Overcoming the Challenges of Obesity Management in Primary Care - - PowerPoint PPT Presentation

Traversing the Chasm: Overcoming the Challenges of Obesity Management in Primary Care

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• Discuss the benefits of weight loss with persons who are candidates for

medical management of obesity

• Discuss weight loss goals and treatment options with people who are

candidates for medical management of obesity

• Describe the indications, administration, and potential adverse events

associated with anti-obesity medications

• Examine approaches for addressing obstacles and adjusting therapy in

the long-term management of obesity

Learning Objectives

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Obesity Is a Chronic Medical Condition Associated With a Number

• f Comorbidities

FDA = US Food and Drug Administration.

• 1. US FDA. www.fda.gov/media/71252/download; 2. Sharma AM. Obes Rev. 2010;11:808-809; 3. Guh DP, et al. BMC Public Health. 2009;9:88; 4.

Church TS, et al. Gastroenterology. 2006;130:2023-2030; 5. Hosler AS. Prev Chronic Dis. 2009;6:A48; 6. Li C, et al. Prev Med. 2010;51:18-23; 7. Luppino FS, et al. Arch Gen Psychiatry. 2010;67:220-229; 8. Simon GE, et al. Arch Gen Psychiatry. 2006;63:824-830.

Metabolic2-5:

• Prediabetes, T2DM, asthma, gallstones, infertility, fatty liver
• Cancers: endometrial, kidney, ovarian, breast, colorectal
• Cardiovascular diseases: stroke, dyslipidemia, hypertension, coronary artery disease, heart failure

Mechanical2,3,6: Incontinence, osteoarthritis, sleep apnea, chronic back pain Mental health2,7,8: Depression, anxiety, bipolar disorder, agoraphobia

US FDA:1 “…a chronic relapsing health risk defined by excess body fat.”

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A Diagnosis of Obesity Improves Outcomes for the Patient

HCP = healthcare provider; OR = odds ratio.

• 1. Kaplan LM, et al. Obesity. 2018;26:61-69; 2. Post RE, et al. JAMA Int Med. 2011;171:316-321; 3. Singh S, et al. Am Heart J. 2011;160:934-942;
• 4. Pool AC, et al. Obes Res Clin Pract. 2014;8:e131-e139; 5. Jackson SE, et al. BMJ Open. 2013;3:e003693; 6. Rose SA, et al. Int J Obes (Lond).

2013;37:118-128.

Increased likelihood of weight loss attempts (OR, 2.42)3 Increased likelihood of actual weight loss (OR, 2.70)3

“I can help you”

Weight loss advice from providers increases a patient’s weight loss efforts by 3.5 to 3.8 times5,6 Obesity is underdiagnosed in the US1,2 A diagnosis of obesity or discussion about weight by an HCP is associated with2-4:

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Case Study: Introducing Tasha

• Tasha has recently moved to the city and is attending your clinic following a health

check-up that raised some worrying results

• Current status

‒ Height: 156 cm (61.4 in) ‒ Weight: 68.9 kg (152 lb) ‒ BMI: 28.7 kg/m2 ‒ WC: 92.5 cm (36.4’’) ‒ BP: 156/94 mm Hg ‒ A1C: 6.1% ‒ FPG: 102.7 mg/dL (5.7 mmol/L) Age: 26 Ethnicity: African American

FPG = fasting plasma glucose; WC = waist circumference.

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Motivational Interviewing (5As)1,2: Start With Asking the Patient Permission to Discuss Weight

• 1. Vallis M, et al. Can Fam Physician. 2013;5:27-31; 2. Bays HE, et al. Obesity Algorithm 2020. https://obesitymedicine.org/obesity-algorithm/; 3.

STOP Obesity Alliance. whyweightguide.org/tool-content.php.

“Would you be open to discussing your weight today?” Seeking permission to discuss weight encourages a nonjudgmental conversation1 Weight and obesity are personal and sensitive topics; discussing them could be difficult for the patient and cause feelings of embarrassment or fear1,3 If the patient makes it clear that they do not want to have a discussion today, respect the choice and table the conversation for a later date1,3

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BMI classification1 kg/m2 Underweight ≤18.5 Normal weight 18.6-24.9 Overweight 25.0-29.0 Obesity class I 30.0-34.9 Obesity class II 35.0-39.9 Obesity class III ≥40

Motivational Interviewing: Assess the Stage and Class of the Obesity

Stage 4: End stage Stage 3: End-organ damage Stage 2: Established comorbidity Stage 1: Preclinical risk factors Stage 0: No apparent risk factors

WHO = World Health Organization.

