OZEMPIC - The "Magical" Weight Loss Drug
You’ve seen it on the news, on Tiktok, and on magazine covers. Ozempic is being credited as a magical weight loss solution, allegedly responsible for countless celebrity transformations, and everyone is talking about it. But now, people with diabetes who need the medication are having trouble getting it. What is Ozempic? How does it work? Why does it cause weight loss and is it safe to use? Today, we talk to Dr. Shauna Levy, an assistant professor at Tulane University School of Medicine and a double board certified physician in General Surgery and Obesity Medicine.
-
Guest
Dr. Shauna Levy is an assistant professor at Tulane School of Medicine and a double board certified physician in General Surgery and Obesity Medicine.
The Takeaways
Ozempic is a brand name for semaglutide.
Ozempic and Wegovy are the same medication, although Ozempic is meant for treatment of diabetes, while Wegovy is meant for weight loss specifically.
Ozempic, or semaglutide, is a GLP-1 receptor agonist, meaning it mimics glucagon-like-peptide-1 (GLP-1). This then increases insulin secretion, which then increases blood sugar disposal, and thus improves glycemic control.
Semaglutide causes weight loss because it also lowers appetite and slows down digestion, thereby reducing hunger and cravings, and often leading to weight loss.
Two types of obesity:
Central obesity - Characterized by higher amounts of fat around the abdominal region and around the organs (visceral fat) which is associated with metabolic disease, insulin resistance, diabetes, fatty liver disease and other health complications.
Peripheral obesity - Characterized by fat in the limbs under the skin (subcutaneous), not associated with chronic diseases.
Off-label use - a common practice in medicine of prescribing a medication for a different purpose than what the FDA approved it for.
Due to supply chain issues with Wegovy, Ozempic started to be prescribed for use to people without diabetes, leading to Ozempic shortages.
Doctors do not treat obesity for “cosmetic” reasons, but for health reasons.
Weight stigma impacts people’s access to care:
Many insurance companies don’t cover obesity medications, or make it very difficult to get covered for them.
Medicare does not cover obesity medications.
These medications are extremely expensive.
Congress and health insurance companies view treatment of obesity as “cosmetic.”
If you lose weight with Ozempic or Wegovy, you will have to use it for the rest of your life to maintain that weight.
Side effects of Ozempic include:
Nausea
Diarrhea
Vomiting
Pancreatitis
Fatigue
Stomach pain
Gallbladder disease
To name a few.
If you stop taking Wegovy or Ozempic, studies show that patients regain the weight slowly over time.
The longest trial on Wegovy has been 16 months long.
Studies
Once-Weekly Semaglutide in Adults with Overweight or Obesity
-
Juna: First things first, guys. We have Eddie, the man, the myth, the legend himself back in the studio today. Back from the Wild. Yes.
Eddie: I was up on the Canadian border in northern New Hampshire, where it just juts into Canada off on a skiing vacation with some people. I just met a way off the grid. No electricity, no running water.
Juna: What an adventure.
Eddie: It was phenomenal. But I'm back.
Juna: Well, you just met. Yes, you did. You're in the middle of nowhere. People you didn't know.
Eddie: It's a great story, but. But my wife said to me as I got into the car, You really have no social anxiety.
Juna: I was like, Oh, my God. So anyways, I want to give Eddie a chance to tell you guys the special news that I feel like I totally stole the thunder in our last little mini episode, but I want Eddie to be able to say it.
Eddie: So the news is that you and I wrote a book. Guess what it's called.
Juna: Take a wild guess, guys.
Eddie: Food. We need to talk. Thus, science based humor. Last word on eating diet and making peace with your body. You can get it now as a preorder in a hardcover, an e-book, or even as an audiobook read by you and me.
Juna: Whew. So if you're interested in pre ordering, which really helps us out, thank you so much to everybody who has preordered already. You guys, the emails I'm getting. There have been so many nice messages. So thank you so much to those of you that have already preordered. And for those of you that haven't yet, the link will be in our show notes. Or you can go to our website. Food We need to talk a dot com slash book. It really lets the publishers know that people are actually interested in this book. So I know I'm a procrastinator. Like when people have preorder links, I'm like, Whatever, I'll get it when it comes out. Just know guys, it does help us out to preorder now instead of later, just because it helps us seem like we actually have people that want to read this book. Wouldn't that be awesome?
Eddie: And as a way to say thank you, if you do preorder, then send us an email at food. We need to talk at gmail.com or message us on Instagram and we'll be picking someone to get a hardcover signed edition of our new book.
Juna: Now on to today's episode, guys. Today, we are talking about something that has been all over the news all over my for you page, and that's where all your videos pop up on your Tik tok.
Eddie: That's where your videos shot.
Juna: If you have a TikTok, that is where the videos pop up. It's all over Hollywood, apparently. And that is the miracle weight loss drug seemingly ozempic.
In my Ozempic trizone. I lowered my agency's TV risk and lost some weight.
Eddie: Mozambique provides. Wait a minute. Mozambique is a diabetes medication.
Juna: So it is. But apparently it has been prescribed to a lot of people who don't have diabetes because of one of its common side effects, which is weight loss. So today we are talking all things Mozambique. Why does it cause weight loss? Is it safe? And what happens if you use it without a clinical need? What are the potential dangers of doing so?
Eddie: I'm Yuna Jara, and I'm Dr. Eddie Phillips, associate professor at Harvard Medical School.
