Ethnicity, Diagnosis, and Treatment Response in Obesity Care

Key Takeaways

Beyond One-Size-Fits-All

Obesity is a heterogeneous, chronic disease, and its clinical presentation, diagnosis, and treatment response vary across populations. Ethnicity-related differences in body composition, fat distribution, and metabolic risk highlight the limitations of universal diagnostic thresholds and standardised care approaches.

Clinical Variation and Diagnosis

Ethnic differences influence how obesity presents and is identified. Variations in adiposity, visceral fat accumulation, and metabolic risk occur at different BMI thresholds across populations, underscoring the need for population-informed diagnostic criteria and more nuanced clinical assessment.

Treatment Response and Biological Diversity

Responses to lifestyle, pharmacological, and surgical interventions may differ across populations due to biological, physiological, and environmental factors. These differences should be considered when evaluating treatment effectiveness and tailoring care pathways.

Psychological and Behavioural Considerations

Appetite regulation, food-related behaviours, and mental health factors vary between individuals and populations. Understanding these dimensions is important for interpreting treatment response and supporting more personalised, effective interventions.

Personalised and Equitable Care

Moving beyond one-size-fits-all approaches requires integrating ethnicity, biology, psychology, and lived experience into care planning. Person-centred, culturally appropriate strategies are essential to improve outcomes and ensure equitable access to effective obesity care.

Future Directions and Next Steps

• Strengthen understanding of ethnicity-specific risk profiles in clinical practice
• Support development of more tailored diagnostic and staging approaches
• Integrate psychological and behavioural insights into obesity care pathways
• Promote equitable access to personalised obesity treatment across diverse populations
• Continue research into variability in treatment response across populations

Summaries are AI-generated from meeting transcripts.

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Speaker 1 • 00:00
Good morning, good afternoon, and good evening, everyone. I’m Volkan Demirhan Yumuk. I’m from Istanbul, Turkey. I’m an endocrinologist from Istanbul University, Cerahpaşa Medical Faculty, and I’m currently the president of the European Association for the Study of Obesity. Today, I would like to welcome you to this joint webinar with the Korean Society for the Study of Obesity and the European Association for the Study of Obesity. The theme of this webinar is Beyond One Size Fits All, Ethnicity, Diagnosis and Treatment Response in Obesity Care. and I think as you will see I will be co-chairing this webinar with Professor Min Seon Kim who is the president of the board of the Korean Society for the Study of Obesity.

Speaker 2 • 01:23
Hello, everyone. My name is Min-sung Kim from Asan Medical Center, Seoul, Korea. As Professor Volkan Umut introduced me, I’m now President of Korean Society of Study of Obesity since last year. The KSSO was established in 1992 and currently has about 2,300 members. Each year, we host the International Congress on Obesity and Metabolic Syndrome, ICOMS, in early September. We are very much delighted to co-host today’s EASO-COMS webinar together with our obesity talk seminar series. I believe this joint effort reflects the importance of global collaboration in addressing the growing burden of obesity. As you may know, Asian population, including Korean, tend to develop obesity-related comorbidities at lower BMI levels compared to European population. Therefore, different diagnostic criteria and different strategies are needed for Asian population. Professor Soo Lim will address these important differences in his lecture today. It is now my great pleasure to introduce our first speaker, Professor Soo Lim. Professor Lim is a professor of medicine in the Division of Endocrinology and Metabolism at Seoul National University Bundang Hospital in Korea. His research focused on type 2 diabetes, antidiabetic therapies, metabolic syndrome, and cardiometabolic disease. He has published numerous review articles in living journals, including Nature Review Endocrinology and Endocrine Reviews. Recently, he read a Step 11 trial evaluating semaglutide 2.4 mg in HM preparation and reported this result in the Lancet. Today, he will present the differences in clinical features and diagnostic criteria of obesity across racial and ethnic groups. Please join me in welcoming Professor Su-Rin.

Speaker 3 • 03:48
Thank you very much. It is my great pleasure and honor. So today I will discuss how obesity can differ across racial and ethnic groups and why this matters for diagnosis and treatment. Obesity is a global epidemic-driving diabetes, cardiovascular disease, and fatty liver disease. its clinical impact extends far beyond body weight. Effective measurement is now a priority in modern medicine. As shown here, obesity defined by BMI over 30 remains less common in Asian populations than in Western countries. However, the metabolic consequences of obesity tend to be more pronounced in Asians, even at lower BMI levels. When we look at diabetes prevalence, we can find interesting patterns as shown here. Despite lower risk rate, several Asian countries, including Korea, Malaysia, India, show comparable or sometimes even higher diabetes prevalence than Western populations. This suggests that Asians develop metabolic disease at lower BMI levels, highlighting the limitation of BMI alone as a universal measure of risk. This increase in obesity has been leading to increase in diabetes. Nearly 800 million people are estimated to live with diabetes globally in 2022. Asia now carries a substantial proportion of the global diabetes burden. Many individuals in this region develop diabetes disease despite relatively modest BMI. This reflects underlying differences in body composition and physiology in many metabolic diseases. This slide presents features of Asian obesity phenotype. Key characteristics include relatively greater visceral fat, excess actofit fat, and lower beta cell function. also have relatively low incretin effect and typically low muscle mass. This phenotype leads to unique dyslipidemia pattern such as high TG and low HDL cholesterol and higher prevalence of pet liver and sarcopenia. As a result, metabolic disease occurs at a lower body BMI threshold in Asians, so traditional Western cutoff may underestimate risk in these populations. So ethnic specific criteria as shown here are therefore essential. So nowadays, many Asian countries adopt lower BMI for defining obesity such as BMI over 25 or sometimes some in some countries BMI over 27 or 28. Fat distribution is more informative than total body weight as shown here. Abdominal and particularly visceral adiposity are key drivers of metabolic risk. This shifts our focus from a simple BMI to excess fat and active fat. Mechanistically, visceral obesity drives inflammation, oxidative stress, and lipotoxicity. These pathways converge to cause diabetes, cardiovascular disease, and fat liver. This process is systemic and progressive. A few years ago, we examined the ethnic differences in pancreatic structure and fat deposition. This provides insight into organ-level mechanisms of metabolic disease. Importantly, the Caucasians and Westerns were well-matched for age, sex, BMI, and this allows a direct comparison of intrinsic differences. Despite similar BMI, imaging reveals clear structural differences. Pancreatic volume is smaller in Asians compared to Western European descendants. This has important metabolic implications. In this study, we found that Koreans showed higher pancreatic fat and lower pancreatic volume. Despite similar BMI, these differences likely contribute to increased metabolic risk. Again, BMI alone fails to capture these differences. Now turning to D-therapy. In creatine basis, agents represent major advances in this era. So semaglutide targets GLP-1, while terzapatide targets both GLP-1 and GLP-2. This mechanism enhances metabolic control and weight loss. Today, I will highlight key studies from the STEP program conducted in both European and Asian populations. Step one was the randomized placebo-controlled trial evaluating semaglutide 2.4-mg-1 therapy over 68 weeks. And participant had severe obesity with a mean BMI near 38 here. This quote was predominantly female and largely white. The three-thirds of population were white. Representation of Asian population was very limited. As a result, semaglutide therapy achieved substantial weight reduction by 16.9% here. This magnitude is clinically meaningful. It redefines expectations for medical therapy. Next, step 6, the spatially evaluated East Asian populations such as Japanese and Koreans. This is highly relevant for understanding ethnic differences in response GLP-1 receptor agonists. The participants in this study had lower BMI such as 31.9 compared with the Western trial, which was 38 of BMI, and 25% of the study participants also had type 2 diabetes. As a result, semaglutide 2.4mg therapy reduced body weight by 13.2% here, demonstrating strong efficacy in ancient patients, although the magnitude was slightly lower than that observed in step one trial. It is important to note that this study included predominantly male population with about 25 percent of participants having type 2 diabetes. These factors should be considered when interpreting the result. Cardiometallic parameters improved alongside weight loss, blood pressure, and waist circumference, and inflammation markers such as HSCRP all decreased significantly. This data showed support benefit extended beyond weight alone. The most striking result in this study was this. Nearly 40 percent of the visceral fat was reduced in this study. This is very critical from my perspective because as visceral artifice T, visceral artifice T is the key driver of metabolic DGH. Therefore, targeting this compartment, I mean the visceral fat area or amount, has clear clinical significance, particularly in Asian ethnic groups because Asians tend to accumulate more visceral fat compared to European descendants. When you take a look at the adverse event, the safety profile was consistent with previous studies. Gastrointestinal symptoms were most common but generally manageable. Cedars-Sarvabas event were rare. Next, step 11, which further evaluated semilutide using BMI criteria specific to Asian population, I mean BMI over 25 here. This approach aligns with real-world diagnostic stress hold in many Asian countries. So this finding, as a result, the finding from step 11 are more directly applicable to clinical practice in Asians. The population of step 11 was younger and predominantly female as shown here. Participants were recruited from Korea and Thailand and this enhanced regional relevance. Weight reduction reached 16% at 44 weeks, confirming the lowest efficacy even at lower BMI levels. Notably, the magnitude of effect was nearly identical to that observed in the global STEP1 trial. And metabolic improvement such as waist circumference, systolic blood pressure, weight, and C-predator weight loss. So, these all cardio-metabolic and/or cardiovascular metabolic risk markers are all improved. This supports comprehensive metabolic benefits. The next study that I would like to highlight is SELECT, which was a landmark cardiovascular outcome trial. It included over 17,000 participants globally. In this study, semaglutide treatment reduced major cardiovascular event by 20%, representing clinically meaningful benefit. Importantly, this benefit appears consistent across diverse populations including Asian ethnic groups. The next study is FLOW Trial, which extended this finding to the kidney outcome in patients with diabetes and CKD. Please take a look at the many Asians participating in this FLOW Trial. This addresses another major complication which is particularly relevant for Asian populations at high cardiorenal risk. As a result, the semaglutide therapy significantly reduced the composite renal outcome by 24%. This finding underscores its important role in cardiorenal protection. So compared to Western population, many Asian doctors are very worried about kidney function, kidney complication, not only in obesity but also in people with diabetes. So I think this finding is very relevant to many Asian countries. This slide summarizes the potential cardiorhinal benefits of GLPN receptor agonist. In cardiovascular system on the left-hand side, they reduce atherosclerosis, lower blood pressure, decrease ischemia, and improve endothelial and cardiac function. From metabolic perspective, on the right-hand side, they improve glucose control, reduce insulin resistance, and lower body weight, particularly visceral fat, as we saw the result in step 6. And it also improves inflammation and increases adiponectin. These all together contribute to improve the cardiovascular and renal benefits obtained in many global trials, including Asian ethnic groups. Let’s move on to the next topic. The skeletal muscle is one of the key metabolic organs. Intramuscular fat impairs insulin sensitivity and overall muscle function. Importantly, there is a very strong concern about potential muscle mass loss with GLPM receptor agonists, particularly in our region, I mean the Asian populations. Contrary to this common concern, GLPM-based therapy, I think, has been shown to reduce fat infiltration within skeletal muscle. This may improve muscle quality and overall metabolic health. Therefore, body composition, not just body weight, should be considered a key treatment endpoint, particularly in Asian ethnic groups. And the XR data from the step 1 trial also showed that fat mass is preferentially reduced, while lean mass or muscle mass is relatively preserved. This is particularly important in Asian populations who tend to have lower baseline muscle mass. Taken together, GLPM-based therapies provide protective effect on skeletal muscle. They reduce oxidative stress and inflammation on the left-hand side, promoting mitochondrial biogenesis and improving muscle quality. In addition, they inhibit myostatin and apoptosis signaling on the right-hand side while upregulating HESHAR protein and myogenic factors such as MyoD along with activation of PKA and AKT pathways. Collectively, these mechanisms help preserve muscle mass and function, supporting healthier weight loss and improved metabolic outcomes. For the last part of my talk, I’d like to briefly introduce the future direction of anti-obesity treatments. In the near future, multi-agonists combining creatins and relative hormones such as glucagon, amylin, peptide YY will be available. Glucagon increases energy expenditure and affects hepatic glucose production. Amylin and peptide YY primarily suppress food intake in the brain. Reverting this synergistic action is the strategy for the next wave of treatment for both obesity and diabetes. So I don’t like pursuing the maximum weight loss itself, such as more about 25% or 30%. I firmly believe ideal body composition should be the target for the next generation of anti-obesity medication. In summary, obesity is a heterogeneous diseases influenced by ethnicity, body composition, and cardiometallic factors. As I mentioned in the first part of my talk, BMI alone can misclassify obesity, particularly in Asian populations. Body composition targeting visceral fat and atrophy fat may provide a more accurate assessment of risk. Finally, a tailored approach is essential for accurate diagnosis and effective treatment, not only in Western population, but also in Asian populations. Thank you for your attention. Volkan, you are on mute.

