"Reach out for Help" - Metabolic Health (Part II) Artwork

Primary Care Pearls

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Primary Care Pearls

"Reach out for Help" - Metabolic Health (Part II)

January 23, 2023 • Primary Care Pearls (PCP) Podcast • Season 1 • Episode 15

In this episode, Dr. Vasudevan and Dr. Moreno explore the ever-expanding treatment options for Obeisty, and our patient tells us about his experience with some of these interventions.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Lifestyle Changes (Diet/Exercies)
3. Chapter 2: Weight Loss Medications
4. Chapter 3: Bariatric Surgery
5. Chapter 4: Advise to Young Clinicians and Fellow Patients
6. Conclusion

=== Learning Points ===

Lifestyle modifications need to be tailored to the patient. This often involves starting with a careful dietary and activity history and helping the patient incorporate small, healthy changes that are congruent with their cultural background
There are multiple medications available for weight loss and selecting the right one requires knowledge of a patient's comorbid health conditions, as well as taking into account their personal preference. Side-effects tolerance cost, and or insurance coverage
Recognize how to counsel patients on when it may be appropriate to pursue bariatric surgery and what they can expect following the procedure.
The most important step in helping patients manage obesity is by starting the conversation and letting patients know that you are there to support them along every step of the way.

=== Our Expert(s) ===

Dr. Jorge O. Moreno is an Assistant Professor of Medicine at Yale School of Medicine.

Dr. Moreno is originally from Mexico and is also fluent in Spanish. He grew up in New Rochelle, NY and completed his undergraduate degree at Columbia University in 2006. In 2011, he obtained his medical degree from the University of Rochester School of Medicine and Dentistry. He completed his internal medical residency at the Yale University’s Primary Care Residency Program Yale New Haven in 2014.

=== References ===

Heymsfield SB, Wadden TA. Mechanisms, Pathophysiology, and Management of Obesity. N Engl J Med. 2017 Jan 19;376(3):254-266. doi: 10.1056/NEJMra1514009. PMID: 28099824. https://www.nejm.org/doi/full/10.1056/nejmra1514009
Wilding, J. P. H., et al. (2021). "Once-Weekly Semaglutide in Adults with Overweight or Obesity." New England journal of medicine 384(11): 989-1002.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Maisie Orsillo
Producers: Helen Cai, JW Allen, August Allocco
Logo and Name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Corbyn Kites, Quincas Moreira, Jesse Gallagher, Patrick Patrikios

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on your favorite podcast platforms: linktr.ee/pcpearls

Metabolic Health Compiled Episode (Part II)

Introduction

[00:00:00] Maisie: Hi, welcome to primary care pearls. A podcast made by learners for learners. And most importantly led by our patients' stories.

[00:00:12] Patient: I always assumed drug intervention for weight loss was things like amphetamines and I've learned so much that it's not, there are so many different other drugs out there that can help with weight loss that aren't related to stimulate.

[00:00:30] Maisie: Today, we will be talking about weight management, part two in our metabolic health series

[00:00:37] Anita Vasudevan: I think that more and more we're realizing as clinicians that we have to leverage all of our resources, including pharmacologic and options for the management of obesity.

[00:00:48] Maisie: over the last several years. The way we think about obesity has changed. Weight loss and diet control are a $71 billion industry in the U S in the past, several companies have taken a shot at a slice of these profits by touting magic weight loss pills that often did not have any research to back up their claims.

[00:01:08] However, recently it appears that we are indeed moving toward making magic pills and more reasonable reality for a select group of patients.

[00:01:17] During our discussion, we'll be joined by a patient, living with obesity, fill

[00:01:22] Patient: I am 53 years old. I have been in Connecticut for a few decades originally from Colorado.

[00:01:29] Maisie: through his experience. We'll learn more about his initial thoughts on weight loss, medications, side effects he experienced and how he approached his decision to pursue. We'll also be joined by an expert from the Yale school of medicine

[00:01:44] Jorge Moreno: my name is Dr. Jorge Moreno. I'm an assistant professor of medicine here at Yale school of medicine.

[00:01:49] Maisie: With the conversation facilitated by our resident interviewer, Dr. Aneetha foster Deyvon

[00:01:55] Anita Vasudevan: my name is and I'm one of the residents in the Yale primary care program.

[00:02:00] Maisie: and our medical student interviewer, Helen sigh.

[00:02:03] Helen Cai: my name is Helen. I'm a student here at the Yale school of medicine

[00:02:06] Maisie: Our discussion will explore the relative efficacies of different lifestyle modifications, FDA approved options for medications prescribed for weight loss and criteria for bariatric surgery. My name is and I'll be your host for this episode. I am a second year resident in the Yale primary care internal medicine residency program.

[00:02:31] We hope that through this discussion, you'll grow more confident in recognizing patients with obesity, develop approaches, to discuss weight management with patients in a way that makes them feel comfortable and also gain an introduction to treatment options for obesity. So before we get started, please know that this content is meant for learning and entertainment purposes only, and should not be used to serve as medical advice.

