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¹ This list is the rapporteur’s summary of points made by the individual speakers identified, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.

The second session of the workshop featured a panel composed of two obesity care patients and an obesity medicine specialist who described their personal experiences in receiving and providing obesity care. Presentations and discussion focused on the limited effectiveness of lifestyle modifications in weight loss, the benefits of AOMs and bariatric surgery, considerations and gaps in obesity care, shifts that may be helpful in primary care to effectively address obesity, the development of obesity treatment plans, and the ability of AOMs to reduce “food noise.” Joseph Nadglowski, Obesity Action Coalition, moderated the first part of the session.

LIVED EXPERIENCE AS A RESEARCHER: A PATIENT’S PERSPECTIVE

Karen Glanz, University of Pennsylvania, reflected on her lived experience of obesity; she described herself as a researcher in obesity, nutrition, and activity, as well as an AOM patient. She described a lifelong struggle with her weight, having experienced repeated loss and regain since childhood. After developing an interest in the field of nutrition during college, she pursued a Ph.D. in health behavior to study why people choose certain foods. Working from a conceptual framework of behavior, environment, and personal factors, Glanz turned to the influence of the food environment on diet and weight. Within the emerging science of healthy nutrition environments, she developed methods for measuring food environments. In 2008, Glanz started a training institute focused on measuring aspects of the built environment and their effects on health.

Throughout her career, Glanz’s weight struggles continued despite maintaining a healthy diet and being physically active. She competed in numerous triathlons over the past 2 decades, including the Ironman World Championship. Experiencing continuous weight fluctuations, Glanz described feeling shame and embarrassment during triathlons while wearing the swimsuit, cycling shorts, and running gear. In 2023, Glanz’s doctor expressed concern about her elevated low-density lipoprotein cholesterol level and recommended that she begin taking a statin medication or have a coronary calcium scan performed. The scan reported a calcium-adjusted odds ratio score of 10, indicating the need to begin statins. This development motivated Glanz to pursue AOM treatment for the first time.

In June 2023, Glanz’s doctor prescribed Wegovy, a weekly semaglutide injection. Her insurance qualification was processed within a few days, but the medication was not available. Her prescription remained on hold at a large, nationwide pharmacy chain for over 3 months. In September, a dietitian and colleague recommended that Glanz try obtaining it at the Penn Medicine Specialty Pharmacy. Typically, Wegovy treatment begins with a 0.25 mg starting dose that is gradually increased to 2.4 mg. The specialty pharmacy informed Glanz that if her doctor approved a starting dose of 0.5 mg, she could access the medication more quickly. Within 2 weeks of that approval—and 4 months after the original prescription—Glanz began Wegovy treatment. She described it as “a miracle drug.” Over the years, diets and high levels of activity repeatedly generated weight loss of 5–10 pounds that was always regained. In 5 months on Wegovy, Glanz has lost 32 pounds and reported feeling well and maintaining her high level of activity. She expressed hope that she will continue to lose weight and maintain the weight loss.

“I AM MORE THAN MY BODY MASS INDEX”: A PATIENT’S PERSPECTIVE

Michele Tedder, Black Women’s Health Imperative, is a nurse, patient advocate, and patient living with obesity. She presented an overview of the challenges that obesity has posed in her life and the benefits of comprehensive obesity treatment. Tedder recounted experiencing overweight or obesity since childhood and decades of extensive dieting efforts that yielded mixed results. Diets that caused weight loss did not maintain it, and she repeatedly regained weight. She voiced her frustration about being repeatedly told by health professionals to eat less and exercise more, noting that these methods had not been successful for her, despite numerous weight-loss programs. With a BMI of 61 before weight-loss surgery, she developed several comorbidities, including type 2 diabetes, severe sleep apnea, high cholesterol treated with statins, osteoarthritis and associated joint pain, and

high blood pressure treated with two hypertension medications. Tedder said that at that time, she was on a path of reduced quality of life and likely a shortened lifespan.

Concerned about these comorbidities, Tedder’s primary care provider (PCP) encouraged her to take additional steps. Underscoring the importance of the patient–doctor relationship, Tedder described how her PCP helped her to understand that obesity is a disease, that she is not at fault for having it, and that additional tools may be required to effectively treat it. Tedder said that being a health care professional herself and having had so many providers tell her to exercise more and eat less, she had developed an implicit bias regarding obesity, but her PCP helped her gain a different perspective. She and her health care team determined that surgery was appropriate in pursuing improved health and quality of life. In December 2017, Tedder had a sleeve gastrectomy; she was 5′1″ and 323 pounds, with a BMI of 61 and hemoglobin A1C above 8. Tedder characterized the surgery as a necessary tool that was “. . . one of the best decisions that I could have made at that time.”

Tedder emphasized that obesity care requires a multipronged approach—tailored to an individual’s unique circumstances—that may include surgery, medication, lifestyle changes, behavioral approaches, and access to healthy foods. Tedder’s own comprehensive treatment plan includes surgical care, medication, lifestyle change programs, and support from an obesity medicine specialist team, a personal trainer, and a behavioral health therapist. Furthermore, she has access to healthy foods, supportive social networks, and bicycling. Highlighting the value in tracking measures of metabolic health, Tedder said that BMI should not be the sole metric.

