Introduction

Lucia Novak (Diabesity LLC, Maryland): Hi everyone, and thank you so much for joining us today. I am super excited to introduce you to our program entitled Meeting of the Minds: Experts’ Perspectives on Clinical Challenges in Obesity Management. And this program is brought to you by Clinical Care Options in partnership with Practicing Clinicians Exchange, and is supported by an educational grant from Novo Nordisk. Today, you have a front row seat: 2 obesity experts answering the top questions from previous obesity‑focused education and real-world experiences. We're going to try in 45 minutes to incorporate the latest evidence, strategies and our expert perspectives on some of the most challenging aspects of obesity management.

[00:00:57]

Speaker and Disclosure Information

I am your moderator, Lucia Novak, and I'm a nurse practitioner, board certified in both adult health and advanced diabetes management, and I do have a certificate for advanced education from the Obesity Management Association. I come from Silver Spring, Maryland, which is right outside of our nation's capital, and I am joined today by both Dr Christopher Still and Donna Ryan. And I'm going to allow them to introduce themselves. Dr Still?

Dr Christopher Still (Geisinger Commonwealth School of Medicine): Thank you, Lucia. Welcome, everybody. It's a pleasure to be here today. I'm a Professor of Medicine in the Department of Clinical Sciences at the Geisinger Commonwealth School of Medicine. My clinical role, I'm the Medical Director for the Center for Nutrition and Weight Management, and I have a research role as the Director for the Center for Obesity and Metabolic Research at Geisinger in Danville, Pennsylvania. It's always my pleasure to be with a good friend and colleague and renowned obesity medicine specialist, Dr Donna Ryan. Donna?

Dr Donna Ryan (Pennington Biomedical Research Center): Chris, thank you. I've learned so much from you over the years. And Lucia, thank you for inviting me to do this. I think it's going to be fun, very interesting. So I am Professor Emerita at the Pennington Biomedical Research Center in Baton Rouge, Louisiana. And while I was there, I was engaged in all of the clinical trials, a lot of lifestyle interventions, some dietary interventions, all of the medications that were developed and are still being developed for obesity I was engaged in. And I also did some work in bariatric surgery. So that's me.

Dr Still: And Donna has written, if not all then part of all the guidelines. And so, we're lucky.

Dr Ryan: I love telling people what to do, Chris.

[00:02:44]

Panel Discussion: Patient Engagement

Lucia Novak: All right. Well, we are so excited to get started with this program. So let's not beat around the bush any longer. And I think the most important aspect of obesity management is, of course, engaging the patient. The patient is going to be the center of everything that we do. And I think 1 of the questions that frequently comes up is, how do you address a patient who isn't yet ready to even discuss their disease of obesity or pre‑obesity, which is overweight? And I know for myself that that conversation actually starts when the patient walks in the door, making sure that my practice is physically welcoming to people that are living with overweight or obesity, meaning that we have chairs that are accommodating, we have blood pressure cuffs that are accommodating. If we have restrooms within the office, they are floor mounted and also can accommodate the weight. We try to make sure the scale is in an area where it's not, you know, open where everyone can see. But then once they feel comfortable, at least by the visual aspect of feeling welcomed, then comes the tough part of trying to get them engaged.

So I'm going to punt to Chris with the first one on, what do you do? How do you engage a person who's not quite ready to talk about obesity, or how do you even find out if they are?

Dr Still: Yeah, I think that's a really important question. And what you said about managing expectations for the patient, I think is really important and welcoming them into your practice. But, you know, if they're in my practice, they all come. I mean, we're an obesity center. So it's easy if they show up, they want to talk about weight. But I think it's really important that if they say, ‘I'm not ready, I don't have time,’ say, ‘That's okay, but just know there are new options out there for patients that are struggling with their weight. And together, you know, maybe we can come up with a plan.’

So, you know, whether it's timing, they don't have time, or they're just not interested or they don't see obesity as part of their, as we're going to get to, as their medical problems. But I would always leave the door open because then they'll say, well, you know, I heard that he said that there's some options and maybe today is not the best time, but next time you come, you can bring it up again or they can bring it up again.

I don't know, Donna. How do you approach that?

