Rethinking Obesity: A Chronic Condition, Not a Choice
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Hi, my name is Michelle Tedder from Pittsburgh, Pennsylvania. Today on a special episode of Health Discovered, we take a closer look at weight management. And I have struggled with my weight my entire life. I developed type 2 diabetes. My blood pressure was getting higher and higher, joint issues, sleep apnea.

For decades, obesity was wrongly viewed as simply a matter of willpower or lifestyle choices. I mean, fasting, keto, low-carb, high-protein, vegetarian, you name it, I tried it. But science has revealed a much more complex reality, one where genetics, hormones, and biology play significant roles in determining weight.

I was the person who was, you know, collecting the data and looking at how people were losing and people would come and get on the scale. I was doing the same things they were doing and I was watching the scale go down for them and it wasn't going down for me. And I'm like, what is happening? Like, why? Why is this my life? Like, why can't I have the same success? And so I was sharing this with my physician and she sat me down and she said, Michelle, this is not your fault.

There's an underlying metabolic issue going on. And there's other evidence-based tools that are available that we know work. Nobody had ever said that to me. This growing medical consensus has profound implications for treatment. Yet stigma persists, preventing many from seeking the medical help that could dramatically improve their health outcomes.

I'm happy to say that with the help of weight loss surgery and GLP-1 medication, I have been able to lose and keep off 80 pounds for the last seven years now. It's easier to buy clothing. I can move better. My type 2 is in remission. I can dance again. I can do all the things that I desire to do. Those are wonderful things.

But I think it's just really important that we keep talking about it and demand that we be treated like anyone else with any other chronic disease. We don't blame people if they're born with type 1 or develop type 2. We don't blame them if they have cancer. So why do we blame people for having the disease of obesity? So how can we overcome the stigma? What treatment options are most effective?

and how can healthcare providers better support patients on their health journey? The answers, when Health Discovered returns from a short break.

If you're an adult struggling with obesity, if you've struggled for years and years, you are not alone. But Zepbound Terzepatide is changing what's possible when it comes to weight loss, along with diet and exercise. Proven to help lose weight and keep it off, Zepbound is a prescription medicine for adults with obesity or some adults with overweight who also have weight-related medical problems.

ZepBound should be used with a reduced calorie diet and increased physical activity. ZepBound injection is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligrams per 0.5 milliliters in single-dose pen or single-dose vial. Don't use with other terzepatide-containing products or any GLP-1 receptor agonist medicines.

It is not known if Zetbound can be used in children. Don't take Zetbound if allergic to it or if you or someone in your family had medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zetbound and call your doctor if you have severe stomach pain or a serious allergic reaction.

Thank you.

To get a better understanding of these shifting dynamics in weight management,

I wanted to talk to Dr. Robert Kushner. Dr. Kushner is a renowned weight management expert, a former medical director of the Center for Lifestyle Medicine at Northwestern Medicine, professor at Northwestern University Feinberg School of Medicine, and past president of the Obesity Society, who has authored over 200 scientific articles and 12 books on obesity and nutrition and

including groundbreaking research on weight loss medications and personalized weight management approaches.

Dr. Kushner, welcome to the WebMD Health Discovered podcast. Thank you, John. Thank you for that gracious introduction. Yeah. Well, I want to start with how have things changed over the last decade and a half? John, we're in a transformation when it comes to obesity care. And I have to say that was primarily triggered by the development and the availability of these new GLP-1 receptor agonists, just known as GLP-1 drugs.

By having an effective treatment for obesity, people are often now coming to their healthcare professional wanting to have information about these medications and asking if they're a candidate for them. It's raising the topic of obesity in almost everyday discussions. And before we dig in more, I'm curious as to what issues or questions that they've asked over these years have inspired your work.

It spans four decades, John, believe it or not. And what got me involved in this field is the underlying biology and our understanding of body weight, but also that human connection. That's really what drove me to trying to help individuals who are struggling to get healthier. They continue to gain weight or have difficulty losing weight.

We really have advanced it quite a bit in having a deeper understanding on why is it so hard to lose weight? Why is it hard to keep it off? What are the biological underpinnings of obesity, which ultimately culminated in the development of highly effective treatments?

Do you think that's what changed our understanding of obesity from being a lifestyle choice to chronic medical condition? Because for centuries, maybe even millennia, people have thought of obesity as it's a lifestyle choice. Where did you start to see this shift?

The shift occurred, I think, over the past one or two decades as we explored the underlying biology of obesity. You're right, John. It has been thought of as a lifestyle choice, even problems of low motivation, low determination, and most interestingly, with moral perspectives. You know, what other medical problem do we put morality onto? Yeah.

by having a deeper understanding of what helps regulate body weight. Why do people weigh what they weigh? Why is it difficult to take weight off? And with the help of our basic researchers and other clinical investigators, we've

We've learned a lot, and I can summarize it, that obesity is in large part an underlying biological disease, one in which appetite regulation or your ability to feel hungry or feel full and be attracted to tasting foods differs between different people. And we've also learned that extra body fat, which is what obesity is,

is actually harmful to your health. And we didn't understand why that was until more recently. And we now think of obesity as an inflammatory disease, like many other chronic diseases, that harms the body. So understanding this underlying biology or pathology

really helped us to turn the corner that's not just a lifestyle choice, that we really had to start targeting mechanisms that are going inside the body if we're going to have a good shot at treating this disease. You talked about the biological role. What about genetics? Do genetics play a role in whether or not you're at a good weight?

Genetics is one of the multiple factors that determines what we will weigh. So, for example, two twins, they grew up apart, they've never seen each other, and they meet in the airport and they look exactly the same. Same weight, same height. So those are actually one of the first observations is twins that were raised apart and then were reunited and they actually weigh the same thing.

The percentage varies anywhere between 35% to maybe 50% or 60% of genetics determines your weight. With identical twins, John, of course, it's nearly 100%. But you know, Bob, to push back on that, I still see patients that will say, my dad was overweight, my grandfather was overweight, my sisters were overweight.

Sometimes it's also learned behaviors in a family, right? So it's not necessarily always genetics, but maybe it's a clean your plate club at dinner. That can confuse the impact of genetics, can't it?

It can. And that's why when you're talking to someone who is struggling with their weight, you try and get all that information pulled apart. If you're talking to an individual who wasn't raised apart from their twin, child rearing, eating habits, physical activity, all of that is part of the story.

But when I talk to individuals who are struggling with their weight, and they tell me, like you said, you know, everyone on my mother's side is struggling with their weight. In fact, my cousin had bariatric surgery. Even though we don't routinely do genetic testing in individuals when they come to the clinic, I use that family history to inform me that there's likely a genetic component to what this individual is struggling with.

Now we're on nature versus nurture. How does environment play a role in terms of weight management? Well, you know, sticking with this genetic theme, because the argument people will say is, you know, genetics haven't changed in the past 70 years or so. So why is it that the number of people who are struggling with their weight has tripled?

And that really strikes directly at the argument that it really is our environment because genetics has not changed much. But the way that we understand this, John, is that individuals who are genetically predisposed to gaining weight, given in what we call an obesogenic environment where we have ultra-processed foods,

Physical activity is essentially engineered out of daily society. Our work is more sedentary than it ever was as we become more urbanized. Food is available just with a phone call. That has changed significantly. So those that are vulnerable genetically to put weight on have put weight on. Now, the first step in everything is diagnosis.

So we have BMI, the body mass index, and I'd love to hear your thoughts on that because there's been controversy about that. But how do you view BMI and then what other metrics do you recommend that should be utilized to assess a patient's health in relation to their weight?

Yeah, BMI has been looked at very carefully over the past several years. And this is our understanding. Body mass index is a height for weight relationship. So as you get taller, you should weigh more. And if you go outside of those norms, you have high BMI, which is highly correlated with body fat. What we have found is that body mass index is a very good indicator on the population level of

the higher the BMI, the greater the risk that that population will have more medical problems like diabetes, heart disease, sleep apnea, arthritis, and so forth, even increased death rate.

