Addressing the challenge of obesity in primary care: a review of effective interventions and implementation strategies

Abstract

Obesity is a worldwide health epidemic that significantly raises morbidity and mortality by means of related comorbidities including diabetes and cardiovascular diseases. By means of effective interventions including behavioral therapies, comprehensive lifestyle modifications, and an increasing armamentarium of pharmacological agents capable of appreciable weight loss, primary care physicians are especially positioned to contribute significantly to the management of obesity. This review summarizes the most recent studies on behavioral interventions (such as cognitive behavioral therapy and motivational interviewing), pharmacological treatment options (including recently approved and emerging agents), and lifestyle changes (such diet and physical activity) in order to manage obesity in primary care environments. It also addresses the several challenges this field faces—including weight stigma and systematic barriers—as well as future directions for research and fair treatment of patients. At last, it emphasizes evidence-based approaches for putting these interventions into use to maximize patient results. More study is needed to guarantee that everyone has fair access to high-quality obesity treatment, understand the long-term consequences of new treatments, and enhance intervention procedures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13098-025-01925-z.

Introduction

Obesity is a complex, chronic, relapsing, multifactorial disease that is recognized as a global pandemic and is typified by excessive fat accumulation that compromise health [1, 2]. Globally, the prevalence of obesity has sharply increased. More than 890 million adults worldwide—or 16% of the adult population—were obese in 2022; this number has more than doubled since 1990. Over one billion people worldwide, including 880 million adults and 159 million children and adolescents, were living with obesity in 2022, according to data from the NCD Risk Factor Collaboration (NCD-RisC), which was published in 2024 after evaluating 3,663 population-representative studies [3]. The situation is similarly alarming in the United States, where the age-adjusted prevalence of adult obesity was 40.3% from August 2021 to August 2023, and the rate of severe obesity was 9.4% [4–6]. According to projections, a third of children and adolescents (746 million) and 60% of adults (3.8 billion) worldwide will be overweight or obese by 2050 if immediate policy reform and action are not taken. There is a serious risk to public health from this increasing trend, which is seen in almost every nation [7]. Beyond its profound health implications, obesity carries a substantial economic burden. Globally, this was estimated at 2.19% of the global GDP in 2019, with projections indicating these costs could exceed US$ 4.32 trillion annually by 2035 if current trends persist. These figures encompass direct medical expenses for treating obesity and its associated comorbidities, as well as indirect costs stemming from lost productivity and reduced workforce participation [8].

Obesity significantly contributes to global morbidity and mortality, increasing the risk of numerous chronic diseases, including cardiovascular diseases (CVD), type 2 diabetes mellitus (T2DM), various cancers (such as endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon), and musculoskeletal disorders like osteoarthritis [2, 9]. Effective obesity management within primary care settings is therefore crucial for preventing associated morbidity and mortality.

Serving as the first and usually most frequent point of contact for people seeking health care, primary care environments are essential in addressing the obesity epidemic. Primary care doctors (PCPs) are positioned to deliver continuous, thorough treatment including early identification, prevention, evidence-based counseling, starting of medical treatment, and coordination of multidisciplinary care. Given the chronic character of obesity, long-term management and support depend on the constant care model that underlies primary healthcare. Effective patient-provider communication and treatment adherence can be hampered by PCPs’ many obstacles, which include time restrictions, insufficient training in obesity management, lack of reimbursement for comprehensive obesity care, and the widespread problem of weight bias and stigma. By aggregating present evidence-based behavioral and pharmacological treatments for obesity management in primary care, investigating ways to overcome implementation obstacles, and advocating fair, patient-centered care, this review meets a critical need [10–12].

This review specifically looks at lifestyle changes, behavioral interventions (Cognitive Behavioral Therapy and Motivational Interviewing), FDA-approved as well as new pharmacological treatment choices. Moreover, this review addresses the difficulties in primary care environments and talks on ways to maximize patient outcomes and support fair treatment. This review intends to guide health promotion practice by stressing successful intervention strategies and implementation issues for primary care providers, so providing an overview of present evidence and challenges. It also points up important areas for next studies and policy development to help control obesity and hence lower the load of this chronic condition.

Foundational clinical guidance from global and national health organizations

While numerous national and specialty-specific bodies provide guidance on obesity management, the recommendations from the World Health Organization (WHO) and the American Diabetes Association (ADA) offer a foundational framework that is particularly relevant for primary care. These guidelines not only define the scope of the problem but also shape the principles of modern, patient-centered obesity care.

World health organization (WHO) perspective

The WHO provides a global perspective on the obesity epidemic, defining it through standardized Body Mass Index (BMI) thresholds: for adults, a BMI ≥ 25 kg/m2 is classified as overweight, and a BMI ≥ 30 kg/m² is classified as obesity. For children and adolescents, age- and sex-specific growth reference charts are used. The WHO frames obesity as a largely preventable and manageable disease, advocating for a life-course approach that begins before conception and continues throughout life.

For individuals, the WHO’s recommendations center on fundamental lifestyle principles including limiting energy intake from total fats and sugars, increasing consumption of fruits, vegetables, legumes, whole grains, and nuts, and engaging in regular physical activity. For children, specific guidance includes promoting exclusive breastfeeding, limiting screen time, and reducing the intake of sugar-sweetened beverages and energy-dense foods.

Crucially, the WHO framework emphasizes that individual-level interventions, while necessary, are insufficient to tackle the obesity pandemic and calls for a multi-pronged, systemic effort that addresses the “obesogenic environment.” This approach highlights the need for parallel actions at the community and policy levels in order to achieve true progress. The WHO calls on the food industry to play a significant role by reducing the fat, sugar, and salt content of processed foods, making healthy choices inexpensive and accessible, and limiting the marketing of unhealthy foods, particularly to children. At the governmental level, the WHO advocates for structural and regulatory actions to create healthy food environments and integrate obesity management into primary healthcare systems.

WHO Acceleration plan to stop obesity, adopted by member states in 2022, which aims to generate political impetus, support country-level implementation, and strengthen accountability for tackling the crisis. This socio-ecological model is vital for PCPs, as it frames their clinical efforts within a larger public health context, acknowledging that patient success is influenced by factors far beyond the clinic walls [13].

