Subscribe
Share
Share
Embed
Micro wisdom delivered to your ears every morning in voice notes ranging from 3 to 15 minutes long. Wisdom on how to live a healthier and more fulfilling life. Every podcast will ground you in the present moment to ensure you know what's important, the here and now.
Right hand side. Perfect. Let's go with this then.
Speaker 2:Yeah, the second, third slide, please.
Speaker 1:Third slide.
Speaker 2:Yeah. So basically, what I wanted to talk about is why are we talking about obesity today? Being an obesity doctor, I just wanted to give that understanding. Why? Because it's one of the biggest public health challenges currently facing not only just in The United Kingdom but the rest of the world.
Speaker 2:And again, what is the challenge with obesity? Because it is a challenge because it is expected. It reduces the life expectancy. And also it is associated with increased risk of people developing conditions for chronic conditions like type two diabetes, heart disease, sleep apnea and it is also associated with some cancers and also it is associated with mental health challenges sort of a thing. So that is one of the key main reasons.
Speaker 2:The reason why I am putting the Dutch slide is basically to just give an understanding that historically we have always been told that people who are living with obesity is all because they're eating more or doing less physical activity. But what science now tells us with the advancement is that yes, they may be playing a part, but actually there are multiple other factors which actually play a significant role in developing people with the obesity sort of thing. And some of them, as you can see, are environmental factors. Some of them are medications itself, which are patients are using it for other medical conditions and stuff. And again, you have other epigenetics and psychological challenges and all these things.
Speaker 2:So what is happening with the patients living with obesity is basically all these external factors which are independent of the patient's ability to modify their model. They're playing a role in that. And as a result of which, then they are affecting the way the person is relationship with the food and how the body is categorising this excess fat in different parts of the body. And as you can see within the last picture, are some there are there's a patient in the middle whose lower limbs are quite significantly swollen and that's where the fat is deposited, where people usually might have heard about something called lip edema. And then you have a person in the third bottom left picture where a person is completely obese in most of the trunk and the upper limbs and the lower limbs sort of a thing.
Speaker 2:So just an indication to say that it's not always that statement of eating more and moving less is the reason for the obesity. That's the key message here. Next page. This slide is mainly for me as a clinician. When people come to see me in the clinic, they tend to usually ask me that question: Doctor, how much weight do you want me to lose?
Speaker 2:What are the things? So this slide gives me a little bit of an understanding where the research based evidence is available to me as a clinician. If I have a patient who's sitting in front of me with a diagnosis of type two diabetes and say, Doctor, I want to lose weight to make this diabetes in remission. So I will be able to say that confidently that there is evidence that if you lose 15% of the total body weight, there is eighty five percent chance of you achieving type two diabetes in remission. And if somebody comes to me saying that Doctor, I have blood pressure and I'm not able to manage this blood pressure with the medication, what is the rough weight I need to lose?
Speaker 2:There is evidence to say each one again, it depends on a person to person, but minimum five to 10% of the total body weight loss is required for somebody to achieve a weight loss, the blood pressure control sort of a thing, or blood pressure to be normalised into normal cells. So this is mainly a slide. Then there is some indication for the sleep apnoea. People who have obstructive sleep apnoea. I don't know if you have heard about, they use a machine called CPAP machine, which is they have to wear it all of the night just to keep the airway open.
Speaker 2:But again, they have challenges keeping that machine on their face. They're always coming into the clinic saying, I wish you can help me with not using the CPAP. And this is where I tell the patients, okay, there is evidence. If you lose 10% of the total body weight, there is a chance that you may not need a CPAP machine. That gives a motivation and that gives some sort of a target to work for the patients as well.
Speaker 2:Next paragraph. Yeah, this is another slide which is I think is quite an important thing. The reason for because people come when they do the consultation with me, they keep mentioning talking about Doctor, I do 10,000 steps, Doctor, I do 15,000 steps, Doctor, I'm not able to lose my weight, I'm not able to shed any weight. So what I have just put on the slide is just The UK Chief Medical Officer's guidelines. For a normal healthy living, yes, there are significant benefits when patients have a healthy lifestyle.
Speaker 2:And the recommendation at the moment as you can see is one hundred and fifty minutes per week. And what is that moderate type of intensity work? How do you define that moderate intensity is where your heart rate is beating fast and you're able to speak but not very clearly. Slowly you're able to speak. That is considered as a moderate intensity work.
Speaker 2:So the recommendation is one hundred and fifty minutes per week or thirty minutes per day for five days a week is a minimum. Someone want to do more vigorous intensity. The recommendation is seventy five minutes per week where the heart rate is fast and the person who is doing the exercise is unable to speak also. And that is something is considered as intense exercise sort of thing. Then you have other type of exercise recommendations to build strength and other things.
Speaker 2:But the key message I wanted to give the message here is that as you can see on the left hand side of the slide, the recommendation is if somebody want to prevent obesity, the minimum recommendation is that forty five minutes to sixty minutes of moderate intensity work on a daily basis. That is the amount of the work you are supposed to be achieving to keep off obesity. If people are living with obesity and want to lose weight or maintain weight, the recommendation as you can see is sixty minutes of vigorous intensity exercise. That's quite a lot. And that is where the challenge comes for most of the patients living with obesity.
Speaker 2:Already they are living with obesity with a lot of arthritis and other challenges. Physical mobility is a challenge and stuff like that. And given that circumstance for people to expect to do that amount of physical activity is quite a challenge. But I've just given the slide to just give them an understanding what actually is a recommendation. Occasionally in the clinics, I tend to get a patient who is able to do that level of physical activity and they do amazingly.
