Maggie McKay (Host): There are so many weight loss medicines and other alternatives, it's hard to keep up with the latest on weight loss information. But joining us today is Dr. Naser Gharaibeh, Medical Director of the Metabolic Medicine and Weight Loss Program to fill us in. 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.

Joining us today is Dr. Naser Gharaibeh. Thank you so much for being here.

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

Host: Let's start with the medicines. If the meds are used for diabetes and a person does not have diabetes, like, you know, a lot of celebrities have been taking medicines like Ozempic, for example, does that mean they're at risk for low blood sugar?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: That's a very common question I get from patients. So these medications, although they are commonly used for management of diabetes as well as weight loss, they actually, if they are used without concurrent use of other agents that would cause low blood sugar, such as insulin, then they actually do not result in low blood glucose.

 And that's why patients who are being prescribed these medications, they have to. This, this process has to be under strict medical supervision, especially if they have multiple comorbidities. But, to your point regarding the celebrities taking the medications, there are indications for taking these medications.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: So, for example, if someone's BMI is 27 and higher with complications related to obesity, or in patients who have a body mass index of 30 or more without even having complications. So I don't necessarily agree with celebrities taking the medication for many reasons. But for patients who are taking the medication for and meet the criteria, then definitely hypoglycemia or low blood sugar is not a side effect to the medication, except if it's taken with other medications, as I mentioned.

Host: And how long do they need to stay on injectables? Do they have to take them forever? Because that's what I've heard.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Okay, that's a good question. You are asking me maybe the frequently and mostly asked questions by our patients. So, same way, high blood pressure is a disease, obesity is a disease, right? So if our patient is having high blood pressure, we prescribe blood pressure medicine, and then they come back, the blood pressure is under perfect control.

We don't necessarily ask, the patient would not necessarily ask, do I stop this medication? Same thing for someone who has, any vitamin deficiency or maybe has thyroid hormone deficiency, if we start them on the medication, then we basically almost always recommend that the patient has to take the medication long term.

But unfortunately, because of our bias towards patients with obesity, we think that, okay, your BMI now is 35, we have given you the medications, you have changed your lifestyle, and then the medication has helped you achieve your target weight, then now it's on you, right? But this is actually a chronic disease.

It's a complex relapsing remitting disease. And it's relapsing remitting disease. And we know that most patients who have obesity and lose weight, even actually if they don't have or do not take medications for weight loss; when they stop the intervention, the disease comes back. So it's a chronic disease, so it can come back and that's why maybe taking the medication long term is needed for patients who actually need the medication, obviously.

Host: There's been a lot of talk in the press about the long term effects. Can you talk about that?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Well, the long term effects, the data we have is more extrapolated from using or studying the medication in patients with diabetes Type 2. And we know that long term use of these medications, especially, I'm talking about the injectables, is safe. We have been using phentramine since 1958. So if you look at things from a benefit risk ratio, definitely the benefit of taking the medication under medical supervision, really outweighs the risk of not managing the disease of obesity.

 Long term complications related to injectable medications include slowing down the transit of food from the stomach to the intestine. So the medical term for this is gastroparesis, where the stomach becomes a little bit weak. So that's something patients need to be aware of.

So if they start having some unexplained gastrointestinal symptoms, that's something to be aware of for patients for sure. But then another kind of complication related to significant weight loss is significant loss of muscle mass, and I think this is underappreciated. So patients always think about weight loss. I just want to lose the weight on the scale. But actually what we want to achieve as physicians and practitioners, is to achieve significant loss of fat and to maintain the muscle mass. So what we do in our clinic, actually, we evaluate not just the weight on the scale, not just the waist circumference, but actually the body fat percentage, and the muscle mass. So losing muscle mass is a big deal because, especially for older patients they may become all of a sudden a little bit frail, right? Because you're losing the muscle mass, which maintains your muscle tone and posture. So this is something we see frequently. And then there are also skin related issues for significant, for patients who achieve significant weight loss.

And this is true for both surgical and medical weight loss, and that can cause a lot of issues and cosmetic issues, that can be a big challenge for many patients. So these are some, but not all of the long term effects of these medications. But again, this is an evolving field, and we don't know down the road what will happen, but what we know from the limited evidence we have accumulated in the last 10 to 20 years, that the benefit definitely outweighs the risk.

Host: Dr. Gharaibeh, can you tell us about the trial, the Minnesota Starvation Trial?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: So in this trial, which was actually started in 1943. So instead of sending people to war, World War II they actually offered that they would study their metabolism and expose them to starvation. So they took healthy subjects who had no known history of eating disorders with normal BMI and they have restricted their calories and exposed them to basically hypocaloric or low calorie intake, and also they increased their physical activity and exercise.

And they obviously lost significant amount of weight. What was interesting is that most of these subjects developed eating disorders. So, and started thinking about food and started licking the, their plates after they finished. And, not only that, they have significantly lost their ability to consume energy.

So every day we spend a lot of energy at rest, even if you're not exercising. And that's usually driven by your muscle mass. So when you lose a lot of weight, when you starve someone, then that would result not just in fat loss, but also in muscle loss. And that would reduce basal metabolic rate.

So in these recruits, they have developed eating disorders, issues with body image, depression, loss of hair, and changes in their skin. And many of these changes we see commonly in patients who achieve weight loss using medications and using surgery.

Host: Are their hormones affected?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Hundred percent. So we know this because what we use for losing the weight is actually hormones, GLP1 receptor agonists. These are hormones and we have a balance in our body between hormones that promote satiety and hormones that promote hunger. So we know that patients who lose significant amount of weight have increase in the hormones that would promote hunger.

One of these hormones is ghrelin and it's actually secreted by the outer portion of the stomach. So patients who lose significant amount of weight after weight loss surgery, that actually happens not just because you are restricting the amount of, of, uh, of food they can eat, but actually because that outer portion of the stomach is taken out with surgery. That's why there has been a push for renaming the term bariatric surgery or the name bariatric surgery into metabolic surgery because this surgery is not just about limiting intake, there is a hormonal aspect to the surgery. And there is a hormonal aspect to the disease of obesity.

Host: Dr. Gharaibeh, if someone has a history of an eating disorder, they might stretch the truth or actually lie to get injectables. So how would a provider know that? Like let's say a new patient comes to you and you don't know their history. How do you deal with that?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: That's why we need comprehensive obesity care. Usually most patients, they come in to the clinic with an agenda and most physicians also come to the clinic with agenda. So we take pride in our clinic and trying to keep an open mind when we approach our patients who come to the clinic.

Obviously in our clinic, we see patients with a BMI of 27 or higher. So the vast majority of our patients, to be honest, they already meet the criteria for taking the medication. But again, as I mentioned before, the goal is not to prescribe the medication. The goal is not to perform weight loss surgery. The goal is to tease out the root cause of the patient's struggles. So if they came to the clinic, there are so many clues that can help the provider figure out if there is a behavioral aspect to the disease of obesity for patients. And that's through establishing rapport with the patient, providing an environment where the patient feels very comfortable, and also asking multiple questions that would address the eating patterns, body image, and, obviously diet consumed with comprehensive review of the trends for the weight.

So for example, if someone is all of a sudden losing a lot of weight and followed by a lot of weight gain, then these are clues that would help the practitioner determine that patient has an eating disorder. And again, that's why the, the treatment will not necessarily be to prescribe a medication, but actually to acknowledge that they have an eating disorder.

And this is a process and that's why we see patients typically every four to six weeks because you need to establish a relationship with the patient, really be the partner in health with your patient. And that's why these weight management clinics as a concept have to evolve into more comprehensive obesity care rather than just quote unquote weight loss clinics.

Host: And somebody struggling with their weight, why should they come to you instead of their primary care doctor?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Well, again, it's the concept of comprehensive obesity care. And, so when we approach patients with obesity, we don't just think about the weight, but actually think about metabolic parameters such as their A1c, their cholesterol, the pain level and the possibility of having obstructive sleep apnea, depression.

But if you look at all of these chronic conditions, they should and could also be handled by a primary care physician. So what's unique about our program, our number one goal, is to provide ourselves as a resource for primary care physicians and APPs to be equipped and to be able to take care of patients who have obesity.

But not all of these patients, obviously, would be able to achieve their goal weight. Then your next step would be basically, to refer patients to the Metabolic Center, which we will call the center Valley Life Start Center for weight loss, because we want patients to know that even if you feel like you had a lot of roadblocks along the way, and it has been a long journey, we will be there for you to help you start that journey all over again, but with success.

Host: I'm sure that's very reassuring to somebody who, like you said, it's a long journey, sometimes a lifetime for a lot of people. What are some complications associated with obesity care in a nutshell?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Yeah, sure. So, these in general are metabolic, such as diabetes, fatty liver disease, heart disease, mechanical, typically chronic pain, back pain, bone on bone, which we call osteoarthritis, acid reflux. And then neurobehavioral complications, challenges with self confidence, less motivation, lower energy, but inflammatory complications as well, and as previously mentioned.

So these are usually the complications. There are so many complications related to obesity, but there is one that I would like to shed some light on, which is cancer. So there are more than 27 cancers have been linked to the disease of obesity.

Host: Wow 27. When you talk about eating addictions, are you talking the whole spectrum, like from anorexic to bulimic and on and on?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: 100%, although the criteria for seeing patients in our clinic, they should have a BMI of 27 or more, but in the future when we improve our capacity, we look into taking care of all of these patients, regardless of their weight, whether they could be underweight, they could have normal weight, or they can have obesity.

And this is very important to mention. And again, I'm telling you the term weight loss clinic is, wrong in a way, wrong term to use. We sometimes use it to design clinics so that it's understandable by patients, but it's about the patient and their challenges and their eating pattern as well.

Host: Are too many people being prescribed by the wrong people? In other words, I know you can get, for example, Ozempic through the mail and just answering a survey online and then they send it to you if you have the resources. In other words, if you can pay for it. Because it's very expensive. Are too many people being prescribed this by the wrong people?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: I know the media has focused on having many patients taking these medications without an indication. But actually practically speaking, if you look at our population, from a population health standpoint; the prevalence of obesity in the United States and actually in the world, it's a very prevalent disease.

So, you would treat any patient with a BMI of 27 or more. We're talking about two thirds of the population. So if you bring maybe 10 people in the United States, maybe six or seven would meet the criteria for taking an anti-obesity medication. Yes, there are some celebrities here and there who took the medication for to improve their physique, but the vast majority of patients who need it, have been negatively affected by that image, and it has resulted in a lot of bias around it.

So, it is a challenge. But most of these programs, even those who have taken this as a business opportunity, they cannot prescribe the medication, except if it's indicated. And if not, I hope that in the soon future, we will have some legislations to make sure that we have a structure through which we prescribe these medications for those who need it.

Host: Right. how does this affect healthy eating? For instance, for people say on Ozempic or Wegovy, now that they have that, does it affect their healthy eating?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: These medications definitely provide a tool for patients to use to improve their eating habits. But I agree, these medications, and commonly they can actually cause poor eating habits. There are many examples of that. So if you suppress the appetite too much, then patients may basically use carbs only to, basically to eat because it's easier to digest.

So that can be a problem. And then some patients become a little bit more obsessed about losing a lot of weight. So they may restrict the calories too much. And again, that may result in excessive loss, not of just fat mass, but of muscle mass, which would down the road result in significant weight regain.

But the vast majority of patients who get the medication in a medically supervised program, they do very, very well, and there is a close monitoring of these patients. Every few weeks, these patients are being seen and evaluated and weighed, and people think, oh, we want patients to lose maybe 20 pounds in a month.

No, actually, the healthy rate for weight loss is 1 to 2 pounds a week. So when we see patients every four weeks, usually our goal is to lose four pounds only. So, and that's why we need these programs, because it's, the goal is not to necessarily lose a lot of weight in a short time period, but to help patients acquire a new eating habits, healthier eating habits, and a better mindset and understanding about the disease of obesity.

Host: Just to wrap it up, what has to be done with medications? Because I imagine you can't just take the medication and not exercise and eat poorly and eat whatever you want. So do you need to exercise, change your diet?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: So what I have seen that most patients who receive these medications and do not change their lifestyle, they are not able to achieve significant weight loss. When it comes to exercise, usually I don't mention the term or name exercise. I would expect patients to be physically active. Right? Because we have to be cognizant of the fact that some patients with obesity may not necessarily be able to exercise. So physical activity is very important. And what's interesting is that exercise or physical activity don't necessarily help patients lose weight, except if they were extreme.

But they definitely help patients maintain the weight, which is a topic that maybe we can discuss in the future, but maintenance of weight loss is as important as achieving weight loss. So in general, if a patient is able to be physically active, a goal of physical activity of more than 10,000 steps a day would be the goal to help maintain the weight.

Regarding diet, also I never mention the term diet to patients, we always say meal plan. Because we're never perfect, right? So we try to give suggestions to the patients and to be honest, based on the evidence we have, there is nothing called like a perfect diet. So the diet has to match or the meal plan has to match patient's needs, schedule, job, how many kids they have, what's the age of their kid, and then based on that we can design a meal plan that would work for the patient, not for the provider.

Host: That's a very good point. Well, thank you so much for sharing this invaluable information. I'm sure we will talk again because there's so much to talk about related to all this. So it's been really helpful. Again, thank you for your time.

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

Host: That's Dr. Naser Gharaibeh. To find out more about medical weight management at Valley or to make an appointment, please visit valleyhealth.com/weightloss or call 201-251-3480, 201-251-3480. And for more information, you can also email Valley Podcast at valleyhealth.com. 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. I'm Maggie McKay. Thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey.