>> From WXXI News.

This is Connections.

I'm Evan Dawson.

Well, our connection this hour was made with a man named Mike during an appointment with his doctor.

Mike's physician told him he was concerned about Mike's weight.

He was close to 300 pounds and was approaching prediabetes.

Mike's cholesterol levels were also not good, the doctor said.

And with all of this in mind, when Mike saw a study for a weight loss drug trial, he decided to enroll.

The results, he says, have changed his life.

After being on the drug.

He's down 30 pounds, but soon after being off the drug, Mike gain the weight back.

He he tried different programs, different diet programs and older pill methods, but nothing worked.

And after jumping through hoops with his insurance company, he was finally able to get back on the drug from the trial.

It was expensive, but between insurance and a coupon, the cost was manageable.

That changed when insurance stopped covering the drug altogether.

Mike had to stop taking it and once again he gained the weight back.

After more visits to the doctor and a diagnosis of not processing glucose normally, Mike's doctor prescribed him Ozempic.

The medication took him out of the pre-diabetic stage and helped him lose 45 pounds.

His doctor then changed his prescription to Mounjaro, and here's what he told our team.

Quote.

This truly helped change things in my life.

I have dropped overall about 80 pounds and I'm doing well.

I am still losing weight slowly, but my blood work is all great and I am not near the highest dose.

The doctor is pretty happy and wants to keep me on it for now, and I've been on it for about a year.

End quote.

Now he says there are side effects, but he thinks they're manageable.

He also said he thinks there is an education in lifestyle component to this conversation.

He says just taking the drug without some diet or lifestyle change isn't the way to go, but for some it may help them get there.

And he says he doesn't advocate using this to drop a few pounds for a wedding, or because you want to look like one of the actresses and actors that are twigs.

He says it should be balanced.

Well, my story is one of millions right now.

According to Emily Oster, writing for The Atlantic last week.

As of last year, an estimated 15 million adults were taking GLP-1 drugs for weight loss.

Some people call them miracle drugs, other call them a public health concern.

In addition to their effectiveness, there are also conversations happening about the cost.

Medicaid doesn't cover the drugs, making them inaccessible to many people.

A month's worth of ozempic can run up to $1,000 without insurance, and in her Atlantic piece, Oster argues that if more people could access the drugs, it could reduce downstream health care costs in the long run.

So this hour, we're talking about the latest with these medications, what they treat, how they work, what we should know about them, who has access to them now, who should be able to have access.

And our guests kind of work in a lot of different areas here.

We'll go around the table, starting with Dr.

Casey Shavon, who is assistant professor in the Department of Surgery, bariatric GI at the University of Rochester Medical Center.

Dr.

Shavon, thank you for being with us here.

>> Thank you for having me.

>> And next to Dr.

Shavon is Molly Ranney, who is lead dietitian for the Bariatric Center at Highland Hospital.

Thank you for being here.

Across the table is Dr.

Zachary Burns, assistant professor of family medicine at the University of Rochester Medical Center and associate director of moving medicine Forward.

Nice to have you.

Thanks for being here.

>> Nice to be with you.

>> And Erica Davis is with us, a patient who uses weight loss medication.

Eric is a theater professional, an educator, and a mom.

Welcome.

Thanks for being with us.

Thank you.

Evan.

So a lot of different places to go here.

And I want to start with just a few questions for the professionals who are probably encountering this a lot more now with how popular these are.

And we'll kind of go around the table here.

So, Dr.

Shavon, what's the change you've seen in maybe the last two, three, five years on this?

How popular are these?

>> Sure.

And these medications are very popular in our office.

So not only do I do bariatric surgery, but I do general surgery.

And a lot of our general surgery patients who are coming in looking for surgery on other aspects of their body are on the GLP-1 for weight loss.

And, you know, you have to have a couple different considerations when you're doing surgery on a patient, on these medications.

But we're very familiar with it.

It's something that we deal with every day, all day.

>> Okay.

Same question for Molly Ranney.

How often are you seeing patients?

People come in with questions about this.

>> So we see obviously patients for weight loss surgery and for patients often now more more often I'm seeing them coming in preoperatively attempting to lose weight prior to having surgery.

And then if they have weight recurrence after surgery, always the opportunity to add another tool to help support them in their lifelong process of of overall health.

So I think it's something we're definitely seeing the increase of and will continue to see.

>> What about you, Dr.

Burns?

>> We see a lot of GLP-1s.

for those unfamiliar, this is the class of medications that some examples are ozempic Wegovy Mounjaro.

So they have proliferated.

It's part of the reason we're having this conversation right now.

The public wants to know what's going on.

They're on TV, they're on billboards.

I prescribe them, I prescribe them as a primary care physician.

and yet I have some concerns, and I come from the lifestyle medicine perspective.

And we could get into that if you'd like.

But I don't think that GLP-1s will solve our chronic disease problem.

>> Okay.

So before I get to Erica's story, let me just hit a couple of other points here.

Dr.

Burns, do you want to describe a little bit for the audience?

The not going too technical, but in general how GLP-1 actually work in regards to the purpose or the goal that some patients have of weight loss?

>> Sure, they essentially make you less hungry, so they suppress your appetite.

Sometimes at the cost of feeling queasy for the duration that you're on the medication.

Hopefully, you know, in other cases, the symptoms subside and you feel okay.

there's a whole range of side effects, some short term, some longer term some reversible, some maybe not.

But yeah, hopefully people feel okay on them and they meet their goals of losing weight.

But it's essentially an appetite suppressant.

And that's why in the manufacturers, the first ones to admit when you go off the medication, often the weight rebounds predictably.

>> Because your appetite comes.

>> Back, comes right.

>> Back.

When people are on them.

Is there a general calorie range that they're in on the day?

I mean, I know calories are not a perfect number.

and this is not my expertise, but I think what I'm asking, what I'm wondering, doctor, is if I came to you and said, okay, I was thinking about I don't think Ozempic is actually qualified as a as for weight loss, is that correct?

Mounjaro is,, is Ozempic now.

>> So, yeah.

Wegovy and Zepbound are the ones that are officially for weight loss.

Okay.

They're the same.

The same compounds as the other ones that are for diabetes.

>> So I come to you and I say I'm thinking about Glp1.

I know some people like my friend Mike, and this has gone well for him, but what happens when my appetite suppress?

How many calories am I getting?

Or how much food am I actually going to eat?

Is there a concern about eating too little?

What do you what do you say to that?

>> Yeah, so it really it depends on your baseline consumption.

the average American is consuming around 3000 calories a day.

it's why today, obesity rate is 42.5% of the American populace has obesity with BMI 30 plus severe obesity, 40 plus has doubled since 2000.

So it comes down to it's sort of the laws of physics.

We're consuming more energy than we're putting out.

And so in the first few months when you ramp up on a GLP-1, often you're at a calorie deficit could approach 1000 calories.

but then that starts to plateau.

So you end up the appetite suppressant effect.

at some point it wears off a little bit and you might consume more calories.

And so that deficit decreases.

And that's part of the reason that people reach a plateau in the weight loss.

You don't lose weight indefinitely or you wouldn't want to.

You'd go down to nothing.

but you also in most cases, if you start with a BMI of 40, you might plateau.

Your BMI is 35, and that's still in the obese range with a host of of risks.

>> So what are the risks?

What are you concerned about with these?

As you said, you are prescribing them, right.

>> I do okay.

>> So what are you concerned about.

>> So and this is the way I counsel my patients because they often come to me, they say, let's talk about glp1.

I saw an ad for Ozempic and I say, all right, here we go.

We're going to need I'm going to be late for my next visit.

But but this is an important conversation I'd like to have it.

So you know, the first thing is we want to get a sense of what theyve done.

what what else have they tried?

What's their journey?

experiencing physically?

Emotionally, with weight.

Because people have a whole relationship with their weight, with any complications and with food.

But you're more asked, you know, so we get through that, you more ask about the counseling on.

All right.

We're starting this thing.

What are the risks?

the risks include gastrointestinal side effects.

So queasiness, nausea, vomiting, diarrhea, bloating.

hopefully those symptoms subside and go away.

They don't always.

Especially when you ramp up to the next dose.

People are like, oh, you know, the first few days after a dose, you can be really uncomfortable.

it's a delays gastric emptying.

And so the stomach, there's more contents in there.

That's part of the way it suppresses your appetite.

And that can lead to gastroparesis.

Gastro stop.

And if that becomes irreversible then, you know, basically you stop the GLP-1.

And after many months, you still have gastroparesis.

It's happening more and more, and then the surgeons have to go in and open up your pylorus at the bottom of the stomach and wrench things open.

so that.

>> Food can is.

>> That exit.?

>> Gastroparesis is a side effect of the GLP-1 is relatively common.

It being.

>> Seen in like 10%, 50%, 3%, 1%.

>> I'm under the impression it's the 10 to 15%.

>> Okay.

That's I mean that's a lot.

Yeah okay.

>> It's what also adds to the nausea that a lot of patients experience when they're on the medications.

There's some low level gastroparesis happening.

Typically it being severe and permanent enough to lead to surgery.

Relatively uncommon.

But it happens okay.

>> Yeah okay.

Continue.

>> So then with the weight loss which does happen at least at first you have increased risk of gallstones okay.

So so sometimes you get pain from coming from your gallbladder.

You have to get your gallbladder surgically removed.

>> We do a lot of gallbladders on patients who are on GLP-1 medications.

>> So and Dr.

Kaci Schiavone will do this, you know, like with their eyes closed and I mean, meaning that you see, you do a ton of these.

I'm sure.

and it's a common procedure, but there's still inherent risks.

But anytime there's surgery.

Right.

And, and then, you know, you also with those gallstones that could lead to pancreatitis, which is another side effect of these GLP-1 medications.

Then you have with that weight loss.

Unfortunately, not all of it is is adipose or fat.

So you have lean muscle loss and different studies have showed a range.

Some people lose up to 40% of the weight lost is lean muscle.

And other studies it showed more like 15%.

But either way you're losing muscle and you have to be very proactive to maintain it with with your weight bearing exercise.

Another thing is like, you before surgery, right?

It increases your risk of aspiration because there's more food in the stomach.

And so you have to be careful and stop the medication a week at least before any surgery.

It can affect the absorption of different medications like birth control pills.

and so you have to be careful there.

Meanwhile.

>> Actually a black box warning on the medications.

>> That you should not.

>> Be.

>> Taking them if you are planning to become pregnant.

>> Okay.

And meanwhile right, because we don't have any safety data around these medications in pregnancy.

So not only do they decrease the efficacy of birth control pills, but you don't want to get pregnant on these and the list goes on.

there's retinopathy, you know, so there there are several things.

And usually after thorough and compassionate discussion with a patient, they actually understand for the first time these risks because they didn't really process it.

And the, you know, the fine print on the TV ad, they say.

maybe I'll take you up on the referral to the Highland lifestyle medicine department or the Rochester Lifestyle Medicine Institute.

>> Okay, so there's some of the background I want to understand Erica's story because everyone's story is is their own.

Not every story is the same, but there are a lot of stories, I think, like Erica's out there where people are experiencing some.

Well, I'm going to let you characterize.

Why don't you take us back to what led you on this path?

>> Sure.

well, I have struggled with my weight my whole life, and meeting me, you might not think that I think I present as a pretty, you know, kind of a normal, normal weight, but I've, I fluctuated, I would say the last 20 years, anywhere from about 180 to about 220 is pretty much my norm now.

I'm 510, so I carry that pretty well.

So even when I'm heavier and I don't really like to talk numbers, but I figured I'm here, so I'll just throw it all on the table.

You know, there's there's no day like today to just, you know, throw it all out there.

So I those are the numbers that I pretty much fluctuate it.

And it had a pretty, you know, I live a healthy lifestyle, I eat healthy, I'm pretty active.

but I've always really struggled to keep my weight down.

and when I have been, say, under 200 as an adult, that's really I've had to really work actively to keep those numbers where they are.

And as I was preparing for today, I put together a little sort of like photo montage I put together in my in my phone.

I went through, you know, the last 20 years and, you know, the very, you know, the, the ups and the downs.

And I would say in any given year, I would go from that like one, 80, one, 90 place to like the 220 place to maybe a little higher at the holidays.

And it would go up and down maybe 2 or 3 times throughout the year.

And that's about how often I have a full wardrobe of clothes.

And I go back and forth, you know, and I think a lot more women go through this than, than people realize and you can see throughout the years and in the family pictures and my children stay the same, and the Christmas tree stays the same, but my weight goes up and down, even to the fact where, you know, you can see certain holidays, certain vacations even as I was thinking about, you know, my journey with weight loss, I realized that I was essentially starving myself to meet with my doctor.

I would go on a crash diet every time I had a physical coming up, because I was so embarrassed to go into my doctor's office and admit that I had gained weight.

he was an old family friend.

He knew my parents, and the thought of going in and registering as obese on his on his scale was just mortifying to me.

so that's sort of, you know, the background of, of and that's, that's been my whole life.

That's, you know, I remember this at 14 years old.

This is just sort of been how it's been.

Now I'm 44 and, you know, there just sort of comes a point where you go, I give up, I surrender, you know, and I always knew that, you know, my whole family is, you know, we all have, you know, we go up, we go down, we like our cookies, you know but.

I knew menopause was going to come.

I knew my hormones were going to change.

I knew at some point I wasn't going to be able to crash diet and get back to looking great.

You know, if I if I cut out carbs for a week, I could fit into that dress to go to a friend's wedding or you know, look good in a bathing suit on vacation with my kids.

and then about a year ago, I, you know, sort of said, you know, it's time to to balance this out.

And I, I started really buckling down and I really was eating healthy and I was exercising.

I was doing everything I was supposed to do, but the weight wouldn't come off and it just wouldn't budge and it wouldn't budge.

And I started to get really disheartened.

so all these, all these ads were coming out for all of the, you know, the all of the wonderful prescriptions that that we're talking about today.

And I was really, really against it.

And some of my girlfriends had started taking them, and they were losing a tremendous amount of weight.

I was so jealous, and I was so bitter.

And I was sitting there going, not me, not me, not me.

I'm not going to do it.

So I doubled down on myself.

I said, I'm going to lose this much weight by this point in time, and I'm going to look fantastic.

And I tried and I tried and I tried and I didn't.

And now some of my other girlfriends have started taking these pills, and now they're looking great and everybody's looking great.

And I'm sitting here and I'm going, I look, I don't look the way that I want to look.

I'm trying so hard.

I feel terrible about myself.

and then finally, I just got to the point where I said, you know what?

I want to enjoy what I'm doing.

I'm working hard.

I'm eating healthy.

I want to enjoy food.

I don't want to feel this guilt all the time.

And I really wasn't.

I wasn't overindulging, I wasn't doing anything wrong.

I just wanted a little bit of help.

so one night I just decided to to give it a try.

it was very difficult for me to come to terms with, with ordering the pills.

and I did order them online.

I did not go through my doctor.

and that was because when I finally made the.

Excuse me, this decision, it was at 2 a.m.

It was in the middle of the night, sitting on my patio, crying by myself and having one of those come to Jesus moments where you just go, hey, universe, I give up and I need to try something different, and I need to try something better for myself.

And the hardest part in all of this was the next day when I felt this tremendous sense of obligation to explain to my teenage daughters that I was going to be taking this journey with these pills because they're influential.

You know, I mean, it's a very it's a it's a very delicate situation to be in as a parent.

especially with teenage girls at home.

and I take I take that position very seriously.

And I didn't want to I didn't want for it to come across as seeming haphazard, that I had just jumped into the decision to take these pills.

and they were incredibly supportive.

And we, you know, wonderful.

I mean, I couldn't have asked for a better response from them, but it was it was very, very difficult to to get to that point.

with them.

And even when the pills did come in the mail, it still took me two weeks to finally decide to start taking them.

They sat in my linen closet for two weeks while I really thought again, long and hard about is this something that I need to do?

Can I do this on my own?

And finally I realized I needed I needed some help, and I'm really glad I did because it really has changed my life.

>> So we're going to go back to your process in a moment here, because I think some listeners are hearing this going like, wait a second, I thought there was we're talking about prescriptions, and now you're talking about ordering on the internet, and it's a whole different world before we even get there.

In general, any side effects for you when you started taking them?

>> Yes.

extreme nausea for about two weeks.

my joints hurt.

I felt very frail.

That's that's almost the best word I can describe it.

My my bones, my muscles, everything about me.

And maybe it was because I was losing weight rather quickly in the beginning.

not, I believe, because of the nausea.

I was extremely nauseous.

It was similar to morning sickness.

about a month.

it took my body to adjust to all of it.

>> And did you think about scrapping it at any point because of the side effects?

>> Not for a second.

>> Okay.

All right.

and once you got past those side effects, any ongoing side effects now?

>> No, no, I feel great.

After about a month, I feel fantastic.

>> Okay.

How long have you been taking them now?

>> Three and a half months.

>> Three and a half months.

what has been the result for you in terms of weight loss?

>> 23.3 pounds.

>> Okay.

>> So far.

>> and how do you feel?

>> Physically excellent.

>> All right.

>> Excellent.

Sleeping better.

Moving better.

>> just feeling better in my skin.

feeling.

Feeling like I move better.

My body.

there there was a moment when I had lost a little bit of weight.

Not a whole lot.

Maybe.

Maybe five, five, 8 pounds, something like that.

But I looked in the mirror and it was just something simple, like my jawline.

Something looked a little different about my face, and it was like I could see myself again.

And that moment when I could see myself again was so motivating.

And it really turned the corner for me.

And it went from being, hey, this was where I was to, this is where I'm going.

And that just kept everything.

You know, it's the momentum.

It's great.

>> So you said you're an active person.

Berry.

Okay, so do you have are you getting enough food to feel like you can do the activity that you want to do?

>> Oh, sure.

Sure.

>> Absolutely.

I mean, it's a lot of work and it's a lot of meal prep and it's a lot of planning.

>> You have to make yourself eat.

Are you hungry?

Do you get hungry?

>> You know, I don't get nearly as hungry as I used to.

And I find that I eat I eat much later in the day than I used to.

I do, I get up, I have coffee, I have a lot of water.

I drink a lot of lemon water.

I probably don't really start eating until about two in the afternoon.

That's something I have noticed about this, is that I don't get hungry until later in the day.

And.

And when I do, I eat about a third as much as I used to.

And then my body just says, I'm done, I'm good.

And I just stop.

>> Okay.

Are you planning to do this long term?

Now?

>> I'm planning to do this indefinitely.

>> Indefinitely?

Because, I mean, that's kind of the conversation.

It's like you start this and we've heard the stories of what happens if you stop it.

So this is I hate to use the word forever.

Nothing is forever.

But for you.

And your mind is kind of forever.

>> I would have no problem with that.

>> Okay.

>> Yeah, I take other medications forever.

I mean, I take thyroid medicine for forever and blood pressure medicine for forever.

Why not this too?

>> Okay, so back it up here.

So you decided at that low moment at 2 a.m.

that you were tired of feeling the way you did.

You were at that breaking point and you decided I'm ordering them.

Yep.

Was it hard to find them?

No.

Okay.

>> Not at all.

>> and it was it legal to find them?

>> Absolutely.

>> Yeah.

I don't think you're on here talking about breaking the law.

No.

Good, good.

Okay.

I'm really glad.

Yeah.

but when it comes to the process, you could have taken, why not talk to a doctor first?

>> Well, frankly, I would have had to pay an exorbitant copay just to get in, to see my doctor, to have the discussion, to order the pills.

So I might as well have just done it myself online.

>> Okay.

How has your relationship been like with the medical community about your weight?

>> Embarrassing.

>> In what way?

>> I have, when I have been heavy.

when I have been textbook obese, I have never had a doctor look at me and actually tell me that they always skirt around the topic topic.

They don't want to discuss my weight.

They don't want to say, you know, I've had doctors say to me, yeah, yeah, you could you could lose a couple of pounds you know, but you're a beautiful girl, or you carry it well, or, you know, you'll lose it next year or I know that, you know, I know you're working on it.

nobody has ever said, hey, hey, for your health, you probably should.

Should lose 40 pounds.

And I think it would be best for your heart and best for your cholesterol if you, you know, cut out the sweets and cut down on the red meat.

>> But isn't there a difference between a patient who definitely needs to, for their own health of maybe addressing it, versus some who maybe carry a few extra pounds?

Well, I'm not the doctor here, everybody.

And I'm not defending your doctors.

It sounds to me like you wanted bluntness.

>> Absolutely.

>> And you didn't get it.

>> Absolutely.

>> Because the way I see it is my entire life I've carried enough extra weight that I believe in the long term is going to affect my health.

And I would have appreciated if, if maybe somebody had been a little bit more stern with me early on.

>> Would you would you have been in a situation where you got a GLP-1 through a physician?

If you had a better relationship with the medical community before the last few months?

>> Yes.

>> Do you think so?

>> Yes.

>> Okay.

and I guess you're paying for the drug now.

>> Yes.

>> Out of pocket?

>> Yes.

>> Not covered by anything?

>> No.

>> Pretty expensive.

>> Not nearly as expensive as as I thought it would be.

I paid $900 for a six month supply.

>> 900 for six months.

Okay, can I ask which one.

>> I use?

The hers website.

>> Okay.

All right.

So that's a bit of Erica's story.

I want to kind of go back around the table here.

And Dr.

Burns, I'll start with you.

So I want to ask you if you think that I mean, you haven't been in the room with her doctors, but she hasn't had a good relationship with her medical providers over the years about her weight.

and that has not probably been good for her mental health.

That hasn't been good for, you know, the kind of trust that happens.

Are you worried about that?

you know, a disconnect between people who are struggling with issues like weight and the medical community trying to address that appropriately?

>> Definitely.

Yeah.

First of all, I just appreciate your courage in being here and opening up about your story, because not a lot of people would do that.

So that's great and gives us insights into the patient experience.

>> Well, thank you.

>> So yes.

I am concerned when people can't they don't feel comfortable coming to us and spilling the beans.

And so every, every visit, every gesture is sort of in the spirit of, making someone comfortable so they can open up.

And it's a beautiful part of our work.

now it's first of all, it's just inherently awkward to broach the subject of weight.

And so I think that's why a lot in the medical community, we don't necessarily bring it up.

We think we're going to offend somebody or that it'll be it'll disrupt our cherished patient doctor relationship.

there are also, you know, in my residency program, which was not here, there was a massive de-emphasis on weight and bring in speakers to tell us that weight made no, no impact on health.

>> Healthy at any size.

>> All right.

So this sort of movement, I think it comes from a good place.

>> But do you think that's wrong?

>> Yes.

>> Okay.

>> I think.

>> That's a direct answer.

>> I think that it comes from a good place.

We larger people have been discouraged by health care system.

It's it's really terrible.

we need to make them feel welcome and comfortable participating in health care.

And also just societally, we do not want anyone to feel ashamed.

that said, we have to be real in the exam room about the risks associated with having extra weight.

And I found, I mean, echoing Erika's sentiment, my patients typically enjoy when I'm direct, they don't want you to dance around stuff.

So yeah, they want to talk about it.

And what I try to do is ask permission.

I say, would it be all right if we talk about your weight?

And then they could say, no, in all respect that.

and if they say yes, it's like they've kind of given me the green light to get into it.

And almost everybody says yes.

And then.

Yeah.

And then, you know, we can we can talk.

And they're relieved to be having that conversation because it, you know, it.

There's a lot of angst about it at home.

It can be really troubling.

to be obese to struggle with your relationship with food.

And so you want the opportunity to, to make a plan with your doctor.

>> So let's go around the table here.

Molly Ranney.

What do you make of some of Erica's story?

>> I, again, am very appreciative for you sharing what you've shared.

And I hear it all the time, not only in the work that I do at Highland, but just in conversations with people that, you know, I'm friends with or family.

And I think it's unfortunate that we again, look at people based on weight and size.

And I know at our center we really want people to come with us and understand this is a collaborative effort.

We are going to help you move through a process of improving your health, whether that is weight loss medication, whether that is having a surgery that will get you farther down the road.

As far as overall health we're in the process of working to have a medical bariatrician.

We've been approved for the position, so we are going to be expanding our offerings to people so that we have people that will come to us and really have someone, you know, that's part of their team to help them.

>> Okay.

And Dr.

Shavonn, you want to weigh in on the story as well?

>> Yeah, I think, Erica, unfortunately, it's a story that we hear a lot of, like Molly mentioned and a lot of it revolves around stigma.

Right?

Patients feel that stigma because there's a lot of shame when you've struggled with your weight from societal pressures, your own internal pressures.

There's a lot of stigma coming from providers, right?

Many times we've documented that even providers who work with those who suffer from obesity treat those with obesity slightly different than those who don't suffer from obesity.

Whether it's internalized stigma is, you know, plenty of research has gone into this.

So there's stigma from both sides.

And people are in my office to talk about their weight.

And not everybody wants to talk about their weight.

Right.

It's still hard to kind of broach that subject with all patients.

And the only thing we can do is sort of reduce that stigma so that people feel comfortable coming to us.

Right?

Because as you described, you even felt some sort of stigma even reaching out for the medications.

Right?

There's a lot of this conversation where, oh, it's taking the easy way out, which is so inaccurate.

>> Oh yeah, definitely.

It was, it was I was so embarrassed at the thought of even going.

And it was like, I would have wanted to wear a disguise to go into the doctors to, to ask for the medication.

I mean.

>> Yeah, exactly.

>> Yeah, absolutely.

>> And the things that we're doing in our office and Molly can attest to this is we use inclusive language and we make the environment comfortable for people to be able to open up and talk about all of the good and the bad and the ugly with us.

>> So and let me also just say, observationally, I don't have any of your expertise.

The only thing that I do is talk to people, observe how people communicate and form beliefs, and share information with each other.

And one of the things that has been interesting to me over the last, well, I don't I don't know when the ozempic's really hit the scene.

I don't know if it's five years ago, it's probably longer, but they've really taken, you know, taken off in the last few years.

And I've had a lot of physicians privately, medical professionals privately over the years say to me, I can't say this on the air, but I'm not all that comfortable with the healthy at any size movement, with the idea that, you know, every every weight, every size is equally healthy and okay.

And so when you say Dr.

Kaci Schiavone that it can be really hard to talk about this subject, like my response is twofold.

It's like, yes.

And then it's like, not as hard.

It shouldn't be to, you know, to the point that Dr.

Berns was making, most of the patients you ask when you say, is it okay if we talk about your weight?

You said most of them say yes.

Correct.

Okay.

Maybe more than you would have expected.

You know, back in residency, it's like people will say yes.

And I'm kind of with Erika, it's like, no, I need you to talk about my way to that moment.

Like, I want you to talk like I don't.

This is not me out at a restaurant like, this is me with the medical.

I want you to talk about this.

I need you to tell me.

>> I would have welcomed it at any point in time.

And frankly, it's it's probably in the top five of my, you know, most sensitive topics that I would want to talk to.

Number one, I would want to connect with my doctor on it.

And number two, it's it's going to help me with my mental health.

It's going to help me with my self-care.

You know what I mean?

So it would it would benefit me tremendously to talk to my doctor about that.

>> Yeah.

So go ahead, Dr.

Berns.

>> So because as a medical community, we tend not to talk about it because we're squeamish or whatever, or we've been told not to talk about it or we have this perception that patients don't don't care.

They haven't noticed that their BMI is 45. then we what we what happens is the only option for weight loss that patients seem to be aware of is like going on a GLP-1 because they're inundated by the advertising.

in the year 2024, the three drugs Wegovy, zepbound and ozempic, there are half a trillion, half $1 billion rather of advertising just in one year for three medications.

So you wonder, like, well, if these things are so good, why do they have to advertise so much?

like maybe like doctors would just recommend them on their own?

No.

Not necessarily.

because there's some issues and there's some alternatives.

so they rely on advertising for people for the, for the public to be really fixated on this and feel like they need to be on one.

and so, you know, there is an alternative.

I just want to make sure I mention this lifestyle medicine talks about the basics, and it's not controversial stuff.

Eat your fruits and veggies, take some walks.

reduce stress, sleep adequately.

Right.

And it sounds silly, but it's like this is actually the center of human health.

it's lifestyle medicine.

And there's a huge international movement that is getting us back to that.

the American College of Lifestyle Medicine is kind of the hub, and here in Rochester we have the lifestyle medicine department at Highland.

So they sit down with people 90 minute intake.

They make a comprehensive plan around these different pillars diet, physical activity, et cetera.

and then in the community, the Rochester Lifestyle Medicine Institute, they do a two week jumpstart.

And what are these organizations have in common that I mentioned?

It's evidence based nutrition.

So it comes down to whole plant foods.

Sometimes we call it whole food plant based.

it is we just have mountains of evidence that it can prevent.

And also reverse the vast majority of human chronic disease including stuff that we didn't think could be reverse.

So helping people stay in remission from prostate cancer or reverse their advanced coronary artery disease that leads to heart attacks or reversing type two diabetes.

That's another question I ask my patients who come to me from someone else and they have type two, or, you know, I check their sugar level and it's a new diagnosis of type two diabetes.

I asked for my own mental charting.

I say, has anyone ever told you that type two diabetes is reversible?

Invariably they say, no.

No one's ever told them that.

But even the American Diabetes Association has criteria for remission.

So if you go back to a normal sugar level for three months off medication, you don't have type two diabetes anymore, you're in clinical remission.

And everyone deserves to have that option presented to them.

and most people who are granted that option, they say, yeah, tell me how this works.

>> Okay.

But before we were really late for a break, they're going to start yelling at me in a moment.

And I've got a lot of listener feedback to share.

But just briefly, Dr.

Burns, if I take what you're saying on on all of those points, but then the logical question I have then is, why are you prescribing anybody with Glp1 after, you know, the great presentation you just made for Whole Foods plant based?

>> Sure.

Yeah.

Thanks for giving me that chance, because I realize it could be confusing.

So I prescribed GLP-1s because I think they're appropriate in some cases.

For some people.

And I don't want to be a gatekeeper.

And so I give them the options.

I make sure that they understand the lifestyle approach with adequate, you know, I make sure they understand all the side effects, not just paying lip service to a couple of them.

We talk thoroughly about the risks, benefits and alternatives, which you're supposed to do before making any medical decision.

and at that point, if they'd like to proceed with the GLP-1 and they meet criteria, then we roll with it and we consider it harm reduction.

So I have plenty of people in that situation.

I think it can be appropriate as an interim solution.

While we're aggressively working on lifestyle changes to both mitigate side effects and keep them in a healthy place when often their employer based health insurance or whatever, whoever's covering the GLP-1 changes their mind and they show up at the pharmacy counter and they feel like they're back at square one.

So we got to build sustainable lifestyle habits to keep the weight off.

>> So does that convince you you're going to get rid of the GLP-1s and go whole food plant based?

>> Nope.

>> Maybe after the break I can provide the counterargument.

>> Okay, all right, let's do this.

Let's get our only break.

We're very late here.

>> We're talking to Dr.

Zachary Burns who is a professor of family medicine at the University of Rochester Medical Center and associate director of moving medicine forward.

next to Dr.

Burns is Erica Davis, who is sharing her personal story.

And across the table, Dr.

Kaci Schiavone, who's a professor in the Department of Surgery, bariatric GI at the University of Rochester Medical Center, and Molly Ranney, who is the lead dietitian for Bariatric Center at Highland Hospital.

We'll come right back.

More on Connections in a moment.

Coming up in our second hour, the team from Open Door Mission joins us.

They have a different view on what is working and what is not working in dealing with homelessness.

I say different because many people in that space in Rochester talk about housing first, talk about different strategies and open door missions has a lot of this is just not working.

And it's time to say so out loud.

They're going to talk about their views on what to do about all of this next hour.

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>> This is Connections.

I'm Evan Dawson okay doctor Siobhan, the floor is yours here.

Go ahead.

>> Thank you.

So lifestyle changes, diet and exercise are obviously one of the pillars of weight management that we offer in our clinic.

However, we have decades of research that show that just lifestyle management isn't enough to continue to lose weight.

Right?

If that was it, then I wouldn't have a job and I very much do.

So I think one of the really interesting examples of that is the show The Biggest Loser, which I think all of us are familiar with.

It was on NBC, was a competition show basically with diet and exercise, seeing who could lose the most amount.

>> Of weight.

>> Starvation.

And it was that was extreme.

>> Yes, it was extreme diet and exercise.

So there was one really amazing paper that followed a season of those contestants for 16 years after the show, and they found that all of them regained all of their weight, despite following the strict diet and exercise plan that they had developed on the show.

So even though they were doing everything, right, they still regained all of that weight.

And when they went and they did some evaluations of their BMI and their fat percentage and their metabolic rate, they found that their metabolic rate actually had decreased throughout time with that strict diet and exercise, which meant it was harder for them every year to continue to lose weight and to continue to maintain that weight loss.

So we know that just diet and exercise isn't enough.

We know that obesity is a hormonal and a genetic disease, not just a disease of lack of willpower, which I think is a lot of where that stigma comes from.

Right?

This is not just lazy eating.

>> Okay.

Is that fair?

By the way, Dr.

Burns, do you agree with that?

>> I, I would say that diet and lifestyle can absolutely be enough.

we have not as a medical community, we've not adequately, educated the public.

on these themes.

There's so much to it.

It involves, you know, a ton of follow up.

and support and just we have public health.

We have not invested enough in lifestyle medicine.

And we really need to given the health issues that we're facing.

>> So you're saying with a bigger sample size, more, more study, you think it would bear out that what you're describing would be sufficient?

>> Yeah.

There are plenty of lifestyle studies that do show.

>> What about genetic markers for obesity?

What about some of what your colleague across the table is talking about?

>> Yeah, obesity is multifactorial.

There are some genetic predispositions for all of these chronic diseases.

It's just that the environment plays an infinitely larger role in this issue.

And the elephant in the room is, is, is our we are in an obesogenic environment.

So we have billboards for Chick-fil-A, we have all this junk everywhere and fast food everywhere.

you know, the ads you might see, it might be a consecutive advertisement for Taco Bell and then Ozempic and then McDonald's and then Mounjaro.

these are these are it's big money.

so that's that's what we have.

That's like our exposure.

And we need to address that.

Just like in the 90s, we did with tobacco.

The public health community said this is actually enough.

The suffering and the the actual costs inflicted on the health care system are enough.

We got to do something about this.

>> So let me ask you, your colleagues, if they want to respond to go ahead.

Yeah.

If you both want to jump in here.

>> Well.

>> One of the things that I think is a challenge for, for everyone out there is that we are bombarded by nutritional opinions left and right.

Eat this, don't eat that, eliminate this food group.

And I know one of the things that we focus in on our center is eating whole foods, like moving away from processed foods, getting in adequate protein, getting in enough fiber, moving your body more.

We are up against a very seductive food environment and it is very difficult, I think, for people to follow through on the foundation of what we're discussing at the table.

And some people don't have, you know, affordability is a is a piece of that puzzle.

Accessibility is a piece of that puzzle.

So I know in our center, when I'm working with people, I try to distill down, let's keep it simple, you know, let's work together with what you're consuming.

Let's make these changes in a process.

Regardless of what way you go, whether you have surgery or you take a weight loss medication, it is a win, right?

Nutrition movement is going to be a win for everyone.

But I think we have a lot working against us and our patients as far as their ability to follow through with just moving more and adjusting what they're eating.

>> Can you want to add Dr.

Chevelle?

>> I would agree that diet and exercise lifestyle is critically important, and I like to at least tell our patients that it's one tool that we have in our toolkit.

It's not the only tool.

>> let me also, before I get some feedback here from the audience Excel has sent us a note this morning just wanting to say that there was some confusion in September centered around whether or not we are covering GLP-1 in 2026, Excel says GLP-1 are used to treat certain medical conditions like diabetes, and they are still covered.

Three GLP-1 for weight loss Wegovy, Zepbound and Saxenda can still be covered through an exception request from the member's provider, as long as the prescriber can verify that the member meets our coverage criteria.

And so it goes on to say our coverage guidelines ensure that members who would benefit the most can access these drugs while receiving vital nutrition and fitness education, as well as support from their provider.

and the ongoing debate at the federal level is, you know, how much should GLP-1 be covered?

Emily Oster writes this piece in The Atlantic last week, basically saying it is going to be expensive and the federal government should cover them because of the downstream effects.

because of the way that they will reduce health care costs outside of the immediate need for GLP-1.

>> There's.

>> A statistic you're nodding.

You agree with that?

>> Agree.

There is a statistic that persons who suffer from obesity will experience a 34% increase in their cost of medical care.

So obesity itself is expensive.

Treating obesity is cheaper than dealing with the repercussions and the ramifications of obesity.

>> So you agree that the federal government should be willing to put some money forth upfront, saying that the downstream effects are going to be worth it.

>> As somebody who treats obesity, yes, I think that the GOP ones are another tool that we have in our toolkit for the right person.

>> Dr.

Burns, should the federal government be covering GLP-1, should Medicaid cover it?

>> I actually think so, because I don't want people to not have access to GLP-1 just because they have a lesser insurance policy.

and at the same time, if we're going to do that, which will increase national health expenditures by so much, you know, Emily Oster's article, it's a little speculative.

We don't know exactly how much it will save and if there will be some savings from chronic disease complications, maybe.

But either way, it's going to be an astronomical increase in our national health spending, which is already more than any other country in the world spends by far.

on health care.

We're not doing too great, right?

For the chronic disease perspective.

And so if we're going to cover more GLP-1s, we should aggressively invest at the same time in public health, pull the junk food advertising from TV, pull the pharma advertising, to be honest, because it's just inappropriate.

There are only two countries in the world that allow direct to consumer advertising of drugs.

And and, and let's educate the next generation of doctors.

to, to to bring nutrition and lifestyle into the exam room instead of dancing around it or just not really having learned so they don't feel comfortable providing that counseling.

So that's in my nonprofit, Moving Medicine Forward.

That's exactly what we do.

We we reach med students and residents around the country to make sure that because it's not in their curriculum, just learning about food as medicine.

So we get it in and they find it really inspiring.

>> Okay a little bit more feedback.

Here.

Some questions on addiction.

And I think it was Molly Ranney lead dietitian for the Bariatric Center at Highland Hospital.

You might want to jump in on this point.

People are asking whether GLP-1 also have an effect outside of just obesity.

What do you want them to know?

>> In my experience, the patients that are taking them have said to me, you know, first and foremost, the food noise disappears.

And I don't know that people who haven't had the experience of dealing with the food noise to the to how impactful that is on on their life.

So when people say to me, you know what, I don't I don't have this constant chitter chatter of what I should be eating or the struggle about maybe not eating something and how freeing that is for patients.

It allows them to then execute execute the meal plan that we're discussing and doing more movement.

so some of the other side effects that I've seen are what patients have just told me is alcohol consumption goes down.

they're not shopping as much.

maybe, you know, people who like to gamble aren't gambling as much.

So there's an overall impact on the addictive behavior.

And we have to remember that food is highly addictive.

>> And briefly, alcohol consumption for you, can I ask?

>> Yeah, absolutely.

>> once I started taking the the pills I noticed a tremendous decrease in my desire to drink alcohol at all.

I really went from being like somebody who would drink maybe a glass or two of wine a day to not craving it at all and not even really enjoying it anymore.

So it really it was great because it was just less calories I was consuming and more weight that was coming off.

So it was a win-win.

>> I real quick here, keep going with your comments.

Greg wants to know he heard gallbladder issues are common for people who use new weight loss meds.

Is that true?

Gallbladder issues?

>> Very true.

So any sort of rapid weight loss is going to increase the amount of gallstones that you have, or have you developed them for the first time.

It can lead to problems where you're just having right upper quadrant pain to like Dr.

Byrnes mentioned, having issues downstream where you're developing pancreatitis.

For that, we typically recommend having your gallbladder taken out, which is another surgery.

>> Jamie writes in to say it was not difficult for me to access the medication at all.

My endocrinologist prescribed it.

They were looking to get my glucose levels down to a more steady range, and at first started me on Ozempic.

There was not much of a change, so I switched to Mounjaro.

Since I see my endocrinologist every three months, they notice my a1-c dropping and my glucose readings were in the normal range.

Over the course of a year, we've increased my dosage from 0.2 5 to 1.25, and I have lost 57 pounds.

so it says so far, so good for Jamie.

I mean, a lot of people are sharing stories like that, and we appreciate hearing from listeners.

So we're just going to be brief here.

If I can ask you to do it in 30s or less, what do you want to leave with the audience leaving today's conversation?

>> Dr.

sure.

We need to address obesity, diabetes and other chronic diseases, which account for 90% of our national health expenditures.

And we need to really address this.

and we got to do it by the root cause.

So why are we this sick?

It's only been in the last 40 years or so that the rates of these diseases have proliferated.

So is that because we suddenly developed a different genome?

No, it's because the food environment has become extraordinarily toxic.

So let's address that from the public health level.

And then on the individual level, do tons of lifestyle counseling.

And in rare cases, if and when appropriate, we do a GLP-1 because it can be the lesser evil and it can certainly make a difference for people.

but only if we're also working on lifestyle change simultaneously.

>> Molly Ranney final thoughts?

Keep it tight.

>> I would say ditto to everything you just said, that I feel like we need to do a better job of educating our public on what it means to eat healthy, and to move more, and then we have these other tools that we can incorporate.

>> Dr.

Kaci Schiavone I would say obesity is a chronic disease that affects multiple organ systems in your body.

We have a lot of tools available to treat it.

I would say that the only tool that can permanently alter your hormonal cascade and allow for continued weight loss is surgery.

GLP-1 do it temporarily while you're on them.

>> Okay?

And Erica, okay.

Continued.

>> Good luck.

>> To you.

Go ahead.

>> Final thoughts?

>> just.

>> That it's it's it's okay to let yourself be happy.

and you don't have to be stuck.

>> Stuck in the situation that you are.

And go ahead and go ahead and give it a try.

>> Put it on your calendar.

One year from today, we'll come back, talk to you, then.

See how you doing?

Sounds good.

You're welcome back.

In fact, you're all welcome back.

Really?

I appreciate all of your expertise.

Thank you for sharing it with us.

And thanks for being here.

Our thanks to Dr.

Zachary Burns.

Dr.

Kaci Schiavone Molly Ranney from the Bariatric Center Highland Hospital and Erica, thank you for sharing your story.

Thanks to everybody here.

>> Thank you.

>> More Connections coming up.

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