We're going to get some questions answered here. Let me pull some of these. What do you do if the patient refuses to be weighed? I'll take that one, Sue Ellen. I think the first thing is we want to recognize the patient has autonomy. We don't want to make patients do something they don't want to do. After all, we're asking them to be weighed, and if they say no, then we need to respect it. But I think the way that I deal with it, however, is I tell them why we want to get their weight, and I really reinforce that it is a biomarker, like I would measure their blood pressure. So if I'm managing you for hypertension, I need to know your blood sugar. If I'm managing for diabetes, I need to know what your blood sugar is. Similarly, weight gives me some idea where you're at regarding either gaining weight, maintaining weight, or so forth. So I try to tell them I do it, and of course, I tell them I'm the only one going to look at it. The last thing I want to mention is you want to know where the scale is located. If it's in a public place, I could understand why they don't want to be weighed, or who's going to weigh it? They're going to yell out the weight in the clinic. So bottom line, you want to respect what they're saying, but actually explain to them the importance of getting their weight. Yes, very important. And go ahead. What I do is perhaps regular weights with their physician, they will be willing to do, but then at home, sometimes they don't want to, they're afraid of that scale, and it brings a lot of emotions. So I start asking, hey, how are your clothes fitting? And we measure progress in a way that is not necessarily related to the scale, but in other areas of their lives. Okay, we have another question that came through. You mentioned for non-GLP-1 weight management medications, a 5% weight loss is considered successful. Would you apply this to somatotude and trizepatide as well? Yeah, that's a good question. So today we were talking about obesity in the context of diabetes. And so when we are using trizepatide or semaglutide or liraglutide, which all can be used for weight or diabetes, for our patient with diabetes, our first priority is going to be glycemic control. And it is harder for patients with type 2 diabetes to lose weight. What we see in the trials for both semaglutide and trizepatide is patients with type 2 diabetes don't usually lose quite as much weight as someone without type 2 diabetes. And some of them don't lose weight. So about 80% of people in those trials will lose weight on the GLP-1s when they have diabetes. But some of the patients with type 2 diabetes will not lose weight, but their glycemic control improves. And so that may be sufficient, and they should continue, say, trizepatide if they have good glycemic control and are tolerating the medication, even if they don't lose any weight if they have type 2 diabetes. But for someone who doesn't have type 2 diabetes, our threshold for a clinical intervention for any of our anti-obesity medications is at least a 5% weight loss once they're on the full dose for at least 12 weeks, is usually the criteria. But with diabetes, glycemic control is enough for meds that are used for glycemic control. But if you were to add on an anti-obesity medication, like the Phentermine, for example, you would be looking for at least a 5% weight loss to continue it. Well, let me just add something to what Carolyn mentioned, is that it is important to look for that early response, which is exactly what she's saying. And the whole reason is what all the trials show is that if you don't have an early response, the likelihood of having a successful response after a year is very, very low. It's not non-existent, but it's very low, so low that it's not worth continuing on that drug by itself. So that early response, particularly the first few months, is very, very important to be looking at. OK. Great. Now we have more a nutrition-focused question here. Do yogurts and fruits, such as watermelon, mangoes, raise blood glucose? I mean, yes, but at the same time, fruit has so much fiber that is not going to be an issue. Now, will I ask a patient to have like two pounds of fruit a day? No, but they should feel free to eat fruit in normal-sized portions a few times a day, two, three times a day will be no problem. Yeah, and it's all about what you combine it with as well, right? So, yeah, don't want to put any of your cultural fruits off-limit. Oh, that's a big one, because once you tell a patient that they cannot have something that they love, you might lose them and they might not listen to you at all. But maybe you tweak them. Right. The other day, a patient that she eats, she has a boyfriend that is Mexican and love to make pozole. I know that you can make pozole the good way or the bad way. And when I tweak it, she loved it, the boyfriend loved it, and everybody happy. If a patient is at optimal glycemic control, will you continue to increase the GLP-1 with a goal for decreased weight if the patient is tolerating the medication and is at BMI in the obese category? I can repeat that if you want me to. Yeah. Well, I'm just deferring to Dr. Kushner. No, go ahead. I could jump. I'm on stage with one of my idols right now. I'm like, I don't want to speak for him. So certainly, you can continue to increase those medications for the weight loss benefits. And different patients are going to have different responses. It depends where their A1c is starting. So sometimes you'll start, you know, trazepatid or semaglutide, and the patient's A1c is, you know, 6.8, and it improves really, really quickly with that medication. But you may still want to keep titrating it up to the highest dose to get the treatment benefit in terms of overweight or obesity. And keep in mind, for those medications, the indication is overweight with a comorbidity. So that could be a BMI of 25, honestly, at this point, with type 2 diabetes. And so you have a lot of range there you can work with in terms of weight, if that makes sense. Let me just jump on board just quickly to reinforce what Carolyn just said, is that the whole idea of using a weight-centric or obesity-centric approach is to get away from just a glucocentric approach. Individuals with obesity could present with over 200 medical problems. Very important in quality of life issues. So even though the sugar is brought under good control, that doesn't necessarily mean all the other complications and comorbidities are brought under control. So I would continue to treat that patient above just looking at the hemoglobin A1c. And diet and exercise, along with fiber and protein, are very important for patients on these medications. So definitely nutrition support is essential. Okay, I think we have another minute for one more question, and then we'll close. So how much weight should we expect patients to lose, and what is a good goal weight? Of course, it's individualized, right? I'm just going to quickly say I call an ideal weight the happy weight, and it's whatever the patients feel comfortable with and that's where we stay. And I found that very often, especially when they're using GLP-1s, they might give me a number because they're very afraid of going lower because they think they're not going to reach that weight, and they go lower after. Yeah, and I'll add, again, patient-centered. It's going to be health-centered, too. Patients with diabetes have other risks. They have heart disease risks. They may have sleep apnea. So you may be working to treat some of these other conditions through weight loss as well. And you may set a goal there. A 5% to 10% weight loss is a really good goal. But again, some patients with diabetes, it's very hard to lose weight. And so we really want to see how the patient's responding individually. How would you give specific nutrition advice? Really quickly, I'm going to say you get to know the patient. Starts with taking a good history. Otherwise, how could you counsel a patient if you don't take an obesity-focused history that's comprehensive? So it all starts with asking questions.

patient autonomy

weight management

personalized nutrition

cultural sensitivity

health-centered targets