Patient-Centered Communications and Shared Decision-Making in the Management of Obesity

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Welcome to CME on ReachMD. This activity, titled “Patient-Centered Communications and Shared Decision-Making in the Management of Obesity” is provided by Prova Education.

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Dr. Vega:
Hello. I’m Dr. Chuck Vega from the University of California at Irvine, and I’d like to welcome you to our patient-clinician connection on patient-centered communications in obesity. Obesity and overweight are a national epidemic and a leading contributor to morbidity and mortality in the United States.

Clinicians have been slow to prescribe weight-loss medicines, or anti-obesity medicines. However, evaluation of the latest clinical trial data demonstrates novel and existing therapies are safe and effective treatment options. In addition, primary care clinicians are challenged with initiating conversations with patients who have obesity or overweight. Remember, when discussing treatment options, it’s important to align patient and clinician goals. Today I’ll be illustrating my approach to implement motivational interviewing and shared decision-making through clinical vignettes. Let’s get started.

Patient Vignette #1: Initiating the Weight-Loss Discussion

Dr. Vega:
Hi, Annette. How are you feeling today?

Annette:
I’m doing good, thanks.

Dr. Vega:
I remember you saying in a recent visit that you were concerned about your health and weight. Is it okay if we talk about your weight and lifestyle today?

Annette:
Yeah, sure. I mean, overall, I feel okay, but I’m starting to be concerned about my health. I was told at my last visit that I’m a candidate for developing diabetes, and I’m trying to address that by losing some weight. I’ve tried in the past and I haven’t had much success. Besides eating less, I don’t know what else to do. I’ve worked with other doctors, but most have told me that I have to have more willpower when it comes to sticking to my diet.

Dr. Vega:
Gosh, I’m really sorry to hear about your frustrations, and I know it’s a difficult journey. Obesity/overweight is a chronic disease, just like diabetes, heart disease, or cancer. Many factors contribute to it, and it’s not your fault. I want you to know that there are some options for treatment that we can discuss.

Annette:
Oh, that sounds interesting. Haven’t heard that before. Can you explain more about my options?

Audience Education #1

Dr. Vega:
Unfortunately, society has an anti-obesity bias, and perhaps even more unfortunately, healthcare professionals are a top source of discrimination against people with obesity, as reported by those people with obesity. Even healthcare professionals who have obesity themselves have been shown to have an anti-obesity bias, in some research. What does this lead to? Lots of shame and guilt on the part of patients, where they feel that the obesity is their fault, it’s due to personal shortcomings, when of course it’s not. Obesity is a disease. So now let’s return to our discussion with Annette to see how we can address these issues.

Patient Vignette #2: Lifestyle, Motivation & Treatment Options

Dr. Vega:
Sure. So before we get to thinking about medications, I’d like to know a little bit more about your lifestyle now. Can you tell me about your diet?

Annette:
Well, I eat mostly sandwiches. I like my carbs. I eat fast food probably 3 times a week. Probably 2 sodas and day, and I do try to sneak in some servings of fruits and vegetables, you know, 2-3 servings a week.

Dr. Vega:
Right. And I like my carbs too, and nobody has a perfect diet, but I think there’s some things we can work on there. What about physical activity? How do you stay active?

Annette:
I do like to get out and walk whenever I can take a break. So I do probably go out about 4 times a week, and I try to walk about 20 minutes.

Dr. Vega:
Okay, great. That’s a wonderful start. Can you tell me how your weight has changed over the years?

Annette:
Well, definitely college and having kids. You know, after I had my kids, the weight started creeping up. Having the inability to get to the gym as much and then, you know, just with work and the kids and the schedule, not having the willpower and then the energy to really just get to the gym and work out as much as I’d like to.

