Weight Loss Medications

Podcast Transcript

Dr. Scott Steele: Butts & Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. It's always great to have another expert back for an additional time, and today I am very pleased to have Dr. W. Scott Butsch, who is the director of obesity medicine at the Bariatric and Metabolic Institute. Scott, thanks so much for joining us on Butts & Guts.

Dr. W. Scott Butsch: Thanks for the invitation, Scott.

Dr. Scott Steele: So, for those who haven't gone to our back episodes, you were one of our early experts on. Tell us a little bit about your background, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. W. Scott Butsch: Sure. Originally from Buffalo, New York, and I specialize in obesity medicine, it was through the track of internal medicine. I did internal medicine residency, went on to do a specialty in clinical nutrition in Alabama. Then I was the first physician in the United States to complete a fellowship in obesity medicine at Harvard and Mass General Hospital in 2008.

Dr. Scott Steele: Wow, that's absolutely fantastic. I did not realize that. So today we're going to talk a little bit about weight loss or obesity medications and how the obesity medicine program in the Bariatric and Metabolic Institute here at the Cleveland Clinic helps patients to find the right treatment that is right for them.

So I got to be honest with you, it seems like medications like Ozempic and Mounjaro have been hot topics recently. Can you tell me a little bit more about these medications?

Dr. W. Scott Butsch: Yeah, these are two brand names of medications, one which is called semaglutide, which is known as Ozempic, for the treatment of type two diabetes, and Wegovy for the treatment of obesity. The other medication is called tirzepatide, which goes by the name of Mounjaro for the treatment of type two diabetes, and Zepbound for the treatment of obesity. This excitement began a few years ago with the FDA approval of Wegovy, which is that higher dose of Ozempic in 2021, and it was the first medication approved for the treatment of obesity in about seven years. The excitement was really around the effect it had on body weight, up to 15% body weight in the one-year trial, which far exceeded the previous drugs, which were less than 10% body weight. Then a year later, Mounjaro came out for the treatment of type two diabetes, but the study itself showed that the weight loss in individuals on the medication was over 20%. So here you had two drugs that really shifted the treatment of medical obesity.

Dr. Scott Steele: So, can you tell me a little bit more about how these medications actually work?

Dr. W. Scott Butsch: This is a class of medications that's been available for type two diabetes and obesity for the last 20 years, starting in 2005 actually. It's produced about four to six medications that have changed in terms of their delivery. Most of these are injectable forms and they've been delivered once a day, and now you see these longer acting drugs working once a week. What they do is they mimic a natural hormone in our intestinal cells that is released after our intestines receives the nutrients that we eat. This has a natural effect on the brain that tells our brain that we're full, and also on our stomach, delaying the stomach from emptying, which also gives us an earlier sense of fullness.

Dr. Scott Steele: So, if they've been around for the last 20 years, why do they seem to be on every television commercial that I turn on now? What has changed?

Dr. W. Scott Butsch: Yeah, I think it's the excitement. So you have a combination effect here. You have the excitement over the effectiveness, clearly outdoing all the other previous medications. Second, you have a drug and a class of drugs that people have been used to. They understand the side effect profile, they understand the effect on their patients over the last 20 years, and are comfortable with using it for the treatment of obesity. Whereas previously, providers might've been scared, not wanting to use the older medications for lack of knowledge or lack of experience, etc.

Then you have patients, patients have been seeking a very effective medical treatment and has taken several decades for that to come around, and here you have it. So it's like a perfect storm, Scott, where you have all these things happening at once. Then all of a sudden you had a shortage of these medications because there was so much excitement and a lot of people fell back to Ozempic, which is the lower dose of Wegovy, not for the treatment of obesity, but it was the alternative therapy. So then you see the excitement around that as terms of a brand almost, for this whole class of drugs.

Dr. Scott Steele: Does a patient need to have diabetes diagnosis to be prescribed these medications?

Dr. W. Scott Butsch: No, and that's the thing, that these medications work in two different pathways. One to benefit control of sugars, and the other one to control weight in the body weight pathways.

Dr. Scott Steele: The other thing I see that's out there a lot is the fact that patients that may not really truly have obesity are taking Ozempic. I've seen some perils associated with that, and one needs to look no farther than the internet to see that. But can you talk a little bit about this?

Dr. W. Scott Butsch: Sure, yeah, good question. I mean, again, as I said before, you have a huge provider group that all of a sudden can treat and will treat obesity, but you also have a rebranding of the cosmetic industry that's coming up saying, okay, we can just get somebody on one of these medications. So you're getting a whole industry that is practicing obesity medicine incorrectly, probably leading to some of these safety concerns that you have. Really, I think to your point, matching it almost using these medications as diet supplements, whereas clearly these are medications that have been well studied for the treatment of obesity and diabetes, but they're being used as sort of a crutch, a dietary supplement, per se.

Dr. Scott Steele: Can you talk a little bit more of the effectiveness of this? I mean, are the results guaranteed to work for everyone?

