S1: It's time for Midday Edition on Kpbs. New weight loss drugs are changing the way doctors talk about and treat obesity , but the stigma around treatment and body image remains. I'm Jade Hyndman. Here's to conversations that keep you informed , inspired and make you think. County data show nearly 1 in 4 San Diegans are obese. The local doctors share the capabilities and limitations of new treatments.
S2: Look at the person as a whole. We don't want to address somebody who's who has excess weight as just a person with excess weight.
S1: Plus , we'll talk about body acceptance and better health in the face of these new treatments. That's ahead on Midday Edition. New weight loss drugs like Ozempic and Wego V , generically known as semaglutide , have taken the medical world by storm. Doctors know they work and their understanding of how they work is evolving. For many of those struggling with obesity and weight related health problems , the medication initially used for type two diabetes has been life changing. The FDA approved it for weight loss in 2021. Earlier this month , whey govi was also approved for heart attack and stroke risk. Two. It's the first weight loss drug to get that classification. All of this could open the door for more insurance coverage for a medication that is pricey and hard to get. Today on Midday Edition will break down what these weight loss drugs are and how doctors are adapting their practices around them. Joining me now is Doctor Deepa , senior obesity and lifestyle medicine physician at UC San Diego Health. Doctor Cindy , welcome.
S2: Thank you. Really glad to be here.
S1: Glad to have you. I want to start with this. We hear all of these terms thrown around Ozempic wego v semaglutide.
S2: So what they do is that they actually mimic a hormone in our body that's produced naturally called GLP one. They bind to the receptor and they actually act much more strongly than the endogenous molecule of GLP one. And produce they act in a couple of different places. They act in our intestines to slow down the movement of food through our stomachs and our intestines. And they also act at the level of our brains to produce satiety and which which means our sensation of fullness and , and also kind of reduce the desire for food. And it's a little less clear on how exactly that work works. But we know that they work at kind of very primitive parts of our brain.
S1:
S2: So Ozempic and Govi are the brand names for a molecule called semaglutide. Um , and that actually is a main , uh , medication. It's also similar to liraglutide or seconda , which doesn't work as strongly as semaglutide , but works in the same way in that it mimics that GLP one molecule and and bound the newer medication are both , uh , different brand names for the medication called peptide. And this is actually , um , this works on both uh or mimics GLP one and GIP uh , which is gastric and inhibitory peptide um in both um and works a little bit more strongly than even some of Glu tied uh , and has potentially fewer side effects as well.
S1:
S2: Uh , there are FDA approved criteria , whether somebody has a BMI of 27 with a comorbidity or a BMI of 30. I'm also looking at risk factors , whether they have a history of thyroid cancer , a history of pancreatitis , which is inflammation of the pancreas. I'm also looking at whether they have a history of eating disorder and what what role that plays. I'm looking at the patients desire for , uh , for weight loss medication and their values and what they want to , uh , what they want to do. And I'm having a conversation with them about risks and benefits. So I'm talking to them about how their life will be impacted by this medication. So , you know , there are a lot of different factors involved. You know , and one person with obesity is really one person with obesity. And you really have to think about what they need as an individual.
S1: And what are some side effects of semaglutide.
S2: All of these medications have similar side effects , so they can cause nausea , constipation. Sometimes they can cause increased heart rate. If somebody has a history of kidney issues , then , uh , the nausea from the medication might cause them to not eat as much. And and it can potentially cause worsening of the kidney issues if we're not careful in the way we prescribe them. And the nausea usually lasts 2 to 4 weeks , the constipation often has to be managed. But those are really the typical issues that we see every once in a while. We also see people's. Go up. Uh , and sometimes that's related to the dehydration and sometimes it's related to because as the hunger goes down , the thirst also goes down sometimes. And and sometimes it's related to just the medication by itself. And that's a relatively rare side effect. As we get older there are some concerns about bone loss. And there are there's some discussion back and forth about muscle loss as well. That seems to be a little bit more so with semaglutide than appetite or liraglutide , which are seconda and found , or Majuro. And it's not very clear about the about the muscle loss. So some , some , some things that we have to factor in and something that I think we do need to make sure that people understand is that once you are on these medications , the likelihood is that you do have to stay on them. So the other risk is that people actually stay on a medication for life , really , if they want to continue to have the weight loss that they had and they they lose , they regained the weight. If they stop the medication , it's useful for us to also think about , you know , expectations with regard to weight loss , too. You know , it's it's really important for us to know , you know , people with just because somebody has been on a medication or use lifestyle change , they will not necessarily go back to a normal weight , you know. And that's also really important for us to consider.
