Abstract
Obesity is a chronic, relapsing and often progressive disease. Obesity Canada defines obesity as an excess or abnormal body fat that impairs health. 1 In Canada, the prevalence of obesity has increased by three-fold over the last 30 years and is now affecting 1 in 4 adults and 1 in 10 children. 1 Unfortunately, this problem is only predicted to get worse. Importantly, obesity is not a “lifestyle disease”—no one chooses to have obesity.
Obesity involves a complex interplay between biological influences, social determinants, sociocultural practices and beliefs, environmental effects, public policy and psychological factors. 1 These factors are further complicated by weight bias and stigma in our society and in the health care system. Health professionals often lack training in obesity medicine and rarely receive comprehensive stigma education in their university programs. 2
It has been noted that obesity is not being well managed in our current health care system.3,4 As well, individuals living in rural areas where there are limited health care resources have a higher prevalence of obesity. While access to care is improving, there are still several gaps in the system that must be addressed. More interdisciplinary care models and novel patient programs in the community and primary care settings are necessary.
The involvement of pharmacists in obesity medicine has been lacking and cited reasons are a lack of knowledge, time, private consultation space and difficulty in following up with patients. 5 Not surprisingly, it is postulated that stigma also plays a role.
Community pharmacists are among the most accessible health care providers and are highly trusted by patients. 6 Indeed, many patients contemplating weight loss will visit a pharmacy first for a non-prescription weight loss product and health advice. 7 This is an opportunity for specialized care and an untapped opportunity for pharmacists to take on a greater role in obesity medicine. Innovations in research and development are leading to the increased availability of pharmacotherapy options used in the management of obesity. Pharmacists are well positioned to provide medication management and support to their patients living with obesity.
For pharmacy staff engaging in obesity medicine, an important first step is to check your own attitudes and biases towards individuals that have obesity. This can be completed by reviewing the “Checking your Attitudes” checklist. 8 Should you find that you have weight biases, it’s not that you are a bad person. Instead, view this as an opportunity to gain a greater understanding of your patients’ experiences and how your internal biases may negatively affect their care.
Second, health care providers must use people-first language,9,10 though sadly this is often ignored. The goal of people-first language is to separate the individual from their disease—we as individuals are not defined by our medical conditions. For example, we should not state “John is obese,” but instead should say “John has obesity.” Similarly, we should not state, “Jill is a diabetic,” but instead should state “Jill has diabetes.” Using people-centred language and avoiding stigmatizing language will go a long way in supporting a patient’s care journey.
Third, is your pharmacy environment inclusive and destigmatizing? We suggest visualizing your pharmacy from the perspective of a patient with obesity. Do you have waiting area and consultation room chairs that will accommodate a patient with a higher BMI? Do you have a range of blood pressure cuff sizes? These are examples of important factors to ensure patients feel comfortable in an inclusive setting. 2
The following are some strategies for pharmacists to use in supporting patients with obesity in using anti-obesity pharmacotherapy:
Assess appropriateness
Current anti-obesity pharmacotherapy agents are safe and do not have many drug interactions or contraindications. A few helpful hints are listed below; however, it is important to always reference the product monograph.
GLP-1 or GLP-1/GIP agonists 11
A personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia-2 (MENS-2) is an absolute contraindication to use.
Caution must be exercised in patients with a history of pancreatitis, cholecystitis, gastroparesis or bowel obstructions, as there is potential for rare complications.
Oral contraceptive absorption may be decreased, leading to reduced effectiveness due to slowed gastric emptying; pharmacists should suggest a switch to a non-oral agent or recommend using 2 forms of contraceptives.
Bupropion-naltrexone (Contrave) 11 :
Significant drug interactions exist—suggest always using a drug interaction checker.
Contraindicated in patients with a seizure disorder or those with chronic opioid, opiate agonist or partial agonist use.
Screen for eating disorders
Anorexia and bulimia have a high mortality rate 12 and using the above pharmacotherapy agents that effectively reduce appetite can pose a significant risk to an individual’s health. There are 2 quick and easy questionnaires that pharmacists can incorporate into their practice to assess a patient’s history of eating disorders: the SCOFF Questionnaire 13 and the Binge Eating Disorder Screener (BEDS-7). 14 These questionnaires are not diagnostic, however, they should be considered and reviewed with every patient initiating an anti-obesity medication. It is important for the pharmacist to refer the patient for more in-depth assessment as needed.
Manage side effects related to anti-obesity medications
Mild to moderate gastrointestinal side effects are common with treatment initiation and dosage titration for GLP-1–based therapies. 15 These effects generally include nausea, heartburn, diarrhea, constipation and, in rare cases, vomiting. Management strategies include:
Education on the likelihood of side effects and their management at the time of medication counselling.
Slow dosage titrations; suggest remaining on a lower dose for greater than the usual titration schedule or using a dose that is in between standard dosage intervals.
Switch between agents; suggest using less potent agents to support medication tolerance, such as starting with Rybelsus then switching to Wegovy or starting with once-daily Saxenda.
Management of specific side effects:
○ Heartburn: Over-the-counter products such as Gaviscon, Tums and H2 antagonists. Proton pump inhibitors can also be considered for short durations.
○ Nausea: Ondansetron and other more centrally acting agents are preferred. Dimenhydrinate has anticholinergic properties that can lead to further gastroparesis.
○ Constipation: Fiber supplements or PEG 3350 initially and more potent motility agents as necessary.
○ Diarrhea: Fiber supplements. Imodium can be used in more severe situations; however, caution is warranted as it can also contribute to gastroparesis.
Nonpharmacological measures include eating smaller, more frequent meals through the day; focusing on bland foods and avoiding foods that are spicy; avoiding alcohol; and avoiding lying down within 60 minutes of eating.
Counselling and education regarding weight-loss expectations
Patients often have weight-loss expectations that are much greater than what is clinically expected. 16 When these expectations are not met, or the patient’s weight reaches a plateau, it can often lead to patient disappointment and discouragement, resulting in treatment discontinuation. Further, many individuals believe that using anti-obesity medications is for the short term; they do not realize that upon discontinuation the vast majority will regain the weight that they lost. 17 Pharmacists can provide appropriate education and support to help patients understand the need for medication adherence, setting appropriate expectations and stressing the additional benefits of weight loss on their overall health.
Managing prescription costs
Unfortunately, anti-obesity medications are costly and often are not covered by private or provincial insurance providers. This is in part due to the misconception that obesity is not a chronic medical condition and is a lifestyle choice. 18 Regardless, pharmacists should be supporting patients in completing necessary special authorization forms, identifying patient support programs and advocating on behalf of their patients to public and private insurers to provide patients with medication coverage for anti-obesity medications. In certain jurisdictions, pharmacists can also prescribe or recommend alternative agents that may be less costly.
Ongoing support and management of comorbid conditions
As the most accessible health care providers, pharmacists are well positioned for frequent patient follow-up to support ongoing lifestyle and behaviour changes, which will not only support adherence, but also enhance treatment success. Comprehensive, collaborative obesity care and close follow-up has been shown to result in weight loss and improved quality of life for individuals living with obesity.19 -21 Individuals living with obesity are at an increased risk for multiple comorbidities, including hypertension, dyslipidemia, metabolic dysfunction-associated steatotic liver disease (MASLD), cardiovascular disease, stroke, cancer, type 2 diabetes mellitus, asthma, osteoarthritis, depression and anxiety.1,2 Sustained weight loss of at least 5% is associated with a significant reduction in the development and delayed onset of many of these conditions.22,23 Pharmacists as medication experts can ensure therapies are appropriate, improving outcomes and reducing adverse events.
The 6 strategies above are meant as a starting point for pharmacists to be more comfortable with incorporating obesity care into their practice; the goal of these strategies is to improve patient adherence and treatment success (Figure 1).11-23 Non-adherence to anti-obesity medications is one of the major causes of treatment failure. Ko et al., in 2022, found the main reasons for discontinuing liraglutide (Saxenda) 3 mg daily were due to cost, perceived weight-loss failure, or an adverse event. 24 Adherence to medication therapy is important in obesity management, both for achieving successful weight-loss (5%-10%) from baseline and the maintenance of weight lost long-term.
Strategies pharmacists can use to improve patient adherence and treatment success with anti-obesity pharmacotherapy
Future plans
A novel pharmacist-led obesity management clinic exists in Alberta and is led by Dr. Dan Burton. Recently, this clinic received funding (the RxOC-IT study) to further this initiative to train and mentor pharmacists as satellite clinics to improve access to obesity care across the province. The RxOC-IT project represents an innovative solution to the primary care crisis facing Alberta by providing comprehensive obesity care in community pharmacy settings. The project would result in the creation of a new obesity care access point and improves access to care for those without a primary care provider. This research provides pharmacists the opportunity to work directly with patients on an ongoing basis to achieve measurable health and well-being outcomes related to obesity.
Hypertension Canada and Obesity Canada are planning a joint annual meeting on April 3-6, 2024, in Banff, Alberta (see https://obesitycanada.ca/sciencetosolutions/), with lots of programming relevant to pharmacists.
Pharmacist involvement in the obesity epidemic will improve the health of our communities and is well positioned to provide our health care system with significant cost savings.