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JAAPA Podcast
Elevating Obesity Care in Primary Practice: PAs in Obesity Medicine's Expert Take.
00:45:00
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- [00:00]
Lydg Ballesteros
Foreign.
- [00:06]
Podcast Host
Welcome to the JADPA Podcast where we explore how PAS contribute to healthcare and the practice of medicine. Today we are joined by some board members of PAS and Obesity Medicine, an official caucus of the aapa. Don't forget, listeners can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you can listen to the podcast, then complete this post, test and evaluation in AAPA's learning central@cme aapa.org before we dive in, I want to introduce the board members who are joining us today to explore the landscape of obesity care and primary care practice. Ladies, I'd love for each of you to share your name, your role on the board, what first drew you into obesity medicine, and a snapshot of your current clinical work.
- [00:54]
Lydg Ballesteros
I'm Lydg Ballesteros. I am president of PAS in Obesity Medicine. I actually have been practicing Internal medicine since 2008, but obesity medicine since 2015. Basically what drew me in was I, along with hundreds and millions of other Texans also was suffering from obesity at that time and as a practitioner was having a difficult time helping my patients as well as myself. So I really got focused into obesity and how we could better serve it. As far as what I do for clinical work, I do internal medicine predominantly in a multi specialty clinic and there I opened up our obesity management program where I do weight management for our patients, predominantly those that are elderly or in having financial hardships as well.
- [01:43]
Nicole Fox
My name is Nicole Fox, I am the secretary of PAS and Obesity Medicine and I practice rural family medicine and a bit of emergency medicine in southeast Utah at two different clinics. And I got involved in obesity medicine because my background is in public health and I've, I've always been really attracted to getting to the root causes of a lot of the things that we tend to treat in primary care. So when AAPA had their primary care obesity medicine certificate program, that was my first intro into obesity medicine and just really loved it and found a lot of interest within my patient population that I was treating. And I would say now about a good 40% of my patient visits are obesity medicine focused within my primary care practice. And I really love it. I think it's, it's especially empowering to be able to do that in a rural area where patients are often underserved and we don't have any types of obesity medicine specialists in the area. So really, really enjoy being able to do that within primary care.
- [02:44]
Karen Potter
My name is Karen Potter. I'm the treasurer of PAS in Obesity Medicine and I was a dietitian for about 15 years before I went to PA school. And as a dietitian, I had gained certifications as a certified diabetic educator and the Level 1 and Level 2 certificate programs offered by the Academy of Nutrition and Dietetics. So I kind of had naturally already been doing it. Prior to going to PA school, I actually worked in a weight management program in an endocrinology office. And as I came out of PA school, I mean, the whole reason I went to PA school was to be able to provide more complete care than what I could with medical nutrition therapy alone. And so when I came back out, I just kind of naturally went back into a primary care environment doing some obesity medicine, and then was providing an obesity medicine clinic in a hospital environment. And currently I am working in women's mental health environment where about 60 to 70% of my practice is actually obesity medicine.
- [03:41]
Katie Earls
My name is Katie Earls. I'm a member at large with PAS in obesity medicine. I started out right out of school, not really knowing what I wanted to do, and fell into bariatric surgery. And I spent a few years working in the surgical world and then really found a love and joy for specifically medical obesity management. And so for the last probably eight years or so, I've been strictly obesity medicine. I work in a practice that has five other apps and one physician to oversee us, and we take care of a pretty large patient panel in a rural area. And it's. It's been great.
- [04:24]
Elena Sullivan
And my name is Elena Sullivan. I am a member at large in PAs in obesity medicine. I work as an obesity medicine specialist at a practice called KnownWell that provides national weight inclusive metabolic and primary care. And I was drawn to obesity medicine because it requires treating patients holistically, both all of their mental, physical, emotional health, every organ system of the body. And my particular interests include emotional relationships with food, body image, combating weight stigma. So this was a field where I felt I could really incorporate all of these elements into my daily clinical practice.
- [05:02]
Podcast Host
Well, very impressive, everybody. Let's head into our first question. So when you think about the current state of obesity care and primary care, what is the biggest gap you see and why does it persist?
- [05:13]
Nicole Fox
And this is Nicole again. I work in rural primary care, so I'm very aware of the gaps that we face. I think that the thing to keep in mind that's really encouraging is I do see that there's actually more opportunities than gaps. I feel like that's narrowing quite a bit. I feel like there's quite a bit of interest in obesity Management now from primary care, which has been really exciting, like being a part of different either AAPA presentations or different ongoing CME presentations over the past few years. It seems like there's a lot of interest from general practitioners to be able to address the root cause of a lot of things that they're already very familiar in treating with that. Some of the biggest gaps that I still see, I think stem from limited education on different pharmacotherapy as we're going through school. So 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. I think those are a little bit easier because we're familiar with those from diabetes management. Some of our older but still very effective medications such as phentermine and topiramate, phentermine, bupropion and naltrexone. I feel like there's not as much familiarity with them. And so that's still a gap that I see in a lot of people being able to use all of the available options, especially given cost barriers for, for obesity care. I also still see a little bit of, of pushback just I think from lack of understanding of these meds. Sometimes I'll have patients come back that are on for example phenter aminotopiramate and they'll say, yeah, I went to this outside facility and I am taking this medication. Then they question why I was taking it and if it was safe. So I, I still think the biggest gaps are really even stem back in our training just to not having a lot of focus on obesity medicines specifically.
- [07:00]
Podcast Host
I certainly empathize with that. You know, coming from working in hospital medicine and moving into primary care. A lot of the medications that you mentioned, Nicole, are very unfamiliar but very effective. So excited to learn a little bit more about yalls thoughts about it. So our next question. You know, many PAs are interested in obesity medicine but feel overwhelmed by the complexity. What are the first two or three practical steps that make the learning curve less intimidating?
- [07:25]
Karen Potter
So I'll take this one. This is Karen. You know, I think obesity medicine feels complex because it is complex. It touches many body systems, mental health, cardiometabolic, you know, and it also touches a lot of the patients lives. It touches what they eat and how they move and how they interact with people. So it's very complex. But I think that something that PAs can do to get started is to first acknowledge that it's complex both for yourself and your patients to, you know, get on the same page and, you know, talk to the patient, say, this is a journey we're going to take together. Start with a simple framework, learn a simple framework for assessment for patients and develop a limited list of therapeutic options that you want to start by offering as well as some referral sources in your community that you can start with. And then as you begin to find continuing education and learn more about different pieces, you can incorporate that into your practice. I think it's very important to understand that one of the most important things about obesity medicine is the frequency of visits. So do what you can in a visit and make sure you have frequent.
- [08:42]
Elena Sullivan
Follow up with your patients.
- [08:43]
Karen Potter
That allows you to learn as well as the patient to learn and you guys will have a lot of success together.
- [08:49]
Martine
So as we know, obesity is a chronic disease, so yet it's often treated episodically. How can clinical practices shift toward a chronic care model without burning out their team? And what complications should be avoided in selecting appropriate anti obesity medications?
- [09:06]
Lydg Ballesteros
I honestly think that, you know, when we look at obesity medicine, we really have to take a look at it as we would with diabetes, hypertension, hyperlipidemia, or any cardiovascular or metabolic disorder. So, you know, when we talk about shifting into chronic care model, it would be very similar to, you know, what we practice every day. So I think that the prime way that we do this without burning out our teams is education. You know, I think as Nicole mentioned earlier, we do have that issue where unfortunately the PA schools and many PA graduates and many PAs have been practicing forever, it seems, didn't get the education of how to treat obesity. So I think that the first thing we do as far as that shifting towards chronic care is educating our team members. And by educating, it's simple. You know, we start out with, okay, this is how we do the BMIs, this is how we do the waist circumference, this is what we're looking for. And so if we start out from the bottom up, it also helps. So in my clinic, I have my ma, you know, she does the weight, very patient friendly on there to where we are kind of watching and saying, okay, people, first language, making sure we're avoiding those biases, making sure that the setting is predominantly safe for those patients. So we weigh them in their room, we avoid certain languages, we make sure that the person feels comfortable when we're asking about waist circumferences. And then it goes into, you know, what my peers and I do in the room and when we're treating diabetes, rather than say, okay, well, we need to follow with a diabetic diet. We explain to them the importance of that diabetic diet. We explain to them the issue and the comorbidity that diabetes and obesity fall in. You know, when we're talking about medications, we're taking a look at all their medications and seeing, okay, what can we avoid? What could be causing obesity in that? So, you know, the best way that we shift towards chronic care is, is by including it in chronic care, including it as your assessment and plan, including it with the treatment of the other complications, the comorbidities that we're seeing, and then by not burning out our payments the way we would do with any other disorder. Now, when we look at complications to avoid, when we're selecting appropriate anti obesity medications, well, that's very similar to taking a look at which meds you would not do if we're dealing with, you know, cardiovascular disorder. So a lot of times when I'm looking at my medications, the first thing I'm looking at is what medications are the patients on right now, right? Are there any crosses, Are there any issues that we would avoid? If we're doing phentermine, should we avoid it on a person that's tachycardic? Do I avoid it on my significantly elderly population with afib? You know, if we're looking at naltrexone, bupropion, One of the big things I'm looking for is does a patient have a history of psychiatric disorders? Does a patient have an issue as far as suicidal ideation in the past or are they taking any psychiatric medications? So when we're thinking about anti obesity meds, we have to remember they are medications, right? And so a lot of times they can affect the person. So nowadays we're using semaglutide, tirzepatide, a lot more, right? So we're seeing a lot more of the GLP1s. And one of the big things that we're looking for is that a lot of patients are coming in with side effects and GI complications and they're discontinuing these medications. But I think the big issue is, you know, as Nicole had mentioned before, we're not educating them, right? So if we educate them, if they overeat, they may get the upper GI symptoms. If they eat something that's fatty, greasy, or with too many carbs, they may get the lower GI symptoms. If we're looking to see, you know, hey, do they have a history of gallstones or pancreatitis? Do they have gastroparesis already? These are not great candidates for these medications. So when we talk about complications in treating the these patients, we're honestly looking to see what can we avoid by taking a good look at their medical history, a good look at their medication history, and figuring out which ones, you know, would just which medications we would avoid from the start. So I honestly think that that's the big thing. And when I train my students and stuff, that's one of the big things we look at. What medications are they on, what history do they have, and what do my medications do?
- [13:36]
Martine
I'm totally with you on this. It's a whole cultural change, in other words, in the practice, because I had to start also an obesity medicine practice in a cardiology setting. And it's all, you have to do a whole training for the staff. It's a whole mindset change. So everything you just touched on, I totally agree with. So now let's talk clinical nuance. Like what misconceptions do clinicians still hold about pharmacologic therapy like GLP1s emerging and older agents that you wish would disappear? How do you ladies decide, for example, in your practice, which medication to choose for a patient? Because I get also that question a lot. They would ask me, do I have a preference or is it based on pricing? So, taking into consideration the role of the agent, other than the popular GLP1, how do you make that decision in your practice?
- [14:32]
Elena Sullivan
That's a great question, Martine. This is Elena speaking now and targeting your first question. I think one of the biggest misconceptions that I wish would go away is that using pharmacologic therapy for obesity is cheating or that someone is doing something wrong or, you know, not going about it in the usual way about just changing lifestyle and eating less and moving more. Many of my patients have come to me already trying many lifestyle changes. They've done diets, they've done exercise, they met with trainers, dietitians, commercial programs. And they've struggled to maintain their weight long term and have struggled even against their own bodies physiology. A lot of times people lose weight, but then have struggled with being able to maintain that weight. And those are very. Two very different processes in the body. And so when patients come to me kind of feeling, feeling discouraged that other providers have. Have said that, well, if you just, you know, cut some of these calories or have you tried Weight Watchers or done xyz, they feel. They don't feel like they're heard. And so I think as clinicians, one of the best things that we can do is really listen to our patients and really believe them when they say that they've tried many different things and know that pharmacologic therapy is not an easy way out. It's not cheating in the same way that we wouldn't look at someone with hypertension and say that being on a hyp hyper antihypertensive medication is cheating. Similarly to I also would like clinicians to know that we shouldn't withhold pharmacologic therapy and wait for patients to demonstrate that they can, you know, for instance, cut calories or exercise more before they're a good candidate for them. A lot of times I feel, and I, and I've seen in practice that pharmacologic therapy is a tool for patients that make lifestyle changes actually feel more feasible and realistic in terms of how they're able to apply these into their day to day basis in their day to day lives. And then targeting your second question about how do we decide what medications to choose for a patient? I always break it down with patients in terms of three different criteria that I use. So Legi talked a lot about different comorbidities and she gave great examples. For instance, if someone, we think about a, what is someone's candidacy for these medications? So what are their comorbidities? For instance, if someone has type 2 diabetes, we're more likely to think GLP1s or metformin. What are the contraindications? If someone has had a heart attack or stroke, then we're going to want to stay away from medications like phentermine or qsymia. Similarly, as Legi said, different medications that patients are on can also interact with some of these medications. And so in someone on a long list of psychiatric medications, I'm a little bit more hesitant to introduce something like phentermine or some medications that may lead to more anxiety symptoms. If, if patients are really struggling with poorly controlled anxiety. So number one, is their candidacy based on their comorbidities, current medications and any contraindications. Number two, I always think about insurance coverage and cost for a patient because as we discussed, we really want any intervention that we select to be sustainable and for patients to feel like they can continue them long term because with any intervention, if we stop doing the, the thing that's successful, then it's a lot harder to sustain the same result. So I talk to patients about cost and I explore what their insurance coverage is like. If a patient has insurance coverage for GLP1s, that's going to make them a lot more feasible or realistic than self paying for some patients, although prices have come down. But typically with GLP1s, currently we're looking at between three to $500 a month, depending on the agent and depending on the dose for some patients. So 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 shortly. And then the third is I talk about realistic expectations for weight loss with patients and what their weight loss goals are. And so selecting an agent can also depend on that. Granted, everyone's body is very different, but roughly, for our oral medications for weight loss, we see between 5 to 10% of their total body weight loss. With GLP1s, we see more like 15 to 22% with the agents that we have now, potentially even more with some of the agents in the pipeline and then with bariatric surgery. That's often when we're seeing more like 25, 30% or beyond in terms of total body weight loss. And that's not to say that I haven't had many patients lose 30% of their total body weight loss with an oral agent or lose, you know, 5 to 10% with a GLP1. But we also want to make sure that we're setting realistic expectations based off of where someone's starting in terms of what is realistic to lose, so that they're not getting frustrated if there's a plateau or if there's a period of time where they're not continuously losing weight. So to summarize, the three key things are one, how good of a candidate is someone for the medication? Two, what is cost and insurance coverage going to look like? And three, what is one's weight loss goals and what's the best way to hopefully get them there?
- [19:30]
Martine
Totally. And they say the best intervention is the one that the patient will stick to, basically, because if they're not going to do it, it's not going to work. And if they cannot provide, if they cannot afford it or not, something that's feasible for them. So we would just be wasting our time. So what does effective counseling actually look like in a 15 to 20 minute visit? I know in primary, I know for me, I do. My pharma visitors are typically 20 minutes. And we know in your busy world that might not be enough if you have to add on top of pharmacotherapy, you have to add nutrition counseling, exercise counseling, and so on and so forth. So how do you blend lifestyle guidance, risk certification, and shared decision making in that time allocated in a typical primary care?
- [20:18]
Katie Earls
It can feel really Overwhelming to try to fit all of that in to a short 15 to 20 minute visit. A lot of us in obesity medicine can be lucky enough to get at least that 20 minutes to focus on obesity management. I get a full 20 minutes for my follow ups, 40 minutes for new patient visits, so we can really dive in and focus on that. But when it comes to those briefer follow up visits to get effective counseling in, I always really try to start with just being very focused and getting an assessment of what the patient is currently doing. At the very least trying to get a 24 hour recall. I ask my patients to keep food journals so you know, if they're doing that, we review the food journal briefly together and from there making the assessments and recommendations for what types of things might be realistic for the patient to try to work into their life. I think too when we're giving this guidance in a visit, focusing on your individual patient and really working with them, meeting them where they're at to make realistic goals with your patient. Of course we also have to provide the risk stratification, you know, looking at the patient's comorbidities and sometimes we're going to prioritize certain interventions over others. I mean when we're looking at these patients if where, you know, we've been doing lifestyle modification and we know that often this is not enough and we're looking at medications kind of like what some of the others have already touched on with these comorbidities we might find, oh well, we have Tirzepatide which is now FDA approved to treat moderate to severe sleep apnea. And so those are some things that we can work in to the visit as well. But again, just just to summarize, really being focused with the current assessment of the patient and providing some realistic and personalized goals for the patient and whatnot.
- [22:17]
Podcast Host
So, so many of these medications are all over the place now. They're all over TikTok and the Internet. But even with that and increased awareness, so many patients come in with this misinformation or stigma from internalized years of bias. How do you navigate those conversations in a way that both are both evidence based and patient centered?
- [22:37]
Elena Sullivan
This is Elena, but I always start my discussion with patients around kind of meeting them where they are, but also discussing that unfortunately with weight it is one of the few conditions that we can wear on our bodies and that is very visible. And for that reason many people have had negative reactions with responses or interactions with the medical community and in day to day life and have internalized ideas or thoughts about what their weight struggles should and should not be. And so I often make comparisons to mental health and how we've come a long way in mental health care and sort of saying that, you know, we should just smiling more is, you know, is not going to cure depression if that is something that we're clinically dealing with. And so in the same way that we have to continue to be, to be mindful and we have to understand that obesity is a chronic, relapsing, multifactorial disease. And I often quote the Obesity Medicine association's definition from 2013 when they established that obesity was a disease. And then I talk about the complex interplay between genetics and environment and behavior and all of these factors and how they contribute to our weight and our body set point and that how that varies very much from body to body. And I also talk about how obesity is not a personal choice. It's not your fault. It's not a lack of willpower. Our adipose tissue or this excess weight is very hormonally active. And there's so many competing factors and many different hormones in our bodies that are contributing to our weight and where our body is. And sometimes we have to pull on different levers or use different tools to be able to treat our weight effectively. And oftentimes people, patients will also come to me and ask if they need to be on medications for life. And there's a certain stigma also associated with that of, oh, is this something that I need to be on long term? But I often also draw comparisons to antihypertensive medications or diabetes medications or cholesterol medications where if that medicine is effective in reducing someone's blood pressure, reducing their cholesterol, oftentimes if they stop that medication, their blood pressure, their cholesterol may creep back up. And it's the same thing with weight. If we stop those interventions, many times we can have some relapses in weight and weight regain during that time. And so I often describe interventions, especially anti obesity medications is sort of bowling with the bumpers up. The goal is to prevent you from feeling like you're falling into the gutter no matter what you do. It's not replacing the lifestyle factors that have to happen. Nutrition and sleep and stress and movement that are going to get that spare or that strike when you get all of the pins down. But it's so much easier to do those things and they feel so much more attainable when those bumpers are up and you're not chronically struggling with, you know, cravings or thoughts of food or hunger, especially in cases where people have lost a significant amount of weight. And there's what's called metabolic adaptation that happens where their body quite literally starts to fight that weight loss and starts to want to regain weight, and so they become hungrier. They're not using as many calories or burning as many calories at rest. And so we have to really understand that obesity is not a choice or moral failure. It's really a complex disease and we have to treat it as such, just as we treat many other chronic diseases that way. And I also remind patients, too, I've marathon runners who have high blood pressure, who have had heart attacks or strokes even. And so we can't tie someone's weight to their health, and we have to really look at the whole person and take care of them as such.
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Podcast Host
That is such an important perspective. So y' all have mentioned that, you know, obesity is a chronic disease and it has many associated risks. So in your experience, what are the most overlooked cardiometabolic risks in patients with obesity that primary care PAs should be identifying or flagging earlier?
- [26:32]
Nicole Fox
This is Nicole. I think that that primary care is actually really, really crucial to finding these cardio metabolic risk factors before they become an even bigger problem. So one that I really pay attention to as I'm doing either an obesity related visit if somebody's interested in pursuing an obesity pharmacotherapy, or if I'm just doing regular screenings for my patient. I'm really looking for metabolic syndrome. So I think a lot of times in the past, a lot of people would say, oh, you're in. As a reminder, metabolic syndrome is a low hdl, high triglycerides, hyperglycemia, but not to the level that it's either overt hyperlipidemia or diabetes. So a lot of times we're seeing these small changes and an increased waist circumference as well. So there's different sub subcategories for women and for men. So for women, it's a waist circumference greater than 35 inches, for men greater than 40 inches. So if you have this constellation of what used to be called syndrome X or metabolic syndrome, then we're, we're starting to see some of those risk factors take root. So the triglycerides are going up a little bit. That cardio protective HDL is coming down a bit. We're seeing an increased waist circumference where we're getting more of that visceral adiposity and that central adiposity that we