135. Why Only 0.4% Of Obese Individuals Receive Weightloss Medication... and more

This episode is our monthly news bite, the wrap-up of relevant and interesting research and news in the weight loss, health, and wellness world.

Tune in to Health Bite, the podcast for small steps towards a healthier life! In this episode, we redefine your relationship with food for weight loss and overall well-being.

Listen now for valuable insights!


What You'll Learn In this Episode;

• Discover the challenges physicians face in prescribing weight loss drugs and the FDA approval of Semaglutide for diabetes and obesity treatment.
• Understand the significance of recognizing obesity as a disease to remove stigma and promote effective treatment.
• Learn about the limited access to anti-obesity medications, with only a small percentage of eligible individuals receiving prescriptions.
• Find out how BMI affects brain response to food, with lean individuals experiencing greater feelings of fullness and satiety compared to obese individuals.
• Recognize the need to challenge biases, improve drug availability, and reshape public perception of obesity for better treatment outcomes.
• ...and many more

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Transcript

Welcome back to Health Bite, the podcast for small, actionable bites towards healthy living. I believe your relationship with food is a window into your relationship with yourself. 

And in this podcast, we will explore how to redefine this relationship so you not only achieve your weight loss goals, goals, but greater mental, emotional and physical wellbeing.

I'm your host, Dr. Adrianne Youdim, and I am excited to share with you this week's bite. So this episode is our monthly news bite, the wrap up of relevant and interesting research and news in the weight loss, health and wellness world. First up, I wanna share with you some interesting data on physician prescribing practices of weight loss drugs, or what we like to say or call anti-obesity medication.

And I have to say, I know firsthand that physicians are not comfortable with prescribing these drugs. This is in part why I think as someone who is trained and experienced and comfortable with doing so, I've had the referrals of my colleagues over the years, but. The FDA approval of Semaglutide, also known as Ozempic when used to treat diabetes and Wago V when used to treat obesity, has cast a spotlight on the medical condition of obesity and on the prescribing of these drugs and anti-obesity drugs in general.

Now as it backdrop to this conversation, I want to remind you that while you may have negative feelings or associations with the word obesity, giving excess weight a name is critical to recognition of this complex condition and critical to availing treatment. In fact, in June of 2013, the American Medical Association defined obesity as a disease.

This was also critical in helping remove the stigma that continues to exist around excess weight and a nod to the science behind it. As we will discuss later in today's episode, obesity causes changes in the body, changes in hormones, and in neurotransmitters in the brain that cause and promote metabolic harm in the body.

Any time normal physiology changes to support a harmful bodily state, that is by definition a disease. And I wonder, what do you all think about this? Does seem validating to you identifying obesity as a disease or does it feel pathologizing like we're calling people broken. And honestly, I can see it from both sides.

I'm curious what you all think about it. But again, I do think this is important for the reasons I've already mentioned, but also it's critical to making treatments available and accessible. When we have a name for a condition, we have a way to define it. We are better able to identify the people who could benefit from treatment, and this is a limitation that has become.

Blatantly clear this past year with availability of these new drugs. Now, research was presented this week at the Endocrine Society that showed between the years of 2016 and 20 20, 1 of the nearly 2 million people who were identified as having a diagnosis of overweight. And or obesity who are actually eligible for medications.

Only 0.4% of people were prescribed anti-obesity medication that is abysmal. Imagine if only 0.4% of people with diabetes. Were given medication or 0.4% of people with breast cancer were offered chemotherapy. That's less than half of a percent. Of course, this was in the years leading up to the advent of wavy, which popularized anti-obesity medication.

But that being said, access to these drugs are limited, so we may be prescribing more, but are people actually getting it? In fact, last week the Washington Post reported that insurers like Anthem Blue Sh Blue Shield. Started clamping down on the off-label prescribing on OZ of ozempic for non-diabetics and physicians started to receive quote education letters about how to prescribe.

We in California started to hear this week that our patients were no longer getting this medication covered as well. Now some of you may judge off-label prescribing of a drug that is meant for diabetes, but I want you to consider this. Number one, this diabetes drug is also F D A approved for weight loss.

It is the exact same chemical that is approved for diabetes and approved as an anti-obesity medication. Number two, there are many, many, many drugs for diabetes, and there are literally a handful of anti-obesity medications, and this one is by far the most effective. So what are our options when you take away semaglutide?

And last but not least, and I think perhaps most importantly, There is currently a quote shortage of Wago V, but not ozempic. Again, remember that this is the exact same medicine, the exact same chemical or molecules that are used to treat these two conditions. So what choice do practitioners and physicians have in prescribing when Wego V, that same drug is not available, but Ozempic is?

What does that say about our bias against obesity in this country? So, These are really important questions that we are forced to reckon with. Our comfort with these drugs is something, as physicians that we are forced to reckon with. The availability of these drugs is something that we are forced to reckon with, and if it is true that only half a percent of eligible people are actually given the option for medications.

That is also an important and sad reality that we are forced to reckon with. But the good news is that because of the adv, advent of these drugs, physicians, insurers, and even governmental agencies are being forced to reckon with it. And I hope that this trickles into how we as the general public see and view the problem of obesity as well.

We have shamed people about their weight long enough, and to be honest, I am quite sick over it. The second news bite speaks to the ways in which the physical state of excess weight impacts. Our physiology. So a recent study was done by researchers at Yale that looked at the impact of B M I or simply put our weight on the way in which nutrients were sensed and responded to in the brain.

So basically, this is what researchers did. They took individuals who were both lean and obese as defined by an elevated B M I. And fed these individuals via feeding tube, so food was delivered by a v feeding tube directly to the gut. By doing this, they were able to bypass the mouth and therefore the role of oral pleasure and taste in eating in order to have test the effect of nutrients on nutrient signaling alone.

In the area of the brain that is involved in motivation for food intake and involved in eating behavior. So again, subjects were fed via feeding tube and researchers looked at the effect of nutrients on the striatum of the brain, which is one of the areas of the brain that's involved in eating behavior.

And this is what they found. Lean study participants were found to have decreased brain activity in this critical part of the brain and increased dopamine levels when they were fed sugar and fat. And this resulted in greater feelings of fullness and satiation or satiety in lean subjects. However, in obese individuals or individuals with obesity, brain activity in the striatum did not change in response to sugar or fat, nor did their dopamine levels increase in response to this intake.

So let's recap. Obese individuals did not have the same dopamine response that neurotransmitter, that helps us feel pleasurable response to food intake, nor did they have the same satisfaction or satiation as compared to lean counterparts who did experience a dopamine response as a result to these palatable nutrients.

And the authors rightfully state that these results indicate that patients with obesity have a reduced neurochemical capacity to process nutrient intake and to experience satiation. That is really significant because if you can't experience satiety or fullness, Then what is your sensor to stop eating?

What's even maybe more important is that after obese individuals lost 10% of their body weight, they still did not reveal these physiologic changes in brain chemistry that signaled greater fullness. And this really speaks to the bias. And to the false belief that obesity is just a matter of willpower because again, if you consider that you don't get that signal of fullness and that that's cha signaling does not change even when you lose weight, it really speaks to why keeping the weight off is so very hard.

And in my mind it also speaks to the fact that medications to treat obesity are really critical in not everyone, but in a ha a significant amount of individuals. Meaning to say that we really need to have a different view of. What obesity means and what it means to treat obesity, becoming more open and making access to medications more readily available.

Really interesting stuff. And I do have prior podcast the talk about changes in hormones, neurotransmitters and neurochemistry in individuals when they develop obesity. It's really important and really fascinating to know that there are. Physiologic changes that occur when individuals develop excess weight.

Next up, the American Medical Association this week adopted a new policy clarifying the use of B M I or Body Mass Index in the diagnosis of obesity. Now, just as a, uh, reminder, B m I or Body Mass Index. Is a number that is determined by taking in an individual's weight and height, putting it in a calculation, and giving us a number that allows us to determine.

Or that we use to determine the degree of excess weight that an individual has. Now, keep in mind that this calculation is the same regardless of gender, regardless of age, regardless of ethnicity. So A B M I of 30 is considered obesity, whether you are. 18 years old or 85 years old, whether you're Hispanic, Asian, Caucasian, or black, um, whether you are female or male.

