Today, welcome to Treating People Living with Obesity. Brought to you by Lily. Lily is proud to support the work of the American Diabetes Association to address obesity. Today's training topic is focused on improving health outcomes for people with obesity. My name is Sue Ellen Anderson-Haynes, and I am the moderator for today's session. To share a little bit about myself, I am a registered dietician, certified diabetes care and education specialist, of over 15 years. My specialties include women's health, diabetes, and wellness, and I've worked in the inpatient and outpatient setting in a variety of roles. One of them, which is a bariatric dietician. I own a private practice, 360 Girls and Women, and launched a digital healthcare app, Cultured Health, and a non-profit Beat Gestational Diabetes. I'm excited to be here today. This is a very timely and important topic. Today, you will be hearing from three amazing speakers, each providing a unique perspective. Dr. Robert Kushner, Dr. Brown, and Dr. Escobar. We'll start with Dr. Kushner. He's a professor of medicine and medicine education at the Northwestern University, Finberg School of Medicine, and past director of the Center for Lifestyle Medicine in Chicago, Illinois, USA. Dr. Kushner is past president of the Obesity Society, the American Society for Parenteral and Enteral Nutrition, the American Board of Physician Nutrition Specialists, and a founder and first chair of the American Board of Obesity Medicine. Dr. Kushner has authored over 250 original articles, reviews, books, and book chapters covering medical nutrition, obesity, and obesity medical education, and is an internationally recognized expert on the care of patients living with obesity. Dr. Kushner's research interests include medical and obesity education, and lifestyle and pharmacological approaches to obesity. Next, we'll introduce Dr. Brown. Dr. Brown is a board certified in family medicine and a diplomat of the American Board of Obesity Medicine. She owns and operates Green Mountain Partners for Health and Colorado Weight Care in Denver, Colorado. She serves on the Obesity Medicine Association Board of Trustees, and was awarded the Dr. Vernon B. Astler Award for dedicated service and support of OMA in 2017. Dr. Brown is the founder of helpyourpatientsloseweights.com, the host of the Dr. Frankel Villa Show, a podcast about weight and health, and founder of the GLP Strong. Dr. Escobar is a doctor in clinical nutrition, and a registered dietitian nutritionist dedicated to helping women over 40 achieve their weight loss goals, and counseling individuals using GLP-1 receptor agonist. With a deep understanding of the unique needs of these populations, she combines her clinical expertise, patient counseling experience, and research insight to provide valuable support. Beyond her patient's work, Dr. Escobar speaks at national conferences, and has served as the Academy of Nutrition and Dietetics spokesperson. Thank you all for joining us today. We will spend today's session reviewing case study on Maria. Maria is a 48-year-old woman living with obesity. By the end of today's session, you will be able to analyze the multifactorial aspects of obesity, including genetics and social factors. Social factors, apply the latest research updates and effective assessment methods in obesity care. Implement comprehensive strategies for effective assessment and management of obesity. While we are working our way through the case, please include any questions you have in the Q&A box located on the control panel at the bottom of the screen. We will work to reply throughout the session, and I will now pass it over to Dr. Robert Kushner. Thank you, Sue Ellen, and glad to be here today. Sue Ellen said we're going to do a case study to make it practical, so that you can use this information as you work through the management of your patients who present with diabetes and obesity. This is visit one, and this is Maria. Let me introduce Maria to you. She's a 48-year-old Hispanic female returning for a scheduled appointment. She was last seen six months ago. She has a three-year history of type 2 diabetes, hypertension, depression, and obesity. Emotionally, she's frustrated about her health and concerned about her worsening diabetes despite taking her medication. She is on metformin, ampicliflozin, lursartan, hydrochlorothiazide, and citalopram. Social history, she's an advertising executive, married, and has one daughter. Her diet, there's really been no changes since her last visit, and she tries to avoid sweets and desserts. Physical activity, she walks her dog every morning and evening. On exam, she's 5'4", 195 pounds, her BMI is 34, blood pressure 138 over 88, and heart rate is 76. The labs, as you see there, hemoglobin is 7.8 percent. Most significantly, it has increased since her last visit six months ago when it was 7.4 percent. Blood sugar is 160, and you see her lipid levels and her renal function there. Treatment goal is weight and glycemic management, because that's what we're focusing in on, is not just glucose control, but also weight management control. Thinking about obesity, how do we broach the topic? How do we actually bring it up? Well, here's some discussion points for you to be thinking about. Certainly needs to be patient-centered. I think all of our interventions are patient-centered. Certainly has to be empathetic. Not only empathetic