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🎙 The Weight Debate: Myths & Evidence Behind Weight Loss & Medications Ep 230

• Dr. Michael Koren, Dr. Scott Marberry • Episode 230

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Can hormones like insulin and leptin dictate our hunger and, consequently, our weight? Join us on MedEvidence as Dr. Michael Koren and Dr. Scott Marberry, a seasoned family care physician and obesity medicine specialist, walks us through the intricate dance of hormones like insulin, ghrelin, and leptin in managing hunger and how leptin resistance can trap individuals in a perpetual state of hunger. We also shed light on the different kinds of fat lurking in our bodies, from the risky visceral fat to the somewhat friendlier subcutaneous and brown fat, and explore the severe metabolic consequences of adiposopathy.

Obesity's impact on healthcare is staggering, and Dr. Scott Marberry helps us unpack the higher medical expenses and health complications associated with excess weight. We lay out a comprehensive treatment blueprint, starting with individualized patient assessments and moving through dietary tweaks, exercise regimens, medications, and even bariatric surgery for severe cases. The conversation underscores the importance of ongoing follow-up and mental health support, ensuring that both patients and healthcare providers are partners in this long-term journey towards better health.

Imagine improving your cholesterol levels and stabilizing blood sugar with just a 5% weight reduction. In this episode, we discuss how small changes can lead to significant health benefits and dive into cultural factors influencing obesity, from family food habits to societal norms around celebrations. Dr. Scott Marberry shares the philosophy of portion control over strict diets, various diet options, and the personalized exercise routines that can make a difference. Additionally, we explore the transformative role of GLP-1 medications in appetite control and the potential life-saving benefits of bariatric surgery for those with severe obesity. This episode offers a holistic view of managing obesity with practical insights and expert advice.

Talking Topics:

  • Understanding Obesity
  • Health Impacts and Treatment of Obesity
  • Impact of Weight Reduction on Health
  • Diet, Exercise, and Obesity Medications
  • Severe Obesity and Bariatric Surgery
  • Impact of GLP-1 Medications on Appetite



Recording Date: August 9, 2024

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Music: Storyblocks - Corporate Inspired

Thank you for listening!

Announcer:

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren:

I'm really excited about this talk. I'm going to give you a little fist pump as a sports medicine guy.

Dr. Scott Marberry:

Okay, yeah.

Dr. Michael Koren:

And Scott and I have known each other for some years, and Scott's a tremendous family care physician who has also been involved in sports medicine and obesity treatment. Yes, absolutely, and so we're excited to have you as part of our MedEvidence family of educators. So thank you for joining us.

Dr. Scott Marberry:

Thank you very much for having me.

Dr. Michael Koren:

So one of the things I like about these talks is that I always learn something, and today I learned that you're a DABOM, d-a-b-o-m, so why don't you tell everybody else why you're a DABOM?

Dr. Michael Koren:

Yeah, I knew that, of course, but I didn't know. You had a formal description of it, right.

Dr. Scott Marberry:

So I completed my board certification for obesity medicine. I didn't realize that when you do that, instead of having MD or, as you have FACC, they call it a Diplomat, the American Board of Obesity Medicine. So DABOM I like that, Dr. DABOM?

Dr. Michael Koren:

Okay, here we go, ready to roll.

Dr. Scott Marberry:

Yes.

Dr. Michael Koren:

Okay. So, as people that have done this before know, is that, although you think you're getting a free lunch, you're really not. We say that there's no free lunch and that the audience needs to work for their food, so of course, we're going to have questions about obesity and hunger and things of that nature. So the first audience question which hormone makes us feel hungry and can occur at higher levels in obese individuals? At higher levels in obese individuals, is it A insulin, B ghrelin, C, leptin, D, kryptonite or E? All of the above? Okay? Who says A? Who says B? Who says B? Who says C? Who says D? All right, so we have some Superman fans out there. And who says E? Anybody? Okay? The answer is actually C. So that's an interesting learning point, and the key thing here is it makes us feel hungry, so go ahead, yeah.

Dr. Scott Marberry:

Right, so we're looking at these answer choices here. Let's actually just go through those real quickly. So, answer choice A insulin that's a hormone produced from our pancreas. When we eat food, particularly carbohydrates, our insulin levels should come up. So the insulin helps get the sugar from our bloodstream into the cells where the sugar can be processed. So after you eat, insulin can certainly be elevated.

Dr. Scott Marberry:

Ghrelin, that's a hormone that also comes from the stomach and what it does is when you are hungry, when you haven't eaten, that starts to come up, and after you do eat, that starts to go down. Leptin tends to do the opposite. So when you are hungry, leptin tends to be low, and after you're full, leptin tends to go up. The problem that we see is this condition called leptin resistance, and that is where individuals who suffer with obesity and have excess weight and adipose tissue. They actually tend to have higher levels of leptin and the body doesn't respond to that appropriately. So instead of feeling full, as in, we're not hungry, we don't want to eat anything. Our body is kind of ignoring that leptin and so that is why we continue to feel hungry with high levels of leptin, and it tends to be higher in obese individuals.

Dr. Michael Koren:

Okay, All right, so move on to the next slide. Which type of fat distribution is considered more dangerous to health? Is it A subcutaneous fat, Is it B visceral fat, Is it C brown fat, Is it D Fat Tuesday, or is it E? All of the above? So who says A subcutaneous fat, who says B visceral fat, who says C brown fat, who says D Fat Tuesday or E all of the above? And the answer is visceral fat, and you can see that this cat is a good example of it central obesity. So comment on that.

Dr. Scott Marberry:

Yes, so again, let's talk through these answer choices one by one. So answer choice A subcutaneous fat. That is referring to fat that is underneath the skin. So if we were to actually dissect right through my abdomen we would see I have some skin, I have some dermal tissue and then we have my subcutaneous fat right there. Deep to that is going to be my abdominal wall with my ab muscles and then inside of that are going to be my internal organs and if I have fat in that area, that is what we call the visceral fat.

Dr. Scott Marberry:

So subcutaneous fat is the kind of outer fat. It also tends to be called the more stubborn fat, sometimes hard to lose. But B answer choice visceral fat. That is the more dangerous fat. That is the fat that is located deep inside our abdomen. It tends to be more associated with other metabolic problems fatty liver, high cholesterol, high blood pressure, even certain cancers, and so that is the fat that we would ideally like to see very low levels of in individuals. Answer choice C brown fat. That's actually a really good fat for us to have. Brown fat is metabolically active. Actually it tends to be in very high proportions in infants and small children. It's a fat that helps them have a lot of energy. It also keeps them warm, and brown fat, again, is something that helps us to actually burn calories and burn fat.

Dr. Michael Koren:

Yeah, in fact, Fat Tuesday may be dangerous to your health for other reasons. Next slide, please, all right. So why don't you talk about the sick fat disease?

Dr. Scott Marberry:

Right. So this is a bit of a tongue twister, this word here the adiposopathy. What we're trying to say here is break it down to two forms Adipose is the medical terminology we have for fat tissue, and pathy meaning pathology. So when we have too much fat, that actually becomes a problem for the body. So we have this condition adiposopathy. Essentially we're talking about a sick fat, meaning that there's excess fat in the body that's actually causing problems and medical health issues, which, again very common ones that are associated would be things like type 2 diabetes, high blood pressure, high cholesterol, multiple cardiovascular disorders, liver disease, and so if we can work on getting some of this excess fat, this sick fat, down, then we can make some major improvements in health in multiple arenas.

Dr. Michael Koren:

Yeah, so I think adiposopathy or sick fat disease is just the concept that obesity isn't just cosmetic, it's associated as a disease, and we're understanding that better and better through a lot of interesting science and research, which is something that we both do on a regular basis. Next slide, please.

Dr. Scott Marberry:

I like this slide because it kind of brings again attention to the point for why we're even here today. Why are we even talking about obesity? Why is that even relevant? Well, several things here on this graph. You can see that from that first picture with that cartoon hospital, you can see that obesity tends to, on average, cost more as far as medical care for people. People who do have excess weight tend to have more medications they have to take if they are to get sick. They might be in the hospital longer. They might have to suffer more complications. So, just in general, obese individuals tend to pay more as far as maintaining their health care.

Dr. Michael Koren:

Yeah, these are pretty compelling data to show why this is a big problem in the United States and certainly why we're focused on treatment. Next slide, please.

Dr. Scott Marberry:

So this slide is a bit busy here, but this is something that I go through with my patients in the clinic. If obesity is something that we're going to be tackling or talking about in that visit. So if you can see, if we start with the contemplation phase and the initial assessments, what we're trying to say there is if a patient's coming into the clinic and say I've got a lady and she's obese, but she just had a manicure and she's got an infection at her fingernail, a paronychia and she's coming to see me for this, I'm not going to start the conversation with are you concerned about your weight?

Dr. Scott Marberry:

So I'm not going to bring it up then we're talking oh, we've got to take care of this nail, take care of that infection. But if a patient's coming in and they come to me and they're concerned about their weight, then we'll start having that conversation. Or maybe they're coming in so we can review some of the lab work and they're wondering well, how can I maybe get my liver enzymes down, how can I maybe get my sugars down? That opens the door to suggest, you know, can we talk about the weight? That might be an avenue for us to help get you on a healthy path. And so from that standpoint then, from initial assessment, looking at their vitals, looking at the labs measurements, from that standpoint, then we'll determine, you know, what should we do.

Dr. Scott Marberry:

Should we really just focus on, maybe, diet? Do we need to make some improvements there? Are we eating a lot of junk food? Do we need to clean up the diet? Do we need to do exercise? Everyone's heard the phrase diet and exercise. It's not that simple, because if it was, then there would be no obesity. And on that last slide we saw about 40% of Americans actually weigh in a range of obesity.

Dr. Scott Marberry:

So for some people, if they don't have a whole lot of other medical issues. We may just want to be focusing on what they're eating, what they're doing for activities or how we might be able to tweak some of those components, as you see there. On stage two, that might describe an individual who also has high blood pressure or diabetes, and so we might be thinking, you know, is there a way that we might also be able to incorporate medication to help with this individual to get their weight down? And stage three maybe we have an individual that has really severe health issues and it may be something we also need to consider, something like bariatric surgery to help get the weight down.

Dr. Scott Marberry:

And from that point on, you can't just leave it there. You've got to maintain follow-up, you've got to continue to engage with these individuals, because that's a very important process with this. I could have everyone in this room lose 10 pounds in 10 days if I really wanted to. I could get all of you guys to do that, but that's not going to do you any good if you can't keep that weight down a month from now or a year from now, if that's what your goal is. And so it's very important to maintain that care, that continuity, and keep up with the healthy eating, the healthy activities. Mental health is also listed on there. That is something that often is overlooked or not paid much attention to, but it's definitely a huge component with helping people to maintain healthy weight and going further.

Dr. Michael Koren:

And this is a good template for what we're going to be discussing over the next 15 or 20 minutes. So AACE is that American Academy of Clinical Endocrinologists? Okay, so this is coming from an endocrinology standpoint. Hormone physicians yes, all right. So the obesity algorithm? So?

