New Emerging Therapies for Obesity and Weight Loss

Transcript:

Narrator: Welcome to MedEvidence podcast, this episode is a rebroadcast from a live MedEvidence presentation.

Dr. Darlene Bartilucci:

Well, good afternoon. This is a very healthy crowd and probably the biggest crowd that I've spoken to ever, so I do appreciate you being here, and this is my colleague, Janet. She and I work together at the Jacksonville Center for Clinical Research and we're just going to have a little chat today about some of the new therapies that are available for obesity and weight loss. That clearly is the hot topic today. I'm sure everybody has heard of Semaglutide, Wegovy Mounjaro, so we're going to give you guys a little bit of information about it. Talk about diabetes. Talk about the relationship between obesity, diabetes and some of the new treatments that we have available. All right, so first question Janet, you want to take?

Janet Garvey, ARNP, DNP: 0:45
Sure, just a little food for thought for you guys. We don't really want an answer, but we just want to get you guys, your creative juices rolling. So what's the best piece of advice you've ever been given pertaining to your weight? So, just mull over that as we move along. All right.

Dr. Darlene Bartilucci: 1:00
So question number two which of the following is considered one of the greatest health risk factors? And again, these are just rhetorical questions. This question is for you to be thinking about. We came up with a few of them. Obviously, smoking is one of the major ones that we know of, and the risk for lung cancer, relationship to heart disease, stroke, hypertension, heart disease go together. Then we have physical inactivity is another one. Basically, all of these are risk factors and they kind of lump together, but they play a part in how our lives, how our health, is affected. And then we have the big one, obesity, that we'll be talking about today. And then, finally, happy birthday. That's really the best way to say it. All, right, so let's get started with this.

Dr. Darlene Bartilucci: 1:51
What is obesity right? We hear about it all the time. You know, unfortunately, there's a lot of negative stigma associated around it. There's, you know, we call fat shaming. But what does it really mean? How do we use that word? A lot of individuals, a lot of my personal patients, you know when I hate to use that word when I'm describing, you know, a 48 year old obese female, or I see those, those, those words that come across in the, in the history, and when you talk to the patient about what obesity is, immediately their mind goes to the worst case scenario. Okay, I'm, you know, slovenly, I'm, you know just a lot of negative connotations that go with the word obesity. But what does it really mean?

Dr. Darlene Bartilucci: 2:34
Well, obesity for us in healthcare is defined as having too much mass, too much mass. Body mass that's what we're talking about. How much space you occupy. And in health care, we use the term BMI to determine where you fall in the scheme of normal weight versus obesity. And a BMI is a measurement of your body weight against your height. That's how we use it. So we're just trying to figure out what you look like, how much space you're occupying. That's how we use it. So we're just trying to figure out what you look like, how much space you're occupying.

Dr. Darlene Bartilucci: 3:07
We've determined that a body mass index, a BMI of 30 or higher, is a usual benchmark. That's what tells us. Okay, that's what obesity is. A BMI of 40 or higher is considered severe obesity. And maybe some of you have heard the term morbid obesity. We don't use that word anymore. So when we talk about obesity classifications. How do we identify this? So there's three different classes. A BMI of 30 to less than 35 is class one. Then we have class two, which is a BMI of 35 to 40. And then class three, which is your severe obesity, would be 40 or more. So see, these are some of the BMI ranges. What do they look like? So people with a BMI of 18 to 24 are considered normal, healthy weight.

Dr. Darlene Bartilucci: 3:50
Now I have to say, Janet and I were talking about this earlier, about how sometimes BMI doesn't really capture what we're trying to say in terms of, okay, how much space do you occupy? Because you could look at a bodybuilder. Take, for instance, Arnold Schwarzenegger in the prime of his career. He was massive, right, he would fall into the category of obese because he occupied so much space. So it's not necessarily when we talk about body mass, it's not always fat, it's just your mass, how much space you occupy. And then you can see 25 to 29 is considered overweight. 30 and 40, like we talked about.

Dr. Darlene Bartilucci: 4:27
All right, this is the graph that we use in our office to help us find out where you are, and I really think this is. We developed this today because the other one was just entirely too busy and I think that, Janet, this you know, this is a good one to help people understand. What does it mean? What does it look like? I was talking to my daughter about this last night and I was trying to. She says she would ask me. She says, well, what does that really look like? Well, if you just take here, for instance, we have a individual who is 5'4" right, and if this you guys can see I don't want to make sure you guys can see so we have a 5'4 individual. So if we go up this line here, this is your height in inches, and then this line here is your weight. So if you just follow this line right here, when we get to 80, well below, I guess this would be about 85 or no, 100 something. So once we get to 100 pounds, then we're considered in the normal range.

Dr. Darlene Bartilucci: 5:22
And somebody who's 5'4" Then by the time you cross this line here which is probably about 145 pounds. So a woman who is 5'4 and 150 pounds now falls into the overweight category and for some people that can be pretty offensive. They're like I'm overweight. How do I fall in that category? Well, guess what? I fall into that category.

Dr. Darlene Bartilucci: 5:47
And so, unfortunately, the way that they've calculated these ideal body weight numbers hasn't changed for decades. It started with the actuaries at New York Life Insurance Company when they were trying to insure individuals, and nothing has changed in terms of how we calculate ideal body weight. So I think this data is quite misleading, but it's all we have to go by, so anyway. So if you follow that same line, so here we are at 5'4" and we're going to go all the way up to here. By the time you get to 180, guess what? Now you're obese, a woman who's 5'4 and 180 pounds. And then you just keep going up the line and you can see, by the time you get to 40, remember, anything over 40 is considered severely obese. So that's an individual 5'4, 260, 250 pounds.

