Dr Jennifer Seger (Seger Wellness and Weight Management): I am super excited to be here today to speak to you about a topic in medicine that is absolutely a passion of mine. As you all know, it is the most prevalent adult chronic disease and leads to so many other diseases, impacts every organ system.

No matter what area you might be working in, this is important for all of us to better understand.

[00:06:16]

Smart Patients Obesity Online Focus Group

I want to start with helping you understand what Smart Patients is. It is an online platform where patients and caregivers, loved ones can gather, and there are all sorts of different disease, entities, groups that you can join as a caregiver or a patient. But it is just a place to dialogue with one another to exchange ideas, experiences and build support.

[00:06:38]

Patient Case #1: Ms. Brenda

We are blessed today to have Brenda as a representative from the Smart Patients group. She is a 75-year-old retired business analyst who lives with her husband. Her past medical history significant for renal cell carcinoma, treated surgically in both 2008 and 2014. She has psoriasis and hyperlipidemia. Her body mass index is 32, but note, she has already lost 35 pounds but would like to lose another 30 pounds.

Lifestyle consists of portion controlled, well-rounded meals with emphasis on protein, and she does cycling about 3 to 4 times per week.

What I want to just say is just understand this is a snapshot. When you are face-to-face with a patient in your clinic, getting a detailed, thorough history of the pattern of weight gain, things that they have tried, but not just an overall summary of diet, but really a dietary recall. Things like sleep, stress, hormone concerns, all those things are so important to get into before even going down that path of discussing treatment.

[00:07:50]

Patient Case #1: Ms. Brenda’s Prior Healthcare Experience

At this point, you have got some summary points that we listed here from the Smart Groups. But I would like to introduce Brenda and have her speak directly from the heart about what some of her experience has been like when talking to providers about weight gain and what she can do about it. Brenda?

Brenda: Hello. It is an honor to be here today. Actually, I have not had any conversations with my doctors. The 1 time I approached one, I was told to read a book, and that was the end of it. Most of the time, what I notice is in my after visit notes, it always says exercise more and watch your weight. And that is all it says. But I never 1 on 1 had a doctor approach me about my weight. At 1 time I was 248 pounds, so not 1 said anything to me.

Dr Seger: Interesting. Thank you for sharing that with us. How did that make you feel?

Brenda: What it made me think is there is not any hope for me. But it is like, is that not important with my other issues. Because I had the issues. I had, like we said, the psoriasis, and then the kidney issues and high cholesterol. You would have thought with that high cholesterol they would have said something. But no, none of them ever said anything.

Dr Seger: Do you remember when talking about your chronic diseases that you were facing, was there ever anybody that helped to tie those things together with your weight, and that being a concern to him or her?

Brenda: No, never.

[00:09:56]

Smart Patients Focus Group

Dr Seger: Okay. Thank you so much for sharing that. To the audience, I want you to understand that these are some of the—not just from Brenda, but the entire group that was included in this analysis and some of the things that we gleaned from it. But again, Brenda was part of that. I think hearing straight from her will be more powerful for you.

The summary is here for you. But Brenda, can you share a little bit more about the experience and the group?

Brenda: Yes. The group did consist of the 12 patients, and we had a lot of complex medical issues that were presented. But there were 3 gaps we noticed. One that was a recurring theme was the lack of long-term management. I myself have lost a lot of weight through the years but gained it back and then insufficient shared decision-making. We know our own bodies, and so we know what has worked for us and what has not. We just have trouble not having the tools.

Then inadequate lifestyle counseling. We get to eat less, exercise more, but we need some real guidance for day to day. So those were that.

Dr Seger: What about some of the other barriers that maybe some of the other members in the group expressed? Were there ever concerns about their providers maybe not feeling like they were even knowledgeable or educated about how to help the patients or their financial or other systemic barriers that you can recall being mentioned?

Brenda: Yes. There definitely is financial. That has a lot to do with insurance coverage. I feel like as a retired person, I have the best I can have with Medicare and with the supplemental and Part D, but even at that, it is not going to pay for weight loss medications for me or to go to a doctor who actually specializes, because I have tried to get that help.

Dr Seger: I am sorry to interrupt. Did anybody in the group mention a referral to an obesity medicine specialist or an endocrinologist or somebody who might be able to also provide a little bit more help than the person they were being cared for?

Brenda: Well, actually, no. Even though 1 doctor even told 1 patient, you are fat. I thought they told me that that would not only shut me down, but I would probably cry. Yes, so financials and issue. I am not diabetic, and I do not recall anyone even in the group saying they were diabetic, but if you are not diabetic, you could not get the GLP-1s, at least for it to be paid by insurance.

[00:13:04]

Approaching Obesity as a Chronic Disease: A Management Model

Dr Seger: Yes, I got you. Thank you so much for sharing that feedback and those points. I think it is very powerful for us as learners, as providers to hear from the patient perspective. Let us pivot a moment. We are going to be talking about approaching obesity as a chronic disease and management model.

[00:13:21]

What is Obesity?

The Obesity Medicine Association, which did have a role in supporting this presentation defines obesity by a very long definition, which actually I have to admit I was part of constructing back in around 2013. But it is a chronic disease, progressive, relapsing, but also very treatable even when we understand that it is multifactorial and neurobehavioral.

You can begin to understand. Maybe this is why it feels so intimidating to many of us as providers. It is very complicated and far more complicated than eat less, exercise more. We have got to start to understand that ourselves as providers. If we cannot, we need to keep doing what you are doing, go to conferences, learn as much as you can, be able to explain the complexities, in a compassionate and empathetic way with our patients.

It is the adipose tissue, the fat tissue dysfunction and the overall abnormal fat mass forces that lead to other chronic diseases and adverse metabolic, biomechanical and psychosocial health consequences. So ways that we currently define obesity, it is heavily focused on body mass index. That is where you take the weight in kilogram divided by the height in meters squared.

As you are going to see in a minute, I think there are obvious flaws with that. The abdominal circumference is another way to estimate central adiposity, which we know does correlate with one's cardiometabolic disease risk, and then body fat percentage. There is a number of ways which we will show in a moment to be able to assess that directly.

[00:15:10]

Historical Definitions of Obesity

Again, historical definitions. I am not going to read through each of these. I think they are very easy to understand. I do want to point out that with body mass index that cutoffs for those vary with certain ethnicities, especially in the Asian population, and we just need to be aware of that. There is actually some very interesting new data about African Americans having a different threshold as well, although that has not been formally published.

[00:15:40]

Redefining Obesity: A Clinical Framework for Diagnosis and Policy

How do we define obesity? As we mentioned, there is limitations in BMI, and it does not really tell us much about the individual's health status. I always like to think of the football team. You have got people that might be diagnosed as overweight or even obesity, but some of them have a percent body fat of 10% or less.

It is important that we do determine adiposity in some way so that we can understand that person's individual risk. I think it is important to do a confirmation through other ways which we are going to look at in just a moment here.

[00:16:21]

Diagnosing Clinical Obesity

We define 3 different body size measurements. One is waist circumference which can be done in the office. It is important to train your medical assistants about the proper technique of how to do this and understand that above body mass index of 35 it becomes less reliable. There is waist-to-hip ratio and then waist-to-height ratio, which is maybe a little bit easier because it is easy to remember 0.5 for both men and women.

Once we have those, in terms of now trying to understand does this patient have excess adiposity, you can use 1 of the body size measurements that is highly suggestive plus body mass index. You can use, 2, measurements from body size with or without BMI. Or you can use 1 of our direct methods for assessing body composition.

DEXA is by far the gold standard, but it is not very accessible to a lot. It is a very pricey piece of machinery. While some radiology centers are starting to offer it, they are not contracting with insurance to cover it. So it is usually about a $300 charge.

Let us say that none of the markers showed obesity, then you can see the little person raising those weights up. We do not suspect that there is obesity. If there are indications of excess adiposity or obesity, then we want to understand is this impacting that patient's overall health in some way. So signs, symptoms, blood pressure, cholesterol, blood glucose starting to trend up, joint aches and pains, all of these things. If they are present, then we clearly have the diagnosis of clinical obesity.

If you have signs or symptoms but no organ dysfunction, they would fall into the pre-clinical obesity category.

[00:18:12]

Multifactorial Contributions to the Disease of Obesity 

Worldwide, my friends, not just in the US, obesity is an epidemic. We are seeing it all over our Earth. There is a lot of different contributing factors. You can think about biologic or physiologic factors in terms of altered levels of hormones. Yes, that can mean even male/female hormones, but also these gastrointestinal peptides are really becoming more in the forefront for their dysfunctional patterns when we are seeing obesity, weight-positive medications, health conditions that can lead to a lower metabolism, hypothyroidism.

Then we think of genetic factors. While we are not there yet to be able to alter our genes, we know that there are hundreds of different genetic mutations that can lead a person to have a higher propensity to develop obesity.

Epigenetics, our environment that can activate certain genes and inactivate certain protective genes. There is behavioral issues, diet, inactivity, emotional contributing factors, poor sleep, even smoking cessation, which is a wonderful thing, but we have to really help support that patient to prevent weight regain during that time.

Then environmental, there are definitely socioeconomic factors that can contribute. There is lack of access to healthy foods. There is costs. There are cultural differences, as you can see here. Then there are sometimes social, cultural attitudes that sometimes do not have as clear of understanding of the health risks around obesity and in some ways can be an accepted state for that culture.

[00:20:04]

The Tug-of-war of Weight Management

The other thing to understand is even that patient sitting across from you who may be carrying an extra, for instance, 50 pounds, that has become the new normal for that patient. Some people refer to it as a set point.

When we institute different modalities to try to bring that weight down, the body is going to push back. We call that metabolic adaptation. So we might try decreasing calories or increasing activity. But then the body might push back by decreasing metabolism or increasing our hunger hormones and decreasing the satiety hormone. It is pretty complicated, and again really takes us understanding the dynamics of this push and pull that is going on.

I will turn it back over to Tracey for a few more polling questions. Tracey, you are going to take the polling questions for us, please?

[00:21:00]

          Poll 3

Tracey Piparo: I am going to need you to read that first 1.

Dr Seger: Certainly. Which best reflects how you typically start discussions about obesity? Is it:

1. I link it to related conditions;
2. I ask the patient for permission to discuss weight; or
3. I provide a BMI or weight update; or
4. I often do not initiate the conversation.

I will give you guys just a minute or so to answer those questions. Okay, we are getting some answers. There we go. Split between the first 2 there. We will go on to question number 2.

[00:22:02]

          Poll 4

Poll question number 4. Tracey, do you want to take that 1?

Tracey Piparo: I got that 1. How can HCPs successfully reframe obesity as a chronic disease? I want you to select all that apply. You can choose more than 1 answer.

1. Explain obesity as a biologically driven treatable condition;
2. Incorporate obesity into routine chronic disease management workflows;
3. Respectful patient-centered language during weight discussions;
4. Focus on long-term treatment plans rather than short-term weight loss; or
5. Only address obesity when it complicates other health issues.

Remember, you can choose more than 1 answer this time. I have a pretty good split on answers there, Dr Seger.

Dr Seger: I like it. Well, if we are asking them to choose all of the above, I like it. Most people did choose the top 4, which I think is a great thing. Glad to see that.

[00:23:13]

Setting the Stage for Success: Individualizing Treatment Plans

Okay, let us press on, my friends. Setting the Stage for Success: Individualizing Treatment Plans. I mean, we do this with lots of other diseases when you think about it, blood pressure, depression, anxiety, diabetes. There is a whole menu of options as a way to think about it in terms of how we can help our patients.

[00:23:40]

Clinical Benefits Increase With Greater Weight Loss

One thing I want to point out, and this is so important that you impress upon the patient that even small amounts of weight loss. We are talking 3%, 5%, as you can see here, can make significant improvements. As we lose more weight, you will see more disease impacts. But for instance here improving hypoglycemia can start as low as 5%.

Now if we are talking about reversing diabetes altogether, then we are looking at higher amounts of weight loss, as high as 10% to 15% triglycerides. You can see improvement with 3% HDL as well.

Obstructive sleep apnea. We do see that based on the studies, it is a little bit higher 7% to 10% but a little goes a long way. So I think that is important because if somebody, for instance, needs to lose 50 to 100 pounds, that can feel so overwhelming.

We start with just some, here, let us just focus on this first 5% with patients. That feels a lot more doable to the patient.

[00:24:46]

Obesity Treatment Pyramid

This is our obesity treatment pyramid. Along the left-hand side, you see this red arrow with the treatment intensity increasing. Then at the bottom, what you see, and it really should be the foundation of all treatment and that is lifestyle modifications. Starting with nutrition, nutrition, nutrition. Then when a patient is feeling a little bit more comfortable is when I like to say, let us really work on getting more steps in our day. Just the low-hanging fruit that you can ask a patient to do.

I think that is an important point, is you want to ask the patient and draw out those solutions from the patient in terms of what works. But moving forward, there are prescriptive nutritional interventions. So getting familiar with at least a couple of those different ones so that, again, you have a menu of what might work. Adding pharmacotherapy which can get you higher amounts of weight loss, up to 20% to 24% even, and then endoscopic procedures. And at the top, we see bariatric surgery.

I will just put a plug in here because there are going to be times when you need to think about bariatric surgery right out of the gate. That might be somebody who needs an organ transplant, or they are absolutely miserable from that hip that is impairing their ability to walk and that the orthopedic society has mandated that they want that patient to be at least below body mass index of 40. Just think about these things. They are not to be used in isolation.

Many of the times it is in all of the above approach, or at least many of the above, to get patients to their goal.

[00:26:27]

Real Talk: Patient & Provider Perspectives

Now, we are going to bring Brenda back in and talk a little bit more about, again, how we can help as providers. Maybe you have some specific points that from your experience, you can share with our audience that you feel like would be a great way to bring up the conversation. Do you have any insight for us here in terms of the deficits that you saw during your journey, what you heard from the other members on the panel, anything you would like to share here?

Brenda: Sure. In order to open the conversation, I think a lot of times if you come forward with a positive message that that will draw the patient in. You really have this chronic situation with your health and we need to see if we cannot get that in control. Would you be open to discussing weight management? Those kind of things work.

I had maintained my weight, although it was high. I think if the doctor had noticed that I had been maintaining but I still had a lot to lose. If they said, “Oh, Brenda, you are doing a great job maintaining your weight. But what do you think about seeing if we can help make it go down further and improve your health? Things that are positive reinforcement would be most helpful.

Dr Seger: That is so important. To the audience, I would really encourage you to celebrate those non-scale victories too. And I'll ask you, Brenda, in a minute, if there were any things along your journey that were just really powerful non-scale-related victories, because that is what it is all about, is helping a patient get back to living his or her best life. We can do that, my friends. We absolutely can help our patients get there. It is important to draw out from the patient what is bothering them the most? What is the burden that this excess adiposity is having on them? And what do they want to focus on first and foremost?

Well, what do they think in this first 2, 3 months would help them feel better. And we can direct it that way and make a game plan around those things.

[00:29:06]

Real Talk: Patient & Provider Perspectives

Okay, so we talked a little bit more. Assessing that full picture is very important. Then again, Brenda, did anyone ever ask you at all about your goals? Like, for instance, when you said, well, I would really like to lose another 30 or 40 pounds. Was there ever pushback?

They said, “Well, you did good. You do not really need to worry about that. Or how did that go?”

Brenda: Actually, we have not even had that discussion with any of my primary care or other specialists. Now I have gone to a doctor outside my insurance, and that doctor does specialize in weight management. What I enjoyed about that person discussing with me about how it can improve different things, including my kidney health because I had a lower EGFR.

I always run things by my nephrologist before I do something out of the box. So I ran it past her and I said, what do you think about GLP-1s?

She said, “Oh, they have even been proven to help with the EGFR.” It improves the kidney health. I have been on a program right now since July, and sure enough, my EGFR has gone way up and it has been the most impressive thing.

Dr Seger: That is just wonderful. Congratulations. That is great. Wonderful. Thank you so much for sharing that.

[00:30:50]

FDA-Approved Obesity Management Medications

Guys, this is a slide that shows us all of the different FDA-approved obesity management medications, which we are moving more towards that. When I first started, everyone described these medicines as anti-obesity. But it felt like it had a little bit of a negative connotation. So we are calling them obesity management medications.

Just a good overview. You can look here at this slide and very easily see where that mechanism of action is taking place. Some of the medications, for instance, liraglutide, semaglutide, tirzepatide. You can see those arrows are going in lots of directions. So it is pretty exciting that we are achieving impacts in the brain at the level of the pancreas and the liver as well.

We are going to talk about pipeline medications in a moment, but off label medications I wanted to point that slide out because I think that is a really important 1 to understand how to appropriately use off-label medications to help our patients with weight loss and think outside of the box as long as it is done, of course, in a safe manner.

[00:31:57]

Comparisons of Obesity Management Medications

This first slide really speaks to the obesity management medications that are all happen to be orally taken once or twice a day, depending on which medication we are talking about. Starting with the top 1, bupropion, naltrexone. That interacts with the dopamine and norepinephrine neurotransmitters in the brain to overall decrease appetite.

I will say patients do report an improvement in cravings as well. I will let you guys read the common adverse effects and contraindications. Phentermine and topiramate work predominantly on the GABA receptor and the norepinephrine releasing agent. Again, overall across the board just takes that appetite down a level.

Even though it is not specifically studied in the trials, I do see people saying they are having fewer cravings with these. Obviously, you would not want to use this in someone who had uncontrolled blood pressure, a recent heart attack or stroke. But I will tell you, I have been in this field for over 17 years, and the cardiologists have come a long way in terms of saying absolutely no way phentermine to, yes, absolutely, because their blood pressure is under great control. They are 6 months out from their event, and that the benefits of weight loss is going to far outweigh any potential side effects.

Again, these patients need to be monitored closely. Orlistat is oral. It is an old medication. I actually have never prescribed it and I do not see many of my colleagues prescribing it because it tends to have some pretty undesirable side effects with diarrhea and fatty stools that can sometimes come on rather quickly. It is in the toolkit and sometimes you might want to consider it, but it is just not very commonly used.

[00:33:47]

Comparisons of Obesity Management Medications (cont’d)

Then we get into the newer generation, if you will. These are the injectable incretins. We have got liraglutide, semaglutide and tirzepatide as the newest 1. Tirzepatide, I will point out under mechanism of action. It hits 2 gut hormones. First of its kind GIP and then GLP-1 like the others. All of the contraindications are exactly the same. So that is easy to understand and remember in your brain. And really all of the side effects which are going to be nausea, vomiting, diarrhea, constipation, which is interesting that it can be on either spectrum and then indigestion, heartburn.

You will see a few others listed there, but I wanted to focus on the most common ones for you guys.

[00:34:34]

Comparisons of Obesity Management Medications (cont’d)

I do want to point out here that semaglutide and tirzepatide also have other FDA-approved indications. That kind of cracks the door for more patients, hopefully to have access to these medications. For semaglutide, it is now got the FDA indication to treat MASH with moderate to advanced liver fibrosis. We are still figuring out what are the criteria or the proof that we need to provide to insurance companies because it is all over the map. Is it a FibroScan, is it a FIB-4, we are still figuring that out, but it never hurts to try. But you will need to get some other parameters when you submit that prior auth.

I will also add here that it is indicated for individuals that have had a prior heart attack, stroke, or peripheral vascular disease.

Tirzepatide now also has the FDA indication for sleep apnea, which a lot of our patients have. I would have a really low threshold to order that sleep study if there are any signs or symptoms of obstructive sleep apnea.

[00:35:41]

Future Nutrient-stimulated Hormone (NuSH) Therapy

Then look at this, my friends. The future is bright. This is a summary of all the things that are being studied. A lot of them are already in phase II, as you can see. But 5 are in phase III. Stay tuned, my friends. You have got to make sure that you have the right feeds coming in to your inbox, because there are some and I cannot go into details that are within the next 6 months, and certainly the next year that we will see emerge.

But some new targets like Amlin is one. Then certainly, some of the triple acting, as you can see under that green box as well, that brings in the glucagon as well. So very exciting time to be in the field of obesity medicine.

[00:36:28]

          Poll 5

All right. Tracey, I am going to kick it over to you.

Tracey Piparo: Here we go guys. Which of the following is the most important when you discuss obesity management medications with the patient? Remember select all that apply. So you may have more than 1 answer.

1. Setting clear expectations about duration and potential need for long-term use;
2. Discussing the role of medication in managing hunger and metabolic drivers;
3. Exploring patient concerns about side effects or cost; and
4. Emphasizing the benefits beyond weight, such as improved blood pressure or sleep apnea.

Take a few minutes for this, and remember there could be more than 1 answer. You guys are doing great with these questions. We are getting such good feedback. Participation is awesome.

[00:37:34]

          Poll 6

Let us go to our next 1. Which treatment outcomes should guide your shared decision-making with patients living with obesity? Again, you are going to select all that apply.

1. A specific target weight or BMI;
2. Improvement in related conditions such as blood pressure, glucose, sleep apnea;
3. Enhanced quality of life and daily functioning;
4. Reduction in cardiovascular and metabolic risk factors; or
5. Patient-identified goals and values.

Remember, there could be more than 1 answer. Be sure to hit the submit button.

Let us talk about those 5 C's Dr Seger.

[00:38:25]

The 5 C’s for Choosing an Obesity Management Medication

Dr Seger: Yes. Thank you so much, Tracey. I want you guys to think about this is a good way when you are assessing, is this a good choice for the patient? Is this indicated? Safety, safety, safety. That is the contraindications and cautions looking at their past medical history, their medication list. Do they have renal insufficiency? Hence, they need to reduce the dose of phentermine for instance.

Comorbidities. Can you kill 2 birds with 1 stone, so to speak. Think about if somebody comes in and they have got depressive or anxiety symptoms. Maybe that bupropion naltrexone is a good choice for him or her.

Cues, you have really got to listen to that patient who is their own best expert in terms of what might be the best. And not just about what they are struggling with around eating, but if they are saying I am a terrible daily medicine taker, I certainly cannot do it twice a day, those kinds of things.

Do not be afraid at all to think about combinations. I use combinations left and right. You just do not want to use 2 GLP-1 medications.

This last 1, although it is number 5, unfortunately, it becomes really up there in one of our most important things to think about. What does the patient have access to through his or her insurance? Then if not, what is the cash pay going to be for that patient?

[00:39:48]

Precision Medicine in Obesity: Personalizing Pharmacotherapy for Better Outcomes

Precision medicine, a hot topic. Really what I want you guys to think about with this is individualizing that patient's care. It is fine to have some basic handouts and things like that, but that cannot be all that you do, because every single person who walks through your door is going to need some tweaks, some customization to their plan. So think about bringing in outside providers to be able to help you deliver that customized care.

Remember that what you start with is very likely to change as the treatment process goes on. That does not mean it was a failure. It means you are learning more about the patient.

[00:40:26]

In it For the Long-Haul: Unpacking Strategies for Long-Term Management

So in it for the long haul. Let us unpack some strategies for long-term treatment.

[00:40:33]

Weight Recurrence Following GLP-1 RA Cessation

These 2 slides really are taken from STEP-1 which studied semaglutide, and SURMOUNT-4 which studied tirzepatide. The take home-message is these medicines are intended to be long-term. I would say at least 85% of my patients when we are deciding on a medication, they are very reluctant, especially around the GLP-1 medications, because of the expense about do I need to be on this long term? And so you just have to be honest.

You cannot sugarcoat it here literally or figuratively and relay that data. I think insurance companies are starting to understand that this is going to be a maintenance medicine. In the beginning we had to prove a certain amount of loss to get it continuation of care. I have seen that really outside of the early months that it is working. I have seen that kind of fallen by the wayside.

[00:41:24]

Clinical Strategies to Prevent Weight Regain and Comorbidity Recurrence

What else? We know that there are some strategies. We have got to preserve lean muscle or skeletal muscle mass as best that we can. So having some modality to be able to track body composition is so important. Ask colleagues, ask imaging centers what they have available. Consider getting an impedance monitor for your clinic. But that is really important because it is a telltale sign that that patient's not getting enough protein, which is easy to do when you are on medications that work so well to decrease your appetite.

Then again, planting that seed of even if we do not focus on physical activity at Day 1, we have got to figure out a way to layer that in moving beyond that.

[00:42:11]

Optimizing Changes in Body Composition During Obesity Management

Then we talked a minute ago about the importance of protein. There is some great publications out there. The obesity medicine has a nice guideline for you in their obesity pillars. But you want to, aside from the protein, also really stress the importance of the resistance training. It goes a long way to help send signals to your body of what the game plan is. Build muscle, burn fat.

Tracey, the next poll.

[00:42:37]

          Poll 7

Tracey Piparo: Let us get back to these questions. What is the most common barrier you face when counseling patients on long-term management of obesity?

1. Limited time during office hours;
2. Lack of patient motivation or follow through;
3. Inadequate referral systems or team support;
4. Difficulty individualizing lifestyle recommendations; or
5. Uncertainty around what to monitor beyond weight.

Take a few seconds to answer this 1.

[00:43:22]

          Poll 8

Which of the following should be included when monitoring long-term treatment responses for obesity? This is another selecting all that applies, so it may be more than 1 answer.

1. Clinical labs such as A1c, lipids and liver enzymes;
2. Functional health and daily activity level;
3. Emotional well-being and patient-reported outcomes;
4. Weight and BMI only;
5. Adherence to medication and behavior plan.

Remember to hit that submit button. Really good answers here. Let us keep going Dr Seger.

[00:44:08]

Real Talk: Patient & Provider Perspectives

Dr Seger: Okay. Another real talk. We are going to bring Brenda in here a little bit. We are talking about barriers about personalizing that treatment plan, treatment check ins and then whole health and support team. Brenda, is there a little piece of advice that you can give to our learners today in terms of the next time they have an encounter with a patient who is interested in losing weight? Do you have anything you would like to share there?

Brenda: Well, I think there would be several things. One, that, of course, a shared vision of what the plan would be, because the patient knows what has worked for them in the past. And going forward, what the best path might be for them. But of course, like I said, they need some tool.

I think it is working together. I think also a lot of patients do not realize that it is a chronic condition, that it is something for the long term. I think that even needs to be emphasized that you may be on this medication a while and then also whenever they are speaking of this, they do not just give some kind of weight by some chart, you need to be this or you need to be that. That helps me a lot.

When I said originally that I needed to lose about another 30 pounds, that is really just another gold spot for me. I really would like to be less as far as the scale, but if I say what I really think, it is just overwhelms me. So just a bite at a time.

Dr Seger: Yes. I try to tell patients, well, let us just focus on the next 10 pounds, right. Because when you are running a marathon, I know that they are not thinking about that 26 mile marker. They are thinking of let me get to the next 5. So good advice there.

[00:46:11]

Interdisciplinary Care Team for Comprehensive Treatment

Guys, it is very important. And you do not have to have this all in 1 house, right, meaning in your practice. But I want you to work on identifying good nutritionists, dietitians in your community, therapists, psychologists, even ones that have expertise in dysfunctional eating or eating disorders and build that, have those ready to go so the checkout person knows exactly where to send people when you check that box.

[00:46:37]

Collaborative Solutions to Overcome Barriers

It is a collaborative approach. It really is. I want you to mention here the American Board of Obesity Medicine, which you can get certified in. If you are a physician, there is also a certification I know for nurse practitioners as well. But even if you do not go through certification, there is wonderful resources there.

There is wonderful CME through all those organizations as well as TOSS and ASMBS, but integrate those tools as much as you can.

[00:47:07]

Key Counseling Points for Obesity Management

Especially when it comes to talking about a sensitive subject about weight, we need to be compassionate, empathetic, and first of all, just build that trust. Because if you act in a way that shows negative bias and stigma, your patients not even likely to come back. So work on your own internal bias. Make sure that you are owning it and then trying to reframe that thinking. Always, of course, speaking in a non-judgmental way there.

[00:47:34]

Key Counseling Points for Obesity Management

Address what might be going on outside of just the nutrition. Maybe this person is dealing with a tremendous amount of family stress or work stress. Oh my goodness, all the government furloughed workers. That was a common thing that I was talking to patients about recently. Just always kind of asking them, what do you think you want to focus on between now and your next visit? What would be the 1 thing that you feel like you can commit to?

Maybe it is starting to take that walk. Maybe it is giving up sodas, whatever it is. But let us set some not too many, but a couple of smart goals there.

[00:48:10]

Thank You for Sharing Your Story, Brenda

I want to thank you, Brenda, again so very much for sharing your story. Tracey, thank you so much for being a wonderful facilitator. I think now we are just going to go through the answers to those questions from the beginning.

[00:48:20]

Takeaway Points: What Have We Learned From Smart Patients and Brenda?

We are going to do takeaway points first. I think I already did these actually. We will let you read these. But remember go beyond BMI, shared decision-making and get past your own bias when dealing with patients. Tracey?

[00:48:38]

          Posttest 1

Tracey Piparo: We are going to do these post-test questions. I think everyone is going to do great. A 52-year-old patient with hypertension on atenolol reports gradual weight gain. Remember his BMI is 34. In addition to your discussion about obesity being a chronic condition, which of the following would you recommend as the next step to address his concerns?

1. Advise the patient to diet and exercise to stop the gradual weight loss;
2. Measure waist circumference and waist-to-height ratio or body composition;
3. Obtain advanced fat assessment; or
4. Just reassure the patient, note atenolol's role and tell the patient not to worry about the weight gain.

Take a few seconds. I think most people are paying attention and improving on this question, which is awesome.

[00:49:49]

          Posttest 1: Rationale

B is the answer. Our next 1. Remember our 45-year-old female patient with a BMI of 34 and also has apnea-hypopnea index of 40 events an hour, continues to have poor sleep and metabolic complications despite her lifestyle changes. Which next step is most appropriate to improve weight and cardiometabolic health?

1. Refer for oral appliance therapy;
2. Initiate a GLP-1 receptor agonist;
3. Start a dual GIP/GLP-1 receptor agonist; or
4. Refer for bariatric surgery.

I think some people are still stuck between the GIP and the GLP-1 there, Dr Seger.

[00:50:51]

          Posttest 2: Rationale

The answer is C, to start that dual therapy.

Dr Seger: That is because of that FDA indication.

[00:51:02]

          Posttest 3

What if you had the same exact patient as before? Remember your 45-year-old woman with a BMI of 34, but instead of a high AHI, the patient had an FIB-4 score of 3. Assuming access to obesity management medications, which treatment would you recommend to improve both weight and liver health?

1. Initiate semaglutide;
2. Prescribe phentermine/topiramate ER;
3. Intensify lifestyle therapy with structured interventions; or
4. Refer directly for bariatric surgery.

[00:51:52]

          Posttest 3: Rationale

I think people did great on this question. Everyone was paying attention. The correct answer is A, you are going to initiate semaglutide.

[00:52:02]

Q&A

We have some great question and answers coming in, Dr Seger, if you are ready.

Dr Seger: I am ready.

Tracey Piparo: Yes. Lots of people want to know is what kind of techniques do you use to help keep a patient from just quitting the journey altogether? Sometimes you may not see results right away. How do you keep them going and motivated?

Dr Seger: Well, I actually do a new patient seminar before the patient even comes in to see me, because I kind of want them to know what they are getting into. I am happy to share that with anybody. Just send me a message. But 1 of my first slides is encouraging that patient to ask themselves why. Why is this important to me? Is it because I want to have a wedding coming up and I want to look good in my dress? Do I have health problems I want to reverse?

