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- [00:00]
Podcast Sponsor/Advertiser
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- [00:58]
Dr. Brooke Mattson
Run the List, a medical education podcast in internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only and should not be understood as medical advice under any circumstances. Before we get to the show, a quick word on the sponsors for today's episode.
- [01:13]
Walker Red
Open Evidence is the premier AI powered medical information platform for physicians and medical students. It's like ChatGPT for anyone who practices clinical medicine. Whether you have a clinical question, a question that comes up during your literature review, if you have a question that comes up when trying to synthesize a topic you're going to teach, you can just go to openevidence.com, enter your question and it'll synthesize the answer for you while also linking to those actual articles. It's an outstanding resource. Welcome back to Run the List. This is your host, Walker Red, and I'm here again for another Endocrinology episode with my friend and endocrinologist here at University of North Carolina, Brooke Mattson. We are going to go over an incredibly important topic today. I don't need to convince our listeners that it's really important to understand the topic of obesity both in terms of how an endocrinologist approaches this, how we can help patients with a multimodal approach, including lifestyles and potentially pharmacotherapy. Really excited to have you back today, Brooke. Thank you so much for joining us.
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Dr. Brooke Mattson
It's great to be back. Thanks for having me.
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Walker Red
All right, let's go ahead and run the list. So, Brooke, let's imagine we're seeing a patient in the primary care clinic setting, and we are wanting to think about how we may be able to approach a discussion around obesity, around the patient's weight, before we dive into some of the next steps of management. I just want to really emphasize this. You've helped me learn more about how this can be done in a really sensitive and compassionate and yet informative way. So how do you sort of approach it, and how do you think about this?
- [02:53]
Dr. Brooke Mattson
First, I think it's important to emphasize that blame should be taken out of the conversation with a patient. If a patient's coming to you looking for help with weight management, they shouldn't be made to feel like that it's their fault that they're living with obesity. So I think that's a really important point to emphasize. And many people wonder, well, what causes obesity? And it's not an easy answer. You know, it's not the fault of the person. It's a complex interaction between genetics and our environment, including ultra processed food, the physical inactivity, and how these things interact. And so along those lines, we define obesity as a chronic disease requiring chronic management, just like any other chronic disease like hypertension or diabetes. So, you know, we reflect that in our language by not using obese as a descriptor, as an obese person. Rather, we would say a person with obesity or person living with obesity.
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Walker Red
Yeah. If our listeners take away nothing else from this episode, those are the couple most important points. Right. Helping the patient understand that you are not placing blame on them as an individual, that they are someone who is living with this condition, and that we're here to help them in a totally nonjudgmental way. To that end, I know you think about the goal of treatment is not necessarily just like a certain BMI threshold or lowering that, but how do you kind of explain that and frame that to them?
- [04:05]
Dr. Brooke Mattson
Yeah, I like to think of the goal as some degree of weight loss to prevent complications associated with excess weight, including hypertension, hyperlipidemia, type 2 diabetes, metabolic liver disease, sleep apnea, those types of things. And I always emphasize that there are health benefits from losing even just a small amount of weight, such as 5%. Even a small amount can make a big difference.
- [04:27]
Walker Red
And I think that's sometimes a lot easier place to start, with something like 5%. And then they can continue to try to make progress from there. So we are going to get to a little bit deeper, dive on some of the pharmacotherapy and options for helping patients with management. But of course we don't want to skip over what's really important, which is lifestyle modification. So we're just going to do some quick hitting discussions of some of the low, lower hanging fruit that you can discuss with patients and make sure they do. One thing I know you've reminded me of before is just to review the medication list. So often people are not deprescribing medications are hanging around even if they're not needed. And sometimes those medications may have weight gain as a, as a potential side effect or at least be contributing a bit. So what are some of those common meds you see pop up on list that you want to review?
- [05:09]
Dr. Brooke Mattson
Yeah, this list includes medications like steroids, beta blockers, certain diabetes treatments including insulin, sulfonylureas, lots of centrally acting medications such as SSI, SRIs, SNRIs, TCAs, antipsychotics, seizure medications, and pain medicine like gabapentinoids, in addition to some contraceptives including OCPS and nexplanon and Mirena. This is not a comprehensive list, just a general list. I don't want to imply that any of these are singular causes for obesity in and of themselves, but as you said, the idea is to eliminate low hanging fruit that could be working against weight loss efforts that, that people are starting with lifestyle interventions and, or pharmacotherapy.
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Walker Red
That's super helpful. And so then of course you want to talk to them about their nutrition, what they're eating and diet. I'm sure patients bring that question to you. So how do you summarize that for them?
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Dr. Brooke Mattson
Yeah, there's not one single recommended diet that is best to recommend to every patient looking to lose weight. The overall goal and theme of dietary interventions is to reduce calorie intake and improve the quality of food that people are eating. And at the end of the day, the best diet is the one that the patient can adhere to.
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Walker Red
That's such a key point. Building on that, I know a couple other things that you, you go through with folks are physical activity and along with that would be sleep and mental health. So take me through what, what advice you give patients for those.
- [06:25]
Dr. Brooke Mattson
Yeah. Guidelines Recommend at least 150 minutes of aerobic activity per week in addition to at least two strength training sessions. I do review this with patients. It is difficult for many people with obesity to meet these guideline recommendations because many are limited by their weight in terms of pain or musculoskeletal issues associated with weight. And, and I still emphasize that movement is important. In any way that they're able to or any way that they like to do. So asking them how they like to move their body. And as you said, I think of sleep and mental health in the lifestyle intervention bucket as well. Both quantity and quality of sleep are important. And we know that even just a small amount of sleep deprivation can induce insulin resistance. So getting that good quality sleep and if they have sleep apnea, making sure that that's being treated. And then finally, as far as mental health goes, any mental health disorders like anxiety or depression, it's going to make all of this more difficult than it already is. And so I frequently encourage therapy if they're sharing a lot about stressors in their life with me during a clinic visit. And there are some nice groups out there that integrate nutrition and mental health in the context of weight and weight management as well. So I would consider these for the right person.
- [07:31]
Walker Red
I think that rounds out what is really a holistic approach here. With that framework in mind. I know that not every practice setting is going to have more resources available, but in settings where there are some opportunity to collaborate. Who are some other folks that you end up getting to help out with to achieve some of these lifestyle modifications for patients?
- [07:50]
Dr. Brooke Mattson
Yeah, it's definitely, definitely a team approach. And other people I think about on the team include dietitians for medical nutrition therapy, personal trainers or physical therapists, depending on patient's need, if they have functional limitations or, or if they have pre diabetes. I always recommend that people look into their local diabetes prevention program. These are typically held at community centers or YMCAs, places like that, very affordable. And they can serve as a nice structured lifestyle program if people are looking for help, kind of figuring out how to incorporate some of these things.
- [08:18]
Walker Red
All right, so now we want to have a high level overview of the pharmacological therapy that can be helpful in treating obesity. But before we do that, I do want to highlight something that I've learned from Brooke and my other friends who are endocrinologists, which is really that it's important to highlight with patients. This is not like an easy way out. This is really building on the foundation of lifestyle interventions. It's not that those parts of this are going to stop, it's just that medications may make some of those lifestyle changes easier to adhere to and help with a little bit further weight loss. So drugs used for weight loss, Brooke, have been an incredibly relevant topic both in medicine and in the popular press recently. And so if you could just share with us who the patients are who are candidates and as you go through these kind of how much weight loss is expected with each of these drug classes. And also you're going to start by giving us a little bit of the historical background. Right. Of how we got to GLP1s.
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Dr. Brooke Mattson
Absolutely. To people that are candidates for obesity pharmacotherapy, include people with a BMI greater than or equal to 27, with at least one weight related comorbidity or a BMI greater than or equal to 30. And as you mentioned, GLP1s are all the rage these days. But we, we did have FDA approved medications for weight prior to, you know, recent years with Everybody talking about GLP1s. And so these are earlier medications that have been around for a long time. I think of these medications as causing up to about 5% weight loss. And these FDA approved medications include combination medications like Phentermine Topiramate under the brand name Qsimia or Bupropion Naltrexone under the brand name Contrave. And these aren't prescribed as often in the present day and age with GLP1 receptor agonists, though I have been reaching for these more often in the past as coverage for GLP1s has been fluctuating so much over time. A couple of other medications that we tend to use that are not FDA approved for weight loss but are often used in this context also include metformin or SGLT2 inhibitors.
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Walker Red
Yeah, some really important points there. If you are having insurance coverage issues with GLP1s, you can reach for some of those older agents. And then keeping in mind the good old metformin and SGLT2 inhibitors are another way to augment things a little bit even in the absence of getting the GLP1 prescription. And so those medications are often a little bit more, I think, on about the 5% weight loss like we were just discussing. So for GLP1s, I know that there's potential for more weight loss. And so can you kind of step through that and take us through the different agents and where we are now?
- [10:39]
Dr. Brooke Mattson
Definitely, of course, GLP1s are what everyone wants to hear about these days. They are the most effective medications that we have for weight loss at the, at the present time. And we can expect anywhere from about 10 to 20% or even more with individual GLP1 receptor agonist. The first, first FDA approved GLP1 receptor agonist for weight loss was Liraglutide or Saxenda. This was a daily injection still available and on the market. Of course, people hear a lot about Semaglutide or weak OV these days, which is a weekly injection and yields more weight loss than liraglutide. And then finally, Tirzepatide under the brand name Zepbound is a weekly GLP1 and GIP receptor CO agonist. And that does tend to result in more weight loss than semaglutide. Zepbound is actually now FDA approved for treatment of obstructive sleep apnea as of the end of 2024 as well. And so that's exciting.
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Walker Red
Yeah. Thanks for stepping through the specific agents and reminding them of the names. How do you think about other specifics of how to use these medications?
- [11:37]
Dr. Brooke Mattson
I think it's important to remind people that people with obesity but without diabetes generally tend to lose more weight on these medications than people with diabetes. Though of course these medications are used to treat diabetes as well under different brand names, but same active ingredient. They're not approved for use in pregnancy or during breastfeeding at this time. And so that's always something important to counsel patients as well. Talk about contraception, those types of things, and generally you probably hear about this a lot on the GI side, but we generally increase the dose every four weeks as tolerated. And the primary side effects that people experience are GI related, including nausea, vomiting, diarrhea and constipation. And we often address these by talking about different dietary approaches, including talking about some small portion sizes, eating slowly, making sure you're paying attention to satiety signals, those types of things. I'm curious if you have other things you talk about with people in clinic.
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Walker Red
No. Since these medications came out, it's been increasingly discussed in the GI world. We were seeing more of these patients in clinic. I think now a lot of prescribers are a little bit more attuned to just having the conversation with the patient, helping set expectations. Like so many medications, finding the right dose the patient can tolerate without having sort of intolerable GI side effects and still having as much efficacy as possible is what. What we're certainly aiming for too. There are some cons which we'll talk about too, in addition to some of those side effects or some challenges, at least with these meds. But let's not skip over the really increasingly exciting positive results we have associated with them. Some of those most recent findings, absolutely.
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Dr. Brooke Mattson
The GLP1 receptor agonist and CO agonist with GIP and glucagon coming down the line as well, are certainly leading to weight loss that previously was not achievable with pharmacotherapy before the present era. So that's really exciting and of course, an addition, exciting benefit that we're continuing to get more data on and learn more about is about cardiovascular risk reduction.
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Walker Red
Yeah. I mean, you just can't say enough about how exciting that is because anything we can do to help decrease the burden of cardiovascular disease even a little bit is just a tremendous gain for our patients. But on that note, what are some of the things that do come up in terms of cons? I know there's the practical side of the supply and the shortage and the insurance coverage. Let's talk about that a little bit first and then we can talk about some of these other things that you see.
- [13:44]
Dr. Brooke Mattson
Yes, very common questions from patients and a source of frustration as well, which is certainly understandable. So the, the insurance coverage has been fluctuating, is really hard to keep up with and I think will continue evolving over time. One common question I get related to this is about compounded GLP1 receptor agonist. A lot of people will come in asking about. I generally tell them, you know, because the compounded medications are not regulated in the same way that the brands that we, we all know and love are used, I just can't feel comfortable recommending them just because there's generally less oversight. And these were not the same products that were tested in clinical trials. We just know less about kind of what's out there.
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Walker Red
Very important part of patient education. I think some other things that you can help make sure patients understand as well is weight regain and this loss of lean body mass are also come up. So what do you tell them from a practical perspective to help?
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Dr. Brooke Mattson
Yeah, these are common questions from people, too. We do know that people regain weight when they stop the medication. So when people ask about this, I generally refer back to what we were talking about earlier, that obesity is a chronic disease requiring chronic management. And when people's blood pressure is better, we don't stop their blood pressure medicine. We continue their blood pressure medicine to keep their blood pressure under good control. So that's kind of how I frame the discussion about continuing these agents long term.
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Walker Red
That's very helpful.
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Podcast Sponsor/Advertiser
Great.
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Dr. Brooke Mattson
Finally, as far as loss of lean body mass, I really hammer home the importance of strength training and maintaining muscle mass while they're on these medicines as well.
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Walker Red
The last modality here I think we should touch on would be bariatric surgery. I think you just give us a really quick rundown of who are candidates and what sort of weight loss patients can expect with that.
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Dr. Brooke Mattson
Yeah, important to remember that this is an option too. Candidates include people with a bmi greater than 35 with an obesity related comorbidity or BMI greater than 40. And there are primarily two options, sleeve gastrectomy, which is a restrictive procedure, and roux en Y gastric bypass, which is a restrictive and malabsorptive procedure. And we can expect up to about 30% weight loss with bariatric surgery. The medications are catching up quickly, but that's kind of where we are right now in the present day and age.
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Walker Red
Great. So we've reviewed, you know, how you can discuss this disease with patients, how you can build from lifestyle modifications to medications if needed, or even potentially surgery. With that in mind, what are the most important few take home points about this really important topic, Brooke, that you want our listeners to remember?
- [16:01]
Dr. Brooke Mattson
First, obesity is a chronic disease and it should be treated as such like we've been talking about. It should be divorced from patient blame. The goal is not to achieve a normal bmi, but the goal is to lose weight for prevention of weight related comorbidities. Second, as you were talking about, lifestyle interventions and pharmacotherapy are synergistic. Medicines are not an easy way out. It's really important to continue lifestyle interventions along with medications as well. And then finally, the combined GLP1 GIP receptor, coaginas, tirzepatide or Zepbound is currently the agent that leads to the greatest amount of weight loss, though there are a lot of other medications coming down the pipeline that may supersede this in the future.
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Walker Red
Well, Brooke, thank you so much for that summary. Thank you so much for joining us and thank you so much for our listeners for tuning in to hear more about this incredibly important topic. Hopefully this empowers you to have informed discussions with your patients and take great care of them. Thanks so much for tuning in.