• Exercise alone not sufficient for weight loss but can improve CVD risk, glycemic control, BP, functional status
• BMI is an imperfect way to screen for and make decisions for treating obesity, but its a start to get a sense of generally where someone falls
• Clinically meaningful weight loss is 5-10% of total body weight - goal should be 5-7% in one year, with ultimate goal to be BMI <25 (knowing its imperfect measure)
• In general - to lose 1-2 lbs per week should shoot for 500 calories below your daily caloric requirement - this will work to take off some weight initially but most will plateau with just caloric restriction (and this should be expected physiologically)
• Lots of other things other than calories contribute - age, size, height, sex, bone density, muscle-fat ratio, lifestyle, genetics, the food itself 
• The best “diet” is one that someone can largely stick to, but not all diets are the same, nor do they all have the same goals regarding weight loss - focus on simplicity, ease, and remind yourself of other risks like heart disease; in general low-carb and low-fat are best if goal is weight loss, and there are not significant differences between them
• Mediterranean Diet often regarded as top because of weight loss AND decreased overall and CV mortality
• Pharmacological options are meant to be short term and almost all patients who stop medication will end up gaining back most of the weight
• Exercise - SMART goals - specific, measurable, attainable, relevant, time-based
• When patients discuss wanting to focus on exercise, say that burning 500 calories is accomplished by running 5 miles, and cutting 500 calories in the diet is equivalent to not drinking two glasses of soda
• Behavioral economics and exercise - make it fun (bundle with vices - TV, podcasts, etc), change your environment for success (shoes and clothes set out ngiht before), be specific (I will exercise on [day] at [time] at/in [place]; highlight short-term gains, make commitment contract with a partner to hold you accountable, 
• GLP-1 likely involved with satiety in brain (physiologically takes 20-30 minutes to have effect which is no good for modern life where we eat big meals quickly)

        Medications associated with weight gain

• Antipsychotics - clozapine, olanzapine, quetiapine, lithium
• Antiepileptics - gabapentin, pregabalin, valaproic acid, carbamazepine
• Antihistamines - diphenydramine
• Antidepressants - citalopram, fluoxetine, paroxetine, sertraline, mirtazapine, nortriptyline
• Antihypertensives - prazosin, metoprolol
• Antidiabetics - insulin, glyburide
• Hormones - glucocorticoids, progestins

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        Pharma intervention

• ‍If: BMI >30 OR BMI 27-29.9 and weight-related comorbidities AND have not lost at least 5% TBW after 3-6 months with comprehensive life changes

• Liraglutide (Saxenda) - GLP-1 agonist (delays gastric emptying to decrease food intake) - 8% weight loss; injectable; n/v/d, can increase lipase levels; don’t give to people with fhx of medullary thyroid cancer or MEN
• Semaglutide (Wegovy) - GLP=1 agonist (as above)
• Orlistat (Alli) - pancreatic and gastric lipase inhibitor - inhibits fat malabsorption - 8% weight loss on average (not commonly used due to very oily stools) - sold OTC
• Phentermine-Topiramate ER (Qsymia) - NE-releasing agent and GABA receptor modulation decreased appetite; 8-10% loss; insomnia, dry mouth; avoid MAOi’s, those with glaucoma, hyperthyroid 
• Naltrexone-Bupropion SR (Contrave) - act on CNS, decrease appetite; 6.4% loss; make sure no hx of seizures, drug or EtoH withdrawal, long-term opioid use
• Note that lorcaserin (Belviq) used to be used but was taken off the market due to SI and cancer
• Cellulose and citric acid hydrogel (Plenity) - take a pill with water/food, hydrogels expand in the stomach, make feel fuller; being marketed heavily, not a huge amount of weight loss, technically a medical device

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        Bariatric surgery

• If: BMI >40 OR BMI >35 AND obesity-related complications remediable by weight loss; works by reducing stomach volume to limit intake; need to monitor nutrients afterward every 6 months

• Roux-en-Y - creates smaller stomach, get pancreas juices from one limb, and a good deal of the food bypasses the stomach entirely - creates a “dumping” physiology - lose 60-85% of excess weight; monitor for micronutrient deficiencies, ulcers, dumping syndrome, fistulas‍
• Sleeve Gastrectomy - take out greater curvature of stomach - creates a tube-like stomach, smaller stomach and decreased appetite hormones  - lose 55-80% of excess weight; after done can revise to a roux-en-Y; watch for GERD‍
• Gastric banding not done much anymore

• Meta-Analysis comparing weight loss among diets - 2014 - link - general takeaway is that most low-carb and low-fat diets lead to weight loss and there are not significantly different
• PREDIMED - Mediterranean Diet - major CV events 3.4-3.8% vs 4.4% in placebo

• STEP 1 Trial - 2021 - weekly semaglutide plus lifestyle intervention in those without diabetes showed mean change 14.9% at week 68 vs 2.4% in placebo; 10% body weight loss in 69% with intention to treat; nausea and diarrhea most common AE, often subside with time - 4.5% dropped out due to side effects
• SURMOUNT-1 Trial - 2022 - weekly tirzepatide in those BMI >30 or >27 with co-morbidity not including diabetes led to mean percent change by week 72 in 15%, 19.5% and 20.9% (5, 10, 15mg respectively); 89% had weight loss of 10% or more; most common AE GI-related
• NEJM 2017 - roux-en-Y Bypass shows long-term durability of weight loss, remission of T2DM, HTN, and dyslipidemia ‍
• Risks and Benefits of Bariatric Surgery - Review (JAMA 2020)

• How Many Calories Should You Eat Per Day to Lose Weight - link
• Bariatric Surgery for Morbid Obesity - Graphics (NEJM) - link 
• Maintenance Phase Podcast - The Body Mass Index
• Atomic Habits - YouTube Summary

        Books

• The Obesity Code - Dr. Jason Fung
• The Omnivore’s Dilemma - Michael Pollan
• Salt, Sugar, Fat - Michael Moss

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