Welcome, everyone. My name is Mona Chadha. I'm an endocrinologist with the Ochsner Health Care System in South Louisiana, welcoming you to our first part of our webinar on reframing obesity. Tonight, we're going to be addressing some of the myths and stigma and bias in regards to obesity treatment. I'd like to welcome our faculty this evening, my co-presenter, Dr. Mogollon. Yes. Hello, everybody. Good evening, and thank you for joining us. My name is Maria Mogollon. I'm a foreign physician in internal medicine, specialize in obesity and diabetes, also an APRN here in the United States, and clinical faculty at Miami Regional University. Thank you and welcome. The rest of our panelists, Dr. Almendoz and Dr. Clements. Hi. Good evening, everyone. I'm Jamie Almendoz. I'm an associate professor at UT Southwestern in Dallas. I'm an endocrinologist and medical director of our Weight, Wellness, Obesity, Medicine program. It's great to be here. Thank you. Hi, everyone. My name is Jennifer Clements. I'm a clinical professor and director of pharmacy education with the University of South Carolina College of Pharmacy. Thanks for being here. Our first part of the webinar series presented by ACE is Breaking Down the Barriers, Addressing the Bias and Stigma. We don't have any financial issues to disclose. These are some of the objectives for the discussion this evening that we're going to get a better understanding and recognize and address some of the myths, misconceptions, and stigma associated with treatment of obesity and understanding obesity as a complex and chronic disease requiring a multidisciplinary approach and offering some patient-centered communication strategies to effectively engage patient evidence-based obesity management, including pharmacologic and non-pharmacological interventions. To get us started, just starting off with some vocabulary here, what are some of the myths? Starting off with one of the more prevalent ones that for decades, it was considered that obesity is not a disease. It's simply about willpower. While it was understood that patients with cardiovascular disease, hypertension, arthritis, those were defined as disease, for many years, obesity was not considered a disease. Some of the pushback against defining obesity as a disease felt that with this medical condition affecting growing numbers of the population and various scientists and physicians around the world not wanting to classify large percentages of the population as being ill, there was a great deal of pushback in defining obesity as a disease, but the NIH declared it as a disease in 1998 and the American Obesity Society defined it as a disease in 2008. It took some of the other professional organizations, such as ACE and AMA and others, another few years until 2013 to define obesity as a disease. The issue is that there are a number of extrinsic forces with societal issues, but also with intrinsic biases from patients themselves and from us as healthcare professionals in how we view our patients with obesity. And so, current thinking and certainly in 2025, we want to be able to reframe how we perceive patients with obesity in terms of long-term management. The second myth is that obese patients are always unhealthy. There are two sides of that coin, that with the way that we define and diagnose obesity with using BMI as the metric, there are limitations with that terminology. And so, patients who achieve a certain degree of weight loss, whether that's 10, 15, or 20 percent, by BMI they may still be defined as having class one or class two obesity, but they've improved their overall health. That being said, we also need to look at various patient populations in terms of older patients or patients of different ethnic groups, such as Asians, who may develop cardiometabolic consequences related to visceral adiposity with what is considered a normal BMI. And certainly those patients with lipodystrophy and other body composition issues may also have chronic health issues, but still be defined as having a normal BMI or simply overweight. That's such a wonderful point. As we talk about obesity and definitions, even the simple terminology that we use as we look at this, the way in which patients who are living with obesity are referred to, I think it's so important that we look at the classifications that we use patient-first language in all the things that we do and talk about patients with obesity and not kind of, you know, to use an example of kind of older or outdated terms that are stigmatizing, such as obese patients. I think you're making wonderful points here. Thank you. And that's a great point to add to. I want to say that, you know, we're all educators, right? And so I know in my role, while I'm educating pharmacy students and I teach the obesity lectures, I will spend, you know, addressing how I'm going to use person-centered language throughout the whole lecture and then encourage them to do that, you know, throughout their professional career. And so obviously we're examples for those young learners as well as they come along, but we're all educators in promoting that person-centered language. That was a very good point to add. Absolutely. Thank you. So in defining obesity as a disease unto itself, we realize that it's not simply a consequence of environmental factors. And in doing that, that creates responsibility for us as healthcare professionals to educate our patients on all the numerous factors that can contribute to obesity, to promote measures to prevent obesity, especially in our younger patients, where we are seeing