The Future Of Obesity Treatment

Introduction to Dr. Albert and obesity medicine 0:00

For this DrTalks I have a really wonderful guest who is going to walk us through sort of the future of obesity treatment. Dr. Albert is a double board certified internal medicine and obesity medicine specialist and a leading expert in obesity medicine. He founded the Cedars-Sinai Medical Weight Loss Program and is the co-founder and chief medical officer of Accomplished Health, a virtual obesity medicine practice. He's the leading authority on obesity and preventative health, and he delivers lectures nationwide.

One time we got to do one together. and he's all over social media, so, you'll want to follow him. I see him on LinkedIn all the time that I know you're really prolific on Twitter as well, right? Yeah, absolutely. So great quality information on his social media that I highly, highly, highly recommend checking out. Dr. Albert, let's start with the basic why do people struggle to lose weight and keep it off? Yeah, I think thanks for having me, by the way. But I think we're I would start with that is by talking about the world in which we live today, and then sort of get deeper into the science and maybe is less well understood.

And I think on a basic level, the world that's been constructed today has not been constructed in a way to do us any favors. Right. There is this sort of convenience environment, the service industry that has been optimized to provide sort of our every needs. I sort of talk about this with patients like the Amazon effect. You get everything you want within 24 hours or less. You know, it's ultra processed, ultra ready, ultra available. And I think that makes it really, really hard for people to sort of work against those natural tendencies, which are to be healthier, to be more active, to be more mindful about the things they eat and do.

And and I think that's just dealing with the basics, the basics of our reality

Why weight loss is hard: environment and biology 1:56

in the world that we are constantly trying to navigate in a way that really honors the type of life we want to live in, the type of health we want to have. And I think if you go deeper as I said, we get into sort of the biology and more of the hard core science. If you go deeper, there is this very well understood and described phenomenon. When people lose weight and we believe it happens to a greater degree, and maybe even to a more dysfunctional extent in certain people, that when they try to lose weight, that their body on some level can reject that effort after talking, talk to people about it in terms of like where the body feels like it should be, in terms of how big it is, in terms of how much fat it should hold.

And as a response to that, if the body does not believe weight loss for that individual is appropriate, maybe because of some progressive change in the way that the body views that person's weight, that it may not it may reject that attempt to lose weight through a traditional mean, like being in a calorie deficit or exercising more to try to increase your energy expenditure or something. And so what we see consistently time and time again in a number of people is that there is this response by the body that sort of systematically rejects attempts to lose weight and keep it off.

And so there are underlying nine biological mechanisms to really get into sort of the minutia of it, but underlying mechanisms that basically reject people's attempt to improve their weight, health. And so what's important insight within that is that it's not an individual's fault when this is happening, right, that this is something happened to them biologically. And we know this type of response is variable. So in some people it's more pronounced, in others it's more modest. And so that is part of why we see a range of response is in terms of the things that people respond to, where some people can respond quite robustly to exercise, where the others have been dieting and exercising for decades and have not been able to lose 10 pounds.

And so it's really important we understand the various layers at play, this world that is constantly promoting really poor health and this biology that is not ever doing us favors. I shouldn't say never, but there's often not doing as favors or is not working in alignment with what we want for our health. Yeah. So I think like two key things I heard the environment we live in is makes it easy to gain weight and hard to lose it. Right. Like I, I tell people when we start talking about exercise, you know, a hundred years ago we didn't have to tell people to exercise, right?

It was part of your life. You had to go tend to your garden. You had to hand wash dishes and clothes. You had to walk to get places. Not everyone had a car, right? almost no one had a car 100 years ago. Right? So, you know, we had to move as part of our lifestyle and food, right? I mean, there wasn't ultra processed food 100 years ago. So many different things in our environment. Right. But, you know, environment one. But a lot of us live in that same environment and don't struggle. Right. And so then there's how your body responds to that environment.

And I love the word you said reject. I've not heard someone use that term sometimes people say fail, which is not as helpful of a term. Right? It sounds like you did something wrong, but your body may reject what you're doing. It's like, nope, I'm just going to adapt. Exercise isn't going to work. Oh, nope. I'm just going to adapt. I'm not going to let, diet work and it's just rejecting what you're doing. So I think that's a really powerful message that our bodies respond differently. Yeah, 100%.

