Episode Transcript
Cassie Alvine (announcer):
This is the “Health and Wellness” podcast brought to you by Sanford Health. Our conversation today is about weight management options, including discussion on recent medications for weight loss. Our guest today is Dr. Jennifer Schriever with the Sanford Weight Management Center. Our host is Alan Helgeson with Sanford Health News.
Alan Helgeson (host):
We’re talking with Dr. Jennifer Schriever on the “Health and Wellness” podcast. Are there any statistics or things that you can share regarding BMI as we maybe start our podcast today?
Dr. Jennifer Schriever (guest):
Well, the history of BMI is, it’s a really old measurement based out of men in Belgium. So it’s not a perfect measurement, but it’s what the current standard is. So to come to our clinic, we generally require a BMI of 30 and above, or if you have a BMI with weight associated diseases, then we will consider those as well.
We are now starting to accept pediatric patients 12 and above, and they have different ways to qualify their BMI. It’s greater than or equal to the 95th percentile for pediatric or obesity or if overweight and have medical co-morbidities related to weight. Then their BMI is at the 95th, 85th to the 95th percentile for age.
Alan Helgeson (host):
Dr. Schriever, we’re hearing things like weight management versus weight loss management. Are those the same thing?
Dr. Jennifer Schriever:
They are different. Certainly, the goal of most of our patients as they come in is weight loss, but then we want to make sure it’s done in a healthy fashion and appropriately because we want to make sure you’re able to keep your weight off for the long term. And it’s not just about weight, it’s about how is your body composition? And if you have extra skeletal muscle, that’s going to play a factor in how much you weigh. So we want to make sure that you keep that skeletal muscle on board and have the appropriate body composition. So that is more weight management than weight loss.
Alan Helgeson (host):
You know, we hear so much about diets. I mean, we’re just programmed to talk about diets. We see commercials, the ads. Regardless of where you look at it, it’s all about diets. Body image. Do diets work?
Dr. Jennifer Schriever:
No, really because a diet tends to be something short term, and really that you’re not going to be successful unless you find something that can be long-term for you. Short-term weight loss doesn’t necessarily add up to long-term weight loss if you resume old habits. So, and a lot of diets are something that people don’t find sustainable and weight loss may not be in a healthy fashion.
To me it needs to be a lifestyle change that you can develop and continue and adapt to so that you have new habits and understanding that of how you lead your life leads to improved health versus just a short-term program where you can lose weight fairly quickly but then it doesn’t stay off because of maybe your metabolism changed. Or once you resume more routine diets that you’ve done previously, then you can easily gain the weight back.
Photo by Sanford Health
Alan Helgeson (host):
So if I’ve done a diet in the past, I’ve lost this 20 pounds, you know, a fairly quick fashion, but then I’ll go back to my old ways and it sneaks back on. But not only that 20 pounds but it’s 25 pounds or maybe it’s 30 pounds. Why does that happen?
Dr. Jennifer Schriever:
Yeah. Often what is happening with rapid weight loss or large weight amounts of weight loss fairly quickly is we’re also losing skeletal muscle, and that holds the majority of our metabolism. So if we lose weight through dieting and aren’t aware and understand about how is the best way I can keep my skeletal muscle, then we lose skeletal muscle. Thus our metabolism declines.
And then as we resume old ways, or it can be just become more difficult to maintain that weight loss and easier to gain again because your metabolism has declined.
Alan Helgeson (host):
Dr. Schriever, let’s talk about specifically what weight management options does Sanford offer.
Dr. Jennifer Schriever:
A variety of weight management options. You can start with your primary physician and they can help refer you to a dietician or their health coach in the office to help you with some information on healthy eating and maybe meal planning for your family. Some primary physicians and other specialists are comfortable with weight loss medicines and providing some lifestyle guidance.
Obviously we have the Sanford Weight Management Center and then we have a nice comprehensive team with a dietician and we have connections to behavioral health that can help you with depression and anxiety and binge eating disorder or anything that affects how you feel about eating and the stress related to that or even body dysmorphia. We’ll prescribe medications according to what is safe for you and your health conditions as well as your medication list and physical activity guidance. And as I alluded to earlier, we can help monitor your body composition.
Another option is bariatric surgery. The guidelines are a little bit different than weight management. They now recommend surgery if you want to at a BMI of 35 and above, or above 30 with weight associated medical conditions. And maybe even surgery should be considered lower than that if someone has really made some significant efforts at weight loss.
The first steps: checking on what you should do or consider, you can certainly talk to your primary physician or one of your specialist physicians for recommendations and also check with your insurance and see what is covered. If you are interested in our program, certainly call or have your physician refer you. We will give you some guidance on how to check with your insurance, but you can also be self-referred or have your physician refer you bariatric surgery. You can have your physician refer you to a bariatric surgeon’s office here at Sanford.
You have two surgery options, I believe the sleeve gastrectomy and then gastric bypass. Often they will know, that office will know if your insurance covers it so that they can help save you the time if your insurance doesn’t cover bariatric surgery. And they also often have informational meetings that you can come and get informed in what that process is like.
Alan Helgeson (host):
What are some signs that a person may need weight management care?
Dr. Jennifer Schriever:
First of all, just if they want that in a comprehensive program. Think if you have multiple medical problems, then you might want someone more specialized and focused in with a training to help people with their weight management.
If you feel like you’ve worked on your weight and lifestyle without improvement in your health and are really frustrated and need a new plan, then we can help with that.
If you appreciate and would like ongoing, regular and frequent contact and support, then we’re a good program for you because that’s what we’re here for the duration, for life if you need it or if you’re just confused and not well informed about nutrition and what’s so important in lifestyle because that has been a difficult topic to learn over time. And there hasn’t always been great nutrition information out there. So, and that just keeps getting better. And our group is pretty dedicated to stay up with the latest and greatest.
Alan Helgeson:
I want to go back to something you mentioned when we first talked about this question. One of the things you mentioned is if you have multiple medical problems, could you maybe go into that? It seems like so many things we hear about, one of the things we hear is weight related of just about everything. Weight is tied into so many things. Could you maybe expand a little bit on that Dr. Schriever?
Dr. Jennifer Schriever:
Sure. Sometimes it’s even hard to think of something that is not weight related. You know, certainly diabetes and heart disease are weight related. A variety of cancers are related to weight. So we can reduce risk of cancer by improving one’s health. Mental health is tied to the disease of obesity. So depression or anxiety or eating disorders. High blood pressure, high cholesterol, if you have arthritis and problems with your knees or hips for example or even chronic back pain, it’s going to be related to the disease of obesity.
Alan Helgeson (host):
We were getting ready for the program today and you had mentioned there’s some calculation that losing a certain amount of weight and, and I can’t remember what that number is, but that if you lost such, it equates to another number of taking pressure off your knee.
Dr. Jennifer Schriever:
Yes. So for every pound of weight you lose, it takes four pounds off your knees. So you can see more rapid improvement in your knee pain just with even smaller amounts of weight loss because of the effect of gravity in addition to the weight.
Alan Helgeson (host):
Everybody has knee pain, right?
Dr. Jennifer Schriever:
A lot of people certainly. Or back pain.
Alan Helgeson (host):
Or back pain too. So everything is tied to, I mean so many things are tied to weight related issues. OK. We talked about maybe how to go about getting some help and maybe some of those signs. What does a person need to know about weight management?
Dr. Jennifer Schriever:
So the goal of weight management is to create a lifestyle that leads to improved health and body composition so that you reach a point that you’re comfortable with where you are. Those chronic diseases can improve with just as little as even five to 10% of weight loss. Cancer reduction risk I think is closer to 20% of weight loss. We use a body composition scale to help guide you too so that you understand and appreciate what is going on rather than just trying to watch the scale budge.
Alan Helgeson (host):
Can we talk a little bit about watching that scale? If it’s only about a number, how can you get people off that piece, Dr. Schriever?
"For every pound of weight you lose, it takes four pounds off your knees." Dr. Jennifer Schriever, Sanford Weight Management Center
Dr. Jennifer Schriever:
I think in our clinic it becomes easier because we do have a scale that helps to measure body composition. So we go over that each visit. It includes obviously the total weight but also what does your lean tissue weigh such as a total number for your bones, muscles and organs. It also has the dry lean mass. So that’s looking at what do your muscles and maybe bones weigh without any water content. So that reflects your muscle health and balance as well as just a number that reflects your skeletal muscle weight.
So we can help you monitor that because as you lose weight, we really only want you to lose less than 20% of your skeletal muscle compared to your total weight loss. There’s also a percent body fat, and we watch visceral fat – that’s the fatty tissue inside our trunk, around all the organs. So that’s different than subcutaneous, which is underneath our skin. The visceral fat causes inflammation and puts us at risk for all the diseases that can occur from organs in our belly like diabetes and heart disease. And then reducing that reduces all of our risk factors or reduces risk for the cancers that occur in those organs.
Alan Helgeson (host):
So we’re talking about what are some of the keys to healthy weight management. Let’s talk about what are some of the do’s and don’ts of weight management?
Dr. Jennifer Schriever:
Find a plan that is sustainable and stick to it. Don’t look at those fad diets or advertisements for supplements that just seem to be amazing because they probably aren’t. And I hate to see patients spend money on something that isn’t well studied for our program. It is most effective or if you follow our guidance then if you feel like you’re stuck and what we’re telling you isn’t working to come back and tell us what you’re doing and give us some details so we can help figure out how we need to adjust that.
Encourage patients never to be embarrassed to come back because life happens and interrupts everything and makes following your plan difficult. And we also strive for consistency, not perfection. So that’s important because we want to participate in different things in life. That might mean we’re eating something that we don’t consider as healthy as others, but that doesn’t mean you can’t enjoy it once in a while.
We focus a lot on tracking nutrition at some point. We don’t want that to be stressful, which it certainly can be for some people, but you’ll find the most success over time tracking to some extent or doing a check-in with yourself. And we at least start with having patients know the right amount of protein to get and working towards getting to that. And then as comfort level improves or understanding of nutrition improves, we can look at other ways to track nutrition.
Exercise is also very important. We do strive to help our patients find a way to do that that is comfortable for them because it can be very uncomfortable at first or they have joint problems that make exercise or knowing how to exercise difficult to understand. So we try to collect as many resources as possible to make that work for them.
And then just don’t give up. We’ll help you figure it out.
Alan Helgeson (host):
Let’s talk about some of those keys that are really core to healthy weight management. Could you cover some of those please?
Dr. Jennifer Schriever:
Sure. So there are, through the Obesity Medicine Association, four pillars that are integral and important to improving lifestyle and they all need to be included.
- So one of course is nutrition, and the main focus here is getting adequate protein and then creating a calorie deficit for what you need. But we’ll help you adjust to that and figure that out over time.
- The second pillar, highly important – actually they’re all important – is physical activity. So I always point out it says physical activity, not just exercise. So how much are you moving every day? And for heart health you need at least, or it’s recommended to get 5,000 steps a day or more and sit less than six hours. So that’s really important and that’s called neat non-exercise activity thermogenesis or some people will say time. So how much are you moving every day? And little bit by little bit even extra steps here and there are super helpful in managing your weight.
- The third pillar is behavior. We often have stress eating or emotional eating or binge eating that we find as we get new patients. I also often talk about how do you get through a social event and feel comfortable about it, go out to eat, go on vacation, and we can help you with some thoughts on how to do those things if you want to keep your health in mind. Now sometimes you might say, this is my time, I’m going to enjoy myself and that’s totally fine, but often it’s as simple as get some protein first, whether it’s there or on your way and then that’ll help fill you up so you don’t feel so hungry there.
- The final pillar after, so the first three were nutrition, then physical activity and behavior. Then the final pillar is medication. So all of those pillars are important to develop a lifestyle that works for you and medication should be included as long as you need them, as long as they aren’t causing any harm. And even in when you get to a maintenance phase or where you’re comfortable, they’re part of what we’re working on. And so as long as there’s no adverse effects then we continue with those to support you as long as you feel like you need them.
Alan Helgeson (host):
Do you talk to your patients about using the wearable technology and some different apps? Are those important within your clinic?
Dr. Jennifer Schriever:
I think they’re definitely valuable to the right person because it gives you an idea of where you’re at and if you can consider improvement. You know for some patients they don’t or aren’t able to move a lot. So then I say well then can you add an extra 50 to a hundred steps a day, depending on their capability? Or do we look at, can you increase by 250 to 500 steps on average? To make small goals that seem more obtainable. Then we all tend to think that 10,000 steps a day is what we need and if we think we need that, that doesn’t seem reachable. So I do encourage them, if they’re able to get one of those or to at least maybe carry your phone more often for a day. Because it does count your steps and then you at least know where you tend to be at.
Alan Helgeson (host):
Let’s switch topics here because this is really dominating so much of the category of weight management and weight loss. It’s the medications. Could you talk a little bit Dr. Shriver about these medications and how they work and why they’re getting so much attention?
Dr. Jennifer Schriever:
The generic name for Ozempic and Wegovy is semaglutide. And so Ozempic is the brand name used for diabetes and then Wegovy is the brand name used for weight management and the dosing is slightly different. Those are both a GLP-1 it’s called, which is a hormone that your small intestine makes and distributes once you have eaten.
So it triggers some insulin and blocks glucagon secretion, which means that your blood sugar level doesn’t peak as much and you get better blood sugar control. It also slows down your stomach from emptying so you feel full sooner and faster and also sends a signal to your brain to tell you you’re full and satisfied. So it can take away some of those cravings and food noise that people talk about.
Then Mounjaro, it is a GLP-1 medicine but it also has GIP in it and that’s another GI or gut hormone that can increase satiety. So it can help with full feeling but mainly acts by affecting a portion of the brain that makes you feel satisfied, that helps to decrease then your calorie intake. It also is affecting the insulin and the glucagon after you eat and is released into that response. It also can help kind of your fat distribution, encouraging fat deposition into your fatty tissue rather than your organs, which is where you really don’t want it.
Alan Helgeson (host):
Who is a candidate for these medications?
Dr. Jennifer Schriever:
The criteria for medications is the same as the criteria for our program. So anyone with a BMI of 30 and above or the BMI of 27 and higher with a weight associated condition.
Alan Helgeson (host):
But what is an ideal patient journey for these types of medications?
Dr. Jennifer Schriever:
Yeah, it’s kind of funny how a drug gets named. So the drug company goes to the FDA and says we’ve studied this medicine, here’s our evidence and this is a condition we studied and then they pick a brand name.
And then they go back after they’ve studied it and clarified that it can be used for weight management and then they rename it and then it’s called Wegovy and then that’s how the patents are created. But that’s also how insurance determines what they cover those medications for through that process. Which is why your insurance won’t cover Ozempic for weight loss.
So certainly we want to make sure as we screen patients that they qualify based on their BMI and health conditions or and also that they don’t have a contraindication – which sometimes the contraindications are listed but maybe not necessarily an absolute. But generally we don’t start patients on these medicines if they have a history of pancreatitis that we don’t necessarily know why. Although I think some studies show that that’s maybe not as concerning as we initially thought.
There’s a family history of a specific type of thyroid cancer that we wouldn’t recommend those medications for and that’s medullary thyroid cancer, which is not very common. I would also hesitate if a patient has known gastroparesis, which means their stomach already doesn’t empty very quickly and if the patient still wanted to, we’d have a significant discussion about how that’s going to go.
Alan Helgeson (host):
So we talked about the insurance thing. If someone’s insurance doesn’t cover this and they still wanted to pay for it out of pocket, could they do that?
Dr. Jennifer Schriever:
They certainly could. Generally mainly the ones that are FDA approved for obesity but it’s fairly expensive for a while. Maybe you could get it for $500 but I think lately it’s more like $800 a month and we’re still dealing with drug shortages so can be pretty hard to find at the moment.
Alan Helgeson (host):
At what point can we start identifying as something for long-term success with them?
Dr. Jennifer Schriever:
Well by the time a medicine like this has come to market, it’s been well studied and some of the evidence out there is as long as five years. The Ozempic has been out since 2016, not necessarily used and dose adjusted for weight management, for more for just diabetes. So then Saxenda, which is the daily injection liraglutide is also Victoza and that’s been out since 2012 I believe. So then we have some more longer term data in the general population but they’re studied well beyond that for several years prior to coming to market. Probably more like 10 to 20.
Alan Helgeson (host):
So it’s been out there a while.
Dr. Jennifer Schriever:
It has. So far we don’t know of any definite long-term risks of these medicines. I mean certainly there are rare complications which maybe we want to get into.
Alan Helgeson (host):
Yeah, let’s talk about some of those. That’s a good lead into those.
Dr. Jennifer Schriever:
Yeah, so some of the concerns initially and especially based on study is significant or can be significant nausea and constipation. I actually supply the patient with a prescription for something for nausea and caution them to definitely eat slower and drink slower because these are slowing your stomach from emptying and the effect of that can be fairly immediate or it can take several weeks into the dosing.
The latest on that gastric emptying or the stomach emptying slowing, seems to be out there where there are cases reported where they talk about their stomach being paralyzed. That was never necessarily found in the studies as the drug companies did prior to bring it to market. Certainly that condition can happen randomly, so I don’t know if that is a true association and, but it does slow your stomach from emptying. So that is a risk.
And if I have a patient at risk with diabetes for example, which they are at risk, I might ask them a lot of questions about how they feel around eating and if they have any symptoms that make me suspicious. So I have checked a few patients for that prior to prescribing it.
There’s a list of diabetic retinopathy, which is an eye complication that can lead to blindness for patients with diabetes. If their blood sugar is pretty stable, it’s not really a risk if you know these medicines can help their diabetes improve so then that can change their blood sugar levels quickly. But I don’t think that risk is as significant as worried but it certainly doesn’t hurt to contact their eye doctor about what they would recommend as far as maybe dose adjustment or what their blood sugars are doing or what is the status of their diabetic retinopathy.
The medications, you know, can cause pancreatitis. So we might hesitate depending on the cause of the pancreatitis. If it’s due to your gallbladder or some other concern, then the medications are still fine. If we aren’t really sure then we will have extra precaution about continuing those. It can raise heart rate typically only a few points and not an ongoing problem, or can make it feel be significant. But generally that often isn’t a reason that we have to stop it.
They’re the common, just like any medication, since these are injections, you can have a rash at your site or an allergic reaction. Low blood sugars are possible but not very common. Another common one, like in the media or social media is about kidney problems. Often if you’re going to have severe GI problems like nausea or vomiting or sometimes you end up with diarrhea and you aren’t able to stay hydrated, then you know that is a risk for having some stress on your kidneys.
So certainly on these medications especially you don’t think this is just a side effect that I can try to deal with at home, seek care sooner than later.
And then one thing, I don’t know if it’s still such a big deal out there, is that Ozempic face? Ozempic face. Yeah. Really anyone who has weight loss, you know they’re going to lose weight or fatty tissue in particular in a variety of places. So some people will lose more in their face and maybe look a little gaunt or quite a bit different than they used to. So I think that’s what that’s referring to. But that can happen with any weight loss method.
Alan Helgeson (host):
If you are taking these medications, are you on them for a long time or just till you maybe get to a point where you don’t need them anymore?
Dr. Jennifer Schriever:
I think that’s going to vary on the individual. Certainly it’s very important to incorporate all the lifestyle and the pillars that I talked about earlier.
So we have to focus on the nutrition and that certainly helps with satiety feeling. It’s important to focus on the exercise and strength training because we need to maintain that skeletal muscle health, which we also need the protein for.
Have we learned how to address our behaviors or know some techniques or improved with counseling around mental health concerns or binge eating. And how stressful has weight management been for you most of your life?
So for some patients they really do well with those lifestyle changes or a lot of them do, but it depends on, I think, their life experiences and the fear of that hunger returning, how long these medications are needed. Some have done very well having to suddenly stop them based on insurance changes, job changes, et cetera, that they’ve done well and at least maintained stability before they’ve come back to see me. And some certainly have a lot of anxiety of what’s going to happen when they go off. So it really should be a long-term medication that the patient and the doctor can work on a plan if they’re ever ready to go off. But it’s not that way for everyone.
Alan Helgeson (host):
In a quick summary here, a lot of things you would hear the media and some places would say this is the quick miracle drug of the moment. It’s getting its 15 minutes of fame. OK great, whatever, what isn’t this medication?
Dr. Jennifer Schriever:
Yeah, I think the unfortunate part about how it’s advertised, and maybe it’s just what we really hear from that message is how successful these medications are in the studies to help someone with weight loss. But it’s so imperative to do everything together because by themselves they may work to some extent but they’re not going to work for the long term if you aren’t keeping aware of what does my nutrition need to be and how do I support my muscle health and how do I exercise to keep my metabolism?
Because for some it is such a relief to not be hungry anymore and historically they might have lost weight just by eating a lot less or not eating, but that’s not going to work in the long run based on your metabolism and all sorts of things that change internally. So it’s still a comprehensive plan, but that’s a major tool to include. But it doesn’t mean it’s the only thing.
Alan Helgeson (host):
On social media, they’re talking about how these medications may have an unknown added effect that is spilling over into some other addictions. How it is maybe working to curb some other addictions?
Dr. Jennifer Schriever:
Yeah, so the details certainly aren’t fully known yet, but we do know that part of their effectiveness is how they not only send a message to the stomach from the GLP-1 standpoint, but both the GLP-1 and GIP effects are going up to your brain to tell you you’re full and satisfied. That seems to be triggering a portion of the brain that does help with addiction and compulsive behaviors by just taking away that desire to continue to do those sort of things.
And it seems to be having an effect on the dopamine pathway. And our dopamine chemistry is behind a lot of our addiction and cravings behaviors. So people, I even have patients who aren’t necessarily have an alcohol addiction but they just don’t crave that alcohol anymore or it’s helping them quit smoking and then, you know, certainly people do feel addicted to food sometimes and so it helps taking those cravings away. So that’s just such a benefit. Because as you think about those thoughts, they’re very stressful. Because you don’t want those thoughts, you might not want that food or to drink more alcohol, but yet that craving is there.
Alan Helgeson (host):
If you watch the various news reports, they’re making the miracle thing of the moment, but it’s just a thin slice of one of the many options. And there’s so many things that Sanford offers in helping somebody in a journey to finding a healthier way to live. And it’s a lifestyle thing, right?
Dr. Jennifer Schriever:
Certainly. And there are other medication options. Patients are often so disappointed to know that their insurance might not cover these medicines, and they’re so expensive to consider out-of-pocket.
But some of the cheaper medications we have patients very successful on that and they’re also incorporating of course, nutrition and lifestyle changes like exercise and the physical activity as well as any behavior things that need to be addressed. And so they do very good on medications and if weight management isn’t covered by insurance and you don’t have a contraindication to take some of the pills, patients are spending $25 a month out of pocket.
Alan Helgeson (host):
It’s nice to know that there are so many options available and that Sanford Health has really, really gotten behind helping people get healthy in so many ways. And the big takeaway, if you could give people one takeaway from this, what do you want them to do or want them to know?
Dr. Jennifer Schriever:
Wow. Big question. But I think what I really want people to know is that there is a healthy and sustainable way to help you with your weight loss. And it’s now available at Sanford and we do our best to meet everyone’s needs and it make an individual plan that works for them. And it is very frightening to come into a clinic and discuss your weight and just know that we are going to treat you kindly and without any bias and really aren’t going to judge because everybody has a different life journey.
Alan Helgeson (host):
Before we go, I want to mention that many of the services and care options mentioned during the conversation with Dr. Schriever are available at the Sanford Weight Management Center in Sioux Falls. If you’d like information on what options are available near you, call your provider, your clinic, or visit sanfordhealth.org.
Cassie Alvine (announcer):
This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify and news.sanfordhealth.org.
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Posted In Family Medicine, Healthy Living, Heart, Internal Medicine, Nutrition, Sioux Falls, Specialty Care, Weight Loss
