Jan. 5, 2026
Overview of Obesity
Endocrinologist Brooke Matson joins Walker Redd to outline a practical framework for obesity management, including patient-centered counseling, lifestyle interventions, the use of GLP-1 receptor agonists, as well as when to consider bariatric surgery.
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[SPEAKER_01]: Welcome back to Run the List.
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[SPEAKER_01]: This is your host, Walker Red, and I'm here again for another interconology episode with my friend and interconologist here at University of North Carolina, Brooke Matson.
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[SPEAKER_01]: We are gonna go over an incredibly important topic today.
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[SPEAKER_01]: I don't need to convince our listeners that it's really important to understand the topic of obesity, both in terms of how an interconologist approaches this, how we can help patients with a multimodal approach, including lifestyles, and potentially pharmacotherapy.
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[SPEAKER_01]: Really excited to have you back today, Brooke.
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[SPEAKER_01]: Thank you so much for joining us.
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[SPEAKER_00]: It's great to be back.
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[SPEAKER_00]: Thanks for having me.
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[SPEAKER_01]: All right, let's go ahead and run the list.
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[SPEAKER_01]: So, broke what's the magic we're seeing a patient in the primary care clinic setting?
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[SPEAKER_01]: And we're wanting to think about how we may be able to approach a discussion around obesity or on the patient's weight.
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[SPEAKER_01]: You before we dive into some of the next steps of management, I just want to really emphasize this.
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[SPEAKER_01]: You've helped me learn more about how this can be done in a really sensitive and compassionate and yet informative way.
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[SPEAKER_01]: So, how do you sort of approach it and how do you think about this?
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[SPEAKER_00]: First, I think it's important to emphasize that blame should be taken out of the conversation with a patient.
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[SPEAKER_00]: If a patient's coming to you looking for help with weight management, they shouldn't be made to feel like that it's their fault that they're living with obesity.
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[SPEAKER_00]: So I think that's a really important point to emphasize.
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[SPEAKER_00]: And many people wonder, well, what causes obesity and it's not an easy answer?
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[SPEAKER_00]: You know, it's not the fault of the person.
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[SPEAKER_00]: It's a complex interaction between genetics and our environment, including ultra-processed food, this collective activity, and how these things interact.
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[SPEAKER_00]: And so, along those lines, we define obesity as a chronic disease requiring chronic management, just like any other chronic disease like hypertension or diabetes.
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[SPEAKER_00]: So, you know, we reflect that in our language by not using obese as a descriptor as an obese person, rather we would say a person with obesity or person living with obesity.
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[SPEAKER_01]: Yeah, if our listeners take away nothing else from this episode, those are the couple most important points, right, helping the patient understand that you are not placing blame on them as an individual, they are someone who is living with this condition and that we're here to help them in a totally non-judgmental way.
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[SPEAKER_01]: To that end, I know you think about the goal of treatment is not necessarily just like a certain be a my threshold or lowering that, but how do you kind of explain that and frame that to them?
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[SPEAKER_00]: Yeah, I like to think of the goal as some degree of weight loss to prevent complications associated with excess weight, including hypertension, hyperlubidemia, tissue diabetes, metabolic liver disease, sleep apnea, those types of things.
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[SPEAKER_00]: And I always emphasize that there are health benefits from losing even just a small amount of weight, such as 5%, even a small amount can make a big difference.
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[SPEAKER_01]: And I think that sometimes a lot is your place to start with something like 5% and then they can continue to try and make progress from there.
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[SPEAKER_01]: So we are going to get to a little bit deeper dive on some of the pharmacotherapy and options for helping patients with management, but of course we don't want to skip over which really important, which is lifestyle modification.
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[SPEAKER_01]: So we're just going to do some quick hitting discussions of some of the lower hanging food that you can discuss with patients and make sure they do.
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[SPEAKER_01]: One thing I know you've reminded me of before is just to review the medication list.
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[SPEAKER_01]: So often, people are not deeper scribing, medications are hanging around, even if they're not needed.
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[SPEAKER_01]: And sometimes there's medications, may have a weight gain as a potential side effect, or at least be contributing a bit.
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[SPEAKER_01]: So what are some of those common meds you see pop up on list that you want to review?
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[SPEAKER_00]: And this list includes medications like steroids, beta blockers, certain diabetes treatments, including insulin, sulfony ureas, lots of centrally-acting medications such as SSRIs, SNRIs, TCAs, antipsychotics, seizure medications, and pain medicine like evapentinoids.
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[SPEAKER_00]: In addition to some contraceptives including OCPs and next plan on in Marina.
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[SPEAKER_00]: This is not a comprehensive list, just a general list, I don't want to imply that any of these are singular causes for obesity in and of themselves, but as you said, the idea to eliminate low-hanging fruit that could be working against weight loss efforts that people are starting with lifestyle interventions and or a pharmacotherapy.
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[SPEAKER_01]: that's super helpful.
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[SPEAKER_01]: And so then, of course, you want to talk to them about their nutrition, what they're eating and diet.
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[SPEAKER_01]: I'm sure patients bring that question to you.
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[SPEAKER_01]: So how do you summarize that for them?
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[SPEAKER_00]: Yeah, there's not one single recommended diet that is best to recommend to every patient looking to lose weight.
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[SPEAKER_00]: The overall goal and theme of dietary interventions is to reduce calorie intake and improve the quality of food that people are eating.
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[SPEAKER_00]: And at the end of the day, the best diet is the one that the patient can adhere to.
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[SPEAKER_01]: That's such a key point.
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[SPEAKER_01]: Building on that, I know a couple other things that you go through with folks are physical activity and along with that would be sleep and mental health.
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[SPEAKER_01]: So take me through what advice you give patients for this.
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[SPEAKER_00]: Yeah, guidelines recommend at least 150 minutes of aerobic activity per week in addition to at least two strength training sessions.
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[SPEAKER_00]: So I do review this with patients.
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[SPEAKER_00]: It is difficult for many people with obesity to meet these guideline recommendations because many are limited by their weight in terms of pain or muscular skeletal issues associated with weight.
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[SPEAKER_00]: And
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[SPEAKER_00]: and I still emphasize that movement is important in any way that they're able to or any way that they like to do.
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[SPEAKER_00]: So asking them how they like to move their body.
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[SPEAKER_00]: And as you said, I think of sleep and mental health in the lifestyle intervention bucket as well, both quantity and quality of sleep are important.
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[SPEAKER_00]: We know that even just a small amount of sleep deprivation can induce insulin resistance.
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[SPEAKER_00]: So
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[SPEAKER_00]: getting that good quality sleep, and if they have sleep vacuum, they can make sure that that's being treated.
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[SPEAKER_00]: And then finally as far as mental health goes, any mental health disorders like anxiety or depression, it's going to make all of this more difficult than it already is.
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[SPEAKER_00]: And so I frequently encourage therapy if they're sharing a lot about stressors in their life with me during a clinic visit.
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[SPEAKER_00]: And there's some nice groups out there that integrate nutrition and mental health and the context of of weight and weight management as well.
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[SPEAKER_00]: So I would consider these for the right person.
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[SPEAKER_01]: I think that rounds out what is really a holistic approach here.
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[SPEAKER_01]: With that framework in mind, I know that not every practice setting is going to have more resources available, but in settings where there are some opportunity to collaborate, who are some other folks that you end up getting to help out with to achieve some of these lifestyle modifications for patients.
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[SPEAKER_00]: Yeah, it's definitely a team approach and other people I think about on the team include dietitians, for medical nutrition therapy, personal trainers, or physical therapist, depending on patients need if they have functional limitations.
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[SPEAKER_00]: Or if they have pre-diabetes, I always recommend that people look into their local diabetes prevention program.
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[SPEAKER_00]: These are typically held at community centers or YMCA's places like that, very affordable and they can serve as a nice structured lifestyle program if you're looking for help, kind of figuring out how to incorporate some of these things.
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[SPEAKER_01]: Alright, so now we want to have a high level overview of the pharmacological therapy that can be helpful in treating obesity, but before we do that, I do want to highlight something that I've learned from broken my other friends who are in a chronologist, which is really that it's important to highlight with patients.
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[SPEAKER_01]: This is not like an easy way out.
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[SPEAKER_01]: This is really building on the foundation.
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[SPEAKER_01]: of lifestyle interventions, it's not that those parts of this are going to stop, it's just that medications may make some of those lifestyle changes easier to adhere to and help with a little bit further weight loss.
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[SPEAKER_01]: So, drugs use for weight loss broke have been an incredibly relevant topic both in medicine and in the popular press recently.
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[SPEAKER_01]: And so, if you could just share with us, crew the patients are who are candidates, and as you go through these kind of how much weight loss is expected with each of these,
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[SPEAKER_01]: drug classes and also you're going to start by giving us a little bit of the historical background rate of how we got to GOP ones too.
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[SPEAKER_00]: Absolutely.
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[SPEAKER_00]: So people that are candidates for obesity pharmacotherapy include people with a BMI greater than or equal to 27 with at least one weight related comorbidity or a BMI greater than or equal to 30.
