It Pays to be Thin

In this episode, we tackle some hot topics and share inspiring stories. We start with a big piece of news: the CEO of Novo Nordisk being brought before a Senate committee. This is huge because Novo Nordisk is a major player in the GLP-1 medication world, and there's a lot of scrutiny on how these drugs are priced and covered by insurance.

We also dive into the incredible story of Leslie, who needed a combination of nutrition, exercise, GLP-1 medications, and bariatric surgery to lose an astonishing 157 pounds. Her journey is a powerful reminder that weight loss isn't a one-size-fits-all solution and often requires a multifaceted approach.

On a different note, we discuss some eye-opening research showing that obese people tend to earn less money than their non-obese counterparts. This wage gap is especially pronounced as education levels increase, which is both shocking and troubling.

We also get into the nitty-gritty of insurance coverage for GLP-1 medications. It's frustrating to see how many barriers there are for patients trying to get these potentially life-changing drugs. We offer some tips on how to navigate these challenges and advocate for better coverage.

Overall, this episode is packed with important information and real-life stories that highlight the complexities of weight loss and the broader societal issues related to obesity.

Transcript

Dr. Weiner: 0:17

Men classified as obese earn 5% less money on average than their non-obese colleagues. So if you're overweight and this is where our title comes from it pays to be thin. If you're overweight, then you're going to make 5% less than everyone else.

Zoe: 0:40

All right, welcome back to the Pound of Cure Weight Loss Podcast, episode 36. It pays to be thin.

Dr. Weiner: 0:46

Yeah, we'll see where that comes from.

Zoe: 0:51

So tell me about what Laura brought you today.

Dr. Weiner: 0:54

So, first of all, greatest job ever my patients bring me like super healthy treats. So Laura brought us cranberry, orange protein bread and honestly, it totally tastes. It has that cake texture. Like I hate the word moist, but it is moist and it has that texture. How'd she do it? Because there's no wheat flour in it right, there's no sugar in it. Yeah, there are eggs in it.

Zoe: 1:25

Yeah, so there's almond flour, which you know, we know is a great alternative for baking, since it's not a refined wheat flour.

Dr. Weiner: 1:35

Right.

Zoe: 1:36

Um, we've got protein powder in there. I love baking with protein powder also, just because it's like you know by now. You guys know that I love sweet treats, so I got to get creative, so Laura did a great job with this. If you have not already listened to Laura's podcast, definitely go listen to that.

Dr. Weiner: 1:54

You can always tune in directly with Laura, because she's one of our peer leaders in our nutrition program.

Zoe: 1:59

Exactly. Yeah, actually her group is tonight.

Dr. Weiner: 2:02

Oh well, not tonight we're recording.

Zoe: 2:06

That doesn't help you so anyway, we've got low sugar orange juice, eggs, greek yogurt Another great thing I like to bake with and then she made a little icing on the top with swerve confectioner's sugar, so that's like a powdered sugar substitute. And then the low sugar orange juice. Oh, she has the seven grams of protein, five grams of sugar from the orange juice and the cranberries, and 95 calories per slice.

Dr. Weiner: 2:29

Yeah, amazing. It's a beautiful planned indulgence, like I think, and that's great. Like, is this officially metabolic reset diet certified? Absolutely not for many reasons, but not, you don't have to always follow the diet.

Zoe: 2:42

And also I always like to say there's everything on nutrition is a spectrum.

Dr. Weiner: 2:46

Right.

Zoe: 2:47

Right. So over here we have the lemon pound cake from Starbucks Starbucks yes. At 700 calories a slice.

Dr. Weiner: 2:56

It's an extraordinary number of calories.

Zoe: 2:58

Oh, and so much sugar.

Dr. Weiner: 2:59

I actually have them in the doctor's line or something similar. And I look at it and it's like four, it's like a tiny little square and it's like 480 calories.

Zoe: 3:05

Yeah, it's crazy, oh my gosh. So we've got, you know overall here at the like super indulgent pound cake, sugar filled, and then over here, maybe we have like a completely, we have that you're eating an orange Right. We have like a completely, we have that you're eating an orange Right, an orange Perfect. And so this fits a really great step on the spectrum in my opinion.

Dr. Weiner: 3:27

Yeah, so anyway, thank you, laura. They have definitely been enjoyed and we appreciate you. You bring it over. We appreciate everything you do for our practice, Absolutely. So let's move into our In the News segment. So this comes to us from US News. So let's move into our In the News segment. So this comes to us from US News and the title of the article is US Senator Sanders' optimistic Novo Nordisk can be pressured to cut WeGoV and Ozempic prices.

Leslie: 3:51

I like the sound of that yeah this is good.

Dr. Weiner: 3:53

So the CEO of Novo Nordisk his name is Lars Jorgensen is set to testify before the Senate Committee on Health, Education, Labor and Pensions. It's the Health Committee and that's chaired by Bernie Sanders, and so, you may remember, Bernie was largely responsible for bringing down the price of insulin. So the drug companies knew once a diabetic was on insulin, they had no choice but to purchase the insulin, and the prices were just extraordinary, despite the fact that insulin is like 100 years old.

