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JAAPA Podcast
World Obesity Day Special - How PAs can shape the Future of Obesity Care: Science, Access, and Comprehensive Treatment
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- [00:00]
Carly Burridge
Foreign.
- [00:06]
Martin (Host/Moderator)
Welcome to today's special episode in recognition of World Obesity day, which is March 4. Obesity is a chronic relapsing neurohormonal disease that affects more than 40% of adults in the United States and more than 1 billion people worldwide. According to the CDC, in 2024, at least 1 in 4 adults in all US states and territories had obesity. Yet stigma persists, access remains uneven and treatment is often fragmented. Obesity Care Week, March 2 through March 6, aims to raise awareness, educate and advocate for people living with obesity, providing us the opportunity to create lasting change. Today we are joined by pas on the front lines of obesity care, sharing their perspective on what comprehensive evidence based treatment truly looks like in 2026. As we recognize World Obesity Day today, we will examine the realities of caring for obesity as a chronic disease in the era of online GLP1 prescribing platforms, rising patient demand, and evolving insurance coverage proposals. Our guests are physician associates who practice obesity medicine every day. They manage complexity, address stigma, navigate prior authorizations, and build structured treatment plans that extend far beyond a single prescription. This conversation is about science, accountability, access and the leadership role PAs play in shaping the future of obesity care. Before we get started, don't forget listeners can now earn CME by listening to the podcast. To review 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.
- [01:49]
Carly Burridge
Org.
- [01:50]
Martin (Host/Moderator)
Now I'm excited to introduce our guests, Joseph Zukey, Angela Thatcher, and Colley Burridge. Before we discuss obesity medicine, could each of you share a little about your background? What drew you to this field, how long you've been practicing and where you currently work?
- [02:05]
Joseph Zukey
Thanks Martin. Honored to be here. Thank you for having me. My name is Joseph Zukey, I'm a physician associate and I am the clinical supervisor at Transition Medical Weight Loss in Salem, New Hampshire. I've worked in obesity medicine my entire career. Even prior to going to PA school, I worked at Obesity Medicine center, also personal training background similar to Carly, so very much into the fitness world and really passionate about nutrition and impact on chronic disease. At my office in transition, we have truly worked to make the most comprehensive program we possibly can. We have body composition analysis, a registered dietitian on staff, a social worker. We have a healthy food store in our office to provide healthy meals to patients. We do support groups, we have a lab on site so we try to address all aspects from counseling to nutrition to exercise to of course, medication. So it's been very rewarding we just hit 50,000 pounds of weight loss. As a, as a practice, we're looking forward to helping more patients. So glad to be here.
- [03:01]
Angela Thatcher
Hi, I'm Angela Thatcher. I'm a PA and obesity medicine specialist in North Carolina. My journey into this field started almost 10 years ago when I was a new PA working in family medicine. Very early on I had a frustrating realization that while most of my day was spent treating chronic disease, I wasn't actually addressing the root cause of many of those issues. And that's because I really hadn't learned in PA school about the disease of obesity or how to treat it. And so after pursuing some additional education, I began integrating obesity medicine into our family medicine practice. And very quickly those visits became my favorite part of the day. My background in before PA school was in social work. And so I really enjoyed having the time for patient education and counseling. And it was incredibly rewarding to see how patients health and lives were transformed when we actually addressed obesity instead of just treating the comorbidities. So four years ago, I made the decision to work in obesity medicine full time and I opened my own practice, Lifelong Health and Wellness. And now I am committed to providing comprehensive, compassionate, evidence based care for my patients and also advocating for improving access to that type of care for all of our patients with obesity.
- [04:29]
Carly Burridge
Thank you, and I'm very excited to be here with you all today. My name is Carly Burridge. I'm a PA and a Master Fellow of the Obesity Medicine Association. Like Joe, I also kind of started my journey in obesity medicine before I even knew what it was, honestly. For my undergraduate, I had degrees in psychology and physiology and went on to study clinical exercise physiology and graduate school school before attending PA school with the goal really of helping patients who were living with chronic diseases like diabetes and heart disease and obesity and even things like depression and. And my goal was really to help them with these chronic conditions with lifestyle factors like nutrition and sleep and physical activity. Had I known at the time about obesity as a disease, I for sure would have gone into obesity medicine right away. But it was not a field that I even knew existed when I graduated PA school. And so I started out in primary care and a few years later found, kind of just fell into a job in bariatric surgery. And that was really my first exposure to obesity as a disease and learning about all of the hormones and the, the neurobiological processes and genetics and the complex nature of obesity. And so it was really through bariatric surgery that I learned more about obesity and then also discovered that there was this whole field of obesity medicine. So I joined the Obesity Medicine Association. I've been very involved with them. And I started a medical obesity program within the surgical program and then developed several obesity programs in various different settings and a large hospital with bariatric surgery within primary care, most recently within a mental health practice. And I've just fell in love with the field of obesity. And I kind of eat, breathe and sleep obesity medicine. I'm served on the board of the Obesity Medicine association, the Illinois Obesity Society, and I'm a co founder and past president of PAS and obesity Medicine. So I'm just thrilled to be talking to you all on obesity today. Thank you. Joseph, Angela and Carly, we're excited to have you. You are all leaders in this field. So let's go ahead and get started with some. World Obesity Day focuses on changing systems, not just individual behavior. Obesity is a complex issue. How does framing it as a chronic disease rather than a matter of personal choice, change the approach to care? From your perspective, what does comprehensive obesity care actually mean in clinical practice? This is a great question and I'll kind of jump in. I know we're probably all itching to answer this question because it really gets at the root of, of, of so much of what we're going to talk about today. And I think, you know, identifying obesity as a chronic disease, one thing that it does is it removes some of the blame and shame. So often in the past, especially, and unfortunately, many people still believe this, that obesity is a lifestyle choice, that people choose this disease and not that it's a complex neurobehavioral disease with many, many factors that go into whether somebody develops obesity or not. Genetics definitely plays a huge role, but there's so many different factors that go into this. And by treating it as a disease, recognizing it as a disease, it changes the way that we approach it. Right? And so just like any other chronic disease, if we were treating diabetes or anything else, we want to make sure that we're first of all considering the many factors that may go into somebody contributing to somebody developing the disease. And then we want to make sure we're doing a thorough assessment. We want to make sure that we are addressing all of the factors that we could be addressing. So when it comes to obesity, there are so many different factors. Somebody could be on weight promoting medications, they could have medical conditions that are contributing to their obesity. There could be psychological conditions, there are socioeconomic factors. I mean, the list goes on and on of the different contributors. And so by framing obesity as A disease. We really want to look at all of those different factors when we're treating somebody. We want to make sure we're doing a thorough physical exam that is obesity related. We want to make sure that we're ordering appropriate labs and doing an appropriate assessment and then of course, treating with evidence based treatment options. And all of those things are part of treating a chronic disease. And we do this for so many other chronic diseases. Right. And that's why it's so important that we understand obesity as a chronic disease. We understand the pathophysiology, which I think is something that a lot of clinicians have not learned about because it is not part of our education. And so I think all of these things, including reducing some of the weight bias and stigma and the shame around obesity, are all important reasons why we all need to recognize obesity as a chronic disease and not just recognize it as such, but treat it as such.
- [09:36]
Angela Thatcher
Carly, I think that's an excellent explanation about the comprehensive nature of how we need to be treating obesity and the importance of, of treating it as a disease. I think just a couple of other nuance points that are important in that same discussion are that when we recognize obesity as a disease, it makes us, it makes long term treatment and understanding that when we're helping someone to treat obesity, it's not something we're doing right now while they lose weight, but it requires ongoing management in order for them to sustain the weight that they were able to lose. And I think this is also a big part of the pathway for us to improve access to treatment. Because as you touched on, we should if obesity is a disease and that's how we're treating it, and that's how we're approaching it and discussing it, then we should expect very similar access to care that we have for other chronic diseases. And that is definitely not the case yet.
- [10:36]
Joseph Zukey
Just agree with everybody. It's an excellent explanation by Carly and Angela, just explaining the complexity here. I think for so many patients, they've been, you know, unfortunately stigmatized or criticized over the years and they develop, you know, they feel like it's a lack of willpower. And they've been told that story many times. And so helping them to understand that this is beyond control here and this is a biological disease state is so important. It helps them to have compassion, helps to have the providers caring for patients that help them work through this. It's not going to be an easy journey. It's not just a simple diet fix or just an exercise plan. It's looking full picture and helping them to know there's options. Right. It's just trying to help them to be aware that we're here to help you and hopefully taking the blame away and giving them the tools between. Just like the OMA recommends the four pillars, right. We have nutrition, exercise, behavior, and of course medication is available as well. So just helping patients understand their options is powerful. And knowing that we have better tools than ever to make this disease better treated, very insightful.
- [11:34]
Carly Burridge
So obesity is portrayed in the media and marketing in ways that reinforce stereotypes. From your perspective as clinicians, how do current depictions of obesity shape public understanding of the disease?
- [11:45]
Angela Thatcher
I think often when we see people with obesity pictured in the media, they're either pictured participating in an unhealthy activity or they're shown as essentially a body part, often like no head. And that is important for us to recognize and, and push to change because it's further underlying the stereotypes around obesity of this being a choice or a character flaw. And I think not showing a whole person is really very dehumanizing. And it, it also, it leads to a place where it's easy to not have as much empathy or to see someone as a person when you start to see them as a body part instead. And so I think that's really important for us to recognize and work to show our patients. Or when we're picking depictions for literature in our offices or things that are displayed on our website that we're using very person first and people centered imaging that shows positive depictions of patients no
- [12:57]
Carly Burridge
matter their body size. Yeah, I agree with that. When we see images of patients with obesity engaging in unhealthy behaviors, we again are perpetuating that stereotype that people with obesity don't necessarily eat healthily or that they don't exercise or anything like that. And, and honestly, when you've been working in obesity and, and if you even go to ask the questions, you'll see our patients with obesity are the hardest working. They have more willpower than I would ever have when it comes to, you know, when you, when you ask them about the different types of nutrition plans that they have tried, they often have tried every diet under the sun. They have tried so many different things over and over again to try to manage this disease is usually the picture of willpower. And so I think again, having stigmatizing images just shows people the wrong image of what, you know, people with obesity are the activities that they're engaging in. And it's just oftentimes very, very incorrect. And it just reinforces that stereotype that is just simply not true.
