Weight Loss Medications

Episode 25 - Weight Loss Medications

[00:00:00] Dr. Chehab: Welcome to IBJI's OrthoINFORM, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoINFORM, our goal is to provide you with an in depth resource about common orthopedic conditions that we evaluate every day. Today, it's my pleasure to welcome back Dr. Inbar Kirson and Dr. Lynn Gettleman Chehab. Who will be speaking about metabolic disorders and specifically about the wave of new drugs to treat them. With the explosion of these drugs onto the market, such as Ozempic, Wegovy, and others, we thought it would be helpful for our listeners to learn about these groundbreaking medications.

How they work, why they can be effective, and what are their potential drawbacks. Both Dr. Kirson and Dr. Gettleman Chehab are particularly well qualified to help us understand these medications. They are board certified in obesity medicine and have been the physician leaders for IBGI's OrthoHealth program, which treats obesity in adults, primarily Dr. Kirson, and in children, primarily Dr. Gettleman Chehab. For a full review of Dr. Kirson's and Chehab's impressive backgrounds, please refer to our prior episode, number 12, Understanding Metabolic Health. So Inbar and Lynn, welcome back to OrthoInform and thank you for being here. Thank you. Thanks.

[00:01:13] Dr. Kirson: We're happy to have you here.

[00:01:14] Dr. Chehab: You are the first two guests who are being welcomed back. So, thank you for coming. , I thought it'd be great to have a discussion about the medications that have come out on the market for the treatment of obesity. I think there's a lot of Buzz, obviously, but also probably a lot of misunderstanding about how the medications work and who they're effective for.

So just to open the discussion, , can you, can you tell us a little bit about, I guess first of all, what those medications are intended to treat? And then secondly, again, the, how they work, , what are the effects of that, what's the effect of this, of these medications, and then what are the potential drawbacks?

[00:01:50] Dr. Kirson: Yeah, so I think we, , should first start with defining obesity because, , it's, it's interesting to me that a lot of patients, or a lot of people in the world, define obesity based on BMI. And BMI is really not the defining factor for obesity, it's just a measure we use to identify patients at risk for obesity.

And so if we look at the actual definition of obesity and I like to use the obesity, the Obesity Medicine Association definition because to me it's the most complete and it's the society that represents the investigation into obesity and metabolic disorders. So I'm just gonna read it but, , obesity is defined by the OMA as a chronic relapsing multifactorial neurobehavioral disease wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces.

Resulting in adverse metabolic, biomechanical, and psychosocial health consequences. So, in a nutshell, what does that mean, right? It means that when we have excess adipose tissue, adipose tissue is fat, it can malfunction, it can cause disease, , or lead to disease, and it can also cause, , trouble with carrying excess fat.

So, we know that, , patients who struggle with, , with obesity have an increased risk of knee, you know, other joint issues, knees, ankles, hips, even shoulders, but they also have increased asthma, things like that, and I think, you know. Right,

[00:03:16] Dr. Lynn Gettleman Chehab: and just the fat, excess fat tissue is very metabolically active and can cause disruptions in hormones and lead to diseases such as diabetes.

polycystic ovarian syndrome, and just overall systemic inflammation, which is why I think people with obesity had a really hard time with COVID because they just had high inflammation at baseline. And as Imbar mentioned, you know, there are people who, , can be metabolically actually functional with excess fat tissue, but as Amber mentioned, the consequences of carrying that extra tissue on joints and organs also leads to dysfunction like arthritis and scoliosis.

And then there's the psychological effects. So we know that there's an incredible amount of discrimination against people with obesity. It's like the last thing we're allowed to Make fun of and joke and people have a lot of shame around it and so with adults we just see missed days of work, poor treatment by physicians and at medical facilities and with children we see a lot of bullying.

So there's, they're real. consequences to carrying excess weight.

