Scott Webb (Host): There's been a lot of buzz on TV or online about celebrities using weight loss drugs, and we're here today with Dr. Sonia Hans. She's a board-certified physician in endocrinology, diabetes, and metabolism, and an Obesity Medicine physician, to discuss when would be the appropriate time to add these medications to your weight loss journey.

 Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. Doctor, it's so nice to have you here. We're going to talk about weight loss drugs, weight loss medications, and maybe sort of the controversies swirling around. It feels like a very hot topic. So, thanks for being here.

Dr. Sonia Hans: Thank you for having me. I appreciate you for inviting me to talk about this great topic.

Host: Yeah. It's nice to have an expert on to talk about this. And I was just sharing with you my sort of anecdotal story of my mom being on a diabetes drug that causes people to lose weight. But from your perspective, from an expert's perspective, why are these weight loss medications considered controversial.

Dr. Sonia Hans: So, it's a little complex. There's two thoughts that are sort of happening simultaneously with weight loss medications. One, we have a couple of FDA-approved weight loss medications under the names of semaglutide and tirzepatide. Brand names are Ozempic and Mounjaro, and they have the exact same drug molecule FDA approved under a different brand name, Wegovy and Zepbound used for weight loss.

And the first controversy is that when these weight loss drugs first became FDA approved, most insurances were not covering them. And the cost of these medications was astronomical. And a lot of patients were having their prescribers prescribe Mounjaro and Ozempic, which were covered by insurers. However, those medications are only covered for diabetics, but we are seeing several, and I put that word lightly, but we see a lot, thousands, maybe even a million or so of patients using these diabetic drugs for weight loss only who do not have any diabetes.

So, the controversy became, diabetics are already at a high risk of co-morbidities and, you know, cardiovascular disease risk, stroke risk. And when they do not have the treatments that they need to help control their disease and prevent a major complication, that becomes a healthcare issue that we aren't able to care for these patients well. On the flip side, you have patients who suffer with obesity, metabolic disease, struggling with weight, who are trying to prevent themselves from becoming diabetics, wanting access to these medications, and others doing it for vanity. And so, the controversy became, well, who should get the drug? And when do we draw the line that it's okay to prescribe semaglutide for everyone, or do we just use the FDA approved uses only? And that has been a major issue for a lot of clinicians in every state in this country, because it's put them in this sort of ethical point of, I want to do the best for my patient, but then you have these FDA regulations.

Host: That's great. Great way of breaking it down. I love how succinct you are. I love that as, you know, the host of the podcast and thinking about listeners. And so, let's talk about that, like the weight loss part of this. I've talked with other providers, other experts about sort of how this all came about basically. And maybe we don't have to go all the way back to the beginning, but essentially the way it was explained to me was, okay, so, you know, we had these diabetic drugs and it turned out folks lost weight while they were taking these drugs for diabetes. And then, someone was like, "Well, wait a minute. Lots of folks want to lose weight for whatever reasons, again, to maybe not become a type 2 diabetic and/or vanity, et cetera." So, maybe you can take us through this a little bit. How did we get here that these drugs are being now used, these medications being used for weight loss?

Dr. Sonia Hans: Yeah. Isn't it honestly the history of science that some of the greatest scientific discoveries have been by pure accident while trying to research and study something else?

Host: Yeah.

Dr. Sonia Hans: And this discovery and the mastery of research and technology to create the GLP-1 receptor agonist is I truly think, in my lifetime, one of the greatest scientific discoveries on metabolism and overall trying to prevent every single adiposity-based chronic disease related to metabolic disease.

So, you're right. It's in 2004 was the first GLP-1 receptor agonist that came into the market. Now, these GLPs, they didn't quite match exactly what was sort of in the human body, but they were effective in helping to lower blood sugar levels, not as great as the ones that we have currently on the market. But as technology advanced and they were able to master the molecule, we've had a couple of brands that have come out that are phenomenal. And the peptide hormone, that's what a GLP-1 receptor agonist is, it almost looks exactly like the human one without maybe one amino acid change. And so, when we started matching, when these GLPs started being equivalent to what the human GLP was, we saw an array of benefits. And one of the greatest benefits was that patients reported they were able to help, you know, control themselves in terms of losing weight, appetite, hunger. And if you talk to a diabetic, that's one of the most difficult things that they all explain is that, "Once I got diagnosed with diabetes, it was even harder to lose weight." But that's the number one recommendation to a diabetic is please lose weight. And so, we started using Victoza. Trulicity actually is another one. Trulicity, Victoza, and then Ozempic came. And when Ozempic came, there was a huge difference of, oh, wow, these people are really losing significant amounts of weight when they're focusing on their diet and nutrition and movement. And that's when Novo Nordisk went, you know, I think, deep into understanding, my goodness, GLP wasn't just a glucose metabolism medication. This truly is a metabolic drug that's going to affect multiple pathways in metabolism in the body, because there are other benefits to the GLP-1 receptor agonist. You know, we see cholesterol coming down. We see the fatty liver improving, liver metabolism improves. We are now seeing all by itself, semaglutide can prevent a heart attack and stroke. Huh, there must be some sort of anti inflammation, some prevention of making plaque in those arteries. And so, this is all metabolism. And now, you have Lilly that came out with Mounjaro and Zepbound, which is called tirzepatide. That's two protein peptides. And they right now have shown the diabetes improvement being significant, and that's A1c reduction, but they've also shown significant weight loss. I think, you know, when patients were on it for about 72 weeks, almost 20% body weight loss, which is the most we've ever seen in a weight loss drug in history. And so, it's really exciting and hopefully we're going to see some information about all the other comorbidities that it helps to reverse and prevent.

