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Diabetes Core Update
Special Edition - Obesity as a Chronic Disease - Treatment Approach March 2026
00:40:03
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- [00:03]
A
Welcome to this special edition of Diabetes Core Update. This is the second of our special series focused on obesity in 2026. I'm your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. This special edition of Diabetes Core Update is sponsored by Lilly. In the first episode of this series, we talked with doctors Donna Ryan and Sue Kucera about obesity as a chronic disease and how that understanding has really shaped and continues to shape our approach to obesity care so that it is consistent with the care provided in other chronic diseases. Dr. Ryan summarized 40 years of research by saying, and I'm going to quote here, we have to fight biology with biology, meaning that between the hormonal changes that occur when one gains or loses weight and the metabolic adaptation that occurs when one loses weight, all of that resists sustained weight loss. And so therefore, pharmacotherapy has an important place in our weight loss paradigm both to achieve weight loss and to maintain weight loss. And let's just be really clear here, that does not mean that a healthy diet and exercise aren't important. They are very important both in achieving weight loss and weight maintenance and most importantly, in achieving optimal health. But it is to say that lifestyle alone often is not sufficient to achieve and sustain the weight we desire to lose. Joining us to discuss an approach to weight loss in 2026 is Dr. Robert Kushner. Dr. Kushner is a Professor Emeritus of Medicine and Medical education, Northwestern University Feinberg School of Medicine, and former Director of the center for Lifestyle Medicine at Northwestern Medicine in Chicago, Illinois. He is, and I'm going to take a big breath I start this sentence. He is past president of the Obesity Society, the American Society for Parenteral and Enteral Nutrition, the American Board of Physician Nutrition Specialists, and a founder and past chair of the American Board of Obesity Medicine. He was awarded the 2016 Clinician of the Year Award by the Obesity Society. He's authored over 250 original articles and reviews, as well as multiple books, most recently a book that just came out titled Patient Centered Weight Management for Clinicians. And all of that makes him ideally suited to discuss our topic today. And finally, he was one of the professional practice committee members putting together the recently released American Diabetes Diabetes Association's Standards of Care on Pharmacologic Treatment of Overweight and Obesity. Yes, Bob, I am finally done with your introduction. Welcome to our podcast.
- [03:31]
B
Neal, thank you for that gracious introduction. It really was quite overwhelming, but I appreciate being here today and look forward to this.
- [03:39]
A
Bob, you're the perfect person to discuss this because you've been involved in this field for a long time. And with that in mind, before we dive into the topic of today, share with us how you got interested in obesity medicine, which, let's face it, 30 to 40 years ago, when you started out after residency, this was not a very popular field.
- [04:07]
B
Yeah, you know, everyone in obesity medicine has their own story to tell. You know, they get into it weaving into different directions. I got into it because in medical school, I got interested in diet and nutrition. I even went on and do a fellowship in nutrition, a master's in nutrition nutritional biology. And I decided to focus my early career on disorders of nutrition, undernutrition like tpn, short bowel syndrome, Crohn's disease, you know, difficulty absorbing and digesting food. And then the other end of the extreme, which I thought of as over nutrition, which was obesity. Now, who knew back then in the 1980s that obesity would absolutely explode? And I don't think of it no longer as a problem of over overnutrition. It's really like Donna Ryan said, a biological paintings with genetics causing the predisposition to gaining weight.
- [05:02]
A
Yeah, that's interesting, because back when you started, that makes so much more sense to me now because there was all of this interest in these disorders. And over time we realized the underlying biology of OBEs. Now, when you shifted to obesity initially, can you tell us about the approaches that were used way back then, which isn't, let's face it, that long ago.