[00:04:27] Dr. Kirson: Yeah, and I think, you know, obesity is still seen in society as a disease of willpower. And that is such a misunderstanding and misconception of obesity because, and I like to describe to patients that, you know, in life we're climbing up a hill.

Right, we're all climbing up a hill, we're all carrying our own baggage, right, everybody has their own baggage. The difference with patients with obesity is that they have a spring attached to their back and that spring is constantly pulling them down the hill. And so the effort that they need to get up the hill is so much greater.

And that's not just the physical, again, climbing up the hill, it's everything. It's the metabolic, it's the psychosocial, it's the, you know, everything in their life is just harder because they've got this spring pulling them down the hill. And so, our job as physicians who treat obesity is to weaken that spring because the spring never goes away.

It just needs to be weakened. And that's what these medications are so great at, is they help weaken the spring so the patients have less effort climbing up that hill. And I just think that visual helps them better understand, , what they're dealing with and the understanding that obesity is a lifelong disease.

It's not something that goes away. Now you can overcome it, you can control it, you can put it into remission just like high blood pressure, just like diabetes, just like all these other diseases that we have. That we treat patients for and medication for obesity is just as important as medication for blood pressure and diabetes.

[00:05:53] Dr. Chehab: So let's review some of these medications.

[00:05:55] Dr. Lynn Gettleman Chehab: Right? What can I add one, I was gonna add one thing, , that I think is what's so exciting about these new medications is that they show. is a disease because you cannot inject somebody with willpower. So what these medications show is that there are things beyond people's control.

And I think that's really, really important in our framework of, of how we look at people in society who are carrying excess weight.

[00:06:21] Dr. Kirson: Right. Yeah, go ahead.

[00:06:22] Dr. Chehab: Well, let's talk, what are the medications? We hear some of the names, but. Can you just list the names of these medications just to begin with?

[00:06:29] Dr. Kirson: Yeah, and just to clarify, right, these medications, they're called GLP 1 receptor agonists, and what that means is GLP 1 receptors exist, , these are, you know, receptors in our body, um, they exist in the brain, in the gut, and on the pancreas, and probably elsewhere.

 Because we do see side effects, , but those are the, that's the target of these medications. And so they will reduce hunger at the level of the brain, they'll slow gastric emptying, and, and so that you, your food transit is slower, and so you feel fuller, faster, and longer. And they control how insulin reacts to glucose in our bloodstream or sugar in our bloodstream.

So insulin is kind of the deciding factor of whether or not you can pull fat out of a fat cell or you're in storage mode. So if there's insulin floating around, , then there, your body's in storage mode, right? You're just going to store all that food into the fat cell. If insulin is not there, then food can exit the fat cell and be used as energy by our bodies.

And so This medication controls when insulin is there and when it's not, so that it's appropriately there. So when you need to store energy, it's there, and when you don't need to store energy, it's not. And so this medication was first designed for diabetics, right, for people with diabetes. So we have two categories of these medications.

 We have liraglutide, which is, or I should say the first medication was in 2004 and that was exenatide. Now that was only designed for diabetes. Then we have liraglutide, which is what everyone thinks of as victosa or saxenda. Victosa was, , for diabetes and saxenda was developed for obesity.

[00:08:05] Dr. Chehab: So same molecule, three names.

[00:08:08] Dr. Kirson: Exactly. Well, same molecule, two names. Exenatide was the, was Bietta, and that was just diabetes. But now Lyric, oh yes, three, right, three names.

[00:08:16] Dr. Chehab: So there's a scientific molecular name, which is a name that's very difficult to pronounce. Yes. And I, I heard a bunch of theories why they make these drugs so difficult to pronounce.

Basically that when it becomes a generic. You can't pronounce it. So you go back to the, to the, to the trade name and keep it on.

[00:08:31] Dr. Lynn Gettleman Chehab: Right. But I still question who makes up these trade names.

[00:08:35] Dr. Chehab: But the trade, so,

[00:08:36] Dr. Kirson: Lyric Luteid is the trade name and then Victoza, molecular name, sorry. The, yeah, sorry. It's the molecular name.

