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Cited by 103Pharmacology and Obesity TreatmentObesity and Health PracticesBariatric Surgery and Outcomes

Approach to Obesity Treatment in Primary Care: A Review

Open access
Yanovski, Susan Z., Yanovski, Jack A.·2024·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2023.8526PMC PMC12182808
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Abstract

Importance: More than 40% of US adults have obesity, which increases the risks for multiple chronic diseases and premature mortality. Historically, nonsurgical interventions often have not led to sufficient weight loss and maintenance to improve health, but highly effective antiobesity medications (AOMs) have recently become available, and additional effective therapeutics are under development. Given that most medical care for adults with obesity is delivered in primary care settings, guidance for integrating weight-management approaches is needed. Observations: Lifestyle interventions can lead to a mean weight loss of 2% to 9% of initial weight at 1 year and increase the likelihood of weight loss of 5% or more, but weight regain over time is common even with continued treatment. Adjunctive treatments, including AOMs and surgical approaches, can lead to larger, more sustained weight loss and improvements in numerous obesity-associated medical conditions. Highly effective AOMs, including nutrient-stimulated hormone-based therapies, induce mean weight loss of 15% or more. Barriers to intervention, including access to care, have a disproportionate influence on populations most affected by obesity and its consequences. Conclusions and Relevance: Primary care clinicians play a vital role in the assessment, management, and support of patients with obesity. With careful clinical assessment and shared decision-making, a flexible treatment plan can be developed that reflects evidence of treatment efficacy, patient preference, and feasibility of implementation. Adjunctive therapies to lifestyle interventions, including more effective pharmacotherapeutics for obesity, offer hope to patients and the potential for considerable improvements in health and quality of life.

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Crossref · 10.1001/jamainternmed.2023.8526

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Claims the paper makes

0 of 125 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Highly effective anti-obesity medications, including nutrient-stimulated hormone-based therapies, produce mean weight loss of 15% or more.

    “Highly-effective AOMs, including nutrient-stimulated hormone-based therapies, induce mean weight loss of 15% or more.”
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    Weight regain over time is common even when treatment continues.

    “some weight regain occurs over time even with continued intervention.34,35”
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    Nutrient-stimulated hormone-based therapies are the most efficacious anti-obesity medications currently available.

    “They are the most efficacious AOMs currently available (Figure 1).[61][62][63][64]”
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    Highly motivated participants in efficacy trials receiving intensive lifestyle intervention can lose up to 9% of baseline weight at one year.

    “Although highly motivated participants in efficacy trials receiving ILI can lose up to 9% of baseline weight at 1y”
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    Weight-loss maintenance may require greater amounts of physical activity than guidelines for general health.

    “weight-loss maintenance may require greater amounts of PA. 4”
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    Premisecitation

    Lifestyle interventions produce average weight loss of 2-9% of starting weight at one year and raise the probability of losing at least 5%.

    “Lifestyle interventions lead to a mean weight loss of 2-9% of initial weight at 1y and increase the likelihood of weight loss ≥5%”
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    Adjunctive treatments including anti-obesity medications and surgery can yield larger and more sustained weight loss and improve many obesity-associated medical conditions.

    “Adjunctive treatments, including AOMs and surgical approaches, can lead to larger, more sustained weight loss and improvements in numerous obesity-associated medical conditions.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Randomized clinical trials suggest tirzepatide has greater weight-loss efficacy than GLP1-receptor agonists, with mean weight loss of about 20% (placebo-subtracted about 18%) in adults without type 2 diabetes, and 36% losing at least 25% of initial weight.

    “RCTs [75][76][77] suggest weight-loss efficacy greater than GLP1-RAs, with mean weight loss of ≈20% (placebo-subtracted ≈18%) in adults without T2D, and 36% losing ≥25% of initial weight.”
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    Premisecitation

    All anti-obesity medications FDA-approved for long-term use reduce weight on average by at least 5% more than placebo after one year; the proportion achieving at least 5% weight loss is significantly greater than with placebo; several also prevent progression of prediabetes to diabetes and improve quality of life.

    “All AOMs that are FDA-approved for long-term use reduce weight on average by ≥5% more than placebo after 1y; the proportion achieving weight loss ≥5% is also significantly greater than that achieved by the placebo group; several also prevent progression of prediabetes to diabetes and improve quality of life (QoL).[79][80][81]”
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    Premisecitation

    BMI correlates reasonably well with high body fat at BMI ≥30 but has considerable inter-individual variability, especially in the overweight range.