- [05:29]
B
Right. Well, it's before the current medications, but because we didn't have an effective biological treatment like you said, regarding Donna Rye and treat biology with biology, I really became early on an expert in counseling and healthy lifestyle behavioral management. I really got my. My beginnings by spending a lot of time on nutrition physical activity principles and models of behavioral care like cbt, cognitive behavioral therapy, learning about habit formation, motivational interviewing, shared decision making, because that's what we had, is to encourage patients to take care of themselves better through lifestyle. And that led to basically a 5 to 8% weight loss on average. But as you know and all the listeners know, it's very difficult to sustain that weight loss with behavior. Again, but my foundation is in lifestyle, and that's why my clinic at Northwestern was called center for Lifestyle Medicine. To me, that's foundational, regardless of all these other treatments that have been introduced.
- [06:35]
A
You know, that's fascinating, and we may have time to come back to that later. And a question that I think many of us struggle with is how Important are those behaviors behavioral foundations now as we have medicines. But for now, let's move on and talk about in your opinion, what is the fundamental difference in our approach now.
- [07:00]
B
Well, as we all know, the highly effective GLP1 medications have transformed obesity care. It really has laid squarely that obesity is a biological based disease. I have worked with patients for years, if not decades who have struggled to control their weight, reduce their calories, keep their weight low, exercising as much as they can, and yet it's difficult. And we now know, but by using a medication, that struggle that the individuals have had for years or decades is removed. The food noise is removed, the cravings for food are reduced, appetite is under control, and they're now able to follow the lifestyle counseling recommendations that I've been talking about them for years. And they're following it with resolve and ambitious to go beyond what they thought they could even do like become more physically active, begin exercising, become more socially involved in community where they were perhaps reticent to do it because of their weight. So it really has changed the entire management of obesity. And lastly, Neil, I want to say is for all those years before these medications came about, it was difficult to even have a conversation about medication because patients would say, I know what to do, it's my fault, it's my responsibility. Medications are dangerous. The difference now is that many patients come into the clinic wanting to have a conversation about medication. Tell me more about it, I've heard about them. Am I a candidate for medication? Finally, can you prescribe a medication? For me, it's 180 degree difference from the year before these medications were developed and what it is like now.
- [08:47]
A
Yeah, I agree with you. I think one of the things that always impresses me as I talk with patients and you use the term it's my fault. And so many patients still feel that way. And for me, one of the more common pull out the tissue box, hand someone a tissue moment is when they realize after our discussion that it's not my fault. And there's so much shame that comes along with having felt that you don't have the willpower that it takes to do something. That in fact is in contradiction to all of the underlying evolution and biology that has led to the problem that you have. And it, in my opinion, one of the biggest advances in addition to weight loss is being able to relieve people of that burden.
- [09:51]
B
100% correct. I say that all the time when I give presentations and CME conferences. Is that one phrase that you said so well, is it is not your Fault is so powerful to have patients here that it really resets the, the, the way people think and they almost calm down and they realize they are in a non judgmental zone and they're being very transparent and open with you as a clinician and really sets a change in the conversation we're having about obesity.
- [10:24]
A
Yeah, and, and that, that was really made clear in the beginning of the standards of care where the obesity standards of care, the A D A says, and I'm going to quote here, obesity medicines are an essential component of a comprehensive approach to obesity management offering significant benefits beyond lifestyle alone. And we're not going to go into a deep dive on each of the medicine classes today, but rather we're going to focus on an approach to pharmacologic management. And I want to step back for a moment. You had said, and I completely agree. So many patients now come in ready to talk, but there's still a lot of patients who are not ready to talk. Can you help our listeners, our clinician listeners with some advice on how do you open the conversation when you have a patient in front of you who has an elevated bmi, who has consequences of that elevated BMI but hasn't brought it up proactively?
