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An obese, 55-year-old man with metabolic syndrome meeting all 5 of the Adult Treatment Plan III National Cholesterol Education Program criteria,1 including hypertension, type 2 diabetes mellitus, atherogenic dyslipidemia with low high-density lipoprotein cholesterol, elevated triglycerides, and abdominal obesity with a high waist circumference, is having trouble losing weight on his own through lifestyle intervention. He has hired a personal trainer and is working out 3 times a week but has lost no weight. He enjoys eating out with his wife or his business associates 3 to 4 times per week. This is where he reports consuming most of his excess calories in both food and alcohol. He takes 7 medications to control his obesity-related comorbidities. These include: Atenolol 50 mg once per day, valsartan 80 mg once per day, glipizide 5 mg twice per day, pioglitazone 30 mg once per day, metformin 500 mg twice per day, atorvastatin 40 mg once per day, and insulin glargine 20 U nightly. Anthropometrics and laboratory data include a weight of 264 lbs, height 5 feet 10 inches, body mass index (BMI) 38 kg/m2, waist circumference 47 inches, blood pressure 150/95 mm Hg, hemoglobin A1c 7.2%, fasting blood glucoses 150 to 175 mg/dL, total cholesterol 220 mg/dL, triglycerides 300 mg/dL, low-density lipoprotein cholesterol 130 mg/dL, and high-density lipoprotein cholesterol 40 mg/dL.The 2013 guidelines2 encourage the provider to help patients lose weight with lifestyle modification. Adding a low-calorie diet to his exercise routine would be an important first step to enhance lifestyle modification. Another important step for the provider would be to evaluate the medical regimen to determine if there are any medications that might exacerbate weight gain, and to consider alternatives.If diet, exercise, and antiobesity agents do not achieve weight loss and weight maintenance, he is a candidate …

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The 2013 American Heart Association/American College of Cardiology/The Obesity Society Guideline for the Management of Overweight and Obesity in Adults