And I think I often talk to people, you know, there are different sort of abstract conceptualizations at this point. Some people talk about the body weight set point being this sort of abstract idea where the body's promoting a particular weight or particular fat amount that the body wants to hold. I think regardless, there is this concept whereby people have particular ambitions for where they want their weight health to be, and the body is in complete disagreement with what that is. And so there's this sort of natural misalignment between what ambition can you have for your health and what the biology is actually willing to accommodate.

And that's where I use the term rejection, because it sort of highlights that there's this, discordance between that, but between what you consciously wan, what your body's willing to accommodate. And so I think I think that's important because historically when we talk about people's weight struggles, it's been so driven and a lot and aligned around the idea of like, how do we get people to work harder? And it's important that we acknowledge that there are some things going on that people don't always have control over, not, you know, it's not readily available to them. Right.

Some of these biological systems. And so in those cases, when we talk about which I'm sure we'll get into some of these various treatments that can help us to address these sort of, misaligned biological systems, then, then then we can really help people. Right. And and that's not to say that this is something that affects everyone in the same way. And I think that's important is that people are going to have different responses. Bodies are going to receive things in different ways to different degrees.

And so that's where we get back to, especially the work I do, talking about sort of individualized approaches, which is some people may do really well with a particular approach, whereas other people may really need to leverage other types of treatments to benefit them. And I think that's really key, and something I've tried to highlight in this summit, because we have offered a large variety of strategies and all of these strategies work for someone. Some of them work more consistently, some of them have more dramatic results, but they all work for someone.

But just because something worked really well for your neighbor, your best friend, your coworker, whoever you know, if it doesn't work for you. I like your term. Your body's just rejecting that it's not you. Something about your biology isn't responding to that particular thing. I have one question before we move on to the treatment that, I want to, you know, help clarify, which is, you know, we said we agreed like, the environment is part of the problem. but a lot of people will say, well, what if I change the environment, right?

What if I eat this? Really, you know, wholesome, you know, maybe plant based or whole foods diet? I go back to eating how people eat. 100 years ago. I increase my movement, but I don't see my weight changing. Why is that occurring? Right? I've now effectively changed my environment. I have moved out of this modern world. I've done all the right things lifestyle wise that has been recommended, but I'm not really seeing a dramatic change in my weight.

Why lifestyle changes alone may not be enough 8:30

Can you explain a little bit more what's going on there? Yeah, I think, I'm always a huge proponent, of making important behavioral changes, lifestyle changes as they're appropriate, whereas you can accommodate them within your individual context. So I think that should always be permit promoted because that's by itself health promoting, even if it's not always weight loss promoting. Right. but why some people don't respond once again is the way in which their body is operating and how it's treating fat and energy and how these systems are communicating internally.

And, you know, not to get sort of too into the sort of, nuanced nature of the science, but but we know that some people's bodies will very much rigidly defend elevated weight states, meaning they will reject many typical attempts to lose weight, including really well formulated diets. You know, where that diet may promote good insulin signaling and good, you know, and healthy amount of, of calorie management and all of these other principles. It's going to reject the facilitation of weight loss.

And that is, once again, where I get back to this idea that that there are other biological, hormonal hormone, neurological systems that are involved in regulating weight and that some of those systems once again won't be accommodated regardless of the type of dietary pattern someone adopts. And so if that is the case, and often that is very evident, as you know, and taking a good history on these people that it's like it's it's sort of defeating to to try and continue to iterate on those different efforts because we already know that person doesn't respond to those types of thing, like adding a few more whole grains isn't going to be the thing that makes a difference in those people, right?

It's not going to be meaningful enough. And to in terms of changing the way their body functions. So that's really where we get into a lot of, my sort of expertise, which is the more sort of advanced therapies. How can we address the underlying biology that is rejecting or not responding to the signals that we would hope it to? And, and then how can we get the body to work better for people, not against them and sort of what I talk about. But let's talk about then what are some of the solutions and treatments that you get most excited about, or that you find yourself recommending the most frequently?

Yeah. So there's a spectrum of treatments that I sort of categorized as advanced therapies for weight management or for obesity. And within that, you know, we talk about the advancements in pharmacotherapy, which is medications. We talk about procedures which, you know, broadly speaking, encompass, you know, minimally invasive procedures and more invasive surgeries. all of these things are setting out to do categorically kind of the same thing, which is change the way that your body processes weight so that it allows and accommodates your ability to live at a lower, healthier weight for you.

Right? And not hold on to that fat in such a sort of resilient way. And and so even though they do, they, they, they pursue that through different means, different mechanisms. They're all trying to do that same type of thing, which is get the body to work better for you again. And that happens through changes in hormones, that happens through changes in the gut functioning and gut health that happens, that are changes. And, the nervous system function, a range of things, but they're all ultimately trying to achieve that same thing, which is helping to improve biology in a way that allows for sustainable weight health, to be realized in when we talk about things that get me really excited just because it's sort of my day to day work, which is leveraging medication and pharmacotherapy.

I really love where we are in the space right now, because we've really hit this inflection point, of leveraging and utilizing treatments that are highly efficacious and then have been approved and validated for long term use. And so when I look at the timeline of a drug development for weight management and obesity, we've gone from drugs that were only approved for short term use, which are sort of so-called first generation therapies to second gen, which were really kind of long term, but maybe modestly effective drugs.

and then now we're entering this sort of third generation or new era, which is highly efficacious long term therapies. So these are drugs that have been studied and approved for long term use, which we generally say is like greater than one year.

Advanced obesity treatments and new medications 13:11

And in drugs that are increasingly resulting in levels of health improvement that not only improve weight in a significant way, where people can measurably, you know, feel it, but also improve health outcomes. So increasingly, we're acknowledging improvement in cardiovascular health, kidney health, diabetes and metabolic health more broadly in a range of other sort of health states. So so I think it's a really exciting time, particularly around pharmacotherapy, which is my bread and butter, because there's an increasing number of highly efficacious tools that are also proven to be safe.

and I think that's a really important point because unfortunately, the the history of drug development in the obesity space has been one plagued by, drugs that had some, some really, you know, nasty long term side effects. And so, I think it's a really exciting time. And we can talk about specific agents if you want to, but but I think, I think as a whole, it's a, it's a really exciting time to be a part of the sort of medical space within obesity, because there's so much that we can help people with.

I couldn't agree more. It has been a really exciting time the last couple of years with the new medications, the highly effective ones, like we'll go the internet bound that we have access to for our patients. though I still love some of our older medications as well, you know, because there are people who have results and there are some wonderful things about those medications as well in terms of access and cost. but we do have this new era of really highly effective medications. So when we're thinking about medications like, that bound or will go the these GLP one receptor agonist, you know, I find that some of the people who I find would be the best candidates for these medications, the people who have the most health related issues to their weight, maybe they even have to type two diabetes and would qualify for the medication even without weight or people who have significant sleep apnea fatty liver disease, they're high risk for heart disease or already have heart disease sometimes are the people who are most resistant to wanting to take this medication.

in my clinic, a lot of times people who come in and have less weight to lose, maybe their weight isn't clearly impacting their health yet are very willing and wanting to use these medications. But I find sometimes it's hard for me to convince the people who I know will have a huge health benefit from these medications to take them. How do you go about, you know, selecting the right treatment for the right patients and then maybe also talking about like that risk benefit of like, you know, when do we know that this medicine is more likely to have a benefit than a risk for people.

Yeah. I mean, so I'm, I'm a huge data guy by the evidence, you know, and I really try to stick as closely to the data in terms of like, what has been validated as an appropriate use case. So I think, on the line of GLP ones that you highlighted, we know people with more advanced metabolic diseases, like diabetes, can have more severe forms of obesity that may have related health issues like cardiovascular disease. Those are going to be people. We're very clearly in the majority of cases, the benefit will far outweigh the risks.

And and so those people should at least have a conversation with their provider about what drugs are appropriate. But those drugs, it very well may be appropriate. I think something that you mentioned just talking about sort of appropriate narrative selection. So let me mention I think is really worth sort of, fleshing out. And that is this idea of like finding the right drug for the right person. And unfortunately, we're not at a time yet where we have this really, in-depth understanding of drug selection and sort of precision drug selection.

