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Acknowledgments The authors gratefully acknowledge the critical reviews and insights of Sarah Armstrong MD, Nancie MacIver MD PhD, and Lisa Rasbach PhD CPNP

Participants had to have: BMI 40 1 obesity-related comorbidity (OSA, HTN, CVD, dyslipidemia) Documented failure of lifestyle interventions Almost 69% were female , average age 52 years , and mean BMI 46.3