Scott Webb (Host): When it comes to weight loss drugs, it's not one-size-fits-all, and it's best for folks to work with someone like my guest today to determine an overall treatment plan and whether or not that should include some of the newer weight loss drugs. I'm joined today by Dr. Kenneth Wells. He's the Medical Director of Summa Health's Medical Weight Management Program.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Dr. Wells, it's so nice to have your time today. We were talking a little football before we got rolling here. We're going to basically talk not about football, but about some of the newer weight loss drugs, this kind of new wave of weight loss drugs, if you will. So just to kind of set the stage for everybody here, let's talk about some of the drugs that are currently approved and on the market and maybe what their original purposes were.

Dr. Kenneth Wells: I think that historically, as physicians, we have used these weight loss drugs, not always in the right way. I think that the number one thing with these medications, as I tell patients, I want to keep them within their borders. What I mean is I want them to eat the right way for their metabolism.

And so, I think there's two things we see in the office. We see increased appetite. But we see, I think, that one thing that's even harder to control is cravings. And so, that's where I see these medications can be very helpful. So historically, some of the prescriptions that the FDA has approved, you have Contrave, which is Welbutrin and naltrexone. You have Qsymia, which is Topamax and phentermine. They've been around for probably 10 to 15 years. Phentermine is a stimulant. It's been around for a long time. In the state of Ohio, we can only prescribe it for no more than three months at a time. I'm not a big proponent because I think, particularly in my folks over the age of 50, we have to watch out for hypertension and atrial fibrillation, and just the stigma attached to the phentermine. Doctors back in the '60s, '70s and '80s would just open up shops and just sell this, and just really, I think, did a lot to damage the credibility in treating this disease. Metformin is an off-label drug that I've used for a long time. We know it from diabetes, but it also helps to improve insulin resistance, which is really the hallmark abnormality that we see in patients that have weight disease in general.

 The newer medications now are the big talk in the media and that's the glucagon-like peptides, GLP-1s, and these medicines, the most famous was semaglutide. There was a study that came out in 2021 that showed, with this medication, there was an average weight loss over 40 months, which was about 22% of the patient's total body weight. And if you look at comparing that to what we see average weight loss post bariatric surgery, we see a 30 to 35% weight loss with bariatric surgery on average a year after surgery, 22% were approaching that. Before these group of medications, Scott, the closest thing we would get, maybe an 8-9% loss with the other drugs that I mentioned. So, these drugs certainly have been a good tool in our arsenal to use with our patients.

Host: Yeah, I definitely have. And just, doctor, when we think about weight loss in general, right? So, folks who set out to lose weight, whether they're trying, as you say, bariatric surgery or some of these various drugs, some of the older school things, and we're talking about the new wave today a little bit, is it just a fad? Is weight loss just a fad do you find? Or are folks generally pretty serious about it? Will they stay with it?

Dr. Kenneth Wells: And that's a great question. I think as a culture, we've historically approached weight disease very wrong. Even in the medical profession, eat less and exercise more. Push yourself away from the table. Scott, I would say the majority of patients I see, that's not the case. They come in tears and say, "I don't eat that much," and I say, "I believe you." Now, don't get me wrong. I do have a subset of population of you would define them maybe by biblical standards as gluttons. But the majority of my patients, that's not the case. The genetics of this disease are so rich.

But let me give you a little story, side story, that might even explain this better. In 2013, the American Medical Association had their meeting, I forget where it was at, but they had all their delegates, and they voted that obesity is a disease, 60/40 vote. So, what that tells me is there's still a great majority of physicians that don't believe it's a disease. Now, 10 years later, I think the science is crystal clear that it is a disease when you look at the genetics. And we have 22,000 genes in our body, 5,000 are dedicated to metabolism distributed between the brain and the gut. We now know that from the mapping of the human genome. We know from twin studies that are 30 years old, biological twins, do they gain weight because of nurture with the families they live with or nature from the biology from their biological parents? A hundred percent from their biological parents. And we've mapped out now some of these pathways between the midbrain, the digestive tract. It's a very complicated system. We still operate though, from what you said originally, is it a fad? Is it just more discipline? And it's absolutely not.

Now, granted, I see patients, what's their motivation level? They have to put some skin in the game and participate in what we're doing. But an analogous situation with our clinic, a bariatric clinic, is I look at an oncology or cancer clinic. They have surgery, they have chemo, they have radiation, they have now immunotherapy. So, what we have, it first starts with the nutrition. Not dieting, not calories, not fat grams, but eating the right food at the right time, pairing our carbs with our protein, and that's new and that's important. Then, we look at our medications that we could potentially use, and I don't start new patients on medications. I want to see what they can do with their meal plan, because most of my patients for the first time have been instructed how do I eat for my metabolism, not how do I diet. And then for some of our folks, the surgery option is definitely, and sometimes we use all three. But we approach it, I think, with the same level of respect and detail we approach a lot of diseases.

Host: Yeah. It makes me wonder if they had that vote now, 10 years later, that 60/40 vote, it feels like it wouldn't be 60/40. It'd be maybe 90/10, something like that, as you say.

Dr. Kenneth Wells: Yeah. I would say probably closer from what I see in clinical practice, probably 70/30, maybe 80/20. But the other problem, Scott, is in our medical schools, our medical education for obesity is not standardized. And many medical schools have a one-hour class on nutrition, which doesn't even begin to scratch the surface when you talk about this disease as we know it in 2023.

So, there's a lot of things that, like I said, we need to get caught up. So at minimum, the physicians should be able to look at their patient, talk respectfully with their patient about their disease, come up with a game plan. Some of the stuff we do, primary care doctors can do in their office. Some of the stuff we do, we should probably be managing that because of the complexity of this disease, particularly when we have patients that have emotional eating disorders. But again, I love the challenge to not only treat our patients, but to educate our healthcare providers.

Host: Yeah. So, you say that it's a part of a plan. You start with the meal plan. You don't go right to the medications. But when we think about these newer medications, diet pills, if you will, how do they work and how do they really lead to the weight loss? I am assuming that they're not magic, that it really requires the meal plan plus the pills and so on basically. So, take us through that. How does this work?

Dr. Kenneth Wells: I think what you're asking me is what is the physiology or pharmacology of these medications, and I'll do it in a way as I tell people in this foreign language of medicine, I'll explain it in a way that can be understandable. When you look at the GLP-1s, I'll start with the newest first, they work by a couple different mechanisms. They slow down gastric emptying, which causes earlier satiety, and we see that as one of the mechanisms we see in our postop patients, too. But I think many people think bariatric surgery is just a restrictive surgery that just cuts down on the amount of food we eat, and that's not the case. It works centrally, it improves the communication between the brain and the gut and some of the regulatory steps between the brain and the gut. Your GLP slows down gastric emptying, but it also improves insulin efficiency. I'm going to explain a little bit about insulin resistance, because I think this is very important for the public to understand.

Most of our patients, particularly if they put weight on their midsection, have a family history of diabetes, they themselves have prediabetes, have insulin resistance. What does that mean? Their bodies produce higher amounts of insulin, because that insulin doesn't work very well. So, insulin's job is to bind to cells in the body and allow glucose to be entered into the cell to be used for energy. So, higher levels of insulin drive eating behavior. They tend to make people hungrier at night. They tend to cause people to snack at night. They tend to cause people not to want to eat during the day. They tend to cause fatigue and they cause fluid retention. All of these, Scott, are a vicious cycle that cause more weight gain. And so, the person that's following their calories and they're reducing their calories, they're not really getting to the cause of the insulin resistance. It's futile and many times it's cruel, because they can't maintain because they're so hungry and they're craving and stuff. So, understanding the mechanism of insulin resistance is important and the GLPs help to improve that. We lower insulin resistance. We also can help with both metabolism and also with our cravings and appetite.

When I prescribe a medication that's treating hypertension, we may have 50 hypertensive drugs. Which one's going to work best for you and your genetics? Unfortunately, we can screen sometime between ethnicities, but many times it's trial and error. It's finding a medicine that controls your blood pressure that doesn't give you side effects. And that's how we do it now when we look to treat weight disease. As we get more into our genetic testing, I believe we'll be able to tailor those drugs closer to what the patient, how they'll respond the most. When we talk about drugs like Qsymia and Contrave, they tend to work more centrally on receptors that are in the midbrain that control satiety or appetite and craving centers. So, those are more centrally acting drugs. By the way, we use Topamax, which is a derivative of Qsymia. We use it for migraines. But for us, it helps tremendously for cravings. But again, it's, I think, statistically, in what we've seen with the GLP-1s, it tends to work better for the majority of patients. But we have had patients that have not responded to that medication. It's not that common. But just 80% of the patients will have an average response, 10% will have a below predicted response, 10% will have an above predicted response. And that's all treatments, including surgery.

Host: Yeah. And I know that you're the medical director of Summa Health's Medical Weight Management Program. So, I want to hear from your perspective about these treatments. When you think about how they fit into an overall treatment plan, you know, I know it's so patient-centered and so patient-specific. How do you do that?

Dr. Kenneth Wells: I just saw a new patient before our podcast. And as I get to know this patient, weight disease ran on her mom's family. She's only recently struggled over the last two years, so she's 41. Two things contributed to this weight gain. She maintained a weight of, I think, she said 150 pounds, and didn't have to worry about how she ate, which is very typical. But as she's entering perimenopause, the changes in hormones. And many times that will usher in the genetic trait of insulin resistance, which passes through her mom's side of the family, with mom and grandma both struggling with their weight later in life, and now she's starting to see that. She comes in very tearful, "I've never had to worry about my weight. My weight's up 60 pounds." And when I interviewed her and I went through her meal plan, and, Scott, if it's okay, I'll introduce what I mean by eating according to metabolism, is that okay right here?

Host: Yeah, for sure.

Dr. Kenneth Wells: Okay. Basically, it starts with time. Our metabolism slows down by up to 80% after 6:00 pm for carbohydrates. If you have insulin resistance, you tend to have an appetite greater at night, and you tend to crave carbohydrates at night. So with this gal, doesn't eat that much food, which is very typical. And I asked her, "Do you snack at night?" She said, "I do, but it's only healthy food, it's popcorn." And when I hear that, there's a certain weight loss company, I'm not going to mention the name, that have promoted popcorn, light popcorn, because it's not going to cause any problems at night. It causes tremendous problems, because we raise our insulin at the worst time of the day and it can affect metabolism for days.

The other thing at night that's critical, is we keep our dinner around 6:00. We're not eating dinner at 8:00, 9:00 because that can be equally as detrimental. Then, we go to the beginning of the day. I said, "Do you eat breakfast?" She doesn't eat breakfast, so many times she's not eating until the afternoon. If we know if we do get some protein in the morning, that can go a long way to not only help satiety during the day, but also to help some of the cravings at night. So for her, she's not used to eating. We put her on a protein drink in the morning. So, she's going to have her protein drink in the morning. She's going to have a good lunch around 1:00. She's going to have her dinner around 5:30. Her meals are based on protein and good carbohydrates. What I mean by good, carbohydrates that are not high in sugar and starch, carbohydrates that have a lot more nutritional value, fiber, et cetera. So if you go back and say, "Okay. What's the biggest challenge for her?" The nighttime eating, skipping meals, and that all goes back to that insulin resistance that started about a year and a half before she came in today.

Host: Yeah. So when you're prescribing these medications, talk about, again, as a part of the plan, is it really just to sort of kick start weight loss and chronic disease management? It seems like some pills, once you start to take them, no matter what happens, you're on them for life. Is this just sort of a kick starter, or is it a sort of a lifelong journey that people have begun?

Dr. Kenneth Wells: I would say both, and let me answer it this way. So for this gal, normally I don't start a new patient on medication. I want to see how they do on the meal plan. Because I have had patients that have started that meal plan that we just described and have lost and maintained their weight and have maintained it for years and years. We had a patient in our practice in '09, was BMI over 60, started in our surgical program. He lost 40 pounds the first six months and said, "Doc, can I do that on my own? Because I'm losing." And I said, "We'll see how you do. But if you hit a set point where you don't go any farther, we definitely want to continue on and pursue surgery." He went on to lose a total of 230 pounds and he's maintained that now for 14 years.

So, what happened? When I went back and questioned him, because I was intrigued, he didn't really have a strong genetic history of weight disease. What happened is when he was in his 20s, he had a major trauma, head trauma, back surgery, became disabled. He went to what I call the grateful dead lifestyle, where he ate and drank whatever he wanted, whenever he wanted. And he gained over 200 pounds over period of about 20 years. We did not need to use any medication. It was just once we set him up, no carbs at night, eating four times a day, protein and carbs together, watching his high sugar carbs, that's all he needed and he took off. But I would say that I wish that happened more often, but many times it doesn't because of the genetics of this disease.

When I use the medications to answer your questions, I'm looking at to see how are they keeping within the borders of that meal plan. If they're struggling with cravings, and no matter how hard they're working, they're struggling with the night cravings, which can be so tough, that's a patient that a medicine like a GLP-1 could be very helpful or metformin can be helpful or some of the other ones we talked about. Which one I pick isn't as important as is it working and are they having side effects?

The second part of the question you asked me, "Do they have to be on them for life?" And the answer to that question, according to the pharmaceutical industry, they would say yes. And I chuckle because I think that's good for their bottom line. In reality, some yes, for sure, and some no. And I think when we get to a target weight, my strategy is I will slowly taper off the medication and the patient will tell me by their cravings if they're coming off and can maintain that, or as soon as we start to lower the dose, the cravings come back in a fury, and we have to keep them on the medicine for a lifetime.

Host: Yeah. I see what you mean. Let's assume that a patient is the right candidate to be on medications as a part of their plan. What do they need to know before they start? What questions maybe should they ask you before they start?

Dr. Kenneth Wells: With the GLP-1s and then just for the audience, these are the Mounjaros, the Ozempics, the Wegovys, the Trulicitys, those are the groups of medications that patients will hear or see advertised. Those are the GLP-1s. Currently, the GLP-1s that are indicated for patients that don't have diabetes, but just for weight disease, are Wegovy, and this week, the FDA approved Mounjaro for weight loss in patients that don't have diabetes. These drugs really treat both diabetes and weight disease. So, we have two drugs now that are officially FDA approved.

So anyways, when you look at these medications and what patients need to know, we ask them, there's really one major contraindication. Absolutely, we would not prescribe that drug, major contradiction, and it would be if they have a family history of medullary thyroid cancer. It's a black box warning. It's very uncommon, but it runs in families. I have not seen it. One of my partners ran up against it the other day. So, the bottom line is since there's very little major contraindications to this drug, it's very safe, it doesn't have drug interactions.

Patients will say, and they've seen in the media, social media, "Oh, it can paralyze my stomach." And what I would say to that is if a person's a diabetic, they may have an underlying problem with their stomach, a neuropathy, and this drug would not be the best for them. And I think there was a famous lawsuit recently on this drug, and that person was a diabetic, and I believe that was undiagnosed. To actually cause the stomach to be paralyzed from this medication, I have not seen anything in the literature.

Lisa Marie Presley died and she was on one of these medicines and it was blamed for it. There were other circumstances without violating any privacy for her that contributed to her death. She should not have been put on that medication because of these other circumstances. And I just picked these two things because I think I get sampled by patients.

The other medications are individual like Topamax, Qsymia. We have to be extremely careful with pregnancy age women because they can cause terrific problems with the baby. With the naltrexone, we don't want them on any other chronic narcotic because naltrexone is a narcotic antagonist. So, there are some things that are specific for each medication, which physicians should go over with their patients. But I think from the big picture, these medications tend to have a good side effect profile, minimal drug interaction. And I'm talking about the GLP-1s first. And, you know, I think that they're very safe.

Host: So, it does seem, doctor, that patient history, family history, there's a lot to go through to get this right. But as you say, overwhelmingly, they are safe and effective and it maybe involves some trial and error. "Let's try this one. Let's try that one. How are you doing?" That kind of thing. Wondering then, so when folks are in search of weight loss medication or a weight loss specialist, if you will, a provider, whom should they look for, what should they look for, questions they should ask, those kinds of things?

Dr. Kenneth Wells: I'm board-certified in internal medicine. I practiced internal medicine and private practice for 23 years. I also am a diplomat of the American Board of Obesity Medicine, meaning that I achieved a certificate of specialty in this area. And so ABOM, if a patient is looking to see a specialist in this area, that would probably be the credentials. Some physicians are family practitioners and have their certification. Others are internists. Some are endocrinologists. But that ABOM, I think, goes above and beyond as far as the training in metabolic disease. Because, let's be honest, for most physicians in medical school, we haven't really been taught really how to approach this disease as a disease and to treat it with all the tools that we have.

Host: Yeah. I want to have you too, while we're here, while we're on the line here today, talk about some of the benefits of the program at Summa Health. I know it's a full scope of services between lifestyle, habits, diet, everything. Maybe you could just break that down for folks.

Dr. Kenneth Wells: Absolutely. So, we are a multidisciplinary team that incorporates a number of disciplines to be able to treat this disease effectively. Our program was modeled after Harvard Medical School's program, which is one of the longest standing programs in the country, which was a real privilege, because we got to interface with them. And so, we've been here now almost 20 years.

So when you look at what we have to offer, we have bariatricians, which are physicians like myself that see both surgical and non-surgical patients. We have five board-certified bariatric surgeons that are extremely well-trained. And we are recognized as a center of excellence because of what we offer here. We have dieticians that compliment both our non-surgical and our surgical team. We have psychologists that deal with the whole area of emotional eating. And also, probably half of our patients are going to have some type of treatment for mental health disorder, which is every bit as important as any physical disease. So, we want to make sure for instance, if they were having surgery, that any medications can be adjusted accordingly after surgery. We want to make sure that if they have emotional disorder, that we address things to make sure they're even keeled before we would move forward with surgery. We have these psychologists also leading support groups for our non-surgical and our surgical patients. I would say probably, Scott, 50% of the patients we see that comes through the door, surgical or non-surgical, have some degree of emotional eating disorder, which can be something as simple as boredom to as complex as binge eating disorder, posttraumatic stress syndrome, anorexia. So, we have a wide spectrum of emotional eating disorders. We have a gal who's an exercise scientist who has helped us in plan programs for our patients. We have a great team of folks that make sure with insurance and finances that they're able to answer questions. Does a patient have the benefit to be able to see us? Those are very important questions and they do that and they do a great job with that. And yeah, so that's our team.

Host: Yeah. And it's a great multidisciplinary team. And as you say, we could do an entirely separate podcast on just the emotional side of eating. So, the teams of folks working emotionally, physically on this, the medications, the media coverage, all of it, the whole ball of wax. Do you think it's going to help to change the sort of cultural view of obesity and the treatment of obesity and really improve and educate folks to an understanding that it is a disease, one that can be treated?

Dr. Kenneth Wells: Yes. First, I would say, let's look at the enormity of this disease. In 1950s, the census said that two out of 100 Americans struggle with their weight, defined by a BMI above 25 or 30. BMI is an estimation of body fat, so 25 to 30 BMI would be defined as overweight; a BMI from 30 to 40, mild obesity; a BMI of 40 to 50, moderate obesity; and a BMI above 50, severe obesity. So, how many folks struggle with their weight today compared to 1950? And I'm looking at 2021 statistics, that would be 75 out of 100. So, you're looking at, I think, 240 million people.

Now, granted, when you look at that group of patients, a good portion of those will be people that are overweight with a BMI of 25 to 30, may not be having any problems at all, or maybe those 25 to 30 BMIs are already starting to show signs of prediabetes and other problems, rather waiting until 40 years old, that needs to be addressed in the 20s or 30s. And that's where our primary care doctors are vital and huge in this. This is a problem that not just our multidisciplinary center could even begin to scratch the surface. We are there certainly to treat all comers. But I tend to think we treat some of the more severe whether it's patients with severe emotional eating disorder, severe weight disease. But it really comes down to the primary care doctor, what they feel comfortable with treating.

Listen, being a primary care doctor for 23 years, I empathize with the four or five medical problems they have to treat. "And by the way, doc, I want to lose some weight." That's like an overwhelming question. So, I think that we have to look at the enormity of this disease but I think for the future, and I think getting back to your question, I think that as we are educating and certifying more of our docs for obesity medicine slots, bariatricians. I think that's going to help, but we have a shortage of primary care doctors. We certainly have a shortage of obesity medicine doctors. So, I think on a global basis, my hope would be is that we're able to regionally establish and align ourselves with our healthcare providers to be able to really treat more and more patients that suffer out there that don't have to suffer. A lot of patients have failed diets. And I say to my patients, "You haven't failed. The diet's failed you." Do you remember the show The Biggest Loser, Scott?

Host: Yeah, absolutely.

Dr. Kenneth Wells: This is a big, this is a great illustration. I use this with my patients. Fifty-three people came in, had severe obesity as defined with a BMI above 50. They were put on reduced calorie diets, way excessive exercise. And when they weighed them in, most of them lost significant amount of weight. But here's the sad part, three years later, the National Institute of Health saw these patients. They looked over data, they had measured their metabolisms before they entered into that show, they measured them three years later. Every single patient gained every single ounce of weight plus 10 to 15%. Their metabolism slowed down by approximately 15%. So, what happened? They cannibalized lean muscle mass being on that low-calorie diet and extreme exercise. It sent way the wrong message to the general public. And I believe it exploited these people.

Now, some of these folks went on to have bariatric surgery and have done very well and they've maintained their weight. Some of these folks are right where they were before they ever started this catastrophe. So again, you know when we see these folks, my heart goes out to them. Because I think for us, Scott, many times we're the last resort. They've been on every diet, they've tried every supplement. And by the way, most supplements they just have to be safe. They do not even have to work, because the FDA does not make them show the research that these work effectively. Two billion dollars are spent every year on supplements and, unfortunately, would not have too much to show for it.

So, I think that we have a lot of work to do to be able to educate our healthcare providers, even our pharmacists, even our dieticians, even our nursing staffs, to look at these folks with the disease, not that they're lazy or just they're gluttons or some of the historical biases that we've shown toward these patients and, literally, to be able to talk honestly and show the empathy to see where can I get this person to, how can we get them the help that they need?

Host: Yeah. I feel like whether it be football or weight loss, we could probably spend hours talking this through. And hopefully, we've at least scratched the surface today. We've at least whetted people's appetites, pun intended.

Dr. Kenneth Wells: That's right. That's right. Yeah.

Host: Yeah. Really good stuff today. Thank you so much.

Dr. Kenneth Wells: This was outstanding. What a great public service.

Host: And to learn more about your weight management options, visit summahealth. org slash weight loss. And if you enjoyed this episode of Healthy Vitals, we'd love it if you'd leave us a review. Your review helps others find our educational content. I'm Scott Webb. Thanks for listening, and we'll talk again next time.