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Anytime someone is struggling with the weight, the standard statement goes, "Just
eat less and move more."
Yeah.
What does that leave out in the biology? What do people miss?
It's far beyond willpower. It's definitely a chronic multifactorial disease.
Welcome to Next Phase Human podcast, where medicine meets performance and science
meets longevity. Our guest today is Dr.
Ayad, who is an obesity medicine specialist and has years of experience in this.
And we're going to talk about weight loss, the difficulties a lot of us struggle
with, and how the new and the old weight loss medicines compare, what are the
challenges that you face along with, things to watch out for, when you can and
can't use these things. So let's dive in. Thank you, Dr. Ayad, for doing this.
Thank you, Dr. Sandhu, for having me.
So we'll dive straight in. Obesity, we know, is a huge problem, and
it's increasing year over year. There is a lot of our peers who struggle with this,
a lot of our patients who struggle with it.
And we have started treating risk factors like high blood pressure, diabetes.
But when it comes to obesity, there's almost a stigma about treating this like any
other illness. Why is that?
It's a great start.
The main reason it's not considered yet as a chronic disease, a lot of us as
physician and a lot of patient don't see it as a chronic disease.
So, the Obesity Medical Association came with the definition for obesity that it's
a chronic,
treatable-
Mm
... progressing, relapsing, multifactorial disease.
Okay.
So if you look at the definition, it really would tell you that if we look at it
like we would look at the hypertension, the hyperlipidemia, the diabetes, and treat
it as a chronic disease, our perception and our way of dealing with it will change
a lot.
Right. So treat it not as a failure of willpower, but it's actually a disease that
people struggle with.
Exactly.
It's not just simple lack of willpower-
Exactly
... that it's labeled as.
Yeah. For the longest have been lack of willpower-
Mm-hmm
... I'm too lazy to do it. It's far beyond a willpower.
It's definitely a chronic multifactorial disease.
So how long have you been doing this?
So I've been board certified obesity medicine since 2013, and since that time, I've
been doing only weight management for more than 12 years, or like now 13.
And, so I run the medical center for the Adventists, and we have
surgical and non-surgical weight management, and that's all what we do as a weight
management program.
Okay, and what got you started in this? What made you do this?
So I took my residency in Wheeling, West Virginia, and if you know about West
Virginia, it's one of the highest states in obesity, where more than 40% struggle.
And taking my residency, family medicine, unopposed family medicine, we had to
readmit and readmit same cases back to the hospital with long list of medication.
You struggle to get them back home to be discharged-
Mm-hmm
... because they can't get them even-
Right
... in the house. They have to build a ramp to get them back in their house.
Same medical problem, we keep adding more prescription medication.
So you come to the conclusion that it's not about adding more medication to treat
the complication, it's treating the main problem for all their other medical
problem that were triggered by their weight.
Right.
So this is when I start looking for obesity medicine board certification and went
from there.
And was there any particular patient or case that sticks out that kind of you
remember vividly, "You know what?
This changed how I think about it."
A lot of the patient I have seen over there, if you had to transfer a patient to
get MRI in the zoo because their weight is not fitting, you feel like, no, we need
to help those patients. A lot of those frequent flyer back to the ER were way far
beyond dealing with more problem and adding more medication to their list.
So a lot of-
Right
... those stick in. But in my practice, I could tell you that the longer you do it
and you see it, you learn a lot from your patient.
Right.
And you know that it's definitely a multifactorial disease because I treat
patient that had sleeve gastrectomy and went for a gastric bypass, regained all the
weight after the two surgical cases, and were waiting for a treatment to treat the
main problem of their weight that was far beyond their surgical intervention.
So a lot of those cases, I could go on and on with lots of stories, but you
could see that you have to treat far beyond
an anatomy change or one factor. You have to attack more than one.
It's the biology-
Yeah
... that needs to change, not the anatomy.
Definitely, yeah, a lot more than just sleeving the case, way more far beyond that
part.
And for the longest time, you keep hearing from people, anytime someone is
struggling with the weight, the standard statement goes, "Just eat less and move
more."
Yeah.
What does that leave out in the biology? What do people miss?
Yeah. It's a great point. So if you let your patient, okay, exercise more and eat
less, you really didn't help them much. Yeah.
So, when you look at the
obesity as a chronic multifactorial disease, you look at
many factors, okay, genetic factors, 30 to 40% or more contributing for our
personal variation. They think it's more up to 60 to 70 even percent.
So you have your genetic, you have your environmental, you have your physiological
changes and behavioral changes, okay?
So you want to look at more than one factor treating.
So you could have a patient coming, or I could be a patient coming, saying that,
"Yeah, since my thyroid problem, my weight went up.
Since I went in menopause, my weight went up." So I could have that idea, I could
be right, and it could be a trigger factor, but it could be more than one factor.
So conclusion-wise, you have to look at it as a multifactorial and treat more than
one reason to trigger that weight.
But it's always good to know what triggered that and then build your treatment
based on that trigger and far beyond that part to look at all the factor that
caused that weight to start going up gradually.
So a lot of our patients don't have to feel ashamed about it because there's a lot
of shame that goes with it. They feel, "I'm just lazy," or, "I don't have
willpower," and that's what they hear over and over again.
Yeah.
So it may be there's a lot more going on here that they don't understand, and it's
a little bit of disservice to just say-
Yeah
... "Eat less and move more."
Yeah.
It's probably not as straightforward for a lot of our patients.
Exactly, yeah. Thank you for saying that, because this is really what help a lot of
patients to go far beyond thinking that it's really all on them.
It's all on their willpower. It's far beyond that part, for sure.
And there is a concept that I keep hearing, food noise.
Can you elaborate on what that is? How's that differing from regular hunger or
emotional eating? How do you see that?
Yeah. So very common to hear, and you know when you're hungry, you have your
ghrelin, your hunger hormone, okay?
And that hunger hormone is coming, and you feel that real feeling of, "Okay, I need
to consume some calories because I'm hungry." But we're not always eating because
we're hungry. We're sometimes eating because we're bored.
Sometimes it's triggered by emotion and stress.
Some would lose weight when they are stressed.
Some would gain weight when they are stressed.
Some eat when they are happy, not only when they're stressed.
So a lot of factor would really define that food noise.
So I would say that we could call it craving, we could call it food noise,
but that trigger a lot of our decision to grab it.
So to grab that option because I have that food noise in that really tell me,
"Okay, I need to eat this." So, and you could see a lot with the medication and a
lot of those intervention now that patient could come and say, "Yeah, I don't have
that food noise anymore." Versus when even with their bariatric surgery before,
it didn't take away that food noise.
They were still feeling that, "I need even if I'm going to get a small portion of
it, but I still have that food noise that really consume my time on and on and on,
that I can't get rid of it." That's a very little bit of control.
You could hear it all the time, and all of us experience that food noise,
definitely.
So I presume we'll dive a little more into it in terms of what modalities you use.
We're going to come to that. But this was just to kind of break out into it.
And you see this, I'm sure
People try to lose weight, but it's much harder to keep the weight off.
Mm-hmm.
And they regain it quickly. Why do you think they regain that quickly despite
multiple-- Someone loses it by dieting, someone loses it by more exercise or
changing their food preferences, but the harder part is keeping it off.
Yeah.
So what do you think happens there?
It's the metabolic adaptation. So the reason we're not able to maintain the weight,
and I could have patient coming and say, "I lost it five, six times or more before
coming to you, and I gained it all back." And they feel even ashamed to come back
because of the weight regain. It's the metabolic adaptation.
Every time we lose weight, there are three factors pulling us the opposite way.
The first thing is the metabolic rate drop, and it dropped to the lowest weight you
reached. Okay?
Right.
So I was 250 pounds, lost weight to 150, gained back to 300.
My metabolic rate's still at the 150, and it stayed at 150 for a little bit of
time.
Sorry to interrupt, but why do you think that happens to you?
Is it because you lose a lot of muscle when you lose weight a certain way?
So, basically you lost the muscle. That's true.
And whatever caloric intake is good enough to maintain your vital organs at that
smaller weight, not the biggest weight.
Uh-huh.
And they retracted with the biggest loser contest before, and so that the metabolic
rate dropped, and it wasn't going back up when the weight was going back up.
It took time to go back up back again.
So that's the first factor, metabolic rate drop.
The second factor is the hunger hormone, that ghrelin that we were talking about,
is all the way up. So they feel hungry more often.
Uh-huh.
Even after bariatric surgery, even after a lot of intervention, they would say,
"Yeah, maybe I'm not eating a big portion, but I feel hungry more often." And the
third factor is the satiety hormones, okay-
The leptin
... are basically all those leptin are down.
So those are the three factors that push the weight back.
And it's like your body fighting it back.
It thinks just you are in a famine or a war, and the body want to get you back to
where you used to be. So
the metabolic adaptation is a real thing, and that's the big reason weight
maintenance is way harder than losing weight.
So for a lot of our patients who are listening, it's not really your fault.
Yeah.
Your body is actually fighting you against it, so there is help for that.
Definitely, yeah.
So
this is something I hear a lot about Indians.
On surface, they don't look terribly big,
but... That's okay.
Yeah.
Go on, please. On surface, they will look
not terribly big, but the metabolic milieu is such that they are still
behaving like they are obese.
Mm-hmm.
How does that work? Like regular size person, is it just about the size of the
person, or is there something like they are internally still obesity metabolism,
like visceral fat or whatnot, or skinny fat?
Mm-hmm.
A lot of people say that. How does that play into it?
So it's a good point that the BMI, okay, your weight with your height,
is not the only factor to determine that you need intervention or you need
treatment for your weight or not. Because it's also
the percentage of your body fats, okay-
Mm-hmm
... and the visceral fats.
Right.
So you could be really in a BMI
that's considered to be normal range, but you carry a lot of visceral fats.
You have other metabolic factors on board that you'd definitely be considered that
you need more intervention for the weight.
So it's far beyond just the number-
The BMI
... of pounds on the scale with the BMI, with your height.
And you could see Asian, for example, they have a different BMI criteria.
So for us, we would say a normal weight is between 18 to 25 BMI.
For Asian population, it's between 18 to 23 BMI.
So I could have an Asian female
that her BMI is 23.5, and she's considered to be overweight.
And she carries a lot of that visceral fat.
So they see that the BMI criteria is different for Asian population because they
tend to carry more fat deposition with a smaller body weight.
So that's why the criteria for their BMI is different than Caucasian.
So you will see there, yes, anywhere between 23 to 27 BMI, they will be considered
overweight, and 27 and higher they will be considered obesity class one.
Versus someone like a different racial group will have an obesity rate of a 30
BMI or higher. So definitely it's far beyond their just weight and BMI.
And the BMI or body mass index, do you think it's a perfect measure to define
obesity, or there is other variables that you consider?
Definitely not enough. It's still considered to be easy to track because all our
electronic medical records will populate the weight and height and the BMI-
The weight
... on our chart, so we still can track it.
Insurance surgical criteria will still follow the BMI criteria because this is
something that's going to be clear-cut.
Right.
But for us treating the problem, we look at body composition.
Like I would do body composition in my office for free for a patient.
They bring it back, and they look at their fat storage and muscle mass.
So you could be a smaller weight with a higher fat storage than someone who has a
higher weight than you and carry way more muscle mass.
So we would look at the body composition, and we would look also on the fat
deposition. Is it more like a visceral fat that carry more cardiometabolic risk
factor versus someone who has a different fat distribution?
Got it. So it's not just a straightforward number. There is a lot more to it.
Exactly, yeah.
And when someone comes to you for treatment, how do you start evaluating?
Where would you start? If someone comes to see you, what should they expect to
start?
So I definitely expect to take a good history, and this is when I would say, "Okay,
when this problem started." And it helps a lot to know what they tried, what
failed, what worked, what didn't work. This is all your history taking.
Doing basic lab to know what's their thyroid, vitamin level, all of those things.
Taking also their medical history to know are they diabetic?
Do they have any other factors contributing to their weight?
And then after that, discussing their body composition and going from there to
discuss, okay, what's the diet modification we'll do and what medication we can add
if needed to help correct if there are any labs abnormality and also help them stay
on the lifestyle modification needed. So it's not one size fits all.
It's always going to be tailored based on how that patient, what they need help
with, and what's their status. Because I could have patient coming that want to be
off prescription medication. They are on long list of medication.
Right.
And they are here because they want to get off their insulin and all of those meds.
And I could be having a patient that tried it all and coming for extra help and
needs to address other problems, and medication could be an option for them.
Or surgical cases that maybe need even a revision after bariatric surgery and need
more intervention. So it's definitely different models of treatment.
Do you see a lot of prior history of bariatric surgery patients coming to you for
help still struggling with this?
Yeah, a lot, because 50% of sleeve gastrectomy are coming back for revision
worldwide, not only here.
So that's basically the cut part of the stomach?
Mm-hmm. Yeah.
Yeah.
So when they had the sleeve, they got the stomach smaller size in a banana shape,
for example. They were able to stretch it back.
So statistically speaking, we see 50% of those cases coming back for
revision. And sleeve was never meant to be only one step, okay?
It was supposed to be two-step surgery.
But when they found that patient respond, they made it approved for one step.
It was supposed to go get the sleeve and then go back and get the bypass.
Okay.
But they approved it as a case, and then they are finding that 50% of those cases
coming back for revision. But yes, it's very common to see weight regain.
It's not like it's a bad option. I work with four bariatric surgeon that are great
and have great success, but still, sometimes it's not the final answer.
So that alone is unlikely to help a patient.
It's actually a combination of things that's needed.
It's a multifactorial disease, like you said.
Exactly, yeah.
And do you think in your experience, are we waiting too long to treat people?
I kind of see that a lot of times in practice treating cardiovascular patients.
Say a blood pressure of
120 or 125 is normal and 135 and above is abnormal, while
they may be slowly creeping up that way.
An A1C of 5.5 is normal and 5.8 is pre-diabetes.
Are we missing the direction While we just focus on absolute numbers, do you see a
lot of that in your practice, years of cardiovascular risk factors missed-
Mm-hmm
... while the patients are struggling with this?
Definitely. And the earlier the better because when you had a previous stroke or MI
or anything, it's not about, okay, are we thinking is there a second one or not?
It's when is the second one, and can we intervene before a second one happening?
And this is when you say the earlier the better.
And when I have a patient would say, "Okay, next week, I'm going to start it." I
want to tell you to just start yesterday.
Start as soon as you can,
because the earlier the better. You can prevent a lot of problems, even with a
small weight loss.
Right.
It doesn't have to be a lot, but any intervention will give us benefit.
And when you see these pa- in majority of the patients in your clinic, because
there's two kinds that I see, some who just want to lose, "You know what?
I just want to look the way I want to look.
I want to lose 20 pounds," or someone who's struggling with perhaps 100 pounds of
extra weight.
Mm-hmm.
Who do you see more in your clinic? What is it like typically?
I really see a lot of different weight.
You could see in the waiting area someone who's really small and someone who's five
times that size. So I see all,
that big mix, and I never underestimate any patient need because, as I said, I
could have a patient that's 10, 15 pounds overweight, over her usual weight.
Mm-hmm.
Okay? She could be 140 pounds. With her height, she needs to be 125 or lower.
And carrying those 15 pounds, I never underestimate what she came for because she
feels the difference with her joint, with her back.
She has a borderline diabetes that can be completely reversed with 5% to 10% weight
reduction.
Right.
So that's why I always tell my patient, "You don't need to lose 100 pounds to feel
the difference. 5% to 10% weight reduction, you're going to start feeling it for
sure."
So you don't have to be morbidly obese or obese to see a specialist for this
and get the help that you need. Even 10, 15 pounds, if that's not your ideal
weight, could be a problem.
Right.
And then we switch on to, you, of course, start with diet and lifestyle changes
with most of your patients as we've shared.
Patients I've seen, you kind of have them work with that first.
But in terms of medications, and now we can define, there is almost two eras of
medications. There were ones before semaglutides and ones that are after.
So I want to go back a little bit because every time we talk about obesity
medicines, we talk about the newer ones, the semaglutides.
But there's a whole host of other options which may, I'm sure, be good for some
patients.
Mm-hmm.
So I just wanted to touch up on a few of the older medications.
The one that
when I trained, I heard a lot about is phentermine.
Mm-hmm.
What are your thoughts on that?
So phentermine was approved back in the '50s, really an old prescription.
And
the data, if you look back, they approved it for a short-term study, okay, because
the fen-phen was taken off the market because the other fen that was in the
medication caused leaky valve.
Right.
And because of that leaky valve seen in cases, they took the other fen off the
market, and it was only phentermine, not a fen-phen anymore.
The phentermine, because of the cardiac stimulation, it's a sympathomimetic-
Right
... so it stimulates your heart. So they got FDA approval for three months use,
okay? And every state is different.
For us in California, three months to get the patient off.
So because of the cardiac safety, because back in the days, they didn't have to do
a cardiac safety to get the medication released in the market.
And after another medication got also taken off the market, they decided that no
medication can be in the market until you get a cardiac safety for those
medication. And they also approved that we want to get the medication approved for
a chronic weight management use. So going back to phentermine, phentermine, it has
a lot of stigma, but safety data on it, and we can look a lot of studies, and I had
seen a lot in the literature, that it had not proven to
increase that blood pressure-
Mm-hmm
... but it had shown increasing in their heart rate, okay, for those patient, which
you could get a heart rate increase with energy drink, okay?
Right.
So you have to be cautious about what patient population you prescribe, okay?
And in my opinion, I don't like depending on the treatment for energy, okay?
So if I have that patient coming, I want the energy because of phentermine, I would
say, "Let's improve your diet, take a multivitamin, not use a medication for their
energy."
But if you want to use it for the food noise, if you want to use it for some
craving, I use it in my practice with lower doses, extended-release capsule form.
They have now even down to the Lomaira dose, which is eight milligram versus 37.5
milligram-
Right
... on the treatment. So I would use eight-milligram.
I use a 15-milligram capsule form as needed occasionally, okay?
And I always tell the patient, "Don't depend on it," because taking it regularly is
not going to be the key-
Right
... because you're going to feel the difference when you don't take it.
So if it goes here and here as needed, it's still generic, it's still available,
covered. And you have to be cautious that I'm not going to prescribe it with an
AFib or SVT or cases that are already having fast heartbeats.
And be cautious also with the insomnia and the sleeping disturbance part because if
I have a patient already perimenopausal or menopausal that struggle with her sleep,
I'm not going to put her on a stimulant so she can't sleep and she starts snacking
through the night.
Right.
So it has its selective group of patients.
But I think because the data were old when the phentermine was out, it didn't
give the approval for a longer use.
And then on and off the treatment was your clinical judgment.
But in my opinion, you could have a fit for those type of treatment for some
patients.
So cardiac patients, likely not the best candidates for phentermine.
Is that a reasonable blanket statement?
I agree.
Okay.
Yeah.
Then phentermine came with a combination topiramate, so the trade name was Qsymia.
Right.
Is there any upside to that?
So Qsymia got a cardiac safety with their study, and because extended release of
the phentermine and the topiramate get extended from their afternoon to their
evening time. So in my opinion, I would feel more confident prescribing this for a
patient from their cardiac safety.
It comes with some discount voucher that lower the price for the patient.
Some insurance still cover it. So you would have a better coverage for the craving
in the evening because most patient would come and tell you, "I'm busy in the
daytime," and most craving are in the evening.
You can't take phentermine and stay up all night.
Right.
So that could be a good fit because you could use the phentermine in the Qsymia
that get released in the day, and the topiramate get released in the evening to
cover their cravings through. And I still would tell them skip a day here and
there, but that help to help their evening craving as well and give them more
cardiac safety because they still can sleep because the topiramate get released in
the evening-
Right
... and it doesn't have the same stimulation.
They don't feel the heartbeats racing the same way they would feel it with a
separate phentermine.
And
I'm presuming both these are not pregnancy safe.
Exactly. Topiramate is teratogenic, so you definitely have to be very cautious and
let the patient know that. And I always give them heads up, those medication are
not safe during pregnancy.
And does it affect topiramate in terms of mood or cognition?
Do you see any of that?
I do. I see patient-- And you will have your patient really, it's very valuable.
I have those patient will see, "I
feel like I'm not really sharp," and I could feel that the next day I carry that
effect. And I have patient that function perfectly fine and would say why, even
when they take topiramate separate and they've been taking it for migraine
prophylaxis, they divide the dose morning and evening and function perfectly
through it. So there is a big variability with patient, but I always advise them to
be well-hydrated while taking topiramate.
But it has the carbonic anhydrase inhibitor effect that help a lot to change the
taste.
Okay.
So your patient that loves soda will hate it-
Okay
... because it tastes metallic and awful.
So I really feel it's a great help for those type of patients.
They don't need to stay on it a lot because they hate the soda, they don't care for
it after, and they maybe use it as needed and don't need to stay on it too long.
That's interesting.
Yeah.
Yeah. What about Contrave?
So Contrave also FDA-approved for chronic use, so you can use it for that weight
loss and maintenance. And it has in it basically your Wellbutrin or bupropion, the
generic name, and the naltrexone.
So that mix help because your Wellbutrin
is a good option for emotional eating, for eating out of stress and emotion.