Juna: And you're listening to Food We Need to Talk. The only podcast that has been scientifically proven to not have any of the following side effects nausea, vomiting, diarrhea, low blood sugar or pancreatitis. Guaranteed just by listening. Let's just kick off today's episode by reading one of our favorite reviews for the week. Eddie, will you do the honors, please?
Eddie: Yes, it's from Reb begins. Reb Jin's highly recommended five stars as a cardiology P.A. That would be a physician's assistant who are now becoming physician associates. Promoted. Promoted. Someone who has struggled with weight. And mom. Two young adults who are now managing their own health. I find this podcasts super informative, fun, and useful to myself, my family, and my patients. Can't wait to read the book. Thank you again.
Juna: So actually, I'm pretty sure this is Rebecca. Me and Rebecca have chatted on Instagram and she really wanted a shout out on the show, so I'm pretty sure this is Rebecca. So, hello, Rebecca. Thank you for your wonderful review. And remember, if you want to get a shoutout on the show, you can always leave us a five star rating and review. We read them out every single time we have a show, and it really helps us out because it helps other people find the podcast. Now for today's guest, we are talking to Dr. Shauna Levy. She is an assistant professor at Tulane University School of Medicine and a certified board physician in obesity, medicine and general surgery. Welcome, Dr. Levy, to the podcast.
Dr. Shauna Levy: Oh, thank you so much for having me.
Juna: So can you tell us what exactly obesity medicine it is and how it relates to general surgery and then how you got into it and like what your practice looks like?
Dr. Shauna Levy: So in addition to clinic and operating, I opened our weight loss clinic. And so I've been directing that and seeing patients for medical weight loss. And that's just exploded in terms of demand from patients. A lot of people are very apprehensive about getting surgery, but they're much more open to having a conversation about taking medications. So it's an avenue to have that conversation about, you know, what is the best treatment option for you.
Eddie: As an obesity medicine practitioner. And we're going to distinguish that from your extensive training as a surgeon. What else are you talking to your patients about in addition to the several medications that are out there?
Dr. Shauna Levy: You know, I have to see where my patients are at when I talk to them in clinic. Right. Because there's all sorts of varying educational levels and understanding of nutrition and exercise and the lifestyle modifications that they might need to change. You know, you have to see what opportunities patients have. You know, sometimes patients can only get fast food, like saying no more fast food means no more eating. Right, because that's the only opportunity. Some people are night shift workers and have to work within their schedule. And so you really need to understand why the patients luckily we work with dietitians to they can work specifically with patients. But label reading, I find, is one of the most universally misunderstood thing for patients. So really starting with that and understanding that the front of a box of anything is a lie, it's a scam, it's a little marketing, and you need to turn that package around to have more transparency of what you're eating. And that's actually a really hard concept for people to understand because of like what they've been lying to me this whole time are scamming me. I guess I don't even know what the right word is. So we talk about that and how to increase movement into their life. Some people can't do that because they're, you know, have arthritis, which is a consequence of their weight. And then we talk about trying to have access to whatever they can. Like pool exercises are great. So, yeah, I mean, that's majority of what our visits are about. But ultimately, because I'm not a dietitian, I am an obesity medicine specialist, I find that most people are coming in to talk about medicines. And so, you know, while we have that conversation and I can follow up with them, they're like, well, I've also tried most people, I've tried, you know, calorie restrictive diets, plus or minus exercise for years. And they want to know how else can they be helped.
Juna: I think that's such a good point. We don't talk about it as often as we should on the podcast, but just the privilege of being able to like, get in more steps outside in your neighborhood, more like having access to like fresh produce or whatever is something that I think we take for granted. So I really appreciate you bringing that up and to pivot to the medications. So what does someone what criteria do they have to meet to be considered for medications for obesity? Is it a certain weight? Is it that they've tried dieting before and it hasn't worked? Like, when do people usually turn to medication?
Dr. Shauna Levy: So your answer is not as straightforward as it might seem, because the question is who are you asking that from? Are you asking from the medical practitioners who look at criteria to decide who qualifies from a health perspective? Or are you asking the insurance people who are going to then reimburse or approve these medication because they're different? So from purely a health standpoint and like the criteria that were used in the recent randomized controlled trials for the GLP one agonist, which I'm sure we're going to talk about, it's a body mass index of 27 to 29.9 with a weight related comorbidity like diabetes, high blood pressure, sleep apnea. Mm hmm. Or a body mass index of 30 and above. And you do not necessarily need a weight related comorbidity. And that's the criteria that the obesity medicine organizations use to determine when medical weight loss is indicated. But insurance companies set their own requirements. So that can be totally different like that. They've. Quote, failed medication before or that they've a lot of times I see that they've been on diet and exercise programs for at least three months and it's documented or that they have been a certain BMI for some period of time. And you have to have documentation of that. Mm hmm. And there's a lot of hoops that they have to go through to get help.
Eddie: So I wanted to sort of stipulate that a lot of the episodes that we've done were critical of the use of the BMI. But for purposes of talking about indications for medication and for having a common measure, you know, so that we can go to bat and argue with the insurance companies or or determine what's best. You know, we're using the BMI here as part of that. It's it's not ideal. I actually if you want to weigh in on the BMI that.
Juna: No pun intended.
Dr. Shauna Levy: Yeah. Yeah. We know I think it's well-described and acknowledged that body mass index is an imperfect measure, but it's something that we can't get rid of because, number one, it's easy. Number two, it's cheap. You know, anybody can do it as long as you have a scale and you can measure their height. And like you said, insurance companies use it as criteria. So even if we don't want to acknowledge BMI, we have to unless we're in a total cash pay business.
