February 3, 2025 • 42 mins
This episode unravels the complexities of using Ozempic, a GLP-1 receptor agonist, for weight loss—especially among people without diabetes. Dr. Anne Peters highlights the health implications, individual responses to the drug, and the broader context of weight management.
• Examination of Ozempic’s functions and benefits
• Discussion on who should consider using Ozempic
• Clarifying misconceptions about weight loss and obesity
• Insight into the body’s set point and its impact on weight
• Risks associated with using medications for non-diabetic individuals
• Emphasizing the need for a multifaceted approach to health
• Historical context of obesity and diabetes in society
• Conclusion on prioritizing health over aesthetic standards
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:12):
I'm Dr Anne Peters.
I'm a professor of clinicalmedicine at the University of
Southern California, where I runtwo different diabetes programs
, one in Beverly Hills and onein under-resourced East Los
Angeles.
Speaker 2 (00:24):
And Dr Peters here is an old friend.
I think I met you when I was inmy mid-20s and I'm no longer in
my mid-20s, so that's a whileago.
You are a world expert indiabetes and it was just an
opportunity to grab you and askyou about some things, about a
Zempik because we've got thispodcast and we're talking about
(00:45):
lots of different topics.
But one of the things thatpeople keep asking over and over
again is about this new groupof agents and whether they
should be using them.
This isn't people that are 100pounds overweight and have
diabetes.
These are friends who aremoderately thin and, like I,
just would like to be thinner.
Should I use it?
So I would like you to tell usabout these drugs and who we
should be using them in and whatare the upsides and downsides
(01:06):
for regular folks using them.
So let me VO my own VO here andsay that Ozempic is a
prescription drug here in theUnited States.
It's semaglutide and it is aGLP-1 receptor agonist.
So it hits that receptor and itactivates it, and so that's
glucagon-like peptide 1.
So you'll hear this a lot GLP-1.
(01:26):
So after you eat, you get thisGLP-1 hormone that goes up and
that increases the amount ofinsulin that comes out of your
pancreas and that deals with thesugars and stuff that are now
in your blood and it puts theminto the cells.
So this drug mimics that actionand we'll be talking a lot
about weight loss here and ithas a number of different
mechanisms, and so one of theways that it works is that it
(01:48):
goes to your brain and says I'mfull, I'm done here.
So it reduces your hungercravings in lots of people not
everybody, but in lots of peopleand so you feel satiety, I'm
done, I don't have to eatanymore.
So that's one of the ways thatit works.
It also can reduce your GIemptying, so the how quickly the
food goes through your stomachand your GI tract.
This also can make you feelfull, Like you've had a big meal
(02:10):
and like I couldn't eat anymore.
It gives you that sort ofsensation, and there's probably
a whole bunch of other ways thatit's used, but it's
predominantly used, or should beused or is FDA approved, for
patients who have obesity andtype 2 diabetes.
That is the kind of diabeteswhere you have insulin but you
don't have enough of it, and sothis can increase the levels and
(02:31):
decrease your weight and ittastes great less filling, as it
were.
Oh, and one other thing I'mgoing to say here because I know
it's going to be triggering forsome people.
We talk a lot about being fat,but not in a derogatory way.
We talk a lot about fat andsometimes those two are mixed,
but I know for some people it'sreally triggering.
You can't say somebody's fat.
We do that here.
It is not meant in a derogatoryway at all and if that's
(02:54):
triggering for you, I'm sorry,don't continue.
We talk a lot about obesity.
We talk a lot about BMI,measuring central circumference.
So forgive us if we haven'tused always the politically
correct terms, because we arepeople of a certain age and mean
nothing derogatory by it.
Now let's go back and let'stalk about these drugs.
And the other thing I shouldsay is that we use a lot of the
(03:14):
trade names, not the drug names.
They are just easier toremember.
If this was a CME program, wewould change it, but for the
purposes of what we're doinghere, we're just going to use
the trade names that people use.
It's just easier because thenpeople know what we're talking
about.
Speaker 1 (03:28):
Well, first of all, these aren't new.
The first of this class, whichis called the incretin class but
specifically what Ozempic is isa GLP-1 receptor agonist.
This class was first introducedwith Biada, which was a twice a
day injection, which was about20 years ago.
(03:49):
So one of the things thatcomforts me as a physician is
that we have a long history ofusing these drugs and I, as a
diabetes specialist and actuallya diabetes specialist who
writes the guidelines knows thebenefits and risks.
So I'm completely comfortableusing these agents and I'm
completely discomfortable makingthe right choices with patients
(04:11):
, helping patients make theright choices when it comes to
using them.
So they're not so new.
It's just that the media madethem new because suddenly we had
a once a week form instead of atwice a day form, and where
everybody has caught on to thefact that you can lose weight
and it's relatively easy.
Speaker 2 (04:28):
So let's talk about that as a weight loss drug, so
as a diabetic treatment.
You've been using it for 20years.
You're quite comfortable withit.
Risks, benefits in favor of themedication.
So let's talk specificallyabout its use for weight loss
and non-diabetics, which Iassume is off-label, fda
approved but used all the time.
Speaker 1 (04:48):
Well, it's not off-label.
So this is what the drugcompanies did, and even this
started 10 years ago.
So there was a drug calledVictoza, which is a once a day
GLP-1 receptor agonist and weuse it in people with diabetes.
And these drugs, by the way,are great in people with type 2
diabetes because their glucoselevels go down, they lose weight
(05:11):
.
All the things that are notright about them get better.
Their risk of heart diseasegoes down, their risk of heart
failure goes down, their risk ofkidney disease goes down.
So these are to me, I wouldsuppose, one of the two most
miraculous classes of drugs I'veever had to treat people with
diabetes.
And they work and they're muchbetter than, for instance,
(05:31):
insulin.
I still use insulin all thetime, but these drugs work.
But I'm not quite so sure.
When the drug that was Victozafor diabetes also became Saxenda
, which is a drug for weightloss Very same drug once a day
it was just three times asstrong, and so on label Saxenda
(05:54):
has been available for, I'm sure, 10 years.
I could be wrong, but it's beena while.
And the problem with the drugfor weight loss is that insurers
didn't want to pay for it.
We don't consider obesity adisease.
We consider it a condition andtherefore insurers don't pay for
(06:16):
drugs for a condition.
Now, I personally am of thebelief that people who are
overweight are overweight for avariety of different reasons,
and it's exceedingly hard forpeople to lose weight because
your body defends your weightand these drugs make it easier,
and the reason I like them forpeople who are overweight is
(06:37):
because it takes somethingthat's a real problem for them
and makes it.
It solves the problem.
It doesn't necessarily takeaway from the desire to eat
entirely, but it helps peoplelose weight, and a headline for
me throughout this podcast isthat people need to eat well and
take these drugs, because itstill matters that you eat well,
(07:01):
because if you don't eat welland take these medications, you
can lose too much of your musclemass.
You can become unhealthy.
That's not what we're talkingabout.
What I'm talking about istaking people who are obese or
overweight, helping them loseweight, and that helps their
health in a thousand differentways.
Speaker 2 (07:18):
So you talked about this sort of the set point that
we have.
And you know, even I find thissort of the set point that we
have.
And you know, even I find thisI want to lose.
I'm 160 pounds, five foot nine,five foot eight, so just about
the right.
I want to lose 10 pounds.
It's really hard, you lose itand then you go right back to
this sort of set point thatyou've had for years.
So do these drugs help youchange that set point or do you
(07:40):
have to stay on the medicationto keep the weight off?
Speaker 1 (07:44):
You have to stay on the medication for the rest of
your life.
Now let me just tell you this.
So in my world, I believe inindividual response.
So when I have a patient whohas diabetes or doesn't have
diabetes and takes thesemedications, if somebody wants,
for whatever reason, to stop itand again, as I said, I think
(08:05):
the cause for people beingoverweight is multifactorial so
there's not just one reason andthere are people who I know who
eat because they're sad andthese drugs don't make you happy
.
They make you feel healthierperhaps, but not necessarily
happy.
And so in about 25% of peoplethere is no weight loss response
.
So people who go on thesemedications for weight loss may
(08:27):
or may not lose weight.
Like anything in life, there'san individual response.
But say you go on these, youlose weight.
You get to another point.
You feel like you're able toexercise more, you've learned
how to eat differently, you'veworked with a dietician.
Then I say we can try to taperthem.
I don't stop them, cold turkey,I taper.
I say we can try to taper them,I don't stop them, cold turkey,
(08:47):
I taper.
And then I start by saying,okay, let's take it once every
10 days instead of once everyseven days.
Then I say once every two weeks, then maybe I'll get to once a
week, once a month.
But I'll go down slowly andthen and also I'll ratchet down
the dose.
So the maximal dose of Monjarois 15.
You can go down in 2.5milligram increments, down from
(09:10):
15 to 12.5 to 10 to 75.
So I believe in the lowest drugfor the most benefit.
So I'll tell you about me.
Am I allowed to tell you aboutme?
Speaker 2 (09:22):
Tell us about you.
Speaker 1 (09:24):
So I was getting diabetes.
I found this out from bloodtests I did on myself and we
doctors are not necessarily goodpatients, but that's okay.
But I'm not just gettingdiabetes.
I'm getting type 1 diabetes andI use these drugs in type 1
diabetes as well, but that'sslightly a different story.
(09:44):
But I'm getting type 1 diabetesslowly as an adult.