Correct. The generic kind of molecular name. And then, , Victoza is the. medication for diabetes, and then saxenda is for obesity. But it's all the same medication, just different names. So the same concept applies to the next medication that was developed, which was semaglutide. That's the molecular name.

And then we have ozempic for diabetes, and wegovy for obesity. And then, then most recently, we have What's called a GLP 1 GIP. So these are, this is now attacking two different receptors, also in the same locations. And that is going to be, the trade name is terzep, sorry, the molecular name is terzepatide.

Then we have munjaro for diabetes, and we have zepbound, which again, don't understand that name. That was just approved for obesity. And then we have lots more medications that coming down the pike. , Wegovy is going to now be a, an oral medication, , as well. So the GLP1s up until this point have been injections, except for ozempic and rybelsus, which is the semaglutide, because ribelsis is now an oral version of it.

So now they're developing an oral version for the obesity medication.

[00:09:59] Dr. Chehab: Okay. And previously though, when these drugs came out, they were all injectable?

[00:10:03] Dr. Kirson: Yes, all of them were injectables.

[00:10:05] Dr. Chehab: And then obviously that carries some difficulty for patients to administer. So the pharmaceutical companies would love to have all of these be oral medications.

Yes. Okay. And those are the, the names of these medications, obviously we hear a bunch about this and the whole media explosion around them. So these GLP 1 agonists work at the brain level. at the gut level and at the tissue level. And they control basically, they modulate insulin and the effects of insulin.

And in the brain, they can tell you that you're full in the stomach. It will slow down how quickly, , food passes through the GI. And then in the tissues, it will affect whether those, particularly the adipose tissue is in storage mode or in release mode. They have a multifactorial, pathways.

Multiple effects, but primarily through insulin.

[00:10:59] Dr. Lynn Gettleman Chehab: Well, yes, but yes and no, like they really hit a, I would call it a primitive satiety center in the brain. They do something where they quell cravings. So if you talk to someone, , who's on one of these medications, they'll say, before I was on the medication, All I could think about was food and I, it was, it was almost like telling someone who pulled an all nighter to stay up an extra night the way it would be for them to not want food and this constant craving for food.

And I have one patient talk about She would be going to a restaurant. She'd look at the menu and she'd be thinking for days, all excited and really stimulated by the idea of having this food. And this, this noise is always on there. And these medications quiet the noise. And she said, it's just the strangest thing.

[00:11:47] Dr. Chehab: She goes to the restaurant. And she eats half a meal and she's fine. So we've talked about the mechanism of how these medications work. How effective are they?

[00:11:57] Dr. Kirson: Yeah. So they're actually very effective, , and they're getting even more effective. So if we start with, the liraglutide. which is your Victoza and saxenda.

So let's just stick to obesity medications. So we're going to talk about Sexenda and Wegovy because I think it'll just be easier. , if we look at the studies, the studies show us that Sexenda gives us anywhere from a 10 to 12 percent weight loss. And then with Wegovy, we're seeing closer to a 15 to 18 percent weight loss.

And now with , ZepBound, we're seeing a 21 to 24 percent weight loss. So they're just getting better and better and better at achieving weight loss, but more importantly, I think, you know, it's not just about the weight loss. It's really about the change in metabolic function, and this is where it's super important that when you're taking this medication, you're also working with an obesity medicine physician or a practice that's teaching you how to eat on these medications, because if all you do is eat less of the food you're already eating, that has Already, you know, caused some metabolic dysfunction in your body, then you're not really improving things, you're just putting a bandaid on it.

So if we really address, if we use these medications to take away that chatter in the brain to give people a little bit more control, to allow them to weaken that spring, then they have the ability and the, capacity to make habit changes. But then we also have to provide them with those tools, and that's what we do at Ortho Health, is we work as a group.

We have dietitians, we have health coaches, we have physical therapists, and we have our obesity medicine specialists. We work as a group to provide all of the habit changes and the support that the patients need in order to really make changes that are going to be lifelong, meaningful, and sustainable.

[00:13:50] Dr. Chehab: So the medications themselves aren't necessarily a magic bullet. You have behavioral changes, coaching, and so And that, that go along with it. Yes. So can I ask, what is that coaching? What are you telling patients to do? Not to give away necessarily trade secrets, but what are you doing for this?

[00:14:07] Dr. Lynn Gettleman Chehab: So one thing, these medications do have side effects.

So people can experience, I say the most common one is nausea, constipation. And so if they're not coached to eat a certain way, those side effects will be worse. So our dieticians are a key point of, just being able to take it and then they work so much better because there are things that will bypass how these medications work like if you drink sugar, you're not going to get the effect of delayed gastric emptying with liquid.

So we really coach them on how to eat in a way that Helps with side effects, but also improves how the medication works.

[00:14:44] Dr. Kirson: Yeah, and I think it's super important You know I think a lot of people are hearing about muscle loss about the ozempic face Like these things that we're hearing about on the internet that aren't necessarily true if you're really paying attention to nutrition Right.

We we you have to I really consider food as medicine. It's the best medicine we have and in order to To have these medications work at their best and have them do what they are supposed to do, which is help you lose fat tissue and an abnormally functioning fat tissue so that you become metabolically healthier, you have to support your body with the food and this and essentials that it needs.

And so we focus on making sure patients are getting enough protein in their diet. That's super important to support their muscle mass. If they're not supporting their muscle mass, then the default of the body is actually to degrade muscle and to use it as energy. And so we have to fight against some of the defaults of the body, which are survival mechanisms of the body.

 We educate people really on getting adequate protein and then using vegetables and some fruit for getting their micronutrients and their fiber. And those are the essentials, right? And as long as they focus on getting the essentials, And if they have room, really, at this point, this is why the medication works so well is they don't have room anymore for the food that they don't need to be eating.

 It really changed. And once you start eating that way for a period of time, the body's signaling changes and you no longer actually want that food as much.

[00:16:15] Dr. Lynn Gettleman Chehab: And then I was about to be, so the other thing that we're really lucky to have at OrthoHealth is we have an army of really great physical therapists, and we have a way, we have the mechanisms, we have machines to measure muscle mass.

So we keep a very close eye on the muscle mass of our patients on these medications, and if they're losing too much muscle, we will have them work with our physical therapists to work on resistance exercises to make sure they're improving their muscle mass.

[00:16:43] Dr. Kirson: And increasing their protein. Yeah.

[00:16:45] Dr. Chehab: So just to go, Over this ground one more time.

These medications have side effects and if taken just by themselves and you continue to eat the way you have been eating, you can get in some trouble. You can have minor side effects, but troublesome nonetheless of constipation, nausea, vomiting, and more importantly, muscle wasting. We know how important it is to sustain muscle mass through life.

And if you do have muscle wasting, that's a huge issue, both. For the present for the future. Yep. And so the coaching that goes into using these medications So that they can be most effective at improving your metabolic health is avoidance of sugar sweetened beverages and sugar in general Consuming enough protein and then having a mix of vegetables in order to get the micronutrients that our body needs to perform.

[00:17:36] Dr. Kirson: Yeah, it's also recognizing that if you overeat, that will make you sick. And so there's, there's this,

[00:17:42] Dr. Chehab: that delayed gastric emptying, where it's slower to go through the system. If you just put too much in, it's going to, it's not going to go forward.

[00:17:49] Dr. Lynn Gettleman Chehab: And especially carbs, because they will They expand in your stomach, so you will feel very sick with refined carbs.

[00:17:57] Dr. Chehab: You do kind of steer people more towards a low carbohydrate diet on these medications?

