Obesity: How Can Practitioners Improve Their Approach to Weight Management?

For patients with obesity or overweight, managing weight loss can present an immense challenge—and despite existing guidelines for clinicians on best practices for helping patients manage their weight loss journey, implementation of these practices remains low.

So, how can healthcare practitioners improve their approach to obesity management in the clinic? According to recent findings, applying a "chronic disease model" to obesity management and incorporating anti-obesity medications, such as the FDA-approved semaglutide and tirzepatide, into the treatment algorithm may represent a step in the right direction.

Weight Management in Practice: The Physician Experience

"Two recommendations emerge consistently across guidelines: (1) obesity should be treated as a chronic disease and (2) obesity should be managed in primary care," Dayna Lee-Baggley, PhD, of the Department of Family Medicine at Dalhousie University in Halifax, Nova Scotia, Canada, and colleagues explained in their study published in Clinical Obesity. "Viewing obesity as a chronic disease rather than a failure of willpower or a lifestyle choice prompts a number of effective and appropriate changes in the clinical management of obesity. Similar to other chronic diseases, such as diabetes and cardiovascular disease, effective obesity management should include a number of medical management tools, including medication, surgery and behavioral interventions to support lifestyle changes. Weight loss medication and surgery are recognized as important treatment components across guidelines and should not be offered only because lifestyle approaches have ’failed’."

Given the prevalence of obesity, primary care is considered an ideal setting for helping patients manage the condition; however, findings suggest that less than 5% of primary care visits are for the purposes of weight management, despite the fact that 70% of the US population is affected by overweight and obesity. And, while behavior change counseling can be effectively delivered in this setting, rates of obesity management in primary care remain low.

In order to better understand how to support implementation of best practices for this patient population, Lee-Baggley and colleagues conducted a survey study to examine the experiences of Canadian physicians working with individuals who had overweight (BMI 25-30 kg/m²) or obesity (BMI >30 kg/m²).

For survey inclusion, participants had to be a practicing primary care, internal medicine, or endocrinology physician in practice for 3 years or more, and had to have discussed weight loss with at least one patient in their practice over the preceding month. The survey included questions designed to collect "demographic characteristics about the HCPs and their patients, HCP views on definitions of overweight and obesity, their impressions about the importance of weight loss and the methods used to achieve weight loss, as well as the challenges of helping patients manage their weight."

Online surveys were conducted from Jan. 23-Feb. 12, 2019. A total of 192 physicians responded, including 140 primary care specialists, 30 endocrinologists, and 22 internists. Most were men (68.2%) with over 20 years experience (59.5%), and nearly half were located in Ontario (49.5%).

Among the findings:

• The proportion of patients with whom physicians discussed weight loss were 14% for primary care, 39% for endocrinologists, and 27% for internists. Physicians also reported the specific topics they discussed with regard to weight loss and these were specific to each specialty: "The top three responses for each specialty were: exercise/physical activity, dieting/nutritional changes, and referrals to a dietitian. The most notable difference between the groups was the proportion of conversations that included a discussion of weight loss medications (12% for primary care physicians and internists; 40% for endocrinologists)."
• Primary care physicians estimated that 35% of their patients had obesity and that 29% had overweight; the corresponding estimates for endocrinologists were 49% and 26%, respectively; for internists, the estimates were 43% and 31%.
• Each physician group reported similar challenges associated with helping patients lose weight, namely that "patients do not comply with weight management advice" (89%), "lack of time" (63%), and a lack of resources to address the problem (53%). When asked to report their own challenges, physicians cited compliance (19%), lack of patient motivation (19%), and changing habits/behaviors (18%) most commonly.
• The majority of respondents reported considering obesity a chronic condition, "but most did not incorporate a multi-dimensional, chronic disease model of obesity treatment (ie, combination of lifestyle interventions with psychological, medical, and/or surgical interventions)," they added. "Endocrinologists reported management practices consistent with a chronic disease model more frequently than primary care physicians."

Lee-Baggley et al noted that several studies show that the majority of clinicians recognize that obesity is a disease, and that practitioners should participate in patients’ weight management.

However, "results from the present study show that physicians report ’lack of willpower’, ’compliance’, ’lack of patient motivation’, ’difficulty changing behaviors’ and ’patients not complying with weight management advice’ as key challenges in weight management," they wrote. "Thus, although physicians agree that obesity is a chronic condition, their beliefs on the causes and factors contributing to weight primarily focus on individual choice and neglect additional elements that influence weight, such as genetic and environmental factors. These responses suggest that physicians view lifestyle recommendations as an intervention in and of themselves, whereas best practices highlight the need to support lifestyle changes with medical interventions, including medication, surgery, behavioral interventions or their combination."