Where it falls apart in large part is on the individual basis. So if someone comes in the office and has an elevated BMI, that person may or may not have excess body fat and may or may not be at increased risk. So that's where a detailed history and physical examination comes in to assess the person individually. Now, you asked what other measurements should be done. Yeah.

What we are recommending is that an additional body measurement be performed along with BMI to assess, is the elevated BMI also associated with increased body fat, which means increased risk? So we are recommending that a measurement such as waist circumference or another calculation called waist-to-height ratio or waist-to-hip ratio be performed in the office, which is very simple to do. Yeah.

We know that lifestyle changes are always something that people who are overweight should focus on. But we know that there are circumstances when medication's appropriate. When do you decide?

So it would be someone who has obesity, someone who shows harm to their body from that extra body fat, like shortness of breath or swelling in the legs, elevated blood pressure, sleep apnea, or other problems like diabetes, in which weight loss would be helpful. But in addition to that, it's often someone who...

has not been able to reach their goals with weight loss through lifestyle changes alone, or someone who was able to do that at one point in their life, but the weight came back on. Or lastly, someone who has lost weight, but insufficient amount of weight loss to get the outcomes they're looking for, either improvement in health or quality of life.

Now, what's a realistic goal? Because you had said people haven't reached their goals. And goals are somewhat subjective. Sometimes we say for conditions like diabetes and other things, it's 5% to 10% of weight. What's a realistic goal? If you're trying to get control of your weight on your own, we usually talk about a 5% or 10% weight loss over six months. Now, that's often difficult for a lot of people. Yeah.

But the other way that health professionals think of goals, and I'm glad you brought this up, John, is we have learned a lot now about how much weight is needed to achieve different outcomes. So, for example, if your blood sugar is running a little high, your blood pressure is a little high, you probably don't need much weight loss to improve that, probably even 2% to 5% weight loss, right?

If you have type 2 diabetes and you're looking to get it under tight control, you're talking probably 5% to 8% weight loss. If you have severe sleep apnea, a lot of people who are living with obesity have, now you're talking about 10% to 15% weight loss. And lastly, if you want to reduce your risk of developing cardiovascular outcomes, like a second heart attack or a second stroke, now you're talking about a 15% weight loss or more.

So it really depends on what your personal goals are or your health outcome goals are. Now, Bob, part of my time at WebMD, I was at FDA, and the FDA's graveyard is littered with drugs that said they were going to be successful for weight loss. Let's talk about GLP-1s and how they're different from previous weight loss medications. Remind our audience how they work.

After 40 years in practice, we have finally found the target in helping people lose weight and keep it off despite all the earlier medications that were not as successful. And it's the gut. We always... It always comes down to the gut. Yeah.

So what we have found is right in our own intestines, right in our gut all along, GLP-1 is a naturally occurring hormone. And what we have found is that if you take this gut hormone, of course, manufacture it artificially, that's what a pharmaceutical company does, and give it back to people in super high doses...

they have profound effects on appetite. And that's how these drugs primarily work for losing weight. It profoundly changes your appetite such that you are less hungry, you're full sooner, you're more content between meals, food is less enticing to you, and it helps you to manage your body weight better. And every drug has risks and benefits. You talked about some of the benefits in terms of losing weight.

What are some side effects? Because there's data that shows a certain percentage of patients cannot stay on them for a variety of reasons. Yeah, the most common side effects of all the drugs in these categories, these gut hormone medications, are gastrointestinal. So they will likely cause some nausea, diarrhea, constipation, may have vomiting, may have heartburn.

What we've learned, John, by doing these trials, and I had the opportunity to participate in a lot of these key trials, is that we can reduce the occurrence of many of these side effects by doing two things. One is start the drugs at a very low dose and slowly escalate them on a monthly basis. The second thing we learned is you have to monitor and change your diet to

to work with the medication. A diet that is modest in portion sizes, reduced in overall fat and fatty foods, a dietary pattern where you're not skipping meals or going out to dinner after not eating all day long, and planning ahead. By doing those two things, slowly escalating the dose and paying attention to your diet, we can get the majority of individuals to tolerate the drug.

More from Health Discovered after a quick break.

ZepBound should be used with a reduced calorie diet and increased physical activity. ZepBound injection is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligrams per 0.5 milliliters in single-dose pen or single-dose vial. Don't use with other terzepratide-containing products or any GLP-1 receptor agonist medicines.

It is not known if Zetbound can be used in children. Don't take Zetbound if allergic to it or if you or someone in your family had medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zetbound and call your doctor if you have severe stomach pain or a serious allergic reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes, depression or suicidal thoughts before scheduled procedures with anesthesia.

If you're nursing, pregnant, plan to be, or taking birth control pills, taking ZepBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Discover the weight loss you could be bound for. Ask your healthcare provider about ZepBound or call 1-800-545-5979. Explore savings options regardless of insurance status at saveonzepbound.com. Terms and conditions apply.

Now, back to our conversation with Dr. Robert Kushner. Bob, I want to turn to stigma. I mentioned the impact of stigma at the beginning. Unfortunately, the history of medicine is replete with stigma. Even over the last few decades, we've seen stigma in patients who have HIV.

We've seen stigma in patients that suffer from alcohol and substance abuse. We see stigma in people that develop lung cancer and that were smokers. And we know that that impacts how they seek treatment. So I want to turn back to the topic of obesity because we talked about it being a chronic disease. Everyone doesn't agree with us still on that. Let's just put it out there. Everyone's not informed of the latest literature.

So how has weight stigma in healthcare affected people seeking treatment? And what approaches can we utilize to create a more supportive environment? Yeah, this has been very sticky with obesity. There's two other examples I want to mention, though, as a background that gives me some hope.

depression or mental health issues and substance use. Not that long ago, individuals with depression were told to think happy thoughts. What's wrong with you? Snap out of it. I don't think very many people think that anymore because of the national awareness of depression or suicidal thoughts and ideation. And the same thing with substance abuse. You know, stop drinking, stop using heroin or cocaine. I think people understand there's more to it now and they have much more compassion for these individuals.

Obesity is sticky. And I have to say it's one of the few diseases I'm aware of in which there is a moral perspective given to the disease. You are, you know, sloth and gluttony.

The other thing that's different about obesity is that you can't hide it. So we're hoping that by educating individuals, not only living with obesity, but those around them, that this is a chronic recurrent disease like the other ones I've mentioned. People understand that they're not doing it to themselves. There is an underlying basis for it.

The other is you asked, how does it affect people seeking treatment? What I've noticed is individuals living with obesity are often shamed for their weight. But yet when they try to seek a treatment like medication, they're often shamed for even taking a medication. They can't win either way.

How should people think about initiating the conversations about weight in a way that respects the patient's dignity? You know, we talk about a lot of that with our educational activities from medical school on. And it also applies to if you want to talk to another family member. And what we recommend is your first thing you should do is ask a question. And it's something like this. Is it okay to

to talk about your weight? Is this a good time to talk about your weight? Or a healthcare professional could say, you know, I've noticed that you've been gaining weight over the past several years. We've been working on getting your diabetes and your arthritis under control. Weight can have a role here. Is this a good time to talk about your weight? Because we have a lot of treatments available now that were not available five years ago.

So let's start with a question, John. You know, something I've seen with some patients, Bob, is, you know, they start the GLP-1s, they do lose weight, and I ask them, what have they done differently? And I'll tell you, sometimes patients will say, you know, honestly, Dr. White, I just eat less. I feel full.

And they haven't necessarily changed from unhealthy foods to healthy foods. They're just eating less pizza or less snacks.

we still have to remind patients food is medicine, right? How do we integrate that? Where sometimes that's actually a challenge because they're finding success not doing those things. So why should they change anything? That's a conversation that we have very early on in our treatment. And that has to do with what is the goals? What are your values? Where are we going with this treatment regimen? And

And what we emphasize is that weight loss is one of the vehicles in order to improve your health. Health is the singular focus here. So I'll ask them when they come in, in addition to losing weight, what is it else about your weight that is affecting your health? There's that word again. And they'll say climbing a flight of stairs, getting into something that makes me feel good. I want to get off my blood pressure medication and so forth.

