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A reduction in muscle mass can lead to a decrease in resting metabolic rate, further complicating weight loss efforts

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doi:10.1210/jcem.81.1.8550773 21

Generally, Aetna requires a BMI of 30 or greater, or a BMI of 27 or greater with at least one weight-related health condition like high blood pressure, high cholesterol, or sleep apnea

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A foundational 2005 study by Guideri et al