Dr. W. Scott Butsch: Like any other medication for any other disease, there's variation. Not everybody who gets anti-hypertensive or a blood pressure medication resolves their blood pressure. Some people just don't respond to the medication. These medications are no different. Some people do very well, some people don't do well at all, but we don't blame the patient saying, well, you must be doing something wrong because you're not responding, you're not losing weight with a medication. Just like a chemotherapy is not working for somebody's cancer, we just choose another medication.

Dr. Scott Steele: So, we talked a little bit about concerns potentially over the safety profile of these patients, but can you talk a little bit about the side effects of taking these obesity medications? Are they safe for long-term use?

Dr. W. Scott Butsch: Like any medication, there's potential side effects. The more common side effects in this class of medications, which includes the ones we're talking about, are gastrointestinal. So they slow the stomach from emptying. So some people get a little bit nauseous, some people vomit. There's a little bit of change in the motility of the gut, so some people have diarrhea, constipation, fatigue. Those are the more common side effects, if they have some side effects. Concerning ones would be the association with medullary thyroid cancer. So it's very important to look and ask our patients who may have a history, family history, personal history of that, or MEN2, which is a endocrine tumor constellation. So we really try to make sure that there's none of that in the family history.

Dr. Scott Steele: What about the long-term use, is that safe?

Dr. W. Scott Butsch: So again, these medications have been out for 20 years, they've been well studied. There's not a 20-year study that's going on, but I think people feel safe. That said, I think that we need to have long-term trials for these drugs to look at the safety. Right now there's over five year trials that show that these are safe to be used for that period of time.

Dr. Scott Steele: Truth or myth, truth or myth, a person with obesity does not need to make any other lifestyle modifications when they're taking this obesity medication.

Dr. W. Scott Butsch: Yeah, that's a myth. I think the thought is that these medications will be the end-all, the be-all, the magic formula. These two need to be utilized together, you need to work on a lifestyle and modify that to whatever that person's needs are. What we see these medications coming in as either they have a direct effect on the brain or the gut, or maybe they do have an indirect effect on making us feel more full and because of that we're losing weight, or maybe they make us feel less hungry, but that in itself can't be used by itself.

Dr. Scott Steele: Scott let's be honest, historically there's been a lot of stigma and even bias attached to a diagnosis of obesity, and a lot of shame, to be honest, from a patient perspective. So, how has that stigma impacted patient care?

Dr. W. Scott Butsch: I mean, I think we have to look at historically how obesity has been viewed. It's been viewed essentially as that person's fault. We as providers have blamed our patients for having obesity, judging them on their size, why we look at them thinking that they're over eaters, they're lazy, and all the other stereotypes that we all know. Because of that, not only has it placed the blame and people as a result feel shame for having obesity, they don't even seek medical care, because why would I want to go to you as a provider if you're just going to tell me to eat less and move more? Even in the setting when I say as a patient, I'm eating less and I'm moving more and I'm still not losing weight, you bashaw it and say, you just got to do a better job. So we've cast these people who have obesity, which is highly genetic and has profound hereditary traits that are attached to the disease of obesity. We've tied that in with a distinct behavioral trait as if everybody who's thin has a higher moral of choosing the better foods or exercising more. I think you and me both probably would know. There are people who are thin out there who are eating garbage and not really exercising, yet they maintain their leanness. Not because they're good people and people who have obesity aren't bad people.

So I think the more and more we recognize it as a disease, I think we'll reduce that stigma because people who have obesity get less care, less time is spent with them. They're less likely to get preventative care, there's a decrease in pap smears or mammograms in Caucasians who have obesity. Then that input on the patient. Actually, people who were polled who have obesity, over 3,000 people, 65% of them believe that obesity is a disease, only 65%. More than 80% of people who have obesity who were polled believe that their weight is their responsibility. So there's a historical, continued concern among the patients who think it's their fault.

Dr. Scott Steele: That's pretty incredible statistics. So, okay, I'm a patient. I'm thinking about taking this medication or I'm on this medication. What happens when somebody stops taking the medication?

Dr. W. Scott Butsch: Yeah, back to the analogy of using it in the context of other chronic diseases. These medications, if they have some effect indirectly on the brain or their gut and they're useful just like a blood pressure medication or cholesterol medication, when they're stopped, you're going to see a return to that higher state. In this case, it's a higher weight. So weight regain would be one of the complications of that.

Dr. Scott Steele: With the popularity of these medications, certainly as you described earlier, the demand for these medications has increased, but there's certain patients out there that, let's be honest, can't get access to them. So are there alternative options for those patients?

Dr. W. Scott Butsch: Yeah, I think we have to recognize, at least in our field of people who specialize in obesity medicine, we recognize there's 10 other medications that have been around for 10, 15 years that are perfectly fine in some people. We should utilize those, that we're not just sort of all on this GLP-1 party bus thinking it's a GLP-1 drug or nothing.