[00:02:56] If you, or a loved one is struggling with any of the topics discussed in or related to today's episode. Please be sure to discuss it with a licensed medical expert. Now let's get on to the show.

Chapter 1: Lifestyle changes (Diet/Exercise)

[00:03:10] Helen Cai: we're in Colorado. Where are you from?

[00:03:11] Patient: Colorado Springs,

[00:03:12] Helen Cai: Colorado Springs. I've been there a few times

[00:03:14] Patient: with the Rockies.

[00:03:15] Helen Cai: Oh yeah. There's I don't know how closely tied you are with Colorado pop culture at the moment, but there's a big green chili feud between New Mexico and Colorado.

[00:03:24] Patient: That's not new. That feud has been going on for many decades,

[00:03:28] Helen Cai: so many decades. Yes. I, I believe it's uncontested, but I'm sure you and I can talk about that at some other time.

[00:03:34] Maisie: In our last episode, we spent time understanding obesity, both through the patient's personal experience and how he defined it clinically. Today, we are transitioning to discussing practical ways. We can help patients move towards a more healthy weight. There are many ways we can support patients in achieving this, but the method that is within reach for most people is to start with lifestyle changes.

[00:03:59] Helen Cai: what do you like to do in your free time fill?

[00:04:00] Patient: it usually involves some sort of food or booze.

[00:04:03] I love to smoke smoking is, probably the biggest part of my cooking. I love to smoke meats and vegetables. I've, I've gotten into trying different things with cauliflower. For instance, I smoked Mac and cheese. I smoked things that people didn't think you could smoke. I just, I love. And I love to experiment with different things and try different things.

[00:04:24] what I've been trying to do is apply my love of cooking and my love of experimenting with how can I do healthier things. And, you know, I mentioned cauliflower, so that's one of the things, you know don't fry it, don't slather it in butter, smoke it with some season.

[00:04:42] I've tried weight Watchers. I've tried to spoon SlimFast. I've gone to the gym. I've done good on those. I've done that on those. It sounds so cliche, but it has to be a lifestyle change. It can't be a diet that restrict your calories for. It's seven months until you get to your goal weight, and then you just eat whatever you want. It needs to be a way that you can figure out how to eat and keep eating that way and at 53 years old, I'm still trying to figure that.

[00:05:12] Jorge Moreno: I do a really thorough diet history. What they're, what are they eating for? Breakfast snacks. What are their drinks? A lot of people say I don't eat a lot, but I'm drinking a lot of high calorie drinks. So you really have to be aware of that. So those are like, I go through that first, their diet and then also their lifestyle in terms of their work and home.

[00:05:36] Right? Like what are, what are they doing at home? What are they doing at work? Some patients I've have surprised to hear that they're nighttime workers. Right. And not surprised, but like that really affects everything. Like if they're working nights and, you know, nights are not easy for you residents, right?

[00:05:51] Like we're, we're eating just to stay awake sometimes at night because it's not natural to be up in, you know, at two in the morning. However, some patients have that schedule because. Their work.

[00:06:05] Anita Vasudevan: How do you work with patients to understand what modifications that their specific lifestyle needs?

[00:06:12] Jorge Moreno: it's patient tailored as an example, I had a patient recently that really never cooked at home. Always would it be eating fast food? And, and again, I don't want to make it, it's not all about the diet. It is an important part of weight loss, but when you can make these big changes, it will result in big results.

[00:06:33] So, you know, one of the first things I, I basically worked on the patient is let's talk about. Increasing the variety of your foods, right? Like it can not just be the same thing over and over again. Just trying to increase his fiber intake, trying to increase his water intake, trying to decrease the high caloric density foods really helped him because he was kind of stuck on this pattern of fast food, fast food, fast food.

[00:07:01] And so just trying to teach him that there's other food, even if you cook the same food at home, it would have way less calories because as we know that they're just loaded with calories in some of these fast food. But back to your question about what I do, it's. Patient-centered like like you have to talk about their culture right.

[00:07:22] Because sometimes you know, we say stop eating bread and pasta, but if the patient doesn't eat bread and pasta, if they're eating maybe and beans, because they're from Puerto Rico, they're have tortillas because they're from Mexico or they're doing a combination of everything. Cause they're, they're from different backgrounds.

[00:07:38] You just have to know what they're eating. And so you really will be more effective if you kind of do this with the patient. Like over some time getting to know what their lifestyle is at home. And so that's what I typically do.

[00:07:54] Patient: Cauliflowers just one thing, you know I've, I've learned that, you know, I can get by without carbs. For instance, I'm not a low carb guy. I'm not a keto guy, but you know, we. Italian type dishes in my house. We're not Italian, but we love Italian type dishes, but honestly, if I'm making my own spaghetti sauce and my own meatballs, I'd rather put that over some roasted broccoli or cauliflower, then over pasta. I, I find that to be a richer taste and then maybe have a piece of garlic bread. Instead.

