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Managing Obesity: Patient Case
Patient Cases From Primary Care: A Patient With Obesity

Released: December 11, 2023

Nicole Fox
Nicole Fox, MPAS, PA-C, CPAAPA
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Key Takeaways
  • Multiple medications are approved by the FDA for the treatment of obesity and are valid options for patients depending on their unique history and comorbid conditions.
  • Treatment should be chosen after using shared decision-making to discuss options with patients.

In this commentary, Nicole Fox, MPAS, PA-C, discusses in more detail the second of 2 interactive patient cases from the program “Overcoming the Challenges of Managing Obesity: Strategies for the Primary Care Setting.” She provides insights on how she would approach these patients if they were coming into her primary care clinic. The second case is about a patient with obesity who does not have type 2 diabetes (T2D).

Medical, Social, and Family History
Renee is 38 years old and has come to the primary care clinic for routine follow-up. She has a history of weight gain from her pregnancies. After numerous unsuccessful attempts to lose weight, her current BMI is 35.5 kg/m2. She has tried over-the-counter orlistat, which caused gastrointestinal issues, and any weight that she lost from her previous efforts was regained. She does not report any sleep issues, and she has health insurance through her employer.

Her medical history is significant for a history of gestational diabetes (GDM), which resolved after her last pregnancy, and asthma. She is currently taking albuterol 1-4 puffs/day and depo medroxyprogesterone for birth control. Her labs are significant for a fasting glucose of 99 mg/dL. Her total cholesterol is within normal limits, and she has slightly elevated triglycerides of 155 mg/dL.

According to Renee’s social history, she has never smoked and drinks socially. She is not currently exercising. Her family history is significant for a father with T2D and hypertension who died of a myocardial infarction at 70 years of age. Her mother is still living at 68 years of age and has T2D.

If I were seeing Renee in my office, the first thing I would do is order additional lab tests. I would be interested to know her A1C in particular because she has a history of GDM, and we know that GDM predisposes a patient to an increased likelihood of developing T2D during her lifetime. A fasting insulin test also may be beneficial to see if she has some insulin resistance, which may guide your therapy options toward both blood glucose considerations and antiobesity medications. Because she has a family history of T2D, if we find that she does have some insulin resistance, I would first consider a medication that would help with insulin resistance and hyperglycemia (if she experiences it after meals) and obesity.

Treatment Considerations
|One option would be to have Renee start on a glucagon-like peptide-1 (GLP-1) receptor agonist such as semaglutide or liraglutide, both of which are indicated for T2D and obesity. A second option would be to start her on the dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 coagonist tirzepatide, which was approved recently for obesity in addition to T2D. Although those might be good options for her, with all of her labs being normal and all of her vitals within normal limits, she is also a great candidate for a lot of other antiobesity medications. I often have patients telling me that they have heard about the injectables but also have heard that they can cause stomach upset and are expensive, and they do not want to give themselves an injection. It is important for healthcare professionals to remember that we have other good oral options available.

I think phentermine/topiramate extended release (ER) or bupropion/naltrexone sustained release (SR) also would be great options for Renee. Of the 2 options, and because she did not say that she has trouble with cravings necessarily or depression, I would choose phentermine/topiramate ER. If she had comorbid considerations for depression or binge eating or craving behaviors then bupropion/naltrexone sustained release (SR) would be a good option and would also be my next choice for her if she wanted another oral option. It is important to use shared decision-making when discussing the various treatment options that might benefit your patients.

Other things to consider for Renee are her nutrition goals and her physical activity goals. She states that she is not currently physically active, so really trying to set a specific goal that she feels like she can fit into her daily schedule and can work on incrementally is something I would encourage her to do. At every appointment, I would make sure that we are getting her body moving to help reduce glucose uptake by her peripheral muscles and to help with antiobesity treatment.

Regarding Renee’s nutrition history, I would like to see a thorough 24-hour recall of her typical daily dietary patterns, both to see if there is anything I can suggest in the office and/or if there might be an indication to refer to nutrition for ways to increase different micronutrients and to work on a more detailed meal plan for her. I also really would like to dive into her history of social drinking, especially as the WHO recommendation for women to have ≤1 drink per day is lower than the recommendation for men. If there are episodes where she is exceeding this limit, alcohol intake may be contributing to excess calories and promoting weight gain. I often find that when I do a nutrition recall with patients, many times they are not thinking of beverages as extra calories, so I account for any beverages that are not water to see if those might be a source of extra calories.

In addition, I would make sure that obesity is added to Renee’s diagnosis list. This is to ensure a follow-up on that, as well as on any other comorbidities, such as insulin resistance. Of note, from a coding and reimbursement perspective, you typically need to add a diagnosis code other than obesity as the first primary diagnosis for reimbursement within your clinic for the patient to be covered by their health insurance. When I first started providing obesity care during my primary care visits, I had some patients who were not getting their visits covered because obesity was the primary diagnosis. We hope that insurance companies will improve coverage as obesity becomes more well recognized as a chronic disease with a distinct pathophysiology.

Follow-up Visits
After prescribing an antiobesity medication, it is important to follow up regularly to assess the patient’s progress. Remember that most agents and guidelines recommend changing therapy if the patient has not achieved at least a 5% weight loss at 12 weeks. This also allows you the opportunity to assess for additional barriers that may arise over time. In the case of Renee, she experiences a family emergency 6 months into her treatment and stops taking all her medications to care for a family member. I see things like this commonly in practice. If a patient stops their medication because of a life circumstance, it is OK to meet them where they are. If they were having success with a particular medication, it is reasonable to restart the same medication. If they were at a higher dose and it has been a longer period of time, you may need to restart at a lower dose again and titrate up gradually to prevent adverse events.

Your Thoughts?
In your practice, are your patients with obesity interested in incretin-based therapies? Share your experience by leaving a comment and answer the polling question below.

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