Speaker 1 • 21:11
Yeah, I did it again. Sorry for that. Well, thank you very much, Professor Su Lin, for this excellent talk. And you explained to us why there are differences among racial groups in case of or regarding diagnosis and treatment of obesity. I would like to move on to the second speaker, who is Professor Jason Halford. Jason is a professor of psychology at University of Leeds. He’s the past president of EASO, and he’s currently the co-chair for the Psychology, Behavior and Mental Health Working Group at EASO. Professor Halford is going to be talking about psychological, biological and mental health considerations in personalized obesity care.

Speaker 4 • 22:24
Jason, the floor is yours. Thank you very much, Volkan, and it is a great delight to be with my Korean colleagues on the call today. I’ve enjoyed three excellent ICOM meetings and I look forward joining one in the future very soon. Now I’m going to be talking about psychological, biological, mental health considerations in personalised obesity care. I’ll probably focus more on the psychological and mental health aspects but I will allude to the biological mechanisms underpinning those. Now we know there are a variety of major health issues associated with obesity. The link between depression and obesity, major depressive disorder, dythemia, And obesity is well known. It’s a strong link there I’ll talk about first. But also there are links with anxiety disorders, including generalized anxiety disorder, panic disorder, specific phobias, social anxiety, school anxiety and post-traumatic stress disorder as well. Obviously, eating disorders, we know people with obesity, particularly higher BMI, have disordered eating and some reach the clinical diagnostic criteria for binge eating disorder or bulimia nervosa. We have increasingly become aware of a strong link between obesity and neurodivergence, particularly ADHD and autism. And we also know that there are links between the so-called psychotic disorders, bipolar disorder, schizophrenia, schizoaffective disorders and obesity. Now, some of that obviously relates to medication. We know there’s a medication associated with schizophrenia, such as olanzapine, can produce white gain. There is a strong link between substance use disorders and obesity, and it is part of coping with food, is similar with coping with alcohol and things like that. So there’s a common underlying mechanism there. And we also know personality disorders are also associated, or some personality disorders are also associated with obesity. We know there are psychological factors, underpinning all of this including stigma bias discrimination distress trauma is a particularly important one isolation body dissatisfaction and obviously the impact of living with obesity the physical strain of living with obesity how that impacts your mental health we know the underpinning biological factors such as chronic low-grade inflammation we know there are hormonal factors as well alterations in brain function and again chronic pain that’s a big factor in mental health and obesity, as I mentioned before, side effects of medications as well. Now, we call the relationship between obesity and depression bidirectional. We know that obesity or overweight at baseline predicts subsequent likelihood of suffering depression. And conversely, baseline depression increases the odds for developing obesity. So there does seem to be a reciprocal link here. We know early onset obesity particularly is a problem as well. We know that those who suffer obesity at an earlier age have higher levels of current BMI, they have more weight loss attempts, but they are less successful in those weight loss attempts, and that induces feelings of helplessness and hopelessness. And this is how we can understand through repeated efforts in terms of dieting and failure that has an impact on people’s mental health. They’re fighting their own biology. And how early does this start? Well, here’s some data from the UK Millennium Study. It being a millennium study, it started following children when they were born, the millennium year. And what it does is it tracks BMI and internalization, which is a measure of depression at age three, age five, age seven, age 11, and age 14. And what they found from age seven, BMI at age seven predicted internalization at age 11. Similarly, internalization predicted BMI at age 11. So internalization at seven predicted BMI at 11. Similar relationship between BMI at 11 and internalization at 14, and internalization at 11 and BMI at 14. So there is a reciprocal relationship here, which starts as children become more aware of their environment, more independent as they start going to school, as they start absorbing social norms around obesity, and as they start noticing that they are different. Now, here’s a study from the Action Teen Study. And this was a study done all over the globe. I think it had actually a data collection in South Korea, if I remember, and it had data collection also in Turkey, along with the UK. And what we know is that rental well-being scores are worse and self-esteem scores are worse in adolescents living with obesity. And obviously, as the obesity class increases from class one through to class two and three, it gets worse. We know it gets worse with age, and we know it’s particularly marked in girls as well. So we know there are real problems with mental health and self-esteem in adolescents. So if you’re dealing with adolescents living with obesity, these are things you should be cognitive conscious of. Now here’s an interesting slide from the same study and it’s attitudes towards weight loss. And here we’re looking at the adolescent and their caregiver. And one thing I want to draw out in this slide is this one. This is the adolescents globally. 