The study authors highlighted that endocrinologists were most likely to report endorsing treatments more in line with a view of obesity as a chronic condition. For example, endocrinologists ranked medical interventions—surgery, prescription medications, and psychological interventions—as the most effective interventions for weight management in this population, rather than lifestyle changes, and they were more likely to discuss weight loss medications with their patients compared to primary care physicians (40% versus 12%).

"In addition, endocrinologists appear to be more likely to engage in early intervention," they added. "For example, they reported placing higher importance on weight loss for every BMI class, whereas general practitioners and internists reported primarily targeting patients in higher BMI classes."

This may reflect the AACE/ACE guidelines, which adopt the chronic disease model for weight loss management, which states that medication and lifestyle interventions can be initiated concurrently and do not require the patient to ’fail’ lifestyle changes before medication can be prescribed."

To help address the perceived challenges in weight management for patients with overweight or obesity, Lee-Baggley and colleagues suggested use of the 5As framework, "a theoretically-based, empirically-supported behavior change counseling model that can be delivered effectively by physicians within their scope of practice. The 5As consist of (1) asking for permission to discuss weight and explore readiness; (2) assessing obesity-related risks and ’root causes’ of obesity; (3) advising on health risks and treatment options; (4) agreeing on health outcomes and behavioral goals and (5) assisting in accessing appropriate resources and providers. Studies have shown that utilizing the 5As framework is associated with a two-fold increase in obesity management in primary care settings and is associated with increased motivation in patients to manage their weight."

Limitations to their study include that participant recruitment was from a pre-existing, opt-in, online panel and therefore, may not be representative of the general physician population in each specialty; that the opt-in nature of the survey limited statistical analysis and extrapolation to larger physician populations; and that the structured interview used for data collection was not a validated questionnaire.

Weight-Loss Medications: Spotlight on Semaglutide and Tirzepatide

In discussing their findings, Lee-Baggley et al highlighted another avenue that may help physicians improve their approach to weight management—namely, recent improvements in obesity medication, which may offer physicians "more ’scalable’ tools to use and thus decrease barriers to initiating discussions about weight. This is also consistent with recommendations that if high-intensity lifestyle interventions are not available, medications may be a useful addition to help patients adhere to lifestyle changes."

Potent incretin-based therapies—specifically glucagon-like peptide-1 receptor agonists (GLP-1 RA)—have been making waves in recent years as a potential treatment option for patients with obesity or patients with overweight and at least one obesity-related comorbidity who have not managed to achieve sustained weight loss through the power of lifestyle interventions alone.

And, according to findings from a systematic review and meta-analysis by Signe Sørensen Torekov, PhD, of the University of Copenhagen in Copenhagen, Denmark, and colleagues, once-weekly subcutaneous injections of the GLP-1 RA semaglutide (2.4 mg) as well as the dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) RA tirzepatide (10 mg or 15 mg) have demonstrated "substantial and clinically relevant reductions in body weight and waist circumference" among patients with obesity without diabetes.

They reported their findings in Obesity Reviews.

For their analysis, Torekov and colleagues evaluated the safety and efficacy of semaglutide and tirzepatide—in the doses approved for obesity—for reducing body weight and waist circumference in patients with overweight or obesity without diabetes who were treated for at least 1 year. Their analysis included a total of seven phase III, randomized controlled studies; of these, five focused on semaglutide 2.4 mg once-weekly for 68 weeks (STEP 1, STEP 3, STEP 8, and STEP TEENS) or 104 weeks (STEP 5), and two investigated tirzepatide 5 mg, 10 mg, or 15 mg once weekly for 72 weeks (SURMOUNT-1 and SURMOUNT-3). All studies mentioned lifestyle interventions in combination with active treatments and placebo; in all studies, the lifestyle component consisted of individual nutritional and physical activity counseling.

Torekov and colleagues found that all included studies demonstrated significant changes in body weight and waist circumference in the intervention groups compared to placebo at follow-up (P<0.00001).

