GUIDELINES FOR TREATING AND MANAGING OBESITY12
Treatment for an overweight or obese person incorporates a two-step process: assessment and management. Before starting a weight loss regimen, complications related to obesity, such as hypertension, type 2 diabetes, hyperlipidemia, atherosclerotic cardiovascular disease, osteoarthritis of the lower extremities, gallbladder disease, gout, and cancers should be assessed and managed. Risk factors that increase the cardiovascular risk of obesity include: cigarette smoking, hypertension, age >45 years for men or age >55 years for women, family history of premature CHD (coronary heart disease), high-risk LDL cholesterol (>160mg/dL), low HDL (<35mg/dL), and impaired fasting glucose (normal: 110–125mg/dL).

The three major components of weight-loss therapy are dietary therapy, physical activity, and behavior therapy.12 Lifestyle therapies should be attempted for at least six months before considering pharmacotherapy. Dietary therapy recommends a low calorie diet of 1000–1,200kcal/day for most women and 1,200–1,600kcal/day for most men. The goal is a weight loss of 1–2 pounds per week. Physical activity should also be an integral part of weight-loss therapy and maintenance. Moderate levels of physical activity for 30–45 minutes, 3–5 days a week is encouraged. This level of exercise is also beneficial for reducing risks of cardiovascular disease and type 2 diabetes. Behavior therapy is also a useful adjunct to planned adjustments in food intake and physical activity. These adjustments include self-monitoring, stress management, stimulus control, and social support.

Pharmacotherapy may be useful as an adjunct to diet and physical activity. Current guidelines recommend orlistat, phentermine, phendimetrazine, and diethylpropion. Orlistat is approved as prescription-only Xenical (Roche) which is indicated for use in adults and children >12 years of age. The recommended dose is 120mg three times a day with each main meal containing fat.13 It is also approved as an over-the-counter agent Alli (Roche) which is indicated for adults >18 years of age. The recommended dose is 60mg three times a day with each main meal containing fat.14,15 Phendimetrazine (Bontril PDM and Bontril Slow Release; Valeant) is approved for use only in adults. The recommended dose 35mg two or three times daily, one hour before meals, to a maximum of 210mg/day in three doses.16 Diethylpropion is approved for adults and children >16 years of age and comes as an immediate-release and a controlled-release tablet. The usual dose for the immediate-release diethylpropion is 25mg three times a day, one hour before meals, and in mid-evening if needed to cover for meals. 17 The usual dose for the controlled-release diethylpropion is 75mg once a day in the morning.18 With pharmacotherapy, appropriate monitoring for side effects is recommended. Pending the launch of the recently approved therapies, guidelines may shift in their approach regarding short-term treatment with older agents versus chronic therapy with the newer agents. Phentermine is approved for adults and children >16 years old. It is available in a capsule and tablet formulation (usual dose: 15–37.5mg/day given in 1–2 doses), as well as an orally- disintegrating tablet (usual dose: 15mg or 30mg taken every morning).


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A 10% reduction in body weight within six months to a year is considered good progress, however, it is important to recognize that some patients may be more apt to lose or gain weight depending on their regimen, and that this should not necessarily be attributed to the degree of compliance. Once achieved, weight maintenance should be encouraged through continued contact with the healthcare practitioner for education, support, and monitoring.