[00:18:02] Dr. Kirson: Yeah, and I think also because if you think about it, the people who respond best to this medication, because there is something we didn't talk about, there's a subset of people who don't respond to these medications at all, you can put them on it and they just will not lose weight.

Right? And it's not that they're doing something wrong, it's that their body isn't responding to the medication. So the patients that respond best to this medication are actually patients with metabolic disease. Metabolic disease, by definition, responds to low carbohydrate meal plans. So it goes hand in hand, and really what you're using is the medication to train the patient to eat correctly, right?

To eat for their body.

[00:18:36] Dr. Chehab: It goes to your point about food as medicine. Yes. Right. Yeah, and and so these incredibly effective drugs when administered appropriately can lead to Significant improvements in metabolic health. Yeah, and so maybe as much as My wife would like to stick me in the middle of the night with one of these medications so that I can lose weight and snore less.

That in itself would not work. I would have to eat fewer Skittles, drink fewer sodas, take in more good protein, eat more fruits, eat more vegetables to get the micronutrients. So just simply. Sticking and living is not appropriate.

[00:19:14] Dr. Lynn Gettleman Chehab: This is not a medication where you give someone a prescription and say, I'll see you in a year.

Like it needs, like Embar said, a lot of coaching and a lot of monitoring.

[00:19:25] Dr. Chehab: Yeah. So, so now let's move on to, we know it's effective. Just share a few anecdotes if you don't mind because I think the anecdotes are very compelling. Yeah.

[00:19:36] Dr. Kirson: We're going to take, in the interest of HIPAA, not, not identifying anybody, , I think, uh, if I take the average patient, right?

The average patient that we see at OrthoHealth probably has a BMI between 40 and 50. What does that mean? It means that they are carrying an excess amount of weight enough to cause usually metabolic disease. So they have prediabetes, they have high blood pressure, they have high cholesterol, , and they are usually coming in to us, you know, sometimes referred by an Illinois bone and joint physician and they need a knee replacement or a hip replacement and they have to lose a certain amount of weight in order to proceed with their surgery.

And that would say, I would say, is a very common example of what we see. , so, you know, several patients that come to mind, but I think, , just to use one as an example, without identifying anything, , I, you know, she's 45 years old. She, , has struggled with her weight on and off throughout her life, probably from her teenage years, and, , after having kids, couldn't lose the weight, , so she, we did get approval for her to start WeGoV.

And, , within, you know, probably a week or two, she's already saying to me, Gosh, this is incredible. I'm no longer thinking about food all the time. I'm not obsessing with food. I can serve my kids their food and not have to clean their plate. I can, , I'm already, you know, I'm already down five or ten pounds and I'm feeling lighter and I have more energy.

And that's because we've unlocked the energy in her fat cell, like that her energy was trapped, right? So she can finally Access all that energy that she has stored, but more importantly, she's able to kind of really pay attention to what her, you know, what her habits are, and now she's realizing all these things that she was doing before that she was, you know, that she's more aware of, and she's able to change some of her habits, and so fast forward six months, and she's lost 35 pounds, and she is fitting into better clothing, she's feeling good about herself, Her depression has gotten better, um, and that's, you know, again, all tied into the fact that she was metabolically dysfunctional, like her body was metabolically dysfunctional.

And so, and, you know, if you fast forward another six months to this patient, because now we've had her in the practice for a year and a half, fast forward another six months, she , she's doing so well. She's down 50 pounds. She was able to have her knee replacement surgery, so she now can be more physically active.

She can do more things with her kids. She, , and she's on a very moderate dose of the medication. She's not on the highest dose or the lowest dose. She's on the moderate dose of medication and she's really just able to live her life to its fullest.

[00:22:20] Dr. Chehab: That's great. I mean, that's exactly the whole Yeah, that's the point.

And then Lynn, with a pediatric patient, , obviously there are a host of different issues, but if you can just anecdotally walk us through your typical patient and what are the special circumstances for which you may use one of these medications, because obviously the implications of children on medications versus adults are different.

