Anti-Obesity Medications: Part 1

Welcome back to another episode of the podcast. I'm so excited to be here because I suspect that today is gonna be one of those episodes that a lot of you have been wanting to hear from me. We are gonna talk about the anti-obesity medications available Conventionally, you'll hear of these referred to as the weight loss medications. There's actually so much to talk about here that I'm going to split this episode into two parts, part one and two. So make sure that. right now.

If you're liking this episode, you hit subscribes that you don't miss next week when part two comes out and also realize, I say this a lot, but yes, I'm a physician, but there's no medical advice being given here. This is very informational. This is a very brief overview. I mean, lightning flash style because I cannot possibly in this short context, talk about all the risks and benefits of these medications. There are so many other things that I'm not able to talk about here.

We get whole board certifications and this this is a whole specialty I mean, I laugh when I say this, but people want, they literally want in 10 characters. Is this right or wrong for me? And it's, it's just, it's much more complex than that. We're gonna start to broach the topic. You know that something I'm really passionate about is not gate keeping this information anymore.

And unfortunately, a lot of physicians are actually not educated in this, and so you might actually get some information today that might help empower you a little bit, and then you might be able to bring it up with them and then you can research it together or maybe. You give them this episode, to listen to. So we are really all in this together.

Again, you do not make decisions, big things that you're changing with your health, medications, all that kind of stuff without talking to your medical team. And by the way, stick around in part two. I'm gonna talk about, one of the questions I get asked the the most often is, how can I find. Physician, that can help me with this. I'm gonna tell you what I think are some of the best places to look for that. Okay? So let's go through who even qualifies

for the medications now I feel like I'm always giving lots of, you know, caveats on things. All right. We're gonna talk about the body mass index, b m i, the body mass index. While there's many reasons that it's garbage, and we will talk about this in future episodes, it's a actually a, a a a a pretty not nice history, to be honest of where it came from. We will talk about all that. It is a screening tool. It is used all over medicine.

It's steeped in the insurance industry, and so we need a way in medicine, we medicalize things, meaning we kind of put buckets and diagnostic criteria, kind of what goes into what category. I really wanna stress here that you are not a number. and so when you get this number, this does not mean anything about you. It does not actually mean anything about your health necessarily.

This is why when you meet with your doctor, it's really about a more global context because you might have amazing, healthy habits. You might be eating really great food that's supportive. You might have amazing exercise practices. You might be super active. Your mental health is amazing. There might be so many things that are going great. Uh, poor family history of anything. No medications. You're on. I don't know your history, I don't know the body composition that you're working with.

So keep in mind we're talking isolated numbers and isolated cases here, so talk to your team. Right. Okay. So in a conventional sense, who qualifies now? Keep in mind, again, certain ethnicities and populations, these numbers will actually be lower for them. So again, this is why it's really important to work with a physician that knows what they're talking about.

But just in general, okay, so not certain ethnic populations, but in general, if your body mass index, that BMI number, if you look up online, you do a calculator, BMI calculator, you put in height for weight, if it's between 27 to 29.9, so right under 30. Medical comorbidities or over 30 period, you qualify for the weight loss medications. Now, in that overweight category of the BMI 27 to 29.9, with medical comorbidities, they have to be things that relate to what we think relate to weight.

So for example, things like type two diabetes, high blood pressure, high cholesterol. Things like that. Okay, so it's things that are influenced by that. And then period, if the weight is 30 or over, that's the category that's the number that we start to use when we give the medical diagnosis of obesity. Again, this is not a morality thing. This is not a character thing. This is not to say that some people that have higher BMIs are actually not still amazingly healthy.

We're not having that conversation today. We're having the conversation about just numbers. Okay? So if that's the case, yes, you would qualify for these medications, does not mean that it's appropriate. Again, you're gonna have that conversation with your doctor. I'm giving all this cause I feel like I really, you can't like go into a doctor and be like, well, my BMI is 28 and I have whatever going on, and that means you're gonna write me a med.