American diabetes association (ADA) 2025 standards of care

The ADA’s annual “Standards of Care in Diabetes” provides some of the most current and influential guidance on weight management, particularly for the vast number of patients with or at risk for type 2 diabetes. The 2025 update solidifies a paradigm shift toward a more holistic and long-term approach to obesity care. A central theme of the 2025 guidelines is the emphasis on a person-centered approach. The ADA advocates for using person-first, inclusive language (e.g., “person with obesity” instead of “obese person”) and for actively detecting and mitigating weight stigma and bias in clinical settings. This recommendation acknowledges that stigmatizing experiences are a significant barrier to care, leading to patient avoidance and reduced treatment adherence. For treatment, the ADA recommends a weight loss goal of at least 3–7% through lifestyle interventions, with more ambitious targets for achieving specific complication-related benefits. The guidelines now firmly position obesity as a chronic, relapsing disease, analogous to hypertension or diabetes itself. This reframing has profound implications, most notably in the guidance for pharmacotherapy. The ADA recommends that anti-obesity medications (AOMs), when used, should be continued long-term to maintain weight loss and health benefits, explicitly warning against the weight regain and worsening of cardiometabolic markers that often follow discontinuation. This reframes AOMs from short-term aids to long-term, disease-modifying agents [14, 15].

Behavioral interventions

For decades, behavioral approaches—which evolved from basic behavior modification strategies to more advanced psychotherapeutic interventions like Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI)—have been the pillar of obesity management. By addressing underlying beliefs, emotions, and motivations, these therapies seek to enable sustainable changes in eating and physical activity behaviors. Though long-term maintenance is still difficult, multicomponent behavioral interventions—often including self-monitoring, dietary and physical activity counseling, and problem-solving—can produce 5–10% weight loss (Table 1) [16].

Table 1.

Key behavioral intervention strategies for obesity management in primary care

Intervention Strategy	Core Components	Primary Goal(s)	Key Considerations for Primary Care	Representative Citations
Lifestyle Modification	Calorie-restricted diet (e.g., 500–750 kcal deficit); Increased physical activity (e.g., ≥ 150 min/week moderate)	Achieve negative energy balance for weight loss; Improve metabolic health; Maintain weight loss long-term	Individualize diet based on preference & adherence; Combine aerobic & resistance exercise; Emphasize sustainability.	[6, 16, 44]
Cognitive Behavioral Therapy (CBT)	Self-monitoring; Goal setting; Stimulus control; Cognitive restructuring; Problem-solving; Relapse prevention	Identify & modify maladaptive thoughts/behaviors related to eating & activity; Improve coping skills	Effective for BED; May require referral to trained therapist; Can be adapted for brief primary care interventions; Focus on skill-building.	[28–31, 36, 37]
Motivational Interviewing (MI)	Express empathy; Develop discrepancy; Roll with resistance; Support self-efficacy; Open-ended questions; Affirmations	Enhance intrinsic motivation for change; Resolve ambivalence; Facilitate patient commitment to goals	Patient-centered; Avoids confrontation; Useful for ambivalent patients; Requires training for effective delivery; Often best combined with other behavioral strategies.	[38–42]
Structured Behavioral Programs (often multicomponent)	Regular contact (individual/group); Education on nutrition/activity; Behavior change techniques; Social support	Achieve & maintain clinically significant weight loss (typically 5–10%); Improve health behaviors	Can be delivered by various health professionals; Digital platforms offer scalable options; Intensity & duration matter for effectiveness; Address barriers to adherence.	[11, 76, 77]

_{BED = Binge Eating Disorder}

_{These strategies are often most effective when combined and tailored to the individual patient}

Lifestyle modifications

Achieving a negative energy balance through lifestyle modifications remains the cornerstone of managing obesity. Insulin sensitivity, lipid profiles, blood pressure, and energy metabolism are all impacted by these therapies [17]. Dietary interventions aim to reduce caloric intake, typically by 500–750 kcal/day from baseline, in order to induce weight loss [1]. Numerous dietary regimens have shown promise. The Mediterranean diet is recommended due to its short-term weight loss benefits and possible long-term cardiovascular benefits. Nuts, whole grains, fruits, vegetables, and unsaturated fats are all abundant in it. Low-carb diets (limiting carbohydrate intake to less than 130 g/day or even less than 50 g/day in very-low-carbohydrate approaches) can also help people lose weight and improve their glycemic control, especially those with type 2 diabetes. However, cardiovascular safety and long-term adherence—especially with animal-based versions—need to be carefully considered. Even though they are common, intermittent fasting and time-restricted eating (like the 5:2 diet or alternate-day fasting) haven’t been shown to consistently result in more weight loss than continuous calorie restriction when total caloric intake is equal. But for some, they might offer a different approach. Other options include low-fat diets (less than 30% energy from fat) and high-protein diets (which can maintain lean mass and improve satiety during weight loss). Ultimately, the most effective diet is one that is nutritionally adequate, long-term sustainable, and supports overall health [18]. The fundamental principles of any given diet are to prioritize whole, unprocessed foods, reduce intake of refined sugars and saturated fats (especially sugary drinks), and ensure adequate fiber intake. The effectiveness of dietary interventions can be impacted by a number of other modifiable risk factors, such as frequent consumption of ultra-processed foods, sleep deprivation, and food insecurity, highlighting the necessity of a comprehensive approach [1, 19, 20].

Physical activity is a crucial addition to dietary changes for initial weight loss in order to sustain weight loss and lower obesity-related comorbidities. Current guidelines, such as those from the ACC/AHA and ESC, generally recommend at least 150 min of moderate-intensity aerobic activity (like brisk walking) or 75 min of vigorous-intensity aerobic activity per week for health benefits. Maintaining weight loss and preventing weight gain may require up to 200–300 min of moderate-intensity exercise per week [21]. Combining resistance and aerobic exercise often yields the best results. Aerobic exercise significantly enhances cardiorespiratory fitness, while resistance training—two to three sessions per week focused on major muscle groups—helps build and maintain muscle mass, which can be metabolically advantageous, particularly during calorie restriction. Resistance training has also been independently associated with a lower risk of obesity. Using tools like pedometers or activity trackers, as well as integrating physical activity into daily routines (e.g., active commuting, taking the stairs), can increase adherence and overall activity levels. Exercise regimens for obese older adults should be tailored to their individual preferences, realistic goals, and any physical limitations they may have, such as sarcopenic obesity [18, 22]. A systematic review and meta-analysis showed that aerobic, resistance and combined aerobic-resistance training methods all significantly improve cardiorespiratory fitness in overweight and obese adults. Resistance training, while less effective than aerobic exercise for cardiovascular fitness, does build muscle strength [23]. In addition, a prospective cohort study reported that resistance exercise independently lowered the risk of obesity; the lowest risk was seen when guidelines for both resistance and aerobic exercise were met. Such findings suggest that different modes of exercise play complementary roles in managing obesity [24]. Other practical strategies involve integrating physical activity into a person’s daily routine, like walking to work, group exercise, or simply wearing an accelerometer that acts as a device for tracking activity.