[00:08:24] Some of the sustainable changes, aren't so much an action or an activity, but a brain. In the past, it was always, well, I had a donut this morning, so I'm just going to throw the whole day out the window. And that can't be your attitude. It's never an all or nothing. It's never an either or it's. Yeah, I had a donut. Okay. I'll make a better choice for my next meal. you know, I just heard this today from my husband, the days divided into quarters morning, noon, afternoon night. And if you screw up a quarter, it doesn't mean you have to screw up the other three. Don't let perfect be the enemy of good

[00:09:08] In July, when I decided that I needed to up my game on the weight loss, I went into the gym and I. Stack cash down and said, give me a membership for a year and give me three months of training twice a week.

[00:09:25] And the training coordinator says what your goals? I'm like, I need to lose 35 pounds so I can have my knee replaced. She was like, oh, I've got the perfect trainer for you, Natalie. She's awesome. She's trained a guy before who had to lose weight for knee surgery.

[00:09:38] Perfect. This is great. Schedule me with. At 5:00 AM on Tuesdays and Thursdays. So, yeah,

[00:09:49] Helen Cai: I can't believe we talked about Natalie until now, but what are, what are some of the other great things that you love about your relationship with Natalie?

[00:09:55] Patient: Natalie and I have this great relationship. We hate showing up at five o'clock in the morning. The first time she met me, she really hated me because up until then, her first client was five. But now I've got this great relationship with an awesome trainer who gets me out of bed twice a week.

[00:10:12] I didn't even know there was a 5:00 AM and you know, I finished with her and I feel great and I feel stronger for the day. She pushes me really hard. But she's also so adaptive, like this morning's workout was supposed to be a circuit in the trainer cage and they had to evacuate the building because of a gas smell.

[00:10:36] So she grabbed the exercise bands and she told me to grab a medicine ball and I'm out there in the parking lot, slamming an 18 pound medicine ball down and, you know, pulling on exercise bands while everyone else is standing around doing nothing. I got my money's worth out of my training session this.

Chapter 2: Weight Loss Medications

[00:10:53] Maisie: alto lifestyle tends to be first-line let's face it, changing our lifestyles can be really difficult. Life demands. A lot of us between work childcare responsibilities and day-to-day tasks. It can be a challenge to prioritize health and weight. Getting regular exercise or preparing healthy foods. These things take time and energy that sometimes we just don't have.

[00:11:18] Further lifestyle changes don't work for all patients as our patient astutely pointed out certain diet or lifestyle programs that are promoted to the general public are not right for everyone. Even if these changes can be made and sustained for a period of time, it doesn't always lead to sufficient weight loss to reduce the risk of health consequences.

[00:11:38] At the stage, clinicians often need to discuss some adjunctive therapies with patients, such as medications.

[00:11:45] Helen Cai: you mentioned a little bit earlier in our conversation that at first you were maybe hesitant to try medications for your weight loss, or maybe had a different perception of them.

[00:11:55] And so how has that perception changed?

[00:11:57] Patient: Well, now that I've had my eyes opened about the different options about medication and weight loss. I know that I know that there's at least four or five different avenues of, of weight loss medications. You can approach and different ways that you can do things.

[00:12:13] And that I used to think that the ways of weight loss were diet, exercise, scary drugs, or bariatric surgery. And I know that now it's diet exercise, a whole menu of pharmaceutical options and bariatric surgery. And it's not any one of those that could be, it's like a buffet, funny saying a buffet where you talk about weight loss, but you can pick and choose because no one answers right for any one person.

[00:12:50] I, I was pretty knowledgeable about the diet and exercise, and I had done a lot of research about the bariatric part before I engaged in that process. Seven years ago, when it came to the pharmaceutical options, I didn't really have a lot of knowledge and I never really sought it out until it was kind of put in front of me and they said, you're willing to try this. And I'm like, What does it do? What are the side effects? And when the side effects, weren't that scary? I said, that's not going to do much, but sure. And lo and behold, it did stuff and it wasn't scary.

[00:13:25] Anita Vasudevan: how frequently are your patients achieving their goals with lifestyle changes alone versus needing like adjunctive therapy with the surgery or from a collegic.

[00:13:34] Jorge Moreno: So here, this is where the patient autonomy really comes in. they're at different spectrums a lot of them, some of them are like at the very beginning of the thought process. And they're like, I just wanted to know if I could change some factors in my lifestyle, whether it's activity level or or their eating or their mental health, or like they really want to address these things first.

[00:13:55] So then I tell them that, obesity is very complex and there's various factors that are contributing to this. And so if, if they're, if they're open to I recommend a weight loss medication that would be appropriate for them taking into consideration their chronic medical conditions if they have them.

[00:14:16] And so I, I do mention it and you have to be willing to have two types of conversation that no, I don't want it, and then the do you think that at this stage I need to do a weight loss medication.

