Weight Management Updates in the 2023 ADA Standards of Care

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I’ve had the great privilege to serve on the American Diabetes Association [ADA] Professional Practice Committee with you over the last couple of years, and you’ve been integral to the obesity weight-management section. Tell us about what’s new for 2023 in the Standards of Care, regarding weight management and obesity.

Scott Kahan, MD, MPH: The last few years have been wonderful, serving with you and our other colleagues. Over the last few years, there’s been a nice progression in what we’ve been able to codify in these standards and share with the medical community. One thing we’ve built over the last few years that we’ve stressed, especially this year, is that it’s important to manage obesity as a chronic disease—1 that’s typically progressive and often associated with medical, physical, and psychosocial complications. That helps take clinicians away from thinking about a patient as someone who’s heavy and needs to lose weight to fit into societal norms or into a healthier body mass index or a healthier weight status. Instead, they think about it in a broader way, as a health condition that has a lot of effects on the individual’s life. They work up those health problems and work with the patient to ameliorate them and improve their health and their wellness.

Second, we’ve noted the importance of not only weight loss but also of the maintenance of lost weight. It’s as important to keep the weight off as it is to take the weight off, especially when it comes to preventing diabetes or managing and mitigating diabetes, so we focus on that. One of the biggest tweaks in the guidelines this year has been clarifying the importance of smaller and larger weight losses as being potentially valuable. One thing we’ve known for many years, at least since the publication of the National DPP [Diabetes Prevention Program] studies, is that small weight losses—as little as 2%, 3%, 4%, or 5% weight loss—can go a long way in terms of preventing diabetes and improving health conditions and risk factors. But we also know—we’ve had an explosion of data supporting this—that while small weight losses are often valuable and a bit easier for individuals to wrap their heads around, especially when they have a lot of weight to potentially lose, larger weight losses are more healthful and sometimes a lot more healthful.

We tried to communicate in the standards that clinicians should discuss with their patients the value of smaller and larger weight losses and then support their patients on how to put that into place. For some patients, it’s not going to be realistic to aim for 10% or 15% weight loss. That’s OK because smaller weight losses are extremely valuable. For them, it’s a great goal to start with a lesser weight loss; you can aim higher later perhaps. For other patients, particularly those with diabetes and those with more significant diabetes, it will likely be even more valuable to aim for higher weight losses if that makes sense in the context of the doctor-patient discussion with respect to weight. That was another important point that we tried to make in the standards.

Natalie Bellini, DNP, FNP-BC: That’s amazing. When some patients present, if you say to them, “I need you to lose 15% of your body weight” and they weigh 350 pounds, then they might leave and they never come back. We’ve done that before in diabetes management. If your A1C [glycated hemoglobin] is 12%, you need it to be 6%, but 10% is much better than 12%. Outcomes improve every time we drop it. I love the idea of saying to a patient, “Let’s start somewhere.” That’s going to improve our messaging to patients and to individuals with diabetes and obesity. It’s a big improvement.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: What are the different approaches that the ADA recommends to achieve and maintain weight loss for individuals with obesity?

Scott Kahan, MD, MPH: ADA guidance is analogous to the other published guidelines on obesity management. It doesn’t have to happen in this linear, step-wise fashion, but we often discuss it this way. It starts with healthful behavior and behavioral changes. Adjusting what individuals eat, their physical activity level, and some relatively modest changes in health behaviors can go a long way in terms of improving risk factors, preventing diabetes, and improving quality of life.

However, in many other cases, patients aren’t able to achieve or sustain them, or the behavioral changes may not be enough to see the health benefits. In those cases, we can escalate to more intensive evidence-based and often structured weight-management programs. That can be in primary care settings or in specialty settings. It usually includes a number of different counselors and specialists that patients are working with, such as physicians, registered dieticians, behavioral therapists, and potentially other health care providers. That usually includes regular, intensive interactions between doctors—meaning the whole range of health care providers—and the patient to support them in making more significant behavioral changes.

When that’s insufficient, then we can escalate to FDA-approved medications for weight loss and often ongoing weight maintenance. When that’s insufficient, we can escalate to metabolic surgery. All of these have been shown to be effective on average, and different combinations of these may be more appropriate for different patient groups.

I’ve presented it in a linear, step-wise fashion, but it doesn’t have to happen that way, and it’s not always most strategic for it to happen that way. Sometimes, individuals have done a lot of work on behavioral change and have met with dietitians and other specialists before and worked at it. Even if you’re seeing them the first time, it may be perfectly appropriate to escalate to pharmacotherapy even on day 1. The same thing with bariatric surgery. It may be particularly strategic to utilize multiple strategies in combination rather than 1, and then the next, and then the next. That gets to the art of medicine. It gets to differences from patient to patient, but those are the general categories of obesity treatment.

Transcript Edited for Clarity