Table 2.

Lifestyle modification for weight management with second-generation anti-obesity medications (AOMs)

	Critical questions	Assessment	Intervention
Dietary intake	During weight loss with AOMs, do patients • Consume an appropriate dietary pattern (including lean proteins, fruits, and vegetables) to promote cardiometabolic health? • Consume adequate amounts of protein to preserve lean body mass? • Maintain adequate hydration? • Limit problem foods to mitigate potential gastrointestinal (GI) side effects related to AOMs?	• Before beginning AOMs, use brief interview or screening questionnaires [84] to assess dietary intake. Repeat this assessment periodically (e.g., every 3 months) • Assess patient’s daily schedule of meals and snacks • Have patients periodically monitor food intake for 2–3 days, particularly for protein and fluids • Evaluate relationship of GI side effects to dietary intake or timing of intake (e.g., high-fat or high-sugar foods, eating late at night)	• Recommend reduced-calorie diet (500 kcal/d deficit) that promotes cardiometabolic health and encourages consumption of lean proteins, fruits, and vegetables and fewer highly processed foods (i.e., high in fat and sugar) • Recommend daily protein intake of at least 0.8 g/kg of body weight, with potentially higher amounts for patients with BMIs ≥ 40 kg/m2 • Recommend water and non-caloric fluids to maintain hydration (2.2–3 L/d) • Refer to registered dietitian (RD) for patients with clinically significant problems or who desire more education and support
Physical activity and body composition	During weight loss with AOMs, do patients • Increase their physical activity (planned and lifestyle) to improve their cardiometabolic health (e.g., cardiorespiratory fitness)? • Benefit from strength training (ST)? • Maintain appropriate nutrition and hydration to support increased physical activity?	• Use brief interview, activity diary, or step counter to assess baseline physical activity and changes during treatment • Assess appropriateness of ST based on general health, and potentially with DXA in older adults when body composition, bone mass, or strength are of concern (e.g., sarcopenia) • Assess dietary intake using methods described	• Recommend ≥ 150 min/wk of physical activity (e.g., walking) during weight loss, potentially increasing with weight-loss maintenance • Recommend ST (2 day/wk) as part of general activity program, as appropriate • Refer to certified clinical exercise physiologist for patents with clinically significant problems or who want more education/support
Psychosocial and behavioral issues	During weight loss with AOMs, do patients • Have appropriate mental health and realistic goals for improving weight, health, and quality of life (QOL)? • Based on their psychiatric history, have a risk of psychosocial distress (e.g., suicidal thoughts/behaviors, anxiety, depression, relationship changes) or a desire to continue losing weight below an appropriate BMI (e.g., 20-22 kg/m2)? • Need to frequently monitor their food intake and physical activity or to have more than approximately monthly lifestyle contacts • Wish to stop taking AOMs for reasons other than side effects or financial costs (e.g., belief that the medication is no longer working)? • Have plans and strategies for maintaining their weight loss after discontinuing medication?	• Assess mood and psychosocial status at baseline and follow-up visits. Use PHQ-9 [104] and C-SSRS [105] as needed • With weight loss, periodically inquire about changes in mood, sleep, and energy level, as well as satisfaction with work, social interactions, and feelings about themselves (body image). Use PHQ-9 when concerned • Have patients monitor food intake (e.g., MyFitnessPal) and physical activity (e.g., step counter) frequently during first few weeks to support self-learning and behavior change • Discuss patients’ reasons for wishing to stop AOMs and the possible consequences of doing so (e.g., return of appetite and weight) • Assess patients’ strategies for maintaining weight loss without support of AOMs	• With patients who report concerning changes in mood and psychosocial function, or desire to reduce below an appropriate BMI, provide reassurance and education. In clinically significant cases, not responsive to education, refer to a mental health professional. Consider medication dose reduction in patients who have achieved an appropriate BMI (e.g., 20–22 kg/m2) • Adjust patients’ frequency of self-monitoring (and lifestyle contacts) accordingly to achieve their goals for eating a healthier diet, increasing physical activity, and other outcomes • Review patients’ potential concerns that “the medication is no longer working.” Provide reassurance and education about the benefits of continued medication use and likely results of discontinuation • With patients’ terminating medication, consider down-titrating the dose over several months to reduce potential rebound in appetite and eating. Assist patients in joining (or developing) a behavioral weight loss maintenance plan, with high levels of physical activity and frequent monitoring of weight and dietary intake

DXA dual energy X-ray absorptiometry, PHQ-9 Patient Health Questionnaire-9, C-SSRS Columbia Suicide Severity Rating Scale