Episode Overview

Title: Elevating Obesity Care in Primary Practice: PAs in Obesity Medicine’s Expert Take
Podcast: JAAPA Podcast
Date: January 30, 2026
Host: Martine (JAAPA)
Guests: Board Members from PAs in Obesity Medicine

This episode brings together a panel of Physician Assistants (PAs) leading the charge in obesity medicine. The discussion orients around the realities of providing obesity care in primary practice, from gaps in training, pharmacotherapy challenges, building care teams and algorithms, to insurance navigation and innovations on the horizon. The guests offer practical strategies, confront misconceptions, and underscore the importance and feasibility of integrating obesity management into busy practices.

Guest Introductions & Perspectives ([00:53]–[05:01])

Moderator Prompt: Each guest shares their background, what drew them to obesity medicine, and a snapshot of their current clinical work.

• Lydg Ballesteros (President, PAs in Obesity Medicine):
  Internal Medicine since 2008, obesity medicine since 2015, motivated by both her own and her patients' struggles with obesity. Opened an obesity program focused on elderly and financially challenged patients.

• Nicole Fox (Secretary):
  Rural family medicine and ER in Southeast Utah; background in public health, focused on root causes. Became interested through AAPA's obesity medicine certificate. “About a good 40% of my patient visits are obesity medicine focused within my primary care practice.” ([01:42])

• Karen Potter (Treasurer):
  Former dietitian/diabetes educator, transitioned to PA for more complete care. Currently works in women's mental health with 60-70% practice obesity-focused.

• Katie Earls (Member at Large):
  Started in bariatric surgery, now specializes in medical obesity management in a rural group practice. “We take care of a pretty large patient panel in a rural area and it’s been great.” ([03:41])

• Elena Sullivan (Member at Large):
  Obesity medicine specialist at KnownWell. Drawn by the holistic approach obesity requires, including mental, physical, and emotional health. Focuses on weight stigma, emotional relationships with food, and body image.

Major Gaps in Primary Care Obesity Medicine ([05:13]–[07:00])

Key Insights

• Nicole Fox identifies biggest gaps:
  • Limited formal training in obesity medicine, especially pharmacotherapy beyond GLP-1 agonists.
  • Persistent lack of familiarity with older medications due to curricular gaps.
  • Ongoing stigma and lack of understanding from other providers.

“Obesity medicine is still not part of a standardized PA curriculum. So I think a lot of us graduate and we don’t have a lot of familiarity with more than the GLP1 medications.” — Nicole Fox ([06:10])

Context

• Most PAs and providers are only familiar with contemporary obesity meds (GLP-1s) due to overlap with diabetes management; older drugs like phentermine or naltrexone-bupropion are underutilized.
• Cost barriers and insurance limitations also challenge comprehensive obesity care.

Practical Steps to Start Obesity Management ([07:25]–[08:48])

Karen Potter offers a roadmap for new clinicians:

• Acknowledge complexity: Both with yourself and patients; frame it as a shared journey.
• Start simple:
  • Use a basic assessment framework.
  • Develop a short, manageable list of therapeutic options and local referral sources.
• Prioritize frequent follow-up:
  • "Do what you can in a visit and make sure you have frequent follow up with your patients."
  • Iterative learning for both provider and patient.

“…One of the most important things about obesity medicine is the frequency of visits. Do what you can in a visit and make sure you have frequent follow up.” — Karen Potter ([08:36])

Shifting to a Chronic Care Model ([09:06]–[13:36])

Lydg Ballesteros compares the approach to other chronic diseases:

• Obesity care should be managed like “diabetes, hypertension, hyperlipidemia, or any cardiovascular or metabolic disorder.”
• Education is key:
  • Educate all staff on the basics (BMI, waist circumference, patient-first language).
  • Cultivate a safe, nonjudgmental, and supportive clinical environment.
• Choosing medications requires the same thoroughness as managing comorbidities:
  • Review current meds for potential interactions.
  • Evaluate for contraindications, esp. cardiac and psychiatric.
  • Educate patients on med side effects (GLP-1s may cause GI issues, some meds inappropriate for certain comorbidities).

“…When we’re thinking about anti obesity meds, we have to remember they are medications, right? …What medications are the patients on right now, are there any crosses, are there any issues that we would avoid?” — Lydg Ballesteros ([12:19])

Misconceptions about Pharmacotherapy & Medication Decision-Making ([14:31]–[19:30])

Elena Sullivan & Panel:

Misconceptions

• Pharmacologic therapy is not “cheating”; not a substitute for willpower.
• Many patients have tried multiple lifestyle interventions with limited success due to physiological “set point.”

“Using pharmacologic therapy for obesity is not cheating… It’s not an easy way out… we wouldn’t look at someone with hypertension and say being on an antihypertensive is cheating.” — Elena Sullivan ([14:44])

• Do not require patients to demonstrate willpower before offering meds.

