This article is sponsored by the Academy for Continued Healthcare Learning. Visit the CME activity and Clinical Inertia Assessment Tool. This activity is supported by an educational grant from Lilly.

It’s been over twenty years since clinical inertia was coined a term, and since that time, experts have debated on how to define it, and where and when it exists across the treatment paradigm. Every year, scores of information cross HCP’s desks on clinical inertia, but when it comes to your patients, how do you determine whether your decisions to delay treatment intensification are clinical inertia or “appropriate inaction?”

And what about obesity? Individualizing treatment targets for patients with diabetes requires a comprehensive approach to minimize associated morbidity and mortality. Because most patients with T2DM are overweight or obese, effective glucose control and weight loss are needed to reduce cardiovascular risk factors and other complications of T2DM. However, misconceptions about the causes and mechanisms of obesity, and the false assumption that patients can manage their weight with simple behavioral modifications, contribute to ongoing clinical inertia in patients with diabetes.

Interestingly, while most HCPs can identify clinical inertia in their peers, they fail to recognize it in themselves and typically underestimate the number of patients in their care who have failed to meet their therapeutic targets. Whether they attribute it to the patient, the lack of time, or an absence of guidance on how to effectively individualize treatment, the problem persists.

To better support HCPs in their efforts, Donna Ryan, MD, professor emerita at Pennington Biomedical and Robert Kushner, MD, DABOM Professor of Medicine and Medical Education at the Northwestern University Feinberg School of Medicine, in collaboration with the Academy for Continued Healthcare Learning (ACHL), have developed a clinical assessment tool to provide HCPs with a “report card” on how effective they are in achieving short- and long-term therapeutic goals for their patients along with personalized recommendations on how to address inertia through weight-centric treatment strategies.

Visit the CME activity and Clinical Inertia Assessment Tool.

Donna Ryan is professor emerita at Pennington Biomedical in Baton Rouge, LA, USA, where she oversaw clinical research for 25 years. Her research interests included lifestyle intervention and diet for weight loss, and she was an investigator on NIH studies, including POUNDS Lost, Look AHEAD, DPP, and DASH.

Robert Kushner is a professor of medicine and medicine education at Northwestern University Feinberg School of Medicine, and director of the Center for Lifestyle Medicine in Chicago, IL, USA.  Dr. Kushner is past president of The Obesity Society (TOS), the American Society for Parenteral and Enteral Nutrition (ASPEN), the American Board of Physician Nutrition Specialists (ABPNS), and a founder and past chair of the American Board of Obesity Medicine (ABOM).

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we have a special sponsored episode by the Academy for Continued Healthcare Learning, with two leaders in obesity and dysglycemia care. Dr. Donna Ryan is professor emerita at Pennington Biomedical in Baton Rouge, Louisiana. Dr. Robert Kushner is professor of medicine and medicine education at Northwestern University Feinberg School of Medicine and director of the Center for Lifestyle Medicine in Chicago, Illinois. I’m excited to have this discussion about the challenges with weight loss in patients with dysglycemia and type 2 diabetes. Donna and Robert, welcome to the show.

Donna Ryan: Thanks for having me.

Robert Kushner: Thank you, Kevin. Happy to be here.

Kevin Pho: So before we start, I’m just going to ask you to briefly share your stories and journeys to where you are today. Donna, why don’t you go first?

Donna Ryan: OK. So I am a person who worked for many years in clinical research in obesity. I have always had a passion for good weight management as a pathway to better chronic disease management, and so I spent a lot of time talking to primary care physicians, trying to encourage them to embrace weight management.

Kevin Pho: Great. And Robert, briefly share your story and journey to where you are today.

Robert Kushner: Yeah, Kevin, I fell into this very haphazardly. When I was a medical student, I did an elective in nutrition because I wanted to get to the West Coast. I live in Chicago. It was literally life-changing. The six-week elective in Davis, California, changed my entire career direction, because I really thought diet and lifestyle were the most important things to maintain health. Everything I did since that time, internship, residency, fellowship, has all been toward helping people get as healthy as they can be, with a kind of subfocus in weight management, because early on, in the 1980s, that really jumped out at me as one of the biggest threats to individuals’ health: the weight gain that they have as they age.

Kevin Pho: Wonderful. Let’s get right into it. We’re going to talk about the challenges with weight loss in patients with dysglycemia and type 2 diabetes. Donna, I’m going to ask you the first question. Can you please describe the clinical inertia that exists with weight loss management in patients with dysglycemia?

Donna Ryan: We all see a lot of patients with type 2 diabetes. It’s 14 percent of the population with diabetes; it’s huge. You know, in the VA system, 40 percent of the patients have type 2 diabetes. So we see it all the time, but we have this clinical inertia, I believe, for a couple of reasons.

One reason is that, you know, we’ve all been taught this chronic disease model for type 2 diabetes. What that means is that we don’t have to treat it all at once. We need to treat it over a period of time; we need to keep the patients coming back. But I think what that does is make us a little complacent. We also are complacent about trying to achieve normal glycemia. You know, our ADA-sanctioned standard-of-care goal for glycemia is a hemoglobin A1c less than seven. Well, that’s a laudable goal. Only about 50 percent of our patients are making that goal. But still, I think what it does is it doesn’t capture that, you know, normal glycemia is not less than 6.5. We make the diagnosis of diabetes at a hemoglobin A1c of 6.5. We call prediabetes 5.7 to 6.5. But look, in that dysglycemia period, that prediabetes period, there is an increased risk for all of the cardiovascular and microvascular complications of diabetes. So it’s not really pre-anything. We need to be aiming for normal glycemia.

Kevin Pho: And Robert, what percentage of patients with dysglycemia would benefit from treatment intensification, for instance, to also manage obesity?

Robert Kushner: That’s a good question, Kevin. About 85 percent or so of adults with type 2 diabetes have coexistent obesity or excess body weight. In fact, it’s the weight that drives the increased incidence and prevalence of diabetes that we’re seeing in our country. So overall, 85 percent would benefit from weight loss, but even the additional 15 percent would benefit from intensification of lifestyle: eating healthy, being more physically active, getting a good night’s sleep, dealing with stress, and so forth.

So we are now thinking about diabetes, we’re kind of reimagining, this whole dual epidemic of obesity and diabetes, and combining it into diabesity. I really envision that over the near future, as this paradigm shift goes on, individuals who come in and see their clinician with diabetes and are overweight are going to have this dual focus, this dual target treated. It’s not just getting the blood sugar under control, which Donna just talked about; it’s also getting body weight under control, as two targets of treatment.

Kevin Pho: Donna, you mentioned earlier the importance of overcoming clinical inertia. How do we go about doing that?

Donna Ryan: I was just at the American Diabetes Association meeting, and for a long time, we’ve talked about weight-centric diabetes management, but this is the first time that I actually felt, among the people who were at the ADA meeting, that they were really interested in using weight management as a pathway to better diabetes management. We can do better. We can do better in our glycemic management. We can do better in our management of blood pressure, of lipids, of all the complications that are associated with obesity, and the pathway to do that is through weight management.

We’re finally getting some tools, some tools that work, that help us help patients lose weight and keep it off. Heretofore, it has been difficult with lifestyle change alone to achieve sufficient weight loss to really have an impact on all of those health risk factors. But now we’re getting some better medications, better diabetes medications, better weight management medications, that help us help our patients to better health through better weight management.

Kevin Pho: And Robert, what challenges do clinicians face with addressing weight loss in patients with dysglycemia?

Robert Kushner: Kevin, I think the biggest challenge they face is education in the skill set needed to manage weight. I think any clinician can see a patient who comes into the office and see they’re overweight. It’s visually apparent, or you do a body mass index and so forth. So it’s not diagnosing and recognizing that someone’s overweight. The challenge is what do you do about it, and that gets back to training and education. We are trying to get more education into medical schools and residency programs as time goes on, and once clinicians are educated, I think they do a better job.

The other thing I want to mention, though, is that excess weight, or obesity, really is unique among medical problems. I think very few clinicians have a challenge bringing up the problem of diabetes with their patients, or hypertension, or sleep apnea, and so forth. But the art of bringing up and having a sensitive, empathetic conversation about weight is not as easy. Weight is very personal. There are a lot of connotations and shame and stigmatization, quite frankly, about it. So in addition to the education, I think clinicians need to learn how to communicate in a very sensitive manner, and that’s a challenge, but they can do it with a little bit more coaching.

Kevin Pho: So Robert, take us into the exam room and give us a case study, story, or example that kind of illustrates what you just said.

Robert Kushner: You know, a common example is when a patient makes an appointment with their provider. They could be talking about diabetes, but they’ve also been struggling with their weight. The patient is often hesitant to bring it up because of fear that they’re going to be chastised, or that there’s going to be a paternalistic “I told you so,” or “What’s wrong with you?” or a sense of self-blame. There’s often this legacy effect, like, “I have seen 10 providers, and they always blame me; therefore, I’m not even going to bring it up.”

