From the Guidelines
I strongly recommend a comprehensive approach to address this patient's weight loss challenges, focusing on a multifaceted strategy that combines dietary changes, exercise, and possible medication, as this approach has been shown to be most effective for patients with severe obesity, as indicated by a BMI of 40.16 1. To start, I will order comprehensive labs, including thyroid function tests, fasting glucose, HbA1c, lipid panel, and liver function tests, to rule out medical causes for weight loss resistance. While awaiting results, the patient should begin tracking all food intake using a calorie-counting app to establish his actual caloric consumption. Despite his current efforts with exercise and carbohydrate restriction, he may be consuming more calories than he realizes. For a BMI of 40.16, which indicates severe obesity, I would consider medication options such as GLP-1 receptor agonists (like semaglutide or tirzepatide), starting at the lowest dose and titrating up as tolerated, as these have been shown to produce significant weight loss, with tirzepatide having the greatest effect, with a mean weight loss of 21% at 72 weeks 1. Additionally, I recommend consulting with a registered dietitian for personalized nutritional guidance beyond his current carbohydrate restriction strategy. The patient should continue his exercise regimen but consider adding more high-intensity interval training to maximize calorie burn. Weight loss resistance often occurs due to metabolic adaptation, underestimation of caloric intake, or underlying medical conditions, which is why a multifaceted approach combining dietary changes, exercise, possible medication, and addressing any medical issues is most effective for patients with severe obesity, as supported by recent guidelines 1. Some key strategies for weight maintenance after successful loss include frequent self-weighing, consumption of a reduced-calorie diet, and high levels of physical activity, as well as participation in a long-term comprehensive weight loss maintenance program with monthly or more frequent contact 1.
From the Research
Patient's Current Situation
- The patient has a BMI of 40.16 and is struggling to lose weight despite working out every day and following a strict diet.
- The patient refrains from consuming carbohydrates after 1:00 PM, sugar, and desserts.
Potential Solutions
- According to 2, surgical options such as bariatric surgery and endoscopic surgery can induce more durable weight loss than pharmacotherapy or lifestyle interventions alone.
- However, 2 also states that patients often experience weight regain and weight loss plateau after surgery, and the addition of multimodal or multihormonal pharmacotherapy may be a promising tool to address these challenges.
- 3 suggests that certain medications such as phentermine-topiramate and liraglutide can be effective in achieving at least 5% weight loss at 52 weeks.
Considerations for Treatment
- 4 highlights the potential relationship between thyroid disorders and polycystic ovary syndrome (PCOS), which may be relevant to the patient's situation.
- 5 found that exenatide, dapagliflozin, or phentermine/topiramate can differentially affect metabolic profiles in PCOS, and that combination therapy with exenatide and dapagliflozin may be superior to monotherapy.
- 6 suggests that orlistat combined with lifestyle changes can be effective in managing overweight and obese patients with PCOS, resulting in improvements in insulin resistance, hyperandrogenemia, and cardiovascular risk factors.
Next Steps
- Ordering labs and scheduling a follow-up appointment to start with a plan for weight loss is a good first step.
- Considering the patient's BMI and dietary habits, it may be helpful to explore pharmacotherapy or surgical options in addition to lifestyle interventions.
- Further evaluation of the patient's overall health and potential underlying conditions such as PCOS or thyroid disorders may be necessary to determine the best course of treatment.