Obesity, Autoimmune Diseases and Weight Loss Drugs (Mounjaro, Ozempic, Zepbound) with Dr. Michaela Mocanu

In this episode of "Thriving with Arthritis," host Dr. Diana Girnita welcomes Dr. Michaela Mocanu, a board-certified nephrologist and obesity medicine specialist, to explore the intricate connections between obesity, kidney health, and autoimmune diseases. They will also discuss the role of weight loss drugs like Ozempic, Mounjaro, and Zepbound.

Episode Highlights:

1. Obesity-Kidney Connection: the complex relationship between excess weight and kidney function, including risks for chronic kidney disease 

2. Revolutionary Weight Loss Medications: Learn about GLP-1 agonists (Mounjaro, Ozempic, Zepbound) and their potential to address obesity and autoimmune diseases

3. Obesity's Far-Reaching Impact: Explore how obesity affects various body systems, from brain health to cancer risks, and the potential improvements with weight loss.

4. Inflammation and Autoimmune Diseases: Discover the link between obesity, inflammation, and autoimmune conditions, and how weight loss drugs may help manage these disorders.

5. Personalized Approach to Weight Loss: Understand why a "one-size-fits-all" approach doesn't work and the importance of addressing individual factors in obesity treatment.

6. Lifestyle Interventions: Learn about the crucial role of physical activity, sleep, and dietary changes in conjunction with medication for effective weight management.

7. Direct Care Model: Gain insights into the benefits of a patient-centered, direct care approach in managing complex health issues like obesity and kidney disease.

Dr. Mocanu shares her expertise on integrating nephrology, obesity medicine, and lifestyle interventions, offering invaluable insights for anyone dealing with obesity, kidney issues, or related chronic conditions. 

Dr. Mocanu's Website: https://www.weightkidneycare.com/

Transcript

 Welcome to Thriving with Arthritis, the podcast that empowers you to live a better life despite all the challenges of arthritis and autoimmune diseases. Whether you're newly diagnosed or have been living with arthritis for many years, this podcast is here to support you every step of the way.

Let's begin.  

 Welcome back to another episode of Thriving with Arthritis.  Our today's topic is related to kidneys. Kidneys are one of the most important organs that we have in our bodies. And in autoimmune diseases, many times kidneys are affected by inflammation. But not only that, apparently, obesity, which is also linked with low grade chronic inflammation, was recently shown to affect our kidneys.

Not only that, it will increase the risk for inflammation, But it also will increase the risk for rheumatoid arthritis, other autoimmune diseases, and increase the risk for blood pressure. And why do I say all of that? Because today we have the expert in the house. We have Dr. Michaela Mocanu, that she's a board certified nephrologist.

So a kidney doctor for those of you that doesn't know what's a nephrologist do, but she's also a very good expert in obesity medicine and she is board certified also in internal medicine.  Dr. Michaela Mucano, welcome to the show.  Thank you so much for having me here and for such a kind introduction. I'm absolutely delighted to be talking to you today and to your  Dr.

Mocanu has graduated from Carol Davila University of Medicine and Pharmacy in Bucharest, Romania, the country where I am from. And she graduated in 2003, but then she moved here in the United States where she completed an internal medicine residency at Georgetown University. And then she follow up with a nephrology fellowship at University of Pennsylvania.

Not only that, but she is certified in hypertension or high blood pressure. And she got a board certification from Columbia University for obesity medicine. Who is better to ask questions about obesity, inflammation, the new drugs that are coming in than Dr. Mocanu?  Thank you so much. I appreciate that.

I actually graduated from Georgetown Washington Hospital Center program. closely related to Georgetown University. 

We know that you are both an expert in kidneys, but also an expert in obesity. And I know that you can tell us a lot about both, but what is the connection between these two areas of medicine? 

That is an absolutely excellent question. Many people, including my patients, are asking me the same. It turns out that when we carry excess weight, it puts a lot of stress on our entire body, and also it puts a lot of stress on our kidneys. And many of my patients struggle with excess weight. So there are many mechanisms so that through which obesity can affect our kidneys and to better understand I think I have to explain it how the way I put it to my patients when they come see me.

So we want to think about kidneys as this big filter that is made out of millions of smaller filters and blood vessels take the blood through the small filters that work very hard at removing the waste metabolites from our body, as well as controlling our bodily fluids. And in this process, they balance out our blood pressure and our electrolytes.

So as many of us know, obesity is closely linked with diseases such as hypertension or high blood pressure,  high cholesterol, and type 2 diabetes.  All of these represent risk factors for chronic kidney disease. And the way they do that is, for instance, the high blood pressure and the high cholesterol, they affect those larger vessels that take the blood to the kidneys.

And over time, they can lead to chronic kidney disease.  And diabetes actually affects those tiny filters that filter our entire body. blood. And by doing so, it damages the small filters and can also lead to chronic kidney disease. Another way that obesity is linked with chronic kidney disease is that it's through excess body mass.

When we carry a larger body, we also have more blood filtering through the kidneys. And over time that creates, and that can lead to permanent changes within our kidneys. We call this FSGS or in fancy terms focal segmental glomerulosclerosis. And it's a fancy way of saying the filter is damaged. So we start losing protein in the kidneys and over time that leads to chronic kidney disease.

And last thing that I must mention is the kidney transplantation, the connection with kidney transplantation  that you see some people are unfortunate enough to get to the stage where they would require dialysis or transplant. And there is a lot of research that demonstrates that in this patient's  obesity is associated with a higher rate of complications, to the point where centers across the country kidney transplantation centers, they actually have BMI cutoffs for which patients can be offered a kidney transplant since there are so many complications related to it.

So to put all this together, when we treat obesity is not just for the purpose of looking good, it's actually for the purpose of staying in good health. and preventing disease. So when I decided to pursue more training in obesity medicine, I felt that I could actually help my patients more by looking at them as a whole.

And I firmly believe that actually every physician could benefit from learning more about it because obesity medicine is nothing but learning about lifestyle interventions and adding onto it medications. Learning on how to use medications to help your patients achieve a healthier weight. And by this, my patients in particular will achieve a healthier kidney weight, but also their whole body will get in better health.

I'm so excited that you mentioned about transplantation. Transplantation is very dear to me. When I came in the United States, I pursued a fellowship in immunology, transplant immunology. I did study hearts, not kidneys. But I have to tell you that in the beginning I did not understood why they were putting that kind of cut off.

And it took me years to even ask myself, why are they putting that cut off? Why are they pushing the patients to lose weight? And many years after I understood the connection between obesity and inflammation. Now, because you mentioned drugs, we all got excited, and millions of patients suffering from obesity, because obesity is a disease, it's not only a stigma, so millions of patients got excited when the FDA finally approved the GLP 1 medication, Zep Bound Mongiaro. 

I think it was in November 2023.  You as an expert in obesity, what is your opinion regarding these drugs and the help that they could bring to these patients?  Excellent question. So thanks for asking that because a lot of patients nowadays, a lot of people talk about this newer medications that they're all excited about this newer medications.

And so are us as providers, because they really. work. They are effective and they're generally very well tolerated by our patients. And not only do they help patients lose the weight, but also improve their cardiovascular outcomes, which is extremely important. It's extremely important as a mean of prevention of father disease.

cardiovascular complications. This is number one reason for death in this country is cardiovascular disease. Now, let me tell you a little bit more why I'm excited about them. And patients have good reason to get excited about this new medications. They are very effective and generally very well tolerated by the body.

So terzapatide, which is a medication you mentioned, also known as z bound or Munjaru,  is a combination of Two hormones that our bodies naturally produce.  produce. Hormones are secreted by our small bowel in response to food. Now they are called GIP or glucose  insulinotropic peptide and GLP 1 agonist or glucagon peptide one.

And the thing is that they found that this Hormones are tiny chemicals that can actually get inside our brain and reach receptors in our brain that are important in appetite regulation. What it means to us is that the gut talks to our brain In response of the food that we eat and through that mechanism, our brain is able to regulate our appetite, but also our energy expenditure.

Some patients that suffer from obesity are believed to have lower levels of this hormone. When we give back these hormones that their body is missing, it restores this link that was lost in between the gut and the brain, and it helps them improve the weight and lose the weight. So basically the way these medications work is when a patient takes them,  patient is having of an easier control over what they eat.

