The Checkup with Doctor Mike - Confronting An Obesity Doctor About Ozempic & Weight Loss | Dr. Rocio Salas-Whalen

Episode Date: October 11, 2023

Watch the full video interview here: https://go.doctormikemedia.com/youtube/RSWOzempic Dr. Rocio Salas-Whalen is a double board-certified physician with broad experience across all facets of endocrinology, with a particular emphasis on obesity, diabetes and thyroid disorders. She has been an outspoken proponent of Ozempic injections to help patients navigate diet and weight. I've been a bit skeptical about the emergence of Ozempic, so I wanted to dive in with an expert who can really discuss the nuts and bolts of the science to get to the bottom of who exactly should be taking these medications and what impacts they can actually have. Follow Dr. Rocio Salas-Whalen here: Instagram: https://www.instagram.com/drsalaswhalen/ Facebook: https://www.facebook.com/newyorkendocrinology/ TikTok: https://www.tiktok.com/@newyorkendocrinology 00:00 Intro 01:00 Ozempic overview 03:44 BMI, Diabetes, Skinny Fat 06:44 Who Needs Ozempic? 09:13 Fat Bias 17:20 Every obese patient should be on Ozempic? 20:55 Big Food vs. Big Pharma 23:02 Celebrity Use 25:55 Side Effects 27:30 Professional Athletes 29:26 Quick Fix 32:28 Getting Off Ozempic 38:49 Ozempic Shortages 44:18 Snake Oil 47:17 Advice for patients Host and Executive Producer: Doctor Mike Produced by Dan Owens and Sam Bowers Art by Caroline Weigum

Do you think that every patient should be on, that is classified as obese by the American medical standards, should be offered a medication? I cannot say 100% of the patients that have obesity, but the majority would benefit from the drug, yes. That's scary because then we're saying like a huge percentage of the United States should be on these medications. Have we con that far? Please welcome to the Checkup podcast, Dr. Rosio Salas-Walid, who is triple

board certified, internal medicine, endocrinology, and obesity medicine. I brought in the top specialist to talk about a topic that I know so many people are interested in, OZempic and related medications. Today we talk about how a lot of people who are trying to lose weight are actually doing it wrong. And Dr. Salasuelan has a very strong message for those who believe that taking OZempic is the easy way out. Hope you enjoy this conversation as much as I did. Let's get started. Pee-whoop. All right, Dr. Salasuelan, we're here to talk about the current situation that exists in the world with the ozempic craze, the conversation that has stirred up surrounding weight, obesity,

and I can't think of a more appropriate person to talk about this conversation with than yourself being an endocrinologist and being board certified in obesity medicine. So you're the top of the top expert on this field. Does that feel like a fair assessment? I do. I do think so also because I've been using the weightless medications since they were first available back in 2010, but the first one was in 2005 for type to diabetes. But off label, we've been using them for almost 20 years now. So yeah, I feel like I have enough expertise with these medications. I saw this coming way before it actually made so much news, right? So were you already

seeing patients within your practice using the medication off label before it became this hit? Since 2010, when Victosa came out, actually, Bayetta was the first one in 2005, but it was there was very, very new. So in 2010, Victosa was approved for type 2 diabetes as a daily injection. And when we started using it because it was a new drug, we were seeing patients coming back with better glucose control and weight loss. But because it doesn't cause hypoglycemia, then we started using it off-labeled Victosa back then for weight loss without diabetes, then Saxenda came out as the weightless version two years

later. And for the people at home, they may have heard of Ozempic, and that's the one that's in their mind, simply because of media, but there are multiple medications that are using either the same exact medicine that's found within Ozempic or maybe a sister medication or related medication. How many are there? Why are there so many? Can you take us through that? So I think Oscepe became the poster child of incritons and weight loss medications, but definitely there's many varieties. So the class of drugs are called incritins. And as with any class of drugs, we're going to have different versions, right? And every time a pharmaceutical is going to come with a new one, it should be better with less side effects and more effective, right? And that's

what we're seeing. So the first ones was Victosa, named or branded as Accenda for weight loss from over Nordisk, then Ossempec for type 2 diabetes and branded for weight loss as Weigobi. And our newest of the bunch, I like to say, is the iPhone 15 now of the drugs, is Monjaro by Ila lily, which is tersepatite. But this is only the beginning, right? Many other pharmaceuticals, Pfizer, Amgen, they're coming with their own version of it, right? I think the more competition we have, that hopefully they will be less expensive. What's your take on doctors using the ones that have been FDA-approved to be used for type 2 diabetes or a related condition as off-labeled strictly for weight loss?

I think it's a necessary evil. Unfortunately, the way that we diagnose obesity right now is with BMI. But unfortunately, if we use BMI exclusively to diagnose or to choose or to say who's going to need the medication or benefit for the medication, we're cutting a lot of the public. that will benefit from the drug. So if we go beyond measurements, actually the American Medical Association now said that we should not use the BMI as a sole diagnostic tool for obesity,

which I think it's huge. It's a huge advance, right? We have to use other measurements, percentage body fat, muscle mass, visceral fat. If we use those, more people will benefit from the drugs, right? And I think if we just concentrate on who the guidelines tells us, then again, we're going to be missing many patients. So that's why we can use them off-label, even on patients that a BMI may not be diagnosed

as obesity or overweight. In my head, when I think of BMI being inaccurate in labeling someone as obese or not obese, it comes to mind like a strong person, a bodybuilder with a lot of muscle mass, that their BMI might look really high. But I could see every muscle in their body and they're not actually an unhealthy, figure, if you will. They're not carrying excess weight. And I would say that's the minority of a wrong BMI. What I see more in my clinic over 2,000 patients that I have doing body composition is we tend to underdiagnose more than overdiagnosed, meaning that I've seen

many patients with a normal BMI or even a VMI of 21, 22, which you say they're completely normal. But once you look at their body composition, they have higher body fat than muscle mass. And it's coming out as a normal MMI because BMI is just a multiplication between height and weight. So if you average it out, body fat and muscle, you may have a normal BMI, but that's not metabolically healthy. That's what we call sarcopenic obesity or skinny fat, right? And is the way that you conduct these measurements through like a DECSA scan? I do a body composition with an impedance machine. Okay.

How accurate are those? Because I've heard mixed results. I mean, they're very accurate. The goal standard for that is an MRI, right? But we're not going to do MRI on every patient. The second will be a dexas scan. Also, again, more radiation and a bigger machine, expensive. And then the third option is an impedance machine.

Got it. And so in general, when a patient would come to see you in your practice, you're doing these calculations to see who would benefit from the medicine. Are they coming in with wanting to be healthy? Are they coming in as overweight? Like, what's the patient, like, process like for you? It's amazing, I have to say. I've learned so much.

So I see, this is what I see normally in my office. They come, patients come with the concept of losing weight and more of an external improvement, right? They want to have a better appearance. Maybe they want to feel better. But it's really interesting that through the journey of the weight loss process, there's a shift by doing the right way, which is concentrating on muscle and muscle. body fat there's a shift in the patients halfway the journey where they start becoming stronger right they're starting become more motivated the fear lighter they start going to the gym and then it becomes

part of their DNA of their of their of their lifestyle they become stronger they feel stronger they're starting to look fit and that's when we're concentrating on muscle right and patients adapt to that lifestyle very quickly and it's really interesting how it shifts the the reason that they came to see me or that they continue to see me is now is to continue in a fit level, right? And then in your practice, I'm assuming you work with nutritionist or a dietitian or maybe like some kind of physical therapist to get people exercising or how does it work like through a collaborative care. It's a one woman show.

Okay. Well, I'm very controlling of my patients. Like I mean, I'm triple board certified in internal medicine andocrinology. obesity. So I feel like I have a really good understanding of nutrition and what I want patients to follow. And again, I've seen at the beginning when I started treating patients and doing this body composition, I was seeing patients, yeah, they were coming losing weight, but losing muscle. So I've incorporated in my practice the diet of higher protein intake, right? So many times I've noticed that it can be some conflicting recommendations between nutritionists and dietitians

than what I'm looking for my patient in regards to their body weight into preserving muscle. I do have some trainers that I do recommend because there is some muscle loss most of the times and now when we're starting to build muscle, many patients have never lifted a weight, right? So I don't want them to go and hurt themselves. So if we start with the basics, so they get proper learning on how to do the proper form when lifting weights. Yeah, because the most important things when we talk about a patient having significant weight loss with one of these medicines is to make sure that the weight loss is healthy, that they maintain protein intake resistance train, which will allow to create a better proportion of muscle

to body fat. Now, you've been pretty vocal about us kind of being fat biased in the medical world, outside even the medical world, and I absolutely see where that's coming from. Do you see that conversation shifting these days as we're talking about Ozempic? Very slowly. And I think it's going to take one or two generations before we are more comfortable with the concept of obesity as a chronic disease. I feel like it's very new for the majority of people. Even for the United States, the WHO classified obesity in 1942 as a chronic disease. 1942 in the American Medical Association, 2013, they incorporated it as a chronic disease. So I think for the general population, is going to take even longer, even as health care providers, right?

I feel like health care providers there are later, in their 50s and their 60s and 70, they're still more adapted to the idea of eating less and exercising more and the patient should be able to manage it. And again, I think it's going to take one or two generations before that becomes as a common standard. What changes when obesity is now listed as a chronic disease versus when it wasn't? I think the biggest thing should be acceptance of treatment. Right? Because if we continue to see it as a lifestyle problem, that we're going to continue to beat the idea of it's going to be lifestyle, what's going to improve obesity and what's going to cause weight loss, right? So we're living it pretty much of the patient's responsibility on 100%. But when we see it as a chronic disease, one, we take the guilt of the patient from his shoulders or her shoulders, right? When we explain, I've seen this in my patients, when I explain to them, there's a,

a huge genetic factor in a patient in particular with obesity, hormonal changes, aging, environmental factors. You can see the sense of relief of the patients that they always thought that it was up to them, right, that they were causing it. So I think by accepting as a disease, one, we're relieving the patient of the guilt and the sole responsibility. Second, we're allowing to see it as a disease and use medication and treatment for it, right? Because no other disease, if you diagnose somebody with hypertension, type 2 diabetes, you talk about lifestyle, but you still use medication, right? It's this obesity right now is still being not understood completely

with medication to be used medication, but I think accepting as a disease that's going to open up, accepting medication and then also accepting that the medication is for long term, right? It's a chronic condition. We're not curing the obesity. We're controlling the obesity. like we don't cure diabetes, we control the glucose, we don't cure hypertension, we control the blood pressure, same concept with obesity.

So does that mean for this medication that would be like these incredents would be lifelong medications? Chronic use. And I think we should remove the negative concept about this and see it as a positive because for the first time we can offer something that can also help with the weightless maintenance, right? any diet, any crazy diet that is out there, can take the patient to the goal, maybe, but the maintaining is the hard part, right?

The five-year, 10-year success rates. Exactly. So with the medications, the patient can lose the weight and be relieved that we can continue with the medication maybe at a lower dose for long-term maintenance. During the Volvo Fall Experience event, discover exceptional offers and thoughtful design that leaves plenty of room for autumn adventures. and see for yourself how Volvo's legendary safety brings peace of mind to every crisp morning commute. This September, leased a 2026 X-E-90 plug-in hybrid from $599 biweekly at 3.99% during the Volvo Fall Experience event.

Conditions supply, visit your local Volvo retailer or go to explorevolvo.com. it wouldn't it be fair to say that currently or I guess before this medication and the old school way of thinking was putting it all on the patient shoulders and saying it's calories in calories out exercise and diet that's the way you lose weight that's the only way and that was the hard way where hard way like hard thinking way and then as time went on we started introducing bariatric surgery and we said look there's an alternative treatment and we have something available now we're moving into the medication and phase, isn't there still a benefit to getting patients to believe that it is within their control? And the reason, I just want to point out why I'm saying this, in AA, we've seen tremendous, in Alcoholics Anonymous, we've seen tremendous success from that program with people who suffer with substance abuse. One of the downfalls of that program, or maybe one of the issues that some doctors have with that program, is that they classify alcoholism as a disease, which you're right does take away some of the pressure off of the patients who are struggling

with the condition. At the same time, it also creates a situation where they feel like they have no control over it. So just like with any dietetic, it's true and it's not and it's good and it's bad. So how do we make sure that we're striking the right balance with this situation? So that is a huge, huge key point that I want to make clear is that the medication does not replace. a healthy lifestyle, right? The medication, I like to tell to my patients, the medication is going to be 50% of your journey

and the other 50% is still what you choose to eat and the exercise that you're going to put in, right? So I think we have this false idea that it's an easy way out, that is a cheating part because we are thinking in that way that it's replacing completely a healthy lifestyle. No, this doesn't come to replace a healthy lifestyle. And if you incorporate a healthy lifestyle, you will be able to maintain the weight long term,

maybe without the need of medication, or maybe with the lowest dose of medication, right? So I think the problem with many practitioners or online clinics that are giving this medication, they're not having that discussion about muscle mass, about body composition, about decreasing your percentage body fat. The more muscle you have, the better you'll be able to maintain long term the weight loss, right? the less muscle they have, the more they're going to depend on the medication. And we cannot go down on the doses. So it really lifestyle is going to be key to determine your maintenance and your maintenance regimen.

How is it going to look like? Do you have patients that come to you seeking weight loss that you only prescribe lifestyle recommendations for and no medicine? As an obesity specialist, I get, I'm pretty much the last stop for a lot of patients, right? that they've tried many diets that I learn about a new diet every time that I see patients. They've seen a specialist. They've tried pretty much everything. So really for many of my patients, they've done the work for decades.

Some for decades, right? Some patients tell me my first diet was at seven years old, at eight years old. And they're in their 40s. They're under 50. So when they come to me, they're looking, exactly. They're looking already for us. Then I'll phrase the question a different way. What advice do you have for me as a primary care doctor?

who's not as far down the line, who may be seeing a patient who's now interested in taking care of their health and perhaps losing some body fat and getting to a healthier weight for them. Do I start with lifestyle factors or do I right away institute the medication? It depends if it's a patient that really has not started anything,

hasn't tried anything, which I doubt, because again, they start from childhood teenage years, then definitely, it's always going to be part of the conversation, right? And if your physician is not having a discussion about you, about lifestyle, exercise, nutrition, while giving you this medications, then you have to go somewhere else, right? I think it's a complete visit. And I understand that many primary care offices, doctors don't have body composition machines. But I think if you make sure to have the conversation about muscle mass, increase their protein intake to the patient, then if the patient

is following these recommendations that you can rest assured that what they're losing is body fat and not muscle. Yeah, that's the safe way for me to get this medication on board for a patient. Maybe even more pointedly with this question, do you think that every patient should be on, that is classified as obese by the American medical standards, should be offered a medication? I cannot say 100% of the patients. Large majority. But the majority would benefit from the drug, yes.

Also, we have to remember that obesity is an inflammatory condition. It puts the body in inflammation. We saw that with COVID, right? That we used to tell patients in 10 years and 20 years, you're going to have complications from your weight. So you have to start working. But came COVID out of nowhere. And the patients with obesity were the ones that are having higher mortality,

higher ICU stays. And it was because of the chronic inflammatory state that obesity puts the patient in, right? So I do believe that beyond just the weight loss, we are doing other things for the patient's health. We're seeing now it has cardiovascular benefits, right? And I think that is just the beginning because those studies hasn't been done. But now the more patients are on these drugs,

we're seeing improvements in dementia, I mean, in psychiatry, right? So I think there will be more things coming up in the pipeline that is beneficial of those drugs. So I do feel like it is important for patients, for the majority of patients to be on these drugs. Also, I can see the motivation. When a patient feels motivated, when they start seeing some weight loss, it's like it just keeps going the machine, right? It's very hard to ask a patient to feel motivated if they're not seeing results or it's going to be very slow and very difficult that it becomes their second job, right?

That's another way that you can know when does this medication require the weight loss medication? When would the benefit? Maybe I'll give them a try lifestyle. but at what degree is that lifestyle change is affecting their patient, right? For many patients, it becomes a full-time job and everything revolves around that. That's not sustainable. And I think we can relieve the patients from that with the medication. That's scary because then we're saying like a huge percentage of the United States

should be on these medications. And it's interesting to me that we're then saying that appetite needs to be controlled over the majority of the United States. Have we con that far? I believe so. I mean, it's predicted that by 2030, half of the U.S. population will have obesity. Half worldwide also will have obesity

in the next decade by the WHO. So I think we've lost the perspective around food, around portions, right? When you're on this medication, you really see things differently. It's like a blindfold was removed from. from your eyes. You can see that we mostly were overeating, right? Food that was probably unnecessary in the amounts. So I do feel like, same as the concept of obesity,

I think is going to take one or two generations for us to return to a healthier state in regards eating habits. I mean, the food industry has a lot to do with it, right? I feel like the food, it's available here in the United States, it's very high in endocrine disrupting chemicals, it's processed food, right? So that's contributing also to obesity. I feel like it is going away from our hands to self-control, right?

Because environmental issues, stress, our work scenarios, now COVID, people working from home. So that's an environmental factor that is contributing to obesity. Yeah, I'm trying to think about this from the viewer's perspective. And I'm seeing a zoomed-out version of the world where, you know, food companies have created on a population, level, a type of food or this increase in processed foods and all these issues that have led us to become overweight. Now, pharma companies are giving us a medication to fight back against this. And it feels like it's just other people guiding us what we do. Doesn't it feel like then we lose a little sense of control of what's going on around us? Definitely. And that's one thing that

you always want to give the patient the feeling of self-control, right? That they still, what they do it still contributes to their lifestyle and to their health. But I do feel the degree in the numbers of obesity rising, and especially in children, childhood obesity, is very high. I do feel that because of those drastic numbers, we do need drastic measurements. Now, incritons go beyond pediatric surgery, right? If we can compare one with the other,

or a biiatric surgery is an invasive procedure, right? The thing with biiatric surgery that doesn't happen with weight loss medications is that the behavior doesn't change. You restrict the patient mechanically for a certain amount of food, right? But the drive, the reward of food is still there. And that's why many patients regain the weight. With the incritance, because we have receptors in the amygdala and the hedonistic eating and drinking area, you can really change the behavior.

towards food. You eat for fuel. You eat when hungry and when you're hungry, you enjoy the food, but otherwise you're not looking for food as an emotional anxiety, boredom, social relief. Would you go as far as saying that these medications are less a diabetes or weight loss medication and more so a psychoactive medication? I think. And behavior medication? It works in behavior. We're seeing in alcohol intake, right? I mean, it's being studied for alcohol. I've used again because many patients are looking for that reward in alcohol, in tobacco, and it just changes the behavior and your view towards those things. Interesting.

What's your take on, it's been popularized in media, celebrities who are looking to lose a few pounds for a role, a photo shoot, a wedding. I've had patients ask me, being honest about that, where they're like, hey, can I just get this to lose 10 pounds because I have this wedding coming up? what's your take on that situation? I think we have to educate people, right? I think we have to educate that there's still medications, that any medication has side effects,

and we always have to put in a balance the benefits towards the side effects. So really if a patient is just looking for a quick fix, this should not be it because then they can look for any type of diet for a quick fix, right? I think patients need to be educated in regards to their weight and what is it that we're really aiming for, right? I've had patients that told me, I didn't come to you to gain muscle. I came to you to lose weight, right?

So it's educating those patients and guiding them to make the right choices, even on medications that we can use or not on them. How do you counsel your patients? I can imagine I'm one of your patients that you're thinking about starting one of these medications on me. What risks do you share? So, I mean, I do a full, of course,

a full history, I go very deep into their family history, into their environmental history. What are you looking for? Family history of obesity and their parents and their siblings, overweight, even going beyond the grandparents, siblings, children, if they have children. And I would say three out of four patients have a strong genetic background in obesity. I look for age of the patient, like if they're middle age, especially if they're a woman, they could be perimenopausal, menopausal. If they're younger, they can have PCOS.

Those contribute to obesity to or contribute to waking, aging, the age of the patient, because as we age, our metabolism, unfortunately, slows down. And then environmental factors, how's their sleep, how's their mental health, right? Where do they work? Do they travel for work? Do they work from home? How is their stress level? All of those things, I go over with patients very thoroughly.

And then I do a body composition. I do a physical exam, a body composition. And then once I review with the patient, the body composition, it opens up more the use for health benefits than for what maybe they initially came for, for an external weight loss or for it to look a certain way, right? It becomes part of health, your quality of life, your risk of disease. And it really changes many times patients' perspective towards the drugs.

They see it as, okay, this drug is going to improve. my quality of life, is going to reduce my risk of disease beyond making me look slimmer. Sure. Sorry, maybe I misstated the question. Like, what risks do you warrant? Like, if I give a patient an N-SED, I talk about kidney issues or Tylenol, I talk about liver issues. Sorry, side effects, yes. So the most common side effects are nausea.

I would say that, of course, on most patients, but it's tolerable. It should not be a nausea that's going to keep you home for not working or not doing your daily activities, right? Dehydration. I counsel patients on dehydration because I feel like dehydration is even harder on patients than the nausea because then they'll complain of extreme fatigue, dizziness, lightheadedness, and also I counseling them about muscle loss, right? I do mention that in rats and lab, there was an increased incident of melular arthritis carcinoma. That's another thing that I go over their family history, that there's no first degree family history of malacarcinoma. But as far as pancreatic cancer, pancreatitis, I mean, out of the 10 years,

12 years that I've been using these drugs, I've never had a patient with pancreatitis. I think because I have very close supervision with the patients, I see them every eight weeks. There's never a time that I don't see them for six months and they develop pancreatitis or they develop something else, right? And what about, I heard, thyroid cancer is now something that's being discussed? Is that something? Well, that's myelarocarcinoma. a very rare type of cancer to begin with. It runs in families, and it's very aggressive. But in humans, we have not seen increased incident

in medullaryothy carcinoma, only in mice in the lab. Got it. Is there a world where you see, or maybe you even have patients like this, that are professional athletes? Like very commonly, I participate in boxing, and there's a large mandate to lose weight to get into a lower weight class.

Because if you're naturally at a higher weight, when you fight at a lower weight class, you can then have more success. Do you see people using it that way? I think we cannot see those medications to create superhumans either, right? For me, my point of view in those cases is at what degree is becoming part of your life or involvement of your life around you losing weight, right? When it becomes an extreme measurement, when it becomes that you have to eat very small amount of calories, when it becomes that you have to work out three, four hours, two hours a day, three hours a day, right? When it's not, it's taking more into your life than what is giving you back, then that's the moment that you say, well, maybe then they can benefit from this medication

because it's not a natural weight loss that they're having. They're recurring to extreme measurements that are not sustainable. And that becomes a moment that you can say, okay, maybe they'll benefit from this drug. got it what about your number one misconception that you see surrounding them one that there are new drugs I think that's the most common misconception and they're not that we do have plenty of data up to 30 years of data in safety and effectiveness on these medications another misconception is that they're used there's a quick fix right they're not and also that patients that are using them they're taking the easy way out I mean it's not really the easy way out they have

have to see me or see their doctor every eight weeks, they have to inject themselves once a week, they have to increase their protein intake. They have to, I mean, it's work. It's not, it's not easy, it's not an easy way out to be on these medications. If, if this is not the easy way out, I'm going to play devil's advocate for a moment. Why are so many people requesting it in this moment? Because nobody, there's not a bunch of people lining up in my door and asking me, let's all work out together, right? But yet everyone's asking for a Zepic. So I'm curious about why you think that's happening. I think because many of those patients are demotivated, that they've tried everything possible and they didn't see success. I think it's very hard for them to present to them

the same response that every other physician or every other diet has given them, right? And expect new things. I think we really have a very poor fighting chance to overcome everything that is promoting obesity or promoting us to a lifestyle that we cannot work out in the gym twice two hours a day, every day, that we can expend eating healthy, clean food. I feel like we have many things against us that even if we want to somehow we cannot get there, everybody cannot get there. Because of outside pressures.

Because outside pressures, exactly. In economic, right? I mean, you cannot ask somebody who's working 10 hours a day, you still have to go to the gym for two hours, so you can lose weight. Well, I don't want to scare people and think that they have to work out two hours every day to lose weight.

That's not also. That is not, yes, I take that back. Or decrease in their color I can take, right? Well, the one thing I want to make sure people don't lose in the conversation with these medications, because I know people get very excited. And I've seen my friends get very excited about it, is that I'm curious if you agree,

that if we could, and this is taking into account, the difficulties that people have with their jobs, the fact that they're single parents, they live in food deserts, difficulty of accessing gyms, financial issues, all of these issues. If we could solve those and put people on 150 minutes of moderate intensity exercise in a week,

put them on the appropriate caloric, intake for their healthy body weight that we could put an average on. They would all get there. But the question is, could we do all that? I mean, could we, we may? Is it going to be the solution for every single person? No, no, no, absolutely not. No. The reason I point that out is because when we say that obesity is a genetic condition, then it wouldn't be true that if I cut my calories and work out that I would lose weight. That's why I say that for some people, it will be a solution if there's no genetic history,

if there's no genetic predisposition, but for some that do have that generic predisposition, then even by doing that, their body will always try to push them to gain the weight, right? And speaking a little bit about that, like discontinuing of the medication, do you ever have conversations with your patients about if they are interested in stopping?

What guidance do you give them there? tell my patients, muscle mass will help you either stop the medication or require the minimal amount of a dose, right? The more muscle that patients loses, the less probability that they're going to able to maintain the weight loss. So many patients, I do present this as an option, right? If at one point you want to venture off the medication, muscle mass and the lifestyle that you adapted around it is what's going to help you maintain it, right? I do want to make clear that this medications do not, is never going to replace a healthy lifestyle. And that's why I always make a point to say the other 50% is still what the patient does in regards to physical activity and they're

eating habits, right? Even with the medication, the few times that I've seen patients not lose weight is the patients that are still having a very high-caloric dense small meals. Sure. Right. So smoothies, liquids. Even I always tell my patients, if you, I'm never, even if I throw the sink at you, I'm never going to catch up with the coloric intake that you're having. So their choices and what they're eating is still going to matter. So they're losing weight, ideally maintaining muscle mass. We can talk about the discontinuation. I'll give you an example of something I do in my practice. When I start a patient on an SSRI, an antidepressant, we have a conversation that this medicine is not going to be targeted to be lifelong. I talk about creating a time that we will catch

up. We will discuss how it's going. Early on, we do it more often. Then once we get stable, we can do every three months, then we can do six months. And then we create a timeline. Maybe at six months, we discuss if we've gotten to a place where we can discontinue it. Do you have a strategy with every single patient? So my strategy is to get them to the goal. Sometimes I may use one or two drugs to get them to the goal. Once we're at the goal, and then I get a very good gauge how long it took to take to the goal, what has the patient incorporated in their lifestyle. But once we get to the goal, I wean off to the lowest dose possible gradually. And if I can push back to the lowest dose, there's a high likelihood that at one point the patient can be off the medication. But if I

cannot go beyond the higher doses, then more unlikely that the patient will benefit from, will be able to stay off the medication. But for every patient, my goal is always to bring them down back to the lowest dose possible and off if possible. I think the idea, and because this is a very new science, right? The studies that were done on these drugs were one, two years, three years, but I feel the more data we have and what I'm seeing in my practice is if the patient really takes into account building muscle, incorporating resistance, string training into their lifestyle, I feel that then when the patient really incorporates that lifestyle, we'll be able to pull back from the medication.

So you're viewing it as a kickstart to the healthy medication. I think that's what it's going to start happening, as we're seeing more patients on there and more results. What percentage of your patients have come off the medications? Well, I mean, I would say I'm on the, I opened my practice four years ago. So many of them reach their goal now, and I'm starting to win off and incorporating. And again, this is something that I'm learning every day, right?

So by looking at the body compositions, I realize the error of not take into account muscle. So now in my patients that I'm always incorporating muscle and making a point, and I make it actually every visit more about muscle than body fat, or more about muscle than weight loss itself, right? And now I'm seeing that patients can really decrease the need of the medication or the amount of the medication. Again, the science or the strategy is still being perfected. And it's honest that you say that because what we're talking about,

while it is a science, it's human behavior. So it's very imperfect and different and subjective. So when you could have one patient that you feel like may be ready to come off and you could start decreasing, they could have a major change of life events that suddenly make them not a candidate to come off, right? Exactly. You reevaluate. You re-evaluate, right? I mean, and then what I do with some patients is I start spacing on more our visits in a lower dose, and if at six months at the lowest dose, they've been able to maintain their weight and continue to incorporate their lifestyle, then we can venture off to take it off, right? Once I see that the patient really embrace that lifestyle, that's the time that you can start probably winning them off of the medication.

Do you feel like when the medication gets introduced to your patients that the lifestyle actually does start kicking in? Once they start losing weight. Once they start losing weight. I mean, for many patients with obesity, they lose 30 pounds and they're starting to feel able to go to the gym, right? I had a patient today that told me, for the last three years, I couldn't tie my shoes. So for the first time, I was able to bend and tie my shoes. So for some patients, they need that initial weight loss to start feeling. motivated, right? Because I've come into certain situations, I wouldn't say this is the majority,

but it's a significant minority where, let's say cholesterol is an example, I'll start them on a statin, and their cholesterol goes down. And instead of using that in the same way that your patients are using it, where they're using it as a motivating factor to improve their lifestyle habits, they say, oh, I can still keep eating unhealthy, but the statin is preventing me from having high cholesterol so kind of almost instigates their bad behavior or makes them feel like they don't need to stop. Do you ever run into that situation? I don't see that. Again, I feel the patients feel so much better physically, mentally. The cholesterol is something that they don't see that they don't feel, right? But the weight loss, it's something that every minute of their day, they're noticing

a change. They're noticing an improvement. So they don't take that for granted, right? They don't take that for granted. And really, if they still eat crappy food or large amounts of calories, we're not going to see the weight loss. So it's not that the results are going to happen regardless of the lifestyle of the patient. Why do you think the shortage is happening to the degree that it is? Because it was, I think two things happened. One, COVID happened, right? That people with obesity really got the message that they need to improve their weight. They need to improve their health because out of nowhere a virus comes and you're dying from it, right? So one, I think that people really get the message about obesity. Second is that we had the resources available to treat obesity. So I feel like it was

a perfect storm also because the drugs work and because there is such a high number of people with obesity overweight and including children, right? So I feel like it was meant to happen. I'm surprised that pharmaceuticals. Yeah, and the pharmaceuticals didn't see this as happening when there's so many people with obesity and the drugs work, right? It was going to happen. You don't think that there's a contributing factor of people who are using it for just aesthetic purposes? Off-label or like meaning, you know, some shady clinics writing it for them.

Oh, definitely. Those, I mean, again, those I can. Because I view that as a big part of the shortage. Definitely. I feel like people are prescribing it like if they're at all, like it's aspirin, right? And not giving it the right. follow-up for the right person. But that's why I personally always try to educate in my social media that this

continue to be medications that you should go to a specialist. If you go to a obesity specialist or an endocrinologist or somebody who has expertise on this, it's not going to give you the drug to lose five pounds. Yeah, exactly. Number one, right? We'll have a conversation and say, okay, this may not be the option for you. Let's try other things. I worry, though, because I completely agree with what you're saying about seeing a responsible

physician who's going to pair it with exercise, the muscle mass conversation, the protein with your nutrition, all of these factors. But I don't want people to think that it has to be an obesity specialist because in parts of the United States and even where I work in a community health center, if I give a patient referral to an obesity specialist, it's months. And there's family medicine doctors who are doing that in primary care internists that are doing this responsibly. Do you think it's fair that they can still be prescribing the medicines as well? One hundred percent. I feel like as long as the prescriber feels the comfort feels comfortable prescribing, managing, and following this patient. And is responsible with it. Exactly. Which a lot of them unfortunately are.

I mean, that's the other subject, rather the other side of the coin is yet definitely there's only 6,800 obesity for certified physicians in the country versus 72 million people with obesity. So definitely we're not enough and we cannot see every patient. Endocrinologist also, there's a shortest of endocrinologist. So definitely we're going to be relying on primary care. And I think that should be it. Otherwise, again, I'm missing so many people that I can treat, right, just because there's one of me. Of course. So the more we can educate other specialties, I think, the better. And if you think about it, every specialty that we have is going to encounter a patient with obesity. Of course. So it's a misopportunity there to have that discussion and potentially treat the patient.

Even for cardiologists, with especially the data coming out on cardiovascular benefits. So gastroenterologist, I think every specialty is always encounters patients with obesity. So those are misopportunities that we can potentially help the patient there, right? So I feel like there's a lot of courses online for obesity. So I always try to encourage primary care to get some courses and, if possible, obesity were certified, right? I think obesity medicine was the most applicants in specialty this year, which I think it's great. So, yeah, I think the more the merrier, right? I think a lot of that is business driven.

And right now these medications have become big business in not just clinics, but also people and pharmacies creating non-branded semi-glutide. Have you heard about this? Yeah, definitely. Where they compound them basically to some degree? And, I mean, I always question, what is it that they're doing? What are they making? Because semaglutide has a patent.

Well, they're doing semaglutide sodium, which is not what's... Exactly, which is not semaglutide. And the FDA is against that. I don't recommend compounded medications, one, because we don't know really what you're getting, right? They're not... There's been a lot of pharmaceuticals. There was just recently a Washington Post article about... this, that they're unhealth, they're not sterilized, right?

That they've closed many of these companies because they're not following protocols. They don't have a protocol, right? Nobody's checking on them, unfortunately. So, and I understand the desperation. I understand the need for this drug, but going to compound their medication is not the right way, the right way to go. Yeah. And even to make matters worse, now they're calling it like off-label Ozempic where people are

recommending formulas of diuretics, laxatives, and all sorts of things. Has that come across your media plate? No, I'm a media plate, but I can see this. I mean, again, this is becoming, everybody wants a piece of this, right? But that does necessarily mean that it's going to be the best for the patient in regards to their health, and we can potentially harm patients, and that's always what we want to avoid as physicians, right? Is there something on the market that's targeted for weight loss?

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Does it work? Well, I cannot think about something. Like I saw there's a doctor who takes care of Dana White, the president of the UFC. And he recently, in a TikTok, said that going into a cold plunge burns fat off your body faster than anything he's ever seen. I mean, when your patients come in with that, how do you respond? It's same as supplements, right? I always tell my patients. Supplements, natural things. Would they work? Maybe. As long as they don't harm you, I'm okay for patients to try. Is it going to give you the effect that we need? Is it going to make you lose 60, 100 pounds? Probably not. Right? But if they want to try, then it's fine as long as it doesn't create harm. I worry about that because how can I predict whether or not harm is created when I don't even know what's in it? And it's not enough to, read the label because when consumer labs and consumer reports actually tested the things on the

shelves, not like got it from somewhere and then tested it. They literally went on the shelves, pulled it off the shelves, and tested it. And it wasn't what was written on the label. So I worry for my patients. Like as a very good example, in gas stations, they would sell like those erection medications for people suffering with erectile dysfunction. And they found sydenafil in it. So like that's a controlled, not a controlled substance, but it's a prescription. substance that is now being put into an over-counter supplement. We've seen the same thing with ephedra back in the day with hydroxycutts. So, like, it's not, I don't even know what's safe.

And many of those had thyroid hormone. Yes. Right? So many of those had thyroid hormone, and that was a common practice to give thyroid hormone for weight loss. Yeah, definitely, I think if it's not FDA regulated, then we really don't know what you're getting. If it's going to be harmful, what amount you're really getting, there's no regulatory

in those, right? I think we just have to educate the patient and hopefully they will steer away from them, right? What do you say to a patient who says natural is always better? Not necessarily. Not necessarily. I mean, I believe in evidence-based medicine. Again, natural is not going to make you lose 60, 100, 120 pounds, right? You mean from a supplement?

from a supplement, from Barbary, right? That's one natural supplement. They're saying the nature of Sempec. I mean, does it improve insulin resistant? Does it improve? Yes, maybe. It's not going to bring your A1C from 10 to 6.5. It's not going to help you lose 30 pounds, right?

Yeah, so it's not taking the whole picture into control. There's also a lot of pushback from people. When I even did my video on Ozempic discussing pros and cons, answering some questions of people saying that it's still healthier to lose weight through traditional diet and exercise alone without the medication. Do you agree with that or do you fully push back against that notion? I think we have to have an open mind, right? I think we have to see more far away. And when me talking to patients with obesity every day, multiple times a day, I'm learning so much.

I'm learning that we are so misinformed in regards to patients with obesity. They're trying. They're following. Many of them are eating healthy. Many of them are on exercise routines. Many of them read books about nutrition. I mean, they are trying. I have yet to meet a single patient with obesity that is the couch potato that we have the picture of, right?

So it's hard for me to believe that people that are really trying and they're not losing weight. People that have obesity are trying to. You're saying that most people assume they're not trying. Exactly. Most people assume that they're not trying and that they're not doing anything about it, but it's actually quite the opposite. I mean, they are trying. Their lives revolve around there for many patients. Yeah, I definitely see both groups. I see the groups of people trying and there's a lot of them. And maybe they're trying unsuccessfully because the things that they've tried, they've been misguided on, like they've been promised mirror.

supplements or they think that if they just follow this incredibly restrictive diet, they're going to lose weight. They drastically do caloric restriction that's unheard of and unhealthy. And then they fail and they're not even sure why they're failing. So I see that. As much as probably I see the person who is sedentary and who is not moving around a lot. And actually, those patients don't come in for weight related conditions or maybe they're partially due to weight-related conditions, they come in for pain. I frequently get patients that come in with osteoarthritis, that come in with low back pain, and part of it is not just the weight, that they're carrying more weight on their

joints, but also the fact that they're sedentary. So they're not trying to do something, and it takes some motivation, some serious motivation to get that started, and it's not easy to do that. It's not easy. And as physicians, we know that, I mean, our current health care system doesn't, allow us to spend the enough time to have to dive to dive deep into this conversation and if you think about it especially a patient that is not even mentioning to you their weight and you're going to approach them about their weight they need to feel comfortable they need to trust you they need

to be they're going to their most vulnerable part of their life of their body right and to do that in five minutes and 15 minutes we can't so that's why we cannot have that connection with the patient many times right do you think that that, well, I guess let's end it this way. For a patient that would love to have you as their doctor, but they don't live in New York. Finances are an issue. Their doctor gives them 15 minutes.

You know, that's the sad reality. That's what they get. What can they do to safely consider these medications or safely consider weight loss? What advice do you have for them? I think that's what I do in my social media and my platform is educate, educate the patient, to know what right questions to ask,

ask to know what to look for. I mean, I would always tell, ask if they have experience with this drugs, right? Have they treated patients? What are their side effects of their patients? Or if they had to stop the medication on the patient, what was the reason for, right? So you feel comfortable that who's giving you the medication has some knowledge and experience with it, right? If your doctor is not talking to you about muscle, about your diet, if they're not asking the lifestyle questions and they're just giving you the prescription, then unfortunately you should go somewhere else, right? or ask your provider and tell them about these things.

Many of providers need to be educated still, right? So I always say the patient that knows more does better, right? And if unfortunately many of us as health providers are not trained in obesity, we can educate the patients to and have that conversation and ask for those questions to whoever's giving them the prescription or potentially trying to give this prescription, right? I think after this conversation, you've done a great job educating people. So thank you for your time, Dr. Silasuelan.

And it's really, I think, a shame that folks who are overweight are going through this judgment and the current state of things. And I hope that we find some sort of healthy balance where we can celebrate those who are losing weight through lifestyle and exercise and find optimal ways to do that. But then also leave room for pharmaceutical and surgical approaches because there's no one size fits all in medicine, especially when it comes to the human mind. And every single patient is always different. So it's very individualized medicine, especially with obesity. Weight loss is complex that I've learned. It's not simple as just following the scale and seeing the numbers drop.