That's not necessarily how it works because keep in mind, all of these medications have a lot of benefits and a lot of risks, and we need to weigh that out for you. And so there might be a scenario. And I actually really empathize with these patients. So something that happens not quite often, but every so often I'll get someone that maybe has a BMI that's 27, but there's, there's no other medical comorbidity happening and I'm evaluating, I'm looking, and I just don't find any reason why.

There's anything pharmacologic that I can provide. I can't justify it, but they tell me, look, I've struggled for years and I'm, I have to measure and weigh and they're, they're in distress about how hard they're having to work. And I empathize with them. And there are many things that I can offer, but medication might not be one of them. And so I'm not minimizing that cuz I'll, I'll give you another example. I have also people that will come and approach me that.

Maybe they, let's say their, their body mass index has been on the lower side in the normal range, like 18, and they now maybe are up to 22, and that's a weight gain for them, and they don't feel comfortable at that. Right. And so if I'm just plugging in numbers isolated, You know, they're wanting help on that. But just unfortunately, according to these diagnostic criteria, that is not, I would not be able to write a medication for them that would be inappropriate in my estimation.

It does not mean that that person is not still having a hard experience and going through it. Really what I focus on on this podcast is the treatment of obesity. So really b m i 30 and over. Okay, so just coming back here. So again, all medications are gonna have risks and benefits, so it's really. we weigh that risk

when we talk to you and our body. You know, I think a long time, what was taught in medicine is what this calories in, calories out model. So every single doctor was, well, you need to eat less and you need to move more. And the problem is that like, it's not really true because they, because they would do studies and that's not really how. How everybody behaved. And again, we'll talk about that much more in future episodes. But I wanna just provide you a quick number here. So

about 5% of people are gonna be able to lose 20% of their body weight with lifestyle changes alone. And if you are one of those, one out of 20, I'm so happy for you. I want that to be the case, right? We know that there are success stories where, where someone said, and then they'll, they'll build a whole company on it, right? That they lost a hundred pounds and I just did it with small changes and, and that's amazing.

And listen, I would like that for you, but the reality is that's about 5% Everybody else. If you look at sort of the trajectory over their lifetime, and if this is a chronic medical problem that they're dealing with, maybe they're able to have periods where they lose and then they regain. The best time. When I saw this illustrated, I just wanna story time for a minute.

I, I worked previously at the va in Indianapolis and the va, if you're not familiar, That, within the states, if you've never worked at one of them, they have a medical record system up till now. I know, I know it's gonna change here coming up soon, but they had a medical record system that's one of the longest known in the US and so you really had really long-term data from the vets.

And one of the things I did, the weight clinic there and something that was fascinating to me about it would be you'd pull up the weight chart and it's classic, so they would start wherever they were at in, in adult life. You could look back 10, 20 years. And you would see that they would've periods where they would lose and then they would regain, if not a little bit more, and then they would, then they lose and then they regain a little bit more.

So you end up with this scenario where overall year after year, there's always a few pounds being put on and you always see the attempts, right? And it's just classic for what we would say is yo-yo dieting. And that's when you try to lose weight, but inevitably you put it back on. The reason we're talking about anti-obesity medications

today, it's one tool to help either stabilize or bring down weight long term that allows you to fight these metabolic adaptations. Our body actually really doesn't like to release weight. It always wants to go back to where it was so historically we know a lot of the lifestyle things on their own don't work long term, and that's not to say that it never works for people or that it's not completely necessary to incorporate with the medications. Right. It's, it's a, it's a super critical pillar.

We're gonna talk so much more about it, but we know that on its own there are so many things that happen when you lose weight that usually if we don't have some type of medication assistance for many, not for everybody, but for many, it's very challenging for them to keep the weight off. And here's another thing I want you to think about, cuz some people fight me. They say, well, you know, I, well I did it.