65% of adolescents globally thought my weight loss was completely my responsibility. This is despite the biology of obesity. So these individuals are internalizing the responsibility inwards. They’re taking on sole responsibility. They’re not seeking medical help and they’re coping with failure and that failure has a mental health consequence. now in terms of depression obesity we think also about life events and trauma we know that traumatic life events such as relationship breakups widowhood or other forms of loss can affect body weight we know past trauma a history of trauma including post-traumatic stress disorder are well established a significant relationship between trauma and obesity and particularly childhood obesity and the more severe and the more chronic that trauma the stronger that relationship is and often particularly when you’re dealing with female patients abuse including sexual abuse comes up as well so trauma is important if you don’t take into account trauma when treating people living with obesity you’re not dealing with some of the core drivers there mechanisms include maladaptive coping as a defense mechanism and to emotionally regulate. Now, here’s a useful side, which my good colleague Robert Kushner provided me, and it looks at impact of life events on body weight. And you can see that there are things like going to college, getting married, becoming pregnant, which all increase body weight. There’s also personal illness, family illness, being the stressful job, also changes in family structure, and these all have an impact. Nobody seems to steadily gain weight over time. It seems to be stepped, and there are some periods of successful weight management. There’s some periods where weight management is more difficult. And obviously, through understanding these things, you can get a better idea of a patient’s story. Again, what is driving their obesity as well? now the effects of stress mood on weight management are well known this comes actually from the eating disorders literature uh from the early work of Herman and Pallavi who looked at the impact of dieting on stress and mood and dietary restraint and we know that stress impacts on dietary restraint uh it over time undermines it and undermines weight management success it’s an acknowledged phenomena in the literature what i find it interesting and this speaks to the underpinning biology is that for identical twins discordant for body weight so genetically identical but are displaying different body weights the difference in fat visceral fat accumulation is associated with psychosocial stress which is important so this is all that sort of cortisol stuff going on and what we know is repeated exposure to stressful life situations are associated with emotional eating and a greater preference for end-eating foods rich in fat, sugar and salt. Comforting foods. People go to comforting foods to regulate emotion. And we know underpinning biological mechanisms such as elevated cortisol and other hormonal and metabolic changes underpin this. Now here again is a meta-analysis of the relationship between perceived global and job-specific stress and visceral obesity. This has been repeatedly found in studies. It’s a robustly shown phenomenon. So we know the link between the biology of obesity and the psychology of mental health issues of obesity are linked. They’re not distinct. They’re part of the same thing. They can’t be disassociated. On my last few slides now, I want to talk a little bit, I’ll focus a little bit more on this slide, because often when we’re dealing with people living with obesity, we’re trying to deal with them in the real world. And one of the behavioural approaches we use to dealing with obesity is the ABC model, which many of you will be familiar with the antecedents the behavior and the consequences of of of an action and this is often how we work with people living with obesity in terms of behavioral modification not psychotherapy psychotherapy is different and i’ll come on to that a little bit later but we now quickly can gather data in in real world using mobile devices we begin to understand a little bit more about these antecedents behavior and consequences and there’s two uh there’s one antecedents I’d like to talk about. And there’s one behaviour and consequence I’d like to talk about. The antecedent is temptation. Now, temptation is a sudden urge to break diet, at which you felt you were close to the brink. So it’s kind of self-diagnosed. We ask people, did you experience this? Did you feel a sudden urge to break diet at which you were close to the brink? And when people report these, we ask them, what was your appetite like? Well, they said, well, I experienced greater hunger. I was less full. So obviously, you know, your biology of your appetite system can lead to temptation because you’re hungry, you’re not full. About the situation, what’s interesting with temptations, these can occur pretty much anywhere, anywhere where there is a food queue within your environment, be it actual physical presence of food or food advertising or people talking about food around you. So it’s pretty bored in situational terms. But also mood, emotion is important. Feeling of greater sadness, feeling deprived, feeling stressed. We’ve talked about stress and also boredom. Feeling less relaxed, feeling less content and feeling less in control also lead to temptations. Now, in terms of lapses, now a lapse is an instance where you believe you broke your diet. We don’t assign a caloric value to it. It’s a self-defined state. And again, there are appetite drivers of this, greater hunger, feelings of less fullness, a greater desire to eat. But there are also situational factors as well. Now, the situational factors seem to be a little different with lapses. It’s often associated with being at home, being in the evening or at weekends as well. And often people talk about evenings and weekends as real problem times for people living with obesity. Again, the mood issues are similar. Greater sadness, feelings of deprivation, stress, nervousness, less feeling of being in control. Remember, people living with obesity feel that the food is in control of them. And what we are trying to do in obesity management is putting them back in control or them feeling like they’re back in control. Now, unlike a temptation, a lapse leads to something else, an absence violation. And this is the psychological consequence of that lapse. that feeling of failure, which in turn has an impact on people’s feelings of their confidence, their ability to resist to the future, and their judgment about future success and their willpower. Now, a single lapse in terms of energy balance is not going to do a great deal in terms of people’s weight management outcomes, but it is the psychological damage that lapse does. It is a failure that that lapse, feeling of failure that that lapse causes, which impacts on self-esteem, but also importantly, something we call self-efficacy. And the self-efficacy is your belief that you can do something about your situation, that your behaviours will make a difference. And if you impact self-efficacy negatively, people are less likely to engage with weight management moving forward and are more likely to believe that their efforts will fail ultimately. And considering they’re living with the biology of obesity, that’s