Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And we have two AHN physicians for you today in a thought leader panel, and our discussion focuses on weight loss medication versus surgery.

Joining me today is Dr. Fahad Zubair, he's the Medical Director of Obesity Medicine, and Dr. George Eid is the System Chair at the Bariatric and Metabolic Institute. Doctors, thank you so much for joining us. I love that we are having this discussion today. This is something that is really on the minds of so many people. We have an obesity epidemic. People are hearing about weight loss medications and surgeries. There's a lot of information. So today, we're going to really summarize and put it together for the listeners. But before we do, I'd like you both to tell us just a little bit about yourself. Dr. Zubair, tell us a little bit about your role at AHN, your experience, and your expertise in this field.

Dr. Fahad Zubair: So, my background is in Internal Medicine and fellowship-trained in Obesity Medicine and Clinical Nutrition. I joined AHN about five years ago, just a little over five years ago as the Medical Director for Obesity Medicine. And my role at that time has evolved with time.

First, we started in collaboration with Dr. Eid and our Endocrinology team under the Bariatric and Metabolic Institute to develop a robust Obesity Medicine Clinic, and having care pathways for obesity, where patients are treated with a multidisciplinary approach for the disease, rather than patients being seen as somebody who just needs a treatment with a medication and then followed up accordingly.

We are trying to tackle patients from behavioral approaches. We're trying to tackle patients' challenges from dietary approaches. We're trying to help educate patients about their physiological barriers, their medical barriers, and at the same time then treat them medically or surgically. And that role eventually evolved into a more and more comprehensive system-wide role where we connect with a lot of other subspecialties, and work with them to get the best patient outcomes, which is even better longterm outcomes, whether that's with a medical or a surgical approach.

Melanie Cole, MS: Well, thank you for that. And Dr. Eid, the same to you. Can you please give us an overview of your role at AHN, your experience and expertise in the field?

Dr. George Eid: Absolutely. I've been in the field of obesity care for the past 24 years of my career. I'm a minimally invasive bariatric surgeon. And 12 years ago, I joined the Allegheny Health Network with the idea of building an Institute, an umbrella that covers all the different treatment options for obesity care from endocrine diabetes to surgery to medicine and everything in between, spanning across research, best patient care.

And the idea is obesity is a heterogeneous disease. It's not one size or one way of treatment fits all. There are different options that we need to explore for our patients. And that's what I did. So, I'm also certified in Obesity Medicine as well as Surgery. So, this is the idea of having comprehensive care, tackling the different ways of treating a very devastating disease affecting almost half of our population.

Melanie Cole, MS: Well, it certainly is. And as we said, this is really an epidemic, but also there's been such a stigma over the years, and we're hoping now to really bust that up a little bit so that it's not quite so humiliating, and that we hope that more people that have this disease are going to seek treatment. And that's what we're talking about today.

So, Dr. Zubair, let's start with weight loss medications. As we work on separating fact from fiction, because boy, there's a lot of it rolling around right now. Can you give us a bit of an overview of current weight loss medications right now and dispel some of those common misconceptions that are fueled by the media hype? It's just all over the place.

Dr. Fahad Zubair: So, we can divide the weight loss medications into oral medications versus the relatively newer injectable medications, or another new way to look at it is non-incretin-based versus incretin hormone-based medications, which are the injectable medications.

Some of these medications have been available for decades. For example, there is a medication, which is a stimulant in nature called phentermine. And this medication basically works on stimulant hormones in your body, the adrenaline hormones. So, it works as an appetite suppressant. It helps with some energy and focus. And it's really good sometimes to kickstart your journey for weight loss. It is a medication that is almost six decades old and still continues to be one of the most widely prescribed medication because it's very cheap, out of pocket. Insurance coverage, therefore, generally is not an issue with it. It is still very effective. So for those reasons, a lot of patients who have barriers to using more costly medications, it's widely used in those patients especially.

There's another medication called Contrave, which is actually a combination of two medications in one. One part of it is Wellbutrin, which is historically used as a mood stabilizer. But whenever we see patients who are presenting or have phenotypes of stress-induced eating or emotional eating, any mood-related behavior towards food, it becomes very effective in such patient populations. The second part of that medication is called naltrexone, which has been previously used in addictive disorders, even in alcohol abuse. So if we see patients with food-addictive behaviors, uh, see patients, uh, sugar addiction or even high alcohol consumption, It has a great application in such patient populations.

Now, the newer class of these medications, the GLP-1 receptor agonist, which are the injectables, these are not medications which are five-year-old medications. Some of these are very old, decades old medications, like the older generations, Victoza (liraglutide), Ozempic (semaglutide). The newer ones out of these are the semaglutide brand, which is Wegovy, which is just a higher dose of semaglutide. And the latest one that is available to use is called tirzepatide. which works actually on two hormones rather than one. It is a GLP-1 receptor agonist along with a GIP agonist. So, it's a dual agonist rather than a single agonist.

And the main understanding to really take from the effectiveness of these medications is that they are the most potent appetite suppressants. They work chemically in your brain as well to reduce cravings, hunger, food noise. So, they're not only acting at physical hunger, they're also attacking the background food noise or brain hunger that we call. And they have a lot of benefit in comorbidity management. So, a lot of the metabolic abnormalities that coexist with weight gain, they help treat or alleviate some of those problems too.

The major challenge that we see obviously with the different medications is cost. And it's really important to really look at a patient's risk and then characterize each patient based on their phenotype, based on their insurance to the right treatment option, whether that's oral medications or injectables. So, it's never to go by the hype and see that these medications can help you lose, for example, 20 pounds a week or 25% of your body weight. It's always best to really understand the patient's challenges, what medical problems they're facing, what risk classification are they in, and then go with the right approach in terms of treatment. So, this is in a little bit of a nutshell, the current landscape of Obesity Medicine.

Melanie Cole, MS: Thank you for such a comprehensive answer, Dr. Zubair. And Dr. Eid, in this era of GLP-1s, Dr. Zubair has given us such a great look and an overview of them, but people then worry about some downsides, risks, side effects, contraindications. Can you please give us very clear Indications of when this is not for certain patients and things that you want other providers to know about these side effects as they are counseling their patients about these medications?

Dr. George Eid: I think to answer this question, I would like to step back just a little bit and emphasize two facts that we already know over the years from doing research and literature and understanding obesity. Number one is a physiological disease. There are factors with those patients that are preventing them from achieving weight loss through diet and exercise only.

Patients need help not because of poor willpower. It's because of the physiology in them preventing them from achieving what they need to achieve. And this is why all these interventions are available for them. So, I will use this analogy as if you're swimming against the current. No matter how good of a swimmer, at some point you get tired. And that's what happened to those patients. They try to lose weight on their own, diet and exercise. They get to a point they can't do it, and they have to get a setback. So, they need the help.

Number two, to understand well, it's a heterogeneous disease, and I cannot emphasize enough. What I mean by that, I mean by that is that not all obesity is the same. Each patient have different struggle, different phenotype, like Dr. Zubair mentioned, that had different comorbidities. And for each patient, they may respond to one or the other, or then we need both. Look at every other disease state we treat or any physician treat. You have surgery, you have medication, and sometimes you need the combination of both.

To answer back to your question, let me give you some examples. Patients with very high BMI, patients who need to lose 150 pounds or more, patients with severe metabolic diseases, poorly controlled diabetes, polycystic ovarian syndrome, some of those patients, the medication may not be as effective to get them to where they need to be and surgery is a much better option for those patients. Whereas patients who have lower BMI, not metabolic diseases, medication can be a good option.

So, the question here is that it's not one-size-fits-all. This is why we work together as a group. This is why we have this institute because we need to individualize the treatment care for each patient and that's what it comes down to, keeping in mind we know from all the studies we have in some cases 10-12% patient don't tolerate those medications. They take them. They have a lot of reaction, a lot of side effects, and they have to stop it. So, what we do in those patients, sometimes you need to offer them other treatment options. So, that's the kind of idea I want to leave my listeners with, is let's individualize. It's not all obesity the same. Some people need medication, some need to do surgery, and sometimes they need both at the same time

Dr. Fahad Zubair: I would completely agree with what Dr. Eid said. And I'd just like to add a little bit to the misconception part of the question, is that we really need to not look at just misconceptions about medication or surgery. Even the medical world, there is a huge misconception about the disease itself. You know, we have to change the lens on how we look at obesity, and it has to be looked at as a chronic medical disease, which it is, based on how long the patient struggle with it and then it's a continued lifestyle management, which is for life to maintain their status, even if they do well.

So once you understand that you're treating a chronic disease, then it really helps you understand that it needs to be managed medically versus surgically with an option that has to stand long-term to help them heal and then stay at that state.

