Psychiatry & Psychotherapy Podcast - Obesity and Weight Loss with Endocrinologist Rocio Salas-Whalen

Episode Date: September 23, 2022

In today's episode of the podcast, I interview Dr. Rocio Salas-Whalen, owner of New York Endocrinology on Park Avenue. Dr. Salas-Whalen has deep expertise in diabetes, metabolism, obesity, thyroid abnormalities and other endocrine disorders. She completed her internal medicine residency at Albert Einstein College of Medicine and her endocrinology fellowship at the University of Maryland School of Medicine in Baltimore. Additionally, she was a research fellow at Johns Hopkins University School of Medicine and is board certified in Obesity Medicine. We will be discussing obesity and weight loss. The definition of obesity has changed significantly in the last few years. In 1942, WHO classified obesity as a chronic disease. In 2013, the American Medical Association accepted it as a chronic metabolic and multifactorial disease. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Dr. David Puder and Dr. Rosio Salas-Walen have no conflicts of interest to report. All right, welcome back to the podcast. I am joined today with Dr. Rosio Salas Wallen. She is the owner of New York endocrinology on Park Avenue in New York. She has a deep

expertise in diabetes, metabolism, obesity, thyroid abnormalities, and other endocrine disorders. and today we will be diving into specifically obesity. She did her internal medicine residence. He had Albert Einstein College of Medicine, endocrinology fellowship at the University of Maryland. And she did a research fellowship in John Hopkins, where she published some papers. And now she does full-time, it seems like, obesity management.

And I have become acquainted with your work through Instagram at New York, endocrinology, right? Correct. And yeah, so I was thinking where we could start, kind of maybe paint the picture of how you got into helping people with obesity. And then I'd like to get maybe into your approach, like how you take a history and go from there. Definitely. So I'm from Mexico. And in Mexico, diabetes is the number one cause of death.

So going into medical school, I always knew that I wanted to work. with diabetes and type 2 diabetes specifically goes linked with weight goes linked with lifestyle right so it's a it's a relationship go they go hand-in-hand type 2 diabetes and weight or lifestyle right you can treat one without treating the other basically um so my dive into endocrinology was diabetes and metabolism and through my fellowship i started to get more interested in obesity in weight loss and having more information and being, having removing bias in obesity, like it really opened my view and my mind into treating obesity, right? And it's a conversation that all of us physicians encounter one point with our patients, and it's a long, deep conversation to have. And I feel like having more a specialty in

endocrinology and obesity allows us to have more of that discussion, or more deep discussion, right yeah i was i think your background in endocrinology really positions you well um and for you you were telling you were talking about how obesity is more about total metabolic function or tell me like you know the the and being an endocrinologist i still did obesity medicine i got board certified in obesity medicine and i mean the knowledge that you gain doing obesity medicine versus endocrinology itself there's a big vast of a difference, right? Many things that we're not taught in medical school or residency or fellowship regarding obesity, right? So obesity, the term and the definition of obesity has changed significantly in the last years. More ago in Europe, in 1942, the WHO classified obesity

as a chronic disease. But it's not until 2013, 2013, that the American Medical Association adapted it and accept it to classify as a chronic multifactorial disease, right? Before it was considered more of a lifestyle problem. It was the eat less, exercise more, and then come back, and nothing was happening. Right. Now we can actually accept it as a chronic metabolic multifactorial disease, right? So that's where we are now. And then can COVID and COVID really pushed obesity more in our face, right?

Like you as physicians and what would tell patients is if you don't take care of your weight and you don't lose weight in 10, 20 years, you might develop type of diabetes, hypertension, all this chronic condition that we know could happen with obesity, right? But what happened with COVID? It hit us out of nowhere. And all the studies show and you can go to PubMed and there's so many studies that show that patients with obesity or higher BMI had more severe COVID, higher admissions to the ICU. in higher mortality and higher need of mechanical ventilation, so intubated patients, right?

So I feel like COVID did something positive and has brought this light to obesity. I had a lot of influence of patients coming in and saying I'm scared. I know I'm overweight. I know that I have obesity and I don't want to get really sick with COVID. So I feel like COVID really put it out there that obesity is causing some sort of inflammation, some sort of problem that we don't have to wait 20 years for a complication. Came this fire from nowhere, and it was the highest mortality people with obesity, right? So I feel like people really got the message, the general population and NASA's health care providers.

Yeah, I remember there was a, someone had posted on social media how like that was just not true, how obesity wasn't really increasing mortality. and I remember looking back at the study and specifically, like I didn't understand how that person, I don't even remember who it was, but how they got to their conclusion that it wasn't a big deal because it is a big deal. It does increase mortality quite a bit. Can you speak to the controversy of that? So what happened is that many of the studies were initially done in Europe and in Asia.

So the rates of obesity are not as high as in the United States, right? So when it came to the United States, COVID, because first, it was all Europe, right? They started COVID with the pandemic and then it came to New York and then the rest of the country, right? But when the patients were coming here and it was in NYU that did the first study, that it showed that the patients that were being admitted to the ICU were related to BMI, right? And now looking back to Europe, now they have their own studies showing that, yes,

even there, even though obesity is not as high, the patients that were being, having severe COVID were the ones that were overweight or higher obesity, right? And all the studies show is because there's chronic inflammation in obesity, right? So when there's chronic inflammation, your immune system is being preoccupied with the chronic inflammation and the adipose tissue. Then came the virus and it didn't have enough immunity to fight the virus. So that's the, in a simple way to say what's happening with obesity and COVID, right? Okay.

Yeah. And just for my audience, you know, in mental health, so often, We see people and we're not thinking about weight at all, honestly. So it's good to have this conversation so that we could start seeing it as like, okay, this is increasing inflammation and can potentially cause a ton of issues. But even worse than that, often we are putting them on meds, which increase weight, right? It's interesting that you bring mental health because mental health is something that we don't associate so much with obesity as a consequence of obesity, right? but I feel like my my perspective, my perspective towards obesity has changed through the last

three or four years that I've been practicing clinically with obesity. I think 90% of my practice is obesity. And going into how what history or how is my evaluation is I go very detailed in their weight history. I always ask the patients this question, how young were you? And I'm an adult physician, right? So most of my patients are 20s, 30s, 40s, 50, 60s, right? But I always ask my patients, how young were you the first time that you remember that you had something with weight, that you had a weight issue, that you had to think about food, that it was part of your life. Childhood, nine years old, puberty, 10 years old.

So I have a 30-year-old, a 40-year-old, a 50-year-old patient that throughout their teenage years, their young adult life, their 10, 20, 30 years. their life has surrounded around their weight, right, around that plate in front of you. How is that going to impact my weight? How is that going to impact my diet moving forward? So that takes a toll into mental health. So I've had grown men cry in our appointments because it's so emotional. It's such a deep personal, emotional journey that the patients had. And it's very similar for every single patient.

You know, I've never met a patient with obesity that is that idea that we have, that they're lazy, that they could do better if they wanted, that they're there because that's their lifestyle. Every single patient when they come to me, I mean, David, they tell me about diets that I've never heard in my life. They've gone through fat temps, nutritionists, a physical trainer, all the diet the juror will be. They've done their life work and it's not working. So that's not the problem. It's not the lifestyle. It's not what they're doing or what they're not doing. And knowing that, it relieves the patient from a lot of pressure, right?

And talking about health and obesity and why changing the way we view obesity is going to relieve a lot of those patients from that pressure and that guilt, right? And also open their mind to go and ask for treatment. right yeah there's that idea that oh this is the easy way out but we wouldn't think that of in a type two diabetic if they go and look for medication and treatment right it's just that bias that we have regarding weight and weight loss and weight loss medications right so yeah 100 percent i mean food is comfort food is culture food is like i've like i've had my fair journey you know it's like i could almost be a patient of years. But the, you know, and mental health is so intertwined. Often in mental

health, we're seeing anorexia, bulimia, and, you know, people who, you know, who have anorexia, they could be very slender, but they still believe they're fat. And people with bulimia, they could, you know, it could be like an impulsive sort of cluster of issues that leads to that or the fear of getting fat or a disgust towards food. I mean, there's a multiplicity of reasons why. why people have bulimia. And then we also see people who aren't eating because they're depressed and they just lost the desire to eat. And those like the severe melancholic depression tends to be that way where they just stop eating and drinking maybe. I've had a couple of those patients. Yeah. So okay, so where I'd like to go is kind of like as you're taking the history,

what are things that you ask now that maybe, you know, as an internal medicine doctor, as an endocrinologist, you didn't ask before. And what are some things that kind of like are part of your history taking that you've learned to kind of include in the history? So definitely family history plays a big role. And I go as far as up as I can go or as far as a patient has knowledge of, right? So I always ask about their parents' weight history. I mean, I don't want a number, but I want to know if they've struggled with weight or they're

conscious. And many times they say, oh, no, they're normal weight. And I asked them, do they, it's a conscious, do they have to, do they exercise? Do they are always watchful? I mean, or is this more ever natural? Oh, no, my mom eats very little or no, my mom goes to the gym a lot. So even getting that information, uncle, like siblings from the parents, I always want to find out where is the obesity gene coming from if there is any. And I would say 98% of the cases there is, right?

I ask about siblings, and depending on their age, children, how's the weight of their children, how's their health of their children, if they're teenagers? And, I mean, there's a very strong familiar link, right? So then we add that genetic part to the multifactorial causes, right? Then I ask about if they're female, they're menstrual history, right? They have regular periods, regular periods, just trying to get some history of PCOS. So in male, also, if they have obesity, libido, erectural function, because that can guide me hypogonadism or not, either due to the obesity or the obesity causing the hypogynidism, there could be some relationship. I asked them about siblings, same thing, right?

So a very detailed family history. I asked them about lifestyle, right? What is your lifestyle? Do you exercise? What type of exercise do you do? What are your eating habits? What's your relationship with food? Right. And then job. Sleep is always, I mean, it's very important. It's part of my question. How do you sleep? Do you sleep well? Do you sleep throughout the night? I mean, I would say the majority of patients don't have proper sleep, right? And that's a, that's one of the environmental factors that can contribute to obesity. A lot of patients travel if they travel for work, then that's environmental factors too, right? Stress, traveling, flying, being in airports, not having access to to normal routine food that the patient would have, right?

that that contributes to obesity too, right? And then, I mean, age, medication, for sure, medication lists always, right? I mean, we know there's a lot of weight gaining medications, anti-hypertensives, psych medications, right? So it's a very detailed history, right? I really go, I dig very deep in their medical history and in their lifestyle, too. Yeah, that's so important with like, sleep. How often do you uncover something like sleep apnea and how does that play a role in obesity? Many times because it's just like a vicious cycle, right?

So if they're not sleeping because they have sleep apnea, then they're not sleeping is raising their cortisol and that can promote waking and obesity. And they're just feeding each other, right? So many times patients, they're not aware that they have a sleep apnea, but then when you start asking, do you snore? or does your partner, do anybody complain of your snoring? Do you have deep dreams? Do you remember deep dreams? So it's just getting a little bit more history and they're into their sleep, right? So it's a very detailed visit.

Yeah. And that's more my clinical questions. Then I do have like an in-body machine in my office, which is, it's an impedance. It checks. It tells you about escalatal muscle mass, visceral fat, percentage body fat. and it gives me a really good background on what's the number in the scale, right? Because many times, and even BMI, right? Once I have those values, I don't really think about BMI or the number in the scale.

BMI, what I see most with the fault with BMI and guiding us on BMI is that many times the BMI looks normal. And you think, well, no, this is a normal BMI. You don't need treatment. But when you do more deep studies, like, I mean, the gold standard is an MRI. Dexa is the second one and then impedance machines are the third one for getting those more diagnostics values in regards to metabolic health

right? Because when I see a normal BMI is due to higher fat mass and lower muscle mass. Yeah. So that's not healthy, right? Yep, yep. So okay, we're talking metabolic health. Metabolic health. What is metabolic health? So metabolic health,

in a simple way is to say that the ratio of your muscle, your skeletal muscle mass is higher than your body fat mass, right? And that your visceral fat is low, or you don't have visceral fat, or that's normal, right? Oh, okay. That's metabolic health. Okay, so visceral fat, and that's where the MRI is, like, can measure visceral fat?

Or a bone density at the excess scan, or the impedance machines that works with ions. Okay. differentiate between fat water and muscle and mixed calculations. I think it's important to just be redundant. You're not paid by any companies at this point. You don't have any relationships with pharma companies, right? Pharma and I don't even have a relationship with anybody.

