Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode. We are going to talk about a very important topic, which is anti-obesity medications, or more commonly known as weight loss medications. And if you have been having questions, wondering if weight loss medications may be part of your journey, if they should be part of your journey, who is a good candidate for them or not for them? This is going to be a great episode for you and I want you to stay tuned. Even if you're someone who's like, no way, I'm not going to use medications to support my weight loss goals. I believe very strongly in informed consent. And so even if you've decided, you know what, I do not want that to be part of my journey, I want you to take a listen to today's episode and see do you have all the information that you need? When you think about using medications to support your weight goals, have you considered all of the different options? Have you ever met with a physician who is board-certified in obesity medicine to talk about your individual concerns, your individual medical conditions, and what may or may not make sense for you? I want everyone to come into today's episode with an open mind and we are going to be talking about all of the weight loss medications, some of the popular new ones like Wegovy and Zepbound, but then all of the oldies, but goodies too. And we know that there are lots of medications that depending on the reasons by which you're struggling with weight may be a really good fit for you. Before we get into today's episode, I want to ask and invite you guys, I will be interviewing a bariatric surgeon in a couple of weeks, and what I would love to hear is if you've been thinking about having metabolic surgery, weight loss surgery, bariatric surgery, you'll hear all of these terms used. If you're like, huh, I wonder if I might be a fit for that, I want you to send me a message. You can go to www.sarahstombaughmd.com, you'll find the link in the show notes. Go to the contact me page, send us a message. What I would love to know is do you have any questions when you're thinking about yourself and having bariatric surgery? Are there any considerations that you would want to make sure that are addressed in the podcast? I'm really excited to interview him and I would love to ask, have all of your questions answered, so please do share those with me. I will be recording that episode about one or two weeks after this episode goes live, so please do reach out with that information. Alright, let's dive in and talk about the use of anti-obesity medications, otherwise known as weight loss medications. So it's really interesting because in the last couple of years there's been a big popularization of weight loss medications. There's been a lot of conversations about things like Ozempic, Wegovy, Mounjaro, Zepbound, all of this talk about a group of medications called the GLP-1 receptor agonist. Now, this is not a new group of medications. Interestingly, the earliest medications in this category were FDA-approved more than 20 years ago. So we have really great safety data for these medications and some of the new ones as they've developed these a little bit more have become less frequent. Some of the old versions were twice daily or once daily dosing. And then some of the newer medications that we're using are once weekly injections and they are effective both for the treatment of type two diabetes as well as for reducing weight. We also know they recently in the last year got FDA-approved for the treatment of cardiovascular disease and cardiovascular risk reduction for patients who've had heart attack or stroke or other cardiovascular disease in the past. So this group of medications has been all over news, all over social media. You hear about them all of the time, and so a lot of people who come into my practice either for good or for bad think, okay, I'm going to leave with one of these prescriptions, and while that may be an option, there are a lot of other medications and let's spend some time talking about some of the different medications that are available and why we might choose one versus another medication. So for starters, I want to take a step back and think about what is the purpose of using medications for the treatment of weight and who is a good candidate for these medications. So officially, in order for a medication to be FDA-approved for the treatment of obesity, it needs to have undergone studies specifically for that purpose and then seek FDA approval for that. So we do know there needs to be at least 5% total body weight loss on these medications. There also needs to be that those have beneficial approved. So some of the older medications, like we'll talk about metformin for example. We'll talk about some of the individual ingredients of some of these medications that can have an impact on weight, but actually aren't even specifically FDA approved for the treatment of obesity. Now, who is a good candidate for these medications? People may be a candidate for these medications if they have a BMI of 30 or higher or people who have A BMI of 27 or higher with a weight related comorbidity or another weight related medical condition. So when we think about weight related medical conditions, we think about things like high blood pressure, high cholesterol, diabetes or pre-diabetes, liver disease, things like arthritis, and there's many others as well. These are some of the more common ones that we use when we're thinking about comorbid conditions, things that are related to weight. So patients who have either that BMI of 30 or higher or 27 or higher with comorbidities may be indicated to use these medications based on the FDA approval for the use of anti-obesity medications in general. Now, one of the challenging things comes in is that at this time I hope someone will listen to this podcast five years in the future, and this will not be true, but as of 2024, there is not universal coverage of anti-obesity medications. So patients when they have commercial insurers, so when they have a traditional insurance plan with their job, for example, companies will opt into or opt out of treatment for obesity. So if you work for a company that does treat patients for obesity, you may have coverage for these medications. But if you work for a company that does not have coverage for obesity medications, there's nothing I can say, there's nothing a primary care physician, there's nothing anyone can say in order to get these medications covered if your employer has opted out of treating obesity. Similarly, at this time, there is not Medicare coverage for obesity treatment, although these