Inpatient / Endocrinology

Obesity and Weight Loss

Last Updated: 03/5/2023

#Obesity - BMI ***

#Weight Loss


-- Explore the patient’s history with their weight - are they interested in discussing it further, what have they tried in the past that has and has not worked, do they have any current goals, etc.

-- Review med list - are there any medications associated with weight gain that can be changed out?

-- Calculate daily caloric requirement - link

-- Exercise and Activity - assess fitness level, set SMART goals, start low and progress slowly, warm up, listen to your body, build activity into daily routine, allow time for recovery, put it on paper and track progress


-- Weight Loss Goal: *** in general can start with 5-7% body weight; within ***

-- Exercise and Activity Goal: *** activity logs; >30 mins activity 5 days per week is goal, can start with standing/walking with TV, using stairs

-- Diet : food diaries, limit sugary drinks/added sugars, refined carbs; drink more water; eat more protein, vegetables, fiber; utilize smaller plates; restrict the time you eat

-- Medications: *** if BMI >30 or 27-29.9 with weight-related comorbidities and have not lost at least 5% TBW after 3-6 months life changes; liraglutide/semaglutide/tirzepatide, orlistat, phentermine-topiramate, naltrexone-bupropion

Bariatric referral: *** if BMI >40 or BMI >35 and obesity-related complications despite weight loss attempts

Template coming soon!

Patient Guidance and Information

If You Remember Nothing Else

Clinically meaningful weight loss is 5-10% of total body weight. BMI is an imperfect measurement, but in general the goal for most patients should be <25. A thorough intake includes exploring the patient's history with their weight, what they have tried in the past, and whether they have any goals for their weight. While caloric restriction has historically been the mainstay of diet approaches, many other factors can contribute including age, height, sex, bone density, muscle-fat ratio, genetics, and the food itself. Lifestyle changes include diet (low carbs/artificial sugars, rich in vegetables, intermittent fasting), and exercise (goal >30min 5 times per week, combo of aerobic and resistance training). The focus of pharmacologic management has shifted recently towards GLP-1 agonists and should be considered when BMI >30 or BMI 27-29.9 with weight-related co-morbidities and the patient has had trouble losing at least 5% of their total body weight after 3-6 months of comprehensive lifestyle changes. Bariatric surgery may be an option for patients with BMI >40 or >35 with obesity-related compliations remediable by weight loss.

Clinical Pearls

  • 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

        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

        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

Trials and Literature

  • 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)

Other Resources