Introduction

Welcome back to MEDS eNews! This month we spend some time with Metabolic and Endocrine Disease Summit Fall faculty Christine Kessler, a nurse practitioner specializing in general endocrinology, obesity, and metabolic medicine and founder of Metabolic Medicine Associates in rural Virginia.  She shares her excitement with us on access to hormone-based weight loss therapies, Incretin therapies, single and combination hormones for obesity and T2DM, as well as takeaways from her recent talks on Obesity Care and Management in the Cardio-Metabolic Patient and Hypothyroidism Management Tips. Following the interview is our Rapid Fire segment!

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Save the Date! 

MEDS 2023—Join us on October 12-14, 2023 in Orlando, Florida…

The latest advancements in metabolic and endocrine diseases, from diabetes and thyroid and adrenal disorders to obesity…MEDS will get you current via panel discussions, Q&A, and case studies—We look forward to seeing you there!

panel discussions, Q&A, and case studies https://events.medscapelive.org/website/35587/home/

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Thank you to Christine Kessler for her time here and as faculty. Please contact me at colleen@cmhadvisors.com with comments or suggestions. Thanks for reading! —Colleen Hutchinson

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5 Minutes with Christine Kessler, MN, CNS, ANP-BC, BC-ADM, FAANP

Christine Kessler is an award-winning NP specializing in General Endocrinology, Obesity, and Metabolic Medicine and founder of Metabolic Medicine Associates in rural Virginia where she provides general endocrine clinical consultation and weight loss management.

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Anything on the horizon in research and development that you look forward to utilizing in 2023?

Christine Kessler: I look forward to having greater access to hormone-based weight loss therapies (which promote the greatest weight reduction). With supply chain issues resolved, Wegovy (semaglutide 2.4 mg) will again become available, and the FDA’s fast-tracking of dual-incretin tirzepatide (Mounjaro) for obesity management will offer additional impressive weight loss options for our patients.

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What do you think about the recent pharmacological advances for weight control and type 2 diabetes?

Christine Kessler: It’s thrilling! We now have “game-changer” medications that simultaneously address the two greatest metabolic disorders afflicting this country: obesity and T2DM. Incretin therapies, single and combination hormones (GLP-1 receptor agonists alone and in combination with glucagon-inhibiting-proteins [GIP]), have been shown to significantly improve glycemic control, while promoting dramatic weight loss, which can also reduce risk for cardiovascular disease. The success of these medications has finally drawn medical attention to the devastating disease of obesity.

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How about in your presentation Weighing the Options in Obesity: Case Presentations?

Christine Kessler: 

• When approaching weight loss management, it is important to understand that the focus should be on metabolic health and not merely the numbers on a scale.
• Lifestyle changes (addressing food choices, physical activity, sleep, and self-defeating behaviors) underlie all weight loss therapeutics and should continue for life; followed by anti-obesity-medications (AOM), approved gastric devices/endoscopy, and bariatric (“metabolic”) surgery.
• The “best diet” for weight loss is primarily determined by genetic influences and patient adherence. In general, diets leading to some caloric restriction are commonly preferred.
• AOMs should be considered, along with lifestyle interventions, if the BMI is 27 with one obesity-related complication. Delaying treatment leads to greater morbidities.
• AOMs can promote weight loss by as much as 5% to 20+%. Choice of drug is determined by cost, contraindications, and impact on underlying morbidities. All are contraindicated in pregnancy and breast-feeding.
• If there has not been at least 4% weight loss within 12 to 16 weeks, consider stopping the medication or switching to a different AOM, as the patient is not responding or is adherent to the medication. 

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What are some pearls or takeaways you shared in Obesity Care and Management in the Cardio-Metabolic Patient at the Metabolic and Endocrine Disease Summit Fall?