Juna: Mm hmm. Right.
Dr. Shauna Levy: And the other thing is, you know, abdominal circumference, neck circumference, these are certainly increasing in the conversation about what is obesity or how is it medically defined. But what I've seen is more body mass index is a criteria.
Juna: Okay.
Dr. Shauna Levy: You know, there's two different types of obesity. I'm sure you guys have talked about this, the podcast before, but central adiposity versus peripheral adiposity. So somebody who has central adiposity actually has a higher likelihood of having metabolic syndrome and having these medical comorbidities, but they might be a lower BMI, which is, you know, hence the problem.
Eddie: And just a little jargon alert's a central adiposity. We're talking about weight around the middle of.
Juna: Your stomach.
Eddie: Around the viscera and your internal organs. And that's what's more dangerous. And then the other type of body shape or.
Dr. Shauna Levy: Peripheral, and it's peripheral. So you have more fat distributed in your, you know, your arms, your legs in the skins and in the tissues below the skin. You know, you've seen the two different shapes and it's actually healthier. You have less likelihood of having metabolic syndrome if you have the peripheral fat. Right, rather than the central fat, because it's not as likely to be deposited in your organs and causing damage to your organs. So I see patients all the time. They're like, Well, I'm super healthy despite my weight. And of course, yes, I see that all the time. And people who have are more, quote, thin, you know, look smaller. I'm junk on small everywhere except for my belly. I hear that all the time. We are more likely to have diabetes, high blood pressure, sleep apnea, one of those problems.
Eddie: So we've asked you here to actually talk about a really hot topic, which is ozempic.
Dr. Shauna Levy: Yeah.
Eddie: But I'm going to just pause for a brief historical side.
Juna: Now because Eddie's favorite thing on the podcast actually he does a brief historical side note and enlightens us on the history of what we're talking about.
Dr. Shauna Levy: Now. I love it.
Eddie: So history shows some weight loss drugs can do more harm than good. So back in the 1800s, thyroid medications, thyroid hormone was used. What could go wrong? Except that people became hypothyroid, which is rather dangerous. And in 1940s, that was the rise of speed.
Juna: Oh, my God, yes.
Eddie: Amphetamine was used, but, you know, people got addicted. What could go wrong? 1960s. I never heard this one before, but they had what was called rainbow pills so that we took the speed, added some diuretics. Oh my God. And the diabetics would get you to shed water. So that makes sense. And then digitalis. But people died. Phen fen. God was removed from the market when it's found to damage, I think was heart valves in the late nineties. And then since then I think it was 2008 through or in 2010. There are other weight loss drugs withdrawn only because people were getting liver damage, suicidal thoughts and more heart disease. Which brings us to the latest.
Juna: Yes. Okay. Yes. So full transparency. The reason I thought of this topic was because Ozempic has been all over my for you page on Tick Tock. That's when I first encountered it was like basically people talking about celebrities being on it. And I was like, first of all, I was like, so infuriated. I was like, Why are celebrities getting medications the rest of the people can't get? And then I heard about the shortages and I was like, Oh my God. So can you explain what Ozempic is and what it's usually prescribed for?
Dr. Shauna Levy: Yes, I can. If I may make a point of clarification, because I think that Ozempic is the buzz word, you know, on the street. But there are two medications, and one of them is Mozambique, and one of them is called Wegovy. And both of them are a molecule called Semaglutide. And Semaglutide is a GM GLP one receptor agonist, which yeah, I get it jargon alert, as you just said.
Eddie: But but, but spell it out.
Juna: Yeah, explain how it works.
Eddie: Glucagon like like.
Dr. Shauna Levy: Peptide one receptor agonist. So it GLP one is a naturally occurring hormone in our body and it regulates blood glucose. It also regulates hunger. Mm hmm. And people with the disease of obesity actually can have lower levels of GLP one than somebody with thinness. I don't think we understand the frequency with which it is lower, but it's it's part of the disease. And so this medication ozempic and we go v Semaglutide basically augments your naturally occurring GLP one in your body. Mm hmm. And with that, the diabetes component of it is that it regulating your blood glucose without making you hypoglycemic or having low blood sugar because it is glucose dependent. So it doesn't really work if you're not eating versus other medications that are not glucose dependent and just work like if you took insulin or something like that, it would lower your blood sugar regardless. Regardless. Yes, but this is glucose dependent, so you have to eat for it to work or have some sort of glucose bolus. Mm hmm. But also from a obesity standpoint, it quiets the hunger cues because of the receptors in your brain and it delays stomach emptying. So food stays in your stomach longer than it would, you know, if you had lower levels of GLP one.
Eddie: So in the best cases, people that are taking this and I know the indications are different for Ozempic or Wegovy, whether they're diabetic or not, but it's same medication, correct.
Dr. Shauna Levy: So literally the identical molecule. And so this category of medication, GLP one receptor agonists have been around since the early 2000s, but in other medications. And so we've known that they've led to weight loss. The thing that's great about Mozambique and we govee is it's led to the most weight loss and it's given in a relatively easy manner of the once weekly injections.
Eddie: Mm hmm.
Juna: So does that last a whole week? You get it injected once and for the whole week. Your GLP one receptors are acting differently.
Dr. Shauna Levy: So yes and no, it definitely starts to wane. I think it's probably more effective on a six day dosing. But you know, that's complicated and not completely necessary because by day six it definitely starts to decrease. I have patients report that they feel more hungry on day six than, you know, day two or three. I think, you know, I mean, just like any medication, there's a curve right, where it starts working the very most, you know, it's the less effective, more effective and then comes down. But for the most part, last week, I mean, that's something I talk about my patients with strategy, right? Like, so if you find that you have the most temptation on the weekends and you're hungriest on the weekends, you know, just because of activities and whatnot, then maybe take your shot on Wednesday or Thursday that by your peeking at sunrise Sunday, but that's up to you. So anyway, this class of medication has been around since the early 2000 and then they came out with a zombie and I think 2020 and there was no shortage and it was given to diabetics, great medication. And then we go V came out in 2022, and now we're using it more for obesity because it's indicated for obesity. And they had manufacturing issues just like all sorts of supply chain issues like everybody was having because of COVID and all of a sudden it was out of stock. And so then everybody was like who had been on Wegovy was just jumping back over to Ozempic and writing it totally like a ton of off label usage. You know, we're just hearing about it. We're talking about it more. It was more on tick tock. Yeah, sure. The celebrities are component too, but there's also other reasons that I don't think really anybody's talking about as to why there's no xebec shortage.
Eddie: So just a little clarification. Off label usage is what Dr. Levy and I do all the time, which is there's a medication that's approved for. Something usually very narrow. And then as a doctor, you are allowed to use it for other things. So medications.
Juna: So that's common.
Eddie: Extremely common. I think I've written for thousands of light vaccine patches which are available over the counter now. And I think after, oh, I don't know, a dozen plus years, I finally wrote it for the one indication that it's for. So that's there's nothing sinister about an off label use. Just to be clear. So we're just going to take the off label part, you know that it's.
Juna: Really not that crazy for something into the Afflalo.
Eddie: No. However. Well, maybe you could now talk about what caused this.
Juna: Yeah, things besides, because I was most aware of the celebrity stuff that's on like what I saw the most. But what are in your perspective? Like, what are the other things that really caused this shortage?
Dr. Shauna Levy: Well, I think it's a supply and demand issue, right? Like these were the best weight loss medication on the market, like hands down, because it has the lowest side effect profile and it actually works. So the best weight loss medications before this are, you know, pills that make you feel like you're having heart palpitations, like your heart is beating out of your chest, not for everyone, but for a lot of people. Right. And so they would take it for a while. But then it's like it just made me feel no good. And so I don't want to take it anymore. So then here comes these medications that don't really bother people. You know, nausea, vomiting is part of the side effect profile, but it's usually very short lived. And as people grow, awareness are like, Well, I've been fighting this disease my entire life. I want this too. So as the awareness builds, people want it. And so combine that with we go V, who had manufacturing issues with their plant and they had some other supply chain issues due to COVID and just universal supply chain issues. So they were pretty much out of pocket for almost one whole year. So they came to market. Everybody's so excited about it. Even more awareness of this medication. And Mozambique was in stock. So me as an obesity medicine person, I would write for Mozambique as often as I could. Now, I couldn't do it if somebody didn't have any, you know, pre-diabetes or diabetes or anything even close unless they wanted to pay out of pocket. But from an insurance perspective, I couldn't write for that. And everyone was doing that. Right. And there's other places that are just cash pay and writing for Mozambique. So all this demand led to shortage of supply minutes, I guess economics 1 to 1 or something like that.
Eddie: We'll be right back. And we're back. We're here with Dr. Shauna Levy, an assistant professor of surgery at Tulane University. And we're here talking about Ozempic.
Dr. Shauna Levy: I think the best thing about these medications is raising awareness that this is, in fact, a disease. Mm hmm. It wasn't until 2013 that the American Medical Association even acknowledged obesity as a disease and not a cosmetic disorder. That's not that long ago.
Eddie: We now know. Yes.
Juna: So can you describe I think a lot of people who might not be well versed in this topic would be surprised that obesity is thought of as a disease. And also, I think people in general like kind of in the fitness industry, which is not exactly related to this industry, but it's tangential. Yeah, I think often argue like it's not a disease, it's a result of your choices that are to what made obesity be classified as a disease and how do we know it's a disease? How has that classification come about?
Dr. Shauna Levy: You know what is a disease? A disease is something in our physiology that has negative consequences in our health. Mm hmm. Right. And we know that as our weight increases, it leads to other downstream impacts to our body, like diabetes, high blood pressure, sleep apnea, fatty liver disease, kidney disease, cancers. These are all linked to worsening obesity. Mm hmm. Right. And so, I mean, that's just one of the reasons why it's categorized as a disease. And to say that it's just your choices is ignoring the fact that we have countless studies looking at intensive lifestyle interventions that had structured fitness programs and structured diet programs and follow them long term people could not sustained weight loss. Is that because they're all lazy? They've all made these bad choices that even when they're in a study that's intensely watched and meal plans that are provided for them and they still can lose weight. So we're still saying that it's their choice. Mm hmm. You know what I mean? Yes. Diet, exercise are part of the treatment. You could make better choices, but ultimately, it's not the answer. It's not the problem. Contributing factors. Yes. The reason? No.
Juna: I think it people get really, I guess, touchy about this because they'll say things like, well, we're all living in the same environment. If it's the environment, why isn't everybody obese or whatever? And I think the role of genetics is kind of underplayed, maybe because it's like it's out of our control. And so people don't really want to talk about it because there's nothing you can do about it seems like.
