A patient asked me this week if they could stop their obesity medication.

I told them what the data says:
67% of people who stop regain almost everything within a year.

That's not a failure of willpower. That's biology. And we finally have trials that prove it. 1/ ECO 2026 just changed the conversation in obesity medicine. For 3 years, every major meeting asked: how much weight can we lose? Istanbul asked something different: how do we keep it? Here's what we learned. 🧵

1/ I'm a physician.
I just left traditional healthcare. 2/ I spent years inside the system.
7-minute visits.
Portal messages answered three days later by someone the patient had never met.

Care fragmented across platforms built around billing codes — not people.

Every morning I take five things.
A statin. Ezetimibe. Psyllium. Creatine. A multivitamin.

Once a week, I add a sixth: tirzepatide.

No rapamycin. No NMN. No Bryan Johnson protocol.

Here's what the evidence actually says—and why I left everything else out. 🧵 1/ Every morning I take five things.
A statin. Ezetimibe. Psyllium. Creatine. A multivitamin.

Once a week, I add a sixth: tirzepatide.
I used to raise an eyebrow at longevity stacks. Then I realized I'd quietly built one—each addition requiring enough evidence to clear the same bar I hold my prescriptions to.

I'm 36. I'm a physician. I take a statin—and ezetimibe—every day.

No symptoms. No cardiac history. Just an honest read of the evidence.

Here's what I found—and why I stopped waiting for a reason to act. 1/ I take a statin and ezetimibe every day.
My LDL in 2018: 127 mg/dL.
My LDL today: 41 mg/dL.

Here's exactly what changed — and why the evidence earned my confidence.🧵

The cholesterol wars are over.

LDL won.

New guidelines. Four landmark trials. An oral PCSK9 inhibitor that matches injectables. And data proving we should be treating patients we currently aren't.

Here's everything clinicians need to know. 🧵 1/ The 2026 ACC/AHA Guideline just retired 10-year-old guidance and brought back something crucial: explicit LDL-C numeric targets.

Not "treat to benefit." Treat to a number.

<55 mg/dL for most established ASCVD. <70 for high-risk primary prevention.

Eleven societies signed off.

🌍 The world is preparing to be transformed by nutrient-stimulated hormone-based therapies (NuSHs) like GLP-1 medications.

However, here’s the problem: more than 99% of clinics aren’t ready to deliver them at scale.

Here’s why ⬇️ 🧵benefitspro.com/2025/08/05/glp… 1⃣ Insurance navigation
Most clinics lack the workflows and staff necessary to obtain prior authorizations efficiently.

Even though >50% of their patients (modest estimate) could qualify for these medications, they can only push through a handful of approvals because:
🔹Prior auth processes are slow and fragmented
🔹There’s little reimbursement to justify hiring dedicated support
pmc.ncbi.nlm.nih.gov/articles/PMC11…

1/ WHAT YOU NEED TO KNOW ABOUT THE QUALITY OF WEIGHT LOSS. 🧵 2/ When you lose weight, you don’t just lose from fat but also from other body compartments, including lean tissues.

1/ Are lean mass losses a real concern with GLP1 meds?
peterattiamd.com/the-downside-o…
🧵 2/ Simply, yes. And it is a concern any time you lose significant wt. I would remind people that human outcomes are the most informative, as physical functioning scores and QoL improved in STEP trials & SURMOUNT-1. However, the LT health impacts of LM loss need to be monitored.

1/ Merry 🧵-mas
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WHY DECADES OF "EAT LESS AND MOVE MORE" WAS TERRIBLE ADVICE

For starters, remember semaglutide? How could you not? Journalists have written 1000+ celebrity weight loss stories on it. 2/ If you're familiar with semaglutide, you may know it is FDA-approved for treating obesity and chronic weight management under the brand name "WE-GOVY."

NASH Treatment Strategies:
1) Reduce Adiposity
2) Improve adipose tissue function (more difficult; PPARg agonists) link.springer.com/article/10.100…

Treat-to-target for NAFLD/NASH:
🔑 is ≥ 10% weight loss.
journal-of-hepatology.eu/article/S0168-… Bariatric surgery is exceedingly effective for people with obesity and NASH.
Aminian et al., JAMA. 2021.
jamanetwork.com/journals/jama/…

1/DAY 1 of #OW2022 in the books.