such tremendous increases in obesity rates, especially severe obesity. We want to find these healthy treatments, both pharmacological and non-pharmacological, as well as identifying means of reducing relapse because obesity is a chronic disease that has the potential for relapse as well. Moving on with our myths here, that it used to be considered that all calories were equal. And so back in the day, we remember those pictures from our grandparents and great-grandparents that patients would want to follow low-calorie diets or very low-calorie diets. And oftentimes that could lead to weight loss, but then when those nutrition plans were stopped, that led to rebound weight gain. And so I remember talking to patients saying that not only do you gain that weight back, but it brings friends, right? So people would always regain plus more. So we know that it's not simply about weight loss, but achieving overall health for our patients. And with foods that are highly processed, sugary drinks, how these can contribute more to not only obesity, but also to cardiometabolic health versus more nutrient-dense, less processed whole grain types of food items. So moving on, this is a classic one. The myth of weight loss is simply based on eating less and moving more. And the calories in, calories out approach, I think most of us in healthcare these days know that this is quite outdated. It is no longer supported by any clinical evidence. And we realize that obesity and weight management is based on numerous hormones and numerous complex mechanisms, including nutrition, activity, as well as sleep that impact weight management. So with that, we will come to our first case and I'll turn this over to Dr. Mogollon. Thank you, Dr. Chadha. Yeah, with all this information about the myth and all your input, Dr. Chadha, we have this interesting case and very common case in clinic. She's a Maria. She's a 52-year-old female going through probably perimenopause or menopause with depression, joint pain, poor sleep, abdominal weight gain. She's also changing her lifestyle. She's doing intermittent fasting. She's walking daily, but she expresses frustration because nothing seems to work for her. She goes to her primary care physician and the doctor says that weight gain is common at your age. Maybe you want to try cutting more calories and exercising more. Maria continues expressing concern that she's already doing that and maybe there's other underlying causes that needs to be explored in order for her to achieve the goal. The doctor dismisses her worries and it says this is just part of getting older. Losing weight will help. So, next question. The question will be, what is the most appropriate patient-centered approach in this scenario? Option A, reinforce the need for stricter calorie restriction and increased exercise. Option B, acknowledge the patient's concern. Conduct a thorough history and physical examination. Explore potential underlying causes, including hormonal changes, sleep disturbance, weight-promoting medication, metabolic factors. Option C, explain that weight gain during menopause is inevitable and that lifestyle will have little impact on her health. Or option D, prescribe weight loss medication immediately without further evaluation. So, let's hear the panel. See what do you think about this case and if you have encountered situations like this. Dr. Almodose, do you see this type of patient in your clinic? Yeah, I think there's so many challenges when people come in hoping to talk about something and the clinicians start talking in a way that really doesn't engage them. And, you know, we have many patients who come in and I think a key demographic in our patient population is women in the age 40 to 60. When you look at kind of recent kind of representative national data in the U.S., one in seven women between the age of 40 and 60 has a BMI of 40 or greater and has likely had obesity for a significant period of time. And if you suggest, hey, how about you walk 30 minutes, five days per week, or have you considered counting calories or putting half the entree in a to-go box when you go to the restaurant? It's really not going to help to engage that patient in a way that's supportive. It makes a lot of assumptions when you make kind of comments like that out of the gate that patients are inactive. You're tacitly saying that they're overeating as well and I think it's important to take a meaningful history and to address their concerns. Many women around the time of menopause will have concerns about their hormonal health and those of us working in the endocrine space will see a lot of consultations for this and making sure that we address things in a meaningful way that's not dismissive, that acknowledges concerns. Help me understand why you're worried about cortisol, for example. Help me understand what to do and, you know, if appropriate, do the right testing or try to reassure the patient to the best of your ability as to why you don't think that this is an issue. I think too often patients will come in with a concern and feel dismissed in a way that really doesn't support them. They don't feel heard and it's very hard to engage them in chronic disease care if you don't have that relationship with your patients. Also, and I see this case, I immediately relate to one of the myths that Dr. Chadha mentioned about calorie in and calorie out. Such a simplistic way of treating excess of body fat, like, is very simplistic. It's more than just calories in and calories out and this is a representation of that myth. I also think that from my experience, I feel like, you know, people are still stuck that it's the person's fault, that they're living with obesity and they are not educated themselves that there's many factors into why someone may be living with obesity and so that's where, you know, I completely agree with everything that's already been mentioned where they're just maybe on autopilot and they go straight into recommending, you know, what the textbook says or the guideline says but they're not focusing on what the person is actually saying to them. That's exactly right and what you mentioned, Dr. Clemmons, is part of the blame and shame culture that we see both coming from healthcare professionals, coming from society in general and so we're definitely going to be addressing that later on in our discussion. So moving on, Dr. Mogollon. Yeah, so definitely we agree based on our conversation and experience that the correct answer is option B. The answer is the best, validate the patient's concern, definitely avoid stigma, insurance, a thorough evaluation and, I'm sorry, a weight-inclusive approach, address hormonal disbalance, weight-promoting medications, overall all the conditions that might play in a role in just calorie-in calorie-outness. Absolutely and then moving on, I think you wanted to illustrate some of those points in this slide. Correct and this brings us to this study that is relevant to what we just mentioned. This is a study done by data from the Women's Health Initiative. It was done with more than 70,000 post-menopausal patients and the aim of the study was to see the impact of weight-promoting medications in post-menopausal women throughout three years. So what this study results were that in terms of BMI, patients, post-menopausal women that were not using weight-promoting medications have very minimum impact and the more the weight-promoting medications they use, the more BMI increased. Same happened with the waist circumference. The medications they were studying, the weight-promoting medications they studied was steroids, antidepressants, beta blockers, and insulin and the patients that use a combination of all of them in the last more than six weight-promoting medications had the higher BMI and higher waist circumference. So definitely is another example that is not just calorie-in and calorie-out. Absolutely. All right, let's move on to our next myth that it's been widely held that patients living with obesity are lazy or don't want to make changes. Sometimes patients may think this about themselves, but more often we know that patients living with obesity have tried numerous nutrition plans and exercise plans and different supplements in order to lose weight. By the time they come to their healthcare professional for help, they've really tried to figure out what would be best for their own. And this search for answers, this search for the magic bullet or the quick fix is evidenced by the economy around obesity and obesity management. And just some statistics behind that, that just in the US alone, the weight loss market was valued at approximately $58 billion. And that was actually following a decline in 2020 because of the COVID-19 pandemic. And in 2023, that number had reached 90 billion. This was at the time where we could use medications like the GLP-1 receptor agonist agents a little bit more freely because in July of that year, there were far more insurance restrictions placed, which kind of put a halt to that in 2023. But the economy of this is expected to surpass 100 billion in the next five years because of the demand and the increase for new pharmacological treatments to manage long-term obesity. Moving on, looking at the stigma of obesity. And we see this in numerous, numerous settings. And when we talk about weight stigma, what we're referring to is that set of language and discriminatory acts and ideologies targeted towards patients living with obesity simply based on their weight and size. And we see this in various social settings such as movie theaters and restaurants and on the airlines where patients may have difficulty fitting comfortably in those types of social settings. We see this in our very young patients at school with various desks or even in the playground and in the locker room and even in the workplace. Patients living with obesity can face bias in terms of hiring and promotions which can overall lead to negative outcomes. Social media for years has had a stereotype of what the ideal body should look like. And it's taken a long time with marketing to turn some of these trends around. And these stigma and ideologies can lead to bullying and social isolation, which makes it more difficult for our patients to seek help. We know that obesity has impacts not only on cardiometabolic health and biomechanical issues but on mental health as with any chronic disease. And so when we are addressing the disease of obesity we need to be enabled to address the depression and anxiety and potential eating disorders that can go along with chronic disease management which can make weight management more challenging. Is this something that you all have seen in your practice? Yeah. I see patients all the time who've had very kind of negative experiences that really kind of drive a lot of, unfortunately they're challenging interactions with healthcare where it's kind of a challenge where they're coming in to get help and assistance. And what they're doing is they're kind of approaching things cautiously because of negative interactions they've had before. We recently published a paper this