Host: Yeah, it's truly amazing. Never in our lifetimes. I mean, it's astonishing, really. So, maybe we should go through the different types of medications and how maybe each one of them works. Are they just appetite suppressants or is it more than that?

Dr. Sonia Hans: So, there's a few unique medications in the class. There's been several over the last 30, 40 years. But I would say, right now, most clinicians are focused in on a few drugs. So, one we've just been talking about, these controversial ones, which are the most popular, the GLP-1 receptor agonists, which are injectable drugs. So, that's one class that's going to be your Wegovy, Zepbound, which is two peptides. And there's another one called Saxenda.

And then, you have a couple of pills. The one that we've known for many, many years, good old phentermine. phentermine is an appetite suppressant. And so, it works to tell the brain, you know, I don't feel hungry. However, It tells the brain that we're not so hungry and the appetite can be suppressed. However, it can't overcome what we call stress emotional eating or, for some people, profound sugar cravings that can happen with metabolic disease. There's a medication called Qsymia, Q-S-Y-M-I-A, and that is a combination drug, which I think has mastered what phentermine was doing, plus it added another medication called topiramate to it. So, Qsymia is a dual drug, phentermine and topiramate put together. And what that does, it helps with appetite suppressant and also helps to curb what I call the food noise. And so, that feeling of like, "I need to eat, I need to eat."

Host: "I need food."

Dr. Sonia Hans: "I need food." Right. And so, that's been a great medication. And then, there's a third group, and I really call this the dopamine pathway modulators utilizing an antidepressant we've all known well, it's called Wellbutrin or bupropion. And it combines it with a medication that's being used in addiction medicine, and that's called naltrexone. And that medication is called Contrave. So, it's a combination of bupropion and naltrexone. And it really is effective for that individual who suffers with a little bit more that food addiction behavior, the sugar cravings that just can't get quenched. And so, it really depends, you know, where someone is in their stage of metabolic disease. And it's really important for people to understand the different drugs, the mechanism of action. And really, you have to understand what's happening within the patient to know which medication is going to be best suited for them on the weight loss journey.

Host: It's been great to have you here. Great to have your expertise. And thankfully, we have folks like yourself, medical professionals who understand all of this and can sort through all of it. And that kind of leads to my final question, which is why is it so important? Why do you believe it's important that we use these medications with the guidance of a physician?

Dr. Sonia Hans: Throughout our conversation today, you can hear there's a lot of complexity in these medications, you know, and they modulate the brain and they have a huge effect on our gut and our liver. And so, you need to work with an expert, who is well-trained and well-versed and understanding how they work in the body, how they interact with what other health conditions you may have and other medications you may be on, and your history.

 I think that we've seen several patients, unfortunately, suffer quick, easy-access providers who just hand them medicines, and then I see them in my clinic for the consequences that has had. And so, I think it's really important to have an expert who knows how to take care of, you know, this disease and all your other health issues and looking at these medications related to all your other healthcare needs and cost as well to give you the best care because weight loss and weight management is a long-term disease. There's no quick fix. And so, you want a provider who's going to be there for you for long-term management.

Host: Yeah, it really is. As you say, it's long term. It really is a journey. I think that's like the best word/ and great that we have, you know, compassionate, highly knowledgeable experts like yourself to help us. So, thanks for your time today.

Dr. Sonia Hans: You're welcome. Thank you so much for having me.

Host: EvergreenHealth's Accredited Center of Excellence for Weight Loss and Bariatric Surgery offers three pathways to help patients with weight loss, all using an evidence-based clinical approach, proven to produce long-term results. To learn more, visit evergreenhealth.com/weight-loss. I'm Scott Webb. And please remember to subscribe, rate, and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.