Dr. Scott Marberry:

this is another fairly busy slide, but this is also kind of characterizing what we just talked about, where, you know, I'm seeing a patient, I'm looking at the data, I'm looking at their labs, I'm looking at their vitals, their weights, and we're evaluating that, assessing what kind of conditions do they have, what might be options for them, the management decisions Something I would put an asterisk next to that is shared decision making. So this is not something where I'm going to say I'm the doctor, this is what you're going to do, this is how we're going to go about this, this is where I'm going to lay out some options, talk about what we might be able to do and how we could work together to find that solution to go together to get us to where we need to be, and on the bottom of the slide are the categories of treatment.

Dr. Michael Koren:

So I guess at the end of the day, you and your patients have to decide which categories of treatment are appropriate for that patient.

Dr. Scott Marberry:

Correct.

Dr. Scott Marberry:

And of those five down there, the nutritional intervention, the physical activity, the behavioral therapy or mental health, and the pharmacotherapy, or really what I'd consider just more of like the medical aspect. So, from the American Obesity Medicine Association, what they consider the four pillars of health for obesity medicine is the medical aspect of things mental health aspect of taking care, physical activity and nutrition, and then certainly bariatric surgery is also a potential option.

Dr. Michael Koren:

Okay, so back to the audience questions option. Okay, so back to the audience questions. Which conditions occur with obesity? Is it A high blood pressure, is it B type 2 diabetes. Is it C GERD, which is reflux disease. Is it D elevated cholesterol. Is it E obstructive sleep apnea. Is it F osteoarthritis. Is it G polycystic ovary syndrome, or all the above. And if you needed a hint there it is. So obviously. The point of this slide is that obesity is associated with a lot of health risk.

Dr. Scott Marberry:

Absolutely so. If we go through each one of these answers, obese individuals tend to have higher blood pressure. Obesity and that excess fat or that you know, fat pathology, as we talked about in that prior slide that is going to increase inflammation in the body and we have excess levels of inflammation that can lead to a whole host of other complications that people can have. If people already have excess levels of inflammation, that can lead to a whole host of other complications that people can have. If people already have high blood pressure, it can make it even more difficult to get that blood pressure down. That excess weight can also contribute to insulin resistance and developing type 2 diabetes. That excess weight, particularly the visceral fat in here, if that's not pushing on our stomach and pushing up, that can also contribute to more reflux. So if we get that weight down, there's less pressure on the abdomen and the stomach, so that can also help reduce reflux symptoms. For people, adipose tissue is fat tissue and cholesterol. So certainly there could be elevated cholesterol and in particular cholesterol deposits in the liver which can be dangerous Obstructive sleep apnea. Excess weight on the neck or thickening of the neck can also impair our breathing while we're sleeping and if we're having poor quality sleep, we're going to have less energy during the day, slower metabolism it just nothing really feels great. And osteoarthritis unfortunately, that tends to go in only one direction where if we've got excess weight, we're putting a lot of pressure on our joints, our knees, our hips, our ankles, our spine. And something that's very encouraging, that I like to always comment on with my patients as we're losing weight, is that for, statistically, about every pound of weight that you lose, that takes about four pounds of pressure off of your joints. So even when I see a patient who has lost maybe four pounds, I'm saying, hey, that's like taking a 16-pound backpack off your shoulders and setting it down. That's got to feel good being able to take that weight down. Or if someone had a 10-pound weight loss, it's like, wow, it's like a hiking, you know 40-pound backpack that you're able to kind of take off and move around. So when we can get weight down, that can dramatically reduce the stress and pressure through our joints and slow down progression of things like osteoarthritis.

Dr. Scott Marberry:

And that last answer choice, polycystic ovarian syndrome we'll never have to worry about that. But for women that have ovaries, if they have this condition they're going to have cysts on their ovaries. They're going to have a lot of other kind of hormonal imbalances and obesity is one of the things that tends to go along with that and then it's one of those kind of negative feedback cycles. So they have polycystic ovaries and they're gaining weight. Now they have high levels of adipose tissues. That increases inflammation. That makes those ovaries unfortunately in the worst condition.

Dr. Michael Koren:

right now is to address these secondary elements of obesity. Right now is to address these secondary elements of obesity. So we'll have actually a hypertension study or an obstructive sleep apnea study, and the intervention is something that helps you lose weight. We want to see what type of impact it'll have for those other problems. Yeah, so we're doing these studies as we speak. So if you're interested, you'll have the opportunity to talk with one of the staff members and maybe get involved or send a family member over, somebody that you think might benefit from it. Okay, so why treat obesity as a disease?

Dr. Scott Marberry:

treat obesity as a disease. Let's say it is a disease. If we don't say it's a disease, if we just say, oh, it's a condition or oh, I just happen to have some extra weight, I'm a little overweight, and not actually call obesity a disease, unfortunately in our healthcare system it's not going to be taken seriously from that manner. So healthcare dollars, research, funding, insurance coverage for taking care of obesity is not going to go anywhere unless we actually call it and consider it a disease, just like we'd call high blood pressure hypertension. We'd call that a disease If we just said, oh, my blood pressure just runs a little bit high and we just kind of push it off like that, then we wouldn't be spending money on medications for blood pressure or development or research for blood pressure. So it's important that we actually consider obesity as a disease process because of how it also influences so many other aspects of the body. So not just from being able to get the health care, the medications, the treatment that we need. But again, if we can get that excess weight down, we've got a whole host of improvements, of things that can happen Again. Glucose and cholesterol metabolism, blood pressure improves Statistically.

Dr. Scott Marberry:

A 5% weight reduction for people can have really dramatic effects on their sugars, their cholesterols and their blood pressure. So even if someone starting off with a BMI, which is a body mass index, and if they start off at a BMI of 39 and we got them to drop down to 37 and they had a 5% weight reduction, they're still considered an obese individual. But by that 5% weight reduction that they've experienced, statistically they should have better cholesterol levels. Their bad cholesterol tends to go down. Their good cholesterol goes up. Triglycerides can go down by up to 40 points. Sugar stabilized A lot of times. I love when I can start taking away medications from patients versus having to prescribe more medications as the weight comes down. Blood pressure improves. Likelihood of having clots, dvts, thromboses those go down. Complications in the hospital it's after surgeries goes down.

Dr. Michael Koren:

There's just a lot of benefits, so many benefits, yeah, and BMI, just for your knowledge, is a body mass index. Normal is between 20 and 25 typically, and point being is that you could be well above that, but any movement that you make towards a normal BMI is helpful, absolutely.

Dr. Scott Marberry:

And to also kind of piggyback on that. I think it might be on one of the other slides, but I want to mention with that BMI, so that body mass index. It's really just a ratio of a height to weight and it's a generally good marker for the average person as far as determining, you know, are they overweight, are they obese or do they have severe obesity. But something I always like to talk about with my patients each year is I'll look at the NFL draft and I'll take a look at who is the first wide receiver who gets picked and who's the first running back who gets picked. I'll look at their height to weight ratio and I looked at it again last night and the top wide receiver, his BMI is 25. So he just made the cutoff for overweight.

Dr. Scott Marberry:

But this is one of the fastest, most agile guys on the field and one of the top, top running backs is BMI came out to 32. And this guy is not making millions of dollars being an obese guy running and crushing through people. So BMI, you got to take that with a grain of salt because it really just looks at a height to weight ratio. So if you have really athletic individuals with more muscle mass, their muscle proportion and fat proportions might be disproportionate, so their BMI could be a bit high. But again, they may not necessarily be overweight or obese.

Dr. Michael Koren:

It's an interesting question and a bit of a controversy, because some will argue that the longevity of NFL players isn't as much as people in other occupations and is their training and diet and other things a contributing factor to those things. But we won't go there right now. But it's an interesting discussion.

Dr. Scott Marberry:

That's another talk for another day.

Dr. Michael Koren:

yeah, but anyhow getting into correctable causes for non-genetic obesity. I want you to run through that quickly.

Dr. Scott Marberry:

Right. So with this slide we're not going to focus on what might be a genetic predisposition or a genetic defect that might contribute or be a main cause for someone to have obesity, but more of things from a lifestyle standpoint, things that we have some control over as far as how we get to a point where we might be obese. People do not become obese overnight. It's not something that just happens like that. It tends to happen over time, it tends to happen from behaviors, it tends to happen through stress and things going on through our life. So with that first bullet point, I really like that one about the food and family environment, because if we live in a family where there's always got to be excess food, we always have to have rice, we always have to have dessert with every meal, that's something that can certainly lead to obesity.

Dr. Scott Marberry:

And an interesting thing from a culture standpoint is we even kind of program ourselves from the very beginning to maybe go in this path. You know, if any of you have ever been to a one-year-old's birthday party, they tend to have a smash cake and so congratulations, you made it for a year in your life. How are we going to celebrate? We're going to give you sugar and carbs and candy and sweets, and we're going to continue that pattern every year of, we are also pushing ourselves to a level where we use food and sweets and candies and things that are not necessarily the healthiest options, but we look at those as things that we use to celebrate or things for fun events.

Dr. Scott Marberry:

Just if you want to take a moment with me and go in bizarro world, what if over the last 50 years? And to go forward, if, for every birthday, instead of a birthday cake, we celebrated with broccoli, could you? I mean, I don't want to celebrate broccoli every year, but could you imagine what the landscape of our people might look like if, again, instead of eating sugars and sweets, if, what if? Hey, Tommy, it's your fifth birthday, blow out your five candles on your wedge salad. How that might actually look as a culture.

Dr. Michael Koren:

Picking up on your bizarro theme, I tried to launch a business to do vegan birthday cakes for one-year-olds and we went out of business in the first month.

Dr. Scott Marberry:

I don't think the broccoli thing is going to take off, Otherwise bizarro world. I like my cake too, but I think it's just something interesting from a cultural standpoint that we are actually kind of. You know, we can actually kind of push ourselves in that direction without actually really intending to.

Dr. Michael Koren:

That's just kind of how we're kind of developed and that's where we go, and just a quick comment on some of the other things in the slide. I think the point here is that there could be other things that you need to look at from a medical standpoint. So, is it sleep problems? Are you on drugs that are causing you to gain weight? That's a huge issue that I deal with as a cardiologist all the time, and obviously often we eat as a response to emotional stress and maybe we have to treat the stress rather than just the obesity.

Dr. Scott Marberry:

Absolutely so. When I'm meeting with a patient and we're talking about their weight and maybe how do they get to the point where they're at. Something I want to know is what's a typical day for you as far as what you're eating? When are you eating? Are you eating late at night? Are you fasting? Are you constantly grazing throughout the day? What kind of foods are you eating? What are you drinking? Are you drinking sodas? Are you drinking your calories? Are you drinking alcohol? Are you drinking juices? Are you active? Or do you have a job where you're at a desk from eight to five and you really don't get up and move all day long, so you're not having any kind of activity there? Have you just gone through a stressful event in your life, maybe a move or a death in the family or a change in jobs, and so maybe things have changed?

Dr. Scott Marberry:

Something very unique with COVID how that developed or how that's happened is many people who may not have even really considered themselves to be athletic or going to the gym or really doing so much for the activities. Maybe part of their routine was at lunch, I go with Karen and we walk around the building. We get up and we walk and we do that, and I even park in the back of the parking lot, so I force myself to walk longer to get into the building and I'll take the stairs. And now with COVID, when people are now working from home, they're going from their bedroom to their living room and the kitchen and the snacks are right over there. So even those types of things of how we've adjusted can definitely contribute to why people could be gaining weight or developing weight gain.

Dr. Michael Koren:

So there's a lot of different components involved here and I'll add just one other thing to this slide is that we have done studies looking at stool transplants, which is looking at this concept of the gut microbiome, and there are some animal studies that show if you take an overweight mouse or an underweight mouse and you exchange stool, they'll change their weight. So basically you have an overweight mouse, then you give it the gut flora, the stool basically of a skinny mouse, a mouse, and you'll flip that switch for the mouse.

Dr. Scott Marberry:

Right, I'm excited to see some more of those studies coming out here and I know they're going to be coming out in the near future and there's some specific. species in particular, where we tend to see higher proportions or populations of acromantia in stool content in individuals who are at healthy weights or don't have diabetes versus people who are obese, overweight, have some of these other medical issues. And the other thing is that we see that those types of bacteria that also help with weights and health maintenance, they like to be fed good food. They don't like to be fed processed food, junk food, fried food. So when you're eating your fresh fruits, your fresh vegetables particularly these fruits and vegetables where the skin is still on there, like grapes or apples, plums, cucumbers, things like that those gut bacteria that help us to maintain healthy weights and maybe more predisposition in those healthy mice and even healthy people they like those gut bacteria, they like those healthy foods they don't like processed food.

Dr. Michael Koren:

So, nutrition, interesting research that is ongoing in this community as we speak. All right. So, speaking of nutrition, why don't you give us a rundown on this slide, right? So?

Dr. Scott Marberry:

nutrition obviously plays a very important role and should always. The conversation as far as weight management should go should include nutrition. Now, from my standpoint, I don't like to push people into one specific diet plan like, hey, we got to get you on a keto plan. Or hey, we got to put you on a Mediterranean or paleo or Atkins.

Dr. Scott Marberry:

I'm not a huge fan of any specific diet plan, because as soon as we do something like that and now we are narrowing the food options

Dr. Scott Marberry:

that we have I can't wait to finish

Dr. Scott Marberry:

this diet and go back and eat my Cheetos again. So I'm not a huge fan of any particular diet plan in particular, and I'm more in favor of portion control. You know, and we have one life to live. We want to eat, we want to experience, we want to travel, we want to have celebrations. Yeah, we still want to have cake and ice cream and things like that, but if we can keep that in healthy proportions, we can enjoy all those things without being restricted, as like well, I can never eat ice cream again. So I'm more in favor of reducing portions, which would also then contribute to a lower calorie diet.

Dr. Michael Koren:

Yeah, and my rule of thumb for my patients is that you get 90% of the pleasure from eating from the first 10% of the calories.

Dr. Scott Marberry:

That's a good point. Yeah, that's true.

Dr. Michael Koren:

So when you think about it that way, it sometimes helps people to push things aside. All right, so is there a perfect plate? You mentioned that there's a lot of diets out there and I think you gave your philosophy, but maybe just talk a little bit more about specifics that you might offer folks.

Dr. Scott Marberry:

Sure. So I've had several patients where they've had a lot of success getting their weight down, doing something like ketogenic style of diet. So that is a diet particularly high fat and high protein and very little or absolutely no carbs. My issue with the keto diet is that for most of my patients though, I just don't find this very sustainable. They might do it for weeks, they might do it for several months, they might even do it for half a year, but as soon as they kind of come off that diet, it seems that most of the progress that maybe they've made with weight loss just bounces right back. It's almost like the body can't wait to see those carbohydrates again and just lock them right back in. So a keto diet people can have some weight loss with that. But also we call it a keto diet because we're causing ketosis. We're causing fat breakdown and protein breakdown to try and make sugar and glucose in the body. So that's what causes the ketosis and that has its own potential metabolic problems and issues and dangers.

Dr. Scott Marberry:

A Mediterranean diet is, in general, a very great diet and there's a lot of data, a lot of research and, particularly from the cardiovascular standpoint of things, a lot of data showing Mediterranean diet is terrific for reducing inflammation and reducing heart disease and all-cause mortality with people that do have any kind of heart or cardiovascular issues. And the Mediterranean diet as you see it, it's pretty wide, so you got several options there, but things that you don't see on there. You don't see so much of a red meat. You don't see processed food, junk food, so you see a lot of nuts, dairy vegetables, fruits, beans, things like that, fish. The DASH diet that's a diet against hypertension or to stop hypertension, and so again, we're looking at trying to incorporate more vegetables, fruits, whole grains, reducing sodium, reducing salt, reducing alcohol, other things that can also increase our blood pressure. Vegetarian diet okay, no meat, you'll get that one.

Dr. Scott Marberry:

Intermittent fasting I get this question a lot from people Should I try intermittent fasting? My friend is doing that. He's dropped 12 pounds in the last two months. Should I do intermittent fasting? And I think for intermittent fasting for some people I think that does work very well.