S1: You mentioned appetite doesn't have as many side effects. So in that case , why would semaglutide be prescribed even for for someone um , for weight loss over appetite. What decisions go in into that ? Oh , that's.
S2: A great question. I think a lot of it right now unfortunately has to do with availability. And really it's not a one size fits all. And you know we have the data. But then there's also the person. So sometimes people might do better on wigo V or Ozempic compared to Majuro. Or is that bound. And we just don't know who is impacted in what way. Mhm.
S3: Mhm. All right.
S1: I see. So so tell me I mean have these weight loss drugs change the way you treat obesity.
S3: Yes drastically.
S2: I started off in integrative medicine and lifestyle medicine. And I really still have those aspects of medicine as part of a big part of my practice. And in fact , I still consider myself a lifestyle medicine physician. When I first became exposed to these medications , it really became very clear to me that the patients that I was seeing who was who were starting on anti-obesity medications , were not trying to look for an easy way out. These were people who had really tried to lose weight on their own , and nothing was working. And these medications were actually helping them stick to their healthy lifestyle plan or diet or exercise plan in a way that previously had not been possible for them. And I saw this with actually medications that preceded these newer medications. And it is even more so the case now with the current medications that are available. Yeah.
S3: Yeah.
S1: So these weight loss drugs , they don't work in isolation. I mean there are there are a number of tools that also work together to achieve the goal of weight loss.
S2: Uh , lifestyle medicine is the foundation of treatment for excess weight in general. So whether you're talking about just the excess weight or whether you're talking about any of the conditions that are associated with excess weight , like diabetes or high blood pressure , high cholesterol , pre-diabetes , all of these things , all the the medical association guidelines have to do with starting with lifestyle at the beginning , um , lifestyle medicine is a discipline that consists of diet , exercise , sleep , stress , risky substance avoidance and , and social connectedness and all of these things kind of look at the person as a whole. We don't want to address somebody who's who has excess weight as just a person with excess weight. They are a multi-dimensional person. And we have to make sure that their needs are getting met in other ways as well , because especially all of these aspects are also affecting their health in myriad other ways. So it's really important to make sure to address the lifestyle first. The other thing , though , is that we don't want to use lifestyle as a way to obstruct their care , because being on a medication doesn't necessarily mean it's either or. Um , these medications also do help people stay on stay the course with regard to their lifestyle , in fact , not just with regard to their diet and exercise. You know , we've had people , uh , be able to avoid smoking. We've had people be able to avoid alcohol as a result of these medications. It is very possible that we come up with , uh , indications for these medications related to addiction. So it's it's , uh , it's more complicated because when you have a situation which you actually have a. In the world that can help you eat a salad. Um , or maybe stay away from the cookie that's sitting right in front of you. And so it's really , uh , it's it's not so simple as , you know , is it ? Lifestyle first and then the medication , or is it lifestyle only or is it medication only ? It's really you have to kind of figure out what works for each person.
S1: That's doctor Deepa Nidhi , obesity and lifestyle medicine physician at UC San Diego. After the break , we'll continue our conversation with Doctor Kennedy. And also joining us is Doctor Jennifer Shapiro. She's a licensed clinical psychologist and director of Everybody Behavioral Health in San Diego.
S4: We also have to talk a little bit about body acceptance , because they're going to lose some weight with lifestyle approaches , but not in the quick and drastic way that the medications will assist them.
