Scott Kahan, MD, MPH

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Diana Isaacs, PharmD, BCPS, BC-ADM, CDCES, and Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES, interview Scott Kahan, MD, MPH who serves on the committee that creates the ADA Standards of Care in Diabetes, to discuss the latest updates in weight management guidelines.

Updates in the Standards of Care in Diabetes in 2023 - Obesity and Weight Management

One of the most important things that Dr Kahan talked about was small weight loss goals and larger weight loss goals in our discussions with people with diabetes.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: 

That’s helpful because so often I see people come to me with this all or nothing thinking. Like, “I need to weigh what I weighed in high school. I need to lose 100 lb,” and that, wow, that’s overwhelming to approach it that way. But if you say, let’s aim for a 3%, or a 3% to 5% weight loss, maybe that looks like 15 lb, 10 lb. All of that is meaningful and can improve outcomes.

I agree. The other thing I think is important is his underlying messaging of, it takes a team. You don’t get one thing. He talked about this linear path discussion, but that no person with diabetes is really linear, are they? A patient might come in who has already done some of the work, already tried certain things, and to start them back from the beginning is, again, it’s a blow. It shouldn’t happen. We should be able to meet the patient where they are and say, “OK, here you are along this journey. Let’s start here, let’s work on this next, let’s do it from this point.”

Yes, I think of it as shared decision-making. Laying out what are the different options. Of course, there’s exercise and nutrition changes, and bariatric surgery. There are a lot of medication treatments. It’s shared decision-making; it could look like a circle. I like how he mentioned the art of medicine because often people come and they’re like, “What’s the protocol? What’s the treatment algorithm?” Those do provide great guidance, but at the end of the day, people are individuals and medicine is an art. And so, it is about choice and shared decision-making.

I think that if we practice medicine better in that alone, our outcomes will improve. I do.

Another interesting thing about the standards of care this year is that even though, yes, the 3% to 5% weight loss is great, now they do mention even up to a 10% or 15% weight loss has additional benefits. Now with new therapies, we have new data, for example, from tirzepatide. Even though that’s not FDA approved yet for weight management or obesity, we know, for example, from the SURMOUNT-1 trial, it showed 20% body weight loss. As these therapies are available and emerging, we can in some cases realistically say, yes let’s aim for the 15% weight loss if we can do it.

I agree. We need to go back to our foundation. The patients I’ve had using any GLP-1 [glucagon-like peptide-1 receptor agonist] who have lost the most weight tend to be those patients who are working with other health care professionals. They’re working with a dietitian, maybe an exercise physiologist, they have a support system in place. It’s not only take your weekly injection and expect it all to happen. Occasionally we do see that, don’t get me wrong, but most of the time it is a team approach. They’re seeing a psychologist, there’s a lot to this. Obesity and being overweight is not something that happened yesterday. It’s happened over a long period of time, and patients need to decide what’s important, how they want to do it. And those other health care professionals, as a clinician, help me help the patient achieve what they’re looking for.

That’s a great point. That team-based care is so important because we are fighting against biology. Unfortunately, the body wants to keep its current weight, and to counteract all of that, it takes using all the tools we have in our toolbox, but taking advantage of the team as well as having a clinical psychologist or someone with additional behavioral support. Having the dietitian, the nutrition therapy, having the pharmacist for medication management. All of that leads to better outcomes when you have a team.

Absolutely, right. I 100% believe in that.

Another thing I appreciated was when we asked, how do you approach a person about their weight? Because there’s a stigma, unfortunately, associated with it, and it can be hard. People have seen their team, their primary care provider, or other people on the health care team, and it could be that no one’s mentioned it for 10, 20-plus years. I liked that simple, just ask permission. Just ask permission, and if the person says no, OK. But at least you tried, and you never know. It could be that nobody’s brought it up, so the person didn’t think losing weight was important or should be a priority.

When you and I think about going backward toward diabetes and looking at data or talking to a patient about blood sugar management, it’s the same thing. We ask permission before we start talking about their blood sugar management. “Can we talk to you about some of your challenges?” That is something we have taught other educators, other clinicians, other providers. We now need to take that another step, and say it’s time to talk about weight. It should be addressed at every visit, and if the patient says “No,” then we respect that and say, “OK, I’ll write it in the note that you’ve chosen not to talk about it today. But we can address it in the future when you’re ready.”