So we always circle back to those other health outcomes. So it's called health beyond the scale. And you're so right about it is so important to eat a healthy, balanced diet, get in more physical activity. And I'll add, John, here, since I mentioned this,

is that these medications in some people are so effective. I mean, they're losing 20, 25, some people 30% of their body weight. Can you imagine that? I never thought I would be concerned someone's losing too much weight on these medications. But with that comes not only a loss of body fat, which is

good, but in many people, a loss of lean body mass or muscle mass. And we want to prevent that frailty or the low muscle mass. So their physical activity, particularly resistance training, becomes very important. And now, Bob, I'll ask you a personal question, if I may. Have you ever struggled with weight? And if you haven't, how do you have such empathy for patients?

John, I'm not going to give you an Oprah moment here. I have not lived with being overweight. I'll give you how I tell patients because patients will often look at me and go, how could you possibly understand? That's what I'm getting at, yeah. Right, of what it's like for me who have lived in this larger body and struggling to get it under control with all my health problems. And I will tell them right up front, I have not been overweight or had obesity myself. However, I have heard literally thousands of

of patients or individuals living with obesity, and I've heard every one of their stories. I have as deep an understanding as I possibly can without living through it myself. These GLP-1 medications have been around for a long time because they really were discovered for diabetes. It's a different dosing regimen for obesity.

You mentioned some of the side effects. Do we know about long-term effects of these medications at this dosing? Yeah, I'm glad you circled back to that because I think that's an important point. John, it's actually been 20 years. It was 2005 that the very first GLP-1 drug was approved.

These drugs have been around that long. They have circled the globe. Probably millions of individuals have taken a GLP-1 medication, mostly for diabetes. But for the two newer medications, they're called semaglutide and terzapatide, they are relatively new, 2021 and 2023. But the class of drugs have been around for almost 20 years.

there haven't been any new or unexpected side effects that have arisen over this period of time. So there are surveys in place through the FDA and other regulatory bodies that are always looking for the occurrence of new side effects or unintended outcomes, but we have not seen that. What typically happens when patients...

discontinue these medications? And how do you manage that transition? Some people are suggesting that they need to be on this for the rest of their lives. Others are saying they just need some help initially. There's data that suggests people regain the weight. What's your thoughts on what's happening when patients discontinue the medications? If this conversation, John, was about high blood pressure, high cholesterol, or diabetes,

And you asked me, what happens if someone stops taking their medication to these medical problems? More likely than not, these things are going to come back. Diabetes will come back, blood pressure will go back up, as well as blood sugar will go back up. And that's the framework that we need to be thinking about obesity because that's exactly what we see.

These GLP-1 medications and others that are coming around the corner are highly effective in reducing appetite, which we've just talked about, and highly effective in weight loss and maintaining that weight loss as long as you're on a medication. But once you stop the medication...

All those effects go away. It isn't impossible to keep your weight off, but when you finish a meal and you're not on the medication anymore, you're going to say to yourself, you know, I'm still kind of hunkery. I think maybe I'll take a little bit more. So very slowly, we call perniciously,

the weight starts to come back. Now, one final comment. This is not true for everybody. In all of the outcomes studies we've done, on average, people regain their body weight, but it is not everybody. Unfortunately, we don't know who's who at this point. All right, Bob, let's be very practical. These medications can be expensive. How do we help patients navigate insurance coverage and affordability?

Cost has to come down, no question about it. Individuals living in the United States pay more money for these drugs than any other country in the world. And that's how the pharmaceutical industry works. They make their money in the United States. Generics are going to be available. There is one now called loraglitide.

How do you navigate through insurance companies? Of course, advocate for yourself, kind of a bottom-up approach to let your insurer know that this is very important for the workforce or the community of individuals that you have. Work with your healthcare professional regarding prior approvals. Currently, Medicare does cover semaglutide if you have heart disease, but that doesn't mean they're going to pay full freight for it.

Medicaid does not pay for these medications very much because of cost. One of the saddest things I go through as a clinician, John, is I'll see a patient in my office and I will take their history, do a physical exam like we talked about. And then the next thing I do is I look at the electronic medical record which posts their insurance.

And it will tell me whether they are eligible or not. And so sad is that my determination of their treatment is going to be determined by that one panel I'm looking at in electronic medical record and ask, who's helping to pay your insurance? And that's a whole other podcast that we should have to talk about that.

What about some upcoming treatments or approaches that look promising to you? As you alluded to, these are injections. Are we going to see a pill soon that might make it a little easier and more affordable? Yeah. So there's two major developments that are being worked on that the public will start seeing over the coming years. One is...

GLP-1 is only one of multiple gut hormones that are effective in appetite regulations. The other names are GIP, glucagon, amylin. These are just different gut hormones. And when you start combining them, you end up with extra treatment, not only with appetite control, but things like heart disease, sleep apnea, liver disease. So you're going to see...

combination medications coming out. The other game changer, I think that's going to come, they're called oral small molecules, and that allows one to take a pill once a day and get the same GLP-1 effect as if you're taking an injectable once a week. Bob, I want to end with, at Health Discovered, we always like to leave our listeners with some practical advice.

And everyone's not going to have the privilege of seeing someone like you, Bob, who is empathic, who is knowledgeable about all the issues that we've discussed. So give us some tools or examples that listeners can use to talk about these issues to their next visit with a clinician. What advice do you have for them? Thank you for that kind setup, John.

The first is directly to the listener. It is not your fault that you're struggling with your weight. We think of it now as a chronic disease with what we call biological underpinnings.

When you see your healthcare professional, I would proactively mention to them that I am struggling with my weight. I know my weight is affecting my health. It is difficult to do this alone. I understand there are multiple treatment approaches available that can help me, including seeing a registered dietitian, getting support and accountability, and potentially one of the newer available medications.

Would you please help me in this journey of getting my weight and health under control? Well, Bob, it has been such a privilege talking to you today. So thank you for all the work that you're doing on this topic and have done for the past four decades. Thank you, John. This has been enjoyable. And to our listeners, if you or someone you know is struggling with weight management,

please consider sharing this episode and encouraging them to talk to their doctor or to find a doctor that will talk to them about treatment options for obesity. And as always, more information is available at WEMD.com. Thanks to Michelle Tedder, who you heard from at the top of the show.

Michelle is a registered nurse and public health advocate. She hosts the podcast, Dear Healthcare Provider. And again, I want to thank a very special guest, Dr. Robert Kushner, for joining us. And thank you so much for listening to this special edition of the Health Discovered podcast. Please take a moment to follow, rate, and review our show on your favorite listening platform. And if you'd like to hear about a particular topic in the future, please send me an email to webmdpodcasts at webmd.net.

I'm Dr. John White, the Chief Medical Officer for WebMD, reminding you that better information leads to better health. See you next time.

If you're an adult struggling with obesity, if you've struggled for years and years, you are not alone. But Zepbound Terzepatide is changing what's possible when it comes to weight loss, along with diet and exercise. Proven to help lose weight and keep it off, Zepbound is a prescription medicine for adults with obesity or some adults with overweight who also have weight-related medical problems.

ZepBound should be used with a reduced calorie diet and increased physical activity. ZepBound injection is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligrams per 0.5 milliliters in single-dose pen or single-dose vial. Don't use with other terzepratide-containing products or any GLP-1 receptor agonist medicines.

It is not known if Zetbound can be used in children. Don't take Zetbound if allergic to it or if you or someone in your family had medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zetbound and call your doctor if you have severe stomach pain or a serious allergic reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes, depression or suicidal thoughts before scheduled procedures with anesthesia.

If you're nursing, pregnant, plan to be, or taking birth control pills, taking ZepBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Discover the weight loss you could be bound for. Ask your healthcare provider about ZepBound or call 1-800-545-5979. Explore savings options regardless of insurance status at saveonzepbound.com. Terms and conditions apply.