Sierra: 4:28

Right, there's nothing new.

Dr. Weiner: 4:30

Right, yeah, it's super cheap to make and so. So Bernie brought, brought the no, it was Novo, lilly and Sanofi and he brought them in front of the congressional committee and actually, before they even got to the committee, they agreed to lower the price. So there's history here that when these drug companies are brought to testify in front of the Senate committee, that that's a lot of pressure, that's not a good day for Novo Nordisk. I don't think Lars is really looking forward to September and testifying because he knows he's going to be grilled. And so Bernie said I think the major thing that we can do and we've done this successfully in the past with insulin is to put a focus on the greed of the pharmaceutical industry in general and Novo Nordisk in particular, in terms of them ripping off the American people. So that's what they're walking into.

Zoe: 5:25

He's fired up.

Dr. Weiner: 5:26

Yeah, but this is what we've been talking about that these medications are overpriced. We've gone over. Every time we look at access to care and again we have lots to say about PBMs and insurance companies and everything like that. But every time we talk about access to care, if the price was lower, more people would get it, and there's more to that with the shortages and everything like that. But so the Nova Nordisk spokesperson said more than 80% of Americans with insurance pay $25 or less per month for the drugs, which, first of all, I call total BS on that, yeah that's not true I mean, when I see a patient who's paying 25 bucks or less, I'm like oh my God.

Zoe: 6:05

What a job.

Dr. Weiner: 6:07

I tell everybody I'm like, if you can get this for under a hundred bucks a month, that is amazing. That is amazing. And I think we presented an article a couple of weeks ago where we talked about how much people are paying out of pocket for this and it's at least a hundred bucks kind of heading up toward 200. It's increasing too over time as the employers and as the insurance companies are passing on more of the expense of these drugs to the patients. Guess how much Ozepic is in Canada? Wholesale price, not what we can buy online, but the wholesale price to the pharmacies.

Zoe: 6:43

Oh gosh, I bet it's cheap.

Dr. Weiner: 6:45

Like 155 bucks In the US, $935. Of course. And Wegovi is $1,349. Wow, yeah, that's the wholesale price. And so we are seeing a huge, huge markup in the US on these medications. And it's the same drug. I don't understand why. Because we'll pay it because our system is broken and they're exploiting the broken system. Right, why are they paying? Because, why are they charging that much? Because they can Right, right, because they can. Why are they charging that much? Because they can, right, right, because they can. On one hand, it does ensure that they're pushing the majority of the supply to the US because they're going to get paid more for it.

Dr. Weiner: 7:27

That's true. On the other hand, you know, it's not necessarily good for the American people. So Sanders has also acknowledged that he's currently focused on Nova Nordisk, which is who makes Ozempic we go, the Southern Glutide but that he is going to go after Eli Lilly next. So Zep Bowne, monjaro is also, and my hunch is whatever happens here, eli Lilly will just be like oh okay, all right, yeah, yeah, yeah, yeah, yeah, yeah, we got you.

Zoe: 8:00

So is there like a proposed date, or do you know when this is gonna kind?

Dr. Weiner: 8:06

um, it's in September. So this is, I mean, this is what needs to happen. Right, we need and and you know, we can talk all we like about whether government intervention is a good thing or not, but the problem is is, whatever the system is that we have right now, it's not working for most people and so we really have to intervene on and the government is the only entity that is capable of doing it, because health insurance companies and the pharma industry they're too big and nobody else, no companies, can take them on and, in fact, consumer pressure can't even really hold much weight, especially because we're facing shortages, and I think the shortages are really the Achilles heel of this.

Zoe: 8:48

Right.

Dr. Weiner: 8:48

Because it's like, well, the market's setting the price, supply and demand baby America capitalism right, and they're kind of right here.

Dr. Weiner: 8:58

right, I mean, that's a very valid argument, because if there was plenty of a supply, then we can make this argument. But when there's shortages, well you know, people pay it, and there's still shortages. But we have seen that both Eli Lilly and Nova Nordis have ramped up their manufacturing and we'll talk a little bit later next week about an update on the shortages. But anyway, so yeah, I think this is good news for us.

Zoe: 9:31

I really think it's good news. Sounds like it could be that tipping point we needed to maybe push through that bottleneck.

Dr. Weiner: 9:37

Yeah, I mean a tipping point is a little overly optimistic, maybe a nudge in the right direction, kind of we've gotten and we've talked about this we've gotten off kilter. There's just too much power in the pharma and the health insurance companies right now and they're leveraging this and taking advantage of it and it's hurting the American people and we just need to push it back a little bit. What I would really like to see is for the government to start to look at some of the patents and again, making semaglutide in 2026. It's a legit fight. To make semaglutide generic in 2026. That's a year and a half away. That's legit and the government can put some pressures on to make that happen. And then we'd have some competition. Some generics allow a couple of different companies to manufacture it and we might see the price come down, and so that would be also a great thing.