Dr Ryan: You know, you're right, Chris. You know, this occurs especially in primary care. I mean, patients are not used to talking about their weight with their physician or with their nurse practitioner. You know, what's going on here is that most patients feel like they have control of their weight. They are responsible for their body weight. They think it's their fault. Whatever their body size is, they own it. And so this has not been a subject that has traditionally been discussed. And look, it is a sensitive subject. And so we're always taught to ask permission before we raise the issue. And occasionally some people are going to answer that question that, no, they don't want to talk about their weight today. So we bring this up gently. Is today a good day to talk about your weight and how it might be affecting your health?

We always link weight to health. This is not a judgment of anybody's body size. What we're here for is to improve their health. So if patients say, ‘Look, I'm trying to take care of my mother. She's in a nursing home. My son just got arrested last night. I do not have time to go down this road, doctor.’ You say, ‘I understand. Let's agree, we're going to bring this up next time I see you. And don't worry. This is something that we're going to discuss together, and it's not going to be bad. Don't worry.’ The most important thing for you to do is to keep your patient coming back and not alienate that patient. So you want to make the link between health and body weight status, and you want to keep the patient coming back.

Lucia Novak: I think that's excellent. We need to make sure that the patient feels safe and can come back and then bring it up themselves, which I find is happening a lot more often now that all of the treatments have been so commercialized, I guess, through social media and so forth. They're coming prepared to talk some of the talk.

Dr Ryan: So, you know, Lucia, I think patients also don't want their health care provider to blame every 1 of their symptoms on their weight.

Lucia Novak: Yes. You’ve got it. Especially since most of my patients tend to be women, it's a very sensitive topic, for sure.

So, Chris, you mentioned that typically obesity is the underlying condition that then causes a lot of the comorbidities and complications that patients experience, and they don't even realize that maybe that needs to be addressed before we can successfully manage the other issues that they are contending with. How do you help them to understand that?

Dr Still: Yeah, because then you can take it away from their weight specifically and put it on, so your blood pressure is creeping up. You know, we can either put you on a blood pressure medication or, you know, studies have shown just a 3% to 5% weight loss can reduce your blood pressure. And so, you know, you give them the option, patient centered interaction to see together what you and he or she want to come up with. But a lot of people think they have to lose 100 lb to have significant medical benefits and we all know that that's not the case, especially with, you know, glycemic control, fatty liver disease. You know, more is better but even a modest weight loss has a significant impact. And so that's why I think you can tie in patients with obesity having that as their primary problem to tackle first.

Lucia Novak: I think that's a great idea. So Donna, let's say you've got the patient engaged and they want to talk about their obesity and they actually are on the track with managing. I find that it's often more difficult to help them to stay engaged. One of the tactics that I use is frequent follow up, whether it's seeing them directly, virtually or in person, but also maybe an occasional text or message through our portal. ‘Hey, how's everything going?’ How do you help patients stay engaged and determined in their plan of care?

Dr Ryan: Well, I think the conversation begins with this is not something we're going to cure. This is something we're going to be managing for a long time together. You know, so you set that expectation that this is going to require a lot of follow up. It's amazing how often primary care physicians will think that it's a 1 and done. Like, I'll just give them advice about how to reduce food intake, increase physical activity, and that's going to do the work for me. No. That's why we have to maintain that support with patients.

But in terms of maintaining interest and motivation, that's where our motivational interviewing skills come in. So what we're trying to do there is we're trying to coach patients, not prescribe patients, and we're trying to use our coaching techniques of rolling with resistance. When our patients say, ‘Oh no, I can't do that. I'm having trouble with this,’ we acknowledge that and then we make a suggestion, ‘Well, what do you think we could do that might be better? How important is this to you?’ We ask questions that get them engaged in that way.

Dr Still: Yeah. The other thing is, I think, as we talked about before, setting realistic expectations because life happens and you don't want to think that they're a failure. They're not a failure. It's just that, you know, sometimes we expect too much. And so we need to think that this is a marathon and not a sprint, and it takes small goals and award when they make the small goals because it's difficult.

Lucia Novak: A lot of that really is going to be in the hands of the clinician as well. I think the reason why patients feel that they are a failure or not meeting whatever goal, is that we have said time and time again, if you would just eat right and exercise and the weight would come off. And so when they come in to see me, usually it's also part and parcel with their diabetes. They'll ask me what their A1C is, and then they'll give me a litany before I could even get the word out that, you know, it's A1C, but on top of that. you know, I feel like I have to listen to a litany of confession because they're telling me all of their life experiences. It was their birthday, it was someone's anniversary. It was this, it was that, and that's why they're not doing what they're doing. And that's when I tell them that's the shame and blame, and we really need to change the conversation. And I think the way that you 2 brought it up is just so beautiful and really empowering for the patient, as well as for the clinician, to know that there are tools out there.

[00:12:17]

Panel Discussion: Assessment

So now let's talk about assessment. I think 1 of the key things that we need to keep in mind is that people who have the disease of obesity are overweight. Typically, they didn't just look in the mirror that morning and figured out that they were not happy with their body and how they were feeling and the things they weren't able to successfully do, and they've probably tried a number of things. So, you know, I typically find that my person that’s seeing me for obesity management isn't, you know, unable to commit to anything. It's just that things are not really sustainable. But tied into that can also be some issues with eating disorders and things like that. So we need to be mindful of eating disorders, especially with the pharmacotherapies that we have available. Donna, can you touch upon, you know, how do you screen, especially when you're considering weight loss medications in that population?

Dr Ryan: Yeah. You know, I think it's so important to do a good assessment at the beginning. And so as part of the assessment at Pennington, we have a screener for binge eating disorder. It's 7 questions that are asked. And anybody can go on the on the internet and download this binge eating disorder 7 questionnaire to help screen patients with this. But that's in the context of a lot of other things we're screening for. We want to know their history, their weight history. We want to know what they've tried in the past, what's worked and what hasn't. So it's in in that context.

But, you know, I think that it's very important that if you're going to engage in obesity treatment, that you really understand that binge eating disorder is a psychological problem. I was very fortunate to work with behavioral psychologists at LSU, who had an excellent program in behavioral psychology, and they really taught me a lot about binge eating disorder. So what this is, is there is a diagnostic statistical manual, DSM‑5, criteria for diagnosing binge eating disorder and what they're really looking for there is evidence that patients over a fairly protracted period of time, at least 3 months, have had episodes of uncontrolled eating, defined as eating more than a person would eat under ordinary circumstances, and also that this was associated with feelings of lack of control. They could not control their eating. And then also there has to be with it, anxiety. This event creates anxiety among the patient and a sense of shame. So those are the sort of elements that are there.

But if you talk to patients and if you have a really low bar, lots of patients will overeat on occasions. And so it's very important to distinguish that that's really a response to restriction. You know, if you're on a very strict diet and you're restricting, all of your appetite mechanisms are in overdrive and it is possible to overeat and so you could have a binging episode.

But this is a psychological disorder. And so I strongly recommend that everybody in obesity treatment have on their speed dial a good behavioral psychologist who will do a formal assessment of this, because it really does require a psychologist, a clinical psychologist approach to treatment.

But that's not to say that individuals who have these binge episodes overeating actually have that. They don't, most of the time. it's really pretty rare.

Dr Still: It is very rare. That's what I want to bring out. It is important to diagnose, but at least it is rare. And we all overeat. We all eat too much, but we don't have true binge eating disorder.

Dr Ryan: That's correct. That's right. And anything that affects appetite will improve binge eating disorder. So you know, there's actually 1 medication that's approved. It is lisdexamfetamine. Yes. You heard me correctly. It's dexamfetamine, lisdexamfetamine. So we're really reluctant to use it in older patients, in patients who have hypertension or pre‑existing cardiovascular disease.

But other medications have been shown to be effective and virtually any medication that has an effect on appetite can improve binging episodes. I guess the 1 that most of the psychologists will use is topiramate in addition to that lisdexamfetamine. But all of our anti‑obesity medications, including the GLP‑1s, have some published evidence for their efficacy in this. So it shouldn't hold anybody back from treating those patients with medications.

Lucia Novak: Fantastic. So part of the assessment is also defining, you know, does a person have the disease of obesity? And the tried and true what we are still using by and large is the BMI. We know that is not the most accurate measurement for many reasons. It's really just height and weight, and that's about it, doesn't really tell us about fat distribution. Not everyone can afford those bio impedance devices. DEXAs are not readily available. So, Chris, what else do you use? Do you use the waist circumference or do you prefer to use the waist to height ratio? What do you use in your clinical setting?

Dr Still: So you pointed out the BMI is good for screening, you know, on a population base because it is height and weight. Everyone has height and weight. But on an individual basis we just use a simple waist circumference throughout around the umbilicus. You know, we know that a disease, obesity is a disease of inflammation, and we think that driver is that visceral fat. So simply in women with waist circumference greater than 35 or men with waist circumference greater than 40, we have that upper body weight distribution. And in my opinion, irrespective of BMI, those individuals are at higher risk for cardiometabolic disease and complications. And so I think a simple waist circumference, which everybody can do. Just make sure you have a large enough tape measure for our patients so we don't make them uneasy or embarrass them. But a simple waist circumference I think is important and should be part of the vital signs, if you will, in addition to blood pressure, weight and things like.

Dr Ryan: You know, Chris, it can also help reinforce the biology of obesity, that what we're looking at here is to improve your health and that health is related to ectopic or abnormal body fat, not your total body size. So I think that having that discussion about obesity being a disease, about it having its own biology and that weight regulation is a is a very much a function that is regulated by the body. It is not under your control and it's not your fault.

Dr Still: And Dr Ryan has taught me many times, you know, a modest weight loss of even that 5% to 10% has a significant decrease in visceral adipose tissue. So if you lose 10% of your body weight, what has it done? Like 30% reduction in visceral adipose tissue. So you get a lot of bang for your buck from a cardiometabolic improvement with just a modest weight loss because of that visceral fat driving the inflammation.

Lucia Novak: What I like about using the waist circumference is it's something that a person can be taught to do at home. So many of my patients are triggered by having to get on a scale. They just don't like the changes and they're not seeing the changes that the scale is representing. So teaching them how to do a waist circumference or an arm circumference or a thigh circumference is just another way for those to be able to keep track themselves.

For the clinicians, I want to make sure they understand that if we just look at the BMI, and we look at the BMI in Asians, we see a difference in the cut offs, right? We see overweight is 23 in the Asian population. Obesity starts at 27. Which is not where we are accustomed to seeing. And when you look at an Asian person with a BMI of 23 or 27, they don't appear to have the disease of overweight or obesity, and that is because of that visceral fat. That is why we really do want to include that waist circumference in that initial assessment.

[00:21:03]

Panel Discussion: Treatment Selection

So we're going to move right now to treatment selection. So in addition to, of course, nutrition and physical activity, which are part of the pillars, as well as behavioral modification, we do have actual medications now that address the pathology of the disease. Unfortunately not everyone can get access to them, and we are working really hard to change that. But probably the most common and the most heard about, the most TikTok‑ed, is going to be the GLP or the GLP‑GIP combination. So I'm going to throw this out there. Chris, I'll start with you. How do you select between using a GLP‑1 receptor agonist or a GIP‑GLP, which is the combination? Do you make that differentiation?

Dr Still: Well, unfortunately, most of the time the insurance companies will make that determination, to be honest with you. So, if they are fortunate enough to have coverage, you know, this is the first time, and Donna and we all have been doing this a long time, you know, this is the first time that we've actually, on a consistent basis, reached that 10% consistent weight loss or greater. And so I don't really have – you know, the side effects are really GI related and they're common in both. So I don't really say that 1 is better than the other. So, I would just say if you do have access, to start at the lowest dose and titrate up. But I don't know, Donna, if you have 1 preference over the other, but I just think that if they have coverage for 1 or the other…

Dr Ryan: I think the indication may give us a little help there. So tirzepatide is indicated for obstructive sleep apnea, and that will sometimes get it paid for by the insurer. And semaglutide is indicated in adolescents and adults, so that's good. That adolescent indication helps us. And then also it's indicated for cardiovascular risk reduction. So you can get it paid for by even Medicare if the patient has had a heart attack, a stroke or symptomatic peripheral artery disease. So that's another sort of differentiation that's going to help you.

But no, you know, there's such a variation in response to each 1 of these medications. There's a lot of overlap, and you cannot predict in advance how your patient is going to do. The current 2 that are currently available, tirzepatide and semaglutide, both have dose escalations. You start low and you go slow and judge your response. If the patient is responding well, you don't go up until they need more.

Dr Still: But the good news is, as Donna alluded to, the response rate of these 2 medications are significantly higher than the older oral medications and even the liraglutide. So not only are they losing more weight, but more responders, more patients, they're losing greater than 5%, 10%, 20%.

