Special Populations and Long-Term Management in Obesity Medicine

Function

Obesity Management Clinical Considerations 

Obesity management requires considering the various factors that impact a patient's weight, eg, drug-induced weight changes, pregnancy-related weight gain, menopause-associated metabolic changes, or sarcopenic obesity in older adulthood. 

Drug-induced weight gain management

Medication-induced weight gain represents a significant challenge in obesity management, affecting up to 25% of patients with obesity.[3] The most effective approach involves identifying weight-promoting medications, considering alternative options, and implementing adjunctive strategies to manage weight. The process of tailoring treatment for medication-induced weight gain relies on structured evaluation. Clinicians should evaluate all current medications for their potential to promote weight gain and assess a patient's reproductive status, including contraceptive needs. Clinicians should also carefully assess age-related metabolic changes and screen for genetic or syndromic indicators of obesity.

Functional assessments help identify mobility limitations and caregiver support requirements, while psychiatric comorbidities and potential medication interactions demand close attention. This comprehensive approach ensures that treatment modifications address physiological and psychosocial factors contributing to obesity, allowing for more precise and effective patient care. Common weight-promoting medications include antipsychotics, antidepressants, anticonvulsants, corticosteroids, and certain diabetes medications such as insulin. Alternative medications with neutral or beneficial weight effects should be selected when clinically appropriate. For patients requiring weight-promoting medications, adjunctive use of obesity pharmacotherapy can help mitigate weight gain.

Reproductive health considerations

Clinicians should assess reproductive stage–specific contraceptive needs and integrate appropriate contraception into the patient's obesity management plan. (see Table 1)

Table 1. Contraception and Obesity Treatment Timing

Clinicians should consider a woman's reproductive stage when planning obesity management. During pregnancy, the Institute of Medicine recommends total gestational weight gain of 11 to 20 pounds (5–9 kg) for women with obesity.[4] Most obesity medications should be discontinued during pregnancy, with lifestyle interventions forming the primary treatment approach. Pregnancy weight gain recommendations vary by prepregnancy body mass index (BMI), with closer monitoring required for women with a higher baseline BMI. Behavioral interventions that emphasize nutrition and physical activity can help reduce excessive weight gain during pregnancy.[5] Breastfeeding provides natural weight loss benefits for most women, with exclusive breastfeeding associated with greater postpartum weight loss. However, women with obesity may face challenges initiating and maintaining breastfeeding, requiring formal lactation support.[6] 

Obesity Management Modifications for Special Populations

Obesity management in special populations requires a highly individualized approach that takes into account life stage, comorbid conditions, medication effects, and social factors that influence health. 

Menopausal individuals

Hormonal changes associated with menopause significantly impact weight distribution and metabolic function. Estrogen deficiency is associated with increased visceral adiposity and decreased energy expenditure. Treatment modifications should address hormonal influences on appetite regulation and metabolic rate. Menopausal women may benefit from a higher protein intake to help preserve lean body mass and participation in regular sessions of resistance training. Hormone replacement therapy, when appropriate, can help mitigate specific metabolic changes; however, an individualized risk-benefit assessment is essential.

Geriatric populations

Older adults require modified approaches due to age-related changes in metabolism, medication sensitivity, and functional capacity. Weight loss targets may be more conservative, emphasizing preservation of lean body mass and functional capacity over absolute weight reduction. Sarcopenic obesity, characterized by the combination of excess adiposity and muscle loss, requires particular attention to protein intake and resistance exercise. Medication dosing may need adjustment due to altered pharmacokinetics in older adults.

 In the above clinical scenario, clinicians should consider the following:

• Drug-induced weight gain mechanisms 
  • Evaluate sertraline's 5-hydroxytryptamine 2C receptor antagonism contributing to weight gain.
  • Consider switching to bupropion or duloxetine if clinically appropriate.
• Reproductive health status: Assess perimenopausal status, contraceptive needs, and plan for potential medication adjustments during transition.
• Impact of menopausal symptoms: Address how hot flashes and sleep disturbances affect eating behaviors, physical activity, and treatment adherence.
• Coordinated care planning: Establish communication with psychiatry for medication management and primary care for hormone evaluation.

