Exploring Effective Weight Loss Methods

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 and Guts. I'm your host, Scott Steele, the President of Main Campus Submarket here at Cleveland Clinic in beautiful Cleveland, Ohio.

And today I'm super excited to have our expert Natalie Larson, who's a nurse practitioner within the Bariatric and Metabolic Institute at Cleveland Clinic. And today we're going to talk a little bit about weight loss options. So Natalie, thanks so much for joining us on Butts & Guts.

Natalie Larson, APRN: Thank you for the invitation, Dr. Steele. I am so excited to be here.

Dr. Scott Steele: Well, we're excited to have you too. And so as always, we want to get a little bit of background for our listeners about you. So tell us a little bit about where you're from, where did you train, and how did it come to the point that you're here at the Cleveland Clinic?

Natalie Larson, APRN: Sure. So originally from Youngstown, Ohio. I did my undergraduate training in nursing at Youngstown State University, and earned my advanced practice degree at Walsh University, which led me to my passion in the specialty of obesity medicine. I am currently completing a training in the field through a fellowship program here at the Bariatric and Metabolic Institute here at Cleveland Clinic, which is the first of its kind in the country for advanced practice providers in this subspecialty.

Dr. Scott Steele: That's fantastic. And so today, we're going to be talking about weight management options available for people living with obesity. But before we jump in there, can you tell us a little bit more about how a treatment plan is developed for those who are looking to work with an obesity trained medical practitioner?

Natalie Larson, APRN: Yes, absolutely. So here at the BMI, we provide many different weight management options for individuals living with obesity. We utilize a shared making decision approach in which an individualized treatment plan is created that is very specific to meet the patient's individual needs. As we all are learning and seeing on the media and internet, treatment options for obesity are rapidly evolving. And the evaluation goes way beyond a person's body mass index or number on the scale to determine an appropriate and effective treatment plan.

So here at BMI, our highly skilled obesity providers take into consideration the whole picture through an in-depth evaluation where we learn about the individual's lifestyle. Through addressing specific factors that could be contributing to weight gain, including a thorough health history. And we assess for weight promoting medications, eating behaviors and styles, perhaps, exercise routines, sleep patterns, and stress levels, just to name a few.

Dr. Scott Steele: Yeah, I'm not going to lie to you. I do like to eat somewhere between 8:00 P.M. and 10:00 P.M. at night, get into the candy or maybe a little bit of chips there. So, let's talk a little bit more about this. When patients come to see you, I would imagine a lot of them have tried diet or maybe exercise or a medical approach. But can they step right into bariatric surgery? Or for those that haven't tried this, do you guide them to a certain diet? And can you talk a little bit about that?

Natalie Larson, APRN: Yeah. So many people may enroll in our bariatric surgical pathway, right from the get go. Many individuals have tried, like you said, multiple home interventions, through fad diets and exercise programs for many years without sustainable weight loss. And they may have pre-existing conditions that would limit them from specific medication options. And so, they do decide to pursue a surgical approach.

Or maybe on the other hand, you have an individual with a higher body mass index with multiple comorbidities to where surgical interventions would be the best long-term treatment option for their obesity. So for instance, just an example based on some of the clinical trials that have been done, the roux-en-Y gastric bypass is one of the most effective treatment options with a dual benefit on the pathways that regulate weight and blood sugars, and those who suffer with both obesity and diabetes. So in these instances, pharmacotherapy for weight loss may not always be trialed first.

Dr. Scott Steele: So Natalie, can you talk a little bit about how all these things come together, surgery, medicine, nutritional, evaluation, and nutritional care? Are these ones that are worked in combination, or are they options that are looked at separately?

Natalie Larson, APRN: We highly recommend and encourage the use of a combination approach for obesity management. So just like any other chronic disease state or process, there may be one intervention that is successful, or maybe an individual needs a combination of therapies. So if someone's struggling with atrial fibrillation per se, a heart arrhythmia, and they're on an anti-arrhythmic medication to control their heart rate, they may at some point also require procedure such as an ablation to treat the arrhythmia itself.

And so, treating obesity is performed in a very similar fashion. We know that healthy lifestyle through diet and exercise is essential. However, the evidence reveals that obesity is much more than that. We are dealing with a chronic progressive disease. So just like when individuals have diabetes or high blood pressure, sometimes it takes a combination of interventions to be successful with multiple anti-diabetic agents or insulin, along with many other antihypertensives when treating hypertension.

However, once medical providers understand the science behind obesity, I think that they will support and believe that we can't just tell our patients to eat less and move more. A combination of treatments is typically necessary. And they're highly encouraged for individuals seeking weight loss.

Dr. Scott Steele: So if you do a full evaluation on patients and you decide a medical option is the best option, at least for the start for that patient, can you tell a little bit more about these medications? I know we've had Dr. Butsch on in the past, and I encourage all our listeners to go back. But do they simply suppress the hunger, or how do they work?

Natalie Larson, APRN: So, there's multiple different classes of drugs that we prescribe to treat weight loss. And they all kind of work differently. But there are different forms as well, of medications that can be delivered in different routes. So we have oral forms that patients take by mouth, so we have those kinds of pharmacological agents. And then we also have our once daily to once weekly injectable medications that are newer to the market. And the medical option may include a single medication or a combination of multiple medications that entirely are based on the patient's profile, contraindications to those drugs, allergies, et cetera.

However, with the newer injectable medications that are on the market, such as the GLP-1 receptor agonist like Ozempic that is FDA approved for type 2 diabetes and Wegovy that is FDA approved for weight loss. And the newer ones, Mounjaro and Zepbound, in which mounjaro is used for type 2 diabetes and Zepbound for weight loss. These classes of medications work by mimicking natural hormones that are released by intestinal cells after we eat a meal. So in turn, this helps to delay gastric emptying, as more satiety hormones are circulating in the GI system. And this makes people feel fuller for longer periods of time, which is the mechanism behind the reduced hunger and appetite suppression.

Dr. Scott Steele: So truth or myth, truth or myth, weight loss is guaranteed, once a patient begins taking a weight loss medication?

Natalie Larson, APRN: That is a myth. So again, obesity as we know, is a complex chronic disease. It may not be completely resolved after an intervention. There are many variations in how individuals may respond. So some medications, individuals respond extremely well. We call them super responders. And some others not as much. They may require a higher dose of that medication or an additional pharmacotherapy agent and adjunct. Or they may require a different medication or a different alternative therapy altogether. However, we do know that when individuals follow a healthy diet and exercise regime, we see that they tend to respond to these medications more effectively.

Dr. Scott Steele: So, you mentioned a little bit earlier that weight-related diseases can have an impact on a patient's quality of life or underlying comorbidity. So are these medications able to help address those underlying conditions, along with the weight loss?

Natalie Larson, APRN: Yeah, great question. We get this a lot, amongst our patients as well. And this is one of the many benefits of weight loss treatments in access and care for an obesity-trained provider. As weight loss occurs, weight-related complications do improve. And as I may have mentioned earlier, there are many cardioembolic and kidney complications related to overweight and obesity. So, these medications target hormones to help shift that weight set point, which is a theory that we use in practice that is essentially an idea that every person predetermined fat mass or weight range. And there are various physiological mechanisms that come into play with that.

And so as this weight set point "resets" with obesity treatments in many that we have already discussed, we see that metabolic disease does improve. And so, this may be better management of blood pressure, adequate blood sugar control, less risk of mortality associated with cardiovascular risks. And we use these medications that can decrease hunger and increase satisfaction with less food. And sometimes, it may help to reduce binging and cravings, and reduce that preoccupation with food and also increase metabolism.

And so, many of these medications we use to treat obesity may also have a dual impact or effect on treatments of other disease processes that help patients improve their overall quality of life. So we see that know headaches may improve, individuals suffering from depression may have an improvement in their mood, addiction, asthma, arthritis, chronic pain. There are so many other disease processes, but just to name a few.

Dr. Scott Steele: So, what are some of the qualifications that a patient would have to meet to start these weight loss medications? I turn on the TV and I see you can even have a phone call and go on nowadays. But are there specific criteria that has to be met?

