Diabetes Core Update – Special Edition: Obesity as a Chronic Disease – Treatment Approach (March 2026)

Date: March 24, 2026
Host: Dr. Neal Skolnick, American Diabetes Association
Guest: Dr. Robert Kushner, Professor Emeritus of Medicine, Northwestern University Feinberg School of Medicine

Episode Overview

This special episode focuses on the evolving approach to obesity treatment in 2026, emphasizing obesity as a chronic, biologically driven disease that requires ongoing, multifaceted care. Dr. Neal Skolnick speaks with leading obesity medicine expert Dr. Robert Kushner about the significant paradigm shift in obesity management, from lifestyle-only interventions to evidence-based pharmacotherapy and individualized care plans. The discussion is highly relevant for clinicians managing patients with obesity and related comorbidities like diabetes.

Key Discussion Points and Insights

1. The Historical Perspective and the Biologic Bases of Obesity

• Origins of Obesity Medicine: Dr. Kushner recounts his entry into the field, initially viewing obesity as a problem of "overnutrition," shifting to a recognition of its genetic and biological components. (04:06)
• Early Approaches: Before effective medications, management was "lifestyle, lifestyle, lifestyle"—nutrition, physical activity, behavioral counseling (e.g., CBT, motivational interviewing), yielding modest 5–8% weight loss, but maintenance was challenging. (05:29)
• "Fight Biology with Biology": Quoting Dr. Donna Ryan: “We have to fight biology with biology,” meaning lifestyle alone often isn’t sufficient due to robust biological mechanisms that defend body weight. (00:44)

2. The Transformational Role of Pharmacotherapy

• GLP-1 Medications: The arrival of highly effective medications (GLP-1s, dual agonists) has revolutionized obesity care and confirmed the biologic nature of obesity. “The food noise is removed, the cravings for food are reduced, appetite is under control…” (07:00)
  • Many patients now initiate discussions about medications, contrasting with past reluctance. “Tell me more about it... Am I a candidate?” (08:13)
  • The concept of shame and the burden of “willpower” as barriers: “It’s not my fault is so powerful for patients to hear.” (Neal Skolnick, 08:46)
• Shifting the Patient Narrative: Empowering patients by removing blame; therapeutic alliance is reinforced when clinicians affirm obesity’s biology. (09:50)

3. Opening and Structuring the Obesity Conversation in Clinical Care

• Starting Points: “Start with an ask,” using the 5A’s behavioral model. For example, “Is this a good time to talk about your weight?” or “Are you aware your weight may be affecting these other problems?” (11:36)
  • Respect autonomy, schedule dedicated obesity visits for in-depth discussion.
• Pre-visit Patient Preparation: Encourage tracking diet, steps, weight trajectory, prior interventions, and personal goals—creating an “activated, informed patient.” (12:44)
• Adopting the Chronic Care Model: Emphasize ongoing, proactive management rather than quick fixes. (13:47)

4. The Initial Evaluation and Shared Decision Making

• Beyond BMI: Assess whether excess weight is causing harm (e.g., sleep apnea, diabetes, arthritis). (14:17)
• Options on the Table: Present all therapeutic choices upfront—lifestyle, pharmacotherapy, bariatric surgery—rather than requiring “failure” of prior steps. “Pharmacotherapy should be discussed at the initial visit as an option.” (15:56)
• Guidance Based on Patient Goals: Steer recommendations according to the likelihood of achieving clinically meaningful outcomes—e.g., diabetes remission generally requires ≥15% weight loss, which is unlikely with lifestyle alone. (17:55)

5. Medication Categories and Efficacy

• Medication Classes: (19:19)
  • Centrally Acting: e.g., Phentermine, Phentermine/Topiramate (Qsymia), Naltrexone/Bupropion (Contrave)
    • Modest efficacy (3–8% placebo-subtracted weight loss)
  • Peripherally Acting: Orlistat/Xenical/Alli
  • Nutrient-stimulated Hormone Based: GLP-1 agonists (e.g., semaglutide), GIP/GLP-1 dual agonists (e.g., tirzepatide)—“transformative,” >13–20% weight loss. (21:41)
    • “Some people are losing 25 to 30% of their body weight.” (Dr. Kushner, 21:41)
  • Analogy: “Like giving insulin… but at higher levels for people with diabetes.” (Dr. Kushner, 20:54)

6. Clinical Impact and Patient Transformation

• Life-Changing Outcomes: Major improvements in sleep apnea, joint health, mobility, and quality of life. “It’s really life-changing for many people…” (Dr. Skolnick, 22:36)
  • Weight loss empowers patients to increase activity and social engagement. (23:57)
  • Sustained, meaningful thank-yous are more common than with other chronic disease interventions. (24:36)

7. Duration of Therapy and Expectations

• Long-Term, Not “Jump Start”: “This is a long-term medication... Not permanent, not lifelong, but long-term.” (Dr. Kushner, 25:29)
  • Shared decision making: “I’ll be there with you if you do want to come off it... we don’t know who can get off; if medication is stopped, weight generally comes back.” (27:42)
• Realistic Counseling: Be transparent about limitations, monitor for signal of recurrence of appetite/cravings (27:42).

