What are the new weight loss drugs & the science behind them? We explore the current surge in Wegovy and Ozempic use for both on- and off-label purposes, the media misconceptions and underlying discrimination, and what is included in the cost of these drugs.
Hi, welcome back to our April edition of Sisterhood and Surgery. Today, we are weighing in on the new obesity medications on the market. It's been a hot topic. Um, my co-host Paul, we have two great guests here. Um, and um, why is this important? Well, I mean, jokingly, Jimmy Kimmel announced at the Oscars, you know, why is Ozempic? Right, for me. Right. But because apparently all the celebrities are taking it and it's this hot new drug. But, you know, honestly, the stats are pretty depressing, you know, in the US, about 41% of patients are obese. And what does that lead to that leads to heart disease, stroke type two diabetes and certain types of cancers. And this, these are some leading causes of preventable premature death. We definitely see that in the vascular world, lots of end stage diabetes, chronic kidney disease, hypertension, all this leads to terrible vascular problems and it costs the US about $173 billion to treat obesity. This was stats from 2019. And so we figured this was a great topic, not only for sisterhood and surgery, but for really anybody that is more interested in this and just to get the pros and cons and, and see what it's all about. So, um, I'll start off with my first guest, Doctor Seana Levy, who's also my friend and we were residents together. She's in New Orleans where I'm from. She's an assistant professor of surgery at Tulane University Medical Center. She started there in 2000 17. She's double board certified in general surgery and obesity medicine. She is fellowship trained in minimally invasive surgery with an emphasis on for gut and bariatric surgery. And she's also the medical director of Two Lanes, Bariatric and Weight loss Center. She's been very interested in fitness, weight loss and nutrition. She's passionate about, about helping her patients treat the disease of obesity and she specializes in anti obesity medications as well as surgical weight loss treatments. Um She works with each patient to help them achieve long term weight loss. She has um been improving access to care for obesity treatments and educating the public on obesity treatment options. She is recently famous featured in many news outlets um such as the Hill magazine BBC, World News, NBC news online, the Daily Mail and Food. We need to talk podcasts, um America Dissected podcasts and soon the Atlantic in her personal life, she is her favorite role is a mom of two young girls and they enjoy spending time exploring Louisiana. Welcome Dr Levy. Thank you so much for having me. So happy to be here. And it's my pleasure to introduce our second guest, Dr AANA Sado, who is an assistant clinical professor at the Y Cornell Medical College and adjunct assistant professor at Texas A and M Health Sciences. Her medical career began with the Doctor of Medicine from the David Geffen School of Medicine at UCL A where she finished with honors and also completed her internal medical training as well as fellowship in endocrinology, diabetes and hypertension. Since 2010. She has held positions of system director of the diabetes program and director of transplant endocrinology at the Houston Methodist in Texas. She leads this large a hospital system in evidence based clinical practices, clinical research and education to ensure comprehensive high quality and cost efficient care of persons with diabetes. Additionally, doctors has unique expertise in a complex group of patients who undergo organ transplantation and in particular pancreas transplantation and serves as the medical director of the pancreas transplantation at the JC Walter Transplant Center at Houston Methodist Hospital. She is also passionate about educating all health care professionals that impact the care of persons with diabetes and has been an invited lecturer at national and international conferences. She's also received recognition for our expertise and has been awarded the Alan Jay Garber Diabetes educational lectureship for the prevention and management of the complications of diabetes by the American Association of Clinical Endocrinology. Additionally, I understand that she's also well sought after her public appearances and also through the newspaper. She's been in the Chronicle local Fox News and tomorrow we will be on the local news. So check her out tomorrow. Thanks for joining us. Thank you for being here and we are so blessed to have two um such experience and experts in this field. Remember, this is a live show so you can send in your questions. Join by web, go to po ev dot com, enter or join by text, text to 237607 and we will get your questions answered. Um So what are the new weight loss drugs and the science behind them, doctor? Do you wanna start? Absolutely. Thank you for having me. Yes, it is going to be a wonderful discussion and um so much to say about it. So this new class of drugs um is phenomenal. It is part of what we call the in uh system, which basically means hormonal um hormones that are related to gut and everything related to food. Really. Um So there is the first class of the system was the G LP one receptor agonist and this is the wave and Ozempic brand names that we often refer to. Um And then the newest class is a dual Linkin hormone, which is both G LP one and G IP uh together. And this is um the newest or so this is a whole