14: Telehealth Obesity Medicine and the Death of Diet CultureMay 22, 2023
I was recently invited to be a guest on the new PlusSideZ podcast, born from a TikTok trend-turned-movement to educate on treating obesity medically as a chronic disease. This is a community that wants to remove the stigma around obesity and advocate for access to affordable medications.
I have been so excited to share this with my own community, as we dive into a number of topics that I know will benefit you as well. We discuss the traumatic damage that diet culture causes, the rise of telehealth obesity medication, and how GLP-1 medications like Ozempic, Wegovy, Saxenda, and Mounjaro can help obese patients create a healthier lifestyle.
Why have telehealth medicine practices specifically designed around treating obesity become so popular?
The obesity medicine community has always been underserved. They have never had a voice, and they've never had sound medical advice, where they've been taken seriously or been listened to, and this has compounded in several ways.
Firstly, access to obesity care is extremely limited. There are not enough specialists or people who hold this information that are willing to help in this area. If you are someone that wants to get this help, there might not be anyone near you geographically to serve you. Telehealth provides the opportunity for specialists to have greater reach, but it remains an issue that there are not enough specialists.
Secondly, when you look at the community where people have been struggling with weight, they've often been stigmatized or experienced bias when they have visited a doctor. This means a lot of people feel more comfortable accessing a telehealth platform where you can be in the comfort of your own home.
Unfortunately, there are a lot of medical providers that are not up to speed in terms of obesity being a chronic medical condition, and how to help and recognize their own bias and stigma.
What are the differences between some of the anti-obesity medications in terms of how they are marketed or packaged?
As a medical provider, we should really be able to write for any medication that we think is sound for our patient, yet weight is held to a different standard with roadblocks put up by insurance. Quite often in the initial study, they'll see that weight really came down and they kept it off long term, but they'll force those companies to go through another round of randomized controlled trials just to be able to use the medication for a different indication and to get it FDA approved.
Victoza is the same thing as Saxenda, and the generic name is Liraglutide. Victoza is marketed for diabetics, whereas Saxenda is marketed for weight management. They are usually very much interchangeable, but there will often be a slight dose difference. It’s the exact same medication, with the exact same side effect profile.
The drug Ozempic came out first, and was followed by Wegovy (generic name: Semaglutide). Ozempic is for diabetics, whereas Wegovy is for weight management, but you could really use it interchangeably.
How is Mounjaro different from the other drugs in the GLP-1 class?
Mounjaro (generic name: tirzepatide) came out as being FDA approved for type two diabetics. In the trial they had amazing weight loss, seeing around 20% total body weight loss, which comes close to what bariatric surgeries do.
When you look at other GLP-1 medications like Saxenda or Wegocy, they are just a GLP-1. Mounjaro, however, is a GLP-1 plus GIP, and so acts in two different ways, meaning it has more of an effect than just a GLP-1. Mounjaro has a higher weight loss percentage compared to a drug like Wegovy, which is just GLP-1, and sees around 15% total body weight loss compared to over 20% with Mounjaro.
Therefore it’s important when working with a patient to know how much weight they are trying to lose and roughly where they are headed. Goal weights can be triggering, but if you’re looking for example at a BMI over 40, you might have a hard time getting closer to your goal without a medication like Mounjaro.
The problem has been that Mounjaro has not yet been FDA approved for weight management. They have done trials and this will be coming soon. When the drug first came out, they had a savings card to try to promote it. When this happens, drug companies often give doctor's offices samples and they do coupon cards.
The problem is when the savings cards run out, people are in a position where they run up against the stigma and bias of insurance companies saying that this is aesthetic, and it's not a medical condition, so they're not going to cover it. In those scenarios, I really recommend that people work with their doctor because there are other options. There are generic oral options and other things that we can do. It’s important to work with the medical doctor and not let this be the part where all the weight comes back on.
What are your thoughts on WeightWatchers entering the telehealth prescription drug space?
