Joey Wahler (Host): They can work effectively when used properly, so we're discussing weight loss medications. Our guest, Dr. Peter Lalor, he's Medical Director and Double Board Certified in Obesity Medicine and General Surgery for Wood County Hospital. This is Health Matters, insights from WCH Medical Experts. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Lalor. Welcome.

Peter Lalor, MD: Hi. Nice to meet you Joey.

Host: Same here. Appreciate the time, of course. So first, who exactly is a candidate for weight loss medications? What would be their profile?

Peter Lalor, MD: Well, as we know, obesity is a big problem in America, but in terms of candidacy for weight loss medications, someone with a body mass index above 27 with medical problems or a body mass index above 30 with or without medical problems. Now, in general layman's terms, this means someone that's probably 20 to 25 pounds overweight with medical problems or someone that could be up to 40 or 50 pounds overweight with or without medical problems.

Host: Gotcha. And so what are the options these days for weight loss meds? And give people an idea from a layman's standpoint. How do they actually work?

Peter Lalor, MD: So the first thing is that the medicines don't necessarily work on themselves. A very important point is to mention that it's really a multidisciplinary comprehensive program in addition to the medications that's going to have the most success for people. But we're talking about lifestyle intervention, dietary changes and exercise regimen and making sure all the medical problems that get in the way of obesity are addressed as well.

And then in addition to that, medications can be an option for some people to give them that extra boost in terms of trying to achieve their goals. What those options are, there's a number of what we call anti obesity medications on the market are the weight loss meds. It includes some of the old medications that are commonly known as Adipex, which is a sympathomimetic, which it's basically a stimulant of sorts, which takes away appetite, gives you a burst of energy.

That's the cheapest one on the market that's been around for a while. Patients can only take it for about three to six months based on state law because of the addictive nature sometimes of it, but it can be very helpful and effective for patients. The second group of medications are what we call combination medications, and these are combination drugs that have two medications based in one pill.

There's one called Qsymia. This starts with a Q. This has actually a little bit of Adipex or phenermine in it, combined with Topamax, which is what we been used for epilepsy and migraines and things to kind of dull some of the nerve sensations. This is about a hundred dollars a month. It's been pretty effective for patients and can be a good tool in addition to the whole program.

The other combination medication is called Contrave. This has an antidepressant in it and naltrexone, which is an anti opioid medication. This is kind of more for the depressed patient that's eating, and that's about a hundred bucks a month, and, patients can still have success with this. This is twice a day and so there's a little more compliance and maintenance involved with it.

But the last and maybe the most exciting category of anti obesity or weight loss medications is the shots, as they're commonly known as, or what they call the GLP 1 agonists. These have become very popular because they've given the best results overall, above and beyond not just the comprehensive program, but those other medications. And these shots are given once a week.

Host: And so, as you well know, we hear so much these days about Ozempic. Where would you say that falls in in terms of that whole spectrum you just described.

Peter Lalor, MD: So Ozempic is the brand name for what we call semaglutide, which is the generic name. It's actually the same medication as Wegovy and basically that's a GLP1 agonist medication. So it works directly on some of the gut hormones to make you feel full earlier when you do eat and take away hunger in general.

So that combined with a comprehensive program, as I mentioned with a lot of lifestyle changes and good goals for your diet and so forth; patients can see a pretty good weight loss in the right candidate.

Host: And I'm going to ask you about some of those other things that people need to keep in mind they must do along with taking a medication. We'll talk about that in a moment, but let's talk first about expectations. Doctor, what are they when it comes to weight loss drugs and how do they compare with the results? Because I would imagine that one challenge for you is keeping people's expectations managed properly, right?

Peter Lalor, MD: Yeah, that's a great question, Joey. I mean, it's all about expectations. And what the data shows is that if you just use diet and exercise alone, you're probably only going to lose 3%, 5% of your weight. If you enroll in a comprehensive program in the combination with some of the basic medications that we mentioned before, that weight loss might be up to 5 or 10% of your extra weight.

And sometimes the shots, the GLP 1 agonists, you might get up to 20% of your weight. But as you can know, that's sometimes a drop in the ocean overall. And if you have a significant amount of weight, you might want to look beyond medication. And that's where surgery comes in if you have even more weight to lose than that.

Host: So when we talk about lifestyle changes, you mentioned diet and exercise of course, what are some of the basics that people in need of these type drugs normally need to keep in mind when it comes to diet first along with the medication?

Peter Lalor, MD: Yeah, and in simple terms, losing weight is about your diet. It's about calorie restrictions. So, the goal of a program is to be very specific about what your calorie goal is and to stay under it consistently. If you're able to do that, in theory, you should be able to lose weight over time. Now, when we set these goals, however, your body and your genetics is fighting you.

It wants to gain weight. It doesn't like being restricted to any point. And so that's where your hunger kicks in and some of these other hormones that can make it hard for you to achieve those goals. And that's where the medicine can come in to help curb some of that appetite and cravings, if you will, to help achieve those goals.

So it's the, not the medicine that gets you to lose weight. The medicine helps you lose the weight as long as you're you know, adhering to these restrictive goals.

Host: Gotcha. And then how about exercise? For people that either have never exercised, haven't in a while, do but simply not enough, people that need to exercise more in short, where do they start? Because sometimes if someone has been inactive, it's a little daunting to think about how to take that first step, right?

Peter Lalor, MD: Yeah. So in terms of exercise, we used to think in the medical field, when a patient came in overweight, what did the doctor used to say? Oh, you got to get off your butt and exercise more, right? Well, we've learned that that's not really the case. Exercise up front doesn't play as important a role as we used to.

Really weight loss is about diet first and exercise second. Where exercise comes in it certainly has a role up front, but where it really comes in is long term to help maintain the weight. And what we would tell our patients and our program is you just have to start somewhere. We're not expecting our patients to run marathons, but they start with simple things that they can do.

For instance, walking or getting on a treadmill or swimming if that's what they like to do. We have to take the individual patient in mind, you know, I'm not going to tell them to swim if that's a great exercise, if they're not a swimmer, and so forth. So it's about starting somewhere, and really, ultimately, it's about creating a habit to burn calories to some extent in the long term to be successful.

Host: Now you use the word marathon there, Doc. Interesting, because it leads me into my next question. How much do you stress to patients that as the old saying goes, weight loss is a marathon and not a sprint.

Peter Lalor, MD: I think it's important to remember that obesity is now recognized as a chronic disease. And just like other chronic diseases, whether it's hypertension or even cancer, how do we treat these diseases? We treat them on multiple levels. Whether it's surgery and radiation and chemotherapy or if you have high blood pressure, you're often on three or four blood pressure medicines to help address the problem and that's where the treatment of obesity has gone to is that it's a multimodal approach to try to fight this disease overall. And so that's where we, we're trying to teach long term habits that eventually the patients might not necessarily need medicine in the long term, but we also understand that with genetics and the obesity problem today; that there are many patients that will need significant help, both from a full program and even a multiple medication standpoint.

Host: You mentioned genetics, which brings up another point, and that is, how often is it genetics that's largely behind someone having a difficult time managing their weight?

Peter Lalor, MD: I think it's genetic in everybody to some extent. We tend to think in kind of a binary bias standpoint where it's black or white. Either you have the gene or you don't. And, but it's not that simple. The obesity problem is different genetically in every single person because our mechanisms of people's metabolisms, how we gain and lose weight is different in everybody to some extent. And there can be any genetic abnormality or, difference between them that's, gonna contribute to weight gain. So I would tell you that it's a component in everybody. Now there are some clear identified genes that have clearly been identified as major problems for a very small subset of people, but overall it is a genetic problem.

We're designed to store energy even from the days of the caveman when they didn't know when their next meal was, when they were going to, kill the next big lion. Right. So, we're designed to store fat in this day and age of extra food and how easy it is to get calories in; our genetics, unfortunately haven't changed.

Host: How about the side effects and possible complications associated with these weight loss drugs?

Peter Lalor, MD: Yeah, I mean, like anything, everything can have side effects and complications. We're addressing the gastrointestinal tract, your stomach, your intestines. So, when you do that and give some of these medications, probably some of the most common things can be some nausea. Can be some upset stomach, sometimes even diarrhea or constipation. Other common things that we see in some of these medications would be like dry mouth and constipation, that kind of stuff. We do have to be careful, whatever medication that we use to make sure there's no contraindications in the patient's history. For instance, some of the GLP 1 agonists recommendations are if there's a history of thyroid cancer or pancreatitis or significant biliary or gallbladder problems, we need to be very careful about using those medications in that patient population and really it would be contraindicated.

And also the patient's medical profile in general has to be very seriously taken into effect because medications can have cross interactions and so forth.

Host: When you say the biggest misconception is that the uninformed or under informed have when it comes to these drugs?

Peter Lalor, MD: I think the biggest misperception is the shot is the answer. We're unfortunately in our today's society looking for the quick fix and it's very exciting to think that, hey, if I just take a shot once a week that I'm going to eat what I want, do what I want, and I'm going to lose weight.

And that's far from the case. I think the common misperception is you know, that the shots alone is the answer and that's not the case. It's really the combination of the diet, number one, the exercise and your commitment to the whole program. The other misperception is that, as a surgeon, this is very close to my heart, but it's hard to sometimes explain to patients that, okay, look, if you're 25 pounds overweight, the shot's a great option to help you with what you're trying to achieve.

But if you're 125 pounds overweight, the shots are not going to be enough. The program's not going to be enough. You're going to have to do something more invasive to really put the big kind of dent in your weight loss and your medical profile that you want to.

Host: Interesting last point you made there because I would imagine a lot of people probably think it's the opposite, right? That the shot is more for people that are way overweight to make it come down faster and you say it's basically the opposite, yeah?

Peter Lalor, MD: Yeah. I mean the data is pretty clear. The shots and the medication patients will lose up to about 20 percent of their weight. But when you're talking surgery, it's 30 to 35%. And those are averages, of course. But really the surgery is two to three times what the medication can be. Now, obviously you have to be a surgical candidate for that, and that's another conversation. But you know, simply the shots sometimes aren't enough, unfortunately.

Host: A few other things, you mentioned cost earlier, how about insurance coverage? Are these drugs typically covered at least partially?

Peter Lalor, MD: Well, that's the kicker to be honest, because they're usually not. And which is kind of amazing when you think about obesity nationally, that the problem that is; most insurance companies don't cover these medications. The shots at their brand name levels are extremely expensive in excess of a thousand dollars.

There's now compounding pharmacies making generic versions of them, which are still cheaper, but also expensive in the 200 dollar plus range per month and most people can't afford that. So unfortunately insurance coverage is an issue to getting patients some of the medication they need.

Host: And then in summary here, what would you say about the importance of using these weight loss drugs only as directed and under supervision by a doctor like yourself and staying away from trying to self medicate and that type of thing?

Peter Lalor, MD: Yeah, I think it's pretty clear that the most successful patient and the safest way to do it is under a healthcare professional's guidance. That's not just writing for the shot. But also supervising the other components of really what's going to make you successful, which is what we've been harping on, which is getting to see a dietitian or nutritionist, setting calorie goals, sticking to that, having some sort of exercise regimen that you're committing to.

And sometimes even the psychological proponent can be very important with this to help motivate and to stick to the program, which we haven't mentioned yet. But again, it's the comprehensive program that are going to make people the most successful and give them the best chance of what they want to do.

Host: Absolutely. And maybe you want to just touch on the psychological aspect, the fact that people often in this situation where they're trying to lose weight, especially for better health, sometimes there's a component where they need therapy and to address the mental aspect of it as well, right?

Peter Lalor, MD: Yeah, I mean, a lot of people feel that obesity is a big brain game. I mean, it's all the hormones in our brain and how it messes with our motivation and, you know, not only on a physical level of how we process food and fat and so forth, but that mental challenge of trying to make decisions and go against our reward pathways and so forth. So, behavioral therapy or what we call intensive behavioral therapy has been shown to be a great aspect of a program that can really motivate patients to make better decisions. And usually the toughest time for people is at about six months out. Most of us have dieted or tried to lose weight for periods of time, but at six months when your results tend to plateau; that's when you lose interest because you're not seeing results and you lose your motivation.

And so, you know, that point or just before that point is actually a good time to start thinking about what you're trying to do and certainly the right therapist and the right program can help you.

Host: Yeah, it is largely a mental game indeed. Folks, we trust you're now more familiar with weight loss medications. Dr. Peter Lalor, valuable information indeed. Thanks so much again.

Peter Lalor, MD: Thanks, Joey.

Host: And for more information or to make an appointment, please call 419-373-7699. If you found this podcast helpful. Please share it on your social media. I'm Joey Wahler. Thanks again for being part of Health Matters, insights from WCH medical experts.