Speaker 2:But it's not for everyone. Again, it depends on multiple factors. People should have time. Sustainability is a key thing. No point in somebody starting a physical activity, joining a gym, going three days, four days a week, and then after two three months just reducing it to two days and then one day and then after stop, then you're not going to gain much about it.
Speaker 2:This is just an indication sort of a thing. Next question. I just wanted to just give you a hypothetical patient. Is sort of something like a common scenario for in the obesity clinics where I meet someone like Tracy. I've taken this picture from the Obesity Society.
Speaker 2:They have images, patient images, which we can borrow to do the presentation. So she comes in with saying that I've been living with obesity. I have tried lifestyle changes which includes diet and exercise but I'm not able to do any improvement. So, I would like to hear from the audience to say what do you think is the reason why people like Tracy are struggling to achieve the personal goals? Any anybody want to shout out anything?
Speaker 2:Would they feel that is the reason?
Speaker 1:Stress.
Speaker 3:High stress levels.
Speaker 2:Stress levels. Yeah. And hormones? Hormones. Yes.
Speaker 2:They they they play all role. They all play a role. Definitely, they all play a role as well. I just want to give you a background sort of a thing. I don't know if you have any other audience have ever heard of something called a set point theory.
Speaker 2:So we, as a human race sort of thing, we have evolved over thousands of years sort of thing in terms of our evolution. This is the only one generation in the whole human race where we are trying to lose weight to maintain healthy weight. Until now, people had to maintain weight and gain weight to live healthily. So we have a complex, intricate chemical system in the brain which does not allow us to lose weight because that has been the protective mechanism for the whole of the human race to actually survive through the times of periods of drought, famines, war, when there has been significant rationing of the food and all these things, the body maintains such a complex system. So when a person wants to lose weight, usually you lose weight one or two kgs or maybe a half a stone sort of thing.
Speaker 2:Weight loss is quite easy for most of the people. But by the time they come to a stone of weight loss, then they feel that they are hitting the wall, where in spite of the making an effort, a full effort in terms of whatever they have done initially, they're doing the same thing, sometimes even more than what they're doing. But still, the scale is not moving and then things become very difficult for them. The reason for that is the body's complex chemical system as triggered in a system where it is trying to preserve energy. So, it doesn't allow you to lose any more weight.
Speaker 2:Why? Because it has shut down some metabolism activities in the body because the chemical system is telling this person is losing weight. We need to save the person. And how do we do? By shutting down some of the metabolism.
Speaker 2:So people start they have lost weight, but they start feeling a bit tired, exhausted. I don't know if anyone has experienced that. You you on one side, you feel that, okay. I'm great. I've lost one stone in weight.
Speaker 2:I've lost two stones in weight. But you know what? I feel tired. I feel exhausted. I'm not able to do things what I felt I could do.
Speaker 2:Initially, I thought I could lose one stone and do this activity, but I'm not able to do. Is what the experience is, real experience? Is that a real feel? Yeah. So that is one of the key simple reasons is body is trying to save energy.
Speaker 2:So it is shutting down the metabolism, take you back to the original way. And that is what we call it as a set point sort of a theory. The higher you go in your body weight, the set point sets higher. But unfortunately, the set point has never been come able to set at the lower point. For example, somebody is at 11 stool.
Speaker 2:You want to say you go high to 11.5, then the set point goes up. But the same person, if they come to 10.5, the set point unfortunately doesn't reset lower. So that is where I hope the science can sometimes soon try and find some things to do that sort of thing. Think that day would be a great winner day. So that is one of the key reasons why people like Tracy, when they are doing a lifestyle, lose weight.
Speaker 2:But after that, it becomes such a challenge for them to maintain the weight, and they yo yo all the time, up and down sort of a thing. Is that clear? Any questions for that?
Speaker 3:How do you tackle set points? That resonates with me.
Speaker 2:At the moment set point thing is yes, theory is there, but how can we, as the clinicians, help the patient is trying to give them help? That is where I think the medication thing has come into a big way. Until that, the science had a very limited sort of options available for people to support to overcome that set point sort of a thing where the body's metabolism is trying to shut down and not lose any more weight. And that is where we have gained a little bit of a step forward with the advent of this all these new medications which I'm going to come back. Next slide, please.
Speaker 2:So I've just given a rough in a human body, there is a synergy between a couple of different systems to regulate the body weight. What are the key things? There is one thing called homeostatic system. What does it do? It is associated with hunger.
Speaker 2:It maintains the balance, balancing balance out. It's like a machine. How much energy you need per day and energy output sort of thing, that sort of a balance you do. But the key thing for us is something called hedonic system, which is actually the part of the brain which gains some pleasure for us to eat and it is something where we crave the food for. In a normal healthy person, both this homeostatic and hedonic system are put in control by a cognitive system.
Speaker 2:What we call it is the frontal cortex or everything. There's the upper center which regulates them. And a person who has this synergy, a good synergy between all these three systems and working systematically, then the weight is maintained healthily. What happens in majority of the people living with obesity is that synergy synergistic system is broken down. How is it broken down?
Speaker 2:That hedonistic system, which has a craving for pleasure and stuff like that, is overridden by the environment external influences. External influences like the availability of the food, the cultural practice, social issues, psychological. So in these people, what happens is majority of the time, the idolics system is overtaking whatever the control, the cognitive system, which should have controlled the all of this body food intake and food outtake, that is disrupted. So I just wanted to give an understanding that there are a couple of complex systems in the brain which are working to maintain the weight. When these systems are disrupted and there is an imbalance in between, then the signals are not passing each other very quickly in the right way.
Speaker 2:And that is where the challenges are, where the Adonis system takes upper hand and just overrules all other signals and it bypasses them. And that's where the challenge that's where the people start having weight gain. Is that clear? Yeah. Next slide, please.
