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Back to Basics: Equipping Patients With Practical Lifestyle Changes to Improve Long-term Weight Loss Outcomes—Medical Minute
CME/CE Information

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Physician Assistants/Physician Associates: 0.25 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 0.25 Nursing contact hour

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Released: December 26, 2024

Expiration: December 25, 2025

Christopher D. Still
Christopher D. Still, DO, FACP, FTOS

Back to the Basics: Equipping Patients with Practical Lifestyle Changes to Improve Long-term Weight Loss Outcomes

Introduction

Dr. Christopher Steele (Geisinger Commonwealth School of Medicine): Hello, and welcome. Welcome to this Medical Minute presentation on Back to the Basics: Equipping Patients with Practical Lifestyle Changes to improve Long-term Weight Loss Outcomes.

I am Dr. Christopher Steele, Professor of Medicine at the Geisinger Commonwealth School of Medicine. I also serve as the Medical Director for the Center for Nutrition and Weight Management, and the Director for the Center for Obesity and Metabolic Research at Geisinger Health System in Danville, Pennsylvania. It is a pleasure to be with you today.

Overview

So we know the benefits of weight loss. If someone has obesity and comorbid medical problems, it is well established that weight loss helps with amelioration or controlling many medical problems such as diabetes, sleep apnea, fatty liver disease, cardiovascular disease, blood pressure, cholesterol and the like.

And how that does it. We know that if we can reach at least 10% body weight, that has been shown to be the most effective for helping all of those comorbid medical problems. The reason for that is really the driver of obesity in and of itself. That is visceral adipose tissue.

Visceral adipose tissue is defined really about the adipose tissue around our waist. It is defined in women with waist circumference greater than 35 and men with waist circumference greater than 40. We have that increase in visceral adipose tissue. Visceral adipose tissue is the driver of the inflammatory response of obesity.

We know that individuals with higher visceral adipose tissue have:

  • Worse cardiometabolic parameter;
  • Impaired insulin sensitivity;
  • Higher blood insulin;
  • Higher blood glucose;
  • Increased inflammatory markers.

But the good news is with a 10% weight loss, there is a 30% reduction in this visceral adipose tissue, this driving force of this inflammatory response of obesity. That is why we want to try and our efficacy and treatment parameters to get at least 10% weight loss.

On the flip side, on the right-hand side, you can see improvement of this with decrease in visceral adipose tissue and increase in subcutaneous adipose tissue, you have improvements of all of those cardiometabolic parameters that we talked about.

Components of Effective Obesity Management

Components of effective obesity management program. Everybody is talking about the new medications and bariatric surgery. But really what I want to focus on is:

  • Healthy eating patterns;
  • Behavior modification; and
  • Physical activity.

We know that medications, specifically the newer medications can promote a significant amount of weight loss, very similar to bariatric surgery. We know that patients are not eating as much as they did before. So now healthy eating pattern and diet quality is imperative for healthy eating, behavior modification techniques and physical activity. Physical activity not so much for weight loss, but for weight maintenance, which we will talk about in just a minute.

Effects of Weight Loss Intervention on Body Composition

The effects of weight loss intervention on body composition. We talked about the reduction in fat mass, specifically the reduction in visceral adipose tissue, which lowers metabolic risk. There is also a significant reduction in bone mineral density that can lead to osteoporosis.

With weight loss, there is hormonal adaptation. There is decrease in a hormone called leptin that is produced by the fat cell that goes to the brain. That is a very important hormone that really runs the furnace and the thermostat, if you will, to determine how much fat mass we need. With weight loss, there is a significant reduction in leptin.

There is also another hormone called ghrelin, that is a hunger hormone that is produced predominantly in the stomach. And when we lose weight, ghrelin levels increase and leptin levels decrease, all to get us back to that set point where we gain back weight to where we once were.

There is also, with weight loss, can be significant lean body mass. And with that lean body mass reduction, there is a reduction in resting energy expenditure. So that is why for weight maintenance, exercise is key to preserve our lean body mass, to try to maintain our energy expenditure.

Effects of Weight Loss Intervention on Body Composition

The effects of weight loss intervention on body composition. What strategies to preserve muscle mass? Adequate protein intake. I am going to be a little more specific in the next few slides. But consuming sufficient protein supports muscle maintenance during caloric deficits, which is very important.

High protein diets during weight loss helps preserve that muscle mass and improving muscle preservation while reducing fat mass.

Resistant training incorporating helps to stimulate muscle growth and prevent that muscle mass during weight loss.

Balanced nutrition. We talked about that good diet quality is really important because patients are decreasing their calories, and we want to make sure what calories they are taking in has very good diet quality.

Outcomes Associated with Decreased Muscle Mass

Outcomes associated with decreased muscle mass. We talked about the decreased resting expenditure, greater length of stay, poor wound healing, need for rehab, post-operative complications, patients become fat, become frail and increase in falls and fracture, physical impairment and disability, shorter survival, treatment or disease progression and treatment toxicity, specifically specific cancers, and finally poor quality of life are all associated with decreased muscle mass. So it is important that we try to preserve this muscle mass as we lose fat mass.

Optimizing Changes in Body Composition

Optimizing changes in body composition during weight loss. High higher protein diets. So we want to try to achieve at least 1.2 grams per kilogram of body weight per day with caloric restriction. As I said, these medications and surgery significantly reduces our appetite. So we are consuming fewer and fewer calories. We want to make sure what calories we take in is good diet quality, and it starts with the protein.

We know that greater protein:

  • Produces greater weight loss;
  • Improves satiety;
  • Preserves the muscle mass; hopefully greater fat mass than muscle mass; and
  • Improvement in select cardiovascular risk.

Moderate resistance and enduring exercises decreases loss in lean body mass, with decrease in visceral fat. It increases overall caloric expenditure, improve weight loss maintenance, as we talked about, improve metabolic parameters, specifically improvement of insulin sensitivity, decrease in blood glucose and lipids. And preservation of resting energy expenditure is the main goal.

So I like this treatment intensification pyramid. So we know based on one's body mass index and comorbid medical problems how intensified our treatment options should be. So see down at the bottom rung a BMI greater than 25 with no medical problems. Lifestyle modifications may be sufficient. You can see on the right-hand side what the efficacy of that would be.

So on average with lifestyle modification, we can achieve about 2% to 5% weight loss after one year. Some people lose more, some people lose less, but on average it is about 2% to 5%. More intensified prescriptive nutritional intervention, you can achieve about 5% to 10% weight loss.

Pharmacotherapy ranges now between 5% and 20% weight loss. There is endoscopic procedures, the space occupying balloons, and the endoscopic sleeve gastrectomy that can promote between 10% and 20% weight loss.

And finally, bariatric surgery can produce between 20% and 40% weight loss. I think it is important when patients come in to have realistic expectations on what treatment modality they want to do with the corresponding efficacy that they should be able to achieve. Many people come in and they want to do a little bit of lifestyle modification, but they want the efficacy of bariatric surgery. We will talk about setting realistic expectations in just a minute.

Lifestyle Modification

This basically just says the same thing but in a different way. So lifestyle modification, as I said, the efficacy is about 3% to 5%. The second generation anti-obesity medication, which includes the phentermine and topiramate combination, the naltrexone-bupropion and the once a day liraglutide, can achieve about 8% weight loss. Some people lose more, some people lose less, but on average about 8%.

Patients on semaglutide one milligram, mostly for diabetes, can achieve about 11% weight loss. And now the newer medications, the third generation anti-obesity medication, the semaglutide on average is about 15% weight loss, and tirzepatide 15 milligram can achieve around 21% weight loss. In bariatric surgery between the sleeve and the bypass is about 25% to 35%.

So again, knowing expectations with the treatment modality I think with our patients is very important.

          SURMOUNT Trials

These are two studies looking at tirzepatide. And you may recall tirzepatide is a combination of a GLP-1 and GIP. And it is approved for two indications. One is the treatment of diabetes and one is the treatment for obesity.

On the left-hand side you see the SURMOUNT-2. So this is their efficacy trial in patients with type 2 diabetes, which traditionally patients tended to lose less weight. But you can see on this slide in the SURMOUNT-2 after 72 weeks, patients that were randomized to 10 milligrams of tirzepatide in the diabetics lost 13% body weight, and the 15 milligrams lost 15% weight loss versus 3.2% in the placebo.

On the right-hand side is the SURMOUNT-1. This is the nondiabetics. They were randomized to either five, 10 or 15 milligrams of tirzepatide. And you can see a higher weight loss of 15%, 19% and 21% randomized between the three doses versus 3.1% in the placebo. So again in the 15 milligrams, that is where we saw the 21% from the previous slides.

One thing about these medications that I think is very important that they are not a short-term fix, both the STEP-1 extension as also the tirzepatide SURMOUNT-4. Once you stop these medications, two thirds of the patients will gain back their weight within one year. So like any other chronic disease, you want to treat obesity like a chronic disease.

Take for blood pressure, hypertension, for example. If you take blood pressure medication and you get your blood pressure down to normal, you do not stop the medication. Your blood pressure is going to go up. Same thing with diabetic medications. If you are on a diabetic medication and your blood sugar comes down to normal, you do not stop it or your blood sugar is going to go back up.

Same thing with treating obesity. And it is very important to understand this with the newer medications, because once you stop these medications, they are so effective in decreasing appetite that our weight does come back within one year.

So obesity treatment is a team sport. As many patients that we can get involved in this treatment is important. So the primary care provider, and then there is many specialists endocrinologists, surgeons, obesity medicine specialists, their support groups, physical therapists, medical assistants, psychologist, registered nurses, physician assistants, nurse practitioners and registered dietitian. Not everybody needs to see everybody. But a tailored approach I think is important.

So there is strategies of patient-centered approaches, personalized care, of personalizing individuals that need more people or less people in that circle that we talked about, collaborated goal settings, continuous support groups, and education and empowerment are all very important.

          Key Points in Obesity Management

So key counsel points of obesity management. We want to show empathy, not sympathy. We want to show empathy in individuals in their treatment weight loss journey. I understand this can be challenging and you want to be partnered with them. You do not want to just tell them what to do. We want their input in the patient-centered approach:

  • Consistent follow-up;
  • Personalized care;
  • Foster open communication;
  • Create a safe space;
  • Include inclusive language.

So this is important. We want to use patient first language. We do not want to say patients are obese. We want to use the terminology patient with obesity. We do not say patients are cancerous. We say patients have cancer. So I think that is really important. And it is hard to do. It takes some practice. But we want to try to say patients with overweight and obesity, not obese patients.

And as I said, we want to be an active listener. We do not want to just tell the patient what to do. We want to know what their goals and expectations are and listen to them.

Explore emotional triggers. What has worked in the past, what has not. Try to exploit those and try to be mindful of what has worked in the past and what has not. Big knowledge about stigma. Stigma is real, and we need to make sure that we acknowledge it.

As we said, there is mental health providers. Some people may need more help than others, and they are there and should be utilized. We want to encourage manageable expectations, like I said. So we want to manage patients expectations, set realistic goals, long-term management, adverse effect and ongoing monitoring. That is really key.

We want to monitor not so much of what they are eating but how they are eating. Are they getting into good diet quality, good diet micro and macronutrients.

          Summary

So in summary, effective obesity management.

  • Approach obesity as a chronic disease with patient-centered plans;
  • Provide non-judgmental patient counseling with realistic goal settings;
  • Interventions to target fat loss, and address risk of muscle loss;
  • Strategies to include balanced nutrition with high protein and resistance training; and
  • Finally, individualized treatment options to include lifestyle changes with or without pharmacotherapy and/or bariatric surgery.

Thank you for your time. If you would like to learn more about obesity treatment, please go to clinicaloptions.com.

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