Dr. Samantha Harris discusses the best approaches for weight management with your patients.
Back to Symposium Page » I am going to jump in here just for a moment because our next speaker is this session's moderator as well. And I just want to give you a little bit of background on Samantha Harris. I've known her for a number of years. Now she is part of the Scripts Clinic Medical Group. She is an adult endocrinologist but also has advanced training in obesity management and is part of our weight reduction weight management program. Here it's scripts. She conducts research in this area and is goingto provide an update on what's available for weight management in diabetes the most recent information. And I think this is incredibly challenging. We get questions from our patients all the time about this. We get questions for providers, including our nurses dieticians. So, Samantha, I'm hoping you're gonna help clarify a lot of this or at least, uh, introduce how we should be thinking about this as we move forward in our care in patients with diabetes. So thanks so much. Thank you, Athena. Yes, I get the pleasure of speaking about which weight management, which is something I'm extremely passionate about. I'm going to pre warn you that I would probably have twice as many slides as I should have, but all of you will have the slides available. It just seemed like everything was pretty critically important, and I wanted you guys to have access to the materials afterwards. So don't fret if I go through something too quickly that you want to spend more time going through. So here are my disclosures. Objectives. We're going to talk about the connection between obesity and type two diabetes. We're gonna identify a good approach to weight loss and patients. I use a five pillar approach and use evidence based recommendations to address those. And then we're going to talk about new and future weight loss therapies. What's exciting? So we know there's a correlation between weight and diabetes. And, as you can see, the trends from the 19 nineties up to the latest of 2015. As obesity becomes more prevalent in this country in various states, so does diabesity diabetes, often called caused, often called diabesity because of the close correlation between the two. So why is this happening? In general, being an active or sedentary or obese leads to this chronic systemic inflammation, and it can affect numerous cells throughout the body, including apple sites, immune cells. And these can release release a downward cascade of different hormones and factors that can influence other organ systems. So at the at the site, the fat cell level there is release of inflammatory markers on brother materials that can cause insulin resistance at the muscle, which can lead to Type two diabetes. There are a lot of complications associated with being overweight or obese, and as you can see here, it affects pretty much every organ system in the body and the major ones we know about cardiovascular disease but also lung disease in various malignancies as well. There are other lesser discussed complications of obesity that I think are important to note, and those include things such as dementia, mood disorders like depression, anxiety, sexual dysfunction, personal and social costs, as well as professional unemployment costs, which I think are under looked and often underappreciated amongst society. In general, there's a huge amount of weight bias and discrimination in society today, and if you just Google obesity or overweight, these are the types of images that come across in a Google image search. These are some of the top images, and it's it's showing people as sloppy, not motivated, lazy, like they're not actually trying to do anything about their weight. And I think that that is a huge, uh, downfall in our society and doesn't help people seek therapy and treatment for diabetes as well as obesity. So can't you just lose weight by cutting calories? Why is it so hard in general? Yes, calories in versus calories. Out does have a standing. It's true, but it's not so simple. Why isn't it simple? Certain diets might be easier for patients to adhere to, or patients may respond better to certain plans. Medications can can muddy up the pictures, such as beta blockers, psychiatric medications, steroids, menopause can can lead to awaken, especially abdominal waking and then products like artificial sweeteners, which might have zero calories. But can they affect your weight? Do they have a correlation with diabetes? And lastly, unfortunately, the body fights weight loss incredibly hard. So even though someone might be able to lose weight, maintaining that weight loss is incredibly difficult and we often hear these dismal statistics, like 95% of people who lose a meaningful amount of weight, regain the weight, and there is some truth to that. But why does that happen for every kilogram or £2.2 of weight lost, Your body fights you by lowering metabolism by 30 calories less per day and increasing appetite by 100 calories per day. And that is often overwhelming to think about. So let's say somebody loses 10 kg, or about £22 of weight there now burning 300 calories less per day so they're based on metabolic rate has lowered by 300 but their appetite has increased by 1000 calories per day. So whereas maybe 1,502,000 calories per day was satiating to them, they now need 1000 more calories per day in order to feel satiated. And I think a lot of people who have lost weight have had that experience of you do well for a couple weeks or a couple of months, and then suddenly it's like you can't stick to the plan anymore, and everyone thinks it's a matter willpower. But really, it's your body that's fighting it way losses hard in general, but diabetes can make it even harder, and we'll touch base a little bit on some of those reasons. So how much weight do you need to lose toe? Have meaningful improvements in some of these parameters? Even just that 2 to 3% of your total starting body weight. You will notice reductions in risk for things like developing diabetes. So people who have prediabetes and lose 2 to 3% have improvements. Obviously, the more the better. It is a continuum, a spectrum of improvements, but 5%. You have improvements and blood, sugars, blood pressure, lipids, other things like incontinence. 10% even better improvement sleep apnea, orthopedic issues, um 7 to 10% can really help prevent progression of pre diabetes to diabetes, and then 15% or more is even greater. In general, we consider the 5 to 10% body weight loss to be meaningful and significant because of the reductions in these co morbid conditions and their effect on morbidity and mortality. So why is it so difficult for providers to help patients lose weight? Ah, lot of health care providers don't feel comfortable talking about Wait. There's a stigma and they don't want to be offensive. There are time constraints, oftentimes, patients presenting with concerns not related to their weight, and it's hard to dedicate an entire visit to wait when that is not what the patient comes in for. There is a huge increase in medications, both diabetes as well as weight loss. And unless people train using those medications when they're in medical school or beyond medical school or whatever type of training program they dio, there's a lack of comfort and a lack of awareness. Furthermore, in patients with diabetes glycemic control, the numbers often become become the main focus more so than wait so they want to see the blood pressure is the Staten often override. To focus on weight management, you really need high intensity in person interventions that air comprehensive to result in meaningful weight loss. This includes things like dietary modifications, physical activity, behavioral counseling and high intensity is at least 14 to 16 visits over six months, and this is from from evidence based data. That's a lot of visits in six months. There are no health care providers, physicians primarily who are able to see a patient 14 to 16 times over six month period. Eso You really need to involve the whole team and this has to include personalized feedback, so low intensity interventions have generally not been found to be effective. So how do we overcome these obstacles to provide these high intensity interventions with these limitations? First of all, I always recommend finding a respectful, nonjudgmental way to bring up. Wait just one sentence, one line that you feel comfortable. I think we all have, like, our lines of repetition. But just practice one. Would it be okay if we discuss your weight today, or how are you feeling about your weight set realistic and achievable goals with patients? According to the CDC, you are free to say the good news is no matter what. Your weight loss goal is even a modest weight loss, such as 5 to 10% of your total body weight. It's likely to produce health benefits like improvements and blood pressure, blood cholesterol and blood sugars. We don't I often have patients come in and they want to lose £50.100 pounds. They want to look like they did when they were in high school or in college, and even just those daunting goals could be overwhelming. So just set small goals that let them know that they have made an improvement in their health, even though they might not physically be in the place. They want to be up to be high intensity. Like I said, most health care providers cannot do 14 to 16 visits in a six month period. So use other resource is dietitians commercial programs like Weight Watchers Jenny Craig. They have data to group, visits, phone calls or refer to a comprehensive medical weight loss clinics, such as what we have here. It's scripts. Where we can provide these higher intensity solutions that may be in other outpatient settings is just not feasible. So what is new? We are. We're here for updates. So spoiler alert. There are four main new things that have come out since I last gave this talk. Last year, number one LV core Lord Kasserine was withdrawn from the market, and I'll talk a little bit more about that. There is a new medication called Jealous 100 or planete, that just was approved and is new to the market. Everyone is obsessed with Keto and low carb diets. I guess that hasn't completely changed from last year, but I think it's it's still growing, and everyone is trying to do some type of variation of intermittent fasting. So here are the five pillars of weight loss, and I'm going to go into further detail on those things that I hope you don't think that was always going to say about. It's coming, Don't worry. So the five pillars of weight loss include diet, exercise, behavioral modifications, medications and surgery, and we're gonna go through each of each of these topics. So in terms of diet, diet is the cornerstone of weight loss. For all patients, with or without diabetes, it is the first pillar is the fundamental pillar on which all the other ones rely. So weight loss medications, surgery, behavioral interventions, all those help influence what you are eating. And but that is what they're doing. They're affecting what you are putting into your body. So which diet is proven to be the best? And I've asked this before, both to patients as well as health care providers, and sometimes I have people shouting out from the audience, but obviously we don't have that interactivity today, but, you know, some people say Mediterranean or dash. A lot of people are starting to say, you know, whole food, plant based or, you know, low carb. And the truth is you can't say there is no diet that is best right? And the A D A. Has come out with some guidelines that say, as all energy deficit food intake will result in weight loss, eating plans should be individualized to meet the patients personal needs while still promoting weight loss. It is not a one size fit. All there are are no longer specific carb recommendations per meal, as there used to be for male and female recommendations with minimum amount of carb guidelines and carp servings per meal that is outdated information. So hopefully we're moving forward with the 88 general theme of individualizing care, both with diet as well as medications. Significant weight loss can be achieved with any type of program that results in a 55 100 to 750 calorie per day deficit in general, that somewhere between 1215 100 calories per day for women somewhere between 1518 100 for men and the composition of that food intake can be different. Whether it's limiting