And I'm thinking, yeah, you're part of the 5% But the other thing I want you to look at too, it's not keeping

weight off. I no longer want you to think in weeks and months. I want you to think in years and decades. You know when someone tells me, okay, they're eight months into whatever sustained change, high five, congratulations. I'm so happy for you, but I'm really thinking at the five year mark, are they gonna have gained that back or not? That's where my sort of barometer for long-term success is.

Everybody's a sort of different, but I want you to not reach that five year statistic where majority of people put it back on. So I'm thinking a little bit differently here. One last thing before we get into the medications. Majority of these, what you're gonna see, the, the understanding in obesity medicine today is that these are long-term medications. A lot of people say, well, what are the effects long-term?

Sure, some of them are newer on the market, but actually a lot have been around a really long time. And one of the things we wanna prevent is weight cycling. So this gaining and losing and gaining and losing, cuz metabolically, it's very tough on our body. Number two, it's extremely hard to lose weight again, the next. So you make it harder and harder on yourself. So these are long-term medications. All right, so let's talk about what are some options.

So we're gonna start all the way at the beginning. The first one that's available been around the super long. It came out in 1959. It's a sympathomietic amine, and it's a, it's a stimulant medication. It's called Phentermine. Sometimes you'll see the name Adipex or it goes by a few other names. This, again, it's in that stimulant category. We see maybe about like 7% weight loss. It does a really great job with suppressing hunger. And one thing I just wanna double back to real quick.

You'll see me see some numbers as I go through the percentage of weight loss. You might hear some of these numbers if. In the medical community and you might say, oh, you know, 7% isn't that much anything. 5% or more is super significant as far as health outcomes. So 5% weight loss or more might be the reversal of pre-diabetes, might be your blood pressure improving. a lot of changes like that.

Now, depending on what we're looking to improve, if you have some more significant changes, like you wanna reverse fatty liver, things like that, we might be looking at more like 15- 20% weight loss. Again, depending on what's going on, but really that percentage of weight loss is rather significant.

The other thing I really wanna highlight, I'm trying to pull from some studies with this, but realize different studies, different times are gonna quote, different numbers do not get locked into them. It's an average. Some people lose less, some lose more. And again, there's an art to all of this. Hopefully you're working with a doctor. Alright, back to phentermine. So about 7% weight loss. The benefit of it is that it's super cheap. It's been around a really long time.

We know kind of what to expect from it. Even if you don't have insurance, it's covered. That's, you know, really great with it, the fact that it can be covered. Some of the cons that I see with Phentermine is that because it's a stimulant, some people really can't handle this in the sense that they'll start to develop insomnia with it, even if they take it right in the morning. Or depending on what the formulation is, they still have problems.

Some people, again, because of the stimulant nature, they'll end up getting heart palpitations. So the heart beating funny on them. Some of the effects such as dry mouth are not tolerable. The other thing that's kind of a challenge is some states only approve it for three months to be written at a time, and then there has to be breaks in between, while really we know that people do extremely well long-term on phentermine actually.

And so there's lots of physicians are actually working with legislation to get these laws reversed and so that people can stay on these medications long-term. But there's just a lot that needs to go into it. The other thing that really needs to be looked at, because it's a stimulant sometimes, depending on the doctor, maybe an e EKG is needed. Meaning your heart needs to be checked out before we do it because we're going.

Put you on something that, the way I like to describe it, it's like you're having a bunch of cups of coffee so we don't want anything to be going on with your heart.

Again, there's many other things that go into this, and I think another thing that that has become challenging with this medication is that because it's in that stimulant category, it's a controlled medication, so you're not gonna be able to get this through most telehealth services because if it's remote, they're not seeing you face-to-face and there are lots of laws some of them had been relaxed during the pandemic, so they were able to do that.

But, coming up in the coming months, you need face-to-face visits For this, you really need to be followed up. I mean, there's no universe where I have someone on phentermine and I'm not listening to their heart and really following things closely. So, Kind of, yes, it's cheap. Yes, it works. It's an option if nothing else is covered. But there are so many drawbacks if there's a heart history, if it causes insomnia, side effects.

So there's just a lot to look at with it, but it's been around a long amount of time. The next one that I wanna talk about is called Qsymia. Qsymia is actually a combination of the one we just talked about, phentermine Plus Topiramate, or Topamax, might be the other name that you know that. So it's a combination. Medication. This one may be about, again, 10% weight loss. Something that I think is really good to look at as well is when you hear those numbers, that's the average.

But when you look at the studies, when they break it down, there will be a certain percent that have been able to lose 20% of their body weight. So with this medication, about 15% can lose 20% of their body weight. And so I'll keep kind of comparing as I go forward. what those numbers look like for future ones, and you'll see that it gets higher and higher as far as the percentage of people that can lose significant amounts of weight and keep it off.

So this, Has been around about 10 years and the problem that I see the most with this, yes, it can get great results. It's like, here are my thoughts. someone either does great on it, it's amazing. Or the thing I hear the most about it because of the, the combination of it, it's this brain fog. It tends to be something that people just really don't like experiencing that brain fog and so if that's something that happens, it's just really something that people don't wanna deal with.

The other thing I will say is that, and this goes for saying about all of the medication, but especially with Qsymia, because it has that topiramate in it, it is very contraindicated for pregnancy. So you can get birth defects. The babies can get cleft lip and palate. This is really serious. We do not want that to happen.

And so definitely this is something that, always, if there's a young woman, there needs to be a birth control plan, but especially for this, again, realizing that also if you have a history with kidney stones, this is not gonna be the medication for you. Again, we're not getting into all the side effects, just kind of the big things that I look at for that. The next medication is called contrary, and I forgot to say that.

Phentermine, Qsymia, and now Contra, they are all oral options, so tablets that you're gonna take. So Contra is actually has two ingredients as well. So again, it has, one ingredient that is called Bupropion. The conventional name of that that you might think of is Wellbutrin. And then the other ingredient is Naltrexone. So Bupropion we tend to think of as, Something that we might use for treating mood, we might use it for tobacco cessation.

And then naltrexone, you might hear about it with helping with alcohol use disorder or, opioid addiction. So there's different use for both of them. It's about maybe a 7% weight loss. Again, where I see this being the most helpful is with cravings. So when someone. tells me, okay, you know, after dinner, they always want something sweeter at night. They always want a snack. I find that this is the medication that usually will move the needle the most for them.

And again, just like qem, I see that there are either people where this helps or it doesn't so they're, maybe it's that there was already like a slight underlying depression that wasn't treated and they get on this and they feel better or that it's actually helping with those food thoughts. But one of the pros that I really see, it's decreasing those food thoughts all the time.

I had a patient that literally sent me a message and said, I just can't even believe that this is possible within a few weeks of slowly titrating up on the dose. The other thing that's really nice about Contrave and also the medication before this Qsymia, but with contrave is that we can make generics of it. If the name brand is not covered, I'm very familiar with sending in for my patients the both of the medications independently.

The only thing that we really need to look at with that is that we're trying to mimic the extended release state of the medication, the brand name itself, but. We need to sometimes be using generics because unfortunately, the insurance industries don't wanna cover these medications. They still see obesity as an aesthetic problem. They do not see the medical necessity and it often, which is ridiculous on its own. But again, we need to have options for people.

One thing I'll say is that you, we really need to be careful here. If you're someone that your, alcohol patterns don't permit this, it will not be a medication for you. The other thing is if you are on chronic opioid pain medications, the naltrexone part is gonna block that. And so that's not gonna be a medication for you. So again, this is where we look at what are the medications that you're on all the time, and then we adjust according.

The next category that we're gonna talk about are called the GLP one Agonist, that family. So there are definitely several in here. This group of medication, majority of them are going to be subq, meaning right under the skin. It's going to be, the smallest injection ever. There is one that is gonna be an oral option, however, it's not as effective. And, again, we'll, we'll talk about that more. But majority of these are injection.

So FDA approved, you're gonna hear the name Liraglutide, that saxenda back in the day to diabetics, it was sold as Victoza. It is still being sold as such, but again, Victoza, if it's diabetes, Saxenda, if it's FDA approved for weight management, we see about 10% weight loss. And again, it's been around a really long time. It's been used since 2010. So this is when, I'll give you the example.

When people say, oh, this is an entirely new medication when everyone's only been talking about ozempic, right, which we'll talk about in a second. These medications have actually been around a long time actually GLP one s even before that with another medication. And so it's, they're not exactly new to the market. We've had over a decade with safety testing with this. So again, that Saxenda is actually a once a day injection. And then we have the other category, it's called Semaglutide.

Again, if it's FDA approved for weight management, it's called Wegovy. If it's for treatment of diabetes, it's ozempic. And then the oral route of semaglutide, is the medication ri bsis. So that medication we step up. It's about 15, 16% weight loss. So that's even better right now. Remember we talked about how many can lose 20% of the body weight, about 35 to 40%. So you see how we took that step up from the medication I talked about before to now.

So again, you get the GLP one medications, the amount goes up. The difference here is that something like Saxenda is a daily injection and then semaglutide with Wegovy. That one is actually a once weekly injection. The really nice thing about these medications that they're gonna delay stomach emptying, so you're gonna feel full quicker, and you're also gonna get the enough signaling in the brain so that you're not sitting there thinking about food all the time.

You actually feel satisfied, which is something that many of my patients have honestly never experienced. A lot of this breaks down to insulin resistance and leptin resistance. These are hunger hormones. Again, we'll talk more about them coming up. These medications are solving a real physiologic need that we have with the chronic treatment of obesity. Not only are they affecting the stomach as well as the brain, but they also have a lot of other positive effects, such as for the heart.

One of the pros that I look at here is how many positive things it's impacting on the body, the higher weight loss. The cons of this medication, unfortunately, price. Okay, so it's like insurance. they don't wanna cover it, even though they have all the literature of people being able to lose the weight and keep it off that they've never been able to do in the past. They just care about monthly what the cost is.

And the other thing that would be a con here is some people, they just won't be able to tolerate the GI side effects. Maybe they're gonna feel sick on it. Now what we do see is that the longer you're on the medication, The more these side effects go down. And also if you have the proper education, when you start them, how to hydrate, how to eat, what to do. I find that that's a lot better. But I find that people that typically don't tolerate it, it's because they had no education.

They were, they got this medication written for, they picked up at the pharmacy. They didn't know how to change eating or what to do, and then they failed the medication. But again, some people, even if everything, right? They just can't tolerate it, and that's okay. Not all medications are gonna be tolerated by everyone, so. So now we're gonna just talk about a last few medications. There's another one that a lot of weight management physicians have been using. The name of it is Tirzepatide.

The brand name is Mounjaro. Again, it's about 22% average weight loss, so that's very exciting. And hopefully in the coming year here, they're gonna have that FDA approved for weight management. I know those trials are going through and what's incredible here is that. If you look at bariatric surgery, those numbers that you get with Tirzepatide, they're actually starting to be close to what you see with bariatric surgery.

So that's really amazing that we have medications now that can mimic surgery. Not that it replaces it Okay, so we're gonna have another conversation coming up in the future. Surgery is still an amazing tool at a certain time for a certain person. Maybe before or after medications. We're gonna talk about a lot of that more in a upcoming episode. The next medication that we have on here is something called Plenity. Now, Penity is actually a capsule that you take with water.

You take it before meals. It's a hydro gel that increases your fullness with meals. It's basically like taking a bunch of fiber. They have coupon codes for this. I don't really use it that often. I think it's a nice maybe addition for certain things, but it's sort of, again, for the right person, for the right place. The one thing about penity that's unique is that it goes down to a BMI of 25 that it's indicated for. So this sometimes is for people that have lower amounts of weight to lose.