• 1. WHO. www.who.int/dietphysicalactivity/childhood_what/en/; 2. EOSS Staging tool. www.drsharma.ca/wp-content/uploads/edmonton-obesity-

staging-system-staging-tool.pdf.

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BMI classification1 kg/m2 Underweight ≤18.5 Normal weight 18.6-24.9 Overweight 25.0-29.0 Obesity class I 30.0-34.9 Obesity class II 35.0-39.9 Obesity class III ≥40

Motivational Interviewing: Assess the Stage and Class of the Obesity

Stage 4: End stage Stage 3: End-organ damage Stage 2: Established comorbidity Stage 1: Preclinical risk factors Stage 0: No apparent risk factors

WHO = World Health Organization.

• 1. WHO. www.who.int/dietphysicalactivity/childhood_what/en/; 2. EOSS Staging tool. www.drsharma.ca/wp-content/uploads/edmonton-obesity-

staging-system-staging-tool.pdf.

Tasha is overweight according to the WHO classification system, with a BMI of 28.3 kg/m2 However, she has stage 2 obesity per the Edmonton Obesity Staging System because she has established hypertension

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Motivational Interviewing: Assess Drivers, Complications and Barriers, and Readiness for Change

Mental Health

Feels low/isolated following move to new city; husband frequently away for work, leaving her to care for young child Reports eating out of boredom during evenings/weekends Recently started a stressful new office job

Mechanical

None reported

Metabolic

Hypertension Prediabetes Missed periods Reports concern about her newly diagnosed health problems

Monetary: Well educated; insurance will cover medical

therapy for obesity if needed

“Have you experienced problems in any of the following domains, which could contribute to weight management?” “Are you interested in taking some steps to lose weight?” If the patient is not ready to make a change:

• Work to address barriers to readiness,

such as existing health conditions

• Invite the patient to let you know when

they are ready If the patient is ready to make a change:

• Ask about previous weight loss efforts

and what has worked in the past

• Determine the level of support the

patient desires from you

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Motivational Interviewing: Advise That Small Amounts of Weight Loss Can Lead to Meaningful Health Improvements

• Weight loss required for therapeutic benefits (%)1,2

GERD = gastroesophageal reflux disease; NAFLD = nonalcoholic fatty liver disease; PCOS = polycystic ovary syndrome.

• 1. Cefalu WT, et al. Diabetes Care. 2015;38:1567-1582; 2. Lean MJ, et al. Lancet. 2018;391:541-551; 3. Blissmer B, et al. Health Qual Life
• Outcomes. 2006;4:43.

5 10 15 Diabetes (prevention) Diabetes (remission) Hypertension Dyslipidemia Hyperglycemia NAFLD Sleep apnea Osteoarthritis Stress incontinence GERD (males) GERD (females) PCOS 3 to 10% 3% to >15% 3% to >15% 10% 10% 5% to 10% 5 to >15% 5% to 15% 10% 5% to 10% 10 to 15% 5% to 10% 5% to 10% weight loss can improve quality of life, and this improvement is maintained even if some weight is regained3 10%

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Why Is Modest Weight Loss Beneficial?

VAT VAT

Abdominal

• besity,

increased WC After weight loss, reduced WC

Deterioration Lipid profile Improvement Impaired Insulin sensitivity Improved  Blood insulin   Blood glucose   Risk markers for thrombosis   Inflammatory markers  Impaired Endothelial function Improved

10% weight loss = 30% VAT Loss

Increased Risk Lowered Risk

SCAT = subcutaneous adipose tissue; VAT = visceral adipose tissue. Adapted from: Després J, et al. Br Med J. 2001;322:716-720.

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• Weight loss goals1-4

─ Good initial goal: 5% to 10% within 6 months ─ Complications? More aggressive approach? ─ Reassess therapy when health goal is met ─ Greater losses yield greater benefits

• Goal-setting tips5

─ SMART (Specific, Measurable, Attainable, Relevant to you, Time limited) ─ Short and long term ─ Expect setbacks ─ Reassess and adjust

Motivational Interviewing: Agree on a Weight Loss Target and Approach

• 1. Garvey WT, et al. Endocr Pract. 2016;22:842-884; 2. Apovian CM, et al. J Clin Endocrinol Metab. 2015;100:342-362; 3. Jensen MD, et al.
• Obesity. 2014;22(suppl 2):S1-S410; 4. Bays HE, et al. Obesity Algorithm 2020. https://obesitymedicine.org/obesity-algorithm/; 5. Mayo Clinic.

https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20048224; 6. Dietitians Association of Australia. https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/weight-management/weight-loss-goals-other-than-the-scales/.