Behavioral therapy

Behavioral approaches, which range from basic behavior modification to more advanced methods like motivational interviewing and cognitive-behavioral therapy, have been the cornerstone of managing obesity for the past 60 years. Their main goals are to change eating and exercise habits in order to bring about long-lasting lifestyle improvements [25, 26].

Cognitive-behavioral therapy (CBT)

Cognitive Behavioral Therapy (CBT) is recognized as the best-established, first-line treatment for Binge Eating Disorder (BED), a condition commonly associated with obesity. CBT demonstrates robust effectiveness in reducing the frequency of binge-eating episodes and improving eating disorder psychopathology, with remission rates of 40–60% that are well-sustained at 12-month follow-ups. However, a crucial clinical consideration is that while CBT is highly effective for the eating disorder itself, it generally fails to produce significant weight loss on its own. Studies have shown that achieving remission from binge-eating is significantly associated with greater subsequent weight loss, suggesting that addressing the underlying eating disorder behavior is a critical step in long-term weight management for this patient population [27–30]. New research also suggests that other therapeutic approaches, like dialectical behavior therapy (DBT) and interpersonal therapy (IPT), can be incorporated into cognitive behavioral therapy (CBT) to treat complex eating disorder behaviors [31, 32]. Studies have confirmed that obese BED patients present with severe psychological complications compared to obese non-binge-eating patients and thus require specialized psychological intervention [33–38].

Motivational interviewing (MI)

Motivational Interviewing (MI) is a collaborative, patient-centered counseling method designed to resolve ambivalence and enhance a patient’s intrinsic motivation for behavior change. By emphasizing empathy, collaboration, and respect for patient autonomy, MI helps establish a therapeutic partnership and avoids a paternalistic approach that can worsen feelings of stigma [39]. Evidence supports MI’s effectiveness in promoting healthy behaviors. When employed as a stand-alone intervention, its effects on promoting physical activity in adults typically decrease within a year, despite studies showing that it can considerably reduce central obesity, especially in adolescent females. This suggests that for long-term weight management, MI is most effective when integrated into a comprehensive, continuous support plan [40]. The successful implementation of MI in primary care is often hindered by practical challenges, including the need for adequate time for patient-centered discussions, regular follow-up, and specific training in MI techniques, which many primary care providers report they have not received. When used effectively, however, MI can empower patients to overcome obstacles, promote shared decision-making, and lead to more productive conversations about weight. By focusing on active listening and a non-judgmental perspective, MI can also lower the risk of patients having negative counseling experiences [41, 42].

Pharmacological interventions

For patients who do not achieve adequate weight loss with lifestyle and behavioral interventions alone, pharmacotherapy is a key adjunctive treatment. The landscape of anti-obesity medications has expanded significantly, offering new mechanisms of action and greater efficacy. Current long-term options include intestinal lipase inhibitors (orlistat), combination agents targeting central appetite pathways (phentermine-topiramate, naltrexone-bupropion), and incretin-based therapies.The development of glucagon-like peptide-1 (GLP-1) receptor agonists (such as liraglutide and semaglutide) and dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonists (such as tirzepatide) represents a major advancement, demonstrating average weight loss ranging from 5% to over 20% in clinical trials. These agents promote weight loss by suppressing hunger, increasing satiety, and slowing gastric emptying. Emerging therapies, including triple agonists (retatrutide) and novel combinations, promise even greater efficacy in the future. The selection of a pharmacological agent should be individualized based on its efficacy, side effect profile, patient comorbidities, and access, always used as an adjunct to, not a replacement for, ongoing lifestyle modifications. According to current clinical practice guidelines, people with a body mass index (BMI) of ≥ 30 kg/m² or ≥ 27 kg/m² who also have at least one weight-related comorbidity (such as hypertension, type 2 diabetes, dyslipidemia, or obstructive sleep apnea) should generally be evaluated for AOMs. Efficacy, safety profile, possible adverse effects, patient comorbidities and preferences, contraindications, drug interactions, cost, and accessibility should all be considered when choosing an AOM (Table 2) [43]. Detailed information on specific agents is provided in Supplementary Table 3.

Table 2.

Overview of FDA-approved and key emerging pharmacotherapies for chronic weight management in adults

Medication Class	Agent(s)	Mechanism of Action	Typical Placebo-Subtracted Weight Loss (%)	Key Common Adverse Events	Important Considerations/Contraindications	Representative Citations
Lipase Inhibitor	Orlistat	Inhibits gastric and pancreatic lipases, reducing dietary fat absorption by ~ 30%	3–5%	GI: Steatorrhea, oily spotting, fecal urgency	Malabsorption of fat-soluble vitamins; caution with history of kidney stones (oxalate nephropathy), cholestasis.	[54]
GLP-1 Receptor Agonist	Liraglutide 3.0 mg	Activates GLP-1 receptors; increases satiety, slows gastric emptying, enhances glucose-dependent insulin secretion	4–6%	GI: Nausea, vomiting, diarrhea, constipation	Risk of pancreatitis, gallbladder disease; Boxed warning: thyroid C-cell tumors (rodents); contraindicated in MTC/MEN2 history.	[55–57]
GLP-1 Receptor Agonist	Semaglutide 2.4 mg	Activates GLP-1 receptors (as above)	12–15%	GI: Nausea, vomiting, diarrhea, constipation	As above for Liraglutide. Cardiovascular benefits in patients with CVD and obesity.	[58, 59]
Dual GLP-1/GIP Receptor Agonist	Tirzepatide	Activates both GLP-1 and GIP receptors	18–21%	GI: Nausea, vomiting, diarrhea, constipation	As above for GLP-1 RAs (pancreatitis, gallbladder, thyroid C-cell tumor warning).	[45, 60]
Opioid Antagonist/Antidepressant	Naltrexone ER/Bupropion ER	Affects hypothalamic appetite pathways and brain reward systems	4–5% (RCTs); ~4% (real-world at 6mo)	Nausea, constipation, headache, vomiting, insomnia, dizziness	Boxed warning: suicidal thoughts/behaviors (bupropion); ↑BP/HR; contraindicated in uncontrolled HTN, seizures, MAOI use, opioid use, eating disorders. CV safety ongoing.	[61–65]
Sympathomimetic/Anticonvulsant	Phentermine/Topiramate ER	Phentermine suppresses appetite; topiramate enhances satiety (multiple mechanisms)	7–10%	Paresthesia, dry mouth, constipation, insomnia, dizziness	↑HR; Topiramate risks: metabolic acidosis, kidney stones, glaucoma, cognitive effects; Category X (teratogenic - oral clefts); taper on discontinuation.	[59, 66–69]
Emerging: Oral GLP-1 RA	Orforglipron	Oral non-peptide GLP-1 receptor agonist	~ 8–15% (Phase 2/3 data)	GI: Nausea, vomiting, diarrhea (similar to injectables) Potential for thyroid C-cell tumors (class effect). Full Phase 3 for obesity pending.		[70, 71]
Emerging: GLP1/GIP/Glucagon RA	Retatrutide	Activates GLP-1, GIP, and glucagon receptors	Up to ~ 22–24% (Phase 2 data)	GI: Nausea, vomiting, diarrhea (similar to incretins) Potential for thyroid C-cell tumors (class effect). Phase 3 ongoing.		[72, 73]
Emerging: Amylin/GLP-1 RA Combo	Cagrilintide + Semaglutide	Combines amylin analogue (satiety) and GLP-1 RA effects	~ 16–23% (Phase 3 data)	GI: Nausea, vomiting, diarrhea (similar to GLP-1 RAs) Potential for thyroid C-cell tumors (semaglutide component). Regulatory filing planned.		[74, 75]

Weight loss percentages are approximate mean values from key clinical trials or reviews, typically representing additional weight loss compared to placebo over 1 to 1.5 years, unless otherwise specified. Individual results may vary

ER = Extended Release; GI = Gastrointestinal; GLP−1 RA = Glucagon−like Peptide−1 Receptor Agonist; GIP = Glucose−dependent Insulinotropic Polypeptide; MTC = Medullary Thyroid Carcinoma; MEN2 = Multiple Endocrine Neoplasia syndrome type 2; BP = Blood Pressure; HR = Heart Rate; HTN = Hypertension; MAOI = Monoamine−Oxidase Inhibitor; CVD = Cardiovascular Disease

Emerging agents are investigational and not yet FDA−approved for obesity; efficacy and safety data are based on reported trial results and may evolve

All AOMs should be used as an adjunct to a reduced−calorie diet and increased physical activity

Limitations of existing studies

It is critical, however, to interpret the impressive efficacy data from these landmark trials with caution due to significant limitations in their real-world applicability. Recent analyses reveal that the populations recruited for major trials like SELECT and SURMOUNT are not representative of the true U.S. obese population in terms of age, sex, and race. Specifically, Black participants have been consistently underrepresented across these trials, while female participants were disproportionately represented in some key studies. This demographic mismatch creates an “evidence-practice gap,” meaning the results cannot be uncritically extrapolated to all patient populations seen in a typical primary care setting. Therefore, clinicians must be critical consumers of this data, and there is a pressing need for real-world evidence (RWE) studies to supplement trial findings and contextualize the effectiveness of these agents across diverse, real-world populations.

Safety and monitoring

Careful patient selection, customized treatment plans, and careful ongoing monitoring are necessary for the safe and effective use of pharmaceutical treatments for obesity in order to maximize effectiveness and minimize potential side effects. To evaluate medication adherence, tolerability, the emergence of any side effects, and treatment response (in terms of weight loss and improvement in obesity-related comorbidities), routine follow-up appointments are crucial [44].

Baseline assessment and patient selection

A thorough baseline assessment is essential prior to starting any AOM. This consists of a comprehensive medical history (including substance abuse, mental health issues, and previous attempts to lose weight), a physical examination (including measurements of vital signs and waist circumference), and pertinent laboratory tests. To rule out untreated hypothyroidism as a factor in weight gain, standard laboratory tests may include a thyroid-stimulating hormone (TSH), a lipid panel, a complete blood count, a comprehensive metabolic panel (including renal and liver function tests, electrolytes), fasting glucose and HbA1c, and a metabolic panel. Every medication’s unique contraindications need to be carefully examined and recorded. The patient’s comorbidities (such as the presence of T2DM, CVD, hypertension, mood disorders, seizure history, and gallbladder disease), concurrent medications (to prevent drug interactions), patient preferences, lifestyle factors, and potential financial or insurance coverage should all be taken into consideration when choosing an AOM. For instance, GLP-1 RAs and tirzepatide should be avoided by patients with a history of pancreatitis, medullary thyroid cancer, or MEN2 [45]. Naltrexone-bupropion shouldn’t be given to people who have uncontrolled hypertension, a history of seizures, are taking MAOIs, or are on opioids [46]. The teratogenic risks of substances such as phentermine-topiramate and the importance of using effective contraception throughout treatment must be thoroughly explained to women of childbearing age; a negative pregnancy test should be verified prior to starting treatment and checked on a monthly basis [47].