On the clinician side, they may not know how to bring it up, or they don’t want to embarrass the patient. If they talk about obesity, do you use the word “obesity”? Do you say “excess weight”? Do you say “weight gain”? Do you say “fat”? Or if they put it down on a problem list, they’re afraid the patient is going to be concerned that obesity appears on a problem list and is going to take fault with it. So there’s all this silent dynamic dance going on, and you know what ends up happening? It’s not even discussed in the office. So we need to train clinicians on how to bring the topic up in a sensitive way, such as, “Is this a good time to talk about your weight?” to show respect and to ask permission to do so.

Kevin Pho: And Donna, back to clinical inertia: What strategies do you employ in your practice to overcome clinical inertia with weight loss treatment in patients with dysglycemia and type 2 diabetes?

Donna Ryan: Well, it is a sensitive subject for patients, you know, so I think the focus in the conversation with the patient is about health, because if I start the conversation about weight, I’m judging that patient for their body size. So I think the emphasis has to be on health. You know: “The single best thing you could do to improve your health would be to make some changes that could result in some moderate weight loss, and you would maybe need fewer blood pressure medicines, diabetes medicines, things like that. Will you work with me to make some changes to your medications and to your lifestyle?” So I think, going at it, the inertia is not just there on the physician’s, the prescriber’s, part; it’s also there on the patient’s part. So I think you have to go to where the patient is. Don’t start where you are, but start where the patient is.

I think we can all do better at prescribing with weight centricity in mind. We really need to avoid those sulfonylureas, which drive weight gain, and of course, insulin is a huge growth factor. We need to avoid insulin whenever we can. The TZDs improve the metabolic profile, but they also cause weight gain, so often a year or two after your TZD has been prescribed, you’re heavier, and you’ve got all your metabolic complications back. So we need to do better with our prescribing and know the profiles of the medications and their weight effects. That’s not just true for diabetes medicines. It’s also true for the antidepressants, many of which drive weight gain, and it’s even true for contraceptive medications, for example. We need to not produce iatrogenic weight gain whenever possible.

Kevin Pho: And Robert, what can care teams do better to overcome the clinical inertia?

Robert Kushner: Yeah, Kevin, so we’ve been talking about challenges and clinical inertia thus far, and one thing we haven’t talked about is our system of practice, which is set up for acute care visits. It’s very difficult for a clinician him or herself to manage a chronic care problem in an acute care system. So that’s where these chronic care models come in, and part of a chronic care model is working within a team, not only a team within your office, but also extending it to the community.

So when we talk about improving weight management and dysglycemia, it’s helpful to think about who else should be invited onto the team to help this patient. Those would be, as an example, registered dietitians to help with medical nutrition therapy. It could potentially be health psychologists to deal with coping and stress-related issues. It could be a physical therapist or a personal trainer that you would refer out to, as well as advanced practice providers, such as a nurse practitioner, physician assistant, or a nurse in the office. All of these individuals are a team that can provide for all the needs of a patient who’s dealing with a chronic care problem such as being overweight and dysglycemia.

Kevin Pho: And just to follow up on that, Robert, what are some of the obstacles that prevent more of these teams from existing?

Robert Kushner: The biggest obstacle is that our health care system is not set up for it, with an acute care visit that is usually 10 to 15 minutes. Dietitians are often not reimbursed. Physical therapists and personal trainers are rarely reimbursed, and we often don’t have the resources and protocols readily available to us in the office to help patients with what they need when they leave the office, right? Because we have to think: Even though we only have 10 to 20 minutes with them, they go home, into their own environment, their own home, to manage this chronic problem. So the more resources we can provide and the more of a team approach we can offer, I think the more successful they’re going to be.

Kevin Pho: All right, let’s move on to talking about the treatment options that are available for patients with both obesity and dysglycemia. Donna, I want to address that question to you.

Donna Ryan: Yeah, that’s great. You know, I really want to endorse what Bob said about it taking a team and the multiple approaches that can really help patients. A couple of things he didn’t mention. First is bariatric surgery. So for patients with a BMI of 35 or higher who have diabetes, especially if it’s not being well controlled, bariatric surgery is an option, and about 50 percent of patients will no longer have type 2 diabetes after their Roux-en-Y gastric bypass. It’s a little less with the gastric sleeve, but that’s still a great option for patients. You know, our thinking about obesity has always been that it’s a chronic disease, but we’re learning that if we can get enough weight loss, we can actually put patients with diabetes into remission, that is, normal glycemia on no diabetes medications. So that’s one important thing.

Another thing he didn’t really mention was commercial programs. We’re fortunate in that we have some commercial programs that do have a good evidence base around them. For delivering lifestyle intervention, we’ve got Weight Watchers, Jenny Craig, and Nutrisystem, all of which have published their results. There are also some published results around Noom. These are great commercial lifestyle options for patients. I think the problem is so large that we really cannot handle all of this in our health care system. We need the private sector to step up and help us. Unfortunately, patients really have to navigate that private sector, because they’re often exposed to treatment approaches that don’t work, have no evidence base behind them, and are potentially unsafe. So if it sounds too good to be true, it probably is, and that’s why we need to be advising our patients on which of the commercial options are really the best ones.

Kevin Pho: Now, Donna, to follow up, for the patients listening to this episode, how can they better evaluate those private sector options? What kind of tips can you offer them?

Donna Ryan: You know, I think the ones that are tried and true, the ones that have been around a long time, such as WW, the new name for Weight Watchers, which has the greatest consumer satisfaction on the basis of both efficacy and value. You know, the treatments that are suggesting their efficacy with the before-and-after picture, avoid those. You know, losing weight is hard work, and it’s not as simple as taking a before-and-after picture. I think you want to make sure that the commercial program has an advisory board of competent clinicians and scientists, and that the treatments are evidence-based. With a little research, patients can find those things on the internet.

Kevin Pho: So when it comes to lifestyle interventions, Robert, what is the efficacy of weight loss with these lifestyle interventions alone?

Robert Kushner: Kevin, I can tell you, if you take all the studies that have been published, the average weight loss after about one year ranges between five to eight percent from where you started. Now, that could be a little misleading, because that’s an average, and I’ll tell you, any patient who walks into a room doesn’t think of themselves as average. They think, “I’m the one who’s going to do the best.” We have to take into consideration that there’s a great deal of heterogeneity with any treatment, lifestyle included. Some gain weight with a lifestyle treatment, and some lose much more body weight, but the average is about five to eight percent.

There are a lot of reasons for that. It could be the genetic makeup, the biology of what is going on with the patient, or how intense the lifestyle treatment is. We know that the more intense the delivery, not only in frequency but also in guidance, and the adherence to those changes, the more successful they’ll be. And then there’s culture and access and affordability, all these social determinants of health.

Probably one of the biggest concerns, though, in addition to that, is the difficulty sustaining the weight loss, and that’s where treatments like Donna was talking about, pharmacotherapy or bariatric surgery, become very important. In almost all the studies published, again looking at averages, if you lose five to eight percent in the first year, or even 15 percent if someone does very well, and you follow that group of individuals over time, there’s a slow weight regain. That’s because of the biological forces that cause one to regain weight, as well as the fatigue that probably sets in with changing lifestyles. So, very important: Lifestyle is foundational to health and to chronic disease management, like for individuals with dysglycemia who are struggling with their weight, but they often need more intensive treatment for long-term success.

Kevin Pho: And Donna, I’m going to ask you now about those pharmacological options. I understand there are dual GIP and GLP-1 agonists under investigation. Can you tell us more about these and how you think they will fit into the current treatment paradigms?

Donna Ryan: The big news in the management of diabetes and weight management is these biologic approaches. You know, we’re finally doing much better in our understanding of the biology of glycemic regulation and the biology of body weight regulation, and it’s really these better biological understandings that have given us some great medicines. We have the GLP-1 receptor agonists. They’ve been around about 15 years, and they’re getting better, producing even more glycemic control and robust weight loss. The same thing is true for the SGLT2 inhibitors. We’re lucky to have them because they also produce weight loss, more moderate weight loss, but still some pretty good weight loss.

But the biggest news that’s happening in diabetes is this combination GIP/GLP-1 molecule that affects both the GIP and the GLP-1 receptors, and that is producing, on average, about 13 percent weight loss at one year in patients with diabetes. In obesity, they released their results, and it was 22 percent weight loss in patients with obesity. It’s not approved for obesity yet; that’ll take about two years to work through the regulatory process. But meanwhile, we have this drug that’s quite efficacious for weight loss in persons with type 2 diabetes. There’s also a more powerful GLP-1 receptor agonist, for example, semaglutide. It produces, on average, almost 10 percent weight loss in persons with type 2 diabetes. So these are great drugs, and the pipeline for what’s coming is getting better.

You know, Kevin, I think one of the big reasons that we have not been more weight-centric in managing diabetes is that we haven’t had a way in our primary care practices to help people lose weight and keep it off, and we’re finally getting there with these drugs. So I think it’s going to really make an enormous change in the management of diabetes, in the prevention of diabetes, and in the prevention and management of all the complications that occur with obesity. I’m hopeful.

Kevin Pho: So Donna, to follow up, tell me who the ideal patient would be. I’m a primary care internal medicine physician. Tell me the ideal patient that I would consider prescribing some of these medications to.

Donna Ryan: Yeah, for the patients with type 2 diabetes, it’s exactly like, you know, the guidelines we have for more robust glycemic targeting. So we want patients who are not older; we want younger patients. We want patients earlier in the course of their disease. We want patients who don’t have a lot of complications. We want patients who are motivated and willing to undertake a more intensive weight loss effort. So I think it is possible to select those patients and offer this treatment to them.

You know, these medications don’t work as well on their own. They do produce some weight loss, but if we really want to get the benefits of these medications, we need to be prescribing them with lifestyle advice around diet and physical activity. So among your diabetes patients, those who are younger, those who are motivated to undertake lifestyle change, those who haven’t had diabetes for 25 years or are earlier in the course of the disease, this sort of approach can really produce dramatic improvements in glycemia, hypertension, dyslipidemia, and lots of the complications that go along with type 2 diabetes. So that’s really the patient profile we want to find.

I think it’s more difficult for patients who are in their 70s and up to lose weight. It is possible to do it safely, but we always are more cautious in older people because we’re more concerned about the loss of lean mass in addition to the fat mass. Of course, what we’re trying to do here is reduce fat mass, especially that ectopic, abnormal fat that’s really driving the dysmetabolic syndrome.

Kevin Pho: So Robert, can you tell us about the exciting assessment tool and CME activity that you and Donna developed together?

Robert Kushner: Kevin, we created this clinical inertia assessment tool to help clinicians assess how effective they are in achieving short- and long-term therapeutic goals for patients with type 2 diabetes. Clinicians can gauge their skills in addressing dysglycemia and obesity and see how they measure up to their peers. This tool also provides additional resources and education based on individual needs. We recommend participating in the CME activity available after completing this tool. In this CME activity, Dr. Ryan and I offer a how-to method for introducing strategies into practice. This tool is available in the show notes. It’s also available at achlcme.org/t2d-management.

Kevin Pho: You’re listening to a special sponsored episode by the Academy for Continued Healthcare Learning, with two leaders in obesity and dysglycemia care. We are excited to interview Drs. Donna Ryan and Robert Kushner. Now, I’m going to ask each of you for your take-home messages to the KevinMD audience. Donna, why don’t you go first?

Donna Ryan: OK. My take-home message is, I think you need to aim for 10 percent weight loss or 15 percent weight loss. It is not necessary for patients to achieve a BMI of 25, or even 30, or even 35, to get a lot of health benefits with weight loss. The physiology of weight loss is such that no matter what your starting BMI, the loss of 10 or 15 percent can really result in dramatic improvements in glycemia, in blood pressure, in lipids, in inflammatory markers, and a lot of health improvements. Patients will feel better, and they will have a much better metabolic profile. So you don’t need to aim for an ideal weight. Ten or 15 percent should be your goal.

Kevin Pho: And Robert, what are some of your take-home messages to the KevinMD audience?

Robert Kushner: Kevin, my take-home message is that we are facing a dual epidemic in this country of both obesity and diabetes, and we combine them into one word called diabesity. We want to tackle both of them simultaneously. The challenge on the provider side is knowing how to do it effectively and successfully in a very short office practice. Most clinicians are already out of training, so it’s really incumbent upon them as adult learners to educate themselves through CME, through podcasts like this one, and through articles, to increase their skill set and competency to treat both obesity and diabetes, and to learn the communication skills needed so they can partner with their patients in a supportive, empathetic manner.

Kevin Pho: And once again, the CME activity and tool from Drs. Ryan and Kushner are available in the show notes and at achlcme.org/t2d-management. Donna and Robert, thank you so much for sharing your time and insight. Thanks again for being on the show.

Donna Ryan: Thank you, Kevin.

Robert Kushner: Thank you, Kevin. I enjoyed it.