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Christine Kessler: The most important takeaways include that:

• Fat mass (adipose tissue) is an important, life-sustaining body organ that, with regulatory input from the brain, maintains crucial energy stores and metabolism to meet the body’s fuel requirements.
• Like other body organs, fat mass can become dysfunctional with regard to excessive growth (size/weight) and deposition into ectopic locations (e.g., visceral adiposity), which can contribute to over 200 complications—most significantly, cardiovascular disease and NAFLD.
• Obesity (adiposity) should be considered a chronic, progressive disease and treated with as much urgency as severe hypertension or cardiovascular disease.
• The cause of obesity is multifactorial (genetics and environmental) and complicated. It is NOT due to a character flaw; nor is it curable. It can, however, be successfully managed.
• The frustrating phenomenon of weight regain is due to a genetic fat mass “set-point” and metabolic adaptation; whereby, the body attempts to restore and defend an increased fat mass via anti-satiety hormonal influences on the hypothalamic appetite regulation centers and a corresponding reduction in the resting metabolic rate. 
• The incidence of obesity among adults and children in the U.S. continues to increase with little evidence of abatement.

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Can you share some of the clinical tips from your talk, Hypothyroidism Tips on Management?

Christine Kessler: Clinical tips are as follows:

• Thyroid disorders are the second most common endocrinopathies seen in clinical practice.
• Thyroid laboratory data, along with clinical signs and symptoms, should be congruent when diagnosing and monitoring treatment efficacy for clinical hypothyroidism.
• Hypothyroidism should be a considered a cardiometabolic risk.
• Initial treatment for clinical hypothyroidism is monotherapy with levothyroxine. If thyroid replacement hormone (TRH) achieves target thyroid laboratory levels, but symptoms of hypothyroidism persist, clinicians should consider using combination T4:T3 hormone replacement (i.e, liothyronine [‘Cytomel], liotrix [Thyrolar], or desiccated thyroid extract). Approximately 15% of individuals have genetic polymorphisms that lead to insufficient levels of T3.
• For best absorption, TRH should be taken on an empty stomach with only water 30 to 60 minutes prior to consuming food or caffeine; or 2 hours after eating then waiting 30 to 60 minutes before consuming food or non-water drink. It can be taken at bedtime 2 hours after eating.
• Asymptomatic subclinical hypothyroidism in patients over 65 years of age should not be treated with thyroid hormone replacement due to increased cardiovascular risk and osteoporosis.
• If the patient forgets to take their monotherapy TRH dose, they can simply take a double dose the following day due to the long, 7-day half-life of thyroxine (T4). This is NOT to be done with combination TRH due to the shorter half-life of T3.
• Non-celiac gluten sensitivity is common in Hashimoto’s hypothyroidism. 

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Your role as Co-Chair of Session I: Endocrine Part 1 at the Metabolic and Endocrine Disease Summit Fall was a significant one, given all that this session encompassed. What were some of the takeaways from this session of presentations that you found most helpful to everyday practice?

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Christine Kessler: The content of Session 1 was strategically offered on the first day of the conference for the following reasons:

• Session 1 addressed several of the more intimidating, misunderstood and misdiagnosed endocrine disorders encountered by primary care providers. The content was presented on the FIRST day of the conference when the attendees’ minds were more likely to be fresh and focused.
• Presenting lectures on pituitary, adrenal, and thyroid conditions helped to clarify the hypothalamic-pituitary-adrenal/thyroid axis --a concept which is fundamental to understanding the underlying pathophysiology and diagnostic findings of a variety of endocrine disorders.
• Of greatest significance is the fact that pituitary, adrenal, and thyroid function/dysfunction affects every other endocrine and metabolic condition presented at MEDS.
• Session 1 helped raise clinician awareness of (and demystify) pituitary, adrenal, and thyroid disorders, with the hope to promote prompt diagnosis and early, effective management of them.

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What’s a tool in your clinical/device arsenal you can’t live without?

Christine Kessler: COMMON SENSE!!!!

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Rapid Fire:

Most critical new advance in my area of medicine: Combination incretin therapy for obesity and adiposity (and, if necessary, T2DM)

Where I go for continuing education: At conferences where I am lecturing (I lecture a lot!)

My mentor: My amazing endocrine mentor was, Dr. Robert Vigersky, formerly of the Department of Endocrinology and Metabolic Medicine at Walter Reed National Military Medical Center.

Advice that has helped in my career: Maintaining a compulsive sense of inquiry; to ask & answer “WHY?”

Best tool in my clinical arsenal: Quickly earning my patients’ trust!

Female practitioners in my area of medicine: Are well-represented in both endocrinology and obesity medicine.

What I wish the patient would remember: Developing T2DM or a proclivity for obesity isn’t their fault.

Biggest challenge for me and my colleagues: Access to affordable medications; and BIASED medical research!