[00:14:28] just to kind of go back to the logistics, a little of, when do you recommend weight loss medication? So a BMI greater than 30, you can prescribe weight loss medications, a BMI greater than 27 plus a coexisting condition. You can prescribe weight loss medication. So, so those are like the bare bones criteria for that.

[00:14:48] some patients come to me and they're like, I don't want to try meds. I don't want to do this, but I want to go to for surgery and fine. Like don't. Don't avoid the conversation because you feel they should try something first. I mean, yes. You have to help guide them.

[00:15:06] Yes. So of course, if there's a patient that X, many reasons doesn't meet bariatric surgery. Try to help them get the information they need making a final decision.

Do you happen to be on a medication regimen right now?

[00:15:20] Patient: I am I'm onto pyramid, which is what I was put on a year ago by my original PCP and Dr. Murano's kept me on that.

[00:15:29] Anita Vasudevan: How do you factor in patient's co-morbidities when you pharmacotherapy

[00:15:34] Jorge Moreno: if a patient has obesity and diabetes, in my book, they should be on a GLP one agonist, unless they have some contra-indication for it, whether it's malaria, thyroid cancer, or some sort of pancreatic cancer, whichever extremely, extremely rare.

[00:15:51] Maisie: There are five major classes of medications used to treat obesity that will be discussed. The first R G L P ones or glucagon-like peptide one receptor agonists, such as semaglutide or liraglutide.

[00:16:10] Jorge Moreno: so the, the, the GLP one agonist have been proven to be very effective at weight loss. Some downsides is that they're injectables, right? So there's two agents that are approved for weight loss that or GLP one agonists Victoza, which is a brand name or their Achla tide at high doses are approved for weight loss alone. At lower doses, is approved for diabetes alone. But even at low doses for diabetes, it will produce weight loss. So the Architizer is a great agent and the brand name of liraglutide for weight loss is to send them.

[00:16:46] Patient: so we tried a couple of different options. Like maybe I could fall back to Olympic, but I got declined cause I'm not diabetic. And at the diabetic specific. Whereas go V is specific for weight loss. So now I finally, today, while I was on the drive here, Saxenda got delivered at my house. So I'm going to start that tomorrow.

[00:17:06] Jorge Moreno: So the newest kid on the block, which is a year and a half, but it was just got approved for weight loss is semaglutide. So semaglutide at low doses is and it's used for type two patients. Even at low doses, again, it has been proven to help with weight loss. And then the higher dose is called Weatherby and Weatherby was approved in June of 2021 or middle of 2021 and it was so popular that it's, it was out of stock pretty quickly.

[00:17:39] Patient: I was put on a web TV in July when it came out shortly after it came out and I was halfway up the titration scale when I couldn't get the next titration schedule. Even today you can't get a dose.

[00:17:53] Jorge Moreno: Okay. So what, so why is this important? whenever the patient loses weight it changes a set point and there's forces counteracting that weight loss. And so you're going to have increase hunger you're going to reach a plateau. You're not going to be able to lose more weight. And so all of these forces are trying to reset the set point so that you go back to the old way because it's being protective of you because you're losing weight, right.

[00:18:21] That's kind of the biology a little bit simplified, but with the GLP one agonist, you are preventing that set point from being the high step point, then you're creating basically a new set point.

So GLP one agonist have signals in the gut to increase the tidy so you feel fuller longer. They also work in the hypothalamus and in the brain circuit that really affects appetite. And so they're decreasing appetite. And so peripheral and central GLP one agonist. So they're targeting two of the main areas of of the body that are, are going haywire when patients have obesity. So now you're re introducing something that is shifting the patient's ability to eat. So

[00:19:12] You know a lot of people say it's all about carbohydrates or it's all about the proteins, but it's, it's more than that. It's not just macronutrients. It's not just. There is a biology behind it. And these GLP one agonists have been proven to be very good. .

[00:19:26] And I'll just finish off about this, in order for a medication to be approved, it has to prove that you've lost 5% weight by the FDA in a majority of the patients in a, in a period of three to six months, just so that approved almost 90% of the people in the study for semaglutide and there was thousands of people in this study lost 5% of their weight.

[00:19:49] But the cool thing was that a third of them lost 20% of their weight which is like totally off the charts compared to other medications. If we talk about bariatric surgery, which is the most weight loss that we can typically get right now, it would be expected 30% about weight loss with, with bariatric surgery.

[00:20:09] So one medication could potentially create a change in weight of 20% and that semaglutide it's just that, that kind of remarkable. And so the other thing is that it was safe. Like they, they had some side effects, like GI side effects. Some people get nausea, some people get diarrhea, but after a couple of weeks being on it, the side effects resolved.

[00:20:33] Maisie: The second is a combination medication Welbutrin naltrexone.

[00:20:37] Jorge Moreno: Welbutrin which is an antidepressant and naltrexone, which is an opiate antagonist.