They feel less hungry, they have fewer cravings, or no cravings sometimes, and they feel full after ingesting a smaller amount of food. At the same time, the reason why these medications are important is that they also regulate the glucose metabolism. It helps the body handle glucose better  after a meal and improves our lipid metabolism as well.

And this is very important and maybe it explains why these medications also help the body. in cardiovascular risk prevention. So people think about the way I like to think about them is offering my patients something that maybe they don't have enough of or their body is missing in certain patients. 

That's helped achieve a better weight and a healthier weight. You mentioned cardiovascular diseases and we know that's the number one killer in the world and in the United States, of course, but also in the world. But besides obesity and besides cardiovascular health, do you think that these drugs, they have the potential to tackle other chronic diseases? 

Absolutely. Because by tackling obesity, we actually tackle all the chronic diseases that are linked to it. And I think the best way is to give you some examples, starting with a head going to the toe, starting with a brain. When we notice that patients that are affected by obesity have a higher incidence of dementia, and they may have a higher incidence of stroke.

stroke or peripheral neuropathy. So obviously by achieving a better weight, maybe there is an improvement in all of this as risk factors. Now, moving down, if we were to think about the heart, there is study after study that demonstrates that obesity plays a major role in getting our hearts to become stiffer.

We call this diastolic heart dysfunction or congestive heart failure from stiff heart, diastolic heart dysfunction. Patients with obesity have a higher incidence of atrial fibrillation and hypertension, to mention a few, and cardiovascular, coronary artery disease. So by getting them to achieve a better weight, maybe we can tackle some of these problems.

And lungs. There is something that I really want to emphasize here about the lungs. There is a recent study that was published actually on April 17 this year. It was a study on terzapatite, known as ZepBound or Monjaro, and it demonstrated that up to two thirds of the patients included actually had fewer improvements.

This is huge, but it also tells us that as people lose weight, we have to monitor to make sure that those patients change their settings of the CPAP machine. For instance, other improvements would be improvements in asthma or upper respiratory infection. Moving down, if we were to think about take, for example, the gut and the liver, that I will have to mention fatty liver disease.

Also, a study published maybe in February this year  on, about terzapatite demonstrated that patients that were taking  terzapatite when compared to those that were not, actually had improvements in fatty liver disease. About 70 percent of them had resolution of theatral hepatitis. which is huge without scarring or fibrosis or without leaving any scar in their livers.

If we were to look at the kidneys, I already mentioned chronic kidney disease, but patients with obesity also have a higher incidence of kidney stones. So it may help with that as well. And if a lot of younger women are struggling with infertility. A lot of patients that are affected by obesity also have PCOS, and we've all heard about those ozempic babies or Z bound babies.

The fertility rates go up. Now, we don't use these medications as a primary intention for improvement of PCOS or polycystic ovarian syndrome. However, losing weight has been associated with improvement in the so called PCOS. And since you are a rheumatologist, I will have to mention the impact on osteoarthritis, improvements in osteoarthritis, but also inflammatory diseases and most often associated with  psoriasis, rheumatoid arthritis, and gout.

And you may be able to tell me more about that, but there people would see improvements in these conditions. And the last one that I will mention is aging. Everybody is excited about longevity and everyone wants to live longer. There are many podcasts on longevity nowadays, many books published on longevity.

So it turns out that patients that suffer from obesity age faster. And that happens at the molecular level. It happens that within their cells at the level of nucleus, there is evidence telomere attrition and their blood vessels less elastic. And so they have something we call endothelial dysfunction.

And there are other mechanisms through which obesity can contribute to faster aging in patients. I'm pretty sure I may have miss a lot of other diseases. But in general, what I have learned in according to this study published in Diabetes Care in 2015,  people would have to achieve, depending obviously on the weight that we start at, but to see improvements in all these conditions, we typically have to achieve maybe 5 to 10 percent of weight loss.

Actually, according to that study, people achieved anywhere in between 5 and 15 percent total body weight loss, but even a little bit of weight loss counts when we tackle all these conditions that are affecting our body as a whole. And I did forget to mention that cancers. and blood clots are other risk factors that are triggered by obesity that, and by losing the weight, we can help prevent these cancers from happening or maybe occurring at a later age.

