Overweight and Obesity: Putting Guidelines Into Practice

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.  

Geralyn Warfield (host): I'd like to welcome our audience to today's episode, where we're going to be speaking with Dr. Golden, who I'm going to allow to introduce yourself, and then we'll get started with our content. 

Angela Golden (guest): Hi, I'm Angie Golden. I own NP Obesity Treatment Clinic in Flagstaff, Arizona, and basically treat patients with the chronic disease of obesity using evidence-based practice.  

Geralyn Warfield (host): Well, obviously that's a topic we could probably spend weeks on, but we will definitely be focusing on some very specific parts of that today. 

I'm wondering if we could start our conversation with you discussing a little bit about the overlap of obesity and diabetes epidemiology.  

Angela Golden (guest): So, I think the interesting part that a lot of people are starting to recognize is, [00:01:00] obesity really is the cause of type two diabetes in about 85% of patients with type 2 diabetes. There are about 34 million people in the United States with type 2 diabetes (adults), and 85% of them do have obesity. Versus 140 million people with obesity. 

So, are we looking at a growing epidemic? Even more so for diabetes? Probably. if we don't start making headway in this almost pandemic of obesity that we have. So, I think that's why it's so important to understand the connection between the two.  

Geralyn Warfield (host): So, as a clinician, what kinds of triggers do you see for people coming to your facility, that maybe they've recognized that interconnection or perhaps they haven't, and that's something that you end up helping them recognize and learn? 

Angela Golden (guest): So, it's interesting. A lot of my patients come to me from family referrals. [00:02:00] They have family members who already have diabetes and obesity, and they don't have diabetes yet. And so, they come really to prevent that from occurring for them. Others are coming because a primary care provider may have told them, “If you could lose weight, you might be able to prevent or reverse your pre-diabetes.” So, a lot of patients are coming with, you know, that early beta cell dysfunction.  

So, I do see that, but also have a fair number of patients that, you know, they still come to me just like most of the world thinks that “It's a cosmetic thing” and they're just coming because they want to lose weight and they don't understand that that excess weight, that excess fat cells, have the potential to cause 236 other obesity-associated disorders. 

So, I think for some of them that first visit is [00:03:00] a real eye-opener—to realize that this is a chronic disease, and it can cause so many other things, including cardiovascular disease and cardiometabolic things like diabetes. So, sometimes that first visit can be a kind of long one as people start to let that kind of settle in for them. 

Geralyn Warfield (host): You've spoken a little bit about the fact that obesity is indeed a chronic disease. And we've seen the stigma around obesity shift in recent years. And I'm wondering if you could speak to, a little bit, about people with obesity, people with overweight, and that maybe that first conversation. And how to do that most respectfully, and so that the patients feel respected and listened to in that clinic visit. 

Angela Golden (guest): I think your point is so well made because so many of our patients with obesity and pre-obesity or overweight have just had such a horrible time in a place they should have been the safest—the [00:04:00] healthcare environment. The bias and stigma of healthcare providers has been shown in the research to be some of the toughest places for patients to be.  

So, I think the way to do it is just, first of all, be sure, you know, if you have your own bias and stigma around obesity. And some of it's self-blame, if you're a person with obesity, you're already self-blaming yourself. So, it's a lot easier to reflect that out. So be sure that you've checked that before you start the conversation. 

And then I always tell people, “Talk like you would to your best friend: kind, empathetic, let people know this is a safe place for them, that there's no judgment, so that they can have the conversation.” And The Stop Obesity Alliance—you can Google them, they're out of George Washington University—has excellent examples of ways to start the conversation. [00:05:00]  

Sometimes in my family practice, I'll start the conversation with things like, “You know, I've noticed that your BMI has gone up a little bit. That's different than your weight. Your BMI is kind of a different number.” Sometimes people don't even know what BMI is, and so it's a curious way to start the conversation. 

And I'll ask permission. That's the first thing. “Can I have your permission to talk about your weight today?” And, before I stop that question though, I will say, “Because I have some tools that can help with, with that. And I'd love to be able to have a conversation with you about it.”  