know, confers more cardiometabolic risk. And we're not quite seeing diabetes, but we're maybe seeing a little creep up in either insulin levels or A1C, not to the level of diabetes yet, but all of these things together. We know that you don't suddenly start accumulating ASCVD risk when you hit an A1C of 6.5. You know, like these, these are all cumulative processes. And catching this early by doing good screening with routine screening labs, as well as talking to our patients about them and not just saying, oh, you're, you're not in a severely elevated LDL category that needs a statin immediately, or, oh, you're not a diabetic yet, just work on diet and exercise. I think that those critical time points where we notice those changes happening are really crucial to have an intervention and have a really good conversation about potential adverse effects down the line. I think in terms of obesity management and obesity treatment, there's, there's two indications with two of our GLP1s that are really important and can offer a way to get some coverage for these medications as a secondary indication. So, for example, the select trial demonstrated that semaglutide reduced major adverse Cardiovascular events by 20% in adults with overweight or obesity with established cardiovascular disease, but without diabetes. And I found for me, this took a little bit of time to really get into my algorithm of how I was thinking of ascvd. So oftentimes we'll get a patient back after an mi, for example, and we're used to them being on tons of new medications. Like they've got potentially a beta blocker and they've got a statin and they're probably, if they're status post dent placement, they've got some, some blood thinners that they're on. But it took a bit for me to start saying, hey, there's another thing that could reduce cardiovascular events over time if there is established ascvd. And so semaglutide can be a great option for that. And I'm starting to see a little bit more insurance coverage for that as well. So in the patient that meets that group, that's, that's not only an impact on obesity or overweight, that's a huge reduction in their cardiovascular risk over time. And then similarly, tirzepatide in the Surmount OSA trial was shown to have a really significant effect on obstructive sleep apnea in our patients that have moderate to severe sleep apnea. So I think, especially if we're, if we're working in primary care, we're really used to having a lot of hard conversations and a lot of resistance for what a CPAP entails and tolerance of a cpap. And so this, this isn't necessarily to say that the CPAP isn't still indicated, but this can be another really important tool that treats our patients that struggle with moderate to severe sleep apnea and also can make a big impact on obesity and cardiovascular risk.
- [30:30]
Podcast Host
So lots of opportunities. Now we know practice integration is a major hurdle. How can a PA in a busy clinic start to build structured obesity care algorithm based care, follow up systems, multidisciplinary referrals without needing a full redesign?
- [30:46]
Lydg Ballesteros
That's a great question because it's one that I see a lot. This is legit by the way. I actually don't think a full redesign is necessary. I think that you can integrate obesity care in any primary care office. And so it's. We start looking at how we use the visit, right? So the initial visit, we're gathering information when you meet a patient, whether it is for internal medicine, primary care, however it is, we're gathering their information. We would do the same with obesity care. We're going to gather that detailed medical history, create a detailed physical exam and in this case add in the weight history. Many of US are using EMRs. So I love our EMR systems flow sheet. And so many times I'm asking the patient, okay, well when did this start being an issue? Or when did you notice the weight? And they may tell me, oh, it was during the pandemic, I must have gained like 30 pounds. And then when we look at the flow sheet it's like, well actually you, you've been the same amount of weight since 2011. So a lot of times, you know those flowsheets and gathering that medical history does affect how the patient is perceiving this medical condition, then we're going to perform, right? So just like we would perform on any other disease, on that initial visit you're going to collect the labs, right? You're going to do your routine labs, whether they're CMP, lipid hemoglobin, A1C, thyroid, possibly specialized 1tsH, insulin, hormones, food allergens, possible rheumatoid test. If the person has insinuated that they've had problems in the past. And then in my situation, because we are giving anti obesity medications, a lot of I do add in an ekg. And then when we're doing the initial visit again, we can incorporate this with their diabetes, blood pressure, cholesterol by adjusting those lifestyle modifications, possibly putting them on a better nutrition plan that will help both. You know, I have patients with rheumatological issues that we put on anti inflammatory diets. My diabetic patients, my patients, hypertension, hyperlipidemia, do very well with Mediterranean based diets or low carb diets. So at this point we're treating the comorbidities while we are addressing that obesity. And so I feel that when we do that on that initial visit, that takes a lot of time off of what many providers are so worried about when they think, oh, we're going to treat