Speaker 2:I just wanted to see I know most of them are UK based. So I just thought people keep talking to me and asking me about what is available on the NHS. What do the specialist weight management clinics do sort of a thing. So I just want that I'll just give a good just a brief thing that the key thing the NHS is definitely a healthy lifestyle thing which we all promote. We tend to usually have some sort of a holistic dietitian physical activity sort of thing That parts the main core of the main medical and the surgical management sort of thing.
Speaker 2:But at the moment, on the NHS, under recognized by the NICE, which is an organization which approves the medication, we have three drugs on the NHS at the moment. So the first one was called Saxenda, which is liraglutide, which was a daily injection. Not much of a favour now, and it's not much in availability also is gone. The second one we had in the specialist weight management clinics was Kobigovi, which is a semaglutide, once weekly injectable. And then we have Terazepatide Mounjaro, which is again once weekly.
Speaker 2:So at present, these three drugs are only available in the NHS and the specialist weight management clinics. But again, each of these medications have quite a significant criteria. There's a lot of gatekeeping for us as obesity physicians to actually weigh who can avail these medications on NHS. But again, I just wanted to mention surgical management, which includes weight loss surgeries, is still the gold standard weight loss management therapy. Because that is one thing which has shown consistently over the last three to four decades, where people who have gone through this have been able to achieve a significant weight loss and also been able to maintain most of the weight loss.
Speaker 2:But again, it's a life changing. It's not for all. It's once in a while. Reversibility is very minimal. So once you have the operation, you can't reverse it back.
Speaker 2:So, there are challenges but it is still considered to be a gold standard. And the two main surgeries done in the NHS. One is called sleeve gastrectomy and the second one is called gastric bypass. Yeah, next one. I just wanted to give a lifeline of this medication.
Speaker 2:People think the weight loss medication thing has been something recent but actually if you go to the history, the first drug licensed approved by the Food and Drug Administration in America was 1959. That was the first time a weight loss medication has been approved. And since then, it has been a very, very long journey. And only until recently twenty fourteen-twenty twenty one when we have these current drugs available things have changed and the big reason why the previous medication there were so many medication which were in use for obesity, not much in The United Kingdom, but mostly in America, those were all targeting the central nervous system. They're all targeting the brain chemicals.
Speaker 2:And that was one of the reasons they were not able to get a good success because the side effects required significant. Whereas the current generation of the drugs injectable medicaid, including therapies are mostly acting on the gastrointestinal system and that is where they have bypassed the brain and that is where the success is coming able to achieve. And initially, we had a one single hormone called GLP-one which you might have heard. It was the one injectable incretin therapy which injection came. Then the signs were thought there are more chemicals to be identified.
Speaker 2:They identified two which is a Mounjaro, which is a dual GLP-one and GIP. If you go to the next slide, Scott, if you don't mind. Yeah. So I'm just to put the list of so many new pipeline drugs are coming, which are all dual therapy, two chemicals, three chemicals, and sometimes even four chemicals, different different chemicals are being used to try and make this medication. And some of them are just pushing the boundaries.
Speaker 2:These are all in the clinical trials now. Most of them are still not yet been approved by NICE in UK. But I'm just showing you a snapshot. I can imagine there ritaptopril, which is almost getting 28.7% of the total body weight loss. That's amazing, pushing the boundary to a quite a significant, almost reaching the weight loss surgery sort of a thing.
Speaker 2:But again, they are still in the phase three trials, what we call it as, till to be approved. But I just thought I'll just give you some idea of what is in the future. I started obesity in 2015, where we did not have, apart from the orlistat, which was only one drug, apart from that we did not have any approved obesity drugs. Fast forward now, ten, eleven years, I definitely have quite a few medications at my disposal to help the patient living with obesity. In two, three years' time, I think the doctors will have even more oral therapies and injectable therapies to help people living with obesity.
Speaker 2:I think that there's a bright future for the science sort of thing in terms of trying to help this big public health challenge which we are facing now. Again, this slide mainly, I just emphasize again, people say, Doctor, I'm doing a lot of cardio and cardio. But what I would like to emphasize that is when people are using the weight loss management, the key thing is the resistance type exercise, which actually builds the muscle. That is the key message I just wanted to share with you all is cardio is great. Don't get me wrong.
Speaker 2:Walking and cardio, and they're all great. They help the general health in many other ways. But for weight loss management, resistance type exercises is the key apart from cardio. That is what I want to emphasize because you need to build the muscle because people, when they lose weight, they lose muscle mass as well. And when you lose a muscle mass, it leads to a lot of quite a big challenges, especially in terms of the mobility and all other things.
Speaker 2:So that is the key reason message I just wanted to present to the audience that. The next slides are just a patient's guide to people in the audience. If people are using the weight loss medications, I just wanted to put a small guidance. What is the nutritional requirement that eating small and frequent meals and prioritizing protein? And I'm sure you might have heard, but I just wanted to emphasize again that these remain the core pillars of the weight loss management, especially for people who are using weight loss injections that nutrition plays a key role.
Speaker 2:And so the type of nutrition, especially increased protein intake and nutrients and multivitamin tablets are the key for this because people don't realize that when the appetite is reduced with this injection, the amount of the food intake is low and then the body is not receiving all the micronutrients and macronutrients enough for the body. So there is quite a lot of people when we do blood tests for these patients who are on injectables and not the appetite is reduced, we find a lot of vitamin deficiencies. So we always are highlighting that and we are recommending people that please make sure that you have good vitamin support as well, hydration. And again, the same thing I've mentioned about muscle mass is building the muscle mass is a key message, take home message today. And regularly having a checkup with the doctors and stuff.