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[SPEAKER_00]: And as you mentioned, GOP ones are all the rage these days but we did have FDA approved medications for weight loss prior to
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[SPEAKER_00]: And so these are earlier medications that have been around for a long time I think of these medications as causing up to about 5% weight loss.
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[SPEAKER_00]: And these FDA-proof medications include combination medications like ventramine to pure mate under the brand in kusimia or be appropriate on now trexone under the brand in contrave.
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[SPEAKER_00]: And these are prescribed as often in the present day and age with GOP1 receptor agonist though I have been reaching for these more often in the past
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[SPEAKER_00]: A couple of other medications that we tend to use that are not FDA-approved for weight loss, but are often used in this context also include met-formin or STL-T2 inhibitors.
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[SPEAKER_01]: Yeah, some really important points there.
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[SPEAKER_01]: If you are having insurance coverage issues with GLP ones, you can reach for some of those older agents.
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[SPEAKER_01]: And then keep it in mind, the good old Met form and the SGLT2 inhibitors are another way to augment things a little bit, even in the absence of getting the GLP one prescription.
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[SPEAKER_01]: And so those medications are often a little bit more I think on about the 5% weight loss.
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[SPEAKER_01]: Like we're discussing.
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[SPEAKER_01]: So for GLP ones, I know that there's potential for more weight loss.
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[SPEAKER_01]: And so can you kind of step through that and take us through the different agents and where we are now?
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[SPEAKER_00]: Definitely, of course, GOP ones are what everyone wants to hear about these days.
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[SPEAKER_00]: They are the most effective medications that we have for weight loss at the present time.
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[SPEAKER_00]: And we can expect anywhere from about 10 to 20 percent or even more with individual GOP-1 receptor agonist.
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[SPEAKER_00]: The first FDA approved GOP-1 receptor agonist for weight loss was Leragotide or sex endo.
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[SPEAKER_00]: This was a daily injection.
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[SPEAKER_00]: It's still available in on the market.
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[SPEAKER_00]: Of course, people hear a lot about some agglotide or we go VD's days, which is a weekly injection and yield more weight loss than the agglotide.
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[SPEAKER_00]: And then finally, it turns that agglotide under the brand name Zepound as a weekly GLP1 in GIP receptor co-agonist.
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[SPEAKER_00]: And that does tend to result in more weight loss than some agglotide.
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[SPEAKER_00]: The Zepound is actually now FDA proof or treatment of a certain sleep apnea, as of the end of 2024 as well, and so that's exciting.
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[SPEAKER_01]: Thanks for stepping through the specific agents and reminding them of the names.
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[SPEAKER_01]: How do you think about other specifics of how to use these medications?
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[SPEAKER_00]: I think it's important to remind people that people with obesity both out diabetes generally tend to lose more weight on these medications than people with diabetes.
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[SPEAKER_00]: Of course, these medications are used to treat diabetes as well under different brand names, but same act of ingredient.
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[SPEAKER_00]: They're not approved for you some pregnancy or during breastfeeding at this time.
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[SPEAKER_00]: And so that's always something important to counsel patients as well.
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[SPEAKER_00]: Talk about contraception, those types of things.
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[SPEAKER_00]: And generally, you probably hear about this a lot on the GI side, but we generally increase the dose every four weeks is tolerated and the primary side effects that people experience are GI related, including nausea, vomiting, diarrhea, constipation.
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[SPEAKER_00]: And we often address these by talking about different dietary approaches, including talking about small portion sizes, eating slowly, making sure you're paying attention to satiety signals, those types of things.
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[SPEAKER_00]: I'm curious if you have other things you talk about with people in clinic.
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[SPEAKER_01]: No, since these medications came out, it's been increasingly discussed in the GI world.
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[SPEAKER_01]: We were seeing more of these patients in clinic.
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[SPEAKER_01]: I think now a lot of prescribers are a a little bit more tuned to just having the conversation with the patient, helping set expectations, like so many medications, finding the right dose.
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[SPEAKER_01]: The patient can tolerate without having sort of intolerable GI side effects and still having as much efficacy as possible is what what we're certainly aiming for too.
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[SPEAKER_01]: There are some cons which we'll talk about too in addition to some of those side effects or some challenges at least with these meds, but let's not skip over the really increasingly exciting positive results we have associated with them, some of those most recent findings.
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[SPEAKER_00]: absolutely the JLP1 receptor agonist and co-agonist with GIP and Guga gone coming down the line as well are certainly leading to weight loss that previously was not achievable with pharmacotherapy before the present era so that's really exciting and of course an additional exciting benefit that we're continuing to get more data and learn more about is about cardiovascular risk reduction.
