The South African Medical Journal (SAMJ) - first published in 1884 - is a monthly, peer reviewed, general medical journal publishing leading research impacting clinical care in southern Africa.
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Copyright (c) 2025 Claudia Naidu https://creativecommons.org/licenses/by-nc/4.0
Reducing weight bias in obesity management, practice and policy
RECOMMENDATIONS 1. HCPs should assess their own attitudes and beliefs regarding obesity and consider how their attitudes and beliefs may influence care delivery (Level 1a, Grade A). 2. HCPs should recognise that internalised weight bias (bias towards oneself) in PLWO can affect behavioural and health outcomes (Level 2a, Grade B). 3. HCPs should avoid using judgemental words (Level 1a, Grade A), images (Level 2b, Grade B)[2] and practices (Level 2a, Grade B)[13] when working with PLWO. 4. We recommend that HCPs avoid making assumptions that an ailment or complaint a patient presents is related to their body weight (Level 3, Grade C).
Copyright (c) 2025 J Hellig, C Nieuwoudt, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Transforming obesity care: Evidence-based guideline for South Africa
Copyright (c) 2025 Marli Conradie-Smit https://creativecommons.org/licenses/by-nc/4.0
Clinical Practice Guideline For The Management Of Obesity In Adults In South Africa
Copyright (c) 2025 A Dhai https://creativecommons.org/licenses/by-nc/4.0
RECOMMENDATIONS 1. Healthcare providers should recognise and treat obesity as a chronic disease, caused by abnormal or excess body fat accumulation (adiposity) that impairs health, with increased risk of premature morbidity and mortality (Level 2b, Grade B). 2. The development of evidence-informed strategies at the health system and policy level should be directed at managing obesity in adults (Level 2b, Grade B). 3. Continued longitudinal national and regional surveillance of obesity that includes self-reported and measured data (i.e. heights, weights, waist circumferences) should be conducted on a regular basis (Level 2b, Grade B).
Copyright (c) 2025 J H Goedecke, J Hellig, M Conradie-Smit, W May, A Cois https://creativecommons.org/licenses/by-nc/4.0
KEY MESSAGES • Obesity arises from a complex interplay of genetic, biological, behavioural, psychosocial and environmental factors. • Obesity has a strong genetic component, with twin studies indicating a 50 - 80% concordance in body mass index (BMI) and regional fat distribution. A Swedish study on identical twins raised apart found no correlation between BMI and their adoptive families but a strong correlation with their biological twin, despite being raised in separate households. • The regulation of appetite, body weight and energy balance is highly complex, governed by a network of hormonal signals from the gut, adipose tissue and other organs, as well as neural signals that shape eating behaviours. Many of these signalling pathways are disrupted in people living with obesity. • Since body weight is homeostatically regulated, weight loss triggers physiological adaptations that promote weight regain. These include a decrease in energy expenditure, and hormonal changes that enhance appetite while reducing satiety. • Adipose tissue influences the central regulation of energy homeostasis, and excess adiposity can become dysfunctional, with production of proinflammatory cytokines and associated metabolic health complications. • Individual variations in body composition, fat distribution and function result in a highly variable threshold at which excess adiposity begins to negatively affect health. • Emerging research in obesity science has widened to include brown fat, the gut microbiome, immune system regulation, and the intricate mechanisms that regulate body weight. • Obesity can be classified as primary, secondary and genetic obesity. • In the current management of primary obesity, prevention (the path in) and treatment (the path out) need to be distinctly separated. • Effective primary obesity treatment requires an integrated approach that addresses the non-modifiable cause (increased appetite) together with modifiable contributors (poor diet quality, increased stress, poor sleep, reduced physical activity and increased sedentary behaviour). Behavioural modification and psychological support provide additional benefit. • Effective treatment in genetic and secondary obesity requires treatment of the underlying causes along with modification of the contributors.