Monitoring efficacy and adverse events

After starting treatment or achieving the desired maintenance dosage, the weight loss response to an AOM should normally be evaluated three to four months later. According to guidelines, a medication should be reevaluated if a patient has not lost a clinically significant amount of weight by this point (e.g., at least 5% of their starting body weight, a lower threshold for some medications like orlistat, or as indicated by the drug’s labeling). The current AOM may be stopped, a different agent with a different mode of action may be used, or combination therapy may be considered if necessary. Common gastrointestinal side effects, such as nausea, vomiting, diarrhea, and constipation, are common during dose initiation and titration for the highly effective incretin mimetics, such as tirzepatide and GLP-1 RAs [48]. These frequently call for proactive management techniques, such as recommending dietary changes to patients (e.g., eating smaller, more frequent, low-fat meals and avoiding trigger foods), starting at the lowest dose and increasing very gradually (e.g., every 4 weeks), and making sure patients are getting enough water. Patients taking sympathomimetic medications such as naltrexone-bupropion or phentermine (either alone or in combination with topiramate) should have their heart rates monitored. Additionally, since naltrexone-bupropion can raise blood pressure, it is important to keep an eye on it [6]. Because naltrexone-bupropion contains bupropion, patients’ mental health status, including mood swings, depression, and suicidal thoughts, should be regularly evaluated. Maintaining proper hydration to lower the risk of kidney stones, keeping an eye out for ocular symptoms like pain or blurred vision, and keeping an eye out for signs of metabolic acidosis, such as fatigue or hyperventilation, are crucial for patients taking phentermine-topiramate. Patients with pre-existing kidney disease or those with specific AOMs may benefit from periodic evaluations of renal function [49].

Long-term use and “Off-ramping”

Similar to diseases like type 2 diabetes or hypertension, obesity is acknowledged as a chronic, relapsing illness. Since many AOMs are therefore authorized for long-term use, it may be necessary to continue pharmacotherapy indefinitely in order to sustain the weight loss and related health benefits. Partial or total weight gain is frequently linked to stopping AOMs, especially the stronger ones. This biological fact emphasizes the disease’s chronic character and the function of drugs in controlling the underlying physiological causes of weight. However, there is still much clinical debate and ongoing research regarding the ideal length of treatment, particularly for the more recent, highly effective, and frequently expensive incretin mimetics. In order to safely and effectively taper or stop these medications while minimizing weight regain and transferring patients to other sustainable weight maintenance strategies (which may include less intensive AOMs, or intensified lifestyle and behavioral interventions alone), there is currently little evidence and a lack of established guidelines on “off-ramping” strategies. Continuous efficacy, tolerability, patient preference, cost, and a careful balance of risks and benefits in a collaborative decision-making process with the patient should all be taken into consideration when making decisions about the long-term continuation or discontinuation of AOMs.

Cost-effectiveness and access

For many patients and healthcare systems, the cost of AOMs—especially the more recent generation of GLP-1 RAs and dual agonists like tirzepatide—is a major factor and a major access barrier. Although these medications provide previously unheard-of weight loss and proven cardiometabolic advantages (such as lowering cardiovascular risk with semaglutide), their exorbitant list costs may be unaffordable. If access is restricted to people who can afford to pay out-of-pocket or have full insurance coverage, this financial burden may worsen health disparities.

Cost-effectiveness analyses (CEAs) for these more recent AOMs have produced inconsistent and occasionally contradictory results, which are frequently heavily influenced by the particular comparators, the analysis’s time horizon (lifetime vs. short-term), the payers’ willingness-to-pay (WTP) threshold, and presumptions regarding price negotiations and long-term efficacy. For example, a 2025 CEA indicated that, over a 68-week period, subcutaneous tirzepatide might be more cost-effective than oral semaglutide, with an incremental cost-effectiveness ratio (ICER) of $34,212 for each quality-adjusted life-year (QALY) gained. Another 2025 lifetime CEA, however, found that tirzepatide and semaglutide were not cost-effective at their current net prices and that significant price reductions were necessary to reach a common WTP threshold of $100,000/QALY (30.5% for tirzepatide and 81.9% for semaglutide). However, naltrexone-bupropion was found to be more cost-effective in the same study. Although orlistat is typically less costly, its effectiveness is also more modest. This variation in CEA results emphasizes how difficult it is to determine economic value. Policymakers and PCPs need to understand that “cost-effective” is not a fixed concept and that various analyses may produce varying results, which makes resource allocation decisions difficult.

Primary care doctors are frequently at the forefront of navigating these complexities, advocating for patients’ access to appropriate therapies and talking with patients about treatment options while keeping the financial implications in mind. Health systems are also struggling with how to control the financial impact of these expensive but efficient drugs. In order to control costs and primary care capacity while guaranteeing that foundational lifestyle interventions are in place, NHS England, for instance, is putting tirzepatide into primary care through a phased rollout strategy, prioritizing access based on comorbidity burden and requiring companion wraparound lifestyle support. This strategy presents a viable real-world model for striking a balance between comprehensive care, cost containment, and clinical need.

Comparative effectiveness and shared decision-making

When choosing between behavioral and pharmacological interventions, clinicians and patients must navigate a fundamental trade-off between safety and efficacy. A major systematic review for the US Preventive Services Task Force found that while behavior-based interventions are associated with a lower risk of harms, medication-based interventions lead to substantially greater weight loss. For instance, meta-analyses show behavior-based interventions result in a mean weight loss of approximately 2.4 kg at 12–18 months, whereas pharmacotherapy can achieve weight loss ranging from 5% to over 20% of total body weight. This evidence highlights the need to move away from a rigid, one-size-fits-all approach toward a flexible model centered on shared decision-making, as strongly advocated by the 2025 American Diabetes Association (ADA) guidelines. This patient-centered approach allows for the alignment of treatment with an individual’s specific health profile, risk tolerance, and personal goals.

Role of self-monitoring and digital tools

A key component of behavioral support that should continue in conjunction with medication is patient self-monitoring of weight, food consumption, and physical activity. The emergence of digital health technologies, such as wearable activity trackers, smartphone apps, and online health platforms, provides scalable and easily accessible tools to support self-monitoring and offer continuous behavioral education and support. There is growing evidence that using these digital tools in conjunction with AOM therapy can improve weight loss results and increase patient engagement. A 2025 study, for instance, discovered that patients utilizing GLP-1 RAs who actively participated in a digital weight management platform lost a significantly higher amount of weight than those who did not [50, 51].

Integrating behavioral and pharmacological interventions

A synergistic combination of behavioral interventions and pharmacotherapy is frequently the best way to manage obesity since this strategy addresses the disease’s biological and behavioral causes. Patients who receive behavioral therapies and lifestyle changes are equipped with the fundamental knowledge and techniques needed to make long-lasting adjustments to their eating patterns and levels of physical activity. In turn, pharmacotherapy can help overcome physiological adaptations (like increased appetite or decreased metabolic rate) that encourage weight regain, increase the effectiveness of these lifestyle modifications, and improve adherence to the treatment plan as a whole.

