Faculty Interviews
Gain valuable insights from an international panel of experts.
“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 diabete”
- 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
Ask the Expert