← Diabetes Core Update
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- [00:03]
A
Welcome to this special edition of Diabetes Core Update, where we will discuss processes and pathways of care for obesity management. There are a lot of approaches out there. Some of them work better than others. There also are a lot of offices that actually don't use any approach at all, and that doesn't work quite as well. I'm Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University University. This special edition of Diabetes Core Update is sponsored by Lilly. And joining us to discuss processes and pathways of care for obesity management is Dr. Lee Perot. Dr. Perot is a physician. She is a clinical researcher and a professor of medicine in the division of Endocrinology, Metabolism and Diabetes at the University of Colorado Denver School of Medicine in Aurora, Colorado. Her research. Research interests are broad and they include understanding the different pathways by which people develop type 2 diabetes, developing tailored strategies for diabetes prevention, and most recently and most relevant to our discussion today, she's become interested in processes of care for obesity management and has come up with a very important process that we'll be talking about. She's authored over 100 papers in the scientific literature, including publications in the New England journal of Medicine, Jama Lantha, IT and Nature Medicine, all in 2025. And she also writes the obesity section of up to Date. I don't know, Lee, how you have time to eat and sleep. Today we're going to be talking about your paper in Nature Medicine on a novel process of care for obesity mansion called Pathway. Lee, welcome to our podcast.
- [01:58]
B
Yeah, thanks so much, Neil. It's a thrill to be here.
- [02:01]
A
Lee, you created this innovative program for weight management at the University of Colorado. The name of the program is Pathway. I'll just note for our listeners since they are listening. Pathway in this case is spelled P A T H W E I G H Pathway. Before we talk about that, though, can you tell me a little bit about yourself, the evolution of your practice over the years and how you became interested in this area?
- [02:36]
B
Yeah, absolutely, Neil. As you mentioned, I'm an endocrinologist. I've been at the University of Colorado for 30 years, which is amazing. I don't know how that happens, but I have a traditional academic appointment there. I see patients, I do research, and I teach. But it was about 18 years ago that I moved my medical practice out of our main campus into one of our community clinics, that is a family medicine clinic. I practice in this community clinic affiliated with the university. That is, I practice as an endocrinologist in this family medicine Clinic. So I practice side by side with primary care and it has been very eye opening to see everything that they slash you do. It has given me a tremendous amount of respect and awe. And so I think it's. Sometimes I run in circles with other specialists and they say, gosh, you know, we really need to get primary care to do, you know, fill in the blank. And I'm like, oh, no, no, no, no, no, we don't need to do that. What we need to do is make their job easier, give them less to do. But it was one day, probably about eight years ago, I was just seeing patients and I kind of put my face in my hands and I just thought, you know, I'm prescribing drugs like mad for people's obesity related diseases and complications and nobody wants to take all these medicines, nobody wants to have all these diseases. If I could just treat their obesity, maybe they wouldn't have all this, these diseases anyway. And the good news was there was a family medicine doctor in a clinic with me and a behavioral health specialist and they were kind of feeling the same way. So we went to our kind of local EPIC people because our health system runs on epic, that's our electronic medical record, and asked them to sort of build us a care process that we could track the people in whom we were prioritizing their weight versus their weight related complications, just to kind of see how we were doing. So that is really how pathways started, huh? Right there.
- [04:33]
A
Yeah. No, that's, that's amazing. And you kind of have to be in the middle of it to understand that. They talk about generals, talk about the cloud of war. I think of it often as the cloud of primary care. You know, you got this busy day, you're four patients behind, and you're right, a lot of people tell you what you should be doing better, but not everyone takes the effort to try and make it easier for us to do, to make it implementable. So tell me more now about the evolution of pathway. What are the components of it that are obviously distinctly different than what was there before, which was not any organized method of care?
