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  5. Episode 36: Weight Management and Obesity Treatments in Diabetes

In Episode 36, Drs. Kalyani and Marci Laudenslager, return to dicuss weight management and treatment options for obesity in this second podcast in a 2-part series. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating, Activity & Weight Program. She is a Diplomate of the American Board of Obesity Medicine and her clinical expertise is in obesity and obesity-associated disorders.  She was recognized as a “Top Weight Management Doctor” by Baltimore Magazine in 2021, 2022, and 2023. Dr. Laudenslager is a clinician educator and researcher – her work is specifically focused on the educational gap that exists in obesity medicine. She teaches learners at all levels of medical training and designs curricula aimed at improving obesity medical education. Dr. Laudenslager received her doctor of medicine degree from Drexel University College of Medicine. She completed her internal medicine residency at the Hoftra Northwell Internal Medicine Residency Program where she additionally served as Chief Resident. She became a Harvard Macy Scholar during her year as Chief Resident.  Dr. Laudenslager received her Master of Health Science degree from The Johns Hopkins Bloomberg School of Public Health and completed her General Internal Medicine Fellowship training at The Johns Hopkins University School of Medicine.

Transcript

EPISODE 36: Diabetes, Weight Management and Treatments for Obesity

Rita Kalyani: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.

We are thrilled to welcome back Dr. Marci Ladenslager, who will be talking about weight management and approaches to treatment. Dr. Laudenslager is an internal medicine and obesity medicine physician in the Johns Hopkins Healthful Eating Activity and Weight Program. She’s a diplomat of the American Board of Obesity Medicine, and her clinical expertise is in obesity and obesity associated disorders. She received her Doctor of Medicine degree from Drexel University College of Medicine and completed her internal medicine residency at the Hofstra Northwell Internal Medicine Residency Program, where she additionally served as chief resident. She became a Harvard Macy’s scholar during her year as chief resident. Dr. Laudenslager received her Master of Health Science degree from the Johns Hopkins Bloomberg School of Public Health and completed her general internal medicine fellowship training at the Johns Hopkins University School of Medicine. Welcome Dr. Laudenslager to our podcast.

Welcome Dr. Ladenslager

Marci Laudenslager: Thank you for having me. It’s such a pleasure to be here.

RK: Now, moving on to treatment, how do we address overweight and obesity in practice and specifically in people with diabetes. As I mentioned, this is a focus throughout our continuum from prediabetes to diabetes. We, we talk about lifestyle management all the time. But what does that really mean for you as a weight management specialist and obesity specialist?

What are the factors that we should be considering, or a person with diabetes should be considering, in their lifestyle management?

ML: Nutrition is something that we talk about a lot as is activity, but we mentioned a little bit about this earlier, sleep, stress, mental and emotional health, all such very important facets of, of lifestyle management.

I think that one of the first things that I do in my practice is sort of, unpack what we talk about culturally and separate that from the scientific evidence. That we’re not so anchored in just a nutrition and activity space. We really understand all facets of lifestyle because.

Sleep and stress, especially are very, very important and just as impactful on, on body weight as the other things that we’ve been talking about.

RK: I agree. I think that these are things we don’t talk about as much as we should. And we are beginning to recognize, I know for us in diabetes care, the importance of screening for sleep disturbances and, stress and mental health, and how that can impact also obesity and weight management. You talked about nutrition and exercise, which we have recommendations on routinely for, for people with diabetes, but I wonder if you wanted to talk a little bit about the societal view of obesity and perhaps the stigma that might be associated with that, that makes it difficult for people perhaps to accept and address in themselves. One of the things I’ll say, if I could, that I hear from my patients is, “I feel like I’m to blame, that it is my lifestyle habits that led to this.” And I think that also contributes to the challenges of managing weight. I just wondered, what you would say.

ML: I think the most important thing that I can say about that topic and about the way that we view obesity is, we really need to separate the cultural dialogue on this from the scientific evidence, so obesity is truly this chronic, highly complex metabolic disease. This is not a lifestyle choice. I think that culturally we’re taught to feel that and it’s difficult to unlearn some of what we’re taught culturally. It is very hard, and I think going back to those etiologies that we discussed before. There are many etiologies of obesity and many, many, many driving factors for weight gain. Understanding that I think is an important place to ground yourself and you’re thinking about experience with body weight. It goes so far beyond nutrition and activity, and it goes so far beyond that oversimplification of obesity as just a math equation; calorie balance in the day. It is very much not that our fat tissue is so dynamic, where you were dealing with a chronic metabolic condition that is based in hormones and there are so many of them and they talk to each other in a complex way. I describe this to folks in my practice as, a lively discussion amongst family members at Thanksgiving. There’s a lot of talk back and forth. There’s a lot of shouting over people. It really is complex the way that hormones interact in an obesity state. Beyond that, there are also these important. metabolic adaptations to weight loss that I think we don’t talk about enough. And what I mean by that is as the body is losing weight, our hunger hormone, ghrelin, goes up and our satisfaction hormones of which there are many, they go down. And that means that we are hungrier, and the body basically gets fewer calories in our calorie budget for the day, and that makes weight loss on its own difficult, but it’s also difficult to maintain weight loss for this reason, because of what’s going on with those hunger and satiety hormones.

As we’re losing weight, generally hungrier, and our metabolism rate goes down. The driver of our metabolism just so that folks know is really our muscle mass. As you’re losing weight, it’s important to maintain your muscle mass as you’re losing body fat, because if you’re losing your muscle, you lose your metabolism in a sense. You can simplify it that way. If your metabolism rate is going down, that makes long term weight maintenance very challenging. I think the biggest misconception about obesity is that it’s a lifestyle choice – it is not. That it is simple – it is not. That there are these quick fixes – there aren’t. Lots of different threads of dialogue out there. And I think, the obesity space is unique in medicine and that there’s a lot of misinformation and disinformation out there so that when you yourself are a patient at home looking for we used to help yourself through this.

It’s hard to unpack, what’s legitimate and what isn’t. It’s a really crowded space. And it’s really important to talk with your health providers about this so that you can understand for you as an individual, what are those things that are driving weight gain for you? I can’t tell you how many times I make a diagnosis of something like polycystic ovarian syndrome. There are genetic factors that are at play that, folks hadn’t talked. about before. It really is complicated. And for that reason, seeing an obesity specialist or an endocrinologist is really important to understand what those driving factors are.

That is the place where we start. Sometimes it’s something as simple as, Hey, I have a really, really, really challenging sleep problem. I’ve had insomnia for decades and I take Benadryl every night to go awake. Well, we have a major sleep issue there, which is going to cause a problem. And Benadryl is inherently waking promoting.

And so, somebody might be scratching their head at home thinking, “Hey, what’s going on? I’m highly active. My nutrition is super balanced. What is driving weight gain?” And the answer there is sleep. Number one and taking a weight gain promoting medicine Benadryl without knowing that that’s the effect the medication has.

It is highly complicated. I think really, really emphasizing that lifts the burden of responsibility. This is not a place of fault. This is a complex disorder that really needs to be deeply understood so that we can address those things that are driving weight gain and help folks move forward in their health.

RK: I think one of the things that I hear from what you’re saying and I think that maybe gets lost in the conversation, sometimes when we talk about weight management is the mental approach-  what our psychological mindset is to approach some of the challenges, like you mentioned with stress and how it affects weight.

I wonder if you could talk a little bit about that. Cause I think there are many programs out there that really leverage that in terms of their ability to lead to weight loss. Could you talk about the role of some of our mental thinking approaches to weight management?

ML: We can talk about stress and anchor there for a second because I think that that does share real estate with a lot of other common topics and emotional health. Stress is like transient diabetes. Think about it that way when we’re under high levels of stress, especially if this goes on for a long time.

Our stress hormones, we can think about cortisol as a common one. It has many friends, cortisol and company. They all go up that can cause insulin resistance as well as changes in some of those other satiety metabolism hormones. The net effect of that is typically a decrease in our metabolic rate and an increase in our food intake because we’re much hungrier.

That is sometimes centered around this increase in what’s called “the hedonic drive,” which is basically that emotional feeling around foods. It’s centered in the the reward pathway. The emotional reward the body receives from taking in certain foods and that hedonic drive, that place of thinking that is more geared toward palatable foods.

That’s what it searches for basically comfort foods all of that taken together before under high levels of stress. Cortisol goes up, a whole bunch of other things happen hormonally, our metabolism rate suffers, we’re hungrier, and we’re hungrier for specific things. Those comfort foods that are typically those high calorie, ultra processed foods.

And with that, we typically can get an increase in that visceral fat as well. Thinking about stress that way is important and connecting that to sleep. We can do that easily as well because the body is see sleep disorders as a form of stress in a way if we’re not getting adequate sleep, our hunger hormone, ghrelin, goes up and our satiety hormones, things like leptin, they go down we’re hungrier, we’re less satisfied with the foods that we’re eating. One of the things that I typically use in my practice; this is a nice tool for, where do I start with managing some of the emotional connections to food; and let’s use stress as an example here: if I know for myself that stress is something that leads to cravings and, man, I’m always reaching for this particular food. How do I manage that? Think about something you can do and a few seconds, something you can do in a few minutes. And then another thing you can do in a few hours or the better part of it, the day and give yourself some indoor and outdoor options and write them down because that makes things a little bit more concrete. If we’re just thinking things in the mind, it seems a little bit more abstract and it’s hard to really use those things as a tool later think about those things with great intention and write them down and then the next time that you’re feeling stressed think about the environment that you’re in: Okay, I’m at work. I can’t do my outside thing But, I told myself that maybe one of my things was listening to a little bit of of music or doing like a puzzle or something like that., you have to find the thing that really speaks to you. Maybe it’s just taking some deep breaths because I’m in a meeting and I can’t do any of those other things.

So find something that can be there for you no matter what environmental situation that you’re in. And over time, the brain will start connecting those new activities to, hey, these relieve stress as well. It isn’t just that connection to food that exists that starts to disintegrate, and the brain learns a new, healthier habit.

Over time, this does take practice. Let’s take practice that it takes time. We can, number one, help with our levels of stress because we’re giving ourselves tangible tools for how to manage things. And we’re thinking about tools that are non-food or drink related we’re separating food and emotion in the brain, and that can be really helpful as well.

RK: Thanks for sharing those tools that you use in your practice because I think– and we’re going to talk next about the lifestyle changes and the medications, which are of course, very important–but what you are describing, which is the emotional reaction to food and the cravings and stress is very important and, for some people, may be a main driver. And so, I think that strategy of thinking of healthier habits that can replace the reward, the emotional reward, that people associate with food over time can be learned and I think that’s a practical tip that anybody can do in any environment thank you for sharing that.

Talking a little bit about lifestyle the logistics of that let’s start with diet. Is there a right diet for weight loss in diabetes or without diabetes? What would you say?

ML: Yeah, I love this question because this is probably the number one question that comes up clinically.

Is there a right way to eat? And the short answer to this is no. And if we look at decades of research, and we look at those studies that have taken specific nutrition plans, fad diets especially, line them all up, put them head-to-head and see which one is the best for weight management, at the end of the day, they’re all the same. It is the sustainability of a nutrition plan that is going to help folks be successful long term. I think when we’re talking about diabetes, there are a number of evidence based based nutrition styles that can help lower blood sugar. And I’m thinking about, a lower carbohydrate diet.

And that means a lot of different things. Generally, can think about that as being 25 to 45 percent of total daily calories from carbs, but again, there are lots of ways to follow a lower carb plan, a plant based. Diet can also be helpful in lowering A1C or blood sugar that’s vegan or vegetarian, both of those will be effective in that way.

And the Mediterranean nutrition style can be helpful. But I think that, what all of those have in common, when we think about, plant based, Mediterranean the DASH diet is another nutrition style that comes up a lot in research studies and in health. And that stands for the dietary approaches to stop hypertension.

So that’s one we usually use in the blood pressure management space. But if we look at the common principles to all of those evidence-based nutrition styles. One thing stands out and that they’re all whole foods based, they emphasize lean proteins, fruits, veggies, whole grains, and they minimize things like sweets and ultra-processed foods.

