More than just novel obesity treatments

On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole discuss the practice article in the journal entitled, “Five things to know about…Novel obesity treatments". They discuss the impact of new medications like semaglutide and tirzepatide in treating obesity with Dr. Shohinee Sarma, the lead author. Dr. Sarma explains the significant effects these drugs have on weight loss and cardiometabolic health. They also discuss how these treatments can be combined with behavioral therapies for improved results, while considering potential side effects and complications.

Next, Dr. Ashley White, a family physician and diplomate of the American Board of Obesity Medicine, emphasizes the need for a comprehensive approach to obesity management. She stresses the importance of establishing realistic expectations with patients, addressing self-image concerns, and considering the long-term impacts on metabolic health. The conversation also touches on the societal biases and stigmas around obesity, highlighting the necessity for a change in how physicians and society view this medical condition.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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Transcript

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. This is the CMAJ Podcast.

Dr. Blair Bigham:

Today we're talking about a practice article published in CMAJ titled, “Novel obesity treatments.” Jola, you were really interested in this paper. Tell us why.

Dr. Mojola Omole:

So there's two parts of my interest. One is that, as a surgeon and working in a densely populated racialized area, we have a lot of patients who are on a lot of these medications. The older ones, and probably soon the newer ones too. And from a surgical point of view, we've had to change our practices in terms of when we stop them because it does cause profound gastroparesis that can lead to aspiration upon induction with anesthesia. So that is of interest.

And also I trained as a general surgeon and did bariatric surgery. This has the potential to close up bariatrics. What would happen to the surgical management of obesity when you have medication that is 100% cheaper with less complications than going through a bypass or gastric sleeve? So I'm very interested in learning more about these medications.

Dr. Blair Bigham:

And there was just that big New York Times article that looked into just how big of a moneymaker bariatric surgery is in the US. And certainly in the ER, it's always terrible having to manage patients who come in after these surgeries who can have many months or years of success and then they're suffering from some pretty brutal complications sometimes.

Dr. Mojola Omole:

100%.

Dr. Blair Bigham:

But we also have a couple complications that we see in the ER as well, people come in very dehydrated, sometimes acidotic. So I'm very curious to speak to our guest today. And just to be clear, we're talking about newer glucagon-like peptide receptor agonists, so semaglutide is one of them, and then the other one is tirzepatide.

Dr. Mojola Omole:

I'm so happy you said these because I can't say big words-

Dr. Blair Bigham:

It took me a couple takes.

Dr. Mojola Omole:

So we're going to first speak to the lead author of the article that's in the CMAJ, and then we're going to go beyond these new medications and just look to how they fit within a broader-based approach to management of obesity. 

Dr. Shohinee Sarma is an endocrinologist at Beth Israel Deaconess Medical Center in Boston, Massachusetts. She's the author of the one-page practices article in the CMAJ. Shohinee, thanks so much for joining us today.

Dr. Shohinee Sarma:

Thank you for having me.

Dr. Mojola Omole:

So just how significant are these new treatments for obesity?

Dr. Shohinee Sarma:

So, I think they've demonstrated pretty profound effects in patients with diabetes previously and now for adults with obesity. They've been shown to have pretty demonstrable effects in terms of weight loss, but also significant improvements to cardiometabolic profiles. So I think these medications have really transformed the landscape of obesity management. So it's very exciting that we have options now for treating adults with obesity.

Dr. Mojola Omole:

So, are these medications, do they work when they're paired with other therapies like behavioral therapies or they work just on their own?

Dr. Shohinee Sarma:

So they have been studied paired with behavioral therapies and the amount of weight loss is, of course, even better, even improved when you have ongoing lifestyle modification. But even on their own, they've had pretty terrific effects, both in terms of weight loss and also in terms of cardiovascular effects of these medications. In terms of the cardiovascular effects, there's ongoing studies to look at whether these effects are in fact independent of weight lowering and independent of the mechanisms of hypertension lowering or lipid lowering. So there's work being done in that area in translational and basic science research. So, that's also an exciting discovery to really look forward to. But yeah, from these large clinical trials that we've seen, these medications are quite profound in terms of their weight lowering and cardiometabolic effects.

