Melanie Cole MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and we have a physician panel for you today on weight loss modalities. Joining me is Dr. Veronica Johnson. She's an assistant professor of medicine and Dr. Eric Hungness. He's a professor of gastrointestinal surgery and medical education, and they're both with Northwestern Medicine.

Dr. Hungness and Dr. Johnson, thank you so much for being with us today. Dr. Hungness, I'd like to start with you. Tell us a little bit about the current state of weight loss surgery. What are the potential long term effects of weight loss procedures on a patient's overall health and well being?

Eric Hungness, MD: Well, first of all, I want to just thank you for the opportunity to come and talk about this, important topic, as, as you know, and, physicians know, obesity is a, is a major, major, health issue across the, the country, and it's only getting, getting worse, and if you look at some of the The data, it's, it's almost like an epidemic, and if this was an infectious disease, or a cancer, or COVID, there'd be like this huge public, you know, outcry about stuff.

And so, you know, the state of, the state of, bariatric surgery is that it, it's really, become the, the, the gold standard, I would say, of, of helping patients with, Class 2 or 3 obesity, and that, I'll define that as body mass index of 35 or higher with medical problems, or a body mass index of 40 or higher.

and so, this, these patients just have a lot of, medical problems, that are associated with their, with their weight, a lot of quality of life issues, and, and weight loss surgery has, has, been proven now to be the most durable and effective tool, that we have as a medical community for, to help, to help patients.

And it's not, it's more than just losing, weight or a, a number, it's, it's That long term, you know, studies, study after study shows that the weight loss for most patients stays off, but more importantly, the medical problems improve, particularly diabetes, and, you know, a lot of high blood pressure, sleep apnea, all these things that really affect patients quality of life.

And then other studies have, you know, suggest that... If you improve those things, that people, people are living longer and they're, and they're happier. And so, so weight loss surgery is really kind of, been that gold standard. However, you know, we continually try to improve. We're a part of quality improvements and there's, there's lots of great data that show that this can, these can be done safely, very safe procedures now, unlike, you know, maybe 20, 30 years ago when.

There was lots of fear around them. These can be done very safely. And we're really excited now about multimodal therapy. You know, we, we, we treat cancers with more than one treatment. Surgery and medications and radiation or whatever. And, and obesity is, shouldn't, you know, it's no different. And, and now, you know, some of the weight loss medications that we're, that Dr.

Johnson will, will be talking about, I think are going to be game changers for a large number of patients. Both. Before surgery. As well as after surgery, or those that don't qualify for surgery?

Veronica Johnson, M.D.: Yeah, and I would just like to chime in with that. you know, I totally agree. Obesity is a chronic disease and it is an epidemic and the most prevalent chronic disease that we have.

And then even with... The most effective tool we have as far as surgery, we know that it's a relapsing remitting disease. And so, you know, we see 20% of these patients who struggle with severe obesity, they, they struggle with their weight even after surgery, they have weight regain. And so they need chronic disease management, which reemphasizes the importance of this multidisciplinary care between, myself and individuals like Dr.

Hungness as bariatric surgeons, we need to address this as a chronic disease and utilize not only surgical modalities, but also these more effective medications to help patients continue to improve their health for the long term.

Host: Well, as an exercise physiologist myself, I've seen how we really are evolving.

And Dr. Johnson, how have the non surgical treatment, because that's what we're focusing on here today, how have these options for obesity treatment evolved over time? Speak a little bit about what you've seen in your profession.

Veronica Johnson, M.D.: For sure. So, prior to, you know, 2021, we, we had medications for weight loss, but they were mildly effective, you know, only promoting on average about five to ten percent weight loss.

And if we had patients with more severe obesity, you know, sometimes they needed multiple agents together to kind of see that benefit from a weight loss perspective and overall health perspective as well. you know, with the passage or approval of semaglutide 2.4 for obesity treatment and weight management, and we were seeing up to like 15% weight loss with these drugs, and so that was something that we had never traditionally seen in the past for obesity treatment, prior to, that, that approval of that drug.

and so now we're seeing this new generation of anti obesity medications coming through the pipeline that are even more effective. And so we do anticipate the approval of terzapatide, tirzepatide which probably will happen by the end of the year. And with that, that approval, we see an average of about 20 to 23% weight loss.

with tercepatide tirzepatide 15 milligrams over that, that clinical trial period. So we are seeing significant weight loss with these medications and we're approaching, the effectiveness that we see with, with surgery, but we're not quite there yet. So again, I just want to emphasize the importance of if we have severe obesity, these patients do likely need surgery to get.

their better control of their weight and, their overall health.

Eric Hungness, MD: Yeah, I'll just, I'll just add that, you know, the number of patients that are coming to me and considering surgery, The number of patients that have already, that have been on one of these medications or are currently on one of these medications is, is, is dramatically, you know, increased.

And so there's, there's a lot of patients that are, being treated with these drugs and so it's, it's great.

Veronica Johnson, M.D.: I mean,

it's, it's great also, but it's, it's not the most, you know, it's not a one shot thing for everybody, right? So other patients may not respond as expected to these drugs. And if they have severe obesity, it's really important to keep in mind of all the other available tools to them outside of the pharmacotherapy options.

Host: Dr. Hungness do you see if the newer weight loss medications we're discussing here today will reduce the number of weight loss operations performed? I'd like you to speak about how they compare with traditional methods of weight management that we've heard about for years. And can the surgical... And the pharmacotherapy be used together.

Is that really the optimal when you speak about the multimodal approach?

Eric Hungness, MD: Yeah, it's, it's, it's, this is great. So, you know, around the fire pit or, you know, around the coffee table with my friends and stuff like that, they, you know, they ask me, are you going to be out of a job? Oh, you know, and, you know, in a couple of years with these, with these medications that are, that are coming out and are you really going to need to do weight loss surgery in the future?

And, My response is that, unfortunately, too many patients that are suffering with this, you know, this, this disease, and so, I don't think this is going to decrease the amount of operations the weight loss operations that are done in, in, in the country. I actually think it's going to increase the number of weight loss, surgeries that are done.

Because there's going to be more people that are going to become... interested in weight loss surgery because, you know, if you, if you look at the numbers, like for in, in Illinois, for instance, there are 12 and a half million people in Illinois. You take maybe between 18 and 65 years old, there's 7 million.

So And then if you take that, if you know that about 40% of those patient, those people, that population has class one obesity, that's two and a half, 3 million people. And then most of those, and of that, most of them are going to be in class one obesity, the the BMI 30 to 35. So you're going to and that's probably.

2 million people, and so you're going to get a number of, you're going to get so many more patients that are going to be interested in healthier living because the barrier is going to be a lot lower. The barrier to go to weight loss surgery is extreme. The patient has to be ready to do it. I think the barrier to initiate...

Weight loss medication is going to be a lot lower, and then they're going to see the benefits or successes and or failures, and then what's the next step? Surgery. so that's the way that I'm thinking about this. So I'm not threatened by it at all from a surgery standpoint. Again, I think it's going to be only You know, a, a good thing for, for, both of our practices and, and most importantly for our patients.

Veronica Johnson, M.D.: I think another thing just to be aware of is that access for these medications is still a big issue and supply is limited. So, as far as access, you know, the patients who could really benefit from these medications, the patients who are insured with Medicaid or Medicare, they have no coverage. And so, you know, They the only option for the treatment of their severe obesity is, is surgery at this time. And until, you know, coverage for these medications is better, you know, they unfortunately don't, they can't get the The non surgical options, the most effective non surgical options we have, so I think surgery is going to be the best treatment for them at this time.

Eric Hungness, MD: And I hope the opposite is true too, that as, as, you know, unfortunately surgery doesn't work for, you know, everybody, and actually there's a significant number of people with weight regain or don't have enough weight loss that they desire. These are patients that are going to be interested, that are interested in starting weight loss, medications.

And so I think you're going to get a lot of patients interested in weight loss medications after weight loss surgery. So it's going to be this kind of, back, back and forth.

Veronica Johnson, M.D.: And you think that's also the beauty of, like, These medications now and how they work physiologically, they kind of augmented the physiology changes that happen after surgery.

So, you know, we look at semaglutide and tirzepatide They're incretin based therapies, so they are GLP 1 receptor agonists that work on GIP, if you're looking at tirzepatide and semaglutide. And, you know, with bariatric surgery, what happens... After surgery, it's not just decreasing the size of the stomach, we have, like, hormonal changes that are occurring, you know, where we have increased GLP 1, specifically that kind of helps from a metabolic standpoint to promote weightloss And that's what these medications are doing as well.

They're augmenting that GLP 1 activity. And so in patients who've had surgery and they are struggling with weight regain, the medications are just kind of augmenting that physiology that is already present after surgery.