The improved results from such integrated care are supported by evidence. A “step-up” strategy, for example, has shown promise in adding AOMs for patients who are early nonresponders to behavioral treatment alone. According to a 2025 randomized controlled trial, patients who started behavioral therapy (BT) with less than 2% weight loss and then continued BT with phentermine added experienced significantly more weight loss at 24 weeks (mean 5.9%) than those who continued BT with a placebo (mean 2.8%). By directing AOMs to those who are most likely to need them in order to achieve clinically significant weight loss, this approach enables a customized intensification of treatment based on initial patient response, potentially optimizing outcomes and resource use.

Similarly, concurrent and continuous behavioral support is regarded as essential, not just an optional add-on, for patients starting the more recent, highly effective AOMs, such as tirzepatide or GLP-1 receptor agonists. This support should be multimodal, with an emphasis on promoting adherence to the medication regimen, managing potential medication side effects (e.g., offering dietary advice to mitigate gastrointestinal issues common with incretin mimetics), and creating and reinforcing healthy eating and physical activity patterns. For long-term weight control, these learned behaviors are essential, particularly if AOMs are eventually tapered or stopped. The use of digital health platforms to provide this kind of integrated care in a scalable way is growing. In addition to facilitating communication with the healthcare team, these platforms can offer tools for self-monitoring of diet, activity, and symptoms, as well as individualized coaching and educational materials. According to a 2025 retrospective cohort study, among people prescribed GLP-1 receptor agonists, active use of a digital weight management platform significantly improved weight loss outcomes (e.g., an additional 3.5% points of weight loss at 5 months for engaged versus non-engaged users). This synergy—where digital tools offer easily accessible behavioral support and AOMs provide a substantial biological push for weight loss—represents a potent new paradigm for supported self-management in the treatment of obesity.

It is possible to strategically incorporate particular behavioral therapies. When co-occurring psychological disorders like emotional eating, body image distress, or binge eating disorder (BED) are present, cognitive behavioral therapy (CBT) can be especially helpful. Cognitive behavioral therapy (CBT) assists patients in addressing maladaptive thought patterns and creating coping mechanisms that medication alone is unable to address. Throughout the course of treatment, PCPs can use the beneficial communication technique known as Motivational Interviewing (MI). Enhancing patient engagement, addressing ambivalence about beginning or maintaining medication or lifestyle changes, and facilitating truly shared decision-making regarding the integrated treatment plan are all possible with MI.

In the end, a customized and flexible strategy is essential for effective integration. The needs of each patient, their psychological profile, the particular AOM being used (and its side effect profile), and the stage of treatment at hand (e.g., initiation, weight loss, weight maintenance, or potential medication tapering) should all be taken into consideration when determining the type and intensity of behavioral support. Strong communication and teamwork are frequently necessary for effective integration, and this may entail a multidisciplinary team consisting of the PCP, a registered dietitian, a psychologist or behavioral therapist, and a pharmacist who are all working toward the same patient-centered objectives. By acknowledging obesity as a chronic condition that necessitates continuous support rather than acute, episodic treatment, this integrated, long-term management approach is crucial [52].

Challenges in primary care obesity management

There are many obstacles to managing obesity in primary care, such as the stigma associated with weight, the inability to identify and treat obesity as a chronic illness, and a lack of behavioral counseling and nutrition education. Time restraints, misaligned financial incentives, and restricted access to multidisciplinary support are some of the challenges faced by providers. Comorbid conditions like PCOS, hypothyroidism, and depression impact metabolism, hormonal balance, and patient motivation at the patient level and make management more difficult. Although they have a weak connection to primary care, family and community environments also have a big impact on health behaviors. A methodical, evidence-based strategy is required to get past these obstacles. This includes advocating for payment models, team-based care models, streamlined referral processes, improved medical school curricula, and easily accessible continuing medical education. Effective interventions must involve the whole family and make use of available resources. In primary care, digital health tools such as telehealth platforms and mobile apps can alleviate time and resource constraints by extending care reach, improving patient engagement, and providing real-time data.

Time restrictions and clinical workload

One often mentioned challenge is the considerable time limit during regular primary care visits. Being a complex chronic illness, obesity calls for a comprehensive assessment, individualized advice on lifestyle changes (diet, exercise, and behavior), an in-depth discussion of the benefits and drawbacks of AOMs, management of comorbidities, and ongoing observation. Usually in a normal 10 to 15 min appointment, it is difficult to sufficiently handle these complicated problems, which leads to little conversation or an emphasis on more pressing concerns.

Many PCPs say they did not get enough instruction and training in managing obesity throughout medical school, residency, and even continuing medical education. Particularly with regard to the rapidly evolving field of AOMs, their mechanisms, efficacy, side effects, and appropriate patient selection, this may cause gaps in knowledge of the most recent evidence-based recommendations. Lack of specialized training can also lead to lowered confidence in beginning weight-related discussions, providing successful behavioral counseling, supervising medication, or handling patient ambivalence. In Saudi Arabia, for instance, a 2025 cross-sectional study found that although most PCPs (70.7%) had a moderate attitude toward obesity, more than half (57%) said they would want additional training in obesity counseling, and their self-reported practice levels were often moderate to poor. This shows how urgently worldwide better educational programs are needed. These challenges are not merely anecdotal; a 2025 joint clinical perspective from the Obesity Medicine Association (OMA) and the American College of Osteopathic Family Physicians (ACOFP) identified insufficient time, inadequate training, and poor reimbursement as primary barriers impeding optimal care in the primary care setting [53].

Attitudes of clinicians: bias, weight stigma, and attachment

Among healthcare professionals, including PCPs, weight bias—unfavorable attitudes, beliefs, and stereotypes—and weight stigma—social devaluation and mistreatment based on weight—are rather common and especially detrimental problems. Explicit or unconscious, these prejudices can manifest as ideas that obese patients are unmotivated, uncooperative, or reluctant. Less respectful communication, a more directive rather than a cooperative approach, poor provision of care, and even a resistance to offer evidence-based treatments can follow from this. Patients who feel weight stigma are those who experience or see shamed, judged, and disrespected by their healthcare providers. These negative events can lead to poorer health outcomes and more psychological distress; they can also cause people to avoid medical care (including preventive services), have less faith in medical professionals, be reluctant to discuss weight-related issues, and not follow treatment advice. The 2025 American Diabetes Association (ADA) Standards of Care on weight bias and the 2023 American Association of Clinical Endocrinology (AACE) Consensus Statement on Stigma and Bias call for healthcare systems and professionals to actively detect and address weight bias. Person-first language (e.g., “person with obesity” instead of “obese person”), establishing a friendly and inclusive clinical setting (e.g., making sure that gowns, blood pressure cuffs, and examination tables are available in suitable sizes), obtaining consent before discussing weight, and having compassionate, nonjudging conversations that emphasize health rather than just weight figures are all important tactics. Key strategies include using person-first language, ensuring the clinical environment is physically accommodating (e.g., appropriate-sized equipment), and asking for permission before initiating weight-related discussions [53].

