................................78

F. Drafting and Submitting the Final Clinical Practice Guideline..........................................................80

Appendix B: Patient Focus Group Methods and Findings .................................................................... 82

A. Methods.............................................................................................................................................82

B. Findings..............................................................................................................................................82

Appendix C: Evidence Table................................................................................................................ 85

Appendix D: 2014 Recommendation Categorization Table .................................................................. 88

Appendix E: Participant List................................................................................................................ 92

Appendix F: Literature Review Search Terms and Strategy ................................................................. 94

A. EMBASE and Medline in EMBASE.com Syntax (all questions).........................................................94

B. PsycINFO in OVID Syntax (for KQ1, KQ2, and KQ3 only)..................................................................99

Appendix G: Dietary Approaches ...................................................................................................... 102

A. Caloric Recommendations...............................................................................................................102

Appendix H: Pharmacotherapy ......................................................................................................... 105

A. Medications Approved for Long-term Weight Management........................................................105

B. Medications and Potential for Weight Gain ...................................................................................110

C. Off-label Pharmacotherapy.............................................................................................................110
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Appendix I: Metabolic/Bariatric Surgery.......................................................................................... 114

A. Non-metabolic Surgery (i.e., Adjustable Gastric Band)..................................................................116

B. Metabolic Surgery............................................................................................................................116

C. Mortality Risk...................................................................................................................................117

D. Morbidity Risk..................................................................................................................................117

E. Suicide Risk.......................................................................................................................................120

F. Non-insulinoma Pancreatogenous Hypoglycemia Syndrome........................................................121

G. Nutritional Concerns........................................................................................................................121

Appendix J: Specific Behavioral Strategies Featured in Comprehensive Lifestyle Interventions ........ 124

A. Goal Setting......................................................................................................................................124

B. Self-monitoring ................................................................................................................................124

C. Stimulus Control or Cue Reduction................................................................................................. 124

D. Positive Reinforcement ...................................................................................................................124

E. Contingency Management..............................................................................................................124

F. Stress Management.........................................................................................................................125

G. Problem-solving...............................................................................................................................125

H. Skill Training .....................................................................................................................................125

I. Social Support..................................................................................................................................125

J. Cognitive Therapy............................................................................................................................125

K. Relapse-prevention Training ...........................................................................................................125

Appendix K: Alternative Text Description of the Algorithm............................................................... 127

Appendix L: Abbreviations............................................................................................................... 128

References .......................................................................................................................................... 131
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I. Introduction

The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work 

Group (EBPWG) was established and first chartered in 2004, with a mission to advise the Health Executive 

Committee (HEC) “...on the use of clinical and epidemiological evidence to improve the health of the 

population...” across the Veterans Health Administration (VHA) and Military Health System (MHS), by 

facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations.[1] This 

clinical practice guideline (CPG) is intended to provide healthcare providers with a framework by which to 

evaluate, treat, and manage the individual needs and preferences of patients with overweight or obesity, 

thereby leading to improved clinical outcomes.

In 2014, the VA and DoD published a CPG for the Screening and Management of Overweight and Obesity

(2014 VA/DoD Obesity CPG), which was based on evidence reviewed through February 2013. Since the 

release of that guideline, a growing body of research has expanded the general knowledge and 

understanding of overweight and obesity. Consequently, a recommendation to update the 2014 Obesity

CPG was initiated in 2018. The updated, 2020 VA/DoD CPG Clinical Practice Guideline for the 

Management of Adult Overweight and Obesity (2020 VA/DoD Obesity CPG) includes objective, evidencebased information on the management of overweight and obesity. It is intended to assist healthcare 

providers in all aspects of patient care. The system-wide goal of evidence-based guidelines is to improve 

the patient’s health and well-being by guiding health providers who are caring for patients with 

overweight and obesity along management pathways that are supported by evidence. The expected 

outcome of successful implementation of this guideline is to:

• Assess the individual’s condition and determine, in collaboration with the patient, the best 

treatment method 

• Optimize health outcomes and improve quality of life (QoL) 

• Minimize preventable complications and morbidity

• Emphasize the use of patient-centered care

II. Background 

A. Epidemiology and Impact in the General Population

The epidemic of overweight and obesity is one of the most significant problems facing the United States 

(U.S.) healthcare system today. The Centers for Disease Control and Prevention (CDC) defines overweight 

and obesity using body mass index (BMI), which is the most widely used and practical way to evaluate the 

degree of overweight. Body mass index is calculated as weight in kilograms divided by height in meters 

squared (kg/m2

).[2]

For adults, having a BMI of 25 – 29.9 kg/m2 is considered “overweight,” while a BMI of 30 kg/m2 or higher 

is considered “obese”. The category of “obese” is further divided into subcategories of Class I obesity (BMI 

30.0 – 34.9 kg/m2

), Class II obesity (BMI 35.0 – 39.9 kg/m2), and Class III obesity (BMI ≥40 kg/m2).[3] For 

individuals of Asian descent, the World Health Organization suggests a lower threshold for overweight 

(BMI >23.0 kg/m2

) and obesity (BMI >27.5 kg/m2). Based on data reported for 2015 – 2016 from the 

National Health and Nutrition Examination Survey, the prevalence of obesity in the U.S. is 39.8% among 
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adults,[4] and the prevalence of overweight in the U.S. is 31.8% among adults.[5] Moreover, approximately 

1 in 13 Americans have a BMI of >40 kg/m2 (i.e., more severe, Class III obesity).[5] 

The evidence links overweight and obesity with an increased risk of chronic health conditions and 

reduced QoL, as well as earlier mortality, particularly among those with Class II and Class III obesity.[6-8] 

Overweight and obesity increase the risk of all-cause mortality with a J-shaped dose-response 

association.[8] The nadir of the dose-response curve is the BMI range of 23 – 24 kg/m2 among never 

smokers and 22 – 23 kg/m2 among healthy never smokers.[8] Though earlier epidemiologic analyses 

suggested that overweight was associated with a reduced risk of mortality compared to normal 

weight,[6] these findings were confounded by smoking and existing illness and also reflect shorter 

durations of follow-up.[8] 

Overweight and obesity are associated with increased prevalence and worsening of several obesityassociated conditions, including type 2 diabetes mellitus (T2DM), hypertension (HTN), dyslipidemia, 

metabolic syndrome, osteoarthritis, and obstructive sleep apnea (OSA).[9] High BMI is also associated with 

elevated risk for at least 17 different cancers.[10] Based on data from 2010 through 2015, nearly 50% of 

adults with obesity had HTN compared with 20% of adults with normal weight, and adults with obesity 

were four times as likely to have T2DM.[11] The CDC estimates that 9 out of 10 people with diagnosed 

T2DM have overweight or obesity.[12] Furthermore, as a result of the obesity epidemic, the lifetime risk of 

diagnosed T2DM from age 20 is 40.2% for men and 39.6% for women, representing an increase of 20% and 

13%, respectively, from 1985 – 1989.[13] The development or worsening of T2DM, HTN, and dyslipidemia 

are particularly hazardous due to their independent effects on risk for coronary artery disease and stroke. 

In addition to the aforementioned obesity-associated conditions, obesity and insulin resistance are among 

the most common risk factors for the development of non-alcoholic fatty liver disease (NAFLD),[14] which 

is the leading cause of chronic liver disease in the U.S.[15] Overall, NAFLD prevalence among adults (≥15 

years old) is projected to be 33.5% in 2030.[16] Non-alcoholic fatty liver disease has surpassed alcohol as a

top reason for liver transplants in the U.S. and will likely become the leading condition necessitating liver 

transplants (ahead of hepatitis C) by the year 2030.[17,18] 

Overweight and obesity have important impacts on many aspects of QoL and well-being, including physical 

and psychosocial functioning, pain experience, and perceptions of health.[19] Individuals with overweight 

and obesity perceive or experience stigma and discrimination across multiple domains from work to 

healthcare to mass media.[20] In addition to morbidity and mortality associated with excess body weight, 

there are significant healthcare expenditures that result from costly associated medical conditions.a From 

2001 through 2015, increases in medical expenditures were greater for adults with obesity than for adults 

with normal weight. From 2010 through 2015, adults with Class III obesity incurred $7,800 in annual 

medical expenditures on average, which was 75% more than adults without overweight or obesity.[11] 

Moreover, based on data from the Medical Expenditure Panel Survey, the share of total healthcare 

spending for treating obesity-related illnesses in non-institutionalized adults has risen from 20.6% in 2005 

to 27.5% in 2010 and 28.2% in 2013.[21] Importantly, expenditures appear to have a J-shaped curve over

the full range of BMI. Specifically, expenditures decrease with BMI through the categories of underweight 

 

a See the infographic on Medical Care Use and Expenditures Associated With Adult Obesity in the United States, available at: 

https://jamanetwork.com/journals/jama/fullarticle/2669713 
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and normal weight, are constant when BMI is in the overweight range, rise slowly through Class I obesity, 

and then rise more rapidly with increasing BMI.[21] 

B. Overweight and Obesity in the Department of Defense and the 

Department of Veterans Affairs Populations

The active duty military and Veteran populations have been similarly affected by the obesity epidemic. 

According to the DoD’s Health of the Force 2018 Report, which provides an evidence-based portrait of the 

health and well-being of U.S. Service Members, the overall prevalence of obesity was 17.4% in 2018.[22] 

This represents an increase from 2014 when the prevalence of obesity was 15.8%. Rates of obesity varied 

across branches of the Armed Services, ranging from 8.3% to 22.0%. It was noted, however, that Service 

Members with higher lean body mass may be misclassified as overweight or obese based on their BMI

which would require further assessment (see Standards of Care). The consequences of obesity in active 

duty Service Members may negatively influence a range of operations related to recruitment, retention, 

resilience, readiness, and retirement.[23] Moreover, in a study of adult non-active duty beneficiaries and 

retirees, 63% of beneficiaries and 86% of retirees have overweight or obesity.[24] Compared with the 

general U.S. population, the combined prevalence of overweight (37%) and obesity (41%) is higher in 

Veterans receiving care in the VA.[4,5,24] This current combined prevalence in Veterans of 78% reflects a 

steady increase over the past two decades, up from 64% in 1996.[25] 

C. Impact of Weight Loss on Obesity-associated Conditions

Both observational studies and controlled trials in populations with specific chronic conditions have 

demonstrated that a 5% weight loss produces clinically significant improvements in these conditions.[26] 

Thus, in this guideline we chose weight loss as a critical outcome for evaluating the effects of weight 

management interventions for overweight and obesity.

III. About this Clinical Practice Guideline

This guideline represents a significant effort toward improving the management of patients with 

overweight or obesity who are eligible to receive care in VA and/or DoD. As with other CPGs, however, 

challenges remain. These include evidence gaps, as well as ongoing needs to develop effective strategies 

for guideline implementation and to evaluate the effect of guideline adherence on clinical outcomes. This 

guideline is intended for VA and DoD healthcare practitioners including physicians, nurse practitioners, 

physician assistants, social workers, psychologists, dietitians, nurses, pharmacists, physical therapists, 

kinesiotherapists, and others involved in caring for Service Members or Veterans with overweight or 

obesity. Additionally, this guideline is intended for those in community practice involved in the care of 

Service Members or Veterans with overweight or obesity.

As elaborated upon in the qualifying statement on page one, this CPG is not intended to serve as a 

standard of care. Standards of care are determined based on all clinical data available for an individual 

patient and are subject to change as scientific knowledge and technology advance and clinical practice 

patterns evolve. This CPG is based on information available through April 8, 2019, and is intended to 

provide a general guide to best practices. The guideline can assist care providers, but the use of a CPG 

must always be considered as a recommendation within the context of a variety of factors such as 
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providers’ clinical judgment, scope of practice, patient values and preferences, state and federal legal 

statutes, ethical guidelines, professional standards, and healthcare system policies.

A. Methods

The current document is an update to the 2014 VA/DoD Obesity CPG. The methodology used in 

developing the 2020 VA/DoD Obesity CPG follows the Guideline for Guidelines, an internal document of 

the VA and DoD EBPWG that was updated in January 2019.[1] The Guideline for Guidelines can be 

downloaded from http://www.healthquality.va.gov/policy/index.asp. This document provides information 

regarding the process of developing guidelines, including the identification and assembly of the Guideline 

Champions (Champions) and other subject matter experts from within the VA and DoD (known as the 

Work Group) and the development and submission of an updated Obesity CPG.

The Champions and Work Group for this CPG were charged with developing evidence-based clinical 

practice recommendations and writing and publishing a guideline document to be used by providers 

within the VA/DoD healthcare systems as well as those within the community who treat individuals within 

the VA and DoD. Specifically, the Champions and Work Group members for this guideline were responsible 

for identifying the key questions (KQs) of the most clinical relevance, importance, and interest for the 

diagnosis and management of patients with overweight or obesity. The Champions and the Work Group 

also provided direction on inclusion and exclusion criteria for the evidence review and assessed the level 

and quality of the evidence. The amount of new scientific evidence that had accumulated since the 

previous version of the CPG was also taken into consideration in the identification of the KQs. In addition, 

the Champions assisted in:

• Identifying appropriate disciplines of individuals to be included as part of the Work Group

• Directing and coordinating the Work Group

• Participating throughout the guideline development and review processes

The VA Office of Quality and Patient Safety, in collaboration with the Office of Evidence Based Practice, 

U.S. Army Medical Command, the proponent for CPGs for the DoD, identified four clinical leaders to serve 

as Champions: LTC Sky D. Graybill, MD; Michael Goldstein, MD; Stéphanie B. Mayer, MD, MHSc; and 

LTC Christopher Tracy, MD.

The Lewin Team, including The Lewin Group, Duty First Consulting, ECRI, Sigma Health Consulting, and 

Anjali Jain Research & Consulting, was contracted by the VA to support the development of this CPG and 

conduct the evidence review. The first conference call was held in December 2018, with participation 

from the contracting officer’s representative (COR), leaders from the VA Office of Quality and Patient 

Safety and the DoD Office of Evidence Based Practice, and the Champions. During this call, participants 

discussed the scope of the guideline initiative, the roles and responsibilities of the Champions, the 

project timeline, and the approach for developing and prioritizing specific research questions on which 

to base a systematic review (SR) about the management of overweight or obesity. The group also 

identified a list of clinical specialties and areas of expertise that are important and relevant to the 

management of overweight and obesity, from which Work Group members were recruited. The 

specialties and clinical areas of interest included: metabolic/bariatric surgery, endocrinology, internal 

medicine, family medicine, nutrition, nursing, pharmacology, physical therapy, psychiatry, psychology, 

rheumatology, general surgery, and primary care.
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The guideline development process for the 2020 VA/DoD Obesity CPG consisted of the following steps:

1. Formulating and prioritizing KQs and defining critical outcomes

2. Convening a patient focus group

3. Conducting the systematic evidence review

4. Convening a face-to-face meeting with the CPG Champions and Work Group members to develop 

recommendations

5. Drafting and submitting a final CPG on the management of overweight and obesity to the VA/DoD 

EBPWG

Appendix A provides a detailed description of each of these tasks.

a. Grading Recommendations 

The Champions and Work Group used the Grading of Recommendations Assessment, Development and 

Evaluation (GRADE) system to assess the quality of the evidence base and assign a strength for each 

recommendation. The GRADE system uses the following four domains to assess the strength of each 

recommendation:[27] 

• Balance of desirable and undesirable outcomes 

• Confidence in the quality of the evidence 

• Patient or provider values and preferences

• Other implications, as appropriate, e.g.:

♦ Resource use

♦ Equity

♦ Acceptability

♦ Feasibility

♦ Subgroup considerations

Additional information regarding these domains can be found in Appendix A. 

Using these four domains, the Work Group determined the relative strength of each recommendation 

(“Strong” or “Weak”). Generally, a “Strong” recommendation indicates a high confidence in the quality of 

the available scientific evidence, a clear difference in magnitude between the benefits and harms of an 

intervention, similar patient or provider values and preferences, and understood influence of other 

implications (e.g., resource use, feasibility). Generally, if the Work Group has less confidence after the 

assessment across these domains and believes that additional evidence may change the recommendation, 

it assigns a “Weak” recommendation. It is important to note that the GRADE terminology used to indicate 

the assessment across the four domains (i.e., “Strong” versus “Weak”) should not be confused with the 

clinical importance of the recommendation. A “Weak” recommendation may still be important to the 

clinical care of a patient with overweight or obesity. 
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Occasionally, instances may occur when the Work Group feels there is insufficient evidence to make a 

recommendation for or against a particular therapy or preventive measure. This can occur when there is 

an absence of studies on a particular topic that met evidence review inclusion criteria, studies included in 

the evidence review report conflicting results, or studies included in the evidence review report 

inconclusive results regarding the desirable and undesirable outcomes. 

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong for (or “We recommend offering this option ...”)

• Weak for (or “We suggest offering this option ...”)

• No recommendation for or against (or “There is insufficient evidence ...”)

• Weak against (or “We suggest not offering this option ...”)

• Strong against (or “We recommend against offering this option ...”)

The grade of each recommendation made in the 2020 VA/DoD Obesity CPG can be found in the section on 

Recommendations. Additional information regarding the use of the GRADE system can be found in the 

section on Grading Recommendations. 

b. Reconciling 2014 Clinical Practice Guideline Recommendations

Evidence-based CPGs should be current, which typically requires revisions of previous guidelines based on 

new evidence or as scheduled and subject to time-based expirations.[28] For example, the U.S. Preventive 

Services Task Force (USPSTF) has a process for refining or otherwise updating its recommendations 

pertaining to preventive services.[29] 

The Obesity CPG Work Group largely focused on developing new and updated recommendations based on 

the evidence review conducted for the priority areas addressed by the KQs. In addition to developing new 

and updated recommendations, the Work Group considered the current applicability of other 

recommendations included in the 2014 VA/DoD Obesity CPG, categorizing them as appropriate based on 

current clinical practice. The 2020 VA/DoD Obesity CPG was developed using the GRADE methodology, 

which does not allow for recommendations to be made based on expert opinion alone; therefore, some 

recommendations from the 2014 VA/DoD Obesity CPG that were based on expert opinion alone and not 

covered in the systematic evidence review carried out as part of this guideline update, or otherwise 

determined to not be included in the scope of the 2020 VA/DoD Obesity CPG, were removed in the 2020 

VA/DoD Obesity CPG. For additional information, see Grading Recommendations, Recommendation 

Categorization, and Appendix D. 

A set of recommendation categories was adapted from those used by the National Institute for Health and 

Care Excellence (NICE).[30,31] These categories, along with their corresponding definitions, were used to 

account for the various ways in which older recommendations could have been updated. In brief, the 

categories considered whether the evidence that related to a recommendation was systematically 

reviewed, the degree to which the recommendation was modified, and the degree to which a 

recommendation is relevant in the current care environment and within the scope of the CPG. Additional 

information regarding these categories and their definitions can be found in Recommendation 

Categorization. The categories for the recommendations included in the 2020 version of the guideline can 
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be found in the section on Recommendations. The categories for the recommendations carried forward 

from the 2014 VA/DoD Obesity CPG are noted in Appendix D.

c. Peer Review Process 

The CPG was developed through an iterative process in which the Work Group produced multiple drafts of 

the CPG. The process for developing the initial draft is described in more detail in Drafting and Submitting 

the Final Clinical Practice Guideline. 

Once a near-final draft of the guideline was agreed upon by the Champions and Work Group members, 

the draft was sent out for peer review and comment. The draft was posted on a wiki website for 14 

business days. The peer reviewers comprised individuals working within the VA and DoD healthcare 

systems as well as experts from relevant outside organizations designated by the Work Group members. 

Organizations designated by the Work Group to participate in the peer review and that provided 

feedback included:

• American Society for Metabolic and Bariatric Surgery

• Endocrine Society

• National Institute of Diabetes and Digestive and Kidney Diseases

• The Obesity Society

• VA National Metabolic Work Group

The VA and DoD Leadership reached out to both the internal and external peer reviewers to solicit their 

feedback on the CPG. Reviewers were provided a hyperlink to the wiki website where the draft CPG was 

posted. All feedback from the peer reviewers was discussed and considered by the Work Group. 

Modifications made throughout the CPG development process were in accordance with the evidence.

B. Summary of Patient Focus Group Methods and Findings

When forming guideline recommendations, consideration should be given to the values of those most 

affected by the recommendations: patients. Patients bring perspectives, values, and preferences into their 

healthcare experience that can vary from those of clinicians. These differences can affect decision making 

in various situations and should be highlighted and made explicit due to their potential to influence a 

recommendation’s implementation.[32,33] Focus groups can be used as an efficient method to explore 

ideas and perspectives of a group of individuals and collect qualitative data on a thoughtfully 

predetermined set of questions. 

Therefore, as part of the effort to update this CPG, VA and DoD Leadership held a patient focus group. The 

patient focus group was held on March 7, 2019, at Womack Army Medical Center in Fort Bragg, NC. The 

focus group aimed to further understand and incorporate the perspective of patients with overweight or 

obesity and who are covered and/or receiving their care through the VA and/or DoD healthcare systems, 

as these patients are most affected by the recommendations put forth in the CPG. The focus groups delved 

into the patients’ perspectives on a set of topics related to their overweight or obesity management, 

including their priorities, challenges they have experienced, the information they received regarding their 

care, as well as the impacts of their care on their lives. 
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The focus group comprised a convenience sample and the Work Group recognizes the lack of 

generalizability and other limitations inherent in the small sample size. The patient focus group consisted 

of seven participants, five men and two women, being treated for overweight/obesity. Fewer than 10 

people in total were included in the focus group to be consistent with the requirements of the Federal 

Paperwork Reduction Act, 1980. Five participants were receiving care from the DoD, one from the VA, and 

one from both the VA and the DoD. Participants’ ages ranged from early-20s to mid-70s, with the majority 

of the group being in their 20s or 30s. The majority of the participants were active duty Service Members 

in the Army. One participant was a Veteran and the spouse of an active duty Service Member and another 

was a Veteran in his/her 70s. Four of the male participants were medics in the Army. One of the women, 

an active duty Service Member in her 40s or 50s joined midway through the focus group. The Work Group 

acknowledges that the sample included in this focus group is not representative of all patients within the 

VA and DoD healthcare systems. Further, time limitations for the focus group prevented exhaustive 

exploration of all topics related to overweight and obesity management in the VA and DoD and the 

patients’ broader experiences with their care. Thus, the Work Group made decisions regarding the priority 

of topics to discuss at the focus groups. These limitations, as well as others, were considered during 

guideline development as the information collected from the discussion was being used. Recruitment for 

participation in the focus groups was managed by the Champions and VA and DoD Leadership, with 

assistance from coordinators at the facility at which the focus groups took place.

Additional details regarding the patient focus group methods and findings can be found in Appendix B. 

C. Conflicts of Interest

At the start of this guideline development process and at other key points throughout, the project team 

was required to submit disclosure statements to reveal any areas of potential conflict of interest (COI) in 

the past 24 months. Verbal affirmations of no COI were used as necessary during meetings throughout the 

guideline development process. The project team was also subject to random web-based surveillance (e.g., 

Centers for Medicare & Medicaid Services [CMS] open payments or ProPublica). 

If a project team member reported a COI (actual or potential), then it was reported to the VA and DoD 

program offices. It was also discussed with the Obesity CPG Champions in tandem with their review of the 

evidence and development of recommendations. The VA and DoD program offices and the Obesity CPG 

Champions determined whether action, such as restricting participation or voting on sections related to 

the conflict or removal from the Work Group, was necessary due to authorship of the literature included in 

the SR. If it was deemed necessary, action to mitigate the COI was taken by the Champions and VA and 

DoD program offices, based on the level and extent of involvement. No COIs were identified for the 

Obesity CPG Work Group members or Champions. Disclosure forms are on file with the VA Office of 

Quality and Patient Safety and available upon request.

D. Scope of this Clinical Practice Guideline

Regardless of setting, any patient in the VA and DoD healthcare system should ideally have access to the 

interventions that are recommended in this guideline after taking into consideration the patient’s 

specific circumstances. 

Guideline recommendations are intended to support the delivery of evidence-based, patient-centered 

healthcare which occurs at the intersection of the best available evidence, patient preference, and 
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practitioner expertise and experience. Effective, open communication between healthcare professionals 

and the patient is essential and should be supported by evidence-based information tailored to the 

patient’s needs. Use of an empathetic and non-judgmental approach facilitates discussions sensitive to 

gender, culture, ethnicity, and other considerations. The information that patients are given about 

treatment and care should be culturally appropriate and available to people with limited literacy skills. 

Treatment information should also be accessible to people with additional needs such as physical, sensory, 

or learning disabilities. Family and caregiver involvement should be considered, if appropriate.

This CPG is designed to assist providers in managing or co-managing patients with overweight or obesity. 

Moreover, the patient population of interest for this CPG is adult patients with overweight or obesity who 

are eligible for care in the VA and DoD healthcare delivery systems including those who are in the 

community receiving care from community-based clinicians. It includes Veterans as well as deployed and 

non-deployed active duty Service, Guard, and Reserve Members and their adult dependents.

E. Highlighted Features of this Clinical Practice Guideline

The 2020 VA/DoD Obesity CPG is the second update to the original CPG. It provides practice 

recommendations for the care of individuals with overweight or obesity as well as guidance for treatment. 

A particular strength of this CPG is the multidisciplinary stakeholder involvement from its inception, 

ensuring representation from the broad spectrum of clinicians and providers engaged in the diagnosis and 

management of overweight and obesity. 

The framework for recommendations in this CPG considered factors beyond the strength of the evidence, 

including balancing desired outcomes with potential harms of the intervention, the potential for variation 

in patient values and preferences, and other considerations (e.g., resource use, subgroup considerations) 

as appropriate. Applicability of the evidence to VA/DoD populations was also taken into consideration. An 

algorithm accompanies the guideline to provide an overview of the recommendations in the context of the 

flow of patient care and to assist with training providers (see Algorithm section). The algorithm may be 

used to help facilitate translation of guideline recommendations into practice.

F. Patient-centered Care

VA/DoD CPGs encourage providers to use a patient-centered care approach that is individualized based on 

patient needs, characteristics, and preferences. Regardless of setting, all patients in the healthcare system 

should be able to access evidence-based care appropriate to their specific needs or condition. When 

properly executed, patient-centered care engages, activates and empowers patients to take a more active 

role in their health and health care. Patient-centered approaches may decrease patient anxiety, increase 

trust in clinicians, and improve treatment adherence.[34-36] A patient-centered approach improves 

patient-clinician communication and supports disclosure of current and future concerns. 

As part of the patient-centered approach, providers should ask each patient about any concerns he or she 

has and barriers to high-quality care he or she has experienced.

G. Shared Decision Making 

Throughout this VA/DoD CPG, the authors encourage clinicians to focus on shared decision making, a key 

component of patient-centered care. A shared decision making model was featured in Crossing the Quality 

Chasm, an Institute of Medicine (IOM) (now called the National Academy of Medicine [NAM]) report, in 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 15 of 147

2001.[37] Patients, together with their clinicians, make decisions regarding their plan of care and 

management options. Patients with overweight or obesity require sufficient information and time to be 

able to make informed decisions. Clinicians must be adept at presenting information to their patients 

regarding risks of overweight and obesity, benefits and potential harms of treatments, expected 

outcomes, and levels and/or locations of care. Clinicians are encouraged to use shared decision making to 

individualize treatment goals and plans based on patient capabilities, needs, values, goals, and 

preferences. See Standards of Care for additional guidance about the use of shared decision making in the 

care of the patient with overweight or obesity. 

H. Co-occurring Conditions

Co-occurring health conditions are important to recognize because they can contribute to the risk of 

developing overweight and obesity, impact the management of overweight and obesity, influence patient 

or provider treatment priorities and clinical decisions, and affect the overall provider approach to the 

management of overweight or obesity. Providers should expect that many Veterans, Service Members, 

and their families will have one or more co-occurring health conditions. Because overweight and obesity

management often takes place in parallel with ongoing care for co-occurring conditions and can be

affected by the treatment of other conditions, especially pharmacologic choices, it is generally best to 

manage overweight and obesity collaboratively with other care providers. When caring for patients with 

overweight or obesity, a careful review of their medication list may reveal medications that promote 

weight gain and are counterproductive to patient weight loss efforts (see Sidebar 2). Some co-occurring 

conditions may require early specialist consultation to coordinate necessary changes in treatment and/or 

to establish a common understanding of how care will be coordinated and delivered. VA/DoD CPGs exist 

for Chronic Kidney Disease (CKD),b Diabetes Mellitus,

c Hypertension,d and Chronic Insomnia 

Disorder/OSA.

e See Standards of Care, Sidebar 1, and Sidebar 3 for guidance regarding the medical 

assessment of patients with overweight and obesity.

I. Implementation

This CPG is designed to be adapted by individual healthcare providers with consideration of local services, 

resources, and capacity (professional, administrative, and logistical). The algorithm serves to inform 

providers of key decision points throughout the complex long-term management of overweight or obesity; 

both of these chronic medical conditions require long-term management with similar resource allocation 

to diabetes and HTN treatments. 

The Work Group’s goal is to disseminate these evidence-based recommendations for weight management 

as widely as possible throughout the medical field, with the aim of improving Veteran and Service

Members’ health and well-being. To this end, the Work Group has also produced supplemental 

 

b See the VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. Available at: 

https://www.healthquality.va.gov/guidelines/CD/CKD/ c See the VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Available at: 

https://www.healthquality.va.gov/guidelines/CD/diabetes/ d See the VA/DoD Clinical Practice Guideline for the Diagnosis and Management of Hypertension in the Primary Care Setting. 

Available at: https://www.healthquality.va.gov/guidelines/CD/HTN/ e See the VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea. 

Available at: https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp 
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educational materials to convey this information as effectively as possible: to practitioners as a provider 

summary and pocket card and to patients in the form of a patient summary.f

 

The VA and DoD have respective plans for dissemination and implementation of CPGs. This CPG is sent to 

several focused email groups within the VA and DoD systems for dissemination. Newly released CPGs are 

presented on quarterly calls to chief medical officers nationally within the VA system. VA/DoD CPGs are 

presented at various national professional society conferences and published in respected peer-reviewed 

medical journals. CPGs are posted to national/international guideline clearinghouses, available free of 

charge, and submitted to frequently consulted online medical resources, including epocrates® and 

UpToDate®, to broaden dissemination. 

The CPG is also meant to inform the VA and DoD about the efficacy of combined tools for weight loss; 

specifically, comprehensive lifestyle intervention programs (e.g., the MOVE! program at the VA), with both 

pharmacologic and metabolic/bariatric surgical interventions. Nationwide harmonization of these three 

weight loss interventions, across VA and DoD healthcare facilities, will improve quality of life and reduce 

progression of obesity-related conditions for our nation’s Veterans and Service Members. 

Operationalization of these recommendations to achieve efficient coordinated management of overweight 

and obesity across the system nationally, and across service lines, is of great importance. We must first 

establish that the management of overweight and obesity is an organization-wide priority. Next is the need 

to track patient, program, and population level achievement of clinically meaningful outcomes. Systemwide integration will assure access to overweight and obesity care across VA and the DoD. This integration 

will promote effective care coordination, stratification by level of patient risk, and patient engagement 

strategies. System-wide integration is clearly needed to implement an evidence-based, multicomponent 

approach to weight management.

Although this CPG represents the recommended practices on the date of its publication, medical practice is 

evolving and requires ongoing awareness by providers and policy makers alike of newly published 

information. New technology and additional research will improve patient care in the future. This CPG can 

assist in identifying priority areas for research and informing the optimal allocation of resources. Future 

studies examining the results of CPG implementation may lead to the development of new evidence 

particularly relevant to clinical practice and resource allocation.

 

f

 See https://www.healthquality.va.gov/guidelines/CD/obesity/ for links to the Obesity CPG’s Provider Summary, Pocket Card, 

and Patient Summary
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IV. Guideline Work Group

Organization Namesa

Department of Veterans Affairs

Michael G. Goldstein, MD (Champion)

Stéphanie B. Mayer, MD MHSc (Champion)

Erin J. Arra, MS, RD, CSOWM, LD

Elaine Furmaga, PharmD 

Earl Gaar, MD, FACS

Navjit (Nicky) Goraya, MD

Gwen Hampton, PMHCNS-BC

Susan D. Raffa, PhD

Carol Volante, DNP, APRN-C 

Department of Defense

LTC Sky Graybill, MD (Champion)

LTC Christopher Tracy, MD, FACP, FACR (Champion)

Charolotte Baldridge, FNP

Maj Zachary M. Leftwich, PharmD

COL Stephanie A. Meyer, SP, DrPH, MS, RD, LD, CHES

CPT Scott J. Santos, PsyD

Col Jason L. Silvernail, DPT, DSc

CPT Bryan A. Stepanenko, MD, MPH

CAPT Gordon G. Wisbach, MD, MBA, FACS, FAMBS, MC, USN

Office of Quality and Patient Safety 

Veterans Health Administration

M. Eric Rodgers, PhD, FNP-BC

James Sall, PhD, FNP-BC

Rene Sutton, BS, HCA

Office of Evidence Based Practice

U.S. Army Medical Command

Corinne K. B. Devlin, MSN, RN, FNP-BC

Patrick Brian Polk, RN, BSN, MHSM, CIC, NEA-BC

The Lewin Group

Clifford Goodman, PhD

Erika Beam, MS

Charlie Zachariades, MSc

Nicolas Stettler-Davis, MD, MSCE

ECRI

Kristen D’Anci, PhD

Stacey Uhl, MS

Amber Moran, MA

Gina Giradi, MS

Laura Koepfler, MLS

Anjali Jain Research & Consulting Anjali Jain, MD

Sigma Health Consulting Frances Murphy, MD, MPH

Duty First Consulting Rachel Piccolino, BA

Megan McGovern, BA

a Additional contributor contact information is available in Appendix E. 
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V. Algorithm 

This CPG includes an algorithm that is designed to facilitate understanding of the clinical pathways and 

decision-making processes used in managing patients with overweight or obesity. The use of the algorithm 

format as a way to represent patient management was chosen based on the understanding that such a 

format may promote more efficient diagnostic and therapeutic decision making; it also has the potential to 

change patterns of resource use. Although the Work Group recognizes that not all clinical practices are 

linear, the simplified linear approach depicted through the algorithm and its format allows the provider to 

assess the critical information needed at the major decision points in the clinical process. It includes:

• An ordered sequence of steps of care 

• Recommended observations and examinations

• Decisions to be considered 

• Actions to be taken

For each VA/DoD CPG, there is a corresponding clinical algorithm that is depicted by a step-by-step 

decision tree. 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.[38] 

Shape Description

Rounded rectangles represent a clinical state or condition

Hexagons represent a decision point in the guideline, formulated as a question that can be 

answered Yes or No

Rectangles represent an action in the process of care

Ovals represent a link to another section within the guideline

Appendix K contains alternative text descriptions of the Algorithm. 
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Algorithm Module

a For patients of Asian descent: is BMI ≥23 kg/m2

?; [39] for patients >65 years old: consider individualized assessment [40] 

b See, for example, 2015-2020 Dietary Guidelines for Americans, 8th edition, available at: 

https://health.gov/dietaryguidelines/2015/ and Physical Guidelines for American, 2nd Edition, available at: 

https://health.gov/paguidelines/second-edition/ 

Abbreviations: BMI: body mass index; CLI: comprehensive lifestyle intervention; DoD: Department of Defense; kg: kilograms; 

m: meters; VA: Department of Veterans Affairs
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Sidebar 1: Common Overweight- and Obesity-Associated Conditions

• HTN

• T2DM and prediabetes

• Dyslipidemia

• Metabolic syndromea

• OSA

• OA/degenerative joint disease

• NAFLD

• GERD

• Cancer [10] 

a See National Cholesterol Education Program definition of metabolic syndrome, available at: 

https://www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf

Abbreviations: GERD: gastroesophageal reflux disease; HTN: hypertension; NAFLD: non-alcoholic fatty liver disease; 

OA: osteoarthritis; OSA: obstructive sleep apnea; T2DM: type 2 diabetes mellitus

Sidebar 2: Select Medications and their Potential Effects on Weighta

Medication 

Classes

Medications with Potential for

Weight Gain

Medications that may be Weight Neutral or 

have Potential for Weight Loss

Antipsychotics

• Quetiapine

• Clozapine

• Olanzapine

• Risperidone

• Thioridazine

• Aripiprazole

• Haloperidol

• Ziprasidone

Antidepressants

• Mirtazapine

• Selective serotonin reuptake inhibitor

(e.g., paroxetine, sertraline, citalopramb

, 

escitalopramb

, fluoxetineb) 

• MAOIs (e.g., phenelzine)

• Tricyclic anti-depressants 

(e.g., amitriptyline, clomipramine, 

doxepin, imipramine, nortriptyline, 

protriptylineb

) 

• Bupropion

• Desvenlafaxine

• Venlafaxine

Antiepileptic 

drugs or mood 

stabilizing agents

• Gabapentin

• Pregabalin

• Carbamazepine 

• Divalproex

• Lithium

• Valproic acid

• Vigabatrin

• Topiramate 

• Lamotrigine

• Zonisamide
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Sidebar 2: Select Medications and their Potential Effects on Weighta

Medication 

Classes

Medications with Potential for

Weight Gain

Medications that may be Weight Neutral or 

have Potential for Weight Loss

Antihyperglycemic 

agents

• Insulin 

• Sulfonylureas (e.g., chlorpropamide, 

glimepiride, glipizide, glyburide)

• Meglitinides (e.g., nateglinide, 

repaglinide)

• Thiazolidinediones (e.g., pioglitazone, 

rosiglitazone)

• GLP-1 agonists (e.g., semaglutide, liraglutide, 

exenatide, dulaglutide, lixisenatide)

• SGLT2 inhibitors (e.g., empagliflozin, 

canagliflozin, dapagliflozin, ertugliflozin)

• Metformin

• Pramlintide

• Alpha-glucosidase inhibitors (e.g., acarbose, 

miglitol)

• Dipeptidyl-peptidase-4 inhibitors 

(e.g., alogliptin, linagliptin, saxagliptin, 

sitagliptin)

Beta-blockers 

• Metoprolol

• Atenolol

• Propranolol 

• Carvedilol

• Nebivolol

Note: Other alternative classes of 

antihypertensive medications may be an option 

depending on the indication (e.g., angina, heart 

failure, HTN, migraine). Consider calcium channel 

blockers, angiotensin-converting enzyme 

inhibitor, ARBs, and thiazide or loop diuretics, as 

indicated. 

Alpha-blockers Terazosin For benign prostatic hyperplasia (e.g., doxazosin; 

alfuzosin, tamsulosin)

Glucocorticoids

• Prednisone 

• Methylprednisolone

• Hydrocortisone

Alternatives for rheumatologic disorders: 

• NSAIDs

• Biologics/disease-modifying antirheumatic 

drugs

• Nontraditional therapies

Hormonal agents Progestins (e.g., medroxyprogesterone, 

megestrol acetate) 

For contraception, consider alternative methods 

(e.g., copper intrauterine device) 

Antihistamines

• Cetirizine

• Cyproheptadine

Depending on symptoms, consider ipratropium 

nasal spray, decongestants, inhalers, and/or 

nonpharmacologic measures (e.g., nasal 

irrigation)

a The information provided in the table is not to be considered all-inclusive and is a compilation of information from the medical 

literature (systematic reviews, meta-analyses, subgroup analysis of clinical trials, cohort studies, reviews), some of which may 

have included differing comparators with variable results based on length of follow-up, baseline weight, patient comorbidities, 

etc.; medical and pharmacy resources; and select product information (adverse events, post-marketing and case reports). 

b Weight gain and weight loss have been reported. 