Dr. Darlene Bartilucci: 6:42
And I will tell you, the average woman in my practice is about five, between five and five, two and then at least 200 pounds, at least 200 pounds. So let's just, let's just find this lady. So she's five, two and she's 200 pounds, and she falls into the obese category. When you get to 250, guess what? Now, she's severely obese, he or she, and you know the same thing goes for men. Let's look at men. So here's an average guy about 6 feet tall, right. So here he is normal at 180. By the time we get to 200, look, he's bordering on, right here, 220. He's between overweight and obese. At 220, 6 feet tall. That just doesn't make any sense, right? But that's where we are and this is what the data is showing us.

Janet Garvey, ARNP, DNP: 7:28
Anything to add. Oh, I was just going to share a little funny. I was helping some nursing students one time get their practice in with their vital signs and we were at a festival or something and there were firemen there and policemen and you know the public and of course these you know little nursing students were there and they were all in line to get their weight and their height checked and I kept hearing this grumbling. So I go over to see what was going on. Well, they're all irate because they're in great physical shape. But these nurses are telling them I'm sorry, you fall in the obese category and they were coming unglued.

Janet Garvey, ARNP, DNP: 8:06
So we had to do a little soothing of the yeah, yeah, all right let's see what we got next slide.

Dr. Darlene Bartilucci: 8:12
All right. So now we understand, we get a little bit of an idea of what obese looks like. Not your oompa loompa. Everybody wants to go there in their mind. You know that that's what they look like. That's not it. So here's some statistics. Now the data is lagging, okay, and so this is the most recent data that I could find. In 2022, this is worldwide. By the way, this is not in the United States.

Dr. Darlene Bartilucci: 8:37
We'll get to that slide in a second but worldwide, one in eight people were living with obesity, and some people might say, well, that's not that big of a deal, considering you know the number of people that we have on the planet. But then when you look at, so there's a slide over here. This number, the fourth one down. They looked at the prevalence. The WHO did a study and they looked at the prevalence of obesity and people being overweight. It did vary by region and here's what's interesting when you look at the prevalence of it, 31% of those individuals were found in the Southeast Asia region and the African region. But then when you get to the Americas, look what happens it doubles. It doubles. Okay, the US ranked 12th, 12th, the 12th heaviest country amongst high-income earners in the world. We're number 12, which makes it, you know, at least we're not number one, right? Okay?

Janet Garvey, ARNP, DNP: 9:39
This slide is going to open your eyes here. We were chatting about this earlier, about the number of red in this slide.

Dr. Darlene Bartilucci: 9:47
Yeah, the amount of red. Okay, again, this is 2022 data. This comes from the CDC and you can see the primary color is red and orange. Right, there are a couple of maroon colored and a yellow or two, and then there's one green DC, apparently in 22 was the state with the least number, the smallest number of obesity, I think, at 27 percent. West Virginia unfortunately wins the category at 47.9 percent of their population is obese .Obese, not just overweight. We're talking about obese.

Dr. Darlene Bartilucci: 10:22
This map here I mean you can see most of it is in the Midwest, Florida 30 to 35 percent, not too bad. But then when you start looking at all these red states and I don't mean red politically, this is red by weight 35 to 40 percent of the population is obese in those states I mean that just doesn't seem like it's possible. And in 22, there were 22 of these states. In 2019, I believe my data. What did it say here? In 2019, or sorry, and in 2021, just the year prior, there were 19. But here's what's the most striking thing 10 years ago, no state had an obesity level greater than 30%, and this is what we have become in 10 years. Why do you think that is?

Janet Garvey, ARNP, DNP: 11:14
Fast food, technology. Lack of activity. Very good, very good.

Dr. Darlene Bartilucci: 11:17
We have become sedentary right. Nobody moves anymore.

Janet Garvey, ARNP, DNP: 11:20
Our jobs have changed more automation. Absolutely.

Dr. Darlene Bartilucci: 11:24
DoorDash right, you know I mean that exploded during COVID.

Janet Garvey, ARNP, DNP: 11:28
The cost of healthy food versus quick and fill you up food.

Dr. Darlene Bartilucci: 11:33
Yeah, so you know we're, we're as a country, we're not moving in the right direction. All right, so again, it just this, the beginning of the slide. It says 22 states, 35% or more, up from 19 in 2021. Ten years ago, there were none. West Virginia wins I'm sorry, that was 40% and Washington at 25.

Dr. Darlene Bartilucci: 11:58
This line right here, this bothered me a lot because when you look at this in 2022, this is what the state of obesity report came from, and this was actually I pulled this out of a Forbes article 49.9% of black adults are obese in our country 50%, one out of every two of you in our country 50%, one out of every two of you. How did we get here? More importantly, how are we going to correct this? Right, now, Hispanics are very close behind, at 45.6%, white adults 41. And, interestingly, Asians are only 16. Go figure, you know. It also reported that adults who live in rural areas are more likely to have obesity than adults in urban areas, and you know, I'm not so sure about that data. I mean, it doesn't really make any sense how people but when you look at the map in the Midwest, all of those folks in the Midwest have more obesity.

Janet Garvey, ARNP, DNP: 13:01
Yeah.

Dr. Darlene Bartilucci: 13:04
All right. So this is a health and nutrition examination survey that's put out by the CDC. So, basically, they call you and they gather data from phone calls. They get this information. NHANES is something that we use as a metric in our clinical practices. Insurance companies use this information to identify demographics within the populations that they're insured. Now, this is from 2017 to 2018. This was the latest.

Dr. Darlene Bartilucci: 13:33
We couldn't find anything more current. There was one other bit of one slide that went to 2020 and compared the rates, but the rates were insignificant in comparison, so I thought that we'll just keep it with this slide. But here in the United States, where are we here? One in three adults 30% are overweight. Just the overweight category, okay, but two out of five are obese. I mean, we have to talk about this. It's a health crisis in our country right now, and if we don't address it, if we don't recognize that we have a problem and put our head in the sand, we're not going to make any changes, we're not going to do anything differently and it needs to come from both sides.

Janet Garvey, ARNP, DNP: 14:15
It needs to come from the medical side and you guys need to embrace this as well and so we can work together, and that's what we'd like to see come from this is working together to solve the problem.

