Current Controversies in Weigh Loss

Erin Winchester (Beyond the Label Nutrition LLC): First, we are going to look at current controversies in weight loss.

[00:06:59]

Components of an Effective Obesity Management Program

Components of an effective obesity management program. I think this is a great slide to start with because it really illustrates pretty simply the 4 major pillars of any effective weight loss program.

We see surgery and medications up here at the top and the medications especially are something that has gotten a lot of attention lately, especially with the advent of the semaglutide and tirzepatide and more effective medications on the market. Because these medications are so effective, it makes these 3 base pillars at the bottom even more important.

For example, for a patient that is taking one of these third generation's obesity medications and is losing weight pretty significantly, their appetite is very much reduced, and so it makes things like the quality of their diet extremely important. This presentation is going to focus on these base pillars and how to support patients when they are using pharmacotherapy for weight loss.

[00:08:00]

Weight Loss Options

In terms of weight loss options, we have 3 lanes here and it is important to recognize that these are not mutually exclusive. Most of the time we see these in combination with most patients. From a diet perspective, it can be based on macronutrients. Low carbohydrate, of course, we hear all about that all the time or low fat. Pretty much anything that reduces calories in the diet will result in some weight loss in most cases. It can be pattern focused such as the Mediterranean diet or plant-based, provided there is still a calorie deficit. Again, this should promote weight loss.

We can look at things like portion control or commercial diet programs. Time restricted eating is another popular one or more commonly known as intermittent fasting. Meal replacement would be something a little bit more structured. That is things like protein bars and shakes in a more prescriptive food plan.

Pharmacotherapy includes, as I mentioned, some of the newer medications which are the GLP-1 receptor agonists or the GIP, GLP-1 co-agonists, semaglutide and tirzepatide. We seem to hear about those all the time these days. There are also combination medications such as naltrexone/bupropion, and phentermine/topiramate that are commonly used as well as some of the older medications are still in play such as orlistat and phentermine.

In terms of surgery, gastric bypass and sleeve gastrectomy, adjustable gastric band and biliopancreatic diversion with duodenal switch is a little less common, usually just used in patients with severe comorbidities and a very high BMI. There is also some devices that are being used for the treatment of obesity now, including things like the intragastric balloon, endoscopic sleeve gastroplasty, and AspireAssist, which is a little vacuum that sucks out some of your last meal.

[00:09:55]

Efficacy of Existing Obesity Interventions

The efficacy of these interventions is illustrated here, and so we can see that with lifestyle changes alone. This is mainly diet and exercise. Statistically speaking, we can expect about 3% to 5% weight loss from these interventions alone.

Getting into the second-generation medications, those combination ones I mentioned, the phentermine/topiramate and naltrexone/bupropion, we tend to see approximately 8% moving up to 11% with semaglutide at 1 mg. Semaglutide 1 mg per week is typically what is prescribed as a maximum dose for treating type 2 diabetes and controlling blood sugars.

Now we are starting to get into the third-generation medications where we are seeing weight loss up to 20% or more. That would be the semaglutide 2.4 mg and the tirzepatide. Then of course at the very top is bariatric surgery, which still at this point holds the highest percentage of weight loss statistically at 25% to 32%. What is interesting here too is when we look at the tirzepatide, it is important to notice that 57% of the patients in this study, the SURMOUNT-1 study, which we will talk a little bit more about later on the higher doses, the 10 mg, 15 mg per week had over 20% reduction. That is 57% over 20% reduction of their body weight, which is pretty significant.

[00:11:18]

Why Is Weight Loss Beneficial?

Why is weight loss beneficial? I think at this point we can probably all agree that for patients with overweight and obesity that weight loss is beneficial. We know there is a lot of positive health outcomes with that, but how much is typically enough?

It depends on a lot of things. Patient goals, what they are expecting, comorbidities. There is a lot of other factors, but generally speaking, an initial goal of about 10% weight loss is usually a pretty good goal. The reason for that is 10% weight loss is associated with approximately 30% visceral adipose tissue loss. Visceral adipose tissue is the fat that we carry around our organs, around our abdomen, and it is the type of fat that is typically related to more comorbidities, such as increased risk of negative lipid profile, decreased insulin sensitivity, type 2 diabetes, increased inflammatory markers.

That is really what we want to target from a health perspective when a patient is losing weight. Certainly, it makes sense for patients to lose more weight as well, but we tend to see diminishing returns compared to that first 10% of weight with regards to the visceral adipose tissue loss.

With that visceral adipose tissue loss, we tend to see, again, improvement in the lipid profile, improvement in blood sugars, inflammatory markers, and the visceral adipose tissue actually has endocrine function as well. It, in and of itself can secrete hormones that carry on the cycle of obesity. This is really something that we want to make sure that we target and we will talk lots about in this presentation.

[00:13:13]

Effect of Weight Loss From Diet and Exercise

Let us look a little bit more at the effective weight loss from those 3 different methods of treatment. Again, with diet and exercise alone, we can expect about 5% weight loss. Again, some patients will experience a lot more, some patients will experience less. This is a statistic, so that is important to remember as well.

One of the downsides is that without the help of medication or bariatric surgery, these results will not continue unless those behaviors are continued. Typically, that requires ongoing treatment and permanent lifestyle change.

With extreme dieting, so an extreme cut in calories, we can see some negative side effects. More temporarily things like what we would refer to as the keto flu. When you are losing water really rapidly, sometimes you can feel lightheaded and headachey, nauseous, vomiting, that kind of thing. More serious consequences of rapid weight loss though can include liver issues, hyperlipidemia, gallstones, it can lead to a slower metabolism, which we will talk about a little bit. Cardiac conditions, binge eating if the calorie restriction is really too much, and we are going to talk a lot more about reduced metabolic rate as well.

[00:14:37]

Effect of Weight Loss From Antiobesity Medications

Effects from weight loss from antiobesity medications. As I mentioned, some of these newer medications can achieve weight loss even in excess of 20%. That being said, it does not necessarily stipulate a difference between fat loss and lean loss. This is just overall weight loss. That is where that lifestyle intervention comes in and we are going to talk a lot about that today.

The other part of the antiobesity medications is that they are meant for long-term use. Weight regain is common upon discontinuation. That is something that is important for your patient to understand.

[00:15:17]

Effect of Weight Loss From Bariatric Surgery

Effects of weight loss from bariatric surgery, again, we generally see the highest percentage of weight loss. Of course, it is a surgery, so it is fairly invasive and requires pretty significant lifestyle change. It may be a really good option for patients with very high BMI or with serious comorbidities. With bariatric surgery, we can see even partial remissions in diabetes, hypertension, and chronic diseases that are associated with obesity. However, at being progressive diseases, sometimes that remission may diminish over time as well.

Of course, with bariatric surgery, long-term follow-up is always really, really important to ensure safety and making sure that patients are not experiencing any nutrient deficiencies.

[00:16:07]

Outcomes Associated With Decreased Muscle Mass

Outcomes associated with decreased muscle mass. As I mentioned, any weight loss intervention does not necessarily distinguish between lean mass and fat mass. What we want to do is really push the body into preserving muscle mass as you lose that visceral adipose tissue or that fat mass.

Probably the most important reason for that is the decreased metabolic rate that you see here. When you think about the different tissues in your body, body fat is really designed more for storage. It is for storing excess calories in case of a period of time where we do not have access to calories or we are in a starvation mode. Fat tissue does not do a lot metabolically. It just hangs out.

You can think of it as one of those storage units where you put your old furniture and it just hangs out and people go in and out occasionally, but really most of the time it is pretty stagnant, vs muscle tissue is a lot more metabolically active. It is like the local gym. There is always lots of stuff going on. Muscle tissue burns more energy just being muscle tissue, which means that resting metabolic rate is going to be higher the more muscle mass you have. That is why it is so, so important that we are targeting fat tissue when more patients that are losing weight and preserving that lean mass.

Other reasons of course include prolonged wound healing, greater length of hospital stay, higher risk of falls and fractures, increased disease progression, postoperative complications, and overall a poor quality of life. Really, really important and we are going to talk all about this.

[00:17:50]

Outcomes Associated With Decreased Muscle Mass

That is just saying the same thing as the last slide.

[00:17:54]

Common Methods for Assessing Body Composition

Common methods for assessing body composition. We know it is really important to make sure that we are maintaining lean mass, but how do we assess that? Body composition is a good thing to assess both at the beginning, so getting a baseline and then periodically throughout the weight loss period. There are different methods for assessing body composition. Some of the probably most accurate measurement tools would be a DEXA scan or hydrostatic weighing or the BOD POD.

However, we do not see these a lot in a clinical setting. One, because they are pretty large, they take a lot of space and they are very, very expensive too. What we tend to see most often in a clinical setting is what is called a BIA or a bioelectrical impedance analyzer. This really just looks like a fancy scale. There are all sorts of different levels. Some that are designed more for medical environments. We see these in gyms and fitness centers a lot. Basically what they do is just shoot a bunch of electricity through you and measure how that resistance in different tissues. It can give you a really pretty accurate reading of how much fat a patient is carrying vs muscle tissue, exactly where they are carrying it, and it can help us monitor that over time as well.

There is also methods like if anyone has ever heard of skinfold calipers or these medieval looking tools that pinch the fat and take measurements. I believe they are still used. I have not seen them used in 15 years or more. They are very cost effective. That is the benefit of them, but they can be pretty inaccurate, especially if there is different providers using them and comparing data. We do not see those in practice a ton anymore.

Then of course there is body scans like MRIs or CTs and again these are going to be very expensive, so not used a lot outside of the realm of research typically.

[00:19:47]

Assessing Body Composition and Long-term Monitoring After Weight Loss

When do we want to assess body composition? Typically, we do a baseline of course. I would typically recommend doing a repeat body composition test every 1 to 3 months during active weight loss for patients depending on their rate of weight loss, and probably long-term at least for 3 years at a stable weight for at least every 3 to 6 months. Just to monitor, make sure things are staying stable and make adjustments along the way too.

If we notice that a patient is not losing too much lean mass vs fat mass, which we typically see in excess of a ratio of 2:1 fat mass to lean mass, we would probably want to alter diet to increase protein or talk about exercise interventions as well, which I will talk a little bit about more later.

[00:20:36]

Patient Connections and Maintaining Weight Loss

Patient connections for maintaining weight loss.

[00:20:40]

Patient Case 1

For this section, we are going to start with a case study. Our case, we have a 43-year-old female accountant who has unsuccessfully tried to diet and exercise and wants to lose weight for her health. She has a BMI of 37.4. Elevated blood pressure at 145 over 90. She has a past medical history of type 2 diabetes, hypertension, lipidemia, sleep apnea, and depression.

[00:21:10]

Patient Case 1, cont.

Her labs are consistent with these diagnoses. We see an A1C of 8.2% showing suboptimally controlled blood sugars. Cholesterols indicate dyslipidemia. Liver function and thyroid function are within the normal limits. Here are the medications she is taking: metformin, lisinopril, atorvastatin, and peroxetine.

[00:21:34]

Poll 2

Here is another question for you guys. Poll number 2, what intervention would be your highest priority discussion and recommendation at this visit? Would you:

1. Discontinue the patient's peroxetine and start fluoxetine;
2. Implement weight loss pharmacotherapy;
3. Schedule a patient for more labs with hormone levels; or
4. Refer the patient to a registered dietician;

You do not just have to say D because I am a registered dietician. I understand.

Speaker: Poll is open. Five more seconds. All right, thank you. We will close the poll and share the results.

Erin Winchester: Okay, perfect. Good. Well, thank you to all those that selected D. I appreciate that. We will take a look at this question a little bit later.

[00:22:42]

Patient Case 1 Assessment

Let us start our assessment. 43-year-old, she has class II obesity, BMI of 37.4 with multiple comorbidities, including type 2 diabetes, hypertension, dyslipidemia, and sleep apnea. Definitely appropriate to treat. She has been trying to lose weight, so she has been working on those lifestyle interventions and just not having success. Pharmacotherapy is probably a good idea, provided the patient is okay with that.

We also want to talk to her about the barriers that she has encountered with her weight loss strategies in the past so we can address those and make sure that she is getting ahead of those.

[00:23:22]

Patient Case 1 Discussion

Again, strong candidate for pharmacotherapy. Semaglutide or tirzepatide aligns pretty well with her needs. These are the GLP-1 and GIP/GLP-1 receptor agonist medications. One, because they are going to offer a weight loss at a significant amount, which is what she is looking for, and as well with her A1C of 8.2%, it is going to offer some glucose control benefits as well.

Along with the patient, we decide that a combination of pharmacotherapy, diet, and structured physical activity is probably the best approach. This is mutually agreed upon. We want to talk to the patient and refer them for any interprofessional guidance that they may need to, such as mental health, physical activity guidance, etc.

[00:24:13]

Obesity Treatment Pyramid

This is actually a great slide or a great image to share with your patients as well, the obesity treatment pyramid. It is a great tool for helping your patients manage expectations, let us say. With each of these modalities of weight loss, there is a range of percentage weight loss that we can typically expect. Again, this is statistics. It is not geared for every single patient individually, but this can help them manage those expectations.

With the lifestyle modifications alone, so we are talking cutting out fast food, maybe taking an extra walk during the week. Fairly minimal changes we can expect between 2% and 5%. More prescriptive nutritional interventions such as seeing a registered dietician and getting on, say, a meal replacement program or seeing a personal trainer for a regimented exercise program can increase weight loss percentage up to 5% to 10%.

Pharmacotherapy, again, we can see up to 20% weight loss with those medications and even more now and then bariatric surgery up towards that 35%, 40%.

When assessing with your patient and deciding what the most appropriate approach would be, we do want to consider the increased health risks with increased adiposity as well. For patients with a BMI over 40 for example, it may not be appropriate to suggest, okay, let us start with just lifestyle modifications alone. Of course, it is an individualized conversation to have with your patient, but this can also help them realize where they may end up in terms of weight loss with the different modalities.

If you have a patient come in and say, "okay, well, I just want to stop eating fast food but I want to lose 20% of my body weight." Then this is a tool that you can use to explain why that may not be the best approach.

[00:26:03]

Tirzepatide Has Substantial Effects on Weight in Patients With or Without T2D

Talking about tirzepatide here. SURMOUNT, this was a multi-stage study, double-blind placebo controlled to study the effectiveness of this medication. On the left side here, SURMOUNT-2, we see the study done with patients that have type 2 diabetes vs SURMOUNT-1, which was done with patients that do not have type 2 diabetes.

You can see both cases very effective as we would expect a little bit more effective for patients that do not have type 2 diabetes. At that 15 mg per week, we see that over 20% weight loss with the tirzepatide. Obviously, very effective medication. This may be a good option for our patient number one here.

[00:26:46]

Weight Recurrence Following GLP-1 RA Cessation

Another important discussion to have with your patient is that these medications are designed for chronic use. With semaglutide in the STEP-1 extension and SURMOUNT-4 for tirzepatide, we can see that when the medication is stopped, patients tend to regain approximately two thirds of the weight that they lost in that first year. It is not a short-term course of treatment. It is meant to be used long-term.

[00:27:17]

SELECT Trial: Cardiovascular Outcomes, August 2023

Another potential benefit for our patient is the cardiovascular protection that semaglutide and tirzepatide offer. With the SELECT trial, it was shown that even independent of weight loss, semaglutide at 2.4 mg, reduced major adverse cardiovascular effects by events by 22%, which is really very significant. With our patient for dyslipidemia, again, this is probably a really good option.

[00:27:48]

Strategies for Assessment: Weight History

Let us look a little bit at her lifestyle and some of the barriers she has encountered, so we can get ahead of those as well.

A weight history is a really good way to take a look at what has happened historically and see if we can identify some of those barriers. For example, in this case, and this does not necessarily apply to our patient number one here, but after a gastric bypass surgery, obviously there was some weight loss. Her why was because of the marriage coming up. Then with children and family responsibilities, we see the weight coming up and then we want to know what is going on with work in there and everything. We can pinpoint where she is running into trouble so that we can address those barriers.

[00:28:29]

Strategies for Assessment: Environmental Factors

Of course, we want to assess the environmental factors. Are they eating meals alone? Are they cooking for their family? What access do they have to gyms? Is there any limitations in terms of physical activity? What are the work hours? Shift work can always be a real challenge for getting on a healthy eating plan. Do they travel a lot? Is there a lot of stress in their work? Do they have access to nutritious foods? What social lifestyle do they have? Are they eating at restaurants often? Are they eating at home, a lot of takeout? These are all things that we want to find out so we can establish the best plan with our patient.

[00:29:05]

Strategies for Assessment: Food Preference

Of course, finding out what they are eating is really important. We want to make sure that any plan that we are putting together is going to incorporate well into what the patient is doing and already. We do not want to give them something that is way off in left field and includes things that they are allergic to or hate or any of that thing. We want to integrate our new plan with their current lifestyle.

Probably the best way to do this is if you are able to is send the patient home with a food diary so that they can take note of what they have been eating for a few days or a week. You can look at that in real time. If that is not possible, a diet history is also very good. We can ask a patient on a given day, what do you typically have for breakfast? What do you have for lunch? What snacks do you have? What do you have to drink, etc.?

I often like to do the food history and then go back and say, "Let us do a quick 24-hour record. What did you eat 2 days ago?" That gives you a pinpoint image as well. Sometimes that is a little different than the ideal, but there are lots of ways that we can assess this and see where the patient's starting from in terms of their eating habits.

[00:30:09]

Strategies for Assessment: Readiness to Change

We want to assess whether or not the patient is ready to change and how ready are they? One tool we can use is a scale of one to 10 and ask them how important is it to you to lose weight? How confident are you that you can succeed? How interested are you in making this change right now?

Knowing your why is such an important part of motivation for a patient in a weight loss journey. That can be absolutely anything as long as it is important to them, and I have heard everything from very serious reasons like, "My father died of a heart attack when he was 58 and I want to avoid the same fate and get healthy," to "I just want to look better in my bridesmaid dress than my sister at the wedding next month." It is all valid. If it is important your patient, it is all valid, but it is very, very important for them to identify it because losing weight is not easy and so they need to make sure that they have that reason clear.

[00:31:07]

Strategies for Assessment: Patient Perspectives

We also want to assess patient perspective. From a cognitive perspective, how confident are they? Do they tend to be all or nothing thinking? Are they a little bit more flexible? In terms of psychology, do they have issues with body image? Do they have childhood food experiences that are influencing their food behaviors now? Would that merit a referral to a psychologist or mental health specialist?

From a behavioral point of view, are they open to self-monitoring? What are their sleep habits like? Social side of things, again, do they eat at restaurants? What support do they have at home? These are all things that we want to find out so we can best put together a plan for our patient.

[00:31:52]

Think of Treating Obesity Like Other Chronic Diseases (Hypertension)

Think of treating obesity like any other chronic disease. The reason for this is because obesity is a chronic disease. A lot of patients will go into weight loss thinking they are going to take medication short term or they are going to see a dietician short term or they are just going to get to that point and then okay, good, I do not have to worry about it anymore. The nature of weight management is that it is a chronic issue. It is something you have to pay attention to forever and ever.

Just like if you had hypertension, for example, and you started taking a medication that worked really well to bring your blood pressure down, you would not stop that medication just because you achieved a good blood pressure. You would keep that going. Same thing with obesity. Same thing with diabetes. We continue those medications for continued results.

[00:32:45]

HCP Role in Relapse Prevention

What is our role in relapse prevention? It is very important to recognize that lapse is a completely normal part of any weight loss cycle. Even when somebody is rocking and rolling and doing all the right things, there is going to be times in life when there is a death in the family or a new job or a move. Something that is going to throw you out of your routine. Lapse is extremely important to consider and it is very common. What we want to do as providers is get some plans in place to make sure that a lapse does not become a relapse.

[00:33:23]

Dealing With Lapse and Relapse

How do we do that? Planning ahead, very, very important. Making sure our patient has strategies to recognize a lapse and has the tools to get back on track. Make sure that we are setting goals appropriately based on what is going on around them. Revisiting that sense of motivation, and then also I think making sure that a patient has access to you. Making sure that your patient is either scheduled for regular visits on a program or has access to contact you and make sure that they can come and see you and get back on track if they run into trouble along the way.

[00:34:01]

Interprofessional Team Processes

Interprofessional team processes.

[00:34:03]

Poll 3

We are going to start this with another poll. Poll number 3, what barrier most affects your patient care process to promote lifestyle education in obesity? Is it:

1. Time constraints of the patient visit;
2. Lack of training, education, and resources; or
3. Patient commitment;

Speaker: Poll is open. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: That is what I would expect. A spread like that. I think for a lot of professionals, a lot of clinics and primary care, it is all of the above as well.

[00:35:12]

Barriers to Effective Diet and Exercise Counselling

Barriers to effective diet and exercise counseling. Again, just as you said, time constraints for sure. We are all always under a lot of pressure in a clinical setting. Lack of training and resources, patient engagement, socioeconomic barriers such as insurance coverage and affordability, communication barriers can exist. There is lots of reasons why this is not such a cut and dry issue.

[00:35:37]

Interdisciplinary Care Team for Comprehensive Treatment

Interdisciplinary care team for comprehensive treatment. It takes a village. I like to always point out here that the patient is in the center and I always say the patient is the most important person in their weight loss journey. We want to make sure that we are always reflecting back to the patient no matter who is treating this patient at what time. We can have other interdisciplinary care team members such as the primary care physician, registered dietician, of course, registered nurses and advanced care practitioners. Psychologists can be really important. Medical assistants, physical therapists, and trainer for exercise programs, community support groups can be an excellent resource, and in a lot of cases, specialists are great for patients that have type 2 diabetes in conjunction with their obesity, they may want to see an endocrinologist, obesity medicine specialist, orthopedic surgeon for someone who is experiencing mobility issues.

[00:36:40]

Collaborative Solutions to Overcome Barriers

One resource that is really fantastic if you either have it in your clinic, if you have it a designation personally, or if you have access to professionals that have certification in obesity medicine or weight management, that can be a really great resource. These are typically professionals that have been specifically trained and have gained a board certification in obesity treatment.

For physicians and advanced care practitioners, the American Board of Obesity Medicine provides board certification. For other disciplines such as pharmacists, nurses, registered dieticians, the commission on dietetic registration offers an interdisciplinary specialization in obesity and weight management or CSOWM. These can be really good individuals to seek out for more in depth treatment options.

[00:37:37]

Overcoming Common Barriers to Obesity Care

Overcoming barriers to obesity care. These are some questions we may want to ask our patient. Do they have access to services? Can they identify local or online obesity management resources? Are they using their pharmacotherapy appropriately? This is definitely something we always want to ask at every appointment. Are they having any challenges with the pharmacological treatment? How do we educate and train our staff? These are great questions to ask both your patients and the people that are working with them. Stigma is something we are going to talk about a little bit more as well.

[00:38:20]

Promoting Sustaining Weight Loss

Promoting sustaining weight loss. We have talked a lot about losing weight, so let us talk a little bit about maintaining that weight loss now.

[00:38:27]

Patient Case 2

This we are going to start with a second case study. In this case, we have a 48-year-old female who works as an office. Her starting weight was 280 pounds 3 months ago when she initiated tirzepatide. She is already taking medication. She is very happy with her success, but she has been dealing with some moderate nausea since increasing her dose. Her current BMI is 41.2. Blood pressure is a little bit elevated but not too bad at 130 over 80. Past medical history includes type 2 diabetes, hypertension, PCOS, reflux, and depression.

Her medications, she is taking tirzepatide. At 3 months, she would have just started the 10 mg. Tirzepatide and semaglutide, if you are not familiar with it, require titration to get to a full dose, mainly because of some of the common side effects that come along with it. Typically, it takes, depending on the medication, around 5 months give or take to get to the typical dose if you are following the titration schedule on time, on track. There are some factors that may influence that.

She would have just gone from the 7.5 mg subcutaneously weekly up to the 10 mg. She is taking metformin, lisinopril, escitalopram, pantoprazole, and vitamin D3. Labs show decent glucose control. Her A1C is already down from 7.4% to 6.8% in the 3 months she has been taking the tirzepatide. Cholesterols are looking pretty good. Liver function, thyroid and comprehensive metabolic panel, all within normal limits.

[00:40:08]

Poll 4

Here is another poll for you. What intervention would be your highest priority for patient discussion and recommendation at this visit?

1. Continue the tirzepatide at current dose of 10 mg per week
2. Discontinue the tirzepatide and start semaglutide;
3. Reduce the dose of tirzepatide back to 7.5 mg weekly or;
4. Start ondansetron or promethazine as needed for nausea;

Speaker: Poll is open. Please vote. Five more seconds. All right, thank you. We will close the poll and share the results.

Erin Winchester: Pretty good spread there too. Let us discuss and take a look.

[00:41:11]

Patient Case 2 Assessment

We know she has class III obesity. She has already demonstrated a really great weight loss in the first 3 months on tirzepatide therapy. Glycemic control is improved. Clinically, the medication is working. It is doing a great job. But she is experiencing those side effects, which puts her at risk of discontinuing the medication. We definitely want to address that.

[00:41:35]

Patient Case 2 Discussion

She has made excellent progress. We do not necessarily want to pull the medication because she is making great progress and she is probably likely to improve, continue improving given the success she has had so far. Nausea is a very common side effect, especially during that titration period. Other common side effects would be a heartburn or a reflux, nausea, vomiting, often diarrhea, constipation. Most cases not severe and they tend to dissipate as the titration increases and as they get used to that full therapeutic dose.

She is definitely motivated. She has seen results and she wants to continue with this weight loss and so she is probably not super interested in cutting out that medication unless she has to.

[00:42:19]

Let Your Patient Take the Lead

Always important to let the patient take the lead. We cannot assume we know what she is thinking. We may start an appointment saying, "Tell me a little bit about yourself and what brings you in today? Describe a time when you felt really good about your weight and your health to give us an idea of where to start or what is one change you can easily make today that would help you get started?" Put the ball in their court and get them to start the conversation. It is usually a good place to start.

[00:42:48]

Starting the Discussion

We always want to ask permission to talk about weight if this is someone you have not seen before. Stigma does exist and we will talk a little bit more about that, but we want to make sure that we are being empathetic and being open and nonjudgmental. Of course, we do need to talk about weight and treatment options, and so we do want to specifically address that.

[00:43:15]

Strategies for a Patient-Centered Approach to Obesity Management

Patient-centered approach to obesity management. Care plans need to be personalized. There is no one size fits all solution. We want to make sure that we are incorporating patient goals, motivations, readiness to change, and really meeting them more they are at. Collaborative goal setting. We do not dictate goals. We come up with goals together with our patients and let them take the lead.

We want to make sure that we are providing continuous support. We have a plan in place for follow-up and we want to empower our patients with education that need to make their own decisions and guide their own journey as well.

[00:43:50]

Key Counselling Points for Obesity Management

Key counseling points. It is very important to show empathy. Again, for a lot of patients they have been through the wringer. They have met healthcare professionals that have been biased or treated them unfairly because of their overweight or obesity. We want to make sure that we are showing them empathy and understanding. Not sympathy. We do not feel bad for a patient, but we want to show her that understanding. We want to foster open communication and make sure that they know they are in a safe place.

Using inclusive language. I think this is a really important point to discuss. Inclusive language means not defining a patient by their disease state. Just like you would not say a patient that has cancer is cancerous, we do not say a patient is obese. We say a patient has obesity or has overweight. Again, we do not define them by their disease.

We want to make sure we are listening actively. Of course, if they are telling us their life story and telling us what is going on in their lives and important factors in terms of treatment, we do not want to be playing on our phone or goofing off write notes, that kind of thing. It is very important to show active listening.

Addressing behavioral and psychological factors. If you do not have the training yourself, may require a referral to a mental health provider.

Encourage gradual, manageable changes. We will talk a little bit about goal setting as well, but make sure your patient understands that this is a lifestyle change, not just an instantaneous change.

[00:45:22]

Diet and Behavior Modifications for Adverse Effect Management With GLP-1 RAs

Diet behavior modifications for the adverse effects. Again, the common adverse effects are things like nausea, heartburn, diarrhea, constipation in some cases. One of the actions of the GLP-1, GIP/GLP-1 medications is that they slow gastric emptying so patients can feel very full a lot faster. For patients that perhaps eat a lot faster or were not necessarily aware of their fullness cues to the full extent, you would want to counsel them to eat a little bit more slowly and stay aware of those fullness cues to make sure that they are not overeating. Because in cases where they are overeating, that is where sometimes they can experience some of those side effects.

Have smaller, more frequent meals, again, for the same reason. More frequent because we want to make sure that they are eating enough too. If you need to get a certain amount of protein in per day, say, 100 grams of protein, it is going to be very, very difficult with that increased fullness to eat 100 grams of protein at one meal, it is going to be impossible.

We want to make sure our patients are having smaller frequent meals in order to get the nutrition that they need during the day.

Ensure adequate hydration. Of course, avoid any foods that make the symptoms worse, and that could be anything. That is foods that a patient deems intolerable if they have tried them and it does not work out. Some of the more common ones would be very high fat foods, things that are fried, creamy, like creamy pastas and that kind of thing. Anything deep fried or chicken wings, I do not know what it is about chicken wings. People do not do well with chicken wings on these medications. Anything that is very high sugar or spicy or generally things that people want to avoid on these medications.

Water rich foods are important. Avoid eating close to bedtime or lying down shortly after eating. This is really just a gravity thing in terms of reflux. If the food is not splashing back up on its own, it is going to help with the reflux. Increased fiber intake and physical activity may be helpful for patients experiencing constipation.

[00:47:26]

Optimizing Changes in Body Composition During Weight Loss

That is what it all boils down to. This slide is really about how do we optimize those changes in body composition during weight loss? The 2 major keys are increased protein intake and resistance and endurance exercise. Protein intake during weight loss should be approximately 1.2 grams per kilogram of body weight or more per day with that calorie restriction, of course in order to promote weight loss.

This is regardless of what method of weight loss that they are using or what combination of methods. 1.2 grams per kilogram of body weight roughly works out to about 80 to 120 grams of protein per day for the patient. It is not a hugely excessive amount, but for most people it can be a bit of a challenge. Why is this important?

One, it leads to greater weight loss. It protects that resting metabolic rate, which is really, really important because it is preserving that lean muscle mass. It improves satiety. People feel more full when they are eating protein, which can help offset some of the binge eating or refractory eating.

Then the other side is that moderate resistance exercise. Again, it helps decrease the lean mass, especially the resistance exercises. It will help decrease that visceral fat. Increase the overall calorie expenditure. Exercise becomes very, very important for maintaining weight loss even more so than during weight loss. It can also, independent of weight loss, improve metabolic parameters such as insulin, glucose, and lipids. Again, it is involved in preserving that resting metabolic rate.

[00:49:08]

Ways to Support Physical Activity in an Office Visit

We know exercise is important. How do we support that for our patients? Most clinics will not have direct access to a gym or equipment or a trainer or anything like that. What we can do is help your patients set goals and you may have heard of this before, SMART goals, which stands for Specific, Measurable, Achievable, Realistic, and Time-bound. It really just means that these need to be really honed in goals. A goal that was something like, "Oh, I want to lose weight." It is not a very good. It is not a smart goal because it is not something that you can put parameters around.

A goal that we want to help our patients that is more process oriented and could be something like, "I will take a walk for 30 minutes on Monday, Tuesday, Wednesday, starting this week for the next month." Once a week thing. That is something that at the end of the day, they can measure that. They can check that box or say, "No, I need to work on this some more." That tends to work a lot better for patients than setting more general goals.

[00:50:13]

Use Apps and Internet Resources to Help

Apps and internet resources are fantastic tool to incorporate into a fitness routine. There are fitness trackers like watches that you can set to track all of your runs, walks, miles, elevation, speed, steps, all that kind of thing. It can be very motivating. They give you little challenges and give you little prizes and things like that if you reach your goals. That is fantastic. There is a lot of apps that you can use at home that you can download exercise classes or activities with or without equipment. A lot of free ones are available too.

There is also a lot of platforms for things like challenges where you can actually hook up with family and friends and heavily monthly challenges and that thing, or even with strangers or different groups. There is all sorts of stuff out there that can really help with the incorporating exercise into a lifestyle.

[00:51:08]

Managing Patient Expectations

In summary here, managing patient expectations. Setting realistic goals, 5% to 15% weight loss is probably a really good initial goal for a patient that is starting a weight loss journey. Long-term management, it is so important for your patient to recognize that obesity and overweight is a chronic disease. It is not something that you can come in and fix in one visit. It typically requires multiple visits, lifelong lifestyle changes, and follow up long-term.

It is important to discuss that there may be adverse effects, especially for rapid weight loss and there can be side effects with pharmacotherapy. It is important to touch all of those bases with your patient and get a plan in place for ongoing follow-ups. With everything else going on in life, it is easy to follow off of that. It is so important to make sure that you have a follow-up plan in place with your patient before they leave.

[00:52:05]

Posttest 1

That is it for our slide. We will get into some post-test questions now. In the interest of time, maybe I will read the question and let you read the answers. Post-test question number one, which statement best reflects the physiologic and clinical outcomes of an evidence-based weight loss intervention?

Speaker: Poll is open. Please vote. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: You guys are awesome. Okay, good. 78% got the right answer. Let us see here. We have the explanation.

[00:53:04]

Posttest 1: Rationale

Perfect. B, the answer is visceral fat loss with lean mass preserved. Effective weight loss interventions focus on reducing visceral fat while preserving lean muscle mass, which improves metabolic health and reduces risk for conditions like cardiovascular disease and diabetes.

[00:53:23]

Posttest 2

Post-test number 2, which of the following strategies is most recommended for promoting sustained weight loss and minimizing unfavorable body composition changes in individualized obesity treatment plans?

Speaker: Poll is open. Please vote. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: Okay, good. All right, so still a bit of a spread, but yeah, most people got the right answer.

[00:54:16]

Posttest 2: Rationale

Moderate energy deficit with structured aerobic resistance training. The rationale is that this approach is best supported by clinical evidence for sustained weight loss and preservation of lean muscle mass by combining moderate caloric deficit, aerobic and resistance training to improve fat loss while maintaining the muscle mass. This is also a good long-term strategy as well.

[00:54:46]

Posttest 3

Posttest number 3. I plan to put processes in place in my practice to promote lifestyle education in the management of patients with obesity.

Speaker: Poll is open. Please vote. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: Good, I love that. Okay, awesome. Agree and strongly agree are way up there. Good. Excellent. Well, I hope that you have learned some things in this presentation that you can incorporate into your practice as well.

[00:55:36]

Posttest 4

Finally post-test number 4. After this program, how confident are you in your ability to establish patient connections that promote evidence-based weight loss strategies and support long-term weight maintenance?

Speaker: Poll is open. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: Okay, good. Excellent. Well, like I said, I hope that you have gained some insight here today that will help you in your practice.

[00:56:23]

Poll 5

Number 5, do you plan to make any changes in your clinical practice based on what you learned today?

Speaker: Poll is open. Please vote. Five more seconds for incoming answers. All right, thank you. We will close the poll and share the results.

Erin Winchester: Nice. Excellent. Love it. Thank you, guys.

[00:57:00]

Poll 6

We can go back to this maybe while we are looking at questions, I just wanted to skip ahead here and just bring your attention to this final slide here. If you use these QR codes or you can go to this clinicalcareoptions.com/obesitybasicsprogram, there are some really good resources that you can use both for yourselves and with patients. There is some infographics that you can share with patients to talk about pharmacotherapy as well as lifestyle intervention as well as video by Dr Chris Still, who is my co-producer on this. I encourage you to go there and check out those resources. They are really, really great. I will go back to this QR code here. Do we have time for a little bit some questions?

Speaker: Sure, yes, we can take those questions, but if learners would please take a moment to scan this QR code and text in some of the biggest barriers that you may face when trying to build a safe, effective evidence-based connections to support long-term weight loss. As I said, if participants would scan that QR code, please, and text in that information, that would be very helpful in the development of content for education and that type of thing.

Erin, are you able to see the questions? Did you want to take a look at those? We have got several, so I do not know which ones, if you have time to address all of them or if you would like to just pick and choose the ones that you feel may need be the most important to address. Can you see those in the Q&A panel?

[00:58:39]

Question and Answer Session

Erin Winchester: Let me find out. I am not quite sure where to look here.

Speaker: I can also read those out if you would like me to.

Erin Winchester: That would be wonderful. Thank you.

Speaker: Okay. The first was, I struggle terribly with weight loss myself. How can I have an impact on my patients who are overweight or obese?

Erin Winchester: That is an excellent question. I think there may be a bit of an advantage there in if that is something that you have that experience. Especially when it comes to that empathy side of things, that understanding, I think you may be coming to the situation with some leverage for sure. I think for both yourself and for your patients, it is extremely important to recognize and explain that obesity is a very multifaceted disease.

Because we can see obesity, it is a disease that we can actually see with our eyes. I think it is important to share with them how many different factors are involved. It was a university in London in the UK that did a study and it is called the Obesity System Map, and you can just Google that look it up online and it shows all of the factors involved in the obesity disease state and how they all interact. I think it is just a great tool for both you to look at and for your patient to look at just to illustrate how many factors are going on.

I think if you feel like your patient is making judgments about you and your behaviors, I think that is a good tool to use maybe to discuss obesity and overweight as a disease state as opposed to a stigmatized condition.

Speaker: Okay. The next one, it is a little difficult, but I am going to try it here. What is your recommendation when at the highest dose the patient stops losing weight despite diet and exercise? If the patient opts to stop the drug, is weaning the drugs, again, the question is not super clear. Let us go ahead.

Erin Winchester: I can see it now too, yeah. I found it. I am going to take that as what to do if the patient is on semaglutide, tirzepatide and has reached the maximum dose and has stopped losing weight despite wanting to lose more weight. If they are still using the right diet and lifestyle intervention and stuff like that, it is a physician discussion. I am not a prescriber, but there are adjunct medications, whether they are on label or off label that can be discussed. If a medication really is not working and they are still experiencing significant comorbidities, the next step probably would be a bariatric surgery in which is the next step. Of course, that is a medical decision.

Speaker: Okay. The next one is, what is the ideal or average maximum daily carbohydrate intake we can give as a target to patients for weight loss?

Erin Winchester: Well, that totally depends. There is a lot of different factors there. It depends on what comorbidities are we looking at for a patient with diabetes vs cardiovascular disease or both. That might be different recommendations. It depends if they are open to doing lower carbohydrate or they prefer to, that is really hard to answer. I would say in my personal practice, average maybe representing about 30% of daily intake. 30% to 35% of daily intake based on calories.

Speaker: Okay. The next one, someone would like to know how to obtain a certification for the obesity specialist.

Erin Winchester: Great question. If you are a pharmacist, dietician, a nurse, or in that realm, you can go to the commission on dietetic registration, CDR They offer an interdisciplinary board certification in obesity and weight management and it is great. You have to have some practice hours and there is a test and everything like that. That is one way. If you are a physician or advanced care practitioner, the Obesity Medicine Association is a good place to start. They offer a board certification in obesity medicine, ABOM.

Speaker: Thank you. Okay. What is your threshold for concern regarding lean body mass loss in patients on semaglutide or tirzepatide?

Erin Winchester: Ideally, if we are doing repeat body compositions tests, a general rule of thumb is that we do not want to see more than 1:2 ratio in terms of lean loss to fat loss. So say for example, a patient has lost 30 pounds, we would not want to see more than 10 pounds coming from lean mass.

Speaker: For patients 5-plus years post bariatric surgery, how do you monitor and intervene around weight regain and body composition changes?

Erin Winchester: I think, again, that goes back to continued follow-up. There should always be a plan in place for them to continue seeing their bariatric registered dietician or a bariatric surgeon's office and continuous self-monitoring as well. We do see a lot more now, especially with the more effective medications on the market post-bariatric patients starting on semaglutide or tirzepatide for long-term weight management.

Speaker: I am not sure how much more time you have there. Do you want me to keep going with the questions?

Erin Winchester: I have time if everyone is okay.

Speaker: How soon after initiating weight loss efforts should patients start resistance training to preserve resting metabolic rate?

Erin Winchester: I would say immediately. As soon as they are ready, from just mental health point of view, I think if patient is making a lot of changes at once, it is certainly something you can put on the back burner for a few weeks or a few months until they are ready. If they are ready to go, then yeah, absolutely. You do not necessarily want to do extreme bodybuilding, like real muscle building stuff during the weight loss phase because your body does not really understand what is going on. It is like telling your body to build and lose at the same time it is like metabolic and catabolic at the same time. It does not really work that well, but doing some high repetition, low weight resistance training really can help preserve that muscle mass. As soon as possible, I would say.

Speaker: We just have one of our attendees that just mentions treating uninsured with pharmacology is a challenge. That was a statement that was entered. Then the last one that I see on the Q&A is if GLP-1 RAs do not work for patients, is bariatric surgery the only option?

Erin Winchester: It would be the next logical step in terms of when we look at the statistics in terms of percentage weight loss. That means, they are very effective medications, and so sometimes it can be a titration thing or just in combination with lifestyle. There is a lot of different things that can be tried if just straight up one of the GLP-1s was not working. Again, another form of pharmacotherapy perhaps. Yes, statistically speaking, bariatric surgery would be the next step.

Just to go back to that comment too about the affordability, yeah, I know it is a huge issue. There is a lot of advocacy work going on to try to get some of these medications covered, especially by Medicare, Medicaid, and more insurance companies and stuff. For commercial insurance, it is the employer that really has to check that box and say they are going to cover obesity treatment but it is a work in progress.

Speaker: There is one comment or one question in the chat that says, what are the best laxatives or fiber supplements to prevent constipation?

Erin Winchester: From a weight loss perspective, probably because you do not want to increase calories and carbohydrates a lot by eating foods that are high in fiber. Things like beans and whole grains, not that they are unhealthy foods, you just do not want to introduce those calories unnecessarily when you are trying to load a bunch of protein into your diet. Probably the best way would be like a sugar-free protein supplement such as Metamucil or Benefiber or something to that effect.

Speaker: Then there is one more. I think it is very important. Are there any patient groups where semaglutide is preferred over tirzepatide? I heard that patients with insulin resistance use semaglutide.

Erin Winchester: The data for cardiovascular, I believe it is probably expected that we will see the same from tirzepatide, but I do not believe that study has been completed yet. I do not know if you remember the slide back that was talking about the 22% reduction in major adverse cardiovascular effects. That was done with semaglutide. I cannot remember the name of the study now, the SELECT study.

I expect they probably see the same as tirzepatide but it may be chosen. I know for Medicare they were covering it for patients with cardiovascular disease, not the tirzepatide though. That would be one instance.

In terms of blood sugar control, I believe they are similar. Then of course with weight loss, the percentage results for tirzepatide are slightly higher. Another consideration is that tirzepatide, because of that GLP-1 additive, patients tend to experience less side effects. It is generally better tolerated than the semaglutide. Those are all considerations too.