So I'm obviously giving a big, big broad topic here, but walk us through a typical pediatric patient who may benefit from these. You know, game changing type medications. Sure.

[00:22:53] Dr. Lynn Gettleman Chehab: Well, first I just want to say these medications for children have only been approved since 2019. So, 2019 loraglutide was approved for diabetes.

It was approved for weight loss in 2020, and Wegovy was just approved for 12 and over, , in 2023. So they're really new on the scene, , and I think that's really important to know. So, again, the cornerstone of what we promote is habits, so, because these medications will work better. , they're so much better than what we had in our toolbox before in terms of side effects interacting with other medications.

I feel like there's two types of pediatric patients that I see. , we have had such a horrible surge of anxiety and depression in children. That's real. And I think the pandemic and social media has Definitely. Exacerbated. Yeah. It's done them no favors. So I have a lot of patients who are referred to me have been put on psychiatric medications that especially in children and teens can cause a lot of weight gain.

And I always say mental health is paramount. Like you can't function without good mental health, so it's not a question of taking them off these medications. But then how do we compensate for what they do to their body? We see a lot of insulin resistance on some of these medications. So here you have a child who's struggling with anxiety and depression, and then they've gained weight on top of it.

So I have a patient who, , did get approval for Wegovi. After gaining, I think it was 60 pounds within two years of being put on these medications, and she finally feels in control of her body. Just the smile on her face is priceless, and she doesn't feel, she, she said to me, I don't know what was going on.

All I thought about was food. I just wanted to eat more and more and more, and she feels like she has control, and she's been on it for the past. Three months and has lost about 20 pounds and is just eating better, also feeling better.

[00:24:52] Dr. Kirson: And I think, I mean, just what you said, like, it's, it's fascinating. The patients don't even know that they were thinking about food all the time.

Until you take it away. Right. They take, they get on this medication and suddenly it's like, oh, wait a second. This is what was going on.

[00:25:06] Dr. Chehab: Yeah, it's so interesting. Right. This brain effect, and I'm sure like investors are like, Oh my God, maybe there's more to these medications.

[00:25:12] Dr. Lynn Gettleman Chehab: They're studying it. They're looking into it for alcohol.

[00:25:15] Dr. Kirson: Alcohol, smoking. I heard online. Online shopping. Online shopping. All these addiction, right? Because it hits the addiction center. You're going to be sticking me in the middle of the night.

[00:25:23] Dr. Lynn Gettleman Chehab: Yeah, but so, just to see the control and then the other thing is once This patient started feeling better about her body, now she's going to the gym with her friends.

Now she's out socializing more. So it's such a big impact. And then the other child or adolescent I see is just someone who's had lifelong struggles with their weight. You go back in their chart at three years old, and they're in the 99th percentile for weight. And there's something so clear that their body is programmed.

just to put on weight. Like a three year old has no willpower. You know, you have parents who are really conscious of feeding their kids in a healthy way and you see it in the family. Like every multiple people in the family has struggled with their weight. So to this patient, I say, Oh my gosh, your body is just programmed in a certain way and it's our job.

We're detectives to figure out how to program it better. And that's where these medicines are an incredible tool. One caveat is I think they're heart, they're, Harder to get approved than the for adults because they're so new harder and kids harder and kids so that's been a real barrier and really Upsetting especially children with public aid replacement insurance like that's really upsetting.

It's really hard to get these medications And then the other thing I just wanted to mention what? What Imbar talked about was, we pay real close attention to muscle mass, because adolescence and young adulthood is your time to build muscle. It's so much harder when you're older, and you don't want to miss this opportunity.

And we look at muscle as its own endocrine organ. And if you think of fat tissue as very Inflammatory muscle tissue is very anti inflammatory and muscles what feed our bones and support our bones and it's really important for bone health. That's when you develop bone mass at this age. So we keep a real close eye on these, on these children who are on these medications to make sure they are continuing to not just, we don't want them to just not lose muscle, we actually want them to Build muscle, but like I said, once they're on these medications and they start losing weight, Yeah, they get really into building muscle, right?