Think Beyond the Scale!6

Health improvement (eg, BP), ability to do more, less pain, better sleep, better diet, etc

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• Nutrition, physical activity, and behavioral interventions are core

components of weight management1-4

Motivational Interviewing: Assist the Patient by Recommending Weight Management Interventions

• 1. Garvey WT, et al. Endocr Pract. 2016;22:842-884; 2. Wharton S, et al. CMAJ. 2020;192:E875-E891; 3. Durrer Scuhtz D, et al. Obesity Facts.

2019;12:40-66; 4. Bays HE, et al. Obesity Algorithm 2020. obesitymedicine.org/obesity-algorithm/.

─ Many types of diet will work (eg, meal replacements, keto, low-carbohydrate, low-fat, Mediterranean, commercial), but aim for a caloric deficit of 500 to 750 kcal/day ─ Consider patient needs, limitations, preferences ─ A supervised very-low-calorie diet is an option for select patients ─ Aim for regular physical activity and a reduction in sedentary behavior ─ Aerobic (>150 min/week; 3-5 days/week) ─ Resistance (major muscle groups, 2-3 times/week) ─ Behavioral interventions: self-monitoring, goal setting, education, problem solving, stimulus control, contracting, stress reduction, psychological treatment, cognitive restructuring, motivational interviewing, social support

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Complication Status Pharmacotherapy Bariatric Surgery

No obesity-related complications Pharmacotherapy should be offered to patients with

• besity–when

potential benefits

• utweigh the

risks–for the chronic treatment

• f their disease1

Consider if lifestyle is not effective and BMI ≥302,3,a Consider if lifestyle not effective and BMI ≥40b ≥1 mild to moderate obesity-related complication Consider if BMI ≥272,3 Consider if BMI ≥35a ≥1 severe obesity-related complication Add if BMI ≥272,3 Consider if BMI ≥35a

Pharmacotherapy and Surgery Can Be Used as Adjunctive Therapies

a American Association of Clinical Endocrinologists recommendations, ≥27; b European Union guidelines: bariatric surgery should be considered for individuals with

BMI ≥30 if lifestyle is not effective and comorbidities are present or if the patient has a BMI ≥30 and T2DM in the absence of previous lifestyle changes.

• 1. Garvey WT, et al. Endocr Pract. 2016;22:s3; 2. Wharton S, et al. CMAJ. 2020;192:E875-E891; 3. Durrer Scuhtz D, et al. Obesity Facts.

2019;12:40-66.

• More severe disease—based on anthropometric measurements and complication

status—warrants more intensive therapy

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Importance of Personalized Care

Group aspect addresses Tasha’s need for companionship after moving to a new city and help address eating from boredom Control comorbidities separately Introduction of “lifestyle activity” reduces amount of time spent on sedentary activities

Fastenau J, et al. Clin Obes. 2019;9:e12309.

• Attend a twice-weekly weight loss support group
• Walk to work 3 times/week
• Interest in taking weight loss pharmacotherapy
• Begin taking ramipril 5 mg/day for hypertension

All interventions take into account Tasha’s personal circumstances

• Patient-centered care is a key concept in the treatment of multiple chronic

diseases, including diabetes, dyslipidemia, and cardiovascular diseases

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The Addition of Pharmacotherapy to Lifestyle Intervention Can Improve Long-Term Weight Loss Outcomes

aSibutramine 15 mg daily.

• 1. Wadden TA, et al. N Engl J Med. 2005;353:2111-2020; 2. Wadden T, et al. Int J Obes. 2013;37:1443-1451; 3. Hill JO, et al. Am J Clin Nutr.

1999;69:1108-1116; 4. Richelsen B, et al. Diabetes Care. 2007;30:27-32; 5. Smith SR, et al. N Engl J Med. 2010;363:245-256; 6. Sjostrom L, et al.

• Lancet. 1998;352:167-172; 7. Standford FC, et al. Obes Relat Dis. 2017;13:491-500; 8. Wharton S, et al. Clin Obes. 2019; 9:e12323.

Long-Term Use of Pharmacotherapy Aids in Weight Maintenance

• Can help maintain weight and

support additional weight loss following dietary intervention2-4

• Weight regain is likely if

medications are stopped5,6

• Effective as adjunct to bariatric

surgery for inadequate weight loss or weight regain4,5,7,8

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• 10
• 8
• 6
• 4
• 2

Medication alone Lifestyle modification alone Combined therapy

Weight Loss Over 52 Weeks, kg

a

a 1

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Agent1 Dosage form; frequency1 Mechanism of action1 Orlistat Oral tablet; 3× daily GI lipase inhibitor Promotes fat excretion (GI) Phentermine/topiramate ER (schedule IV) Oral tablet; 1× dailya (titrate to final dose) Sympathomimetic/antiepileptic Regulates appetite (CNS) Naltrexone ER/bupropion ER 2 oral tablets; 2× daily (titrate to final dose) Opioid antagonist/antidepressant Regulates appetite (CNS) Liraglutide 3.0 mg 1 SC injection; 1× daily (titrate to final dose) GLP-1 RA Regulates appetite (CNS)

Approved Obesity Agents Target Different Obesity Mechanisms

Diethylpropion, phendimetrazine, benzphetamine, and phentermine: sympathomimetic amines that increase satiety; approved for short-term use1-4 Clinical data support administration of phentermine for longer than 12 weeks4

CNS = central nervous system; ER = extended release; GLP-1 RA = glucagon-like peptide-1 receptor agonist; SC = subcutaneous.

a15-mg/92-mg dose for use only if 7.5-mg/46-mg dose is not effective.

• 1. Drugs at FDA. www.accessdata.fda.gov/Scripts/cder/DrugsatFDA; 2. Garvey WT, et al. Endocr Pract. 2016;22:842-884; 3. Apovian CM, et al. J

Clin Endocrinol Metab. 2015;100:342-362; 4. Obesity Medicine Association. www.obesityalgorithm.org.

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Decisions Surrounding Weight Loss Drugs Should Take Into Account a Variety of Factors

Contraindications Insurance coverage/accessibility/ cost Patient-centered discussion

Efficacy of individual agents Potential for adverse events Lifestyle

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• 8.8
• 9.6
• 8.1
• 9.2
• 4.3
• 1.6
• 1.8
• 3.5
• 15
• 10
• 5

Δ BW, %

Medications approved for long-term weight management: 1-year efficacy in clinical trials1,a

Counsel Patients on the Efficacy of Different Weight Management Pharmacotherapies

Liraglutide 3.0 mg/day Naltrexone ER/bupropion ER 32/360 mg/day Orlistat 360 mg/day Control Phentermine/topiramate ER 7.5/46 mg/day

aData not from head-to-head studies; key clinical trials of ≥1 year in duration that included data for recommended doses;

participants had a baseline BW of ≈100 kg and average BMIs in the range of 35 to 39.9 kg/m2; bPreliminary results. BW = body weight; QW = once weekly.

• 1. Garvey WT, et al. Endocr Pract. 2016;22:842-884; 2. GlobeNewswire. www.globenewswire.com/news-release/2020/06/04/2043954/0/en/Novo-Nordisk-reports-weight-loss-of-

14-9-16-9-if-taken-as-intended-in-STEP-1-trial.html; 3. GlobeNewswire. https://www.globenewswire.com/newsrelease/2020/06/12/2047467/0/en/Semaglutide-2-4-mg-shows- superior-weight-loss-versus-placebo-in-the-phase-3-trials-STEP-2-and-STEP-3-thereby-successfully-completing-the-programme.html; 4. FiercePharma. www.fiercepharma.com/pharma/novo-nordisk-s-all-powerful-semaglutide-hits-first-mark-obesity; 5. Lundkvist P, et al. Diabetes Obes Metab. 2019;19:1276-1288.

Future agents may provide additional weight loss options:

Semaglutide2-4,b (phase 3): Exenatide QW + dapagliflozin5 (phase 2a):

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Agent Contraindications1,a AE Profile1,2,d

Orlistat Chronic malabsorption syndrome; cholestasis; pregnancy Abdominal pain/discomfort; oily spotting/stool; fecal urgency Phentermine/ topiramate ER (schedule IV) Glaucoma; hyperthyroidism; during/within 14 days of MAOI use; pregnancy (risk of fetal malformation) Paresthesia; dizziness; distorted taste; insomnia; constipation; dry mouth Naltrexone ER/ bupropion ER Chronic opioid use; uncontrolled hypertension; seizure disorders; anorexia nervosa; bulimia; use of other bupropion-containing products; during/within 14 days of MAOI use; discontinuation of some drugsb GI AEs (nausea, vomiting); headache Liraglutide 3.0 mg MEN2; personal/family history of MTC (potential risk of thyroid C-cell tumors); pregnancyc GI AEs (nausea, diarrhea); headache

MAOI = monoamine oxidase inhibitor; MEN2 = multiple endocrine neoplasia type II; MTC = medullary thyroid cancer.

a For all agents: known hypersensitivity to agent or any component, not recommended during breastfeeding, caution on use of reliable contraception; b Alcohol, benzodiazepines, barbiturates, antiepileptic drugs; c From rat data; risk not determined in humans; d Selected common AEs, generally with incidence >10%,

are noted; please refer to medication package inserts and cited references for complete information.

• 1. Garvey WT, et al. Endocr Pract. 2016;22:842-884; 2. Drugs@FDA. http://www.accessdata.fda.gov/Scripts/cder/DrugsatFDA.

Consider Contraindications, and Counsel Patients on AE Profiles of Different Weight Management Pharmacotherapies

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Case Study (cont’d): 3-Month Follow-Up With Tasha

Initial status Current status Height, cm/in 156/61 156/61 Weight, kg/lb 68.9/152 65.7/145 BMI, kg/m2 28.7 27.4 WC, cm/in 92.5/36.4 81.3/32 BP, mm Hg 156/94 110/70 A1C, % 6.1 5.7 FPG, mg/dL 102.7 88.3 Weight loss: 3.17 kg/7 lb/4.6% BMI reduction: 1.3 kg/m2/4.5%

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Monitor Pharmacotherapy to Assess Need for Adjustment or Discontinuation1,2

aWeight loss ≥5% at 3 months, except ≥4% at 16 weeks with liraglutide 3.0 mg; bWeight loss <5% at 3 months, except <4% at 16 weeks with liraglutide 3.0 mg.

• 1. Drugs@FDA. www.accessdata.fda.gov/Scripts/cder/DrugsatFDA; 2. Apovian CM, et al. J Clin Endocrinol Metab. 2015;100:342-362.

Initiate

Initiate therapy with dose escalation based on efficacy and tolerability; do not exceed the highest approved dose Tasha started taking naltrexone/bupropion 12 weeks ago; the dose was titrated from initial dose of 8/90 mg daily to a final dose of 32/360 mg by week 4

Monitor

Monitor for efficacy, safety, and tolerability monthly for first 3 months and then every 3 months Tasha lost 3.2 kg/7 lb/4.6% over 12 weeks Attendance records show Tasha has attended 22 of 24 weight loss group sessions; she reports following advice from these sessions during her day-to-day life

Adjust

• If effective continuea
• If ineffective, discontinue: consider alternative

medications, treatmentsb

• Discontinue if there are safety or tolerability

issues Tasha’s weight loss was not >5% at 3 months despite adequate engagement with lifestyle

• interventions. Therefore, she should be

switched to an alternative medication; Tasha is switched to liraglutide 3.0 mg/day

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• Congratulate the patient for their achievements so far, including small amounts of

weight loss

• If the patient has not lost weight, do not blame the patient; react with empathy
• Review the causes of and barriers to weight loss; how have these changed since

you last saw the patient?

Communication Tips for Follow-Up Consultations

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Case Conclusion: Status at 6-Month Follow-Up

BP controlled with medication Blood sugars stabilized Weight: 62.6 kg/ 138 lb BMI: 26 kg/m2 BP: 110/70 mm Hg A1C: 5.5% FPG: 86.5 mg/dL

• Tasha is very pleased with her weight loss and resolution of health conditions
• She reports wanting to continue with lifestyle interventions, because she has enjoyed them—

particularly her exercise classes

• Liraglutide 3.0 mg can be continued for weight loss and weight maintenance long term

Weight loss: 6.3 kg/14 lb 9.21% BMI reduction: 2.7 kg/m2 9.41%

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PCE Action Plan

✓ Before beginning any discussion surrounding weight, ask the patient whether they are comfortable discussing their weight on this occasion ✓ Focus conversations around the health-related and quality of life benefits of small amounts of weight loss ✓ Develop a personalized, patient-centric, weight management plan that respects the patient’s preferences, values, and needs and sets achievable goals ✓ Review weight loss medications every 3 months; if weight loss is inadequate, discontinue the medication and consider alternatives

PCE Promotes Practice Change