This really also exposes our healthcare system, which clearly there's disparity of care among people who actually have obesity and need these and would really benefit from these medications, yet insurance companies for the most part, don't cover them. Why? Because if you don't believe obesity is a disease and you think that person who has obesity should just eat better and move more, why would you ever want to cover these medications? So, we've historically battled insurance companies. We're making some inroads, I think there's people who are listening more, but clearly there's an access issue. Supply, as I told you earlier, but a real access issue in terms of our healthcare and then the coverage.

Dr. Scott Steele: So, what are the benefits of working with obesity medical professionals like those within the Cleveland Clinic's Bariatric and Metabolic Institute?

Dr. W. Scott Butsch: I mean, we have a group of highly trained sub-specialized providers who solely focus on one disease, obesity, we don't focus on anything else. So we have people who treat people who have obesity the right way. We're not pejorative, we don't blame them for their disease, we're trying to help them. We also recognize that there's probably many different subtypes of obesity. So we're not going to have a one size fits all approach. Not everybody's going to go on a low-carb diet and not everybody's going to get a GLP-1 medication. We have a variety of treatments. So any treatment you would think that could be delivered for the treatment of obesity is within the Bariatric and Metabolic Institute. We have bariatric surgeons who do surgical operations. We have dieticians who deliver nutrition interventions, psychologists who take care of behavioral treatments, and then people like myself who specialize in obesity medicine, who can deliver pharmacotherapy and tie that in with the lifestyle modification we talked about earlier.

Dr. Scott Steele: One final question. So, do you have any information about patients who get weight loss surgery? We've had podcasts on weight loss surgery that are on these medications, or is it a bridge for these medications to surgery, or is it just you get medication or surgery?

Dr. W. Scott Butsch: Yeah, it's a great question, because if you think about, and I think for the medical people out there, if we think about the treatment of cancer, you're going to get that cancer probably surgically removed, and then you're going to have some other adjunctive therapy or additional therapy like chemotherapy, and maybe some people even need radiation for that cancer. In a similar way, we view obesity as a complex disease that may not be completely resolved after an intervention, whether that's surgery or medication or diet, etc. So we really focus on understanding that it's not of a one monotherapy, it's probably likely that people need more than one therapy.

So for your question, people who've already had surgery, some people respond very well and don't need any other treatment options. Then there's people who respond well but they still have obesity, and then there's clearly people who don't respond. The science isn't there to guide us of who those people are and to pick that right person, but we at the Bariatric and Metabolic Institute recognize that complex disease and are perfectly comfortable with utilizing combination therapies.

Dr. Scott Steele: That's fantastic. So now it's time for our quick hitters, a chance again, to know our experts just a little bit better. So first of all, what was your favorite trip?

Dr. W. Scott Butsch: I took a trip recently to Saudi Arabia, which is really an eye-opener, and it really shows you that there's a country which we think is just a big desert, has incredible resources, natural resources, beautiful natural resources. So that was a favorite trip. Other than that, Alaska. I think the mountains, the snow, the wildlife is a fantastic trip.

Dr. Scott Steele: What was your first car?

Dr. W. Scott Butsch: My first car was, I forget the year, but a Chevy Chevette, a brown one, brown was a pretty interesting color in the '80s, and it had no floorboard. It had so much rust, it had a hole in the bottom of the car, but that was my first car.

Dr. Scott Steele: Fantastic. Salt or sweet?

Dr. W. Scott Butsch: That's a tough one. I think I'm going with the mixture, but I would say probably salty.

Dr. Scott Steele: Fantastic. Then finally, so what did you think you were going to do as a kid when you grew up?

Dr. W. Scott Butsch: I really liked environmental sciences. I thought I would do something with the environment. One of my first classes, I had somebody who worked at Chernobyl, so I was really interested in sort of shaping the environment and reducing garbage and the stuff we still see.

Dr. Scott Steele: Fantastic, and so give us a final take home message for our listeners about this entire weight loss medications and obesity medicine.

Dr. W. Scott Butsch: Yeah, I think if we look back on this class of medications, I think we'll look back at it as foundational therapy for the future. Obesity care, much like the long development of statin drugs for high cholesterol, there's been a long journey in the discovery of these GLP-1 medications. I think multiple mono and combination therapies will be discovered in the years to come.

However, that said, these medications aren't for everyone, and it's important to find a doctor and a provider who's trained in obesity or has experience in treating people with obesity, who can best gauge whether these medications would be helpful in combination with lifestyle modification.

Dr. Scott Steele: Fantastic. So to learn more about weight loss medications or to schedule an appointment with the Bariatric and Metabolic Institute at the Cleveland Clinic, please call 216.445.2224. That's 216.445.2224. Scott, thanks so much for joining us. I'm Dr. Scott Steele with Butts & Guts.

Dr. W. Scott Butsch: Thanks, Scott, appreciate it.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.