probably a lifelong experience. Now, in terms of managing temptations and lapses, obviously, we want to prevent temptations when they occur. We want to provide alternative coping mechanisms when we cannot deal with the temptation. So we can avoid the temptation or come up with an alternative coping mechanism to deal with the temptation other than eating. We can try and work to have an alternative behavior to that antecedents. But equally important, we’ve got to manage lapses. We’ve got to manage lapses and the consequences of lapses. Because what we know, if we do not decatastrophize the lapse, it will lead to more lapses. And the more lapses you have in early in-weight management, irrespective of treatment mode or treatment modality, the more likely treatment is likely to fail. Lapses are critical. So in terms of behavioral therapy, dealing with lapses are critical. Now, this data came from two studies. One study, they studied people living with obesity who were engaging weight management but were pretty much trying to do it on their own and what they found was temptations by and large led to lapses. In the second study they provided people living with obesity a behavioral intervention and that behavioral intervention focused on coping mechanisms dealing with stress and how you use coping mechanisms and those who had stress reduction, this coping mechanism based behavioural therapy, actually had fewer lapses. So the behavioural approach actually worked in those situations where temptations could lead to lapses. And of course, that has the net effect of boosting self-efficacy and increasing the likelihood of a more positive therapeutic outcome. Now, this is my final slide, but it’s a complicated slide. Here we’re talking about the psychological approach. This is not behavioural therapy. This is the ultimate in terms of psychological personalisation. And all therapy is personalised because you’re obviously working with individuals. So by definition, it’s personalised as this behavioural. But this is the kind of the, I wouldn’t say the gold standard, because there’s always could be improvements. But this is kind of the pinnacle of personalisation that you get in mental health. Obviously, we start with cognitive behavioural therapy, and the cognitive bit is identifying and changing the dysfunctional thoughts around obesity. So it’s around cognitive restructuring, helping people with problem solving and coping strategies. But the important bit here is that cognitive restructuring. I’ve already talked about behavioural therapy, which is modified habits through structured intervention. It’s less psychotherapy, more classic behavioural We have motivational interviewing, which is a non-confrontational way of having patient-centered conversations to resolve ambivalences that the patient have in terms of their weight management. So it’s a classic Rogerian sort of therapy relies on a lot of reflection. Then there are the new third wave therapies. And these are the exciting therapies. And if you attend ECO in Istanbul this year, on Tuesday morning, we’ll be talking about these. The first is acceptance and commitment therapy. And that promotes psychological flexibility and acceptance of difficulties. And it’s kind of making sure people are not unrealistic in their aims. It’s to make the aims of their weight management more realistic so they’re more achievable, but also dealing with the difficulties and things like lapses. It will be there to deal with difficulties such as lapses without the person resulting to overeating. Now, there’s mindfulness-based cognitive therapy, and that reduces stress and emotional eating by increasing intention to hunger crews and emotional triggers. So people become more aware of these cues. And it’s one of the psychological approaches which has been particularly used to deal with that new concept, food noise. Now, you’ll be familiar with this concept of food noise because obviously many people living with obesity have reported that they’ve lost all their food noise because they’ve been put on GLP-1 based therapy. So it’s an interesting notion. It seems mindfulness is important there. Remember, we talked a lot about trauma and abuse as well. And many people living with obesity do suffer from or have suffered from trauma or abuse. So you have compassion-focused therapy, which addresses people’s ongoing self-criticism linked to their shame around their struggles. And you have trauma-based therapy that addresses the psychological roots of weight loss issues, such as childhood trauma and weight-related bullying. And these are not distinct. They are techniques which can be blended and merged depending on the clinical, the psychological presentation of your patient. So it’s very, very interesting. We’ll be talking a lot more at the ECO about that. And we probably perhaps have a psychological session at the ICOMS meeting at some stage as well. So I’m going to finish with this summary. People living with obesity struggle daily against their biology to maintain weight control. And often along with this, along with weight stigma, this produces negative psychological consequences that have an impact on mental health. We do know there are a broad range of mental health issues, such as neurodivergence, developmental conditions and mental health conditions, including depression, many forms of anxiety, disordered eating, addiction, ADHD, autism and personality disorders. So there’s lots of stuff there. So if you’re dealing with people living with obesity, you should also be screening for this. You should be looking for a history of this in people with obesity. And they won’t just have one of these. They may have multiple of these because living with ADHD has an impact on depression, if you see what I mean. So you’ve got to see that there’s a kind of rich psychology there. As I said, there’s a bidirectional association between depression and obesity. And we see also that strong association between visceral antipositive and stress. So the link between mental health and physical health in obesity is real. Both stress and depression, as well as weight gain, are linked to life events, including trauma. And understanding life course is necessary for any personalized approach to obesity. And finally, we’ve got 15 seconds left. Working to reduce stress and boost coping can help reduce temptations and lapses during weight management, boosting self-efficacy. But for a really tailored approach, we need psychotherapy, which provides the ultimate in personalization. I will stop there. Thank you very much for your attention.

Speaker 2 • 43:35
Thank you very much, Professor Jason Harford, for your insightful lecture. Your lecture really addressed the importance of psychological stress and mental health status is a key part. in personalized obesity management. I really appreciate your very excellent lecture. We will now move on to the Q&A session. If you have any questions, please submit questions through the chat box. Let me start first question to Professor Jason Harport. Do you think all the obesity people need to get assessed psychological stress or depression by specialised psychologists? And a second question is, is psychological consultation covered by the insurance, health insurance?

Speaker 4 • 44:43
I’ll deal with that because the two are kind of interlinked. Certainly, there should be some psychological screening. Definitely. Now, many practice nurses or nutritionists can do this at a very basic level. There are not enough skilled psychologists to go around to do this. More to the point, in most healthcare systems, there is not the resources to do that. Whether they are state-funded nationalised systems or insurance-based systems or direct pay-based systems, it’s expensive. Because a psychologist to the level of a clinical psychologist has to be trained from undergraduate through to postdoctoral qualification, probably about seven years. So there are not enough around. So we need to be able to find how to do this in the clinical situation because we do need to screen that. But I am a psychologist. Obviously, I’d advocate for more psychologists to be involved in patient evaluation and treatment. But we have to be aware there is not enough psychologists to go around and there’s not enough money to fund an increase in the number of psychologists available immediately.