Dr. Darlene Bartilucci: 14:30
Yeah, this next section is a little bit troubling to me because, you know, if we're and I'm sad that we don't have more current data, because I think the data is actually worse but you know, 2017 to 2018, one in six children or adolescents 20 to 19, 16% were overweight. Okay, I can live with that. But the next one almost 20% of kids two to 19 are obese. How, how is that possible? Cell phones, that's right, you know. Inactivity kids want to sit in front of a screen and they want to play video games all day long. Nobody goes outside anymore, they don't ride their bikes, they got a scooter. And then one in 16, 6%, have severe obesity. So when you kind of add these numbers up, what have we got here? 19, 36, plus 6, 42% of kids, adolescents, are overweight or obese. What's gonna happen as these kids get older? I mean, this data is what are we? '24, six years old? This is our future. I mean, if we have problems as adults and our kids are starting here, and most of us in the room grew up I think most of you look like you're probably boomers or maybe Gen Xs, but we all grew up before the cell phones, before video games. We were outside when you got home or the crack of dawn and you didn't come home until the lights came on outside. Right, that's how it was. We were always outside. Yeah, and kids just don't do that. And what did we eat? Peanut butter and jelly. We didn't DoorDash, it wasn't McDonald's. Mcdonald's was a treat. Remember those days when we would go to McDonald's and that was, oh, you know. Just to bring up, you know, obesity rate.

Dr. Darlene Bartilucci: 16:25
During the COVID pandemic. It increased by 3% between March of '20 and '22. This comes from the. Where was this? This was an article. The USDA did a study and I found that very interesting because personally, in my experience, in my own practice, more people actually lost weight during the pandemic because their lives and their lifestyles changed so drastically. Okay, there was no restaurants. Everybody had to cook at home. A good percentage of individuals were working from home, so they didn't have the commutes. They actually had more time to exercise. I had a couple and they're both very overweight we're talking 300 to 500 pounds both of them and they worked remotely. He had a fear. I mean, he was really very afraid with the pandemic. He was afraid of getting sick and they basically stayed home for a year and a half and they lost an incredible amount of weight. Incredible amount of weight, and they did so because they didn't go out to eat and they stayed home and they exercise and they got. They were able to take care of themselves, and so lifestyle plays a big part in this. How are we going to shift our lifestyles from where we are now at this rate, where we've got 45% obesity in this country, to something where we can have the lifestyle that we want but not have to be so overweight? This is a very interesting.

Dr. Darlene Bartilucci: 17:56
How many of you, just by raising hands, how many of you know about the relationship between obesity and cancer risk? One, two, three, four, five, maybe, Okay, yeah, Okay. Well, that's more than I thought, because I was shocked, actually, and the first time that this came to me was I had a young patient who developed breast cancer, and when I was talking to the breast cancer surgeon, she was the one who told me. She says oh no, obesity is a huge risk for breast cancer in women, and I thought, well, why aren't we getting this word out? Why isn't? Because of the stigmata associated with obesity? Nobody wants to talk about this. We've got to come out from the shadows. We've got to recognize what we have and we have to be able to work together to find a treatment for this. So, when we talk about risk in terms of you know what's your increased risk for developing cancer, it's 17%, and some people might not think that that's that bad, but you know, when you add diabetes, heart disease, cholesterol, all of these things to it, and now, and let's talk about, you know your genetic proclivity towards this, and now we're going to add 17% to that, that'll sometimes push people over the edge. How does this happen? Why does this happen? Well, there's a lot of work going on right now looking at this to try to figure out what is the relationship, and it appears to be that these, you know, the more fat cells that we accumulate, that we develop, they're dysfunctional cells and they release these hormones that actually cause inflammation in the body. And that's really what's driving all of this. It's an inflammatory response and, remember, cancer cells are just normal cells that have gone rogue. They were once normal, but they've kind of fallen off the map and they're going to do their own thing.

Dr. Darlene Bartilucci: 19:42
Let's talk about the cost. You ready for this one? This blew me away $260 billion it costs in a year to look after folks who have obesity and all the related illnesses, and that's inpatient, outpatient medications, all the ways we have to manage these things. Now, with the introduction of these new weight loss drugs that we have available to us, this number is going to go right out of the door. It's going to be crazy Next year when they start gathering the data. It's going to be crazy because the weight loss industry right now is going to be a multi-billion dollar industry within the next year easily. So, Janet, where do we start?

Janet Garvey, ARNP, DNP: 20:26
What do we do?

Janet Garvey, ARNP, DNP: 20:27
Well, like the slide says, it's very complex, but we have to find a way to work together to come up with ideas that work for yourself.

Janet Garvey, ARNP, DNP: 20:38
You've got to really soul search and think about just the fact of moving more.

Janet Garvey, ARNP, DNP: 20:45
You know, like everybody's driving around, you just kind of sit back and watch at Publix and everybody's just circling trying to get that front parking space and it's like just park and walk and if you're not physically able, I get that, but you know, maybe park in the third spot and walk and then next week park in the fifth spot. You know, just try to make it a new little game within. You know your shopping habits to just so you walk a little more, make a couple extra trips around the store while you're there holding onto the cart. You've got a little bit of safety, it's air conditioned, you know that kind of thing. Just try to come up with, search deep inside and see what you can actually do to make some changes, because there are a lot of things we can do and we got to figure out how to motivate ourselves to go through with them.

Dr. Darlene Bartilucci: 21:30
Yeah, and again it goes back to. You know, the final line that I have there on the slide is, you know, stopping the blame. You know we're not blaming anybody. We have to stop blaming ourselves, and we, as clinicians and healthcare providers, we need to stop thinking at it as a as a something that we're blaming you for. It's not that at all. This is a chemical issue that's taking place in your brain.

