Emma is a 39-year-old female that was referred to Heartland Weight Loss by her PCP. At her first visit in May 2021, she reported that she has struggled with her weight her entire life. She reached her highest weight of 380 lbs about two years prior to her first appointment.  She had been working with her PCP successfully for some time and had lost approximately 15 lbs but they were struggling to make further progress. Melinda reported living with her husband, who was already supportive of her efforts. She worked for a local school district and had a high-stress job. She had tried to lose weight on her own multiple times without success. She identified social eating, emotional eating and food cravings as the biggest barriers to loss.  Emma had tried various anti-obesity medications with her PCP and reported having done the best with a combination of Phentermine and Rybelsus (used off-label) and was still taking Rybelsus daily. She had responded well to Contrave but had previously discontinued it for financial reasons. In addition to Rybelsus 7mg daily, she also reported taking the following medications: Wellbutrin XL 150mg daily, Hydrochlorothiazide 25mg daily, Omeprazole 20mg daily, Metformin 500mg daily, and Zoloft 100mg daily. Emma’s past medical history was significant for prediabetes, hypoventilation syndrome, GERD (gastroesophageal reflux disease), depression, anxiety, and dependent lower extremity edema.   She also had a very strong family history of type 2 diabetes (both of her parents and all of her siblings were affected).  We requested her labs from her PCPs office as they were not available at her first appointment.

At her first visit, Emma was instructed to eat a primarily whole-food, low glycemic eating plan and was given details about that plan. We reviewed her previous use of the various anti-obesity medications (AOMs) and decided to keep her on Rybelsus 7mg and restart Phentermine 37.5mg, 1/2 tablet 1-2 times/day to help her implement the recommended dietary changes with the least amount of friction. We also discussed adding a low dose of Topiramate off-label to augment the Phentermine (in essence, creating a generic version of Qsymia). Initial metrics were weight: 363.7 lbs, BMI: 58.7 kg/m2, body fat: 53.0%, waist circumference: 61″ At her second visit, Emma reported that she restarted Phentermine and responded well. She had not filled the Topiramate. She had undergone a sleep study and tested negative for obstructive sleep apnea. We obtained her previous labs and approximately 6 months prior, her Hemoglobin A1C had been 6.0% and her fasting glucose had been 98 mg/dL. She had proactively spoken with her family about collectively trying to remove unhealthy food from the center of every gathering and reported that many of them felt relieved at her proposition

A few months later, Emma reported a desire to start exercising. We rechecked her labs and her Hemoglobin A1C and fasting glucose levels were fairly stable at 5.9% and 103mg/dL, respectively. Her HDL had decreased slightly from 59 mg/dL to 50 mg/dL. We also checked her fasting insulin and it was elevated at 22.7 IU/mL.

As the start of the school year approached, Emma reported some anxiety, as executing a healthy daily routine was more difficult for her when surrounded by coworkers that did not share her habits along with what seemed to be a neverending barrage of unhealthy food at work. She also reported that she was not very compliant with taking her Rybelsus and decided to work on improving this. The following month, she got sick with COVID.

In December 2021, Emma reported that she was at a point in her weight-loss journey where, in the past, she had self-sabotaged. She was also experiencing behavioral fatigue and increased stress and food-centric moments around the winter holidays. She fell back into an old behavior pattern of restricting food in general in order to compensate for consumption of unhealthy foods, which then resulted in a great deal of hunger, impulsive eating patterns, and an overall feeling of shame and guilt. A coworker, impressed by her transformation, made her a before/after headshot and sent it to her spontaneously, which helped her push through her struggles and get back on track.

In February 2022, we redrew Emma’s labs. Pertinent improvements: Hemoglobin A1C 5.23%, fasting glucose 81 mg/dL, fasting insulin 11.5 IU/mL. The following month, she stayed with her family for a week and had very little control over her food environment. This vacation resulted in a temporary weight regain and Emma reported feeling unwell in general. This made getting back on track easier. In April 2022, her workplace had a week-long celebration of the staff, which primarily revolved around unhealthy food. Emma struggled to stay focused on her health while being immersed in this food-centric work environment.

In June 2022, we decided to switch her from Rybelsus to Ozempic and, at this time, we are still gradually increasing her dose of Ozempic per the titration protocol.


Duration of care: 15 months, 18 medical visits, 3 health coach visits

Weight lost: 66.4 pounds

BMI change: 53.0 kg/m2 – 48.0 kg/m2

Body fat change: 54.0% – 50.8%

Waist circumference: 61.0″ – 48.75″

Cost: completely out of pocket as her health plan didn’t pay for any treatment related to obesity