Complex medical populations

Patients with complex comorbidities may require adaptive strategies to optimize obesity management, including the following:

• Multimorbidity: Patients with multiple chronic conditions require individualized approaches balancing competing priorities. Common combinations include obesity with diabetes, cardiovascular disease, and depression. Treatment plans must consider medication interactions, monitoring requirements, and coordination with specialists.
• Pretransplant individuals: Organ transplant candidates often require specific weight targets for surgical eligibility. Rapid weight loss may require intensive interventions, including low-calorie diets, pharmacotherapy, or bariatric surgery. Close monitoring for nutritional deficiencies and medical stability is essential.
• Limited mobility: Patients with physical limitations require adaptive nutrition and physical activity strategies. Chair-based exercises, pool therapy, and assistive devices can facilitate increased energy expenditure. Nutritional interventions become more critical when physical activity options are limited.
• Severe mental illness: Patients with conditions such as schizophrenia or bipolar disorder face unique challenges, including medication-induced weight gain, cognitive barriers to behavior change, and social determinants affecting food access. Collaborative care with psychiatry and social services is essential.
• Thyroid dysfunction: Hypothyroidism affects 5% to 10% of patients with obesity and can contribute to weight gain through a decreased metabolic rate. Thyroid function should be assessed in patients with unexplained weight gain or difficulty losing weight despite appropriate interventions. Thyroid hormone replacement should be optimized before attributing treatment resistance solely to behavioral factors. However, thyroid replacement alone rarely produces significant weight loss in euthyroid patients. A combination of appropriate thyroid management with comprehensive obesity treatment yields optimal outcomes.
• LGBTQ+ populations: These patients face unique challenges, including healthcare discrimination, body image issues, and barriers to accessing affirming care. Treatment approaches should be inclusive and culturally sensitive, addressing specific needs such as hormone therapy effects on weight and metabolism. Individuals identifying as transgender may experience weight changes related to gender-affirming hormone therapy. Testosterone therapy in transgender men may increase appetite and muscle mass, while estrogen therapy in transgender women may promote fat redistribution. Treatment plans should account for these physiological changes while providing supportive, nonjudgmental care.

Genetic obesity populations

Recognition of genetic obesity syndromes is crucial for making appropriate referrals and effectively treating patients with these complex conditions. Please refer to StatPearls' companion resource, "Genetic and Syndromic Causes of Obesity: Diagnosis and Management," for additional information. Rare genetic conditions associated with obesity include leptin deficiency, proopiomelanocortin deficiency, and Prader-Willi syndrome. For certain genetic disorders, therapies such as setmelanotide are available, making a precise diagnosis essential for effective treatment. Red flags for genetic obesity syndromes include:

• Early-onset severe obesity (BMI >95th percentile before age 5)
• Hyperphagia with lack of satiety
• Developmental delays or intellectual disability
• Multiple family members with severe obesity
• Distinctive facial features or other dysmorphisms
• Endocrine abnormalities (eg, hypothyroidism and hypogonadism)

Issues of Concern

Managing Weight-Related Conditions

Managing obesity-related comorbidities requires coordination between obesity medicine specialists and other healthcare practitioners (see Table 2). The approach emphasizes both weight reduction and condition-specific management strategies.

Table 2. Weight-Related Comorbidities and Specialist Referral Guidelines

Type 2 diabetes management coordination

Weight loss is the most effective intervention for achieving remission of type 2 diabetes, with a 7% weight loss associated with a 58% reduction in the progression of diabetes.[7] The American Diabetes Association recommends preferential use of glucose-lowering agents with weight loss benefits, including glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 inhibitors.[3] Medication deprescribing becomes essential as weight loss improves glycemic control. Insulin doses may need to be significantly reduced to prevent hypoglycemia. Continuous glucose monitoring can facilitate safe medication adjustments during phases of active weight loss. Diabetes remission, defined as an HbA1c level of less than 6.5% and the discontinuation of glucose-lowering medications for at least 3 months, is achievable in many patients who undergo significant weight loss. Bariatric surgery demonstrates the highest remission rates, particularly in patients with shorter diabetes duration and better baseline beta-cell function.

