HEART RESERVE Clinical Conversations Obesity and Diabetes Care in Women Narration: Lisa Zahakos, RPA-C · authorized saved voice Runtime: 20:08 at normal speed [0:00] Opening The blood sugar number looks good. The visit still is not finished. What might we miss if that number is where we stop? Welcome to HEART RESERVE Clinical Conversations. I’m Lisa Zahakos, a physician assistant and founder of HEART RESERVE. In this episode, we’ll follow Maya after gestational diabetes, Elena during obesity and diabetes treatment, and Nora as she plans a pregnancy. These are fictional teaching cases for clinicians. You can listen straight through, or use the chapters to return to a case. I’ll ask you to consider a few decisions and then walk through the reasoning. The activity page has the objectives, references and online questions. [0:36] Maya Let’s begin with Maya. Case 1 Complete postpartum testing and continuing care. Maya is seven weeks postpartum after gestational diabetes. She feels well, but the recommended glucose test has not happened. Timing. Case information: 7 weeks postpartum. History. Case information: Gestational diabetes. Current concern. Case information: Missed glucose test. Practical barrier. Case information: Childcare and a fasting visit. Neither the obstetric nor primary care office has arranged Maya’s test. Her recent A one C is 5.4 percent, and she has no hyperglycemic symptoms. What should happen now? Which plan best evaluates her glucose status at this point? Pause here if you would like to consider your next step. The American Diabetes Association recommends a 75 gram oral glucose tolerance test at 4 to 12 weeks after a pregnancy with gestational diabetes. The order also needs a workable completion plan. Confirm fasting instructions, an achievable laboratory appointment and a result reviewer. Ask what would make the visit possible; another order alone will not resolve her childcare barrier. Turn the order into a completed assessment. Primary care accepts responsibility for the test and result and confirms the handoff with obstetrics. If the oral glucose tolerance test cannot be completed, document the barrier and arrange clinician review of an alternative pathway. Teach-back: “This test checks fasting glucose and the response two hours after a glucose drink. How will you prepare, and who will contact you?” Document which office will act if the appointment is missed. The office books an early appointment and confirms childcare and result communication with Maya. Maya’s oral glucose tolerance test is normal by nonpregnancy criteria. She asks whether gestational diabetes can now be removed from her history. What belongs in the ongoing plan? Pause here if you would like to consider your next step. Preserve the history and plan lifelong screening at 1 to 3-year intervals, adjusted to clinical context. Record the reassuring result, ongoing screening interval and responsible clinician. Make the result useful to the next clinician. Prediabetes or diabetes results need the appropriate diagnostic and management pathway. New symptoms or pregnancy warrant assessment without waiting for the routine interval. Record prior gestational diabetes separately from current diabetes, including pregnancy year and postpartum result. Pregnancy history informs prevention; it is not proof of coronary disease. Review other adverse pregnancy outcomes, blood pressure, smoking, indicated lipid testing and overall cardiovascular health. Maya and her clinician record the next screening date and retain gestational diabetes in her history. Postpartum testing and the next action. Maya skips breakfast and avoids most carbohydrate because she fears diabetes. She is breastfeeding, has a limited grocery budget and wants enough energy for her day. Which referral is most useful? The referral should specify the clinical question and the practical circumstances the registered dietitian needs to address. Ask what she usually eats, which foods she avoids and why. Build the plan around familiar, affordable foods. Write a nutrition referral with a clinical question. Send the registered dietitian the lactation context, meal skipping, carbohydrate fear, access concerns and energy goal. Request an adequacy assessment and return of the agreed plan. If food access limits the plan, identify a usable community resource. The referring office checks visit completion and follows up if it is missed. Individualize medical nutrition therapy; this case does not prescribe a universal postpartum diet. The referral includes Maya’s normal oral glucose tolerance test, lactation, nutrition concerns and how recommendations will return to primary care. Before the handoff. Document the completed postpartum test and interpretation. Record the ongoing screening interval and responsible clinician. Send the registered dietitian the specific nutrition question and relevant circumstances. Confirm how Maya will receive results and what happens after a missed appointment. [4:33] Elena Now meet Elena. Her clinical history changes the treatment question. Case 2 Connect cardiovascular benefit with nutrition and function. Elena has obesity, type 2 diabetes, and a prior myocardial infarction. Her A one C is at her individualized goal, but the treatment review is not complete. A one C. Case information: 6.7 percent. body mass index. Case information: 33 kilograms per square meter. Current disease. Case information: Type 2 diabetes and prior myocardial infarction. Pregnancy history. Case information: Preeclampsia in her 30s. Elena takes metformin and secondary-prevention medicines after a myocardial infarction three years ago. She is postmenopausal and has no acute symptoms. A colleague proposes waiting for A one C to rise before reviewing additional diabetes therapy. What is the best next treatment discussion? Pause here if you would like to consider your next step. In type 2 diabetes with established atherosclerotic cardiovascular disease, cardiovascular benefit can guide treatment independently of the need for additional glucose lowering. Her myocardial infarction establishes atherosclerotic cardiovascular disease. Review the rest of secondary prevention, kidney status, symptoms and access. Drug choice should follow relevant population and outcome evidence. Separate the treatment goals. Document the cardiovascular goal so an at-goal A one C is not mistaken for absence of a treatment rationale. Compare options by disease, outcome, contraindications, tolerability, affordability and preference. heart failure or chronic kidney disease may change the choice. Keep nutrition, activity, behavioral support and other appropriate obesity treatments in view. This is not a complete obesity-treatment algorithm. The evidence separates weight, glycemic and cardiovascular findings. Do not infer superior cardiovascular protection from greater weight loss. Agree which clinician will review metabolic and cardiovascular response. Compare suitable options with Elena and document the treatment goal and follow-up owner. From trial evidence to a treatment choice. Elena asks whether more weight loss means better heart protection. Check the population, comparator, endpoint, effect and safety findings before answering. SELECT Established cardiovascular disease, age at least 45, body mass index at least 27, no diabetes. What was demonstrated: Semaglutide 2.4 milligrams weekly versus placebo reduced first major adverse cardiovascular events: 6.5 percent versus 8.0 percent; hazard ratio 0.80, 95 percent confidence interval 0.72 to 0.90. Boundary for the decision: Applies to a defined secondary-prevention population. It does not directly answer Elena’s diabetes question or show benefit after gestational diabetes alone. SURPASS CVOT Type 2 diabetes and established atherosclerotic cardiovascular disease. What was demonstrated: Tirzepatide versus dulaglutide met noninferiority for cardiovascular death, myocardial infarction or stroke: hazard ratio 0.92, 95.3 percent confidence interval 0.83 to 1.01. Superiority was not established. Boundary for the decision: An active comparator with established benefit is not placebo. Do not describe greater weight loss as proven superiority for major adverse cardiovascular events. SUMMIT Obesity and heart failure with preserved ejection fraction. What was demonstrated: Tirzepatide improved the composite of cardiovascular death or worsening heart failure versus placebo and health status. Boundary for the decision: The composite does not establish reduced cardiovascular death alone. Confirm heart failure with preserved ejection fraction rather than diagnosing it from body mass index and breathlessness. STEP H F peff enrolled adults with body mass index at least 30, symptomatic heart failure, left ventricular ejection fraction at least 45 percent, and no diabetes. What was demonstrated: Semaglutide improved symptoms, physical limitations and exercise function. Boundary for the decision: Patient-reported health status and physical function matter, but are not interchangeable with a mortality endpoint. These trials cannot be ranked directly across different populations and methods. Discuss benefit with tolerability: SELECT reported adverse-event discontinuation in 16.6 percent with semaglutide versus 8.2 percent with placebo. Choose the branch that matches the disease. Elena’s myocardial infarction and diabetes guide the evidence choice. If heart failure or chronic kidney disease is present, review the relevant S G L T 2 evidence and indications; incretin therapy does not replace the rest of cardiac or kidney care. FINEARTS H F provides a separate example: finerenone reduced total worsening-heart failure events and cardiovascular death as a composite in patients with left ventricular ejection fraction at least 40 percent. It is not an obesity medicine; selection requires indication, kidney, potassium, interaction and label review. Disease status determines which evidence applies. Find the relevant disease pathway, then check its trial population and endpoint. More than one pathway may apply. Compare Elena’s established disease with Maya’s pregnancy history; do not assume their trial evidence is interchangeable. In a separate variation, Elena asks whether a report about oral orforglipron has established superior cardiovascular protection in diabetes. What