Purpose of review <p>The objective of this review is to provide a framework for shared decision making for the treatment of obesity.</p> Recent findings <p>Obesity is a chronic medical condition with increasing prevalence. Current treatment includes intensive lifestyle change, medical therapy, and bariatric surgery. Incretin based medical therapy now offers efficacy that is approaching that of bariatric surgery (15–20%). However, challenges persist with underutilization of therapy and need for appropriate treatment selection. This review aims to explore how patient and provider expectations, along with behavioral, biological, and socioeconomic factors, influence obesity treatment decisions.</p> What’s the impact on future research? <p>The landscape for obesity management is rapidly changing as new therapies emerge, and more long-term data becomes available for existing therapies. There is growing interest in characterizing obesity genotypes and phenotypes to address the heterogeneous treatment response. The goal is to develop a model of care that individualizes obesity treatment.</p>