And there is a lot of evidence for that as well, for us women. The most linked cancers would be breast cancer and ovarian cancer. This is the most comprehensive overview of obesity linked with chronic diseases that I have ever heard. And although I knew parts of it, I have never had anyone talk about the complexities behind obesity and chronic conditions and the fact that you took it from head to toe and you also tackled autoimmune diseases and chronic degenerative diseases.

It is extremely important for people to understand why they should manage the weight not only to look good because that's how the industry is selling us. It's, it's selling us the dream of looking good, looking at, magazines and envisioning us being very fit. And that's the picture that is portrayed by media between what is the ideal body weight.

And like you, I do talk to my patients about Obesity in the context of autoimmune diseases, in the context of degenerative diseases that you just mentioned, osteoarthritis being one, and the other one is psoriasis, psoriatic arthritis, achillosing spondylitis, and rheumatoid arthritis. And just to make a parenthesis, there is also a lot of evidence that I am aware about, and I actually I have that portrait listed in two books that I have coming.

One is about gout and I talk there about gout, not only as the big toe pain disease, but I talk about iceberg. I see that patients when they get diagnosed with gout, it's like the tip of the iceberg. Then you figure out that they have other diseases. One of them is kidney disease. The other one is diabetes most of the time and obesity.

And many of them, they have psoriasis as well, like you mentioned, all of them being connected, but we tend, being specialists, we tend to see just one. You are a rare breed because I know that you have a holistic approach in your practice and by your trainings,  it shows that you're not only trying to fix the kidney disease, but you also got further. 

Certification in high blood pressure, so heart disease and obesity. Now, are you aware about these new drugs that are coming in the market to decrease the weight, to manage obesity? Are you aware that these drugs could lower inflammation and actually have an impact on autoimmune diseases?  Another excellent question.

So when we think of inflammation and autoimmune disease, most people think about lowering the incidence of psoriasis or aortic arthritis, rheumatoid arthritis, as you mentioned. gout.  Fewer people think about inflammation as also contributing to coronary artery disease. And these medications that we are discussing, GLP 1 agonists and the GIP A relatively newer on the market in regards to terzapatite.

We don't have yet enough data to indicate that it lowers inflammation. However, there is a sufficient data from the WeCoV trials. Let me go a little bit into this data. As I mentioned, the newer. thought behind pathology of coronary artery disease is that inflammation is a major constituent from that contributes to, let's say, worsening of  atherosclerotic plaque disease at the level of the heart arteries, at the level of arteries throughout the body.

So in the WICOV trials, they are called STEP trials. And most recent, published was the SELECT trial. I think it came up in a New England Journal of Medicine in November 2023. They actually took patients that did not have diabetes, but they had underlying cardiovascular disease. And they took a large group, huge group of these people, like 8, 000 people were enrolled in on stemaglutide.

Also known as WeGOVI, and they underwent lifestyle interventions, and they compared them to about a similar group of about 8, 000 people that were only undergoing lifestyle intervention. Then they measured blood work, and they measured skin color. something that we call high sensitive CRP, which you probably order in a lot of your patients.

And it is a marker of inflammation most commonly used at bedside. So we do use CRP or C reactive protein. And this high sensitive CRP is mainly used for patients in whom we like to determine if inflammation is contributing to their cardiovascular disease. And when they validate that these patients are at the end of In the last two years, they realized that 40 percent reduction in the levels of high sensitive CRP, compared to about 2 percent reduction in the level of high sensitive CRP in the patients that were on lifestyle interventions alone.

So I think this is the evidence behind these newer medications contributing to lowering inflammation. They are. not to be used for autoimmune conditions. However, CMS has recently approved the use of Wegovy or semaglutide for patients with BMI of over 27 percent and cardiovascular disease,  atherosclerotic cardiovascular disease, I should mention, be more exact.

So this is huge. It does lower the risk of stroke and heart attacks. And that is what prompted CMS to approve them as a tool. In addition to, let's say, statins or other medications, aspirin, statin, other medications we use, cause by using this, not only do patients achieve a better way than a healthier way, but also patients are less likely to die from stroke.

My patients, anecdotal or not, my patients that they started these medications for obesity, they do have lower levels of inflammation. The inflammation levels come down. But not only that, first they started to tell me that they have less inflammation. pain and they feel less stiffness and they feel less inflamed, especially in the mornings.

