Breaking Through Biases: Building Skills for Collaborative Weight Management in Primary Care and Treating Obesity as a Chronic Disease

Breaking Through Biases
Building Skills for Collaborative Weight Management
and Treating Obesity as a Chronic Disease

Jamy D. Ard, MD, FTOS
Professor

Departments of Epidemiology & Prevention
and Internal Medicine

Vice Dean for Clinical Research

Wake Forest School of Medicine
Co-Director, Weight Management Center
Atrium Health Wake Forest Baptist
Winston Salem, North Carolina

Donna H. Ryan, MD, FTOS
Professor Emerita

Pennington Biomedical
Research Center

Baton Rouge, Louisiana

Copyright © 2000-2024, Peerview

Breaking Through Biases Slides
&
Obesity Training Workshop Slide Library

This document contains two sections:
1. The slides presented in the video modules (pages 2-51)
2. Aslide library for primary care professionals to create an
independent obesity training workshop (pages 52-134)

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Our Goals for Today

Apply current guidelines and evidence to
recognize and prioritize treatment of obesity
as a chronic disease

Initiate weight management discussions in
order to establish realistic, long-term obesity
treatment goals and utilize shared decision-making
with people with obesity

Acknowledging Gaps to Overcome
Clinical Inertia in Obesity Management

Jamy D. Ard, MD, FTOS Donna H. Ryan, MD, FTOS

Professor à Professor Emerita

Departments of Epidemiology & Prevention Pennington Biomedical

and Internal Medicine , i Research Center

Vice Dean for Clinical Research Baton Rouge, Louisiana
Wake Forest School of Medicine
Co-Director, Weight Management Center
Atrium Health Wake Forest Baptist
Winston Salem, North Carolina

Go online to access full CME/NCPD/AAPA information, including faculty disclosures.

Copyright © 2000-2024, PeerView

Obesity Is Increasing in the United States

Prevalence of Obesity 2017-20181? Obesity Trends, 1999-20182
‘Age-adjusted prevalence of obesity among adults aged 20 and over, © -74% of the US population has
by sex and race and Hispanic origin: United States, 2017-2018 ‘overweight or obesity?

Hi NonHsparic into I Non Hpac Black
Bi NontHepane Asan Hapane
40 396
357 349
E 343 337
3 |305 305 %22
i i
E 5
$ En
A
92
47 51 48 59 57 63 64 77 77
= Severe Obesity’

o

1999- 2001- 2003- 2005- 2007- 2009- 2011- 2013- 2015- 2017-
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Survey Yı

* Age-adjusted prevalence o MI (230 kn“) amang US aduts by sx, race, tit. * Adults aged 220 y. NHANES. «Significant near tend
1 Maps fw ce gowinchsidataldatabretren60* pd 2 ips www ede ovine products datant APS him. en
3. MacEwan JP et al. Obes Sei Pract. 2024:0726. PeerView.com

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Obesity Is a Chronic, Progressive, Relapsing Disease’?

+ Many healthcare professionals treat overweight and obesity as
comorbidities of other diseases rather than proactively treating obesity

* Obesity is a chronic, progressive, relapsing disease

Current guidelines and evidence support prioritized treatment of obesity,
however, PCPs:

+ hold biases about excess weight

+ fail to recognize obesity as a chronic disease

+ do not perceive obesity as a treatable target

* remain skeptical about using anti-obesity medications

1. Bray GA etal. Obes Rav. 2017:18:715-725. 2. Hayes S et al. J Commun Health. 2017:10:47-54, 3. Kapoor À eta. Dip Heath. 2020;6:2085207620018715. PeerView.com

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Comorbidities Associated With Obesity’

Pulmonary disease
‘Abnormal function

Obstructive sleep apnea
Hypoventilation syndrome

Idiopathic intracranial
hypertension
Stroke

Cataracts
Metabolic dysfunction-associated
steatotic liver disease

Steatosis Coronary heart disease
Steatohepatitis <— Diabetes
Cimhosis.

<— Dyslipidemia
Gall bladder <—— Hypertension
disease

Gynecologic abnormalities

Cancer

‘Abnormal menses Breast, uterus, cervix, colon,
Infertility esophagus, pancreas,
Polycystic ovarian syndrome kidney, prostate
Urinary incontinence
Oster Venous ssi
shin —T Gout

4. Adapted from European Practical and Patient: Centred Guidelines for Adult Obesty Management in Primary Care. January 2019. Obesity Facts. 12(1)40-6.
2 Dietz WH etal. Obesity. 2019:27:1058-1062.

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Standards of Care
#3 and #4

3. Assess patients for
obesity-associated
comorbidities

4. Educate patients or
clients about the
relationship
between excess
body fat and
health risks

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How Much Weight Loss Is Needed?
A Little Goes a Long Way

but a longer way goes even further!

dit Msomechanical

NAFLD210-13

Side courtesy of Tim Garvey MD.
T.Knonter WC eta N Engl J Med. 2002;246:393-403. 2. Cela WT et al. Diabetos Care, 2015;38:1567-42. 3, Christensen R et a. Osteoarthtis Catlge.
2005.1320-7. 4. Blida H et al. Obes Revs. 2014:15:578-86. 5. Wing RR et al Dabetos Caro. 2011;34:1481-6. 6. Ooi GJ et al. Int J Obes. 2017.41:902:.
7, Courcoulas AP ota. JAMA Sur, 2018:183:427-34. 8. Lean ME etal. Lancet. 2018:391:541-51. 9, Dambha-Miler Hot a. Diabet Mod. 2020;37:681-8.
410. Var Gomez E ot al. Gastoontorology. 2015;149:367.78. 11, Koutouids DA et al Metabolism, 2021:115:154455.

12 PromratK et al Hepatology. 2010:81.121-9. 13. Lu X et al. Obesty Surgery. 2007:17:48692,

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Primary Care Physicians Lack Knowledge of Obesity
Management, But They Want to Learn More About It!

"| don't have enough knowledge“
79.4% of PCPs surveyed felt the need for more training on obesity

Most responded, "| don't have enough time and I’m not
| comfortable initiating the conversation”

PCP mentors can play a key role in improving obesity care

+ Encourage colleagues to take small steps toward
improving their knowledge around obesity care

+ Share foundational knowledge and actionable steps

1. Croghan IT eta. J Primary Caro Comm H. 2019:10:1-14 PeerView.com

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Patient-PCP Communication
and Obesity Management!»

The Five As: Talking With Patients to Uncover
and Treat the Root Causes of Weight Gain

ASSESS Their Story Standards of Care #6
ASK Permission o
“Would it be allright if we discussed “insane ter A tem oct ean + Jointly decide 4%)
polenta: sc) with patients or
Eno combenson and eS + Stage disease severity (Edmonton Obesity clients on obesity
+ Builds patient-provider trust care options
+ Provide referrals for
patients who have
ADVISE on Management not achieved
sufficient weight
Medical Es loss or health
Nutrition Exercise Psychological | Medications er benefits with self-
‘Therapy help approaches
AGREE on Goals ASSIST With Drivers & Barriers
+ Collaborate on a personalized, + Focus on patient-centered health outcomes
sustainable action plan versus weight loss alone,
1. Wharton $ etal. CMAJ 2020:192:6875-891.2. Dietz WH, ot al. Obesity, 2019:27:1058-1062. PeerView.com

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The Complex Etiology of This Chronic Disease!”

Standards of Care
#1 and #2 ©
1. Be competent to
address the role of
social determinants
of obesity and its
Physiologie"? Behavioral? Genetic! Environmental®* ‘outcomes
+ Altered levels of + Diet + Epigenetics + Socioeconomic status 2. Consider an
hormones and + Inactivity + Mutations. + Access tolaffordability
[or + Emotional + Single offood
bra hacen factors nucleotide + Badia
A ° environment
and reward system + Lack of sleep polymorphisms: Gia,
este © Se + Sociocultural attitudes
Petr + Endocrine-disrupting

chemicals
+ Health conditions

1. Lean MEJ ot a. Int J Obes (Lond). 2016:40:622-632. 2. Yu YH et al. Obes Rev. 2015.16:234-247. 3. www. nh nh govhealtvhathtopicsAopic/obeicausest
4 Moleros À et al. Curr Obes Rep. 2013:2:23-31 5, Sharma AM otal. Obes Rev. 2010.11:362-370. 6, Chaput JP et al Obes Rev. 2012:13:681-601. 7. Dietz WH, ot

al Obesity. 201927:1050-1062. PeerView.com

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How Socioeconomic Inequities Compound Over the
Life Course to Promote Obesity’

Wore imo spent

safe outdoor play
or acte transpor

Obesity-related

Pregnancy ale health problems

velop tastes for
ty of foods

1. Kumanyika SK. Annu Rev Nutr 2022:42:453-480. PeerView.com

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Effects of Disparities in Sex, Race/Ethnicity, Comorbidities,
and Social Risk!

Premature Mortality Rates by SDOH Burden

and Obesity Class = Fe ="
oo Disparities in sex, race/ethnicity,
700 comorbidities, and social risk
E e highlight the need for equitable
3 xo patient management and access
EM to efficacious treatment with
$ GLP-1 RAs
L300
Eu + Mortality rates are consistently
3 higher with higher SDOH burden
100 nd es N
o
Non-Obese Obesity Obesity Obesity
Class | Class Il Class Il
BMUSDOH Category
mmsoonot ME OZ MOS MM SDOH-OS
1. Philip Jot al. ACC 24. Abstract 1372-228. PeerView.com

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Homeostatic Regulation of Set-Point Body Weight!

A homeostatic weight regulatory system prevents deviation from a body-weight set point

Metabolic signal Metabolic signal
to increase appetite drive to decrease appetite drive

S

Weight

Energy Energy
expenditure expenditure

Deviation from this set point elicits a physiologic compensatory
mechanism controlling food intake and energy expenditure

41. Yu YH et al, Obes Rev, 2015:16:234-247, PeerView.com

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Healthcare Encounters May Be Experienced Negatively
Among People of Color (POC)'

Inadequate treatment has been reported in cardiovascular disease care,

reproductive and prenatal/postpartum healthcare,
pain management, HIV prophylaxis, and end-of-life care

+ POC report feeling dismissed, disregarded, devalued, and excluded from
decision-making, and their symptoms/complaints are not taken seriously by HCPs

— Results in higher unmet needs, loss of trust in healthcare, and delay in
seeking healthcare

+ HCPs tend to view healthcare as neutral and objective, but POC are often viewed
as uneducated, unreliable, and less desirable patients

— Racism is difficult to acknowledge and perceived to be difficult to discuss

1. Hamed S et al. BMC Pub Host 2022:22:088. PeerView.com

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Biases Among Healthcare Professionals Can Increase
Avoidance of Evidence-Based Treatment for Obesity

+ HCPs often prefer to treat obesity with lifestyle
modifications’? Disrespect
— Only 5%-10% of people using lifestyle modifications alone
succeed in losing 20% of their weight?

— Healthy behavior # weight-reducing behavior Blame Shame

+ Many PCPs...
— Exhibit biases that interfere with seeking, offering, and

choosing evidence-based treatments to people with
obesity (PwO)*

— Bring up weight regardless of the reason for the visit, and
without asking permission to discuss firstó

+ PwO may delay/avoid care or switch physicians because of

stigmatizing experiences and poor communication with HCPs®
1 Rubio Fetal Obes Se Prat 20217:59-668 2. Agarwal M, Nado K_Endocy Pact. 202228:179-14.
3: J0bb SA ota. Lance! 2011378 1485-14024: Brno KJ Communty Heath Nurs. 2018.35: 5, Ferrante JM etal. Obes Si Pret 20162:120-135. a
6. Phelan SM et al. Obes Sci Pract. 2022:8:138-146. PeerView.com

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AAFP Principles for Managing Obesity, and
Evidence-Based Techniques for Implementation’

+ See, acknowledge, and treat the whole person
— Do not attribute all signs and symptoms to obesity
+ Identify bias and assumptions
— Engage in perspective exercises and emotional regulation®
— Have a zero-tolerance policy for stigmatizing language®
+ Practice patient-centered communication
— Use the 5As: start by asking permission to discuss weight
— Discuss obesity as a risk factor for other diseases?
+ Create a welcoming environment
— Provide a weight-friendly clinic space?
— Educate office staff on how to avoid bias in greeting and serving patients
+ Pursue lifelong learning—weight regulation is complex, and obesity science is advancing rapidly!
— Differentiate obesity factors within and outside the patient's control®
— Current and emerging AOMs rival bariatric surgery for weight loss efficacy—will change

realistic expectations
+ Mora deta avaiable in ho Ginstury/Shae systematic review

1 Emo Et Sor A) Destgmatzng obert and overcoming erent bares to obtain improved pa engagement. Updated 202 Jan 2) I: SttPoas

fria, Measure land (PL) Sear Putting. 2023 an. Avalabo rom: hip Tw. cal nm gevboskohBKETBNBT 2: Kennedy AB tal Fam Prot i
Manag. 2022:29:21-25. 3. Abbas J, JAMA, 2023:330-399-400. 4, Miler TO et al. Not Rev Drug Discov. 2022:21:201-223, PeerView.com

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Overview of Pharmacotherapeutic
Options for Obesity

Jamy D. Ard, MD, FTOS } Donna H. Ryan, MD, FTOS

Professor x Professor Emerita

Departments of Epidemiology & Prevention Pennington Biomedical

and Internal Medicine Research Center

Vice Dean for Clinical Research Baton Rouge, Louisiana
Wake Forest School of Medicine
Co-Director, Weight Management Center
Atrium Health Wake Forest Baptist
Winston Salem, North Carolina

Go online to access full CME/NCPD/AAPA information, including faculty disclosures.

Copyright © 2000-2024, PeerView

An Overview of Recommended
Obesity Treatments!

FDA-Approved for Long-Term Use
Liraglutide 3.0 mg, naltrexone/bupropion, orlistat,
phentermine/topiramate, semaglutide 2.4 mg,
and tirzepatide

Talon tal Obey Ast Sie, rosa by he Obey Mine AsoG wn chosen oy, 2023 en
hnpeebesiymesiene gfoesty again power 2 Bayo HE etal. Chessy Pars. 20222 100010 PeerView.com

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Mean Long-Term Weight Change Reported in Phase 3 Trials
of Current AOMs and Gastric Surgery in PwO'2

unsel patients that these results were achieved after a year or more

8

Phentermine/ — Naltrexone/ Liraglutide Semaglutide — Tirzepatide Sleeve Roux-en-Y

Orlistat topiramate bupropion 3.0 mg 24 mg 15 mg gastrectomy gastric bypass
XENDOS CONQUER CORI SCALE STEP-1 SURMOUNT SM-BOSS SM-BOSS
1yr 56 wk 56 wk 56 wk 68 wk 72 wk 5y 5y
0
42 [ 43 O = | E

E a 26 2.4 31

62 6.
Ego 36 3
SE, 106
58 148
De
23-20

-20:
E 5-25 a8
Su 25
= 30 286
35 mPlacebo "Intervention

The mean weight change in th ostat grup sn kg, not in percent (sped bar) ya
1. Chakhtoura M et al. eCinicaiMedicine, 2023:58:101882. 2. Peter R et al. JAMA, 2018:319:255-265. PeerView.com

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FDA-Approved AOMs17

7 u the Pipeline
Phentermine/ aR ES

+ GIPIGLP-1 RA

+ GLP-1 RA/amylin analogs

+ GIPIGLP-1/GCG RA

+ GLP-/GCG RA

+ PYY analogs

+ GDF-15 analogs

Off-Label Medications
Metformin

+ GLP-1 RAs

+ SGLT2 inhibitors

+ Topiramate

+ Bupropion

+ Other stimulants

Standards of Care #10
+ Discuss and/or prescribe obesity medications, when appropriate
+ FDA-approved medications for weight management should

be used according to product label indications
+ Medications should be prescribed in conjunction with the
lifestyle intervention
Agres o sat us ey

1820 sy lo Rend. MO. 2 Ta Y], Le SY. Cu Obes Rap, 22:10:40.9. Gra N.C Datos 202038329144 Arg AM Ll Eco 202249507. ne
557.5 Brand ala Pagos. 208.100 190-2016 Tec Met sk Det 20236.1706-1808. 7. tz WH, ea. beat. 201927 0501062 PeerView.com

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SELECT Trial: Weight Loss Sustained for 4 Years’?

Body Weight BMI Category

MM Heatny D Ciss obesity IN Class Il obesity
I Ovorweight gj Class obesity

Mean Baseline Weight, kg (SD)
Semagluide: 965 (17.5)
Placebo: 96.8 (17.8)

Body Weight Change
From Baseline, %

Proportion of Patients, %

Time Since Randomization, wk

Semaglutide Semaglutide Placebo BL Placebo
BL Week 104 Week 104

Change in Body Weight by 104 Weeks
Semaglutide -9.4% Healthy Weight Status at Week 104

Placebo -0.9% Semaglutide 12%

g Placebo 1.2% _

4. incl AM tal. N Engl J Mod. 2023:389221-2232.2. Ryan DH et al. Not Mod. 2024 May 13. Onine ahead of print PeerView.com

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Current and Future Indications for Medications
in the GLP-1 RA and GIP/GLP-1 RA Classes‘

Current
Indicatio

+ T2DM
+ CV risk reduction
+ Obesity

1. Lincolf AM ot al N Engl J Mod. 2023:389 2221-2232. 2. MtpsIciicaviis govistudyINCTOSSSES12. 3. Malhotra A et al. Contomp Clin Trias. 2024:141:107516.
À! tos www prewswir.convnews-eleasesfizopatideeducee-sloep-apnea-severty-by-upto-nealy two-thirds adults-wit-oosrucivesleop-ap0a-0s9-and-
‘besty302118929.himl 5. Vuppalanchi Ret al. Aliment Pharmacol Ther. 2024 May 20 (Epub ahead of pt] 6. Loomba Rt al. EASL 2024. LBO-001 Pe

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Breaking Through Biases
Uncovering Practical Strategies
to Engage and Motivate PwO

Jamy D. Ard, MD, FTOS Donna H. Ryan, MD, FTOS

Professor am Professor Emerita

Departments of Epidemiology & Prevention Pennington Biomedical

and Internal Medicine z Research Center

Vice Dean for Clinical Research Baton Rouge, Louisiana
Wake Forest School of Medicine
Co-Director, Weight Management Center
Atrium Health Wake Forest Baptist
Winston Salem, North Carolina

Go online to access full CME/NCPD/AAPA information, including faculty disclosures.

Copyright © 2000-2024, PeerView

Intake Form Highlights:
Mike Simons, a White Man Aged 52 Years

Medical history: obesity, hyperlipidemia, hypertension,

sleep apnea, depression dent bua ness social aver
Family history: brother T2DM, HTN; father prostate cancer drinks and high-fat foods

7 years ago; mother MI 3 years ago, dyslipidemia Has had depression for 6 months;
BMI: 36.3 kg/m?; height: 76 inches (193 cm); OS

weight 298 Ib (135 kg) a a te

A1C: 6.2%; BP: 138/87 mmHg en
TC: 180 mg/dL; LDL-C: 90 mg/dL; HDL-C: 40 mg/dL; a conversation about weight in the

15 years he's been at your practice

TG: 250 mg/dL
pa A . Today's visit is to examine his
Current medications: rosuvastatin, benazepril/HCTZ, ankle which he twisted while

paroxetine at the gym

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Overweight and Obesity Increases the Risk of Lower
Extremity Injury: Evidence From the US Army’
Lower Extremity Injury Rates Across BMI Categories
at Accession, 2002-2011 (N = 736,608)

m<18.5 18.5 to <25 125 to <30 #230

2
2
E3
2
5 227
9 2 187 4, 1.93
E
e
8
$e 0.31 o. E 82
51 047
& 027 0.34 AC
2 0.24 0.28 27, 0. 30, 35 0.41
2 0.23 0.270,26 ä
STO Husum TT |
30
E Hip Upper Leg Knee Lower Leg/Ankle FootToe
1. Hnby À ot al. Am J Prev Med. 2016:50:0163-0171. PeerView.com

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Obesity Directly Influences Cardiovascular Risk,
Warranting Specifically Targeted Management!

