Okay, I just started the recording. And I'll hold it up like this.
Perfect. All right. Yeah. So don't worry, either. It's since it's not straight q&a If you're like, Oh, I could totally see that better. You can and I could. Okay. Cut it in and out as as necessary. Yeah, yeah. So so just tell me, I guess I'll pull up that was to start with the first one. Yeah. So what kind of need is there for drugs? Like with goby and ozempic, and stuff like that?
Yeah. So I think there's a huge need for them. And, and a couple of your questions sort of go together as a result of that. And, and the reason is that we have been for for years and years and years, you know, prior to, I'd say, the last 10 years thinking about weight issues, as specifically obesity and overweight, as being a personal failing, and, and, you know, and not wanting to, you know, to be healthy, not wanting to take care of oneself, much in the same way that maybe 40 years ago, we were thinking about depression, and more recently, we've been that we had been thinking about addiction. And we do know, and we've known even before 2013, when the American Medical Association made obesity, a officially a disease, and a treatable you know, chronic, you know, long term, you know, like, disease. And, and, and we know that there's an entire very complex weight regulatory system that involves the hypothalamus involves a bunch of different hormones and neurotransmitters in the brain, and then a bunch more signals in the gut, the pancreas and elsewhere, that regulate body weight, our bodies do not leave weight willy nilly, to us to figure out, if they did, many of us would have why, you know, wildly fluctuating weight. And in that is really not the case, whether you're the way you want to be or the way you don't want to be, your weight does not fluctuate wildly day over day or week over week, for the most part, and in this is a tightly regulated system, because it has to do with survival. And so we know now that when, you know when when this weight setpoint, much like the hypothalamus regulates temperature, or regulates respiratory rate, or regulates metabolism through the thyroid, we know that the weight setpoint that the hypothalamus regulates when something goes wrong and gums up the machinery, that, that, that now there's a misfiring, and the body believes that it needs to send out more hunger signals to, you know, to, to load up on energy as a need for, you know, as a survival mechanism. And, and since for millennia, we have needed to essentially work against food scarcity. That has been the mechanism that has been predominant, rather than, than working on how do you you know, how do you protect against too much energetic or adipose stores in the body. And, and so that's why I think weight loss medications are really, really helpful and really important, because we know that when this weight regulatory system goes awry, that so many other of the chronic conditions that we've been treating, as a primary care providers are, are affected. So when your weight is that at a place where it's not optimal, or healthy, we can end up with insulin resistance, which then leads to pre diabetes, and type two diabetes, blood pressure or hypertension, is also a very large, even a majority of those cases are related to not being in the correct weight. And cholesterol issues much the same. Sleep apnea is almost entirely a condition of not being of, you know, of not being at an optimal weight. And there are 13 different cancers we know that are directly related to, to obesity. So and we do know also that a BMI over 40, which is considered severe obesity, reduces lifespan by eight to 10 years, which is the equivalent of smoking. So so that is how we would define a disease. And and we know that if we treat the roots, so we treat weight, all of these conditions improve. So if we treat the roots instead of the fruits of all the chronic conditions that we're trying to manage, over time, heart disease, and so forth, that instead of playing Whack a Mole with each one of these, we're able to, you know, to treat the root cause and improve people's health. So it's not just a cosmetic thing. It's not just the number on the scale, it's that reducing weight and the maintaining it over an extended period of time improves, improves quality of life and it improves. It improves the lifespan.