8. Addressing Concerns about Muscle Mass Loss

• Normal With Major Weight Loss: Loss of lean mass accompanies all substantial weight loss—about 1/4 to 1/3 of total loss may be lean tissue. (28:39)
  • Not unique to medications; consistent with outcomes from surgery or calorie restriction. (28:39)
• Who’s Most Vulnerable: Older adults, those with type 2 diabetes, CKD, or frailty.
• Clinical Strategies: Emphasize resistance training, adequate protein (65–90g/day or 1.2–1.5g/kg), monitor function (“carry groceries?”), basic neuromuscular exam, consider vitamin supplementation for those with highly restricted diets. (30:37 – 32:27)
• Rapid Weight Loss Warning: If 5–10% body weight is lost in a month or two, consider dose adjustments. “Let’s hold this dose or back down.” (33:15)

9. Practical Follow-Up and Monitoring

• Frequency: Monthly follow-up initially (dose titration, symptom assessment), then every 3 months once stable. Utilize telehealth/MyChart when possible. (34:22)
• Assessments: Weight trajectory, appetite, GI side effects, blood pressure/sugar (as appropriate), reinforce lifestyle measures, monitor for “super-responders.” (34:22 – 35:38)
  • Watch for functional improvement, address new lifestyle goals (activity, travel, social engagement).

10. Managing Suboptimal Response and Considering Combination Therapy

• Non-responders: (~5–15%) First, assess adherence; bring in other professionals (dietitian, psychologist). (36:42)
• Medication Adjustments: Switch to alternate incretin-based therapy (e.g., tirzepatide ↔ semaglutide), or add centrally acting medication. (36:42 – 38:21)
  • Clinical Pearl: “No FDA data on combination therapy, but common in practice.”
• Team Approach: Integrate behavioral, dietary, and pharmacological supports for best outcomes.

Notable Quotes & Memorable Moments

“We have to fight biology with biology.”
— Dr. Donna Ryan (quoted by Dr. Skolnick) [00:44]

“It’s not your fault is so powerful for patients to hear.”
— Dr. Robert Kushner [09:50]

“Many patients now come in wanting to have a conversation about medication. Tell me more about it, am I a candidate? ... It's 180 degree difference from before these medications were developed.”
— Dr. Robert Kushner [07:00]

“If you’re going to open the door… schedule an obesity-focused visit so you can spend the entire session on their weight.”
— Dr. Robert Kushner [11:36]

“If you stop the medication suddenly, it is very highly likely you’re going to start regaining weight.”
— Dr. Robert Kushner [27:42]

“I never thought I’d be working with patients living with obesity and worrying they’re going to lose too much weight…”
— Dr. Robert Kushner [31:38]

“Know the treatment options available and become knowledgeable and comfortable with providing obesity care.”
— Dr. Robert Kushner [38:50]

Timestamps for Key Segments

• 00:44 – "Fight biology with biology": Roots of obesity medicine philosophy
• 04:06 – 06:34 – Dr. Kushner’s background; early approaches to treatment (behavioral focus)
• 07:00 – 09:50 – Transformation with new medications, changing patient attitudes
• 11:36 – 13:47 – How to initiate and structure the obesity conversation in primary care
• 14:17 – 17:22 – Initial visit, shared decision making, comprehensive treatment options
• 19:19 – 22:36 – Review of medication classes and their efficacy
• 25:29 – 27:42 – How long to stay on medication; setting realistic patient expectations
• 28:39 – 33:39 – Muscle loss concerns, clinical assessment, and what to monitor
• 34:22 – 36:18 – Follow-up strategies and patient monitoring
• 36:42 – 38:41 – Non-responders, combination therapy, and clinical pearls
• 38:50 – 39:18 – Final thoughts and takeaways from Dr. Kushner

Final Takeaways

• Obesity is a chronic, biologically mediated disease, not simply a problem of willpower or lifestyle.
• Modern pharmacotherapy offers the potential for substantial, sustained weight loss and greater patient empowerment.
• A comprehensive, patient-centered approach—starting with respectful conversation and including all available treatment options—is essential for optimal outcomes.
• Ongoing monitoring, shared decision-making, and team-based care are critical, as are individualized pacing and attention to nutrition, physical function, and patient goals.

This episode offers a concise but authoritative roadmap for clinicians managing obesity, underscored by both clinical rigor and deep empathy for patients’ experiences.