high fat, limiting high cards, even meal replacements can be a viable option. Okay, There is not an ideal percentage of calories from the various macronutrients. This is from the 88. So diet should be based on the patient's health status, their preferences, the food availability, cultural circumstances. And there is no one size fits all. And I don't know if you guys remember Michael stars, but this was a popular brand back in the nineties and they had on their label. All of their labels said one size fits all. Then they crossed out the all and wrote in most, which I thought was one of the most obnoxious things I've ever seen. It's true. There is no one size fits all. But I think this was in some ways also a sense of fat shaming because here they are making a label one size fits all. But then they said, No, no, no, actually, most because for some of you, this might not fit so to me, this was a subliminal way of also discriminating against people who are not within normal beyond my range. So key factors among healthy eating plans. This is from the a D. A. An emphasis on non starchy vegetables minimizing added sugars and refined grains and choosing whole foods over highly processed foods. So all of those plans that I showed before when I asked which one was best all of them really have. This is a foundation because no plan ever says, Don't eat vegetables. Really? Unless you're Carnivore, I guess, um, you know, use sugar and refined grains or super processed foods. So this country has gone keto crazy. Probably the world. What is Keto? It is a diet low enough and carbohydrates that the state of ketosis is reached. Usually Keto levels less than 20 g of carbohydrates. And perhaps there is some unique benefit in ketogenic diets. Number one is there is a significant amount of diary sis as the glycogen. The sugar stores in the muscle are released, their normally stored with a lot of water. So there's this, like water wash. People urinate like crazy for the first few days, and then suddenly they feel very small. They've lost £5 in a couple days. Um, it's very encouraging, um, burning key toes. Key tones for energy instead of glucose can often result in other positive effects. Number one people have a decrease in appetite. It is a natural appetite suppressant and actually can upset the stomach a little bit. Um, part of a similar mechanism as to how sometimes DK can result in G. I upset nausea, Um, and that makes people now want to eat very much. And it gives people this like energy, like people they call it Keto clarity where they think they're thinking better and the brain is actually able to use ketones as fuel. Um, there's so many different Keto diets out there in low carb diets with variable macro nutrient breakdowns. And the truth is, everyone is talking about keto. But Kato was not new by any means. Low carb diets have been around for many years dating. I mean, probably the 19 fifties and sixties. Um, it was as early as 1972 that Dr Atkins came out with his, um, his Diet Revolution plan. So it in a lot of ways, this is an Atkins type diet that's just given different names and and and subtle variations between them. Um, in general, Keto has more of an emphasis on high fat with very low carbs, and in general, a lot of people think these air high protein diets, they're usually actually moderate protein diets or supposed to be moderate in protein. But when I have a heart attack, if I eat Keto, I have so many people concerned about this health care providers. It's almost like there's a disconnect between you know, what people in the real world world are reading online. And what providers of Ewing told patients are never asking me. Am I gonna have a heart attack of I eat Keto? But providers air really concerned about it? Um, the truth is that long term, large randomized trials on all types of diet are almost impossible to perform. The studies that define low fat and low carb diets. Every study defines it differently, and then what participants actually follow is greatly different. So, you know, in some studies, carbon take might have been 20% of the daily carbon. Take low carb others, it's 40%. In the comparison group. It was 60%. So even within studies that they're comparing groups that weren't even following that different of diet plans. Um, who's going to pay for these studies, you know, with the cardiovascular outcome trials with diabetes medications, obviously drug companies are paying for those that it costs millions of dollars. But can you imagine? I don't know who would actually cover a diet plan and follow it for 5, 10, 15, 20 years to really see what happens to cardiovascular disease as well as cancer. We know that there's some bad data on saturated fat, that there's increased correlation with cardiovascular diseases. Well, a certain type of types of malignancy. But the problem is most people, most of these studies air correlative and people who eat a lot of saturated fat often eat a lot of processed foods. And also most of these studies were in patients who are not restricting carbs. And we know that when insulin is president, which is the result of eating carbs or sugar, bad things happen to the fact that you're consuming. And there is a whole complicated hormonal cascade. And we know that carbs with fat is bad, right? If you eat high carb, high fat diet, that's bad. But the question is, is fat in the absence of carbs really that bad? And we don't have a really good answer. There is no good data right now that suggests that long term Keto diets will increase cardiovascular disease any more than any other way of eating. So I urge you to keep an open mind and know that any diet that helps you or your patients lose weight and keep it off. It's likely toe lower your your markers for disease. You're a one c your blood pressure, your lipid and therefore lower your risk of morbidity and mortality. Just the weight loss alone. Um, whatever means you're achieving it as long as it is sustainable and healthy lifestyle. So amount of carbs needed for optimal health is unknown. The standard American diet is usually somewhere around 300 g per day, which is a lot without diabetes. Recommendation is about 130 g for the brain's glucose requirement. But this energy can actually be