because she is frustrated and we want to feel for her, but also the fact that obesity is a little bit different than other medical problems. It's really with a whole history of shame, embarrassment, frustration, perhaps stigma in the past. We want to recognize that and be respectful. Certainly want to be unbiased. We want to be free of judgment when we talk about her weight. Focused on health rather than weight. Never just looking at the pounds on the scale, but using weight as a biomarker, if you will, regarding overall health. People-first language is extremely important. We've been talking about this for over a decade. We don't want to label people by their disease. Best example is we try not to say a diabetic patient or how long you've been diabetic for. We want to say patients with diabetes or how long have you had diabetes? It's the exact same thing when it comes to weight. We don't want to say an obese patient. We certainly don't want to say a morbidly obese patient. We want to say a patient with obesity or someone with excess weight or a weight problem. We want it to be focused on shared decision-making. Shared decision-making meaning not only you want to take the patient's values and goals in mind, but also we want to provide evidence-based information. When we come to a decision, we're sharing what we know that we imparted to them, taking in their perspective. We want to frame it by using the five A's, where the first one is ask. Now, many of you may be familiar with the five A's from smoking cessation that's actually developed for that particular behavioral problem. When it was originally developed and also applied, by the way, for alcohol misuse, when it was originally developed, that first A was assess. We've adopted it and turned that around a little bit, and we've now changed the first A to ask. That has to do with there is such a strong connotation about weight that patients often feel hesitant or shamed or embarrassed to talk about their weight. It's very private. They think it's their fault due to variety of reasons. By asking patient permission to talk about their weight, it really shows respect for all of these biases that they may have experienced and to put them at ease. The way that I often bring it up is, is this a good time to talk about your weight once you've framed the conversation? The rest of the encounter is framed by assessing the patient's body weight. After you've done that, you may give advice on treatment options. Of course, agree on what the treatment direction is going to be. That's shared decision-making. Lastly, assist the patient for long-term care, as well as arranging a follow-up visit. What we want to do and what we are recommending now is, rather than talk about weight for the last five minutes of an encounter, or when your hands on the doorknob and you're walking out the door and say, if you lost some weight, that would be helpful. What we're really talking about more often now is scheduling a weight-focused visit where you have ample time, and you make weight a priority for that visit. It sounds something like this. Sounds like you're interested in spending more time talking about your weight, and I think there's a lot of options for you. How about if you make a follow-up visit as soon as you can, one month, six weeks, whenever that is, and we're going to devote the entire visit to your weight. You're not going to do medication reconciliation, you're not going to talk about an earache that you have or other issues, it's going to be focused on weight alone. Not only does it take care of time, but you can proactively prepare for that visit by having them complete an assessment questionnaire. Many of us have questionnaires on our websites now in our clinics that they can download and fill out or actually fill out online and then could be propagated or sent right into our note to save time, or handwritten with pen and paper questionnaire. You may often want to ask them to track their diet and physical activity on a smartphone, computer app, or wearable device, so that they can better understand what their diet is, what their patterns are, perhaps what their calories are, their sugar or protein intake, and they can then bring that information to you, and they can learn more about their diet. They can also complete a life events weight graph, which is a wonderful narrative description of their weight, and I'll go over that a little bit more later. So they come in now for visit two, and you are prepared for that in the patient as well. And what you want to do is an obesity focused history. This is something that actually most individuals in training, in fact, a lot of clinicians in practice don't do. They don't take a history of present illness of weight. When it comes to diabetes, which is a good comparator, I think everyone will ask, when did you get diabetes? How was it diagnosed? What have you done to treat your diabetes? What have been the complications of the diabetes? Anyone else in your family have diabetes? I think that is ingrained in our education, but what is not a well-known or practiced is how to take a weight focused history, which you're going to ask the same kind of questions. And I'll go over that in a moment with you. Certainly past medical history as it relates to weight related complications or comorbidities, a detailed social history with diet, physical activity, stress, sleep, other