 Okay, the direct follow-up to that is Dr. Maya Ortandi and Maya got her training in Germany. I think you'll tell in just a moment, you'll be able to tell in just a moment. After getting that education, doing her residency there, she did an internship at Stanford back in 2002 and then another residency at Stanford, stayed on as a clinical instructor until 2009 when she was appointed clinical assistant professor. I first met her in 2009 when I learned she was interested in developing this weight loss clinic as clearly a passion of hers as she continues to push forward to meet these objectives and she's making some encouraging progress. Here's Dr. Ortandi. Thank you. So I'm a primary care physician at Stanford Internal Medicine West and as a primary care physician I take care of patients with obesity and obesity-related comorbidities such as diabetes, heart disease, sleep apnea. I try my best to take care of the comorbidities and the obesity but our resources in primary care and internal medicine are very limited to take care of obese patients and this is why I have become very interested in a Stanford Weight Management Center. If you look at the current treatment modalities for obesity at the base you will always have your lifestyle modifications such as a healthy diet, physical activity and stress management. If a patient cannot control their weight with the lifestyle modifications and the patient has a certain BMI you might be able to add pharmacotherapy but unfortunately our drug options for weight management are very limited. There are really very few drugs that are approved for treatment of obesity. If the patient has severe obesity and significant comorbidities then he or she can undergo bariatric surgery and you would hope that with this approach you can treat everybody with obesity. However, unfortunately in clinical practice it looks a little bit different and this is not up to scale but you still start as a clinician taking care of lifestyle modification with healthy diet, physical activity and stress management but unfortunately only about 2.5% of all obese patients are able to control their obesity with lifestyle modifications. You can add pharmacotherapy but again options are limited and thus only about 0.1% of obese patients can control their obesity with the pharmacotherapeutic options. And then on the top of the pyramid you have the surgery and currently only 1% of all eligible patients undergo bariatric surgery which leaves you with a huge treatment gap of about 96% of obese patients who don't have any treatment modalities for their disease. As you all know, obesity is a very prevalent disease. We currently have an obesity epidemic in this country. Those obese patients need care. It's not easy to take care of them because those are very complex patients that have a lot of associated comorbidities. Fortunately every day we're learning more about the physiology and about the treatment of obesity but currently there are not many physicians who feel comfortable treating obese patients and obese patients if you look at the statistics are getting worse care than non-obese patients. So there's a big provider vacuum which I think supports the case of a Stanford Weight Management Center. We modeled our Stanford Weight Management Center on the Look Ahead Study, the Diabetes Prevention Program and several academic weight loss centers around the country such as the Harvard Weight Center. We believe that a multidisciplinary approach is really important which means that part of the Weight Management Center will be medical and surgical providers, registered dietitians, clinical psychologists, if possible an exercise specialist. We will have nursing staff and administrative and secretarial support. This program is targeted towards patients with a BMI above 27 or above 25 with comorbidities. Those patients need to be motivated to confront serious weight problems with lifestyle changes. And our goal in this clinic is to induce a 10% permanent weight loss. We would like to reduce the patient's comorbidities, improve their fitness and very important because weight maintenance is a big part of this. We want to teach them tools so they can maintain their lost weight. This is an overview of how we are going to organize our clinic. Initially, we're going to have an introductory session, probably every month or every two months. This introductory session will introduce interested patients to the program and the therapeutic options that we offer. If the patient is interested, he or she then will be scheduled with individual appointments with an MD, a dietitian and a psychologist. After these individual meetings, all the providers will come together in a so-called metabolism board. And in this board, we will decide which is the best therapy for the patient. It's either group therapy, individual therapy, which means one-on-one appointments with the MD, RDR, psychologist or direct referral to bariatric surgery. Our group therapy will have different phases. We'll have an intensive phase, a custom phase, and then after six months, a maintenance phase. So, how does that look? For example, you have patient A. She is a 59-year-old obese woman. She has high blood pressure, chronic back pain, and a BMI of 34. She has gained weight associated with each of her pregnancy but has never been on a formal diet. So this patient would be a perfect patient for the group therapy. She has never had any formal diet education. She doesn't really know what to do, and she would benefit a lot from the formal curriculum that the group therapy has to offer. Patient B is a 48-year-old obese woman with high cholesterol, impaired fasting glucose, and depression. She has a BMI of 32. She has tried dieting many times and has read several diet books. She is sedentary and she has not been successful losing weight. So this patient might be possibly bored with the group therapy approach because she probably knows a lot about losing weight already. So this patient might be better served with an individual approach, meeting one-on-one with the MD or the dietitian. And then we have patient C, who is a 43-year-old obese man with poorly controlled diabetes, stable coronary artery disease, and sleep apnea. He has a very high BMI of 50. He has tried dieting and behavioral modification many times but has not been successful. Here we have a patient with severe obesity, significant comorbidities, and this is most likely a patient that we are going to refer directly to bariatric surgery if the patient is interested. So what does our group therapy look like? We are going to have closed groups out of 10 to 20 people. Closed means that the same group will stay together for a whole year. And this will facilitate social interactions but also healthy competition. These groups meet in regular intervals until week 52 and then they have in-between individual MD, dietitian, and psychology visits. The groups have a curriculum and the curriculum focuses on dietary education, behavioral management, and fitness. So we have a 24 weeks long intervention phase. This intervention phase is divided into two different phases. Week 1 to 5 is the intensive phase. We will provide the patient with standardized meals with shopping lists and meal plans. Basically they eat what we want them to eat. In phase 2, which is the custom phase, week 6 to 24, the patients will follow their own appropriate meal plans within their caloric targets. So they eat what they want, however they have to stay in their caloric range. Our expected weight loss is 1 to 1.5 pounds per week. If a patient does not achieve this weight loss goal, there are two box options available. We will start the two box options at week 4. And two box options are, for example, meal replacement, more individualized care, or also weight loss medications. Then they have the other phase, which is the maintenance phase, and this is week 25 to 52. Here the patients are not expected to lose any more weight, but they're expected to just maintain the achieved weight loss. If they want to lose weight, they can restart losing weight after week 52. And our theory behind that, as Dr. Gesundheit pointed out, is that weight gain often occurs over years, sometimes decades. So you cannot expect weight loss to happen within 12 months and then it is done. So we propose that patients lose the weight, and then they maintain the lost weight to get the body used to the new weight, and then they lose again and maintain until they reach the goal they want to reach. And this is our Weight Management Center group. It's me, Dr. Gesundheit, Son Kim, Terry Greco, Mark Berman, Heather Schwartz, and also John Morton. Thank you very much. The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University. Please visit us at med.stanford.edu.