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Expert Answers to FAQs About Strategies for a Proactive Approach to Obesity Management

Caroline Apovian, MD

Professor of Medicine
Endocrinology, Diabetes, and Hypertension
Harvard Medical School
Center for Weight Management and Wellness
Brigham and Women's Hospital
Boston, Massachusetts

Caroline Apovian, MD: consultant/advisor/speaker: Altimmune, EnteroMedics, Gelesis, L-Nutra, NeuroBo, Novo Nordisk.

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Ken Fujioka, MD

Director of Nutrition and Metabolic Research
Diabetes and Endocrine
Scripps Clinic
La Jolla, California

Ken Fujioka, MD: consultant/advisor/speaker: Amgen, Currax, Gelesis, Novo Nordisk, Rhythm, Shionogi, Sunovion, Takeda.

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Released: January 13, 2023

Key Takeaways

  • Obesity management and BMI cutoffs vary among different ethnic groups.
  • Discontinuation of obesity medication after weight loss can lead to reversal of weight loss.

In this commentary, Caroline Apovian, MD, and Ken Fujioka, MD, answer learner questions on strategies for a proactive approach to obesity management from the live symposium with simulcast: “From Simulation to Real-world Practice: Strategies for a Proactive Approach to Obesity Management.”

Are medications recommended for very high-risk patients with a BMI <27 kg/m2?

Caroline Apovian, MD:
If you have a patient with a significant amount of visceral body fat or lower BMI or someone who, for example, had lost weight in the past and is currently at a BMI of 26 kg/m2 but is starting to regain weight, then yes, you can use weight-reduction medications. 

Ken Fujioka, MD:
BMI cutoffs vary among different ethnic groups. We do have lower BMI cutoff points for some. For Asians, a BMI of 23-24 kg/m2 is considered overweight, and the cutoff for obesity is 25 kg/m2. That group is physiologically very sensitive to a small amount of weight gain, and consequently, a small amount of weight loss is very beneficial. Similarly, the Hispanic population in Mexico, Central America, and South America is a very diverse group whose genetics originated from East Asia. This means their genetics relating to carbohydrate metabolism are very similar to Asians, and they also gain their weight very similarly. The Afro-Caribbean population, by contrast, is less sensitive to weight gain.

The superabsorbent hydrogel capsules are approved for patients with BMI ≥25 kg/m2 regardless of comorbidity. They do not lead to large amounts of weight loss, but you can safely use them.

 You should check your state laws regarding prescriptions for weight loss medications for patients with lower BMI. If there is a higher weight documented from a previous diagnosis and the patient initially lost weight but is regaining it, you can start a medication. However, without a documented weight that shows that the patient truly had obesity or overweight, for example, a BMI of 27 kg/m2 with comorbidity, healthcare providers can get in trouble from their state board for inappropriate prescribing practices.

When would you choose semaglutide over tirzepatide for a patient with diabetes?

Ken Fujioka, MD:
A key consideration in selecting one of these agents for patients relates to their insurance coverage, as many insurance plans do not yet cover the newest agents.

Caroline Apovian, MD:
Another consideration is if a patient is unable to tolerate one or the other due to adverse events. Tirzepatide offers more weight loss for some. However, we don't have enough data at this time to have an unequivocal preference. We also do not yet have results from the cardiovascular trial for tirzepatide, so that may be a consideration as well if your patient has a history of cardiovascular disease.

Is the weight loss greater if metformin is given along with a glucagon-like peptide-1 (GLP-1) receptor agonist?

Ken Fujioka, MD:
Metformin is an unusual drug, with low amounts of weight loss according to published studies. It is generic and inexpensive and will help some. The adverse event profile matches that of any of the GLP-1 receptor agonists and requires caution as it can sometimes amplify the nausea and vomiting adverse events associated with them. A GLP-1 receptor agonist should not be added until metformin adverse events have stopped.

If patients have successfully lost weight on a GLP-1 receptor agonist, should we continue the drug after the BMI is <30 or 25 kg/m2?

Caroline Apovian, MD:
If you take patients off the GLP-1 receptor agonist once they get to a BMI of 25 or 24 kg/m2, they will regain the weight. Compare this with patients with hypertension who are started on lisinopril. When they get down to a blood pressure of 110/70 mm Hg, you would not discontinue the lisinopril as this is a chronic condition that needs continued treatment.

If you are concerned about continued weight loss, you can decrease the dose to slow or stop the weight loss while still preventing regain of the weight. In fact, for tirzepatide, the manufacturer recommends not titrating to the maximum dose if not needed. Dosing increases by 2.5 mg, up to 15 mg, would lead to an average of 22% overall weight loss or approximately 50 lbs for most patients. In my practice, I see many patients with severe obesity who don't want to have bariatric surgery, so I do not typically decrease the dose for those patients.

Your Thoughts?
How do you manage obesity in high-risk patients? Join the conversation by adding a comment in the discussion section.

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