    “BMI should be considered a screening tool that correlates reasonably well with high body fat at BMI ≥30, but has considerable inter-individual variability, particularly in the “overweight” range.15”
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    Barriers to intervention, including access to care, have a disproportionate effect on populations most affected by obesity and its consequences.

    “Barriers to intervention, including access to care, have a disproportionate influence on populations most affected by obesity and its consequences.”
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    Premisecitation

    More than 70% of patients on semaglutide lose at least 10% of initial weight versus fewer than 26% with liraglutide, and over 50% lose at least 15% versus fewer than 15% with liraglutide.

    “More than 70% lose ≥10% initial weight (vs fewer than 26% with liraglutide), and over 50% lose ≥15% of initial weight (vs.fewer than 15% with liraglutide).64”
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    Premisecitation

    Phentermine is frequently prescribed off-label for much longer than its short-term indication and has been by far the most prescribed anti-obesity medication in the US, primarily because of its low cost.

    “Despite this short-term indication, phentermine is frequently prescribed off-label for much longer 20,22 and has been by far the most prescribed AOM in the US, 45,46 primarily because of its low cost.”
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    Premisecitation

    Naltrexone plus bupropion extended-release reduces weight on average by about 7% (about 5% placebo-subtracted) and more than either agent alone.

    “Naltrexone plus bupropion extended-release reduces weight on average by ≈7% (≈5% placebo-subtracted) [51][52][53][54] and also more than either agent administered alone.55”
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    GLP1-receptor agonist adverse events are primarily gastrointestinal and often remit if the dose is titrated slowly, although some patients continue to have nausea or vomiting long-term.

    “GLP1-RA adverse events are primarily gastrointestinal (Table 2) and often remit if the dose is titrated slowly, although some patients continue to have nausea or vomiting long-term.”
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    Premisecitation

    Not everyone with a BMI at or above these thresholds is an appropriate candidate for anti-obesity medications, and some individuals accrue risks at a lower BMI.

    “However, not everyone with a BMI at or above these thresholds is an appropriate candidate for AOMs, and certain individuals accrue risks at a lower BMI.20”
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    Premisecitation

    A 5% weight reduction is insufficient to improve many aspects of health, and greater weight losses confer greater benefits, with some data suggesting a threshold effect for reduction in some important comorbidities such as cardiovascular disease and diabetes remission.

    “However, a 5% weight reduction is insufficient to improve many aspects of health, and greater weight losses confer greater benefits, 23,82,83 with some data suggesting that there may be a threshold effect for reduction in some important comorbidities such as CVD and diabetes remission.[84][85][86]”
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    Physical activity is important for overall metabolic and mental health and is among the most important factors for long-term maintenance of weight loss.

    “it is very important for overall metabolic and mental health and is one of the most important factors in promoting long-term maintenance of weight loss.40,41”
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    FDA indications for anti-obesity medication use in adults are BMI ≥30 or BMI ≥27 with obesity-related comorbid conditions.

    “The US Food and Drug Administration (FDA) indications for AOM use in adults include BMI ≥30 or BMI ≥27 with obesity-related comorbid conditions.44”
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    Premisecitation

    Small studies suggest phentermine produces total weight loss of about 8% and mean 6-month placebo-subtracted weight loss of about 5%.

    “Small studies suggest total weight loss is ≈8% and mean 6-mo placebo-subtracted weight loss is ≈5%.47,48”
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    In a study of adults who achieved at least 5% weight loss with a 12-week intensive lifestyle intervention before randomization, adding tirzepatide led to an additional 18.4% weight loss by week 72 versus 2.5% regain with placebo, for total weight loss of 24.3% versus 4.5%.

    “A study that randomized adults who achieved ≥5% weight loss with a 12-week ILI before taking tirzepatide vs placebo found that those who added tirzepatide lost an additional 18.4% of their initial weight by week 72, vs. regain of 2.5% in the placebo group, leading to a total weight loss from start of intervention of 24.3% with tirzepatide vs 4.5% with placebo.77”
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    Study design and conductnone given

    Differences in intensity of concomitant behavioral interventions can affect total weight loss in both drug and placebo groups, and placebo-subtracted weight loss gives a clearer picture of medication efficacy.

    “Differences in intensity of concomitant behavioral interventions can affect total weight loss in both drug and placebo groups, and placebo-subtracted weight loss provides a clearer picture of medication efficacy.”
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    • Rests on an assumption: Placebo-subtracted weight loss provides a clearer picture of medication efficacy.