[00:20:43] And so that the combination works in neurons in the hypothalamus, the arcuate nucleus. there are these neurons called the POMC neurons. These neurons are activating to reduce appetite and so be appropriate, activates it. And I'll Trek sewn prevents the negative inhibition of that.

[00:21:05] So again, resetting the set point and so individually they can cause some weight loss, but together they're more effective at weight loss. That's why that combination works.

[00:21:16] Maisie: The third class of medication is in the stimulant class fender mean

[00:21:21] Jorge Moreno: phentermine has been around forever. And a lot of people have hesitations because it's a stimulant and some of the common side effects are increasing heart rate and increasing blood pressure

[00:21:33] Patient: racing, heart, high blood pressure difficult to concentrating shakes. And I started experiencing this five or six weeks after it happened. And I reached out to her and the team here and I think it was my original PCP who got back to me first and said, yep, you're right. Stop taking this. And because of how quickly it dissipated. It was really just a stimulant reaction. we found out very quickly, the stimulants do not work successfully with me. I mean, I lost weight, but it wasn't worth it for, for the the secondary effects it had on me.

[00:22:07] Jorge Moreno: In younger individuals I have, in my anecdotal clinic experience, I haven't seen elevations in, usually I use the phentermine in younger or individual younger patients where individuals that have no coexisting cardiac conditions.

[00:22:23] Maisie: the fourth type of medication is another combination using fenfluramine in combination with Topia.

[00:22:30] Jorge Moreno: to pure mate combined with phentermine is another medication that is, is also helpful. To pyramid modulator, Gabba in the brain and it can create some decreased appetite effects, Phentermine does the same. You remember to pure made can cause sometimes cognitive slowing. And so they thought combining it with phentermine would be helpful in that. And I have seen that patients do Well

[00:22:55] Maisie: And the fifth and final medication is a lipase enzyme inhibitor called Orlistat

[00:23:00] Jorge Moreno: one medication that I haven't mentioned is or the step. Or list that is a light pacing enzyme. It basically doesn't allow you to digest fats. And so it's over the counter or there are prescription strengths for it, but the side effects of it are too strong for patients to tolerate very long. They have fatty stools. So not many patients will opt for that medication. I just wanted to mention It

[00:23:24] Anita Vasudevan: You prescribe medications, how do you know that they're for your patients? And do you ever prescribed additional loss medications that people are on two things at the same time?

[00:23:37] Jorge Moreno: You want to keep a patient on a medication where they have lost 5% of their way within the first three to six months. Really? That's kind of a successful story, right? 5%. And why is the 5% important is because that's the minimum weight loss to see a clinical effect in blood pressure, hemoglobin A1C lipids. And so 5% you can see a clinical difference. That's the criteria I use to think about the stopping and if, if it's not if it's not been helpful in them if they've reached five or 5% or more I don't stop the medication. I kind of do a step wise at adding of it. So for example, someone with diabetes, if I prescribed semaglutide and they started to plateau, I may add re-appropriate naltrexone if, if you know, they meet the criteria for it and then continue to see how they do on that. And if they, they tolerate that, you can even add a third agent. So it's it's step-wise see where they are and what indications they have for them and what coexisting conditions they may have.

[00:24:42] Just to kind of follow up on that question, Do you stop the medication? I get that question a lot. And just like I alluded to in the beginning, let's say that you had a patient with diabetes with a hemoglobin of 10%, right?

[00:24:56] You gave him the insulin, you gave him a sandbag. You gave them whatever Metformin you gave them, all the meds that you would normally give. And now their hemoglobin A1C is 7%. Now, are you going to stop the diabetes medications? Because they've reached their goal. The answer for diet patients with diabetes is no, right?

[00:25:16] Like we don't stop. We don't even think about stopping them. They're controlled. We're happy. Their hemoglobin is seven. So if somebody is on, let's say two or three medications for weight loss, and they've lost 180, hundred pounds over a year or two year period, why would you stop their medication? We know that there is a, biological basis there is something you're targeting in the brain and the gut, the GLP one, or you're targeting the POMC neurons. You're targeting these areas that are affecting appetite and energy balance. Why would you stop their medication? So right now that's, that's kinda how I think of it. If, if it's helpful, it's not causing problems, they're not having side effects. Which usually are only at the beginning. Then I go ahead and continue it. As long as they're doing well.

[00:26:06] Patient: The experiences with trying to get the drugs were. Extremely demoralizing though. Those were experiences that were almost like, just make you want to throw your hands up.

[00:26:19] Maisie: because many of these medications are still new to the market. Patients can often face large and frustrating barriers accessing them.

[00:26:26] Helen Cai: are there any other kind of like large barriers to your care that you've been experience?

[00:26:31] Patient: some of the, some of the barriers kind of fall outside of the care team. My mail order, pharmacists, they require insurance pre-authorization for some drugs. So he sends a script in, it goes in, they send a note back to him, but they send a note back to him at his old office. They don't have his updated contact information. That was a horrible experience. I had two prescriptions that didn't get fulfilled because of that.