Because if you stop, “Can I have permission to talk to you about your weight?” the first thing the patient may think is, “Oh, another person to yell at me. Another person to tell me I should eat less and move more. Like I don't know that I'm fat.” I mean, that's what's going on in the patient's head.  

So, I'm quick to say, “I have some new tools that might be helpful.” [00:06:00] And that way, they know that I'm there to help. I'm not there to judge. And I think those are really important, but the biggest thing is to do it in an empathetic way. 

And then, understand how it's a chronic disease so you can explain that to them. Because I think that's the second piece of this whole puzzle for people is…I know myself as a woman living with obesity, there were numerous providers that had come in to say things like, “You know, you're overweight. You know you need to lose weight, right?” 

“Well, yeah, I have a mirror in my house,” is what you want to say back to them, right? But offered nothing, really, in response to that.  

So, I think letting people know that you're there to listen to them, that you understand they have a chronic disease, but you have to be able to explain what that means, if you're going to open the conversation to start with.  

Geralyn Warfield (host): We are having a [00:07:00] fascinating conversation with Dr. Angie Golden. We'll be right back.  

Geralyn Warfield (host): We're back with a little bit more information for you about how to talk to our patients with obesity, about the condition, and some tools that they have available to them. And I'm wondering if we could shift our conversation just a little bit, to talk just a bit about medication utilization for both obesity and for diabetes. 

Angela Golden (guest): Absolutely. So, you know, we've got some new tools in our toolbox that really are pretty remarkable because of the impact they can have on both of those diseases. We've got GLP-1 receptor agonists, which have been used for years for patients with diabetes, and now we've found that at some higher doses, some of those same medications can be very effective for, again, bringing down the hemoglobin A1c, but also having a good impact on weight loss.  

Now, the number on the scale's not our end result that we're looking for. What we're looking for is, by [00:08:00] losing weight, having a greater impact on the chronic diseases of diabetes, hypertension, hyperlipidemia, the 236 other diseases. But now we've also got the new dual agonist for diabetes, not yet approved for obesity, but that does have significant weight loss that's being seen in the trials when given to patients with diabetes. So, I think those new tools are really starting to show us that we can have great impact treating two diseases with one medication. 

And then the exciting part is you add in cardiovascular. Those same medications are starting to show some really interesting long-term help with cardiovascular outcomes as well. So how exciting is it that we can do one thing, one tool in our toolbox, one medication, and impact three different very large chronic diseases in the United States? 

Geralyn Warfield (host): It is an exciting time to be in this field and seeing what [00:09:00] the changes are that are on the horizon. And I'm wondering if you have any resources that you would point our listeners towards to find out more information as it becomes available.  

Angela Golden (guest): So, I would look at the Stop Obesity Alliance. They have some really great information for providers. 

The Obesity Medicine Association has a freely available algorithm that is updated each year, so it stays very current. 

And then, there's…Canada also has an obesity guideline that not only has parts for providers, but also has a section for patients. So, it has some nice handout kinds of things that people can use in their clinics to give to patients. 

Geralyn Warfield (host): And I would think that one of the key treatment options is making sure that patients feel empowered to advocate for themselves, but also to describe to, let's say, family members who perhaps don't understand this as a chronic disease. Is [00:10:00] that accurate?  

Angela Golden (guest): Absolutely. I think one of the things my patients take away from my clinic, every time, is the handout on how obesity is a chronic disease. And also, the shared decision-making handouts like how to select an eating plan that will work not just for them, but for their family life. And the shared decision-making on how to select a medication that might be right for them.  

I think that ability for the patient to be a part of that decision-making—it’s critical across every chronic disease, but especially obesity because there's so much bias and stigma, as you mentioned from the very beginning around it, are patients having an opportunity to be so engaged. And then be able to turn around and explain to their families everything that's happening in their treatment plan.  

It’s an absolutely critical part of what we're doing in obesity management.  

