Obesity Doctor on Everything You Need to Know About Ozempic

CHRISTIANE AMANPOUR, CHIEF INTERNATIONAL ANCHOR: Now, we turn to a drug that our next guest says could, “Change the conversation about an often-stigmatized medical condition.” Nearly 2.3 billion people globally, and more than two in five American adults live between overweight and obese. With the help of breakthrough weight loss drugs, Dr. Fatima Cody Stanford is seeing some patients lose as much as 15 to 16 percent in weight. And she joins Hari Sreenivasan to discuss the recent buzz around these medicines.

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HARI SREENIVASAN,CORRESPONDENT: Christiane, thanks. Dr. Fatima Cody Stanford, thanks so much for joining us. You are and obesity medicine physician at Mass General. And I want to know, right now, if I open a newspaper, I’m dating (ph) myself. If I open my phone, I see headlines about new classes of medications with names like Wegovy, and Mounjaro, and Ozempic. First of all, just explain to us what these medicines do.

DR. FATIMA CODY STANFORD, OBESITY MEDICINE PHYSICIAN, MASSACHUSETTS GENERAL HOSPITAL AND HARVARD MEDICAL SCHOOL PROFESSOR: Absolutely. This particular class of anti-obesity medications are what we call GLP-1 receptors agonist. Now, that’s super fancy and it stands for Glucagon-like Peptide-1 receptor agonist. You might not have to remember that, I do. But let’s talk about how these medications work in your body. They actually worked primarily in the brain by causing two pathways to function in a way we want them to. There’s a pathway of our brain called the plum C pathway, it’s a pathway that tells us to eat less and store less. And these medications work by really augmenting that pathway. Stimulating that pathway to be more active. But it also works by down regulating or inhibiting the pathway called the AgRP pathway, and that pathway tells us to eat more and store more. So, you can imagine that since it’s working directly in the brain, we are seeing really potent degrees of weight loss in the order of somewhere between 15 to 20 percent total body weight loss on average for the agents that you mentioned that — the outset. But — and that, they work in few other ways. They actually slow movement through your G.I. tract. What does that mean? You go and eat something and it moves really slowly. So, you can imagine, if you eat breakfast and things move really slowly, by the time lunch happens, you’re probably still full, whereas you would normally be hungry. So, that’s another way it works. And it actually improves how your body secretes a hormone called insulin. And then finally — and this is what a lot of people don’t know, it actually browns your white fat tissue. You might be like, why does that matter? The more brown are fat issue is, the more active it is, which means that even when we are sitting here, like we are doing, Hari, we are burning more at rest than we would be normally. So, it works in a lot of different ways in the body and this is why, I think, it’s gotten as much attention as it’s gotten.

SREENIVASAN: So, we should mention that you do consult for a number of pharmaceutical companies, including the people who manufacture Ozempic.

DR. STANFORD: Right.

SREENIVASAN: And now you say that this is, kind of, a game-changer for how we think of obesity. Why is that?

DR. STANFORD: I don’t necessarily think of this as a game-changer, but I think that these medications have gotten so much attention that they are changing what we think about this disease. You know, it was in 2013 when the American Medical Association acknowledged obesity as a chronic disease, but that new story came and it went. Now, we actually see people really taking medications and benefiting from these medications. We are seeing responses, such that they feel like they no longer have to struggle with weight. And they realized that their weight struggles are not all their fault. And so, I think that that’s where we talk about this changing the conversation surrounding obesity, what we see today here in the U.S. and around the world.

SREENIVASAN: So, tell me a little bit about the side effects that this class of drugs have. I know that each drug is different, but I have yet to meet a drug that doesn’t have a side effect.

DR. STANFORD: You are 100 percent true in terms of looking at this. The number one side effect from GLP-1 agonist is nausea. So, if you look at the clinical studies, particularly as you titrating the dose, so, if we’re looking at semaglutide, which for the treatment of obesity goes up to a dose of 2.4 milligrams, as that patient is titrating from 0.25, 0.5, one milligram, 1.7, and then finally 2.4 milligrams, that titration, they may feel nausea. Up to 44 percent of individuals can experience that. Now, what I have found is that if you need to stay at a dose longer to help mitigate that side effect, that’s going to be really important. Behind nausea, the second most common side effect is constipation. And if you go back to how these medicines work, right, if things are moving through the G.I. tract very, very, very slowly, things can get stopped, and you know. And so, sometimes we have to change a person’s bowel regimen to make sure that we don’t have constipation, which can be very common. Those are the two most common side effects that we see in the population. There are other, kind of, more rare side effects, but those are the most common side effects.

SREENIVASAN: So, is this a forever medicine? I mean, one of the things that people have been reporting is that if they get off of this drug, that the weight that they worked hard to lose is going to come back.

DR. STANFORD: You know, Hari, that’s an excellent question. I’m so glad you asked it because I really want to answer it and make sure that we understand this. I want us to think about this, and I’m going to divert our attention to thinking about diet and exercise. You know, we don’t expect to eat one healthy meal or eat healthy for one month, and that can last us. Similarly, we don’t expect those exercises we were doing back in the late 90s — I was a Tae Bo enthusiast, to last us till today. Similarly, when we are looking at these medications, they only work when we are using them. Tae Bo was really great back in the day. But if you’re not doing it today, it’s not giving you that impact. And when you withdraw the medications and the wilding studies in the New England Journal really demonstrated this, when you pull that back, what we start to see is weight regained back to where the patient was prior to adding that in? Why? We are no longer acting on those pathways of the brain we talked about. It can’t work if it’s not being utilized. So, if you are a responder, if you do need these medications, and they do work for you, this is a chronic use medication for the chronic relapsing, remitting disease, that is obesity.

SREENIVASAN: What are the criteria that you are checking off in your, you know, mental checklist, that says this might be a candidate that would benefit from this versus another candidate who might just have to hear that hard news that diet and exercises are really going to be the best thing for you?

DR. STANFORD: I typically follow the guidelines. And there are several sets of guidelines, but they all align with each other. So, they say that we should consider medications for patients with a body mass index of 27 plus in obesity related disease. In which diseases, Hari, these are disease like high blood pressure, type 2 diabetes, obstructive sleep apnea. Now, if a patient has a BMI greater than or equal to 30, which places them into having obesity by BMI criteria, we could utilize medications in that group also. So, those are the key criteria that we are often utilizing now. I am not a huge fan of BMI people who have heard me talk about this. And so, I think on an individual clinician basis, this is also important to look at the full profile of that individual. What type of obesity do they have? Do they have obesity related disease? What is necessary for that individual in front of you? But making sure, like you said, to use these patients — use these in patients that actually need them and not just people that want these medications.

SREENIVASAN: So, what if there are people watching right now who might not qualify under the category of obese but their doctors are concerned about them heading into pre-diabetic mode. Maybe they have 15 or 20 pounds to lose. Is there a world where these drugs are introduced for a short time to try to get somebody, like, that jump start until — to get them, kind of, into a safer zone where they can get off it or this is just not for that kind of person?

DR. STANFORD: You know, I don’t see these as medications as a jump start, because that puts us into this idea of weight cycling, right. We have something acutely that brings us down. And when we weight cycle, we can lose and then we typically regain, you know, as soon as we withdraw. So, I look at these as appropriate tools for people that do need these long-term, not for a jump start or, you know, anything of that sort. And just thinking, like I said, treating this as a chronic disease. I wouldn’t put, you know, someone on a high blood pressure medicine that came in with one high blood pressure reading, right. And then they didn’t have evidence of sustained, you know, elevation in their blood pressure. And that’s, kind of, how I think that we should be thinking about, these medications.

SREENIVASAN: I asked about need versus want, because one of the things that we have seen with this category of medicines is it is really viral and it’s successful on social media, and you see a lot of people who, especially kind of, Hollywood, who — almost brag about the fact that, well, this is how I lost my weight. This is where it’s worked for me. And some people, it’s kind of like, this sort of, hush, hush thing where they are kind of passing around access to this. And what has done to people who actually need the drugs?

DR. STANFORD: Well, you know, Hari, I think that that is actually — you know, a little bit disgusting. I don’t necessarily use that word when I give interviews, but let’s talk about why I see it as disgusting. There has been a major shortage of these medications. This lasted throughout the course of 2022, and was a major sore spot for me and my patients. I only treat patients with obesity. And so, for patients that I see, these are patients that do need these medications. But for six, seven, eight months of 2022, my patients couldn’t get these medications So, when these patients that need it, that can benefit from the metabolic, benefit from these drugs can’t get the medicines, and they’re being utilized for people that don’t need them, that creates a dynamic of the people that need these for longevity of life, reduction of heart attack, strokes, et cetera, aren’t getting them. And people that are just trying to look cute in a bikini or for whatever their next event on the red carpet, you know, to look great. I tell my patients that I’m caring about their health, and getting them to the healthiest way possible. I don’t care about the next wedding they have, or the next reunion, or whatever it is. I want to align with their health goals and not their aesthetic goals. And I think that’s extremely important.

SREENIVASAN: There is also a pretty significant cost here. I mean, these are not cheap drugs if they’re not being prescribed to them. Which kind of, for me, it raises kind of an access and an equity issue, as well.

DR. STANFORD: You know, absolutely. I’m the director of equity here at Mass General for endocrine division so I’m always thinking about equity and the role it plays and access to therapies, particularly for chronic diseases like obesity. And you’re right, this has created this dimorphism such that those that have wealth and have this tremendous access or able to access them, and those without aren’t able to. And that really creates significant angst for me as someone who cares for a sizeable portion of the population. Who are recipients of Medicaid, which means that the medications would not be covered. Now, I happen to reside in the commonwealth of Massachusetts where our private insurers, meaning Blue Cross Blue Shield of Massachusetts, Mass General Brigham’s insurance, et cetera, are covering these medications for patients that have those high tier plans. People, you know, that fall into the group of myself. But what about those people that who don’t have those high tier plans? Where they can’t get these medications for $30 a month, which is very accessible. It creates a situation where I can’t even prescribe these medications to those individuals that are most needing these medications. You know, I really would like to see a shift in us thinking about this from a Walmart approach, right. If we give full access then people are able to get what they need, we can drive down costs. It’s just pure economics. That’s what I would like to see, eventually. Because we’re talking about over 110 million adults, and over 20 million children that could potentially benefit. And right now, we are seeing less than 2 million potentially being able to access any agent, including this class of medications here in the United States.