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[SPEAKER_01]: Yeah, I mean, you just can't say enough about how exciting that is because anything we can do to help decrease the burden of cardiovascular disease, even a little bit, is just a tremendous gain for our patients.
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[SPEAKER_01]: But on that note, what are some of the things that do come up in terms of kinds?
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[SPEAKER_01]: I know there's the practical side of the supply and the shortage and the insurance coverage.
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[SPEAKER_01]: Let's talk about that a little bit first, and then we can talk about some of the other things that you see.
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[SPEAKER_00]: Yes, very common questions from patients and a source of frustration as well, which is certainly understandable.
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[SPEAKER_00]: So the insurance coverage has been fluctuating, is really hard to keep up with, and I think we'll continue evolving over time.
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[SPEAKER_00]: One common question I get related to this is about compounded GOP1 receptor agamist.
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[SPEAKER_00]: A lot of people will come in asking about it.
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[SPEAKER_00]: I generally tell them, you know, because the compounded medications are not regulated in the same way that the brand that we all know and love are used, I just can't feel comfortable recommending them across the board just because there's generally less oversight and these are were not the same products that were tested in clinical trials, so we just know less about kind of what's out there.
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[SPEAKER_01]: very important part of patient education, I think.
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[SPEAKER_01]: Some other things that you can help make sure patients understand as well is weight regain in this loss of lean body mass or also come up.
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[SPEAKER_01]: So what do you tell them from a practical perspective?
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[SPEAKER_00]: Yeah, these are common questions from people too.
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[SPEAKER_00]: We do know that people regain weight when they stop the medication.
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[SPEAKER_00]: So when people ask about this, I generally refer back to what we were talking about earlier that OBCs of chronic disease, requiring chronic management.
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[SPEAKER_00]: And when people's blood pressure is better, we don't stop their blood pressure medicine.
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[SPEAKER_00]: We continue their blood pressure medicine to keep their blood pressure into good control.
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[SPEAKER_00]: So that's kind of how I frame the discussion about continuing these agents on.
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[SPEAKER_01]: That's very helpful.
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[SPEAKER_00]: Finally, as far as loss of lean body mass, I really hammer home the importance of strength training and maintaining muscle mass while they're on these medicines as well.
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[SPEAKER_01]: The last modality here, I think we should touch on, it would be bariatric surgery.
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[SPEAKER_01]: I think you just give us a really quick rundown of who are candidates and what sort of weight loss patients can expect with that.
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[SPEAKER_00]: Yeah, I'm important to remember that this is an option too.
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[SPEAKER_00]: Candidates include people with a BMI grid in 35, with an obesity related comorbidity or BMI greater than 40.
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[SPEAKER_00]: And they're primarily two options, the slave gastric to me, which is a restrictive procedure and ruin one gastric bypass, which is a restrictive and mountain-sorbative procedure.
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[SPEAKER_00]: And we can expect up to about 30% weight loss with bariatric surgery.
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[SPEAKER_00]: The medications are catching up quickly, but that's kind of where we are right now in the present day and age.
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[SPEAKER_01]: Great.
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[SPEAKER_01]: So we've reviewed how you can discuss this disease with patients, how you can build from lifestyle modifications to medications of needed or even potentially surgery.
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[SPEAKER_01]: With that in mind, what are the most important if you take home points about this really important topic, Brooke, that you want our listeners to remember.
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[SPEAKER_00]: First, obesity is a chronic disease, and it should be treated as such like we've been talking about.
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[SPEAKER_00]: It should be divorced from patient blame.
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[SPEAKER_00]: The goal is not to achieve a normal BMI, but the goal is to lose weight for prevention of weight-related co-orbidities.
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[SPEAKER_00]: Second, as you were talking about lifestyle interventions of pharmacotherapy or synergistic medicines are not an easy way out.
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[SPEAKER_00]: It's really important to continue lifestyle interventions along with medications as well.
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[SPEAKER_00]: And then finally, the combined gel P1GIP receptor coagnes
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[SPEAKER_00]: is currently the agent that leads to the greatest amount of weight loss.
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[SPEAKER_00]: There are a lot of other medications coming down the pipeline that may supersede this in the future.
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[SPEAKER_01]: Well, Brooke, thank you so much for that summary.
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[SPEAKER_01]: Thank you so much for joining us.
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[SPEAKER_01]: And thank you so much for our listeners for tuning in to hear more about this incredibly important topic.
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[SPEAKER_01]: Hopefully this empowers you to have informed discussions with your patients and take care of them.
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[SPEAKER_01]: Thanks so much for tuning in.
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[SPEAKER_01]: Welcome back to Run the List.