Zoe: 10:29

Stay tuned, we'll cover live and late breaking.

Dr. Weiner: 10:34

So who's joining us for our patient story today?

Zoe: 10:36

So we have Leslie joining us. She and I have actually been quite close in the nutrition program and she had her surgery, I believe in 2021. We'll let her tell her but anyway, we're really excited to have Leslie here.

Dr. Weiner: 10:50

All right, fantastic Welcome, leslie.

Zoe: 10:52

All right, leslie, welcome. So glad to have you here with us.

Leslie: 10:55

I'm glad to be here, thank you.

Zoe: 10:57

Awesome.

Dr. Weiner: 10:58

So, leslie, just tell us your story. Talk to us a little bit about just what led you up to surgery, your weight before surgery, and then what your experience was with surgery.

Leslie: 11:12

Sure, yeah Well, I've been obese my whole life and, like many people, struggled with diet. And you know, gone all the different diets, weight loss, um, through weight watchers and diet of hope, and you know Atkins diet everything and I would get some success. But, as we know, with the um learning the new science of that, it's affected. The hormones affected in the brain is what triggers weight loss. I never knew that, so I'd always just be in this kind of vicious cycle where I would have some success and then I would fall off the wagon and then you know, regain plus more Fight against your set point go back to your set point.

Dr. Weiner: 11:45

Fight against your set point. Go back to your set point.

Leslie: 11:47

Absolutely. And you know, during the pandemic I work as a nurse in the hospital and you know the community really came together to support us, and how they would do that is they would give us food, oh yeah, and which was wonderful and it was super generous. But you know, I took advantage of that and I found myself with almost 50 pound weight gain during that time on myself, with almost 50 pound weight gain during that time and it was just so uncomfortable in my body and I had gotten up to 350 pounds and it was just, it was everything was painful physically and you know just the resignation of I'll never be able to. There's so much weight to lose, I'll never be able to do it. So there was a psychological component and my older brother doesn't live here but he had had surgery and he had lost about a hundred pounds and I thought that was impressive. And so you know, I looked into you and came into you and I thought it would be great.

Leslie: 12:43

But the impetus, the thing that really drove me to pursue surgery outside of my brother, was I went to my PCP. I was about to start my fourth antihypertensive medication for my blood pressure and I was needing to go on a third medication for diabetes and at that point it was a real smack in the face. Like you know, what am I doing with my life? I'm going to end up like one of my patients, you know, on dialysis, not doing well, not being able to walk, not being able to move, and I did not want to do that and I think, especially as a nurse, for me it was very, it felt very hypocritical to say to patients hey, you need to work on diet, you need to work on exercise. And then I wasn't really, you know, walking the talk, wow.

Dr. Weiner: 13:27

You weren't working on diet, you weren't working on exercise, you were putting way more energy into it than most people. It just wasn't working Right. It didn't, and that's really. I think that's kind of the conflict that a lot of people have is they're suffering from obesity in healthcare, and we actually just talked you know, we're going to talk in a minute about the pay gap in healthcare and how there's probably some of the most discrimination against professionals in healthcare compared to other fields, and I think a lot of it is this misguided notion that, well, if you're overweight, then you aren't showing good health, you aren't taking care of yourself. But you were. It just wasn't working Right, for sure, and that's an important difference.

Leslie: 14:09

Yeah, I appreciate that distinction, thanks, so yeah. So then I did the surgery in October 2021. I had some pretty decent success. I think I lost about 80 pounds. After the surgery and my post-op one year I came into you and said, well, is this it? Are you done? And I thought, no, I'm not done. I'm not done. I've worked so hard to get to this and I haven't made the. You know, I'm not. I wasn't one of those people that had the surgery and then they just lose a ton of weight immediately. It took me time. I had to wrap my brain around not only the new physicality of my body, but also dealing. I still had a lot of food noise and dealing with, like the cravings of, you know, sugar and carbs. And once I started on the medications the GLP-1 medications that was really life-changing for sure.

Dr. Weiner: 14:59

So what was your weight and how far after surgery did you start the medications?

Leslie: 15:03

So before surgery. So I'd gotten up to 350 pounds, I think. Officially, when I came in to see you I was around 336 or 338. So when I started surgery I was 317, right the day of surgery and then my post-op one year, I believe, I was 253. Okay, so about a hundred pounds from your heaviest weight, yeah. And then I started. We start at that point. We looked into GLP-1. There were some issues with insurance, as everybody's discovered, and I I started in December. I bought some out-of-pocket Monjaro which was incredibly expensive and it was really hit and miss trying to get the drugs because of all the issues with supply and insurance coverage. So consistently. That was a struggle to be consistently on the medications. But this year, starting I believe in February, I was able to start doing ZetBound and there was a little bit of a delay in April that I had to go back on Saxenda for about six to seven weeks, which wasn't very effective for me, but at least it kind of bridged me through and then I was able to pick ZetBound back up.

