1. The Obesity/Diabetes Epidemic: Adiposopathy & ‘Obesity’- The New Disease! Weight Management in Obesity and DM: Emphasis on New Medical Therapies Stan Schwartz MD, FACP, FACE Private Practice, Ardmore Obesity Program Cardiometabolic Diabetes Center and Affiliate, Main Line Health System Emeritus, Clinical Associate Professor University of Pennsylvania Part 9 * *Part 9 of 9

2. Weight Reduction Issues- Non -Insulin 0. In Metabolic Syndrome-consider Incretins/ SGLT-2 inh. 1. 3-4 non-insulin agents before consider insulin a. Not SU/GLINIDE b. AACE first Tier/ Second Tier Principle c. Beta cell- incretin/SGLT-2 Inh/ Pio d. Resistance- Pio/ metformin e. Other- bromocriptine-QR, colsevalam F. EARLY TRIPLE THERAPY 2. Incretins Before Pioglitazone- then don’t gain weight from pioglitazone 3. Ranolazine, SGLT-2 inh to minimize/prevent edema from pioglitazone 4.. GLP-1 RA’s and SGLT-2s have added wt. loss benefit 5. GLP-1 RA’s preferred over DPP-4 in ‘right patient’ 6. GLP-1 RA’s always before start Insulin, even a short trial-

4. 1. UNLESS ‘SICK’, AVOID INSULIN IF NOT FOLLOWING NCS DIET 2. KEEP NON-INSULIN TREATMENTS AS START BASAL- KEEP ON INCRETIN/SGLT-2 INHIBITOR (OTHERS) WHEN ADD INSULIN IF DO SO ONLY ~10% NEED BOLUS. IF ON INSULIN- AS START NCS DIET, DECREASE 25% IF WAS HAVING HYPOGLYCEMIA DECREASE 25% ADD INCRETIN, GLP-1 PREFERRED – DEC. INSULIN AS DO SO ADD SGLT-2 INHIBITOR- DECREASE INSULINS 25% ADD PIOGLITAZONE, METFORMIN, IF POSSIBLE MAY BE ABLE TO STOP INSULIN, LOSE WEIGHT THUS NEW PATIENTS WHO COME TO ME ON INSULIN <40 UNITS/D, NOT ON DIET, HYPOGLYEMIA, EPISODES, I STOP INSULIN START DIET GLP-1 RA AND SGLT-2 INHIBITOR Weight Reduction Issues- Insulin

7. Summary Epidemiology and Economics of obesity/diabetes-costly Perspectives on Obesity- culture Consequences of Obesity, Prediabetes, Obesity Obesity/ Diabetes Risk Factors, Obesity/ Diabetes Onset can be Prevented or Delayed – Early Risk Identification and Intervention. Medical Benefits to Weight Loss Treatment-CDC’s diabetes prevention program and other Evidence-Based Interventions- We can do Better, We must do better