Lucia Novak: Yes. And unfortunately, Donna, you bring up a point about the insurances. More and more insurances are coming up with barriers to paying. Either they need to have a comorbid of sleep apnea in order to get the tirzepatide version, or they have to have established cardiovascular disease. So that's really important and on the onus of the clinician to make sure we are capturing an adequate history, that we're sending our patients for sleep studies to see, you know, they're not going to know if they have sleep apnea. They don't know if they snore. And even if they don't, that's not a nod to them not having sleep apnea. So we want to make sure that we are telling the proper story in our notes that can assist us with getting these medications for our patients.

We also we have, you know, when patients have blood pressure or cholesterol, for whatever reason in the obesity management, insurers seem to believe that they're only going to cover 1 drug at a time. And we know that there are different mechanisms of actions, there are several pathologies at play, and we don't use just 1 drug to manage hypertension or diabetes or blood pressure. So I know I use combination therapy. I might have to go around the insurance, meaning that I'll prescribe the most expensive 1 that the insurance will cover, and then look for alternatives, either the generic version of topiramate or phentermine in low dose, those kind of things. Do you also incorporate combination therapy with your patients with obesity?

Dr Ryan: Absolutely. What about you, Chris?

Dr Still: Yeah. The tricky part is what you alluded to. Sometimes if the insurance company sees that you're on, say, a GLP‑1 and phentermine, they'll say, well, we'll pay for the phentermine but we're not going to pay for the GLP‑1. But yeah, you know, there's no studies that I know of that show, but in clinical practice, you know, just like blood pressure medication, you can add 1 to the other, for sure.

Dr Ryan: Yeah. I think we should use diabetes and hypertension as our guide. Almost everybody is on more than 1 medication if they have Type 2 diabetes and the same thing is true for hypertension. So very frequently we will use medications that are label indicated along with those GLP‑1s, and very frequently we'll use medications off label like metformin, like the SGLT‑2 inhibitors. So sometimes we try to get even more weight loss for those patients who need it. You know, when we say that the average weight loss is 20% or 22% with tirzepatide, that's the mean weight loss there. That means half the patients lost less than that. So for those patients who don't have the maximum response we're hoping for, we always are trying to increase that and adding medications is the route.

[00:27:30]

Panel Discussion: Duration of Therapy

Lucia Novak: Yeah, and you bring up a really good point, because probably the question I get when I'm discussing pharmacotherapy is they're either reluctant to start something because they're afraid they're never going to come off of it. And it doesn't really matter what disease I may be discussing with them, they're afraid to start a medication for fear that they won't be able to come off. And a lot of folks say, when I reach my ideal weight, will I be able to come off this medication? And so it becomes a discussion on the disease process and that we don't have a cure. But how do you, Christopher, put into your discussion with the patient on duration of treatment or when do you decide or how do you implement maybe reducing dose, if you do? How do you practice that?

Dr Still: Yeah. So, those are 2 very important concepts. So the first thing is we treat obesity like any other chronic disease. When a patient reached their normal blood pressure, you don't stop their ACE inhibitor or when they get down to a normal A1C you don't stop their diabetes medications, because if you would, their blood sugar or blood pressure would go right back. Same thing with these medications. And even more profound with these, both tirzepatide and semaglutide, if you acutely stop these medications, two thirds of patients will gain back their weight within 1 year. They are so effective in physiologically decreasing our appetite. So it's not the fault of the patients. You’re not you're not going to say, ‘I'm not going to eat. I'm not going to eat.’ Your appetite comes back and you're going to eat. And like I said, two thirds of the patients gain back their weight.

So you always have to have that discussion that this is not just a jump start, because it's really a waste of a lot of expense and a lot of time and escalating things if you're just viewing it as short term. So I don't know. Before we talk about do we ever, when they get down to their ideal body weight, Donna, do you have any other points to that?

Dr Ryan: Yeah. I want to add a little nuance to what you said, Chris. And that is, you know, sometimes we're using these medications for cardiovascular risk reduction. Sometimes we're using them for obstructive sleep apnea. And in those instances, we do not want to stop the medication, especially in the case of cardiovascular risk reduction. You know, the study, the SELECT study that gave us that indication, it shows that the weight loss is independent of that effect on reducing risk for heart attack, stroke and sudden death. And so we don't want patients to stop it because the effect is mediated beyond just weight loss. There's an effect of the drug itself. So we need to keep that drug in the patients’ bodies if we want to keep having that effect. So there's a slight nuance to that, but I think it's an important one.

Dr Still: Very good point. And then, Lucia, to your question about when they get down to their normal body weight or their goal weight, whatever, you know, that you and the patient discuss. So that's an art. I mean, there's really no, at least for me, there's really no specific criteria. Because if we know if you stop it, what will happen? The weight comes back. So we try to decrease the dose until they're not losing any more. So they're maintaining their weight. If they're still losing on the lowest dose, then we can extend from 7 days to ten days and things like that. But that's what we do.

We've had issues with them going below a BMI of 25 that the insurance companies will not pay. And so, you know, it's different. It's a whole paradigm shift that patients are getting down to their goal weight with medical treatment. And so we really have to work with them because we don't want them to lose their insurance if they go too low. But we also want them to have a good diet quality, getting enough protein, macro, micronutrients and that type of thing.

Dr Ryan: Yeah, absolutely.

Lucia Novak: I also tell patients, you know, let's say that you were able to lose the amount of excess body fat by proper nutrition. You just stop drinking juices or sodas. What do you think would happen if you started drinking those things again? And they automatically associate weight regain with that, And I said, it's the same. Whatever mechanism we are using to help you achieve and maintain a healthy weight, if you pull that away, the weight is going to come back. And that's true also with the medications. And it helps them. I think they're so, ‘I'm taking so many drugs and I'm, you know…’ And I try to tell them, well if we can keep you on this one, it's going to address a multitude of issues, and the weight loss will reduce your risk for heart failure, for heart disease, for chronic kidney disease, for osteoarthritis, for peripheral vascular. I mean, you name it and obesity of course is linked with it.

[00:32:34]

Panel Discussion: Treatment Adjustments

Dr Ryan: I think 1 thing that's important, Lucia, about these drugs, is to recognize that patients lose weight for a long time on them. Our older medications and our lifestyle, we usually got about 6 months of weight loss and that was it. But with these medications they can lose weight for longer than a year. And I don't like to push the weight loss too fast. So I like to go really, really slow and only go up on the dose if patients stop losing weight or if their appetite comes back.

Lucia Novak: That is so important because I've had a lot of patients that were managed somewhere and then were referred to us and, you know, they were rapidly increased every 4 weeks. So while in the labeling it says that, I have to make sure the clinicians out there know that that was really based on the study to get people up to the maximum dose, not to really use in the real world. And so we do want to take our time with adjusting those doses. And I don't advance the drug if they're doing well. And sometimes I have to go back down a little bit if the dose is a little bit too much for them and they're having side effects, because the end goal is to have them maintain on drug for as long as possible.

[00:33:51]

Panel Discussion: Suboptimal or No Response

So we're getting close to time, and I want to make sure that we can answer all the questions that have been put before us. So we talked about combining therapies and managing patients. What about that patient that does have comorbid diabetes? They don't tend to lose as much weight. And that has been true in every study that they have done with the anti‑obesity medicines we currently have. When they look in populations that have comorbid diabetes and those who do not, those who have diabetes tend not to lose as much weight. Sometimes they don't lose any. So what would you hypothesize is the reason for that?

Dr Still: Go ahead, Donna.

Dr Ryan: Oh my gosh, that is a tough question. Look, if somebody knows that, call in and let us know. I don't think, no, no one really understands that. You know, yes, there are more men in the diabetes trials and women tend to lose more weight than men on these medications. But for any treatment, the GLP‑1s, any obesity medicine, bariatric surgery, if you have diabetes, on average, you will lose less weight. But I always look at it this way: if you have diabetes, you've got a whole bunch of medications out there that will produce some weight loss. And if you can stop some of your medications that drive weight gain, you may lose some weight from that.

Lucia Novak: I think that is such a good point for primary care, especially if they're not really interested in being an obesity management clinician, is that we all have a role in not making the disease worse. And so as prescribers, we need to keep in mind what the patients are on. What are we prescribing that could be obesogenic? Is there an alternative, a safe and appropriate alternative to that medication that maybe is at least weight‑neutral if we don't have anything that actually contributes to loss? Chris, do you have anything to add?

Dr Still: No. I think that's really important to take a good medication reconciliation. I mean, it's estimated that 10% of the obesity epidemic is iatrogenic, what we prescribe as prescribers. So it's a lot easier now than it used to be, but I think that you bring up a good point.

[00:36:14]

Panel Discussion: Adverse Event Management

Lucia Novak: So we're coming close to the end and I think probably another big question of our listeners is adverse events and how do we manage them. We alluded earlier that it's typically the nausea, vomiting, GI stuff. I'm more concerned actually about constipation because that can really cause a big problem. But some have really been talking about the loss of skeletal muscle. I know that that can happen with any weight loss, but it seems to be more attributed or blamed on GLP‑1, GLP‑1 GIP use. So, Donna, can you discuss this at all?

Dr Ryan: Yeah, I think, you know, back in the day when the only thing we really had was lifestyle intervention and exercise was absolutely essential to losing significant amounts of weight with lifestyle, this was not as much of a problem. We have this 25% rule, that of the weight that you lose, 75% should be fat and the rest should be lean. So, you know, now that we have medications that really can produce robust weight loss, we're starting to become concerned about that. We haven't done a lot of studies that directly measure muscle. Most of the studies are measuring DEXA lean mass. So what that is, is everything except fat mass and bone, that's lean mass. And so we would see lean mass reductions of 30%, 40% with some of these drugs, and it caused concern. So I think there's more interest in looking at muscle in particular. There's no way that you can lose weight and not have some shrinkage of your organs, some shrinkage of water. What we don't want is loss of that muscle mass, especially in older individuals.

So look, in our bariatric surgery patients, they're having robust weight loss and what do we do for them? Every one of them sees a trainer and they get an exercise prescription. Every one of them has good nutritional support. They're taking supplements. They're taking protein supplements. Very, very important. We need to take the same approach to the GLP‑1 robust weight loss. And patients need to be on vitamins. They may need to be on protein supplements because, look, the appetite effect of these drugs can be profound. And patients can be not consuming enough high quality protein. This is absolutely essential. Especially in women over age 60 and in men over age 70.

Lucia Novak: Yeah.

Dr Still: Hear, hear.

Lucia Novak: So, Christopher, can you, enlighten? How do you assess or what do you do when you're concerned about muscle loss?

Dr Still: A lot of times it's not enough that the patients notice it, but it does happen. And so as Donna said, we work on, on weight bearing exercise to try to maintain that. Because we know that exercise is key. Not so much for weight loss because we can lose weight without exercise, it does augment it, but it's really important for weight maintenance. And so I think that any weight bearing exercise that we can do to try to maintain that lean body mass or maintain their metabolism, maintain their lean body mass, will be better for the patient overall.

Dr Ryan: I like strength training.

Lucia Novak: Me too.

Dr Ryan: And I like protein supplements, especially essential amino acids in the older population.

Lucia Novak: And you don't need special equipment to do strength training. You can use your own body weight and a wall or a chair, so there's many ways to get our patients engaged. Regardless of what level they're at, we can get them started. I had a 29 year old who is doing phenomenally well, and he said to me he was so excited at the appointment with me because all of his liver enzymes are now very normal, the ultrasound of his liver showed that it had gotten smaller, his A1C is now 4.2, he's off blood pressure meds. He's only 29. And he said, ‘You know, Ms. Novak, I was only able to do maybe 1 push up,’ he goes, ‘but now I can do 15 without stopping.’ And it's those kind of moments that matter in the patient's life that really give me the reason to continue to want to work in this field. It's just remarkable.

[00:41:00]

Polling and Assessments Outside of Video Module

I am so excited that we had such a robust discussion and unfortunately we are out of time. We could talk about this all day long, I'm sure, but I want to thank our learners out there, and I want to give a special thank you to Dr Christopher Still and to Donna Ryan for joining me today, and for your expert insight and little pearls of practice that are going to make a big difference for the clinicians out there that are helping patients live better lives with the disease of overweight or obesity.

So please remember to complete the pre and post test questions with the evaluation to claim the education credits that accompany this video module and go online to access more CCO/PCE coverage of obesity, including clinical thought, expert commentaries and text modules on this topic. Until we meet again, thank you for attending.

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