new class of drugs and it um was initially the whole class was studied for patients with type two diabetes and found to be very effective in reducing glucose. But along with it, we also found that it was very effective in reducing weight. So each of these companies, manufacturers have then done subsequent studies for just weight loss alone without the diagnosis of type two and found consistent results with weight loss. And so now, uh semi glut, which is either OIC or wigo can be used for type two diabetes as well as overweight with a chronic condition related to weight loss or obesity or obesity by BM I criteria. And inter at the moment is indicated for type two diabetes, but soon we'll get the indication for the same obesity or overweight with a chronic condition and it, it's all over the news, Seana. Any thoughts on the the misconceptions by news media? Oh, well, there's a lot of thoughts there. I know that's why I brought it up. I mean, I start with depends on specifically what you want to get into. But I think one of the areas that's a little bit confusing is this idea that's been perpetuated that the shortage of Oz, which like was mentioned as FDA indicated for the purposes of diabetes is on shortage because people are, you know, sort of stealing it for the purposes or misusing it for the purposes of obesity. And what we have to remember is about 80% of people with diabetes also have the disease of obesity So there's tremendous overlap. That's the first thing. And you know, the main reason why there's a shortage for Ozbek is because more people need to use it than supply exists at the current moment. You know, of course, there are people that are using it off label or there are people that might be using it for the wrong reasons. But the majority of instances of this medication are used for um you know, the reasons that they were indicated. And we have to also remember that Somali is FDA approved for the purposes of weight. So when we talk about people with the disease of obesity, using Samat, it is a true indication and there's nothing wrong with that. So again, when the media, you know, sort of blames people with the disease of obesity for causing a shortage that's not appropriate. And when we think about obesity, there's very few medications that work really well. One really that works very well with Gobi and, you know, you could argue that sex and also works well. Um but when it comes to diabetes, there's a lot of medications. So it's just really not a fair comparison and it really drives me nuts. So how do you utilize these medications as a transition to having surgery? I mean, do you use them in your practice? Do you initiate the medications as a bridge to surgery? Is that uh an algorithm? Yeah, I mean, me much like chemotherapy when it comes to oncologic patients. Sometimes chemotherapy is used before somebody has surgery for cancer and sometimes it's used after and sometimes it's used in conjunction. It's very similar with treating the disease of obesity. Sometimes we use weight loss medications to help, you know, sometimes people are not interested in weight loss surgery and they, they want to start with weight loss medications and see what they can do with it. And sometimes they find that it doesn't give them enough weight loss and that they want to transition into weight loss surgery. And sometimes we use it to help, you know, bring a BM I down to make surgery a safer possibility. And sometimes people, you know, don't get enough weight loss with surgery and wanna use like weight loss medications in conjunction afterwards. You know, the thing that's, I think important to remind my patients is that they think, why did I fail the sleep or why did I fail the bypass? Why did I not lose enough weight? But the truth is the surgery probably just didn't, wasn't the right treatment for them or didn't offer enough treatment for them and using weight loss medications afterwards is not a sign of failure. It's not a sign that they did something wrong. It's just that their disease could not be treated adequately enough with surgery alone. And then we really need to have a, you know, a mind set, like shift to understand that these are just treatments for disease and not a reflection of not doing enough. So, would you recommend using a medication to get to a certain weight that would then put a patient into a better or lower risk category in your perspective? I mean, would you say if we get you down to this part or this weight now you'll have less complications based on the data. I don't think we have that data, but it's something that we are looking into at our institution. And I'm sure a lot of other institutions of truly understanding how taking G LP one receptor agonists before and after surgery affect the outcome. Because I think, you know, uh, an unanswered question is, for instance, with the sleep, we know that it doesn't impact G LP one to the same degree that a gastric bypasses. So if somebody has weight loss beforehand with a G LP one receptor agonist, and then they have a sleep gastrectomy with affects other hormonal pathways, will they have rebound weight gain? And then that net neutral weight loss, you know, I just not to get overly complicated. But we, I think there's a lot that we still need to understand about these great medications with weight loss surgery. You were about to say something. Well, I was actually just listening but thinking about when to choose a patient for GLP one or any anti obesity medication versus surgery. And we had these conversations