The American College of Physicians (ACP) has issued new clinical guidelines to help physicians choose medications, along with lifestyle modifications to manage overweight and obesity in their adult patients.

The national organization of internal medicine physicians noted 68.5% of U.S. adults are now overweight or obese, chronic conditions that increase the risk of serious health problems including type 2 diabetes, high blood pressure, heart disease and some cancers.

So, the ACP published new recommendations in the Annals of Internal Medicine to help tackle overweight and obesity with medications. It’s known as a “living guideline” because it will be updated periodically as new evidence becomes available.

“The new guideline provides evidence-based recommendations to help people who have overweight and obesity understand the benefits and harms of pharmacologic treatment,” said Douglas K. Owens, MD, MS, chair of the Department of Health Policy and a member of the ACP committee that produced the new guideline. “Lifestyle modification such as improved nutrition and physical activity are cornerstones of management and newer agents can be highly effective and have a favorable impact on a broad range of health outcomes.”

The Guidelines

For nonpregnant adults with obesity (a BMI of 30 or greater), the ACP recommends semaglutide and tirzepatide as first-line options, alongside lifestyle modifications for weight management. It recommends phentermine-topiramate as a second-line treatment, liraglutide as a third-line treatment, and naltrexone-bupropion as a fourth-line treatment.

For nonpregnant adults with overweight (a BMI 27 to 30) and at least one comorbid condition—such as type 2 diabetes, dyslipidemia, hypertension, obstructive sleep apnea, or cardiovascular disease—the ACP recommends semaglutide or tirzepatide as a first-line treatment and liraglutide as a second-line treatment with lifestyle modifications.

The ACP, whose membership includes 163,000 internal medicine physicians, related subspecialists, and medical students, emphasized in the guideline that when starting or changing weight management medications, doctors and patients should talk about the benefits, risks and costs, as well as any warnings or contraindications. They also stressed the importance of discussing potential side effects of weight loss, such as nutritional gaps and loss of muscle and bone density, especially in older adults.

“Overweight and obesity are chronic, progressive conditions that raise the risk of significant health complications and reduce life expectancy,” said Jan K. Carney, MD, MPH, MACP, President of ACP. “While first-line management for overweight and obesity with lifestyle changes such as improved nutrition and increased physical activity remain essential, many adults still struggle to achieve clinically meaningful weight loss. With physician oversight, evidence suggests that pharmacologic treatments can positively impact people’s health and help them achieve safe weight loss.”

The ACP noted in its published guideline that despite the availability of weight loss treatments, patients remain undertreated, likely because of availability and access to these medical interventions.

Economic Burden

Not only does overweight and obesity reduce life expectancy, but they also impact the pocketbook. Chronic conditions linked to overweight and obesity typically lead to more doctor visits, hospitalizations, medications, and surgeries—a compounding problem that impacts employers, insurance companies and government programs. 

“The economic burden of overweight and obesity is also very high,” the ACP guideline committee members wrote.  “As the prevalence of obesity continues to increase, the World Obesity Federation has estimated that the global impact of overweight and obesity, as a result of higher health care costs and lost economic productivity, will exceed $4.3 trillion in 2035, which would account for nearly 3% of the global gross domestic product.” 

The ACP noted that the optimal duration of weight loss drugs remains uncertain and that more long-term safety data are needed. But studies have shown that regaining lost weight does occur when patients stop using these medications.

“A conversation about the possibility of using weight management medications for the patient’s lifetime is important,” they wrote.