There are so many healthy, balanced evidence-based nutrition styles out there. I think this is where, especially if you are managing diabetes, it’s really important to meet with a dietitian or talk to your provider about a personalized plan, knowing that, yes, this whole foods approach, that can be applied in a number of different ways, but there’s no right diet per se. It’s really about finding that sustainable lifestyle plan that will support you in your health goals long term. It’s the sustainability part of it that really is more important.

RK: I think that the sustainability part will be a theme as we talk about medications and potentially surgery as well in terms of getting the weight off but keeping the weight off as well. Moving on to exercise, you mentioned the importance of ensuring that even with weight loss, that the muscle mass is preserved. And as you noted that if you have a calorie deficit, you’re going to lose both fat and muscle and it’s important to maintain that muscle mass. What exercise regimen do you usually recommend for people to maintain that healthy balance of muscle when they’re losing weight?

ML: I typically start by asking folks, where they are in terms of their health goals. If we’re in the weight loss phase, cardio will tend to lower body fat more so than resistance training. If we’re really anchoring in that weight loss maintenance phase, then exactly as you say, that preservation of lean muscle becomes really important because that helps support our resting metabolic rate.

So activity will increase insulin sensitivity and leptin sensitivity. These are all things that in the brain can help lower our appetite and keep our metabolism healthy. All activity will help with cardiovascular risk or heart health. It will help decrease inflammation. It really is about picking the style of activity that matches with what, your health goals are right at that moment. If we’re working really on weight loss, I typically emphasize cardio at the beginning, maybe more so than resistance training. And then, we flip things around when we get farther down the line. We want to really be able to maintain that weight that you’ve been working so hard to lose they’re both important. They just act differently. It’s important to know though that weight loss from exercise alone is typically modest. We use activity and we partner that with, other lifestyle strategies like medications, like surgery, depending on, that particular individual, but knowing the benefits of activity overall. You can use them in those phases appropriately, but at the end of the day, pick something that really, sparks joy, because I think the one thing that can be a barrier to activity is thinking about, what it should be. What’s the ideal? There’s no “should.” There just “is”. What do you like to do? What would you like to do more of? And starting from, from that space, what are you able to do? It really is thinking about the individual person and what brings them joy, what helps with their energy, what helps with their sleep. Activity can do all these things. Getting outside and just moving your body can help with mental and emotional health. It can help with sleep health. Thinking about it as a lifestyle strategy that just boosts overall health and wellness of quality of life- that’s usually where I put my focus and we start where we start, and you can gradually build up over time or change things depending on what the health goals are.

But, when it comes to muscle mass, it is important that we preserve that throughout the journey for, those metabolic reasons we were talking about. We want to make sure you’ve worked so hard to lose body weight. We preserve your muscles so that you can keep the weight off long-term.

RK: Really it should be activity that aligns with the individual’s own priorities in terms of what they want to do. And then the balance of cardio exercise to muscle strength and exercise as well, which should be individualized or really aligned to where they are in their weight loss journey.

Moving now to medications, which is really in many ways, the hot topic these days. What medications are available for people who have tried these other strategies? Let’s say that lifestyle strategies, the emotional regulation, the stress management, and they’re still not successful. And who is eligible as candidates for the weight loss medications?

ML: There are a number of medications available to help treat overweight and obesity, and they range from pills that you take to injections. I think that those are getting a lot of attention right now. We can certainly talk about those. When we talk about oral medications for weight loss; pills that you can take. The oldest one that I can think about is phentermine and that was FDA approved for weight loss in 1959 this one has been been around for a very long time that is a mild stimulant. It will act as an appetite suppressant. There are combination pills. One that actually includes phentermine – a medicine called Qsymia, which is a combination of phentermine and topiramate; also goes by the name Topamax. Another combination pill called Contrave, which is also the mix of 2 medicines: bupropion and naltrexone. Those can give a little bit of metabolism support and they will typically be experienced as an appetite suppressant for folks, but it is doing other stuff in terms of metabolic support, a mild stimulant effect. When we get to the injection medicines, these are the newer generations or weight loss drugs. And the one that I’m thinking about in particular, are those ones that work on GLP1. That stands for “Glucagon-like Peptide One”. These are the injections that you probably see on social media, on the news. These target a really important satiety hormone, GLP1’s. That helps manage weight but also helps regulate blood sugar there really are a number of options or more options I think than folks think about actually, because some are more popular than others right now. They’re just getting more media attention. Doesn’t mean the other ones are not effective. It just means they’re not getting as much media attention. But weight loss medicines have been around for a long time and, talking with your physician about which one may be right for you, I think is important because there are a number of contraindications to certain medicines for example, folks with certain heart conditions wouldn’t be candidates for some of these stimulant medications, you have to know which one is the safest for you to take and which one is going to be the most appropriate. Some of the ones that we talked about can really help with cravings, or hunger at night, or we can use them and tailor them to hunger that happens at a very specific time of day.

So all of that is to say, there are lots of options that can be really tailored to the individual experience and that will be safe for that person. That really is the most important thing. What’s going to be safest and what’s going to be the most effective for your particular experience with your health and your body weight for folks who are candidates for these medications. It’s those who have. a BMI of 30 or greater, or those who have a BMI of 27 or greater, generally speaking, plus a weight associated condition, like diabetes, like hypertension. Although there are others that fall out of, those definitions, that’s the most classic definition of, who can use one of these weight loss drugs.

So, I can talk a little bit more about those injection medicines, because I think that that comes up a lot. I think the one thing that I get asked the most is, why do we use these medicines, the injection ones per se, the GLP ones? Why do we use those in obesity? They’re classically used in diabetes. Why do they also work here? In obesity, post prandial GLP 1, is decreased all of that means the sense of satisfaction that you get during or after your meals is impaired. That is what happens as body weight goes up when we use these injection medicines in obesity, that dysfunctional satisfaction signal is corrected. You appropriately experience fullness with your meals. Those medicines will also increase your energy expenditure, how many calories you burn, going about your day-to-day life. And they have the same effects that are beneficial in diabetes. They affect those hormones that regulate blood sugar.

Diabetes and weight management share hormones in common. And when we use medicines that target, target those certain hormones, that’s why one medicine can work in a bunch of different spaces. It really is important to highlight that, weight management. Heart disease, liver issues, diabetes… there are so many hormones that are shared and that’s why those medications are shared in those different spaces. And that’s what we want from a drug we want it to be impactful for as many things as possible. That’s why you see things like semaglutide; it goes by the brand names Ozempic and Wegovy. That’s why we see it being used for lots of different things because there are these shared hormones with different disease states and that’s why we get benefit across the board in a lot of these different areas.

RK: And you mentioned Ozempic or Wegovy, which is semaglutide some others just to round out the class might include dulaglutide or brand name Trulicity or liraglutide (brand name Victoza or Saxenda). These are medications, like you mentioned some are approved for diabetes and some are approved at the higher doses for obesity. A question that I often get asked is when you use these medications for obesity, any of the medications that you’ve talked about, whether GLP-1s or the other medications that you talked about, how long do you continue on them? And what happens when you stop? Do you regain that weight?

ML: With medications for weight management, I typically frame these as chronic use medicine. Medicines that you’re going to be on long-term because obesity is a chronic metabolic disease, and I view it just like Type 2 diabetes or hypertension. We use hypertension, for example, some folks will, follow the lowest salt diet you can even think about. But there are other things in their family history, their genetics that just predispose them to having a higher blood pressure they need a blood pressure medicine to manage that; to couple with their lifestyle efforts. That makes things better. And if down the line, we take the medicine away, what’s going to happen? Their blood pressure is going to go back up because those underlying things that we can’t control, like their genetic factors are still there with weight management, it’s important to think about the chronic metabolic disease definition and center the way that we use medications in that space. They really are meant to be used long term. Not to say that can’t go off of them, down the line, you absolutely can, but you need to be working with a weight management specialist to do that. The one thing that I think gets confusing in the current cultural conversation around these newer medicines in particular, is that there is a concern that if I stop this medicine, is there a rebound effect?

Am I more susceptible to weight regain because of something that the medicine is doing. And the short answer to that is no, it really is about understanding what things are contributing to weight gain in the first place and are they still there? For someone with polycystic ovarian syndrome, that’s something they’re going to have for a while.

