Updates in the Standards of Care in Diabetes in 2023 - Obesity and Weight Management - Episode 4

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

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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.

Natalie Bellini, DNP, FNP-BC: 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.

Natalie Bellini, DNP, FNP-BC: 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.”

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

Natalie Bellini, DNP, FNP-BC: I think that if we practice medicine better in that alone, our outcomes will improve. I do.

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

Natalie Bellini, DNP, FNP-BC: 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.

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

Natalie Bellini, DNP, FNP-BC: Absolutely, right. I 100% believe in that.

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

Natalie Bellini, DNP, FNP-BC: 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.”

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

Natalie Bellini, DNP, FNP-BC: 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?

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

Natalie Bellini, DNP, FNP-BC: 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.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: 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 MEDcast episodes and other great content in your inbox. We have many more exciting things in store for you. In future episodes we plan to talk about the ADA standards of care, the treatment algorithm, as well as psychosocial health and outcomes. We’ll also be talking about kidney disease and many other exciting topics. So please stay tuned.

Transcript Edited for Clarity