Faculty Interviews
“BMI is just a screener, it doesn’t tell us what the patient’s health status is”
- Donna Ryan
Screening for Obesity
Key takeaways
- PCPs should be screening for obesity-related conditions
- BMI is often taken at office visits, but consider also taking waist circumference just above the iliac crest: this is a risk factor for cardiometabolic disease
- Women: should be less than 35 inches
- Men: should be less than 40 inches
- Look at cardiometabolic risk factors in annual screenings, including HbA1c,
fasting glucose, lipids, blood pressure- Putting this information together will help decide whether obesity is a driver for that risk
SELECT Trial and CVD Breakthroughs
Key takeaways
- SELECT showed a reduction in CV events in people with overweight or obesity but without diabetes; suggesting improvements are due to changes in weight rather than glycemia
- 20% reduction in heart attack, stroke, and sudden cardiac death in patients taking semaglutide compared to placebo
- The data legitimize the treatment of people with obesity who are at high risk of CV disease – with early intervention before they develop diabetes
- SELECT also has data over more than 4 years, giving the long-term picture
- There are also data in a broad range of people, including an older, sicker, and predominantly male population from all over the world: and everyone benefited regardless of age, BMI, ethnicity, etc
- There were also data on reduction of hospitalization and deaths from COVID – shared for the first time at Obesity Week
“This is a first for patients who don’t have T2D—to be able to show that we can actually prevent heart attack, stroke, and sudden cardiovascular death—so it’s a really big deal.”
- Donna Ryan
“It’s a call to action for physicians—let’s identify patients who would benefit from the SELECT findings.”
- Donna Ryan
Integrating Semaglutide in Practice
Key takeaways
- SELECT showed optimal CV risk reduction across patient groups – even high-risk patients on treatments such as statins
- Look at the patients in your care: semaglutide is a good option for people with overweight or obesity and CV risk factors
- Semaglutide can prevent secondary occurrence of CV events
- The evidence from SELECT suggests semaglutide can prevent heart attack, stroke, and CV death in our patients
The Evolving Universe of GLP-1 Medicines
Key takeaways
- GLP-1RA offer hope for the future treatment of metabolic diseases
- New treatments add GIP, glucagon, amylin, or PYY to the GLP-1
- Many new dual, triple, or even quadruple agonists may come to market
- These may offer tailored approaches to not just weight loss, but for metabolic CV, liver, or kidney disease
- Administration options may also evolve – perhaps moving to monthly injections; there are also attempts at gene editing and cell-based therapies
- Possible new indications include osteoarthritis, sleep apnea, Parkinson’s, Alzheimer’s, etc.
“We have multiple buckets of innovation today that are going to change the landscape”
- Daniel J. Drucker
“The reduction in calories turns on a lot of maintenance and repair systems and cells, which is good for cellular health”
- Stephen Kritchevsky
Geroscience and Obesity
Key takeaways
- Age is the number 1 risk factor for problems such as heart disease and cancer
- Targeting aging could control these diseases – improving health and lifespan
- Animal models show it is possible to affect the rate of aging – either genetically, behaviorally, or pharmaceutically
- Calorie restriction is a potent approach to extending lifespan, with supporting data across many animal models
- Reduction in calories switches on many cell maintenance and repair systems
- There is an intersection between weight loss and geroscience – suggesting obesity treatment can slow the aging process
SURMOUNT-1: Three-Year Outcomes
Key takeaways
- SURMOUNT is the first long-term study of a dual agonist for weight loss
- Showed average total body weight loss of 20.9% on 15 mg tirzepatide, sustained over 3 years
- Importantly, there were no new safety signals over almost 4 years
- There were significant decreases in progression of pre-diabetes; almost 99% of tirzepatide patients remain free of T2D
- These data are reassuring for prescribers around long-term benefits and side effects of tirzepatide
- GIP and GLP-1 on the same backbone seem to work better than a mono agonist
“This is a 3-year study … the longest-term duration for a dual agonist.”