Dyslipidemia treatment approach

Weight loss effectively improves lipid profiles, particularly triglycerides and high-density lipoprotein cholesterol. A 5% to 10% weight reduction typically yields clinically meaningful improvements in lipid levels. Statin therapy may require adjustment as cardiovascular risk profiles change with weight loss. Weight reduction yields dose-dependent blood pressure improvements, with a 1- to 2-mmHg reduction per kilogram of weight lost. Medication reduction should be systematic and monitored closely to prevent rebound hypertension. The following management considerations are recommended for patients with hypertension:

• Monitor blood pressure weekly during active weight loss.
• Reduce or discontinue medications, starting with diuretics, then angiotensin-converting enzyme inhibitors, and finally angiotensin II receptor blockers.
• Target blood pressure <130/80 mm Hg unless contraindicated.
• Consider medication interactions with obesity pharmacotherapy.
• Ensure that all changes are clearly documented for the patient's care team to facilitate effective communication and informed decision-making.

Obesity Management and Organ-System Comorbidities

Metabolic dysfunction–associated steatotic liver disease (MASLD)

This condition affects up to 80% of patients with obesity. Weight loss remains the cornerstone of treatment, with a 7% to 10% weight reduction producing significant histologic improvement in most patients. Hepatology referral is indicated for patients with evidence of advanced fibrosis, portal hypertension, or those who may require liver transplantation. Non-invasive assessment of fibrosis using elastography or biomarkers helps stratify patients who need specialist care.

Gastroesophageal reflux disease 

Gastroesophageal reflux disease management in obesity involves weight reduction and symptom control. Weight loss improves reflux symptoms and the underlying pathophysiology of the condition. Bariatric surgery, particularly sleeve gastrectomy, may worsen reflux in some patients, requiring careful preoperative evaluation.

In the above clinical scenario, clinicians should consider the following recommendations:

• Prioritization of specialist referrals: Determine whether an immediate nephrology consultation is necessary to evaluate the progression of chronic kidney disease versus an endocrinology consultation for diabetes optimization.
• Medication interaction assessment: Evaluate contraindications for GLP-1 agonists in chronic kidney disease and potential renal protective effects.
• Monitoring parameter establishment: Develop a systematic approach to tracking estimated glomerular filtration rate, HbA1c, blood pressure, and progress toward weight loss.
• Clinician communication strategies: Establish clear information sharing between nephrology, endocrinology, sleep medicine, and obesity medicine.

Psychiatric comorbidities

Mental health conditions to consider when managing obesity include: 

• Binge eating disorder: Binge eating disorder affects 25% to 30% of patients seeking obesity treatment. Lisdexamfetamine is Food and Drug Administration-approved for moderate to severe binge eating disorder and produces both behavioral improvement and weight loss. Cognitive behavioral therapy represents the first-line psychotherapy.
• Depression and anxiety: Mental health conditions are bidirectionally related to obesity. Depression increases obesity risk, while obesity contributes to depression development. Coordinated care with mental health practitioners is essential, particularly when adjusting psychiatric medications that affect weight. Certain antidepressants, particularly bupropion, may facilitate weight loss and are preferred when clinically appropriate. Selective serotonin reuptake inhibitors typically have neutral weight effects, while tricyclics and mirtazapine commonly cause weight gain.
• Attention-deficit/hyperactivity disorder: Attention-deficit/hyperactivity disorder is associated with increased obesity risk through effects on executive function and impulse control. Stimulant medications may facilitate weight management through appetite suppression, though this effect often diminishes over time (see Table 3).