supplied by other processes, including breakdown of glycogen or glue. Konia Genesis Using fatty acids and amino acids, Um, or even ketone bodies, which do cross the blood brain barrier and have been studying actually in brain cancers because they think you might be able to starve out thes these tumor cells in the brain that are relying really on sugar, sugar can feed tumors address the quality of carbohydrates. Reducing carbs does have good evidence for improving blood, sugars and the D A. Says First, select adults with Type two diabetes. A low or very low carb eating plan might be a viable approach. I'm gonna run through some of this a little bit quickly. But in general, replacing saturated fat with unsaturated fats probably has good benefits for lipids and cardiovascular disease, especially if you are eating carbs, ideally consuming fatty fish. And caution. If you do car restriction or are in nutritional ketosis because you might have a risk for DK if you excessively withhold insulin, such as in someone with type one diabetes or a lotta or if you're on an SLT two inhibitor, there is good data out there for diabetes, either prevention and treatment with the Mediterranean diet, the dash diet, a low fat diet vegetarian, low carb so you can't really go wrong. Recommending these, but obviously individualized your approach. The Mediterranean diet has good data in terms of cardiovascular disease reduction in patients, both with and without diabetes, in comparison with a low fat diet, and there are some very small Type one diabetes trials lowering carbs. So one study, 47 g per day versus to 25 in the short term improved their blood, sugars, time and range and lowered their insulin needs. So pick a plan that's safe, simple, sustainable. But most importantly, let the patient tell you what will work for them because they often can say, Oh, I tried Weight Watchers. I liked it because of X y Z, or it didn't work for me because I don't like to cook food. Well, then, that's not a good plan. So what about intermittent fasting? As it turns out, most Americans are eating all the time. I did not know that I was actually surprised to learn this, but most of them are consuming some type of calories from the time they wake up until almost the time to go to bed, whether it's, you know, sugar and creamer in their coffee, and then dessert after dinner or alcoholic beverage before bedtime. So right now a traditional American might be eating 16 or 14 hours a day and then sleeping eight hours, so any tiny of calories coming in, especially those from carbs. You are in a increased insulin level state which is a fat storage hormone, and you will you will have a difficult time breaking down your fat storage. So what is intermittent fasting? It's really variable. Generally 123 days per week of fasting cycled with non fasting days. Non fasting days. You can eat freely, or you can try to follow a certain type of eating plan or make healthy choices. One example, uh, was afraid of this. My lights don't like to stay on while I'm sitting the fast to diet where five days a week you eat normal, healthy and then two days a week you substitute with 500 calories per day. Um, intermittent fasting can be characterized by complete fasting like water or some beverages with no calories, a very low calorie, such a 500 calorie per day, like I just discussed or time restricted feeding, which is personally my favorite form of intermittent fasting because I think it's the easiest one to follow, and this is eating Onley allowed within set hours of the day. So, as before, I was saying, most Americans are eating 16 hours a day and then fasting eight hours a day. This is the reverse the most common would be 16 and eight. So the first number is how many hours per day people are fasting, and the second is how big they're eating. Window would be so 16 and eight. So fasting for 16 hours eating for eight hours, for example, not eating until 11 a.m. And then not eating anything after 7 p.m. So that is an eight hour window, followed by a 16 hour fast. There's also 19, 5, 12 and 12. Ah, lot of variations that are out there. And if 16 8 is too hard, I might say, Okay, then let's try. You know, 14 and 10. What you meet them where they are, always meet patients where they're starting from. What does the data show? There is data that it can be helpful. Intermittent fasting or time restricted eating has shown in short studies improvements in cardiac and diabetes risk markers. Weight loss is probably similar to that from caloric restriction. Maybe better, with good preservation of lean body mass potential benefits related to neurologic health, longevity, cancer and inflammation. And remember, when you are fasting, you may be entering the state of ketosis, and there might be some benefits, actually, nutritional ketosis on inflammation and other effects that are still not that well known and really minimal long term risk. I don't think it's normal for people to eat 16 hours a day. Evolutionary speaking. We probably didn't have very good access to food. We would probably wake up. We would do a lot of physical activity to try and get that food. And then during daylight hours we might eat. And towards the evening we were not foraging or hunting. And it would be a natural time to, you know, go to bed or rest and not continue eating. So ah, lot of people think that intermittent fasting is easier to adhere to than caloric restriction, that it's like if you know that you have, ah, eating window coming soon and you're able to eat sort of what you want is a little bit easier to stick to than this constant everyday calorie counting and restriction. So just start with simple recommendations and like I said, similar before with ketosis, be cautious, especially in those on hypoglycemic agents like the cellphone areas and insulin or those who are at risk for DK, such as people with inadequate insulin on board or on SLT two inhibitors. You can't really go wrong with recommending a Mediterranean plan, a low carb plan and the 5200 grand per day so not usually as ketogenic as less than 50 g or less than 20. I added a paleo type plan because I think when done right, that can also be a very healthy eating plan. Whole Foods Plant based has good data the dash