- [11:37]
B
Start with an ask. That's the first day 5Amodels and framework. You know, first one's an ask something like, is this a good time to talk about your weight? Or I've noticed that your weight has been climbing. We've been working with you, treating you with hypertension, dyslipidemia, sleep apnea, you name the obesity related complication. Is this a good time to talk about your weight? Are you aware that your weight may be affecting these other medical problems that we are treating over the past several years? If they open the door, and most will say yes. If they say no, maybe because they're running late, they're carpooling today, they have other things going on. But most will say yes. It shows respect and protects autonomy and allows patients to respond accordingly. If they say yes. What we are now recommending is that you schedule an obesity focused visit or obesity prioritized visitors. And what that does is it gets away from the idea that your hands on the doorknob, you're ready to walk out to see your next patient and you say, you know what, it would help if you lost a few pounds and you walk out. So if you're going to open the door and say, is this a good time to talk about your weight? I say to the patient, what do you think about if we schedule your very next visit as soon as there's an opening. And we're going to spend the entire session talking about your weight. And in preparation of that, what I would like you to do is maybe track your diet for a few days on your smartphone. Just get an idea of what you're eating and you can increase your awareness of it, maybe even track and track the steps you take on your smartphone for a few days. Write down, when did you start gaining weight? What were the triggers of gaining weight? What have you tried before? This could be done actually by handout, you give them. So it's kind of a proactive questionnaire that you can review with them. What are your preferences, your goals. May even want to get information on insurance company regarding medication if we're going in that direction. And this is all consistent what we call the chronic care model framework, where you have an informed, activated patient, right? They're coming in, preparing for it along with you, being prepared and proactive practice team, you and your colleagues. And that's a productive interaction. So that's what we are recommending.
- [13:47]
A
I think that's so helpful because it creates that initial buy in and it also addresses at the clinician end something I think we're all worried about, which is being able to manage our time during very busy office sessions. And we have that visit that is a separate visit to discuss a very important issue. It allows us to give the attention and time that it deserves. So they come back with the information that you asked them to collect, lead us through that first visit.
- [14:18]
B
Well, one other thing before I do that, and this relates to the Lancet Commission on obesity that came out last year and that is during your encounter, in addition to asking all the questions and so on, you're taking a life, life course perspective when you're talking to them. So, you know, take me through the, the trajectory of your weight and what you tried before and so on. But the other thing you want to do, Neil, is not just capture bmi, we're moving beyond bmi. What you want to look for as a clinician is is there harm to health because of the excess body fat? For example, if they develop an autoimmune disorder or develop a, you know, CLL or something like that, that may not be related to obesity, but other things like sleep apnea, arthritis of the knees, even psoriasis is related diabetes and so forth, that is directly related to weight. So you want to make that distinction that the weight is causing harm to health because that increases the importance of treating weight and helps Them understand. But to answer your question directly, once you have that information, we use shared decision making. I mentioned that already as a friend to all the clinicians and. And it's important to think about shared decision making on your end. You want to impart information that's going to be helpful in having to make a decision, such as how much weight is needed in order to get me off a CPAP or help my diabetes get in remission. What's the range of options available from lifestyle management, pharmacotherapy, even bariatric surgery? And you lay out for them. These are your options. And here's the option that's going to likely get you where you need to go depending on your underlying health problems. That's your role. Their role is they're going to tell you what their values are, what their preferences are, social circumstances, financial situation, and you come to a decision of where to go. I want to emphasize one thing, Neal. Neal, I think it's very important upfront to go over the range of options for the patient. So you don't just start with lifestyle management and don't talk about anything else. What I want the patient to know is I have your back. If you decide to start a lifestyle management today, I'm with you. But I also want you to know if there are other options in case that's not sufficient because three months down the road they may go. You know, I want to revisit drug therapy, which we talked about on the first visit. And it's not like something you have to beg for. They didn't earn the right to take medication. It was offered right up front. And one other thing, Neil, you talked about the ADA standards of care. There's another important recommendation there, and that is pharmacotherapy should be discussed at the initial visit as an option. So we're getting away from the step care approach. Like you have to fail lifestyle management before we move to pharmacotherapy or you have to fail pharmacotherapy before you go to bariatric surgery. Everything should be discussed up front and then you decide with the patient, where should we start?
- [17:23]
A
That's so important. And having patients involved like that and knowledgeable, creates, buy in. And motivation. We know there's a whole literature on motivational interviewing that it works. It is helpful. So when you go over that range of choices, lifestyle, pharmacologic management, bariatric surgery, do you leave it just wide open or do you help guide a patient to. Toward one or another of those or combined approaches?