They still want something. They really don't qualify for many things. Again, like we talked about in the beginning of the episode, I don't wanna discredit anyone, if you really sit down and hear someone's story, there are many people that they still have some weight to get off. Maybe not as high than numbers, but their, their life is still significantly impacted by it.

So sometimes plenity, can be helpful in that scenario or as an add-on to other medications, which, again, we'll talk about Next's episode as well. But sometimes it can be that, that addition. There are only two, well, three more that I wanna talk about here. So real quick, Orlistat is one that limits fat absorption. It's over the counter, it's half strength compared to what the prescription is. The problem with ORs stat is that it causes it because it's blocking fat absorption.

It can cause a lot of greasy stools and things like that. And so I find that it's only helpful sometimes if someone's having a really bad constipation from a GLP one. Sometimes this can be added to kind of balance that out. Again, I'm not doing it very commonly. I know some doctors are really into it. It's typically a really old medication that's really not used that often. Something that I don't enjoy about it is because it's blocking fat absorption.

You can sometimes get vitamin deficiencies because you're not able to absorb those properly. So there's a lot more monitoring that needs to go in if you use it. That's why I'm just not such a fan of it. The other one that's on here is Lizdexamphetamine. That's goes by the name Vyvanse. That's FDA approved for treatment of binge eating disorder. Again, we'll talk about that in the future. That is something that can. Very effective for that.

Again, it's a controlled medication, so it really needs to come from the right provider, face-to-face. Some doctors are just not as comfortable writing for it for different reasons, and so although it is great, it's FDA approved, it's likely, I don't think being used as much as it could be. And then the last one that I wanna talk about is metformin. I don't even think about it as a weight loss medication. The weight loss percentages is if you, if I tell you 2%, you're gonna laugh at me, right?

But sometimes if there's significant things going on, such as insulin resistance, if we're not helping with some of that, it's very hard to kind of move the needle on other things. So this is sometimes used for many different reasons, but you will see it kind of used in these arenas. So the question that I sometimes get is, do we combine these medications? Yes, we do. What I want you to keep in mind is things need to be in different categories.

So for example, there are plenty of people where, let's say they're on a once a week GLP one medication, let's say they're on, Wegovy. And they reach the 15% weight loss and they're kind of stalled out there and they're doing all the lifestyle changes and they're doing all, all the other things and they kind of can't make progress.

Then I might talk to them and I might find out, you know what, they're really starting to struggle with, urges and cravings for certain foods at certain times, and we might look at those patterns and see, oh, adding Contrave might be a really good option for them and that might work great. So there are a lot of patients that might be on combination medications. Again, not that that's right for everybody.

The other thing too that I didn't mention is I will also look within the first few weeks and months of someone being on the medication, if we're titrating up or we reach wherever the correct, dosage is for them. And if they're not losing weight or not losing appropriate amounts of weight, right? They're not losing at least three to 5% or whatever it is. Why would we keep the medication around, right?

We don't wanna increase risk for side effects, and you're not getting all the benefits that we would expect. There are people where I will remove a medication if I don't feel it's helping them. Okay. So that is what I have for you right now. So part two is gonna come next week we're gonna talk about a lot of other questions, a lot of the hot button stuff. So what about if I stop the medication? Does weight gain recur? What about if I've had bariatric surgery before? Can I still qualify for meds?

Where can I find a physician that's going to help talk me through this and help me on this and not just sit there and judge me And. Stigma and bias and kind of have outdated practices, right? So I wanna go over all of that with you, and I have a bunch more questions that we're gonna go over. I really want to encourage you right now, if you are liking this, you're enjoying this, please make sure to hit subscribe, share it with a friend maybe that you think would like this episode as well.

And then I wanna ask a really big favor here. Can you please leave a written review if you are loving listening to this? Really helps to get the word out to other people so that we can help to change the narrative on this and get everybody the information that they need. All right, talk to you next week.