The most appropriate additional treatment for this patient is behavioral therapy. With a BMI of 29, this patient is overweight, and her waist circumference of 92 cm (36 in) is independently associated with increased cardiovascular risk. According to the American College of Cardiology, American Heart Association, and The Obesity Society, all overweight and obese patients should be offered a comprehensive lifestyle intervention (comprised of diet, physical activity, and behavioral treatments) for weight loss. Behavioral therapy includes providing patients with strategies to facilitate a shift from personal maladaptive eating patterns toward healthful eating and exercise, particularly in this patient who acknowledges eating to reduce stress and suboptimal dietary choices. Such strategies are associated with weight loss and reduced risk for developing diabetes mellitus and hypertension. Although best conducted by a trained therapist, behavioral therapy can be initiated by internists. Specifically, internists can emphasize the behavioral therapy components of self-monitoring, stimulus control, goal setting, and social support. Given this patient's eating patterns and previous dieting attempts, she should be offered behavioral therapy.

Bariatric surgery, such as laparoscopic adjustable gastric banding, should be considered in all patients with a BMI of 40 or higher and in patients with a BMI of 35 or higher with obesity-related comorbid conditions; it is therefore not indicated in this patient.

Pharmacologic agents, such as orlistat or phentermine, are used along with diet, physical activity, and behavioral treatments in patients with a BMI of 30 or higher or in patients with a BMI of 27 or higher with overweight- or obesity-associated comorbidities. This patient does not currently meet the criteria for pharmacologic therapy.