Eddie: But also from what Dr. Leavey, from what you were saying before, we don't all live in the same environment.
Juna: That's right, yeah.
Eddie: You know, like what you're exposed to in your neighborhood or by your economics or.
Dr. Shauna Levy: Yeah. So a few things that I want to talk about. Just going back to that obesity as a disease is that we're not taught about this in medical school. So doctors aren't teaching people about it. And that's a huge gap in our dissemination of correct information about this disease is that a lot of people learn about it from People magazine or, you know, social media at this point or Today show or and not their physicians or not because physicians don't know. No, I didn't learn about it in medical school. I don't know about you know, And so it's a it's a huge problem in terms of the treatment is even the educators aren't being educated. And as far as body positivity goes, I'm all about body positivity and I think that connecting people's appearance to their self-worth is a huge problem, right? Because and that's the first thing I acknowledge when I see my patients in clinic is that you are a beautiful person. That is not what we're here to do. We are not here to have a conversation about your appearance. I'm not here to treat your appearance. You know, that's what a plastic surgeon might do. But I'm here to treat your health. And, you know, not everybody responds that in the same way. But it's true. It's important for me to set that straight from the beginning. And I think body positivity for some reason, feels at odds with treating the disease of obesity when they don't really need to be because you should be beautiful at any size and that shouldn't be relevant to your treatment of disease. Aren't you still beautiful if you lose weight with your disease? But then your knees feel better and your back feels better? I think that. And I hesitate to say this because maybe I'm going to get attacked for it in some way. But I think people with the disease of obesity have been attacked for generations about their appearance, and they're like, enough, enough already. Like I am beautiful and I'm standing up for. And it feels like your pendulum has to swing so far in the other direction to, like, stand up for your appearance and what you look like. That in some ways you have to say like, now you're trying to come at me in another direction when it should have just been about the disease all along, not about anybody's appearance, but they've been so confused for so long and so linked that I think that the new and I can't I'm not a leader in that movement. I can't speak to it. But the impression I get is they're so fiercely protective of the cause that if there was a treatment that it would somehow the body positivity movement was somehow get lost.
Eddie: Where does weight stigma fit into this? I've come to the understanding that weight stigma may have worse health consequences than all of the issues that you've noticed with the disease of obesity just because of the huge psychological toll. But where does your work or where does? We'll get back to the medications. Where did that fit in with weight stigma?
Dr. Shauna Levy: I mean, weight stigma impacts every single aspect of my career and ability to give patient treatment. Right? So we talked a little bit about insurance, but I think only 20% or so of. Private insurance carriers, meaning their employers, determine their insurance. About 20% cover anti-obesity medications. I mean, that's weight stigma, right? Not even covering this disease. When the Affordable Health Care Act came out, states were able to decide on their plans. 28 states opted out of obesity coverage. To me, that's weighed stigma.
Eddie: Wow. It's like on the institutional level, not just having this treaty.
Dr. Shauna Levy: Exactly. Yeah, exactly. So there's a Treat Reduce Obesity Act that's been in Congress since 2013 that's been trying to get passed that would basically acknowledge obesity as a disease, because right now Medicare has an exclusion on anti-obesity medications, because anti-obesity medications are considered cosmetic. That's obesity, stigma.
Eddie: Wow.
Dr. Shauna Levy: Bias. You know, people should be able to do a diet and exercise. There's so many layers of this problem that, you know, patients come to me all the time. Now they've heard and now they know that there are really effective medications out there. But for so many people, I can't even write for it. And when you say, like only the rich can get it because they pay out of pocket, I mean, that's the uber rich, right? Because it's 1200 dollars a month. And if you do the math on that, you know, that's $10,000 a year. Who has money for that? Right. If it's a college tuition.
Eddie: If you work it out for like dollars per pound, that's that's a pretty.
Juna: Big expense.
Eddie: That's pretty expensive fat loss.
Juna: So I feel like all the celebrities and stuff who were doing the you know, that's how it became popularized on social media. I guess I feel like that really draws the conversation away from obesity being a disease, because for all of them, it really does seem to be like a cosmetic thing, right?
Dr. Shauna Levy: I mean, you say that and I'm not going to name names. Right. But there are celebrities that I've heard that just based on my eyeball assessment, because obviously I've never met them in real life. They probably would meet criteria for the medication. And so. Okay. Yes, there are a group of people that are just doing it for cosmetic reasons, but there also could be people in Hollywood that have been suffering, eating like 800 calorie diet their whole life to be thin and have really been suffering or like work out all the time. And we don't know their health history. So, yes. Are there people that are using it for the wrong reasons? Of course. But I think it's maybe unfair to say all celebrities are just using it for the purposes of Vanity Fair.
Juna: Sure. But then the way it's covered is like this person looks great, lost, dented up pounds. Look at this person's new look. It's always like a cosmetic thing. It's not like couldn't disagree more is kind of, you know.
Dr. Shauna Levy: Not agree more. But so actually, honestly, I fault the media, not the celebrities, because a celebrity cannot just go to a pharmacy and say, I want ozempic, I want wegovy. A doctor has to have decided and had a conversation whether the doctor is reputable or doing it for the right reasons. Like that's a whole separate issue. But the celebrities are getting somebody to write this prescription for them. And you're right, I think the way that it's been digested and then portrayed by media is the biggest issue. Like, I mean, I'm sure you know who Remy Baiter is because you're ticked off this. Right.