issues, smoking, alcohol, family history of obesity and medications, physical exams like you would normally do, but you're going to get a BMI and specifically a waist circumference and focus laboratory data and end up with a C assessment plan, assessment and plan, which we will also go over with you momentarily. Now, if you go into an electronic medical record, this happens to come from Epic, you can track one's trajectory of weight. And this, by the way, it can be a way to bring up weight with a patient. You turn the screen to them and say, I've noticed your weight, looks as though you've been slowly regaining your, gaining your weight in a various patterns. Can we use this to talk about your weight? And it's a nice objective non-judgmental way to talk about weight. I'm going to take that one step further and that you can actually have them graph their own weight and put in their own life events as they remember them. And there's, here's a mnemonic you can use on the left here, which is based off the OPQRST mnemonic, which is used for how to take a history of present illness, but we change what those letters stand for. So this is a nice framework you can use in order to take a detailed weight history. O is for onset. What did you weigh different years? P is precipitating factors. How much weight did you gain when you stopped smoking, when you got married, when you had pregnancy? Q is for quality of life. What weight did you feel the best? How is it affecting your quality of life now? R is remedy. What have you tried to do in the past to manage your weight? S is for setting what was going on when you gained weight, let's say in college or when you were traveling abroad and when you got married and so forth. T is temporal pattern. Is it a yo-yo weight gain or progressive weight gain? And on the right is actually what Maria could have filled out. So she sees this progressive weight gain when she went to college, marriage, job promotion, pregnancy, and so on, what she weighed when she developed diagnosis, and later on during depression, which she now has in job stress. So it is a wonderful, rich observation that the patient is telling you their perception of why they've gained weight. Now, it's up to you as a clinician to connect the dots. And that is, did these life events cause you to be more stressed? Did you eat more when you were stressed? Were you less physically active? Did you change your diet? Did you go on any medications that may have caused weight gain? So it gives you a narrative in order to have a discussion with the patient about her weight. Now, you're gonna take a more detailed diet history at this point, and that could be done many ways. I used a typical day with Maria, and I found out that she typically eats three meals daily with an evening snack. Breakfast is a fiber cereal with 2% milk. Lunch is fast food sandwich with chips. A dinner is often a pasta with a meat sauce, vegetable and vegetable, and a snack at night is a yogurt bar. And this is a typical day. It's not the 24-hour recall or food frequency. This is what she typically does. Physical activity, on her smartphone, she actually tracks her steps, and it's 3,000 steps per day. And lastly, I'm gonna ask her from a psychological point of view what is going on with her regarding stress and emotion. And she acknowledges emotional eating, especially during stressful periods, she expressed frustration with her weight and her diabetes, which has affected her mental health and motivation. So some of this could be done by trackers, some of it could be done by targeted questions. This is very important background information. So we could actually then provide a very practical targeted suggestions to her again using SMART goals. When it comes to a physical examination, we're going to measure height and weight and calculate BMI. Our electronic medical record often does that for us. We know Maria's BMI is 34, which is class one obesity. We're also going to measure the waist circumference, particularly in her because her BMI is under 35 and it's 40 inches, which is elevated. It is very important to have a measurement of body fat, in this case waist circumference, which gives us an idea of her visceral fat. BMI is very, very good for screening, but it has many, many limitations and pitfalls. So we use it for epidemiologic studies. We use it for population studies. It's a good screener when you see the patient come in, but it does not tell us anything about the composition of the body, body composition or where the fat is located. Also, a lot of these markers vary by race and ethnicity, as well as gender, changes over the lifespan. So we have to be very careful to add another measurement beyond BMI and take a very good history. So bottom line here is do not treat patient as just BMI, but it's a very, very good screener. At this point, I'm going to hand it over to the next presenter who's going to go over with you where we go from here regarding further evaluation and treatment. Carolyn, go ahead. Thank you, Dr. Kushner. I'm Dr. Frankville. I'm a family physician and taking off from where we left with Dr. Kushner, assuming we are able to do one of these obesity focused visits where we're really better understanding our patients struggle with weight. We view obesity care as having four pillars, nutrition, physical activity, behavior, and medical management. And so we really want to make