[00:27:00] Jorge Moreno: Lately it starting to I've seen a little bit of a shift insurances have started to cover a little bit more than I I'm surprised by. So first things is just, if they have a comorbidity, you should document that. In addition to the weight, the BMI that you're prescribing this for. So for example, if they have diabetes or even pre-diabetes you can add that to the indications for liraglutide and semaglutide because then it's more likely to be covered by insurance because they, they they're approved for those purposes.

[00:27:35] It becomes tricky when it's a weight loss alone. Right. So liraglutide semaglutide are very expensive. So if they're not because they're injectable, if they're not covered, they're not covered. However, I failed to to mention that some of glue type has an oral formulation that sometimes has better coverage than the injectable.

[00:27:53] The injectable for semaglutide is once a week. And the oral for semaglutide is once a day. So you might find that some insurance has covered the oral, but not the injectable. That's another little tip. Contrave, which is Wellbutrin and naltrexone, it's also expensive if it's not covered by insurance, but it's actually Generic, but appropriate is, as you guys know, is generic and covered by insurance.

[00:28:19] Without really much of an issue on formulary and so is naltrexone. I usually use if the patient is not covered for contrary by I use it separately. And then the phentermine is generic at this point. It is a little expensive, but I use good RX for a lot of medication discounts and phentermine is one of the medications that's on there that has a big discount. And then to pyramid is also generic. So all these medications are usually generic.

[00:28:46] Maisie: So in summary, there are five major medication classes that we can choose from when helping our patients explore adjunctive weight loss therapies. It is important for us to think about the side effect profile in the context of each patient case, including the presence of specific co-morbidities to ensure patients are fully informed and to ensure the most appropriate medications are being used.

[00:29:12] So let's review our options. One more. First GLP one agonists that decreased appetite, increased satiety, and which have proven to be very effective agents and promoting weight loss. They are particularly useful if patients also have diabetes. Second Welbutrin naltrexone is a combination that also reduces appetite and can be useful for patients who have concurrent.

[00:29:37] Third is fender mean, which is another effective weight loss medication, but can come with side effects such as higher heart rates and blood pressure that may be intolerable for some patients. Fourth topiramate phentermine in combination can also be helpful in reducing appetite. And lastly Orlistat, which prevents the body from digesting fats, but often comes with difficult GI side effects, such as fatty.

[00:30:02] As we help patients decide which medication to try as providers. We are looking for at least a 5% weight reduction in three to six months to prove that the medication is effective for that particular patient.

[00:30:15] When we're not seeing a reasonable weight reduction with lifestyle changes or a trial of different weight loss medications, it may be time to consider a bariatric surgery.

Chapter 6: Bariatric Surgery

[00:30:25] Helen Cai: you did mention that you had some gastric surgery.

[00:30:28] Patient: Yes. I did have a vertical sleeve gastrectomy.

[00:30:31] Helen Cai: tell me a little bit about that experience.

[00:30:33] Patient: So that was when I had climbed up in weight to over 400 pounds and realized that something needed to be done. And it felt like something drastic needed to be done. I've tried all the other things we've talked about, you know, SlimFast and weight Watchers and this thing and that thing. And the gym and nutrition. I never seemed to be able to keep it off. And it felt like what I needed was something that would give me the boost.

[00:31:03] And regardless of which surgery you opted for at the time, They would give you a boost. And the idea was to take that boost, use that time that the method is working for you to learn new habits and carry on through the end of that.

[00:31:25] Jorge Moreno: For bariatric surgery, the criteria for bariatric surgery is a BMI Gruden 40 or a BMI greater than 35 with pre-existing conditions.

[00:31:37] There's a lot of pre-surgery checklist that needs to happen. Like lab work, all types of cardiac, endocrine, mental health, all the things that we talked about, they have to check off that they're in a stable condition to go through with bariatric surgery. But if the patient has already kind of gotten to the decision of may and they meet the criteria, I don't think it's our job to deter them from the, I think it's our job to give them the information that they need to make an educated decision.

[00:32:06] Right. Here at Yale, there are tons of information sessions for bariatric surgery that occur on a quarterly basis just to get them the basic information of what they need. So yeah, so I think that knowing this information you know, some people may have not thought that it'd be in my 35 would be eligible, but they are.

[00:32:24] And so that's something that as their doctor, you should be okay talking about. And of course, if they have a lot of coexisting conditions, they're there, the patient is not compliant with appointments. The patient is not does not take their medications. The patient wants a quick fix because bariatric surgery is a quick fix for them.

[00:32:45] Just letting them know that it is not a quick fix. That is life altering event that will change. Post-op right. Like they're going to need frequent monitoring. They're going to need to take vitamins. They're going to need to see the surgeon, see their nutritionist and follow a very strict diet initially.