Speaker 2:If someone is using the medication and doing all the right things and in spite of that you're not able to lose the weight, then that is where you need to go back a step back and start thinking, Maybe get an expert opinion to see what is happening there wrong. I also just wanted to put this slide just to caution everybody that people think that weight loss medications are great and people stop weight loss medication. What I just wanted the message to go on is this is a lifelong journey. It's like any disease. You have a patient diagnosed with type two diabetes.
Speaker 2:You have a patient diagnosed with hypertension. You start some medications. So, that medication is supposed to be continued most of your life sort of a thing and actually, in fact, you keep on adding one or two more medication because the blood pressure becomes more difficult to manage. Similarly, weight loss management. Once we have started this injectable therapies, we have to keep supporting the patients.
Speaker 2:Otherwise, this is a this is the trial with the meta analysis which is collected data of nearly 9,000 patients. What they have done is they have stopped the medication, what the people were using for weight loss and what they have noticed within fourteen to sixteen months, all these patients have regained the lost weight. So, take home message for it is there is no, unfortunately, no easy fix for people who want to do weight loss management. The thing is, it's a commitment. It's a sustainability in terms of patients doing the physical activity thing as well.
Speaker 2:And if you're taking the help of medication, you may need to take these medications for a long time.
Speaker 1:Yeah.
Speaker 2:So Thanks. I'm I'm open for the any discussion discussion I wanted to do. I don't want to bombard too much of information. I thought it would be good to have a chat with you all to see what questions you have for me.
Speaker 1:For sure. For sure. I appreciate that. That was very interesting, Satish. A lot of information covered.
Speaker 1:I think there's a few questions already in the chat, so maybe we can go off them.
Speaker 2:Yep. So,
Speaker 1:do you think the NHS will see weight loss medication later when they are cheaper, as more cost effective than long term treatment of obesity related issues? Do you think that's going to happen?
Speaker 2:Yeah, absolutely. You're spot on sort of a thing. I've done some small paper for a journal where the criteria if you were to just purely go by the criteria of the medication licensing, the medicines which are licensed to use for obesity, if you go purely by that, three million population in Britain are eligible for this medication. Three million that will bankrupt the NHS. And that was one of the simple reasons why NHS thought we need to do some gatekeeping.
Speaker 2:Based on the budget what they had, they have made a tighter control. But we are aware of that, that there are some of the medication which are going off patent. Most of the countries, semaglutide, we go. We have already gone off patent in Canada, in China, in India, and other countries. But whether The UK will be able to import that cheaper versions to a year, we don't know.
Speaker 2:But definitely, there are some oral drugs are going to happen, which is one third of the rate, to my knowledge. From what I know from the people I talk about in the pharma field, it's going to be around one third. And that's when I think NHS is going to maybe be a bit more accessible to the more patients and open up the thing for different people.
Speaker 1:Hopefully, we'll see more access there. I got another question for you. For someone who's throughout can you come up and say ah? Because you know you're there. So it's better off you come on and say I know many more.
Speaker 3:Yeah. My question, Doctor. Satish, is I've yo yoed throughout my adult life. And so my question really is what is your advice for maintaining successful weight loss long term?
Speaker 2:Again, thank you for that. I understand the challenges sort of thing. Maintaining the so if if it is a case that you have achieved the weight loss with the help of a lifestyle and you are not able to maintain that, that means that you need help, something else, external agent sort of thing. That is where the challenge because the way the body set point theory mentioned, I mentioned the body always wants to go back to the earlier weight. There's always some systems working in the background to try and make you go back to that weight.
Speaker 2:So if you want to try and maintain the lost weight, then either if it is practical and if it is feasible and if you can do that physical activity, what the recommendation is around forty five minutes to sixty minutes of vigorous intensity if you can do that will maintain. And I have examples where you occasionally come across a patient who can do that. Again, as I mentioned, not everybody can do that, but there are some people who always prove that yes, science is correct. If you can do that, there is evidence. But again, if it is not difficult, if it is very difficult, then the option is to try the injectable medications at the moment.
Speaker 1:And in your experience, Satish, your successful patients, are they all doing the activity? Or is there any abnormalities where they are doing no activity? They're just eating less, and and they've managed to fight against that? Or is that not what you've seen?
Speaker 2:I do have experience of various patients. As I said, on one end of the spectrum, I do have patients who are taking weight loss. And for some wonderful reason, the chemical is so sensitive in these patients bodies that they are losing weight but they hardly are doing much different to what they were doing before the injection, still significantly losing. Other end of the spectrum, I do have patients who take the injections and again doing more exercises and stuff like that, not able to achieve. What the key message here is that unfortunately it's not one shoe fits all sort of a thing.
Speaker 2:Each patient is different, each metabolism is different and we have to try and tackle the metabolism thing. Again, the medications are wonderful, but are they for everybody? No.
Speaker 1:Yeah.
Speaker 2:Maybe seventy percent, eighty percent of the population get benefit. I have more than a thousand patients on the injectable thing. Do all of my patients lose weight? May not lose weight. But seventy five, eighty percent of the patients definitely get benefit.
Speaker 1:And when it comes to your patient's strength, like, what what patterns do you see in their strength over time?
Speaker 2:What sort of dependent repeat again?
Speaker 1:Like their strength. So, like, being able to do the, you know, set and start test.
Speaker 2:Good question. Again, again, when you when as a clinician, when I'm initiating this medication, message is very clear, very clear that you have to put in some effort into the resistance exercise even for a person who is not me. I keep reminding them at least the resistance, you know, the the band sort of a thing, resistance bands and stuff like that. Please get that even sitting in the chair. You can do every half an hour, one hour, even if you do five minutes over a period of the day, you actually will build up thirty to forty minutes of that intense exercise and that usually should be beneficial.