Eric Hungness, MD: Yeah, I totally agree. And it's really the, you know, the gastric bypass is really the one that I think that...

You see that GLP 1 effect after gastric bypass. You don't see that as much with sleeve gastrectomy. But, now if you treat patients with sleeve gastrectomy and add that, then you're almost recreating this, you know, kind of bypass physiology. And, that's really exciting because... The morbidity or the, the, the complication rates with gastric bypass are a lot higher than with sleeve gastrectomy.

and so that's one of the advantages of sleeve gastrectomy. It's, it's less complicated. It's less easier to recover from with lower long term complications. And so if you could offer that with medication... that, again, that, that might be better than gastric bypass for some patients.

Host: It's really all about having more tools in the toolbox, really, and hopefully reducing some of those disparities to availability of these types of modalities.

Dr. Johnson, tell us the indications for prescribing the anti obesity medications. Are there any contraindications? Are there certain patients for whom you just would not choose this route?

Veronica Johnson, M.D.: Sure, so, anti obesity medications are indicated in a patient who has a BMI of 27 or higher, in a, or 27, between 27 and 29.9 with a comorbidity like diabetes or high blood pressure.

you know, fatty liver disease, or if the BMI is 30 or higher, regardless of comorbidities. And so, that's across the board, regardless of the agent used. those are the FDA approved indications for use of anti obesity medications. when we're looking at more of the newer agents, like semaglutide and trizepatide, specifically those are not indicated in those who have a rare form of cancer called medullary thyroid cancer or if they have a personal history of multiple endocrine neoplasia type 2.

Those are the only absolute contraindications for these medications outside of pregnancy or breastfeeding. but we Do you also have to be aware of some of the side effects and use them cautiously in patients who have, you know, more severe, like, GI issues because that's the most common side effect is, is nausea, you can have constipation, diarrhea, reflux, if there's a history of pancreatitis, you know, That can be another red flag.

So if a patient has a history of pancreatitis, I would be a little bit more cautious of using the medications. It's not an absolute contraindication, but, you know, if you don't know the cause of the pancreatitis, using these medications, can definitely cause a, An increased risk for a recurrent pancreatitis as well, so.

Host: Well, along those lines, Dr. Johnson, speak about how these newer medications interact with other medications as you're telling us about the comorbid conditions that patients have, which we know are diabetes and high blood pressure and all these things. They're on many medications. How are these new modalities interacting with the medications that they may be on for all those other conditions?

Veronica Johnson, M.D.: So, these medications right now are just administered, subcutaneously, so they're injected once a week. so there's not really a lot of interaction specifically with, any of the oral medications that they're taking. but, you know, in the future we'll see that there'll be, These GLP 1s that are approved in the oral form, and we have to be cautious about how that would interact with some of the other oral medications that they take.

So if you take like oral semaglutide right now, you know, you have to take it on an empty stomach, without any, other medications because, for example, if a patient has, hypothyroidism, you have to wait at least four hours before, They take their thyroid medication because if you're taking the GLP 1 orally and the thyroid medication, that can affect the absorption.

So, That's, that's one of the big things as far as in the future, but right now, as far as interacting with current medications, there's really, there's really nothing. A lot of the other medications that were traditionally used to treat obesity, you know, were contraindicated if a patient was on concurrent stimulants.

If they had like heart disease, we would try not to use them, but with these medications, they're relatively safe. So, yeah.

Melanie Cole MS (Host): It's a very exciting time in your field, and Dr. Hungness, I'd like you to speak a little bit about patient counseling and education, as we keep saying that these are more tools in the toolbox for weight loss medicine.

Tell us a little bit about where that counseling comes in to help the patient along as they're going through these.

Eric Hungness, MD: Yeah, I mean, patient selection is, is key, and it, it, it, It really requires a motivated patient to do well. And so, you know, we work very closely together to help find the, you know, patients and help them get to a point where they're ready.

for surgery. And so, that involves, a dietary evaluation. They have to have a good understanding of what, what good lean protein is, what foods to avoid, those sorts of things up front. they need to make sure there's a, there's a psychological evaluation just to make sure that there's not an underlying eating disorder or depression that's being, coped with by, by eating and so forth.

And so those are some of the early kind of screening processes that we have. We have a whole, we have a bunch of different dietary classes that are run by our dieticians, a great team of dieticians at Northwestern, to help. patients really understand what are the changes that they're going to need to make ahead of time.

And so the process is not, it's not like, oh, I'm interested in surgery. You have surgery next, next month. It's, it's a, you know, sometimes a three month, six month, nine month, process to get. patients to the point where they're ready. they may not be initially ready right, right now, but again, eventually we're able to get them there with this, multidisciplinary, approach.

And so that's, that's before surgery. Then after surgery, it's almost even more important, cause, and then, so we have very frequent touch points, if the patients come in, if, if a patient has surgery that came through from Dr. Johnson, you know, they'll have surgical follow up. They'll have medical follow up, and, and really kind of approach this from, from a multidisciplinary standpoint.

And for patients that struggle with weight regain or kind of, you know, some other, you know, other, other issues, and we, we, we get them in and, get them the appropriate follow up necessary. We also have support groups. patients learn, well from each other, you know, it, it's hard for me to, I, I, I haven't had weight loss surgery, so it's hard for me to, you know, say that I've walked in somebody's shoes.

You know, having taken care of thousands of patients, I feel like I'm coming closer to that, but I don't know what it's like to have, you know, to live with weight loss surgery. And that's where this support group and peer support is built into our program.

Melanie Cole MS (Host): Dr. Johnson, I'd love for you to expand a little bit on that multidisciplinary approach.

How do you work with patients and collaborating with the dieticians and the psychologists and the support group leaders and exercise physiologists and physical therapists because everybody's involved when somebody is obese and has all of these comorbid conditions. Speak about how you all work together and the communication of the team because I think that's so important.

Veronica Johnson, M.D.: Yeah, for sure. so... Just like surgery, I mean, these medications are adjuncts. So, if you have, we need to optimize the diet from a dietary perspective, the physical activity needs to be there, behavior, sleep, stress, all of that is important, to ensure that the patient is getting the best, results from their, their tool, whether that be medication and or surgery.

And so, I work collaboratively with, a diet, dieticians. we have health psychologists on our team. we can refer out to exercise physiologists for select patients if they need that additional assistance. you know, if there's underlying mood disorders, working collaboratively with a psychiatrist or a mental health professional is important, as well as, you know, referring out to sleep medicine if, you know, there's some underlying sleep apnea and that needs to be managed as well.

So, it, it is, it requires a team and, you know, as an Obesity Medicine Specialist It's important to like kind of have all the resources and the tools so we can refer patients to the appropriate services so they can get the best care.

Melanie Cole MS (Host): It really is such a comprehensive approach and such a collaborative, multidisciplinary way to help these people.

Now, Dr. Hungness and I'd like to give you each a chance for a final thought, Dr. Hungness Tell us a little bit about current research and advancements in weight loss medicine because this is a burgeoning field. It's huge now. So tell us a little bit about what's exciting.

Eric Hungness, MD: I'm most excited about the trials that are going to come out of, of, of concomitant therapy.

So it's going to be, you know, induction, weight loss medication prior to. to weight loss surgery and how does that affect outcomes? it's going to be the patients that have had surgery and having a good result, but Which patients need to just start on, on medication for like a maintenance, maintenance therapy or patients that are increased, you know, having weight regain?

Which patients are, are, are, should, should start medication and seeing what those results are for, for, for combined therapy. That's what I'm, that's what I'm interested in. It's going to take well designed, Large, federally funded kind of trials and or by, with the drug companies to, to, to make that happen, but I, I hope we can get that, those, those studies done.

Melanie Cole MS (Host): And Dr. Johnson, last word to you, what would you like other providers to take away from this physician panel that we have today on obesity medicine, the exciting advancements, whether they're surgical or non surgical, medicational, What would you like the key takeaways to be today?

Veronica Johnson, M.D.: I think the biggest thing is just realizing that obesity is a chronic disease.

I think we still have a lot to do as far as the medical community educating about the different tools. available to treat obesity outside of lifestyle. And I think a lot of our patients come to see us in the general medical community and they, they are often stigmatized because of their weight and they don't get the proper care.

And unfortunately, they unfortunately don't get to see people like myself or Dr. Hungness until it gets to a really severe point. because they're just put a lot of, a lot of blame is put on why they weigh what they weigh. and so, you know, With the advent of surgery and these more advanced medical medications, my hope is that we'll start to use all the available treatment options for our patients who are struggling the most with their, their disease.

Melanie Cole MS (Host): Thank you both so much. What an informative episode this was. Thank you for joining us and to refer your patient. Or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians.

I'm Melanie Cole. Thanks so much for joining us today.