Dr. Darlene Bartilucci: 21:50
We have evolved to um, um, to adapt to our environment, to adapt to our new lifestyle. You know we don't. You know mom's home, dad's working. We have, you know, breakfast, lunch and dinner, and that's all we have. You know, now it's both parents working. You've got kids who are involved in everything and anything, and you're eating at the ball field and you're eating at the pool, and you're eating in the car, getting here and there, and then we get home and everybody's hungry. So it's nine o'clock, we're having something else to eat and oh, by the way, I'd like to have a bowl of cereal. Watching the news at 10 o'clock, right? And so you know what. That's how it happens. So you know, we adapt to our lifestyle, but it doesn't appear that our adaptation is working. Does it? Because we're just getting bigger and bigger, and it's not just us as adults. Look at what we're doing, what we're modeling for our children, because it's the same thing there. All right, so how do we start? Right, you see, the hearts right. Whoops, sorry.

Janet Garvey, ARNP, DNP: 22:51
I've gone too far. I'll go to. You know I'll interview patients. I call it my real job. Research is my fun job. Research is my fun job. But you know, during the week, when I'm working, doing house calls, and I'll, you know, get a person's weight and height. Then it figures out the BMI for me and they're like you know, they don't want to get on the scale. You know, or don't say the numbers out. I said it's girl code, I won't say it, I promise. But then they'll say well, my doctor told me I was obeast and I said you're not obeast, your weight is high and it's obese. It's not a terrible term like a beast. Let's talk about that for a minute. Let's see what we can do about that. You know, as we push the Coca-Cola away and the Little Debbie's away so we can make a spot to chat, but again, that's what's cheap and fills you up when you're hungry. So there's many facets to this, as you all know.

Dr. Darlene Bartilucci: 23:48
Yeah, but acceptance, I think, is the first thing. That's where we have to start. It's like with alcoholism. Obesity is a disease state these days. Okay, so we have to treat it like we do any other disease state we identify it, sort out what the issues are that are contributing to it, make the changes necessary and move on. Right? We can do this, but the first thing we have to do is accept it and we, as clinicians, embrace it, embrace you where you are and as the individual, we have to identify and recognize the fact that, okay, I may have a problem. So, first steps, right, Janet. Yeah, what are we going to do? Baby steps, right. Recognize that it is a complex disease. Okay, it's not like it happened yesterday.

Dr. Darlene Bartilucci: 24:34
I tell all of my patients this. They think, oh, I'm going to try and lose weight. Well, you didn't get here yesterday and it's not going to be solved tomorrow. So there are a lot of factors genetic, environmental, societal. There are socioeconomic ones, cultural ones. I mean you know there are a lot of factors that go into how obesity occurs, so to speak.

Dr. Darlene Bartilucci: 25:00
And then what do we do? We got to educate folks, we do. We just have to start, and you know it starts at home. That's where it starts. If we're not educating and modeling a behavior for our children, the next generation, then we're going to lose them too and they're going to be worse off than us. I mean, we can already identify the things that we're living with, and these are kids who are now already starting off behind the eight ball in the obese state. Then what are we going to do? What are we going to call it super duper obese? Is that the next category that we have to go to? I mean, in some cases that's what we do in medicine, you know. Oh well, we'll just create another category for you. Well, how about we just stop where we are, make some changes and pivot and move in a different direction?

Janet Garvey, ARNP, DNP: 25:45
With education, though also, you know I'd like to put it out there for you guys to just go to your cabinet and start reading labels. You know, try to avoid some of these GMO products and these products that just are not, were not designed for our bodies to handle. I think a lot of that is is, you know, contributing to this problem. But you've got to educate yourself, and there's plenty of stuff on. Well, be careful going on YouTube, but you know there's. Go to some trusted sites, like I'm sure that cdc. gov has how to read a food label and just educate yourself. And then a lot of the offices, the group practices, now have nutritionists in them and you can make an appointment. Insurance generally will cover that if you have. You know, if you fall into one of these categories, but just arm yourself with all you can you know to whether you're 20 or 80, you can make a change.

Dr. Darlene Bartilucci: 26:40
Yeah, I mean the old adage knowledge is power, right.

Janet Garvey, ARNP, DNP: 26:42
Yes, absolutely so all right.

Dr. Darlene Bartilucci: 26:44
So let's look at exercise, because people are like oh my gosh, so what do I have to do? What kind of exercises do I do? Right, I'm allergic actually. Yeah, exactly Right. My response to my patients is anything that you will do, you have to start somewhere. Okay, it's baby steps, Walk. People tell me I hear it all the time oh, I don't have time to go to the exercise, I don't have to get time to go to the gym, I don't have time to do this. We all have 24 hours in a day. Nobody gets any more or any less. Question is how are you using them? You know, for working people I say just walk on the weekends, start with that, get into a rhythm. That's where it has to start. You know, the um, health and human services, put out some guidelines for exercise and I and I, you know I kind of looked at it and I thought, yeah, that's never going to happen. You know, they basically want, you know, 150 to 300 minutes a week. Okay, so what does that fall into?

Janet Garvey, ARNP, DNP: 27:36
My math isn't very good, right now, I think I don't know right there you go very good, yeah, 30 minutes five times a week.

Dr. Darlene Bartilucci: 27:44
Right, who's got 30 minutes? You know. So you know what they developed. They've got this great and I'm sure if any of you have Instagram or Facebook, there's this guy on there who's on a treadmill eating pizza and saying you can, you don't have to exercise like this and you can eat whatever you want. There is a method of exercise that does burn calories very, very effectively, called HIT, which is high intensity interval training, where individuals and there's actually a book out on this, and I've recommended it to several of my patients because it is a great place to start if you're going to do it you just basically you do a high intensity type of exercise for 30 seconds. I mean, when they did the studies, that's what they looked at. They looked at just 30 second intervals, where you just go as hard and fast as you can for 30 seconds and then you rest, and you do that in intervals. So you may do 30 seconds and then you walk for a minute and then you power walk for 30 more seconds and then you walk normally for a minute, and that kind of exercise has incredible results and it doesn't cost you anything. Except time. That's it, yes, that's it.

Dr. Darlene Bartilucci: 28:52
Trusted resources, like Janet was saying. You know you've got to get to a place that's, you know, reputable. Go to your physician. You know, if you don't have a physician or a physician that you trust, you know everybody has. I don't have my cell phone up here, but everybody has a cell phone right, most everybody does. Okay, we have access to the internet. If not, the library has free internet. So there are places that you can go to get trusted information, places, you know things like this that we put out. You know these community resource opportunities. These are the kinds of places where you want to get your information. You know, I insulted my daughter last night when I was rehearsing this talk to her and I said, yeah, you can't go to Facebook or TikTok, certainly not TikTok. And she just thought oh, my God, you don't know what you're talking about, mother. All right, so let's talk about this. This will blow you away, and I'm sure some of most of you in this room. I can tell by the lovely silver hair that we all can identify with these Portions matter. Right? We talked about that earlier, all right, so here we go.

Dr. Darlene Bartilucci: 29:50
So serving sizes 20 years ago, just for a cup of coffee. 20 years ago, average cup of coffee was 8 ounces of coffee with milk and it cost you about 45 calories. Well, today we have to have the grande cafe macchiato with a double shot of espresso and a little bit of syrup of some sort 16 ounces and 350 calories for one cup of coffee. That's crazy, crazy. Movie popcorn I mean, you know it's popcorn, I'm sorry, that's not good for you, certainly not movie popcorn. It tastes delicious but it's not good for you.

Dr. Darlene Bartilucci: 30:31
And we can look at soda. So soda. Remember when Coca-Cola used to come out in an eight ounce bottle, just eight ounces. Well, now we've got to supersize everything. Right, we got to have 40 ounces, 40. That's crazy. But look at how many. I mean, it costs you 450 calories if you did, if you just double, if you did the math and double the 20 ounce bottle of Coke Cheeseburger even a cheeseburger 20 years ago. That just that baffles me. How it was 330 calories 20 years ago and now it's almost 600 calories for a cheeseburger ago and now it's almost 600 calories for a cheeseburger. What are we putting in it? No idea.

Dr. Darlene Bartilucci: 31:12
So I came, I saw this in an article. I think this. I can't remember where I found this, but they did sort of an ad hoc study just looking to compare, okay, america to Europe. What are the portion size? What do things look like? You know that are different and they chose. The cities that they were looking at were Paris and Philadelphia and the average Paris portion size was one-fourth smaller than the US size, portion a quarter. I mean. Just look at those numbers up there. Chinese food 72% more food we eat in one single serving of Chinese food here in America versus what they eat in Paris. I love the last one, yogurt, because everybody thinks that's a healthy food. Right, it is, but do we have to have almost 100% more than people in Europe? I mean, does everything have to be a larger serving for us to be satisfied? These are the kinds of things you see, like I said, it doesn't happen overnight. It's all these little incremental changes that are taking place that put us where we are today. All right, motivation, Janet, you want to take this one?

Janet Garvey, ARNP, DNP: 32:18
Yeah. So you know it's so easy to just go and say, look, here's my problem, I'm laying it out here for you and you need to fix it. So you know, okay, I'm already taking 10 pills, what's one more? Have you got a pill for this? And then also that whole obese thing.

Janet Garvey, ARNP, DNP: 32:39
You know getting your feelings hurt whenever you know you do have that talk, because sometimes you know you're just not ready to hear it. So this motivating folks to make a change, it's a touchy situation and some people don't have that charisma that we would all like for them to have whenever we're having this talk. So i t takes a lot of open-mindedness when you, when you do have this talk with your provider to get some help. But please, I want you to feel comfortable talking with your provider, because if you can't talk to them, can you talk to?

Janet Garvey, ARNP, DNP: 33:20
So, just say, hey, you know we need to. I'm really serious about this and I want to chat about it. And, help me to help myself here. So, and I think people are more open-minded because they see the problems that it's causing. Obesity is just causing so many problems that we've already, you know, talked about, and getting it under control helps in your mental health. It helps your physical health and yeah, and you know skinny doctors.

Janet Garvey, ARNP, DNP: 33:54
Don't trust them.

Dr. Darlene Bartilucci: 33:54
I'm kidding. No, you know, I have found that in my own private practice that you know, sometimes it's difficult to have that conversation, you know, with someone when we look so vastly different, right. But you know, all of us have our own struggles. Okay, we've all been there. If any woman in this room has been pregnant, you know what happens when you get pregnant and how the change happens to your body and then trying to undo those changes. But understanding that if you're going to a trusted individual, they've likely not been exactly where you are, but they've walked the same path and so sometimes it does mean that we have to have these uncomfortable conversations and we have to come out of the shadows and we have to just have these frank conversations about okay, how are we going to address this? You know, and it's sometimes you have to discuss it ad nauseum with you know and and and, like with patients who have, who smoke. It's always every visit. Oh my God, are you going to talk to me about my smoking?

Janet Garvey, ARNP, DNP: 34:59
Oh my God, are you going to talk to be about my weight?

Dr. Darlene Bartilucci: 35:01
Don't bring up my weight. I know I gained a few pounds.

Janet Garvey, ARNP, DNP: 35:04
And don't talk about my alcohol either. Leave that alone.

Dr. Darlene Bartilucci: 35:07
That's right, yeah, but you know, understanding that we've all. We've all been there in some degree or another, okay, and so it's important to be able to have faith in the people that you're talking to. But intentionality is probably the most important thing. You have to step up and you have to say okay, I have a problem, how are we going to get there? But it doesn't happen with just taking a pill, and I know this whole new era that we're in with. I just take a shot and I've lost this weight. How do you?

Janet Garvey, ARNP, DNP: 35:38
What happens when you stop. Why can't we do it?

Dr. Darlene Bartilucci: 35:40
Yeah well, exactly, yeah Well, it doesn't work that way, unfortunately. And you know, the unfortunate side of it is when you stop taking these medications, the weight comes back, and it often comes back plus 10 to 15% before you started. So you know, we have to be intentional, we have to change our lifestyle, we have to couple these things, these weight loss strategies, with activity. Okay, they, the two, have to go together. How do you make a peanut butter and jelly sandwich? I use this analogy all the time. How do you make a peanut butter and jelly sandwich? Peanut butter and jelly right, can't have one without the other. That's what a peanut butter and jelly sandwich is. Well, same with weight loss it's diet and exercise. You have to have the two.

Dr. Darlene Bartilucci: 36:20
So I'll share a little story with you. So I had this patient. I saw her last week and I've known her for at least 10 or 15 years and she, at some point in her life, had a major life event and gained a good bit of weight, and she confided me that she's always struggled with her weight. In fact, she told me that she was every time she came to see me she was nervous about getting on that scale. And oh, I've got to talk to Dr. Bartilucci, so she would kill herself trying to get a few pounds off before she saw me, just to be, you know not as heavy as she was the previous time.

Dr. Darlene Bartilucci: 36:46
Well, when I walked into the exam room and I saw her and I was like oh my gosh. And she says I know, and I'm like where's the rest of you? And she had lost a considerable amount of weight and, using one of the products that are available, she was on semaglutide and was delighted where she was. And she said this is the only thing that has worked. She'd had a trainer. I mean she's lost the same 10, 15 pounds. I've known her for at least the last five years.

Dr. Darlene Bartilucci: 37:15
In March of last year she was at 208. When I saw her in the office she was 156. And I said what's different? And she said I don't eat as much, even though prior, when she was doing it on her own before the medicine, she was going to the gym five days a week. She had a nutritionist that was helping her with her macro and her micronutrients and just. But I think it was just so much stress just trying to manage all of that. I mean how do you go to the gym five?

Janet Garvey, ARNP, DNP: 37:40
six days a week.

Dr. Darlene Bartilucci: 37:41
It is a full-time job. You know, I understand I've got to measure this. I mean, that's stressful on your brain. Anyway, bottom line was, she was asking me, how do I? She hadn't been able to go to the gym since she's been on this drug because she doesn't eat enough. She doesn't need enough calories to be able to go to the gym and exercise. And now her brain wants to get back into the gym and she's asking me how am I going to get back into the gym when I don't eat that much?

Dr. Darlene Bartilucci: 38:08
Because I said give me an average day. What does an average day food look like? She says oh, for breakfast I have an egg and maybe a piece of toast or bacon, and then at lunch I have a handful of nuts. And I said a handful of nuts. I said you, why are you just eating nuts? I don't understand this. And so she says yeah, but I'm not really that hungry. And then she gets home and by 5 o'clock she says I have to almost force myself to have something for dinner and I can't go to the gym like this because I know that I'm not going to be able to be successful. So she and I are working on a plan to get her to reduce the dose of the medication that she's on so that she can consume more calories, so that she can burn them at the gym.

Dr. Darlene Bartilucci: 38:47
So it kind of sounds a little chaotic when you think about it and you're like, okay, it's like you know, it's like I need a pill to help me sleep, but then I need another pill to wake me up in the morning and and, and you know, it's like you know, how did we get here? I mean, ultimately it boils down to lifestyle, but not just lifestyle. Again, like I said, obesity this is a complex disease state that we're dealing with, but understand that it is a disease state that needs to be treated. All right. So here's some of the current therapies. This is what the FDA has approved for us here in the United States. The first one Contrave. There are some problems with that the Bupropion, which is Wellbutrin. Most people tolerate the Naltrexone. Sometimes people will have trouble tolerating that portion. I haven't had many people very successful with this.

Dr. Darlene Bartilucci: 39:35
You have to be really very careful with this particular compound because if people are taking opiates, for whatever reason, that will put them into a withdrawal. So you have to be very careful. It's for a very niche individual group. So Liraglutide is one that I'm very familiar with because we've studied that for at least 10 years. It's also known as Victoza in the diabetes world.

Dr. Darlene Bartilucci: 40:00
So the interesting thing about these weight loss drugs. So when Liraglutide and Semaglutide the Wegovy-Ozempic family when those drugs came to development, when we were studying the Liraglutide, that was for diabetes, and what they found was when they dosed the patients at the lower dose, the diabetes was controlled. Increase it incrementally. People did very well, but then when they got to the higher doses, they found that the diabetes was no more better controlled than it was on the lower dose, but the weight loss was amazing. So then what they decided to do is that, okay, well, we can market the same drug at a higher dose for weight loss and use the lower dose for diabetes. And it's worked, and it is where we are today. That's where we are.

Janet Garvey, ARNP, DNP: 40:45
The takeaway from that her last statements is we want you guys to realize that these drugs, even though they're kind of like the new thing on the block, there's a lot of history behind them, a lot of medical evidence supporting their safety. So that's that was we thought you'd like to realize that. Yeah, and then we have the weight. So that's that was we thought you'd like to realize that.

Dr. Darlene Bartilucci: 41:04
Yeah, and then we have the weight loss surgeries that are, you know, have been around, you know, for forever. These are some of the. This is a little bit of a busy slide. It just talks about the different kinds of medications that we have, like on the previous slide, but it talks about the mechanism of action, how they work. Most of these injectable ones are working on it mimics, a gut hormone that actually crosses the brain. We have this term in medicine called the blood-brain barrier. Not all medications get to the brain but some do.

Dr. Darlene Bartilucci: 41:36
And Semaglutide, Liraglutide, Tirzepatide those drugs do cross the blood-brain barrier and they affect the hunger center in your brain, the hypothalamus, and what they do is they tell you when you're hungry. Basically, it's going back to the way we used to live you eat when you're hungry and you stop when you're full. Right, that's how we do things. But if you grew up in my house, you had to eat everything on the plate, everything, because there were starving children in Africa who needed to eat and you had to eat everything on your plate. So it kind of started, you know, gradually. Again, it goes back to how we do things in the home, the kind of things that we're modeling for our families. But what it does, you know and there's a lot of buzz out there about gastroparesis. You know people's stomachs are paralyzed. They're not paralyzed. It does cause your stomach not to empty as effectively as it does normally. So, basically, you feel full. So it's kind of like when you get a, like a bellyache, and you ate breakfast, and it's like by noon you're still kind of feeling breakfast in your belly and then by dinnertime it's like man, I still taste those scrambled eggs in the back of my throat. It's pretty much the same thing and that's how people feel. They feel full all day long. So this talks about.

