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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. OK, let's move on now to our 3rd objective, which is to talk about how to structure follow-up monitoring to support longitudinal success in obesity management, and this is really important. So, again, polling question for you, how long should weight management pharmacotherapy be continued? A, until weight has plateaued, then we stop. B, until weight has plateaued and then we try to decrease the medication. C, indefinitely, or D, as long as the patient wants to take it. So what do you think? Give you a few seconds. Fantastic. Thank you so much for your answers and your responses. So, the best answer here is C. We don't recommend stopping treatment as the data are very powerful. Continued treatment is required and we'll talk about that. Now, of course, D, as long as the patient wants to take it, we should never ask the patient to do something they don't want to do, they're in charge of their health, but does the patient understand the why of taking treatment long term? Making sure they do is really important because it could alter their response and their thinking. So, let's meet Samir. He's a 52 year old mechanic. He has a history of cardiovascular disease with a prior MI which was medically managed. He has obesity, he has hypertension. We see his medication list here and uh from the obesity uh perspective and cardiovascular risk reduction perspective, he's on semaglutide 2.4 mil. Milligrams weekly and we see he's on his other vascular risk reduction strategies as well. He has a BMI of 29. It was previously 33 before he started semaglutide. His waist is 101 centimeters. His waist to height ratio remains elevated at 0.55, so anything above 0.5 is considered elevated. His BP is well controlled, normal glycemic, lipids look good, and he's got good kidney function. So, in terms of his history, he started semaglutide for weight management and cardiovascular event reduction about 6 months ago. So remember, semaglutide has been shown to reduce cardiovascular events in people with obesity and cardiovascular disease by 20%. That's a really important treatment strategy. He's feeling well. His weight has come down by about 10% since he started Seaglitide, and now he wants to know, can he stop the treatment? He's lost the weight he wanted to lose, and it's expensive, so he's wondering if he can stop the treatment. So what happens if we stop weight management medication? Well, we actually have very clear answers to this from all obesity pharmacotherapy studies ever done, but here's really great examples with step 4, which is semeglutide on the left, and traspetide, which is surmount 4 on the right. In these studies, patients received semeglutide or trazepetide respectively, and after substantial weight reduction, they were then randomized to either stop or continue treatment. In both cases, we see that people who stayed on treatment had continued an impressive weight loss. When they were switched, switched to placebo, patients gained weight and were still gaining weight at the end of these studies. So, every study of obesity pharmacotherapy actually shows us the same thing. At the end of trials, weight is regained and this is accompanied by a regression of health benefits. So, we really want to avoid a yo yo wait cycle where patients have success, then they stop treatment, then weight is regained. This weight cycling has actually been associated with poor health outcomes, including adverse cardio metabolic markers and increased risk of type 2. diabetes over time, and even an increased risk of mortality and cardiovascular events. So, what we need is to have effective weight loss interventions early in the natural history of obesity and sustained weight loss as per the lower trajectory on this slide. So, Samir's on semaglutide 2.4 mg and the data from the select Cardiovascular outcome trial, which was the trial that demonstrated the cardiovascular benefit that we just talked about, they actually looked at weight loss over time. Now, this wasn't actually a weight. Weight loss trial, but they were still able to demonstrate that weight loss was sustained out to at least 4 years. So we want to use these results to encourage Samir to continue treatment, importantly for the cardiovascular benefit and also for sustained weight loss success. And a real-world retrospective data analysis was conducted in people with type 2 diabetes, which suggested that a longer duration of GLP-1 based treatment was associated with a lower risk of cardiovascular events, and concerningly, stopping GLP-1. Strongly and independently increase the risk of a cardiovascular event. So this suggests that the cardiovascular protection of GLP one based medication is better with a longer duration of treatment and that treatment needs to continue for the cardiovascular benefits to continue. So in our pharmacotherapy clinical Practice guidelines, Obesity Canada, we recommend that pharmacotherapy for obesity management should be used long-term when effective in conjunction with health behavior change to avoid weight regain and regression of health benefits achieved with pharmacotherapy. And here we see The, the medications with data to support that, including semaglutide and repetide, we just talked, talked about with very strong level of evidence. And there's actually also data for maintenance of weight loss and preventing weight regain following health behavior changes with the medications listed on the slide here as well. So what are the pitfalls where Samir could possibly be lost to follow up, because we want to make sure that doesn't happen. When his care is returned from his cardiologist to his family physician, it's a potential spot. If Samir doesn't feel supported in his ongoing treatment plan, if we don't talk about the long-term nature of treatment and touch base with Samir uh periodically as regularly as possible. If weight starts to creep back up, you know, Samir could lose confidence in his treatment. And of course, if cost or access to treatment changes. He did comment on the cost as being a driver for his inquiry as to whether he could stop treatment. So we definitely need to explore that and talk with him about that today. And we need to give him extra care at these time points to support and encourage Samir in continuing therapy. So is there a gold standard for what ongoing care means? Well, it's gonna look really different depending on where you are in the world, and where you are within your country, what type of clinical environment you practice in. So, some key points to remember are that studies show that the more frequent follow-up patients have, the better adherence and long-term success they will have with weight management. Of course, there's challenges, there's time constraints. We have busy practices. Patients are busy. They sometimes feel like they have too many contacts and don't want to see us as often and follow-up. So, you know, we really need to engage with our patient to make an individualized treatment plan that works best for, for them. Uh, in terms of triggers for re-engaging with Samir, well, if he starts missing appointments, and proactively reaching out to him and asking him to come in or giving a phone call saying, hey, Samir, what, you know, what's up? How, how, how can I help support you? How are things going? We haven't seen you for a while. Um, if you're getting requests from the pharmacy for renewals, you know, noticed the patient hasn't been in for a while, so now the pharmacy is asking for renewals, there's a flag to call Samir and to have a discussion. So, we really wanna look for, um, any, any red flags where the patient's commitment to treatment may be waning and really jump in to help support them and help keep them on that positive health journey. So the key messages from today are that we want to utilize evidence-based strategies to initiate and continue long-term treatment of obesity. The focus of obesity management should be the improvement of health parameters. Those can be metabolic, mechanical, mental, and or quality of life, not solely weight reduction. And we want to include outcomes that the patient identifies as important as well. And remember that longitudinal follow-up and support are really integral to the long-term adherence and treatment success for our patients.