diet as well as meal replacements, time restricted feeding. You could just say, Don't eat past seven PM If right now they're eating until 10, let's stop it. Eight. See what happens. Let's stop it. Nine. See what happens. I do recommend writing down all of your recommendations. Air, referring to some type of hard resource that patients can use. Providing them printed Resource is air, referring them to a dietitian or weight management center exercise. I only have two slides on exercise. It can from away lost, especially in combination with dietary intervention. The 88 recommends at least 150 minutes per week of moderate to vigorous intensity activity in 2 to 3 days per week of resistance exercise. Those were great recommendations. Those can help look, I seem in control. Cardiovascular mortality, general well being. But it is very hard to out exercise a poor diet, unfortunately, so for weight loss or even maintenance of weight loss, where exercise is very important, you might need twice as many minutes of exercise per week, which is closer to 300 minutes per week, which can be a little bit overwhelming and discouraging sometimes for patients to see. But hopefully they can work their way up over time. Next is behavioral. I'll talk about briefly. Behavioral interventions can include things like counseling on diet, how to self monitor weighing themselves, thes frequent high intensity visits that include feedback. But there are other complicating conditions that I think are under diagnosis the things like binge eating disorder, which is the most common eating disorder out there. We're not doing a great job screening for it. We're not doing a great job treating it, and part of it is because patients don't necessarily feel comfortable telling us what's going on behind closed doors, and they're embarrassed and ashamed. They feel like it's ah, character flaw or weakness on their behalf. So specifically, try to ask those questions. There's some good screening questioners out there, like the Bed seven, which I like to use, so just thinking about I have no idea. But a lot of people wake up in the middle of night and they eat. I thought that was just like crazy to me. But now that I ask about, it's like, Oh, yeah, I wake up at two AM I can't fall back asleep until I have a bowl of cereal. So screening for those types of things can also be helpful. Feel free to refer to an eating disorder specialist. Psychologists who can do CBT or a weight management referral. Where we have those types of resource is, and we have connections with different psychologists who experience with these conditions. Medications. We're gonna talk about the ones for diabetes, but also non diabetes medications and weight loss medications. Um, unfortunately, with diabetes, there is a cycle of waking, so they're diagnosed with diabetes. That foreman is added usually stefanie areas, which I believe is still the second most frequently prescribed medications in this country. So funny areas caused waking aging leads to weight gain. Time leads to weight gain. Eventually, basil insulin might be added mealtime. Insulin might be added. People continue to gain weight. The more weight they gained, the more insulin resistance they become, the more medications they need, it is a cycle. Um, also, metabolism goes down with age. Lean body mass decreases with age. Menopause and women is not a good set up either, And then other medications are often added to the regimen that can contribute to waking as well. So here are the different diabetes medications, the classes and their effects on Wait. So the most waking is seen in a basil Bullis regiment or mixed insulin next with the basil insulin. And I just made this. It's It's an approximation, Um, but in everyone can respond differently to medications. But I think this is a general good representation. The T C. D s like people in his own cause. Weight gain So funny Areas. The DPP four inhibitors have been found to be pretty weight neutral. Met Foreman can result in a few pounds of weight loss the SLT to scan on. Don't talk a little bit about the STL Tutu's and weight loss in further detail. GLP ones even more. Like I said, there's very variability within the classes, and some people respond differently to the different medications. So what does the A D A say? It says, Well, do they have risk factors for after spotted cardiovascular disease CKD or heart failure to help direct you down this path? Where does the path take you a GLP one or an SLT two or an SLT two or GLP one? Okay, so if someone has heart disease, those air your go to, um, But if they don't have established heart disease and wait is a concern, which, to be honest, should be a concern for pretty much everyone. And I don't know if you guys aware. But there is data that says that when it comes to treatment off diabetes, one of the top concerns that patients have is effect on their weight. Um, in diabetes care. In general, we're often telling them that if they do absolutely everything necessary to control their diabetes and keep their numbers, the best outcome is that nothing happens. And and Susan Guzman recently spoke about this at a lecture I was attending and nothing happening, which is great on our behalf, like you don't end up blind. You don't end up on dialysis, but that's really hard for patients to feel motivated by and to necessarily stick to all these complicated diabetes treatment plans. But what's great is weight loss, especially in people who are overweight and care about their weight. Um is a way to provide immediate feedback. So if you go to the column where you want to promote weight loss or minimize weight gain, your options are a GLP one or not guilty, too, or if a Lynsey is still elevated and SDLP to our GOP one. So I think we need to, like, step away from the stuff on areas and the jumping to basal insulin and less necessary and really think about with cardiovascular disease or concern about Wait, we really should focus on these two classes. The medication. This is pretty much everyone in my mind. So what about non diabetes medications? And you will have access to the slide so you will see the class of action Class of medication column right here. Here is a list of medications within those classes that can increase weight, and some of them are absolutely astronomical. In terms of waking, especially some of these anti psychotics, the older antipsychotics, the risk for it all. Um, quite typing lithium lands up in a swell as antidepressants, usually some of the older ones or the ones used by psychiatrists less frequently used by primary care providers or endocrinologist s so you can see this whole list. We already talked about the diabetes medications. Um, beta blockers often overlooked. Um, I think in the past, a lot of providers use this as a new early line medication for hypertension, but they're really not the best hypertension agents. And they do have other effects, including mood and wait. So if you do need a beta blocker, I usually recommend carvedilol because it has less metabolic side effects. Um, and then this right hand column has alternatives to those medications, and the ones I put in bold are things that I sometimes use off label like be appropriate in, uh, to appear, um, ate some of the GLP ones that form and meaning off label because they're not necessarily FDA indicated for the reason I'm using them. For example, I might use metformin in a patient that doesn't have diabetes on DSO just to show you what's out there. I'm not using SLT to use off label, and hopefully I'll be able to touch on that in a little bit. Um, I feel comfortable doing this. I know a lot about these medications and the risks and side effects and benefits. But the endocrine society recommends against using agents that are not FDA approved for weight loss solely for weight loss and less backed by significant research and a provider who feels really experiencing weight management. So if you are not fully comfortable, I would recommend referring to someone so FDA approved weight loss medications. They're indicated for anyone to be in my greater than or equal to 27 with a co morbid conditions like hypertension, hyper lymphedema, diabetes or being my greater than 30. So our patients with diabetes, most of them have a being my greater than 27 meaning that they qualify for use of a weight loss medication. Unfortunately, only 2% of patients who qualify for a weight loss medication in this country are actually receiving weight loss medications, and that's a whole other problem that we could talk about at another time. Weight loss medications can both augment weight loss and improve adherence with behavioral interventions. Unfortunately, weight loss medications have gotten a bad reputation because of the historical, um, medications that were out there. The Fed funds, the Meridia. Um, but newer medications are not necessarily stimulant medications have better long term data and are a little bit better study than they might have been in the past. Okay, Most important evaluate for response to medication. After about three months of use, if not down 5% of body weight, they should be considered a non responder, and the medication should be stopped. So what is out there? We have Benjamin, which is still the number one most prescribed weight loss medication in this country. We had Bell, Vic or Lord Catherine, but earlier this year it was withdrawn from the market. There were some concerns when they analyzed their five year data that there was an increased risk of cancer. Um, the placebo arm had about a 7.1% incidence of cancer. The pelvic arm had 7.7%. And then, when they actually looked at the breakdown of cancers, there were some that were more common in the Bell V group. I honestly, I'm not completely convinced that there was a relationship between the medication and cancer. Um, but really, I don't think the medication was doing that well in the market, and I don't think they're gonna fight it. So I think it's gone for now, probably forever. We have casino, which is combination of sentiment into a pyramid. Contrary, which is a combination of naltrexone on bupropion sex agenda, which is the high dose Laura Gla tied Victoza is the lower dose used for Type two diabetes. We still have Zeneca Lahnd Ali, the orlistat one, which is available over the counter. The rest of these medications, they're all prescription medications and then a new medication that I will jump into called planete, which is technically a device. A jealous ISS hydrogel capsule and more are coming. I'll touch on that quickly. Um, here's a comparative efficacy of weight loss medications. Hopefully, you can see this afterwards. So jealous ISS is an aural, super absorbent hydrogel made of cellulose and citric acid. It forms these like little micro gel beads essentially when taken with a glass of water before, before, um, a meal. It's not considered a medication are pills. Consider device which makes it unique. It's currently approved, but Onley prescribed by designated providers. We happen to have one of the P i s from the studies working at our clinic. So within our clinic, we do have over 20 patients that have been on it. It's given in a capsule form with water before a meal. Here is general weight also over time, this is about six months. So down here is three jealous group and this is about 6.4% body weight loss. At the six month mark, the placebo group, which still did lifestyle intervention, lost 4.39% body weight, which is actually pretty good. And you can see in terms of the jealous versus placebo, how many people were weight loss responders and all of these were clinically significant. But in terms of responders who lost greater than 5% about, I think 58.6% of patients in the jealous group versus 42.2 and then up here is the greater than 10%. So a quarter of participants were actually able to lose 10% of their body weight within six months. What's good about it is, it has a pretty good safety profile, lower being my requirement. You can prescribe it down to be in my 25 which is also unusual pecans or G ay side effects, especially bloating, nausea and abdominal distension gas. One thing that's interesting is in the subgroup analysis. It seems to do better in patients who have prediabetes and diabetes, which is unusual, and probably because people with diabetes, pre diabetes PCOS have this insulin resistance state. And they're just more refractory to weight loss Because, like I said, when insulin is high, it promotes that storage and really tries to inhibit that breakdown. So you'll see appear on the top. These air patients who had normal like Simic values prior to the study. You know, you know, 58% loss greater than 5% body weight. But in patients have prediabetes, or type two diabetes who were not on medication, 72% of those participants lost greater than 5% of the body weight. And throughout the three different amounts of weight loss, it seemed like there was a greater response and patients with diabetes, so that is something to be aware of. The products seem to be related to a lowering and fasting blood sugar more so than the placebo group, although they also had some lowering the blood sugar. What was more significant is there serum insulin levels really seemed to improve even more so than the placebo group, which seemed thio potentially have increased. So why, that is, I have theories perhaps related to the absorption of food and glucose that was consumed related to this gel like state. But I'm not entirely sure, so we'll hopefully see more good data on that. What's coming? There's a lot coming. We're going to see High Dose, some blue tide soon and once a week injection, including GLP ones with Luca gone type formulas, Amylin weekly injection and combos with Amylin. Um, here's a Orel Ghrelin blockade. Um, tres appetite, which is a a product coming out. I think hopefully on the sooner side of is a combination of a GLP one plus, the G I. P, which is a weekly injection which was has in study, has been proven to be quite potent. So I'm excited for that. Um, there's a synthetic leptin out there for a rare leptin deficiency condition and set milana tied, which works at the EMC for our receptor, which is involved in society, which is used in some rare genetic conditions. Then glue gone and P y Y are coming soon. So is weight loss surgery an option? It might be covered by insurance. Most insurance companies do cover it, so if you have a B M I greater than or equal to 35 come over conditions or greater than 40 without any, it's usually covered, the 88 recommends. Actually, considering it for lower BM eyes. If you're of Asian background, that's because usually people of Asian Indian backgrounds tend to have more central obesity, which is indicative of more visceral fat deposits. But you know, this is not yet FDA approved, so actually, getting coverage through insurance companies is highly unlikely. Weight loss surgery is likely to offer the best chance for long term weight loss, and I know patients are really resistant to it, and we always have these conversations. The truth is, if patients have struggled with their weight for their entire lives and have tried everything, which is the vast majority of patients who come see me, it might be time to start thinking about something different because if we keep trying the same things over and over, and it's just not working, Um, I think keeping an open mind is important. So what's out there? Here's what's out there. Although most people are no longer doing the lap band, stomach balloons or temporary means they're only approved for six months of use. And aspire Cyst was like this kind of like a peg to where you actually withdrew food from the stomach, which I think grossed a lot of people out. But the sleeve in the gastric bypass, there's still the two most common. The resolution and reduction of co morbid conditions after surgery is still unprecedented, really amazing. And most importantly, quality of life has improved in about 95% of patients. I very rarely have patients tell me I wish I didn't get surgery. They usually say, I wish I got surgery earlier. Um, there's some data the stampede trial in particular comparing intensive intervention versus surgery for, um, Type two diabetes treatment. So thinking of this not just as a bariatric surgery but as a metabolic surgery, and that has become a theme where we're now calling us a metabolic type of surgery on Duthie intensive medical therapy. Got everything. The newest drugs. Um, good. Follow up dieticians. And still over time. This is one month data a one C was better. These air down here, the sleeve gastrectomy in the bypass, a one c improvement was better than those with intensive medical therapy. B m I The weight loss of the year was better. But, Dr, if I have weight loss surgery, I'm going to regain all the weight because I had a cousin and I had a coworker who lost £100 and she regained all the weight. So I know what's gonna happen. Is that true? In a Swedish prospective controlled study of over 4000 obese patients, Um, at one year, you'll see here, um, this control group, the yellow is the banding. The purple is the sleeve gastrectomy, and the green is a gastric bypass. That one year, Yes, everyone sort of reached their nadir, and there was some weight regain. Right. So 234 years. Yeah, there was weight regain. But look over here. This is 15 years out. They did not regain all the weight that they lost and Here's the percent and change of weight on the Y axis here. So people who had a sleeve gastrectomy, or gastric bypass at 15 years had maintained a weight loss of 16% of sleep group, 25% total body weight loss in the gastric bypass group. Um in the control group, they were plus or minus 2%. So long term, absolutely. Surgery is the most likely to result in success. And most importantly, people have had surgery 15 years out. Their likelihood of dying is better than those who were in the control group, And that is likely because of the reduction of CO morbid conditions like diabetes, high blood pressure, sleep apnea, Onda all the other things that come along with being overweight, including malignancy. So please don't rule out surgery just because it's invasive. Remember the five pillars of weight loss and refer. Early maintenance is hard. Your body is fighting to regain the weight, so pick a diet that you think will be sustainable for your patients. For the long term, remember, just 5 to 10% weight loss is a success. As soon as someone starts to regain weight, find measures to counter act it, refer them to a program. Increased exercise, lower calories, Add medications. Refer the new dietitian or weight management center, such as ours, because that is a critical point of time when you really