So it's FDA-approved for depression and anxiety and emotional eating, okay?
Okay.
And this is one of the medication that we use for smoking cessation to help patient
not to gain weight when they quit smoking. And they added with it the naltrexone.
Naltrexone help more with the appetite regulation, so they help to reduce their
portion while helping the Wellbutrin part with the emotional part.
So it hits two parts. And I have good success with it.
It's a dose escalation where patient reach up to two tablet twice a day.
Reasonable cost for the patient that look for something that's reasonable regarding
cash price and could fit with some patient that really struggle with emotional
eating-
Right
... could be a good fit for them.
Okay. So those will be the key ones where you'd look for.
Yeah.
Is there a contraindication in terms of anything particular that you would
absolutely not use it for?
History of seizures.
Okay.
Because if you have a patient with a history of seizures, you won't use Wellbutrin,
and definitely if that patient is on any narcotics, opioids.
And I tell the patient, "That's not your Tylenol and ibuprofen."
Right.
So if you get prescribed morphine or narco or Percocet, you need to stop the
contrary because of the naltrexone part.
Can increase blood pressure also in certain people?
You could be careful because
I had seen it with Wellbutrin.
Mm-hmm.
So I would be cautious. If that patient doesn't have a well-controlled blood
pressure, I'll take care of-
Okay
... that first before I would add a prescription-
Right
... that could trigger some elevation.
Got it. And then there is this interesting mechanism, Orlistat, different from all
of these.
Yeah.
How is that?
It's over-the-counter now. The Orlistat merely affects the absorption of the fat in
the guts.
And a lot of patients don't like the GI side effect.
I barely prescribe it because of the GI side effect.
And I don't see a lot of data and studies that I could say that it's
causing some malabsorption for the patient.
Right. For the fat malabsorption, right?
Yeah, exactly. So if their main diet is a carb intake, you're not going to see-
It's not going to work
... a lot of good results with that.
And most of us struggle with carb more than-
Right
... you say, "Oh, I can't stop eating meat or fat." It's mainly the carb that
trigger the problem.
I agree. It's very hard to overeat meat.
Yeah.
But those cookies.
Exactly. You can't really stop.
Right. So before we transition into, there's a borderline one, but
are there cases in your practice when an older drug is better than your
semaglutide?
Using an older option?
Yes.
Yes. There are patients that could be resistant for GLP-1 and non-responders, and
because we're not treating the main problem of emotional eating or craving despite
controlling their appetite. So you could have, it's like exactly what we were
saying. It's not one size fits all, and you could find a good success with those
older options for those patients that may be a GLP-1 receptor agonist.
So I could say, yes, there are patients that are a good fit for other options.
Is there any role for metformin?
I love metformin in my practice. Metformin is an old medication, cheap, generic,
available, covered with every insurance.
So has a lot of indication, diabetes, borderline diabetes, and PCOS.
And I have a lot of cases of PCOS, and I could say that I always tell my PCOS
cases, for anything to work, get your metformin on board first.
I always explain it that it's a medication that reduces the gluconeogenesis.
Like you're
getting more glucose synthesis in your liver, and also it
increases the insulin sensitivity.
So you're able to increase that glucose uptake in the muscle level in your fat
tissue. So it has a lot of that function, improve your insulin sensitivity, because
a lot of us struggle with insulin resistance.
Right.
And at the same time, helping those patients with something affordable.
So you could find a lot of good fit for metformin.
It has a lot of stigma about the safety, and patients-
Right
... come and say, "Oh, I heard it's going to damage my liver, and it's going to
damage my kidney." The answer, it's a medication metabolized through your kidney.
So if your kidney already damaged and you have really higher creatinine and your
GFR is really low, then you can't be on metformin to start with.
Right.
But if your kidney function in normal level and we add in metformin, it can be a
good help for you.
And even people who do not have insulin resistance or diabetes, would that
still, like using metformin, be a reasonable option even for those people?
I always look at their fasting blood sugar.
Okay.
Because I could have a perfect hemoglobin A1c of 5.5, and I'm going around with a
fasting sugar of 95, 90. Okay, why it's not 70 or 80?
Why I'm waking up with a 90 fasting blood sugar?
So it takes years for this to be translated into your A1c being elevated.
So I do treat the insulin resistance.
You go back and trace it, they have a strong family history of diabetes, their fat
deposition around the waistline, they could be a good fit despite having a
perfectly normal hemoglobin A1c.
Okay. And what's the best time to take metformin, morning or evening?
So I always ask patients to try it at bedtime or in the evening.
Okay, but everybody's different.
I have patients that will say, "I'm out all day," and teachers, whatever, and they
go back home, and they want to take it when they can go to the bathroom because it
can increase your bowel movement and cause some GI side effects.
But the big trick on metformin, modify your diet before getting on metformin
because it interacts with what you eat.
So if you have a lot of carb intake, you're going to have more of that bloating and
diarrhea.
Okay.
So, and I am a big fan of low-carb plans, so I will tell my patient, do your diet
modification, add a probiotic every morning.
I'm a big fan of probiotic because it helps to regulate your gut.
Any particular one?
I prefer capsule form, high strain, not only coming from yogurt, so not simply
Lactobacillus. And whatever the patient can afford.
I'm not a big fan of adding digestive enzyme on it, but like a simple, a good
strain probiotic. Keep it daily, okay?
Modify the diet to be more on a low-carb side, and then get on metformin.
You don't tolerate it, try half a pill, okay?
So it's one of those medications that your body gets used to it gradually.
So it's not done-
Mm-hmm
... if you tried it one time and it didn't work, okay?
So you have to really keep trying and escalating the dose gradually.
If you tried it with all of those modalities, you couldn't tolerate it, we're done.
We know it's not the right fit for you. But it's worth giving it a good shot.
So just because you didn't tolerate metformin once is not the reason to not try it
again.
Yeah.
Fair?
I agree, yeah.
Perfect. Now, transitioning into the newer ones, but before I get into that,
Saxenda.
Mm-hmm.
That's kind of one of the first GLP-
Yeah
... ones. How do GLPs work? Let's just go through that quickly, a primer.
How do all these medications, the Ozempic, the Wegovy, the Mounjaro, what's the
basic premise or the principle?
The simplest way to know that we all produce those gut hormones.
Okay, every time we eat, within the bite or two of my plate, I start producing
from my gut, from my intestine, those gut hormone.
Those gut hormone in the GI tract, it slows down the GI tract and signals the brain
for fullness. So it's saying, okay, within a minute or two of starting eating, it
tells you, "Okay, slow down, you're getting full." Okay.
So we basically all produce those gut hormone.
So they made it in homologous relationship to our native GLP-1.
That's how I explain it to my patient, that we all produce the same gut hormone.
The difference is our native GLP-1, our native gut hormone, get destroyed within
one to two minutes by DPP-4 enzyme.
They made it to be modified to be resistant for that enzyme with a half-life-
Okay
... of seven days when it's that injection once a week.
So it went through a lot of different modalities because it
started when we had Byetta all the way-
Right
... years ago, and transitioned into a lot of different one, the Victoza after
that, that was the Saxenda for the weight management as a daily injection, and then
they had it with the half-life of seven days with the semaglutide and the
tirzepatide. So, that's exactly as simple as I would say.
