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
Claim free CME for this episode at curbsiders.vcuhealth.org!
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Potential provider-level barriers to addressing obesity in the primary care setting Oshman, 2023).
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.
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 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.
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).
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.
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.
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.
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.
“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.
Helpful for people who have issues with food cravings and for emotional eaters (expert opinion). Common side effects include constipation, dry mouth, and headaches.
This agent is still available and may have some effect on lowering cholesterol.
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 .
How can we prevent loss of lean mass?
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 have been included above
Listeners will update their practice of obesity medicine in primary care
After listening to this episode listeners will…
Dr. Gudzune reports no financial disclosures. The Curbsiders report no relevant financial disclosures.
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.
Written and Produced by: Matthew Watto MD, FACP
Show Notes: Matthew Watto MD, FACP
Cover Art and Infographic: Matthew Watto MD, FACP
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Leah Witt MD
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
In-studio Technical Production: Chris Chiu MD, FACP, FAAP
Technical Production: PodPaste
Guest: Kimberly Anne Gudzune MD, MPH
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.