Maggie McKay (Host): Throughout the decades, there've been so many weight loss options, but what does the future look like? How will science help individuals reach a healthy weight? We'll find out more with Dr. Naser Gharaibeh. Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take.

I'm Maggie McKay. Thanks for listening. Today, Dr. Naser Gharaibeh, Medical Director of the Metabolic Medicine and Weight Loss Program joins us. What a pleasure it is to have you here today, Doctor. Thank you for being here.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Thank you for having me.

Host: Let's just start out with what has come out of research for people who are on long term use of weight loss medications?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: This is a very interesting topic actually, because for the longest time, many patients have been trying to lose weight. And I think we are maybe behind with figuring out the optimal medications for weight management, maybe by 50 or even 100 years. In 1958, phentramine has been FDA approved for management of obesity, and we are still using the medication until now. It's maybe a good medication, but not the perfect medication. But imagine how much advancements we have achieved in management of cardiovascular disease, for example. But still, the field of obesity has not advanced as much. And part of the reason is the stigma around obesity and obesity care and even obesity related research.

So, I'm glad that over the last 20 years we have more and more studies on medications that have been used for management of diabetes and one of these medications, as you may have heard about, semaglutide, such as, which is branded as Ozempic and other similar medications. These medications have shown improvement, not just in diabetes control, but also in weight loss.

And that has drawn a lot of interest from the people, actually, from patients. And since then, over the last 20 years, we have seen more and more evidence addressing anti-obesity medications and the safety of these medications. And because these studies have relatively recently been published; we don't have a lot of safety data about long term use for more than 10 or 20 years for these medications. But definitely the use of the medications for the last 10 years has shown that they are of benefit and the benefit outweighs the risk, at least for a few years or so.

Host: When it comes to medical weight management, tell us about the cardiovascular outcomes.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: So now, I'm very happy to see a lot of studies showing significant improvement in cardiovascular outcomes. So, especially in patients who already have cardiovascular disease. One of the recent studies published in December 2023, showed a significant reduction in the risk of having another event of cardiovascular disease in these patients.

And this is very promising because when we talk about diabetes and diabetes care and obesity care, in my opinion, it should be diabesity care; what we care about and what most of our patients care about is actually having heart disease as a complication to these diseases. So it's not just about being able lose the weight on the scale, it's actually about having a meaningful difference for patients and their lives.

So, the cardiovascular improvement is not just in terms of outcomes and mortality, but actually in terms of quality of life. And being able to be physically more active. And there is also another recently published study where we found improvement in weight has led to improvement in heart failure control.

So this is about the fluid status for patients. And this just tells you something that patients who have cardiovascular disease, for the longest time we have thought about cardiovascular disease or heart related conditions as mechanical problems. So it's, uh, as if it's a pump, but actually it's a metabolic problem as well. And this is based on the evidence we have been seeing. And it's actually an inflammatory problem as well, because markers of inflammation in patients who significantly lose weight also improve by maybe 40 percent or so. So why is that? Why do we see all these improvements? We know a lot. We know better now, but also we don't have the full picture. What we know is nothing but the tip of the iceberg.

Host: That's impressive. 40%.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Yes. So CRP, which is one of the markers of inflammation, for some reason we just, for the last decade or two, we have noticed that patients with obesity, they have high markers of inflammation. These high markers for inflammation would drive a higher risk of cancer, higher risk of heart disease, higher risk of diabetes.

And I'm glad that we have seen with these trials that significant weight loss using these medications does not just help you lose the weight, but actually reduces these markers for inflammation, which we believe are a driving force for multiple complications related to obesity.

Host: Dr. Gharaibeh, what are some of the newest drugs on the market? I know you mentioned a few of them, but in this category, and are there any combination drugs?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Obviously, we have the GLP 1 receptor agonists. They were approved few years ago. So the first one was liraglutide, which is marketed as Saxenda. And then that was followed by another, agent called semaglutide, which is marketed as Wegovy. And the same version of the medication is used for management of diabetes as Ozempic.

And the most recent combination therapy of like, basically two hormones, we call these incretin hormones, responsible for satiety and suppression of appetite when you don't want or don't need to eat food. That's a GLP 1 and a GIP hormone agonist. And scientific name for that medication is tirizepatide, which is branded as Zepbound, which has been the most recently approved medication.

And all of these medications have similar mechanism of action. So these medications, they have a hypothalamic action. So they work on the base of the brain where they suppress the appetite. But also they have, they act on the gastrointestinal system. So they slow down the transit of food from the stomach to the intestine.

They also can improve insulin resistance. So insulin is an essential hormone for anabolism, it builds tissue, it builds fat, it stores the source of energy, which is the carbs, into fat. And fat is a good organ, we need fat to store the energy. But excessive production of insulin to metabolize the carbs, would result in significant weight gain, and other health related issues in patients who have insulin resistance. So these medications don't just suppress the appetite, which would result in weight loss; they actually tackle or address one of the primary problems related to obesity, which is insulin resistance. So we call this in medicine a pleiotropic effect.

So it's not just targeting one problem, but actually targeting multiple problems in the same patient. And again, that's why it's not about weight loss. Honestly, that's why I hate the term weight loss, because it's not just about the weight. It's about excessive body fat, not just any fat. It's the visceral fat, the bad fat, which is not good for your health.

Host: And what is considered excessive fat, 20 pounds overweight or more?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: That's a good question. So the definition of obesity, according to the WHO, it's excessive body weight, right? And this definition is not necessarily accurate. So in patients who have a BMI of 30 or higher, that's going to meet, these patients would meet the criteria for obesity. But also you can be very, very muscular and your BMI is 32 or 33, right?