So, so when people have to keep taking this to maintain the effects, or can you kind of take it for a while, and then meanwhile,
so, um, so the answer is, yes. And and the reason I say that is that it is, as an analogy, it's no different than if we were to treat depression, or blood pressure or cholesterol, we would treat it and say, Okay, let's start this medication will treat your depression, we wouldn't have somebody except for this new postpartum antidepressant, that's, you know, for two weeks, we wouldn't put somebody on an antidepressant for a couple of months, we would put them on for, say, a minimum of a year, and then revisit and say, Okay, how are you doing, let's try to wean off this medication. And there will be some people who will be able to do that, because the environmental stimuli have changed their sleep, their stress, whatever has changed in a way that their neurotransmitters and all the other, you know, all the other factors that have created the depression, for them have been mitigated. And so then you can wean off this medication for some people that machinery cannot rebound. It is, you know, it is permanently in a place where it where it needs support. And so that antidepressant would have to be used lifelong. The same is true of thyroid, some people have to take thyroid medication for the rest of their lives. And some people, for instance, with postpartum thyroiditis may or may not. So this, so obesity and treating weight as much the same, and we don't know some people will need to have it for life, and other people will, will be able to wean it from them. Because their you know, that machinery can regenerate and their weight setpoint will be able to set to a healthy spot and stay there without the medication. Now, we don't have the data for that yet to say who does what it's, you know, it'll be coming in the next five or 10 years, I think as we as we treat obesity in a medical setting, and as we treat it as a as a disease.
Okay, so this kind of relates to just how it works, too. So so let me kind of give you an overview of how it works.
Sure. And keeping in mind, there are like, work, there are a variety of different medications that are FDA approved to treat obesity, and we call those anti obesity medications or EO M's, rather than weight loss drugs, and I ended up putting, like a stick in there for that, because weight loss is sort of part A, and weight maintenance is part B and that's where the rubber hits the road. And that is the holy grail of of health improvement. So once you lose the weight, that's kind of the equivalent of, I always say the equivalent of you know, being engaged and going to the wedding and then you get married and now you have to maintain the relationship and that's part B, or pregnancy the baby is born and now we have to raise the child, that's part B. And so weight loss maintenance is incredibly important. It's not just the number flipping down and, and then and then sort of saying, you know, this is you know, we're done with this, you have to maintain and think of the, the, keeping things steady for a long period of time, as as important. And so and so when we think of these new medications specifically they are called super effective EO M's, what they're doing is it's essentially hormone replacement. So there is a hormone that we've been able to make an analogue for called GLP one and that is what semaglutide which is marketed either as ozempic to treat type two diabetes, or as we go V to treat obesity is out there for and right valses is the the tablet form that's FDA approved for type two diabetes. We also have another class of GLP ones liraglutide that would just extend and Victoza same idea. Those are injectable once a day ozempic ozempic and would go VR once a week. And so a GLP ones do is that they replace a hormone that is either deficient in that person or or resistant and when they do that, they increase satiety. So that person is receiving the signaling that they are full and and the in the food noises is going away. And the way that works is that GLP one does a couple things. In the body, first of all, it crosses the blood brain barrier, and it sends that signal, you know, to the brain, it also stimulates the pancreas to to secrete insulin. And it also slows digestion down. So it takes longer for food to pass through the intestine. And as a result of that, maintains formulas longer.
Gotcha. Okay, so I was reading that, there were some things like this, just other hunger suppressants. So why are these working, so you only need like one injection a week or one poll a week.
These are these, these are long acting as opposed to the other GLP ones, which, which are daily dose, and, and, and, and so those are all in the same class of of medication, they, they're very effective, because they're, they're specifically targeting that, you know, a hormone that is deficient or resistant, as, and other medications are targeting different aspects of the, of the hunger satiety pathways. But this, this particular one is is really powerful because it it's replacing the hormone. Others like phentolamine, or Q Semia, which is the combination of phentermine and Topiramate are also effective because they can suppress hunger and reduce cravings. And then that allows for dietary modifications that allows for, for a lot of different behavioral and lifestyle changes that can happen, which could then decrease inflammation, reset, you know, extinguish certain behaviors, we don't want to have allow for weight loss, which then and weight maintenance, which then allows for someone to become a more physically active increased skeletal muscle mass and and have that advantage to, you know, to maintain to maintain at a healthier weight. They just work through different mechanisms.
Okay, gotcha. So, so will different people need different ones?
Yeah, I think absolutely. I think that that will be the case and is the case, you know, in, in where I, the clinical program that I lead, we, you know, we take an intentional approach, trying to understand, you know, what, what, what's going on, and who needs what, and essentially in our prescribing of medications, and again, you know, this way, it's the same methodology, same thinking that we would use for choosing a blood pressure medication or choosing an antidepressant for someone.