sure we understand a treatment plan that is going to utilize all of our pillars for our patients. So when we try to make an assessment and plan for our patients, again, we're looking at these four pillars. Nutrition should be individualized for a patient's preferences and nutritional needs. We want to have a nutrition plan that's going to create an energy deficit, regardless of the macronutrient composition to achieve weight loss. But the individualization here is very important. And like Dr. Kushner said about getting a history on weight and started to talk about the history on nutrition, it is important that we know what a patient is eating before we try to give them advice on what to eat. So we want to either do that typical day, which is what I utilize the most in my clinic, a 24-hour recall. Or if you're able to have the patient journal before the visit and write down some of what they're eating, that's another way to get that nutrition history. And this is very important. You're going to understand your patient's knowledge base around nutrition when you do this, their preferences. They'll get some idea of budget, cultural preferences and needs. Maybe they're plant-based and that's, you know, they have to be plant-based. Convenience, do they have to eat out a lot with their schedule? Do they like a lot of packaged foods? What's the role in the household? Do they live with a partner who makes the food? Do they live with a parent or a child who makes the food? Do they not even have access to a refrigerator where they live? So those are all important. And then is there any disordered eating going on, which you can sometimes pick up in that diet history. And again, this is important to do. It's going to give them more confidence that you're giving them helpful advice when it's customized to them. It's going to help you understand their eating patterns, cultural factors, economic factors. Sometimes you're going to be able to identify really low-hanging fruit when you get that dietary history. If the patient is drinking a lot of sweet beverages, for example, if they're eating fast food frequently, if they don't have any vegetables or fruits in their diet, that may be a good time to get that dietary history. And then you need to determine how much support the patient needs nutritionally. Are you, as say the primary care physician, going to be able to offer all the nutrition support they need? Or are they going to need to meet with a registered dietitian, a coach, a nutritionist, an obesity specialist? Will they need more support than what you're able to offer with nutrition advice in your clinical setting? So before GLPs existed, the most common question I got when I told people I was an obesity specialist was, what's the best diet for weight loss? And truth be told, we do not have one best dietary strategy for weight loss. I always share this graph, which was published in JAMA many years ago, but it compares four very different types of diets. Atkins, the zone diet, which is more of a macro diet, Weight Watchers, which at the time would have been a low-calorie, low-fat diet, and Ornish, which is a very low-fat plant-based diet. And what they saw was people lost weight based on how well they were able to stick to the diet, and their health consequently improved based on how much weight they lost. So there are different ways to create caloric deficit. There's different ways that can be successful for different patients, and we need to take their lifestyle and their preferences into consideration before recommending nutrition advice. So structured programs are going to give more results for our patients. Weight loss deficits usually need to be around 500 to 750 calories per day. For women, a calorie goal is often between 12 and 1,500. For men, that's often between 1,500 and 1,800. And there may be specifically value in reducing processed and especially ultra-processed foods when we're giving nutrition strategies to our patients. So going back to Maria for our nutrition plan for her, if we were going to give some brief counseling in response to her history, as Dr. Kushner said, she's reporting that she usually has a high-fiber cereal with milk in the morning. For lunch, she'll get fast food sandwich with chips, and dinner is some sort of pasta with meat sauce, maybe a vegetable, and she has a yogurt bar for snack. So if we want to give some brief tips on what she could do, maybe we focus in on her lunch, which is fast food, very likely high-caloric, high-glycemic based on what she's describing with the sandwich and chips. Is there a way we can talk with her about picking a different option at the restaurants she likes to go to? Is there some suggestions of easy foods she could be bring from home? And talking about the role of the carbohydrates in her diet and how we want to get her a more balanced meal, maybe with some more produce and more whole grains in that meal. For her snack, you know, instead of a yogurt bar, which likely looks like a health food when it's labeled for the patient that is probably a high-glycemic snack, could we switch her to a protein bar? Could we switch her to fruit and nuts? Could we switch her to carrots and hummus? Could she have actual Greek yogurt instead of the yogurt bar? So what are some things that might work for her when we're reviewing what she eats? And what, again, are some of those low-hanging fruit that are