- Sean Wharton
“You are going to get GI side effects … everybody needs to know what is going to happen, that expectation is a really big part”
- Sean Wharton
SURMOUNT-1: Managing Medication Side Effects
Key takeaways
- GI side effects are common with GLP-1RA, as they target an endogenous hormone that is produced naturally after food intake to increase feelings of fullness
- Injecting exogenous, additional GLP-1 heightens these feelings and prevents overeating – but it can also cause nausea and GI side effects
- But these side effects are mitigated over time on these agents; if patients understand and expect this, then GI events can be managed
- But if intervention is needed, the first option is to pause treatment or lower the dose
- Medications can be taken in initial stages to help with with burping or heartburn
Tirzepatide in Obesity and Pre-Diabetes
Key takeaways
- In SURMOUNT-1, patients took tirzepatide for over 3 years
- About 1,000 people who enrolled had pre-diabetes
- The risk of progressing to T2D was reduced – about 94% less on tirzepatide than in people receiving placebo
- Tirzepatide has a different MoA to semaglutide – it is a dual rather than mono-agonist, targeting GIP as well as GLP-1
- These agents offer a potential change in the management of cardiometabolic disease – treating weight before problems develop
“The greatest, most impressive result I’ve ever seen in the progression from pre-diabetes to full diabetes”
- Louis Aronne
“We have such effective drugs that, in many cases, we're seeing we have to stop people from losing weight”
- Louis Aronne
What is “Optimal Weight Loss”?
Key takeaways
- It is difficult to have a specific measure for how much weight an individual should aim to lose as this has not traditionally been a factor we can manage adequately
- New weight-loss options are effective, and so there is a need to set new goals and targets
- Evidence now shows that losing ≥15% of starting body weight affects most of the complications associated with obesity
- A good target would be a BMI of ≤27, or waist-to-height ratio of ≤0.53
- At this level, people have a normal risk of developing complications
- But too much weight loss can also be detrimental, so aim for BMI 22–27
Brain-Gut Microbiome and Obesity
Key takeaways
- The brain and gut microbiomes are interconnected systems; understanding this is important for health and disease
- There is a bidirectional loop, with signaling in both directions
- Animal data show obesity is also impacted by the gut microbiome
- The normal homeostasis is shifted in obesity, causing brain and microbiome disruptions that impact eating behavior
- Looking holistically at the system gives multiple opportunities to intervene
- Gut-directed therapies can deliver small changes to their diet that can help promote healthy bacteria in the microbiome
“The brain and the microbiome are BFFs; you can’t separate the two”
- Arpana Church
“Trauma-informed obesity care does not just address physical health—it addresses the whole person.”
- Robyn Pashby
Weight and Obesity: Perception to Perspective
Key takeaways
- When discussing weight with patients, outdated perceptions such as equating weight solely with lifestyle choices can lead to unintentional biases
- The idea that willpower alone is enough to treat obesity damages trust and leaves patients feeling discouraged and ashamed – and more likely to withdraw from care
- Shifting to a trauma-informed perspective means recognizing that many patients with obesity have experienced years of weight stigma, which leaves lasting psychological scars
- Create a safe environment where patients feel genuinely listened to and respected
- Be intentional with language: avoid terms and tone that could reinforce feelings of shame or judgment
- Shift focus away from measured weight as the primary indicator of success; instead recognize that psychological health and overall wellbeing are critical outcomes
- Each patient’s journey is unique: try to support with compassion and patience
What are Predictors of Obesity?
Key takeaways
- BMI is the standard-of-care and is used in many obesity guidelines as it is easy to use and understand
- But there are other tools that can be used in clinical practice to measure obesity
- Fat location is important; one way to quantify this is the waist-to-height ratio
- Waist-to-height is more effective than BMI at predicting the risk of certain diseases, especially CVD
- A ratio of 0.40–0.49 is normal, 0.50–0.59 is increased risk, and the highest risk is ≥0.60
- Even at normal BMI, people with a larger waist-to-height are at greater risk of CVD and complications
- Knowing this may help to identify at-risk individuals in clinical practice
“Waist-to-height ratio is a better predictor of the presence or absence of cardiovascular disease than BMI, which really doesn’t predict it.”
- Louis Aronne
“One of the good things about SELECT was the 4 years of observation in a really diverse, large population.”