medications may be covered for the treatment of type two diabetes sometimes for the treatment of cardiovascular disease reduction. So there are some times in which they are approved, but specifically when we're using it for reduction of weight, they may not be approved and they're not approved by Medicare insurance issues and insurance coverage at this time. And unfortunately, one of the biggest considerations that we have to make in choosing a medication to support weight loss goals. You hear a lot about these newer medications, the Wegovy, Ozempic, Mounjaro, and Zepbound, and while those are really phenomenal medications, I want to take a minute and talk about some of the other ones as well because they don't always get the same press, but there's been some really interesting studies to say that these medications can actually be really pretty effective. So when we look at weight, you can imagine that there are different reasons by which people struggle with their weight. There are people for whom feel like they have cravings all the time, feel like their mind is constantly consumed by thoughts of food, and there are people for whom they feel like they have just a ravenous appetite. They are just hungry all the time from when they wake up to when they go to bed. They're just constantly hungry. There are other people for whom in addition to or on its own may have insulin resistance, a condition by which predisposes them to things like prediabetes or diabetes where their body responds in a hyperactive way to any sort of carbohydrate or sugar load. And when we start looking at these different ways by which people are struggling with their weight, one of the things we can start to look at, is there a way that we can match medications to the specific reason that they're struggling? And the great news is that yes, actually a lot of times, even when we set aside these new medications that everyone's excited about, but they may be really expensive, there may not be insurance coverage. And so if you're someone who's in that position and you're thinking, oh gosh, and there's just nothing available for me, the good news is there may actually be other medications available. So I want to spend a minute and talk about those a little bit. So one of the medications that is FDA approved for the treatment of obesity is a medication called Contrave. Now, this is a combination of two older medications. It's a combination of bupropion and a combination of naltrexone. The bupropion medication is commonly used for the treatment of depression, although we know that it has this effect on the dopamine hormone such that it downregulates some of that urge and craving pathway. It's also commonly used for example, in the treatment of smoking cessation. So we know that some of those cravings and urges, whether it's smoking, whether it's food, that there's similarities among those things, naltrexone is a medication commonly thought of as used in opioid use disorder. When this medication is paired together, it helps to make the bupropion even more effective. So branded contrave actually is fairly affordable, usually on the order of about $100 per month, even if there's no insurance coverage. But then we can actually separate it out and prescribe the individual components, the bupropion component and the naltrexone component, and that can make it really, really affordable. So a lot of times patients are able to get this medication for $20 a month, let's say. There's also a medication called Qsymia. Again, this is a medication that is a combination of two different medications. It's a combination of topiramate, which is a medication that's used primarily for the treatment of seizures, but the way that it downregulates some of the nervous system, it's also used very commonly for migraine prevention, maybe used in treatment of things like anxiety for certain pain syndromes, for example. And then combined with phentermine, which is an appetite suppressant. And those two medications work in separate ways in order to reduce appetite. And so this medication either branded as medication, Qsymia, again, ends up being about a hundred dollars per month, even if there's not insurance coverage for it or those two separate medications, the phentermine component and the topiramate component can be prescribed and used together, and that is often pretty cheap. Again, on the order of $20 a month or so, we also often can prescribe some of these medications on their own. So depending on other medical conditions that someone has, for example, depending on how they tolerate certain, we may be able to prescribe some of these different components. I also earlier mentioned the medication. Metformin. Metformin is a medication that is FDA-approved for the treatment of type two diabetes. We use it pretty commonly also in pre-diabetes when we see elevated blood sugars and some of those early signs of insulin resistance, and even on its own, there's some data to show that there is weight reduction with this medication. Now metformin has been around since the eighties, so it is never going to get FDA-approved for the treatment of obesity. It also shows pretty moderate, moderate reductions in weight, so sometimes three to 4% on average, although when it's combined with other things, and especially when it's used as part of an intensive lifestyle regimen, overall, people can find that this may be a really effective part of their overall treatment to support weight. So there's a lot of different considerations here that we can use. A lot of times we didn't dive in too much to the GLP-1s, have some great episodes on those in the past. But if there's coverage for medications like that Wegovy, like Zepbound, like Saxenda, or some of these other medications that are more affordable, there's really a lot of different treatment options that may be available. So one of the biggest, honestly, maybe the biggest concern that people have when they come to talk to me is not about the side effects. It's not about the coverage. It's just about this idea that, gosh, I really don't feel like I should have to use a medication. Shouldn't I be able to do this on my own? And I want to say that it is incredibly challenging to lose weight on our own, whether that means with or without obesity medications or just simply on our own without the support of a comprehensive team. When we think about losing weight, there are many factors that come into play and the hormonal aspects that make our hunger really go up, that make our cravings really go up when we're losing weight can make it incredibly challenging to lose weight, especially then you layer on things like