changes that might be easier for her to make as opposed to completely rehabbing and doing a brand new diet that might be hard to stick with? Switching to our planned portion for physical activity, our first guideline from our physical activity guidelines for Americans is for all of us, we should all move more and sit less. So sometimes that's where we start with patients, just moving more in any way that we can. Our general guidelines are that adults should get 150 minutes to 300 minutes a week of moderate intensity activity, that there is additional benefit for 300 or more minutes, and that we should be doing muscle strengthening activity that involves all major muscle groups two or more days a week. So these are the sort of easiest guidelines to remember when we're helping any of our patients try to progress with exercise and move closer to health goals. So for Maria, she was already doing some walking and exercise, and so, you know, thinking about what we do to increase for her. For diabetes specifically, the article that was published in Obesity Pillars talks about steps as one goal, starting with 5,000 minimum. She was reporting 3,000. Can we work to push her to 5,000? Again, that 150 to 300 minutes of moderate activity, resistance training, and then again, increasing NEAT. NEAT is that non-exercise activity thermogenesis. That's the movement we do throughout the day that is not formal exercise. That can be things like parking farther away, using a standing desk, taking stairs instead of an elevator, all those little bits of movement we do throughout the day that can also have benefit for our health. And so when we're thinking about our patient, what can we do to push her forward on some of these? She's walking the dog twice a day, but she's only getting 3,000 steps, so maybe not very long dog walks. Can we get her to add a little bit of length to those walks? Can we get her to add some more intensity? Can she walk up a hill? Can we get her doing some resistance training? Sounds like she's not doing any, and the recommendation is twice a week. And are there ways to increase NEAT? Can we work on those things like a standing desk, walking more throughout the day, and just moving a little bit more even if it's not true exercise? Moving forward to our plan for medical management, our third peer of obesity treatment that we will talk about. For our patients with diabetes, we want to consider that we have medications now that are both anti-obesity medications and type 2 diabetes medications. And so these are going to be our first choice for patients when we are trying to treat both diabetes and obesity. And these are our GLP-1 and GLP-1-GIP receptor antagonists, our medications of semaglutide and terzapatide are the ones that are actually approved for obesity in addition to diabetes. And then of course, most of our GLP-1 medications for type 2 diabetes will also have some weight loss effect, though not as dramatic as terzapatide and semaglutide are. We're going to get additional cardiometabolic improvements for our patients with this class of medications as well. We see improvements in lipids, blood pressure, cardiovascular disease risk, sleep apnea, metabolic dysfunction associated with steohepatitis, fatty liver, and more that we are seeing on a regular basis as improvement. So for that reason, these really are becoming sort of the first choice for many of our patients with type 2 diabetes. In addition, we want to think about the other medications our patients with diabetes might be on. So we do have other medications that are associated with some mild weight loss when it comes to type 2 diabetes. Our SGLT2s, our metformin, our Cobase, amylin memetics. We have more weight neutral medications for type 2 diabetes, DPP-4 inhibitors, bromocryptine, alpha-glucidase inhibitors, and bile acid sequestrants. And then we have medications that we've classically used for type 2 diabetes, but that do cause weight gain. Insulin, sulfonylureas, metaglutinides, and theaglutinozones. And these are all medications that can be causing weight gain. So if we have the chance to replace these or decrease the dose in the case of insulin, then we're going to set our patient up to have more success with weight loss. And this is, again, a good reason to have a dedicated visit to focus in on this. Of course, changing medications for diabetes can cause with some additional monitoring that we need to do for our patients, but it's going to be very hard for our patients to lose weight in many cases if they are on these medications that cause weight gain. And then we want to be careful when we're prescribing other medications that are not diabetes medicines to our patients because these other medications can cause weight gain or may have been the cause of weight gain in the past. So the table here that has some of the medications, we don't want to spend too long on this, but medications like steroids, many of our cardiovascular medications like beta blockers, many medications that are used for depression or other psychiatric conditions can cause weight gain. And so if you are a primary care physician taking care of the patient and you might be prescribing some of these other medicines, you have a patient that already has type two diabetes, is struggling with overweight or obesity, trying to prescribe more weight neutral medicines when appropriate, or on some occasions replacing