should guide the response? The July 2026 Foundayo label lists chronic weight management, not a diabetes-treatment or cardiovascular risk-reduction indication. Route of administration does not establish those outcomes. ACHIEVE-4’s September 30 sponsor report compared orforglipron with insulin glargine in 2,749 adults with type 2 diabetes, body mass index at least 25 and increased cardiovascular risk. four component major adverse cardiovascular events hazard ratio 0.84 (95 percent confidence interval 0.59 to 1.20) met noninferiority, not superiority. Mortality analyses lacked family-wise type I error control; ATTAIN-OUTCOMES was ongoing. Review the full label for an eligible weight-management patient: GI effects, medullary thyroid carcinoma or multiple endocrine neoplasia type 2 and hypersensitivity contraindications, dehydration, hypoglycemia with insulin/secretagogues, and C Y P 3 A 4/O A T P 1 B and simvastatin interactions. Concomitant use with another G L P 1 receptor agonist is not recommended. Emerging therapy and the question still unanswered. Retatrutide remained investigational in the September 2026 TRIUMPH-2 sponsor report. Weight and A one C findings do not establish approval, reproductive safety or cardiovascular event reduction. This activity makes no prescribing or enrollment recommendation. At follow-up, Elena reports weight loss, nausea, small meals, constipation and less energy. She can drink and has no persistent vomiting or severe abdominal pain. A dose increase is approaching. Which response best addresses the information she has just shared? Pause here if you would like to consider your next step. Review the whole treatment response, including symptoms and nutrition, before the prescriber decides on dose progression. Assess what she can eat and drink, symptom-related avoidance and daily function. Nutrition review should accompany treatment, before a problem becomes severe. Review symptoms before deciding the next dose. Review intake, fluids, bowel habits, activity, dose history and other medicines; consider other causes. The prescriber decides the medication plan; the registered dietitian assesses intake and communicates concerns. Persistent vomiting, inability to maintain fluids or severe persistent abdominal pain warrants prompt assessment. These examples are not an exhaustive triage rule. Give Elena a contact route if symptoms worsen. The team reviews symptoms and intake before escalation and explains when to seek prompt assessment. After prescriber review, Elena’s symptoms improve. She wants to preserve strength but has knee pain and little resistance-exercise experience. She asks about a protein target seen online. Which approach best fits her goals? Nutrition and appropriate strength activity should be planned together, adapted to capability and health status. Adapt nutrition and resistance activity to capability and health status; consider rehabilitation or physical therapy when needed. Measure a goal that matters to Elena. Choose a meaningful task, such as rising from a chair, and reassess consistently. Worsening function needs evaluation. State the limitation and functional goal in a referral. Reassess intake, symptoms, function, affordability and acceptability. This plan does not guarantee muscle preservation. Weight loss or a lean-mass estimate alone does not diagnose sarcopenia. Elena chooses a feasible nutrition change and suitable activity, with function included in follow-up. Before the handoff. State whether the patient has established atherosclerotic cardiovascular disease, heart failure, or kidney disease. Document the treatment goal, relevant outcome evidence, and patient preference. Connect the nutrition assessment to symptoms and medication decisions. Choose a follow-up measure that includes how the patient functions. [13:51] Nora Our third case brings reproductive planning into the treatment visit. Case 3 Plan treatment around reproductive goals. Nora takes injectable semaglutide for obesity. She would like to try for pregnancy in three months and wants to know what should happen before then. Medication. Case information: Semaglutide injection. Product and reason. Case information: Wegovy for obesity. Pregnancy intention. Case information: Try in 3 months. Diabetes. Case information: Not diagnosed. Nora uses contraception and is not pregnant. She asks which stopping interval applies to her injectable semaglutide. Which guidance fits the product and indication in this case? Pause here if you would like to consider your next step. The current Wegovy labeling specifies at least two months before planned pregnancy for weight reduction. Confirm the product, formulation, indication and reproductive goal. Integrate medication timing with nutrition, other medicines and preconception care. Make the dates understandable. The weekly dosing schedule does not determine the pregnancy stopping interval. For a January 15 intended conception date, a last dose no later than November 15 illustrates two months. Individual review may support earlier discontinuation. Use teach-back and discuss changed plans. Do not make reproductive care conditional on an arbitrary