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Leveling Up Obesity Management in IBD: Integrating Comprehensive Obesity Care Into IBD Treatment

Dr. Sepulveda: Let us talk about how to integrate obesity screening and management into IBD care.

Screening for and Diagnosing Obesity

First of all, let us talk about screening and diagnosis of obesity. The most easily addressed way of identifying obesity and overweight is by BMI calculation in your vital signs. However, we know that BMI is not a completely accurate measurement of adiposity, so we can use additional diagnostic options like body composition techniques and different anthropometric measures like waist circumference.

At initial diagnosis is very, very important to assess comorbid cardiometabolic disease like diabetes or pre-diabetes, or arterial hypertension that might be refractory in some patients, dyslipidemia and any other cardiovascular disorder.

Approaches to Weight Loss for Patients With IBD

How do we approach weight loss in a patient with IBD? First, we should try to discuss lifestyle modification, address their initial baseline nutrition, their capabilities in terms of physical activity, both aerobic and for strength and resistance training, and discuss behavioral modification to see where is our point of starting treatment.

We can discuss at that point different pharmacologic approaches with obesity management and medications and how they impact the treatment of IBD. In some cases, we can also discuss bariatric surgery and how bariatric surgery can improve weight loss and IBD, especially if there is any cardiometabolic health comorbid condition.

Lifestyle Modifications in IBD Care

Now, what should be our goals in terms of lifestyle modifications for IBD care? In terms of physical activity, we should target aerobic physical activity for at least 150 to 300 minutes per week with moderate intensity. I usually tell patients 30 minutes each day makes a big difference. In terms of strengthening and resistance physical activity, we recommend at least twice a week with involvement of two different muscle groups, if possible.

Let us keep in mind that physical activity in general, besides being beneficial for patients with IBD, it reduces stress, reduces inflammation, disease, activity of an inflammatory processes. Most importantly, it also reverses muscle weakness, lean muscle mass loss that is expected with regular weight loss. It also strengthens bones and enhances immune system that is so important in an inflammatory process.

In terms of nutrition, Mediterranean diet and other anti-inflammatory diets can be beneficial to overall health, but we have to keep in mind that ultra processed foods and other type of foods can actually increase IBD symptoms.

Nutrition Considerations With Obesity Management Medications

Nutritional considerations for patients on obesity management medications. First, we have to think that most adults in the US do not meet a healthy diet recommendation. In terms of energy requirements, this could vary a little bit by different parameters like age, sex, body weight, and activity level. For women, around 1200 to 1500 kilocalories per day is generally recommended, and for men, around 1500 to 1800 calories per day.

In terms of macronutrient recommendations, very important to address protein intake to be around 60g per day as a minimum, and an average of 1.5g per kilo per day. Carbohydrates we recommend around 45 to 65 depending on different factors. Fat in general, between 20% to 35%. Fiber is extremely important in terms of intake per day, around 14g over every 1000 kilocalories per day.

Fluid intake or water intake is a very important process when we are dealing with obesity management medication. We recommend around two to three liters of fluids per day. Reduce any sweetened beverage, alcohol, and caffeine because those actually tend to dehydrate. We recommend just consume water or low caloric beverages or nutrient-dense beverages.

In terms of supplementation with multivitamins, it is actually very helpful to reduce the risk for deficiency, but not necessarily would suffice in patients that have pre-existing deficiencies.

Obesity Management Medications (OMM) in IBD

Who should we recommend obesity management medication for in IBD? Any patient that has a BMI higher than 30 or equal to 30, or BMI higher than 27 with a weight-related comorbidity. That is the main indication for obesity management medications in general. However, we have to think of this agent orlistat, which is the only anti-obesity medication or obesity management medication that is not recommended in patients with IBD.

Before starting an obesity management medication in a patient with IBD, we should be very emphatic and make sure that the patient is in remission for at least six months prior to starting therapy. In general, the contraindications for obesity management and medications are the same regardless IBD status.

There is no recommendation that favors any specific obesity management medication, so it is very much patient dependent. This is mostly based on the fact that there is lack of controlled studies in this population specifically. Any patient in obesity management medication should be involved in a multidisciplinary care in order to guarantee that the treatment and monitoring of both disease processes, obesity and IBD, are managed accordingly.

