Overweight (BMI 25–29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) are estimated to affect 59% of adults worldwide1 and 73% of adults in the U.S.,2 many of whom are reproductive-aged women and disproportionately from marginalized communities.3,4 Recent guidelines5 define clinical obesity as “a chronic, systemic illness characterized by alterations in the function of tissues, organs, the entire individual, or a combination thereof, due to excess adiposity,” with complications including type 2 diabetes (T2D), hypertension, cardiovascular disease, several types of cancers, and premature death.6,7 In reproductive-aged women, excess adiposity negatively impacts fertility. In pregnant individuals, obesity is associated with significant short-term maternal and fetal morbidity as well as long-term health consequences for offspring.8, 9, 10 With almost 60% of pregnancies in the U.S. complicated by overweight and obesity,11 the population-level impact is substantial. To ameliorate these adverse pregnancy outcomes and attenuate this global health problem, several international obstetric societies recommend preconception weight reduction but offer little guidance on the optimal method.12 Weight loss between 5–10% has been shown to improve obesity-related comorbidities in non-pregnant individuals,13 and as little as 5% enhances fertility in reproductive-aged women.14 Still, there remains limited evidence pertaining to the best approach to or extent of preconception weight loss to prevent obesity-related adverse pregnancy outcomes, specifically as it pertains to the offspring. Recognizing the critical consideration of maternal health, this paper will focus on the effects of both obesity and obesity treatment on the developing offspring, comparing the well-established teratogenicity of untreated obesity with the risks and benefits of the current weight loss interventions.