weight. Respect the patient’s contraceptive and pregnancy choices. Nora and her prescriber document the dates and arrange preconception care and nutrition support. Consider a separate variation: Nora is taking tirzepatide as Zepbound, uses an oral hormonal contraceptive, and does not want pregnancy. Her prescriber is increasing the dose. She asks whether taking the pill at a different time is enough. What counseling is supported by the current Zepbound label? Discuss a patient-chosen non-oral method or an added barrier method for the specified four-week periods. Explain the product-specific issue, discuss feasible options and confirm understanding without prescribing a particular contraceptive choice. Give a usable contraception instruction. This is a separate Zepbound variation, not a recommended switch. Confirm the contraception route. An October 20 escalation starts a four-week precaution through November 17. Each further escalation starts another period. Record the dates and chosen method in the dose-review plan. Oral formulations differ. Oral Wegovy requires morning dosing fasting, with no more than 4 ounces of plain water and a 30-minute wait before food, drinks or other oral medicines. Foundayo permits food and uses a 30-day contraceptive precaution after initiation and each escalation. Verify the exact label. Separating tablet and injection times does not replace Zepbound’s precaution. The next escalation review includes the documented contraception plan. In another variation, Nora has type 2 diabetes controlled with a G L P 1 receptor agonist. She plans pregnancy and proposes stopping treatment until her first prenatal visit. Which plan best addresses this change? Pause here if you would like to consider your next step. The plan must address both medication discontinuation before conception and ongoing glucose management. Plan time to select and titrate pregnancy-appropriate treatment and establish monitoring. Include nutrition support and a named contact. Coordinate the transition before conception. The Endocrine Society/ESE guideline suggests discontinuation before conception. Evidence certainty is very low; individualize timing with active glycemic management. Send the regimen, glucose information and reproductive goal. Document alternative treatment, monitoring, prescriber and contact for changing readings. Unexpected pregnancy needs prompt exposure and maternal review; Zepbound labeling calls for discontinuation. Limited safety evidence does not predict an individual fetal outcome. Coordinate endocrinology, pregnancy care and nutrition. Assess lactation separately using current product and formulation information. Write the transition, monitoring plan, accepting clinician and review date, including what to do if pregnancy occurs sooner. In a separate variation, Nora starts Foundayo for obesity while using oral hormonal contraception. She assumes an oral medicine needs no contraceptive precaution. Which instruction matches the July 2026 label? Use the label’s 30 days after initiation and each escalation. Discuss a feasible non-oral or added-barrier method and record the dates. Injectable Wegovy for obesity. Specific reproductive teaching point: Discontinue at least two months before planned pregnancy. Coordinate preconception care and ongoing treatment needs. Zepbound. Specific reproductive teaching point: For oral hormonal contraception: non-oral method or added barrier for four weeks after initiation and each escalation. Foundayo. Specific reproductive teaching point: For oral hormonal contraception: non-oral method or added barrier for 30 days after initiation and each escalation. Discontinue when pregnancy is recognized. The July 2026 label does not recommend use in nursing women. Planned-pregnancy stopping intervals and temporary contraception precautions answer different questions. Diabetes requires ongoing glycemic care; lactation needs a separate label review. Teach-back: “Which method will you use, and which dates does the precaution cover?” Use the correct reproductive timing. Check product, formulation, indication and reproductive goal before assigning dates. Use the timeline to check the dates. In the diabetes variation, confirm who will arrange treatment and monitoring before discontinuation. Before the handoff. Record the exact product, formulation, indication, and reproductive goal. Specify product-dependent timing and contraceptive counseling. Plan ongoing glycemic treatment when diabetes is present. Name the next clinician, the review date, and the action if plans change. [19:37] Take it into practice Before you go, bring the three cases back to one question: what will you do differently at the next visit? Complete the right test, match treatment to the outcome you want to improve, and keep nutrition, function and reproductive plans in the conversation. You’ll find the source references, transcript and clinical resources beside this episode. To record your answers and complete the learning activity, return to the activity page for the questions and brief evaluation. This has been HEART RESERVE Clinical Conversations. I’m Lisa Zahakos. Thank you for listening.