Joint TOS/OMA/OAC expert guidance statement on the pharmacological management of United States adults with overweight or obesity using the GRADE approach

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Background: Obesity affects over 40% of US adults, with severe obesity on the rise. Despite recognition of obesity as a chronic disease, it remains underdiagnosed and undertreated. Access to evidence-based obesity treatment is limited, leading to increased obesity severity and related complications. Barriers to obesity treatment include socioeconomic disparities, limited clinician training, stigma, and restrictive or absent reimbursement policies. FDA-approved obesity medications offer significant health benefits, prompting the need for updated, evidence-based guidance. Methods: The Obesity Society (TOS), the Obesity Medicine Association (OMA), and the Obesity Action Coalition (OAC) convened a multidisciplinary panel, including patient representatives and obesity care providers, to develop a guidance statement using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Systematic evidence synthesis was conducted via Epistemonikos databases, with outcomes prioritized for clinical relevance, including weight reduction, quality of life, adverse events, and improvements in obesity complications. Recommendations were developed through consensus workshops and graded as strong or conditional based on evidence certainty, benefits, harms, equity, and feasibility using the GRADE Evidence-to-Decision framework. Results: The panel issued recommendations on FDA-approved obesity medications including orlistat, bupropion-naltrexone, phentermine, phentermine-topiramate, liraglutide, semaglutide, tirzepatide, and setmelanotide. Strong recommendations were made for bupropion-naltrexone, semaglutide, tirzepatide, and setmelanotide, with moderate-certainty evidence. Conditional recommendations were made for other agents and specific obesity complications (obstructive sleep apnea, heart failure with preserved ejection fraction, metabolic dysfunction-associated steatotic liver disease/metabolic dysfunction-associated steatohepatitis, osteoarthritis, major adverse cardiovascular events, and type 2 diabetes). Continuing obesity medications during weight maintenance received a strong recommendation. Conclusion: Obesity is a chronic, often progressive, disease requiring comprehensive, long-term, and person-centered care. Effective obesity medications exist but remain underutilized due to systemic barriers. Expanding access, reducing stigma, and ensuring equitable coverage are essential to translating scientific advances into population health gains. Future priorities include access and integration of comprehensive obesity care in the primary care setting, improving affordability, addressing research gaps, conducting head-to-head trials, and updating guidance as evidence evolves.

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