Table 3. Indications for Referral Versus Comanagement in Patients with Comorbidities

Clinical Significance

Formulating Effective Treatment Plans 

Evidence-based treatment integrates behavioral counseling techniques, cultural considerations, and shared decision-making approaches to inform treatment planning and delivery. The 5A's framework (assess, advise, agree, assist, arrange) provides the following structured approach to patient encounters:

• Assess: Current weight status, comorbidities, previous attempts, readiness to change
• Advise: Clear, personalized recommendations based on clinical guidelines
• Agree: Collaborative goal setting with patient input and preferences
• Assist: Provide resources, referrals, and specific action steps
• Arrange: Schedule follow-up and monitoring plan [1]

The 5A's framework, initially developed for smoking cessation, has been successfully adapted for obesity counseling. Clinical practice reviews demonstrate that improved clinician adherence to counseling guidelines is associated with enhanced patient outcomes when these guidelines are implemented consistently.[8] Research indicates that the comprehensive implementation of the 5A's improves weight loss outcomes compared to brief advice alone. Training programs for healthcare practitioners demonstrate feasibility and effectiveness across diverse practice settings.[1]

Motivational interviewing techniques

Motivational interviewing enhances patient engagement and facilitates behavior change by exploring ambivalence and enhancing intrinsic motivation. Meta-analyses demonstrate significant benefits in weight loss compared to standard counseling approaches.[9][10] Core principles include expressing empathy, developing discrepancy between current behaviors and goals, rolling with resistance, and supporting self-efficacy. The OARS technique (open-ended questions, affirmations, reflective listening, summaries) facilitates effective patient communication.

Shared decision-making

Shared decision-making involves a collaborative discussion of treatment options, taking into account the patient's preferences, values, and circumstances. This approach enhances treatment adherence and patient satisfaction while respecting individual autonomy. Effective shared decision-making requires presenting evidence-based options, discussing the benefits and risks associated with them, and incorporating patients' priorities into the treatment selection process. Decision aids can facilitate this process by providing standardized information about treatment alternatives.

Cultural competency integration

Cultural competency requires understanding how ethnicity, religion, socioeconomic status, and other factors influence health behaviors and treatment preferences (see Table 4). Interventions must be adapted to align with cultural values while maintaining clinical effectiveness. Research demonstrates significant health disparities in obesity prevalence and treatment outcomes across different ethnic and socioeconomic groups. Culturally adapted interventions show improved engagement and outcomes compared to standard approaches.

Table 4. Cultural Considerations in Treatment Planning

Social determinants of health

The following social determinants of health impact obesity:

• Food insecurity: Food insecurity affects treatment success and should be systematically assessed. Referrals to the Supplemental Nutrition Assistance Program (SNAP) and the Women, Infants, and Children (WIC) program can improve nutrition quality and treatment adherence. Healthcare professionals should maintain updated resource lists for local food assistance resources, including food banks, community kitchens, and nutrition education programs. Integration with social work services facilitates comprehensive care and support.
• Access to community resources: Community resources, including recreational facilities, walking groups, and cooking classes, enhance treatment accessibility and sustainability. Partnerships with community organizations expand treatment capacity beyond clinical settings.

Presenting Evidence Levels to Patients

Patients benefit from understanding the strength of evidence supporting different treatment recommendations. A systematic approach to presenting evidence enhances informed decision-making and sets clear expectations for stakeholders. Strong evidence (level A) includes interventions supported by multiple randomized controlled trials, eg, lifestyle modification for 5% to 10% weight loss. Moderate evidence (level B) includes newer pharmacotherapies with emerging long-term data. Limited evidence (level C) includes interventions with theoretical benefit but limited clinical trial data.

Managing Patient Expectations

Realistic goal setting improves treatment adherence and reduces disappointment with outcomes. Initial weight loss targets of 5% to 10% provide clinically meaningful benefits while remaining achievable for most patients. Timeline expectations should reflect typical weight loss patterns, with more rapid initial loss followed by plateau phases. Discussion of weight maintenance challenges prepares patients for long-term management requirements.

Long-Term Management 

Long-term weight management represents the most significant challenge in obesity medicine, with most patients experiencing some degree of weight regain over time. Meta-analyses indicate that over half of lost weight is regained within 2 years, and 80% is regained by 5 years.[7] The following monitoring protocol is recommended:

• Monthly visits: Follow-up monthly for first 6 months, then quarterly
• Weight tracking: Documentation of weight weekly by the patient, recorded at each visit
• Comorbidity monitoring: According to condition-specific guidelines, comorbid conditions should be managed
• Medication adjustment: Pharmacotherapy change based on response and adverse effects
• Behavioral assessment: Mental health evaluation, including adherence to lifestyle modifications
• Laboratory monitoring: Laboratory studies as indicated by medications and comorbidities

Follow-up frequency recommendations

Intensive follow-up contact improves long-term weight maintenance outcomes. The American Diabetes Association recommends at least monthly contact with trained professionals for comprehensive weight loss maintenance programs.[3] Research demonstrates dose-response relationships between contact frequency and weight maintenance success. Programs that provide weekly contact show superior outcomes compared to those with monthly or quarterly follow-up schedules.