But that's the most common accessible for a doctor's office machine brand, right? Yeah, okay. So you have those percentages. I think that's important to kind of like identify clearly what is metabolic health. Is metabolic health have to do with like ability to do a treadmill test or ability to have like hand grip strength in your mind? Insulin resistance A1C, right, blood pressure, cholesterol. Those are more metabolic values that we can use or also diagnostically.

Okay. So you're getting this kind of idea of their total metabolic health. And so just to be clear, like exercise, their ability to exercise, is that part of that? Or is the ability to exercise potentially and strength train? Is that going to adjust those different things that you're looking at? Yeah, I mean, it's definitely a good clinical evaluation on a physical exam. You can get a good idea of the patient. I mean, most patients are already set on exercise, right?

Again, I haven't met a single patient that I see for obesity and weight loss that does. doesn't exercise, do some sort of exercising, right? So it's just guiding them towards the right exercise, especially if we're starting a weight loss treatment, right? Because on any weight loss, even if it's not, we're not talking just medication, if it's just like a restrictive caloric diet, or there's going to be calorie restriction,

and there's going to be muscle loss, right? So it's just guiding the patient on the exercises that would help them maintain or lose the least, amount of muscle on the weight loss face, right? Okay, so I've seen some studies that show that if you were losing weight and you do strength training, you lose more fat than muscle. And I've seen you post on this. Is that kind of your philosophy?

Because there's a lot of people who say, like, oh, I should just do cardio. No, I have all this data from the studies that I do, and it's so beautiful to see how when muscle drops, percentage body fat goes up. And some patients for the muscle loss, could have been, they stopped exercising, they went on vacation so I can see that when the muscle comes down, percentage body fat goes up. And those patients that muscle goes up, percentage body fat goes down. So it opens up like up, right? So anytime there's muscle gain, there's percentage fat lost automatically without medications. And it's really, it's beautiful to see that that change in percentage body fat just from muscle gain. So when we move to a maintenance part,

and let's say we achieve the weightless goal of the patient, when we maintainants, I always try to guide the patient to gain muscle because that extra muscle gain, we're going to rebuild the muscle that was lost, whatever was lost, and then gain muscle, that's going to become part of the maintenance part, that extra muscle becomes that second drug or that extra dose that I decrease. it becomes part of the maintenance part. That's good. Okay. One of the things that got me excited about talking to you was it had been a while

since I had read any articles that excited me with the percentage of weight loss that I was seeing in them. You know, when I think about like 15% weight loss, I think did they get like some sort of surgery, right? And so I'd seen this, a semi-glutide study where, you know, we're talking about 50% of the people had lost more than 20% or around that of weight loss. What is, I guess, what is your like starting medication that you're thinking about? Or is it like 50% of your patients get put on this first or 50% of your patients get

put on this first? Like, how do you make a decision what they get put on first and what are you putting them on first usually? So let's talk about what we have a, available for weight loss, right? What are our waylos drugs that we have available that are FDA-approved? So we have the GLP-1s now, also the GIP, which is a macutide, right? That's the FDA-approved for weight-lose, and we have Therceptet, which is the newest one that is FDA-approved for type 2 diabetes, of label for weight-lose, we could use it, right? Then we have another medication called chrycemia, which is a combination of phentermin and topuramate, an extended release to pyramate. That's an oral drug. and then we have

Saxenda, which is Lira acutide, which is another GLP1, that is the daily version versus what we have once a week in semi-alactite, right? And then we have Orlishtad, which is one of our oldest medications, right? But it has that bad side effect

that we all know that you can give any fatty meal that you have, can give you diarrhea or soiling, right? And they don't work as much for, I mean, they don't produce the weight loss that we see with our newer drugs, right? So I don't really use or less that, I don't really use Accenda.

Definitely, I see more weight loss on the weeklies shots than on the daily shots, significantly difference. Okay, good. So weekly shots, you see better. So whenever I'm doing the history of my patient, and I'm talking into the relationship with food,

that's a part also of the consultation, right? I get a sense of the relationship with food with the patient. If, in the majority, I would say of patients with obesity or overweight, they do have some sort of emotional positive reinforcement with food, right? So in those patients, that GLP1, GIP medications and melatonterceptipe are really well because it works in the, we have receptors in the amygdala for this too, for GLP and GIP. So it dissociates any positive reinforcement from food.