- [05:24]
B
Yeah, absolutely. So what we first built was something that we called a weight prioritized visit. And we placed signage in our clinics at the time that we did the trial for the clinics that had pathway at that time. And they simply said this. Would you like medical assistance with your weight? It's a very non stigmatizing kind of open hand sort of approach to, you know, people who want help can approach the desk and ask to schedule A wait, prioritized visit with their clinician and people who don't, don't. So it's a way to allow people to sort of self select for people who want help and when they want help and they don't go somewhere else to a program, so they do not pay money. They do not have a set curriculum. It's not standardized. People don't graduate in 16 weeks. They go and they see their provider. And so the way prior to visit was really, really nice because the people who wanted help could then get help. And also clinicians knew why the patient was coming. So that sort of like awkwardness of starting that conversation that we hear about both on the side of the patient and the clinician was sort of taken off the table. Everybody knew why the patient was coming. And the clinicians absolutely loves the idea of a weight prioritized visit. Because, Neil, nobody knows better than you. I mean, primary care does 15 things in 15 minutes. So the idea that you could focus on a thing was amazing. And it's not to say you couldn't refill an inhaler or look at a rash. You can, but you guys kind of keep bringing the patient back to, hey, this is like a weight focused visit. Let's talk about your weight.
- [07:01]
A
Yeah, that really is nice. And you know, if I think about it, you're talking about five to eight years ago when this started. Obesity was not usually even a part of most people's problem list at that point. So we would see people with a BMI over 30, but I would say less than 5% of the time was it even appearing on a problem list and being identified as something to talk about. So that that simple change brings it to the forefront.
- [07:36]
B
Yeah, you're absolutely right. And so, and to that end, I just want to really make a point, point to everyone who's listening to this podcast as we talk about Pathway, I really want to make the point that it's not a specific weight loss treatment, it's not a specific diet, it's not a program, it's not a medicine or a series of medicines or a certain procedure. Each of those is like a vehicle to weight loss and pathway is the road for all the vehicles to drive on. So you are precisely correct. There was never a road, never the quote pathway, which is why we named it pathway because it is the pathway for patients to get care for their weight, but also for clinicians to know how to provide weight related care.
- [08:25]
A
So, Lee, it started with a simple sign. Patients could self identify and make that visit. It becomes Part of the problem list, part of what we as clinicians in the office are paying attention to than what was added to the program.
- [08:42]
B
Yeah, exactly. Remember, it's not a program, it's a process. Process.
- [08:46]
A
Oops, sorry.
- [08:48]
B
It's okay. It's okay. It's just important because we really want to make sure that people don't think of it as, like, people graduate in 16 weeks from the program. It's really just. It's the highway for obesity care.
- [09:00]
A
Great point. Thanks for making it.
- [09:02]
B
Yeah. You know, we can always have fun together.
- [09:07]
A
So.
- [09:08]
B
Yeah. So the very next thing was when a patient schedules a wait, prioritized visit, they get an intake, a historical intake questionnaire pushed to them through the patient portal in advance of their visit. And that is really asking them the questions that you and I would ask. You know, how did they get to where they are? Why haven't they been able to get to where they want to be? What are they doing right now, and what are their goals? And so instead of asking all those questions at the time of the visit, they're answered. And then that questioner flows into our note template and becomes our history, present illness. So now you and I, instead of typing and asking questions, we're kind of reviewing the answers to the questions. And the patients kind of really appreciated, you know, us thinking about their answers in advance. And the clinicians knew what they were walking into, so they kind of knew. And then also, you know, they sit down, they open their note template, that questionnaire is there, and. But then the rest of the note template turns into a big menu for what we might want to do. So instead of typing out, hey, I think maybe eating a Mediterranean diet would be a great idea. We kind of wrote it out so clinicians could click, eat this, exercise this. Here's some lifestyle ideas. All the medications we might prescribe, we wrote out their indications, contraindications, their dosing, titration schedules, all kinds of things. And we worked with our pharmacist to know that these were coming so they could get ready for prior authorizations and know where patient assistance and coupon cards and other things were kind of coming from. So that was effectively the process part of it. And then there was education that went behind that too.
- [10:49]
A
No, it's really interesting. And as I'm listening, it's also clear to me that just the process of the patient filling out the form leads to more attentiveness to what their own needs are, mindfulness about what needs to be done, and increased receptivity and commitment to Whatever is coming next. Is that right?