Adherence problems and patient-based characteristics

Managing obesity is mostly difficult when one lacks patient adherence to long-term behavioral changes (diet and exercise) and medication schedules. Some of the many elements influencing adherence are individual motivation levels, socioeconomic constraints (e.g., the cost of healthy foods, access to safe places for physical activity, and affordability of medications), mental health comorbidities (e.g., depression, anxiety, or BED, which can impact coping mechanisms and motivation), a lack of social support, prior negative experiences with weight management attempts, or stigmatizing interactions within the healthcare system. Patients may also hold false opinions regarding the causes of obesity or the effectiveness and safety of different treatments. A strong support network—including peers, family, and healthcare providers—is absolutely vital, based on a 2023 systematic review on patient-reported obstacles and facilitators to implementing lifestyle interventions in primary care. Furthermore crucial are tailored individualized lifestyle intervention programs for every person’s particular situation, preferences, and objectives. Though they generally value their PCP’s participation in their weight management path, patients may become annoyed by inconsistent follow-up, a lack of tailored advice, or a perceived lack of knowledge of the daily challenges they face in managing their weight. Improving adherence and results calls for an awareness of these patient-specific challenges and how to get beyond them by cooperative problem-solving and sympathetic communication.

Systemic and Reimbursement Issues: Apart from issues involving particular doctors and patients, systematic problems in healthcare systems create major challenges. Many times, the comprehensive obesity counseling and management tools provided in primary care are not sufficiently reimbursed. This financial disincentive may make it difficult for practices to commit the time and resources (such as specialized dietitians or health educators) needed for intense obesity treatment. Limited access to specialized obesity treatment resources—such as multidisciplinary weight management programs, bariatric surgery centers, and reasonably priced AOMs—allows PCPs and their patients less choices as well. Furthermore hampered by care fragmentation and poor communication between primary care and specialized services is effective management. Often necessary to remove these institutional barriers and ensure that obesity is recognized and compensated as a chronic illness needing all-encompassing, long-term treatment are local, state, and federal policy changes.

Though PCPs are very important in controlling obesity, the best treatment usually calls for a multidisciplinary team approach including dietitians, psychologists or behavioral therapists, exercise physiologists or physical therapists, and occasionally bariatric surgeons or obesity medicine specialists. Access to these combined multidisciplinary services is often limited, though, particularly in rural or underprivileged areas or in response to limited insurance coverage. This forces PCPs to supervise all aspect of obesity treatment, usually without the required tools or support. When compared to normal treatment, a 2024 RCT carried out in a rural area revealed the benefits of an interdisciplinary obesity care model (NP-led with support from a dietitian, physiotherapist, and psychologist). Showing sustained weight loss and improved diabetes control over a 2-year period, this RCT revealed.

Integration of New Technologies and Treatments: Highly successful AOMs present opportunities as well as challenges related to the rapid development of new technologies (such as digital health tools and AI-powered decision support) Particularly with regard to the efficacy, negative effects, and cost of new drugs, PCPs may find it challenging to remain current on the most recent studies, figure out how to effectively include these new resources and therapies into their practice, and control patient expectations. Clinical decision support systems (CDSS) are being developed to assist PCPs; nevertheless, their usability and workflow integration must be carefully considered in order to prevent alert fatigue or disturbance. For a weight management CDSS, for example, a 2025 proof-of-concept study found that although it raised PCP self-efficacy and self-reported clinical practice habits, issues with patient engagement—completing questionnaires—and PCP perception of productivity persisted. These linked problems complicate the primary care management of obesity. Dealing with them effectively will call for a multifarious strategy including efforts against weight stigma, legislative changes to support comprehensive care, improvements in medical education, and the development of fresh care models better serving patients and PCPs.

Strategies for overcoming challenges in primary care

The complex issue of obesity in primary care requires a multifaceted approach that incorporates improvements in therapeutic interventions, policy reforms, medical education and training, and the development of patient-centered and equitable care models. Future research must focus on adapting study findings into practical, expandable, and long-lasting primary care approaches. To overcome existing challenges, a structured approach is needed. The OMA and ACOFP advocate for a model based on four pillars of care including nutrition therapy, physical activity, behavior modification, and medical interventions. Optimizing outcomes involves systematically addressing each of these pillars [53].

Enhancing medical education and PCP training

A crucial first step is to improve obesity education at all levels of medical school, residency, and continuing medical education for PCPs in practice. Curriculum that go beyond basic pathophysiology should cover the pharmacology of AOMs (including newer agents), practical nutrition and physical activity prescription, evidence-based behavioral counseling techniques (such as MI and CBT adapted for primary care), management of AOM side effects, and strategies for addressing weight stigma and bias. To improve empathy and communication skills, training should include experiential learning methods like standardized patient encounters or reflective practice. The “5As of Obesity Management” (Ask, Assess, Advise, Agree, Assist) framework has been shown to boost residents’ competence and confidence in obesity counseling when integrated into comprehensive training programs. It also provides a useful framework for guiding consultations. The development of practical, evidence-based clinical guidelines and primary care-specific decision-support materials are further ways to empower PCPs. The OMA/ACOFP 2025 joint clinical perspective places a high priority on providing helpful resources regarding the four pillars of obesity management (diet, exercise, behavior modification, and medical interventions) in order to assist primary care physicians.