Abbreviations: ARB: angiotensin receptor blocker; GLP-1: glucagon-like peptide-1 receptor; HTN: hypertension; MAOI: monoamine 

oxidase inhibitor; NSAID: nonsteroidal anti-inflammatory drug; SGLT2: sodium-glucose cotransporter 2
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Sidebar 3: Assessment of Patients with Overweight or Obesity 

• Assess for presence of obesogenic medications (see Sidebar 2 on pharmacotherapy)

• Consider assessing waist circumference for patients with a BMI of 25 – 29.9 kg/m2 (see Standards of Care) 

• Assess for common overweight and obesity-associated conditions (see Sidebar 1) 

• Assess for secondary causes of overweight or obesity if physical exam and history warrant, including but not 

limited to: depression, binge eating disorder, hypothyroidism, hypercortisolism (Cushing’s disease or 

syndrome), traumatic brain injury, brain tumor, cranial irradiation, hypogonadism, menopause, acromegaly

• Assess the potential benefit of starting pharmacotherapy and/or bariatric procedure

• Assess conditions for which weight loss may not be beneficial (e.g., sarcopenia, active carcinoma, some eating 

disorders)

Abbreviations: BMI: body mass index; CPG: Clinical Practice Guideline; kg: kilograms; m: meters

Sidebar 4: Principles and Core Strategies of Motivational Interviewing

• Respect autonomy and resist directing

• Understand the patient’s motivations

• Listen with empathy

• Empower the patient by building confidence

• Ask Open-ended questions to evoke change talk and provide Affirmations, Reflections, and Summaries (OARS)

• For more information refer to the guide, “Moving Veterans To MOVE!”a

a Available at: https://www.move.va.gov/ 

Sidebar 5: Comprehensive Lifestyle Intervention

• Defined as an intervention that combines behavioral, dietary, and physical activity components together (see 

Recommendation 1, Recommendation 6, Recommendation 7, and Standards of Care)

• The intervention can be delivered in an individual or group setting, in person, by telephone, or through 

synchronous video (see Recommendation 1 and Recommendation 4) 

• Though there is insufficient evidence to recommend a specific number of sessions of comprehensive lifestyle 

intervention, most CLIs offer at least 12 intervention sessions in the first 12 months of intervention (see 

Recommendation 2) 

Abbreviations: CLI: comprehensive lifestyle intervention; CPG: Clinical Practice Guideline

Sidebar 6: Assessment for Pharmacotherapy and/or Bariatric Procedures

In addition to CLIs, consider pharmacotherapy and/or bariatric procedures in the following scenarios:

Consider for long-term pharmacotherapy (see Appendix H): 

• Patients with a BMI ≥30 kg/m2

• Patients with a BMI ≥27 kg/m2 and an obesity-related comorbidity (see Table H-1) 

• Individualize choice of medication to patient-specific comorbidities, dosing, administration, and potential for 

side effects 

Consider for bariatric procedures (see Appendix I): 

• Patients with a BMI ≥30 kg/m2 and T2DM 

• Patients with a BMI ≥35 kg/m2 and an obesity-related comorbidity 

• Any patient with a BMI ≥40 kg/m2

Abbreviations: BMI: body mass index; CLI: comprehensive lifestyle intervention; CPG: Clinical Practice Guideline; kg: kilograms; 

m: meters; T2DM: type 2 diabetes mellitus
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VI. Standards of Care for the Patient with Overweight and Obesity 

Some aspects of care of patients with overweight and obesity, although clinically important and part of 

the generally accepted standard of care, do not have sufficient high-quality evidence to support standalone recommendations. In some cases, clinical studies assessing the efficacy of these standards of care 

do not exist because they are determined to be routine actions (e.g., measurement of weight and 

calculation of BMI). In other cases, the standards are based on expert opinion, as was the case for 

several of the recommendations found in the previous version of this CPG.

A. Screening and Assessment for Overweight and Obesity

a. Screening

Calculating BMI is a practical screening tool to determine overweight and obesity in adult populations. The 

BMI is easily calculated, reliable, and is the basis for mortality risk estimates.[41] BMI is defined as a 

person’s weight in kilograms divided by the square of the person’s height in meters (kg/m2). When weight 

is measured in pounds and inches, the BMI is calculated as (weight [in pounds]/height [in inches]2)x 703. 

The optimal frequency for calculating BMI in the clinical setting has not been evaluated and is a matter of 

clinical discretion.[42] Screening at least annually provides an opportunity for patients and providers not 

only to identify overweight and obesity, but also to engage in productive discussions about the benefits of 

maintaining a healthy weight.

Although BMI is the most common way to identify overweight and obesity, there are questions 

regarding its accuracy in distinguishing between some individuals with and without obesity. For 

example, the optimal BMI for those over 65 may be slightly higher than for younger people.[40,43] 

Moreover, the use of BMI alone may lead to misclassification of highly fit individuals who have increased 

lean body mass, impacting assessments of fitness for duty. Measurement of body fat has been 

suggested as an alternative to BMI for screening for obesity, as truncal obesity may be an important 

indicator of risk for obesity-associated conditions, especially in people with a BMI below 30 kg/m2

.[44] 

Waist circumference (WC) is the most practical and reproducible anthropometric measurement for 

assessing a patient’s level of abdominal fat and is an indicator of increased disease risk for patients with 

overweight.[45] Measurement of WC is less relevant in individuals with BMI ≥35 kg/m2 because the WC 

will likely be elevated and will add no additional risk information.[26] We recommend cutpoints (>88 cm 

[>35 in] for women and >102 cm [>40 in] for men) as indicative of increased cardiometabolic risk.[26] 

The WC measurement should be made with a tape measure placed around the bare abdomen just 

above the iliac crest. The tape should be snug, but should not compress the skin and the measurement 

should be obtained while the patient is standing at the end of normal exhalation.[46] Measuring an 

individual’s waist-to-hip ratio may be useful in identifying increased cardiometabolic risk associated with 

central obesity, especially among those with smaller body frames.[47] Though there are several other 

ways to estimate body fat (e.g., skin-fold caliper measurement, hydrodensitometry, dual-energy X-ray 

absorptiometry, magnetic resonance imaging [MRI], and bioelectrical impedance [BEI]), most of these 

methods are not readily available or convenient in clinical settings. The introduction of scales that 

feature BEI technology to measure percent body fat in clinical settings may enhance the assessment of 

overweight and obesity, particularly among Service Members. 
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b. Obesity-associated Conditions

Obesity is associated with a large and varied number of chronic health conditions, including several 

common conditions listed in Sidebar 1. In addition to these conditions, obesity contributes to increased 

risk and/or morbidity for many other conditions, including many cancers, as well as pulmonary, 

cardiovascular (CV), cerebrovascular, endocrinologic, rheumatologic, gynecologic, urologic, gastrointestinal

(GI), and psychiatric conditions, including anxiety, depression, and eating disorders.[48,49] 

c. Medical Assessment of Patients with Overweight or Obesity

An assessment of a patient’s health history (see Sidebar 3) identifies the clinical, social, and behavioral 

factors that may affect his or her weight. In addition to the basic medical history and physical examination, 

patients should be assessed for factors contributing to obesity, including obesogenic medications, 

comorbid medical and psychiatric conditions (e.g., depression, anxiety, eating disorders, substance abuse), 

dietary and physical activity behaviors, previous experience with weight management (including clinical 

interventions as well as self-management) and the patient’s motivation and readiness to commit to a 

weight management intervention.[48,49] Information obtained from the assessment may identify 

opportunities to eliminate or reduce obesogenic medications or mitigate the contribution of comorbid 

medical or psychiatric conditions to the patient’s overweight or obesity. 

The assessment can be useful when counseling the patient regarding healthy behaviors and engaging in 

shared decision making regarding weight management options. 

B. Counseling Normal Weight Patients 

As noted in the Algorithm, the CPG Work Group encourages providers to offer guidance on diet and 

physical activity to patients who are assessed to have a healthy weight. This is supported by a USPSTF 

recommendation to consider offering or referring adults without obesity and without other risks for 

cardiovascular disease (CVD) to behavioral counseling to promote a healthful diet and physical activity.[50] 

This recommendation is based on a USPSTF review of existing evidence that indicates a small benefit of 

behavioral counseling for the prevention of CVD in this population.[51] 

Normal weight patients may be praised for maintaining a healthy weight and encouraged to implement or 

maintain, as applicable, healthy eating, and physical activity behaviors. They may also be educated about 

the health benefits of maintaining a healthy weight, eating in accordance with the Dietary Guidelines for 

Americans, staying physically active, and encouraged to balance caloric intake and energy expenditure. 

Patient education may also include recommending a diet balanced in fruits, vegetables, lean protein,

whole grains, and low-fat dairy products.g In addition, moderate-intensity daily physical activity (>30

min/day, five or more days/week) should be encouraged.h A careful review of medication lists for all 

 

g See MyPlate, available at: http://www.choosemyplate.gov, 2015-2020 Dietary Guidelines for Americans, available at:

https://health.gov/dietaryguidelines/2015/, or VHA’s Eat Wisely Healthy Living Message, available at: 

https://www.prevention.va.gov/Healthy_Living/Eat_Wisely.asp

h

 See Physical Activity Guidelines for American, Second Edition, available at: https://health.gov/paguidelines/second-edition/, or 

VHA’s Be Physically Active Healthy Living Message, available at: 

https://www.prevention.va.gov/Healthy_Living/Be_Physically_Active.asp
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patients may reveal medications that promote weight gain and may undermine efforts at maintaining a 

normal weight over time (see Sidebar 2).

C. Shared Decision Making to Choose Among Weight Management Options

Once an assessment has been conducted, and factors contributing to overweight and obesity have been 

addressed, the clinical team should engage the patient in a shared decision making process regarding 

weight management options. Shared decision making [52] is derived from evidence-based principles of 

health education [53] and health behavior counseling [54,55]and is also informed by motivational 

interviewing.[56,57] The first step in the shared decision making process is achieving a shared 

understanding of the risks related to the individual’s weight and health status and the potential benefits of 

participating in a weight management intervention. It is useful to begin by asking permission to discuss 

weight to ensure that patients are receptive. Asking permission supports patient autonomy and is 

consistent with the principles of motivational interviewing, an evidence-based clinical method for building 

motivation for behavior change.[57] Specific strategies for effectively reaching shared understanding are: 

• Ask permission to discuss weight-related health risks and the potential benefits and risks of weight 

loss and weight management

• Explore the patient’s understanding, beliefs, experience, and values regarding the health risks 

associated with their weight and the potential impact of weight management on their health and 

well-being

• Share information about potential health risks that are tailored to the patient’s understanding, his 

or her BMI, his or her current health status, and the presence of weight-associated conditions

• Emphasize, if needed, the value of viewing obesity as a chronic disease condition that requires 

ongoing attention and weight management

• Provide small amounts of information in a manner that is easy to understand

• Use a “teach-back” method to confirm shared understanding [53,55-58] 

The process of reaching a shared understanding goes beyond simply educating patients about their 

conditions and the benefits of weight loss. Instead, it is a dialogue that begins with exploring the patients’ 

understanding, beliefs, and experiences, and then providing information that is tailored to them. It is 

particularly useful to review patients’ prior experience with weight management, their perceptions about 

the benefits of weight loss, and their values. Exploring what matters to patients about their health and 

function allows the healthcare team to respond empathically and tailor information and advice and align 

recommendations with values (e.g., “preventing complications of DM will help you to be available to your 

family, which you said is very important to you”). Exploring, accepting (without judgment), and affirming 

patients’ values and preferences supports their autonomy, builds trust, and fosters provider-patient 

partnerships. This, in turn, is associated with increased patient follow-through with health behavior change 

and participation in recommended treatment.[57,59] 

Applying a patient-centered approach also requires that clinicians address the impact that weight stigma 

and bias have on patients’ physical and psychological health and well-being, willingness to participate in 

weight management, and success in weight management efforts.[60] Many healthcare providers hold 

strong, negative attitudes about people with overweight and obesity, and there is evidence that such 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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attitudes may impact the care they provide, further exacerbating patient well-being.[60,61] A patientcentered approach that emphasizes clinician awareness of his or her contributions to stigma and bias, use 

of person-first language (e.g., “people with obesity” instead of “obese patients”), and increased use of 

empathy and patient-centered communication skills can enhance the quality of clinical interactions.[60,61] 

a. Motivational Interviewing 

If an initial assessment of the patient’s motivation indicates that the patient is not ready to commit to

recommended treatment, an intervention based on motivational interviewing may be considered. 

Although there is considerable evidence that using motivational interviewing increases the likelihood that 

a patient will follow through with treatment recommendations across a wide range of health behaviors, 

there is only limited evidence for the impact of motivational interviewing on follow-through with weight 

management treatment.[57,62-70] Principles and core strategies of motivational interviewing are listed in

Sidebar 4. 

b. Eliciting a Commitment to Participate in Weight Management and Choosing 

Among Treatment Options

After achieving shared understanding, and after utilizing motivational interviewing if needed to build 

motivation to participate in evidence-based weight management interventions, the next step in the 

process of shared decision making is to elicit a commitment to engage in a recommended weight 

management intervention. This critical step is accomplished by asking an open-ended question. For 

example, a provider might say, “Given what we discussed about the potential benefits of participation in a 

weight management program, how ready are you to commit to treatment?” If the patient expresses a 

willingness to commit to a weight management intervention, the next step is to share the available options 

for engaging in treatment and guiding the patient to choose a treatment that is aligned with their needs 

and preferences. This step in the process can be initiated by referring the patient to an established 

comprehensive lifestyle intervention (CLI) (e.g., VHA’s MOVE! Weight Management Program [MOVE!];

i

see 

Emphasizing the Central Role of Comprehensive Lifestyle Intervention and Recommendation 1 for more 

information about CLIs) or to a member of the healthcare team (e.g., a dietitian, a health coach, a clinical 

pharmacist), who can guide the patient through the process of deciding among available treatment 

options. If the patient is not willing to commit to a recommended weight management intervention, the 

provider might offer educational materials and inform the patient that they will have an opportunity to 

revisit options for weight management in future encounters. A novel technology app, funded by the DoD, 

called Army H.E.A.L.T.H. (Healthy Eating Activity Lifestyle Training Headquarters)

j has been developed for 

active duty, reserves, and national guard service men and women. This app offers content and resources 

to encourage healthy eating, physical activity, fitness, and other healthy behaviors; however, as we noted 

in our recommendations, there is insufficient evidence for or against offering a CLI for weight loss that uses 

technology as its primary mode of delivery (see Recommendation 5). 

Motivational Interviewing strategies may also be applied at these and subsequent encounters. (See the 

discussion of Motivational Interviewing above). Providers might also assist the patient to select a more 

 

i

 Available at: https://www.move.va.gov/ j

 Available at: https://myarmyhealth.org/
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 27 of 147

limited health behavior goal (e.g., increased physical activity, OR eliminating sugar-containing beverages as 

a first step) that may contribute to future weight management efforts. 

D. Emphasizing the Central Role of Comprehensive Lifestyle Intervention

In this CPG, the Work Group strongly recommends offering a CLI that combines behavioral, dietary, and 

physical activity components as a foundational element of any weight management intervention (see 

Recommendation 1 and Sidebar 5). It is critical for patients, and providers, to understand that 

pharmacotherapy and metabolic/bariatric surgery should always be offered in conjunction with or 

concurrent to a CLI. Emphasizing the central role of CLI in weight management is a key element of the 

shared decision making process, as is reviewing the relative benefits and risks of specific 

pharmacotherapies, surgical procedures, and devices when these interventions are under consideration. 

The process of choosing among specific evidence-based weight management interventions includes: a 

review of previous experience with weight loss and response to treatments; identification of conditions or 

factors that increase risk of untoward reactions to elements of treatments (e.g., previous adverse effects 

from weight loss pharmacotherapy or surgical risks); and, of course, further exploration of patient 

preferences for CLI modality (e.g., for group versus individual and telephone versus in-person) and 

preferences regarding concurrent pharmacotherapy or metabolic/bariatric surgery, if the patient is a 

candidate. Consultation with a dietitian, a clinical pharmacist, or a bariatric surgeon may help with decision

making about the choice of specific weight management interventions, especially for patients with 

complex medical histories and/or concurrent pharmacotherapies that may impact the potential benefits 

and harms of specific weight management treatment components.

Whenever patients express an interest in participating in a CLI, it is useful to share and emphasize several 

key concepts that apply to all CLIs: 

• Understand weight management is a lifelong commitment rather than a brief episode of 

treatment

• Emphasize applying weight management practices that are maintainable, rather than those that 

might produce short-term weight loss but are not sustainable

• Create an “energy deficit” through a combination of reduced caloric intake and increased physical 

activity

• Apply specific behavioral strategies (e.g., goal setting, monitoring, problem solving) to support 

incremental changes in both diet and physical activity (see Appendix J) 

• Set specific, measurable, and realistic goals for changes in diet and physical activity, as well as 

realistic goals for weight loss and maintenance

We suggest that providers prepare patients to address the challenges of maintaining weight loss in the 

setting of metabolic, hormonal, and neuroendocrine adaptations to significant weight loss that make it 

challenging for individuals to maintain reduced weight.[71,72] Such preparations may include the 

expectation that they will need to increase their participation in moderate or vigorous physical activity to 

maintain significant weight loss.[73] 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 28 of 147

Once a patient has engaged in a CLI, it is useful to assess current levels of physical activity (including 

activity type, frequency, duration, and intensity) and the presence of sedentary behaviors (e.g., prolonged 

television watching). A dietary evaluation may include an assessment of problem eating behaviors (e.g., 

excessive snacking, frequent high caloric fast foods or liquid sugars). Weight and dieting history may 

include the number and types of diets and attempts at weight loss, possible triggers of weight gains and 

losses, and the range of weight fluctuations. Assessment may identify strengths and resources as well as 

barriers that may impact patient participation in weight loss programs. 

As noted above, setting specific and realistic weight loss goals is a key component of CLIs. Achieving 5 –

10% weight loss after six months is a reasonable initial treatment goal that can produce clinically 

significant benefits, especially for patients with obesity-associated conditions. A short-term initial weight 

loss goal of 0.5 – 2.0 pounds per week is achievable with a net caloric deficit of 500 – 1,000 kcal/day. This 

short-term weight loss goal, along with specific dietary, physical activity, and self-monitoring goals can 

serve as benchmarks for assessing progress during initial treatment.[2,74,75] 

E. Assessment of Progress Toward Weight Loss Goals

When patients participate in a CLI, the multiple encounters that characterize all CLIs provide opportunities 

for patients and providers to assess progress toward weight loss goals (through regular weighing and 

monitoring of dietary and physical activity behaviors), and to make adjustments to address barriers that 

may arise, particularly in meeting short- and intermediate-term dietary and physical activity goals. Patients 

who are meeting short- and intermediate-term goals should continue current treatment until long-term 

weight loss goals are achieved. When patients are not meeting short- and intermediate-term goals, the 

treatment plan should be modified to address identified barriers to health behavior change. If, despite 

increased attention to these barriers, the patient continues to struggle, consideration should be given to 

increasing the intensity of treatment. This can be achieved by increasing the intensity or frequency of the 

CLI, adding a recommended pharmacotherapeutic agent for weight loss, and consultation with, or referral 

to, a bariatric surgical team. As noted in Emphasizing the Central Role of Comprehensive Lifestyle 

Intervention above, consultation with a dietitian or clinical pharmacist may help with decision making 

about the selection or modification of dietary elements of the CLI or consideration of a specific weight 

management medications (see the Algorithm and Sidebar 6). 

Once long-term weight loss goals have been achieved, the focus of weight management shifts to 

preventing weight regain, a goal that requires maintenance of dietary and physical activity behaviors and 

many of the other self-management behaviors that contributed to successful weight loss. Thus, all patients 

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

reassessment (see the Algorithm and Recommendation 3).
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 29 of 147

VII. Recommendations 

Topic Subtopic # Recommendation Strengtha Categoryb Management of Overweight or Obesity a. Comprehensive Lifestyle Interventions (CLIs)

1.

We recommend offering an in-person group or individual 

comprehensive lifestyle intervention that always includes 

behavioral, dietary, and physical activity components for

patients with overweight or obesity. 

Strong for

Reviewed, 

Newreplaced

2.

There is insufficient evidence to recommend a specific number 

of sessions of a comprehensive lifestyle intervention for 

patients with overweight or obesity.

Neither for 

nor against

Reviewed, 

newreplaced

3. 

We suggest offering a comprehensive lifestyle intervention 

for weight maintenance to patients who have completed a 

comprehensive lifestyle intervention for weight loss.

Weak for

Reviewed, 

Newreplaced

4. 

We suggest offering an individual or group telephonedelivered comprehensive lifestyle intervention for weight loss, 

either as an alternative to or in conjunction with an in-person

intervention.

Weak for Reviewed, 

Amended

5. 

There is insufficient evidence for or against offering a 

comprehensive lifestyle intervention for weight loss that uses 

technology as its primary mode of delivery.

Neither for 

nor against

Reviewed, 

NewReplaced

b. Physical Activity 

Component of a CLI

6. 

We suggest choosing one or more of the following as the 

physical activity component of a comprehensive lifestyle 

intervention: aerobic, resistance, and/or lifestyle physical 

activity.

Weak for

Reviewed, 

Newreplaced

c. Dietary Component 

of a CLI

7. 

We recommend offering patients a dietary approach that 

contributes to a negative energy balance to achieve weight 

loss as the dietary component of a comprehensive lifestyle 

intervention. 

Strong for Reviewed, 

Amended

8. 

We suggest meal replacement (for example portion-controlled

shake, protein bar, or meal) as an option to achieve negative 

energy balance as a component of a comprehensive lifestyle 

intervention.

Weak for

Reviewed, 

Newreplaced

d. Long-term 

Pharmacotherapy 

9.

We suggest offering prescribed pharmacotherapy (specifically 

liraglutide, naltrexone/bupropion, orlistat, or 

phentermine/topiramate) for long-term weight loss in patients 

with a body mass index ≥30 kg/m2 and for those with a body 

mass index ≥27 kg/m2 who also have obesity-associated 

conditions, in conjunction with a comprehensive lifestyle 

intervention. 

Weak for

Reviewed, 

Newreplaced 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 30 of 147

Topic Subtopic # Recommendation Strengtha Categoryb Management of Overweight or Obesity (cont.) d. Long-term Pharmacotherapy (cont.)

10.

There is insufficient evidence to recommend for or against 

offering phentermine monotherapy, benzphetamine, 

diethylpropion, or phendimetrazine, for short-term, longterm, or intermittent weight loss in patients with overweight 

or obesity.

Neither for 

nor against

Reviewed, 

New-added

e. Dietary Supplements

and Nutraceuticals

11.

We suggest against using dietary supplements or 

nutraceuticals for clinically meaningful short-term weight loss 

or long-term weight management.

Weak 

against

Reviewed, 

New-added

f. Metabolic/Bariatric Procedures and Devices

12.

We suggest offering the option of metabolic/bariatric surgery, 

in conjunction with a comprehensive lifestyle intervention, to 

patients with a body mass index of ≥30 kg/m2 and type 2 

diabetes mellitus.

Weak for Reviewed, 

New-added

13.

We suggest offering the option of metabolic/bariatric surgery, 

in conjunction with a comprehensive lifestyle intervention, for 

long-term weight loss/maintenance and/or to improve 

obesity-associated condition(s) in adult patients with a body 

mass index ≥40 kg/m2 or those with body mass index ≥35

kg/m2 with obesity-associated condition(s).

Weak for

Reviewed, 

Newreplaced

14. There is insufficient evidence to recommend for or against 

metabolic/bariatric surgery to patients over age 65.

Neither for 

nor against

Reviewed, 

Amended

15.

There is insufficient evidence to recommend for or against 

percutaneous gastrostomy devices for weight loss in patients 

with obesity. 

Neither for 

nor against

Reviewed, 

New-added

Short-term Weight Loss 

(Up to 

Six 

Months) 

16.

We suggest offering intragastric balloons in conjunction with a 

comprehensive lifestyle intervention to patients with obesity 

(body mass index ≥30 kg/m2

) who prioritize short-term (up to 

six months) weight loss. 

Weak for Reviewed, 

New-added

17.

There is insufficient evidence to recommend for or against 

intragastric balloons for long-term weight loss to support 

chronic weight management or maintenance. 

Neither for 

nor against

Reviewed, 

New-added

18.

We suggest offering a low-carbohydrate diet over a low-fat 

diet as the dietary component of a comprehensive lifestyle 

intervention for patients who prioritize short-term (up to six 

months) weight loss.

Weak for Reviewed, 

New-added

a For additional information, please refer to Grading Recommendations. 

b For additional information, please refer to Recommendation Categorization and Appendix A. 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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A. Management of Overweight or Obesity

a. Comprehensive Lifestyle Interventions 

Recommendation

1. We recommend offering an in-person group or individual comprehensive lifestyle intervention 

that always includes behavioral, dietary, and physical activity components for patients with 

overweight or obesity.

(Strong for | Reviewed, New-replaced) 

Discussion

We define CLIs for weight loss and weight maintenance as interventions that combine three critical 

“lifestyle” components (i.e., behavioral, dietary, and physical activity components) that aim to produce a 

negative energy balance. CLI is the term used in the 2014 VA/DoD Obesity CPG, other recent CPGs, and 

evidence reviews of weight management interventions.[26,75] In this guideline, we define “in-person” as 

an intervention that necessitates the patient’s and clinician’s physical presence rather than telephone or 

synchronous interactive video, or synchronous online chat or text. 

The 2014 VA/DoD Obesity CPG found that CLIs produced clinically significant weight loss among patients 

with overweight or obesity. Comprehensive lifestyle interventions were recommended as “central to 

successful and sustained weight loss” and, more specifically, as a primary intervention to achieve weight 

loss and improve obesity-associated conditions in adults with overweight or obesity. Since the 2014 

VA/DoD Obesity CPG, a 2018 SR of CLIs commissioned by the USPSTF identified 80 good or fair quality 

randomized controlled trials (RCTs) of CLIs for weight loss (n=30,394 adults with overweight or obesity).[2] 

Findings were also published in a 2018 article from the Journal of the American Medical Association.[76] 

Results from 67 of the RCTs (n=22,065) indicated greater weight loss from CLIs compared to minimal 

intervention or usual care control conditions at 12 – 18 months (mean difference [MD] in weight change: -

2.39 kg; 95% confidence interval [CI]: -2.86 to -1.93).[2] Moreover, intervention participants had a 1.94 

times greater probability of losing 5% of their initial weight over 12 – 18 months compared with the 

control group (risk ratio [RR]: 1.94; 95% CI: 1.70 to 2.22), which translated into a number needed to treat

of eight.[2] Additionally, at 24 months, the pooled RR of achieving a 5% weight loss was 1.51 (95% CI: 1.25 

to 1.81), and the pooled RR of a 10% weight loss at 12 – 18 months was 3.06 (95% CI: 2.41 to 3.88). For all 

weight loss outcomes, there is moderate confidence in the quality of evidence.[2] 

When considering the impact of weight loss on health outcomes, the 2014 VA/DoD Obesity CPG Work 

Group found evidence that weight loss, including weight loss associated with participation in CLIs, 

produced clinically significant benefits for patients with DM and HTN.[77-86] The 2018 USPSTF systematic 

review also examined the impact of CLIs versus control conditions on a variety of health outcomes, 

although studies that focused on a specific chronic disease for which weight loss/maintenance is part of 

disease management (e.g., CVD, HTN, DM) were excluded.[2] Across nine trials (n=3,140) that evaluated

the impact of CLIs compared to control conditions among individuals with overweight and obesity selected 

for baseline impaired fasting glucose, the pooled RR of developing incident DM was 0.67 (95% CI: 0.51 to

0.89).[2] Within these, the two largest, good quality studies (n=1,817 combined) that focused on the 

prevention of DM (the Finnish Diabetes Prevention Study [87,88] [n=522] and the Diabetes Prevention 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 32 of 147

Program Outcomes Study [89] [n=1,295]) showed an absolute risk reduction of developing T2DM of 

approximately 14.5% over 3 – 9 years, as described in the 2018 USPSTF systematic review.[2]

However, data from the 2018 USPSTF systematic review on the long-term impact of CLIs versus control 

conditions on the prevalence of HTN, metabolic syndrome, use of CVD medications, and 10-year risk of 

CVD was limited to a small number of trials or was inconclusive.[2] Data were also limited or inconsistent 

on the long-term impact of CLIs on all-cause mortality, CV events, and QoL.[2] However, CLIs delivered in 

studies evaluating long-term health outcomes generally lasted for only 1 – 2 years, limiting the ability to 

assess an effect on these outcomes. Moreover, both observational studies and controlled trials in 

populations with specific chronic conditions have demonstrated that a 5% weight loss produces clinically 

significant improvements in these conditions.[26] 

We recommend both group and individual in-person modalities for delivering CLIs, as subgroup analyses 

performed for the 2018 USPSTF systematic review found no pattern of effects on the main outcome of 

change in weight at 12 – 18 months follow-up according to the main mode of intervention delivery (i.e., 

group versus individual versus technology-based versus mixed).[2] Technology-based modalities included 

computer- or web-based intervention modules, web-based self-monitoring, mobile phone-based text 

messages, smartphone applications, social networking platforms or DVD learning.[2] 

However, there was evidence of a greater effect among CLIs that included any group sessions versus those 

that did not (coefficient: -1.19; p=0.004).[2] Other intervention characteristics (e.g., intervention duration, 

the number of sessions in the first year) did not modify the effect of the intervention on change in 

weight.[2] Additional subgroup analyses found that mean baseline weight category (i.e., overweight, Class 

I obesity, Class II obesity) was not associated with differences in effects on weight change,[2] supporting 

the Work Group’s recommendation of CLI for weight loss for patients with overweight as well as obesity. 

However, the heterogeneity of the interventions, confounded with differences in the populations, settings, 

and trial quality, made it difficult to identify which variables may be driving larger effects.[2] (See 

Recommendation 2 regarding the number of intervention sessions, Recommendation 4 regarding 

telephone-delivered CLI sessions, and Recommendation 5 regarding technology-delivered CLI for 

additional information that supports these recommendations.) 

As noted above, CLIs combine behavioral, dietary, and physical activity components that aim to produce a 

negative energy balance. Although the evidence reviewed does not allow us to recommend any specific 

constellation of behavioral strategies for achieving clinically significant weight loss, the behavioral 

component of the CLIs included in the 2018 [2] and 2011 USPSTF systematic reviews [74] usually included 

the following elements: setting weight loss, physical activity, and dietary goals; self-monitoring (e.g., 

weighing, physical activity, and calorie/food tracking); stimulus control; cognitive strategies; identifying 

barriers to change; problem solving; relapse prevention; peer support; and in-treatment support.[2,74] 

These elements are also emphasized in other reviews of CLIs for weight loss not included in the systematic 

evidence review carried out for this CPG update.[75,90] Most interventions provided tools to assist with 

weight loss (e.g., pedometers, food scales, exercise videos), and 12 of the CLIs included an explicit 

motivational interviewing component to promote participant follow-through with CLI sessions and use of 

behavioral strategies.[91] For more information about specific approaches and behavioral strategies 

commonly included in CLI, see Standards of Care. See also recommendations and discussions on physical 

activity (Recommendation 6) and dietary components (Recommendation 7 and Recommendation 8).
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Additional SRs and individual studies testing CLIs for weight loss that were identified in the evidence 

review conducted for this CPG update either did not compare a CLI with an appropriate control (i.e., 

usual care or minimal intervention) or were rated as low or very low quality. Therefore, these studies did 

not contribute to the VA/DoD CPG Work Group’s recommendation.

Data from the 2018 USPSTF systematic review showed that larger differences in weight change were seen 

in trials that specifically enrolled adults with increased CV risk, subclinical risk of CVD or cancer (e.g., 

prehypertension, prediabetes, gestational diabetes), and elevated cancer risk compared to trials that 

enrolled adults who were unselected or generally at low risk (coefficient: -1.15; p=0.004). Sample retention 

at 12 months was also associated with greater weight loss (coefficient: -0.05; p=0.011).[2] These data 

suggest that CLIs have a greater impact among individuals at increased risk for CVD and cancer and that 

interventions that effectively engage subjects produce larger effects.

Despite the high heterogeneity found across the 80 CLIs in the 2018 USPSTF systematic review, the 

consistency in effects seen across specific interventions and various adult subgroups emphasizes a broad 

range of benefit from CLIs that is likely related to unmeasured individual, social, and environmental factors 

influencing an individual’s weight loss, rather than on specific intervention characteristics.[2] 

Evidence indicates the risk of harms from CLI is low. Rates of adverse events were reported in 27 trials 

(n=12,235) among the 80 behavior-based weight loss trials included in the 2018 USPSTF systematic 

review.[2] There were no serious harms related to the interventions, and most trials noted no differences 

between groups in the rates of adverse events, including CV events.[2] Musculoskeletal events were most 

commonly found to be related to the intervention groups, although only one trial found a statistically 

significant difference in events across intervention and control groups. In the Diabetes Prevention Program 

trial (n=2,161), a statistically significant increased rate of musculoskeletal symptoms (e.g., myalgia, 

arthritis, arthralgia) was seen among those in the lifestyle intervention group (24.1 events per 100 personyears) compared with those in the control group (21.1 events per 100 person-years) (p<0.0167) over four 

years of follow-up.[89] Although there is some burden to patients when participating in a CLI that includes 

multiple clinical contacts over many months or weeks, the benefits are significant, and there are many 

options for participating in effective interventions, including telephone-delivered counseling and videotelehealth programming that may attenuate the burden. 

The patient focus group that was convened for this CPG update highlighted the importance of developing a 

patient-centered lifestyle modification treatment plan that includes dietary and exercise components as 

well as education on how to make changes that will lead to sustained weight loss. Moreover, the focus 

group participants emphasized the importance of having a treatment plan that is individualized, offers 

treatments in a variety of formats, and includes access to tools and resources that leverage technology

(see Patient Focus Group Methods and Findings). These patient preferences and values are aligned with 

the elements and approach inherent in the delivery of CLIs and the findings that a variety of modalities, 

including group, individual, and mixed modalities, are effective for weight loss.

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation[2] and considered the evidence put forth in the 2014 CPG.[77-86] The 

primary source of evidence was a large 2018 USPSTF-sponsored SR that included 80 good and fair quality 
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July 2020 Page 34 of 147

RCTs that randomized 30,394 adults with overweight and obesity to CLIs for weight loss versus minimal 

treatment or usual care control interventions.[2] Results included greater weight loss from CLIs versus 

control at 12 – 18 months follow-up (MD: -2.39 kg) and a 1.94 times greater probability of losing 5% of 

participants’ initial weight over 12 – 18 months compared with control groups, which translated into a 

number needed to treat of eight.[2] Across nine trials (n=3,140) that compared the impact of CLIs 

compared to control conditions among individuals selected for baseline impaired fasting glucose, the 

pooled RR of developing incident DM was 0.67; however, the impact on other intermediate outcomes and 

health outcomes was mixed.[2] Evidence indicates the risk of harms from CLIs is low. The Work Group

recommends both group and individual in-person modalities for delivering CLI, as subgroup analyses 

performed for the 2018 USPSTF systematic review found no pattern of effects on weight change at 12 – 18 

months follow-up based on whether the main mode of intervention delivery was group or individual.[2] 

The Work Group’s confidence in the quality of evidence was moderate. Patient focus group participants 

highlighted the value of CLIs, particularly when they are available in a variety of modalities. Thus, the Work 

Group decided upon a “Strong for” recommendation. 

Recommendation

2. There is insufficient evidence to recommend a specific number of sessions of a comprehensive 

lifestyle intervention for patients with overweight or obesity.

(Neither for nor against | Reviewed, New-replaced) 

Discussion

As noted in Recommendation 1, we recommend offering an in-person group or individual CLI to patients 

with overweight or obesity for weight loss to support long-term weight management and to prevent or 

improve obesity-associated conditions. The 2014 VA/DoD Obesity CPG recommended offering at least 12 

sessions of a CLI within 12 months, based on the evidence reviewed at that time. However, the Work 

Group’s review of additional studies conducted since the 2014 VA/DoD Obesity CPG was published led 

them to conclude that there is insufficient evidence to recommend offering a specific number of CLI 

sessions to produce significant weight loss. However, the evidence also suggests that CLIs that offer at 

least 12 sessions in the first 12 months of intervention produce a larger and more consistent effect on 

weight loss at 12 – 18 months of follow-up than CLIs that offer less than 12 sessions in the first 12 months.

As detailed in Recommendation 1, a 2018 USPSTF systematic review of 80 RCTs of CLIs for weight loss 

demonstrated greater weight loss from CLIs compared to minimal intervention or usual care control 

conditions.[2] To examine the effect of intervention intensity on weight loss outcomes, investigators who 

conducted the 2018 USPSTF systematic review abstracted the total number of sessions conducted in the 

first 12 months for each intervention arm.[2] Sessions were defined as any group or individual counseling 

session conducted face-to-face or by telephone, or any web- or computer-based module or session.[2] 

When number of sessions was examined as a continuous measure, a higher number of intervention 

sessions in the first 12 months was associated with significantly more weight loss (coefficient: -0.03; 

p=0.023).[2] However, the number of sessions in the first year was not associated with greater weight loss 

after controlling for the presence of group sessions (coefficient: -0.015; p=0.212). Moreover, when 

intervention intensity was examined in a subgroup analysis according to the number of intervention 

sessions in the first year (>26 sessions, 12 – 26 sessions, and <12 sessions), results showed significantly 

greater effects versus controls for all three subgroups. Although there were larger effect estimates among 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 35 of 147

interventions with more sessions in the first 12 months of intervention (>26 sessions, MD: -3.06 kg, 95% CI: 

-3.85 to -2.28; 12 – 26 sessions, MD: -2.48 kg, 95% CI: -3.35 to -1.61; 0 – 11 sessions, MD: -1.73, 95% CI: -

2.32 to -1.13), the CIs across all three of the subgroups overlapped, so these differences were not 

statistically significant. 

Although there was no significant difference found for number of sessions in the first 12 months of 

intervention, almost two-thirds (n=44) of the 67 interventions included in the analysis of weight loss at 12 

– 18 months offered at least 12 sessions within the first year of the intervention.[2] Also, the absence of a 

significant difference for number of sessions in the first year was likely influenced by the inclusion of eight

technology-based trials in the 0 – 11 session subgroup that offered a high volume of additional contacts 

(through mobile phone text messages, emails, or interactions with other web-based or social media 

platforms) to supplement the sessions. Moreover, more than half (n=12) of the 23 trials in this subgroup 

offered at least five sessions in the first year, and several trials in the 0 – 11 session subgroup offered 

sessions beyond the first 12 months of the intervention. Moreover, the quality of the evidence for a 

differential impact based on the number of CLI sessions was rated as low due to the large clinical and 

statistical heterogeneity of the CLIs included in the SR and the lack of studies directly evaluating the impact 

of number of sessions on weight loss outcomes while controlling for other intervention characteristics.[2] 

Also, the systematic evidence review carried out as part of this CPG update did not identify individual 

studies that specifically tested the differential impact of number of sessions while controlling for other 

characteristics of the CLI. 

Although the Work Group concluded that there is insufficient evidence to recommend a specific number of 

CLI sessions in the first 12 months of a CLI, the larger effect sizes found for CLIs that offer 12 – 26 sessions 

(MD: -2.48 kg), or >26 sessions (MD: -3.06 kg), when compared to <12 sessions (MD: -1.73 kg), are 

meaningful differences and suggest CLI intensity matters. As noted previously, although there was a 

significant effect of CLI over controls conditions for CLIs that offered 0 – 11 sessions, the majority of the 

studies that were in this subgroup provided at least five sessions in the first 12 months, and most of the 

others were technology-based and included other forms of contact with participants. Moreover, the 

American Heart Association/American College of Cardiology/The Obesity Society Guideline for the 

Management of Overweight and Obesity in Adults, published in 2013, strongly recommended providing a 

high intensity CLI (≥14 sessions in the first six months) CLI.[26] 

The Work Group also notes that there are limitations in offering a weight management intervention that 

features many sessions, including the large variability in the way patients wish to receive their sessions. 

Some may prefer a CLI that includes fewer sessions, while others may prefer one that includes a greater 

number of sessions. Additionally, some subgroups of patients may be unable to participate in CLIs that 

require many sessions (e.g., a patient who is limited by transportation, telephone availability, or lack of a 

computer). CLI session number and frequency may also be limited by healthcare facility constraints such as 

lack of staff and space and an inability to provide the interventions in accordance with all patient 

preferences. Lastly, there are differences in the ability of VA and DoD programs to provide CLIs of greater 

intensity. In the VA, the MOVE! program, which meets the criteria for a CLI, has already been integrated 

into clinical practice, increasing resources devoted to CLIs. No comparable agency-wide standardized 

voluntary weight management program has been consistently adopted across the DoD, which may present 

a challenge for many DoD locations. 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 36 of 147

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed the 

evidence related to this recommendation.[2] The Work Group concluded that there is insufficient evidence 

to recommend a specific number of sessions of a CLI for patients with overweight or obesity, although as 

noted, there may be a dose-response effect for number of sessions in the first 12 months of a CLI, as 

almost two-thirds of RCTs of CLI offered at least 12 sessions during the first 12 months. Confidence in the 

quality of the evidence is low due to heterogeneity of CLIs and the lack of studies that directly tested high 

versus low number of sessions. There is likely variation in patient preferences regarding participating in 

CLIs with many sessions. Thus, the Work Group decided upon a “Neither for nor against” recommendation.

Recommendation

3. We suggest offering a comprehensive lifestyle intervention for weight maintenance to patients 

who have completed a comprehensive lifestyle intervention for weight loss.

(Weak for | Reviewed, New-replaced)

Discussion

The 2014 VA/DoD Obesity CPG Work Group found that offering a maintenance CLI that includes dietary, 

physical activity, and behavioral components plus ongoing support reduces the likelihood of weight 

regain.[74,75,92] Since the publication of the 2014 VA/DoD Obesity CPG, a 2018 USPSTF systematic review

(n=2,704) compared CLIs for weight maintenance after weight loss to no interventions (four trials), 

minimal intervention (three trials), or usual care (two trials).[2] The SR included RCTs of participants with 

pre-intervention BMI ≥25 kg/m2 who reported weight or adiposity change at least 12 months following the 

start of the weight maintenance intervention. Interventions included group or individual counseling 

sessions delivered by phone, in-person, or through technology. The interventions were designed to help 

study participants maintain weight loss by continuing a healthy diet, physical activity, and use of behavioral 

strategies such as goal setting, problem solving, relapse prevention, and self-monitoring (see Standards of 

Care for more information about the components of a CLI). The frequency and intensity of interventions 

were variable. In most studies, the duration of the maintenance intervention was 12 – 18 months and 

included 12 – 26 sessions in the first year. 

The SR found a significant difference favoring the intervention versus controls (eight studies, n=1,408) in 

maintenance of previous weight loss reported as kilograms or pounds lost at 12 – 18 months postintervention (MD: -1.59 kg; 95% CI: -2.38 to -0.79).[2] Results of one included trial (n=1,029) also favored 

the intervention group regarding continued maintenance of ≥5% weight loss at 30 months postintervention (intervention: 42%, control: 34%; RR: 1.24; 95% CI: 1.02 to 1.51) and 60 months postintervention (intervention: 37%, control: 27%; RR: 1.37; 95% CI: 1.03 to 1.82). Although there are relatively 

few maintenance trials and the net benefit is small, three of the maintenance trials included some 

participants who were not successful in meeting initial weight loss goals, limiting the likelihood of finding a 

significant difference in maintained weight loss between maintenance intervention conditions versus 

control conditions. An additional RCT by Mai et al. (2018) was identified but the study quality was rated as 

poor.[93] The 2018 USPSTF systematic review also determined there is insufficient evidence to favor group 

or individual treatment.[2] 
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Comprehensive lifestyle interventions for weight maintenance have a very low risk of harms. This was 

reflected in the results of the 2018 USPSTF systematic review, which found no serious harms and similar 

rates of adverse events between participants in behavior-based interventions and controls (see 

Recommendation 1 for discussion of potential harms for CLI).[2] Therefore, the benefit of participation in 

CLI for weight maintenance was determined to outweigh potential harms. 

Despite general consistency in supporting CLI for weight maintenance, there is some variability in 

patient preferences for this treatment. Significant time is required for participation, and patients vary in 

their willingness and ability to travel to receive an intervention. Patients also vary in their willingness to 

devote resources to weight maintenance. To benefit, patients must engage with the intervention and 

practice skills. There are also limitations related to intervention resource availability, as clinicians who 

deliver maintenance CLI also usually deliver CLI for weight loss. It may be less feasible for some groups 

of patients (e.g., rural Veterans, soldiers who are deployed or on temporary field training) to access a 

maintenance CLI. 

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation [2,93] and considered the evidence put forth in the 2014 CPG.[74,75,92] 

Maintenance CLIs were found to significantly impact maintenance of weight loss at 12 – 18 months and 

maintenance of ≥5% weight loss at 30 and 60 months post-maintenance intervention compared to 

controls. Though the net benefit was small, these benefits outweighed the potential harm from adverse 

events, which was minimal. The body of the evidence had some limitations including a small number of 

trials reporting >5% weight loss and one trial with wide confidence intervals;[2] however, all nine trials 

reviewed in the 2018 USPSTF systematic review were rated fair or good quality, and overall, the Work 

Group’s confidence in the quality of evidence was moderate. Patient values and preferences were 

somewhat varied. Thus, the Work Group decided upon a “Weak for” recommendation.

Recommendation

4. We suggest offering an individual or group telephone-delivered comprehensive lifestyle 

intervention for weight loss, either as an alternative to or in conjunction with an in-person

intervention.

(Weak for | Reviewed, Amended)

Discussion

The 2014 VA/DoD Obesity Work Group recommended offering telephone-based CLI either as an 

alternative to, or in conjunction with, an in-person intervention. As noted in Recommendation 1, the Work 

Group recommends offering an in-person group or individual CLI to patients with overweight or obesity for 

weight loss to prevent or improve obesity-associated conditions. Based on the evidence reviewed in the 

2014 VA/DoD Obesity CPG and evidence published since then, the Work Group suggests offering an 

individual or group telephone-based CLI for weight loss to support long-term weight management, either 

as an alternative to or in conjunction with a face-to-face intervention. “In conjunction with” is defined as in 

addition to another intervention, while “an alternative” is defined as in place of an intervention.
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As detailed in Recommendation 1, a 2018 USPSTF systematic review of 80 RCTs of CLIs for weight loss 

demonstrated greater weight loss from CLIs compared to minimal intervention or usual care control 

conditions.[2] Fifteen of these RCTs tested CLIs that included a telephone-delivered component.[2] 

Investigators examined the effects of intervention modality on weight loss outcomes produced by CLI and 

found no significant difference in the magnitude of effects between in-person versus telephone 

modalities. Two fair-quality RCTs, not included in the 2018 USPSTF systematic review, directly compared 

the impact of telephone-delivered versus face-to-face CLIs on weight loss outcomes and found no 

significant differences between the intervention conditions.[94,95] Though the systematic evidence review 

conducted as part of this guideline update did not identify any studies that specifically evaluated the 

impact of synchronous video-delivered CLI, this emerging intervention modality is likely to be efficacious 

compared to telephone-delivered CLI. The visual cues offered by synchronous video-delivered CLI may 

enhance provider-patient communication and thereby enhance patient engagement in the intervention.

Based on this evidence, the Work Group concluded that telephone-delivered CLI is effective as an 

alternative to face-to-face CLI and in conjunction with face-to-face CLI (i.e., when used to increase the total

number of sessions attended).[2,75,94,95] 

Despite general consistency in the evidence supporting telephone-based CLI, there is some variability in 

patient preferences regarding this modality. The patient focus group revealed that any CLI can be 

burdensome to patients, as CLI requires frequent contacts (see Appendix B). For certain populations, 

telephone-delivered intervention may be less feasible (e.g., patients with hearing impairment or unreliable 

phone service). Furthermore, there may be limited access to telephone-based CLI, as there are relatively 

few providers who have been trained in CLI, or have dedicated time for telephone-delivered interventions. 

Summary

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[2,94,95] and considered the evidence put forth in the 2014 CPG.[75,92] 

The Work Group’s confidence in the quality of evidence was low. No good quality RCTs were identified

that directly compared telephone to face-to-face modalities of intervention while controlling for other 

characteristics of the CLI. The benefit of weight loss outweighed any potential harm, which is minimal for 

CLIs (see the discussion for Recommendation 1). Patient values and preferences were somewhat varied. 

Thus, the Work Group decided upon a “Weak for” recommendation. 

Recommendation

5. There is insufficient evidence for or against offering a comprehensive lifestyle intervention for

weight loss that uses technology as its primary mode of delivery. 

(Neither for nor against | Reviewed, New-replaced) 

Discussion

For this recommendation, the Work Group considered interventions that use technology as a primary 

mode of intervention delivery. These include computer- or web-based intervention modules, web-based 

self-monitoring, mobile phone-based text messages, smartphone applications, social networking 

platforms, DVD learning, and print-based tailored materials. 
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As noted in Recommendation 1, we recommend offering an in-person group or individual CLI to patients 

with overweight or obesity for weight loss to support chronic weight management and to prevent or 

improve obesity-associated conditions. However, there was insufficient evidence to recommend for or 

against offering a technology-delivered CLI either as an adjunct or alternative to CLI delivered in-person or 

by telephone. 

As detailed in Recommendation 1, a large 2018 USPSTF systematic review included RCTs of studies that 

used technology as the main mode of intervention for CLI, along with trials that featured other CLI delivery 

modalities (i.e., individual, group, mixed).[2] Subgroup analyses found no consistent pattern of effects on 

weight loss outcomes according to the main mode of intervention delivery on change in weight, suggesting 

technology-delivered interventions were effective.[2] However, the MD in weight loss outcomes favoring 

the 12 technology-delivered interventions versus control was small (MD: -1.14 kg; 95% CI: -1.59 to -1.09), 

especially considering the MD between CLI versus control for all 67 trials included in the primary analysis (-

2.39 kg; 95% CI: -2.86 to -1.93). Moreover, the 12 studies of technology-delivered CLIs [96-107] included in 

the 2018 USPSTF systematic review identified a wide range of technologies employed across the trials. 

Seven [96,98,101,102,105-107] of the 12 individual trials did not find a significant difference between 

intervention and minimal intervention or usual care control groups on weight loss at 12 – 18 months. One 

of the five positive trials focused on post-partum weight loss.[103] Another was found to be effective in 

men but not women.[104] In addition, two trials explicitly described face-to-face, interactive 

components.[96,101] Most of the other trials included some form of human interaction, making it difficult 

to determine the degree to which the technology component of the intervention contributed to outcomes. 

Additionally, a 2019 SR evaluated the effectiveness of web-based digital health interventions compared to

no active intervention.[108] The authors conducted a meta-analysis of five RCTs and found a significant 

effect favoring active interventions on weight loss, though the quality rating of the SR was poor. None of 

the trials reported outcomes beyond nine months, and three of the five trials reported outcomes at four 

months or less. Another recent SR by Park et al. (2019) evaluated the effectiveness of mobile phonedelivered CLI for weight loss versus no treatment or educational materials.[109] Twenty RCTs in adults 

with overweight or obesity were included in this SR. However, weight loss outcomes at 12 or 24 months 

were reported for only four mobile phone intervention conditions in three trials,[106,110,111] and none of 

these produced significant effects versus controls. Moreover, the meta-analysis conducted in the Park et 

al. (2019) SR [109] was flawed, as the investigators included 12- and 24-month outcomes from a single trial 

[110] as two separate trials in the meta-analysis. Several additional individual studies testing technologydelivered CLIs for weight loss that were identified in the evidence review conducted for this CPG update

had poor or very poor quality ratings due to methodological deficiencies.

Although the Work Group found insufficient evidence to recommend for or against the use of technology 

as a primary means to deliver CLIs, it is important to consider variation in patient values and preferences, 

efficiency of resource utilization, and potential reach of interventions. Patients vary in their desire or 

preference for technology-delivered interventions; for some patients, a technology-delivered intervention 

may increase their access to lifestyle intervention. While these interventions may reduce burden and 

travel time related to in-person intervention, use of technology may introduce burdens as well, which vary 

depending on the type of technology. In terms of equity, while most Service Members and Veterans have 

access to smartphones, data plans vary, and not all individuals have access to all types of technology. Also, 
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individuals in rural or remote locations may not have the same opportunity to benefit from technologybased interventions when infrastructure lags in these areas. 

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed 

evidence related to this recommendation.[2,106,108-111] The Work Group’s confidence in the quality of 

evidence was very low. The body of the evidence had significant limitations including poorly defined and 

heterogeneous interventions, small MDs between interventions, and minimal intervention or no 

treatment controls and/or reported weight loss outcomes at less than 12 months of follow-up. Thus, the 

Work Group decided upon a “Neither for nor against” recommendation regarding technology-delivered 

CLIs for weight loss. However, technology-inspired tools and resources can play a valuable role in 

supporting self-monitoring and tracking of diet, physical activity, and weight loss outcomes when 

patients are engaged in an in-person or telephone-delivered CLI, especially for those Veterans and 

Service Members who value technology-supported approaches. Internet, text-based, mobile apps, or 

other technology-supported approaches also have great potential for extending or increasing interaction 

with CLI staff. 

b. Physical Activity Component of a Comprehensive Lifestyle Intervention 

Recommendation

6. We suggest choosing one or more of the following as the physical activity component of a 

comprehensive lifestyle intervention: aerobic, resistance, and/or lifestyle physical activity.

(Weak for | Reviewed, New-replaced) 

Discussion

The primary evidence in support of physical activity interventions for weight loss is nested in studies of CLIs 

for weight loss to support long-term weight management that combines physical activity, dietary, and 

behavioral interventions.[2,112-114] As detailed in the discussion accompanying Recommendation 1, a 

2018 USPSTF systematic review of 80 RCTs of CLIs for weight loss demonstrated greater weight loss from 

CLIs compared to minimal intervention or usual care control conditions.[2] A physical activity component is 

also a core element of CLIs recommended for weight maintenance.[2] The CLIs included in the 2018 

USPSTF systematic review all featured similar messages related to energy balance (i.e., gradual increases in 

moderate-to-vigorous intensity physical activity and healthful dietary patterns following national 

guidelines).[2] The physical activity component generally promoted at least 150 minutes of moderateintensity activity per week (see also the discussion for Recommendation 1). There was additional evidence 

from two fair quality SRs showing an improvement in weight loss with the addition of physical activity to a 

dietary-only component and the addition of physical activity to a comparator that combined dietary and 

behavioral interventions.[112,113] The Work Group did not review research that evaluated exercise-alone 

weight-loss interventions, as a large body of previous research concluded that exercise alone produces 

small impacts on weight, especially when compared to studies that included both dietary and physical 

activity elements.[112,113,115-117] 

The evidence reviewed compared different types of physical activity utilized in a CLI for weight loss

including aerobic training (e.g., cycling, supervised walking programs), resistance training (e.g., weight 
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training), and “lifestyle physical activity” (generally increasing activity during the day such as climbing extra 

stairs, unstructured walking activity, or getting more steps using a pedometer). Studies comparing the kind 

of physical activity used as part of a CLI, or as part of a multimodal (physical activity and diet) approach, did 

not reveal important differences by the kind of physical activity for weight loss or other important 

variables;[114,118,119] however, some evidence indicated higher intensity of physical activity has better 

effects on weight variables than lower intensity activity programs.[118] There was no specific weight loss 

benefit associated with a specific kind of physical activity (aerobic, resistance, or lifestyle) in the evidence 

reviewed. While not reviewed in this guideline, higher volumes of physical activity (e.g., over 300 minutes 

of moderate activity per week) were associated with improved weight maintenance after weight loss.[115] 

The benefits of having physical activity as part of a CLI were judged to outweigh the relatively minor 

potential harms. The benefits are large and far reaching but are beyond the scope of this guideline. For the 

background on these benefits, please see the 2018 Physical Activity Guidelines for Americans (PAGA).[120] 

In addition to the general health benefits of physical activity, there is evidence that patients with 

overweight and obesity are likely to benefit from increasing physical activity regardless of its impact on 

weight status. This includes the positive effects of increased physical activity on comorbid conditions 

associated with overweight and obesity [113,118,120,121] and related benefits/effects such as healthrelated QoL and self-efficacy/physical function.[119] For example, osteoarthritis, chronic pain syndromes, 

and HTN (among others) are responsive to the doses and types of physical activity included in CLIs for 

weight loss. As noted in the discussion for Recommendation 1, musculoskeletal events were commonly 

related to CLI groups, although only one trial found a statistically significant difference in events across 

intervention and control groups.[89] Other potential harms include the burden of time and effort 

expended to follow a physical activity program.

The Work Group also considered how patient values and preferences regarding physical activity 

interventions might impact the recommendation. Patients often want specific information on practical 

steps for increasing physical activity to support weight loss and maintenance (see Appendix B). The Work 

Group judged that both patients and providers might have large variations in preferences for different 

kinds of physical activity. In addition, there are variations in constraints faced by different subgroups of 

patients, such as access to a gym or exercise spaces/equipment, preexisting musculoskeletal or other 

health-related conditions that limit activity ability, and proximity to safe outdoor activity options. Since the 

systematic evidence review carried out as part of this guideline update did not find significant differential 

effects of specific activity types, patients and providers have a wide scope of options when considering 

specific physical activity modalities. The PAGA recommends choosing physical activity types that align with 

the patient’s values, abilities, and preferences, as well as consideration of activities that are accessible and 

more easily incorporated into the patient’s daily life (e.g., walking).[120]

k,l

 

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation,[2,112-114,118,119] and considered the evidence put forth in the 2014 

CPG.[89,115-117] The overall confidence in the quality of evidence comparing types of physical activity for 

weight loss is low. The benefits of having physical activity as part of a CLI outweighed the relatively minor 

 

k These options are discussed in the PAGA at https://health.gov/paguidelines/second-edition/. l

 Physical activity options are reviewed in detail at https://health.gov/moveyourway/. 
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potential harms. Thus, the Work Group decided upon a “Weak for” recommendation. However, beyond 

the impact of physical activity on weight, there are large benefits of increasing physical activity levels in 

this population for general health and to reduce the impact of common comorbid 

conditions.[113,118,120,121] The Work Group recommends future research to compare different kinds of 

physical activity (aerobic, resistance, lifestyle) in CLI programs for weight loss to discover any differential 

effects and reveal any differences in adherence, acceptability, or feasibility. 

c. Dietary Component of a Comprehensive Lifestyle Intervention 

Recommendation

7. We recommend offering patients a dietary approach that contributes to a negative energy balance 

to achieve weight loss as the dietary component of a comprehensive lifestyle intervention.

(Strong for | Reviewed, Amended) 

Discussion

Using a dietary approach that enables patients to achieve a negative energy balance is a core component 

of CLIs and has been found to promote weight loss in patients with overweight and obesity.[2,122-134] As 

detailed in the discussion accompanying Recommendation 1, a 2018 USPSTF systematic review of 80 RCTs 

of CLIs for weight loss demonstrated greater weight loss from CLIs that included a dietary component 

compared to minimal intervention or usual care control conditions.[2] A dietary component is also a core 

element of CLIs recommended for weight maintenance.[2] The CLIs included in the SR all featured similar 

messages related to energy balance (i.e., gradual increases in moderate-to-vigorous intensity physical 

activity and healthful dietary patterns following national guidelines).[2] See also the discussions for 

Recommendation 1 and Recommendation 3. Based on these studies, a negative energy balance to support 

weight loss can be achieved through a variety of dietary approaches.[122-134] Findings from multiple 

other studies, conducted in a variety of patient populations, have been consistent with this finding.[135-

144] There is no evidence of harm to patients in achieving a modest negative energy balance.[122-145]

However, patient harm is possible if a very low-calorie diet (≤800 kcal) is followed; that harm may include 

“cholecystitis, asthenia, fatigue, headache, constipation, and nausea.”[129,146] 

Patients seeking to lose weight recognize the need to achieve negative energy balance, but determining 

how to do that can be difficult. Providers can discuss a patient’s medical condition(s) and dietary 

preferences to help guide patients to the dietary approach best suited to those preferences to promote 

adherence during weight loss as well as maintenance once weight loss is achieved. Ideally, patients are 

referred to a CLI that is delivered by an inter-professional team, including a registered dietitian, who can 

work with the patient to best meet nutrient needs for health and management of the medical condition(s) 

while promoting weight loss. See Appendix G on dietary approaches for additional guidance on selecting 

the dietary component of a comprehensive lifestyle intervention.

Summary

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed evidence 

related to this recommendation,[2,122-126,128-134,142] and considered the evidence put forth in the 

2014 CPG.[127,135-141,143-145] The Work Group’s confidence in the quality of evidence was moderate. 

The body of evidence had some limitations including heterogeneity in dietary approaches, heterogeneity 
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in how specific diets were defined, variable lengths in the intervention duration across studies, small 

sample size in some individual studies, and insufficient control for confounding variables in the analyses

limiting interpretation of study results.[122,123,130,135,140] The benefits of weight loss on comorbid 

conditions outweighed the potential harm of adverse events, which was small. Patient values and 

preferences were aligned with achieving a negative energy balance. Thus, the Work Group decided upon a 

“Strong for” recommendation. Providers should refer patients to a registered dietitian to aid in 

determining the approach for achieving a negative energy balance that best supports the patients’ overall 

medical history and dietary practices.

Recommendation

8. We suggest meal replacement (for example portion-controlled shake, protein bar, or meal) as an 

option to achieve negative energy balance as a component of a comprehensive lifestyle 

intervention.

(Weak for | Reviewed, New-replaced) 

Discussion

Meal replacement has been found to support weight loss in patients with overweight and obesity when 

provided in conjunction with a CLIto support long-term weight management (for all CLIs see 

Recommendation 1).[122] Based on an SR of 23 RCTs, meal replacement provided significantly more 

weight loss than other dietary approaches (MD: -1.44 kg at one year; MD: -2.71 kg at more than one year; 

and MD: -4.20 kg at four years). Greater weight losses were achieved when meal replacement was coupled 

with weight loss support.[122] Meal replacement also resulted in improvements in systolic and diastolic 

blood pressure (BP), total cholesterol, and fasting serum insulin levels.[122] Findings from multiple other 

studies, conducted in a variety of patient populations, have been consistent with this finding.[147-149] 

One study of 66 matched participants included in the 2014 VA/DoD Obesity CPG revealed equal weight 

loss between participants using meal replacements and participants using a structured weight-reduction 

diet.[150] Evidence indicates that meal replacement does not pose harm to patients.[122] 

Meal replacement can be used to achieve a negative energy balance as part of a CLI. While the evidence 

review only identified one SR on this topic, it included 23 studies and 7,884 study participants.[122] The 

findings of the SR and meta-analysis [122] align with evidence from the 2014 VA/DoD Obesity CPG [150] 

that meal replacements are convenient to use and provide manageable dining out options.

There is general consistency in the evidence supporting meal replacement.[151] There may be some 

variability in provider and patient preferences regarding this treatment based on the acceptability and cost 

of meal replacement products. Service Members receiving Subsistence in Kind (SIK) are provided meals in 

DoD dining facilities – an entitlement that cannot be used to purchase meal replacement products. 

Veterans with limited financial resources or those on a fixed income may also find purchasing meal 

replacement products burdensome. Patients may get weary of eating the same meal replacement product 

every day; however, providing a variety of meal replacement options may promote adherence.

Meal replacements address patients’ desire to know how to achieve negative energy balance, aligning with 

the focus group members’ preference for specific guidance. Meal replacement products enable patients to 

know what to eat for the meal(s) being replaced. Meal replacement, when offered in conjunction with a 
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CLI, can help patients develop the knowledge, skills, and confidence needed to manage their weight and 

address both short- and long-term weight management needs. 

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed 

evidence related to this recommendation [122] and considered the evidence put forth in the 2014 

CPG.[147-150]The Work Group’s confidence in the quality of evidence was moderate. The body of 

evidence had some limitations including variability in the level of bias, with five out of the 23 studies 

deemed to be at high risk for bias in at least one domain. Biases included unclear allocation and 

concealment of intervention and heterogeneity of meal replacement products used; additionally, 

several studies were industry funded.[122] Most studies (19 out of 23) included in the Astbury et al. 

(2019) SR and meta-analysis were included predominantly of female participants.[122] Other 

considerations regarding this recommendation included the benefits (including weight loss as well as 

improvements in systolic and diastolic BP, total cholesterol, and fasting insulin) outweighing the 

potential harm of adverse events, which was small (reported adverse events were not likely associated 

with the meal replacement). Patient values and preferences were somewhat varied. Thus, the Work 

Group decided upon a “Weak for” recommendation.

d. Long-term Pharmacotherapy 

Recommendation

9. We suggest offering prescribed pharmacotherapy (specifically liraglutide, naltrexone/bupropion, 

orlistat, or phentermine/topiramate) for long-term weight loss in patients with a body mass index 

≥30 kg/m2 and for those with a body mass index ≥27 kg/m2 who also have obesity-associated 

conditions, in conjunction with a comprehensive lifestyle intervention.

(Weak for | Reviewed, New-replaced)

10. There is insufficient evidence to recommend for or against offering phentermine monotherapy, 

benzphetamine, diethylpropion, or phendimetrazine, for short-term, long-term, or intermittent 

weight loss in patients with overweight or obesity.

(Neither for nor against| Reviewed, New-added)

Discussion

Pharmacotherapy should be used in conjunction with CLI for weight loss for individuals with a BMI ≥30 

kg/m2 or BMI ≥27 kg/m2 with an obesity-associated condition, as this was the patient population 

represented in the evidence base. All clinical trials of pharmacotherapy were conducted in conjunction 

with a CLI, and study medication was generally administered concurrently. Therefore, the Work Group 

specified the importance of initiating pharmacotherapy in conjunction with a CLI in the recommendation. 

However, the Work Group did not identify evidence to guide decisions for when to initiate 

pharmacotherapy in conjunction with CLI. 

The critical outcomes of weight loss and safety were evaluated in one large, comprehensive SR and metaanalysis that included 28 RCTs (n=29,018).[152] This contributed to moderate confidence in the quality of 

the evidence that the combination of a CLI and a weight loss medication, approved by the U.S. Food and 

Drug Administration (FDA) for long-term use (specifically liraglutide, fixed-combination 
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naltrexone/bupropion, orlistat, and fixed-combination phentermine/topiramate) results in greater weight 

reduction than a CLI alone. This SR and meta-analysis also included data on the weight-loss medication 

lorcaserin. However, in February 2020, the FDA requested the withdrawal of the weight-loss drug 

lorcaserin (Belviq, Belviq XR) from the U.S. market citing potential risk of cancer outweighing the benefits

of use.[153] The meta-analysis reported that after a minimum follow-up of 12 months, each of the four

medications was associated with a greater reduction in total body weight compared to placebo. Further, a 

greater proportion of patients in the medication group achieved at least 5% or 10% weight loss from 

baseline compared to placebo, which is considered to be clinically significant.[152] 

Based on the meta-analysis, patients who received fixed-combination phentermine/topiramate had the 

highest probability of achieving a 5% or 10% weight loss, followed by liraglutide, fixed-combination 

naltrexone/bupropion, and orlistat.[152] The mean weight loss of these agents compared to placebo 

followed the same pattern and is also shown in Table 1 below. 

Table 1. Weight Loss and Adverse Event Outcomes with Medications for Long-term Weight 

Loss* [152] 

Medication for weight 

loss

Mean weight loss 

versus placebo

≥5% weight 

loss (OR)

≥10% weight 

loss (OR)

Discontinuation due to 

an adverse event (OR)

Phentermine/topiramate -8.80 kg 9.22 11.40 2.29

Liraglutide -5.24 kg 5.54 4.99 2.95

Naltrexone/bupropion -4.95 kg 3.96 4.19 2.64

Orlistat -2.63 kg 2.70 2.42 1.84

* lorcaserin is not included in this table as it was requested to be removed from the U.S. market in February 2020.[153] Data for 

lorcaserin: MD -3.25 kg; OR >5%: 3.10; OR >10%: 3.20; OR discontinuation due to adverse event: 1.34. 

Abbreviations: OR: odds ratio

Pharmacotherapy may produce significant weight loss in conjunction with CLI; however, treatment 

individualization is critically important due to the potential for adverse effects. As reported in the SR by 

Khera et al. (2016), all of the weight loss medications evaluated were associated with a statistically 

significant risk of medication discontinuation due to adverse events when compared to placebo.[152] 

Liraglutide had the highest odds of treatment discontinuation, followed by fixed-combination 

naltrexone/bupropion, fixed-combination phentermine/topiramate, then orlistat (see Table 1).[152] As 

noted in the 2018 USPSTF systematic review,[2] trials of weight loss medications often had very selective 

inclusion and exclusion criteria. Included patients who volunteer for participation in research may have 

higher levels of adherence than community-dwelling patients. Patients may be excluded from participation 

due to medical conditions that are often present in the patient populations intended for management by 

this CPG. The Work Group considered the applicability of these results to the general patient population as 

well as the potential harms from the weight loss medications. In addition, certain pharmacotherapies may 

be inappropriate for patients with conditions such as HTN, hyperthyroidism, valvular heart disease, 

nephrolithiasis, glaucoma, cholestasis, seizure disorder, drug misuse disorder potential, pregnancy, or are 

breastfeeding. Patients should be informed of the risks and adverse effects of each medication to properly 

incorporate patient preference in the medication selection (see Appendix H for additional information on 

pharmacotherapy considerations). It is also appropriate to carefully evaluate medication lists to eliminate 

or reduce agents that cause weight gain as a side effect (see Sidebar 2).
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There are also several medications approved by the FDA for short-term (i.e., “few weeks”) weight 

reduction (e.g., benzphetamine, diethylpropion, phendimetrazine, phentermine). However, these 

approvals were based on studies conducted before 1975. The systematic evidence review carried out as 

part of this guideline update did not identify any current SRs or individual studies that evaluated 

benzphetamine, diethylpropion, phendimetrazine, or phentermine for short-term use (i.e., less than or 

equal to six months). Therefore, the Work Group was unable to comment on the safety or efficacy of these 

medications for short-term weight loss. 

This CPG update also evaluated the long-term health benefits (e.g., impact on morbidity and mortality) 

following long-term (defined as greater than six months) or intermittent use of these medications. One 

small RCT compared diethylpropion (n=28) as one of five different medications (two not available in the 

U.S. [fenproporex, mazindol], one removed from the market [sibutramine], one off-label [fluoxetine]) to 

placebo (n=29) for weight loss in premenopausal women with obesity.[154] After 52 weeks, treatment 

with diethylpropion resulted in a significant weight reduction (-10.0 kg) compared to a placebo (-3.1 kg). In 

addition, 71.4% of patients treated with diethylpropion versus 33.3% of patients in the placebo group 

experienced a ≥5% reduction in body weight. Adverse events with diethylpropion included constipation, 

anxiety, and irritability, which were reported more frequently with treatment versus placebo. Given the 

lack of additional data on long-term treatment in a large patient population, as well as the unknown longterm benefits and harms of intermittent short-term weight loss with this class of agents, the Work Group 

determined there was insufficient evidence to make a recommendation regarding the use of these 

medications for long-term or intermittent use. Moreover, these sympathomimetic drugs are classified by 

the U.S. Drug Enforcement Administration as Schedule III or IV controlled substances, as they have 

potential for abuse, and prescribing information suggests they not be used in individuals with a history of 

CVD. As treatment options for short-term weight loss were noted as a topic of interest by participants in 

the patient focus group, additional data on the safety, efficacy, benefits, and durability to achieve and 

maintain weight loss goals using this practice are needed. 

Weight Maintenance

The Work Group also reviewed evidence on continued use of weight-loss medications for weight 

maintenance. One SR comprised the evidence base; it demonstrated a benefit on maintenance of weight 

loss with liraglutide or orlistat.[2] Maintenance of 5% or 10% weight loss during 13 months of follow-up 

(after an initial weight loss of at least 5%) favored treatment with liraglutide compared to placebo. In 

addition, patients receiving higher dose orlistat had significantly less weight regain (2.6 kg) than patients 

receiving a placebo (4.4 kg). However, when evaluating results from both the higher and lower doses of 

orlistat, there was no difference in the proportion of patients who maintained a 5% or 10% weight loss 

compared to placebo.[2] It was also noted that orlistat was more likely to cause adverse reactions resulting 

in treatment discontinuation compared to placebo. A larger percentage of patients experienced GI adverse 

events with orlistat (up to 95%) versus placebo (up to 68%). Patients treated with liraglutide also 

experienced more GI adverse events compared to placebo (74% versus 45%, respectively), and withdrawal 

due to GI adverse events was higher with liraglutide versus placebo.[2] The 2014 VA/DoD Obesity CPG also 

included evidence in support of the role of fixed-combination phentermine/topiramate in maintenance of 

weight loss.[155] This study found that significantly more patients in the fixed-combination 

phentermine/topiramate treatment groups experienced a ≥5% weight loss (79.3% with fixed-combination 

phentermine/topiramate 15 mg/92 mg versus 30% with placebo) or ≥10% weight loss (53.9% with fixed-
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combination phentermine/topiramate 15 mg/92 mg versus 11.5% with placebo) after 108 weeks.[155] As 

reported in the SR by Khera et al. (2016), there is a lack of data on maintenance therapy (i.e., after the 

initial 13 months of use) with fixed-combination naltrexone/bupropion.[152] Due to the lack of studies on 

this medication in the evidence base, it is not addressed in the recommendation. Data are available on the 

benefits of weight loss maintenance following two years of continued lorcaserin use after initial weight 

loss of ≥5%.[156] However, the FDA requested this agent be removed from the U.S. market on February 

13, 2020, over the potential increased risk of cancer outweighing the benefits of use.[153] 

Although the evidence on weight maintenance was not included as supporting evidence for the current 

recommendation on pharmacotherapy, the Work Group included this topic in the discussion given the 

recognition in 2013 of obesity as a chronic disease requiring intervention by the American Medical 

Association.[157] Further, it is important to emphasize that long-term weight management includes both 

initial weight loss as well as maintenance of weight reduction. As patients regain weight when weight loss 

medications are discontinued, many patients may require long-term therapy (see also Recommendation 3

regarding offering a CLI for weight maintenance). Long-term use of medication for weight maintenance

may be challenging, especially given the potential for adverse events and subsequent high discontinuation 

of medications.[2,152] 

Comorbidities and Cardiometabolic Parameters 

As patients with overweight or obesity may also have related comorbid conditions, the Work Group sought 

evidence on the impact of weight-loss pharmacotherapy on the critical outcomes of weight loss and 

adverse events in patients with select comorbidities. In addition, the effects of treatment on 

cardiometabolic parameters were considered important outcomes in patients with overweight or obesity 

who may or may not have a weight-related comorbidity. In general, the impact on cardiometabolic 

parameters was inconsistent and varied across medications.[152] According to one SR that included 

studies with orlistat and phentermine/topiramate, in addition to weight reduction, weight-loss

pharmacotherapy had a beneficial effect on BP reduction in patients with HTN.[158] Additionally, 

pharmacotherapy improved glycemic parameters and reduced progression to and increased remission of 

T2DM.[159-161] The benefit of weight-loss pharmacotherapy in patients with T2DM or prediabetes is also 

supported in the literature noted in the 2014 VA/DoD Obesity CPG,[162-164] as well as in an individual RCT 

from an SR included in systematic evidence review carried out as part of this guideline update.[165] 

Overall, treatment with weight-loss pharmacotherapy appeared to be well tolerated; however, treatmentrelated side effects were also noted in several of the studies.[158,159,166] Data were limited on the longterm outcome benefit of weight-loss pharmacotherapy on reduction in CV events or mortality in patients 

with overweight or obesity. Evidence from one RCT with 3.3 years follow-up designed to assess the CV

safety of lorcaserin found no difference compared to placebo in the primary safety outcome of major CV

events. However, this agent has been removed from the U.S. market.[153] Additional evaluation of the 

efficacy outcome of extended major CV events reported no difference with treatment compared to 

placebo.[16] Regarding the effect on cardiometabolic parameters, one SR and meta-analysis noted that, 

overall, pharmacotherapy for obesity had a modest reduction in fasting blood glucose and hemoglobin A1c

(HbA1c) compared to placebo, a small-to-moderate decrease in WC, and minimal changes in BP and lipid 

parameters.[167] The Work Group acknowledged the variable effects on cardiometabolic parameters of 

the different weight-loss medications and the need for individualized treatment based on these as well as 
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other factors, including the potential for adverse effects and patient tolerability (see Appendix H on 

pharmacotherapy). Also, the scope of the systematic evidence review carried out as part of this guideline 

update included only FDA-approved medications with the specific indication for weight loss at the time of 

the inquiry. Additional agents may gain FDA-approval for an indication of weight loss in the future.

The evidence to support the recommendation was moderate for the outcomes of weight loss and 

achievement of 5% and 10% weight loss in comparative studies of treatment versus placebo. Most studies, 

including the SR,[167] documented the serious limitation of attrition above 30%. For the weight-loss

medications considered in the evidence review (specifically liraglutide, fixed-combination 

naltrexone/bupropion, orlistat, and fixed-combination phentermine/topiramate, lorcaserin having been 

removed from the U.S. market) [153] the benefits outweigh potential patient harms when the medication 

regimen selected is customized to individual patients and considers comorbidities, potential 

contraindications, and adverse effects of the medication. Additional data should help determine the longterm outcome benefit of specific pharmacotherapy as well as any potential harms with long-term 

maintenance. Weight-loss medications also have the potential for high cost and resource use with longterm therapy. In addition, as noted above, the high attrition rates in clinical trials and the SRs suggest low 

feasibility for long-term use. Participants in the patient focus group were interested in pharmacologic 

therapy for weight loss and in obtaining additional information on the efficacy as well as potential side 

effects of these medications (see Appendix H on pharmacotherapy and Sidebar 2 on select medications 

and their potential effects on weight). 

Summary

As Recommendation 9 is a Reviewed, New-replaced recommendation, the Work Group systematically 

reviewed evidence related to this recommendation [2,152,154-156,158-160,164,166,167] and considered 

the evidence put forth in the 2014 CPG.[155,162,163] The Work Group's confidence in the quality of 

evidence was moderate. The body of evidence had high attrition, which was considered a serious 

limitation. The benefit of greater weight loss with pharmacotherapy in conjunction with CLI compared to 

CLI alone outweighed the potential harms of adverse events, which may be reduced if medication 

selection is individualized for the patient. The lack of outcome data for long-term benefits and harms, 

limited feasibility due to high attrition, and higher cost and resource use compared to CLI alone, were also 

noted. Patient values and preferences were somewhat varied. Thus, the Work Group decided upon a 

"Weak for" recommendation. Research is needed to address the numerous knowledge gaps in 

pharmacotherapy for weight loss and weight maintenance (see Knowledge Gaps and Recommended 

Research for more information).

As Recommendation 10 is a Reviewed, New-added recommendation, the Work Group systematically 

reviewed evidence related to this recommendation.[154] The Work Group's confidence in the quality of 

evidence was low. The body of evidence had serious study limitations including a single-blind evaluation 

and moderate-to-high attrition. The benefits and harms were unknown due to the small sample size in the 

only trial evaluating long-term treatment and no evidence that met the search parameters for short-term 

or intermittent use. The potential for harm with long-term use of these sympathomimetic agents is 

unknown, especially in an older patient population with potential for CVD, or in patients at risk for or with 

a history of substance use disorder. Patient values and preferences were somewhat varied. Thus, the Work 

Group decided upon a "Neither for nor against" recommendation. Given that most research with these 
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medications was conducted decades ago, and primarily for short-term use, additional research is needed 

to determine the safety and efficacy of these medications when prescribed long term or for intermittent 

use. In addition, as treatment options for short-term weight loss were noted by participants as a topic of 

interest in the patient focus group, additional data on the safety, efficacy, benefits, and durability to 

achieve and maintain weight loss goals using this practice are needed.

e. Dietary Supplements and Nutraceuticals

Recommendation

11. We suggest against using dietary supplements or nutraceuticals for clinically meaningful shortterm weight loss or long-term weight management. 