- [11:14]
B
It absolutely is. I think sometimes it makes them think about how did I get here? And the questions are really not only designed for patients to kind of be able to have epiphany around that, but also they're really intended to help drive the conversation and the treatment plan. Just to give you one example, the. So if a patient says, I've been having a lot of life stress, I just, I feel like I can't get to this. So that is something that you and I would see and we would think, ah, okay, maybe they need help, maybe they need behavioral health involved or say they had a hip replacement but they didn't fully rehabilitate, so they're not as mobile as they like, okay, back to physical therapy. Or they have back pain that they can't kind of quite cope with. So maybe that person needs to go to pain management. So it really does help you. And I understand like some of the other ancillary folks that we would want to get involved to help us.
- [12:10]
A
That makes a lot of sense. And as you're saying that you mentioned someone with the knee replacement and back pain, I'm thinking actually of some patients I've seen over the last two weeks. These are not made up cases. These are common things that happen. So you develop this process of care. It's an easy thing to conceive of something. It's a hard, hard thing to get buy in, particularly from lots of different clinicians and from administration. How did that go?
- [12:45]
B
Yeah, that. And for our listeners, listen carefully to this answer. So anybody thinking about building a process of care for obesity at your health system? Having health system leadership support is the very, very first necessary step. So we had primary care clinicians on our team, so they were really our kind of conduit to leadership and they could explain to them what we were doing, why we're doing it. And also to remind them that a, this wasn't costing anything, it was built into our system already and that it was completely voluntary to use. So we were not forcing any clinicians to do this. This was like, hey, we're trying to make your life easier. If you'd like to use this, you can, but you don't have to. So it was pretty easy to get unanimous leaders support. And once the leadership support came in, then that directed resources for us to do the builds inside of our electronic health record and also have access to our clinics to go in and do the trainings to show them how the process worked, put their fingers on the keyboard and actually show them how the whole process worked together for the entire clinic, as well as just directing some of the clinicians to educational opportunities for best practices in weight management.
- [14:09]
A
That's really impressive. And so our listeners understand we're not talking about one large office here, we're talking about a health system. And how many offices was this rolled out to?
- [14:24]
B
Yeah, so at the time that we received funding from NIH to implement and then assess it, we had 56 clinics in our health system. So those 56 clinics were randomized in our research project. But throughout the conductance of the research, the system acquired 10 additional primary care practices. So we did deploy to the 10 additional clinics, but because they were not randomized, they're not in our data set. So you're talking about 66 clinics that empanel nearly 1 million patients in color.
- [14:55]
A
Oh my gosh, that's. No, I mean, as you say, that, that's, that's pretty mind boggling. And, and, and you did this with the rigor that, that allowed it to not just be rolled out, but to collect data on it. And, and this was eventually published in Nature Medicine. And can you share with us what you feel are the, the relevant results?
- [15:22]
B
Yeah, absolutely. So I just want to make the point to people that so worked was that the clinics started in usual care and we randomized them into three clusters so groups of clinics that were balanced in terms of percent Medicaid, patient volume, location, type of practice, et cetera, and then kind of one at a time a group would receive pathway. So it was a one way crossover. And we looked at average patient weight trajectory. So most of the patients that were adults with a BMI of 25 or higher, they never received any weight related care ever. So this is an intent to treat analysis that is across the entire population of people, most of whom never saw any weight related treatments. And what we were able to do, our first finding was that we prevented population weight gain in more than a quarter of a million patients for the first time anywhere in history. So that was our first finding, which was absolutely amazing. And as I mentioned, most people never received any weight related care. But Pathway increased the likelihood that a patient or an adult with a BMI of 25 would receive weight related care.
- [16:41]
A
And I just want to pause there for a second because that's a big deal before we even talk about numbers and weight. We live in this world and we've talked on other podcasts and our listeners understand about toxic food environment and lack of open spaces in which to have physical activity. All of that that promotes weight gain over time. So the idea of changing the trajectory of a population, and you mentioned a quarter of a million people, this is not like a house down the block. This is a, you know, this is a big town or small city of people that you were able to change the weight trajectory for. And that's a pretty phenomenal outcome.