with our patients all the time in the office. So we're kind of initiating the thought process a lot of the time. Um Obviously, as I mentioned, these drugs are phenomenal for glucose reduction and improvement in diabetes. They also have other indications for cardiovascular protection. They also help with chronic kidney disease. So when you have this whole syndrome together, along with the weight, these drugs are usually our first go to treatment plan and when we don't get enough of the weight loss and we're still struggling with the other diseases related to the weight, like the diabetes, et cetera, we can offer also bariatric surgery. But even if we do offer bariatric surgery and even if we get the desired weight loss from surgery, these drugs may stay on as indications for all these other benefits. Um most of the time as well and we were talking before, before this um about your comments because you do, you do get asked to speak about the shortage and how that relates to the international supply. So, can you comment on that? Well, this is just the information that I've been given from multiple sources and it makes sense that this is what the picture was was Gove came FDA approved and a pretty big demand, obviously. Um However, there were two issues that happened, the demand was much more international than us because here coverage as we mentioned already for, for these drugs deemed as cosmetic purposes is really hard to get and they're very expensive for patients to pay out of pocket. So one that a lot of the supply was going internationally. And I believe that there was some manufacturing issues with the drug in some of their plants and that also hindered. So decreased supply with increased demand, created a significant shortage of wave. So then Ozempic which had been on the market much longer than Mugo became a alternate off label indication for weight loss even when patients did not have diabetes. So it was a domino effect. Really one led to another and both drugs became extremely unavailable in the US at least. And why are they so expensive? Um And both of y'all can comment. I mean, you know, is it the marketing, is it the actual making the drug itself? I mean, why is it? And is that other countries, are they paying those prices? The government paying those prices. This is a very big topic and doesn't only apply to these drugs but many, many right. Yes. So you can go down the line on, on each step of the process between manufacturing. These are peptides. Uh And that's obviously gonna be much more labor intensive and manufacturing them. And uh the regulates that kind of manufacturing very closely and it's costly in the US. So that's one thing any injectable is going to be much more, much more expensive in the manufacturing. Then you go all the way down the line to marketing and recouping R and D costs, which I think are not as big as some Pharma claim to be the reason for their drug pricing. But marketing is a big one. And now they're doing a lot of direct to consumer marketing. So that part of the budget has really expanded for these companies. And then you have the negotiation of the pricing with the PB MS, the pharmacy benefit managers who are the middle men that go from the from the actual Pharma company to the insurance company to the patient that also contribute to the inflation. And so how is this different than, than the international market? Well, you know, those are usually universal health care and they don't have all of these steps along the way. And yes, I think pharmaceutical companies do price them a lot less internationally. The same drug will be a fraction of the cost in the international countries in the US. Um and you know, uh insulin, for instance, insulin has been around just celebrated two years ago, its 100th anniversary. It is one of the most expensive diabetes drugs still. I mean, it should be cheap and it took a national policy change for finally discovered 100 and one years ago to this year being affordable for patients at a set cost of $35 a month. So you can imagine how slow we are in the US in addressing um drug costs. Yeah, I I think if I might add one thing that we can't forget is the role that obesity discrimination and bias plays into this conversation. It's my understanding that about 99% of insurance companies um cover OVI which is a diabetic a medication, you know, of course, as we mentioned with the indication of her diabetes. Well, goby, which is the identical molecule, they're both sat is covered by about 20% of private employers. It's not covered by Medicare. It's only covered by a fraction of Medicaid and a fraction of Affordable Care Act. Um States coverage plans. And you know, when you look at the identical molecule and same approximate cost, the differential of insurance coverage, how can it not be obesity discrimination? I find it hard pressed to believe that this is not a, a huge factor when we think about coverage in these circumstances. And so then when we understand when we think about why drug drug is so expensive, we only have to think about it because insurance is really not paying for it because if insurance coverage were better, I don't think people would be discussing the cost as much as they are absolute. I mean, how much, how much does it cost without insurance? So these drugs run uh anywhere between 900 to 1300 a month a month um for cash pay. So they really are prohibitive. Yeah, I mean that, I mean, unless you, you're rich you can, I mean, that's a lot of money for each month. That's a big chunk of somebody's budget for sure. Yeah. And, and, and you mentioned that this is true for a lot of other medications like antihypertensive medications and like some of the fancier insulins are very expensive and, but they're covered, I mean, a lot of times they're covered and so the coverage true, but coverage does not always, also, even for the diabetes indications, coverage does not equate affordability. They're usually much higher tier. Um and a patient still on a limited income has to decide. Do I take $4 a month? Metformin or this Ozempic Fancy new drug that will be maybe 200 not 1000 but $200 still um not affordable for them. And um and it's not, you know, just these medicines, it's, it's a lot of medications that fall under this category. Um But certainly I understand what you're saying about the obesity discrimination. It's similar to type two discrimination. Well, you did this to yourself. So um it's on you. Uh there is an underlying um message that yeah, this is not critical for our life. Um although insulin is um and then, you know, we will make this less accessible. Yeah. And so you, you can see the socio economic implications of these drugs, of course, especially in the US where, you know, there's so self selects just by being very expensive, it self selects and social determinants of health are unfortunately a great role in access to this drug. Well, um and so the short term, long term, I mean, y'all both talked about having to, you know, take this medication for life. Um And so what are some of the complaints that y'all's patients say about these drugs? It's interesting. Um Well, again, it depends on the indication. So if it's just obesity, um a lot of them will come and say, you know, is it time for me to get off? I've gotten a significant amount of weight off from these drugs. And that's when we have the conversation about all the variables that go into weight. So it's great that you lost £30 or you're at your weight goal now and now you want to be off the drug, whether it be for cost, whether it be for concern for long term side effects because we really don't have decades of data on this uh on this drug class yet. Um Whatever or there's a shortage and now I gotta get off the drug. I'm really afraid. Uh now I'm forced to be off the drug and I'm afraid I'm gonna gain all this weight back. So this is a time to really have that conversation about lifestyle changes. And I did a recent discussion about this and how do you advise a patient who has to come off the drug to manage their weight? And I think there's really great tools now that help people understand how many calories they are consuming and that's really important. So as you know, the in class, this GP one effect is not only in the gut, actually, it goes to the brain and directly suppresses the appetite center. And that's one of its main mechanisms for weight loss. So when you lose that, your appetite rages back really. And so then you have to really force yourself to follow the same caloric intake that you were using on the drug. And so as we've been trying to taper patients off the drug who want to be off the drug or have to be off the drug. Um, we start with, well, look at how many calories you're consuming because of your appetite suppression from the drug and maintain that caloric intake when you can't take the drug and then physical activity, I cannot tell you how important that is to substitute when you have to, for this drug being, doing that regular exercise regimen. Um, 30 day, 30 minutes a day, 100 and 50 minutes a week, uh, moderate cardio with, with strengthening and it really does help maintain your metabolic rate. And that's really what you're trying to do. You're trying when you come off the drug, your basal metabolic rate immediately goes up and you want to be able to match that basal metabolic rate with lower calories and increased energy expenditure to maintain the weight that you had. And so with diabetes in these medications, if the patients have lost the weight and control the glucose once they get off of it, if they're able to, have you seen patients success, successfully transition to, you know, glucose control, which is diet. Ok. That's great. Diet and exercise is, is, is probably a little more rare, but it can happen. It can certainly happen. Um, but because we're afraid of losing that glucose control, we're substitute with some of our older, you know, Metformin might be enough now, whereas before, with, you know, 30 extra pounds, Metformin wasn't, wasn't enough. So we may be able to, uh, bring deescalate their diabetes, therapies from the weight loss, um, to, to the G LP one at class. Well, that's great news. Yeah, I just, sorry, go ahead. No, go ahead. I was just gonna say that even the, uh, benefit of improving their mobility. A lot of the patients I see in the office who are overweight, they have terrible knees, their joints and they say I can't get my knee replaced because I still weigh too much. I have to lose weight to get my knees done, but I can't exercise because my knees hurt. So I can't wait. It's awful for them. And these drugs are perfect because they will get them to. Actually, I have a patient in exactly that position. A young patient actually. And with a congenital issue that caused the, the hip, actually, it was a hip issue and she needed surgery, but the weight was so high that the surgery wouldn't be as successful. And so we bridged with, with this drug class and with significant weight loss, she was able to get the surgery. Now, she can be more mobile and maintain the weight with or without the drug, depending on what they choose to do. Shana. I was just gonna say um that we know from step four of the clinical trial on wave that when they stop the medication, most likely everyone is gonna gain their weight back over time. You know, I'm speaking from people with the disease of obesity, they did a crossover um halfway through the trial and half the patients were taken off will go and half of them continued on Wabe. The people who continued on, Wa Gobi continued to lose weight and the people who were stopped on Wabe by the same end point had not only regained all their weight had gained back, probably about £8. So we, you're saying £8 more than their base than their starting weight? Ok. So gaining more weight. Ok. Yes. And, and that's pretty typical with the disease of obesity is that when you lose weight, our body drives us to gain the weight back and usually gain back more weight. And that's because of our hypolemma set point, uh which is our body's way of saying, you know, where we want our weight to be. And this is something that, you know, prehistoric from our hunter and gatherer days that our body is meant to be in this place where we have to find our next food. And so it's a survival advantage for our body to hold on to calories. But now that we're in a place where, you know, calories are plentiful and they're not hard to find. Um, our body really holds onto calories in the same way and it leads us to gain weight. And, um, you know, I've been asked before, is this not a manmade solution to a manmade problem? Of course, it is, but it's gonna be very difficult for us to change our environment to go back to where we were. So we kind of have to deal with our weight in our current situation and these medications help us do that. And so when somebody talks about wanting to come off medication, I usually encourage them from the very beginning and advise them that this is a lifetime medication. I guess some people have to come off of it, you know, for cost or for whatever reason, but they really most likely are gonna gain back weight and it's not because that they're failing or it's not because they're not trying. It's not because they're not disciplined. It's simply because of the way the disease of obesity, there's, there's many hormones at play that, um, rebound, uh, for instance, will rebound once you come off these drugs and just drive that appetite back up, um, and lower the, the metabolic rates and it really is an uphill battle when you come off the drug. Um, and, and you're absolutely right. Obesity is a chronic condition, just like if you had hyper, you wouldn't encourage someone to come off the drug once the blood pressure is controlled. Um, but unlike those, uh, other conditions which have been, um, you know, well established with multiple types of therapy, obesity, we have this, this drug classes just cost prohibitive right now. And so for many reasons, patients, um, need a plan sometimes on how to transition off the drug. Unfortunately. But yes, all of these things can get worse. Your diabetes can get back if you are taking it, you gain enough weight or you could continue to develop beta cell dysfunction and go into diabetes. And again, you know, if you have cardiovascular conditions that are related to the weight, these drugs have benefits there and if you come off, you're gonna lose that benefit as well. So, um, a lot of reasons to maintain the therapy, but we have to provide them access to the therapy and when they don't have access to the therapy, we still have to give them some guidance on, on what to do about weight. My, my big point about all of this and you're absolutely right. You know, there's, there's a lot of stigma associated with this. Um, and there's a lot of variables, not just the patients will, uh, which often is, is cited as the main reason um that go into obesity as a society. And um I think the most valuable intervention is going to be education with our kids and making sure that they don't become adults with obesity that then just begets obesity in the next generations to follow. And um, it's been such a problem with pediatric obesity now, about 20% of kids, um, from age 2 to 1920% that's a lot we have um overweight or obesity. And so all we're doing is pushing the problem down the line and, and it's such a problem that these drugs have now have indications to use in pediatrics. And the American Academy of pediatrics just released their guidelines this year in January saying we need to be more aggressive with, with everything but also use pharmacotherapy when everything else is failing because we just can't afford to have all of these kids grow to become adults with obesity and all the medical conditions related to that. It's going to be a disaster. So we need to attack this problem in multiple different directions. And so are those insurance is paying for the for the? Yeah, I was gonna say, you know, I mean, uh but, but when, when evidence is so strong and it comes into the guidelines, this is what changes coverage eventually, eventually, eventually, not, not immediately, of course, and then, you know, then you have to have supply of the drug as well, which has been our most immediate problem. So they political activists uh working on this, I know, and vascular surgery we have got, we make guidelines and recommendations. We take the data. Uh and then we, in fact, in June, we're going to march on Washington to promote some vascular surgery, um things that we need to address. But, um, what's