Dr. Blair Bigham:

So were these drugs, and were they designed just for people who were overweight or were they originally designed for diabetes? How does a diabetes-obesity thing interact here?

Dr. Shohinee Sarma:

Yeah, that's a great question. So although we wrote this article in the CMAJ, and we call them novel obesity treatments, mainly because what we're referring to in this article, which is semaglutide at the higher dose, I'm going to use a brand name for a second, which is Wegovy, and then tirzepatide specifically for obesity, which again, I'm going to use the brand name for a second, which is Zepbound. These two medications are specifically for people, adults with obesity who do not necessarily have diabetes. Previously we have these compounds, so we have semaglutide available and in use for patients with diabetes, but those were marketed differently. So that's Ozempic, and then we have dulaglutide, which is Trulicity. We had liraglutide, which was Victoza, and then Saxenda. And Saxenda was approved for obesity as well. And so the two medications that we discussed in the CMAJ article are specifically for patients with obesity, not necessarily with diabetes. But yes, to answer your question, these medications have been available for people with diabetes and we've been using them.

Dr. Mojola Omole:

How are we diagnosing that someone has obesity? Is this based on BMI? Because the common example is that there are some many people, and I think for me, I'm always a bit of an advocate for this. I have a high BMI, but I'm also someone who works out five days a week. And so how do we determine which person with obesity would benefit from these medications?

Dr. Shohinee Sarma:

Yeah, that's a great question. So in the clinical trials of the patients who were enrolled for these medications, the main criteria was BMI. So it was body mass index over 30 alongside obesity-related comorbidities. If you had a BMI that was, let's say 27 or greater, but you had one obesity-related comorbidity such as hypertension or type two diabetes or sleep apnea then you were eligible. BMI in itself, like you alluded to, is not the best indicator of obesity in many different populations. But it was what was used as eligibility criteria in these studies. And so in the clinic, for example, if your question is are we classifying obesity with a BMI? That's a very good question, because there's data to suggest that in some populations, waist circumference or other measures of adiposity may be more useful. But for now, yeah, it is body mass index that we're using.

Dr. Mojola Omole:

And what populations are you alluding to just so our primary care practitioners who are listening could have that kind of understanding?

Dr. Shohinee Sarma:

So for example, there's data to suggest that people who are of Asian descent, East Asians or South Asians may actually develop cardiometabolic complications of adiposity at even lower BMI. So there's a question of whether we need to consider these people at higher risk, even though they're not meeting the criteria for obesity per se. So BMI is not the best indicator in every population, but it is what we're using as a cutoff for treating patients with obesity.

Dr. Mojola Omole:

And how did these drugs work? I know people who are on them mainly for vanity, not for health, but how do they actually work in our bodies?

Dr. Shohinee Sarma:

Yeah, you raise an interesting point there with your comment about the vanity, and I think that maybe I can quickly touch on that for a second as well before I answer your question further.

Dr. Mojola Omole:

Maybe I shouldn't say vanity because that seems judgy. I don't know what the word I'm thinking, but vanity seems judgy.

Dr. Blair Bigham:

Self-confidence.

Dr. Shohinee Sarma:

No, these drugs have been used and they're available now, and even medical spas, for example, for people who are not actually eligible for them. One of the concerns with these medications is that they do induce pretty profound levels of weight loss. With tirzepatide, we're seeing 20% weight loss from baseline, over 72 weeks at the highest possible dose of 15 milligrams. That's pretty profound. Before these medications, the only other thing that caused weight loss to that degree was bariatric surgery. So this is profound weight loss. And so this type of weight loss makes sense clinically for patients who require it because of improvements to their cardiometabolic health or improvements overall to their general wellbeing. So if patients or if people are using this for inducing weight loss for self-image or other reasons, it's not clinically indicated and there's always adverse effects to medications. So, I think that is something that we need to be mindful of in general practice as well, and to be cautious about how people are using these medications and who is using these medications.