Monitoring parameters

Systematic monitoring should include weight trends, adherence to behavioral modifications, medication and adverse effects, and comorbidity status. Patient-reported outcomes provide additional insights, including quality of life, eating behaviors, and physical activity levels. Technology-enhanced monitoring, utilizing smartphone applications, wearable devices, and telemedicine platforms, can supplement in-person visits and enhance patient engagement. However, these tools should complement rather than replace clinician contact.

Management of Weight Plateaus and Regain 

Weight plateaus are normal physiological responses to caloric restriction and occur in virtually all patients. Early identification and intervention can prevent progression to significant weight regain (see Table 5). Biological factors contributing to weight regain include decreased metabolic rate, increased appetite hormones, and reduced satiety signals. These adaptations persist for years after weight loss, necessitating ongoing interventions to maintain weight loss.[11]

Table 5. Troubleshooting Weight Plateaus

Evidence-based maintenance strategies

Successful weight maintenance requires specific behavioral strategies distinct from those used for initial weight loss. High levels of physical activity (200–300 minutes per week) represent the most consistent predictor of maintenance success.[12] Other evidence-based strategies include frequent self-weighing, continued dietary self-monitoring, maintaining a consistent diet pattern, and adhering to regular meal timing. Problem-solving skills and cognitive behavioral techniques help patients navigate challenging situations. Continuation of pharmacotherapy improves weight maintenance outcomes compared to discontinuation after initial weight loss. Most obesity medications demonstrate sustained benefits when continued long-term, although individual responses vary.

In the above clinical scenario, clinicians should consider the following:

• Biological factors: Assess metabolic adaptations, including decreased leptin, increased ghrelin, and reduced metabolic rate, which contribute to the regain of weight.
• Behavioral factors: 
  • Evaluate adherence to self-monitoring, physical activity, and meal planning.
  • Identify specific behavioral targets for intervention.
• Psychological factors: Address discouragement, shame, and "all-or-nothing" thinking patterns that may lead to treatment discontinuation.
• Treatment intensification: Consider increasing the liraglutide dose, adding combination therapy, or bariatric surgery referral while maintaining behavioral support.

Ongoing Behavioral Support

Long-term counseling approaches

Maintenance-focused counseling differs from weight loss counseling in that it emphasizes relapse prevention, problem-solving, and adaptive responses to weight fluctuations. Cognitive behavioral therapy techniques help patients develop flexible thinking patterns about weight management. Group-based maintenance programs offer peer support and provide a cost-effective delivery of ongoing interventions. Research demonstrates comparable effectiveness to individual counseling for many patients, with additional benefits of shared experience and accountability.

Family engagement strategies

Family involvement has been shown to improve treatment outcomes, particularly for pediatric patients and adults. Family-based interventions target household food environments, physical activity patterns, and social support for promoting healthy behaviors. Strategies include family meal planning, shared physical activities, and education about supportive communication techniques. Addressing family members' health behaviors can often improve the overall household environment.

Other Issues

Integration and Clinical Application

Integrating special population considerations, comorbidity management, behavioral counseling, and long-term maintenance strategies requires systematic clinical approaches. Successful programs demonstrate several common characteristics, including interprofessional teams, evidence-based protocols, and comprehensive patient tracking systems.

Case study

A 45-year-old Hispanic woman with a BMI of 38 kg/m², type 2 diabetes (HbA1c 8.2%), hypertension, depression (taking sertraline), and perimenopausal symptoms presents for weight management. Clinical assessment reveals multiple obesity-related comorbidities, as well as cultural considerations (preference for a traditional diet), reproductive transition, and psychiatric medication effects.

The recommended management for this patient includes:

• Intensive lifestyle modification with culturally adapted nutrition counseling
• GLP-1 receptor agonist for diabetes and weight management
• Coordination with endocrinology for diabetes management
• Mental health collaboration for depression management
• Regular monitoring with gradual antihypertensive reduction as indicated
• Family involvement in meal planning and physical activity

Follow-up strategies should include:

• Monthly visits for 6 months, then quarterly
• Weekly self-weighing with structured problem-solving
• Quarterly HbA1c and comprehensive metabolic panel
• Annual ophthalmologic and podiatric screening
• Ongoing motivational interviewing and behavioral support

Decision-Making Algorithms

Systematic algorithms that address common scenarios, including medication selection, specialist referral timing, and treatment intensification triggers, benefit clinical decision-making. These tools enhance consistency and ensure comprehensive care.

High-Yield American Board of Obesity Medicine Clinical Pearls

The following should be kept in mind when managing obesity:

• Special populations
  • Leptin replacement therapy is indicated for congenital leptin deficiency.
  • Setmelanotide is approved for use in patients with POMC, PCSK1, and leptin receptor deficiencies.
  • Most obesity medications are contraindicated in pregnancy.
  • Geriatric patients require conservative weight loss targets (5%–10%).
• Comorbidity management
  • 7% weight loss reduces diabetes progression by 58%.
  • A weight loss of 10% to 15% can significantly improve sleep apnea.
  • Metabolic dysfunction–associated steatotic liver disease (MASLD) improves with a 7% to 10% weight reduction.
  • Medication deprescribing is often required during weight loss.
• Treatment planning
  • The 5 A's framework improves counseling effectiveness.
  • Motivational interviewing enhances patient engagement.
  • Cultural adaptation improves treatment outcomes.
  • Shared decision-making increases adherence.
• Long-term management 
  • Approximately 80% of the lost weight is regained within 5 years without intervention.
  • Monthly contact improves maintenance outcomes.
  • Physical activity (200–300 minutes per week) is a predictor of maintenance success.
  • A weight plateau is normal; regain requires intervention.

Long-Term Success Metrics

Program evaluation should include both clinical outcomes (eg, weight change, improvement in comorbidities) and patient-reported outcomes (eg, quality of life and treatment satisfaction). Long-term follow-up data provide insights into program effectiveness and areas for improvement. Key performance indicators include percentage of patients achieving 5% and 10% weight loss, maintenance of weight loss at 1 and 2 years, improvement in obesity-related comorbidities, and patient retention rates.

Practice Optimization Strategies

Successful obesity medicine practices demonstrate several organizational characteristics, including standardized protocols, multidisciplinary team approaches, robust follow-up systems, and integration with specialist care. Electronic health record optimization facilitates systematic care delivery through clinical decision support tools, automated reminders, and standardized documentation templates. Quality improvement methodologies help practices identify and address care gaps. Regular staff training in motivational interviewing, cultural competency, and evidence-based obesity management ensures consistent, high-quality care delivery. Patient feedback mechanisms guide continuous program improvement.

Enhancing Healthcare Team Outcomes

Obesity treatment for special populations requires individualized strategies that account for life stage, comorbidities, medication effects, and social determinants of health. Drug-induced weight gain, pregnancy-related needs, menopausal transitions, and geriatric considerations all influence treatment planning. Psychiatric illness, limited mobility, and the unique needs of LGBTQ individuals further highlight the importance of tailored, evidence-based approaches to improve safety, adherence, and long-term outcomes.

Effective care relies on an interprofessional approach that emphasizes personalized treatment, behavioral counseling, and medication optimization. Physicians and advanced practitioners lead diagnostic evaluations and treatment planning, while general practitioners ensure continuity of care across settings. Nurses provide patient education, monitor adherence, and support behavioral change. Pharmacists assess medication regimens for weight-promoting effects and recommend safer alternatives. Interprofessional communication facilitates the coordinated management of comorbidities, including diabetes, hypertension, and MASLD. By aligning strategies across disciplines, healthcare teams can strengthen patient-centered care, enhance safety, and achieve sustainable outcomes and long-term improvements in weight management.