Dr. Vega:
Or the time. It sounds like you’re really, really busy and so that’s a natural obstacle. But again, it’s something that we see every day, and we can try to work with it. And I appreciate that you’ve already made some changes that work with your limited time. As busy as you are, you’re already doing some things, like the exercise, like fruits and vegetables. That can be helpful, so you should give yourself some credit too. What’s your motivation for losing weight? Why do you want to lose the weight?

Annette:
Well, I’d really like to get off my medication. If I could be able to stop taking the medication for hypertension, that would really benefit me.

Dr. Vega:
Oh, sure. That’s a great goal. How motivated are you by that goal to stop your blood pressure medication?

Annette:
Well, honestly, if I could see a difference and start losing weight, then I’d be really motivated.

Dr. Vega:
Okay. And do you have any ideas in terms of things you can do right now, and start today, that could help you lose weight?

Annette:
So I think the easiest thing right now would be for me to cut back on soda – maybe just, you know, 1 can a day, and then maybe if I could just stop within the month.

Dr. Vega:
And do you know much about medications for weight loss?

Annette:
No, I’m not sure. I only know the things that I’ve heard on the news. Aren’t they dangerous?

Dr. Vega:
Right. Well, that is a common misperception, but current treatment is actually quite safe and it is effective as well. There are a number of different treatments available, and they have different mechanisms of action. They are administered differently. Some are oral, so they’re pills. Some are injected. And they include orlistat, naltrexone, bupropion, another combination drug, phentermine with topiramate, and then you have 2 drugs that are known as GLP-1 receptor agonists. That’s liraglutide and semaglutid. Orlistat doesn’t affect appetite. It produces a modest weight loss by blocking fat absorption. And the others work centrally for both naltrexone/bupropion and phentermine/topiramate. And liraglutide and semaglutide are different; they work through a system called the glucagon-like peptide receptor agonist system.

Audience Education #2

Dr. Vega:
So how do we initiate the discussion regarding obesity and then start to move towards potentially treatment with anti-obesity medicines? First of all, I think it’s important to ask permission to discuss this subject. Some patients just won’t be ready to discuss their body weight and lifestyle, and that’s okay. Usually, over time, with continuity, we are going to get them to a point of comfort where we can have that conversation, and certainly there’s always lots to focus on in primary care. I’m also going to really call out factors that were positive in the past that helped them to lose weight, feel more confident. And I’m going to celebrate those. We’re going to go back to those and try to continue those.

I also want to really stress that this is an important lifelong kind of effort and that we are there to support our patients every step of the way. That’s a whole healthcare team – myself as primary care, dietitian, if they’re seeing specialists as well and even group therapy – we’re all working towards the same goals, and they are the patient’s goals, first and foremost.

And then we want to make sure we do address lifestyle. We want to use motivational interviewing to try to help patients find the solutions that work for them, and then we are going to try to create specific choices with a timeframe that’s realistic, so we can follow them up and make sure that the patients actually complete those lifestyle changes. And then finally, we want to celebrate it when they do. When they have success, you know, that becomes our success as well. 

So when thinking about incorporating anti-obesity medications into that same intervention, we want to certainly consider efficacy, but we also want to consider potential side effects, and even some safety issues. Those are often the deciding factors, when it comes to selecting the right anti-obesity medication for a particular patient. Let’s watch as I discuss these issues with Annette.

Patient Vignette #3: Shared-Decision Making: Choosing a Medication

Annette:
Oh, that’s interesting. I mean, are there any side effects that I should be concerned about?

Dr. Vega:
So for orlistat, that works in the gut, and it prevents fat absorption into the gut. And so what can you get? You get fatty stools, and for some folks, this will cause – maybe they’re having more frequent stools, smellier stools, or they have fecal urgency, they have to go right away, or rarely, incontinence.

Phentermine/topiramate is different, works centrally in your brain. And so its side effects include headaches, you can get some dizziness, some difficulty concentrating, and if you’re thinking of becoming pregnant, it’s not a good choice. Topiramate is associated with fetal cleft palate, and so we don’t want to give it if you’re trying to become pregnant, certainly.