And so, unfortunately, a lot of our conversations around appropriate use and drug selection are based on population responses. So like, how does the average population respond to this drug that may not just describe how an individual will respond. And so I tell people, even with some of these great new drug therapies, there's something like 20 to 30% that will not have, you know, a clinically meaningful response. And with some of the older drug therapies, you know, that have been around ten plus years, there are some people that do really, really well to your point.

And like, they're just because your cousin is on Ozempic or where you go doesn't mean that maybe that's the best drug for you. Like everyone needs to figure out what's the best drug for them. And when I talk to people, I sort of, narrow it to a few considerations. One is like, objectively, how are you responding? Are we meeting sort of the health goals that you and I set out for you in terms of the things we would like to see, whether it's a certain amount of weight loss to improve your house, whether it's addressing a particular comorbidity, etc..

And so we're constantly evaluating the drug while they're on it, across those sort of pre-specified field goals. The other one is like tolerance. You know, there's I always tell people there's no such thing as a free drug. People respond very uniquely at times to different drug therapies. Whereas one person may have no side effects, another person may have every side effect that has ever been listed. And so we need to make sure a drug is, you know, solving more problems than it's causing, as I often talk to patients about.

And then the last increasingly when I talk about drug selection is around access

Choosing the right medication for the right patient 18:38

and that gets at affordability that it gets at market availability of the drug. All of these things factor in. I don't care how great a drug is in theory for you, if you can only access it one month out of the year, it's likely not going to provide you a significant benefit. And so, you know, getting back to the sort of act's accessibility or availability of the drug is huge when it comes to how well you'll do. And sometimes that means we go in a different direction than, than maybe we originally thinking, because one of those three sort of principles just did not live up to the bargain.

And so I often talk about we don't necessarily always know, but this is what we can sort of expect. And then ultimately we have to then scrutinize it as you're taking it, to make sure that it's living up to the bargain that we sort of originally outlined. And sometimes it does, or sometimes it exceeds our expectations, other times it doesn't. And that's when we have to make changes. But it's important to understand there is no one size fits all treatment. There's not a GLP one for all sort of methodology that we practice.

It's very, very individualized and helping people find the right therapy for them. Yeah, I think that's really important to share. And I try to highlight the same thing as well, right, that we're looking for what your individual goals are, are your goals to have more energy? Are your goals to be able to walk farther, go on a big trip to Disneyland and walk the whole time? are you trying to reduce your heart, reduce your heart disease risk? Are you trying to improve your blood sugar? What are you trying to accomplish and what makes sense for your health?

Sometimes, as the physician, we have to help people look at the big picture and recognize their risk for cardiovascular disease or something like that as well. but, you know, couldn't agree more that it's like, what is that individual goal you're looking for? And are you meeting it? Right? So you know, there's the average response we expect. There's people who respond better than average and people who maybe the scale isn't as dramatic as it could be on a different medication, but their blood sugar looks great, their energy is good.

They have no health risks. They've reached their goals regardless of what the scale says. Yeah, absolutely. And so I think that's really important to sort of ground a lot of the conversation because there there's a lot being said right now in terms of, many of these different drugs. some of that information I think is less helpful in terms of an individual's health journey. And I think it's always a good idea to ground the conversation into in terms of like, what are we trying to accomplish for you?

Not for your cousin, not for your friend, not for whoever your second cousin. It's like, what do you want out of you for your life? Like, where do you want your health to be? And like, what are the options that could help us realize that for you? And then ultimately making sure that that is the case? Yeah. It's so really a perfect name for your platform of accomplish, right. That like, did we accomplish it? Like are we reaching what your goal is? 100%? I mean, I think the pun is very much intended in that case.

Right. Like we want people to realize better health for themselves that accomplish health. And and so like every day we set out to do that and we try to provide the resources and education so that people can realize better, you know, sustained health for themselves, whether that's through significant weight reduction, weight loss, improvements in cardiovascular and functional health or the like. So when we're trying to think about sort of this quantity versus quality weight loss, how do you navigate that discussion with your patients?