So using a medicine to help control that will help manage their weight. And if you go off of that, Weight management medicine than the weight gain that comes with polycystic ovarian syndrome will come back So it is more nuanced in that way, for someone who has Insomnia someone who is under chronic stress for someone who had like all of the etiologies those causes of weight gain that we Talked about before if those things are still there. They will continue to contribute to weight gain I think a really important example of this is those who are on medicines that cause weight gain, and they need to be on them. Insulin is one example, but there are many others. There are certain cancer medications that cause weight gain, and we of course need to continue those.

There are mental health medications that folks need to be on, and they cause weight gain, but they need to continue them. When that’s the case, a weight loss medicine is critical because the thing that’s going on in the background that caused weight to go up in the first place is still there. There’s nothing inherently about the weight loss medicine that creates this rebound effect. It’s just about understanding what affects weight gain. And if those factors are still present, you take the medicine away. Weight will come back on for those reasons. It’s a little bit subtle and nuanced, but yes long-term medicines for most of these is typically the way that I use them.

RK: It makes sense that you really do have to address the underlying factors contributing to why you’re gaining weight in the first place. And you mentioned that the newer agents, particularly are really ones that can be used chronically especially if there are underlying factors.

But as I understand that the stimulants are really designed to be used just for a few months at a time. Is that right? Some of the older medicines?

ML: That’s a state-by-state question. When you’re a provider, it’s important to know the laws of your state, because the evidence supports long term use of stimulants like Phentermine, but in some states, it is still only approved for short term use. And by short term use, I mean three months or less. There is a discrepancy by what is supported by the literature and what is still listed in FDA guidelines and how the states interpret those things. All of that is to say, we can absolutely safely use the stimulant medications long term. Guidelines support that use, but that isn’t always possible depending on where you live. That all said. It’s important to be closely monitored when you’re on any of these medications because we want to make sure that you’re safe and supported while you’re on these drugs. It’s important to monitor blood pressure and heart rate and things like that. A good example of the long-term use. Phentermine, for example, is in one of those combination pills we talked about, Qsymia, that’s approved for long term use. It really just is about the way that the medications are labeled at the federal and the state level. My feeling about this is that the current labeling guidelines are not necessarily up to date with the current science of weight loss. My hope is that the labeling catches up to that. But that is where that confusion point comes from. I use these medicines long term in my practice, provided that, folks meet criteria to do that safely, but that will vary significantly state to state, depending on what those state laws are.

RK: That’s really good to know thanks for going over that. We didn’t have the chance to really go into the side effects of some of these newer medications like the GLP 1s. I think that the GI side effects and also the cost tend to be limiting factors on an individual basis something also to keep in mind.

Lastly, I think we probably don’t need to go into great detail about surgery, but I wonder if you could briefly talk about whom you might consider for surgery if the lifestyle changes, and the, and the medical management isn’t achieving the desired goals.

ML: Sure, the surgical guidelines have actually changed, and I can highlight that evolution and who is eligible for bariatric surgery it used to be that folks would need to have a BMI of 40 kg/m2 or greater or 35 kg/m2 or greater plus a weight related disorder like diabetes like hypertension.

The new guidelines say that bariatric surgery should be considered for those with a BMI of 30 to 35 kg/m2 class one obesity and in folks who have that BMI, but have not achieved significant or durable weight loss or a comorbidity improvement with non-surgical methods like lifestyle management or pharmacotherapy medications. And then for everyone who has a BMI of 35 kg/m2 or greater with or without a weight associated comorbidity, they would also be eligible there is basically this shift downward by five BMI points.

