Dr Weber:

Guideline-based Obesity Treatment

So we will start with guideline-based obesity treatment.

[01:19:51]

          AACE/ACE Algorithm for Medical Care of Patients With Obesity

So AACE/ACE. Do you guys know what this is? It is the American Association of Clinical Endocrinologists and American College of Endocrinology. So their algorithm for medical care of patients with obesity. You see the reference here is from 2016. So a little bit older but it is still a very good document.

I recommend pulling it up. It is really long. But at the end, there is some nice visuals that summarize everything. And we will talk about it a little bit here.

Okay. So first how do you diagnose obesity? What is the evaluation? So like you would with any new patient or new patient concern, you take a history. Right. So you do your medical history, do your physical exam, do your clinical laboratory tests. But then you have a few things that are specifically related to weight.

So a review of systems emphasizing weight-related complications. Of course, you will do a general review systems. And the way I look at it is the review of systems, yes, to look for weight-related complications, but also to look for secondary causes of obesity, right. So do they have physical exam findings? But signs or symptoms of Cushing's syndrome. Do they have knee pain that would suggest arthritis. So dial in on the obesity-related questions.

And then, like we talked about last session, getting a more in-depth obesity or weight history. So do the graph of the weight versus age. Plug in when they had different medication changes, what was happening at that point in their life, especially major milestones. And then you ask about lifestyle patterns or preferences, previous interventions. So lifestyle patterns and preferences. I had a mentor tell me once, if your diet plan that you are giving someone does not allow for chocolate or diet cola, it is not going to work. And the point being, you have to come up with something that is going to work for the patient that they will actually participate in.

[01:22:02]

          Anti-obesity Medications as Adjunct to Lifestyle Therapy (BMI >27 kg/m²)

Okay. So let us talk about anti-obesity medications as an adjunct to lifestyle therapy. Okay. I love that initiate lifestyle therapy is right here off by itself because that should be everybody, right, whether you have obesity or you do not have obesity, to prevent weight gain just for overall health, this is stuff we should be talking about with our patients at their annual preventive visit once a year, at least in the absence of obesity. And then more frequently, if we are trying to treat obesity.

So when do you add anti-obesity medication? All right. I love the phrase difficulties with lifestyle therapy. I would say if lifestyle interventions are ineffective, right. Like almost any intervention you are going to have responders and non-responders. So tightening up the nutrition, adding some exercise. That may be enough for some people. But for the vast majority of people, it is not adequate. The average weight loss someone doing their own diet and exercise sort of thing is somewhere 3% to 5%, which is great, right? Anytime you are not gaining weight in America that could be a success.

But often you need greater weight loss than that to treat the obesity and the obesity-related medical conditions. And that is where anti-obesity medications come in.

So if lifestyle therapy is ineffective, leading to inadequate weight loss, that is when you can add an anti-obesity medication. If the BMI is greater than or equal to 27, and they have weight-related medical complications, then consider an anti-obesity medication.

If they have weight regain on lifestyle therapy, so that is very common. It is very common with almost any weight or many ways that we lose weight. You lose weight, you stop doing what you are doing. You can regain the weight. Or like we talked about earlier, the metabolic adaptation, you lose weight, your body is still trying to pull you back up. You could keep doing the same thing. And it does not work like it used to.

And so just because lifestyle interventions worked at one point does not mean it is going to work in the future. So that would be a time to add an anti-obesity medication, weight regain after lifestyle therapy.

And then if someone has weight-related complications, lifestyle interventions, medication at the same time absolutely appropriate and indicated. And compared to other chronic medical conditions. Someone comes into your office and their blood pressure is 180 over 110, right? Okay. You will say go do the DASH diet, work on your stress, maybe get a little exercise. You come back and see me in 6 months, and if your blood pressure is still super high, we will do a medication. No, you do that lifestyle counseling but you also start a medication, right? So same thing with treating obesity.

Yes. You do the counseling, lifestyle interventions. But if a medication is indicated, consider it.

[01:25:07]

Why Use Medication With Obesity Treatment?

So why? Why would we use a medication with obesity and trying to treat obesity? So it is therapy aimed at the currently dysregulated weight-related biology. The hypothalamus, those pathways. They are not working like they used to. In fact, they are sort of working against you, because of that metabolic adaptation, the body's counter-regulatory processes that are resisting weight loss, further weight loss, weight loss maintenance and trying to cause weight gain or regain. These medications work on those pathways. Okay. So you are treating the pathophysiology.

And then obesity is a metabolic adaptation. It is difficult to treat with diet, exercise, behavior modification alone. Again, those things are pivotal. They are foundational, but they are often not enough.

And then anti-obesity medications can assist in managing obesity-induced complications and comorbidities also. And so we will get into that. Many of the medications we use is not just getting someone to lose weight. That is important. But it also can either directly or indirectly treat and improve all of these other weight-related medical conditions.

[01:26:25]

          FDA-Approved Anti-obesity Medications

All right. So let us look at the currently FDA-approved anti-obesity medications. I am just going to start at the top of the slide here. And we will get into some more details about these in the rest of the talk here.

So you will see a lot of these, most of them work in the brain. So in the hypothalamus, like we looked at that that picture earlier. Some of them work in the gastrointestinal tract as well. So you will see.

Let us start with bupropion and naltrexone here. Well, the bupropion increases dopamine norepinephrine, okay, and that increases the firing of, if you remember, the POMC, the I am full side of the hypothalamus. And naltrexone works on an opioid receptor to facilitate the bupropion action.

If we move over to phentermine by itself here. So phentermine, similar to bupropion, it increases dopamine and norepinephrine. It is a sympathomimetic. And that increases the firing of the POMC pathway. So increases fullness and decreases hunger.

And then phentermine and topiramate ER is marketed as a combination. So you have the phentermine part which I just mentioned. And then topiramate works on GABA. And that has action on the other side of the agouti-related peptide side of the hypothalamus. And so the phentermine-topiramate combination both decreases appetite and increases fullness.

Okay. And then let us look at the GLP-1 receptor agonists. So liraglutide and semaglutide, they work centrally in the hypothalamus and also decrease the rate of gastric emptying. And then tirzepatide is a GLP-1 and GIP dual receptor agonist. And so it works also centrally in the hypothalamus also decreases gastric emptying and also affects lipolysis as well.

And there is a biodegradable device. So this you swallow it. It expands in your stomach essentially triggering your body to think that it just had a meal. And so it takes up space in the stomach, and then it biodegrades and passes through.

And then orlistat works exclusively in the gastrointestinal tract, decreases gastrointestinal lipases. So there is less essentially absorption of free fatty acids.

And then there is, in this gray box here, a list of off-label medications. So these we often use for weight loss or for obesity treatment. Personally I always prefer the FDA-approved medications, but if cost or availability is an issue or contraindications for a specific patient, these medications are used off-label and may be helpful. So metformin, other GLP-1 receptor agonists that are not FDA approved for obesity treatment.

The SGLT2 inhibitors. Topiramate is a single agent or bupropion as a single agent. And then here is a whole list of pipeline medications. And we have another slide on this coming up. So we have other dual agonists GIP/GLP-1 receptor agonists. There is oral GLP-1 receptor agonists. And then there is tri-agonists here as well. So all sorts of exciting things coming or at least being developed and studied in the pipeline.

[01:30:29]

          Efficacy of FDA-Approved Obesity Therapy

So let us look at the relative efficacy of these different interventions. So as a comparison to surgery, which you see at the top. We have sleeve gastrectomy here. There is a few other kinds of bariatric surgery. But for example, here we have sleeve gastrectomy, about 25% total body weight loss.

And then tirzepatide is our most potent anti-obesity medication. See that is 22.5%. Semaglutide comes in next at close to 17% total body weight loss. The phentermine/topiramate ER, 14%. And then liraglutide, which is a daily GLP-1 receptor agonist, around 9%. Orlistat is similar, close to 9%. The bupropion/naltrexone right around 8%. And then phentermine as a solo agent or as monotherapy about 7%.

You also have to look at the duration of therapy for these. So how long it takes to reach that amount of weight loss. And that is important when talking to patients too because expectations are very important. And it is hard to know unless you are in this field how much should I lose, how fast should I lose. How long is it going to take? Am I doing good or bad? Although I try to stay away from judgment, words like that.

So it is helpful to tell patients, hey, on average, people taking tirzepatide lose 22.5% of their weight, and the studies show that that took about 72 weeks. Okay. So they have some idea of what to expect.

[01:32:06]

          The 5 C’s of Choosing an AOM

So how do you choose which anti-obesity medication to use. So this is a nice construct to help you be systematic about it. So we call it the 5 C’s:

1. Contraindications and cautions;
2. Comorbidities;
3. Cues;
4. Combinations;
5. Cost and coverage.

Okay. So let us start with contraindications and cautions. When I see a new patient come in, first thing I look for is, hey, is there a reason absolutely not to use a certain medication? Because if the patient has a contraindication, that one is off the list. You only have to talk about it. So you should assess the patient's clinical history and then the risk benefit of each anti-obesity medication.

You consider the risk and benefit of using the medication. Also, you have to consider the risk and benefit of not using the medication. All right. Sometimes we forget that part.

And comorbidities. So when it is appropriate, it is nice to use an anti-obesity medication that can treat the obesity but also maybe improve their other medical conditions. So a simple example is type 2 diabetes and a GLP-1 receptor agonist.

And then cues. So you consider the patients how they describe their appetite control and symptoms. I do not know that the scientists were quite there yet, but it is interesting. So what I am talking about here is some people, they might never feel hungry, but they never feel full, right? So fullness is the problem. Once they start, they cannot stop. Other people, it might be stress or emotion that triggers their eating. And other people may just be hungry all the time, but when they eat, they get full. Anyway, there is all these different phenotypes. And so at some point we may get smart enough that we know which medication helps each one. So you can help guide your choice a little bit.

And then also, of course, the mode of delivery is important. Some people I do not want a shot. Not at all. Other people that, yes, give me a shot once a week. That is way easier than doing 4 pills a day. So patient preference is important.

And then combinations. And of course like we have talked about many times already today, lifestyle interventions absolutely should be combined with any anti-obesity medication. And then also you like other chronic medical conditions, you can combine anti-obesity medications. Someone’s blood pressure is high enough, you use 2 antihypertensive medications. So same thing with anti-obesity medication. Consider combinations.

And also with surgery. Okay. Now this is still being worked out. Do you do medication beforehand and then have surgery, or do you do surgery and then medication? There is no standard at this point. But they are definitely used in combination not necessarily concurrently at the same time but medication, surgery, medication in some order. So something to think about, depending on the patient's situation of course.

And then the last C is cost and coverage. So aside from contraindications, this is usually the second one that I look at when I see a new patient. So consider the medication cost and the patient's insurance coverage. If it is too expensive and they cannot get it, it is not going to work. Believe it or not, you have to take the medication for it to work.

And many of these medications are expensive. There are coupons and discounts, all sorts of other things. But you have to find one that is going to be affordable for the patient.

[01:35:53]

          Comparisons of Anti-obesity Medications

So there are a few slides here, charts with more details on each of these medications. I am not going to read all of this to you, but I am going to pull out some of the high yield things that are either very important or unique.

So with bupropion and naltrexone, the most common side effects nausea, headache, gastrointestinal symptoms. The bupropion component, we use it to treat depression, but it can also worsen depression. It can cause jitteriness or anxiety.

And then a note on pregnancy. We use none of the anti-obesity medications during pregnancy. Okay. And they have not been studied in breastfeeding. So I also do not use them if someone is breastfeeding.

And then for bupropion and naltrexone particularly uncontrolled hypertension, seizures, anorexia and bulimia are reasons not to use it. And also chronic opioid use because of withdrawal with the naltrexone component.

And phentermine and topiramate, dry mouth and constipation. Most common things I see by far. Paresthesia from the topiramate component. An interesting side effect that not everyone gets, and it is not listed here, but is fairly common is dysgeusia for specifically carbonated beverages. So if someone has a problem with sugar sweetened beverages, soda, sometimes the topiramate can be helpful.

And also decrease bicarb with the topiramate. So if you are using it in combination with metformin, which could also do that, it might be worth checking a bicarb level if you are doing the combination. Okay. Contraindications. Hyperthyroidism and acute angle-closure glaucoma can be triggered with phentermine/topiramate.

Orlistat. The gastrointestinal side effects are very common. Not everyone gets them, but most people do. The orlistat is decreasing fat absorption essentially. And so that fat just goes right through you. So steatorrhea, oily stools, sometimes leaking also. And you can also, if you are using it regularly, have decreased fat soluble vitamins. You are not absorbing the fat. So those fat soluble vitamins are not being absorbed either.

So there are certain medications with orlistat that would get absorbed abnormally. So warfarin and cyclosporin in particular and antiepileptics.

[01:38:34]

          Comparisons of Anti-obesity Medications (continued)

I should note that GLP-1s and GLP-1/GIP receptor agonists, gastrointestinal side effects. I mean, the list of side effects is exactly the same for all 3 of these. So nausea, constipation are the most common things I see. Gas, bloating, belching all possible as well. Headache and tiredness are on the list. In my experience, not quite as common as the gastrointestinal side effects, but definitely happen.

All right. And then I already mentioned pregnancy as a contraindication for all the anti-obesity medications, specifically with the GLP-1 receptor agonists. A personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 is also contraindications.

[01:39:32]

          Liraglutide 3.0 mg Reduced Visceral Adipose Tissue Over

All right. So let us look at some outcome studies here. So this is liraglutide. This is the daily GLP-1 receptor agonist at m mg, which is the maximum dose. And this study reduced visceral adipose tissue over 40-week course. And you can see the reddish orange is placebo and the blue is the intervention group with liraglutide.

So we have already talked about how visceral fat is associated with metabolic disease, fatty liver disease, dyslipidemia, etc.. And so visceral adipose tissue decreasing is great. That is what we want for metabolic health.

So in this study, anyway visceral adipose tissue decreased. So it was not just decreasing a BMI or weight but also specifically visceral adipose tissue.

[01:40:26]

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

Okay. And you may know that the GLP-1/GIP receptor agonists originally were for diabetes. We still use them for type 2 diabetes. Is the weight loss effect any different if you have diabetes versus you do not have diabetes? Is it going to work in one and not the other one?

So this is the SURMOUNT trial. So SURMOUNT-1 and SURMOUNT-2 and tirzepatide. So SURMOUNT-1, which is on the right side of the screen here, was done in participants without type 2 diabetes. And SURMOUNT-2 on the left side was done in participants with type 2 diabetes.

Both were 72 weeks. And you can see the lighter blue is 10 mg. No, I guess it is different.

Okay, let us focus on the SURMOUNT-1 on the right side here. So the lighter blue on this graph is 5 mg. The medium blue is 10 mg, the dark blue is 15 mg. And then the reddish orange is placebo. And you can see weight kept decreasing higher. You went on the tirzepatide dose. And then the dark blue, you can see that is right around that 22.5% like we saw on the prior slide, total body weight loss.

Okay. And then if we look at SURMOUNT-2 trials. So this is in participants with type 2 diabetes. The lighter blue is 10-mg dose, and the darker blue is 15-mg. And you can see, yes, people did lose weight. Not as much as in the SURMOUNT-1 trial in people without diabetes. And you will see with the 15 mg in the SURMOUNT-2 trial, it was right around 15%. So still effective, but not as much weight loss as in the SURMOUNT-1 trial.

[01:42:17]

          Weight Recurrence Following GLP-1 RA Cessation

All right. How long do I have to stay on my anti-obesity medication for? How long do I have to stay on my antihypertensive for? The short answer is forever. And there are studies that show this. And this goes back to the metabolic adaptation, the body's counter-regulatory processes that want to, as far as we know, indefinitely cause weight regain.

All right. Well, let us look at the left side first here. This is STEP-1 extension for semaglutide. All right. So it is 68-week treatment phase and then 52 weeks off of treatment. You see the orange group, they lost a little bit of weight, regained most of it by 68 weeks. And then their weight kept increasing. The intervention group, they lost a bunch of weight. And then when they stopped, look, weight regain. Okay. That is what happens with a chronic medical condition. It is not a sinus infection that you treat for 5 days and you are cured. It is a chronic condition.

SURMOUNT-4. So this is similar study but looking at tirzepatide. So everybody got tirzepatide to begin with, up to 36 weeks. And then they were randomized to continue tirzepatide use, and they kept losing weight, or these poor people were randomized to placebo and they regained weight. Okay. So you need to stay on your medication indefinitely to control the underlying pathophysiology.

[01:43:48]

          SELECT: Durable Effectiveness of Semaglutide for Weight Loss at 4 Yr

All right. So does the medication keep working or does it wear off at some point? So this is semaglutide. So orange is placebo. Not a lot of weight loss, 1% or so and wobbling up and down. The intervention group who got semaglutide lost weight somewhere around 10%. And yes, they kept it off long term. Long term being 208 weeks in this study.

Okay. And then I think this stuff is all interesting, but when you look at the breakdown of how different people respond to medication, so interesting the variation. So you will see in this study in particular, about two thirds lost at least 5% of their weight, but close to 5% of people who lost over 25%. And often I will tell patients this be like, hey, this is the average weight loss we expect whatever, 15% with semaglutide. But boy, some people lose a lot more than that. Some people do not lose as much. So again, it is helpful to set expectations from day one.

And then there is a note here of a 20% decrease in cardiovascular endpoints. So we will touch on that in a slide coming up here.

[01:45:06]

          Think of Treating Obesity Like Other Chronic Diseases (Hypertension)

So I already talked about this. Medications work when you take them for chronic medical conditions. And they do not work when you do not take them, right?

Here it says, if you stop, the condition returns. I do not know that the condition went away. So it has gone. It comes back. It is still there. It is just not controlled when you stop the medication.

[01:45:27]

          Individualized Responses to GLP-1 and GIP/GLP-1 RA

This gets at the individual response. So liraglutide, semaglutide, tirzepatide going left to right. And you can see, in general, the degree of weight loss is shifting to the right. So more weight loss with each of these, but also how much variation there is person to person. I mean you had people in semaglutide, the red graph in the middle. Look how many people lost about 41 to 45 pounds. There were a lot. Most were around the 15% or so. So very interesting. And you will see that clinically as you are working with patients, the variability in response.

[01:46:16]

          Ineffective Response to Therapy  

So there are some people who the medication does not work for. Does not mean another medication would not. There is so many different pathways. There is so many things going on externally in our environment. And we looked at all the complexities. So if one does not work, you can try a different one. Actually, let us walk through here.

So if someone does not lose 5% of their weight at 12 weeks on the maximum dose, consider making a change of some sort. Okay. That medication, they are not responding to it adequately. So you could increase the dose if it is a medication that allows for that.

Now, if someone cannot tolerate the maximum dose or going up on the dose, then changing to a different medication would be reasonable. But even at 3% to 4%, if weight-related medical conditions are improving, you could consider continuing it.

[01:47:08]

          Direct and Indirect GLP-1 RA-Mediated Cardioprotection

Okay. The GLP-1s. So SELECT study showed that GLP-1, specifically, semaglutide decreased risk for major adverse cardiovascular events. And so this slide looks at how GLP-1s may lead to cardioprotection. So they decrease adipocyte tissue burden in the body and decrease body weight. And so you have fewer free fatty acids in the circulation that decreases hepatic steatosis and the circulating lipids. Kidney function improves, decrease in albuminuria. Blood pressure can decrease by various mechanisms, which improves the microvascular and coronary artery flow. There is decreased inflammation when you lose excess adipose tissue and plaque that may be present becomes more stable.

And then the myocardium itself, the function can improve. So decreased apoptosis of those cells, decreased inflammation, improved glucose metabolism, and less ectopic visceral fat in the myocardium as well. And all of that can protect cardiac function.

[01:48:20]

          Semaglutide for Cardiovascular Event Reduction in People With Overweight or Obesity: SELECT Study

So this is the SELECT trial looking at semaglutide. So the inclusion criteria were people who have had a heart attack, stroke or peripheral arterial disease. And it was a large study, 17,000-some participants, mostly male, a little bit older than in some of the clinical trials looking specifically at obesity and mostly non-Hispanic white as well. And the exclusion criteria was diabetes. So many had prediabetes but not diabetes.

And the summary is that it showed a 20% reduction in major adverse cardiovascular events in people treated with semaglutide 2.4 versus placebo. I will say both groups, intervention and placebo were on optimal cardiovascular medication treatment. So they were on their ACAE or their ARB. They were on their beta blockers, indicated their statin or lipid management medication. So that significant 20% reduction in major adverse cardiovascular events.

[01:49:29]

          Tirzepatide: Results in People With MASH

Okay. And these medications are being studied for obesity and all sorts of other medical conditions. So there you just saw cardiovascular disease. This is metabolic dysfunction associated steatohepatitis. And so you can see that tirzepatide with increasing doses increases the rate of resolution of MASH. And on the right side, improves the degree or the stage of fibrosis in MASH.

[01:50:00]

          SURMOUNT-OSA: Tirzepatide for Obesity and OSA

SURMOUNT-OSA. So SURMOUNT are the tripartite trials, and this one specifically looked at obstructive sleep apnea. You can see the decrease in the number of AHIs, the apnea hypopnea index, which is how we measure the severity of obstructive sleep apnea. What is fascinating here is in trial 2, participants who are currently using PAP therapy. So they are already being treated for obstructive sleep apnea. Look at the dramatic decrease in episodes. All right. About 29%, 30% in trial one. It was in patients who had sleep apnea but who were not currently using CPAP/BiPAP therapy. And there was also improvement.

So these medications are addressing weight and also all these weight-related medical conditions.

[01:50:51]

          Compounded Peptides

So just a word on compounded peptides. I am not going to read through all of this here. But compounded peptides I get asked about them multiple times a day from patients and providers. You maybe have patients asking you as well. I would direct you to the Obesity Medicine Association. They have a statement on it. The FDA has statements on compounding pharmacies as well.

So at least as far as the Obesity Medicine Association in the shaded box here, just right of center. They do not recommend for or against compounding peptides, but they do caution that you need to be very particular and thorough when deciding if you are going to use a particular pharmacy, as far as doing due diligence and ensuring informed consent for the patient, the safety, the efficacy of the active product ingredient that the compounding pharmacy is using, and then make sure that lawful regulatory practices are being followed.

Okay. And the FDA statements say, because it is true that they do not regulate the compounding pharmacies. And so they cannot assure the same safety, efficacy and purity for compounded peptides as the approved medications which they do regulate.

[01:52:12]

          Use of Anti-Obesity Medications Short-Lived in United States: Discontinuation and Switching 2015-2018

Anti-obesity medications are short lived as far as how long people use them for. And we have learned by now and established that there they are approved for long term use. That is how you treat obesity as a chronic condition. You will see here 51% discontinuation, 19% for the naltrexone/bupropion, liraglutide 13% discontinuation. So the mean treatment was 81 days. It is not often you treat high blood pressure or type 2 diabetes for 81 days and then stop. So this is, is it side effects, is it cost? My suspicion, it is mostly a misunderstanding of the disease state of obesity.

[01:52:56]

          Bariatric Surgery Criteria and Weight Reduction

Just one slide on bariatric surgery here. Bariatric surgery is indicated if you have a BMI of 35 or higher. If you have a BMI of 30 to 35 with a weight-related medical condition and type 2 diabetes being an example, it is indicated. Very safe procedure. Very effective procedure. As shown here are 4 different ones that are done. The adjustable gastric banding is not commonly done at this point. Many people still have a band from when it was more commonly done in the past.

A sleeve gastrectomy, you essentially just remove this part of the stomach. So common sense the stomach is smaller, you get fuller sooner. But also ghrelin, the hunger hormone, comes from this part of the stomach. So these hormone signals and pathways change with sleeve gastrectomy.

And also with the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch. So the bypass you resect the stomach. And so the food comes down into the stomach and is fed into the distal part of the small intestine. So it bypasses the proximal part. So you essentially mal-absorb. You don't absorb as much food and nutrients, but you still have the biliopancreatic limb, so that those digestive juices are able to mix with the food that you eat.

And then as we go from left to right here, there is more involved of a procedure, but also greater weight loss.

[01:54:27]

          Weight Loss Is Highly Variable After Surgery

And like medications, the response is quite variable, as you can see here. On the left is the bypass and on the right is the sleeve gastrectomy.

[01:54:38]

          Post-Bariatric Weight Recurrence Is Expected

And it is normal to regain some weight after surgery. You see after about a year or 2 there is a bump up. Okay. So I tell patients, hey, a year or 2 after, you should continue losing weight on average for a year or 2 after surgery. And then there is often a bump up after that. So that is a very important reason to keep these folks engaged in care long term to catch the weight regain.

[01:55:02]

          Anti-obesity Medications Support Long-Term Weight Loss After Surgery

And this is just one study of using anti-obesity medication after surgery. Okay. Take a look at the left graph here. You can see adding a GLP-1 receptor agonist had the greatest effect for continued weight loss after bariatric surgery, although lifestyle, at least up to 6 months was modestly helpful. Although at 9 months you see not effective and weight gain. And then non-GLP-1 anti-obesity medications were helpful as well.

[01:55:44]

          Nutritional Considerations for People Taking Anti-obesity Medications

So if someone taking anti-obesity medications, you should do an assessment for nutrient deficiencies. Sometimes it is just the dietary history. You want to assess body composition. You are losing muscle is not good. So you want to get adequate protein, like it talks about on the right side here. Adequate protein, adequate fiber, adequate fluid. Energy varies. You can calculate it. You can measure resting energy expenditure. This is just a broad kind of general recommendation.

And then if someone has symptoms of any micronutrient deficiency, consider a multivitamin or laboratory testing to diagnose the deficiency.

[01:56:25]

          Posttest 1

All right. Let us go back to this question here. So a 38-year-old woman with a BMI of 29.8 requests assistance with weight loss based on clinical trial data and current guidelines. Which of the following would likely be the best option for this patient?

1. Bariatric surgery;
2. Liraglutide;
3. Phentermine/topiramate ER; or
4. Tirzepatide.

Okay. Let us see. We have the explanation here.

[01:57:10]

          Posttest 1: Rationale

Tirzepatide is the correct answer. So there are no head-to-head trials comparing the effectiveness of anti-obesity agents, or at least all of them. Placebo controlled trials cannot be directly compared. But based on estimated results from these trials, and we looked at the expected weight loss at the beginning of this session, tirzepatide appears to be the most effective of these listed medication options, with up to 22.5% weight loss in the trial participants, whereas the other medications were less effective.

And bariatric surgery, very effective option, but not recommended based on where her BMI is at this point.

[01:57:51]

          Targets Beyond Appetite

All right. Then just very briefly, we 2 more slides here. There is a lot being studied right now as far as other agents. I am not going to read all of these, but they work by very different mechanisms than what we have talked about already. So feel free to read these slides more closely on your own.

[01:58:11]

          Future Nutrient-stimulated Hormones

Well, again, it is all interesting. But nutrient stimulating hormone. So you take the medication and they are essentially active when you eat food, similar to GLP-1 and GIP. So different variations of those medications that are being studied as well.

[01:58:31]

Shared Decision-making

All right. That is enough from me. Dr Golden, you are up.

Dr Golden: All right. Thank you. I may have to have some help with the slides because the little slide thing is not there. But thank you, Dr Weber. Personally, as a woman who also lives with chronic obesity, that is never on my disclosure slides. I am not sure how to get it there.

Of all the chronic diseases, I think that obesity holds a really special space for shared decision-making. Those of us with obesity have been shamed in healthcare situations. You heard about that with bias and stigma. So having clinicians offer to make me part of that shared decision-making can really increase our patients’ engagement in treatment, as well as create that environment of trust.

[01:59:22]

          What Do Patients Want/Expect From Us?

So this slide is very telling. From the past 24 years, 71% of patients want to participate in their decision-making. Only 60% of patients say we listen to them. 40% do not feel that we do. I often hear my colleagues say that patients do not want to really understand risk and benefits, but the research is clearly telling us that patients do want to be informed.

[01:59:48]

          Defining Shared Decision-making

Shared decision-making needs to occur when patients are facing choices for chronic conditions. That is going to impact their daily lives, especially those that have health, financial or quality of life.

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