A Conversation on GLP 1s, Obesity & Metabolic Care

Obesity affects millions of people and is increasingly recognized as a complex chronic disease shaped by biology, genetics, environment and metabolism. In this episode of the UB Medicine Podcast, host Dr. Allison Brashear is joined by Dr. Ajay Chaudhuri, an internationally recognized expert in diabetes, obesity and metabolic disease, and Dr. Kathleen Bethin, a pediatric endocrinologist and specialist in childhood metabolic health, for an in-depth discussion about the science transforming obesity care.

Together, they explore how our understanding of obesity has evolved, why stigma remains a barrier to treatment, and what patients and families should know about metabolic health. The conversation also examines the rise of GLP-1 medications, explaining how these therapies work, why they represent a significant breakthrough in obesity and diabetes treatment, and the broader health benefits clinicians are seeing beyond weight loss.

Listeners will gain insight into obesity and metabolic care across the lifespan, from children and adolescents to adults, as well as the importance of combining medication with nutrition, physical activity and behavioral support. The episode concludes with a look at emerging research, unanswered questions and the future of personalized obesity treatment.

Transcript

SPEAKER_02 0:02

Hello, everyone, and welcome back to the UB Medicine Podcast. I'm Dr. Alice Brashir, Dean of the Jacobs School of Medicine and Biomedical Sciences, and Vice President for Health Sciences at the University at Buffalo. Today we're discussing one of the most talked-about topics in medicine: obesity, metabolic health, and the emergence of the GLP1 medications. Over the last several years, these medications have transformed public conversations about weight loss and obesity treatment. They generated enormous interest among patients and providers and researchers alike. And beyond the headlines, there's really a much deeper story about metabolic health and my own role as a neurologist, how that impacts the brain, how metabolic health impacts chronic disease, and really how the science of our bodies regulate appetite, energy balance, and weight. At the Jacobs School, our faculty are helping advance the understanding and treatment of obesity, diabetes, and metabolic disease while educating the next generation of health professionals. Today we'll explore what these medications are, how they work, who may benefit from them, and what the future may hold for obesity treatment and metabolic care. Joining me today is Dr. A.J. Chowdhury, Professor of Medicine in the Division of Endocrinology and Diabetes and Metabolism at the Jacobs School of Medicine and Biomedical Sciences. Dr. Chowdry is an internationally recognized expert in diabetes, obesity, and metabolic disease, and has spent much of his career studying how these advances in treatment can improve patient outcomes. We're also joined by Dr. Kathy Betteen. She's a clinical professor of pediatrics at the Jacobs School of Medicine, Vice Chair of Clinical Affairs for UBMD Outpatient Pediatrics, and an attending physician in pediatric endocrinology and diabetes at the Galisano Children's Hospital, Buffalo. Dr. Bettine specializes in endocrine and metabolic disorders affecting children and adolescents, and she brings an important perspective on obesity and metabolic health across the lifespan. Thank you both for being here. Let's just start with the really big picture to set the stage for our conversation. For years, obesity was often viewed as a lifestyle issue. How is our understanding of obesity involved and why is this so important to recognize obesity as a chronic disease?

SPEAKER_00 2:31

Yeah, I think that's a that's a very interesting point that you bring up, that we really need to think about obesity not just as an appearance or a body weight problem. It's really a health issue, you know, because it does increase the risk of chronic diseases. So I'm glad that eventually now we are thinking about it as a chronic disease rather than just a lifestyle problem. Just like we wouldn't think about treating hypertension or asthma, you know, just by changing lifestyle, but with some medications along with some of the lifestyle changes. So I'm glad that we have reached that stage now.

SPEAKER_02 3:09

That's quite a bit different from when people trained just not so long ago. Um and Kathy, as we think about children and the impact of what happens in early childhood and the impact that happens when they're adult and older adult, how has that changed?

SPEAKER_01 3:29

So we are seeing a lot more obesity in children and unfortunately a lot more type 2 diabetes. We are also finding some of the kids do have genetic changes that could be responsible for excess weight gain.

SPEAKER_02 3:50

That is interesting. So you mentioned genetic, then there's biological, environmental factors all playing into both children and adults. Do we have genes impacting this both in children and adults?

SPEAKER_00 4:04

Yeah, so as far as genetics are concerned, what we understand is that, you know, genetics do decide, you know, what our body weight should be. Um, you know, what is the amount of food that we should generally be eating and the energy that we should be expending. And so there are some genetic um uh, you know, we have identified genes that can affect our perception as far as hunger is concerned and also energy metabolism. Um but then the environment does play a role because it's possible that because of your genes, you're supposed to be a certain weight, but then because of your environmental influences, you know, the food choices that you make or the environment that you grow up in, or because of stress factors, you know, you could then gain more weight than you should. So that is the way I look at in terms of genetics and the in interaction, you know, with the environment in uh, you know, in obesity.

SPEAKER_02 5:07

And Kathy, with children, that environment is really shaped early on. How does that impact the trajectory the children find themselves in?

SPEAKER_01 5:19

The children don't really have a choice of what other people are bringing into the home. And there's also the problem that kids are home alone after school, and so they walk to the closest store, which only sells junk food and right, right.

SPEAKER_02 5:40

And and um, you know, obesity has a stigma that really still exists today. And how does that affect patients seeking treatment? I mean, um, you know, now we have these drugs, so how has that changed your practice, people coming to be want to be treated?

SPEAKER_00 5:58

So this is something that is very near and dear to me, you know, having practiced this for 30 years. Um, you know, seeing a lot of patients who, you know, came in really thinking about that, you know, the reason why they are not able to lose weight is because they are not trying hard enough. Um and then, you know, we didn't really have too many treatment options that could help them along, you know, in spite of understanding that really their own body is not really helping them to lose weight. Yeah, because the body's natural mechanism is to try and preserve weight, yeah, because uh if we lose weight, the body's signals go up where it makes you feel more hungry, you know, you adapt by reducing your energy expenditure, etc. So, really, what the conversation has changed with some of these medications is that now um, you know, we can have that conversation. Yeah, that really don't think about it just as an appearance. It's you've got to really think about it as a health, as a as a health issue. Um it's chronic, so you need to still follow those nutritional and behavior changes and exercise. And these are the medications that are going to help you to be able to uh work against the natural responses of the body, which makes you try to, you know, to make you gain weight. So really, you know, removing that stigma that it is not just, you know, a thing about willpower or a character flaw, you know, has really helped this conversation. And I'm I hope more and more people will understand this and uh, you know, get more help and have that conversation.

SPEAKER_02 7:47

That's so important. And I can imagine that for a child who has challenges with weight, that that would be a stigma that could stay with them for their life. So, how how can these new treatments help children?

SPEAKER_01 8:03

Well, the kids are actually bullied quite a bit. And so they can be quite depressed when they come in. So it if we could get the medication for the kids, which is another issue, um, it would be helpful along with lifestyle changes.

SPEAKER_02 8:28

Let's uh let's just jump in here and talk about these medications, the GLP1 medications that have gone from relatively being unknown to being uh common everyday uh words. Um for the listeners who aren't familiar with the science, what exactly do these medications do and how do they work?

SPEAKER_00 8:50

The GLP ones, these are a class of molecules which are we call ingredient molecules. So these are gut hormones that are usually secreted. So as soon as we eat, these gut hormones are secreted by the gut. And their purpose is that you know it slows down gastric empting, it suppresses appetite, and also increases the secretion of insulin in, you know, as glucose levels are going up. Um now, what we understand that both in diabetes and in people who are overweight, uh the effects, there is a resistance to the effect of these medications. So now you can understand that if there's going to be a resistance, even though these GLP ones are being secreted by the gut, you know, it is not as effective in suppressing appetite or making the body secrete insulin. So then, you know, because of that, you can develop higher blood sugars, i.e., diabetes, and also, you know, you will have a tendency of gaining weight. So with the modifications, you know, with pharmacological modifications, what we now do is that with these medications, we achieve what we call higher than physiological doses. So higher than what the body normally produces to be able to overcome the resistance, the natural resistance that is there. And then that allows the body to be able to regulate blood glucose better. And it also suppresses appetite, you know, so that people can lose weight. And um, I just want to kind of say that, you know, these molecules were initially discovered primarily to treat diabetes. And then because of its appetite losing effect, they are very effective now also for weight loss.

SPEAKER_02 10:46

How interesting. I did not know. Was that an adult or children?

SPEAKER_00 10:50

So this was an adult. So, you know, it was discovered because you know, there's a lizard called the Gila monster that can survive without eating anything. And I remember I was at the Endocrine Society and somebody was presenting, you know, data that it's from the saliva of the Gila monster that they discovered this molecule that is called exendin. And when they, you know, looked at the effects of exentin in animal models, they showed that it could regulate blood sugar and also suppress appetite.

SPEAKER_02 11:20

So interesting. And and have these medications, Kathy, been used in children?

SPEAKER_01 11:25

Um, yes. Um, we started with using it in children with type 2 diabetes. And when we can get it for kids that have general obesity, um, we use it. And then some of the uh genetic mutations, um, we've been able to use it in the kids too.

SPEAKER_02 11:50

Why do you think that these medications have just taken off and um are so commonly used? Um, every time we turn on the TV, there's something about these medications. Um any ideas?

SPEAKER_00 12:04

You know, really what these medications have done is that, so again, having done 30 years, you know, treating people with diabetes and uh and weight, the previous treatments really, you know, used to make people lose 3 to 5 percent of their body weight. And yes, that was important from the metabolic aspects of it. But with all the side effects and the way that you had to take that medication, I never really felt whether, you know, I would really be providing benefit to some patients. Now, these medications now are making people lose anywhere from 15% of their baseline body weight. So for somebody who weighs 250 pounds, they could lose 35 pounds on an average. Some other medications, they are making people lose 20% of their body weight. So if somebody who's 250 pounds could lose 50 to 55, 50, 55 pounds. And not only is it making a difference in their underlying health conditions, because that is really the most important thing out here. But remember, you know, somebody who's had trouble, you know, losing weight is now able to lose that. That has a tremendous benefit, you know, psychologically, because they suddenly start feeling much more confident, you know, in themselves. Because, you know, previously they are struggling saying, oh, if only I could do this, you know, it's something that I'm not doing, that is not allowing me to lose weight, not understanding that it's a chronic disease. There are certain things in the body that don't cooperate with you to make you lose weight. Yeah. And then now they are successful. A lot of the times, you know, they are doing the things that were, that they were doing normally but not losing weight. And now they are doing the same thing, but now they are losing weight because the body is cooperating with them in terms of so it's been tremendous. And to see it's been fascinating for me to see patients come in um, you know, overjoyed. I'm saying it's really it's really a treat to see, you know, the uh the kind of the smile on their faces and the positivity when they when they walk in, you know, when they see the effects of these medications.

SPEAKER_02 14:26

Well, I can imagine as a physician, as you said, who's been treating um individuals for over 30 years, and Kathy, um, you as well, um some of the health benefits must be beyond just blood sugar and the weight loss. I mean, I can just imagine arthritis, stroke, hypertension, et cetera, the list goes on. How do we really articulate those benefits of weight loss? Uh it's a broader, really public policy issue, right? So I don't know, Kathy, you must see this in kids that their trajectory for health the rest of their life is dramatically different.