Stage 2 Stage 3

Stage 4
Clinical CVD in
CKM syndrome

Stage 0 Metabolic risk Subclinical
No risk factors factors and CVD in CKM
CKD syndrome

E
N EZ

+ Focus on primordial + OvenweighVobesity + Hypertriglyceridemia + Subclinical ASCVD + CHD

NO

prevention and + Abdominal obesity + Hypertension + Subclinical HF + AF
preserving CV health + Impaired glucose (ronmetatolcebooaies) + Risk equivalents of + HF
tolerance sul subclinical CVD: + Stroke
= kr, very high-risk CKD; + PAD
igh-ris i S
Mo CKD high predicted isk
+ Metabolic syndrome for CVD using risk
calculator
1. Ndumele CE et a. Circulation 2023:148:1606 PeerView.com

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Duration of Overweight/Obesity and
Degree of Activity Matterst22b

CVD Risk Increases With Longer Duration + Negative legacy effect with

of Overweight and Inactivity ee ile u e E

e res overweight and physical activity
q 18 M Active Ml Inactive + Overweight and inactivity leads
8 16 to worse outcomes than being
£14 1.25 overweight and active
g 12 dE 1.00
E à
x 08 Standards of Care #8
& 06 0.43 Recommend appropriate
Q 04 levels of physical activity
8 02 NA and/or refer patients/clients to

0 programs that include

physical activity counseling as

Healthy weight now Overweight now Overweight now part of an obesity care effort

and 10 y ago but not 10 y ago and 10 y ago

+ 1443 adits aged 3685 year, NHANES 2003-2006. CVD risk cor ranged rom 0-6 based on the total number ol CVD risk factor: (1) hypertension
{140/90 mig) (2) dabeles (lasing glucose 2126 mol. or A1C 28.5%) (3) hgh ed cel iron wath (14.5%); (4) gh CRP (20.3 mal) (6) low HDL

{males <40 mola, females <50 maid. (6) high TS (>150 mL. Tew

1. Dankel SJ et a. Int J Carto. 2015201:P88.P89. 2. Dietz WH, et al. Obesity. 2019:27:1059-1082. PeerView.com

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Guidance on Conducting a Weight Management Visit

Standards ofCare#5 ¿Q)
Employ evidence-based NA
counseling techniques to
facilitate behavioral change

agree) and assist), eto
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Many Medications May Cause Weight Gain

Summary of Weight Promoting
Medications and Alternate Theropies

ight Promoting
ate Theraples

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Standards of Care #9
Minimize the use of
medications that may
cause weight gain and
tially consider

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Incorporating Dietary Counseling in Primary Care

Nutritious Food Is Filling!

DD)

on he end ate NOVA Ciao Sem

Standards of Care #7 ©,
+ Refer patients/clients to an evidence-based program or recommend an evidence-based dietary strategy
+ Consider individual preference and the potential health benefit of diet composition

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Communicating With Patients About AOMs

Know More About Anti-Obesity Medications Know More About Anti-Obesity Medications

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Start Low and Go Slow: Initiating and Titrating AOMs
in People With Overweight or Obesity Without T2DM

‘Titration Schediles!*
a nece na y verse
Dm ra tem

H Serena e nk
a a e pme

a cdi
carmen o ae

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Recommendations for Mike

Medical history: obesity, hyperlipidemia, hypertension,

sleep apnea, depression rentables socal even
Family history: brother T2DM, HTN; father prostate cancer drinks and high-fat foods

7 years ago; mother MI 3 years ago, dyslipidemia Has had depression for 6 months;
BMI: 36.3 kg/m?; height: 76 inches (193 cm); AS

weight 298 Ib (135 kg) a nn

A1C: 6.2%; BP: 138/87 mmHg Appears (usted bat has never inicio
TC: 180 mg/dL; LDL-C: 90 mg/dL; HDL-C: 40 mg/dL; a conversation about weight in the

15 years he's been at your practice

TG: 250 mg/dL
ae = a Today's visit is to examine his
Current medications: rosuvastatin, benazepril/HCTZ, ankle which he twisted while

paroxetine at the gym

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Intake Form Highlights:
Janice Harris, a Black Woman Aged 59 Years

Janice

p 7 3 a n Visit Notes
Medical history: di d with HTN 8 ; ly di d
ical history: diagnosed wi years ago; newly diagnose’ School secretas

with T2DM Rae
Family history: father T2DM with amputations; mother T2DM ñ in your Re

with dialysis weight management

BMI: 34.2 kg/m?; height: 66 inches (168 cm); weight 212 Ib (96 kg) | - Janice doesn't

want to “end up like

A1C: 9.0%; BP: 126/86 mmHg her parents”

eGFR: 60 mL/min/1.73 m?; UACR: 45 mg/g

TC: 180 mg/dL; LDL-C: 115 mg/dL; HDL-C: 38 mg/dL;

TG: 160 mg/dL

Current medications: lisinopril, omega-3 fatty acids, metformin

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Weight Loss Interventions Can Induce Diabetes Remission’

ARMMS-T2D is a pooled analysis of four
US single-center RCTs investigating Diabetes Remission
long-term glycemic control and safety of
bariatric surgery vs medical/lifestyle
management in PwT2DM.

+ Studies were conducted between 2007
and 2013 (prior to approval of GLP-1
RAs and GIP/GLP-1 RAs for obesity)

+ Interventions included medical/lifestyle
management, RYGB, sleeve
gastrectomy, or adjustable
gastric banding

+ Bariatric surgery is superior to medical we. or Parscipants
therapy/lifestyle intervention at7to12 — tuoncsuey ime te di do do de tena
years of follow-up, but remission is
not a typical outcome

à sus
eee a .
sw Medicallifestyie . .
cee ee
á ... CEA

Participants Achieving Remission, %

Annual Visit

1. Courcoulas AP et al. JAMA, 2024:331:654-664. PeerView.com

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Weight Loss Is Critical for Diabetes Remission: DIRECT

Diabetes Remission:
Endocrine
Society/EASD/Diabetes
UK/ADA Consensus
Definition!

1. Sustained metabolic
improvement in T2DM to
near-normal levels

2. Return of A1C <6.5%
persisting for 23 mo
without glucose-lowering
medications*»

3. Annual testing thereafter
to assess long-term
maintenance of remission

Alternate criteria A1C is an unrelable marke of cron
, Ten 'A1C jst prior to an intervention (

MI oa

Weight loss of 10-15 kg (~10%-15%): 57% achieved diabetes
remissions
Weight loss of 215 kg (2~15%): 86% achieved diabetes remissions

00090000 24% Mi 11%
Maintained 210 kg Maintained 215 kg
(2-10%) weight loss (2-15%) weight loss

MAMMA 64% HHO? 70%

Achieved diabetes remission Achieved diabetes remission

toni hai antl na para ae FPG 128 mo eAG 8.5% cused tom COM as.
surgical. Host) and no sooner than 3 months aftr inition and wihdrawal of any glucose-Jower

rarmecsioge .
‘owe at Oates Cow DE ae sted 2 Coon ME m8 Lancet 201894 i119 Loan ME cat Lance Datos Enema ES. PeerView.com

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Adding a GLP-1 RA With Proven CVD Benefit Is Recommended
for PwT2DM in the 2024 ADA Standards of Care!”

Indications Dulaglutide ee Er Liraglutide Lixisenatide is no mn

‘Adjunct to diet and

exercise to improve Y
glycemic control in

adults with T2DM

Y Y Y Y Y Y

Adjunct to diet and
exercise to improve Y Y

glycemic control in
patients aged 210 years

Reduce risk of MACE in
adults with T2DM with
established CVD

Reduce risk of MACE in

adults with T2DM with é
multiple cardiovascular

risk factors

1 ps ww accossdata (da govserpslcerda.2. Star Not al Nat Med. 2022220:591-508 ñ
3. Gragnano F et al. Eur Heart J Cardiovasc Pharmacother. 2024:107:. PeerView.com

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Adding an SGLT2i With Proven CVD Benefit Is Recommended
for PwT2DM in the 2024 ADA Standards of Care!

Indications

Bexa Cana Dapa Empa Ertu
Adjunct to diet and exercise to improve glycemic control in adults with T2DM Y Y Y Y Y

Adjunct to diet and exercise to improve glycemic control in patients with T2DM aged 210 years

Reduce risk of MAC!

adults with T20M

established CVD.

Reduce risk of CV death in adults with T2DM and established CVD

Reduce risk of ESKD, doubling of SCr, CV death, and hospitalization for HF in adults with
T2DM and diabetic nephropathy with albuminuria

T2DM + HF + CKD

Reduce risk of hospitalization for HF in adults with T2DM and either established CVD or
multiple CV risk factors

Reduce risk of CV death, hospitalization for HF, and urgent HF visit in adults with HF = = = =
Reduce risk of CV death and hospitalization for HF in adults with HF = = = y os

Reduce risk of sustained eGFR decline, ESKD, CV death, and hospi
with CKD at risk of progression

ization for HF in adults 2

Reduce the risk of sustained decline in eGFR, ESKD, CV death, and hospitalization in adults Y
with CKD at risk of progression

Not recommended to improve glycemic contol if GFR < 30 mLJmin/1.73 me, ™
1. tps www accessdata fóa goviscritsicderida.2. American Diabetes Association Professional Practice Commitee. Diabetes Care. 2024:47(suppl 1)s158-8178. PeerView.com

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Weight Loss Efficacy of Glucose-Lowering Medications
in PwT2DM!

eS

Lf?

an most other classes of glucos

ELLE

lp booed

10

Jowering agents

iii

o
4 |
46

86

Weight Reduction vs
Standard Treatments, %
e

1.SWQ et al BMJ, 2023:381:0074068,

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22 20 18 4

A

04

EB GIP/GLP-1 or
GLP-1-based agent

8 Other agents

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Weight Loss Studies of Semaglutide and Tirzepatide
in PwT2DM

STEP-21 SURMOUNT-2?
008 kg
o
* E
EA & 33 32
3 i ‘
E a
qa 5
E É
ES Semaguide 10 mg ra Tirzepatide 10 mg
E = H
¿e = 44 1428
4 $ 5] Tirzepatide 15mg ag, ENT
+0 Semaglutide 2.4 mg 3 A
2 n= 404 3
2 4
TIRA a à à + © @ OST D © © E E
stand
Time Since Randomization, wk ‘Time Since Randomization, wk
1. Davies M et al. Lancet. 2021:397:971-984. 2. Garvey WT et al. Lancet. 2023:402:613-626. PeerView.com
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Recommendations for Janice

Janice

f 7 > a i Visit Notes
Medical history: di d with HTN 8 ; ly di d
ical history: diagnosed wi years ago; newly diagnose’ iSchool eacretany

with T2DM an
Family history: father T2DM with amputations; mother T2DM ñ in your ne

with dialysis weight management

BMI: 34.2 kg/m?; height: 66 inches (168 cm); weight 212 Ib (96 kg) | - Janice doesn't

want to “end up like

A1C: 9.0%; BP: 126/86 mmHg her parents”

eGFR: 60 mL/min/1.73 m?; UACR: 45 mg/g

TC: 180 mg/dL; LDL-C: 115 mg/dL; HDL-C: 38 mg/dL;

TG: 160 mg/dL

Current medications: lisinopril, omega-3 fatty acids, metformin

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Train-the-Trainer
CDC Training of Trainers Model

Jamy D. Ard, MD, FTOS Donna H. Ryan, MD, FTOS

Professor Professor Emerita

Departments of Epidemiology & Prevention Pennington Biomedical

and Internal Medicine Research Center

Vice Dean for Clinical Research Baton Rouge, Louisiana
Wake Forest School of Medicine
Co-Director, Weight Management Center
Atrium Health Wake Forest Baptist
Winston Salem, North Carolina

Go online to access full CME/NCPD/AAPA information, including faculty disclosures.

