Tirzepatide plus guided resistance exercise for weight loss in adult survivors of childhood ALL

Inclusion Criteria:

* ≥5 years from diagnosis of acute lymphoblastic leukemia (ALL) treated with chemotherapy only
* ≥2 years from completion of therapy
* Participant has a negative (urine or blood) pregnancy test (if female)

Consistent with the FDA-approval for marketing of Tirzepatide for the treatment of obesity:

* Age ≥18 years at the time of enrollment
* Participant has obesity (BMI \> 30kg/m2) or overweight (BMI \> 27kg/m2) with ≥1 weight related co-morbidity (hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease)

  * hypertension: treated or with systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg
  * dyslipidemia: treated or with low-density lipoprotein (LDL) ≥160 mg/dL (4.1 mmol/L) or triglycerides ≥150 mg/dL (1.7 mmol/L), or high-density lipoprotein (HDL) \<40 mg/dL (1.0 mmol/L) for men or HDL\<50 mg/dL (1.3 mmol/L) for women
  * obstructive sleep apnea
  * cardiovascular disease (for example, ischemic cardiovascular disease, New York Heart Association (NYHA) Functional Class I-III heart failure)

Exclusion Criteria:

* Participant has known diabetes or is found at baseline to have laboratory evidence of diabetes including HbA1c ≥ 6.5%
* Participant is using or has used weight management medication in the past 3 months or had recent significant weight loss \> 5kg in the last 3 months Severe renal dysfunction (eGFR \<30 mL/min/1.73 m²)

  * Saxenda® (liraglutide 3.0 mg)
  * Xenical®/Alli® (orlistat)
  * Meridia® (sibutramine)
  * Acutrim® (phenylpropanolamine)
  * Sanorex® (mazindol)
  * Adipex® (phentermine)
  * BELVIQ® (lorcaserin)
  * Qsymia® (phentermine/topiramate combination)
  * Contrave® (naltrexone/bupropion)
  * Compounded or generic incretin mimetic (GLP-1) medication

Note: Use of metformin or any other glucose-lowering medication, whether prescribed for polycystic ovary syndrome or diabetes prevention is not permitted.

* Participant has Multiple Endocrine Neoplasia Type 2 (MEN2) or family history of medullary thyroid cancer
* Participant has severe renal dysfunction (renal-eGFR \<30 mL/min/1.73)
* Participant has history of major cardiovascular event in past 3 months (e.g. acute myocardial infarction, cerebrovascular accident, unstable angina, hospitalization due to congestive heart failure or currently NYHA class IV heart failure symptoms)
* Participant has uncontrolled hypertension during clinic assessment (SBP ≥160 mmHg or DBP ≥100 mmHg) ▪ Participant has known acute or chronic hepatitis or signs and symptoms of other liver disease determined by alanine aminotransferase test (ALT) \> 3 times the upper normal limit
* Participant has known chronic pancreatitis or recent acute pancreatitis (in the past 1 year)
* Participant is pregnant, or within 3 months post-partum, or nursing, or planning to become pregnant
* Participant has clinically significant gastric emptying abnormality or chronically takes medications that affect GI motility (does not include Proton pump inhibitor (PPI) or histamine 2 blockade)
* Participant has a transplanted organ or awaiting a transplant
* Participant has current active cancer or undergoing treatment for active cancer
* Participant has untreated hypothyroidism with thyroid-stimulating hormone (TSH) \> 10 uIU/mL or symptomatic
* Participant has severe mental health disorder (e.g.major depressive disorder, schizophrenia, bipolar disorder, or other serious mood or anxiety disorder) or a history of suicide attempt
* Participant has a patient health questionnaire-8 (PHQ-8) score of 15 or more at screening
* Participant has a history of known drug or alcohol use disorder that in the opinion of the investigator may preclude the participant from following and completing the protocol
* Participant has history of self-reported marijuana use in the past 3 months and unwilling to abstain during the trial.
* Participant is unwilling or unable to perform self-injections of study drug (visually impaired or physically limited) and does not have assistance of a sighted individual/support person who is trained
* Participant has cognitive impairment that, in the opinion of the investigator, would preclude the ability to participate in the intervention including self-injections and virtual study visits
* Participant is Non-English speaking
* Participant has no access WiFi availability for exercise sessions
* Participant lives in a state that we cannot ship medication per current St. Jude Pharmacy restrictions