S1: That's after the break , and we'd love to hear from you. Do you have questions or reactions to the topics discussed on today's show ? Call and leave us a message at (600) 945-2022 eight. Kpbs Midday Edition is back right after the break. Welcome back to Kpbs Midday Edition. I'm your host , Jade Hindman. This hour , we're discussing the class of weight loss drugs known as semaglutide and the way they're changing how doctors treat and talk about obesity. There's many layers to this conversation , one being how we approach conversations around body acceptance as weight loss drugs become more popular. We're talking with Doctor Deepa Cindy , obesity and lifestyle medicine physician at UC San Diego Health. I also want to welcome to the conversation Doctor Jennifer Shapiro. She's a licensed clinical psychologist and director of Everybody Behavioral Health in San Diego. She specializes in eating disorders and obesity. Doctor Shapiro , welcome to you.
S4: Thank you so much for having me.
S1: We're so glad to have you here.
S4: And I really thank you for valuing the importance of behavioral health in this conversation. You know , these medications are really improving the health of a lot of our patients and patients who have tried and tried everything , every diet approach , you know , are really finding a lot of success with the medication. The problem that we're seeing in addition to this is as a field , we've done so much work to stop drive for thinness and body shaming , and we've worked really hard to promote body acceptance. So what's happening now is when everybody wants to be on these medications , even the people that don't , quote need it. You know , maybe people who are not technically in an overweight or obese classification or people who don't have comorbidities. And it's really driving that. I guess. Drive for thinness. How to say it. Um , and it's causing a lot of stress in patients because they're seeing , you know , their family members and their friends get on these medications and lose weight so quickly , and they want to jump on the bandwagon , too. And so , you know , with some of our patients who have worked really , really hard to accept their body , to make the lifestyle changes , you know , to not have this body shaming body phobia. Here we are now introducing , hey , you know , let's let's try this for weight loss. And it creates that dilemma for them all over again.
S3: And talk a bit.
S1: More about that , because I know that. There's.
S3: There's.
S1: I would imagine in your practice , there are a lot of patients who feel shame around being clinically obese , but also shame around taking these medications. Absolutely.
S4: Absolutely. And before these medications , you know , in our practice , from a behavioral health perspective , you know , we see eating disorders meaning diagnoses of anorexia nervosa , bulimia nervosa , binge eating disorder. But we work a lot with communities such as those who are struggling with obesity and or those who are thinking about having bariatric surgery. And when someone's working with us , you know , whether it be managing their depression , managing their anxiety , perhaps working on some binge eating disorder as they're making the lifestyle changes that they need to be making. We also have to talk a little bit about body acceptance , because , you know , most people , you know , they're going to lose some weight with lifestyle approaches , but not in the quick and drastic way that the medications will assist them. So here they are , working so hard to be happy where they're at with their weight. And , uh , or I shouldn't say necessarily be happy , but at least accept where they are if it's not going to go any lower. And now we're saying to them , okay , well now you want to try the medication. So let's kind of undo all of this body acceptance that we've done. Well.
S1: Well. Yeah.
S4: And , you know , they have to understand that they're going to be on the medication life long. Um , if they're not on the medication , they may experience weight recurrence or if they're somebody who struggles with emotional eating or binge eating or unstructured eating , these medications don't necessarily change that. They stop the cravings and thinking about food and maybe caring about food. But if the medications don't work for you in terms of side effects , or if it's something that you don't want to take long term , it really is important to think about what your own triggers for eating are and , um , and how you can accept yourself for who you are if you're not going to be on this medication long term.
S1: Doctor Cindy , I know you've got something you'd like to add to this. Yeah.
S2: Yeah. You know , I just want to share that I really agree with a lot of what Doctor Shapiro is sharing in my practice , when I see a patient who has , uh , obesity or excess weight , and it's saying to me that I want to be happy with who I am , I don't I don't feel good about myself. I actually turn away from my computer and I make sure I make eye contact , and I talk to them about the fact that there is such a thing as weight stigma. It is something that they have internalized , and it is something that they will experience less of if they have less body weight on them. But when they lose weight , that does not mean that they will be happy with themselves. There is more to that piece of the picture then weight loss , and I often really start with that discussion. Um , even from the very first , I see patients in group visits , and I even from our very first group visit , I talked very explicitly about that internalized weight stigma. It's unfortunately such a part it's such a huge part of our practice and really interwoven with what we do , because weight stigma actually causes increased weight gain. Now , I have seen these medications help with binge eating , but um , and they are being investigated for binge eating , but it doesn't necessarily stop the binge eating if the stigma is really strong. Um , and it doesn't necessarily stop the binge eating for everybody either.
S1:
S3:
S2: So weight stigma is. Is internalized bias. You know , when we have a weight that's higher than what are the expected norm is for society , then we have we are discriminated against in our daily life , whether that's at school. Children with excess weight experience more bullying , whether that's in our jobs. There are data that show that people earn less money and maybe have fewer promotions. Even people who have excess weight are thought to have less discipline , or maybe even , you know , less hygiene and things like this. So these are obviously very , uh , untrue ideas. In fact , my patients are extremely resilient. I often ask people to think about when they see somebody who has obesity , think about maybe that this person might be somebody who has put themselves second in a situation where they were a caregiver or they have they were previously £300 and have lost 10% of their body weight and are now £270 , or they were incapacitated or disabled due to an injury and were unable to be active for a period of time , or are now on the other side of a mental illness and have been on a medication that caused them to gain weight. But unfortunately , the research shows that when people have weight stigma , they they actually eat more in response to that weight stigma. Um , and uh , they , they also avoid receiving health care. They avoid talking about it with their doctors. They avoid going to the doctor. They avoid getting needed preventive health screenings like pap smears or colonoscopies. Uh , it's it's a real harm in our society.
S1: Well , and now I want to add another layer to this conversation. And it has to do with the concept of obesity as a disease.
S2: So is it a subjective term ? Um , so obesity has specific criteria , medical criteria. Basically a BMI of over 30 is the common definition that we use. There are other ways to define obesity , whether it's waist hip ratio. Um , there are some cutoffs that we can use based on body composition by uh , using either Dexa scan or what we call bio impedance , where you stand on a scale that measures the density of the tissues that you have. So and we can also use waist circumference , just waist circumference. I know that BMI sometimes gets a bad rap and there are some issues with it. Um , BMI is uh , is is mostly based on just entirely weight and height , right ? So it doesn't really look at our waist , our body composition. And what matters as far as comorbidity goes , right ? In terms of the medical relevance of weight , it's really the fat around the organs and the fat that's that's infiltrated our organs. That really matters. And so it complicates things because say somebody has a higher BMI and they happen to be very athletic. Well , you know , they might not have as much fat between the , uh , around the organs and infiltrating the organs. But , um , beyond a certain BMI , they , they still might have certain risks like sleep apnea and obesity , hyperventilation syndrome and things like this. Um , somebody might have a BMI that's even lower. Um , even in the 20 fives , particularly those of Asian descent , people have , uh , fat around the organs at very low BMI and , and have , uh , diabetes and hypertension and pre-diabetes and insulin resistance. And they might look very thin while they have that those , those issues going on. So so BMI is not a perfect measure. But we it's not very practical for us to have to measure everybody's body composition. And there are problems that come with that.
S1: But does obesity always need to be treated or cured with weight loss ? Um , or is it something that people can live a healthy life with ? I mean , you know , weight stigma is something that is very real. Uh , oftentimes I see on social media debates between , uh , whether society's reaction to someone is rooted in weight stigma or if it's rooted in health consciousness. So can you really unravel that and break that down for me ? Yeah.
S2: So okay , so first of all , having excess weight is not a disease state. I often describe myself. I heard this at a conference once. I'm a co-morbid ologist. I address people's health as it relates to their weight. There is a concept of metabolically healthy obesity. There is some dispute as to whether it is , uh , it is a reality. I subscribe to it. Um , there is some data that suggests that people who have , uh , metabolically healthy obesity are , uh , at a higher risk potentially of. Slightly shorter lifespan. But I think that that research is not perfect and that we weren't able to look at all of the other health conditions or whether those health conditions were properly screened for. So I do think that there is something such as metabolically healthy obesity. But obesity has many comorbidities. So arthritis , for example , is a comorbidity , reflux is a comorbidity , um , and clinically significant depression and anxiety when one could argue are potentially a comorbidity , diabetes , high blood pressure , but also even things that are more subtle like idiopathic intracranial hypertension , high pressure in the brain , polycystic ovarian syndrome. So there's many , many different comorbidities or having excess weight. And , um , and all of those have to be taken into consideration. When it was made that when that decision was made , there was some controversy around that. But the reason the AMA made this decision that obesity is a decision is because obesity really affects every single system in the body , all the way from our our muscles and our bones to our brain. At this point , we do believe that obesity is a disease , but I think we don't treat obesity because someone has a body that looks different. And we have to respect that. There are differences in our in people's bodies , but that doesn't mean that we don't treat somebody's obesity. And that's why it's a patient centered discussion. And it's a discussion that involves the risks and benefits with each patient. I don't think that that changes the fact that it's really challenging. And listening to Doctor Shapiro talk about some of the challenges that she's seeing in her , um , eating disorders patients. And I do see some patients in my practice as well , who who are struggling with those things. It's very challenging.
S1: Well , it is a very complex issue.
S4: Um , but also as a behavioral health perspective of , you know , there is such a vicious cycle between obesity and whether it's depression or anxiety or binge eating. And we see patients who struggle with obesity for many different reasons. So , you know , partly there's genetics or , you know , medications that contribute to this. But , you know , when we talk about the stigma , we also see such successful people , you know , CEOs , top of their company that like what you were saying , Doctor Kennedy , is they're putting everything else first and they're not putting themselves first. And that's the part that this medication , you know , will help them with. But that's where the lifestyle piece comes in. In addition , you know , some of the other , I want to say , causes but fact maybe risk factors that might lead to obesity could be , you know , a trauma that's happened in someone's past. Right. So , you know , sometimes we see sexual abuse where patients even have such good insight that they've built this barrier around themselves to help protect themselves. And while obesity , you know , may be considered a disease , what we have to remember is any disordered eating that comes with it , whether it be binge eating or emotional eating or non structured eating , that is not the disease. And binge eating disorder in and of itself is a behavioral health disorder , a psychological disorder. And that needs to be worked on because those underlying issues , whether you take a medication or you don't , they're still going to be there.
S1: I've been speaking with Doctor Jennifer Shapiro , licensed clinical psychologist and director of Everybody Behavioral Health in San Diego. Doctor Shapiro , thank you so much for joining us.
S4: Thank you so much.
S1: And also , Doctor Deepa , sanity , obesity and lifestyle medicine physician at UC San Diego Health. Doctor Cindy , thank you for joining us.
S2: Thank you Jade.
S1: And a question for our listeners. Have you experienced weight stigma or shame ? Give us a call. Share your story at (619) 452-0228. Again , that is (619) 452-0228. We'd love to share your story. Still ahead. Some doctors are concerned weight loss medications are being overprescribed.
S5: People sort of think of it as a magic pill , because we have a weight loss industry that has lots and lots of billions of dollars fueling it , that tells people that magic pills can fix their life.
S1: More on that. You're listening to Kpbs Midday Edition. Welcome back to Kpbs Midday Edition. I'm your host , Jade Hindman. On today's show , we're talking about how doctors are adapting their practices around new weight loss drugs. Conversations around weight loss and health often start in the primary care office , and that's long before a patient sees an obesity specialist if needed. Well , one family care doctor has been vocal about her concerns around fitting weight loss drugs into her weight neutral approach to medicine. I sat down with Doctor Mara Gordon , family physician in Camden , new Jersey , to hear her thoughts. Here's that interview. So you say you're a weight neutral doctor. What do you mean by that ? Yes.