(Weak against | Reviewed, New-added)

Discussion

There is a lack of evidence demonstrating clinically meaningful short-term weight loss or to support longterm weight management or weight maintenance using nutraceutical or dietary supplements. A 

nutraceutical can be defined as “a food or dietary supplement that is believed to provide health 

benefits”.[168] A combination of eight SRs and RCTs, which studied various nutraceuticals, were identified 

and reviewed for this recommendation.[169-176] Overall, the confidence in the quality of evidence was 

rated low to very low due to lack of adequate randomization, blinding, allocation concealment, and high 

risk of bias. Inconsistent dosing of specific nutraceuticals and lack of generalizability of findings was noted 

across multiple studies. 

An SR of 15 RCTs (n=1,130) by Huang et al. (2019) showed a small but statistically significant weight loss of 

0.89 kg (p=0.0006) with chitosan versus placebo for short-term weight loss (<24 weeks).[169] No serious 

adverse events were reported. The most commonly reported adverse events were GI complaints (e.g., 

abdominal pain, bloating, constipation, indigestion, non-infectious diarrhea). The studies included in this 

large SR utilized multiple dosing regimens and used varying products and formulations of nutraceuticals, 

making dosing recommendations impossible. 

Mousavi et al. (2019) conducted an SR of 12 trials on the effects of cinnamon supplementation on obesity, 

finding statistically significant differences in short-term weight loss (-1.02 kg; p=0.002) and BMI (-

0.39 kg/m2

; p<0.001).[170] The generalizability of outcomes to the VA/DoD population is limited. 

Specifically, of the 14 studies included in the SR, only three were conducted in western cultures – two in 

the U.S. and one in the United Kingdom (U.K.); the remainder were conducted in the Middle East. 

Additionally, at least half of the included studies included only female subjects. Inconsistent 

heterogeneous dosing of cinnamon was also noted. 

With regard to garcinia cambogia, a small RCT conducted by Tripathy et al. (2013) found statistically 

significant (p<0.0001) short-term weight loss, measured by BMI, following four months of garcinia 

cambogia use.[171] Limitations included a small study population (n=100) and non-stratified results 

between men and women. An online search of FDA warnings lists garcinia cambogia as a nutraceutical 

dietary supplement that is sold as a combination supplement. When taken in that form, it is associated 

with risk for coronary disease events, stroke, and liver damage. Harms and burdens of garcinia cambogia 

outweigh the benefit. In addition, the FDA previously recalled a product being used for weight loss for 
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being associated with reports of liver damage related to the ingredient hydroxycitric acid – an ingredient in 

garcinia cambogia products or dietary supplements. Given these risks, harms and burdens of garcinia

cambogia were judged to outweigh the limited potential benefit.

No statistically significant weight loss was found with the use of green tea versus placebo across the two 

studies reviewed.[172,173] Limitations included that comparators were not the same between subject 

groups. Green tea was used in conjunction with other supplements, making it unclear whether green tea 

specifically had any effect.

Statistically significant weight loss was seen in one small RCT (n=60) looking at phaseolus vulgaris over 

12 weeks with an MD in weight loss of 1.7 kg between phaseolus vulgaris and control.[174] Phaseoulus 

vulgaris is also known as the common bean, green bean, and French bean. Adverse events were not 

severe, not serious, and not related to the supplement. Pill burden was a concern, with subjects taking 

six tablets per day.

An SR of 15 studies using probiotics showed no statistically significant difference in weight loss outcomes 

versus placebo.[175] Limitations included the heterogeneity of supplements studied. 

A small RCT using raspberry ketones did not show a statistically significant outcome for weight loss for up 

to 12 weeks.[176] The study participants were all female.

Responses obtained from the patient focus group reflected some interest in dietary supplements,

nutraceuticals, and over-the-counter (OTC) products for short-term weight loss, particularly in the active 

duty cohort who noted the negative effects of overweight and obesity on their military careers (see 

Appendix B). However, the Work Group found insufficient evidence of benefit to support an evidencebased, positive recommendation for the use of any nutraceutical for clinically meaningful short-term 

weight loss or long-term weight management. Since dietary supplements and nutraceuticals are not 

evaluated for safety and effectiveness before sale to consumers in the U.S., products sold to consumers

may vary in purity, consistency, ingredient content, and dosing.[177]

Moreover, dietary supplements and nutraceuticals have generally not been studied in conjunction with 

CLIs, so there is insufficient evidence on whether the active dietary supplement or nutraceutical product 

outperforms placebo in conjunction with CLI, which the Work Group considered being a core component 

of any long-term weight management intervention. Moreover, the perceived benefits of dietary 

supplements and nutraceuticals, fueled by marketing and anecdotal reports, may create unrealistic 

expectations that limit patient and clinician interest and investment in the specific evidence-based 

interventions recommended in this CPG. 

Summary

As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[169-176] The Work Group’s confidence in the quality of evidence was 

low. The body of evidence had many limitations and confounders of the evidence, including small sample 

sizes,[171] heterogeneity of supplement dosing and concentration,[170] use of highly selective study 

population,[174] and risk for bias.[174] Additional considerations were cost to the patient, pill burden, and 

the potential to divert patient interest and investment away from evidence-based interventions. There is 
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also concern that dietary supplements and nutraceuticals are not tested by the FDA for safety and 

effectiveness before being sold, allowing for product contamination and inconsistent formulation of 

product contents. The limited evidence for benefit was weighed against potential harms, including toxicity 

and other adverse health effects. Thus, the Work Group decided upon a “Weak against” recommendation.

e. Metabolic/Bariatric Procedures and Devices 

Recommendation

12. We suggest offering the option of metabolic/bariatric surgery, in conjunction with a 

comprehensive lifestyle intervention, to patients with a body mass index of ≥30 kg/m2 and type 2 

diabetes mellitus. 

(Weak for | Reviewed, New-added)

Discussion

Surgeries for weight loss – also known as metabolic/bariatric surgeries – are procedures that involve 

stapling part of the GI system. There is growing recognition that these procedures contribute to 

neurohormonal effects on the regulation of energy balance and hunger control. Metabolic/bariatric 

surgeries, in conjunction with CLIs, are the most durable modality to affect long-term weight loss and offer 

a potential remission of T2DM without the use of diabetic medications. Multiple studies confirm the 

superiority of surgical intervention to medical management of T2DM for achieving remission of T2DM 

among Class I obesity.[178,179] 

One RCT of participants with a BMI of 30 to <35 kg/m2 (Class I obesity) demonstrated that 65% of those 

who had metabolic/bariatric surgery experienced remission of T2DM compared to 0% with medical 

management; HbA1c decreased from 7.7% to 6.2% with surgery and from 7.9% to 7.4% with medical 

management.[178] 

An SR of 13 controlled trials of metabolic/bariatric surgery versus medical management (which included 

lifestyle modification and weight management) in patients with T2DM and a mean BMI <40 g/m2 included 

two RCTs and six observational clinical studies that only included subjects with a BMI <35 g/m2

.[179] 

Among the eight studies in the SR that included only patients with BMI <35 kg/m2 (n=331), the odds ratio 

(OR) for achieving remission of T2DM was 21.8 favoring surgery (95% CI: 7.7 to 61.6), and the OR for 

achieving an HbA1c less than 7% with or without DM medication was 11.4 (95% CI: 3.8 to 34.7), favoring 

surgery.[179] 

Of the two RCTs [180,181] from the Muller-Stich et al. (2014) SR [179] that only included subjects with a 

BMI <35 g/m2, one included participants with a BMI over 28 kg/m2 and a mean BMI of 30.48±0.94 

kg/m2

.[180] Type 2 diabetes mellitus remission (HbA1c from 10.47% to 5.98%) was achieved in 90% of 

patients who underwent surgery, in contrast to no remission (HbA1c from 10.88% to 8.14%) with medical 

management. In the second RCT [181], which included participants with a BMI of 25–30 kg/m2

, T2DM 

remission was achieved in 52% of patients who underwent surgery (mean HbA1c from 6.9% to 6.1% after 

surgery), in contrast to only 8% of participants with medical management (HbA1c from 7.2% to 7.3%). 

Randomized controlled trials that included only participants with a BMI of 30 – 40 kg/m2 showed similar 

results. For example, another RCT [182] from the Muller-Stich et al. (2014) SR [179] in which the mean BMI 
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was 37±2.7 kg/m2 showed T2DM remission in 73% of patients following surgery (HbA1c from 7.8% to 6%) 

and 13% of patients with medical management (HbA1c from 7.6% to 7.21%). Similarly, in another RCT 

[183] from the Muller-Stich et al. (2014) SR [179] in which the mean BMI was 34.9 kg/m2

, T2DM remission 

was achieved in 49% of patients following surgery (HbA1c from 9.6% to 6.3%). This contrasted with T2DM 

remission in 19% of patients with medical management (HbA1c from 9.6% to 7.8%). Likewise, in another 

RCT [184] from the Muller-Stich et al. (2014) SR [179] in which mean BMI was 35.5±3, T2DM kg/m2

, T2DM 

remission was seen in 50% of patients with Roux-en-Y Gastric Bypass (RYGB) (HbA1c from 8.7% to 6.4%), in 

27% of patients with sleeve surgery (HbA1c: 7.9% to 6.85%), and in no patients with medical management 

(HbA1c from 7.0% to 6.94%).

Additionally, an RCT [185] from the Muller-Stich et al. (2014) SR [179] of participants with a BMI of 27 – 43 

kg/m2 (mean BMI: 37 kg/m2 ±3.3 kg/m2) showed superior remission of T2DM with metabolic/bariatric 

surgery compared to medical management. T2DM remission was achieved in 42% of patients following

surgery (HbA1c from 9.4% to 6.5%) and 12% with medical management (HbA1c from 8.9 to 7.5%).

Type 2 diabetes mellitus and obesity are both chronic diseases, with an expectation of progressive 

deterioration over time in glucose control (secondary to progressive loss of beta-cell function). The 

opportunity to intervene in this disease earlier in its course is appealing. The potential benefits (improved 

QoL with remission of T2DM) of metabolic/bariatric surgery outweighed potential harms (surgical 

complications). Patients with Class I obesity have been observed to not lose “excessive weight” (i.e., they 

do not reach an unhealthy weight loss resulting in malnutrition) as a result of surgical intervention. 

Surgical intervention is a major decision and an individual patient may not accept potential surgical 

inconveniences or risks, or be a suitable surgical candidate. Moreover, active duty military personnel are 

not authorized to receive metabolic/bariatric surgery.[186] 

Similar recommendations have stemmed from the Diabetes Surgery Summit II and have been endorsed by 

numerous medical and scientific organizations worldwide.[187] These society endorsements, however, did 

not contribute to the process we utilized to generate this recommendation. 

Summary

This is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[178,179,187-189] The Work Group’s confidence in the quality of 

evidence for most outcomes assessed in the reviews comparing metabolic/bariatric surgery to non-surgical 

interventions was rated as low to very low. These ratings are primarily due to limitations in the 

methodological quality of both the randomized and non-randomized trials and to evidence of substantial 

heterogeneity in the effect estimates between trials. Most of the reviews involved small study populations 

and long-term data is lacking. Thus, the Work Group decided upon a “Weak for” recommendation.
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Recommendation

13. We suggest offering the option of metabolic/bariatric surgery, in conjunction with a 

comprehensive lifestyle intervention, for long-term weight loss/maintenance and/or to improve 

obesity-associated condition(s) in adult patients with a body mass index ≥40 kg/m2 or those with 

body mass index ≥35 kg/m2 with obesity-associated condition(s).

(Weak for | Reviewed, New-replaced)

Discussion

The 2014 VA/DoD Obesity CPG recommended offering metabolic/bariatric surgery in addition to a CLI

for weight loss and to improve most obesity-associated conditions in adult patients with BMI >40 kg/m2

or those with BMI 35.0 – 39.9 kg/m2 with one or more obesity-associated conditions. Evidence published 

since 2014 further supports that metabolic/bariatric surgery, in conjunction with a CLI, results in 

significant weight loss and sustained weight management in patients with a BMI ≥40 kg/m2 or those 

with BMI >35.0 – 39.9 kg/m2 with one or more obesity-associated conditions. 

Based on research conducted by Cheng et al. (2016) and O’Brien et al. (2019), treatment with 

metabolic/bariatric surgery was associated with improvements in excess weight loss and long-term (>10

years) excess weight loss.[187,189] Yang et al. (2018) also found a significant improvement in BMI.[190] 

The evidence for the effect of metabolic/bariatric surgery on weight loss included a large, fair quality SR of 

16 RCTs (n=1,194) comparing metabolic/bariatric surgery to lifestyle and/or medication interventions in 

patients with obesity. Follow-up ranged from 1 – 3 years.[187] The investigators reported an MD of -20.96 

kg (CI: -24.51 to -17.41) in weight loss at least one year post-surgery across all metabolic/bariatric surgery 

techniques (sleeve gastrectomy, RYGB, laparoscopic adjustable gastric banding [LAGB], biliopancreatic 

diversion [BPD]).[187] Across the eight studies (n=478) that calculated percent excess weight loss, the MD

was 63.74% (95% CI: 58.73 to 68.76).

Metabolic/bariatric procedures are associated with T2DM remission.[191,192] as well as improvements in 

WC,[187,193] fasting glucose and HbA1c,[187,191] triglycerides, BP, total cholesterol,[187,191,193] 

QoL,[194] and physical functioning.[195] 

Evidence from an SR of 19 non-randomized studies (n=28,528 patients who received surgery, n=169,704 

patients who received non-surgical interventions) suggests that metabolic/bariatric surgery reduced allcause mortality (OR: 0.55; 95% CI: 0.46 to 0.65) as well as mortality from myocardial infarction (MI), stroke, 

angina, ischemic heart disease, any type of cancer, and obesity-related cancer compared to non-surgical 

interventions at an average of 10 years follow-up.[196] However, evidence from seven RCTs reported in 

the same SR did not demonstrate a significant difference between metabolic/bariatric surgery and nonsurgical interventions for these outcomes at 1 – 2 years follow-up. Six RCTs from another SR had no 

treatment-related deaths among patients with T2DM who underwent RYGB, nor were there deaths among 

patients who received non-surgical lifestyle or medication therapy at 1 – 5 years follow-up.[193] However, 

there were more nutritional deficiencies, anastomotic ulcers and leaks, and intestinal obstructions in the 

surgical group.[193] In addition, there is evidence from an SR of 32 non-RCTs (n=148,643) that suggests 

patients who undergo metabolic/bariatric surgery are at elevated risk for death by suicide and suicide 

attempt/self-harm compared to control populations with similar demographic characteristics.[188] This
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may be related to a range of contributing factors including possible psychiatric, medical, psychosocial, and 

physiologic changes. 

Despite general consistency in the evidence supporting bariatric procedures for weight loss and 

improvement in obesity-associated medical conditions, there is variability in provider and patient 

preferences regarding this treatment. Furthermore, active duty Service Members are not authorized to 

receive this permanent weight loss surgery.[186] Therefore, by denying this effective obesity treatment, 

an active duty career may be affected by decreased promotion and retention. Other considerations 

include access to trained surgical personnel, high cost for the procedure, insurance coverage, availability of 

post-surgical monitoring, and requirements for managing comorbid medical and psychiatric conditions. 

Summary

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[187-196] The Work Group’s confidence in the quality of evidence was 

very low because it included observational data. The marked benefits, such as including improved mean 

weight loss, improvement in percent excess weight loss, improved weight maintenance for a large 

proportion of surgical patients, T2DM remission, and remission of other obesity-related conditions, 

outweighed the potential harm of adverse events. Patient values and preferences were somewhat varied. 

Thus, while the Work Group considered metabolic/bariatric surgery standard of care, the data limitations 

restricted the Work Group to a “Weak for” recommendation. 

Recommendation

14. There is insufficient evidence to recommend for or against metabolic/bariatric surgery to patients 

over age 65.

(Neither for nor against | Reviewed, Amended)

Discussion

There are data comparing people older or younger than age 65 who underwent metabolic/bariatric 

surgery. One observational study showed that the benefits of weight loss, remission of T2DM, and 

incidence of HTN and OSA after metabolic/bariatric surgery were similar for both age groups.[197] 

However, three observational studies showed that people ≥65 years who received metabolic/bariatric 

surgery experienced a higher prevalence of early post-surgical complications and mortality than younger 

people.[198-200] One of these studies included 24,014 people between the ages of 40 and 49 and 739

people over age 70. It showed the prevalence of minor complications was 4.6% in the younger cohort and 

9.1% in the older cohort; major complications were 2.2% in the younger and 6.3% in the older cohort; and 

30-day mortality was 0.1% in the younger and 0.5% in the older cohort.[198] Another of these studies 

included 5,395 people age 65 or younger and 5,395 people over the age of 65. This study found that 

mortality was 0.14% higher and nonfatal complications were 1.01% higher after sleeve gastrectomy in 

people 65 years or older than in those who were younger than 65 years. The complication rates were 

higher overall for patients undergoing RYGB than sleeve gastrectomy, but there was no significant 

difference in complication rates for older versus younger patients who received an RYGB in this study.[199] 

The final study included 39,465 people who received an RYGB and 42,495 people who received a 

laparoscopic sleeve gastrectomy whose average age was 43.7±10.8 years. It also included 2,010 people 
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who received an RYGB and 2,055 people who received a laparoscopic sleeve gastrectomy whose age was

67.5±2.48 years. The study showed that serious morbidity with RYGB was 3.4% in younger and 5.7% in 

older people. It also showed that serious morbidity with laparoscopic sleeve gastrectomy was 2.2% in 

younger and 4% in older people. Furthermore, it showed that 30-day mortality with laparoscopic sleeve 

gastrectomy was 0.07% in younger and 0.29% in older people.[200] 

Additionally, there is data comparing people older or younger than age 60 who underwent 

metabolic/bariatric surgery. An SR of nine observational studies that included 4,025 people under the age 

of 60 and 366 people age 60 or older who had metabolic/bariatric surgery showed that people age 60 or 

older who underwent RYGB experience significantly higher rates of early post-surgical complications (OR: 

1.89; 95% CI: 1.07 to 3.3).[201] Similarly, older people had higher mortality at 1.6% than younger people at

0.3% (OR: 4.38; 95% CI: 1.25 to 15.31). Interestingly, three of the studies included in this SR, including 793 

younger people and 148 older people, suggest people 60 years and older did not lose as much weight 

compared to younger people (MD: -5.86; 95% CI: -9.15 to -2.56). This contrasts with the data comparing 

people who are older or younger than 65 years where weight loss benefits were similar. 

The decision to offer metabolic/bariatric surgery is a clinical judgment based on individual patient risk 

factors and preferences. The benefits of weight loss and remission of obesity-related comorbidities appear 

similar for people ≥65 years compared to those who are younger. However, part of the surgical benefit is 

the length of improved QoL, and older people have, on average, a shorter lifespan after surgery than those 

who are younger.

Summary

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[197-201] The Work Group’s confidence in the quality of evidence was 

very low. Concerns about the quality of studies comparing older and younger patients contribute to the 

uncertainty about the relationship between older age and benefits and harms from surgery. Limitations of 

the evidence including retrospective observational study designs, limited information about patient 

selection, and cofounder analyses. Patient values and preferences have large variations regarding surgery. 

Thus, the Work Group decided upon a “Neither for nor against” recommendation. 

Recommendation

15. There is insufficient evidence to recommend for or against percutaneous gastrostomy devices for 

weight loss in patients with obesity. 

(Neither for nor against | Reviewed, New-added)

Discussion

Percutaneous gastrostomy is a device used for weight loss and is similar in structure to percutaneous 

endoscopic gastrostomy (PEG) tubes. However, patients remove gastric contents after meals with the 

percutaneous gastrostomy device instead of using it for feeding. The use of a percutaneous gastrostomy as 

a weight-loss device has been found to offer a modest improvement in short-term weight loss for patients 

with a BMI of 40 – 45 kg/m2 or a BMI of 35 – 39.9 kg/m2 with comorbid conditions. 
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A 2017 RCT by Thompson et al. (n=207) compared the percutaneous gastrostomy device plus a CLI versus 

CLI alone.[202] At 52 weeks, subjects in the device group achieved a mean excess weight loss of 35.1% and 

total weight loss of 12.1% compared to a mean excess weight loss of 9.8% and total weight loss of 3.5% in 

the CLI-only group.[202] This study was limited to one year and does not provide long-term safety or 

efficacy data. The most frequent adverse events reported were abdominal pain and discomfort, peristomal 

granulation tissue, and peristomal irritation.

The overall findings of the limited evidence available assessing the efficacy of the FDA-approved 

gastrostomy device suggest there was a reduction in weight loss as compared to a control that included a 

CLI. The evidence from these trials also suggests the device may improve obesity-related comorbid 

conditions including T2DM, hyperlipidemia, and HTN. It may also improve CV and metabolic biomarkers 

including fasting blood glucose, HbA1c, and BP. Ikramuddin et al. (2014) notes the limitations of low 

representation of patients with T2DM, hyperlipidemia, and HTN within their study group population.[203] 

Summary

As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation.[202-205] The Work Group’s confidence in the quality of evidence was 

moderate. The benefits of weight loss and improved QoL outweighed the potential harms, which include 

pain and gastroesophageal reflux disease (GERD). However, there is concern that the use of percutaneous 

gastrostomy devices could promote continued poor lifestyle habits. Overall, because the evidence for 

efficacy of each device is limited to one RCT, the Work Group determined there is insufficient evidence 

to recommend for or against the use of percutaneous gastrostomy devices for weight loss. Further 

research is required to compare the effectiveness of weight-loss devices to other obesity treatments 

and to assess long-term durability of weight loss and safety.

B. Short-term Weight Loss (Up to Six Months)

Recommendation

16. We suggest offering intragastric balloons in conjunction with a comprehensive lifestyle 

intervention to patients with obesity (body mass index ≥30 kg/m2

) who prioritize short-term (up to 

six months) weight loss. 

(Weak for | Reviewed, New-added)

17. There is insufficient evidence to recommend for or against intragastric balloons for long-term 

weight loss to support chronic weight management or maintenance.

(Neither for nor against | Reviewed, New-added)

Discussion 

Intragastric balloon (IGB) devices are placed into the stomach either endoscopically or by swallowing the 

deflated device while being medically supervised. The device is then inflated with gas or fluid and resides 

in the stomach for up to six months. These non-permanent devices are deflated and subsequently 

removed after a treatment period. 
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The use of any non-permanent bariatric device for the treatment of obesity (BMI ≥30 kg/m2) or obesityrelated conditions should be discussed with a bariatric surgeon or gastroenterologist as they can manage 

the placement, monitoring, and removal of the device.

IGB devices are currently FDA approved for a treatment duration of up to six months for patients with a 

BMI of 30 – 40 kg/m2

. No studies that examined longer term use of IGBs met criteria for inclusion in the 

evidence review carried out as part of this guideline update. Additionally, there were no long-term studies 

(>12 months) evaluating the impact of short-term use of IGBs in combination with CLI on long-term weight 

loss to support chronic weight management or weight maintenance. 

Short-term use (up to six months) of IGBs reduces weight, BMI, waist circumference, and percent body fat 

to a greater degree than lifestyle interventions or sham therapy alone.[206-209] In a 2015 SR of four RCTs, 

Zheng et al. found that when the IGB treatment duration was less than six months, the MD in weight loss 

was -1.54 kg (95% CI: -2.02 to -1.06; n=171) and the MD in BMI was -1.19 kg/m2 (95% CI: -2.10 to -0.281; 

n=82).[209] When the duration of treatment with IGB was six months, the MD in weight loss was -8.87 kg 

(95% CI: -10.28 to -7.46; n=262); the MD in BMI was -3.10 kg/m2 (95% CI: -3.91 to -2.30; n=244); and the 

MD in percent excess weight loss was -21.0 kg (95% CI: -27.4 to -14.6; n=256). Treatment with an IGB was 

also associated with higher remission of comorbid T2DM when compared to CLI alone. 

A fair quality SR by Popov et al. (2017) found an OR of 1.4 (95% CI: 1.3 to 1.6; n=4,232) for the remission of 

T2DM with IGB compared to conservative control in nine observational studies. It also found that the MD 

in fasting blood glucose was -12.7 mg/dL (95% CI: -21.5 to -4.0; n=555), and the MD in HbA1c was -1.1% 

(95% CI: -1.6 to -0.6; n=63) in the IGB group compared to the control group in eight RCTs.[206] There was 

conflicting evidence, however, regarding improvements in comorbid conditions including HTN, 

dyslipidemia, and NAFLD.[206,207] Evidence also indicates some level of harm associated with IGB. A 2015 

SR of four RCTs, Zheng et al. identified the following adverse events: nausea (72%), vomiting (39%), 

abdominal pain (50%), and gastric erosion (32%).[209] In a 2018 SR of 10 studies (five RCTs and five 

prospective non-randomized trials), Trang et al. identified the following adverse events: nausea (63%), 

vomiting (55%), abdominal pain (59%), and gastroesophageal reflux (21%).[210] It is unclear if and how 

frequently these adverse events led to attrition before the FDA-approved six month treatment period.

Despite general consistency in the evidence supporting short-term use of an IGB in conjunction with a CLI

for weight loss in patients with obesity, there is a high amount of variability in provider and patient 

preferences regarding this treatment. The patient focus group revealed that patients want education and 

counseling on more weight-loss options. They specifically want more options to achieve short-term weight 

loss, which can affect them medically (e.g., weight loss prior to surgery, weight loss to get pregnant, weight 

loss to control T2DM) and professionally (e.g., retention in the military, promotion candidacy). There is 

little, if any, evidence that there is a medical benefit to achieving short-term weight loss. Access to this 

treatment is limited, as the procedure usually requires a surgeon or endoscopist with adequate training as 

well as a facility meeting safety and quality standards to support the procedure. Active duty Service 

Members have additional constraints, as they are not permitted to undergo permanent 

metabolic/bariatric surgery procedures.[186] Temporary and removable bariatric devices like the IGB may 

provide an effective short-term, non-permanent alternative for active duty Service Members. Financial 

constraints may additionally burden the patient, as the cost of treatment is not always covered by 

insurance companies. A certain level of subjectivity in candidacy for this bariatric procedure is present 
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based on the professional experience of the surgeon or endoscopist in identifying the true and total risks 

and benefits unique to each patient. 

Summary

As these are Reviewed, New-added recommendations, the Work Group systematically reviewed evidence 

related to them.[206-210] The Work Group’s confidence in the quality of evidence was moderate. The 

main limitation regarding the body of evidence is the short-term use of the intervention (up to six months) 

with short-term follow-up (up to 12 months). Other considerations regarding these recommendations 

included the benefits of comorbid T2DM control or even remission outweighing the potential harm of 

adverse events as they were mild in severity, despite being common. Thus, regarding IGBs, the Work 

Group decided upon a “Weak for” recommendation for short-term weight loss and a “Neither for nor 

against” recommendation for chronic weight management or weight maintenance. 

Recommendation

18. We suggest offering a low-carbohydrate diet over a low-fat diet as the dietary component of a 

comprehensive lifestyle intervention for patients who prioritize short-term (up to six months) 

weight loss.

(Weak for | Reviewed, New-added)

Discussion

A low-carbohydrate diet (the specific definition of which varies substantially from study to study) of ≤40% 

of calories from carbohydrate or ≤120 grams of carbohydrate a day has been found to promote weight loss

(MD weight loss ranged from -2.04 kg to -3.6 kg) in the short-term (≤6 months) in patients with overweight 

and obesity compared to low-fat diets.[130,134,137,139,141,144,211] 

An SR of 17 trials (n=1,797) by Sackner-Bernstein et al. (2015) found that, compared to a low-fat diet, a 

low-carbohydrate diet was associated with statistically significant improvements in BMI (MD: -0.7 kg/m2

), 

triglycerides (MD: -28.8 mg/dL), and systolic BP (MD: 1.7 mmHg). There was, however, a statistically 

significant worsening of total cholesterol (MD: 9.1 mg/dL) and low-density lipoprotein cholesterol (LDL-c) 

(MD: 8.6 mg/dL) but a statistically significant increase in high-density lipoproteins cholesterol (HDL-c) (MD: 

5.1 mg/dl) in those on a low-carbohydrate diet compared to a low-fat diet.[130] A meta-analysis of five 

trials (n=447) by Nordman et al. (2006) which was not included in the evidence review also found that, 

compared to participants on a low-fat diet, participants on a low-carbohydrate diet lost more weight than 

those on a low-fat diet at six months (weighted MD: -3.3 kg); however, at 12 months the difference was no 

longer significant. Those randomized to a low-carbohydrate diet had significant improvements in 

triglycerides (weighted MD: -22.1 mg/dL) and HDL-c (weighted MD: 4.6 mg/dL) but worsening of total 

cholesterol and LDL-c on a low-carbohydrate diet (weighted MD: 5.4 mg/dL) at six months.[139] 

Another meta-analysis of 23 RCTs (n=2,788) by Hu et al. (2012) found that, compared to participants on a 

low-fat diet, participants on a low-carbohydrate diet had less reduction in total and LDL-c (2.7 mg/dL and 

3.7 mg/dL, respectively), but the low carbohydrate arm had more triglycerides lowering (-14.0 mg/dL), and 

a 3.3 mg/dL improvement in HDL-c.[138] Finally, a fourth SR by Hession et al. (2009), not included in the 

evidence review, which included 13 RCTs of low-carbohydrate diets compared with low-fat/low-calorie 

diets of at least six months duration, also found that there were significant differences between the groups 
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for weight at six months, HDL-c, triglycerides, and systolic BP in favor of the low-carbohydrate diet. There 

was similar weight loss between arms at 12 months. They found lower attrition for the low-carbohydrate 

arms, suggesting there may be a patient preference for low-carbohydrate diets.[211] 

Other smaller studies, some of which were not included in the evidence review, yielded similar results of 

more weight loss at six months on a low-carbohydrate diet compared to a low-fat diet, with similar weight 

loss on both diets at 12 months and more improvement in HDL-c and triglycerides in the low-carbohydrate 

arms.[134,137,141,211] In a 2004 study by Yancy et al., not included in the evidence review, 120

participants (BMI 30 – 60 kg/m2 with total cholesterol >200 mg/dL and LDL-c >200 mg/dl or triglycerides 

>200 mg/dL) were randomized to either a low-carbohydrate ketogenic diet (initially, <20 g of carbohydrate 

daily), or a low-fat diet. Participants on the low-carbohydrate ketogenic diet reported a statistically 

significant increase in adverse events compared to participants in the low-fat arm: constipation (68% 

versus 35%), headache (60% versus 40%), halitosis (38% versus 8%), muscle cramps (35% versus 7%), 

diarrhea (23% versus 7%), general weakness (25% versus 8%), and rash (13% versus 0%), deemed ‘mild’ by 

the authors. The authors reported greater weight loss in the low-carbohydrate diet group at six months 

(MD: -12.9% versus -6.7%; p<0.001), and more patients randomized to the low-carbohydrate diet 

completed the study (76% in the low-carbohydrate arm versus 57% in the low-fat arm).[144] 

Despite general consistency in the evidence supporting a weight loss advantage to low-carbohydrate diets 

over low-fat diets for short-term weight loss (up to six months), there is some variability in provider and 

patient preferences regarding this treatment. As discussed in Recommendation 7, the dietary approach 

most appropriate for each patient is determined by what the patient can adhere to and sustain for weight 

loss and maintenance. The patient focus group revealed that patients want specific information about 

effective dietary approaches, but some patients may find that following a low-carbohydrate diet does not 

meet their food preferences. 

Summary

As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed the evidence 

related to this recommendation.[130,134,138] The Work Group’s confidence in the quality of evidence 

was very low. The body of evidence had some limitations including short duration, loss to follow-up, high 

dropout, and heterogeneity in study interventions.[130] The benefits of improved body weight and lipid 

values outweighed the potential harm of adverse events, which was small. Patient values and preferences 

were somewhat varied. The Work Group also considered the resources requirements of training providers 

to provide diet plans and the challenges patients may face in adhering to diets. Therefore, the Work Group 

decided upon a “Weak for” recommendation. 

VIII. Knowledge Gaps and Recommended Research

During the development of the 2020 VA/DoD Obesity CPG, the Work Group identified many topics for 

future research. Given the continued rise in national rates of obesity, as tracked in the Behavioral Risk 

Factor Surveillance System monitored by the CDC,[212] more effective interventions and implementation 

of current options are needed. Projects to address these topics will lead to stronger evidence to support 

current recommendations, as well as new evidence to guide future CPGs.
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Despite the progress that has been made since the publication of the 2014 VA/DoD Obesity CPG in 

identifying effective interventions to assess and treat overweight and obese adults, many important gaps 

remain, particularly regarding the impact of weight management interventions on long-term outcomes, 

including long-term maintenance of weight loss, QoL, NAFLD, CV morbidity (e.g., MI and ischemic stroke), 

and all-cause mortality. Because BMI may not be the best predictor of future disease and mortality, future 

trials should include more recently developed classification systems to characterize obesity severity, 

including use of body composition measures that are relevant to military service and readiness.[213,214] 

There is an imperative to develop an actionable diagnosis and staging system relevant to the current needs 

of the U.S. military. Future research should also focus on the benefits of weight-loss interventions in lower

risk and specific subgroups (e.g., those who are overweight, older, from lower risk racial/ethnic groups,

after spinal cord injury/disorder, or “metabolically healthy”) to determine if weight loss has lasting benefits 

in these populations.[2] 

Comprehensive lifestyle intervention programs can be expensive and difficult to deliver and maintain. 

Therefore, more research is needed to identify accessible, scalable, and practical ways to deliver the three 

core elements of these programs (behavior change, nutrition, and physical activity) in ways that align with 

patients’ abilities, values, and preferences. For physical activity, more research is needed comparing the 

effectiveness of offering interventions that feature generalized “lifestyle physical activity” with more 

intense and structured exercise programs on multiple key outcomes, including weight loss, weight 

maintenance, obesity-related comorbid conditions, and other health-related outcomes. Within the sphere 

of nutrition, ongoing confusion remains, and there is a need for clarity regarding the standard definitions 

of specific dietary patterns. This is most evident when attempting to compare the efficacy of dietary 

interventions between and among studies, as the actual dietary interventions vary, limiting true 

comparisons. Specifically coming to a consensus within the research community as to what constitutes 

various dietary interventions (e.g., a low-fat diet, a low-carbohydrate diet, a low glycemic index diet, a 

Mediterranean diet, duration and timing of fasts within intermittent fasting) would be of critical 

importance to move this field forward from hypotheses to a more solid evidence base. Clarity and 

consistency in definitions of diets would then allow for more head-to-head comparisons between diets. 

For example, when considering the dietary component of CLI, consensus is needed on definitions of “lowcarbohydrate” and “low-fat” nutrition. Research comparing calorie restriction and carbohydrate restriction 

to assess effectiveness and feasibility in the long term is also needed. Research must also consider how 

individual preferences, whole diets (diets characterized by types of foods and meals, rather than on micro 

or macronutrient content), and eating patterns impact long-term adherence to diets that support weight 

loss and weight maintenance. Such research would improve our ability to offer treatments that more 

closely align with sustainable behavior change for individual patients. 

As with all other chronic disease states (e.g., HTN), obesity pharmacotherapy management likely requires 

long-term use. Research is needed to determine the underlying causes of variability in weight-loss 

response to medications among individuals. Research is needed to quantify the degree of weight regain 

after cessation of each of the pharmacologic agents to better inform patients and providers before

initiation. Longer study durations are therefore needed. Further, patients struggling with obesity may 

benefit from multi-modal pharmacotherapy for weight loss, which may be synergistic when agents with 

different mechanisms of action are used in tandem. Research is needed to determine benefits and harms 

and head-to-head comparisons of various multi-agent regimens. Certain pharmacologic therapy 
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combinations may be more effective for initial weight loss and other combinations may be more effective

for long-term weight maintenance. It is unknown whether the approach to maintenance of weight loss

requires a different approach or different medications to maintain weight that has been lost than 

interventions and medications to produce initial weight loss. This raises the concern of whether short-term 

pharmacologic interventions are of true benefit if overshadowed by weight regain after cessation. Further 

research is needed on the safety (e.g., cardiac, abuse potential) of long-term use of sympathomimetic 

agents currently approved only for short-term weight loss (e.g., phentermine, diethylpropion).

Phentermine, when combined with topiramate (Qsymia), is approved for long-term use, noting that 

dosages of phentermine used in combination with topiramate (ranging from 3.75 mg to 15 mg maximum 

dose phentermine + 92 mg topiramate) are lower than typically prescribed phentermine dosing in shortterm monotherapy (15 to 37.5 mg daily phentermine, or 8 mg 3x daily for Lomaira). Finally, further 

research into the underlying biology of food intake and body weight regulation is needed to provide new 

pharmacotherapeutic targets. 

While network meta-analysis provides some moderate-quality evidence supporting the use of different 

weight-loss medications, more direct comparison trials are needed to provide information for selection of 

optimal drug therapy for distinct patient populations to provide an appropriately tailored management 

approach. In addition, long-term outcome data on the safety and efficacy of maintenance 

pharmacotherapy for all the chronic weight management medications are needed, as well as direct 

comparison trials for maintenance pharmacotherapy. More research is also required to appropriately 

assess the safety and efficacy of pharmacotherapy for long-term weight management, including chronic or 

intermittent use of medications traditionally prescribed for short-term use. In addition, data are not 

currently available on the safety and efficacy of the combination of two or more weight management 

medications in conjunction with CLI for patients with obesity, so more research is needed. 

The currently available research on dietary supplements and nutraceutical agents is lacking in 

methodological rigor and clear protocol implementation. For these products to be viable, consistent, 

and trusted therapeutic options that can be measured and evaluated, clarity is needed in product 

content and dosage, and assurance is needed in purity and quality. Nationally, more rigorous regulation 

of dietary supplements and nutraceuticals would be required for these products to be of therapeutic 

value in the U.S.

When considering research needs in bariatric procedures, developing a validated screening tool to assess 

patient suitability and potential benefit versus risk would be beneficial. There is a particular need for 

subgroup population evaluation for weight loss procedures in those over age 65 and active duty personnel 

for whom immediate fitness for deployment is of critical importance. Potential alternative procedures such 

as the mini-gastric bypass and endoscopic plication will need to be further explored and matched to the 

population most suitable to benefit. Research is needed to evaluate the long-term effects of weight-loss 

devices, specifically, the rate of weight regain after removal of short-term weight-loss devices. The 

replacement, implementation, and practice of weight-loss devices, and their efficacy comparison one to 

the other, requires further investigation. 

Moreover, the vast majority of reviewed research studies were conducted in academic settings, among 

non-active duty and non-Veteran populations that also included individuals who were predominantly 

women, white, young or middle aged, and motivated to participate in a weight management trial. There is 
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a need for more research evaluating screening and weight management intervention effectiveness in 

Veterans and Service Members, particularly active duty service men and women, among older adults, and 

in those with mental illness. Gaps also remain regarding the efficacy of alternative modalities of lifestyle 

interventions (e.g., internet, phone apps, secure messaging), the efficacy and comparative effectiveness of 

various interventions for maintaining weight loss, and the efficacy and comparative effectiveness of lowand intermediate-intensity lifestyle interventions (e.g., number and frequency of CLI sessions over what 

span of time), particularly when integrated within primary care settings and/or paired with 

pharmacotherapy. Finally, there is also a need for research that evaluates comparative cost-effectiveness 

among weight management interventions. A recurring concern among providers is how to best implement 

recommendations within healthcare systems, including the VHA and DoD. Research specifically evaluating 

implementation and effectiveness in real-world clinical settings is needed to best inform policies and 

resource allocation.