- [14:07]
Angela Thatcher
I also have noticed more and more focus on before and after pictures, and I think it's important that we stay away from that when we're using them, using clinic depictions, because before and after pictures really reinforce the misconception of the treatment of obesity as being a quick fix, or that it's only about appearance or a number on the scale. When in truth, if we're approaching this from the standpoint of obesity being a disease and us treating it as such, the focus needs to be on health and on how we're impacting that across the lifetime, not just a before and after representation of what a patient looks like after a certain amount of weight loss.
- [14:54]
Carly Burridge
Joseph and Angela, you've brought this up already, but I want to talk about internalized stigma. Many patients carry shame long before they walk into our clinic. How does internalized weight bias show up in your patients and how does it affect engagement and care?
- [15:08]
Joseph Zukey
I think, you know, so many patients like we talked about are struggling with obesity for many, many years. This is not just something that just happened. It's a chronic, ongoing battle. And they've tried so many diets before, so many quick fixes, fads, exercise programs, and certainly have seen success likely at some capacity. But the sustainability is the problem. And a lot of diets are a means to an end, which is the problem, because it's not a, you know, 30 day fix. This is something we need to make a lifestyle out of it. Sustainability is so important and I think helping the patients to understand that the biology is so powerful. You know, they need to know that, yes, when we lose weight through diet and exercise, unfortunately, the body has this compensatory response where it's going to increase hunger, decrease fullness, slow down our metabolism, and try to pull its weight back to its kind of previous set point. And that helps them to understand why when they've lost and gained back the weight, it's. It's not their fault. It's actually the biology is trying to pull them back there. And that's kind of just programmed from. We are programmed to not starve to death. And so our body has these compensatory responses to try to prevent that from happening. And so that's why they need to understand that this is not a lack of willpower, this is a biological response. And let's help you, of course, with the lifestyle, but also potentially medications which can help to counteract some of that biology. That's very challenging.
- [16:23]
Angela Thatcher
I think a great example that probably we've all experienced when we were talking with a patient of internalized stigma is the apologizing that patients do when you start to ask them basic questions about symptoms or about, you know, how things have been going. And it's this automatic apology of, well, I could have done this better or I should have done this different, or I'm sure this is related to, you know, if I lost weight, this would be better. And it's because so often in their interactions with other people and with other clinicians, they, they've have felt like they've had so much blame placed around their weight and, and their own choices and that they've started to treat coming to a medical office more like a confessional than a consultation. And when you internalize that type of stigma and you start to believe that it's your fault and that all these different things are just because of needing to lose weight, it means that you start to avoid preventative care. You don't want to go into an office if you're worried that you're going to be ridiculed or that there's going to be a negative comment about your weight. It also, often I find that people start to minimize symptoms. And in my intakes with new patients, frequently I discover that there's a condition that's not really ever been worked up appropriately because either it was already dismissed as being something related to weight, or the patient never brought it up because they assumed it was related to their weight. And I think it's important for us to recognize that that internalized stigma has very real consequences for patients in their interactions with us in clinic as well as just their interactions within the medical system.
- [18:17]
Carly Burridge
Yeah, I'm really glad that you brought up the reluctance to seek care, because that is really problematic. And that is what the data really shows, that when people experience weight bias and stigma from clinicians and from society, but especially if they are experiencing that internalized weight bias, where they have started to believe these negative beliefs about themselves that can be really, really detrimental to their health and delay care and all of those things. And like you said, we see it with patients when they come in and see us and talk to us. And so I kind of started asking, you know, rather than, you know, how are things going? Because to your point, Angela, a lot of times people will immediately jump to the one time that they slipped up or they ate something they shouldn't have. Right. And that's a sign of that internalized weight bias. So I like to start with asking them with what went well and, you know, kind of start the conversation from there.
- [19:12]
Angela Thatcher
Great point.
- [19:13]
Carly Burridge
As PAs, we often serve as the first point of contact in primary or specialty care. What practical steps can we take to improve how obesity is discussed and depicted in clinical settings? How can PAs actively work to reduce stigma and increase their competency and comfort level while treating patients with obesity?
- [19:30]
Joseph Zukey
I think first of all, it's just trying to use person first language and helping patients to, you know, instead of telling somebody that you have morbid obesity or calling a patient obese, it's helping them to, you know, kind of use the term. Weight is a bit more of a gentle term. Or we can say a patient with obesity is a more understanding term. And so that's one thing. Second piece is trying to help to move away from oversimplifying weight loss to just, you need to eat less and move more. I mean, sure, that's part of the goal, possibly that we need to work on, but at the same time, there's much more than that. Helping patients to know that we, you know, there's. This is a complex disease state and given the right resources, is going to help with that too. And not being judgmental, you know, if somebody has a bad week, sometimes they can feel like they're going into the principal's office for their weigh in this week and it shouldn't be that way. It should be. Those are the weeks I'm here to help you the most and I'm looking forward to helping you. You know, we can learn from that and make this next week ahead better. I remember a person last week that after our consultation had tears in her eyes and she just said, thank you for seeing me for who I am and not just for my weight. And you can see she was so grateful that it was a comfortable meeting and it wasn't, you know, stigmatizing. But at the same time, it's sad to know that she probably had gone through several other visits prior to this where she perhaps was treated in a different way because clearly she was touched by a different response. And then lastly, I think comes down to education, just helping more clinicians to be aware of how complex obesity is so that they can best treat their patients or at least refer to providers who are able to provide the best quality care.
- [20:53]
Carly Burridge
Yeah, I'd like to piggyback on that. I think, you know, everything you said is spot on. But I want to circle back to the education piece a little bit too. I think for so many of us, if we haven't had specialized training in obesity medicine outside of a PA school, we may not have ever received this type of education. So I think it's really important that all PAs make sure they receive some kind of education on obesity. And there's a lot of resources now for PAs to get educated. There's great resources through AAPA, they have their whole obesity toolkit. You can get plugged in with PAs and obesity medicine. And then, you know, if it's really something that you want to specialize in a little bit more or want to dig deeper, I highly recommend organizations like the Obesity Medicine association or the Obesity Society. Through the obesity Medicine Association, PAs can get the certificate of advanced education in obesity Management. Through AAPA and the Obesity Society, they can get the primary care certificate in obesity management. So there's lots of different avenues and places where PAs can get educated. But it's so important that, you know, we all need to have at least a basic understanding of obesity pathophysiology and basic treatment and assessment of patients. And certainly if we have patients that require more specialty care, we can refer to specialists. But I think it's so important for all PAs to have some baseline knowledge of obesity and obesity care. And then also, you know, when it comes to clinical practice, you know, the things that Joe said, super important. Make sure we're using patient first language and things like that. And then also just starting with a simple model like the 5A's model, which starts with asking permission to discuss weight. So that's something especially if, you know, you're new to this. How do I even bring up this conversation? Just asking the patient, hey, you know, I'm concerned about your weight and how it might be affecting your health. Is it okay if we talk about this today? Is today a good day to talk about this? And if it's not, that's okay. We want to respect patient autonomy. Maybe it's not a good time or not a good day or they're not open to discussing it, but at least you have opened up that door to that conversation that if later down the road, if they wanted to talk about it, you were letting them know that you're there for them.
- [23:10]
Joseph Zukey
I love that. Thank you so much. That's so great to hear. And just asking permission, really good advice. The next thing I want to get into is the wonderful world of online platforms for medication and medical treatment. So I want to know, if you have a patient that comes to you after receiving medication from an online platform, how do you approach that conversation? You know, we want to encourage access to care while balancing quality. In what ways does current insurance coverage reflect or perpetuate stigma in the field of obesity treatment, this is the most complex issue we've been dealing with over the past few years in our field here. So it's become the wild west, unfortunately, with all of these online places. And of course, first I will say that at the end of the day, patients are being proactive for their health and I applaud them for that. And I understand the access and the costs are a big issue. So never, we should be, never blaming somebody for attempting to get healthier by using these different tools. But it is definitely a mixed bag of options out there. There are some very reputable evidence based obesity medicine programs that are virtual, that are excellent and so the patient may be in a good program, but there are also a lot of programs out there that are unfortunately just uh. It's hard to even describe how poorly they're serving their patients. It is not even, they're not even seeing a patient. They're getting a compound prescription sent to them at their door. No one's monitoring them, no one's giving them any guidance. And it can lead to dangerous side effects. Plus the concern of are they even getting a valid medication. And of course we know that compounds are not FDA approved medications. And so it's very important that we help patients understand at least why these options may not be as safe as they seem. And of course these places do a lot of marketing and messaging to try to appeal to patients and rope them in. So I always want patients to know that, you know, hopefully they can find the best option that's fit for them. But also to be leery of these places that are trying to sell the quick fix for something that as we have been talking about is a chronic disease that's going to require long term therapy.
- [25:11]
Angela Thatcher
Yeah, I think that's really important, like leading with validation for the patients first so that we're not further adding to blame and stigma around the very condition that they're looking for help with. And I have found that sometimes it's helpful just to sort of emphasize the comprehensive, the importance of comprehensive treatment. Because so often a lot of these online platforms are really just focused around a prescription and that is only a small part of what the patient actually needs in terms of help when they're trying to address issues around obesity. So providing education, sometimes just asking some questions about like, you know, well, what are, what's the follow up? Like, how are they monitoring things? How do you receive information around dosing and providing some education? This is very confusing for patients. Patients really don't understand the difference. A lot of patients really don't understand the difference between FDA approved medications and compounded medications that they are told they're generics and they believe those people. And so I think it's important to be honest and provide good information, but also help with ensuring safety for patients and making sure that they are getting comprehensive care.
- [26:31]
Carly Burridge
Yeah, I think both of you guys make really excellent points there. And Andrew, just want to re emphasize what you just said. Obesity medicine is not just about a prescription. Right. It's the four pillars of obesity care that Joe was just talk about earlier. The medical treatment and medications may be a part of the medical treatment, but that's certainly not the only part of the medical treatment part. And then there's the nutrition guidance, the physical activity, the behavioral, and then there's other things like stress and sleep and there's so many things that that are affected. So a prescription alone is not going to be the solution. But like you said, Angela, it's really important that we help explain this to patients. And also many providers also don't understand quite what the difference is or what the potential harm could be.
- [27:14]
Joseph Zukey
I will add in that the unfortunate reality of why we're in this circumstance where patients are looking to find compounds is the unfortunate fact that obesity is not covered by many insurances and that's why these patients are now looking for better affordability options. Because unfortunately commercial coverage is getting worse. Medicaid has been very worsening with coverage and Medicare has refused to cover obesity medications. All that may be changing this year, but it is the biggest issue is that if we're treating obesity as a disease state and we provide coverage for diabetes or hypertensive medications, then why is obesity withheld? It is not vanity. It should be treated and it should be covered as a standard on the formulary. And certainly I agree costs are too high, costs should be coming down and will hopefully continue to come down as more options become available. But if obesity was covered better as a medication, then we wouldn't probably be in the circumstance where patients are having to resort to compounds and places online.
- [28:10]
Carly Burridge
Yeah, a lot of it comes down to that bias and stigma, unfortunately.
- [28:13]
Angela Thatcher
I was curious and actually went to a couple of websites and just sort of clicked through and I was amazed that on many of them, basically the patient is choosing what medicine and what dose and they ask questions like how fast would you like to lose weight? Would you like to lose weight faster? And like these are not helpful questions to ask patients without the medical guidance piece. So it still just blows my mind that that's the way that this is all happening online.
- [28:44]
Joseph Zukey
Such great points. And like, I think I had another question, but you actually already answered it so much because it's, it's like it goes into a lot of the bias within our, just the healthcare system in the, in the US in general. And so I think that you've, you've touched on a lot of that. You know, I think there's also disparities in obesity care that remain significant across race, ethnicity, income level and geography. What are some barriers to screening and early intervention and maybe access to treatment that you see?
- [29:18]
Angela Thatcher
Well, very often the groups with the highest prevalence of obesity also unfortunately have the lowest utilization when it comes to advanced treatment for obesity and including Medicare medications. Joe touched on issues with access in terms of cost and that's a huge barrier when it comes to socioeconomic barriers. I think the other thing is you end up with areas in, around your state that like very rural areas, it's only going to be primary care probably that is interacting with those patients. And so if primary care is not adding that in and as part of their care and treatment and addressing it and screening or referring, then those patients probably just are not getting that treatment at all. Whereas in a very urban area you might find multiple clinics that offer treatment for obesity specifically. So there's barriers in that respect too.
- [30:20]
Carly Burridge
Yeah. And there's access to health care, there's access to treatments, but there's also access to healthful foods that are limited to people in certain geographic areas where there's food deserts or socioeconomic factors that prohibit people from being able to eat the healthier foods or even to have safe places to be active. Right. So it's one thing for us to say we should all be more active, but if somebody doesn't have a safe place to be active outside or doesn't have those types of resources, that makes it really challenging. So there's so many different levels where this can impact a patient's health and well being. Not to mention, you know, chronic stress being an important contributing factor to obesity as well. And that concludes, you know, includes systemic racism and sexism and all those other things as well. So certainly all of those things impact patients health and well being and their ability to get access to treatment as well.
- [31:16]
Joseph Zukey
I think it's Also, I agree 100% with both Carly and Angela and it's so important that we be proactive with treating obesity. A lot of times patients are not given options or even it's even discussed until there's comorbidities that develop. Oh, now that we have diabetes. Now let's start talking about medications or now that we have free blood pressure medications, the earlier we can intervene, we can prevent the downstream effects. We are treating obesity at the top of the stream and it's truly correlated with 200 different comorbidities. And the earlier that we can treat this disease state, the better we can intervene and prevent us from progressing and relapsing and so forth. So just helping all providers to at least like Carly or talked earlier, it can be a difficult conversation, but at least opening the door in a compassionate way to the conversation so we can help patients know that they're, we're here to help them.
- [32:02]
Carly Burridge
Yeah, and I also think it's important, you know, as you mentioned, treating earlier and I think that's really important. Yes, there are some really great new medications that have hit the market in recent years and they're very effective and safe. But we have other obesity medications that have been around for a long time. Right. Phentermine has been around since 1959 and especially in patients with maybe class one or less severe obesity who are maybe younger and healthier. You know, if we started treating patients earlier, before they progressed to severe obesity, before they have developed all of these obesity related complications and now we're really needing to have, you know, use the big guns, if you will, you know, the more expensive injectable medications. If we start treating earlier, then maybe we don't get to the point where we have to use those medications if we can use some of the oral and more affordable options earlier. Now, ideally, of course, everybody would have access and it would be covered and all the medications would be covered for all patients. But you know, we are in reality right now, we're not there yet. So we also have to use the tools that we have available to fast.
- [33:08]
Joseph Zukey
Yeah, these are great points. As we as we're all kind of interacting with our patients and keeping all these things in mind. You started mentioning Carly about the pharmacotherapeutics that are, that are available to us. And you know, I know that we've seen a lot of rapid advancement with pharmacotherapy. Can you describe like the current landscape and excitement around maybe some of these, these new obesity medications?
- [33:31]
Carly Burridge
Absolutely. So in terms of the medications that are already available. Right. So I mentioned phentermine has been around since 1959. In 1959 we didn't recognize obesity as a chronic disease. And so when it was developed, it was studied in short term use, for short term use, because we didn't understand obesity as A chronic disease. In fact, the first hormone that was discovered that actually indicated that weight is centrally regulated by the brain is was leptin. And it wasn't discovered till 1995. So really prior to that we didn't have any understanding that weight was regulated by the brain. So anyways, that's a departure from phentermine. But just to say phentermine has been around a long time. It is FDA approved for short term use, but many of us do use it long term because we recognize that these use a chronic disease. And this is supported by some of the literature and data. Although you do need to know your state laws in terms of using phentermine long term. So phentermine is around. We have the combination of phentermine topiramate that is approved for long term use, that is an oral medication. We have naltrexone, bupropion that's been around for quite a long time, that's also an oral medication. And then we have the injectable medication, so the GLP1s and then we have the GLP1 plus GIP. We have a medication called set melanotide that's specifically for monogenic forms of obesity. So these are rare forms of obesity. So those are the medications that we have currently available. And then there's so much more in the pipeline. You know, it's really crazy to look at all of these different receptors and new mechanisms that people are looking at different hormones like amylin, including other hormones like glucagon, and then also looking at medications that affect the muscle. So there's many different medications that are currently in the pipeline that are being investigated for, for the treatment of obesity and obesity related complications. So it's certainly a very exciting time because I think the more tools that we have in our toolbox the better because not every patient is going to respond to medications the same way. We know that there's not one form of obesity. There's obesity. There's many, many different forms that people are going to respond to different types of treatments. So it's great to have, you know, more options available and so many more coming down the pipeline.
- [35:55]
Angela Thatcher
It is exciting. I know we also are getting some differences in terms of formulation. So this year we are seeing oral GLP1s that we have access to. There's going to be down the road injections that move beyond weekly injections. Looks like maybe monthly and maybe even quarterly dosing. So these things just offer us more options and may remove barriers for patients. But big picture, I think this also just really makes a big difference in terms of making sure that there is access to these treatments from a supply chain standpoint. We've gone through some really difficult times in the last couple of years related to supply of medications as they've come out. And then, you know, in big picture, my hope is that as we see more competition in this area and we continue to see prices come down, that that just further helps us in terms of getting better coverage for patients through insurance plans and plans like Medicaid and Medicare.
- [36:58]
Joseph Zukey
Excellent summaries. And you know, both in terms of what we already have available and what's to come, it's super exciting. And that's the, the excitement for our field ahead here is this is just the beginning and we're going to have hopefully more personalized medicine where we can find the right fit for each patient. And we'll have, you know, certainly single agonists, these incretins, GLP1s are certainly showing such benefits, but not just on weight. I think we need to think of it's not just a vanity drug, it's not just an obesity drug, it's a cardiometabolic drug. We are treating and reducing risk factors for heart disease, strokes, kidney issues. Of course, we know the benefits on blood sugar already in terms of diabetes. Obstructive sleep apnea is now an FDA approved indication. So we're seeing, you know, MASH is also an FDA approved medication. There are ongoing trials for things looking at everything from osteoarthritis to overactive bladder to, you know, even possibly reducing risk of cancers. And we know again, that if we're helping patients to lose weight, that it's likely going to improve upon their health. But there is some benefits of these medications that are going to go beyond that, where glucagon may really help with reducing liver fat. And we've seen the benefits on inflammation. So it's just such an exciting time. Hopefully we have access and cost and coverage that fits into making this feasible for patients. But getting into obesity medicine or, you know, progressing in this field is. It couldn't be more exciting.
- [38:14]
Martin (Host/Moderator)
Thank you all three of you. You did a very nice summary of what's in the pipeline and what's currently available in terms of pharmacotherapy. And I know your programs, you don't only hand out prescriptions, but you take a comprehensive multidisciplinary approach. And throughout our conversation, we've touched a lot on this. But I want you guys to emphasize for me, why is this holistic model essential and why is a prescription for JLP1 is not sufficient on its own.
- [38:47]
Joseph Zukey
I've done my best to make our program as truly comprehensive as possible and I really feel that leads to better outcomes. It's so many different factors. Certainly each practice is going to have its limitations in terms of access, but we try to see patients weekly. So having more touch points allows them to have better success. Of course, when they're in a good groove, maybe it's spaced out a bit more. But having more accountability and support through the ups and downs, through the titration, through the nutrition education is really going to lead to better results. But as I kind of alluded to earlier, we do assess body composition because it's not just about weight, it's about preventing muscle loss, it's about maintaining hydration status. You can sometimes see with these bioelectro impedance scales, even visceral fat estimations, these are going to help us to make sure that the weight loss is achieved as healthy as possible. Having access to a dietitian, as we do in our program, is helpful. So patients are getting the education on portion control and protein intake and vegetables and spacing out meals and helping them to know that it is not some fad diet, but a lifestyle and helping them to navigate eating out and things like that, which are so important too. So as exciting as the medications are, we don't want to kind of brush aside the lifestyle because that's just as important. It's a tool in the toolkit and they work best together. Myself and our nurse practitioner are both certified as personal trainers, so we even make workout plans for patients. We partner with our local gym so we could provide a free membership to our patients when they do our program. So just trying to offer resources for patients. Again, support groups can be helpful for those that are comfortable talking to others and helping to not feel alone on the journey because they can sometimes feel isolated while going about weight loss. Offering either education on food or in our case, we even provide food options for those who need structured meals and don't have access to that or don't have time to make the meals. And of course assessing lab work and you know, having that caring, compassionate check ins and accountability really goes a long way. So the best programs will hopefully be able to factor all these different pieces in. So patients are not just losing weight, but they're getting healthier too.
- [40:46]
Angela Thatcher
Yeah, and I think that's what's important is that we, if, if the focus is on health and that's why we're working on weight loss, then it's Important that we're actually getting adequate nutrition and we're not creating nutritional deficiencies because patients aren't getting what they need day to day because that puts them at risk of other issues downstream. You touched on the importance of protecting muscle mass and avoiding sarcopenia. There are behavior changes that need to happen. And the more that we understand about obesity, we see so many things that are a part of this picture. Sleep is a, is something that's getting a lot more attention now that hasn't before. But we understand that if people aren't getting adequate sleep sleep and aren't getting good sleep, then it tends to affect their weight management. So I think when, when we keep the focus on health instead of weight loss, it, it makes sense that we would be providing comprehensive care. Right. And I think as PAs, we're really well suited for that because we've learned, you know, the pathophysiology of, of body systems and how they work together. And if you take the time to learn about the pathophysiology around obesity and these different other conditions and comorbidities, it makes it easier to see what, where you need to be putting effort and which things you need to support for patients as they're working on weight loss. Absolutely.
- [42:11]
Carly Burridge
Yeah. I agree with what both of you guys are saying and that comprehensive care is so important. And again, I've worked at and even developed a lot of different programs and a lot of different settings. And so it's so important that all of the pillars of obesity care are being addressed. But I do want to let PAs know that that doesn't mean that you have to have all of those things under your roof. Right. So, Joe, as you mentioned, you know, people are going to have limitations of what they have access to, who they have in their office and what they can offer their patients. So what I would say is maybe you can't have a dietitian and an exercise physiologist and a mental health specialist all under one roof working with you. But, you know, work with people in your community. And these days, even with telehealth, you know, you may not have a dietitian, especially if you're in a rural area, you don't have access to dietitians, but you might have access to dietitians via like a telehealth service or a behavioral specialist via telehealth. Tap into your local resources, sources like physical therapists. They can be amazing to get patients started with exercise, especially if they have some physical limitations or pain. That is that prohibiting them from starting you know, a physical activity program. So, you know, get educated yourself. I think if you have a real interest in this, as you know, all of us here do, you can get a lot of that education to provide some of the nutritional counseling and things like that yourself. But certainly if you don't feel like you have that background or the time to, to do that, then make sure you reach out to your resources in your local area to make sure that you can refer your patients, when needed, to those resources and really create a network of clinicians who can all work together to support your patients.
- [43:57]
Joseph Zukey
Agree so much with that. I think something just to piggyback on that is anyone that is a PA that's interested in getting in this field is, I encourage you to definitely explore it. And I am a preceptor to PA students and it's great to see those to come in here and become so passionate for it and within even a month or two, they really learn so much. But it's, I think after you work in this field, it's so rewarding. We're truly helping patients. These patients come in and they truly are thankful. They come in very empowered, they are very motivated. This is not like they're forced to come in here. They want to get healthier. And so you're able to see them throughout this journey. This is not urgent care, where we see them once we see them throughout their process. And I had a patient last week that just hit 200 pounds down, and it's like, it's life changing. So to help these patients get off of medications to prevent comorbidities, we're hopefully adding, extending their lifespan, preventing heart attacks and strokes. There's nothing more life changing than to be able to do this. So it's so rewarding for us as providers. And you can hopefully see from all of us how passionate we are because we've been able to touch lives and we hope to inspire other providers to do the same.
- [44:59]
Angela Thatcher
Yeah.
- [44:59]
Carly Burridge
And I would add to that. Yeah, it's amazing for patients, their lives change, but also for us as clinicians, like, it is the most fun thing that you can do to help patients with this. And I know all of us went into health care because we wanted to help people. We wanted to help people feel better. And when you can help them with their obesity, it makes such a massive impact on their lives, on their health and wellbeing. You know, when you're helping somebody with your, their blood pressure, like, it's great, but they don't necessarily feel that much better or feel so Much different. It doesn't impact them in the same way that treating somebody's obesity can. So just want to encourage everybody that this is a really, really rewarding field to be in, not just for our patients, but for us as clinicians as well.
- [45:40]
Martin (Host/Moderator)
Very well said, all of you. And I concur from someone who practices obesity. Medicine is such a rewarding field and in order. In other words, Joe, they can reach out to you guys as mentors, anyone who's interested in that field. This is a very common question. We get what certification is best? What should they do if they want to, you know, start working in that field? Before we wrap up, I'd like to do a rapid round in one sentence each. Please respond to the following. First, most misunderstood fact about obesity. Angela, you want to go first?
- [46:11]
Angela Thatcher
Sure. That the only way for us to diagnose obesity is with bmi and that BMI is an indicator of a healthy weight versus obesity.
- [46:23]
Carly Burridge
I would say, I guess most misunderstood fact about obesity is that people think it's about willpower and it's not. It's about biology.
- [46:31]
Martin (Host/Moderator)
That's a great one.
- [46:32]
Joseph Zukey
Carly, you stole mine.
- [46:33]
Carly Burridge
Oh, sorry.
- [46:34]
Joseph Zukey
That's all good. I agree. I just helping people to understand it's a complex biology biological disease state and there's many different mechanisms behind it and our body is programmed to defend its weight and just helping people understand that.
- [46:46]
Martin (Host/Moderator)
Okay, second one is single best misconception or myth that people hold about GLP1 medications. Joe, you get to go first since they stole your Sounds good last round.
- [46:57]
Joseph Zukey
The biggest myth, I would say is helping both providers and patients to say this is not a crutch, this is not a cop out, this is a tool and it's going to help counteract the body's biology and assist in the lifestyle. And it's not in place of lifestyle. If anything, it enables the lifestyle to become easier because now patients are not struggling with the hunger and the cravings and the food noise that makes it so challenging.
- [47:17]
Martin (Host/Moderator)
Looks like Angela wants to have.
- [47:18]
Carly Burridge
Go ahead, Angela, because you might steal mine too. But that's okay.
- [47:23]
Angela Thatcher
I made a whole list on this one. But I would say one would be that GLP ones are the only option that we have for the treatment of abcd. Carly did an excellent job of explaining that earlier and similar that it's the right thing for every patient.
- [47:41]
Carly Burridge
It's not great and I like both of those. And one that I will add is a big misconception that medications are a kickstart to treating obesity and that people just need A kickstart, and then they can manage it on their own. And we know that this is a chronic disease state. And as Joe has mentioned multiple times, when we lose weight, the body has compensatory mechanisms to try to get you to regain that weight. And so, you know, when we're talking about obesity treatment, we do need to think about this chronically. And using medications is not a kickstart for weight loss or obesity treatment. It needs to be maintained long term for most people to continue to see the health benefits.
- [48:24]
Joseph Zukey
Just to quickly add to that, I think a quick little tip that sometimes can help providers even relate this point to patients is that sometimes the patient's on a blood pressure medication or a cholesterol medication, and if you told them, would you take this medication for a couple months for your blood pressure and then stop it? And we would hope that your blood pressure would be maintained. We would expect the blood pressure would rise when we discontinue the medication. So helping them to understand the same for this that we need, that's likely for long term to sustain the weight loss can help them to kind of put it in perspective in a sense.
- [48:52]
Martin (Host/Moderator)
I agree. Joe, One policy change that would improve patient outcomes tomorrow, I would say the
- [48:58]
Angela Thatcher
formal removal of the statutory exclusion under Medicare Part D that excludes treatment for using any medications for weight loss.
- [49:12]
Carly Burridge
Yep. I would say if we could pass the Treat and Reduce Obesity act troa, which would help not just with coverage of medications, but also the comprehensive care of patients and dietary counseling and everything, if we could pass that and have comprehensive obesity care be covered for all people with obesity would be world changing.
- [49:33]
Joseph Zukey
Agree 100%. It's just coverage and treating obesity as a chronic disease and allowing consistent coverage for both care and medication.
- [49:41]
Martin (Host/Moderator)
So, yes, totally agree with all of you. Lastly, what gives you the most hope and optimism regarding the future of obesity care and treatment in that landscape?
- [49:49]
Joseph Zukey
She said the science is stronger than ever. And more clinicians are recognizing obesity as a disease worth treating. And patients are becoming more, you know, proactive with treatment, which is great, but understanding again, that treating obesity is not just cosmetics. This is about cardiometabolic health at the end of the day, and hopefully that leads to better coverage. But the future is very bright, both in terms of care and many medications in the pipeline that are fantastic.
- [50:13]
Carly Burridge
Kari, I would say that what gives me the most hope and optimism is that we are finally starting, starting to get a glimpse that of, you know that when we treat obesity, we are treating the root cause of over 200 other chronic diseases. And medical conditions. And I think we're finally starting to see this with all of the data coming out about the numerous health benefits that we see when we treat obesity comprehensively and effectively. So I've, you know, long said that we should be revolutionizing healthcare with obesity medicine and I'm very optimistic that we are on the way to doing that.
- [50:54]
Angela Thatcher
Yeah, I totally agree. I think it allows us to move from feeling like we're doing damage control when it comes to chronic disease to actually preventing chronic disease, which is really exciting.
- [51:06]
Martin (Host/Moderator)
Awesome. That was such a great conversation tonight and I know we could go even another hour talking about obesity management. Unfortunately, our hours coming to an end, today's conversation reinforces a simple truth. Obesity is not a failure of willpower. That's very important. That's one of the biggest takeaway tonight. It is a chronic disease that requires structured, longitudinal, evidence based care. As we recognize well obesity day on March 4, let us commit to advancing comprehensive treatment, protecting patients from fragmented care and advocating for responsible coverage expansion. Thank you to our guests for your leadership in that field and to our listeners who continue to move the standard of care forward. And before we leave, I want to remind our listeners that they can now earn CME by listening to the podcast. And to receive your CME credit and access your certificate, you just listen to the podcast and complete the post test and evaluation in AAPA's gardening centralme.aapa.org until next time.