Dr. Scott Marberry:

Some people feel really great on intermittent fasting, where they may be consuming all their calories in just a span of six hours during the day and the other 18 hours they're not eating anything. If anything, they're just consuming water, so they're not consuming calories. Some people do very well with that. My youngest daughter, you know, god forbid. She does something like that because she is hangry, so we have to keep her fed. So intermittent fasting would never work for her and it's not always going to work for everybody. And my other issue with intermittent fasting is again it might work really well for a while, but is that something we're going to continue the rest of our life or we're just going to do it for a little while? And so if we get any of that progress as soon as we go back to our kind of daily habits or regular eating habits, are we just going to put that weight back on or maybe actually even go a little bit higher on the weight?

Dr. Michael Koren:

And exercise is something that I do a lot as a cardiologist, but I find that you have to be explicit with people and generally the rule of thumb is you need to do at least two hours a week in sessions that are at least 20 minutes long and maybe help people with individual recommendations. A joke I like to tell is when I was early in my career and I wasn't specific. I had a patient once. I said well, maybe you should walk about five miles a day and call me in 10 days and see how it's going. So he calls me and says, doc, I'm 50 miles from home. Now what do I do?

Dr. Scott Marberry:

So you have to be very specific, is the point you do have to be specific and that two hours that the principal just mentioned there, that's a great kind of a bullet point right there to try and shoot for or maintain. But if you're taking someone who just came off of an injury, they haven't been out there or they've kind of been cooped up in the house. They haven't been out walking. They may not want to walk or they may not want to go to the gym or they might have a knee issue. They don't want to do high intensity aerobic activities. So I like to know what can my patients do? What do they like doing? How can we get you from doing maybe nothing or very little and how can we make some incremental changes?

Dr. Scott Marberry:

Because the other thing about exercise I find is for a lot of people who are not exercising routinely, when they first start you've got to put energy into it, you've got to commit to it, and that can be pretty tough, that can be sore, achy. It cannot be so fun when you first start. But if you get over that hump, exercise is one of those things that most people then very much enjoy. They get more energy from it. And then when you have athletes, I'm sure you see this as well, as I see in my clinic, if I have an athlete with an injury like when can I get back out there and run? This is killing me. I can't sit around anymore. I've got to get out there. This is driving me nuts, not being able to exercise or do activities. So if we can get incremental changes and improvements in the exercise, that all puts us in a better direction.

Dr. Michael Koren:

So diet and exercise can certainly work, but it doesn't always work. So what's next?

Dr. Michael Koren:

We obviously there's a lot of focus these days on obesity drugs.

Dr. Scott Marberry:

Absolutely so. That's been a really fascinating change as far as how things have been going. Some of the more traditional medications we've looked at for weight loss and obesity tend to be stimulant medications which can actually increase heart rate, increase blood pressure, contribute to seizures. There could be some dangers with some of the more traditional weight loss medications and, again, a lot of people may not be very good candidates for that. If you had a patient with atrial fibrillation, you'd absolutely say no, I don't want you taking fentermine, and some of the other options out there have only been moderately effective or some of the side effects have been really uncomfortable a lot of bloating, a lot of gas or GI issues. So these newer lines of medications for obesity are very interesting because they tend to be much better tolerated. They also tend to be much better sustainable and again we're seeing that there's not just one health benefit but tends to be many, many health benefits from these new medications.

Dr. Michael Koren:

So this is a really complicated slide and we don't want to bog people down, but there's a lot of mechanisms of action that are being studied for obesity treatments.

Dr. Scott Marberry:

Right, I like this slide, I like to call it the science nerd slide of obesity. And so again, you can see that obesity is not just a simple process. It's not just a simple answer. You can see factors that act on the CNS, that's talking about factors that work on our brain. So we've got hormones on there, we've got proteins on there, we've got neurotransmitters, we've got a lot of different things affecting our brain. And then, from our brain, deeper inside the brain, is the hypothalamus, and that's where we make a lot of decisions as far as what we're going to eat, what we're not going to eat, and that happens consciously. That also happens subconsciously. So a lot of people who are eating too much, they may be having more of a what's that?

Dr. Scott Marberry:

I'm kind of hungry, I want to go grab a snack, and people who are not hungry or are not thinking about that or not going for a snack and some of these newer medications kind of help tip that scale to. I'm not thinking about food or I'm not hungry or there is a snack there, but it's not really appealing to me right now.

Dr. Michael Koren:

Right. So with that in mind, say, meds are either not tolerated or they are not desired for one reason or another. When do you recommend bariatric surgery?

Dr. Scott Marberry:

So bariatric surgery is something that we kind of consider. If we've already tried diet, exercise, we've got the mental health in place, we've got the right nutrition, everything is going as best as we can. We're trying medication or we've looked to alter medications if there are weight gain medications We've looked. Is there a metabolic abnormality that we need to address? Let's take care of that to see if that helps to get our weight down. If we've tried all those things and we're still struggling with weight, or if we have someone who's just so severely obese that with all those things it would still take a very long time for them to actually get to a healthy weight, then we want to actually consider something like bariatric surgery. So you can see from that drop-down there that BMI of 40 or higher so that's what we would call 40 and plus a severely obese weight range.

Dr. Scott Marberry:

It's also called morbidly obese and I think that's actually a really interesting name there because from the data and from the research we've seen that people who have a BMI of 40 or higher, that statistically can take off 14 years of life. So that's where that term morbidly obese means. There's so much weight and so much inflammation that excess weight is causing the body that those people might actually be losing 14 years of their life, not just because of the weight but because of how that's going to affect and play a role with other metabolic processes. Or again, if someone who might get a pneumonia who has a BMI of 24 versus someone who has a BMI of 47, that person 47, probably higher likelihood they're going to end up in the hospital and have a harder outcome.

Dr. Scott Marberry:

So, people that have a BMI of 40 or higher they would be candidates for considering bariatric surgery. People who have a BMI of 35 and higher, or if they have 35, as well as some other comorbidities such as high blood pressure, cholesterol, diabetes, obstructive sleep apnea there's a lot of inclusion criteria there. They would all be candidates for what we would consider as bariatric surgery. And, in brief, bariatric surgery would be a surgical procedure to affect how we can absorb food, how much we can eat. So that could be something like a gastric sleeve that is squeezed in the stomach so we just can't put as much food in there, so we can't eat as much. Or it could be a Roux-en-Y surgery, where we're actually making changes, or gastric bypass or doing things that are actually going to affect our gastrointestinal system.

Dr. Scott Marberry:

The reason we also would consider bariatric surgery as maybe kind of the last line of defense for helping with this is because, like most surgeries, once you go forward you can't really go back. So there can always be complications, there could be infections, there could be scar tissue adhesions. It could be several things that can go back. It could be several things that can go wrong. The way that bariatric surgeries are performed now their success rates are actually really incredible. And something also that bariatric surgeons also incorporate is they also again make sure, hey, are we still? We have a good diet plan in place, we have a good exercise plan in place, because we also have seen people who've had really successful weight loss with bariatric surgery and if we follow them five years or 10 years, maybe that stomach has now expanded and they're back to a morbidly obese point.

Dr. Michael Koren:

Historically, it's been hard to get insurers to pay for bariatric surgery. Has that gotten any better, or is it still tough?

Dr. Scott Marberry:

I would say this is still very tough for a lot of insurance companies. They want to see have you completed something like a medically supervised weight loss plan for at least six months? Have you tried certain diets? Have you met with a nutritionist? Have you met with a psychologist? Have we really explored the medications, all those other options, before we just signed the bill, all those other options before we just signed the bill? So yeah, go ahead and go get to surgery.

Dr. Michael Koren:

It can be a little tricky. So, getting back to the audience questions, and this will be sort of a final important point we make when we talk about obesity, is this concept of food noise? There's a lot of discussion in social media about this, in the medical literature about this. There's a lot of discussion in social media about this. So let's define this. What is food noise? A persistent and intrusive thoughts about food. B a concept not limited to individuals with diagnosed eating disorders. C an idea described as food-related intrusive thoughts, or frits. D contributes to overeating and obesity. Or E all all the above. Yeah, so it looks like there's a consensus that in fact it is E, all the above. So tell us a little bit about this food noise concept.

Dr. Scott Marberry:

Yeah, so I really like this food noise concept and I want to share a quick story about one of my patients. So this is a guy who had been a high school football player. He'd always kind of been a bigger guy. He played college and then after college he continued to eat like he was still playing football. So he gained a lot of weight. Then later in his 20s he's like hey, I'm going to get on this and I'm really going to make some dietary changes. I'm going to get back into the gym, had a 60-pound weight loss. He was doing fantastic.

Dr. Scott Marberry:

And then life moves on new job moved to a different city, now we have kids. Now he's coming back to some of those eating habits where he's eating large portions again and the weight's coming back. And now he just seems that he can't seem to get that weight down. And all day long he's got a little voice in his brain chirping. He's like I want something sweet or something salty, something crunchy. And there was a guy at his office who would frequently bring donuts and any time he brought donuts it just turned into this willpower battle for him because it was like, ooh, messenger of death, yeah, I'm not supposed to get that donut. I don't want to eat that donut, don't go in there. And if he went to the break room and ate that donut, he'd kind of beat himself up mentally and feel bad about it. And then that might mean, like well, I already ate the donut. So now I'm just going to. You know, let's go by Taco Bell and let's get everything on the menu.

Dr. Scott Marberry:

Or hey, I didn't get the donut today pat myself on the back All right, let's head over to Cheesecake Factory. So that was kind of the issue that he was having. We put him on one of these GLP-1 medications which we're about to talk about, and this is what the light bulb moment for him was. So that food noise thing. When I saw him at a two-month follow-up he said you know, doc, I told you about that. I have a hard time avoiding sweets. I've noticed this happened just the other day. Bob brought donuts. Karen came by and said hey, Bob bought donuts. He's like oh, that was really nice of Bob and just kind of turned around, went back to his work. And he didn't have that willpower battle, he wasn't conflicted, he wasn't thinking about it, he just kind of went back to his work and didn't even think about it until the end of the day. As he's walking by the break room he sees, oh, hey, there's that box of donuts. I didn't even think about that at all today.

Dr. Michael Koren:

Yeah it's amazing yeah.

Dr. Scott Marberry:

And in fact I can see my favorite donut is still right in there and I could get it right now, but I'm actually not even interested in it, and for him.

Dr. Scott Marberry:

That was just, that was just amazing for him that with the medication.

Dr. Scott Marberry:

He found that chirping, that constant. You know what's in there, what's in the pantry, or let me. I looked in the fridge five minutes ago but did something change. Those kinds of things changed for him. He didn't have those behaviors and he didn't have that food noise in his brain.

Dr. Michael Koren:

Yeah, and this gets into the research that everybody has heard about at this point, but involves a class of hormones called incretins and, just for the interest of time, the first one was actually discovered in the saliva of the Gila monster, which led to the development of a drug called Byetta or Exenatide. And of course, that's now moved on to these quote wonder drugs that we have, GLP, and they trick your brain into thinking you are full even after just a few bites of food. And I have an interesting anecdote I was at a restaurant in Barcelona called Disfrutar and it was considered the number one restaurant in Europe, and I went with my college roommate and he's gained a little bit of weight lately and we were eating our meal and it was one of these 11 course tasting meals. So it was pretty amazing and we're all excited about it.