The Work Group also recommends research that addresses the following specific questions:

• What is the best method for screening for overweight and obesity and risk stratification (e.g., WC, 

waist-hip ratio, BMI, fitness, metabolic status) in active duty Service Members to meet the needs 

of the U.S. military? In Veterans? 

• Are there individual differences (e.g., racial/ethnic, genetic, socioeconomic, geographic, 

psychological, presence of specific comorbidities such as spinal cord injury/disorder, polycystic 

ovarian syndrome (PCOS), and transgender persons) that predict response to a specific CLI, a 

specific pharmacotherapy, or a specific bariatric procedure?

• How should a provider prioritize choice of intervention based on the presence of specific obesityassociated conditions?

• What is the comparative effectiveness of varying modalities for delivering comprehensive lifestyle 

interventions: for example, comparing individual sessions, telephone sessions, internet modalities, 

mobile apps, video conferencing, to group sessions? 

• What is the comparative effectiveness of varying types and combinations of physical activity 

(e.g., “lifestyle activity” versus more structured fitness approaches versus both)? 

• What are the essential intervention components of CLI (including specific behavioral strategies, 

intervention modality, number of contacts, duration, and intensity)?

• Is there an optimal number of sessions of a CLI that should be provided to patients with 

overweight or obesity?

• What are the benefits and harms of weight loss or weight management in patients who are 

overweight with or without obesity-associated conditions?

• What tailoring of the risk profile is required for different ethnic groups? What BMI cutoffs confer 

additional risk for various ethnic groups?

• What is the degree of weight regain after cessation of weight loss pharmacotherapy? Is 

pharmacotherapy for the treatment of obesity by necessity long-term therapy, similar to the 

treatment of other chronic disease states?

• What are the benefits and harms of long-term use of weight-loss medications that are currently 

only approved for short-term use, such as phentermine and diethylpropion?
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• Is there any advantage to specific weight-loss pharmacotherapy choice for initial weight loss 

versus maintenance of weight that has been lost?

• Is multi-modality pharmacotherapy (using dual, triple, or more therapy), each with different 

mechanisms of action for weight loss, synergistic? Would multi-agent therapy confer a weight-loss 

advantage over a single agent? Which medication combinations are most effective for weight 

loss? For weight maintenance long term?

• How do we more rigorously regulate supplements and nutraceuticals to assure clarity in product 

content, dosage, and assurance of purity and quality? 

• What are the benefits and harms of bariatric procedures for patients with a BMI of 30–35 and how 

do benefits and harms vary based on the presence or absence of obesity-associated conditions?

• What are the effects of bariatric procedures on active duty personnel and benefits and harms to 

deployment readiness? 

• What are the best screening measures for bariatric procedure candidates to optimize outcomes 

and minimize adverse events from the surgical intervention?

• What role should ethnic background play in recommendations for bariatric procedures?

• What is the degree of weight regain after removal and long-term effects of devices currently only 

approved for short-term use?

• When directly compared, which weight-loss device is most effective both in the short term and 

long term? Are there patient characteristics that favor use of one device over another?

• What is the appropriate role of the primary care clinical team in addressing the stigma associated 

with overweight and obesity; communicating with patients about weight and weight 

management, engaging in shared decision making about intervention options; motivating patients 

to actively participate in treatment and self-management; and delivering weight management 

interventions?

• What organizational and health system interventions are needed to: address equity and ensure all 

patients have equal access to treatment options; increase access to interventions, especially 

among rural populations; implement an integrated and coordinated approach for overweight and 

obesity care that enhances care coordination and health outcomes; and promotes efficient use of 

resources across the entire population of patients served? 

• What kind of clinical decision support should be considered to provide healthcare teams with 

tailored options that are based on the individual patient’s care needs?
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Appendix A: Evidence Review Methodology

A. Developing the Scope and Key Questions

The CPG Champions, along with the Work Group, were tasked with identifying KQs to guide the SR of the 

literature on overweight and obesity. These questions, which were developed in consultation with the 

Lewin team, addressed clinical topics of the highest priority for the VA and DoD populations. The KQs 

follow the population, intervention, comparison, outcome, timing, and setting (PICOTS) framework for 

evidence questions, as established by the Agency for Healthcare Research and Quality (AHRQ). Table A-1

provides a brief overview of the PICOTS typology.

Table A-1. PICOTS [215] 

PICOTS 

Element Description

Population, 

Patients, or 

Problem

Describes the patients of interest. It includes the condition(s), populations or sub-populations, 

disease severity or stage, co-occurring conditions, and other patient characteristics or 

demographics.

Intervention 

or Exposure

Refers to the specific treatments or approaches used with the patient or population. It includes 

doses, frequency, methods of administering treatments, etc.

Comparison Describes the interventions or care that is being compared with the intervention(s) of interest 

described above. It includes alternatives such as placebo, drugs, surgery, lifestyle changes, standard 

of care, etc.

Outcome Describes the specific results of interest. Outcomes can include short, intermediate, and long-term 

outcomes, or specific results such as quality of life, complications, mortality, morbidity, etc.

Timing, if 

applicable

Describes the duration of time that is of interest for the particular patient intervention and 

outcome, benefit, or harm to occur (or not occur).

Setting, if 

applicable

Describes the setting or context of interest. Setting can be a location (such as primary, specialty, or 

inpatient care).

Abbreviation: PICOTS: population, intervention, comparison, outcome, timing, and setting

The Champions, Work Group, and evidence review team carried out several iterations of this process, each 

time narrowing the scope of the CPG and the literature review by prioritizing the topics of interest. Due to 

resource constraints, all developed KQs were not able to be included in the systematic evidence review. 

Thus, the Champions and Work Group determined which questions were highest priority, and those were 

included in the review. Table A-2 contains the final set of KQs used to guide the SR for this CPG. 

Once the KQs were finalized, the Work Group prioritized the outcomes they had defined for each KQ 

based on how important the Work Group judged each outcome to be. Rating outcomes by their relative 

importance can help focus attention on those outcomes that are considered most important for clinical 

decision making when making judgments regarding the overall quality of the evidence to support a 

recommendation.[216] 

Using GRADE methodology, the Work Group rated each outcome on a 1 – 9 scale (7 – 9, critical for 

decision making; 4 – 6, important, but not critical, for decision making; and 1 – 3, of limited importance 

for decision making). Critical and important outcomes were included in the evidence review (see 

Outcomes); however, only outcomes judged to be critical were used to determine the overall quality of 

evidence (see Grading Recommendations).
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a. Population(s) 

• Adults age 18 years or older who are candidates for weight loss/maintenance interventions based 

on an above-normal BMI (e.g., ≥25 kg/m2

) 

• Adults with secondary causes of obesity (e.g., due to certain medications) 

• Including pregnant women, women of childbearing age, women with a history of preeclampsia,

deployed Service Members, and patients with comorbidities (e.g., DM, CKD)

b. Interventions 

• Key Questions 1 and 2

♦ CLIs need to incorporate the following 3 components:

○ Diet

○ Physical activity

○ Behavioral change components (e.g., monitoring, goal setting, problem-solving, 

stress management, cognitive strategies, stimulus control, etc.)

• Key Question 3

♦ Modes of delivery include technology-assisted; individual; group; face-to-face; telephone; 

virtual, video, or clinical video telehealth (CVT); automated; or self-delivered

• Key Question 4

♦ Dietary approaches of interest include different macronutrient (low carb, Atkins, South 

Beach, ketogenic, Ornish, Zone, LEARN, low-fat, or balanced low calories); eating plans 

(DASH, Mediterranean, paleo); meal replacement; intermittent fasting or time-restricted; 

very low calorie (<800 kcal/day) (includes interventions that are primarily diet but may 

also include a behavioral component) 

• Key Question 5

♦ Aerobic, strength training, moderate or high-intensity physical activity, or other structured 

or prescribed physical activity; exercise interventions should be added to a weight loss 

intervention

• Key Questions 6 and 7

♦ FDA-approved medications for short-term use, or studied for intermittent use 

(benzphetamine, diethylpropion, phendimetrazine, phentermine) and FDA-approved 

medications for chronic weight management (liraglutide [3 mg], lorcaserin, combination 

naltrexone/bupropion, orlistat, combination phentermine/topiramate)

• Key Question 8

♦ Bitter orange (Citrus aurantium L.)

♦ Caffeine (as added caffeine or from guarana, kola nut, yerba maté, or other herbs)

♦ Chitosan
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♦ Cinnamon

♦ Cissus quadrangularis

♦ Fenugreek (Trigonella foenum-graecum L)

♦ Garcinia cambogia (hydroxycitric acid)

♦ Germander (teucrium)

♦ Ginseng

♦ Glucomannan (konjac root fiber)

♦ Green coffee bean extract (Coffea arabica, Coffea canephora, Coffea robusta)

♦ Green tea (Camellia sinensis) and green tea extract

♦ Guar gum

♦ Hoodia (Hoodia gordonii)

♦ Raspberry ketone

♦ White kidney bean (Phaseolus vulgaris)

♦ Forskolin

♦ Dandelion

♦ Oregano

♦ Gymnema sylvestre

♦ Rosemary

♦ Cuminum cyminum L

♦ Probiotics

• Key Questions 9 and 10

♦ Lap adjustable gastric band

♦ Sleeve Gastrectomy

♦ Roux-n-Y Gastric Bypass

♦ Duodenal Switch

♦ Endoscopic gastric plication 

• Key Questions 11 and 12

♦ Electrical Stimulation Systems - Maestro Rechargeable System

♦ Intragastric balloons: Orbera, ReShape, Obalon, Spatz, Elipse

♦ Gastric Emptying Systems – AspireAssist equivalence (versus inconclusive), using defined 

clinical significance thresholds
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c. Comparators 

• Key Questions 1 and 2

♦ No treatment

♦ Waitlist

♦ Inactive control

♦ Standard of care or treatment as usual

♦ Active comparator with diet or lifestyle alone

• Key Question 3

♦ Other modalities of delivery of the same or an equivalent CLI

• Key Question 4

♦ Different dietary approaches (study must have controlled for other elements of lifestyle 

interventions, such as physical activity and behavioral strategies)

• Key Question 5

♦ Diet and/or behavioral intervention without exercise or different exercise approaches 

(e.g., aerobic versus strength or weight training; high versus low intensity). Participants 

should be enrolled in behavioral/diet intervention w/o exercise. 

• Key Questions 6 and 7 

♦ Placebo, other FDA-approved weight loss medication, or other non-pharmacologic weight 

loss intervention, such as comprehensive lifestyle, weight loss device or bariatric surgery

• Key Question 8

♦ Placebo, no treatment, different dietary supplement, or FDA-approved weight loss 

medication

• Key Question 9 

♦ Non-operative management

♦ Reversible FDA-approved weight-loss devices

♦ Sham procedure

• Key Question 10

♦ Different type of surgical procedure (does not compare variations in how a single surgical 

procedure is performed or the materials/techniques used to perform that surgery)

• Key Question 11

♦ Non-operative weight-loss intervention

♦ Sham device

• Key Question 12 

♦ Other FDA-approved weight-loss medical device
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d. Outcomes

• Critical outcomes

♦ Changes in or maintenance of weight status (as defined by the publication of interest and 

at different time points), including: 

○ Absolute weight loss (kg/lb), relative weight loss as percentage of baseline weight, 

relative weight loss as percentage of excess weight, changes in percent ideal body 

weight

○ Changes in absolute BMI (kg/m2), relative BMI as percentage of baseline BMI 

○ Percentage achieving clinically significant weight loss, defined as >5%, >10% 

reduction

♦ Safety/adverse events (for Key Questions 6-12), including:

○ Any treatment-related adverse events 

○ Discontinuations due to adverse events 

○ Hypotension related intervention 

○ Syncope

○ HTN, change in systolic BP/diastolic BP

○ Dyslipidemia 

○ Falls, injuries

○ Cardiac valve injury

○ Eating disorders, binging

○ Surgical complications, infection

○ Death: all-cause, death from surgical complications, suicide

○ Malabsorption, malnutrition, micro-nutrient deficits

○ Gallstones

○ Kidney stones

○ Tachycardia, arrhythmias

○ Anxiety, or any changes in behavioral/mental health status

○ Depression or depressive episodes

○ Suicide behavior (ideation or attempt)

○ Substance use disorders, risky alcohol use
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• Important outcomes

♦ Changes in or maintenance of body composition, fat mass, fat distribution (as defined and 

measured by the publication of interest and at different time points), including: 

○ Changes in absolute body fat (kg/lb), percent body fat (%), fat mass index (kg/m2) 

○ Changes in skinfold thickness

○ Changes in waist, hip, neck, arm, or thigh circumferences 

○ Changes in circumferences ratios

♦ Prevention and risk of an event, progression or reversal of comorbid conditions; 

conditions of interest include:

○ Diabetes, prediabetes (as defined by the Americans with Disabilities Act), 

metabolic syndrome

○ Hypertension, change in systolic BP/diastolic BP

○ CVD: congestive heart failure, major adverse cardiac events, MI, coronary artery 

disease, aortic events (e.g., aneurysm rupturing) 

○ Dyslipidemia 

○ Stroke

○ Transient ischemic attack (TIA)

○ CKD

○ Osteoarthritis

○ OSA

○ GERD

○ Cancer

○ Non-alcoholic fatty liver disease

○ Non-alcoholic steatohepatitis (NASH)

○ PCOS

♦ Changes in biomarkers of comorbid conditions, including:

○ Lipids: total cholesterol, non-HDL cholesterol (total cholesterol minus HDL 

cholesterol), triglyceride, LDL-c level, HDL-c level, 

○ Aspartate transaminase (AST), alanine transaminase (ALT), albumin, platelet count

○ NAFLD fibrosis score

○ Total testosterone level in males

○ Glycemic control: blood glucose (fasting, postprandial), insulin level fasting and 

post-prandial, HbA1c, insulin resistance (homeostatic model assessment [HOMA], 

homeostatic model assessment of insulin resistance [HOMA IR], homeostatic 

model assessment of β-cell function [HOMA-β]) 
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♦ Functional status/QoL

○ As measured in included publication

♦ Safety/adverse events (for Key Questions 1-5), including:

○ Any treatment-related adverse events 

○ Discontinuations due to adverse events 

○ Hypotension related intervention 

○ Syncope

○ Hypertension, change in SBP/DBP

○ Dyslipidemia 

○ Falls, injuries

○ Cardiac valve injury

○ Eating disorders, binging

○ Surgical complications, infection

○ Death: all-cause, death from surgical complications, suicide

○ Malabsorption, malnutrition, micro-nutrient deficits

○ Gallstones

○ Kidney stones

○ Tachycardia, arrhythmias

○ Anxiety, or any changes in behavioral/mental health status

○ Depression or depressive episodes

○ Suicide behavior (ideation or attempt)

○ Substance use disorders, risky alcohol use

♦ Adherence to therapy

○ As measured in included publication

B. Conducting the Systematic Review

Based on the decisions made by the Champions and Work Group members regarding the scope, the

KQs, and the PICOTS statements, the Lewin Team produced an SR protocol prior to conducting the 

review. The protocol was reviewed and approved by the Champions and Work Group members. It 

described in detail the final set of KQs, the methodology to be used during the SR process, and the 

inclusion/exclusion criteria to be applied to each potential study, including, but not limited to, study 

type, sample size, and PICOTS criteria. 

Extensive literature searches identified 7,027 citations potentially addressing the key questions of interest 

to this evidence review. Of those, 5,440 were excluded upon title review for clearly not meeting inclusion 

criteria (e.g., not pertinent to the topic, not published in English, published prior to study inclusion 
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publication date, or not a full-length article). Overall, 1,587 abstracts were reviewed with 932 of those 

being excluded for the following reasons: not an SR or clinical study (see the General Criteria for Inclusion 

in Systematic Review), did not address a key question of interest to this review, did not enroll a population 

of interest, or published prior to February 1, 2013. A total of 655 full-length articles were reviewed. Of 

those, 349 were excluded at a first pass review for the following: not addressing a key question of interest, 

not enrolling the population of interest, not meeting inclusion criteria for clinical study or SR, not meeting 

inclusion criteria for any key question, or being a duplicate. A total of 306 full-length articles were thought 

to address one or more key questions and were further reviewed. Of these, 199 were ultimately excluded 

and reasons for their exclusion are presented in Figure A-1 below. 

Overall, 107 studies addressed one or more of the key questions and were considered as evidence in this 

review. Table A-2 indicates the number of studies that addressed each of the questions. 

Figure A-1. Study Flow Diagram

Abbreviations: CS: clinical study; KQ: key question; SR: systematic review
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Alternative Text Description of Study Flow Diagram 

Figure A-1 Study Flow Diagram is a flow chart with nine labeled boxes linked by arrows that describe the 

literature review inclusion/exclusion process. Arrows point down to boxes that describe the next literature 

review step and arrows point right to boxes that describe the excluded citations at each step (including the 

reasons for exclusion and the numbers of excluded citations). 

1. Box 1: 7,027 citations identified by searches

a. Right to Box 2: 5,440 citations excluded at the title level

i. Citations excluded at this level were off-topic, not published in English, or 

published prior to inclusion date

b. Down to Box 3: 1,587 abstracts reviewed

2. Box 3: 1,587 abstracts reviewed

a. Right to Box 4: 932 citations excluded at the abstract level

i. Citations excluded at this level were not an SR or clinical study, clearly did not 

address a KQ, did not report on an outcome of interest, or were outside cutoff 

publication dates 

b. Down to Box 5: 655 full-length articles reviewed

3. Box 5: 349 full-length articles reviewed

a. Right to Box 6: 349 citations excluded at 1st pass full article level

i. Articles excluded at this level did not: address a key question of interest, enroll 

the population of interest, meet inclusion criteria for clinical study or systematic

review, meet inclusion criteria for any key question, or were a duplicate

b. Down to Box 7: 306 articles reviewed

4. Box 7: 306 articles reviewed

a. Right to Box 8: 199 citations excluded at 2nd pass full article level

i. 36 Wrong study design or doesn’t address a KQ

ii. 70 Not an intervention or comparator of interest

iii. 7 No outcome of interest

iv. 3 Not a study population of interest

v. 3 Unclear or inadequate follow-up

vi. 12 Inadequate reporting of data/no data extract

vii. 11 Other (e.g., duplicate, published outside date range)

b. Down to Box 9: 107 included studies

5. Box 9: 105 included studies
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Table A-2. Evidence Base for KQs

Question 

Number Question

Number of Studies and

Type of Studies

1 What are the benefits and harms of comprehensive lifestyle interventions 

on weight loss and health outcomes?

5 SRs

9 RCTs

2 

Among adults who have achieved initial weight loss, what are the benefits 

and harms of comprehensive lifestyle interventions on weight 

maintenance and health outcomes?

1 SR

1 RCT

3 

What is the comparative effectiveness of different modes of delivering 

comprehensive lifestyle interventions on weight loss or weight 

maintenance and health outcomes?

5 SRs

12 RCTs

4 What is the comparative effectiveness and harms of various dietary 

approaches on short and long-term weight loss and health outcomes?

4 SRs

9 RCTs

5 What are the benefits and harms of physical activity on short- and longterm weight loss and health outcomes?

2 SRs

8 RCTs

6 

What are the benefits and harms of FDA approved medications for shortterm use (<6 months) or chronic use (>6 months) on weight loss and 

health outcomes?

3 SRs

3 RCTs in 5 publications

7 What are the benefits and harms of FDA approved medications on weight 

maintenance and health outcomes?

1 SR

1 RCT

8 What are the benefits and harms of dietary supplements or nutraceuticals 

on initial weight loss and long-term weight loss?

5 SRs

7 RCTs

9 What are the benefits and harms of bariatric surgery on short- and longterm weight loss, health outcomes, and comorbid health conditions?

14 SRs

10

What is the comparative effectiveness of different forms of bariatric 

surgery on short- and long-term weight loss, health outcomes, and 

comorbid health conditions?

6 SRs

1 RCT

11

What are the benefits and harms of FDA-approved weight loss devices on 

short- and long-term weight loss, health outcomes, and comorbid health 

conditions?

4 SRs

3 RCTs

12

What is the comparative effectiveness and harms of FDA-approved weight 

loss devices on short- and long-term weight loss status, health outcomes, 

and comorbid health conditions?

1 SR

Total Evidence Base 107 studies

Abbreviations: FDA: Food and Drug Administration; RCT: randomized controlled trial; SR: systematic review

a. General Criteria for Inclusion in Systematic Review

• RCTs or SRs published on or after February 1, 2013, to April 8, 2019. If multiple SRs addressed a 

KQ, the most recent and/or comprehensive review was selected. SRs are supplemented with RCTs 

published subsequent to the SR. 

• Studies must have been published in English.

• Publication must be a full clinical study or SR; abstracts alone were not included. Similarly, letters, 

editorials, and other publications that are not full-length clinical studies were not accepted as 

evidence. 
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• SRs must have searched MEDLINE or EMBASE for eligible publications, performed a risk of bias 

assessment of included studies, and assessed the quality of evidence using a recognizable rating 

system, such as GRADE or something compatible (e.g., the Strength of Evidence grading used by 

the Evidence-based Practice Centers of the Agency for Healthcare Research and Quality). If an 

existing review did not assess the overall quality of the evidence, evidence from the review must 

have been reported in a manner that allows us to judge the overall risk of bias, consistency, 

directness, and precision of evidence. SRs were not used as evidence if the overall quality of the 

evidence in the review was unable to be assessed. 

• Intervention studies assessed CLIs, various dietary approaches, physical activity, FDA-approved 

weight loss medications, select dietary supplements or nutraceuticals, FDA-approved medical 

devices for weight loss, and bariatric surgical procedures and must have been a prospective, RCT

with an independent control group. Crossover trials will not be included unless they report data 

for the first phase of the study separately. 

• Study must have enrolled at least 20 patients (10 per study group). 

• Study must have enrolled at least 85% of patients who meet the study population criteria: adults 

aged 18 years or older with overweight or obesity. 

• Study must have reported on at least one critical or important outcome of interest.

b. Literature Search Strategy

Information regarding the bibliographic databases, date limits, and platform/provider can be found in the 

table below. Additional information on the search strategies, including topic-specific search terms and 

search strategies, can be found in Appendix F. 

Table A-3. Bibliographic Database Information

Name Date Limits Platform/Provider

Cochrane Database of Systematic Reviews 

(Cochrane Reviews) February 1, 2013, to April 8, 2019 Wiley

Cochrane Central Register of Controlled Trials February 1, 2013, to April 8, 2019 Wiley

Database of Abstracts of Reviews of Effects February 1, 2013, to April 8, 2019 Wiley

EMBASE (Excerpta Medica) February 1, 2013, to April 8, 2019 Elsevier

Health Technology Assessment Database (HTA) February 1, 2013, to April 8, 2019 Wiley

MEDLINE/PreMEDLINE February 1, 2013, to April 8, 2019 Elsevier

PsycINFO February 1, 2013, to April 8, 2019 OvidSP

PubMed (In-process and Publisher records) February 1, 2013, to April 8, 2019 National Library of Medicine

C. Convening the Face-to-face Meeting

In consultation with the COR, the Champions, and the Work Group, the Lewin Team convened a three and 

one half-day face-to-face meeting of the CPG Champions and Work Group members on July 16 – 19, 2019. 

These experts were gathered to develop and draft the clinical recommendations for an update to the 2014 

VA/DoD Obesity CPG. The Lewin Team presented findings from the evidence review in order to facilitate 

and inform the process. 
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Under the direction of the Champions, the Work Group members were charged with interpreting the 

results of the evidence review and were asked to categorize and carry forward recommendations from the 

2014 VA/DoD Obesity CPG, modifying the recommendations as necessary. The members also developed 

new clinical practice recommendations not presented in the 2014 VA/DoD Obesity CPG based on the 2019

evidence review. The subject matter experts were divided into three smaller subgroups at this meeting. 

As the Work Group members drafted clinical practice recommendations, they also assigned a grade for 

each recommendation based on a modified GRADE and USPSTF methodology. Each recommendation was 

graded by assessing the quality of the overall evidence base, the associated benefits and harms, the 

variation in values and preferences, and other implications of the recommendation.

In addition to developing recommendations during the face-to-face meeting, the Work Group members 

also began to revise the 2014 VA/DoD Obesity CPG algorithms to reflect the new and amended 

recommendations. They discussed the available evidence as well as changes in clinical practice since 2014, 

as necessary, to update the algorithms.

D. Grading Recommendations

This CPG uses the GRADE methodology to assess the quality of the evidence base and assign a strength for 

each recommendation. The GRADE system uses the following four domains to assess the strength of each 

recommendation:[27] 

• Balance of desirable and undesirable outcomes 

• Confidence in the quality of the evidence 

• Values and preferences

• Other implications, as appropriate, 

♦ Resource use

♦ Equity

♦ Acceptability

♦ Feasibility

♦ Subgroup considerations

The following sections further describe each domain. 

Balance of desirable and undesirable outcomes refers to the size of anticipated benefits (e.g., increased 

longevity, reduction in morbid event, resolution of symptoms, improved quality of life, decreased 

resource use) and harms (e.g., decreased longevity, immediate serious complications, adverse event, 

impaired quality of life, increased resource use, inconvenience/hassle) relative to each other. This 

domain is based on the understanding that the majority of providers will offer patients therapeutic or 

preventive measures as long as the advantages of the intervention exceed the risks and adverse effects. 

The certainty or uncertainty of the provider about the risk-benefit balance will greatly influence the 

strength of the recommendation.
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Some of the discussion questions that fall under this domain include:

• Given the best estimate of typical values and preferences, are you confident that the benefits 

outweigh the harms and burden or vice versa?

• Are the desirable anticipated effects large?

• Are the undesirable anticipated effects small?

• Are the desirable effects large relative to undesirable effects?

Confidence in the quality of the evidence reflects the quality of the evidence base and the certainty in 

that evidence. This second domain reflects the methodological quality of the studies for each outcome 

variable. In general, the strength of recommendation follows the level of evidence, but not always, as 

other domains may increase or decrease the strength. The evidence review used for the development of 

recommendations, conducted by ECRI, assessed the confidence in the quality of the evidence base using 

GRADE methodology and assigned a rating of “High,” “Moderate,” “Low,” or “Very Low.” The outcomes 

judged to be critical were used to determine the overall quality of evidence. Per GRADE, if the quality of 

evidence differs across the critical outcomes, the lowest quality of evidence for any of the relevant critical 

outcomes determines the overall quality of the evidence for a recommendation; the overall confidence 

cannot be higher than the lowest confidence in effect estimates for any outcome that is determined to be 

critical for clinical decision making.[33,216] 

The elements that go into the confidence in the quality of the evidence include: 

• Is there high or moderate quality evidence that answers this question?

• What is the overall certainty of this evidence?

Values and preferences is an overarching term that includes patients’ perspectives, beliefs, expectations, 

and goals for health and life. More precisely, it refers to the processes that individuals use in considering 

the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive 

measures in relation to one another. For some, the term “values” has the closest connotation to these 

processes. For others, the connotation of “preferences” best captures the notion of choice. In general, 

values and preferences increase the strength of the recommendation when there is high concordance and 

decrease it when there is great variability. In a situation in which the balance of benefits and risks are 

uncertain, eliciting the values and preferences of patients and empowering them and their surrogates to 

make decisions consistent with their goals of care becomes even more important. A recommendation can 

be described as having “similar values,” “some variation,” or “large variation” in typical values and 

preferences between patients and the larger populations of interest.

Some of the discussion questions that fall under the purview of values and preferences include:

• Are you confident about the typical values and preferences and are they similar across the target 

population?

• What are the patient’s values and preferences? 

• Are the assumed or identified relative values similar across the target population?
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Other implications consider the practicality of the recommendation, including resource use, equity, 

acceptability, feasibility, and subgroup considerations. Resource use is related to the uncertainty around 

the cost-effectiveness of a therapeutic or preventive measure. For example, statin use in the frail elderly 

and others with multiple co-occurring conditions may not be effective and, depending on the societal 

benchmark for willingness to pay, may not be a good use of resources. Equity, acceptability, feasibility, and 

subgroup considerations require similar judgments around the practicality of the recommendation.

The framework below (Table A-4) was used by the Work Group to guide discussions on each domain.

Table A-4. GRADE Evidence to Recommendation Framework

Decision Domain Questions to Consider Judgment

Balance of desirable 

and undesirable 

outcomes

• Given the best estimate of typical values and 

preferences, are you confident that the benefits 

outweigh the harms and burden or vice versa?

• Are the desirable anticipated effects large?

• Are the undesirable anticipated effects small?

• Are the desirable effects large relative to 

undesirable effects?

• Benefits outweigh harms/

burden

• Benefits slightly outweigh 

harms/burden

• Benefits and harms/burden 

are balanced

• Harms/burden slightly 

outweigh benefits

• Harms/burden outweigh 

benefits

Confidence in the 

quality of the 

evidence

• Is there high or moderate-quality evidence that 

answers this question?

• What is the overall certainty of this evidence?

• High

• Moderate

• Low

• Very low

Values and 

preferences

• Are you confident about the typical values and 

preferences and are they similar across the target 

population?

• What are the patient’s values and preferences? 

• Are the assumed or identified relative values similar 

across the target population?

• Similar values

• Some variation

• Large variation

Other implications 

(e.g., resource use, 

equity, acceptability, 

feasibility, subgroup 

considerations)

• Are the resources worth the expected net benefit 

from the recommendation?

• What are the costs per resource unit?

• Is this intervention generally available?

• Is this intervention and its effects worth 

withdrawing or not allocating resources from other 

interventions?

• Is there lots of variability in resource requirements 

across settings?

• Various considerations

The strength of a recommendation is defined as the extent to which one can be confident that the 

desirable effects of an intervention outweigh its undesirable effects and is based on the framework above, 

which combines the four domains.[217] GRADE methodology does not allow for recommendations to be 

made based on expert opinion alone. While strong recommendations are usually based on high or 

moderate confidence in the estimates of effect (quality of the evidence) there may be instances in which

strong recommendations are warranted even when the quality of evidence is low.[27] In these instances, 

the balance of desirable and undesirable outcomes and values and preferences played large roles in 
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determining the strength of a recommendation. This is explained in the discussion section for the 

recommendation.

The GRADE of a recommendation is based on the following elements:

• Four decision domains used to determine the strength and direction (described above)

• Relative strength (Strong or Weak)

• Direction (For or Against)

The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong 

recommendation indicates that the Work Group is highly confident that desirable outcomes outweigh 

undesirable outcomes. If the Work Group is less confident of the balance between desirable and 

undesirable outcomes, they present a weak recommendation. 

Similarly, a recommendation for a therapy or preventive measure indicates that the desirable 

consequences outweigh the undesirable consequences. A recommendation against a therapy or 

preventive measure indicates that the undesirable consequences outweigh the desirable consequences.

Occasionally, instances may occur when the Work Group feels there is insufficient evidence to make a 

recommendation for or against a specific therapy or preventive measure. This can occur when there is an 

absence of studies on a particular topic that met evidence review inclusion criteria, studies included in the 

evidence review report conflicting results, or studies included in the evidence review report inconclusive 

results regarding the desirable and undesirable outcomes.

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong For (or “We recommend offering this option ...”)

• Weak For (or “We suggest offering this option ...”)

• No recommendation for or against (or “There is insufficient evidence ...”)

• Weak Against (or “We suggest not offering this option ...”)

• Strong Against (or “We recommend against offering this option ...”)

Note that Weak (For or Against) recommendations may also be termed “Conditional,” “Discretionary,” or 

“Qualified.” Recommendations may be conditional based upon patient values and preferences, the 

resources available, or the setting in which the intervention will be implemented. Recommendations may 

be at the discretion of the patient and provider or they may be qualified with an explanation about the 

issues that would lead decisions to vary.

E. Recommendation Categorization

a. Recommendation Categories and Definitions 

A set of recommendation categories was adapted from those used by NICE.[30,31] These categories, along 

with their corresponding definitions, were used to account for the various ways in which 

recommendations could have been updated from the 2014 VA/DoD Obesity CPG. The categories and 

definitions can be found in Table A-5. 
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Table A-5. Recommendation Categories and Definitions* 

Evidence 

Reviewed

Recommendation 

Category Definition

Reviewed

New-added New recommendation following review of the evidence

New-replaced Recommendation from previous CPG that has been carried over to the 

updated CPG that has been changed following review of the evidence

Not changed

Recommendation from previous CPG that has been carried forward to the 

updated CPG where the evidence has been reviewed but the 

recommendation is not changed

Amended

Recommendation from previous CPG that has been carried forward to the 

updated CPG where the evidence has been reviewed and a minor 

amendment has been made

Deleted Recommendation from previous CPG that has been removed based on review 

of the evidence

Not 

reviewed

Not changed Recommendation from previous CPG that has been carried forward to the 

updated CPG, but for which the evidence has not been reviewed

Amended

Recommendation from previous CPG that has been carried forward to the 

updated CPG where the evidence has not been reviewed and a minor 

amendment has been made

Deleted Recommendation from previous CPG that has been removed because it was 

deemed out of scope for the updated CPG

*Adapted from the NICE guideline manual (2012) [30] and Garcia et al. (2014) [31] 

Abbreviation: CPG: clinical practice guideline

b. Categorizing Recommendations with an Updated Review of the Evidence 

Recommendations were first categorized by whether or not they were based on an updated review of the 

evidence. If evidence had been reviewed, recommendations were categorized as “New-added,” “Newreplaced,” “Not changed,” “Amended,” or “Deleted.” 

“Reviewed, New-added” recommendations were original, new recommendations that were not in the 

2014 VA/DoD Obesity CPG. “Reviewed, New-replaced” recommendations were in the previous version of 

the guideline but were modified to align with the updated review of the evidence. These 

recommendations could have also included clinically significant changes to the previous version. 

Recommendations categorized as “Reviewed, Not changed” were carried forward from the previous 

version of the CPG unchanged. 

The “Reviewed, Not Changed” category was used for recommendations carried forward to the updated 

CPG with review of the evidence and where no changes were deemed necessary to the recommendation 

language. For recommendations carried forward to the updated CPG with review of the evidence and 

slightly modified wording, the “Reviewed, Amended” recommendation category was used. This allowed 

for the wording of the recommendation to reflect GRADE methodology as well as for any other nonsubstantive (i.e., not clinically meaningful) language changes deemed necessary. The evidence used to 

support these recommendations was carried forward from the previous version of the CPG and/or was 

identified in the evidence review for the update. 

Recommendations could have also been designated “Reviewed, Deleted.” These were recommendations 

from the previous version of the CPG that were not brought forward to the updated guideline after review 
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of the evidence. This occurred if the evidence supporting the recommendations was out of date, to the 

extent that there was no longer any basis to recommend a particular course of care and/or new evidence 

suggests a shift in care, rendering recommendations in the previous version of the guideline obsolete.

c. Categorizing Recommendations without an Updated Review of the Evidence 

There were also cases in which it was necessary to carry forward recommendations from the previous 

version of the CPG without an updated SR of the evidence. Due to time and budget constraints, the update 

of the Obesity CPG could not review all available evidence on the management of overweight and obesity

but instead focused its KQs on areas of new or updated scientific research or areas that were not 

previously covered in the CPG. 

For areas of research that have not changed, and for which recommendations made in the previous 

version of the guideline were still relevant, recommendations could have been carried forward to the 

updated guideline without an updated SR of the evidence. The support for these recommendations in the 

updated CPG was thus also carried forward from the previous version of the CPG. These recommendations 

were categorized as “Not reviewed.” If evidence had not been reviewed, recommendations could have 

been categorized as “Not changed,” “Amended,” or “Deleted.” 

“Not reviewed, Not changed” recommendations refer to recommendations from the previous version of 

the Obesity CPG that were carried forward unchanged to the updated version. The category of “Not 

reviewed, Amended” was used to designate recommendations which were modified from the 2014 

VA/DoD Obesity CPG with the updated GRADE language, as explained above. 

Recommendations could also have been categorized as “Not reviewed, Deleted” if they were 

determined to be out of scope. A recommendation was out of scope if it pertained to a topic 

(e.g., population, care setting, treatment, and condition) outside of the scope for the updated CPG as 

defined by the Work Group. 

The categories for the recommendations included in the 2020 version of the guideline are noted in the 

Recommendations. The categories for the recommendations from the 2014 Obesity CPG are noted in 

Appendix D. 

F. Drafting and Submitting the Final Clinical Practice Guideline

Following the face-to-face meeting, the Champions and Work Group members were given writing 

assignments to craft discussion sections to support each of the new recommendations and/or to update 

discussion sections from the 2014 VA/DoD Obesity CPG to support the amended “carried forward” 

recommendations. The Work Group also considered tables, appendices, and other sections from the 2014 

VA/DoD Obesity CPG for inclusion in the update. During this time, the Champions and Work Group also 

made additional revisions to the algorithms, as necessary. 

After developing the initial draft of the updated CPG, an iterative review process was used to solicit 

feedback on and make revisions to the CPG. Once they were developed, the first two drafts of the CPG 

were posted on a wiki website for a period of 14 – 20 business days for internal review and comment by 

the Work Group. All feedback submitted during each review period was reviewed and discussed by the 

Work Group and appropriate revisions were made to the CPG. 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Draft 3 of the CPG was made available for peer review and comment. This process is described in the 

section titled Peer Review Process. After revisions were made based on the feedback received during the 

peer review and comment period, the Champions presented the CPG to the EBPWG for their approval. 

Changes were made based on feedback from the EBPWG and the guideline was finalized. 

The Work Group also produced a set of guideline toolkit materials which included a provider summary, 

pocket card, and patient summary. The final 2020 VA/DoD Obesity CPG was submitted to the EBPWG in 

June 2020. 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Appendix B: Patient Focus Group Methods and Findings

A. Methods

As part of the effort to update this CPG, VA and DoD Leadership held a patient focus group on March 7, 

2019, at the Womack Army Medical Center in Fort Bragg, NC. The aim of the focus group was to further 

understand and incorporate the perspective of patients with overweight and obesity, who are covered 

and/or receiving their care through the VA and/or DoD healthcare systems, as these patients are most 

affected by the recommendations put forth in the CPG. The focus groups explored the patients’ 

perspectives on a set of topics related to their overweight or obesity management, including their 

priorities, challenges they have experienced, the information they received regarding their care, as well as 

the impacts of their care on their lives. 

Participants for the focus group were recruited by VA and DoD Leadership with assistance from the 

Obesity CPG Champions. Patient focus group participants were not intended to be a representative sample 

of VA and DoD patients. However, recruitment focused on eliciting a range of perspectives likely to be 

relevant and informative in the guideline development process. Patients were not incentivized for their 

participation or reimbursed for travel expenses.

The Obesity CPG Champions and Work Group, with support from Lewin, developed a set of questions to 

help guide the focus group. The focus group facilitator led the discussion using the previously prepared 

questions as a general guide to elicit the most important information from the patients regarding their 

experiences and views about their treatment and overall care. Given the limited time and the range of 

interests, knowledge, and information of the focus group participants, not all of the listed questions 

were addressed.

B. Findings 

The following ideas and suggestions about aspects of care that are important to patients with 

overweight or obesity emerged as recurring themes during the discussions (Table B-1). These concepts 

were important parts of the participants’ care and added to the Work Group’s understanding of patient 

values and perspectives.

Table B-1. Obesity CPG Focus Group Findings

Obesity CPG Patient Focus Group Concepts

A. Providers should use shared decision making to develop an individualized, patient-centered lifestyle-modification 

treatment plan that incorporates both a dietary regimen and exercise routine. 