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A Multicultural Call to Action:

Taking the Lead to Improve Care for PwO

“Knowledge was meant
to be shared.”

— Louis L'Amour

“When you learn, teach,
when you get, give.
Maya Angelou

“Real influence is
gained by sharing
knowledge and
educating by example.”
— Rachel Miller

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“Knowledge is a
commodity to be shared.
For knowledge to pay
dividends, it should not
remain the monopoly of
the selected few.”

— Moutasem Algharati

“Share your knowledge.
It is a way to achieve
immortality.”

— Dalai Lama

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Downloadable Resources Included
With This Activity

Slide Library More Practice Aids | Tralning-of Trainer

You can also develop your own obesity management resources!
Consider providing patient education brochures, website links, apps, lists of cooking
classes, recreation centers, and more

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CDC Training of Trainers Model!

93] Train instructors

qe A ToT workshop can build a pool

of competent instructors who can then
teach the material to other people

Direct participants

Direct participants to supplementary
© |] © resources and reference materials

yf) Lead discussions
00% Lead activities that reinforce learning

1. nips vw ede govineathyschoolthetrain_tainers_model him.

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a
€
am

Listen effectively

Help instructors be more effective

in their practice and more responsive
to the needs of the learners they serve

Make observations

Provide insight into how adults learn,
and help instructors be more effective
in their practice

Support participants
Provide completed, continued, and
targeted follow-up support once a
professional development event
has been completed

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Forms Included With
the Downloadable
Practice Aids

Action Plan

Step 1: Prepare

Q Collect or develop resources to support obesity care for your practice area
Q Invite colleagues to participate in a training workshop

Q Administer the Baseline Survey to participants

Q Develop an educational activity based on the needs revealed by the Baseline Survey

Qe

Step 2: Execute

Q Include opportunities for the participants to practice the skills you've taught
Q Listen to participants’ feedback and answer their questions

Q Ask the participants to complete the Self-Reflection Worksheet

Q Provide resources to participants based on their needs

Step 3: Follow Up

553 @ Follow up and provide ongoing support to the participants after the activity
Q Use the feedback to refine or extend your next training workshop

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Good public
speaking and

Future
trainers
should be
well
respected

1. ps twa tutto. comino rines model.

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active
listening
skills

Self-reflective
and open to
receiving
feedback

Some
amount of
experience
and
expertise in
the field

Should have a
positive
attitude and
willing to help
colleagues

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Preparing the Obesity Management
Training Workshop

+ Use the Baseline Survey results to guide
the content

+ Download slides from the Slide Library
to build your slide deck

Don't just lecture: include opportunities
for discussion, listening, and questions

+ Demonstrate counseling practices
through roleplay

Invite a patient to speak

Include a refreshment break to
encourage network development

.

.

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Practice Aids

Ask those registered for your training session to complete the Baseline Survey.
Then, use their responses to ¡at gaps they perceive with regard to

.. their skills to care for people with obesity

... their professional attitudes toward care for people
with obesity

1. Sanchez Ramirez DC et al. BMC Med Educ. 2018:18:278. PeerView.com

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Insights to Share With Colleaguegs

As You Prepare the Presentation, Remember to Discuss ...

How weight stigma and any anti-fat bias impacts medical care for PwO
The recent advances in obesity science and the evolution of
| } anti-obesity medications

Multifactorial mechanisms of action, key efficacy, long-term safety data,
including comorbidity benefits of approved and emerging options in
anti-obesity medications

Shared-decision making to identify and initiate treatments that meet the

patient's needs and that will realistically achieve their individualized

weight loss goals
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Tips for Being a Successful Trainer of Trainers!

+ Maintain eye contact
+ Present a positive attitude
+ Speak in a clear voice
+ Gesture appropriately
+ Maintain interest
— Help participants link training to their practices
+ Dissipate confusion
— Lead discussions, listen effectively, and answer questions

— Direct participants to supplementary resources and
reference materials

1. nips ww de govineathyschoolthatrain_tainers_ model htm. PeerView.com

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Group Discussion for the
Self-Reflection Worksheet

Have those attending your trainin
1e Self-Reflection Woi
Then, discuss the answers to these questions as a group:

What are the biggest challenges to offering respectful, evidence-based

obesity management in our area?

What ideas does this group have for improving respectful, evidence-based _
obesity management in our area?

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N Following Up After the Workshop:

Checking Moore’s Levels!

How many learners came?

Knowledge Can they answer questions correctly?

Are they using their new skills in practice?

LET DAS Can they demonstrate their skills correctly?

Are their patients healthier?

Is the community healt!

1. Moore DE Jr ot al. J Contin Educ Hoal Pro, 2009:29:1-1.

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e?

Use this feedback to
refine the agenda for
your next workshop

Answer learner

questions after the
activity

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Key Takeaways

+ Ask a patient if it's ok to discuss their overweight/obesity; use a shared
decision-making approach with all management considerations

+ Check your stigma at the door before any conversation about obesity!

+ Anutritious diet and physical activity are foundational to healthy living, but may
have only modest effects on weight

+ GLP-1 RAs and GIP/GLP-1 RAs are effective agents for addressing obesity
and its comorbidities and have favorable effects on CV risk factors and A1C

« Obesity cannot be managed solely by obesity specialists

— Train the Trainer! Teach your colleagues to train others about how to
improve the quality of the care they provide to PwO

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Obesity Training Workshop
Slide Library

Use these additional slides to create an independent obesity
training workshop for a primary care professional audience.

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Epidemiology and

Statistics

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The Mean BMI Is Increasing in the United States

202112 Trends, 1999-20182

60
40 ony BS"
3 222 343 337 57 349 ange
E [sos 305
$
5
La
92
47 51 48 59 57 63 64 77 77
Severe Obesity’
o
1999- 2001- 2003. 2005- 2007- 2009. 2011- 2013- 2015- 2017-
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Survey Years
+ Palace of separa bosty (Ml 290 g/n") among US adults by state and rt, BRFSS." Adu age 220 y, NHANES. Sgncant nar on ze
o 4 y PeerView.com

1: aps vin dc govlobesiydatalprevalence-maps hi. 2. Maps ww ede goVInchs/products/Gatabrts/do380. Mim.

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How Reliable Is BMI for Assessing Obesity?12

Healthy weight Class | obesity | Class Il obesity | Class Ill obesity

18.5-24.9 kg/m? 30.0-34.9 kg/m? | 35.0-39.9 kg/m?

« BMI is an estimate of body fat in the general population

« Different BMI cutoff points may be more appropriate based upon sex, race, ethnicity,
and menopausal status

+ Among Asian patients, a BMI 223 kg/m? may be a more appropriate cutoff point to
define overweight and to screen for T2DM

+ Among postmenopausal patients, BMI may underestimate body fat

+ Among retired athletes, like NFL football players, BMI overestimates body fat; the body
fat measurement by DEXA was a more accurate measure of obesity than BMI

1. Fitch AK, Bays HE. Obesity Pilars. 2022:1:100004. 2. Hyman MH et a. J Occup Environ Med. 2012:54:816-819, PeerView.com

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Lifetime Risk of CVD Morbidity and Mortality
Among Middle-Aged Individuals’

Middle-Aged Men Middle-Aged Women
æ
Morts obese zoo
E Di Mo 20 Qt
on 38
Normal ¿E ©
woot Eq
unserm À 5 50
SE.
2,
Ton a DS oo 0 5 © 0 5 05 DS DS © 8 Dw
Follow-Up, y Follow-Up, y
+ Remaining cumulative lifetime risk estimates for total CVD + Lifetime risks for total cardiovascular disease
events (adjusted for competing risk of noncardiovascular ‘exceeded 30% for men and women in all BMI groups

death) in middle-aged (index age, 40-59 years) men and
women stratified by BMI groups: underweight, normal,
‘overweight, obese, and morbidly obese

* Population-based study using pooled individual ive ata rom adits across 10 large US prospective cohorts, 3.2 milion person-years of flow trom 1964-2018. u
1. Khan SS eta. JAMA Carla 2018:3280287. PeerView.com

+ Participants in higher BMI strata had higher lifetime
risks for cardiovascular disease through age 95 years

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Pathophysiology of

Obesity

The Complex Etiology of This Chronic Disease!”

Obesi

Physiologie"? Behavioral? Genetic* Environmental®®
+ Altered levels of hormones + Diet + Epigenetics + Socioeconomic status
and gastrointestinal peptides. inactivity + Mutations + Access tolatfordabilty
+ Altered homeostatic and + Emotional factors + Single nucleotide of food
reward system pathways ak deen polymorphisms + Built/physical environment
+ Weight-positive medications 7 So A + Cultures
+ Health conditions EN + Sociocultural attitudes
+ Endocrine-disrupting
chemicals

1. Lean MEJ eta. In J Obes (Long) 2016.40622.632.2. Yu YH eta. Obs Ro. 2015:16234-247, 3, www bi goveltnheat-topisopislobelausest
4 Molero À et a Cur Obes Rep. 2019223315. Sharma AM et a Obos Rev 2010.11:362970.0. Chaput JP el Obes Row. 2012.13681391. .
7. Dietz WH eta. Obesity. 2019:27:1059-1062, PeerView.com

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You Don’t Consciously Control Your Metabolism: Ditching Old Assumptions
About Energy Balance for a New Approach to Obesity Treatment’

Old Assumption
Purposeful behavior drives the physiology

New Approach
ysiologic regulation of energy
balance drives behavior

Changes in the modern diet alter
energy balance physiology

The chemical composition
of calories is critical

Increased caloric intake
drives weight gain

All types of calories
have similar effects

Physical activity causes weight
loss directly by burning calories

Re-regulation of abnormal
physiology is essential for success

1. Gill HJ, Kaplan JM. Front Neuroendocrinol 2002:28:240, 2. Suman P et al. N Engl J Med. 2011:365:1597-1604, PeerView.com

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Body Weight Is Regulated by Numerous Hormones and
Other Factors That Are Not Under Voluntary Control!