Dr. Weiner: 16:10

So you, you've been on all the meds, all of them, yeah, yeah, what's your favorite?

Leslie: 16:14

I, I really like zep down. I thought manjaro was good. Um, I mean, well, jar was up.

Dr. Weiner: 16:18

I would say right, it'd be pretty much.

Leslie: 16:20

Um, the was better than the sex end of sex end is okay, um, it's not. You know, it didn't really last. He's a daily injection, which i't mind, but it didn't really last me the whole 24 hours and I, you know, would start feeling hungry and I definitely noticed a lot more food noise with that one. But Zabound really has been an awesome medication because it does take away my appetite and I still feel hunger. But I'm really more focused on eating when I do feel hungry and not, oh, you know, I feel like I should eat, just because in the past this would be. Or, you know, we're having a celebration at work and somebody brings something out, oh, I should indulge myself. Well, no, maybe I don't need to, maybe I can just be celebratory without eating.

Zoe: 17:54

Yeah, that's kind of an interesting thing of knowing when to honor your body and listen to it when it's hungry and stop when you're full, but then also knowing that, hey, I need to nourish my body as well. Maybe I don't need to nourish it with the cake from the break room, but I have my own snacks that I brought and so that food noise doesn't make as big of an impact.

Leslie: 18:18

Yeah, definitely it's been a lot better. It's been a game changer for me. Um, it's to be on those medications. I think that I would not have lost the additional. I'm down another like 60 pounds from um the two, 53. So I think I would not have lost that additional weight um as easily not that it was ever easy, but um as easily not that it was ever easy.

Leslie: 18:39

But once I did have that one year follow-up, I really got invested in the gym and I started doing yoga, love it, and it was really great for me to just have more agency over my body, being able to work on things like mobility and balance and strength. That was something that was inconceivable. You know, four years ago I could not do that and I, you know I was having issues with falling and tripping and balance and it was not comfortable to live as a 350 pound woman. That was a very uncomfortable body to be in. But now, you know, I'm 193 pounds and it's much more comfortable for me and a lot of times I have the body dysmorphia where I actually think I'm bigger than I really am. So when I go to try and close, I'll try on something and I think it's going to fit me, and then I'm swimming in it. I think, well, that doesn't seem right, you know. But then I realized okay, this is my new reality. And I still am struggling with wrapping my brain around that it does.

Leslie: 19:39

Yeah, I would think yeah.

Zoe: 19:40

Yeah.

Leslie: 19:40

It's great though.

Zoe: 19:41

That's amazing. Yeah, and so you're doing yoga? Yes, and that's something that's like part of your regular routine.

Leslie: 19:49

I go three to four times a week and I love yoga. It's, you know, sometimes when you're doing some of the poses it's kind of like what am I doing, why? And afterwards I just feel so good and it's really helped with my mobility and joints and achiness and pain. I was talking to Dr Weiner before we started the podcast about chronic pain and I had somebody. You know I've had back surgeries and I've had chronic pain a lot of my life and at one point you know I've been on pretty much every opioid that they make and I had been off of them for a few years before surgery and I was just managing my pain.

Leslie: 20:25

You know, doing like heating pads, doing Tylenol, doing lots and lots of ibuprofen I mean I ate that like it was candy but I was always in pain my hips, my back, everything, my knees. But with the weight loss I saw a huge improvement in that and um, and with yoga, especially in the, the weight training, I think that my um, my pain level, like I don't have pain normally I will get stiff, especially on if I go for a stretch without doing yoga, I notice that I'm more stiff. But um, just being able to, to go through life and not be dependent on, but just being able to go through life and not be dependent on NSAIDs and taking way too many NSAIDs. I kind of wonder how my kidneys were doing. That's a little nerve-wracking, but yeah, it's been a huge difference.

Dr. Weiner: 21:13

So you're not taking any NSAIDs now.

Leslie: 21:14

I do take Tylenol, tylenol.

Sierra: 21:16

Yeah, tylenol's legal Right, I do take.

Leslie: 21:18

Tylenol, um, you know, as needed, uh, especially if I'm working a long shift, I'll come home. You know, if I'm a little achy or sore I'll take some tylenol, but mostly I just I do yoga. I have a wonderful heating pad that is my friend that I use on my shoulders and and my back if I need it. Um, and yeah, I don't take anything and far less pain than before surgery yeah, way less pain which.

Dr. Weiner: 21:39

I think is something. A lot of patients come in and they're pretty dependent on NSAIDs. They have a lot of aches and pains. There's a lot of concern hey, am I going to be able to stop these NSAIDs? I can't do a surgery where I'm not going to be able to take my Advil, my Aleve, my whatever. And I think this is very reassuring, because our experience is exactly what you're telling us, which is there's so much less pain once the weight's down.

Leslie: 22:02

Oh yeah, I would go to Costco and get those huge bottles of ibuprofen and I would go through those. But now they have things like lidocaine patches and you can slap one of those on if you have a hip pain or knee pain or whatever, and that's just as good to me as taking a fistful of ibuprofen, right, I think.

Dr. Weiner: 22:21

Also, this is such a great example of kind of the four set point lowering techniques because you've leveraged every single one right, and that's what it takes, honestly, to go from 350 pounds to 190 pounds. Right, if you're going to lose 160 pounds, it's not easy. If it was easy, we wouldn't have obesity. And so you've changed your nutrition dramatically, following a nutrient-dense, pound-of-cure-like meal with a few planned indulgences. I know you and Zoe have worked a ton on this, right. Yes, you're exercising yoga, weight training, flexibility, balance, all of those things. You're really building muscle and using it as much as you possibly can safely. You're on the meds and you had the bariatric surgery. Yeah, and you know, on one hand that's a lot, it's a lot, but on the other hand it works. It's been life changing, fantastic. We're happy for you.

Zoe: 23:14

Yeah, thanks so much for sharing your story with us and our listeners, of course, but it was really great to have you on.

Leslie: 23:20

Thank you so much. I appreciate everything, all the hard work you do for patients in this community. It's really valuable. Thank you.

Dr. Weiner: 23:26

We're glad that we were able to participate in your journey. Thanks, yeah.

Zoe: 23:30

We'll talk soon. Yeah, all right, very good, wow, I just I love all of our patients' stories are so good.

Dr. Weiner: 23:37

I know we really have such a great job.

Zoe: 23:39

Absolutely. Being a part of people's journeys is just like. What more could we ask for so?

Dr. Weiner: 23:44

much fun. This is, like you know, this is our Tuesday right, so regular Tuesdays we get to be a part of this and get to share in someone's success. So you know we we do accept patients from all over Arizona and we actually even have programs for for patients from outside of Arizona to come and either have their surgery done by us or to manage your medications and work with you on your combination therapy. There's a lot to this right, but once we start to stack nutrition, exercise, medication, surgery, when we put it all together in a really coordinated package, we get results like what we saw with Leslie the quad factor.

Zoe: 24:20

Yeah, so if you're interested in becoming a patient coordinated package, we get results like what we saw with Leslie, the quad factor.

Dr. Weiner: 24:21

Yeah, so if you're interested in becoming a patient, please you can give us a call. Check out our website at poundicureweightlosscom and you know we'll be happy to see you and see what we can offer.

Zoe: 24:32

All right. So let's move into the nutrition segment and, although this isn't like nutrition super specific, it's something that I talk about all the time in our nutrition program with our patients and it's something that I find really, really valuable, which is not waiting until you are in maintenance to try to make a change. I always like to say success is the biggest motivator. Right, when you're feeling successful, you're feeling proud of yourself. That's why we always start every support group with sharing our wins, because we want to cheer on those successes. Right, when you're feeling this momentum, it makes it so much easier to continue making those positive changes. Right, it's like that positive reinforcement that we use with potty training or, you know, training a dog or whatever it is, and so thinking about okay, wow, this success that I'm experiencing, this better energy, this decrease of hunger, this better sleep quality, my clothes fitting better, all of these wins that we can stack up, using that as the motivation there's that word motivation that we know is fleeting Using that as harness it up.

Zoe: 25:47

Use that as motivation to build the momentum and keep it going. Because, guess what, it is super duper hard if you coast that. The honeymoon period can be a trap for some people who do not use it wisely. So the honeymoon period, if you're, for some people who do not use it wisely. So the honeymoon period, if you're not familiar, is that chunk of time, whether it's after surgery or while you're in your weight loss phase with your GLP-1, when you're losing the majority of your weight right, when it feels like, okay, this is kind of easy, but it can be a trap if you do not use that time wisely to change your habits for long-term weight maintenance and success.

Dr. Weiner: 26:22

Right.

Zoe: 26:23

So anyway, uh, that does not mean that if you're in maintenance you can't make changes and productive changes, of course but we want to harness the good momentum of while you're in your honeymoon phase, for sure.

Dr. Weiner: 26:38

Huh, interesting. So I think, something that I when we first started with the GLP-1 meds, there was a movement that said, hey, the first thing you should be really doing is getting patients to change their nutrition and then, once their nutrition is in place, then we add the meds in. And this was really, I think, before it kind of caught all the momentum and the popularity that it has. This is kind of in the 6-7 days. Five or six years ago that was the typical thinking and actually that's what I did at first and I started to realize, hey, a lot of times I didn't see the changes until after we started the medication, and that really just kind of shows this idea that it's the success that sometimes drives the motivation and also the fact that the medications also will kind of push you toward those healthier habits.

Zoe: 27:24

Exactly.

Dr. Weiner: 27:25

And that they actually work together. They're synergistic. A lot of people ask that question like well, if I have to change my habits, why do I need the meds? Why should I have surgery? Why don't I just change my habits? And there's a. It's a really good question, but there's some very clear answers. The first is because the habits don't work as well when used in isolation, and the second is for what you just mentioned. It's that by getting some weight going, it kind of helps. It helps spur some of those positive changes.

Zoe: 27:51

Well, it's not called the honeymoon period because it lasts forever, right?

Dr. Weiner: 27:54

Exactly All right.

Zoe: 27:56

So what do we have for the economics of obesity today?

Dr. Weiner: 27:58

So our economics of obesity, kind of this, is. This is like we're visiting our past guests on the show. So this comes from Chrissy, who was one of our first guests on the show and so she shared this article to me. It's from Psychology Today and it talks about a study that was done in the British Medical Journal and it's a meta-analysis. So there's all different kinds of scientific studies. We've talked very recently about observational studies.

Dr. Weiner: 28:23

A meta-analysis is when you look at like 15 or 20 different studies and you kind of pick out, you know the ones that make the most sense, and you pull the data from all these studies together and try to build a bigger sample size so that you can make some observations.

Dr. Weiner: 28:40

So they pulled this, and what's interesting too is you get a lot broader of data. So they got 16 US studies, three UK studies and two Canadian studies, and what they looked at was salaries and compared them to patients' BMIs, and so what they found was that men classified as obese earned 5% less money on average than their non-obese colleagues. So if you're overweight and this is where our title comes from it pays to be thin. If you're overweight, then you're going to make 5% less than everyone else. And what we also saw was that, as your education level increased, the pay gap also increased. Wow, the pay gap also increased. So obese men with a graduate degree earned 14% less than those who are not obese. And the same was true for women For women with a bachelor's degree 12% less. With a graduate degree 19% less.

Dr. Weiner: 29:46

So it was even more, it was more first of all, they didn't look at this, but there's been a lot of studies showing that there's a pay gap by gender. And then what we see is that, with obesity, if you mix the gender and the obesity together, then we see a huge pay gap. And so guess what field saw had the largest pay gap?

Sierra: 30:09

This is tragic.

Dr. Weiner: 30:11

This is tragic Healthcare. I know those of us who are best prepared to acknowledge the discrimination and the unfairness of this. We had the largest pay gap. It was, on average, 12% difference.

Zoe: 30:27

That is really blows my mind.

Dr. Weiner: 30:30

Yeah, so, um, so, interestingly, obese uh, workers in production and construction and agriculture, kind of lower paying jobs earned more than their non-obese colleagues just a little bit. But in the lower paying jobs, in the non-college degree requiring jobs, there's really no difference. The difference is in college degree and kind of middle upper, middle management type of jobs. So what can we do about this? Because so, first of all, why is this? I think we all know why. This is right, discrimination right. This is obesity bias, discrimination. We've talked about it, we see it. We see comments on YouTube and TikTok and Instagram on this. It's out there.

Zoe: 31:15

It's obesity bias, supported by data.

Dr. Weiner: 31:18

Yes, yeah, I mean. This really to me is proof of obesity bias, and there is some additional research also that shows that this pay gap is the direct result of discrimination. Looking at two people, who should we give the raise to? Let's give the raise to the thinner person. New York City has recently passed a law against obesity discrimination and I think New York City is always a great place to look at the laws. I lived in New York City for my residency and I was there. They were like the first place to outlaw smoking inside restaurants. I mean, I remember when I first started there you'd go into a restaurant and it was like you'd walk out of the restaurant, you'd stunk like smoke and you know the people who worked there. I think they showed it was like the equivalent of smoking a pack a day of cigarettes if they worked like an eight-hour shift in a crowded bar.

Dr. Weiner: 32:11

So they ended up outlawing smoking and there was a lot of big outcry and it was like what are you doing? And then we all have kind of that's all. I mean, I don't know if there's any state in the country now where you can smoke in a restaurant or a bar.

Zoe: 32:23

Unless you're in a Vegas casino.

Dr. Weiner: 32:26

Vegas casino, yes Vegas.

Zoe: 32:28

You can do it in.

Dr. Weiner: 32:29

Vegas. Yes, that does make sense. So so the New York city also has passed a sugar sweetened beverage tax right. So buying a soda is more expensive than buying water, which is actually the opposite of what we usually see.

Zoe: 32:45

Yeah, like thank goodness, it's about time. Yeah so anyway, this is out there.

Dr. Weiner: 32:51

And you know what can we do about it? Again, I think it really gets back to legislation and looking at what New York City's done, because what will happen is it'll be a big trial something, and then people will start to catch on and say, okay, hey, well, let's make sure that we're not discriminating against people by their weight, and I think that would be important weight and I think that would be important. So, but this is important literature. It's important for this to get out. You know, I think if you are working and you feel like you're being discriminated against based on your weight, that bringing this up and kind of making this an open conversation, I think it's appropriate. Now, there's some good scientific data to support it. And I think, especially if you kind of approach it with your employer more collaboratively and less adversarially and saying, hey, listen, this is out there, this is out there in every company, I feel like I'm experiencing it. You know, how can we make this right?