I really ask people to dig deeper, and I say, this is a fork in the road, and things can continue status quo. And if that happens, imagine what your health might look like. The doctor sometimes can help you lay that out. But on the positive, which I tend to stick with, what would your life look like? What would you be able to do more of? Have less of like pain medications in 10, 20, 30 years.

Just like we tend to think about our financial future, we have got to think of our health future. Then I always help people understand it does not matter if you are with the world's best obesity medicine specialist, dietitian therapist. You have got it all. 100% of your patients will hit plateaus. That is a time to not panic. It is a time for you guys to come together as a team and not to judge, but to say, “Well, do you have any thoughts in terms of something that might have changed because you were doing good the last 2 months? New stressor, poor sleep, whatever it is.”

It is important that you develop an approach to plateaus or stalls and teach people to not panic, but just to do some self-reflection, but also to make that follow up appointment to say, okay, have not done anything different. I am just wanting to make sure is this sometimes it is the body just catching its breath because it just let go of 35 pounds of fat tissue, which is a big deal, and it needs to kind of rebalance and say, okay, Jenny has not been locked in a dungeon or in a prison camp.

It is possible, but use your therapists and psychologists and health coaches in your area that can help.

Tracey Piparo: That is great. It goes along with 1 of the next questions we got, which sometimes patients are really eager to start their journey and be on a GLP-1 therapy. But maybe they are not making those changes to their eating habits or their physical activity. They are not updating their lifestyle. How do you share the importance of that in conjunction with the medication therapy?

Dr Seger: I think that is such an important question, especially with the number of online platforms, that you can get these medications from. A lot of the responses that patients get in terms of support are automated and bot driven and things like that. When people just are eating less, but they are eating the same types of foods that may not be the best choices as they were in the beginning, that is still going to drive inflammation, my friends.

You need to be guided by somebody who understands the comprehensive approach. Less fast food and soda, but still drinking those same things is not going to bode well. Losing too much muscle, that is going to set you up for weight regain, like there is nobody's business.

Again, monitoring that body composition. I think you got to make a decision. Again, this is not a judgment thing, but you have got to keep coming back to it is not just the medicine. There are no magic pills or shots that melt the fat away. This has to be in conjunction 100% of the time with nutrition and optimizing those other variables. Sleep, stress, hormones, gut bacteria, all that good stuff.

Tracey Piparo: Do you have any recommendations for those patients that, folks talk about maybe their GLP-1 or GIP resistant? Does that exist? Is it just the plateau phenomenon that we are seeing? What do you think about that?

Dr Seger: I am not aware of any data that says that there are true patients that are resistant. I think there are a lot of things that can play into the fact that this medicine had been working well and now it is not. Again, doing that deeper dive with the patient. I think, again, sometimes you layer in another medicine that has a completely different mechanism of action, right?

Do I have patients who absolutely cannot tolerate them because of GI side effects? Yes. But I would say as long as you are smart about how you prescribe it, you lay out those potential side effects and you tell that patient to have a low threshold to reach out if they are having daily nausea, constipation that has led them to go to the ER, god forbid. We do not want patients to get to that point.

I think having a game plan about here is what to look for, here is some easy things to try at home. But if that does not work, you let us know. As long as we are not eager, which some patients are, they want to get to that highest dose as soon as they can and I see disasters with that all the time. You just go slow and again you are working on all the pillars of health along with it.

Tracey Piparo: Yes. Can you just reiterate again? I think we touched on it. What are some labs or measures that can also be used to track success? Everybody wants to see success. So beyond just the weight loss alone, when folks are maybe rebalancing, like you said, the body's making sure that everything is okay, what are some other things that you should look at to reassure the patient that things are continuing to go well?

Dr Seger: Absolutely. Well, remember, about two thirds of Americans are walking around with insulin resistance. Some of them also with diabetes. Many of those with insulin resistance have no idea that they have it. I do not think we have done a good job helping to teach people that the triglyceride to HDL ratio, when it is above 2, that is a telltale tale sign for insulin resistance.

Measuring fasting insulin is important. And it is cheap, so there is no reason to not be doing it. It can be very impactful because we know that not only does insulin drive fat storage, but it drives inflammation, cancer grows damaging to the brain long term. Markers of inflammation like C-reactive protein seeing that come down.

Then a nonlab one that is important is blood pressure. I see a lot of people that are losing weight. We do not always look at it when we are, oh, your blood pressure is 105 over 70. We might need to back off those medicines. Be sure that you are looking at ways to deprescribe. Maybe they need a lower dose on statins. For sure, triglycerides tend to go down. So just really being able to show those lab improvements across the board are super important I think.

Blood sugar and markers of inflammation, liver function tests, that is a huge 1 as well.