- Donna Ryan
Long-term Effects of Semaglutide
Key takeaways
- SELECT provides 4 years of observation in a diverse population of over 17,000 people
- These additional long-term safety and efficacy data support the known profile of semaglutide and the wider GLP-1RA class
- Tolerability is well known, and there are steps that can be taken in clinical practice to manage common GI side effects
- With no new safety signals, SELECT reinforces this and helps to build confidence in using this class in everyday practice
SELECT CVD Outcomes and Obesity
Key takeaways
- The CV benefits seen with semaglutide may transform patient care and obesity management
- Even in people at very high CV risk, semaglutide may reduce heart attack, stroke, and CV death as seen in the SELECT trial
- There are multiple CV benefits, including improvement in heart failure and CKD, and this may result in a broadening of indications for semaglutide
- But semaglutide is already an option for secondary prevention of CVD, and this is translating into payer willingness to fund
- Results also suggest semaglutide is a powerful anti-inflammatory drug
“It’s not just about heart attack and stroke; it’s improvement in heart failure, it’s improvement in chronic kidney disease.”
- Donna Ryan
“People living with obesity [and osteoarthritis] decreasing the patient’s weight…decreased their pain and their physical function at a rate we’ve never seen with a pharmacological intervention”
- Sean Wharton
Once-weekly semaglutide for knee osteoarthritis in people with obesity
Key takeaways
- The STEP-9 trial looked at participants with obesity and knee OA with moderate-to-severe pain
- Over 68 weeks, there was a greater than 13% decrease in weight with semaglutide
- Compared to placebo, there was a significantly greater reduction in pain related to knee OA
- There are mechanical aspects to OA, so reduced weight is beneficial
- But there are also potential anti-inflammatory aspects
- Extending the study to people with OA but without obesity would help to answer this question
GLP-1 for Obesity and Beyond
Key takeaways
- More competitive alternatives are coming, including small molecules and additional injectable therapies
- Over time, these therapies may save money by keeping people healthier and keeping them in work
- New options are adding additional agonists to the original GLP-1
- This includes glucagon, GIP, amylin, PYY to create novel dual, tri, or even quadruple agonists
- Some may be better for different aspects of disease, such as metabolic liver disease or chronic kidney disease
“Price pressure will bring the cost of these medicines go down.”
- Daniel Drucker
“Sleep and obesity are very bidirectional”
- Dayna Johnson
Sleep Disparities and Health
Key takeaways
- Socioeconomic factors can influence sleep; this includes certain racial and ethnic groups, as well as people from disadvantaged backgrounds
- Key factors include lower income and reliance on shift work, which impact natural sleep rhythms
- Neighborhood factors include light exposure and air pollution Sleep and obesity have a bidirectional link
- Short sleep duration results in more opportunity to eat
- There are also metabolic processes involved, such as hormone imbalances
Practicing Sleep Hygiene
Key takeaways
- Social determinants can have an impact on sleep quality; strategies to address this include non-medical factors
- Stress is a key contributor to both socioeconomic and racial disparities
- Mindfulness can be used to manage stress and anxiety – with a positive influence on sleep, hypertension, and obesity; there are apps such that can be used for this
- Healthy sleep practices also focus on dark, quiet, and temperature
- Some people may not feel safe sleeping in the dark, but night lights can be used to illuminate other areas of the house for security
- Think about the context in which people live and help them tailor their environment to promote healthy sleep practices
“The work we’re doing is really looking upstream. How can we modify your household or neighborhood…in order to have a positive influence on improving your sleep and reducing your risk or adverse health outcomes such as obesity”
- Dayna Johnson
“Are we offering our patients the care they need and deserve?”
- Karli Burridge
Building Successful Obesity Care Programs: Proven Strategies
Key takeaways
- Start with a good, solid business plan and define the mission for the program Funding is key to ensure costs and overheads can be covered
- Have appropriate furniture and equipment so that larger patients are comfortable in the practice
- Incorporate patient perspectives and create a good, safe, empathetic relationship
- Ask the patient about themselves and their history
Growing and Marketing Your Obesity Practice
Key takeaways
- Reimbursement is an issue for obesity care services
- Create a flexible model that can link with other services in the area, and also adjust to unforeseen circumstances such as pandemics
- Telemedicine is popular with patients
- Get feedback from patients to ensure they are at the center of care
- Clinical trial data is important and should be built into everyday practice
- There are important rules to follow if recruiting patients for trials
- Most referrals come from other clinicians, so make good networks to help market
“Over 90% of their patients appreciate having telemedicine available.”
- Karli Burridge