And of course, as you can imagine, this presents a significant limitation. And so we have been talking about this for a long time. And finally, the A m A came out with this policy suggesting that B M I should really be used in conjunction with other valid measures of risk. Including visceral fat, which can be measured with a waist circumference.

Remember again, visceral fat, is that harmful fat that is found in the belly. Uh, looking at body composition, looking at genetic and metabolic factors. So again, suggesting that. Duh. We need to be looking at the big picture and not just this one number in order to kind of wrap everybody up into a diagnosis.

This policy goes a really long way, I think, in acknowledging that the B M I is an imperfect way to measure body fat in multiple different groups. To acknowledge that it doesn't account for differences across race, uh, and ethnicity, different genders, sexes, and age spans. Now, what I think is really interesting is that a group did a follow-up study that was presented this week also at the Endocrine Endocrine Society annual meeting that revealed that.

The B M I vastly understated obesity. In this study, they looked at nearly 10,000 Americans and measured body fat by dexascan. Now, Dexascan, as you may know, uh, as a bone density scan. Is a technology that allows for accurate assessment, not only of bone density, but it also allows for a very accurate assessment of body fat.

And so researchers did DEXA scans on these 10,000 individuals and compared body fat by DEXA to b bmi. And this is what they found, that among the 64% of the study group who were not obese by b I, so their BMIs were normal, DEXA scan showed that 53% of them actually did have obesity based on body fat content.

So over half of individuals who were missed. By B M I and had normal weight for height, actually had abnormal or excessive body fat content. So the B M I did not show obesity, but this imaging study of the body did Additional analysis, showed that the rate of misdiagnosis of obesity was by far the most common.

In Hispanic and Asian ethnicities and amongst women, and in fact, 59%. Uh, showed a 59% prevalence of obesity by DEXA among women within the normal B M I range group. So this really speaks to the limitations of B M I. We have discussed frequently how B m I might overestimate excess weight in certain groups.

But this study really speaks to the underestimation who is walking around out there with abnormal stores of body fat, abnormal stores of perhaps visceral fat, which is the harmful fat that are not being caught by that standard B M I or weight for height ratio. The study means that many more people have excess body fat than what is picked up by B M I alone.

And let's think about that in a system that currently uses B M I as the sole determinant of obesity and is used by insurers as the only metric for whether or not they qualify for medications to treat obesity. Understanding that B M I is an inadequate measure of excess weight, has really serious implic implications.

I think though the silver lining, and as you know I always have a silver lining, is that this information is really what I think. Will be important and the start of what will hopefully shift the tide in how we are viewing and managing this disease. Now, what does this mean for you? Because DEXASCAN is expensive.

It em admits radiation. And as such, it can't be expected to be used willy-nilly every time you walk into your doctor's office. As easily as we would have you jump on a scale. But there are other measurements like waist circumference for example, which is a measure of the waist at the. IAC Crest, which is basically the top of your hip bone.

You can press down on your hips and find the top of that bone. And we know the waist circumference is a really good surrogate for visceral or belly fat. So obtaining a waist circumference is one potential metric. Another is bioelectric impedance. Now this is a technology that is currently found on many household scales that allows, uh, the measurement of body fat.

Again, it's not as accurate of course as dexa, but when used in the right way can be a good alternative. And we actually use bioelectric impedance in our medical offices. So really interesting stuff in terms of medications for, uh, obesity treatment, prescribing patterns by physicians, and how we even determine who is an appropriate candidate for these drugs.

What an exciting time to be in the field of obesity medicine. Science is advancing, facts are changing, and I'm so happy, really, and excited to be at the forefront of this change and to offer you this information in hopefully what you find to be small, manageable bites. That's all for this week. Thank you for listening in.

If you loved what you heard, I hope you'll head over to Apple Podcasts or anywhere you listen and write us a review. Really, please do it like go right now and do it. And finally, you can head over to dr Adrian udi.com to download my free health and wellness guide and check out the many other resources I have for you.

The link is in the show notes below. Have a wonderful week and come back next week. I have a amazing lineup of expert interviews for the month of July that will nourish you, I promise, mind, body, and soul. I'll see you then.