obesity care. You know, many times on that initial visit, I'm adjusting possible medications. Maybe they had been started on a high dose of insulin and we can adjust it and Maybe prescribe a GLP1 and lower down the insulin, maybe they had been prescribed a antipsychotic and we can provide a better antipsychotic or an antidepressant that has weight lowering effects. And then in that visit, that initial visit, we may be referring to specialists and referring to specialists, they can help you out. So many of us have 20 minute slots for patients. Feel free to use the team. You know, so a lot of times when the person's first seeing me, I'll have them follow up also with a dietitian and say, okay, well, you know what, I'm going to focus primarily on this, but I want you to be seeing the dietitian routinely so y' all can talk about dietary changes. Many of my patients are elderly, so we work a lot with sarcopenia or we worry about weakening the muscles as they lose weight. Especially with those GLP1s. They tend to have muscle atrophy if they don't have enough protein. So we start them on physical therapy. I always find it kind of fun to tell providers, like physical therapy is covered for patients with obesity. We can put for strength training, we can put for abnormal gait, we can put for all their arthritis issues. And so they get their physical activity from physical therapy. I also try to see if we need to involve a therapist or psychiatrist. Sometimes obesity can be related to a psychological issue, whether it's binge eating, night eating disorder, whether it's even anorexia and bulimia. You know, many times we see these eating disorders, we don't think obesity, but they have some correlation. I've had patients before that we've treated for obesity or morbid obesity that have unfortunately gone to the other spectrum and now have issues of bulimia or anorexia so possibly having a therapist involved. Some of my patients do a lot of group therapy or chat rooms for Overeaters Anonymous, etc. And then when we're adding that in, you know, our follow ups are very similar to routine follow ups, right? So they come back to me usually six weeks when they, we originally, originally start. And then once we get them into a rhythm, I usually see them about two months and then we kind of push them out a little bit, three months. And to be honest with you, a lot of that has to do with the fact that they are seeing their, their other PCP at the same time or they may be seeing a specialist at the same time. And then once they're down, you know, on those numbers and they've kind of, you know, they know what's going on, we're just going to the maintenance and maybe I'll see them every three to six months. And during that time we're gathering any information that's changed. In those last visits, I pride myself in making sure that all of my patients have a food journal. And a lot of people are like, how do you get them to do a food journal? You'd be amazed. If you tell patients, I need this food journal, I need it to be able to help you. Otherwise, you know, not much good to you. They'll bring those food journals in. So we look at the food journals, we look at physical activity logs. When we're gathering those follow up visits, I look to see has anyone adjusted any of your medications, Maybe a cardiologist gave them something that would cause weight gain. I had a patient this morning that the OB GYN started her on a medication, a hormone replacement that unfortunately had given her some meds. Actually today I also had another patient that was started on an antipsychotic in October and she's gained 23 pounds since then. Nothing else has changed. So we want to see, are there other adjustments that we need to make, are there other comorbidities that we're addressing? And then when we're doing that, we're performing the physical exam just like we are for the diabetes, just like we are for the thyroid disorder. And we're adjusting their lifestyle modifications based on how they all interact with. So I think that when we're talking about how do we incorporate obesity into primary care, there's no need for a full redesign. We just have to incorporate it in saying, hey, they are, they are correlating, you know, they are related to it. So if I'm taking care of their diabetes, I'm taking care of their obesity, I'm taking care of their hypertension, I'm taking care of their obesity. And I think that that works vice versa. When we started my program out in 2015, soon after, we started using it for an algorithm. So many of my patients are managed care and they work through Medicare and so forth. And so I'm part of an algorithm for any referrals to outpatients. So in order for them to have a referral for an orthopedic surgery or an elective surgery, they have to have a BMI under that 35. And so, you know, one of the things that they have to meet in order to be referred out is, you know, are you on pain medications? Have you seen, you know, your doctor routinely? Are we doing physical therapy? And then of course, have we shown the weight loss? And so once we're able to do that, you know, we're able to kind of help out a little bit more. So I think that incorporating obesity into those algorithms helps out as well.
- [37:58]
Martine
These are all great interventions, Reggie. However, we all know how access and cost barriers are real. What strategies have you ladies found most effective for navigating insurance, prior authorizations and patient affordability?
- [38:14]
Katie Earls
So I'll take that one. So in my experience, navigating the insurance and affordability requires a multi prong approach. First, I think it's important to try to understand the prior authorization process. There can be very different criteria for different insurers. And so having some idea of what these criteria are is going to be key. And I think when you're practicing this and you're exposed to these criteria over and over, you're going to learn what document, documentation and what supporting evidence is going to be needed to get these approvals. Sometimes that might be a certain number of monthly visits with you. Some insurers might need these to be not just visits, but consecutive monthly visits, among some other things. But knowing that is going to really help you get a medication. When you're trying to prescribe something approved the first time around and save a lot of time and effort. Not everybody though has coverage that's, you know, has a policy that's going to allow for coverage for anti obesity medicines, unfortunately. And so if coverage isn't available, it's important to then maybe consider expensive exploring cash pay options. And so a lot of these medications now have programs through the manufacturers that offer reduced cash prices and they are a lot lower than the retail costs straight from a pharmacy. Sometimes that is still too costly for a patient though, and still not affordable. I think Elena had said earlier, the cost for some of these injectable GLP drugs, cash pay now is, can be anywhere from 300 to $500 a month on average. And I know where I am from in a very rural area, that is too much for a lot of people. So at that point, if we can't look at cash pay options, I think it's important to maybe pivot and talk about affordable oral medications. Sometimes we can find these a little bit more affordable than the others and sometimes even the branded oral options still continue to be a little bit beyond reach for some patients in terms of cost. So in that case, that's where we really start to get creative, at least in my practice. And we might talk about using some of these components of oral medications off label. But if you're going to do that, it's going to be incredibly important to talk to patients about risks and benefits and always just ensuring that the patient's safety and their preferences are prioritized. But I think it's really about being flexible and trying to be resourceful in order to provide the best care possible to these patients and offering pharmaceutical therapy when it's appropriate.
- [40:53]
Martine
I like that, Katie. Being resourceful, isn't that what we are best at doing? And hopefully there's some hope in the future. Supposedly some of those meds should be even lower the price, the price should be going down. I don't know when. Hopefully within the, in the new year. So looking ahead, what innovations or shifts in policy training or team based care do you believe will shift the next five years a little bit? Obesity medicine, especially for PAs on the front lines in the last couple of.
- [41:23]
Karen Potter
Years, I think the conversation around obesity care has completely permeated our society like no other time in history. And I just don't think it's. I think it's like a genie that's been let out of the bottle and this time it's not going back in. I mean, I think that the public in as a whole, our patients as a whole, are starting to truly understand this is not a failure of my own willpower. And they want effective treatments. They want treatments that they have access to and can afford. So I think that's going to be very helpful to those of us who are trying to get to practice obesity medicine is to have the general patient population's voice behind us. And so I think most immediately it's going to be challenging, but it's also going to be exciting for a few years. I think some of the things we're going to see first Are some shifts around potentially Medicare covering some things, these cash pay programs, costs, new indications. I think that's going to be something we're going to see pretty soon is additional indications. We already have indications beyond just obesity for some of these medications and helping patients or diagnosing and risk stratifying appropriately so that they can get access to it is going to be something that's going to be really helpful to us in the coming, you know, years. But as well as we're going to see new things such as new medications, there's quite a few that are in development which will give us new mechanisms of action. Some of these things will be going generic, giving us better options for price and competition among the manufacturers. But some of the things that we may be looking at beyond medications, there's been some use of continuous glucose monitoring to help patients understand lifestyle interventions. That may be something that we see in the future. More tools, technology tools to help patients understand what they're, what's going on with their bodies. But as well as things like genetic testing for rare forms of obesity, genetic phenotyping, more precision medicine to help really hone in on the types of diets, the types of exercise and even the types of medications that may be the most helpful to patients and help them achieve their goals.
- [43:25]
Martine
Thank you for this, Karen, and the future is looking great. And I'm excited as well for all those new drugs in the pipeline and in your indications. Amy and I thank you all for joining us today. Any additional closing thoughts quickly before we go?
- [43:42]
Lydg Ballesteros
Well, we want to thank you for inviting us out here. Pam is very excited to be on the forefront of obesity medicine and having PAs, you know, our peers and other practitioners, you know, follow in suit and hopefully help with this epidemic. So I think my biggest words of advice is don't be afraid to try with our patients. You know, don't be afraid to try to help them out with that obesity. It does not mean you have to be a specialist. It does not mean you have to have a slot for just obesity. Feel free to incorporate it into your practice and I think that by doing so, we will slowly start moving that needle where it needs to be.
- [44:21]
Martine
All right, thank you, lady. And for more information and resources, you can visit the PAS no Busy Medicine website at pasnobizidingmedicine.mypanetwork.com and to our listeners, thank you all for joining us. And before you go, don't forget that the podcast is associated now with cme. And to receive your CME credit and access your certificate you just listen to the podcast, then complete the post test and evaluation in AAPA's Learning Central at cme.aapa.org until next time.