And when I check their markers of inflammation, indeed, their markers of inflammation go down. And I have researched myself and there are some studies, like you said, the one that you just mentioned, which I think it's huge because it becomes. Science, not only anecdotal reporting, that this medication do influence not only the risk to develop a disease, but also when you have a disease, that inflammation or that disease might have a better chance to be controlled faster and better.

And I think that's huge for these patients. You just mentioned about a two year study. And many of my patients will ask me how long it's going to take until I see effects from these medications. Can you give us a rough idea about that?  That's also the question that every single one of my patients is asking, so how long will it take for me to lose the weight?

We have to consider that every patient is different and every patient needs to lose a different amount of weight. And not all the patients respond to the medication the same way. And not only to this newer medications, but even to the older medications or bariatric surgery, not everybody responds well to this interventions or not.

Everybody, I should say, responds the same way to this intervention. So you would have the patients that will lose, let's say, 40 percent of their body mass on the same dose of Wegovy  compared to patients that will lose 5 percent or less of weight on, let's say, you mentioned earlier, terzepatide. 

Terzepatide is known to have three maintenance doses. So patients on terzapatite may be on the maintenance dose of five milligrams. And for that dose, they may lose on average, the keyword here is average,  up to 15 percent of their body weight, according to the terzapatite trials,  called the Surmount trials.

Now, you would have patients. on terzapatide, 10 mg. And those patients, maybe they would lose on average, according to the trials, about 19 percent of their total body weight. Again, the key word here is average. And you would have the ones on 15 mg of weekly terzapatide. And those, according to the trials, they lost about 21 percent of  body weight on average.

Now, when you think about it, the curve is like this. So even though the majority of patients that would start terzepatide, and when I say that maybe 96 percent would lose 5 percent of their body weight, there will be patients, like the 4 percent of those patients will not 5 percent of their body weight.

This emphasizes the fact that obesity is such a heterogeneous disease. Not everybody that has obesity responds the same way to medications, in a sense that if you want to tackle this problem and help them lose the weight, you have to find out what is the underlying physiology behind the reason why they are accumulating the weight.

So how long it takes my patients. So typically what I like to see, I would like to see them lose about two pounds max per week. I try not to go beyond that. I feel that targeting a lower and a healthier weight is like a marathon. Not like the sprint if you achieve a faster weight loss, which could be possible within this newer medications that most of the times give the body what it's missing, such as this hormones to achieve a healthier weight loss.

hormonal balance and achieve weight loss. If you go faster, you can run into complications and complications that come first in my mind when I think of that would be primarily cholelithiasis.  So people would acquire gallstones if we go to fat weight loss. And the other complication that I think it's maybe more important, especially for older patients,  is muscle loss.

So because when you lose weight with these medications, you actually don't lose just fat mass. You also may lose up to 25 percent of muscle mass and it's a rheumatologist You know that muscle and bone are connected. So when you lose muscle also, there is less weight on the bone so you have a higher risk of osteoporosis as well and That also together risk of fall higher risk of fall.

So here is where I feel that aiming for a slower Curve of weight loss is very important because it gives patients time to get used and implement some healthy habits. And one of these key healthy habits is actually physical activity. And that physical activity should have an emphasis on muscle training, strength training, and balance training to prevent a lot of these complications.

And the other thing that I find that important to mention, even though you asked me how long. So for every patient is different. The duration of time it takes to lose, because every patient has a different target, but what I want to emphasize, since you gave me this opportunity, I want to emphasize that there is a safe way of using these medications and when patients lose a lot of weight.

Sometimes they don't realize that other medications have to be adjusted. By losing weight, your sympathetic tone is different. People have lower and easier to control blood pressure. I find that many of my patients can actually, we can reduce their blood pressure regimen or even Stop altogether some of their medications.

Of course, this won't happen after a month, but gradually it happens. The other thing to keep in mind is that some of them can have hypothyroidism, low thyroid. The dose of thyroid hormone is weight based. So that must be adjusted because then you run into the problem where patient may be taking a higher dose of thyroid hormone, and then you have two medications.