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[SPEAKER_01]: This is your host, Walker Red, and I'm here again for another interconology episode with my friend and interconologist here at University of North Carolina, Brooke Matson.
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[SPEAKER_01]: We are gonna go over an incredibly important topic today.
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[SPEAKER_01]: I don't need to convince our listeners that it's really important to understand the topic of obesity, both in terms of how an interconologist approaches this, how we can help patients with a multimodal approach, including lifestyles, and potentially pharmacotherapy.
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[SPEAKER_01]: Really excited to have you back today, Brooke.
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[SPEAKER_01]: Thank you so much for joining us.
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[SPEAKER_00]: It's great to be back.
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[SPEAKER_00]: Thanks for having me.
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[SPEAKER_01]: All right, let's go ahead and run the list.
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[SPEAKER_01]: So, broke what's the magic we're seeing a patient in the primary care clinic setting?
00:40.712 --> 00:47.281
[SPEAKER_01]: And we're wanting to think about how we may be able to approach a discussion around obesity or on the patient's weight.
00:47.782 --> 00:51.928
[SPEAKER_01]: You before we dive into some of the next steps of management, I just want to really emphasize this.
00:51.988 --> 00:57.055
[SPEAKER_01]: You've helped me learn more about how this can be done in a really sensitive and compassionate and yet informative way.
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[SPEAKER_01]: So, how do you sort of approach it and how do you think about this?
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[SPEAKER_00]: First, I think it's important to emphasize that blame should be taken out of the conversation with a patient.
01:06.679 --> 01:12.748
[SPEAKER_00]: If a patient's coming to you looking for help with weight management, they shouldn't be made to feel like that it's their fault that they're living with obesity.
01:12.808 --> 01:15.412
[SPEAKER_00]: So I think that's a really important point to emphasize.
01:15.813 --> 01:19.278
[SPEAKER_00]: And many people wonder, well, what causes obesity and it's not an easy answer?
01:19.779 --> 01:22.282
[SPEAKER_00]: You know, it's not the fault of the person.
01:22.803 --> 01:30.855
[SPEAKER_00]: It's a complex interaction between genetics and our environment, including ultra-processed food, this collective activity, and how these things interact.
01:30.835 --> 01:39.389
[SPEAKER_00]: And so, along those lines, we define obesity as a chronic disease requiring chronic management, just like any other chronic disease like hypertension or diabetes.
01:39.430 --> 01:48.625
[SPEAKER_00]: So, you know, we reflect that in our language by not using obese as a descriptor as an obese person, rather we would say a person with obesity or person living with obesity.
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[SPEAKER_01]: Yeah, if our listeners take away nothing else from this episode, those are the couple most important points, right, helping the patient understand that you are not placing blame on them as an individual, they are someone who is living with this condition and that we're here to help them in a totally non-judgmental way.
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[SPEAKER_01]: To that end, I know you think about the goal of treatment is not necessarily just like a certain be a my threshold or lowering that, but how do you kind of explain that and frame that to them?
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[SPEAKER_00]: Yeah, I like to think of the goal as some degree of weight loss to prevent complications associated with excess weight, including hypertension, hyperlubidemia, tissue diabetes, metabolic liver disease, sleep apnea, those types of things.
02:26.520 --> 02:34.592
[SPEAKER_00]: And I always emphasize that there are health benefits from losing even just a small amount of weight, such as 5%, even a small amount can make a big difference.
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[SPEAKER_01]: And I think that sometimes a lot is your place to start with something like 5% and then they can continue to try and make progress from there.
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[SPEAKER_01]: So we are going to get to a little bit deeper dive on some of the pharmacotherapy and options for helping patients with management, but of course we don't want to skip over which really important, which is lifestyle modification.
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[SPEAKER_01]: So we're just going to do some quick hitting discussions of some of the lower hanging food that you can discuss with patients and make sure they do.
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[SPEAKER_01]: One thing I know you've reminded me of before is just to review the medication list.
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[SPEAKER_01]: So often, people are not deeper scribing, medications are hanging around, even if they're not needed.
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[SPEAKER_01]: And sometimes there's medications, may have a weight gain as a potential side effect, or at least be contributing a bit.
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[SPEAKER_01]: So what are some of those common meds you see pop up on list that you want to review?
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[SPEAKER_00]: And this list includes medications like steroids, beta blockers, certain diabetes treatments, including insulin, sulfony ureas, lots of centrally-acting medications such as SSRIs, SNRIs, TCAs, antipsychotics, seizure medications, and pain medicine like evapentinoids.
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[SPEAKER_00]: In addition to some contraceptives including OCPs and next plan on in Marina.
