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Welcome back, everyone. And uh now I'm delighted to take us through the Canada chapter in this Global Obesity Academy. So, bowling question for you again. According to the 2025 Obesity Canada Pharmacotherapy Clinical Practice guidelines, which of the following conditions does not have evidence to influence the choice of obesity pharmacotherapy? Is it pre-diabetes, cardiovascular disease, polycystic ovary syndrome, or osteoarthritis? Give you a minute. OK. Great work on the responses. So, the correct answer here is polycystic ovary syndrome. We actually searched on this topic in our, uh, um, production and development of this guideline, and we actually did not find sufficient evidence to guide us in specific pharmacotherapy for PCOS. Uh, that doesn't mean that there aren't medications that can be very appropriate for a woman living with obesity and PCOS, but we don't actually have dedicated trials to tell us specifically which one. That's actually a big gap in, in, uh, clinical trials. which we're hoping to improve upon in the future. So, let's talk about where we do or do not have evidence for obesity pharmacotherapy to help Jamie. So she's a 42 year old accountant. She has a history of MASH or metabolic dysfunction associated steatohepatitis with F2 fibrosis. She had gestational diabetes a few years ago, currently normal glycemic. She has obesity and she has moderate sleep apnea, and she uses a CPAP machine for that. She's not currently taking any medications. We see that her BMI is 34. Her waist to height ratio is elevated at 0.61. She's got a great BP, lipids look good, and she has a mildly elevated ALT in consistent with having MAS. So, in terms of her history, she tells us that she's tried lifestyle approaches on her own for weight management. She's felt a lot of blame and shame around her weight, and she's coming in for an appointment today specifically for help with weight management. She says that she lost about 3 kg with a low-carb diet a couple of years ago, but she regained the weight. She struggles a lot with cravings. This is a real barrier for her. She says she's really active about 5 days a week. She tries to eat well, cravings get in the way. She wants to know what else she can do to lose weight, keep it off, and be healthier. She wants whatever medication will give me the most possible weight loss. She's heard about some of these medications and wants the most effective treatment. Her husband has had a vasectomy, so we don't need to be thinking about, uh, pregnancy considerations in the context of use of medication. So let's remind ourselves again from our Obesity Canada Clinical Practice guidelines that we recommend following the five A's of obesity in clinical practice. So again, this starts with asking permission. Jamie's already come to ask for help, so we don't have to ask permission here. The Second A is assessing their story, their medical history, identifying causes and contributors to the patient's obesity, and health complications arising from their obesity. And remember that 4M's framework of metabolic, mechanical, mental health issues, as well as monetary or social media in our assessment. We want to conduct an obesity-centered physical exam and order the appropriate lab work as well. And we remember again that the 3 pillars of obesity treatment are psychological support, pharmacotherapy, and bariatric surgery. And they support the ability to adhere to healthier lifestyles. And I wanna highlight again our decision tool and table from our 2025 Obesity Canada Pharmacotherapy Clinical Practice guidelines, which I'm the lead author on. We really wanted to develop an easy to use decision tool and table to help guide clinicians on the use of pharmacotherapy in clinical practice. So, again, we want to identify the goals of treatment in partnership with Jamie. This can include management of her obesity-related complications, uh It may include weight loss if that's important to Jamie, and she's already said, I want to lose the most weight possible. So, clearly, that is going to be an important treatment goal for her. Now, um, when we identify suitable medications from the 55 main medications approved in Canada, those are loaglutide, naltrexone, bupropion, orlistat, semaglutide, and trazepetide, we then refer to the accompanying decision table in making our selection. We'll go back to that in a moment. We wanna consider patient values and preferences, contraindications, uh access to medication and cost, of course. We then initiate medication, titrating as needed, as tolerated, and as appropriate to achieve goals of therapy. That's a key message. If our patient has reached their best weight, defined as the weight that a person can achieve and maintain while living their healthiest and happiest life, and or if they have achieved optimization of their obesity-related health complications, so for example, sleep apnea, we'll need to see how that improves for Jamie. Then we continue treatment long-term and we reassess goals of treatment as needed. If we haven't achieved the best weight or optimization of obesity-related health issues, then we really wanna consider contributing factors, revisit the pillars of treatment, and we can consider adding or substituting treatment. So, I'd like to talk through the obesity decision table again in the context of Jamie. It's really essential to use this tool when you're making your decision. Really easy to use, very straightforward. So, we listed each of the five main obesity pharmacotherapies in Canada across the top, and going down the side, and we're gonna pick out the ones that are relevant to Jamie here. We have Uh, then laid out so you can see what benefit each medication may or may not have demonstrated for each health complication. So, we've got cardio metabolic in the first section, we have mechanical complications in the second section, and we have patient reported outcomes in the third section, including cravings benefit. That was an issue for Jamie as well, quality of life, of course, that's important for everyone. So we remember that Jamie has obstructive sleep apnea. She also has MAS. She also struggles with cravings, and her goal was to maximize weight loss. So while it can seem kind of, you know, overwhelming to think about all these health issues and what should I do, all you have to do is look at the table. So for sleep Sleep apnea, we see that there's benefit with repetide, which is actually quite impressive based on data from the Surmount OSA trial. The reglutide also has some benefit, though it's quite modest. We see that for MASH, there's benefit with all of the GLP-based medication. The strongest data is for simmaglutide. Across the bottom, we see the weight loss effect, which is, which is greatest with reappetide, and that's what aligns with the patient's goals. She wants to lose as much weight as possible. So, here, resettide would likely be the first line choice here to unify the goals of improving Sleep apnea, improving her mash, and her goal of maximizing weight loss. So in about 30 seconds, we can assimilate all of the evidence, the data, Jamie's goals, our goals for Jamie, and come to a fairly straightforward decision. But we're not done yet. Once we've advised on treatment options, we've discussed and selected the medication we're going to use, we need to then agree on treatment goals in partnership with our patient. That includes some really important things. One is realistic expectations for the magnitude of benefit of medication and the time it takes to get there. Also, there's great heterogeneity from person to person. So, the average weight loss we see is not reflective of what we see in each patient. They can be quite different. We need to be talking about sustainable goals, sustainable health outcomes, and ensuring these are personalized to fit the goals you've set with the patient and to set them best up for success. And then, the fifth A, we need to assist our patients in managing the barriers and drivers to successful treatment. That can include providing education. In some cases, referrals may be needed. Now, ideally, we want to feel empowered to To take on the obesity care rather than just refer that onward. But here, I wanna say, don't feel overwhelmed. You can do this in bite-size multiple visits. Obesity is a chronic health condition and it's usually not possible to look at all aspects of obesity at one visit, and that's OK. Um, one area where referrals can be really great is for allied health support, um, as needed and of course, if it's available to the patient. And so important is we need to book that follow-up visit. We never want to send the patient out the door with one obesity visit. Remember, it's a long-term health condition that needs long-term care.