My highlight 🧵: 2/The Effect of COVID on Clinical Research by Drs. Laughlin and Evans:
—Significant increase in new onset diabetes
—A lot of COVID specific research for years to come
—COVID19 disproportionately impacted female scientists, parents and caregivers #OW2022

My living 🧵 on the highlights from 'Causes of obesity: theories, conjectures and evidence.' #RScausesobesity
@royalsociety

Link: causes-obesity.royalsociety.org DAY 1 -- From genetics to nutrient-dependent conditioned eating, variable mitochondrial energy efficiency, neuroendocrine feedback systems, and nutrient-sensing food liking, obesity is very clearly more complicated than CICO. Energy balance is a constraint, that is all.

1/Bariatric surgery is often described as "barbaric" and "radical." I believe most of these polarizing opinions are derived from ignorance, so let's explore the science of bariatric surgery to better understand what is happening. 🧵 2/The greatest misconception is that surgery works through the "radical mutilation of the small intestine" or that wt loss is 2/2 to malabsorption.

In fact..."extensive small bowel resection is associated with a compensatory increase in food intake." Cosnes et al., 1990 h/t LK

While GLP1 therapies primarily exert their weight loss effect through a reduction in food intake, I’m increasingly convinced the most important mechanism behind the decrease in Ein is an attenuation of motivation-reward. I suspect homeostatic modulation plays a smaller role LT. Mind you that this is speculative, but as my friend, @DavidMacklinMD often says, all roads lead to hedonic hunger. Do you WANT to eat? Are you compelled? Most people describe having better control, less interest, and a lack of compulsion while on GLP1s. It’s hedonics!

1/ NOT THE THREAD DIGITAL HEALTH WANTS TO READ, BUT THE THREAD IT NEEDS TO READ. Walk with me…🧵 2/ Many people know about the darling of digital health — Livongo. Arguably the highest profile digital health company ever due to an $18.5 billion dollar merger with Teladoc back in 2020. medcitynews.com/2020/10/telado…

Why is losing weight hard? Evolutionary adaptations to prevent starvation and death constrain weight loss. Conversely, hypothalamic inflammation can promote wt gain affecting the fxn of the homeostatic feedback system that constrains wt.
-Dr. Katherine Saunders #YWM2022Virtual Weight Loss Goal? Not a number but a health improvement. With modern treatments, I would argue we should aim for 10% TBWL. #YWM2022Virtual

"If someone has myopia, you wouldn't tell them to try harder to see. You would not shame them for needing glasses." -Lee Kaplan

Yet, in obesity, we shame people for seeking evidence-based treatments and implore them "to eat less and move more" harder. #YWM2022Virtual The legacy bias in bariatric surgery qualification #YWM2022Virtual

1/ STEP 4 Trial of Semaglutide for obesity treatment is a beautiful illustration of the physiology of body weight regulation. Let's explore it in this 🧵 2/ First off, all study participants "received open-label once-weekly subcutaneous semaglutide, 0.25 mg, increased every 4 weeks to the maintenance dose of 2.4 mg once weekly by week 16, and continued to week 20."

1/ Understanding Obesity Pathophysiology Through Outcomes:

IMO, the limitations of these surrogate measures (fMRI & PET), make outcome studies a more reliable insight for understanding obesity mechanisms.

A [thread] on outcomes for clinical interventions for obesity. 🧵

https://twitter.com/TheMooreLab/status/1505419727593689090

2/ Do Diets Matter? Yes and No. They matter because you have to eat, and you want to do so in a way that promotes health. But, are they reliable txs for obesity? No. Meta-analysis of long-term RCTs (avg wt loss 0-4 kg). Most intensive diet interventions result in 3-5% wt loss.

1/ Is Obesity A CHOICE?

The thread 🧵. For starters, please answer the following question ⬇️ 2/ So Why We Are Gaining Weight? Unquestionably, we are eating more, and this increased consumption at a population level is the leading candidate.