medications that are causing weight gain if they're still actively causing weight gain. And then we do have other medications for the treatment of obesity besides our GLP-1 class of medication. And so these would include things like fentermine, fentermine-topiramate combo, naltrexone bupropion. We want to consider the risk benefit for the patient. If someone already has type two diabetes, it's probably going to make the most sense to use a medication like trazepatide or semaglutide, but sometimes we will use combinations of these medications to help patients get the needed results depending on the clinical setting. For these medications, they do need to have that diagnosis of overweight or obesity, and they should have a 5% weight loss over the course of three months to continue the medication. And then finally, in our medical management category, we want to consider bariatric and metabolic surgery for people with type two diabetes. It does have superior weight loss and glycemic management compared to non-surgical interventions, and sometimes can be the best treatment strategy for patients. So going back to Maria, right now she's on metformin, impaglifozin, lisartan, HCTZ, and citalopram. Her A1c has gone up, and so we do need to make a change in her diabetes management to improve her glycemic control. And so to me, naturally, the choices would be to consider trazepatide or semaglutide so we can both improve her glycemic control and we can help her with the weight loss that she is interested in achieving. So you'll have a choice to make here. You'll likely want to stop the impaglifozin and start the GLP-1 with careful monitoring of her blood sugar, but you would potentially be able to add the medication as well to what she's currently on. The other thing to consider here is citalopram. Citalopram is a medication that can cause weight gain, but in my clinical experience, what we really need to consider is whether or not that medicine is still causing weight gain. Once someone has gained weight from something, getting rid of that thing doesn't make them lose weight. So if citalopram made Maria gain weight 20 years ago when she first started it, but she's had that weight on since then, changing her mood medication is probably unlikely to make her lose weight. But if she just started the citalopram six months ago and has been gaining weight and having worsening glycemic control since starting it, it might be worthwhile seeing if she responds to a more weight-neutral SSRI. So when it comes to medication management, we want to think not just about diabetes, but the treatment of obesity and other medications that could be contributing to weight. And then our final component of our obesity treatment plan is going to be behavior modification. So as the clinician, we're going to use motivational interviewing strategies to help our patient achieve their goals. We're going to look for barriers to care that we can help patients overcome. We want to be patient-centered. We want to address treatment of mental health diagnoses. This can certainly make it very hard for people to activate and make change if they have depression that's untreated, for example. And so that's, you know, part of the role of this comprehensive care. And then the more touch we have with the patient, the more contact they get, the high frequency of counseling is going to be predictive of if a patient is successful. So whether that's us or a larger treatment team, we need to consider how we can help our patient be the most successful with their weight loss plan. And so in summary, there's four pillars of obesity care, nutrition, physical activity, behavior, and medical management. We want to utilize all of them when we are coming up with a treatment plan for our patients, but we don't have to do this all alone. You don't have to do this all in one visit. I think that obesity focused visit is really key to be able to get the solid history and to be able to come up with a treatment plan in all these domains, but you don't have to do it all at once and you don't have to do it all by yourself, especially as a primary care physician, where you have lots of other things you are doing. And so with that, I'm going to pass it off to Dr. Escobar to talk a little bit more about how other team members can help support you. Thank you, Dr. Francavilla. Exactly. Once they're seeing the physician, I'm there to provide the support in terms of nutrition. In the case of Maria, we know that we want that weight and glycemic management. In my mind, I'm thinking I want to create a calorie deficit of about 500 to 700 calories, and I'm gonna see what Maria can do and how I can get there. And I wanted to do it in a way that is sustainable, something that she changes now and she can stick with the changes. That's to me very, very important to avoid that yo-yo dieting. Now, I talked to Maria and what she said, she doesn't care about the numbers on the scale. She is frustrated about her diabetes, but she really doesn't care about the numbers. What she really cares is about feeling better because she's not feeling better and she has a lot on her plate. She also wants to reduce the size of her stomach because that, for some reason, really bothers her. And I learned that she has recently joined the adult group of her daughter's dance academy. They dance like folkloric, Mexican folkloric music, so I'm very happy, obviously, because