Latest VA/DoD obesity guideline backs earlier and sustained use of effective therapies

Clinical takeaway: Offer comprehensive lifestyle intervention to all appropriate patients, but do not require a lifestyle-only trial before considering pharmacotherapy. For eligible adults, initiate semaglutide or tirzepatide through shared decision-making and prepare patients for long-term treatment because stopping medication commonly leads to weight regain.

A synopsis of the 2025 U.S. Department of Veterans Affairs and Department of Defense guideline, published August 24 in Annals of Internal Medicine, highlights a more personalized approach to obesity assessment and treatment. The update calls for evaluating obesity-related risk using BMI alongside waist measurements, comorbidities, functional status, and clinical context.

Comprehensive lifestyle intervention, combining behavioral strategies, a dietary approach that produces negative energy balance, and physical activity, remains the foundation of care. However, no single diet or specific intervention intensity is preferred.

Medication may be incorporated promptly rather than reserved for patients who first “fail” lifestyle treatment. The guideline strongly recommends semaglutide or tirzepatide, together with comprehensive lifestyle intervention, for weight loss and maintenance in adults with BMI of at least 30 kg/m² or BMI of at least 27 kg/m² plus an obesity-associated condition.

Phentermine/topiramate extended release or liraglutide receives a weaker recommendation for weight loss and maintenance in the same populations, while naltrexone/bupropion extended release is suggested for weight loss. GLP-1-containing therapy is also suggested for patients with overweight or obesity and prediabetes or type 2 diabetes.

Evidence was insufficient to recommend for or against orlistat, metformin, SGLT2 inhibitors, or pramlintide specifically for weight loss. The panel also advises reviewing other medications and, when clinically feasible, replacing obesogenic drugs with weight-neutral or weight-reducing alternatives.

“Obesity is a chronic disease that requires lifelong management,” the guideline states. Consistent with that approach, the panel suggests against discontinuing effective obesity medication because withdrawal frequently produces weight regain; evidence remains insufficient to determine whether dose reduction or less-frequent dosing can preserve the benefit.

Endoscopic sleeve gastroplasty is a new option for patients with BMI of at least 30 kg/m². Metabolic and bariatric surgery may be considered for durable weight loss at BMI of at least 35 kg/m² or at BMI of at least 30 kg/m² with type 2 diabetes, while intragastric balloons may provide temporary weight loss for selected patients.

What’s changed

• Semaglutide and tirzepatide receive a new strong recommendation for both weight loss and maintenance.
• Clinicians need not delay pharmacotherapy until completion of a lifestyle-only trial; evidence does not support mandatory stepwise sequencing.
• Continued treatment is emphasized, with a new recommendation against routinely discontinuing effective obesity medication because of weight regain.
• GLP-1–containing agents are newly suggested for patients with overweight or obesity plus prediabetes or type 2 diabetes.
• Endoscopic sleeve gastroplasty is newly recommended as an option, and bariatric surgery eligibility is broadened to BMI of at least 35 kg/m² regardless of comorbidity.
• The update adds guidance on internalized weight bias, suggesting cognitive behavioral interventions for affected patients.

Source: Sall J, et al. (2026 Aug 24) Ann Intern Med. Adult Overweight and Obesity Management: Updates From the 2025 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines