(upbeat music) - Hello, and welcome to "Prairie Pulse."

Coming up a little bit later in the show, we'll profile master wood carver Joe Wavra.

But first joining me now, our guest is Sanford Health physician Dr. Brad Kohoutek.

Dr. Kohoutek, thanks for joining us today.

- Yeah, thank you for having me.

- Well, as we always get started, tell us a little bit about yourself and your background.

- Yeah, so as you said, I'm Dr. Kohoutek.

I'm a staff psychiatrist at Sanford Health, and I also spend just about half of my time in our Eating Disorders and Weight Management Clinic.

A little bit about me personally.

I spent my early years in Ledgerwood, North Dakota, but I call Wahpeton my hometown.

I graduated from high school there, attended NDSCS, before going up to NDSU for my bachelor's degree.

Then attended UND for medical school.

After medical school, I did general psychiatry training also through the University of North Dakota.

I graduated in 2013, and I've been a staff psychiatrist since then.

Then in 2019 started pursuing further education in obesity management, and in 2022 I became a diplomat of the American Board of Obesity Medicine.

- Okay, well, of course, we asked you to come today, sort of a topic that you hear a lot about, at least in as and things, over the last few years, weight loss drugs like Ozempic and Wegovy.

Let's start with, can you talk some about how they were developed, maybe the science behind them and how they were approved?

- Yes, when we talk about medications like Ozempic, Wegovy, really, we're talking about a class of medications called GLP-1s, and actually GLP-1s have been out for quite some time.

They were originally developed actually for treatment of type two diabetes.

The first one of these was a medication called Exenatide, which was actually FDA approved back in 2005.

It didn't take long for us to learn, though, that not only do these medications help manage diabetes, but they can be helpful in weight loss.

And so over the years, many new medications have been FDA approved for that reason.

Recently, we've had kind of an uptick of medications that were approved for this indication.

In 2017, semaglutide, which is Ozempic, was approved for diabetes.

Later in 2021 that became approved under the brand name Wegovy for obesity management.

Then more recently, kind of the newer medication that we have is tirzepatide.

That was FDA approved for diabetes in 2022, followed shortly after by its approval for weight management in 2023 under the brand name Zepbound.

- Okay, so in the grand scheme of things, these are relatively new approvals.

I mean, '17 and '22.

- [Dr. Kohoutek] Yeah.

- And we'll talk more about effects, and, yeah, but so what specifically do they do?

What do they do to the human body?

- Yeah, well, that's a good question and actually, I should go back a little bit.

Actually, the first one of these that was approved for weight management was back in 2014 under the brand name Saxenda.

But what do they actually do in the body?

It's a great question, and what these medications are is they're called incretin mimetics, meaning, they work on a hormone that's naturally, or they work like a hormone that's naturally produced in the gut.

And we think about, you know, how do they work for weight loss?

I really think about, they do three different things, and this is kind of a very simplistic view of what they do.

The first one is they help your body use energy more efficiently.

So they help your pancreas secrete insulin in response to a meal, and they help reduce glycogen, which is a kind of a storage form of glucose that we all have.

So that's the important part as far as, you know, energy metabolism.

Now, as far as weight loss, they also do two additional things.

So it slows transit of food through your gut, so you feel fuller faster after you eat.

And also they work on your appetite center in the hypothalamus, so it helps you not be as hungry and feel full or have satiety after a smaller meal.

- We'll come back to that in just a minute, but you said you work at the Sanford Health Weight Management Clinic.

- [Dr. Kohoutek] I do.

- So can you expand on kind of what the work, what goes on there, and maybe how you've been, have you been inundated with request for these drugs?

I mean, we always say, boy, we'd like to have a magic pill and be the perfect weight.

- [Dr. Kohoutek] Right.

- And now maybe there is something to do that.

So tell us more about the management clinic.

- Yeah, so I work in the Eating Disorders and Weight Management Clinic at Sanford.

And really what that is as a multidisciplinary team whose main focus is to assess, you know, patient's weight and their health factors, things like that with the ultimate goal of helping patients to manage obesity.

We have a multidisciplinary team that consists of, you know, psychologists, we have other prescribers like myself of various backgrounds.

We have RN health coaches, registered dieticians, we have our regular nursing staff and nonclinical support staff all helping us, you know, for that one goal.

As far as being inundated with, you know, requests, we've always been a very busy clinic, but what I would say is that there is kind new enthusiasm out there with these new tools that are coming to market that we are fielding more and more questions and getting more interest for these new medications.

- Yeah, well, talking about Ozempic and others, you know, I understand they're costly.

Am I correct there?

And even with insurance.

And can maybe you explain how it works.

- Yeah, they can be very costly.

So, you know, if you were paying for these out-of-pocket full costs, they can be upwards of $1000-1,300 a month.

Now, thankfully, some insurances do cover them and the amount of coverage can vary.

You know, I have patients who have a very minimal copay, some patients who have to pay 50% of that, and, you know, 50% of a lot of money is still quite a bit of money.

And so, unfortunately, in some cases, they are not cost effective, but yes.

- Well, with that said, now I said we'd come back to this.

So what are the benefits of Ozempic, Wegovy, or a drug like this?

- So the benefits are vast, and we're learning more and more about these medications all the time.

Not only benefits as far as, you know, treatment of diabetes and obesity, but we've actually had some expanded indications for some of the GLP-1s recently because we're finding that they can benefit other conditions.

Good examples of that would be we had tirzepatide, which was FDA approved for management of sleep apnea.

Semaglutide, otherwise known as Ozempic or Wegovy, was FDA approved for cardiovascular risk reduction in patients with a known history of cardiovascular disease.

And then more recently, as of about a week ago, there was another FDA indication for semaglutide to help protect against further renal disease in patients with a history of diabetes and kidney problems.

- Okay, let's flip the coin.

You know, what are the downsides to taking 'em, side effects, long-term effects, things like that?

And maybe even things we don't know yet.

- Yeah, you know, I think what's reassuring is like I said, initially, you know, these medications have been out for some time, so we know a lot about them.

But that being said, there are some side effects and occasionally we have people who have, you know, significant side effects enough that we have to stop the medication.

Now, the more common side effects would be gastrointestinal nature, so things like nausea, vomiting, changes in stool habits.

There are also some more what I would call rare complications that have reported.

So things like pancreatitis, gallbladder issues, kidney problems in the context of vomiting and dehydration.

Things like that thankfully are rare and that we monitor for.

And so we don't see them very often.

- Can these medications actually trigger or cause eating disorders, or, of course, have unintended consequences?

- That's also a very good question, and I can tell you that there's a lot of study right now looking at that.

You know, when people think eating disorders, a lot of times the first thing that comes to mind is anorexia, you know, being very low weighted.

And, you know, we think the risk of that is very low, but the study is ongoing.

What I see more in clinical practice is a different eating disorder that's much more common.

We know that from previous studies, we know that about 30% of patients who present to a weight management clinic have a condition called binge eating disorder.

And that has actually been studied with the GLP-1s and preliminary data shows that actually the GLP-1s can really help normalize eating behaviors and help those patients lose weight as well.

- Yeah.

Do doctors know what causes various kinds of eating disorders?

Or is it just an individual by individual case?

- Eating disorders are considered to be multifactorial, meaning, that there are different contributions, things like biology or genetics, as well as environmental factors, and sometimes personality factors.

We also know that there are some risk factors for developing eating disorders.

You know, certainly a positive family history, comorbid, you know, psychiatric issues like depression, previous trauma, stress, and then things like weight bullying and extreme dieting can also be risk factors.

- Yeah.

So your medical recommendation to someone interested in these medications who's a patient of yours, do you suggest other options first, or how do you go about that?

- My initial recommendation is the same for every patient and that is be ready to make some changes, or at least be open to changes.

You know, when they studied these medications for weight loss, what they don't advertise is that they studied them along with diet, calorie-restricted diet, and physical activity.

And so being ready to make those changes is helpful.

As far as medication selection, we really have to look at the whole patient individually and see if they're a candidate for those types of medications.

- Okay.

You know, is there a stigma out there for people who have a significant weight loss in a short period of time?

You know, are people less likely to admit they took Ozempic because it's considered maybe a shortcut?

- I think there's some of that, you know, and actually I see it both ways.

So we have some people who are reluctant to talk about how they've lost the weight.

I would say though, on the other side, I actually hear from my patients that, you know, they've been working very hard, you know, with lifestyle changes.

They've used this very important tool that we have to lose weight, and people aren't asking them about it and they're like, "Wait a minute, isn't anyone noticing?"

And I think people are reluctant to ask for that reason as well.

- Well, with that said, can you tell us about any success stories without revealing any patient information, obviously?

- Yeah, you know, that's why I love this type of practice is because we have success stories every day.

And, you know, these medications, yes, they're new, but we've had medications to assist with weight loss since the '50s.

And so we do have a lot of success stories and I would say these newer medications do tend to have more magnitude as far as the amount of weight that people can lose.

So it's a really exciting time to be doing this type of work.

- And, again, flip the coin, what about some cautionary tales?

That maybe, you know, there's gotta be stories of that also out there.

- There are, you know, and we have had patients who have had to stop the medication due to side effects.