SREENIVASAN: I want to also talk a little bit about kind of the cultural costs. Because it seems like all the previous conversations we’ve always had about weight has been with a little bit of a bias. That we’ve all, kind of, been told its diet and exercise that will do it. And if you don’t exercise enough, if you don’t eat right, you’re going to end up obese. And then the inverse, if you are obese, then that means you must not be exercising, that you must not be eating right. But I know people in my own life who do everything by the book and cannot change the way their body is shaped.

DR. STANFORD: Yes, Hari, I’m going to change one of your words. I’m going to delete the word obese, just because it can produce stigma. But you’re, that the right most common form of stigma that’s still acceptable is weight bias, right. We are well within our purview of treating people that have excess weight, obesity, in ways that are demeaning, devaluing, and not believing what they say. Not recognizing that they are putting forth the sweat equity and they’re just not yielding results. And I really learned this as a resident. My own biases as a physician, as someone who has not struggled with my weight, has been an athlete, these types of things. I had a patient that was in her mid-40s who had severe obesity, and had struggled with severe obesity her entire life. I was in internal medicine and pediatric resident in South Carolina. And what I would do is every single visit, she would come in and see me every two to three months. I would give her this diet recommendation, or this exercise recommendation. All of these things. And over the course of three years, you know, I didn’t see her weight shift. She would shift maybe down two pounds, up one pound, really maintaining her weight set point. Well, one day, Hari, I was leaving my work out, I ran into the grocery store and who did I see but this patient. As she was about to check out at the grocery store line. So, I’m talking to her, she’s like, hey, Dr. Stanford. I’m like, hey. And we’re talking, but I’m trying to glance at her cart, and I’m trying to glance without looking, right. I’m trying to be inconspicuous. Not doing a good job at it, because she says the following to me. She says, see Dr. Stanford, I’ve done everything you told me to do. And when you looked at her cart, and this generates some emotion from me. It was pristine, perfect, everything we had ever talked about for three years in her grocery cart as she’s about to check out at the grocery store. And it was at that point that I realized that this is not just about diet and exercise. Now, as someone who no longer works and has not worked in South Carolina for over 12 years, I’ve been in Boston. I have no idea where she is and what her health is. But I can tell you that I failed her. I didn’t know that I was just giving her more and more recommendations. She was doing all the things, but I wasn’t changing her biology. And so, it gives me significant pain to know that I wasn’t able to have a major positive influence. And in many ways, was reflecting my own stigma and bias against what she was and was not doing until that key moment in the grocery store. So, I think that that was where, it was — you know, moment, an inflection point in my life and my training is what brought me here to Boston, into Harvard to do three years of obesity medicine fellowship. To learn how it could be better for patients, and that’s really changed everything in the world for me and my patients that I care for.

SREENIVASAN: You also said on the obesity section of the Academy of Pediatrics, and I wonder what you think about giving children over 12 access to these medications.

DR. STANFORD: I think a lot of people have fear and a lot of the backlash that I’ve heard in the media, particularly in social media about the new guidelines that were released by the AP regarding the use of medications and surgeries, like, we’re setting people up from eating disorders, and we’re going to have people hyperfocus on their weight. But I have a 12-year-old patient that is being treated with pharmacotherapy for obesity, that I’ve been taking care of the last two years. And I happen to take care of both her father and her mother. Recently, for some reason, they asked her what she thinks about her weight doctor. I don’t call myself, but that’s what they asked her. And she was like, I don’t see a weight doctor. And they were like, well, yes, you do, Dr. Stanford. She was like, oh, is that what she does? And so, you wonder, how might I able to talk and deal with a patient from the ages of 10 to 12, seeing her at least seven or eight times over that time, and her not know what I’m doing. Because my focus is her overall health. I know this can be done in a way that’s respectful, that doesn’t set someone up for disordered eating. And something that when she looks back at 12, she had no idea even what I do for a living until recently when her parents told her. That she will not feel as though this was a punitive situation. She’s been able to live life in a much fuller fashion after being treated for her obesity. Similarly, my patients that underwent surgery. Several of my patients underwent bariatric surgery in their, you know, teens, 14, 15, they’re now in their mid-30s. And the opportunities they have in life because we know that weight stigma sets up for discrimination in the workplace, discrimination with hiring, discrimination in higher education, et cetera. And those opportunities are very different after they’ve been treated and treated with dignity, kindness, and respect.

SREENIVASAN: Dr. Fatima Cody Stanford, obesity medicine physician at Massachusetts General Hospital and a professor at Harvard, thank you so much for joining us.