What is the cause of the patient's inability to lose weight despite daily exercise, including cardio and weights, and a restricted diet, with a current Body Mass Index (BMI) of obesity?

From the Guidelines

I strongly recommend a comprehensive approach to address this patient's weight loss challenges, prioritizing medication options such as semaglutide (Wegovy) or phentermine-topiramate (Qsymia) in conjunction with lifestyle modifications, as supported by the most recent evidence from 2023 1. The patient's current BMI of 40.16 indicates severe obesity, and despite his exercise routine and carbohydrate restrictions, he may be consuming excess calories through other sources. To address this, I suggest the following:

• Evaluate for underlying medical conditions that may hinder weight loss, such as hypothyroidism, insulin resistance, or sleep apnea, through the ordered lab work.
• Begin tracking all food intake using a calorie-counting app to identify hidden calories.
• Consider medication options such as semaglutide (Wegovy) starting at 0.25mg weekly and titrating up, or phentermine-topiramate (Qsymia) if appropriate after reviewing his medical history, as these have been shown to be effective in achieving significant weight loss 1.
• Consult with a registered dietitian for personalized nutritional guidance and suggest smaller, more frequent meals to maintain metabolism.
• Incorporate strength training to build muscle mass, which increases basal metabolic rate.
• Be aware that weight loss plateaus are common due to metabolic adaptation, and periodic adjustments to diet and exercise routines may be necessary. As noted in the 2023 review on obesity management in adults, a comprehensive approach combining lifestyle modifications, pharmacotherapy, and potentially metabolic or bariatric procedures can be effective in achieving and maintaining weight loss 1. Additionally, the 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults emphasizes the importance of considering alternative treatments, such as more intensive behavioral therapy or referral for bariatric surgery, if patients are unable to achieve sufficient weight loss with their current treatment 1.

From the Research

Weight Loss Strategies

The patient's current BMI is 40.16, and despite daily workouts and a restrictive diet, they are struggling to lose weight. Several studies suggest that a multi-faceted approach to weight loss may be more effective than a single strategy.

• A study published in 2016 found that pharmacological treatments for obesity, such as orlistat, lorcaserin, naltrexone-bupropion, phentermine-topiramate, and liraglutide, can be effective for weight loss, with phentermine-topiramate and liraglutide associated with the highest odds of achieving at least 5% weight loss 2.
• Another study published in 2021 found that exenatide, dapagliflozin, and phentermine-topiramate can differentially affect metabolic profiles in polycystic ovary syndrome, with dual therapy with exenatide and dapagliflozin resulting in the most loss of weight and total body fat 3.
• A study published in 2014 found that orlistat combined with lifestyle changes can induce substantial weight loss in women with polycystic ovary syndrome, resulting in improvements in insulin resistance, hyperandrogenemia, and cardiovascular risk factors 4.
• A case report published in 2020 found that a multi-faceted approach to weight loss, including an elimination diet and lifestyle modifications, can be effective for weight loss, with the client losing 18 pounds over a six-week period 5.

Complexity of Weight Loss

It's also important to note that weight loss is a complex issue, and there is no simple solution.

• A commentary published in 2015 noted that implementing complicated, multi-faceted interventions may not always be more effective than simple, single component interventions, and that issues such as tailoring interventions and evaluating efforts can be complex and do not have simple solutions 6.
• The patient's restrictive diet and daily workouts may not be enough to achieve weight loss, and a more comprehensive approach may be needed.
• Further evaluation and consideration of the patient's individual needs and circumstances may be necessary to develop an effective weight loss plan.