Speaker 2 • 46:07
The remaining clinic session will be read by Professor Borjan Umut.

Speaker 1 • 46:14
Okay. So we have many excellent questions. I’ll start with the one that comes and asks about body composition. What aspect of body composition do you think clinicians are currently overlooking that matters most for patient outcomes. This is for Professor Su Lim.

Speaker 3 • 46:45
Yes, that is a very important perspective. I think obesity should increasingly be viewed not only as excess adiposity, but also as a disorder of body composition, including impaired muscle quantity and muscle quality. This is particularly relevant in Asian populations where lower muscle mass and higher activity fat contribute to metabolic risk. So I firmly believe integrating both adiposity and muscle health into diagnosis and measurement can provide a more accurate and clinically meaningful approach.

Speaker 1 • 47:27
Thank you very much. The second question, Jason, would be directed to you, but Sue Lim can also comment. Do we have any evidence that experiences like food noise differ across ethnic or cultural groups?

Speaker 4 • 47:49
I don’t know whether there have been enough studies around food noise. And one of the problems is, is they’re still trying to develop a tool to measure food noise. but something similar around the drive to consume and the ability to turn it off is to look at something around constructs of food reward and we do know that reward-driven eating is seen in different cultures it’s expressed in different ways because there are different food cultures but we also know that the new generation of glp1 and glp1-gip combination drugs are quite effective at turning it off. But obviously how these things present in different cultures and the foods they relate to will be different.

Speaker 3 • 48:34
I would like to echo Jason’s excellent comment. I also think the direct evidence is still limited. So most studies on appetite regulation and food noise have been conducted mainly in Western populations. So we do not yet have strong data comparing ethnic groups. However, it is likely that experience may differ. Cultural eating habits, food environment, and biological factors such as encryption response could influence how people perceive their hunger and food-related thoughts. Overall, this is still an underexplored area, and more research is definitely needed.

Speaker 1 • 49:18
The other question is about the differences in ethnic experiences in obesity and biological stress responses. And it asks, how can we help mitigate this in clinical practice?

Speaker 4 • 49:39
You want me to comment on that one first, Volkan, and then we can talk about a more biological answer. I think stress is a very personalized thing. I think it’s personalised to the individual and how we deal with that, you know, also very cultural as well. What is particularly stressful for individuals in certain cultures may not be such an issue for individuals in other cultures. In terms of ethnic differences and underlying stress response, the biology of stress, I cannot speak to that directly, but I imagine there will be differences there.

Speaker 3 • 50:17
Actually, I’m not an expert in this area, but the managing mental stress in Asian patients require both biological and cultural awareness. Stress is often under-recognized due to stigma and may represent physical symptoms such as fatigue, insomnia, dizziness, or somatic complaints rather than emotional distress. So I suggest intervention should be practical and cultural sensitive, such as regular physical activity or steep optimization or simple mindfulness. I love the word mindfulness. So we need more, several diverse strategies to overcome this detrimental condition.

Speaker 1 • 51:14
With the clinical trials that are carried out for the incretin-based therapies for obesity, we see that clinical research includes diverse populations. The question is, is diversity now more prevalent in these trials?

Speaker 3 • 51:43
Yes, I think so. So it’s a little bit difficult, a very sensitive issue, maybe. Diversity in clinical trial is improving, definitely, but it is still not where it needed to be. Historically, most obesity trials were conducted predominantly in Western populations, limiting generalizability. Most recent studies, however, including global programs like Step 6, 7, and 11, and FLOW, which included many Asian participants, have made efforts to include broader populations, including not only Asians, but also Latin America or African-American, which I think is a very important step forward.