But to answer your question about how they work, so these are two different molecules. So semaglutide is a GLP-I receptor agonist. Basically it slows down your digestion and so increases your levels of satiety. So to keep it very broad. And, same thing with tirzepatide, it's two different molecules with tirzepatide, it's a dual agonist, so I won't go into details, but essentially it delays gastric emptying and improves satiety. And that's the main mechanism for how most people end up feeling a little bit full as well and losing their appetite when they're taking these medications.

Dr. Mojola Omole:

What are some of the contraindications to taking these classes of drugs?

Dr. Shohinee Sarma:

One of the main things to consider or to counsel patients when I see someone that I would consider starting these medications on. So the main contraindications would be if they have any personal or family history of medullary thyroid cancer, and then some rare endocrine conditions like multiple endocrine neoplasia or if they have hypersensitivity or an allergy to these medications. Those are the main contraindications.

Dr. Blair Bigham:

Tell me more about the thyroid contraindication, because there's some conjecture about a risk of thyroid cancer with these drugs.

Dr. Shohinee Sarma:

So the specific type of thyroid cancer that was associated with these medications was a very specific type called medullary thyroid cancer. But more recently, there was a recent study that was done that showed a higher risk of different types of thyroid cancers, of different histologic subtypes for patients who were treated with the GLP-I receptor agonists. So, further investigation is ongoing, but it's just something to counsel patients about. So in patients who've had a family history of medullary thyroid cancer, I would not use these medications.

Dr. Blair Bigham:

I wanted to ask about more acute complications. We hear a lot about euglycemic DKA. What are some of the things that doctors should be on the lookout for when they're seeing a patient who's on one of these medications?

Dr. Shohinee Sarma:

So the euglycemic DKA is very specific to the SGLT-II inhibitors. So we've not seen that with these classes of medications with the GLP-I receptor agonists.

Dr. Blair Bigham:

But they do go into some sort of keto, Oh, maybe they go into some sort of ketoacidosis. Is it like starvation ketoacidosis?

Dr. Shohinee Sarma:

They could if there was not enough nutrition uptake. But usually, yeah, ketoacidosis is usually primarily concerned with SGLT-II inhibitors. With the GLP-I receptor agonists, we see more gastrointestinal adverse effects. So getting nausea, abdominal discomfort, those are the main ones. And then also gallbladder pathology, so gallstones, et cetera. So those are the ones to consider.

Dr. Mojola Omole:

What's the best way to manage these side effects of the medication, the gastrointestinal complications?

Dr. Shohinee Sarma:

So in all patients, as we start these medications on, I counsel them to start them at a low dose with a very slow dose up titration over time. So in general, we start at the lowest possible dose. So for example, with semaglutide, starting at 0.25 milligrams, staying on that dose for a month and then going up to the 0.5 milligram dose, staying on that for another month before increasing further. And then sometimes patients aren't able to tolerate even that type of slow dose increase. So the pen actually has markings on it. So sometimes I go up even in between doses. So instead of going from 0.5 to one, I go up to 0.75 and then stay on that for some time until they adjust to it. And then there's a small subgroup of patients that are actually just not able to tolerate it at all. So then that's not something I would advise using or continuing. But for those who are able to, those who have abdominal discomfort initially or nausea, it does go away with that slow dose titration.

Dr. Mojola Omole:

So what do you think are some of the key takeaways for primary care physicians with these medications?

Dr. Shohinee Sarma:

I think the key takeaway is that historically obesity management was limited, and I think obesity was not even seen as a chronic condition that requires ongoing management just like we do with diabetes. So I think that's a new way of thinking about obesity as a chronic disease that we need to manage. So I think that's number one. Two, again, being mindful of the fact that obesity stigma still exists and ensuring that when these discussions happen, they're done in a patient-centered way and that the patient's perspective and their desires are taken into account. And so I think that's a really important thing. And then three, that now you have these profound new medications in the toolbox for treating obesity. So we have the older medications still, they're still available, so it's not as if this replaces everything and in the right context, the right medication is applicable, but now you have new medications. So I think that's the main takeaway. And the weight-lowering effects of these medications are quite profound.

Dr. Mojola Omole:

Wonderful. Thank you so much.

Dr. Blair Bigham:

Thank you.

Dr. Shohinee Sarma:

Thank you.

Dr. Mojola Omole:

Dr. Shohinee Sarma is an endocrinologist at Beth Israel Deaconess Medical Center in Boston. Thank you so much for joining us. Before the rise of semaglutide medications, the treatment of obesity was not centered on a single powerful intervention. Weight loss required a range of therapies, surgical and non-surgical that could be challenging for patients to adhere to and sometimes slow to show results. So how much have these medications changed the way physicians need to treat obesity? Dr. Ashley White is going to help us answer this. Dr. White is a family physician certified and practicing in obesity medicine and emergency medicine in Oakville, Ontario. Ashley, thank you so much for joining us today.

Dr. Ashley White:

Thank you for having me. This is great.

Dr. Mojola Omole:

So in your experience, how often do you have patients who want to continue to use these medications beyond the point at which further weight loss is not necessary or beneficial from a health perspective?

Dr. Ashley White:

It is normal for patients to want to pursue ongoing weight loss after achieving a weight loss goal that meets their health outcomes or health outcomes that I would consider excellent because we live in a society where thinner is better. And for most physicians, that is the paradigm that we've come from, that more weight loss equates to more health. And in some cases that may be true, but for many people, the loss of five to 15% of their total adult body weight achieves most good metabolic outcomes. And in doing so, we have the opportunity to reduce poor cardiovascular outcomes, reduce stroke, reduce lots of morbidity and mortality due to hypertension and all of the chronic diseases we see every day. So patients, of course, want to continue to pursue weight loss because often when weight loss happens, there are lots of good things that also happen in their lives.

Some of these things involve more belonging. They often feel a little bit more like they belong in the world that we live in, both from a built environment perspective, it's easier to fit in certain places, it's easier to buy clothes that fit. And also the people around you endorse the loss. They look at how good you look and how healthy you seem. And so it's very reasonable to want to continue to do so. It's not always advisable. And in fact, often there is a bottom, and we have to be very cautious about helping people find out where that is.

Dr. Mojola Omole:

So at what point can it become harmful to patients?

Dr. Ashley White:

So GLP-I medications, these are hormones. And so when you give a body a hormone, you have to expect that there are going to be downstream consequences in terms of other hormones. So when someone's appetite is suppressed meaningfully through GLP-I agonist therapy, you can expect there to be changes to their appetite, which result in changes to their bone density as they lose weight, changes to their lean muscle mass as they lose, changes to their fat, as well as the fat that is contained within their viscera, including the liver, the pancreas, the abdomen, the colon. So you can see all of these changes happen in a person who's losing meaningful weight. However, what starts to happen also is that the patient is just simply not eating enough to maintain vital functions. And we start to see this stripping away of really important tissue, particularly bone tissue and muscle tissue.

This tissue is what gets us to an older age in a vigorous and vital state. So it's really important that weight loss does not occur at the expense of longevity and a quality  long life. And that is often what could be happening in terms of how I see a lot of prescribing happening right now. And that's largely as a result of this just being really new to all of us.

Dr. Mojola Omole:

I guess the question is, so I'm thinking out loud, so it might take me a while to get to the question.

Dr. Ashley White:

Of course.

Dr. Mojola Omole:

So let's say someone is considered morbidly obese and they've lost the 15 to 20% of their body mass and they want to keep on going. Could they still on the outside be what society would consider fat still, but actually be losing the bone density and all of the harmful effects you're talking about?

Dr. Ashley White:

Absolutely. So what we know from a group of studies that were done actually with the folks who were in the TV show, The Biggest Loser, so those folks were very, very large when they started the show, and they lost extreme amounts of weight using calorie deprivation or calorie restriction and massive amounts of exercise. A lot of them lost a lot of weight. And they were followed longitudinally over many years through a pretty comprehensive cohort study. And what we found is that by the time people lost 30% of their highest adult mass, their resting metabolism, their resting metabolic rate started to downgrade. And so they would start to essentially shut down their metabolism such that less food was required to maintain their current size. And so these are people who are already eating less than their appetite wanted them to. And now their metabolism was slower, which means they had to eat less to maintain the loss.

And the data didn't show that it mattered how fast you lost this weight or the weight in which you lost it. It was really like once you got to 30%, the brain started saying, this is famine. I'm not okay. This is a starvation and I need to shut down vital functions, and so my core metabolism is going to alter. And then what happens is at some point you can't eat that little, and so you're going to start gaining. And so now you're gaining weight while eating less food than it took you to gain before. And the only tools at your disposal are eating less, which you can't do because you've tried that and moving more. And there's a cap on that because once you become quite fit, your body adapts to that too. The metabolism is a persistently adaptive creature, and there's a nutritionist, Lane Norton, a PhD in the states who describes the human metabolism as a gas tank that becomes more efficient as it gets closer to empty.

And so we're asking large folks to basically live at empty. And in my opinion, that's no way to live. And this phenomenon is going to also be happening with pharmacotherapy for obesity. And so we're going to have very large folks lose potentially 20, 25% on some of these medications, often combined with surgery or at different stages of their life, and they're going to still be large after having lost 25% of their body weight. And we need to say, and that's okay. And if you continue to lose, this is the harm we’re looking at frail bones.

Dr. Mojola Omole:

How do you talk to people? Because that is such a massive shift from the paradigm that we live in when it comes to how we quantify obesity. For me, this is something that I'm interested in because I'm also someone who lives in a larger body. And so even when people talk about, well, if people are over this BMI, their risk factors for surgery increase, et cetera, et cetera, but we're saying that you know what? At a certain weight, if you are 350 and you get down to a smaller size, whether that's maybe 250, I can't do math, that might be it for you. You're still in a larger body, but that is all that is safe. How do you talk to patients about that and how do we educate each other that you can be in a larger body and that's still okay from a metabolic point of view?

Dr. Ashley White:

I think one of the things we have to be very sure about is that when we start working with a patient on weight, we set two different kinds of objectives. The first objective is often a weight loss objective and a metabolic objective. So we look at the LDL, we look at the ApoB, look at the A1c. We're actually talking about quantifiable, trackable numbers, and often a weight is tagged onto that. But I like to track metrics more than weight, and I also track body composition. And then there's this other group of objectives, which is really what do you want your life to be like? And that's the work of body acceptance. So the work of body acceptance is a different body of work than the work of weight loss. And those two need to be pursued in tandem because there is a belief out there that once you achieve a certain size, everything in your life will be better and it won't. And actually attaining that size is going to hurt you.

And the conversation amongst physicians obviously has to be advanced because we're not there. And then the conversation among people has to be there, because we're not there either. I think so much about being a larger bodied kid and the ways in which I was excluded from certain athletic opportunities until I forced myself in there and all of a sudden I'm included, I'm worthy of inclusion because athletic performance and body size aren't actually as deeply linked as we think. And Jola, maybe you've also experienced that as well. We have to create places for big kids of all different shapes and sizes and colors to participate in physical activity. I think that's huge. That's something I feel strongly about. We also have to model for each other self-acceptance and an approach to our own body that is deeply loving and caring. And we're not in the nineties anymore, so that's fun. But we do-

Dr. Mojola Omole:

... when moms are done for.

Dr. Ashley White:

Yeah. Yeah, we risk with GLP-I, allowing everyone to have a BMI of whatever, we risk going back to this time when we didn't accept a broad array of bodies as well. And so we may never accept a broad array of bodies as beautiful, but we must accept a broad array of bodies as well. And that is something that physicians must lead.

Dr. Mojola Omole:

My question for you. So how do you create this holistic approach in tandem with using these GLP-I agonist drugs?

Dr. Ashley White:

Yeah. Part of it is setting expectations, very, very clear expectations. I start talking to my patients about the scope of our work early on. And then the other thing is this work that I do so often uncovers trauma, it so often uncovers a place at which people have been dislocated from their bodies. And so we are often looking at having people turn their gaze back on themselves because it's been dislocated by something. And so a lot of my work is about helping people clarify how they see themselves and helping them unpack the labels that often come with fat.

So fat is not lazy, fat is not stupid. Fat is not slow. Fat is not any of those things. It's just fat. And we have to do a lot of coaching. I use coaching because it's a technique I find really helpful, but lots of people use CBT or acceptance and commitment therapy, mindfulness. There's lots of ways to help people unhook the idea, unhook the gaze of others from their own gaze. And it's about building out an identity, your own identity without the gaze of others. And that's stuff that's really hard to do when you're 60, but it's easier to do when you're younger.

Dr. Mojola Omole:

And that's also hard for physicians, because by definition, sorry, I'm a little emotional because I was also the kid that grew up way too fast. Well, maybe not too fast, but I grew up faster than others around me. So my body was always commented on even up until university. And so that really hit a nerve with me about the gaze, but also we're physicians, I'm a surgeon. My joke is we live for external validation. So I think this is challenging for physicians, whether it's family physicians or specialists, to remove that because we're so intricately linked, even for ourselves to look at how people view us as part of our identity.

Dr. Ashley White:

Yeah. I lost a reasonable amount of weight after my second pregnancy, and one of my colleagues who I had actually never really spoken to otherwise came up to me, touched my shoulder, and she had never really come near me before and said, you must be doing so well after I had... And I was like, yeah, I'm doing great, but I was always doing great. So maybe we just start with how we treat each other. We probably have to do some deconstruction of internalized bias around our views of what thin means and what health means. We've got lots of folks whose genes were primed to be big because about 60 to 70% of body size is inherited. It's pretty meaningful. So we probably have to start with ourselves, I think.

Dr. Mojola Omole:

And how do we talk to patients, and how would family physicians talk to patients about what is a healthy weight for that person? For example, as I was saying when we were talking before, I have patients of all shapes and sizes, they're five, six, they weigh 280 pounds, but this person is very active, has no metabolic conditions, has no issues at all. But I'm sure people will be like, well, they probably need to lose some weight, but they have no metabolic disorders, so do they need to lose some weight?

Dr. Ashley White:

So the health at every size movement, which emerged in the nineties, two thousands, would say that no weight loss is never a reasonable objective. And that was before the advent of actually decent therapeutic interventions for weight. And the health at every size movement has done a lot to help identify and bring forth the biases that we carry. I think it's a very meaningful voice in the spectrum here. However, there is a happy medium in which we can talk honestly with patients about their future metabolic risk without making them feel bad about where they are now. And I think the way that we do that, my opening question always is how do you feel in your body right now? So I don't ask for permission to talk about weight, I don't do any of that. I just say, what is it like for you and your body right now?

And I do this because you can ask a thin person this question as well. And I do this also because the patient gets to decide if talking about their weight is part of that. Patients delay talking about their weight with their doctor on average about five to 12 years. And so the patients that are starting to have conversations with you about weight, this is not the first time they've thought about it. The other thing about... So if we take this patient who's metabolically healthy from the metrics that we have, but they're in a body that is large and it's possible that they're fine right now, there is likely going to be a progression of their weight because we know that weight obesity is a progressive chronic disease. The weight is probably going to continue to go up. And the risks of that from a surgical perspective very well, particularly from an obstetrical perspective for young folks are huge.

And if we have the ability to gently and safely in a way that recognizes the depth of internalized bias, both of ourselves and the patients, open this conversation to say, all right, well if this is the way that you feel in your body right now and it's not the way that you want to feel, how do you want to feel in your body? And then we can start setting expectations and goals that might really capture a way that a person wants to feel. And most of those folks, if you spend enough time talking to them, you will realize that they do have some things that they'd like to be different. It's not like they'd like to be small. That's often not possible, but they may like to be able to run a little longer or not necessarily need an Advil after the sport that they enjoy, or they might like to fit in a size of bathing suit that this brand carries because it's the best quality brand or whatever. There may be some things that really do motivate them in terms of a feel perspective.

The other thing that's I think is really important is that because of this 30% loss resulting in a degradation of the resting metabolic rate, the sooner we intervene, the easier it is to help someone maintain a size that is not necessarily small or thin, but suits them and their genes, but also allows them to enjoy life, which is important. But if we allow someone to gain hundreds and hundreds of pounds without offering them an opportunity to consider something else, we've done them a disservice because reversing it is much harder than preventing it. And so I think we need to be brave and have this chat with folks.