Dr. Darlene Bartilucci: 42:52
This slide just shows you all the different places that these new drugs are targeting. You know, when we were, you know, in the early stages of diabetes treatment, all we had was insulin. And then we started looking at okay, so we know that there's an insulin deficiency, but what else is there? What else could be going on? It's not just that the pancreas isn't producing enough insulin, there's more to it than that.

Dr. Darlene Bartilucci: 43:17
Then we came out with these pills and we said, okay, well, maybe it's not just insulin. If we could get the pancreas to function more efficiently instead of just replacing what they need. Maybe we can overcome diabetes that way. And that's that. One's not on here. Then we looked at the liver, the muscle. Metformin came out and then we realized, wow, you know, we used to have only four areas of the body where diabetes was really impacted in terms of where were the deficiencies, and now we have eight. So the brain, the stomach, the pancreas, you know, the liver, the fat cells themselves, and so these particular drugs affect all of these now in the body. All right, so many nutrition plan options, janet, what do we do here? How do we?

Janet Garvey, ARNP, DNP: 44:08
Again, just like the E word exercise. You've got to come up with something that works for you and your lifestyle, food wise. You know some people are allergic to different foods, they can't tolerate other foods, and but it's also got to be something you can live with. I mean something you can carry on throughout the week, and so we're not here to say this diet's better than another diet or eating plan is better than one over the other, but it's worth it for you, so that you get a buy-in to explore and decide what works for you and your makeup, and sometimes a nutritionist can help you um, you know, decide that and give you some insight on that.

Dr. Darlene Bartilucci: 44:48
Yeah, and there's online nutritionists that are available now. I mean, you know, one of the positive you know, consequences of the pandemic was the fact that we um were able to learn how to do things remotely right, so you can log in, you can see a psychiatrist, remotely on the computer, you can see a nutritionist but definitely identifying the thing that works best for you. So just yesterday yesterday, I saw a patient and again a long-time patient of mine lost the same 10 or 15 pounds forever. This last time he was like, ah, whatever, it is what it is, I am who I am. And when I walked in this time again I was like wow, how did you do this? How did you manage to lose 26 pounds since I saw you last six months ago? And he says I'm a carnivore and I'm like okay, can you explain that to me, because I don't understand what that means. Basically, he just eats meat of all kinds and very little vegetables. He says I'm a very picky eater, so that's what he does. And he's lost 26 pounds. I told him, I looked at him, I said, yeah, your labs are going to look awful, I can't wait to see him. And he says, nope, they're not. And sure enough. His labs were beautiful. I couldn't believe it. So everybody, everybody is different and everybody responds differently, and so you just have to find what works for you. You know the Mediterranean diet vegetarian, you can be vegan. There's a paleo diet, whole 30, weight Watchers.

Dr. Darlene Bartilucci: 46:15
I was a huge advocate for Weight Watchers for a really, really long time and I'll tell you why. Because they broke it down to something that worked for people Very, very simple. You counted points. Then, when people started cheating, then it was like, well, that's not working anymore. You have to be honest with yourself. Either you're going to do what you're asked to do or you're not. That's just it.

Dr. Darlene Bartilucci: 46:34
But what I loved about Weight Watchers and Janet, I don't know if you've ever done Weight Watchers, but it teaches you how to eat. So you get a fixed amount of points that you can have with every meal and you can take that anywhere you go. You can eat like that on vacation, you can eat like that at work, you can eat like that at the dinner you know if you have a dinner party or a birthday or anything because they're telling you okay, you only get a fixed amount of points at this meal, at this meal, at this meal. But it helped. The point I'm trying to drive here is that you had to be intentional about it. You had to be intentional about counting your points right. And you know when I started hearing patients talking about, oh, I just save all my points for one meal in a day and I'm like, well, good luck with that, it's not going to work.

Dr. Darlene Bartilucci: 47:18
I'm going to tell something that works for you, that you can live with, that's not stressful, okay, it can't create more stress in your body, because when you have stress in your body, your stress hormone called cortisol elevates. And what does cortisol do? It layers us in fat. It's that hormone, that's that fight-or-flight hormone. So what it does is it tells us I don't know where food's gonna be, but we can use fat as a source of energy, so, so let's layer in fat and that's what your body does. So if you have, if there's stress that is associated with the diet that you're doing, it's the wrong diet. It's the wrong diet.

Dr. Darlene Bartilucci: 47:54
Thank you for attending this afternoon. It has been a pleasure to share my thoughts, my thoughts and, Janet's, we do appreciate your attendance and hope that you find this very helpful and useful in the future. You can go to MedEvidence. com and you will be able to find this presentation. Within the next few weeks we will have a follow up podcast and we will be able to answer some of the questions that you all presented with us today. So thank you and have a great day. 

Narrator: Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence.com or subscribe to our podcast on your favorite podcast platform.

Narrator: 0:00

Welcome to the MedEvidence podcast. This episode is a rebroadcast from a live MedEvidence presentation, Dr. Bartilucci. Does Metformin cause weight gain? If so, why prescribe it?

Dr. Darlene Bartilucci: 0:16

Metformin is a drug that has been used for a number of years to treat diabetes, and as we have used this drug over the years, we've learned that it has many uses. Initially, the drug was designed to help the body utilize sugar more efficiently by transporting the sugar from the bloodstream into the cells muscle cells to be used as energy. And what we have learned over the years with regards to what diabetes does in the body is that it actually raises insulin levels and you get into a state where your body is resistant to insulin. Perhaps some of you have heard the phrase insulin resistance. What happens when the body produces too much insulin is that it can't utilize it all, and Metformin is a drug that helps the body to utilize the insulin more efficiently.

Narrator: 1:11

How is obesity linked to diabetes? Does it alter insulin levels?

Dr. Darlene Bartilucci: 1:15

Obesity and diabetes can go hand in hand, but they don't always. Obesity creates a change in the body that affects the metabolism. In many ways. It does affect insulin levels, because the extra weight creates that insulin resistance that we spoke of earlier. When you reach a certain weight, your body doesn't know what to do with the insulin and your brain is perceiving that there isn't enough sugar in circulation, so it tells the pancreas to produce more insulin, therefore increasing the insulin levels. Now, when insulin is in circulation, you're again, like I said, your brain is starving for energy and therefore it makes you hungry. Because your brain isn't getting enough energy, because it doesn't know how to process the insulin which is bringing sugar to the brain, and so it's sending a message to the pancreas I need more insulin, and the insulin is what causes you to want to eat excess carbs, essentially. And the more carbs you eat, the heavier you get, and the heavier you get, the more resistant to the insulin that you become, and that's the vicious circle that occurs.

Narrator: 2:31

What is an ideal weight loss rate? Would it be one pound a week or three pounds a week? Is a slower rate better?

Dr. Darlene Bartilucci: 2:38

That's another good question. Yes, often people will ask that you know how quickly can I lose? You know can I get to the weight that I'm looking to achieve? And the slower weight loss is better because that's going to be permanent weight loss. When folks lose weight too quickly, the body doesn't have time to assimilate to that new weight and unfortunately people will gain all of their weight back plus a certain percentage. It's usually between 16 and 20% of the weight that they will plus in addition to what they lost. So, yes, I would recommend losing weight slower and ideally about one to two pounds a week is where the studies have shown that individuals have been able to sustain the weight loss.

Narrator: 3:24

I've heard that if you exercise regularly, it offsets the extra weight. Is this true?

Dr. Darlene Bartilucci: 3:36

That's something that we would all like to believe is true, but not necessarily, because it really depends on how much exercise you're doing, how many calories you're burning versus how many calories you are consuming and, like I mentioned in the talk, ideally what happens. In order to lose weight, we have to put ourselves into a caloric deficit. That's how weight loss is achieved. We consume fewer calories than we are burning calories, so you can exercise regularly and it will help. It can potentially offset some weight gain, but if you're consuming the same amount of calories that you are burning off, then your weight is going to remain neutral.

Narrator: 4:16

Dr.. Bartilucci Bartolucci, what about the relationship between the stress hormone, cortisol, and weight gain? What are your recommendations?

Dr. Darlene Bartilucci: 4:24

Well, cortisol, like I mentioned in the talk, is your stress hormone, and by that I mean it is a hormone that is secreted when the body perceives stress, and it could be good stress or bad stress. I think most people associate it with the fight or flight response, as I mentioned in the talk. What happens when cortisol is produced in excess in the body? It layers the body in fat because it does not perceive what the stress presented is a good stress or bad stress. It just knows that there is a stress, and the idea being that your brain doesn't know if it's going to be able to find food, and so what it does is it layers you in fat because it can live off of the fat. So that's why so many individuals are, you know, asking about cortisol levels and how do I reduce my cortisol level?

Dr. Darlene Bartilucci: 5:13

And ultimately, it has to do with the amount of stress in your life and, like I said, it could be good stress or bad stress. I also mentioned earlier that oftentimes, when individuals pursue a certain diet, it's stressful to them because it's so opposite of what they're used to doing that it creates more stress. That's why it's really important to try to find a diet that works for you that doesn't create more stress, because, in an effort to try to engage in a weight loss diet that you think might work for you, it's creating more stress, elevating cortisol. Then you're really not going to be losing weight successfully.

Narrator: 5:50

I've been on Weight Watchers since 1975, up and down like a yo-yo. How do I keep the weight off permanently?

Dr. Darlene Bartilucci: 5:57

That's a great question, and I tell you that is something that many of my patients struggle with. Sustainability has always been an issue when it comes to weight loss, because what often happens is that individuals will decide that they want to lose weight for various reasons. Either they have a cruise that they're want to be you know that's upcoming or they have a wedding that they're going to be attending, and so what happens is is people will lose weight to a target number, and when they get to that target number, then they essentially stop doing what they were doing to get them to that number. And so when we talk about sustainability, the idea is lifestyle changes. Ultimately, that's what it boils down to. It's not about reaching a target number. It's about changing your lifestyle in a way that you can live with. That will help you sustain the weight loss that you have achieved or that you are looking for.

Narrator: 6:58

What are your thoughts on the value of intermittent fasting?

Dr. Darlene Bartilucci: 7:01

Well, that's a hot topic right now, for sure, and it's really a lecture in and of itself. But basically the theory is that our bodies can go without eating for a certain period of time and be okay. What's happened as we have evolved as a society and become more technologically advanced is that information has become available to us pretty much around the clock. So whereas back in the 50s the television would go off at midnight, people would go to bed, or 11 o'clock people would go to bed, they wake up the next day and they would start their lives again. And so there was this period of time where people weren't eating overnight, and so it could be between eight and midnight, whereas now people are up until late in the evening, sometimes one or two o'clock, and oftentimes what happens is it throws people into another eating cycle, and so they're eating way into the wee hours of the evening, and then they're not giving their body that break. So it's a little more complicated than I think what is put out there.

Dr. Darlene Bartilucci: 8:08

There was an article in the New England Journal that talked about intermittent fasting, and it gave several suggestions I would suggest. You know, perhaps maybe we can put a link in the talk to that. But basically it talks about the benefits of intermittent fasting, and intermittent fasting doesn't necessarily have to be a daily occurrence. There was one portion of the article mentioned that you could eat regularly five days a week and then two days a week you can restrict your calories to five to 600 calories per day, and that too would be considered intermittent fasting. So it's not necessarily what all of the Hollywood you know dietitians are saying is that you have to eat, you know, six hours a day and then you're fasting for 18 hours a day. You have to find something that works for you.

Narrator: 8:56

Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence.com or subscribe to our podcast on your favorite podcast platform.