Dr. Michael Koren:

By the third course he starts to not look so good. By the fourth course, he has to run to the restroom to retch. And he comes back and I say, Dan, are you on a GLP-1 drug by chance? He says yeah, I forgot all about it. So, interestingly, one, two take-homes from this story. Number one if you're on a GLP drug like Ozempic or Mounjaro, be careful about what restaurants you go to and keep in mind that if you have a fixed price meal, you may not get through it. And the other thing is that they're incredibly effective. They literally change the way your whole appetite circuit works.

Dr. Scott Marberry:

Absolutely so I don't even want to piggyback on that story, because all of you make this example in my clinic. As you see there, there's four bullet points with the GLP-1s. What I tell my patients in the clinic is these medications are predominantly going to do three big things. Okay One sugar. Two, motility. Three, brain. What I mean by that is one with the sugar. If your sugars are too high, it's going to help you get your sugars down. So these medications again, they were first developed for diabetes and so they do help get the sugars down. A nice safety profile about them is that if your sugars are already in a healthy range, they're typically probably not going to dip down much lower. Conversely, if I had someone who has a normal, healthy blood sugar and they were to dose themselves with insulin, their blood sugar could drop very dangerously low. So that could be dangerous. So one if the sugars are an issue, it's going to help lower the sugars, and if the sugars are already in a healthy range, it kind of it's like it's hands off. It kind of backs off on the sugars and leaves that alone. Two we said the motility. So just as you mentioned about your buddy with that 11-course meal, that gastric emptying so it slows down how food processes and digests from the stomach into the intestines. So I'll actually make this analogy.

Dr. Scott Marberry:

In my clinic I'll say you know, if you were to go to a really nice restaurant that has maybe a five-course meal, you get the first one, the next and so forth, and now by the time that dessert's out there you're like, hey, I saved a little bit of space for that dessert. I've been waiting for that. That's because what you had for an appetizer or the bread and most of the entree it's probably already been digested and making its way into the intestines now. So you do have that space that you can put that dessert in there. When you have a medication like a GLP-1 in your system now it's like that server came out and he brought all five items all at once.

Dr. Scott Marberry:

So have at it. You try to eat that, but you wouldn't be able to get all the way to your dessert because you'd just be too full. Your stomach would already be filled up. So these medications they slow down gastric emptying, so food's going to stay in there longer. That's going to send hormone responses to our brain, nerve responses to our brain, saying we're full, we don't need to keep eating. Interesting, yeah.

Dr. Michael Koren:

And so these are just a list of the different drugs in this incretin class that have been approved by the FDA at this point, and there's quite a few. You'll recognize the names, I'm sure. And just keep in mind that what we do day to day is we run clinical trials, and there's been a lot, a lot of clinical trials in this space, and most of the clinical trials are not based on cosmetic changes. They're based on changing health parameters. So, for example, I was very involved with this drug, this study called the SELECT trial, which is listed in the middle, and that was a cardiovascular study using Ozempic and showing that people that were taking Ozempic, compared to people that weren't, had a 20% reduction in serious adverse cardiovascular events 20% fewer strokes, heart attacks, congestive heart failure, heart failure admissions. So that's pretty impressive. So it's not just about weight loss.

Dr. Scott Marberry:

Absolutely. This is one of those things that these trials really help kind of drive home that point that if we can get people's weight down to a healthier levels, other health benefits happen in the body. That bottom one, the Synergy NASH trial, reduced fibrosis or fatty infiltration in the liver With your trial, with the SELECT, we saw that people are less likely to have major adverse cardiovascular events. The LEADER trial, the SUSTAIN trial so these are trials that are showing that this medication, although it was first developed I think we're going to just work on diabetes here we found that, hey, this also has a lot of other unique aspects of health that it can improve for people Totally.

Dr. Michael Koren:

All right. So again, we always like to tell people that there's always a balancing act when we use drugs and there are side effects of all these drugs Not effective for all patients. These are expensive drugs. What's a Ozempic face? I'm not even sure what that is Right.

Dr. Scott Marberry:

So Ozempic face is a condition that some people describe. When you see people who maybe hadn't seen in several years, the last time you saw them they were really large and they lost a lot of weight. Now their skin's kind of droopy. We might even hear Ozempic butt, where now they got kind of a flat butt. To be honest, I haven't had any patient in my clinic who's lost weight, who's complained or said their friend said you have Ozempic face or anything of that nature. The biggest drawbacks or barriers I see in my clinic personally are, yes, the cost so if it's not covered by the insurance these medications can be very expensive and also that bottom bullet point there supply chain issues. These medications have become very popular, very high in demand, and the supply has not always been there. So I've had patients that have had great progress with the medications, they're doing well on it, and now they can't find that medication for several weeks or a month and it can be very difficult.

Dr. Michael Koren:

But I think, in conclusion, obesity is a complex condition and I think we covered all the major treatment elements dietary changes, exercise, medications, a behavioral modification program, social support and, of course, clinical trials, which you and I are very much involved with, and these answer the unknown questions in obesity. So we do know that GLP-1 drugs work. They're very effective at helping people lose weight. They can lose 20% of their body weight but does it reduce heart attacks? We have the select study now that shows this. It does. Does it improve your sleep? Does it improve your mental health? Does it improve your sex life, et cetera, et cetera. So there's all these questions that are coming out as to whether or not these interventions make a difference.

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