#405 Obesity Medicine, GLP1 agonists, Weight Loss Management Tools and Tips

July 24, 2023 | By Matthew Watto, MD

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Hone your obesity medicine skills in primary care! We discuss overcoming barriers, patient counseling, obesity pathophysiology, motivational interviewing, tools and tips from a weight loss program, and how to discuss medications for weight loss including phentermine/topiramate, bupropion/naltrexone, orlistat, oral superabsorbent hydrogel, and GLP1 agonists. We’re joined by obesity medicine expert, Dr. Kimberly Anne Gudzune of @HopkinsMedicine, recorded @SocietyGIM #SGIM23 in Denver, Colorado 

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Show Segments

• Intro
• Barriers to treating medicine in primary care
• Patient counseling and obesity pathophysiology 
• Motivational Interviewing 
• Telemedicine for obesity
• Tools and tips for a weight loss program
• Medications for Obesity
• GLP1 agonist prescribing tips
• Outro

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Obesity Medicine Pearls

1. Obesity is a chronic disease! It requires chronic management. 
2. Be sure to mention the diagnosis of obesity to patients because they may read it in their chart. 
3. Ask about functional limitations (inability to play with their kids) and the psychological impacts of obesity as potential motivating factors for patients instead of solely focusing on the metabolic impacts of obesity. 
4. Weight regain is common because weight loss triggers the body to increase appetite (hunger), and slow the metabolic rate to get back to the previous “set point”. Thus, prevention of obesity is key!
5. Telemedicine can be used to achieve the frequent patient contact crucial to weight management.
6. Tracking food intake can be helpful for patients with obesity, but is contraindicated in patients with an eating disorder! Screen with the SCOFF questionnaire.
7. Patients taking a GLP1 agonist should cut portion sizes in half to reduce nausea and increase fiber intake to avoid constipation. 
8. Recommend adequate protein intake and resistance training to patients on a GLP1 agonist to mitigate muscle loss. 

Obesity Show Notes

Barriers to Discussing Obesity

Potential provider-level barriers to addressing obesity in the primary care setting  Oshman, 2023).

• Lack of confidence in their abilities
• Worried about offending the patient
• Patient did not bring up weight loss
• Time-consuming
• Lack of billing/reimbursement

Dr. Gudzune points out that most physicians lack training in weight loss management. Further, some PCPs worry about lack of reimbursement for time spent discussing obesity, but obesity codes are often now reimbursed. 

Kashlak Pearl: Schedule a separate visit to discuss weight management options to allow the appropriate time. 

Discussing Obesity

• Obesity is a chronic disease! It requires chronic management. 
• Be sure to mention the diagnosis of obesity to patients because they may read it in their chart. 
• Initially, start by asking “Is it okay to discuss your weight?”.
• Later, it’s helpful to briefly check in with patients and ask “How are things going with your weight?” even if it’s not the sole focus of a visit.
• Dr. Gudzune asks about emotional eating, triggers, eating habits, and perceptions of hunger. 

Pathophysiology of Obesity

The body seems to have a “set point” anchored to a person’s body weight (Garvey, 2022). Weight loss triggers the body to increase appetite (hunger), and slow the metabolic rate (Busetto, 2021) to get back to the previous set point. For example, a 250-pound patient who loses fifty pounds will often slowly go back to 250 pounds and may even overshoot their previous “set point”. This is why it’s important to prevent patients from developing obesity so their “set point” is at a lower body weight. 

Motivational Interviewing & Obesity

Motivational interviewing did not increase effectiveness of behavioral weight management programs (BWMP) in a systematic review and meta-analysis (Michalopoulou, 2022). Dr. Gudzune speculates that patients enrolled in BWMPs have already found their motivation and that may be why motivational interviewing was not ineffective in the study population. Motivational interviewing may still have a role among a primary care population. Dr. Gudzune asks about functional limitations (inability to play with their kids) and the psychological impacts of obesity as potential motivating factors for patients instead of solely focusing on the metabolic impacts of obesity. 

Telemedicine for Weight Management

Frequent contact with a patient is important for treating obesity. The visits do not all need to be in person. Tchang et al, observed that telemedicine participants in an academic obesity medicine clinic had similar clinical outcomes compared to in-person or hybrid groups and were able to complete more visits (Tchang, 2022).

Weight Management Tools and Tips

Dr. Gudzune is the director of the Johns Hopkins Healthful Eating, Activity & Weight Program https://www.hopkinsmedicine.org/gim/clinical/lifestyle-weight/index.html. Here are some resources that can be recommended to patients. 

• USDA, MyPlate https://www.myplate.gov/ 
• Recipes from https://www.eatingwell.com/ 
• Tracking apps for sleep, steps, activity, calories, etc. 

Dr. Gudzune recommends utilizing tracking apps for accountability and mindfulness more so than for precision. Note well: Tracking is contraindicated in patients with an eating disorder as it may worsen symptoms (Levinson, 2017; Simpson, 2017)! The SCOFF questionnaire can be used to screen for eating disorders (Morgan, 2000). 

If an eating disorder is suspected, look for a local psychologist trained in eating disorders (e.g. binge eating, night eating syndrome), especially one trained in CBT, which can be transformative for patients. 

Dr. Gudzune recommends clinicians be comfortable discussing and recommending at least three simple diet options: Mediterranean, DASH, and Low Carb.

Older Medications for Obesity

Think of these as tools to help treat obesity. Dr. Gudzune recommends discussing the spectrum of available agents before jumping right to GLP1 agonists. See the prior Curbsiders episode #324 Obesity Medicine FAQ with Dr. Fatima Cody Standford for lots of details on these meds. 

Phentermine

Suppresses appetite, and possibly metabolic rate. FDA-approved for short-term use (about 3 months), but can be used off-label for two years or more. Dr. Gudzune recommends starting at a low dose. 

Phentermine/topiramate

“Taste aversion” is a side effect that some patients find helpful, especially those with a “sweet tooth” or who crave carbonated beverages (expert opinion). Counsel patients about the risk of birth defects and kidney stones from topiramate. Prior bypass surgery is not a contraindication even though these patients have some increased risk of kidney stone formation. 

Bupropion/naltrexone

Helpful for people who have issues with food cravings and for emotional eaters (expert opinion). Common side effects include constipation, dry mouth, and headaches.

Orlistat

This agent is still available and may have some effect on lowering cholesterol. 

Oral Superabsorbent Hydrogel 

The FDA recently approved a first-in-class “device”, an oral superabsorbent hydrogel, to treat obesity. Patients take a few pills before meals to help them feel full and eat smaller portions. “It’s kind of like eating five cucumbers” -Dr. Gudzune . 

• Randomized controlled trial of superabsorbent oral hydrogel for weight loss (​​Greenway, 2019)
• Review of therapies utilizing superabsorbent hydrogel technology to treat obesity Arrone, 2021 

GLP1 agonists

How can we prevent loss of lean mass?

• Patients should incorporate resistance training to preserve muscle mass as they lose weight, especially in older adults (expert opinion).
• Patients should prioritize lean protein, and other high-quality nutrients since they will be eating smaller portions (expert opinion). Sometimes Dr. Gudzune  asks patients to track protein intake initially to ensure appropriate intake. 

How can we mitigate gastrointestinal side effects?

Dr. Gudzune titrates GLP1 agonists to effect instead of indiscriminately ramping all patients to the highest dose. 

Kashlak Pearl: Tell patients to eat half their normal portion size to prevent nausea because gastric emptying will be slower (Maselli, 2021). For similar reasons, constipation is also increased, so ensure adequate fiber intake and consider psyllium-based fiber supplement (expert opinion). 

Links

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Goal

Listeners will update their practice of obesity medicine in primary care

Learning objectives

After listening to this episode listeners will…

1. Discuss effective measures to deliver obesity medicine care in primary care
2. Deploy a holistic approach to obesity medicine

Disclosures

Dr. Gudzune reports no financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Watto MF, Gudzune KA, Williams PN, Witt L. “#406 Obesity Medicine, GLP1 agonists, Weight Loss Management Tools and Tips”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date July 24, 2023.