[00:33:05] Patient: they were still offering bands at the time or some surgical areas we're still doing bands at the time, but not here at Yale. They were so out of favor now, but they were still doing bariatric or gastric bypass and vertical sleeve. Vertical sleeve seemed to be the most attractive one. It wasn't as quick of a weight loss, but it seemed to be more sustainable. It seemed to have less of a long-term side effects, long-term impact, particularly with nutritional uptake in the digestive system. So we, we, we did our homework, my husband and I both went through it actually three weeks apart. And It was a successful procedure. I recovered very quickly from it and very easily. I don't have any complaints about it.

[00:33:55] Jorge Moreno: You have to really understand what it means as the provider for the patient so that you can provide them all the details so that they know what they would be going through. And you're not the final say there you're the first person that sees them, but you have to be able to make that determination.

[00:34:12] Maisie: Although surgery can be a helpful adjunct in many patients, weight loss journey. It is not a perfect solution.

[00:34:21] Patient: I don't have any regrets about it at all. Without it, I don't know where I would have been. The fact that I got down to two 60 and then didn't continue is, is my failure, not the surgeries. Is one of those life get in the way things, probably an indication that I probably should have been in therapy at the time. You know, I've, I've got a lot of things. I got a lot of baggage and I think being in therapy is what's helped me be a little more successful this time around.

[00:34:51] Maisie: Weight loss surgery is a complex decision that requires a well-informed multi-disciplinary approach and one which has long lasting impacts as our patient and Dr. Moreno pointed out, there are specific dietary guidelines that must be adhered to and multivitamin supplementation that must be taken on a daily basis for life.

[00:35:12] It also requires regular follow-up with a weight loss specialist, surgeon, and primary care visit. There can be complications, post procedure, including the risk of regaining weight. Hence why weight loss surgery is not a perfect solution. That being said, weight loss surgery can be life-changing and very successful for some providing a weight loss boost that motivates them to continue on their weight loss journey.

Chapter 7: Advice to Fellow patients and Young clinicians

[00:35:41] Maisie: So as we wrap up our discussion today, we'd like to provide some last minute wisdom to our listeners who may be struggling with their weight as well as learners and practitioners, working with patients, living with OB.

[00:37:23] Anita Vasudevan: do you have any resources that you would recommend for clinicians to support their patients in weight loss goals?

[00:37:31] Jorge Moreno: you really should have the patient be aware of resources in their job. Because a lot of jobs now have programs or incentives for people to lose weight. They could have a discount at a WeightWatchers that you didn't know. I mentioned weight Watchers because it's a very it's a lifestyle change, but it's also and it's also kind of thinking about the psychology of eating and it it's, it's more than just like losing weight, but anyway, so there's various programs. The Y YMCA has a lot of programs that they may be eligible for. If they're older, there's also programs targeted for older individuals they're trying to lose weight and they have like uh, lower cost, gym memberships and things like that.

[00:38:18] In terms of like handouts and things, I find that there are some good information on like the CDC websites that they have a lot of good thoughts about some changes that they can make some guidance about diet, but also the health, I think it's obesity, Canada. I think that that's what they're, it's a government agency in Canada that I find their resources very helpful. Very easy to read, very patient friendly. And so they they talk about glycaemic index, which we didn't get to today, but it's just more info about helping your patient. And so those are some resources to do, but I also didn't mention that depending on the patient and where they are, I use some apps that are available for free, like my fitness pal and lose it. And that's really used more for the purposes of guidance like, oh, I didn't know that I was drinking 700 calories of juice a day and then not necessarily to like, be on a strict like calorie plan. Cause you know, we talk

[00:39:25] about that, but we want to Just give them about what they're doing so that those apps have been helpful more for educational purposes.

[00:39:34] So there's a lot of support groups out there. There's a lot of Facebook groups, running groups and all the patients are actually more versed in some of these groups than I am because they search for them. They, they find them in they do find them very helpful. Also family, right? Like, so if you have a family member that, you know, I have a lot of husband and wife teams that are trying to lose weight, they're cooked better. They work out together. I have a couple that actually went through bariatric surgery together.

[00:40:04] Patient: I think that having the support system I do now, lets me sit back and say, I don't have to be 220 pounds to be happy. I need to have my health. I need to be taken care of the things that are holding me back health wise.

[00:40:25] Jorge Moreno: Think of your support system because that's also who they see every day and that's who can help with. When they're in the rut, right? How to, or when they have a setback, how to support them through that. And you're always going to be there, but having that other person, oh, you want to come running with me or you want to come you know, make this meal today or whatever. I think that that's going to be also important in this multi-disciplinary way of really tackling their weight, managing.

[00:35:56] Helen Cai: is there anything that you would tell someone else who was struggling with their own weight or metabolic health?

[00:36:01] Patient: Reach out for help? Get it start with your PC. And if you're struggling with either being significantly overweight, or if you're struggling with an eating disorder and you're significantly underweight, you need to ask for two referrals. And one is two someone to help you with the metabolic side of that, and someone to help you with the mental therapy outside of that, they go hand in hand.

[00:36:32] I firmly believe that. And I am doing everything I can in my day job as an engineer with employee engagement, to make sure that the stigma of mental health goes away, people need to understand that getting help for an eating disorder or for weight loss or for mental health, it's, don't be ashamed of it because if, if you're still struggling with your weight, either an eating disorder or being overweight, if you're still struggling with that, that means that you need help. You haven't been able to do it on your own and you shouldn't have to do it on your own.

[00:37:22] Helen Cai: That's very powerful advice.

[00:37:23] Anita Vasudevan: do you have any resources that you would recommend for clinicians to support their patients in weight loss goals?

[00:39:25] about that, but we want to Just give them about what they're doing so that those apps have been helpful more for educational purposes.

[00:40:57] Helen Cai: Do you have any advice for any young future physicians who might be treating patients like yourself?

[00:41:05] Patient: Ask why.

[00:41:07] Just keep asking the question why, you know, I'm not saying that there's always some sort of childhood trauma or there's something else, but, but there's something going on

[00:41:19] Jorge Moreno: so you just have to kind of, you have to investigate or be a little bit of a detective to figure out what were the main triggers in this patient's life that really affected their weight gain.

[00:41:31] Patient: You know, they, they either are in an uncomfortable situation. They're in a crappy job. They might be in an abusive job relationship. I know somebody who's in a absolutely horrific job situation right now. This is an actual soul killer. And if you continue to do that, 40 50, 60 hours a week, it'll wear on you. Whether that's a job or relationship or how somebody treats you or acts towards you or how you treat yourself, it wears on you and you go to the one thing that makes you feel good. And what we're taught from a young age is here. Eat this you'll feel.

[00:42:26] I need to be working on my mental health and not just with therapy, but with recharging with my friends. And I need to make sure that I'm doing what I can to stay here and be present.

[00:42:44] That's what having a successful relationship with my weight means to me right now.

[00:42:52] Helen Cai: That's beautiful. That's very well said. Thank you for sharing.

Conclusion

[00:42:55] Maisie: Wow. I don't know about you, but I felt like this was really informative. I feel like discussing weight with my patients can be such a no pun intended heavy topic.

[00:43:08] Patients understandably can be sensitive about their weight, but are usually motivated to. But there are several factors that impact one's ability to manage way, including life or job stressors, mental health conditions, past trauma or grief, or the existence of other medical conditions. As Dr. Moreno discussed obesity is complete.

[00:43:31] It is not a moral failure, but a medical condition that we need to approach in a collaborative spirit with our patients. I think it can be really helpful to know that we don't simply have to tackle obesity through lifestyle changes, but that there are medications available to help our. Lifestyle modifications are of course essential and should be frequently reflected upon with patients as food choices and physical activity certainly have an impact on overall health.

[00:43:59] However, it is reassuring to know that we have additional tools such as the five key medications we discussed in our toolkit when it comes to tackling obesity and managing metabolic health.

[00:44:13] And that concludes our episode for today, as well as our metabolic health series. Here are some key points to take away from today's show one lifestyle modifications need to be tailored to the patient. This often involves starting with a careful dietary and activity history and helping the patient incorporate small, healthy changes that are congruent with their cultural background too.

[00:44:38] There are multiple medications available for weight loss and selecting the right one requires knowledge of a patient's comorbid health conditions, as well as taking into account their personal preference. Side-effects tolerance cost, and or insurance coverage. And three recognize how to counsel patients on when it may be appropriate to pursue bariatric surgery and what they can expect following the procedure.

[00:45:03] And remember the most important step in helping patients manage obesity is by starting the conversation and letting patients know that you are there to support them along every step of their.

[00:45:18] We hope you enjoyed this episode, which was made possible by contributions from our patient, Phil, our resident interviewer, Dr. Anita foster Tayvon, our medical student interviewer, Helen sigh and Dr. Jorge Moreno, who provided faculty peer review for the project and served as our expert. Special, thanks to our producers august a Loco, Helen sigh and Dr. Joshua on Django as well as our faculty advisor, Dr. Katie Gila. Be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times. Thanks again for joining us today, we look forward to sharing more expert opinions and patient experiences at our next episode, till next time, this was primary care pearls.

[00:46:18] Helen Cai: That you're spending your Tuesday with us, even though you have to get up super, super early for your workout. Um, and we'll, we'll be in touch in the future.

[00:46:26] Patient: When do I get my check?

[00:46:29] Helen Cai: Retroactively? We're working on some grants in 99 years. Exactly. If a state

[00:46:35] it's in, it's in the mail.

[00:46:36] Oh yeah. Great. May have gone to your old car.

[00:46:39] Patient: I went to my old address.

[00:46:41] Helen Cai: Your physician has to approve it or else we can't

[00:46:44]