- [17:55]
B
Yeah. So let me. So I give them the information which is the likelihood of achieving their goal. So let's get an example. Someone comes in with type 2 diabetes and they say, you know, I heard that you could actually put diabetes in remission, like get it under control with no medication and keep the hemoglobin A1C under better control. I will often say to them, you know, we could try lifestyle management, but we know from the data that you need about a 15% reduction in your body weight to achieve remission. And it's hard to do that with lifestyle alone. It'd be more beneficial, more likely you'll get there if we use a medication. Now again, you're using medication to achieve, you know, like a reduction in hemoglobin, amc, but I'll let them know we could try lifestyle management, but it's going to be a lot harder to get there versus using a medication. Or let's say I want to get my CPAP pressure down. You could try lifestyle alone, but you're more likely to get there if we add a medication or bariatric surgery in some cases. So I give them that information, but it's still up to them.
- [19:04]
A
Yeah, and that's so important. So let's now kind of hone in on pharmacological management. Can you go over the broad categories of medicines that are available and then how you choose among the different options?
- [19:19]
B
Broadly speaking, there's three categories of medications. That's how we think about it. The first is centrally acting medications. These are, we would call the earlier medications or the, the first generation medications. They have medications that work directly in the brain to moderate neurotransmitters that we know about like dopamine and norepinephrine, serotonin. They're all in the brain. So drugs like this would be phentermine, phentermine plus topiramate, which is qsymia, or naltrexone, bupropion, which is contrave. Those are the medications that work directly in the brain. They're effective, but I'd say modestly effective. And that's why there was never a big uptake of those medications because of balance between risk benefit ratio. Second category. There's only one medication in this category and that's peripherally acting states in the gut to reduce or inhibit the absorption of some dietary fat. That's Orlistat, Xenical. And in fact it's the only over the counter FDA approved medication under the trade name Alli. So that's what Orlistat is. Then we get to the third category, which is the Blockbuster medication, transformative medications. The category is, wait for this, nutrient stimulated hormone based medications. So these are, these are naturally occurring gut hormones that are released from the diet we call nutrient stimulated and they affect appetite. That's how they work their appetite. Examples would be the GLP1 medications like semaglutide or the GIP, GLP1 dual agonist tirzepatide. And the ones around the block that are coming very quickly are adding amyloid and glucagon. It's important to note that these are all naturally occurring hormones that when we synthesize them and give them back as peptides, we supercharge the body with mimics or mimetics of the naturally occurring hormones where we give it at very high levels and that's what affects the appetite in individuals and allows them to lose weight. A good comparison is like giving insulin back to someone for diabetes, but at very high levels and it controls our blood sugar. We all have insulin, but we give higher doses back to individuals with diabetes.
- [21:31]
A
That's a great analogy. Can you briefly go over the relative weight loss efficacy in percent? You had talked about the modest efficacy of the older medicines.
- [21:41]
B
Yep. So we can combine, we can combine the centrally active medications and orlistat probably into one one bucket. And that is a weight loss, a placebo subtracted weight loss of about 3 to 8% difference. So you get increased boosts over placebo 3% to 8% or so with these highly effective medications. Now you're talking about a placebo drug subtracted weight loss of 13% to even up to 18 or 20%. It's a completely different animal, if you will. It is truly transformative in how effective these medications are in total weight loss. I'd probably make it even easier. If you're on semaglutide or tirzepatide, you're talking about the average weight loss of 15 to 20% of your body weight. Some people are losing 25 to 30% of their body weight. I mean that is a tremendous amount of body weight.
- [22:37]
A
It is, it's really life changing for many people both in how they feel in general and for different diseases. I mean, obstructive sleep apnea. I think in the surmount OSA trial about half of the people essentially resolved their sleep apnea that AHI became less than 5 or less than 15 without daytime sleepiness. And I've had people just, you know, talk about their hips and knees and how much better they feel and what has, what has really fascinated me and impressed me as a clinician. Is something, Bob, that you said earlier that, that people who didn't do lifestyle approaches beforehand because maybe they were embarrassed to go to a gym or maybe their knees hurt too much when they walked suddenly have, and you use the word resolve, and I love that word, suddenly have the resolve to carry out the things they were unable to before they lost. We talk about 15, 20%, a 200 pound individual, that is 30 to 40 pounds. That is weight loss that you notice.