One is like you're making them  hyperthyroid, and second is like you're giving them the medication to lose their weight so they can lose in a more accelerated way the weight, and that's not good for them. That's not good for their heart. It's dangerous. And other medications would be statins.

People may not be aware, but trizepatide also lowers cholesterol.  Strong extent as the SAS would, but it does contribute to a lower lipid panel. So overall, long answer short, everybody is different. Everybody will lose the weight in different amount of time. And faster is not always better. I feel that slower may actually be in patient's advantage.

So that's why when you advance the dosing on those medications, very important to actually touch base with a patient. I personally touch base with them once a month, at least, even though when we get to maintenance dose, the first three months, I see them every month and after three three months. After that, I would see them every three months, but we still touch base in between once a month at least, if not more than that, to make sure that we are in target, make sure that we don't need to make changes in between.

But this is very important because you put together a lot of good information. And if I can summarize, I think that the patients should know that this is not a sprint, it's a marathon. The dose needs to be adjusted slowly and this kind of communication with the doctor, which I think you have the opportunity to do that being in direct contact with them.

And I know that your practice is based like mine on a direct care type of approach. When you and the patient decide when you have to see each other, how long you have to see Spend through these appointments. It's not like rush appointments every three months. Your practice is completely different. And why don't you tell us a little bit about your practice, about how you practice?

Because usually patients that needs to deal with a physician in the traditional medical system, they do not have this kind of approach where it's very centered to the patient needs. And not only that, and it's very.  personalized approach, and I think this is important for people to know how you practice.

Me and my patients, we have a partnership here, so I am involved in their care. I'm responsible for guiding them towards a better health, and I like to learn as much about them as possible. So the first visit is always at least 60 minutes, sometimes longer, because sometimes it takes longer time to learn about someone.

somebody. And then I put a huge emphasis on communication with my patients. And in between visits, patients can reach me directly, usually cell phone. I have this app that allows HIPAA compliant messaging and we communicate frequently. I do want to know if they have any questions. Any side effects and actually I do want to know if they have questions I want them to learn about how to use their medications and I actually feel that Explaining them why we're doing what we're doing Empowers them to make better choices for their health so far  It's been going very well in this regard and I'm happy I feel that I can offer for more and I feel that I can practice medicine the way I thought I would practice when I went into medical school and it's more rewarding to me as a physician as well.

And I go to the office and I know where I'm not rushed. I'm going to spend time. the time with this patient. And I can also have the time to learn and become a better doctor in the end. So it does give me that flexibility and I highly appreciate it. So overall, I think I made the right choice in that direction.

And yeah, that's my impression about direct care and it's a great way to practice medicine the way we all imagined it would be when we first went into medical school and it does offer a closer partnership between you and your patient.  For people that do not know that this kind of practices exist, this is also very important because it's important.

What people envision when they need to go to a doctor today is like long waits outside in the waiting room and then short time appointments, difficulties to communicate with the doctor. And most of the time they have to take a little bit from the doctor, but then research it on their own. And the fact that you remain available between appointments and you want to know.

This is very important. You want to know and you want to learn from your patients. It's the normal way to communicate with patients, but it's not longer what patients expect. Now, I would like you to give me one tip or two tips if you want to share from your strategy that you help your patients to be successful in this battle with obesity.

kidney disease and all these chronic conditions that we talked about.  First and foremost, I don't want patients to think that taking a medication alone would the panacea and help them fix the problem. It could be, but not in a healthy way. Because as I mentioned, this medications also lower muscle mass because you lose weight, but you also lose muscle, may have weaker bones in the end.

All the trials with this newer medications were done together with lifestyle interventions, not without lifestyle interventions. For my patients, I emphasize the importance of this lifestyle interventions with every single visit that we have together.  And when lifestyle interventions, I mean making sure that they participate in.

physical activity. And when I say that, I feel that if someone were to leave this conversation with something besides the information on this newer medications for lifestyle intervention, the most important piece is physical activity. And we don't think about muscle as an endocrine organ, but it is, it secretes hormones that go to the brain and go to other parts of our bodies.

Muscles secretes hormones called myokines that go to the brain and simulate the release of this substance called BDNF or brain derived neurotropic factor. And that helps with improved brain plasticity. It helps us prevent Alzheimer's in the long term. term. So there are four types of physical activity.

