Virtual Grand Rounds: Pharmacotherapeutic Approach to Obesity Care Part One

CommonSpirit Health hosted a Grand Rounds session discussing the pharmacotherapeutic approach to obesity care. This is the first in a two-part series on the topic. 

See Part Two here.

Speaker:
Layla A. Abushamat, MD, MPH, DABOM, Endocrinologist and Assistant Professor, Section of Cardiovascular Research, Baylor College of Medicine

Anila Chadha, MD, Obesity Medicine Internist, Dignity Health Medical Group – Bakersfield

Panelist:
Thu Le, PharmD, Clinical Pharmacist, Dignity Health
Mahmuda Tasneem, MD, Internal Medicine, Virginia Mason Franciscan Health

Transcript

SPEAKER_00 0:04

Welcome everybody to Grand Rounds. I'm Dr. Thomas McGinn, the Chief Physician Executive Officer here at Common Spirit Health. I am very excited about this subject. It is such a dynamic subject. We had some previous discussions a few years ago, but boy, oh boy, have things just kept changing and more data, all good news for the most part, on the topic of uh pharmaceutical therapies for obesity and just the general approach to obesity. And we have a host of experts that'll be joining us this week and next week. So I'm gonna hand it over quickly to Dr. Sagar to introduce our experts for today, and there'll be a panel conversations afterwards. Ankara?

SPEAKER_03 0:45

Thanks, Dr. McGinn. Good morning, everybody. So part one of two series, so please bookmark them. And it's my pleasure to introduce our speakers and panelists for today. We have Dr. Leila Abushamat, who is an endocrinologist in the section of cardiovascular research at Taylor College of Medicine.

unknown 1:02

Dr.

SPEAKER_03 1:02

Abushamat's clinical and research focus is in cardiometabolic disease. Specifically metabolic syndrome, obesity, lipidology, and cardiovascular disease prevention. We have Dr. Anila Tada, who is a board-certified family medicine and obesity medicine physician in Bakersfield, California, affiliated with our dignity health medical group. And we have on our panelists this morning, Dr. Mamila, who is an internal medicine physician and a food certified obesity medicine. Driven by recent groundmaking, groundbreaking. And to round out our panel this morning after two late, receiving her professional doctoral degree in pharmacy from the University of the Finishing a Master's of Healthcare Administration degree, board of pharmacy specialty certified and ambulatory care and geriatric pharmacy. Needless to say, these are quite the accolades for our panel and our speakers this morning. And we will be able to hear from them today and also next week. And in the most latest updated guidelines that we will draw for you in the chat as the turn round progressive. With that, Dr. Abu Shabbat, I welcome you to the club.

SPEAKER_02 2:49

Great. Thank you so much for the wonderful introduction. Let me just share my screen. Good morning, everyone. And I have the pleasure today of presenting updates in obesity care, which, as we just talked about, is almost impossible to do in an hour, let alone two hours. But we're going to give you really just a high-level update. And like we were just saying, this is a very exciting time to be in obesity medicine. So with that, today we're going to review the definition of clinical obesity and current weight loss management pharmacotherapy options, highlight recent updates in obesity pharmacotherapy, as well as some future directions. So some definitions and scope. And this is nothing new, but this is how traditionally we defined obesity is by a body mass index, which is your weight in kilograms divided by your height in meters squared. And based on these definitions, a BMI of 25 to 29.9 is considered overweight, and a BMI of over 30 is considered obese. And you can see here that based on values from 2021, over two-thirds of Americans are overweight and or obese. And so this is a large portion of people here in the US as well as globally. However, these definitions were based off of definitions that were made for white populations. And so really it's a population-based definition. And so it should vary by age, sex, race, and ethnicity. And while we use these cutoffs oftentimes in our research studies and in clinical trials, this may not be applicable to patient populations. And then lastly, anti-obesity medications, like I mentioned, is what we uh we define the need based off of this BMI with a BMI of over 27 with weight-related comorbidity or a BMI of over 30. And that's because that's what the clinical trials were done for in the inclusion criteria. Now, as many of you know, there are limitations to using the BMI as a way of measuring uh obesity because it's not a direct measure of fat. It doesn't establish a distribution of fat around the body, and it cannot determine what excess body fat is a health problem. And so, you know, we've all heard people say, well, you know, my BMI is not over 30, but I feel like I have excess body fat, especially compared to where I had before. And I have other comorbidities, and so I feel like this would be helpful for me. Or the athlete who has high muscle mass, and so their BMI comes up in the obesity range, when in reality their body fat composition shows that they have very low body fat percentage. And so there are several limitations, and while it works, it's not a perfect measure. And as we've established previously, obesity is a chronic disease, and we're starting to think of it more as an obesity-based chronic disease. And what I mean by that is that when we talk about obesity, we're talking really about adiposity. It's both a fat mass disease as well as a sick fat disease. And we know that the adipose tissue is actually the largest endocrine organ, and that's because it puts out both immune markers as well as endocrine markers, so hormones. And it's that's the way that it communicates with the rest of the body. But at the same time, if you have excess adiposity, it can also cause just physical strain. You have mechanical forces that are altered with this as well. And if we think about obesity from the perspective of complications rather than BMI, we can help reduce weight stigma and internalized weight bias. And again, focusing on obesity-related complications makes sense because we know that with each amount of weight loss that we lose, we have benefits. And we can see 2.5 just with 2.5% weight loss improvements in blood sugar and triglycerides. At 5%, you see benefits in knee pain and mobility, sexual function depression, all things that patients can affect their quality of life. At 10%, you start seeing things like sleep apnea and cardiovascular outcomes. And at 15% is where you see all cause and cardiovascular mortality affected. And uh thankfully, the American Heart Association, as well as other different associations, have recognized this. We have the emergence of this new term, cardiovascular kidney metabolic syndrome, by the American Heart Association since 2023. And it's really just recognizing that here at stage one, excess and dysfunctional adipose tissue is on the path towards development of clinical cardiovascular disease, as well as metabolic risk for things like high blood pressure, diabetes, chronic kidney disease, and subclinical heart diseases and heart failure. And as we have an aging population, we have these are diseases that oftentimes occur in older people as well. And so prevention at an early point is really key. So management of weight can be considered cardiovascular disease prevention and cardiometabolic care. And based on this, uh there was actually a new definition and diagnostic criteria put out in the Lancet Diabetes and Edochrinology of what how do we define clinical obesity? And so, first step here is to actually define excess body fat one of three ways, either with body size and BMI. And that includes things like waist circumference for measurement of body size or waist-to-hip ratio or waist-to-height ratio, which are all ways that can be measured pretty easily in clinic. And having two measurements of body size, regardless of BMI, is also possible. So let's say you have someone who meets criteria based on waist circumference and waist-to-hip ratio, but not based on BMI. That could be considered excess audiposity. And then lastly, and this hasn't really entered clinical practice just yet, but direct body fat measurement and using something like a DEXA scan that we usually use actually for measurement of body of bone mineral density, we can use it to measure body fat composition and body fat percentage, and using that as a measure to define whether or not someone has obesity. Then, based on medical history, physical exam, and blood tests, you can define whether or not there's organ dysfunction that's obesity related. And if there isn't, then that's considered preclinical obesity and potentially someone to monitor or really to intensify lifestyle intervention. And if there is, then it would be considered clinical obesity. And this is a new really definition and really just focusing on there may be others that would benefit from this definition of being defined as clinical obesity and maybe may benefit from some of our pharmacotherapies. And the biggest buzz here is with incrementin therapy, particularly those with obesity indication on the market. These are the ones that are currently available. We have lyriglutide, which is our oldest and first generation. It's a subcutaneous injection daily, to