So it's it's just really exciting.

[00:27:27] Dr. Kirson: You also go back to like the fact that the three year old, right? Three year olds, they self regulate, and if a child is not self regulating, there's something genetically abnormal there. Right? So obesity does have genetic causes and, um, and there is, you know, an opportunity for us to test for genetic diseases and so anyone who does present at that age, we're usually sending, like if I get an adult who tells me they were taken at five years old to the doctor for obesity, I'm checking them for genetic abnormalities because that opens up a whole other, you know, armamentarium of medications that that can be addressed, that would address specifically their type of obesity.

Right. And I think that's where obesity medicine is getting so exciting is there's so much more precision medicine in obesity right now that we can identify certain phenotypes and genotypes so different, you know, genetic causes and physiological causes of obesity so that we can target the medication specifically to the patient.

[00:28:26] Dr. Lynn Gettleman Chehab: And that's what the first thing I'll say is. I say we're nerds, we're like obsessed with this, we love this, and our job is to be a detective and figure out what's going on in your body and how to program your body in a better way. And we do have testing in our office, cheek swabs and things like that.

But it's very rare that we actually find anything. It's interesting. I have found a few patients who are carriers of these rare genes for obesity, which means their body is definitely programmed. And, and we're identifying more and more, but it's, it is super, we are nerds about this and it is super exciting.

[00:29:04] Dr. Chehab: So, I mean, it sounds like the toolbox has gotten much larger. Yes. Much

larger and more precise.

[00:29:12] Dr. Kirson: Yes. Obviously this is not the Swiss Army knife that's going to cure every form of obesity, but it is certainly going to be helpful with for patients who have a select set of issues. Yeah, and so you're not prescribing this for everybody, I assume.

No, not at all. Are you prescribing it for the majority or the minority of patients, do you think?

[00:29:32] Dr. Lynn Gettleman Chehab: Oh gosh, well pediatrics I'd say minority because if they're more metabolically plastic, right, and if I can help Their obesity with habits. Then I'm like, we just have this in the kitty for later, and these medicines are gonna get better and better.

They getting better, better, better. And that's what I tell patients. Like, look, if this doesn't, this isn't a good idea for you. Now it's there. And it will always be there and it's going to get better.

[00:29:55] Dr. Kirson: A little different with adults, right? Adults are dealing with something different. I'd say in our practice, I want to say probably about 30 to 40 percent of patients are, you know, uh, considered for this medication, or probably larger percentage considered for it.

About 30 to 40 percent are on them. But again, the largest barrier is insurance coverage. Yeah. Yeah.

[00:30:15] Dr. Lynn Gettleman Chehab: Okay. And for me, I would say 10 percent. 10 percent are on

[00:30:18] Dr. Chehab: them. I assume the insurance barrier is expense? Expense.

[00:30:21] Dr. Kirson: Yeah, it's an expense. I mean, there are companies, as of January 1st, we found out there are companies that are dropping obesity coverage and, you know, this is where it gets a little So, it gets a little sticky and frustrating for us as obesity medicine physicians because obesity is a disease.

You don't carve out a disease from insurance coverage, right? And unfortunately, though, it's still, again, it's seen as a stigmatized disease of willpower. And so insurance companies think they can just carve it out. We're not going to cover obesity. And that's just, um, to me, that's ludicrous. Yeah.

[00:30:55] Dr. Lynn Gettleman Chehab: And it's, and it's so short sighted.

Like that's the other thing you think they would pay off in spades later to prevent all these diseases. Right. Right.

[00:31:05] Dr. Chehab: And so I guess our final topic with these medications is, do you have to be on these for life? I mean, we probably, obviously we don't have enough experience, the medications haven't been around long enough, but is the thought that once you're on them, , you'll be on them for life or you can wean off and you still have the.

Good metabolic effects or because you've been able to maybe augment the other tools from lifestyle changes that this one tool becomes less important. What are your thoughts on where you see this going in terms of lifelong administration or any potential drawbacks of the medications?

[00:31:36] Dr. Kirson: Yeah, so I think drawbacks, you know, we have had these medications since 2004.

So we have about 20 years of experience with these medications. So I don't necessarily foresee any unknown, you know, long term negative effects. But again, we don't know that, right? We don't know that at this point. I would say that it's very individual. I have patients who have been on this medication for six months and somehow flipped a switch and they were able to come off the medication and maintain their weight loss and continue to lose weight.

And then I have others who I think are going to be on it for life. And I think the goal is to identify which patients are which and then to also give them the least amount of amount of medication that they need in order to sustain a reasonable response, right? And that's what we do with every medication, right?

We don't want patients on the highest dose of blood pressure medicine or diabetes medicine or anything like that. We want to find the sweet spot of what is the lowest amount of medication that controls their disease that keeps them healthy. And we're going to do the same thing with these medications.

[00:32:39] Dr. Lynn Gettleman Chehab: I was going to say, for children, or teens, what's exciting is, like I said, they're more metabolically plastic. So I I think Most of my patients on these medications have very few on the full dose. They do well on what I would call baby doses of these medication. And that's the hope that if they can change that, if they can really work on habits, and it's not just eating habits, it's sleep, coping with their mental health issues, like that's so keen, key for anybody, but I think especially teenagers.

And if they can do that, we can wean them off. But that's the consideration when I have a lot of parents who ask me about these medications. And like I said, the only Wegovy and succenda are approved for children. Zep Bound is not approved for children, not even for diabetes. But I say like, you know, I, we will try everything else first before the idea of putting a a child on a lifelong medication, but if they need it, they need it.

[00:33:39] Dr. Chehab: Yeah. Okay. So just to summarize, so, these medications have really helped us. treat obesity more effectively. They work in multiple pathways on the brain, on the gut, on the tissues. The side effects can be managed with appropriate coaching and with appropriate lifestyle choices with diet, sleep, and, and, and, and one of the main, main important factors of avoiding one of the big side effects of the muscle wasting.

is adequate protein intake, and these anecdotes of success are things that you probably haven't seen in the past. Like, have these medications been game changers?

[00:34:17] Dr. Kirson: This is changers, and we're approaching bariatric surgery numbers in terms of some of these newer medications that are coming out. They're really, we're getting up to, like, almost 30 percent body weight loss, which is bariatric surgery numbers.

[00:34:30] Dr. Lynn Gettleman Chehab: And I just want to To put that in perspective, the American Academy of Pediatrics came out with new guidelines for the first time in 11 years, , or even more, , this last year. And they talked about, , recommending bariatric surgery earlier, but the problem with those guidelines is they came out before, before all these medications came out.

So I think that's, it's going to change, it's going to change it. And I think in the end. The nice thing about the medications versus the surgeries is surgery has lifelong complications that you can't reverse and you can reverse or you can stop a medication if it's not working.

[00:35:08] Dr. Chehab: My guests today are Dr.

Inbar Kurson and Dr. Lynn Gettleman Chehab. Any final thoughts?

[00:35:14] Dr. Lynn Gettleman Chehab: No, just like, like I said, we're nerds. We're really excited about this. And I mean,

[00:35:19] Dr. Kirson: we could talk about this for hours. Yes,

[00:35:20] Dr. Lynn Gettleman Chehab: but thank you.

[00:35:21] Dr. Chehab: Okay. Well, so you guys totally touched on the high points. I can't thank you enough for being here on OrthoInform.

Thanks so much for being here again. And I hope to have you back with the next breakthrough.

[00:35:31] Dr. Kirson: Absolutely. Thank you. Thank you.