Principles of Medical Weight Management

Wyatt J West, MD

Board Certified Family Medicine

Board Certified Obesity Medicine

Tanner Clinic Obesity Treatment Program

Disclosures

• Speaker for Eli Lilly
• Always open to adding more conflicts of interest…

Goals and Objectives

• Persuade the audience that obesity is a complex disease state, and should be approached as such
• Demonstrate our approach to the treatment of obesity
• Illustrate a few successes and pitfalls of obesity treatment with actual patient case presentations from our clinic

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Hypothetical Patient: Personal History

• 46-year-old, overweight male who wants to begin weight loss program
• Professional – 60+ hour work weeks
• Family – wife, 3 teenage kids
• Responsibilities at home, work, church, and community…
• Sleep – 5-6 hours nightly, snores
• Often feels stressed, overextended, fatigued
• Commonly eats “on the go,” snacks at night to decompress
• Experienced gradual weight gain despite diet and exercise attempts

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Hypothetical Patient: Weight History

• Weight history - gain gradual
• College: 190 lb. – BMI 24
• Current: 225 lb. – BMI 29
• Peak: 236 lb. - BMI 30
• Efforts
• 11 lb. weight loss (4.4% TBWL) with 1 year of diet, regular exercise
• Comorbidities
• Pre- to Stage I hypertension
• Hyperlipidemia developing over last several years

Hypothetical Patient: Perspective, Expectation

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Clinician Perspective�

Obesity: a chronic, progressive, and relapsing disease state, rather than a moral failure of the patient or a�cosmetic condition

Obesity: A Complex Disease State

• According to W.H.O.
• Obesity and overweight affects 43% of world population
• 3.4 billion adults overweight or obese
• 35 million children <5 yrs old
• 390 million children 5-19 yrs old
• Rates have doubled to tripled since 1990
• Multitude serious diseases directly attributable to or worsened by
• Estimated cause of 3.7-5 million premature deaths per year
• Estimated cost by 2030: $3 trillion/year

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• WHO report on Obesity and Overweight, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight, 8 Dec, 2025

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Guidelines for Treatment of Obesity

Endocrine Society 2015 guidelines and American Association of Clinical Endocrinology (AACE) 2025 Consensus Guidelines

• Individual treatment plans should be based on obesity severity
• Overweight with BMI >27 with 1 comorbid condition, OR
• Stage 1, II, III obesity with BMI >30,with or without comorbid conditions
• All should be strongly considered for Obesity Medication Management (OMM)

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Endocrine Practice. 2025 Nov;31(11):1351-1394.

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Obesity in Primary Care: A Comprehensive Approach for Family Physicians

• 40% of obesity patients received counseling on weight loss during medical visits in one year
• Yet, only 5% of obesity patients received treatment with medications in 2025
• Most common reason PCPs do not address obesity treatment with their patients is a perceived lack of time

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Cureus. 2025 Aug 22;17(8):e90742. 

Resources: Evidence-based Approach to Weight Management

• 29 step algorithm:
• Pathophysiologic assessment
• Education for nutrition, exercise, and behavior changes
• Begin medical/surgical interventions as appropriate
• Professionalism and advocacy

Our Approach

Medical Weight Loss

Clinical Environment

• Acknowledge challenges
• Lead with empathy
• Avoid blame, accusations
• Create a collaborative relationship

Initial Consult: Medical Evaluation

• HPI
• Personal, family, etc.
• Medical, psychological, other contributors
• Metabolic dysfunction
• Orexigenic medications
• Disordered eating
• Schedule further evaluation
• Fasting laboratory panel
• DEXA body composition scan
• Sleep apnea screening
• CGM trial

• Obtain a weight specific history
• Chronicity
• Treatment attempts
• Obtain an exercise history
• Current exercise
• Barriers – orthopedic, professional, etc.
• Weight loss medication contraindications
• Cardiac, GI, neuro
• Inquire about their personal goals

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Case Report: Value of CGM

• Monitoring continuous glucose can unmask insulin resistance that static labs miss
• 38-year-old female
• Hgb A1c 5.6%
• Fasting insulin 9 uiu/mL
• CGM results
• Regular postprandial glucose in 180s mg/dLs
• 2 occasions of postprandial glucose >200 mg/dLs

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Hypothetical Patient: Initial work up

• Labs
• Lipids
• Total 250 mg/dL
• LDL-C 177 mg/dL
• Metabolic Panel
• ALT 35 U/L
• Hypogonadism
• Total testosterone: 233-303 ng/dL
• CGM
• No evidence of insulin resistance
• Sleep apnea screen
• Normal home sleep study

Weight Loss Group Visit

• Accountability
• Diet
• Exercise
• Stress response
• Medication options

Accountability: Key to Behavior Change

• Professional accountability
• Regular office visits
• 1-2 times per month at first
• Once per quarter for maintenance
• Other accountability partners
• Network of dieticians, personal trainers, health coaches
• Personal accountability
• Tracking food intake, exercise output
• Trials of CGMs provide immediate feedback accountability on dietary choices

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Dietary Intervention: Key to Weight Loss

• Promote healthy food choices
• Micronutrition focus
• Calorie-deficit diet
• 500 kcal/day deficit
• Macronutrients
• Protein malnutrition is significant problem
• Muscle-centric approach
• Provide dietary resources
• Dieticians, health coaches with similar philosophy

Exercise: Key to Long-term Weight Loss Maintenance

• Intensity
• Low, moderate, and high
• Frequency
• 40-60 minutes
• 4-6 days per week
• National Weight Control Registry
• Successful long-term weight loss
• 90% exercise 60 min per day
• Exercise resources
• Personal trainers with similar philosophy, provide discounts

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Case Report: Lifestyle Treatment Alone

• 67-year-old-female with severe obesity
• Initial presentation, 2017
• Height 5’6”
• Weight of 377 lbs.
• BMI 60.8 kg/m2
• Last visit in February 2026
• 201lbs.
• BMI 32.4 kg/m2
• 46.7% total body weight loss
• Strategy
• Mild calorie deficit diet and light exercise

Sleep and Stress Management

• Quality sleep assurance
• 7-9 hours of quality sleep
• Sleep apnea evaluations
• Evaluation of hormone profile
• Thyroid, menstrual hormones, testosterone
• Adrenal, pituitary as appropriate
• Address mental health challenges

Weight Loss Medications

Under 10% total body weight loss

• Orlistat (Xenical/Alli)
• 3-6%
• Phentermine (Adipex-P)
• 5%
• Bupropion/Naltrexone (Contrave)
• 5-9%
• Liraglutide (Saxenda)
• 8%

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Over 10% total body weight loss

• Phentermine/topiramate (Qsymia)
• 7-11%
• Orforglipron (Foundayo)
• 11.2-12.4%
• Semaglutide (Wegovy)
• 15-21%
• Tirzepatide (Zepbound)
• 15-25.8%

Weight Loss Medications: Clinical Considerations

Stimulants

• Pros:
• Abundant
• Inexpensive
• Minimal dose titration
• Cons:
• Side effects
• Tolerance
• Contraindications
• Heart arrythmias
• Seizure disorders
• Glaucoma

GLP-1/GIP RAs

• Pros:
• Most weight loss of any medication class
• Cost, insurance barriers decreasing
• Long-term efficacy
• Cons:
• Side effects
• Cost considerations
• Contraindications
• C-cell thyroid tumors
• Severe gastroparesis

Case Report: Prescription without Supervision

• 55-year-old female new patient
• Chief complaint
• Plateau of weight loss
• History of obesity, mental illness and an eating disorder
• Treated for one year by online provider with compounded tirzepatide.
• Approx. 40 lbs. of successful weight loss 
• Abdominal complaints
• Recent upper GI study concerning for gastroparesis
• Developed generalized weakness, difficulty rising from a chair

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• General appearance
• Mildly overweight – BMI 26 kg/m2
• Laboratory evaluation
• Metabolically normal
• Normal thyroid studies
• Requesting increased dose of tirzepatide despite frequent episodes of anorexia and vomiting

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DEXA Body Composition Scan Results

• Total Mass
• 162.1 lbs.
• Fat Mass
• 82.1 lbs. = 50.6%
• Lean Mass
• 75.6 lbs. = 46.6%
• Resting Metabolic Rate
• 1127 kcal/day
• Relative Skeletal Muscle Index
• 5.47 kg/m2
• Diagnoses:
• Sarcopenia from malnutrition while on tirzepatide
• Active Disordered Eating

Hypothetical Patient: Treatment Plan

• Address comorbid conditions
• Hyperlipidemia: rosuvastatin 5 mg
• Hypogonadism: testosterone cypionate
• Improved dietary, exercise compliance
• Tracking on App
• Regular follow up
• Consider working with personal trainer, health coach

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Hypothetical Patient: Medication Options

• Rationale for treatment with a medication
• BMI 29
• One comorbid condition
• Meets AACE criteria for OMM
• Goals
• Lose +/- 10% original body weight
• No contraindications to treatment
• Medication options
• Bupropion/naltrexone – 5-9%
• Phentermine/topiramate - 7-11%
• Orforglipron - 11.2-12.4%
• Semaglutide - 15-21%
• Tirzepatide - 15-25.8%

Hypothetical Patient: Medication

• Medication options
• Bupropion/naltrexone – 5-9%
• Phentermine/topiramate - 7-11%
• Orforglipron - 11.2-12.4%
• Semaglutide - 15-21%
• Tirzepatide - 15-25.8%

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Hypothetical Patient: Medication

• Medication options
• Bupropion/naltrexone – 5-9%
• Phentermine/topiramate - 7-11%
• Orforglipron - 11.2-12.4%
• Semaglutide - 15-21%
• Tirzepatide - 15-25.8%

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Questions?