Obesity Evaluation & Management (Endocrine Society 2022)

Algorithm Steps

1. ▶

   Start

   Obesity Assessment

   BMI ≥30 or ≥25 with comorbidities

   1. ●

      Action

      Comprehensive Evaluation

      Identify contributing factors

      • Medication review (obesogenic drugs)
      • Screen for secondary causes: hypothyroidism, Cushing's
      • Assess eating behaviors, food security
      • Evaluate for sleep apnea
      • Assess mental health (depression, binge eating)
      1. ◆

         Decision

         BMI Stratification

         Determine treatment intensity

         • 25-29.9: Overweight
         • 30-34.9: Class I Obesity
         • 35-39.9: Class II Obesity
         • ≥40: Class III Obesity
         1. ●

            Action

            Lifestyle Intervention (All)

            Foundation of all obesity treatment

            • Caloric deficit: 500-750 kcal/day reduction
            • Physical activity: 150-300 min/week moderate
            • Behavioral counseling
            • Consider dietitian referral
            • Goal: 5-10% weight loss initial target
         2. ◆

            Decision

            Pharmacotherapy Eligible?

            BMI ≥30 OR ≥27 with comorbidity

            • Comorbidities: T2DM, HTN, dyslipidemia, OSA, NAFLD, PCOS
            1. ●

               Action

               Anti-Obesity Medications

               FDA-approved options

               • Semaglutide 2.4mg weekly (Wegovy): 15-17% WL
               • Tirzepatide (Zepbound): 20-25% WL
               • Phentermine-topiramate ER: 8-10% WL
               • Bupropion-naltrexone: 5-6% WL
               • Orlistat: 3-5% WL
               1. ●

                  Action

                  GLP-1 RA / GIP-GLP-1

                  Most effective agents

                  • Semaglutide: Start 0.25mg weekly, titrate to 2.4mg
                  • Tirzepatide: Start 2.5mg weekly, titrate to 15mg
                  • Titrate slowly (every 4 weeks) to minimize GI side effects
                  • Contraindicated: personal/family MTC, MEN2
                  1. ◆

                     Decision

                     12-Week Response

                     Assess weight loss

                     • Response: ≥5% weight loss
                     • If <5% on max dose, consider alternative agent
                     1. ●

                        Action

                        Continue Therapy

                        Long-term maintenance

                        • Medications often needed indefinitely
                        • Weight regain common if stopped
                        • Continue lifestyle modifications
                        • Monitor for side effects
                     2. ◆

                        Decision

                        Bariatric Surgery Eligible?

                        NIH criteria

                        • BMI ≥40
                        • BMI ≥35 with obesity-related comorbidity
                        • BMI ≥30 with T2DM (metabolic surgery)
                        • Failed lifestyle + pharmacotherapy
                        1. ●

                           Action

                           Bariatric Surgery Referral

                           Most effective for severe obesity

                           • Sleeve gastrectomy most common
                           • Gastric bypass for DM, GERD
                           • 20-35% sustained weight loss
                           • Lifelong vitamin supplementation
                           • Multidisciplinary team required
      2. ●

         Action

         Address Comorbidities

         Obesity-related conditions

         • Screen for OSA (STOP-BANG)
         • Assess and treat NAFLD
         • Optimize glycemic control
         • Manage hypertension, lipids
         • Address mental health