Melanie Cole, MS: Okay. Then, let's talk about surgery as the next option, doctors, because as you've said, the medications don't work for everybody, and this is not really something that is across the board. Everybody doesn't work with one particular treatment or another. So, Dr. Eid, I'd like you to give us an overview of the tried and true weight loss surgeries. They've been around a very long time and we've seen remarkable changes in people that have gone through these surgeries. So, speak about what's going on in the field right now.

Dr. George Eid: Absolutely. Surgery, like you mentioned, has been around for a long period of time. I personally have been performing bariatric surgery for over 24, 25 years. So, you can see we have long-term data on those surgeries, and they're very safe, safer sometimes than performing a gallbladder surgery. And that's something we need to keep in mind that not because it's surgery, it's a risky operation.

The main surgeries we offer right now are two of them. One is called sleeve gastrectomy. And what it means is removing around two-thirds of the stomach out, removing the part that makes people hungry and allow you to overeat, leaving you with a smaller stomach the shape of a sleeve. I sometimes like to call it a skinny banana because it's the shape of a skinny banana. And it's done in a minimally invasive fashion, making five small incisions. It takes around 40 minutes to perform and patients tend to go home the next day.

On the other hand, we have the other operation that has been also around for a very long period of time called the gastric bypass. And a gastric bypass involves creating a small stomach, the size of a small egg or smaller, and rerouting your intestines so not everything a patient is eating is absorbed in your system. And that's also done in a minimally invasive fashion, takes 15 hours and a half to perform, and patients also most of the time tend to go home the next day. We also share with our patients our track records, which has been phenomenal. I mean, the mortality rate with those is less than 0.1%, and they have very good long-term track records. And, like I said, we've been doing it for a very long period of time. Keeping in mind that those operations also allow the patient to have more of those incretins that Dr. Zubair mentioned, those medications we have on the market. When I do a gastric bypass, as if I'm giving them those GLP-1s all the time, because that's how they work. One of the ways they work is by increasing the levels of those GLP-1s, which are now made into medications, as if I'm giving them five, six, seven medications all the time at the same time, and that's how they work on the long-term. So, this is basically a quick overview about surgeries, and it has been shown to be the most effective in diabetic patients. We have long-term data, more than 10 years showing patients, who were diabetics, still not taking any diabetic medication more than 60% of the cases. So, in some cases, it has been shown to put diabetes to remission for a very, very, very long period of time.

Melanie Cole, MS: That was an excellent overview, Dr. Eid, because these have been around a long time. And as we've said, we've seen really remarkable results now. Dr. Zubair, as we think of both of these things, medications and surgery, are there guidelines and a clear process for setting up patients? And let's talk about surgery for a second here, but the criteria, because we're looking at insurance, we look at the psychological aspect of this type of life-changing surgery, really. When is it important, do you think, to refer to the specialists at the AHN Metabolic and Bariatric Institute, but also the guidelines? What are we looking for them to do while they wait for surgery?

Dr. Fahad Zubair: One thing is definitely when you're trying to see patients in the medical clinic and assess their risk, assess their current medical conditions, their weight, you have to, in this day and age, go by their current insurance, see what they qualify for, and what options then we can put on the table. At that time, whatever is, for example, covered for a patient, then we talk about expected outcomes.

And I think the best way to put this to you would be by giving you an example of a hypothetical patient who comes in with a weight of almost 300 pounds and a BMI of almost 50 and has severe metabolic syndrome with diabetes, requiring insulin with high blood pressure, high cholesterol, sleep apnea. And this is a pretty typical picture in the clinic. And this patient has commercial insurance that covers all medical weight loss options. What would be my advice to this patient? My advice to this patient would be that we have to, first of all, treat your weight as a chronic medical disease. We have to treat not just the weight, but we have to treat the other comorbidities that are associated with your weight.

With all these comorbidities, the common denominator is the weight. So if we treat that, and we treat the comorbidities, then you look at reducing your risk for atherosclerotic cardiovascular disease in the future. Look at reducing your risk for certain malignancies and cancers in the future. And really, that's the type of counseling and education we need to do primarily in the clinics.

At that point, we need to discuss with patients the expected outcomes. So, my next step would be, I would say to the patients, "Okay. Let's see, out of these medications versus out of these surgical options, what is the option that can help you potentially lose most of your weight and help you reverse most of these diseases?" And in that scenario, from a clinical perspective, it would become a clear choice that, in a very severely diseased patient, surgery is the treatment of choice without a doubt.

As far as coverage goes, from an insurance standpoint, most insurances, they require patients to have currently a BMI of more than 40 or a BMI of more than 35 with a weight-related medical comorbidity, and that has expanded, you know, things like diabetes, sleep apnea, hypertension, high cholesterol, fatty liver disease, and so on.