Dr. Weiner: 33:40

Right, and coming at it from that approach, I think you'll probably be a lot more productive than if you come at them, because then next thing you know you're looking for a new job, you start coming after them or something like that, and then it gets very, very dicey very quickly. So all right, well, let's bring in Sierra to have her read our questions from social media on health halos.

Sierra: 34:07

I had a gastric sleeve revision in October and started back on WeGoV three months later. I'm now being denied by Blue Shield of California because I had weight loss surgery within 12 months. Any advice?

Dr. Weiner: 34:20

Being denied for one of these medications is super frustrating and, unfortunately, super common, and what we're seeing is that the insurance companies are really the PBMs. They're the ones where this is coming from. They're coming up with any excuse they can get. We have a PBM from an insurance that we treat a lot of patients from and they will mandate the dose. So we'll start someone on Zepbound 2.5 and then they're doing great, they're losing weight, everything's fantastic. Maybe they're even having a little bit of side effects. We're just trying to modify and so we're like well, we're going to keep you on this dose. We're not going to increase the dose because you're doing great with weight loss and you're having some side effects, so let's try to keep you comfortable.

Dr. Weiner: 35:07

Uh-uh, not allowed to do that. Every month you have to go up. It's crazy. Which is crazy, that's just crazy. So I mean this really is an example of the PBMs playing doctor without a license, right? They're making rules about what dose of a medication someone has to be on without seeing that patient, without knowing anything about their history, and you know, honestly, I think they're going to get in trouble because if a patient lands in the.

Dr. Weiner: 35:34

ER. They can come back to the PBM and be like you made me increase the dose and that landed me in the hospital. That caused my pancreatitis. So we're seeing all this kind of crazy stuff and this definitely falls into it. So I think the first thing is I totally disagree with this policy.

Dr. Weiner: 35:52

We use these meds, you know, all the time. If this was a diabetes med and bariatric surgery treats diabetes as effectively as it treats obesity. We've been using GLP-1s after surgery for over a decade now without any pushback at all from the insurance companies, and this is clearly targeted obesity. This gets to the obesity bias that we saw in the pay gap and we continue to see over and over where they're making new rules. So I think when you're fighting these types of things, you have to know the rules. These types of things, you have to know the rules. And the truth is, if this is in their policy, if it's actually in their policy, you probably aren't going to be able to overturn it and you're going to have to wait it out and that sucks, but that's what it is. But I would bet this is not in their policy.

Zoe: 36:49

They're just trying to get out of pay.

Dr. Weiner: 36:51

They're just throwing something against the wall and seeing what's going to stick. My guess is they did not put this in their medical policy. So what should you do in this situation? You should get a copy of your medical policy and look and see if it actually says that you cannot be prescribed these medications within 12 months of surgery. If it is in your policy and again my guess is it's not but if it is, you can file an appeal and say this is unreasonable. There's no evidence to support it. In fact, there's a growing body of evidence supporting the use of these medications in coordination with bariatric surgery. So where are you coming from? I'd like to file a complaint. This is BS. Probably won't get you the med, but at least you should do it, because this type they just you know, just like we see Nova Nordis being brought in front of the Senate help committee. We need people to be held accountable for these decisions. If you, the more we let them just make these decisions, the more of these decisions we're going to get.

Zoe: 37:51

Right, the more appeals that keep showing up, and showing up, and showing up and the less that we just roll over and let them do what they think that they can get away with.

Dr. Weiner: 38:00

Yep, and I would also ask your bariatric surgeon to write a letter on your behalf for this, saying this is a totally bogus restriction. Now, if it's not in your policy, you got a great case and you file an appeal and say this is not in the medical policy you are making this up. You don't have a right to make this up and you have to authorize it, and so if it's not in your policy, you probably can get it approved. Otherwise you're going to have to wait.

Sierra: 38:27

Next question is from Instagram on our video. She just couldn't lose weight. I'm 22 years out. My biggest question is when do we eat if we aren't hungry?

Zoe: 38:39

So whether you're one year out or 22 years out.

Zoe: 38:44

We want to think about towing the line. There's this line that we have to toe between listening and honoring your body listening to and honoring your body and not eating when you're not hungry and stopping when you're full. But then there's this other side of the line where we know that, due to surgery and due to the medications, there's a hormonal override, if you will, that's telling you that you're not hungry and that you don't need very much. And so we need to, like I said, toe the line between recognizing and honoring what your body's telling you, but then also recognizing and honoring that you need to fuel your body, and you can't go all day long and not eat anything and expect your body to remain healthy and energized, right. Just like when your car is on empty, you have to go to the gas station or else you're not going to make it very far.