B. Patients, particularly those in the DoD, face stigmatization and discrimination based on their weight. For active 

duty Service Members, not meeting their weight requirements can have significant effects on their careers. 

C. Active duty participants expressed concern over the methods used to screen for overweight and obesity. 

Participants believed the “Tape Test” is inaccurate and prone to human error. 

D. Patients utilized a variety of internet tools and mobile apps to manage their weight loss goals. Providers should

offer telemedicine and other technology options to augment care but recognize these options may not align with 

the preferences of all patients.

E. Patients would like to receive more education regarding weight loss and effective treatment strategies, including 

specific types of diet and exercise plans, dietary or herbal supplements, and pharmaceuticals. 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 83 of 147

a. Providers should use shared decision making to develop an individualized, 

patient-centered lifestyle-modification treatment plan that incorporates both a 

dietary regimen and exercise routine.

• Patients expressed a desire for more individualized, patient-centered treatment plans. Providers 

should use shared decision making to find a treatment plan that works best for each patient.

• Patients varied in their treatment preferences; some patients found weight loss success by 

changing the types of foods they ate, while others found that the timing of meals was important to 

their weight loss.

• Patients stated that being surrounded by individuals who share their weight loss goals would be 

beneficial to their treatment. Additionally, patients avoided group settings where unhealthy food 

was being eaten in an effort to improve their diet.

• Patients expressed a desire to receive individualized dietary advice but found scheduling 

appointments with dietitians difficult.

• Patients stated that their family members were affected by their treatment plans and should, 

therefore, be included in treatment planning and education, not only for the benefit of the 

patients’ health but also for the health of their family members.

• Providers should be mindful of and take into account each patient’s co-occurring conditions, 

particularly mental health conditions, when developing their treatment plan. 

b. Patients, particularly those in the DoD, face stigmatization and discrimination 

based on their weight. For active duty Service Members, not meeting their 

weight requirements can have significant effects on their careers. 

• Patients in the DoD face stigmatization and discrimination based on their weight. This is 

compounded by mental health stigmas issues many patients face.

• Most participants’ military careers have been significantly impacted by their weight.

• Several of the participants expressed that they would do just about anything to meet the military 

weight criteria that would allow them to move on with their career.

• The main challenge for active duty patients was to have more information and more time to 

achieve the weight criteria, not that they found the dietary or physical activity changes difficult to 

implement.

c. Active duty participants expressed concern over the methods used to screen for 

overweight and obesity. Participants believed the “Tape Test” is inaccurate and 

prone to human error. 

• Some patients expressed their frustration that while they were in the best shape they had ever 

been in and had no difficulty passing the physical fitness requirements for duty, they were still 

failing to achieve the “Tape Test” (waist and neck circumferences) standards.

• Patients stated that the “Tape Test” is unfair to individuals with wider hip bones or small neck 

circumferences and felt that it is not an accurate measure of physical fitness or health. They 

believe the “Tape Test” is inaccurate, imprecise, and prone to human error.
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 84 of 147

• Patients agreed that the timeframe given by the military to meet the physical requirements should 

be adjusted based on an individual’s baseline weight.

d. Patients utilized a variety of internet tools and mobile apps to manage their 

weight loss goals. Providers should offer telemedicine and other technology 

options to augment care but recognize these options may not align with the 

preferences of all patients. 

• Younger patients used mobile apps and websites to help them track their calories, determine if 

foods were healthy or not, count their steps, and measure their weight loss progress.

• Patients varied in their desire to use telehealth.

e. Patients would like to receive more education regarding weight loss and 

effective treatment strategies, including specific types of diet and exercise plans, 

dietary or herbal supplements, and pharmaceuticals. 

• Patients desired more education from their providers regarding their options for effective 

strategies to treat overweight and obesity.

• Patients used a variety of methods to lose weight, most of which they discovered through their 

research, word-of-mouth, or online.

• Dietary supplements and OTC weight-loss drugs are used by patients to provide short-term fixes 

ahead of the “Tape Test”; patients want to learn more about the safety and efficacy of these 

supplements.

• Patients were receptive to using prescription weight loss medications, even if the side effects 

could be harmful. Providers should educate patients about the risks and potential benefits of 

pharmacologic treatment.
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 85 of 147

Appendix C: Evidence Table

Table C-1. Evidence Tablea,b,c,d

Recommendation

2014

Grade Evidence 2020 Strength ofRecommendation

Recommendation

Category

1. We recommend offering an in-person group or individual 

comprehensive lifestyle intervention that always includes 

behavioral, dietary, and physical activity components for

patients with overweight or obesity.

C, A, I, A, B, 

C, I, A, B

[2,77-86] 

Additional References:

[26,74-76,87-91]

Strong for Reviewed, New-replaced

2. There is insufficient evidence to recommend a specific number 

of sessions of a comprehensive lifestyle intervention for 

patients with overweight or obesity.

B [2] 

Additional References:

[26] 

Neither for nor 

against

Reviewed, New-replaced

3. We suggest offering a comprehensive lifestyle intervention for

weight maintenance to patients who have completed a 

comprehensive lifestyle intervention for weight loss.

B [2,74,75,92,93] Weak for Reviewed, New-replaced

4. We suggest offering an individual or group telephonedelivered comprehensive lifestyle intervention for weight loss,

either as an alternative to or in conjunction with an in-person

intervention.

B [2,75,92,94,95] Weak for Reviewed, Amended

 

a 2014 Grade column: The 2014 VA/DoD Obesity CPG used the USPSTF evidence grading system. Inclusion of more than one 2014 Grade indicates that more than one 2014 CPG 

recommendation is covered under the 2020 recommendation. The strength of recommendations were rated as follows: A- a strong recommendation that the clinicians provide 

the intervention to eligible patients; B- a recommendation that clinicians provide (the service) to eligible patients; C- no recommendation for or against the routine provision of 

the intervention is made; D- recommendation is made against routinely providing the intervention; I- the conclusion is that the evidence is insufficient to recommend for or 

against routinely providing the intervention. “None” indicates that the 2014 VA/DoD Obesity CPG recommendation was not graded. “Not applicable” indicates that the 2020 

VA/DoD Obesity CPG recommendation was a new recommendation, and therefore does not have an associated 2014 Grade. b Evidence column: The first set of references listed in each row in the evidence column constitutes the evidence base for the recommendation. To be included in the evidence 

base for a recommendation, a reference needed to be identified through the 2019 evidence review or included in the evidence base for the 2014 VA/DoD Obesity CPG. The 

second set of references in the evidence column (called “Additional References”) includes references that provide additional information related to the recommendation but 

which were not systematically identified through a literature review. These references were not included in the evidence base for the recommendation and, therefore, did not 

influence the strength and direction of the recommendation. c 2020 Strength of Recommendation column: Refer to the Grading Recommendations section for more information on how the strength of the recommendation was determined 

using GRADE methodology. d Recommendation Categorization column: Refer to the Recommendation Categorization section for more information on the description of the categorization process and the 

definition of each category.
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Recommendation

2014

Grade Evidence 2020 Strength ofRecommendation

Recommendation

Category

5. There is insufficient evidence for or against offering a 

comprehensive lifestyle intervention for weight loss that uses 

technology as its primary mode of delivery. 

I [2,106,108-111] 

Additional References:

[96-107] 

Neither for nor 

against

Reviewed, New-Replaced

6. We suggest choosing one or more of the following as the 

physical activity component of a comprehensive lifestyle 

intervention: aerobic, resistance, and/or lifestyle physical 

activity.

A, A, A, EO [2,89,112-119] 

Additional References:

[120,121]

Weak for Reviewed, New-replaced

7. We recommend offering patients a dietary approach that 

contributes to a negative energy balance to achieve weight 

loss as the dietary component of a comprehensive lifestyle 

intervention. 

A [2,122-145] 

Additional References:

[146] 

Strong for Reviewed, Amended

8. We suggest meal replacement (for example portion-controlled

shake, protein bar, or meal) as an option to achieve negative 

energy balance as a component of a comprehensive lifestyle 

intervention.

A [122,147-150] 

Additional References:

[151] 

Weak for Reviewed, New-replaced

9. We suggest offering prescribed pharmacotherapy (specifically 

liraglutide, naltrexone/bupropion, orlistat, or 

phentermine/topiramate) for long-term weight loss in patients 

with a body mass index ≥30 kg/m2 and for those with a body 

mass index ≥27 kg/m2 who also have obesity-associated 

conditions, in conjunction with a comprehensive lifestyle 

intervention.

A, B [2,152,154-156,158-

164,166,167] 

Additional References:

 [153,157,165]

Weak for Reviewed, New-replaced

10. There is insufficient evidence to recommend for or against 

offering phentermine monotherapy, benzphetamine, 

diethylpropion, or phendimetrazine, for short-term, long-term, 

or intermittent weight loss in patients with overweight or 

obesity.

N/A [154] Neither for nor 

against

Reviewed, New-added

11. We suggest against using dietary supplements or 

nutraceuticals for clinically meaningful short-term weight loss 

or long-term weight management.

N/A [169-176] 

Additional References: 

[168,177] 

Weak against Reviewed, New-added

12. We suggest offering the option of metabolic/bariatric surgery, 

in conjunction with a comprehensive lifestyle intervention, to 

patients with a body mass index of ≥30 kg/m2 and type 2 

diabetes mellitus. 

N/A [178,179,187-189] 

Additional References:

[180-186] 

Weak for Reviewed, New-added
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 87 of 147

Recommendation

2014

Grade Evidence 2020 Strength ofRecommendation

Recommendation

Category

13. We suggest offering the option of metabolic/bariatric surgery, 

in conjunction with a comprehensive lifestyle intervention, for 

long-term weight loss/maintenance and/or to improve 

obesity-associated condition(s) in adult patients with a body 

mass index ≥40 kg/m2 or those with body mass index ≥35 

kg/m2 with obesity-associated condition(s).

A, A [187-196] 

Additional References:

[186] 

Weak for Reviewed, New-replaced

14. There is insufficient evidence to recommend for or against 

metabolic/bariatric surgery to patients over age 65.

I [197-201] Neither for nor 

against

Reviewed, Amended

15. There is insufficient evidence to recommend for or against 

percutaneous gastrostomy devices for weight loss in patients 

with obesity. 

N/A [202-205] Neither for nor 

against

Reviewed, New-added

16. We suggest offering intragastric balloons in conjunction with a 

comprehensive lifestyle intervention to patients with obesity 

(body mass index ≥30 kg/m2

) who prioritize short-term (up to 

six months) weight loss. 

N/A [206-210] 

Additional References:

[186] 

Weak for Reviewed, New-added

17. There is insufficient evidence to recommend for or against 

intragastric balloons for long-term weight loss to support 

chronic weight management or maintenance. 

N/A [206-210] 

Additional References:

[186] 

Neither for nor 

against

Reviewed, New-added

18. We suggest offering a low-carbohydrate diet over a low-fat 

diet as the dietary component of a comprehensive lifestyle 

intervention for patients who prioritize short-term (up to six 

months) weight loss.

N/A [130,134,138] 

Additional References:

[137,139,141,144,211] 

Weak for Reviewed, New-added
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Appendix D: 2014 Recommendation Categorization Table 

Table D-1. 2014 Recommendation Categorization Tablea,b,c,d,e

2014 

Location

2014 Recommendation Text

2014 

Grade

Recommendation

Category

2020

Rec

Recommendation

. 

NumberPage

1 20

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 Not reviewed, 

Deleted – 

2 20 Screen for overweight and obesity at least annually. EO Not reviewed, 

Deleted – 

3 20 Assess for the presence of obesity-associated conditions among overweight patients or 

patients with increased waist circumference. B Not reviewed, Deleted – 

4 20 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 Not reviewed, Deleted – 

5 22 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 Not reviewed, Deleted – 

6 23

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 Reviewed, Newreplaced Recommendation 1

7 23 Offer comprehensive lifestyle intervention to achieve weight loss and to improve blood 

pressure and/or glucose control in overweight patients. A Reviewed, Newreplaced Recommendation 1

 

a 2014 Location columns: The first two columns indicate the location of each recommendation within the 2014 VA/DoD Obesity CPG. b 2014 Recommendation Text column: The 2014 Recommendation Text column contains the wording of each recommendation from the 2014 VA/DoD Obesity CPG. c 2014 Grade column: The 2014 VA/DoD Obesity CPG used the U.S. Preventive Services Task Force (USPSTF) evidence grading system: 

http://www.uspreventiveservicestaskforce.org. The strength of recommendations were rated as follows: A- a strong recommendation that the clinicians provide the intervention 

to eligible patients; B- a recommendation that clinicians provide (the service) to eligible patients; C- no recommendation for or against the routine provision of the intervention is 

made; D- recommendation is made against routinely providing the intervention; I- the conclusion is that the evidence is insufficient to recommend for or against routinely 

providing the intervention. “N/A” indicates there was no grade assigned to the recommendation in the 2014 VA/DoD Obesity CPG. d Recommendation Category column: This column indicates the way in which each 2014 VA/DoD Obesity CPG recommendation was updated. e 2020 Recommendation column: For recommendations that were carried forward to the 2020 VA/DoD Obesity CPG, this column indicates the new recommendation(s) to which 

they correspond.
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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2014 

Location

2014 Recommendation Text

2014 

Grade

Recommendation

Category

2020

Rec

Recommendation

. 

NumberPage

8 23 Offer comprehensive lifestyle intervention to overweight patients with dyslipidemia for 

weight loss and to improve lipid levels. B Not reviewed, Deleted – 

9 24

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

intervention for weight loss to overweight patients with degenerative joint disease, nonalcoholic fatty liver disease, and/or obstructive sleep apnea to reduce harms of these 

conditions.

I Reviewed, Newreplaced Recommendation 1

10 25 Offer obese patients comprehensive lifestyle intervention for weight loss to improve lipid 

levels, blood pressure, and/or glucose control. A Reviewed, Newreplaced Recommendation 1

11 25 Offer obese patients comprehensive lifestyle intervention for weight loss to reduce harms of 

obstructive sleep apnea. B Reviewed, Newreplaced Recommendation 1

12 25 Consider offering obese patients comprehensive lifestyle intervention for weight loss to 

reduce harms of degenerative joint disease. C Reviewed, Newreplaced Recommendation 1

13 25 Current evidence is insufficient to support weight loss through comprehensive lifestyle 

intervention for reducing harms of non-alcoholic fatty liver disease. I Reviewed, Newreplaced Recommendation 1

14 26 Reach a shared understanding with overweight and obese patients about the risks of 

overweight and obesity, and the benefits of weight management. EO Not reviewed, Deleted – 

15 27 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 Not reviewed, Deleted – 

16 27 Use motivational interviewing techniques to evoke patient motivation to accept and 

participate in weight loss treatments. EO Reviewed, Deleted – 

17 27 Convey the importance of weight loss and maintenance as a lifelong commitment rather 

than a brief episode of treatment. EO Reviewed, Deleted – 

18 28 Offer patients at least 12 contacts within 12 months of a comprehensive lifestyle 

intervention that combines dietary, physical activity and behavioral strategies. B Reviewed, Newreplaced Recommendation 2 

19 29

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 Reviewed, Newreplaced Recommendation 1

20 30 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 Not reviewed, Deleted – 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 90 of 147

2014 

Location

2014 Recommendation Text

2014 

Grade

Recommendation

Category

2020

Rec

Recommendation

. 

NumberPage

21 30 Re-evaluate the treatment plan for patients who have lost an average of less than 0.5pound 

per week. EO Not reviewed, Deleted – 

22 30 Offer patients who have met their weight loss goals a comprehensive maintenance program 

consisting of behavioral components and ongoing support. B Reviewed, Newreplaced Recommendation 3 

23 31 Offer comprehensive lifestyle interventions for weight loss, in either individual or group 

setting. B Reviewed, Newreplaced Recommendation 1

24 31 Offer telephone-based comprehensive lifestyle intervention for weight loss, either as an 

alternative or an adjunct to face-to-face intervention. B Reviewed, Amended Recommendation 4 

25 31 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 Reviewed, Newreplaced Recommendation 5 

26 32

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 Reviewed, Amended Recommendation 7 

27 32 Offer very-low-calorie diets for weight loss, but only for short durations (12-16 weeks) and 

under close medical supervision. B Not reviewed, Deleted – 

28 32 Offer meal replacements to achieve low-calorie or very low-calorie diets. A Reviewed, Newreplaced Recommendation 8 

29 34 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 Reviewed, Newreplaced Recommendation 6 

30 34 Offer physical activity options that include short intermittent bursts (at least 10minutes) as 

well as longer continuous exercise. A Reviewed, Newreplaced Recommendation 6 

31 34 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 Reviewed, Newreplaced Recommendation 6 

32 34 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 Reviewed, Newreplaced Recommendation 6 

33 36

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 Reviewed, Newreplaced Recommendation 9 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 91 of 147

2014 

Location

2014 Recommendation Text

2014 

Grade

Recommendation

Category

2020

Rec

Recommendation

. 

NumberPage

34 36

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 Reviewed, Newreplaced Recommendation 9 

35 36

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 Reviewed, Deleted – 

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

medication for weight maintenance. B Reviewed, Deleted – 

37 38

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 Reviewed, Newreplaced

Recommendation 

13

38 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 Reviewed, Newreplaced

Recommendation 

13

39 38

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 Reviewed, Amended Recommendation 

14

40 39

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 Not reviewed, 

Deleted – 

41 39

Provide lifelong follow-up after bariatric surgery to monitor adverse effects and 

complications, dietary restrictions, adherence to weight management behaviors, and 

psychological health.

EO Not reviewed, 

Deleted – 
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Appendix E: Participant List

Erin Arra, MS, RD, CSOWM, LD

Primary Care/ALS Dietitian

Facility MOVE! Weight Management Program 

Coordinator

VA Medical Center

Cleveland, OH

Charolotte K. Baldridge, FNP

Family Nurse Practitioner

San Antonio Military Medical Center

Joint Base San Antonio, TX

Elaine Furmaga, PharmD

National Clinical Pharmacy Program Manager

VA Pharmacy Benefits Management Services

Hines, IL

Earl Gaar, MD

Professor of Surgery 

University of Louisville School of Medicine

VA Medical Center

Louisville, KY

Michael G. Goldstein, MD

Associate Chief Consultant

Office of Patient Care Services

VHA National Center for Health Promotion and 

Disease Prevention (NCP)

Durham, NC

Navjit (Nicky) Goraya, MD

Primary Care Physician

Department of Ambulatory Care

VA Medical Center

Washington, D.C.

LTC Sky D. Graybill, MD

Chief of Endocrinology

Brooke Army Medical Center

Join Base San Antonio, TX

Gwen Hampton, PMHCNS-BC

Chief Nurse for Mental Health

Psychiatric Mental Health Clinical Nurse Specialist

Mental Health & Behavioral Sciences

W.G. Bill Hefner VAMC

Salisbury, NC

CPT Zachary M. Leftwich, PharmD

Deputy Chief, Pharmacy Branch

AMEDD C&S Pharmacology Instructor 

Interservice Physician Assistant

Joint Base San Antonio, TX

Stéphanie B. Mayer, MD, MHSc 

Associate Professor

Divisions of Endocrinology and Metabolism

Hunter Homes McGuire Veteran Affairs and VCU

Richmond, VA

COL Stephanie A. Meyer, SP, DrPH, MS, RD, LD, 

CHES

Nutrition Consultant to TSG & Nutrition Program 

Manager

HQ, US Army Medical Command

Joint Base San Antonio, TX

Susan Raffa, PhD

National Program Director

Supervisory Clinical Psychologist 

National Center for Health Promotion and Disease 

Prevention

Veterans Health Administration

Durham, NC

CPT Scott J. Santos, PsyD

Clinical and Aeromedical Psychologist

Behavioral Health Officer

Fort Bragg, NC

COL Jason L. Silvernail, DPT, DSc

Assistant Chief of Staff

Walter Reed National Military Medical Center

Bethesda, MD

CPT Bryan Stepanenko, MD, MPH

Family Practice Physician

Martin Army Community Hospital 

Fort Benning, GA

LTC Christopher L. Tracy, MD, FACP, FACR

Chief, Rheumatology Services

Director, Infusion Treatment Clinic

Womack Army Medical Center

Fort Bragg, NC
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Carol Volante, DNP, APRN-C 

Nurse Practitioner, Cardiology

SLC VA Medical Center

Salt Lake City, UT

CAPT Gordon G. Wisbach, MD, MBA, FACS, 

FAMBS, MC, USN

Director, Metabolic & Bariatric Surgery Program

General Surgery Department

Naval Medical Center San Diego

San Diego, CA
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

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Appendix F: Literature Review Search Terms and Strategy

A. EMBASE and Medline in EMBASE.com Syntax (all questions) 

Set # Concept Strategy

#1 Obesity 'abdominal obesity'/exp OR 'diabetic obesity'/exp OR 'morbid obesity'/exp OR 'obese 

patient'/exp OR 'obesity'/de OR obes*:ab,ti,kw OR overweight:ab,ti,kw

#2 Weight Loss 'body weight loss'/exp OR 'obesity management'/exp OR (((pound* OR weigh* OR 

bmi) NEAR/2 (loos* OR loss* OR off* OR reduc* OR shed*)):ab,ti,kw)

#3 Weight 

Maintenance

('body weight loss'/exp OR obes*:ab,ti,kw OR 'obesity'/de OR 'obesity 

management'/exp OR 'weight loss':ti OR 'weight loss'/exp) AND ('body weight 

maintenance'/exp OR longterm*:ab,ti,kw OR 'long-term':ab,ti,kw OR 'maintenance 

therapy'/exp OR maintain*:ab,ti,kw OR maintenance*:ab,ti,kw OR sustain*:ab,ti,kw) 

OR (((keep* OR maintain* OR maintenance OR sustain* OR longterm* OR 'long-term') 

NEAR/3 (weigh* OR pound* OR bmi) NEAR/3 (loos* OR loss* OR off OR reduc* OR 

shed*)):ab,ti,kw)

#4 Behavioral 

Treatments 

(Psychological) 

'behavior therapy'/exp OR 'cognitive behavioral therapy'/exp OR 'cognitive 

therapy'/exp OR 'counseling'/exp OR 'dialectical behavior therapy'/exp OR 'food 

addiction'/exp OR 'motivation enhancement therapy' OR 'patient counseling'/exp OR 

'problem solving therapy'/exp OR 'psychiatric treatment'/exp OR 'psychotherapy'/exp 

OR (((behavior* OR behaviour* OR cognitive OR dialectical OR emotion* OR 'mental 

health' OR mindful* OR psych*) NEAR/2 (coach* OR counsel* OR intervention* OR 

manag* OR support* OR therap* OR treat* OR train*)):ab,ti,kw) OR ((food* NEAR/2 

addict*):ab,ti,kw) OR psychotherap*:ab,ti,kw

#5 Behavioral 

Treatments

(Lifestyle 

Modifications)

'behavioral economics'/exp OR 'behavior modification'/exp OR 'dietary 

compliance'/exp OR 'eating habit'/exp OR 'environmental change'/exp OR 'feeding 

behavior'/exp OR 'food preference'/exp OR 'food seeking behavior'/exp OR 'goal 

attainment'/exp OR 'habit'/exp OR 'health behavior'/exp OR 'healthy lifestyle'/exp OR 

'lifelong learning'/exp OR 'lifestyle modification'/exp OR 'motivation'/exp OR 

'motivational interviewing'/exp OR 'patient education'/exp OR 'portion size'/exp OR 

'problem solving'/exp OR 'social learning'/exp OR 'social learning theory'/exp OR 

'stress management'/exp OR (((adjust* OR adapt* OR adopt* OR alter* OR chang* OR 

health* OR improv* OR modif* OR new OR overhaul*) NEAR/2 (activ* OR behav* OR 

environment* OR exercis* OR habit* OR health* OR lifestyle* OR pattern* OR 

physical* OR regimen* OR routine*)):ab,ti,kw) OR ((behav* NEAR/2 (economic* OR 

theor*)):ab,ti,kw) OR ((motivat* NEAR/2 interview*):ab,ti,kw) OR ((portion* NEAR/2 

(control* OR size*)):ab,ti,kw) OR (((collaborat* OR combin* OR comprehensiv* OR 

customi* OR group* OR individuali* OR integrat* OR interdisciplin* OR multi* OR 

personali* OR speciali* OR tailor*) NEAR/2 (approach* OR care OR component* OR 

deliver* OR method* OR modalit* OR plan* OR program* OR regimen* OR strateg* 

OR support* OR technique*)):ab,ti,kw) OR ((social* NEAR/2 learn*):ab,ti,kw) OR 

comprehensiv*:ti OR group*:ti OR program*:ti OR service*:ti OR transtheoretical*
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 95 of 147

Set # Concept Strategy

#6 Modes of 

Intervention

'face to face support group'/exp OR 'group therapy'/exp OR 'internet'/exp OR 'mobile 

application'/exp OR 'mobile health application'/exp OR 'mobile phone'/exp OR 'online 

monitoring'/exp OR 'self care'/exp OR 'self monitoring'/exp OR 'self report'/exp OR 

'social media'/exp OR 'support group'/exp OR 'technology assisted health coaching' 

OR 'teleconsultation'/exp OR 'telehealth'/exp OR 'telemedicine'/exp OR 

'telemonitoring'/exp OR 'text messaging'/exp OR 'videorecording'/exp OR 

'workplace'/exp OR 'weight loss program'/exp OR android*:ab,ti,kw OR app:ab,ti,kw 

OR apps:ab,ti,kw OR 'clinical video telehealth':ab,ti,kw OR cvt:ab,ti OR 

device*:ab,ti,kw OR digital*:ab,ti,kw OR electronic*:ab,ti,kw OR 'e-mail':ab,ti,kw OR 

email:ab,ti,kw OR 'face-to-face':ab,ti,kw OR facebook:ab,ti,kw OR internet:ab,ti,kw OR 

iphone*:ab,ti,kw OR 'mobile health':ab,ti,kw OR mhealth:ab,ti,kw OR 'm 

health':ab,ti,kw OR 'one-on-one':ab,ti,kw OR online:ab,ti,kw OR phone*:ab,ti,kw OR 

'in person':ab,ti,kw OR 'in-person':ab,ti,kw OR 'smart-phone':ab,ti,kw OR 

smartphone*:ab,ti,kw OR 'smart watch':ab,ti,kw OR smartwatch:ab,ti,kw OR 'short 

message service':ab,ti,kw OR sms:ab,ti,kw OR technolog*:ab,ti,kw OR 

telephone*:ab,ti,kw OR text*:ab,ti,kw OR video*:ab,ti,kw OR virtual*:ab,ti,kw OR 

wearable:ab,ti,kw OR web:ab,ti,kw OR 'web site*':ab,ti,kw OR website*:ab,ti,kw OR 

wireless*:ab,ti,kw OR workplace:ab,ti,kw OR ((self* NEAR/2 (actuali* OR administer* 

OR care OR deliver* OR direct* OR monitor* OR report*)):ab,ti,kw) OR (((shar* OR 

group*) NEAR/2 appointment*):ab,ti,kw) OR (((employ* OR work* OR office*) NEAR/2 

(based OR environment* OR place OR setting* OR space*)):ab,ti,kw) 

#7 Dietary 

Approaches

'atkins diet'/exp OR 'dash diet'/exp OR 'fasting'/exp OR 'ketogenic diet'/exp OR 'low 

calorie diet'/exp OR 'low carbohydrate diet'/exp OR 'low fat diet'/exp OR 

'mediterranean diet'/exp OR 'paleolithic diet'/exp OR 'time restricted feeding'/exp OR 

'very low calorie diet'/exp OR 'very low calorie ketogenic diet'/exp OR (((atkins* OR 

dash OR keto* OR mediterranean* OR paleo* OR 'south beach') NEAR/3 (ate OR 

consum* OR diet* OR eat* OR feed* OR food* OR plan* OR regimen* OR 

style*)):ab,ti,kw) OR (((low* OR minim* OR reduc* OR restrict*) NEAR/2 (calorie* OR 

carb* OR fat*)):ab,ti,kw) OR ((meal* NEAR/2 (replac* OR substitut*)):ab,ti,kw) OR 

((time* NEAR/2 restrict*):ab,ti,kw) OR 'dietary approaches to stop 

hypertension':ab,ti,kw OR fast*:ab,ti,kw

#8 Physical 

Activity

'aerobic exercise'/exp OR 'cardio respiratory fitness' OR 'exercise'/exp OR 'exercise 

intensity'/exp OR 'fitness'/exp OR 'high intensity interval training'/exp OR 

'jogging'/exp OR 'martial art'/exp OR 'moderate intensity continuous training'/exp OR 

'physical activity'/exp OR 'physical activity, capacity and performance'/exp OR 

'pilates'/exp OR 'resistance training'/exp OR 'stretching exercise'/exp OR 

'swimming'/exp OR 'tai chi'/exp OR 'training'/exp OR 'treadmill'/exp OR 'treadmill 

exercise'/exp OR 'walking'/exp OR 'weight lifting'/exp OR 'yoga'/exp OR 

bicycle*:ab,ti,kw OR bike*:ab,ti,kw OR biking:ab,ti,kw OR cardio:ab,ti,kw OR 

cycling:ab,ti,kw OR exercis*:ab,ti,kw OR fitness:ab,ti,kw OR jog*:ab,ti,kw OR 

hike*:ab,ti,kw OR hiking:ab,ti,kw OR 'martial art*':ab,ti,kw OR pilates:ab,ti,kw OR 

ran:ab,ti,kw OR run:ab,ti,kw OR runner:ab,ti,kw OR runs:ab,ti,kw OR running:ab,ti,kw 

OR sport*:ab,ti,kw OR swim*:ab,ti,kw OR 'tai chi':ab,ti,kw OR treadmill*:ab,ti,kw OR 

walk*:ab,ti,kw OR 'weight training':ab,ti,kw OR workout*:ab,ti,kw OR ((work NEXT/1 

out*):ab,ti,kw) OR yoga:ab,ti,kw OR (((aerobic* OR physical*) NEAR/2 (exercis* OR 

fitness)):ab,ti,kw) OR (((activ* OR exercis* OR fitness* OR physical* OR train*) NEAR/2 

(boost* OR duration* OR encourag* OR engag* OR enhance* OR frequen* OR 

improv* OR increas* OR intens* OR interval* OR partake* OR participat* OR plan* OR 

promot* OR regimen* OR regular* OR routine* OR schedul*)):ab,ti,kw) OR (((desk* 

OR workstation* OR 'work station*') NEAR/2 (activ* OR adjust* OR stand*)):ab,ti,kw)
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 96 of 147

Set # Concept Strategy

#9 Pharmacother

apy 

'amfebutamone'/exp OR 'amfebutamone plus naltrexone'/exp OR 'anorexic 

agent'/exp OR 'antiobesity agent'/exp OR 'benzphetamine'/exp OR 'liraglutide'/exp OR 

'lorcaserin'/exp OR 'naltrexone'/exp OR 'phendimetrazine'/exp OR 'phentermine'/exp 

OR 'phentermine plus topiramate'/exp OR 'sibutramine'/exp OR 

'tetrahydrolipstatin'/exp OR 'topiramate'/exp OR alli:ab,ti,kw OR 

amfebutamone*:ab,ti,kw OR belviq*:ab,ti,kw OR benzphetamine:ab,ti,kw OR 

bupropion*:ab,ti,kw OR contrave*:ab,ti,kw OR orlistat*:ab,ti,kw OR 

diethylpropion:ab,ti,kw OR liraglutide*:ab,ti,kw OR lorcaserin*:ab,ti,kw OR

naltrexone*:ab,ti,kw OR phendimetrazine:ab,ti,kw OR phentermine*:ab,ti,kw OR 

qsymia*:ab,ti,kw OR saxenda*:ab,ti,kw OR sibutramine*:ab,ti,kw OR 

tetrahydrolipstatin*:ab,ti,kw OR topiramate*:ab,ti,kw OR victoza:ab,ti,kw OR 

wellbutrin*:ab,ti,kw OR xenical*:ab,ti,kw OR zyban*:ab,ti,kw OR 'appetite 

suppressant*':ab,ti,kw OR ((('anti-obesity' OR antiobesity OR 'weight loss') NEAR/1 

(agent* OR drug* OR medicat* OR pharm*)):ab,ti,kw)

#10 Dietary 

Supplements/

Nutraceutical

'beta glucan'/exp OR caffeine/exp OR 'calcium sulfate'/exp OR capsaicin/exp OR 

carnitine/exp OR 'chinese medicine'/exp OR chitin/exp OR chitosan/exp OR 

chromium/exp OR cinnamon/exp OR 'cinnamon extract'/exp OR 'cissus 

quadrangularis'/exp OR cola/exp OR 'conjugated linoleic acid'/exp OR 'dietary 

fiber'/exp OR 'dietary supplement'/exp OR 'ephedra sinica'/exp OR fucoxanthin/exp 

OR 'garcinia cambogia'/exp OR 'garcinia cambogia extract'/exp OR germander/exp OR 

'guar gum'/exp OR ginseng/exp OR guarana/exp OR 'guarana extract'/exp OR 

'herbaceous agent'/exp OR hoodia/exp OR 'hydroxycitric acid'/exp OR 'ilex 

paraguariensis'/exp OR 'mannan'/exp OR 'mineral supplementation'/exp OR 

'nutraceutical'/exp OR 'phaseolus vulgaris'/exp OR 'probiotic agent'/exp OR 'pyruvic 

acid'/exp OR sinecatechins/exp OR 'sour orange'/exp OR 'sour orange extract'/exp OR 

supplementation/exp OR trigonella/exp OR 'vitamin d'/exp OR 'vitamin 

supplementation'/exp OR yohimbine/exp OR (((diet* OR calcium* OR fiber* OR fibre* 

OR herb* OR mineral* OR nutrient* OR nutrition* OR vitamin*) NEAR/2 

supplement*):ab,ti,kw) OR 'african mango':ab,ti,kw OR 'beta-glucan*':ab,ti,kw OR 

'bitter orange':ab,ti,kw OR caffeine:ab,ti,kw OR calcium:ab,ti,kw OR 'camellia 

sinensis':ab,ti,kw OR capsaicin:ab,ti,kw OR carnitine:ab,ti,kw OR chitin:ab,ti,kw OR 

chitosan:ab,ti,kw OR cinnamon:ab,ti,kw OR 'cissus quadrangularis':ab,ti,kw OR 'citrus 

aurantium':ab,ti,kw OR 'coffea arabica':ab,ti,kw OR 'coffea canephora':ab,ti,kw OR 

'coffea robusta':ab,ti,kw OR 'cola nut*':ab,ti,kw OR chromium:ab,ti,kw OR 'coleus 

forskohlii':ab,ti,kw OR 'conjugated linoleic acid':ab,ti,kw OR 'cumin':ab,ti,kw OR 

'cuminum cyminum l':ab,ti,kw OR dandelion*:ab,ti,kw OR forskolin ab,ti,kw OR 

fenugreek ab,ti,kw OR fucoxanthin:ab,ti,kw OR 'garcinia cambogia':ab,ti,kw OR 

germander:ab,ti,kw OR ginseng:ab,ti,kw OR glucomannan:ab,ti,kw OR 'green coffee

bean extract':ab,ti,kw OR 'green tea':ab,ti,kw OR 'guar gum':ab,ti,kw OR 

guarana:ab,ti,kw OR 'gymnema sylvestre'/exp OR 'gymnema sylvestre extract'/exp OR 

'gymnema sylvestre':ab,ti,kw OR hoodia:ab,ti,kw OR 'hydroxycitric acid':ab,ti,kw OR 

'irvingia gabonensis':ab,ti,kw OR kola:ab,ti,kw OR konjac:ab,ti,kw OR 'lcarnitine':ab,ti,kw OR 'ma huang':ab,ti,kw OR mannan:ab,ti,kw OR mate:ab,ti,kw OR 

nutraceutical*:ab,ti,kw OR oregano:ab,ti,kw OR 'phaseolus vulgaris':ab,ti,kw OR 

probiotic*:ab,ti,kw OR pyruvate:ab,ti,kw OR 'raspberry ketone*':ab,ti,kw OR 

rosemary:ab,ti,kw OR 'rosmarinus officinalis extract'/exp OR 'sour orange':ab,ti,kw OR 

teucrium:ab,ti,kw OR trigonella:ab,ti,kw OR 'vitamin d':ab,ti,kw OR 'white kidney 

bean*':ab,ti,kw OR 'yerba mate':ab,ti,kw OR yohimbe:ab,ti,kw
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 97 of 147

Set # Concept Strategy

#11 Bariatric 

Surgery

'bariatric surgery'/exp OR 'biliopancreatic bypass'/exp OR 'gastric banding'/exp OR 

'endoscopic gastric plication' OR 'gastric plication' OR 'gastric bypass surgery'/exp OR 

'laparoscopic gastric plication' 'laparoscopic sleeve gastrectomy'/exp OR 'laparoscopic 

surgery'/exp OR 'percutaneous endoscopic gastrostomy'/exp OR 'roux y 

anastomosis'/exp OR 'roux-en-y gastric bypass'/exp OR 'sleeve gastrectomy'/exp OR 

'biliopancreatic diversion':ab,ti,kw OR 'biliopancreatic diversion with duodenal 

switch':ab,ti,kw OR 'bpd/ds':ab,ti,kw OR 'bpd-ds':ab,ti,kw OR 'closed loop gastric 

electrical stimulation':ab,ti,kw OR 'duodenal jejunal':ab,ti,kw OR 'duodenal 

switch':ab,ti,kw OR 'gastric bypass':ab,ti,kw OR 'gastric by-pass':ab,ti,kw OR 'gastric 

sleeve':ab,ti,kw OR 'sleeve gastrectomy':ab,ti,kw OR 'roux-n-y':ab,ti,kw OR 'roux-eny':ab,ti,kw OR rygb:ab,ti,kw OR (((bariatric* OR metabolic OR obes* OR 'weight loss' 

OR 'weight reduction') NEAR/3 (operat* OR procedur* OR surg*)):ab,ti,kw) OR 

((laparoscopic* NEAR/3 band*):ab,ti,kw)

#12 FDA-approved 

Weight Loss 

Devices

'digestive surgical device'/exp OR 'gastric balloon'/exp OR 'gastric band'/exp OR 

'gastric pacemaker'/exp OR 'implanted vagus nerve stimulator'/exp OR 'stomach 

bypass device'/exp OR 'weight loss device*':ab,ti,kw OR abiliti:ab,ti,kw OR 

aspireassist*:ab,ti,kw OR elipse*:ab,ti,kw OR endobarrier*:ab,ti,kw OR 

enterra*:ab,ti,kw OR heliosphere*:ab,ti,kw OR 'lap band*':ab,ti,kw OR 

lapband*:ab,ti,kw OR maestro*:ab,ti,kw OR obalon*:ab,ti,kw OR orbera*:ab,ti,kw OR 

reshape*:ab,ti,kw OR smartbyte*:ab,ti,kw OR vbloc*:ab,ti,kw OR (((balloon* OR 

band* OR bypass* OR 'by-pass' OR electrostimulat* OR emptying OR fda OR 'food and 

drug administration' OR gastric* OR 'intra-gastric*' OR intragastric* OR 

neurostimulat* OR sleeve* OR stimulat*) NEAR/3 (device* OR implant* OR 

system*)):ab,ti,kw) OR (((nerve* OR vagus OR vagal) NEAR/2 block*):ab,ti,kw)

#13 Study 

Designs/

Publication 

Types/ 

Date and 

Language 

Restrictions

[english]/lim AND [2013-2019]/py NOT (abstract:nc OR annual:nc OR 'book'/exp OR 

'case report'/exp OR conference:nc OR 'conference abstract':it OR 'conference 

paper'/exp OR 'conference paper':it OR 'conference proceeding':pt OR 'conference 

review':it OR congress:nc OR 'editorial'/exp OR editorial:it OR 'erratum'/exp OR 

letter:it OR 'note'/exp OR note:it OR meeting:nc OR sessions:nc OR 'short survey'/exp 

OR symposium:nc) AND ([cochrane review]/lim OR 'meta analysis'/de OR 

metaanaly*:ab,ti,kw OR ((meta* NEXT/1 anal*):ab,ti,kw) OR 'randomized controlled 

trial'/de OR random*:ti OR pool*:ab,ti,kw OR systematic*:ti OR 'systematic review'/de 

OR 'systematic review*':ab,ti,kw)

#14 Remove 

Pediatric/

Pregnant/and 

Animal 

Populations

(abortion*:ti OR abortus:ti OR adolescen*:ti OR ((ante* OR post* OR pre*) NEXT/1 

(adolesc* OR natal* OR partum)):ti OR antenatal*:ti OR antepartum:ti OR baby:ti OR 

babies:ti OR birth*:ti OR boy*:ti OR (breast* NEXT/1 (fed* OR feed*)):ti OR child*:ti 

OR classroom*:ti OR 'day care':ti OR ectopic:ti OR embryo*:ti OR fetal:ti OR fetus:ti 

OR gestation*:ti OR girl*:ti OR gravid*:ti OR infan*:ti OR juvenil*:ti OR 'in utero':ti OR 

kinder*:ti OR kid:ti OR kids:ti OR maternal:ti OR maternity:ti OR miscarry:ti OR 

miscarriage*:ti OR multigravid*:ti OR multipar*:ti OR multip:ti OR neonat*:ti OR 

newborn*:ti OR nullipar*:ti OR nurser*:ti OR infan*:ti OR obstaetric*:ti OR obstetric*:ti 

OR paediatric*:ti OR pediatric*:ti OR perinat* OR (post* NEXT/1 (natal* OR 

partum*)):ti OR postnatal*:ti OR postpartum:ti OR (pre* NEXT/1 (adolesc* OR matur* 

OR natal* OR pubes* OR teen* OR term*)):ti OR preadolesc*:ti OR preeclamps*:ti OR 

pregnan*:ti OR prematur*:ti OR prenatal*:ti OR prepubesc*:ti OR preschool*:ti OR 

preteen*:ti OR preterm*:ti OR primigravid*:ti OR primip*:ti OR pubert*:ti OR 

pubesc*:ti OR school*:ti OR secundigravid*:ti OR stillbirth*:ti OR teen*:ti OR 

toddler*:ti OR trimester*:ti OR young*:ti OR youth*:ti OR equine* OR canine* OR cat 

OR cats OR dog* OR feline OR horse* OR mice OR mouse OR ovine OR pig OR pigs OR 

porcine OR rabbit* OR rat OR rodent* OR sheep OR swine)

#15 KQ1 (#1 AND #2) AND (#4 OR #5) AND #13 NOT #14

What are the benefits and harms of weight loss behavioral interventions on weight status 

and health outcomes?
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 98 of 147

Set # Concept Strategy

#16 KQ2 #3 AND (#4 OR #5) AND #13 NOT #14

What is the effectiveness (versus no intervention, wait list, intervention unrelated to 

weight), comparative effectiveness (versus another weight maintenance behavioral 

treatment), and safety of weight maintenance behavioral treatments on weight 

maintenance starting after initial weight loss? Does this vary with intervention intensity 

(number of contacts) or intervention duration?