Yeah, I think it's a really important one. And as the discussion continues to evolve in this space around weight loss, I think it's important that we bring it back to what we understand quality weight loss to be. And and so part of this is we have all these amazing, amazing new tools at our disposal. And certainly in the right people, they should absolutely be considered, if appropriate, to use them. Right? Absolutely. But it's not just about employing a new tool and forgetting the things we know that serve as the foundation for health improvement and especially when we have an increasing number of tools that can lead to significant weight reductions, we want to make sure that that weight that's being lost is preferentially coming from fat tissue.

Right. Is is sparing the types of tissues that we know are associated with long term health, like lean tissue, like muscle and bone and, and and that we are approaching this in a way that creates a level of sustainability in the way that we do things in our process. And so it's not just about medication, it's not just about surgery in some cases, because we deal with a lot of patients that are undergoing surgery as well, or even non-surgical options about like, how do we look at this comprehensively in a way that's not going to sacrifice our health or our experience along the way?

And so every, every single one of our patients gets evaluated in terms of sort of their nutrition approach. Often they work longitudinally with a health coach or a registered dietitian. we will use, mental health professionals at time if it's appropriate, either to work on someone's mindset in their behavioral approach or to address outstanding mental health concerns that might be a real blocker to quality weight health improvements. we look at sort of the comprehensive nature, whether it's improving the way that they approach stress and coping, or are they getting adequate sleep that will be a blocker to their

Quality weight loss and comprehensive care 24:10

healthy weight reduction, you know, making sure that we are exercising in a way that's consistent with, you know, their life context and their goals for their health. And if we anticipate a significant amount of weight loss or if they're at high risk, how do we encourage them to move their bodies in a way that's not going to compromise their health during that process? And so I think it's really being comprehensive. It's not looking at any single consideration in isolation. But how can we leverage all of these really strong and appropriate evidence based principles together to give people the best health outcomes?

And so it's not just a drug. It's not just a diet. It's not just, you know, exercising until the wheels fall off. It's like, how do we look at all these insights, put it together in a way that makes sense for an individual that really promotes good, long term, sustainable health. And you know what? I know of a conflict health, you guys. And what I've seen for you on social media and when we've interacted together, you guys offer this really comprehensive care for weight, which as I think we've talked about, is really key, right?

There's not one thing. And all these pieces have to work together for people. People may need a medication. They need a medication. And surgery. They may need surgery like they may need mental health support. There's so many different things that have to come together. at the same time, there are a lot of options when someone goes online now to maybe access the medication. can you tell me how someone can make sure they're accessing quality care when it comes to weight as opposed to, you know, maybe just getting a medication without support?

Yeah. So I'll share a little bit of my bias this way. I, this is what I think is, is, you know, if you start here, I think you're, you're, you're going to be in a good place. One is, you know, our clinicians who supervise the disease management, the long term care plans for our patients are all specialized in the treatment of obesity. So whether it's our physicians or our nurse practitioners, they all have special certification. I have a board certification, obesity medicine that is, provided by the American Board of Obesity Medicine.

So if you're looking at working with a clinic, do they have specialists that have unique certifications, like their physicians being able I'm certified or they're nurse practitioners having certain OMA or SMS certifications like that shows a level of sort of, focus to the approach and commitment that I think, suggests that there probably operate in a higher level of competency. the other thing that I would mention is like, how do you interact with the your provider? Are you forming a longitudinal therapeutic relationship?

Like, you get to know every single one of your providers on your care team, you know, whether it's the nurses you work with, whether it's the physician, the dietician, the coach, whoever like you see them, you develop a relationship with them. And I think that's important because it's not a faceless person who you don't know who's providing you what kind of reliable information. Like, you get to see it, you get to vet this person, you get to form a trust between them that that you know, or at least you can determine in your own right if what they're doing seems to be inconsistent with your best interest.

And, I think it's also about like the type of approach. Once again, I just talked about quality weight loss. Like for us, you know, we deliver this comprehensive experience online. So it's a fairly new concept within health care. But we do so via synchronous interactions like this as well as leveraging technology in asynchronous interactions as well. So we communicate with patients remotely asynchronously. We interact with them in terms of collecting data asynchronously that can inform their progress for us and give us insights in how to their how they're responding.