- [17:38]
B
Yeah. Thank you. We had 274,182 unique patients randomized in our trial. It is one of the largest, if not the largest randomized trial that's ever been done. And so it is, I won't lie, it was more than a little bit of work. But I think it is just something that it had to be done to show that it can be done right. That we can stop what we've all seen in the news for the last 30 years, which is just this steady, consistent increase in population weight, that there are actually things we can do that don't need to be super fancy, that we can do this in primary care.
- [18:16]
A
Yeah. And so continuing on with the results.
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B
Yeah, so more people did receive weight related care during when the clinics received pathway, which was great. And for the people who did receive weight related care, they lost a significantly more amount of weight. But the interesting thing was even in patients who never received weight related care during the intervention, they gained weight, but they gained less weight. Which makes me think there was some bleed over of the intervention in those clinics. Like the patients, maybe they saw the signs in the waiting room and maybe their clinician didn't feel like they did enough counseling to really bill for it. But there was little things that were being done that were sort of insidious. So the population weight gain started coming down and then intervention, even for people who didn't ever receive weight related care. So there's. That's a lot of good news.
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A
Yeah, that's fascinating. And among the people in the program, what was the degree of weight loss?
- [19:20]
B
Yeah, so it increased. So if people received obesity related care in usual care, their average weight loss over 18 months was a kilo. And basically it was like two and a half kilo if it was during the intervention. And this is again average over time. Most of this was not done with medication. So medication use did increase in the intervention, but the overall use was still pretty low. And the trial was conducted in 2020-2024. So it was kind of during the boon of popularity with the GLP1 receptor agonist. But it was also done during the time of scarcity. Right. The time that the drugs were not available. And so the overall usage was still actually pretty low. And so I think most of this was done kind of the good old fashioned way. But it's just really a starting point and a proof of concept that it can be done.
- [20:17]
A
And I think that idea of a starting point is really important also because we're used to looking at clinical trials where everyone's enrolled in the trial, receives a medication and has, for instance, with semaglutide or tirzepatide, 15% weight loss, 22% weight loss. And this is not to be compared to that. This is where we're talking about large numbers of people who live in the real world, some of whom, but not many, it sounds like, got medicine, many of who didn't have insurance that could pay for medicine even if they wanted it. And like you and I see all the time in our, in our office, even for the people who would go on medicine, some would then stop because insurance changes, they decide they don't want, whatever. But the point being that that weight gain is real, is important and shouldn't be looked at in the context of clinical trials that we often talk about when we talk about medication, treatment. Is, is that a right way to understand this?
- [21:31]
B
Yeah, yeah. It has to do with kind of the analysis of the trial. So this is not like a, like you're saying, a classic randomized clinical trial where people get a medicine or they get a placebo and everything's compared to the medicine. And most of the people who get put on the medicine stay on the medicine. In our particular trial, only 6% of adults with a BMI of 25 or higher received anything that you and I would consider treatment, a referral even to a dietitian or to a specialist or a medicine of any kind or a bariatric procedure. So only 6% ever received anything. So it's totally impossible to compare it to a trial where 95% of the people who are randomized to drug actually receive and stay on.
- [22:19]
A
Right. And that's what I really wanted to make sure we understood when we're talking about outcomes here. And it seems to me that enrolling in that process of care also lets medicines become a part of our ordinary treatment of obesity that's offered as medicines have over time becoming more commonly used and will over time hopefully be paid for more and more by insurance.
- [22:48]
B
Yep, absolutely. So I totally agree with that. And like I said, the note template, it wasn't necessarily prescriptive, like, hey, this patient would be a great candidate for X drug because we want the clinicians to have the autonomy to have their conversations with their patients decide what they feel like is best in that sort of shared decision making moment and select that. But yeah, the medicines were absolutely part of the option. And just to help with people feeling comfortable with them, we did list the indications, contraindications. And just because not everybody knows the contraindications of some of, say the older medicine as well as the titration schedules of the, you know, the medicines that are out there. Not, not everybody knows that either, including myself or some of the brand new medicines. So it's really important just to have that in front of people's eyes.
- [23:39]
A
It really is real time decision support. Because when you do something all the time, you and I may be very comfortable with obesity medicines. Not all of our colleagues have the same background and experience. Now one of the things we, we are concerned about whenever we roll out new programs and certainly administration is concerned about is is it going to cost a lot? Did you look at that?
- [24:02]
B
Yeah, we absolutely did do. And so the cost to implement was really, really nominal. I mean, we used existing resources, conventional workflows and the experience known to patients which was coming to their providers, you know, they're not going somewhere else, they're going to the people that they trust. And so we did that. But we also looked at revenue generation for weight related care and we were able to generate more than $15 million in revenue for our health systems in weight related care. Yeah, and some of that was due to just increased numbers of visits for weight related care. But even when you adjust for the increased numbers of visits, we still made revenue for the health system. So there's no way to say that this can't be done. It can be done. It was done and it was done in a way that was economically both viable and feasible. So I think that's a really important.
- [24:52]
A
I think you just convinced administrators in different systems to sign on to the program. So what a great idea to have really looked at it through that lens of economic cost benefit is the program, let's say someone in a different health system wanted to replicate this. Are they able to?
- [25:20]
B
Yeah. So again, it's not a program.
- [25:22]
A
Oops, sorry, Lee. Thank you.
- [25:26]
B
So the care process. So the answer is, yeah, we're in the midst of actually applying for funding to deploy it to four health systems. So health partners in Wisconsin and Minnesota, to Johns Hopkins in Maryland, UT Southwestern in Texas, and also to Atrium Wake Forest Baptist in the Carolinas, again to disseminate outside of Colorado and then test it across us. Different geography, different Patient populations kind of adopt it and show what we can do. And because it's going to become, it's now very shortly, next few days going to be standard of care for obesity. We want to make sure that the standards of care are built into the pathway, that highway I was talking about. Because what it does is it brings those standards of care for obesity the first ever inaugural standards of care from the journal to the point of care. So really kind of bolstering pathway with standard of care. So it's going to be just an amazing time to be able to deploy pathway to different health systems. And any other health system that's interested in this can definitely contact me directly.
- [26:39]
A
Lee, this is amazing. Did you ever think that you would be involved in something that has this sort of scope?
- [26:46]
B
You know, I'll tell you kind of a personal story. So probably about 10 years ago, I got a phone call from George Bray, who I think most people widely regard as the father of obesity medicine. He asked me to take over writing the obesity section of up to Date for him. And he has the biggest shoes, Neil. I mean, such big shoes. I felt like I could never, you know, be deserving of such an amazing honor and privilege and responsibility. And so it was at that moment that I vowed that I would build something as an homage to George to be really amazing for the field of obesity, for clinicians and scientists, to really advance us. And it was in that moment that I conceived a pathway and then it's just been a labor of love since then to bring it. But I think this is something that any of us practicing obesity medicine over the last last ten years can say. We've seen change like in transform in ways that are so beautiful that we can now imagine preventative medicine becoming something real for patients. It's not so reactive the way that we've been trained and practicing most of our careers.
- [27:53]
A
Yeah. Lee, thank you. That's a touching story and thanks for sharing that because it's so, yeah, so meaningful. We covered a lot of ground today. What do you think are the main take home learning points for the thousands of clinicians that are listening to our podcast today?
- [28:13]
B
Yeah, just that having a care process can make the difference between patients receiving obesity care and you all for knowing how to deliver obesity care. So embrace the notion of a care process. It's something that we haven't had in the past, but it is here now. And it's something that you can adapt to your practice to make things flow and actually be less work, not more.
- [28:38]
A
That's the catchphrase. Less work, not more. Better care. I love it. Lee, thank you so much for joining us.
- [28:47]
B
Thank you.
- [28:49]
A
And most of all, of course, thanks to our listeners. Thank you for joining us on this special edition of Diabetes Core Update discussing Pathway, an important new process of care. We spend a lot of time on this podcast discussing new medications that is incredibly important. We all need to know how to use them. We don't often spend time discussing processes of care which are integral to each and every visit that we see in all of our practices. So I am so appreciative of Dr. Lee Prosch sharing her experience, wisdom and joy in practice. We thank everyone for listening. For the American diabetes association, I'm Dr. Neal Skolnick. Till next time, stay safe and keep learning.