Speaker 1:Yeah. And but most people lose strength. Is that what you see? Do you see that?
Speaker 2:They do. Especially people who are very sensitive to the drug because in my experience I have people who lose five stone six stone sort of thing as well with the drug. These are the super sensitive patients who for some reason I don't think science has ever found out but there are some people who really respond very well and those are the patients who have a quite a significant effect because in them the weight loss is also rapid. And that is another big question. What are you trying to do?
Speaker 2:That is the one reason why I'm very careful in titrating the medication doses because the pharma companies advise you to increase every four weeks, but we never do that at all. We always review the patient. We always look at the patient, and we always discuss with the patient what's happening and then take it from there.
Speaker 1:Yeah. That makes sense. And then there's a question as well is that the medication essentially is to trick the body to set a new lower set point. That's the reason that it could be useful, or you think it is another way? Is it time based?
Speaker 2:What what the what the medication is basically doing is basically it is slowing down the stomach emptying. Basically, that is the key thing it's doing. It's doing anything different now when compared to all the previous drugs which we're targeting the appetite and that are not being very successful. This one is acting on the gastrointestinal system. So, not use.
Speaker 2:Can I say that it's tricking? It it is maybe in a different way. It is creating a false sense of thing to the center saying that there's a food in the stomach because we all we all when you're in a a normal in a normal case when we eat food, the food stays in the stomach for three to four hours But when people who take the injectables, the food stays up to twelve hours. So by the food staying in the stomach for up to twelve hours because the muscle movements are slowed down, you're tricking the brain in a different way.
Speaker 1:Yeah. It makes sense.
Speaker 2:Yeah. And
Speaker 1:so we just got reminded now in the comments that when we spoke to Scott last week, he was saying that he's the other maybe it takes one year plus, maybe a few years to have a new set point maybe. So it takes time, you said. Some of
Speaker 2:the new things. It takes time, and it also depends on other factors as well. The other factors on the thing, how much you are able to maintain the weight as well and how much food activity and physical activity is happening. You know what, to be honest, the field is so rapidly changing. The science is definitely just going so much rapid sort of thing.
Speaker 2:Twenty years ago, fifteen years ago, people did not have much understanding of the whole of the obesity thing. Now things are completely changing. We, as a clinician, also learn a lot on a regular basis.
Speaker 1:Yeah. And good question here on gut health. Is there anything you know about gut health linked to successful weight loss? Does the GLP-1s affect the gut health negatively, positively? And, yeah, is that a link you've seen now?
Speaker 2:Gut health, the good question. Again, when the food is slowed down, I believe there is more action on the microbes and microbiota, the bacteria and stuff on the food. So some people are experiencing some increased gastrointestinal side effects like bloating and other sensation sort of thing, a flatulence passing a lot of wind, gas and all these things and sometimes constipation is the biggest challenge in this because you're slowing down the bowel movement. So, that is where that is where again you need to review the patient and justify whether there is a need for you to continue the medication or not. But definitely it is changing the whole bacteria thing because the food is in the gastrointestinal tract for a long duration of time.
Speaker 1:Yeah. And then for people who you know, there's a lot of talk about GLP-1s now because, obviously, it has to be discussed because it's always been spoken about in the public discourse. But for people that don't wanna go on GLP ones that that that come to you, what is your kind of toolbox for them? The same thing? Or
Speaker 2:think Scott, isn't that not okay? Once you once you fits all sort of thing, you always go back to the same basic question for the patient. So what is the reason why the patient has come? Okay, patient wants to lose some weight. Great.
Speaker 2:What are the patient's target? Does the patient have any other chronic diseases or anything like that? Is the patient looking for a healthy lifestyle or is the patient looking to, for example, patient has a chronic condition. Does the patient have any type of diabetes? Does the patient have any sleep apnea?
Speaker 2:Those are the questions you ask the patient. If your patient says, yes, I have type two diabetes, then I will be honest with the patient to get the diabetes into remission. You need minimum of 15% of the total body weight loss. Will that be able to be achieved just by lifestyle? It is a challenge but there are a few people who do that and then we remind the patient that, yes, there are some very young people who can do that.
Speaker 2:But for the majority of the people, it will be a challenge unless you take the help of this medication. Because losing weight is not the only point. That's only one side of the coin, isn't it? The other side of the coin is regaining the lost weight. People struggle to keep maintain the lost weight.
Speaker 2:There are so many people who I see in clinic who have a different different diet regimes and different different ways of losing weight. They every time I get reminded about a new diet and existing in the in the world. But bottom line is they lose weight. But when they're able to maintain the weight, that's where the challenge comes. Maintaining the weight is the biggest challenge to me as a clinician always.
Speaker 1:Yeah. And from your clients that you see that have maintained their weight loss, what do they say to you that's helped them the most? Is there anything advice you've given or We
Speaker 2:have been using this incretin injectable therapies actually for a long time. I've been using them for the last fifteen years, even though because of my experience of working in a complex obesity center, we have been using it off license. So we have been using it for a long, long time. But now they are licensed people use but that is that is one of the one method of maintaining the lost weight and the other one is people bariatric surgery is the one other option but neither of that only healthy lifestyle. It is not easy.
Speaker 2:It is doable, but it takes a lot of factors to come into together to support the patient journey through that.
Speaker 1:Okay. There's a question here for you. Do you have any suggestions for getting over fatigue when losing weight or being in a calorie deficit?
Speaker 2:I mean, I go back to the basics where where the fatigue comes. Is a is a diet very good? Is a patient getting all the nutrients and stuff like that. That is the key thing as you know. A lot of people also start losing hair and all these things and stuff like that.
