Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Caitlin Whyte (Host): It feels like weight loss drugs are being talked about everywhere these days. From Hollywood to just my personal group text with friends, it's the topic on everyone's tongues. So, we are going to discuss our options today as well with Dr. Zaid Jabbar, a weight loss management physician and Chair of the Weight Management Department at Duly Health and Care.

Well, Doctor, thank you so much for being on the show today. To start off our conversation here, can you provide an overview of the different types of medications currently available for weight management?

Dr. Zaid Jabbar: Yeah. Thank you for having me. There are multiple medications for weight management. I would classify them into three generations. So, the first generation medications, they actually go all the way back to the 1950s. They've been around for a long time, and they're rather cheap and expensive. Most people are familiar, for example, the medication phentermine. There's also a close cousin of it called diethylpropion. Also, in the first generation medications, once again, this is all back in the 1950s, started out in the '50s and forward. Also, other medications that have been repurposed for weight management, such as medications used for diabetes, such as metformin; also other medications, such as bupropion. So, these are the so-called first generation medications that have been around since the 1950s. The second generation medication, I would say the past 10 to 15 years, have been these medications where some companies have looked at those older generation medication and have combined them together. And these are the sort of second generation medication that have come about the past 10 to 15 years. For example, there is a medication out there called Contrave, which is a combination of Wellbutrin and Naltrexone. There's another medication called Qsymia. That's a combination phentermine and Topamax. So, this is the second generation of these weight management medications.

Last but not least is the newest, or what I would call the third generation medications, which are the so called GLP-1. Everybody's familiar with GLP-1. But there's also another medication that's also GLP-1/GIP, which is another combination, and these are mostly in the past three to five years. So basically, you have three generations of medication: first generation all the way back 1950s, second generation the past 10 to 15 years, and some of the newer generation medications, like the GLP1s in the past three to five years.

Host: Wow. So, really, decades of developments that have brought us to this current moment in time. Now, doctor, I would love to know how do these medications fit into a broader weight management plan that includes diet, exercise, and lifestyle changes?

Dr. Zaid Jabbar: Great question. In weight management, we feel that diet, exercise, lifestyle, and behaviors are the cornerstone of weight management. As a matter of fact, when I talk to my patient, I tell them, think of diet, exercise, and behavior is sort of like the foundation of a house. So, when you build a house, like when you pour the foundation, you pour that concrete, you want that to be extremely solid. Because once you have a solid foundation, whatever you build on it is going to be solid. So, diet, exercise, behavior is the cornerstone, is the foundation of weight management. Everybody has to really take part into that.

The weight management medication comes in as a very, very important and effective tool to help us with diet, exercise, and behavior. And the way I explain it to my patient, I say, listen, we're going to have a nutrition plan, we're going to have an exercise plan, we're going to have a behavioral plan, because we have to talk about stress, we have to talk about sleep, and the medication is just going to help us stick to this plan, and as well as the medications are also important in help addressing some of the metabolic derangements that we see on the blood tests and whatnot. So, for the most part, the medications are important in helping sticking to the diet, exercise, and behavior by, for example, reducing appetite, improving metabolism, and helps the patient stick to the plan. So, it's an important tool and effective tool that helps us with diet and exercise and behavior.

Host: Of course. Thank you for that answer. Well, you mentioned earlier those GLP-1 injections, and I'd love to dive into those for a bit. So, tell us, what are GLP-1 injections and how do they work to help with weight loss? How do they compare to other weight management medications in terms of efficacy and safety?

Dr. Zaid Jabbar: So, to start out, I think it's important for folks to understand that GLP-1 is actually a natural hormone that's made by the body. It's actually made by the small intestine, specifically the L-cells in the small intestine. So, this hormone is a natural hormone that's made by the body, and it happens to be a very, very important player in metabolism and reducing hunger craving. GLP-1, also, what's interesting it's not only a hormone, but it's also a neurotransmitter. So, it actually crosses the blood-brain barrier, and it affects appetite centers in the brain and also, metabolism centers in the brain. And now, we now know that also the brain is also producing some of this GLP-1. Folks that seems to be struggling with weight seem to not make enough of it. And some folks may make enough, but maybe they're resistant to it, it's not working as well. That's why giving it seems to be helpful.

In regards to, in general, efficacy and safety, the older generation weight management medications, generally, efficacy in the weight loss world, we think about 5-10% weight loss. So, most of these, the first generation, you know, whatever your weight is, they give you about 5-10% weight loss. Now, in the second generation, once you start combining some of those medications, maybe you can get up to maybe perhaps 10-15% weight loss. With the GLP-1, we are definitely seeing much, much bigger jump, up to 15-20% or even more.

Now, as far as safety, all those medications that I'm talking about are FDA approved, of course. In order to have FDA approval, you need to have efficacy as well as safety, so are they all generally safe? What's interesting, however, with the GLP-1, not only they are generally safe, but the newest data shows that they actually have some cardiovascular benefit. And that's, I think, one of the things folks need to understand a little bit, is that they're generally all safe. But with the GLP-1, we have, perhaps, cardiovascular protection, cardiovascular benefit.

Host: Well, unfortunately, these new GLP-1 injections are still quite expensive. So, can you discuss the cost factors and whether there are any more accessible alternatives?

Dr. Zaid Jabbar: Yeah, the first question is cost. These medications are indeed costly. If people want to buy them, they usually cost about a thousand dollars a month, which makes it out of reach for a lot of folks. However, a lot of insurances are now covering them. Just to give you a sense, we are seeing about 30-40% coverage with commercial insurance. So, out of every 10 patients, three or four patients are getting coverage. So, the coverage is definitely improving.

The other interesting thing with the GLP1s, there are some of them that actually have coupons and discounts. So if folks, their insurances don't cover them, they can get a discount and they can bring the price down, maybe perhaps down to about 500, and with skilled clinicians, some clinicians could perhaps spread out the doses a little bit. So, you end up spreading the $500 over two to three months. So, that makes it a little bit more cost-feasible.

The other thing to think about, too, is that if the GLP-1s are definitely out of reach for a lot of folks, going back and looking at some of the older generation medication. The first generation, for example, metformin, I kind of think of metformin as, you know, your cheap GLP-1. That could be very effective. It doesn't work as quick, as fast as the injections. That's an oral option that is cheap and effective, and that could easily be potentially used if the patient is not able to afford the injections.

Host: All right, wonderful. Well, there's a trend, doctor, towards using compounded GLP-1s, especially in non-medical settings like spas. So, can you explain what compounded GLP-1s are and how they differ from that FDA-approved GLP-1 used in clinical settings?

Dr. Zaid Jabbar: Understanding the history a little bit behind the compounding, the reason the compounding products have become available, because some of these GLP-1 medications were listed on the FDA shortage list. So once a medication is listed on the FDA shortage list, that opens up the opportunity for some of these compounded products.

What's important to understand with these compounded products is, number one, a lot of them are using the salt formulation, Number two, it's important to understand they are not FDA approved. Number three, they have zero efficacy data, meaning we don't know how well they work. Last but not least, number four, they have zero safety data. We don't know what their safety is. So, that's the compounding. It's trying to provide a cheaper alternative. But of course, I think it's important for people to exercise great cautions with it, but that's what they are. And the most important thing to remember is that they are not FDA approved.

Host: Well, that kind of leads me into my next question here. What are the potential risks or concerns associated with compound GLP-1s?

Dr. Zaid Jabbar: So once again, they are, not FDA approved. As a matter of fact, I think the risks have been laid out by the FDA. As a matter of fact, there have been multiple FDA warnings in regards to the content of these compounded materials. There have been some reported even deaths as some of the compounding, formulation have contained insulin. I've read some studies showing that there are up to 25% impurities. So, the main risk is, number one, you don't know what you're injecting. And potentially, I think it suffices to say is that we just don't , the actual safety of it because a lot of them are using the salt formulation.

So, my message to my patient or the patients out there is to just exercise big caution, ask a lot of questions. And when they're using these compounded, materials are oftentimes administered in these spas. A lot of times, whoever is administering them, I'm not even sure if they're providers at some point, but not significantly trained.

The other thing that's important to remember is that there could be potential complications, right? So, what are some potential complications with GLP-1? Significant constipation, nausea, vomiting, diarrhea, people could have significant amount of dehydration. They could have even bowel problems. So, it's important to, number one, know what you're injecting. And, number two, it has to be done by a professional provider that is certified in weight management.

Host: Of course, some good tips there, doctor. And as we wrap up, if someone is considering using medication or injections to aid their weight loss journey, what steps should they take to begin this process? And what are some important considerations, you've mentioned some already, that they should discuss with their healthcare provider?

Dr. Zaid Jabbar: A good place to start is always the primary care doctor. I think your primary care doctor is very knowledgeable. They're oftentimes both certified in Internal Medicine or Family Practice or even Pediatrics. That's a good place to start. And I can tell you that a lot of primary care doctors now are dual board-certified in their specialties, like Internal Medicine or Family Practice, plus Obesity. And people should know that there is a separate Obesity board certification. You know, talking to the primary care doctor to see what's their interest in prescribing weight management medication or perhaps referring them to an appropriate provider.

But once again, I would advise them to try to talk to the primary care doc, because the primary care doc could either try to help them themselves, because they have a little bit of training in weight management, or they can refer them to the appropriate specialist for weight management.

But if folks want to do kind of their own research on weight management, there is a very nice website. It's called the American Board of Obesity Medicine, American Board of Obesity Medicine. This list has basically a list of all the providers, throughout the United States that are board-certified in Obesity Medicine. So, that's a nice website to consider.

A couple things to kind of also keep in mind when talking to your primary care doctor or when you're talking to an obesity specialist as far as history, I think it's important to talk about your weight loss journey. I think it's important to be honest, anybody that's doing weight management, understand that there are multiple things that contribute to weight, their genetic components, their environmental components, sleep, stress. So, it's important, I think, to talk about your weight loss journey, talk about whether you're a stress eater, emotional eater. Talk about your sleep habits. Be honest about all the medications that you take, whether it's prescribed or over-the-counter, and your provider will hopefully take a good history and a physical exam, hopefully do some blood tests to look into the weight problems, because there could be a lot of hormonal problems with weight. And so, blood tests are important. And then, your provider, hopefully, can do maybe an EKG to assess your cardiovascular risk.

At the end of the day, I think people need to understand that one of the important things with weight management is we want to reduce the risk of the number one killer in this country, which is heart attack and stroke. Evaluating cardiovascular risk, I think it's going to be another consideration for the provider. So, I would consider talking to the primary care doctor first. They can maybe perhaps consider checking out the American Board of Obesity Medicine website to do their own research. And once you see the doctor, be very honest about weight loss journey, and good things will happen.

Host: Well, doctor, some great advice here today. Thank you so much for your time and for all the work that you do to help others. And thank you for listening. If you found this podcast helpful, please share it on your social channels and check out our full podcast library on your favorite podcast app or at dulyhealthandcare.com. This is Duly Noted, a health and care podcast from Duly Health and Care.