What the first year looks like

Month one

What happens: if treatment is started, it starts at a dose designed to be tolerated rather than to work. That is deliberate and it is not a waste of a month. If there is no medicine, this is the month the food and protein pattern is built.

What you will notice: less interest in food, more than less hunger. People describe the constant background negotiation with the fridge going quiet. Some nausea in the first few days.

What counts as working: nothing on the scale, necessarily. If you are eating differently and tolerating it, month one has done its job.

Months two and three: the hard part

What happens: the dose steps up, and each step brings a few days of nausea, and in some people constipation that nobody warned them about. This is where most of the people who quit, quit.

What actually helps: slowing down. There is no prize for reaching the top dose quickly, and staying eight weeks at a dose rather than four is a perfectly good clinical decision. Tell us you are struggling rather than stopping quietly. Almost every reason people give for quitting has a fix, and the fixes are dull: smaller meals, less fried food, more water, a laxative, a slower ladder.

What counts as working: weight starting to move, and more importantly waist starting to move. Blood pressure often falls here, and if you are on tablets for it, they may need reducing.

Months four to six: the good months

What happens: side effects have usually settled, appetite is stable, weight comes down steadily. This is the phase people imagined the whole thing would be.

What to do with them: build the habits that will hold when this phase ends. Get the resistance training started properly. Fix the protein. The work you do in these months is what determines what happens in year two, and this is the single most commonly wasted opportunity in obesity treatment.

Review at month three or four: repeat bloods. Sugar, liver and lipids have usually moved by now, sometimes dramatically. Medicines for diabetes and blood pressure often need reducing.

Months seven to nine: the plateau

What happens: weight stops falling. This is not failure and it is not you cheating. The body defends its weight, energy expenditure falls as you get lighter, and a new balance is reached.

What we do about it: check whether the plateau is real by looking at body composition rather than weight, because losing fat and gaining muscle can hold weight completely still while the body changes underneath. Then look at protein, sleep, alcohol, dose, and whether something else has drifted. Sometimes the answer is to change the treatment. Sometimes the answer is that this is your result and the job is now to hold it.

Months ten to twelve, and then what

What happens: the question shifts from losing to keeping. It is a different job and it needs a different plan.

The conversation to have: how long you intend to continue, what happens if you stop, and what a supported stop would look like. That is important enough to have its own page, and it is worth reading before you start rather than at the end.

What "working" means, at each point