Scott Webb (Host): It seems everywhere we turn these days, there are ads for anti-obesity medications. And since some are FDA approved, and some aren't, and there can be benefits and also side effects, it seems prudent to have an expert to discuss these medications. And I'm joined today by Dr. Ellie Chuang. She's an endocrinologist and obesity medicine specialist with Southern New Hampshire Weight Management.

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. 

Doctor, it's so nice to have you here today. I know in the popular culture and the news and social media and just about everywhere, it seems like they're talking about anti-obesity medications, maybe sometimes referred to as weight loss drugs, but today we're going to refer to them as anti-obesity medications. And so, it's a very hot topic, if you will. So, great to have you on. I just want to start here, what is Southern New Hampshire Weight Management's approach to weight loss?

Dr. Ellie Chuang: First and foremost, we understand that obesity is a chronic disease similar to diabetes or hypertension. It's a complex disease that is best treated in a multidisciplinary team approach, partnering with the patient to find the best way to help them achieve what I like to call their best weight. I just define that as this healthier place you can get to all around that you can maintain long term with a plan that you're happy to do long term.

Host: Yeah, that sounds right. You know, you and I were just chatting before we got rolling here, and a lot of folks are, you know, maybe self-diagnosing, they're getting on the scale, they're going on the internet, and, you know, we really want to encourage them to speak with their provider, get referrals if necessary, because, you know, there could be some complications, some side effects, whatever it might be. So, who's a good candidate for anti-obesity medications?

Dr. Ellie Chuang: Well, there are certain guidelines out there, which I'll review first. So, a good candidate would be someone who has already failed attempts to lose weight with lifestyle habit modifications, you know, whether it's that they weren't able to achieve what they wanted to or that they did do well and got to where they wanted to perhaps, but weren't able to sustain it, especially if there have been multiple attempts. 

And then, also, going off the BMI, or body mass index, which is a screening tool to assess for obesity, the official guidelines are that if you have a BMI of 30 or greater, which is technically considered obesity, then you are a good candidate. If you've already tried and failed lifestyle modification, you are a good candidate for an anti-obesity medication. Also, if you have a BMI of less than 30 but at least 27, which puts you in the overweight category, and you have at least one obesity-related comorbidity like high blood pressure, high cholesterol, or diabetes, then you would also be considered a good candidate to consider an anti-obesity medication.

However, BMI—again, it's a screening tool—doesn't tell us the whole story about health or even obesity. So, looking at the waist circumference can be another very important metric. If that is elevated, that can point to a person having excess adipose tissue or fat, which is another definition of obesity. So, although it's not in official guidelines, if your waist circumference is elevated regardless of your BMI, that would be another reason to consider anti-obesity medication. 

Host: So many times, that BMI seems like the be-all and end-all. But as you say, it's a screening tool, but there's more to it. Patient history, just sort of listening to their behavior and lifestyle, looking at some other things, as you say, other comorbidities and so forth. So, really great to have a medical professional to speak with about this kind of stuff. I guess, you know, maybe the $64,000 question, what are the different types of medications that are available? How do they work in the body? And what are the potential benefits and risks associated?

Dr. Ellie Chuang: Well, I have to laugh here, Scott, because this is a very large topic that we could definitely have a conversation of more than an hour, probably, going through all of these things. So, I'm going to try to hit some important points because I know a lot of people are, of course, very interested in this. You know, it's a lot out in the public and are, you know, curious about the pros and cons, et cetera. So, I guess to address the elephant in the room, kind of, everybody knows pretty much about the medications that are popularly called GLP-1s. In a more inclusive way of calling this category would be incretin mimetics. These include medications such as Ozempic, Wegovy, ZepBound, Mounjaro, and a few more. 

So, these medications were originally developed for diabetes. And they noticed people lost weight on that, so they developed several of those drugs into a format that then became FDA-approved for weight loss. They work by giving you back the action of one or more of the incretin hormones, which are gut hormones produced in your GI system, which can have various effects. So, where they impact your weight is that they can make you feel full sooner. They can directly suppress your appetite, and sometimes, they can decrease cravings. So as you can see, that could be very effective for healthy people. As a class of medications, they are the most effective class that we have right now for treating obesity, on the lines of up to 21% weight loss on these medications in the clinical trials. 

Host: That's pretty amazing. It's easy to understand, especially for folks who want to lose weight or maybe actually qualify as being obese, of which there are many tens of millions in America, but easy to understand why these medications would be appealing.

Dr. Ellie Chuang: Yeah, absolutely. I mean, we've seen some amazing effects here. So, in terms of side effects, they are generally most commonly gastrointestinal in nature. The most common one is nausea. You can also see diarrhea or constipation, as well as some worsening in acid reflux. So, other potential benefits of these medications, by the way, is obviously blood sugars, even though we use them in patients who do not have diabetes. And also, one of them, Wegovy, has recently been shown and FDA approved to help prevent cardiovascular events. 

So, another class of anti-obesity medications we have are the stimulant class. The most common one we use in the stimulant class is phentermine, and it can help treat obesity by suppressing appetite, sometimes decreasing cravings. And then, for reasons we don't completely understand, they sometimes seem to particularly help people who have a large component of a slow metabolism issue going on. Side effect-wise, I always like to tell patients it's similar to drinking a lot of caffeine. So, palpitations, anxiety, jitteriness, dry mouth, insomnia. Also, it can sometimes increase blood pressure, so that's something we have to monitor. 

Then, we have another stimulant called Vyvanse, which is used for ADHD, but it is also the only FDA-approved medication for treating binge eating disorder, which is something that we screen for in our evaluation. There's also a medication called Orlistat, which is also available over-the-counter under the brand name Alli. And that blocks the absorption of fat. Another thing that we can use is basically considered a medical device. It's called Plenity. And these are gel capsules that you take before meals to kind of help fill you up beforehand. 

Then, there are two FDA-approved combination drugs. One of them is called Qsimia, which is a combination of phentermine that we already mentioned and another medication called topiramate. As well as another one called Contrave, which is a combination of bupropion and naltrexone, which brings me to the drugs that we use that are sometimes considered off-label, meaning they are not FDA-approved specifically for weight loss, and that includes topiramate and the naltrexone and the bupropion previously mentioned, as well as a medication FDA approved for diabetes called metformin. The various side effect profiles are different for those meds, which are all oral medications. So, it should just be noted, although most people probably know that the incretin mimetics are almost all injectables either daily or weekly.

So, the various side effects and indications for some of these other medications I've mentioned are probably beyond the scope of this podcast. But I do want to say that the decision in terms of which medication to use in a person is totally individualized, and it's going to be based on what we have a sense could be most helpful for you in terms of, you know, what characteristics you have, what your health problems are, what your preferences are, etcetera.

Host: Yeah, definitely not one-size-fits-all, and some benefits, some risks, some side effects, and so forth. Again, as I've stressed here today, good to have a medical professional involved in the decision-making, of course. What are some of the common misconceptions about anti-obesity medications?

Dr. Ellie Chuang: I think maybe the most important one is that these are not a magic bullet. Yes, some of these drugs can be very effective for people, but first of all, everybody can have a different response. So, some people could be total non-responders, and some people could be what I call hyper-responders. But unfortunately, at this point, we can't predict that ahead of time.

They're not a magic bullet in the sense that they shouldn't just be given in a vacuum. To get the best effect and to do it in the most healthy way, you want to also make sure that you are working on the foundational things, which are developing healthy lifestyle habits that you sustain long term. So, I just want to put in a caution here. Obviously, there's a lot out there about these drugs, including the ability to get them from med spas or online services with compounded semaglutide, for example. The warning I would have is that these are not actually FDA-approved or regulated formulations of the drug. They are not recommended by multiple societies. If you're interested in being treated with one of these medications, I would encourage you to talk to your healthcare provider and potentially get a referral to an obesity medicine specialist.

Host: Yeah. You talk about those that respond, you know, immediately and fabulously. It seems like those are the stories I see get shared on Instagram and Facebook, and I'm guessing some folks are on these things for longer and may not respond initially and may have to try some different things. So, it makes me wonder, you know, how long should someone expect to be on these medications? And have they been studied long enough to know if there are any potential long-term effects?

Dr. Ellie Chuang: That's another almost like a misconception is that you can just take medication for obesity to jumpstart your weight loss journey and then be able to go off of it after a few months or something like that. The point of fact is we talked about how obesity is a chronic disease, which, unfortunately, at this point, we don't have medications to cure. So, the majority of people will require anti-obesity medication in some form or another long term to maintain a healthy weight. There have been studies showing that when you go off anti-obesity medication, such as some of the incretin mimetics, a large majority of them will regain weight within a year or two.

In terms of long-term effects, one thing I want to reassure people about is that the incretin mimetics have actually been around quite a long time, almost 20 years, even though it seems like they just came up. And that's because as I said before, they were originally developed to treat type 2 diabetes. And then, the ones that were developed as the anti-obesity medications did come later, but they are not new medications. So, in terms of that, they've been around for a long time, and we have not seen so far, any clear evidence for severe long-term effects. And in fact, as I mentioned, at least one of them has been shown to have cardiovascular benefit. 

Then, we also have phentermine, which is actually the oldest anti-obesity medication that we use right now that's been around even longer than Incretin mimetics. We have lots of data on that medication, no evidence that we have seen for a long-term negative effect.

Host: So, I just want to finish up and ask you what role an obesity medicine specialist plays in monitoring someone's progress while they're on medications. I'm sure potential patients want to know how they can get started with you or the team at Southern New Hampshire Weight Management.

Dr. Ellie Chuang: So, I really encourage people to try to find an obesity medicine specialist if they can when being treated with these medications because we have the training and the experience to really help you derive the most benefit in a healthy way. Ideally, you would be followed up with regular clinic visits every one to two months or so. And what your specialists would do is monitor how you're doing, both in terms of how you're doing with formulating and sustaining your healthy lifestyle habits. And then, in terms of monitoring the medications, find out how you're doing in terms of any potential side effects, and then assess how well it's working and whether any adjustments need to be made, whether that would be a change in the dosing or maybe adding a different medication. 

In terms of accessing our program, you can have your primary care provider send a referral to our clinic. You can also then call our office at 603-577-3275 to start the process. And that's going to involve signing up for one of our monthly info sessions where we go over in detail what our whole program offers. At that point, you would also fill out our intake questionnaire. And then as you leave the session, be able to schedule your first appointment.

Host: Yeah, that sounds good. Just something along the lines of one-stop shopping, which is great for folks, of course. And it's been really educational today. As you said earlier, we could talk about this for hours, but we don't have hours today. But what we really want folks to do is speak with their providers if they believe they're a good candidate or get a referral and speak with you and the team there to find out. But it's just great to have you on. Great to learn more. Thank you so much.

Dr. Ellie Chuang: Thanks. 

Host: For more information, go to snhhealth.org/weightloss. If you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.