Copyright (c) 2025 W May, J H Goedecke, M Conradie-Smit https://creativecommons.org/licenses/by-nc/4.0
Prevention and harm reduction of obesity (clinical prevention)
KEY MESSAGES FOR HEALTHCARE PROVIDERS Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications, and reduces lifespan. Obesity arises from a complex interplay of genetic, biological, behavioural, psychosocial and environmental factors, and can develop via slow and steady weight gain over an extended period, or from rapid bursts of weight gain. Obesity prevention should take place in a range of settings that access whole populations or high-risk groups. The individual-based approach to prevention is primarily used by healthcare providers and targets those with the highest level of risk of obesity. The population-based approach addresses the behavioural, sociocultural and environmental factors that contribute to non-communicable diseases in populations, including obesity. Primary care clinicians have an important role in early identification of people living with obesity. Regular assessments of body weight are needed to catch early weight gain. (See the chapters ‘Assessment of people living with obesity’ and ‘Primary care and primary healthcare in obesity management’.) Primary care clinicians should initiate discussion around weight gain early and contemplate interventions that consider its complex causes, providing guidance beyond ‘eat less and move more’. Many medications are associated with weight gain side-effects that can contribute to long-term weight gain. The risks and benefits of such medications should be weighed up for each specific person before prescribing. Excess pregnancy weight gain and post-pregnancy weight retention are significantly reduced with behavioural interventions. Primary care clinicians should counsel women attending prenatal care not to exceed pregnancy weight gain guidelines, in the course of dietary, physical activity and psychological interventions during prenatal visits. Health benefits of smoking cessation outweigh the cardiovascular consequences associated with smoking cessation-related weight gain. Short-term behavioural interventions (generally 6 months or less) aimed at preventing weight gain during young adulthood, menopause, smoking cessation and breast cancer treatment have not yet been shown to be effective. Longer-term interventions are likely to be needed to properly examine strategies for preventing weight gain for many of these high-risk groups and in the general population.
Copyright (c) 2025 Z Bayat, J Lubbe, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Enabling participation in activities of daily living for people living with obesity
RECOMMENDATIONS 1. We recommend that HCPs ask PLWO if they have concerns about managing self-care activities such as bathing, getting dressed, bowel and/or bladder management, skin and/or wound care, foot care (Level 3, Grade C). 2. We recommend that HCPs assess falls risk in PLWO, as this could interfere with their ability to participate in physical activity and their interest in doing so (Level 3, Grade C).
Copyright (c) 2025 M Conradie-Smit, S A Bhana, W May https://creativecommons.org/licenses/by-nc/4.0
Assessment of people living with obesity
RECOMMENDATIONS We suggest that HCPs involved in screening, assessing and managing PLWO use the '5As' framework to initiate the discussion by asking for their permission and assessing their readiness to initiate treatment (Level 4, Grade D, Consensus). HCPs can measure height and weight and calculate BMI in all adults (Level 2a, Grade B), and measure waist circumference in individuals with a BMI 25 - 35 kg/m2 (Level 2b, Grade B). We suggest that a comprehensive history to identify root causes of weight gain as well as complications of obesity and potential barriers to treatment be included in the assessment (Level 4, Grade D). We recommend measurement of blood pressure in both arms, fasting glucose or glycated haemoglobin and lipid profile to determine cardiometabolic risk and, where appropriate, alanine transaminase to screen for metabolic dysfunction-associated steatotic liver disease in PLWO (Level 3, Grade D). We suggest that HCPs consider using the Edmonton Obesity Staging System to determine the severity of obesity and guide clinical decision-making (Level 4, Grade D)
Copyright (c) 2025 A Murphy, P N Diab, J H Goedecke, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
The role of mental health in obesity management
RECOMMENDATIONS 1. We recommend regular monitoring of weight, glucose and lipid profile in people with a mental health diagnosis who are taking medications associated with weight gain (Level 3, Grade C). 2. Healthcare providers can consider both efficacy and effects on body weight when choosing psychiatric medications (Level 2a, Grade B). 3. Metformin and psychological treatment, such as CBT, should be considered for prevention of weight gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain (Level 1a, Grade A).