#17 KQ3 (#2 OR #3) AND #6 AND #13 NOT #14

What is the comparative effectiveness of different modes of delivering behavioral weight 

loss or maintenance interventions? Including:

Technology / virtual versus in-person

Group versus individual

Self-directed versus professionally-directed

Individualized / tailored versus standard

#18 KQ4 #1 AND (#2 OR #3) AND #7 AND #13 NOT #14

What is the comparative effectiveness and safety of various dietary approaches on weight 

status and health outcomes? Including:

Different macronutrient compositions: low-carb / Atkins / South Beach / ketogenic versus

low-fat versus balanced low calorie 

Eating plans: DASH, Mediterranean, paleo

Meal replacement

Intermittent fasting / time-restricted eating

Very low calorie diets

#19 KQ5 #1 AND (#2 OR #3) AND #8 AND #13 NOT #14

What are the benefits and harms of physical activity on initial weight loss and long-term 

weight status? Does this vary with physical activity type (e.g., aerobic, resistance) or 

intensity (e.g., frequency, duration)?

#20 KQ6 AND KQ7 

(Searched 

together)

(#1 OR #2 OR #3) AND #9 AND #13 NOT #14

What are the benefits and harms of short term administration of FDA-approved weight 

loss pharmacotherapy on initial (short-term) weight loss and long-term weight status?

What are the benefits and harms of chronic administration of FDA-approved weight loss 

pharmacotherapy on weight maintenance and health outcomes? 

#21 KQ8 (#1 OR #2 OR #3) AND #10 AND #13 NOT #14

What are the benefits and harms of dietary supplement / nutraceutical on initial weight 

loss and long-term weight status?

#22 KQ9 AND 

KQ10

(Searched 

together) 

(#1 OR #2 OR #3) AND #11 AND #13 NOT #14

What are the benefits and harms of bariatric surgery on initial weight loss, long-term 

weight status, health outcomes, and comorbid conditions (e.g., diabetes, hypertension, or 

osteoarthritis? Does this vary by:

Patient initial BMI: including 30-35, 35-40, >40

Patient initial comorbid conditions: including diabetes, hypertension, osteoarthritis

Patient age or “physiological age”

What is the comparative effectiveness of different type of bariatric procedures on short 

and long-term weight loss, health outcomes and comorbid conditions
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 99 of 147

Set # Concept Strategy

#23 KQ11 and 

KQ12

(Searched 

together)

(#1 OR #2 OR #3) AND #12 AND #13 NOT #14

What benefits and harms of FDA-approved weight loss devices on initial weight loss, longterm weight status, health outcomes, and comorbid conditions (e.g., diabetes, 

hypertension, or osteoarthritis)? Does this vary by:

Patient initial BMI: including 30-35, 35-40, >40

Patient initial comorbid conditions including diabetes, hypertension, osteoarthritis

Patient age or “physiological age”

What is the comparative effectiveness and harms od FDA-approved weight loss devices on 

short and long-term weight loss, health outcomes and comorbid conditions

#24 Combine 

Concepts

#15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 

B. PsycINFO in OVID Syntax (for KQ1, KQ2, and KQ3 only)

Set # Concept Strategy 

#1 Obesity exp obesity/ OR exp overweight/ OR (obes* OR overweight).mp

#2 Weight Loss exp weight loss/ OR ((obes* OR overweight) ADJ2 manag*).mp. OR ((pound* OR 

weigh* OR bmi) ADJ2 (loos* OR loss* OR off* OR reduc* OR shed*)).mp.

#3 Weight 

Maintenance

(exp obesity/ OR exp overweight/ OR exp weight loss/ OR obes*.ab,ti. OR weight 

loss.ab,ti.) AND (exp maintenance therapy/ OR exp weight control/ OR longterm.ab,ti 

OR long-term.ab,ti OR maintain*.ab,ti OR maintenance*.ab,ti. OR sustain*.ab,ti.) OR 

((keep* OR maintain* OR maintenance OR sustain* OR longterm* OR long-term) ADJ3 

(weigh* OR pound* OR bmi) ADJ3 (loos* OR loss* OR off OR reduc* OR shed*)).ab,ti.

#4 Behavioral 

Treatments 

(Psychological) 

exp cognitive behavior therapy/ OR exp cognitive therapy/ OR exp counseling/ OR exp 

dialectical behavior therapy/ OR exp mental health services/ OR exp psychotherapy/ 

OR exp problem solving/ OR exp psychotherapy/ OR ((behavior* OR behaviour* OR 

cognitive OR dialectical OR emotion* OR "mental health" OR mindful* OR psych*) 

ADJ2 (coach* OR counsel* OR intervention* OR manag* OR support* OR therap* OR 

treat* OR train*)).ab,ti. OR (food* ADJ2 addict*).ab,ti. OR psychotherap*.ab,ti.

#5 Behavioral 

Treatments

(Lifestyle 

Modifications)

exp attitude change/ OR exp behavior change/ OR exp behavior modification/ OR exp 

behavioral economics/ OR exp client education/ OR exp eating behavior/ OR exp food

intake/ OR exp food preferences/ OR exp goals/ OR exp habits/ OR exp health 

behavior/ OR exp lifestyle/ OR exp lifestyle changes/ OR exp motivation/ OR exp 

motivational interviewing/ OR exp problem solving/ OR exp social learning/exp OR exp 

stress management/ OR exp transtheoretical model/ OR exp treatment compliance/ 

OR ((adjust* OR adapt* OR adopt* OR alter* OR chang* OR health* OR improv* OR 

modif* OR new OR overhaul*) ADJ2 (activ* OR behav* OR environment* OR exercis* 

OR habit* OR health* OR lifestyle* OR pattern* OR physical* OR regimen* OR 

routine*)).ab,ti. OR (behav* ADJ2 (economic* OR theor*)).ab,ti. OR (motivat* ADJ2 

interview*).ab,ti. OR (portion* ADJ2 (control* OR size*)).ab,ti. OR ((collaborat* OR 

combin* OR comprehensiv* OR customi* OR group* OR individuali* OR integrat* OR 

interdisciplin* OR multi* OR personali* OR speciali* OR tailor*) ADJ2 (approach* OR 

care OR component* OR deliver* OR method* OR modalit* OR plan* OR program* OR 

regimen* OR strateg* OR support* OR technique*)).ab,ti. OR (social* ADJ2 

learn*).ab,ti. OR comprehensiv*.ti. OR group*.ti. OR program*.ti. OR service*.ti. OR 

transtheoretical*.ab,ti.
VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity

July 2020 Page 100 of 147

Set # Concept Strategy 

#6 Modes of 

Intervention

exp cellular phones/ OR exp digital video/ OR exp group psychotherapy/ OR exp 

internet/ OR exp internet usage/ OR exp mobile devices/ OR exp monitoring/ OR exp 

self-report/ OR exp self monitoring/ OR exp social media/ OR exp support groups/ OR 

exp technology/ OR exp teleconferencing/ OR exp telemedicine/ OR exp text 

messaging/ OR exp workplace intervention/ OR (android* OR app OR apps OR "clinical 

video telehealth" OR cvt OR device* OR digital* OR electronic* OR "e-mail" OR email 

OR "face-to-face" OR facebook OR internet OR iphone* OR "mobile health" OR 

mhealth OR "m health" OR "one-on-one" OR online OR phone* OR "in person" OR "inperson" OR "smart-phone" OR smartphone* OR "smart watch" OR smartwatch OR 

"short message service" OR sms OR technolog* OR telephone* OR text* OR video* OR 

virtual* OR wearable OR web OR "web site*" OR website* OR wireless* OR 

workplace).ab,ti. OR (self* adj2 (actuali* OR administer* OR care OR deliver* OR 

direct* OR monitor* OR report*)).ab,ti. OR ((shar* OR group*) adj2 

appointment*).ab,ti. OR ((employ* OR work* OR office*) adj2 (based OR 

environment* OR place OR setting* OR space*)).ab,ti.

#7 Study 

Designs/

Publication 

Types/ 

Date and 

Language 

Restrictions

(("randomized controlled trial*" OR "systematic review*" OR "meta analysis" OR "meta 

analyses" OR metaanaly*).ab,ti. OR (random* OR systematic*).ab,ti.) NOT (exp case 

report/ OR (authored book OR book OR edited book OR encyclopedia OR dissertation 

abstract OR electronic collection).pt. OR (abstract collection OR bibliography OR chapter 

OR clarification OR "column/opinion" OR "comment/reply" OR dissertation OR editorial 

OR encyclopedia entry OR "erratum/correction" OR letter OR obituary OR poetry OR 

publication information OR reprint OR retraction OR review-book OR review-media OR 

review-software & other).dt.)

#8 Remove 

Pediatric/Preg

nant/and 

Animal 

Populations

((abortion* OR abortus OR adolescen* OR antenatal* OR antepartum OR baby OR 

babies OR birth* OR boy* OR child* OR classroom* OR day care OR ectopic OR 

embryo* OR fetal OR fetus OR gestation* OR girl* OR gravid* OR infan* OR juvenil* 

OR in utero OR kinder* OR kid OR kids OR maternal OR maternity OR miscarry OR 

miscarriage* OR multigravid* OR multipar* OR multip OR neonat* OR newborn* OR 

nullipar* OR nurser* OR infan* OR obstaetric* OR obstetric* OR paediatric* OR 

pediatric* OR perinat* OR postnatal* OR postpartum OR preadolesc* OR preeclamps* 

OR pregnan* OR prematur* OR prenatal* OR prepubesc* OR preschool* OR preteen* 

OR preterm* OR primigravid* OR primip* OR pubert* OR pubesc* OR school* OR 

secundigravid* OR stillbirth* OR teen* OR toddler* OR trimester* OR young* OR

youth*).ti. OR (equine* OR canine* OR cat OR cats OR dog* OR feline OR horse* OR 

mice OR mouse OR ovine OR pig OR pigs OR porcine OR rabbit* OR rat OR rodent* OR 

sheep OR swine).ab,ti OR ((ante* OR post* OR pre*) ADJ1 (adolesc* OR natal* OR 

partum)).ti. OR (breast* ADJ1 (fed* OR feed*)).ti. OR (post* ADJ1 (natal* OR 

partum*)).ti. OR (pre* ADJ1 (adolesc* OR matur* OR natal* OR pubes* OR teen* OR 

term*)).ti.)

#9 Combine 

Concepts and 

Apply Date 

and Language 

Limits

7 NOT 8

#10 Apply Date 

and Language 

Limits

limit 9 to (english language and yr="2013 -Current")

#11 KQ1 (1 AND 2) AND (4 OR 5) AND 10

What are the benefits AND harms of weight loss behavioral interventions on weight status 

AND health outcomes?
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July 2020 Page 101 of 147

Set # Concept Strategy 

#12 KQ2 3 AND (4 OR 5) AND 10

What is the effectiveness (versus no intervention, wait list, intervention unrelated to 

weight), comparative effectiveness (versus another weight maintenance behavioral 

treatment), AND safety of weight maintenance behavioral treatments on weight 

maintenance starting after initial weight loss? Does this vary with intervention intensity 

(number of contacts) or intervention duration?

#13 KQ3 (2 OR 3) AND 6 AND 10

What is the comparative effectiveness of different modes of delivering behavioral weight 

loss or maintenance interventions? Including:

Technology / virtual versus in-person

Group versus individual

Self-directed versus professionally-directed

Individualized / tailored versus standard

#14 Combine 

Concepts

11 OR 12 OR 13

#15 Remove 

Duplicates 

from 14
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Appendix G: Dietary Approaches

For all the diets listed below, formal consultation with a registered dietitian is advised.

The Academy of Nutrition and Dietetics (Academy) Evidence Analysis Library (EAL) Adult Weight 

Management Guideline (2014) [218] found strong evidence that weight loss, weight maintenance, and a 

reduced-calorie diet should be part of a comprehensive weight management program that also includes 

“increasing physical activity and behavioral strategies.” This is supported by the 2016 Academy Position 

Statement for treating overweight and obesity.[219] The Academy EAL guideline further states that, “the 

registered dietitian should prescribe an individualized diet, including patient preferences and health status, 

to achieve and maintain nutrient adequacy and reduce caloric intake,” and that calorie reduction can be 

achieved by one of the following: 

A. Caloric Recommendations

• A reduction to 1,200 to 1,500 kcal per day for women and 1,500 to 1,800 kcal per day for men, 

adjusted based on the individual’s body weight;

• A 500 to 750 kcal energy deficit/negative energy balance per day; or

• Restriction of certain food types, such as high carbohydrate foods, low fiber foods, or high-fat 

foods to create an energy deficit/negative energy balance by reducing food consumption [218] 

The National Heart, Lung, and Blood Institute’s Obesity Expert Panel echoes the Academy EAL, adding that 

a 30% energy deficit may be used as the basis for estimating calorie reduction versus using the 500 – 750 

kcal range to estimate the calorie prescription to achieve negative energy balance.[220] Many different 

dietary approaches can be used to achieve a negative energy balance/calorie reduction. The systematic 

evidence review conducted for this CPG update did not yield any exhaustive review of the various dietary 

approaches that may be considered for weight loss; therefore, the dietary approaches described in this 

appendix do not encompass the totality of evidence-based approaches that a patient and healthcare 

provider may consider. The Academy Position Statement recommends shared decision making to 

determine the specific dietary approach that considers and addresses patients’ “preferences, health, and 

nutrient status.”[219] 

Table G-1 provides a summary of dietary approaches for which evidence exists to support weight loss 

when accompanied by an energy deficit/negative energy balance. For all the diets listed below, formal 

consultation with a registered dietitian is advised.
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Table G-1. Dietary Approaches to Support Weight Loss

Dietary Approaches Description

Mediterranean dieta

[221] 

• A dietary pattern that is focused on plant-based food consumption, which includes 

vegetables, fruits, whole grains, nuts and seeds; minimally processed foods; olive 

oil as the primary fat source; low to moderate amounts of dairy, fish, and poultry; 

and minimal amounts of red meat.[220] This dietary approach is evaluated based 

on the intake of specific food groups with positive health outcomes rather than 

meeting specific nutrient standards.[221] 

• An SR of five RCTs (n=998) that compared the Mediterranean diet to lowcarbohydrate, low-fat, or the American Diabetes Association diet found that at 12 

and 48 months, participants on the Mediterranean diet lost an average of between 

3.8 and 10.1 kg, lost more weight at ≥12 months, and lost a comparable amount of 

weight to the remaining diets.[222] 

Dietary Approaches to 

Stop Hypertension 

(DASH) dietb [219] 

• The DASH diet is a dietary pattern that focuses on reducing hypertension and 

promotes the consumption of vegetables, fruits, whole grains, nuts, legumes, 

seeds, low-fat dairy foods, and lean meats. It also limits the consumption of sugarsweetened foods and beverages, sodium, caffeine, and alcohol. 

• The DASH Diet is low in saturated fats and rich in potassium, calcium, magnesium, 

dietary fiber, and protein. The sodium levels are between 1,500-2,300 mg daily. 

This dietary approach is recognized by the USDA as an ideal eating plan for 

Americans.

• A 2016 SR and meta-analysis of 10 studies (n=1,291) found that participants who 

followed the DASH diet lost more weight than controls (WMD: -1.42 kg), and that 

DASH diet with and without energy restriction yielded statistically significant weight 

loss (WMD: -2.27 kg and -0.85 kg respectively). Studies varied between 8 and 24 

weeks.[142] 

Low-carbohydrate diet

• The definition of low carbohydrate varies based on the specific dietary approach.

• The Dietary Guidelines for Americans recommends that 45 – 65% of calories each 

day come from carbohydrate and sets the RDA at 130 g.[221] Therefore, any 

recommendation that is less than 130 g of carbohydrate may be considered low

carbohydrate. 

• Adherence to modest carbohydrate reductions may be more achievable than more 

strict carbohydrate reductions, while still promoting weight loss.[134,138,223] 

• Low-carbohydrate ketogenic diets (<50 g carbohydrate) are effective for weight 

loss, but this dietary approach may result in: headache, upset stomach, fatigue and 

dizzy spells (also called the “keto flu”); constipation; and may require micronutrient 

supplementation given limitations of vitamin and mineral-rich carbohydratecontaining foods.[123,130,144,224] 

• Typically, low-carbohydrate, ketogenic diets (induction phase of <20 g of 

carbohydrate) may be best implemented under medical supervision with attention 

paid to lifestyle and need for monitoring medications and comorbidities. 

Medications, especially diuretics and antiglycemic agents, may require adjustment 

on this diet plan.

Low-fat diet 

• The definition of low-fat varies from less than 20 – 30% of total calories from fat, 

without formally prescribed energy restriction but with an energy deficit.[26] 

• Studies found that there was significant weight loss in both the low-fat and lowcarbohydrate diet groups.[128,130] These findings are consistent with the findings 

in the 2013 AHA/ACC/TOS Guidelines for the Management of Obesity and Weight 

Management in Adults.[26] 
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Dietary Approaches Description

Alternate day fasting 

and Intermittent fasting

• Alternate day fasting and intermittent fasting are both forms of intermittent energy 

restriction using varied plans for when energy is restricted (by day or in the same 

day). 

• Current research is limited on this dietary approach. 

• Studies using an alternate day fasting or intermittent fasting methodology yielded 

the same results, which was that there was no difference in weight loss when 

compared to an alternate calorie-restriction method.[125,126,131-133] 

a For further information about the Mediterranean eating pattern see the 2015-2020 Dietary Guidelines for Americans, available 

at: https://health.gov/dietaryguidelines/2015/ 

b For further information on the DASH dietary pattern visit: https://www.nhlbi.nih.gov/health-topics/dash-eating-plan and 

https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf 

Abbreviations: ACC: American College of Cardiology; AHA: American Heart Association; DASH: Dietary Approaches to Stop 

Hypertension; g: grams; kg: kilograms; mg: milligrams; RDA: recommended dietary allowance; SR: systematic review; 

TOS: The Obesity Society; USDA: United States Department of Agriculture; WMD: weighted mean difference 
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Appendix H: Pharmacotherapy

A. Medications Approved for Long-term Weight Management 

The following table includes prescribing information for the five medications currently FDA-approved for long-term weight management. The 

information has been compiled from the respective manufacturer’s product information. See the individual product information for the most 

current prescribing information.
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Table H-1. Pharmacologic Information for Long-term Weight Management Medicationsa, b 

Medication Dosing Monitoring

Common Side 

Effects Contraindications Warnings

Phentermine/ 

topiramate ER

(Qsymia®)

Schedule for 

Controlled 

Substances: 

CIV

• Phentermine 3.75 mg/

topiramate 23 mg capsule each 

morning for 14 days; then 

increase to 7.5 mg/46 mg each 

morning for an additional 

12 weeks

• Per the product information, if a 

3% loss of baseline body weight 

is not achieved after 12 weeks, 

increase dose to 11.25 mg/

69 mg each morning for 

14 days; then increase to 

15 mg/92 mg daily

♦ If a 5% loss of baseline body 

weight is not achieved after 

12 weeks, it is unlikely that 

the patient will achieve a 

clinically meaningful weight 

loss with further treatment; 

discontinue by tapering 

(one dose every other day 

for ≥1 week to avoid 

inducing a seizure)

• Renal Impairment: 

♦ Moderate/severe 

(CrCl <50 mL/min): 

♦ Maximum dose: 7.5 mg/

46 mg daily

• Hepatic Impairment:

♦ Moderate (Child-Pugh score 

7 – 9) 

♦ Maximum dose: 7.5 mg/

46 mg daily

• Weight

• Blood pressure 

(orthostatic) and/or 

signs/symptoms of 

hypotension 

• Resting heart rate 

• Serum bicarbonate, 

especially if the patient 

is taking another 

carbonic anhydrase 

inhibitor

• Serum potassium, 

especially if the patient 

is taking another 

carbonic anhydrase 

inhibitor

• Glucose and/or signs/

symptoms of 

hypoglycemia in 

patients with diabetes

• Mood (depression) 

and sleep disorders

• Pregnancy tests in 

women of 

reproductive age 

• Baseline and periodic 

monitoring of serum 

creatinine (SCr)/

estimated glomerular 

filtration rate (eGFR)

• Increased heart 

rate

• Paresthesia 

• Dizziness

• Dysgeusia

• Headache 

• Insomnia 

• Decreased 

serum 

bicarbonate 

• Xerostomia 

• Constipation 

• Upper 

respiratory tract 

infection 

• Nasopharyngitis

• Pregnancy

• A REMS program 

exists to inform 

prescribers and 

patients of risks

• Glaucoma

• Hyperthyroidism

• MAOI use during 

or within 14 days

• Metabolic acidosis

• Cognitive impairment

• Elevated heart rate

• Nephrolithiasis

• Hypokalemia

• Mood and sleep disorders

• Depression or suicidal ideation

• Increased creatinine

• Adjust hypoglycemic 

medications to avoid 

hypoglycemia

• Abuse potential: Phentermine 

is pharmacologically related to 

amphetamines, which have a 

high abuse potential; 

prolonged use may lead to 

dependency

• Anticonvulsants (including 

topiramate) should not be

discontinued abruptly to 

minimize the possibility of 

increasing seizure frequency; 

tapering over at least 1 week is 

recommended

• Avoid concomitant 

consumption of alcohol due to 

increased serum 

concentrations of topiramate 

which may lead to increased 

CNS depressant effect

• Multiple drug interactions 

(CYP 2D6)
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Medication Dosing Monitoring

Common Side 

Effects Contraindications Warnings

Naltrexone/ 

bupropion ER

(Contrave®)

• Naltrexone 8mg/bupropion 

90 mg dose-escalation schedule:

♦ Morning Dose/Evening Dose

ο Week 1: 1 tablet / None

ο Week 2: 1 tablet / 

1 tablet

ο Week 3: 2 tablets / 

1 tablet

ο Week ≥4: 2 tablets / 

2 tablets

♦ Maintenance dose: 2 tablets 

twice daily (Naltrexone 

16 mg/bupropion 180 mg)

♦ Per the product information, 

discontinue if a 5% weight 

loss is not achieved by week 

12, as it is unlikely that a 

meaningful weight loss will 

be achieved and sustained 

with continued treatment

• Renal Impairment: 

♦ Moderate/severe: 

♦ Maximum dose: 1 tablet 

twice a day

ο Not recommended for 

use in patients with endstage renal disease. 

• Hepatic Impairment:

♦ Maximum dose: 1 tablet in 

the morning.

• Weight

• Pregnancy 

• Glucose and/or 

signs/symptoms of 

hypoglycemia in 

patients with diabetes 

Blood pressure and/or 

signs/symptoms of 

hyper- or hypotension 

• Heart rate

• Signs and symptoms of 

depression, suicidal 

thought or behavior, 

cognitive impairment, 

or changes in mood

• Recommend to add 

baseline and periodic 

monitoring of renal 

and hepatic function

• Headache

• Sleep disorder

• Nausea

• Constipation

• Diarrhea

• Vomiting

• Dizziness

• Xerostomia

• Opioid use 

(agonists or 

partial agonists)

• Pregnancy

• Uncontrolled 

hypertension

• Seizure disorder

• Bulimia or 

anorexia nervosa

• Abrupt 

discontinuation of

alcohol

• Acute opioid 

withdrawal

• Concomitant 

MAOI use or 

initiation in 

patients receiving

linezolid or IV 

methylene blue

• Suicidal thinking/ behavior 

[U.S. Boxed Warning]

• Neuropsychiatric symptoms 

• May precipitate acute opioid 

withdrawal in patients 

receiving opioids

• Seizures

• Increase blood pressure, heart 

rate

• Hepatotoxicity

• Adjust hypoglycemic 

medications to avoid 

hypoglycemia
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Medication Dosing Monitoring

Common Side 

Effects Contraindications Warnings

Orlistat 

(Xenical®, Alli®)

• Xenical®: 120 mg 3 times daily 

with each main meal containing 

fat (during or up to one hour 

after the meal); omit dose if 

meal is occasionally missed or 

contains no fat.

• Alli®: OTC labeling: 60 mg 

3 times daily with each main 

meal containing fat

• Renal Impairment: There are no 

dosage adjustments provided in 

the manufacturer’s labeling

• Hepatic Impairment: There are 

no dosage adjustments 

provided in the manufacturer’s 

labeling

• Weight

• Blood pressure 

(orthostatic) and/or 

signs/symptoms of 

hypotension

• Glucose and/or signs/ 

symptoms of 

hypoglycemia in 

patients with diabetes

• Liver function tests if 

signs or symptoms of 

hepatic dysfunction

• Renal function in 

patients at risk of renal

impairment

• Gastrointestinal 

effects (e.g., oily 

rectal leakage, 

abdominal 

distress/pain, 

flatulence with 

discharge, 

bowel urgency, 

steatorrhea). 

Frequency may 

decline over 

time

• Headache

• Fatigue

• Anxiety

• Menstrual 

disease

• Neuromuscular 

and skeletal pain

• URTI 26.1% – 

38.1%

• Influenza 39.7%

• Pregnancy

• Chronic 

malabsorption 

syndrome

• Cholestasis

• Increased urinary oxalate and 

nephrolithiasis

• Hepatotoxicity

• Cholelithiasis

• Interference with absorption 

of fat-soluble vitamins,

cyclosporine, thyroid 

hormone, and anticonvulsants

• Adjust hypoglycemic drugs to 

avoid hypoglycemia
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Medication Dosing Monitoring

Common Side 

Effects Contraindications Warnings

Liraglutide 

(Saxenda®)

• Initiate dose titration with 

0.6 mg daily, subcutaneously for 

1 week; increase daily dose by 

0.6 mg per week until reaching 

a target dose of 3 mg; slow 

titration to every other week if 

the patient cannot tolerate 

weekly titration

• Per the product information, 

discontinue if 4% weight loss is 

not achieved by week 16 as it is 

unlikely that a meaningful 

weight loss will be achieved and 

sustained with continued 

treatment

• Patients on secretagogues (such 

as sulfonylureas) or insulin: 

Consider reducing the dose of 

the secretagogue (e.g., by 50%) 

or insulin to avoid hypoglycemia

• Dose in Renal Impairment: 

Use with caution in renal 

impairment

• Weight

• Blood pressure 

(orthostatic) and/or 

signs/symptoms of 

hypotension 

• Resting heart rate 

• Glucose and/or 

signs/symptoms of 

hypoglycemia. Use 

additional caution if 

the patient is using 

another glucoselowering agent. 

• Mood (symptoms of 

depression) and sleep 

disorders

• Increased heart 

rate

• Headache

• Hypoglycemia

• Nausea

• Diarrhea

• Constipation

• Vomiting

• Dyspepsia

• Abdominal pain

• Fatigue

• Pregnancy

• Personal or family 

history of 

medullary thyroid 

carcinoma (U.S. 

Boxed Warning) 

or MEN2

• Injection site reactions

• Hypersensitivity reactions 

(caution if previous reactions 

to GLP-1 agonist)

• Thyroid C-cell tumors [Boxed 

Warning]

• Gallbladder disease

• Pancreatitis (discontinue) 

• Increased heart rate

• Renal impairment

• Acute cholelithiasis and 

cholecystitis 

• Tachycardia

• Acute/chronic renal failure 

exacerbation

• Suicidal behavior and ideation

• Adjust hypoglycemia drugs to 

avoid hypoglycemia

a If applicable, refer to VA (http://www.pbm.va.gov/) or DoD (http://www.health.mil/PandT) guidance/criteria for further recommendations on use of these agents. 

b In February 2020, the FDA requested the withdrawal of the weight-loss drug Belviq, Belviq XR (lorcaserin) from the U.S. market, citing potential risk of cancer outweighing the 

benefits of use. 

Abbreviations: CIV: Schedule IV controlled substance; CrCl: creatinine clearance; ER: extended-release; GLP-1: glucagon-like peptide-1 receptor; IV: intravenous; MAOI: monoamine 

oxidase inhibitor; MEN2: multiple endocrine neoplasia type 2; mg: milligram; min: minute; mL: milliliter; REMS: Risk Evaluation and Mitigation Strategy; XR: extended-release 
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B. Medications and Potential for Weight Gain

In the overall management of patients with obesity or overweight, it is critical to consider the impact of 

prescribed medications on the potential for weight gain and whether alternate medications may be a 

more appropriate option for patients who are overweight, obese, or at risk. Providers should review the 

patient’s current medications for any medications that may be contributing to increased weight. The side 

effects of weight gain should be considered when prescribing a medication for a patient in whom weight 

gain may be of concern. If an alternate medication is not an option, participation in a weight management 

program may benefit the patient whose only option is a medication associated with weight gain. The 

information in the Sidebar 2 is provided as only one aspect of medication selection for a patient with 

overweight or obesity (or at risk for transition to overweight or obesity). Optimal medication management 

should take into account the potential effect on weight, as well as other patient factors, efficacy, safety, 

and available long-term outcome data. 

C. Off-label Pharmacotherapy 

Several drugs have been used off-label as a long-term treatment for weight loss.[225-227] Below is a list 

and brief discussion of some of these medications. 

a. Topiramate (Monotherapy) 

Weight loss was noted as a side effect when topiramate was used to treat epilepsy. A mean of 3.9 kg is lost

at three months and 5.9 kg at one year although the amount of weight loss tends to be greater in those 

with a higher BMI. Studies that have identified greater weight loss with higher doses have reported a 

ceiling effect at a dose of 192 mg/day.[228] 

A meta-analysis that included 3,320 patients with obesity from 10 studies (19 treatment arms) comparing 

topiramate (64 mg – 400 mg/day as a weight loss agent) to placebo over periods of 16 – 60 weeks found 

the mean weight loss experienced by patients taking topiramate was 5.34 kg greater than with placebo. 

The amount of weight loss was a function of both dosage and duration of exposure. Safety data were 

available for 6,620 patients. The risk of study withdrawal due to an adverse event was greater for 

topiramate treated patients (OR: 1.95) and was associated with a higher dosage. This same dose-related 

pattern was observed with the other common adverse events including paresthesias, taste perversion, 

psychomotor impairment, hypoesthesia, difficulty concentrating, anorexia, memory impairment, and 

nervousness.[229] In a meta-analysis in patients with obesity and T2DM, topiramate reduced weight and 

HgA1C; however, serious and total number of adverse events occurred more frequently with 

treatment.[230] 

b. Metformin 

Modest weight loss has been well documented with the use of metformin when used to treat patients 

with DM, pre-diabetes, metabolic syndrome, and PCOS.[89,231-235] It has also been shown to cause 

weight loss in patients without DM with antipsychotic-induced weight gain.[236] In patients with T2DM, 

reductions have persisted for 10 years or more and the most important influence on both weight loss and 

maintenance is adherence to metformin therapy.[237] Additional data are needed for the use of 

metformin for weight loss in patients without the aforementioned conditions.[238,239] Metformin is 

generally safe, though the risk of lactic acidosis (boxed warning) must be considered, particularly in 
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patients with dehydration, renal insufficiency, or those receiving acute loads of intravenous contrast media 

for radiologic procedures. According to the product information, GI side effects are one of the most 

commonly reported adverse events in patients treated with metformin; measures may be taken to 

minimize these side effects (e.g., take the dose with a meal; use of the extended-release formulation). 

c. Glucagon-like Peptide-1 Receptor Agonists (exenatide, dulaglutide, 

lixisenatide, semaglutide; note: liraglutide 3 mg dose FDA-approved for longterm weight management) 

A Cochrane review of 17 RCTs involving 6,899 participants and typically lasting 26 weeks showed weight 

loss of 2.87 kg and 3.24 kg for exenatide and liraglutide (3 mg dose FDA-approved for weight loss), 

respectively in patients with T2DM.[240] Additional data on weight loss are available in an open-label 

trial designed to evaluate the effect of treatment on HbA1c in patients with T2DM; the mean baseline 

BMI of patients in this trial was approximately 34 kg/m2

, with a weight loss of 5.6 kg with semaglutide 

and 1.9 kg with exenatide.[241] A Phase 2 trial with semaglutide in patients with obesity (without DM) 

compared to liraglutide 3.0 mg daily and placebo has also been published with positive results. Weight 

loss was significantly higher in all semaglutide groups versus placebo, and significantly higher compared 

to 3.0 mg liraglutide at doses of semaglutide of 0.2 mg per day or more.[242] Nausea is common with 

these agents and tends to subside with continuation of therapy. Clinically, it is feasible to dose escalate 

more slowly to an eventual goal dose if a patient reports GI intolerance, given multi-click pen 

formulations. The risk of inducing pancreatitis is a concern, though in the Liraglutide Effect and Action in 

Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial including a total of 9,340 patients 

with T2DM, there was a higher absolute number of patients in the placebo arm with acute pancreatitis 

(23, 0.5%, 1.7 events/1,000 patient-years of observation [PYO]) than in the treatment arm with 

liraglutide (18, 0.4%, 1.1 events/1,000 PYO).[243] Due to rat and mice data with increased C-cell tumors 

in those animals, there is a boxed warning of thyroid C-cell (medullary) tumor risk and GLP-1 agonists 

are contraindicated in patients with a personal or family history of medullary thyroid cancer (MTC) or 

multiple endocrine neoplasia type 2 (MEN2). 

d. Sodium-glucose Cotransporter 2 Inhibitors (empagliflozin, dapagliflozin, 

canagliflozin, ertugliflozin)

As a class, sodium-glucose cotransporter 2 (SGLT2) inhibitors cause glucosuria by inhibiting reabsorption of 

the filtered glucose load in the proximal tubule. In this fashion, calories are lost through the urine. This can 

result in some weight loss in patients with T2DM in whom this class of agents has current FDA approval for 

use. In trials of 12 – 52 weeks duration, with two of these agents (dapagliflozin, canagliflozin), weight loss 

of 2 – 3 kg was seen.[244] In a meta-analysis of trials of one to two years duration, SGLT2 inhibitors 

(canagliflozin, dapagliflozin, and empagliflozin) showed an MD at two years compared to placebo of –2.99 

kg (95% CI: -3.64 to -2.34). Warnings and precautions for the SGLT2 inhibitors include ketoacidosis, genital 

mycotic infections, as well as rare cases of necrotizing fasciitis.[245,246] There remains a boxed warning 

for use of canagliflozin in the setting of foot ulcers or amputations. Renal function should be monitored 

with use.

e. Bupropion 

Bupropion, as monotherapy, has been noted to cause weight loss when used in patients with depression 

or those seeking to abstain from tobacco.[247] In studies of patients taking daily bupropion combined with 
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naltrexone, there was a weight loss of approximately 5 kg more with treatment compared to those 

receiving placebo.[248-250] The combination of naltrexone sustained-release/bupropion sustained-release 

is now FDA-approved for long-term weight management. Bupropion has a boxed warning for suicidality 

and is contraindicated in patients with a seizure disorder, bulimia, or anorexia. 

f. Amphetamines/Stimulants (e.g., mixed amphetamine salts, lisdexamfetamine, 

methylphenidate) 

Weight loss in children prescribed stimulants is considered a treatment-limiting adverse event. No studies 

have been published with weight loss as a desired outcome in adults with obesity. All of these medications 

have concerns and/or boxed warnings for abuse/dependence and CV/central nervous system side effects. 

g. Testosterone Replacement Therapy 

Testosterone replacement therapy has been advocated to achieve weight loss in hypogonadal men with 

obesity.[251] However, two SRs showed that adipose tissue decreased by only 1.6 kg while lean body 

mass increased by 1.6 kg, with no overall difference in body weight versus placebo.[252,253] Similarly, 

testosterone supplementation in eugonadal men (total testosterone 350-400 ng/dL or higher) leads to 

no improvement in weight loss. There also remains significant controversy and mixed results regarding 

the cardiovascular effects of testosterone therapy in general.[254-256] This is an area requiring further 

review.[257] 

h. Human Chorionic Gonadotropin 

Human chorionic gonadotropin (HCG) has no role in weight loss therapy, is ineffective and has serious 

safety concerns. A meta-analysis published in 1995 reviewed the use of intramuscular HCG in 24 studies to 

include 14 RCTs.[258] The authors concluded that HCG was no more effective than a placebo or diet alone 

for weight loss, fat redistribution, or a sense of well-being. Since 1995, there have been no further trials 

evaluating intramuscular HCG. To date, there are no studies demonstrating the efficacy of HCG drops, 

pellets, lozenges, or HCG injections (in the absence of severe calorie restriction) over placebo or alternate

therapy. Serious adverse events, including deep vein thrombosis and pulmonary embolism (PE), have been 

reported.[259]

i. Cyanocobalamin (vitamin B-12) 

Vitamin B-12 has a very limited role in promoting weight loss. Based on theoretical extrapolation of the 

actions of vitamin B-12 at the cellular level, it is sometimes used to promote weight loss. There are no 

studies evaluating weight loss with vitamin B-12 injections, tablets, sublingual pills, or drinks. Conversely, 

B-12 deficiency has been associated with weight loss, particularly after bariatric surgical procedures, and 

can lead to permanent nerve damage if left untreated.[260] No weight loss should be anticipated as a 

result of the use of exogenous vitamin B-12. Risks of injection site reaction might be anticipated if that 

route is chosen. In patients with normal renal function, a hypervitaminosis state is unlikely. 

j. Thyroid Hormones 

Several small studies have evaluated the association between weight loss and the use of levothyroxine and 

liothyronine replacement in hypothyroid patients.[261] Normalization of the hypothyroid state is 

associated with small losses of weight (typically less than 1 kg), which are not durable beyond 12 – 24 
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months. Normalization of the hyperthyroid state is associated with a weight gain of approximately 7 kg. 