Tedder reported that her access to a comprehensive obesity treatment plan has fostered a range of improvements in her health, including remission of type 2 diabetes, discontinuation of cholesterol medication, substantial reduction in joint pain, decreased severity of sleep apnea, elimination of one hypertension medication, and dose reduction of another. Tedder weighs 238 pounds, reflecting 85 pounds in weight loss, with a BMI of 45 and a hemoglobin A1C of 5.1. “Comprehensive individualized obesity care has changed my life,” she reflected.

WEIGHT MANAGEMENT SPECIALIST: A PHYSICIAN’S PERSPECTIVE

Holly F. Lofton, NYU Langone Health, spoke from the perspective of a provider managing obesity and other weight conditions. She outlined considerations in treating patients with obesity, gaps and barriers in obesity management, treatment options, and steps needed to improve obesity care. She stated that a common patient experience entails (1) providing a medical

history; (2) having vital signs, height, and weight measured; (3) seeing a provider who prescribes medication for any presenting issue; and (4) being told to return in a couple of months. For example, a 40-year-old man who weighs 250 pounds, is 5′6″ tall, and has a blood pressure reading of 140/90 might be prescribed 20 mg of lisinopril for hypertension and scheduled for a follow-up visit in 1–2 months. Lofton said that as a board-certified obesity medicine specialist, she would consider his elevated blood pressure, BMI of 40, and potential issues arising from his body composition. Obesity causes not only subcutaneous fat but also fat deposits around visceral organs that can lead to inflammation, heart disease, stroke, and metabolic-associated steatosis liver disease (formerly referred to as “fatty liver disease”). It can also cause osteoarthritis in joints, particularly in the knees. Lofton noted that she would consider these possible ramifications and ask the patient how he feels. She commented that BMI is a number, and how a patient feels is more important to her efforts in supporting weight loss in a manner that fosters patient health and happiness.

Lofton highlighted the starkly inadequate number of U.S. board-certified obesity medicine specialists relative to the need. Obesity prevalence is 40 percent among those aged 20–39—with a higher rate among older adults—and it affects approximately 110 million U.S. adults. However, the ratio of board-certified specialists to patients is just 1:17,000. Therefore, the services of PCPs and specialists in other fields are needed, particularly given that all health care providers have patients with obesity. Lofton has surveyed providers on why they do not treat obesity. They often cite lack of time, lack of knowledge of effective treatment, lack of reimbursement, concerns about their own obesity and feeling unable or unwilling to broach the subject, and biased perceptions that patients are lacking in willpower or treatment is futile.

Lofton presented a pyramid of current obesity treatments that features lifestyle modification at its base (Fitch, 2021). All patients are candidates for lifestyle modifications, which result in 2–5 percent weight loss. Prescriptive nutritional interventions (specific diets) increase average weight loss to 5–10 percent and are a component of a comprehensive weight management program. Pharmacotherapy is available for patients with a BMI greater than 30—or greater than 27 with a comorbidity—and results in an average weight loss of 10–20 percent. Endoscopic procedures and bariatric surgery are options for some patients with severe obesity; these yield average weight losses of 10–20 and 30–40 percent, respectively. She highlighted the prior authorization process as a barrier to pharmacotherapy care for some patients. Insurers often require that patients try and fail older, less expensive medications before authorizing a newer medication for weight loss. Lofton emphasized that this undermines physician autonomy in providing the best treatment. Moreover, it is time-consuming for both patients and providers,

and requiring stepped therapy delays effective treatment for patients at risk for weight-related comorbidities. Lofton stated that this system is designed to control costs rather than provide effective care. The Centers for Medicare and Medicaid Services (CMS) cover medical nutrition therapy (MNT), enabling patients who meet the criteria for overweight or obesity to see a dietitian. In most states, access to AOMs is more limited than access to bariatric surgery under state Medicaid plans. She underscored that 80 percent of AOM prescriptions are not filled due to lack of insurance coverage or prohibitively high costs.

Lofton proposed several steps to bridge the gap between the need for obesity treatment and the level of access. Weight bias and sensitivity training are needed for people in and outside of the medical community to shift the perception of obesity from character flaw to medical condition. She outlined that increased access to care should include: community-based programs; healthy food options in cafes and vending machines; obesity codes for coverage by dietitians, weight management specialists, and other obesity care; incentives for physical activity beyond gym memberships; AOM coverage in all managed public and private insurance; and coverage of bariatric surgery. Electronic medical record tools could facilitate obesity treatment by including BMI as a vital sign that prompts nonspecialist prescribers to consider prescriptions, referrals, and standardized lifestyle handouts. Lofton said that providers need more medical education on obesity treatment options and approaches to offering care.

DISCUSSION

A panel discussion addressed topics including communication between health care providers and patients with obesity, obesity treatment planning, physician bias, and food noise. Nadglowski opened by asking what an ideal care system for people with obesity would look like. Lofton replied that it would provide equal and open access to medications, surgery, and lifestyle recommendations regarding diet, exercise, and behaviors for all such patients. Additionally, because obesity is a chronic condition, an ideal system would provide continued care to support maintenance after weight loss and for weight regain. Lofton noted that support for patients who regain weight should be free from any stigma or shame.