Dr. Mojola Omole:

Thank you so much, Ashley. This has been a really fascinating conversation. So thank you so much for joining us today.

Dr. Ashley White:

Thank you for having me. This was fun, and I hope people are open to this kind of thing.

Dr. Mojola Omole:

Dr. Ashley White is a family physician certified and practicing in obesity and emergency medicine. She joined us from Oakville today.

Dr. Blair Bigham:

So Jola, this is way more complicated than just prescribing Ozempic.

Dr. Mojola Omole:

What blew my mind was that once you lose more than 30% of your adult body mass, you are actually going to be harming yourself. That is something that I've never heard in my whole entire career or even life. And it goes-

Dr. Blair Bigham:

Totally.

Dr. Mojola Omole:

... goes against what we see because everyone's always like, Ooh, my weight loss journey and da, da, da, da, da, and I lost over a 150, I lost over 200 pounds. But it's like, wait, you shouldn't do that. So that to me was actually very profound to hear.

Dr. Blair Bigham:

But why wouldn't people, of course you want to just, if you're having success, you're going to want to keep going. You're going to want to get to be whatever it is you think society wants you to look at.

Dr. Mojola Omole:

Yeah, and I think it was really important that she pointed out that oftentimes people haven't developed their own internal gaze, and their gaze is what everybody else gazes is. So I think that is really important. And for me, being in medicine and being someone who lives in a larger body, I get to hear conversations when people make jokes about bigger patients and then say, Oh, sorry, because it's going to offend me. I'm like, I'm quite comfortable with who I am because I have no metabolic issues. But also that we have an attitude in medicine that thinner is better, that thinner patients are healthier or thinner patients are, they're easier to operate on, so therefore that equals better. And not really thinking about the fact that for some achieving that thinness is at the cost of their longevity in the future.

Dr. Blair Bigham:

Totally. When I try to put myself in those shoes, as you and Ashley were talking, I was like, wow, if there was a medication, I grew up as the scrawny kid, and-

Dr. Mojola Omole:

And now you're built out.

Dr. Blair Bigham:

Oh, hardly. But if there was a drug that I could inject, not, obviously, there are drugs that I could inject, but if there were healthy drugs, not steroids, that I could inject to gain muscle mass, and people were like, Oh, wow. Now you filled out. Now you look a little bit more like what society would think was the hunky guy. I'd probably keep going. I'd end up Arnold Schwarzenegger, why not? So I see now that the flip side of that just keep going. And so how you counsel someone to get ready for that moment where no, no, medically you are healthier. You don't need to keep pursuing medication use. I see that being a huge challenge, especially when people these days just want to go on their app and get their prescription refill and maybe not commit to the holistic approach that Ashley was mentioning.

Dr. Mojola Omole:

What also was of interest is that obesity has always been viewed as a byproduct of, it's your fault. You did this. This is why you're obese.

Dr. Blair Bigham:

Yeah.

Dr. Mojola Omole:

Her paradigm, and probably what should be the conventional paradigm for management is that this is a chronic disease based on genetics. Just as we know that some people are going to have hypertension, that is the genetics of it. And so therefore, even though this is managed in the realm of family physicians and primary practitioners, there is, maybe there are subsets of patients that do need specialized care. And instead of us viewing it as something that I need to just, okay, well just get rid of your obesity and then move on, move on. But while if someone is on two hypertensive drugs, at some point you do refer them to the cardiologist, because you're like, this is becoming hard to treat. We don't view obesity as a chronic disease. We view it as a lack of willpower, and this is actually very fascinating. And for me, knowing that it's 70% genetics, I'm just going to blame my dad, because he was also larger.

Dr. Blair Bigham:

That's it for this week's episode of the CMAJ podcast. Thanks so much for listening. Please do us a favor, like, share, comment, buy a loud speaker and talk about us in public, whatever you can to help us get the word out. I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. Until next time, be well.