Speaker 1 • 52:37
And also in these trials, I think older adults, which is 65 plus people who are living with obesity, should also be included as far as the approach, the treatment is concerned. Another question would be to Jason Halford. Is there any evidence to show whether specific psychological approaches to treatment work better for specific ethnicities or in different cultures?

Speaker 4 • 53:18
The problem there is we do not have the data. Compared with pharmacological approaches to treatment, where we are now doing clinical trials globally, although you can argue within each country there may be biases against certain populations within, the problem is the psychological studies are not global. The treatments conducted in one study may differ from what is reported in another country as well. So I don’t think we have that breadth of data to talk about that in purely psychological terms.

Speaker 1 • 53:58
I have another question that is asking about practical and low-cost tests evaluations for measuring muscle quality and function.

Speaker 3 • 54:10
Yes, I think this question is for me. So there are several practical and low-cost options that can be used in routine clinical practice. I strongly recommend to use hand-weight strength, which needs just a small device. It’s not that expensive. It is simple and inexpensive and reliable proxy of overall muscle strength and function. And what else? The gait speed. usually 4 meter walking speed and a chair stand-up test and balance test may provide additional information on physical performance and low extremity function. Or if you have some money, you can buy the bioelectrical impedance analysis machine which is not that expensive compared to

Speaker 1 • 55:02
DEXA or CT or MRI. So it’s up to you. This question is to both speakers. What is the most exciting emerging topic in your area of expertise related to personalized approaches to obesity

Speaker 4 • 55:20
management? I go first. I think on the last slide, I mentioned these new third wave psychotherapists coming in beyond standard cognitive behavioral therapies. And that includes the mindfulness-based therapy, the acceptance and commitment-based therapy, the compassion-based therapy, and the trauma-informed therapy as well. Those four coming in have been big advances in psychotherapy in terms of people living with obesity. And I think they are beginning to inform overall approaches to patient care as well. they really influence that holistic approach to treatment. It’s not just standalone psychological components. I could talk for ages on this, but I won’t. I’ll hand over to my colleague.

Speaker 3 • 56:13
From my perspective, from my side, a rapidly advancing field is multi-agonist therapies, as I mentioned in the last part of my talk, and combination approach targeting pathways such as GL, not only in GLP-1, but also GIP, which is already available, and glucagon, and amylin, and peptide YY. You know, the Genagam type from Noble and other departments to the company now have preparing the GLP-1 and amylin derivative, and the Amgen company also conducting clinical trial with GLP-1 and GLP-2 antagonists. And this therapy may enable tailored approach depending on the individual metabolic profile and therapeutic goal. And I also add the integrating digital health and behavioral phenotype and possibly biomarker or genetics will further refine personalization. So now we are living in an era of personalized or tailored medicine. So I firmly believe the obesity treatment should focus on that area.

Speaker 1 • 57:32
Could incretin-based treatments be customized for different ethnicities? Is the success rate equal, the efficacy equal for all? How to actually understand or implement this is a very interesting question.

Speaker 3 • 57:49
Dr. So when we compare the weight reduction between Western European descendants and Asian populations, it is very surprising to see almost identical weight loss regardless of their baseline weight, their body weight. But when you take a look at the data in detail, we found that the maximum tolerate dose might — was slightly different. So most Asian people couldn’t — could not tolerate the maximum dose of semalutide or terzapatide. So maybe submaximal dose might be appropriate for Asian populations. So now we are not using the maximum dose. Now you are not titrating to the maximum dose. So some maximum dose might be beneficial for our populations.

Speaker 1 • 58:58
Thank you very much. I think I have the last question to Jason Halford. Could you give any tip to distinguish temptation from lapse easily?

Speaker 4 • 59:12
Yeah, I’m sorry if it wasn’t clear earlier on. Now, temptation is where you feel drawn to consume something. It’s where you feel you’re very much drawn to do it. But a temptation may not necessarily lead to a lapse. A lapse is only when that temptation has led to an act of consumption. So you have, in quotes, given in to the temptation, or you’ve succumbed to the temptation. So the temptation is the orientation to being tempted by the food. The lapse is the succumbing to the temptation, which leads to food consumption.

Speaker 1 • 59:56
Well, I think we have come to the end of the session. And we had wonderful presentations and excellent questions. I learned a lot. And I know that all of you, all the participants have learned a lot. I would like to thank the speakers and my co-chair Min Se-un Kim for their support. And as Jason is continuously talking about the eco in Istanbul and the icons in Seoul, well, you are all welcome to these meetings. And also would like to remind you of the official journals of our societies, Obesity Facts being IESO and JOMES of KSSO. thank you very much

Speaker 5 • 01:00:59
to everyone and see you soon

Speaker 2 • 01:01:04
thank you see you in Istanbul

Speaker 5 • 01:01:06
okay thank you bye thank you bye