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    Premisecitation

    Orlistat three times daily in long-term trials has potential benefits for weight (mean total loss about 7%) and cardiovascular risk factors, but placebo-subtracted weight loss is about 3% and side effects limit its use.

    “Orlistat three-times daily [56][57][58][59] was found in long-term trials to have potential benefits for both weight (mean total loss ≈7%) and cardiovascular risk factors, but placebo-subtracted weight losses are ≈3% and side-effects such oily stools limit its use.60”
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    Premisecitation

    Phentermine plus topiramate extended-release at the highest dose leads to mean total weight loss of about 10% and placebo-subtracted weight loss of about 8%, greater than either drug alone.

    “Phentermine plus topiramate extended-release at the highest dose (phentermine 15mg and topiramate 92mg) leads to mean total weight loss of ≈10% and placebo-subtracted weight loss ≈8%, 49,50 which is greater than observed for either drug administered alone.47”
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    Interpretationcitation

    Strength training and other strategies to preserve lean body mass are likely particularly important for patients using anti-obesity medications or undergoing metabolic and bariatric surgery, and for older adults with sarcopenic obesity.

    “Strength training and other strategies to preserve lean body mass are likely to be particularly important in patients using AOMs or undergoing MBS, 41 as well as older adults who may have sarcopenic obesity.43”
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    Premisecitation

    Phentermine/topiramate may cause acute myopia and secondary angle-closure glaucoma.

    “W: May cause acute myopia and secondary angle closure glaucoma”
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    Premisecitation

    Phentermine/topiramate is contraindicated in pregnancy, and monthly pregnancy testing is required during its use.

    “C: Pregnancy -must perform monthly pregnancy testing”
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    Premisecitation

    Agitated states are a contraindication to noradrenergic agonist therapy.

    “C: Agitated states”
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    Premiseown data

    Glaucoma is listed as a contraindication for the anti-obesity medications in the table.

    “C: Glaucoma”
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    Premisecitation

    Nutritional deficiencies are more likely with RYGB than SG, but micronutrient supplementation and monitoring is recommended for all patients.

    “Nutritional deficiencies are more likely with RYGB than SG, but micronutrient supplementation and monitoring is recommended for all patients.116”
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    Premisecitation

    Evidence-based strategies for assisting patients with inadequate weight loss or weight regain after metabolic and bariatric surgery are few, but adjunctive treatment with anti-obesity medications may provide benefit.

    “Although evidencebased strategies for assisting patients with inadequate weight loss or weight regain after MBS are few, adjunctive treatment with AOMs may provide benefit.121,122”
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    High-quality observational studies show that metabolic and bariatric surgery is associated with greater remission of type 2 diabetes, lower cancer incidence, reduced cardiovascular disease morbidity and mortality, and lower all-cause mortality compared with matched non-operated controls.

    “while high-quality observational studies show greater remission of T2D, lower cancer incidence, reduced CVD morbidity and mortality, and all-cause mortality compared to matched non-operated controls.106”
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    Premisenone given

    Adjunctive treatments including anti-obesity medications and metabolic and bariatric surgery lead to larger and more sustained weight loss and improvements in numerous obesity-associated medical conditions.

    “Adjunctive treatments, including AOMs and MBS, lead to larger and more sustained weight loss, and improvements in numerous obesity-associated medical conditions.”
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    Most professional society, governmental, and other guidelines have not yet incorporated research findings or recommendations for newly-approved or investigational medications.

    “Most professional society, governmental, and other guidelines have not yet incorporated research findings or recommendations for newly-approved or investigational medications.”
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    Premisecitation

    In an extension of a semaglutide 2.4 mg trial, participants lost 17.3% of initial weight; discontinuation of the drug and associated lifestyle intervention led to regain of two-thirds of the lost weight in the ensuing year, with similar reversion in improvements of cardiometabolic variables.

    “in an extension of a clinical trial of semaglutide 2.4mg in which participants lost 17.3% of their initial weight, discontinuation of the drug and associated lifestyle intervention led to regain of two-thirds of the lost weight in the ensuing year, with similar reversion in improvements of cardiometabolic variables.98”
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    Study design and conductreasoning

    This review is not a systematic review, and some relevant publications may not have been included.

    “While we searched the published literature, this is not a systematic review, and some relevant publications may not have been included.”
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    Premisecitation

    RYGB appears to increase risk of later alcohol-related problems, although it is uncertain whether SG confers similar risk.