Right, and another thing interesting this year about the ADA [American Diabetes Association] standards of care, is that social determinants of health have continued to be more incorporated into all the sections, including obesity and weight management. It is important to address these underlying social determinants of health. Like Dr Kahan mentioned, some people live in food deserts. They live in places where they can’t get fresh fruits and vegetables. I’ve experienced driving, you go to certain places, and they only have regular soda. There’s not even a diet or a low sugar option. So what can we do to ensure better access to healthy foods, to being able to exercise and get physical activity? Some people live in neighborhoods where it is dangerous to be outside. We live in cold climates where it’s freezing in the winter. There are real challenges, and what can we do as a society to better overcome these?

It’s an ongoing challenge, and it’s going person to person who presents in front of us, and how can we help them achieve what they need. I know there was a horrific shooting in Buffalo, New York, this year, a racist shooting at a grocery store. They have stocked refrigerators with free food now in the neighborhoods, with produce, milk, good for you foods that lots of the people who live in those neighborhoods could never afford before, and now it’s free. An answer to a horrific challenge was, we’re going to bring this to them. We all need to stop and look at what can we do to improve the lives of people who don’t have the advantages that others do?

Speaking of that, we asked Dr Kahan also about children. We touched upon that, but we are seeing that obesity is increasing so much now in our children. It begs the question, the causes, certainly social determinants of health can be at play. We know the food is not always the best, there’s more processed food, children may have more limited physical activity these days. It’s definitely a big issue. Any recent developments in children?

There are new guidelines, obesity management guidelines, and as Dr Kahan mentioned, they’re similar to the guidelines for adults. Again, it’s not linear. We have to find—it’s the family too. It’s not the child, it’s the family that we need to treat, and where is this family? What can we do to help, how do we address it because you can’t treat a child with obesity and not treat the family. It’s not going to work. There’s a lot of work to be done in that. I do know that semaglutide was recently approved, a once weekly GLP-1. Before that we had liraglutide, which is a daily GLP-1. You and I are both parents. I can’t imagine giving an injection to a child every day on top of the rest of the things we have to do. Obviously families with type 1 diabetes do it all the time, but again, it’s another thing, it’s another part of the burden. That will make things easier, but it’s not the panacea, just like it isn’t for the adults. We need to balance it with the support of social work, psychology, dietitians, exercise physiologists to help these children.

It’s good the American Academy of Pediatrics did develop a guideline, even though it is similar to what we see in adults. Hopefully it will get more on the radar in pediatrics so we can address it, and hopefully we can also follow Dr Kahan’s advice in pediatrics about asking the child, asking the family for permission to be able to discuss this.

Thank you so much for the very rich and informative discussion, and thanks to our audience for tuning in. If you enjoyed the content please subscribe to our e-newsletter to receive upcoming 

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Drs Diana Isaacs and Natalie Bellini highlight the need for engaging patients in shared decision-making and addressing social determinants of health in diabetes and obesity management in adults and pediatric patients.

Shared Decision-Making to Improve Long-Term Outcomes in Diabetes and Obesity

I appreciate that because everyone wants an algorithm, and there are algorithms, but so much of it is an art in taking in the individual patient characteristics. It’s been exciting with pharmacotherapy in terms of more agents getting approval and showing benefits in weight loss. There has been this Hollywood explosion about certain drugs and GLP-1 [glucagon-like peptide-1] receptor agonists. I’m curious to hear your perspective about what’s happening in Hollywood and the increased use of these agents.

It’s been upsetting to me, what I’ve seen over the last 6 to 12 months regarding some of the newer medications, and most of what I’m reading, either in traditional media and certainly in social media, I think is bunk. On the one hand, people are saying that we finally have these magic medications. First, we’ve had really good medications for at least a decade. They’re often underused, but they’re very good. And some of the newer ones may even be better, but now we have a number of medications between the ones that have been on the market for a bit and the newer ones. Second, these aren’t miracle pills. These aren’t miracle medications. In some cases, they have miraculous outcomes for some patients. In other cases, they don’t work all that well for other patients. On average, they’re good, but they aren’t miracles unfortunately. Other talk is about how they’re terrible medications, and everybody gets horrible adverse effects, and everybody regains their weight. And that’s not true either. You can get adverse effects, but most people don’t. And you can regain your weight, but used appropriately and with good ongoing support and a long-term plan, most people don’t regain their weight. We could go on and on with this. Certainly the idea of Hollywood people or anyone who doesn’t have obesity, who isn’t a clinical candidate for the medications, to be using it, whether to look good for a movie role or to lose 5 lb for the prom, or to put on their bathing suit on the beach, that’s inappropriate. These are serious medications that are needed for people who have serious diseases. They’re not things to be used lightly. You can see I’m a bit heated about what’s been going on of late.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES

: I’m glad I asked. It’s great to hear your perspective about it. I think a lot of people find it challenging when you have someone in front of you who has obesity or would benefit from weight loss. How do you start that conversation without offending the person? Any tips in that regard?

There’s a really straightforward, quite simple tip that goes a long way here. That is to essentially ask permission before diving into it. Tell the patient that you’ve been working together for some years, and the weight has been increasing and as such their blood sugar, their blood pressure has been increasing. And we know that frequently weight leads to lots of health problems. Offer yourself as a resource, and ask if it’s OK to talk about weight and to work together on the weight in a matter of fact and an empathic way. When you do that, on the one hand, most patients will greatly appreciate it and will be eager to get your help and your support. And for those people who don’t feel comfortable with it, they’ll know when they’re ready that you are someone they can come and talk to because you’ve treated them respectfully and thoughtfully by eliciting their opinion and what they need, rather than going in and telling them they need to lose weight. And lastly, it gives you a quick, easy way of shifting the conversation in that direction. Whereas otherwise it can be easy to fumble around with it. It’s a simple and real, and at the same time a somewhat profound way of starting a conversation.

I love that. When a patient says to you, I’m not ready—you’re different because you’re in obesity as a specialty, they came to you for that fix or that treatment. When a patient says no, a lot of times I’ll say, “You know what? We can address it at your next visit. You’ll let me know when you’re ready.” Sometimes that, just opening the door, and, “Last time we talked about I don’t know, your postprandial blood sugars, or whatever, and weight. Are you ready to talk about those today? What would you like to talk about today?” Continue to bring it up and say, “I’m here for you.” We can’t push them to do it anymore than I can push a patient to take mealtime insulin.

That’s a great key takeaway, ask permission. We also see not only adults, but now a lot of children and adolescents are faced with obesity as well. Any recommendations in terms of what we should do with this population to help them?

Interestingly, I don’t know if it was yesterday or the day before….

Yes, the American Academy of Pediatrics put out their newest guidelines, which largely mirror the adult guidelines, which is to say certainly we need to be careful when using more intensive treatments for obesity, whether metabolic surgery, whether medications, but we should not shy away from those for appropriate adolescents, at minimum adolescents. That’s a big shift. That’s going to take some time for a lot of pediatricians to wrap their heads around, and a lot of parents to wrap their heads around. But that’s where things will likely go. Just as with adults, it doesn’t mean that healthful behaviors are any less important. In fact, the healthful behaviors are at least as important. It’s just that it’s so hard for most of us to do them. And if after trying and trying again, we have not been able to make much of a dent in the obesity and the weight-related health problems, then it’s important to utilize the range of treatments available to us regardless of the patient’s age, as long as it fits within appropriate guidelines.

It’s been exciting to see more drugs being studied in this population and showing benefits as well.

I want to thank you so much. Thanks for talking with us today. I know our listeners will benefit from so much great insight and wisdom. Thank you so much.

Scott Kahan, MD, MPH, discusses with Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, and Natalie Bellini, DNP, FNP-BC, how the controversial use of new diabetes and obesity medications is creating access issues for people who really need these medications, and shares strategies to initiate the conversation about weight management with patients.

Controversial Use of New Diabetes and Obesity Medications and Steps to Initiate Discussion About Weight Management

I’ve had the great privilege to serve on the American Diabetes Association [ADA] Professional Practice Committee with you over the last couple of years, and you’ve been integral to the obesity weight-management section. Tell us about what’s new for 2023 in the Standards of Care, regarding weight management and obesity.