Eddie: But I want to take some credit here. In researching for this episode before talking to you, Dr. Levy, I looked up, you know, the physiology of what goes on and reviewed some some basic stuff. But I also looked at the celebrity pages and I saw Remy, you.
Juna: Know who Remy did.
Eddie: This, And I guess.
Juna: That's big. I've never heard of it. You know, one of the tick tock people. Sorry. Sorry to interrupt. Go on about Remy Baiter.
Dr. Shauna Levy: You know, I mean, I actually don't really have issue with her and her talking about her experience. It was the coverage of her experience that really drove me bananas because the focus was like, Mozambique makes you gain back double your weight, Like there's no conversation about the physiology or the mechanism of action of the medication. There's no coverage about actually, it's the disease of obesity that causes you to gain back double your weight. It has nothing to do with the medication itself. And so then all these people are like, Oh, ozempic messes your metabolism up and now you're going to gain back double your weight. That's not true. That's not how it works. And that's not what happens. But that's exactly. How it was portrayed, at least my impression of it, and how the media was covering this medication. And it honestly, it was so incredibly upsetting. As somebody who's an advocate for this disease and thrilled by the treatments to to tarnish the name of these wonderful medications was very upsetting. I thought.
Juna: So. Okay. For people that don't know, Rami is most famous on TikTok for posting realistic hauls of clothing brands that we don't usually get to see on bigger bodies. And she shows them on Tik-tok. And she's very funny, very entertaining. She's beautiful. I think she's actually like a really famous model now, and that's kind of what her TikTok videos went viral for. But she did publicly speak about her journey with Mozambique, basically. And actually her experience of it was something I want to ask you about. So when somebody goes on to Zambia, obviously the most obvious thing they're going to notice is they're probably not as hungry. So they're going to be eating less, I'm assuming. Is it something you have to be on for the rest of your life in order for it to be effective? Or do people often have a rebound if they go off of it?
Dr. Shauna Levy: So Remy better publicly acknowledges that she has binge eating disorder, which is not the same thing as obesity. Right. And a lot of people think and I think this is also part of weight stigma that people with the disease of obesity all have binge eating disorder, too. You know that everybody's obesity just eats on healthfully uncontrollably. You know what? I'm being a little bit extreme when I say all, but I think that a lot of people think that. But they are two completely separate diseases. And while ozempic and we go, we are helpful for treating binge eating disorder, they are not the treatment for binge eating disorder. So there's no there should be no expectation that when you go on this medication that it's going to cure or fix your binge eating disorder. So it's no surprise that when she came off of it, she still had binge eating disorder because the treatments for binge eating disorder are actually vyvanse and cognitive behavioral therapy most of all. So that's one thing I wanted to clarify, too, in layman's terms and in practical terms, Ozempic and Wegovy quiets the hunger noise that's in your head. That's like, eat it, eat it, eat it, it's okay, it's okay, it's fine, it's fine. You know? And your voice may seem different. That's what my voice sounds like. You know, when you're at the aisle of the checkout, at the pharmacy, and there's all this candy there, it's like, Mm.
Juna: No.
Dr. Shauna Levy: You're like, not even bothered by it. You know, you can just go about your day and not be fixated.
Eddie: How is that actually happening? What is the medication?
Dr. Shauna Levy: What's because of the GLP one receptors that are in your brain that are driving that hunger signal? So when you have more GLP one attaching to those receptors, it quiets the noise. I mean, there's more though. I mean, I'm sure you're not going to want to get into like the agouti related peptide, you know, the normal neural pathways that are going, but that's the short version of how it works.
Eddie: So you could run the gantlet at the checkout, even if you've got a full basket and you're waiting on line and things don't seem as necessary, like.
Juna: Fighting a temptation constantly to like, yeah.
Dr. Shauna Levy: Yeah, like my my assistant has a candy bowl in our office and every time I walk by that thing, it's like, eat me, right? Yeah.
Juna: When we talk about the way that it reduces hunger, do we know that with people who have the disease of obesity, do they experience this sensation of, like, needing to eat things as you pass them about more than other people? Because like you said, like you pass the candy bowl yourself and you're like, ooh, candy. So do I. Every time I pass the cabinet, like, oh my God, chocolate. Is it stronger for people with obesity? Is it more frequent? Is it like proven that it's something that because I feel like we all kind of experience that to some extent. So how do you know it's something that you need medication for versus just like a normal part of humans passing tasty food? It's like, you know what? Yeah, right.
Dr. Shauna Levy: Well, I mean, I think now this is just one aspect of it, right? Because how you're raised, what your education, what access to food that you have, those are all contributing factors. So I don't want to be misleading in answering this question, saying that people's self-control or the talking cannibal is the sole thing, but it is a contributing factor. It as your disease of obesity gets worse, then these signals and cues that drive hunger are worse. We know that on a hormonal level, like ghrelin, that's another hunger hormone. It's not part of this medication pathway, but we know that ghrelin spikes before a meal to make you hungry, to make you want to eat. And then it drops after a meal. People with the disease of obesity, it does not drop as low than somebody with thinness. Right. So there are hormonal pathways that we have interpreted as self-control, but they're actually hormonally driven.
Juna: I mean, it reminds me a lot. You remember when we did the Habit episode, when we had Professor Wendy Wood, and she was saying that people who have really good habits, it's not that they have more self-control, it's actually better. They just don't see temptation the way that people who quote unquote, have poor habits do, which I thought was really interesting because she said it's not like this big exertion of like, I'm stopping myself from eating the cake. It's like they open the fridge, they just don't notice the cake there. And they like, get the food for lunch and they eat lunch and whatever. And it kind of similar to that.
Dr. Shauna Levy: It look. Fortunately, such unfortunately, I don't meet criteria to go on medication, but I would love to go on it to understand better how it makes me feel. So right now my only option is to talk to all my patients who are on it and say like, How are you experiencing this on a day to day level? And it's exactly how you describe. They don't notice the food anymore. Of course they eat. It's not like they're starving themselves and they do still feel hunger. It's just there's not as much noise around them. They can do the thing you said, open the fridge, just get what they want and move on with their life.
Juna: Can you talk about some of the other side effects of Mozambique?
Dr. Shauna Levy: Okay. So the most common side effects are gastrointestinal issues. So nausea, some vomiting, diarrhea can occur like if you eat something that's, you know, perhaps less nutritional value, you may have diarrhea, rare side effects, but still occurred were pancreatitis, which I think was like 1% of patients. And so we don't tend to prescribe it for patients who have, you know, a history of alcoholism that might lead to pancreatitis or high triglycerides that have had episodes of pancreatitis. Now, somebody who had another reason for pancreatitis, like leeches, that they had gallstone pancreatitis, and now they no longer have a gallbladder, I'd probably still prescribe that medication.
Eddie: So with the shortage, there are cases of people having to go off of the medication. Mm hmm. What happens when you go off of the medication?
Dr. Shauna Levy: So we know from like the step four of the clinical trial that was done with Wegovy that patients will regain their weight slowly over time. The pathophysiology of that is related to the disease of obesity in itself. And just like when somebody goes on any diet or exercise, people are usually able to sustain their weight loss for about one year and then they slowly start getting their way back. And that's because of the hormonal changes that occur in your body with this disease. So there's a spring model of metabolic adaptation. So weight loss kind of acts like a slinky or a spring. So the more weight you lose, the harder that spring is wanting to pull back, to get back to the baseline. And that's driven by your hypothalamus because our weight is kind of like a thermostat. So there's a set point. So when you lose weight, it's trying to harder to pull you back. So to that point.
Eddie: So the further you pull the spring, the more it wants to pull back.
Dr. Shauna Levy: Towards your SO and the way it does that by increasing hunger and slowing your metabolism down. Right. So when you take these weight loss medications, it's quieting those hunger cues that are going to increase as you lose weight.
Juna: So does that mean that it is a thing you'd have to be on for the rest of your life? If you want to maintain the weight loss that you do get.
Dr. Shauna Levy: So, you know, nothing's impossible, right? There are probably people who can have this dramatic lifestyle modification and go off of it. But if we're speaking about the average person, which is generally how we like to talk about things, yes, obesity is a chronic progressive disease that gets worse with age. And just like any other chronic progressive disease, like high blood pressure, you know, if you come off medication, the medication no longer works.
Eddie: What's particular about obesity as the disease is that if it's properly treated, yes, you're on this medication forever, but now you're also reducing the risk of, what, 200 associated ailments and diseases with the disease of obesity. That's not a bad return on investment. You know, for one medication to possibly reduce your risk for 200 other ailments. I think just to start wrapping this up a little bit, we're hearing that these medications are quite effective. I mean, that's how they were. Proved properly used. And here we're going to go back to the indications. If you're diabetic and you're taking that would be ozempic right and right or you meet criteria for your weight with complications to be prescribed Wegovy they work and we're not here to contest that. But I wanted to kind of put a fine point on the idea that if you have not been properly prescribed this, do not do something crazy like get the molecule in the mail and mix it.
Juna: Or do this on eBay.
Dr. Shauna Levy: Well, do not do that. I mean, I don't know if you guys want to get into compounded semaglutide and what that.
Eddie: Or explain what that is and why you don't want to know what it is.
Dr. Shauna Levy: So especially during the shortage of we go v compounding pharmacies were making like ordering semaglutide, which is the active ingredient and mixing it with things like B12 and selling it as they were calling it generic wegovy. But we know that Novo Nordisk that the company that makes we go by has a patent for the next decade. So we know there's no such thing as generic wegovy but that's how they were selling it and they were selling it for relatively affordable prices and people were just taking it in. It's so incredibly tempting as a provider to send your patients who don't have insurance benefits for Wegovy to get that. But it's scary because I don't know how it's made and I don't know what's in it, and I don't know that it's been rigorously tested and made in a clinic. I don't know any of those things. And plus, if there's a problem, there's nobody to look for it. There's nobody to question. You know, I can't call the compounded Semaglutide rep and say, what's the problem with this? You know, or this isn't working or they're having this problem. And so I feel super uneasy and not in the official statement. An obesity medicine is do not prescribe this right now. Like you said, you know, I didn't even hear about this until a publication asked me and told me that people were ordering Semaglutide in the mail and tried to do it themselves. That is craziness. But the actually what I hear when I see that is people are desperate for treatment. And because of the problems with access to care, they can't get their hands on medication. And so I think that our tendency is to point to people and say, What are they doing? That's nuts, And I'm not going to disagree with that point. But we should also hear their cries for medication that treats their disease and give them access.