1. Mller TO et al Not Rev Drug Discov. 2022:21:201-228 PeerView.com

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Approach to Treating Obesity as a Chronic Disease

Exclude 2° causes
Medications, medical, Y

Integrated Weight/Comorbidity Management

Nutrition Activity Behavior

L_ Pharmacotherapy

Li» Bariatric procedure

Image courtesy of Jaime Almandoz, MO. PeerView.com

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Communicating
With Patients About

Obesity

What Influences Do People Think Explain Obesity?"

+ Ademographically representative survey of 1,009 individuals was conducted in 2006-2007 to gauge
support for 16 different policies that were proposed to combat obesity in the United States
+ Participants were asked which factors explained the development of obesity

High individu Low individual blame

Toxic food

Sa D En D ou D a
ld 50.5 712 58.0 65.2 513 541 5
factor, %

Very important
ei 176 158 125 141 96 124 239

+ 46.4% identified 3-4 factors as important
+ 42.2% identified 5-7 factors as important

1.Bary CL et al. Mibank Quarterly. 2009:87:7-47. PeerView.com

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Weight Stigma Damages the Physician-Patient Relationship
and Leads to Poorer Quality Care!

+ Attribute all sx
- Blaming & E aes
shaming ‘oor Favor
ee je Noncompbant: SCG preventive tests Epa
ay CO - Fever dx tests outcomes
+ ‘Overindulgent”

+ Less time in

+ “Unsuccessful” office visits

1. Kennedy AB ot al. Fam Pract Manog.20222921-25,

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Internalized Stigma: An Impediment to Change’2:#

“Lazy”
“Noncompliant”

Hopelessness/despair

Body shame Healthcare avoidance

External Internalized

Appearance
monitoring

Exercise/social avoidance
Increased morbidity/mortality

“Lack of will power”
“No self-discipline”

+ Figure adapted rom OMR Washington Center for Weight Management and Research ñ
1. Tyka TL tal J Obes. 20142014:983495. 2. Han SY et a. BMC Obes. 2018.5:1. PeerView.com

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Five Strategies to Reduce Stigmatization!

1. Zero-tolerance policies for
stigmatizing language

« Stereotypical language, images, or humor
inaccurately depicting patients as being lazy or
lacking self-discipline

1. Ginsburg BM, Sheer AJ. In: StatPoarts Intemot] Treasure Island, FL: StatPoaris Publishing, 2023. ps www nc nim ni govibooks/NBKS78197. PeerView.com

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Five Strategies to Reduce Stigmatization, cont'd’

2. Provide weight-friendly clinic space

+ Avoid hurtful comments, jokes, and disrespect

+ Use patient-first language (eg, "patient with obesity," not “obese patient")

+ Use neutral, factual terminology, (eg, healthy weight, overweight, severe
obesity, BMI), not terms such as fat, large, or morbidly obese

+ Use motivational interviewing, not unsolicited advice

+ Provide chairs, sofas, and exam tables that can handle high body
weights without tipping or breaking; extra-large patient gowns; large
blood pressure cuffs; extra-long needles for phlebotomy; large vaginal

speculums; scales that can measure patients who weigh >400 Ib and are
preferably located in a private area

1. Ginsburg BM, Sheer AJ. In: StatPoars [Intormol) Treasure Island, FL: StatPoaris Publishing; 2023. ps ri ni nim ni govibookS/NBKS78197 PeerView.com

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Five Strategies to Reduce Stigmatization, cont'd’

3. Engage in perspective exercises
and emotion regulation

« Have HCPs wear obesity simulation suits in public to
increase empathy

« Listen to dramatic readings about obesity prejudice

+ Use standardized questionnaires and surveys to help
HCPs recognize obesity bias

« Use meditation or deep breathing prior to emotionally
difficult encounters

1. Ginsburg BM, Shoor As In: StatPears Inte]. Treasure Island, FL: StarPearis Publishing: 2023. ps www. ncbi im nih gowbooksNBK578197. PeerView.com

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Five Strategies to Reduce Stigmatization, cont'd’

4. Discuss obesity as a risk factor for other diseases

+ Permits focus on weight as modifiable and treatable

+ BMI, central adiposity, and duration of increased body weight can
predict T2DM development

+ Some cancers are more common in PwO (eg, colorectal, prostate,
breast); guideline-directed screening for these diseases may open
an opportunity to discuss weight

+ Discussions with patients who want to reduce their risk of CVD and
other diseases that impair QOL (eg, gout, PCOS, OSA,
osteoarthritis) may permit weight to be addressed without being
the focus of the discussion

1. Ginsburg BM, Sheer AJ. In: StatPoarts [toral] Treasure Island, FL: StatPearls Publishing, 2023. ps nn nc nim ni govibooks/NBKS78197 PeerView.com

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Five Strategies to Reduce Stigmatization, cont'd’

5. Differentiate obesity factors outside
the patient’s control

+ Genetics, socioeconomics, and psychology
(eg, humans prefer to eat food that tastes good)

« Educate HCPs on the epidemiology and
pathophysiology of weight regulation; teach
them to discuss the science with patients,
not blame them

1. Ginsburg BM, Shoor Au In: tatPears Intomot Treasure Island, FL: StatPears Publishing: 2023. htpsJwww.ncbi im nih govibooksINBKS78197/ PeerView.com

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Motivational Interview Technique: The Five As!

+ Ask for permission to discuss body weight
+ Explore readiness for change

+ Assess BMI, waist circumference, and obesity stage
+ Explore drivers and complications of excess weight

+ Advise the patient about the health risks of obesity, benefits of modest

Pass weight loss (5%-10%), need for long-term strategy, and treatment options

+ Agree on realistic weight loss expectations, targets, behavioral changes, and

male? specific details of the treatment plan

A / + Assist in identifying and addressing barriers; provide resources
assist + Assist in finding/consulting with appropriate HCPs; arrange regular follow-up

EBBBB

1. Freshwater M ot al. Obesity Pilars. 2022.2.100014, PeerView.com

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Stages of Change’

Precontemplation
Unawareness of the problem Zn

Contemplation \

Thinking of change in the next 6 months |
Preparation
Making plans to change now
Action
Implementation of change
Maintenance |
Continued favorable change without relapse }
|
Relapse E y
Restart of unfavorable behavior

1. Freshwater Met al. Obesity Pitars. 2022:2:100014, PeerView.com

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Establishing a “Virtuous Cycle” in
Comprehensive Obesity Management!»

- > Plan is

Goal is met Working

In a clinical trial program
for a GLP-1-based
therapy in PwT2D,
improved glycemic
control and reduced

Distress is
reduced;

Set achievable

Intervention
Ele 2 E meaningful
ee weight plan to is attempted weight was associated Donets aro
the goals with adoption of other noticed
healthful behaviors
(dietary modifications,
increased exercise)
en Encourages
g adherence
are added (m °°
1.Valis M. Int J Cin Pract 2016.70:196-205. 2. Matza LS et al. Patient. 2022:15:367-377. PeerView.com

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Social Determinants

of Health

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Perceived Weight Stigma in Doctor-Patient Relationships, As Reported
by Women of Color With Obesity Attending a FQHC1

Doctor recommended diet even if you didn't intend to discuss weight
Doctor said weight is a health problem when you are in good health
HCPs suggest diets without asking for advice

Doctor told you to lose weight, but didn't offer treatment options or help
Medical staff stared at you

Doctor blamed unrelated physical problems on your weight

Doctors or other HCPs assume you have emotional problems

No BP cuffs or gowns that fit you

Doctors or other HCPs assume you overeat or binge-eat

HCPS treat you as incompetert because of your weight

HCPS treat you as lazy because of your weight

Overhearing medical staff make rude comments about you

o 5 10 15 20

Patients reporting situation occurring at this practice
at least once during the past 12 months, %

FOHC, Federaty quali heathcare cote.

"Top 12 most equenty reported situations by 149 women, mean age 47.5 y, mean EMI 39.4 kom

77% non Hspan Black, 19% Hispanic 8% non Hspani Who, 2% er. en

1. Ferrante JM et al. Obos Sei Pract. 2016:2:128-135 PeerView.com

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As the Number of ACEs Increases, the Risk for Negative
Health Outcomes, Including Obesity, Increases13

The Likelihood of Selected

Health Risks in Adulthood

ACEs With 24 ACEs
Abuse Anxiety Respiratory disease
Abandonment 3.7 times more likely 3 times more likely
Neglect Cancer Substance use disorder
Divorce 2.3 times more likely 5.6 times more likely
Death of parent CVD Suicide attempts
Domestic violence 2.1 times more likely 30 times more likely
Substance use Diabetes Teenage pregnancy
disorder 1.5 times more likely 4.2 times more likely

Victim of violence

1.3 times more likely 7.5 times more likely

4. Fait Vd et al Am J Prov Mod. 1998:14245-258. 2. Hughes K etal. Lancer PUBIS Hoalth 2017203560388 7
3. ps: childrens. heath qua gov aulwp-contentuploads/POF iream-bg/Dream-Big-Act-Big-or-Kids-tssue-1-ACESs-Toxic- Stress pi PeerView.com

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Depression and Obesity Have
Shared Bidirectional Biological Mechanisms‘

Genetics
Unhealthy
Chronic microbiome
stress
ACES?
Abuse
Abandonment
Neglect Early life
Divorce stress A d
Death of parent = Sedentary

Domestic violence lifestyle
‘Substance abuse

Depression and obesity

1. Mlanesch Y et a. Moloe Peychity, 201924:19-33.2. Flt VI tal. Am J Prov Med, 1998:14245-258. 7
3. Hughes K et al. Lancet Public Healh. 2017.2.0356-0368, PeerView.com

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Communicating Within the Patient Encounter!

Is now a good time for us to discuss how your weight and health may be affecting each other
and how we can work together on it?

Response From PCP
understand you may not be ready
to discuss your weight. However, |
am about the impact of
your weight on your health. There
may be some things we car

together in the future. Please make
a follow-up appointment when you

are ready for another discussion.

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Encouraging Timely
and Appropriate

Action

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Lifestyle Modifications Are the Foundation of
Weight Management, But They Are Just the Beginning

| Obesity

| Management

Es | Lifestyle

+ Only 5% to 10% of people using lifestyle modifications alone
succeed in losing 20% of their weight!

Healthy behavior # weight-reducing behavior

1. Jobb SA eta, Lancet. 2011:378:1485-1492. PeerView.com

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Life’s Essential 8: Healthy Living Is for Everyone

den Eat better

Q
EP Be more active
In)

® Quit tobacco

N Get healthy sleep

American Heart Association Guidelines:

@

Frl
ES

ARS

Manage weight
Manage cholesterol
Manage blood sugar

Manage blood pressure

1. ps heart orgmadiaHealthy-Lhing-Fles/LEB-Fact ShoetsLes_Essenial_8.Fact_ Sheet pl. 2 Loyd-Jones DM et al. Creulaton. 2022:146:1843. PeerView.com

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Ngee

Ske courtesy of Over Bemard, B. Pharm, M Se: htps/0 wp conv. thopharmafst.comwp-contenVuploads/2019/10/ad-detfecycle-FULL png?sst=t PeerView.com

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Nutritious Food Can Be Appetizing, Flavorful,
and Easy to Prepare*?

Diabetes Plate Method

y fruitiveg 3
intake Healthy
= eating is for
Las everyone,
mortality

people with

diabetes

1 ps Gaboto org ealyiingrecpes-nuion. 2. tps nv dabetesioodnub oxpariceslereate yur pate-impily:meal-planning-withshe-plate-method im à
3. Wang DD etal. Creulaton, 2021;143:1642-1654. PeerView.com

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Nutritious Food Can Be Appetizing, Flavorful,
and Easy to Prepare

Beef chili with
beans, and kale
apple slaw

Vegetarian
ratatouille with
beans, and
Greek salad

1. petalos operaron. 2. ips dabatosocdnub onericesceate your late planning wi-ine-pte meto hin A
3 Wong DD ot a raton 20%;16 1642054 EN PeerView.com

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Dietary Advice Made Simple

Planned portions a

ve of plants P and proteinsa,

that are practical to prepare “À

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Obesity Interventions

How Much Weight Loss Is Needed to Improve Health?

Improves + Notas much as many patients would like to lose!
health1-5 - Unrealistic weight loss goals are common and
self-defeating!0-13
+ Weight loss of 5% to 10% may be disappointing

Reverses some to patients’

disease - Itis better to set a 5% goal and celebrate that

processes? ® success than to set a 20% goal with
inadequate resources and quit in frustration

Reduces CV

events and

complications?

Wing RR ot. Dates Core. 2011:34:1481-148,2 Lazo M eta Diabetes Care 2010: 2156-2169. 2 Phelan Set al. J Urol 2012:197.900944
Wing RR et a: ates or. 201336 2997-204, 5. Wing et td Sox Mod. 201071561656. Engel SG eal Obos Res 2000.1.1207 1218
Int Mad 2009:469 619-1620 9, Després J ea. BM. 2001322710720.
‘Obes Rele Dis 202117.139-148 ie
ER Se Hoo, 202136854951 PeerView.com

Promrat K et al. Hopatoogy. 2010.51:121-129. 8. Foster GD at al. A
10. Pétré B at al, Prov Med Rop, 2018;12:12-19. 11. van Riswik AS at
12. Conceigäo EM ot al. Surg Obes Rola Dis. 2020.16:992:99. 13.

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Lifestyle Modi

ations Have Modest Effects on Weight’

Outcomes From Four Different Real-World Implementations of the NDPP

Weight Loss From Baseline 5% or More Weight Loss at

Baseline 6 months 12 months 1 Year
9 71
2
45
36 38 40
x4
É
pe
5
-8 | —+-CDE-ed cinic-based program (n =277) & # Eee >
10 | 7 Pesrtes community program (n= 45) Sá PS ESAS
7 —»—Nonprofitfitness-focused program (n = 206) S $ & eg
„12 | —*-Oniine personal health coach (n= 248) ES E
NDPP offered a no out-of-pocket cost 1 employees, dependents and ross aged 18 or older with prediabetos and overweight or obesity who were enrolled ina
‘nworty-based sounded heath insranco plan, a
iman WA eal Dates Res Cin Proc 202320511083, PeerView.com
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Weight Loss Responses to Bariatric Surgery Vary!

RYGBP SG
10

Patient Per Surgical Group, %
a

0
0 10 20 30 40 50 60 O 10 20 30 40 50 60

Maximal Weight Loss, %
1. Manning S tl. Surg Endose. 2015:29:1484-1491, PeerView.com

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Bariatric Surgery Has Durable Effects for Obesity’

Swedish Obesity Study
+ N=4,047

+ Nonrandomized
prospective study

+ Surgical group

= n=2,010

— 68.1% VBG

— 18.7% banding

— 13.2% gastric bypass
+ Controls (usual care)

- n=2,037
A

1-SJostróm Let al. JAMA, 2012:307:56-6.

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Weight Change, %

Control
s
10
a Banding
Pr VBG
= GBP
36

01234 6 68 © 5 20

Follow-Up Time, y

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When and Why Anti-Obesity Medications
Are a Good Option’

Complication Status Anti-Obesity Medication

No obesity-related complications (ORC) eas pee oie MEUS

21 mild to moderate ORC Consider—if BMI 227 kg/m?

21 severe ORC Add—if BMI 227 kg/m?

+ Helps to better manage ORCs
+ Reduces the risk of developing further complications

+ Improves overall health and QOL

American Assocation of Clinical Endocrinologists (AACE) recommendations indicate BMI 227 koi.

‘Garvey WT et al. Endocr Pact. 2016.22 842-884, 2. Apovian CM et a. J Cin Endocrinol Metab, 2015:100-342-362. 3. Jonson MD et al. Obesity
£2014:22(cupp12)SS1-S410. 4, Tondt Jet a. Obesty Aloritm Sides, presented by the Obesty Medicine Associaton 2023. www obosiyalgorthm org. BearvView.
5. tips. accessdata Ida goviscripsicdeidal 6, Mechanik Jet a. Obesity. 2020,28:1-58 7. hipsobesitymedicne. 'eerView.com

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Suggested Obesity Treatment Algorithm"

À Glan Ret a Front Phamocat202'1390816-5 hp: acta Gore ann 6 Osaka À tal Lancet Oates Exc. 2022 10:298-408 PeerView.com

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The Science of Obesity Treatment and AOMs
Has Evolved Over Time’

Initial bias against pharmacotherapy AOMs: past, current, and future

to treat other metabolic diseases

=
/ Earlier Days +f Today Many Past AOMs ‘Current & Future AOMs
+ Skepticismibias against + Medications to treat DM, Did not meet + Highly effective and meet
the use of medications to HTN, and dyslipidemia patient/linician. patient/cinician
treat T2DM, HTN, and are adjuncts to lifestyle ‘expectations for degree ‘expectations for weight
dyslipidemia ‘modification of weight reduction reduction and improved
+ Considered + Considered effective, Were not safe nor well- ea
consequences of poor represent standards of tolerated + Safe and well-tolerated
lifestyle choices a may a ea! as Did not improve CV + Improve CV outcomes
pe for quelly <i care) ‘outcomes + Reduce risk of cancer or
Did not decrease improve cancer outcomes
mortality + Improvement in
sleep apnea
+ Improvement
arthritis/mobility
a + Decrease mortality
1. Bays HE etal. Obesty Pilrs. 2022:2:100018, PeerView.com

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Setting Realistic Weight Management Goals and Developing Long-Term
Plans Requires Evaluation of Distress and Treatment Expectations’?

measurable targets for the

amount and speed of
weight loss is a key factor
in successful weight
management

Common mental
health disorders

Obesity

Psychological factors.

Distress affects motivation
to initiate and maintain
behavioral changes

Repeated, unsuccessful

Social factors

weight loss attempts eg, stigma, reduced support
can lead to guilt,
hopelessness, and Behavioral factors
increasing distress eg. diet, exercise, adherence
1. Haynes A et al. Obes Rev. 2018:19:347-363, 2. Poly. Int J Obes. 2001:25(supp! 1) 580-584 3. Valk M. nt J Cin Pract. 2016:70:196-205. PeerView.com

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Safety Considerations Vary Among Oral AOMs
Approved for Long-Term Weight Management!.2.2

Agent Common AEs Contraindications Safety Considerations

Oily spotting, flatus with discharge,

Orlistat fecal urgency, fatty/oily stool, Chronic malabsorption, ee ae

360 mg oily evacuation, increased | galliadder disease, pregnancy — ¿300% of colono) malva edlainttation
defecation, fecal incontinence 5

oo o | Teratogenicity (obtain pregnancy tests),

Topiramate er Paresihesia, dizziness, dysgeusia, Glaucoma, hyperthyroidism, increases HR, suicida, moodisleep disorders,

gie insomnia, constipation, dry mouth MAOI use, pregnancy cognitive impairment, elevated Cr, metabolic

acidosis, acute myopia and glaucoma, REMS

Seizure disorder, anorexia nervosa

Naltrexone SR/ — Nausea, constipation, headache, or bulimia, abrupt alcohol Suicidality, mood changes, increased BP,

bupropion SR vomiting, dizziness, insomnia, discontinuation, antiepileptic drugs, increased HR, glaucoma, hepatotoxi

32/360 mg dry mouth, diarrhea uncontrolled hypertension, discontinue use if pregnancy is recognized
chronic opioid use, MAO! use

* Masur a day doses show, :
1 hte Mm acosedata agosto PeerView.com

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Safety Considerations Vary Among Injectable AOMs Approved
and Emerging for Long-Term Weight Management!»

