The US Department of Veterans Affairs and Department of Defense have updated their 2020 guideline on adult overweight and obesity, with a synopsis written for primary care. A multidisciplinary panel reviewed evidence published from April 2019 to January 2025 against 12 key questions, with independent third-party review and GRADE methods.
Three changes matter in a general clinic. Screening is suggested for all adults at a BMI of 25 kg/m² or above — and 23 kg/m² or above for Asian adults — with waist circumference and clinical context used to refine risk. Comprehensive lifestyle intervention remains strongly recommended as the foundation of care. But the panel found insufficient evidence to recommend for or against delaying drug treatment relative to lifestyle intervention, and states there is no requirement to complete lifestyle intervention before starting additional treatment. It also discourages stopping a medication that is working, on the grounds that weight regain follows.
That last point is the one to carry. The sequential model — diet and exercise first, drugs only if that fails, stopped once target is reached — has structured obesity care for decades and is not supported here. Treating obesity as a chronic relapsing condition means the drug question is about whether it is working, not about whether the patient has earned it. The lower Asian threshold is directly relevant to Indian practice, though this is US guidance and the availability and cost of GLP-1 receptor agonists here remain the practical constraint.
- Use a BMI threshold of 23 kg/m² for screening Asian adults, with waist circumference alongside
- Do not require a completed lifestyle programme before discussing pharmacotherapy
- Do not stop a weight medication that is working simply because target has been reached
- Frame the treatment plan as long-term from the first conversation, including what happens if the drug is stopped
Why it matters
The sequential 'lifestyle first, then drugs, then stop' model that has shaped obesity care is not supported by the current evidence.
Don't overread it
This is guidance written for US veterans and service members — the recommendations transfer, the resource assumptions do not.
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