happening on the, I mean, it seems like you just have to guess so many reasons. I know. Yeah, I mean, how could they not say no? That's what I don't understand. But, well, you know, like I said, it took over 100 years to get insulin. So you can imagine how slow these wheels turn. But uh the American Obesity Society of three different endocrinology societies, pediatrics, American family of physicians, you know, are all saying the same thing, these drugs are needed. These drugs should be accessible universally, you know, not just to those insured, but every, you know, address the social determinants of health as well for the future health of this country. Is it the Obesity Action Coalition is one of our main obesity societies that's advocating for, you know, rights for people with the disease of obesity. But there's also the Stop obesity Alliance. Um that's advocating for, you know, of course, our obesity surur surgical societies are also advocating for the same rights. So it sounds like you have many lobbyists but is it the the insurance company, you know, like, I mean, they, they, I mean, I hate, wow. Yeah, I'm about to get removed from the world. But I mean, I'm just, you know, you know what we need to remember about uh insurance. And I think this is a point of confusion for a lot of people that unless you're talking about government funded insurance, we're talking about employer based insurance. And so the employers decide which plans they want to include And obesity is often an opt in or opt out situation. However you want to whatever language you want to use. So employers have to decide that they want to cover obesity as opposed to other things that are considered essential health benefits that they don't have to decide include or not include obesity is often left out of that. And so you have to actively decide that you wanna cover obesity. Do you know if your institution covers obesity? We do? Actually that's, that's lucky enough. I think our employer based insurance uh does cover these drugs. Again, it may not be affordable for the employee depending on their total salary and, and the copay for the drug as as it relates to their budget. Um but at least it's cover. Yeah, I mean, that's, well, I would the reason why I say the whole lobbying because you know, that's part of when we talk about vascular surgery and getting, you know, getting, you know, getting rid of the Medicare cuts and you know, because there's only like one pot, right? And so it's like, who gets part of the pot? There's no, like, extra. So if you're taking away from one specialty, it's because you're giving it away to another specialty. And we are just such a small group that even though we're lobbying in June, we don't compare to, you know, like the cardiology, like American College of cardiology. There's just, you know, or the people, I mean, they're massive, you know. And so, and, and really, I mean, there's like we could do a whole show on this but like, you know, so we're really under, you know, the American College of, you know, to be bigger and to fight for, you know, to have, um, more, um, in our fight. But I mean, that's just what I wonder sometimes, you know, like as physicians, you know, we have, um, a medical organization like the A MA, but it's like we're too busy taking care of patients to go lobby for the, you know, for funding for, uh, you know, for not no Medicare cuts for benefits for physicians. So that's why I asked that question does take a team of, of approach to get this done and it can be done. It's been done. Uh I, I keep coming back to insulin. It's been done. It's just, but it took a, it took 100 years, you know, and the patent for insulin, uh, by the founders was sold to the institution for $1 so that it can be accessible for everyone. Wow. And yet the pharmaceutical industries ran away with it for over 100 years. So, um I've been working closely with lobbyists and, you know, some of the goals with obesity are to really get, like you mentioned before, to get government to change policy. As mentioned before the treat Reduce Obesity Act, you know, we've been working on that since 2013, but also the Affordable Care Act, which I'm sure you're familiar with, you know, push through with Obama to get coverage for people. Um has an exclusion on obesity and it's not considered an essential health benefit. So we've been trying to get that changed as well, uh which would be through the health and human services. And so that would be very beneficial for millions and millions of people if we could get that language changed. So it becomes an essential health benefit because really if Medicare starts covering anti obesity medications, Affordable Care Act, I mean, employers are gonna really have no choice but to cover it. So that really needs to be where change starts. Oh, we have a question, social media though the social media II I mean 100 years ago, social media, right? But I mean, you can, you could take one thing and make a blog, you were on a webinar discussing this, right? I mean, it's a different era. Yeah, and, and I agree with you and I'm on tiktok, so I'm trying to spread the word as well. Um There's a bunch of us out there that are trying to advocate and, you know, communicate and patients are saying the same thing, like, look how much my life has changed and, you know, we haven't even gotten it to compounded to macro, but there's a lot of conversation about that on social media as well. You know, I, as, as Doctor Lee mentioned, you know, I wrote an op ed for the Hill magazine, which is a Capitol Hill uh magazine trying to talk about the same issues. So we're, we're trying to spread the word as much as we can. But it's just hard because not everybody is willing to listen a lot. There's so much shame when it comes to the disease of obesity. So a lot of people feel like uh if I had only worked a little bit harder, if only I tried a little bit harder, maybe I could have done a better job. But no, it's a disease. It's so much more than willpower. And, you know, that's also part of the message because I think if people really understood that this is in fact a disease, it would be a no brainer that of course, we treat other diseases, we treat disease with medication and surgery. There's a question from the audience, is it possible that insurance companies will see covering these drugs as profitable in the long run by preventing complications from obesity. Well, that's the hope, isn't it? Um, but to convince them, um, or as you mentioned, it does start with government payers. Medicare once Medicare is convinced and does something, it, the commercials follow. Um, but we did cost effective studies to show them the numbers. It makes intuitive sense. Obviously, you have a 30 year old with obesity and you bring their, um, BM I down from 35 to 25 they'll be less likely to get type two diabetes and hypertension dyslipidemia, cardiovascular disease, joint disease, you name it and so many things. But then you have to do this study in the very, very long term. And I don't think anyone is funded to, to be able to do that. Um So we need to do, uh you know, we need to do our um our due diligence and show that our researchers should need, needs to demonstrate the potential benefits, the economic benefits of this drug class or weight loss alone, even from this drug class. And that will hopefully drive the train a little faster, get everyone to uh understand. So I have a personal story about that. This was when Saxenda Lalu was first approved for weight loss alone and I had a patient prediabetes, pre hypertension and BM I mid to late thirties. And so I prescribed the drug and um and of course, it came back denied. And so, um I did a, you know, peer to peer um, uh discussion. And I explained to this physician on the other side, representing the insurance company, this is where this lady's path is going. This patient's path is headed towards type two diabetes, headed towards hypertension cardiovascular disease. If we can just get her weight down, now, you are preventing all of this. And in the end, this saves you money. And I was successful in this one case, she said I will give it for six months and then we'll see. Um, and then I think the patient did take it, uh, did get some weight loss, but this wasn't the most effective weight loss drug, not like our stomach glut. And these days, um, and then I lost her like she, she moved and I didn't get to follow up. And this is what I believe and I've also read some literature about is an insurance company really is only responsible for a patient. It was a commercial insurance company for a few years. They tend to change jobs and change insurances. So their financial statement is very limited. So if you tell them I'm going to prevent you, you give me $50,000 to treat this patient with a prevention medicine now and I'm going to prevent diabetes and heart disease 20 years from now. They're like, well that our financial statement doesn't go out that far and, and probably in 20 years, that person is not gonna be our problem. Anymore. It's not gonna be our problem. So they, I mean, they, they are super smart. Uh, that's even less. I've read three years. But so they change every, every couple of years. Yeah, a lot of people change their jobs about every 18 months. I mean, not us. Right. Like, we usually stay a lot longer but, you know, for other types of employees and employers, they look at about 18 months of coverage for somebody. And so there's a lot of concern about the upfront investment and having to pay for these medications. So that's, I mean, the issue we've had with bariatric surgery as well, we do have those cost analysis and we see those savings and we know that there's prescription savings spent. It's starting at three months post bariatric surgery and about by 18 months, bariatric surgery tends to pay for itself, especially when patients have diabetes. But insurance policies are, I mean, insurance covers, worry more about the upfront, you know, having to pay for all those surgeries, having to pay for medicine. And so it makes it hard for them to think about the long term gains. But if there was universal coverage, everybody would win. I never thought, you know, I mean, I don't know why I didn't, but I never thought of the short term, you know why you didn't, because, because you don't have to deal with the cir vascular surgery. It's covered. Yeah, these people need these emergency surgeries. And you don't have to worry about. Does this patient have this type of insurance? What are their stipulations? Do they have to be, you know, jumping through hoops for six months before they can have their vascular surgery? I mean, maybe I'm wrong because I'm also not a vascular surgeon, but these are the kind of things that we have to deal with, with obesity. Yeah. Well, I mean, I would say for us literally probably a third of the time it's emergent. I mean, Paul, what would you say? Like there is, we don't, I mean, it's through the, er, you know, you're about to lose your leg or your meso ischemia or you had a stroke. So really, we don't, the inpatient side, we don't even check because it doesn't matter, like, even if they're not covered, they need the procedure. So some insurances for claudication are required demonstration of smoking cessation for a period of time, but it's, I think it's a minority, not the majority. Yeah, I mean, I think it's pervasive through all of us health care that coverage is always going to limit access. Uh, I don't think that's uh specialty dependent or even some procedures unless, unless, like you said it's limb threatening or life threatening. Uh, you're most likely as a physician in the US going to have a, uh, have to address these issues with any kind of coverage for drugs or for procedures or coagulation. Yeah. The newer imaging uh new technology, all of it for sure. Um Require some kind of jumping through the hoops a little bit. Yes. Yeah. So have y'all noticed any difference with these drugs between men and women since we are the sisterhood surgery is they're on non gender bias. Actually they work in both gender. Yeah, that's a plus. Um Probably I don't, I'm sorry, go ahead. Oh I was gonna say probably for obesity indications women are more actively seeking the treatment or any treatment at all than men. And I think that's just that is a gender difference there. Um But the drug effects are are pretty pretty according to clinical trials. That's good to know Shana. I think in general, men tend to lose weight easier than women. I think it goes down to like their electron transport chain or something is more efficient than women's. But uh either way most obesity seeking patient or weight loss patients are women. You just know, but it's really hard when you have a husband and wife team that are trying to do the same thing and that, you know, it's aggravating for the woman because the men tend to lose weight a lot faster. Interesting. Yeah. Palma. Any, any we're about to um run up, it's about to be six. So any last questions or comments? Time flies. Yeah, I I just think this has been incredibly informative and I think uh I'm so excited that you guys are so passionate about it and I never had to worry about this. It might just work out and I've really never been overweight. So, you know, it's, I'm ignorant to a lot of this. But, um, I really admire everything you're doing for these people and this disease process because I think who wants to live this way, worry that I can't eat one piece of pizza or, you know, I have to eat 1000 Callies a day. I mean, how long can anybody endure that? It's just not fair. So I congratulate you for and commend you for that. Well, we have good tools now to manage obesity and we're lucky to be practicing in this era because I can tell you just a decade ago, our advice was really limited to lifestyle changes and we all know how effective that is in the majority of cases. Some cases. It works amazing. It really does. But, um, you know, our patients come back over and over and we've not seen a budge in the weight or they've been disappointed or even depressed over their weight. And, um, now we really have effective tools uh to use for them. That's, that's a very exciting time to practice. We just have to get over the hurdles we discussed today. Yeah, I, I could, I couldn't agree more. This is the most exciting time to treat obesity. I feel so lucky to be in this era to really help patients. I absolutely love what I do, I love being this, you know, advisor in this uh part of people's lives. But I just want to say for anybody who's listening, this is not your fault, this is a disease and there's help and there's plenty of people, you know, I'm not in Houston, but there's plenty of people. There. You can go to the American Board of Obesity Medicine website and look for a provider near you who's board certified in obesity medicine. And of course, the American Society of Metabolic and Bariatric Surgery to look for somebody who might be able to help you with your weight loss journey through surgical interventions. But we have an amazing weight loss, we have an amazing weight loss center here at the. So um uh check that out and we do both, you know, medical management as well as um surgical management. So uh and, and then all the complications of obesity, which we all see. Yes. And then last question, I mean, can you comment on the new drugs, the newer drugs that are coming out and what's exciting about that? Well, there are so many and I think again, it's really looking at different mechanisms of action. So it's a complex group of compounds not to, you know them, but just to say that this is going to get even more exciting. Um it's going to be hard I think to demonstrate the same effectiveness as for instance, or even some glut. But um we will see, you know, and the thing is we will have a variety of agents. So for patients who have contraindications to one class, we have other classes for patients who have side effects to one class, we have other things to offer so much, many more options. That's what it's about. It's, you know, the right treatment plan for the patient uh that suits all of their needs and competition, which is good for lowering cost. Exactly. Yeah, so, well, thank you so much. This was so informative. I've been looking forward to this uh topic for a long time. So I thank you for your time, your expertise and um just your, well in general, what y'all are doing in life to help, you know, these patients. Pleasure to be here. Thank you for the invitation. Thank you so much for having me. Good night. Good evening. Have a good night.