SPEAKER_01 15:05

Right. I mean, it's hard because you're asking someone to spend five dollars or fifty dollars to say 5,000 in 50 years, or you know. Um so it's it's hard to get that. And one of the requirements is that they have to have had intensive six months of dietary counseling, like Weight Watchers or Noom or something like that, um before they'll even consider covering it. And my viewpoint is the children are our future, and if we make them healthy now, they will be healthy adults rather than very sick adults in the future.

SPEAKER_02 15:56

Oh, so well said. Um, what do you both think are some of the common misconceptions about these drugs?

SPEAKER_00 16:03

Yeah, so you know, the common misconception is one is, as I mentioned, that people think about it, that it's about, you know, appearance and cosmetic, and it's really about health and and and and and longevity. Um the second thing is that people think that they are taking an easy way out, and it's not really taking an easy way out because you still have to do those, you know. See, all the studies that have been done, they were done when you had to follow nutrition recommendations. So you had a 500-calorie deficit, you had to exercise 30 minutes every day, you know, five days a week. You also had behavior health counseling. So they were successful in that kind of environment. Yeah. Um, and the third misconception that people have is that it's a short-term thing. You know, if you start thinking about obesity as a chronic disease, then people have to understand that take this opportunity while they are on this medication to improve their behavior, to improve their nutrition, carry on with their exercise, and also understand that it's something that will require a long-term treatment. You know, when I speak to people, I've asked them so many times, you know, everybody tells me, oh, yes, I've been able to lose 10 to 20 pounds, but they always regain it back. Yeah. So they have to understand that it's something that is a chronic thing, that we will need to have an approach to maintain, you know, long-term weight loss.

SPEAKER_02 17:34

So um, what are some questions that patients should ask their physicians if they're thinking about these medications?

SPEAKER_00 17:43

You know, I really start off when people are, you know, coming to me, you know, especially from just from the from the weight point of view. Obviously, you know, I run a diabetes endocrinology center. So a lot of people also have diabetes, you know, along with um as far as this the weight is concerned. But if it's primarily, if they are being referred, you know, primarily for obesity management. I don't like using the word obesity, first of all. Like so if they're if they are there, so you know, obviously, what is their, you know, BMI, what is their waste circumference, what are the underlying metabolic conditions that they have, you know, what have they tried before? What are their expectations? These medications have certain side effects and contraindications, so we need to be absolutely sure. And this is why sometimes when I see people getting onto these medications without proper evaluation, I get scared because you know, you don't know. Because these medications do have side effects. Um, so we, you know, and then obviously we set up the expectations about nutrition. So I know that the insurances are recommending certain things, but I think there is a reason for that because you really need to have long-term success and long-term expectations. So, and they need to be absolutely, you know, they need to tell us about what are the medications, et cetera, that they are using. So that is how we start off. And then, you know, we look at is there other reasons why they might be gaining weight and not losing weight, and also associated chronic conditions. Yeah, we do nowadays we do fibro scan to look at, you know, whether the liver is stiff or not, you know, of obstructive sleep apnea. You know, we have a metabolic center that we have now with a multidisciplinary approach that we are looking at what are the other medical conditions that people who are overweight or you know have a high BMI come in with and screen for that to provide them with the right approach, a comprehensive approach, which is not just focused just on weight, but health.

SPEAKER_02 19:38

That's so important. And Kathy, tell us a little bit about how the conversation is with parents or caregivers of children who have uh issues with weight management.

SPEAKER_01 19:50

So one thing that I think is very important, and this was discovered at UB, is the whole family needs to make changes. It doesn't matter what anyone else weighs, the whole family needs to eat healthier. And, you know, you can be thin and still have hypertension and still have diabetes. So everyone needs to eat healthier. You can't expect the kid to live in a house full of potato chips and not eat them all the time.

SPEAKER_02 20:25

Yes, yes. Um, I completely understand that. Such an important point. What we only have a little bit of time left. What excites you most about the way where the scientists headed? Kathy, I'll ask you first.

SPEAKER_01 20:38

Um that they're actually combining these drugs with other drugs to sh to be more effective, even, especially for controlling diabetes and helping people to get to the weight that they want. So I'm just excited about the future. And AJ?

SPEAKER_00 21:00

Yeah, I'm saying apart, you know, I know we are talking about GLP1s, but you know, there are dual incritant agonists, GLP1 and GIP. Uh there are triple agonists now. You know, we call it the Godzilla.

SPEAKER_02 21:12

Oh my goodness.

SPEAKER_00 21:13

You know, which is actually causing 25%, you know, weight loss. We are combining with other uh mechanisms like you know, amylene products uh in terms of um, you know, weight. Um we are developing oral non-peptide molecules, you know, that work on the GLP one. And the other very exciting thing is that we are actually using an approach to uh reduce weight by actually increasing muscle mass. Yeah. So I know we think about weight as just you know the fat cell, um, but you know, if you can increase muscle mass, yeah, that can increase energy expenditure. And there are trials that are going on with certain medications. Because one of the things with the incredible therapy, also the GLP ones, is that as we lose weight, you know, we are losing muscle. So that's something of concern. But this other approach where we are actually trying to increase muscle mass, and then we are realizing that by increasing muscle mass, you can actually make people lose weight. So it's extremely exciting.

SPEAKER_02 22:18

That's really incredible. Um, and you just gave us so much more information about it's just not these one couple, one drug, it's a combination. Well, we're almost out of time. So before I conclude, I just want to ask you each one final question. So, Kathy, we'll start with you. What is one of the most important messages you hope our listeners take away about obesity and metabolic health and GLP1 therapies for children?

SPEAKER_01 22:44

Well, I think it's the same thing that Dr. Chaudri said is it's not really about how you look, it's about your health. And I actually always tell the kids that they're they have a little bit of extra weight for their height because I don't like the word obesity either. It's very negative.

SPEAKER_00 23:05

Oh, true. So, you know, there are three things that I would like the viewers to kind of take away from this. Again, one is again emphasizing it's not about appearance, it's about health. The second is there are now um, you know, uh medications are available that can help you to fight the body's mechanism that's not allowing you to lose weight. So please take advantage, you know, of this. And the third is just remember that it's not just the medication alone that is going to give you success. It has to be a multidisciplinary approach where the medications are helping you to follow, you know, the nutritional guidelines. You need to exercise and you need to make behavior changes.

SPEAKER_02 23:52

So you both mentioned you don't like the word obesity. So help me educate our listeners. How do we refer to this?

SPEAKER_00 24:02

See, so we basically characterize this that, you know, this is your BMI, this is your body mass index. The word obesity and overweight still comes in because it's something, but I think we need to really start thinking about, you know, just like we think about blood pressure, we think about blood sugar, you know, it's a value. We have to start thinking about it as body mass index. It's a value.

SPEAKER_02 24:28

Got it. Kathy, would you agree with that?

SPEAKER_01 24:31

Sort of, except kids' BMIs change as they grow. So I still like to say unhealthy weight versus healthy weight.

SPEAKER_02 24:42

Okay. All right. Well, we will try to change our language. And I just want to thank Dr. Chowdry and Dr. Peteen, both of you, for a really exciting conversation and for sharing your expertise with us and with everybody of our listeners. Um, one of the themes I've heard through our conversation is that um uh unhealthy weight uh is a complex and chronic disease. It's certainly not a problem with willpower or individual choices. It's a it's a disease of um health, and we're trying to refocus on that rather than the number on the scale, for sure, um, and the downstream effects of getting to a healthy weight on overall your health for your lifespan when it starts with children and adults. I want to thank you both. And here at the Jacobs School of Medicine and Biomedical Sciences, our faculty are continuing to advance research, educate the next generation of physicians, and improve the lives of patients through innovation and clinical care and scientific discovery. I just want to thank you both, and I want to thank our listeners, and I hope you'll continue to join us for the UB Medicine podcast. And until next time, take care.