Okay, yeah. So, so with that, is there kind of, like, a way you can, what is that methodology for choosing, I guess, isn't asking, is there a way you can know,
there's not a, there's a way that we can, you know, we have algorithms that, you know, particularly where, where I practice and the and the team that I lead, that will ask certain questions and try to understand, you know, who needs what, how chronic has your condition been? What are the different factors? Is it you know, is it stress is it sleep, and, you know, there, you know, we've identified nine key factors that sort of come into this equation, and then we'll work through them and try to understand where you know, where to focus first. And if the medication is indicated, which medication might impact that impact that the most, having said that GLP ones are very effective. And in many cases, they, they can be a very good medication for, for many of the patients, even if it's not just a satiety issue, per se, they can also decrease cravings, and it can improve binge eating disorder as an example. So, so so there's a lot of signaling in our body. That that is fascinating. And we're still learning we're still learning about but we do see patterns such as that
we live through so these questions that instead of a lot of them with first one, yeah, they're
all kind of like very related. So yeah, so it's kind of like a full circle.
Yeah, works works really well. Um, yeah. So just kind of Lastly, now. You know, I was looking at just stocks rising in companies making Oh, AMS
Aom. Yeah.
Hmm. Stocks are rising, you know, all this stuff. Do you kind of see how that's going? Do you see what do you what do you see for the industry? I guess?
I see that the industry, there are a lot of medications that are coming down the coming down the pike because we're understanding Wait, more and more and we're understand The the impact that it has overall on health and the width, you know, 70 to 75% of the country's having a weight issue if you include overweight, and I and so it's not, you know, everybody, three quarters of the country is not trying to not be at the weight, they want to be in spending billions of dollars on it. It's an issue. And all those and as we mentioned, like all that issue leads to all the other issues and is is, you know, putting excess undue stress on the health care system, because we're treating these conditions rather than treating the root cause. So there are a lot of medications now, as we understand these pathways more and more, which are in phase two, and phase three studies right now. And then one of them has already been approved. It's a double hormone therapy. And the generic is terzetto peptide, which is also known as Manjaro. And, and that is, by Eli Lilly and slated to also receive FDA approval. Most likely, by the end of the this year, or maybe early 2024, I would think at the latest. And so Manjaro is a combination of GLP one, as well as another hormone called G AIP. And when you put those two together, there's, it's even more effective, you know, in terms of in terms of weight loss, and weight maintenance. And, and so, so that medication is you know, already, you know, out and, and has, has results when combined with intensive lifestyle intervention. So behavior, nutrition and physical activity, because it's not just you just throw a pill into it or give a shot. And you know, you're all done. And, and it is having very close to Sleeve Gastrectomy results, and so you're getting surgical results without the surgery. And and then we can impact more lives, we can improve, you know, improve people's health. And then there was just the Select study that that came out regarding semaglutide and shows that there's a 20% risk reduction in cardiovascular disease and stroke when using SMAC, low tide, and those results are going to be presented in the fall at at the Obesity Society Conference. And and that's powerful, because we're, you know, we're really saying this, you know, and these weren't people who had type two diabetes, these were people who had obesity, and and so what we're saying here is that this, these, these medications are powerful. And it's not just because you want to look good, it's because they're saving lives. Yeah.
All right. Well, I think that's just about all my questions. And I don't want to go too far over what I said. So as Yeah, they're just anything else you want to say about it?
I think that would be about it. The you know, there are a bunch of other medications, if you're interested. There's the macro Mab, which is a monoclonal antibody, all sorts of things. But, but that would be probably be getting into the weeds and geeking out, but there's lots of interesting stuff coming, you know, coming and and that we will see, you know, in the market in the next, you know, two to five years, and I think it's really changing the landscape of how we'll be changing the landscape of how we practice medicine.
All right. Actually, before I let you go, I've woman thing can you just tell me like, you know, Hi, I'm
sure. So I'm Lydia Alexander, and Dr. Lydia Alexander, and I'm a I'm a board certified in internal medicine, as well as two sub specialties that are related to the work I do. One of them is obesity medicine. So I'm an obesity specialist. And the other is lifestyle medicine. I am also trained as a medical chef, which is just a fun fact, but very relevant to the work I do as well. And I am the Chief Medical Officer at a telehealth startup in in medical weight management called the NARA health as well as the the incoming president or the president elect for the obesity medicine Association, which is the largest medical association in our field. That's that for clinicians who practice or intend to practice obesity medicine.
Right, thank you so much. Um, yeah. I am seeing more question Do you have do you have five minutes? Okay, sure. Um, I just wanted to when I was when I was hearing, you know, you're losing a lot of weight with especially like, Manjaro. That sounds like it could be unsafe. So, you know, how, what kind of tests are going into making sure that these are okay. Yeah. How long in development? I guess.
Yeah, the developments. I mean, GLP ones have been around since 2005, which I think not many people, you know, may know or appreciate. There are some predecessors that needed to be dosed twice a day and In other things like that, but we're superior to insulin and continue to be so, you know, so So we're good, and we just keep on getting better at it. So there is long term data with any medication that's effective, there are going to be risks and there are going to be, and there are going to be benefits, there are going to be adverse events, and there are going to be side effects. And this is true of aspirin. It's true of thyroid medication, it's true of antidepressants and every other medication that we use. And so this, this area is really no different than that. There are some people who should not take the medication. And you know, for some rare, some rare reasons that I have personally not seen in my practice, like modularity, thyroid cancer, or multiple, multiple endocrine neoplasia. If, if there's a family history or personal history of those, then an individual shouldn't be taking GLP ones, because theoretically, we've seen in, in mice studies that they can cause these tumors to to occur cause cancer, I would say in terms of very adverse side effects. pancreatitis is possible. A toxic mica colon I've seen, so I don't think that is, you know, I haven't personally seen but have heard of as a case study. There can be an increase in suicidality, though, though, I also do not see that very commonly at all, either. And I would say that antidepressants also have this risk. And, and we don't see it that that commonly either just to kind of put things in context, because I know it can sound scary to say that. And, and then we have very common side effects such as nausea, constipation, diarrhea, fatigue, and that's why these medications are slowly titrated, up over over four or five, six weeks. And and then those those symptoms go away. Some people have can develop a rash at the injection site. And sometimes it's just not possible to have this medication because somebody, you know, because it doesn't, because it's there's an allergic reaction. So that's, you know, so that's kind of the, you know, the, the the way that it goes, and, and again, like but no different than the other medications that are medications that we use that are far more high risk, but we need to use for very high risk situation, and so we do.
Okay, cool. All right. Thank you so much. My pleasure. It's, it's all if you could just email me that recording. Yeah, be fantastic. Okay. Absolutely. Yeah. And let me know if you find anyone that I could talk. Yeah.
So a question on that, like, you're looking for somebody who is on with Goby, or on ozempic? Is, is there anything in particular beyond just being on the medication that you're interested in?
Or, I mean, really, it could be anybody who's taken a weight loss medication, or Oanh? aylen?
Alm? Yeah. Anti obesity medication?
Akos, personally, alphabet soup goes first. Um, so? Yeah, I'm really anybody because I'm just looking for somebody to kind of be a face for this does that? Oh, yeah. You know, I've done this and this happened, and either it was good, or it was bad. Okay. I'm done now. Or, you know, okay.
Yeah, I have I have three patients, I can think of that. That probably would, would be willing, you know, because as you know, like, you know, weight is, you know, there's high, personal, it's very personal. There's a lot of stigma and judgment that happens. And we're, you know, which is very unfortunate, but, but I think we're getting the message across, you know, in, you know, in the patients that we treat that this is not a personal failing, so I think I could probably get them to, to, you know, to, to connect.
Yeah. And it's also just as an encouragement, like, this is really it's an exciting thing. Like, this is a story about something exciting. Something like, oh, this has happened in your culture. What's going on? Right? Makes sense.
Yeah. Yeah. I think I know what you mean. And, yeah, it's for it's more about medical, scientific, you know, what's, you know, what's on the horizon? It helps health related, rather, rather than let's talk about the fat or, or something sensational that you would see in people. Exactly. Got it. Okay.