Speaker 2:People think, why is that? Because they start developing iron deficiency anemia and other things multivitamins and that is the key reason. And then I keep reminding them about the resistance type exercise. You're losing weight but you're not losing muscle waste, tired and fatigue. Yesterday also in my clinic, I had a patient who was just complaining about tiredness fatigue.
Speaker 2:She lost three stones of body weight using the injectable therapy. The doctor, the same thing. But I said to her, you need to try and build a really no point in going for swimming, which is great, but it's not building your muscle up. But you need to do some resistance type exercise, something like a squat or something or lifting some weight in upper limb and lower limb. That is where you need to build it.
Speaker 1:Yeah. I think people think because doing, like, a few squats is a bit easier than going for a run or swimming, they don't feel the same, like, high or, I don't know, satisfaction from strength training. Does that make sense?
Speaker 2:Yeah. It
Speaker 1:feels like you're doing less, but actually, it's very different. So, like, I think what's the essay? So, like, yoga, pilates are great. Maybe with weights, it's needed. You know?
Speaker 1:So it's sometimes hard for people to not see the benefit. There is a benefit to pilates and yoga, but to say, okay. Well, is that nothing compared to weights? Like, what where would you stack these things? Would you say, like, yoga, pilates is okay?
Speaker 1:And you say, like, but lifting weights
Speaker 2:It it it on the the the patient capacity in terms of the the strength and stuff like that. Pilates require a little bit more strength yoga. Maybe you can sit down and do that and maybe not a big challenge. But the other it all depends on the the person. I always go back to the patient and say, what do you think is practical for you?
Speaker 2:No point in me as a clinician giving out all these things and say, do this, do that, do that. Patient might not be able to do. I just go back to the patient always and ask them, what is practical for you? What you can build on? Try and do that rather than me I can give you guide you.
Speaker 2:What is a better way of doing that? But what point in me telling about go and do this one hour of gym and come back? It's not practical.
Speaker 1:Yeah. Makes sense. That's a good question here. It's great that there's medical solutions to help people, but surely, and it was your opinion this, more focus needs to be put on education in schools early on. She's saying that she grew up in a farm in Zimbabwe and was very shocked at The UK's lack of knowledge about food and nutrition.
Speaker 1:Do you think that plays a big role or do you think?
Speaker 2:Absolutely. I totally agree with the who has made the comment sort of the thing. You need to start from the childhood obesity. I think UK is the leading in the Europe and they're going to be not so good data in terms of that. As of now, even now, there's I believe thirty five percent to forty percent of the school going children I believe are considered to be in the obese category sort of a thing and that is a real challenge for the public health and definitely there is an emphasis there has to be more investment, there has to be more But I suppose, again, I'm sure you might have heard a lot of times in the magazines and stuff like that, these fast food centers and stuff.
Speaker 2:And even you look at the map of all these fast food centers, they're all scattered near the schools and stuff like that. And that is where the biggest challenge is at the moment. And those are unhealthy food shops and stuff, and they all are located in the areas where there are schools and stuff. And that is where the councils again have a big role in that public health. But unfortunately, people have a different views on that.
Speaker 1:Yeah. And do you think that because most people probably are not going to do strength training on GLPs, and they'd be getting them on the black market, they're going to be taking doses that are massively overdone, do you think that we're going to have maybe a frailty issue in the future with this? Or do you think it's overblown? What do you think?
Speaker 2:Yeah, definitely. It might not lead to immediate. But again, science again is learning what are the risk of patients having this sort of weight loss. And in five years time in ten years time, what effect does it do? Does it also change the way we start thinking?
Speaker 2:Does it have any effect on the brain because the chemical messaging system has been altered as well? So, there are sort of challenges definitely. The key thing is the quality of life at the moment is that is focused. That is what is we always emphasize to patient. The quality of life is important.
Speaker 2:Weight loss is important but actually the quality of life. Why are you doing this weight loss? It is to improve your quality of life As long as you're having a good quality of life, we'll be on this journey. But if it comes to a point where your quality of life is not as good as it should be, then we need to start thinking about why.
Speaker 1:Yeah. Good points. And so in terms of your opinion in the future then for people who are going to be maybe starting on these GLPs or starting on a weight loss regimen, just in general, you're telling your patients, just to be clear, you need or be highly advised to do resistance training. And I saw your slide. You were saying that doing just like five, ten reps of press ups into squats into like mountain climbers or something a couple of times a week.
Speaker 1:You find that your patients that follow that? Most of
Speaker 2:them follow most of them follow because they can see that that is helping them. Because if they have not done, they'll straight away notice that, that they are feeling bit tired and exhausted and stuff like that. Then I keep reminding them. They keep asking me that question, Doctor. Ambrini.
Speaker 2:But then I remind them again, this is what I've been emphasizing on.
Speaker 1:Okay. And then when you use the chart that was interesting, it's like 2% weight loss and then 15 weight loss and the improvements you can get because some someone was mentioning in the group yesterday about blood pressure was high and now wanna go on to lose weight to improve it. Why do you think, like, just having extra fat is causing so many of those problems? Does that make sense? Like, it's a huge list of problems.
Speaker 2:There is quite a complex we call the process called inflammatory processes because when people are living with obesity, what is happening is they have extra fat is deposited in the various organs of the body. And as a result of which they are all triggering some abnormal pathways where there is a quite a definite inflammation what we call it as and they're triggering some inflammatory pathways where some not so good chemicals are being secreted into the system and as a system of this they are triggering the increased risk of people developing some other chronic diseases people developing chronic kidney disease people developing heart disease people develop their sleep apnea because of the various challenges.
Speaker 1:I see I see
Speaker 2:and it's also very highly linked to the cancers as well and that is one of the biggest one of the mechanisms what people talk about is it is altering this increased fat That fat is becoming abnormal fat, and that is triggering that all these inflammatory processes.
Speaker 1:Okay. So when people talk about anti inflammatory diets and all this stuff, you would say this, really like, too much body fat is the first factor.
Speaker 2:Yeah, there is a quite a role of antioxidants what we call it as which have a very positive effect on the all these patients people some of the there is a new theory that patients should be advised take some antioxidants like some vitamins and stuff like that which helped in the thing which can actually counteract that people with living with obesity whatever the inflammatory process is happening in their bodies they should be able to counteract the use of antioxidants.
Speaker 1:Okay. That's interesting. Yeah, so when it comes to that case then, if someone was on a gain in weight, but they were eating all of these micronutrients and fruits and vegetables and steak, lean meats maybe, whatever, that's not enough because the weight gain is causing problems even if the diet's actually very good.
Speaker 2:I'm not sure. See, by you reducing, you're reducing the calorie intake. By you reducing your calorie intake, yes, you're not giving the body excess calories, but the body definitely does need some calories to do with day to day metabolism. Yeah. So, whatever you're doing, it it is required for that but how do you lose that excess weight?
Speaker 2:Do you understand the point? So, you've reduced the calorie intake. What is that doing? That is stabilizing most likely your body weight But whatever the excess body weight you have, you have to do something to reduce that weight and the physical activity that is where the role of the physical activity comes that if you were to combine the physical activity along with the reduction in the calorie intake both combined together gives you the positive benefit of weight loss. If you were to just reduce the calorie, may be able to maintain the weight.
Speaker 2:Yeah. But losing weight becomes very difficult because the body also, whatever that you're eating, your body needs to run the body, isn't it? If you put a thermometer in the ear, 37 degrees centigrade, 37 degrees is quite a lot. People don't realize how the body runs the fuel. Yeah.
Speaker 2:You understand? I mean Yeah. Very good. Very good. Is not the we we are get feeling warm when the temperature is 30 degrees outside.
Speaker 2:Can you imagine the body is running at 37 degrees inside all the time?
Speaker 1:It's hot.
Speaker 2:Yeah. It is running on the fuel, so the body needs it. That what the reduced calories will help in the maintaining.
Speaker 1:It makes sense. It makes sense. And there's a question on that one as well. I guess a good question as well. So how do you go about tracking inflammation in the body?
Speaker 1:Understanding being overweight means there is inflammation, but how do you track it, or what blood test results could I do to say, do you know what, Scott, you've got inflammatory markers here?
Speaker 2:Good question. Again, to my knowledge, there is I don't I've not come across any specific markers which test the inflammatory process, but that's a that's a theory. It's a theory. The science tells you the theory that this is what is happening. People when they have studied that excess fat and they have seen what it does, that is what they have seen.
Speaker 2:They have seen that more inflammatory markers are being circulating in the body. But in the human body, what sort of test can detect that? I don't think I have come across any of that.
Speaker 1:I see. Because, yeah, there is there is, like, the endometriosis and the anti inflammatory diet for that and things like that. So that people talk about inflammation a lot, but it's not very tangible. You know? It's just
Speaker 2:As of as of now, there is no definitive test or anything which can can give you that indication how much inflammation is going on in the body sort of thing.
Speaker 1:Okay. Okay. It's good to know that that's where we stand because and social media will trick everyone. Another good question here. So, Debbie, Debbie, do you wanna come and sit talk about this one, or are you not there on the microphone.
Speaker 4:Sorry. I'm just moving room because I'm right by my daughter. She's asleep.
Speaker 1:No worries. No worries. Yeah. Share with us what the the question when you're done.
Speaker 4:It's not really a question. It's just more of the I was on Mount Jaro for about thirteen months, and I started on a trial program, which was run by a clinic and Weight Watchers. While I was doing it with them, I'd have weekly calls which would talk about behaviours and what we found difficult and just talking about have we met fibre targets and protein targets and fluid targets and just exercise and really went into it. Once a month the actual clinic you'd have a call with them and they'd talk about your mental health and your side effects from Mount JAVA and everything as you were going through it. But then when I then changed to one of the companies online, you got none of it.
Speaker 4:It was basically you fill out a form saying how you doing and it's like oh yeah we'll just give it to you'. And I find for talking to others as well that they you don't have any of that support so you kind of they're giving it and you know you hear people that oh I've just ate the chocolate bar today and it's like yeah but that's yeah and then you get then people saying oh that's why Mount Jaro's really bad' but it's like if they're not getting taught all the importance because yes you can quite you can say to people we recommend this, we recommend that' but if it's not monitored in a way it's not going to so with all the frailty, you know as you say in years to come, people are giving it but they're not really taught the proper use of it. To be fair for me, I lost 10 pounds the first month, but I actually just recently looked through those thirteen months. The last five months I didn't lose anything and I actually started to gain a little bit which is why I came off it because there's a lot of money for it to not work.
Speaker 4:But actually a lot of the time I was only losing maybe two to three pounds a month which was it's frustrating in a way but I did lose the weight eventually and I did focus a lot on trying to maintain eating three meals and eating the better parts of it, but that's because I was taught it right from the start. So just for future, like with other people, there's so many people that take it, like say as the pharmacy or even my friend who is through NHS with diabetes, she wasn't even seen or spoken to properly throughout hers. So again, I just always find it quite surprising just because I think how I started it, it was done in such a good way because you had a lot of support. But then when that trial finished, that support went because it's a finished trial. But I had that benefit of having that start, which was I found really good and helpful.
Speaker 2:I think that you're absolutely right, Debbie, to be honest. Thank you for sharing the story. It is incredible to listen to stories like this, because this is what reinforces me as a clinician, what the message should be along with the medication, what we actually should do, what we call it as a wraparound service around when you are using the injectables and stuff like that. But at the moment in the NHS, we only have a digital one at the moment. When we start patients with obesity, we can refer under the for the digital program.
Speaker 2:But again, I, as a clinician, know digital program is not for everybody. Again, not everybody fits into their criteria sort of a thing. But we, as a specialist clinic, we tend to try and find some sort of assistance in some sort of programs and stuff like that. But again, when the budget is so tight and you are being scrutinized every day, everything, whatever you do in the clinic by your managers and stuff like that, who only look at the financial figures, that becomes a big challenge when you go to the management board and when you are trying to put in a business case for a dietitian like my colleague Scott, who does amazing job sort of a thing, and he and his colleagues and stuff like that. And patients are very fortunate in our setup where they have their expertise like them who can do the session for the patient.
Speaker 2:But other centers, yes, you're right. There's not much of that education around. And then that is a fear for me as a clinician. What will happen to all these patients four years down the road, five years down the road as a result of weight loss? Will they have some other medical problem challenges because nobody has advised them about all these things?
Speaker 2:That's the question for everyone.
Speaker 1:Yeah, probably. Did you spoke to thousands of people here? Like, are people willing to want to learn? Are they willing to you know, do you use some digital stuff or apps? Obviously, everyone here uses apps.
Speaker 1:You use your mobile phone. It's one of the ways we can learn and stay stay connected. Would people prefer in person things? What do you think if you could design the gold standard wraparound, what would it be? And what do think would help the most?
Speaker 2:So to me, a mixture of both. I'm going say I know the practicalities of holding face to face is not always possible. Practical, I could be holding all the face to face for next six months for my patient population. But again, people work. People sometimes do day shift, night shift.
Speaker 2:People are distance after travel. So not practical. But usually, I feel an option of either a face to face and a practical, like one month face to face, one month virtual sort of thing sometimes helps people do that. They just feel that they are connected, even though sometimes they cannot attend it. But if you provide virtual, sometimes they feel that connection.
Speaker 2:As Debbie earlier mentioned, every month, there was a call. So that was at least she was looking forward for that call. And then that reminds her that what things she has to do to maintain that sort of thing. Just having that sort of a call or ability to join a virtual program also keeps you on the toes in the sense that you are always reminding yourself what you have been advised and what to do. Sometimes virtual sometimes may not be practical for everyone.
Speaker 2:Full face to face might suit some people who are living near the place you provided. But if people have to travel, people are working, it might not be the right one.
Speaker 1:Yeah. But you know the start on this is the last question that we've gone over a bit, so I hope you don't mind. When people get told, smokers or whatever, like you've got COPD or whatever, have to stop smoking, you've got to do something, or you're going to die in a few years. And they still don't quite do the lifestyle changes, even though it's imminent that they have to do it. It's the same in saying when people want to lose weight.
Speaker 1:You say, look, if you don't do the exercise and protect muscle and strength down the line, it's going be bad. Same as smokers, don't take it too seriously. Like, how would you have you found anything that breaks through that? Or do you think some people just will not listen, they will lose weight, they will just eat still the same foods? To
Speaker 2:me as a clinician, if a patient has come to me to say, doctor, I need help, and I'm giving them some advice and doing that. And in spite of that, if the patient is not able to do that, I always go back a step and look at evidence to see, is there any eating disorder for this patient? Or is there any psychological issues which are see, to be honest, I could be sitting and giving the best advice of the diet. I could do all the diet thing. But honestly, sometimes I see patients who come and tell me, doctor, I have 10 pounds to spend per week.
Speaker 2:Doctor, I have 15 pounds to spend per week. You're talking to me about all this healthy diet. You're talking about this diet, that diet. What can I afford in my money? Sometimes you have to go back to reality and, hang on.
Speaker 2:What's up to a challenge? This is a thing. I would say this is a big challenge for that. Sometimes I take a step back. I always think that hang on.
Speaker 2:There might be something which is not allowing this patient to achieve from go from A to B. There is always when you look at back there is always some sort of a psychological cause out there, or there is a financial thing or something like that. There are some social reasons or something like that. Somebody might be living at a home who doesn't have a cooker to cook the food. Or she might be living in a home or renting a place where there's only a microwave.
Speaker 2:I'll come across people like that, where there's no place to cook. All they can do is warm up the food in the microwave. So they are. So we have to always fine tune to the people what the living conditions are. As I say, it's easy to talk about everything.
Speaker 2:Do this, do that, do that. But sometimes, it doesn't work like you have to be honest and practical. And that's why sometimes you have to unpick a few things to say where is the challenge here.
Speaker 1:For sure. I agree. It's easy to sit back and, you know, someone's got all the money to buy all the foods and the gym memberships and the weight to the home and online programs and stuff. You've been lucky to be doing these programs. You know?
Speaker 1:So a lot of people don't have access. But, hopefully, we'll be able to help somehow. But yeah. No. Satish, you've been awesome.
Speaker 1:Learned a lot from you. Appreciate your time. Everyone else, thanks for joining as well. Satish, you're joining again in a few weeks, yeah, towards the end of the challenge. Sure.
Speaker 1:So as things go on and people, you know I
Speaker 2:hope everybody has enjoyed. Yeah. You very much.
Speaker 1:You sure. For sure. And everyone listening back on record, let us know in the email on the group so you found it. And I'll pass on to you, Satish. Any comments, stuff, and Thank
Speaker 2:you very much. Thank you. Thanks, everybody. Thank you.
Speaker 1:I'll stop