Speaker 2 (09:48):
So perhaps for the non-docs listening to the show,
type 1 diabetes is an autoimmunedisease where your beta cells,
which are in your pancreas, aredestroyed by antibodies.
It tends to occur in youngpeople that are thin and then
they develop diabetes thatrequires insulin.
If they don't have insulin,they die.
But now we're learning, aswe're about to hear, that this
can happen to people that areolder, and can happen slowly,
(10:10):
which is sort of blowing my mind, which means my beta cells that
make insulin still are makinginsulin.
Speaker 1 (10:17):
They're just not making enough.
If I hadn't started myself onOzambic, I would be on insulin
now because if you look at myglucose levels, I go up and down
a lot when I eat.
So taking Ozempic helps my bodymake insulin better, like a
type two, because that's whatit'll do.
So I'm taking these to preventmyself from eating insulin and I
(10:40):
technically have diabetes atthis point, but I take Ozempic
and that's how I treat it.
On the other hand, I'm skinnybut, just like you, I was at the
same set point and I was at aset point of 140 pounds and I'm
5'10 on a good day 5'9 if youwant to remeasure.
Speaker 2 (10:58):
We're going through the shrinking years.
So you know, yeah, theshrinking years are happening.
Speaker 1 (11:02):
And so I took it and I lost.
Probably.
I lost down to like 128 orsomething, which on me is a lot
of weight, and so now I'mconsidered underweight.
But darn, is it a great weight?
Because I look really good inclothes.
(11:23):
I mean mean, like you know, 140was fine, I was normal weight.
But you know I hang out and Ilive in LA and there's Hollywood
and my husband's a Hollywoodperson, so you know I look great
in clothes.
But the problem for someone likeme is losing too much weight,
and I didn't want to lose toomuch weight because I would lose
too much muscle mass.
(11:43):
And so what I did was I clickedup the dose really, really,
really slowly.
I didn't use the doses on thepen, I used this click method,
or micro dosing, till my bodytolerated it and I got to about
0.5, which is a really low doseof Ozempic, and I don't go up
and I don't go down.
If I go down I get hungry, if Igo up, I lose more weight.
(12:06):
So I take a tiny dose ofOzempic every week and for five
years I have reset my set point.
I am at this lower set point, Idon't go up, I don't go down,
and I've worked really hard tomaintain lean body mass.
So I exercise, I eat moreprotein and I eat more fiber so
that the drug doesn't cause meany ill effects.
And that's where the drug and Iare.
We're happy together.
(12:26):
And eventually I'll needinsulin.
I know this, but for now Idon't.
So it does reset your set point, but I know in me if I skip a
week I'm really hungry in a wayI've never been before, because
I think it's been suppressing myhunger.
Speaker 2 (12:42):
So then let's dive a little bit deeper in that.
You said something at a GrandRounds conference years ago that
has stuck with me, that even 10pounds of abdominal fat can be
diabetogenic.
Just a little bit of a bellyfat is very hormonally active.
Is that still our understandingtoday, and is this a reason why
(13:06):
people who look pretty leanmight actually benefit from
being on medications to dropthat weight, or is that
overstating it?
Speaker 1 (13:13):
It's not overstating it at all, but this is what
we've learned since I gave thatlecture.
We've learned that there'sprobably a thousand different
types of what we used to calltype 2 diabetes and possibly a
couple hundred types of what weused to call type 1 diabetes,
and so we're no longer at leastin the sort of evolution of
(13:36):
guidelines, calling them sodistinctly type 1 and type 2,
that a lot of people will haveelements of both.
And that belly fat can happenin the lead person or an
overweight person, and that candrive insulin resistance and it
also drives these hormones thatmake you have more inflammation.
And the problem is is thatpeople who are overweight or
(14:00):
obese or even have central fatnot only can get diabetes, they
can get higher rates of heartdisease, they get higher rates
of cancer.
That fat in all of us ismetabolically active.
It's not a silent organ andit's you know.
You can't do liposuction to getrid of it because it's
abdominal, it's inside there,and so for most people, losing
(14:23):
that fat and again, I don't carewhere you start losing fat
helps you reduce thatmetabolically active tissue and
your risk for other healthproblems goes down, and that
includes things like joint painand back pain and sleep apnea,
and I think there's 250 otherconditions caused by that organ
that is fat.
So I take that seriously.
(14:44):
But you can't use these drugs ifyou're lean without doing it
with a doctor or somebody whoknows what they're doing,
because you'll get too thin andI mean what's good about these
drugs can be what's bad aboutthese drugs.
So you just you can't just usethem.
I think you need guidancebecause otherwise you can get
(15:05):
worse.
So I have people where I haveto beg them to stop the drug.
They're too thin, especially ifpeople are older.
I'm like you cannot keep doingthis.
You've got to stop it or reducethe dose.
I worry people get dehydrated.
I mean, people are writing alot about side effects of these
drugs and I'm like the vastmajority of those side effects
are because people are justusing them without actually
(15:27):
being guided in their use.
Speaker 2 (15:29):
So tell us about that weight loss.
These by their nature cause asort of syndrome of losing
muscle.
You become muscle wasting, andwe hear about this ozempic butt.
Is that what they're talkingabout?
It's basically just some muscleloss.
Speaker 1 (15:43):
Well, this is the thing, Ozempic.
The reason I like it, rather,is that I'm an endocrinologist,
which makes me a geek forhormones, and Ozempic is a
hormone and Monjaro is twohormones, and these are hormones
that are inside of all of us,and so when you give somebody a
gut hormone, known as insulin,you're giving them an injection
every day, or multipleinjections every day that are
(16:05):
replacing what their body isn'tmaking.
And when you give somebody agut hormone like Ozempic or
Monjaro or Wegovi or Saxenda orZepbound, whatever they are
called, these are hormones thatare injected because they're
peptides and otherwise your bodywould destroy them, and I guess
that you can get them as a pill, but the injections work better
, I think.
(16:25):
But the point is is we'rereplacing a hormone, and it may
be that people who are moreoverweight are more resistant to
this hormone or they make lessof this hormone, who knows what?
But it's not like back when wegave things that sped up your
body or did bad things to yourheart.
This is a drug that's known toyour body and so you're giving
it to your body and it's notgoing to make you, you know,
(16:48):
suddenly grow I don't know athird year.
It's basically not going tomake you, you know, suddenly
grow I don't know, a third year.
It's basically just going tomake you lose weight.
But any weight loss,particularly rapid weight loss,
will make you waste muscle.
So it's not that these drugsare specifically bad at that,
it's that they're fast at that.
And if you lose weight fast,you know, if I gave this to you
(17:09):
and you lost, you know, 20pounds in the next six weeks,
you wouldn't look so good.
Just a thought.
You look perfect now.
Speaker 2 (17:18):
Thank you.
So that's.
I wanted to touch on thatbecause my understanding is that
every other single weight lossdrug that has been used in the
West has resulted in a classaction lawsuit because it's
resulted in cardiacabnormalities and fen-phen and
all these things.
So you think these areintrinsically different than
those prior weight loss drugs.
Speaker 1 (17:39):
Correct.
These are hormones, the otherswere chemicals.
It's completely different.
It's not that I don't thinkthese drugs have side effects,
but I think they have a sideeffect that's related to their
effect in the body.
We're just giving more.
So people who lose weight fastwill end up with gallbladder
problems, no matter how you losethe weight, or they slow
gastric emptying, so they slowthe food transit through your
(18:03):
intestines and you know they cangive you constipation, they can
give you diarrhea, they cangive you delaying gastric
emptying, particularly if youhave a problem with gastric
emptying.
But most of these side effectscan be mitigated by using lower
doses, going up slowly and againusing them with somebody who
knows them.
(18:23):
So if I have somebody who hasreally bad gastrointestinal side
effects A, I go down on thedose, but I don't.
I use those Ozempic pensbecause you can click them.
You can give a effects A, I godown on the dose, but I don't.
I use those ozempic pensbecause you can click them.
You can give a very, very, verylow dose compared to if you're
using, say, a fixed dose.
Pen like Monjaro comes in and Ijust go on little doses.
Or I have people give them lessoften.
(18:44):
But if somebody gets too sickfrom these, I don't keep them on
it.
I mean, there are people whojust don't tolerate them and
that's just life.
But it's different than theothers.
So they're not chemicals, Imean.
I guess they are, but they'rereally not.
They're hormones.
They're hormones that we'regiving you, that your body knows
.
And the other thing is is we'veused them for 20 years.
So you know there will belawsuits about almost any drug.
(19:07):
But as somebody who's usedthese, who knows the genius
people in this field, I don'treally think that there's some
horrible scary thing thathappens that's worse than the
other horrible scary thing whichis the consequences of being
overweight or obese or havinguncontrolled diabetes.
I mean, these drugs have somany non-glucose related
(19:29):
benefits.
So you've got to look at riskand benefit.
Nothing is risk-free, nothingis side effect-free.
But learn what the side effectsare, reduce the risk and then
stop the drug if it's nottolerated.
Speaker 2 (19:42):
This begs the question of who should be on it.
I want to go back to that.
I'm kind of stunned that you'redeveloping diabetes, because I
have this old schoolunderstanding of diabetes which
has completely changed andyou've been the person, probably
as managed as anybody in theworld, that's helped us
understand this.
When I was in medical school,there were two types of diabetes
autoimmune destruction of yourbeta cells, insulin dependent
(20:02):
DKA that one, skinny people andthen there was obesity,
long-term insulin resistance.