Obesity Care Communication and Treatment Planning

In response to a question about experiences with health care providers, Glanz stated that she had been treated by her provider for approximately 2 years before being prescribed Wegovy. This provider was concerned about Glanz’s cardiovascular health—particularly given her participation in

triathlons—and emphasized seeing a cardiologist more heavily than AOM treatment. This doctor did not suggest Wegovy; rather, Glanz requested it after reading about its efficacy. During the months of being unable to access Wegovy, Glanz’s doctor retired, and her new provider discussed contraindications and the process of self-injecting it. Tedder described her experience as “kissing a lot of health care frogs” before finding a provider who offered comprehensive obesity care and suggested options beyond lifestyle modifications. Tedder said that years earlier, she saw a PCP who also treated obesity and comorbidities; he shared that he was going to have weight loss surgery. She reported that at that time in Pittsburgh, a full bypass or Lap-Band surgery were the only surgical options available. Approximately a month after her appointment, Tedder was notified that he had died, and she later learned from a mutual acquaintance that it was from complications from the surgery. Tedder described that in her last conversation with him, he told her he would update her about his surgery in case she wanted to consider it, but his death precluded that idea for a long time. Tedder eventually shared this experience with her current PCP, who processed it with her and discussed the options that had become available since then. Together, they determined that sleeve gastrectomy was a viable option. Tedder said that she experienced no complications and has no regrets about the surgery.

Lofton said that as a scientist, she thinks about issues from an evidence-based standpoint. She always asks her patients what their goals are; their varying responses include wanting to be a certain weight or clothing size, a desire to eliminate some of the medications they are taking, concerns about comorbidities, and wanting to appease their referring doctors. Lofton assesses the likelihood of achieving each patient’s goals, and she also considers laboratory results when determining treatment options. She noted that many of her patients want to lose 20 percent of their body weight. Based on the science, the likelihood of achieving that goal with AOMs is about 50 percent, whereas lifestyle modifications without other treatments only carry a 3 percent chance. Lofton emphasized that 3 percent indicates that it is technically possible, but it is much less likely than with medication. She added that lifestyle modifications in diet, exercise, and behavior are always a component of her treatment plans, and their specifics shift over time; safety is also an important consideration. She also considers efficacy, the likelihood that a treatment will improve multiple aspects of health—such as weight and blood pressure—and medication cost and accessibility. Given that AOM treatment is often lifelong, Lofton considers long-term accessibility when determining a treatment plan. For example, she might recommend weight-loss surgery for a patient whose lifestyle modifications have not been successful in reaching health goals and whose insurance covers bariatric surgery but not AOMs. Once the plan is put into place, an ongoing provider–patient relationship is needed to enable patient monitoring, said Lofton. When a

patient gains weight, she is careful to address this as an indication that the plan needs to be reevaluated rather than insinuate that the patient has done something wrong.

Lofton said that she discusses potential side effects with patients and emphasizes the importance of collecting information from reliable sources. Given the number of easily accessible, unreliable sources, Lofton prints out studies conducted under controlled circumstances on the likelihood of certain side effects and provides these to her patients. For instance, AOMs can cause gastrointestinal side effects, and other medications have potential side effects, such as insomnia. She discusses these with patients while determining a treatment plan. Underscoring the importance of a patient’s comfort and willingness in bringing side effects to the provider’s attention, Lofton tells patients that she wants them to report any side effects that make them uncomfortable or affect their quality of life; she also reiterates that the goal of treatment is their increased health and happiness and not discomfort. Nadglowski added that some news sources report AOM side effects but fail to differentiate between those attributable to the medication and those expected with significant weight loss. For example, some side effects reported by the media are also seen in patients who experience significant weight loss, such as those experienced after bariatric surgery, and thus these are not true side effects of the AOM.

What Patients Want Doctors to Know

Nadglowski asked the panelists what knowledge they wish all doctors had when working with patients with obesity. Glanz replied that she wishes PCPs had a deeper understanding of obesity treatment, given that most patients do not have access to an obesity medicine specialist. Moreover, she would like to see physicians shift from a stigmatizing view of obesity as a moral failing to understanding it as a chronic disease. Glanz recalled a recent conversation with an endocrinologist friend in which she shared being on AOM treatment. Her friend responded by emphasizing that AOMs are lifelong. Glanz was dismayed that a health care provider would immediately focus on that aspect rather than the potential benefits. Tedder said that she wishes that all doctors (1) were aware that they hold implicit biases, (2) would be willing to explore their biases related to obesity, and (3) were committed to creating safe spaces in which patients with obesity feel they can express their authentic selves. She described carrying shame and implicit bias about obesity; fortunately, her PCP was respectful in holding meaningful, transformational conversations to address the views that she had about herself. Tedder stated her wish that all providers had this level of skill, awareness, and ability to create safe spaces for patients. She added that providers should hold one another accountable regarding attitudes.

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