Copyright (c) 2025 K Mawson, E J Barnard, J Lubbe, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Medical nutrition therapy in obesity management
RECOMMENDATIONS We suggest that nutrition recommendations for adults of all body sizes should be personalised to meet individual values, preferences and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally acceptable and affordable for long-term adherence (Level 4, Grade D). PLWO should receive individualised MNT provided by a registered dietitian (when available) to improve weight outcomes (body weight, BMI), waist circumference (WC) and glycaemic control, and to establish lipid and blood pressure (BP) targets (Level 1a, Grade A). PLWO and impaired glucose tolerance (prediabetes) or type 2 diabetes (T2DM) may receive MNT provided by a registered dietitian (when available) to reduce body weight and WC and improve glycaemic control and BP (Level 2a, Grade B). PLWO can consider any of the many medical nutrition therapies to improve health-related outcomes, choosing the dietary patterns and food-based approaches that support their best long-term adherence: CR dietary patterns emphasising variable macronutrient distribution ranges (lower, moderate or higher carbohydrate with variable proportions of protein and fat) to achieve similar body weight reduction over 6 - 12 months within a CR plan (Level 2a, Grade B). Mediterranean dietary pattern to improve glycaemic control, high-density lipoprotein cholesterol (HDL-C) and triglycerides (Level 2b, Grade C), reduce cardiovascular events (Level 2b, Grade C), reduce risk of T2DM (Level 2b, Grade C) and increase reversion of metabolic syndrome (Level 2b, Grade C),[11] with little effect on body weight and WC (Level 2b, Grade C) Vegetarian dietary pattern to improve glycaemic control and established blood lipid targets, including low-density lipoprotein cholesterol (LDL-C), and reduce body weight (Level 2a, Grade B), risk of T2DM (Level 3, Grade C), and coronary heart disease incidence and mortality (Level 3, Grade C). Portfolio dietary pattern to improve established blood lipid targets, including LDL-C, apolipoprotein B (apo B) and non-HDL-C (Level 1a, Grade B),[16] and reduce C-reactive protein (CRP), BP and estimated 10-year coronary heart disease risk (Level 2a, Grade B) Low glycaemic index dietary pattern to reduce body weight (Level 2a, Grade B), improve glycaemic control (Level 2a, Grade B) and established blood lipid targets, including LDL-C (Level 2a, Grade B), and reduce BP (Level 2a, Grade B)[20] and the risk of T2DM (Level 3, Grade C) and coronary heart disease (Level 3, Grade C). Dietary Approaches to Stop Hypertension (DASH) dietary pattern to reduce body weight and WC (Level 1a, Grade B), improve BP (Level 2a, Grade B), established lipid targets, including LDL-C (Level 2a, Grade B), CRP (Level 2b, Grade B)and glycaemic control (Level 2a, Grade B), and reduce the risk of T2DM, cardiovascular disease, coronary heart disease and stroke (Level 3, Grade C). Nordic dietary pattern to reduce body weight (Level 2a, Grade B)[26] and body weight regain (Level 2b, Grade B), improve BP (Level 2b, Grade B)[27] and established blood lipid targets, including LDL-C, apo B (Level 2a, Grade B)[28] and non-HDL-C (Level 2a, Grade B), and reduce the risk of cardiovascular and all-cause mortality (Level 3, Grade C) Partial meal replacements (replacing one to two meals per day as part of a CR intervention) to reduce body weight, WC and BP and improve glycaemic control (Level 1a, Grade B). Intermittent and continuous CR achieved similar short-term body weight reduction (Level 2a, Grade B) Pulses (i.e. beans, peas, chickpeas, lentils) to improve body weight (Level 2, Grade B), glycaemic control (Level 2, Grade B), established lipid targets, including LDL-C (Level 2, Grade B), and systolic BP (Level 2, Grade C), and reduce the risk of coronary heart disease (Level 3, Grade C). Vegetables and fruit to improve diastolic BP (Level 2, Grade B) and glycaemic control (Level 2, Grade B),[39] and reduce the risk of T2DM (Level 3, Grade C) and cardiovascular mortality (Level 3, Grade C). Nuts to improve glycaemic control (Level 2, Grade B) and established lipid targets, including LDL-C (Level 3, Grade C) and reduce the risk of cardiovascular disease (Level 3, Grade C). Whole grains (especially from oats and barley) to improve established lipid targets, including total cholesterol and LDL-C (Level 2, Grade B). Dairy foods to reduce body weight, WC and body fat and increase lean mass in CR diets, but not in unrestricted diets (Level 3, Grade C), and reduce the risk of T2DM and cardiovascular disease (Level 3, Grade C). PLWO and impaired glucose tolerance (prediabetes) should consider intensive behavioural interventions that target a 5 - 7% weight loss to improve glycaemic control, BP and blood lipid targets (Level 1a, Grade A), reduce the incidence of T2DM (Level 1a, Grade A)[48] and microvascular complications (retinopathy, nephropathy and neuropathy) (Level 1a, Grade B), and reduce cardiovascular and all-cause mortality (Level 1a, Grade B). PLWO and T2DM should consider intensive behavioural therapy that targets a 7 - 15% weight loss to increase the remission of T2DM (Level 1a, Grade A) and reduce the incidence of nephropathy (Level 1a, Grade A) obstructive sleep apnoea (Level 1a, Grade A) and depression (Level 1a, Grade A) We recommend a non-restrictive dietary approach to improve QoL, psychological outcomes (general wellbeing, body image perceptions), cardiovascular outcomes, body weight, physical activity, cognitive restraint and eating behaviours (Level 3, Grade C).
Copyright (c) 2025 M Conradie-Smit, V R Fourie, W May https://creativecommons.org/licenses/by-nc/4.0
RECOMMENDATIONS 1. Aerobic PA (30 - 60 minutes of moderate to vigorous intensity most days of the week) can be considered for adults who want to: a. achieve small amounts of body weight and fat loss (Level 2a, Grade B) b. achieve reductions in abdominal visceral fat (Level 1a, Grade A) and ectopic fat such as liver and heart fat (Level 1a, Grade A),even in the absence of weight loss c. favour weight maintenance after weight loss (Level 2a, Grade B) d. favour the maintenance of fat-free mass during weight loss (Level 2a, Grade B) e. increase cardiorespiratory fitness (Level 2a, Grade B)[9] and mobility (Level 2a, Grade B). 2. For adults living with overweight or obesity, resistance training may promote weight maintenance or modest increases in muscle mass or fat-free mass and mobility (Level 2a, Grade B) 3. Increasing exercise intensity, including high-intensity interval training (HIIT), can achieve greater increases in cardiorespiratory fitness compared with moderate-intensity aerobic activity, and reduce the amount of time required to achieve similar benefits (Level 2a, Grade B). 4. Regular PA, with and without weight loss, can improve many cardiometabolic risk factors in adults who have overweight or obesity, including: a. hyperglycaemia and insulin sensitivity (Level 2b, Grade B) b. high blood pressure (Level 1a, Grade B) c. dyslipidaemia (Level 2a, Grade B). 5. Regular PA can improve health-related quality of life, mood disorders (i.e. depression, anxiety) and body image in adults with overweight or obesity (Level 2b, Grade B).
Copyright (c) 2025 M Conradie-Smit, G Fourie, W May https://creativecommons.org/licenses/by-nc/4.0
Effective psychological and behavioural interventions in obesity management
RECOMMENDATIONS 1. The recommendations outlined below are summarised in the model presented in Fig. 1 and supported by the evidence summarised in Table 1. 2. Multi-component psychological interventions (combining behaviour modification [goal setting, self-monitoring, problem solving], cognitive therapy [reframing] and values-based strategies to alter nutrition and activity) should be incorporated into care plans for weight loss and improved health status and QoL (Level 1a, Grade A)[1-8] in a manner that promotes adherence, confidence and intrinsic motivation (Level 1b, Grade A). 3. HCPs should provide longitudinal care with consistent messaging to PLWO to support the development of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal, meaningful reasons to change), to encourage the patient to set and sequence health goals that are realistic and achievable (Level 1a, Grade A), to self-monitor behaviour (Level 1a, Grade A), and to analyse setbacks using problem solving and adaptive thinking (cognitive reframing), including clarifying and reflecting on values-based behaviours (Level 1a, Grade A). 4. HCPs should ask patients’ permission to educate them that success in obesity management is related to improved health, function and QoL resulting from achievable behavioural goals, and not the amount of weight loss (Level 1a, Grade A). 5. HCPs should provide follow-up sessions consistent with repetition and relevance to support the development of self-efficacy and intrinsic motivation. Once an agreement to pursue a behavioural path has been established (health behaviour and/or medication and/or surgical pathways), follow-up sessions should repeat the above messages in a fashion consistent with repetition (the provider role) and relevance (the patient role) to support the development of self-efficacy and intrinsic motivation (Level 1a, Grade A).
Copyright (c) 2025 J Bantjes, C Arendse, M Conradie-Smit, W May, K Mawson https://creativecommons.org/licenses/by-nc/4.0
RECOMMENDATIONS 1. Pharmacotherapy for obesity management can be used for individuals with a BMI ≥30 kg/m2, or ≥27 kg/m2 with adiposity-related complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions (semaglutide 2.4 mg weekly [Level 1a, Grade A] liraglutide 3.0 mg daily [Level 2a, grade B], naltrexone/bupropion 16 mg/180 mg twice a day [BID] [Level 2a, Grade B], orlistat 120 mg three times a day [TID] [Level 2a, Grade B]). 2. Pharmacotherapy may be used to maintain weight loss and to prevent weight regain (liraglutide 3.0 mg daily [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]). 3. Pharmacotherapy for obesity management in conjunction with health behaviour changes for people living with prediabetes and overweight or obesity (BMI ≥27 kg/m2) can be used to delay or prevent T2DM (liraglutide 3.0 mg daily [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]). 4. Obesity pharmacotherapy can be used in conjunction with health behaviour changes in people living with T2DM and a BMI ≥27 kg/m2, for weight loss and improvement in glycaemic control (semaglutide 2.4 mg weekly [Level 1a, Grade A], liraglutide 3.0 mg daily [Level 1b, Grade A], naltrexone/bupropion 16 mg/180 mg BID [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]). 5. Pharmacotherapy can be considered in conjunction with health behaviour changes in treating people with obstructive sleep apnoea and a BMI ≥30 kg/m2, for weight loss and associated improvement in the apnoea-hypopnoea index (liraglutide 3.0 mg daily [Level 2a, Grade B]). 6. Pharmacotherapy can be considered in conjunction with health behaviour changes in treating people living with metabolic dysfunction- associated steatohepatitis (MASH) and overweight or obesity, for weight loss and improvement of MASH parameters (liraglutide 1.8 mg daily [Level 3; Grade C], semaglutide 2.4 mg [Level 4 Grade D]). 7. Metformin and psychological treatment (such as cognitive behavioural therapy) should be considered for prevention of weight gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain (Level 1a, Grade A). 8. For people living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest choosing medications that are not associated with weight gain (Level 4, Grade D, Consensus). 9. We do not suggest the use of prescription or over-the-counter medications other than those approved in SA for obesity management (Level 4, Grade D, Consensus).
Copyright (c) 2025 M Noeth, F H Van Zyl, J Hellig, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Metabolic and bariatric surgery: Selection and preoperative work-up
RECOMMENDATIONS 1. We suggest that a comprehensive medical and nutritional evaluation be completed and nutrient deficiencies corrected in candidates for MBS (Level 4, Grade D). 2. We suggest screening for and treatment of obstructive sleep apnoea in people seeking MBS (Level 4, Grade D). 3. Preoperative smoking cessation can minimise postoperative complications (Level 2a, Grade B).