insulin resistance, and our body is really holding onto fat in a way that our bodies don't necessarily do if there's not insulin resistance. So working with medications can be a way in order to support all of the efforts that you're making. I think a lot of people think about weight loss medications as I'm going to use these medications and it's cheating, but it's not. These are patients who are following diet recommendations, they're following exercise recommendations, they're addressing their sleep, they're addressing their stress levels, they're doing all of these things and it's not working, and it's not working in an effective way that they want it to or that they feel like their body should be able to respond. And the cool thing about the medications that support weight loss is that they are very effective in allowing all of those other things that we're doing to become more effective. So eating right, moving your body, getting good sleep, managing your stress, all of that is still important. And when you combine that with medications that can support your weight loss goals, it is absolutely a phenomenal package to support long-term weight loss reduction. Another question that people often have is, do I have to take these medications forever? And the answer is probably yes. In general, these medications are designed for long-term use. When we look at the studies of these medications, when we look at how people use them, they are designed to be used over a longer period of time. That being said, there are certainly stories of patients who've used these for a temporary period of time and have found that they don't necessarily need them anymore, just depending on many, many factors. But similar to, let's say you have elevated blood pressure and you've been prescribed a medication for your blood pressure while you're taking that medication and you're checking your blood pressure numbers, you may find that the readings are exactly in a range where you and your doctor have discussed, but if you were to stop taking that medication that you'd see that those numbers went back up. And as a result of that, we know that those medications are designed to be used for long-term. Similarly, in the role of weight loss, these medications can support our body when we're continuing to use them. So it can be common that if these medications are discontinued, that patients may find that they have issues with weight regain. Another thing though is that cost-wise, insurance coverage wise, it can be really challenging because you may have coverage for a medication like Wegovy or Zepbound, which are notoriously expensive out of pocket. These medications can range $1,000 to $1,500. And if you have insurance coverage for that, and you're getting it for let's say $20 a month, and now all of a sudden you switch jobs or your employer changes coverage, for example, you may be finding yourself in a place where there's not coverage. We can consider switching to other medications. Are there other things that we can do to support you and your goals? And oftentimes the answer is yes. Another thing that I want to consider is that even with medications, it doesn't necessarily mean that you're going to get to your ideal weight. So a lot of times we have this weight number in mind, and we may be able to get your body to a weight that makes sense for your age, for your activity level, for your movement level, for all of these things. And when we look at the studies of medications for the treatment of obesity, we do want to make sure that our goals are in line with how these medications support us. And so on average, some of these medications may produce 10 to even up to 26% total body weight loss, which sounds great. And it absolutely is. We know at those numbers, we start to see a risk of high blood pressure conditions dropping, kidney disease, heart disease risk, cancer risk. All of these things start to really decrease when you've had that amount of weight reduction. And it's important starting out your weight loss journey that you have realistic expectations that let's say you are living in a 300 pound body, if you lose 10% of your total body weight, that's 30 pounds, which may make a huge difference in your ability to move and some of your other factors, but we're talking about 270 pounds now. Or even if some of the most effective medications, losing 26% of your total body weight would be a reduction of 78 pounds, putting you now at about 222, recognizing of course that these are averages. There are people for whom these medications are more effective. There are patients for whom these medications are less effective. And what we know across the board is that when we combine medications with nutrition, with movement, with sleep, with stress management, that all of these things support us in having the best response possible. The other thing though is that the result is not instantaneous. I think sometimes the way these are portrayed in the media or portrayed on social media, it seems like people just lose weight overnight. And it does happen really pretty quickly in sort of the grand scheme of things. But if you imagine losing, let's say, one to two pounds per week, that can take a while. Let's say you have a hundred pound weight loss goal. If you're losing a pound per week, that will take you two years to achieve that. And in the grand scheme of your life, that is such a short window of time. But when you're in the thick of it, you're still very much in the day-to-day making these decisions that will be best in line with your health. So it's not instantaneous, but it can absolutely support you in your goals. So if you've been listening to this and thinking, oh gosh, I wonder, should I consider medications like this? Are there things that my insurance covers even if I don't have insurance coverage, are there things that I could consider that might be a good option for me? That is an excellent question to address with a board certified obesity medicine physician. If you go to the American Board of Obesity Medicine website, you can find they have a physician finder where you can find people who are certified in obesity medicine. I will put the link to that in my show notes. You're also welcome to reach out and ask me any questions. You can find my information on the contact me page, and if you live in Illinois or Virginia where I'm licensed to practice medicine, I would love to support you in your weight loss journey. You can learn more about me and my practice at www.sarahstombaughmd.com. All those links are in the show notes page. I can't wait to see you all next week. Thank you so much for joining me. Bye-Bye.