We all produce the same gut hormone, but it's destroyed one to two minutes after we
eat versus having a longer half-life with the medication that we're given.
So it just gives us a sensation of fullness, so you don't end up eating.
Exactly. By slowing the gut. So it slows the gut.
That's why it's good to know this part, because you don't expect to finish the same
portion when everything sits here longer.
Right.
You expect to finish smaller portion, and it signals that brain for fullness
sensation. So that's how basically it work.
And that's why they cause nausea, I presume.
Right. So exactly, you have to really
check where if I'm overeating despite feeling full and that food's still sitting
here, I'm going to feel nauseous. If the medication slow the gut and you have five,
six cups of coffee in the morning on empty stomach with your vitamin that was not
even supposed to be on empty stomach, it's going to be nausea.
Certain food won't agree well with you, like spicy food, fatty food, certain
things, because everything's slower.
So that you could expect, if you understand the idea, then you could expect what-
Right
... will trigger more of the GI side effect.
Constipation can be a side effect because everything moves slower.
Right.
Lots of those things you would expect to happen from the mechanism of action of
those treatment.
Got it. And there's multiple options now, tirzepatide, then there's Ozempic,
Wegovy. How do you decide which one to put a patient on?
So your semaglutide is your Wegovy and your Ozempic, and the tirzepatide
is your Mounjaro and your Zepbound.
Basically,
it's a lot of different factors. In my opinion, they work the same.
They give a good benefit for the patient.
It depends, definitely-- I look at definitely insurance coverage, what the
patient-- Because if the patient is diabetic, and I'm able to get the diabetes
medication, which are exactly the same one that are approved-
Right
... for weight management, but approved for diabetes, then I'm going to try to get
it through their insurance with their diabetes.
That could be their Ozempic or their Mounjaro.
Right.
I respect the patient tolerance. If they come and say, "Yeah, I tried that one, and
I couldn't tolerate it because of the GI side effect," I would try the other one.
We have good data on different FDA approval beside the weight management.
So your patient with obstructive sleep apnea, have the FDA approval for the
tirzepatide, your Mounjaro or Zepbound.
Your patient with a cardiovascular event, previous MI, previous stroke, had a good
select trial that approved
your Wegovy and your Ozempic for those patients.
So I would put in consideration what other medical problem they have, their
tolerance, and their insurance coverage. But at the end, they work well.
You're going to get good results with any of those prescriptions.
It depends on your lifestyle modification wisdom.
Right. So they do not work alone. They have to be with lifestyle modifications.
Yeah.
Correct.
Exactly. And this is even the FDA approval came with, along with their lifestyle
modification, adding that prescription on board.
So let's go through the lifestyle modifications. What do you tell your patients?
For this to work, for the semaglutides to work, what must happen?
I'm a big fan of the low-carb plan. So I'm always encouraging my patient to reduce
their carbohydrate intake somewhere, because I'm always telling them, if the only
thing happen is I cut the portion smaller, but what's in the plate didn't change,
the minute those prescriptions stop, you're going to gain it all back.
Right.
And they published that in their studies. They didn't lie about it.
So I'm always saying, let's do the change.
So if we can replace option to be on a low-carb side, and you feel more in control,
not the prescription in control, you will be able to get good success.
Because if you are consuming a big amount of carbs, you're still going to produce
your insulin. And if you're insulin resistance, you're going to produce a lot of
that insulin. And the sugar's going to go like a roller coaster, despite that
injection.
Right.
You won't even feel it, and you're not going to get a good result out of it.
And when you stop it, you're going to have a rebound weight gain.
So you're going to hate the day you sow those injection on board.
So that's why I would always say, just lower the carb.
It doesn't have to be drastic. Small changes.
Maybe I decided to change anything I drink was more of a sugar-free drinks or
alternatives-
Right
... that are not loaded with sugar.
Maybe I'm going to stop some of the fast food, or maybe I'm going to modify my
choices there to do more of a lettuce wrap or whatever. Change option.
It doesn't have to be drastic, but small changes. But it will help a lot.
So that's what I'm a big fan on, more like lowering the carb intake.
It's not a high-fat diet. It's more of a low-carb Mediterranean plan.
But it gives a good result for those medication to kick in.
Got it. And there is obviously, you just briefly touched on, there's a lot of other
benefits to these medications, the heart outcomes, the sleep apnea.
Could that alone be the indication? What if someone is like, "You know what?
I don't care about my weight" but to reduce their risk-
Mm
... from these comorbidities like heart disease or heart failure or sleep apnea, is
that a good enough reason to consider these medications?
Absolutely, yes. Because they've proven, like that SELECT study for the semaglutide
had 17,000 patient, and they were not really after the weight loss with those
patient. They were after the occurrence of MI or stroke or cardiac event, and they
found they had less cardiac event despite not losing that much weight. Okay?
They even tracked the patient that gained weight on the treatment during the study,
and they found they had less cardiac event.
So this is when I tell my patient that it has way more than benefit, okay?
They don't know exactly the mechanism of action, how they reduce the cardiac event.
But what we could say that all of us agree that they reduce inflammation and how we
could see the inflammatory markers for those patients come down.
So you could get a lot more benefit than just number of pounds on the scale.
And just taking a step back, you mentioned about low-carb diet.
So I used to hear a lot about this when people talked about keto diet.
They're like, "This is great. I can eat sausage and bacon and still lose weight."
Mm-hmm.
So can we define a clean keto diet versus kind of processed meat keto diet?
Right. I'm a big fan of a low-carb Mediterranean plan, and I always tell the
patient, I'm not talking about keto diet because I don't ask you to add the fat in
it, okay? So this is when you want to explain to your patient, yes, get your lean
protein. It could be your salmon, it could be your tuna, your chicken, your lean
protein. Yes, you want to do your steak occasionally.
You don't want to have mashed potato next to it.
Right.
You want to have non-starchy vegetable next to it, so you run on that fat for fuel-
Mm
... occasionally. But that picture where you're holding a butter-
Right
... in your hands was the picture of that, we call it like a dirty keto diet, where
you have unlimited amount of fat. They come and argue that if you're taking that
much fat and you're not getting the carb, you're still going to run on the fat.
But in my practice, I don't push that fat intake higher.
And I barely have-- Even my female patient would say, "Oh, I barely eat even red
meats." Okay? So what I let them focus on is how to lower their carb
using lean protein. So I'm not talking about that high saturated fat intake.
I'm thinking about, I'm telling them, cook with your olive oil, use your avocado,
use your lean protein intake, but focus on reducing the carb.
And once you focus on reduce the carb and you're not as hungry, a lot of your other
choices change because you're not as hungry.
Right.
So it's definitely a different criteria than upping the saturated fat and
encouraging the patient to have that much fat intake.
You could use keto recipe because they're going to have less carb, but you have to
be selective about more of your lean protein intake, especially when you have those
patients coming with a very high lipid panel.
You want to work on-
Right
... reducing the lipid panel as well.
Correct.
Yeah.
And now we have these oral ones coming in for Wegovy and
then Mounjaro. Is there any difference from the injections? Where do you pick them?
