Bob Underwood, MD (Host): It's common knowledge that America is experiencing an epidemic of obesity, and this issue impacts individuals, lives, and families. And while the use of diabetic drugs for obesity treatment is not entirely new, we're continuously building our understanding of mechanisms of action, safety profiles, and long-term effectiveness to help address this epidemic.

This is Expert Insights with the Carle Foundation Hospital. I am your host, Dr. Bob Underwood. We're going to explore some of the impacts of using diabetic drugs to treat obesity with Carle Health family physician, Dr. Brandyn Mason.

On Expert Insights today, we'll shed some light on the obesity pandemic, discuss the use of diabetic drugs, along with lifestyle changes for obesity management. Dr. Mason, it's good to have you join us today. Thank you for coming on to discuss this important topic.

Dr. Brandyn Mason: Well, thanks for having me.

Host: Yeah, absolutely. So, we understand that America's got an obesity epidemic. How does that epidemic really influence your approach as a family physician at Carle Health?

Dr. Brandyn Mason: I mean, you can look at kind of just the epidemic numbers even. I mean, currently, there's no state or territory within America that has an adult obesity prevalence under 20%. DC is between 20 and 25%. There's six states between 25 and 30%, but 22 states between 30 and 35%, 19 states between 35 and 40%, where a bulk of the obesity epidemic lies an adult population between 30 and 40%. We look at this and you say, "Okay, the disease state continues to climb over the last several decades with reviewing, CDC data from 2011 to 2022," which is the last available set of data. You can see that this continues to climb, and will continue to do so unless we start approaching this as the disease that it is.

So, the problem is there's a certain stigma that comes with obesity that centers around the patient's need for a better diet and exercise as the sole reasons and rationale for them being obese. But there's plenty of data to indicate that there are several other factors that contribute to this disease state, including industrialization, which changed our food production and its abundance; cultural influences affecting the intake of energy-dense foods, and their lifestyle, plus the attitudes toward body image. And so, we look at this and say from a patient perspective and family medicine, we need to consider that person in its entirety, including their mind, body, spirit, and all of that has to be part of the discussion. So, obesity has 60 at least comorbid conditions associated with it, including migraines, sleep apnea, dyslipidemia just to name a few. And all of these can be really improved if we treat the underlying condition, which is the obesity itself. So, it does affect a lot of what we do from a family medicine perspective, because there's a lot more of what we need to do, and there's a lot of misconceptions about obesity and the treatment thereof, including the fact that most individual patients believe they need to get to a normal weight in order to reverse some of these disease states. But most of the studies demonstrate just 5-10% weight change is really all that's needed to show significant improvement in almost all the symptomology of most of these diseases.

Host: And I love the approaching the whole person, in terms of addressing the obesity disease state. I think that that's a great way to look at it. And I think that's a misconception even among providers, I would say. So, can you discuss the impact of diabetic drugs for treating patients who suffer with obesity?

Dr. Brandyn Mason: There's a number of different medications that are currently available to treat obesity on the market, but none have really been shown to be as effective as those diabetic medications, namely from the classes of the GLP-1s and the GLP-1/GIP group. They really demonstrate, you know, about a 15-25% weight loss on average on their own. But there's a lot of things that go into how this works. Is it safe for everybody? But one of the bigger issues that we run into is these medications vary on coverage and affordability, based on their insurance. And without insurance assistance, they can be very cost-prohibitive. And so, we have to mind that, and there's also warnings and possible side effects that need to be monitored for these medications to be used. And we found that, generally, a slower titration allows for a better tolerability of that medication. So, sometimes you see things where people kind of move through quickly to get to a higher dosage. But there's also the aspect of monitoring for obesogenic medications. Especially in diabetics, something as simple as switching from insulin to one of these other medications that may help with weight, they can maintain their same level of control for that disease state, but also decrease their needs of other medication and reduce their weight loss over the time. So, while these diabetic medications do help tremendously, they're not the only aspect of weight management that's out there.

Host: Sure. And how would you navigate a conversation with the patient about using these types of medications for the management of their weight?

Dr. Brandyn Mason: I think you start at the foundation, which is the conversation centers around the patient being the priority and what are they willing to do to improve their overall health? It's not about just treating the obesity, but what do they want to do? And understanding and helping the patient understand that this is a lifelong project for these individuals that requires an understanding of what they're going to be able to do and helping them set realistic expectations about what a medication can do and the understanding that lifestyle modifications are necessary for a sustained, successful long-term benefit.

And so, the conversation really centers around safety, overall health, with cornerstones of the treatment options. We ask that they use the medications as directed and follow up as directed, but we focus really on future success instead of past experiences and try to move away from that kind of learned helplessness that they feel from their previous attempts at trying to lose weight. We discuss that patients are indeed human beings, that it's commonly forgotten and address certain foods and behaviors as bad is not a good thing to do. Instead, when they say things such as, "Oh, I'm never going to do that again," we know that that really only sets them up for a future failure. And instead, we try to refocus and ensure that these individuals understand that they'll occasionally make decisions that may be viewed as less than ideal, but rather than focusing on that negative aspect and that negative verbiage, we really look at how we can turn that into a positive to build a better tomorrow for them. So, that's how we navigate through that conversation.