Copyright (c) 2025 J G M Smit, J Lubbe, A Murphy, K Mawson, M Z Koto, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Metabolic and bariatric surgery: Surgical options and outcomes
RECOMMENDATIONS 1. MBS is recommended for individuals with a BMI >35 kg/m2, regardless of the presence, absence or severity of comorbidities,* to: a) reduce long-term overall mortality (Level 2b, Grade B) b) induce significantly better long-term weight loss compared with medical management alone (Level 1a, Grade A)[4] c) induce control and remission of T2DM, in combination with best medical management, over best medical management alone (Level 2a, Grade B) d) significantly improve QoL (Level 3, Grade C) e) induce long-term remission of most obesity-related diseases, including dyslipidaemia (Level 3, Grade C),[8] hypertension (Level 3, Grade C) and MASLD (Level 3, Grade C). 2.MBS should be considered for individuals with metabolic disease and a BMI of 30 - 34.9 kg/m2*. 3.We suggest that the choice of metabolic and bariatric procedure be decided according to the patient’s need, in collaboration with an experienced MDT (Level 4, Grade D, Consensus). 4.We suggest that adjustable gastric banding should not be offered owing to unacceptable complications and long-term failure (Level 4,Grade D). 5.We suggest that one-anastomosis gastric bypass should not be routinely offered owing to long-term complications in comparison with standard Roux-en-Y gastric bypass (Level 4, Grade D). *Recommendation 1 (Level 5, Grade D) and Recommendation 2 (Level 2a, Grade B).
Copyright (c) 2025 J Lubbe, J G M Smit, M Z Koto, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Metabolic and bariatric surgery: Postoperative management
RECOMMENDATIONS 1. HCPs can encourage PLWO who have undergone MBS to participate in and maximise their access to behavioural interventions and allied health services at an MBS centre (Level 2a, Grade B). 2. We suggest that MBS centres communicate a comprehensive care plan to primary HCPs for patients who are discharged, including MBS procedure, emergency contact numbers, annual blood tests required, long-term vitamin and mineral supplements, medications, behavioural interventions, and when to refer back (Level 4, Grade D, Consensus). 3. We suggest that after a PLWO has been discharged from the MBS centre, HCPs should annually review nutritional intake, activity, compliance with multivitamin and mineral supplements and weight, as well as assess comorbidities, order laboratory tests to assess for nutritional deficiencies, and investigate abnormal results and treat as required (Level 4, Grade D, Consensus). 4. We suggest that HCPs consider referral back to the MBS centre or to a local bariatric medicine specialist for technical or gastrointestinal symptoms, nutritional issues, pregnancy, psychological support, weight regain, or other medical issues related to MBS as described in this chapter (Level 4, Grade D, Consensus). 5. We suggest that MBS centres provide appropriate follow-up and laboratory tests at regular intervals after surgery with access to appropriate HCPs (dietitian, nurse, social worker, surgeon, bariatric physician, psychologist/psychiatrist) until discharge/referral to primary care level is deemed appropriate for the patient (Level 4, Grade D, Consensus).
Copyright (c) 2025 J Skelton, A Murphy, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Primary care and primary healthcare in obesity management
RECOMMENDATIONS 1. We recommend that PHPs identify PLWO, and initiate patient-centred, health-focused conversations with them (Level 3, Grade C). 2. We recommend that PHPs ensure that they ask PLWO for their permission prior to discussing weight or taking anthropometric measurements (Level 3, Grade C). 3. Primary care interventions should be used to increase health literacy in individuals’ knowledge about and skills in weight management as an effective intervention to manage weight (Level 1a, Grade A). 4. PHPs should refer PLWO to primary care multi-component programmes with personalised obesity management strategies as an effective way to support obesity management (Level 1b, Grade B). 5. PHPs can use collaborative deliberation with motivational interviewing to tailor action plans to individuals’ life context in a way that is manageable and sustainable to support improved physical and emotional health, and weight management (Level 2b, Grade C). Features of primary care and primary healthcare community-based interventions for PHPs and developers: 6. Interventions that target a specific ethnic group should consider the diversity of psychological and social practices with regard to excess weight, food and physical activity as well as socioeconomic circumstances, as they may differ across and within different ethnic groups (Level 1b, Grade B). 7. Longitudinal primary care interventions should focus on incremental, personalised, small behaviour changes (the ‘Small Changes’ approach) to be effective in supporting people to manage their weight (Level 1b, Grade B). 