Right. So to make sure everyone is clear about it, your oral Wegovy is exactly a
semaglutide, so same exact gut hormone, okay, that semaglutide oral.
It still has a half-life, by the way, of seven days-
Okay
... but it's taken daily, okay? And you have to make sure you take it 30 minutes
before you eat or drink with four ounces of water. Okay?
Okay.
Otherwise, it's not absorbed properly.
You don't want to get it out of the bottle or put it in your pill container because
it has a SNAC technology that help to increase your pH of the stomach lining to
help reduce the proteolysis, the destruction of that gut hormone, to be properly
absorbed in your bloodstream.
Okay.
Okay? So this is your oral Wegovy, okay?
Dosing escalation is different, but it's daily intake.
Your Foundeo, it's a different molecule. So Foundeo is not an oral tirzepatide.
It's a different peptide, and they were able to have it also daily.
Those one, you don't have to take it on empty stomach with four ounces of water.
You can take it any time. And it's a daily intake.
The weight loss on their studies, they were able to see 17% weight reduction up to
the highest dose on Wegovy. They were able to see 11% weight reduction on the
highest dose of Foundeo. So it's still great options.
It's great to have many options for our patient-
Right
... but it's good to understand that the Foundeo is not the oral tirzepatide.
It's a different peptide. It's still a daily dose that you can take, but it's
not an oral tirzepatide.
So it's just patient preference at that point?
Right.
Not available-
And affordability, because they have discount voucher on low doses for the Wegovy
or the Foundeo. And also some would say, "No, I don't want to take first thing in
the morning," versus, "I want to take it any time of the day."
Right.
But your thyroid patient can take their thyroid medication at night, but it's a
preference, too, and affordability. But it's a more option.
And the more we have option-
Right
... we expect pricing to get better for patient as well.
Absolutely.
Yeah.
And what's coming down the pipeline, Retta, we hear a lot about?
Yeah. So Retatrutide, Lilly expecting-- I think it's in phase III
trials.
Mm-hmm.
Still not in the market, so that Retatrutide that patient get it compounded is not
FDA-approved, and I really discourage using anything that you don't have a safety
data on it. But that's S3, gut hormone, so basically
have a very promising results that we could expect to see soon.
And the CagriSema, which is also coming in the market, that's Novo.
And I think this is going to be Amylin and Semaglutide, also very good data
And I think Amgen has another medication coming, Pfizer, another medication, but
more step two trials. Or I'm sorry, phase two trial.
But it's great to feel like there are more options coming because you know how many
blood pressure medications-
Right
... cholesterol medication, diabetes medication we have.
Right.
And we have a huge demand for treating obesity for sure.
So-
Right
... definitely having more options is great for our patients.
No, definitely. And how's Retat different? Is it better?
If presuming it's approved-
Mm
... let's just take a step forward.
Do you find any difference in, is it more efficacious, so to speak, because of the
glucagon-mediated effect that it also has?
Expectations that they have higher percentage of weight loss on their trial.
So I think it's going to be more clear once everything released in the market, but
expectations is to see more weight loss.
CagriSema will have also the approval, not to reduce the bone density.
So those-
Okay
... female patients that you worry about osteoporosis-
Osteoporosis, yeah
... and losing muscle mass, this is going to be your possibly CagriSema patient
that you could prescribe, and they have proven not to
cause just more osteoporosis and muscle mass loss.
So I think it's going to be tailored differently, each patient and what they try
and what's their initial weight and the coverage and all of this, but more options
is great.
So I'm glad you mentioned the bone loss.
With all this use of semaglutides, and it's essentially for a number of times
weight loss by starvation-
Mm
... for the lack of a better word.
Mm.
Are we worried about people losing, as they get older, a lot of muscle and
bone loss with it? Are we going to see an epidemic of instability and hip
fractures?
And sarcopenia?
Mm-hmm.
Yeah. So this is a very common concern, and this is when I
always tell the patient, "You have to avoid this by increasing your protein intake
and your weight lifting." Even my 70 and 80 years old, they can do their small
weights sitting in their chair with a YouTube video or nothing.
But it depends on how you eat with it.
So if it's a starvation like you're talking, it's completely different than someone
who has a good nutritional value-
Right
... in what they eat, even if it's two small meals.
But there are colorful plates that has your vegetable salad, your protein, your
intake. So yes, absolutely, it's a concern, and the only way around it is to up the
lean protein and increase resistance, your weight lifting.
Whatever it is, it doesn't have to be structured in the gym, but some weight
lifting will help a lot to reduce muscle mass loss.
And another thing I saw, at least in my practice, a lot of patients who started on
this started having dizziness or lightheadedness sometime down, and
even I've seen some syncopes.
Mm.
What do you tell your patients to watch out for that?
Check their blood pressure.
Right.
Because what happened, they are on four blood pressure medications.
Right.
Okay. And they could have a systolic of 90.
They used to be 170 over-
Right
... 80, and now they are really lower blood pressure with all the weight loss they
lost. This is when they really need to taper down and correlate that with their
primary care, their cardiologist, whoever follow that, to taper down their blood
pressure and keep an eye on it. And I always say, even if you reduce it, any
problem, go back up again on that blood pressure.
But when they feel that dizziness, when they stand up, change position, tie their
shoes, this is usually their blood pressure.
So the only time the medication, and this is when I always tell the patient,
"If the dizziness is triggered by hypoglycemia, then you trigger that by
the way you eat." So we call it more of a rebound hypoglycemia.
Right.
But if you're really following a low carb, those gut hormones are smart.
They are released in response to when you eat. They are not continuously in action.
So this is when I would say, yes, if you have your blood sugar like a
rollercoaster, you could feel shaky and dizzy in between.
That's triggered by a rebound hypoglycemia that you triggered it.
So you can always look at it before you eat it and say, "Is it worth it to have
that much carb and then feel really bad after?"
Right.
And you got to really modify to the side because you say you modify your decision
because you say, "Oh, I experienced this. It wasn't pleasant.
And I don't want to go through it again." So those are the two common reasons,
blood pressure and the rebound hypoglycemia that we can always avoid.
Is dehydration a common thing with this?
A good point. The dehydration is common, so how you can get the hydration through
the day. Some patients can be nauseous in the morning.
They can't really get a lot of fluid in.
They can get it through the day, but very good point to keep their fluid in no
matter what type of fluid, like their water, their whatever intake,
to help the hydration through. But very common, definitely.
And they could say the fatigue and all of this also related to how they eat and how
they hydrate.
Got it. So generally, I understand these medications are safe, but still some
major concerns that come with that.
What do you typically, like someone who started this, what are some of the red flag
things they should watch out for when they started on semaglutides?
What are some of the major complications that you worry about?
If they were very prominent GI side effects.
So if that patient didn't tolerate even the lowest dose with continuous nausea,
vomiting, GI side effects, then this is not the right fit for them because you
don't want to go into a renal problem because of that.
If that patient go into hypovolemic problem-
Right
... then they're going to really affect their kidney and affect other organs.
So it's not the right fit for them. They can't keep pushing it despite the GI side
effect.
Those are really important, too, because most common side effect with those
medication are the GI side effect.
So that's what I would really put in mind.