Geralyn Warfield (host): So, as we're thinking about [00:11:00] treatments, I'm hoping you could address for us the paradigm overlaps in those treatments that are available, or are on the horizon.  

Angela Golden (guest): So, I think, I think starting with just the baseline of treatment, it's the same for obesity, cardiovascular, and metabolic. And that's a good lifestyle intervention plan. I mean, it all starts with helping people have a relationship with food that's healthy. Learning to be more active.  

I don't use the word ‘exercise’ because a lot of people think of exercise as having to go to a gym. Just be more active. Maybe it's going to be gardening for one person. Maybe it's walking their dog twice a day instead of once a day for another person. And just so individualized. 

And then, especially, that behavioral intervention piece, which some people go, “Ooh, that sounds kind of complicated.” It's really not. It's just about teaching. Because when we are teachers, we're listeners first. We [00:12:00] hear the roadblocks that our patients are coming up on, and then we help them find a way around that roadblock. That’s what behavior intervention is.  

So that's our baseline of treatment. And then we use what else is in our toolbox, whether that's medications—and for obesity, it might be surgery if the patient meets certain criteria. But those medications impact the pathophysiology of the disease of obesity, just like our medications for diabetes impact the pathophysiology of diabetes. 

So, we need to keep that in mind at all times. These aren't vanity drugs. They're not really weight loss drugs. They're impacting the neurohormonal pathophysiology of the disease. And those support the patient's ability to stay with their intensive lifestyle interventions.  

Geralyn Warfield (host): So, in your practice, obviously we are talking about pharmacotherapies, we're talking about [00:13:00] lifestyle and behavior change. And do you, in your practice, have a support system available, or do you have resources that you can connect the patients to, to help these patients as they progress in this treatment? 

Angela Golden (guest): So, many obesity practices do. I don't. I live in a pretty rural area, so I do all of it with my patients: I help them select their eating plan. I help them stay on track with it. I help them progress in their activity. Now, I do have a couple of physical therapists, that if the patient has specific issues with, with movement and stuff, that I will refer patients to, in order for them to get that taken care of. But not specifically part of a team.  

Now, some of the bigger obesity practices will have dieticians with them that understand the disease of obesity. They'll have exercise physiology teams. They'll even have psychologists or counselors to help with that. And there are some excellent online [00:14:00] tools.  

That said, I do have a couple of my patients who will use, for instance, Weight Watchers as their eating plan. I'm a hundred percent behind patients utilizing that. It's a well-established program for an eating plan. They just show me that that's what they're using, and if they have any roadblocks when they're trying to do it, I help them maneuver through those. So, as long as the patient is comfortable with whatever eating plan they've chosen, that is a healthy eating plan, then I'm great with that. And that's a great community resource for a busy practice to use, too.  

And it's just an example of one. There are many others that people could use, and some are online, which make it easier for patients to utilize. 

Geralyn Warfield (host): I do appreciate the fact that we live in a time where there are options available. It's not just a one-and-done because not everything, as you've described, works for every patient. So having this wide diversity of things online, [00:15:00] in person, you know, family support, shared decision-making—all of those play into the success for our patients and helping them, you know, do what they want and need to do so that they can be as healthy as they possibly can. 

Angela Golden (guest): And that is the absolute bottom line. It's not about the number on the scale. It's about living their healthiest life.  

Geralyn Warfield (host): Great words from Dr. Angie Golden. Is there anything else that you would like to add that I've neglected to ask?  

Angela Golden (guest): I think I would just ask the listeners to start being more proactive. Patients with obesity, who are sitting in your clinic, when their weight isn't brought up, they feel invisible. So, learn how to bring the conversation up. And learn what the resources are in your community, if the resource isn't in your practice, so that you can help them find the care that they need. 

Geralyn Warfield (host): Thank you so very much for these great words of wisdom that we can take and apply into clinical practice tomorrow. You have been just a joy to speak with today. We are so [00:16:00] grateful to you for your time, Dr. Golden. And this is Geralyn Warfield, your host, and we will see you next time. 

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