But that's related to excessive muscle mass, not fat mass. And that's why in our clinic we use body fat percentage. So we measure body fat percentage, and not just the weight and body mass index. And, obesity is defined by having a body fat percentage of 32 percent or more in women and 25 percent or more in men.

And women tend to have more fat mass. And that's because of the hormone estrogen versus men they have testosterone, which is an anabolic hormone that helps people or men build muscle mass. And that's why there is a little bit of difference in body composition between men and women.

Host: How do you see the industry growing and changing in the coming years? It seems like maybe just the public wasn't aware of all these medications or drugs, but it seems like in the last few years, there have been a lot of new options.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Yeah, definitely. I think this is an exciting time for those who are practicing obesity medicine and obesity surgery. I think we are just starting. This is an evolving field for sure. And different healthcare systems have been trying to basically strategically build programs to tackle the disease of obesity.

And there is a significant shift in the mindset of providers, but most importantly in people's and patients mindset; where we are looking more and more at obesity as a disease. I always tell my patients, same way breast cancer is a disease, you have to think about obesity as a disease. Same way heart disease is basically considered a true medical condition and patients would easily consider, you know, having a procedure such as a cardiac cath or surgery, open heart surgery, right? Or taking a medication for that disease. We also need to keep an open mind when we are think about obesity as a disease, and that applies for all, for physicians, for providers, for patients, and most importantly now, this is the biggest challenge now, is the insurance plans, where you have a lot of patients and physicians saying, yes, this patient needs to lose the weight, the patient is trying their very best to seek medical advice, but unfortunately, many of these medications are not covered.

So how would the industry evolve? I think technology will be a big part of the evolution and part of the reason many of the patients are more on the tech savvy now. We're dealing with Gen Z. So the way you treat this generation is totally different than the younger generations. I think artificial intelligence will be and has been part of management of obesity, but I think we will see more and more efforts tailored toward management of obesity, utilizing artificial intelligence.

I think medical devices tailored towards helping patients suppressing their appetite, but most importantly, tracking their blood pressure, their heart rate, their body fat percentage and their blood sugar all in one device. These are actually already being studied. They are already around, but these will evolve in the future.

So that the patient will make more informed decisions. We also need better handling of how to count calories. How to track the physical activity and energy expenditure. So all of these things are being addressed by different companies, by healthcare systems. And obviously as we discussed, the medications. There are so many medications in the pipeline that would address obesity as a disease and not just the insulin resistance piece, but even the inflammatory piece. So there are now medications being studied for suppression of the inflammation that would result from obesity and other medications that would help patients control their appetite.

And there is also a better understanding of obesity as a problem that's associated with basically treatment options. Not one size fits all. It's going to be a different approach where we can customize the treatment plan for the patient's needs.

Host: Dr. Gharaibeh, why do you think Valley's program is different in their approach when you compare it to other clinics and healthcare systems in the area?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: I think what's unique about our program is the unique design and the mindset. The mindset involves having basically the surgeons and the endocrinologists and nurse practitioners as part of the clinic. We have a one stop shop for patients. And the mindset also involves having an agreement amongst our physicians and providers that we don't think about the patient as basically the goal out of treatment is not surgery. The goal of treatment is not about giving a medication. The goal of treatment is to actually address the disease of obesity and its complications which are metabolic, mechanical, and neurobehavioral. And I mention neurobehavioral because this is frequently dismissed.

We frequently forget how, how many neurobehavioral aspects the disease can have. So obesity is linked to depression, anxiety, absenteeism from work and less productivity and at the same time, poor quality of life. These patients have challenges also. These are mechanical challenges such as so the fat pushes on the stomach causes acid reflux, back pain, bone and bone, and obstructive sleep apnea.

So if you are thinking about these complications, you're not just managing one disease, you're managing the patient as a whole. So it has that holistic approach to it, and we feel that this is going to be a noble cause. We don't think about our patients as one patient at a time, but we are also thinking about the population.

And that's why we think this is a really good model for value based care rather than volume based care. In the future, delivering care will not be dependent on taking care of one patient at a time. It's going to be about outcomes in the community. And that's why we need to focus on outreach for programs, for supporting patients, even after they get the weight loss surgery, about training our physicians and nurse practitioners, and making sure we have didactic and continuous medical activities to spread awareness, not just in the hospitals, but actually in the school, in the universities.

And using multiple media outlets. And that's why we have that vision that we want to transform the way we care of patients, not in clinics, but in the community, in the population.

Host: Well, this has been so fascinating. Thank you so much for sharing your expertise with us about a topic that is important to so many people.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Thank you so much. Yeah, I really appreciate the opportunity to be part of this podcast. And again, because this is what we believe, we made sure we have a series of podcasts because again, this is not about getting the business and bringing the patients in. This is actually about spreading the awareness.

Not among our physician colleagues, but also among patients, but also not about patients. This is about policymakers as well. So I really hope that someone who's able to make a decision would basically come up with a policy that would help us address obesity as a disease and improve the health in the community.

Host: Thank you so much. Again, that's Dr. Naser Gharaibeh. If you'd like more information about medical weight management at Valley or to make an appointment, please visit valleyhealth.com/weightloss, or call today. 201-251-3480. That's 201-251-3480. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. You can also email Valley Podcast at valleyhealth.com to find out more.

Thanks for listening to conversations like No Other presented by Valley Health System in Ridgewood, New Jersey.