want to stop this yo yo effective weight loss. I think I went through all this in detail, so I'm going to move ahead and just say thank you and turned to any questions. Thanks so much, Samantha. I realized it's an enormous amount of data to have to cover in a very short time period. But you covered the highlights and the updates really, really well on what's going on in this topic. We do have a couple of questions I wanna ask you before we move on to the next speaker. What is from one of our primary care physicians? Joyce, Who's saying, How much weight gain is it? £3 or £20? Um, that's occurring in some patients on some of these very commonly used medications meant Oprah, LOL, Cymbalta, gabapentin and these are medications that are very commonly used in their primary care practice. There was so valuable, and yet you know what is the effect and what that that's a great question, and and the truth is, um, it's really variable. So a lot of this is dose dependent. The beta blockers. Yes, they lower your metabolic rate by a couple 100 calories potentially per day. So if you just do that, Matthew could say, Oh, just a few pounds. But keep in mind, it also makes people more tired, and it can make people feel more sluggish or depressed. So their desire potentially to want to lose weight or to do exercise their ability to even increase their heart rate when they're exercising is diminished. So it has a bunch of other effects things like Gabba, Gabba, Penton, very dose dependent. So if someone is on 100 mg 300 mg, just a bedtime for some type of sleep disorder, um, not quite is concerned, but when they're on 1200 mg three times a day for diabetic neuropathy, then I'm like, Okay, this is probably having effect. Um, the antidepressant Cymbalta is it is super highly variable sometimes depends on duration of use, dose of use. Um, but also, if somebody is depressed, that can affect their eating habits. So if you treat the underlying depression they might eat more or they might eat less. So it's honestly, it's super confounded and hard to really study, but it varies. Some medications, like the antipsychotics we're talking £30.40 pounds, £50. Their patients I've had I've had patients who have gotten, you know, progesterone Onley, types of birth control. Um, Depo Provera. Next plan on who have gained £50 unexplained where The Onley thing that they can account for young, healthy women. The only thing they can come up with is this birth control. So and But you know, the data doesn't usually say, on average, these patients usually game, you know, maybe 5 to £10. But when you take an individual who is unfortunately, that person who gained £40 from it, it could be really profound. And it's hard to predict. Yeah, alright, so it sounds like you have to weigh the pros and cons, and are there other medications that could be offered in place of these that might have less of an effective yes. So hopefully that column showed good alternatives. There is also some data of offsetting the waking from the psychiatric medications, so there's data for Topamax there's, uh, a pyramid, I should say. There's also data for Met Foreman that in conjunction with some of these anti psychotic medications, it can offset waking or mitigate the waking. But again, that's off label. So if you are not necessarily feeling comfortable, you're not well versed in using those medications. Like please find somebody that you have confidence. And to do that great. I'm gonna ask you one more question. We have a couple more, but maybe during the breaks, Samantha and the chat section can answer a few more of these. But, um, what would you tell a patient with Type two diabetes when Donna Keto diet 20 g of carbs per day? So that's pretty limited has hyper lip Adina, but the A one c improved tremendously. You alluded to this that, you know, by going on some of these diets, you have weight loss. You have less carbon take. You are going to improve your A one C, which is a benefit. Um, e don't know. What do you know? This is an excellent question and a huge debate. A debate amongst providers who are involved in weight management, A few things that I often recommend one l D l C is not necessarily perfect. There are some flaws to it. Um, sometimes if you dio NMR type profile breakdown and you look at the l. D. L. P, it might tell you more about the quality of the LDL that's present. So it might be the fluffy puffy, the less afra genic. Um, people on low carb diets have great improvements, usually in triglycerides. The LDL is variable. Half of people have improvements of LDL. Half of them have increases. So, um, while people are actively losing weight, sometimes those lipid profiles or not as accurate, especially in terms of LDL so often times I'll do an NMR profile, um, to see what the risk is. And I'll also recommend, perhaps once they've reached a more stable level, repeating the lipids if they do not want to go on medication therapy or just want to monitor, See, you know, six months after they stabilized 6 to 12 months after their way to stable what's happened to their lipids? Um, I'll recommend perhaps a reduction in the saturated fat intake, replacing it with mono and polyunsaturated fats. So we focus on things like nuts and avocados as opposed to the butters and the coconut oils and the fat, Um, recommending grass fed meat instead of grain fed meat. And then, obviously if we're really worried, But we feel so good on a low carb diet, then perhaps considering a medication for the Hyperloop Adina would be a good option at that point. Yeah, that's great, thank you. And one thing I know you mentioned this, but certainly a statin therapy, as I mentioned early on, is really recommended. If they have Type two diabetes, if they can tolerate if there's no contraindications and that really could go a long way and lowering that L D l and reducing the burden on at risk cirrhosis and then adding other medications, if if needed. In addition to the status now, the A B a is is making those recommendations as well as the A C C h j Yes, absolutely. This was great. Thank you so much. I'm actually gonna turn it back over to you, Samantha Thio, introduce our next speaker to really speak about some important topics related Thio Primary care physicians