And now you've made it allblurry and you're a perfect
example, super lean, active, andyou're developing what is sort
of this mixed picture of yourbeta cells.
Are they autoimmune destruction?
Are they just getting old andthey die?
(20:22):
Or this happened to myfather-in-law as well.
He was 87 and he developeddiabetes Fit, healthy, lean.
I'm like what is happening tomy worldview of diabetes?
Speaker 1 (20:31):
Well, your worldview should change completely.
I have sky high antibodies.
I am getting true type 1diabetes, but nobody knows
because nobody's even studied itin people greater than 45 years
of age.
My oldest patient with newonset type 2 diabetes was 94.
So you can get type 1 at anyage, and now we know that it's
(20:52):
more common if you're an adultthan a child.
But it looks a lot like type 2diabetes in some people Like I.
Have an entire clinic in East LAof people who you would think
have type 2 because they'recentrally obese, they're
overweight, have hypertension,they have a family history of
type 2.
And yet I measure theirantibodies and they actually
(21:13):
have type 1.
But type 1 in adults, the onsetis much more like a type 2.
You just don't know it.
So it's very important thatpeople who are atypical get
their antibodies tested and thenpeople like me who are atypical
, end up on insulin sooner thansomebody else.
But I would typically just beon insulin, but I don't want to
(21:36):
be on insulin.
I'm not against insulin.
I'll take it when I have to,but I like being on a little bit
of Ozempic and, like I said,I've been on it for five years
and it and I seem to be happytogether, so it's fine.
Speaker 2 (21:50):
What is overweight now?
So is it true I'll make somestatements which may or may not
be true that obesity or beingoverweight over the long term
produces insulin resistance andmaybe you wear out your beta
cells?
I don't know if that's true ornot.
What is the right weight and atwhat point should you say I
need to start a drug to drop myweight a little further?
Do you just look at the personor is there a BMI?
(22:13):
What do you use?
Speaker 1 (22:15):
Well, that's a very fraught question, like all
things in medicine.
So, first off, if somebody putson a continuous glucose monitor
, which you can now get over thecounter, and you find out that
you're having spikes either inthe morning or after eating, you
may have prediabetes, and thatone's easy, because in that case
(22:37):
you need to see a physician.
You need to exercise, loseweight if you're overweight at
all and again, that 10 pound ofcentral fat can cause it.
And I've had patients who arelean, if you looked at them,
lose 10 pounds and theirpre-diabetes goes away.
So you want to look for amanifestation of the fact that
that weight isn't good for you.
(22:57):
But if you look at a body massindex, it depends on if you're
Asian or not.
Speaker 2 (23:04):
So I actually didn't know this, but it turns out that
in Asian populations the BMI isgenerally not considered to be
interpreted as the same as otherethnicities, because Asians
tend to have a higher percentbody fat and a lower BMI
compared to other groups.
All this is way above my paygrade, because then it's sort of
like which type of Asian or howAsian, because I have lots of
friends who are half Asian, halfCaucasian, etc.
(23:26):
That's why we have experts thatdo this all day, like Dr Peters
.
Speaker 1 (23:37):
But in a non-Asian individual, a body mass index of
more than 25 is consideredoverweight and greater than 30
is obese.
And then there are otherclasses of it.
But there are bigger people andleaner people by nature.
I mean, I have the world'sskinniest bones, so you know, on
me, you don't want me.
You would want my body massindex, which has always been
about 19.
I mean, I'm lean and that'sjust who I am, and not that I
(23:58):
can't get, you know, flub hereor there.
We're all aging, but I'm lean.
But I have these guys who are,you know, big guys and I know
their body mass index.
If they had a body mass indexof 19, they'd look like they
were skeletons.
So I think there's anindividualization for this.
And then people say that youshould measure waist
circumference.
And if you look at waistcircumference, that tells you
(24:21):
about that center fat and thattells you about that
metabolically bad for you, worsefor you, because all fat is not
so good, although there's fatas a storage form of nutrition.
So it's not entirely bad foryou, it helps you survive.
So they say measure around thewaist.
Well, the problem with that isthat you have to actually have
something that makes you and I'mshowing you but I'm going to
(24:44):
say it in words is you have tohave something that stabilizes
the weight the tape measurearound your center and you have
to do it in exactly the rightspot.
So the New York Times recentlyran an article about the fact
that waist measurements arebetter than BMIs, and they had a
picture of somebody measuringsomebody's waist and the top
(25:04):
part of the tape measure washigh up and the bottom part was
down low, and that picture wasexactly the reason we can't do
waist measurements accurately,because you have to have
something that makes the tapemeasure going exactly
horizontally, and nobody doesthat and nobody has it.
I've been doing it in researchfor years, but in random
(25:26):
practice people don't measurethe waist circumference
correctly and so it becomesreally hard to do that.
But I think most of us knowwhere do you gain your weight,
and as you get older you'regoing to gain it in your center.
That's just where our bodiesare doing it on purpose, because
your body wants weight in thecenter to help you survive
famine and you want to have ahigher body mass index as you
(25:48):
get older to survive old age.
I mean you're not going tosurvive it forever, but at least
it helps.
Speaker 2 (25:54):
Yeah, okay, so it's complicated and working with a
physician to determine if weightloss is enough, whether you
should be on one of thesemedications.
One of my physician friendssaid she goes to the gym and
she's got all these skinnygirlfriends and all of them are
on Ozempic.
That really concerns me, justtrying to get that extra five or
(26:15):
10 pounds weight loss.
It concerns me because you'retaking this from a group of
people with diabetes orpre-diabetes and then you're
doing it in a population ofpeople who basically don't have
any of those things.
There's got to be moredownsides than upsides.
What do you think about that?
Speaker 1 (26:34):
I don't know exactly, because if these people are the
same people who are going to gohave plastic surgery and have
liposuction or something,there's also a risk to surgery.
I mean, again in life, I'malways comparing it to whatever
the alternative is In a universewhere everything was available.
Maybe it's not so bad becausepeople are going to do something
to lose weight.
By the way, you don't loseweight by exercise unless you've
(26:57):
exercised two hours or more aday.
Exercise is incredibly good foryou.
It makes you much fitter, butit's not going to cause weight
loss because exercise makes youmore hungry and it also slows
down your basal metabolic rate.
But I think the goal is to befit and healthy, and I think you
can be too thin, and so I wouldsay that the best way to lose
(27:18):
weight is through diet and thenexercise to keep yourself fit.
And I don't know.
You know it's very hard for meto answer this question.
I don't think, as a you knowhuman who cares about public
health, that we should be givingpeople a drug like Ozempic to
lose five to 10 pounds.
But people do all sorts ofthings to look better.
(27:40):
I mean you can tell, looking atmy wrinkles, that I do not do
Botox, facelifts or any otherthing and my gray hair and
everything else, because I justbelieve that you should age and
healthy and age in a healthy way, and I just feel like that.
A lot of that stuff is, I don'tknow, in a world that I don't
really agree with.
But again, if you look at,maybe, what they might otherwise
(28:03):
do, maybe it's that your friendwho isn't that skinny is the
healthier person, but I justdon't know.
You've got to individualizethis.
But as the body mass index getsabove 28, people get concerned
and the insurance companies havecutoffs for where they'll pay
for weight loss drugs now, andit's a higher body mass index.
(28:24):
But if you have diabetes,hypertension or abnormal
cholesterol levels, it's a lowercut point, so it's hard to know
, but right now it's a lower cutpoint, so it's hard to know,
but right now we have a hugesupply problem.
Let's take away those peoplewho are fancy and let's just
talk about regular people.
And again, I think thatbecoming leaner if you are obese
or overweight, and coming downto a healthy body mass index,
(28:46):
which isn't going to be 19, it'sgoing to be 23, 24, 25.
That's great, and as you'reolder, going down there is great
too.
And I feel like we don't need tohave a society that focuses on
ultra thinness.
We need to have a society thatfocuses on health and I think
that no matter what your weight,you can be healthier or less
(29:06):
healthy.
So even if you're, you know, Ihave patients who have body mass
indexes who are significantlyoverweight.
They're in their, you know, thebody mass index is 34 and they
can't tolerate Ozempic and theycan take Monjaro, but they don't
really lose any weight and youknow I don't tell them to give
up.
I say I can help lower yourcholesterol, you can eat better,
you can exercise more and youcan be healthy heavier.
(29:30):
It's just that if you'rehealthy and leaner you are
continuing to enhance things.
But I don't tell people ever togive up and I think that you
really can have health at nearlyevery weight.
But it just becomes somewhateasier on some of these drugs to
achieve weight targets.
But I really believe in givingpeople what they need to be
(29:53):
healthy period, and sometimesthat's this image that they
should be way thin and I getthat.
To me some of that becomes onthe side of disorder, eating a
disorder, body perception.
And I have patients ironicallyI have patients with bulimia who
I've given a low dose of a druglike Ozempic or Ozempic where
(30:15):
the bulimia stopped because thecravings got better and they
started to eat more normally andactually regain some weight.
But again, this is all undermedical supervision.
You have a problem.
You're binging and purging.
Let's see if we can get that toa better place.
And it's amazing, usedcorrectly these drugs are
(30:36):
life-altering in a really goodway.
But what we've done in theCounty of Los Angeles, and I'm
very proud of us, is that eventhough these medications are
more expensive, most of theMedi-Cal programs, most of the
county programs, will.
If someone fits the criteria,which in general is having
diabetes but in some cases beingsignificantly overweight, they
(30:58):
can get these medications.
