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Management of obesity in adults: a review | Bariatric surgery | JAMA

Obesity affects approximately 42% of American adults and is associated with increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death.

A body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ≥ 25-27.5 ), although the use of BMI alone is not recommended to determine individual risk. Obese people have higher rates of cardiovascular disease. Among men with a BMI between 30 and 39, cardiovascular event rates are 20.21 per 1,000 person-years, compared to 13.72 per 1,000 person-years among men with a normal BMI. Among women with a BMI between 30 and 39.9, cardiovascular event rates are 9.97 per 1,000 person-years, compared to 6.37 per 1,000 person-years among women with a normal BMI. In obese people, a 5 to 10 percent weight loss improves systolic blood pressure by about 3 mm Hg for people with hypertension and can decrease hemoglobin A.1 C 0.6% to 1% for people with type 2 diabetes. Evidence-based treatment of obesity includes interventions addressing 5 broad categories: behavioral interventions, nutrition, physical activity, pharmacotherapy and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for each patient. Multi-component behavioral interventions, ideally comprising at least 14 sessions over 6 months to promote lifestyle changes, including elements such as weight self-monitoring, diet and physical activity counseling and problem solving, often produce 5-10% weight loss, although weight recovery occurs in 25% or more of participants after 2 years follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction generally results in less weight loss (2 to 3 kg), but is important for maintaining weight loss. Commonly prescribed medications such as antidepressants (e.g., mirtazapine, amitriptyline) and antihyperglycemic agents such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Anti-obesity medications are recommended for non-pregnant patients with obesity or overweight and weight-related comorbidities, in conjunction with lifestyle modifications. Six drugs are currently approved by the United States Food and Drug Administration for long-term use: glucagon-like peptide 1 (GLP-1) receptor agonists (semaglutide and liraglutide only), tirzepatide (an insulinotropic glucose polypeptide -GLP-1 dependent/agonist). ), phentermine-topiramate, naltrexone-bupropion and orlistat. Of these, tirzepatide has the greatest effect, with an average weight loss of 21% at 72 weeks. Endoscopic procedures (i.e., intragastric balloon and endoscopic sleeve gastroplasty) can achieve 10-13% weight loss at 6 months. Weight loss due to metabolic and bariatric surgeries (i.e., laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining weight loss long-term is difficult, and clinical guidelines support the use of long-term anti-obesity medications when weight maintenance is not sufficient with lifestyle interventions alone.

Conclusion and relevance
Obesity affects approximately 42% of adults in the United States. Behavioral interventions can achieve approximately 5-10% weight loss, GLP-1 agonists and glucose-dependent insulinotropic polypeptides/GLP-1 receptor agonists can achieve approximately 8-21% weight loss, and bariatric surgery can reach around 25 to 30%. % weightloss. Comprehensive, evidence-based treatment of obesity combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures tailored to each patient.

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