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Welcome to the Quick Consult podcast, brought to you by Metall. Before starting this podcast, please review the faculty information, disclosure statements, and learning objectives using the link in the episode description. To claim your CME credit, complete the evaluation using the link in the episode description. This podcast is a continuing education activity managed and accredited by Affinity CE in collaboration with Metal. This activity is supported by an independent medical education grant from Lily. Welcome to episode 3, where we'll be learning how to build structured follow-up pathways. Given that obesity is a chronic disease requiring long-term care, effective follow-up is vital for adherence and sustained success. I'm joined again by Doctor Patrice Forner. Let's start with embedding care into practice. How can a busy practice effectively embed ongoing obesity care into their existing chronic disease management workflows, ensuring that patients receive the longitudinal support necessary for long-term adherence. A lot of busy practices worry that adding obesity care means completely overhauling their systems, um, but the truth is the most effective approaches usually build on workflows that are already in place for other chronic conditions. Firstly, we need to prioritize ongoing longitudinal support. I've said this before, but this is an important point. Obesity should be treated like any other chronic condition, and patients need regular engagement to stay on track. Long-term follow-up is actually one of the strongest predictors of lasting success. Secondly, increasing the frequency of follow-ups really helps. These check-ins give clinicians a chance to troubleshoot challenges and make adjustments before small setbacks become bigger problems. And thirdly, is integration. So instead of creating a completely separate pathway, we Fold obesity care into existing chronic disease workflows, like diabetes reviews, cardiovascular risk checks, or metabolic health assessments. Scheduling weight-related follow-ups alongside these routine visits normalizes care, reduces stigma, and makes it easier for the patient to stay engaged. What key monitoring milestones beyond weight measurement should be scheduled at follow-up visits to ensure we are achieving the broader health benefits we discussed? When we think about follow-up visits in obesity care, it's essential to move beyond the scale and focus on whether we're achieving the broader health gains. So we want to uh track improvements across the metabolic, mechanical and mental health domains as well as overall quality of life, and these dimensions will often shift well before the number and the scale. We can build specific monitoring milestones into the follow-up schedule. For metabolic health, for example, we could routinely check an A1C, BP, and lipids for mechanical symptoms, reassess things like obstructive sleep apnea, osteoarthritis, and day to day physical function, and for mental health, we really need to take time to review mood, internalized weight bias, and quality of life changes because these factors heavily influence adherence and long-term success. It's also important to discuss adherence openly, so check in about cost, access, and practical barriers to treatment. These challenges often determine whether a patient can sustain the plan, and if we incorporate these milestones into routine follow-up, we get a far more accurate picture of progress than if we focus on weight alone. When should a patient's progress or non-response trigger a referral to an interdisciplinary team, such as a dietitian, psychologist, and bariatric surgeon versus an internal medication adjustment? I think the first thing we need to remember is that obesity management always sits on the foundation of the three pillars, nutrition, physical activity, and psychological support. This needs to run alongside any medical treatment we prescribe. In the ideal world, all patients would be receiving intensive lifestyle intervention, have access to a dietician, an exercise physiologist, and a psychologist, but often this is not the case. If a patient hasn't met realistic health or weight loss goals, we need to figure out if this is purely a pharmaceutic therapy issue or if there's a problem with one of those fundamental pillars. If there's a problem with one of the fundamental pillars, then we need to refer to appropriate providers or interdisciplinary teams. On the other hand, if the patient's doing all the right things, they're engaged, they're taking the medication consistently, they're supported psychologically, and we're still seeing a plateau or suboptimal weight loss, that's when I start looking at pharmacotherapy adjustments, and that might mean up titrating the dose, switching agents, or even combining medications, and of course we would consider bariatric surgery if the patient's eligible and their treatment goals are unmet. Consider a 52 year old patient who has a history of a heart attack and is on a long-term regimen of semaglutide for weight management and cardiovascular event reduction. After achieving 10% weight loss and feeling well, they ask to stop the medication due to cost. What should the clinician communicate about discontinuation? And what are the triggers for re-engaging a patient who may be lost to follow up? This is such an important and very real scenario because we see this all the time in clinical practice. So, imagine this 52 year old, he's had a heart attack, he's been on long-term simmaglatide, not just for weight. But also for cardiovascular risk reduction, which is really a key point, and they've done incredibly well, achieved 10% weight loss, they're feeling better, and then they say, look, the cost is just too much and I want to stop. The first thing I do is acknowledge the cost because it is a barrier, and there's no point minimizing it, but I also make sure that the patient understands what we've learned from clinical trials, and I explain this in very simple terms. So I might say somaglatide is treating chronic disease. When we stop the treatment, the benefits stop too. We have very clear evidence that weight is regained once medication is stopped, but what's even more important in this particular case is that the cardiovascular benefit also diminishes. Samaglatide isn't just helping with weight, it's reducing the risk of major adverse cardiovascular events. So I say something like, You've done the hard work, your body's responded really well, and the medication is helping to protect your heart. If we stop it, your weight will likely drift back-up over time and the cardiovascular protection will weaken as well. I want you to have all this information so that you can make a decision that's right for you. And I think that kind of transparency is essential, and ideally it's something that we talk about right at the initial consultation so the patients know that these medications are required long-term. Now there are situations where a patient simply cannot continue because cost is truly prohibitive, and in that case, I work with them to explore lower cost options, revisit lifestyle support, address any weight promoting medications, and ensure their cardiovascular risk is still being aggressively managed in other ways. Now, in terms of re-engaging patients, it's very common for people to disappear from follow-up when they stop medication. Obesity is a chronic relapsing condition, which means patients dip in and out of care. So I look for a few key triggers. So missed appointments is often the first sign that someone's drifting, uh, pharmacy renewal requests when I haven't seen the patient in months, uh, that's a flag that I need to check in. Or reports of weight regain, worsening comorbidities, or new diagnoses such as hypertension or diabetes, these are all opportunities to start another weight discussion. Preventing medication discontinuation and subsequent weight regain is clearly a long-term goal. To our listeners, here is a reflective question. Do your current follow-up workflows actively monitor for mental health or cost barriers? What is one change you can make this week to build more comprehensive monitoring into your practice? Thank you, Doctor Forner. Join us for our final episode on addressing stigma and improving patient engagement. You can access the full series along with other comprehensive resources and CME credit by visiting metaleducation.com. Thank you for listening. To claim your CME credit, complete the evaluation using the link in the episode description.