- [23:57]
B
Yeah, it's, you know, it's very rewarding as a clinician to see someone transform their personality, their way of life, how they interact with others. I always saw that early in my career when individuals underwent bariatric surgery. That's where I got my early experience where individuals are losing £100, £120 and they would come in empowered and having fun again and feeling connected with everybody. And now we're seeing the same effect with medication as far as the changing of world outlook.
- [24:35]
A
Boy, is that true.
- [24:36]
B
Yeah.
- [24:36]
A
It's funny that you mentioned that because it is one of those areas where you get a thank you. You don't get thank yous when you give someone a medicine for their blood pressure and cholesterol. People are happy, they avoid a future event, but seldom are they coming in with that feeling in the room of you've really made a difference. Let's go on now and talk about some questions that come up during those first visits. We'll cover at least a few of them. And though we will talk about weight maintenance strategies at a later podcast, the issue of how long you need to stay on the medicine often comes up at that first visit. Patients say, okay, I'm going to start this, but how long do I need to stay on it? What do you tell people?
- [25:29]
B
That's the number one question. How long? And we want to get away from the whole idea of jump start, Doc, I just need a jump start. And I talk about that right off bat. It's not a jump start. This is a long term. That's the word I use long term medication. Just like you had diabetes. We're not talking about jump starting your diabetes on a control. I use that as a comparator, Neil, all the time. Diabetes. I think it's very helpful one. So I say this is really a medication used long term. I do not use the word permanent, I don't use the word lifelong because people, despite the biology of obesity, and I think people are starting to understand that there is still a sense that it is my personal responsibility to take care of myself and manage My cravings and my desires and my motivation. And I don't know why I can't do that. And it's hard to let that go. Even though we talk to them that it's a biologically based disease and the fact that you are having food noise and having cravings and not feeling full enough is biology. It's not a lack of willpower. So they still have this feeling like once I get myself in good control, I think I can get off to medication. And there I tell them, I never say you have to be on it. It's shared decision making. But I will tell them that we have studies where individuals are on medication for three years. This is the extension of the step one trial. People with prediabetes maintained weight loss for three years. And you know what happened after three years of habit formation? And I got this doc, they stopped the medication because the trial is over and weight started to go back up again. I can tell you that's one of the most frustrating stories I tell patients. They go, really? I can't get off it. So you really have to have a conversation of realistic expectations. I'm going to work with you. If you feel you want to go off it, we will work on that together. We don't actually know today how to get people off medication. We don't know who can get off medication. So that's still a big question mark. So it's not like we have all the answers. But the trials show if we stop the medication suddenly, it is very highly likely you're going to start regaining weight.
- [27:43]
A
Yeah. And that's so important that patients realize it's long term, but realize I have very similar approach, Bob, that I'll be there with you if you do want to come off it. We won't stop it suddenly. We'll titrate down slowly and we'll see how you do. And there's a lot we're still going to learn. And, and people come back and they say, oh, I'm beginning to get those food cravings again. Let's dial back up a dose. And I think I agree with you. That approach sounds wonderful. Another question that I've just begun to get recently, though we as clinicians have known this area for a while is about muscle loss with weight loss medicines. And that has just over the last few months hit the popular media as well. How do you handle that question?
- [28:39]
B
Yeah, so what most of almost all the data is showing is that GLP1 medications do not directly attack or reduce muscle mass independently of the weight loss that's occurring. In other words, if you lose 15 to 20% of your body weight, whether it's bariatric surgery through an aggressive balanced calorie deficit diet or medication, there isn't significant differences in change in body composition. In other words, the loss of muscle mass is a natural response when you're losing this much weight. The reason we didn't have this conversation before is the earlier medications we talked about. You're only losing, you know, 8 to 10 to 12% body weight and it's not really noticeable. But when you're losing, you know, 25% of your body weight, you are losing a fair amount of muscle mass. The, the rule of thumb is about 1/4 to 1/3 of your weight loss is muscle, is lean body mass, of which is not all muscle mass, and the rest is fat mass. So I talk to them about that. But that does lead to the question of what do we do about it and who's at the greatest risk? So individuals who are, are older. Neil. Hello, you and me. Individuals who are older, let's say 65 and older, perhaps even younger than that. We're concerned. So I want to carefully watch their weight trajectory. In other words, what percent weight loss they're having. Always asking about their function, their strength, ability to carry, groceries. Are you exercising? Always emphasizing to get involved in resistance training, to try to at least be either maintain the muscle loss or prevent the reduction in muscle mass. Adequate protein in a diet that's big on social media. It's absolutely true. We're Talking about anywhere 65 to 90 grams of protein a day. That's if you want a kind of ballpark figure, 1.2 to 1.5 grams per kilo, which is hard to calculate. Lean proteins, whether it's dairy, certainly lean, lean meats, soy and so forth as good protein sources. Keep yourself hydrated. So, and lastly with the exam, although we're not doing a full functional exam with individuals, you probably want to pull up your neurology exam, you know, the muscle strain, you know, squeeze my fingers, stand up from the chair unassisted, you know, with the armrest. You may want to have someone actually look at their gait, particularly in someone who's older, just to do a brief exam of their muscle mass and function.
- [31:18]
A
Yeah, that's so important. And for me, that's one of the main reasons I bring people back regularly, to make sure that they are doing those exercises, that they're keeping up with protein. And hopefully by seeing me, that continues to motivate them to stay on it.
- [31:39]
B
I think I just want to. One other thing. I never thought that I would be working with patients who are living with obesity and I'm worried they're going to lose too much weight. I mean, talk about a long career. I never thought that you'd have medications where I have to counsel them. But we have to be careful. I could tell you there are medications being developed that are highly effective. You're talking about average body weights of 25% and then you get categorical weight loss even more. We have to be very cautious and monitor our patients carefully, particularly those that are susceptible to loss of muscle mass we call sarcopenia. Those with type 2 diabetes, chronic kidney disease, elderly population, you want to be very careful and when you're dosing, dose, escalate them, monitor them very, very carefully.
- [32:27]
A
Is there an amount of weight loss that you feel? How do you gauge that? When do you worry?
- [32:36]
B
Yeah, it's hard to say. I mean, we usually talk about, you know, if someone's losing, you know, 5 to 10% body weight within the first month or two, that is scary to me. I always use the electronic medical record to look at the weight change. It's a nice way to get an idea of the, of the weight or the, the, the trajectory of the loss of body weight. Always talking to them about, again, why, what is your muscle strength, what is your function? Hydration is very important. We did talk about vitamin mineral supplements. If someone's diet is really restricted, I mean, their appetite is so low they're not having a balanced diet, you may want to actually get some measurements on vitamin D or iron and actually supplement them with vitamin mineral supplement. It's really, again, kind of getting back to shared decision making. And I will tell them, you know, I'm a little concerned. Your weight is rapid, you're not eating as much, you're not engaged in physical activity. Let's hold this dose or even back down on the dose.
- [33:39]
A
That's really interesting and I think that's really helpful to hear because all of the studies of course have forced titration because studies have to be done a certain way. But clinically, having the permission to use judgment, perhaps with some people who are losing weight, rapidly, titrate up a little more slowly, plateau out for a little while. I haven't heard a lot of that and I think that's really helpful, Bob, to hear from an expert like yourself. Let's now talk about follow up. What sort of follow up do you generally recommend and what things do you go over at those follow up visits?
- [34:22]
B
Well, the first part of the follow up is to safely dose escalate the patient we're talking about because you always start at a lower dose to reduce the GI side effects. So we have to touch base with our patients probably on a monthly basis. And it could be done through MyChart messaging or Tell. It doesn't have to or telehealth doesn't have to be an in person. But what I want to know on a monthly basis before I dose titrate to the next level is of course, confirm what dose are you on. Tell me about your appetite, tell me about your physical activity. Are you having any side effects? Of course, you could assess blood pressure if that's what you're treating, or blood sugar, but I'm not going to go up on the dose until I've heard from that patient. How are you doing to get back to what you just said? We have super responders. They may not need more than going two doses to get to where they need to be regarding weight loss and how they're feeling so early on. You need to hold their hand, if you will, to make sure they're able to get up on the dose and not drop out because of a GI side effect. Once they're on a stable dose and doing well, we recommend seeing someone or he's having an interaction with them about every three months. And it could be through telehealth. If you can actually see the individuals and you're communicating with them and you know what their weight is.
- [35:37]
A
Yeah, it's not.
- [35:38]
B
It's not. You certainly want to see them. At some point you're going to get some labs and so forth, but you need to monitor the patient. And once they're on the medication, as we talked about before, Neil, they may be more open to getting a personal trainer, to eating healthier, maybe dealing with some of the other goals they haven't done before. Take a trip, be more socially active, take ballroom dancing, you know, whatever it is, it's going to give them joy. But ongoing monitoring is very, very important. Whether you're getting a telehealth visit with a commercial program or they're seeing you, they need ongoing monitoring.
- [36:18]
A
So important to know. So you talked about super responders is one category. Regular responders of course, is another. Sometimes people have a lot less weight loss than expected in those cases. Bob, what do you do and is combination therapy ever appropriate? Things like combining a GLP one with. With perhaps naltrexone, bupropion?
- [36:42]
B
Yeah, that's a good question. I could tell it's one of the most frustrating experiences we have because they hear about how wonderful everyone does and yet they're not doing wonderful. Anywhere from 5 to 10, even 15% of individuals in the trials don't lose at least 5% of their body weight. We call that a poor response or insufficient response. So you're going to see that. So the first thing I do is I go over what are you doing? Are you taking the medication? Tell me about your diet, tell me about your physical activity. So I want to make sure they're actually optimizing what we talked about here. You want to do a shout out to other team members. Maybe they'd benefit from seeing a registered dietitian, maybe an exercise trainer or personal trainer, maybe health psychologist because you're dealing with other behavioral issues. So that's non pharmacologic treatment, but that's a team approach if they're not doing well on the medication itself. And you'll know that by about three months because if they're not responding within three months, that's when you really probably want to have that conversation. Number one, you could change to another incretin based medication. So if one is on semaglutide, you can think about changing to tirzepatide or the other way around. This is not a class effect like a beta blocker. Each one has unique properties. So that's the first thing I would do. If they're on a GLP1 like medication, you could also potentially add to it like we do with other chronic diseases. Very typical diabetes, hypertension. Right. We're using combined medication and we can do that. So you could do a centrally active medication. You mentioned naltrexone, bupropion. You could add it to the GLP1. Medication is very reasonable. Or the other way around. If they're on phentermine, topiramate, you could add a GLP one. I do want to add one caveat though, Neil. We have no data at all and that's not really an FDA approved studied combination. But we do it in practice actually quite a bit.
- [38:42]
A
That's so helpful, Bob. Bob, we're almost out of time. Do you have any final thoughts for our listeners?
- [38:50]
B
Well, I think to summarize, I think we want to be proactive in our care. Don't wait for a patient to bring it up to you. Broach the topic by asking permission, such as is this a good time to bring this up? Consider a weight focused visit so you don't run out of time with other competing priorities and demands. Know the treatment options available and become knowledgeable and comfortable with providing obesity care.
- [39:18]
A
Dr. Bob Kushner, thank you so much for joining us, sharing your experience. And Bob, I gotta tell you, I just enjoyed this conversation.
- [39:28]
B
Good. Sort of. I thank you for having me, Neil.
- [39:32]
A
And to our listeners, thank you, of course, for joining us on the second part of our series on obesity, sponsored by Lilly for the American Diabetes Association, I'm Dr. Neal Skolnick. Till next time, stay safe and keep learning.
- [39:49]
B
Sa.