The last few years have been wonderful, serving with you and our other colleagues. Over the last few years, there’s been a nice progression in what we’ve been able to codify in these standards and share with the medical community. One thing we’ve built over the last few years that we’ve stressed, especially this year, is that it’s important to manage obesity as a chronic disease—1 that’s typically progressive and often associated with medical, physical, and psychosocial complications. That helps take clinicians away from thinking about a patient as someone who’s heavy and needs to lose weight to fit into societal norms or into a healthier body mass index or a healthier weight status. Instead, they think about it in a broader way, as a health condition that has a lot of effects on the individual’s life. They work up those health problems and work with the patient to ameliorate them and improve their health and their wellness.

Second, we’ve noted the importance of not only weight loss but also of the maintenance of lost weight. It’s as important to keep the weight off as it is to take the weight off, especially when it comes to preventing diabetes or managing and mitigating diabetes, so we focus on that. One of the biggest tweaks in the guidelines this year has been clarifying the importance of smaller and larger weight losses as being potentially valuable. One thing we’ve known for many years, at least since the publication of the National DPP [Diabetes Prevention Program] studies, is that small weight losses—as little as 2%, 3%, 4%, or 5% weight loss—can go a long way in terms of preventing diabetes and improving health conditions and risk factors. But we also know—we’ve had an explosion of data supporting this—that while small weight losses are often valuable and a bit easier for individuals to wrap their heads around, especially when they have a lot of weight to potentially lose, larger weight losses are more healthful and sometimes a lot more healthful.

We tried to communicate in the standards that clinicians should discuss with their patients the value of smaller and larger weight losses and then support their patients on how to put that into place. For some patients, it’s not going to be realistic to aim for 10% or 15% weight loss. That’s OK because smaller weight losses are extremely valuable. For them, it’s a great goal to start with a lesser weight loss; you can aim higher later perhaps. For other patients, particularly those with diabetes and those with more significant diabetes, it will likely be even more valuable to aim for higher weight losses if that makes sense in the context of the doctor-patient discussion with respect to weight. That was another important point that we tried to make in the standards.

That’s amazing. When some patients present, if you say to them, “I need you to lose 15% of your body weight” and they weigh 350 pounds, then they might leave and they never come back. We’ve done that before in diabetes management. If your A1C [glycated hemoglobin] is 12%, you need it to be 6%, but 10% is much better than 12%. Outcomes improve every time we drop it. I love the idea of saying to a patient, “Let’s start somewhere.” That’s going to improve our messaging to patients and to individuals with diabetes and obesity. It’s a big improvement.

What are the different approaches that the ADA recommends to achieve and maintain weight loss for individuals with obesity?

ADA guidance is analogous to the other published guidelines on obesity management. It doesn’t have to happen in this linear, step-wise fashion, but we often discuss it this way. It starts with healthful behavior and behavioral changes. Adjusting what individuals eat, their physical activity level, and some relatively modest changes in health behaviors can go a long way in terms of improving risk factors, preventing diabetes, and improving quality of life.

However, in many other cases, patients aren’t able to achieve or sustain them, or the behavioral changes may not be enough to see the health benefits. In those cases, we can escalate to more intensive evidence-based and often structured weight-management programs. That can be in primary care settings or in specialty settings. It usually includes a number of different counselors and specialists that patients are working with, such as physicians, registered dieticians, behavioral therapists, and potentially other health care providers. That usually includes regular, intensive interactions between doctors—meaning the whole range of health care providers—and the patient to support them in making more significant behavioral changes.

When that’s insufficient, then we can escalate to FDA-approved medications for weight loss and often ongoing weight maintenance. When that’s insufficient, we can escalate to metabolic surgery. All of these have been shown to be effective on average, and different combinations of these may be more appropriate for different patient groups.

I’ve presented it in a linear, step-wise fashion, but it doesn’t have to happen that way, and it’s not always most strategic for it to happen that way. Sometimes, individuals have done a lot of work on behavioral change and have met with dietitians and other specialists before and worked at it. Even if you’re seeing them the first time, it may be perfectly appropriate to escalate to pharmacotherapy even on day 1. The same thing with bariatric surgery. It may be particularly strategic to utilize multiple strategies in combination rather than 1, and then the next, and then the next. That gets to the art of medicine. It gets to differences from patient to patient, but those are the general categories of obesity treatment.

Dr Scott Kahan shares the latest updates to the 2023 ADA Standards of Care related to weight management and describes the different weight loss approaches recommended by the ADA.

Scott Kahan, MD, MPH

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