VA/DoD 2025 Obesity Guidelines Save

Annals of Internal Medicine has published the updated 2025 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines on adult Overweight and Obesity management.  This effort involved a multidisciplinary panel of key stakeholders, who after a systematic review of the evidence, addressed 12 PICOT questions and used GRADE consensus to formulate guidelines.

Obesity affects roughly 40% of U.S. adults and up to 68% of active-duty service members are overweight or obese. It is also highly prevalent among rheumatic disease patients. It drives incident disease, worsens disease activity, impairs drug responses (RA, PsA, axSpA, and OA), and compounds comorbidities associated with rheumatic diseases.

This document was unique in that it introduced several new practice-changing updates, focused on how obesity is defined and assessed, when and how pharmacotherapy (especially GLP-1–containing agents) should be utilized, and acknowledges a shift toward chronic-disease, longitudinal, stigma-informed care.  They underscore obesity as a chronic, relapsing, multifactorial neurobehavioral disease driven by brain and hormonal dysfunction, and recommends comprehensive lifestyle intervention (CLI) as the foundation of care. There is insufficient evidence to recommend for or against delaying pharmacotherapy relative to CLI, and there is no requirement to complete CLI before starting medication or other treatments. Flexible, simultaneous integrated care is recommended.

This guideline updates the 2020 VA/DoD CPG using GRADE methodology, reviewing evidence from April 2019–January 2025 across 12 key questions. It generated 23 recommendations: 8 new, 4 replaced, 7 amended, and 4 carried forward unchanged.

The guideline formalizes a whole-health, non-judgmental approach using the "5 As" framework and shared decision-making tailored to veterans and active-duty service members.

5 Key Takeaways for Rheumatologists

1. BMI alone is insufficient. Screen with BMI (≥25 kg/m², ≥23 for Asian patients) plus waist circumference (≥102 cm men/≥88 cm women; lower Asian cutoffs) to better capture cardiometabolic risk. This is relevant given the CV burden already inherent to RA and PsA.
2. Comprehensive lifestyle intervention (CLI) is foundational, but not a prerequisite. CLI (behavioral, dietary, and physical activity components together) is strongly recommended, but there is no requirement to complete CLI before starting pharmacotherapy. Delaying effective treatment risks reinforcing stigma and losing therapeutic windows.
3. GLP-1 receptor agonists now carry a "strong for" recommendation. Semaglutide and tirzepatide are recommended for weight loss and maintenance (BMI ≥27 with an obesity-associated condition, or ≥30), producing 15–25% total body weight loss with cardiometabolic benefit. This is directly relevant given emerging GLP-1 data in inflammatory arthritis and metabolic-associated joint disease.
4. Don't stop effective obesity medications. The guideline recommends against routine discontinuation of GLP-1 therapy once effective, since discontinuation reliably triggers weight regain (SURMOUNT-4, STEP 4 studies showed that con-tinuation of tirzepatide or semaglutide was superior to discontinuation for weight, metabolic, mental health, and quality-of-life outcomes).
5. Weight bias/stigma screening is now a formal recommendation. Cognitive behavioral interventions are suggested for patients with internalized weight bias; a population overlapping substantially with chronic rheumatic disease patients who already experience disease-related stigma.

Prioritization: What to Do Before Pharmacotherapy

Although CLI need not be completed first, the guideline supports this sequence in primary care:

1. Screen and stage: BMI + waist circumference; consider EOSS or AACE staging for context (not mandated).
2. Evaluate contributing factors: review weight-worsening medications - notably corticosteroids (prednisone, methylprednisolone) and possibly some biologics. Several of the newer b/tsDMARDs have been linked to weight gain, although this is primarily mediated by the abrogation of inflammation driven anorexia, especially with cytokine inhibition.
3. Baseline labs: lipid panel, HbA1c, comprehensive metabolic panel, FIB-4 (liver fibrosis risk).
4. Assess readiness and offer CLI (in-person or telephone-delivered) as the structural foundation. This should include self-monitoring, goal setting, dietary approach targeting a 500–750 kcal/day deficit and combined aerobic/resistance exercise.
5. Initiate pharmacotherapy concurrently (not sequentially) if indicated; particularly for BMI ≥27 with an obesity-associated condition (e.g., inflammatory arthritis with metabolic syndrome) or BMI ≥30.
6. Refer for bariatric surgery/endoscopic sleeve gastroplasty when BMI ≥35, or ≥30 with type 2 diabetes — referral rates remain critically low (1–6%) and should not be treated as last-resort.

A Team Approach to Obesity Management is Paramount!

• Primary care/internal medicine - anchors screening, CLI, and medication initiation
• Endocrinology - complex metabolic cases, GLP-1 titration
• Rheumatology - medication reconciliation (steroid-sparing strategies), disease-activity–weight interplay, referral trigger recognition
• Behavioral health/psychology – Counseling and cognitive behavioral therapy (CBT) should be offered to those who experience weight bias and stigma.
• Bariatric surgery/GI (endoscopic) - for BMI ≥30–35+ thresholds
• Registered dietitians - individualized dietary strategy (no single diet is superior)
• Pharmacy - managing weight-worsening drug substitutions, avoidance of polypharmacy through de-prescribing. 

For rheumatologists, this guideline reinforces that obesity management (and comprehensive lifestyle intervention) should run in parallel with, not sequentially before, disease-modifying therapy.  GLP-1 RAs are now first-line, evidence-strong options warranting proactive co-management rather than delay or deferral to other specialties.