Amanda Wilde (Host): Welcome to the Health Exchange with Speare Memorial Hospital. Today, we're discussing the hot topic of weight management with medications and the Weight Management and Wellness Center at Speare Memorial Hospital. I'm Amanda Wilde. And joining me today is Dr. Jennifer Bentwood. Dr. Bentwood is a family doctor and medical weight loss specialist. Dr. Bentwood, welcome to the podcast.

Jennifer Bentwood, MD: Thank you so much. This is so nice to be talking with you.

Host: Well, like I said, weight loss management with medications is a hot topic, but let's start first with the big picture. Why did Speare Memorial Hospital feel it was important to create a dedicated weight management and wellness center that supports primary care?

Jennifer Bentwood, MD: So, we've had a weight management center for some time now. But with all the new medications coming on the market, we really felt like it was time to provide specialized expertise in the area. And so, I and our other provider who work up there are really able to stay up to date on the latest obesity med research, all the new medications that are in use that you hear about in the news so often. We have a dietician. We have staff who's dedicated to only weight management. And so, in that clinic, we really have more time for visits than a doctor would in a traditional primary care setting, and we have more frequent visits. So, treatment plans can be really personalized for weight loss and address other obesity-related conditions.

 The other thing that I believe Speare felt and that how I felt specifically was I think it gives weight management the importance that it deserves as a chronic medical condition, just like any other medical specialty offers.

Host: Yeah, I mean, it's a medical condition that affects thousands and thousands of Americans.

Jennifer Bentwood, MD: Many people. Yes. Yep.

Host: So, you're talking about your role alongside primary care. How do you work in partnership at the Weight Management and Wellness Center with the primary care providers?

Jennifer Bentwood, MD: Yeah. So by training, I am a primary care provider. I was trained in Family Medicine. And I was in primary care practice for 10 years. And so, I'm really sensitive to the time constraints that many primary care doctors have. And when you're in the primary care setting, weight management can be one of several complex medical conditions that you're expected to help a patient manage, and there often just isn't enough time in a visit to thoroughly address all the components that should be.

I had many patients say, "Well, I know I'm supposed to lose weight. I just don't know how," or "I don't know what medication," or "I don't know what I'm supposed to eat." And in our clinic, I feel like we've developed that expertise that addresses insurance questions, followup issues, referrals nutrition. We have a great relationship with our sleep center.

And so, I think because we have more time and this is all we focus on, we can really stay more up to date and we have more time to do that than a primary care doctor does. Primary care is so overloaded right now not just with patient conditions, but also with paperwork, insurance issues. And unfortunately, I just don't think that they have the time that it takes to manage all the complex issues that come along with this. And when I say complex issues, a lot of that is insurance issues.

Host: Do you help with that as well?

Jennifer Bentwood, MD: Our clinic does. My medical assistant is amazing. She is incredible, and she will get on the phone, talk to insurance companies, and she has the time to do that and the expertise now that you really need.

Host: So, you really give patients more time, attention, and support for specifically weight loss.

Jennifer Bentwood, MD: Yes, because we can. And that's why we opened the clinic. I think it helps take some of that off of the primary care so they can focus on other issues, which are just as important.

Host: Right. Medication as a tool for weight loss, does this replace surgery?

Jennifer Bentwood, MD: Oh, that's such a good question right now, and I would argue that a lot of people think it does. It really doesn't. Surgery absolutely has its place, weight loss surgery. But I will say that these medications, when used as a tool and in conjunction with lifestyle changes, dietary changes and exercise, can be incredibly effective. And for patients who are wary of surgery, which many are, this can be a great alternative.

Host: So, let's talk more about the potential benefits and also risks and side effects of these medications so we get the whole spectrum of what can happen with these medications, which really seem to be rapidly coming out now. Is that just my impression or is that the case?

Jennifer Bentwood, MD: So many people are using them. And obviously, there are people using them inappropriately. But I would argue that most people, certainly when you're getting them in a medical clinic, I think they're being used appropriately. So, the benefits obviously are great. I mean, these medications-- and when I say weight loss medications, I'm mainly talking about the GLP-1 agonists. So, you hear about Wegovy, which is FDA approved for weight loss, which is same as ozempic, which is FDA approved for type 2 diabetes, that's semaglutide. Tirzepatide is Zepbound, which is a similar medication and used for weight loss. If I can get those and if a patient does not have a contraindication to them, those are the ones I'm going to opt for if a patient can't get them because they're very expensive. And if their insurance doesn't cover them, we will opt for some oral medications. Two of them being Qsymia, another one being Contrave. I would say those are the four main medications that I use.

So, I'm going to talk mainly about the GLP-1 agonists: Wegovy and then tirzepatide as well. And I would say that the benefits are huge and these medications mimic hormones that essentially make you feel full longer. They decrease your appetite. Food sits in your stomach longer, so you tend to eat less. It increases your natural release of insulin, which then decreases your sugar levels, which have benefits. It also acts in your brain. It attaches to receptors in your brain that basically tell you you've had enough, like you don't need to eat more. Cravings are dramatically decreased.

Another thing that you'll often hear people talk about, and I actually had never heard about until I started doing this work, is food noise or a food voice. And I think those of us who don't have it, to have somebody describe it, it's just a constant preoccupation with food and with eating. And I will tell you that many of my patients, not all, but many of them say that is almost instantaneously gone, even at very low doses of this medication, which for a lot of people buys them the time and the head space they need to focus on getting healthy, creating those behavior changes, changing their diet when they're not constantly preoccupied with what they're going to eat next. And that's been a huge benefit.

The risks of the medications, we talk about risks, we talk about side effects more than anything. The side effects, as you can imagine, are also gastrointestinal. So if food sits in your stomach longer, you may have more reflux, you may get nauseated. Many people struggle with constipation because your gut does slow down. Some people get diarrhea. But I would say constipation is certainly more common. And then, there's the risks of the medication and that would be gallbladder issues, pancreatitis. Gastroparesis is when your gut stops working. And while these are rare, these are significant. And so, we have to have these conversations with patients. And again, that takes time to have that conversation and to really have shared decision-making in the office and say, "Hey, these are the risks and we have to decide if that's worth it." And so, we monitor patients very closely.

Host: I was just going to say, at least as a patient, you have someone monitoring you while you are trying this very new thing for your system.

Jennifer Bentwood, MD: And the other risk, I tell people these medications are incredibly effective. But they do not discriminate. So, you are going to lose fat, but you're also going to lose muscle. And that is why it is so critical that patients meet with our dietician. They understand how much protein they need to eat. And a lot of people have a hard time getting that much protein in a day. And they need to lift weights, they need to do resistance training. And that is another component of our program. We have a gym on site, which is huge benefit for our patients.

Host: How long are people typically on these medications?

Jennifer Bentwood, MD: So, they were developed to be lifetime medications, just like any other medication for a chronic disease, like your blood pressure medications, your cholesterol medications, your diabetes meds. A lot of people don't want to use them in that way. Unfortunately, when you stop, people tend to regain their weight pretty quickly.

Host: So, you get to a point, a stopping point at some point, but you're still on the medication.

Jennifer Bentwood, MD: Yep. And some people will decrease their dose. They'll go on a maintenance dose or they may even space out their dosing to make the medication last longer. I've had a few patients able to stop it. And I would say that is an incredibly small percentage of people who are able to do that. It tends to be people where their weight was a more recent issue. I can think of two women who were generally very fit, athletic women who gained 20 to 30 pounds in their early menopause years. And they both were able to take it and get off it. They lost the 20 pounds and then stopped, and so far have not regained. But I would say that is the exception to the rule.

Host: Boy, that is so typical too of that change in life.

Jennifer Bentwood, MD: Oh yeah.

Host: So, who's a good candidate for these medications? Those people in menopause perhaps?

Jennifer Bentwood, MD: These are tough questions because whenever you talk about weight with somebody, it's a very sensitive issue. And the patients I meet with, again, I have quite a long initial visit with them. And so, they come to me ready to talk about their weight. In the primary care setting, people don't often come to the doctor to talk about their weight and it's brought up. And so, that can feel very threatening. So when patients come to me, they know what we're talking about.

And so, good candidates, people who are referred to me, you can go at the technical numbers, so anyone with a BMI of 30 or higher is a candidate for weight loss medication, anybody with a BMI 27 or higher with comorbidities, meaning conditions that are chronic diseases like hypertension, diabetes, high cholesterol, or sleep apnea, those can be other things that are related to weight or comorbidities of being overweight.

So if you think about it, if you look at your friends and you wonder, BMI of 27 is not obese, 30 is considered obese, but I would say that's a pretty common BMI. And so, I personally, if I have a patient with a BMI of 30 who comes in, I will often talk to them first about lifestyle changes, specifically what they're doing as far as eating where they can make changes there, and then what they're doing for daily exercise. And I'll try and focus on that first.

But if I have a patient come in who says, "If you look at a picture of me in kindergarten, I was always the bigger child. If you look at my family photos, we are all obese, this runs in my family," and they've been struggling with this for their entire life, I'm not going to talk about behavior change and exercise solely. I'm going to start medication if they're a candidate along with those other things.

Host: One of the other hurdles in weight management is addressing the mental and emotional side, which you've just touched on. On one hand, you say patients come to you ready to talk about weight and it makes me think people are more in the head space to tackle that issue. And you also mentioned the medications got rid of the food voice. So, there's a mental, emotional change that happens due to the medications. Are there other behavioral health challenges you're still struggling to solve?

Jennifer Bentwood, MD: Oh, yes. Sadly, many patients come to me and say, "I just want the medication." And we don't do that. And I always tell patients I do not have any special power that your primary care does not have. If you just want medication, you can get that through your primary care. We are a comprehensive clinic. We expect people to meet with me to discuss medication, chronic disease management related to their weight. We expect them and we require that they meet with our dietician to go over their food and how they can make changes there. And we expect them to have a consultation at our gym, Rehab Fit, with one of our trainers there.

Now, if somebody comes to me and they're already going to their gym and meeting with a trainer, obviously, I'm not going to make them do that, but most people are not. And so, for us, I have a number of people say, "Oh no, I'm never going to work out. That's not for me," or "Nope, I'm not changing my diet." And I say, "Then, this clinic is probably not a great fit for you." And of course, I always offer to work with them, because I think over time I can get people to make those changes with the right kind of support and encouragement. But a lot of people come to us really resistant to changing their lifestyle

Host: And many of us know what we should do, but that doesn't mean doing it.

Jennifer Bentwood, MD: Right. And it is funny. I always say the one component we're missing is a therapist. And so, I do a lot of referrals to our local therapists to talk to people about why food plays this role in their life, why they eat the way they do, what triggers them. And food is such an integral part of our life. And I had one patient and she had seen a therapist. She said, "I feel like you're criticizing the way I was raised." That's a deep conversation. And so, you really have to tread lightly when you're talking about changing this. People have grown up this way. How you show our love to our children can often be tied up in food. And so, it's a sensitive topic for people. So, I do a lot of referrals to behavioral health. I wish we had someone in our clinic with us. But really getting people to change habits is, I think, the biggest struggle that probably most weight loss clinics have. And so, one of the things, we have a Tuesday night group meeting and I found that the patients who have opted into that are doing the best. Having that group support and the encouragement of other people who are also working on this is really helpful.

Host: Yeah, it sounds like support is the key to all of these, really.

Jennifer Bentwood, MD: Oh yeah, totally. I always tell people I'm going to be your biggest cheerleader. I can't go home with you. I can't change what you're doing at home, but I am here for you. And I will do everything I can to help them along the way.

Host: That can really be transformative though when you're feeling judged about your weight or the way you eat when you walk in to get that kind of support.

Jennifer Bentwood, MD: Yep. Totally. And the number of patients who tell me that they have felt ostracized because of their weight, it's almost a hundred percent at some point or another. I'm sure I've been guilty of that in my career at some point. It's hard. A lot of people, especially people who are morbidly obese, we're talking BMI greater than 40 where a lot of complications are directly related to their weight. It can be challenging. But the successes are huge. I had a patient the other day who I came in the room and she said, "I just walked up the stairs to get here," and we have a decent flight of stairs. I said, "That's awesome." She said, "No, Dr. Bentwood, you don't understand. I haven't walked up a flight of stairs in years." And so, just that, those little differences I think are huge.

Host: So, you're going to have big results from patients seeing those steps along the way, those results that may seem small, but that are huge, like walking up the stairs.

Jennifer Bentwood, MD: They are so huge. And if we can help people get there, if we can help people be more mobile, be more independent and remain independent throughout their life, especially in their older years, I think that's a huge win. This isn't just scale victories. This is keeping people physically independent and able-bodied. I would say that has been a huge goal for us and we're seeing that, which is great.

Host: The more results people see in their own story, the more motivated we will all be to watch after our health.

Jennifer Bentwood, MD: Yeah. And I think getting back to the behavioral health changes, one of the benefits of these medications is that you'll see results pretty quickly on the scale, and that is very motivating for people. I have a lot of patients who say, "I exercised and I exercised," and I had one woman the other day said, "I exercised for a month and didn't see any difference." And we both laughed because she knew that was completely unrealistic. But we live in a society where we want immediate results and immediate gratification. And when I hear people say, "No," like, this is going to take years. And I tell people, "It took years for you to carry this weight and get to this size. It may take years to get it off. But you don't have to be perfect. You just have to be very consistent." And so, that is a struggle for a lot of people because they don't see the results they want quickly. But these medications do help with that. And so, I think it motivates people to continue.

Host: Exactly. Well, Dr. Bentwood, thank you for your insights on how to integrate medications into a healthy weight management plan and how the Center for Weight Management and Wellness is supporting that.

Jennifer Bentwood, MD: Thank you for having me. It's been fun talking to you about it.

Host: That was Dr. Jennifer Bentwood. For more information, go to spearehospital.com. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening to the Health Exchange with Speare Memorial Hospital.