Host: Yeah. And I think that that's really incredibly important. Many patients do suffer from this. I've tried over and over again and been unsuccessful and they start to have, you know, kind of a defeatist mindset and naturally so. And so to approach it from that perspective, I think, is really, really important. And you just talked about it being a lifelong project. So, how important are lifestyle changes and modifications along with weight management and treating obesity effectively?

Dr. Brandyn Mason: As we mentioned previously, those lifestyle modifications, they're the foundation upon which all the other weight loss activities and medications are really built. And so, without those modifications, patients may experience some success with medical therapy. But generally, they're unsustainable and without the medications, they tend to revert back to their previous state. So, what we commonly see is that most individuals, when they decide, "Okay. Now, it's time for me to get to a more healthier weight, lose some weight," is they attempt to change everything about themselves overnight. You know, they start with these unrealistic goals of, "I'm going to go to the gym for an hour every single day and follow an extremely restrictive diet," which is generally unsustainable. And when they begin to catch up and find they can't maintain this level of change, they feel like a failure, give up on everything, and revert back to their previous level. And so, what we really try to do is work on smaller, SMART goals, sustainable, measurable, achievable, relevant, time-dependent goals with that individual on adjustments that they can make over the course of, you know, four to six weeks to move towards a healthier lifestyle, so more like climbing a hill instead of starting at the precipice of the mountain.

And we know from science it takes eight-ish weeks for something that they do regularly to become a habit. And so by doing it this way, we allow patients to understand that change is possible. And that over the course of several months, their new normal will be a healthier lifestyle, that they will have already adopted as a habit, and be doing naturally and so, kind of working through those. And when they're unable to meet some of the goals that they set for themselves, we don't focus on why they failed, but rather what can we change to improve the chances of success? Really looking at the positives and how to make this a more positive experience rather than what you did wrong, rather what could help you do better. And so looking at things from that perspective and moving up towards those lifestyle modifications really helps and understand there's going to be ups and downs to weight management. And this is not a linear decline over time. There's lots of different steps and things that happen along the way that go back to that same statement. People are people. They're humans. They're allowed to live life and should be encouraged to do so.

Host: Absolutely. So. What does the future hold? What are some of the latest advancements in treatment or research for obesity that you particularly find is promising?

Dr. Brandyn Mason: I mean, there are a lot of several advancements and treatments and research and weight management that are all in varying stages of development. I think currently there are approximately, I would say, about a dozen different medical options that are in those varying degrees, all showing success. Most of them, being built off previous medical therapies with maybe a new addition to a different biochemical pathway in addition to some of the other medications they use to really augment the thing. But again, pharmaceutical therapy is only going to go so far. Ultimately, what you really have to have is that trusting open and honest relationship with a medical provider about what you can change and what you're unable to change about your lifestyle. And along with the understanding, this is a lifelong commitment to these changes. And so, those are some of the big things.

I think the other biggest roadblock in the future is insurance coverages of the pharmaceutical therapies. It's really needed in order to continue to supply patients with the tools needed to find a healthier and more productive future life within their communities and within themselves. And so, there's a lot of stuff that's coming through. But until we get them to a more affordable level, we continue to build on that foundation, which is the lifestyle modifications and understanding that human beings need assistance and they're willing to listen and change as long as that change is something they can accomplish.

Host: Yeah. And we don't have time to wait for these medications to come off of their patents so that they're available as a generic. People need those medicines now. So, anything you'd like to say as we close out today? Any other guidance you could give us?

Dr. Brandyn Mason: For the most part, we kind of covered a lot of this. Lifestyle modifications, again, are what you build everything off of. And while somebody can find some success without them, they're not as sustained and a healthier success. So, we really want people to be encouraged to find out what they can do and take smaller chunks, smaller pieces to build towards the future rather than start at the top and then roll down, as you find that's unsustainable. So, start with smaller goals and start with different things.

And the other thing we really do focus on and try to tell people is not to focus on a number. That's the other thing that a lot of individuals do when they try to get in to weight management and losing weight, is they pick a certain number they want to weigh at. But ultimately, what we tell people is what do you want to feel like or be able to do at a lower weight that you can't do currently, because that number is going to fluctuate and maybe you come close to it, but don't reach it. But if you feel fantastic, did those extra couple of pounds really mean anything? And so, we try to drive away from just following a number.

Host: Yeah. It's really patient-directed clinical outcomes rather than arbitrary numbers. Thanks for being on, Dr. Mason. We really, really appreciate you being on Expert Insights today.

Dr. Brandyn Mason: Well, I appreciate you guys having us.

Host: Absolutely. And for our listeners, if you'd like more information and to get connected with one of our providers, please visit carle.org. That's C-A-R-L-E dot O-R-G. And also, for a listing of Carle providers and to view Carle-sponsored educational activities, head on over to the website at carleconnect.com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood.