Prognosis

Diet and exercise ± psychological therapy ± drug therapy

Diet and exercise alone typically produces a modest decrease (5% to 10%) in body weight over the short term, but the relapse rate can reach beyond 50%, depending on the length of the follow-up period.[101][213][214]

Adding psychological therapy to diet and exercise can produce a small but statistically significant increase in weight loss, but long-term durability of the weight loss is still poor.[215]

Historically, pharmacotherapy for obesity has had modest short-term efficacy but a high attrition rate and a lack of long-term efficacy.[216]​ Newer drugs approved for long-term use (e.g., semaglutide) are more effective, but adverse effects are still common and evidence suggests that patients may regain weight and see reversal of cardiometabolic improvements if treatment is stopped.[128][217]​​​ Overall, reported weight loss in clinical trials was between 3% and 10.8% higher in pharmacotherapy groups, and treatment discontinuation ranged from 34 to 219 per 1000.[128] 

Surgical therapy

Bariatric surgery has the best efficacy, and should be considered for patients with more severe obesity, or patients with obesity and persistent poorly controlled weight-related comorbidities despite non-surgical attempts at management.[170][173]​​​ A review of 85,000 previously published cases reported 30-day mortality in all types of bariatric surgery to be 0.28%, with differing rates in subgroup analysis.[218]

Biliopancreatic diversion with duodenal switch produces the greatest weight loss (≥100% excess body weight) but is complicated by significant protein and vitamin deficiency.

Gastric bypass produces the best balance between weight loss and health of the patient.[219] In experienced hands, with good patient follow-up, patients achieve approximately 60% to 75% excess body weight loss (EBWL). European gastric bands achieve approximately 40% to 50% EBWL.[220][221] Long-term efficacy and safety data in the US are not available for gastric banding. Short-term results for sleeve gastrectomy are promising, with results of 50% to 60% EBWL.[181][222][223][224][225] Revision to decrease the size of the gastric pouch, gastrojejunostomy, or addition of a malabsorptive procedure to a purely restrictive procedure can be done for surgical failures, although the evidence for this is controversial. Studies have shown that revision of a restrictive procedure to incorporate malabsorption results in greater weight loss than purely restrictive procedures alone.[226]

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