week looking at experienced weight stigma across lifetime. And it's kind of interesting. One of the findings we had was that people who develop class three obesity under age 18 are three times more likely to report experiencing severe stigmatizing experiences. And what that points out that it's kind of important for us to meet patients where they're at but also to know where they've come from from an obesity and healthcare perspective to make sure that we avoid creating, let's call it opportunities for misadventure with regards to using the wrong language or to basically not understanding why they may be talking about things in a certain way or approaching things in a certain way. We really need to meet patients where they're at in the context of where they've been. Absolutely. And the stigma that our patients face, I mentioned various scenarios where it impacts them in social settings and in the workplace, but importantly, it can affect them at home with personal relationships as well, with spouses and partners or parents and children and siblings. And this is why it really does take a multidisciplinary approach in long-term treatment of obesity because that cycle can be very difficult to break, especially if patients feel that isolation in their own home. So as Dr. Clements had mentioned before, there's definitely a blame and shame when it comes to society in general. And we need to look at this in different ways because as healthcare professionals, we try to turn and create change in how we are reframing obesity and how we are communicating with our patients, et cetera. And so, one question to ask is, as healthcare professionals, when patients seek help, what are the situations do they face? In our lobby, are there chairs that are appropriate to accommodate our patients living with obesity? If we have them change into gowns or the setting in our clinic exam rooms, are those appropriately appointed for our patients living with obesity? Many patients would say no, that they're not. As healthcare professionals, do we treat our patients living with obesity differently than those living with other chronic disease processes such as cancer or autoimmune processes? So, and then in terms of how we describe patients, there have been anecdotal studies that state that clinicians often describe certain characteristics to patients with class two or class three obesity, describing them as lazy or weak-willed or non-compliant. And we certainly know that that is a myth and not validated by any means. And in doing that, I'd like to bring us to this slide here that summarizes some of these myths and stigma that we've discussed, where if we focus on the left side of the slide, that there are certain societal as well as stigma in the healthcare profession against people living with obesity, which can augment mental health issues, emotional and binge eating disorders, affect their overall activity and body weight. Whereas the reason that we're doing this webinar at this time is to try to create a shift and create that reframing in how we approach patients living with obesity to create those preventative measures and educational resources, as well as therapeutic agents to treat obesity as a long-term chronic disease. So with that, I will bring us to case number two. Thank you, Dr. Chara. Yeah, and this is a case that represents that clinical and social stigma. And this is a 24-year-old professional soccer player who suffered a serious knee injury that require a complex surgery and a long recovery. The patient was bedrest. He was very limited in movement because of the knee injury. During this long period, he became increasingly withdrawn, which is understandable, right? He's a professional soccer player. He was diagnosed with depression. And on top of that, he was prescribed an antidepressant medication, an SSRI, by his physician. The following month, Luca gained noticeable weight. He increased weight and he began isolating himself. He didn't wanna socialize anymore. He started to receive some visits from some of his friends that they were making joke out of his weight gain. And some of them were telling him that he looks more like a fan than a player. Although he laughed, but he felt ashamed. He felt embarrassed and became avoiding social interaction. In the following physical therapy visit, also the physical therapy mentioned that he might be slowing down his progress because of that weight gain. The tone also felt dismissive to Lucas. He felt ashamed and unmotivated to continue therapy. Now, the question. So in this scenario where it's evident that we have a case of social and clinical stigma to weight and recovery, which of the following action will be most help for the healthcare provider to support Luca's recovery? Option A, dismissing Luca's emotional concerns and focusing solely on weight loss. Option B, encouraging Luca to attend therapy sessions without addressing his emotional distress. Option C, acknowledging Luca's emotional struggles, providing weight neutral care and encourage open communication about his mental health. Or option D, avoiding discussion about Luca's weight entirely assuming it is not important to his recovery. And I wanna just give another very important information that everybody that is in the healthcare industry is exposed to patients with weight issues or with excess of body fat. So we all need to learn how to address this type, not necessarily primary care or endocrinologists. Physical therapies can also be needs to address and reframe the way we expressing and communicating to our patients are struggling with this type of situations. So what is the panel opinion about this case? I think there's so many avenues of patients experiencing weight bias and kind of stigma in society. I think, you know, you bring up a great point that it's not just kind of frontline clinicians or nursing or death staff that need, let's say, training or to have a heightened awareness of their interactions with patients, but everyone, you know, particularly as we kind of talk about obesity care and let's call it the supply challenges we experienced in the last two years with obesity medications. One of the challenges many of our patients had with trying to get obesity medications was in the pharmacy. And they'd say, you know, the pharmacy staff told me that I didn't need this medication. I was told that I was stealing medicine from people with diabetes to treat my obesity. And so, you know, there are a variety of different ways in which patients may have unintended healthcare related weight stigma and bias when they're trying to get access to care. You know, I think this is a very challenging situation with poor Luca, who's, you know, been sidelined and has been started on medications for mood regulation. You know, we know that there's so many medications that can really contribute to excess body weight accrual. And, you know, his friends clearly aren't kind. As much as they were joking, everyone's pretty mean, right, about weight. And I think it can be really challenging unless we, you know, option C, acknowledge that Luca's emotional struggles providing weight neutral care with regards to his mental health medications as much as we can and acknowledge open communication about his mental health. I think it's so important to provide people with resources that will support their overall health and their weight in a way that makes sense to them in that moment. And I agree. I think, you know, with that, we would, with that approach, be developing a strong relationship with Luca to help him. You know, it would be important for him to know that he could feel comfortable discussing, you know, his concerns, and we'd be addressing his concerns as well, his struggles, whatever they may be when he comes in, knowing that's a safe space for him to express his thoughts and what's going on. Again, these strategies, I think, are to have that relationship with him, and ultimately he would be successful down the road. Absolutely. As we move towards the answer, I mean, Luca, his identity is as an athlete, and literally while he is sidelined now and then dealing with other health issues, which he may never have dealt with before, as healthcare professionals, we need to be able to create that safe space, that community, that language, in order for him to be restored to, you know, to good health, both mentally and physically. Absolutely. Well, yeah, the answer is C, acknowledging Luca's emotional struggle, providing weight-neutral care, and encourage open communication about his health, mental health. Yes, excellent. And so I think on this next slide, when we talk about the categories of the complications related to obesity, I think for, historically, that we've focused on the cardiometabolic issues, certainly, but we also have to consider a patient's quality of life, their mental health, their self-identity, as well as some of the biomechanical issues that patients living with obesity may experience. And so we want to be able to take a comprehensive, compassionate, and holistic approach in the care of our patients, especially the long-term care, when it comes to obesity management. So moving on, so we've talked about some of the myths, some of the stigma, which we have dealt with historically. And so starting a little over 10 years ago, ACE designated obesity as a chronic disease, as well as other professional organizations, AMA and the World Obesity Society, et cetera. These were primarily based on BMI, but they also acknowledged the cardiometabolic and the biomechanical complications related to obesity. But I think one of the most salient features of that designation was that we looked at adipose tissue as an organ in and of itself, and the hormonal aspects of disease as it relates to obesity management. And so, again, there were issues initially in framing this as a disease process, because BMI alone has its limitations. We certainly are aware of that. And there was just a great deal of uncertainty in how do we create policy in terms of patient education, in terms of insurance issues and health benefits, and regardless of ACE and other organizations, professional societies designating obesity as a disease, there were still great levels of stigma and bias in the public domain. And with that, because obesity, the word itself can be stigmatizing, in 2019, an alternative term was created. It's very easy to remember, A, B, C, and D, obesity-based chronic disease, where we look at abnormalities of adipose tissue, and this, again, would include our patients with lipodystrophy and other body mass composition issues, as well as the biomechanical and cardiometabolic complications that could impair health and confirm morbidity and mortality. So A, B, C, and D, which then brings us to case number three. Yeah, thank you, Dr. Shada. And this is also a very important case, and I believe is a very common also. She is Camila, a 35-year-old woman that falls into the high weight range. She has been trying to conceive for over a year. She visits a woman health clinic with concerns and mentioned that she's having fertility problems. She has a regular period, fatigue, excess facial hair. During her appointment, the nurse, during the interview, the nurse mentioned that losing some weight maybe will get her pregnant. Also, when she meets the doctor, the physician also focused her fertility issue by encouraging her to lose at least 10% of her weight. Later on, during the day after she goes to home and talk to her husband, and husband also mentioned, maybe if you actually do more strict diet, you might be pregnant soon, adding her a layer of frustration and feeling ashamed that all the fertility problem is because of her. Several years after, she's still having the same challenges and she decided to go to a reproductive endocrinologist. This time, she was diagnosed with polycystic ovary syndrome. Next question, how can weight bias and social stigma affects Camila's care? Option A, they promote a more holistic approach to treatment, prioritizing psychosocial support and fertility care. Option B, they may delay the proper diagnosis and lead to overemphasize on weight loss, ignoring underlying conditions like PCOS. Option C, they can encourage healthcare providers to address PCOS directly and consider all factors, including social and psychosocial issues. And option D, they help improve patient's outcome by reinforcing weight loss as the primary treatment for fertility changes. Now let's open this for discussion about this case with this amazing endocrinologist that we have here. I think this really summarizes some of the stigma that this patient has endured from various healthcare professionals, from her own spouse, and then intrinsically. And until she was able to get her diagnosis of PCOS, that she might not have received the appropriate treatment. What's your experience been, Dr. Clements, with this type of patient? Yeah, I feel like in this day and age that we live in due to so many reasons, there's a lot of patients that come in, I think, experiencing bias and stigma from different environments, different people, et cetera. Again, I think there's many different strategies we can put into place. I mean, from the time they walk into your office, meaning they could feel comfortable sitting in your chairs, for example, how you welcome them, how you teach the staff to also address them and things like that. I think there's so many strategies, right? But with that, in order to implement a strategy, I think we also have to look at ourselves and recognize what we can improve upon and make those changes gradually. We can't incorporate a lot of things. It's hard for us to start to change our language, for instance, as we talked about with person-centered language. But if we look inside and kind of set ourselves up for success and make it more comforting for them when they come into the office, we'll be better down the road. So we also have to be part of that change as well. Absolutely. This case actually has two questions. So I'm gonna move us on to the first part. Yeah, so the option B is the correct answer. They delay the proper diagnosis and lead to overemphasize on weight loss, ignoring the underlying cause like PCOS. So the second, this case has another question, which is what is the best approach for endocrinologists when treating Camilla considering both clinical and social bias? Option A, prioritizing weight loss strategies and delay further testing until weight goals are met, conduct thorough PCOS tests and providing a holistic approach, addressing medical and social factors impacting Camilla's health. I think this is very obvious answer. Option C, focus solely on managing insulin resistance with weight loss as secondary goal after addressing metabolic issues. And option D, focus on providing emotional support for dealing with weight stigma and delay fertility treatment until she's emotionally ready. What are your opinions? Well, after our rich discussion, it's pretty obvious, conducting thorough PCOS testing, providing holistic approach, addressing medical and social factors impacting her health, having a very health and a focused approach to this and acknowledging that it's a complex situation when we're living with excess and dysfunctional adiposity, that there's gonna be impacts on insulin resistance, PCOS and other disease states. We can't treat things in isolation and we need to approach things in a sensitive, compassionate and patient-centered way to really engage that person with evidence-based care. Absolutely. So answer is option B, exactly conduct a thorough PCOS testing and provide holistic approach. Definitely we need to be a comprehensive evaluation when we treat patients with excess of body fat. Thank you. And with that, Dr. Mogollon is going to go through this slide knowing that weight in and of itself, BMI in and of itself, these are metrics that are limited in terms of defining and diagnosing obesity. So this is an interesting article that was published in the Lancet just recently. Yeah. So this is a report from the commission and it's a proposal for like in comparing it with the traditional measurement of obesity. And they make two distinctions. One is the preclinical obesity that they define a patient with excess of body fat with non-impairment function of the organs and clinical obesity that are excess of body fat with organ impairment and limitations in daily activities. So those two distinctions are the ones that play important role in the new way of diagnosing obesity. So what they're trying to compare is that BMI is not giving us the entire picture of the health of a patient with this new, they're proposing this new method to have a better understanding of the health depending on the patient's BMI. So if we see the case number one is a typical patient with a BMI in normal range, 23.7, no excess fat, body fat, normal muscle mass and no signs and symptoms or no dysfunction of the organs. So in the old and the new way of diagnosis obesity, the category is not obesity. But if we see the scenario number two and number three, the difference between them is the composition, the body composition. It gives scenario number three, the patient has excess of body fat. If we compare it with the scenario number two, this scenario, the patient doesn't have excess of body fat. In the old way of categorizing obesity, this patient will fall under the overweight and different with a new way of diagnosing obesity, this patient will not be obese. Different with the patients with excess of body fat and normal or low muscle mass, this patient will fall in the new way of categorizing this patients will be in the preclinical obesity, a different in the old one will be overweight. So what we're trying to understand is what's the impact of the excess of body fat in the health of the patient. And I'm not gonna go through all of them, but I'm gonna go to the scenario numbers five and six. That is a very good representation of what a preclinical obesity and clinical obesity depending on the BMI and other components or body composition. So these two scenarios have combined same BMI, 39.2, 39.2. Both of them with excess of body fat, but the different in this two scenarios is one of them has signs and symptoms or organ dysfunction, which is this one case number six has signs and symptoms or organ dysfunction and case number five don't. So this will fall under preclinical obesity and the last one with the signs and symptoms will be falling under the clinical obesity. If we're categorizing in the old way of addressing obesity, both of them will be in the same category. And what this means is that that about the weight is about the general health of the patient and the impact of the excess of body fat in the patient's health. Thank you for that. All right, moving on to our next couple of myths, which are sort of related and again, reiterating that weight and BMI don't tell the whole story that reversing that or reducing weight alone equates to health. And we need to recognize that there are non-scale victories in addressing the not only cardiometabolic parameters, but also biomechanical as well as the mental health. Again, approaching the patient in a very comprehensive and holistic way of decreased pain, improved range of motion, exercise endurance, that can all have a tremendous impact on overall health that goes beyond the simple amount of weight loss. And we are not trying to achieve rapid or erratic weight loss because that could actually be more unhealthy than the smooth, steady, progressive weight loss. Recognizing that obesity is a chronic disease, we need to take a chronic approach to it and recognize the potential for relapse. Moving on to how we communicate with patients, we've discussed patient-centered language. And so there are some do's and don'ts and recommendations when it comes to healthy communication and how do we address this with our patient that will not contribute to that overriding weight stigma. And so some of the examples, we want to use neutral phrases such as patients living with obesity or higher BMI and using people first language as we've mentioned previously in the discussion. We want to use accurate facts and figures and be scientifically based and be very clear on the health issues of the patient as it relates to obesity and be very explicit and clear in our language saying obesity affects health in X, Y, and Z ways. Because I think that especially for patients, I live in South Louisiana and patients can often say, well, people in my family or people in my neighborhood or people in my community, they all look like me. So it's not a curse, it's not a strain, it's not a plague, but we do want to make those appropriate word choices with our language in explaining to patients how and why we should be treating obesity. So with that, that brings us to the five A's of obesity management. For those of us in healthcare, we know that the five A's, especially as it leads to therapeutic lifestyle changes, these are a framework of patient-centered counseling and behavioral change in order to create positive benefit in terms of disease management. And the first A is ask. We can discuss weight with the patient, assessing health status and comorbidities and causes of weight gain, looking at all those numerous factors that can contribute, advising the patient on treatment options, both pharmacological and non-pharmacological options, creating that shared decision agreement with weight loss expectations and treatment plans, wanting to set smaller and larger long-term goals and assisting the patient in the continuous process of weight management. Do you all use this in your day-to-day communication with patients? Do you find the five A's helpful? Yeah, I think it's a great framework for providing or for kind of initiating and carrying out very kind of patient-centered and kind of compassionate communications, particularly around stigmatizing topics like this. I think too often, clinicians who are either pressed for time or are otherwise motivated will just dive right into a sensitive stigmatizing topic, even if it wasn't on the patient's agenda and it can really blindside people. So I think kind of even asking for permission, even though it may seem silly, give somebody an opportunity to consider why you're coming at them with something that they may not have considered was even gonna be on the agenda today. And I think setting the tone for helpful conversations is always a great way to do this. And it's very fair and balanced. What we're doing is making sure that we're assessing things in a holistic way and advising on what treatment options are. This is key for shared decision-making that's really kind of underpins chronic disease care and making sure that we're doing this in the right way with patients is so important. Perfect, so with that, we will come to our last case of the discussion this evening. Yeah, so the last case is Angela. She's a 47-year-old female with history of hypertension, type 2 diabetes, treated with metformin, insulin, glycogen, and losartan. She struggled with adhering to dietary recommendations. She also reported knee pain, which she attributes to her weight and leads to sedentary lifestyle. On examination, the patient's BMI is 38.5, which is a class two obese. Blood pressure is 145 over 90 and A1C 8.2. She also has elevated cholesterol and triglycerides. During the initial visit with the primary care physician, he focused on her weight as a primary cause of her health issues. And I think that this is a very good representation of what you just mentioned, Dr. Shanna. The communication is key when we talk to our patients when we want to address the health. And definitely, I want to open the discussion to see what is the rest of the panel opinion. I'll offer the question here, and that might prompt some discussion on the panel. So what is the most appropriate patient-centered approach in this scenario? Recommend pharmacotherapy immediately without asking Angela opinion. Use the BMI chart to highlight obesity risk. C, ask open-ended questions about her perspective on her weight and its impact. And option D, suggest pediatric surgery as the only option. Yeah, I think, you know, with this case and then referring to the question and the answer choices, it's pretty obvious that, you know, we're not going to just like jump the gun and get right into it and be like, hey, we got this drug and, you know, all this stuff. We don't really know much, right? But as we've already discussed and talked about, particularly with communication, is we want to have that relationship. So we need to kind of understand where they are currently and where they've been. So we've heard that before. So of course, I think we're going to be, you know, asking her appropriate questions to kind of gain that knowledge for ourselves to better address her concerns with weight and how it's impacting her at this time. I normally, what I do in this type of scenarios, I approach the patient asking the readiness to make changes. If the patient is ready, then I continue advising and applying the five A's. I was going to say that I apply the five A's, but I'm not in the same order, probably sometimes. But I think asking for readiness is very good way of approaching this type of patients. Absolutely. So, which brings us to the answer and the rationale there. Yeah, option C is the best choice because using open-ended questions for a patient-centered approach and respect Angela's perspective by asking about reviews and the impact on her health. And of course, everything else that we have talked about during this session. Wonderful. So to wrap it up, you know, with our recommendations in terms of reframing obesity and decreasing bias, decreasing weight stigma, we want to focus on using people-first language as has been suggested numerous times, adopting positive language about obesity and especially now in 2025, where we have good scientific means of achieving healthy weight loss. We want to avoid language that is derogatory or pejorative. We don't want to contribute to the stigma that our patients already deal with, maybe from their friends and family and partners. We want to be very clear and use easy to understand language to illustrate why obesity is a disease in and of itself that needs to be addressed as any other health condition. And we want to look at the numerous factors that contribute to weight management and obesity where relevant. And again, using language that diminishes the blame and shame that serve pervasive in our society. So the reality of addressing obesity and its treatment can be challenging. And this is a situation that is something, a challenge that's formidable for both patients and healthcare professionals alike. But hoping that our discussion tonight brings awareness that obesity is a complex and multifactorial chronic medical condition. And we want to, as healthcare professionals, start off with creating that environment with our physical offices and clinics, using our language and creating that safe space where patients feel comfortable to come to us for treatment. Would anyone like to add anything as we wrap up our conversation this evening? I think you made some really wonderful points about the importance of addressing obesity in the context of a chronic complex disease framework and also acknowledging that many patients who live with high BMI and in larger bodies may have had negative experiences, may impact their willingness to talk about their weight and that we need to be sensitive in terms of how we approach that in the office, especially if the chief or presenting complaint is not weight-based.

obesity

stigma

chronic disease

multidisciplinary approach

BMI limitations

person-first language

patient-centered communication

mental health

healthcare biases