Of course, a patient who had a previous history of pancreatitis-
Right
... triggered by that class of medication, not triggered by their triglyceride
being elevated before or alcohol intake, then they are not a good fit for that
medication. I won't start any GLP-1 for those patients.
If they had a history of acute pancreatitis triggered by a GLP-1 receptor agonist,
they are not the right fit for that medication.
Got it.
Those are really the big. If you have gallbladder issues and gallstones, get it out
of the way before you add a medication that cause more GI issues.
Clear it out of the way. Those are common.
Anaphylactic reaction or severe allergic reaction to a one, not a topical reaction
at the site of the injection. Those are all things that we would avoid it because
they were really not a good fit for the treatment.
And family history of thyroid cancer?
Medullary thyroid cancer. So not all types, and this is a black box warning in all
GLP-1 receptor agonists, and it was found in rats, not in humans.
And if I had a patient with a history of thyroidectomy, I would ask what thyroid
cancer they had. Most commonly, you're going to see it follicular or papillary
thyroid cancer. But if you have a history of medullary thyroid cancer, which is
rare to see in our practice, then those are not the right
fit-
Right
... for any GLP-1. It's a black box warning on all of them.
And
sometimes people lose weight, but they're becoming weaker because they're losing a
lot of muscle. Do you track that regularly with them, like the muscle loss versus
total weight loss? How do you differentiate that?
I track it by the body composition, and that's why they are motivated to bring back
their previous body composition and compare it.
Uh-huh.
It's a simple one. Really, to get a perfect body composition, you need to measure
underwater-
Right
... or DXA scan. So whatever we have available in our office, we try to help with
it.
So those can track, and this is when we say, "Okay, let's pay attention to up your
lean protein." And even if that patient not able to get it through their diet, they
might increase some protein shakes or whatever source of lean protein they can add
to improve their muscle mass, improve their weight lifting.
And then we could modify the dose. Maybe they are on a high dose and need to lower
the dose, or maybe we need to change a GLP-1 if they had a lot of GI side effects
and couldn't tolerate it.
Right.
We're just going to have to avoid further muscle mass loss.
Right.
Because I'm always saying, if you really lose your muscle mass, it's very tough to
maintain your weight.
Right.
It's very, very hard.
You lose your metabolic rate, basically.
Exactly. You're really losing a big part of what your body...
So it's very difficult to maintain the weight.
And the risk of fracture, and they don't need to fall. They can move wrong.
Right.
Okay? And
here we go, and everything goes wrong.
Exactly.
Once they have that hip fracture, nothing really gets better.
Right.
So that's something that we can definitely avoid.
So some of the things, just to sum up what you've said in terms of things to watch
out for if someone's starting on, definitely should eat the lean protein and take
good-
Mm-hmm
... hydration is important, monitor your blood pressure, especially if you're
getting dizzy, and weight training-
Exactly
... is an absolute must.
I completely agree. Yeah.
Perfect.
So a lot of patients have access to qualified physicians like yourself, but there
are people who are listening who may not have, in their immediate neighborhood,
someone who they could go to. That's where there's a proliferation of online
services for this. If someone is looking at that, what should they be looking for
to know and make sure that this is appropriate and the right avenue for them to
pursue?
It's a very good question because it's scary how things online are really not
always the right-
Right
... option. I think you have to make sure that this is
either a physician, a nurse practitioner, or a PA that's licensed to practice.
Okay, so you have to check that part, and you have to check that you have a
legitimate prescription, okay? Because if you get
basically a package that has nothing labeled on it, just a syringe or
a vial or a pill that you don't know exactly what you put in your body, this is so
scary, okay?
Mm-hmm.
Because the impurity of preparation of those things are harmful for certain organs.
Right.
And they've been death rates, death cases that were related to wrong dosing on
those compounded prescriptions.
So I would definitely check that this is a certified physician
to practice, and I
would definitely be very
clear about making sure that they order lab, and they check history, and
it's not like, okay, you're not connected to any person, and here you go, your
prescription sent. And when they send that mix of things of the B12 and two, three
other prescription, and they didn't even take your history or check your lab, you
have to be very suspicious about that part, right?
Right.
And you're not going to trust that whatever, because they could be prescribing
something that harm other organ because what if you have a problem with your kidney
or liver, and they are sending a medication metabolized through your liver or
kidney?
Right.
So those are things that I would be very skeptical about to make sure that whatever
I seek, because I could exactly live in an area or somewhere where I have to seek
help-
Right
... virtually, and it's a good option, but you have to make sure that it's done
properly.
The right avenue.
Yeah.
That's perfect. No, that sums it up.
And then there is a few things I want to tie these medications to just because so
many people are using this, so I want to just bring those,
how would I say, tie-ins together.
So in terms of pregnancy,
semaglutide and pregnancy.
It's not indicated during pregnancy.
You need to stop it two months before conception, the same as the tirzepatide.
So I work with a lot of fertility cases where they need to lose weight before in
vitro fertilization, before getting pregnant, or before even getting on their own
with PCOS cases. We agree. Okay, that's a great prescription for you, but we're
going to stop the treatment two months before pregnancy.
Okay. Thyroid, we talked about that. So medullary thyroid cancer.
Exactly. It's contraindicated for that type, but other type of cancer, yes.
But breastfeeding, it's not indicated during breastfeeding.
And the oral pill were found in breast milk.
And during that time, you don't want to deprive the nutrition.
Right.
So that's part that I would also avoid.
They could finish and then start a treatment.
So those are my mainly recommendation, but those are definitely on the
prescription information of those prescriptions.
Got it. Procedures, if they're going for a procedure under anesthesia.
Yeah, good point. You need to hold it.
Mm-hmm.
And you have to treat the pill the same way you treat the injection.
So even if the pill is once a day, you still have to hold it a week or two, and I
let them follow the instruction of their anesthesiologist because some GI want to
hold it for two weeks because they want to clear it completely because when they
scope, they want to see everything.
So just follow the instruction versus someone who say, "Okay, just hold it one week
before."
Okay.
But treat the pill the same way as the injection.
Even if you're taking that pill every day, you have to hold it a week or two-
Before
... because it has still a half-life of seven days.
Got it.
Yeah.
So now kind of coming to the closing of the interview, I want to address a few
things that are not as easy perhaps to sort of define.
But starting, we get someone started on this, they lose weight.
Do you discuss their goals before and a stop point is defined, or these are
indefinite? How do you define that?
It's a great question. I ask them. I get the patient involved, okay?
Because your goal is
you want to let them know where is the good medical part, and I always tell them,
"Okay. You are below, for example, BMI of 40 or somewhere.
This is way more cardiac protection." So I would say, "We're out of the red zone.
We're getting in a better area." But I always work around their goal because you
could have someone who could be overweight or even a BMI above 30 and in a phase
one obesity, and that's where they could maintain.
And I have patient, also older population, that would say, "I look older as I lose
more weight, and I carry it better that way." So I would put the goal together and
agree, and as we get closer, we have our maintenance plan where we say, "Okay, this
is our maintenance plan regarding our diet and regarding our medication" and work
around it, because it definitely has to be tailored based on your patient need and
what they can achieve.
Do they ever go off it completely in your practice, or the low dose will continue?