she's moving three days a week plus presentations on the weekend in a way that is fun for her and that she doesn't perceive as exercise, but she's really tired. She cannot keep up with the class, and we're going to use that later on. Obviously, my focus is going to be on nutrition, but I often help patients to find out physical activity that matches them well, something that they get excited about doing and that fits their schedules, and I will work on behavioral changes to make the nutrition and physical activity changes possible. Now, working with a registered dietitian, a meta-analysis shows that patients improve BMI, weight, waist circumference, blood pressure, fasting blood glucose, and above all, and most important, quality of life. Now, what is our scope of practice? We use the nutrition credit process to provide client-centered interventions, and we've been talking about for the entire hour. We need to base on the interventions in what the client needs and wants, and all the decisions of care, we want to involve them. How this looks for me, I usually will spend like the first two-thirds of our appointments talking about what went well, the challenges that they had. I provide some education, but in the last part of the session, we come up with goals for the patient to do for the next week or two or until the next session, and I always have them come up with the goals, because when they make the goals, they own them, and they're more willing to come back the next session and tell me, yes, I was successful, whether it is 100% successful or at least somewhat successful. The difference between a registered dietitian, a certified dietitian, or a health coach is that we can provide medical nutrition therapy and see a little bit more complex cases. We also want to monitor and evaluate outcomes and adaptive goals and interventions for clients, and we want to do this in a way that minimizes the weight loss bias and stigma by targeting that client-centered goals, individualizing interventions, and really using client-preferred terms, as Dr. Kirshner mentioned before, and honestly, this is very, very important. Not too long ago, I had a client that was very, very upset with me because I used BMI as a tool. I was measuring many things in her case, but we talked about her goal weight, and when she told me the number, I really couldn't gauge if it was something good for her or not, and I wanted to have an idea of whether or not it makes sense, and when I brought up the BMI, I lost her. She just stopped listening to me after I brought BMI because she really believes that that's not a good measurement, and while I agree with her, I was using it as a tool, so it's really easy to lose a patient if you're not using the language that they prefer. Now, the American Diabetes Association's new guidelines say the same thing. We want to personalize interventions. We want to own our food preferences, eating styles, nutrition, and needs. We want to create that caloric deficit regardless of the nutrient composition, and we want to consider systematic, structural, cultural, and food insecurity and hunger. Now, let's go back to Maria because I feel like it's much easier to, you know, give examples using a real case scenario. When the clients see us or when the patients see us, our visits are about 60 to 90 minutes long with our initial visits, and after that, nowadays, I'm very happy because insurance are covering more and more meetings with a dietician, so when I have 60 to 90 minutes, you bet I get a lot of information about my patients. With Maria, I realized that the food that she chooses are largely based on convenience. This is a person that gets up in the morning, drops off her kid to school, then goes to a very stressful job. At work, they have a lot of entertainment to clients, so they always have, like, delicious food that is not the best for your health available. There's a snack bar for the patients, for the patients, for the clients and the employees, so it's very easy to grab something that perhaps is not the healthiest option, and she's so stressed that it's very easy to cope with stress by using food. After that, she comes home, she picks up her, well, she picks up her child, goes to the dance rehearsal, and then gets home around eight, so at eight, she makes a pasta with the meat sauce just because that's really fast, and she throws the, like, any vegetables that she can do in, like, two minutes. That resulting in vegetables that don't look great, or they have ranch, bacon, beets, and other quick things that make them taste better, but again, they're not, like, really great for their health. The husband cooks, but he's very often out of town because he travels a lot for work, and when he's home, he's able to make a little bit of choices. She likes vegetables, but often she often skips them because she doesn't have time to cook them, and as I mentioned before, she eats due to stress. Now, the good news is that she's now exercising a lot more. She's moving a lot more. It's perhaps not the exercise that I would like to see because I would like to see Maria doing some strength training exercises, but three hours of exercise a week, I love it. That, yeah, that about, like, it's enough to, to fit the guidelines. Now, I also learned that she feels really overwhelmed through life. She, we talk about the fact that she's depressed, and she's very