I think this conversation really shows that the future is not in ignoring that obesity is actually a medical condition and that there are potential treatments for it. The evidence cannot be overlooked anymore. The literature exists showing that only 5% of people can lose 20% of their weight with lifestyle alone and keep it off. For most people, it's around 5-7%. So if you are in a larger body, it's not unreasonable for you to maybe want to lose more than 5%.
Diets in the conventional sense over the past few decades have always been encouraging people to stick to exact numbers, or count a certain amount of points. They often provide meal plans to stick to with no regard for your food preferences, religion, cultural background, or upbringing. They do not encourage you to listen to your body and hunger signals. These approaches where you are never listening to yourself and always looking to external recommendations, never work in the long run. They ignore your body's physiology.
WeightWatchers probably sees this and knows it can’t ignore the evidence any longer. I don’t know what direction this company wants to go in but in general, I think we know diet culture doesn't work long term, no matter how much people want to believe it.
What is your perception on maintenance and encouraging the medical community and even insurance, that obesity is a lifelong condition?
The maintenance conversation is something that's really evolving right now, and will look different for different people.
What we see from the studies is that if you stop the medication, the weight gain slowly comes back. That's not to say that everybody gains it back, but like with any medical condition, if you had to use that on the way down, then you might need to keep using it. This might look different at maintenance, so it might be that instead of every seven days, it's spaced out a little bit more or the dose comes down a bit. I don’t think that it's a reasonable expectation for the majority of people to suddenly stop the medicine.
Before I ever start medicine with a patient, I make sure that they know this might be a little bit of a long haul. If they’re not willing to do it long term, then it's not helpful because you're going to have this rebound hunger when it goes away and get back into a yo-yo cycle.
I personally don't know that we have a cure. Unfortunately this is something that needs to be managed for life. You might be doing great for a period, but then we might need to change medication, or stop it for a different reason, or look at bariatric surgery.
What is the reason behind the recent shortages in the GLP-1 drug class, which have been a cause for a lot of anxiety and stress?
I don't think this has happened as a result of media attention and people just trying to “lose a few pounds”.
A really big percentage of the population qualify for this drug and in the past year, it's finally become public knowledge that this medication is available. People have become aware that there's an effective treatment out there.
And as far as drug shortages go, that's a manufacturer problem. It really comes down to the fact that there's been an ongoing need that we have not been able to meet. Now we finally have some of that treatment, everything else needs to catch up with it, including legislation, insurance coverage, and medication being made at a high enough rate.
What is the ‘compassion pause’ and how can it help people to lose weight sustainably?
A lot of what we're wanting to do is develop a new relationship with food where we're stopping at enough and not full. But sometimes that can be hard to work on if you've never worked on that. So one of the tools that I came up with is called the ‘compassion pause’, which does take a long time to implement.
This is when you notice, for example, when you're in the middle of a meal, that you’re satisfied but you want to keep going because it tastes good. You have an urge, but you're not physically hungry. The compassion pause helps to physically pattern interrupt in some way. You could leave the room, or put the fork down. Something needs to break the circuit so that you can ask yourself what you really need right now. You might realize that you’re actually really tired, or annoyed, or irritated.
Some of us, especially women, can feel resentful at the end of the day when you’re carrying the second load of having to do all the housework. Food might have always been the answer. That’s ok, because you are always taking care of yourself in the best way that you know possible. So don’t villainize the current or past version of you because it won’t lead to a great future you.
If you can physically pause in those moments and try to build up to five minutes, that’s great. in the future you can see if you can solve for that and not have that extra food to see what happens.
After you’ve stopped and asked the question ‘what do I really need?’, give yourself permission. If you want to eat that thing, eat it, and that's fine. But now you've disentangled that this is happening to you and you're starting to build up the emotional resilience and emotional strength to realize it’s an emotional eat. You're able to label it and gain mastery over time of not always turning to food. But it's not restriction as it’s coming from a different place.
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