I have patient off treatment for GLP-1, for example, they lost their insurance,
can't afford it because they were doing cash pay.
So I have a lot of patients that have been on the medication and off the treatment
for now a good period of time, and they were able to maintain their weight pretty
well because I always say that that medication maybe helped them to get them on
track with their lifestyle-
Right
... modification, that now they do it naturally because it became a habit.
So it became a lifestyle.
Right.
Right.
It becomes naturally happening.
And we talked a little bit about surgery before.
So when does surgery enter the conversation in this now that we have such good
number of medications? When does surgery ever enter the conversation?
So surgery approval had always been for most insurance, BMI of 35 and higher with
two comorbidity. That could be hypertension, hyperlipidemia, obstructive sleep
apnea, diabetes, okay? And/or BMI of 40 and higher, 40 and higher with no
comorbidity. That's most insurance, Medicare, Medi-Cal.
That's most of the time the coverage for surgery.
So it's a stepwise technique, okay?
You can't really jump on surgery without addressing, and most surgical cases need a
six months medical weight management where they lose 10, 15 pound in preparation,
or if they are above 450, they need to be below 450 for certain criteria in certain
center. Depends on the OR table and the technique of the center where you operate.
But those are the general criteria.
So you have to go through the options with your patient because you could have a
patient coming and say, "Oh, I tried it all and I'm here for surgery because that's
the right fit."
Right.
So definitely those are the criteria for insurance coverage, and then your
conversation more about, okay, did we try different options, and are we
ready? And I'm always saying, if you didn't do the lifestyle modification, then
surgery's not the right fit also.
Right.
So you have to be ready for it from that perspective.
But you could have done already the lifestyle modification, and you still need
that extra help. And I have patient did surgery preparation during the prepare
because we see them also for the program, and they lost a lot of weight, and they
were so ready to proceed with surgery.
And I have patients lost that much weight and said, "Okay, I just want to continue
medicine."
Right.
So I don't think surgery going to go away, okay?
It's a great tool if it's used in the right
timing.
Right concept, yes.
Yeah, and you're ready for it.
Got it.
And definitely, it's a good to have all your options open if it's an option for
you.
And the other thing I see a lot of times, patients start on a dose, and then the
dose escalation, and that's when the problems start happening.
How do you deal with dose es-- Does everyone need a dose escalation, or how do you
proceed with that?
I really take my time with the dose escalation, especially, by the way, you have a
GLP-1 receptor agonist approval for adolescent, for 12 and up, and those are, I
take my time through, okay? And I never go up on the dose until I see the patient,
and I ask, "Okay, are we ready for the following dose?" Because if you're nauseous,
why we want to up the dose-
Right
... okay, and have more GI side effect-
Right
... and don't get any benefit out of it. We could even lower the dose.
If we didn't tolerate it, then let's lower the dose and see if we can do better.
So when they are on it, say you escalated the dose, they're on it, they don't feel
hungry at all
Now the concern is protein intake. So they come and tell me, "You know what?
I don't even feel hungry." So how do they approach eating the right calories that
they need to maintain muscle?
Yeah. This is when you really have to adjust also their dose and their intake, and
I would tell them, "Put your alarm on." Okay, so even if you have intermittent
fasting and you have two small divided meals, make sure you had your protein in it.
General intake,
we're talking about not anymore 0.8 gram per kilogram body weight.
We're talking about more than average of 1.5 to 2 gram per kilogram body
weight protein intake. So they could supplement with the protein shake and make
sure they get something that has a good protein intake value in it.
And they try their best, even if, as I said, if they put their alarm on to
remember. But I always ask them, at the end of the day, ask yourself, did you get
some? It doesn't have to be your steak.
It doesn't have to be the things that you can't really-- I have patients say, "I
can't even look at it. I don't want to see it." You have to be selective about
whatever source of lean protein, because your Greek yogurt can give you 20 gram of
protein in it.
Right.
It doesn't have to be always-
I mean, it is
... a source that you can't really tolerate, but you have to go around it to get
some protein in.
So you'll have to be very intentional about keeping that up.
Right. You have to have the mindset to track it.
And if you're struggling with it, perhaps it's time to back off the dose a little
bit?
Exactly. You definitely need a lower dose, because if you're going to higher dose
and all you have is c******s and smoothie and then a carb intake and whatever,
you're not losing weight and you're going through all of those side effects and
you're losing muscle mass.
Right.
I don't think that we did any benefit, right?
No, that's not good. Mm-hmm.
It's about time to do some modifications to get appropriate nutrition and get a
good benefit out of it.
So higher dose is not necessarily better-
Exactly
... for everyone.
I agree.
So someone who's considering going on weight loss medications and planning to go to
a doctor, what would you tell them?
What are the things that they must ask their doctor as they're starting this
journey?
Their primary care, for example, or-
Or obesity medicine specialist that sees someone for the first time.
What would you call a prepared patient who comes to you?
What would make your life easier and the patient's journey better?
Prepared patient, how does that come?
Is to be ready from the lifestyle modification, okay?
To put it on board and to feel like, yes, I'm ready for the next step, so I can
feel the benefit out of it. That's why we would usually encourage.
It could be
making sure their labs are good and they are ready from that perspective, because
if you already have to treat their thyroid or vitamin deficiency or iron deficiency
anemia or whatever it is, it's good to take care of that.
It's good to set their, and I would say your grocery shopping, whatever it is, even
if you live among other people at home, just have your stuff ready.
And also address the other medication, because you could be on some of the
weight-promoting medication. Okay, some medication cause weight gain, so let's
adjust that as well. And set the field to say, "Okay, we're ready to start to use
that medication so we can benefit out of it."
Got it. Any particular questions they should ask their doctor on first visit?
Particular things they should be mindful of?
When they start the treatment?
Mm-hmm.
No, it's mainly navigating through the side effect and its effect.
Because I'm always asking the patient, "Do you feel the medication?" Because the
longer you stay on some of those medications, some would say, "Oh, I don't even
know if I'm injected or not."
Right.
But they get off and they feel that, yes, it was there in their system.
So I think it's more checking how they feel on the medication, any
side effect and its effect, and what change they did and what did it help them to
do that was different-
Got it
... than before. Yeah.
So to sum a final question, so what would you tell someone who struggled with
weight for 20 years and they kept thinking it's a character flaw?
Telling them it's not your fault. Okay, take the burden off.
You don't have to keep beating up yourself because of something that you're not the
one that caused that problem, okay?
And put it off your shoulder and get the help you need because it's far beyond the
willpower game.
It's biology.
Yes. It's far beyond eat less and exercise more. So we know better.
We didn't know that long time ago, and now we have a good knowledge about it, that
it's far beyond the willpower, and it's not anymore that you have to keep beating
up yourself about it.
Got it. And if someone would want to see you as their doctor, how would they get in
touch with you?
So I don't need any referral. If they have a PPO coverage or Medicare, they can
call the office and schedule, like our call center for Adventists.
And
that's the good part, that they don't need any referral to be seen.
If they feel like, yeah, we need the help, we'll be happy to see them.
Perfect. Well, this has been very insightful.
Thank you so much for taking the time.
No, thank you so much for having me tonight.
All right. Thank you. Take care.