    “RYGB appears to increase risk of later alcohol-related problems, although it is uncertain whether SG confers similar risk.114”
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    Premisecitation

    Randomized clinical trials suggest RYGB and SG have similar efficacy for weight loss and diabetes remission for up to 5 years, although a very large comparative effectiveness study found significantly greater weight loss with RYGB at up to 5 years (RYGB -25.5%; SG -18.8%).

    “RCTs suggest that RYGB and SG have similar efficacy for weight loss and diabetes remission for up to 5y, 107 although a very large comparative effectiveness study found significantly greater weight loss with RYGB at up to 5y (RYGB -25.5%;SG -18.8%).108”
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    Long-term data for newer and investigational anti-obesity medications are not yet available.

    “Long-term data for newer and investigational AOMs are not yet available.”
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    Premisenone given

    Lifestyle interventions are often insufficient to help patients achieve weight loss-related goals.

    “Lifestyle interventions are often insufficient to help patients achieve weight loss-related goals.”
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    Premisecitation

    Semaglutide 2.4 mg improved symptoms and exercise tolerance in patients with heart failure with preserved ejection fraction, with greater effects among those with higher baseline BMI.

    “Semaglutide 2.4mg also improved symptoms and exercise tolerance in patients with heart failure with preserved ejection fraction (HFpEF), 90 with greater effects among those with higher baseline BMI.83”
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    Premisecitation

    The SELECT trial found that semaglutide 2.4 mg reduced the risk for major adverse cardiovascular events by 20% in patients with obesity and cardiovascular disease but without diabetes, even though most were already taking cardioprotective medications such as statins.

    “Results from SELECT, a cardiovascular events trial of semaglutide 2.4mg in 17,604 adults, indicate that semaglutide reduced the risk for major adverse cardiovascular events by 20% in patients with obesity and cardiovascular disease but without diabetes, even though most were already taking cardioprotective medications such as statins.89”
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    Premisecitation

    Phentermine/topiramate is not recommended in severe hepatic impairment.

    “W: Not recommended in severe hepatic impairment”
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    Premisecitation

    Insufficient weight loss or significant regain is more likely with SG than RYGB, but regain to within 5% of preoperative weight occurs in only 2-4% of RYGB and 10-15% of SG patients at 5-10 years.

    “Insufficient weight loss or significant regain is more likely with SG than RYGB, but regain to within 5% of preoperative weight occurs in only 2-4% of RYGB and 10-15% of SG patients at 5-10y.107,109-112”
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    Premisecitation

    In the SURMOUNT-4 trial, participants lost an average of 21% with tirzepatide after 36 weeks and were then randomized to continued drug or placebo for an additional 52 weeks; continued treatment led to additional weight loss of 5.5% between weeks 36 and 88, versus regain of 14% in the placebo group.

    “The SURMOUNT-4 trial, in which participants lost an average of 21% with tirzepatide after 36 weeks and were then randomized to continued drug or placebo for an additional 52 weeks, demonstrated additional weight loss of 5.5% between weeks 36 and 88 with continued treatment, vs regain of 14% in the group switched to placebo.99”
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    Premisecitation

    SG has a lower cumulative incidence of hospitalizations, endoscopy, and reoperations than RYGB, but mortality with both is low.

    “SG has a lower cumulative incidence of hospitalizations, endoscopy, and reoperations than RYGB, 113 but mortality with both is low.”
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    Premisecitation

    Diabetic retinopathy should be monitored for worsening during GLP-1 receptor agonist therapy.

    “W: Monitor diabetic retinopathy for worsening”
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    Premisecitation

    Metabolic acidosis and reduced renal function should be monitored during phentermine/topiramate therapy.

    “W: Monitor for metabolic acidosis and reduced renal function”
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    Premisecitation

    Depression and suicidal thoughts should be monitored during phentermine/topiramate and naltrexone/bupropion therapy.

    “W: Monitor for depression/suicidal thoughts”
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    Premisecitation

    Pulse and blood pressure should be monitored during naltrexone/bupropion therapy.

    “W: Monitor pulse and blood pressure”
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    Premisecitation

    Phentermine/topiramate is not recommended when the glomerular filtration rate is below 30 mL/min because it is renally cleared.

    “W: GFR < 30 mL/min (renally cleared)”
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    Premisecitation

    Creatinine should be monitored during phentermine/topiramate therapy.

    “W: Monitor creatinine”
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    Premisecitation

    Hepatotoxicity and hypoglycemia should be monitored during naltrexone/bupropion therapy.

    “W: Monitor for hepatotoxicity, hypoglycemia”
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    Premisecitation

    Pulse should be monitored during phentermine/topiramate therapy.

    “W: Monitor pulse”
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    Premisecitation

    Orlistat is not recommended when the glomerular filtration rate is below 30 mL/min.

    “W: GFR < 30 mL/min”
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  • The paper relies on this without support.

    Most medical care for adults with obesity is delivered in primary care settings.

    “Given that most medical care for adults with obesity is delivered in primary care settings, guidance for integrating weight-management approaches is needed.”

  • The paper relies on this without support.

    In-person intensive lifestyle intervention is more effective than remote delivery.

    “Although in-person ILI has been shown to be most effective, lifestyle treatments delivered remotely are increasingly used and have the advantages of convenience and accessibility.”

  • The paper relies on this without support.

    Placebo-subtracted weight loss provides a clearer picture of medication efficacy.

    “Differences in intensity of concomitant behavioral interventions can affect total weight loss in both drug and placebo groups, and placebo-subtracted weight loss provides a clearer picture of medication efficacy.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The claimed minimum drug effect conflicts with the orlistat result

    Minor

    The paper says every anti-obesity medication approved for long-term use produces at least 5% more weight loss than placebo after one year, but it reports an approximately 3% placebo-subtracted loss for orlistat, which it describes using long-term trials.

  • Adverse-event discussion points to the BMI table

    Minor

    The cited table classifies body weight by BMI; adverse events appear in Table 3 instead.

2 of 2

The citation lists haven’t been fetched yet

References 116 · Cited by 103

Research works printed but not linked: 13

  1. Flegal, 2013, Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis., JAMA, 309, 71, 10.1001/jama.2012.113905 · DOI · Paper page
  2. Yuen, 2023, Health complications of obesity: 224 obesity-associated comorbidities from a mechanistic perspective., Gastroenterol Clin North Am, 52, 363, 10.1016/j.gtc.2023.03.006 · DOI
  3. National Institutes of Health, 1998, Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report., Obes Res, 6, 51S
  4. O’Gurek, 2018, A practical approach to screening for social determinants of health., Fam Pract Manag, 25, 7
  5. Curry, 2018, Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement., JAMA, 320, 1163, 10.1001/jama.2018.13022 · DOI · Paper page
  6. LeBlanc, 2018, Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: updated evidence report and systematic review for the US Preventive Services Task Force., JAMA, 320, 1172, 10.1001/jama.2018.7777 · DOI · Paper page
  7. Yanovski, 2018, Weight management in adults with obesity: what is a primary care clinician to do?, JAMA, 320, 1111, 10.1001/jama.2018.11031 · DOI
  8. Yanovski, 2014, Long-term drug treatment for obesity: a systematic and clinical review., JAMA, 311, 74, 10.1001/jama.2013.281361 · DOI · Paper page
  9. Davies, 2015, Efficacy of liraglutide for weight loss among patients with type 2 diabetes: the SCALE Diabetes randomized clinical trial., JAMA, 314, 687, 10.1001/jama.2015.9676 · DOI · Paper page
  10. Weintraub, 1984, A double-blind clinical trial in weight control: use of fenfluramine and phentermine alone and in combination., Arch Intern Med, 144, 1143, 10.1001/archinte.1984.00350180055008 · DOI · Paper page
  11. LeBlanc, 2018, Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: updated evidence report and systematic review for the US Preventive Services Task Force., JAMA, 320, 1172, 10.1001/jama.2018.7777 · DOI · Paper page
  12. Colquitt, 2014, Surgery for weight loss in adults., Cochrane Database Syst Rev, 2014
  13. Kim, 2000, Endotext

Authors
Yanovski, S. Z., & Yanovski, J. A.
Affiliations
National Institutes of Health (US)
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2024-07-01
Volume
184
Issue
7
Pages
818
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2023.8526
PMC
PMC12182808
OpenAlex
W4392662846
Cited by
103
References
116
Citations by year
2026: 59 · 2025: 35 · 2024: 9
FWCI
6.45
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • U.S. Department of Health and Human Services
  • National Institutes of Health (Z99HD999999)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (ZIAHD000641)
Topics
  • Health Sciences › Medicine › Pharmacology › Pharmacology and Obesity Treatment
  • Health Sciences › Health Professions › Pharmacy › Obesity and Health Practices
  • Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
Keywords
obesity treatment, primary care, anti-obesity drugs, lifestyle intervention, weight loss, weight regain, bariatric surgery, shared decision-making, health care access, barriers to care, obesity-related comorbidities
MeSH terms
Humans, Life Style, Obesity, Primary Health Care, Weight Loss, Anti-Obesity Agents, Bariatric Surgery

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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