Case 37: GLP-1

Obesity Case Study

A 67 year old female with a past medical history of anxiety, breast cancer s/p lumpectomy and radiation in 2012, partial hysterectomy, OSA (on cpap), vitamin D deficiency, OA of right knee, prediabetes, mild persistent asthma, CVA, hypertension, GERD, and Class III obesity (Body mass index is 41.77 kg/m²) presented to clinic for discussion of weight loss options.

Patient reported previous attempts with lifestyle behavior changes including weight watchers, ketogenic diet, and intermittent fasting. Has lost about 35 lbs. with lifestyle changes in the past.

Denies prior cardiac issues, kidney stones, pancreatitis, seizures, glaucoma, medullary thyroid cancer, multiple endocrine neoplasia type 2.

Her weight is currently 251 lbs., with a goal weight of about 199 lbs. 

True or False: Can the patient be an appropriate candidate for anti-obesity medication (AOM), in particular glucagon-like peptide 1 receptor agonist (GLP-1RA)?

PRACTICE PEARLS

Prevalence of Obesity

Obesity is a complex relapsing disease process that involves neurobehavioral, biochemical, and environmental factors that play a role in the chronicity of the disease process. The most recent data trends from the Centers for Disease and Control report during the years of 2021 – 2023 the prevalence of obesity in United States was approximately 40 – 43% among adults ¹. This has remained stable compared to previous survey from 2013-2014, however, it was noted that severe obesity (BMI > 40 kg/m²) increased from 7.7% to 9.7% ¹. Prior to the introduction of GLP-1RA medications and other incretin therapies for weight loss, a study from NEJM used historical trends they predicted by 2030 the national prevalence of adult obesity and severe obesity will rise to 48.9%². New data has shown that BMI and obesity prevalence in the US has decreased in 2023 for the first time in a decade³.

Pathogenesis of Obesity

The pathogenesis of obesity is multifactorial involving neuroendocrine dysregulation, environmental factors, epigenetic and genetic predisposition, and metabolic dysfunction leading to an excess of adipose tissue ⁴.  The biochemical process involves a complex of multiple hormonal pathways throughout the body influenced by environmental and genetic factors, along with neuroendocrine dysregulation which leads results in a net positive energy balance. The majority of patients with obesity have polygenic obesity which can involve over 300 genetic mutations and has little substantial effects on the BMI in the general population. Whereas monogenic obesity affects about 0 - 3% of individuals with obesity and can result in severe obesity⁴.

Dysfunction of adipose tissue, known as adiposopathy, leads to development of other chronic diseases like hypertension, type II diabetes mellitus, dyslipidemia, insulin resistance, chronic kidney disease, metabolic dysfunction associated steatotic liver disease (MASLD), polycystic ovarian disease and along with several cancers including breast cancer⁵.

Diagnosis of Obesity

According to the World Health Organization (WHO), obesity is defined as an abnormal or excessive fat accumulation that presents a risk to health⁶.

Currently we use body mass index (BMI) > 30 kg/m², which has been acknowledged by organization and societies as a poor measurement for obesity, however, we do not have any other current modalities to define obesity at this time ^5,7. 

Table from NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Treatment Options

Depending on the patient’s BMI, there are several options for weight loss.

• Lifestyle is the cornerstone of all weight loss guidelines.
• Anti-obesity medications (AOMs)
• Endoscopic bariatric therapies
• Bariatric surgeries

Cast Study Follow up

Given the patient had Class III obesity (Body mass index is 41.77 kg/m²) along with her multiple comorbidities relating to obesity like OSA, vitamin D deficiency, OA of right knee, prediabetes, hypertension, and GERD she was presented with all the options for weight loss. After a discussion, we decided to start with the anti-obesity medicines. She was particularly interested in the incretin therapies, also known as NuSH therapies.  With no contraindications, we started on Semaglutide 0.25 mg weekly with dose titration each month until we reached the maintenance dose of 2.4 mg weekly.

Anti-Obesity Medications
Nutrient Stimulating Hormone-Based (NuSH) Therapies

Dose titrations occur monthly until the desired dose is reached (except for Liraglutide – this is a weekly dose titration). If the patient is losing weight, we maintain the lowest effective dose. 

Tables created by Sarah Kosinski, DNP, APRN, FNP-BC.

REFERENCES

1. Emmerich SD, Fryar CD, Stierman B, Ogden CL. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021-August 2023. NCHS Data Brief. 2024 Sep;(508):10.15620/cdc/159281. doi: 10.15620/cdc/159281. PMID: 39808758; PMCID: PMC11744423.
2. Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, Long MW, Gortmaker SL. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019 Dec 19;381(25):2440-2450. doi: 10.1056/NEJMsa1909301. PMID: 31851800.
3. Rader B, Hazan R, Brownstein JS. Changes in Adult Obesity Trends in the US. JAMA Health Forum. 2024 Dec 6;5(12):e243685. doi: 10.1001/jamahealthforum.2024.3685. PMID: 39671205; PMCID: PMC11645646.
4. Lingvay I, Cohen RV, Roux CWL, Sumithran P. Obesity in adults. Lancet. 2024 Sep 7;404(10456):972-987. doi: 10.1016/S0140-6736(24)01210-8. Epub 2024 Aug 16. PMID: 39159652.
5. Sandra Christensen, Christina Nelson, Chronicity of obesity and the importance of early treatment to reduce cardiometabolic risk and improve body composition, Obesity Pillars, Volume 15, 2025, https://doi.org/10.1016/j.obpill.2025.100175.
6. World Health Organization. (2025, December 8). Obesity and Overweight. World Health Organization. Obesity and overweight
7. National Institute of Diabetes and Digestive and Kidney Diseases. (2023, May). Definition & Facts for Adult Overweight & Obesity. Definition & Facts for Adult Overweight & Obesity – NIDDK
8. Chawla S, Tessarolo Silva F, Amaral Medeiros S, Mekary RA, Radenkovic D. The Effect of Low-Fat and Low-Carbohydrate Diets on Weight Loss and Lipid Levels: A Systematic Review and Meta-Analysis. Nutrients. 2020 Dec 9;12(12):3774. doi: 10.3390/nu12123774. PMID: 33317019; PMCID: PMC7763365.
9. Moon J, Koh G. Clinical Evidence and Mechanisms of High-Protein Diet-Induced Weight Loss. J Obes Metab Syndr. 2020 Sep 30;29(3):166-173. doi: 10.7570/jomes20028. PMID: 32699189; PMCID: PMC7539343.
10. Willoughby D, Hewlings S, Kalman D. Body Composition Changes in Weight Loss: Strategies and Supplementation for Maintaining Lean Body Mass, a Brief Review. Nutrients. 2018 Dec 3;10(12):1876. doi: 10.3390/nu10121876. PMID: 30513859; PMCID: PMC6315740.

Author

Sarah Kosinski DNP, APRN, FNP-BC is the Lead Advanced Practice Provider for the Digestive Diseases and Nutrition Division at Rush University Medical Center with 7 years of experience in gastroenterology. She received her doctorate in Nursing Practice from Rush University In 2018. She is currently adjunct faculty for the College of Nursing at Rush University and serves on the ASGE APP Committee.