Naltrexone/bupropion – one thing to monitor is your blood pressure. So if you have hypertension, we’re really going to want to make sure you’re under good control before we started that one. It may not be the best choice for you. Also, if you have any history of seizures, bupropion can unmask seizures in folks with epilepsy, so we want to avoid that one there.

Now, liraglutide and semaglutide – the main side effect we are concerned with is gastrointestinal, especially upper gastrointestinal, which means nausea with or without vomiting. But I’ve found that over time, working with folks on their diet, making some simple changes make this drug tolerable.

I think the other thing to remember is that for all of these drugs, the side effects can be limited if we start with a lower dose and then go upward to get greater efficacy over time. And then finally, realizing that the side effects are usually worse in the first couple weeks of taking them. If they’re modest side effects and you can stick with it, a lot of times they get better with time.

Audience Education #3

Dr. Vega:
So let’s think about shared decision-making in choosing an anti-obesity medicine. So first of all, I think it’s important to list the options to patients. And there are many different options, and you can’t judge just based on my perception, per se, what is the best treatment for patients. But I am there to make a recommendation, as well, and I want to address patient concerns. So I really want to make them aware of what the drugs can do and cannot do, so I want to set realistic expectations around the drug.

Also, I want to make sure that they’re aware of potential side effects. That will help them to understand that this is something that they might feel normally in the course of therapy, and especially if it's a modest side effect, not stop the drug, that they can continue through it. And that’s why I also want to follow them up shortly, within several weeks, with a telehealth appointment to make sure that they’re still taking the medication, they’re tolerating it okay, and see how they’re doing on some of those lifestyle changes as well. And I find that overall, using that approach, patients feel supported. They feel cared for, and they feel more invested in their care, more likely to generate success.

Patient Vignette #4: Developing a Treatment Plan and Managing Expectations

Annette:
And then, once I start taking them, about how long would it take for me to actually start losing the weight?

Dr. Vega:
So that’s the great news. Usually, you can expect some weight loss in the first several weeks.

So I think that, especially if you’ve been working and struggling with lifestyle changes over time, it’s just nice to be able to see a positive effect and get it sooner rather than later, and that, in turn, can help you to motivate to do other changes with your lifestyle that make a difference over time.

Annette:
Oh, wow. Doctor, you really, you’ve answered a lot of questions for me, given me a lot to think about.

Dr. Vega:
Do you have any other questions I can answer today?

Annette:
No, Dr. Vega, I mean, this has been great. Thank you for all your help.

Dr. Vega:
No, thank you. And thanks for all the efforts you made.

Annette:
Thank you.

Audience Education #4

Dr. Vega:
So I’m sure you’re dying to know what happened with Annette. Well, she was started on anti-obesity medicine, and sure enough, she did have some side effects during the first week, but she found they were tolerable, and she already knew they were coming because we had talked about them during her clinic visit. But the good news is, the medicine worked. She lost 5 pounds in 3 weeks, and the medicine – she is very happy with it. So she’s excited about that, but she’s also excited about the fact that she’s completely stopped drinking soda, ahead of her deadline in a month, so she is now just drinking seltzer water. She finds that’s a great replacement, and so she feels positive that she made this change – so positive, in fact, that she’s now recommending her husband come and see me. Her husband has overweight, and she’s also worried about her children’s health as well. So her husband will see me in clinic for a potential treatment, and I found that she’s cooking more with vegetables at home to try to encourage healthy weight for her entire family. So it’s a happy ending.

Dr. Vega:
I think that the model presented in these vignettes can be adapted to address the many scenarios we face daily in our medical practices, when discussing and managing obesity. When prescribing anti-obesity medications to these patients, it’s important to apply shared decision-making, with consideration of patient preference and potential advantages, as well as challenges in treatment adherence to maximize efficacy. Thank you for joining me for our patient-centered communications and shared decision-making in the management of obesity. Be well.

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