It’s important to note that while these guidelines have recently been updated, and I think that it’s great to be able to offer surgery to folks who would benefit from it, not all insurance companies have quite adopted this new guideline statement. For that reason, not all surgeons are offering bariatric surgery at those lower BMI thresholds. But in time, that will be the new standard. Right now, we typically will talk about surgery with those old cutoffs, 40 or above, or 35 and above with a weight associated comorbidity. If someone has really difficult to manage diabetes, for example, and their BMI is 32 kg/m2, and their insurance will cover a bariatric procedure, we absolutely will talk about that. Because we’re in this transition space of guidelines, it really does require talking to each individual person and saying, ” what are your health goals? Is this something that you really want to consider at a lower BMI threshold? Is insurance going to cover it? Is it affordable for you?” it’s important to make sure that we address that. All of those things Surgery is a wonderful tool, with the sleeve gastrectomy, which is, one of the more common procedures you can expect to lose 20 to 25 percent of body weight with the gastric bypass or the Roux-en-Y, so to speak 30 to 40%. With diabetes, if we’re talking about that specific example, we can get remission. of diabetes with surgery, 29 percent of those who have a bypass and 23 percent of those who have a sleeve. All that is to say they’re very effective. When we’re looking at how surgery intersects with the evolving landscape of medications, it is actually very exciting because some of the new drugs that we’re using for diabetes and for weight loss are approaching how effective surgery is.

I think that that is going to continue to happen. That we have medicines that are valuable in a similar way to bariatric surgery somebody would qualify by newer guidelines, but their insurance won’t cover it, then, they’re an incredible candidate for some of the, the stronger anti-obesity like some of the newer generation injection drugs that we were talking about.

RK: I agree. It’ll be interesting to see in the years to come how some of our medications may approach the outcomes that we see with surgery and remission, like you mentioned for diabetes. It’s something that we may not have talked about a few decades ago, and to think that surgery or even some of the medications that we have now could lead to remission of diabetes, not having diabetes at all anymore is pretty amazing, in some people that that could be seen. Of course, with any surgery, there are potential procedural complications that we need to be aware about, but in general, in the hands of an expert it can be done safely particularly in, in huge surgery centers. Absolutely.

As we round out our conversation today and thank you so much for taking the time to talk with us about this important topic, I was wondering what you would say to a person who’s listening today who might be struggling with their weight loss goals and really feeling discouraged in terms of what they’ve been able to accomplish.

How do you counsel your patients who are beginning or are struggling with their weight loss journey in terms of what they can attain and what is feasible in the short and long term.

ML: The first thing that I’ll say is that this is hard. We’ve been talking a lot about this complex conversation with metabolism hormones. It can get really deep when we talk about what causes weight management challenges and, makes them more difficult to kind of manage over time. It’s really important to understand the complexity of all of this and how much it sometimes feels like folks who are struggling are at odds with their hormones.

They’re sort of fighting it. against them in a way, ” Hey, my body’s not really doing what I wanted to do. What’s going on?” This is a really complex disorder. It is absolutely manageable with a healthcare partner who, can really kind of help you navigate what has been the key contributor to weight gain, and then we can understand how to provide support going forward. It is difficult. This is a lifelong journey for so many folks who are not alone. For those reasons, it’s important to seek out expert care so that we can understand, is there another medical condition that’s contributing? Is there a medication that you’re taking that’s making this a little bit harder? Are there lifestyle habits that we can give support around? Are there other medical conditions that we can help manage? Just think through your lifelong journey and know that you’re not alone in this. There are absolutely folks who it is our job. It is our pleasure to help. That is what we are here to do. And there are so many ways that we can help with weight management and help with long-term sustainable weight loss for the providers out there, I think it’s important to really listen to folks, listen to the lifestyle journey. I learned so much from my patients just sort of asking, can you walk me through your journey. That can tell me so much. Then once I understand your journey, that’s when I can understand, how do I begin to provide support? How do we begin to help make weight management a little bit more approachable and how can I give you support long-term and give you back your quality of life? Seeking health care support from an expert I think is truly important just because it’s really complex as we’ve been talking through. We as providers are here to offer compassion and supportive guidance, never judgment. That is a key takeaway for my practice.

RK: Well, thank you so much, Dr. Laudenslager, for being here today, for sharing your expert perspectives on weight management and obesity, specifically in diabetes and the non-judgmental compassionate care that’s so important for long term success and the different options that individuals have in terms of managing and approaching challenges with weight management. Thank you again for being here today.

ML: It’s been such a pleasure. Thank you for having me.

RK: I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit hopkinsdiabetesinfo.org. We love to hear from our listeners. The email address is [email protected]. Thanks for listening. Be well and see you next time.

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