Current and Emerging Incretin-Based OMMs

What are the current emerging incretin-based obesity management medications? We have the GLP-1 receptor agonists like semaglutide and liraglutide, and the dual agonists GIP and GLP-1 receptor agonists like tirzepatide. They both help obesity associated risk modifiers for IBD and induce weight loss. They all have GLP-1 signaling, which have an anti-inflammatory effect. Sometimes adverse effects, or GI-related adverse effects, can mimic or even worsen IBD symptoms if the patient is not treated accordingly for their IBD.

The new generation, it is the nonpeptide GLP-1 receptor agonist, Orforglipron, and this is relatively new, so we expect potential benefits and similar adverse effects as the other group of GLP-1 and incretin-based obesity management medications.

SURMOUNT-5: Tirzepatide vs Semaglutide in Obesity

What is the effectiveness in terms of total body weight loss in comparison? The SURMOUNT-5 is a study that was done comparing tirzepatide to semaglutide in terms of their total body weight loss achieved. In terms of semaglutide, the expected total body weight at 72 weeks is 15.4% of total body weight, and with tirzepatide, it is expected at 21.6 total body weight loss at 72 weeks.

ATTAIN: Orforglipron vs Placebo in Obesity

Orforglipron, the new medication, at the highest dose, it is inducing a total body weight loss of around 11.2% of total body weight, and it is an oral medication instead of a subcutaneous version of an incretin-based therapy.

Safety of Incretin-Based OMMs in Patients With IBD and Obesity

In terms of safety, tirzepatide and semaglutide are pretty similar in patients with IBD and obesity. They both reduce BMI and induce weight loss. They have similar outcomes in patients without IBD and those patients with IBD. Most adverse effects from these medications are manageable and long-term safety data for both still relatively limited at this point.

Anti-Inflammatory Effects of Incretin-Based Therapies

How are the anti-inflammatory effects of incretin-based therapy? When we have microbiological metabolites or components that stimulates the L Cell in the GI system, when we have an increase in GLP-1 that stimulates the intraepithelial lymphocytes, stimulates a higher circulating GLP-1 and enteric neurones which there is receptors for GLP-1 in multiple organs, including the brain, and heart, lungs, liver, that action in those organs or peripheral targets, reduces inflammation overall.

Special Considerations for Comanaging IBD and Obesity

Some special considerations in patients with comanaging IBD and obesity. We tend to avoid concomitant use of medications like carbamazepine and rifampicin because there is CYP3A4 inducers, especially with sulfasalazine and upadacitinib. Especially other medications that we need to be careful with, is ciprofloxacin, clarithromycin, and grapefruit juice, as well as amiodarone and carvedilol, mostly because they are cytochrome CYP3A4 inhibitors, and PGP inhibitors as well.

In terms of ozanimod and etrasimod, thy should not be used concomitant with CYP2C8 inhibitors or MAO inhibitors like clopidogrel and linezolid. We should also avoid these medications together in patients that have prolonged QT interval.

In general, let us keep mindful that patients with IBD are at increased risk for sarcopenia, so monitoring lean muscle mass across the process of weight loss is extremely important as well. All right. And I will hand it back to Amy.

Skills Building II

Amy Stewart: Thank you so much. With that, let us get back to our patient here, Maya. We kept Maya. She is still here.

Revisiting Patient Case 1: Maya R, 42-Yr-Old Woman with Ileocolonic CD

Reminder that Maya is 42. She has ileocolonic Crohn's disease. She was diagnosed eight years ago. She has increased fatigue, intermittent loose stools, she has hypertension, pre-diabetes, she has got that knee pain, as well as anxiety. She is on ustekinumab, amlodipine, vitamin D, and sertraline, and she has an elevated CRP with a BMI of 36.

Maya says, I know my weight is affecting my health, but my GI symptoms worsen every time I try to diet. I worry that my Crohn's disease is blamed on my weight. During a conversation, Maya says that her main goals – and we asked her goals, right? And the shared decision-making conversation and asking permission. Dr. Sepulveda and Dr. Gold talked about how they really ask patients about what their goals are, what they are looking for.

Maya says that her goals are to reduce fatigue, improve her confidence that her Crohn's disease is controlled. She wants to avoid restrictive diets that worsen symptoms and lower her long-term diabetes risk. She is open to weight loss treatment, but she is worried about nausea and diarrhea and that it might worsen her Crohn's disease. “I do not want another plan that just tells me to eat less. I need something that works with my Crohn's disease, not against it.”

On the right-hand side, looking at focus assessment findings here, she is going four times a day. her stools are loose but no blood. Intermittent right lower quadrant cramping. She has fatigue but no fever, and she is increased her weight of about 24 lbs. over two-year period. Her blood pressure is 138/86. Her A1C is 6.1, her albumin is normal, her hemoglobin is borderline low, her vitamin D is low despite supplementation, and her CRP here is 53. No recent fecal calprotectin, vitamin B12, or iron levels.

What is your assessment here? Looking at these assessment findings, does anything stand out to you in terms of Maya with her ileocolonic Crohn's disease, either from a metabolic health position or from her Crohn's disease? Dr. Sepulveda, I will start with you. Looking at her blood pressure, her A1C, any thoughts here?

Dr. Sepulveda:  In general, the main first step is making sure that we screen accordingly for stabilization of her IBD, and then obviously discuss the options in terms of obesity management medications if needed. Patients, at times you might want to do a slower titration of this type of medications just to ensure that there is safety.

Also, I feel like confidence comes in place as well when we do a slow, very patient-driven or patient-centered titration. It is basically a discussion that needs to happen and also reassuring that the weight loss can also help her current symptoms as an ultimate outcome. Creating that conversation and that openness about safety is extremely important in this case.

Amy Stewart: Thank you so much. Sorry. Go ahead Dr. Gold.

Dr. Gold: Absolutely. I would just add, she definitely has active – it looks like there is active IBD here. This is a nice moment maybe even for an intestinal ultrasound which you can do bedside, and you can actually show the patient where the disease is, how much disease there is. Then once you get her onto an effective therapy, really show that improvement. I think it is empowering for patients to be able to actually see that.

I think you can treat the overweight obesity in addition to the active IBD and making sure that we are really getting this patient. I always tell them, this is not about getting thin, this is about getting healthy and keeping you healthy, and anything I can do to do that. I think that really resonates with patients to recognize.

Amy Stewart: Really important. Thank you so much. In follow up, we want to get a fecal calp because maybe my clinic does not have intestinal ultrasound. Similarly, you can watch that fecal calp drop over time, but if we do not have a baseline, we do not know where our goal is. We order labs for CRP, CBC, CMP, iron studies, vitamin B12, D, and A1C. We refer Maya to a registered dietitian with IBD experience, and after discussing her results, we tell Maya that her Crohn's disease is likely not fully quiescent and that her cardiometabolic risk also warrants treatment.

Two weeks later, her fecal calprotectin, CRP, are mildly elevated, she does have some iron deficiency without severe anemia, her vitamin B12 is low to normal, her A1C is 6.2, and she has no obstructive symptoms that suggest a high grade stricture. Her priorities are fewer symptoms, more energy, reduced diabetes risk.

I am willing to consider medication if we go slowly and monitor GI symptoms, and I think that really hits home the points that our faculty have talked; about going slow, titrating up, understanding what our objective biomarkers are to monitor IBD, also as we work through starting this therapy.

Revisiting Patient Case 1: Maya R, 42-Yr-Old Woman With Ileocolonic CD

We talk to Maya and agree on a coordinated plan. Repeat objective IBD assessment after treatment optimization, treating the iron deficiency, reassessing fatigue. In a visit with a dietitian, there was a focus on a Mediterranean style diet pattern adapted for symptoms.

Planning physical activity, keeping in mind that she is got knee pain, but she is also got fatigue. So, Based on her energy level and joint symptoms, it is probably not realistic to tell Maya, who has knee pain, to go run a half marathon tomorrow, but keeping in mind what can she do, time wise, body wise, and also what feels good to her. I will tell you a pro tip I use, and a lot of patients with obesity and overweight have been told over and over again exercise. That word alone can be triggering. I actually talk to patients about how can we move your body in a way that feels good to you, and then it becomes a positive connotation rather than negative.

Also, reviewing our anti-obesity medication options, including benefits, tolerability access, and monitoring. We schedule a follow up visit in six to eight weeks. This is not someone we are going to set it and forget it on, but rather bring her back in for continued assessment and discussion as well.

Poll 8

With that moving into a poll, what follow-up plan best reflects individualized evidence-based management?

A. Begin pharmacotherapy with monitoring, IBD assessment, and adjust the plan based on tolerability, biomarkers, and goals

B. Delay pharmacotherapy until all Crohn’s disease symptoms resolve, then reassess weight-management options after confirming endoscopic remission

C. Start a fixed-dose medication plan because cardiometabolic risk reduction should take priority over symptom attribution in this setting

D. Focus on calorie restriction and exercise alone for 6 months because pharmacotherapy may confound interpretation of Crohn’s disease symptoms

All right. And about 72% of patients chose option A, which is beginning pharmacotherapy with monitoring IBD assessment, adjusting the plan based on tolerability, biomarkers, and goals. We have talked about this pretty extensively throughout.

Posttest 2

Moving on to posttest question number two. Which statement best describes the expected efficacy of incretin-based pharmacotherapy in a patient with IBD and obesity?

A. “Patients with IBD generally lose less weight with GLP-1–based therapy, so pharmacotherapy should be reserved for those without active gastrointestinal symptoms”

B. “GLP-1–based therapy can support clinically meaningful weight loss in patients with IBD, but response is individualized and should be monitored alongside IBD activity”

C.“ Because GLP-1–based medications may have anti-inflammatory effects, weight loss and symptom improvement can be used as indirect markers of Crohn’s control”

D. “Antiobesity pharmacotherapy should be considered only after lifestyle therapy fails because efficacy data in patients with IBD remain insufficient”

In the pre-test questions, about 70% of people chose option B. In the post test, about 78% of patients chose that option. Looking at here, the correct answer is GLP-1 based therapy can support clinically meaningful weight loss in patients with IBD. Our response is individualized and should be monitored along IBD activity. The rationale is listed here that available data suggests that GLP-1 based therapies can produce clinically meaningful weight loss in patients, although long-term prospective IBD specific data remain limited. The key counselling point is not that IBD precludes efficacy, but that treatment response, tolerability, nutritional status, and objective IBD activity should all be monitored together.

Recent studies report weight/BMI reductions in IBD patients with generally manageable safety profiles, but emphasize the need for longer-term data. I think this is in line with what we have been going through here.

Dr. Sepulveda:  Yeah.

Dr. Gold: Absolutely.

Amy Stewart:

Poll 9

Another poll question. Maya says, "I am most worried about nausea and diarrhea. I do not want a medication side effect to be mistaken for a Crohn's disease flare or the other way around."

Which plan best addresses adverse effects and safety monitoring when initiating incretin-based pharmacotherapy for Maya?

A. Start at a low dose and titrate gradually, and advise that nausea, early satiety, and stool changes are expected medication effects unless bleeding or fever develops

B. Select an incretin-based agent with the greatest expected weight loss, delay dose escalation only for severe symptoms, and monitor weight, A1C, and patient-reported tolerability

C. Defer incretin-based pharmacotherapy until CD biomarkers normalize, then initiate treatment using standard titration and routine obesity medicine follow-up

D. Start at a low dose, titrate gradually, document baseline GI symptoms, monitor hydration and nutrition, and reassess IBD activity

All right. Looking down here, about 64% of patients chose option D. I will tell you this one was a little bit tricky because there is a few parts of the other answers that sound right. Like part A starting at a low dose and titrate gradually, sounds good, but we do not want to say that you are going to feel terrible and you have to keep feeling terrible unless bleeding or fever develop, right? Any thoughts there, Dr. Gold or Dr. Sepulveda?

Dr. Gold: No. Absolutely. The only point I would make here is that exactly what we have been talking about, Dr. Sepulveda mentioned, we really run these doses pretty low for our IBD patients and have had excellent clinically significant weight loss. I think the way I describe this to patients, it is a booster to the excellent lifestyle modifications they are making, and so it makes it easier and more effective to make those changes. You are really able to use low doses of medication, limited side effects, and our patients do really well.

Dr. Sepulveda:  I think it is important not to be afraid to leave a patient at a low dose for a little bit of time. I always try to reinforce that even though we are doing a minimal dose, it is still causing a very beneficial effect cardio-metabolically. I think that is important to understand because they at times see the escalation protocols and they see like, now this is what I need to do, right? A lot of times, just setting up the tone and how we are going to try to do it patient centered, it is important to address in every visit.

Poll 10

Amy Stewart: Thank you so much for that. Moving on to another poll. How confident are you in prescribing an anti-obesity agent for your patients living with IBD?

A. Not confident

B. Somewhat confident

C. Confident

D. Very confident

E. Extremely confident.

All right. Thank you so much for those responses. Now let us take a minute to write one change that you can make in your practice with regard to using anti-obesity agents for patients with IBD. Go ahead and type in your answers now.

Thank you so much for sharing those changes we are going to be making in our practices.