The Livy Method Podcast - Meet Dr. Sandy Van - Winter 2025

Episode Date: February 5, 2025

Medical Doctor and obesity expert Dr. Sandy Van joins Gina for an eye-opening conversation on obesity management and the evolving landscape of weight loss medications. She breaks down the diet industry before these treatments existed and covers the key qualifiers for seeking medical support, the latest in obesity treatments, and how weight loss medications have advanced over time. Plus, the pros and cons of medication use and the role of bariatric surgery in long-term weight management.Dr. Sandy Van is a licensed medical doctor in Family Medicine and founder of Haven Weight Management.Where to find Dr. Sandy [e-mail] Weight Management - VirtualMedCan Weight Managementmedcan.comYou can find the full video hosted at:www.facebook.com/groups/livymethodwinter2025To learn more about The Livy Method, visit www.ginalivy.com. Hosted on Acast. See acast.com/privacy for more information.

I'm Gina Livi and welcome to the Livi Method Podcast. This is where you'll have access to all of the live streams from my 91 Day Weight Loss program. With a combination of daily lives, guest expert interviews, and member stories, there is something new almost every day. Miss the Morning Live? Want to relisten to one of our amazing guest experts? Well, this is the place.

This podcast is hosted on Acast, but it's available on all podcast platforms, including the one you're listening to right now, Spotify, Apple, and Amazon music. This is an opportunity to become curious. To learn some things. How do we help you feel less overwhelmed so you can continue on your journey? Keep believing in yourself and keep trusting the process. Just be patient.

Okay, this is going to be a hot topic that we've never really covered in the groups before. And today joining me, we are so lucky, y'all, to have this guest with us today. She is a world renowned leading expert in obesity medicine. She's also an MD. She's a diplomat of the American Board of Obesity Medicine. She's the founder and medical director

of Haven Weight Management and co-founder of Three Sales, a program focused on mental resiliency and weight management. Hello, Dr. Sandy Vance. Hey, Gina and the gang. Thanks for having me on again. So many of you may remember Sandy when she came and joined us with Sandra, and we had that conversation at the end of the last program talking food addiction, how to handle the holidays, that really that mental part of weight loss and weight management. Okay. So I don't even know where to start this conversation

with you. How about just a bit of an introduction and why you have such a passion for this? Well, my name is Sandy Van. I'm a trained family doctor, but I've never practiced in family medicine beyond my residency training years. I've only ever practiced in obesity medicine and mental health. And the reason why I specifically chose this focus was because I just felt like we weren't as family docs doing the work of addressing the weight-related concerns

beyond the antiquated messaging of just eat less, move more. I think the message has changed a lot more, like a lot differently now that many years have gone by since I graduated presidency, but our offerings were really limited at that time and family docs have just so much to know and understand about medicine that I felt like I wanna become a master at actually addressing the one thing in people's lives that permeates all aspects of their lives.

And what I was finding was that people were getting treated with blood pressure problems, diabetes, fatty liver, and those are things that are very, they merit specific treatment and management by the doctor. But I also thought these were a lot of things related to obesity management that could possibly be prevented in many cases. And so I decided to get into obesity. And at that time, there wasn't the pharmacotherapy available that there is now. And so I really just did it as a purist, like using the

behavioral interventions that were available at that time and using cognitive behavioral therapy. And I actually, interestingly enough, didn't have, didn't think that anybody would refer to me in the community. So I started my practice as a primary care mental health physician using GP, like as a GP psychotherapist. And I knew at the back of my mind, these were patients that would likely have weight management concerns. And so we would always address the mood issues using CBT,

but then as soon as they graduated from the mental health program, I could say, hey, I'm offering the weight management program. Would you want to join me here? And many of those patients who struggled with weight because of their mental health or because of medications that they've been on were really gung-ho about doing it.

And so I started my practice in that way. It just happened kind of organically. I mean, to me, that's really ahead of the game, but obviously you've been doing it for a while. So let's talk about before pre-weight loss medications. Yeah. I mean, it's amazing that we have access to them. I'm actually not opposed to them at all.

I think they can be an absolute game changer for people. It's really exciting. But before we got into that conversation, let's talk about the fact that you were understanding there was more to weight loss than eating less and exercising more. What did you think of the diet industry? Did it not just make you mad?

Well, my first exposure to doctors who were actually managing weight loss were some of them were, I guess you could call associated with the diet industry, because the the advice that they were providing patients was themed on specific diets, whether they were keto or just counting calories or I forget what the other one was, it was like super high protein, very minimal carbs. And so that was my first exposure. And I remember talking to a supervisor and I was saying, I really want to help people with weight loss. I think that that's an important part of medicine. And she said, well, why didn't you just become a dietitian? And so that's just to give you an idea of the culture at that time. And it wasn't until I met somebody named Dr. Sean Wharton,

who's actually a pioneer of obesity medicine. Like you introduced me as a world renowned expert, like that, that to me, he is a world renowned expert in this field. And he told me, the first thing he said to me was, if you want to understand obesity, you need to understand the medication piece. And that was my first exposure to obesity and the science behind it, how hormones and biology and the brain are actually driving a lot of this,

these weight problems along with our environment. But it wasn't really simply about what people were consuming. There was a lot of things that were influencing the way people consumed and what those types of foods were actually doing to our brain and the conditioning processes that were occurring. So I think that I got really nice exposure to that really early on. So I ditched the one diet fits all sort of methodology. And now the general consensus among doctors is, among the community is, do what works for you long term. Do what actually you can sustain long term and can reasonably enjoy without feeling overly restricted because we know that that often

comes back and bites you in the butt. Which is why I actually like the Genealogy program. Because a lot of my patients who have come to me found out about me either through the program or through other ways. And they're like, yeah, I'm doing Genealogy. And these patients never tell me that they feel bad about not staying on track. They don't often tell me that the diet is so rigid

that it's hard to sustain unless they have other intrinsic problems that might be going on like perfectionism and all or nothing thinking, but a lot of the time they take this very gentle approach to it, which I can definitely agree with. Yeah, I mean, they're doing the foundational stuff, right? We do focus on what you're eating and when.

We try to focus on awareness, especially what's happening mentally with issues and associations tied into food with habits, beliefs, some people pass traumas. What do you believe is the secret sauce to sustainable weight loss? I don't think that there is one specific answer to that. So it's a bit of a boring and kind of nuanced response. But I think that everybody's different in why they have excess

weight. You've already mentioned a number of things that can influence somebody's calorie consumption. Early adverse childhood experiences, for instance, traumas, those are things that can really influence somebody's self-evaluation. So if you think negatively about yourself, you're more likely to also absorb a lot of the weight stigma in societal culture and sort of just have that intrinsically believed. And then that affects the way you feel when you eat and then you feel negatively about how you eat

if you're not doing it right. And so I think that it can be really complex from a psychological standpoint. Mood disorders can also influence it because somebody who might have depression or anxiety, it could be sometimes at times, depending on the severity, really paralyzing and make it harder for you to self regulate and a lot of weight management and

like, structuring meals and meal planning, all those things requires a lot of one motivation and two, willingness and three, attention to understand when these like, thoughts and feelings are coming up. Like you mentioned, self awareness is a really important piece, right? So, so I think that when you start honing those skills, that self awareness piece, but also understanding the biology of the fact that when you lose weight, when you lose a lot of weight, especially

your brain is has this biological imperative to want to regain. And how does it do that? It increases your hunger, it decreases fullness, it slows metabolism. And it doesn't mean that it's hopeless to sustain weight loss on dietary interventions. I've seen it happen many times before, but I think that it's important to acknowledge that there are just some pressures that people might face that make it harder to sustain long term. And so they got to find, going back to the message, you have to find what you can sustain long term and that you can reasonably enjoy so that you can recalibrate and that's your new default. Do you find that people are resistant to come and see someone like you?

And what are the qualifiers to do that? I think at the beginning, yeah, certainly. When I started practice in 2016, some patients referred to me and said, I don't even know why I'm here. Why would I see a doctor for obesity management? But now, now that it's turned, I'm so lucky. Sometimes I think I'm so lucky right now because I actually get to practice obesity medicine and people actually come to me and want treatment,

whether it's CBT or medications. Most of the time right now it's medication management. And so people are really open and eager. And I like the thing about the patients I see is that they're always so grateful to be heard. They're so grateful to have a doctor actually hear them out to reflectively listen to their story, meaning that listening to their story is not enough. It's like actually understanding their story.

And I think that people actually just, you know, the culture has changed in medicine where I find that people are really excited to see me or other obesity doctors and maybe they're afraid. You know what, I've had patients who have said, before I saw you the week before, I've, I've just been off track with my eating because I thought that you would be really strict with me. But it's the complete opposite. I think that it's more about self discovery and what works for that patient more than it is about me telling you what to do.

With the exception of, I will say the exception of, if I think a patient would truly benefit from medication and they haven't ever tried it because they've seen this weight cycling history, they just never had proper treatment. And I always say, you deserve real treatment. You don't deserve to just be told, go on this diet and to see that you will fail again, not because of you, but because of the biological pressures.

And I think that it's just worth trialing something that is really well-evidenced to support sustainable weight loss. Okay. So let's get into that. When you talk about the treatments for obesity medicine, I know people are asking what's CBT, cognitive behavioral therapy. I mean, we do have a psychologist that comes on and has these sort of generalized conversations and helps us, but sometimes people need more than that. And so when you talk about obesity medicine and treatments, what are we talking about here? Yeah, there's clinical guidelines

for doctors practicing obesity medicine or providing weight loss care. And historically, like I said, people would just say, eat less, move more, self-monitor your calories, maybe follow a diet. But now, and then people would inevitably come back and say, it's hard, I can't. Like I'm just, I'm having off-track eating episodes,

I'm emotionally eating, I'm stress eating. And there was nothing in that, like those dietary recommendations that would address that part, right? Like that would address, because everybody knows what to do. And everybody knows why they need to do it. But it was that bridge of the how like, so this is where treatment paradigm for weight management has changed. Now, instead of saying that somebody successful if they're doing diet and exercise, it's actually about diet and exercise are now the outcome of treatment, they're no longer the pillars of treatment. So psychological supports or mindfulness based techniques is one pillar. Medications is the second pillar. And then the third one is surgery. These are all things that are

well substantiated by empirical evidence to support that if you're going, if they're, if these things are working, it means that the adherence to the dietary intervention and exercise goal setting is probably going to be more likely. And when they adhere to those things, that's what we consider, oh, okay, like this person is responding pretty well to treatment. It's almost like if you had, if you got started on a blood pressure medication, when you go into the drug, sorry, into the doctor's office, they're checking on your blood pressure and your heart rate to see how responsive you are to the treatment. And so our target now is changing.

It's not even just about weight loss anymore. It's about how does this person's quality of life look like and how do they feel they're doing in terms of their self-efficacy around these things that they're planning to do and that are considered the ideal way of which they've managed their lifestyle. So that's how the paradigm has shifted. So I offer both the psychological and medical management support, and we refer to bariatric surgery for severe cases when needed. Let's break it down step by step.

So the mental side of things, that's that first piece. And so what are the various treatments? It's just CBT, like what are the various treatments for that and how important is that? Yeah, from a clinical standpoint, if there's any doctors listening, it's motivational interviewing and cognitive behavioral therapy

are the types of interviewing strategies or counseling techniques you use to try to get patients to discover what changes they can reasonably make for themselves. When it comes to cognitive behavioural therapy, CBT, which you were referring to earlier, that is based on the premise that your thoughts affect what you do, i.e. behaviour, thoughts affect behaviour, and your thoughts affect emotions, and

that they're all bidirectional. So if you engage in a certain behavior, if you stop and think about that behavior in that moment, you'll often find that there's a number of thoughts that emerge indicating why you're doing that behavior, right? In the context of eating, for instance, I remember one day I saw my daughter. She was with the nanny and she cut her finger. She cut her finger and I looked at it and there was blood. What did I go and do? I made a bee line to the kitchen and there was an apple turnover for some reason. I started eating it and I paused and I thought, oh, this is weird. What am I doing here? So you could think to yourself, oh, that was just an automated response or reaction, which is weird. Why, what am I doing here? And so you could think to yourself,

oh, that was just an automated response, or reaction, which it was. But if you stopped and you paused and you thought about that behavior because it was totally misaligned with what I would normally do on a regular workday, I had the thoughts of, this will make me feel so much better.

That was stressful. I need this feeling to go away, right? Like you notice there's these like little whispers of things. And that those are just your automatic thoughts that are guiding you in a way that it thinks is going to be helpful for you. But CBT is about recognizing these distortions and being able to change the way you think in that moment. Because the idea is that if you can change the way you think, that's a pretty powerful skill to hone. That's changing the way you think, changing your attitude or your perspective. All of those things are sort of interchangeable, can change your behavior and change your emotions. Right? So if you think to yourself, like somebody cut you off

on the road when you're driving, your immediate reaction could possibly be WTF? Why? He doesn't know that I'm on my way to school and I'm going to be late for the Gene Olivia interview. Like, what the hell? Like you could think that and then your emotion could be stressed, frustrated, anger. But if you paused in that moment and redirected your thought to something different that was actually more rational and realistic, oh, that person might be in a rush too. Or maybe they got a pregnant person in the car. You know, like you have to change your perspective in a way that generates an emotion

that isn't going to necessarily take up too much mental real estate. I always say that like the negative emotions take up a lot more space than you meant to give it. And then you have more bandwidth to actually focus on what matters in that moment, right? So I hope that that's a really complex sort of way or abstract way to describe it, but it's really about changing your thinking so that you change what you do and you develop this skill of self-control and self-regulation

in moments that are the hardest to gain. Yeah, no, I love that. Let me ask you this, because you've been studying obesity medicine far before the new weight loss medications. How have the new weight loss medications changed? Oh, wow. They've changed a lot. For one thing, there's a lot more people who are interested in suddenly practicing obesity medicine, which I could see why, because now there's actually access to treatment that you can offer in a clinical setting and it can shorten, it can make everything a little bit more brief. Like, let's just say this, when I started in obesity medicine and I was only offering psychotherapy, my sessions were 76 minutes long. They were 76 minute long sessions. And then over time, I got better at the counseling technique.

And then some people were on medication, some people were interested in it. So my sessions then became 46 minutes long, 46 minute durations. Now that everybody wants to be on treatment, these sessions have become 20 minutes long. And the reason why I'm not saying that it's because it's gotten easier, I'm saying that it's because a lot of the things that people were talking about in that 76 minute session, i.e. I can't manage my hunger, my cravings are out of control, what's wrong with me when I go to a buffet, I can't control myself, when I go on travel, like I feel all this pressure to eat and I can't control that. Like those were all those experiences that we had to dig deeper and deeper and deeper into. But a lot of that appetite signaling was generated internally from biological hormones. Like we have like a ton of appetite hormones, one hunger hormone, but like

a dozen fullness hormones. So everybody's hormones are different and everybody's cravings or experience with pleasurable foods is different. And so we'd have to get into all these nuances. But now people who are on medication, they don't necessarily now that that appetite is regulated, because that's what these medications do, proper medications will regulate appetite, people don't have the noise. They're like, oh, I'm actually, I have more time to do things that are important to me. I actually focus my time on work.

It's like, it builds this intrinsic motivation unknowingly to engage in lifestyle behaviors. I have patients who have for a long time just had this really strong affinity to ultra processed food. And when I start them on treatment, so many times patients have described to me, I actually don't even care about that food anymore. had this really strong affinity to ultra processed food. And when I start them on treatment, so many times patients have described to me, I actually don't even care about that food anymore.

When I have a craving, I crave whole food. And that's not an indication for the medication. That's not even something that's studied to my knowledge. But people, I think what it does is it clears the air. Like let's say that your mind's really polluted with all of our environmental food products. Like you're just occupied and distracted. It just clears the air. Like, let's say that your mind's really polluted with all of our environmental food products, like you're just occupied and distracted. It just clears the air. And then the default is if that person's always aspired to eat in a certain way, to move in a certain way, it just gives that person more space to move in that direction, if that makes any

sense. So I think that's what's going on. When patients say to me, I actually crave the salad, I crave the apple. And I think to myself, you've just, you've wanted that all along. It's just that your, your reward drive is so tainted by all these other substances. Um, I think, I think there's this takeaway where people feel like their body hates them. Their body hates them. Oh no. I kind of screw them over. Yeah, yeah, yeah.

No, that your body doesn't hate you. Your body doesn't hate you. Your brain's just doing what it was designed to do, right? We, our ancestors, if you, this is where I have to talk about the hunter gatherer and some people glaze their eyes over when they hear me talk about it. But it's actually true that your brains are no different now than they were when, when it evolved, your brains evolved. Our ancestors lived in an environment of food scarcity. So it makes sense that our brains are hardwired to seek out calories, to survive, to seek out sedentaryness and comfort in sedentaryness

to conserve energy in an effort to conserve energy for that next big hunt and to seek out pleasure. Pleasure whether it was from sex so that we could proliferate offspring and you know build out human like human community and all those things like these are all primal hunter gatherer drives there's nothing wrong with your body it's just that we are now plopped in an environment and there's this evolutionary mismatch where our brains still think that there's food scarcity But yet there isn't so it can't distinguish between the calories that you're getting from pizza versus the calories you're getting from Like an apple an apple has less calories than pizza

So why not have the pizza especially if it's gonna give you that that pleasure in that pain relief? Because that's what it does when you eat ultra processed food that has this really unique combination of salt, sugar and fat, it elicits this reaction in the brain and that reward center of the brain that releases opioids. Opioids are produced endogenously in your body, but they're also, if you think about opioids,

we've got opioids outside of our body too that have been produced like morphine, fentanyl, like all of these things. What do those things get prescribed for? Pain relief. But we make that ourselves when we actually consume ultra processed food or substances of abuse, right? So it makes sense that your brain would naturally like it

and learn to get more of it. And that's where the conditioning occurs, where that slice of pizza might not do the same thing for you next time. You might need a little bit more. It might need to be kicked up a little notch. You might need to add some sauce to it to get the same pleasure. You might need another slice of it. So you see how this, you know, the addiction, the addiction framework, you can't totally apply to eating, but there are aspects of it being the aspects of dopamine and opioids that you can draw inference from, from the addiction model. You just like food more, you learn it, and then you want more of it, and then over time it becomes really automated. So there's nothing wrong with your body. It's

just your brain doing what it thinks is good for you. And so these weight loss medications kind of calm that noise. I mean, it doesn't mean that you don't still need to do the work to get in tune to your body, but they help calm the noise. What are they doing physically as well? Cause I think there's a lot of misconceptions about like, what, and I know each medication

might be a little different. I do also want to address the whole Ozempic because we've had people been taking it to manage diabetes for years. There are a lot more medications on the market. And I think people are still caught up in the fact that Ozempic, there was a shortage for people who needed it to manage diabetes.

That's no longer the truth, yeah? Well, yes, but Ozempic, so Ozempic is indicated for type two diabetes, is not indicated for weight loss, though it's, doctors commonly, before Ozempic, commonly prescribe things off label, so there are a lot of patients who are using it for weight loss off label, right? So we can't really deny that. But I just have to mention that Wigoby is the brand. It's exactly the same active ingredient,

semaglutide. That's indicated for obesity. So people are using that more and more because it's actually indicated, but the active ingredient is exactly the same. And so the question of its mechanism of action, it's really interesting because, so when it comes to GLP-1s, there are more than just GLP-1s on the market for weight loss, by the way. There's also something called Contrave, naltrexone slash bupropion,

that's the active ingredient that is also indicated for weight loss. And then there's also other like forms of GLP-1s that are once daily injectables, but for the purpose of what's popular right now. Once weekly injectables are, what they do is the GLP, it's a mimic of a hormone that our gut actually produces.

It's called GLP-1, glucagon-like peptide-1. And this is a hormone that was first discovered to signal to the pancreas, regulate blood sugar. It slows down gastric emptying, but that's not its mechanism of action. The way it works on weight loss and by diminishing hunger and increasing fullness is that it signals to this hunger center in the brain and it tells you that part of the brain, you're full, you're good. But remember, it's just one of a dozen other fullness hormones that we have, we only have access to this one of like a dozen, right, that we're mimicking. So, so it's signaling fullness. So it's actually a centrally mediated process.

It's not that it's causing you to not want to eat So it's actually a centrally mediated process. It's not that it's causing you to not want to eat because it's causing heartburn or like side effects like nausea. A lot of people assume that that's how it works, but that's not actually how it works. So the other medications for weight loss, the naltrexone bupropion, that one is it does something similar, but through a completely different mechanism of action. It works through the neurotransmitters of dopamine and norepinephrine. So it signals satiety, but it also happens to have this precise action in the reward center as well and can blunt cravings. GLP-1 also anecdotally will blunt cravings, but I often find that patients who have binging

disorder or very uncontrolled eating, if I put them on a GLP one, they might still have this residual really like strong reward drive for tasty, tasty food that then responds really well to adding a medication like contrave as well. Right. So, so there's no, with medications similar to diet, there's no one size fits all. And I think one of the misconceptions is that once you get started on a GLP-1, you're good, you don't, you're done, you don't need to do anything else. That's completely untrue because a lot of people, some people don't

respond to it at all. And a lot of people do respond but not everybody responds in the same way. And so that active collaboration with, you know, the lifestyle modifications like watching what you eat, engaging in activity, all of that stuff really matters and can make a difference. Let's take a minute to hear from our podcast sponsor today because this new year, why not let Audible expand your life by listening? Kind of like what you're doing right now. So you can explore audiobooks, podcasts, even exclusive Audible originals that are no doubt going to inspire you, but more so motivate you. All you have to do is open up the app, tap into your wellbeing, and you can hear advice and get insight from

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where Audible can help. They can help you reach the goals that you set for yourself and you can start listening today when you sign up for a free 30-day trial at audible.ca. Thank you for coming on because I think what people are learning is sound bites they're getting off of social media. And I think one, there are other options other than ozempic and you're not taking medication away from anyone. There are a variety of different types that work differently. And this is why it's so important that we are informed

rather than not seeking out this kind of treatment because you're concerned about this or concerned about that. I mean, this is why you'd wanna go and see someone like Dr. Sandy Vann and have a really robust conversation about options and what's gonna work for you. And it's not just as simple as taking a pill or getting a shot.

It's not gonna solve all of your issues. There is a lot of work, that mental piece as well, changing your diet, trying to manage your stress, I would imagine, factor in getting a better sleep. What do you want people to know about these options? I want people to know, because you just mentioned something that actually spurred a thought that

I have a lot of patients who come in for these weight loss treatments and some of them don't even want them. Some of them just hear about them on social media and because they've historically tried losing weight so for so long, they think that they should entertain this option of medication.

And then I tell them, I'm like, and if they're metabolically healthy, they don't have pre-diabetes, no cholesterol, no family history of heart disease, X, Y, and Z, if there's nothing wrong with them other than the fact that they just have higher weight, I often tell them, like, what are you actually treating it for? Is it going to make you function better? Are there any mechanical limitations that it would allow you to improve? Do you care? Does it change the way you see yourself?

A lot of these patients actually don't mind the way that they're living and nothing is impeding them except for the fact that they think that because there's a treatment, they shouldn should be on it. And they're so relieved when I tell them, you don't have to go on it. You don't have to go on a treatment just because it's there. Just continue as is and continue to work on your lifestyle modifications and adhere to those things. I have a lot of patients who also similarly don't have like a ton of weight to lose when it comes to, let's say this BMI category, and they wanna lose just like, you know, five or 10 pounds in their body, but their body image dissatisfaction is so high,

so crazy high. And it's disproportionate to the weight that they're presenting with, right? So, I often will describe to them, yeah, sure, this medication is gonna help you lose weight, but will that change anything about the way you see yourself or about that negative dialogue you wake up with every day telling you you're bad, you're fat, you're ugly? That medication doesn't change that.

That is responsive to help from like a counselor or mindfulness based techniques because you can still develop self-acceptance despite whatever weight you're at and improve your quality of life in that way through changes in the way you think about yourself rather than trying to change something externally, that by the way, even if your weight comes down, there's no guarantee that your weight

is going to remain static forever because there are other physiological processes that occur as a byproduct of time. I have a lot of patients who say, I will love myself when I lose this 15 pounds or I'm going to be so much happier with myself when I lose this 30 pounds. And I'll start working out when I lose X amount of weight and I'll start meal prepping more when I do this. And I'm like amount of weight and I'll start meal prepping more when I do this. I'm like, why wait though? Why wouldn't you just start that now and uncouple it from weight loss because it's

good just for your health. So I think that we've gotten lost in the messaging about these weight loss treatments. The target has become so isolated to just wait alone. But think about like the context of your life. Does when you look back on your life, if you're at your eulogy, will somebody ever say Gina was, she was so thin. Yeah. Amazing because she was so thin. Like nobody's going to say those things. So think about what makes your life, what actually enriches your life? What in, in I never, I've never seen anybody say my lower weight enriches my life? What in I never I've never seen anybody say my lower weight

enriches my life dramatically. Sure, it helps. But it's usually my connection with other people, my going out, my, my exercise activity, my mindfulness, those are the things that enrich your quality of life. Love yourself no matter what your size. Love yourself right now. Your best day is today. If you woke up and you're alive today, today is your best day. So what is, there's been a lot of talk about obesity as a disease. Where's the line there? And does skinny necessarily make you healthier? Does carrying excess weight make you unhealthy? Like where's the line there?

Yeah. Well, okay. So that's, there's a question there and then sub questions. So the first question is, what makes obesity a chronic disease? High BMI alone does not make obesity a chronic disease. Anthropometric measures like high BMI or just waist circumference is insufficient now at just defining obesity as a disease. Obesity is a disease when that excess adipose tissue or fat is actually causing impairment to one's health. And impairment can be broadly classified into three categories.

It can be psychological, it could be mechanical, meaning like you got osteoarthritis or sleep apnea, or you actually have difficulty mobilizing. Um, it could also be medical pre-diabetes, diabetes, hypertension, cholesterol, fatty liver. And so when that excess weight is actually impairing your health, then that's what we would consider obesity. And then you could stage it from there.

But as I was saying earlier, just because you have a high BMI doesn't necessarily mean that you have obesity. Arnold Schwarzenegger, by definition, possibly has severe obesity, but it doesn't account for the fact that he's really muscular, right? So BMI accounts for only height and weight, but it does not account for body composition. Some people have higher subcutaneous tissue, subcutaneous tissue or subcutaneous fat. That is not a bad thing. That's just fat that is stored and it's insulating, but it doesn't necessarily have the same level of inflammation that central adipose tissue would have, um, which is more visceral, right.

And inflammatory. So once you start getting into, um, encroaching on health, that's when you can categorize it as a as a chronic disease. And then you were asking, I think about whether skinny can be considered is considered healthier, not necessarily because it often depends on that person's genetics, their ethnicity and a number of other factors. I, for instance, do not suffer with overweight or obesity, but I likely have underlying insulin resistance

because East Asians are at higher risk in pregnancy, I had gestational diabetes, I had to be on insulin as needed when I wanted to eat something that was a little bit richer. So there's a lot of patients of mine who have obesity going into pregnancy, they don't have those problems, they don't have that metabolic derangement.

And so I have to be super careful now because my risk of developing type two diabetes is super high because I've got a mom and an aunt and a grandmother who had it. So, yeah, skinny doesn't necessarily equate to healthier, but epidemiologically, like BMIs are used in epidemiological research for large bodies of population, right?

So epidemiologically, higher BMIs can be associated or are associated with higher health impairment and chronic disease. But if you're a super underweight, that could also be associated with health impairment as well. Great. Just running into the conversation on these weight loss medications, what do you think is the amazing thing about them and what do you think are the things that people, maybe the concerning things about them?

Oh, amazing things about them? I think they just, one of the most amazing things I see about them is that they can validate people's experience. Because by the time people get to me, like you have to be referred to me, so they've probably tried a number of other things. They already feel a sense of failure because they've failed dieting. But the opposite is true. It's that dieting actually failed them.

It was never an intervention for that person to work long-term anyways. Oftentimes if you dig a little bit deeper, they've got this strong family history. There were a lot of things they couldn't avoid about their weight they could try to influence, but it's hard to change body shape if everybody in your family has the same body shape. Right.

So the things that are amazing are, especially with these GLP ones, that they can be incredibly validating once patients start on them. And if they're responding well to the treatment and they start to notice, even that's just a small dose, wow, the noise is a bit quieter. Whoa, I don't think about eating that second portion in the same way with the same intensity that I used to. It just allows them to understand the biological underpinnings

of their appetite system. And when you're supplementing with a hormone, especially that is mimicking another hormone, I always liken it to, you know, if you've got low thyroid, you're supplementing with thyroid, nobody blames that person for using that. When you're supplementing with GLP-1, they're all of a sudden like, oh, I get it. That's why Alicia, who's thin beside me, could stop eating and not really care as much about eating a second

boarder because she probably makes a good amount of fullness hormones. And I'm always feeling like I need a little bit more to feel satisfied. So I think that it just levels the playing field a little bit for, for patients. And then of course the, the weight loss that they experience, and then the sustainability of that loss. Cause a lot of my patients are like professional dieters. They can lose weight easily. And a lot and much of the time when they lose weight on medication, they're like, yeah, yeah, that's not a big deal for me. I can do this no problem on my own, but it's the sustainability of it. It's that medication actually holding it off without the reflexive hunger and cravings that they really, really enjoy.

And then it opens up like, I love when I see patients who work out a lot, like marathon runners or triathletes who have hard time losing weight, they get started on these medications and they were already doing everything right to begin with. And then all of a sudden they're performing even better. Yeah, they just, they just perform like so much better, like they're running more marathons or doing more triathlons and their quality and they really take advantage of its benefit in that way, right, to enable better activity and better lifestyle. So that's the amazing thing about it, I think. And then your other question was, what's not so amazing? I guess there's a lot of there's a couple of things. There's, there's the fact that they're cost prohibitive right now, that not everybody has the privilege of being able to access them. I think that weight loss

medication right now is really, it's for people who have some affluence, right? Like it's not, it's starting to show the disparity in socioeconomic status among our community of people who struggle with their weight. Because people who deserve the treatment sometimes can't access it because their insurance companies don't cover it or because they don't have the money to budget for it. It's 250 to 500 bucks for some of these medications per month. And if you consider it to be a long-term treatment option, then you've got to budget that for how many years of your life? That's a lot. That's a lot for somebody to consider. And then the other thing is that they, what's not so amazing, they're meant to be long-term treatments. They're not cures. Everybody considers them to be like a short-term treatment, but they're meant to be long-term

sort of like hypertension meds or diabetes meds. And then the other not so amazing thing is that every medication comes with its risk of side effects and so you've always got to weigh the risks and benefits whether it's something that's appropriate for you. That's why when somebody's metabolically healthy and they don't have excessive weight to lose and I always tell them this is a long-term treatment though I don't want to cause harm and I don't think that the risks outweigh the benefit for you in this scenario. I thought it was I love that you mentioned thyroid because people have thyroid issues they take thyroid medications right they have diabetes they take you know diabetes medication blood pressure blood pressure medication

doesn't mean that you just take a pill and and that's it there's a lot of lifestyle factors and things obviously to can do obviously to offset. That was one of the biggest questions that we got with people who are interested in taking or people who are taking, can I get off it? You can and you can get off anything. Nothing's permanent but it's more about did you derive benefit from it? Did you derive benefit and did you see clinically significant outcomes from it? Because those outcomes that you got are likely going to rely on long-term treatment of it. Because as soon as you withdraw treatment, your physiology goes back to what it was doing previously, right? Your appetite changes dramatically, especially with the weight reduced state.

If you've and a lot of people, there's been a lot of bad media press about this, that people say that they're even more hungrier when they come off of treatment. But that actually physiologically makes sense. If you're if you get a set point that's at like 240 weight, medications got you down to 190 and you come off of medications, it totally makes sense that your brain is like, whoa, let's recoup that. Like, let's try to get that back, there's something wrong.

And that's what I mean by your brain is designed to defend against weight loss. It's not normal to lose weight and keep it off naturally. But with that being said though, I never say that it's impossible to come off these medications, but I will tell patients, if you're really keen to get off, maybe just trial a dose reduction instead to see how your appetite responds to that and whether you're able to sustain

that and continue to monitor, self-monitor your appetite, your weight changes even, the way clothes are fitting. If you're starting to notice changes, then you know that it inevitably is causing some weight regain. Sometimes with patients who have done a total overhaul of their lifestyle, like let's say, let's give you, I'll give you two examples. One example might be a patient who is super active to begin with, healthy eater already, plans everything, gets on this treatment, loses weight on treatment.

If they're wanting to come off of treatment, then nothing's really changed, right? Like about their physiology, except that they're lower weight. That person I consider anecdotally to be at high risk of weight regain. Whereas if it's a person who is coming to me, sedentary lifestyle, didn't have great nutritional literacy, but then on treatment, they just had more bandwidth to gun for all these changes and did a complete 180. I have patients who are boxing five times a week and meal planning and they've got meal services coming in.

That person I consider to have done a major overhaul. They might titrate down or come off and just see what happens and see if they can sustain it based on their new lifestyle. It's not that one person is worse than the other. It's just that that first person was already doing a lot of things that were meant to help you sustain weight loss, right? So this is not, that's just my anecdote. I just noticed that, that when somebody's done an overhaul, they're probably more likely

to reduce the dose at least. I don't have too many people coming off of it though. Just because they're scared. Like when they do that titration down there, they can tell immediately that their appetite is changing. Okay. Well, science is always changing. We're always learning new things, which is what's very exciting.

It's a great foundation to build on and, and, you know, can be a game changer for some people. And there's so many questions that people have, we'll have to have you back. I want to just touch on quickly that third. So we talked about the mental side of things. We talked about medicine and treatments. I want to quickly touch on surgeries. Everyone thinks gastric. Is there anything new there that people and why would someone choose a surgery over a weight loss medication or is that one of the pros of the new weight loss meds? Yeah, you know what, to be honest because I'm not in the world of bariatric surgery as much as I am in the world of pharmacotherapy

and CBT that I'm not sure about the recent developments, but I do know that there are a lot of misconceptions about bariatric surgery. It is considered a very effective weight loss treatment for people who have severe obesity. Severe obesity meaning BMI over 40 or BMI over 35 plus comorbidities like hypertension and diabetes.

That is, it is the one thing that people with diabetes and to have that BMI cut off can do to like to cause diabetes remission. Like it's the one thing that we know of that can actually do that. You come off medications almost immediately, right? So, and most people think that bariatric surgery, and when I say bariatric surgery, I mean Roux-en-Y,

the gastric bypass and the gastric sleeve, those are the gold standard surgeries, not Lap-Ban, not any other weird surgery, I mean, Roux-en-Y, the gastric bypass and the gastric sleeve, those are the gold standard surgeries, not lap band, not any other weird surgery. Maybe some like, yeah, duodenal switch also gold standard, but not typically used as first line. But, but when you use these surgeries, they are not malabsorptive, meaning a lot of people think that you lose weight because you're your gut, for instance, from bypass is like a golf size pouch. That's not the only reason you would lose weight. The reason you lose weight is because there are changes in those appetite hormones that occur as a byproduct of your gut being different. So people see decreased hunger, increased fullness. When I have patients who undergo bariatric surgery,

they come back to me and say, Whoa, that's like super medication. I feel like that connection between my gut and my brain are completely cut. And not everybody responds that way. There are some people who regain their weight and still continue to have these urges, these cravings. But many of the patients I've seen have noticed significant changes in their appetite that allow them to sustain their losses long term. bariatric surgery weight loss outcomes are between 20 to 40% roughly. So

you lose a lot more at the beginning. And then sometimes people regain a little bit, but the net loss is significant. And it's higher than what you typically see with pharmacotherapy, though some of the pharmacotherapy agents now are showing like lower end of weight loss range in bariatric surgery. So we're almost getting to the point where they're competing a bit, but oftentimes patients can go on medications after bariatric surgery if they're still noticing those appetite changes

occur. So I think bariatric surgery gets a bad rep, but it improves the quality of life of many people. And by the way, in Ontario, if that's where you're from, it is an O-hip covered surgery. So instead of paying for medication, you can have access to a very like highly effective treatment. And it doesn't cost you money. But of course, it comes with the inherent risks associated with surgery. So it's always again, the risk benefit you have to to balance out. Great. Again, I just want to remind everyone who's joining us live or listening after the fact, this is a conversation of awareness, right? It's not prescriptive or not telling anyone

they need to take this or do that. It really is about awareness. It's just about empowering you with knowledge to have, you know, conversations with your doctor, if you have any questions or you have any interest or you're not sure, how would someone reach out to you? Reach out to me specifically? Yes, or CCC. Or reach out to, oh, well, I have Haven Weight Management that I run, so I work at two places. I got Haven Weight Management,

it's a virtual program I founded, and so I could provide access and care to Ontarians. It's got a nominal cost associated with it and it's considered a low intensity weight management program. I'm also affiliated with a program called MedCan Weight Management. And so this is a higher intensity weight management program that, that provides ongoing like a high cadence of visits with like registered dietitians and myself. And that is like virtual, the virtual program I have is very accessible to everybody is just lower intensity and there's lots of group meetings. And then the MedCan one is if you want one-on-one and like lots of touch points

with longer session appointments. And so to access Haven Weight Management, you just gotta go to drsandyvan.com. There's a tab that says weight program and you can get your doctor to refer using that referral form. And then for MedCan weight management, you can reach out to MedCan at MedCan.com to book an appointment if that's of interest as well. That one is a higher cost

program. The other one's a lower cost program. Okay. So if you want to reach Dr. Sandy Vann, it's DrSandyVann.com. I believe you're also on Instagram as well. Oh yeah. I should have probably promoted that. It's at DrSandy.md. I'm the worst. I need a PR person. DrSandy.md. I think that's my Instagram handle. It is.

It is. It is. You know what I love about all of our guest experts? They're so busy doing what they're doing that they don't really have time to do social media because it's like having a whole second job. I'm so grateful for you taking the time to come on here and talk to our members. I know they are also so grateful as well. Please come back and join us again. We have a lot of things that we can and want to talk about with you so much. Thank you for having me. Have everybody have a good day. Let's take a minute to hear from our podcast sponsor today because this new year,

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