S5: So I , I'm a primary care physician. Um , I take care of both children and adults , which I love. And I have started a journey to becoming what I call a size inclusive physician , uh , over the last couple of years. And it's something I've written publicly about for NPR because it's something that I increasingly think is really , really central to practicing compassionate and evidence based medicine. I also identifies a health at every size physician , uh , which is a term that , uh , listeners might see when they're looking for a doctor themselves. I basically don't direct my patients to lose weight , and I don't bring it up with them. I don't say , hey , have you thought about jumping on the treadmill a little more often ? Um , I've stopped sort of pushing weight loss on my patients. I still have a lot of patients who want to talk about their weight. Um , we live in a very , very weight focused society. We have a very powerful diet industrial complex that spends a lot of money telling us all we should lose weight. So a lot of my patients don't want to talk about it. And , you know , as their physician , I'm more than happy to I'll talk about whatever they want to talk about with me , but I don't push it on them anymore. Yeah.
S3: Yeah.
S1:
S5: Um , I have to say it really started with reading. Um , I read , I love to read , and I read some memoirs , uh , a few years ago by fat authors. Um , and just as a brief aside , I'll , I want to clarify that I use the word fat , um , really taking my lead from fat activists who've been working in this space for many years. So I use the word fat as a neutral description in the same way that I might say somebody is brunette or , you know , they're short or tall. Um , and it's a term that I wouldn't call a patient unless it was a term they self-identified with. But I found it really powerful to sort of reduce some of the taboo around fat bodies to start reclaiming the word fat. So I read some books by fat authors , memoirs about their experiences living in bigger bodies , uh , authors like Roxane Gay , Lindy West , um , Casey Layman , um , among many others. And they described many experiences of fatphobia and discrimination. But central to many of them were experiences with doctors. And it made me reflect on my own practice. And I was pretty uncomfortable. I started to realize , was I alienating my patients ? Was I making them not trust me ? Um , and I , I started reading more about it , uh , about the practice of weight loss counseling. So weight loss counseling , meaning a primary care doctor like me saying , hey , have you thought about cutting calories or something like that ? Doctors offices are one of the most consistent places that that patients experience stigma , experience shame. And when our patients feel shamed and stigmatized , they just don't come back to see me , right. Um , they don't trust me. And so if my goal is to support them , um , in living well lives and living healthy lives , weight loss counseling was not helping with that. So , um , I decided to stop , and I found a great community of other weight neutral providers in the health that every size movement , um , there's a growing number of us and it's really , really resonating with patients.
S1:
S5: I mean , I just I feel so much more trust with my patients. I feel like so much more of a therapeutic alliance. Um , people are just so relieved to not feel judged and shamed by a doctor anymore. And that that makes me so sad for my profession , right ? Because most of us get into this field because we want to help people. We want to , uh , earn their trust. We want to support them in living the healthiest lives that they possibly can. Um , and so it brings me great pride and great pleasure to be able to , um , have my patients feel like I'm their ally. Yeah.
S1: Yeah.
S5: Have just gotten pathologized in a very , very specific way. Um , in modern medicine that is absolutely related to racism and sexism. Um , and it's everywhere , right ? And I can't speak to Hollywood. I can't speak to , you know , fashion. I mean , there's so many facets to this complex problem , but I can speak to medicine , my field , and I think , you know , from day one of medical school , um , larger bodies are really pathologized in a way that , um , now that I've come to learn more about it really isn't grounded in , in science as much as I thought it was. Um , and again , the relationship between body size and health is is very complicated. Um , and there are some proposed alternative measures rather than body mass index , for example , like visceral adiposity , which means basically the amount of adipose tissue or fat tissue around your internal organs seems to be a risk factor for developing metabolic disease. Um , and , you know , as I said , people with , uh , I have many patients who live in very thin bodies , um , who turn out to have fatty liver , right , which puts them at risk for , uh , lots of issues with , um , liver function , diabetes , abnormal cholesterol , um , and , uh , and so we need much more sophisticated and nuanced tools to think about how to risk stratify and screen our patients for development of disease in the future. Uh , BMI just really isn't cutting it.
S1: And then enter these new weight loss drugs.
S5: Um , thank you Oprah. So I've been using this medication for a year. I've used them to treat patients with diabetes way , way , way before there was any talk about using them specifically for weight loss. Um , and they're very helpful medications. I'm so grateful to the researchers who develop them. Um , I mean , part of my practice as a health editorialized doctor , is that I don't direct weight loss. Right ? So if we've diagnosed diabetes in somebody , I absolutely suggest it. It can be really helpful for patients with diabetes. Um , it's not something I'm going to suggest to somebody who , you know , has a BMI of 31 and no evidence of diabetes. So I have a lot of patients who ask about it because , you know , they see it as a quick fix for many issues in their lives , because we live in a culture that's obsessed with thinness. And each of those is a really individualized conversation. I've had people confess that they think starting Ozempic is going to make their marriages happier or , um , help them run a marathon or whatever , and it doesn't do those things. Um , it has very specific applications. Um , and when those applications are medically indicated , like , you know , reducing glucose levels in the blood , right ? Preventing the risk of cardiovascular disease , like it is absolutely an amazing fix for those things. Um , but I think that's diet culture talking , right ? That's , um , our deep obsession with thinness in our culture , talking when people think that , oh , if I just start taking ozempic all of these things that are not going well in my life going to be fixed , that's sadly not true. Yeah.
S3: Yeah.
S1: Well , I mean , and for those patients , you've prescribed it too. What kinds of reactions have you heard from them ? Yeah.
S5: I mean , again , it really depends on the patient. Right. I think um , it does have some side effects. Uh , mostly stomach upset. Some patients have had a lot of nausea , vomiting , diarrhea , uh , on it. And , you know , I think it depends on the patient. One experience side effects to begin with , too , if they're willing to tolerate them. And you know , I have patients who have really severe diabetes and have severe cardiovascular disease. And they feel like absolutely tolerating the side effects is worth it for them because they feel like the medical benefits are so great , right ? I have other patients who have no comorbidities , have taken it specifically for weight loss , and they felt like the side effects were too big to bear. Right ? They felt like it took away their enjoyment of food. And food is so cultural. It's it's about family. It's about pleasure. It's about connecting with the people that we love. And to feel like that was no longer part of their life , I think was really sad for some of my patients. Um , and they , some of them have decided to discontinue it.
S3: I mean.
S1:
S5: Um , as more and more people are asking for ozempic. And my core guiding principle as a physician is supporting bodily autonomy for my patients. Right. Um , so I have not found that it's therapeutic for me to try to. Argue with a patient when they really , really believe that weight loss will solve certain problems in their life. Whether or not I agree or disagree , I don't always feel like it's my place to try to convince them otherwise. So , you know , I try to have a thoughtful conversation with my patients about why they want to lose weight. I mean , usually that's my first question. When patients say , hey , you know , Doctor Gordon , I want to lose weight. I say , well , tell me , tell me more about that. What's on your mind ? Why do you want to lose weight ? Right. And then and then we talk about it and sometimes we dig into it and we realize that their goals are really about , you know , physical activity and exercise. Right ? They want to be able to keep up with their kids. And the way to do that is , is not necessarily to take goes mpic. Right. The way to do that is to make small incremental changes to physical activity. And I'll just say I'm super pro. Exercise , um , exercise is great for all of us. Exercise does not need to result in weight loss for us to experience , you know , cardiovascular benefits , mood benefits , um , sleep benefits. So , you know , those conversations can be difficult. Um , sometimes patients and I disagree , right. Sometimes say patients say I really want to be able to fit into my clothes that I bought 15 years ago. And that's why I want to take those unpick and we hash it out a bit. We explore those feelings. Um , but ultimately , right , I think the patient gets to decide what's best for their body. I , I do want to emphasize that I think there's so much heterogeneity in the way that doctors are prescribing this medicine. Right. And , um , it depends on the insurance company. There's there's FDA indications around , um , like FDA approved indications for GLP one agonists around diabetes diagnosis , um , history of cardiovascular disease in the setting of diabetes. So if you have diabetes and you're especially high risk for cardiovascular disease , it is FDA approved specifically for weight loss. What the parameters of that are are vague , right. So we're finding that a lot of people are using this as a cosmetic drug. I mean , that's not surprising at all. Um , and it's very easy to find an online telehealth company where you can lie about your weight , um , you know , pay the fee and , and get shipped ozempic in the mail.