Juna: Mm hmm. Can I ask you, on the trials that have been done in Mozambique and Wegovy, just like full disclosure, I'm open to this being just like a bias that I need to work on. But just the idea of anything being taken for life, I'm always like, there has to be some sort of downside, especially if it's affecting something in your brain. And like, I totally understand that there are a lot of diseases where people do need to take things for the rest of our lives because that's the way to keep you the healthiest. But it just seems to me like you can't get something for free with the human body. Like there has to be some price you pay or something. Do we know if there have been trials on people taking this for years and years and years, or does it stop being as effective? Do you have to keep increasing the dosage or does it continue to be equally effective and do the side effects go away? And I don't know, just on a longer timescale, what happens basically.
Dr. Shauna Levy: So specifically for Wegovy, there's a two year trial data at this point, like intensive two year trial data with two years. You say it's not a lot, but for a randomized controlled trial in a setting like this, it's actually very long data more than we have for a ton of other medications. But like I said, this category of medication has been around for 20 years. So we know it's highly effective. We know that the side effect profile is very low. So we know that the medications work really well. They're well-tolerated and that's what makes them so great. You know, if they didn't work that great or that they made people be really sick, they wouldn't be as popular as they are. And I agree with you, there are risks and benefits of whatever you do. But what we can't forget is that there are risks of the disease, of obesity as well. And so I feel like often when patients come to talk to me about treatment, whether it be medication or surgery, they forget that you can't just weigh the risks of treatment versus nothing. There's the risks of not treating as well. I don't mean to be a broken record, but obesity is a chronic progressive disease, so the longer it goes untreated, the more damaging it could potentially be to your body. Right. And so a lot of people have developed diabetes and then they develop diabetic eye diseases and kidney diseases and have toe amputations and all that could potentially have been prevented if we had just treated their obesity way earlier on in the pathway.
Juna: Now, if somebody. Has a higher weight but doesn't display these other health complications that are usually associated with obesity.
Dr. Shauna Levy: Right.
Juna: How do we know when obesity is becoming like a disease that is causing problems versus just its higher weight? Is it like how much visceral fat there is? Is it these other things that indicate diabetes and high blood pressure, or is it just the weight?
Dr. Shauna Levy: I mean, it is multifactorial. I don't think it's just one thing. And that's why doctors, you know, and not like vending machines have jobs is that we have to take each patient. So, so far I know every year, maybe in our lifetimes, hopefully we'll still have a job. But it's multifactorial. And you're right. Like I mentioned before, there's healthy fat and sick fat and people with different distributions of fat. And so for people who aren't going to develop the diabetes high blood pressure, they may develop knee pain, hip pain, back pain. And my question back to you and to people in general is do we need to wait for those problems to treat the disease? Right. Most people will with the disease of obesity will probably gain at least £1 per year. So do we need to wait for them to gain more weight before treating? Maybe we should be treating earlier on in some people or later on in other people. We just have to look at the individual patient to understand that.
Eddie: Can I also add to round out the conversation and start bringing this home that taking a medicine is not a defeat? It's not sort of like I tried everything else and yeah, I and nor is.
Juna: The thing to be embarrassed.
Eddie: Of, nor is it any reason to stop doing all the other stuff that we talk about that is going to help you regardless of your weight.
Juna: So don't take the medications. I'm like, I'm going to stop exercising.
Eddie: Yes. Right. I mean, like you should.
Dr. Shauna Levy: Say, that's an important point. And I'm sorry to interrupt you, but it's actually extremely important to continue exercising because when you lose weight, you lose weight of all kinds, right? So you're losing muscle weight and fat weight. So the only way to preserve your lean muscle mass is to continue to exercise as you're losing weight. So patients are like, I don't even need to workout anymore. That's a problem. That's a problem because it's not just about weight, right? We want to preserve our lean muscle mass. And you should know more about this to me probably as PM and R, because it's going to help your longevity and bone density and, you know, overall physical health and you don't want to be frail, which is a whole other thing.
Eddie: And I think we could apply that to all the other behaviors that we talk about so often. Like you should really seek community. You know, being connected to other people is remarkably healthy and well and you should sleep well. And a little meditation is probably going to be yes, be helpful and on and on, Like none of those things goes away. And this is not as much as we've spent a while talking about a medication. It's not the be all and end all know. So with that, we'd like to thank you so much for your your time, your passion, your expertise, your expertise and for explaining so much to us.
Dr. Shauna Levy: Thank you so much.
Juna: Thank you so much to Dr. Shawn Levy for joining us. On today's episode, we will be linking to her work on our website, Food We Need to Tor.com. You can find us on Instagram at Food. We need to talk. You can find me on Instagram at the official Yoona and unit data on YouTube and TikTok. You can find Eddie.
Eddie: Up in the Northwoods. Okay.
Juna: Are you going back?
Dr. Shauna Levy: You can't leave us again.
Juna: No. You can find Eddie staying here in the northwest.
Eddie: Okay, For.
Juna: Now. Okay. Food We need to talk is a production of PRX.
Eddie: Our producers are Morgan Flannery and Rebecca Seidel.
Juna: Tommy Bazarian is our mix engineer with production assistance from Isabel Kirby McGowan.
Eddie: Jocelyn Gonzalez is executive producer for PRX Productions.
Juna: Food We Need to Talk was co-created by Carey Goldberg, George Hicks, Eddie Phillips and me.
Eddie: For any personal health questions, please consult your personal health provider to find out more. Go to food. We need to talk Dcoms. Thanks for listening.
Juna: Oh, it's big.
Eddie: It's magic.