So, that's from an insurance perspective. And I think Dr. Eid could probably attest to that, that some of this might change in the future and we might again go by more risk of the patient and the disease state rather than just a BMI, because the BMI is not the most accurate measure of risk at the end of the day. It's the adiposity, which is a more accurate measure of risk. It's the insulin resistance. It's the background illnesses, which are more accurate measures of risk.

Melanie Cole, MS: Absolutely true. And we're learning more and more about BMI not being an accurate representation of a person's body type. I'd like to give you each a chance for a final thought here. As the running message of today's episode has been that this is a chronic disease, and to reduce the stigma from both the public, but also the medical community, doctors, I'd like to start with Dr. Zubair. And I'd like you to speak about that multidisciplinary approach, the need for the medical community to see this as the chronic disease that it is, and what you would like them to know about what you're doing at the AHN Bariatric and Metabolic Institute.

Dr. Fahad Zubair: We need, as we discussed during this time, to really treat obesity as a chronic disease and we need to take it very seriously early on. We do not have to wait for the damage to be done and then take advanced actions. We need to start treating obesity aggressively. We need to start educating our healthcare provider community. We need to start educating our patients and spending time with them about helping them understand the disease.

Most of the fear that comes in terms of seeking treatment is not only historically from bias, but also from lack of understanding the disease itself. And if we take time with our patients to help them understand the physiology behind the disease, help them realize why some of the things in their previous weight loss journeys happened, it would really help them focus on the future and what they need to do now differently and how they need to look at their disease, which will help them make the better choices for better long-term outcomes.

So for that, to really begin with, that multidisciplinary approach is so important because, like Dr. Eid mentioned, it's a heterogeneous disease. It presents differently in people and there are different treatment responses with all various different treatment options in people. So, we have to tackle it from all aspects. We have to help patients tackle their behavioral challenges, their dietary challenges, their motivational challenges. We have to improve their lifestyles. We have to avoid any extreme measures that patients are unable to do for long-term plans. And then, we have to implement along with the right education, the treatment option that would best fit that particular patient for long-term outcomes for reversing most of their medical problems, not just a number on the scale.

And then, at the same time, we need to follow these patients chronically as well and make sure that their disease state is improving and staying in an improved state. We should never be afraid of adding on therapies in treatment of obesity, whether that's medication on medication, whether that's surgery on medication, whether that's medication after surgery, if needed.

So, this landscape is ever-changing. The treatment options are ever-increasing. We need to really take all of this with open arms and and go at it and keep our patients at the same level as we are to really help them explore the best options out there for their long-term success.

Melanie Cole, MS: Beautifully said. And such an exciting time for Obesity Medicine in your fields. And Dr. Eid, last word to you. I'd like you to speak to other providers now about choosing AHN for bariatric and metabolic care. Give us a little bit of an overview, the advantages of the program, the support services, outcomes, and why it's so important that they refer.

Dr. George Eid: Absolutely. I think it's well said by Dr. Zubair, and I think what I need to leave everybody with this thought because it is a heterogeneous disease, it's not about medication versus surgery. This is not that medication would replace surgery or vice versa. It's about working together as a group to see what best fit that particular patients based on their history, their comorbidities, and so on and so forth.

And we have the advantage and this has been around for now nine, 10 years, is that we have this comprehensive approach. We all work together. So even if the patient can see 10 providers as if they're seeing one, because we work together, we discuss the patient live. It's not about referring them to this side or the other side. We look at the patient from all angles. And whatever makes sense for that particular patient, that's what we're going to do. And that's what we are. We proved one of the best outcomes when it comes to surgical treatment or medical treatment. And this is not me saying things about myself that we do a good job. We are a certified center where basically our data get audited, especially the surgical data. They look at our outcomes and our complications. And for the past 20 years or more, we've had one of the most stellar outcomes, and I share those outcomes with my patients and our providers. We print out those report cards, so to speak, that we get. And then, I share it with our patients and our referral providers to know exactly what we're doing.

So, the advantages are many. And the idea is we understand the disease from the fact this is not about one treatment or the other. It's about this comprehensive approach. And I think that's the main attribute to what we offer to our patients.

Melanie Cole, MS: This was such an informative episode. Doctors, thank you so much for joining us and having this frank discussion about the importance of Obesity Medicine and what's going on in the field and what's exciting. I thank you both for sharing your expertise today.

And to learn more or to refer a patient, please call 844-MD-REFER or visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.