I strongly emphasize to my patients, it's good to mix them together. Not one type alone works because people are oftentimes inclined to only do one type of physical activity. If you are aiming for longevity, Alzheimer's prevention, cardio is important. If you are aiming for weight loss maintenance, then strength is important.

And if you're aiming for flexibility and balance and prevent falls Then we have to incorporate all these four types of physical activity  In our daily practice and that can be like 10 minutes a day not more than that But those 10 minutes are important now to win the battle against obesity It's important to go to the root of why is it that my patient accumulated excess weight?

Because as I mentioned before, every single patient is different. And obesity stems from an abnormal physiology that occurs at the level of our brains.  So what is also important for my patients to understand is that it's the brain that controls what someone's weight should be.  And what that means is that everyone has in their brain a fat mass set point.

So that means that in one patient, the fat mass set point could be 200 pounds, whereas in another person, the fat mass set point could be 130 pounds. So what the brain does, it would spend anything it needs. to defend that fat mass set point. In order to win the battle against obesity, we must change that fat mass set point, and change it permanently.

And in some patients, it means taking a good history and finding out what other factors are contributing. Do they have another underlying condition, like low thyroid levels, for instance, or do they have a genetic condition? predisposition up to  30%. I was reading in a study up to 30 percent of people that are affected by obesity from childhood, carry a genetic predisposition for it.

And some of those 30 percent of people may actually have a genetic underlying condition that we can treat nowadays. There is another newer medication on the market. It's called set melanotype. People don't talk much about that because it's only given in those select patients. But in order to tackle their pharma set point, you have to go to that root of the problem.

And most commonly, we all live in an obesogenic environment. So what that means is that there is plenty of processed food. We don't sleep very well. Sometimes we work night shifts. So our circadian rhythm is interrupted. We don't exercise or we don't engage in physical activity very often. So our muscles may be unhealthy.

So there are various reasons, including medications. Few people think and about medications as promoting weight gain, but actually we have medications over the counter that we can buy from the store, such as antihistamines that can actually promote weight gain. So looking.  Closely, even at the medication list that a patient is on, is important.

So if you fix  problem that drove the patient to accumulate excess weight in the first place, then you modify the fat mass set point, you lower it, and then it's when you win the battle against obesity. And all that, it takes comprehensive evaluation, and it also takes engaging in making healthy lifestyle changes, forming new habits.

to keep you at that lower weight and healthier way. So that's the way I see things. It's not just medication alone. It is thinking, okay, what works for this particular patient? Because not everybody works this response the same to a medication and not everybody responds the same. to tackling environmental factors.

So I may respond better to physical activity, but then someone else, or I may, maybe sleep would help a lot. I'm sure sleep would help a lot, everybody. So there are lots of interventions that have to be considered in addition to medications when we battle obesity.  This is so comprehensive answer. And I Know that there are people out there that will listen to this interview and will understand Their goal in working with someone that is not only so knowledgeable But also very personable and it's someone that will look at the root of the problem and just Don't treat What we see because I know people would love to work with you How can they find you and where can they find you to open that collaboration?

They can find me on my website at www.  wade. com  kidneycare. com  and I do have a page on my website with free resources for patients that struggle with obesity, but also that struggle with kidney disease. And I selected the resources that I've learned about from different conferences I participated at.

And I've learned about as being very useful tools for my patients and my list is growing. The more patients I see I would add more to that list, but I feel it is quite comprehensive. And I also have a blog for patients that are interested to see it. I have to share with the world that your blogs are phenomenal, are full of knowledge, are very well written, and it's all written by you, not by artificial intelligence.

I read your blogs and I highly recommend them and I also want to tell people that the fact that you put together all these resources, it shows so much that you want to give to your patients. And not only that, but now you have something else to add to your list. This is your first podcast. We want to congratulate you for doing such a wonderful job in going deep to the problem and explaining in easy terms to people the complexity that is behind obesity and also removing that stigma from the obesity patients.

With that, I would like to thank you very much, Dr. Moccano, and I hope that you're going to accept my invitation to be in another podcast very soon.  Thank you so much. It was an honor to be here. I'm so glad we got to talk together today. It's been a pleasure. Thank you