semaglutide, which now newly is available as an oral or has been available as a subcutaneous injection weekly. Terzepatide, which is a dual GLP1 GIP receptor agonist, which is a subcutaneous injection weekly, and then orforgliperon, which is another new therapy that's an oral daily therapy. And so we have now both oral and subcutaneous options. And with some semaglutide, trisepatide, and orphoglypron, all of these can lead up to 14, 15% weight loss or greater. And you know, so here with the oral GLP1 receptor options, you can see here with semaglutide, which is the oral GLP1 receptor agonist, you uh take this daily. Over the course of 64 weeks in its trial, there was on average a 13.6% weight loss. And then with orphoglypron, um, you can see here that over the course of 72 weeks at the highest dose, you can see relative to placebo, a 12.4% weight loss. Um, and then overall without placebo, the 14 or so percent weight loss. So these are great options for those who are averse to being on injection therapy. And so the options have expanded since um in the last year or so. Now, in addition to having the options expanded, thankfully, we've also started having other indications for recent incretin therapies. So I mentioned the ones on the market. Now, douloglide is not on the market for obesity, but it is on the market for diabetes. So all of these therapies are helpful for uh for diabetes and have an FDA indication except for ortho glipron, that's in the works. And then liriglutide, doulaglutide, and semaglutide are used for both type 2 diabetes and heart disease or those with high cardiovascular risk because it can reduce cardiovascular disease risk. Semaglutide has an FDA now indication for type 2 diabetes with chronic kidney disease. It can reduce risk of adverse renal events. Liroglutide, semaglutide, drzepatite, and orphoglypron are for overweight with comorbidity or obesity, as I mentioned in an earlier slide. Then semaglutide is now both in the oral and subcutaneous form, has an FDA indication for obesity and ASCBD or high cardiovascular disease risk. So this was major in that it reduces risk of heart disease by 20% in those with overweight and obesity in a history of heart disease. Now we also have an indication for semaglutide and trzepatide are benefits for both for obesity with heart failure with preserved ejection fraction. And then for trzepatide, we have an indication for moderate obstructive sleep apnea with obesity. And that was FDA approved for that indication of sleep apnea in December of 2024. And then lastly, semaglutide has an indication for metabolic associated steatotic hepatitis or MASH, which is formerly called NASH or non-alcoholic steatohepatitis. And so this was as of end of last year, it's one of the medications that can be used as therapy for someone with fibrosis specifically, which is again major in that it can reduce fibrosis in the liver in this case. And, you know, with the in the case of MASH, actually, it's the number one cause of cirrhosis now. Um it's kind of overtaken alcoholic uh liver disease. And so I think, you know, there are many indications, but it really is highlighting that we should be focusing on the comorbidities and that this list here is comprehensive, but we still have more to see. We have current studies ongoing in osteoarthritis, in inflammatory lung diseases, in various uh rheumatological diseases. And so I think that this uh list will continue to expand as the years go on. Now uh to just quickly focus on some upcoming therapies before I pass on the baton. Uh so first um that came out of uh, you know, recently in the last few months is a phase three for servodutide, which is a GLP1 glucagon receptor agonist. And with servodutide, this is a therapy that, you know, is actually the with the glucagon receptor, it actually also acts on the liver. You see a 16.6% weight loss, but also you see some reduction in hepatic fat. And so this may be another one of those that gets an indication for fatty liver. And I guess you know, we'll see with more data as that comes out. Then we have also in phase three, and so hopefully coming soon, CAGRECEMA, which is a combination of CAG rillinotide, which is an amylen agonist, plus semaglutide, which is our GLP1 receptor agonist. And with this combination, you can get up to a 23% average weight loss in about 68 weeks. And so again, this is another exciting combination option. And then lastly, we have our uh phase three for retitrutide that was um the released just recently here at the ADA, uh the GLP1 GIP glucagon receptor agonist. So it's a triple receptor agonist, and you can see here the data over the course of uh 80 weeks, you can see a reduction in weight of up to almost 30%, which is bariatric surgery levels. Um, again, this option is something that will hopefully be available soon, but um it it's it's something to make keep note of is how much weight loss is too much weight loss. Maybe you know, now as we have more options available in the market, then you can start deciding where uh who which patients get which therapies depending on need and comorbidities. And then we have some exciting things on the horizon as well. Firstly, is less frequent dosing. Barobinatide is an ultra-long-acting injectable GLP1 receptor agonist. And they are looking at look going from weekly to monthly dosing, and the trial is ongoing. But at ADA, they released data showing that after 28 weeks, placebo-adjusted weight loss of 12% with a monthly dose, and it's a lower monthly dose than what we see with some of the other ones. So this is something that is exciting and may be an option in the near future. But also, um, given this concern about lean mass loss with GLP1 receptor agonists and really with any weight loss, um, there are several studies that are ongoing with uh combination of lean mass preservers. The currently reported full phase two studies that are out there are epitigromab, which excuse me, the the pronunciation is going to be a little difficult, but myostatin activation inhibitor, and that's in combination with trzepatide. And with that, you get the same weight loss uh as you see with trzepatide, but instead of losing lean mass, you have almost a 55% lean mass retention at 24 weeks relative to placebo, and then bimagromab, which is an active in type 2B receptor antibody that helps preserve muscle. And this is given in combination with semaglutide. And rather than losing almost 7% of muscle mass as you see with placebo, here you see a 2.9% lean mass loss only. So it's uh able to preserve a lot of the muscle loss that you see with GLP1s. And with that, I'm gonna stop sharing and pass on to uh Dr. Chada. Hi, good morning, everyone.

SPEAKER_05 18:22

Um, welcome you all to this uh Grand Round series. Uh I'm Dr. Anila Chada and I am obesity medicine physician. Um I am practicing here in uh Bakersfield, California. Today my topic will be uh lifestyle intervention recommendations during GLP1 therapy and debunking misinformation on these medications. Next slide. I have no financial disclosures. So when we start patients on GLP1 medication, it comes with a whole package that both clinicians and patients should commit to. And that includes uh nutritional education and lifestyle uh recommendations that all clinicians should make to give to the patients so that they can follow that while being on these medications. It's just not a simple prescription you go. And to take care of that, four prestigious societies came up with a consensus statement last year. Uh it was through American College of Lifestyle Medication, the American Society for Nutrition, Obesity Medicine Association, and Obesity Societies. So they all came up with these wonderful recommendations, what to tell our patients and how to guide them while they are on GLP1 medications. Next slide. All these recommendations fall into these eight categories. And today we will be discussing most of them. Uh, the category about managing the uh adverse effects, especially the gastrointestinal adverse effects, will be discussed uh next week in our part two of the series by Dr. Tasni Memuda. Today I will be talking about how to initiate GLP1 therapy uh while in a patient-centered approach, promote and support lifestyle measures. And there will be times when patients will have plateaus and what can we do to maximize weight reduction, and then preservation of muscle and bone mass, very important during GLP1 therapy. And we also need to make sure that we are preventing uh nutrient deficiency and keeping into account patients' dietary preferences and intake while managing all this. Next slide. As we know that these medications are now being increasingly prescribed by cardiologists as well, this uh these strategies uh were condensed from that consensus paper by American College of Cardiology. And what it tells us is that the GLP1 therapy should be patient-centered and the weight reduction goal should always be health-related. It should not be anything else like vanity or anything like that. It should always be weight reduction for health purposes. Uh, we, other than doing this other screening that we do for obesity treatment, we also have to do some baseline screening for their nutrition, for their activity level. We have to make sure that they do not have any eating disorders. And if we identify something like that, we make appropriate referrals to behavioral therapist or psychiatrist. Before prescribing, we have to make sure that patients do not have certain GI problems or we take care of that, those before prescribing. So, for example, GERD, if they already have too much GERD, they have a lot of symptoms, and we take care of that while initiating the medication. There are certain things like gastroparesis, all that information needs to be taken into account before starting the medication. If you have an access to body composition, Analysis, then it's a good idea to have a baseline for their muscle mass. If it's applicable, for example, in women above 65 years of age, we have to make sure that they do not already have severe osteoporosis, muscle strength in elderly patients to make sure that we are not going into sarcopenia for them. Then, very important social determinants of health. While we make our recommendations, we have to always take into account what patients have access to. Can they even have access to gym? Or if we are recommending meal replacement, something like that, do they have access to the foods or nutrition therapy that we are telling them to do? And their activity level has to be assessed. We have to give them recommendations based on where they can, they are uh where they are uh functionally and whether they are mentally ready for this commitment to be uh initiate obesity treatment with GLP. Um and and we always take into account their sleep, mental stress, substance abuse. Next slide. Uh the nutritional recommendations given in that consensus statement uh um come in a form of an acronym SMART, which means specific, measurable, actionable, realistic, and time-sensitive. Basically, all that means is that it has to be patient-centered. But the common foundation for uh all the nutritional recommendations comes down to reduced calorie diet, which has to be nutrient-dense, high protein, high fiber, and it has to be sustainable. Patients will always ask you what kind of diet should I follow? The basic idea is whatever you can sustain for a long period of time, and it has to follow these little criteria with reduced calorie, high protein, high fiber, especially while being on GLP1 medication. And the general things about minimally processed foods to be encouraged, fruits, vegetables, whole grain, legumes, lead proteins, and avoiding uh obviously the refined grains, sweetened beverages, processed meats, and many fast food. We have to kind of go into detail while um uh talking to patients about these because many times patients are not aware of simple things like maybe juices are healthy for them. We have to dive deep into their nutritional history. Next slide. As Dr. Abu Shamah mentioned, that there uh can be uh muscle and bone loss or or uh we a lean reduction in the lean body mass. Uh, we have to make sure that we are giving them the right recommendations and we are telling them what can be possible if they do not do that. So um step there are there were two trials, step one and surmount one trials for semaglutide and terse epite. And it was seen in that that there could be up to 20% reduction of lean body mass from the total amount of weight loss. And this is not just with GLP1 therapy. This was also seen in bariatric surgery or from very uh restricted uh diets when it was not accompanied with uh measures to preserve the muscle and bone like high protein or strength training. There are some factors which were seen which can exacerbate reduction in uh lean body mass. These are rapid or accelerated weight loss when the doses are uh of the incredients are increased in a very rapid manner, uh like even when the patient is losing weight appropriately at a particular dose and we still keep on increasing the dose, sometimes that can lead to accelerated weight loss. Low protein consumption and absence of structured strength training uh can also obviously lead to, as I said before, lead to a reduction in the lean body mass. And there's emerging uh evidence that intermittent use of GLPs that getting off and on can also cause reduction in the uh lean body mass. Next slide. So, to preserve our muscle, uh what we have to recommend to our patients is that protein requirement is very, very important. Uh protein and the there have been recommendations that uh protein can be taken from 0.8 to 1.6 grams per kilogram. But um on an average, we can recommend patients to consume at least 80 to 120 grams of protein per day. If the protein requirement for the patient is falling below 0.5, then it can lead to muscle atrophy and functional impairments. And prolonged intake of more than two grams per kilogram can lead to potential adverse effects and even uh weight gain because excess protein can be converted into fat. So a lot of unfortunately, a lot of patients get information from social media and things like that, and and I see that they are consuming two or higher than two, and I we you have to educate them. So if you have an access to uh body composition analysis, then uh a good way to assess the protein requirement is 1.5 gram per kilogram of lean body mass is considered more accurate. Next slide. Similarly, uh structured strength training is recommended because there have been uh two studies, and one of them was randomized trial last year, uh two years ago that was done, and it showed that GLP1 therapy alone without strength training resulted in decreased uh bone density. And retrospective studies have shown that uh if the exercise, including strength and cardio, can be increased to 360 minutes per week, uh, it can prevent the reduction in the fat-free mass. So, what we should recommend our patients that um whenever we are initiating GLP1 therapy, there has to be 150 minutes of moderate intensity aerobic exercise plus uh three sessions of strength training, and that can uh uh potentially preserve muscle and bone mass. There need to be more studies done to uh corroborate these findings, but so far this is the recommendation from the consensus statement. Next slide. Now, while our patients are on uh caloric uh restricted diets, there can be nutritional deficiencies. Uh, if patients are complaining of excessive fatigue, hair loss, skin flakiness, muscle weakness, poor wound healing, unusual bruising, uh, we can do testing on the vitamins. Otherwise, there is no need. But if there are symptoms, we can. We can recommend to take a multivitamin. Uh, these can be more pronounced, these deficiencies, uh, when patients have had bariatric surgery. I see that a lot. That uh patients who started regaining weight after bariatric surgery and put them on GLP1 therapy, uh special uh uh uh you know uh assessment should be done to make sure they do not have nutritional deficiencies. Next slide. Fiber intake uh important uh when initiating GLPs because uh it can lead to constipation. So USDA recommendations um has recommendations for fiber intake, depending on age uh and sex. Uh for women um less than 50 years of age, 25 grams, and uh for men, 38 grams per day. For uh men older than 50, uh 30 grams per day, and for women older than 50, 21 grams per day. While being on GLP1 therapy, uh sometimes patients are not able to meet uh the adequate requirement for fiber intake because their appetite is suppressed. So you can always recommend them to um have the to complete this uh requirement by having a psyllium husk, commercially available psyllium hus, so that the fiber intake is there. Next slide. Now, uh a lot of patients will talk to you about intermittent fasting while they are on GLP1 therapy because now their appetite is suppressed and they want to add more to their weight loss. But long periods of fasting without sufficient protein intake or different type of uh you know um nutrient-dense diet can lead to uh nutrition deficiency, loss of fat-free mass, uh, even decrease in the resting energy expenditure. So I do not recommend patients doing a long period of fasting uh during uh GLP1 therapy. If they really want, they can do like um, you know, after 8 p.m. to next morning, uh 8 a.m., like 12 hours uh overnight, but not more than that. Also, while being on GLP 1 therapy, many patients do have um uh um hypertension. They already have hypertension because of obesity. And then when they are losing weight, uh their blood pressure is also going down because of weight loss. So uh doing that kind of fasting can also lead to decreased blood pressure, dizziness, lightheadedness. So it is not really recommended that while being on GLP1 therapy, they should do prolonged fasting. Next slide. Now, um, this uh there are predictors of long-term success with weight maintenance. This is through weight control registry. This is in general for general population, not necessarily for patients only on GLP1 therapy. We know that there have been uh problems with um the studies have shown that only uh certain patients, a percentage of patients continue to adhere to GLP 1 therapy either because of access issues or because of um uh insurance problems. So, what are the general predictors for maintaining weight for a long period of time? Uh I thought this was interesting, and and everybody should know that. So, eating at regular times, not skipping breakfast, uh, of course, uh eating um whole foods, avoiding sugary drinks. Um then uh permit uh you know, not not recommending your patients' extremely restrictive diet. Uh, but as you can see, very important that regular physical activity, more than 60 minutes per day, that is very important. Most of the people they will say that uh, you know, I walk for 30 minutes every day, uh, five times a week, that is not going to uh help in the weight maintenance or weight loss. That is good for general, very important and good for general health. But when we are talking about weight maintenance or weight loss, then we have to up our regular physical activity. And self-monitoring of body weight, food intake activity, very important. I see it all the time. Patients uh who are more successful in losing uh weight are the ones who are actually monitoring their uh food. They are uh paying attention to their carb intake, their macros, their protein intake, and their general uh caloric intake. Of course, limiting screen time and having good support always helps in long-term success with the weight maintenance. Next slide. We have to see if they their sleep is good. It is recommended that patients should have at least 7.5 hours of sleep for good metabolism. Chronic stress is a well-known factor for obesity because of uh because it can really uh uh change the hypothalamic pituroadrenal axis, causing elevation in cortisol levels, interfering with insulin sensitivity, promoting energy storage, and that causes cravings for ultra-processed foods. We see this in our practice all the time. Patients may ask to do the cortisol levels. Uh, it is not necessary, this will not show up mostly in the blood work. So this is just for our general information that this can happen, but it will not go, the cortisol levels will not go to the levels that uh they will be seen in the blood tests. Uh, many times your patients are going to ask for it. Uh, then uh make sure uh you tell them what's evidence-based. Then uh substance abuse, including tobacco, alcohol, opioid, illicit drug, this should also be addressed in the beginning if it's there when starting GLP1 therapy and see if the patient is committed to uh improving lifestyle and uh and and quitting uh the substance abuse because uh a lot of time calories can come from alcohol or beer intake, and you have to make sure that those are not contributing to stalling in the weight gain. Next slide. Now, uh this is a question that every patient is going to ask you that um do I have to take these medications for the rest of my life? Uh, or they will ask you, um, when do I when do I stop taking the medication? So we have to give the evidence-based answer based on the two studies that were done for semaglutide, which was step four trial, and terzepitide or sermon four trial. What the researchers did in these two trials that patients achieved weight loss uh for three by taking these medications for three years. And after that, the group was divided into two parts. One was uh one continued the medication, uh semaglutide in the step four and uh terro's epidite in Seramount 4. And the other group, the medication was stopped. And what was seen, uh next slide, that uh approximately 80% of the patients regained two-thirds of the body weight in the placebo trial who did not receive the medication. So, uh, what we know that when the medication is stopped, the weight gain starts happening. And this happens with every form of weight loss strategy, whether it is uh from reduced calorie diet. If you patients start uh they resume their previous diet, then also weight gain will happen. Now, when they take these medications, these medications work via brain and tell the brain not to store more fat. And and that stops when we stop the medication, and patients slowly over the time they start gaining weight. So two-thirds of the body weight can come back, and 80% of the pay uh population, if they stop the medication. This is the information that we have to give patients why before we initiate GLP1 therapy and see if they really want to go in that direction. 20% of the patients, yes, they can uh uh maintain the weight loss even after discontinuing the medication. Whether that patient in front of you is amongst the 80% or 20%, we don't know. So uh all this information has to be told to a patient upfront in the beginning itself, and a mutual decision has to be made. So the correct answer to tell our patients is the treatment for obesity is long term in most cases. There are currently no guidelines on discontinuation or tapering of these medications because these obesity, in as in general, is a chronic medical disease. It is relapsing. So the treatment for obesity is going to be long-term to treat obesity, just like any other chronic medical disease. Next slide. Uh, there is so much misinformation about these medications, uh, GLP1 medications on social media. And we uh have to tell our patients uh in a very evidence-based manner what is the right thing. So uh American Diabetes Association and Obesity Medicine Association, they release their statements on compounded GLP1 medications. So, according to them, if compounded medications are not subjected to review by FDA for safety, effectiveness, quality before they are marketed, then they are not recommended because we cannot predict or monitor uh any adverse effects because there is no labeling, and there can be contamination, subpensy, superpotency, or incorrect dosing. So uh just tell your patients, inform your patients, compounded medications were okay when uh there is shortage. Currently, there is no shortage, and and that too, only those compounded medications which undergo FDA review were okay. Otherwise, uh we do not recommend compounded medications if they are not subjected to review by FDA. Next slide. Similarly, micro-dosing, it is a marketing term, uh has become very popular. It is not labeled by FDA and it should not be recommended by clinicians. It's off-label and can lead to dosing errors and reduced efficacy. Next slide. When your patients can ask you uh about the GLP1 enhancer type of medications that they see on the shelves, like patches, shakes, gummies, drops, and uh you have to tell them they they are not the FT-approved versions of GLP1 medications.

SPEAKER_03 40:13

So I think one of the first questions that was added into the chat, and it's something that comes to mind as well, is the importance of having sure the medication, having that discussion on what's appropriate, what is the whole package. Um can you guys walk us through a little bit how do you have that conversation about the nutrition, the exercise, right? Because those things matter a lot, and it takes quite a bit of time in the visit itself to do those conversations. So um I guess I will start with our panelists first. So Dr. Kazneem and then Dr. Leigh.

SPEAKER_06 40:50

Uh I think Dr. Chada brought this up. Uh, the the first visit with your patient is kind of the most important because you're going to get into the nitty-gritty, the hard topics. When do you sleep? Where do you go? Uh do you get food from outside? Where do you what is the restaurants you choose? Those are the questions I ask. How much do you drink? Do you smoke? Uh and I go into the depths. I have like a questionnaire, 10 questionnaires, and I will have them answer each one of them. And I use that as my base. And at every visit, I will go back and say, okay, you said you ate this for snacking. Have you changed this? You said you go out so many times, how many times? And I negotiate with them. I'm like, what can you do? Tell me, you're eating five times a week. Can you bring it down to two times? And when you give them choices, it makes it easy. They're like, okay, she doesn't want me to stop it completely. I'm willing. And then they'll say three. How come from five, can I get it to three? I'm like, okay, let's start there.

SPEAKER_03 41:51

Yeah.

SPEAKER_01 41:52

The choice it matters a lot. I agree. Uh, counseling from our um primary care providers and our specialists are uh very important. Um, I I don't know if we know this, but um, Medicare and other insurance companies uh also cover obesity behavioral therapy um under Part B. And so um, you know, we can we can use as many tools as possible to get our patients as many uh face-to-face um appointments with other professionals as well in the interdisciplinary space. And um for the there was a question in the uh webinar about um nutrition therapy for someone already with diabetes and obesity. Um for those patients, medical nutrition therapy is covered um under Medicare Part B. Three hours, you know, for initial coverage and then two hours of follow-up of each calendar year. I recommend um using those resources.

SPEAKER_02 42:54

Yeah. I I just want to add too, I just I think that highlights the importance of a multidisciplinary team. That one provider is not gonna be enough to cover all of this and may not um, you know, reach the patient. And so the more people that kind of relay this message and talk about uh behavioral therapy, so that's why I love that medical nutrition therapy was brought up in the chat because um we should be using those referrals. I think the biggest barrier is that oftentimes it isn't always covered, and so you really need to have the patient ask what is covered under their commercial plans. Um we just talked a little bit about what was covered under Medicare. Um for diabetes, I think most commercial plans will cover uh medical nutrition therapy, but it is something to keep in mind know your resources, know what referrals you have available to you in your vicinity.

SPEAKER_00 43:48

Can I just in that realm? I think first of all, yes, multidisciplinary, I love it. Tap into your insurance coverage wherever you can find these you know, the recommendations, which I thought was interesting, and I I think a new lens on this to me. Is you know the lean muscle mass loss question that comes up. Um and I found it interesting. I think we some of the recommendations were 150 minutes of aerobic exercise and three sessions of strength training. Now, I've been recommending that since I was like an intern in training, and no one has followed my recommendations. Um, including myself until recently. So I think the question is what's different now that you're on a GLP and you're losing weight and potentially losing not bone mass and muscle mass. So you know, this is a a behavioral challenge that we've been trying to get people to do this long, you know, for a very long time. Um and I I and now it seems more urgent to me that folks particularly do some resistance training because you know the the worst we can do is have you know these folks, particularly if they're a little older and unstable and lose lean mass and they fall. Um so any thoughts on that? I I don't know how how what's different now that's gonna have folks actually do this. Am I asking the right challenge? I I've got them quiet. I don't know what happened.

SPEAKER_06 45:11

I uh I we don't know who you want. I think there's so many.

SPEAKER_00 45:16

I think those that are managing patients, you know, have you had success getting folks who traditionally are not really doing this, you know, to suddenly start doing it because they're on a GLP. I I I I'm I'm concerned about that. And I don't know how we can get folks to do this. Um, that's I'd like to know.

SPEAKER_06 45:36

Yeah, it definitely is one of the toughest questions that we have to deal with with patients because their lifestyles are so different. Like I said, you meet them where they are, but this is a long-term relationship we are having with our patients. We so we meet them where they are, and then we gently keep asking the same questions. It's more like an intense therapy. Every time they come, we ask the same questions, and then they finally, and when they start losing weight, you there's a shift in their Well, I think that's what I was kind of looking for.

SPEAKER_00 46:08

Uh you know, I was kind of hoping you were gonna tell me that. Because you know, I've you know, my primary care background in clinical work in this space has been pre-GLP. I haven't done as much one-on-one care, but I'm hoping to hear from you guys. Well, you know, once they lose a few pounds, Tom, they suddenly get motivated to get out of bed and do some resistance training.

SPEAKER_06 46:28

I mean 100%. That is what happens.

SPEAKER_00 46:31

That's what I want to hear. Good. That's the good news.

SPEAKER_06 46:33

About three to four months into any not GLP alone, any of the anti-obesity medications, within three to four months, when they start losing 10 pounds, the amount of energy that they have.

SPEAKER_00 46:44

I've had patients tell me we've seen this in the sleep apnea world where people treated for sleep apnea suddenly start exercising because they they finally have the energy to do so. I see Dr. Chaja, uh, am I saying your name right? I don't know.

SPEAKER_05 46:55

Chada. Yes.

SPEAKER_00 46:56

Chada, you were about to jump in, I know.

SPEAKER_05 46:59

Yeah, I see that all the time, as Dr. Tusteen said, that uh somehow they are motivated. I think it's also because uh reduction in uh adiposity leads to less inflammation because that adipose tissue was causing a lot of inflammation. And then they they are hurting less, but they are uh motivated. I see this all the time. And then I also kind of uh show them uh what kind of strength training they have to do. I have bands in in my pocket and my and I kind of show them uh if they have dumbbells and I I kind of tell them, write them the exercise prescription as well, and they are actually motivated.

SPEAKER_02 47:36

Yeah, I was gonna just jump in real quickly. Obesity is associated with, and also actually diabetes, with higher um relative perceived exertion with activity. So it's much harder to do exercise. So once you start losing weight, um not only do you have that less of that mechanical stress. And so that oftentimes helps. And, you know, one thing I do is at the initial visit, I often tell them, you know, I would love for you to exercise, but at the same time, I understand that it may not be possible right now for you to, you know, do this 150 minutes per week and three times a week of uh resistance training. So again, meeting them where they are, there are so many um, you know, free programs available virtually now, especially since the pandemic. But also um I take care of a uh patient population with multiple comorbidities, and several of them are elderly. Um, tapping into what physical therapy benefits they have, to a actual assessment. Again, going back to the multidisciplinary team. So doing an assessment or cardiac rehab for a lot of my cardiac patients and having them go to cardiac rehab so they can um be monitored and have um some oversight because I think for a lot of them, they're scared that something bad's gonna happen while they're exercising. And so it is it is a barrier there, but also that they don't know what to do. Um, or they're wheelchair bound and they're like, well, I can't exercise. But there are things that can be done um regardless of your mobility status and regardless of your.

SPEAKER_00 49:04

I'm excited by all these positive answers, Ankara.

SPEAKER_02 49:06

Yeah, I'm glad. I am glad.

SPEAKER_01 49:08

Okay, as we um continue to work more with our patients, inadvertently we get better with behavioral therapy, Dr. McGinn. So I will send some more patients your way so that you can get that practice. Um my approach is uh to set patients up for success. I give them a stepwise process. So my approach is never to hand people um this large plan of 150 minutes. Uh actually start um initially with a more mild goal.

SPEAKER_00 49:44

Yeah, yeah. Yeah, that's my end with the question.

SPEAKER_03 49:48

This is this these are the hard questions, right? Because we when you're seeing patients every day and they're coming back and you're doing the agenda setting during a visit and you're saying, hey, I want to go, I want you to go and see all these people, and then I want you to come back and you're gonna be so much better. And we're gonna ride off into the sunset together, ideally. Um, one of the the barriers that comes, and I think we're we talked about it a little bit, but I want to bring it out is the the importance of making sure that the interdisciplinary approach where the patients are truly in the center, but they also understand that each each profession has a role to play in getting them. And the reason I ask that is because a lot of times, at least in the practices I've been in, the patients will feel, well, you know, I tried it, I tried it for a few months, I'm not losing any weight. I've been on the GLP one. Can you just increase my dose and keep going up until I start losing weight? How at what point do you intervene and at what point do you redirect them beyond that singular focus of the GLP one dosing? Because patients, as much as we don't want them to go to compound farm disease, they they might be going there because they are more affordable. So, how do we bring them back into the fold? I think that's a that's a really tricky situation for patients to be in.

SPEAKER_02 51:20

I can jump in while others unmute, but I think setting the expectation from the first visit and discussing what's out there, discussing what the patient's concerns are. I always ask a little bit of a trick question, or I just call it a trick question to my patients. And I ask, what is your ideal body weight? And some people will answer, you're supposed to tell me that. Or um, but it's for me to gauge what their expectation is for weight loss, because there have been studies to show that what a physician would be really happy for their patient isn't necessarily what the patient is going to be happy with. And so kind of meeting on being at the same on the same page. And I always stress, you know, you have these comorbidities. And what I'm specifically looking for isn't the number on the scale. It's more so looking at what's your A1C now? Um, what's your blood pressure? How many blood pressure meds am I able to get you off of? And um, you know, I discuss up front these barriers with cost and coverage because that's something that we've dealt with now for five, six years. And sometimes the coverage goes away randomly, and then the poor patients off the medication. This is so common. And so really understanding, you know, where they're at and what we can do in the interim when that happens, and um coming up with contingency plans for them. So I think it's a lot of just expectation setting. I'll let other panelists chime in.

SPEAKER_01 52:48

My approach is to redirect um the patients. Um because if we're if we're so hyper-focused on a number on a scale, like Dr. Abu Shama was saying, um, patients oftentimes will get discouraged. And so um we redirect them to things like energy, um improvement in pain, um, improvement in their um breathing because of um maybe resolution or improvement in the obstructive sleep apnea, improvement in the ability to walk because you know the heart failure symptoms are improving. Um, definitely a redirection tactic.

SPEAKER_00 53:29

Um mild, moderate, and unofficial. I mean, this is now not evidence-based, but some, you know, if you really ever sat in a sleep lab and looked at the diagnostic criteria for sleep apnea, it's pretty, pretty dramatic. You have to have a lot of apnea periods for very long. I I look at people sometimes in a lab and I'm like, this is not apnea, you know, because and if so there's a lot of people with really you know pre-apnea, sleep, formal sleep that we're we're reducing their weight, they're gonna they're gonna feel better from an energy standpoint, and measuring that somehow, I think, or getting them to engage in that is I think it is is interesting to think about. Um, and I love that. But the thing is, patients like to see a number, you know, they want to know my blood. My blood sugar and my weight, you know, those are their two most favorite things to look at. And we're like, you know, hey, you're feeling better. How's that? How about that?

SPEAKER_06 54:25

So in my practice, what I do is uh when I first meet them, I ask them, What are your health goals? And I actually document that. They would say things like, I want to be, I want to be bend down and play with my grandkids. I'm like, okay, that's a good goal. I want my diabetes to resolve. Okay, that's a second good goal. I don't want knee pain. I'm like, okay, that's a third goal. I really avoid talking about what is your weight goal, but I will say you need to get down to 10%. That is my goal for you. To get you healthy, I need you to come down to 10%. So those are my parameters that I use. And then when they start feeling better, I say, listen, I know your weight is not where you want it to be, but look, you we've ticked away all these boxes. And that kind of gets them back to expectations, like Dr. Abu Shamahad said, it's all about setting expectations. Uh, sometimes they want to be weights that they've never been. Um, they're like 270 pounds, but they want to be 150 pounds.

SPEAKER_04 55:25

So Dr.

SPEAKER_01 55:27

Begin mentioned like a number, and oftentimes um, with Dr. Chaznim's questions, I assess a number, like a ranking scale for those numbers. Like, for example, what is your energy level, you know, at the start of the nice energy level scale or something.

SPEAKER_00 55:45

Yeah.

SPEAKER_01 55:46

Yeah, yeah. And then later on, you know, three months down the line, six months down the line, you can re-ask them those number questions to redirect from the weight.

SPEAKER_03 55:56

Well, I think this has been a great part one of the conversation. I know that the chat has a lot of questions on hey, a lot of activity there. Very exciting. What about side effects? Are there cautions? What about special populations? I'm hearing about patients getting maybe a little bit of flat ass like with GLP ones, or maybe a little bit of increased somewhat uh pancreatic disease. We are going to answer all of those questions next week. Um, so please, please, please, everybody come back. And we're gonna have Dr. Kazim and Dr. Leigh go through some of those questions as well as others that are related to special populations and cautions around GLT1s and increased and bridging, also. Um, but for today, really a big thank you to our speakers and our panelists and to Dr. McGinn joining us this morning for a great discussion. Um, thanks everybody. We will we will join you next week. Same time, same place.

SPEAKER_00 56:53

Excellent job. Thanks, everybody.