A Better Way to Help Patients Drop Excess Weight

Matthew F. Watto, MD; Paul N. Williams, MD


September 01, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to the Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Nelson Williams. Tonight, we're going to be talking about obesity medicine. We had a great guest on the Curbsiders podcast, Dr Fatima Cody Stanford, and she taught us so many great pearls about obesity. The first thing I want to highlight, Paul, is that obesity is not the patient's fault. It is not a moral failure. I know you know this.

Paul N. Williams, MD: Yes, but I'm enjoying your lecture.

Watto: Obesity is a disease. One of our expert's big take-home points was that it's a disease that requires chronic treatment. We have just not been treating it like we do with high blood pressure or diabetes. We put those patients on chronic therapies, and we need to do the same for obesity. This is not the patient's fault. We know that there are unfavorable metabolic changes that are working against the patient. It's not just that the patient is not exercising or eating the right things. Many are doing so, but they plateau or start to slowly regain weight. So we really have to think about this differently. What was one of your favorite takeaways from this episode?

Williams: I've actually adopted discarding the term "morbid obesity" in my own practice. Dr Cody Stanford made a great point that we don't say "morbid malignancy" or "morbid hypertension." It's by definition that if you have a disease, there's morbidity with it. So you don't need to double up and label it. You can use the term "severe obesity," which is a more appropriate way to classify it. I'm going through problem lists and discarding "morbid" and replacing the term with class 3 or severe obesity.

In terms of how to actually frame the discussion, something I really liked was Dr Cody Stanford's practice of refusing to name a target weight for her patients. We hear this all the time. Patients ask, "What should my weight be?" She cheerfully ignores the question and tells patients that she's ignoring the question and instead talks about goals as getting to a place where they're healthy and feeling well. We follow the metabolic parameters. Is your blood pressure at goal? Is your A1c improving? Has your sleep apnea improved? Do your knees feel better? We target weight loss to address health, but not with a specific number, because that's not a helpful way of looking at it.

Watto: Osteoarthritis does seem to be more than just wear and tear. There's some metabolic stuff going on there, so maybe their knees will feel better. That was totally game-changing for me in the way that I talk to patients about obesity. I say, "You don't have to look like a Marvel superhero. We want you feeling well, and we want to improve your metabolic parameters." That seems much more doable.

Patients also appreciate when you tell them that this is not your fault. Your body is working against you. We need to give you the tools to do this. Dr Cody Stanford said that merely talking to patients about diet and exercise, after a while, is like using a teaspoon to remove snow from your driveway. Using medications is more like a shovel, and bariatric surgery is like a snowplow.

Weight loss medications provide, if you're lucky, about 10% weight loss. Now, the GLP-1 and GIP/GLP-1 receptor agonists are resulting in 15%-20% weight loss. We talked about how medicines are underutilized and how Dr Cody Stanford uses them. I know the GLP-1 agonists are not available to everyone because of cost. If that's the case, she splits up the other FDA-approved meds, such as phentermine, topiramate, naltrexone, and metformin. She starts with one agent and uptitrates it, adding a second agent based on patient experience. So we have a lot of tools at our disposal between the medications and the metabolic surgeries, and we really need to think about using them, especially for patients who have tried other things and have not had success.

Paul, is there anything else you would like to add in before we say goodbye to our lovely audience?

Williams: I would just emphasize your point that as internists, we should be comfortable with these medications. We talked briefly about phentermine, which many are uneasy with because they are concerned about hypertension and tachycardia. She mentioned that you're much more likely to see high blood pressure with bupropion. You monitor both regardless of which you prescribe first, but statistically bupropion, which many internists have more comfort with, is more likely to cause hypertension. It's just a matter of being comfortable with these medicines — learning how to prescribe them and not being afraid of them because our patients benefit from them.

Watto: Like addiction medicine, managing obesity should become a core skill for internists. We should be comfortable with the medications for diabetes that do double duty for obesity as well. We will become comfortable because of that crossover.

Listen to the full episode at Obesity Medicine FAQ with Dr. Fatima Cody Stanford

and start to prescribe medication and take better care of your patients with obesity.

This has been another episode of The Curbsiders. Until next time, I've been Dr Matthew Franck Watto.

Williams: And I remain Dr Paul Nelson Williams. Thank you and goodbye.

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