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Obesity Management in Cardiometabolic Disease
Shifting the Paradigm: Prioritizing Obesity Management in Cardiometabolic Disease

Released: February 07, 2023

Expiration: February 06, 2024

Michael Jensen
Michael Jensen, MD
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Key Takeaways
  • Initial discussions on weight loss should include behaviors to improve health to help patients achieve their goals.
  • Newer drugs for type 2 diabetes—particularly GLP-1 receptor agonists—have weight loss and long-term cardiovascular benefits, in addition to helping with glycemic control.
  • Office support can help healthcare professionals be more successful in incorporating these agents into their practice.

As with many healthcare professionals (HCPs), my approach to persons with obesity has evolved over the years. Now, it first includes a thorough analysis of both their daily regimen and the medications they may be taking for other conditions. I then review with patients how burning more calories than they eat might improve comorbid conditions they may have, such as type 2 diabetes (T2D), heart failure, dyslipidemia, sleep apnea, and more.

I focus the discussion on behaviors—that is, the health benefits of improved eating habits and getting more physical activity. We discuss medical approaches that might help them succeed with reduced energy intake, including medications. Unfortunately, there is no medication to increase activity, and low physical activity is itself a risk factor for cardiovascular disease. So, what options do we have, and how can we help patients achieve them? Our conversation has become a collaborative dialogue about behaviors as opposed to a judgment of them as a person. This approach has been very successful in terms of a de novo conversation with patients about the topic of weight loss.

I then try to shift the conversation into specific health problems. For example, if the patient has T2D, new medications are available—the glucagon-like peptide-1 (GLP-1) receptor agonists—that not only help lower blood sugar directly, but also help with long-term T2D management and help people consume less food, which results in significant weight loss. Certain agents also have been shown to reduce cardiovascular risk and even may provide renal benefits. If patients have heart failure with reduced ejection fraction, I might suggest the sodium-glucose cotransporter 2 (SGLT2) inhibitors that, despite their more modest weight loss, have impressive effects on improving cardiac function and reducing mortality. By tailoring the therapy to the patient’s specific needs, we can positively affect their other comorbidities, in addition to helping them achieve their weight loss goals.

Finally, I always ask patients about their definition of “success” regarding weight loss. I want to make sure we are in agreement on realistic outcomes. If patients feel that they will not be happy unless they lose half of their weight, then I advise them that, except for bariatric surgery, we probably do not have anything that will meet their expectations. If they are expecting 50% weight loss and I am expecting 20%, and we get 20%, I am happy—but they are not. Having comparable expectations will make the experience for your patient much more fruitful.

Using GLP-1 Receptor Agonists in Your Practice—The Practical Aspects

We know that weight loss itself reduces cardiovascular risk, and many guidelines now recommend that we treat obesity as we would a chronic disease. These newer medications—particularly the GLP-1 receptor agonists—are much more effective weight loss agents than earlier drugs. As such, one might anticipate that insurance companies may eventually allow us to use these drugs as first-line options because their many benefits result in greater long-term reduction in adverse health outcomes, which, in turn, provides long-term cost benefits. Unfortunately, right now there is just a small subset of patients whose insurance coverage will allow us to use the drugs as a first-line option for obesity management without a prior authorization.

In a primary care practice, using these newer agents may require some effort. My advice would be to start by choosing one agent that you think might work for most of your patients. If you pick one of the injectables, make sure that your office is set up to manage using this drug and that patient counseling on its use is provided. In some practices with many HCPs, it may make sense for one of the HCPs to become the primary person who prescribes these newer agents and to have all patients needing that agent to see that HCP. You may need a dedicated staff person to manage the paperwork for insurance authorizations. This will increase efficiency and allow you to focus on the medical aspects of patient care.

Your Thoughts?

Are you using SGLT2 inhibitors and GLP-1 receptor agonists in your practice? What are your experiences? Answer the polling question and leave a comment to join the conversation.

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How often do you prescribe SGLT2 inhibitors or GLP-1 receptor agonists for patients who would like to lose weight and have additional cardiometabolic diseases?

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