S1: But let's talk more about weight related comorbidities. I mean , could weight be tied to someone's health problems ? Yeah.
S5: So , um , the relationship between weight and medical comorbidities is extremely complicated. Um , and I am not my my approach is not saying that there is absolutely no relationship between , um , body size and weight. Um , and it's it's pretty complicated , actually. Um , and it is not very well reflected in body mass index , which is just a measure of weight for height. Um , and in fact , the American Medical Association , which is the , you know , representative body for all physicians in the United States , has actually said that doctors should no longer use BMI to assess an individual patient's health. It's just , um , it's not a good metric for it's it's too blunt of an instrument to really , um , be able to be predictive of developing disease. And there's really , really high quality epidemiological research from researchers at the centers for Disease Control , namely , um , Katherine Heigl is one I'd love to point listeners to , um , who has found that there's actually sort of a U-shaped curve. When you look at the relationship between body mass index and risk of early death. So we find that people at really low weights and people at really high weights have an excess risk of death. And actually being in the overweight or sort of early stages of obesity categories is protective for health , which is really interesting. It's it's really different from what I was taught in medical school. Um , so my approach , because it seems like there's so much we don't understand about the relationship between body size and risk of comorbidities. My approach is to test for disease , right. If somebody has evidence of insulin resistance , um , we treat that right. If somebody has diabetes , we treat that. And , um , I have plenty of patients who live in very thin bodies who have unfortunately very advanced diabetes , cardiovascular disease. And I have lots of patients who live in big bodies , um , who have no evidence of insulin resistance at all. Um , so if somebody has hypertension , we treat that somebody has back pain. We treat that right. Um , so it's sort of like a case by case basis rather than saying , hey , uh , you know , your BMI is above a certain cutoff , I'm automatically going to start yelling at you to , to lose weight , which is not a therapeutic approach , nor does it have good scientific basis.
S1:
S5: Shame. When you go to the doctor , you you can tell your doctor that you don't want to talk about your weight. You should feel empowered to do that. Um , in many , many cases , you may not need to be weighed. There are a few scenarios where weight is really , really important. You know , if you're getting chemotherapy , it needs to be weight based dosing , right. But for general primary care appointments , you do not need to be weighed. Um , and you should feel empowered to ask to avoid that. Um , or at least have a discussion about the doc with the doctor about why they think it's important. Um , if they do want you to be weighed. Um , if they're telling you to lose weight. Press back on that and say , you know , that's not something I want to talk about today. Um , I'm I'm willing to talk about this XYZ , but , you know , I , I don't want to feel shame and stigma when I come into your office. And , you know , the same goes for doctors , right ? We really need to step it up. Our patients deserve better. Patients are demanding better. Um , and , uh , we need to make people of all body shapes and sizes feel welcome in our practices because our health depends on it.
S1: That's Doctor Mara Gordon , primary care physician in Camden , new Jersey. Her most recent piece for NPR is called My Patients think Ozempic is a wonder drug , but it can't fix fatphobia. Listeners , let us know. Do you have thoughts or questions about the way we treat obesity in medicine ? Have you experienced weight stigma ? Call and leave us a message at (619) 452-0228. You can be featured in a future show of Midday Edition.