And so I feel like, as a publichealth person, that I'm using
it in these patients whootherwise have poorly controlled
diabetes and they use thesemedications and I get them
better.
That to me, is a miracle.
That's where I care the most ishelping people become healthier
who have diabetes.
But you could have anybody gethealthier, but again, I'm not so
(31:21):
sure that what you're talkingabout in those people in the gym
is about health.
It's more about vanity and youcan be who you are with that.
That's not who I'm going toprescribe these medications for
this is a more sort of generalquestion.
Speaker 2 (31:35):
Again, I feel like everything I was taught about
health and weight was wrong, andthat's I remember in medical
school.
The dean of the medical schoolsaid to us and this was in the
80s half of the things thatwe're going to teach you are
wrong.
We just don't know which half,and I felt like that's
absolutely been true.
Is this historically?
Is obesity and hypertension andmetabolic syndrome?
(31:58):
Is this a new phenomenon?
Is this a Western world highfructose corn syrup issue, or
has this been an issue atdifferent times through human
history?
Speaker 1 (32:08):
Well, it's been an issue not the same issue but
we've never had so many people,we've never had such an
abundance of food, we've neverhad such an abundance of
unhealthy food.
But again, it's complicated andbecause places where there's
food insecurity you often seethe highest weights, because
poverty and being overweight arerelated, because you get even
(32:31):
poorer quality food.
But they think these genes fordiabetes at least are survival
genes and the genes for hangingon to fat are survival genes, so
that if you took me and put meon a mountaintop and somebody
who's got a bigger BMI, who'sgot type 2 diabetes, they could
last a year living off their fatstores and drinking water,
(32:54):
whereas I'd probably be dead intwo weeks.
So there's an incrediblesurvival advantage to genes that
make you eat more and there's asurvival advantage to genes
that put fat in your center.
And the whole point is is thatyou need to be in an environment
where there's not excess food.
So if you have these genes andyou were living in rural,
(33:15):
mountainous Mexico, you neverhad type two diabetes because
you weren't eating enough.
But then if you moved to theUnited States and you suddenly
were in a place where you ate alot of junk food, and it's not
just junk food, it's overalleating more you're going to gain
weight, and then they all gotdiabetes.
So the highest rates ofdiabetes are in those people who
came from a place where therewas no diabetes.
(33:37):
It's about the environment inwhich you live less exercise,
more food.
But one of the interestingthings is and again, these are
survival genes.
These are really good for you.
If you're living in sub-SaharanAfrica, if you're living in
Central and South America,you're working really hard for
your food, and probably ourancestors, who were chasing
around after something that theyhad to kill and then they'd eat
(33:58):
, and then they wouldn't eatagain for two weeks.
They needed to live on theirfat stores.
They think that in NorthernEurope that these genes happened
a long, long, long time ago,and then the upper class got
more food and they became moreobese.
So if you look at the picturesof people in that we have, of
the paintings, we see that theybecame more and more overweight
(34:21):
at least the wealthy did and wethink that they might've
actually died out, because thesegenes, in the presence of too
much food, give youcardiovascular disease, cancer,
hypertension, and those aregoing to kill you.
And so if you don't have modernmedicine to treat those things.
It may be that these genes wereeliminated in a Darwinian kind
of way from Northern Europeansbecause we don't see nearly as
(34:41):
much type two there as we see inSouthern climates.
So it's possible thathistorically these genes were
eliminated from a subset, butnow they're expressed, because
to be eliminated you have tocause something to happen at
birth that you can't pass onthese genes, right?
Because if they are expressedin your 40s and 50s, you've
(35:03):
already passed them on.
And it turns out thatgestational diabetes is a
condition where the moms getdiabetes and can cause babies to
be born less often or born withmore complications, and so
these genes actually couldtheoretically be eliminated
because they could cause harmearly.
It's fascinating to me.
We don't know for sure all ofthis stuff, but we do know that
(35:24):
these are very good genes forsurvival, and that's what I tell
people when they're feelingreally bad about themselves.
It's like well, this is yourgenetic makeup and there are
thousands of genes that have todo with your weight maintenance.
So, as another comment aboutmyself, a while ago I did some
analysis of my genes and I foundout that I have many of the
(35:48):
known obesity genes.
And I looked at my family tree.
My grandmother had like 19siblings and nobody in my entire
genetic lineage has ever beenoverweight.
And you know, we're goodMidwestern Mennonites and we,
you know, ate well and I don'tknow, worked on the farms but
there's no obesity.
(36:09):
And actually in those familiesthere was some obesity, but they
were the adopted children,which is again interesting,
because genes have a lot to dowith how you eat and metabolize
things.
But we should be all overweight, but we're not.
And so I looked further into myown genes and this is like
crazy.
But I have something I call thewiggle gene, and I've invented
(36:31):
this term, and that means I havea thermic response to exercise,
which means when I exercise Ilose weight.
When most people exercise, as Imentioned, they don't lose
weight, but when I exercise Ilose weight and I wiggle all the
time.
You can see, I've wiggled athousand times since I've been
sitting here, and so I thinkthat I wiggle my weight away
(36:51):
while I'm just in life.
But that's the point.
It's not just one thing, it'slike oh well, I have the wiggle
gene and oh, I have the obesitygene, oh, I have this gene, and
oh, I have that gene, and sotype two diabetes is so
polygenic.
There's so many genes that haveto interact in a person, and
then that person interacts withthe food environment, and then
(37:13):
that person interacts with thepollution in the air, and you
know how much we exercise andall of that.
So it's what you learned inmedical school wasn't wrong.
It was just what we knew at thetime and we thought it was
simple, and it isn't.
But very little in human healthis simple, and that's actually
why medications can be fraught,because often if you do one
thing, another thing turns outto be worse.
(37:34):
But because we've had thesemedications up for long enough
for me to feel safe, and Ididn't at first.
I'm not a person who jumps onthe bandwagon of new medications
.
I feel like I've had enoughexperience to use them
knowledgeably and calmly.
I'm not like here give you this, this is going to be magical.
It's like well, let's see howit does.
Speaker 2 (37:57):
You say that these are survival genes, but they're
basically survival genes in afood-poor environment.
They're not survival genes whenyou've got lots of food.
They're actually the exactopposite of that, because you
become obese and you developother.
But they come from a time whenwe were running on the Maasai
Mara eating the deer, not thedeer, the elk, zebras eating the
(38:20):
zebras, and they're not eatingfor two weeks.
In an environment where we haveso much food then they work
against us.
Speaker 1 (38:27):
Exactly, and there are other genes that way too,
like sickle cell I mean genesthat can protect you from
malaria can cause a horribledisease.
Our genes are meant to adapt toour environment, and our genes
haven't been able to adapt yetto this environment.
A and B.
We're not necessarily lettingour genes adapt anymore, because
(38:48):
we do a lot to make sure thatpeople survive, and so that
means these genes are carriedforward.
Speaker 2 (38:54):
It's also interesting to me that you talk about those
Northern European paintings andhow everybody got fatter and
fatter and it was a positivething in my understanding was
like to be called fat, was likeif I said you're fat, that means
you're rich, you're doing greatin life, and now being fat is
the exact opposite of that.
You're more likely to beimpoverished, to have poor food
choices.
It is really interesting tofollow the arc of history in
(39:17):
this.
Speaker 1 (39:18):
Yes, and I think that it gets down to I just I think
that it gets down to, again, anindividual and how people feel
about themselves, and I thinkthat you know it's important to
do sort of a self-analysis ofwhat is important and what
matters.
And who do you want to be?
You want to eat healthy, youwant to exercise, you want to
(39:41):
make sure you take themedications that your body needs
and no more.
You know it's a balance and I'mvery careful.
Speaker 2 (39:48):
And thank you so much for your time.
I think this has been reallyhelpful.
It's complicated, and I hatethat.
I wanted you to give me ananswer yes, no, this weight,
this BMI, but it is complicatedand you've got to balance all of
these things.
And so go and see a clinicianand have this managed correctly.
Don't just take it willy-nilly,because there are other issues.
(40:11):
It's about and I really want toemphasize it's about being
healthy.
It's not about being aparticular weight, it's not
about looking a particular way.
It's about being healthy, and Ialways like this idea of the
concept of compression ofmorbidity.
We're all going to die.
All you can hope to do is makethat time period where you're
frail as short as possible, andone of the ways to do that is to
eat healthy and be lean and bestrong and then maybe, instead
(40:34):
of for 20 years, being able tosit on the couch and that's all
you can do, maybe you can getthat to five years, and that's
what we want Compression ofmorbidity.
Be as healthy as you can for aslong as you can.
Speaker 1 (40:42):
Exactly.
You want your health span andyour lifespan to be equivalent.
I must say, as a corollary toall this is that I decided to
become a lunatic backpacker.
I have a bad back.
I don't know what happened tome, but I just decided that was
my road to health, because Idon't like exercising on a
machine and I think I'm probablyfitter than I was when I was 45
(41:02):
.
I can hike up mountains, I goto the Sierras, I do all this
stuff and I really think that ifyou're careful and again, as
you get older you break more youcan actually be healthy, hearty
, in a really good condition asyou age.
But again, it's about what youfocus on.
I focus on health and I thinkwe can keep each other much more
(41:23):
healthy without worrying somuch about you know every pound
you gain or lose or how you lookon the outside nearly as much
as how you are on the insideAgain, thanks to Professor Anne
Peters.
Speaker 2 (41:37):
She literally is the world expert in this, has
written books about it,guidelines, research Amazing
that we got to have 40 minutesof her time and I hope this has
been useful to you and I hopeyou've heard that message over
and over again.
These drugs are very powerfuland very positive about them,
but you should be doing thisunder supervision of somebody
(41:58):
who actually knows what they'redoing.
It's about being healthy, it'snot about being a particular
weight.
I love that.
I'm Dr Anne Peters.
I'm a professor of clinicalmedicine at the University of
Southern California, where I runtwo different diabetes programs
, one in Beverly Hills and onein under-resourced East Los
Angeles.
Speaker 2 (00:24):
And Dr Peters here is an old friend.
I think I met you when I was inmy mid-20s and I'm no longer in
my mid-20s, so that's a whileago.
You are a world expert indiabetes and it was just an
opportunity to grab you and askyou about some things, about a
Zempik because we've got thispodcast and we're talking about
(00:45):
lots of different topics.
But one of the things thatpeople keep asking over and over
again is about this new groupof agents and whether they
should be using them.
This isn't people that are 100pounds overweight and have
diabetes.
These are friends who aremoderately thin and, like I,
just would like to be thinner.
Should I use it?
So I would like you to tell usabout these drugs and who we
should be using them in and whatare the upsides and downsides
(01:06):
for regular folks using them.
So let me VO my own VO here andsay that Ozempic is a
prescription drug here in theUnited States.
It's semaglutide and it is aGLP-1 receptor agonist.
So it hits that receptor and itactivates it, and so that's
glucagon-like peptide 1.
So you'll hear this a lot GLP-1.
(01:26):
So after you eat, you get thisGLP-1 hormone that goes up and
that increases the amount ofinsulin that comes out of your
pancreas and that deals with thesugars and stuff that are now
in your blood and it puts theminto the cells.
So this drug mimics that actionand we'll be talking a lot
about weight loss here and ithas a number of different
mechanisms, and so one of theways that it works is that it
(01:48):
goes to your brain and says I'mfull, I'm done here.
So it reduces your hungercravings in lots of people not
everybody, but in lots of peopleand so you feel satiety, I'm
done, I don't have to eatanymore.
So that's one of the ways thatit works.
It also can reduce your GIemptying, so the how quickly the
food goes through your stomachand your GI tract.
This also can make you feelfull, Like you've had a big meal
(02:10):
and like I couldn't eat anymore.
It gives you that sort ofsensation, and there's probably
a whole bunch of other ways thatit's used, but it's
predominantly used, or should beused or is FDA approved, for
patients who have obesity andtype 2 diabetes.
That is the kind of diabeteswhere you have insulin but you
don't have enough of it, and sothis can increase the levels and
(02:31):
decrease your weight and ittastes great less filling, as it
were.
Oh, and one other thing I'mgoing to say here because I know
it's going to be triggering forsome people.
We talk a lot about being fat,but not in a derogatory way.
We talk a lot about fat andsometimes those two are mixed,
but I know for some people it'sreally triggering.
You can't say somebody's fat.
We do that here.
It is not meant in a derogatoryway at all and if that's
(02:54):
triggering for you, I'm sorry,don't continue.
We talk a lot about obesity.
We talk a lot about BMI,measuring central circumference.
So forgive us if we haven'tused always the politically
correct terms, because we arepeople of a certain age and mean
nothing derogatory by it.
Now let's go back and let'stalk about these drugs.
And the other thing I shouldsay is that we use a lot of the
(03:14):
trade names, not the drug names.
They are just easier toremember.
If this was a CME program, wewould change it, but for the
purposes of what we're doinghere, we're just going to use
the trade names that people use.
It's just easier because thenpeople know what we're talking
about.
Speaker 1 (03:28):
Well, first of all, these aren't new.
The first of this class, whichis called the incretin class but
specifically what Ozempic is isa GLP-1 receptor agonist.
This class was first introducedwith Biada, which was a twice a
day injection, which was about20 years ago.
(03:49):
So one of the things thatcomforts me as a physician is
that we have a long history ofusing these drugs and I, as a
diabetes specialist and actuallya diabetes specialist who
writes the guidelines knows thebenefits and risks.
So I'm completely comfortableusing these agents and I'm
completely discomfortable makingthe right choices with patients
(04:11):
, helping patients make theright choices when it comes to
using them.
So they're not so new.
It's just that the media madethem new because suddenly we had
a once a week form instead of atwice a day form, and where
everybody has caught on to thefact that you can lose weight
and it's relatively easy.
Speaker 2 (04:28):
So let's talk about that as a weight loss drug, so
as a diabetic treatment.
You've been using it for 20years.
You're quite comfortable withit.
Risks, benefits in favor of themedication.
So let's talk specificallyabout its use for weight loss
and non-diabetics, which Iassume is off-label, fda
approved but used all the time.
Speaker 1 (04:48):
Well, it's not off-label.
So this is what the drugcompanies did, and even this
started 10 years ago.
So there was a drug calledVictoza, which is a once a day
GLP-1 receptor agonist and weuse it in people with diabetes.
And these drugs, by the way,are great in people with type 2
diabetes because their glucoselevels go down, they lose weight
(05:11):
.
All the things that are notright about them get better.
Their risk of heart diseasegoes down, their risk of heart
failure goes down, their risk ofkidney disease goes down.
So these are to me, I wouldsuppose, one of the two most
miraculous classes of drugs I'veever had to treat people with
diabetes.
And they work and they're muchbetter than, for instance,
(05:31):
insulin.
I still use insulin all thetime, but these drugs work.
But I'm not quite so sure.
When the drug that was Victozafor diabetes also became Saxenda
, which is a drug for weightloss Very same drug once a day
it was just three times asstrong, and so on label Saxenda
(05:54):
has been available for, I'm sure, 10 years.
I could be wrong, but it's beena while.
And the problem with the drugfor weight loss is that insurers
didn't want to pay for it.
We don't consider obesity adisease.
We consider it a condition andtherefore insurers don't pay for
(06:16):
drugs for a condition.
Now, I personally am of thebelief that people who are
overweight are overweight for avariety of different reasons,
and it's exceedingly hard forpeople to lose weight because
your body defends your weightand these drugs make it easier,
and the reason I like them forpeople who are overweight is
(06:37):
because it takes somethingthat's a real problem for them
and makes it.
It solves the problem.
It doesn't necessarily takeaway from the desire to eat
entirely, but it helps peoplelose weight, and a headline for
me throughout this podcast isthat people need to eat well and
take these drugs, because itstill matters that you eat well,
(07:01):
because if you don't eat welland take these medications, you
can lose too much of your musclemass.
You can become unhealthy.
That's not what we're talkingabout.
What I'm talking about istaking people who are obese or
overweight, helping them loseweight, and that helps their
health in a thousand differentways.
Speaker 2 (07:18):
So you talked about this sort of the set point that
we have.
And you know, even I find thissort of the set point that we
have.
And you know, even I find thisI want to lose.
I'm 160 pounds, five foot nine,five foot eight, so just about
the right.
I want to lose 10 pounds.
It's really hard, you lose itand then you go right back to
this sort of set point thatyou've had for years.
So do these drugs help youchange that set point or do you
(07:40):
have to stay on the medicationto keep the weight off?
Speaker 1 (07:44):
You have to stay on the medication for the rest of
your life.
Now let me just tell you this.
So in my world, I believe inindividual response.
So when I have a patient whohas diabetes or doesn't have
diabetes and takes thesemedications, if somebody wants,
for whatever reason, to stop itand again, as I said, I think
(08:05):
the cause for people beingoverweight is multifactorial so
there's not just one reason andthere are people who I know who
eat because they're sad andthese drugs don't make you happy
.
They make you feel healthierperhaps, but not necessarily
happy.
And so in about 25% of peoplethere is no weight loss response
.
So people who go on thesemedications for weight loss may
(08:27):
or may not lose weight.
Like anything in life, there'san individual response.
But say you go on these, youlose weight.
You get to another point.
You feel like you're able toexercise more, you've learned
how to eat differently, you'veworked with a dietician.
Then I say we can try to taperthem.
I don't stop them, cold turkey,I taper.
I say we can try to taper them,I don't stop them, cold turkey,
(08:47):
I taper.
And then I start by saying,okay, let's take it once every
10 days instead of once everyseven days.
Then I say once every two weeks, then maybe I'll get to once a
week, once a month.
But I'll go down slowly andthen and also I'll ratchet down
the dose.
So the maximal dose of Monjarois 15.
You can go down in 2.5milligram increments, down from
(09:10):
15 to 12.5 to 10 to 75.
So I believe in the lowest drugfor the most benefit.
So I'll tell you about me.
Am I allowed to tell you aboutme?
Speaker 2 (09:22):
Tell us about you.
Speaker 1 (09:24):
So I was getting diabetes.
I found this out from bloodtests I did on myself and we
doctors are not necessarily goodpatients, but that's okay.
But I'm not just gettingdiabetes.
I'm getting type 1 diabetes andI use these drugs in type 1
diabetes as well, but that'sslightly a different story.
(09:44):
But I'm getting type 1 diabetesslowly as an adult.
Speaker 2 (09:48):
So perhaps for the non-docs listening to the show,
type 1 diabetes is an autoimmunedisease where your beta cells,
which are in your pancreas, aredestroyed by antibodies.
It tends to occur in youngpeople that are thin and then
they develop diabetes thatrequires insulin.
If they don't have insulin,they die.
But now we're learning, aswe're about to hear, that this
can happen to people that areolder, and can happen slowly,
(10:10):
which is sort of blowing my mind, which means my beta cells that
make insulin still are makinginsulin.
Speaker 1 (10:17):
They're just not making enough.
If I hadn't started myself onOzambic, I would be on insulin
now because if you look at myglucose levels, I go up and down
a lot when I eat.
So taking Ozempic helps my bodymake insulin better, like a
type two, because that's whatit'll do.
So I'm taking these to preventmyself from eating insulin and I
(10:40):
technically have diabetes atthis point, but I take Ozempic
and that's how I treat it.
On the other hand, I'm skinnybut, just like you, I was at the
same set point and I was at aset point of 140 pounds and I'm
5'10 on a good day 5'9 if youwant to remeasure.
Speaker 2 (10:58):
We're going through the shrinking years.
So you know, yeah, theshrinking years are happening.
Speaker 1 (11:02):
And so I took it and I lost.
Probably.
I lost down to like 128 orsomething, which on me is a lot
of weight, and so now I'mconsidered underweight.
But darn, is it a great weight?
Because I look really good inclothes.
(11:23):
I mean mean, like you know, 140was fine, I was normal weight.
But you know I hang out and Ilive in LA and there's Hollywood
and my husband's a Hollywoodperson, so you know I look great
in clothes.
But the problem for someone likeme is losing too much weight,
and I didn't want to lose toomuch weight because I would lose
too much muscle mass.
(11:43):
And so what I did was I clickedup the dose really, really,
really slowly.
I didn't use the doses on thepen, I used this click method,
or micro dosing, till my bodytolerated it and I got to about
0.5, which is a really low doseof Ozempic, and I don't go up
and I don't go down.
If I go down I get hungry, if Igo up, I lose more weight.
(12:06):
So I take a tiny dose ofOzempic every week and for five
years I have reset my set point.
I am at this lower set point, Idon't go up, I don't go down,
and I've worked really hard tomaintain lean body mass.
So I exercise, I eat moreprotein and I eat more fiber so
that the drug doesn't cause meany ill effects.
And that's where the drug and Iare.
We're happy together.
(12:26):
And eventually I'll needinsulin.
I know this, but for now Idon't.
So it does reset your set point, but I know in me if I skip a
week I'm really hungry in a wayI've never been before, because
I think it's been suppressing myhunger.
Speaker 2 (12:42):
So then let's dive a little bit deeper in that.
You said something at a GrandRounds conference years ago that
has stuck with me, that even 10pounds of abdominal fat can be
diabetogenic.
Just a little bit of a bellyfat is very hormonally active.
Is that still our understandingtoday, and is this a reason why
(13:06):
people who look pretty leanmight actually benefit from
being on medications to dropthat weight, or is that
overstating it?
Speaker 1 (13:13):
It's not overstating it at all, but this is what
we've learned since I gave thatlecture.
We've learned that there'sprobably a thousand different
types of what we used to calltype 2 diabetes and possibly a
couple hundred types of what weused to call type 1 diabetes,
and so we're no longer at leastin the sort of evolution of
(13:36):
guidelines, calling them sodistinctly type 1 and type 2,
that a lot of people will haveelements of both.
And that belly fat can happenin the lead person or an
overweight person, and that candrive insulin resistance and it
also drives these hormones thatmake you have more inflammation.
And the problem is is thatpeople who are overweight or
(14:00):
obese or even have central fatnot only can get diabetes, they
can get higher rates of heartdisease, they get higher rates
of cancer.
That fat in all of us ismetabolically active.
It's not a silent organ andit's you know.
You can't do liposuction to getrid of it because it's
abdominal, it's inside there,and so for most people, losing
(14:23):
that fat and again, I don't carewhere you start losing fat
helps you reduce thatmetabolically active tissue and
your risk for other healthproblems goes down, and that
includes things like joint painand back pain and sleep apnea,
and I think there's 250 otherconditions caused by that organ
that is fat.
So I take that seriously.
(14:44):
But you can't use these drugs ifyou're lean without doing it
with a doctor or somebody whoknows what they're doing,
because you'll get too thin andI mean what's good about these
drugs can be what's bad aboutthese drugs.
So you just you can't just usethem.
I think you need guidancebecause otherwise you can get
(15:05):
worse.
So I have people where I haveto beg them to stop the drug.
They're too thin, especially ifpeople are older.
I'm like you cannot keep doingthis.
You've got to stop it or reducethe dose.
I worry people get dehydrated.
I mean, people are writing alot about side effects of these
drugs and I'm like the vastmajority of those side effects
are because people are justusing them without actually
(15:27):
being guided in their use.
Speaker 2 (15:29):
So tell us about that weight loss.
These by their nature cause asort of syndrome of losing
muscle.
You become muscle wasting, andwe hear about this ozempic butt.
Is that what they're talkingabout?
It's basically just some muscleloss.
Speaker 1 (15:43):
Well, this is the thing, Ozempic.
The reason I like it, rather,is that I'm an endocrinologist,
which makes me a geek forhormones, and Ozempic is a
hormone and Monjaro is twohormones, and these are hormones
that are inside of all of us,and so when you give somebody a
gut hormone, known as insulin,you're giving them an injection
every day, or multipleinjections every day that are
(16:05):
replacing what their body isn'tmaking.
And when you give somebody agut hormone like Ozempic or
Monjaro or Wegovi or Saxenda orZepbound, whatever they are
called, these are hormones thatare injected because they're
peptides and otherwise your bodywould destroy them, and I guess
that you can get them as a pill, but the injections work better
, I think.
(16:25):
But the point is is we'rereplacing a hormone, and it may
be that people who are moreoverweight are more resistant to
this hormone or they make lessof this hormone, who knows what?
But it's not like back when wegave things that sped up your
body or did bad things to yourheart.
This is a drug that's known toyour body and so you're giving
it to your body and it's notgoing to make you, you know,
(16:48):
suddenly grow I don't know athird year.
It's basically not going tomake you, you know, suddenly
grow I don't know, a third year.
It's basically just going tomake you lose weight.
But any weight loss,particularly rapid weight loss,
will make you waste muscle.
So it's not that these drugsare specifically bad at that,
it's that they're fast at that.
And if you lose weight fast,you know, if I gave this to you
(17:09):
and you lost, you know, 20pounds in the next six weeks,
you wouldn't look so good.
Just a thought.
You look perfect now.
Speaker 2 (17:18):
Thank you.
So that's.
I wanted to touch on thatbecause my understanding is that
every other single weight lossdrug that has been used in the
West has resulted in a classaction lawsuit because it's
resulted in cardiacabnormalities and fen-phen and
all these things.
So you think these areintrinsically different than
those prior weight loss drugs.
Speaker 1 (17:39):
Correct.
These are hormones, the otherswere chemicals.
It's completely different.
It's not that I don't thinkthese drugs have side effects,
but I think they have a sideeffect that's related to their
effect in the body.
We're just giving more.
So people who lose weight fastwill end up with gallbladder
problems, no matter how you losethe weight, or they slow
gastric emptying, so they slowthe food transit through your
(18:03):
intestines and you know they cangive you constipation, they can
give you diarrhea, they cangive you delaying gastric
emptying, particularly if youhave a problem with gastric
emptying.
But most of these side effectscan be mitigated by using lower
doses, going up slowly and againusing them with somebody who
knows them.
(18:23):
So if I have somebody who hasreally bad gastrointestinal side
effects A, I go down on thedose, but I don't.
I use those Ozempic pensbecause you can click them.
You can give a effects A, I godown on the dose, but I don't.
I use those ozempic pensbecause you can click them.
You can give a very, very, verylow dose compared to if you're
using, say, a fixed dose.
Pen like Monjaro comes in and Ijust go on little doses.
Or I have people give them lessoften.
(18:44):
But if somebody gets too sickfrom these, I don't keep them on
it.
I mean, there are people whojust don't tolerate them and
that's just life.
But it's different than theothers.
So they're not chemicals, Imean.
I guess they are, but they'rereally not.
They're hormones.
They're hormones that we'regiving you, that your body knows
.
And the other thing is is we'veused them for 20 years.
So you know there will belawsuits about almost any drug.
(19:07):
But as somebody who's usedthese, who knows the genius
people in this field, I don'treally think that there's some
horrible scary thing thathappens that's worse than the
other horrible scary thing whichis the consequences of being
overweight or obese or havinguncontrolled diabetes.
I mean, these drugs have somany non-glucose related
(19:29):
benefits.
So you've got to look at riskand benefit.
Nothing is risk-free, nothingis side effect-free.
But learn what the side effectsare, reduce the risk and then
stop the drug if it's nottolerated.
Speaker 2 (19:42):
This begs the question of who should be on it.
I want to go back to that.
I'm kind of stunned that you'redeveloping diabetes, because I
have this old schoolunderstanding of diabetes which
has completely changed andyou've been the person, probably
as managed as anybody in theworld, that's helped us
understand this.
When I was in medical school,there were two types of diabetes
autoimmune destruction of yourbeta cells, insulin dependent
(20:02):
DKA that one, skinny people andthen there was obesity,
long-term insulin resistance.
And now you've made it allblurry and you're a perfect
example, super lean, active, andyou're developing what is sort
of this mixed picture of yourbeta cells.
Are they autoimmune destruction?
Are they just getting old andthey die?
(20:22):
Or this happened to myfather-in-law as well.
He was 87 and he developeddiabetes Fit, healthy, lean.
I'm like what is happening tomy worldview of diabetes?