Among the findings:

• For change in body weight percent: "[T]he pooled estimate of the mean difference in body weight in the five STEP trials was -12.9% (95% CI, -14.7 to -11.1; P<0.001) compared with placebo. The SURMOUNT trials showed a mean difference of -19.2% (95% CI, -22.2 to -16.2; P<0.001) in body weight compared with placebo. The total mean difference in body weight for all seven trials was -15.0% (95% CI, -17.8 to -12.2; P<0.001) compared with placebo."
• For change in waist circumference: "[T]he pooled estimate of the mean difference in waist circumference in the five STEP trials was -9.7 cm (95% CI, -10.8 to -8.5; P<0.001) compared with placebo. The SURMOUNT trials showed a mean difference of -14.6 cm (95% CI, –15.8 to –13.4; P<0.001) compared with placebo. The total mean difference in waist circumference for all seven trials was -11.4 cm (95% CI, -13.7 to -9.2; P<0.001) compared with placebo."
• For change in fat mass and lean mass: Two studies, STEP 1 and SURMOUNT 1, used dual-energy X-ray absorptiometry to evaluate changes in fat mass and lean mass in study subpopulations. "In STEP 1, 140 participants were scanned before and after treatment. Reductions in total fat mass were -8.4 kg with semaglutide and -1.4 kg with placebo (mean difference: -7.0 kg; 95% CI, –9.8 to -4.2). Total lean mass was reduced with -5.3 kg with semaglutide and -1.8 kg with placebo (mean difference: –3.4 kg; 95% CI, -4.7 to -2.1)." Meanwhile, in SURMOUNT-1, "[t]otal fat mass was reduced by -33.9% with pooled tirzepatide (5 mg, 10 mg, and 15 mg) and -8.2% with placebo (mean difference: -25.7%; 95% CI, -31.4 to -20.0). Total lean mass was reduced by -10.9% for pooled tirzepatide and -2.6% for placebo (mean difference: -8.3%; 95% CI, -10.6 to -6.1)."
• For change in body weight (kg): "[T]he pooled estimate of the mean difference in body weight was -13.0 kg (95% CI, -14.8 to -11.2; P<0.001) compared with placebo in the five STEP trials. Measures of the variance of body weight change in kg were not accessible from the SURMOUNT-1 study and, therefore, not included in the analysis. SURMOUNT-3 showed a mean difference in body weight of -25.0 kg (95% CI, -27.0 to -23.1; P<0.001) compared with placebo. The total mean difference in body weight for all six trials was -15.5 kg (95% CI, -20.2 to -10.8; P<0.001) compared with placebo.

As for safety, in the STEP trials, 91% of semaglutide-treated patients and 88.9% of placebo patients experienced at least one adverse event (AE); the most common of these were gastrointestinal disorders—such as nausea, diarrhea, constipation, and vomiting—which occurred more frequently in patients treated with semaglutide (76% versus 52%). In the SURMOUNT trials, 81.5% of tirzepatide treated patients and 73.5% of placebo patients had at least one AE; as with semaglutide, the most common AEs reported with tirzepatide were gastrointestinal disorders. With both drugs, AEs were described as mild-to-moderate, transient, and primarily occurring during the dose-titration period.

In discussing their findings, Torekov and colleagues pointed out that, per the STEP and SURMOUNT trials, the weight loss seen with semaglutide and tirzepatide "is markedly larger than other approved obesity medications, which have shown treatment effects of –3.07 kg (95% CI, -3.76 to -2.37) with orlistat, -4.39 kg (95% CI, 5.05 to -3.72) with bupropion-naltrexone, and -5.25 kg (95% CI, -6.17 to -4.32) with liraglutide."

Limitations of this review include that only two studies each assessed effects with tirzepatide and changes in fat and lean mass in subpopulations, and that most studies did not include detailed reporting of design and patient adherence to concomitant lifestyle components.

The study by Lee-Baggley et al was funded by Bausch Health Canada.

Lee-Baggley reported personal fees from Tobacco Free Nova Scotia, Bausch Health, Canadian Spondylitis Association, New Harbinger Publications, Novo Nordisk, CPD Network Association, and grants from Kidney Foundation of Canada, QEII Foundation, CIHR, SSHRC.

Torekov reported receiving research grants and lecture fees from Novo Nordisk A/S.

Lee-Baggley D, et al "Improving implementation of best practices in obesity management: Physician experiences in obesity care" Clin Obes 2024; DOI: 10.1111/cob.12624.

Torekov SS, et al "Potent incretin-based therapy for obesity: A systematic review and meta-analysis of the efficacy of semaglutide and tirzepatide on body weight and waist circumference, and safety" Obes Rev 2024; DOI: 10.1111/obr.13717.