8. Primary care multi-component programmes should consider personalised obesity management strategies as an effective way to support PLWO (Level 1b, Grade B). 9. Primary care interventions that are behaviour based (nutrition, exercise, lifestyle), alone or in combination with pharmacotherapy, should be utilised to manage PLWO (Level 1a, Grade A). 10. Group-based nutrition and physical activity sessions informed by the Diabetes Prevention Program and the Look AHEAD (Action for Health in Diabetes) programme should be used as an effective management option for PLWO (Level 1b, Grade A). 11. Interventions that use technology to increase reach to larger numbers of people asynchronously should be a potentially viable lower-cost method in a community-based setting (Level 1b, Grade B). Educational recommendations to support development of obesity management skills in the primary healthcare clinical workforce: 12. Educators in undergraduate, graduate and continuing education programmes for PHPs should provide courses and clinical experiences to address the gaps in skills, knowledge of the evidence, and attitudes necessary to confidently and effectively support PLWO (Level 1a, Grade A).[20]
Copyright (c) 2025 P N Diab, Z Dire, J Hellig, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Commercial products and programmes in obesity management
RECOMMENDATIONS 1. For adults living with overweight or obesity, some commercial programmes exist that should achieve mild-to-moderate weight loss over the short or medium term, and a mild reduction in glycated haemoglobin values over a short term in adults with type 2 diabetes compared with usual care or education. 2. We do not recommend the use of over-the-counter commercial weight loss products for obesity management, owing to lack of evidence (Level 4, Grade D). 3. We do not suggest that commercial weight loss programmes be used for improvement in blood pressure and lipid control in adults living with obesity (Level 4, Grade D).
Copyright (c) 2025 Z Bayat, S A Bhana, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Emerging technologies and virtual medicine in obesity management
RECOMMENDATIONS 1. Implementation of strategies in the management of obesity can be delivered through web-based platforms (e.g. online education on medical nutrition therapy and physical activity) or mobile devices (e.g. daily weight reporting through a smartphone phone application) (Level 2a, Grade B). 2. We suggest that healthcare providers incorporate individualised feedback and follow-up (e.g. personalised coaching or feedback via phone or email) into technology-based management strategies to improve weight loss outcomes (Level 4, Grade D). 3. The use of wearable activity-tracking technology should be part of a comprehensive strategy for weight loss (Level 1a, Grade A).
Copyright (c) 2025 F H Van Zyl, M Noeth, P N Diab, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0
Weight management over the reproductive years for adult women living with obesity
RECOMMENDATIONS These recommendations pertain to the management of weight over the reproductive years for adult women living with obesity (i.e. body mass index ≥30 kg/m2) with a singleton pregnancy, who are ≥18 years of age and do not have pre-existing diabetes or gestational diabetes. General advice. We recommend that healthcare providers (HCPs) should discuss weight management targets specific to the reproductive years with adult women living with obesity: pre-conception weight loss (Level 3, Grade C); gestational weight gain of 5 - 9 kg over the entire pregnancy (Level 4, Grade D); and postpartum weight loss of – at minimum – gestational weight gain (Level 3, Grade C), to reduce the risk of adverse outcomes in the current or a future pregnancy. Combined behaviour change interventions. HCPs should offer behaviour change interventions, including both nutrition and physical activity, to adult women living with obesity who are considering a pregnancy (Level 3, Grade C), who are pregnant (Level 2a, Grade B) and who are postpartum (Level 1a, Grade A),[16] in order to achieve weight targets. Nutrition counselling alone. We recommend that HCPs encourage and support pregnant women with obesity to consume foods consistent with a healthy dietary pattern in order to meet their target gestational weight gain (Level 3, Grade C). Physical activity counselling alone. We recommend that HCPs encourage and support pregnant women with obesity who do not have contraindications to exercise during pregnancy to engage in at least 150 minutes per week of moderate-intensity physical activity to assist in the management of gestational weight gain (Level 3, Grade C). Pharmacotherapy. HCPs should not prescribe metformin for managing gestational weight gain in women with obesity (Level 1b, Grade A). We suggest no weight management medications during pregnancy or breastfeeding (Level 4, Grade D). Breastfeeding. We recommend that women with obesity be offered additional breastfeeding support owing to decreased rates of initiation and continuation (Level 3, Grade C).
Copyright (c) 2025 Z Dire, J Hellig, M Conradie-Smit, W May https://creativecommons.org/licenses/by-nc/4.0