Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. This week I want to revisit the prevalence of OBESITY, and why it matters.
I started Performance Medicine 17 years ago with the sole purpose of getting people leaner. Writing prescriptions and piling medicines on people (my former way of practicing traditional family medicine) wasn’t solving their blood pressure problem, nor their cholesterol, diabetes, arthritis, or depression. Adding fuel to the fire, those years included two of my three children being diagnosed with Type 1 Diabetes. Thus, my fight is to find the root cause of disease.
Two thirds of Americans are either overweight or obese, and it’s getting worse. Moving forward, as I continue to study the health effects of OBESITY, it is becoming more and more clear to me the things we need to know.
For starters..
Eat Less, Exercise More?
When you go to the doctor and they tell you to lose weight, your first response is usually, “how?”. Often, the words you hear back are, “It’s simple! Just eat less and exercise more.” Well, that really doesn’t work. I’m not saying you can’t, but it’s almost impossible to cure obesity on your own. You certainly can’t do it by diet and exercise alone.
We need to start thinking of obesity as a chronic disease (which I firmly believe that it is). Obesity is a chronic disease just like hypertension is a chronic disease. There are many factors involved that contribute to a person’s obesity.
- Psychological
- Genetics
- Hormones
- Sleep
- Poor dietary knowledge
- Poor habits
- Lack of exercise
Obesity is really a problem of metabolism. A mistake that people often make is thinking they can start a diet (or even a medication) and once they lose the weight, go back to their normal. NOT. The weight comes back and they have to start all over again. Lesson learned: A chronic disease needs lifelong treatment. I always tell my patients that life isn’t fair. You may eat way less than your skinny friend, and yet they are skinny and you’re not. Plus, it gets more difficult as you get older!
Obesity is a chronic disease, and it’s also being controlled by many factors including HORMONES. Hormones like:
- Insulin (insulin resistance)
- Cortisol
- Estrogen
- Testosterone
There is also a certain amount of GUT HORMONES that you may or may not have heard about:
- Ghrelin
- Leptin
- PYY
- Neuropeptide Y
- Cholecystokinin
- GLP (Glucagon-Like Peptide)
These gut hormones are released by the gut, signaling when you are full (basically controlling your appetite). The different functions of your gut hormones relate to what you weigh. Some people tell me they can control their hormones. My response is, “Can a woman control their ovulation? No, they can’t. Likewise, you can’t control your gut hormones. Granted, you can starve yourself and lose weight, but eventually you will gain it back unless we find the answer.”
Your mind can’t control your gut hormones, but you can certainly help them out. TWO things I always tell my patients: (1) Eat less carbs and (2) practice intermittent fasting. Both are helpful, but if you’re battling obesity, you might want to think about adding medication. Note: If you just cut down your calories, your body’s going to go into a lower metabolism. It’s going to be that much harder to lose weight. If you go on a diet (even with assistance) and then get off that diet or medication, you’re most likely going to gain the weight back, unless you’re in that 1-2%.
Medications For Weight Loss
Out of the 50% of those that qualify for a weight loss medication, only 2% are getting treatment. That’s because a lot of people (even doctors) don’t know they qualify, or doctors for some reason won’t use medication.
Through the years, weight loss medications have gained disfavor and some have even been pulled from the market. There are factors that need to be considered before going on weight loss medication. Some are stimulants. One in particular I will emphasize in this next section. But before moving on, please note there are many factors to weigh before deciding whether or not to go on medication for weight loss.
GLP-1 Receptor Agonist: The Game Changer
To me, the GLP-1 receptor agonists are the drugs of the century. We started out with Victoza and Saxenda, medications that are really for diabetes because they do help control blood sugar. Note: In my opinion, a lot of weight gain is caused by fluctuating glucose control. In fact, I think the majority of it is (along with the gut hormones previously mentioned).
It’s 2023, and I don’t know of any drug that’s come close to helping as many people as this class of drugs, the GLP-1 receptor agonists. It not only helps you lose weight (and get off a lot of medications you didn’t need in the first place), but it also protects your heart, kidneys, and helps to reverse non-alcoholic fatty liver disease. The GLP-1 receptor agonists are also neuromodulators, so they actually improve your mood! Note: I’ve had several patients tell me this. This really is a game changer. We’ve seen unbelievable results from it.
WEGOVY is the one GLP-1 receptor agonist that is FDA approved for long term sustained weight loss. It’s also the most studied. As I have mentioned before (but will say again), Wegovy and Ozempic are the exact same medication, both branded by Nova Nordisk. Ozempic was formulated to help diabetics control their blood sugar, but because we’ve used it more for weight loss, Nova created a second brand name, Wegovy (the exact same medicine/semaglutide product but using different dosages, and a different way of operating the pen). Note: The good thing about Wegovy is that it’s once a week, which I really like. It works, AND insurances are starting to cover it!
I recently attended a seminar that disclosed recent studies on Wegovy. One was a 68 week trial that showed a 15% average weight loss on Wegovy (15% of your body weight, which is an average of 35 pounds). One third of the people lost greater than 20% of their body weight, averaging out to be 46 pounds. That was the average weight loss!
To qualify for this drug you need to have a BMI of greater than 30, OR a BMI greater than 27 with 1 comorbidity, i,e.,
- Hypertension
- Diabetes
- High cholesterol
- High triglycerides
Wegovy has also been approved for pediatrics. For age 12 and older, you have to be in the greater than 95th percentile for your BMI to qualify.
The most important thing I’ve learned about this drug (and by looking at all of the studies) is that you need to stay on the medication. The important thing is sustained weight loss. I can’t tell you how many times I’ve helped people lose weight just to see them gain it all back. It’s very difficult! You must remember, it’s gut hormone related, and one of the functions of this medicine is to send signals to your brain that your stomach is full. Note: it works four different ways, but that’s the main one that helps you through a gut peptide that you probably didn’t even know you had.
Most people that have a weight problem are going to need to stay on Wegovy (along with a better diet and of course exercise). Note: Exercise is the best overall thing you can do for your health, but don’t count on it as a weight loss tool.
So far, Wegovy is the only once-weekly GLP-1 receptor agonist for chronic weight management, with significant sustained weight loss. In the studies, when patients stopped the medication after reaching their end point, they gained back an average of 6% of their body weight. That’s a significant amount. I’m not against trying it, but just realize it’s an uphill battle, and if you have a significant problem with obesity, you’re probably going to need to stay on this medication.
Side Effects
The main side effect is nausea, because it delays gastric emptying. You’ll definitely learn to eat in small amounts, and not too much. Some people get constipated. Most of my patients have been able to take Wegovy. Most of my patients have stayed on it.
You can’t take it if you’ve had recurrent pancreatitis or medullary thyroid cancer, or something called MEN Syndrome 2 (Multiple Endocrine Neoplasia, which is an array of endocrine cancers). Again, these are very rare. Note: I tell people if they get severe abdominal pain (and vomiting) while on Wegovy, stop taking it. Also, if you’ve felt a lump in your neck on Wegovy, let us know.
Lack Of Insurance Coverage
The main problem I’ve had with this group of medications is insurance coverage. Note: these medicines are expensive. BUT, I think Wegovy is probably going to be covered for many people.
Final Thoughts
Obesity matters. If you have a significant problem with your weight, you probably need the help of medication (like Wegovy). As an integrative functional medical doctor, I’m all for natural stuff. BUT, as an integrative functional medical doctor, I’m also a blend between traditional and alternative. And when it comes to the fight against OBESITY, I’m going to take the best of both.
If a patient is struggling to lose or maintain their weight loss, they may need medication to help. Think about this new class of medications that can help you get the weight off, and keep it off. Note: I firmly believe that you can learn how to eat a lot better. When I started Performance Medicine, I had to relearn everything about nutrition. It’s a huge factor.
At Performance Medicine we’re here to help you figure this whole thing out. We are with you in the battle against obesity.
Till next week.