Addressing Obesity Through Shared Decision Making in an Interdisciplinary Weight Management Clinic

As of 2021, approximately 41% of adults aged between 20 and 30 years are obese in the United States, explained Monica Orsborn, PharmD, clinical pharmacy services coordinator, Indian Health Service, during a presentation at the American Pharmacists Association (APhA) 2024 Annual Meeting & Exposition in Orlando, Florida. By 2030, it is predicted that 1 in 2 adults in the United States will be classified as obese, and 1 in 4 will be also classified as a severely obese, according to Orsborn.

“We all know that people with obesity are at a higher risk for coronary heart disease, hypertension, stroke, diabetes, and certain types of cancer, which is really a problem,” Orsborn said during the APhA session. “The United States is spending as much as 173 billion [US dollars] annually in costs related to obesity [prevalence].”

Orsborn explained further that people with obesity spend approximately $1800 a year in medical costs more than those who have a healthy weight, demonstrating the financial impact of the disease alongside the health impacts.

“We started an interdisciplinary weight management clinic about 6 months ago,” Orsborn said during the session. “When we started the clinic, we wanted to look through guidelines. The most common guidelines [used are] the 2013 American Heart Association [AHA]/American College of Cardiology [ACC]/The Obesity Society Guideline for the management of overweight and obesity in adults. They are kind of outdated, so they do not list a lot of the new medications that we have for obesity, or for weight management. But most of [the guidelines used] recommend starting in the same place.”

This starting place recommendation, Orsborn explained, is a loss of 5% to 10% from baseline weight within 6 months. However, the AHA/ACC/The Obesity Society Guideline recommends this initial amount being obtained through lifestyle changes, according to Orsborn.

“We reevaluate our patients after 6 months, and if the goal hasn't been achieved with lifestyle changes—diet and exercise—then [the guideline] recommends determining the risk and the benefits of weight loss medications,” Orsborn said during the session. “This is where we do most of our best work, which is helping to choose the right medication for the specific patient.”

The AHA/ACC/The Obesity Society Guideline primarily recommends this decision be based on the patient’s comorbidities. However, Orsborn said the American Diabetes Association (ADA) also have helpful guidelines for this purpose, and they update their recommendations every year. In the 2024 recommendations, the ADA guidelines advise that it is best to choose glucose lowering medications, as they are more effective for weight loss for patients. Additionally, Orsborn said that her clinic also uses the Obesity Medicine Association (OMA) guidelines for treatment decisions, as they also update their recommendations for treatment every year. In the OMA guidelines, they recommend medications be used right from the start for patients with a BMI greater than 30 or for patients who have a BMI of 27 or greater and have 1 or more comorbidities. The OMA then recommends reevaluating the patient after 12 weeks following initiating treatment for obesity.

In the OMA guidelines, they recommend medications be used right from the start for patients with a BMI greater than 30 or for patients who have a BMI of 27 or greater and have 1 or more comorbidities. Image Credit: © InputUX - stock.adobe.com

“If we need more weight loss or if we are trying to also work on A1c, we can change the medication or go more intensive on the dose,” Orsborn said during the session. “These [OMA] guidelines are different on the matter that they also provide us with a reference of information for when we should be referring our patients to a weight or obesity medicine specialist or for bariatric surgery.”

Orsborn noted that her and her colleagues started their clinic because most of their patients were diabetic and were already using weight loss medications. However, since they were not a weight management clinic back then, there was not much in the way of guidance or monitoring of progress that they could provide patients.

“So we said, ‘Well, let's start,’” Orsborn said during the session. “If we can have patients that are being referred to us, we can start to do more of a comprehensive approach, and that will make [our patients’ weight loss efforts] more successful, while also helping patients with their diabetes.”

As the guidelines recommend, Orsborn explained that the clinic started with supporting lifestyle changes for patients, such as behavioral interventions, healthy eating, and physical activity recommendations, as well as medications.

“But also, we recognize that by doing this, we were advocating for patients. We were actually providing more support by giving them more education than when they were just seeing their primary care provider. We kept them more engaged, and we actually gave them options for the interventions,” Orsborn said during the session. “That helped us to help patients make their own choices when it comes to their care plan. This also empowers people because they learn about how to eat healthier, be more physically active, and [manage their] behavioral health. For some of them, if they wanted, we could refer them to have more behavioral health support.”

When the clinic looked at each patient’s care plan, they tried to ensure they were SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals. This then helped to ensure a more patient-centered approach to care, according to Orsborn.

Additionally, Orsborn explained that as a pharmacist in the interdisciplinary weight management clinic, her role is to look at the risks of the patient’s obesity, assess appropriate weight loss goals for the patient, propose slight modifications, discuss why the patient would like to lose weight, address the role of medications with the patient, and discuss potential adverse effects of the medication with patients.

“Effective educational strategies are what empowers patients to want to lose weight,” Orsborn said during the session. “[We also use] motivational interviewing and implement shared decision making so that patients are more involved in their own care.”

REFERENCE

Orsborn M. The Role of the Clinical Pharmacist in an Interdisciplinary Weight Management Clinic. American Pharmacists Association 2024 Annual Meeting & Exposition; March 22-25, 2024; Orlando, Florida.