Jessica is a 33-year-old female that was referred to Heartland Weight Loss by her gynecologist. During her first visit at Heartland Weight Loss in July 2021, Jessica reported having struggled with weight her entire life. However, she stated that she had been gaining more rapidly over the previous four years and presented at her highest weight of 271.3 pounds. Jessica is a registered nurse with 2 small kids and a supportive husband. She had tried to lose weight on her own multiple times and had also tried several commercial weight loss programs. Jessica identified convenience eating, emotional eating, boredom eating, and food cravings as her primary barriers to successful weight loss and maintenance. She was taking no medications at the time of her first visit. Her past medical history was significant for acne. She had not had any recent labs done..
At her first visit, Jessica was instructed to eat a primarily whole-food, low glycemic eating plan and was given details about that plan. Knowing her barriers to implementation were significant, we discussed adding an anti-obesity medication (AOM) to help her implement the recommended dietary changes with the least amount of friction. After reviewing the risks/benefits/indications/contraindications of the various AOMs, we decided to start phentermine 37.5mg, 1/2 tablet daily. A basic lab panel was ordered and Jessica was instructed to have these labs drawn before her follow-up appointment in 2 weeks. Initial metrics were weight: 271.3 lbs, BMI: 40.1, body fat: 50.2%, waist circumference: 45.75″
At her second visit, Jessica reported struggling w/ evening cravings so we increased her phentermine to ½ tab BID. We reviewed her labs, which were essentially normal except for her fasting insulin, which was slightly elevated at 10.2 IU/mL, and her HDL cholesterol, which was low at 38 mg/dL.
Over the next several months, Jessica dropped the dose of her phentermine back to ½ tab daily as she had absolutely no appetite at all and was struggling to get her weight-negative foods in daily. She found her biggest barriers to success were social functions and the social pressure to indulge in unhealthy foods but she learned how to best navigate these situations with time. She reported indulging in sugar periodically, but because it made her feel physically unwell, she kept it to a minimum. Jessica’s husband remained supportive and the two of them learned that cooking on the weekend for the upcoming week was essential to keep them eating well as a family. By Christmas, Jessica had lost as much as her 5-year-old daughter!
By February 2022, Jessica reported that she no longer had to shop in plus-size clothing (a huge non-scale victory for her). She also reported that she was no longer taking her phentermine daily and was doing “OK” managing cravings on days that she missed it.
In April 2022, Jessica was feeling great and made a conscious choice to move into weight maintenance (although she kept losing, albeit more slowly).
In June 2022, Jessica had regained a little weight and wanted to get it back off. She felt like she was not making significant progress despite good adherence to the eating plan. We repeated her labs and her fasting insulin was still elevated at 11.2 IU/mL. Her HDL cholesterol had normalized to 46 mg/dL. We started Metformin ER 500mg daily and decided to have her use a CGM (continuous glucose monitor) for a month to evaluate her glycemic response to her diet. She learned that her blood sugars were very stable except when she ate grapes, which sent her blood sugars very high. She cut back her intake of grapes and stopped using the CGM.
In August, Jessica decided to return to maintenance and stopped Metformin. She is only using phentermine as needed to help with cravings when the social cues to eat unhealthily are powerful. She is continuing her visits monthly throughout the beginning of maintenance and will start spacing out visits after several months of weight stability.
Duration of care: 13 months, 17 medical visits, 9 health coach visits
Weight lost: 71.8 pounds
% lost: 26.5%
BMI change: 40.1 kg/m2 – 29.5 kg/m2
Body fat change: 50.2% – 38.2%
Waist circumference: 45.75″ – 36.75″
Cost: Commercial health insurance paid the majority of her first 7 visits (minus her copay). In 2022, she had a high-deductible plan and was required to pay out of pocket.