Policy changes to promote all-inclusive obesity care

Promoting legislative changes is essential to creating a healthcare environment that supports effective obesity management. This involves advocating for equitable remuneration for the laborious obesity treatment and counseling services rendered in primary care, which is currently a major barrier. Better insurance coverage for evidence-based interventions, including behavioral programs, bariatric surgery, and AOMs (especially more recent, more costly, but more effective agents), is necessary to ensure equitable access to care. Policies that make multidisciplinary teams easier to access or integrate into primary care can also improve the quality of care. Additionally, public health policies that look for improving food environments and encourage physical activity at the population level, can support individual efforts made in clinical settings.

Advances in novel and pharmacological treatments

Research on new pharmacological treatments must continue. The success of GLP-1 RAs and dual GLP-1/GIP agonists has encouraged more research into multi-agonist therapies (e.g., tri-agonists like retatrutide) and novel mechanisms of action that may offer even greater efficacy or improved tolerability. The development of effective oral formulations of incretin mimetics, like orforglipron, may significantly increase patient convenience and adherence. Research should also focus on long-term safety and efficacy, cardiovascular outcomes of novel agents, techniques for sequencing or combining medications, and identifying predictors of response to specific AOMs in order to enable more customized prescribing. Research on gene-based therapies, the role of the gut microbiota in obesity, and the creation of innovative bariatric procedures is still ongoing, despite the fact that they are currently farther from being widely used in primary care.

The development of distinct “off-ramping” techniques for patients who have used potent AOMs to achieve notable weight loss should be the main goal of future pharmacological research. Understanding how to taper or stop taking these medications while preventing weight gain—possibly by relying on highly reinforced behavioral techniques or transferring to less intense AOMs—is an important unmet need.

Developing equitable and patient-centered care models

Future obesity treatment models must prioritize equity and patient-centeredness. At every level of the healthcare system, it includes thoroughly dealing with stigma and bias related to weight. Healthcare professionals must be trained to provide collaborative, respectful, and nonjudgmental care, acknowledging the patient as an expert in their own life and preferences. Care models should be sensitive to cultural differences and tailored to the specific needs and financial situations of different patient populations. This might mean hiring community health workers, reaching out to underserved communities via telehealth, and ensuring that educational resources and programs are accessible and culturally appropriate.

Patient-reported outcome measures (PROMs) must be more systematically incorporated into routine clinical practice in order to provide truly patient-centered care. From the perspective of the patient, PROMs provide a more complete picture of treatment success, capturing not only weight loss but also improvements in physical function, symptoms, self-esteem, and satisfaction with care. A core set of PROMs for clinical obesity care includes measures like the BODY-Q (covering physical function, symptoms, psychological function, social function, eating behavior, and body image) and the IWQOL-Lite (for self-esteem). These information can be collected in a systematic way and utilized to improve collaborative decision-making and personalize treatment regimens.

Using technology in digital health

The management of obesity in primary care could be greatly enhanced by advancements in digital health. AI-powered clinical decision support systems (CDSS) can assist PCPs with risk stratification, treatment selection, and adherence to guidelines, but their integration into clinical workflows must be optimized to ensure usability and avoid alert fatigue. Telemedicine can improve access to care and allow for more frequent, quick check-ins for monitoring and support, especially for patients who live in remote areas or have limited mobility. Wearable technology and mobile health (mHealth) apps can provide patients with the tools to self-monitor their weight, sleep habits, level of physical activity, and diet, in addition to providing personalized feedback and motivation. There is growing evidence that incorporating AOMs with digital health platforms can enhance weight loss outcomes by providing structured behavioral support. However, after six months, there is a chance of weight regain and the effectiveness of smartphone-only apps for managing weight without comorbidities appears to be limited. This implies that apps might need to be more individualized and incorporated into broader care models in order to sustain long-term benefits. Ensuring data privacy, security, and digital equity is crucial as these technologies become more widely used.

Prioritize implementation science

Finally, to understand how to successfully integrate evidence-based obesity interventions into routine primary care practices, a greater focus on implementation science is needed. This includes researching implementation enablers and barriers, evaluating different service delivery models (e.g., shared medical appointments, team-based care, and integration with community resources), and developing strategies to promote the adoption and sustainability of effective practices. NHS England’s phased implementation plan for tirzepatide in primary care, which includes defined models of care, mandatory wraparound lifestyle support, and specific cohorting, is an example of a health system attempting to operationalize the rollout of new, complex interventions. Learning from such initiatives will be crucial to scaling up effective obesity care globally.

Conclusion

Obesity, is a chronic public health trend that needs thorough management, mainly in primary care settings. The basis for effective treatment is behavioral interventions, which can be lifestyle modifications and physical activity. Behavioral therapies, such as CBT and MI, are of vital importance in keeping patients compliant over time with the introduced lifestyle modifications. Pharmacological treatments, including GLP-1 receptor agonists and combination therapies like Naltrexone-Bupropion, can further support weight loss and metabolic health for those who cannot make lifestyle changes alone. Also, Primary care providers have a crucial role in managing obesity; however, there are certain barriers: time constraints, lack of training, and patient compliance. Overcoming these barriers will be very useful in the management of obesity. Future efforts should be directed at improving medical education, advocating for policy changes that promote better access to care, and using digital health technologies to improve patient engagement and adherence. Innovations such as AI-powered decision support, telemedicine, and wearable devices are promising ways to monitor patient progress and provide timely feedback. Finally, effective management of obesity as a global health crisis needs a multi-faceted strategy that integrates evidence-based behavioral and pharmacological approaches, addresses systemic challenges, and puts personalized care at the forefront.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

M.K conceptualized the study, conducted the literature search, designed the tables, drafted the initial manuscript, and performed critical revisions. R.A carried out the literature review, extracted data for table compilation, and drafted sections on the theoretical framework. A.EN developed the overall methodology, selected and curated studies for inclusion in the tables, and edited the content. S.H.B performed thematic analysis, structured and formatted the tables, and prepared visual elements as needed. M.H managed references and formatted the tables according to journal guidelines. A.S.S interpreted the clinical implications, carried out writing-review and editing tasks. K.R reviewed the final manuscript and provided scientific supervision and guidance and gave final approval of the manuscript. R.P oversaw project administration and conceptualization, supervised all stages of the work, handled correspondence with the journal, and coordinated preparation of the final manuscript.

Funding

No funds, grants, or other support was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

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Consent for publication

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Competing interests

The authors declare no competing interests.

Consent to participate

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Data access statement

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This study is not a clinical trial. Registration details not applicable.