Thankfully, we don't see very often significant complications simply because we're doing a good job of, A, educating our patients upfront, you know, telling them what to expect and what some of the warning signs of those rare complications would be.

And then we're doing a really nice job of managing them.

- So how about somebody who gets on the product, you know, how does one keep the weight off once the medication kicks in?

Or is this something that you have to continue on forever, I guess, or consistently?

- Yeah, it's a great question.

So all of the GLP-1s that are approved for weight management have been approved for long-term weight maintenance, meaning, that it's recommended that you stay on them long-term.

We know from recent studies that the risk of weight regain after stopping them is quite high.

One study showed that patients who stopped the medication within the first year, two-thirds of them have gained a significant amount of the weight back.

- Okay, well, what about copycat drugs or medications out there?

Are there some?

And, of course, I would say that have not been approved by the FDA.

- Yes.

You know, I'm always cautious.

It doesn't take long in a Google search to find somebody claiming to have a GLP-1 in their, you know, whatever product.

And I certainly recommend shying away from those.

Now, there are what some would consider copycat medications out there called compounds.

And actually we use those quite frequently and they do have a role in treatment of obesity, especially when patients can't access the FDA-approved versions.

Now, compounded medications are produced by licensed compounding pharmacies and so they can be used safely in a subset of patients.

- Yeah.

You know, maybe a tough question here, but there's been a lot of progress over the years in body image acceptance, but, you know, how do you balance that with the fact that things like morbid obesity is actually unhealthy and how do you balance that with your patients?

- Yeah, I think the word is balance.

You know, there's been a lot of good things that have come out of the body positivity movement.

You know, we know that having a good self image is important for people's general health and wellbeing, but that also has to be balanced with what we know are the risks of having the disease of obesity.

And so, you know, I think we're doing a good job of addressing the bias of obesity, not only in healthcare, but in general, but we also have to keep doing a good job at educating people on their health and making sure they're making the right choices and keeping that balance.

- You talked about having to stay on the drug long-term, but, you know, just in weight loss in general, whether it's Weight Watchers, eat healthy, heart healthy, isn't it usually a lifestyle change that you have to accept and follow no matter what you do?

- Yes, that's a very good point.

And, again, you know, when these medications are studied, the two main components are that, yes, a calorie-reduced diet and there are are certain diets that may be recommended based on whatever medical comorbidity you have and an increase in activity, and you're right, so those are extremely important.

- Yeah, so what got you interested in the area of study, weight management issues and eating disorders?

- Yeah, you know, as part of my training as a psychiatrist, we spend a lot of time in eating disorders, but I more so learned after I started practice in 2013, that, unfortunately, many of the medications that we use in psychiatry actually caused weight gain.

And so I actually, you know, really found myself wanting to help my patients avoid weight gain.

You know, prevention is key, and then look to ways to manage that as well.

So that's really what triggered my interest.

- Yeah, with that said, somebody comes to you wanting to lose weight, whether it's a few pounds or a lot of pounds, how do you approach it?

What's your first recommendations?

- Lifestyle change, and then that is always the recommendation and then, you know, we really look at the patient as an individual.

We look at what are their medical comorbidities and try to figure out what tools do we have that can help them.

And sometimes it's not medication, and we've had patients be very successful even without these new meds.

- Yeah, well, crystal ball questions, I always throw one out or often throw one out.

Where do you think in five years on medications like Ozempic, Wegovy, where are they gonna be?

What's gonna be going on, or there'll be more of them or less?

What do you think?

- Yeah, so as a psychiatrist, people think I can read mines, which I can't, and I also can't predict the future, but a quick Google search here shows that there are about 16 new medications in the pipeline that are, you know, in development being studied for, you know, what the drug company hopes is an eventual approval for obesity management.

You know, my hope is that we have more options for patients, different delivery methods, meaning, gosh, it would be nice to have an oral option for some patients.

You know, not everybody likes a shot once a day or once a week.

So my hope is that we're gonna have more delivery options, more competition, which will hopefully drive costs down, and just ultimately better access for patients.

- Real quick, what's the best thing about your job?

- I think seeing the success stories and getting to know my patients, it's just great.

You know, we work with a lot of good people.

- Well, if people would like more information about this topic we've talked about today or these medications, where's the best place for 'em to go?

Who can they contact?

- Yeah, they can certainly contact us over at the Eating Disorders Weight Management Clinic.

The number is 701-234-4111.

Another good place to start is having a conversation with your primary care provider.

Many of our providers are, you know, comfortable assessing the causes of obesity and doing some treatment, or they're happy to refer to us as well.

- Well, thank you so much for joining us today and thank you for all the great information.

- [Dr. Kohoutek] Yeah, thank you for having me.

- Stay tuned for more.

(light rock music) Joe Wavra of Red Lake Falls, Minnesota is a master wood carver who uses various chainsaws to craft amazing designs like bears, cartoon characters, and eagles.

It all started as a hobby years ago, but he has built his business Klondike Carvings into a full-time gig.

(upbeat music) (chainsaw buzzes) - It is a hard job, but I enjoy it.

And every morning, I'm thankful I get to come out and make some more sawdust.

(twangy music) I am Joe Wavra from Red Lake Falls, and my little business here is called Klondike Carvings.

I've been carving with the chainsaw for about 20 years now.

Part-time to start, but now it's just the full-time.

It's all I do.

So, it keeps me out of trouble and busy.

(chainsaw buzzes) My wife and I built a log house down between the two rivers in Red Lake Falls by where the Clearwater and Red Lake River meet.

And we built a log house, and then she wanted some decor for it, and she was gonna buy this and that.

She had plans and I told her, "Well, let me try to make that for you."

And she said I couldn't do it.

So it challenged me to start.

It just kept going, I started selling a few of them.

And the more I did, the more I did, and the more that sold and they just kept working it up.

And then I was busy working full-time and building a house and carving some.

And then after I got my house finished, then I started carving a lot more.

Like, every day I was carving, weekends, and word of mouth was most of it.

People would come and say, "Oh, can you make me this?"

And I'd like, "I don't know, but I can try."

That's kinda how it started.

It was a lot of wonder, you know, can you do it?

Will anybody come?

Will I make this work or not?

You know, you never know until you try, but you gotta roll the dice, you got gotta try it.

If I wouldn't have tried it, I would've not been happy.

(upbeat music) I get most of my wood up north of Bemidji, some loggers I know up there, and I've been buying from them for about 20 years now.

I'm looking for white pine or red pine normally.

So I like the white better, personally, but they both carve really nice.

(upbeat music) My style's more like folk art, I guess.

That's what I'd call it.

I'm not trying to make a realistic looking bear.

I make a caricature bear.

I do a lot of cartoon characters too.

I've done Goofy, Popeye, Bugs Bunny, Daffy Duck, lots of those kind of old classic cartoon characters.

Yeah, there's always bears.

You can never make enough bears.

They're just kind of like meat and potatoes, part of the deal.

I've made, I don't know how many, they never were my favorite thing to make, but it's what it is.

People want 'em so you just keep punching 'em out.

I do a lot of but like bears and logs and laying down and different styles.

Like, on a bear it's about nine cuts, and I can pretty much have one blocked out.

And then the rest is detail, different saws.

I got, I don't know how many chainsaws, 14, 15 different ones that are set up different for whatever I'm doing.

And then I'll do the detail part.

And then you have tools you have to build yourself, like eye tools, and there's some weird stuff you wind up learning how to make from other carvers.

I like my flying eagles, probably are one of my favorite things to make.

Anything you're trying to get like flying with the wings spread out is a lot harder than a perched eagle.

They're nice when they're done.

They're really pretty.

I do a flag holding eagle that's really popular.

It's a soaring eagle that holds a flag pole.

We have a really nice trail system.

So I got a bunch of benches that I've done for the city.

So people that are on the walking and hiking, biking trails can take a break, sit on a bench.

So I got a quite a few of those.

There's a lot of people in town that have supported me very well.

There's sculpture everywhere in town.

There's a lot.

My favorite way to work is when I don't have to think about it anymore.

I just start the saw (chainsaw buzzes) and my hands know what to do.

It's almost like autopilot where I'm not thinking about what I have to do.

I can just do it.

That's, I think, when I do my best stuff, my body knows what to do.

That's why I like chainsaw, it's fast.

I call it speed art.

It doesn't take me forever 'cause I don't have a lot of patience.

I do hand carve like some of my human faces and stuff with chisels, but more in the winter when I have more time.

When it's 40 below, I don't want to be outside working anyway, so I'll take the hammer and the chisels and knock some stuff out that way.

And I enjoy that too.

But I do like the saw 'cause you can move a lot of wood fast and things get done.

(chainsaw buzzes) I just want to thank the people for supporting me.

It's been hard, it's a lot of work and it's risky.

I mean, I don't know if anything will sell ever, but I got faith in myself and what I can do.

I wake up every morning and I'm happy.

I'm like, oh yeah, I get to go do what I want to do today.

(gentle music) - Well, that's all we have for "Prairie Pulse" this week.

And as always, thanks for watching.

(upbeat music) - [Announcer] Funded by the Minnesota Arts and Cultural Heritage Fund with money from the Vote of the People of Minnesota on November 4th, 2008.

And by the members of Prairie Public.