So any anticipation that you have from food or even alcohol in some patients, that anticipation of getting something emotional, social, some sort of positive reinforcement, it takes it away. So for those patients that struggle with that with snacking, craving, drinking, this type of medications are great. Wow. It rewires the way you see food. It changes your perspective of food. you really think of food when you're hungry, but then it increases your satiety hormones. So you get hungry, but then you get full with small amounts. And in between meals, it decreases your hunger hormones.

So you're really not thinking of food only when you're hungry, then you eat too satisfied. And then that's the last time you thought of food, right? You still enjoy food. That's a question that I get from my patients. They're like, oh, I'm not going to enjoy food. Definitely, you're still going to enjoy food. You're still going to save your food, but there's not going to be that anticipation or emotional response from food. or alcohol. Yeah. Yeah. I guess I'll disclose. I've tried this, you know, the weekly injection.

I won't say which one. But one of the things that I've found is your, my stomach feels full. It doesn't empty as fast. I don't crave the last meal of the day like I used to. Like so I like nine o'clock at night, you know, that lasts like 500 to 1,000 calories or so. it's like I'm not even thinking like I could put more in my stomach which is which is interesting and you know what's the amazing thing and that that's the biggest difference with pediatric surgery because body surgery and this is the research that I did in job

pediatric surgery and by the way this of the this incritons they're called incritons they were discovered mostly after biiatric surgery because we didn't know it was just the mechanical restriction that patients were losing weight then we found that there was this hormone, the GLP and GIP are producing the L cells of the small intestine. So when the ruin Y, you're making that transfer from food to the small intestine faster, right? So there was a faster release of this hormones, and that's how they were discovered this hormones, right? That's how we found out that it exists. But the difference with biiatric surgery is that, yeah, you have more release of the GLP1,

and you have a mechanical restriction because they're physically shrinking your stomach, right? I mean, you have a small capacity, a small place to put food. That's a mechanical restriction of biiatric surgery. And while there's more production of endogenous GLP and GIP, it gets degraded within two minutes. It has a very short, very short halfway. There's an APP4 enzyme degrades this hormone. And it doesn't have enough time to cross the blood, brain barrier. Now, the synthetic form, it can go to the receptors and the brain.

So we don't get that reward system shut down in biiatric surgery. That's why there's a lot of regain. Yes, because you're restricting them mechanically, but the psyche didn't do nothing happening in the psyche. They still want to eat. They still get that emotional feedback from food. And what happens eventually they regain weight. I'm seeing Ruin Y gastric bypass patients that are regained most of the weight back, which

the Ruin Y was like a gold standard. less regain of weight, right, versus this sleep or the gastric sleep. So it's very interesting to see what's the difference is that this is actually working also in your brain and mechanically in your gut versus pediatric surgery is just doing a mechanical restriction, but it doesn't change this idea. Wow. Okay, so GLP1, I think can you just for someone who hasn't heard anything about this type of medication, like give me the basic. basics on like what a GLP one is doing. You've you've, you've put it in a little bursts, but say it again just so that we're all on the same page. I think it's really interesting to say

that this are not new drugs, right? I think there's like this conception that, oh, they're so new what's going to happen. We're not going to know what's going to happen. Now they're safe, rather than not safe. The first incretin, which is a gut hormone is this type of hormone that regulates glucose. That's a true definition of an incretin. They were discovered in 2005. So since 2005, we've had this sort of medication. The first one was Bayera, that was a commercial name. Exanatite was the hormone name. That was our first GLP one that was made in 2005.

And it was developed for type 2 diabetes because they regulate glucose control by producing, helping your pancreas make more insulin or work better than insulin. That increases insulin sensitivity and increases insulin. in production in type 2 diabetics, right? The beautiful thing of this drug is that the effect on the pancreas is glucose dependent. You actually have to have hyperglycemia or type 2 diabetes to work as a diabetic drug. If your sugar is normal, if your glucose is normal, it doesn't touch your pancreas, passes along, right?

That's why we can use it independent of diabetes and obesity. Because you don't get hypoglycemic. And I've seen that in the studies. there's no one getting hypoglycemic? The only time we see hypoglycemia is if the patient is on insulin or a cellophonylurea, right? And those need to be titrated down because now the patient is going to be eating less. So if any hypoglycemia is because they're on medication that can cause hypoglycemia. But the drug itself does not cause hypoglycemia.

Yeah. Okay. And then eventually when we started using them for, because they came off for diabetes, we knew nothing about weight. As we started using them, patients were coming back with better glucose control, better A1C, and weight loss. And we rarely see that with any diabetes drug that we have. I think insulin gains weight. Yeah. And then we had the PPR, the pyoglitason.

I mean, those medications can also make you gain weight, sulfonylureas. So any medication can cause a bulimia can cause weight gain. And then the pyoglitazone can tend to also. to gain weight. So we really didn't have any diabetes drug that actually also causes weight loss. So then we started seeing that clinically that patients were coming back with weight loss and better glucose control. Then we branched out of label to start using it for independent of diabetes for weight loss. Then the studies came out, right, from Lyraclyde. What's the first one?

The one that we started as was being Victosa is still off on the market. Victosa was a daily injection. And then they got the FDA approved with the studies for Saxenda, which is the FDA version approved for weight loss. Then in 2017, they brought the same pharmaceutical de brom semaglite, which is a longer acting molecule, right? That is just once a week. And it was FDA approved for type 2 diabetes. And we started using a label for weight loss. Then 2020 came the indication, the FDA approval for obesity and the rebrand.

Every time they could be an indication for obesity. Yeah, yeah. We're branded, but it's exactly the same molecule, right? Right. And now the newest one that came out this year, it's the first combination drug. It has GLP and GIP, which all the other versions was just a GLP one. So this is our newest version, which two-incretin to call it, because it has both incretins in it. This is the...

Trisipatide. Trisipotide, yeah. And that, like, I was looking at this study you sent, you know, 2005. 539 participants, average age 45, 40% with pre-diabetes, average weight going in 231 pounds, and the change in waist circumference in the 15 milligram group, so there were three groups and a placebo group. In the 15 milligram group, almost 7 and a half inches of off their waist. 21% weight loss. And that, yeah, that was pretty impressive.

We will put links to these studies on our website, Psychiatrypodcast.com, as well as a link to your website. And so when I was looking at that, I was like, wow. And interestingly, okay, so you may as a patient be like, okay, how do I get this? And first of all, this is medical information. We're not your doctors. You should go talk to your doctor. They may be expensive. And if your insurance doesn't cover, I actually send this, I ordered through Canada.

I don't know what you do. If there's a cheaper way, let me know. But I have a couple of patients who've ordered from Canada because it's off-label, at least Zembek. Yeah. I don't know. How successful are you getting these paid by insurance companies? So there's a bit of a loop right now that it's beneficial for patients with

their appetite. And again, I'm not sponsored. any pharmaceutical, none. I just use these drugs and I see what they do, right? I mean, this is what I do day to day. They work. What terseptitite is doing now for one year for patients with commercial insurance, they're not doing prior authorization.

It's just a $25 coupon per month for 12 months. So that's what tersepartite is doing. The problem with semaguletide is that they came out with Wigobi. that's the FDA approved for weight loss version of somagulatite. They run out of stock. They run trouble into production because they didn't anticipate the usage. The demand, right? So they shut down production.

And actually, all the patients that we started on Wigobi, most of it had to default into OSEMPEC. And now there's even shortage of OSEMPEC, right? So even now, it doesn't matter if you can actually pay for it, this and we actually get it right um so there's loops that you that you can work by to having patient access to the medication uh i mean it is an expensive medication right but it's it's truly an investment in in health and and versus the money that patients have spent through the years in diets sure yeah that don't work yeah that didn't work this is actually that actually is going to

work, right? And that at the long run, it may be cheaper than continue to do all those diets. Right. People, you know, and if there's anyone in the insurance companies listening to this, like, please, like, why would you not, the problem with insurance companies is they're not thinking, like, we're going to have this person on this insurance 30 years from now. And, you know, they're going to be more prone to more complicated diseases, which if you get to the ICU, it's really, really expensive. So yeah, the problem with the insurance companies, they're not thinking like this is going to help this person reduce costs 30 years from now. It's the healthcare system also, right? We as a healthcare system, we got comfortable in a specific physicians, we got comfortable

catching all the complications for obesity. That's the only thing we had, right? We had diabetes medication, we had hypertension medications. We got comfortable doing that. I feel like we built fellowships on the complications of obesity, right? But now actually we have medication to treat the cause, which is obesity, right? So I feel like us, as physicians, we have to change the mentality and the way that we see obesity and treat it as what it is, right? We would never think twice of treating somebody with an A1C of nine, right? Start him on medication. But with obesity, we still have like, oh, let's try the non-medication way, right? So I feel like as providers, we have to remove that bias in obesity, right?

And then once there's more demand of the physician prescribing this drug, more demand from the patient for this drug, I feel like insurances will cut up too, right? But if us as physicians don't prescribe it, don't think the use of it, we're still thinking of obesity as a lifestyle problem and putting everything in the patient's shoulders, then there's that disconnection of, yeah, it's a great drug. but we're not receiving that demand from it in orders, right? So I feel like there's many pieces of the puzzle that's going to have to fit together if everything changes, right? I know I only have a couple more minutes. I think it's important to talk about side effects. And then maybe I'll have you come back for part two and we'll talk about these other meds.

Side effects of GOP-1s, nausea, because you have slow emptying, potentially if you eat too much vomiting. but there's, I guess, in rat studies, there were some, like, cancer. Can you speak to that? So there's medallary thyroid thyracarcinoma, which is a very rare familial type of thyroid carcinoma aggressive. But since 2005, with the first synchrotin, there hasn't been a single human case report of medallari carcinoma. In any, like in your history, you always have to ask about family history of thyroid

cancer, and if there is, if it's papillary follicular hurdle, there's no issue with that. If it's medullary thyracarcinoma on a first-degree relative, then that patient is not a candidate for it, right? But we don't do screening ultrasounds. We don't go and screen for nodules and biopsy them before we start this medication. Again, not a single human case has been reported in almost 20 years. Okay. So what are the common side effects, and do you have any tips on how do you deal with the side effects with the checking ones? I want to talk about pancreatitis.

That's another big one. Okay. In my 12 years of clinical practice with these medications, I've seen two cases of pancreatitis and there were on patients with type 2 diabetes. Remember, if you don't have diabetes, it doesn't touch your pancreas. So very rare, right? And I've only seen it on patients with type 2 diabetes. Now the day-to-day side effects, nausea on somalibutitis specifically, less significant, less

nausea on terseptit. Oh, wow. Okay. Dehydration is the biggest one that we don't talk enough about and the one that can put patient on more complications. It can cause severe dehydration that patients can develop kidney stone, have lightheadedness, have syncopal events from dehydration. As it takes away your hunger, it takes away your thirst. So you may not feel thirsty all day, even though you're dehydrated, right? And that's an effect of the medication.

So there has to be conscious hydration. I always tell my patients that I'm going to write it in a prescription. Fluid intake is part of the treatment, right? Dehydration is going to make the patient feel run down, tired, fatigue, and then you can get worse to develop kidney stones. I have never seen renal failure. I have seen kidney stones, but loss of consciousness from dehydration and then the patient can fall and hit their head, right? So dehydration is very simple. it sounds silly and simple, just water,

but I can really make it or make it very difficult for patients at the beginning, more than the nausea, more than the gastric side effects, actually. Yeah, that's really good. Okay, well, we have like three more minutes. I want to honor your probably next patient encounter, but I do want to have you come back. And so, yeah, anything else you'd like to say in the last three minutes? I think very important is to tell patients regarding insurance

is to make sure that their insurance coverage, when they're time to renew, that they add weightless medication coverage, right? Employers for their employees, they should also, they should open more of those benefits. And then we don't run into veniles, right? So that's a good way of getting patients or medication. And very important, I feel, so the drugs work well.

They're relatively safe. The experience in the provider giving you the medication is key. It's going to add, right? It's going to make a huge difference. in some places you don't need a prescription to get it. I do not recommend that. There's still drugs and there still have side effects. And then you may not even have results because it's not being used properly, right?

And you can get into a lot of trouble. So they're great drugs. They work great. But there's still medication and they still need medical supervision. Yeah, 100%. And now what states do you see clients in or do you do coaching worldwide? I have in California, Florida, Vermont, Georgia. So I do enter New York, okay, in New Jersey.

So I do telemedicine too, but also in person. Great. Okay. Well, hey, thank you so much for coming on. It was a pleasure having you, and we will have to come back for part two. And so if you have any questions for part two, shoot me an email. You can contact me through the website. Psychiatrypodcast.com, and I will start to just curate those questions for part two.

Thank you so much. You're welcome.