Joey Wahler (Host): Are they right for you? And if so, which one? We're discussing weight loss medication. Our guest, Dr. Jeremy Byrd. He's a pediatrician and internal medicine physician for Prisma Health.

This is Flourish, a podcast from Prisma Health. Thanks for listening. I'm Joey Wahler. Hi, Dr. Byrd. Thanks for joining us. So first, we hear so much about them, but simply put, for those unaware, how exactly do weight loss drugs work in the first place?

Dr Jeremy Byrd: Well, I think that's a great question. It really depends upon the medication we're talking about. There are several different medicines out there. Of course, recently, we've been hearing a lot about the medicines, which are the GLP medicines, like Ozempic or Victoza or Trulicity, which you've heard about on the news. But it just depends upon the person and which medicine is actually going to be used.

Host: But generally speaking, for those of us, unlike yourself that didn't take the time to go to medical school, what exactly is happening in our bodies that makes them work?

Dr Jeremy Byrd: So, weight loss medicines most of the time work by appetite suppression. So, there's something in the medicine, depending upon the mechanism, that decreases your interest in food. And so, you just end up eating less and needing less. So therefore, you'll have weight loss as a result. Most medicines don't work through increasing the metabolism, which would be a dangerous thing really, and certainly those type of things have been out there in the market in the past and inappropriately used, but they work by just decreasing the appetite.

Host: Gotcha. And speaking of being inappropriately used, we'll talk more about that in a moment. But first, as you all know, people are overweight to varying degrees and for a multitude of different reasons. So, who's a good candidate for weight loss medicine?

Dr Jeremy Byrd: That's a great question, and I think it comes back to a thing called BMI, which you may have heard your doctor talk about before. What's interesting is that BMI is actually an insurance indicator that doctors have adopted to give us some type of indicator of how much you weigh given your height. But BMI's give us some type of clue as to if the medicine be right for you. And so, we consider folks overweight if they're between a BMI of 25 and 30, and obese if they're over 30. And so, weight loss medicines are right for you if you're overweight and you have another risk factor such as heart disease, or if your BMI is over 30, that is something that you can definitely talk with your doctors about.

Host: BMI, of course, stands for body mass index, correct?

Dr Jeremy Byrd: That's correct. But, you know, a lot of weight loss experts really want the focus to shift off of this BMI measurement because, like I said, it was an insurance measurement used I think in the '30s and '50s and something we've just held on to. What's a better indicator actually is your waist circumference and men with a waist circumference over 40 or women over 35 are considered overweight, and that is actually a better indicator or even a goal for loss of weight.

Host: Okay. So, a need to update that going on a century later, right?

Dr Jeremy Byrd: Yeah, right.

Host: So generally speaking, how effective are these weight loss medications?

Dr Jeremy Byrd: This is what's exciting. But I want to back up in answer to your question, doctors recognized obesity as a chronic medical condition about 10 years ago in 2003 or 2002, depending upon who you listen to. And so, that should have shifted our focus from obesity as a personal fault, for lack of a better word, to a chronic condition, just like something like blood pressure or diabetes. And so, it's something that you have and you're going to have for a long period of time. And so, having said that, that gives us a clue as we approach treatment. It is something that we want to treat lifelong and chronically. So, they're very effective. And most of your doctors, primary care doctors can talk to you and address using a medication that would be the right fit for you. There are a lot of different medicines on the market. Not every medicine is right for every person because it depends upon your risk factors, such as if you have a history of diabetes or heart disease or something else. But there are great medicines out there and they all have different benefits, but there are so many things that can be tried and prove effective in weight loss, for sure.

Host: To pick up on your point from a moment ago, you were saying that oftentimes people's obesity or being overweight is not "their fault", right? It can be tied to another underlying medical condition, for instance. And so with that in mind, how safe is it for most people to take these weight loss drugs and what are some of the risks associated?

Dr Jeremy Byrd: And so, I think that depends upon the medicine we're using. And so, maybe it'd be helpful if I just mentioned a few specific medicines, or at least categories of medicines. Sometime ago, there was a medicine that was used called fen-phen, and it had some really bad side effects. But what we discovered is that one of the medicines in this fen-phen called phentermine was actually very safe for use. And this is in fact probably one of the best medicines out there, but not for everybody particularly if you have a cardiovascular history, and I've seen a lot of effective weight loss with this medicine. And so, that is often a good choice primarily because it's been studied so much, it's been proven safe and it's affordable. Whereas some of the things that you hear about in the news are not so affordable depending upon your payer source or your insurance. And so, that's one common medicine that's used.

We've heard a lot of news about the GLP-1 agonists, which are medicines like Ozempic or Victoza, to use the brand name. And those medicines were first used or studied with diabetic patients and they're used for diabetes and offer diabetics great control of their blood sugars. They are injectable medicines, which is kind of a hard thing for folks to get over, understandably so. But we've seen dramatic weight loss with these medicines up to 14% of a person's weight. And the side effects with these medicines are not very much, except for some nausea. And so, they're very safe to use and really exciting, because folks that have not been able to lose weight on their own have some other options available to them.

Host: How about if you're on a weight loss medication and then want to or need to stop taking it for whatever reason? Can you, at any time, stop cold turkey, so to speak? Or do you need to wean off and why?

Dr Jeremy Byrd: So, that's a good question. And I think it goes back to something we were saying before, this shift in focus where being obese is a chronic condition. And I think we, as the medical community, need to shift our focus. This is something that doesn't go away. And so, most of the time, we try to maintain a medicine and it could be maintained for years, something like phentermine that folks have had patients on these medicines for years and years safely. And usually the medicines, the GLP-1 medicines I was mentioning like Ozempic or Victoza, those medicines also have to be taken lifelong. But I don't recommend stopping them without talking to your doctor because there are other options, as I said, out there to help out.

And, you know, I think as long as folks shift their perspective, if you go on a medicine, for example, for diabetes, most of the time, you're going to have to stay on something for diabetes, and it's rare to come off of it, and you wouldn't want to stop it, unless you were put on something else. And so, likewise, with obesity, it's something you'd want to stay on long term. But we do in the office monitor things like blood pressure and weight and side effects, trying to make sure that we're being as safe as possible in terms of treatment of obesity.

Host: Sure, understood. So, you led me beautifully into my next question, doc, because you mentioned diabetes and diabetics, of course, take weight loss medicines because the two are often tied the need to lose weight and being diabetic. So with a medication like Ozempic, for instance, that's now also taken by those without diabetes. So, how common is that so called off label prescribing. And in this instance, is it a good idea, in other words, to take a weight loss medication associated with diabetic patients and use it even if you're not someone with diabetes?

Dr Jeremy Byrd: The medicine that we're talking about, its generic name is semaglutide. And there is a diabetic version of that called Wegovy. And then, there's an obesity version of that medicine called Ozempic, as you just said. And so, we found just dramatic weight loss in our folks with diabetes and improvement in their blood sugars. And so, that data was extrapolated and it is considered a weight loss medicine. And so, it's perfectly safe to take.

There is a mention of possible associated thyroid C-cell cancer with ozempic. And I talk with all my patients about that. That's something I've never seen before, but it's just something that was mentioned in regards to this medicine. And I think it's just something patients need to acknowledge. There's always a risk with any medicine, even though not something I've ever seen or really even heard of, it's just a mention of a side effect.

And so, going back to your question, the medicines are very safe to take and we do see weight loss. And usually, we start at a low dose and will increase slowly as long as the patient tolerates it. The most common side effect really is nausea and stomach upset or just decreased appetite all together, which is kind of what we're looking for anyways. We don't see a significant drop in blood sugars, which might be something that someone would be worried about because if they hear it's taken for diabetes, they may be afraid that their blood sugar is going to drop. But that doesn't happen with this medicine. I've never seen that before, unless someone's just not eating, which obviously you still have to eat with this medicine.

Host: Gotcha. And with off-label prescribing in general, just to close out that thought, doctor, it really has become more common in general in the medical field in recent years, hasn't it? Like just to name one other example, I know that seizure medicine is used for a number of other things besides people that have seizures, right?

Dr Jeremy Byrd: So sometimes, we'll find medicines have additional benefit. And so, there'll be a shift in where it's used for a different medical condition. But I wouldn't necessarily use the terminology off-label per se with Ozempic. It's been indicated and been proven for weight loss, it's just that it was more like we discovered, the medical community, that it had such great benefit and excitedly made a transition to where it could be used throughout our population, not just in our diabetic patients.

Host: Gotcha. And like you said, it does have the two versions, if you will, right?

Dr Jeremy Byrd: Yeah, exactly. Although very similar, I think the dosing can be a little bit different, but it's very similar. Now, availability is another thing altogether, and insurance coverage is another thing altogether too. And so, those are barriers we face. It depends upon what state you're in. It depends upon what your insurance company will cover. But like I said, although folks are coming in the office interested, understandably interested in these medicines they're hearing about on the news and such, there are other options out there. And we've only mentioned a couple. There are other things out there that can be used and have great benefit with weight loss. It's just really an exciting time, because I think so many of us have felt dejected by our inability to lose weight.

I heard a great analogy recently by an obesity expert. She lived up north and she said, "When it snows, how would you handle the snow?" And if somebody says, "Well, you know, I don't know. I go out there and get a shovel or a bulldozer or whatever to clean off the streets." She said, well, what happens if I gave you a teaspoon to go clean out the snow?" And I think that's a great analogy. She said, "That's how people approach weight when they're doing diet and exercise. And that's how you feel because you can't make an impact." You lose a couple pounds, but you've got so many more pounds that you'd like to lose, you know, with your personal target. And so, I think we have been giving people teaspoons to clear the snow, so to say, and these medicines have allowed us real tools to help people treat a chronic condition with success.

Host: Well, you're talking there really about, I think in part, people in this situation needing to take that first step without feeling too overwhelmed, right? So, what would you say are a few other examples of weight loss options short of starting drugs where maybe people can avoid them altogether? What are some common things that people can try that maybe they kind of know about already, but maybe they just haven't thought about lately?

Dr Jeremy Byrd: And so, I mean, diet is so important and it's so hard, because we have so many great options available to us, but I think making a shift to a healthier diet, and so you've heard things like the Mediterranean diet, of course, or the DASH diet, but a diet that's a little higher in vegetables and fruits, if you're not worried about the sugars as much in your diet, and away from the starches and the fats. That's going to be hard to do on your own. And so, one of the websites that's recommended by obesity experts is called eatingwell.com, where you can develop a food plan and kind of get some ideas about recipes. And we all could probably eat healthier. But I think that is a hard thing to do on your own. And so, sometimes you can reach out and try to find someone to kind of counsel you through that, whether it be a nutritionist or otherwise or a dietitian. That is hard, once again, to identify those folks and sometimes your physician can help you out with that.

And then exercise, I think just you cannot exercise in isolation most of the time. You just need a community, and so whether that be joining an aerobics class or a swim class or going with a friend, that is the only effective exercise in my opinion. If you're going to do it on your own, it doesn't usually pan out because you can't stick with it or keep up with it without some type of community or family commitment.

Host: Yeah, that camaraderie alone, right, of just being around other people in the same boat, if you will, can be a big motivator.

Dr Jeremy Byrd: Absolutely. I mean, it works with me when I go to the gym and I have folks rooting for me, I can do things that I didn't think I could do on my own otherwise.

Host: That's great. Final question for you, doc. You mentioned earlier that in terms of insurance covering these weight loss drugs, it really depends upon who you have as your insurance carrier. But something else you mentioned, that sometimes depending upon where you live, there are issues with availability. What did you mean by that?

Dr Jeremy Byrd: So, we're having a lot of folks we would like to start on, in particular, the GLP-1 medicines like Ozempic. And we've had a hard time finding availability sometimes in the pharmacy, just because so many folks are reaching for them appropriately so, and so just sometimes they're not in the pharmacy, they're trying to increase production.

There is talk, and this is super exciting, about a pill of this medicine coming out where folks won't have to do the injections. And so, there are some pill options, but I mean for folks who are struggling with obesity in particular, and so that's on the, horizon, and I think I can't be more excited about that. But availability is always going to be something, because this is all something relatively new for us in terms of these new medicines.

Some of the older medicines that have been used are out there and something to talk to your doctor about. We talked about diabetes medicines. But for example, a very common medicine for folks with diabetes called metformin. Some people can lose a lot of weight on that medicine. It's not everybody. And non-diabetics can take that medicine and lose weight. And so, there are generic medicines out there that are options when we can't find brand names that we've kind of mentioned.

Host: You mentioned the word exciting a number of times during our chat, doctor. So, it sounds like that indeed is a great way to kind of end here and sum up, regarding the fact that there's a lot going on that's new and different in this world of weight loss medication. We're going to have to do this again and talk about some more of them down the road, yeah?

Dr Jeremy Byrd: I think sometimes providers are either Just have a lot going on or busy or, nervous about addressing the weight with their patients. So, I just encourage patients to ask their doctors what option would be right for them and just not feel that this is a, once again, a moral failure. This is something that so many of us are struggling with and there's not an easy answer like always on your own. Exercise and the diet are sometimes the hardest things, and we want to give people a little bit more than teaspoons to address the issue. And so, just talking with their doctor, engaging them and talking with options, most primary care providers should be able to address this.

Host: Absolutely. Folks, we trust you're now more familiar with whether weight loss medication is right for you. Dr. Jeremy Byrd, great information. Thanks so much again.

Dr Jeremy Byrd: Thank you.

Host: And for more information, please visit prismahealth.org forward/flourish. Again, prismahealth.org/flourish. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for listening to Flourish, a podcast from Prisma Health.