anxious, and lately her sleep has been very bad, and she also mentions that her periods are irregular, so you might now start thinking the same thing that I'm thinking. Beyond everything else that Maria has going on, she is in the transition to menopause, and that impacts the weight. Now, at the end of the session, once I have all this information, and much more, because once you have the time with that patient, with that client, they're, they're open up, and they're able to tell you details that you might use to be able to tailor a lot more than nutrition intervention. At the end of this session, of the first session, Maria picked three SMART goals, and as I mentioned before, she's very overwhelmed. She just cannot do big changes, so what she selected is to decrease her soda intake, because although she is eating less sweets and desserts, she just didn't thought that soda really was, you know, worsening her situation, and she was drinking anywhere between two to three cans of Dr. Pepper, and that is about 140 calories per can, and 40, like 40 grams of sugar. Well, I'm exaggerating, 39 grams of sugar per can, and she agreed to decrease that to one. Very simple changing, very possible, very doable, and achieving that goal is going to make her feel stronger to achieve more complicated goals. She also agreed to try a few other drinks that are not soda, but give that same feeling. When she's going out, she's going to have sparkling water with a splash of cranberry juice, and she's also going to try some of the probiotic sodas. The second goal that she chose is that she is not ready to stop going to fast food for her lunch, but she's going to skip the chips or the fries, and she's going to have water instead of having the soda. We also went into the nutrition analysis of the three fast foods that she visits more often and select better options. The food is still very processed, but we're getting her to make better choices all the time, and last, she was going to start thinking about ways to cope with stress that do not involve food. We didn't talk too much about it during the first session, but definitely that's something that we're going to consider, and because she's really into dancing and being able to keep up with the dancing, she agreed to walk the dog for a little longer every morning. She is okay with waking up 10 minutes earlier and walk the dog for an extra 10 minutes in the morning. We briefly discussed how the attention to menopause can impact weight, and she was going to bring that to her physician the next time that she will see him or her, and she is also, as I mentioned before, she is going to develop better coping mechanisms to deal with stress, and we'll see, you know, she might need to see a therapist, but you know that's something that it will come with time, and we set up a follow-up visit. The beauty of being on this time is that we now have a lot of visits covered by insurance, not in every case, but many patients now have unlimited visits, when before with someone with diabetes they might only have three visits. For long-term weight management, we want to promote monthly contact and support, frequently self-monitoring, and obviously physical activity is something that they need to do for life. We often communicate with healthcare providers by sending letters or talking to them if we're in the same setting, and we encourage patients to seek expertise from other providers as pertinent, so in the case of Maria, probably she will need to be seeing a therapist as well to decrease that anxiety levels, and probably she is, and with this, I'm going to move away to the key takeaways by our wonderful moderator. Before we close out, I want to review some key takeaways from today's session. We've spent a lot of time talking about how to reduce bias, and here are some key takeaways to discuss. You want to make sure you're considering scheduling a separate weight-focused visit and use the Five A's framework to guide the encounter. Individualized patient-centered care is the best approach to treating obesity. So, speakers, I want to ask you, would you like to provide any additional takeaways before we close out? I'll just emphasize, well, first of all, thank you for inviting me and all of us to participate, and it's just refreshing to look at the patient as a whole and not just get the diabetes under control in someone who presents with overweight and obesity, since the vast majority of our patients with type 2 diabetes also have overweight or obesity, so treating the patient as a whole is going to be key. Okay. For more resources on obesity care and weight management, please visit professional.diabetes.org forward slash person-centered approach obesity care. On this site, you can access the webinars, which are non-CE and CE obesity care and weight wellness case study competitions, and focus on obesity podcast series and infographics. The link can be found in the chat, and it's going to be posted here. Thank you for participating in today's session. So, after today's session, a survey will be emailed to you. We encourage you to complete the survey as your feedback is invaluable. This concludes today's session. Have a great remainder of the day. Thank you for stopping by.

obesity care

health outcomes

Sue Ellen Anderson-Haynes

Four Pillars

GLP-1 medications

bariatric surgery

patient-centered approach

dietitian

sustainable lifestyle changes