Natalie Larson, APRN: Yes. So in order to start a pharmacotherapy or medication, individuals do have to have a body mass index of 27 or greater with an existing comorbidity. So, that could be the high blood pressure, high cholesterol, sleep apnea, or BMI of 30 or greater. And here at the Bariatric and Metabolic Institute, we also medically manage bariatric and metabolic surgical patients, preoperative management for individuals who may be undergoing an upcoming procedure or surgery, such as an organ transplant, a joint replacement, or hernia repair surgery. And we also do preop combination therapies with anti-obesity medications for individuals with a BMI above 60.

Dr. Scott Steele: So, let's say that you start me on medications and I stop them. Can the weight come back?

Natalie Larson, APRN: Yes. So again, being that obesity is a chronic progressive disease, we do see that weight can return after weight loss, whether individuals stop medications or maybe they have bariatric surgery. One of the biggest complications we see from bariatric surgery is actually weight regain. And so, that's why consistent follow-up is really important. So in the post-operative medical management, we like to see our patients at three months, six months, 12 months, and then annually. Same with medicine. We follow our patients pretty frequently, and so we can intervene early if anyone's struggling with weight regain.

Dr. Scott Steele: Yeah, I was going to ask you about the surgery as well. That's so interesting that it can come back after surgery. So, do you typically have to be put on medication after surgery then? Or is it only for the patients who maybe the weight loss starts to come back?

Natalie Larson, APRN: This is all really patient-specific, so it depends. Some individuals can start a medication after surgery, and it does. It helps with the weight regain and they lose and they can be back to their lowest weight after surgery. We have some individuals that may undergo another procedure to treat that weight gain. So, it's very patient-specific.

Dr. Scott Steele: So are there any advancements on the horizon, when it comes to medical weight loss?

Natalie Larson, APRN: There is. So being that this is a very evolving field in medicine, there is going to be a medication that is on horizon. It's called the Triple G, which actually helps to target GLP-1 hormones, GIP hormones, and glucagon. And these three hormones are all responsible for insulin control and the feelings of fullness, hence the Triple G nickname. So, this is being tested currently in weight management, obstructive sleep apnea, and knee osteoarthritis in phase three trials. So, more to come on this in the near future.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our guests a little bit better. And since we're talking a little bit about food, so salt or sweet?

Natalie Larson, APRN: That's a hard one. I'm going to have to go with sweet.

Dr. Scott Steele: Is there anything specific within that sweet bucket that you want to share with our audience?

Natalie Larson, APRN: I come from a full Italian family, so I'd have to say my mom's homemade cannoli.

Dr. Scott Steele: Oh, fantastic. So, what was your first car?

Natalie Larson, APRN: My first car, I had a Chevy Cruz, a red Chevy Cruz.

Dr. Scott Steele: Very, very nice. And so, is there a particular location or trip that you would tell the audience out there that this is a must-see, you got to be able to travel there?

Natalie Larson, APRN: So I actually recently just last month, I went on a trip to Greece. And that was incredibly beautiful. Definitely a must-see.

Dr. Scott Steele: A specific island you want to share with us? There's a lot of different islands. Or was it just Athens, the mainland?

Natalie Larson, APRN: I went to Crete, and so it's just really cool. The water's beautiful. There's so many natural resources there. And a lot of olive farms, but the land is just gorgeous. Clear, clear crystal blue waters. And the weather was awesome, so I highly recommend.

Dr. Scott Steele: No, that's fantastic. So give us a final take home message for our listeners with regard to weight loss options, or the medical approach, if you will, to weight loss.

Natalie Larson, APRN: Weight loss varies from person to person and from treatment to treatment. So sometimes it's a trial and error process, until one or a combination of treatments are successful. However, I think it's really important to ensure that individuals know that our team, we practice medicine from the heart. And we understand the struggles that a lot of our patients with obesity face in their everyday lives. And so, our goal and mission is to really help those out there struggling to know that they're not alone in this fight of obesity. And we are here to help. We work diligently to help you rate individuals weight loss goals, indefinitely.

Dr. Scott Steele: That's fantastic. And so to learn more about weight loss options available or schedule appointment with the Bariatric and Metabolic Institute here at the Cleveland Clinic, please call 216.445.2224. That's 216.445.2224. Natalie, thanks so much for joining us on Butts and Guts.

Natalie Larson, APRN: Thank you so much, Dr. Steele.

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