Agent Common AEs
Nausea, diarrhea, constipation,
vomiting, ISR, headache,
Uraglutide hypoglycemia, increased lipase,
3.0 mg
upper abdominal pain,
pyrexia, gastroenteritis
Nausea, diarrhea, vomiting,
constipation, abdominal pain,
Semaglutide headache, fatigue, dyspepsia,
2.4mg dizziness, abdominal distension,
eructalion, hypoglycemia,
flatulence, gastroenteritis, GERD
Nausea, diarthea, decreased
ae appetite, vomiting, constipation,

dyspepsia, abdominal pain

Maximum total daily doses shown,
1 tps vin accossdata da govisrpslederdal,

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Contr

ations

Personal/family
history of medullary
thyroid carcinoma or

MEN2, pregnancy

Personal/family
history of medullary
thyroid carcinoma
or MEN2

Personal/family
history of medullary
thyroid carcinoma
or MEN2

Safety Considerations

Thyroid C-cell tumors (rodents), acute pancreatitis,
acute gallbladder disease, hypoglycemia,
increased HR, renal impairment, suicidality

Thyroid C-cell tumors (rodents), acute pancreatitis;
acute gallbladder disease, hypoglycemia,
tachycardia, acute kidney injury, suicidality; monitor
retinopathy and HR; discontinue use if pregnancy is
recognized and discontinue use in women and men
at least 2 months before a planned pregnancy

Thyroid C-cell tumors (rodents); pancreatitis;
hypoglycemia; acute kidney injury; severe Gl
disease; diabetic retinopathy; acute gallbladder
disease; may cause fetal harm; patients using
oral contraceptives should switch to non-oral
contraceptive method or use a barrier method for
4 weeks after initiation and each dose increase

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Obesity and OSA: Mechanisms of Disease’

Cardiovascular and 4—— visceral fat
metabolic comorbidities

Fatinfitration
in the neck

ho ‘Abnormal upper airway Increased leptin
— secretion

neuromechanical control

4. Lévy P at a. Nat Rev Dis Primes. 20151-15015. PeerView.com

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How Does Weight Loss Affect OSA?
Evidence From Clinical Trials

MIMOSA! A
6-month RCT Weight Loss vs AHI Dose-Response’
180 ‘tb
Adults with moderate-to-severe OSA
and overweight or obesity m
3 interventions so 3
- Standard care H H
- Mediterranean diet we ee!
— Mediterranean lifestyle o +
8»
Separately, a meta-analysis of 10 RCTs | = +
calculated the following rates for
changes in AHI using various lifestyle E pe
interventions lasting up to 1 year?* 400
+ -8.61 events/h, diet alone am
+ -8.08 events/h, exercise alone -30 A 15
+ -8.15 events/h, diet + exercise Weight Change, %
Fe cla eee oe go aan PeerViewscom

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An Overview of Recommended Treatments
for OSA and/or Obesity

OSA Treatments! Treatments for Both Obesity Treatments’

Behavioral therapy to
improve sleep patterns and
positional therapy

+ CPAP Behavioral therapy
BPAP + Pharmacotherapy
Oral appliances ne

— Mandibul devices EL

ER es

= Phentermine/Topiramate
= Semaglutide 2.4 mg

+ Liraglutide 3.024
+ Tirzepatide?a
Bariatric procedures*

Nutritional intervention
Physical activity

+ OS is not an FDA-approved indication for this medication.

4. Pennings N etal. Obesty Piers. 2022.4:100043. 2. Backman A et a. In J Obes. 2016:40:1310-1319. 3. htps:/wwn.pmewswire.comnows-rloasosttrzepatde-

‘educa deep apes eve. up many hd id tc sep apna ost and aber 302118929 Hi 4 Kennedy Day At a Eur ht

‘Med. 201426.922.925 5. Jebb SA etal. Lancet. 2011;378: 1485-1492. 6. Tondt J etal Obesty Alorihm Sides, resented by the Obesty Medi ia
‘Associaton wi. obesiyalgorthm or, 2023. hipe./obesiymedeine rg)obosty-algarihm-powerponu. 7. Bayes HE era. OBosiy Pars 20222 100018. PeerView.com

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Tirzepatide Improved OSA Symptoms In Moderate-to-Severe
OSA + Obesity: SURMOUNT-OSA!

Change in AHI Change in Weight
mTirzepatide mPlacebo mTirzepatide Placebo
0 0
= oe 43 =
2 48 = 24 23
E -10 =z
= 3 0
= 45 3 -
E E
= 20 8 15
2 25 5
5
8 6 20 184
o -30 -27.4 abd 204
= 55% || 5% -63% || -6% Beary] 25
A —= —— ——
Study 1 Study 2 Study 1 Study 2
(no PAP) (PAP) (no PAP) (PAP)
1. Malhotra A et al. N Engl J Mod. 2024 Jun 21. [Epub ahead o print PeerView.com

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Tirzepatide Improved Fibrosis in MASH:
Topline Results From SYNERGY-NASH12

MASH Resolution Without 21-Stage Improvement in Fibrosis
8 Worsening Fibrosis Without Worsening MASH
g
380
& 60 51 su 549 mTZP 15 mg
5
En ne = TZP 10 mg
2 = TZP.5mg
$ 20 Placebo
£
20
Weight change—No T2DM Weight change—With T2DM
E
a 413
E
3
5 11.4
2 12 MM.
E 13.7
S 20 18.4 -20
1. Voppalne Rata Ament Phamaco! Ter. 2024 May 20 [pub ahead of pi 2 Loomba Real Ent J Med 2024 Ju 8 [Epub ahead of pet PeerView.com

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Obesity Affects a Substantial
Proportion of Patients With HFpEF!

Total HF Hospitalizations and CV Death Total HF Hospitalizations and CV Death

‘According to BMI ‘According to Waist-to-Height Ratio
qe 2”
uE io Poverall=.009 A Poverall=001
(N = 4,796), greater 33 FE
abdominal adiposity ie mn ie
(as assessed by 4 E
WHR) was associated » 5 oa 5 06 07 08 09
with a higher risk of HF ane mo oem nee
TEA «Cause Death
Le and CV ase + According to Waist-to-Height Ratio
leath, with no g e
‚evidence for an at É 4
E A
És 3%:
A Ponte 58

04 0506 a7 oa de
Waistto-Height Ratio

1.Pokert A to. ACC 24. Abstract 1086-08. PeerView.com

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STEP-HFpEF Trial Design: Effect of Semaglutide 2.4 Mg SC
Weekly in Persons With Obesity and HFpEF'!

PA —$ 26 treatment, plus:
1.7 mg

Semaglutide 2.4 mg SC once weekly

‘Adults 218 years,
BMI 230 kg/m?

EF 245 and HFpEF
Excluded T2DM
N= 529

Week 0 Week 16 Week 52 Week 57
Randomization End of dose escalation End of treatment
Dual primary endpoints Confirmatory secondary endpoints
‘Change from baseline in + 6-min walk distance
+ KCCQ-Clinical Summary Score + Hierarchical composite (win ratio)
+ Body weight + Change in hs-CRP
1.Kosiborod MN etal. N Engl Y Med. 2023:389:1069-1084 PeerView.com

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Fast Facts About the STEP-HFpEF Trial!

Participants Had Obesity Baseline Treatment
and HFpEF Diagnoses and HF History

N=529 80.7% used diuretics
56.1% female; 69 years old (mean)
80.2% used ACEI, ARB, or ARNI
Median EMI 37 6.8% 81.9% had HTN
66% had Hispanic/Latinx 52% had AF 79% used $ blockers
BMI 235 4% Black | |18.5% had CAD!
34.8% used MRA
; Median LVEF
Median NT- | | Median CRP 57% 15.3% had HF hospitalization within 1 year
4508 pg/mL 3.8 mg/L NYHA Class Il
CES 3.6% used SGLT2i

Median KCCQ-CSS: 58.9 points

1. Kosborod MN ot al. N Engl J Med. 2023:389:1089-1084. PeerView.com

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STEP HFpEF: Change From Baseline to Week 52
in Body Weight!

‘Overall Mean Baseline

Body Weight, kg
zs 0
E
É
fe ®
E
<> -10
38 15 m.133% I
E a
-20 ES A A RS vum ı Y Y rh
0 4 8 121620 28 36 44 52 52
Time Since Randomization, wk
EN
E see: on 16 me a

The data at wook 52 are the estimated mean changes from baseline to week 52 based on analysis of covariance (ANCOVA) and an imputation

‘approach for mig ata, 6
1. Kosiborod MN ot al. N Engl J Med. 2023:380:1069-1084. PeerView.com

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STEP-HFpEF: Change From Baseline to Week 52
in KCCQ-CSS'

18 3 Semgutée 24m y | 2 166 pois —

ETD: 7.8 points
P= .0000006

1 87 points J

13

Mean Change
in KCCQ-CSS, points
œ

-2

0 20 36 52 52
Time Since Randomization, wk
Participants.

Sema 24 mg 263 249 225 243 263
Placebo 266 242 217 237 266

Tin dat nk 52 ra estate mon hanes tom usina o wack 2 based on andy of covariance ANCOVA) ná an pura

‘approach forma ñ
1 Kosten al N Eng J Med, 202,88 1060-1084 PeerView.com

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STEP-HFpEF: Change From Baseline to Week 52
in 6-Minute Walk Distance’

28 4 | omimeneneie yop
24 JE Semaglutido 2.4 mg
2 E 20 la 5 meters. ——
52 16
ge ETD 20.3 meters
og 12 P<.001
5 8
33 à
=
E
7 0 Le meters ——
-4 +
0 20 52 5>
Time Since Randomization, wk
Participants
Sema24mg 263 245 240 263
Placebo 266 22 225 266

+ Tho data at wook 52 ar Io estimated mean changes rom baseline to week 52 based on analysis o covariance (ANCOVA) and an imputation
‘proach for maxing ata, 7
1. Kosiborod MN et al. N Engl J Med. 2023:389: 1069-1084, PeerView.com

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STEP-HFpEF DM: Effect of Semaglutide 2.4 mg SC Weekly
in People With T2DM, Obesity, and HFpEF!

STEP-HFpEF DM Trial Design

00 treatment, plus:
17m9

Semaglutide 2.4 mg SC once weekly

‘Adults 218 years,
BMI 230 kg/m?
T2DM
EF 245 and HFpEF
N=616

Weeko Week 16 Week 52 Week 57
Randomization End of dose escalation End of treatment

Dual primary endpoints Confirmatory secondary endpoints

‘Change from baseline in + 6-min walk distance

+ KCCQ-Css + Hierarchical composite (win ratio)

+ Body weight + Change in hs-CRP

1. Kostorod MN et al. JACC Heart Foi, 2023:11:1000-1010. PeerView.com

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Fast Facts About the STEP-HFpEF DM Trial!

STEP-HFpEF DM Participants Had Baseline Treatment
Obesity-Related HFpEF and T2DM and HF History

N=616 80% used diuretics
44% female; 69 years old (mean)
80% used ACEI, ARB, or ARNI
à 82% had HTN
Median BMI 37 i

64% had ae = 37% had AF 83% used ß blockers

BMI 235 Ber 25% had CAD
34% used MRA
a Median LVEF
Mm, N Median CRP 57% 16% had HF hospitalization within 1 year
418 pg/mL 3.7 mg/L NYHA Class Il
te 35% used SGLT2i
Median KCCQ-CSS: 60.4 points
1. Kosiborod MN et al. N Engl J Mod. 2024:390:1394-1407. PeerView.com

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STEP-HFpEF DM: Semaglutide Effectively Targets
Obesity-Related HFpEF in People With T2DM'

Change in KCCQ-CSS

a2 éco | At 1 year, semaglutide led to larger reductions
3 in dual primary endpoints in patients with
FI obesity-related HFPEF and T2DM
a
á ESS era)
E N Change in Bodyweight
$ o
$ 5 À 534) caine stron,
£ porras vom
3 Corne)
oot Partant é pa
ape 310 2 m mm A hos
Pato x m mm m x PR
4
Semaglutide reduced A1C, despite well- 3
controlled glycemia at baseline, without an
increase in clinically significant hypoglycemia cir» m » à Re
rs Time Since Randomization, wk
Somoza 010 907 97 200200 282 m m m M m
1. Kosiborod MN et a. N Engl J Med. 2024:390:1394-1407. Placebo 906 200 298 287 292 289 2%? am zum zu © Peer View.com

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Prior MI, stroke,

SELECT Trial: Effects of Semaglutide 2.4 mg
Weekly on CV Outcomes’

Age 245 years
BMI 227 kg/m?

Semaglutide 2.4 mg once weekly + SoC
AIC <6.5%

or PAD Placebo + SoC

N = 17,604

Event n; 1,225 MACE
| (Estimated follow up 59 months)

Randomization (1:1)

Primary outcome
Time to first occurrence of CV death/Ml/stroke

1. Lincoll AM eta. N Engl J Med. 2023:389.2221-2232. PeerView.com

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Fast Facts About the SELECT Trial‘

Participants were at high or very high .. and had high rates
cardiovascular risk ... of CV medication use

91% antihypertensive medication

89.8% LDL-C-lowering medication

N=17,605
72.5% male; 61.1 years old (mean)
scion 81.7% had 76% had a
: hypertension prior MI
11% had BMI 240
Mean 24.3% had HF | | 10.8% had
1c 5.8% || (NYHALII|) GER
-co%winarc | | 128% HFper | | <60 mL/min/
5.7%-5.4% 7.6% HFIEF 1.73 m

85.9% platelet inhibitors

33.3% diuretics

19.8% anti-anginal medications

12.6% antithrombotic medications

[3.3% antiarthythmic agents

Baseline BP: 131/79 mmHg, TC: 153 mg/dL, LDL-C: 78 mg/dL, HDL-C: 44 mg/dL, TG: 135 mg/dL

4. Ryan DH eta. Cardiovasc Endocrinol Metab. 2023:12:1-5. 2. Lingvay | etal. Obesity (Sivor Spring). 2023:31:111-122.

3 Lincotf AM et al. N Engl J Med. 2023.380:2221.2232.

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SELECT Trial: CV Death, Nonfatal MI, or Nonfatal Stroke’

Primary Cardiovascular Composite Outcome

3

HR 0.80 (95% Cl, 0.72 to 0.90) Placebo
Ps.001 701 events (8.0%)

Ry Semaglutide
8 569 events (6.5%)
5
206
3
£
24
3
3
E2
3
ö

0

0 6 12 18 24 30 36 42 48
Time Since Randomization, mo
1: Lincoff AM et a. N Engl Mod. 2023:380:2221-2292. PeerView.com

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SELECT Trial: CV Death or Hospitalization
or Urgent Visit for Heart Failure!

Second Confirmatory Secondary Outcome

6 + HR 0.82 (95% Cl, 0.71 to 0.96)

Placebo
361 events (4.1%)

Semaglutide
300 events (3.4%)

Cumulative Incidence, %

0 6 12 18 24 30 36 42 48

Time Since Randomization, mo
1: Lincoff AM et a. N Engl J Mod. 2023;380:2221-2292. PeerView.com

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Special Populations

Can AOMs Be Used in PwO and Depression?

+ Obesity and mood disorders can frequently co-occur and
have a bidirectional relationship, especially in women!

+ Obesity and psychiatric diseases share pathogenic pathways
(endocrine, immune, and nervous systems; HPA)!

CCS SC . AOMs may reduce weight, depression, anxiety, and stress, as
well as improve adiposopathic-related metabolic diseases and
eating behavior?
- A 52-week observational study of liraglutide, phentermine/
topiramate, naltrexone/bupropion, and their components in PwO

with psychiatric illness and a recent MI found no deterioration of
mental health for any treatment except topiramate

+ It is prudent to monitor PwO using AOMs for changes
in mood?

1. Christensen SM et al. Obesity Pilars. 2022:4:100041. 2. Tham M etal. Obes Res Cin Prac. 2021:15:49-5. PeerView.com

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Menopause and Obesity’

Early Perimenopause Late Perimenopause tmenopause
Hormones
Hormones Hormones 7
+ DE, (lat LE: (or 2 years after FMP, then stabilizes)
a o LEA 1 FSH (for 2 years after FMP, then
stabilizes)
Body Composition
CVD Risk Factors Body Composition 1 Fat mass (abdominal fat for 2 years after

+ 1 C-IMT and vascular remodeling
+ | Endothelial function (FMD)

1 Fat mass (abdominal fat)
| Fat-free (lean) mass

FMP, then stabilizes)
| Fat-free (lean) mass (for 2 years after
FMP, then stabilizes)

‘Note: Few studies of women in early
‘perimenopause have been conducted
because of the inherent difficulty in
‘categorizing women in this earlier stage;
as a result, the cardiometabolic changes
that occur during early perimenopause
have yet to be fully elucidated

Energy Intake and Expenditure
| 24-h, sleep and physical activity EE (?),
resting EE, fat oxidation, and energy intake

Energy Intake and Expenditure
| 24-h, sleep and physical activity EE,
fat oxidation (remains low into
postmenopausal years)

Cardiovascular Risk Factors
1 Dyslipidemia (mostly within 1 year of
FMP), C-IMT, aortic PWV, vascular
remodeling, insulin resistance, sleep
disturbances

| Endothelial function (FMD) and
cardiac health

Cardiovascular Risk Factors
1 Dyslipidemia (mostly within 1 year of
FMP), insulin resistance and glucose
intolerance (associated with abdominal fat
accumulation), sleep disturbances

1. Marat KL tal, Obosiy (Sivor Spring). 2022:30:14-27.

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Discussing Priorities in the Context
of Competing Goals of Care

Pregnancy Goal

¡OM recommends patients with obesity
gain 11 Ib to 20 Ib during pregnancy?

A

e ~ All AOMs have
— contraindications

and/or warnings
with respect to
pregnancy?5

Weight Loss Goal
Weight loss or inadequate weight gain
during pregnancy increases the risk
of SGA infants by -50%2

AGO, Obeso Gynecol 2013121210212 2 Chen Wal Int Ender! 2023:2023 048171. Mes acon i octet
À: toa Jr myponty com/stoasstlcomponontaipateacg, hep. lentypryeicancl. march. 2021 pdt: Greenmay FL at al Obesity (iver Song) ñ
201927205216. PeerView.com

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Workshop Time!
Baseline Survey

2 Think about your answers to these questions. Overall,
what gaps do you perceive with regard to ...

Please complete the
Baseline Survey

... your skills to
care for people

with obesity?

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Completing the
Self-Reflection

Worksheet

Workshop Time!
Self-Reflection Worksheet

2. Think about your answers to these questions ...

Please complete the
Self-Reflection

MORE What are the biggest

challenges to
offering respectful,

evidence-based
obesity management
in our area?

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Completing the Self-Reflection Worksheet

Obesity Set Reflection Worksheet (page 1.012)

What will help me remember to look beyond
RE 4 nero a mnomonic at wl hip you and
meeting wih Regents e a your staff remember to look beyond size?
Does your staff treat
EVERYONE respectfully?

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Completing the Self-Reflection Worksheet

Obesity Sef Reflection Worksheet (page 1 of 2)

Do I have waiting room furniture,
examination tables, wheelchairs, gowns,
blood pressure cuffs, and scales that can
accommodate individuals weighing >400 Ib?

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Where can you buy bariatric office
furnishings in your area?

Who can supply gowns and
blood pressure cuffs?

Do you document obesity on
the problem list?
Do you avoid weighing patients
unless medically necessary?

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Completing the Self-Reflection Worksheet

Obesity Sef Reflection Worksheet (page 1.012)

Do you use the 5As approach?
Have you undergone training specifically
in motivational interviewing?
Do I look for opportunities to discuss weight
with patients, with their permission? Do you know where to look for

motivational interviewing courses?

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Completing the Self-Reflection Worksheet

Obesity Set Reflection Worksheet (page 1.012)

Do you ask patients which aspects of their
health are most concerning to them?
Do you know how much weight loss would be
needed to ameliorate their top health
concern(s), if applicable?

Do I discuss weight and weight loss goals in
terms of their effects on overall health?

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Completing the Self-Reflection Worksheet

| Obesity Self Reflection Worksheet (page 2 of 2) | Do you know how much weight patients can
Do I have realistic expectations for weight reasonably be expected to lose, given the
loss interventions? (eg, amount of weightloss, intervention you are recommending?

speed of weight loss, need for ongoing maintenance

Do you know how quickly they'll see results?
How will they know if the intervention is working?

Are they aware that they will need to continue
medications, just as they would for hypertension or
diabetes, to maintain their weight loss?

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Completing the Self-Reflection Worksheet

Obesity Set Reflection Worksheet (page 2 of 2) |

Do you know who should and who definitely should
not use the AOM you're recommending?
Can you explain how the AOM might make patients
feel when they first start taking it (eg, dry mouth,
disinterested in food, dizzy, nauseated)?
What's your plan for keeping up to date with the
rapid developments in AOMs?

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Completing the Self-Reflection Worksheet

Obesity Set Reflection Worksheet (page 2.012)

It takes a team!
What other HCPs offer respectful care to Who can you call on to be a teammate for care
patients with obesity within my practice area? that’s outside your scope of practice?

(eg, obesity specialist, endocrinologist, psychiatrist
dietitian, diabe

‘educator, bariatric surgeon)

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Completing the Self-Reflection Worksheet

Obesity Set Reflection Worksheet (page 2.012)

In addition to HCPs, connecting patients to healthful
activities to support their weight loss efforts is
important to sustaining behavior change.

What options are available in your area?

What obesity management resources are Can you keep a list of resources updated and ready
e to give to your PCP colleagues?

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Breaking Through Biases: Building Skills for Collaborative Weight Management in Primary Care and Treating Obesity as a Chronic Disease

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Breaking Through Biases: Building Skills for Collaborative Weight Management in Primary Care and Treating Obesity as a Chronic Disease

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