This patient should be advised to reduce his caloric intake to maintain a deficit of 500 kcal/d. With a BMI of 36, this patient meets the criterion for obesity (BMI greater than or equal to 30). Furthermore, his waist circumference is higher than 102 cm (40 in), which is independently associated with increased cardiovascular risk. Treatment of overweight and obese patients should begin with establishing a weight loss goal and individualized treatment plan. A reasonable goal is weight loss of 0.5 to 1.0 kg (1.1-2.2 lb) per week to achieve a total weight loss of 10%. The mainstay of obesity treatment is lifestyle modification that includes diet for weight loss, increased physical activity, and behavioral therapy. In addition to increasing physical activity and behavioral therapy (aimed at avoiding fast food and inappropriate snacking), this patient should be prescribed a diet that maintains a 500-kcal/d deficit. Maintaining a continuous negative energy balance of 500 kcal/d results in a weight loss of about 0.5 kg (1.1 lb) per week. Involving dieticians, exercise therapists, and behavioral therapists increases the chances of success.

Bariatric surgery, such as laparoscopic adjustable gastric banding or sleeve gastrectomy, 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. This patient does not meet the criteria for bariatric surgery at this time.

Pharmacologic treatment is preferably used as an adjunctive therapy 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 who have not achieved significant weight loss with comprehensive lifestyle interventions. Orlistat is an inhibitor of gastric and pancreatic lipases that leads to malabsorption of approximately 30% of ingested fat. It is available both over the counter and by prescription. If lifestyle interventions are ineffective in obesity treatment, a pharmacologic agent such as orlistat can be added to, not substituted for, those lifestyle interventions.

Lorcaserin is another an effective weight loss agent that acts as an appetite suppressant by stimulating serotonin 2C receptors in the brain. However, it would not be a preferable next step in management prior to initiation of comprehensive lifestyle interventions.