Zoe: 39:45

The same thing goes for you and fueling your body, whether you've had surgery one year ago or 22 years ago, right? So my recommendation here is when to eat if you are not hungry is try to keep kind of a little bit of a schedule consistent with when you would be eating otherwise, and that can be smaller portions, that can be. Maybe you have a smoothie instead. It doesn't have to be forcing yourself to have a big meal, but you still need fuel. So maybe having alarms set if you forget to eat because you're just not hungry, having some sort of consistent routine, can be helpful for that as well.

Dr. Weiner: 40:26

I think this also is such a good example of why people should be meeting with registered dieticians, because, first of all, we kind of throw these numbers out there, and we're guilty of this in our own practice 64 ounces of water, 60 grams of protein but these are just kind of random numbers, and when we look at a 180 pound woman versus a 400pound man, we just can't use those same numbers for both people. But we do, and so you know, in this scenario, let's say you're fairly sedentary, you're not doing any resistance training, you're very comfortable at your current weight and you're 65 years old that's going to be a different answer than if you're 25 years old Well, this person's 22 years out from surgery, but you're younger, you're bigger, you're doing vigorous exercise. Those needs are going to be very different, and so the recommendation that we would give to those two different people would be very different.

Sierra: 41:24

Last question is from our YouTube episode 34, will Ozempic Make you Go Blind? Clark Kent asks what is the recommended diet consistency from the days where I have to remember to eat just after taking a shot versus the days where I'm super hungry days before taking another shot? Should I be leaning into the medication or resisting for daily consistency in diet?

Zoe: 41:47

Oh, I come across this a lot. Actually, it's a matter of kind of riding that wave. So I would say, yes, lean into the medication on those days that you are not feeling very hungry and don't need to eat as much.

Zoe: 42:02

But we still want to prioritize your hydration, of course, and your protein intake. But if that means on that day that medication is at its height in your body, that maybe you're just having smoothie and some smaller things, then fine. And then, as the week goes on and as you start to feel hungrier this is the same conversation I have with people who you know months and months after surgery, they start to feel hungrier, they can start to eat more. Guess what? We want to honor that, just like what I was just talking about. We want to honor, recognize and honor what your body's telling you and give it more food, but we have to be careful of what it is that you're giving it more of. So maybe in those first couple of days you're relying mostly on easy protein sources and then, as the week goes on, you add in that extra volume, that extra fiber, that extra bulk through more produce and vegetables and fruit.

Dr. Weiner: 42:54

Yeah, I think so. I have a couple of questions for you. So we know with like fluids, if you don't drink any fluids for like a day or two, you're in trouble, you're dehydrated. But we also know like you cannot eat for a day or so, many religious holidays go, you know, 24 hours, sometimes even longer, without eating and we don't really see any significant health consequences from that. If we're looking at just protein consumption, and because what we're seeing here is like an average right, some days are eating more than other days and so if their body and weight is going to respond to the average, what's the time period on average? If fluid is a day or two, what's protein? Is it a week? Is it a month? Is it?

Zoe: 43:33

two weeks. I think that people start to see decreases in their energy levels pretty soon. But if it's a matter of your muscles starting to waste, you're going to have a bit longer of a time, maybe a couple of weeks. A couple of weeks, yeah. So I was actually just talking with somebody on a one-on-one today. She was freaking out because she hasn't gotten she recently had surgery. It hasn't gotten her protein needs met for the past couple of days. She's like I'm doing really well the first week and now like it's been three days. Stop stressing about it, it's going to be okay. Your fluid is your priority. So it's like it's a similar conversation, right? But I will say you likely will start to see more cravings, more hunger, lower energy, and that doesn't always necessarily equate to the same timeline as muscle wasting.

Dr. Weiner: 44:22

Yeah, but I think when we're looking at these shots, these are weekly shots, so we're going to see fluctuation within a week and if you eat very little right after you know when the shot's at its maximum strength and then right before your next shot, you're eating a lot more and the average is kind of right in line with what we would want someone to get that's going to be okay.

Dr. Weiner: 44:42

And I think that as long as that timeframe is a week if it's a month, we can start to see some problems. But if, within a week, you're seeing some fluctuation, that's actually pretty common. I mean, people eat differently during the week and on the weekend and your body weight and your overall health will actually kind of be the average of that. So I think that, yeah, I agree completely with you about leaning in and just you know, when your body's telling you don't eat, then you can kind of back off a little bit. But when you're hungry, then make sure you honor that and you know, and especially if it's specific cravings for healthier food, that probably means you need a little bit of the nutrients in that food.

Zoe: 45:17

So definitely Well, another awesome episode.

Dr. Weiner: 45:21

Yes, so I want to thank Ben from Bloom House Media for his videography and editing of this episode. We want to thank our special guest, leslie, and if you're interested in learning more, check us out on TikTok, on YouTube, on Instagram, we're actually doing a little bit of a refresh. We're going to change some of the types of content we put out on social media, so we'd love your feedback on it.

Zoe: 45:44

Yeah, if there's anything specific you'd like to see, send us a message. You know where to do it, all right.