Speaker 1 (20:31):
Well, your worldview should change completely.
I have sky high antibodies.
I am getting true type 1diabetes, but nobody knows
because nobody's even studied itin people greater than 45 years
of age.
My oldest patient with newonset type 2 diabetes was 94.
So you can get type 1 at anyage, and now we know that it's
(20:52):
more common if you're an adultthan a child.
But it looks a lot like type 2diabetes in some people Like I.
Have an entire clinic in East LAof people who you would think
have type 2 because they'recentrally obese, they're
overweight, have hypertension,they have a family history of
type 2.
And yet I measure theirantibodies and they actually
(21:13):
have type 1.
But type 1 in adults, the onsetis much more like a type 2.
You just don't know it.
So it's very important thatpeople who are atypical get
their antibodies tested and thenpeople like me who are atypical
, end up on insulin sooner thansomebody else.
But I would typically just beon insulin, but I don't want to
(21:36):
be on insulin.
I'm not against insulin.
I'll take it when I have to,but I like being on a little bit
of Ozempic and, like I said,I've been on it for five years
and it and I seem to be happytogether, so it's fine.
Speaker 2 (21:50):
What is overweight now?
So is it true I'll make somestatements which may or may not
be true that obesity or beingoverweight over the long term
produces insulin resistance andmaybe you wear out your beta
cells?
I don't know if that's true ornot.
What is the right weight and atwhat point should you say I
need to start a drug to drop myweight a little further?
Do you just look at the personor is there a BMI?
(22:13):
What do you use?
Speaker 1 (22:15):
Well, that's a very fraught question, like all
things in medicine.
So, first off, if somebody putson a continuous glucose monitor
, which you can now get over thecounter, and you find out that
you're having spikes either inthe morning or after eating, you
may have prediabetes, and thatone's easy, because in that case
(22:37):
you need to see a physician.
You need to exercise, loseweight if you're overweight at
all and again, that 10 pound ofcentral fat can cause it.
And I've had patients who arelean, if you looked at them,
lose 10 pounds and theirpre-diabetes goes away.
So you want to look for amanifestation of the fact that
that weight isn't good for you.
(22:57):
But if you look at a body massindex, it depends on if you're
Asian or not.
Speaker 2 (23:04):
So I actually didn't know this, but it turns out that
in Asian populations the BMI isgenerally not considered to be
interpreted as the same as otherethnicities, because Asians
tend to have a higher percentbody fat and a lower BMI
compared to other groups.
All this is way above my paygrade, because then it's sort of
like which type of Asian or howAsian, because I have lots of
friends who are half Asian, halfCaucasian, etc.
(23:26):
That's why we have experts thatdo this all day, like Dr Peters
.
Speaker 1 (23:37):
But in a non-Asian individual, a body mass index of
more than 25 is consideredoverweight and greater than 30
is obese.
And then there are otherclasses of it.
But there are bigger people andleaner people by nature.
I mean, I have the world'sskinniest bones, so you know, on
me, you don't want me.
You would want my body massindex, which has always been
about 19.
I mean, I'm lean and that'sjust who I am, and not that I
(23:58):
can't get, you know, flub hereor there.
We're all aging, but I'm lean.
But I have these guys who are,you know, big guys and I know
their body mass index.
If they had a body mass indexof 19, they'd look like they
were skeletons.
So I think there's anindividualization for this.
And then people say that youshould measure waist
circumference.
And if you look at waistcircumference, that tells you
(24:21):
about that center fat and thattells you about that
metabolically bad for you, worsefor you, because all fat is not
so good, although there's fatas a storage form of nutrition.
So it's not entirely bad foryou, it helps you survive.
So they say measure around thewaist.
Well, the problem with that isthat you have to actually have
something that makes you and I'mshowing you but I'm going to
(24:44):
say it in words is you have tohave something that stabilizes
the weight the tape measurearound your center and you have
to do it in exactly the rightspot.
So the New York Times recentlyran an article about the fact
that waist measurements arebetter than BMIs, and they had a
picture of somebody measuringsomebody's waist and the top
(25:04):
part of the tape measure washigh up and the bottom part was
down low, and that picture wasexactly the reason we can't do
waist measurements accurately,because you have to have
something that makes the tapemeasure going exactly
horizontally, and nobody doesthat and nobody has it.
I've been doing it in researchfor years, but in random
(25:26):
practice people don't measurethe waist circumference
correctly and so it becomesreally hard to do that.
But I think most of us knowwhere do you gain your weight,
and as you get older you'regoing to gain it in your center.
That's just where our bodiesare doing it on purpose, because
your body wants weight in thecenter to help you survive
famine and you want to have ahigher body mass index as you
(25:48):
get older to survive old age.
I mean you're not going tosurvive it forever, but at least
it helps.
Speaker 2 (25:54):
Yeah, okay, so it's complicated and working with a
physician to determine if weightloss is enough, whether you
should be on one of thesemedications.
One of my physician friendssaid she goes to the gym and
she's got all these skinnygirlfriends and all of them are
on Ozempic.
That really concerns me, justtrying to get that extra five or
(26:15):
10 pounds weight loss.
It concerns me because you'retaking this from a group of
people with diabetes orpre-diabetes and then you're
doing it in a population ofpeople who basically don't have
any of those things.
There's got to be moredownsides than upsides.
What do you think about that?
Speaker 1 (26:34):
I don't know exactly, because if these people are the
same people who are going to gohave plastic surgery and have
liposuction or something,there's also a risk to surgery.
I mean, again in life, I'malways comparing it to whatever
the alternative is In a universewhere everything was available.
Maybe it's not so bad becausepeople are going to do something
to lose weight.
By the way, you don't loseweight by exercise unless you've
(26:57):
exercised two hours or more aday.
Exercise is incredibly good foryou.
It makes you much fitter, butit's not going to cause weight
loss because exercise makes youmore hungry and it also slows
down your basal metabolic rate.
But I think the goal is to befit and healthy, and I think you
can be too thin, and so I wouldsay that the best way to lose
(27:18):
weight is through diet and thenexercise to keep yourself fit.
And I don't know.
You know it's very hard for meto answer this question.
I don't think, as a you knowhuman who cares about public
health, that we should be givingpeople a drug like Ozempic to
lose five to 10 pounds.
But people do all sorts ofthings to look better.
(27:40):
I mean you can tell, looking atmy wrinkles, that I do not do
Botox, facelifts or any otherthing and my gray hair and
everything else, because I justbelieve that you should age and
healthy and age in a healthy way, and I just feel like that.
A lot of that stuff is, I don'tknow, in a world that I don't
really agree with.
But again, if you look at,maybe, what they might otherwise
(28:03):
do, maybe it's that your friendwho isn't that skinny is the
healthier person, but I justdon't know.
You've got to individualizethis.
But as the body mass index getsabove 28, people get concerned
and the insurance companies havecutoffs for where they'll pay
for weight loss drugs now, andit's a higher body mass index.
(28:24):
But if you have diabetes,hypertension or abnormal
cholesterol levels, it's a lowercut point, so it's hard to know
, but right now it's a lower cutpoint, so it's hard to know,
but right now we have a hugesupply problem.
Let's take away those peoplewho are fancy and let's just
talk about regular people.
And again, I think thatbecoming leaner if you are obese
or overweight, and coming downto a healthy body mass index,
(28:46):
which isn't going to be 19, it'sgoing to be 23, 24, 25.
That's great, and as you'reolder, going down there is great
too.
And I feel like we don't need tohave a society that focuses on
ultra thinness.
We need to have a society thatfocuses on health and I think
that no matter what your weight,you can be healthier or less
(29:06):
healthy.
So even if you're, you know, Ihave patients who have body mass
indexes who are significantlyoverweight.
They're in their, you know, thebody mass index is 34 and they
can't tolerate Ozempic and theycan take Monjaro, but they don't
really lose any weight and youknow I don't tell them to give
up.
I say I can help lower yourcholesterol, you can eat better,
you can exercise more and youcan be healthy heavier.
(29:30):
It's just that if you'rehealthy and leaner you are
continuing to enhance things.
But I don't tell people ever togive up and I think that you
really can have health at nearlyevery weight.
But it just becomes somewhateasier on some of these drugs to
achieve weight targets.
But I really believe in givingpeople what they need to be
(29:53):
healthy period, and sometimesthat's this image that they
should be way thin and I getthat.
To me some of that becomes onthe side of disorder, eating a
disorder, body perception.
And I have patients ironicallyI have patients with bulimia who
I've given a low dose of a druglike Ozempic or Ozempic where
(30:15):
the bulimia stopped because thecravings got better and they
started to eat more normally andactually regain some weight.
But again, this is all undermedical supervision.
You have a problem.
You're binging and purging.
Let's see if we can get that toa better place.
And it's amazing, usedcorrectly these drugs are
(30:36):
life-altering in a really goodway.
But what we've done in theCounty of Los Angeles, and I'm
very proud of us, is that eventhough these medications are
more expensive, most of theMedi-Cal programs, most of the
county programs, will.
If someone fits the criteria,which in general is having
diabetes but in some cases beingsignificantly overweight, they
(30:58):
can get these medications.
And so I feel like, as a publichealth person, that I'm using
it in these patients whootherwise have poorly controlled
diabetes and they use thesemedications and I get them
better.
That to me, is a miracle.
That's where I care the most ishelping people become healthier
who have diabetes.
But you could have anybody gethealthier, but again, I'm not so
(31:21):
sure that what you're talkingabout in those people in the gym
is about health.
It's more about vanity and youcan be who you are with that.
That's not who I'm going toprescribe these medications for
this is a more sort of generalquestion.
Speaker 2 (31:35):
Again, I feel like everything I was taught about
health and weight was wrong, andthat's I remember in medical
school.
The dean of the medical schoolsaid to us and this was in the
80s half of the things thatwe're going to teach you are
wrong.
We just don't know which half,and I felt like that's
absolutely been true.
Is this historically?
Is obesity and hypertension andmetabolic syndrome?
(31:58):
Is this a new phenomenon?
Is this a Western world highfructose corn syrup issue, or
has this been an issue atdifferent times through human
history?
Speaker 1 (32:08):
Well, it's been an issue not the same issue but
we've never had so many people,we've never had such an
abundance of food, we've neverhad such an abundance of
unhealthy food.
But again, it's complicated andbecause places where there's
food insecurity you often seethe highest weights, because
poverty and being overweight arerelated, because you get even
(32:31):
poorer quality food.
But they think these genes fordiabetes at least are survival
genes and the genes for hangingon to fat are survival genes, so
that if you took me and put meon a mountaintop and somebody
who's got a bigger BMI, who'sgot type 2 diabetes, they could
last a year living off their fatstores and drinking water,
(32:54):
whereas I'd probably be dead intwo weeks.
So there's an incrediblesurvival advantage to genes that
make you eat more and there's asurvival advantage to genes
that put fat in your center.
And the whole point is is thatyou need to be in an environment
where there's not excess food.
So if you have these genes andyou were living in rural,
(33:15):
mountainous Mexico, you neverhad type two diabetes because
you weren't eating enough.
But then if you moved to theUnited States and you suddenly
were in a place where you ate alot of junk food, and it's not
just junk food, it's overalleating more you're going to gain
weight, and then they all gotdiabetes.
So the highest rates ofdiabetes are in those people who
came from a place where therewas no diabetes.
(33:37):
It's about the environment inwhich you live less exercise,
more food.
But one of the interestingthings is and again, these are
survival genes.
These are really good for you.
If you're living in sub-SaharanAfrica, if you're living in
Central and South America,you're working really hard for
your food, and probably ourancestors, who were chasing
around after something that theyhad to kill and then they'd eat
(33:58):
, and then they wouldn't eatagain for two weeks.
They needed to live on theirfat stores.
They think that in NorthernEurope that these genes happened
a long, long, long time ago,and then the upper class got
more food and they became moreobese.
So if you look at the picturesof people in that we have, of
the paintings, we see that theybecame more and more overweight
(34:21):
at least the wealthy did and wethink that they might've
actually died out, because thesegenes, in the presence of too
much food, give youcardiovascular disease, cancer,
hypertension, and those aregoing to kill you.
And so if you don't have modernmedicine to treat those things.
It may be that these genes wereeliminated in a Darwinian kind
of way from Northern Europeansbecause we don't see nearly as
(34:41):
much type two there as we see inSouthern climates.
So it's possible thathistorically these genes were
eliminated from a subset, butnow they're expressed, because
to be eliminated you have tocause something to happen at
birth that you can't pass onthese genes, right?
Because if they are expressedin your 40s and 50s, you've
(35:03):
already passed them on.
And it turns out thatgestational diabetes is a
condition where the moms getdiabetes and can cause babies to
be born less often or born withmore complications, and so
these genes actually couldtheoretically be eliminated
because they could cause harmearly.
It's fascinating to me.
We don't know for sure all ofthis stuff, but we do know that
(35:24):
these are very good genes forsurvival, and that's what I tell
people when they're feelingreally bad about themselves.
It's like well, this is yourgenetic makeup and there are
thousands of genes that have todo with your weight maintenance.
So, as another comment aboutmyself, a while ago I did some
analysis of my genes and I foundout that I have many of the
(35:48):
known obesity genes.
And I looked at my family tree.
My grandmother had like 19siblings and nobody in my entire
genetic lineage has ever beenoverweight.
And you know, we're goodMidwestern Mennonites and we,
you know, ate well and I don'tknow, worked on the farms but
there's no obesity.
(36:09):
And actually in those familiesthere was some obesity, but they
were the adopted children,which is again interesting,
because genes have a lot to dowith how you eat and metabolize
things.
But we should be all overweight, but we're not.
And so I looked further into myown genes and this is like
crazy.
But I have something I call thewiggle gene, and I've invented
(36:31):
this term, and that means I havea thermic response to exercise,
which means when I exercise Ilose weight.
When most people exercise, as Imentioned, they don't lose
weight, but when I exercise Ilose weight and I wiggle all the
time.
You can see, I've wiggled athousand times since I've been
sitting here, and so I thinkthat I wiggle my weight away
(36:51):
while I'm just in life.
But that's the point.
It's not just one thing, it'slike oh well, I have the wiggle
gene and oh, I have the obesitygene, oh, I have this gene, and
oh, I have that gene, and sotype two diabetes is so
polygenic.
There's so many genes that haveto interact in a person, and
then that person interacts withthe food environment, and then
(37:13):
that person interacts with thepollution in the air, and you
know how much we exercise andall of that.
So it's what you learned inmedical school wasn't wrong.
It was just what we knew at thetime and we thought it was
simple, and it isn't.
But very little in human healthis simple, and that's actually
why medications can be fraught,because often if you do one
thing, another thing turns outto be worse.
(37:34):
But because we've had thesemedications up for long enough
for me to feel safe, and Ididn't at first.
I'm not a person who jumps onthe bandwagon of new medications
.
I feel like I've had enoughexperience to use them
knowledgeably and calmly.
I'm not like here give you this, this is going to be magical.
It's like well, let's see howit does.
Speaker 2 (37:57):
You say that these are survival genes, but they're
basically survival genes in afood-poor environment.
They're not survival genes whenyou've got lots of food.
They're actually the exactopposite of that, because you
become obese and you developother.
But they come from a time whenwe were running on the Maasai
Mara eating the deer, not thedeer, the elk, zebras eating the
(38:20):
zebras, and they're not eatingfor two weeks.
In an environment where we haveso much food then they work
against us.
Speaker 1 (38:27):
Exactly, and there are other genes that way too,
like sickle cell I mean genesthat can protect you from
malaria can cause a horribledisease.
Our genes are meant to adapt toour environment, and our genes
haven't been able to adapt yetto this environment.
A and B.
We're not necessarily lettingour genes adapt anymore, because
(38:48):
we do a lot to make sure thatpeople survive, and so that
means these genes are carriedforward.
Speaker 2 (38:54):
It's also interesting to me that you talk about those
Northern European paintings andhow everybody got fatter and
fatter and it was a positivething in my understanding was
like to be called fat, was likeif I said you're fat, that means
you're rich, you're doing greatin life, and now being fat is
the exact opposite of that.
You're more likely to beimpoverished, to have poor food
choices.
It is really interesting tofollow the arc of history in
(39:17):
this.
Speaker 1 (39:18):
Yes, and I think that it gets down to I just I think
that it gets down to, again, anindividual and how people feel
about themselves, and I thinkthat you know it's important to
do sort of a self-analysis ofwhat is important and what
matters.
And who do you want to be?
You want to eat healthy, youwant to exercise, you want to
(39:41):
make sure you take themedications that your body needs
and no more.
You know it's a balance and I'mvery careful.
Speaker 2 (39:48):
And thank you so much for your time.
I think this has been reallyhelpful.
It's complicated, and I hatethat.
I wanted you to give me ananswer yes, no, this weight,
this BMI, but it is complicatedand you've got to balance all of
these things.
And so go and see a clinicianand have this managed correctly.
Don't just take it willy-nilly,because there are other issues.
(40:11):
It's about and I really want toemphasize it's about being
healthy.
It's not about being aparticular weight, it's not
about looking a particular way.
It's about being healthy, and Ialways like this idea of the
concept of compression ofmorbidity.
We're all going to die.
All you can hope to do is makethat time period where you're
frail as short as possible, andone of the ways to do that is to
eat healthy and be lean and bestrong and then maybe, instead
(40:34):
of for 20 years, being able tosit on the couch and that's all
you can do, maybe you can getthat to five years, and that's
what we want Compression ofmorbidity.
Be as healthy as you can for aslong as you can.
Speaker 1 (40:42):
Exactly.
You want your health span andyour lifespan to be equivalent.
I must say, as a corollary toall this is that I decided to
become a lunatic backpacker.
I have a bad back.
I don't know what happened tome, but I just decided that was
my road to health, because Idon't like exercising on a
machine and I think I'm probablyfitter than I was when I was 45
(41:02):
.
I can hike up mountains, I goto the Sierras, I do all this
stuff and I really think that ifyou're careful and again, as
you get older you break more youcan actually be healthy, hearty
, in a really good condition asyou age.
But again, it's about what youfocus on.
I focus on health and I thinkwe can keep each other much more
(41:23):
healthy without worrying somuch about you know every pound
you gain or lose or how you lookon the outside nearly as much
as how you are on the insideAgain, thanks to Professor Anne
Peters.
Speaker 2 (41:37):
She literally is the world expert in this, has
written books about it,guidelines, research Amazing
that we got to have 40 minutesof her time and I hope this has
been useful to you and I hopeyou've heard that message over
and over again.
These drugs are very powerfuland very positive about them,
but you should be doing thisunder supervision of somebody
(41:58):
who actually knows what they'redoing.
It's about being healthy, it'snot about being a particular
weight.
I love that.
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