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[SPEAKER_00]: This is not a comprehensive list, just a general list, I don't want to imply that any of these are singular causes for obesity in and of themselves, but as you said, the idea to eliminate low-hanging fruit that could be working against weight loss efforts that people are starting with lifestyle interventions and or a pharmacotherapy.
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[SPEAKER_01]: that's super helpful.
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[SPEAKER_01]: And so then, of course, you want to talk to them about their nutrition, what they're eating and diet.
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[SPEAKER_01]: I'm sure patients bring that question to you.
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[SPEAKER_01]: So how do you summarize that for them?
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[SPEAKER_00]: Yeah, there's not one single recommended diet that is best to recommend to every patient looking to lose weight.
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[SPEAKER_00]: The overall goal and theme of dietary interventions is to reduce calorie intake and improve the quality of food that people are eating.
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[SPEAKER_00]: And at the end of the day, the best diet is the one that the patient can adhere to.
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[SPEAKER_01]: That's such a key point.
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[SPEAKER_01]: Building on that, I know a couple other things that you go through with folks are physical activity and along with that would be sleep and mental health.
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[SPEAKER_01]: So take me through what advice you give patients for this.
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[SPEAKER_00]: Yeah, guidelines recommend at least 150 minutes of aerobic activity per week in addition to at least two strength training sessions.
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[SPEAKER_00]: So I do review this with patients.
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[SPEAKER_00]: It is difficult for many people with obesity to meet these guideline recommendations because many are limited by their weight in terms of pain or muscular skeletal issues associated with weight.
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[SPEAKER_00]: And
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[SPEAKER_00]: and I still emphasize that movement is important in any way that they're able to or any way that they like to do.
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[SPEAKER_00]: So asking them how they like to move their body.
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[SPEAKER_00]: And as you said, I think of sleep and mental health in the lifestyle intervention bucket as well, both quantity and quality of sleep are important.
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[SPEAKER_00]: We know that even just a small amount of sleep deprivation can induce insulin resistance.
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[SPEAKER_00]: So
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[SPEAKER_00]: getting that good quality sleep, and if they have sleep vacuum, they can make sure that that's being treated.
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[SPEAKER_00]: And then finally as far as mental health goes, any mental health disorders like anxiety or depression, it's going to make all of this more difficult than it already is.
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[SPEAKER_00]: And so I frequently encourage therapy if they're sharing a lot about stressors in their life with me during a clinic visit.
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[SPEAKER_00]: And there's some nice groups out there that integrate nutrition and mental health and the context of of weight and weight management as well.
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[SPEAKER_00]: So I would consider these for the right person.
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[SPEAKER_01]: I think that rounds out what is really a holistic approach here.
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[SPEAKER_01]: With that framework in mind, I know that not every practice setting is going to have more resources available, but in settings where there are some opportunity to collaborate, who are some other folks that you end up getting to help out with to achieve some of these lifestyle modifications for patients.
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[SPEAKER_00]: Yeah, it's definitely a team approach and other people I think about on the team include dietitians, for medical nutrition therapy, personal trainers, or physical therapist, depending on patients need if they have functional limitations.
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[SPEAKER_00]: Or if they have pre-diabetes, I always recommend that people look into their local diabetes prevention program.
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[SPEAKER_00]: These are typically held at community centers or YMCA's places like that, very affordable and they can serve as a nice structured lifestyle program if you're looking for help, kind of figuring out how to incorporate some of these things.
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[SPEAKER_01]: Alright, so now we want to have a high level overview of the pharmacological therapy that can be helpful in treating obesity, but before we do that, I do want to highlight something that I've learned from broken my other friends who are in a chronologist, which is really that it's important to highlight with patients.
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[SPEAKER_01]: This is not like an easy way out.
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[SPEAKER_01]: This is really building on the foundation.
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[SPEAKER_01]: of lifestyle interventions, it's not that those parts of this are going to stop, it's just that medications may make some of those lifestyle changes easier to adhere to and help with a little bit further weight loss.
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[SPEAKER_01]: So, drugs use for weight loss broke have been an incredibly relevant topic both in medicine and in the popular press recently.
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[SPEAKER_01]: And so, if you could just share with us, crew the patients are who are candidates, and as you go through these kind of how much weight loss is expected with each of these,
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[SPEAKER_01]: drug classes and also you're going to start by giving us a little bit of the historical background rate of how we got to GOP ones too.
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[SPEAKER_00]: Absolutely.
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[SPEAKER_00]: So people that are candidates for obesity pharmacotherapy include people with a BMI greater than or equal to 27 with at least one weight related comorbidity or a BMI greater than or equal to 30.
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[SPEAKER_00]: And as you mentioned, GOP ones are all the rage these days but we did have FDA approved medications for weight loss prior to
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[SPEAKER_00]: And so these are earlier medications that have been around for a long time I think of these medications as causing up to about 5% weight loss.
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[SPEAKER_00]: And these FDA-proof medications include combination medications like ventramine to pure mate under the brand in kusimia or be appropriate on now trexone under the brand in contrave.
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[SPEAKER_00]: And these are prescribed as often in the present day and age with GOP1 receptor agonist though I have been reaching for these more often in the past
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[SPEAKER_00]: A couple of other medications that we tend to use that are not FDA-approved for weight loss, but are often used in this context also include met-formin or STL-T2 inhibitors.
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[SPEAKER_01]: Yeah, some really important points there.
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[SPEAKER_01]: If you are having insurance coverage issues with GLP ones, you can reach for some of those older agents.
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[SPEAKER_01]: And then keep it in mind, the good old Met form and the SGLT2 inhibitors are another way to augment things a little bit, even in the absence of getting the GLP one prescription.
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[SPEAKER_01]: And so those medications are often a little bit more I think on about the 5% weight loss.
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[SPEAKER_01]: Like we're discussing.
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[SPEAKER_01]: So for GLP ones, I know that there's potential for more weight loss.
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[SPEAKER_01]: And so can you kind of step through that and take us through the different agents and where we are now?
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[SPEAKER_00]: Definitely, of course, GOP ones are what everyone wants to hear about these days.
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[SPEAKER_00]: They are the most effective medications that we have for weight loss at the present time.
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[SPEAKER_00]: And we can expect anywhere from about 10 to 20 percent or even more with individual GOP-1 receptor agonist.
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[SPEAKER_00]: The first FDA approved GOP-1 receptor agonist for weight loss was Leragotide or sex endo.
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[SPEAKER_00]: This was a daily injection.
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[SPEAKER_00]: It's still available in on the market.
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[SPEAKER_00]: Of course, people hear a lot about some agglotide or we go VD's days, which is a weekly injection and yield more weight loss than the agglotide.
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[SPEAKER_00]: And then finally, it turns that agglotide under the brand name Zepound as a weekly GLP1 in GIP receptor co-agonist.
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[SPEAKER_00]: And that does tend to result in more weight loss than some agglotide.
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[SPEAKER_00]: The Zepound is actually now FDA proof or treatment of a certain sleep apnea, as of the end of 2024 as well, and so that's exciting.
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[SPEAKER_01]: Thanks for stepping through the specific agents and reminding them of the names.
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[SPEAKER_01]: How do you think about other specifics of how to use these medications?
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[SPEAKER_00]: I think it's important to remind people that people with obesity both out diabetes generally tend to lose more weight on these medications than people with diabetes.
09:53.348 --> 10:00.096
[SPEAKER_00]: Of course, these medications are used to treat diabetes as well under different brand names, but same act of ingredient.
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[SPEAKER_00]: They're not approved for you some pregnancy or during breastfeeding at this time.
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[SPEAKER_00]: And so that's always something important to counsel patients as well.
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[SPEAKER_00]: Talk about contraception, those types of things.
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[SPEAKER_00]: And generally, you probably hear about this a lot on the GI side, but we generally increase the dose every four weeks is tolerated and the primary side effects that people experience are GI related, including nausea, vomiting, diarrhea, constipation.
10:20.619 --> 10:30.089
[SPEAKER_00]: And we often address these by talking about different dietary approaches, including talking about small portion sizes, eating slowly, making sure you're paying attention to satiety signals, those types of things.
10:30.129 --> 10:33.032
[SPEAKER_00]: I'm curious if you have other things you talk about with people in clinic.
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[SPEAKER_01]: No, since these medications came out, it's been increasingly discussed in the GI world.
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[SPEAKER_01]: We were seeing more of these patients in clinic.
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[SPEAKER_01]: I think now a lot of prescribers are a a little bit more tuned to just having the conversation with the patient, helping set expectations, like so many medications, finding the right dose.
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[SPEAKER_01]: The patient can tolerate without having sort of intolerable GI side effects and still having as much efficacy as possible is what what we're certainly aiming for too.
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[SPEAKER_01]: There are some cons which we'll talk about too in addition to some of those side effects or some challenges at least with these meds, but let's not skip over the really increasingly exciting positive results we have associated with them, some of those most recent findings.
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[SPEAKER_00]: absolutely the JLP1 receptor agonist and co-agonist with GIP and Guga gone coming down the line as well are certainly leading to weight loss that previously was not achievable with pharmacotherapy before the present era so that's really exciting and of course an additional exciting benefit that we're continuing to get more data and learn more about is about cardiovascular risk reduction.
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[SPEAKER_01]: Yeah, I mean, you just can't say enough about how exciting that is because anything we can do to help decrease the burden of cardiovascular disease, even a little bit, is just a tremendous gain for our patients.
11:39.181 --> 11:42.667
[SPEAKER_01]: But on that note, what are some of the things that do come up in terms of kinds?
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[SPEAKER_01]: I know there's the practical side of the supply and the shortage and the insurance coverage.
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[SPEAKER_01]: Let's talk about that a little bit first, and then we can talk about some of the other things that you see.
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[SPEAKER_00]: Yes, very common questions from patients and a source of frustration as well, which is certainly understandable.
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[SPEAKER_00]: So the insurance coverage has been fluctuating, is really hard to keep up with, and I think we'll continue evolving over time.
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[SPEAKER_00]: One common question I get related to this is about compounded GOP1 receptor agamist.
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[SPEAKER_00]: A lot of people will come in asking about it.
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[SPEAKER_00]: I generally tell them, you know, because the compounded medications are not regulated in the same way that the brand that we all know and love are used, I just can't feel comfortable recommending them across the board just because there's generally less oversight and these are were not the same products that were tested in clinical trials, so we just know less about kind of what's out there.
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[SPEAKER_01]: very important part of patient education, I think.
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[SPEAKER_01]: Some other things that you can help make sure patients understand as well is weight regain in this loss of lean body mass or also come up.
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[SPEAKER_01]: So what do you tell them from a practical perspective?
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[SPEAKER_00]: Yeah, these are common questions from people too.
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[SPEAKER_00]: We do know that people regain weight when they stop the medication.
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[SPEAKER_00]: So when people ask about this, I generally refer back to what we were talking about earlier that OBCs of chronic disease, requiring chronic management.
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[SPEAKER_00]: And when people's blood pressure is better, we don't stop their blood pressure medicine.
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[SPEAKER_00]: We continue their blood pressure medicine to keep their blood pressure into good control.
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[SPEAKER_00]: So that's kind of how I frame the discussion about continuing these agents on.
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[SPEAKER_01]: That's very helpful.
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[SPEAKER_00]: Finally, as far as loss of lean body mass, I really hammer home the importance of strength training and maintaining muscle mass while they're on these medicines as well.
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[SPEAKER_01]: The last modality here, I think we should touch on, it would be bariatric surgery.
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[SPEAKER_01]: I think you just give us a really quick rundown of who are candidates and what sort of weight loss patients can expect with that.
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[SPEAKER_00]: Yeah, I'm important to remember that this is an option too.
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[SPEAKER_00]: Candidates include people with a BMI grid in 35, with an obesity related comorbidity or BMI greater than 40.
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[SPEAKER_00]: And they're primarily two options, the slave gastric to me, which is a restrictive procedure and ruin one gastric bypass, which is a restrictive and mountain-sorbative procedure.
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[SPEAKER_00]: And we can expect up to about 30% weight loss with bariatric surgery.
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[SPEAKER_00]: The medications are catching up quickly, but that's kind of where we are right now in the present day and age.
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[SPEAKER_01]: Great.
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[SPEAKER_01]: So we've reviewed how you can discuss this disease with patients, how you can build from lifestyle modifications to medications of needed or even potentially surgery.
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[SPEAKER_01]: With that in mind, what are the most important if you take home points about this really important topic, Brooke, that you want our listeners to remember.
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[SPEAKER_00]: First, obesity is a chronic disease, and it should be treated as such like we've been talking about.
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[SPEAKER_00]: It should be divorced from patient blame.
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[SPEAKER_00]: The goal is not to achieve a normal BMI, but the goal is to lose weight for prevention of weight-related co-orbidities.
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[SPEAKER_00]: Second, as you were talking about lifestyle interventions of pharmacotherapy or synergistic medicines are not an easy way out.
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[SPEAKER_00]: It's really important to continue lifestyle interventions along with medications as well.
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[SPEAKER_00]: And then finally, the combined gel P1GIP receptor coagnes
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[SPEAKER_00]: is currently the agent that leads to the greatest amount of weight loss.
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[SPEAKER_00]: There are a lot of other medications coming down the pipeline that may supersede this in the future.
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[SPEAKER_01]: Well, Brooke, thank you so much for that summary.
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[SPEAKER_01]: Thank you so much for joining us.
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[SPEAKER_01]: And thank you so much for our listeners for tuning in to hear more about this incredibly important topic.
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[SPEAKER_01]: Hopefully this empowers you to have informed discussions with your patients and take care of them.
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[SPEAKER_01]: Thanks so much for tuning in.