Decision Factors for Medication Choice:

1. Candidacy: Comorbidities, medication interactions, contraindications.
2. Cost/Insurance Coverage: Sustainability of the chosen agent.
3. Patient Goals & Realistic Expectations:
   • Orals: 5–10% body weight loss.
   • GLP-1s: 15–22%.
   • Bariatric surgery: 25–30%+.
   • “We want to make sure that what we select is going to be something that can be continued, not just started for a month and then discontinued.” — Elena Sullivan ([16:59])

Effective Counseling in Time-Limited Visits ([20:17]–[22:17])

Katie Earls:

• Get focused: Brief assessments like 24-hour recalls or food journals.
• Tailor advice: “Meeting them where they’re at” and set realistic, patient-centered goals.
• Prioritize based on comorbidities—sometimes medications like tirzepatide are selected for specific conditions (e.g. sleep apnea).
• Use team-based visits (dietitian, therapists, etc.), when possible.

Navigating Stigma, Misinformation, and Patient-Centered Counseling ([22:36]–[26:14])

Elena Sullivan:

• Meet patients where they are; validate experiences with weight stigma and internalized blame.
• Compare to mental health: Antidepressants don’t imply a lack of willpower—same with obesity meds.
• Emphasize the chronic, multi-factorial, relapsing nature of obesity.
• Dispel the myth that needing life-long medications implies failure.

“Obesity is not a personal choice. It’s not your fault. It’s not a lack of willpower…” — Elena Sullivan ([24:22])

• Use metaphors (e.g., “bowling with the bumpers up”) to explain supportive nature of medication.

Cardiometabolic Risks Often Overlooked ([26:31]–[30:29])

Nicole Fox:

• Early detection of metabolic syndrome is critical.
  • Look for: Low HDL, high triglycerides, increased waist circumference, mild hyperglycemia.
  • Intervene before overt diabetes or hyperlipidemia develop.

“Primary care is actually really, really crucial to finding these cardio metabolic risk factors before they become an even bigger problem.” — Nicole Fox ([26:31])

• Highlight recent evidence:
  • GLP-1s (semaglutide) can reduce major cardiovascular events by 20% in those with established ASCVD (even w/o diabetes).
  • Tirzepatide can improve moderate-to-severe sleep apnea.

Building Obesity Care without a Full Clinic Redesign ([30:46]–[37:58])

Lydg Ballesteros outlines a practical framework:

1. Integrate into routine care:
   • Assess obesity history alongside other chronic diseases.
   • Use EMR tools, flow sheets for tracking.
2. Initial visit:
   • Full history, labs, weight trajectory, medication review.
   • Begin care planning with comorbidities in mind.
3. Use team resources:
   • Refer to dietitians, physical therapists (covered for obesity), mental health when needed.
   • Consider group visits/support programs.
4. Follow-up:
   • Early, frequent (start with 6 weeks, then taper as appropriate).
   • Focus on journals, lifestyle logs, med adjustments.
   • “No need for a full redesign. We just have to incorporate it in saying, hey, they are correlating…” ([36:48])

Insurance Navigation & Patient Affordability ([38:14]–[40:53])

Katie Earls:

• Know insurer requirements: Some require regular monthly visits, specific documentation.
• Explore manufacturer cash programs: Many injectable GLP-1s now ~$300–$500/month, but even that can be a barrier for many rural patients.
• Use off-label, affordable oral meds if needed—always with full risk/benefit counseling.
• Flexibility and resourcefulness are key in finding workable, safe pharmacotherapeutic options.

Innovations & Policy Shifts on the Horizon ([41:22]–[43:25])

Karen Potter:

• The public’s understanding and demand for effective, accessible treatment is growing—"the genie’s not going back in the bottle."
• Anticipates:
  • Expanded insurance/Medicare coverage.
  • New cash-pay programs and medication indications.
  • Growth of generic options, price competition.
  • Emerging tools: continuous glucose monitors, digital health solutions, and eventually, genetic phenotyping for individualized therapies.

Closing Thoughts ([43:42]–[44:20])

Lydg Ballesteros:
Encourages all PAs:

“My biggest words of advice: don’t be afraid to try with our patients… It does not mean you have to be a specialist… Incorporate it into your practice and… we will slowly start moving that needle where it needs to be.” ([43:46])

Notable Quotes by Timestamp

• On Complexity:
  “Obesity medicine feels complex because it is complex. It touches many body systems, mental health, cardiometabolic…”
  — Karen Potter ([07:25])

• On Medication Choice:
  “We shouldn’t withhold pharmacologic therapy and wait for patients to demonstrate that they can… cut calories or exercise more before they’re a good candidate for them.”
  — Elena Sullivan ([15:59])

• On Stigma:
  "Obesity is not a personal choice. It’s not your fault. It’s not a lack of willpower…”
  — Elena Sullivan ([24:22])

• On Integration:
  “No need for a full redesign… If I’m taking care of their diabetes, I’m taking care of their obesity…”
  — Lydg Ballesteros ([36:48])

• On the Future:
  “I think the conversation around obesity care has completely permeated our society like no other time in history… it's not going back in.”
  — Karen Potter ([41:25])

Key Takeaways

• Primary care PAs are essential for flagging early risk, counseling, and initiating therapy for obesity.
• Integration—not isolation—of obesity care is possible and practical in any primary clinic setting.
• Addressing stigma, providing comprehensive education, and frequent follow-up are crucial components of effective care.
• Medication choices must be individualized, taking into account comorbidities, access, coverage, and patient goals.
• The field is evolving rapidly, with broader access and innovative tools on the near horizon.

For resources and further information: Visit the PAs in Obesity Medicine website at pasinobesitymedicine.mypanetwork.com.