And then we have these touchpoints that are in many ways like measurables for us, where we can figure out is everything that we're seeing in terms of our asynchronous interactions aligning with what we're seeing in person and able to validate ourselves. And I think what that lends itself to, particularly at our, you know, through our platform at Accomplish Health, is that like people are getting this very comprehensive of experience while they're being followed by a team longitudinally over the long term, because they understand that this health condition, their dealing with is not going to go away in 30, 60 or 90 days, like maybe the weight loss has been positioned historically, but this is something you're going to have to deal with for the rest of your life, especially if they have weight related health issues that also have to be addressed concurrently.

Right? Like many cases, I see patients coming to me sometimes from other providers, mind you, and like they're not having their blood pressure adjusted even though they've lost 50 pounds and now they're hypertensive. But like because we can monitor their blood pressure at home and see that we can adjust their medicine and talk to them about how their body all works together. Because none of this happens in isolation, isolation. So how do I find someone that's reliable and has my best interest at heart?

Who's really going to support me throughout my health journey? I think it's starting to vet them across those sort of different considerations. Do I get to know my providers? Do they have a team that's supporting me that that provides comprehensive offering? you know, a if it's important to me, am I using my insurance benefits like we offer

How to find trustworthy obesity care 29:38

entire covered in network services through insurance payers? So like, like these are all the types of things that you have to then figure out. And for some people, they're going to want the convenience of a particular type of experience. And that's their right and more power to them. But for people that need more consideration who want a long term partner, I think offerings like us with special specialist providing comprehensive care, I think is a really strong place to start. Yeah, yeah. Thank you for sharing that.

Because you one of the things that's been a little alarming to me is how easy it is for people to sort of just fill out a survey and get a medication. And I know from my decade plus of experience that that is probably not going to yield the same results as working with either a clinician who spends lots of one on one time with you, or a whole team where they are taking into account all these other things your mental health, your sleep, your blood pressure, the whole complexity of weight, and really using the medication as part of that plan as opposed to just getting the medication if if all you're doing is just getting one of these newer medications, you're probably not doing your health, justice here.

Yeah. And I think listening it becomes a slippery slope, like everything that we're trying to do once again is to help someone realize better health for themselves. And, you know, if your health is being looked at in sort of isolation, if you're not considering the other things are going, you know, there's potential for you to address some other things and then just be left with the problem, the outstanding problems. And and sometimes that has a paradoxical effect that it actually makes things worse.

Right. And so I think, we need to understand I think increasingly healthcare is understanding that like nothing happens in isolation, like everything is talking to each other. That's why we're realizing, oh, and treating obesity, we can address diabetes and osteoarthritis and fatty liver disease and and heart disease. It's like every system talks to each other. Right. So if your mental health is suffering, it's going to impact other aspects of your health. And if your kidney health is suffering, it's going to impact your heart.

And you're like every. So it's important that someone's looking at this comprehend civilly it's not a transaction, right? A transactional consideration around your, you know, a particular measure of health, which is just your weight. once again, people have the right to figure out what's the best path for them. My bias being, I think it needs to be a long term consideration where you're looked at holistically as a person and that you're working with a team that really knows what they're doing and they're providing you comprehensive support.

That's my bias, and I'm sticking to it. As I said, I love it. I have the same biases, you know so well. Dr. Albert, thank you so much for all of your information.

Where to learn more and connect with Dr. Albert 32:28

If people want to find out more, where can they find or connect with you? Absolutely. So I run a clinic called Accomplished Health. You can go to our website to sign up if you're interested in becoming a patient of ours. We're active in 22 states and growing, so we may be in a state you're in if we're not currently, but go find us at Accomplished Health. If you know you want to be a patient of ours, you can go to accomplish.health/start. if you're interested in more of what I have to say, I am @MichaelAlbertMD on all my socials.

LinkedIn x TikTok, YouTube. You can find me there @MichaelAlbertMD or at Accomplish Health. And, we'd love to work with you. Yeah, he's definitely worth following. get great information for him on all those places. Well, thank you so much. Take care. Thank you.