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Hello, everyone, and thank you so much for joining us today for the Global Obesity Academy International Program. My name is Doctor Sue Peterson. I'm an endocrinologist and obesity medicine specialist in Calgary, Canada, and I'm delighted to take you through this presentation that I've developed for you today. These are my disclosures. So in the next 30 minutes, we'll cover the following objectives. We'll talk about how to initiate evidence-based obesity treatment plans. We'll learn how to apply internationally applicable leading obesity guidelines to reassess and adjust therapy when targets of treatment are not being met. And we'll talk about how to structure follow-up monitoring to support long-term longitudinal success in obesity management. And we're gonna do all of this using internationally applicable evidence-based guidelines approaches. So let's get started with the first objective. And I'd like to do this in the context of Maria. We always want to talk about a clinically relevant patient case when we're learning so that we can take our learnings into our practice the following day. So, Maria is a 45 year old office assistant and she's aware of pre-diabetes lab work results, and she's wanting to come in to talk with us about that today. So, she has a past history of mild depression, which is well controlled. She also has obesity. Her only medication is bupropion for her depression. And when we look at the assessment, we see that her BMI is 35, waist circumference 105 centimeters. Her waist to height ratio is 0.6, which is elevated. We'll talk about that. BP is excellent and her A1C is 6.3% in keeping with her pre-diabetes. Good kidney function and lipids are normal. So first of all, a question for you. How do you bring up the topic of weight with Maria? Do you say, A, your lab work shows that you have prediabetes. Has your weight been going up? B. Your weight must have gone up for prediabetes to be showing up. C. Prediabetes can be seen in relation to elevated weight. Is it OK if we talk about weight today in the context of that concern? Or D, have you been doing anything to try to lose weight? So I'll give you a few seconds to answer that question. Great. Thank you so much for your responses. So the best answer here is answer C. Let's talk about that. In our Canadian Clinical Practice guidelines for obesity, clinical care begins with asking patients for permission to discuss obesity. This shows empathy, compassion, and promotes a trusting relationship. The second A is assessing their story. We then want to advise on treatment options, agree on treatment goals in partnership with our patient, and assist them in managing drivers and barriers to successful treatment. So when we ask permission to talk about weight, Maria opens up and she tells us that her weight struggle began after having her first child. She now has 2 children. She's tried lifestyle approaches on her own. She's felt a lot of blame and shame around her weight from her family, criticizing her, and also a lot of shame and blame from healthcare professionals in the past. So she's been really nervous to talk about this with us. Now, in the second A of, which is assessment, we want to assess the patient's medical history, identifying causes and contributors to that patient's obesity, and health complications that may be arising from their obesity. We can use the 4 M's framework of metabolic, mechanical, mental health issues, as well as monetary or social milieu aspects that may be barriers to care. We want to conduct an obesity-centered physical exam and order the appropriate lab work as well. Now, an important point I really want to emphasize in assessment is when we are looking for excess adipocity, we want to move beyond simply evaluating body mass index. The BMI doesn't provide evidence or information on body composition, muscle versus fat, nor on fat distribution, whether the fat is central metabolically active fat or subcutaneous peripheral fat. So in our newly updated 2025 Obesity Canada Pharmacotherapy Clinical Practice guidelines, which I was the lead author on, we recommend considering other anthropometric measures in addition to BMI including waist circumference, waist to hip ratio, and or waist to height ratio as these correlate strongly with adipocity-related complications. So in advising on treatment, here's a really important point about managing obesity from our Obesity Canada clinical practice guidelines. While diet and exercise were previously considered the mainstays of obesity treatment, they are not actually interventions in and of themselves. In fact, the vast majority of people will not have success with lifestyle intervention alone to lose or maintain clinically significant weight. The treatments of obesity are the three pillars of therapy. which are psychological intervention and support, pharmacotherapy, and or bariatric surgery. And we use these treatments as needed to support a better ability to adhere to healthier lifestyles. Regarding pharmacotherapies, which we'll talk about further, note that this is the list of medications that are approved based on the evidence in Canada. Available medications may differ depending on which country you practice in and what obesity medications have been approved by your local regulators. Now, of course, we still want to empower and support our patients in healthy behavior strategies. There's several different eating patterns that can reduce weight and cardio metabolic risk and obesity-related health issues, and you can see a list here including Mediterranean diet, lower glycemic index diet, and so forth. Long-term adherence to dietary intervention alone though, can be a challenge. Physical activity is also important, of course, and that can have many health benefits, even in the absence of weight reduction, and you can see some of those health benefits here on the slide. Resistance exercise also improves weight maintenance and can modestly increase muscle, uh, or fat-free mass and mobility as well. And what about psychological therapy, this pillar of treatment? So, what does that actually mean? Well, this can include behavioral strategies such as uh behavioral substitution, self-monitoring, or stimulus control. You can see some examples here. Um, managing cravings. This falls into many of these categories. And one key point is, rather than focusing on having what we want, we want want to want what we have, and that kind of thinking and cognitive restructuring can be really helpful for patients. Um, helping our patients optimize and manage sleep, time and stress as well is really important. So, why should we use pharmacotherapy as one of the treatment pillars? Well, health behavior changes alone are most often not sufficient for achieving sustained weight loss. and improvement in health. Pharmacotherapy can be really beneficial to decrease weight, optimize health, and support health behavior changes. In our 2025 Obesity Canada Pharmacotherapy chapter, which we mentioned earlier, uh, which we've also just published, we've developed an easy to use decision tool and table to help guide us in the use of pharmacotherapy in clinical practice. So the first The first thing we want to do is identify the goals of treatment with our patients. That can include weight loss, weight maintenance, and or management of obesity-related health issues. Now, we need to stop and consider whether our patients should be evaluated for rare monogenic or syndromic obesity, and we should consider genetic testing if there's early onset obesity with hyperphagia or features of monogenic obesity. So if, uh, we, yes, then we should consider cemelanoide for certain rare monogenic obesities like Bartlett Beetle syndrome. And if no, then we go back to the main decision tree on the left side. And this is where we'll spend our time with 99.99% of our patients. So here, we identify suitable medications from the 5 main medications approved in Canada. And again, here, it's very important to refer to the accompanying decision table in making our selection. I'll show you that in a moment, and also look at the medications that are available by regulators in your country. We want to consider patient values and preferences, contraindications, access, and so forth. We then initiate medication titrating as needed and tolerated and appropriate to achieve goals of therapy. So if our patient has reached their best weight, which is defined as the weight that a person can achieve and maintain while living their healthiest and happiest life, and or they have achieved optimization of their obesity-related health issues, then we continue treatment long term and reassess goals of treatment as needed. If they haven't achieved those goals, then with our patient in partnership, we should consider contributing factors, revisit pillars of treatment, and consider adding or substituting medication. Now, let's talk through our decision table, which, as I pointed out, is essential to include in the use of that decision tool that we just went through. So here we have listed each of the five main obesity pharmacotherapies available in Canada across the top. Then going down the left side, we can see that we have obesity-related health complications, and this is laid out so that we can see what benefit each medication may or may not have demonstrated for each health complication. And the color coding reflects the level or strength of the evidence for each medication. So going down the side, we have cardio metabolic and mechanical complications, and then we have patient reported outcome measures including quality of life, physical function, and cravings. So you can look at what obesity-related health issues your patient has, which medication could be of benefit to that health issue. If the amount of weight loss is important to your patient, then you can take that into consideration, and we have that listed across the bottom of our table here. So for Maria who has obesity and pre-diabetes, we can see that there are data for all of the available GLP-based medication, as well as