Despite recent advances in the treatment of obesity, lifestyle medicine remains foundational to the treatment of individuals with obesity, regardless of the modality chosen by the patient with the guidance of the clinician they are working with, including in conjunction with, as appropriate, anti-obesity medications and metabolic surgery. Lifestyle medicine involves the use of diet, exercise, sleep, stress, and other lifestyle modalities in the treatment of disease. Clinicians and health systems should, after a patient-centered discussion with the patient, do their best to ensure access to lifestyle treatments. Gold standard guidelines recommend intensive, multicomponent lifestyle change programs for obesity treatments with evidence-based diet and exercise counseling and established, theoretically driven behavior change components. Clinicians treating obesity should be aware of their own biases, make efforts to reduce stigmatizing experiences in their practice, and address weight stigma in their treatment plans as needed. A variety of dietary patterns can be used to support patients with obesity, and clinicians should make evidence-based but patient-centered recommendations that aim to maximize adherence. Diet and exercise can play an important role in reducing the side effects of treatment and optimizing outcomes in weight loss, attenuating the effects of metabolic adaptation, and weight maintenance. Exercise should be increased gradually to reduce injury with a goal of 200–300 min (approximately 3.3–5 h) of moderate to vigorous intensity exercise per week to maximize weight maintenance effects with exercise prescriptions customized to patients risks. A variety of practice models can be leveraged along with the use of an interdisciplinary team to provide lifestyle medicine care for those with obesity.

Background: Preoperative assessment is a key but inconsistently taught skill in internal medicine residency, particularly in the ambulatory setting. Many residents report low confidence and limited formal training. Objective: To evaluate the impact of a structured, gamified Jigsaw-based workshop on internal medicine residents’ knowledge acquisition and self-reported confidence in preoperative assessment. Methods: In 2025, we conducted a quasi-experimental pilot study at the University of California, San Diego. Primary Care Track residents (intervention group) completed a three-hour interactive Jigsaw workshop on four domains of preoperative management: cardiovascular risk, medication management, anticoagulation, and considerations for special populations. Residents in the control group received standard residency training in preoperative medicine through routine clinical exposure during inpatient rotations (wards, intensive care unit, and consult services) and outpatient settings, including continuity clinic and ambulatory electives. Additional instruction occurred through the residency’s protected didactic curriculum, including Wednesday School and Friday School, four-hour conference blocks covering rotating internal medicine topics. Preoperative assessment was addressed within this broader curriculum but not through a dedicated standardized program. Pre- and post-surveys assessed knowledge (multiple-choice) and confidence (Likert scale). Due to the small sample size, formal hypothesis testing with p-values was not performed. Instead, effect sizes were calculated to estimate the magnitude of differences between the intervention and control groups. Results: A needs assessment of 159 residents (12% response) revealed low confidence in perioperative care; over half reported no structured training. In the control group ( n = 11 pre, n = 10 post), notable gains are observed in special population (40% to 49%, effect size = 0.45) and anticoagulation (41.1% to 48.50%, effect size = 2.00). Cardiovascular risk and medical management remain stable (45.40% to 39.40%, effect size = 0.18, and 60.60% to 56.1%, effect size = 0.04, respectively). In the intervention group ( n = 11, n = 10 post), all categories show notable gains, with special populations and cardiovascular risk reaching statistical significance: cardiovascular risk group (37.50% to 66.70%, effect size = 4.04), medication management (64.5% to 75%, effect size = 0.45), special population (45% to 95%, effect size = 4.26), and anticoagulation (45.80% to 58.30%, effect size = 0.42). In the control group ( n = 11 pre, n = 10 post), mean confidence scores remained largely unchanged, with minimal effect (2.35 vs 2.38; effect size = 0.10). In contrast, the intervention group ( n = 8 pre, n = 8 post) demonstrated substantial improvements in confidence across all domains following the workshop, with mean Likert scores increasing from 1.86 to 3.18 (effect size = 2.48). Qualitative feedback showed that residents valued the interactive, case-based format and the gamified “Escape the OR” activity. Conclusions: A single Jigsaw-based workshop integrated into a primary care residency curriculum was observed to be associated with improvements in resident knowledge and confidence in perioperative assessment. These early findings suggest that structured, interactive workshops may help address gaps in perioperative education and support further evaluation of learner-centered instructional strategies in larger training settings.

This case describes the resolution of refractory chronic idiopathic urticaria (CIU) with setmelanotide in a patient with Bardet-Biedl Syndrome (BBS). While setmelanotide is approved for syndromic obesity, this report highlights a novel anti-inflammatory effect potentially mediated by melanocortin-4 receptor (MC4R) agonism, expanding current understanding of its immunomodulatory role in mast cell–mediated disease. The patient presented with lifelong hyperphagia and class III obesity beginning in childhood, along with multiple features fulfilling BBS clinical criteria: visual impairment with night vision difficulties, renal abnormalities with proteinuria, irregular menses with polycystic ovaries, and neurodevelopmental delay. She also reported refractory CIU with pruritic hives occurring several times weekly despite dual antihistamine therapy. On examination, BMI was 40.5 kg/m², and dermatologic evaluation confirmed recurrent hives unresponsive to standard treatment. Genetic testing revealed a heterozygous pathogenic BBS9 variant (c.1120C > T; p. Arg374∗), supporting a BBS diagnosis. Secondary causes of urticaria were excluded. Setmelanotide was initiated at 2 mg daily and titrated to 3 mg, leading to complete urticaria resolution within three weeks and cessation of antihistamines. Symptoms recurred during a brief treatment pause and resolved upon reinitiation, demonstrating a temporal association. Hyperphagia scores improved from 20 to 0, with significant quality-of-life gains. Adjunct phentermine 18.75 mg daily was later added to optimize appetite control. After ten months, urticaria remained in sustained remission, with only one isolated cold-induced episode. Setmelanotide produced durable remission of refractory CIU in a patient with BBS, suggesting MC4R agonism may exert immunomodulatory effects beyond weight regulation. This finding underscores the broader potential of precision therapies for rare obesity syndromes to reveal new mechanisms of inflammation control.

Background: Preoperative assessment is a key but inconsistently taught skill in internal medicine residency, particularly in the ambulatory setting. Many residents report low confidence and limited formal training. Objective: To evaluate the effect of a structured, active learning workshop on resident knowledge and confidence in preoperative assessment. Methods: In 2025, we conducted a quasi-experimental pilot study at the University of California, San Diego. Primary Care Track residents (intervention) completed a 2-hour Jigsaw workshop on cardiovascular risk, medication management, anticoagulation, and special populations. Categorical residents (control) received usual training through consults, conferences, electives, and clinic. Pre- and post-surveys assessed knowledge (multiple-choice) and confidence (Likert scale). Results: A needs assessment of 159 residents (12% response) revealed low confidence in perioperative care; over half reported no structured training. In the control group (n=11 pre, n=10 post), minimal gains occurred (p = NS), with improvement only in anticoagulation (43.8% to 53.3%). In the intervention group (n=11 pre, n=10 post), knowledge rose in special populations (55% to 96%) and cardiovascular risk (43.3% to 66%); however p value was not statically significant. Confidence scores (n=8 pre, n=8 post) improved consistently across all domains (p <0.05), unlike controls (p = NS). Residents valued the interactive, case-based format and the gamified “Escape the OR” activity. Conclusions: A single Jigsaw-based workshop significantly improved resident knowledge and confidence, offering a scalable model to address gaps in perioperative education.