Treatment of euthyroid patients to hyperthyroid levels has not been reported outside of control groups in 

early phase clinical trials. The risks associated with hyperthyroidism – particularly cardiac, ocular, bone, 

and neuropsychiatric – make intentional creation of a hyperthyroid state highly inadvisable for weight loss. 

Hyperthyroidism (e.g., Grave’s disease) is a condition that requires treatment to avoid negative health 

consequences. Latrogenic hyperthyroidism accrues significant harm. 
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Appendix I: Metabolic/Bariatric Surgery

Metabolic/bariatric surgery frequency has increased over the last decade, paralleling the obesity epidemic 

in the U.S. Advancement in laparoscopic surgical techniques, surgical instrumentation, and accreditation 

programs (American College of Surgeons and American Society of Metabolic and Bariatric Surgery) have 

led to significant reductions in morbidity and mortality and increased public acceptance of these 

procedures. Irrespective of surgical approach, these are major operative procedures with a target 

population that may have multiple comorbidities. Current operative mortality of <0.5% and major 

morbidity of <4% are significantly improved.[187,262,263] Nonetheless, all patients considering surgical 

intervention require careful pre-operative evaluation, paying particular attention to cardio-pulmonary risk 

factors and pre-habilitation as indicated. Evidence from five RCTs suggests that metabolic/bariatric surgery 

significantly improves systolic blood pressure, HbA1C, fasting blood glucose, HDL cholesterol, and 

triglycerides compared to non-surgical lifestyle and/mediation therapy at 1 – 5 years followup.[179,187,191,192] A survival benefit has been demonstrated.[264] Evidence from 23 observational 

studies shows continued absolute and excessive weight loss among overweight and obese adults >10 years 

after surgical intervention.[265] Evidence from 13 observational studies in one SR suggests that 

metabolic/bariatric surgery significantly reduces the incidence of hirsutism, menstrual irregularity, and 

infertility in women with PCOS and obesity at one year and longer follow-up.[266] Counter to this, 

however, is the finding that morbidity and mortality have been noted to be increased in those patients 

over the age of 60 who undergo bariatric surgical procedures compared to younger people.[201] 

As with all surgical procedures, a complete history and physical is required and the preoperative evaluation 

should include a review of the screening and assessment elements noted in the Standards of Care. This 

includes identification of problematic maladaptive eating patterns that may require further assessment or 

management. Although nearly all patients with obesity have shortness of breath, if shortness of breath is 

severe, an assessment for sleep apnea and cardiopulmonary function is warranted to identify any potential 

contraindications to surgery or health issues that may be correctable or improved prior to surgery.[267] 

Any biliary symptoms should be evaluated with ultrasonography.[268] Patients who smoke should be 

encouraged to quit and abstain from smoking due to its deleterious effects on pulmonary function and 

wound healing. Patients that have active, untreated addictions to drugs or alcohol should not be referred 

for metabolic/bariatric surgery.[269] 

Patients considering metabolic/bariatric surgery should be concomitantly enrolled in an integrated 

comprehensive lifestyle intervention program, both prior to and after the surgical procedure, to provide 

ongoing guidance and support. The support includes counseling concerning dietary regimen, appropriate 

physical activity, behavioral treatment, and social support. Adherence to a restricted diet, physical activity, 

and lifestyle changes is essential to long-term maintenance of weight loss after surgery. Patients should 

receive preoperative nutritional counseling to ensure they understand postoperative dietary requirements 

and the need for lifestyle alteration. Metabolic/bariatric surgery support groups often facilitate this 

education both pre-operatively as well as postoperatively. In addition, lifelong medical surveillance after 

metabolic/bariatric surgery should include monitoring for changes in the status of chronic health 

conditions and procedure-specific complications such as nutritional deficiencies.[270] 

Numerous insurance companies mandate enrollment in a structured weight-loss program for a prescribed 

period of time before patients can be considered for these procedures. There is conflicting evidence as to 
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the benefit of such an approach and it has been condemned by the American Society of Metabolic and 

Bariatric Surgery.[265] The requirement of pre-surgical psycho-social evaluation of patients seeking 

weight-loss surgery has been adopted by the majority of third-party payers and by over 80% of bariatric 

programs in the U.S. Psychosocial factors have significant potential to affect long-term outcomes of 

bariatric procedures, including emotional adjustment, adherence to recommended postoperative lifestyle 

regimens, weight-loss outcomes, and comorbidity improvement and/or resolution. The evaluating clinician 

plays a number of important roles in the multidisciplinary treatment of the bariatric patient. Central 

among these is the role of identifying factors that may pose challenges to optimal surgical outcome and 

providing recommendations to the patient and bariatric team on how to address these issues.[271] 

Classic indications for metabolic/bariatric surgery are patients with a BMI ≥40 kg/m2 who have failed to 

achieve significant weight loss by non-surgical means and are fit to withstand a major operative procedure 

or those with an obesity-related comorbidity and BMI ≥35 kg/m2

. All must commit to long-term follow-up. 

In this publication, we provide evidence to support the option of metabolic/bariatric surgery in conjunction 

with a comprehensive lifestyle intervention, for patients with DM and BMI ≥30 kg/m2

 (see 

Recommendation 13). 

Expert consensus states that pregnancy is not recommended during the rapid weight-loss phase after 

metabolic/bariatric surgery; therefore, counseling and follow-up regarding contraception during this 

period is important.[272] Other contraindications to metabolic/bariatric surgery that are supported by 

expert consensus include severe heart failure, unstable coronary artery disease, severe coagulopathies, 

severe chronic obstructive pulmonary disease (COPD)/end-stage lung disease, active peptic ulcer disease, 

active cancer treatment, portal hypertension, active alcohol/substance abuse, and impaired intellectual 

capacity/inability to follow pre- and postoperative instructions.[273,274] Consultation with the bariatric 

surgeon should be performed to discuss all possible contraindications for surgery for any specific patient. 

Figure I-1: Most Common Types of Metabolic/Bariatric Procedures Performed in the U.S. [275] 
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A. Non-metabolic Surgery (i.e., Adjustable Gastric Band) 

With the adjustable gastric band procedure (AGB), a silastic inflatable band is placed around the cardia of 

the stomach. A reservoir port placed under the skin is subsequently injected with saline to expand or 

desufflate a balloon in the band to create more or less restriction to the passage food.[276] The AGB is 

considered to be a reversible form of the previously popular vertical banded gastroplasty. Reducing the 

band lumen via band filling is done postoperatively gradually over time with repeated adjustments or 

“fills”. It rapidly became a popular procedure early after its introduction in the U.S. but has been 

abandoned by many due to its high rate of complications (and associated high rates of removal), and lower 

effectiveness compared to other procedures.[277,278] 

B. Metabolic Surgery 

Metabolic surgery includes procedures that involve stapling part of the GI system. There is growing 

recognition that they contribute to neurohormonal effects on the regulation of energy balance and 

hunger control.

a. Roux-en-Y Gastric Bypass

The RYGP can be an open, or more commonly, a laparoscopic procedure. It involves creating a 30 mL 

gastric pouch which empties into a Roux limb of jejunum. A variable distance downstream from this 

anastomosis (~150 cm), another anastomosis is created with the biliary limb to form a “common channel” 

that travels to the cecum.[278-280] 

b. Laparoscopic Sleeve Gastrectomy

Since the publication of the 2014 VA/DoD Obesity CPG, laparoscopic sleeve gastrectomy (SG) has emerged 

as the most commonly done operation for obesity.[281] Its origins began as a component of Scopinaro’s 

BPD with a duodenal switch (DS).[278,282-284] In the “super-obese population”, sleeve gastrectomy was 

used as an initial procedure to bring the patient down to a “safer” operative weight when a more definitive 

by-pass component could be added. Seeing the impressive results of SG alone has established SG as a 

primary bariatric operative option. 

The procedure involves removing 75 – 80% of the greater curvature of the stomach, re-shaping the 

stomach into a banana or “sleeve” shaped organ. The procedure permanently reduces the size of the 

stomach though there could be some dilation of the stomach later in life. Resection starts approximately 

5 – 6 cm proximal to the pylorus and progresses close to the gastric cardia. It is usually fashioned over a 

36 French bougie. It is a relatively simple procedure utilizing a laparoscopic GIATM stapling device to 

resect the greater curvature with surgeons often using buttressing material around the staples to 

minimize postoperative leaks. 

Several studies demonstrate that SG and RYGB provide more comparable weight loss than seen after 

adjustable gastric bands or nonsurgical interventions [187,282] with no reliable conclusion regarding 

which operation procedures result in the greatest weight loss following surgery. In a randomized trial 

(RT) conducted by Zhang et al. (2014) in China, SG and RYGB led to similar weight loss at one year, but 

RYGB was found to be superior at five years.[285] Similar resolution of type II diabetes with both 

procedures has been observed.[190] SG is associated with significantly fewer major complications within 
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30 days of surgery compared to RYGB or BPD. Reports of increased incidence of GERD have been noted 

after sleeve gastrectomy and remission of GERD is seen more often with RYGP. 

As with any bariatric procedure, long-term weight regain can occur due to patient non-adherence with 

postoperative dietary instructions and may require one or more of a variety of re-interventions if 

applicable. 

c. Biliopancreatic Diversion with Duodenal Switch

BPD with DS entails an SG and duodenal bypass affected by a proximal roux-en-y duodeno-jejunostomy. It 

is the longest studied of all bariatric operations and has the highest efficacy in terms of weight loss and 

T2DM resolution, but also has a higher risk of complications.[189,286] Technical complexity and long-term 

nutritional deficiencies have limited its acceptance and popularity in the U.S. The American Society for 

Metabolic and Bariatric Surgery published estimates from 2011-2014 that BPD comprised only 0.4% of 

bariatric procedures performed.[287] A lesser performed procedure is the “single anastomosis gastric 

bypass” or “mini gastric bypass” (MGP), which in essence is an SG combined with a loop gastrojejunostomy. Reports show impressive results compared to RYGB and SG.[288,289] 

C. Mortality Risk

Bariatric procedures have potentially serious complications, and there is a risk of mortality from these 

procedures. The risk of mortality varies according to the type of procedure performed. With laparoscopic 

RYGB, in one study of 16,509 patients, mortality was 0.3%.[290] Data from Longitudinal Assessment of 

Bariatric Surgery Consortium demonstrated 30-day mortality for LAGB, laparoscopic RYGB, and open RYGB 

of 0% of 1,109 patients, 0.2% of 2,975 patients, and 2.1% of 437 patients, respectively.[291] The Bariatric 

Outcomes Longitudinal Database 30-day and one-year mortality rate for 128,349 patients undergoing 

laparoscopic RYGP was 0.13% and 0.23% respectively. For SG, they were 0.06% and 0.11% respectively. 

BPD carries the highest risk of mortality, with a 30-day mortality at 1.2%.[292] Risk factors for one-year 

mortality included older age, male sex, higher BMI, presence of 30-day leak, 30-day PE, and 30-day 

hemorrhage.[263,293-295] In most studies, PE is the most frequently reported cause of death. 

D. Morbidity Risk

Based upon the Longitudinal Assessment of Bariatric Surgery database including 4776 patients, the rate 

of failure of discharge from hospital at 30 days was 4.1%.[291] Over-all complication rates have 

decreased in time from 4.6% (2006) to 3.0% (2013).[286] The type of procedure done is associated with 

risk of morbidity. A one-year analysis of 4,756 patients from the American College of Surgeons' National 

Surgical Quality Improvement Program (ACS NSQIP) database showed that LAGB carried a lower 30-day 

rate of major complications compared with laparoscopic RYGB (1.0% versus 3.3%), return visits to the 

operating room (0.9% versus 3.6%), and shorter postoperative stay (median one versus two days).[296] 

Similarly from the same database, open RYGP had a higher morbidity (7.4%) than the laparoscopic 

approach (3.4%). BPD with DS had the highest rate of morbidity and mortality, paralleling its increased 

technical difficulty.[292] The following is a list of potential complications associated with the various 

surgical procedures:
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a. Gastric Anastomotic Stricture (RYGB, BPD, LSG, MGP)

An SR (n=230) found that the risk of stricture for RYGB, BPD, and laparoscopic sleeve gastrectomy (LSG) 

was 3.3%, 1.2%, and 3.5% respectively.[297] Stenosis with a sleeve can occur if the sleeve kinks, twists, or 

narrows. An anastomotic stricture may form secondary to improper healing of a marginal ulceration of the 

anastomosis. Anastomotic stricture presents with dysphagia, vomiting, and/or food intolerance. This 

problem is generally addressed by endoscopic pneumatic balloon dilation. Multiple follow-up dilations 

may be required, but surgical revision is rarely required. 

b. Marginal Ulceration (RYGB, BPD, MGP)

Marginal ulcers are peptic ulcerations that occur at the gastrojejunal anastomosis on the jejunal side of the 

anastomosis and typically occur within 30 days of the index procedure. A prospective study found the risk 

to be as high as 12.3% at one month following surgery.[298] The clinical presentation may include 

hematemesis, hematochezia, obstructive symptoms, and pain. They are felt to be the result of tissue 

ischemia. Helicobacter pylori, smoking, and usage of NSAIDS are also risk factors. First line treatment is 

with proton pump inhibitors. Follow-up endoscopy should be performed to document resolution. When 

refractory to medical treatment, the anastomosis may require operative revision. Marginal ulcer bleeding 

can be severe but usually responds to endoscopic intervention.

c. Bowel Obstruction/Hernias (all)

As with any operation, adhesive bowel obstruction may occur. Presenting symptoms include vomiting, 

abdominal distention, and pain. Internal hernias can present more insidiously with intermittent symptoms 

such as cramping and abdominal pain. Rates for bowel obstruction of 6% have been reported with 

laparoscopic approaches.[299] 

A curious site of intestinal obstruction secondary to internal herniation occurs in “Petersen's Space”, which 

is the space between the roux limb going to the gastric pouch and the transverse mesocolon. In one study 

(n=11,918), the incidence of this hernia was 2.51%.[300] Often seen when a roux limb is brought up in a 

retro-colic position it can cause a closed-loop obstruction. It occurs secondary to failure to close this 

potential site of internal herniation. Physical findings may be misleading and often a “swirl” sign can be 

seen on computerized tomography (CT) imaging. The incidence of internal hernias is somewhat higher 

with laparoscopic procedures compared to open procedures secondary to the relative lack of adhesion 

formation following laparoscopic procedures.[301] 

Port-site hernias may develop in laparoscopic procedures secondary to technical errors in fascial closure. 

Incisional hernias from open incisions can occur in 6.4% to 8.6% of midline incisions [302,303] compared to 

0.47% (port site) with the laparoscopic approach. In the same study,[303] bowel obstructions were seen in 

2.91% of patients with the laparoscopic approach, compared to 2.1% with the open approach.

Partial bowel obstructions secondary to postoperative adhesions require admission and intravenous (IV) 

fluid hydration with initial conservative care. Gastrograffin small bowel studies may be helpful in the 

localization of a transition point (point of obstruction) and predicting the future need for operative 

intervention. Most partial obstructions resolve with IV fluid resuscitation and nasogastric tube 

decompression. Complete bowel obstructions or those with tight transition zones require emergent 

surgery.
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Obstructions around the distal anastomosis (RYGB, BPD) may result in acute “gas bloat” of the distal 

(partitioned off) stomach. This is a true surgical emergency in that if the distal stomach is not vented, 

gastric necrosis, perforation, and death may rapidly ensue. Patients often present with epigastric fullness

and “hiccups”. Diagnosis is suggested by a large gas bubble in the right upper quadrant on plain films. 

Distal gastric remnant is decompressed via tube gastrostomy and attention directed to the etiology of the 

distal anastomotic obstruction. 

d. Gastrointestinal Bleeding (all)

Gastrointestinal bleeding occurs in approximately 1 – 2% of patients after RYGB (1.92% open versus 0.59% 

laparoscopic) [303] and usually occurs from one of the various staple lines in the immediate postoperative 

time period. Pre-operative identification of the site of staple line bleeding may be nearly impossible: the 

distal anastomosis in an RYGB or BPD may be as far as 150 cm distal to the gastro-jejunostomy proximal 

anastomosis making endoscopic access to this anastomosis difficult. The gastric pouch and gastric 

anastomotic staple lines are easily identified with an upper endoscopy. As with most GI bleeding, 

endoscopic therapy is the preferred method of management. Fortunately, most staple line bleeding in the 

immediate postoperative time period usually stops with conservative care alone. Bleeding can also occur 

in the gastric remnant from the partition staple line, which is usually not accessible through normal 

endoscopy. Many surgeons consider transfusion requirements in excess of 4 units of packed red blood 

cells as an indication for operative intervention if endoscopy is not revealing. There is no substitute for an 

experienced bariatric surgeon in these cases. Bleeding can later occur in conjunction with a marginal ulcer 

as discussed above.

e. Pulmonary Embolism (all)

In one study the incidence with open surgery of PE was 0.41% and with laparoscopic surgery 0.77%.[303] 

In another study, the overall risk of PE within 90 days of surgery was 0.42% with 27% occurring before 

discharge and 73% occurring post-discharge. Most occurred within 30 days after surgery, though overall 

risk can extend past the 30-day postoperative period.[304] While chemical prophylaxis is indicated, there is 

no substitute for early postoperative ambulation. Risk factors for venous thromboembolism after 

metabolic/bariatric surgery may include high BMI, advanced age, immobility, prior venous 

thromboembolism, known hypercoagulable condition, obesity hypoventilation syndrome, pulmonary HTN, 

venous stasis disease, hormonal therapy, expected long operative time or open approach, and male 

gender. Most series report postoperative PE as a leading cause of death along with anastomotic leaks. 

Prophylactic measures reduce the risk of PE, but they do not completely eliminate the risk. The use of 

Inferior Vena Cava (IVC) filters as the only method of prophylaxis before metabolic/bariatric surgery is not 

recommended. Filter placement may be considered in combination with chemical and mechanical

prophylaxis for selected high-risk patients in whom the risk of venous thromboembolism (VTE) are 

determined to be greater than the risks of filter-related complications.[305] 

f. Anastomotic Leak/Staple Line Leak (all except AGB)

In a study from 2015 in RYGB patients, leaks were seen in <1% (0.99%) of 4,444 patients studied. Of 

these, 39 (89%) underwent abdominal reoperation, three (7%) died, and 93% recovered from the 

event.[306] A high index of suspicion is mandatory as many of these patients with obesity will not 

exhibit classical peritoneal signs. The risk of leakage is increased with open and revisions surgery. 
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Another study from 2018 with 133,478 patients, who had either laparoscopic RYGP or SG, found the 

over-all leak around to be around 0.7%, with fewer leaks seen with SG.[307] Preoperative comorbidities 

associated with increased risk for anastomotic leak were history of oxygen dependency, 

hypoalbuminemia, sleep apnea, hypertension, and DM. Gagner in a recent SR of 40,653 SG patients 

reported an over-all leak rate of 1.5%.[308] 

Early hallmarks of leaks are unexplained tachycardia, dyspnea, pain, and a feeling of impending doom. 

Despite negative imaging studies, persistent symptoms require exploration or diagnostic laparoscopic 

evaluation. Reoperation at a minimum entails wide surgical drainage. Endoscopically placed stents across a 

leak may be particularly helpful. 

g. Portal/Splenic/Mesenteric Vein Thrombosis (all)

Portomesenteric vein thrombosis occurs most commonly with laparoscopic SG. A prevalence of 0.52% has 

been cited and ranges from 0.2% to as high as 1.81%.[309] Risk is increased with a personal history of 

malignancy or T2DM. Abdominal pain is usually the presenting symptom and diagnosis is confirmed with 

CT scanning with IV contrast. Treatment is with anticoagulation. 

h. Pneumonia (all)

All postoperative patients having general anesthesia have some element of atelectasis that usually is 

addressed with incentive spirometry and vigorous pulmonary toilet. In a meta-analysis comprising 

(n=185,328) comparing pulmonary complications with both laparoscopic and open procedures, 

pneumonia was reported in 0.5% of laparoscopic cases and 1.1% in open cases.[310] 

i. Complications Specifically Related to Laparoscopic Adjustable Band 

Although this procedure is associated with fewer acute peri-operative complications, it has its own set of 

potential problems stemming from the insertion of a prosthetic “band”. Gastric band slippage (<5%), 

pouch dilation (12%), persistent GERD (7%), port malfunction (<1%), late port infection (<1%), and band 

erosion (<1%) are examples of complications that may occur after LAGB.[311,312] Patients may also 

present with severe food intolerance which may be related to the degree of band over-inflation. Acute 

stomal obstruction can occur in up to 14% of laparoscopic adjustable band (LAB) patients and may be 

related to the inclusion of excess perigastric fat under the band, insufficient diameter of band, or acute 

tissue edema. Persistent symptoms after edema has subsided may require revision or removal. 

E. Suicide Risk

In a recent SR by Castenda et al. (2019), evidence from 29 observational studies suggests that mortality by 

suicide is higher among post-bariatric patients compared to the general population and matched controls 

(matched on BMI, age, and gender).[188] The post-bariatric suicide event rate was 2.7/1,000 patients, 

while the suicide/self-harm attempt event rate was 17/1,000 patients. Evidence from seven observational 

studies included in the SR suggests that suicide or self-harm attempts are higher among post-bariatric 

patients compared to the general population or matched controls (matched on BMI, age, and 

gender).[188] As depression is not uncommon before or after metabolic/bariatric surgery, increased 

vigilance for suicidal ideation and other risk factors for suicide (e.g., alcohol and other substance use 

disorders) is warranted. 
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F. Non-insulinoma Pancreatogenous Hypoglycemia Syndrome

After gastric bypass procedures, non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), can 

occur resulting in postprandial hyperinsulinemic hypoglycemia 1-3 hours following a meal, accompanied 

by neuroglycopenic symptoms. Its incidence is unknown and is probably under-diagnosed as many 

patients have mild presentations. Post-prandial hypoglycemia appears to be observed after procedures 

that divert nutrients into the mid-small bowel, such as RYGB, and not purely restrictive procedures such as 

adjustable gastric banding.[313] Though some may be responsive to an ultra-low-carbohydrate/highprotein diet, a variety of medical treatment options may be required (acarbose, calcium channel blockers, 

octreotide, and diazoxide).[314] Treatment response is variable. Bypass reversal or conversion to SG, and 

partial/total pancreatectomy are surgical options.[315] The most appropriate surgical therapy remains 

undefined.[316] 

G. Nutritional Concerns

All patients should be followed regularly and closely for potential nutritional deficiencies. In its evidencebased CPG for endocrine and nutritional management of the post-metabolic/bariatric surgery patient, the 

Endocrine Society has provided a strong recommendation for periodic clinical and biochemical monitoring 

for micro- and macro- nutritional deficiencies after metabolic/bariatric surgery.[270,317] Metabolic 

procedures have the greatest risk for nutritional deficiency, especially the BPD. Less mixing of bile and 

pancreatic enzymes results in fat and protein malabsorption. Non-metabolic surgeries can also result in 

nutritional deficiencies since the volume of food intake is markedly reduced; it is best for patients to take a 

multivitamin and then be monitored for nutritional deficiencies. Furthermore, all postoperative patients 

should receive an average of 60 – 120 g of protein daily.[317] Those with mal-absorptive components of 

their procedures require a low carbohydrate diet to avoid “dumping”. 

Several nutritional deficiencies are common and supplementation at higher than the usual recommended 

daily dose may be required. Typical doses of elemental calcium are 1,200 – 2,000 mg daily, preferably as 

calcium citrate, which is better absorbed in the absence of gastric acid. Vitamin B12 is absorbed in the 

duodenum, thus, if bypassed, sub-lingual formulations are recommended. Iron deficiency is common and 

typically all patients undergoing bariatric procedures receive prophylactic therapy in conjunction with 

vitamin C to enhance absorption. Women with ongoing menstrual losses should receive a higher dose. 

Folate and B-complex vitamins are usually supplied in the form of a complete multivitamin. Fat-soluble 

vitamin (K, A, D, and E) status should be monitored by clinical and laboratory methods. Though not as 

common as in BPD procedures, deficiencies may occur with all procedures, especially of vitamin D 

deficiency. Together, calcium and vitamin D deficiencies contribute to secondary hyperparathyroidism, 

which can be seen following metabolic/bariatric surgery and may require higher than typical replacement 

dosing of both vitamin D (which should be taken with food for best absorption) and elemental calcium, 

ideally in the form of calcium citrate for best absorption after metabolic/bariatric surgery. Thiamine 

deficiency can also occasionally occur typically associated with intractable vomiting after surgery. 
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Table I-1. Post-Surgical Schedule for Clinical/Biochemical Monitoring [317] 

Preoperative1 

Month

3 

Months

6 

Months

12 

Months

18 

Months

24 

Months

Continue

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 Xa 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 +/- +/- 

Zinc X +/- +/- +/- +/- 

Bone mineral density 

and body composition X Xa Xa Xa

Vitamin B1 +/- +/- +/- +/- +/- +/- 

X: Indicate the suggested schedule for laboratory monitoring after metabolic/bariatric surgery.

Xa: Examinations should be performed after Roux-en-Y gastric bypass

+/-: optional

Abbreviations: LFT: liver function test; PTH: parathyroid hormone

All patients should be monitored routinely by an experienced team to detect nutritional deficiencies (see 

Table I-1). Due to potentially poor dietary tolerance or reduced intake, monitoring may still be required. 

The American Association of Clinical Endocrinologists, The Obesity Society, American Society for Metabolic 

and Bariatric Surgery together, and the Endocrine Society have both issued recommendations for 

postoperative nutrient deficiency monitoring for various bariatric surgical procedures, and this publication 

provides a wealth of information beyond the scope of this appendix.[270] Table 1 in Lupilo et al. (2017)

contains a suggested schedule of biochemical and nutritional monitoring for various bariatric 

procedures.[318] The reader is referred to these publications for specific details.

a. Recommended Post-metabolic/Bariatric Surgery Nutritional Supplementation 

and Medications [319] 

1. Daily (lifelong) multivitamin (bariatric/pre-natal) with the following requirements:

• Thiamine (B1) 50 – 100 mg

• Cobalamin (B12) 350 – 1,000 ug (if duodenum bypassed then recommend 1,000 ug sublingual 

or parenteral (IM/SQ) administration to maintain normal levels

• Folate 400 – 800 ug (800 – 1,000 ug in women of child-bearing age)

• Iron 18 mg males/45 – 60 mg elemental iron in menstruating females or with duodenal bypass
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• Calcium 1,200 – 1,500 mg/d

• Vitamin D (D3) 3,000 IU/d

• Vitamin A 5,000 – 10,000 IU/d

• Vitamin E 15 mg/d

• Vitamin K 90 – 120 ug/d

• Zinc 100 – 200% RDA (8 – 22 mg/d)

• Copper 100 – 200% RDA

2. Ursodiol 300 mg twice a day for six months (if gallbladder present without stones) for gallstone 

prophylaxis during acute weight loss

3. Chemical venous thromboembolism prophylaxis – no clear consensus on dosage or postoperative 

length of treatment

4. Proton Pump Inhibitors for RYGB/BPD with DS to prevent marginal ulceration. Not indicated for SG 

unless development of symptomatic reflux.

5. Avoidance of ALL potential ulcerogenic medications (i.e. NSAIDs/acetylsalicylic acid) 

6. Diabetes medications will likely stop or at least substantially reduce after surgery

7. Weight-based medication doses will likely decrease over time

All bariatric procedures can lead to deficiencies in iron, vitamin B12, folate, and calcium during subsequent 

pregnancies. These deficiencies can result in maternal complications, such as severe anemia, and in fetal 

complications including neural tube defects, intrauterine growth restriction, and failure to thrive. Nutrient 

supplementation following metabolic/bariatric surgery and close supervision before, during, and after 

pregnancy can help prevent nutrition-related complications and improve maternal and fetal health. 

Therefore, women who have undergone weight loss surgery and subsequently become pregnant need to 

receive intensive nutritional follow-up by providers with expertise in clinical nutrition. 
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Appendix J: Specific Behavioral Strategies Featured in Comprehensive 

Lifestyle Interventions 

A. Goal Setting 

Goal setting involves setting realistic, specific goals for behavior change. The goal includes the specific 

action to be taken and when, where, how, how long, and how often the individual will engage in that 

behavior. Writing down the goal and keeping a record of progress with self-monitoring helps the patient

monitor progress toward goals that might be modified as goals are attained. Attaining goals motivates 

continued adherence to changing behaviors. An example of a behavioral goal for increased physical 

activity is, “I will walk around the block for 20 minutes at a brisk pace every day at 11:30 A.M. If it rains, I 

will do 20 minutes of low-impact aerobics in the living room.” An example of a behavioral goal for 

making healthier food choices is, “I will eat at least three servings of non-starchy vegetables per day.”

B. Self-monitoring

Self-monitoring is perhaps the most often employed and the most important, behavioral strategy. This 

involves recording all instances of the behaviors in question. For weight management purposes, 

individuals record all details of food intake, physical activity, and body weight daily. Record-keeping 

often includes information about times of day and associated thoughts, feelings, places, and events that 

might affect food intake and physical activity. This record-keeping allows individuals to identify eating 

and physical activity patterns, cues, measurement of actual food intake, and physical activity. Awareness 

of these factors promotes the development of specific actions to address unhealthy behaviors.

C. Stimulus Control or Cue Reduction

Stimulus control or cue reduction strategies refer to efforts to change the environmental signals or cues 

for any specific behavior, in this case, eating and/or sedentary behaviors. Examples include removing 

unhealthy food from sight, eating only at the table rather than in the living room, not watching TV when 

eating, avoiding fast-food restaurants, having healthy snacks immediately available, having walking 

shoes placed in a convenient spot where they will be noticed, and so on. The overall idea is to eliminate 

signals for inappropriate eating and substitute cues for helpful weight control behaviors in their place.

D. Positive Reinforcement

Positive reinforcement refers to the provision of rewards for desirable behavior.

E. Contingency Management

Contingency management is establishing a defined schedule for the delivery of either rewards or 

punishments. Accordingly, a reward is delivered “contingent upon” completion of a specified behavior 

or performance of a desired behavior (e.g., staying within a certain caloric intake for a day or performing 

30 minutes of exercise). Positive reinforcement is generally preferred over punishment to alter weight 

control behaviors, because people develop a positive association between desirable behaviors and 

receipt of reward. In this fashion, the desirable behavior eventually becomesself-rewarding. It is 

recommended to encourage choosing a reward that does not involve calories. Examples might include 

watching a movie, getting a new CD or comic book, going out bowling or roller-skating, or an activity 

that you enjoy that does not include food.
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F. Stress Management

Stress management is utilized in the treatment of numerous conditions to reduce felt stress because 

excess stress often stimulates inappropriate or self-defeating behavior. In weight control, excessive 

stress frequently leads to over-eating and/or failure to exercise. Stress management includes a wide 

variety of techniques such as relaxation training, biofeedback training, stimulus control, cognitive 

restructuring, social support, assertiveness training, problem-solving, and skill training. Taken together, 

the patient becomes more resistant to becoming overly stressed and more capable of coping with and 

reducing felt stress when it is noticed.

G. Problem-solving

Problem-solving involves training the patient to effectively analyze problems which might otherwise 

lead to inappropriate or self-defeating behavior such as over-eating. Once contributing factors are 

accurately analyzed, possible solutions are considered and evaluated for the pros, cons, and probable 

outcome of each solution, and a workable solution is agreed upon.

H. Skill Training

Skill training refers to training a patient in those skills that are likely to enhance success. For example, 

weight control patients are taught skills in evaluating the caloric content of various foods and in 

planning to avoid overly tempting eating situations. Patients might be taught skills in eating more slowly, 

cooking more healthfully, or refusing offers for second helpings or dessert from relatives or friends who 

might be pressuring them to overindulge.

I. Social Support

Social support is widely acknowledged to facilitate almost every difficult behavior and to improve coping 

in troublesome situations. People receive encouragement, positive reinforcement, emotional empathy 

and support, and guidance from others. A comforting (and stress-reducing) feeling of “not being alone” 

comes from being in the presence of others who are in the same difficult situation, as occurs in weight 

control groups, Alcoholics Anonymous, cancer support groups, and many others.

J. Cognitive Therapy

Cognitive therapy or “cognitive restructuring” is a process whereby individuals are taught to become 

fully aware of negative or self-defeating thoughts, to counteract those thoughts, and to then replace 

them with more realistic, adaptive, and positive thoughts. Those thoughts then stimulate more desirable 

behaviors. Negatively oriented, discouraging, self-defeating, over-reactive, and unrealistic thoughts 

mediate inappropriate and/or maladaptive behavior. People are frequently not fully aware of thoughts 

such as “I MUST clean my plate!”, “I’ll just DIE if I can’t have that piece of cake!” or “Taking a walk is 

really going to HURT!” These thoughts often lead to engaging in undesirable behavior. Cognitive therapy 

can be used to identify and modify dysfunctional thoughts and attitudes about weight regulation.

K. Relapse-prevention Training

Relapse-prevention training helps people respond productively to lapses in their efforts to adopt new 

behaviors or reduce and avoid maladaptive behaviors. Lapses are inevitable during efforts to change any 

health behavior. However, many people respond quite negatively to lapses and experience feelings of 
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July 2020 Page 126 of 147

guilt or shame, as well as negative, self-defeating thoughts (such as “I am a failure!” or “I’ll never be 

successful at managing my weight.”). Relapse prevention approaches help people to reframe lapses as 

learning opportunities rather than failures and helps them to use cognitive restructuring to address 

negative thinking and problem-solving strategies to both proactively and reactively plan ways of 

managing situations that lead to lapses. Role-playing and even “planned lapses” are used to help people 

practice adaptive responses to lapses.
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Appendix K: Alternative Text Description of the Algorithm 

1. The algorithm begins with Box 1, in the shape of a rounded rectangle: “Adult enrolled in the 

VA/DoD health system”

2. Box 1 connects to Box 2, in the shape of a rectangle: “Obtain height and weight; calculate BMI to 

screen for overweight and obesity at medical visits”

3. Box 2 connects to Box 3, in the shape of a hexagon, asks the question: “Is the patient’s BMI ≥25 

kg/m2a?” 

a. If the answer is “Yes” to Box 3, then Box 5, in the shape of a rectangle: “With permission, 

assess patients (see Sidebar 3) and screen for overweight- and obesity-associated 

conditions (see Sidebar 1) and obesogenic medicationsc

” 

b. If the answer is “No” to Box 3, then Box 4, in the shape of a rectangle: “Offer guidance 

about healthy eating and physical activity to maintain a healthy weight;b consider 

screening for overweight- and obesity-associated conditions (see Sidebar 1) and 

obesogenic medications (see Sidebar 2)”

4. Box 5 connects to Box 6, in the shape of a hexagon, asks the question: “Is patient ready to engage 

with a weight management program?” 

a. If the answer is “Yes” to Box 6, then Box 8, in the shape of a rectangle: “Offer a CLI (see 

Sidebar 5); Continue to monitor and reassess the patient (see Appendix K); Consider 

pharmacotherapy and/or bariatric procedure concurrently with CLI (see Sidebar 6)”

b. If the answer is “No” to Box 6, then Box 7, in the shape of a rectangle: “Offer counseling 

on nutrition, physical activity, and behavior change; ask for permission to readdress at 

subsequent visits. (see Sidebar 4)”

i. Box 7 connects to Box 6, in the shape of a hexagon, asks the question: “Is patient 

ready to engage with a weight management program?”

5. Box 8 connects to Box 9, in the shape of a hexagon, asks the question: “Has patient achieved 

weight management goals?” 

a. If the answer is “Yes” to Box 9, then Box 10, in the shape of a rectangle: “Continue a CLI 

and any additional therapy for weight maintenance; reassess periodically including for 

pharmacotherapy and follow-up for long-term post bariatric procedure management”

b. If the answer is “No” to Box 9, then Box 6, in the shape of a rectangle: “With permission, 

assess patients (see Sidebar 3) and screen for overweight- and obesity-associated 

conditions (see Sidebar 1) and obesogenic medicationsc

” 
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Appendix L: Abbreviations

Abbreviation Definition

Academy The Academy of Nutrition and Dietetics

ACEI angiotensin-converting enzyme inhibitor

AGB adjustable gastric band 

AHRQ Agency for Healthcare Research and Quality

ALT alanine transaminase 

ARB angiotensin receptor blocker 

AST aspartate transaminase

BEI bioelectrical impedance

BMI body mass index

BP blood pressure

BPD biliopancreatic diversion

CCB calcium channel blocker

CDC Centers for Disease Control and Prevention

CI confidence interval

CKD chronic kidney disease 

CLI comprehensive lifestyle intervention

COI conflict of interest

CPGs clinical practice guidelines

CV cardiovascular

CVD cardiovascular disease 

CVT clinical video telehealth 

DASH Dietary Approaches to Stop Hypertension

dL deciliter

DM diabetes mellitus

DoD Department of Defense

DS duodenal switch

EAL evidence analysis library

ERCP endoscopic retrograde cholangiopancreatography

FDA U.S. Food and Drug Administration

g grams

GERD gastroesophageal reflux disease

GI gastrointestinal

GLP-1 glucagon-like peptide 1

GRADE Grading of Recommendations Assessment, Development, and Evaluation

HbA1c hemoglobin a1c

HCG human chorionic gonadotropin
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Abbreviation Definition

HDL-c high-density lipoprotein cholesterol

HTN hypertension

HOMA homeostatic model assessment

HOMA-β homeostatic model assessment of β-cell function 

HOMA-IR homeostatic model assessment of insulin resistance

IGB intragastric balloon

IOM Institute of Medicine

KQs key questions

LAGB laparoscopic adjustable gastric banding

LEADER Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results

LDL-c low-density lipoprotein cholesterol

MEN2 multiple endocrine neoplasia type 2 

mg milligrams

MI myocardial infarction

MTC medullary thyroid cancer

NAFLD non-alcoholic fatty liver disease

NAM National Academy of Medicine

ng nanogram

NICE National Institute for Health and Care Excellence

NIH National Institutes of Health

NASH non-alcoholic steatohepatitis 

NSAID non-steroidal anti-inflammatory drug

NIPHS non-insulinoma pancreatogenous hypoglycemia syndrome 

OTC over-the-counter 

PAGA Physical Activity Guidelines for Americans 

PCOS polycystic ovary syndrome 

PICOTS population, intervention, comparison, outcome, timing, and setting

PE pulmonary embolism

PEG percutaneous endoscopic gastrostomy 

PYO patient years of observation 

QoL quality of life

RCT randomized controlled trial

RD registered dietitian

RR risk ratio

RYGB roux-en-Y gastric bypass 

SCr serum creatinine

SG sleeve gastrectomy

SIK subsistence in Kind
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Abbreviation Definition

SR systematic review

T2DM type 2 diabetes mellitus

U.K. United Kingdom

U.S. United States

USPSTF U.S. Preventive Services Task Force

WC waist circumference
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